iBii#ii !'ilp!'i''i5"*i^^^ THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES 5371 SEMEIOLOGY AND DIAGNOSIS OF DISEASES OF CHILDREN TOGETHER WITH A THERAPEUTIC INDEX BY N. ^ILATOV LATK PROFESSOR ORDINARY OK PEDIATRICS IIS' THE IMPERIAL UNIVERSITY OF MOSfO\V. AND PH YSIOI AN-IN-t'HI EE TO K:HL01TI>0EF*S children's HOSPITAL. TRANSLATED I'-ROIM THE RtJSSIAX HY (J. ii. 1L.VSSIN. M. 3) CHICAGO AVITH KXTENSIVK .VUDITIO^TN BY' FRANK B. EARLE, M. D. PROFESSOR OF PEDIATRICS AND CLINICAL PEDIATRICS, COLLKOK OK MEDICINE OF THE TTNIVERSITY' OF ILLINOIS, CHICAGO. IN TWO VOLUMES VOLUMK I JlXustratcd. CLEVELAND PRESS CHICAGO 1904 Copyright 1904 BT THE CLEVELAND PRESS (All Rights Kuscrved.; Bioinodical Library ERRATA. [A final comparison of the printed text reveals the following errors, which the translator begs the reader to mark in the designated places — G. B. H.] Page 85. The third line of the note should read:— this turbidity dis- appears on shakhig. If there be added so much acid, etc. Page 225. (9th line from the top) read nipple (instead of navel). Page 232. (2nd line from the bottom) read: — the hardness being nut very great. Page 281. (17th line from the top) read: — after the operation does cough upon, etc. Page 284. (I2th line from the bottom) read: — during inspiration. Page 298. (Qth line from the top) read: — the exact diagnosis is pos- sible only. Page 311. (5th line from the bottom) read: — is always lower. Page 329. (20th line from the top) read : — only in inspiration. Page 341. (8th line from the bottom) read: — appear later. Page 375. (gth line from the bottom) read: — appearance of the re- action. Page 383. (6th line from the top) read: — -resemblance to poliomye- litis. Page 392. (7th line from the bottom) read: — ata.\-ia which does not. Page 420. (6th line from the bottom) read: — parenchymatous neu- ritis. Page 441. (14th line from the top) after the words "several days'" add the following: — the stool remains normal. Page 442. (15th line from the top) should read: — a more pronounced retardation cannot be expected. In the period of deeper somnolency, es- pecially after convulsions, etc. Page 479. (21st line from the top) read: — there is much albumen. Page 492. (2nd line from the bottom) read: — potassic chlorate and phosphorus. Page 515. (loth line from the bottom) read: — considerably less. Page 532. (17th line from the bottom) read: — of the upper lip. Page 562. (13th line from the bottom) read: — bone (instead of skin). Page 596. (last line) read: — in the former case. Page 606. (7th line from the top) read: — reaches 39.6" (103.3' F.). Page 609. (3rd line from the top) after the word "mixed" add the following: — zvith one cub. centini. of the second. Page 623. (6th line from the bottom) read:— a rough vesicular respi- ratory. Page 647. (i8th line from the top) read :— from the tip. Page 685. (5th line from the bottom) read :— ^rv (instead of fif- teen). <9 9 9 kJkJ^^J Biomodical Library GREETING While this work may be said to appeal with especial force to the young- physician, because of its unique arrangement along diagnostic lines and its exceptional clearness in indicating the meaning of particular clinical signs and groups of signs, at the same time the practitioner of experience will find it a welcome aid and medium of clinical refreshment to his semeiotic knowl- edge. These facts have been sufficiently vouchsafed in the popu- larity the treatise has enjoyed in the original Russian editions, and in the French translation. It is believed that the reader of this life-work of a prominent Russian teacher and clinician will discover an attractiveness in ex- pression and a thoroughness of detail which are not very common. and therefore are perhaps oftentimes over-exalted when found. Suffice it to say, however, that there is a style of statement in medicine which gives exceptional interest to the subject dealt with ;. and that this has been a pronounced feature of Filatov's writings is conceded. Not only have the teachings of this author been ad- vanced and logical, but they have always been so expressed as ta convey the highest degree of value and command the keenest at- tention and confidence. The American editor has found it a difficult task to effect any additions to the translated text; and deletions none. The many editions in the original allowed of such emendations as seemed proper ; as well as of those additions which would render the finally revised edition wanting in little. The new material that has been supplied by the American editor represents such more or less important findings or opinions as have been brought out or suggested during the past two years; and so far as possible 577959 4 GREETIXG the "line of thought and method of statement" of the author have been approximated. The chief purpose in this connection has been to preserve the harmony of the teaching in every particular. Many illustrations appear in this American edition that it is hoped will at least not detract from the merit of the text. So far as possible due credit is given to the references from literature. A word should be said about the Therapeutic Index. This is arranged alphabetically and can be very readily consulted by the reader in connection with any particular affection mentioned in the text, or is quickly available without the text. This last feature is the best reason for the present plan, which has been preserved in the original under very favorable general regard. The extreme simplicity in all remedial measures will strike the reader at once. Finally it may be mentioned that the publishers have spared no effort of any kind to make the work as creditable in this country as it has been in Russia, France and Germany. TABLE OF CONTENTS. THE EXAMINATION OF CHILDREN. HISTORY. THE OBJECTIVE EXAMINATION AND THE MKAXIXO OF SKI'AUATE SYMPTOMS : The posture of the body 27 The expression of the face and eyes 2S General nutrition and complexion 29 The weighing- of children 3^ The growth of the body, oi the bead and chest 32 Atrophy of children S^ The Examination of flic Head 3^ Large Head 39 Softening of the skull-bones 4^ Anomalies of the fontanelles and sutures 4^ Tumors of the head 43 The Exaiiiiiiafioii of the Mouth, and Fauces 45 The Examination of the Neck 4'^ The Examination of the Chest 49 The respiration of the newdiprn S~ Disfigurations of the chest .iS The Examination of the Heart 57 The frequenc}' of the pulse "^ Senieiology of the Cry /- Cough ^ ^ The Examination of the Abdomen 7^ Senieiology of the navel / 9 The Examination of the Urine ^4 The Measuring of the Temperature ^9 VI TABLE OF CONTEXTS DISEASES OF THE DIGESTIVE ORGANS. Diseases of the Mouth 89—1 12 a — Diseases of the Mouth zvhich are not Accompanied by the formation of Ulcers, nor by a Fcetid Odor: 8q Catarrh of the mouth 89 Changes of the tongue 89 Thrush (Soor) 92 Annular desquamation of the epithehum 95 Affection of the mouth in measles 96 Bohn's nodules 98 Dentition 98 b — Diseases of the Mouth zvhich are Accompanied by Ul- cerations of the Mucous Membrane, but without a Fat id Odor: Diphtheroid stomatitis 10 r Aphthae of the mouth loi Bednar's aphthae 103 Ulcers of the frenulum 104 Affection of the mouth in syphilis 104 Bitten wounds of the tongue 104 c — Diseases of the Mouth with Formation of Ulcerations on the Mucous Membrane, and Stench from the Mouth: Foetid inflammation of the mouth 105 Noma of the cheek 107 Foot-and-mouth disease (aphthae epizooticae) 109 Osteogingivitis gangrenosa neonatorum no Semeiology of the Appetite 112 — 117 Gluttony and loss of appetite 112 Why does the child not take the breast ? 1 14 Increased thirst 116 Diseases of the Fauces 1 17 — 144 I — Diseases of the Fauces Characterised by Red )i ess: Angina catarrhalis 117 Changes of the mucous membrane of the fauces in in- fectious exanthematous diseases 118 TABLE OF CONTENTS Vll 2 — Diseases of the Throat with Formation on the Tonsils of Whitish Islets : Angina follicularis 1 19 Angina lucanaris 119 Angina aphthosa 1 20 Punctate diphtheria 120 3 — Diseases of the Throat with Formation of Coats : Angina herpetica 122 Pseudo-diphtheria 122 Diphtheria of the throat 126 Angina scarlatinosa 134 Angina ulcerosa — Vincent's Angina 135 Angina syphilitica 140 Gangrenous angina 141 Semeiology of Difficult Deglutition 144 — 147 Spurious and real dysphagia 144 Paralysis of the soft palate 145 (Esophagitis corrosiva and thrush 145 Stricture of the oesophagus 146 Semeiology of Vomiting 147 — 159 Eructation 147 Bloody vomiting 148 Common vomiting •. 151 Vomiting during cough 152 Gastric and cerebral vomiting 152, 155 Vomiting from blood-poisoning 156 Cyclic or recurrent vomiting 156 Vomiting from irritable debility and simulation 157 Eructation of the food which did not reach the stomach. . 15S DISEASES OF THE STOMACH AND BOWELS. Acute Diseases of the Stomach and Bozifels in Nurslings : Dyspepsia I59 Fatty diarrhoea i6r Acute catarrh of the small bowels 162 Cholera infantum i^4 Acute catarrh of the large bowels 165 The green diarrhoea i^ Viii TABLE OF CONTENTS Diseases of the Stomach and Bowels in Elder Children : Acute and subacute catarrh of the stomach and bowels. . 167 Periodic diarrhoea 173 Semeiology of Bloody Stools 179 — 187 Bloody stools in constitutional diseases 180 Ulcers of the bowels 181 Dysentery 182 Polypus of the rectum .186 Semeiology of Constipation 188 — 195 Constipation in nurslings 188 Its causes 190 Fissures of the anus 195 Diseases zvhich are Characicrizcd by Obstinate Constipa- tion and Vomiting 195 — 211 Intestinal obstruction 195 Pyloric stenosis 199 Inflammation of the caecum (appendicitis) 201 Acute peritonitis 209 Gymnastic pains of the abdomen 210 Semeiology of Abdominal Pai]is 21 1 — 218 Hypersesthesia of the skin of the abdomen 211 Pain in the muscles and aponeuroses 212 Pain in the peritoneum 212 Pain in the bowels (catarrh, neuralgia, malaria) 213 Semeiology of the Distended Abdomen 218 — 231 A normal and distended ahdomen 2t8 Dropsy of the abdomen (from hydriemia, thrombosis of the vessels, diseases of the liver) 219 Serous and tuberculous peritonitis 224—228 Tumors of the Abdomen 231 — 242 Enlargement of the liver 2^2 Enlargement of the spleen 235 Tumors of the kidneys 239 Tumors of the retroperitoneal glands 241 Helminthiasis 243 — 25 1 DISEASES OF THE ORGANS OF RESPIRATION. a — Diseases of the Nose 252—259 Rhinitis 252 TABLE OF CONTENTS ix Diphtheria of the nose 2^3 Chronic snuffles 254 Epistaxis 258 b — Diseases of the Larynx and Trachea Characterised bv Stenotic Respiration 260 — 279 Acute diseases of the larynx prodncino- its stenosis: False croup and true croup 262 Qidema of the larynx 265 Foreign bodies in the larynx and nuiscular spasm 267 Retropharyngeal abscess 269 Chronic Strictures of the Upper Respiratory Branches: Syphilis of the larynx 273 New growths 274 Perichondritis laryngea 274 Tumor of the thyroid gland 275 Hyperplasia of the bronchial glands 275 c — Diseases of the Lungs in -wJiieli the Percussion Sound is Xornially Clear 279 — 306 Catarrh of the respiratory branches 279 Bronchitis crouposa 280 Chronic pharyngitis and pcri(^dic niglU-cough 282 Capillary broncliitis 283 Bronchial asthma 284 La grippe 286 Whooping-cough 298 (Edema of the lungs 305 Emphysema 3^5 d — Diseases of the Lungs zvhich are Characterized by a Dull Percussion Sound 306 — 336 Croupous pneumonia 3^^ The diagnosis of pneumonia from pleuritis 310 Abnormal forms of pneumonia: Abortive pneumonia 3^5 Cerebral pneumonia 3^4 Convulsive pneumonia 3^4 Aleningeal pneumonia 3^^ Wandering pneumonia 3^7 Catarrhal pneumonia 3^'^ Hypostatic pneumonia 3^1 TABLE OF CONTEXTS Pneumonia during la grippe 324 Pleuritis 329 Hydrothorax 335 Pneumothorax 335 e — Diseases of the Lungs with Foetid Secretion 336 — 339 DISEASES OF THE NERVOUS SYSTEM. Semeiology of Headache 339 — 348 Acute headache 339 Headache during diseases of the brain 340 Chronic headache 342 Migraine 343 Supraorbital neuralgia 344 Headache from malnutrition 344 School headache 345 Headache from anom'aly of refraction 346 Semeiology of General Convulsions 348 — 371 Cerebral convulsions 349 Febrile convulsions 350 Afebrile convulsions in older children 355 Afebrile convulsions in children under the age of two- and-a-half years 359 St. Vitus' dance 362 Tic convulsif and spasmus nutans 366 Tetania 367 Contraction of the Muscles of the Neck 371 — 374 Contraction of the neck 371 Lateral contraction of the neck 7)7^ Semeiology of the Paralyses 374 — 420 The difference between central and peripheral paralyses. 374 Paralyses imth Flaccidity of the Muscles : Infantile paralysis 376 Striimpel's cerebral paralysis 380 Polyneuritis 383 Inflammation of the spinal cord 384 Progressive muscular atrophy 385 The weakness of the legs in rachitis 387 False paralysis (epiphyseal syphilis) 38S Post-natal paralyses 389 TABLE OF CONTFtNTS XI Diphtheritic paralysis 390 Paralytic chorea 392 Hysterical paralysis 394 Facial paralysis 397 Bilateral cerebral infantile paral\sis 398 Unilateral cerebral paralysis 402 Idiopathic spastic paralyses 404, 407 Pott's disease 4^0 Spondylitis of the neck 415 Ataxia 420—433 Inflammation of the Cerebral iMcmbraitcs 433 — 473 Pathologico-anatomical characteristics 433 Etiology 434 Tubercular niening-itis 437 Acute simple hydrocephalus . 452 Meningitis circumscripta 453 Hydrocephaloid 453 Passive hyperaemia of the brain 455 Thrombosis of the sinuses ; 45''> Suppurative inflammation of the pia mater 457 Epidemic cerebro-spinal meningitis 462 False meningitis 468 DISEASES OF THE GENITO-URINARY ORGANS. .Semeiology of the Urine 473 — 5^^ Albuminuria 473 Acute parenchymatous nephritis 477 Acute interstitial nephritis 481 Qironic parenchymatous nephritis 4^3 Amyloid of the kidney 4^4 Hypostatic kidney (passive hypenemia of the kidney) . . .485 Primary interstitial nephritis 4^6 Haematuria 4^6 - Haemoglobinuria 49- Pyuria 493 ''Semeiology of Micturition 500 — S'^7 Hindered and painful micturition ^00 Incontinentia urins 50/ Xll TABLE OF CONTENTS Tumors of the Scrotum and of the hv^iiiiial Canal . . . .508 — 511 Hernia 508 Hydrocele tunicae vaginalis and of the spermatic cord. . .508 SEMEIOLOGY OF THE SKIN AND OF THE SUBCUTA- NEOUS TISSUE. GENERAL TINT OF THE SKIN. a — Diseases Characterised by Paleness of the Skin : Common anaemia 512 Infantile splenic anaemia 518 Anaemia pseudo-leukaemica of Jaksh 519- Leukaemia 520 Malignant anannia 522 CTilorosis 524 b — Diseases Characterised by Yellozc lint of the Skin : Icterus of the new-born 5.25 Cyanosis afebrilis icterica perniciosa cum haemoglobi- nuria ( Winkel's disease ) 525 Icterus catarrhalis 526 Infectious jaundice 526- c — Diseases Characterised by Bluish Ti)it of the Skin : Cyanosis 528 Exanthematous Diseases 529 — 564 d — Diseases Characterised Chiefly by Redness of the Skin : The physiological erythema of new-born 529 Dermatitis exfoliativa 529- Erysipelas 531 Erythema caloricum 5 32 Erythematous prodromal small-i)ox rash 532 Spotted erythemata 533 Roseola 533 Erythema multiforme 535 Erythema nodosum 536- Spotted form of herpes tonsurans 537 Medicamentous eruptions '. 538. e — Diseases Characterised by Small Hcrmorrhages in the Skin : Traumatic petechiae 539 Purpura simplex, haemorrhagica and rheumatica 540- Barlow's disease 542: TABLE OF CONTENTS XUl Purpura urticans 544 Purpura f ulminans 544 Purpura variolosa 545 / — Diseases of the Skin Characterised by Fonnatioit of I'csiculd, Abscesses and Crusts: Varicella 547 Sudaniina 547 Herpes and herpes zoster 5^8 Eczema 5-19 Seborrhoea 549 Favus 550 Herpes tonsurans 552 Impetigo simplex and contagiosa . . 553 Ectyma 554 ^ — Diseases of the Skin Characterized by Formation of Separately Located Blebs: Pemphigus 554 h — Diseases of the Skin Characterised by pruritus ( ilehini:_ ) : A common itching of the skin 554 Papular eczema, prurigo, scabies 555 / — Skin-Diseases ivith Induration or CEdenia of the Sub- cutaneous Tissue : Sclerema neonatorum 558 (Edema of the body and of se])arate parts of the body . . . 559 Neuropathic oedema 563 Subcutaneous emphysema 565 INIyxoedema 5^5 CONSTITL^TIONAL CHRONIC AFEBRILE DISEASES WITH VARIOUS LOCALIZATIONS. a — Scrofulosis 5^7 — 57<^ Its symptoms S^S Diflferential diagnosis between leukaemia and hereditary late syphilis 5^9 b— Rachitis 57i— 57^ Symptoms of a developed and a beginning rachitis 572 The difiference from syphilis 57^^ c — Hereditary Syphilis S77 — 593 Its symptoms S77 Xiv TABLE OF CONTENTS Syphilis hereditaria tarda 57^- Parasyphilitic appearances 579 The diagnosis of an hereditary syphihs from an acquired one 59'^ FEBRILE DISEASES. Febrile diseases of the skin 595 Inflammation of the glands of the neck 596 Periparotitis epidemica 597 Glandular fever 59^ Otitis 599 Snuffles 599 Diseases of the mouth and throat 599 Diseases of the lungs, heart and bones 600 Local diseases with a latent course 601 FEBRILE DISEASES WITHOUT STRICT LOCALIZA- TIONS. DISEASES ClIAR.\CTEKlZi:i) I'.V FEVER OF THE CONSTANT TYPE. a — Typhoid Fever 603 — 618 Reaction of Gruber and Widal 603 Symptoms 605 Typhus levis and gravis 6to The diagnosis of typhoid fever from intennittens 611 From typhus fever 612 From tuberculosis 613 From typhoid form of tubercular meningitis 615 From ulcerous endocarditis and suppurative meningitis. .615 From osteomyelitis 6t6 b — Relapsing Fever 618 c — Acute Miliary Tuberculosis 620 — 629 Its dififerent forms 621 Typhoid form of tuberculosis 621 Subacute form 624 The diagnosis from typhoid fever 625 Chronic influenza 626 d — Diseases with Intermittent Fever 630 — 643 Malaria 63a Its atypical forms 630 — 641 TABLE OF CONTENTS XV Anaemic fever 5^ c Hysterical fever 638. FEBRILE DISEASES OF TYPICAL COURSE WITH LO- CALIZATION OX THE SKIN. a — Exantheniatous Fevers 644 — 645 b — Scarlatina 645 — 658 Symptoms 646 Its different forms 651 The diagnosis from measles 653 From scarlatinous rubeola 654 From sudamina 656 From medicamentous rash 656 From variolous erythema 657 c — Measles 658 — 666 Symptoms 658 Different forms 661 Diagnosis in the prodromal period and in the period of eruption 663. The diagnosis from rubella 665 d — Small-pox 666 — 669 c — Varicella 669 APPENDIX 671 THERAPEUTIC IXDEX .675—806 TABULATIONS 809—814 PRESCRIPTION IXDEX 815— 82r> GEXERAL INDEX EXAMINATION OF CHILDREN The examination of elder children does not exhihit anv great peculiarities in comparison with that of adults, so that we shall here take into consideration especially small children, those about two years old. Proceeding- to the inspection of such a child the phvsician must first of all take care not to frighten his patient, as his violent cry and restlessness may hinder the examination. It is best, enter- ing the patient's room, not to pay any attention for a while to him, but to occupy one's self with the history of the disease and thus let tlie child contemplate the new person ; the examination will then be more successful. It is needless to say that one must not only with caution begin procedures which are disagreeable for the child, but also those that are painful. For this reason it is better, for instance, to perform percussion and auscultation after the general inspection of the bowels? Normall\' mu'slings move the bowels two or three times in twenty-four hours ; after one year, at least once a day. The dejecta (the diet being ex- clusively milk) should be of jelly-like consistency, of uniform yellow-orange color, odorless, without any admixtures, as mucus, white lumps, green color, blood, etc. Any deviation from the normal condition regarding the frequency, consistency, color or composition is abnormal, so that questions must be referred to all these qualities separately, in order to ascertain if the child has dyspepsia or intestinal catarrh, or follicular enteritis. Does the diarrhoea appear periodically at a certain time of the day, or every second day? (marked malaria). Are there abdominal pains? (in nurslings attacks of colic). Do they occur in paroxysms or steadily"'' — and if in attacks, then after or before meals? ( ta])e-worms. cardialgia), or ])eriodically ? ( intermittens larvata ) . If there be some inclination to constipation, then is the con- sistency of the dejecta normal (soft, gruel-like, signifying intesti- nal atony or congenital stricture of the anus), or hard? (which is, for a nursling al)nrirmal altogether). Is the act of defecation accompanied by tenesmus (constipa- tion, mucous diarrhoea) ; by violent pain (fissure of the anus) ; or by prolapsus recti? After defection are some drops of blood ex- truded ? ( polypus ) . Are there eliminated, together with the dejecta, ta])e-wonns or separate joints thereof? Is there itching at the anus? (oxyuris vermicularis ). Respiratory orga)is. Is there snuffles (acute or chronic) ? In the case of acute snuffles is there a discharge of muco-purulent fluid (common cold in the head, influenza, measles), or a caustic one with the admixture of blood ? ( diphtheria of the nose, svph- ilis). In the case of chronic rhinitis are both nostrils aft'ected EXAMINATION OF CHILDREN 25 (scrofula), or only one (foreign body)? Does epistaxis occur, and under what conditions? (after cough it indicates pertussis; from unknown causes — -habitual nosebleed, polvpi of the nose, heart failure; periodical epistaxis is suspicious of intermittent fever (f. larvata, especially if occurring in the night-time). Does the baby cough ? Harsh, ringing (laryngitis or croup), or a common cough? Dry (a recent cough), or wet (resolved bronchitis) ? When does the baby cough the worse, in the day- time or in the night? (This question, together with the following, should determine whether the patient has whooping-cough). Does the paroxysm of cough lead to flushing of the face, and does it end with vomiting? Is the cough accompanied by a whistling inspiration ? Is there a discharge of viscid mucus after cough ? When was the cough stronger, in the beginning or at present? Was there a fever? Regarding la grippe of especial importance are the following questions : — Was there in the beginning violent fever, snuffles and shooting pains in the ear? Regarding inflammatory diseases— is the cough painful ? The circulatory organs do not require any subjectively ap- plied questions, as the diagnosis of their diseases is based on the results of objective examination. Children almost never com- plain of palpitation and pain in the region of the heart. Goiito-nrinary organs. Is the micturition normal regarding frequency? It is difficult to say how often a normal child should pass water, because the individuality here plays a decided role. Elder children usually do not urinate in the night-time. In the case of irritation of the bladder the patient urinates, for instance, every hour and very little at a time. Is micturition painful ? Is the urine clear? Is there retention of the urine, or z'icc -versa, incontinence during the night-time? Xcn'oiis system. Is there headache? Is it of recent origin or chronic, often relapsing? Does it always occur after mental exercises? Did it appear after contusion? The location of the pain? (One temple, viz., one side of the head in migraine). Are there other pains? Are there convulsions? If so, then how often do they recur? 26 EXAMINATION OF CHILDREN Are they accompanied by whistling- inspiration (laryngismus stridulus) ? or by severe fever (eclampsia from fever) ? or by weakening of the mental capacity, paralyses and other cerebral symptoms (cerebral convulsions) ? Are there paralyses ? How is the sleep of the patient? in the normal condition infants, as well as elder children, sleep the whole night without rousing; under two years the child also sleeps in the day-time. Abnormal sleep is characterized either by the child often awaken- ing, or, after falling asleep in the evening, he suddenly wakes up, jumps in his bed frightened, looks around with wide-open eyes, while he does not recognize even the nearest relative, some- times crying out the name of a thing which had frightened him during his sleep. After a few minutes he recovers his senses, becomes calmed, falls deeply asleep again and does not remember anything of the occurrence the next morning. Such attacks, known as "night-terrors" are mostly observed in children from two to five years of age and are repeated cither every evening, or only from time to time. If any restless slcej) occurs in a child who has fever, then this symptom is invaluable ; if, however, a poor sleep is of more or less common occurrence, then it proves the abnormal condi- tion of the central nervous system (irritability). In some children, about three years old, uneasy sleep usually depends upon general aut'emia (anaemia of the brain), because of rachitis or long-continued diarrhcea. In other cases again, uneasy sleep depends upon the irritated (dentition) condition of the nervous system. In older children disturbed sleep also depends often upon anaemia or general nervousness (influence of heredity). In anaemia and in nervous children night-terror is of most fre- quent occurrence, especially when they have adenoid vegetations in the naso-pharynx. In school-children the most frequent causes of sleeplessness are forced mental exercises. Among the causes of poor sleep is also included irritation of the bowels by intestinal worms or by products of abnormal diges- tion (absorption of ptomaines), or by stagnant excrements (con- stipation). Fever. Are fever, chill, or sweatins: noted in the child? EXAMINATION OF CIIII.DRRX 2/ Has fever been in long^ continuance and how difl it run ? We have here indicated only the most important questions. It is conceivable that in every individual case still other addi- :tional questions will be required, but it is unnecessary to enumerate ^11 of them here. Objective exaisiination and the significance of sepa- 3RATE symptoms. It is best to begin the examination with a general ins[)ec- tion which may furnish many data for the diagnosis. During this -examination attention should be given to the general countenance, to the so-called habitus of the patient, i. e., his posture, expres- sion of his face and eyes, condition of the nutrition, peculiarity ■of the skin, character of respiration, and generally to every thing the eye may note. If we have to deal with a little child, then it is better to see him while he sleeps, for the purpose of counting the respiration and the pulse and to get a proper idea regarding i;he color of the skin, because all these symptoms change decidedly under the influence of restlessness and the crying of the child. Tlic posture of the body may be involuntary or voluntary. It is called involuntary when the child assumes such a posture -instinctively, forced to such posture, inasmuch as any other causes ►either pain or some inconvenience. A forced posture at once leads the physician to think of the corresponding diseases, and together with other symptoms of the habitus it may plainly point to the diagnosis. For instance, the constant position on one side (the diseased) is in itself very char- acteristic of a pleuritic exudation (because another posture would still more hinder respiration by dislodging the mediastinum to the v^ell side, with compression of the healthy lung) ; if, at the same time, we see that the patient has become thin and pale (meaning that he has been ill for many days) and suffers from dyspnoea (accelerated breathing, distention of the nostrils), the heart-beat •being displaced toward the opposite side and the intercostal spaces being flattened on the sick side, then the diagnosis of abundant ;pleuritic effusion may be made even without any examination of the thorax; it will perhaps be necessary to resort to a very limited percussion to exclude pneumothorax. Also characteristic is an iiiiiiiobile f>ostiire on the baeic zcith 28 EXAMINATION OF CHILDREN slightly bent legs (in acute peritonitis) ; posture on the abdomen (in some cases of Pott's disease, phlegmons of the back and in case of severe photophobia, to hide the face in the pillow) ; sitting posture zcith the head throzvn back (In cases of laryngeal steno- sis) ; the posture of a setter {"en chien de fusil" of French authors — on the side, rolled up) occurs often in acute hydrocephalus,, when the contracture of the neck prevents the recumbent posi- tion. Restlessness, manifested by constant changing of posture,, is met with in severe headache, dyspnoea and high temperatures, which occur with delirium and blunted consciousness. It is also important to give heed to the expression of the face and of the eyes. The quick change of the color of the face, the motionless look fixed in the distance, the icide open, seldom- zvinking eye-lids, are very characteristic of meningitis and may be the most certain sign for its differentiation from typhoid. The characteristic trembling of the eye-balls, the so-called nystagmus, clinically expressing spasm of the eye-muscles, ap- pears usually in very early life, according to some authors being sometimes inherited, and shows only that llie vision of the child suffers from the first months of life from any cause. (Small spots- and cloudiness of the corneae, congenital cataract or amblyopia albinismus and pronounced anomalies of refraction. In complete- blindness nystagmus never develo])s. but atypical movements of the eye-balls are observed). In more advanced age nystagmus seldom occurs. If this symptom be associated with trembling of the limbs during volun- tary movements, then it appears as strong evidence in favor of multiple sclerosis of the central nervous system. Bright-red cheeks, contrasting with tJie paleness of the lips,. chin and nose, always occur in scarlet fever, but never in measles. Very pale and puffy face suggests nephritis. However, a puffy face with moist and hypergemic eyes is in favor of whooping- cough. The face is very characteristic of whooping-cough when the patient has, simultaneously with the puffiness, haemorrhages of one or both eye-balls. A puffy, as if oedematous, face with thick lips, thin hair on the head, together with impaired mental and physical condition, is very peculiar of myxoedema. On the- contrary, a lean face, with slightly sunken eyes, surrounded by EXAMINATION OF CIIILHRF.X 29 ■blue circles, show abundant loss of water by the org-anisni, i. c., watery, cholera-like diarrhoea, or the desolation of the arteries because of collapse of the heart, for instance during^ acute peri- tonitis. Punctate, thickly-crowded petechia- on the checks and espe- cially on the eye-lids indicate temj)orary, but considerable, venous stagnation in the skin of the face and permit the supposition of •either violent vomiting-, or whoopino-cough or an attack of general convulsions with hindered respiration. Jl'a.vy paleness of the face without any trace of a^dema in- dicates considerable diminution of hsemogiobin in blood, occur- ring during chlorosis, false and true leukciemia, malignant an?emia, and in small children during rachitis associated with a large tumor. Pallor zcitli yelhncish tint of the face with simultaneous dark pigmentation and seborrhoea of eye-brows and long-continued snuffles in a child several weeks of age renders possible the diag- nosis of inherited syphilis long before the appearance of more char- acteristic symptoms. Senile, wrinkled face in nurslings occurs in all kinds of atrophy which most often depend upon chronic starvation (lack -of breast-milk or the food does not correspond to the age), or upon chronic diarrhcea and tuberculosis. Inz'oluntary tz^'itchiiigs of different muscles of the face cause the appearance of peculiar grimaces, by which it is not difficult to recognize chorea. \Mien the face is draw)i toivard one side we recognize a facial paralysis, and think first of all of a carious process in the temporal bone. Painful disfiguration of the features of the face, occurring every time there is palpation of a certain part, allows us to de- termine exactly the place of pain. The face also expresses labored breathing (movements of the al« nasi) and very pronounced disturbance of circulation in the form of cyanosis of the lips. In short the face gives to the physician many data for hij ■diagnosis, of which the foregoing are the most important. About the general nutrition and complexion of the patient we judge from the development of the skeleton and muscles, from 30 EXAMINATION OF CIIH.DREN the size and weight of the body, from the tint of the skin and" mucous membranes, from the amount of subcutaneous fat and from the condition of the glands. If we find the skeleton to be developed normally, the muscles being firm to touch, then we say the baby is strong ; if, however, the bones be thin, the chest flat, the muscles flabby and as if atrophied, then we recognize that he- is of weak constitution. As to the subcutaneous fat, both its abundance (obesity) and insufficiency (exhaustion) are equally abnormal. Iispecially significant is a rapid euiaciatio)i without any visible caus'e, as such a "groundless" emaciation occurs most frequently in latent tuberculosis, although it may depend also upon other causes, for instance, upon rapid growth, loss of appetite because of anaemia or forced mental exercises, and especially upon masturbation. By the external examination (inspection) one can discover only gross defects of development of the organism, but when we deal with the definition of the primary stages of malnutrition,, when one watches the development of the child step by step, then inspection alone is, of course, insufficient ; here are necessary exact measurements of the length of the body and its separate- parts, especially of the head and the chest, as well as a determina- tion of the weight. All these means are resorted to in all cases where we have ta do with a nursling and when w'e have to decide whether he re- ceives a sufficient amount of food, whether the wet-nurse is good and whether it is not time to wean the child or to give additional' food. In such cases the surest results may be obtained from the regular zveighing of the cliild, at least once or twice a week. In view of the findings there are certain normal standards to be- taken into consideration, marked deviations from which are to be- held as pathological. As every child develops in his own way, the growth of the- body never proceeding proportionally, it is, of course, impossible to establish an exact standard, pro|Der for every body, therefore, almost every author having occupied himself wnth this matter has oiTered his own tables of weight. But all these tables, in my opinion, have no advantage in comparison with the so-called "Bouchard's ideal curve" of the increase of the weight of the- EXAMINATION OF CHILDREN 31 body, which is very easy to be kept in memory. Therefore, I shall take this curve as a standard to be considered in estimating the results in each individual case. The normal weight of a new-born is between 2,500 and 5,000 grams, an average of 3,250 grams (eight pounds). A weight under 2,500 indicates incomplete development of the child, occur- ring in abortive children. During the first days after birth some loss of weight is always to be expected, reaching its maximum about the fourth day, totally Name, Date of Birth, ISO Gms. Lbs. 1 2 3 1 6 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 1120 1310 1200 1080 3970 3850 3710 3C30 3510 3100 3290 3180 3060 2910 2830 2720 2610 2190 2380 9X 9M »^ 9 «x 8>i 8 7X 7« 7 5X 6X ^ ^ ^ -^ ^ r-^ -^ I ^ --' --' \ ^ ^ \ h ^ ^ \ <-^ J _J ■ Fig. I. — Weight curve of the first twenty days. amounting to about 130 to 140 grams. Toward the tenth day the weight should rise to the original point, otherwise there is some abnormality. In firstlings, likewise in abortive children and those fed artificially, the loss in weight is usually greater and be- comes normal later (abortive children, according to Miller, com- pensate the loss of weight usually not earlier than at the end of the second week). After the tenth day the weight of the child increases progressively, reaching a maximum during the first and 32 EXAM IXATIOX ()|- C II II.DRKX second montlis, and then with every month the increase becomes slower. In the case of correct development the original weight is doubled toward the end of the fifth month, and toward the end of the year becomes trebled. (Fig. i.) According to Bouchard's tables the increase of weight occurs in the following way : — Total increase In one day Total weight during month. gms. g'lis. of child, gms. Tst 750 25 4,000 2n(l 700 23 4,700 3rd 650 22 5,350 4tii <'ioo 20 5-950 5th 550 18 6,500 6th 500 17 7,000 7th 450 15 ^^450 8th 400 13 7,850 9th 350 12 8,200 loth 300 10 8,500 I iLli 250 8 8,750 I2th 200 7 8,950 Toward the end of the year the child's weight thus must be about 9,000 grams (twenty-two pounds). This weight becomes doubled about the sixth year (the yearly addition is about 1,500 to 1,800 grams) reaching forty to fifty pounds. Then again after seven years it becomes doubled (yearly 1,800 to 2,000 grams; and after ten years about 3,000 grams). (Fig. 2.) The growth of the body, head and chest. The normal length of the newly-born is an average of 50 centimeters (minimum 45, maximum 58). Growth is quickest in the first months of life; the increase toward the end of the year, according to Quetelet, being twenty centimeters (eight inches) ; the increase in the sec- ond year, ten centimeters (3 4-5 inches), in the third year — seven centimeters (2 3-5 inches), then every year from four up to six- teen years — alx)ut 5.5 centimeters (2 inches). From sixteen to seventeen years the increase is about four centimeters (ij^ inches), then up to twenty-five years about 2.5 centimeters (about one inch) ; and totally the increase amounts to 128 centimeters (about 50 inches), so that the normal length of the l>ody of an adult person rs equal to 178 centimeters (about 68 inches). According to Liharzik all healthy persons grow quite identi- EXAMINATION ()!• CHILDREN 33 cally. in periods ; he defines twenty-three periods, each being- longer than the preceding, while the difference increases in arithmetical progression ; the first period — one month, the second — two, the third — three, etc. During any period under the twenty- first month (the end of the sixth period) the length of the body increases about 'jYj centimeters (about three inches), the circum- ference of the head — 2y2 centimeters (one inch), that of the chest — 2V2 centimeters. After twentv-one montlis the growth is I^atne, WEIGHT CHART. Date of Birth rSo ■^ i _l MONTH OF AGE. 1 2 3 4 5 6 7 8 9 10 11 12 lOSiW IU30 W80 9630 9070 8S20 C1«0 7710 7800 6800 63fiO S»00 UM «990 UM MWO 3630 3180 2720 2Z70 21 23 22 21 20 10 18 17 16 15 U 13 12 11 10 9 8 7 6 ~ '~ "■ 1 — 1 , ** '' < ■^ ^ ». * ■ ■* ,. « "^ ^' _ ** ^^ ,>" > / / / / / / - - - / 4 f / ^ - .- _^ _j ^ _ 1 1 Fie Tlu In curve of the first year. much slower; the length of the body increases only five centi- meters (2 inches) during each period, the circumference of the head, 13-24 centimeters, that of the chest 13-24 to ix-17 centi- meters; from twelve years (the eighteenth period) the growth of the chest increases considerably ; the amount of the increase is for each period 13-24+5 centimeters (2 inches) growth of the body. 34 EXAMINATION OF CITII.DREN All these data are expressed in the following table Peri- The The The The The cir- The cir- The ods. lumber j^rowth growth growth cumference cumfereuce length in of the of the of the of the of the of the of the order. mouths. head. chest. body. head. chest. body. cm. cm. em. cm. cm. cm. 1 1 2¥j 214x13-17 Ji/.- 371/2 36 9-34 ••57 Mi 2 3 2V2 2 1^x13-17 7 ' •> 40 39 18-34 65 3 (j 2% 214x13-17 71/j 421/0 42 27-34 72 V, 4 10 21/2 214x13-17 7'/.. 45 46 2-34 80 ;") 15 2V^ 214x1317 714 47'/. 49 11-34 871/2 6 •Jl 21/0 214x13-17 71/j a> 52 20-34 95 7 28 13-34 13-34x13-17 5 50 i3-:i4 .53 25-:}4 KM) 8 3(i 13-34 13-34x13-17 r^ 50 26-:i4 54 30-34 1(15 9 45 13-34 13-34x13-17 r 51 1-34 5(i 1-34 110 10 55 13-34 13-34x13-17 5 51 18-34 57 2-:^ 115 11 66 13-34 13-34x13-17 5 51 31-34 5S 11-34 120 12 78 13-34 1:; ::4-i3-i7 5 52 10-34 50 16-34 125 13 ni 13-34 i:; ;!J1:m7 5 52 20-34 t>o2i-:u 130 14 105 13-34 1:! .-ui:; 17 5 53 2-34 61 26-34 135 15 120 13-34 i:',-34- 13-17 5 53 15-34 62 31-34 140 16 136 13-34 13 341:M7 5 53 28-34 M 28-;i4 145 17 153 13-34 13 34, 150 In a normally developed new-born child the circumference of the head exceeds that of the chest by from one to two centi- meters (about half-an-inch to one inch) ; the size of the chest ex- ceeds the half of the length of the body by nine to ten centimeters (about four inches), minimum of seven centimeters (three inches). If the difference between the head and the chest is greater than two centimeters (one inch), and that between the chest and the half of the body less than seven centimeters (three inches), then this points to congenital weakness of the child, his reduced vitality. Generally speaking, the stronger the constitution of the child the more his chest equals the head in dimensions ; the weaker the child the more the head prevails in size. It follows from Liharzik's table that the circumference of the chest becomes equal to that of the head toward the end of the first half of the year ; but in reality such a growth of the chest is a quite rare occurrence, being only observed in the most robust children. In the majority of healthy children the chest begins to exceed the head only in the third year; in feeble and rachitic children during the fifth or the sixth year. Regarding the length of the body we noticed that the circum- ference of the chest must exceed that of the half of the body at least by seven or eight centimeters (three to three-and-a-half inches), an average of ten centimeters (four inches). This differ- ence gradually vanishes during the first years of life and descends to zero by the seventh or eighth year; after that the circumfer- ence of the chest begins to remain behind the half-growth, the difference in favor of the latter reaching, at twelve years, two to four centimeters (one to two inches). The better the child is developed — the stronger he is — so com- paratively larger is the circumference of his chest. The latter •exceeds, in children about ten vears old. the half-growth of the 36 EXAMINATION OF CHILDREN body bv four or five centimeters (two or two-and-a-half inches) and becomes even only toward fourteen or fifteen years. If the primary weight of the body be under 300 grams (seven pounds ) , the dimensions of the head and chest being of the above said form, it means the child was born weak ; if, however, all those sizes are above the normal average, then the child was born robust. We speak of children-giants when the weight exceeds at birth 500 grams (twelve pounds). The largest weight at birth, learned from literature, (x:curred in Dr. Wisin's practice (9,000 grams, or twenty-one pounds). The under- weight of the new-born, or its general atrophy, either indicates that he is an abortive child, or (if born at full term) that his nutrition during uterine life was abnormal because of disease of the mother (most often syphilis), or disease of the placenta. Atrophy occurring in children born healthy and robust is usually caused by chronic starvation : — this is simple or true atrophy. The causes of emaciation in other cases are some chronic diseases, most often diarrhrea and general tuberculosis : — this is symptomatic atrophy. Simple atrophy as an entirely independent disease, i. e., one wdiich is not caused by intestinal catarrh or other diseases of the viscera, occurs only in children during the first months of life, and by its aetiology, symptomatology and thera])y must be decided- ly distinguished from symptomatic atro])hy as the result of ex- hausting diseases. The aetiology of pure atrophy is traceable to chronic starvation, no matter whether it depends upon lack of milk in the nursing woman, or upon abnormal artificial feeding by small quantities of diluted milk, or by food which is altogether improper to the child's age so that it cannot be assimilated. Symptoms of any form of atrophy are manifested by general emaciation of the organism, consisting especially in the complete disappearance of the sulxutaneous fat, and with flabbiness or folding of the skin. In children of the earliest months of life there is also among the characteristic symptoms a depression upon the top of the skull because of diminution of the brain : the large EXAMINATION OF C 1 1 I I.DRKX 37 fontanclle is deeply (le|)ressc(l and the l)()nes of the skull slide over each other. Simple, uncomplicated atroph\- ditters from the syui]:)toniatic variety caused by chronic diarrhoea 1)\' the following peculiari- ties : — ( I ) It develops most often during the first four months and very seldom after six months ; while the symptomatic form ap- pears later. (2) Instead of diarrhcea and distended abdomen there usually is constipation, the belly being sunken and flattened and the urine scanty (see the section on Constipation). (3) There is never redema of the suljcutaneous tissue, which seldom fails (around the malleoli ) in emaciation caused by diarrhoea. If simple atrophy be complicated by intestinal catarrh ( which happens not infrequently, especially if the atroph\- arises under the influence of improper nourishment), then considerable ex- pansion of the belly may also occur, so that for the correct esti- mation of the case there remain the first and the third criteria and the history (if considerable emaciation began before the diarrhcea : inquiry after the previous feeding of the ch.ild and about its amount; examination of the breasts of the mother in regard to the quantity of milk). Symptomatic atrophy, met with sometimes in grave cases of rachitis, diiTers from the genuine form, not only in the child's age, but by the symptoms of pronounced rachitis. The last circum- stance obtains especial diagnostic value in view oi the interesting fact, found by Bohn, that children sufifermg from simple atrophy do not manifest any disposition to rachitis, so that even softening of the occiput is then absent. The most difficult to distinguish is simple atrophy from tuberculosis of small children, especially when the atrophy be- comes complicated by bronchitis or pneumonia, which is so often to be met with. On the other hand even the absence of cough does not exclude tuberculosis. If simple atrophy may be ex- cluded on the ground of the anamnesis and no visible causes be found for the explanation of the marasmus, then tuberculosis is to be suspected, and we must try to confirm it b\ the febrile condition and heredity. 38 EXAMINATION OF CHILDREN Inspecting the skiu one must pay attention to its color and tO' possible eruptions. ( See the section on the Senieiology of the Skin). About the condition of the lymphatic glands we get an i;lea by inspection and palpation of the neck, axillae and groins. In entirely healthy children, the subcutaneous tissue being moderately developed, the lymphatic glands cannot be palpated. Chronic en- larged glands, evident to a common e-xamination, indicate a serious disorder of the general nutrition (tuberculosis, true or false leukaemia, or at least a pronounced scrofula), in the case of niicropolyadcnisni, i. e.. when one can palpate at the nape of the neck, in the axilUe and groins, a great number of glands, solid, movable, painless, small (from the size of a hemp-seed to that of a coffee-bean), we may draw a conclusion about tlie weakness of the lymphatic glands, i. e., abinit their vulnerability in the sense of being ])rone to hyperplasia and caseous degeneration. Such patients we hold as scrofulous, liable also to hyperplasia of the internal glands as, for instance, the bronchial. In the opinion of some French authors, micropolyadenism and swelling of the spleen in pale and marasmic children are certain signs of general tuberculosis. At any rate one must not become much discouraged by the presence of micropolyadenism, as this symptom may alsa occur, besides in tuberculosis, during other forms of marasmus, for instance, under the inlUience of chronic diarrhrea. svphilis and bronchopneumonia. .Vssociation of micropolyadenism with swelling of the spleen, and often of the liver, indicates, at any rate, considerable exhaus- tion of the organism. Micropolyadenism occurs most often in children of early age, those of five or six years. Examination of. the head is carried out by inspecting, pal- pating and measuring. Attention is to be given to the shape and size of the head, the condition of the sutures and fontanelles, the hardness of the bones and the condition of the skin. The head of a normal child must have an oval form, without any pronounced character of the parietal and frontal protuber- ances, and entirely symmetrical. The bones of the skull must be solid, neither yielding to pressure by the finger even on the sutures or at the point of the frontal fontanelle. The latter remains often. EXAMIXATIOX OI' (11 1 l.l1Ki;.\ 39 until the twelfth to the sixteenth months, however the lambdoidal, sag-ittal and coronal niav he felt not later tliaii before the end of the third month. About the size of tlie head of the new-born, its increase ac- cording to the age. and about the relation of the circumferences of the head and the chest. I have already spoken. Deviations fron: the normal condition may be manifold. Ir- regular, ang-ular shape of the head, because of abnormal growth of the parietal and frontal protuberances, points toward rachitis, in the highest degree of which the head becomes saddlc-shapcd. This form is characterized by flattening of the skull imd bv a con- siderable development of the protuberances, while depressions are to be seen in those places of the skull which correspond to the sutures. A slight asyiiniictry of the skull in the form of some flatten- ing of one side ( usually in the region of the connection of the parietal bone with the occipital ) occurs very often in small children, depending uix)n the constant lying of the child on one side. Such an asymmetry has no importance ( pathological ) . s(jon disappearing if care be taken that the child should not lie upon one side. Another thing are the highest degrees of asymmetry which depend upon the early ossification of the sutures of one side of the head, or upon the congenital maldevelopment of one hemisphere. If the circitmference of the chest in the first year of life is much larger than that of the head, then this indicates maldevelop- ment of the head (microcephalia), being a reason for fearing future idiocy. ( )n the contrary, if the head be, in comparison with the chest and the age. too large, then is the child suiTering either from rachitis, with simple sinutltaneous hypertrophy of the brain, or chronic hydrocephalus. Chronic hydrocephalus is usually a cc^ngenital malady and consists in accumulation of fluid in the cerebral ventricles. With advancing age it usually increases. Franz Mayr differentiates the characteristic features of hyper- trophy of the brain and those of the hydrocephalus in the fol- lowing table : ( * ) *Franz Mayr: Jarbiichcr fi'ir Kiudcrh. I. B. S. 15. 40 EXAMINATION OF CHILDREN Hypertrophy of the Brain. Hydrocephalus chronicus. The shape of the skull: Wide, angular with eminent Spheroidal, witliout any frontal and occipital protuber- pronounced eminences, ances. Enlargement of the skull Develops very slowly, almost • Develops rapidly, so that a imperceptibly, and never be- visible increase of the diame- comes so considerable that the ters may be noticed even after face is, in comparison with the two weeks: the face, in com- skull, disproportionally small. parison with the skull, is pro- portionally '^mall. The anterior foutauelle Is larocr than normal ; it is / 'ery lari;c. protruded and elevated and ])ulsates intense- does not pulsate at all. or very ly. little. The hones Are movahle at the location of Are connected by membran- the sutures, but somewhat dis- ous. tense interspaces, connected. Coinplications. Traces of bc.i^innint;- rachitis Retarded development of in the rest of the skeleton. the bones and muscles. Laryngismus stridulus. General convulsions. Mental development. Occurs normally, sometimes Hindered, at least in sepa- remarkably well. rate forms. Often idiocy. The conse(]uenees of compression of the brain Imperceptible, if in the l)eg-in- Are always present. \^omit- ning of the disease the fonta- ing, heaviness of the head, nelle was still open. tremor on motion, strabismus, wide pupils, tonic spasm in the legs. etc. Softening of the skull-bones may be inherited or acquireeing- covered with normal skin ; in short, a tumor very similar to a brain hernia. The diag'nosis may be corroborated by the possibility of palpating, at the base of the tumor, the margin of the bone-opening and of reducing, or at least decreasing, the tumor by a moderate force, while symptoms of brain pressure may appear. However, it is not difficult to distinguish between the true and false hernije ; besides the history, the place occupied by the tumor positively indicates what the trouble is ; the false brain hernia is never located on a suture, but always on the bone itself, generally upon one of the parietal bones. In elder children there sometimes occur on the scalp circum- scribed periostites, simple, purulent, and sarcomatous tumors. The examination of the month and fauces is performed by inspection, for which purpose one must sometimes forcibly open the child's mouth. In new-born children and nurslings it suffices to make a slight pressure on the chin by the finger, but in children three to live years old the physician sometimes meets a resistance on the part of the child not easy to overcome. In many cases one succeeds in making the child open the mouth by means of com- pressing the nostrils, but this does not always follow, because some children contrive to breath through the slits of the teeth. In such cases one must introduce the handle of a tea-spoon be- tween the cheek and the teeth behind the last molars and then turn the spoon in such a way that the handle comes edgewise between the gums. By this procedure the child will always open his mouth, and if his head is well fixed then a few seconds will be sufficient to inspect his throat. During the examination of the mouth diverse inherited anomalies may be met with, as, for instance, complete or incom- plete adhesion of the lips, division of the upper lip — hare lip (labium leporinum) or of the soft palate — cleft palate (palatum fissum). Some symptoms pertaining to the mouth may have signifi- cance in the diagnosis of other diseases, for instance, convulsive contraction of the maxillse is usually the first symptom of tetanus. 46 EXAMTNATIOX OF CHILDREN A constantly open mouth often occurs in scrofulous children suffering with chronic rhinitis and hypertrophy of the tonsils. In acute cases an open mouth with salivation occurs in aphthous stomatitis ; the same in a chronic form being peculiar to idiotism. Thickening of the upper lip belongs to the signs of a scrofu- lous habitus and develops under the influence of repeated snuffles with caustic secretion, which occasions a mild inflammatory pro- cess of the skin and the subcutaneous tissue of the lip. The mucous membrane of the lips appears as a favorable place for the manifestations of hereditary syphilis in the form of fissures and mucous patches. (Diseases of the Mouth and Throat will be found in separate sections.) Inspecting and palpating the neck may occasionally furnish many data for the diagnosis. Attention must be granted to the position of the head (see Torticollis and Contracture of the Neck), to the condition of the spinal column (spondylitis), of the lymphatic glands and of the cellular tissue. Regarding the im- portance of circumscribed (edema of the neck we shall speak tmder the Semeiology of the Skin and that of the Subcutaneous Cellular Tissue. But besides oedema there occur on the neck of- tener than elsewhere diffuse phlegmons and abscesses of the lym- phatic glands. The phlegmons most often accompany malignant scarlatinal sore throat, however, suppuration of the glands may develop either independently, especiall} in the glands behind the ears, or because of some wet eruptions on the head (occipital glands in small children) or on the face (the glands under the cliin). About micropolvadenitis we have already spoken (page 3B). As an inherited anomaly there sometimes occurs on the neck a fistulous opening or small, constantly wet hollow, as the conse- quence of incomplete closure of the branchial-archs. The open- ing is locatecl either in the middle line of the neck and communi- cates through a narrow canal with the trachea (fistula colli trachealis congenita), or on the sides, above the sterno-clavicular articulation, and leads to the oesophagus. Of the tumors of the neck, besides those which depend upon acute swelling of the glands and cellular tissue, there is developed in new-born children a small, smooth, solid, oval growth, cov- EXAMINATION OF (11 i LDKl'^.V 47 ■ered with normal skin and located just on the sterno-cleido-mas- toid muscle. This tumor develops in the first days of the child's life, indicating rupture of this muscle during labor and is de- pendent upon haemorrhage at the place of rui)turc and upon the formation of an inflammatory scar (hccinafojiia musciili sterno- clcido-mastoidei). This tumor is always unilateral and vanishes, without leaving any traces, in two or three weeks. [Theron W. Wilmer lately reported three cases of h?ematoma ■of the sterno-cleido-mastoid muscle. The mode of origin of the Fig. 3. — Characteristic position of liead in hsematoma of the sterno-mastoid muscle (after Kihner). tumor is described by the author in the following manner : — "In breech presentations in which a midwife tries to disengage the after-coming head by pulling with great force upon the child's legs, this affection is almost certain to follow on account of the laceration of the mastoid muscle. The expulsive efforts of the uterus alone may be sufficient to cause this condition." The hccmatoma occurs, according to the same author, usually at or 48 EXAMINATION OF CHILDREN above the middle of the muscle. Wheii the injury occurs, the blood escapes from the torn vessels and causes a soft swelling be- tween the torn fibers ; the tumor gradually becomes harder as the clot is converted into fibrous tissue. The skin over the tumor is freely movable and of normal appearance. The size of the tumor varies from that of a small hazelnut to that of a walnut, and sometimes the whole length of the muscle is involved. The characteristic position in which the infant holds its head is noticeable. The head is dra'icii toicard the affected side by the contraction of the muscle, (hig. 3-) Fig. 4. — Position of tumor in hematoma of the sterno-mastoid muscle (after Kilmer). The usual duration of the tumor is from one to three months. A torticollis may persist after the swelling has disappeared. The situation of the h?ematoma in the substance of the muscle dift'er- entiates it from the swollen lymph-nodes. (Fig. 4.) The anatomical foundation is "laceration of, exudation in, and slight inflammation of the muscle itself.""^ — Earle.] Of chronic neck tumors there sometimes develops in elder children enlargement of the thyroid gland, the so-called goitre — struma, easily recognisable b}- its softness and location on the anterior surface of the neck. In our locality (Moscow) this *Mcd. Record. February 27, 1904, pp. 335-336. :x.\M[NAru)\ ()|- ( II I i.i)Ki:.\ 49 disease seldom occurs. Comparatively more frequent are chronic tumors of the lymphatic ij;!aiids. diffusing in big, knobby collec- tions. The glands appear iri such cases caseously or sarcomatous- ly degenerated. Such tumors must not be confounded with congenital cysts of the neck — liygroma cysticum coiigenitiim colli. This tumor consists of a conglomeration of small and large cysts, as deter- mined by inspecting and palpating, showing the presence of elastic and fluctuating elevations of spherical form. The tumor arises from the submaxillary region, being always congenital. Its size varies from that of a walnut to that of the fist of an arlult jier- son, and even larger. Sometimes it remains /';/ .s-/(///^ quo: how- ever, it may grow remarkably rapid and lead to suffocation. The skin which covers the tumor is usually unchanged, or thinned in places, but in some cases may be very much thickened, i'unc- ture gives in some instances a fresh or slightl\ -turbid Huid, in others, because of admi.xture of blood, that of cliocolate-color. This tumor is caused by hyperplasia of the lymphatic vessels and may be called lymj^hangioma c}sticum congenitum. It may be mistaken for sarcoma because of the rapid growth and solidity of the connective tissue stride, which serve to connect separate cavities, but sarcomatous elements are not to be found even in tumors with a very rapid growth. The development sometimes stops, but spontaneous healing almost never results. In examining the vertebral column one should give attention to its form, mobility, painfulness during movement or pressure Uj^jon the head and upon the spinal processes as well. The examination of the chest in children is performed by the same methods as in adults, i. e., by inspection, palpation, measuring, percussion and auscultation. Supposing our readers are entirely acquainted with all these methods of examination, we need onl}- offer brief remarks regarding some peculiarities of percussion and auscultation in children, because some trifles are encountered from a non-acquaintance witli which the physician may be led into entirely false conclusions. Thus, percussing an asymmetrical chest, when the ribs on one side are more convex, the other one being flattened, we get, ccvtens paribus, on percus- sion of the convex ribs a duller sound than from the tiattened ribs. The chest being normall>- developed, a mistake ma.\- be ob- 50 EXAMINATION OF CHILDREN tained because of the child sitting improperly, when, for instance, he is bent over to one side. In such a case, likewise in lateral curvature of the vertebral column, the greater dullness will be on the concave side. If the muscles be tense on one side of the chest, because of unequal position of the arms, the other side relaxed, then dullness will be obtained on the side of the con- tracted muscles (provided the percussion be performed over the contracted muscle). To avoid these errors one must liold llic child in such a manner that his shoulders be on a level and that the position of the shoulders be equal on both sides, if we deal with a child one or two years old, then 1 recommend to hold him firmly during percussion of the back. To this end the child is seated on a horizontal surface, for instance, on a pillow placed on the table, the arms being bent at a rectangle, the ellx)ws with the fore- arms on the abdomen so that they cross each other; this iX)sition is maintained by the right arm of the mother, who should stand at the right side of the child. The left arm she puts on the oc- ciput of the child, bending the head forward by slight pressure, in order to prevent it being thrown backwards, which always happens as soon as the percussion of the l>ack is begun. Further, one should bear in mind that the percussion sound becomes considerably dulled if the examination be undertaken during crying; this dullness being most perceptible in the inferio- posterior portions of the chest, where the majority of expiratory muscles are attached. Therefore, if the child is crying the phy- sician should percuss one place by short and frequent strokes until the child takes a deep inspiration. If the dull resonance be ob- tained again, then it is quite certainly real. Percussion should always be performed by light strokes, as the vibrations, owing to the great elasticity of the child's chest and its small dimensions, are too easily transferred to remote portions of the lungs, so that on strong percussion the dull re- sonance of a circumscribed area may be entirely deadened by the intense resonance of the healthy surrounding portions of the lungs. In percussing the back beginners often make a mistake by placing the pleximeter too low, i. e., where there is no lung tissue. Regarding the position of the lower edge of the lungs one may l^e guided by certain marks of the skeleton. The question is EXAMINATION OF CHIMmEN" :; I simplified by the relation of the lungs to the skeleton being in both small children and adult persons constant, namely: on the back the lower margin corresponds to the spinal process of the eleventh vertebra and goes from this point forward, intersecting, on the left side, on the linea axillaris, the ninth rib ; and on the right, the 1. mamillaris, the sixth rib. Auscultation of the back is hindered by continuous move- ments of the child and its cry. Because of restlessness in small children auscultation by a common stethoscope is very difficult, being sometimes altogether impossible. In examining the back one may be assisted by adopting the direct metho<:l. the child hav- ing been jammed, so to say, between the head and the hand applied to the chest, in which position it is not so difficult to hold him immovable. But before applying the ear to the child's chest one should mark the place to be examined, and then listen. Without this precaution the beginner often makes great mistakes by auscul- tating, for instance, the vertebral column, the back and the lum- bar region instead of the postero-lateral surface of the chest. It is inconvenient to directly auscultate the anterior surface of the chest, especially the upper portions, because of lack of .space. It is better to use for such purposes a soft, elastic stetho- scope, b\" means of which it is easy to watch the movements of the child, and by the aid of which one may listen with(iut pro- ducing great pressure upon the skin or causing any pain. But one should be accustomed to such a stethoscope in order to ap- preciate the sounds. With regard to the child's crying, this is an obstacle per- haps only for the beginner, while an experienced physician takes .advantage of the time of the cry as a moment favorable for the ■examination, first, because of furnishing a possibility of examin- ing vocal vibrations (such an important symptom in distinguish- ing pneumonia from pleurisy) and bronchophonia, the importance of which in the diagnosis is not less than that of bronchial respira- tion ; secondly, during the cry the patient necessarily takes deep inspirations, so that one may better than in quiet breathing hear the character of the inspiratory murmur and rales, especially min ute and crepitant ones. On auscultation of the chest of a crying child by the direct method it is advisable, according to Ziemssen, to stop the free 52 EXAMINATION OF CHILDREN ear bv the finger, in order to concentrate the attention on the sounds coming- from the chest to the auscuhating ear. The beginner should bear in mind that the vesicular respira- tory murmur is normally expressed very sharply after the second year (therefore it receives an especial name — puerile resi)iration)and may be mistaken for bronchial respiration. In children under one year of age the resjiiratory murnnir seems to be diminished under tlie iniUience of feeble muscular activity. ( )n ins f^cc fillip the chest we have to regard the number and character of the respiratory movements, the place of the apex- beat, the shape of the chest and the condition of the skin. The resf^iratioii in iiew-bor>i and nurslings is of the abdomi- nal ty])e and becomes gradually costal only at the age of four years. In cliildrc'u, during the first months of life the respiration, in the normal condition during com])lete rest, for instance, when the child slee])s, is not entirely regular, because shallow insignifi- cant respirator)- movements alternate with deejier ones, ac- companied by intervals. Similar irregularities may be held as pathological only in children after the second year of life, being of especial im])ortance for the diagnosis of cerebral diseases, al- though occurring also during ])ainful respiration, for instance, in rheumatism of the muscles of the chest and in pleurisy. To ordinary occurrences in small children there may also be referred the sinking of the points of attachment of the diaphragm on the lateral and anterior walls of the chest (peripneumonic fis- sure of Trousseau), easily noticeable also during quiet breathing, but especially pronounced during the cry. In a child over four years such a sinking should not be visible during quiet breathing ; otherwise we have right to suppose one of two things : either the access of air to the lungs is hindered, or the ribs are abnormally yielding, soft. If the obstacle to respiration be in the larynx or trachea, then a stenotic respiratory murmur wall obtain, together with deepening of the supraclavicular and jugular fossae. If, however, the obstruction be in the bronchi, the respiration neces- sarily becomes considerably accelerated, and the child coughs violently ; in the absence, however, of both the cough and symp- toms of the laryngeal stenosis, it remains only to suppose softness of the ribs, dependent upon rachitis. Politzer refers to habitual, continuous, (from the moment of EXAMIXATIOX OF CH I I.DRr-LX 53 birth) loud, bleating c.vpiratioii, observed suineiiuics m new-born during the first days of life. This symptom, depending upon ab- normal innervation, and disappearing in time without any conse- quences, is uneven, divided into five or seven intervals, and ac- companied by a loud sound like the bleating of a goat; while in- spiration is free, hardl}' audible, short and in general normal. In the majority of cases such a respiration having appeared im- mediately after birth lasts until the eighth month or even the end of the year. If once developed it does not stop day or night. The importance of this symptom consists only in that the physi- cian being acquainted with it should quiet the parents and not re- sort to unnecessary measures. The counting of the respiratory movements is performed either by the eye, or by the hand applied to the epigastrium. It is impossible to define exactly the number of respirations in small children, as it varies greatly even in an entirely passive state, judging from the contradictory testimonies of authors. Vogel. for instance, gives the average number of respirations in the new- born as 26.4. but Ouetelet says 44. On vertical position the new-born breathes one-third quicker : awakening has the same effect (46 to 58 times a minute). At an average the number of respirations in the second year is accepted as about twenty-eight : in the third and fourth years — twenty-five ; from six up to ten years it is twenty to twenty-eight. The frequency of respiration in all ages increases considerably under the influence of fever and forced movements (in the first two years of life, the temperature being 104 to 105 degrees F., one may not infrequently count from fift}- to seventy respirations in a mimite ) : therefore quick- ening of the respiration does not prove of itself the presence of pulmonary disease. It is in favor of the latter only when the child exhibits at the same time other symptoms of dyspnoea, as, for instance, distention of the al?e nasi, sinking of the points of attachment of the diaphragm, sighing and groaning at each ex- piration. Attention should also be directed to the ratio of the number of respirations to the pulse. If the former bears to the latter a normal ratio of i 13.5 or 4.5, then this proves the cause of the accelerated breathing not to be an affection of the lungs, becaus: the ratio then becomes i :2.5 to 2. 54 EXAMINATION OF CHILDREN Retarded breathing denotes some serious disorder of the respiratory nervous mechanism. It occurs in cerebral diseases which produce compression of the brain, in uraemia and cholera. (*) In acute hydrocephalus there are characteristic deep inspira- tions followed by long intervals. Such inspirations at first take place from time to time, but later, in the stage of coma, they may be observed every minute in the form of Cheyne-Stokes respira- tion. The latter consists in the hardly noticeable breathing be- coming with each inspiration deeper and deeper, reaching the acme and then again decreasing gradually until it stops for about ten to thirty seconds. Cheyne-Stokcs type of respiration indi- cates exhaustion of the respiratory center, being, in the majority of cases, a symptom of impending death. That this symptom is not to be hel EXAMINATION OF CHILDREN ^5 pure, being almost always combined, i. e., a lesion of one valve leads to affection of anotber one, for instance, congenital narrow- ing- of tbe pulmonary artery is almost always combined witb patency of the ductus arteriosus, or with insufficient development of the interventricular septum ; stenosis of the tricuspid — with patency of the oval opening, etc., so that murmurs may arise In several places. As a peculiarity of congenital heart lesions one may also point out that they are referred especially to the right heart (pulmonary artery) and that such patients are verv prone to cyanosis (become cyanotic when crying) and are characterized by muscular weakness and general malnutrition. The following cardiac defects bear an especial relation to childhood, being mostl}- congenital. (i) Stenosis of the pulmonary artery. (2) Patency of the ductus Botalli. (3) Insufficiency of the semilunar valves of the pulmonarv artery. (4) Stenosis of the tricuspid valve. (5) Insufficiency of the tricuspid valve. (6) Defect of development of the interventricular septum. (7) Patency of the foramen ovale. If any of these defects exist definitely, then it may be recog- nized by the following symptoms: Stenosis of the pulmonary ar- tery, like patency of the ductus arteriosus (d. Botalli), manifests itself by a systolic murmur in the area of the pulmonary artery (the second left intercostal space) and by hypertrophy with dila- tation of the right ventricle (increase of the cardiac dullness to- ward the right side, pulsation in the epigastrium). The differ- ence is that in patency of the ductus arteriosus the pulmonary artery is overfilled w-ith blood and therefore the second sound is considerably accentuated ; while in narrowing of the pulmonary artery the second sound is also accentuated, but the cyanosis is here more pronounced than in the former. For the diagnosis of pure stenosis of the pulmonar}- artery a murmur alone is in- sufficient ; one nnist yet prove the presence of dilatation of the right ventricle. In acquired stenosis of the pulmonary arter\- a murmur in the carotid arteries is never present, which circum- stance may serve in doubtful cases for the differentiation of stenosis of the pulmonary artery from aortic stenosis. However. 66 EXAMINATION OF CHILDREN in congenital defects this s}mptom is not of decided value, as the systolic murmur in the carotid arteries may also accompany pul- monary stenosis, when there exists simultaneously an opening in the interventricular septum (often a complication of pulmonary stenosis) or a patency of the ductus arteriosus. The latter being open the murmur on the back (between the left scapula and the vertebral column) is, on auscultation, often louder than over the chest ; it increases during inspiration ( because of the strong blood- current from the aorta produced by the sucking activity of the lungs) and decreases during expiration ; cyanosis being absent. In stenosis of the pulmonary artery the murmur also spreads on the back, but remains always weaker than on the front of the chest. It is best heard on a line connecting the second inter- costal space — at the sternal end — with the inner third of the clavicle. (The murmur decreases rapidl\- in all other places and especially in a direction towards the right ) . As general symptoms of stenosis and insuificiency of the tri- cuspid valve there will be : Increase of the cardiac dullness toward the right, because of hypertrophy and dilatation of the right heart (especially of the auricle) ; a marked venous stasis, manifested by cyanosis, dropsy and venous pulse ; desolation of the pulmonary artery, so that its second sound is not accentuated. These symp- toms are the same as occur in narrowing of the pulmonary artery, but the difference lies in the position of the loudest murmur; in lesions of the tricuspid valve it is near the right end of the sternum in the area of the fourth or fifth intercostal space, being" diastolic in stenosis, and systolic in insufficiency. In defects of the interventricular septum the blood passes during the systole partly from the left ventricle into the right one, which becomes therefore hypertrophied. The second pul- monic sound, because of increased arterial pressure, becomes ac- centuated ; in the middle of the sternum or at the place of the apex-beat there is heard a systolic murmur. These symptoms are quite the same in insufficiency of the bicuspid valve, so that an exact diagnosis is seldom possible, especially in those cases where the systolic murmur is decidedly audible over the sternum in the area of the third intercostal space, the sounds being clear at all openings. According to Kissel an opening in the interventricular septum may be diagnosticated when a congenital narrowing of the EXAMINATION OF CHILDREN ( ,- pulnionary artery in an elder child is accompanied neither by a marked dilatation of the right heart (especially of the auricle), by dilatation of the neck-veins, nor by symptoms of labored and increased heart activity, while the cyanosis is at the time very well developed and changes but little in its degree. (*) The communi- cation between the ventricles is usually not accompaned by cya- nosis. Hypertrophy of the heart is not necessary even in cases of a very strong murmur which is felt under the hand as a "cat's purr." Absence of cyanosis and of hypertrophy of the heart is in the presence 'of such a murmur characteristic of the existence of an opening in the interventricular septiun. Patency of the oval opening does not manifest itself in many cases by any objective signs. If it be impossible, as often happens, to find out at what point the murmur arises, and its coincidencies, while the hvpertrophy of the heart is at the same time distinctly developed, as well as cyanosis or some inclination to the latter, then the diagnosis is only that of some congenital anomaly of the heart. When dealing with cardiac murmurs in a child, it is not always easy to decide whether they depend upon an inherited or an acquired defect of the heart. In deciding such a question the history is of great value. In favor of an inherited defect the following facts are important : (i) The child has manifested some disposition toward cya- nosis from the first months of life, to become cyanotic during crying or coughing. (2) The parents have noticed the increased heart activity. (3) Heart-murmurs were perhaps found by the physician during the first months of life. (4) The child was born in a state of asphyxiation (this circumstance plays a role in the aetiology of patency of the ductus arteriosus). (5) The child suffers neither from rheumatism, nor from any other acute infectious disease which creates a disposition to heart lesions, (although an idiopathic endocarditis sometimes occurs in childhood, but it always ends with convalescence in from two to four or eight weeks). *"rratch" 1892. No. 2. 68 EXAMTX.\TIO>T OF CHILDREX In the case of an incomplete anamnesis, which does not dis- pel the donbt, the following circumstances may be of significance in the diagnosis : (t) Age under three years. Acquired heart diseases occur in small children very seldom ; accidental and anaemia murmurs still more rarel}'. Therefore, a cardiac murmur in a small child mav by itself prove the existence of an inherited disease of the heart, especially if the murmur be loud and spreading, since acquired cardiac diseases are at this age almost exclusively in the form of a mild mitral insufficiency, manifested by a soft blow- ing murmur. (2) An inherited heart disease may be suspected with great certainty in all cases in wliich we have to deal with a diffuse, loud murmur spread all over the cardiac region, while its punctum maximum is not well expressed. This is frequently met with in combined heart diseases which are almost always congenital. On the contrary, in acquired diseases the punctum maximum is usual- ly easily determined. (3) Inherited cardiac defects are. in the majt)rity of cases, characteristic in giving rise to the appearance of systolic murmur (stenosis of the pulmonary artery or of the ascending portion of the aorta ; patency of the ductus arteriosus ; opening in the interventricular septum, insufficiency of the mitral or tricuspid valves because of congenital endocarditis, as well as a combina- tion of some of these lesions). For this reason pure diastolic nuirnuu"s hardly ever occur in congenital heart defects. They are seldom met with even when combined with the systolic mur- mur, and this occurs comparatively oftener in elder children be- cause of complication with endocarditis of the cusps). It follows that a pure diastolic murmur almost excludes congenital lesion of the heart. (4) The cyanosis of the skin and of the mucous membranes, or some disposition to cyanosis (its appearance at each cry, cough, etc.), in the absence of any other apparent signs of disturbance of circulation, is met with only in the inherited heart diseases. If cyanosis be noted in a child from the first days of life then the diagnosis of congenital heart disease may be made posi- KXAMIXAIION OK CUll.DKKN (nj tively, even in the absence of murninrs and enlargement of cardiac dullness. (*) In the presence of a cardiac mnrninr any deforniitv or mal- development (labium leporinum, palatum fissum. i)olydactilia, epispadia, etc.,) may be in favor of an inherited defect. Of the same value is retarded physical and mental development, gen- eral debility of the organism and pronounced pallor from the first year of life. To these data one luay add the following, drawn 1)\ lloch- singer from his observations: (**) (1) rcry loud cardiac niiinnurs, the dullness of the heart beiii^ normal or slii^htly increased, occur in childhood only during congenital heart diseases. If. however, loud murnuirs signify an acquired heart lesion, then the_\ are alnwst always accompanied by considerable enlargement of the heart dullness. (2) Cardiac uuu-nuu-s, in the presence of increased cardiac dullness, the apex-beat being feeble, in small children points toward some congenital defect, because the spreading of the dullness de- notes in such cases hypertrophy of the right heart, the left being altered but little. However, in acquired endocarditis of children the left heart becomes particularly afifected, so that the apex-beat will be increased. (3) Complete absence of murmurs in the area of the apex- beat, while they are distinctly audible on the sternum and in, the area of the piilnu^iiary artery, speaks for the defect of the inter- ventricular sept II in or narrowing of the pulmonary artery, rather than for endocarditis. 14) An abnormally feeble second pulmonic sound in the presence of a distinctly developed systolic nuu'mur in earl\- child- hood may be explained only by inherited stenosis of the pulmonary artery: therefore, this symptom has great diagnostic value. (5) Absence of noticeable thrill, despite irry loud murmurs all over the pericardial area occurs almost wholly in inherited defects of the septum, and speaks thus against an acquired heart disease. (6) Loud sysfolic murmurs with the pnnctum maximum in the upper portion of the sternum, and without considerable hyper- *Kissel : I'ratch. t. 11, IcSqj, p. 55, No. 2. ** /. c. p. 145. yO EXAMINATION OF CHILDREN trophy of the left ventricle, are very important in the diagnosis of patency of the ductus Botalli, and cannot be explained by endo- carditis of the aortic valves. Hochsinger also ascribes great significance to the accentua- tion of the second sound. The main thing is that the second sound at the base of the heart is, contrary to that in adults, normally never accentuated, so that, if the second sound of the pulmonary artery prevails, this undoubtedly proves the considerable in- crease of pressure in the small blood circle. If the second sound be noted in a cyanotic new-born, or in a nursling, then the diag- nosis is in many cases much easier, as, for instance, in the follow- ing conditions : (i) Loud murmurs on the manubrium, as well as cyanosis and accentuated second sound, are in favor of a zcide opening of the ductus arteriosus. (2) Clear sounds with very considerable cyanosis and an increased second sound are pathognomonic signs of inherited transposition of the pulmonary artery and aorta (generally speak- ing, the accentuated second sound shows that the pulmonary artery has. in such a case, its origin from the left ventricle). (3) The cardiac murmurs which are not to be referred to the openings of the heart (for instance, on the sternum in the area of the third rib), cyanosis and decidedly accentuated second sound signify with great probability in favor of combination of the transposition of the vessels with the simultaneous patency of the foramen in the interventricular septum. The frequency of the pulse in children is liable to still greater variations than the respiration. The cry and restlessness of the child quicken the pulse to such an extent that its counting at the time cannot give a satisfactory result. In small children only is the counting of the pulse during sleep of some importance. Pulse counting is determined by the finger, the radial artery being slightly compressed. During febrile conditions and in gen- eral during any considerable quickening of the pulse, when the latter reaches, for instance, about 160 or more, one must count two pulse beats for one, in order not to lose the number. By such a method we may correctly count even 200 beats per minute, while by the ordinary method of counting one cannot correctly note even 160 pulsations. EXAMIXATIOX OF CHILDREN y\ 111 examining: the pulse attention must be directed especially to its frequency, rhythm and fullness. From 120 to 140 beats per minute is regarded normal fre- quency during the first half year ; in the second half, from 100 to 130; during the second year, 90 to 120; from three up to five years, 70 to 100; from six to seven years, 70 to 100. Crying and fever both accelerate the pulse rate 20 to 50 beats per min- ute. A retarded and irregular pulse occurs most often in cerebral ■diseases, occurring with symptoms of brain compression, as well as in all kinds of jaundice (in elder children), in gastritis, during the period of convalescence after acute febrile diseases, under the influence of some drugs (digitalis, opium), and in some children €ven in a normal condition. The younger the child, the weaker is the prohibitory nervous apparatus in general, and the vagus espe- cially, therefore the more rarely is a retarded pulse met with. In children during the first or second year of life it is seldom pos- sible to note a characteristic cerebral pulse even dtiring acute hydrocephalus. At this age an important diagnostic sign is a relative retardation, for instance, 112 pulse beats, the temperature being 38 degrees C. (100.4 degrees F.), while in elder chiUlren the pulse rate falls, under the same conditions, to 70 and even to 60 beats per minute. A feeble pulse, being at the same time frequent, denotes heart-failure. About the degree of danger attending this symptom we judge from the accompanying signs on the part of other organs. As bad omens there may be mentioned frigidness of the extremities; symptoms of dilatation of the right heart (dilatatio cordis), manifested by an extension of the dull sound beyond the right end of the sternum, the apex-beat being feeble ; the liver congested because of venous stagnation ; and cyanosis. Heart failure in its acute form occurs most often in grave cases of acute febrile diseases, especially in scarlet fever, but in some cases paralysis of the heart appears in patients even in the absence of any elevation of temperature, because of the influence of various toxins. Such an acute paralysis of the heart most often occurs during dysentery and especially during diphtheria. In the latter case the heart failure becomes especially important 72 EXAMINATION OV CHILDREN because it occurs in the period of convalescence, when the patient seems to be out of an}- danger. The frequency of heart paralysis depends upon the character of the epidemic. Many think that death from diphtheritic paralysis sets in suddenly, but this is not true, as careful examination of the patient always indicates many hours, or even several days, in ad- vance diverse precursors of the imminent catastrophe. Paralysis of the heart after diphtheria affects boys oftener than girls (2:1) ; and weak, emaciated children oftener than those with a good nutrition. Heart failure must be feared when, despite the resolution of the local morbid process in the fauces, the general condition of the patient does not improve ; the child does not care for eat- ing ; remains languid and apathetic ; sleeps poorly during the night ; and when ])aralysis of the soft palate appears. In the fur- ther course undoubted symptoms of cardiac weakness appear, as feeble, quickened or (this is still more important) retarded and irrcij^iilar pulse. In severer cases extension of the cardiac dull- ness toward the right side takes place, swelling of the liver, and diminutiiMi of the quantity of urine ; the patient is either somno- lent and apathetic, or excited, constantly changing his posture as if from cardiac anxiety (anxietas cordialis). Auscultating the heart the sounds are found very feeble, sometimes at the apex an in- significant nuirmur is audible : the second pulmonary sound may be increased, in cases of rapid course there appear, together with symptoms of cardiac failure, ivniitiug and violent pain in the abdomen, but without diarrhciea. These symptoms are ominous ; the face grows pale and slightly cyanotic ; the pulse rate, at first retarded and irregular, becomes now very frequent and small ; dyspnoea soon appears, and death occurs sometimes within a few hours after the onset of abdominal pains and vomiting. \'ery much depends upon the condition of the respiratory and circulator}- organs, also the cry. so that we may here say a few words regarding this symptom, which is so frequently met with m small children. A loud cry after birth belongs to the normal and is a very desirable occurrence. It indicates that the first inspirations are deep. On the contrary a screaming, feeble cry at birth show-s either general weakness of the child ( abortive child), or it depends EXAMIXAIION OF CHILDREN 7^^ Upon the abnormal course of the labor as well as upon intra- uterine asphyxia of the child, raising the suspicion of pulmonary atelectasis or congenital heart lesions. (In close connection with the atelectasis is patency of the ductus arteriosus). A continued, loud cry denotes an acute pain in the child. To clear awa}- the cause of such crying usually requires the further examination of the patient. \\'hatever the reason for the cry may be, one must first of all strip the child and examine not only the whole body, but also the child-bed linen and the bed. The cause of a constant restlessness and uneasy sleep may be a needle in the mattress, or the presence in the bed of fleas or bugs. In determining the cause of crying one must bear in mind that not every severe pain produces a loud cry in a child. If the pain increases under the influence of venous stasis or action of the abdominal muscles, or in deep inspiration, then during such a pain the child avoids a violent cry, but he will groan dolefully, whimper or squeak, but not cry with all his force. On this account one may be guided by the cr\- in the differentiation of headache from meningitis, pains in the chest from pleuro-pneumonia. and in the abdomen during peritonitis. On the contrary the most violent cry in children accompanies : ( I ) Acute abscesses in the subcutaneous cellular tissue ( in the new-born inflammation of the mammillary glands must be es- pecially mentioned). ( 2) Acute affections of the bones and articulations (fracture, synovitis : pathognomonic of these lesions is a sudden appearance of the most violent cry on the slightest passive movement of the affected extremity). (3) Colics from dyspepsia. (4) Hindered micturition. (5) Inflammation of the external and middle ears. (6) Starvation. The first and second causes of crying are determined or ex- cluded by the results of general inspection of the whole body. A cry from dyspeptic colic is characterized by occurring sev- eral times during the day, especially at night-time, in the form of violent attacks, which suddenly arise, and also suddenly stop. In the intervals the child seems to be entirely well, he is cheer- ful and has no fever. (A temperature higher than 38 degrees 74 EXAMINATION OF CHILDREN Q — 100.4 degrees F. excludes a common dyspepsia). The child often expells intestinal gas and frequently becomes calm after the passage of flatus. The dejections show signs of dyspepsia (green- ish color and admixture of white lumps). The abdomen appears on examination more or less distended. It is especially char- acteristic of the cry with colics that it stops immediately after a movement of the bowels, therefore an enema may be resorted to for diagnostic purposes. If the dejecta be of normal color and consistency, the abdomen not distended but soft, fever being present, then it is improbable that the child cries because of colic. The diagnosis of the latter is often assisted from the child "twisting his legs" during the crv, i. e., either flexing the thighs on the abdomen, or extending them, rubbing one leg over the other. This sign is of no special importance, occurring during any violent cry. Crying from ])ain is most often met with in children imder three months of age. A (TV which depends upon paitijul niictitrition is characterized by the child crying Ijcforc micturition and growing quiet after evacuation of the bladder. Among the causes one should bear in mind in children during the tirst weeks of life is the occurrence of sand in the kidneys (remnants of sand on the pneputium or on the diaper) and a marked phimosis. In order to become convinced that crying de- pends upon bladder-spasm one must examine the diaper. If it be found that this is wet every time at the end of crying, then spasm of the bladder, as the cause of crying, becomes very prob- able, especially in cases where dyspepsia may be excluded. Ac- cording to Politzer {'-■-) the diagnosis becomes confirmed by ad- ministering lycopodium in the form of emulsion, which removes quickly an ordinary spasm of the bladder. He describes a case of spasm in a two-year-old girl, who cried eight or ten times each night for four weeks and who was calmed after the first doses of lycopodium. If the cry depends upon ear iiiHamDiafion, then it increases from pressure upon the tragus or by drawing the ear-shell back, as well as in concussions of the body and quick movements of the *Politzer, Jalirb. f. Kinderh. 1884, p. 30. EXAMINATION OF CHILDREN 75 •head, and in deglutition and sucking. Therefore Troltsch holds as very noteworthy in the cry caused by inflammation of the ears its appearance each time as soon as the child begins to take the i>reast or the bottle. If the physician suspects the cause of cry- ing to be a lesion of the ears, then he may confirm his suspicions •by the therapy, inasmuch as it often occurs that such a cry. having lasted with slight intervals the whole day, stops imme- -diately after pouring into both ears a few drops of warm oil or •cocaine solution. If the earache be produced by furunculous inflammation of the external meatus, then the diagnosis is easy by a mere inspec- tion. Pain depending upon otitis externa or media is usually ac- •companied by fever. The cry of hunger is not difficult to recognize, but despite -this it often remains unappreciated during many days and even weeks, depending upon the fact that the physician does not grant it enough attention. To diagnosticate a cry due to hunger, one must maintain the rule to examine the breast of the nursing Avoman without delay. To avoid a possible error one should in- vestigate the quantity of milk immediately after the child has •taken the breast. If then the milk can be squeezed out by drops only, it signifies there is but little in the breasts, and znce versa, if one succeeds in obtaining streams of milk, then it may be said positively that the child's cry is not due to hunger (supposing, of course, that the child can suck the breast well, or that a wet- nurse, being dissatisfied with her position, does not stai"ve the baby intentionally). If there are weighing scales at hand the diagnosis is easier, because, first, one may directly determine how much milk the child had sucked (*) ; and secondly, one may observe, by a daily notation, the rapid decrease of the child's weight. If the -decrease of weight cannot be explained either b}- fever, or by any other disease as, for instance, diarrhcea, then this mere circum- stance may point toward starvation. Starving children seldom pass much water and usually sufifer from constipation, although dyspepsia does not exclude starvation at all, because a small *The child should suck out. during the first months of Hfe. at each aiursine about i-iooth of weight of his body. •j6 EXAMINATION OF CHILDREN quantity of milk in the breasts usiiallv corresponds to its poor quality. If one suspects that the child's cry is caused l)y hung-er it is very easy to prove the point, as it is only necessary to feed the baby with cow's milk, when, if starved, he very soon becomes- quiet and falls into a deep sleep for a few hours, an event which had probably not happened for quite a long time. Thus, dealing with a crying child, one must strip the baby,, inspect his whole body, feel his ears, ask about his dejecta and micturition, examine the quantity of milk, and, according to the results obtained, administer for the final diagnosis such a thera- peutic remedy as indicated. A prolonged violent cry, regularly repeated at certain hours,, depends most probably upon a typical neuralgia of malarial origin. The diagnosis becomes confirmed by the favorable action of quin- ine, which is to be given four or six hours before the beginning of the regular paroxysm. In other cases a similar periodical cry, especially after midnight, may depend u])on the beginning of spinal meningitis due to caries of the vertebral cohnnn. A short, violent cry, or a loud, monotonous screaming, noted in a child which is in a somnolent condition, occurs most often in. acute hydrocei)halus and hydrocephaloid (see the corresponding- section) and therefore is called clamor ccf^halicits (cephalic cry ) . ( )f entirely diti'erent import is the night cry. of two or three minutes duration, in children five to eight \ears of age apparent- ly in good general health. Such a cry is accompanied by a frightened expression of the face and becomes repeated either each night, or after several nights, but almost always during the first hours of sleep. It is peculiar of so-called night-terror. Ac- cording to Politzer the certain and rapid action of quinine, five or eight grains, two hours before sleep, given several days in suc- cession, is also helpful in the diagnosis of night-terror. Crying during defecation, associated zcith fear of tliis act, together with persistent constipation, may be held as a pathogno- monic symptom of anal fissure. In one of my cases, in a three- year-old girl, "the fear of the toilet" was noticed not before defe- cation, but with each micturition, which was accompanied each. EXAMINATION OV CiriLDRICN 7- *ime by crying-. The cause of the latter was found in superficial erosions on the inner surface of the labia majora. The character of the voice is also important in diagnosis. A hoarse voice denotes an affection of the larynx. In acute cases •either a catarrh or croup may be indicated, in chronic cases, how- ever, syphilis is thought of first of all. In children of a few weeks ■of age, the hoarse voice is the result of a too loud, almost con- tinual cry, which lasted a couple of days. Such a cry hardly •ever occurs in common colics but often depends upon hunger or the formation of an abscess in some place (mastitis), or upon lesion of the ears. A'asal voice (snuffling) is met with in all cases of paralysis of the soft palate after diphtheria and very often in retro- [pharyn- geal abscess, as well as in cleft palate, in an obstructed nose and sometimes in hypertrophy of the tonsils. The important diagnostical meaning of cougli results from the fact that it directly points toward an affection of the respira- torv organs. In many cases one may get an idea of the situation and the nature of the disease from the character of the cough. As, for instance, if the cough appears in violent attacks, inter- rupted by whistling inspiration, and consisting of a ivhole series of coughing spells, following each other in succession without rest, and ending with vomiting or expidsion of viscid sputum, we shall hardly make a mistake in saying the patient is suffering with whooping-cough (regarding the possibility of error see Whoop- ing-cough). A short, hoarse, so-called "'ringing cough" denotes a false or true croup. In bronchitis we judge the period of the disease from the character of the cough ; if the cough, being dry and frequent, interferes with the patient's sleep, then we speak of the first period -of bronchitis ; in the event, however, of moist cough, then of the resolution of the catarrh. A short, painful cough, accompanied by discomposure of the face, or by sighing, denotes pneumonia •or pleurisy. Examination of the sputum in childhood is of the same im- portance as in adults : but as children under five years, and fre- quently even elder ones, usually swallow the sputum, it is some- times difficult to get it for examination. If a small child, accord- yS EXAMINATION OF CHILDREN ing to the observation of the parents, expectorates the sputurtr each time after coughing, then this is in favor of whooping- cough. Blood in the expectoration of children is very seldom met with, because the most frequent cause of hsemoptysis in adults — consumption — occurs in children without bloody expectoration. In older children haemoptysis occurs almost exclusively in cardiac lesions, and very much more seldom in purpura. A small admix- ture of blood in sputum occurs sometimes after the attacks of severe cough in bronchitis, and especially in pertussis. More often there is noted some blood not in the expectoration, but in the saliva. Such a bloody discharge occurs in ulcerous stomatites^ especially in stomacace, as well as in diphtheria of the fauces. Inspecting the abdomen attention must be devoted to its- size and shape. Normally, i. e., if the abdomen be neither dis- tended, nor sunken, its anterior and lateral walls, in the recum- bent posture of the patient, must be on the level of the inferior margin of the chest, that is, the abdominal walls seem to be an immediate continuation of the chest. About the semeiology of the distended abdomen I shall speak in a particular part ; but with regard to the sunken abdomen it may be said that this symptom is, by itself, of no other importance than showing a small amount of gases in the intestines, which in adult persons signifies a good digestion. Especial importance should be attached to the sunken abdomen only in the presence of some other symptoms, as, for instance, if the child suffers from diarrhoea, then the sunken abdomen denotes the too rapid elimination of gases. This is- usually observed in very frequent evacuations of the bowels, oc- curring especially in nuicous or blood>- diarrhoea. Therefore a sunken abdomen occurs much oftener in follicular enteritis than in catarrh of the small bowels. If the sunken abdomen, in spite of constipation, be observed in a febrile patient in whom the course of the temperature and other data are in favor of typhoid, then the mere absence of meteorismus should raise the physician's suspicion of possibility of tubercular meningitis. The suspicion becomes a positive fact if the patient becomes sonmolent, despite the temperature being" comparatively low (below 39 degrees C. — 102.2 degrees F.). In small and rachitic children, in whom the abdomen is large, it re- EXAAriNATKt.X ()!■ illllDRKN 79 mains somewhat enlarged even in the period of well-developed meningitis, but here it is important to note the considerable soft- ness of the abdomen and the tendency of its walls to yield, so that, despite some meteorismus, one often succeeds in reaching- the vertebral column by the palpating fingers. Such a softness of the abdomen has the same diagnostic importance as the sunken abdomen in adult persons. Furthermore, in inspecting the abdomen of small children we regard the condition of the navel. Normally the remnants of the umbilical cord become mummified and fall ofif on the fifth day (in abortive children and when Wharton's jelly is too thick — somewhat later). The process of minnmification must not be ac- companied b}^ an odor, which denotes suppuration of the cord and depends most often upon improper care of the funiculus, when, for instance, this is wrapped in an oily rag- and thus its drying-up is prevented. After sloughing off the cord exhibits a suppurating surface circumscribed by a small area of slightly inflamed skin. This umbilical wound usually heals about the end of the second week, but it may suppurate even longer with- out being abnormal, provided the reactive inflammation is not in- creased, that is, neither the quantity of the secretion, nor the redness of the skin, increase ; otherwise we have ulceration or excoriation of the umbilicus. If the suppurating umbilical wound spreads over the adjacent surface, discharges malignant pus, or becomes covered as if with false membranes, then it is spoken of as an umbilical sore, or croup and diphtheria of the navel (local infection). If at the same time infiltration of the connective tis- sue appears around the navel (bright redness, solid swelling and painfulness upon pressure in the region of the umbilicus), to- gether with a febrile condition, then we have inflammation or phlegmon of the navel (infection of the connective tissue around the navel) — omphalitis. Such a condition of the navel is ominous for the patient's life, as the inflammation may easily spread to the perivascular connective tissue of the umbilical vessels, when periarteritis or periphlebitis umbilicalis supervenes, with subsequent pyaemia or septicaemia. Inflammation of the umbilical vessels is not easy to be recog- nized, because there are usually no local symptoms which would -80 EXAMINATION OF CHILDREN be especially indicative of this affection. The assertion of some authors about the redness of the skin along the course of the arteries does not become verified in the majority of cases. One may suspect inflammation of the umbilical vessels in all cases where, the navel being inflamed, the child begins to mani- fest fever, and when there quickly develops collapse ; or where local symptoms of pyaemia appear in the form of subcutaneous abscesses, inflammation of the joints, of the serous membranes, •etc. In short, periarteritis occurs much oftener than ])eriphlebitis ; therefore, in the presence of the above-named symptoms, there is more probability of the afl'ection of the arteries ; but if at the same time severe jaunduce be noticed it is a symptom of peri- phlebitis. If a spherical tumor, the size of a pea, be noted during the inspection of a continuing suppuration of the navel, which is pedunculated and bleeds easil}' upon touch, then such a tumor, caused by growing granulations, is known as umbilical fungus — fungus umbilici, s. sarcomphalus. . Left without any treatment the tumor continues suppurating for a few months and may reach the size of a walnut, but finally becomes covered with scars or sloughs off. The umbilicus is sometimes the source of an abundant haemorrhage of two kinds, arterial and parenchymatous umbili- cal haemorrhage. The former is observed in children when the cord is not ligated firmly, lilood also appears from the umbilical vessels before the sloughing of the cord, but may be easily checked by applying a new ligature. On the contrary parenchymatous haemorrhage is very persistent. It always depends upon a gen- eral disease of the organism, the so-called temporary hccmophilia: under the influence of which hccmorrhages also occur from other ■organs (mucous membrane of the mouth, gums, vulva, etc.,) and under the skin. Parenchymatous haemorrhage usually begins about the fifth day and in the great majority of cases (eighty to ninety per cent.) ends fatally in a few days. Temporary haemophilia may be the consequence of inherited syphilis, general sepsis and acute fatty degeneration of the new- liorn. The latter malady is, post-mortem, characterized by paren- chymatous degeneration of the viscera and haemorrhages in the EXAMINATION OF CHl[J)RI-:x Si skin, serous nitMnl)rancs ami viscera. Clinically the disease mani- fests itself by icterus and different haimorrhag-es, while the tem- perature fre^iuently remains normal. If the umbilicus be much protruded this may depend either upon an uiiiblllcal hernia or upon the superfluity of the skin — cutaneous uinhilicus. In the fortuer case the tumor has a spheri- cal shape, reaching- the size of a walnut or that of a nut-gall. Still larger umbilical herniae assume conical or pyriform shapes. Upon compression with the fingers this tumor mav be easilv re- duced through the umbilical ring into the abdominal cavitv, but during the cry it appears again. In the case of cutaneous um- bilicus it appears like a cylindrical supplement, which does not change from pressure and cannot" be reduced ; furthermore the shape and size of the navel do not change during the cry. After inspection one proceeds to the cxainijuifioii of the abdomen by palpatiui^. Normally the abdomen in children when palpated makes an impression as of an elastic pillow which is moderately inflated with air. An exception to this rule is found in children of the first months of life, in whom even normally the liver, and especially the spleen, may often be palpated. If some hardening, or tumor, be palpated in an elder child, then this is at once an abnormality, pointing either toward an enlarge- ment or induration of one of the abdominal organs (liver, spleen, lymphatic glands, kidneys), or to a new growth of inflammatory or other origin. Palpating the abdomen is done in the recumbent posture of the patient. The physician applies the plantar surface of his hands to the abdomen, using slight pressure with the ends of his fingers (by the soft parts of the third phalanges), until the child makes an inspiration. During expiration the abdominal wall becomes relaxed and then it is possible to feel, by the sinking fingers, any undue firmness in the abdominal cavity, provided the former be at the place of pressure by the hand. When the child is crying then the best moment for palpation is during the deep inspiration : but, as this moment is too short, one must have considerable experience to successfully palpate a crying child, and even then only the more pronounced anomalies can be detected. In determining the lower border of the liver or spleen one should begin the examination from below, for instance from the 82 EXAMINATION OF CHILDREN level of the umbilicus, and then move the fingers, during each in- spiration, one or two inches higher. Such a method of gradual moving of the fingers is recommended because palpating the margin of an organ is much easier than its surface. In many cases of not very pronounced hardening of the liver or spleen their surfaces are not palpable even when their edges are easily felt. We also employ palpation of the abdomen for estimating the tension of the abdominal walls (in cases of limited transudations in the abdominal cavity there is relaxation of the abdominal muscles; in exudation there is tension) and for determining fluctuation. By percussing the abdomen we may learn the boundaries of the organs (see Diseases of the Liver and Spleen), the degree of distention of the bladder, the thickness of tumors palpable through the abdominal wall (inflammatory infiltrations in the abdomen and omentum sometimes make an impression of vol- uminous tumors, but, due to their insignificant thickness they give on percussion a tympanitic note, by which they decidedly differ from solid new-growths which have their origin in the retro- peritoneal glands, kidneys or ovaries). By percussion we find out also the quantity of fluid in the abdominal cavity (by the upper border of the dull sound). Inspection of the extremities may furnish very important data in different directions, as, for instance, peculiar curvatures of the bones allow us to make an exact retrospective diagnosis between an old rachitis and late hereditary syphilis (see descrip- tion of the latter). Characteristic scars appear during many years as true signs of an antecedent carious process. Deficiency in the unilateral grow^th of the extremities, the muscles being well con- served, occurs in chronic abscesses of the brain. Thickness of the third phalanges of the hands undoubtedly shows a permanent hindrance to circulation due to a cardiac lesion, or to a purulent pleurisy, which was, perhaps, cured long ago. Our observations have convinced us that beginners meet with most difficulty in the diagnosis of nervous diseases, which de- pends, perhaps, upon a poor acquaintance \vitli the methods of examination of such patients, largely because these methods are not very commonly used in pediatric clinics. In discussing, there- EXAMINATION (il" CUILDREX 85 fore, the examination of the nervous system I will enumerate more minutely those points to which one must especially pay at- tention when dealing- with the diseases of the nervous svstem. Of the suhjective symptoms essentially important are dizzi- ness, headache, variahle painful sensations in other places, anies- thesia, paresthesia, etc. In the objective examination one's at- tention is called to the expression of the face, condition of the men- tal abilities, ability of speech (naming of surrounding objects, counting, loud reading, writing — from dictation and spontaneous- ly) the understanding of speech, writing and gestures. Upon examination of the motor apparatus attention should be given to the gait and the posture of the body, to the condition of the nutri- tion antl muscular tonus (atroj)hy or hypertroph\- of the muscles : their rigidity or complete relaxation, flabbiness), active move- ments, strength of the hands (dynamometer) and of the legs; co- ordination of movements ( standing or walking with closed eyes ; tremor during active movements and during rest ; choreic tremor and fibrillar contractures) ; clonic and tonic convulsions and con- tractures ; reflexes from the mucous membranes (winking, sneez- ing, contraction of the uvula) ; cutaneous reflexes; abdominal re- flex (contraction of the muscles of the abdominal wall when a line is drawn over the skin of the abdomen by the nail or handle of the hammer), cremaster reflex (elevation of the testicle toward the inguinal canal upon irritation of the inner surface of the thigh) ; the sole and tendon reflexes, especially from the tendon of the extensor of the leg (patellar reflex, or "knee-jerk"), as well as from the triceps and Achilles tendon (ankle-clonus) ; the mechanical irritability of the nerves and muscles. Examining the sensibility one notes the response to contact,, pain, localization, temperature and pressure, while especial atten- tion should be given to the sense of pressure on the nerve branches and muscles. About the condition of the so-called muscular sense we judge by estimating the weight of things and by passive movements, by the ability of determining the position of the limbs and by per- forming movements with the closed eyes. Further follows the examination of functions of the cerebral nerves. I, Smelling, II, vision (subjective sensations, acuteness and field of vision, ophthalmoscojiic examination); III. l\' and 84 EXAMINATION OF CHILDREN VI, movements of the eye-balls (strabismus, ptosis, nystagmus, the size of the pupils and their reaction to light and accommoda- tion) ; y, sensibility of the face; taste; VII, movability of the muscles of the face and of the soft palate; VIII, hearing; IX, taste on the posterior half of the tongue ; X, sensibility of the pharynx and oesophagus ; disturbances on the part of the heart and respiration ; X and XI, paralysis of the pharynx and laryngeal muscles ; XI, paralysis of the sterno-cleido-mastoid muscle and trapezius and, XII, the tongue. The examination is ended with information alx)ut the vesical and rectal functions (frequency of the desire to pass water, the night and da\- incontinence, retention of the urine), vasomotor, tr()])hical and secretory disorders. In examining the i^ctiifo-iirliiary ori:;aiis attention should be given to the condition of the external genital organs, and when there is complaint of painful micturition particular regard must be devoted to the condition of the praejiutium (piiimosis, balani- tis). In retention of the urine one examines, by palpating, the urethra for an impacted stone, and in the case of absence of the latter, proceeds to the catheterization of the bladder. To the semeiology of micturition we shall devote a separate part, but we will say a few words here about the examination of the urine. Normally the urine in children, except in the new-l^orn, ex- hibits in general the same properties as in adults. It is of straw- yellowish color, entirely clear and transparent, does not give any deposit when fresh, is of faintly acid reaction, specific gravity about 1005 to loio, and is voided in larger quantities the older the child. One may say approximately that from one up to five years, 150 grams for each year is voided in twenty-four hours ; from five up to ten years, 125 grams in twenty-four hours. In children in the first year of life the urine is distinguished b)y its very pale color and low specific gravity (about 1002) ; in new-born, on the contrary, the urine is cloudy from the admixture of mucus, epithelium and uric acid salts, usually containing during the first eight or ten days albumen and casts (physiological hype- rsemia of the kidneys). Examination of children's urine is performed according to the same methods as in adults ; therefore it would be superfluous to here enter into minute descriptions. We shall, therefore, only point out some sources of error in determining the presence of EXAMINATION OF t 1 1 I LI )Ki:\ S5 albumen in the urine l)y means of eommon methods. He wlio ignores the possiliihty of sueh errors mav not find albumen even where it is jiresent in great quantities, or. I'icc versa, he will find albuminuria in normal urine. It is known that upon boiling an alkaline urine we do not get any albumen reaction, therefore it is advised in all text-books to acidif\' the urine by adding acetic or nitric acids ; further it is mentioned that the albumen becomes dissolved upon boiling when there is superfluity of acid, so that reaction fails, and one must therefore add to the urine but a few drops of the reagent. I Jut there is one fact which 1 have met occasionally, and which is not ex])lained by any literary data : one or two drops of pure nitric acid to a feiv cubic centimeters of acid urine, does not allow the albumen to coagulate when heated, so that urine, even ^'cry rich with albumen and of 7'ery stroui^ acid reaction, remains absolutely transparent ; but if some more drops of the same acid be added, then the test succeeds admirably, as well as without any addition of acid. (*) These experiments have been conducted l)efore my students and colleagues of the hospital. It is thus obvious that it may readil_\' (xxnu" that albumen will not be found, in spite of a considerable albumimiria. Furthermore it is well known that turbidity of the urine which is obtained upon a mere addition of nitric acid without boiliiii^ does not yet prove the presence of albumen in the urine, because such a reaction may be obtained from propepton (very seldom) or from uric acid salts (often). In both cases the urine becomes clear again when heated ; however, if the turbidity depends upon albumen then upon heating not only does it not disappear, but even increases, and flakes of albumen are obtained. Therefore in the text-books it is recommended to use not only the nitric acid test, but also, for controlling, the heat test. *If there is much albumen in the urine, then every drop of nitric acid causes cloudmess even without boiling, but this turbidity disappears on the further addition of urine. If there be added so much urine that shak- ing does not remove the turbidity, then the boiling gives a positive resu't, that is. the urine becomes more turbid, and flakes of albumen arc formed. For the obtaining of a negative result one may add the acid by drops ^mly tin the urine remains clear after shaking. My observations are referred to the urine in acute nephritis after scarlatina: in one case of all)uminuria in diphtheria a negative result was not obtained from adding any amount of acid. 86 EXAMINATION OF CHILDREN This advice is understood by many to mean that a new por- tion of urine must be taken in a test-tube and heated. In the case of a positive result (appearance of cloucUness) the presence of albumen in the urine is held as proven. lUit a new mistake may here take place, because tlie presence of ph.osphates may give cloudiness or even a deposit upon boiling, and, as the urine some- times contains great quantities of both urates and jihosphates sim- ultaneously, both these tests, taken separately may give a positive result, in spite of the complete absence of albuminuria. It is, of course, very easy to avoid an error, and that that end one must ob- tain both reactions zcith the same portion of urine, that is, first boil, then add acid (acetic or nitric). The estimation of the temperature in children is. as in adults, efifected by means of a maximal or a common medical thermometer (Celsius or Fahrenheit). The (|uickest and at the same time the most e.xact method of measuring temperature consists in placing the thermometer in the rectum, the child being placed on a pillow, on the mother's knees, in a recumbent posture on the side with the back directed forward. The bulb of the thermometer is covered with some fat and introduced in the rectum one-and-a-half or two inches (the deeper the instrument is introduced, the better, because so much the quicker will the mercurial column ^-each the maximal ])oint of given temperature). If only the bulb of the thermometer be placed in the rectum, then the time required will be about five minutes ; if, however, the thermometer is introduced at least two inches, then two minutes will suffice. While the thermometer is in the rectum one must hold the child in such a manner that he can- not break it by a rapid movement. The instrument must also be supported, otherwise it will slip out. Measuring in the axilla requires a longer period of time, therefore this method is recommended only for children of more advanced age, who have patience enough to keep the thermometer /// situ during a certain period. For small children with puffy hands, in spite of protest of some German physicians, I again recommend taking the tempera- ture in the axilla by means of a i<:arnied thermometer, by wdiich I observe not the elevation of the mercurial column, but its fall. After one minute the mercury falls from a certain height and ap- EXAMIXATFON OF CllILDRILX S/ preaches very closely the c(M-rect temperature of the patient. The liability to mistake is less the higher the fever is, and the latter being, for instance, 39.5 degrees to 40 degrees C. ( 103 F. to 104 degrees F.), it is equal approximately too.i to 0.2 C. (0.13 to 0.36 F". degrees), and in lower degrees to 0.3 degrees C. (0.5 degrees F.). This method requires some experience in warming of the bulb of the thermometer and great accuracy in placing the ther- mometer under the axilla. Warming of the thermometer is ac- complished by rubbing its lower end with the dr)- hand or a blanket, etc., by which means it is possible to bring the mercurial column up to 43 degrees C. (109.4 degrees F".) in a half-minute. When this is done the thermometer is quickly placed in the pre- pared axilla (that is, the collar of the shirt must be unbuttoned, but the axilla must be closed by the adducted arm ; otherwise, under the influence of free air the skin becomes too cool, pro- ducing inaccurate results). The mercury immediately begins to fall, so that the measuring may be determined in one or two minutes. In some cases the mercury sinks so slowly that after one minute it is higher than it should be, reaching the proper level only after two or three minutes, while in other cases it sinks so quickly that after two minutes it is perhaps somewhat too low. In view of such occurrences, which cannot be foreseen, we may compare the indication of the thermometer after one minute with that after two, and then take the average between them. For instance, if it shows after one minute 39.5 degrees C. (103.1 de- grees F.), and after two minutes 39.3 degrees C. (102.7 degrees F.), then it may be accepted that the patient's real temperature is 39.4 degrees C. (102.9 degrees F.). If the height of the mer- curial column was not altered during the second miniUe. then U means that the exact result was obtained after one minute. Although this method cannot be held as an entirely exact one, nevertheless it gives results which are sufficient for the pur- poses of a practitioner, because a mistake of o. r degree to 0.2 degrees cannot be of great importance. [It should be remembered that the temperature of the new- born does not at once assume a constant normal equilibrium, but rather fluctuates for several days, under varying conditions of environment until it finally settles down — so to speak — to the physiological standard. No doubt this variation of the bodily »e EXAMINATION OF CHILDREN temperature depends upon the imperfect development of the power of heat regulation — of heat production and heat conservation. Babak (*) has recently shown by a series of experiments that newly-born infants register a comparatively low temperature even when well-clothed and under ordinary domicile surroundings. For instance, infants an hour or two old, in a room showing an atmospheric temperature of 59 degrees F. may exhibit a body temperature as low as 93.2 degrees F. The bodily heat gradually rises, however, during the first few days, yet with considerable irregularity. It may be said that at least a week is required before the temperature reaches a level of constancy — a state of adjust- ment. The practical point here is in connection with the thorough protection of the child from cold, not alone in the maintaining a proper temperature of the apartment, but in the clothing of the infant (quality and quantity) and also in the daily baths, which should be hot and carried out with the very least amount of ex- posure. — Earle. j *Arch. f. d. gcs. Physiol.. Bonn, 1902. DISEASES OF THE DIGESTIVE ORGANS DISEASES OF THE xMOUTH. Diseases of the mouth occur in children very often and at any age. Some of these diseases are entirely spontaneous, while others appear only as symptoms of coincident diseases, especially of general ones, and then they may considerably assist in the diag- nosis of the latter, as, for instance, in syphilis, scarlet-fever, mea- sles, etc. DISEASES OF THE MOUTH UNACCOMPANIED EITHER BY THE FORMATION OF ULCERS OR AN OFFENSIVE OROR. Stomatitis erythematosa, s. catarrJialis, — the catarrhal in- flammation of the mouth in nurslings manifests itself by a redden- ing of the mucous membrane of the tongue and gums and by sali- vation. This disease occurs very often in children, preceding the development of thrush or accompanying dentition. The child grows irritable, capricious, sleeps uneasily and has some fever. This, the so-called tooth fever, in some children attains such a high degree, that convulsions occur. However, such complica- tions in reality occur infrequently, inasmuch as the fever in stom- atitis erythematosa is not great, usually disappearing in about three days. In older children some swelling of the tongue' may be noted sometimes, so that marks of the teeth are obtained on its edges in the form of small, but distinctly noticeable, impressions. The tongue being at first red very soon becomes covered, because of increased proliferation of the epithelium and diverse fungi, by a more or less thick, whitish-yellow or grayish coating, which makes it look like felt, and occupies its whole upper surface ex- cluding the margins and the end — coated tongue. The severer the catarrh of the mouth, the more the tongue is coated and the quicker an odor from the mouth appears, especially in the morn- ing, immediately after the sleep. This odor differs from that 90 DISEASES OF THE MOUTH which is the symptom of a more serious inflammation of the mouth by being, first, not repugnant and so faint that it may be distinguished only at a very short distance, and secondly, by disap- pearing for a short time after cleansing the mouth. In some cases, especially in children suffering from chronic indigestion, the tongue appears as if covered by tender, thin, but very noticeable black hairs, which makes it dark brown. This, the so-called black or hairy tongue, has no special diagnostic value. From Gundobin's investigations {Medic. Ohozrenjc t. xxx, p. 604), and those of Brosid {ibidem, abstract p. 612), it is evi- dent that the old opinion alx)ut the mycotic origin of the hairy tongue is incorrect ; in reality the threads consist exclusively of the horned and darkened epithelial cells. There was not found in the oral cavity, in lingua nigra, any specific i)arasite of this lesion. [Gundobin's and Crosid's investigations seem to be confirmed by Beck, who, from the residts of careful study of a case of lingua nigra, came to the conclusion that this morbid form is a hyper- plasia of the epithelium, of papilhe filiform?e which grow to such an extent as to be nianipulable. and wliicli rcsemljle wet hairs. Tbe pathologic change is a keratinization of the epithelium. The color is said to be due to the aged condition of the epithelium, and its horny change — a constant decrease of the normally present pig- ment. In a word, this disease is regarded as a combination of h}-- perkeratosis and pigmentary growths. (Illinois Med. Journ., Jan- uary, 1904; p. 591.) — Against the parasitic theory are also the opinions of the majority of the leading hTench dermatologists (Barthelemy, Darier, Gaston ).as well as the experimental bacterio- logical investigations of Weil and Roger, who did not succeed in producing lingua nigra experimentally by inoculation of a fungus, which was described by Ruynaud and Lucet as the real cause of this disease. (*) — Earle.] The dark, hairy tongue must not be confused with the black tongue due to its occasional staining with food articles or some •drugs, as, for instance, black-berries, cherries, iron-preparations, etc., or to the formation on its surface of black-brown crusts, as in grave typhoid. ^Semaine Mcdicale, 1903. Disi-:.\si-".s oi-- 'iiii-; Mor-pu 91 A simple catarrh of the mouth arises under the influence of the most variable causes. I'or instance, in the new-born it usu- ally precedes the devel()])ment of soor, later on it often accom- panies dentition, as well as all febrile i)rocesses and local dis- eases of the fauces, stomach and bowels. However, despite the manifold causes, a coated tongue, or the way of its clearing- up, may to some extent aid in the diag- nosis. So, in doubtful cases of stomach catarrh which simulate meningitis, a thickdy-coated tongue (felt-tongue) points strongly to an affection of the stomach and against meningitis. The course of the cleaning up of the tongue is of value in the diiterential diagnosis of tx'phoid from the first period of "recurrent fever. I"or the majority of cases of moderate typhoid it is typical that the tongue begins to clean up from the margins and the end in such a way that on the anterior half of the organ "there arises a red triangle turned with its apex to the base of the tongue, while in recurrent fever the tongue (all the time) remains moderately coated. In the later stages of typhoid fever the tongue becomes some- what dry; when pushed out it looks narrow, thick, sharp-pointed; while in relapsing fever it is, in the overwhelming majority of instances, wet, wide and flat, with a roundish end. Still more characteristic is the cleaning of the tongue in scarlet-fever, and the so-called scarlatinous tongue is well known. During the first two or three days the tongue in scarlet fever is usually quite coated, then it gradually begins to clean (first at the tip and margins ) , and after about two days becomes entirely free from the coating and appears of an intense red-strawberry color with considerably enlarged papillae. Such a tongue (red, with large papillae) is very typical of scarlet fever, because it •occurs in well-developed form almost solely in this disease, and may therefore decide the diagnosis in doubtful cases of scarla- tina, which run, for instance, entirely or almost without any eruption, but with sore throat. One should, however, bear in mind that the absence of the scarlatinous tongue cannot serve as a reason for excluding scarlet fever, and that on the first or ^ven the second day of the disease the character of the tongue has 92 DISEASES OF THE MOUTH HO iiiiportaiicc in the diagnosis at all. because its cleaning upr begins later. In nurslings fed exclusively on milk, the tongue appears white, because of a thin layer of milk which remains on its rough surface. In some bottle-fed children there gradually ac- cumulates on the tongue remnants of casein which, in their color and localization, are very similar to a "coated tongue." The dif- ference is that the coating of a genuine "coated tongue" cannot be removed by the handle of a spoon, but the coagul?e of casein Fig.g — Pavement epitlie iiim covered by spores of the Oiditmi All)icans- (After Ch. Robin). are removed in large pieces, being crumbled like the shell of an egg. Casein is not difficult of recognition in the dry crusts, even: to the unaided eye. Some similarity to a coated tongue may show in a mycotic disease of the mouth known under the names of soor, or thrush. This disease is characterized by the appearance of entirely white DISEASES OF THE MOL'TII ) > islets on the tong^ue. the posterior surface of the hps. on the mucous membrane of the cheeks and g:ums, and, in jrravc cases, also in the throat and oesophagus. The islets are. in the beginning-, firmly attached to the mucous membrane, but in the period of convalescence they sepa- rate spontaneously. If thrush remains without an\- treatment, then the separate islets (luickly become larger, and when coales- cent luay form a continuous layer, which lines the whole surface •of the mouth, not excluding the hard and soft palate. Among" the characteristic features of soor there mav also Fig. 10 — Spores and branches of the Oidium Albicans (Charles Robin). be included the age of the patient, because as a genuine disease this occurs 0)ily in children during the first days of extra-uterine ■life, but in older ones it develops exclusively during other dis- eases which result in exhaustion of the organism, for instance, in dysentery, being in such cases usually a symptom of imminent death. The growth of the fungus {oidium albicans of Robin) (Figs. 9 and lo) is favored by the acid reaction of the oral mucus; therefore soor appears especially often in children who :sufTer from dyspepsia with acid eructations and in whom the oral •cavity is kept unclean. A snow-white color of thrush-spots is a certain sign for in 94 DISEASES OF THE MOUTH easy differentiation of thrush from aphthous inflammation of the mouth. In the latter there also appears islets upon different parts of the mucous membrane, but these islets, first, are yellow- ish, and, second, look like superficial ulcerations. Generally speaking, white deposits in thrush are so characteristic that the practitioner will hardly ever, for diagnostic purposes, resort to- the microscope in order to find the thrush-fungus, which consists of long, twisted threads, divided by septa, and round spores which intensely refract the light. (Figs ii and 12.) Fig. II — Thrush-fungi (Lenhartz). In color and mode of spreading most similar to tlirush are small coagulae of milk, which sometimes remain in the child's mouth after nursing, or after regurgitation. The dift'erence is that these coagulae may be very easily removed by wiping the mouth ; in the period of convalescence some of the islets of thrush, may also be easily removed, but never all at once. A thickly-coated tongue is not easily confused with thrush,, because the white coating in the latter is never entirely limited to the tongvie, spreading also to the other parts. The favorable place of accimmlation of soor-membranes is the inner surface of the cheeks. For the sake of completeness I also, mention that the white spots or coats on the oral mucous membrane may be obtained DISKASES ()1-- rili-: MOUTH 95 from cauterization with nitrate of silver or salicylic acid, but tlie history easily determines this ((uestion. Markedly similar white, but tender and easily removable, membranes occur on the oums durin^- any stomatitis. Their orioin is due to hyperplasia of the epithelium. From the spots of thrush thev differ by beiu"; easily removed ; it suffices there- fore to pass the finger over the gums. A peculiar aspect of the tongue is obtained in the annular dcsqiiaiiiafion of the cf>lthcliii!ii — pityriasis liiii^iicv. Tn this form of stomatitis (probably also of mycotic origin) on the upper surface of the tongue (the lower surface never be- comes affected) there arise islets the size of a pea, of pale-rose 12 — Thrush fungus: (a) niAccliuni ; (h) spores; (c) epitheHal cells from the mouth ; ( d ) leucocytes; (e) detritus (After Jaksch). color (normal mucous membrane), circumscribed by a whitish areola (hyperplasia of the epithelium). These rings (sometimes there is only one) increase each day, like the same affection occurring on the skin in psoriasis, herpes iris, etc., the surround- ing rings coalesce in their peripheries, while at the point of their union the white areola disappear, and instead of rings there are obtained, on the surface of the tongue, twisted lines, which well define the pale-rose, normal ])laccs from the neighboring whitish, coated ones — a map-like toiii^ne. 96 DISEASES OF THE MOUTH After the lapse of a certain time the tongue becomes clear over its whole surface and, recovering its usual epithelial layer, returns to the normal, but seldom remains so very long, the annular desquamation starting again, and in such manner the disease may last many months without causing the patient any discomfort, as there are no pronounced subjective symptoms. It is very often met with in children of any age, in healthy as well as in ill ones, but especially often in rachitis. The diagnosis is not difficult even in that stage when instead of rings there remain twisted lines, because the characteristic areola on the boundary of the normal mucous membrane of the tongue cannot be confused with anything else. In the first period of sickness it may be looked upon, perhaps, as a stomatitis aphthosa, but the ulcers are absent, as well as the salivation and pains. Parrot was wrong in accepting pityriasis linguae as a symptom of inherited syphilis, some sequelae of which have really a remote similarity to pityriasis linguae, especially from a superficial examination. Besides the fact that in inherited syphilis it- is almost always possible to find the characteristic erup- tion on the skin, the difi^crcnce is that syphilis never makes itself evident on the tongue in the form of the above described rings, but always in the form of jxitches. (See page 104.) SrOxMATiTis Moi-iiuLLosA. Au affcctiou of the mouth in measles, in the form of s])otted or papular-spotted eruption on the oral mucous membrane, aj^pears twelve to thirty-six hours earlier than the cutaneous rash, so that it may allow us to diag- nosticate measles in the prodromal period ; therefore, this rash is called prodromal measles rash. It consists of small, red spots which first occupy the soft palate, but very soon spread also over the lips and cheeks. At the place of the prodromal eruption there appears, on the following day, desquamation of epithelium in the form of very tender, whitish islets, easily removable by the finger, and which make the mucous membrane look as if dusted w'ith bran. The latter is best seen on the inner surface of the cheeks, lips and on the gums. This "bran-like"" appearance does not occur in other forms of stomatitis, so that its diagnostic significance is by no means less than that of the prodromal mor- billous rash. In some cases the prodromal eruption appears rather tardilv, comins: on either simultaneously with the rash DISEASES OF THE MOUTH 97 on the face, or even still later, so that the absence of the erup- tion on the palate cannot prove that no measles infection exists. [This peculiarity was pointed out by Prof. N. Flatov in his Lectures on Acute Infectious Diseases in Children, edition of 1894-1895; thus earlier than Koplik described his spots. Accord- ing to Prof. Jurgensen,* Dr. Flindt, of Denmark, described very minutely in the sixties of the past century the prodromal measles rash in the mouth. This rash becomes evident in the throat (soft palate and tonsils) on the first day of the fever, in the form of a rather diffuse redness, which increases on the second day and then consists of round, irregular-shaped, slightly-elevated spots. The rash on the third day spreads further over the posterior two- thirds of the hard palate, consisting of numerous, confluent, very red spots. The latter occur also on the cheeks and conjunctivae, the rest of the mucous membrane being normal. On the fourth day the spots on the hard palate and the mucous membrane of the cheeks become still more pronouncetl, those on the cheeks appearing diffuse. Filatov's sign is not less important and characteristic of measles than the so-called Koplik sign. In 1896 Dr. Koplik, of New York, described some peculiar, bluish-white, slightly elevated spots, from two to six millimeters in diameter. These spots are found most constantly on the mucous membrane of the cheeks, but may also be found on the lips, and sometimes on the tongue. They can be removed by dressing-forceps without producing pain or haemorrhage. They never become confluent and consist of an accumulation of fatty, degenerated epithelial cells. Their diag- nostic importance lies in their appearing usually on the first or second day of the prodromal period and increasing in number during the subsequent six or seven days. Koplik's observations are generally confirmed in America, as well as in Europe, although lately some authors, Aronheim, for instance, are inclined to regard Koplik's sign as not an absolutely constant and certain one of measles, because during an epidemic of this disease he met Koplik's sign only in six per cent. (Of 150 cases only nine proved positive.) — Earle.] *Nothnagcl's Encyclop., Vo!. IV., P. II., p. 92, 93, 1896. *Aronheim: Sind die Koplik'shen F!ecken ein sicheres Friihsymptom der Masern? (Miiiich. Medic. IVoch. N. 28, 14 July. i903-) 98 , DISEASES OF THE MOUTH f Comedones palati duri. In the nevv-boni and in children of the first weeks of Hfe, one may ahnost always see on the hard palate congenital formations known as Bohii's nodules. They have the aspect of small (not larger than a pin's head), entirely white, conical elevations, located in groups, several nodules in each, in the middle of the hard palate, along the sutures. These nodules are of diagnostic value only when they occur on the gums of children several months old, and thus simulate teething. A distinction is made, first, by the fact that these formations remain long on the same place and then disappear without leaving any trace ; secondly, being semi-solid, they do not give, on percussion with some metal, that characteristic sound which is obtained by percussing a coming tooth. Dentition. In close connection with the diseases of the mouth is dentition, regarding which it would be suitable to here say a few words. The first dentition in children begins at different times, de- pending upon the hereditary disjiosition, condition of the general nutrition of the organism and upon different diseases. The aver- age time for the beginning of dentition may be accepted as the seventh or eighth month, at which period the two inferior middle incisors appear, later (ninth or tenth month) the four upper in- cisors, so that toward the end of the year a healthy child should have all incisors (eight teeth). Then the intervals become longer (about two months), and from the fourteenth up to the sixteenth month the first molars appear, from the eighteenth up to the twentieth the canines, from the twenty-second up to the twenty- fourth the second molars, when the cutting of the milk-teeth is ended. The first teeth are sometimes cut several months earlier than the normal term mentioned, for instance, in the fourth or fifth month, but sueli a premature appearance of the teeth is of no special importance. In the majority of such cases the subse- quent groups are cut in the normal term, so that toward the end of the year such children have no more than seven or ten teeth. Too short intervals, depending upon the abnormally in- creased nutrition of the embryonal teeth, between the separate eroups, is sometimes observed in children prone to active hyper- aemia of the head, and frec|uently terminates with acute hvdro- DISEASKS OF THE MOUTH gtj cephalus, so that the too rapid appearance of the teeth mav be looked upon somewhat as an unfavorable omen. Retarded dentition means that either only the first ^roup ap- pears too late, all those following coming at the proper time, or that the intervals are too long, so that dentition occurs too slowly, being protracted until the end of the third or fourth year. In the former event, that is, when the initial group does not duly erupt, the order of appearance of the groups remaining nor- mal, then the late dentition is of no pathological value, as such a retardation is observed not infrequently in healthy children, esj)e- cially when there is some family predisposition, where a similar anomaly occurs, for instance, in all or in the majority of brothers and sisters of the same household. It is entirel}' dilterent when long intervals pass between the eruption of separate teeth, or when groups are erupted simultaneously. Such an irregularity is indicative of a retarded process of ossification of the skeleton, and is usually peculiar to rachitis. With regard to the question whether dentition may influence the child's health, the author's opinions do not agree altogether with others. Some exaggerate the importance of this physio- logical process in the aetiology of disCfises, others, on the contrary, deny it completely. In my opinion it is impossible to deny the existence of some connection between dentition and some diseases of childhood, but in each case one must be very cautious not to overlook any other cause. The dependence of a disease upon teething may be suspected only when the disease begins shortly before the appearance of the tooth, when the cor- responding place of the gum becomes szvoUen, tense, and when the appearance of the tooth causes the disease to disappear. The physician has still more reason to suspect a causative relation between dentition and a disease if the same morbid ap- pearance be repeated at each "teething," and when it is impossible to detect another cause of the given sickness. If we are to be guided in the diagnosis of "teething-dis- eases" by the criteria just given, then it is evident that a depend- ence of diseases upon teething is not often met with, and that such diseases are neither grave, nor so frequent as commonly be- lieved. Teething is in many cases accomplished entirely inipercep- lOO DISEASES OF THE MOUTH tiblv. being recognized only when the top of the tooth appears. In other cases, especially when the thick crown of the molar is cut. a catarrhal or aphthous stomatitis, accompanied with fever, irritability, sleeplessness, etc., sets in several days before the appearance of the tooth. That stomatitis depends in such cases upon teething, but not upon any other cause, one may conclude from the inflammation being mostly developed on that part of the gum where the tooth is cut. Mothers often ask the physician if the child is teething, and point out that he is suffering from a constant salivation and that he puts his fingers into the mouth. The mother becomes com- pletely convinced if she notes, somewhere on the gum, Bohn's nodule. In deciding such questions one should bear in mind that sali- vation in children two or three months of age is a physiological occurrence, because, in this age, begins the increased activity of the salivary glands, v.'hich during the first few months of life are almost inactive. The mistake is easily avoided if attention be directed to the child's age and to the absence of signs of local irritation of the gums. Teething may further produce a slight disorder of digestion, in the form of frequent vomiting and varied dejecta as well. Such a disorder usually docs not last very long, is associated with apparent symptoms of irritation of the gums due to dentition, while it disappears soon after the eruption of the tooth, often reappearing in the following teething, while no definite cause of the disorder may be found. Whether eclamptic convulsions may be produced by dentition, is a disputable question. It rarely happens that perfectly healthy children suft'er from convulsions during dentition only, and that they recur with each teething group ; but, on the other hand, it is undoubtedly true, that dentition may be an occasional provocation of reflex con- vulsions in such children as are predisposed to them, as. for in- stance, in rachitic ones. It is evident, however, that in diag- nosticating "teething convulsions" the conditions mentioned on page 99 must always be present. For alteration in the shape of the teeth the reader is re- ferred to part on Syphilis. DISEASES OF THE ]\r()rTll 10 [ DISEASES OF THE MOUTH OCCURRING WITH THE FORMATION OF ULCERATIONS UPON THE MU- COUS MEMBRANE, BUT WITHOUT OFFENSIVE ODOR. Especially peculiar to childhood is one form of ulcerous in- flammation of the lips, which was described by Sevestre under the name of staphylococcus diphtheroid stomatitis (stomatite diph- theroide a staphylocoques).* The morbid process is localized mostly (and sometimes exclusively) on the inner surface of the lips, often travelling over the inner surface of the cheeks. The affected parts, especially the lips, are covered with a yellowish exudation, which looks like a diphtheritic patch. The lips soon become covered with black, bloody crusts because of the forma- tion of bleeding fissures. The morbid process never extends over the gums, but some- times occupies the cheeks and the tongue. After a few days the exudation begins to disappear gradually, and the superficial ulceration of the lips heals in from seven to fourteen days, with- out any scar. Simultaneously with the affection of the lips, there is frequently noticed an impetiginous, eruption on the face. The disease differs from diphtheria by its benign course, non-conta- giousness and absence of LotHer's bacillus. Sevestre found the staphylococcus aureus in the exudation taken from the mucous membrane, as well as in the pus of impetiginous pustules ; so that this morbid form may be called stomatitis impcfigiiwsa. Staphylococcus stomatitis which often occurs in the nezv-born of the foundling hospitals, and which occurs with simultaneous lesion of the soft palate, fauces and other parts of the mucous membrane, was described by Epstein as septic stomatitis. In Epstein's opinion such stomatites give rise to the development of general sepsis in the new-born. Of much more frequent occurrence is aphthous infla^[- MATiON OF THE MOUTH — stomatltis aphthosa. This disease is char- acterized by the occurrence on the mucous membrane of the tongue, lips and cheeks of round, superficial ulcers, from the size of a pin's head up to that of a lentil, covered with yellowing exuda- tion and circumscribed bv a red areola. This maladv is most often *Rcziue mens, des )miladies des enfcints, iiSg2, page 47. 102 DISEASES OF THE MOUTH met with in children about the time of the first teething. The causes of this disease are unknown (infection?). [Regarding the etiology of this form of stomatitis it will be interesting to refer to Brush's observations of an epidemic of foot-and-mouth disease among the cattle in New England. Brush * says that there is undoubtedly some relation between aphthae of the mouth in the human young and foot-and-mouth disease in cattle, and that we may distinguish two forms of aph- thous stomatitis, viz: contagious (i. e.. due to foot-and-mouth disease of cattle) and non-contagious. The diagnosis between these two forms may be determined by the treatment, that is, the severer variety caused by an infected milk rapidly subsides as soon as the milk is stopped. — Earle. | An unclean condition of the mouth, mentioned in the text- books as an ^etiological factor, does not play a very important role. These ulcerations are either found in small groups (one to six), or are thickly-crowded, so that some coalesce, forming larger ulcerations of irregular outline, but always superficial and of yel- lowish tint. The formation of ulcers is always accompanied by considerable painfulness (especially when using hot drinks, -as well as salted, sweet and hard food), salivation and intensely coated tongue. Aphthous stomatitis has either a subacute course, without fever, or an acute one with fever, the temperature rising fre- quently to forty degrees C. (104 degrees F.) and higher, and in small children (under two years of age) convulsions may also occur. In such cases the eruption of aphthae does not occur at the very first (signifying that the stomatitis does not produce fever), but only on the second or third day after the elevation of temperature. This fact, in connection with the additional one that sometimes several members of the same family become affected one after the other, is indicative of the infectious nature of the disease, — something similar occurring in the eruption of herpes on the lips (fievre herpetique, of the French authors.) The similarity, and perhaps the identity, of these diseases, i. e., of the acute febrile form of aphthous stomatitis and herpes of the lips, appear also in the aphthae. These are sometimes met *Jouni. Amcr. Med. Assn.. June- 20, 1903, pp. 1700-1704. DISEASES OF THE MOUTH IO3 with on the tongue, or on other parts of the mucous membrane of the mouth, in groups which consist of several thickly-coated, round ulcers. Such a form of stomatitis is sometimes described under the name of herpetic iiiHaiiimafioii of the mouth — stomatitis hcrpetica. In other cases aphthous inflammation of the mouth seems to depend upon stomach disorders or on dentition (especially of the molars). This disease always terminates in rapid recovery with- out disagreeable consequences, by wdiich it differs from the other form of ulcerous stomatitis — the so-called stomacace. Aphthous ulcers are by themselves so characteristic that it is difficult to confound stomatitis aphthosa with anything else, except, perhaps, with foot-and-mouth disease (aphthae epizoot- icae), of which I shall speak later on. (About differentiation from soor see page 94; from stomacace, see page 105.) Somewhat similar to aphth?e is ivricelloiis stomatitis (stom- atitis varicellosa ) . wdiich is characterized by the eruption of vesicles, the size of a pin's head, on the hard and soft palates, and partly also at other points. These vesicles seldom become con- verted into ulcers. Their character is easily determined by the presence of the varicella eruption on the skin. From aphthous stomatitis one must distinguish another af- fection of the mouth, which, notwithstanding the name, has noth- ing to do with this tlisease. We refer to the so-called aphthcc of the nezv-born, or Bednar's aphthcc. This disease is peculiar only to children from two days to six weeks of age, and is indicated by the appearance of two symmetrically-located (in the angles of the palate, in the portero-external corner of the horizontal part of the palate bone), round, superficial, grayish-yellow ulcera- tions occupying exactly that spot on the mucous membrane where the latter is supported by one of the processes of the sphenoid bone (hamulus pterygoideus). The ulcers disappear without local damage, in the great majority of cases, in from one to three weeks, but in the presence of poor hygienic conditions and in marantic children these small ulcers spread over the surface, as well as in depth ; they then coalesce with each other, form deep ulcers, reach the bone, occupying the whole soft palate, so that they may simulate diphtheria. The chief points in the diagnosis are, first, the classical location of the ulcerations ; sec- I04 DISEASES OF THE MOUTH end, the ag-e of the patient, and, third, a febrile course (only if there are no other causes for the elevation of temperature). The cause of the ulcers is a mechanical one. viz : friction and pressure by the base of the tongue, during the act of sucking, upon the prominent point of the pterygoid process. To the diseases of the mouth which may determine the diag- nosis of a general disease belongs also ulceration of the frenulum of the tongue and syphilitic stomatitis. Ulceration of the frenulum linguae is a characteristic symp- tom of whooping-cough, the ulceration arising because of the frenulum being cut or torn by the inferior incisors during the violent attacks of coughing. The ulceration resembles a per- fectly white membrane, the size of a lentil, located just on the frenulum. It almost never occurs in children having no inferior incisors. The diagnostic meaning of this ulceration is typical, inasnuich as it is encountered almost exclusively in |)ertussis. Sni'IIII.itk' sroMATiris is observed in syphilitic children very often, especially in the relapses. This malady is indicated by the a])pearance of whitish, slightly-elevated ])atchcs (condylo- mata) on the nnicous membrane of the mouth, especially on the inner surface of the cheeks near the angles of the mouth, as well as on the lips, tongue, soft palate and tonsils. These patches differ from all other formations occurring in this part by their papillar structure, so that one may sometimes succeed in seeing on the surface, even with the naked eye, the numerous, very thickl\- crowded tops of papill;v in the form of whitish-gray spots. Less distinctive of syphilis are fissures of the lips and of the corners of the mouth. These symptoms have comparativel} greater diagnostic value in inherited syphilis in children during the first weeks of life. In children, however, of more advanced age, fissures of the lips occur also in the absence of syphilis, for instance, under the influence of fever. Such fissures sometimes become developed into very painful ulcers. In other cases the cause of the ulcerations of the lips is the tendency of children to tear ofi pieces of cuticle from the drying lips. In conclusion we may also refer to bitten zvourids of the foiii^^iie, caused by the patients themselves either during an epi- lei)tic spell or other attacks of an entirely diiTerent nature, in the DISEASKS OF THE MOUTH ' 105 diagnosis of which these wounds may be of vahie when the his- tory is insufficient. DISEASES OF THE MOUTH, ACCOMPANIED BY THE FORMATION OF ULCERATIONS ON THE MUCOUS MEMBRANE AND AN OFFENSIVE ODOR. The mouth is not always the only cause of stench. The ■source of the foetor may be : — (i) Foetid rhinitis (stench is most noticed with expiration through the nose, while the mouth is closed, being almost absent during the expiration through the mouth, when the nostrils are •compressed). (2) Stomach-catarrh with fcetid eructation. (3) Bronchiectasis with foetid contents; and especially (4) Gangrene of the lungs. A not very intense foetor, easily removable by a common •cleansing of the mouth, occurs with any thickly-coated tongue, in various catarrhs of the oral cavity, especially during febrile pro- •cesses, likewise in carious teeth and from decomposition of meat food remaining between the teeth. But in all these cases such a stench as associated with a more serious affection of the mouth never takes place. FoiTID INFLAMMATION OF THE MOUTH StOHUlCace, S. StOlll- -atitis ulcerosa. This disease of the mouth, depending upon gen- -eral malnutrition, is characterized, first, by an intense odor from the mouth ; second, by an ulcerous process which always begins at the free margin of the gums, of the incisors or canines, and then extends over the gums of the other teeth ; and third, by never occurring in toothless children. Fourth, there is also a characteristic alteration of the gums, which become swollen, fri- able, intensely hypenemic, and easily bleed upon the slightest touch. This form decidedly differs from aphthous stomatitis, first, in the shape of the ulcers (in the latter, small round ulcers spread all over the mucous membrane of the mouth : in the former, ulcerative destruction of the iiiari^iu of swollen and easily-bleed- ing gums ) ; second, by violent stench from the mouth ; and, third, by its prolonged course. In neglected cases the destruction of the gums, accompruiied I06 DISEASES OF THE MOUTH by falling out of the teeth, may even lead to necrosis of the jaw. On the other hand, the ulcerative process, because of auto- infection, readily spreads from the gums to the adjacent mucous- membrane of the cheek, so that after about two weeks from the beginning of the disease there appears on the cheek a mark of the gums in the form of a double ulcerous strip of yellowish tint, due to the characteristic tendency of the ulcers in stomacace to- spread, not so much over the surface as in depth (different from diphtheria). The original superficial ulceration of the cheeks assumes, after a few days, the aspect of deep ulcers, the floor and the margins of which are covered with a dirty-yellow deposit. The whole cheek becomes swollen (ciedematous). the submaxillary glands enlarged, but the skin of the swollen cheek remains pale. Fever may be entirely absent, but if the temperature rises it is only in the beginning of the disease, and does not reach a high degree (38 degrees to 39 degrees C. — 100.4 degrees to 102.2 de- grees F.). The further difl^erentiation of stomacace from aphthous stom- atitis consists in the relation of both these diseases to the action of potassium chlorate (potassium oxymuriaticum s. chloricum),. which is specific only for stomacace, being quite indifferent in aphthje. In view of these symptoms the diagnosis of typical cases^ of stomacace is always easy. Difficulty may occur only when stom- acace becomes complicated with aphthae, which complication oc- curs quite often. Then we have, simultaneously with the symp- toms of the former { foetor from the mouth, ulceration and bleed- ing from the gums), also numerous round, yellowish ulcers on the tongue and neighboring parts. In such cases stomacace is of more importance, being a graver process. Foetid inflammation of the mouth, caused by the immoderate use of n^Qvcury—stomatifis incrciirlalis { which occurs also in small children during calomel treatment) differs from stomacace by having a certain ^etiological factor. \\'e have the same to say regarding scorbutic stomatitis, which, however, is seldom met with in childhood. Of other causes of stomacace the most important are to be sought in the general malnutrition of the organism, depending either upon bad hygienic conditions, or upon acute infectious dis- DISEASES (IF THE MOUTH IO7 eases. Therefore, fcetid inflammation of the mouth occurs oftener in poor famiHes in damp dwelHngs. [This disease is a contagious one, its contagiousness having been very well illustrated by Bierens de Haan, * who described an epidemic of ulcerative stomatitis among the Boer troops dufr ing the South African war. The infection spread rapidly from one person to another, sparing those, however, who did not come into immediate contact with victims of the disease (for instance, the Kaffirs). Haan thinks that the epidemic was largely due to lack of salt in the diet, inasmuch as it began to disappear as soon as a proper supply of this substance was obtained. — Earle.] With relation to acute disease, stomacace readily appears after measles and typhoid. The course of the disease, left without any treatment, is very uncertain ; it may last for weeks and cause a loss of all teeth, but when properly treated usually ends in a few days, so that the prognosis in recent cases is generally good, but when neglected a fatal termination may take place because of the subsequent development of noma, or because of septico-pyaemia. In the period of ulceration and swelling of the cheek the clin- ical picture of stomacace is very similar to that of noma, or water- cancer of the check, cancer aquaticus. In the beginning of the disease there always appears a tumor of the cheek, the integument being pale, not hot, and painless upon pressure ; then follows ulceration of the mucous membrane and a very violent odor from the mouth. The similarity to stomacace is still greater in that in both cases the lymphatic submaxillary glands become swollen, but fever is often absent ; both stomacace and noma arise in emaci- ated children ; finally, the relationship of these two diseases man- ifests itself in that stomacace sometimes degenerates into noma, the latter, however, in its turn, very seldom develops spontane- ously, but usually from stomacace. [Walsh, in eight cases of noma, found four that began with stomacace.** — Eakle. ] Nevertheless it is not difficult to recognize noma. The diag- nosis is based upon the aspect of the affected parts, on the rapidity *Dcut. Med. Wochenschr., Febr. 12, 1903. **Proceed. Phila. Path. Soc, June, 1901. io8 DISEASES OF THE MOUTH of the course, and the issues. The morbid process of noma does not consist in the ulceration of the mucous membrane of the cheek, but in gangrene, so that the affected part does not assume a yellow tint, but a brown or black one with a gangrenous odor. The destruction of the cheek, and of the surrounding soft parts, is effected quicker than in stomacace, because gangrenous perfora- tion of the cheek may take place in three or four days, and later on the gangrene spreads daily farther and farther, so that in a few days all soft parts of the cheek disappear, provided death. Fig- 13 — Gangrenous stomatitis, following measles (After Holt). the common although not the certain termination of noma, does not stop such a destruction. (Figs. 13 and 14.) Noma sometimes begins with the skin of the cheek. In such "a case it could be easily confounded with anthrax. The lat- ter starts with the formation of a small pustule, which is soon transformed into a solid, odorless scab surrounded by an areola of new vesicles, and only then there appears a tumor of the soft parts. The process spreads rapidly, but does not lead to perfora- tion of the cheek, as in noma. DISEASES OF THE MOUTH 109 Somewhat equally between aphthous stomatitis and stomacace occurs FOOT-AND-MOUTii DISEASE (aplitlicc cpizooticcc) , notable in children after using" raw milk of cows sufifering from foot-and- mouth disease. This disease in children is characterized by the eruption of vesicles, with turbid contents, on the mucous membrane of the cheeks, lips and soft palate; the temperature is elevated (39 de- grees to 40 degrees C. — 102 degrees to 104 degrees F.). The Fig. 14 — Noma with the affection of both lips, cheeks, a'ae nasi, eye-lids, skin of the forehead and temples, gums, tonsils and pharynx (Albert). spots differ from aphthae by usually being absent from the dor- sum of the tongue, the posterior wall of the pharynx and tonsils. After the disappearance of the vesicles no ulcers remain, but there is always a disagreeable odor from the mouth, salivation and intense rhinitis. Frequently there occur pains in the abdomen, diarrhoea, and sometimes vomiting. The disease lasts one to two weeks. In diagnosticating foot-and-mouth disease from aphthous stomatitis especial attention should be given to the presence of no DISEASES OF THE MOUTH vesicles, their absence on the dorsum of the tongue, the odor from the mouth and to the violent snuffles. The diagnosis is still easier in cases in which epizootic aphthae are accompanied by the vesicular eruption on the skin, as the same seldom occupies the whole body, is most often located near the nails of both the fingers and toes, and has the aspect of small (the size of a pea) vesicles with clear contents. In Weissenberg's cases * itching and severe thirst were also observed. The vesicles appeared in the mouth, after the three days' duration of the prodromal fever, when the tempera- ture fell to normal. An extensive epidemic of foot-and-mouth disease was observed by Siegel. During one month more than two-thirds of the inhabitants of a small town became ill from this disease. The prodromal fever lasted from three to eight days, then an inflammation of the mouth developed in the form of swelling of the tongue, which was covered with a thick, black coating; then considerable swelling and friability of the gums with falling out of the teeth and a very severe odor from the mouth ; the lips and the angles of the mouth were ulcerated. The patients complained of pain in the ears and the masseters. On the skin there frequently a])peared a rash with small petechicC. The disease always had a prolonged course, of one to one and a half years, because of relapses. Among the complications were haemorrhage from the stomach, pneumonia, endocarditis, painful swelling of the liver, vast haemorrhages under the skin, in the muscles and even in the cavity of the skull, orchitis and album- inuria. Siegel cultivated a microbe from organs taken from the dead ; the inoculation of this microbe into cows produced in them foot-and-mouth disease (aphthae epizooticas). Generally speaking, foot-and-mouth disease is seldom met with in childhood and further observations are therefore desirable. As I pointed out, stomacace never occurs in toothless chil- dren, but in the pre-dentition age a similar morbid process occurs, described first by KHmentovsky in the Medical Report of the Foundling Hospital of Moscow, 1876, under the name of Osteo- gingk'itis gangrcrnosa neonatorum. (The last epithet is not suf- ficiently specific, because of his six patients only one was six days *Jahrb. f. Kinderh.^ 32 S., 1890. DISEASES OE THE MOUTH III of aj,'e, and in two other cases the malady began on the 39th and 54th days.) Osteogingivitis of the new-born starts as a Hmited, inflammatory swelUng of the gum, which very soon becomes g-angrenous at the point of attack and from the thus-formed ulcer the crown of a milk-tooth falls out after two or three days. This morbid form is accompanied by fever and collapse ; if the patient survives the first days of the disease, then the malignant suppuration spreads over the jaw. producing caries of the bone. In Klimentovsky's cases death occurred on the fifth and the forty- fifth day of the disease. In Klimentovsky's opinion, osteogingivitis dififers from stom- acace by the following : There is no foetor from the mouth. ; the children become affected before dentition, the starting point of the disease is not the mucous membrane, but the deeper parts ; the swelling of the gum, preceding- the falling out of the tooth, seems to be limited and well-defined, so that it rather resembles parulis than stomacace ; the gums do not bleed. From noma this malady dififers by the absence of the gangrenous odor and of gangrene of the soft parts. Among the foetid ulcerative stomatites there are also to be included inflammations of the oral cavity depending upon gen- eral infectious diseases, as diphtheria, small-pox, scarlet-fever ; but in a diagnosis all these forms of stomatitis are of no special value, because they appear after all other symptoms of these dis- eases have developed so distinctly that the diagnosis cannot be difficult. SEMEIOLOGY OF THE APPETITE. Increased appetite is of favorable meaning if it appears in the child during convalescence from an acute febrile disease or any other emaciating sickness. Such an appetite does not usually last long, disappearing as soon as the child entirely recovers. Gluttony, as a physiological occurrence, is observed in nurslings in the first months of life, being the most frequent cause of dys- pepsia and other intestinal disorders, because at this age the child does not refuse to swallow more milk than it can digest, (lluttony is also favorable to the development of obesity in nurs- lings. As a pathological occurrence an increased appetite is ob- served in some rachitic children, as well as in idiots, diabetic pa- tients and in chronic diarrhcea. Loss of appetite, bordering sometimes upon aversion to food^ is observed in all febrile diseases, in stomach and mouth dis- eases and in hysteria. Loss of appetite, as a single and most important symptom of which the parents complain, is often observed in children seven to twelve years of age, manifesting at the same time a typical picture of malnutrition, which could be named school ancumia. Such children, being comparatively tall, have a narrow chest, are considerably emaciated (so that all ribs may be counted by the eye), manifest paleness of the skin and mucous membranes (but this pallor is not so developed as in chlorosis), and suffer from complete loss of appetite, especially with regard to meat. They usually are constipated and often complain of headache. During- summer these patients improve and eat better, but with the com- mencement of school-lessons the appetite again declines, and so the trouble continues up to twelve or fourteen years, when the patient seems as if regenerated, begins to eat more and grows stouter. The same picture is to be seen in some cases of chronic SEMEIOLOGY OF THE APPETITE 113 stoinach catarrh or chronic dyspepsia, so that oftentimes it is difficult to say whether the loss of appetite depends upon the anaemia, or both diseases depend upon the stomach catarrh. The latter proposition becomes more reasonable if the tongue is thickly coated, the patient often complaining of eructations or even nau- sea, if he sometimes has pains in the abdomen, while constipation follows diarrhoea, and if there may always be noted a yellowish tint of the conjunctivae. Despite this, however, the question often remains undecided whether such children suffer from symptoms of stomach catarrh, because their aucemia produces diminished secretion of gastric juice, and thus makes them especially predisposed to stomach dis- eases (Dyspepsia nervosa). The differentiation of stomach catarrh from nervous dys- pepsia may be materially assisted by examining the stomach with the tube. The period of duration of food in the stomach in nerv- ous dyspepsia remains normal (about six or eight hours after a light dinner the stomach is empty ; in stomach catarrh this period is longer). It is noteworthy that in nervous dyspepsia the pa- tient's physical condition has great influence upon his appetite. The so-called anorexia hysterica is most often found in young girls, in age from ten up to seventeen years, frequently being the first symptom of hysteria. The trouble is usually first mani- fested under the influence of an idea (the desire to become thin, to excite sympathy or to exact a great deal of attention, or be- cause of spasms of the oesophagus, vomiting, etc.) ; the patient begins to eat much less than formerly, and very soon entirely refuses food or drink. Absolute starving produces the most intense emaciation of the organism (there remain, as it is said, only skin and bones), marked weakness (the patient cannot either stand or sit), the extremities become cold and cyanotic. When the patient reaches such a stage of emaciation, then a fatal ter- mination is possible. In hysterical anorexia it is somewhat characteristic that the patient's condition usually improves quickly if taken to the hos- pital and there fed through a tube. A prolonged feeding through a tube is, however, seldom necessary, as the patient usually begins to take food in the natural manner after two or three days. A child sometimes refuses food not because of a bad appe- 114 SEMELOLOGV OF THE APTETITE tite but on account of entirely different reasons. I refer here to nurslings disinclined to take the breast. The child may refuse to take the breast either from birth, or after a term of nursing may then cease taking the natural food. If the neiv-born child should not take the breast during the first day of life, such an event does not prove anything, being of very frequent occurrence and onl\- temporary : but if he con- tinues refusing the breast on the second or tliird da}' then one must be inquisitive. All causes upon which the refusal of the breast may depend may be divided into two groups: (i) Either the child cannot suck; or (2) he has nothing to suck. The child cannot nurse the breast either because he is too weak (abortive), or he was lx)rn in a condition of asphyxia and suffers from atelectasis, or there is a maldevelopment, as hare-lip. cleft-palate, or mikrostomia. In the other class the child does not take the breast because it is entirely empty, or, even when it contains milk, he can get nothing because the breast is too firm and too heavy for the child ; or the nipple is not very well developed. If the child took the breast during the first da\s of life, but later on refused, then it mostly depends ui)on thrush or u])on the presence in the mouth of small ulcers, aphthous or sxphilitic, as well as upon fissures of the lips, which cause pain ujxju the act of suckling. It sometimes occurs that the baby readily takes the bottle, but refuses the breast (as the latter requires more force), or suckling proves impossible because of trismus (in new-lx)rn, in tetanus; in elder children in the last period of men- ingitis), or because of snuffles (cannot breath during suckling), or the child stops taking the breast as a result of general debility because he is an abortive one, or because of some disease. Finally, in the third class of cases the cause of refusing the breast is the giving up too early of the breast for the bottle. It is very easy to spoil a child by instilling in him different bad habits, as it is likewise easy to accustom him to order. Having been used to a sweet sucking-bottle or to sugared cow's milk, the child will persistently refuse the breast (especially if the latter be hard and demands from the child a certain force in suckling) tiid ends by completely turning away from the breast. SEMK[()[,0(;V OF THE APPETITE II5 In all such cases the child manifestly does not take the breast, that is, his lips remain plainly immovable when the nipple is introduced into his mouth ; he makes only feeble attempts to suck and soon stops, bursting- into a loud cry. Besides these, still other cases are met with, as when the •child starts suckling ravenously, but very soon chokes and stops nursing. In this case inability to nurse depends upon the great •quantity of milk in the nursing woman, and upon the weak chest ■of the child, so that he has no time to swallow the necessary quantity and therefore chokes. The laity think the most common reason why the child does not take the breast well is the too short frenulum of the tongue. This, however, never produces complete interference with suck- ling, although it may hinder it. It is not difiticult to recognize the presence of a short frenulum. If the free end of the tongue be lifted by a pallet-knife it will be seen that the frenulum is stretched like a thin membrane, attached too far in front, so that when the tongue is pushed out or lifted a groove is formed on its top, which is absent if the frenulum is not short (i. e., attached not "very far in front). If the child refuses the breast because there is no milk, or because it is too firm, the condition can be learned by examining the breast, that is, by squeezing out (milking) milk. Mothers often complain that the child does not take the "breast, yet an examination shows that the child sucks, but not so long as the mother would like. Then the physician has to decide the question, whether the child soon stops suckling because of being satisfied, or on account of some other cause. If the child becomes satiated quickly he may still appear well nourished be- •cause of the breast being very rich with milk. However, if he stops suckling because of general debility, etc., then he starves ■continually and progressively grows thin. This question may also be decided directly, namely, by weigh- ing the child before nursing and immediately after. The addi- tional weight shows accurately the quantity of milk taken. To judge whether this amount is sufficient one may be guided by Snitkin's data, according to which the child nurses on the "irst ■day one one-hundredth of his weight (30 grms., or one ounce), and then every day adding one gram more, so that by the end Il6 SEMEIOLOGY OF THE ArPETITE of the first month he takes about two ounces ; at the end of the third month about four, etc., until the sixth month; after that time the quantity of sucked milk remains approximately the same. In private practice, because of lack of proper scales, one must content himself by the approximate determination of milk. Increased thirst occurs in children oftener than gluttony. It is, for instance, observed frequently in rachitic children, even when they do not suffer from diarrhoea, nor from increased sweat- ing. Polydipsia is further a constant symptom of diarrhoea and diabetes, false or true. In many cases copious drinking of milk or sweet tea, especially in the night-time, depends simply upon a bad habit and upon the fact that such children are fond of the taste of the beverage. If the milk, for instance, be changed to plain water, it will he immediately noticed that the child does not drink so much because of thirst as of habit. In children oftener than in adults a perverted appetite is met with, the so-called pica, which manifests itself by the child being passionately desirous for some uneatable things, as chalk, lime, sand, etc. This symptom I have noticed most often in rachitic children. DISEASES OF THE THROAT. Acute inflammations of the mucous membrane of the fauces, the so-called sore throats, occur in childhood very often ; but, since children younger than five years visually do not complain of painf\d deglutition, it is very easy to overlook a sore throat, provided the physician does not strictly observe the rule to ex- amine the throat in every diseased child, especially in febrile con- ditions. The rigid fulfilment of this rule is the chief means of a correct diagnosis of throat diseases in children. In many cases, especially in nurslings, inspection alone is insufficient; one must also feel the throat with the finger, by which it is very easy to discover a retro-pharyngeal abscess. Sore throat is always manifested by a reddening and swelling of the mucous membrane of the tonsils and soft palate ; some- times these symptoius are all that appear, while again whitish or yellowish islets, or patches, and a diffuse coating appear on the red surface. DISEASES OF THE THROAT CHARACTERIZED BY A REDDENING OF THE MUCOCS MEMBRANE OF THE TONSILS AND SOFT PALATE. Here must be included first of all simple or catarrhal sore THROAT — angina catarrhalis. This disease appears either pri- marily as a result of exposure to cold, in entirely healthy chil- dren, or secondarily during exacerbations of a chronic catarrh of the throat, especially in scrofulous children with hypertrophied tonsils, or in acute infectious diseases, namel\ , in influenza, scarlet-fever and measles. Genuine catarrhal sore throat, angina catarrhalis rlicn- matica, occurs quite seldom, more rarely than other forms of sore throat accompanied by spots. This disease is characterized by a considerable fever (in older children by painful deglutition) and redness, with swelling of the mucous membrane of the tonsils and Il8 DISEASES OF THE THROAT soft palate. In two or three days recovery occurs. If similar attacks take place repeatedly in a child during autumn and winter, and if the tonsils are enlarged, or there are some other signs of chronic catarrh of the throat, as dilatation of the vessels and swell- ing of the glands of the posterior walls of the pharynx whose mucous membrane is usually dry, then we have to deal with an exacerbation of the chronic catarrh, the fever being in such cases insignificant and sometimes even entirely absent. Catarrhal sore throat as an accompanying symptom of an in- fectious disease, differs from a primary sore throat by the char- acteristic signs of the latter: In la grippe snuffles is always pres- ent, and often also cough ; in scarlet-fever a characteristic eruption on the skin ap])ears at the end of the first twenty hours ; in mea- sles, however, the diagnosis may be aided by the mucous mem- brane of the fauces remaining normal on the first day of the fever, and on the second or third day there appears not a diffuse redness, but a spotted one. Spots of the size of a pea appear in limited number on the soft, and partly on the hard, palate, on the normal, i. e., not reddened mucous membrane; the dift'usc hyper^emia occurring later on, for instance, after twenty-four hours, when separate spots disa])pear. They are easier seen on the other parts of the mouth, especially on the mucous membrane of the lips and cheeks. (About the diagnostic value of this prod- romal rash see Diseases of the Mouth, page 96.) In scarlet fever, from the very first, the redness of the fauces- is also not of a dift'use character, but consists of very small points. The spots are much smaller than the patches in measles, are situated closely together, and sometimes one may notice that they are produced by petechia. If the scarlatinal eruption of the soft palate is not accompanied by punctate haemorrhages it very soon becomes converted into a diffuse redness which to some extent is characteristic, because in the beginning it occupies the center of the soft palate and is limited by very abrupt edges (map-like redness), while in simple catarrhal sore throats the tonsils become affected more often, and the redness never differs decidedly from the normal mucous membrane. After one or two days the specific character of the scarlatinal catarrhal sore throat disappears, the redness becoming diffuse and spreading over the tonsils and pos- terior wall of the pharynx. DISEASES OF THE TIJROAT 119 DISEASES OF THE THROAT MANIFESTED BY FOR- MATION ON THE TONSILS OF WHITISH-YPiLLOW ISLETS. FoLLicuLArt Sore Throat — aiii^iiia foUicularis. — Inflamma- tion of the follicles results in the appearance on the reddened sur- face of the tonsils of a considerable number of yellowish, round, slightly elevated islets or plugs the size of a pin's head. This angina differs from all other spotted sore throats by the equable size and rei^tilar shape of the islets, so that the tonsils look like a "starry sky" (Stromeyer). The eruption of the islets never ex- tends beyond the margins of the tonsils. This disease starts from the very first with high fever, sometimes with vomiting, and may therefore create a suspicion of scarlet fever, inasmuch as scarla- tinal sore throat sometimes develops in the form of a follicular one. The doubt cannot last longer than twenty-four hours, i. e., until the appearance of the scarlatinal rash. Lacunar sore throat — angina lacnnaris — differs from the preceding by the shape and color of the islets. On the reddened tonsil there are noticeable irregular, sometimes chinky, figures of an entirely zvhite color. Here we do not deal with elevations of the mucous membrane, i. e., not with swollen follicles, but simply with an accumulation of catarrhal secretion (mucus, epithelium, fungi) in the hollows, which are so abundant in the tonsils, espe- cially when they are hypertrophied. If the plugs of the lacunas are of a purely white color, then the diagnosis is easy, because in other punctate sore throats the islets are of a yellowish or grayish tint ; if, however, the lacunas are filled out with muco-purulent se- cretion and look like islets, then the disease may be regarded as a spotted diphtheria. The latter has two peculiar signs, which should aid the diagnosis immediately, or at least not later than twenty-four hours. The first peculiarity of diphtheria is that the exudation (wherever diphtheria may be — in the throat, intestines, etc. — it is immaterial) first occupies the eminent parts of the mu- cous membrane (in dysentery, for instance, the tops of the villi), and therefore the diphtheritic process will aftect first not the cavity of a tonsillar hollow, as occurs in lacunar sore throat, but the edges of the latter. To be able to find out minutely the localiza- tion of the islets, it is necessary, of course, that the patient should show- his throat, but this is often not possible with children. In I20 DISEASES OF THE THROAT such a case one must postpone the final decision until the next day, meanwhile taking advantage of the other peculiarity of diph- theria, namely, its liability to spread over the surface. If, on the next day, the islets have become larger and some of them con- fluent, having formed patches, then it is probable that we have to do not with a lacunar, but with a diphtheritic sore throat. Lacunar sore throat begins and continues with high fever (nearly 40 degrees C. — 104 degrees F.) and has a cyclic course, ending with crisis on the third, seldom on the fourth, day. If however, diphtheria starts with high fever, it always has a pro- gressive course during the first days, assumes a membranous form and never terminates so quickly without the serum treatment. The abortive form of diphtheria which remains until the end as a punctate sore throat may end with recovery in three to four da\s, but in such case it remains as a purely local morbid pro- cess, running not only without fever, but also without redness of the affected mucous membrane. Lacunar sore throat is to be considered as an acute infectious disease. 'J1iis is proven by its cyclic course and appearance as family epidemics ; the latter fact makes the diagnosis easier, be- cause the epidemics of diphtheria cannot occur as slight sore throats with a typical course. Aphthous sore throat is characterized by the formation on the mucous membrane of the soft palate and tonsils of small (the size of a pea) round, superficial, yellowish ulcerations with decid- edly hypen-emic edges. It is not easy to confound this morbid form with diphtheria or other punctate sore throats, because the ulcers are never confined to the tonsils alone, but are always ac- companied by aphtha? in other parts of the oral iiiucoiis membrane, especially on the tongue, lips and gums. Aphthous angina, like aphthous stomatitis, is often accom- panied with considerable fever. Punctate diphtheria differs from other punctate sore throats, as already pointed out, by two peculiarities : the liability to extend over the surface, and primary appearance on the em- inences of the mucous membrane. Diphtheria, even when mem- branous, often runs with almost normal temperature, but its punc- tate variety may be almost excluded if there is considerable fever; if we have to deal with family epidemics, then the diagnosis may DISEASES OF THE THROAT 121 1)6 easy, owing to the fact that typical forms of diphtheria occur simultaneously with abortive spotted forms. The appearance of paralysis in the patient after two or three •weeks indicates that there was diphtheria, notwithstanding the fact that Gubler long ago described several cases of paralvsi*^ very •characteristic of diphtheria yet developing after sim])le sore throats ; but his observations were made in pre-bacteriological times. More demonstrative are the cases of Bourges, of a diph- theritic paralysis after streptococcus angina, and those of Fiit- terer ; at any rate, the occurrence of paralysis after non-diphther- itic sore throat is so infrequent that it may be disregarded. DISEASES OF THE THROAT ACCOMPANIED BY THE FORMATION OF COATS OR MEMBRANES. In a normal, non-h}pertrophied tonsil there may always be -seen in its center quite a large hollow (lacuna) of an ovai shape with its longest diameter from above downward. This hollow is sometimes tilled, in a catarrhal or parenchymatous sore throat, with a mucous plug ( as in lacunar angina the small hollows are iilled), and then a white spot of the size, for instance, of the end 'Of a small pencil, appears in the center of the swollen and red- -dened tonsil. The spot is so firmly adherent that it cannot be re- moved with a brush and simulates therefore, as well as by its ■size, a diphtheritic sore throat. This variety of lacunar sore throat is often accompanied by a considerable swelling of the whole gland — angina parench}'ma- rtosa — and often terminates in the formation of an abscess. The beginning of the disease is manifested by violent fever, usually associated with chills, and in older children by difficult •deglutition. The white spot, developing on the site of a lacuna, has some peculiarities by which it can be differentiated from a diphtheritic coating : (i) It akvays occupies the center of the tonsil. (2) It always has an ozhiI form with the longest diameter from above downwards. (3) Its edges are sharply limited, the surface, however, a^eaching the mucous membrane, is seldom elevated. (4) Its color is, at the start, intensely zvhite. 122 DISEASES OF THE THROAT (5) The size of the spot remains stationary during several' days. On the other hand, the diphtheritic coating is of grayish, or yellowish tint, is irregular in its contour and grows larger every day, extending not only over the tonsils, but usually also- to the soft palate (uvula) and posterior wall of the pharynx. Herpetic sore throat or herpes of the throat — herpes toii- sillarum, sive angina herpetica — is characterized by the appear- ance on the tonsil of a group of thickly-crowded vesicles which very soon rupture and leave in their place an erosion, surrounded by a bright-red ground. The erosion soon becomes covered with a fibrinous membrane which simulates diphtheria. The eruption of the small vesicles and the formation of the yellowish coating is preceded by a febrile condition of two or three days' duration,, sometimes very severe. The disease terminates in recovery in three or four days. If the physician did not see the vesicular period he may easily fall into a mistake by accepting the grayish-yellow surface of the erosion for the diphtheritic coating, which it resembles in its color and outlines. According to Cadet de Gassicourt, herpes of the pharynx is the most frequent source of error in this respect, not always avoidable by a single examination ; but one can hardly agree that angina herpetica appears as a frequent cause of doubt,, as this form of malady occurs very seldom. The differential points from diphtheria consist first of all in the ^etiological factors (angina herpetica arises from an unknown cause or from an undoubted exposure to cold, diphtheria from in- fection) ; then in the persistent and high prodromal fever, in the- origin of the coating from a group of vesicles (if the exudation be removed from the surface of the ulceration by means of cotton,, it is often easy to see the scalloped margins of the erosion, alluding to its vesicular origin), in herpes of the lips often accompany- ing the pharyngeal herpes, and in the rapid recovery. ,. Membranous or pseudo-diphtheritic (diphtheroid) sore throat — pseudo-diphtheritis, s. angina diphtheroidea, s. an- gina FiBRiNOSA SIMPLEX. — We employ this name in a purely clin- ical sense and understand by it every kind of inflammation of the mucous membrane occurring with the formation of white or whitish-yellow coats similar to diphtheritic, but independent of the diphtheritic poison, i. e., sore throats in which Loffler's bac- DISKASES OF THE TIIKOAT i-'3 illiis cannot be found either by microscopical examination of the membranes, or by making cultures on blood serum. That diph- theritic coatings may be produced not only by Loffler's bacillus, but also by other microbes, is now undoubted, but what microbes possess this peculiarity we do not know positively ; it is certain only that different microbes as, for instance, streptococci, Brisou's small coccus, staphylococci, Frankel's pneumo-bacillus, etc., can produce such membranes. On the basis of personal observations made during late years on the clinical material of the hospitals for contagious diseases (Moscow) we have come to the conclusion that the staphylococcus and streptococcus are the most frequent elements in the pseudo-membranous sore throats and that, for in- stance, almost all cases of scarlatinal diphtheria may be called streptococcous from the bacteriological point of view. It is also undoubtedly truethatstreptococcous pseudo-diphtheritic sore throat is sometimes observed without scarlet fever, viz., as a genuine independent disease. In such cases, to be sure, one cannot deny the possibility of scarlet fever without eruption ; but such a prop- osition may be sometimes denied positively by the fact that the patient immediately after streptococcous pseudo-diphtheritic sore throat becomes infected with scarlet fever. I observed such a case in the infectious departments in December, 1892. Klebs* observed a whole family epidemic of false diphtheria which was caused by a large micrococcus of the group of monades, so- that ^'the con- tagiousness is not to he held as a proof that a given sore throat is not of psendo-dipJitheritic nature." Dr. Boulloche** describes, besides the streptococcous sore throat, three other forms of pseudo-diphtheritic angina due to staphylococcus, pneumococcus and coccus. In his opinion all these infections, including the streptococcus variety, are not con- tagious, being usually of a short and favorable course. [Cruchet classifies the various forms of pseudo-membranous angina into the following groups (besides the forms above named by Boulloche) : ( I ) Pseudo-diphtheritic or diphtheroid angina due to vari- ous microbes, but not to Klebs-Loffler bacilli. =^K!ehs: Rcal-Eiicyclopacdia of Prof. Eulciiburg, Article "Diphthcrm" p. 164. **Dr. BouMoche: Lcs angincs a fausscs membranes. Paris, 1894, pp. 142-153- 124 DISEASES OF THE THROAT (2) Pseudo-diphtheritic angina (kie to pseudo-diphtheria bacilli (bacillus of Hoffmann). (3) Pseudo-diphtheritic angina due to pseudo-diphtheria bacilli other than Hoffmann's bacillus. (4) Diphtheritic angina due to Klebs-Loffler bacillus.* The latter form would, in our opinion, l)e more properly classed uny clearing up the question through its further course. Numerous investigations by many authors show that diph- *Arch. dc Med. d. Enf. vi., 1903. **Report on the twenty-five years' activity of the Children's Hospital of the Prince of Oldenburg, S. Petersburg, 1894, p. 334 (Russian). ***See Vratcli., 1890, p. 708 (Russian). DISEASES OF THE THROAT 1 25 theroid sore throats are far from being rare; from Polievktow's table* one can see that out of 1.169 cases, examined in different chnics, pseudo-diphtheritic sore throat (i. e., not caused by Lofif- ler's bacilhis) occurred 151 times, viz., in 15 per cent. In our chnic (Moscow) out of 100 cases pseudo-diphtheria was found 26 times; Martin met them still more often, namely, of 112 cases, 43 times, i. e., in 38.4 per cent. It is self-evident that the per centage of false diphtheria will be still greater if all cases of sore throat with white spots, which clinically do not look like diph- theria altogether, be referred to this disease. In many cases pseudo-diphtheria resembles the genuine Loff- ler infection to such a degree that even the most experienced physician is unable to reach a final conclusion without a bacterioscop- ical examination. The practical rule in such cases is therefore the following: If the physician be in such an environment that he cannot resort to a bacteriological examination, he should, in all doubtful cases, make a subcutaneous injection of antitoxin and isolate the patient. On the ground of clinical and cXtiological data one may with greater or less reliability exclude pseudo-diphtheritic sore throat and accept diphtheria, if in a given family there has previously occurred cases of this malady, if the latter runs without, or with insignificant, fever (but not vice versa, because high fever does not exclude diphtheria) ; if the membranes spread over the edges of the tonsils, for instance, on the soft palate, uvula, nose or larynx. Among the pseudo-diphtheritic sore throats only the scar- latinal variety is very liable to extend far over the borders of the tonsils ; all other forms do not affect the soft palate, or the pos- terior pharyngeal wall, with, of course, rare exceptions. Albuminuria is not infrequently met with in pseudo-diph- theria; but the subsequent paralyses in diphtheria only (Bourge's case, see above). Pseudo-diphtheria may be suspicious, then, when in a given family there has occurred several cases of a seemingly slight diphtheria ; if the membranes be of white color and not firmly at- tached to the mucous membrane ; if the disease began as a severe catarrhal sore throat, i. e., with a high fever associated with in- *Traitsactions of the Society of Pediatrics in Moscow for the year 1893-94, P- 113- 126 DISEASES OF THE THROAT tense redness of the fauces and very painful deglutition. It is important to point out that in pseudo-diphtheria the membranous exudation almost never extends to the borders of the tonsils, so that the presence of a coating on the soft palate, uvula and the posterior pillars points toward a genuine diphtheria ( it must again be borne in mind that the scarlatinal false diphtheria is an excep- tion). Finally, the estal)lishment of the diagnosis may be con- firmed by the result of the serum treatment. In a recent case (two or three days from the beginning of the disease) of genuine diph- theria, a decided improvement is usually obtained in from twelve to twenty-four hours after the injection ; in the case, however, of false diphtheria the serum does not influence the further course of the morbid process. Diphtheria of the iwuces. — On the basis of pathologico- anatomical data only such a sore throat should be regarded as diphtheria in which a real diphtheritic exudation is developed ; when so-called coagulation necrosis of the mucous membrane is formed ; in the period of recovery the necrotic parts should slough ofif by reactive suppuration and on the site of the diphtheria an ulcer must remain, with a scar after healing of the latter. But from the clinical standpoint something else is known as diphtheria, something that does not lead to necrosis of the mucous mem- brane, nor to the formation of ulcers or scars, although such processes here may have place. In the diagnosis of diphtheria of the throat the clinicians are guided not by the anatomical changes of the mucous membrane, but by setiological causes, namely : diphtheria of the throat is an inflavDnation of its mucous inem- hrane produced by the poison of diphtheria — Loffler's bacillus. It is immaterial whether the throat be affected by a croupous exudation, or the inflammation be only a catarrhal one ; as soon as we find that in a given case the cause of sore throat is Lofifler's bacillus we should regard such morbid process diphtheritic and should so characterize it. Thus we distinguish the catarrhal form of diphtheria, croupous diphtheria and gangrenous or septic diphtheria. These forms are all varieties of the same pathological process — diphtheria which belongs to contagious and epidemic diseases. Since not only Loffler's bacillus is liable to produce croupous or diphtheritic inflammation of the mucous membranes — i. e.. DISEASES OF THE THROAT 127 membranous exudations, but other microbes may also have similar action, it is obvious that the presence of a membranous coating alone on some part of the mucous membrane does not prove that Ave have to deal in any given case with diphtheria : for instance, in a severe bloody diarrhoea there occurs diphtheria of the large intestines ; but this does not mean that the i)atient contracted the •diphtheritic virus, because such a disease is usuall\- produced bv the virus of another affection — namely, dysentery. In the latter case dift"erent degrees of inflammation are met also, as in di])h- theria of the throat, and therefore catarrhal, croupous and diph- theritic varieties are described — in fact the analogy is complete. The same occurs in the throat during scarlet fever, which virus -always produces inflammation of the mucous membrane of the fauces ; but the degree of this inflammation varies in diverse cases from a simple catarrhal sore throat to a real diphtheritic necrosis. Thus, according to the stage of development of local and -general symptoms we have the spotted form of diphtheria, mem- "branous diphtheria, and the septic variety. The spotted or catarrhal form of diphtheria is characterized by the appearance on the mucous membrane of the tonsils of yel- lowish and grayish islets of the size of a pin's head or larger; fever is low or is absent ; the submaxillary glands do not become swollen ; the whole disease may end with recovery in three or four ■days. Pathologico-anatomically the spotted form can be called neither diphtheria nor croup, because there is no fibrinous exuda- tion, and we have to do here merely with a slight catarrh of the mucous membrane, where yellowish-gray spots are formed by the islet-like deposit of a mucous exudation in the upper layers of the epithelium (Heubner). If this form does not go farther, but stops in the period of the formation of spots, then it is easy, of course, for it to be mis- taken for a lacunar or some other catarrhal sore throat. The dif- ferences have been pointed out above. Since all catarrhal sore throats usually begin with considerable fever, diphtheria alone being an exception, then a normal, or nearly normal, temperature -in spotted angina is suspicious of its diphtheritic character ; and if at the same time there are, or have been, cases of distinctly de- 128 DISEASES OF THE THROAT veloped diphtheria in members of the same family, then the diag- nosis is more than probable. Such forms, indeed, occur very seldom. The diagnosis may be aided by the fact that every day the separate islets grow- larger, spreading over the surface, coalescing and forming coats and membranes at first only on the tonsils, and later on the soft palate. We can then say positively, if the margins of the uvula or of the soft palate are involved, that it is not a simple catarrhal sore throat, but diphtheria or scarlet fever, which will be decided by the inspection of the skin. Croupous or membranous form of diphtheria develops either from a spotted one, or appears primarily as such, starting in such case like catarrhal sore throat, with considerable fever. Inspection of the pharynx o\\ the first day of the disease only shows signs of a severe catarrhal inllammation : bright-red tonsils and soft pal- ate and oedematous swelling of these parts with enlargement of the uvula. ( )n the second day the exudation appears on the ton- sils, and on the third or fourth day a coating is also seen on the soft palate, the fever at the same time persisting. In the initial stage the membranes are firmly attached and cannot be separated without bleeding, but after several days they slough ofif. Such sore throats are always accompanied by swelling of the submaxillary glands and those of the neck, which, however, never suppurate (dififering from scarlatinal sore throat). Absence of fever and swelling of the glands does not exclude diphtheria. The duration of the croupous variety is from five or six days to two or three weeks, seldom longer. Slight as diphtheria may appear in a given patient, one may never be sure of a favorable termination, owing to the liability of an extension of the morbid process into the larynx (croup). Apyretic conditions do not secure one from such an event, but seem to favor it. The more time that has elapsed since the begin- ning of the disease, the less likelihood of the larynx becoming involved, thus making the prognosis more favorable. Diphtheria is very liable to extend over the surface during the first five days, so that if the first week has passed happily one may hope that na croup will develop. The younger the child the less is the distance from the tonsils DISEASES OF THE THROAT 129 to the larynx, and the quicker one must expect the occurrence of false croup ; in children younger than two years diphtheria is espe- cially dangerous, because its extension into the larynx at this age is almost the rule. Diphtheria of itself may be dangerous, as well as by its action on the general condition of the organism and on the heart activ- ity. The thicker the false membranes, the more surface they cover and the stronger the odor, the severer the diphtheria. The spread- ing of the diphtheritic process to the posterior pharyngeal wall, and especially on the nasal nmcous membrane, is justly regarded as an unfavorable omen ; of the same value is the extensive swell- ing of the glands of the neck and oedema of the surrounding sub- cutaneous tissue. The most favorable data for the prognosis are derived from the temperature ; according to Botkin, high fever in diphtheria permits of a better prognosis than a low temperature. Septic, malignant or toxic forms of diphtheria differ from the preceding by the character of the local appearances, as well as by the general condition of the organism. The considerably enlarged tonsils are coated with dirty-gray exudation, having a very foetid odor ; from the nose there is a sero-purulent, some- . times bloody, liquid discharge ; the neck becomes swollen, not so much because of infiltration as from oedema of the cellular tissues ; then comes collapse, the extremities grow cold, the pulse feeble. These cases are almost always fatal ; if symptoms of ady- namia appear from the very beginning, then the patient seldom survives the first week ; some die during the first two or three days. Diphtheria in its membranous or septic variety is very similar to a severe scarlatinal sore throat, which is also characterized by the formation of diphtheritic coats in the fauces. There is, however, not only a clinical, but also an etiological difference. The difference between diphtheria and malignant scarlatinal sore throat may be summed up in the following manner : Scarlatinal diphtheria is the result of poisoning of the organism by the scar- latinal virus (according to some authors by the secondary infec- tion due to streptococcus), and therefore, together with the sore throat, there also appears a scarlatinal eruption : genuine diph- theria, however, arises from infection by the diphtheritic virus which has nothing to do with the skin and thus does not produce I30 DISEASES OF THE THROAT any rash. Therefore, if the membranes in the throat be devel- oped simultaneously with a certain rash on the skin, we have to do with a scarlatinal sore throat, or scarlatinal diphtheria ; if, however, there is no rash — then, with a common diphtheritic sore throat, or a diphtheria. But this rule, being true of the over- whelming majority of cases, admits also of some exceptions, namely in two directions : First, there occur cases of scarlatinal diphtheria without eruption (this happens usually in grown per- sons), and, secondly, the patient may contract both viruses, those of scarlet fever and of diphtheria, and then it may occur that in a scarlatinal patient there will develop simultaneously a genuine bacillar diphtheritic sore throat. In case diphtheria complicates scarlet fever, an exact diagnosis from the inspection alone of the sore throat is impossible. In such an instance, a bacterioscopic examination is needed. Scarlatinal diphtheria appears in the patient during the early ■days of the disease, usually on the third to the fifth day ; therefore, if the diphtheritic sore throat shows earlier than the rash or, vice versa, after the end of the first week, then we may think that we have to deal with a genuine diphtheria, which becomes the more probable the later it occurs. Scarlatinal sore throat often spreads into the nasal cavities, but almost never afifects the larynx ; therefore, if in the scarlatinal patient diphtheria appears late and extends into the larynx, a genuine diphtheria becomes very probable ; the diagnosis is undoubted if the characteristic diphtheritic paralyses occur in the period of recovery. Cases of scarlet fever complicated with genuine diphtheria occur in private practice very seldom, so that all cases of diphtheritic angina in scarlet fever may be held as malignant scarlatinal sore throat (or as scarlatinal diphtheria). This being the case, the physician has very little chance of making a mistake in diagnosis ; but in badly constructed hospitals, where all contagious patients are placed together in the same ward, cases of double infection are common. In doubtful cases of all kinds of spotted or membranous sore throats one should have a bacterioscopic examination of particles of membrane, taken from the patient's throat, because at the pres- ent time it is well proven that in all cases of genuine diphtheria the Klebs-Loffler bacillus can be found in the membranes. He DISEASES OF THE THROAT 13^ who is familiar with the question of the diagnosis of diphtheria by the microscopic examination of the membranes or mucus, will agree with Roux and Yersin, that "nothing is easier and quicker than the microscopic examination of the false membranes, and nothing is more plain than obtaining colonies on serum." Thev advise this technique : Particles of the membrane should be dried by filter paper and smeared on the slide so that the latter should be covered with a sheath of the false membrane, but not of mucus ; then the slide is passed through a flame and is stained by Loffler's methylene blue, or by gentian-violet according to Gram.* The stained specimen is washed with water and exam- ined wet by the immersion system. The diphtheritic bacilli are slightly bent, have a club-like swelling at the ends, are granular and not proportion at eh- stained. One must admit that the swell- ing at the ends and the unequal staining are not visible in all specimens. In membranes of a true diphtheria such bacilli are met with constantly, often together with other microbes. For the diagnosis of diphtheria the external appearance of separate bacilli is not so much of value as their method of grouping; for it is characteristic of diphtheria that the bacilli are situated on the specimen not in groups, but as if forming "felt." The microscop- ical examination itself takes only a few minutes and gives, in the majority of cases, entirely definite results. If the disease is near recovery the diphtheria bacilli diminish in number, while the secondar\- microbes increase — which circumstance is of importance in the prognosis. In slight cases the diphtheritic bacilli are very few in number from the very first, but there are a great many other microbes. In instances where the number of bacilli is very small then, for the purpose of making the diagnosis, Roux and Yersin advise *Our observations in the clinical infectious departments have convinced us that Loffler's bacillus is not difficult to be found even without the re- moval of particles of membrane by the forceps ; it is sufficient to scrape the surface of the membrane in the throat by a platine-loop and to put the obtained mucus on the cover glass, to dry it and after that stain with Lof- fler's methylene blue. For the preparation of such a stain we take a sat- urated alcoholic solution of methylene blue, filter and mix it together with aqueous solution of hydrate of potassium (i:iooo), while for every lOO parts of the latter we take 30 parts of solution of the stain. The dried cover glass is put, together with the mucus, into the stain for ten minutes, then it is washed off with water, dried with filter paper, put on the slide with a drop of copaiba balsam, and the specimen is ready. 132 DISEASES OF THE THROAT the employment of cultures on blood serum, to which is added one-third calf bouillon containing one per cent, sugar and pepton and 0.5 per cent, sodium chloride. This serum constitutes such a favorable medium for diphtheria bacilli that after fifteen hours A „ ',».-,/-■*'' \\\ f--^ »M ^•/ <* v:^ Fig. IS — Diphtheria — A. Culture of diphtheria bacilH on serum with gela- tiiie. B. Several diphtheritic colonies. C. Diphtheria bacilli. (Dieula- foy.) entirely distinct colonies are obtained, while the majority of the secondary microbes only begin at that time to grow. It is suffi- cient to scrape with a platine loop the surface of the coagulated serum in two or three tubes which are then placed in the incubator DISEASES OF T[1E TtlROAT 133 at a temperature of 95 det^rees — 98 degrees F. (35 degrees — 37 degrees C). Usually after ten to fifteen hours diphtheria colonies are distinctly seen: roundish, grayish-white elevated spots with the center less transparent than the periphery. But, as similar colonies may be produced by the coccus, one must, for controlling, prepare microscopic specimens and stain them. Cultures may also be obtained from the dry membranes. It is then necessary to wet them in sterile water (dry diphtheria bacilli may be con- served very long, standing a temperature of 96 degrees — 97 de- grees C. (179 degrees- 181 degrees F.) during one hour.* (Fig. 15). Diphtheria bacilli seldom occur as pure in plain specimens or in cultures, being usually mixed with some other microbes, the importance of which should not be neglected, because from them we can judge of the malignancy of any given case. Observations show that purely bacillar and bacillo-coccus sore throats run a more favorable course than those where a great number of strep- tococci are met with, together with the specific bacilli. It seems that almost all cases of so-called toxic or septic diphtheria could be placed among these bacillo-streptococcus sore throats. There is an opinion that not very much stress should be laid upon the bacterioscopic examination, because the so-called pseudo- diphtheria bacilli are frequently found in dilferent kinds of sore throats, as well as in the mucus of the mouth of entirely healthy persons. This bacillus is analogous to a genine diphtheria bacillus by its cultures and mode of development on blood serum, differing merely by not being poisonous (i. e., inoculation of guinea-pigs by pure cultures of this bacillus proves negative). On this ac- count Roux and Yersin remark that in non-diphtheritic sore throats, as well as in healthy persons, the bacilli are always very few ; on serum there are obtained one to four colonies, or out of several tubes only in one. Therefore they affirm that the diag- nosis of diphtheria by means of cultures cannot be obscured by the presence of pseudo-diphtheritic bacillus, because, in the case of diphtheria, many characteristic colonies may be obtained. [Graham Smith,** among other conclusions on this distribu- tion of diphtheria bacillus, state as follows : *Vratch, 1890, p. 708. **Journal of Hygiene, April, 1903, p. 253; (quoted from the American Year Book of Medicine and Surgery, by Gould, 1904, p. 575) • 134 DISEASES OF THE THROAT (i) Diphtheria hacilh have been found in a considerable proportion of persons who have come in contact with cases of diphtheria or with other infected persons. (2) Carefully conducted investigations among healthy per- sons who have not at a recent date been in contact with diphtheria cases or infected "contacts/' have shown that znrulent diphtheria bacilli arc very seldom (three examples among 1,316 persons) present in the mouth of the nornml individual. — Earee.] Lately Fraenkel pointed out Neisser's method of double stain- ing to be the right way of determining the true or false diph- theritic bacillus* The technique of this method is not difficult : the dried, smeared-on-the-cover-glass particle of the culture to be examined is put for from one to three seconds in an acetic acid solution of methylene blue, then washed with a watery solution of Bismarck brown. The genuine diphtheritic bacilli become yel- lowish-gray, containing at the ends violet-blue granules. These granules are entirely wanting in the pseudo-diphtheria bacilli. Frcenkel asserts that any micro-organism cannot be held as a genuine diptheritic one if the polar bodies be not manifested by Neisser's method of double staining. The composition of the stains for Neisser's method is the following : (I) Methylene blue, I.O (gr. xvi.) ; alcohol, 96 per cent — 20.0 (5 dr.) : glacial acetic acid, 50.0 ( i oz. 5 dr.) ; Aq. destill. ad. looo.o (lb. iii). (2) Watery solution of I'ismarck brown 2:1000. Scarlatinae sore thro.\t. — An extensive discussion of this variety is not needed ; it is sufficient to say that the scarlatinal virus possesses the property of producing inflammation of the throat ; the character of the afifection depends ui)on the malig- nancy of the virus and on the soil on which it develops (indi- vidual immunit}) : in other words, the intensity of the scarlat- final sore throat depends upon that of scarlet fever itself. In mild cases (moderate fever, pale-pinkish rash, good gen- eral condition) we find a simple scarlatinal sore throat; in cases of moderate severity — the follicular or lacunar form ; in grave cases — the diphtheritic form in all its possible stages of evolution, but without Loffler's bacillus. All these different forms of sore throat we regard as scar- *Bcr!incr Kliiiischc Jl'(n-hc)isclir. 1897, No. 50. ni>i-:.\sr:.s (>f thi-: riiRoAr 135 htinal, provided they occur simultaneously with the scarlatinal rash on the skin. On bacterioscopic examination we constantly find streptococci. Of course, we have cases where Loffler's bac- illus is present, but such cases always occur in a combination of scarlet fever with diphtheria. I observed such a case in a family where three contagia prevailed at the same time, viz., scarlet fever, diphtheria and varicella, so that out of four children of this family one had diphtheria, another scarlet fever and varicella, the third, scarlet fever with diphtheria, and the last one all three diseases together. Trousseau distinguished two kinds of membranous scar- latinal angina: ( )ne was called by him recent sore throat (aii- i:;iiic psciido-nioiibraiiciisc precoce ) , the other late ( tardive ) . The former occurs in the period of eruption ( the second up to the fourth day ) always being- accompanied 1)\- involvement of the nose and submaxillary glands, but sparing the larynx ; it cannot be considered as diphtheria. The latter variety appears in the period of convalescence (second to third week) and extends into the larynx. The former, according to Trousseau, depends upon an infection by the scarlatinal virus, the latter, by that of diph- theria. Recent bacterioscopic investigations amply confirm the correctness of his views, because the streptococcus occurs in fresh scarlatinal diphtheritic sore throats, together with (^thcr microbes, but in the later stages there is Lotfler's bacillus. I'lcerous sore thro.vt (ani^ina I'ineenti or I'ineent's an- gina). — By ulcerous sore throat I understand ulcerous destruc- tion of the mucous membrane of the tonsils, based on the same morbid process as stomacace — an ulcerous fretid inflammation of the mouth. In both cases the mucous membrane becomes swollen, takes on a bluish tint and easily bleeds on touch. The affected mucous membrane very soon undergoes superficial necrosis and decay, with the subsequent formation of an ulcer, covered with a thick, soft, dirty-yellow, foul-smelling deposit. These symp- toms, with the stench from the mouth, are accompanied by a slight fever and swelling of the submaxillary glands, so that this form of sore throat highly resembles diphtheria. The first cases of ulcerous sore throat I observed in a con- sultation with Dr. Schlossberg. The diagnosis was here assisted by the fact that the girl had a pronounced stomacace, while the 136 DISEASES OF THE THROAT simultaneously pronounced swelling, the bleeding mucous mem- brane of the mouth and the friable, soft coating contraindicated diphtheria. As neither myself, nor my colleague, had heard at that time of such a form of sore throat our diagnosis was made only as a supposition and was confirmed by the successful action of potas- sium chlorate. Another case of ulcerous sore throat I observed in a twelve-year-old girl. She came under observation on the third day of the disease, which began with a violent fever and painful deglutition. On the day of her entrance to the clinic the following symptoms were noted : A violent stench from the mouth, very characteristic of stomacace, although the gums w^ere not afifected ; both tonsils, especially the left one. were enlarged to such an extent that the uvula was compressed by them and the posterior wall of the pharynx could not be seen ; lx)th tonsils and partly the uvula, were coated with a grayish-yellow, very fri- able and thick exudation ; under the angle of the inferior maxilla there was a considerable swelling of very hard consistence, caused by ])eria(lcnitis ; the voice had a nasal twang; fever, 39 degrees C. (102 degrees F.). In the exudation a great many dilTerent cocci were seen, bin no Lofller bacilli could be demonstrated. Although the gums were not involved in this case, never- theless we had a right to exclude diphtheria and to diagnosti- cate ulcerous sore throat on the ground of the characteristic stench, the appearance of the exudation and solid tumor under the angle of the inferior maxilla (in diphtheria the swelling of the subcutaneous tissue is usually of the oedematous character). The treatment, which consisted especially in administering in- ternally, and applying externally, potassic chlorate (Bertolet's salt), in both cases, two per cent, solution, amply confirmed our diagnosis, because the stench had diminished by the following day. and at the same time the local appearances in the throat also decreased, and after r. week the patient recovered entirel}'. A short description of this sore throat may be found in \'ol- ume II of Traitc cliniqiic ct pratique des maladies des enfants, by Barthez et Sanne, p. 226. According to their observations "angine ulcero-membraneuse." ulcero-membranous sore throat (as they call this form) is not always accompanied by stomacace; in such a case the diagnosis will be more difficult and mav be assisted DISEASES OF THE THROAT I37 l)y the aspect of the affected parts, by the aetiology (the same as for stomacace) and by the prompt action of potassium chlorate. Very distinctive of this disease is the characteristic stench from the mouth, as in stomacace, being entirely different from that in gangrene or diphtheria. Ulcerous sore throat was described minutely by Professor Simanovsky in the medical journal "Vvatch,""^ He observed this malady occurring as a small epidemic simultaneously with cases •of ulcerous aft'ection of the oral mucous membrane and called it pharyngitis ulcerosa. He also often observed aft'ection of the posterior wall of the pharynx and tonsils, while in some cases the mucous membrane of the mouth and gums remained normal. The ulcerous lesion of the throat was accompanied only by verv slight general symptoms, moderate fever or no elevation of the temperature. The disease usually lasted from seven to ten days or more. Sometimes only one tonsil was affected. If the lesion of the gums be absent, then is the analogy with diphtheria still greater, because albuminuria is of frequent occurrence in this sore throat. In Simanovsky "s cases the ulceration of the gums was always present. Nevejin** sums up the symptomatology of ulcerous sore throat in the following way ( from his own eight cases and twenty- eight cases from literature) : (i) Specific odor, being the same as in stomacace, but dif- ferent from that in diphtheria and scarlatinal sore throat. (2) The form of the coating — it looks as if greasy, grayish- yellow, friable, little resembling the solid diphtheritic coat or :any fibrinous exudation. (3) Sympathetic participation of the mucous membrane of the mouth (even in the form of a very slight catarrh), hence -visible irritation of the salivary glands and persisting salivation. (4) The presence of characteristic ulcers. (5) The most characteristic solidity and enlargement of the submaxillary glands, without simultaneous oedema of the subcutaneous tissue (this oedema, due to periadenitis, is pathog- nomonic of diphtheria when the latter is associated with wide- spread coating in the throat). *See "Vratch," 1890, No. 1-7. ^^Transactions of tlic Society of Pediatrics in Moscow (Russian), 1894, 138 DISEASES OF THE THROAT (6) The general condition of the patient: good pulse and" preservation of physical forces simultaneously with apathy, vast coats in the throat and often elevated temperature. (7) The development of the disease is favored by the same conditions of exhaustion of the organism and external hygi- enic influences as in stomacace (Barthez and Sanne). All of our patients lived in a bad environment. (8) The prompt action of chlorate of potassium, which for this disease is of the same value as quinine in malaria. (9) Finally, one more characteristic difference between diphtheria — absence of paralyses in the period of convalescence. Bacteriosco])ic examination of the exudation (staining by Loffler's nicthvlcne blue) in the ulcerous form, as well as in stomacace, alwavs shows fusiform bacilli with sharp ends and spirilla;. If we are to be guided in the diagnosis of ulcerous sore throat by this sign, we may say that recent and slight cases of angin?e ulcerosje are accompanied neither by stench from the mouth, nor by swelling of the submaxillary glands. Without bacterioscopic examination such slight forms cannot be diagnosed from the mild lacunar sore throat. I will point out, by the wa>, that our rule is to begin the treatment of an\- "■fretid" diphtheria with internal doses of potas- sium chlorate. [These fusiform bacilli and spirilla; were first described by Mncent in the years 1896- 1898 as the cause of ulcerative angina. The fusiform bacillus is swollen at the centre, with pointed ex- tremities. It is generally straight, but is sometimes curved or bent upon itself and measures 6 to 12 micro. It is encountered in irregular masses, often as a diplobacillus. and sometimes two are seen lying at an angle to each other. Their motility has been questioned by a few, but is maintained by Xiclot and Marotte. The bacilli stain readily with the basic stains, but are gener- ally decolorized by Gram's method. The dimensions of the spirillae vary, but they are very long and of equal width through. They are observed singly, in groups, and are sometimes seen in an inextricable mass. Their motility may be retained for many hours, but diminishes rapidly on ex- posure to air or cold. Where the disease process is superficial the spirillum may be absent, but in the deeper lesions the combina^ DISEASKS OF fllK THROAT 139 tion is invariable. This description taken from Fischer's article, "Report of Two Cases of Ulcerative Angina and Stomatitis, As- sociated With the Fusiform Bacillus and Spirillum of Vincent,"* is confirmed also by other observers (Sobel and Herman,** Hess and others). Hess*** distinguishes two forms of Vincent's ulcer- ous angina : a croupous and a diphtheroid-ulcerous form. The Fig. 16 — The bacilli and spiulla of VincL-nt (after Fisher). former is characterized by the formation of pseudo-membranes without any loss of tissue, the latter by the formation of more or less deep ulcers. Of the former ouly the fusiform bacillus is characteristic, while in the latter both parasites appear simul- taneously. These parasites (fusiform bacillus and spirochetes denticola)are saprophytes of the cavity of the mouth and digestive apparatus. The bacillus alone may cause the disease, while the spirilla is pathogenic only when associated with the fusiform bacillus. (Fig. 16.) *Amcr. Jour, of Med.. Sc. September, 1003 **Nczi' York Med. Jour., January 7, 1901. ^**Deut. Med. JJ'oeh.. 190.3, No. 42. 140 DISEASES OF THE THROAT Ulcerous angina may be easily (listinjjuished from other sim- ilar forms by the following: (i) Both parasites must be present abundantly. (2) Absence of diphtheritic bacilli. (3) Syphilis may be excluded. (4) In the superficial layers of the mucosa staphylococci and streptococci are occasionally found. Sobel and Herrmann had under their observation twelve cases of Vincent's angina and in all of them the above described parasites were found in large numbers. — E.\rle.] Syphh^itic SORE THROAT occurs in two forms, condyloma- tous and ulcerous. Angina syphilitica condylomatosa, s. condylo- mata faucii, as a manifestation of hereditary syphilis, occurs espe- cially in small children from two to five years of age, while angina syphilitica ulcerosa, s. nlccra syphilitica faucii (syphilitic ulcers of the fauces) appears usually as a symptom of the late period of syphilis and therefore is seen mostly in older children after seven years of age. The favorable situation of the ci)nd\iomata is the inner sur- face of the cheek ; they appear first of all on the corners of the mouth ; then on the soft palate and more seldom the tonsils and the tongue become affected. Condylomata look like pinkish white patches, considerably elevated over the surrounding mucous membrane.. On touch they do not bleed and they are painless ; reactive, inflammatory redness around them is not to be seen. As the condylomata are caused by the proliferation of the papillae of the skin, or of the mucous membrane, they may therefore always be recognized by the vil- lous structure, appearing as very small, punctiform, whitish ele- vations, so crowded together that the condvloma looks like a slen- der mosaic. The development of condylomata is slow, lasting weeks, but, being painless, they are often overlooked. It is seldom that con- dylomata of the mouth and fauces constitute the sole evidence of syphilis; usually there also exist sinuiltaneously condylomata on the skin and very often circa anuiii. which fact aids the diagnosis very much. As the condylomata are always elevated above the surface of the neighboring mucous membrane, it is impossible to confound DISEASES OF THE THROAT I4I them with other ulcers. They are rather more hke a diphtheritic patch, and are sometimes recognized as such if occupying only the soft palate and tonsils, and if the history, together with the other objective symptoms of syphilis, be absent. In such cases attention must be given to the color of the patch (condyloma is of pinkish-white color, the diphtheritic patch of yellowish-gray) and to its structure. Angina syphilitica ulcerosa is characterized by the appear- ance on the mucous membrane of ulcers of different size and shape, usually with sharply-cut edges and a dirty-yellow floor. They occupy either the soft palate, often producing its perfora- tion, or the tonsils and the posterior wall of the pharynx. Often there may be seen scars of old ulcers together with new sores. The course of the disease is very protracted with few sub- jective symptoms. .Sores of the fauces usually occur from decayed gummata, thus corresponding to the late period of syphilis, and therefore there is very often observed, as accompanying symp- toms, the affection of the bones ; the patients usually complain of pains in the legs (increasing in the night), on the examination of which painful periostites on the anterior surface are noted. Tubercular and lupous ulcerative processes being of chronic course could be confounded with syphilis of the throat, and occur in childhood very seldom. Of these two chronic ulcerous pro- cesses lupus is of greater importance in childhood. The picture of destruction in lupus is very similar to that of syphilis. The diagnosis is based on : ( 1 ) Accompanying symptoms (lupus of the nose) . (2) On the history (no signs of syphilis). (3) On the result of treatment with iodine (lupus does not yield to iodine, while syphilitic ulcers heal quickly). [Gangrenous Angina (primary). — Besides the enumer- ated forms of angina a pritnary gangrenous angina is also de- scribed. In the previous editions of his Semeiology and Diagnosis of Children's Diseases* Prof. Filatov says: "Barthez and Sanne also describe in their Text-Book gangrenous angina which is analogous to gangrene of the cheek (noma). I cannot speak of such an angina from my own experience, as I never saw the same." *Prof. Filatov's Semeiology, etc. 2nd Russian ed. 1891, Moscow, p. 84. 142 DISEASES OF THE THROAT E. Oberwarth collected twenty-four cases of primary gan- grenous angina (two cases have been reported by Fullerton in The Lancet, June 7, 1902), which with his own case'''* make a total of twenty-five cases. The nature of this morbid process consists in a necrosis of the mucous membrane of the throat ex- tending to the neighboring soft parts of the mouth and larynx, and thence to the lips, cheeks and occasionally to the Eustachian tubes. Anatomically this disease is shown by the formation of grayish-black patches with sharp, yellowish edges which seem to be elevated after the separating of the crust. Clinically it is characterized by : (i) A foetid odor from the mouth, fscal-like. (2) Severe pain in the throat, especially during the act of swallowing. (3) Nasal tone of the voice. (4) Occasional presence of enlargement of the cervical glands. (5) Absence of fever (the temperature is even subnormal). (6) Cyanotic tint of the skin. (7) General collapse, accompanied by psychical depression. (8) HcTemorrhages from the capillaries, small veins and large vessels. (9) Malignancy of the course (this disease being always fatal). ' The course of the affection covers three or four weeks, al- though cases are rei)orte(l wherein the disease continued for eighteen months. The aetiology is unknown, some authors contending that it is always of secondary origin. Trousseau thought it might aft'ect, without any visible cause, entirely healthy persons, quickly lead- ing to death. According to Oberwarth the cause of the disease is some microbe resembling the diphtheria bacillus. In his case, a twelve-year-old boy, Hansemann conducted the post-mortem and found a large number of streptococci, but Oberwarth does not seem to be willing to regard them as the cause of the malady. This disease may be confounded (i) with Vincent's an- _**Primare Angina GangnTnosa bei einem Knaben (Dent. Med. Woch., 1903, No. 17 and iS). DISEASES OF THE THROAT I43 gina (ulcerous angina) ; (2) zi'itli diphtheria, and (3) with syphilis. Angina Vincenti differs from the gangrenous form ( i ) by its benign course; (2) by the odor not being so offensive, i. e., •does not resemble the gangrenous odor of this form, and (3) by bacteriological findings. The bacteriological examination ; the peculiarity of the odor ; the swelling of the cervical glands (which are developed in diph- theria but may be absent in gangrenous angina) may easily dif- ferentiate it from diphtheria. With syphilis it may be confounded according to Oberwarth. •especially in the event of a primary affection of the tonsils with the primary chancre ; in the latter case a few days after the first complaints there appears on the neck an enlargement of the glands reaching from the size of a pigeon's egg up to that of ■one's fist. Therapy is practically- helpless although cauterization with nitric or chromic acid, rinsing of the mouth and throat and the administration of stimulants arc suggested. — Earle.] SEMEIOLOGY OF DIFFICULT DEGLU- TITION— DYSPHAGIA. If the mother complains that the child cannot swallow it does not necessarily mean that there exists an obstacle to the passage of food from the mouth into the stomach. Sometimes, as in some cases of diffuse aphthous stomatitis, the child does not even attempt to swallow the food, forcing it out of the mouth. Numerous small ulcers upon the tongue and other parts of the mouth may render chewing so painful that the child refuses hard food altogether, or promptly rejects it as soon as it is taken into- the mouth. Hot, sour and sweet food is also badly borne, but cool milk is readily swallowed, and in this fact consists the pecu- liarity of this form of false dysphagia, the true cause of which may be easily discovered by inspecting the mouth. In other cases there is a real impossibility of swallowing de- pending either upon diseases of the throat and pharynx or upon stricture of the oesophagus. To the former belong all acute and subacute cases of dysphagia, to the latter, chronic ones. It is noteworthy that different forms of catarrhal and fol- licular sore throat in children run entirely imperceptibly in this regard, so that they are often overlooked. The same may be said of many cases of diphtheritic and of scarlatinal sore throats- On the contrary, difficult deglutition occurs in phlegmonous an- ginas terminating with the formation of an abscess of one of the tonsils, as well as in retro-pharyngeal abscesses and in severe cases of diphtheritic and scarlatinal sore throats. A simple in- spection or, in the case of an abscess, palpation, make the diagno- sis of all these morbid forms easy. Swallowing of soft, as w^ell as of liquid, food sometimes causes such a pain that the child entirely refuses any food ; such an occurrence frequently happens because of the formation of erosions on the tonsils after sloughing of the diphtheritic mem- branes. SEMEIOLOGY OF DIFFICULT DEGLUTITION 145 Difficult deglutition accompanied by choking due to fallinf ot food, or water, into the larynx, and by regurgitation of the swallowed fluid through the nose, depends upon paralysis of tJur soft palate, as the result of previous diphtheria. On inspection the mucous membrane of the fauces appears normal, but the soft palate remains immobile during deep inspiration and phonation, as well as upon touching it with a brush. In nurslings regurgi- tation of the milk through the nose may occur even without paralysis of the soft palate, namely, because of cleft-palate. Of acute oesophageal diseases creating a barrier to swallow- ing in childhood, there occur: CEsophagitis corrosiva (may be recognized from the history and presence of burns in the mouth and fauces), soor of the oesophagus peculiar to children exclu- sively during the first days or weeks of life from a neglected thrush, and spasm of the cesophagus in older children. It is true that we do not find in text-books on Children's Diseases any allus- ions to the fact that, besides hydrophobia, the cause of the com- plete impossibility to swallow may be an oesophageal stricture due to spasm of the oesophageal muscles ; nevertheless this sometimes occurs, as, for instance, in one case which was demonstrated in my clinic in November, 1889. A girl, seven years old, previously in good health, but rather thin and pale, was brought to the clinic on account of complete inability to swallow. The disease began ten days before by lumps, of hard food sometimes stopping in the oesophagus, and soon re- turning to the mouth. During the last days even fluid passed with difficulty and produced a peculiar rumbling sound. The obstruc- tion was sometimes so great that the patient could not even swal- low a teaspoonful of milk. No hindrance was found on examina- tion by the sound, which, provided with a sponge the size of a walnut, passed very freely, and after that the patient could drink a few drops of water. The patient was given sodium bro- mide, and a week later it was found that the difficult deglutition had disappeared entirely. Here the quick development and rapid disappearance of the oesophageal obstruction determined the diagnosis. Similar, purely nervous strictures of the oesophagus, are sometimes easily recog- nized by hard food passing easier than liquids, or by the con- siderable variation in the degree of the stenosis. Spastic stric- 146 SEMEIOLOGV OF DIFFICULT DEGLUTITION ture of the oesophagus, like other neuroses, particularly occurs in children of neuropathic parents. Interference with swallowing; due to obstruction or stricture of the oesophagus is characterized by the food or water being kept in the oesophagus, but without reaching the stomach, and soon re- gurgitated unchanged. That the regurgitated food does not come from the stomach is evident by the absence of hydrochloric acid, or bile. ( )nc mav determine with the sound not only the place of stricture, but even its degree. The most frtxiuent cause of (esophageal strictures in chil- dren is burning of the oeso])hagus with some caustic substance (sul])huric acid, sodic hydrate, etc.), usually indicated in the historv. The stricture appears during the stage of cicatrization of the ulcerated mucous membrane, gradually increasing for several months. Cicatrizant strictures in chiKlren very seldom develop from other causes, such as, for instance, sy]:»h.ilitic ulcers, injuries result- ing from swallowing foreign bodies, small-])<>x i)ustules, etc. Com- paratively more frequent, but also rarely, (esophageal stenosis arises in children because of compression from tumors of the anterior and ])osterior mediastina, as, for instance, caseous degen- erated glands, abscess caused by vertebral caries, etc. In other cases again stenosis of the oesophagus i-s an inher- ited defect of development. Then we have to contend with either the formation of diverticula, or with a limited contracture of the oesophagus. In the former case the sound sometimes glides freely into the stomach, but again stops in the blind sac and does not go any farther. When particles of food lodge in the diver- ticulge, they remain there indefinitely, being regurgitated later in a purulent condition. When the oesophageal stricture is congenital the sound does not always detect it at one place (this becomes gradually normal), but the parents notice that the child very often chokes as soon as he begins to eat. as if he had tried to swallow food not well masticated. In complete inherited obstruction of the (Desophagus the new-born very soon (in three or four days) dies from starva- tion, always regurgitating the milk which they apparently swal- low ravenously. SEMEIOLOGY OF VOMITING. Vomiting occurs in children much oftener than in adults, appearing- easier the younger the child. During the first months of life it frequently occurs in entirely healthy children because of overfeeding, bearing the name of habitual z'oiniting or eructa- tiuJK The latter differs from real vomiting by its sudden appear- ance in a perfectly healthy and cheerful child, without any pre- monitions which indicate nausea, \vithout disfiguration of the face and without any exertion, that is, no contraction of the abdominal muscles. The child remains after the eructation as cheerful as he was before. Eructation appears especially easy in a child immediately after suckling, if he is carelessly taken in the hands (compres- sion of the abdomen ) or if he is bounced. On the contrary, a real vomiting is usually preceded by a nausea which makes itself evident in a nursling b}- the face grov/ing pale, by general rest- lessness, a small, quickened pulse and frigidity of the extremi- ties. The vomiting itself occurs with the aid of the abdominal muscles ; therefore, the contents of the stomach are expelled with considerable force, while at the end of vomiting the patient utters a peculiar sound which gives the impression of suffocation. The peculiarity of the milk rejected with eructation is of no special value in a differentiation from vomiting, because it may in both cases be either entirely fresh, or coagulated, depending upon the time which has elapsed since nursing. If eructation takes place immediately after nursing, then the milk is liquid, however, if some time after, for instance, after twenty minutes, then it is coagulated. When the milk is thrown out uncoagulated, not- withstanding a sufficient interval of time after suckling, then it denotes insufficiency of acid (or rennet-ferment) in the gastric juice, so that such a vomiting cannot be regarded as a plain eruc- tation, but should be looked upon as a pathological condition. The same may be said regarding a considerable amount of mucus mixed with the eructated milk, as well as regarding vomitus 148 SEMEIOLOGY OF VOMITING which is entirely free from milk, consisting of a small amount of fluid mixed with bile (the stomach being empty, the vomiting can not appear as eructation). Of particular value is vomiting where the stomach-contents show considerable admixture of blood. Bloody vomiting in children occurs very seldom, as the common causes of such vomiting, namely, round ulcer of the stomach, cancer, and chronic diseases of the liver, are unusual in childhood. It is true that in literature a few cases of ulcer of the stomach and duodenum are described, but all refer to chil- dren in the first weeks of life. These maladies sometimes pro- duce in the new-born bloody vomiting and bloody dejecta, and the loss of blood is usually so abundant that the patients die in a few days with symptoms of acute anaemia. This disease is described in the text-books as melccna neonatorum, cases of re- covery from which are rare. Much oftener than ulcers of the stomach as a cause of in- testinal and gastric haemorrhages in new-born is general mal- nutrition manifested during life by debility and a tendency to bleeding from the mucous membranes and skin, and post-mortem by haemorrhages into the serous cavities and parenchymatous or- gans. The aetiology of the disease, called by Grandidier transitory hemophilia of the new-born, has not yet been definitely deter- mined. There may be included here cases of septicaemia and of so- called acute fatty degeneration of the new-born (Buhl), and some cases of inherited syphilis, syphilis hcemorrhagica neona- torum. Bloody vomiting, as a symptom of temporary haemophilia,, differs from melaena neonatorum by the haemorrhages appearing in the former cases not only from the gastro-intestinal canal, but also from various organs, and this fact alone suffices for the diag- nosis of temporary haemophilia. According to the frequency of occurrence the order of the haemorrhages is as follows : Umbilical, gastro-intestinal, from the genito-urinary organs, from the mouth and nose, the con- junctivae, from the ears, skin and kidneys. [An interesting case of conjunctival haemorrhage is reported SEMEIOLOGY OF VOMITING 1 49 by Meyer Wiener.* The haemorrhage started in the morning following- birth ; was persistent during five days ; and ended with death. The post-mortem proved negative. Syphilis and gon- orrhoea was discovered in the history of the mother. The cause was, in the author's opinion, silver nitrate which was applied to the baby's eyes after birth. — Earle.] The haemorrhage is never active (arterial umbilical hsemt^r- rhage cannot be included here, being a local disease), but oozes from the healthy mucous membrane. Haemorrhage most often appears from the fifth up to the twelfth day of life, proving very quickly (in from three to five days) fatal. Recovery is possible, but seldom occurs. [Abt** classifies the haemorrhages in new-born in (i) trau- matic or accidental, and (2) spontaneous. Spontaneous haemor- rhages are very seldom met with ; one case in 500 or 700 births. Of thirteen reported cases in ten haemorrhage developed shortly after birth, two were a few weeks old and one five and one-half months. Spontaneous haemorrhage should be regarded as a symp- tom of some infection and as an indication that the porosity of the vessel walls is increased, or that the tendency of the l:)lood to clot is diminished. Jacobi claims that this disease was very frequently noted when puerperal fever was of common occur- rence. Walls observed one case where the haemorrhage was due to malarial intoxication, in another case obstructive jaundice was the cause of haemorrhage. In general, says Abt, this disease may be caused by a number of different conditions, and that no one causal factor is responsible for the haemorrhagic diathesis in infants. — Earle. ] In elder children also bloody vomiting usually appears as a symptom of temporary haemophilia, but the meaning of this condition is entirely different than in the new-born, inasmuch as gastric haemorrhage occurs in older children most often in purpura lueiiiorrhagica, s. morbus maculosus Werlhofii (see Purpura) and, less frequently, in the prodromal period of haemor- rhagic small-pox (ibidem). In diagnosticating bloody vomiting one should bear *St. Louis Medical Reviezv, April 25, 1903. **Journal Am. Med. Assoc, Jan. 31, 1903. (See also Abt's Abstract in The Practical Medic. Series, ed. by Abt, June, 1903, pp. 15. 16.) 150 SEMEIOLOGY OF VOMITING in mind that besides real h?ematemesis there is alsa false luonatciiicsis. The latter is nothing but vomiting of the swallowed blood, while in a true haematemesis the haemorrhage takes place from the mucous membrane of the stomach itself. False hsematemesis in nurslings occurs in the presence of fis- sures on the nipples of the nursing woman, the child suckling the blood together with the milk (very rare cause) : or there is haemorrhage from the mucous membrane of the mouth, for in- stance, after cutting the frenulum linguae, or after operating for hare-lip ; according to Rilliet and Barthez it also occurs from swallowing blood during the confinement, etc. In all such cases the diagnosis of false hrematemesis is based, first, upon the de- tection of the source of bleeding; second, upon the small amount of blood in the dejecta, and third, upon the condition of the gen- eral nutrition, which scarcely suffers at all because of the slight loss of blood ; while in true haematemesis the child is always very weak and ])ale. In elder children the most frequent cause of false haemateme- sis is epistaxis, especially when occurring in the recumbent pos- ture. As in nose-bleeding some blood always appears externally, this symptom alone may easily determine the diagnosis. To false haematemesis are also referred cases of vomiting wherein blood is mi.xed with the voiuited substance as streaks or small drops, usually thus arising from the fauces because of blood-stasis during the act of vomiting. Such admixture of blood shows only that the act of vomiting was accompanied by great tension of the abdominal muscles. Haematemesis is sometimes simulated by materials which have nothing to do with blood, having only a color resemblance,, for instance, red wine taken by the patient shortly before vom- iting, drugs containing cochineal, etc. One should bear in mind all these possibilities in the history of the disease before real hsematemesis is diagnosticated. In case of doubt a microscopical examination for the red corpuscles must be undertaken, and if the latter be so altered by the gastric juice that even the micro- scope does not decide the question, then it remains to perform the chemical test of Heller, which is recommended for haematuria and is based on the following : If an alkaline fluid containing blood and phospates be heated then a deposit of bloody pigment SEMEIOLO(iY OF VOMIYIXG 151 will be precipitated and become stained a bright-red color. One proceeds in the following way : The vomitus being mixed with a weak solution of sodic hydrate, is filtered and mixed with an equal volume of urine (tliat is, with a liquid con- taining phosphates) and is then boiled. Regarding the similarity of hsmatemesis to h?emoptysis, this circumstance cannot be of great value in childhood, because haemoptysis does not often occur in children. We would, how- ever, remark that blood after having been in the stomach for awhile differs from pulmonar_\- blood by its darker color, and acid reaction. Diseases in which a common vomiting occurs ma\' be divided into two groups, depending upon whether they begin with high fever or run with normal or almost normal temperature. The diagnostic meaning of -c'oiiiifiis in acute febrile diseases will be diff'erent, depending upon the patient's age. In small children, two or three years of age, vomiting which occurred only once, accompanied by rapid and considerable elevation of temper- ature, is of no particular value in a diagnosis, because at this age vomitus appears during any febrile disease, whatever the cause of elevation of the temperature up to 39.5 degrees to 40 degrees C. (103 to 104 degrees F.) may be. The matter is different with vomiting in older children and where it occurs only in the be- ginning of a few diseases, among which of the exanthemata, may be included scarlet fever, small-pox and erysipelas, and of the local diseases, inflammation of the cerebral meninges and the peritoneum. These diseases must be considered wdien the physician deals with a child older than three years, who is taken ill with violent fever and vomiting. In the beginning of other febrile diseases the vomiting is caused almost exclusively by im- proper diet, so 'that it will be of value in the diagnosis of the above-mentioned diseases onlv when it appears with an e)iipty stomach, that is, if the patient vomits nnicous fluid mixed with bile, and if there may be excluded the influence of different drugs chief of which are the more recent antipyretics, as. for instance, antipyrine, salicylate preparations, etc. For diagnostic purposes, and in view of all these antipyretics being useless in their influence upon the morbid process itself (the brief lowering of tempera- 152 SEMEIOLOGY OF VOMITING ture is not of much use), it is very desirable that the physician should not be too hasty in administering medicines. V'omiting with fever, or with slight elevation of tempera- ture, occurs in various diseases. For the correct estimation of vomiting one must first of all intiuire whether it arises after coughing, or without the latter. Vomiting after coughing most often occurs : (1) in pertussis (whooping cough), but not exclusively here. (2) Jn dr\ pharyngitis, when the mucous membrane is in such a condition of hyperesthesia that a few coughing spells are sufficient to produce vomiting by refiex action upon the fauces. (3) In chronic hyperplasia and caseous degeneration of the bronchial glands. (4) In bronchitis due to cold if it develops in a child which recently had whooping cough ; finally, in a suffocating cough occurring sometimes. (5) In hrmichiectasicr with abundant, but tenacious spu- tum. (6) In purulent pleuritis opening into the bronchi. Briefly speaking, the diagnosis of these cases is not difficult. The two latter conditions may be determined by means of phys- ical examination (see the corresponding sections) ; the former ones differ from each other by the course and the character of the cough (see the part on \Miooping Cough), although they may give negative results on percussion and auscultation. Vomiting at the end of the coughing-spell has a particularly important bearing upon the diagnosis of whooping cough in nurslings. It frequently exists without the characteristic whistle, but attended with vomiting, while another kind of cough which would produce vomiting almost never occurs in this age. A febrile vomiting, independent of cough, occurs either be- cause of irritation of the gastric mucous membrane, or reflexly from the affection of other organs, or from general intoxication of the organism (blood-poisoning). Gastric vomiting which depends upon introducing irritant substances into the stomach, whatever they may be, indigestible food or simply emetic remedies, is characterized by not being associated with any other symptoms, as well as by the absence SEMEIOLOGV OF VOMITING I53 •of any bad sequelae. The child remains, after such a vomiting, •entirely healthy and even does not lose his appetite. In other cases gastric vomiting is only one of the symptoms of an affection of the stomach, as dyspepsia or catarrh (see the corresponding •description). As a result of some neurosis (hyperaisthesia) of the stomach, vomiting sometimes occurs simply because of general nervous- ness and chlorosis, as, for instance, in the following case : A girl, eleven years of age, previously in good health, en- tered the hospital on account of daily vomiting, which had ex- isted interruptedly during the past two months. She never vom- ited when the stomach was empty, but always after meals, solid ras well as fluid ones. Before vomiting the patient had suffered •during the whole preceding month from singultus (hiccough). The parents claimed that she had moved the bowels not more ithan four times during the last two months. When the patient ■entered the hospital she was not emaciated at all, but somewhat pale and weak. Record: She can walk now about a mile, but before she became sick she was much stronger and with better .nourishment. The tojigiie is clean; the appetite not bad; the thirst, normal ; the epigastrium not distended and painless upon pressure; the abdomen is distended considerably, but is painless without, as well as upon pressure; no tumor is palpable ; the bowels seem to have been constipated for about ten days ; neither fever, nor cough ; the -sleep, good ; tape-worms were absent ; temperature ^^y degrees ■C (98.6 degrees F.) ; pulse 88, regular; urine without albumen. During the first day in the hospital she vomited twice, in the ■morning after a few tablespoons of soup and in the afternoon after tea ; the vomiting occurs easily, without any eff'ort. After •supper (a few spoons of gruel) there was no vomiting. On the second day the vomiting again took place twice ; the third day, no vomiting ; a spontaneous movement of the bowels, very dense •dejecta. Up to the tenth day there was one more defecation; the xvomiting did not occur every day. She was given : Tr. quin. comp. 3^8, Fowler's sol. mxx. Sig. Twenty-five drops before dinner and supper. 154 SEMEIOLOr.Y OF VOMITING After one day the vomiting and constipation disappearecT. and did not reappear even when, a week later, the arsenic was stopped. Several months later, the patient entered the hospital again on account of vomiting, but arsenic did not help this time. The patient was soon taken away by her parents and her further history is unknown. The question whether we had to do in this case with t'o;;/- ifing from simulation remained unsolved. The ease with whicli vomiting took ])lace after the smallest quantities of food allowed the supposition that the patient threw out the food without swal- lowing it, but observation cHd not ccMifirm this opinion. Henoch f)l)serve(l vomiting caused b\' lixj^era^sthesia of the stomach (vomitus nervosus), especially in nervous children, in the mornings after hasty eating. In two cases vomiting occurred also in the later day-time in a boy of seven years and in a girl eight years old, but always after some nervous excitement. Such vomiting with intervals of several days lasted months without any further conse(|uences. and then stopped entirely either spon- taneously, or under the influence of tonic treatment. The diagnosis of the nervous origin of vomiting is based especially on the possibility of excluding diseases of the stomach and of other organs, upon which vomiting may depend. Nervous vomiting is often characterized by its obstinateness and easy occurrence, often without nausea, and by its continuation being in contrast with the good appetite and relatively good general con- dition of the nutrition. This is at least correct for childhcKxl. We have observed a few cases of nervous vomiting in boys, as well as in girls, who suffered from daily vomiting during several months in succession, and who nevertheless did not grow thin ; but in adults this symptom is more dangerous, because women sometimes fall into the most dangerous degrees of marasmus as: the result of vomiting. Reflex vomiting is most often caused by irritation of the bowels, peritoneum or brain. Vomiting niay accompany an}- sci'cre pain in the abdomen, whether this be of nervous origin (colics), or inflammatory ; and further by any obstinate constipation, especially because of intestinal obstruction and when uncontrollable finally becomes of fcccal character (if not b}' its aspect, at least by the- odor) . sKMF.ioLocv OF N'oMiri xc; 155 Vomiting; is also sometimes caused by intestinal worms. The latter cause may be suspected onlv when the jiatient complains of nausea, particularly with an em])ty stomach, while taking fcxjd not onl}' docs not cause vomiting, but even prevents it bv remov- ing the nausea. The diagnosis of ta])e-worm becomes completelv confirmed if the microscopical examination of the dejections de- tects there the presence of ova, from the character of which the species of the parasite may be determined. 1 besides this method, the diagnosis of intestinal parasites may be absolutely established by still another symptom, namely, by the elimination of the ])ara- sites or their segments with the dejecta. Cerebral vomiting accompanies acute, as well as chronic, diseases of the brain and its membranes. Many authors lay spe- cial stress upon the character of the vomiting ; they claim that gastric vomiting dififers from cerebral by the former being pre- ceded by nausea occurring soon after taking food, while cerebral vomitus appears without nausea, suddenly, as if the patient ex- pectorates the contents of the mouth, but not those of the stom- ach, h^urthermore, cerebral vomiting is peculiar by often appear- ing when the stomach is empty, especially after changing the horizontal posture for the vertical one. The above said symp- toms must, of course, be taken into consideration when the diag- nosis of cerebral vomiting is made, but they have no decided value at all, because exceptions are met with in both directions ; that is, on one hand it is not always easy to note nausea even in gastric vomiting, which, like the cerebral, also sometimes arises from changing the horizontal posture for the vertical one ; and on the other hand, it is undoubted that cerebral vomiting very often arises after taking food or drinks and especially after taking medicine. Of great significance in the diagnosis of cerebral vom- iting is its persistence; it does not yield for several days either to the diet, or to medicines ; as well as to the fact that the patient feels partially and sometimes completely relieved after gastric vomiting, while after the cerebral variety he feels still more weak- ened. Further in favor of cerebral vomiting are : the clear tongue, normal stools (or constipation), absence of bad odor from the mouth, painfulness upon pressure in the epigastrium and of meteorismus, violent headaclie ( whicli. however, is far from being present as such in all cases at the beginning of tubercular men- 156 SEMEIOLOGY OF VOMITING ingitis), somnolence and irregular, retarded pulse. Generally speaking, no one of the enumerated sym.ptoms may be regarded as absolutely certain, and each one taken separately may be absent, therefore" the complexity of symptom? exhibited is of the most important significance. In some cases vomiting is necessarily preceded for several hours by violent headache, diffuse or unilateral, but after vomit- ing the patient falls deeply asleep and awakes entirely well. Sim- ilar attacks are repeated either once a week, or at greater inter- vals, for instance, once a month, or two to three times a year, depending upon migraine which occurs in children from seven to ten years of age, although not sparing even children of the first years of life. Infantile migraine is usually accompanied by the face growing pale, sometimes by a somewhat retarded pulse and even by slight elevation of temperature, so that the physician, if he does not know the anamnesis (as w'ell as in the case of the first attack of migraine), may suppose the beginning of acute hydrocephalus ; but the question becomes determined very soon, of course, because the child appears entirely well after sleep. The similarity with the cerebral form is still greater when repeated vomiting occurs during migraine, while sleep occurs very quickly. As an example of vomiting due to blood-poisoning may be that which occurs after the subcutaneous injection of apomor- phine. To the same category is referred nrccmic vomiting during acute or chronic nephritis, and vomiting from chloroform. In diagnosticating the latter one should bear in mind that it some- times persists for a couple of days after the operation without yielding to any remedies. (I would point out, by the way, that to prevent such vomiting one should try change of air, for in- stance, transfer the patient from the hospital to a private house ; cases are known wherein this measure had a magic influence on the vomiting.) [In American literature there have been described a few cases of the so-called cyclic or recurrent vomiting. This form usually does not depend upon any digestive disorder, being un- accompanied by pain ; and by this peculiarity cyclic vomiting differs from that occurring in tabes dorsalis, neuroses of the stom- ach and hyperchlorydria. The vomiting arises either suddenl}-, or is preceded by a short prodromal period consisting of general SEMEIOLOGY OF VOMITING 1 57 malaise, headache and anorexia. In the beginning the vomited material is composed of food particles, later on of sero-mucous fluid, and finally of blood. At the same time constipation is ob- served, as well as fever, which conditions lead to exhaustion. The paroxysm of vomiting usually stops suddenly, the recovery be- ing rapid. Death may occur from collapse. The intervals be- tween the attacks are indefinite. The vomiting is believed to be due to elimination by the stomach of some poison which irritates the mucous membrane of that organ (Hand).* These poisons are probably due to faulty metabolism (C. Ely),** occurring most- ly in gouty and neurotic children. According to Edsall*** recur- rent vomiting is caused by an excessive amount of acids, his view being corroborated by the fact that a rapid improvement sets in under the influence of an alkaline treatment (which must be car- ried out energetically, a hundred grains of bicarbonate of soda being the small average quantity, daily, at the commencement of the treatment). In the urine of such patients indican was found (Griffith)**** and also aceton (Edsall, Marfan) ; the latter, ac- cording to Marfan, causes the vomiting (the result of acet- onaemia), so that recurring vomiting, provided Marfan's view is correct, may be included in the group due to blood-poisoning, — Earle.] Leyden describes voniitijig due to irritable zveakness.'^^**'^ In his opinion this nervous vomiting is the consequence of hyperaes- thesia of the stomach in weakened and highly irritable persons recovering from severe diseases. According to his observations this vomiting is one of the most formidable forms, because it is sometimes very violent, thus being dangerous to life. Such a vomiting is often accompanied by convulsive singultus. The cause may be some dietetic fault, or some drug (in Leyden's case — antipyrin) . Leyden regards this vomiting especially dangerous in the period of recovery from cerebro-spinal meningitis, typhoid and diphtheria. In typhoid fever, Leyden observed attacks of severe *Proc. Pliila. Co. Med. Soc, September, igo2. **Jour. Anier. Med. Assoc., March 28, 1902. ***Amer. Jour, of Med. Sci., April, 1903. ****Amer. Journ. of Med. Sciences, November, 1900. *****Leyden: Zeitschr f. Klin. Medic, XII., 4 Heft. 158 SKMEIOLOGV OF N'OMITING vomiting during the treatment with baths, with the cessation of which the vomiting stopped. Nervous vomiting in convalescents from (Hphthcria mu.'tt be especially mentioned, because it occurs in childhood much oftener than after other acute diseases, depending, i^robably. upon paralysis of the vagus. We have observed it only after grave forms of diphtheria. It is usually preceded by paral\sis of the soft palate, weakness, or irregularity, and retardation of the pulse. Shortly before vomiting the patient begins to complain of severe abdominal pains which last either a few minutes, or from two to three hcnirs. After the vomiting there sets in con- siderable cardiac collapse ( feeble, sometimes irregular, pulse, dilation of the right heart, enlargement of the liver because of passive hvperccmia, diminution of the amount of urine, albuminu- ria). The patient may die on the very first day from cardiac ])aral\sis. but death occurs oftener on. the second or third day. Recovery is possible, but seldcjm follows, therefore, such a symp- tom-complex as ^ccakncss of the heart, abdominal pains and vom- iting, in the jiericMJ of recovery, must be regarded as very omin- ous. From vomiting there must be ditTerentiated regurgitation of fcx>d or drinks which did not reach the stomach, being observed, first, in strictures of the oesophagus and, second, during paralysis ■of the soft palate. OBsophageal sfrieture develops in childhood almost exclu- sively after burns with hot water or caustic substances, for in- stance, sulphuric acid, which is often used in households to pre- vent window-panes from frosting. The diagnosis is not difficult, the impossibility of swallow- ing hard food or considerable quantities of fiuid, with the his- tory, is entirely sufficient ; the place and degree of contracture are determined b}' the stomach sound. Paralysis of the soft palate develops after diphtheria (his- tory) and manifests itself by the fact that the patient suddenly ■chokes when swallowing food, or drinking, and forces the food out through the mouth or nose ; the patient's voice assumes a nasal twang; on inspecting the throat it is easily noticed that the soft palate is immovable during phonation and during its irritation bv tickling with the end of the sound. DISEASES OF THE STOMACH AND IN- TESTINES. .ACUTE DISEASES OF THE STOMACH AND INTESTINES IN NURSLINGS. Acute disorders of digestion in nurslings occurs in three chief forms, known under the names of dyspepsia, catarrh of the small intestines, and follicular enteritis, or catarrh of the large bowels. The first form — dyspepsia — is dependent upon the mucous membrane of the stomach and intestines being irritated by the products of the fermentation of food not entirely digested. The disorder of digestion does not depend here upon some gross anatomical changes of the mucous membrane, but simply upon the inefficient activity of the gastric juice. At any event, it is impossible to mark a sharp boundary between dyspepsia and -catarrh of the stomach. The anatomical feature of the second form consists in catarrh of the mucous membrane of the small intestines ; and that of the third form in inflammation of the mucous membrane of the large intestines, with special lesions of the follicles. The differential diagnosis of all these diseases is based, first, upon the character of the dejections and, second, on the concom- itant appearances. In analysing the child's dejections it is nec- •essary to pay attention to their iiiiiiiber during twenty-four hours ; •their consistency, color, odor and casual admixtures. A healthy nursling, when the stomach is normal, moves the bowels two or three times in twenty-four hours. The fasces are of pap-like or jelly-like consistency, do not contain a superfluity of water, that is, normal fgeces should wet the diaper approx- imately as one centimeter of fluid. The more water in the dejec- tions, the wider becomes the circumference of the soiled swaddle. Further, normal stools are of an equally bright-yellow or orange <:olor. being of faint, not repugnant, sourish smell. The reaction is faintly acid, and they usually contain, a noticeable admixture of l6o DISEASES OF THE STOMACH AND INTESTINES mucus, which is intimately blended with the faeces and does not appear in the form of separate lumps or "nests," as in follicular enteritis. Dyspeptic stools exhibit the following peculiarities : They are abundant, but not frequent (instead of two or three times the child moves the bowels about five times in twenty-four hours) and consist especially of faeces; the amount of water in them if* not increased ; therefore, their consistency remains as normal jelly- like; the amount of mucus is somewhat increased, but this, as in normal stools, is intimately mixed with faeces, yet, if it occurs in separate lumps, then it shows irritation of the large bowels^ and hence the transformation of dyspepsia into follicular enteritis. Especially characteristic of dyspepsia is the presence in the stools of great quantities of undigested milk, in the form of coagulcE,. which consist especially of fat, salts of fatty acids, epithelium and casein. Furthermore, the alteration of the color is also char- acteristic ; bilirubin becomes easily transformed during dyspepsia into biliverdin, so that the yellow color of the stools appears mixed with green. The mixture of yellow, green and white colors give to the stools a peculiar aspect which justifies its com- parison with "scrambled eggs." In chronic cases, especially in bottle-fed children, the stools appear, because of lack of bile- pigments, pale-yellow or even colorless altogether. The odor and the reaction of dyspeptic dejections usually are faintly or strongly acid ; in neglected cases foetid dejections are also met with. The act of defecation is performed easily, frequently with noise, because of the passage of flatus, but without tenesmus and pain. Dyspepsia also manifests itself by vomiting, meteorismus and colicky attacks. Dyspeptic vomiting usually occurs after meals, sometimes immediately, and in other cases one-fourth to one-half hour after meals, accompanied by nausea and restless- ness, by which it differs from eructation. Meteorism and colics depend upon the accumulation of gases in the bowels, the product of fermentation of undigested food. The attacks of colic consist in periodically-occurring abdominal pains. Fever is absent in dyspepsia. If the diagnosis of dyspepsia is established on the ground of the above-mentioned symptoms, only half the matter is settled. DISEASES OF THE STOAIACII AM) INTESTINES lOI because it still remains to determine the cause, otherwise the treatment cannot be successful. All causes of dyspepsia may be included in the irregular diet. In breast-fed children overfeeding is the. most frequent cause of dyspepsia; either the child is given the breast oftener than every two hours, or the baby is allowed to nurse more than fifteen minutes, or he is fed many times suc- cessively from the same breast, while the breasts should be given alternately. Especially often do children of young, strong mothers rich with milk, but with weak breasts, suffer from dyspepsia, (the milk spouts from a feeble breast by several streams, even when slightly pressed by the fingers ; on the contrary, from a firm breast the milk is more difficult to be sucked or pressed out). Furthermore, the cause of dyspepsia may be spoiled milk, re- sulting from the influence of indigestible and slightly nutritive food (fish-meals), as well as of sour fruits, menstruation and mental excitement. The quality of the milk may also be in- fluenced by the age of the mother { under twenty and after forty years) and the condition of health of the nursing" woman, as well as the time elapsing since the confinement (new-born chil- dren often fall ill with dyspepsia, if the nurse feeds them with old milk). The causes of dyspepsia in bottle-fed children are so numer- ous and various that only the most important can be pointed out ; cow's-milk of poor quality (besides the admixture the care of the cow may be of significance), especially when it has turned sour or if it be diluted insufficiently with water, and if it is given with some admixtures which do not correspond to the child's age. So, for instance, it may be held as proven that, for children under three or four months of age, neither starch, nor cocoa, nor dif- ferent kinds of coffee are good. I shall not refer to the diagno- sis of all these causes, because they are based siniplv on the his- tory. Some authors describe still another form of dyspepsia char- acterized by the appearance of dejections very rich with fat and known under the name of fatty diarrha-a. first described by Demme and Biedert. This disease is always obstinate and may be cured only by administering food poor in fat. According to Biedert, chemical determination in percents of the fat, contained l62 DISEASES OF THE STOMACH AND INTESTINES in the dry remains of the fseces, is required for the exact diag- nosis. The percentage of fat in fatty diarrhoea varies from 41 to 47, while in normal stools from 4 to 25. For practical pur- poses one may content himself by a superficial microscopical ex- amination ; a small particle of the dejection is diluted with a drop of water on the slide and examined. In normal stools there ap- pears in the field of vision of the microscope only small drops of fat, and in very small amount, while in fatty diarrhoea the entire field of vision is occupied b>- large drops of fat or crystals of fatty acids and salts. More recently Uffelmaun and Tchernofif have shown that considerable increase of fat in dejections occurs in any dyspepsia, so that one cannot be guided by this sign in the diagnosis of fatty diarrhoea, and thus the existence of fatty diarrhoea, as an independent form of dyspepsia, cannot be held as proven. In ACUTE CATARRH OF THE SMALL INTESTINES the dcjCCtionS are abundant, as in dyspepsia, but at the same time more frequent (six or seven times during twent}-four hours) and liquid, be- cause water prevails over other constituents. They are water- ish, pale, and discharged as a strong stream with noise from the eliminated gases. The abdomen is usually distended, but painless on pressure. Fever is absent. If the stomach is simultaneously affected, vomiting appears. Such varieties of gastro-entcntis form the transition from a simple catarrh of the small intestines into infantile cholera, known also under the name of summer complaint. Four conditions play the chief role in the aetiology of INFANTILE CHOLERA: (i) age Under one year; (2) bottle-feed- ing; ( 3 )badly- ventilated rooms, and (4) summer heat. [Cotton* says that statistics indicate that in fatal cases of summer diarrhoea less than 3 per cent were exclusively breast- fed. No clinical phase of this subject begins to rival in import- ance the one fact that summer diarrhoea with rare exceptions means practically summer artificial feeding. — Earle.] [Martin is inclined to see in the common house-fly the cause of summer diarrhoea ; "Each succeeding year confirms my obser- vation of 1898 that die annual epidemic of diarrhoea and of t}"phoid is connected with the appearance of the common house- *Joui: Am. Med. Assn., June 13, 1903, p. 1644. UISEASKS OF TIIK SIOMACH AND INTES'll N' KS 163 fly, which becomes very numerous at the beginniii"^ of July, and breeds chiefly in privy-vaults. The increase and decrease of the annual diarrhoea and typhoid epidemic can be foretold with a great degree of accuracy, an increase in the diarrhcea cases oc- curring in a week, and typhoid notifications in three or four weeks after an increase in the number of flies is observed. The annual epidemics of these two diseases begin and end with the appear- ance and disappearance of the domestic fly."'* — Earle.] In a pathologico-anatomical sense cholera is nothing but a very acute catarrh of the whole gastro-intestinal canal, of course ■of mycotic origin although the specific microbe has not yet been found. It is probable that infantile cholera is produced by various •saprophytic bacteria. [Shiga's bacillus is held by some authors as the most com- mon cause of summer diarrhoea. Duval and Bassett** isolated this micro-organism from the stools of forty-two children suffering from this disease. They did not find the bacillus in the stools of healthy children, or those suffering from a simple diarrhoea or other affections. Gray and Knox*** also reached the con- clusion that Shiga's bacillus is the cause of most cases of sum- mer diarrhoea among children.**** Knox says : "There is good reason for the confidence that a proportion, and probably a large one, of the so-called summer diarrhoeas of infancy is caused by the bac. dysenterice (Shiga). — Earle.] The infectious origin of infantile cholera is evident from and the sudden beginning of the disease, sometimes with high fever ; and the rapid occurrence of collapse and death, without any corre- spondence to the number and quality of the dejections. Clinically, infantile cholera manifests itself like the epidemic variety, by a severe and persistent vomiting, violent diarrhoea and quick onset of collapse. The patient moves the bowels about ten to twelve times in twenty-four hours. The evacuations arc entirely liquid, like water, very abundant and are entirely free of bile (the diapers are wet as if by urine) ; they are turbid bc- *Public Health, Aug., 1903, 652, quoted from Gould's American \'e-v Book of Medicine and Surgery, 1904, p. 580. **Am. Med., Sept. 13, 1902. ***Jour. Amer. Med. Assoc, July 18, 1903, pp. I7S-J70- ****Univ. Pa. Med. Bui, 1902, xv., 407. t64 diseases of the stomach and intestines cause of admixture of intestinal epithelium and numerous fungi ; the reaction in the beginning is acid, later on alkaline, with a hardly perceptible, sometimes ammoniacal odor ; the belly, because of frequent dejections, is soft and not distended; fever is usually absent, but temperature rises sometimes in the commencement of the disease up to 102.5 to 104 degrees F. (39 to 40 degrees C). Constant vomiting and abundant diarrhoea are accompanied not only by severe thirst and scanty secretion of urine (complete anuria sets in sometimes, as in epidemic cholera), but also by the rapidly occurring appearances of collapse, which constitutes the characteristic symptom of infantile cholera as against a sim- ple catarrh of the stomach and bowels. In such a case there are noticed first of all frigidity of the extremities, small and fre- quent pulse, great weakness, and, later on, cyanosis (of the lips) develops, the eyes become sunken, the pulse almost disap- pears, the mucous membrane of the mouth is almost cold and covered with viscid mucus ; hoarse, faint voice ; the fontanelle depressed, the scalp-bones slide over each other (the margins of the frontal and occipital bones slide under the margins of the parietal bones). Shortly before death sclerema appears, that is, hardening of the skin and subcutaneous tissue, depending upon the absorption into the blood of parenchymatous fluids. Sclerema, like frigidity of the limbs, begins at the feet and hands, spread- ing over the back, trunk and even the face. In the latest stage there sets in somnolence, contracture of the neck and finally death with the symptoms of so-called hydrocephaloid. The course of infantile cholera is a very acute one — death or a return toward recovery occurs in a few days. Infantile cholera is most easily confused with epidemic cholera, inasmuch as the symptoms are the same in both cases. The diagnosis is based upon the character of the epidemic ; Asiatic cholera does not spare adults any more than children, and is not so much dependent upon summer heat as infantile cholera, which rapidly abates with the appearance of cool days. In doubt- ful cases one should, of course, resort to a search for cholera bacilli in the dejections. For this examination it is best to take mucous lumps which swim in the "rice" dejections. After hav- ing prepared from them a dry specimen on the cover-glass the latter is stained with methylene blue or fuchsine (slightly heat- DISI'LVSES OF 'lllK STOM \CII AM) I NTICS'II XF.S 1(35 ing for two or three niinutesj and examined with a magificatii.n of 400 to 600. Since in cholera nostras, and sometimes m cholera infantum (Lesage), a microbe of the shape of a coma ( Finkler-Prior's coina), resembling very much Koch's cholera coma, is found, therefore, it is necessary for a positive diagnosis to make cultures according to methods outlined in text- books on bacteriology. [The main difference between Koch's comma-bacillus and that of Finkler-Prior is the following: If some pure or diluted acid (sulphuric or hydrochloric) be added (a few drops) to a twenty-four hours' old bouillon-culture of cholera bacilli, then a pinkish-red, or purple-red color will be obtained. This is the so-called nitroso-indol reaction, due to the ability of the cholera bacilli to form indol, and to convert nitric salts, which are always contained in the nutritive media, into nitrous ones. The Finkler- Prior bacilli do not possess this property, so that their cultures will not become red upon the addition of pure hydrochloric or sulphuric acid (i. e., an acid which does not contain any traces of nitric acid).* — Earle.] In small, as well as in older, children there frequently appear during hot summer months disorders of digestion in the form of very fluid and foetid dejections. Such foetid diarrhoeas are often accompanied by fever, and sometimes vomiting. An im- portant factor in their aetiology is a meat diet. Symptoms of acute catarrh of the large intestine — en- teritis follicularis — may be easily explained by participation of the mucous membrane of the rectum in the morbid process. The dejections consist especially of colorless or greenish mucus, stained sometimes with blood; they are not abundant, but very frequent. The patient moves the bowls about ten or fifteen times during twenty-four hours, while each stool is accompanied by painful tenesmus in the rectum and straining. The mucous de- jections are almost odorless. In mild cases there appears, after a few mucous evacuations, normal fluid fseces from the upper por- tions of the intestines, and after that pure mucus again appears. In more serious cases the same is observed only after taking physic, but in the most severe cases f.necal stools cannot be pro- *Klemperer and Levy : Grundviss dcr Kliiiislicn Bactcriologie, 1895. See also Kahlden : Technik dcr Iiistologisclwii Uiitrrsucliniig, etc., i8g8, p. 89. l66 DISEASES OF THE STOMACH AND INTESTINES duced even by means of castor-oil (by this one may be guidecT in the prognosis). The abdomen usvially becomes sunken, some- times thrre may be noticed painfulness upon pressure in the re- gion of the descending part of the large intestine. The further (hfference between follicular enteritis and other forms of catarrh consists in it being usually accompanied by fever, which, how- ever, may be absent in mild cases. Mild forms of follicular enterites may terminate in recovery in two or three days, but severe ones are protracted for about two or three weeks and more, or become transformed into chronic intestinal catarrh. Some French authors ( Hammon, Vigier, Winter, Delattre^ Lesage) have noticed a peculiar form of diarrhoea, which is de- scribed by them as green diarrhoea (Hayem) depending upon the chromogenous green bacillus in the intestines. Not every green diarrhoea in children is necessarily of bacillar origin, because the green color of the dejections may depend also upon the admixture of bile — this is the bilious green diarrhoea of the French authors. Both these forms of green diarrhoea may be easily distin- guished without the microscope ; it is necessary only to test the faeces with nitric acid ; if the stain depends upon bile, then the green color either directly becomes transformed into a violet or pinkish one, or it becomes at first of deeper color. In case, how- ever, of bacillar diarrhcea, the faeces become colorless under the influence of nitric acid. The age is also of importance in the diagnosis ; biliary diar- rhoea most often occurs in children of the first two months- of life, in whom the bacillar diarrhoea very seldom occurs. On the contrary, between two and twelve months the green diarrhoea depends oftener upon the chromogenous bacillus. After two- years the latter almost never occurs. Lesage distinguishes three stages of the green bacillar diarrhoea in children ; the mild, medium and grave ones. The first stage is afebrile, the number of the dejections is not more than six, and recovery takes place in a few days. In the medium form the number of dejections is from six to ten, the child has fever, the diarrhoea is frequently protracted to a chronic form. In the severe form, or the cholera-like green diarrhcea, the num- ber of the dejections equal about twenty, collapse comes on rap- DISEASES OE 'tHE STOAJ \C11 AND IXTESTIN'ES 167 idly, but vomiting-, in contradistinction to cholera infantum, is usually either absent altogether or is insignificant. Death mav ensue in thirty-six or forty-eight hours. ACUTE DISEASES OF THE STOMACH AND INTES- TINES IN OLDER CHILDREN. A transient catarrh of the stomach in children occurs in the acute and subacute form. Acute catarrh, or a foul-stomach, i^astritis acuta, s. gas- tricisDiiis — not infrequently occurs in entirely healthy children after coarse or faulty diet (abuse of candies, especially chocolate, fruits, desserts, etc.), and manifests itself from the first by vom- iting, usually repeated, and violent fever (about 40 degrees C. or 104 degrees F. ) . There is commonly constipation in the be- ginning, but later there may be diarrhoea associated with ab- dominal pains. Complete absence of appetite is noticed from the very first, with bad taste and disagreeable odor from the mouth, coated tongue and considerable thirst, especially for cold drinks. As vomiting frequently occurs during the rapid elevation of temperature, the same as in other diseases, then it is obvious that the diagnosis of such gastritis during the first day of the disease is not easy, and the more so because ever a coated tongue is not characteristic of a g'astritis alone. For the proper estimation of a given case the history is extremely important (faulty diet). The vomited substance con- sists usually of remnants of undigested food which had produced the disease ; distension of the epigastrium and [^ain upon pressure thereon ; relief after vomiting ; finally, rapid recover}' after a re- stricted diet and the taking of some physic. The absence of an epidemic in a given locality makes the diagnosis easier. The second form — gastritis subacuta — begins gradually with loss of appetite, headache, general weakness and malaise, with insignificant fever and jaundice, but frequently without any vomiting and diarrhcea (although both may be present). Fever varies between 37.8 degrees to 38.5 degrees C. (100 to 101.3 degrees F.) being sometimes protracted from ten to fourteen days. If the case begins with vomiting, then it is easy to con- found the disease with tubercular meningitis, which also com- mences with vomiting, headache, constipation, apathy and slight elevation of temperature. l68 DISEASES OE THE STOMACH AND INTESTINES The diagnosis may rest upon the tongue being coated, a foul odor from the mouth, distension and sUght painfuhiess in the epigastrium during pressure upon it, as well as the ycUowishness of the conjunctk'CF. Herpes labialis. which is rarely observed during tubercular menmgitis, but frequently met with in "gastric fever" is also of diagnostic value, (^n the contrary, against gastritis and in favor of meningitis will be an irregular and at the same time retarded pulse (the irregularity alone without re- tardation of the pulse is of no special value), slightly sunken ab- domen and a clean tongue. Acute catarrh of the small intestines in older chil- dren differs in no essential manner from the same catarrh in grown persons. This malady is characterized by more or less frequent (four to six times in twenty-four hours), abundant, fluid dejections, accompanied by colicky abdominal pains. Chronic catarrh of the stomach is seldom markedly developed in childhood, being more peculiar to adults and charac- terized by eructations, heartburn, vomiting of great quantities of mucus, and considerable tenderness of the epigastrium (^n pres- sure. Mild degrees of stomach catarrh are oftener met with in which the patients lose their appetite, grow thin, become languid and. in general, represent the picture of ansemia which was spoken of in the section on Appetite, where was also indicated the points for the differential diagnosis. Chronic gastritis in children is comparatively seldom asso- ciated with dilatation of the stomach. The chief symptoms of the latter consist in abundant vomiting by which there is ejected food taken more than twenty-four hours before, and in the con- siderable spreading of the tympanitic tone of the stomach (to the level of the umbilicus, and also below). Taking an effervescent mixture sometimes renders visible the boundaries of the stomach. In doubtful cases examination by means of the stomach- tube should be, as in adults, resorted to. Chronic catarrh of the rowels is one of the commonest diseases of childhood. This condition develops from any acute intestinal catarrh, being especially often the consequence of dysen- tery or summer complaint, but diarrhoea sometimes seems to appear from the very first in the chronic form, that is, one cannot find in the historv of the case a violent diarrhoea, the DISEASES OF THE STOMACH AXlJ INTESTINES 16eral) are most often the result of an acute neglected entero- *This is also the fault of the text-books on Children's Diseases, in the jnajority of which malarial diarrhoea is entirely ignored. **Perityphlitis and Paratyphlitis in children, Kiev, 1892, p. 31. 176 DISEASES OF THE STOMACH AND INTESTINES colitis (that is, of an acute or bloody diarrhoea) ; and according- to Edlefsen* periodical diarrhcEa is the most certain si^^n of catarrh of the large bowels due to coprostasis. Whatever it may be, it is true that periodical diarrhoea sometimes occurs during catarrh of the large bowel, differing from malarial diarrhcea in the tenderness of the abdomen on pressure over the region of the large bowels, and by not yielding to quinine, but rather to- castor-oil, milk diet and large enemata of one per cent, solution of tannin. Meat and fat must be positively forbidden during such, a diarrhoea. We have yet to say a word about a peculiar chronic lesion of the intestines known as enteritis mcmbranacea, s. colica mu- cosa. The disease is characterized by attacks of abdominal pairt accompanied by the voiding of mucus per anum, either in the form of membranes resembling tape-worm, or in that of casts (the impress of the intestinal segment), or simply in the form of nests of mucus. Together with the mucus there is also generally a discharge of faeces in the form of separate dry lumps ; but this is significant^ because nuicus may also l>e voided without fscal matter or ac- companied by pap-like stools. The discharge of mucus lasts one or two days, or several days in succession, when it stops for an indefinite time ; the intervals between the attacks lasting in some cases several weeks, while the attacks in graver cases are re- peated every week. To the characteristic signs of the disease also belongs constipation in the period of the intervals. In contra- distinction from proctitis, in which much mucus is also voided^ there is neither tenesmus nor straining. The disease always has a chronic course, lasting months and even years, although in some cases it is limited to one or two attacks. In many cases the patients are very sensitive to errors of diet ; a small increase in the amount of food, or a change in its quality (un- common food), are sufficient for the appearance of the attack. Some patients do not tolerate meat, others, milk, and still others- something else, so that each separate case demands individual- izing when the diet is administered, this being determined by ex- perience. The majority of contemporary authors regard this affection *Lchrb. dcr Diagnostik dcr inncrcn Krankheiteii, 1890, p. 109. DISEASES OF THE STOMACH AND KVTESTINES I77 not as a catarrh of the large bowels, but as a neurosis. The latter may manifest itself by increased activity of the mu- cous glands, and is favored, first, by the periodical course, and second, by its appearance mostly in nervous, hysterical women. According to our observations "nervousness" in childhood does not play the leading role, although it cannot be denied that a neu- ropathic heredity and a tender constitution (white, soft hair; thin, transparent skin; thin bones; scanty fatty tissue) are often noted in such children. On the other hantl, it cannot be doubted that membranous enteritis occurs in those children who either have suffered since early childhood from diarrhsea alternating with constipation, or who shortly before had been sick with dysen- tery ; in a word, the influence of the intestinal catarrh is very probable in such cases. On this account Nothnagel says that there are probably two forms of membranous enteritis ; one purely nervous and the other catarrhal. In the former the discharge of mucus is accompanied by attacks of violent pairi (colica mucosa), in the latter there is no pain, or if present, is not severe. [Membraneous enteritis is of frequent occurrence in child- hood, being often accompanied by inconsiderable elevation of tem- perature (Comby, Hutinel). Three symptoms are essential to this disease : ( 1 ) Elimination of mucous masses. (2) Irregular activity of the intestines. (3) Abdominal pains. Regarding the first point it should be noted that the mucous masses may be discharged in (a) an amorphous, and (b) incin- branoform state. The former resembles the white of a more or less coagulated egg, being sometimes intermingled with blood ; the latter appears under the form of real pseudo-membranes of dififerent dimensions, resembling either cylindrical tubules or some variety of intestinal worms (oxyuris vermicularis and tape- worms). The histological peculiarities are those of mucus mixed in different proportions with epithelial cells, epithelial nuclei, and leucocytes. As to the second point — the irregularity of the bow- els — it may be said that constipation is very characteristic of this disease, being obstinate and prolonged, followed by persistent diarrhcea, and in older persons, with hsemorrhage (due to ulcera- tions of the mucous membrane or to its hyperemia). The 178 DISEASES OF THE STOMACH AND INTESTINES diarrhaa in its turn gives place to a return of constipation, so that periodical onset of persistent constipation and diarrhoea is a very notable feature of membranous colitis. The pain, which is the third cardinal symptom, is of different character and location, being- usually confined to the right iliac fossa, and thence either around the umbilicus, or spreading all over the abdomen. The pain sonietnnes occurs in the form of crises. Of other symptoms, Maurice de Langehagen. who wrote a very exhaustive article on this subject,* points out the following: ( I ) Flaccidity or flabbiness of the abdominal walls, their de- pressibility which allows a thorough palpating of the alxlomen down to the vertebral column; one may thus (2) palpate the in- testines and ( 3 ) ascertain the loss of their elasticity and their tonus (only of the large intestines). Sometimes, however, it is possible (4) to note a tension, or hardness of the intestines, so that some intestinal segments may seem to be in the condition of com- parative stenosis, others, in that of dilation. This observation is explained bv the s]:)asmodic condition into which the intestinal segments are sometimes excited. (5) h\u"ther, it is very often possible to detect in the region of the c?ecum gurgling and tur- bulence ("gargouilement et clajjotage" of the h'rench authors) along the transverse colon. i^)esides these symptoms some disorders on the part of the liver (hypen-emia, enlargement, or contraction) ; of the stomach (distension and different gastric disorders — anorexia, coated- tongue, nausea, vomiting, etc.) are observed. In the differential diagnosiss it should be remembered that tubercular enteritis bears a close resemblance, from which mem- branous enteritis differs by the occasional persistent constipations, by the absence of tubercular evidences in other organs, by the location and character of the pain (crises), and above all by the periodicity and the extremely protracted course. This long course produces a marked cachexia, which may likewise result from tu- berculosis of the intestines and chronic intestinal catarrh. Mucous enteritis is considered by most authors as a mani- festation of some diathetic nervous disorders. Langehagen re- gards it as connected with a neuro-arthritic diathesis. — Earle.] *L'enterocolite muco-membraneuse ; symptomes, etiologie et traitement. La Scmainc Medicate, 1898, No. i, pp. 1-7. SEMEIOLOGY OF BLOODY INTESTINAL DEJECTIONS. The presence of blood in the dejections may usnally be easily recognized from mere inspection of the stools, the color and aspect of which vary depending not only npon the amount of mingled blood, but also upon the location of the hccmorrhage (that is, near to or far from the stomach), and how long the blood remained in the bowels. Generally speaking the nearer the hjemorrhage to the stomach the longer the blood remains in the bowels, and thus the more it undergoes changes from the action of the alimentary juices, being therefore strongly altered in color when eliminated (becomes dark). The blood corpuscles appear under the microscope disfigured or completely destroyed. In such cases the blood has time to be mingled with the faeces, which become of equal dark-brown or even darker color. But a dark color of the fseces is also observed after the use of certain substances, for instance, iron, blackberries, coal, etc. To recognize the admixture of blood in doubtful cases a par- ticle of faeces has to be dissolved in water ; the latter then im- mediately becomes stained a red color from the presence of blood. In the case of further doubt. Heller's test may be resorted to (see page ISO). Blood without admixture of f.neces usually comes from the colon. If the evacuations be often and the haemorrhages, even when they occur in the upper portions of the bowels, copious and repeated, then, in these cases, the stools may consist of blood alone, which is eliminated either fluid, tar-like, or coagulated, but at any rate dark and much altered. Pure, crimson-colored blood, not intermingled with faeces, but only streaking the latter, positively comes from the rectum. The causes of haemorrhage change with the age of the child, therefore we do not observe in the later stages of chiklhood some kinds of haemorrhage which are met with in nurslings, so that all cases referred to here mav be divided into two groui)s. l80 DISEASES OF THE STOMACH AND INTESTINES To the first belong intestinal hgemorrhages observed exclu- sively in young children during the first months of life ; to the second those in older children. To the first group are referred intestinal haemorrhages in nielana neonatorum and in temporary haemophilia, which were spoken of in the section on bloody vomiting (page 148). According to Bohn, bloody dejections in children under one year of age often appear because of malaria. Bloody dejections in older children also occur from gastric or intestinal haemorrhages. The causes of the latter are : (i) Constitutional diseases, the so-called diseases of the blood. (2) Diseases of remote organs in which the reflux of the blood from the intestinal veins is hindered. (3) Diseases of the intestinal walls themselves. To the diseases of the first category belong variola hieni- orrhagica, morbus maculosus Werlhofii and scurvy. In all these cases the haemorrhage usually occurs in the upper portions of the bowels, so that the blood is seen to be either intimately inter- mingled with the faeces, or without the latter if the haemorrhages be repeated and frequent, but at any event it is considerably changed. The diagnosis is not difficult in the majority of cases, being made on the ground of alterations exhibited by the skin and the mucous membranes peculiar of any given disease, as, for instance, affection of the gums in scurvy, purjiura in Werlhof's disease, etc. It is most difficult to recognize hjemorrhagic small-pox, especially in the beginning of a small-pox epidemic, because haemorrhagic variola takes place very quickly, frequently causing the death of the patient before the papulous small-pox eruption appears. Petechiae in the skin and hremorrhages into the internal organs appear as early as on the first day of the prodromal pe- riod, accompanied by very high fever with delirium and convul- sions. Among general diseases in which blood in the dejections may appear, are included all diseases leadmg to a great wasting of the organism, as morbus Brightii chronicus, caries, chronic diar- rhoea, etc. There almost always appear in such patients, before death, obstinate, waterv diarrhoea, during which bloodv DISRASKS OF THE STOMACH AND IXTliSTI X ES l8l dejections are also occasionally observed (althongh seldom), probably because of rupture of the amyloid degenerated vessels. Cases of the second category, that is, intestinal haemorrhages because of the hindered reflux of venous blood, occur in children in extremely rare instances, like those diseases of the liver upon which intestinal h?emorrhages most frequently depend. As bloody dejections in such cases play a secondary role, we shall not speak further about them. To the third class belong, first, various ulcerations of the mucous membrane of the small intestines. Inkers are usually caused by general affections of the organism, and most often by typhoid fever and tuberculosis. The diagnosis of these ulcers is not always possible, as they do not invariably cause pronounced symptoms. While it is true that they are generally associated with diarrhoea, still the latter does not depend upon the ulcers, but rather upon the concomitant catarrh. In case the catarrh be absent, then, despite the ulcers, there may be constipation, as happened in observations of tubercular ulcers of the bowels* by Rilliet and Barthez. The same authors noticed the fact that the gravity of the diarrhoea does not depend upon the number of ulcers. Pain in a limited part of the abdomen, increasing on pres- sure, is also sometimes observed in ulcers, but it may be absent, depending not upon the ulcers themselves, but upon the limited in- flammation of the peritoneum corresponding to the ulcer. Pus is formed in small amounts, being so intimately mingled with the dejecta that it is impossible to be detected; so that in view of the enumerated considerations bloody dejections are the most certain sign of intestinal ulcers, if they appear during typhoid or tuberculosis. It is self-evident that this sign is far from being constant, because intestinal ulcers seldom give rise to the appearance of hsemorrhages. Pure blood, mingled in greater or less quantity with non- copious, mucous stools, voided with violent tenesmus and abdom- inal pains, points to an affection of the large bowels, and espe- ciallv of the rectum. Such stools are observed in acute follicu- *K!i!dcrkraiiI;licitcn III., s. 993. l82 DISKASES OF THE STOMACH AND IXTESTIN'ES lar enteritis, dysentery and follicular ulcers of the lower portion of the bowels (chronic dysentery). Symptoms of acute follicular enteritis have been already mentioned in the part on the diarrhoea of nurslings. Dysentery, like any other infectious disease, appears in exceedingly various forms. There are different transitory forms between the mildest cases, terminating with convalescence in two or three days, and even in a few hours, for instance, after the first dose of castor-oil, and the gravest, leading to death in a few days. For the sake of convenience three varieties may be described ; mild, medium and severe. The general symj^toms of all these forms are; small, frequent, nuicous stools, tenesnnis and abdom- inal pain. Mild fonns do not differ in their symptoms and course from the medium and mild cases of follicular enteritis (page 165), the only point is that dysentery is an epidemic and infectious dis- ease, while follicular enteritis is not contagious, being, therefore, called sporadic bloody diarrhcea. As the most characteristic peculiarity of the mild form of dysentery we shall only ]X)int out that Nirc Dtiicoiis stools ore cither entirely absent, or they apf^ear alternately with paf^-like jceeal matter several times a day. In the /;;//(/ form the number of evacuations ranges from ten to twenty daily. Hiey are ordinarily composed of pure mucus, green or white, stained with blood. The tenesmus is consider- able. Faecal dejections do not ap])ear for two or three days in succession, but may be produced by a laxative. In the beginning of the disease elevation of tem])erature is noticed for a couple of days. The abdomen is painless u]:)on pressure, or the pain is slight, being limited to a small area in the region of the left iliac fossa. Collaf'se is absent. After about eight to twelve davs the period of amelioration occurs, that is, all symptoms gradually abate, while there begins to appear, oftener with each twentv- four hours, fsecal matter together with mucus, and, after about two or three weeks, the muco-bloody diarrhoea becomes a sim- ple one, and, after one or two weeks more, everything reaches tlie normal standard. The ^i;;-fl7r variety of dysentery depends upon the formation DISEASKS OF TllK STO.MAC 11 AM) 1 N ri':STI .\ HS 183 of a clij)htheritic exudate on the inflamed mucous membrane, be- ings characterized, not so much by the initial hij^h fever and the too frequent pulse and violent straining-, as by symptoms of im- minent collapse and considerable painf^tlness of the abdomen on pressure over the course of the colon, especially of the colon descendens. Faecal dejections are absent for several days in suc- cession, being difficult to obtain even after a laxative. Red de- jections, like "washed raw meat" and consisting of evenly-stained, serous fluid mixed with mucous lumps, occur only in grave cases of dysentery. If the patient survives the acute period (two or three weeks), then the further course becomes considerably protracted, so that the picture of chronic diarrlnra is obtained. The i)atient moves the bowels not very often, about six or eight times during twenty-four hours, the evacuations being very offensive, watery or pap-like, mingled with purulent mucus, while there are usually colic-like pains in the abdomen together with tenesmus. By the persistent tenesmus and admixture of purulent, sometimes sanious, mucus in the faecal dejections, chronic dysentery differs from a common chronic intestinal catarrh, in which the evacua- tions, although also offensive, are not often accompanied by ab- dominal pains (see the section on the Chronic Catarrh of the In- testines, page 168). The duration of chronic dysentery ranges approximately from two to six months, finally terminating in the majority of cases, with recovery. [At present two forms of dysentery are distinguished : One due to an amoeba and the other to a bacillus (bacillar dysentery and amoeba dysentery). The difference between these two forms is the following : The amoeba dysentery develops endeniically. especially in hot countries, pursues a chronic course with remissions and exa- cerbations, and is often complicated u'ith abscesses of the //z'^r,* Pathologically it is characterized by the necrosis starting in *Amberg** says that abscess of the liver, which is rather a frequent complication of amoebic dysentery in aduks seems to be of very rare occur- rence in children. Twelve cases of liver abscess in children following dysentery are reported. Kruse and Pasqualc found Charcot-Leyden crys- tals in the material taken from liver abscesses. **Biil. Johns Hof^kius Hosp.. Vol. XH.. 1901, pp. 355-35i^- 184 DISEASES OF THE STOMACH AND INTESTINES the submucosa. The cause is amoeba coli first described by Loesch, of St. Petersburg, in 187 1. The bacillar form occurs epidemically and in any country, rather than particularly m torrid, it always has an acute course, seldom becoming chronic and does not lead to the forma- tion of abscesses of the liver. The necrosis appears in the upper layers of the intestinal mucosa and gradually extends deeper. The cause of this form is bacillus dysenteriae, first described in Japan ( Tokio) by Kitasato's assistant, Shiga, in 1897- 1899, ^.nd more fully by Kruse, in 1901, so that this bacillus is known under the name of the Shiga-Kruse bacillus. The diagnosis between these two forms of dysentery may be Fig. 17 — Amoeba coli (Losh). cjuite easily effected upon consideration of the symptoms men- tioned, but the chief factors in the diagnosis are, of course, the bacteriologic findings ; in the amceba dysentery — of amoeba Loschii ; or the Shiga-Kruse bacillus in the other variety. Losch's observations have been confirmed all over the world ; in America, by Osier, Councilman and Lafleur, Harris and others. William Osier was the first to describe amoeba coli in 1890, and his investigations have been followed b}- many other excellent articles and monographs. The amoebse are from 12 to 36 mikro-millimeters in diam- eter (even 50 in "giant" amrebas), and consist of protoplasm which always contains a nucleus. The protoplasm is made up of an outer zona ("ectosarc" or "ectoplasm") and an inner one ("endosarc" or "entoplasm"). The latter may be distinguished DISEASES OF THE STOMACH AND IXTESTINKS 185 from the former ("ectosarc") by (a) its highly refractive power; (b) by containing foreign bodies (bacteria, granular detritus, leucocytes, red blood corpuscles, large and small vacuoles). The difiference between ectoplasm and entoplasm is best seen during the movements of the amoeba. The auKieba movement undergoes by throwing out protoplasmic arms — so to speak — thus assum- ing different forms. They are readily stained with methylene blue and toluidine blue ; the endosarc of the amceba taking the stain at once, the ectosarc only after the lapse of several min- .utes.* (Fig. 17.) In the bacillar form of dysentery the bacteriologic findings are different ; here the Shiga-Kruse bacillus looks like the coli- bacillus. It stains with any of the anilin-stains, while the poles take a deeper tint than the middle of the microbe. It does not take the Gram, and does not possess automatic movements (although Shiga pointed out wdiat he believed to be a slight mo- tility). It does not form spores and grows on any nutritive me- dium. It does not liquefy gelatin and is agglutinated by the serum of the patient. When the pure culture is injected in the rectum of some animals, dysentery may be produced, but Rosenthal,** of Moscow^ points out that cats are very often immune to bacillar dysentery^ but never to the amoebic form, which is always pathogenic for cats. This point also shows the great difference between the char- acters of these two forms of dysentery. Shiga's discovery was thus confirmed not only in Germany by Prof. Kruse, but also in Russia (Moscow at least), and in America, Flexner*** de- scribed a dysenteric bacillus very similar to Shiga's, although ap- parently not entirely identical to the latter. Other authors, as for instance, Jiirgens,**** claims that the cause of dysentery lies in many bacilli, and not only in the Shiga-Kruse type. In his twenty-six cases of dysentery Kruse's bacillus was never found, but in eighteen cases Flexner's type w-as discovered. — Earle. ] *See Harris: Amoebic Dysentery (Am. Jour, of Med. Sc, 1898, April). **Zur Aetiologie der Dysentery (Dctit. Med. jyoeh., 1903, No. 6, n. 97, etc. ***P/j;7a. Med. Journal, vi., 1900, p. 414. ****Zur Aetiologie der Ruhr. (Deut. Med. IVoch., 1903, No. 46). l86 DISEASES OF THE STOMACH AND INTESTINES Pure, red blood from the anus in small children always dis- charges in small amount — a few drops. The usual cause of such a haemorrhage is constipation with the formation of solid faeces which tear the mucous membrane during their passage through the anus. For the diagnosis a simple inspection of the stools suffices ; the latter consists of solid, dry lumps of dark-brown or white color (in small children when the diet is exclusively milk), some parts being stained with drops of unchanged blood. The evacuation is somewhat painful, being associated with violent straining (that is, with contraction of the abdominal muscles, but not tenesmus in the rectum) ; older children complain of slight burning in ano after the passage of stools, because of rupture of the mucous membrane. A slight haemorrhage may also occur with tluid, but acrid. dejections, namely, in the case of formation of excoriations on the mucous membrane of the rectum, being analogous to those of the upper lip during coryza. These excoriations usually occupy the posterior wall, being associated with eczema around the anus, which aids the diagnosis. With these insignificant and ra])idl\ -healing excoriations, one must not confound extremely obstinate and jjainful tissiires of the anus, about which 1 shall s])eak in the article on Constipation (page 195). The appearance, after each defecation, of some drops of pure "blood from the anus, but in the absence of constipation and pains during the act of defecation, serves as a certain sign of a polypus in the rectum. Digital examination detects in such cases, some- what higher then the point of the internal sphincter on the pos- terior wall of the rectum, a small (the size of a cherry), soft, elastic, easily-bleeding pedunculated tumor. In some cases the polyp comes out with every evacuation of the bowels and thus may simulate a small prolapsus ani. It suffices to know this fact in order to determine the disease during the digital exam- ination. Similar bloody stools (that is, associated with soft de- jections and without pains) depend not only upon polypus, but on ulcers in the rectum. In prohipsus ani there extrudes a pear-shaped or cylindrical tumor, of purple-red color, easily bleeding. On the top of DISEASES OF lllK STOMACH AND I XTESTIN' KS 18/ the tumor there is an opening- througli which it is eas\- to pass the finger. iJetween the tumor and the anal edges there is a ring-shaped sht. through which it is easy to reach, with the finger, the point of the fold of the everted intestinal wall. The tumor is easily reduced in recent cases and when it does not exceed the size of a common pear. It would be difficult to confuse prolapsus ani 'vvuth anything else. SEMEIOLOGY OF CONSTIPATION. Constipation, as a temporary or subsidiary symptom, occurs- very often during many febrile and other diseases, but here we have in view onlv such cases in which constipation occurs as a single, or, at least, as the chief s\ inplom and is at the same time of uncertain duration. This is the so-called habitual constipation,. most often occurring in children of the first two years of life. The child moves the bowels during the first months of life,, when fed only by the breast, two, three, or four times during twenty-four hours. Hut ihc (|uestion arises here whether one- may speak of a nursing-child being constipated if he has only one passage which, however, is copious, of normal ct^lor and of mustard-like consistency? Some authors give an affirmative an- swer to the question, although, from such a point of view, any criterion for judging where constipation terminates and where normal activity of the bowels begins, is lost, because a single evacuation during twenty-four hours may be more copious than two or three at shorter intervals put together. Therefore, it seems to be more correct to base the diagnosis of constipatioir on the quality of the stools and on the appearances which accom- pany the act of defecation. The function of the intestines in small children, as well as in grown persons, depends u])on the individuality. There are children who move the bowels every second day ; nevertheless their stools always are of normal, jelly-like consistency and of yellow color, the general condition being excellent ; so that there are no reasons to speak, in such cases, about constipation. If the quantity of the child's stools does not correspond to- its organization, then the retention of products of waste will be manifested by certain symptoms, in the presence of which we say that the child is suffering from habitual constipation. These symptoms may be as follows : (i) The stools assume solid consistency and contain formed SEMEIOLOGY OF CONSTIPATION 189 faecal matter, soft and sausage-like (in mild cases), or, in graver cases, in entirely solid lumps of whitish color. (2) The act of defecation is performed by the visible par- ticipation of the abdominal muscles ; the child strains, the face be- comes red and sometimes drenched with perspiration. (3) During defecation, or shortly before the act. abdominal pains occur so that the child becomes restless and sometimes even convulsions follow. (4) The abdomen is distended, but usually is painless u])on pressure, (it is very difficult in a nursling to feel the hard lumps of fseces through the abdominal walls). (5) The evacuations occur in mild cases once a day or •every other day, in severe cases after two or four days, and then the retention of the stools may be the cause of fever. In older children constipation is usually accompanied bv loss of appetite, distension of the abdomen, sometimes colicky pains, as well as wMth languidness, headache and occasionally by fever, so that it may simulate chronic peritonitis, in which there also exists some inclination to constipation, associated with the -distended abdomen, and colicky pains and sometimes with fever. The diagnosis here is not always easy. It is based on the -abdomen being, in chronic peritonitis, not only distended, but also toisc. the constipation often alternates with diarrhoea, the ac- ^cumulation of fluid in the peritoneal cavity is noticed, and in more pronounced cases one succeeds in feeling limited tumors in the abdomen due to inflammatory thickening of the peritoneum and concretions between the intestinal segments ; then also the general condition of the nutrition exhibits a greater degree of wasting than in acute or chronic constipation. If constipation is associated with pronounced fever, gen- eral weakness and headache, such a symptom-complex lasting several days, then it is easy to mistake the disease for a beginning typhoid. In other cases constipation is accompanied by cerebral symptoms, as vomiting, headache, slight elevation of tempera- ture, retarded and somewhat irregular pulse, dilatation of the pupils, somnolence — all these symptoms lasting a few days and rapidly disappearing after a copious evacuation produced by a laxative. (Compare two cases described in the text-book of Bar- IQO SEMEIOLOGY OF CONSTIPATION thez and Sanne, Vol. II., page 532, regarding a nine-year-old girl and a boy aged twenty-seven months.) Jn one of our cases, a boy eight years old, fever simulated intermittent for two weeks, with the morning elevations up tO" 39-5 degrees C. (103 degrees F.) and evening to 40.8 degrees C. (105.4 degrees F.), but not entirely regular and not daily. It did not yield to (juinine but disappeared after a glass of laxative- lemonade. With the exception of such rarities, the diagnosis of con- stipation is, of course, not difficult, but the main thing is to find tlic cause of the constipation in each case, for, only then, a rational therapy is possible. The cause of constipation in small children must be looked for either in the child himself, or in peculiarities of the food. Children are met with in whom constipation seems to de- pend upon a too thorough digestion of the breast milk. They seldom move the bowels because the milk affords but little resi- due for the formation of faeces, and, until a sufficient quantity of the latter accumulates, the watery parts are absorbed in the large bowels, the dejections becoming solid, thus making the act of defecation more difficult. Superfluous formation of flatulence is not noticed during such a constipation, therefore, absence of meteorism and an excellent general condition arc peculiar to it. The child appears healthy in every regard and increases in. weight more than one would expect, that is, he becomes fat. Changing the wet-nurse does not remove such a constipa- tion. Relief is best accomplished by changing the diet of the child, giving for instance, bouillon or a few spoonfuls of plain^ cool water. French authors suppose that the cause of such an inherited habitual co>istipatiou is defect of development of the large intestines, namely, increase of the dimensions and of the number of the curvatures of the sigmoid flexure in such chiKlren. In other series of cases constipation depends upon the weak- ness or torpidity of the intestinal musculature, which may be sus- pected during constipation in children who are in general weak and anaemic, and above all m rachitic ones, in whom the whole musculature is feeble. The same cause, that is, insufficiency of the peristaltic activity of the bowels, we have a right to suspect SEMKIOLOGV (,)]■' CONSTIPATION I9I (luriiii;- clironic hytlrocephalus, as well as in other cerebral dis- eases. What influence is effected, in infantile constipation, by the hereditary disposition in cases of chronic diarrhtjea in the mother^ it is hard to sa}", because this influence is far from being mani- fested in all cases, and especially if the child is fed by a wet- nurse. A cause of constipation in nurslings, existing from the very first weeks of life, may be coiii^cnital contracture of the entire rectum, or of the anus. Xoriually one may introduce the little finger into the anus of a nursling without great difficulty ; when, however, this is contracted the examination does not succeed altogether, or only with great difficulty. This cause of constipa- tion, in spite of its easy recognition, very often remains undis- covered, only because physicians usually do not resort to exam- ination of the anus by the finger, notwithstanding this should be done in all cases of chroiiic constipation in children. In illustra- tion I will describe the following two cases : A child, aged ten months, until nine and a half months was nursed by the mother's breast and was all the time inclined to constipation, notwithstanding the stools having been of normal pap-like consistency. The constipation became so obstinate dur- ing the two weeks after weaning that a laxative had to be given several times, and for the last three days the child did not move the bowels at all, notwithstanding the fact that he was given several tablespoonfvils of Hunyadi. The abdomen was distended and a somewhat dull sound was obtained on percussion of the left hypogastric region. The child became restless, there was vom- iting twice in the last twenty-four hours ; he would strain several times, but without any result. Hoping to find lumps of solid faeces in the lower portion of the rectum I resorted to an exam- ination with the finger, when an entirely different cause of the constipation was found. At a point one centimeter from the external anal opening the finger met a laminated septum with a small opening in the center. The end of the small finger passed with great difficulty, while a sensation was obtained as if the finger was bound by a thin, but strong, india-rubber cord. The examination caused the child severe pain. We thus found here a congenital stricture of the rectum 192 SEMEIOLOGV OF CONSTIPATION caused by the incomplete disappearance of the septum which arises at a certain period of embryonic life when the rectum de- velops. As long as the child was fed by the breast the stools were thin enough to pass the small opening, although not very freely. However, after weaning the stools became somewhat more solid, and the presence of the septum caused a very obstinate constipation. In another case, in a child several weeks old, although the dejections took place several times a day, yet always in very small cjuantities and were associated with straining. The color and the consistency of the evacuations appeared entirely normal, mucus being absent. In this case there was a stricture of the anus itself which was so narrow, because of the fold of the mu- cous membrane which covered its anterior segment, that a com- mon catheter could hardly be passed. Of constipation due to stricture or obstruction of the upper portions of the bowels we shall speak in the next section. In weaned or bottle-fed babies, as well as in elder children, digital examination sometimes detects the cause, and, simultane- ously, the consequence of the constipation in the presence of vo- luminous dry lumps within the anus itself. Despite the strongest straining these lumps cannot pass the external opening of the rec- ,tum because of their great size. It is evident that enemata are, in such cases, not altogether applicable, because the end of the instrument immediately becomes blocked by the faeces, and laxa- tives are also without any result until the fcxcal matter is removed by mechanical means or simply by the finger. If the child suffered from constipation while nursing one wet- nurse, and becomes relieved of it with the change to another, then we may positively suspect the cause of constipation in some peculiarity of the uiilk. What these peculiarities are we do not know, but we infer them to be either in deficiency of fat, or in superfluity of casein. Such milk, known to the laity as heavy milk, sometimes occurs in women suffering from habitual con- ,stipation, as well as in those who had nursed for a long time (old milk) and also in aged women. The cause of constipation may also be deficiency of milk or watery milk. In both these cases the child starves chronicallv, that is, there is little increase in weight, or it grows thin and SEMEIOLOGV OF CONSTIPATIOX I93 suffers from constipation because of want of material for the formation of f?eces. Besides wasting- there are also peculiar to such a constipa- tion, restlessness of the child (he cries very much because of hini- ger) and scanty micturition. As scales are very rarely to be found in our nurseries, and as it is not easy to note with the eye a slowly progressive wasting, therefore very often it happens in practice that the constant cry of the child is ascribed to colics and is accordingly treated by dif- ferent drugs. If, in the absence of eructation, scanty micturition and constipation (instead of dyspeptic stools) the cause of the cry may be supposed to be a lack of milk, then it is very easy to become convinced of the correctness of such a proposition. The child has only to be given cow's milk when he will be calmed for a few hours. It is, however, not difficult to prove, even without scales, that the wet-nurse has but little milk. If there is enough milk, then, immediately after the child has been nursed, the milk should gush from the sucked breast, when pressed, in several streams ; on the contrary, if the milk can be squeezed out only in drops, then it means there is but little of it. As a frequent cause of constipation should be mentioned the nourishment of children with starchy siLbstanccs which do not "become well digested during the first months of life, and then the faeces will show very much starch which had not been converted into dextrine and sugar in the bowels. Such a constipation quickly yields to a proper diet (starchy food must be forbidden). In bottle-fed, as well as in recently-weaned, children the most common cause of very obstinate constipation has to be looked for in the inunoderate use of cow's milk. Constipation is, in such cases, characterized by the appearance of faintly-stained, some- times entirely white, as in catarrhal jaundice, solid and even entirely dry faeces resembling curd. The history shows that the child drinks, during the twenty- four hours, about eight or ten glasses of milk. Practically it is very important to note that such immense quantities of milk are employed by children only if they are given the milk, not alone as food, but also as a drink, during the day and night. Some chil- dren drink and eat nothing else but milk. In the treatment of such constipations an absolute abstinence from milk is tuineces- 194 SEMEIOLOGV OF CONSTIPATION sary. It is sufficient to forbid its use as a drink, especially at night-time; this alone will decrease the amount of milk by three or four glasses, while the appetite will increase. He will also eat other food, and the purpose of treatment will thus be accom- plished by this measure alone, and at the same time the correct- ness of the diagnosis will be confirmed. If the child is too small to be fed with varied ioo<\, the constipation with white dejections being persistent in spite of the diminution of the quantity of milk,, then the latter must be given half-diluted with boiled water. Constipation is, after two years, much less frequently ob- served, the food being more varied Habitual constipation, together with loss of appetite, is usu- ally acc()m])anicd b\- anremia (see page 112) and neurasthenia. In other cases it is accompanied by symptoms of chronic gastritis or depends upon uniform, very dry, food (in the poorer class of people, potatoes and bread) or milk, or astringent medicines, among which are included some iron preparations. The cause of constipation in older children may be the had habit of delaying the desire for a stool. Such a habit results in distension of the lower portion of the large bowels, being neces- sarily accompanied by weakening of the tone of the intestinal musculature. An important influence is sometimes effected by a sedentary mode of life and forced mental work. If no setiological reason, either in the food, in the mode of life, neurasthenia, intestinal catarrh, etc., can be found to account for constipation, then it remains only to suppose atony of the large bowels or rectum owing to anomaly of innervation of these portions of the intestines, or thinness of the intestinal wall. Constipation often develops in children immediately after a chronic diarrhoea has stopped (has been cured). Constipation is in such cases either temporar}^ disappearing in a few weeks by itself, or it may be constant. Its cause is chronic catarrh of the large bowels. If the constipation was preceded by grave dysen- tery, then one may suspect the formation of cicatricial adhesions narrowing the lumen of the bov/els. In children from one up to three years old there occurs another characteristic form of constipation, the typical feature of which is that the child is afraid of moving the bowels, because this causes him severe pain. The child attempts by all means to OBSTINATE CONSTIPATION AND VOMITING I95 refrain from this act ; when seated on the toilet-chair he jumps up, cries, etc. Such constipation almost always depends upon an ajial fissure — fissura ani. One need only to separate the buttocks of the child and inspect its anus, in order to learn the correctness of such a proposition. The fissure is usually located between the mucous membrane and the skin along one of the radiated folds surrounding the anus. DISEASES CHARACTERIZED BY OBSTINATE CONSTI- PATION AND VOMITING. Intestinal obstruction, ilc\is, s. volvidits, whatever the cause ma}' be, is always evidenced by obstinate constipation, in- coerc'ble vaunting (at first of bile, and later it may be faecal) and by a sudden development of meteorism; then follows cardiac fail- u] e with fatal collapse, unless the obstacle be removed. The causes of intestinal obstruction in childhood are far from being so various as in grown people, therefore the diagnosis is comparatively easier. In new-born children the only causes of intestinal obstruc- tion are inherited defects of development, depending most fre- Cjuently upon atresia ani (closure of the anal opening) and rarely obliteration of the lumen of the small intestines. Obstruction of the anus is not dit^cult to recognize, its pres- ence being suspected on account of retention of the meconium and obstinate vomiting. If the obstruction refers to the anal opening, then the diagnosis becomes evident by mere inspection, the only question arising is the height at which the blind end of the rectam termhiates. In order to detect this the physician puts his hand over the child's perineum and from the size of the protrusion of the perineum at the normal point of the anus, during the cry, one may get an idea about the thickness of the sheath which separates the skin from the blind end of the gut. In mild cases, when, for instance, the entire rectum is normally developed, only a membrane remaining at the place of the anus, it is possible to notice the protrusion during crying even by the eye. If the rectum opens into the bladder, then this may be recog- nized by the meconium being mingled with the urine. When symptoms of intestinal obstruction occur in a new-born v.ith a normally developed anus, then the determination of the 196 OUSTINATE COxXSTIPATION AND VOMITING I>oint of occlusion of the intestinal lumen is performed by intro- ducing the finger or the sound. If the rectum be found passable, then the place of the obstruction must be looked for in the small bowels (obliteration of the large intestines rarelv occurs). In the case of obstruction of the duodenum the abdomen is not alto- gether distended. Intestinal obstruction in children under two years of age, as well as older ones, depends not infrequently upon a strangulated INGUINAL hernia. A Strangulated hernia is not difficult to diag- nose, because symptoms of intestinal obstruction, as rapidly-in- creasing meteorism, colicky abdominal pains, vomiting, constipa- tion, etc., are here associated with local symptoms on the part of the hernia ; the latter cannot be reduced (while before it was easily reducible) ; the hernial tumor becomes gradually more and more tense and simultaneously there appears considerable painfulness upon pressure on the tumor, especially near the strangulating ring and somewhat higher. If the physician did not know that the child had had a hernia, or if the latter had been absent before, but became strangulated at the first prolapsus, then one may readily diagnosticate infiammation of the testicle (orchitis) on the ground of the red, swollen, very painful, inflamed and solid (upon palpa- tion), scrotum. Such a mistake is possible even in the presence of distinctly-developed symptoms of intestinal obstruction. The picture of a strangulated hernia in childhood may be simulated by the testicle becoming strangulated in the in- guinal CANAL. The patient complains of pain in the groin (small children signify this simply by loud crying and restlessness). On examination there appears in the region of the inguinal opening an elastic, smooth, tense, spherical tumor, very painful upon press- ure ; usually vomiting also occurs ; the tumor cannot be reduced ; in short the symptoms are very similar to those of a strangulated hernia. A strangulated testicle difl:'ers from a hernia, first by the absence of progressively increasing meteorism, and, second, by tlie examination of the scrotum when absence of the tumor may be proven (monorchismus). Moreover, intestinal obstruction may be produced not only by the rarely occurring internal strangulation or torsion of the intestines, but by accuniulatio}i in the intestines of foreign bodies in the form, for instance, of cherry-stones, clumps of ascarides, OBSTINATE CO.XSIT I'A IK ).\ AM) \().\| 111 \C, \ijj and most often by hi nips of fccccs. 'Ilie last cause (jf intestinal obstruction is of especial interest to the physician, not onlv because it occurs comparatively often, but still more because it is readily diagnosed and easily remoA'ed. The main thing is that lumps of solid fseces accumulate almost exclusively in the lower portion of the colon and in the rectum, being thus very easily accessible to the finger introduced into the anus. Since the obstruction is below, therefore the whole alxlomen becomes distended in this form of intestinal obstruction, and, the peritonetmi not being in- volved, the vomiting is not so obstinate as, for instance, during intussusception, and the evidences of collapse (feeble pulse, sunk- en face, etc.) set in comparatively late. The other form of intestinal obstruction, being very charac- teristic and thus in the majority of cases easily diagnosticated, depends upon the fact that one portion of /ntestine is pushed into the neighboring one that lies next below — intussusceptio. s. in- vaginatio. Depending upon the place of formation of the intussusception, the pathologists distinguish invaginatio ileo-ccecalem, iliacam, colicam and ileo-colicam, but since these forms are seldom to be differentiated at the bed-side, such classification is not very im- portant for the clinician. It is sufficient to say that, usually, we have to deal with invagination of the small bowels into the colon (invaginatio ileo-coecalis and ileo-colica). This malady most often occurs in children (hirini^ the lirst year of life. The process of the invagination makes itself evident mostly by the sudden abdominal pain, persistent z'oniitiug and con- stipation. The vomitus consists first of remains of food, then simply of mucous fluid mixed with bile, or sometimes with ffeces. However, in children there rarely occurs f?ecal vomiting, because they do not survive to that event. Especially characteristic of in- vagination is the occurrence during the first twenty-four hours (in adults later) of frequent, bloody-mucous dejections, or of pure blood, associated with tenesmus of the rectum. The tenesmus is the stronger and the bloody stools are the more frequent, the lower in the intestinal tract the invaginated portion occurs. The small admixture of f?eces at the beginning does not diminish at all the importance of this symptom, because faeces may be present in the portions of the bowels below the invagination, and besides 198 OBSTINATE CONSTIPATION AND VOMITING there does not always occur at once a complete occlusion of the lumen of the bowels at the moment the invagination takes place, but only later on, when the strangulation of the inpacted portion produces an inflammatory swelling of its layers, especially of the peritoneal covering and the mucous membrane. On the other hand, one should bear well in mind that if the colon is not involved in the process of invagination ( invaginatio iliaca), then bloody dejections may be absent, so that their absence does not exclude invagination, especially in case another pathog- nomonic symptom of this lesion exists, namely, if one succeeds in feeling through the abdominal walls, in some part of the abdomen, a sausage-like tumor with a smooth surface which is slightly movable. The size of the tumor depends upon the degree of in- paction which produces the tumor. Unfortunately this symptom is frequently absent, and, if present, then only in the beginning, because later on it is masked by the considerable tension of the abdominal walls due to meteorism; the latter necessarily occurs during the intestinal obstruction, increasing with each day. Tn this period the inpacted portion of the bowels may be felt only in case it sinks down to the rectum. The finger introduced in the rectum feels as if it touches the uterine neck, which may be encircled. The abdominal pains are at first of a paroxysmal character, but later on, when peritonitis develops at the point of the invag- ination, ([uickly spreading over the neighboring parts, then the abdominal ])ains become constant, increasing especially upon press- ure. Simultaneously fever, which is absent at the beginning, ap- pears ; but symptoms of collapse in the form of pale, sunken face, thread-like pulse, coolness of the extremities, etc., set in very early. Fatal termination occurs approximately from the fourth up to the tenth day. Convalescence through the spontaneous delivery of the invaginated gut during the first days of the disease, or through the gangrenous sloughing oft" of the constricted portion after many weeks, belongs to the great rarities. Thus, invagination dift'ers from other forms of intestinal obstruction by the presence in the abdomen of a sausage-like tumor and by bloody dejections as well. It is true that a like tumor mav also be observed during- stercoral obstruction, but 0BSTIXAT1-: rOXS'lIl'ATlON AXO VOMITIXG lC)ij in such a case, as well as when the invaginated portion cannot be palpated, the diagnosis ma}- be easily based on the presence of the bloody stools. At any rate, to confound invagination with intestinal obstruction due to the accunndation of faeces or, in general, to foreign bodies, is difficult, because invagination almost exclusively occurs in nurslings, in whom obstruction of the bowels by faeces, etc., almost never happens. Invagination might be mistaken for a common dysenterx be- cause of violent tenesmus and frequent bloody dejections. But dysentery never starts with sudden abdominal pain, neither is it accompanied by persistent zviuiting; meteorism is here also ab- sent, on the contrary the ahdonien is sniikcii. If invagination of the intestines gives rise to peritonitis, then it is easy to recognize this complication from the violent pain fulness of the abdomen on pressure, but it is not always easy to say what an existing peritonitis has developed from. If the physician did not see the onset of the disease, then there remains onl_\ the circumstantial history. One may usually learn that symptoms of invagination existed several days before the occur- rence of painfulness of the abdomen. Prolapsus ani can hardly ever be confused with the protrusion per anum of the invaginated gut, because in the former case the finger introduced between the margin of the anus and the pro- truded portion of the rectum very soon meets an obstacle pre- sented by the flexure of the intestinal wall. According to English* symptoms of intestinal obstruction may depend upon distension of the bladder. His observations show that the pelves of children, being narrow, an insignificant overfilling of the bladder suffices for a complete compression of the rectum, and thus for the occurrence of symptoms of intestinal obstruction. He proves this opinion by two cases (one post- mortem), on the ground of which he claims that some cases of ileus in children have been but those of retention of urine. [Pyloric stenosis. Persistent vomiting and constipation in children may also be due to stenosis of the pylorus, which disease was first fully described in America by Meltzer, in 1898, similar communications having previously appeared in derman medical literature. This disease is characterized : *.rahrb. fiir Kiudcrh. VIII. S. yg. 200 OI'.STINATE CONSTIPATION AND VOMITING (i) Bx z'ouiiting occurring even after small quantities of food. (2) By visible peristaltic iiwz'cineiits of the stouiach. (3) By feeling a cylindrical and movable tumor in the py- loric region of the stomach. (4) By secondary dilatation (not a constant symptom) of the stomach. (5) The constant absence of bile in the vomited masses. (6) Persistent constipation accompanied by diminution of the quantity of the urine ; depressed alxlomen and distended epi- gastrium. The latter s}mptoms, in connection with those under (2) and (3), render the diagnosis certain. The pathologico-anatomical characteristics of this disease, ac- cording to some authors ( Thompson, I'faundler) is a functional spasm of the jjylorus, so that the treatment, according to this view, should be medical; in the opinion of others (Meltzer) the hyper- trophy of the muscles is associated with the presence of dense fibrous tissue in the submucosa, so that the treatment should be surgical.* l^'urther observations have indicated the latter view to be more correct and operation (pyloroplasty) has been very suc- cessfully ])erformed, among others by Cautley and Clinton Dent.=^* How little familiar many physicians, even of great experience, are with this condition, is shown by the following case of P. Da- vidson, described b\- him in No. 44 of The Liverpool Medico-Chi- rurgical Journal. kjo3.'''*'^'' "R. T. S., a full-time, well-developed male child, bon: July, 1901. He was suckled for a few days, and afterwards, owing to failure of the mother's milk, was fed with cow's milk diluted. From birth he suffered from disinclination to suck, flatulence,, vomiting. \'arious artificial mfants' foods were tried, and finally a wet-nurse, but all without benefit. \'omiting and wasting con- tinued. The vomiting was of a very violent character, so that the contents of the stomach were ejected some distance, the child be- *Cheinisse : La Sciiiaiiic ^h^dicalc, 1903, pp. 261-263. **Lancct, December, 20, 1902. ***Congenital Hypertrophy of Pylorus. By P. Davidson, Senior Physi- cian, Infirmary for Children, Liverpool. APPEXDKITIS AND PEUITVPHLITIS 20I coming livid in the face during the act, and greatly exhausted after it was completed. It appeared to the parents that the quan- tity ejected was more than the child could have taken in its feedings. When I saw the child on .Vugust 27th it was about six weeks old. It was languid and wasted. There was evidence of great dilatation of the stomach ; the lower part of the abdomen was empty and contracted. Washing out the stomach was attempted, with the result of setting up this violent act of vomiting of the character described above. The existence of a congenital obstruc- tion at the lower end of the stomach was evident, and on the fol- lowing visit I asked Mr. ^Murray to see the child, in view of its being relieved by an operation. During our examination marked peristaltic contractions of the walls of the stomach were visible under the skm. It was our opinion that the child was too enfee- bled to stand the shock of abdominal section. Rectal feeding was suggested. The child died of inanition and exhaustion on September 4th. A post-mortem examination was made. The stomach was enormously dilated; the pyloric end firmly contracted, and feeling like a solid tube. The intestines were contracted and almost empty. I have no recollection of seeing a similar case to this one. The symptoms were quite distinct from those of ordinar}- infantile dyspepsia and atrophy, and could not fail to attract attention to the existence of a congenital obstructive lesion. The microscopic examination showed that the stenosis de- pended on an enormous hypertrophy of the muscular coat, the pyloric sphincter ; the mucous membrane in the vicinity being normal." — Earle. ] Persistent vomiting and constipation, with abdominal pains, meteorism and collapse, are also met with during appendicitis and peritonitis. APPENDICITIS AND PERITYPHLITIS. Iiiflaiiuitatioii of the verniifonn process and of the abdominal cov- erings of the ccrcnni. This disease very seldom occurs in nurslings, usually being observed in children from five up to ten years of age who are inclined to constipation. Although this disease begins with ab- 202 APPENDICITIS AND PERITVPIILrriS ■dominal pain, yet never so suddenly, during the complete health, as happens in invagination. On the contrary there are precursors in the form of disorders of digestion, of temporary, coUc-like ab- dominal pains, loss of appetite and constipation. The best grounds for the diagnosis belong to the location and the character of the pain. Painfulness appears first of all in the region of the ccFCum. Palpation readily shows that the point of severest pain corresponds to the position of the appendix, the so-called McBurney's point, that is, near the center of a line connecting the navel with the anterior superior iliac spine. The pain increases upon pressure Simultaneously with the pain, or soon after, a violent tension of the abdominal wall appears, [and hyperiesthesia of the skin of the abdominal wall at the point corresponding to the appendix ; a slight pinching of the skin causes extreme pain if done over the point of the appendix (Dieulafoy).] Likewise at the same time we find fever and vomiting, usually repeated, which therefore later becomes bilious and even fjecal ; the constipation which had been existing before is persistent. On the second or third day a circumscribed hardening in the form of an immovable tionor, very painful up0)i pressure, may be felt in the right iliac region at a point which exactly corresjxmds to the ciecum. The disease ends either by gradual resolution, all symptoms abating, or it gives rise to the development of general peritonitis, usually fatal, or, finally, the process ends with the formation of an abscess in the region of the caecum. [Resides the symptoms of appendicitis enumerated there is one more very important objective sign called in France the sign of Hayem, and in Germany sign of Curschman. This sign refers to the blood-count in appendicitis being based on Hayem's investi- gations of 1889* that circumscribed suppurations following acute inflammatory processes are invariably accompanied by leucocytosis. This law was established by Curschman m regard to appendicitis in the year 1901,** namely that appendicitis is accompanied by the increase of the number of leucocytes. Da Costa, in America, published his observations on the same subject in 118 cases of ap- *G. Hayem : Du sang et de ses alterations anatomiques. Paris. 1889. **Miinch. Med. Wocli. 1901, pp. 1907 and 1962 (March and December). APPENDICITIS AXD PERITVP 11 LITIS 2O3 pendicitis, in the same year as Curschman, and came to the same conclusions. Soon afterwards there appeared numerous investigations along the same line in France, Germany, America, etc., with results as follows : (i) Generally one may admit leucocytosis if there is more than 10,000 white corpuscles in one cub. milimeter. (2) In the beginning of appendicitis there is a slight leu- cocytosis (11,000 — 15,000) even in the absence of any suppura- tion. (3) The number of leucocytes increases with the appear- ance of the first signs of irritation of the peritoneum. (4) The number of leucocytes not exceeding 25,000 indi- cates a mild form of appendicitis, which may end spontaneously with resolution ; but such a number being permanent denotes a suppuration, and thus that operation should be performed with- out delay. (5 ) Absence of leucocytosis does not prove that a given case is not appendicitis, being often absent (a) when the inflammation of the peritoneum becomes diffuse (diffuse peritonitis), so that the defensive force of the organism is too weak to produce leu- cocytosis, and (b) when the abscess is encapsulated. (6) The qualitative count of the leucocytes is of still more importance than a quantitative count, because an increase in the pohmorphonuclear cells out of proportion to the other elements is indicative of progression (Longridge). (7) The blood count in appendicitis requires the most rigor- ous technique (Deaver), and to avoid errors it must be per- formed several times a day, and each time new portions of blood should be taken. (8) The "curvature" of leucoc}tes in appendicitis is a symptom of far greater importance than the pulse and tempera- ture. — Earle.] All these symptoms are plainly sufticient for the correct diag- nosis. From invagination, appendicitis and perityphlitis dift'er by the absence of bloody stools, by the character of the pain (from the very first of the disease the pain is of inflammatory nature, i. e., *Am. Jour, of Med. Sc, Novemb., 1901. 204 APPENDICITIS AND PERITYPHLITIS increases upon pressure), and by the fever. Regarding? the con- stipation, this symptom is not a constant one in perityphhtis, be- cause (harrhcea sometimes occurs. A very important differential sign may be obtained from the digital examination per rectum ; in perityphhtis it is possible to sometimes feel resistance in the- right iliac region in a direction toward the horizontal branch of the pubic lx>ne (Karewsky). [Rectal examination is of especial value when the appendix is located in the pelvis (Lockwood).* — Earle. ] Appendicitis occurs in a very mild form, as well as in a severe one. In the former case there will be acute pain in the caecaL region, vomiting, and there may also be fever, all these symptoms disappearing very soon, that is, after twelve or thirty-six hours. This is the so-called appendicular colic. But there are also cases in which acute fatal peritonitis follows because of early perfora- tion of the vermiform process, death (xx'urring then in from three to six (la}s. ( )f an cntirclv different form arc cases of chronic appendi- citis, characterized by fre(|ucnt relapses. The clinical picture differs. In one case the patient constantly complains of dull pain in the right iliac region, the pain increasing during walking or physical exercise in general, but palpation does not reveal any- thing abnormal. In other cases the first attack of inflammation terminates in apparent complete recovery, but after a few weeks or months the second seizure suddenly appears, then the third, and so on. It frequently happens that the second or third attack is- much severer than the first, and kills the patient. For the differential diagnosis of perityphlitis one should also bear in mind typhlitis stercoralis (inflammation of the caecum), when accumulation of faeces in the caecum also gives rise to an oval tumor in this region, to abdominal pains, vomiting, meteorism, constipation and fever, with the difference that the peritoneum not yet being involved (otherwise it would be peri- typhlitis), the pain upon pressure is not great. It is further char- acteristic that after a copious stool due to a laxative or enema, rapid abatement of all symptoms follows. However, it is impos- sible to make sharp boundaries between typhlitis and perityphlitis^ *Lancct: Dec. 13. 1902 APPENDICITIS AND PKRITVPII LITIS 20^ there being reason why some authors, as, for instance, Jiiarthez and Sanne* hold them to be different grades of one and the same •disease. [Many authors entirely deny the existence of so-called typh- litis stercoralis (inflammation of the caecum due to f?ecal obstruc- tion). Especially has Dieulafoy (France) insisted in numerous papers, in clinical lectures, and in his well-known Text-Book of In- ternal FatJwlogy, that "The old-time typhlitis by frecal obstruc- tion (t. stercoralis) with perityphlitis, ulceration, peritonitis, etc., should be omitted, for this is never primary ; but when it does oc- cur, and this is very seldom, it is invariably consecutive to ap- pendicitis." Simple, catarrhal, mucous and other types of typhilitis and coli-typhlitis are called by Dieulafoy 'pseudo-typhlitis,' but typhlitis stercoralis, i. e., due to faecal stagnation, as described by •older writers, does not exist."** — Earle.] During inflammation of the psoas muscles (psoitis) there is also some pain fulness upon pressure and an immovable tumor in the region of the iliac fossa, associated with fever, but besides the symptoms on the part of the stomach and peritoneum being absent ( absence of vomiting and pain upon pressure over the ab- domen, excluding only a circumscribed area corresponding to liardening), the diagnosis also rests on the position occupied by the tumor : the latter is palpated, during psoitis, in the iliac fossa, frequently spreading over the upper third of the inner surface of the femur (the region of the trochanter minor), while in peri- typhlitis it occupies the region of the caecum, that is, somewhat higher and more externally. The femur always remains, during psoitis, immobile on the diseased side, this symptom being ob- served in aft'ection of the caecum only when the inflammation spreads to the cellular tissue, which lies on the posterior surface ■of the caecum — paratyphlitis. [In the differential diagnosis of appendicitis one should have thought of the following diseases (children's diseases) : ( 1 ) Movable kidney. (2) Hepatic colics. (3) Empyema of the gall bladder. *Traite clinique et pratique des maldies d'enf. Vol. II., p. 473. **Tlic Medical Week (English Edition of La Scmaine Medicate, il pp. 126, 137, etc.). 205 APPENDICITIS AND PERITVPII LITIS (4) Acute phlegmonous cholecystitis and gangrene of the gall-bladder. (5) Nephritic colic (6) Typhoid fever. (7) Lead-colics. (8) Diffuse enteritis (entero-typhlo-colitis) . From movable kidney appendicitis differs by the character of the pain and its location : it is not so severe upon pressure as in appendicitis, corresponding to the anatomical position of the kidney ; the tension of the muscles is almost absent or far less pronounced than in appendicitis ; there is no elevation of tempera- ture and no acceleration of pulse. While very characteristic of movable kidney v^e have prolonged and persistent nausea. It is much more difficult to dift'erentiate appendicitis from he- patic colic, as both may have a sudden onset marked by severe pain and vomiting. Aside from the history the character of the pain may serve us in the dift'erential diagnosis, it being more persistent and severe in hepatic colic than in appendicitis, and is confined more to the inferior portion of the right chest, near the point of the cartilage of the ninth rib; while in appendicitis the pain is situated in the right iliac fossa. In empyema of the gall-bladder the sac is distended and fol- lows the respiratory movements of the patient, especially when he is standing, and there are no adhesions. The history of the case and the tension of the superior portion of the right rectus abdom- inis muscle is characteristic of rupture of the empyema of the gall-bladder, thus differing from an appendicular abscess. In acute phlegmonous cholecystitis and gangrene of the gall- bladder the vomiting is more obstinate than in appendicitis ; the pain is very severe in the event of affection of the biliary ducts, radiating toward the scapular region and becoming general; the respiration is frequent, and of the costal type; general physical depression is very great and general peritonitis sets in very rap- idly (Deaver).* Nephritic colic dift'ers from appendicitis by the pain being confined to the hmibar region, decreasing upon pressure and ra- diating along the ureter ; the pain also decreasing after micturi- *J. B. Deaver: Annals of Surgery, March 189S. APPENDICITIS AND PERITVPII LITIS 207 tion ; here the tension of ahdoniinal muscles is absent, as well as the oedematous condition of the right iliac region ; aside from this the urine may give valuable points regarding the diagnosis. The differential diagnosis between typhoid fever and appendi- citis is sometimes very difficult. When the history of the disease is insufficient and the usual methods of diagnosing typhoid fail, then blood count may be of very distinct aid. As already pointed out, appendicitis is accompanied in the majority of instances by leucocytosis, while not so in typhoid. Lead-poisoning may closely resemble appendicitis, as shown by the observations of Apert, Mathieu, Tribulet and other writ- ers.* In the dififerential diagnosis we must take into consideration : (i) The history; (2) The characteristic line on the gums; and (3) Absence of fever. Then again it is very important to distinguish between ap- pendicitis and diffuse catarrh of the whole intestinal tract (entero- typhlo-colitis). According to Dieulafoy the pain in the latter dis- ease is only exceptionally located in the right iliac fossa, the whole abdomen commonly becoming painful ; therefore, when asked about the situation of the pain the patient points to the region of the transverse and descending colon. Further, the muscular tension (contracture) and the hyper?esthesia of the skin covering the lower abdomen is never so pronounced in entero-typhlo-colitis as in appendicitis. And then the history will always show that the patient suffering with entero-typhlo-colitis had complained for a long time of different gastro-intestinal disorders^''* Further neuromata in the right iliac fossa may give rise to severe attacks of pain, but a careful examination of the region and its palpation will almost always bring out these tumors, and thus settle the diagnosis. It scarcely comes within the province of the pediatrist to determine between appendicitis and different affections of the pelvic organs (womb, ovaries, Fallopian tubes, etc.) and wc there- fore refrain from entering upon the cjuestion. Finally, it should not be forgotten that very often the clinical *See Discussions in Soc. Med. des Hopitaux (Paris), Feb. 27. 1903, in La Semaine Med., 1903. **La Semaine Medicalc, 1899, p. 68. 2o8 APPENDICITIS AND PERITYPHLITIS expression of appendicitis is nothing more than a reflex from the chest, i. e., appendicitis is simulated by some affections of the lungs or pleura. Such very instructive cases have been lately re- ported liy H. L. Barnard, J. P. Crozer Griffith and J. B. Herrick. The differential diagnostic points in these cases are, according to Griffith, the following : (i) The sudden rise of temperature to 103 degrees F. or thereabouts, and a tendency to maintain this degree. (2) The acceleration of respiration, which is out of pro- portion to the pulse rate or to the pyrexia. (3) The relaxation of the abdominal walls between respira- tions. (4) The diminution or the disappearance of tenderness on deep pressure with the flat of the hand. (5) The possible presence of cough.* All these points will assist in most cases in determining the true nature of the disease pneumonia. — Earle.] [Nevertheless appendicular attacks which very frequently af- fect children otherwise in perfect health, are almost always, says Ochsner in his well-known Clinical Surgery, looked upon by the parents and friends, and frequently -fey the physician, as a case of violent, acute gastritis or enteritis, resulting from some indiscre- tion in eating. "This is so common that one rarely sees these young appendicitis patients in whom the correct diagnosis was made from the beginning of the attack. Therefore, the most im- portant point is in dispelling the idea that a severe pain in the re- gion of the stomach in children coming on after taking indigestible food is due to gastritis and is consequently of little importance, because so often a careful examination will demonstrate this con- dition to be a gangrenous or perforative appendicitis. This con- dition frequently occurs in children not more than four years of age. I have seen a number of cases much younger, one as young as seven months, and the accompanying history of a case observed by Dr. W. B. Helm, of Rockford, Illinois, which I quote because of its unusual interest, shows that it ma}- occur in those still younger. *Pneumonia and Pleurisy in Early Life Simulating Appendicitis, by S. P. Crozer Griffith {J own. Am. Med. Assoc, Aug. 29, 1903, No. 9). AITENDICITIS AND I'EKllA- 1' 1 1 1 ,1 I h 209 This i)atient, a bo}^ three months old, was seen b}- Dr. Hchii, Jaiiuar\- 5. 1902. He had suffered ahnost constantly since birth, crying" much of the time, night and day. Frequent tenesmus, al- though bowels w^ere easily regulated. The mother's milk did not agree and various prepared foods were tried. The child took food ravenously, but never seemed satisfied. There was no gain in weight and some fever persisted most of the time. When the child was five weeks of age the local physician was called and de- tected a right oblique inguinal hernia. There was apparently no trouble in reducing it and he tried various forms of retentive ap- paratus. Still the crying, straining and fever continued. Seven weeks later the patient began to fail rapidly, and Dr. Helm found it with a temperature of 103'^ F. and pulse varying from 160 to 190. The child weighed only eight pounds and still cried most of the time. There was a hernial protrusion the size of a small hen's egg. The bulk of the mass could be readily returned, but a small object in the inguinal canal remained. It seemed like an undescended testicle, but both of these organs were found to be in the scrotum. Repeated trials failed to return it to the abdo- men, so an operation was advised. On opening the canal the ■doctor found that the reducible portion was the head of the colon, and the irreducible part was the appendix, slightly adherent and greatly congested. He removed the appendix and closed the canal by the Bassini method. The pain was apparently lessened at once, the fever disappeared on the third day and the child gained two pounds during the first ten days and has since made an unin- terrupted recovery."* — Earle.] Acute inflammation of the peritoneum — PERrroNiTcs ACUTA, is indicated by such well-defined symptoms that it is easily ■diagnosed. The most characteristic symptom is severe pain in the entire abdomen, increasing upon the slightest pressure, as well as ■during movement, cough and other conditions associated with the action of the abdominal muscles, so that the patient, even against his will, lies immovable on his back with the legs slightly bent and literally does not allow anything to touch his abdomen. Along with the pain there is fever (about 40 degrees C. — 104 degrees P.), persistent vomiting and constipation, the abdomen being very *Ochsner: Clinical Surgery, 1903. pp. 126-128. 2IO APPENDICITIS AND PERITYPHLITIS much distended (especially is the diaphragm elevated) with ten- sion of the abdominal walls. Under the influence of irritation of the peritoneum and fre- quent vomiting collapse rapidly develops (thread-like pulse, sunk- en face, coldness of the extremities). Great similarity to peritonitis may be presented by gymnastic pains in the abdominal muscles. When children start g-ymnastic exercising they often complain, during the first days, of abdominal pains in the epigastrium or between the navel and sympliysis pubis. The examination shows that this pain is localized in the recti muscles of the abdomen, being indicated by increasing upon pressure and some movements performed by the straight abdom- inal muscles. Similar ])ains are also met with in children in whooping-cough because of tension of the muscles during cough. These pains being mild are not difficult to diagnose, but the question is altered in grave cases. The pains then spread all over the abdomen, being of a peritoneal character, that is, they increase upon the slightest pressure and compel the patient to maintain an immovable posture. Together with the pains there also appear other symptoms of peritonitis, such as vomiting, constipation, high position of the diaphragm and fever, so that during the first day of the disease the diagnosis is indeed perplexing. But even then there are some differential points ; first of all, the pulse re- mains full, not very much quickened, other signs of collapse being absent ; second, fever does not rise higher than 38.5 degrees C. (101.3 degrees F.) ; third, at last the history may point to some overexertion of the muscles. In one of my cases, described in the January number of Mcdizinskoie Oboarenie, 1880, a ten-year- old boy became ill with the symptoms mentioned after he had ex- ercised in various ways which required exertion of the abdominal muscles, especially of the straight ones. The further course of the affection will solve the problem be- cause gymnastic myositis is very soon over if a quiet position is^ maintained by the patient ; in two, or at least three, days vomiting and fever disappear, the pains become concentrated in the straight abdominal muscles, especially in their lower parts, and pass en- tirelv awav toward the end of the week. SEMEIOLOGY OF ABDOMINAL PAIN. Abdominal pain, like headache, belongs to the most uncertain of symptoms, inasmuch as its causes may be very manifold. In this section I will speak only about abdominal pains in older children. In treating- a child complaining of abdominal pain, one should first of all decide the question as to the location of the distress, that is, find out if the pain is localized in the abdominal wall, or in any internal organ. Pain in the abdominal wall may be : ( 1 ) In the integument of the abdomen. (2) In the muscles and aponeuroses. (3) In the peritoneum. I shall not speak of uiflamiuatory f>ain of the skin (erysipelas^ furunculosis, etc.), as the cause of pain in such cases is clear. HyPER.ESTHESIA of the SKIX OF THE ABDOMEN. The patient complains of abdominal pain which considerably increases upon any, even slight, pressure over the abdomen, being thus similar to the pain of peritonitis. Indeed it is very often mistaken for the latter, especially when appearing during a dis- ease which may produce peritonitis as a complication, for in- stance, as in typhoid, when hypercesthesia of the abdominal skin belongs to the most common symptoms. It is not difficult to avoid error, the diagnosis resting, first, upon the signs peculiar of hyper- sesthesia of the skin in general, and, second, on the absence of other symptoms of peritonitis. Hypersesthesia of the skin is first characterized by a wide area of involvement. In typhoid it is, for instance, readily learned that the pain is not limited to the abdomen alone, but extends also over the thighs and the chest as well ; the patient equally resists, by the features of the -face and by groaning, to pressure over the abdomen as well as upon the inner surface of the thighs. Second, by a greater pressure causing more severe pain than a mild one, while the pain will be equally severe upon pressing either the 212 SEMEIOLOGV OF ABDOMINAL PAIN abdominal wall itself, or only the folded skin. Third, by the pain remaining stationary for a long period, in typhoid, for instance, several days in succession, while no new symptom, peculiar to peritonitis, becomes evident. Besides in typhoid these pains due to hyperjesthesia of the skin of the abdomen and other parts also occur in meningitis (especially cerebro-spinal meningitis) and in other severe febrile conditions, as well as in general nervousness, particularly in girls during the period of puberty (hysteria). Hypersesthesia of the skin in typhoid, when well developed, may lead the physician to an error in causing him to suggest men- ingitis when the latter is entirely absent. Such a mistake hap- pened to me in one case of a seven-year-old girl, entering the hospital on the fifth day of the disease on account of fever of about 40.2 degrees C. (104.4 degrees F.), spleen-tumor, uncon- sciousness and contracture of the neck. The general hyperaesthesia of the abdominal skin was so pronounced that each time, upon folding the skin, the patient, although evidently unconscious, would scream. In view of this symptom, as well as the contracture of the neck and the rapid course, a diagnosis of cerebro-spinal meningitis was made in spite of the speen being very large and painful, the pulse accelerated (152, with a temperature of 40.8 degrees C. — 105.5 degrees F.) and absence of the initial vomiting. Death occurred on the ninth day. The post-mortem showed a -recent spleen tumor with swelling of Fever's patches (in ^hort, typhoid), and complete absence of inflammatory changes in the ■cerebral membranes). Pains in the muscles and aponeuroses of the abdomen arise from two causes : ( i ) From catching cold — rheumatism of the abdominal muscles; and (2) From gymnastic exercises. The former occurs ver\- seldom and from my own experi- ence I would be unable to say anything. Bamberger points out that rheumatic pains of the abdominal muscles may simulate peritonitis. The condition probably resembles that which is ob- served in muscular pains due to gymnastic exertions, which was mentioned in the preceding article (page 210). Pain in the peritoneum during inflammation thereof be- longs to the most severe suffering related to the abdomen. It is, jEirst, indicated by its constancy (although at times increasing, SEMEIOr.OCV OF AiiDoM 1 X AL I'AIN' 2I3 colic-like, under the intiucncc of the peristaltic movement of the intestines) ; second, hv increasing upon the slightest pressure over the abdomen ; third, by always being accompanied by considerable tension of the abdominal walls; and fourth, Ijy being associated with other symptoms of peritonitis, namely, vomiting, constipation and meteorism. The extension of the pain depends upon the area of the inflammation ; in general peritonitis the entire abdomen is painful, in the circumscril)ed variety the ]:)ain is limited to a correspondngly small space. In childhood, local peritonitis most often manifests itself by pains in the CKcal region : Appendicitis and Perit_\phlitis ( page 201). In chronic peritonitis the pain is of secondar}' importance and will, therefore, be spoken of in another place (section on the Enlargement of the Abdomen). Pain in thf bowels — ciifcralgia, s. colica, is characterized by appearing in attacks (paroxysms), separated by free intervals, tlw pain not increasing on pressure and existing ivithont fever. A mild paroxysm of colic does not produce any objective signs and may be recognized only from the patient's complaints. If, how- ever, the pain be grave, then the patient not only groans, pain- fully distorting his face, but his extremities grow cold, perspira- tion covers his forehead, the j^ulse is small, and the patient is continuously restless ; vomiting often appears. According to the cause and the case, the attack lasts from several minutes up to several hours. Colics may depend upon either : (i) Disease of the intestines. (2) Irritation by their contents. (3) Aft'ection of the nerves of the abdomen. (4) Irritation of the neighboring organs. (i) Colics depending npon catarrh of the small bowels are the most common. The attack of colicky pain usually precedes a diarrhoeal dejection, so that the cause of the pain may easily be recognized. If the colic depends upon catarrh of the large bowels, or dysentery, then it occurs much oftener, being accom- panied by tenesmus of the rectum and a mucous stool. Here may also be included colic pain associated with the eliminalion 214 SEMEIOLOGV OF ABDOMINAL PAIN of large quantities of mucus in the so-called enteritis pseudo- meni- branacea. To the same category, that is, ])ain due to disease of the bowels, is also to be referred violent abdominal pain accompanying intestinal obstruction, for instance, intussusception (page 197}, as well as colics sometimes occurring in purpura (see Diseases of the Skin, viz., cutaneous haemorrhages) and probably depending upon hcemorrhages into the intestinal walls. If the colicky pains last a long time, being associated with chronic meteorism. general wasting and paleness, as well as with slight fever, then it points to a tubercular peritonitis : and the latter becomes certain if ten- sion of the abdominal Dinscles be noted together with various thickenings that may be felt in the abdomen. (2) To the second group are referred alxlominal pains due to indii^cstible food {colica ah iiii^estis), for instance, sour fruits (the history), to some drugs, accumulation of faeces in the in- testines — colica stcrcoralis (constipation, distension of the abdo- men, sometimes lumps of faeces may be felt through the abdominal wall. The pain stops quickly after removal of the cause by means of an enema or laxative), and to intestinal wcjrms. Colic due to worms may be suspected if chronic pains in a child are repeated especially in the mornings on an empty stomach, being sometimes accompanied by anaemia, notwithstanding the ap- petite is good, the stools regular and, in general, symptoms of ca- tarrh of the stomach and intestines completely absent. The prob- ability becomes still greater if the child had previously eliminated ascarides or segments of a tape-worm, or if ova of the latter have been detected in the evacuations. Intestinal worms are to l>e regarded as an undoubted cause of abdominal pains onl}- when the pain entirely disappears after the parasites have been removed. (3) Nen'ous pain in flic intestines may be suspected in a case where we cannot find the cause of it either in diseases of the bowels (normal stools, good appetite), or in errors of diet (the pains do not increase from coarse food, neither diminish with the best diet), or in intestinal worms (santonin does not expel ascarides, ova of tape-worms, or their segments, are absent), or in the irritation of neighboring organs. The intensity of pain in itself is here of little help in the diagnosis, being very moderate s^;^IF.lnI/)G^• oi' aiidom ix.\i. paix 215 and even mild in one case, while ni others very severe, depending partly upon the exciting' causes, which may be very manif(dd, namely : (a) IiiflaiiiiiuUioJi of Ihc vcrlcbrcc. Examination of the back detects either a beginning spondylitis (impossiliilitx' of bend- ing the back, painfulness upon pressure over such or such ver- tebra), or very pronounced malum Potti. Abdoniiual pains occur m attacks and especially at night. (b) Lead poisoniui^. Gray (lead) line on the gums, ob- stinate constipation not yielding to common remedies, the abdomen being flat or concave, and hard ; the urine scanty, of high specific _gravity and turbid ; history. (c) General iien-oiisiiess. Nervous abdominal pains de- pending upon this cause occur in }outhful girls marked by pale- ness. They usually are rather thin, eat almost nothing, are prone to constipation but the attacks of pain do not depend upon cos- tiveness. The pains are repeated at different hours of the day whether the stomach is empty or not, recurring every day, or twice or three times a week. Sometimes the patient suffers from an undoubted hysteria. ( d) The cause of the colics may also be a eold ( colica rheii- iiiatica), as a result of wetting of the feet or of the whole body. Diarrhoea is not necessarily present in such conditions. (e) Malaria. J\Iay be a positive cause of regularly return- ing abdominal pains, the nervous character of which is manifested by being entirely independent of the time of taking food and of its quality. If the paroxysm is violent, then it may be associated with vomiting. Tumor of the spleen, and especially elevation of temperature may be absent. These pains are peculiar in other re- spects than belonging to their periodicity, for example, by their obstinacy regarding opium, laxatives, diet, etc., and their quick disappearance after some doses of quinine. In one eleven-year- old girl I observed the interesting alternation of the attacks : the ■disease began with regular paroxysms of quotidian fever which disappeared after quinine, but a few days later the patient began to suffer daily from migraine which would start at two o'clock in the afternoon, but yield readily to quinine; after a few days more periodical abdominal pain developed severe enough to cause the patient to cry. 2l6 SEMEIOLOGY OF ABDOMINAL PAIN Among purely nervous colics one must also include ab- dominal pain sometimes occurring during the period of recovery from diphtheria, and depending perhaps upon an affection of the vagus nerve, because such a pain usually precedes, according to Suss*, sudden death from heart paralysis and has therefore an unfavorable prognostic meaning (seepage 158). Before the diagnosis of nervous abdominal pain is made one must first of all consider renal colic, which occurs in childhood, contrary to hepatic colic, not very infrequently. Renal colic may be suspected if attacks of abdominal pain appear in a child after irregular intervals of time (days, weeks or even months may elapse between attacks) ; especially after bodily jolting (driving on a bad street, riding) ; if the child be well, but his recent urine contains sand : and if there is some tenderness upon pres- sure over the back in the region of either kidney. The pain during the attack is either quite bearable, or so severe that cold perspiration appears on the face, accompanied willi \oniiting and failure of the pulse. The diagnosis of renal colic becomes still more probable if the microscopical examination of the urinarv sediment reveals pus corpuscles, mucus, pelvic epithelium, in l)rief, symptoms of pyelitis. The most diagnostic sign of renal colic is the elimination of a small stony concrement with the urine. The parents of such children often show symptoms of uric-acid diathesis (podagra^ urinary sand) or suffer from migraine. If in a family consist- ing of several children one of them suffers with attacks of renal colic, his brothers and sisters not infrcquentl}' present evidences of sand in the recent urine. The youngest child in which I had the opportunity of observ- ing renal colic, with elimination of small calculi, was about three years old. (4) Xbdominal pain, due to renal colic, belongs to the fourth division of our classification, that is, to pain because of irri- tation of neighboring organs, but not of the bowels themselves. Here also belongs abdominal pain due to movable kidney, which,, although rare, occurs in children. Finally, there must also be included the refiex pains of the '■"Revue mens, des mal, de I'euf. 1887. page 289. SEMEIOLOGV OF AIIDO.M 1 XAL PAIN 21/ abdomen of which chilchx'ii from two to six years old complain so often during- pneumonia and pleuritis. It is remarkable that at this age children when sick with pneumonia crouposa never complain of pain in the side, but always locate the same in the abdomen, so that if a child, complaining of abdominal pain, has fever, cough (dry), while the respiration is accompanied by movement of the nostrils, then the existence of pleuro-pneumonia is highly probable. [This referred pain may be explained, according to Herrick, in his instructive paper,* in the following way : The lower six intercostal nerves — the anterior divisions of the dorsal nerves — supply the abdominal wall, as well as a part of the parietal and diaphragmatic pleura. An irritation, i. e., from inflammation or pressure, in the course of one of these nerves might readily cause a pain that would be referred to the distribution of this nerve, i. e., to the abdominal wall. * * * The eleventh nerve is distributed over the iliac region. Pain here would easily make one think of the appendix, if on the right side, or, if on the left, perhaps of the rarer left-sided appendicular pains. The other nerves would cause pain referred to the umbilical, epigastric or hypochondriac regions and the confusion that might result when we think of the possible significance of such pain in the way of ulcer of the stomach, gall bladder mischief, pancreatitis, etc., is clearly seen. — Earle.] *Herrick: Abdominal pain in pleurisy and pneumonia (Jour. Amer. Med. Assoc, Aug. 29, 1903). SEMEIOLOGY OF THE ENLARGED AB- DOMEN. Normally, that is. if the abdomen is neither distended nor sunken, the abdominal walls durinjj the recumbent posture of the patient should be somewhat lower than the lower level of the chest, or at the same level, as ha])pens with fat children ; if. how- ever, the abdomen be hi.e^her than the arch-rib, then one is justified in saying- the abdomen is enlarf^ed. An enlarged abdomen may depend upon distension of the bowels because of flatus, or upon an accumulation of fluid in the abdominal cavity. It is not difficult to differentiate these condi- tions. In meteorism the abdomen everywhere gives a tympanitic note on percussion, while in dropsy a dull sound is obtained /;/ fhr dependent parts, changing its location u])on a change of ])()si- tion of the patient (provided there are no adhesions to prevent the fluid flowing from one part to another). Fluctuation is readily determined by one hand being placed upon one side of the ab- domen, while the opposite side is lightly struck with the fingers of the other hand. If the abdominal walls are tense, then their con- cussion may give false fluctuation in a common meteorism. One may be guided in such duubtful cases In- the character of the wave which is produced by striking the abdominal wall : in the presence of accumulation of fluid, that is. in a real fluctuation, one may distinctly determine that the size of the wave which impinges ui:)on the hand applied to the abdomen changes. dei)end- ing upon whether the tapping is done with one finger or with tli." ends of several fingers : in the former case the wave will be a small one, in the latter comparatively large. In false fluctuation the concussion of the abdominal wall is not perceptible enough to enable one to appreciate the size of the striking surface of the fingers. One may sometimes obtain an undoubted fluctuation in the abdomen notwithstanding the complete absence of ascites. This occurs in cases of accumulation of fluid in anv sac. whatever it SKMi:ii)i.o(;\- OF THE Kxi,AR(;i:r) AUDDisrEN 219 may be, hxdronephrosis, disteiuled bhuk'er, or ovarian c\sl. Tii -all these cases the dull sound docs not change its boundaries witli a change m the position of the patient. A distended bladder is easily outlined it the abdominal walls are not tense and fat, so that it is convenient to palpate the boun- daries of the bladder through them. It. however, these boundaries cannot be felt then the diagnosis is decided by the form of the dull sound which occupies the space in the median line of the abdomen between the navel and symphysis pubis spreading several inches, symmetrically, to both sides from this line. This dull note docs not change its boundaries on changing the position of the patient, but disappears after evacuation of the urine through -i catheter. Hydronephrosis and ovarian c_\st will be referred to in the •description of Tumors of the Abdomen. Distension of the abdomen develops either acutely — metcorism, or exists in a chronic form — tympanites. Acute meteorism in moderate degree generally accoinpanies acute catarrh of the small bowels and dyspepsia in small chiUlren, as well as in occasionally-occurring constipation. Considerable development of meteorism is to be noted during more serious ■diseases, as intestinal obstruction (invagination) and inflammation •of the peritoneum, local as well as general. The diagnostic meaning of meteorism is, generally speaking, not great, playing in this regard a secondary part, because other more important diagnostic- symptoms are then present. How- ever, in some cases it may aid the diagnosis, for instance, in doubt- ful forms of typhoid, resembling tubercular meningitis ; here a moderate meteorism is in favor of typhoid, while a slightly sunken abdomen is more significant of meningitis. Chronic tympanites occurs in chonic intestinal diseases (diar- rhcea or constipation), as well as in chronic peritonitis (together with ascites, see below), and in man}- cases of rachitis. The activ- ity of the bowels being normal, tympanites may depend, in chil- ■dren, upon indigestible vegetable fcxid, consisting chiefly of bread and potatoes. Dropsy of the abdomen. Accunudation of fluid in the ab- domen may be the consequence of a transudation into the abdom- -inal cavity due to an obstructed circulatic^n in the vena porta, or 220 SKMKIOLOCY OF THE KXLARC.ED ABDOMEN to general hydrasniia and alteration of the walls of the vessels- (Cohnheim) ; or, again, fluid accumulating in the abdomen is the result of peritonitis, this being in the form of exudate. A simple, that is, not inflammatory dropsy of the abdome)'., which depends upon hydrccniia, is characterized, first, by the co- incident presence of anasarca, which either involves the whole body or only some parts, as the face and the feet; second, by the fact that it is always possible to find the cause of hydraemia either in inflammation of the kidneys (examina.tion of the urine) or in the wasting diseases, chief among which is chronic diarrhoea (follicular enteritis). In other cases ascites, as one of the sequela; of general dropsy, is the consequence c^f obstructed circitlatioii in general, and espe- cially in the liver; the cause must then be looked for in cardiac lesions or in chonic atYecti(Mis of the lungs and especially of the pleura (suppurati\e ])leuriiisi. In the latter case the dropsy may be produced by a double cause, that is, by obstructed circulation and by hydraemia due to marasmus. We may then only diagnose a stagnant abdominal dropsy in cases where there are also symptoms of passive hyperaimia of the liver (see Tumors of the Liver). Some difficult}' in diagnosis may be exhibited by cases of inflammatory ascites, when appearing in hydropic persons. Such a com.bination of chronic serous j>eritonitis is observed, first, in chronic nephritis and, second, in tuberculosis. In the former case,, in a seven-year-old girl, the diagnosis was based chiefly on the peculiarities of the aspirated fluid, which appeared turbid because of admixture with great quantities of pus corpuscles and con- tained much albumen. In a tulierculous boy, ten years old. the diagnosis of peritonitis in the presence of general dropsy could be established on the ground of adhesions between the bowels and the abdominal wall, so that the free moving of the fluid on change of position of the patient was limited. There remained a tympan- itic note in the right epigastrium during the erect posture of the patient, as well as during a position on the right side, notwith- standing the very small amount of fluid in the abdomen. An iti- duration could be felt at the same place. The diagnosis was verified in both cases by the post-mortem. In a third case, which did not end fatally, we had an ascites. SEMEIOLOGY OF THE ENLAR(;i:n AI'.DOMEN 221 ^n a ten-year-old girl who suffered from chronic nephritis and 'diarrhoea. Although the ascites here was a part of the general dropsy, yet it probably was also, in part at least, of inflammatory orig-in, because the fluid drawn off by means of a trocar was very turbid from the admixture of pus corpuscles and, besides this, the ascites was disproportionately great in comparison with the •oedema of the feet. Rehn* asserts that exudative peritonites, sometimes arising during renal affections, are characterized by fever and painfulncss in the abdomen ; but these signs are of but little importance in chronic cases, because both may be absent, and in tuberculous patients the fever may depend upon other causes. But in such cases of combined ascites, although rare, the diagnosis of the cause of the ascites, which constitutes a part of general dropsy, is, generally speaking, not difflcult. Much greater difficulties are exhibited in this regard by isolated ascites, when the question arises whether we have a stagnant ascites, that is, transudation, or a chronic exudative peritonitis. The diagnosis ■of both these morbid conditions may be made from analysis of the aspirated fluid, by the aetiology and the history, as well as by the symptoms. The transudate is a transparent, slightly yellowish fluid, ■whose specific gravity is less than 1015, the quantity of albumen not exceeding two or three per cent ; while an exudative fluid, although sometimes also transparent (is usually turbid, grossly resembling water slightly whitened with milk, because of the more or less considerable admixture of pus corpuscles), con- tains much albumen (four to six per cent) and the specific gravity is more than 1015. Fever and abdominal pain indicate peritonitis, but the absence ■of these symptoms does not exclude the latter. Reuss found that the difference in the specific gravity be- tween a transudate and an exudate depends especially upon the -quantity of albumen, so that the amount of the latter may be judged from the specific gravity. Reuss even gives a formula for determining the amount of albumen : if S signifies the specific gravity and E the amount of albumen in per cent, then E equals *Handbucli v. Gerhardt, Vol. IV., 1880, p. 258. 222 SEMEIOLOGY OF THE ENLARGED ABDOMEN ^x(S-i,ooo)-2.8. If, for instance, the specific gravity of the transudate is equal to lOlO, then E equals fi x 10-2.8;=^- 2.8 or E equals 0.95 If a fluid drawn from any cavity coagulates after long stand- ing, then it is, of course, an exudate ; if it does not coagulate, then such fact does not, per se, exclude its character of an exudate. Transudation in the abdominal cavity, in an isolated ascites;: is always of passive origin due to compression of the vena porta or its hepatic branches. Such a dropsy of the abdomen rarely occurs in childhood. Comparatively more frequent causes of ascites are produced by diseases of the liver. Syphilis of the liver is characterized in older children by enlargement of the organ, the formation of gummous nodes and cicatricial connective tissue, so that the liver assumes a lobular shape. This malady may be supposed, or even diagnosticated^ if the child had previously suffered with symptoms of hereditary syphilis (abortions in the mother, eruption during the first year of life, later on ulcerous processes of the long bones) and at present time an enlarged nodular liver may be palpated. The diagnosis- becomes confirmed if under the influence of specific treatment (iodide of potash) for a few weeks the ascites disappears, the liver decreases in volume and the general aspect of the patient improves. Simple cirrhosis of the liver develops in children who have been given wine, or, even without this setiological factor, after acute infectious diseases. [The cause of infan- tile cirrhosis of the liver often lies in the congenital oblit- eration of the bile ducts (over seventy cases are recorded in connection with this aetiology) and congenital syphilis. Alcohol was found by Morse* to be an setiological factor in ten to twenty-five per cent, of all cases. The eruptive fevers rare- ly, if ever, produce hepatic cirrhosis. — Earle.] In the symptoms- this form differs but little from the hepatic cirrhosis of adults. Re- garding the diagnosis it is important to note that, in the first period of the disease, disorder of digestion is commonly found in the form of diarrhoea alternating with constipation, together with ^Boston Med. and Surg. Jounial, Sept. ii, 1902. sEiM]-:i()i.()r.v OF riii-: i-.xlarced abdijmkn 223 abdominal pains. Tlicse symptoms arr the same as we always find in the history of ascites due to tubercular peritonitis, but they are absent in the so-called idiopathic ascites due to chronic serous peri- tonitis. Not less important is it to note, in the history, the occurrence of jaundice, wdiich is rarely absent, being sometimes moderately developed and transient, with relapses ; although it may not be present in any given case in the period of a very pronounced ascites. With great probability one may diagnose hepatic cirrhosis, provided gradual diminution of the liver and enlargement of the spleen are noticeable. Unfortunately the presence of the great quantity of fluid in the abdomen considerably hampers the exam- ination, or renders it negative, unless paracentesis is performed. Amyloid liver never occurs as an independent lesion, but only in exhausted children and especially in scrofulous ones, suf- fering wdth ulcerous processes in the bones or upon the skin, as well as in tuberculosis, s}philitic and generally in cachectic conditions after wasting diseases. In the presence of such aetio- logical criteria, it is not difficult to recognize an amyloid liver. Such a liver is very large (reaching not infrequently to the navel) is firm and hard, the margins are rounded, the surface smooth and painless upon pressure. As the amyloid degeneration almost never is limited to the liver alone, spreading also to the kidneys and spleen, therefore a large spleen together with albuminuria may be held as characteristic symptoms of an amyloid liver. Jaundice is absent if there are no complications. Regarding ascites, it must be said that this is not a constant symptom of the disease in question. As the dropsy often begins from the feet, the abdomen becoming involved later on, one may think that in many cases of ascites due to amvloid liver the main influence in its origin is not the obstructed hepatic circulation, but merely hydremia. It is also difficult to say what influence, in the formation of ascites, may be produced by hyperplastic hai'deniiig of the iher, one of the symptoms of malarial cachexia, the diagnosis of which is based especially on the history (continued malaria). Large, hard spleen, with a considerably enlarged and also hard liver 224 SEMEIOLOGV OF THE EXLARCiED ABDOMEX whose surface is even and, finally, cedenia of the feet and general anaemia, constitute the picture of the disease. Regarding ascites due to compression of the vena porta by enlarged glands in the porta hepatis, or of the inferior vena cava higher than the point of entrance of the hepatic veins, it may be said that the diagnosis is impossible. As the enlargement of the lymphatic glands depends either upon amyloid degeneration anrl tuberculosis, or upon degeneration because of cancer of adjacent organs, then such cause cannot be suspected, if the patient does not appear exhausted and if the history does not show any pos- sibility of degeneration of the glands. One may be guided by these circumstances in the differential diagnosis of a simple ser- ous peritonitis. Exudative ascites. Drops\ of the abdomen as a result cf chronic peritonitis occurs in children much oftener than obstructive dropsy. Chronic peritonitis, as a consequence of an acute, com- mon peritonitis, occurs quite seldom. As an example I refer to the following case: A deaf-mute, ten-year-old boy, of healthy parents, previously in good health, brothers also entirely well, never suft'ered from prolonged diarrhoea, cough, or abdominal pain. He entered the hospital on account of pain and distension of the abdomen. The disease began about a month previously, after drinking some cold beer while in a heated state. The disease started with fever, repeated vomiting and such violent abdominal pain that he was compelled to keep an immovable recumbent posture (on the back) A few days later his father noticed a considerable enlargement of the abdomen. Since that time the patient has not left his bed, being taken to the hospital a month after the beginning of the disease, when the abdominal pain had abated considerably and the patient could sit up. At the time of entering the hospital the patient was pale and thin, but far from being exhausted, the abdomen considerably enlarged (66V2 ctm.), painful upon pressure, especially between the umbilicus and epigastrium, where one could easily feel a hard- ening through the abdominal wall, with a well-defined, firm lower margin which very much resembled the margin of the left lobe of a hardened liver. This margin crossed the abdomen two inches higher than the navel, from one hypochondrium to the other. SEMEIOLOGY OF THE ENl.ARGI-.l) Al'.DOMEN 225 The ii])pcr iii;iri;in of the tumor did not reach the lower end of the stenuini, so that in the epigastrium there remained a small ar(.'a of less resistence, which contraindicated an increased liver. The consistency of the tumor w'as very solid ; the surface not en- tirely even; upon pressure it was painful. L^pon light percussion of the tumor a tympanitic sound, as of the bowels, was obtained, pointing" to a limited thickness of the mass. The liver could not be palpated ; the dull note of the liver began one inch below the navel, reaching the lower margin of the chest. The abdomen gave a distinct fluctuation and a dull sound on percussing the sides, while the dullness changed upon change of position of the patient. The tongue was clean, humid ; the bowels moved once a day, normally ; the appetite good. The urine stained intensely by the urinary pigments and contained much indican ; no albumen. Splenic dullness could be determined. Cough, absent ; sleep, fair; fever, constant and moderate (37 to 37.7 degrees C. — 98.6 to 99.9 degrees F. in the morning, and about 10 1 degrees F. or 38.5 degrees C. in the evening, without any perspiration). Gen- eral condition fair : the patient sat easily in his bed. CEdema of the cellular tissue was noticed only in the scrotum. The diagnosis of simple peritonitis was made on the ground of the history (acute beginning, absence of intestinal catarrhs and tuberculous taint), although the tumor between the navel and scrobiculum cordis, which was regarded as a thickened and cica- trized omentum, favored tuberculosis. Several days later the patient contracted scarlet fever, to which he succumbed. The post-mortem showed in the abdomen the presence of sero-purulent fluid, while the tumor in the upper part of the cavity was not a, degenerated omentum, but merely a greatly thickened peritoneum. The inflammatory infiltration ended, without reaching the umbilicus, with a very thick (as a small finger ) vertical margin, which simulated the margin of the liver. There were no traces of tuberculosis, even in the bronchial glands. The difl:'erential diagnosis of such cases from tubercular peritonitis is reached with some probability only from the facts contained in the history. In other cases chronic serous peritonitis develops independ- entl}-, under the influence of unknown causes, or an undoubted 226 SE.MKIOLOCV OF THE ENLARGi:!) ABDOMEN' cold (Galvani), and proceeds slowly from the very first, without acute sym])toms of irritation of the peritoneum, although accom- panied at the beg"inning with fever. Even when well developed this disease does not lead to any complications, being indicated by no other symptoms except the considerable ascites, therefore, formerly described as idiopathic ascites — ascites idiopathica. Galvani called it peritonitis rhcumatica serosa chronica. Other symptoms are negative: the abdomen is neither tense, nor painful, its form being spherical, like that during a passive dropsy ; no hardening or adhesions, so that the boundaries of the dull sound change freely on altering the position of the patient. Besides these negative symptoms, serous peritonitis exclusive- ly afifects healthy children, the general condition remaining good even during the period of full development of dropsy. The patient has a good appetite, moves the bowels regularly (according to Baginsk} there Is often diarrhoea), has no fever and is not con- fined to bed, by which this disease difi^ers also from obstructive dropsy due to diseases of the liver, wherein the general condition always sufifers rapidly.. The usual termination of this form of peritonitis is in recov- ery, although death is also possible, as liappened, for instance, in the following case : A boy, aged four years and three months, entered the clinic in September, on account of an enlarged abdomen. The parents of the patient were young and healthy ])eo])le ( the father thirty years old, the mother twenty-four) ; tuberculosis, syphilis or men- tal diseases absent in the famih. ( )f two children, the first one, a girl, died when eight months old from diarrhcea, the second, our patient, was born at full term, was fed from the mother's breast eight months, the first teeth appeared in the eighth month ; he began to walk at the beginning of the second year. Had pneu- monia twice, when ten and eighteen months old, after that w^as well until five months ago. On April 15 was taken with fever, temperature 40 degrees C. (104 degrees F.), and cough, but soon recovered. Two months later, about the middle of June, the mother began to notice morning oedema of the eyelids, and a few days later her attention was called to enlargement of the ab- stationary condition of the ascites and the good general condition of nutrition covering a long period of time ; the absence of diarrhoea ; and partly the age of the child (serous peritonitis especially occurring in small chil- dren under five years, cirrhosis of the liver in those older). The diagnosis may be finally determined by paracentesis of the abdomen, for two reasons in j^articular; first, it is more con- venient to examine the liver after the fluid is drawn off; and, second, positive results may be obtained upon examination of the fluid, regarding its specific gravity, quantity of albumen and the microscopical properties (admixture of pus corpuscles in the exudate). The specific gravity of a transudation is no more than loio to 1012; in serous peritonitis 1015 or more. Chronic tubercular peritonitis occurs as the most fre- quent cause of isolated ascites in children. Its development is usually preceded by chronic diarrhoea and abdominal pains, altei^- *See, for instance, Traite des maladies de I'enfance, par Grancher, Comby et Marfan, Vol. III., page 75. **But, in atrophic cirrhosis of the liver in childhood the liver may be increased even in the period of dropsy. SEMEIOLOGV OF TIIK KX I. AR( ;i:i ) AliDO.MI-'.X 229 natin^;" with constipation. The child a[)pcars scrofulous ( chronic eczema, adenites, diseases of tlic bones), or comes from a family with a tubercular predisposition. If, such conditions being present, ascites arise, associated with considerable tension of the abdominal walls, so that the abdomen becomes somewhat compressed at the 'sides and oval in shape (l)ut not spherical as in tympanites or stagnant ascites) with the navel prominent, then one may sus- pect with great probability the beginning of tubercular peri- tonitis. \"omiting, as well as violent pain on pressure over the ab- domen, may be absent, and usually is absent ; more often colic-like pains occur, but upon pressure there is onl\- a slight distress. As the morbid process develops, the diagnosis becomes easier. The abdomen is considerabl\' increased, partly because of meteor- ism, partly because of accumulation of fluid : the abdominal walls are tense, the cutaneous veins of the abdomen are distended : on palpating one may feel in dififerent parts of the abdomen, or in one place, either an induration without well-defined limits, or nodular tumors. At these points the abdomen is always painful upon pressure. If these hardenings depend upon concretions in the intestines, along with the thickened abdomen, then the cor- responding area always gives a tympanitic sound in any position of the patient. Similar symptoms never occur during stagnant ascites ; the fluid moves freely in the cavity, and in the sides a dull sound is. therefore, always obtained. Furthermore, in tubercular peritonitis the wasting of the patient is characteristic, more visible in the extremities, chest and neck, and less so on the face, so that the disease may be diagnosed par distance, in view of the contrast between the large abdomen and the general wasting. Of importance is the fever, with almost normal and even subnormal morning temperature and evening elevations up to 38.5 to 39 degrees C. ( 101.3 to 102.2 degrees F.). Sometimes the fever stops for a few da}"s, and then appears again. In diagnosing tubercular peritonitis one must not be confused by the absence of cough and general symptoms of tuberculosis in the patient. The main thing is, that in childhood the lungs are not the favorite place for the localization of the tubercle bacilli, and, therefore, it often happens that tubercular peritonitis, and still more often meningitis, appears as an isolated disease. It 230 SEMEIOLOC.Y OF THE ENLARGED ABDOMEN occurs more rarely that in tuberculosis or peritonitis some intes- tinal affections in the form of chronic catarrh or tubercular ulcers^ are absent, because the affection of the peritoneum with tubercu- losis usually follows a like condition in the bowels or mesenteric glands. Therefore, one almost always succeeds in finding in the history of a tubercular peritonitis that the patient formerly suf- fered with diarrhoea and abdominal pain. This fact may occa- sionally serve for the differential diagnosis from a simple chronic peritonitis. For comparison we will present the symptoms of chronic non- specific and specific tubercular peritonitis. /Etiology. Peritonitis tuhcrculosci. Occurs in sick children coming from a tubercular family or suffer- ing from any tubercular affection of the bones or internal organ>^. The history gives frequent diar- rhoea with abdominal pains. Peritonitis chronica serosa. In children free from tubercu- lous taint and tuberculosis of oth- er organs. In the history may be noted, shortly before the ascites, the influence of cold (laying on damp ground, wetting of the cloth- ing) or of acute infectious diseases (typhoid, measles). Symptoms. The general nutrition suffers se- verely ; after two or three months, with the beginning of the en arge- ment of the abdomen the patient becomes thin, the skin on the in- ner surface of the thighs hangs in folds, the face is very pale. Tlic form of the abdomen is oval. The abdominal :vall is tense, painful upon pressure over some points, and hardenings are fe't, most often between the epigas- trium and na\'el. Dull sound does not change its boundaries on change of position of the patient, because of perito- nitic adhesions in the abdomen. Fever is always well-developed. The general nutrition suffers lit- tle. After two or three month.> from the beginning of the disease there yet remains a good quantity" of the subcutaneous fat, so that the skin of the thighs is not loose. Tlie form of the abdomen is spherical. The abdominal zvall is- not tense ; no painfulness upon pressure ; no hardenings to be felt. The du'l sound always occupies- the dependent parts. Fever is only noted in the be- ginning ; thereafter the tempera- ture remains normal. The Course. Leads to progiessive wasting of Stationary for many months; the organism, ending usually with usually ends with recovery after death after six to twelve months, four to six months, but fatal ter- although recovery is possib e. mination is also possib'e. si-:.\[F-:i()[.()r.v hf the i;.\i..\rc,i-:i) .\i!nit.\ii;x 2:^1 [Kissel* presents the following- conclusions as regards dia.G^- nosis of tubercular peritonitis in children, his conclusions bein.i^ based on 54 cases of tubercular peritonitis in children under thir- teen years of ag'e : ( i) Tubercular peritonitis is more conmion in children than is usually suppa^ed. (2) It can be laid down as a general rule that all cases of so-called spontaneous ascites are really due to tubercular per- itonitis. (3) Not infrequently the exudate of the peritoneal cavity will disappear under general tonic treatment and the child will regain complete health. (4) In the majority of cases the onset of the disease is imperce])tible. The parents first notice that the child becomes pale and thin, without apparent cause. (5) The presence of coincident serous pleurisy is stroni^ coiifiniiafory c-i'idciicc in the diagnosis. (6) Thickening of the parietal peritoneum is the most valuable sign in the diagnosis. This sign can be readily elicited before adhesions have formed, by picking up a fold of the anterior abdominal wall and palpating the peritoneum between the thumb and fingers, provided the examiner is accustomed to the palpation of the normal peritoneum. (7) In exudative tubercular peritonitis, the fluid obtained by tapping is very rich in albumen and has a high specific gravity. (8) In many patients who present no subjective symptoms, the whole peritoneum is found covered with a thick layer of tubercular masses. (9) Chronic ascites, due to tubercular pericarditis, aflfords the greatest difficulties in difTerential diagnosis, but this condition is very rarely seen. (To) Only in severe cases does tuliercular peritonitis have a severe onset. — Earle.] TUMORS OF TIJE AllDOMEX. The diagnosis of a tumor of the abdomen nuist alwavs be *Archk: f. Kliiiischc Cliinirgic. Bd. 65, Hft. 2 (quoted from I'lie Prac- tical Med. Series of Year Hooks, Vo'. MT.. Pediatrics, ed. Iiy I. .\I)t, p. 62). 232 SEMEIOLOGV OF THE EXLARC.ED ABDOMEN preceded by determining in which organ it arises and then later its nature may be distinguished. Enlargement of the liver an.d spleen are at once recognized bv the place the tumor occupies and its form, while especially characteristic is the fissure on the lower margin of the liver or on the anterior margin of the spleen. About tumors in the liver we shall say but a few words, ?.s tlie\ manifest themselves by the same symptoms as in adults. The liver in children of the first years of life, and in normal condition, extends one or two inches from the ribs on the mam- millary line, and if it cannot be palpated it is only because its margin is not hard enough. But as soon as the liver becomes somewhat harder it immediately becomes easily palpa1)le and seems to be enlarged. In some cases the surface of the enlarged liver appears even and smooth, in others uneven, nodular. Sometimes it is consider- ably enlarged ; sometimes, however, it remains almost normal. In view of these symptoms, and especially ^etiological factors, the diagnosis of hepatic swelling is usually not difficult. Ac}itc moderate enlargement of the liver, with smooth sur- face and moderate hardness, occurs in children, first, from stasis of the bile during catarrhal jaundice; and, second, from parenchy- niaious sivelling or hyi)eraemia of the liver during acute infectious diseases, for instance, typhoid, relapsing fever, etc. In both these conditions the enlargement disappears soon after the causative disease has been cured. Here may also be included hyperjemic tumor of the liver caused by poisoning, for instance, by phosphorus. In chronic cases a large li:'er with a smooth surface and but little pain, or altogether painless upon pressnre, may depend upon the following causes : (1) Passive iivperaemia of the liver occurs in cardiac lesions, chronic pleurisy and, in general, in conditions which hinder the return of venous blood to the heart. The liver is some- what tender or even painful upon pressure, extends from under the ribs on the mammillary line a distance of two or three fingers' breadth in slight cases, and in severer ones descends below the navel, the hardness being very great. The size of the organ de- creases as soon as the cardiac actiiity increases. SE^^l^I()L()^,^ ov 'iiik enlauci-:!) ap.do.men 233 The diagnosis of staoiuml hy]jcra;niia of the liver cannot be ^iiade if there are no astiological conditions, as cardiac weakness or some other obstacle to the blood circulation. A stagnant liver may sometimes be observed during scarlatinal nephritis associated with a dilated heart and its consequent failure. (2) Interstitial hepatitis usually occurs 1)ecause of an old intermittent of long duration. The liver is very hard and pain- less upon pressure. A large and hard spleen is also always pres- ent. Obolensky's* observations show that such hypertrophic cir- rhosis is capable, under the influence of calomel treatment, of un- dergoing retrograde metamorphosis, and together with the de- crease of the size of the liver the general condition of the ]')atient also improves. (3) Fatty liver in children does not reach very great size and hardness, its surface being entirely smooth. It occurs in nurslings, in fat children under the influence of superfluous milk, as well as in exhausted patients, especially in tuberculosis, anaemia -and rachitis. From the amyloid liver which also occurs sometimes in tubercular and exhausted children, the fatty liver difl:'ers prom- inently b}' its soft consistency and smaller size ( never reaches the navel). In cloudy swelling the liver is also but slightly enlarged, soft and smooth, but the aetiology is here quite different, as granu- lar degeneration or cloudy swelling occurs during acute febrile ■diseases and develops acutely. (4) Amyloid li\'er (was discussed on page 22t,). (5) Leuk.T£MIC liver is in size and hardness quite equal to the preceding form, being also accompanied, like the former, "by considerable swelling of the spleen, difl^'ering, however, by be- ing associated with svmptoms of leuktcmia (examination of the blood), while the ^etiological factors peculiar to amyloid liver are absent. (6) EcHiNOCOccus OF the liner also causes considerable enlargement and hardness of the organ, but dififcrs from all other similar processes by its very slow course (several years), and ■still more by the general condition remaining very good even when the liver becomes immense, reaching, for instance, to the navel. *Mc(Iic. Obocr. 1. XXX.. page 254. 234 si-:mf.iolugy of the exlak(ji:i) auuumen Such an al)sence of correspondence between the fi^ood condition of the general nutrition on the one hand and the immense Hver on the other, in connection with the very slow course, absence of ascites and jaundice, makes the diai^nosis of echinococcus very probable, even when the symptoms do not point especially to- echinococcus. However, this rule admits of some exceptions. As^ for instance, during- the fall, 1897, a girl five years old entered our clinic on account of a large abdomen. The mother claimed that the enlargement of the abdomen was noticed three years be- fore. The patient had a gfxid general nutrition, l)ut was pale;, was up during the whole day and made no complaint. The ob- jective examination detected only niu' abnormalit} , namely, a large liver; its lower margin reached the navel in the median line^ on the anterior right axillary line it almost reached the iliac bone. The induration was not great, its surface was entirely smooth;, ascites was absent, as well as jaundice. In brief, everything^ seemed to indicate echinococcus, and the ])atient was therefore transferred to the surgical clinic. Professor llobroff performed an ex])]()rat()ry la])ari)i()my. ex])()sed the li\er, examined the same by palpation and puncture with a needle, but found nothing be- yond the considerable hy])ertroi)hy of the organ. The wound was closed and ihe girl left the hospital in the same condition as before. In January, 1F98, another girl enterel the clinic on account of ])neumonia. The examination of the jiatient detected the same kind of liver as in the preceding case, that is, ecjually big. smooth and not very solid, leading to a diagnosis not of echinococcus of the liver, but of simple hypertrophy. In view of such possibilities one must be very careful in his- judgment until special symptoms of echinococcus appear ; these symptoms occur when the echinococcus cyst is located on the upper surface of the liver, accessible to ]:)al]iation. Then one may easily feel on the free surface of the liver a smooth, half-spherical convexity, which fluctuates more or less noticeably. The fluid drawn through an exploratorv puncture from this convexity dif- fers from any transudate or exudate in not containing albumen, but being very rich with sodium chloride, lender the microscope it is sometimes possible to detect the booklets of echinococcus. If the cyst of the parasite is located near the portal fissure,. SEMEIOLUGV OF Til!'-. i:X I..\KC,l-:i ) A 111 )( ).M i:.\ j ^5 and by compressing- the vena porta or the gall bladder pro in acute as well as m the chronic iovm. Tumor of the spleen mav he recognized by percussion and palpation. Xormally the upper boundary of dullness of the spleen begins at the posterior axillary line (where the spleen extends from under the lung) from the ninth rib. The anterior boundary, corre- sponding to the anterior margin of the spleen, lies on the middle axillary line or passes somewhat beyond the same, but never reaches the line which connects the left nipple with the end of the eleventh rib; the lower end of dullness (the lower border of the spleen) lies on the posterior axillary line near the lower end of the ribs and somewhat backwards from the end of the eleventh rib, which usually lies on the middle axillari line.'' Therefore, the dull note of the spleen may be held as increased if the same begins, on the posterior axillary line, higher than the ninth rib and reaches the eleventh, and if its anterior mar- gin reaches or passes beyo)id the line connecting the end of the clcvoith rib icith the nipple. I hrancesco Sarcinelli describes a new method of percussing the spleen in children. He finds that the ordinary method defines only that portion of the spleen which is uncovered by lung, so he has the child suspended in a position midway between the dorsal" decubitus and the left lateral position, one arm of the attendant being placed under the child's left shoulder, the other under the pelvis. This permits the spleen to sink by the force of gravity toward the abdominal parietes. Percussion should be performed from below upward.** — Eaklk. J But the results of percussion are to be regarded as indicative only in case the same result is obtained for two or three days in succession, because in the contrary event one cannot be sure that the increase of splenic dullness does not depend upon accumula- tion of fseces in the neighboring mtestinal coils, and, vice versa, an enlarged spleen may give a normal area of splenic dullness cov- ered with intestines inflated with gases. Much more certain results are obtained by means of palpat- ing. The younger the child the easier the spleen may be palpated when it is enlarged. In children of the first months of life it may occasionally be palpated even in normal condition. Exclud- *Sahli: Die topograph. Pcrcus. im Kiiidcsaltcr, 1882, S. 155. **QrLOted irom.-i)iicricaii Yrar-Boole of Mcdicuic. 1904. p. 282. SE.Ml'.loi.dclV OF llll-: KXLARCED AUDI )Ml-:x 23/ ing these cases, it may be accepted as a rule that // the spleen is palpable it means that it is enlarged (unless it is displaced by a left-sided pleuritic exudation). To distini^uish an acute swelling of the spleen from a chronic one is not always easy at the first examination of the patient. In chronic enlargement the spleen is in general harder and larger. In acute swelling the spleen seldom extends from under the ribs more than two or three fingers' breadth. If the swelling of the spleen is observed in a patient who is not suffering from any febrile disease, then it is, of course, a chronic occurrence. How- ever, if the patient has high fever we may look upon the splenic tumor as of recent origin only if it developed under our observa- tion, or if it is known that a few days or weeks before the patient had no swelling of the spleen. A recent tumor of the spleen may be suspected then if the same, being inconsiderably enlarged, is painful upon palpation. It is important to determine the existence of an acute splenic tumor, because upon that the diagnosis of a given febrile disease may depend, as it is known that swelling of the spleen is not the same in each febrile disease, even in an infectious one. Acute spleen tumor most often occurs in all kinds of t}-phoid, in malaria and in pysemia. Of special importance is a recent swelling of the spleen in the diagnosis of typhoid when the latter must be differentiated in the first days of disease from dilTerent fevers due to cold or gastric troubles, as well as from son.ie cases of meningitis which may be very similar to typhoid in the course of the temperature and some other symptoms. The presence of the splenic tumor in different other febrile diseases cannot diminish the diagnostic importance of this symp- tom, because all diseases which may be associated with tumor of the spleeu have in the majority of cases almost nothing to do with typhoid, so that they may be easily distinguished from it aside from the splenic symptoms. It would be illogical, for in- stance, to diagnose typhoid on the ground of the spleen tumor, if the patient's skin was covered with a scarlatinal or smallpox eruption, or if there were definite symptoms of croupous pneu- monia. CiiRoxic SPLEEN TL'MOR in children under two years of age 238 SEMEIOLOGV OF THE ENLARGED ABDOMEX occurs most often in rachitis, but also in inherited syphilis. Tn both these diseases the spleen sometimes reaches a considerable size (extending three or four fingers' breadth beyond the ribs), and is very hard (hyperplasia of the connective tissue). Such children usually exhibit an advanced anaemia (waxy pallor) and not infrequently enlarged, hard liver ; in short, the aspect of the disease very much resembles leukaemia or amyloid spleen and liver. The absence of an increased number of white corpuscles dis- tinguishes these cases of chronic hypertrophy of the spleen from a leukaemia, and the termination with recovery, from pseudo- leukaemia. Regarding, however, an amyloid spleen the diagnosis is based mainly on the aetiology. In amyloid degeneration there is the presence of chronic suppuration somewhere in the body (caries, pulmonary tuberculosis, etc.). It is true that chronic tumor of the spleen, together with considerable anaemia, sometimes occurs in children apparently healthy in all other regards, that is, in such as have neither rachitis or s)philis. Such examples are described as infantile splenic anccmia — ancemia splenica infantum. In older children large and hard spleens are most often the sequelae of a protracted intermittent fever ; less frequent of an amyloid degeneration, leukaemia or pseudo-leukaemia. The diagnosis of the causes of the spleen tumor is based on the history and symptoms which are peculiar to this or that disease. The kiihiex may be palpated as a tumor in the abdomen when too movable — movable kidney, or if considerably enlarged. A movable kidney which simulates a tumor in the abdomen may be recognized, first, by its size and shape; second, by the possibility of being pushed to its former place. Also character- istic of the great mobility of the tumor: today it may be found near the navel, on the next day it cannot be found at all, etc. [In Abt's cases the kidney descended into the pelvis on the right side or even crossed over and lodged in the pelvis of the opposite side (during forced movements, running or jumping). These distant excursions caused severe pains, which the patient learned to relieve by grasping the organ and pushing it up in place. '^•' — Earle. ] *Joui: Am. Med. Ass'n., Sept. 28. 1901. SEMKlOlcCN OF llTl- ['.M ..\K( ,i:i) A HI )().\I KX 2^0 Tumors of tiii'. kidnkvs, due to the presence of nialignav.t iiezv-grozutlis in them, are, indeed, of great rarity, nevertheless sarcoma and carcinoma of the kidneys are exclusively diseases of childhood, and it is especially noteworthy that the maximum incidence of these diseases coincides with the age under five years. (According- to Epstein, of fifty-two cases of primary carcinoma -of the kidneys it was found in children from birth up to five vears •old in sixteen cases ; while in adults from forty to fifty in six cases; from fifty to sixty in ten cases.)* Of all internal organs the kidneys and the suprarenal glands l:)ecome aitected with carcinoma most frequently. This fact being very important in the diagnosis, because, if the physician has some reason to make a diagnosis of a malignant new-growth in the abdominal organs, then he may, a priori, suppose that the kidneys are primarily affected in the child, or, which is more correct, one "kidney bilateral carcinoma of the kidneys occurring very rarely. In the first stage of formation of cancer the patient usually does not complain of anything, but at times there appear haema- turia or albuminuria ; but both of these symptoms may, however, be absent. Later on a tumor appears in the lumbar region, pal- pated most readily in the lateral part of the abdomen between the iliac crest and the lower boundary of the ribs. The enlargement of the kidney occurs rapidly, being ac- •companied by considerable pain in the abdomen and the rapid development of cachexia. If the size of the tumor becomes such that it may be easily palpated through the anterior abdominal wall, then it generally presents the following peculiarities : It is immovable (during respiration as well as in passive move- ments) ; its upper boundary may be easily palpated and it will be thus observed that the tumor does not arise from the liver. It ■grows from behind forwards, displacing the bowels to the side, and as the colon, being attached by a friable cellular tissue to the ■quadratus lumborum, does not follow the general displacement of the bowels, it remains over the anterior surface of the tumor ; it may be recognized by the path of tympanitic sound which ex- tends in an oblique direction from the lower end of the tumor to its upper end. The surface of the tumor is nodular; the consist - ^Ziciiisscii's Haiuibncli. IX B. S. 112. 240 SEMEIOLOGY OF THE ENLARGED ABDOMEN enc}' disproportionate. The abdomen is much distended, but ascites may be absent if the new growth has not involved the peritoneum. In the event of subsequent affection of the mesen- teric and retroperitoneal glands, tumors of different size and sol- idity may also be palpated in different locations in the abdomen ; but the chief tumor, which corresponds to the kidney, will be felt only between the crest of the ilium and the false ribs, thence it may be traced backwards to the lumbar region and forwards ta the navel. For the sake of better determining the boundaries of such a tuuK^r the examination should always be conducted with both hands ; one exercising pressure over the tumor on the side of the abdomen, the other placed over the lumbar region. An immense abdomen, painful in some parts thereof, and the presence of tumors of varying size and firmness, gives the im- pression of a disease due either to renal cancer or to that of chronic peritonitis. The diagnosis is based on the more rapid development of cachexia during carcinoma (fatal termination occurs in three or four months, in tubercular peritonitis in about six to twelve months) ; on the form, size and situation of the tumors (in per- itonitis the tumors are most often palpated between the navel and epigastrium ; on percussion they give a tympanitic note, because the limited thickness of the inflammatory infiltrations cannot deaden the tympanitic sound of the bowels) ; on the absence of ascites during carcinoma, and tuberculosis of other organs. On the contrary, normal urine, free from albumen and bloody cannot serve as evidence against carcinoma of the kidney, because albuminuria and h?ematuria may be observed only during such time as the affected kidney continues its physiological function. In children still another variety of tumor of the kidney oc- curs, which sometimes reaches immense dimensions, namely^ HYDRONEPHROSIS. In the abdomen a spherical, fluctuating,, smooth growth, connected with the kidney, may be palpated. A transparent fluid containing urea and uric acid may be drawn therefrom by an exploratory puncture. A similar fluctuating^ tumor may also be met with in echinococcus of the kidney and in ovarian cyst, but both are extremely rare. However, cases of successfully operated ovarian cysts have been described in girls- nine or ten vears old. SEMEIOLOGV Ol" I 1 1 K i:.\ I.ARC.i:! ) A 111 )( )M 1-:N J4 I If a thictuatin^- tunior arising from the kiclnc) depends upon echinococcus, then in the aspirated fluid there can he demonstrated neither constituents of urine, nor alhtnnen, hut hooklets of echin- ococcus will be found under the microsco])e. In large ovarian cysts the tumor is also spherical, smojth and fluctuating, but it arises in the false pelvis occupying the umbilical area and the hypogastrium ; the lateral parts of the back remaining free. On percussion a clear sound may be obtained, depending upon whether the patient lies on the back or on the side. The absence of fluctuation does not exclude ovarian cysts, because this symptom may be incapable of detection by diverse circumstances, as ninltilixnilar c}-sts, thick walls and dense contents. \ oluminous tumors of the abdomen may be produced by cascoHS degeneration of the mesenterie glands, or by sarcoma of the retro-peritoneal glaiids. In the former case a nodular growth is palpated in the umbilical region, unless this be prevented by a considerable meteorism, which, unfortunately, almost always oc- curs in such patients, thus making the enlarged mesenteric glands inaccessible. Sarcomatous degenerated retro-peritoneal glands which lie forwards and on the sides of the lumlxir portion of the vertebral column are more often accessible to palpation. An irregular tumor, sometimes of great dimensions, usually ma}- be felt in the lower portion of the abdomen, or in its lateral portions between the iliac crest and the false ribs. In the latter case the tumor may be mistaken for sarcoma of the kidney. The difl:'erentiation is based partly on the analysis of the urine (in affection of the retro-peritoneal glands the urine is normal, in carcinoma of the kidneys it not infrequently contains albumen and blood) ; and partly on the position of the tumor regarding the vertebral column ( the lym])hatic glands are located in the middle line, the kidneys laterally). We have already mentioned the possibility of palpating tumors due to formation of inflammatory infiltrations during chronic peritonitis and perityphlitis, or sausage-like tumors dur- ing intestinal intussusception. It remains here only to mention tumors caused b}' the accmuulation of f;cces in the large bowels, and the suprapubic, elastic tumor due to the distension of the blad- der with urine. 242 SEMEIOLOGV OF THE ENLARGED ABDOMEN Faecal tumors are felt either in the middle, or in the lateral, portions of the abdomen ; they are movable and painless. Their most characteristic feature is disappearance after a laxative. The young physician must bear in mind that in the epigastric region between the navel and the pit of the stomach, somewhat aside from the median line, a quite solid tumor may be felt caused by the contraction of the upper belly of the rectus abdominis. This false tumor differs from a real one, first, by its being in- constant, and, second, by its outline corresponding to the boun- daries of the muscle. In conclusion we would remark that tumor in the iliac region may depend upon accumulation of pus at this point, for instance in psoitis or in abscesses following vertebral caries. INTESTINAL WORMS. In the lx)\vels of children several kinds of round and flat Avorms are to be found. Of the class of round worms of clinical interest may be named oxyiiris zrniiicularis and ascaris lunibri- ■coides, of tlie tapeworms, tcciiia soliiiiii, tcoiia mediocaiiellata, bothrioccplialns latiis. tcciiia ciicuiiicriiia, s. elliptica and tcciiia nana. [Intestinal worms are observed less frequentl}- in America than in Europe. Holt in 10,000 patients treated for medical dis- eases, in dispensary service, found positive evidence of worms in Fig. 18 — Oxyuris vermicularis (natural size). but 79 cases. Of these nine had tapeworms, forty roundw^orms, twenty-seven threadworms, and three both round and thread- Avorms.* — Earle. J Oxyuris vermicularis is the smallest of all intestinal worms (about half a centimeter in length.) (Fig. 18.) This worm lives particularly in the large bowels and sometimes, especially at even- ing, is expelled from the rectum, causing severe itching at the anus. If the patient be examined at this time then the cause of the itching will be readily detected by the presence of several worms around the anus and its folds. They may also be found in the dejections as very small, movable, white worms. At any rate the night, or evening, itching is of itself so characteristic of this worm that a correct diagnosis may be made even without examin- *Holt: The Diseases of Infancy and Childhood. 1902, p. 441. 244 INTESTINAL WORMS ing the faeces. If a physician ijTnores the indication of oxvuris vermicularis, ascribing the periodically occnrring evening itching to a masked fever, he would act very rashlv. [Rammsted, Shiller think that one should examine the stools for the presence of this worm in each case of appendicitis, as they have seen cases of the latter due to oxyuris vermicularis.* Erd- Fig. 19 — Eggs of oxyuris \erniicularis. man also reported two cases of appendicitis in which the appendix was found to contain numerous i:)in- worms (oxyuris vermicular- is).-^^* — Earle.] The eggs of the oxyuris vermicularis are of irregular, oval form wth contents of equal granularity (Fig. 19}. AscARis ltjMBRIcoides is in shape quite similar to a dew- worm, but differs from the latter by its greater size (about four and a half inches in length) and whitish color with a rose tint. The eggs are recognized by the nodular shell (h^ig. 20). To the group of round worms also belongs the trichocephalus dispar (Fig. 21). which usually lives in the caecum and is charac- terized by the hair-like anterior part, the posterior being much thicker. Its eggs are oval in shape and decidedly differ from the eggs of all other kinds of intestinal worms by having marked thickening at both poles. (Fig. 22.) *Deuf. Med. Wochcnschr., December 18. 1902. **Archiz'cs of Pediatrics. June, 1903. INTESllXAI. WORMS 245 All tapewotms are similar to each other by consistinj:^ of segments connected in a chain. Ihe nearer to the head the smaller the seg'ments become, so that in tlie lliiimest portion of the tape- worm, in the so-called neck, which looks like a thread, thev are not to be distinguished at all by the naked e\e. The smallest variety of tapeworm is tccnla nana. This worm is seldom seen in Europe ( it occurs especially in Egypt and south- Fig. 20 — Ascaris lumbricoides. and the egg of this worm. ern Ital}). Up to the year 1901 oidy one case of this worm was described in Russia, by Prof. Aphanassief¥, of St. Petersburg. This was in a young soldier. Examination of f?eces in our clinic has determined, however, that tsenia nana occurs in Moscow not ver\- rarely. During the last spring we observed three cases of this worm, in a boy eight years old, and his six-year-old sister, and then in a girl one year and three months of age, who died from laryngo-spasm. Despite the fact that this worm inhabits the bowels usually in great numbers (a cou]ile of hundred), yet to find it in the evac- uations is a ver\- diflictilt matter, because it is verv thin and 246 INTESTINAL WORMS small. An examination may be made in the following way : Take on the tip of a flat knife the fluid contents of the intestines and place them in a plate with water. The heavier dejections rapidly sink to the bottom after shaking, and the worms being lighter remain for some time suspended in the water, so that it is easy to notice and remove them. The length of the worm is from one to two centimeters, the Fig. 21 — Trichocephalus dispar (afler Leuckart ) (a) male, (b) female — natural size and magnified. breadth 0.5 to i m.m. The head is armed, as in taenia, by four suckers, a circle of hooks and a beak. The segments are as in. Fig. 22. — Egg of Trichocephakis dispar. bothriocephalus latus of greater width than length, but are char- acterized by their small size, so that about one hundred and fifty segments may be counted in the distance of one centimeter. The sexual orifices (again as in the bothriocephalus latus) are not located on the margin of the joint, but in its center and all on the same side. The eggs are oval in shape, their size being equal to that of the eggs of a taenia, from which they easily differ by the INTESTINAL WORMS 247 Fig. 24 — T;enia nana (after Leuckart). (b) head, (c) hnok. (d) segment, (e) egg. Fig. 23 — Taenia nana (Leuckar:). 248 INTESTINAL WORMS shell ; the latter is thick and is without radiating- stripes. In the egg" the embryo may be seen, armed with four to six hooks. (Figs 23 and 24.) Taenia cucumerina is only seven to fourteen inches long, differing decidedly bv this feature alone from other fc^rms of taenia l"iy. 25 — r:enia cucnmrnna s. cilipiioa (, Lcuckart). whose length may reach several feet. The other important dif- ference is the red color of the mature segments (which are white in all other tceniae), each of themlDeing provided with two sexual orifices, one on each side. ]>v the structure of the head this Fig. 26 — Eggs and .segments of t. solium, nunliocan. and iKJtrioccphalus latus. In the center are two segments of natural size, and in the upper row they are enlarged. worm is most similar to tccnia solium, because it has four stickers and a beak surrounded by a circle of hooks. Infection of children occurs through dogs by means of a peculiar parasite known under the name of trichodectes canis. This intermediary devours the eggs of the t;enia which occasionally adhere to the hairs of the INTICS'l'lNAI. WdK.MS 249 (dogs, becomes contaminated and when it reaches the mouth of the child affects the latter with the t;enia. (Fig-. 25.) BoTHKioCKi'iiALrs 1. ATI'S casilv dillers from the two other varieties of tsnia by the structure of the head and shape of the joints. In t?enia solium and t. mediocanellata the square-shaped Fig. 2"] — Tsenia saginata or niecliocannelata : (a) natural size of the worm of its different portions; (b) head; (c) segments. ihead is provided with four round suckers and in the former with a beak, which is surrounded by hooks ; in bothriocephalus latus the head is oval with two oblong- dimples. The mature segments of the first two kinds are square-shaped in form, the length of •each segment is nearly one and a half times that of the l)readth, 250 INTESTINAL WORMS but in the bothriocephalus latus the opposite obtains, the trans- verse diameter of the segment is greater than its length. The sexual orifices open in bothriocephalus latus in the center of the flat surface of the joint, and are all on the same side, while in the former two in the middle of the margin. (Fig. 26.) Taenia solium and t. medigcanellata (P'ig. 27) dififer from each other only as regards the head, their joints being very similar, the only difference is perhaps in t. solium the matrix, which is in the middle part of the joint, give to both sides fewer branches (seven to tw-elve) than in t. niediocanellata (twenty- five to thirty.) (Figs 27 and 28.) In order to see these branches one must slightly compress- the segments between two glass slides and hold to the light. For t. mediocanellata it is somewhat characteristic that its segments not infrequently appear in the stools, while in t. solium: Fig. 28 — Taenia solium (after Lcuckart ) : (a) liead, (b) segments, (c> cysticereus a'lulosa (turned in — and out). they are only observed in rare cases, although it happens some- times. Finally the history may be of service in the diagnosis^ as it is known that with taenia solium man becomes infected, through raw pork, but t. mediocanellata through beef. It frequently happens that the presence of ascarides or of tai)eworms in the bowels is not manifested by any symptoms, be- ing recognized only after elimination of the whole worm (ascaris- lumbricoides), or of single segments and sections. In other cases,, although diverse symptoms on the part of the nervous system appear (dizziness, tendency to fainting, grinding of the teeth,, choreic or eclamptic convulsions, dilatation of pupils, itching of the nose), or on the part of the organs of digestion (nausea and vomiting on the empty stomach, attacks of colic, irregularity of the stools, changeable appetite), or on the part of the general INTESTIXAL \VOU^[S 25 1 nutrition (pallor, nialii^naiit aiucuiia — aiucinia pcniiciosa, general debilit}-, irregular fever), yet all these symptoms are to such de- gree non-characteristc and inconstant that they can only give rise to suspicion of the existence of worms. The more exact diagnosis is based either on microscopical examination of the faeces for determining the presence of ova of this or that worm, or on the results of general therapy. Regarding the eggs these always may be found in cases of oxyuris vermicularis, ascarides, bothriocephalus latus and taenia nana, but not in taeniae solium and mediocanellata, which do not deposit their own ova in the human alimentary tract, their dis- covery depending upon the occasional destruction of the mature segment in the intestines ; but these two specimens of worms make themselves evident by the elimination of the segments. If ascarides are suspected in a patient, then he should be given a few powders of santonin and in event of success the treatment is continued until the complete expulsion of the worms. If, how- ever, the patient suffers from taenia solium, then after a few days the stool may show segments even without administering specific remedies, as it is very seldom that the segments fail to appear during a prolonged period. The diagnosis of t. solium is, in the majority of cases, effected by the circumstance that the patient himself brings to the physi- cian as corpus delicti separate segments of the worm or whole chains. DISEASES OF THE ORGANS OF RESPIRA- TION. DISEASES OF THE UPPER RESPIRATORY PASSAGES. Snuffles — rhinitis, s. coryca. This morbid condition is shown b}- redness and swelHng of the mucous membrane, and, in acute cases, in the beginning-, l)y increased secretion of transparent fluid mucus ; later on, and in chronic cases, by a more dense muco-purulcnt secretion. If the latter be passive, especially in the neighboring cavities of the cribriform bones, and decomposes, then an odor from the nose — chronic fa^tid coryza — is present. The diagnosis of coryza does not exhibit any difficulties. A question may arise only regarding its causes, which are different, depending on whether we have the acute or chronic form. Acute rliinitis seldom develops in healthy children as an in- dependent malad}' from the intluence of locally acting causes or exposure to cold. If the ])arents complain that their childrea take cold easily, and then suft'er from rhinitis, it is almost certain that we have to do with exacerbations of a chronic rhinitis or with adenoids. Especiall\ inclined to acute rhinitis are those children who are kept within doors the entire winter, or who are too much muffled up. In some cases acute rhinitis is the result of saturation of the organism w^ith iodine. The nasal secretion is characterized in such a case by a peculiar foetor. If acute rhinitis develops in a new-born child on the second or third day of his life, and from the very first a great quantity of purulent secretion appears, then one should regard such a coryza as due to the gonococcus, that is, that it was produced by infection of the nasal mucous membrane from the vaginal mucus during confinement. This is stlil more probable if the child suffers, at the same time, with a blenorrhagic conjunctivitis. The final establishment of the diag- nosis depends upon the result of bacterioscopic examination. It is not difficult to differentiate a gonococcus coryza from a syph- |)Isi-;asi-:s uv ui.snuAiom' svstkm 253 ilitic one, because the latter, besides its clironicity, is portrayed by tlic (h'xness of the mucous nK'nil)raue of the nose. Acute coryza frequently expresses the general ill-health of the organism, namely la grippe or measles (seldom whooping- cough), being in such instances accompanied by catarrh of other organs, eyes, bronchi, etc. Snuffles appears among the first symp- toms of these diseases, thus permitting one, in the case of any epidemic, to make a diagnosis even before the appearance of more definite symptoms (see the section on T.a grippe). The important significance of coryza, in the diagnosis of a beginning febrile dis- ease, is further apparent inasmuch as this symptom serves as a cri- terion in excluding certain diseases which may be confoimdcd with la grippe during the first days of the affection, but for which coryza is not symptomatic at all, as, for instance, typhoid fever, relapsing fever, smallpox, scarlet fever. In other cases the mucous membrane of the nose is the place of primary localization of diphtheria. Primary diphtheria of the nose occurs in two forms: ma- lignant and benign. The main symptom of the disease, in both forms, which distinguishes it from any other kind of rhinitis, consists in the jM^esence on the mucosa of the nose of fibrinous membranes which are readily observed as soon as they involve the nostrils ; however, if they occupy the posterior parts, then they may be made out by syringing the nose or cleansing the same with a tampon. The essential difference between these forms consists in the fact that during malignant diphtheria of the nose, one can say at once that the patient is severelv sick ; the face expresses weakness, the temperature is high (39 degrees C. — 102.2 degrees F. and more), the submaxillary glands are swollen. A few days later diphtheria usually extends over the fauces. This is a disease of small children, especially under one year of age. In the benign form of diplitheria of the nose fever is either entirely absent or is present only during the first days, the disease continuing either with a normal or slightly elevated temperatur-e (about 37.5 degrees C. — 99.5 degrees F.), the general condition suffering so little that the patient gives the impression as if suf- fering with a common catarrhal rhinitis. In brief, the benign form of diphtheria of the nose is a purely local disease, and in distinction from the maliijnant form is described under the name 254 DISEASES OF RESPIRATORY SYSTEM of fibrinous rhinitis — rhinitis Hbrinosa, s. memhranacca. It is a remarkable fact that, despite the local and general symptoms being mild, fibrinous rhinitis is a very obstinate disease, the mem- branes persisting about three weeks or more. That these benign forms belong only to diphtheria one can see, first, from the bacterioscopic examination, detecting Loffler's bacillus in the great majority of cases in the nasal secretion, which is plainly pathogenic for animals ; and, second, that, notwith- standing the slightness of the contagiousness of such rhinites, in- fection occurs to surrounding individuals in whom diphtheria of the fauces develops. Rhinitis fibrinosa, like any membranous affection of the fauces, is not always of diphtheritic origin, that is, is not always produced by Loftler's bacillus. Upon bacterioscopic examination only the staphylococcus or some other microbe may be detected. Such pseudo-diphtheria of th.e nose is held as non-infectious. Staphylococcus fibrinous rhinitis occurs especially often after actual cauterization of the nasal mucosa ; upon the place of cauter- ization the membranes disappear and reappear, but only the staphylococcus may be detected. CiiROXic RHINITIS differs from the acute by the fever being absent and, especially, by its duration. In older children it is usually accompanied by adenoid granulations in the naso-pharyn- geal cavity and serves as a frequent symptom of scrofula ; while in children one to three years of age it usually accompanies ec- zema on the face; but in new-born children the rhinitis is a very important sign of inherited syphilis. This symptom is held as an important one, first, because of its early appearance (earlier than many other symptoms of syphilis), and, second, because it is rarely absent in inherited syphilis. From an acute cor)za, which also may occur in the new- born, coryza syphilitica differs by its slow course, dry catarrh and absence of catarrh of the neighboring mucous membranes (eyes, bronchi). During an ordinary rhinitis a discharge appears, the catarrh being prone to spread over the neighboring organs, because in the majority of cases the same is a form of la grippe. It is further suspicious if epistaxis or a sanious secretion shows once in a while during coryza in a child several days of age. Both these symptoms also happen during diphtheria of the i)isi-:.\si':s c)i' Ki-:si'iK.\ lom- snsiicm 255 nose, but then the corvza is accompanied by more or less fever (which is absent in coryza syphihtica). This (|nestion may also arise if rhinitis appears in an abortive child despite correct hy- gienic measures. All doubt disappears when other s}mptoms of syphilis develop after a short time (see section on Syphilis). If chronic rhinitis is caused by adenoid veg^etations in the naso-pharyngeal cavity, then it is not difficult to recognize their presence. The external aspect of such patients is quite charac- teristic, at least in typical cases. We then have to deal usually with children live to twelve years of age, although adenoids may be met with in very small children, being frequently in- herited. The mother consults the physician because her child snores while sleeping and often awakens, because the child easily catches cold and repeatedly takes ill with cough and snutfles. At a glance there are to be noticed a tired look, loiig face (flat- tened cheeks), narrowed, immobile nostrils, thin nose and a half- opened mouth. In the presence of such symptoms one may sup- pose with great probability the existence of adenoid vegetations in the naso-pharyngeal cavity, but in order to convince himself the physician must examine the fauces with the finger. Normally, the mucous membrane is smooth and as it is attached immedi- ately to the base of the skull and to the vertebral column ; the examining finger directly feels the underlying bone. In case, however, of adenoids there occurs a larger or smaller lobular tumor, of quite soft consistency. As adenoid vegetations produce impermeability of the nose, they lead to different other consequences ; as, for instance, it is obvious that the sense of smell must suffer, and simultaneously, of course, the sense of taste. The obstructed breathing, espe- cially at night, often causes, in small children, narrowing of the chest with prominence of the sternum, as in the rachitic chest. Disturbance O'f respiration also causes disorders of blood-forma- tion, that is, the general nutrition suffers ; the child is pale, weak, takes little food, complains of frequent headache, is inattentive in school and his ability to think is poor. Because of obstruction of the Eustachian tube (by the proliferating adenoids or the accumu- lation of catarrhal mucus) children, suffering from adenoid vege- tations, complain very often of poor Hearing. The latter increases still more if the catarrh spreads from the pharynx to the middle 256 DISEASES OF RESIM RATORV SYSTEM ear, prcxlucing- perforation of the membrana tympani and chronic otorrhoea. Such otites in small children may result in deaf-mut- ism, unless the cause of the disease (adenoids) be removed at the proper time. [Adenoid vegetations may also be the cause of convulsions and spasm of the glottis. Maaloe had the opportunity to treat ten children who suffered with spasm of the glottis or convul- sions ; five of them had only convulsions, in the other five the convulsions were combined with glottis spasm. As no cause of the convulsions could be found, Maaloe looked for adenoid vege- tations, which were present in all ten children. The removal of the adenoids led to the complete recovery of all. One of them had a relapse, but a repeated careful curettage caused full recovery. One of the operated children was only eight months old, the others under one year of age. The action of the adenoids was apparently a reflex one.* Furthermore, cases are reported in literature which show that adenoids are also the cause of incoiitiiiciicc of the urine. One such case was reported by Kantorovitch. A twelve-year old boy zvho had suffered since si.v years of age from involuntary mic- turition. The family history of the patient was good ; aside from measles, no other disease could be found in his personal history. All kinds of treatment, dietetic measures, etc., remained without any result. Upon examination of the posterior nasal cavity, Kan- torovitch found adenoid vegetations quite well developed. In four currcttements he completed the removal of all adenoids. The first operations resulted in a lessening of the frequency of the in- voluntary micturitions and for three months after the last opera- tion there was no incontinence.** — Earle.] If chronic rhinitis be persistent in one side of the nose, then we may suspect either a foreign l)od)- in the nose (examination with the sound), or a polypus. [Chronic foetid rhinitis. atrof'Jiic rJiinitis, "ozccna" or "true ozccim" is described by different authors as a chronic affection of the nose distinguished by : (i) Atrophy of the Schneiderian mucous membrane of the nose. ^Abstract in La Scmainc Mcdicalc. 1903, p. 84. ^*Abstract in La Sciiiaiiic Mcdicalc, 1903, p. 83. DISEASES OF RESl'lUATOUV SYSTEM 25/ (2) Atrophy of the turbinates. (3) By wide nasal fossae. (4) A Feet id odor, and (5) Tlie formation of scabs. It (icciu-s (|uitc often in childhood (Riviere met this affection in early childhood in lo per cent in all cases of ozsenous patients he treated) and in females oftener than in males (Symes). The variet}- of names given to this chronic foetid aft'ection of the nose is explained by Moure* (Bordeaux, France) by the variety of clinical forms it possesses, as well as by the period at which the examination is made, and the ag'e of the patient. .Etiologically this disease is not well established. The com- monest views regarding- this subject are as follows : (i) Symes believes that atrophic rhinitis may be regarded as a chronic form of nasal diphtheria: he fo'und in tw^enty cases out of fift}-seven of ozasna a bacillus resembling in its morpholog- ical and cultural characteristics the Klebs-Loffler variety ; and the correctness of such a view is borne out, in his opinion, bv the further fact that ozaena sometimes yields to the treatment with diphtheritic antitoxine. (2) According to Griinwald ozrena is not a primary disease, but a secondary process due to inflammation of the nasal sinuses, viz, sinusitis. This theory has been abandoned by the majority of specialists as careful examination of the nasal sinuses does not show in most cases any connection between affections of the sinuses and ozaena. (3) Sticker thinks ozaena depends on some parasyphilitic affection called by him xerosc, which would be nothing but an atrophy of the whole organism producing enlargement of the nasal cavities, of the pharynx, bronchi and lungs. (4) Lately a new theory has been advanced by Freudenthal (Xew York) in a paper presented at the last (Madrid) meeting of the International Medical Congress. This is the so-called "dry-air theory." According to this author, ozasna is atrophy of the nasal interior due to atmospheric influences, especiallv to the too great dryness of the air — xerasia. The existing atrophic con- *Moure: Paper read at the meeting of the ^^ladrid Inleniational Medi- cal Congress, 190.3 (quoted from Frogressii'c Mciiic. 1904. \'ol. VI., N. i, p. 274). 258 DISEASES OF RRSIMRATORV SYSTEM dition, in connection with the atmospheric influences, favors the growth and niultiphcat'on of microbes similar to Friedlander's pneumobacillus. whicli. on the suitable soil, produce ozsena.* — Earle. ] Epistaxis (nose-bleed) is by itself easily recognized, but the cause is not always readily detected. If the bleeding occurs from the ])osterior parts of the nose, while the patient is keeping a dorsal posture, then the blood may flow backwards down the posterior wall of the pharynx into the stomach and then be ex- pelled by vomiting — a false l)loody vomiting. The source of epistaxis becomes evident either by the presence of blood-clots in the nose, or by remains of blood on the posterior pharyngeal wall, or, at least, by the further observation of the patient, while he is in bed with the head only slightly elevated. /Etiologically nose-bleeding may be separated into two di- visions : to the first belongs occasional epistaxes resulting from the influence of certain transitory causes and therefore not repeated. There may be included here, for instance, traumatic nose-bleed, as well as epistaxis during acute infectious diseases, especially in typhoid, measles, relapsing fever and morbus maculosus Werlhofii. To the second division may be referred cases of repeated epistaxes, frequently occurring without any cause. Thus first of all the so-called habitual epistaxes, for which very often no espe- cial causes are to be detected, so that one must admit the "indi- vidual predisposition" to rupture of the capillaries of the nasal mucous membrane under the influence, for instance, of heredity or hemophilia. It is noteworthy that the age is here imixDrtant; in children under four or five years these habitual haemorrhages are very infrequent, but from seven up to twelve vears they occur often. According to Rendu'''* habitual nose-bleed not infrequently occurs in children seeniingly entirely well, but the history shows that they have suffered for a long time with indistinctly devel- oped rheumatoid pains, their urine is turbid, with a sediment of uric acid salts. Such children often sufifer with migraine. The nasal congestion ending wMth h?emorrhage is in such cases entirely analogous to acute rheumatic congestion of the joints m older patients, and an antiarthritic diet should be then administered *Quoted from Progrcssn'c Medicine, Vol. VI., No. i, 1904. p. 273. **Rez'ue mois. des maladies de I'eiif. 1884. DISEASES OF KKSIMkATdRN' SNSIKM 259 to the cliikl (alkaline water, less meat, and wine shcnild be entirely forbidden ) . Predisposition to b?emorrhage being present, the exciting causes may be as follows : liigh temperature of the room or of the air (many children suffer with nose-bleed only during the hot summer days) ; forced mental work in a sitting posture, the body being bent, and especially when the collar is tight ; tire- some physical exercises, for instance, during play ; and finally, according to some authors, masturbation and the period of ])ubertv in girls. In other cases habitual nose-bleed is a symptom of chronic cardiac lesion or of diseases of the blood, as true or false leukc'c- mia and chlorosis. Epistaxes occurring daily, sometimes several times during the day, after paroxysms of violent cough, points with great probability to whooping-cough. Of nose diseases, polypi and ulcerous conditions may cause repeated epistaxis. The common location of the hsemorrhage is the cartilage of the nasal septum, w'here very often small ulcers occur, leading to repeated bleeding during many months in suc- cession ; and to various dilated, or small vessels, wdiich break and thus cause a persistent nose-bleed. It is very important for thera- peutic purposes to be accjuainted with these two causes of "re- peated" hsemorrhage, because a hsemorrhage which had not yield- ed to any treatment for months wnll frequently entirely disappear after a single cauterization of the nasal septum with the Pac- ciuelin. It is noteworth)- that acute rhinitis, although always ac- companied by considerable hypera^mia of the mucous membrane, almost never leads to nose-bleed ; more often bleedings are ob- served during chronic rhinitis because of adenoid vegetations. Rhinitis with a sanious discharge in new-born children commonly occurs during hereditary syphilis. In two cases of mine, in a girl six years of age and another one eleven years, nose-bleed was repeated for several days in succession, and each time at between twelve and two o'clock p. m. during sleep. Both stopped after one dose of quinine, therefore 1 regard them cases of febris intermittens larvata. 200 DISEASES OF RESPIRATORY SYSTEM DISEASES OF THE LARYNX AND TRACHEA CHARAC- TERIZED BY STENOTIC RESPIRATION. L'nder the name of stenotic breathing we understand a symp- tom-complex depending upon narrowing of the hu-}nx and trachea. It is easy to recognize stenotic breathing. I'irst, it is always accompanied by a peculiar noise, which the air produces while passing through the constricted part, known as inspiratory stenotic noise. Second, because of hindered access of air to the lungs, the latter cannot coincidently follow the expansion of the chest dur- ing inspiration, therefore a vacuum in the chest is produced. This causes the ap]:)carances of forced inspiration, that is, depression of the \ielding portions of the chest in the form of deepening of the supra-clavicular and jugular fossa; during the act of inspira- tion, as well as of the intercostal spaces and especially of the epi- gastrium and, in general, of the lower periphery of the chest along the points of attachment of the diaphragm (as the latter also becomes concerned, it cannot therefore sink during inspira- tion, and so it depresses by its contractions the lower periphery of the chest). Third, the obstructed air supply of the lungs causes dyspnoea, because of which the patient reinforces all his accessory inspira- tory muscles. This manifests itself by dilatation of the nostrils- and marked contraction of the neck muscles. Thus, the chief symptoms of stenotic breathing arc stenotic inspiratory noise, drawing in of the yielding portions of the chest and the actioii of the accessory muscles. If the dyspnoea does not depend upon stenosis of the trachea or larynx, but upon diseases of the lungs or small bronchi, then there may also occur depression of the yielding portions of the chest together with the forced contraction of the accessory mus- cles, but there is absent the characteristic stenotic sound. In treating stenotic respiration we must decide the questions regarding its degree, the place of narrowing, and its cause. It is important to know the degree of stenosis, because upon this depends not only the diagnosis, but also the therapeutic measures, and likewise the proper decision of the question re- garding tracheotomy. Any division of stenosis into degrees will be, of course, arbitrarv, because between the slightest and the DISEASES OF RESlMKAlom' SVSTEAl 261 severest cases there exist all possible gradations ; yet approxi- mately three degrees of stenosis may be distinguished: (i) the slight, (2) moderate, and (3) the grave. In slight cases stenotic noise and other symptoms appear only during inspiratory movements, for instance, during the cry, while in quiet respiration no signs of hindered access of the air to the lungs are to be noticed. Cases of motlerate severity, which are not immediately dan- gerous and which do not call for an urgent tracheotomy, are characterized by the fact that, although the stenotic noise, the drawing in of the yielding portions of the chest and the action ■of the neck muscles are seen during quiet respiration, the patient can compensate the consequences of the stenosis, so that he does not undergo an oxygen starvation and does not exhibit symptoms of retarded blood circulation in the form, for instance, of cyanosis. Finally, grave cases are indicated by the patient indicating lack of oxygen ; he suffocates, being, therefore, very restless ; his face expresses painful anxiety ; he throws himself about in the "bed, grasps at his neck, etc. Because of the aspiration of blood to the lungs the arteries become empty (pale face and cold limbs), but the veins become overfilled (cyanosis of the lips and fingers). Such a condition cannot last long, and if the obstacle be not im- mediately removed, then the patient will either die during the attack of suffocation, for instance, because of occasional obstruc- tion of the constricted point with a lump of mucus, or he falls into a condition of somnolence and collapse, the breathing becom- ing shallow and not so noisy, the pupils dilated, the cyanosis increases ; finally general ansesthesia sets in and the patient suc- cumbs to carbon dioxide poisoning. The determination of the place of stoiosis brings into ques- tion the throat, the larynx and the trachea. If a laryngoscopic examination of the patient is possible, then the difficulty becomes cleared away very easily, and the physician defines at once not only the place of stenosis, but also its cause. Unfortunately laryngoscopy is, in children, not often applicable and one must make the diagnosis without it. Obstacles on the part of the fauces, either in the form of considerably swollen tonsils or of a retro-pharyngeal abscess, may be comparatively easily determined b\- the eye and the finger, 262 DISEASES OF RESI'IRATORV SYSTEM but it is not always easy to distinguish stenosis laryngis from that of the trachea. Besides the course of the disease, we are also giiided by the peculiarity of voice and cough, as well as by the excursions of the larynx. If the patient's voice appears harsh, and the cough ringing (short spell with a coarse coughing sound, "the patient coughs as if in a barrel," as the mother relates), then the point of stenosis is in the lar\nx. This rule, however, admits of exceptions ; on one part, the voice ma}' reniain clear during afifection of the larynx, for instance, in bilateral paralysis of the muscles which dilate the glottis; on the other hand, it may also be changed during tracheal stenosis, for instance, owing to com- plications with laryngeal catarrh or simply because of the small volume of air dmnng the obstructed expiration. If the stricture reaches a certain degree, then, in the case of laryngeal affection, there is noticed a lowering of the larynx toward the jugular fossa (in conseciuence of aspiration), which appearance is absent it the stenosis occupies the lower part of the trachea. In the diagnosis of the ])laceof stenosis one may also i>e guided by the fact that almost all cases of acute development of stenosis of the resj)iratory passages, except when due to foreign bodies, are to be referred either to the larynx or to the fauces, but not to the trachea ; whereas in chronic cases, either to the trachea, to the larynx or to the fauces. ^■Efiolooically all stenoses of the u])]ier res])iratory passages may be divided into acute and chronic. To the former belong phlegmonous angina, retro-])har\ngeal abscess, false and true croup, foreign bodies in the larynx, spasm glottidis and its cedema. To the chronic variety belong new growths in the larynx, espe- cially papillomata and syphilis, perichondritis, compression of the trachea by tumors of the thyroid and thymus glands or by over- growth of the lymphatic glands of the neck and bronchi. ACUTE DISEASES OF THE LARYXX PRODIXTXG ITS STENOSIS. Acutely arising stenosis of the larynx most often occurs in children during catarrhal or fibrinous inflanmiation of the laryn- geal membrane, that is, during false and true croup. Under the name of false rroitp we understand a catarrh of the larynx, in which the swelling of the mucous membrane causes narrowing of the lumen of the larynx and consequent stenotic nisi:ASF.s nr RF.siMR.\roR\- svstf.m 26^ respiration. As Ixauclifuss has shown, attacks of falsi- cninj) especially arise in those cases wherein swelling- of the snhnnic- ons tissue appears immediately under the vocal cords, hence the naiue larxiio;itis siibclwrdalis. In TRUE CROfp we have to do with crotif^oiis iii/laiiiiiiotion of the nuicous memhrane of the larynx, which is marked by the formation of a fibrinous membrane over the whole surface of the latter. A true croup has, in the ^reat majority of cases, a diph- theritic orig"in. therefore, in the fibrinous membranes, as well as in the mucus taken from the posterior wall of the larynx, the Loflf- ler bacillus may be found; l)ut sometimes cases of membranous, that is, true, criutji are seen due to stai:ih.ylococcus. streptococcus or of other orit^in, as occurs also in membranous inflammation of the fauces. Although in both these cases we have almost the same s}'mp- toius. namely, stenotic respiration, hoarse, rintjiuij;' cousi^h and harsh voice, nevertheless. In the overwh.elmin.i;- majority the differ- ential diag'uosis is not at all difficult. The marked difference be- tween false and true croup is exident from the ver\ be^iiuiing of the disease. False croup begins siiildciily : the patient goes to bed in an entirely healthy condition; (he had. perhaps, a mild cold and ,1 slight cough) ; he sleeps well for about two or three hom\s and then suddenly awakens with a rough cough and obstructed res- piration, while die stenosis may reach even the grave degree. Such symptoms usually do not last long ; in favorable cases im- proving after fifteen to thirty minutes, in severe cases after one or two hours, the appearances of stenosis abate and the patient falls asleep until morning. In the morning he brealhes freely, the stenosis has disappeared entirely or is noted only during the cry (to a slight degree), the cough beciMiies more moist, but is still of a rough character. The next night the attack of stenotic breathing ma\- reappear, being usually weaker than on the first occasion, and in general the patient each subsequent day feels better, and soon he recovers entirel\'. True croup never begins suddenly. P>efore this form reaches a grave degree of stenosis the ])atient for two or three OF Ki-:si'iK A roKN' svs ri-:M 2(>y In otlicr instances, cL'dcma of the glottis ooniplicalt-^ severe inllanmialory processes in neighboring organs, for example, in angina Ludovici. phlegmonous tonsillites, retro-])harvngcal ab- scesses, as well as ulcerous processes in the larynx itself (syphilis, tuberculosis), and perichondritis in acute cases (scarlatina, small- pox, tyi)hoid) and in chronic ones (syphilis, lubcrcuhjsis j. Besides the aetiology in the diagnosis of uedema glottidis, or of lar\ngitis submucosa, one may also use data obtained from inspection ; by strong pressure on the base of the tongue it is often possible to see the considerably thickened and deformed epiglottis, and pali)ating the entrance of the larynx with the finger one may after some ]:)ractice easily reach the epiglottis and the lig. ar\epi- glottica. Stenosis of the larynx or trachea due to the presence of a foreign body is. usually, prom])tl}" recognized from the historv ; the child w|iile in complete health was playing with some small objects, and suddenly a violent attack happened ; he had a fit of coughing and then labored breathing began. These are the characteristic data which are furnished by the parents. If the history is absent, or is very scanty, then the cause may remain undetermined. In the case of a foreign body stopping at the en- trance of the larynx, it ma\- be felt by the finger and even ex- tracted (I would like to point out, by the way, that in all cases of acute development of stenosis in children one should resort to examination of the accessible ])ortions of the pharxnx and larvn.x with the finger. This is the most certain method of determining retro-pharyngeal abscess, but besides this it may serve for the diagnosis of redema glottidis and of the presence of foreign bodies). Should it happen that a foreign body reaches the trachea one nm\ sometimes succeed in feeling its crowding movements by palpation of the neck (external surface) during coughing. If the foreign body has sunken still more and lodged in one of the main bronchi, then a weakened respiration is obtained in the corresponding lung. Attacks of suffocation may also be produced by a foreign botly (a piece of food) stopping in the upper third of the oeso- phagus. This is usually determined b}- the history. Stenosis of the larynx because of spasm of the nuiscles ivhieh 268 DISEASES OF KESPIKATnRV SYSTEM narroii' tJic glottis — spasm glottidis, although it may not lead to death from suffocation, nevertheless the picture of the disease does not resemble croup, neither does it resemble stenosis caused by a foreign body. Spasm of the glottis, as well as the latter cause, is characterized by s}-mptoms of suffocation suddenly ap- pearing in a child in complete hcallh, but spasm appears in con- ditions which exclude any supposition of a foreign body. The attack sets in either during the cry, or when the child is resting in the mother's arms and not playing with any small t6ys, etc. The child makes a whistling inspiration and then suddenly stops breathing, his face becomes cyanotic, he suft'ocates and finally general convulsions come on (twitching of the facial muscles, rolling of the eyes, convulsive stretching of the extremities). The attack of apncea lasts only a few seconds, and then the child begins to breathe freely, that is, without stenotic inspiratory noise, but remains for a while weak and somnolent. If the spasm is so violent that it does not pass off innnediately, then the child after one or two minutes will die from suffocation. It follows that spasm of the glottis diff'ers from laryngeal stenosis due to other causes by the sudden onset of apniva {zvithoiit any cause, or under the influence of some psychical excitement), hy its very short duration and by the loud zvhistling sound duri)ig in- spiration at the I'cry onset of the attack or at its end. As spasm of the glottis is produced, so to say, by intern.-^l causes, that is, as it depends upon a peculiar irritability of the medulla oblongata, under the inlluence of general malnutrition of the organism and especially of rachitis, it never happens that such a cause will produce only a single attack ; on the contrary, laryngismus stridulus is inclined to relapses. The paroxysms are at the beginning not severe and suddenly pass away, accom- panied only by a single crowing inspiration without interruption of the respiration (incomplete closure of the glottis). After some time such alx>rtive paroxysms are replaced by severer attacks, manifested by cessation of breathing, loss of consciousness and convulsions. If the patient does not die during one of such parox- ysms, then the period of improvement follows in the form of gradual diminution of the strength, duration and frequency of the attacks. The course usually becomes protracted for many weeks and even months, while the duration of free intervals be- DISEASES OF RESTIRATORY SYSTEM 269 tween separate attaeks varies greatly from a few minutes (ten to thirty attacks a day) up to many days. It follows that, in making' the diagnosis, one may be guided also by the attacks being repeated, by the general condition of niiirition and tJie age of tlic child. Laryngismus stridulus (laryngo-spasmus) always begins dur- ing the first year of life and seldom continues beyond one and one- half years ; thus its greatest maximum coincides with the period of first dentition. It almost exclusively afi:'ects rachitic children and especially those suffering with craniotabes (softening of the occiput). But this does not mean that laryngismus stridulus depends upon the softened occiput ; the connection between these two morbid processes must be understood to be that both depend upon rachitis. [That spasm of the glottis may be caused by adenoid vege- tations was pointed out in the note to page 256. — Earle.] Difficult breathing due to stenosis of the fauces, for instance during phlegmonous sore throat, may sometimes indeed reach a considerable degree, but the voice in such cases becomes only nasal, and not harsh ; cough is absent, but there is a severe pain on deglutition ; so that these symptoms alone may show that the disease is not located in the larynx, but in the fauces, the inspection of which is sufficient to make the diagnosis. Retro-pharyngeal abscesses {abscessus retro-pharyngeus) are frequently overlooked. For this reason, and likewise because this disease very often exists in childhood and especially in nurs- lings, I shall describe it somewhat minutely. There are two kinds of retro-pharyngeal abscesses in chil- dren: acute, or idiopathic, caused by suppurative inflammation of the lymphatic glands imbedded in the mucous membrane of the posterior pharyngeal wall; and the chronic (burrowing) variety which accompanies caries of the vertebrae. Abscesses of the former group are peculiar especially to nurslings, and occur quite often ; the latter belong to the rarer appearances, never occurring in nurslings. In the beginning of the disease the symptoms are not char- acteristic at all : the first thing the mothers' notice is harsh breath- ing during sleep. With the abscess already developed it is not difficult to recognize the condition ; the patient is in the state of 2/0 DISEASES OF RESPIRATORY SYSTEM severe d\*spnoea with depression of the yielding portions of the chest during each inspiration. A great similarity exists in this regard between croup and this disease. A marked difference, however, may be noticed between them in two features : fir.st, there is absence of the stenotic respiratory sound which is so characteristic of croup (false or true, it is immaterial), and which is always present ; and, second, there is absent the ringing cough as well as the harsh voice. While inspiration is also accompanied by a noise in the case of abscess, yet this noise is an entirely differ- ent one, as it resembles moist snoring, being more in evidence during sleep. The voice also becomes changed ; it assumes the nasal twang, but aphonia is absent. A similar tone of voice may be produced artificiall\- if the throat be compressed between the ascending l)ranch of the inferior maxilla and the upper end of the sterno-cleiflo-mastoid muscle ( l*>okaj). Cough is either en- tirely absent, or it is slight and does not exhibit any peculiarities ; it is only important in the diagnosis that the cough is ringing. Pain on swallowing may be noticed from the very first, increasing according to the enlargement of the abscess, and during the period of its complete development it may happen that the child refuses food and drink altogether — in croup we do not see any- thing like this. Further, the habitus of the patient is characteristic ; the head is somewhat thrown back, or bent toward the more affected side (torticollis). The head is fixed and there is a tumor of the neck under the angle of the inferior maxilla (this tumor, however, is not always present, but swollen glands may at least be pal- pated). If with these symptoms the presence of a retro-pharyn- geal abscess may be suspected, then one should not conclude that a final diagnosis may be made by mere inspection of the throat. On the contrary, this is the reason that abscess of the posterior wall of the pharynx often remains unrecognized, physicians con- tenting themselves with inspection alone. The main thing is that in such a patient deglutition is difficult, therefore, there is always a great accumulation of mucus in the throat, which considerably prevents the examination thereof. Even in a normal condition it is difficult to inspect the throat in nurslings. In order not to over- look a retro-pharyngeal abscess, one should therefore observe the rule to examine the throat in all doubtful cases and feci the disi-:ases t)F RKSpjKAioKv svsii:.\[ 27X posterior wall of the pharynx with the finger. As soon as an ab- scess exists there, then it is readilx- felt as a smooth, elastic, iluctu- ating- tumor located on the posterior wall, usually somewhat lat- erally from the median line. A further difiference as to croup lies also in the course. Croup produces laryngeal stenosis comparatively early, in about three or four days, while retropharyngeal abscess develops slowly, so that from ten to fourteen days elapse from the time of the appearance of harsh respiration during sleep up to the period of considerable stenosis, while about five or ten days are occupied by the period of progressive increase of the stenosis. How^ever, deviations from these average periods occur not infrequently ; for instance, cases of formation of an idiopathic abscess in two or three da}S have been seen (Bokaj) and, on the other hand, there have been cases of five or eight weeks' duration, and accordingly some authors distinguish acute, subacute and chronic idiopathic retro- pharyngeal abscesses. Fever is of no value in the diagnosis : it may be absent in the beginning, but in the period of suppuration the temperature nec- essarily rises to 39 degrees C. (102.2 degrees F.) with great morn- ing remissions. It is not difficult to distinguish an idiopathic abscess from a burrozi'iiig one, because in the latter form symptoms of cervical spondylitis must be decidedly pronounced, as well as the chronic ■course of the disease (see spondylitis). In small chihiren who cannot breathe through the mouth, syinptODis of stenosis of the upper respiratory passages (infre- quent respiration with depression of the yielding portions of the chest, but without the characteristic stenotic inspiratory noise) may appear under the influence of a common rhinitis. In such ■cases the most important distinctive symptom will be that during crying the labored respiration disappears immediately. In exceptional cases something similar occurs also in older children. A boy aged eight years of age became ill in the beginning of November, 1888, with a severe rhinitis and cough (la grippe), and on November 10, under the influence of a beginning menin- gitis, he became very somnolent, and there apjieared a very labored respiration ; this was retarded, and during each inspiration there Avas noticed depression not only of the intercostal interspaces, but 272 DISEASES OF RESPIRATORY SYSTEM also of the lower portion of the sternum, and of the supra-clavi- cular and jugular fossse; in short, as if there was a fully developed croup. But the voice remained clear all the time, therefore the cause of the stenosis had to be looked for elsewhere outside of the larynx (viz, outside of the glottis). Retro-pharyngeal ab- scess also could be excluded. Further examination showed that the patient's tongue was drawn far back, its tip pressed toward the hard palate, so that the air supply through the mouth was prevented ; moreover, the nose was blocked up from snuffles,, hence the result — symptoms of severe stenosis of the upper respir- atory passages. One had only to open the patient's mouth and depress the tongue with a spoon, when the respiration became entirely free. Similar stenosis may be produced experimentally by anyone on himself; it is necessary only. to throw the tongue backwards, compress the nose and try to catch the breath. It is obvious that had our patient not been under the influence of meningitis, in a somnolent condition, he could have removed the obstacle and breathed through the mouth. To the same class of cases also belongs the groaning respira- ■tion of children of the first months of life, which depends, ac- cording to Politzer, who first described such a breathing, upon abnormal innervation of the soft palate. With more advanced age, for instance, toward the end of the year, such a groaning respiration, or snoring, disappears of itself and the breathing becomes normal, soundless. CHRONIC STENOSIS OF THE UPPER RESPIRATORY PASSAGES. Causes of chronic stenosis of the upper respiratory passages- mav manifest themselves either in the larynx, or in the trachea. In the former case the voice will necessarily be changed, becoming either harsh, or aphonic altogether ; in the latter case it remains- clear or changed but little (because of accompaning slight catarrh of the larynx). The degree of stenosis in laryngeal affections may be of all gradations, not excepting even the severest form ; in tracheal stenosis its degree does not go be3-ond the middle form,, that is, the patient can compensate the sequelae of the stenosis by means of increased activity of the inspirations. Chronic stenosis of the larynx in children most often de- DISEASES (IE RES1'1RAT()K^■ SYSTEM 2/3 peiuls upon svimiilis. namely, upon coiidyloinatons proliferations of the laryngeal iiiiic(Uis membrane; in rarer cases upon tubercu- losis or tumors of the larynx. If the history be known, or if the patient presents apj^arent symptoms of syphilis, then the diagnosis is not difficult ; but if the aflfection of the larynx is the single manifestation of syphilis at the given time (this appears not very seldom), then the diag- nosis may exhibit some difficulties. It is important in the diag- nosis that the favorite place for the development of condylomata is the epiglottis, which often may be seen by depressing the base of the tongue, especially during the nauseous movement pro- duced by the examination ; it appears then as a deformed, thick- ened, small, hollow cylinder of whitish-red color. It is still better if the patient can be examined laryngoscopically, even for one moment ; the aspect of condylomata is so characteristic that it does not require a prolonged inspection. However, the diag- nosis is, in the majority of cases, possible even without the lar- yngoscope. As the larynx is never the place of the first appear- ance of secondar}' syphilitic symptoms, on the contrary becoming involved during relapses ; then by inspecting the whole surface of the body one usually succeeds in detecting elsewhere, most often in the anal region, traces of an old syphilis in the form of reddish spots or scars in the place of old condylomata, as well as thicken- ing of the mucous membrane in the corners of the mouth. These are especially characteristic, if whitish in color. Remains of condylomata may also occur in the throat, particularly on the soft palate. (More minutely about the retrospective diagnosis of sypliilis see the section on Syphilis.) The history shows that the Ciiild's mouth was formerl}' affected and there were wet places around the anus ; that the mother had, perhaps, many children, but they died soon after birth ; that some of them were still-born, or even abortion had occurred. As I have said, the larynx becomes involved only during relapses and very lately, therefore almost never in nurslings. Most often we obsen-e sy])hilis of the larvnx in children from two up to seven years of age. Gummata and ulcers occur in the larynx less often than condylomata. Their diagnosis is impt^ssible without the Iar\ngo- scope. 274 DISEASES OF RESPIRATORY SYSTEM I'libercular ulcers in the trachea and larynx occur very sel- dom in children, especially in those under seven years, although cases of tubercular ulcer of larynx even in small children are re- ported in literature, for instance, Rheindorff's patient was only nine months old when hoarseness and cough appeared, being the first symptoms of tuberculosis of the larynx, which was proven by post-mortem in the fourteenth month of life. Symptoms of laryngeal stenosis because of tubercular ulcers occur very rarely; in the overwhelming majority of cases there are to be observed only a harsh voice and cough. The diag- nosis of tuberculosis of the larynx may be assisted by such patients exhibiting apparent symptoms of tuberculosis of the lungs. Chronic stenosis of the larynx may also be produced by new GROWTHS, which in childhood must be referred almost exclusively to papillomata. Regarding the diagnosis it is important to notice that in the great majority of cases they are inherited, therefore this cause of stenosis may be suspected only if development occurs very slowly in a child previously in good health, m whom neither syphilis nor tul^erculosis may be suspected, and if the first symptoms of the affection of the larynx in the form of hoarseness or complete aphonia, and later on in the form of a rough cough, ap- peared during the first days of life or, at least, during the first year. Perichondritis laryngea almost never occurs as an inde- pendent or primary lesion, but always after some general acute or chronic diseases. In childhood this morbid form has been observed after typhoid fever, smallpox, scarlet fever, (the case of Jacubovich* of a girl of one year and eight months old is inter- esting by stenosis of the larynx having developed so quickly that the diagnosis of diphtheria w^as made during life), but oftener in syphilis and tuberculosis, although generally very' rarely. As perichondritis is usually associated with ulcerous processes the patient manifests various symptoms of severe laryngitis long be- fore its real appearance. One may suppose the development of perichondritis in a case, if, in the presence of certain aetiological factors the patient complains of pain in a certain part of the *Arch. f. Kiiidcrh. X. B. I. 35. DISEASES OF RESiMRA I'URY SYSTEM 2/5 lannx, increasing- upon pressure, and if outward swelling; of iIk- cervical cellular tissue corresponds to the place of pain. In countries where struma prevails endeniically the cause of chronic stenosis of the trachea is tumor of the thyrold gland, but in our locality the trachea becomes much more often c6m- pressed at the point of its bifurcation by enlarged and caseously degenerated lymphatic glands. It is easy to recognize compression of the trachea due to struma, as a tumor on the anterior surface is noted at first glance. Hyperplasia and caseous degeneration of the bronchial GLANDS, compressing the trachea at its bifurcation, may be rec- og-nized partly by excluding other causes of stenosis, partly on the ground of positive data and the history. Tlie history shows that the patient suffers with cJironic sten- osis of the upper respiratory passages and that this stenosis de- veloped very slowly. It may be found that labored breathing at the beginning appeared only for a short period, during in- crease of the cough, and in slight degree ; later on, the stenosis would disappear to reappear after a short interval, until it finally became constant, although, perhaps, not to a considerable degree. The patient suft"ers, besides this, with chronic cough, being either scrofulous or rachitic ; his voice is entirely clear and the larynx is thus not involved. On the basis of these data one may suppose with great prob- ability that the stenosis is in the trachea, being dependent upon enlarged glands. In favor of the latter proposition there is the general condition of nutrition of the patient (scrofulosis and rachitis) and chronic catarrh of the respiratory organs, which is never absent in such patients. The minute examination of the patient will bring out still other data. At the point of stenosis mucus, which causes the harsh breathing, frequently accumulates. This sound, resembling either ronchus sonorous or large, bubbling rales is heard all over the chest (conducted rattle), but it is loudest on the manubrium or between the scapulae in the upper portion of tlu- chest; one may also feel it by palpating here. This rattle may sometimes be heard for many weeks in succession, but not always equally well; sometimes it disappears altogether, again it in- creases, especially during any excitement of the child. If the 2/6 DISEASES OF Ui:S[MRAT()RV SYSTEM glands are so large that the whole space between the bifurcation of the trachea and sternum is filled, then they serve as a good conductor of the respiratory murmur, therefore, bronchial breath- ing or, at least, a loud respiration may be heard on auscultation, in the first intercostal space, near the sternal margin in the area of the involved glands. In estimating this symptom one should bear in mind that on the right side (the right bronchus is wider than the left) tubular respiration not infrequently is heard even in the normal condition, so that loud expiration may be of decided importance in favor of enlargement of the tracheal glands only if on the left side it is either very pronounced, or louder. Percussion sometimes (although seldom) gives some dull- ness on both sides of the sternum in the first and second inter- costal spaces, or at the point of the sterno-clavicular articula- tion ; in other cases dullness on the back between the scapuhe may be noted, along the sides of the first three spinal vertebrae. If dullness be obtained only on the sternum upwards, then it may depend upon the thymus, and the younger the child the more probable is this cause. In children five or six years of age the presence of the thymus does not usually manifest itself by a dull sound. In small children the dull sound dependent upon the thvmus either does not pass beyond the margin of the sternum altogether, or extends on one or the other side not more than one-half of a centimeter. In the case of enlargement of the thy- mus a dull sound will be especially expressed over the sternum itself, but not in the intercostal spaces, as in hyperplasia of the glands. Furthemiore, symptoms may be present which point toward compression of the venous vessels (oedema or puffiness of the face, distension of the jugular veins) or of the pneumogastric or the recurrent nerves (convulsive, pertussis-like cough, but usually without the whistling inspiration, change of the voice, asthma) . Stenotic s}-mptoms may be highly characteristic even by themselves, namely, if one of the main bronchi is compressed, with symptoms of the sequelae of stenosis, that is, symptoms of insufficient access of air to the lungs, manifesting themselves only pn the part of the chest. These symptoms consist in that the corresponding half of the chest dilates during inspiration less DISEASES OF RESI'l RA1'( )RV SVS'lEM 277 than the other, whiK- (k'])rcssi()n of the yickhiii;" portions is greater. At the same place a weakened resjMratory murmur may- be noticed and feehk' vocal fremitus, the ])ercussion note being normal. k\>ver in hxperplasia of the bronchial glands may be absent, but as considerable enlargement of the glands is usually observed in tuberculous children (although the lungs ma\- be free from tubercles), the elevation of temperature is seldom absent, so that an miaccoiiiifahlr fc'i'cr obscrr'cd in a child may considerably confirm the diagnosis of tuberculosis of the glands, especially in case it became protracted after some disease which was compli- cated by bronchitis (la grippe, measles, whooping-cough). It is, of course, obvious that even in such an instance a mistake is possible. For instance, in one case I made an erroneous diag- nosis of tuberculous hyperplasia of the bronchial glands on the ground that stenosis of slight degree ( noticeable, however, also during quiet respiration) appeared in a girl four years old who had suffered a long time with bronchitis ; afterwards the cough almost disappeared, but moderate fever (about 38 degrees C. — 100.4 degrees F. in the morning, and 38.5 degrees C. — 101.3 de- grees F. in the evening) was persistent during an entire month. As the girl had rhinitis at the same time, a specialist in nose and throat diseases was consulted. The laryngoscopic examina- tion showed that, despite the clear voice, the place of narrowing was in the larynx and was dependent upon a spasmodic condi- tion of the muscles closing the glottis, so that during inspiration the vocal cords did not separate suf^cientl\ , and the avenue for the passage of air was narrowed. Such a condition of the vocal cords was produced, undoubt- edly, by a reflex action from the mucous membrane of the nose, the local treatment of which ]:)roduced complete iecover_\- of the patient. I do not know whether such neuroses belong to the rarities or not. Prof. Franz Mayr* sums up the diagnosis of hyperplasia of the bronchial glands in the following way: Aside from the results of percussion and auscultation we may suspect this disease : (i) If a child with hereditary predisposition to tuberculo- '*Jalirb. f. Kiinli'ili. 1862. Vol. V. 278 DISEASES OF RESPIRATORY SYSTEM sis or scrofulosis l>ecomes afifected with an obstinate catarrh, dur- ing which there appear at times paroxysms of pertussis-Hke cough. (2) If the same appearances are noted in a child who had suffered previously wath rachitis or chronic eczema and who ex- hibits a superfluous growth of hair on the temples, posterior part of the neck and the back. (3) If the child is repeatedly subject to violent and contin- ued attacks of asthma ; and, finally, (4) If, in a child three or four years old, there appear cough, wasting, fever and perspiration without any symptoms of tuberculosis of the lungs, brain and visceral organs. Hyperplasia of the bronchial, as well as of any other, glands does not always depend upon tuberculosis (the latter is only the most frequent cause) ; but may also arise under the influence of other diseases of the blood, especially syphilis and leukaemia. If stenotic respiration appears in a child of the first months of life, and if there are no reasons to suppose hyperplasia of the bron- chial glands ( ^etiological factors absent), then it is more probable that stenosis of the trachea depends upon an enlarged thymus. Such stenoses appear from the first days of life, increase at times and then decrease again, disappearing gradually and altogether during the second year of life. Stenotic respiration due to chronic lesions producing nar- rowing of the lumen of the fauces occurs in children in hypertro- phy of the tonsils. The access of air to the lungs may then be so hindered that the chest remains undeveloped, assuming the form olt "pigeon-chest," as in rachitis. Usually such children also have adenoid vegetations, exhibiting then a characteristic habitus; they are pale, keep the mouth half open, the voice has a nasal twang, and the nostrils are narrow. During sleep they snore loudly. Inspection of the fauces detects large tonsils the tips of which sometimes meet each otlier in the median line of the fauces and press upon the uvula. One must add that drawing in of the lower periphery of the chest (that is, of the points of insertion of the diaphragm) dur- ing deep inspiration is not always indicative of a prevented air- supply to the lungs, as in small children, three or four months old, such a depression is more or less physiological, persisting DISEASES OF RESPI RA Tt )KV SVSri:.M 2/0 in rachitic children C(>nsiecomes less frequent, softer and more moist, and after a few days disappears altogether. In determining the location of the catarrh we are guided by the character of the auscultatory findings, and the respiration as well. If on auscultation large rales or ronchi sonori be heard, then we conclude the trachea and large bronchi are involved, as such rales may be formed only in cavities and tubes of large cali- ber. If the secretion of mucus be not abundant rales may be absent altogether in tracheitis, the respiratory murmur remaining entirely normal, so that the disease in the beginning manifests itself only by cough and fever; older children complain also of soreness along the trachea. Cough li'ithoiit any rales in the chest, in the absence of any percussion signs, may depend upon chro)iic pharyngitis, which also occurs sometimes in childhood, especially in scrofulous and ansemic children. This cause of cough may be suspected only in such cases where a short, dry cough (like tickling in the throat) is persistent in a child, notwithstanding he is kept well housed, and if no rales are to be found in the chest. Inspection of the throat reveals that the posterior wall of the phar>'nx is red, marked with dilated vessels and dry, as if varnished. Not in- frequently there appear small, flat, oval, pea-sized elevations covered with the same mucosa as the adjacent parts — pharyngitis DISEASES t)F RESPIKATORV SYSTEM 283 grmnilosa. A persistent, dry cou^h may last nianv weeks and •easily recurs on the slightest cold. Here it is also well to mention a peculiar, dry cough which arises without any objective signs on the part of the lungs, lasts one to two months, differing from any other cough by bothering the child only at nights, hence the name, periodic night cough. The cause of this nervous cough, which is especially peculiar to irritable, anaMiiic children, is miknown. It sometimes stops quick- ly after the use of quinine, therefore one ma}- think that it is a symptom of febris intermittens larvata. If medium-sized bronchi are affected, then there are obtained either rales or, in the case of scant secretion, coarse vesicular -breathing and an indefinite respiratory murmur, or a weakened vesicular breathing because of narrowing of the bronchi. In CAPILLARY BRONCHITIS we have a whistling respiration as an indication of the considerable narrowing of the lumen of the small bronchi because of swelling of their mucosa; later on, in the period of formation of the secretion, small, but not con- sonant rales are heard. Besides these signs, capillary bronchitis differs from any ■other bronchitis by dyspiuva which, here, is never absent. Cap- illary bronchitis is always bilateral, and the catarrh which is its •essence is of the diffuse character, that is, it occupies if not all,' then almost all, bronchioles, always producing narrowing of their lumen and thus obstructing the air supply of the alveoli. On this account every inspiration produces rarefaction of the air in the chest (as occurs during laryngeal stenosis), and the result is drawing in of the yielding portions of the chest, and especially ■of its lower periphery along the line of insertion of the diaphragm. Thus, inspiratory dyspnoea arises which, however, is not difficult to distinguish from inspiratory dyspnoea due to stenosis of the up- per respiratory passages. During the latter, first, a character- istic stenotic murmur always may be heard, while in capillary "bronchitis the same is absent ; second, the respiration in stenosis is of normal rate or even somewhat retarded, while in capillary bronchitis it is considerably accelerated (in children under two years, from seventy up to one hundred per minute) and becomes, ■of course, very shallow. There is also some difference to be •aioticed in the action of the respiratory muscles ; the neck muscles 284 DISEASES OF RESPIRATORY SYSTEM (scaleni) act, in stenosis of the larynx and trachea, much stronger than in capillary bronchitis ; therefore the drawing in of the supra-clavicular fossse is more noticeable in the former case. The younger the child the narrower its bronchi, therefore the quicker there may be manifested, in the case of bronchitis, appearances of aspiration on the chest walls ; in children under one year, .i slight depression of the intercostal spaces may be noted in almost every bronchitis. Ca]Mllary Ijronchitis belongs to the most dangerous diseases- of childhood, being usually accompanied l)y (|uitc high and con- tinuous fever, often leading to an insufficient oxidation of the blood, which is shown by cyanosis and other sym])toms of CO2 poisoning. Ca])illar\ l)rnnchitis is also distinguished by occur- ring especially in small children under two }ears of age. Transition from bronchitis to pneumonia is a gradual one, making itself evident b\- the a])pearance of crepitant and con- sonant rales, but later on ])y bronchial breathing and dullness. Some similarity to capillary bronchitis is represented by BRONCHIAL ASTHMA. This disease, dependent upon spasm of the muscles of the small bronchi, is recognized by the appearance of periodically repeated attacks of violent dyspnoea, with a loud, thin (high) whistle in the chest, audil)le even at some distance and accompanied by stasis of the venous bloo not characteristic of whooping-cough ; and that in the former dis- ease the coughing fits are especially violent in the mornings and evenings, while in whooping-cough the attacks are more pro- nounced at night. In the case of a new exacerbation of fever the catarrh may spread to the small bronchi, alveoli (pneumonia), and sometimes to the bowels. Besides these cardinal symptoms of fever and catarrh, the nervous system always becomes affected during any distinctly developed influenza. The most constant symptoms besides head- ache, which never is absent, are insomnia, sometimes very persist- ent in the night-time, and irritability in the daytime. The patient gives the impression of a very disagreeable child. This excessive capriciousness or wrath is highly characteristic of la grippe, espe- ciall\- when we have to consider the differential diagnosis between influenza and typhoid ; the typhoid patients are quiet. In graver cases of la grippe the children are delirious, fre- quently from the very first night (an essential dift'erence from typhoid, in which the delirium usually appears at end of the first week) ; or they jump up in the night, cry as if frightened by something, and, perhaps, even do not recognize the members of the family. The course of la grippe is an extremely in;lefinite and irregu- DISEASES OF RESl'lRATi )KV S>STEM 29I lar one, therefore the prognosis regardiiii^- its duration cannot be very exact, l)ut it is favorable quo ad vitani, as la grippe usually ends with recovery, even when complicated with pneumonia. Severe cases of la grippe may be protracted for several weeks, such a chronic course predisposing to the development of chronic pneumonia and tuberculosis. Regarding the diagnosis of la grippe the disease is most often confused with aciite bronchitis, from which it dififers : First, by its epidemic occurrences and contagiousness. Second, by the fact that besides the bronchi other mucous membranes also become involved. Third, the degree of the fever, its duration, and the violence or the frequency of the cough usually do not correspond to the symptoms of the catarrh. Fourth, the catarrhs during la grippe become protracted, notwithstanding the patient is kept in bed ; and finally. Fifth, during la grippe the nervous system also becomes involved. About the resemblance between la grippe and the first period of whooping-cough the reader is referred to the section devoted to the latter. Here we shall only note that the higher the tem- perature in the beginning of the disease, the more probable is it la grippe, and vice versa, if, despite the normal or subnormal tem- perature, the resolution of the catarrh of the nose and tracliea is delayed, the patient meanwhile being kept in bed, then whoop- ing-cough is probable. During the first twenty-four or seventy-two hours the diag- nosis may vary between la grippe and the prodromal period of vicasles. The character of the redness of the mucous membrane of the throat, conjunctivse and mouth decides the point in the best wa\'. In measles the rechicss of these mucous membranes, especially of the soft and hard palates, is usually a spotted one, in la grippe, however, as in common catarrhs, it is dift"use. Second, the character of the epidemic is here very important. It is obvious that if in any given family wherein someone already has measles, a child takes ill with nasal catarrh and epiphora (increased flow of tears), then we should rather suspect measles, and not la grippe, even if no spotted redness is present in the throat, which is far from being constant in measles. 292 DISEASES OF RESPIRATORY SYSTEM Finally the third, although the less important, sign we have is sneezing, which occurs much oftener in the prodromal period of measles than in influenza. This depends, perhaps, upon photo- phobia also being more intense, and it is known that under the influence of bright light sneezing appears even in healthy per- sons having no rhinitis. In its further course la grippe, accompanied with constant fever, and, perhaps, with diarrhoea, simulates typhoid. The diagnosis is based upon the absence of symptoms which especially point toward typhoid, as rose spots and spleen tumor, and the simultaneous presence of symptoms which are not pecul- iar to typhoid altogether, but are characteristic of la grippe, as nasal catarrh and irritability. A recent swelling of the spleen is against la grippe. If rhinitis has disappeared, then the history gives very essen- tial data; the disease began with rhinitis, fever, the cough was from the very first the chief symptom, the fever was regular, would often fall to the normal level — la grippe ; but if the disease began gradually with headache, loss of appetite, and fever in the evenings ; if at the beginning there was neither rhinitis nor cough ; and the latter made itself evident toward the end of the week, the fever increasing gradually and had reached its max- imum on the fourth or the fifth day, remaining on the same level, with morning remissions — then typhoid. The age is also of important diagnostic value ; under two years typhoid seldom appears, while la grippe very often. The difference between these two diseases is a sharp one, not- withstanding which fact errors in diagnosis occur very often. The physician either mistakes la grippe for typhoid, or he cannot altogether place his case in any definite category of diseases. All such difficulties arise only from the fact that the physician does not well bear in mind the distinctive points of la grippe. Regarding the symptoms and course of epidemic la grippe such a manifoldness exists that different forms of this disease are usually recognized, dependent upon whether one or another set of symptoms are predominant, as, for instance, influenza cephalica ( soinnolence, violent delirium, miconsciousness), influ- enza abdominalis, s. gastrica (loss of appetite, vomiting, ab- dominal pain, diarrhcea), influenza neuralgica (pains along the DISEASES OF RESPIRATORY SYSTEM 293 peripheral nerves as well as in the hack and extremities j, influ- enza thoracica, s. catarrhalis (catarrhs and inflammations of respiratory org'ans). As common symptoms of all these forms there appear, be- sides the rapid and vast spread of the epidemic when people of all ages fall sick, the sudden onset of the disease, in the form of quick elevation of the temperature, as well as its short duration, accompanied with severe headache and considerable general weak- ness ; uncomplicated cases usually end with a profuse perspiration in from two to five days. It has been previously mentioned that in adults true influenza is more severe than in childhood. At least during the epidemic of 1889 and 1890 this difference was so evident that I find it more convenient to describe the course of la grippe in adults and chil- dren separately. In grozvn persons the chief symptoms are nervousness, that is, painful symptoms, while catarrhs of the respiratory organs (which usually are essential symptoms of influenza) are either absent altogether, or appear late, for instance, at the end of fever. The disease almost always begins suddenly (seldom after malaise of one or two days' duration) with severe fever (39 to 39.5 de- grees C. — 102.2 to 103. 1 degrees F.) during the first evening, simultaneously with which severe pains appear; headache, pain in the eyes, which increases upon movement of the eyeballs, pain in the back and legs, especially in the calves. Comparatively in- frequent are pains in other parts of the body, for instance, in the form of general hypergesthesia of the skin and intercostal neural- gise, migraine, as well as arthralgise. Among the constant symptoms there are also loss of appe- tite, great weakness, dizziness when the patient attempts to stand up, sleeplessness, more rarely delirium or sopor. All mentioned pains are characterized by their sudden onset or rapidity of devel- opment, and by not having been accompanied by any symptoms of inflammation (in painful places redness is absent, also swelling, as well as elevation of temperature) and, finally, by their being of short duration, rapidly disappearing soon after the fever ceases, and, only in exceptions, neuralgia sometimes remains for a greater or less period of time. On the contrary, loss of appetite and gen- 294 DISEASES OF RESPIRATORY SYSTEM eral weakness are persistent in almost all patients during two or three weeks, which does not correspond at all to the brevity, nor to the severity, of the fever. During the last epidemic of la grippe all evidences were, in many cases, limited to these nervous symptoms alone and also to the fever, catarrhs being, at the same time, absent. In other cases again catarrhs, and mostly those of the respiratory organs, occurred, namely, coryza, redness of the fauces, hoarseness and cough ; more seldom gastric haemorrhages were met with, as, also, were vomiting and diarrhoea. In the majority of patients the cough appeared late, that is, only after the disappearance of the pains and fever. All these symptoms apparently had a nervous connection, as, for instance, coryza was accompanied by severe pain in the fore- head, over the glabella ; laryngo-tracheitis, by spasmodic dry cough, sometimes with vomiting, as in whooping-cough; tracheo- bronchitis, by severe pain along the sternum and dyspnoea. In case of vomiting, the patients complained of pain in the epigas- trium ; and in diarrhoea of abdominal pain. ()f symptoms which, although occurring in the minority of cases, yet, to some extent, make the diagnosis difficult and lead to confusion of influenza with dengue, may be mentioned pains in the joints, especially in the knees (without inflammatory ap- pearances) ; and different rashes, either in the form of urticaria, or those resembling measles or scarlet fever. The duration of influenza in grown persons is, in mild cases from one to two days, in the moderate or severe forms, from three up to five and even ten days. At any event the duration of in- fluenza varies greatly as, for instance, in individual cases the febrile condition in a non-complicated influenza not infrequently lasts about three or four weeks and longer ; however, in cases of chnviic influenza, a moderate febrile condition without any local appearances, even without snuffles and cough, may sometimes continue up to three months, terminating with complete recovery. Such chronic cases not very rarely occurred among children dur- ing the winter 1897 and 1898. Complicating pneumonia was usu- ally met with. Regarding the symptoms of influenza in childhood, it is cer- tain that (luring the epidemic of i88q children were not so severely DISKASKS OI' Ri:Sl'IU.\ IllKN' SVSTi:.\I 295 sick as adults. /;; child roi not 0)i!y zi'crc catarrhs z'ery often ab- sent, but also pains in the back and cak'cs. Very often children from eight up to ten years of age did not complain of such pains even when asked about the same, so that the whole disease was manifested in children b\ the sudden onset of fever (39 to 40 de- grees C. or 102.2 to 104 degrees ¥.), headache and general weak- ness. After two or three days all symptoms would disappear, and the diagnosis of induenza could be established only on the ground of the character of the epidemic, that is, that all members of the family, without exception, became sick in a very short time. In childhood, comparatively oftener than in adults, there would appear, in the beginning of the disease, nausea and repeated vomiting, as well as epistaxis. The comparative moderation of the disease in children was also manifested by the quick recover}-, (that is, the appetite and the strength returning earlier), and by the fact that complications rarely developed, especially pneumonia. Different rashes sometimes occurreil in children, but they did not differ in anything from rashes of adults. The liver and the spleen, in influenza of children, did not l)ecome noticeably enlarged. As influenza is distinguished by much greater variety of symptoms than our endemic la grippe, therefore, in the diiferen- tial diagnosis of the former very many diseases should be touched upon with reference to this or that symptom. So, for example, a severe headache may cause suspicion of meningitis, especially in conjunction with an incipient vomiting : pain in the legs, espe- cially in the joints, leads one to think of rheumatism ; repeated vomiting and fever, of stomach catarrh ; pain in the back with high fever and vomiting — small pox ; catarrh of the nose, eyes and larynx — measles ; diffuse erythemata — scarlet fever. The diagnosis, in all cases, may be aided b\' the character of the epidemic, that is. by the epidemic occurrence of different forms of influenza in adults and children, and by the symptoms of the latter not being persistent. The doubts of the physician can- not last longer than two or three days, because, after such time. the symptoms of la grippe begin to abate. In sporadic cases, or in the l)eginn-ing of an epidemic, the diagnosis niay be established only in typically developed cases and, especially, from the presence of symptoms on the part of the 296 DISEASES OF RESPIRATORY SYSTEM nervous system in the form of collapse which does not correspond either to the severity, or to the duration, of the febrile condition ; also from various kinds of pain, which have been mentioned. Sporadic cases of infantile influenza, characterized by the ab- sence of specific pains, and not rarely also of catarrhs, are not easy to be diagnosticated precisely, and, in the absence of an epi- demic, such cases are reported by physicians as febris gastrica, or f. herpetica, f. rheumatica or ephemera. The influenza of 1889, because of the frequent absence of catarrh, was very similar to dengue, for which it was mistaken by some French physicians. Both these diseases affect a great number of inhabitants ; both belong to the class of miasmatic- Fig. 3c — Influenza-bacilli (Lcnharlz). contagious diseases ; both come on suddenly amidst complete health, starting with rapid elevation of temperature and headache, backache and pain in the limbs : both end by crisis after two or three, or in five to seven days ; in both diseases relapses are ob- served one to three days after the end of the first attack ; finally, in both diseases manifold rashes appear on the skin, in the form of spotted or diffuse erythemata or urticaria. The resemblance increases still further in that, in dengue, there sometimes appear catarrhs of the mucous membranes of the nose, mouth, and throat, or dyspnoea without catarrh of the bronchi. On the part of the digestive organs, in both cases are observed, as constant symp- toms, loss of appetite, coated tongue and inclination to constipa- DISEASES OF RESIMRATOKV SYSTEM 297 tion, and sometimes vomiting-; furlhermore, peculiar to both dis- eases, are sleeplessness, headache, nose-bleed, collapse and slow recovery. The prognosis is favorable in both affections. The dift'erences are that the pains are localized, in dengue, not so much in the calves as in the joints, the latter becoming swollen as in acute rheumatism ; but in influenza this never hap- pens. Relapses in dengue are common, as in relapsing fever, like- wise the cutaneous rash is rarely absent ; while in influenza both occur in the minority of cases. The main difference is that, in dengue, catarrhs of the respiratory organs are always absent. Thus, the similarity between influenza and dengue may, in separ- ate cases, be complete, they may be almost identical ; but a great difference will be found in the general character of the epidemic ; influenza belongs to catarrhal diseases, dengue does not. In all doubtful cases of influenza occurring with coryza or cough, the diagnosis may be effected through the bacterioscopic examination of the sputum, or of the nasal mucus, for Pfeiffer's bacilli. (Fig. 30.) The influenza bacillus is peculiar first of all by being very small, the length is only twice or three times its breadth, the ends rounded ; they have no capsule ; in the pendulous drop they are immobile ; they stain slowly, therefore the glass covered with smeared sputum must be left in the stain not less than ten min- utes ; for staining, Loftler's methylene-blue or an aqueous solu- tion of fuchsine are the best ; they do not stain by the method of Gram. Obtaining pure cultures is possible only in the pres- ence of haemoglobin or leucocytes. Pfeift'er recommends for this purpose agar covered with blood. The tube containing the cul- ture is placed for twenty-four hours in an incubator at the tem- perature of 37 to 42 degrees C. (98.5 to 107.6 degrees F.). The colonies of the influenza bacillus are very characteristic, and can- not be confounded with anything else (they appear as very small, colorless, as if watery, drops which seldom reach the size of a pinhead ; usually they are so small that they are distinctly seen only through a magnifying glass, The diagnostic value of bacilli is lessened by the fact that first, they are met with only in the sputum and nasal mucus, but not in the blood, so that the bacterioscopic examination is not ap- plicable to the nervous and gastric forms of influenza; and sec- 298 DISEASES OF RESPIRATORY SYSTEM ond, in broncho-pneumonije not due to influenza Pfeiffer found pseudo-influenza bacilli, which are very similar to true bacilli in their form, their relation to stains and their ability to give cul- tures only in the blood-agar ; but are distinguished by being in cultures of greater size, and with a tendency to form long threads. The differential diagnosis of epidemic la grippe from the infantile form is difficult only in catarrhal varieties of the former, because the symptoms are identical in both morbid states and the exact diagnosis impossible on the ground of the bacterioscopic examination (the microbes of infantile la grippe are yet un- known). From typhoid fever the catarrhal form of influenza easily differs by the nasal catarrh, which occurs in typhoid only as an exception ; serious difficulties are encountered in the diagnosis by cases of protracted influenza without coryza. In favor of influenza, there arc to be noted in the beginning the rapid eleva- tion of temperature during the first day of the disease, with pains in the limbs (in children the last symptom seldom occurs) ; and, during the second week, absence of typhoid rose-spots) ; Widal's test and spleen tumor (swelling of the spleen sometimes occurs in influenza, therefore its presence does not exclude this disease), and a considerably ((uickcned pulse (in typhoid fever m children older than five years the pulse is relatively retarded). Whooping-cough, like la grippe, also belongs to general in- fectious, epidemic and contagious diseases. This malady is char- acterized by a peculiar, convulsive cough, because of the localiza- tion of the disease in the mucous membrane of the upper respira- tory passages, and, perhaps, also in the medulla oblongata. In the course of whooping-cough there are to be distin- guished : ( 1 ) The prodromal or catarrhal period. (2) The period of spasmodic cough, and (3) The period of resolution, or the blenorrhoeic period. The first period, the catarrhal, begins either in the form of mild la grippe, or as a marked pharyngitis. In the former case the patient's temperature increases (38 to 38.5 degrees C. — 100.4 to 101.3 degrees F.) and simultaneously he begins to cough, the results of physical examination of the chest being negative (phar- yngitis, s. laryngo-tracheitis), sometimes coryza also appears. DISEASES OI'- RESPIRATORV SYSTEM 299 The picture of the cHseasc is so siinihir to pharyngitis or, when ■coryza is present, to a shght la grippe, that the diagnosis during the first three days may be made perhaps only on the ground of the urinary examination {vide infra) and the character of the •epidemic. In the further course whooping-cough may be suspected be- cause slight la grippe usually does not become protracted, but," on the contrary, the resolution of the catarrh begins after about •three days from the commencement of the disease, the fever stops, the cough becomes less frequent and softer, while in whooping- cough it is the contrary ; even if the fever disappears, nevertheless the cough remains dry and frequent, especially during the ftrst hours of the night (this is characteristic of whooping-cough), W'hile Dover's powder given in the evening usually does not re- lieve the cough. During the second week the diagnosis of whoop- ing-cough, in the majority of cases, may be made with great prob- ability on the ground that, at the same hours of the night,- the •cough assumes a paroxysmal-like character. Before it consisted ■of separate coughing spells, but now of several coughing attacks, and the greater their number the more they are characteristic of whooping-cough (follow each other so rapidly that the child can effect an inspiration only after a whole series of coughing at- tacks). Such a cough resembles that of the second (convulsive) period, differing from the same by the absence of vomiting at the end of the paroxysm and of spasm of the glottis, upon which de- pends the whistling inspiration so characteristic of the real whoop- ing-cough. The transformation of the catarrhal period into the spas- modic one is thus occasioned gradually ; a peculiar convulsive -cough first appears once or twice during the night, and then also during the daytime. This cough is so characteristic that if heard •once it will never be forgotten, and whooping-cough ma\- thus be recognized from an adjacent room. The cough in pertussis consists in the following : the patient begins to cough at once violently; his face grows cyanotic, the paroxysmal fits of coughing follow each other uninterruptedh' until there is but little air suppl}- in the lungs ; then the patient takes a deep inspiration, but at the same time the glottis co!i- tracts spasmodically, and the air, while passing the narrow open- 300 DISEASES OF RESPIKATORV SYSTEM ing', produces a loud sound, which resembles a whistle, audible throug"h several rooms. Immediately after that the cough begins again, followed by a renewed whistling sound, etc., thus occur- ring from two to five times and even more, until the paroxysm terminates with vomiting, or the elimination of a great quantity of viscid mucus or saliva, accompanied by nausea. ' The whooping-cough jiaroxysms are most often repeated at night. Violent j^aroxysms of whooping-cough are very disagreeable to the child, therefore it often happens that the patient, feeling the attack coming on, becomes excited, his face expressing anx- iety. This is very characteristic of pertussis, and nothing similar occurs in bronchitis. In estimating the intensity of the disease attention should be given to the violence of paroxysms and their frequency. If the number of paroxysms does not exceed fifteen during twenty-four hours, then the whooping-cough may be regarded as a mild one ;. if from fifteen to twenty-four times, moderate ; and if more than twent\-four times, then a severe attack. As to the severity of the attacks one may jutlge, first, by the number of the whistling in- spirations from the beginning to the end of the particular attacks of coughing. In severe cases vomiting comes on only after the fourth or the sixth whistling inspiration, hut in tlie mild ones, after the first. The stenotic whistle during cough api)cars as a more con- stant symptom of whooping-cough than vomiting, because in ordinary cases it is evident at any paroxysm, while vomiting takes place about twice or thrice a day, especially after those attacks of coughing which come on immediately after eating. Therefore,, from the frequency of vomiting one may judge about the severity of the whooping-cough. Regarding the diagnosis, it is important to notice that the paroxysm of whooping-cough may be, in the majority of cases, produced by different means calculated to impel the child to- cough. Older children may be plainly told to cough pur- posely, but in smaller ones coughing is excited by pressing with the finger over the jugular fossa or larynx, and still better wdien examining the throat by using a tongue depressor. It is also DISEASES OF RESPIRATORY SYSTEM ' 30 1 known that ])aroxysms may take place upon excitement of the chikl (huit;liing, crying, etc.). Of other symptoms of whooping-cough, which permit the physician to diagnosticate the same witliout hearing the cough, the habitus of the patient, ulceration of the frenuhwi of the tongue, and the characteristic peculiarities of the urine are important. Because of often-repeated obstructions to the circulation of the blood during the cough there arise puffiness of the face, swell- ing of the eyelids, reddening of the conjunctivae, sometimes bloody extravasations in the sclerje and capillary haemorrhages in the skin of the face and most often in the eyelids. Ulceration of the frenulum of the tongue occurs only in chil- dren having incisors, and the sharper they are the quicker an ex- coriation develops. Therefore it appears much oftener in children under two years than after five years of age. The diagnostic meaning of the ulcers of the frenulum is great, as it occurs almost exclusively in whooping-cough. To the peculiar properties of the urine in whooping-cough attention was directed by Blumenthal and Hippius, of Moscow. They noticed that the urine of whooping-cough patients, notwith- standing its pale color, was of high specific gravity (from 1022 up to 1035 according to Vogel's urometer, instead of the normal loio to 1012), and rich with uric acid, which being very easily soluble becomes deposited in the form of minute whitish powder, which, as the microscopical examination shows, is uric acid. I verified Blumenthal-Hippius' conclusions in more than ten cases of whooping-cough and did not see even one exception to the rule established by them, and therefore hold it entirely justi- fied to call such a urine "whooping-cough urine." In the diag- nosis of whooping-cough it is especially important that the pecul- iarities of the urine, according to Blumenthal and Hippius, appear very early, namely, even during the period of incubation of the dis- ease, before the appearance of any cough, or in the very beginning of the catarrhal period, when the diagnosis of the pertussis can- not be based on anything else. Further observations will have to show whether such a urine does not also occur during other kinds of cough, for instance, in an afebrile pharyngitis or in a mild influenza. The diagnosis of pertussis cannot rest alone upon the whist- 302 DISEASES OF RESPIRATORY SYSTEM ling siridor accompanying the cough, because such whistHng in- spiration may be absent. It may also disappear in patients in. whom it had been present ; very often, for instance, it is absent during whooping-cough in nurslings ; it may disappear, in patients in whom it had been observed, because of the development of weakness, or as the result of some complication ; and, finally, it may be absent in mild and abortive cases of whooping-cough in which the disease does not go further than the catarrhal period, with some indications of a spasmodic nature. Sometimes the diag- nosis of such cases is possible only in connection with the occur- rence of other instances, or an epidemic. In a common, uncomplicated whooping-cough, auscultation and percussion of the chest give negative results, as the catarrh does not go beyond the trachea and the first bronchi. Regarding fever, it may l>e said that the temperature is normal during the period of complete development of the disease and, according to all authors, the presence of elevated temperature during the spasmodic period denotes some complication. How- ever, one cannot agree altogether with this last opinion, as cases of whooping-cough are met with in which fever, starting in the catarrhal stage, lasts through the whole spasmodic period, and no- complication occurs, so that, in diagnosing complications of whooping-cough, one should bear in mind that a febrile condition does not, per se, prove the development of a complication. After the three or four weeks' existence of the spasmodic period there is a gradual transition into the third stage, that of resolution or blenorrhoea. The cough becomes less frequent and weaker ; the vomiting and whistle disappear ; diffuse, moist, large and medium rales are heard in the chest ; the sputum, formerly light and viscid, becomes yellowish and may easily be expector- ated. After about two or three weeks the cough ceases altogether and the patient recovers. It is remarkable that in a patient recovering from whooping- cough there remains for a long time (for a few months) a pre- disposition to modified attacks of the disease, in that as soon as he catches cold or falls ill with la grippe, leading to involvement of the upper air passages, then the cough immediately assumes a spasmodic character,, that is, the patient coughs until the face becomes reddened and the whistling inspiration arises because of i)isi-:.\s]-:s ()]•' Ki:si'iR A TORY s^■s'n■:.M 303 spasm of the glottis. This is a relapse not of the specific whoop- ing-cough, hut only ot a pertussis-like cough which does not in- fect anyhody and, if the ])atient remains within doors, passes over as quickly as a conmion hronchitis. In view of the symptoms described, and the course, the diag- nosis of whooping-cough is easy, as the cough in this disease is so characteristic that it is quite impossible not to recognize it, U only it has been once heard. If such a cough occurs in several children of a given family, then the diagnosis cannot be doubtful. Some similarity to whooping-cough may be presented by cases of laryngo-pharyngitis when the patient begins to cough dryly and continues until vomiting results, but at the same time the characteristic whistling inspiration is absent, and the vomiting also does not last long, if the patient remains within his room. A pertussis-like cough also occurs in some cases of hyper- plasia and caseous degeneration of the bronchial glands. Besides the fact that the resemblance between these two coughs is quite a remote one, the essential difference consists in the course and the history. Whooping-cough is characterized by beginning with a dry, short cough which after a few days becomes spasmodic, wdiich in its turn after two or four weeks begins to decrease, be- coming moist and catarrhal. In hyperplasia of the glands the cough first occurs as a chronic bronchitis which, long after, may resemble a whooping-cough, (the child coughs until reddening of the face ; the cough is sometimes accompanied by a whistling inspiration) remaining in this stage of development an indefinite time. Such children are usually rachitic or scrofulous and suiter with swelling of the neck glands, exhibiting either symptoms of stenosis of the trachea (due to compression), or other symptoms of compression by the bronchial glands (page 275). Here it must be added that although enlargement of the bronchial glands very often occurs in childhood, nevertheless the pertussis-like cough seldom appears in the absence of whooping-cough itself. It has been mentioned that one must not confound pertussis with the spasmodic cough (accompanied by whistling and vomit- ing) which develops after exposure to cold in those convalescent from whooping-cough. The diagnosis of whooping-cough is not difficult even in am- bulatory cases. The diagnosis in such is based : 304 DISEASES OF RESPIRATORY SYSTEM (i) On the disease being of epidemic character (several members of the family cough). (2) The paroxysm of cough is accompanied by whistling inspiration and reddening (cyanosis) of the face, ending with vomiting and expectoration of sputum, even in small children (children under five years sufifering with an ordinary bronchitis never expectorate the sputum, but swallow it) ; therefore, if the mother states that the child, after the attack of coughing, dis- charges the sputum, then this circumstance (due to vomiting) is very characteristic of whooping-cough. (3) The cough is more severe at night than in the daytime. (4) Puffiness of the face and swelling of the eyelids. (5) Erosions of the frenulum of the tongue. (6) In many cases the negative results of the physical ex- amination of the chest, nothwithstanding the mother's claim that the child coughs very severely, are also characteristic. It is far more difficult to recognize whooping-cough in the first part of the catarrhal period. About the signs by which one may guided at this time we have already spoken ; the most es- sential are the whooping-cough urine and the existence of a prob- able epidemic in the same family or neighborhood. [Some authors, as Meunier, Wanstall, claim that in the catarrhal stage of whooping-cough there is an inverse ratio be- tween the polynuclear leucocytes and the lymphocytes ; or that the latter are sometimes equal in number to the polynuclear neu- trophile cells ; therefore this sign may be of value for the diag- nosis of whooping-cough in its early stage. — Earle.] In diagnosticating whooping-cough in nurslings, one should bear in mind that at this age the disease may occur without a whistling sound, but it is important to know that the majority of coughing fits end with vomiting; that the fits of coughing fol- low each other uninterruptedly, producing reddening of the face ; that an ulcer often arises under the tongue ; and that a violent cough obtains without fever and often even without any rales. Because of the absence of the inspiratory whistle the physician often does not recognize whooping-cough in nurslmgs, mistaking the same for a "teetlting cough,'' but, of course, without reason, because a cough during dentition dift'ers in no manner from a bronchitis cough ; it soon passes away and is not prone to be com- plicated with vomiting. DISEASES OF RESPIRATORY SYSTEM 305 Amoiii;" pulmonary diseases occurring witliout dullness of the percussion note, but \vith coughing (because of the accompan\- ing bronchitis) and dyspnoea, we have piihnonary a^dcnia a)id oii- f'hyscnia. QKdema of the lungs, in its physical features, resembles diffuse bronchitis, as it is manifested by dyspnoea while the per- cussion note is clear, and in lx)th lungs numerous moist, small and large rales are present. The diagnosis of pulmonary oedema ma}' be considerably assisted by the accompanying symptoms which clear up its aeti- ology. Here are referred, for instance, general dropsy because of nephritis or heart-lesion, heart-failure during severe infectious diseases, retarded blood circulation in the lungs in the presence of an abundant pleuritic exudation, pneumonia, etc. Grave cases are characterized by the rapid development of dyspnoea together with cyanosis, coolness of the extremities and somnolence due to CO.. poisoning. Capillar}' bronchitis never extends so rapidly over both lungs, but increases gradually, beginning with the posterior and in- ferior portions. But the most characteristic symptom of pulmonary oedem:. is undoubtedly the expectoration of an abundant, very fluid, foam}', yellowish or slightly blood}' sputum. In the majority of text-books on children's diseases emphy- sema is not discussed in a separate chapter because a real emphy- sema characterized by dilatation of pulmonary alveoli with sub- sequent atrophy of the interalveolar walls and capillaries almost never occurs in childhood. What is called, in children, "emph}- sema" is indeed not emphysema, but dilatation of the lungs — dilatatio puhnonnni — wdiich is a temporary condition. Such a dilatation of the lungs very often occurs in whooping-cough, as well as in chronic bronchitis, and is especially noted by the dis- placement of the boundaries of the clear pulmonary sound in the area of the anterior margins of the lungs (decrease of the cardiac dullness) and in that of the lower margins (lowering of the upper boundary of the hepatic dullness down to the seventh and even the eighth rib). It seldom occurs that the chest assumes, because of increase of its horizontal dimensions, a "bariel- shaped" form, as is commonly observed in adults. In very chronic 306 DISEASES OF KESPIRATORV SYSTEM cases other symptoms of a real emphysema may also appear, as for instance, symptoms on the part of the circulatory organs in the form of contraction of the arteries, and stasis in the pulmon- ary circulation and in the veins of the whole body ; the accentu- ated second pulmonic sound and pulsation in the epigastrium denotes, in such cases, dilatation and hypertrophy of the right ventricle and increased pressure in the pulmonary artery (stasis in the veins of the pulmonary circulation) ; and enlargement of the liver, obstructive urine and (cdema ()f the feet indicate stasis in the veins of the greater circle. DISEASES OF THE LL'XcJS CHARACTERIZED BY THE APPEARANCE OF A DCLL PERCUSSION SOUND. Croupous Pneumonia. Pneumonia crouposa occurs in chil- dren of any age, not excluding even nurslings, not less often than in adults. It always has a very acute course, being marked by the sudden onset of violent fever and the rapid development of hepatization of a whole, or almost a whole, lobe of the lungs. According to the place of formation of the exudate a dull note is obtained, and as the hepatized lung conducts the sound l>etter than an inflated one, then over the place of dullness l)ronchial respiration and bronchophony are heard, and upon palpation there is increased vocal fremitus. These general symptoms occur in ty])ical as well as in anom- alous forms of croupous pneumonia, variations being indicated by the different character of concomitant s}'mptoms and by the ■course. Typical croupous pneumonia begins in children older than seven years, as w^ell as in adults, with chills ; in those younger with some approximation to such an initiation (coolness of the •extremities, cyanosis of the lips), sometimes with general convul- sions, oftener with vomiting, but for all cases the rapid onset of violent fever is characteristic : even during the first twenty-four hours the temperature reaches about 40 degrees C. (104 degrees F.) and more. Simultaneously there appears a short, dry, pain- fnl cough and a hurried respiration (in children vuider two years about eighty per minute, in older ones about forty to fifty, with dilatation of the nostrils). Children older than five or six years from the very first days complain of pain in the side, increasing DISEASES OF KESI'IKA roKV SVSTIl.M 307 during- cough and dcc'i) ins])iration. which cousidcrahly assists the diagnosis in the heginning of the disease when symptoms of hepatization of the huigs have not yet appeared. Children from three up to five years of age ahnost never complain of pain in the side of the chest, l)ut they point with the same constancy to abdominal pain either in the epigastrium or lower, but in general without an exact localization. The alxlom- inal pain is, in the beginning of pneumonia, in small children, of quite marked diagnostic importance, as infants usually do not complain of abdominal pain when they become affected with acute gastrites, w^hich may resemble croupous pneumonia in point of the incipient vomiting. Peritonitis, however, cannot even l)e thought of here, as the pain in the abdomen during pneumonia usually does not increase upon pressure, therefore its location cannot be determined by palpation. This pain is only a seeming one, reflected, that is, it is wrongly localized by the child. [Reg'arding abdominal pain in pneumonia of children men- tion occurs in a note on p. 217.— Earle.] Thus, if we find a patient wdth violent fever, quickened respiration, wath dilatation of the nostrils, and short, dry, frequent cough, and we suspect from such evidences a beginning pneumonia, then the abdominal pain, even accompanied by repeated vomiting, coated tongue, etc., not only does not contraindicate this proposition, but indeed con- firms it. The pain, in our opinion, has greater significance than even the quickened respiration which occurs during any high fever; so that one should remember that frequent respiration may only have significance as a symptom of hmg- afiFection when accompanied by dilatation of the nostrils and cough, and when its frequency is increased disproportionally to the pulse. Normal- ly, to one respiration there correspond three or four pulse-beats, and in acute diseases of the lungs the ratio changes as i : 1^/2 or 2. If pain on breathing increases considerably, then w'e have sighing expiration in which each expiration terminates with a short sighing efl:'ort. It should be borne in mind that such sigh- ing character of the respiration also occurs in dyspncea from other causes. [Pfaundler records from his seven years' observations that in children sufifering with pneumonia, especially the cerebral form, the knee-jerk is entirely absent or diminished on one or 3o8 DISEASES OF RESPIRATORY SYSTEM both sides, while in healthy children this occurs very seldom. Pfaundler could detect this sign even before the general physical signs made themselves evident.* — Earle.] Judged by the symptoms just mentioned a beginning pneu- monia may be suspected with great probability. A more definite conclusion cannot be made even by means of the results of phys- ical examination of the chest, as hepatization does not occur early. It, therefore, often requires two or three days to reach a positive diagnosis. [Weill called attention to one sign which appears very early during croupous pneumonia in children, and which is always pres- ent. This is lack of expansion of the subclavicular region of the affected side, even when the pneumonic process involves the base of the lung. It is observed sometimes in the very beginning of the disease and is persistent during the whole course of the process.** Weill's observations have been confirmed by Gillet.*** — Earle. ] At first percussion gives either negative results, or a tym- panitic tone is obtained over the point of the inflammation, but this note does not decide the question. On auscultation one may hear crepitant rales, in adults, over a limited area, but these are almost always absent in children during the first period of pneu- monia, because to make them evident, the child would have to take deep inspirations, whereas his breathing, because of pain, is very shallow. Earlier than other signs of hepatization of the lungs bron- chophony appears, which renders it possible to foretell in what part hepatization will develop after about two days. In the further course of pneumonia the fever remains for several days at the same level or rises still higher, up to 41 or 42 degrees C. (105.8 to 107.6 degrees F.), and remains in the form of febris continua with insignificant variations during from five to nine days, when it terminates by crisis in a few hours, the temperature falling below the normal, usually accompanied by abundant perspiration. During this time the local evidences on the part of the lungs *Munch. Med. Woch., July 22, 1902. **Quote(l from Am. Jouru. of Med. Sci., Apri', 1902. **''Gazette des Hopitau.v, 1903, p. 749. DISKASES OF KICSl'I K AK IKN SVS'H'.M 3O9 become clearly appreciable; corresponding lo this or thai loi)e of tlie lungs there is considerable iliilliiess, loud bronchial respira- tion, bronchopJiony and increase of the vocal fremitus. With the fall of temperature the period of resolution of the inflammation sets in ; in place of dry bronchial respiration crep- itation appears, the dull note and other signs of hepatization of the lungs gradually decline, and in a few (la}'s the normal stan- dard is reached. A due consideration of the s}nii)toms named renders the diagnosis easy during the active phase of development of the disease. If the dull sound corresponds to the inferior lobe of the lung the cjuestion may then arise regarding a pleuritic exu- date. Although moderate exudation gives a dull percussion note, yet, as the lungs are not completely compressed, and between tlie observer's ear and the bronchi there is located air-containing pul- monary tissue, therefore not a bronchial respiration is heard upon auscultation, but only a weakened vesicular one; bronchophony is also absent, and the vocal fremitus is necessarily weakened. The occurrence of vesicles of herpes on the lips or within the nose is also strongly presumptive of pneumonia and against pleurisy, because it occurs very often during pneumonia, and al- most never in pleurisy. Nevertheless, cases are observed in which the diiTcrentiation between pneumonia and pleurisy is not so simple as it seems to be ; it is the more difficult the less is the amount of exudate and the younger the child. The greater difficulty of diagnosticating pleurisy in children in comparison with adults depends upon the following conditions : (1) There is no sputum (in adults a bloody, viscid, extens- ible sputum is pathognomonic of pneumonia). (2) It is difficult to examine for the vocal fremitus. Gen- erally speaking this symptom belongs among the most certain for the differentiation of pneumonia from pleurisy ; in the former it is increased; in the latter, decreased, which is especiall\' notice- able in adults, when the voice is low ; in children, however, the voice is loud and this makes the fremitus pectoralis less distin- guishable. In acute pneumonia, as well as in pleurisw the condi- tions are still more unfavorable, as, on account of pain, children avoid loud talking and likewise loud crying ; they only sigh loudly 3IO DISEASES OF RESPIRATORY SYSTEM or groan slio^htly, which is insufficient for vocal fremitus. Further- more, if pneumonia is accompanied by bronchitis and the afferent bronchus is blocked up, then the vocal fremitus may be weak- ened, notwithstanding' the hepatization of the lung, and simul- taneously the bronchial respiration and bronchophony decrease also. The same happens in the so-called massive pneumonia (Grancher), characterized by abundant formation of exudate with obstruction of bronchi with fibrinous clots. (3) Bronchial respiration in pneumonia may be weak, or inaudible altogether, even without obstruction of the bronchi, simply because the child breathes feebly ; and on the other hand such a respiration also frequently occurs in pleurisy, together with bronchophony (but without exaggeration of vocal fremitus), and in cases of more considerable exudation which compresses the pulmonary tissue completely, leaving, however, the bronchi open to the passage of the air. l^he differential diagnosis of doubtful cases of pneumoni i from i^leurisy is based: (a) on the character of the fever; (b) on the form of the dull note, and ( c ) on the course. (a) There are few diseases which are accompanied with so high a tem]X"rature as croupous pneumonia, in which 41 de- grees C. ( 105. cS degrees F.) in the axilla is a common finding, even 42 degrees C. (107.6 degrees F.) exhibits nothing peculiar, such a temperature being neither rare nor dangerous ; and a tem- perature below 40 degrees C. ( 104 degrees I"". ) during the whole first week of the disease almost excludes pneumonia (crouposa). In pleurisy it is dift'erent ; the beginning of the disease is not so sharp, because the initial elevation of temperature does not occur so rapidly ; during the first week there is seldom more than 40 degrees C. (104 degrees F.), and even then not all the time, as toward morning there is usually a marked fall (0.5 to 1.5 de- grees) ; crisis is seldom observed, but, on the contrary, during the second or third week the morning temperature begins to show considerable decrease, ])erhaps even complete intermissions and thus ends with lysis in flight cases in alx>ut three weeks, in grave ones much longer. Thus, if the patient coughs, complains of pain in the side, the percussion gives a dullness in the posterior part of the chest from the half of the scapula downwards, the respiration being at this point indefinite, or weakly bronchial, the fremitus DISEASES dl" KESl'lUAKiRN SNSIE.M 31f impossible tt> be (letennined, tben, in main- cases, tbe question nuist be decided by the course nf teiii])erature : it the patient had a constant fever for several days with a temperature of ahon; 41 degrees C. (T05.8 degrees V.), then it is most probable that he has pneumonia; if, however, the temperature had never ascended to 40 degrees C". (104. degrees l'\ ) , tlvn more likel\' pleurisy obtains. If the tem])erature during the tirst week was about 41 de- grees C. (105.8 degrees ¥.) and. nevertheless, pleurisy was iouu 1 as the cause of it. then one may fear that a purulent exudation has taken ])laee. In other cases such temperatures may accom- pany exudative i)leurisies which com])licale ])neumonia. and a complication of that kind may Ije recognized, if the relativelv dull sound peculiar to pneumonia becomes absolutely dull, if the vocal fremitus (lisa])pears. the resistance considerably increases, and the intercostal s]:>aces become protruded. Bronchial respiration and bronchophony not infrequently increase considerably. Since the hepatized lung cannot be compressed and does not give place to the exudate, symptoms of displacement of neigh.boring organs set in. (b) The dull sound in pneumonia crotiposa, in its area, corresponds to the affected lobe, in the case in question to the in- ferior lobe of the lungs, although it very rarely happens that the infiltration occupies the whole lobe, the anterior margins usually remain free, and the dull sound abruptly ends on the posterior axillary line or somewhat forwards thereof, but does not involve the anterior surface of the chest, so that on the right side, for in- stance, between the nipple and the upper boundary of the liver. the note remains clear. It is also characteristic that the dull sound in pneumonia ai)pears almost at once over the whole surface. In pk'uris}- the dull sound first of all api)ears in the lowest portion of the chest behind and then slowly, for several da}s, rises up- wards, and when the half of the scapula is reached, then it ex- tends also to the anterior surface of the chest where its upper boundary is always higher than on the back. Such a definition of the dull sound is very characteristic of pleuritic exudation and serves as a certain criterium for its distinction, not only from pneumonia. Init also from hydro-thorax, in which the upper boun- darv of the dull sotmd, because of the free movement of the 312 DISEASES OF RESPIRATORY SYSTEM fluid in the pleural cavity, lies on the horizontal level, when the patient is in a sitting posture, that is, the fluid is then on the same level behind as in front of the chest. Finally, it is also noteworthy that, during a considerable left-sided exudation, there decreases or entirely disappears the so- called Traube's semilunar space, which does not diminish during pneumonia ( semilunar space of Traube is the region of the tym- panitic smmd of the stomach extending over the left hypochon- Fig. 31 — Stniilunar space of Traube (after Sahli). drium ; the inferior boundary of the semilunar space is formed by the lower margin of the left half of the chest, and the upper by a curved line with the convexity upwards, which reaches the sixth rib ; the lateral boundaries of Traube's space are limited by the mammillary and anterior axillary lines). (Fig, 31.) In case of large pleuritic exudations it is not easy to con- found pleurisy with pneumonia. In children one can observe, earlier than in adults, the dilatation of the aflrected half of the DISEASES OF KES1'1KA1'()K\' SYSTEM 3I3 chest, noticeal:)lc to the eve and which may be easily tleterniinecl by measuring- (the difference in smah children is 1^2 to 2 centi- meters, in older ones 3 to 4 centimeters) ; also the diminution of its movability during respiration and the displacement of the heart or the liver. Those beginning practice should bear in mind that, even in the presence of very abundant exudates which fill the entire half of the chest up to the clavicle, bronchial respira- tion nevertheless may be heard, and really is frequently heard. If bronchial respiration be present, tlien there is also broncho- phony, but vocal fremitus will be in any case weakened. If the dull sound occupies the whole half of the chest, from the clavicle downward and from the vertebral column to the sternum, then it is almost certainly a pleurisy, as in the so-called total pneumonia (pneumonia totalis) the anterior borders usually remain free, and thus along the sternum the note will be clear W'ith a tympanitic timbre. On the contrary, if the dull sound •corresponds to the upper lobe alone, then it directly points toward pneumonia, and excludes pleurisy. (c) The course of pneumonia is a very acute one, the febrile period ending in from five to seven, sometimes in eleven, ■days, and a few days later the physical signs of hepatization also •disappear ; on the contrary, pleurisy is usually of a slow course, the fever disappears earlier than three weeks, and the dull sound is maintained still longer. (d) If despite the above-named signs the diagnosis re- mains obscure, then for the final determination an exploratory puncture in the area of the dull sound must be resorted to. ANOMALOUS FORMS OF CROUPOUS PNEUMONIA. Abortive pneumonia dift'ers from the typical only by its shorter course; the febrile period lasts about three days, or even only one day, and accordingly the local symptoms soon disap- pear. In the event of incipient vomiting the disease may be mis- taken for an attack of gastric fever, but such an error is avoided if attention be directed to the frequent respiration, cough and the results of physical examination of the chest. Much greater difficulties in diagnosis are presented by cases of central pneumonia — pncnuionia centralis — which are charac- terized by late appearance of the physical symptoms of hepatiza- tion of the lungs. The disease begins like a usual croupous pneu- 314 DISEASES OF RESPIRATORY SYSTEM monia, that is, with violent fever, cough and hurried respiration^ but three or five days will elapse before the real nature and situa- tion of the disease may be learned. It is supposed that the in- flammatorv focus arises primarily in the center of the lobe of the hmgs and therefore remains latent until the hepatization, increas- ing gradually in all directions, reaches the pulmonary surface. It is significant that in the large majority of cases central pneumonia is localized in the upper lobes and that the majority of apex-pneumoni.T belong to the latent variety. Symptoms which lead to the correct estimation of latent pneumonia consist in the following : (i) Dyspiicra, characterized by frequent respiration (the ratio between the breathing and tlie ])ulse is I :2), with dilata- tion of the nostrils and with accentuation in the expiration, which is frequently accompanied l)y sighing. (2) Short, dry painful coiii^h. (3) A very high, continuant type of fever. (4) I'nilateral pain in the chest or, in children under five years, al)d(>minal ])ain. If children do not themselves complain of pain (for instance,, pectoral), then it may be recognized by percussion; the child be- gins to cry each time as percussion is attempted over a certain region, for instance under one or the other clavicle. By means of this symptom we may often determine the place of the inflam- mation about forty-eight hours previously to the appearance of dullness or bronchial respiration. Still more diagnostic difliculties are met with in the so-called CEREBRAL PNEUMONIA — pueumonia cerebralis — in which, as if designedly, everything is so confused as to force the physician to an error: (i) From the very commencement of the disease, together with the development of fever, there appear cerebral symptoms,, simulating;' meningitis (hence the name). (2) We deal usually with apex-pneumonice, running lat- ently. (3) Repeated convulsions and somnolence mask the mani- festations of dyspnoea and cough. Barthez and Rilliet distinguish two forms of cerebral pneu- monia — the convulsive and the meninoeal. DISEASES OF RJCSIMRAIOKV SVSl i:.\I 315 The convulsive form of cerebral pneumonia occurs almost solely in small children about two years old. and especially in nurslings. Like any other pneumonia this form ccjnies on sud- denly, with violent fever, not infrequently with vomiting, and then eclamptic convulsions appear with a subsequent semi-con- scious condition. If eclampsia be not repeated, then the som- nolence is soon over, and the further course of the case is like that of a common jvieumonia and, if you like, it is not worthy of the name of "cerebral pjieiiiiioiiia" \ but, unfortimately, it usu- ally happens that general or local convulsions are repeated for several days in succession, so that the child is in a continuous state of sopor, or in a condition similar to the latter. And under the influence of passive hyper?emia of the brain (due to oli- structed blood circulation caused by convulsions, fever and pul- monary affection) other cerebral symptoms also appear in the form of contracted neck, dilated pupils or of sluggish reaction,, irregular respiration and even temporary squint and paresis of the facial muscles. Therefore of great importance in the diagnosis of such cases is the character of the fever, namely, the constancy of very high temperature. If, for instance, we have in the morning and even- ing a temperature of 40 degrees C. ( 104 degrees F.), then this fact is strongly opposed to meningitis, which occurs with lower temperatures. Furthermore it is known that the rapid onset (witli violent fever and convulsions) is peculiar only to acute purulent meningitis, which does not appear without evident reason, but pertains, for instance, to otorrhoea, contusion of the head, insoli- tion ; thus, the absence of any noticeable cause for acute ineni)i- gitis serves as another criterion for its exclusion. And then again the duration of the disease is also important. If in meningitis we have repeated convulsions, such may be in- dicative of the beginning of the end ; the patient falls into a deep stupor of which he does not become free until death. Acute meningitis is characterized b\ the early onset of con- vulsions ending with death in three or Ave days. In pneumonia, on the contrary, there are no prolouuil changes in the brain, and, therefore, if convulsions occur even at intervals of but a few hours' duration, the consciousness of the patient begins to clear readilv, and he reacts better to irritation (see also 3l6 DISEASES OF RESPIRATORY SYSTEM the Semeiolog-y of Convulsions). It is remarkable that the cere- bral symptoms usually abate as soon as pneumonia becomes well determined. Barthez and Sanne* do not ascribe any diagnostic value to the accelerated breathing which ' also occurs in some cases of acute meningitis in very small children. Of more importance for the correct estimation of the case are the freciuent cough and the expiratory character of the res- piration (the expiration ends with sighing), which symptoms speak positively for pneumonia and against meningitis. On the other hand, the appearance of paralyses and contractures after convulsions points, in their opinion, toward inflammation of the cerebral meninges. If cerebral symptoms do not set in from the very first of pneumonia, but complicate the latter in its further course, and if, in the period of hepatization, the cerebral symptoms not only do not abate, but even increase, then one may believe there is a complication of meningitis and pneumonia, which sometimes oc- curs in children, although very rarely. In the inciiiui^col loriii which is peculiar to older children (two and a half to six years old) convulsions are absent, and after the incipient vomiting and fever symptoms more resembling typhoid fever than meningitis appear ; the patient is somnolent and indififerent ; his tongue is dry and covered with brown crusts ; the faeces and urine are voided involuntarily ; delirium at night, and sometimes also during the daytime. Occasionally also symp- toms of meningitis arise in the form of general hypersesthesia, contracted neck and constipation, while the abdomen is somewhat sunken, but there is neither retarded pulse, deep inspirations, nor change of the color of the face characteristic of meningitis (a sudden redness of the cheeks alternating with pallor).*''' *Traitc Clinique ct pratique dcs iiuiladics dcs citfants, 1884, Vol. I., p. 744- **In this regard Bergeron's case may he held as a rare exception. This case is quoted by Cadet (Tr. din. dcs inal. des cnf., Vol. I., 1880, page 100). The disease began, in a child two and one-half years old, with vom- iting (which lasted three days), fever and somnolence; on the third day, convulsions ; on the fourth, contracture of the neck, unconsciousness, mas- ticatory movements of the inferior maxilla, hypersesthesia of the skin, Trousseau's spots, quick change of the color of the face, and. what is especially noteworthy, the temperature was not higher than 39 degrees C. (102.2 degrees F.), the pu'se was retarded (92), as well as the inspirations (28). On the fifth day consciousness was more pronounced, a cough ap- DISRASES OF RF.SIMRA roKV SYSTEM 3I7 Hie al)scnce of the above-named symptoms, as well as violent fever and the sudden onset, entirely exclude tubercular meningitis. Resi'ardini^ typhoid, the too early appearance of somnolence and of other so-called typhoid symptoms, as well as painful cough- ing and dyspnoea with the dilatation of the nostrils, are neither peculiar to it. Of great importance in the difterential diagnosis between such pneumonia and typhoid is the initial chill in older children, or a convulsive fit in smaller ones. Both exclude typhoid almost positively. It is obvious that doubt may last long only in central pneumonia. Wandering pneumonia — pneumonia migrans — is character- ized by the inflammation not remaining at the place of its primary occurrence, but spreading, like erysipelas, further and further, traveling over the whole lung, so that the disease ma}- become very protracted. It is not difficult to note from the physical examination of the chest that the inflammation resolves in the earlier afifected parts and develops again in neighboring ones. The fever then may be markedly irregular, up and down, signifying by this the formation of a new focus and its termination ("oscillator}^," sac- cadirende, pneumonia). However, such elevations of the temperature are often of such short duration that the}" cannot correspond to the formation of a focus. According to Cadet de Gassicourt we have in such cases only separate, brief pulmonary hypergemi?e, which are mani- fested either by some dullness and crepitation of short duration, or even by no objective symptoms at all. According to Barthez and Sanne* such congestions never protract the disease longer than the twelfth day. but this is not correct, as seen, for instance, in the temperature table on page 326. As such pneumonia oftener occurs in la grippe we shall peared, and a pneumonic focus became clear in the lower lobe of the lung. On the sixth day all cerebral symptoms disappeared and the child soon re- covered. Until the fifth day the diagnosis of pneumonia could not be made, especially because the temperature, the pulse and the respiration were entirely unusual for cerebral pneumonia, while physical examination was not followed. *Traitc din. ct. prat, de )iial. dcs enf., Vol. I., page 732. 3l8 DISEASES OF KESI'IRATORV SYSTEM g^ive the charts when we speak about the grippous pneumoniae. Catarrhal pneumonia — piiciiinoiiia catarrhalis. The chief dififerences between catarrhal and croupous pneumoniae consist in the former always being preceded and accompanied by symptoms of catarrh of the small bronchi. This catarrh by spreading to the alveoli causes the formation of small inflammatory foci, which correspond to the ramifications of the bronchial twigs, hence the name — broncho-pneumonia — or lobular indammation of the lungs, in distinction from the lobar variety, which is peculiar to croup- ous penumonia. In the further course separate small islets of hepatization may coalesce with each other, forming larger foci of hepatization — pseudo-lobar or generalized lobular pneumonia. Clinically such a course of the process makes itself evident in the beginning by symptoms of febrile capillary bronchitis, that is, by dyspnoea and the presence of more or less abundant small rales, especially in the posterior lower portions of the lungs. According to the extension of the inflammation to the alveoli, that is, accord- ing to the development of hepatization of the lungs, the rales be- come louder and louder — consonant rales, and. fmally, there may appear a noticeable dullness, bronchial respiration and broncho- phony. Ca])illary bronchitis is usually more developed in the pos- terior and lower portions of both lungs, while emphysema de- velops in the anterior portion. The same may be said of catarrhal pneumonia. As a matter of fact, the latter is characterized by the appearances of hepatization being first observed on the back, on both sides of the vertebral column. Consonant rales in diffuse broncho-pneumonia ma}- be present in these places for a long time without distinct dullness ; the percussion note remains clear or it obtains a tyuipanitic timbre, which depends upon the fact that between the hepatized foci there yet remains a sufficient quan- tity of normal pulmonary tissue to prevent the exhibition of the dull sound, therefore, it happens that the diagnosis of catarrhal pneumonia in its beginning is far more determinable by ausculta- tion than by percussion. In croupous pneumonia, on the contrary, the inflammation at once occupies the pulmonary parenchyma, without the prelim- inary affection of the capillary bronchi, that is, the development of pneumonia is not preceded by a febrile bronchitis. The focus of inflammation from the very first days involves an entire lobe DISKASKS OF RESPIRAIOKV SYSTEM 3I9 of the Inni^s, or, at least, its larger part, so that very soon there appears a dull note over the region of the affeeted lobe, and on auscultation bronchial respiration and bronchophony obtain. Regarding- the consonant rales, they appear only in the period ■of resolution of the croupous inflammation and only over a lim- ited space, that is, not passing the boundaries of the inflamed lobe. The further course consists in catarrhal pneumonia being mostly bilateral ; its favorite points of localization are the pos- terior lower portions of the lungs ; whereas, croupous pneumonia •oftener alTects only one lung, without preferring the lower por- tions, as it involves equally often the upper parts as well. As to the course of the temperature, in croupous pneumonia the fever reaches a considerable height as soon as the first even- ing, and with considerable oscillations keeps the same maximum level for several days, terminating with marked crisis ; in catar- rhal pneumonia the temperature generally does not reach such a height and only at times rises higher than 40 degrees C. ( 104 degrees F.), remaining, however, at such heights but briefly (from a few hours to forty-eight or seventy-two hours) and then falls again ; in short, the temperature chart in catarrhal pneumonia is distinguished by being inconstant and varying during the twenty-four hours, when it terminates by lysis which lasts three to seven days and longer. In its course croupous pneumonia is a very acute disease ; it sets in suddenly, remains at a certain height several days and after five to eleven days terminates as quickly as it started. Catarrhal pneumonia, however, develops gradually, lasts from two up to several weeks, and ends slowly. The cough in catarrhal pneumonia is violent ; the patient, as it is said, coughs "heavily" ; the dyspnoea is more pronounced ; the cyanosis appears quicker, as well as the pufiiness of the face and feet. -\.n essential difference is also noted in the cetiology ; croup- ous pneumonia affects most often entirely healthy children, thus appearing as a primary, entirely independent disease : while catarrhal pneumonia is a secondary affection developing from l)ronchitis. being, therefore, observed only in children sick with a disease which is associated with the inflammatiiMi of the bron- 320 DISEASES OF RESPIRATORY SYSTEM chi ; therefore most often occurring in measles, whooping'-cough, croup (especially in small children under four years of age) and in rachitis. If catarrhal pneumonia becomes protracted for several weeks then it may be accompanied by the formation of bronchiectasiae, and then, upon examination of the lungs, cavernous symptoms are obtained in the form of large, consonant rales, of a metallic timbre of the percussion note, and cavernous respiration, so that the ques- tion arises, with what kind of cavities in the lungs have we to deal — with caverns of tubercular (caseous) origin or with bron- chiectasicC ? This question only leads to the differentiation of a protracted catarrhal pneumonia from a tubercular one. Physical symptoms alone are insufficient for the decision of this point, because in both cases they will be the same ; besides this, both diseases most often arise after measles and whooping- cough, both arc accompanied by irregular fever and exhaustion, and both last weeks and even months. Characteristic of tul)ercular disease of the lungs in adults are the parts aft'ected, namely, the upper portions ; but in children tuberculosis does not select the apices. The examination of the sputum for bacilli and elastic fibers is mostly impossible, because children under six years of age, in whom catarrhal pneumonia most often occurs, do not expectorate. Likewise the temperature chart does not give sufficient in- formation upon which to base the diagnosis, as in tuberculosis it is of the same irregular type as in protracted catarrhal pneu- monia. Briefly, the differential diagnosis of these two processes is very difficult, notwithstanding that the prognosis depends upon it, as pulmonary tuberculosis almost always ends fatally, while catarrhal pneumonia often turns to convalescence, even when pro- tracted for months and accompanied by considerable wasting and physical signs of pulmonary caverns (bronchiectasice). Tubercular pneumonia may be supposed with almost com- plete probability in case the patient exhibits other symptoms of tuberculosis, for instance, in the form of chronic disease of the bones, joints or glands, or if the chronic inflammatory process involves the pulmonary apices, the patient being above the age oisKASKs OF UKSi'iRAr()k\' svs'i i:m 321 of six years, and the pulmonary lesion itself of ehronic eoiu'se. In older children tuhereular afifections of the lungs differ from the same disease in adults perhaps only by the quicker occurrence of a fatal termination. On the contrary if the disease began in the form of acute catarrhal pneumonia ( for instance, after measles) in a child previ- ously in good health, and especially under three years of age; if the process involves the posterior, lower' i)t)rtions of the lungs; then non-tubercular catarrhal pneumonia may be supposed and thus a favorable termination may be hoped. It is self-evident that there cannot be a complete certainty regarding the absence of tuberculosis during a protracted pneu- monia for the reason that in the presence of some tubercular pre- disposition, which is so often met with in rachitic and scrofulous children, tuberculosis may complicate the original disease. A marked likeness to catarrhal pneumonia is presented by cases of hypostatic pneumonia. The similarity consists in the hypostasis being usually bilateral and occupying the posterior, lower portions of the lungs ; in the beginning a weakened respira- tion with small rales is noted, and, later, symptoms of a genuine pneumonia — dull sound, bronchial respiration and bronchophonv. The difference is based not so much on the symptoms, as on the aetiology ; hypostatic pneumonia requiring for its development two conditions ; a weakened heart-activity and a prolonged re- cumbent posture on the back, and therefore it obtains most often during severe cases of febrile diseases, especially of typhoid. Crepitant rales in the posterior lower portions of the chest may be noted, upon deep inspiration, in children in whom the heart acts well and whose general condition is satisfactory, yet have been compelled for some reason to remain for a long time in bed. This crepitation differs from that of inflammatory origin by its disappearance after two or three deep inspirations, depend- ing not upon the presence of fluid in the alveoli, but upon their walls being glued together, so to say, and then separated by the entrance of air. In one case in a girl eight years of age I ob- served this condition on the tenth day of a very mild scarlet levei ; there was neither fever, dyspnoea, nor cough, so that there could not be any doubt as to the nature of the crepitation. This case proves how early such a crepitation occurs in children. The same 322 DISEASES OF RESl'IRATORV SYSTEM may also be observed after absorption of an abundant pleuritic exudate, and may be noted a long time (weeks) after the child decidedly improves and is up, yet the compressed lung remaining in the condition of atelectasis. In very sick patients the small and large moist rales may be indicative of piilnwnary oedema, that is, of efifusion of serous liquid into the pulmonary alveoli. This condition is chiefly characterized by the wide distribution of the rales, the percussion-note being clear, and by dyspnoea rapidly setting in, as well as by these symptoms appearing either during the course of a general dropsy already developed (diseases of the kidneys, cardiac lesions), or as a death-symptom in diliferent acute diseases in the period of cardiac collapse. From capillary bronchitis pulmonary oedema differs by the rapid onset and spreading of the rales, and, especially, by the sputum, (if only the patient expectorates the latter), which in pulmonary oedema is very abundant, thin and frothy. One may find in the text-books hints by which to distinguish catarrhal pneumonia from capillary bronchitis complicated with atelectasis of the pulmonary alveoli — ^atelectasis pulmonum. It is, for instance, mentioned that atelectasis does not cause fever, that the dull sound and weakened respiration or appearances of consolidation rapidly disappear after the patient makes a few deep inspirations, etc. ; but all these signs are purely theoretical, be- cause in such an atelectasis fever is always present, although de- pending not upon the atelectasis, but on the accompanying capil- lary bronchitis. It is difficult to notice the disappearance of the dull sound after deep inspiration inasmuch as atelectasis usually develops in small children in whom it is difficult to induce deep inspirations. It is sufficient to say that atelectasis may be with certainty suspected in any capillary bronchitis and in catarrhal pneumonia in small children. Congenital atelectasis indeed runs without fever, being char- acterized by a dull sound and weakened vesicular respiration in some certain portions of the chest, or by crepitant rales due to separated pulmonary alveoli. As to the islet-like atelectasis this becomes recognized not from the results of the physical examina- tion of the chest, but from the history (the child was born in DISliASKS OF Ri:Sl-IK.\l()RV S^S^I■;M 323 I? op' 324 DTSEASES OF RESriRATORV SYSTEM the condition of asphyxia), (jf the weak, screammg voice, fre- quent respiration and cyanosis. Pneumonia during endemic la grippe has a different course dependent upon whether it comphcates a case of la grippe running- with constant fever, or a protracted case with an atypical fever. In the former case pneumonia in its physical signs entirely corresponds to croupous ])neumonia with which it is often con- fused ; dull note, hronchial respiration, hronchophony and the exaggerated fremitus develop rajMdly and involve at once a whole pulmonary lobe, the upper or lower one — this is immaterial. After a few days the disease ends almost by crisis, in short, everything seems as in croui)()Us ])iu'um(>nia, yet there is a difference con- sisting ill the following: typhical croupous pneumonia affects healthy children, the grip])ous, however, those w^ho had already been sick several days with la grippe, that is, it alzvays appears several days after the appearance of rhinitis, coiii^h and fever^ most often between the fifth and the ninth days. In this respect it resembles the so-called central pneumonia, the majority of cases of which Ijelong. in my opinion, to la grip])e, especially if we deal with pneumoni?e of the apices. The temperature in croupous pneumonia is distinguished b}' the constancy of the high degrees and the very rapid termination from the fifth up to the eleventh day. In grippous pneumonia the temperature, al- though it also may be a constant one, yet in the majority of cases it makes considerable excursions u]) and down, with a termina- tion not so rapid (approximately in thirty-six to seventy-twa hours). The course of the temperature is sometimes, in the first days of the disease before the development of pneumonia, irregular to such a degree — so typical of la grippe — that croupous pneumonia cannot even be thought of. We reproduce here two charts, one belonging to a ten-months-old girl and the other a seven-year-old boy. A girl aged ten months became sick on February 22d, with rhinitis, cough and fever. From the 24th to the 28th the child felt better, but from March ist fever reappeared, of an in- termittent type. From the sixth of March the temperature is noted on ihe chart (Fig. 32). DISI'-. ASI'.S Ol'- RE >>S'li:.M 325 The objective exainination of llie luniks np lo ilu- Iwelfth day of the disease was nei^ative. the couL;h havini,'- heen incon- siderable, but would increase every time aloiii:; with the period of temperature. 'JMie resf)iration was from sixty to eighty. Tumor of the spleen k'us absent. Ouinine, from two to four-and-a-half grains, pro die. did not influence the lein])erature. On the twelfth day dullness was noticed under tlie rii^ht clavicle, with bronchial respiration and bronchophony. Convalescence, under an indilter- ent treatment, on the twenty-second day. The chart in this case resembles very much that of inter- mittent fever the more .so in that elevations occurred in the ■nHBBHaBllBBin ^■■■■■■■■■1 ■■ ■■■■■■■nni ■■ ^■■flmnmiu gmnnHHHiinni ■■■WHnHHWHBII nimnHBHHHmi ■■■■■BBHHB nn Fig. ;iT, — Temperature curve in pneumonia. mornino- ; but the al)Ove-mentioned peculiarities, marked by italics, as well as the uselessness of quinine, and the bei^inning- of the coryza, seemed significant enough of la grippe. In the second case a boy seven years old liecame sick with la grippe together with his three sisters. The inflammation of the right apex became evidenced on the niiUh day of the disease, and the final crisis followed on the elexenth day (big. 33). In the diagnosis of such cases the ])resence, in a given family, of other cases of la grii)pe, as well as tlie age of the patient, is of importance. Lobar pneumoniae in nurslings and in children under two years of age occur mostly because of la grip])e. while in elder children primary pneumonise oftcner occurs. Pneunioni(C complicating cases of la gi"'p])e niiniing with Z26 1-)I.SEASES OF RESPIRATORY SYSTEM DISKASKS OF Ki:Sl'iK.\ TOkV SYSTEM X^Z"] atypical fever dilTer from the jji't'ccdin^- forms by a vcr}- irrciLi^ular and prolonged course: l)ecaiisc of the repeated formation of new inflammatory foci, the develojiment of the latter Ix^ing- accom- panied in each instance by exacerbation of the fever, and their resohition l)y decline of the temiieratiu'e, so that a most irregular course of the fever is obtained. In comparing cases of central pneumonia during the acute course of la grippe with those of la grippe showing an atypical fever, the pneumonia corresponds with the migrans form. A typical example of such a course of the disease is repre- sented by the following case : — A. D., aged two years, entered the hospital on account of cough of ten days' duration, with fever. During the first two days of the patient's stay in the hospital nothing but a moderate bronchitis could be detected ; on the third da\- there was a slight dullness in the area of the right apex, over the clavicle, and bronchial respiration. With every day the hepatization became clearer and clearer and spread all over the lungs during the fol- lowing weeks (Fig. 34). Thus, during thirty days there were eleven marked and rapid elevations of the temperature and as many falls; some of the latter, as on the i6th, iQth, 24th, 29th and 34th days reached 36.5 degrees C. (97.7 degrees F.), that is, they similated a real crisis, the more so that sinndtaneously there also appeared other symptoms of crisis in the form of perspira- tion and small consonant rales at the place of hepatization. Here also belongs, in my opinion, the case of intermittent pneumonia which I observed, together with Dr. \'erevkin, who described the same in X'olume XXV. of Med. Obocr. (Russian) page ion. The case is that of a girl five years old. The pneu- monia appeared first of all in the lower lobe of the left lung, and later it traveled over the right side, involved each lobe separately and, finally, affected the whole left lung, terminating with the formation of an abscess, after the opening of which, through the bronchi, a complete recovery followed. (Fig. 35.) It is impossible to differentiate by the olijective signs a wan- dering croupous pneumonia (provided such a form in reality occurs) from a wandering grippous one. If the disease started directly in the form of ])neumonia, with chills and fever, in a healthy child, then one ma\' rather su])iK)se the croupous form ; u^ DISEASI'LS OF KKSl'l R ATOKV SYSTEM 329 if, however, ])neumnnia appeared in a patient sntTerin_i;- from la grippe, then the i^rippons variety. If la grippe occurs with involvement of the small hronchi, then it may give rise to the development of a typical catarrhal pneumonia, that is. with localization hehind. on IxDth sides of the vertebral cohnnn. with small consonant rales, without notice- able dullness, but with considerable dyspnoea, as in capillary bron- chitis. A protracted pneumonia in la grippe (catarrhal or migrans) may be mistaken f(^r a tubercular one. For the correct estimation of the case it is important to know the beginning of the disease (snuffles) and absence of hereditary disposition to tuberculosis ; further, in favor of la grijipe may also be the exist- ence of an epidemic, the season, and the absence of bacilli in the sputum, (if there is sputum). Inflammation of the pleura. Plciirifis. Pleurisy may be dry or exudative. ( )f dry pleurisy we have a pathognomonic sign in the friction-rub which, although it may be likened to some small moist rfdes, yet differs from them by being heard during both inspiration and expiration, while the crepitant rales occur •only in expiration. Furthermore, the friction-rub is usually "heard over a very limited area, increases upon pressure with the .stethoscope and does not change after the patient coughs. One must, however, notice that the friction-rub in childhood, espe- cially in small children, is far from being observed so often, in pleurisy, as in adults. Pleuritic exudate — is characterized by the occurrence of a dull sound on one side of the chest, Urst of all behind, belozv, and then sf^readiiii^ upicards and forwards, but in such a way that the upper border is somewhat higher on the back than on the front of the chest. The respirator}- murmur, the lungs being incompletely com- pressed, remains, in the area of the dull note, vesicular but weak- ened. If the exudate be more considerable, if between the bronchi and the chest-wall there be a more uniform, airless medium, then .bronchial respiration appears, but not so loud as in croupous pneu- monia ; and if the exudate is so abundant that even the bronchi are compressed, then the respiratory murmur disappears entirely, at least in the lower posterior portions. If there be bronchial respiratifMi. then Ju-i>uchof^hony nia\' also be iircsent. but roeal 330 DISEASES OF RESPIRATORY SYSTEM fremitus is aki^ays zveaketied. It is always easier to note the diminution of the respiraton,- murmur and vocal fremitus if they be compared first over the place of the dull sound then with neig'hboring- portions of the chest located above, which give a clear sound. If the exudation fills out the entire half of the chest, then still other characteristic signs and symptoms make themselves^ evident : the patient suffers from dyspnoea, which increases upon assuming the recumbent posture and still more upon laying on the healthy side, and therefore the patient is compelled to lie on the affected side. The pressure of the fluid leads (i) to the inter- costal spaces on the affected side becoming even; (2) displace- ment of the heart to the side opposite that having the exudation ; in left-sided pleurisy the apex-beat is felt on the right side of the sternum; in right-sided, on the left axillar}- line; the liver is displaced downwards and its lower border may sometimes be- felt on the level of the navel ; the displacement of the diaphragm on the left side is shown by the dislocation of the spleen down- wards and by the disappearance or diminution of Traube's semi- lunar space (normally the tympanitic sound of the stomach and bowels reaches, in children, on the anterior axillary line the eighth, and on the mammillary line the sixth interspace). The affected side of the chest dilates on inspiration much less than the well side, and upon measurement its circumference- is found two or three centimeters larger. In the beginning of its development pleurisy occurs with- fever, but, contrary- to croupous pneumonia, seldom begins witb violent temperature, vomiting and convulsions.* The tempera- ture usually rises gradually to about 39 degrees C. ( 102.2 degrees F.). continuing with more considerable morning variations, and ends by lysis not earlier than in two or three weeks : but where there is an abundant exudation or a purulent one, it becomes pro- tracted for about six weeks or longer. In the commencement of pleurisy one seldom succeeds in- hearing the friction-rub of the pleura, which disappears accord- ing to the increase of the amount of the exudative fluid. Far *Several such cases have been described by Henoch (p. 389, 3rd ed. 1887). DISEASES OF RESPIRATORY SYSTEM 33I oftener this may be heard during the period of absorption when the absence of pain permits the child to take deeper inspirations. The cough appears in pleurisy from the very first and lasts until the end. At first it is dry, short and painful ; later on more friable. In some cases the cough is absent altogether. Briefly, pleuritic symptoms in children are the same as in adults ; and the more abundant the exudation, the easier is the diagnosis. Only in the beginning of the disease may there appear some difficulty, when the exudation is not yet large (reaching, for instance, the half of the scapula), and pleurisy may thus be confused with pneumonia. Touching the dififerentiation of these two diseases the reader is referred to page 310. In some cases pleuritic exudation developes latently being from the very first not only without a noticeable fever (usually the latter is present, but it is insignificant, and therefore, over-looked), but also without cough, and the w^iole sickness manifests itself by symptoms of progressively-developing exhaustion : the parents relate that the child for the last month has grown thin and pale, that he eats but little and cannot walk long, because he feels tired very soon, and dyspnoea appears, but cough is either absent or very insignificant. If, in view of the last fact, the physician ex- cludes pulmonary disease and does not hold it necessary to ex- amine the chest, then the pleurisy will remain unrecognized for an indefinite time, notwithstanding its diagnosis is very easy, as in the great majority of such cases the parents consult the physi- cian when the exudate is quite extensive and, perhaps, reaches the clavicle. If the latent pleurisy be accompaned by fever, then this disease is mistaken either for typhoid or malarial fever, depend- ing upon the character of the pyrexia. I remember a case of such a pleurisy in a four-year-old girl in whom the exudate oc- cupied the whole half of the chest, nevertheless was not recog- nized, only because the attending physician thought it was malaria and thus regarded it useless to perform percussion of the chest, as the girl did not cough, the respiratory murmur having been heard well on both sides. \\'ith a case of pleuritic exudation the physician must al- wavs think of the character of the exudate, that is, if this be serous 332 DISEASES OF RESPIRATORY SYSTEM or purulent, because upon this point depends the prognosis as well as the treatment. The diagnosis of purulent exudations is not always easy ; it may be based on general as well as on local symptoms. If in a patient suffering with pleuritic exudation the fever assumes the intermitting type, with daily chills and profuse perspiration, and if simultaneously there be noted the quick development of wasting and paleness, then the exudation is positively purulent ; further- more if the fever, in the case of such an exudation, always has a pyseniic character, then the diagnosis should not be difficult ; yet as repeated chills and siveats may he absent, despite a purulent exudation, and the fever of the same remittent character as in serous exudations, then one must resort to other methods for determining the peculiarities of the exudation. In this diagnostic direction the cause of the disease, the age, the quantity of the exudate, the duration of the disease and local symptom^ may be of value. Regarding the causes it is known that pleurisy after scarlet fever is very often i)urulent : and the same may be said of pleuri- sies in persons sufifering with i)y?emia. [Empyema very often complicates pneumonia; this being pro'« en by many observers, among whom may be named Blaker*, Bythell*'', Bogart*''^' and Cotton****. The latter studied i8o cases of empyema in children under twelve years of age, and con- cludes that it usually follows lobar pneumonia or is due to some pneumonic infection. — Earle.] The i^urulent character of the exudation is the more probable the } ounger the child and the greater the quantity of the exudate. Therefore, it is always suspicious if the exudation in a child reaches the clavicle ; and if the child's age is under two years, then the purulent character of the exudate is more than probable. We do not know with certaint}- how long the fever ma>- last in serous exudation. It is only positively known that abundant exudates may be absorbed even after the fever has been of many weeks duration, but such cases do not prove anything, as it is ^Progressive Medicine, 1904, iNIarch, p. 254. **Med. Chronicle, November, 1902. ***Bogart, Annals of Surgery, April, 1899. ****Cotton. Boston Med. ajid Surg. Journal. July 17, 1902. DISEASES OF RICSIMRAIORV SYSTEM 333 undn-.iV.ted that in childhood cvcmi entirely i)urnknt exudations sometimes become al>sorhed. This has been proven by numerous cases of empyema which have disappeared after one puncture, while it is known that it is not always possible to remove the whole exudative contents of the chest by means of a mere punc- ture, even when associated with aspiration. According' to Cadet de Gassicourt" if the absorption of the exudate does not begin after the thirtieth day, and if the tem- perature shows great variations, then the exudation is almost positively purulent. This rule has, of course, exceptions, but for the majority of cases it is true, and therefore it may be of use as an indication for performing an exploratory puncture. As to the local symptoms there are three that positively point toward a purulent exudation, however, in the majority of cases they appear late. These symptoms are : (i) Qidema of the subcutaneous tissues on the affected side of the chest. (2) Formation of a burrowing abscess, which shows an im- minent opening through the chest-wall. (3) The sudden elimination, with cough, of great amounts of pus due to opening of the empyema through the lungs. Regarding the burrowing abscess, of course, not each abscess appearing on the chest-w-all denotes an empyema ; the latter is to be suspected only in case the patient does not suffer from caries of the vertebral column or ribs and if a simple abscess of the cellular tissue can be eliminated. In all these non-empyemic cases percussion of the aft'ected side of the chest gives a clear sound. If after a general and local examination the purulent char- acter of the exudation be doubted, then for a final decision of the question the exploratory puncture by means of a Pravatz's hypodermic syringe must be resorted to. It is quite difficult to determine the most suitable time for this method of examination, because much depends upon the peculiarity of the case, as w-ell as upon the physician's views. It is true that when guided by these varying circumstances one physician will undertake an exploratory puncture earlier than an- *Traitc din. d. mal. de I'cnf. Vol. I., page 372. 334 DISEASES OF RESPIRATORY SYSTEM otlier, or later, dependent upon tliose symptoms which will ap- pear doubtful to this or that physician. I personally hold it neces- sary to make a puncture in the following cases : (i) When the exudation fills the entire half of the chest and; especially, if we deal with a child under two years of age, while the time elapsing since the beginning of the disease has no importance, because the exudation may be purulent even from the very first. (2) If during the fourth week from the beginning of the disease the fever is not inclined to abate, and especially in case it assumes an intermittent type. (3) II after the thirtieth day there is noticed no absorption of the exudate, even if the temperature be normal, as the absence of fever does not exclude purulent pleurisy. It is self-evident that, if there are chills, sweats, and other above-mentioned signs of purulent exudation, the indications for a puncture are urgent. One must not think that the exploratory puncture always gives pure pus in the case of purulent exudation. It sometimes happens that only turbid serous liquid will be withdrawn (the tur- bidity, as the microscope shows, depends upon pus corpuscles), and then, post mortem, it will be found that the walls of the pleural cavity are lined with a thick sheath of dense pus. As a matter of fact, if the purulent exudate is not very dense the blood-ele- ments easily sink to the bottom or become attached to the walls, and a serous fluid is formed above. On this account empyema may be diagnosed if upon exploratory puncture there is obtained not a purulent, but only a cloudy (because of the presence of pus-corpuscles) serous fluid. One might tliink it would be easy to distinguish, by means of bacterioscopic examination of the exudation, a tubercular pleurisy from any other, but it has been found that the matter is not so simple. In the case of exudations the bacterioscopic examination is almost of no value, as in most cases such exuda- tions appear sterile. In purulent exudations pneumococci or streptococci, or other different purulent microbes, are found, but almost never tubercle bacilli. [Bythell studied forty cases of empyema bacteriologically and found the pneumo-bacillus alone in sixty-five per cent (twenty-six cases) ; in nine cases the pneu- DISEASES OF RESPIRATORY SYSTEM 335 Tno-bacillus was mixed with other microbes, in two cases strepto- coccus alone was found, in one, streptococcus with staphylococ- cus, in one streptococcus with pneumo-bacillus and in one Fried- lander's bacillus with the staphylococcus.* Nearly the same results have been obtained by Koplik, who found that empyema was due to pneumo-bacillus in sixty-nine per cent, and to tubercle bacilli in seven per cent'^"^. — Earle.] This observation, however, has Ijroughi out an important fact, that if the bacteriological examina- tion of the purulent pleuritic exudation proves negative, that is, ■does not determine any microbes, then the tubercular origin of such an empyema is very probable. For the purpose of a final ■decision of the question one may inject some pus into the abdomi- nal cavity of a guinea-pig, which will become affected with tuber- culosis after four or five weeks in the event of the tubercular •origin of the pus. Some resemblance to pleuritic exudation is presented by cases of HYDROTHORAX (accumulation of transudative fluid in the pleural cavities) and pneumothorax (accumulation of air in the pleural cavity). The common symptoms of pleuritic exudation and hydro- thorax consists in the appearance of a dull sound in the lower portions of the chest, the upper boundary of which rises higher and higher according to the development of the disease. Over the area of dullness a weakened respiration and feeble vocal fremitus are heard. The differences are the following : (i) The accumulation of a transudate in the pleural cavity is never an isolated condition, but is always accompanied by a transudation at other places, most often in the cellular tissue and abdominal cavity. (2) Hydrothorax is almost always bilateral, although it may "be developed more on one side (the side on which the patient lies). (3) The cause of the dropsy may be found either in diseases of the kidneys (most often), or in disease of the heart, or in hydrsemia due to chronic enteritis. *Med. Chronicle, November, 1902. **Med. News, September 13. 1902. 336 DISEASES OF RESPIRATORY SYSTEM (4) The upper lx)rder of the dull sound in the erect posture of the patient is horizontal in hydrothorax ; or on change of position the border of the dull sound changes also. (5) Hydrothorax occurs without fever, without pain in the side and dyspnoea (provided the amount of fluid is not consider- able), as well as without cough. The common symptoms in hydrothorax and pneumothorax consist in the change of the shape of the chest ; the afifected side dilates but little upon respiration, it is larger than the well side; the intercostal spaces are even ; the respiratory murmur is weak- ened, as well as the fremitus ; the neighboring organs are dis- placed ; the patient complains of dyspnoea and is compelled to lie on his side. The essential difference consists in the results of per- cussion — in exudation a dull sound is obtained ; in pneumothorax a clear one, tympanitic with a metallic timbre. Upon auscultation there is either absence of the respiratory murmur, or amphoric respiration. If pneumothorax develops because of rupture of the empyema through the lungs, then air occupies the place of the exudative fluid, and in the upper portions of the chest a clear or tympanitic note is obtained, which may cause a beginner to sup- pose that the lung which was previously compressed is beginning to dilate and the patient is on the way to recovery. But such an error is promptly avoided if heed be given ; ( i ) to the fact that dyspnoea not only did not diminish, but even perhaps increased ; and (2) that over the area of the clear sound respiratory murmurs are not heard. DISEASES OF THE LUNGS CHARACTERIZED BY THE SECRETION OF FCETID SPUTUM. A foetid sputum denotes either the existence of bronchiectatic cavities in which the secretion of the mucous membrane becomes stagnant and decomposes ; or a putrid bronchitis (bronchitis putrida) or pulmonary gangrene. The sputum in all these cases presents the peculiarity of being very foetid and shows on stand- ing a very marked division into three layers ; the upper, frothy ; the middle one, fluid, quite clear, transparent ; and the lower one, purulent, rich with detritus and crystals of margaric acid. Of an especially repulsive gangrenous odor is the sputum in pulmon- ary gangrene, wherein the breath also is very foetid. DISEASES OF RESIMRAIORY SYSTEM 337 It is further characteristic of bronchicctasice that the patient at times expectorates (especially in the morning' on the change of position) an abtmdant quantity of quite fluid, fcetid sputum. The general aspect, general condition and fever depend upon the l)asic disease. If the dilatation of bronchi is accompanied, for instance, by interstitial pneumonia (the issue of croupous or catarrhal — measles — pneumonia) then the general condition is quite satisfactory, but fever may be entirely absent. The same happens in cases of development of bronchiectasise in a collapsed lung, following an old pleuritic exudate, on the contrary, in bronchiectasije during a tubercular pneumonia there will be fever and exhaustion. Regarding" the physical signs, these may be manifold and their character dependent upon whether the bronchiectasia; are sur- rounded by a dilated or a hepatized lung. In the former case the patient presents symptoms of chronic bronchitis, while in hepatization of the lungs cavernous' symptoms are obtained ; am- phoric respiration or loud bronchial breathing, bronchophony, large consonant rales and, on percussion, a tympanitic note, some- times with a metallic timbre. All these characteristic physical symptoms disappear in case the caz'ity is tilled zvith a secretion, appearing again after a lit of coughing with elimination of a great quantity of sputum. Of course, the same symptoms may also be present in tuberculous cavities, but then there will be bacilli and perhaps elastic fibers in the sputimi. \^'e speak here only of chronic bronchiectasi?e ( because foetid sputum is peculiar only to the latter) , commonly met with in interstitial pneumonije which usually proceed without fever and remain stationary for a long period, therefore, if symptoms of cavities are observed in a patient whose general condition is com- paratively good and who suffers from an abimdant secretion of foetid sputum, then one may positively conclude that he is not affected with tuberculosis, but with bronchiectasise as a restilt of interstitial pneumonia. If the bronchiectatic cavities are so small that no physical signs of cavities are present, then it is impossible to differentiate from foetid bron.chitis because the latter is distinguished by the absence of a periodical secretion of abundant sputum with the subsequent appearance of cavernous symptoms. 338 DISEASES OF RESPIRATORY SYSTEM The foetid sputum during pulmonary gangrene differs from that in bronchiectasise by its stronger odor and by the fact that it is not difficult to detect the presence of remains of pulmonary tis- sue in the form of black tufts which when examined under water appear in the form of irregular lumps. The microscopical ex- amination may easily show that these masses have alveolated structure, but elastic fibers cannot be found as, in gangrene of the lungs, they occur, strange to say, very rarely. In order to more readily detect these remains of pulmonary tissue the sputum must be left to stand and the deposit from the floor of the vessel must be taken for the examination. (A minute description of the microscopical peculiarities of the sputum can be found in Eichhorst's Text-book of Practice of Medicine, Vol- ume I.) The general condition always suffers severely in pulmonary gangrene, the fever not infrequently is accompanied by chills and profuse sweating, and collapse soon comes on. Regarding the physical symptoms, these vary, depending upon the conditions. In the case of a diffuse, rapidly-spreading gangrene, symptoms of hepatization of the lungs predominate, but in circumscribed gangrene with decomposition of the pulmonary tissue, there are cavernous symptoms. Before the diagnosis of bronchiectasiae or pulmonary gan- grene is made from the fcetid sputum, other causes of foetid secre- tion must be excluded, for instance, some diseases of the mouth, as noma, stomacace, ozaena (foetid rhinitis), some cases of retro- pharyngeal abscess and especially sanious exudate from an old pleurisy opening through the lungs. DISEASES OF THE NERVOUS SYSTEM We shall first mention the semeiotic meaning of some symp- toms which are of general importance, and then proceed to the differential diagnosis of separate diseases most often met with in childhood. THE SEMEIOLOGY OF HEADACHE. Headache occurs, to be sure, in children of any age, but as a subjective symptom it often remains unrecognized even in children who can talk, because under five years of age they seldom complain of headache at a certain point, wherever it may be. Headache in small children can be recognized only if the same be very severe and causes the child to manifest it by often grasp- ing his head with the hands, pulling himself by the hair, constant- ly moving his head to this or that side or contracting the fore- head. For the production of such symptoms, however, it is nec- essary that the headache be very severe. Headache due to considerable elevation of temperature of the body usually does not reach such a degree as to be evidenced by objective signs, we find it almost exclusively in cerebral diseases and inflammation of the middle ear, and both these diseases must be first of all be thought ol in treating with a child who cries much, is restless and grasps the head with the hands. Headache in children over five years of age occurs very often, and for diagnostic purposes all cases coming under this descrip- tion may be divided into acute and chronic. In the classification of acute headache we include those cases in which headache appears suddenly, continues, for instance, a few days and wherein the patient previously never suffered from similar headache. The absence of fever does not exclude acute headache. To chronic headache we refer all cases of the so-called habitual headpains, whether these be constant or irregularly re- peated. 340 DISEASES OF THE NERV'OUS SYSTEM Acute headache differs from the chronic, aside from the history, by being always accompanied, with some rare exceptions, by elevation of temperature. If the patient suffers with acute headache associated with elevation of temperature, then the main question to be decided consists in whether the pain depends upon fever, or appears as a symptom of a beginning meningitis. In the first two or three days, and sometimes c\'en longer, this question cannot always be decided. Wc investigate, first, the character of the headache, second, the intensity of the fever, and. third, the concomitant symptoms. The headache in meningitis and acute hydrocephalus is nota- bly severe and constant, that is, does not show intervals, and its intensity does not correspond to the range of the temperature ; while headache depending simply upon fever is usually not severe, unless the temperature is very high (more than 40 degrees C. — 104 degrees F.). If the child complains of headache only when questioned about the same, then it is probably not a meningitis (we say "probably" because insignificant headache does not entire- ly exclude meningitis, especially its tubercular form) ; if, how- ever, he throws alx>ut because of headache, the latter being the chief complaint, then meningitis is the more probable, and still more so the lower the temperature. A very violent, unaccustomed headache with a temperature about 38 or 38.5 degrees C. (100.4 or 101.3 degrees F.) is almost pathognomonic of meningitis. If a severe headache be observed along with a temperature of 40 degrees C. ( 104 degrees F.), then it is of no especial value for the diagnosis of meningitis even when accompanied by vomiting, because, first, both may occur during any febrile condition, and, second, violent fever almost excludes tubercular meningitis, that is, the form which most often occurs in childhood. With reference to the simple purulent, and cerebro-spinal meningites, in which a temperature of 40 degrees C. (104 degrees F.) is not a rarity, one should bear in mind that in these forms (usually rare) other cerebral symptoms very soon set in which clear up the diagnosis. We have just said that a very severe headache is, to some extent, characteristic of meningitis, but it does not follow that it is always of such a character in this malady. The absence of DISEASES OF TJIE M:kVOUS SYSTEM 34: pronounced headache excludes only acute purulent meningitis (meningitis simplex, s. purulenta), but it does not contraindicate a beginning acute hydrocephalus (meningitis tuberculosa). Again the onset of tubercular meningitis is not to remain un- recognized because a severe headache does not obtain. As a matter of fact the degree of headache in acute hydrocephalus depends very much upon the rapidity of development of the disease; the headache will be the severer, the quicker the disease sets in {increased pressure in the cerebral cavity), but as in tuber- cular meningitis hydrocephalus sometimes develops quite slowly. then the headache also may not be severe. As to the concomitant symptoms, the leading one among them is, of course, vomiting, which occurs in all cases of meningitis, acute purulent, as well as in subacute or tubercular. // the patient did not vomit even a single time from the appearance of head- ache, the first twenty-four or forty-eight hours, then one may say almost zcith certainty tliat he has no meningitis. Cases of meningitis without vomiting, although they may occur, are great rarities. We have already mentioned the character of cerebral vomiting. The diagnostic significance of vomiting coincident with headache is lessened, however, by its occurring also during diseases other than meningitis and especially under the influence of repugnant medicines. Another symptom very important in its connection with headache is a retarded and irregular pulse. This symptom is the more pronounced the less the fever and the older the child. In acute purulent meningitis with a temperature of 40 degrees C. (104 degrees F.) the pulse not infrequently remains regular and quickened ; but instead of this in similar cases there rapidly comes on unconsciousness and general convulsions. Other symptoms of meningitis, which will be discussed later on, appear earlier. Headache independent of any cerebral lesion, but associated with elevation of temperature, is of no diagnostic value, with the exception, perhaps, that together with other symptoms of general malaise it aids questions in the history, namely when the child started to be feverish. Severe headache without elevation of tem- perature or with insignificant fever, but in the presence of snuffles, ma}' depend upon extension of the calarrh to the frontal sinuses; 342 DISEASES OF THE NERVOUS SYSTEM in such a case the pain is locahzed in the forehead. Headache is of particular meaning when it appears in a child suffering with acute nephritis. It is immaterial if there is fever simultaneously, or the temperature remains normal ; headache in acute nephritis is always a suspicions sign on account of be- ginning urmnia, and especially in case it be accompanied by vomiting. In estimating the significance of headache of acute character one should bear in mind that it may be localized in the soft cover- ing of the skull, for instance in rheumatism, or in circumscribed inflammatory foci. The location of headache in such cases is determined by palpation, as inflammatory pain increases upon pressure on the affected part. In rheumatism of the galea apo- neurotica the pain is felt not only in the head, but also frequently spreads over the muscles of the neck (torticollis) and increases upon raising the eye-brows and wrinkling the forehead. The history being certain, and if the headache appears in several members of the same family, it is easy to diagnose fumes (CO-poisoning). Headache in such cases is often accompanied by vomiting and general weakness. It is known that the same symptoms may also depend upon alcohol (wine) poisoning. Chronic headache may depend either upon any coarse anatomical changes of the brain, in the form, for instance, of chronic hydrocephalus, tumor of the cranial cavity, etc., or upon the affection of other organs, or it appears as independent. The diagnosis of symptomatic headache connected with chronic disease of the brain is based upon the simultaneous exist- ence of other cerebral symptoms, as vomiting, mental debility, paralyses and pareses, especially of the eye-muscles (strabismus, ptosis, amblyopia) and local or general convulsions. Headache depending upon chronic lesion of the brain is characterized by its pronounced tendency to aggravations. In the case of circumscribed diseases of the cerebral meninges (abscess, syphilis) persistent headaches appear limited to a certain area. Among the characteristic symptoms of such a headache may be also included the fact that in some cases it increases upon percussion of the corresponding point of the skull. Chronic headache, which does not depend upon diseases of DISEASES OF THE NERNoUS SYSTEM 343 the brain and its nuMiibranes occurs in childhood quite often and may depend upiMi various causes. Migraine should be mentioned first of all of this lar.c^e group, the chief cause of which is heredity. Aligraine differs from any other headache by appearinc; in paroxysms, occupying onlv one side (the left) of the head and usually terminating after a few hours with vomiting and then sleep. In slight cases there is usually no vomiting, but it is quite sufficient for the diagnosis that some paroxysms are accompanied by vomiting. As objective signs of migraine in children there are pallor of the face, general languor and sometimes yawning. If such symptoms occur at times in a child who is in all other respects a healthy one, and each time the paroxysm ends in a few hours with vomiting and sleep, then migraine may be recognized even in children who can- not talk. Attacks of headache in migraine appear at irregular, and more or less prolonged, intervals of from a couple of days or weeks up to whole months; almost never docs inii^raiiic occur two days in succession , and in general one may say that if in a child headache be repeated several days in succession, or even every week, then this is most probably not a pure migraine. Attacks of migraine appear either without any certain cause^ or under the influence of physical or mental fatigue ; but heredi- tary predisposition must be held as the first factor (in the history migraine is usually mentioned in some of the parents). [Gould* regards the diseases of the eye as the most frequent cause of migraine. He says in this connection : I am sure that migraine occurs more often in childhood than it is supposed. Gowers goes so far as to say that one-third of all cases begin from the fifth to the tenth year. It all depends on the existence of ametropia and the amount of study, reading, etc., carried on. I have had a large number of school-children afflicted with the malady in vari- ant and typical forms. One little boy I particularly remember whose astigmatism for years increased about 0.5 degrees every few months, was each time relieved of his intense vomiting by a change of glasses until the compensation of the higher astigma- *Gould : "The History and .^Stiology of Migraine." lour. Amcr. Med. Assoc, January, 1904, p. 241. 344 DISEASES OF THE NERVOUS SYSTEM tism a^ain became impossible. — Earle. ] This cause is so con- stant that if headache develops in a child whose parents never suffered with migraine, then this circumstance alone makes it doubtful if in any given case the migraine is an idiopathic one, that is, an independent neurosis ; it is more probable that such a migraine will prove to be either a reflex-occurrence (diseases of the nose), or a symptomatic headache (anaemia, diseases of the brain, etc.)- ]t is also quite characteristic of migraine that headache al- most always may be relieved by taking antipyrin (as many grains as the patient is years old), or antifebrin (one-half such quan- tities), although I do not intend to altogether claim that these remedies are useless in headache of other origin. The general condition of nutrition in children disposed to migraine may remain excellent. Migraine ma\' easily be confused with neuralgia of the supRAORi'.iTAL NERVE (ncuralgia snpraorbitalis), in w"hich pain is also felt unilaterally, but the essential differences are, first, that the patient denotes the supraorbital area as the location of pain, provided he can localize his sensations, and, second, in all cases of supraorbital neuralgia the pain increases upon pressure on the supraorbital opening. Supraorbital neuralgia is comparatively often of malarial origin, returning in such a case regularly every day, or every other day. at the same hour ; therefore, in all cases of intermit- tent headache in a child one should think, first of all, of neuralgia supraorbitalis. Besides migraine, there occurs in children yet another class of nervous headaches v.hich are repeated either daily, or with some irregular intervals. These headaches, sometimes hardly noticeable, sometimes very severe, have no special localization ; the patient complains, depending upon the case, of the forehead, parietal region, occiput or the whole head. Here we find, for instance, headaches which depend upon general iiialiiiitritioii. The diagnosis rests upon the exclusion of other causes of headache and the presence of symptoms of general anaemia (pallor of the skin and mucous membranes, loss of ap- petite, wasting, restless sleep, irritability) or of chlorosis, which differs from a common infantile anaemia liy much more pro- DISEASES OF THE NERVOUS SYSTEM 3J5 nounced pallor (waxy paleness) of the skin and mucous mem- branes as well as by the age of the patients. A common anaemia is usually met with in children five to twelve years of age, in females as well as in males, but chlorosis occurs almost exclusive- ly in females after eight to twelve years. Headache, depending •only upon chlorosis, but not upon any other causes, is also peculiar in yielding readily to iron treatment. In connection with headache in an anjemic child one should bear in mind that ana."mia itself may depend upon some certain ■cause without the removal of which the treatment will be, of course, useless. Among such causes are included catarrh of the stomach, intestinal worms, nephritis (uraemia) and masturba- tion. In the opinion of some authors juasturbation may be su>- pected if the headache is localized in the occiput. But it is better to be guided by other signs, as open meatus penis, tardy reaction ■of the cremaster upon tickling the inner surface of the thigh, suspicious spots on the garments and the bed-clothing. As a very valuable sign, often met with in masturbators, Renzi points ■out the disappearance of the knee-jerk*. It is also characteristic, to some extent, that such victims are inattentive, cannot concen- trate their attention very long, while older children usually be- come too pious. { They have heard of the harm of masturbation and not feeling strong enough for a struggle against the same •they have recourse to religious influence and surroundings.) A peculiar nervous headache occurring in weak, anaemic children, as well as in entirely healthy ones 7vith good nutrition and living in the best hygienic environment, is known under the name of school-headache or headache due to over-exertion, and -likewise headache due to growth ( "cephalagie de croissance," of French authors). This suflering is noted in youths from ten up to fourteen or sixteen years old. Such a headache, like any other nervous headache, is confined either to the forehead, or to the whole head, being often combined with symptoms of neuras- thenia; the child becomes irritable or sad, snivelling, etc., but the main characteristic feature, peculiar of all cases of school-head- ache, consists in the inability to do mental zvork. In mild cases ■headache appears only during forced mental occupation, and in *See Med. Obozr. 1888, No. 11. 346 DISEASES OF THE NERVOUS SYSTEM severe, well-pronounced cases even at the slightest exertion, not excluding even pleasant mental exercise, as, for instance, the- reading of an interesting novel. In these cases headache is persistent from day to day during many months, and to be cured requires the complete cessation of all study, at least for half of a year, otherwise it may last for many years, until the period of rapid growth is overcome by maturity. School-headache is most easily confused with that cephalalgia- which often occurs in children and depends upon abnormal refrac- tion and accommodation, and which can be cured by nothing but corrective glasses. Such cause of headache is not unusual, as may be seen from Bickerton's papers* wherein one thousand patients with refractive errors being examined, headache was a prominent feature among the patients' complaints in 2// cases (27.7 per cent). Of the greatest importance in this regard is hypermetropia with astigmatism. The similarity of headache dependent upon eye-strain with school-headache consists, first, in both appearing only during mental occupation and disaj^ixviring during rest,, second, by sparing neither weak nor strong children. Chronic headache may also depend upon diseases of the nose; while a visible rhinitis, that is, a discharge from the nose, may even be absent, the impermeability of the nasal passages being sufficient. Quite a good many cases of persistent headaches cured. by means of proper treatment of the nose have been described; for example I am reminded of Menier's case**. The headache was in a nine-year-old boy ; had continued for two years, and was cured by the removal of tumors of the nasal mucous mem- brane. If the headache appears in a child after brisk exertion or during hot weather, and is relieved after a nose-bleed, then it proves the same to be dependent upon congestion of the brain. Eichhorst called attention to the appearance of headache,, sometimes accompanied with vomiting, under the influence of temporary albuminuria, which sometimes occurs in youths with- ^Abstract in "Vratch," 1S88, page 680. **"Vratch," 1888, N. 22. DISEASES OF THE NERVOUS SYSTEM 347 out any noticeable cause. Albuminuria may last weeks and months, and during this time there often appear attacks of head- ache, sometimes connected with general debility, weakening of the memory, irritability and even convulsions. SEMEIOLOGY OF GENERAL CONVUL- SIONS. When we have to deal with a child in whom there have ap- peared .e:eneral convulsions of tonic or clonic character, manifest- ing themselves mainly by irregular twitchings of the muscles of the face or extremities, together with loss of consciousness, it is sometimes very hard to determine the cause of such convulsions, and not infrequently the physician when he sees the patient the first time is unable to state more than the mere fact, and unwill- ingly satisfies himself with the sentence that the patient has an eclamptic fit, or the so-called childhood eclampsia. The attack of general convulsions, whatever the cause may be, is nearly always the same; in single cases the difference is only that in one patient the fit lasts longer and the convulsions them- selves are severer, in another they are shorter ; in one case the fits follow each other with more or less brief intervals, so that during twenty-four hours more than twenty fits of general con- vulsions may be counted, and in the other case everything ends with a single attack. The essential difference may be expressed also by the course, namely that in some patients the fit of con- vulsions appear only once, and then does not reappear during the whole life, while in other patients the convulsions occur from different causes (in children suft'ering from laryngismus stridulus, for instance, such a cause is often some excitement, etc., in other •cases convulsions are repeated in the beginning of each severe febrile disease, etc.), or even without noticeable causes during the first two years of life, or even during the whole life (epilepsy). Each single attack of general convulsions usually begins with a short period of tonic convulsions (the child stops breath- ing, his eyes are turned upwards under the upper eye-lids, the face grows cyanotic, the spine becomes curved, the limbs stretch- ■ed), but after a few seconds the tonic spasms give place to clonic DISEASES OF Till-: .\KR\OUS SYSTEM 349- ones, which manifest themselves by twitching of the facial muscles and eye-balls, froth from the mouth, shuddering of the trunk and extremities. This period of clonic convulsions lasts considerably longer than the first one, continuing from two to three minutes up to half an hour and longer. After the attack the child usually falls asleep (soporous period) for a short time. In determining the cause of convulsions, one must, first of all, decide the question whether they depend upon coarse anatomi- cal changes in the central nervous system, or upon some other causes. Convulsions may be met with in chronic and acute diseases of the brain. In the diagnosis of cerebral convulsions, it is im- portant to notice the fact that a cerebral disease almost never begins with an eclamptic fit, so that, if convulsions appear as a symptom of some cerebral lesion in the minute examination of the patient or in his history one may always find indications of the existence of some brain symptoms, as, for instance, in chronic cases, a constant or often-repeated headache, pareses of the mus- cles of the face or limbs, some mental impairment, changes in the eye-fundus, etc. ; and in acute cases, besides these symptoms there may also be somnolence, fever, irregular and retarded pulse, etc. ; therefore, if convulsions occur in a child previously entirely healthy, who after the end of the paroxysm does not exhibit any other cerebral symptoms, then one may claim with great prob- ability that the convulsions zvere not cerebral. Convulsions dependent upon chronic lesion of the brain are also characterized by being very liable tO' relapses, reappearing after various intervals of from a few days up to several weeks. It is true that such repeated convulsions often occur in children under two years of age without any cerebral disease, but the diagnosis in such cases is aided by the fact that of chronic cere- bral diseases only chronic hydrocephalus is to be met with in that age, which is easily recognizable by the considerably enlarged skull and divergency of the sutures. In older children convul- sions repeated during months and even years depend either upon chronic diseases of the brain (most often upon a tumor), or upon epilepsy. A pure, so to say, idiopathic epilepsy usually has a hereditary origin, and differs from a symptomatic epilepsy, that is, men- 350 DISEASES OF THE NERVOUS SYSTEM ingeal convulsions, by its extremely chronic course and by the fact that the child does not exhibit any cerebral symptoms in the in- tervals between the convulsions. (More minutely about epilepsy see below.) If convulsions constantly affect only one side of the body, this strongly points to their cerebral origin, and the more so if the convulsions spread from the leg to the arm and then to the face, that is, according to the order of localization of motor centers in the central convolutions of the cerebral cortex, while the con- sciousness usually remains unimpaired. These symptoms are those of the so-called cortical or Jacksonian epilepsy. In acute cases cerebral convulsions are accompaned by fever, and one must therefore decide the question whether the convul- sions depend upon meningitis (or upon some other lesion of the brain), or simply upon elevation of the temperature. Any rapid elevation of temperature manifested in an adult by chill, may be accompanied in small children by convulsions, and the younger the child, the easier they set in. These so-called febrile convulsions, or eclampsia due to fever, may be admitted only in the presence of three conditions : — (i) Age of the child under three years (exceptions are very rare). (2) Rapid elevations of the temperature, not less than about 39.5 degrees C. (103.1 degrees F.). (3) The convulsions appear during the first hours of the affection, that is, in the beginning of fever. It follows that the convulsions most probably do not depend merely upon fever if one of these conditions be absent, when, for instance, the child is older than three years, or the temperature is low, or developed slowly (covering two or three days), or if the convulsions did not appear during the first day of the disease. As the acute cerebral diseases in children comparatively seldom begin with a sudden and severe fever, then the initial convulsions in such connection are also rare, so that if eclampsia appears in a child just taken sick, the temperature being 40 de- grees C. (104 degrees F.), then it is very probably not a cerebral disease. It is true that some forms of acute purulent meningitis begin with convulsions, but in such a case the disease runs in general DISEASES OF THE NERVOUS SYSTEM 351 ■very rapidly, the patient either not regaining consciousness alto- gether, or the convulsions being repeated one after the other, and after about two days fatal termination sets in. Contrary to this, febrile convulsions usually do not relapse (a violent chill in adults also is not repeated), excluding rare cases of malignant intermit- tent fever (febris intermittens convulsiva). and the patient soon (after ten to twenty minutes) recovers his senses*. Thus, if con- vulsions appear in a small child in the beginning of violent fever, and if tlie child soon recovers Jiis senses, and the convulsioiis are not repeated during several hours — then acute cerebral diseases may he excluded, leaving it yet to be decided upon what condi- tion the fever depends. But besides these initial convulsions there also appears, dur- ing some febrile diseases, eclampsia of another kind in which we have to deal, not with single convulsions, but with repeated ones in children of any age, and not alone those under three years. As such eclampsia occurs in children only during infectious diseases and especially in croupous pneumonia (almost exclusively in children under two years), scarlet fever and small-pox (in small as well as in older children), and at the same time always in grave cases, then one may in such instances look upon the convulsions as not so much depending upon the elevated tem- perature as upon the poison circulating in the blood. If the convulsions are repeated so often that the child has no time to recover from the soporous condition, and the disease soon ends with death (in scarlet fever sometimes after several hours from the onset of the disease), then, of course, the similar- ity ^^•ith grave meningitis (meningite foudroyante) may be so .great that the diagnosis cannot be made on the ground merely of the present symptoms and in the absence of reasonably definite signs entirely characteristic of this or that disease, as, for instance, rash in scarlet-fever and small-pox, or physical signs on the part of the lungs in pneumonia. *Sometimes, although seldom, the convulsions appear as the first symp- toms of tubercular meningitis, but the fever is in this disease so insignifi- cant (about 38 to 38.5 degrees C. or 100.4 to 101.3 degrees F.), that con- vulsions, notwithstanding their occurring once, and the regaining of con- sciousness, cannot be explained by elevation of temperature, so that for their explanation another cause must be looked for. In the great ma- jority of cases convulsions in tubercular meningitis first set in only very ■shortlv before the fatal termination. 352 DISEASES OF THE NERVOUS SYSTEM Of .eireat importance in the diagnosis of such cases is the- aetiology, therefore it is necessary to inquire if the patient had been exposed to the infection of small-pox, and especially scarlet- fever (this is the most frequent cause of fatal cases of repeated convulsions in fever even in more adult children), if he did not hurt his head, if he was not overheated by the sun, if he had not snuffles or cough previous to the severe symptoms (la grippe as a cause of cerebral pneumonia), finally, if in the given locality there are no cases of epidemic cerebro-spinal meningitis. Not infrequently the diagnosis only becomes evident several days after the death of the patient, and when another member of the family becomes ill with a clearly developed infectious disease, which most often is, of course, scarlet fever. If the child takes suddenly sick with violent fever, vomiting and repeated convulsions, dying after twenty to thirty hours with symptoms of coma and collapse, all data for the diagnosis being absent, then the physician usually regards meningitis as the cause of death, in my opinion making a mistake in the great majority of cases. As a matter of fact the tubercular form of meningitis never occurs in such a manner; a simple purulent meningitis requires for its development some certain cause, never arising in a healthy child without reason; and as to epidemic meningitis, this disease in general occurs very seldom, and its hyper-acute forms almost never, so that in cases similar to the above mentioned, scarlet fever must first of all be thought of, then^ small-pox, and at last meningitis. One frequently succeeds in recognizing scarlet 'fever in the very first stage of the disease, because the rash appears very early,, sometimes during the first hours, and if the rash is still absent, then the scarlatinal sore throat is quite certainly present. Small- pox is of more difficult recognition, as in this disease the mucous membrane of the throat is not involved, the rash occurring only on the third day, and in general the precursory symptoms are but little characteristic unless we have a case of haemorrhagic small- pox, in which peculiar petechise appear on the abdomen and also on other parts very early, for instance, on the first or second day. Besides this, eclampsia is, in small-pox, of considerable severity, simulating meningitis by the repeated convulsions. These are the reasons why, practically, eclampsia in small-pox is often DISEASES OF THE NERVOl'S SVSTE^[ 353 confused with meningitis. As an important aid in the diagnosis the character of epidemic in the given locahty should be remem- bered, especially if the patient lives in a small-pox house; also signs of vaccination being absent. We shall not speak here about the distinction of meningitis from the so-called cerebral form of pneumonia, the reader being referred to the section on pneumonia. However, it is necessary to mention urccniia, which in its eclamptic form usually develops in children with considerable elevation of temperature (about 40 degrees C— 104 degrees F. and higher). If the convulsions be often repeated, then the patient does not come out of a coma- tous condition, and the similarity to acute meningitis is then the greater, because vomiting necessarily occurs. Mistakes, how- ever, do not often happen, as it is not easy to overlook nephritis if we follow the rule to examine the urine in every patient. Eclampsia in other febrile diseases in small children may be difficult for the physician to diagnose for a few hours only, as, first, most inflammatory processes soon become determinable, and, second, as has already been said, these convulsions usually are not repeated. In the differential diagnosis of cerebral convulsions from a simple febrile eclampsia, the manner of development or the group- ing of the cerebral symptoms are important, the complexity of which may be such that it can be explained by nothing but the cerebral lesion. Meningeal expressions dependent upon fever differ from genuine cerebral symptoms by the insufficient con- stancy and by their not increasing, but on the contrary decreasing more and more according to the development of the causative disease. As to the convulsions themselves they are usually preceded in cerebral diseases by a very violent headache, ivhich is intensive from the very beginning and does not abate until there is finally loss of consciousness. Real cerebral convulsions in acute diseases of the brain usually occur repeatedly, leaving then a deep sopor- ous condition in which the patient most commonly remains until his death. According to Barthez and Sarme, cerebral convulsions differ from a common eclampsia by the following : — (i) After cerebral convulsions the consequent alterations in 354 DISEASES OF FHE NERVOUS SYSTEIM the sphere of consciousness and motion are more marked (most often there occur, for instance, paralyses and contractures). (2) The (hiration of the attack itself is longer. (3) Cerebral convulsions are very prone to relapses; if in a child older than two years the convulsions be repeated in succes- sion, then they are almost certainly of cerebral origin (we have already mentioned that similar convulsions in older children may depend upon scarlet fever and ursemia). In estimating cerebral convulsions one may also be guide^l to some degree by the condition of the large foiitanelle, while at the same time it should be borne in mind that a protruded and pulsating fontanelle occurs in any severe febrile condition. Pro- trusion and pulsation of the large fontanelle may be held as un- doubted symptoms of hyperccniia of the brain only if both are constant, despite the fei'er lo-wers, while simultaneously somno- lency or other symptoms of the brain-lesion are present. If the fontanelle considerably rises over the parts of the sur- rounding bones, presenting considerable resistance upon pres- sure by the finger, then it points strongly toward the existence of an exudative process in the brain, as in febrile diseases the fontanelle is usually easily depressible, although it may pulsate and become protruded. However, a contrar\- conclusion cannot be made, because the absence of increased resistance of the fon- tanelle does not exclude the existence of exudate in the cavity of the skull. If on the ground of these or other considerations cerebral diseases may be excluded, then it remains to determine the real cause of the convulsions. The causes of convulsions in children are extremely mani- fold so that in this regard four kinds of eclampsia are to be distinguished : — (i) A cerebral or symptomatic one (about the diagnosis of this form we have already spoken). (2) Reflex eclampsia, dependent upon peripheral irritation. (3) Hsematogenous, occurring in different febrile diseases and poisonings, and finally, (4) Idiopathic or essential eclampsia, the causes of which are unknown. According to the advancement of our knowledge the num- niSMASICS OK Till': NKKX'OUS SYSTEM 355 ber of cases included in the latter cate.Q;ory will, of course, de- crease. We include at present in this class convulsions due to fright and otlier psychical conditions, as well as "groundless" convulsions in entirely healthy or anaemic children, who subse- quentlv sometimes suffer from epilepsy. For the ])urpose t>f diagnosis all cases of epilepsy are best divided into two classes : — ( 1 ) Convulsions during elevated temperature of the body, and (2) Convulsions without fever. If there is no fever in the child, and if a cerebral disease may be excluded, then the discovery of the cause of convulsions may be influenced by the patient's age. Afebrile convulsions in children from four up to twelve years old occur, in general, rarely ; their most frequent cause is epilepsy. General convulsions with loss of consciousness and consequent short somnolency are repeated during a series of years at different intervals of from several weeks up to whole months. In epilepsy it is especially characteristic if the attacks sometimes appear at night, or if immediately before the paroxysm of con- vulsions sets in the patient complains of this or that sensation, known as aura. Aura is of great diagnostical iyiportance, because, first, it is seldom absent in elder children, and, secondly, because in the same patient it always recurs quite definitely. ' Most often it is described by the patients as "a blowing" which passes from the periphery of an extremity to the head, in other cases it appears as a painful sensation or as "ringing in the ears," flashes before the eyes, or an odor (aura sensitiva) ; in the third series of cases there are noted the so-called abnormalities in the motor area, trembling, twitching (aura motorica) and on the part of the psychical condition, for instance, hallucinations, dizziness, etc. Aura usually lasts a very short time (a few seconds), nevertheless it enables the patient to assume a more comfortable position and, so to say, to prepare himself for the attack. Of the fit itself there is complete loss of consciousness and the absence of reflexes, among others also the pupil-reflex, the pupils always being dilated. The epileptic fit usually lasts about two or three minutes, 356 DISEASES OF THE NERVOUS SYSTEM but cases of epilepsy occur with fits of much shorter duration or even entirely without definite fits, there being only slight twitch- ings of the face. Such abortive attacks of epilepsy (petit mal s. epilepsia minor) are manifested thus : — The child, while in com- plete health, suddenly loses consciousness, grows very pale and in a few seconds recovers his senses ; the loss of consciousness is over so rapidly that the patient even has no time to fall down ; if he is speaking immediately before the onset of the attack then he stops on the half-word and, the interruption ended, he then continues talking. During the attacks the patient does not feel anything, and after the fit does not remember what had hap- pened to him. If such abortive attacks of epilepsy alternate with convulsive fits, then is the diagnosis easy, however, if real epilep- tic attacks are absent, then the case may be properly appreciated only if there are repeated from time to time entirely identical fits of loss of consciousness of several seconds duration. Similar irregular forms of epilepsy make themselves evident sometimes by very strange fits. For instance, I knew one ten- year-old boy in whom the epileptic fits appeared in the form of sudden loss of consciousness, the patient did not fall, but grasped the first object under his hand and waved it in the air. Once being in a forest near a wood-pile he seized in the same manner a burning piece of wood and caused himself a severe injury ; upon another occasion, while in a company the first time in a house he during a lotto play grasped, without any reason, his neigh- bor's head and soundly pulled him. Reaching fourteen years he became free from such fits. Irregular varieties of epilepsy in the form of the so-called petit mal, like the actual convulsive fits, may be a manifestation of some chronic cerebral affection. The differential diagnosis (Jackson's epilepsy, vide supra), is partly consequent on the condition of the patient during the intervals. In favor of cere- bral lesion are different mono- and hemiplegias, h^emianassthesia, persistent headaches especially with vomiting. All these symp- toms are to be readily observed. It is more important perhaps to point out that sometimes, simultaneously with the fits of petit mal in the form of short dizziness or slight twitching of the facial muscles, there is found for a long time (a few months) out of all cerebral symptoms only a slight paresis of the facial nerve, notice- DISEASES OK THE NERVOUS SYSTEM 357 able, for instance, at the sli()\vin<;- of the teeth, or there arc changes in the eye fundus in the form of oedematous papilla. Both these signs must always be especially taken into consideration, before the physician limits himself to the diagnosis of an idiopathic strand or petit mal (great or small epilepsy). In childhood one seldom has to deal with a feigned epilepsy, which dilTers from a real one among other symptoms by the fact that the patient when falling in convulsions never hurts himself and does not bite his tongue, as well as by the reflexes in a dissembler being always preserved (he shudders upon the sud- den sprinkling of his face with cold water, and his pupils react excellently to light). Great similarity to epilepsy may be presented by some cases of hysterical convulsions, known under the name of hystero- epilcpsy. The paroxysm of the latter differs from epilepsy by the incomplete loss of consciousness and by the epileptic fit beginning usually with screaming, often being accompanied by biting of the tongue, incontinence of the urine and faeces as well as by sopor, and when the attack is over the patient does not remember what happened ; while in hysterical convulsions, biting of ^^^e tongue, screaming, involuntary urination, as well as complete anaesthesia are usually absent. Further, one must pay attention to heredity and ascertain if the patient does not represent some of the char- acteristics of hysteria, known as hysterical labels or stigmata, which most often occur in the sphere of the organs of sense, as, for instance, different hyperccstliesicc and ancesthcsicc. [In in- fantile hysteria the stigmata peculiar to the aft"ection in adults are mostly absent, being usually of iiioiiosyiiiptoiiiatic character (i. e., in the clinical expression one symptom prevails, as paralysis, mutism, tic, vomiting, etc., a combination of symptoms being pos- sible, but I'ery iiiicoiiiinoii). — Thiemish,'^' Bruns.** — Earle.] Hyperaesthesia of the skin shows itself by a considerable pain- fulness upon pressure over some areas of the body, especially over the spinal processes and abdomen, as well as by different neural- gia and frequent headaches. Hyperssthesise of other organs *Thieniish (Ueber Hysteric im Kiiidcsalter — JaJirb. f. Kinderhcilk. LVIII., 6, 1903). **Bruns (Ibidem). 358 DISEASES OF THE NERVOUS SYSTEM of sense manifest themselves by ringing in the ears, flashes before the eyes and pecuHarities of the senses of smell and taste. Still more significant are different anaesthesise which usually do not correspond altogether to the distribution of the nerves, especially notable are hemianassthesige and anaesthesise in the form of cufifs (the hands and the lower end of the forearm of one or both sides), it is also peculiar if over a vast area of com- plete loss of sensibility there suddenly appears a small islet of skin entirely sensitive. Anaesthesia mav be either complete, or affect only some forms of irritation, for instance, the patient does not feel pricks, but is sensible of a slight touch, etc. On the part of special organs of sense concentric limitaticMis of the field of vision in one eye occurs comparatively often, or, more often, in both e}es ; there also occurs in hysteria loss of sensibility of the soft palate and, generally, of the pharynx. It is furthermore important to note in hysteria iuipainncnt of the psychical condition, there being some reason why hysteria is at present held to be a mental disease. The patients are very irritable, snivelling, capricious and are distinguished by rapid changes in their s])irits, either an unreasonable sadness, or an equally causeless exaltation. I lysterical patients easily fall into hy])n()tic sleep and obey suggestions, fre(|ucntly evcii while in the condition of vigilance. All these circumstances should be given attention as soon as there arises any suspicion of the hysterical nature of any symptoms and in the given case of general convulsions. Un- fortunately, all these stigmata occur in childhood with less fre- quency than in adults, therefore the diagnosis of h_\steria in chil- dren mav sometimes present great difficulties. Of special value in the diagnosis of convulsions are two more circumstances; first, the results of bromide treatment. This remedy does not noticeably influence hysterical convulsions, while epileptic fits generally decrease quite rapidly and become less frequent. Secondly, the properties of the urine, which as a matter of fact, are sharply changed after an attack of hysterical convulsions ; the quantity of solids decreases by one-third ( nor- mally forty or fifty grams in twenty-four hours, and after the attack thirty or thirty-five). This diminution ]M-incipally aft'ects DISEASES OF THE NEKN'OUS SYSTEM 359 the urea and the ])hi)S])hates. IJesides this there are striking; chanij;-es in the ratio of the {jhosphate-Hine sahs to the alkalies; normallx the former are approximately one-third less than the latter (1:3), hut after an hysterical attack the ratio is as i ;i, while after epileptic convulsions nothing similar occurs, on the contrar\- the amount of urea and phosphates increases. As to the diagnosis of convulsions dtte to unnemia one should remeiuber that after a real epileptic attack albumin and hxaline casts appear in the urine, but both are observed not longer than twenty-fottr or forty-eight hours. Tf the patient never had convulsions previously, and any data regarding epilepsy or other serious nervous diseases are absent in his history, then one shotild think either of ttnemia (examination of the urine, (edemata), or of poisoning, among other substances, with santonin and alcohol (history). In small children (under five years) the cause of convulsions may be a foul-stomach or intestinal worms (examination of the dejections for eggs and elimination of the worms, viz. their segments). As a rare, but undoubtedly possible, cause of con- vulsions, one may detect a foreign body in the ear, whether this be a large old cerumen, or something else. From eclampsia epilepsy differs not by the cliaracter of the fits, as these are the same in both cases, but by the fact that eclampsia is an acute disease, and epilepsy a chronic one. It is obvious that if the ])hysician has to deal with the first fit. then he cannot know if it will be repeated, so that the diagnosis is in such case impossible. Nevertheless, as epilepsy in children usual- ly begins as petit iiial. and liant nial appears nmch later, after a whole series of small attacks, then one may suppose with some probability that he has not to do with e])ilepsy as soon the first attack of general convulsions appears in a child previousl\- never suffering from "swoons." /;; children from six iiiuiiths up to t'wo and a-half years of ai!;e afebrile convulsions occtu' most t)ften in those stififeriug with rachitis and especially during laryngismus stridulus. L'pon ex- amination of such a child it is easy to note rachitic changes in the skull-bones (in children under one year of age there is always softening of the occiput) and the chest, and in the histor\- at- tacks of larvngo-s])asm. These fits, characterized 1)>- whistling 360 DISEASES OF THE NERVOUS SYSTEM inspiration, appear especially often (several times a day) in a child during crying, but in the great majority of cases they stop so rapidly that they do not do any harm to the patient. But some of them are so severe that the child cannot breathe, general convulsions commencing soon after this apnoea. From any other convulsions the former differs by the beginning or the end of the fit being marked by a whistling inspiration. Eclampsia sometimes occurs in rachitic children even with- out laryngismus stridulus, because of the considerable irritability of their nervous system under the influence of an abnormal con- dition of the general nutrition. It rarely occurs that convulsions affect other than rachitic children, in such cases the irritability of the nervous system develops either on the ground of anicmia, or under the influence of heredity. This latter case manifests itself in almost all children of the given family suffering at a certain age (in the first or second year) from convulsions. Such a curious case of ''a family eclamp- sia" is given by Bouchut : in one family there were ten children and all of them suft'ered during their first year from convulsions ; one of the girls married in due time and also brought forth ten children, in nine of whom there was eclampsia. Thus, the chief cause of convulsions in small children is a peculiar condition of their central nervous system under the in- fluence of rachitis, more rarely anaemia or hereditary predisposi- tion. The disposition to convulsions may be so great that eclamptic fits sometimes appear without any noticeable accidental factors, or under the influence of the most insignificant causes ; in a child with a disposition to laryngismus stridulus convulsions are not infrequently caused by the slightest psychical excitement, the fits being repeated during each loud cry, etc. In such condition about ten or twenty convulsive seizures a day may be observed in a child. One may, in general, say that if in a child a few months old and seemingly, at first glance, healthy, the convulsions are repeated every day and even several times a day, then a minute examination will almost always show that such a child is a rachi- tic one, suft'ering, perhaps, at the same time with laryngismus stridulus and also with a softened occiput. DISEASES OF THE NERVOUS SYSTEM 361 In Other cases convulsions appear onl}' under the inllucncc: of ■some definite cause, wliich is most often fever and foul-stomach, •especially constipation. It is also undoubtedly true that the oc- casional cause of convulsions may be some psychical excitement (fright) and irritation of the peripheral nerves, for instance, during dentition. Eclampsia dependent upon the latter differs from any other eclampsia only by convulsive fits appearing in the x:hild at each new dentition (see page lOo). In children of the first months of life convulsions may be the consequence of colics (dyspeptic stools, expanded abdomen, continuous cry) or of constipation or some diet errors. To the last class Henoch (page 159) refers, for instance, •cases of eclampsia in nurslings after they had taken the breast of a violently excited wet-nurse. In the same category may be included eclami^sia in children after they have taken indigestible food ; in one of my cases convulsions in a sick child were pro- duced, for instance, by a few tablespoonfuls of sour-cabbage soup, in another one, by a teaspoonful of whiskey. Cases described ^by Henoch prove that the same causes may produce convulsions in children two to three, and even six years old. For the correct estimation of such cases it is important to •detect a gross error in the diet, or constipation, in the days pre- ceding the convulsions. Not infrequently the spasms are pre- ceded by vomiting and fever, if constipation be followed by a diarrhoea (occurring, so to say, voluntarily or after a laxative), •then this is usually marked by very foetid dejections. Regarding children of the first months of life it should be mentioned that the cause of convulsions in them may be a tiiii- ■dered urination due to severe phimosis or urinary calculi; in the last case the child cries violently before the micturition, be- •coming quiet after emptying the bladder. Finally, afebrile eclampsia in nurslings may be the result •of passive hyperasmia of the brain for instance, in whooping- •cough or in oedema, and in anaemia during infantile cholera. About febrile convulsions we have already spoken. Convulsions characteristic of eclampsia and occurring in at- tacks of short duration but with loss of consciousness, have no resemblance to those almost continuous, involuntary movements which appear in the presence of complete consciousness char- 362 niSEASES OF THE NERVOUS SYSTEM acterizing St. Vitus' dance — chorea. Chorea occurs in differ-- ent forms, as, for instance, symptomatic, hereditary and hysterical chorea, but all the^e forms will be mentioned later on ; here we will occui)v ourselves only with idiopathic chorea, known also under the name of infantile, or Sydenham's, chorea. In this malady real convulsions are absent, only motor dis- orders of co-ordination being" manifested by the muscles not entirely obeying the will ; the voluntary movements are mixed with involuntary muscular contractions, peculiar of chorea and characterized by the facts ( i ) that they cease during sleep, and (2) thev increase upon the psychical excitement of the patient and his effort to perform a voluntary movement. Once started chorea usually lasts a few weeks or months (the average being about three months). In the mildest cases the whole disease is shown by the restlessness of the muscles ; the patient camiot remain a long time in a c|uiet condition; either his lingers will bend and extend again, or the shoulder will rise, or a grimace will appear on the face. etc. It is esi)ecially easy to note the abnormalit\- of movements if the i^atient be compelled to ])erform some definite muscular act, for instance, to extend the arm, to button up a garment, etc. In mild cases the restlessness of the muscles appears con- stantly, also increasing upon voluntary acts. In many cases the- eve-lids and the tongue are most involuntary in character, this being recognized by the i:)atient being unable to long keep his tongue protruded or to firmly shut his eyes. These particular features may be used in judging whether the disease is improving or not : we make the patient protrude his tongue and so hold it until we count ten; in severe cases the tongue recedes into the mouth after two or three seconds, and after five, eight or ten seconds when undergoing im])rovement. The same with the eye-lids ; the patient can keep his eye-lids well compressed only one to three seconds, and longer with the improvement of the- disease. In grave cases involuntary movements hindei the voluntary ones to such an extent that complete disorder of co-ordination appears, so that the patient cannot, for instance, carry a spoon to the mouth, cannot cross himself, etc., and must lie in a bed DISEASES oi-- nil-. XEinors s^'s■l•|•:^[ 365 surrouiuled with piuldcd walls, as 1 )llKTwisc under llic iuHuciicc of continuous uio\cnicnts ])r()(luced by the trunk, as well as b\- the extremities, he would certainly fall to the floor. Ill the most severe cases chorea continues even at night and entirely deprives the patient of sleep, so that he becomes weak to such a degree that his condition is dangerous. With the ap- proach of death there is sometimes observed, besides collapse, fever and delirium, ending with complete coma. Fortunately such cases belong to the great rarities. Among the constant symptoms of chorea which are met with even in comparatively mild cases may also be included mental derangement and change in the character : the patient loses his memory (it is, for instance, more difficult for him to commit something to memory), is not attentive enough, being therefore punished in school he becomes irritable, whining ; on the con- trary the sensibility remains normal, only hyperaesthesia being sometimes noticed upon pressure over the spinous processes of some dorsal vertebra?. The bladder and rectum are not affected in chorea ; but the same cannot be said about the heart. Under the name of chorea of the heart diverse irregularities of the cardiac activity are described, occurring during chorea and disappearing with the recovery therefrom ; here are included ir- regularities of the pulse without any subjective symptoms, or tachyacardia manifested sometimes by marked cjuickening of the pulse after some slight movements as, for instance, a few steps in the room are sufficient to raise the frequency of the pulse from 90 up to 120 or 130. In other cases there are found inorganic, slight systolic murmurs of blowing character at the apex of the heart ; from the organic murmurs, which are quite frequent in chorea, these dynamic murmurs ( aUcTmic murmurs, or dependent upon the irregular innervation of the musculature of the heart j are distinguished by their changeableness (one day they are stronger, the next weaker), and further by their disappearing after the chorea is cured. Chorea begins either at once quite violently, or disorder of co-ordination first appears in mild degree and especially unilater- ally, then gradually increasing for two or four weeks, remains at the maximum plane one to two months and then gradually decreases, while recovery commonly follows after three months. 364 DISEASES OF THE NERVOUS SYSTEM A patient having been sick with chorea remains for a long time disposed to a recurrence of this disease, which may be repeated every year for two, three and more years in succes- sion. Idiopathic chorea very seldom occurs in strong and seemingly healthy children under the influence of some accidental causes, for instance, fright, but usually develops because of ansemia and hereditary nervousness or under the influence of rheumatism ; in the latter case it is altogether unnecessary that there should be an endocarditis. Chorea may be produced by an acute articular, as well as by a muscular form of rheumatism, for instance, torti- collis. Rheumatic chorea differs from any other form only by being j^receded or followed by rheumatic pains. Much less often than after rheumatism, chorea follows some other infectious diseases, most important of which is scarlet fever. [L. Harrison Mettler has presented elaborate proofs that chorea may also be produced, although not very often, by syphilis, which "should always be thought of as a possibility in the ex- amination of every case" ; that acquired as well as hereditary syphilis may cause chorea ; that most of the cases of syphilitic chorea are unilateral, belonging to the prchemiplegic or posthemi- plegic t}pe of the disease ; that they may or ma}- not be asso- ciated with other signs of an irritative lesion ; that they are not infrequently developed in hereditary syphilitics, and are to be attributed probably to a functional disturbance of an irritative sort in the cortical and ganglionic motor cells.''' Preobrazhensky is of the opinion that chorea minor is due to a streptococcus in- fection, as he was able to find streptococci in the blood of a patient who suft'ered from a severe chorea and which was success- fully cured by him with antistreptococcus serum, while all other methods of treatment, as arsenic, chloral hydrate and bromides failed**. Of the same opinion is Reichhardt who found staphy- lococci in the blood in one post mortem of a choreic patient***. — EarlE. ] As to the relation between chorea and cardiac lesions it *L. Harrison Mettler: Syphilis as a Cause of Chorea. Amer. Journ. Med. Sci., September, 1903, p. 487. **Medic. Obosren. (Abstract in Jour. Am. Med. Assn., Aug. 29, 1903, p. 587). ***Dcut. Arch. f. Klin. Med., Vol. LXXIL, Nos. 5 and 6. DISEASES OF TIIK NERVOUS SYSTEM 365 may be said that, although the latter occur in chorea quite often, nevertheless one should bear in mind that not every murmur in the cardiac region proves the existence of a valvular defect; and that the so-called dynamic cardiac murmurs occur in choreas, perhaps, still oftener than the organic ones. The diagnosis of idiopathic chorea is not difificult ; peculiar twitchings and involuntary movements, distinctive of this malady, are so typical that if once seen they may always be recognized. From symptomatic chorea, as a symptom of a chronic affec- tion of the brain, Sydenham's chorea differs by the former belong- ing to chronic or incurable diseases, accompanied by some other cerebral symptoms, as in some cases persistent headache, paralyses (especially of the eye-muscles) and mental derangement, in other cases — spastic mono- or hemi-diplegia and slow development of the paralyzed extremities. Symptomatic chorea most often oc- curs in cerebral paralyses of inherited origin, therefore appear- ances of chorea (chorea post-paralytica) are dated, usually, from the first months of life. [Mettler, in view of his observations and studies comes to the conclusion that chorea (minor) is not a disease, but a mere symptom dependent upon a variety of possible causes. "All choreas," says he, "are symptomatic — symptoms of a more or less distinctive, or at least disturbing, toxjemia."* — Earle.] Hereditary or Huntington's chorea is characterized by being transmitted hereditarily, is not manifested in childhood, but only after thirty or forty years, and lasts for years until death oc- curs. As to hysterical chorea^ this is of two kinds ; in some cases an ordinary chorea appears in an hysterical person, in others we have to deal with a peculiar manifestation of chorea. The former cases differ from a common chorea by the patient manifesting besides chorea other symptoms of hysteria (haemiangesthesia, ec- centricity of the character, etc.), and a real chorea hysterica is further characterized by the movements being rhythmical, repeated always in the same manner. Under the head of chorea clectrica two entirely dififerc" *Mett]er: Neurological Clinic, Clinical Review, January, 1904, p. 263. .See also Amer. Jour. Med. Set., September, 1903, p. 241. 366 DISEASES OF THE NERVOUS SYSTEM diseases are described ; chorea electrica of Dnbini and chorea electrica of Bergeron. The former seems to occur only in Italy ; it is characterized by rhythmical twitchings of the muscles of the extremities and face ; lasts an indefinite time ; leads to paralyses and ends with death in the condition of coma. On the contrary Bergeron's^ disease is of benign course and usually ends with recovery, although sometimes it becomes pro- tracted for about two years and even more. It is indicated by the appearance, after more or less short intervals of time, of very rapid twitching always of the same muscles, or group of mus- cles. Most often there are movements of the head (backwards, forwards or to the side) and of the upper extremities. If the twitchings appear in the region of the facial nerve then we have the picture of a common tic convulsif, the main difference being the incurability of the latter. As a peculiarity of Bergeron's disease by which it differs from other similar morbid forms the French authors point out the beneficial effect of vomiting-doses of tartar emetic. After taking, every other day, two doses (0.05, or I grain, at a dose) of tartar emetic the twitchings seem to disappear immediately. As chorea electrica almost always occurs in hysterical persons, then it is very probable that such a strong remedy acts by way of auto-suggestion. The value of this remedy is, however, exaggerated, and no diagnosis can be made on the basis of the therapeutic results observed therewith. In Cadet de Gassicourt's case, for instance, this remedy proved useless, and recovery came on after faradic electrization. Some resemblance to chorea, that is to its initial period, may be represented by local clonic convulsions, for instance, by tic CONVULSIF and twitching of the muscles of the face (involuntary grimaces) or of other muscles, especially those of the neck, so that the child performs peculiar movements with the head, mani- fested the clearer the more the child's attention is occupied (as during writing, solving of arithmetical problems, etc.). If such local spasms of the muscles are the expression of a beginning chorea, then in a short time, viz., in about two weeks, the dis- orders of co-ordination will also appear in other portions of the body and especially in the arms ; if, however, the local spasm DISEASES OF THE NEKVOUS SYSTEM Z^^7 \ /fi i ^^- Fig. 2)^ — Position of hands in the spasm of tetanj' (Oppenhein»). 368 DISEASES OF THE NERVOUS SYSTEM occurs as an independent lesion, then it remains stationary for many weeks and even months. To the same class of local clonic convulsions belongs also the so-called spasmus nutans, consisting in that the child con- stantly performs nodding movements with the head (bends and extends the head), or with the whole trunk. This disease usually continues a few weeks, frequently being combined with strabismus and nystagmus (trembling of the eye-balls) and then is over, unless it depends upon some central lesion. According to Henoch, spasmus nutans often disappears soon after the appearance of a new tooth. There should also be mentioned at this point a constant, in- vohmtary movement of the fingers, known under the name of athetosis. These movements usually do not stop even during sleep. This affection has an extremely chronic course lasting many years ; it is usually combined with pareses, or with some other symptoms which show the cause of athetosis to be a central one, localized, perhaps, in the cerebral cortex. Tetany (Tetania). The chief symptom of typical cases of tetania appears in the symmetrical contraction of the hands and fingers, sometimes of the feet, consciousness being non-im- paired, and with no other symptoms which would denote some gross material changes in the central nervous system. This malady is shown by the peculiar form of the contracted parts; the hand is flexed at the wrist-joint, the thumb bent into the palm of the hand, and the four fingers, remaining extended in the interphalangeal joints, are flexed in the metacarpo-phalan- geal ones, while the little finger and the index approximate each other, being located with their ends over the ring and the mid- dle fingers, so that the whole wrist assumes a form very similar to that of the accoucheur's hand when about to introduce the same into the vagina (Trousseau). (Fig. 36.) The toes also are flexed only in the metatarso-phalangeal articulations or remain extended and spread, so that the foot assumes the form as in pes equinus. In nearly one-half of all cases only the arms become in- volved, the legs remaining unaffected. Comparatively seldom the- spasm spreads to the forearm (flexion of the arms at the elbow- joints'! and to ochef above-attached muscles (adductors of the- DISEASES OF THE XKRVOUS SYSTEM 369 shoulders) ; in nursliiii^s the llexion spreads sonictinies to the occiput, back and abdominal muscles and pectoralis major. A forcible extension of the contracted fingers causes the child pain and, necessarily makes him cry. The contracture after once appearing" lasts a long time, from a few hours up to several days, without interruption, even during sleep. The conscious- ness in tetany is not impaired ; the sensibility of the skin remains normal. The contracture seldom ends at once, usually being of a protracted course, that is, the contracture disappears to appear again, while such changes may take place several times a day, the periods of contracture lasting in general longer than the inter- vals. Besides the characteristic contractures three more symptoms are almost always met with, which are specially peculiar to this disease: — Trousseau's syiuptoui — the appearance of contracture of the fingers and wrist upon compression of the brachial artery or brachial plexus: this compression (constricting the shoulder with a twisted handkerchief) being performed during the in- terval; Chovstek's syinpfom or facial pheuomenou — twitching of the angle of the mouth and other facial muscles upon slight percussion with the hammer upon the facial nerve (immediately in front of the ear). This phenomenon is based upon the fact that in tetany there is generally noted a strongly increased ex- citability of the muscles to mechanical, as well as to the electrical (galvanic current) irritations; the latter constitutes Evh's symp- tom. These three symptoms ma}- be used for determining the latent form of tetany when the patient has no contractures, for instance, during the intervals between the attacks. Of complications of tetany the chief is laryngismus stridulus occurring in this malady so often that it is held by some authors to be a manifestation of tetany itself. Indeed, one often suc- ceeds in detecting, in children suffering with laryngismus stridu- lus but entirely free from contracture of the fingers, either the facial phenomenon, or the symptoms of Trousseau and Erb, or even all these three symptoms together, but this being not always the case, one cannot hold all cases of laryngismus stridulus as latent tetany. 370 DISEASES OF THE NERVOUS SYSTEM As to the course of tetany, one may say in general that the whole disease lasts approximately from a few days up to six weeks, ending- usuallx' with recovery, but laryngismus stridulus being present a fatal termination may easily come on. In the aetiology of tetany two conditions play the main part : the age, from six months up to three years, and rachitis, which occurs in tetany almost always, therefore some authors hold tetany as one of the symptoms of rachitis. Of the accidental or exciting causes the most important are — subacute or chronic catarrhs of the intestines and different febrile diseases, especially those of the respiratory organs. In view of what has just been said the diagnosis of typical cases of tetany is not difficult as the symmetrical contracture of the hands and fingers, with the complete preservation of con- sciousness and the periodical course, does not occur in any other disease. If the physician sees the patient in the period of an interval and suspects tetany on the ground of the history, then he may become sure of the diagnosis by the aid of the symptoms of Trousseau and Chvostek. In the same manner he may detect a latent tetany in children suft'ering seemingly only witli laryngis- nuis stridulus. In those rare cases where spasm entirely involves all the limbs and the muscles of the trunk, then such condition may be easily taken for tetanus. The marked dift'erence consists in that in such disease the masticators ( trismus ) become affected most severely and the earliest, then the muscles of the nape of the neck and those of the spine (opisthotono.'O. while the wrists and the fingers are either not involved, or very slightly, whereas in tetany the opposite obtains — the hands are involved at first, the chewang muscles remaining unaffected even in those rare and grave forms of tetany wherein the spasm spreads to the muscles of the occiput and trunk. Furthermore, in tetanus the reflex excitability is strongly exaggerated, but there are absent the symptoms of Trousseau, Chvostek and Erb. Finally, attention should also be given to the aetiology of the case ; in tetanus — a wound; in tetany — rachitis, laryngismus stridulus, age, fever or some disorder of digestion. i)isi:.\si:s (IF Till-: nervous system 371 CONTRACTL'RE OF THE NECK MUSCLES. Immobility of the neck because of contracture of the neck muscles occurs in children quite often. If the posterior neck muscles be contracted, then the head is thrown back (contracture of the nape of the neck), and the neck forms a concavity on its posterior surface , if. however, the muscles of one side are con- tracted, then ihe head is turned toward the corresponding shoulder (wry-neck — torticollis). In slight degrees of contracture of the neck the liead is not thrown back, but remains extended and cannot be passively bent, and each attempt at so doing is very painful, so that even in somnolency due to meningitis, when pricks with the needle do not produce any reaction, children with the contracted neck react, upon the passive bending of the head, either with groaning or disfiguration of the face. To recognize contracture of the neck, even in slight degree, is not difficult even in the smallest children ; one has only to try bending the child's head when he is in a recumbent posture on his back ; if the contracture of the neck he, absent, then it is easy to bend the head to the chest, on the contrary the whole trunk rises together with the head, which remains stretched. Acute varieties of contracture of the neck most often occur during different forms of Dwiiiiii^itis and especially in epidemic cerebro-spinal inflammation of the meninges, in the diagnosis of v.-hicli contracture of the neck appears as a very important sxmptom, because it developes very early, together with other symptoms of irritation, in the first period of meningitis ; so that, if we have a patient who only one or two days previously became ill with fever and headache and who complains of severe back- ache, increasing upon each movement and especially upon bend- ing the spine (change of the recumbent posture into a sitting one) and if he has contracture of the neck, then cerebro-spinal meningitis may be diagnosticated, even if the consciousness be not yet impaired and constipation, as well as retarded pulse, be absent. In tubercular meningitis or in acute simple hydrocephalus, contracture of the neck is not unusual, although not occurring from the first days of the disease, but later, namely in the period of somnolency and impairment of consciousness. One may then 372 DISEASES OF THE XERVOUS SYSTEM note in llic liistory that, ten days previous to the appearance of the contracture of the neck and somnolency . in the child, there was a persistent (usually of many days' duration) vomiting and constipation with mild fever and retarded pulse. If the contracture of the neck appears in the patient several days after a violent fever, then on the ground of this symptom the diagnosis of meningitis cannot be made even in case the patient is in the state of somnolency, half-consciousness, or de- lirium, and if there be clearly developed general hypersesthesia of the skin, because just the same picture may be met with in grave cases of typhoid and relapsini^ fever. High temperatures (40 degrees C. or 104 degrees F. and more) are peculiar to severe cases of these diseases, considerably assisting the diagnosis. That the patient is not suffering with a cerebro-spinal meningitis, one may see from the contracture of the neck having appeared too late (for instance, in the second week) ; against tubercular men- ingitis there is the too elevated temperature and, perhaps, the absence of initial vomiting (which does not often occur during tvphoid or typhus and in relapsing fevers, being never persist- ent). It is obvious that, if the physician can convince himself of the existence in the patient of a recent spleen-tumor and typhoid rose-spots, then the diagnosis of typhoid will be easy. It very seldom occurs that contracture of the neck compli- cates tvphoid from the very first days of the disease; and in such a case the diagnosis remains in doubt for a few days. I have had the opportunity of observing only one such case, in a lewish bov. aged six years, because of complication of typhoid with acute rheumatism of the neck muscles (the patient had also previously suffered with contracture of the neck muscles). Cerebro-spinal meningitis in this case could be excluded in view of the absence of pain in the back, hxpersesthesia of the skin and initial vomiting. If the immobility of the head because of contracture of the neck-muscles occurs in the chronic form, then it almost always depends upon spondylitis in the cervical portion of the vertebral column ; the head in such cases is not thrown back, but remains extended (see the section on Pott's disease). Acute forms of lateral curvature of the neck (torticollis) DISEASES OF THE XERX'OUS SYSTEM 373 most often occur in rhciniiafisni of the stcniO'Cleido-niastoid muscle or of the trapezius or splcnii. In contracture of the sterno- cleido-mastoid muscle the head bends toward the affected muscle, while the face is turned toward the opposite side and the chin somewhat rises. In unilateral contraction of the trapezius muscle the head is also bent toward the affected side and somewhat back, but sinmltaneously the corresponding shoulder is elevated : in case the splenii become involved, the chin is not raised, and the face does not turn toward the unaffected side, but the head is simj)ly inclined toward the shoulder of the involved side. The diagnosis is assisted still further by the affected muscles being felt as more solid and tense than normal. One mav diagnose rheumatism of the neck nuiscles only when the absence of painfulness in the vertebr.-e excludes synovi- tis vertebralis and if there are no signs of inflammation of the neck-glands, cellular tissue or a retro-pharyngeal abscess, in which a changed posture of the head is often observed. In reality, torticollis rheumatica probably occurs not so often as it is com- monly believed, as the majority of cases included in this category show upon closer examination of the vertebral column nothing but s}novitis (spondylarthritis cervicalis of \'olkmann) of the lateral articulations of the vertebral column. These synovites may be of rheumatic or traumatic origin, or they develop after some infectious diseases, especiall}- after scarlet fever. The similarity to rheumatic torticollis is striking the n^ore the posture of the head corresponds to the unilateral contracture of the sterno- cleido-mastoid muscle ; the head is turned toward the well side, the face, however, to the affected one, the chin being somewhat elevated. The diagnosis is easily determined by the contracted muscle being painless, while pressure produces sharp pain when applied to one part of the spinous processes. Torticollis sometimes arises in the form of periodically re- lapsing attacks rapidly yielding to c|uinine, that is, it must be looked upon as febris intermittens larvata. Chronic cases of lateral curvature oi the neck may have an i)iheritcd ori_i^iii (because of rupture of the sterno-cleido-mastoid muscle during labor), and then the half of the head correspond- ing to the contracted nmscle, shows a noticeable degree of atrophy or lack of development. SEMEIOLOGY OF THE PARALYSES. I'nder the name of paralysis is understood inability of per- forniini;- voluntar\- movements, depending either n])on the destruc- tion of the conductibility of the vohmtary impulses along the nervous elements (neurophathic paralysis), or upon the loss of muscular coiitractibility due to disease of the muscle itself ( m}o- pathic paralysis). Therefore, one nuist not make a diagnosis of paralysis only because the child holds immovable this or the other extremitN , but nuist prove that this immobility depends upon disorder of innervation of the neuro-muscular apparatus, and does not depend, for instance, upon pain from inflammation of the joint, or upcTn bone lesion, etc. In childhood, as well as in adult life, the paralyses are of diiferent character, depending upon the parts of the nervous sys- tem involved ; if the paralysis depends upon disease of the motor portions of the cerebral cortex or pyramidal tracts oi the brain or spinal cord, then it is characterized by the peculiarities of so-called central paralysis, if, however, the afifection occupies the anterior columns of gray matter of the spinal cord (nuclear paralyses in the strict sense of the word), then we have the l)eculiarities of peripheral paralysis. The main differences between central and peripheral ])aral\ses are as follows : — (i) The spread of the paralysis — diffuse paralysis, especially the paralysis of one-half of the body, indicates a central origin, while the paralysis of single muscles or muscle-groups, in short, limited paralysis, denotes its peripheral nature. (2) The relation of the paralysed niuseles to the electrical current. In central paralyses the reaction of the nerves and muscles to electrical irritation, with the constant, as well as with the in- terrupted current, does not exhibit any changes, at least in quite nisi':.\si-:s of tiii-: xi^rvots s^■s■|"KM 375 recent cases ( for instance, two or three months) ; later on, how- ever, the electrical excitability changes only ((uantitatively, bnt not (jualitativelx , that is, it merely lowers. On the contrary, in nnclear and purelx ])eri|)heral paralyses the faradic e.xcitaliility in the nerves, as well as in the mnscles, rapidly begins to fall within a few days after the development of the paralysis. In regard to the galvanic current the nervous excitability also falls, and upon the direct irritation of the muscles there is not only quantitative lowering of the excitabilitw but also its (pialitative alteration, which is expressed by the perversion of the physiologi- cal law of muscle-contraction upon closure and opening of the current. Normalh a muscle reacts to a weak current by rapicl twitching at the moment of cathode closure [C C. C. — cathode closure contraction) ; if the current be gradually increased, then similar sudden contractions begin to appear also upon the closure and opening of the anode, being stronger upon cathode-closure (C C C>A C C and A O C, that is cathode closure oontractiou is more than anode closure contraction and anode opening con- traction) ; if the strength of the current be further incfeased, then contraction also appears upon cathode opening. It means norniall}' cathode closure irritates the nuiscles stronger than cathode opening, but in pathological cases of which we now speak we obtain perversion of this law known as reaction of dc<:;cncra- tioii. This reaction is characterized by the fact that the hr>t contraction of the muscles, upon the gradual increasing of the weakest current, sets in at the anode-closure, then, the current being made stron'^er, at the cathode-closure (ACC>CCC) Besides this, the character of the contraction of muscles changes; instead of a sudden contraction we obtain a sluggish, continuous one. Toward the time of the disappearance of the re- action of degeneration the faradic excitabilit\- in the nerves and muscles usually disappears altogether. .Although the reaction of .degeneration always points toward the ])erii)heral (or nuclear) origin of the paralysis, yet is not necessary to the latter at all, so that absence of reaction (^f degeneration dfies not admit of a contrary conclusion. (3) The condition of the muscles. The muscular tonus dur- ing paralvsis mav appear increased or decreased ; in the former 3/6 DISEASES OF THE NERVOUS SYSTEM case the paralyzed muscles are visibly tense and solid to touch, in the latter they are enfeebled and flal)by. Increase of the muscular tonus occurs in central, and a weak- ening; in peripheral and nuclear paralyses. Atrophy of the paralyzed iiiiiscles sets in very soon in peripheral paralyses and very slowly in central. (4) The tendon reflexes in the case of a complete paralysis are retained only in the case of central origin. As the tendon reflexes are exaggerated during any increase of the muscular tonus, then all spastic paralyses are also of central origin, while the peripheral (or nuclear) paralysis characterized by weaken- ing of the muscles, that is, by lowering of their tonus, is ac- companied by the considerable decrease or complete disappear- ance of the tendon reflexes. The preservation of the cutaneous reflexes is more peculiar also of central paralyses. T cannot, of course, enter into the minute discussion of all possible ])aralyses, which would take us too far into the field of neuropathology, referring the reader, regarding these questions, to the text-books u])()n nervous diseases. My purpose here will be limited to a siiort description of the differential diagnosis of the paralyses which are peculiar to childhcxid in particular. PARALYSES W ITH FLACCIDITY OF THE MUSCLES. Infantile i-araiasis or multiple inflammation of the an- terior cornua of gray matter of the spinal cord, polioinyelit'S anterior acutissima. s. paralysis spinalis i)ifa}itiiin, s. paralysis essentialis. This peculiar paralysis dependent upon the extreme- ly acute inflammation of the anterior gray columns of the spinal cord, is called "infantile,"" because it occurs almost exclusively in small children, especially during the first or the second year of life, being somewhat rare at the age of three or four years, much rarer in children after six years and only as a very marked exception in, adult persons. This circumstance has, of course, also a diagnostic value. (Figs. 37 and 38.) The aetiology of the disease is obscure; no cause (infection?) can be found in the great majority of cases ; in other instances spinal paralysis develops after a cold or after acute febrile diseases. DISEASES OF THE NERVOUS SYSTEM 377 Spinal infantile paralysis is distinouished by the following peculiarities : — (i) It develops suddenly when the patient is seemingly in the best of health (for instance, the child went to bed healthy, but awoke with the paralysis of one or several extremities) ; or after a prodromal period of three to five days' duration, in which the patient was in a moderately febrile condition (38 to 39 de- crees C. — or 100.4 degrees to 102.2 degrees F.) ; not very unconi- pig. 2)7 — Section through the cervical enlargement of the spinal cord in poHomyelitis anterior acuta; the left anterior gray horn is very much contracted and is without gang ion-cells (After Charcot and Jafifroy). monly the onset of the disease is marked by vomiting and repeat- ed, or but one, attacks of eclampsia. When the febrile condition ceases, after a few days, then the paralysis is already well-de- veloped. (2) In the beginning the paralysis is usually wide-spread involving, for instance, all four extremities or even the muscles of the trunk (kyphosis and scoliosis) ; but during the following weeks, and even days, many of the paralyzed inuscles return to the normal condition, and the paralysis may finally be confined to •only one limb, and then not to the whole extremity, but only to some of the muscles, remaining therein fixed for a long time or even permanently. The longest term after which one may yet hope the paralysis will disappear is held to be approximately 378 DISEASES OF THE NERVOUS SYSTEM nine months ; in other words whatever cHsahihty remains after nine months will remain permanently. (3) During infantile paralysis seusibility of the skin, as well as of the vesical and rectal sphincters, is never involved. If in the area of the paralysis some disorders of sensibility are ob- served, these being- pain, anaesthesia, or hypera^sthesia, then one mav be sure that the case is not poliomyelitis anterior. Should any disturbance of micturition occur, as may perhaps rarely, then Fig. 38 — Acute spinal infantile paralysis. Iransverse section through the lumbar enlargement of the spinal cord (After Charcot). it is onlv during the tirst days of the disease and for a short time. (4) The paralyzed muscles are always in a flaccid condition, therefore the tendon reflexes are either entirely abolished or con- siderably lessened (retained in the paralyzed muscles). In the further course of the disease three more important signs appear : — (5) Muscular atrophy, noticeable within two weeks from the' beginning of the paralysis. (6) The quick fall of the faradic excitability in the nerves- Disi'iAsi'is (I I' I' 111-: .\i:k\()rs 379 and muscles of tlie paralyzed extremity and the appearance of reaction of degeneration. (The lowering- of the electrical ex- citability may be observed after a few da\s. and after about two weeks there also appears reaction of degeneration in the most affected muscles). If the electrical excitability in the nerves, Fig. 30 — Anierinr iiDlioniyi litis, sliowmg atrophy and sligiit lateral curva- ture (if the spine (Whitman). as well as in the nniscles. disai)pears altogether and does not return even after the lapse of eight or ten months, it is a very bad omen, denoting the incurability of the paralysis. (7) Trophic disturbances are manifested by the consider- able wasting of the extremitv. togetlier with lowering of the 380 DISEASES OF THE NERVOUS SYSTEM temperature of tlic skin. On the contrary bed-sores are never present. As the paralysis is not locahzed in all muscles of the limb, but only in some, then in time a deformity usually develops due to contraction of the healthy muscular antagonists. In the leg" a permanent paralysis of the peroneus longus most often remains, in the arm of the deltoid. In anterior poliomyelitis the permanent paralysis most often affects one limb (two-thirds of all cases), namely the leg — monoplegia ; less frequently both legs become paralyzed — paraplegia; still more seldom both arms (paraplegia cervicalis) or the arm of one side and the leg to the other one (paralysis cruciata) , In consideration of these signs the diagnosis of spinal paraly- sis is not difficult. Of recent eases most like spinal paralysis we have the uni- lateral cereljral infantile paralysis descrilx-d by Striimpell under the name of polioencei'IIaliits acuta, the anatomical essence of which consists, in his opinion, in acute inriammation with the consequent sclerosis and atrojihy of the gray matter of the cere- bral cortex, but in reality the inflammation is not limited only to the gray matter, as in poliomyelitis, but usually involves the white matter also. The resemblance between recent cases of cerebral and spinal paral\ses consists in the following: — ( I ) Both are met with more often in children of the first three years of life, while the cause of the disease usually remains unknown. (Striimpell's opinion that in both cases we have to deal, probably, with the influence of some infection which in some cases is localized in the gray matter of the spinal cord, in others in that of the brain, was confirmed by Moebius' observa- tions : — In one family two children became sick at the same time with paralysis ; in one of them poliomyelitis anterior was found, in the other polioencephalitis.)* (2) The paralysis develops quickly after a febrile period of several days" duration, which starts with vomiting and convul- sions (both the latter symptoms may be absent not only in spinal, but also in cerebral paralysis). *Medic. Obozr. Vol. XXVI., page 891. DISKASES OF T}1K NERVOUS SYSTEM 381 (3) In botli cases the ])aralysis may ])e localized in one entire extremity or only in some muscles of the same. (4) The sensibility of the skin, as well as of the bladder and rectum, remains intact. Nevertheless the diiTerential diagnosis is in most cases not difficult, being- based upon the following data : — (i) Cerebral i)aralysis is always unilateral and appears in the form of hemiplegia as soon as two extremities are involved. This is the most frequent form. If, however, only one limb be paralyzed, then it is oftener the arm than the leg; while in spinal paralysis there is most often paralyzed either only one leg, or both legs, but very seldom only one arm. (2) Sometimes the facial nerve or the eye-muscles (strabis- mus) become paralyzed in the cerebral form. (3) Muscular atrophy and lack of development of the paralyzed limbs develop much slower and do not reach such an extent in cerebral as in spinal paralysis. A noticeable coolness of the extremities and the cyanotic tint of the integument are peculiar only of spinal paralysis. Of further special importance in the differential diagnosis are: (4) In cerebral paralysis reaction of degeneration never occurs in paralyzed muscles ; on the contrary, not only the galva- nic, but also the faradic nervous and muscular excitability are completely conserved for a long time, while in the spinal form both rapidly diminish. (.S) The paralyzed muscles are not flaccid but noticeably tense (therefore the cerebral paralyses bear the name of "spastic hemiplegise"), therefore also the tendon reflexes are considerably exaggerated. (6) Motor symptoms of irritation are often observed in the patient either in the form of a common or a cortical epilepsy (unilateral convulsion on the side of the paralysis without loss of consciousness), or in the form of athetosis and chorea. Some- times the speech ability suffers. As to the mental capacity this does not exhibit constant changes. In some cases of cerebral paralysis the intellect remains normal, in others more or less im- paired ; if the patient suffering with spastic hemiplegia begins to have epileptic fits (they do not appear sinndtaneously with hemi- 382 DISEASES OF THE NERVOUS SYSTEM plegia, but after some time, the duration of which varies from a few weeks to many months), then one may be sure that the psychical condition of such a patient will not remain normal. Besides polioencephalitis the rapid development of hemi- plegia may be also caused b\- cerebral haemorrhage or embolism of the cerebral vessels. In adults, as well as in children, hemi- plegia of such origin is characterized by its sudden onset without prodromal fever, but in the presence of certain setiological factors. Thus in embolism lesion of the cardiac valves may be of import- ance ; in haemorrhage severe attacks of cough, as, for instance, in whooping-cough ; temporary haemophilia, as in Werlhof 's disease ; disorders of respiration and circulation because of convulsions ; in all these cases the picture of the disease will be the same as that in polioencephalitis (see page 399). In long-standing cases, that is, in the period of atrophy of the paralyzed muscles, the following may be mistaKen for polio- myelitis : 1. Polyneuritis. 2. Acute myelitis. 3. Progressive muscular atrophy. 4. Chronic inflammation of the spinal meninges. 5. Weakness of the legs in rachitic patients. The symptoms of separate cases of polyneuritis, or multiple inflammation of the peripheral nerves, vary very much, depend- ing upon whether the motor or sensory fibers are affected prin- cipally, or both equally. Also of great importance here is the aetiology, upon which there depends the localization of the morbid process ; as, for instance, in lead neurites the motor fibers sup- plying the extensors of the forearm and the wrist become almost exclusively affected ; in alcoholic neurites the lower limbs are especially involved, while the chief symptom is severe pain. In diphtheritic neurites the soft palate becomes affected, etc. Briefly, the varieties are many, yet in but few forms of neurites is there reason for their being confounded with polio- myelitis. The greatest similarity to the latter is presented by cases of polyneuritis which appear in healthy persons without any apparent cause, or after an exposure to cold, in short, in the form of an independent, primary, probably infectious disease; and sometimes the same form of polyneuritis develops as a sub- nisEAsi:s OF Tiih: .\i:K\;)rs systkm 383 se(|ncnt disease following- some (Iciinitc infectious ])r()cess (tvphoid fever, snnll-i)ox. etc.). (a) Primary multiple inflammation of the nerves — neuritis )nultiplcx — occurs in childhood jirobably much oftener than one would think to judge from the scanty literary data. The resemblance to |)olyneuritis consists, chieily, in that the paralysis has in both cases the properties of peripheral ])aralysis, that is, the electrical excitability to both currents rai)idly falls in the affected nerves and muscles, and then disappears entirelv, or reaction of degeneration appears. The paralyzed muscles are flaccid, soon undergoing atrophy ; the tendon and cutaneous re- flexes are lowered or abolished ; the bladder and rectum are not affected. There is some resemblance also in the etiology (ex- posure to cold, infectious diseases). As a pathognomonic symptom of polyneuritis by which the latter strikingly differs from poliomyelitis, we may point out the severe pain appearing in the affected limbs from the very beginning of the disease, and to the painful sensitiveness upon pressure over the nerve branches and the muscles in the region of the paralysis ; which sensitiveness remains in the nerves for a long time even in the period of atrophy. The further differences consist in the following : — poly- neuritis is usually bilateral and sy})i metrical, the paralyses being more pronounced in the periphery of the limbs; in the legs the small peroneal nerve (the plantar flexure of the foot is impos- sible) most often becomes affected ; in the arms, the extensors of the wrist. Generally speaking, the lower limbs become affect- ed more severely than the upper. Simultaneously with the paralyses there is usually observed a greater or less degree of ataxia, that is, disorders of co-ordination of movements. In some cases this symptom is the most prominent one. exhibiting the picture of acute ataxia, about which we shall speak later on. Neuritis begins with fever, which is higher and keeps up much longer than in poliomyelitis ( in this disease — five or six days, while in the former, in polyneuritis, frequently several weeks) ; polyneuritis does not especially aff'ect children of the first years of life ; the sensibility of the skin in this disease in- creases to the degree of considerable hypenTesthesia, which is 384 DISEASES OF THE NERVOUS SYSTEM replaced by a complete or incomplete ansesthesia or different parsesthesise, as crawling of ants, numbing of the fingers, etc. Paralysis in neuritis multiplex develops after the pain, ap- pearing not at once very markedly, but gradually spreading to new groups of muscles, beginning from the periphery (leg and forearm, then the thigh and the shoulder), while in poliomyelitis the contrary obtains ; in the beginning a greater number of muscles- become affected, but later on the region of the paralysis gradually decreases. Paralyses in neuritis may disappear entirely even in cases of complete loss of the electrical excitability, which in poliomyelitis is usually absent. The dift'erence can be explained by the fact that the regeneration of the inflammatory degenerated nerves is performed comparatively easily, while regeneration of the cells of gray matter of the spinal cord is impossible. In neuritis there frequently appears, because of affection of the vasomotor nerves, cedema of the feet or the wrists, which is absent in poliomyelitis, but cyanosis and coolness occur in both cases. (b) Paralysis with muscular flaccidity sometimes develops very quickly during inUauimation of the total transverse diameter of the spinal cord (myelitis transversa). In the muscles corre- sponding to the destroyed cells of the anterior cornua there may come on quite ra])i(lly not only lowering of the electrical excit- ability, but also reaction of degeneration and abolition of cutaneous and tendon reflexes. The similarity, however, is also- limited to this, the differences being so striking that it is impossible at the bedside to confuse transverse myelitis with poliomyelitis. Transverse myelitis always produces paraplegia simultan- eously zvith anaesthesia, even if incomplete, from the upper limit of W'hich one may judge the place of affection of the spinal cord,- as, for instance, in disease of the lumbar region anjesthesia ex- tends up to the upper boundaries of the pelvis ; when the lower dorsal portion is aft'ected, then up to the umbilicus or ensiform. process ; if the upper dorsal portion be affected, then anaesthesia may reach the upper ribs ; finally, if the cervical portion be in- volved, paralysis and anaesthesia of the upper extremities ap- pear. Another characteristic sign of myelitis consists in paralysis- DISEASES OF THE NERVOUS SYSTEM 385 of the vesical and rcclal sphincters. If the lunihar portion of the spinal cord be healthy, then, although the bladder and the rectum are insensible and not subordinate to the will, we, despite that, have no complete incontinence, as the sphincters still act re- flexly. As a peculiarity of paralyses dependent upon myelitis transversa there may also be pointed out the greater tendency to the formation of bed-sores in the paralyzed parts, which does not occur in poliomyelitis. (c) Progressive muscular atrophy souietiuics occurs in chil- dren in manifold forms, of which the best known are the juvenile atrophy of Erb, the muscular atrophy of the type of Landouzy and Dejerine and pseudo-hypertrophy of the muscles. But, as all these forms develop under the influence of the same cause, namely, of hereditary disposition, and between the typical repre- sentatives of all these groups there exist all possible transitory forms, we shall not describe them separately, but only say that they all belong to the so-called myopathic muscular atrophies ; while the spinal form of muscular atrophy, dependent upon chronic degenerative processes in the anterior columns of gray matter, as well as in the anterior roots, nervous trunks and mus- cles, being characterized by the atrophy involving first of all the wrists (Fig. 40) and then progressively spreading over the greater part of the muscles of the trunk and limbs (but not the face) and associated in the afifected muscles with the frequent appearance of fibrillar twitchings and sometimes also reaction of degeneration (almost never in myopathic forms), hardly ever occurs in child- hood, its existence being not yet positively proven even in adults (Roth). In all forms of progressive muscular atrophy (not excluding the spinal form) the paralysis sets in after atrophy and develops very slozvly; the electrical excitability in the paralyzed muscles is conserved for a long time, namely, as long as some normal fibers remain ; but, according to the development of the atrophy, the same gradually declines. All these -signs are entirely sufficient for the distinction of progressive muscular atrophy from that due to poliomyelitis. In the majority of cases the diagnosis is easily made even without the history and without the examination of the electrical excitability, but directly on the evidences of the extension of the 386 DISEASES OF THE NERVOUS SYSTEM atrophy : in progressive muscular atrophy the process usually spreads syiiiiiictrically; the muscles of the shoulder and the trunk, often become affected, which is unusual in poliomyelitis, where some muscles of one leg are commonly involved. Separate forms of muscular atrophy differ from each other by the following peculiarities: — psciido-iiniscuhir hypertrophy is characterized by hyperplasia of the interstitial connective and adipose tissues, by some muscles becoming noticeably enlarged, notwithstanding they are in the condition of paralysis or con- siderable weakness, and that other muscles undergo simple atrophy (hypertrophy appears most often in the calves, glutei, quadriceps; atrophy in the muscles of the trunk, scapulae and shoulder) (Fig. Fig. 40 — A. The claw-like hand in progressive muscular atrophy (After Duchenne). B. The claw-like hand in paralysis of the intercostal mus- cles due to affection of the ulnar nerve. 41). As this disease usually begins in early childhood, and first of all in the legs, such children learn to walk very late and usually walk badly, especially upstairs. Erb's jnvende form of atrophy is also of hereditary origin and not infrequently occurs in several children of the same fam- ily, but in distinction from the disease just mentioned it often begins in the shoulders rather than in the legs. The muscles mostly affected are the pectorales, trapezius, latissiraus dorsi,. serratus anticus major, rhomboidei, longissimus dorsi ; while the forearms, sterno-cleido-mastoid, deltoid, supra and infraspinatii DISEASES OF Till': M'.KXOUS SYSTEM 3>^7 usually arc not ct)nccrncd. From the s[)inal i'drni it ditTcrs l)y the wrists and forearms not becomins;- involved; fibrillary contrac- tions being- almost always absent in the affected muscles; and that sometimes pseudo-h}pertro])hy of some nuiscles takes place. Muscular atrophy of tlie T.andouzy-Dejerine type (typus Fig. 41 — Attitude of the body and its external aspect in muscular pseudo- hypertrophy of the lower limbs with atrophy of the muscles of the spine (After Duchenno;. facio-humero-scapularis) begins with the face. Because of the inconsiderable mobility of the lips the patient cannot whistle, keeps the mouth half-open, and the lips become noticeably thick- ened. Complete closure of the eye-lids is often altogether im- possible. Gradually the atroph}- spreatls downwards, as in the iuvenile form. 388 DISEASES OF THE NERVOUS SYSTEM Because of depression of the cheeks and dependancy of the lower lip the face assumes the characteristic expression (face myopathique) which permits of making the diagnosis par dis- tance, especially if there still exists impossibility of the complete closure of the eye-lids. ( d ) Paralyses with atrophy and flaccidity of the muscles sometimes remain after severe cases of acute inflammation of the spinal membranes — leptomeningitis spinalis acuta. In such cases the development of paralyses is preceded by aggravated symptoms of irritation in the form, first, of severe pains in the spine in- creasing during movements and upon pressure over the spinous processes, pain in the limbs (irritation of the posterior roots) and general hyperaesthesia ; and, second, contracture of the muscles of the spine and occiput (irritation of the anterior roots). Later on, together with the paralyses there also develop anaesthesise. The onset of the disease is usually acute with severe fever. (e) Weakness of the legs in rachitic children manifests it- self by the patients beginning to stand and walk much later than normal. It often happens that a rachitic child two or three years old cannot yet stand on his legs, even when supported, while a healthy child stands freely Vv'hen ten or eleven months old. The resemblance to spinal paralysis is evidenced by considerable wast- ing and flabbiness of the muscles, as well as by complete flac- cidity of the muscles and ligaments, so that we get a considerable mobility of the hip-joints. In rachitic weakness there are the following data : — (i) Apparent rachitic changes in the bones. (2) Flabbiness and wasting of the muscles of the lower limbs are not greater than in those of the arms. (3) An actual paralysis is absent, because when lying in bed the patient moves the legs well, only being unable to stand. (4) The tendon and cutaneous reflexes are preserved. (5) Indications that weakness in the legs had developed soon after a short febrile period are absent in the same history. As a cause of erroneous diagnosis of monoplegia due to poliomyelitis the so-called pseudo-paralyses may serve as ex- amples, among which we include cases of immobility of the limbs not because of disorders of innervation but simpl}- because of DISKASKS OF Till': MCKVOUS SYSTl-lM 3S9 pain in the articulation and in the l)ones. l-"or instance, llic cliiM refuses to lift the arm wlien suiTering- with synovitis of the shoulder-joint, etc. It is ()l)vi()us thai such an erroneous diaii;nosis cannot ohtain in an older child, hecause he will call attention to the pain himself as the cause of immohility ; but in a nursling this error is possible if the physician takes the mother's word that the child's arm became at once paralyzed. It is, of course, easy to avoid such a grave mistake even where there is no noticeable tumor of the joint, as there is always a severe pain upon pas- sive movements. As an instance of pseudo-paralysis which is especially peculiar of the first weeks or months of life, one must point out epiphyseal syphilis of hereditary origin (Parrot's disease). Underlying this process, as Prof. Monch showed,* we have periarteritis syphilitica of the bone-vessels, so that necrosis of the endochondrous bone develops which, in its turn, produces reaction on the part of the cartilage, evidenced by development of granulation tissue first in the canals of the preparatory zone, and then entirely separating the cartilage from the diaphysis. Besides this reaction also appears on the part of the jieriosteum in the form of chronic inflammation of the latter. Thus, not the epiphyses alone suffer, but the bone in toto. During life-time this process manifests itself by painful swelling of the ends of the affected bones and sometimes by crepi- tation at the point of the separated epiphysis. Generall\ the process involves the long bones of the upper extremities, and either because of pain or some other cause it is often accompanied by complete immobility of the affected limb which, being lifted, falls as if enervated. Epiphyseal syphilis very readily yields to mercurial treat- ment, while together with the disappearance of the inflammatory evidences on the part of the bone the apparent paralysis also passes away. The diagnosis is based partly upon the syphilitic symptoms in general and tumor of the epiphysis especially. 1\:) mistake this tumor for a rachitic one is impossible, because it is usuall\' uni- lateral. 'Moscow Medical Gazette, 187S. 390 DISEASES OF THE NERVOUS SYSTEM Zappert's case proves, liowever, that the diagnosis is not after all so easy as it seems to be. He observed a child fourteen days of age having undoubted signs of inherited syphilis and with paralysis of the two upper limbs. In the area of the upper epiphysis of the humerus there was noted an abnormal mobility and distinct crepitation. Briefly, everything seemed to have been in favor of pseudo-syphilitic paralysis, yet the post mortem (the child soon died) showed that the bones did not exhibit noticeable changes (crepitation was probably simulated by the dryness of the shoulder joint), and that paralysis of the upper limbs was dependent upon meningitis in the cervical portion of the spinal cord and degeneration of the anterior and posterior cervical roots. The author thinks that such mistakes in diagnosis are not uncommon, therefore he advises care in the diagnosis of Parrot's disease in all cases of seeming syphilitic false paralysis, when passive movements of the paralyzed limbs are not accompanied by pain, when a noticeable tumor of the epiphyses is absent, or when, besides paralyses, contractures are also observed*. To the group of ])aralyses accompanied with muscular flac- cidity and generally with the character of peripheral paralysis, belong, among others after-birth paralyses and the majority of cases of paralysis developing after acute infectious diseases. After-birth (post-natal) paralyses always aflfect the upper extremities, and most often one side only. Either the whole arm becomes paralyzed or only some muscles especially innervated by the radial nerve. I'aralysis due to applying forceps not infre- quently involves the facial nerve. All these paralyses either disappear after a few days or re- main permanent, ending with atrophy of some muscles or of the whole extremity. In the diagnosis of birth-paralysis one should bear in mind false syphilitic paralysis and l^irth-fracture of the bones. Neuri- tis is held l)y many as the anatomico-pathological essence of birth- paralysis. Of paralyses arising after infectious diseases in childhood dipJitJicntic paralysis is of prime importance, running usually so typically that it may be easily recognized even in case the patient *Jahrh. f. Kiiiderh., XLVL, s. 347. Disi-:.\si:s OF tiif. xicuxois systiim 391 duriiif^- the primary disease ( (li])luhoria) was not under tlie ])liv- sician's observation. Dii)luheritic paralysis rarely occurs in tlie period of full development of the original disease, while there are still membranes in the throat ; on the contrary it is found much oftener in the period of apparently complete convalescence, when the patient leaves his room, for instance after three or four weeks from the beginning of the causative disease. Paralysis after diphtheria almost aliivys begins with the soft palate and the pharynx; then if the paralysis extends to new regions, which is far from happening in all cases, the muscles of visual accommodation are involved ; in more severe cases the legs become paralyzed. finall\\ the arms, and in rare, but danger- ous, cases the paral\sis extends to che muscles of the larynx, trunk, bladder, diaphragm and face. The second characteristic feature of diphtheria paralyses is their gradual development, symmetrical spreading and tendency to disappear after a few weeks' duration. It never happens that post-diphtheritic paralysis appears at once fully developed ; for instance, during paralysis of the soft palate the patient begins at first to choke at times, especially when swallowing much fluid, and then with each day the act of sw^allowing becomes more and more difficult until, finally, it may become entirely impossible. The development of paralyses is often accompanied by differ- ent neuroses in the sphere of the sensory nerv^es, as anaesthesia (insensibility to tickling, pricks, cold), par?esthesia (crawling of ants, numbness) and h\peraesthesia. In the paralysis of the soft palate the most disagreeable symptom is the difficult deglutition, as the food and drink pass into the nose and the larynx, the patient often choking; the voice acquires a nasal twang; the attempt at blowing out a candle is unsuccessful, as the expired air. finding a free exit through the nose, does not pass through the narrow slit between the lips. Upon inspecting the throat the soft palate is seen to be immovable upon phonation ; it does not react upon tickling with a brush (anaesthesia and loss of reflex excitability). Recovery may occur in from ten to twenty-five days ; very rarely does the paralysis disappear in four or five days and may be protracted for about two months. Paralysis of accommodation is evidenced b\- the patient los- 392 DISEASES OF THE XERVOUS SYSTEM ing the ability of accommodating- his vision to near-by objects, for instance, he cannot read small print. Paralyses or pareses of the li)iibs usually begin with the limbs. The patient complains of weakness in the legs which may increase until it is impossible to stand. The same gradation of the paralysis is also noticed in the arms ; at first the patient com- plains of weakness and tremor of the arms and of difificulty in the performance of small tasks, and later on even complete paralysis may be developed — the arms hanging lifeless. The paralyzed muscles are flabby, somewhat atrophied, the electrical excitability considerably declines or even entirely disappears and in the period of convalescence returns later than the voluntary movements. The restoration of muscular activity usually follows the same order in which paralyses had developed, that is, begins with the throat and pharynx, and progresses very slowly, so that three or four months, or nvore, are required for the complete restora- tion of strength. If death comes on, then it is either from paralysis of the respiratory muscles, or from pneumonia because of foreign lx)dies falling into the bronchi, or from exhaustion (starving), or, finally, from cardiac paralysis (sometimes sud- denly). Although diphtheritic paralysis is referred to the group of polyneuritic paralyses, yet from primary multiple inflammation of the nerves it differs by quite striking peculiarities, among which, besides the characteristic spreading of the paralysis, with its beginning at the- soft palate, may be included also that the paralysis of the limbs does not reach a considerable degree, there being only some weakness but not a complete paralysis, neither are there markedly developed muscular atrophies, nor complete anjesthesia, nor pain in the limbs along the course of the nerves; but there is frequently observed instead of that considerable anaesthesia which does not correspond altogether to the faintly developed paralyses. Among paralyses with muscular tlaccidity are also to be included functional paralyses occurring in chorea and hysteria. Under the name of paralytic chorea — chorea paralytica — we understand a common idiopathic, the so-called Sydenham's, chorea running with the peculiarity that instead of muscular weak- DISEASES OF THE NERVOUS SVSTE>[ 3^3 ness of the affected limbs there arises complete paralysis or, at least, paresis, so that not only voluntary movements, but even the choreic twitchings are checked. The paralysis is either limit- ed to one limb, most often to the arm, or it appears in the form of para- or hemiplegia, or it spreads over all four limbs and the trunk as well, and in such a case the patient lies immovable be- cause of the complete relaxation of the muscles of the whole body, that is, we have then to do with that form of paralvtic chorea which is known as lymphatic chorea (chorea moUe or soft chorea of the French authors). These paralyses are characterized by negative peculiarities ; the cutaneous sensibility and the electri- cal reaction of the nerves and muscles are not impaired, atrophy of the muscles does not set in even in the case of the many months' existence of the paralysis ; only the tendon reflexes are somewhat lessened or disappear entirely, but not in all cases. As to the time of development of the paralysis and its rela- tion to choreic movements, three kinds of cases may be dis- tinguished : ( 1 ) The paralysis appears earlier than the chorea and, after some time (two to six weeks), is replaced by chorea. JMost often in such cases the paralysis begins in the arm, being limited there- to. The paralysis develops for a few days, being accompanied by no morbid appearances, that is, there are neither pain, fever, facial paralysis, or headache. In Gowers' opinion such a paralysis is characteristic to such a degree as to permit the diag- nosis of beginning chorea with great certainty ; nevertheless, it is possible that such paralysis may be also of hysterical nature. (2) Paralysis appears in the period of the complete develop- ment of chorea ; it seldom comes on suddenly, usually progressing for several days. x\fter a few days it is again replaced by chorea, or, with the disappearance of the paralysis, convalescence im- mediately sets in. (3) In the third series of cases the disease begins with paralysis which is limited to one of the upper limbs, or spreads gradually to all four extremities, and so the disease remains until the end, that is, choreic twitchings do not appear until the paralysis is over and recovery sets in. The diagnosis of such cases is sometimes very difficult ; the above mentioned negative signs must be borne in mind, as well 394 DISEASES OF THE NERVOUS SYSTEM as the gradual, although the quite rapid, development of the paralysis without fever and pain, and especially the important fact that, in the great majority of cases, one may notice in such patients sli,i::ht tzcitchiiigs in the fingers of both hands as the scarcely noticeable manifestation of chorea. The spreading of the paralysis in all these forms is manifold ; besides the limbs the muscles of the trunk and neck may also be paralyzed (the head hangs down as in a corpse, entirely following- its center of gravity), and sometimes also the larynx (aphony) and even the bladder and the rectum are affected. The average duration of the paralysis is difficult to be de- termined because of the small number of published cases, but it may be said to var\- from two weeks up to three, four and even six months. ( The paralysis is seldom a complete one. usually some weak movements are possible. Up to the present no single case of incurable choreic paraly- sis has been reported, nor a termination with atrophy of the affected muscles, so that the prog)iosis always may be said to be favorable. ^^tiologically it is interesting to point out the influence of age and sex. Like the common chorea here also females are affected oftener than males, but as to the age the difference is that a common chorea in children under five years is observed very rarely (ten per cent.), while chorea paralytica most fre- quently occurs at this age. (Of twelve cases I am aware of in literature five occurred in the age from two to five years). The real cause (pathogenesis) of paralyses in chorea is un- known. It is impossible to explain their occurrence by chorea being complicated with hysteria, because of the very young age of some patients and because of the peculiarities of the paralyses themselves. Hysterical paralyses. As the most frequent cause of paraly- ses of the legs in children after five years, we would name verte- bral caries ; and the second place of frequency of their appear- ance is occupied by paraplegia of hysterical origin, which occurs equally often in males and females, especially during the period from ten to fifteen }-ears. In some cases the patient cannot move his legs — paraplegia liysterica; in others, being in bed, he can DISEASES OF THE NEK\'( )rs SYSTEM 395 perform all voluntary movements, hut positively is unable to stand or to walk — astasia-ahasia hysterica. As one of the most cliaractcristic peculiarities of lusterical paralysis one ma\- generally hold that it is uni(iuc, not onl\- hecause it cannot be ex]:)lained by any anatomical changes in the central nervous s_\stem. but even does not permit of deciding the question as to the place of affection, that is, it cannot be included either among peripheral, or central paralyses. For example I refer to the following case : — A twelve-year-old girl entered the hospital from an infant school on account of complete paralysis of the left arm. The paralysis appeared suddenly, about a month before, Avithout any ascertainable reason. Upon entering the hospital the paralysis was seen to affect the whole extremity from the fingers up to the shoulder, while sensibility was also completely lost. As monoplegia occurring with anaesthesia must first of all be of peripheral origin, then one would expect in our patient atrophy of all the nniscles of the left hand with loss of the electrical re- action, neither of which conditions existed. Therefore this paraly- sis could not be recognized as a peripheral one. But. on the other hand, it could not be regarded as central, which woul.l imply the same being dependent ujxjn a very circumscribed focus in the right hemisphere, in the area of the anterior central con- volution, namelv the point where the voluntary center of the arm is located. Then again we could not explain ansesthesia, and to suspect the morbid focus to be in some other location was im- possible because of the monoplegic character of the paralysis. In this case, as in general, hysterical paralyses mostly are similar to feigned ones. Regarding distribution hysterical paralyses do not exhibit anything peculiar, arising in the most varied forms, as mono- plegia, paraplegia, hemiplegia, paralysis of all four limbs or in the form of paralvses of separate regions, for instance, muscles of the larynx, bladder and rectum. In this regard one may notice only that some muscles very seldom becoine involved, others com- paratively often. Among the latter are included, for instance, the laryngeal muscles (hysterical aphonia, stenotic respiration due to paralysis of the dilators of the glottis, hoarse breathing because of paralysis of the posterior arytenoid muscles with depression and bending of the cartilages into the lumen of the glottis) : on 396 DISEASES OF THE NERVOUS SYSTEM the contrary, the facial and the hypoglossal nerves become rarely- involved, so that the integrity of the facial nerve and of the tongue in cases of hemiplegia is somewhat in favor of hysteria, and the presence of this paralysis almost excludes the latter. As to the dcz'clopvient of hysterical paralysis it appears sud- denly in the majority of cases, usually after an attack of convul- sions or some psychical excitement, or after trauma, especially if the latter was accompanied by fright. It frequently happens that between the trauma and the paralysis a couple of hours, and even days, elapse, such intervals being quite characteristic of hysterical paralysis. In other cases hysterical paralysis develops gradually^ and in such instances the paralytic manifestations are not in- frequently preceded by pain or appearances of spasm in the in- volved limbs. The degree of the paralysis is very manifold, varying front an insignificant weakness or rapid tiredness up to complete paraly- sis, accompanied frequently by contemporary cutaneous anaesthe- sia. In some cases the pa^ralysis is spastic, in others the muscles are relaxed (the latter circumstance occurs oftener), but in any event the nutrition of the muscles and their electrical reaction are preserved well and for a long time. A complete parah sis seldom occurs, some movements usually being preserved. It is especially peculiar of hysteria that some muscles act well in one respect or direction, while other acts cannot be carried out, although the same muscles seem to perform them. For example, in one of (nir cases^ which is described in the section on ataxia, an eleven-year-old boy could neither stand or walk, but he could kneel down and move upon all fours. Hysterical paralyses may disappear rapidly under the in- fluence of psychical stimuli, hypnosis and even suggestion in the condition, but they are prone to relapses in which either the same muscles as before become paralyzed, or a new group of muscles- becomes affected. The paralysis not infrequently is the first and the only mani- festation of hysteria (the mono-symptomatic form of hysteria occurs especially often in childhood), therefore the absence of any other symptoms of hysteria cannot by any means serve as proof that the given paralysis is not an hysterical one ; but if DISEASES OF THE NERVOUS SYSTEM 397 Other symptoms of hysteria may he noted (stigmata hystcri^e), then the diagnosis is, of course, easier. The duration of hysterical paralyses is very uncertain — from a few days to many months and even years, therefore the prog- nosis is serious, although in childhood the paralyses rarely last long. As to the differential diagnosis of separate forms of paralysis we have of great importance in monoplegia the absence of atrophy, which negatives the peripheral origin of the paralysis ; as well as the absence of the spastic condition of the muscles, which, to- gether with the presence of anaesthesia, excludes focal afifection of the cerebral cortex. In hemiplegia integrity of the facial and hypoglossal nerves, anaesthesia of the skin and absence of causes for haemorrhage or embolism will favor hysteria. Hysterical paraplegia may be readily viewed as a symptom of myelitis or spondylitis, especially if there be some pain upon pres- sure over some of the spinous processes because of hypersesthesia of the skin of the back. The moveableness of the vertebral colum.n upon bending of the spine and the absence of any allusion to Pott's protuberance must preserve from a mistake. Also important is the integrity of the functions of the bladder and rectum. Anaesthesia of the legs in hysterical paraplegia may be present, but it spares the sacrum and the sexual organs ; while in myelitis it extends also over these parts and the trunk, accord- ing to the situation (height) of the afifection of the vertebral column. The absence of the plantar reflex is common in hysteria (according to Bizzard it is even a constant and therefore a char- acteristic sign), while in spondylitis the tickling of the sole of the foot generally produces a reflex twitching either in the whole leg, or, at least, in the toes. The tendon-reflexes are, in hysteria, preserved, and ankle-clonus is usually absent. In the cases of spastic form of hysterical paraplegia there is observed pseitdo- clomis of the foot due to the twitching of the triceps surae (gastro- cnemius and soleus) muscles, differing from an actual clonus by its irregularity; after a few twitchings rest sets in, after which new twitchings appear. Hysterical paraplegia appears in some cases suddenl}-, in others gradually ; in some cases a spastic condition of the muscles 398 DISEASES OF THE NERVOUS SYSTEM of the lower limbs develops, but the bladder and rectum almost never become involved. Of peripheral paral3'Ses of separate nerves there most often occurs in childhood paralysis of the facial nerve, which is readily recognized by the deviation of the face toward the healthy side ; the small branch supplying the eye-lid is also affected, so that the eye on the diseased side remains constantly half-open. The significance of this symptom is important, because the muscles of the eye-lids do not become involved in the central paralyses of the facial nerve. The most frequent cause of the paralysis of the facial nerve is, of course, inflammation of the middle ear, even without caries of the temporal bone, for instance, in scarlatinal otitis, but oftener in chronic otites associated with affection of the petrous bone in scrofulous and tuberculous children. Much rarer the paralysis of the facial ner\e in children arises under the inlluence of ex- posure to cold or compression of the nerve by tumors or scars around the ear, or, in the newly-born, from the forceps. PARALYSIS WITH TENSION OF THE MUSCLES, OR SPASTIC PARALYSES. Under the name of spastic paralysis such a paralysis is under- stood in which the affected muscles are not relaxed, but, on the contrary, are in the condition of spasm ; therefore the paralyzed limb is flexed, passive movements being performed with difficulty. The electrical reaction remains normal for a long time and the nutrition of the muscles is good, that is, atrophy does not set in. Spastic paralyses are always of central origin, depending thus either upon some lesion of the brain or wdiite matter of the spinal cord. In the former case they most often occur in the form of hemiplegia, but sometimes in the form of diplegia (affection of all four limbs), monoplegia (the arm becomes affected oftener than the leg), and even paraplegia. In the case of lesion of the spinal cord spastic paraplegia most often occurs, but if the process be localized in the cervical region, then also the arms become involved. Thus, from the diffusion of the paralysis one cannot always draw a correct conclusion regarding the localiza- tion of the morbid process. In the case of a symmetrical paraly- sis the following circumstances speak in favor of affection of the brain : DISEASES OF THE NERVOUS SYSTEM 399 ( i) Parescs in tlie area of the cerebral nerves: facial and the l)ranches to the eye-nniscles. (2) ^Mental derangement. (3) The appearance of athetosis or chorea or ataxic move- ments in the paralyzed limbs. (4) Epileptic fits which not infrequently bear the real char- acter of cortical convulsions (begin on one side and spread from the face over the arm and leg, not being accompanied by loss of consciousness — rjackson's epilepsy). (5) Complete preservation of sensibility. (6) Unimpaired activity of the rectum and bladder. (7) Absence of caries of the vertebral column in childhood. Cerebral spastic paralyses. Bilateral cerebral infan- tile PARALYSIS — diplegia spastica iiifaiitnin — occurs in general Cjuite rarely. Spastic diplegia of inherited nature (trauma of the skull during labor), known under the name of Little's disease, are notably peculiar. The symptoms show in the first days or first months of life, manifested by the spastic condition of the arms and legs and sometimes also of the muscles of the trunk and neck (general rigidity) so that voluntary movements become greatly disturbed, despite the absence of complete paralysis in the involved limbs. Little's disease or general rigidity differs from bilateral hemi- plegia, first, by the arms becoming affected less than the legs, and, second, the spasm prevailing over the paralysis. In Little's disease it oftener occurs that the upper limbs are abducted, ex- tended and supinated, and the legs bent in all joints and greatly adducted, while in bilateral hemiplegia the arms are adducted, bent and pronated, the legs, however, extended, the foot being somewhat turned inward (pes equino^ — varus). In Little's disease actual contractures are absent, only habitual position of the limbs being noted, which position differs from contractures by the patient being able to change the given position, neither is it diffi- cult so to do passively, but after some time the limb assumes its former posture. However, between general rigidity and bilateral hemiplegia there exist so many transitory forms that a sharp boundary cannot be made. (Fig. 42.) As every case of cerebral diplegia is the result of bilateral 400 DISEASES OF THE NERVOUS SYSTEM lesion of the hemispheres it is obvious that in diplegia mental derang-ement is often observed (from the slightest degree up to complete idiocy) with disorder of the speech. Not infrequently irregular form and the small size of the skull are seen, with im- perfectness of design or asymmetry in the face, strabismus, choreic or ataxic movements in the limbs, athetosis of the fingers and epilepsy. The tendon-reflexes are, of course, always exag- gerated. The causes of bilateral spastic paralysis are in the majority of cases connected with the process of labor, constituting the so-called Little's cetiolo^y. Here we have included asphyxia, diffi- cult labor, premature labor, twin-births, etc. The immediate cause of the disease in such cases is haemorrhage into the cavity of the skull in the area of the central convolutions of both hemispheres. In other cases hereditary s}philis, cachexia of the mother, her exhaustion due to frequent labors, etc., are of value. Under the influence of such conditions hereditary or family predisposition to the disease may appear. In those rare cases where diplegia develops in a child healthy in the first years, the cause often remains unknown — in some cases trauma or some in- fectious diseases may bear an setiological relation. The course of the disease varies. In cases depending upon Little's aetiology (difficult labor, etc.,), if the haemorrhage was superficial and did not produce deep alterations there may at first be repeated convulsions followed by a period of stationary rigidity with tendency to improvement, so that, although even late, the child yet learns to walk ; in grave cases of congenital diplegia, as well as in cases of diplegia which started during intrauterine life of the child, there is noticed a slow but progressive aggravation evidenced by gradual weakening of the mental condition and the appearance of epileptic fits. The post mortem examination of children who have died many years after the beginning of the disease does not always make it possible to determine the primary pathological process leading to the final alterations found at the autopsy, as partial or lobar sclerosis of the hemispheres, porencephaly (complete disap- pearance of some portions of the brain so that a communication between the ventricles and subdural space takes place), cysts and scars. The cause of all these alterations are commonly haemor- DISK.'.SF.S Ol- IIIK XKRVOUS SYSTEM 40 T rhas^es under the pia mater durint^- ]al)or, in other cases emboHsni. thrombosis, and perhaps also inflammatory and primary degen- erative processes. [There are also chani^es in die spinal cord as seen in Fig. 43.] At any rate, considering the clinical picture of diplegia we cannot make a pathologico-anatomical diagnosis, and the name itself "cerebral diplegia" is used in a ])urely clinical sense for the designation of such cases in ^vhich some affection of the motor area of the cerebral cortex may be suspected. On this Fig. 42 — Litt'e's Disease — Position of the legs in congenital spastic cerebral paralysis (Shattuck). ground, if SMuptoms of diplegia are met with during a distinctly determinable disease of the brain, then such cases luust not be referred to cerebral diplegia or to bilateral hemiplegia. For in- stance, spastic paresis of the muscles of all four limbs may be met with during multiple sclerosis, in tuberculosis of the brain and in chronic hydrocephalus, so that all these dift'ercnt pro- cesses we have to bear in mind while making a ditiferential diag- nosis. It is not difficult to recognize chronic hydroce])halus from the 402 DISEASES OF THE NERVOUS SYSTEM characteristically enlarged head. Much greater similarity to cere- bral diplegia. may be presented during disseminated sclerosis — sclerose en plaques disseminees, of the French authors. This disease occurs in childhood much less frequently than cerebral diplegia. Besides the spastic condition of the muscles this malady is characterized by three cardinal symptoms : nystagmus (oscilla- tion of the eye-balls), slow, inteiTupted (scanning) speech and Fig. 43 — Little's Disease — Cervical section of the spinal cord. Degenera- tion of the pyramidal tract (After Mouratoff). tremor upon voluntary movements ; as well as by the course, the disease progressing by exacerbations intermingled with periods of noticeable amelioration interrupted sometimes by apoplectiform fits. For diplegia there is, on the contrary, the stationary course with tendency to amelioration, as is observed in cases of diplegia acquired during labor (Little's disease). In doubtful cases Little's aetiology (asphyxia, difficult labor, premature labor) and the early occurrence of the symptoms (during the first year of life) strong- ly speak for diplegia. Unilateral cerebral paralysis or cerebral infantile hemi- plegia — hemiplegia cerebralis infantum — occurs in two chief forms : — in some cases the disease begins suddenly with violent fever, vomiting and eclamptic fits, like spinal poliomyelitis ; in other cases the development of paralyses and other evidences oc- DISEASES or THE X i:K\()rS SYSTEM 4O5 curs very slowly, and the onset of the disease may be dctennined only approximately. Of the former type we have already spoken, namely in the section on s^iinal paralysis, to which this form is most similar, at least in its initial period. In cases with an inappreciable onset the picture of the disease varies, as in some instances a spastic condition in the muscles of the paralyzed limbs predominates, in others the spasm is of secondary importance, beinj^ replaced by choreiform movements and athetosis ; in others again there is neither a spastic condition of the muscles, nor choreiform move- ments, the whole disease being- manifested by unilateral paresis of the limbs and lack of development of the corresponding arm and leg. The paresis does not afifect, in acute as well as in chronic cases, all muscles equally ; in the upper extremity the muscles innervated by the radial nerve are the most paralyzed — triceps, suppinator longus and extensor digitorum, and likewise the adductor policis. The habitual posture of the arm is almost the same in all patients, therefore it is very characteristic of in- fantile hemiplecia ; the shoulder is adducted (pressed to the trunk), the forearm flexed at the elbow-joint, the wrist prqnated and flexed in the carpo-metacarpal joint, the fingers flexed in the metacarpo-phalangeal joints, the thumb adducted. The leg is ad- ducted, slightly bent in the knee, the foot drops and is turned somewhat inwards (pes equino-varus). (Figs. 44 and 45.) The tendon-reflexes in the afl:'ected limb are always notice- ablely increased, and sometimes they increase also in the healthy leg. In the affected limbs, especially in the arm, there often develop afterwards symptoms of athetosis or chorea, in many cases, the patients becoming epileptics. In distinction from diplegia, unilateral paralyses are much oftener acquired than inherited during the first years of life. The causes remain mostly unknown; not infrequently hemi- plegia arises after some infectious diseases, especially after scarlet fever and whooping-cough. Striimpell's attempt at including acute cases of hemiplegia in a separate group under the name of polioencephalitis may be looked upon as unsuccessful, since in cases with post mortems there has never been found an encephalitis limited only to the 404 DISEASES OF THE NERVOUS SYSTEM gray matter of the hemispheres ; on the contrary, either the in- flammation was found to also occupy the white matter, or the acute attack at the onset depended upon haemorrhages or embol- ism'^. It is noteworthy that in some cases of seemingly typical paralysis of Strum])ell the post mortem showed a solitary tubercle which evidently remained for some time in a latent condition, and later on manifested itself by the rapid development of hemiplegia after a short period of convulsions. Sf^astic sf^iiial f^anilysis. Si):istic s])inul ])aralysis, or spastic paraplegia, occurs in two forms; to one form belong cases of paraplegia as an independent lesion due to a primary, isolated affection (sclerosis) of the lateral spinal columns. This is the so-called iciiopafhic spastic paralysis characterized, among other indications. 1)\ the dy, then spreading to the depth of the bone. The vertebra thus grows niSKASES OF iME XKRXOl'S SVSTKM 4[I soft and, yieldins;- to the pressure of the upper portion of the Ixxly becomes crushed, and the vertebral column bent in such a vvav that the spinous process of the diseased vertebra forms the most prominent point of the aui^ular curvature. (Figs. 47 and 48.) The latter therefore constitutes the most certain sign in the dis- tinctiiMi of iiaraj)lcgia duo to compression of the spinal cord be- Fig. 49 — Rachitic kyphosis (Whitman). cause of Pott's disease from any other paraplegia, and, as this sign is a very striking one. then as soon as it has made itself evident there is no further difficulty as to the cause of the paraplegia. It is not easy to confound this protuberance with vertebral ciu'vattu'e (Fig. 49), because the latter is always arch-like, and is necessarily accompanied by rachitic changes of the chest wall, and free mova- bility of the back. Concerning the condition of the paralyzed muscles in Pott's 412 DISEASES OF THE NERVOUS SYSTEM disease, although 1 have placed this paraplegia in the class of spastic paralyses, yet by this 1 do not mean to say that the paralyzed muscles are in a condition of tension. Of great im- portance here is the ])eriod of the disease and the part affected. Spastic svmptoms appear comi)aratively late when subsequent descending degeneration of the lateral column has sufficient time to set in, and when the process occupies either the dorsal or the cervical ])ortion of the vertebral column ; while the afifection of the lumbar portion may not be accompanied by a spastic condition of the muscles. Paraplegia dependent r.ot so much upon myelitis as upon compression of the spinal cord is, among other signs, characterized by the ability of movement sutTering considerably more than the sensibility, the cutaneous reflexes being considerably increased, and by the fact that the paralysis of the legs may suddenly dis- appear after extension of the vertebral column by the applied jacket. The nutrition of the muscles and their electrical reaction remain normal for a long time. Tlic tendon and ciifoneous reflexes arc c\va!^i:;cratcd from tlie z'cry bes'inniiia. ,\ngular curvature in the dorsal portion of the vertebral column appears earlier and is more pronounced than in the lumbar portions since normally the lunil)ar portion a])pears concave. For this reason it often happens that one of the lumbar vertebrre may be already considerably destroyed, deformity being still absent,, and the effect is limited, perhaps, only to the physiological lordosis of the lumbar region becoming even or b_\' the protuberance of the corresponding spinous process being hardly noticeable. In some cases one succeeds in i)alpating a tumor due to a burrowing abscess in the abdomen over Poupart's ligament, and thus may recognize vertebral caries, notwithstanding the absence of the angular deformity which has not had time to develop. Such abscesses are indolent and often not accompanied even by the least hindrance in the movements of the thigh, in short, they run latentlv and are detected by the physician only upon the ob- jective examination of the abdomen, by palpating. In doubtful cases, for instance, in small crying children, chloroform must be resorted to for the purpose of diagnosis. It is more difficult to recognize Pott's disease in the be- DISEASES or Till': xi:R\(trs snsi'i:.\i 413 ginnins: of its development. It usually starts with pain in the back. This pain partly cle])en(ls u])on osteomyelitis itself, partlv. however, upon the extension of the intlanimalory process over the spinal membranes and the posterior roots. It is characteri/.ed by increasing" upon pressure over the spinous processes of the diseased vertebrjE and especial!) upon boKliiii:^ the sf^inc, as well as upon passins: a hot spong'e over the vertebral column, or upon applying- the cathode to the afifected place. Because of painful flexion of the si)ine the patient cries, when walking he gives the trunk an immobile, extended posture, and. when he has to lift somethino- from the floor he can do so only by squatting di^wn. that is, he flexes the knees, but the spine is kept erect. If also the posterior roots are involved in the inflammation, then besides the local pain in the spine there also appears reflex i)ain in the area of distribution of nerves arising in the diseased region. These eccentric pains are observed most often in the legs (in the case of aft'ection of the lumbar portion of the vertebral column) and in the abdomen (in case the dorsal iX)rtion is involved) extremeh- troubling the oatient. Thev usuallv occur ueriodically in the form of neuralgiae (or enteralgise), sometimes continuing for several consecutive hours each day. This pain may appear dur- ing the earliest period of the disease, long before the formation of any deformity. As the cause of spondylitis is always scrofulosis or tuber- culosis (trauma, however, which is usually mentioned in the his- tory, is only an accidental cause), then for the correct estimation of the initial pain it is important to give attention to the patient's habitus ; children disposed to spondylitis often appear anaemic, with flabbv muscles, swollen lymphatic glands, chronic eczema, scars due to an old caries, etc. Even in the initial period of spondylitis the child does not walk willingly and does not run about, neither does he jump: when sitting he likes to support his head with the hands, and when Iving he sometimes assumes a posture on the side or, which is more characteristic, on the abdomen if the spine is very sensitive to pressure. Sometimes inflammation of the vertebrae begins with fever. the true nature of which remains for a long time unrecognized. 414 DISEASES OF THE NERVOUS SYSTEM The temperature, of remitting type, with morning falls to 38 de- grees C. (100.4 degrees F.) plus, and the evening elevations up to 39 degrees C. (102.2 degrees F.) during the first days, in the absence of any local symptoms on the part of the spine, as well as of other organs, may simulate typhoid fever, until backache appears which will disclose the condition. In a nursling the Fig. 50 — Cervical disease and characteristic attitude (Whitman). backache is oftentimes indicated by screaming every time it is taken from the bed. Backache increasing upon pressure over the spinous pro- cesses of all, or only of some, vertebrae may occur in nervous chil- dren because of hypercssthesia of the skin of the back, but it is not difficult to distinguish this condition from spondylitis, first, because bending of the spine is not painful in hypersesthesia of the skin. and. second, because the pain increases even upon the DISEASliS OF TII1£ NKRVOUS SYSTEM 415 slightest touch, ^vhilc in spondylitis it a])pcars only upon heavier pressure. Some peculiarities regarding the diagnosis are presented by cervical spondylitis. Even in the oldest cases there is absent an angular distortion, and if a curvature should appear it is in the form of an arch-like kyphosis. Completely developed cases of cervical spondylitis are also characterized by infiltration of the soft parts around the affected vertebne, so that one may palpate and see with the eye a more or less solid tumor on both sides of the spinous processes of the involved vertebrae. (Such tumors also develop, of course, around the dorsal vertebrae, but remain obscure because of the thick sheath of muscles). In this period spondylitis can lead to the formation of a retro-pharyngeal abscess on the posterior wall of the fauces, which may be easily palpated by the finger introduced into the mouth. It will be recognized as a soft elastic tumor which if of considerable size will act as a serious hindrance to deglutition and respiration. Reflex pain in cervical spondylitis is felt either in the head (especially in the occiput), if the upper vertebrae be affected, or in the arms in case the lower vertebrae be involved. Appearances of spastic paralysis together with complete, or oftener incomplete, anaesthesia occur not only in the legs, but also in the arms; because of the paralysis of the pectoral muscles respira- tion is performed almost exclusively by the diaphragm. In affection of the two upper vertebrae the external tumor is usually absent, but the lesion is easily discovered, because the lateral movements of the head become entirely impossible, while bending of the head forwards is possible to some extent. It is also quite characteristic for this spondylitis that, upon changing the sitting posture for a horizontal one the patient necessarily sustains his head, in this or that way, with his hands, for instance by putting them under the occiput or grasping at the hair. (Fig. 50.) With such a localization of the process the patient can suddenly die because of rupture of the odontoid process of the second vertebra, which then may become impinged upon the spinal cord. In the beginning of its appearance cervical spondylitis is characterized bv pain and immobility of ihe neck and contracture 4l6 DISEASES OF THE NERVOUS SYSTEM of the neck-muscles, usually the posterior (Vig. 51), but some- times only of the lateral, the head then bending- to the shoulder — torticollis. (Fig. 52.) In this stage cervical spondylitis may be confused with vari- ous processes leading to contracture of the neck (see torticollis), Fig. 51 — Disease of the upper dorsa: region (Whitman). but the diagnosis is distinguished by all these processes having an acute course and the vertebrae being painless upon pressure. This last sign also occurs only in another form of curvature of the neck, in inflammation of the synovial membrane between the oblique processes — synovitis articnlaris proc. obliq., s. syno- vitis vertehralis — which disease is mostly peculiar to childhood. i)isi:.\sKs oi- Till-: xkkvous system 4'7 Besides the acute course with rapid termination in recovery, vertebral synovitis dififers further from spondyhtis by pressure producino- pain only on one side, and somewhat farther from the spinous processes, while in spondylitis the pain is bilateral and severest in the re^ci^ion of the spinons process itself. Wherever in the vertebral cohnnn the s])ondylitis may be, it is always of slow course, and if it does not lead to death because of pyaemia due to the formation of burrowing abscesses, or gen- eral tuberculosis, it takes from several months to two vears before Fig. 52 — Cervical disease with abscess (Whitman). there will occur complete recovery with the formation of ankylo- sis of the vertebrae at the place of destruction. . [Pott's disease must be also diiTerentiated from the sacro- iliac disease in children. In this connection R. C. Dun says : "From early lumbar spinal disease without deforniit\, the difli- culty of diagnosis may be great, \\nicre movements of the trunk 4l8 DISEASES OF THE ^^ERVOUS SYSTEM give pain, and where irritation of the psoas prevents movement of the spine in sacro-iHac disease, the greatest care in differentia- tion must be employed. Fixation of the pelvis has to be resorted to, when it will be found that careful and gradual flexion of the spine forwards and towards the affected side, so as to relax the psoas muscle, will allow of a wide range of painless movement in this direction. Should this free movement be possible, and swelling be present over the sacro-iliac joint, while point pres- sure over the articulation and separation of the iliac spines pro- duce pain, then spinal disease may be excluded."* — Earle.] The more advanced the process of recovery the less the pain in the area of the aft'ected vertebra upon pressure over it, as well as upon movements of the trunk ; at last paraplegia also disappears, but the angular curvature remains, of course, during the whole life. Complete recovery, that is, formation of an en- tirely solid ankylosis, is concluded from the fact that the patient not only does not complain of pain in the spine, but also moves freely. It is quite certain that in some cases spastic paralysis of the lower limbs may be purely of hysterical origin. One must first of all think of hysteria in those cases wherein spastic para- plegia appears as an acute disease, as, for instance, in the follow- ing case : — M., a girl ten years of age, entered the hospital on February I, 1895, on account of paralysis of the legs. The patient was an orphan, so that a satisfactory history could not be obtained. The present disease started two weeks before. The patient awoke at night with severe pain in the legs and the spine ; toward morning the pain subsided, but the gait became difficult and un- steady; three days later, the patient ceased walking- altogether and could not even sit up. About two days after that incon- tinence of urine and faeces appeared ; at times since this date pains appeared in the lower limbs. During all the period there was neither fever, vomiting, or headache. The present status: — The patient is of fair complexion and nutrition ; the mucous membranes and skin of normal tint ; in- clination to constipation ; the abdomen somewhat expanded ; the ^Liverpool Medico-Chirurgical Journal, June, 1903, p. 207. DisEASi:s OF 'i"!ii-: NKRVou.s svsTl•:^[ 419 lung's and heart normal. The consciousness and speech normal, likewise the superior sensory organs; the cranial nerves not affect- ed. In the up])er limhs treninr upon slight movements, so that feeding- is very difficult, but the strength of the arms is normal. In the legs there are appearances of markedly developed spastic paralysis with exaggeration of tendon-reflexes ; an actual foot-clonus is absent, but if, when the patient is in recumbent posture, the extended leg be lifted, then there immediately appears violent twitching in the leg-muscles, which lasts quite long, de- creasing or increasing. The plantar reflex is absent upon mild tickling, but ap])ears upon rough irritation of the foot-sole. Pas- sive movements of the leg are interfered with in all articulations because of muscular rigidity. A marked anaesthesia in the thighs and the lower portion of the abdomen and in the face. The electri- cal excitabilitv is preserved; trophic disturbances are absent; sphincters normal. A diagnosis of the hysterical form of spastic paraplegia was in this case not difficult ; the acute onset of spastic symptoms ex- cluded any possibility of the so-called idiopathic spastic paralysis, which depends, it is thought, upon primary degeneration of the lateral columns of the spinal cord. Spondylitis could not be ad- mitted either, being contradicted by the acute development of the disease and by the complete movability and painlessness of the spine. Transverse myelitis from any cause could also be ex- cluded by the integrity of the pelvic organs and limitations of anaesthesia. Briefly, the sudden onset of the rigid paralysis, ex- cluding diseases of the brain and spinal cord, decidedly favored hysteria. This diagnosis was confirmed by the weak plantar reflex, peculiar clonus of the foot and results of treatment. The first ten days antispasmin was given, but without results; then suggestion was undertaken (without causing sleep), to the efTect that the paralysis would be over within five days (February i8th) while for the purpose of acting upon the psychical condition a slight faradic current was administered and antipyrin was given internally. Some movability of the legs appeared on the sixteenth of Februar}', and on the eighteenth of that month it was noted in the history : — "The movements in the legs are free, the patient can lift the leg to an extended posture, mox'cs the ttses, can sit tip 420 DISEASES OF THE NERVOUS SYSTEM herself and can even walk." Within one month the girl was discharged as perfectly well. ATAXIA. Incoordination of movements known as ataxia occurs in childhood in acute and chronic forms ; the latter is more uncom- mon. Ataxia is manifested either hy an unsteady gait with wide- ly-spread legs, or h}- the complete inahility to stand or walk. Upon being put upon his legs the patient either totters, or abruptly falls. It is especially difficult for the patient to stand with closed eyes (Romberg's symptom). When lying in bed exact move- ments are impossible, the patient cannot, for instance, put the heel of one foot over the knee of the other leg ; cannot touch with- out mistake the tip of the nose with his forefinger, etc. Acute ataxia, that is, such incoordination as develops within a short period (from a few- days up to several weeks) occurs, in general, quite rarely and especially so in childhood. Acute ataxia is, of course, not a disease, but only a symptom which may be met with in different diseases of the nervous sys- tem, central and peripheral. Ataxia makes itself evident especially in the lower limbs, leading in severe cases to incai)al)ility of walking and even stand- ing. Such cases are described under various names, of which the most common is false locomotor ataxia — pseudo-tabes, and peri- pheral locomotor ataxia — tabes peripherica s. nervo-tabes peri- pherica. The latter name is due to the great majority of cases of false tabes having been proven to be the result of neuritis. .Etiological ly all cases of acute ataxia nia\' be divided into four groups : — (i) Toxic form. This form is the most frequent in adults, but in childhood it occurs very rarely, as children seldom have the opportunity of being poisoned with such substances as pro- duce this variety. Of prime importance here is alcohol, then arsenic, lead and mercury. Acute ataxia develops in these cases because of chronic parenchymatous nephritis. More peculiar to childhood is the second form of false tabes, due to various acute infectious diseases ; this is the (2) Infectious form. Of all acute infectious diseases in this connection the first position is occupied by diphtheria, which pro- duces characteristic paralyses and sometimes also acute ataxia. i)isi:.\si;s OK thf. xiiuvors svstkm 42: tlirou^h the allectioii of ])eriphoral nerves as well as ui the eenlral nervous system. The overwhelmiiif^' majority of cases of acute ataxia in children helon^s to this class of ataxi;e of diphtheritic orif^in. lUu hesides di])htheria, ataxia may also he the result of tyjihoid, small-jiox, scarlet fever, dysentery and sy])hilis in the secondar}- period. In the o])inion of some neurologists we have to i\o in all these cases with neurites, but, as a matter of fact, the symptoms (^f these neurites are in some instances too obscure, so that the degree of ataxia often ckx?s not corresixind at all to the degree of affection of the motor ov sensory nerve fibers, that is. considerable ataxia occurs together with insignificant disorders of sensibility and with slight pareses. According to Mouratofif* **A polineuritic ataxia may occur with exaggerated reflexes, al- most with normal sensibility, and even without any other symi)- toms of neuritis." briefly, as a pure ataxia, but the pathogenesis of ataxia remains in such cases very uncertain and then a sus- picion arises as to the central origin of the condition. ( )ne such case is given in the group of ataxi?e of central origin, where this subject will be spoken of more in detail. (3) The third group is composed of cases of ataxia which have the character of a neurosis. In such the patient does not exhibit any symptoms of organic changes in the peripheral nerves or in the central nervous system ; and at the same time the rapid issue in recovery under the influence of some form of treat- ment, or i)lainl\- imder the influence of suggestion, does not cor- respond to the proposition of the neuritic origin of the aff'ec- tion. To this section Ijelongs first of all ataxia hysterica in the form of astasia j)id abasia, that is, inability to stand or walk, the strength of the lower extremities being preserved, as they can perfectly well be moved by the patient when lying in bed without the slightest signs of ataxia. The sensibility is entirel\ normal, as well as the reflexes from the skin and tendons. Of other nega- tive symptoms one may note absence of spasticity and atrophy of the muscles, pains and dizziness ; indeed the patient exhibits no other svmptom aside from the impossibility of standing and walking. *Lccturcs oil Xcrz'OHs Diseases of Childhood (Russian). 1898. p. 120. Moscow. 422 DISEASES OF THE NERVOUS SYSTEM This form most often occurs in the period of Hfe between ten and fifteen years (Govseyeff collected fifty-four cases of astasia, of which twenty-four cases were in age from six to fifteen years, that is, forty-two per cent). In view of the importance of such cases in relation to the question of diagnosis as well as therapeusis we present here a short history of one of our clinical patients : — K. L., male, aged eleven years, entered the clinic on January 19, 1895, on account of paralysis of the legs. He comes from a tuberculous .familv, the father is an alcohol drinker, the mother suffers from migraine ; the grandfather on the mother's side died during an attack of delirium tremens. Previously always in good health the boy, K., became sick with paralysis under the following circumstances ; in November, 1894, he was violently frightened at school by the threat of the teacher and began to shiver ; the teacher ordered him to leave the class, when a fit happened to him with loss of consciousness, and he awoke at home on the following day. From that time the patient could neither walk, or stand, but was evidently in all other regards entire!)- well. On December 5th, in the evening, the patient cried out and at once fell into a state of unconsciousness, while slight tvvitchings were noticed in the shoulders and in the legs. The condition lasted about an hour before the patient recovered his senses. After that for several days in succession, in the evenings just before bed- time, slight attacks happened to him, but without screaming, in which the patient would look around amazedly, and would not answer questions. The last fit, with screaming, loss of conscious- ness and visual hallucinations occurred on December i8th, also in the evening, having lasted three-quarters of an hour, after which there were no further attacks, and the patient was unable to walk or to stand just as before. The present condition. The patient is of good complexion and nutrition ; the skin and the mucous membranes of normal tint. Organs of digestion, respiration, circulation and of the genito-urinary system do not exhibit anything abnormal ; the vertebral column painless upon pressure and bends freely. On the part of the nervous system the anomalies consist in that the patient is unable to walk or stand ; upon attempts to put him on his feet the legs bend at the knees and hip-joints as if entirely DisiiASi.s ;)F 'jiiii .\i':i<\()i's s^•s^l•;.\l 423 paralyzt'd, yet while Ixiiii^ in l)c(l the patienl perforins with con- siderable force varied movements with both legs; besides this, he can kneel and even move on all fours. The muscles of the lower limbs are not atrophied, the electrical reaction and tendon-reflexes are preserved, anaesthesia and hypenesthesia absent, as well as a spastic state of the muscles. The pelvic organs unaffected. The diagnosis of hysterical astasia-abasia was based espe- cially on the impossibility of explaining the symptoms by any affection of the spinal cord (integrity of the vertebral column, absence of anesthesia and sphincter paralysis) and on the fact that movements of the legs were performed with full strength, while only standing aufl walking were impossible. The diagnosis was amjjly confirmed by the results of the treat- ment. The patient was told that if the pain should be weaker to- day after using the galvanic current than to-morrow, then he will positively recover on the fifth day (Saturday). Of course, we employed a stronger current the next day. In the early morn- ing, about five o'clock, Saturday, the patient awoke and joyfully asked the nurse for stockings as he wanted to walk. He was dressed and immediately walked, after a two months' stay in bed. He was in the clinic seventeen days and then discharged healthy. To the same group of ataxia as a neurosis belong cases of ataxia of reflex origin. These forms are especially interesting in purely ])ractical regards, as the correct diagnosis makes such an ataxia readily accessible to the influence of setiological therapy, which usually leads to quick recovery. From a consideration of the literature one would think that in the aetiology of reflex ataxia a great role is played by irritation of the sexual organs, particular- ly masturbation and phimosis. A very interesting example of acute ataxia due to mastur- bation is given, for instance, by Henoch on page 214 of his text- book (eighth German edition, 1895). This case refers to a seven- year-old boy who had masturbated since five years of age. The child was languid, suffered from sleeplessness and night incontin- ence of urine. For the last two weeks he stopped walking and, if not supported, could not even stand or sit. \\'hen supported he complained of dizziness, moved like a tabetic patient with symp- 424 DISEASES OF THE NERVOUS SYSTEM toms of marked ataxia ; in bed all movements were quite free ; the sensibility was preserved ; the urine and f?eces were retained with difficulty, sometimes discharged involuntarily. Employing luke- warm baths, of ten minutes' duration, with cold drenching of the head and the spine, together with a careful watching of the child for the purpose of preventing him from further continuing his habit, there was noticed after two weeks a considerable ameliora- tion, and after one month complete recovery. That phimosis may also be the cause of ataxia is shown by Hunt's case*. A six-year-old boy for a long time had an unsteady gait, would often fall and, generally, poorly controlled his legs; besides this, twitchings were noticed in his face ; there was in- distinct speech, shuddering at nights and incomplete mobility of the tongue. A complete and rapid recovery took place upon cor- recting the phimosis by operation. In such cases, as well as in cases of rapid recovery from paraplegia after the expulsion of tape-worms, it is well to bear in mind hvsteria as the cause of ataxia, and that recovery may occur through auto-suggestion and in connection with an opera- tion. (4) To the fourth group belong cases of acute ataxia uf cen- tral origin, that is. cases dependent upon some affection of this or that portion of the brain or spinal cord (see below). To the same class one should also refer, with great probability, the case of acute ataxia which we observed during the fall of 1895. B. C, a seven-year-old girl entered the clinic on September 6, 1895, on account of general weakness so that the jiatient not only coiild not walk, but even stand or sit. The history: The patient is the daughter of a factory work- man, locksmith ; her father and mother, as well as two brothers (eight and two years old) are well ; no abortions or still-births in the mother's history ; no signs of tuberculosis, syphilis, alcoholism or nervous disease in the relatives of the family. In the first year of life the girl was fed by the mother's breast, notwithstanding which she frequently suffered from diarrhoea and therefore began to walk late (when two years of age). Until May, 1895, did not suffer from any serious diseases, but in May and June she had a "^Ocstcr. Jahrb. fi'tr Pacd., 1876, s. 128. DISEASES OF THE NEKVOUS SYSTEM 425 violent cous;"h and fever, ihis disease having- been determined bv the physician as \vhooping--cough, complicated with pneimionia. As soon as the girl was through with this trouble she again be- came ill, in July, with fever and persistent vomiting which lasted many days, and in the further course this was complicated by various signs of acute hydrocephalus, as severe headache, somno- lency, the head bending backwards and even general convulsions came on. The physician diagnosed titbercular meningitis and gave an absolutely fatal prognosis, nevertheless the patient began to gradually improve, and after about one and a-half months from the beginning of the disease, when the consciousness was restored entirely and the appetite and the bowels were normal, namely, on September 6, the girl was brought to the clinic, especially because she could neither sit. nor stand, and had jwor use of her arms ; in general all movements of the limbs were performed w ith diffi- culty, were languid and markedly ataxic. During the patient's three months sojourn in the clinic her condition improved greatly. During^ this time she was demonstrated to the students with the following status prcrscns: — The patient is of fair complexion, the subcutaneous cellular tissue is developed moderately, the skin and the visible mucous membranes are not very pale ; the lymphatic glands cannot be jialpated on the neck, neither in other parts ; the hair and the nails normal, the skeleton is formed correctly. The skull is symmetrical, without pronounced eminences or de- pressions, painless upon palpation and percussion, the spinal colunm entirely movable and painless. On the part of the digestive, genito-urinary, respiratory, and circulatory organs nothing pathological could be found ; the ap- petite was good, the bowels moved thick freces daily, the functions of the bladder and rectum were normal, that is, entirely subordinate to the will ; the heart-sounds were clear, the pulse — about ninety per minute, regular ; the dull sound of the liver and spleen was not increased ; the temperature during the entire time of staying in the clinic remained about t,/ degrees C. (98.6 degrees F.). On the part of the nervous system the most striking fact was that the patient entirely lost the sense of balance. Being put on her feet she could not keep her vertical ]x>sture even for on*^ second, falling immediately without bending the logs, the arms or the trunk. The stren<^th of the amis and le^^s upon coarse 426 DISEASES OF THE NERVOUS SYSTEM examination appeared normal; lying in bed the patient could bend and extend the knees with such force that an adult person only with great strength could prevent these movements. The patient easily performs and with strength dorsal flexion of the foot, free- ly snpinates and extends the wrists. She could not, for instance, touch the knee with the heel of the opposite foot, neither touch with the forefinger the tip of the nose, etc. ; while it was not difficult to notice that in the legs the ataxia was more expressed , than in the arms. The muscular sense zvas preserved : — the patient with closed eyes defined very well the position of her limbs and recognized passive movements ; muscular iveakness especially in the flexors and extensors of the knee and foot was not noticeable, but the tibio-dorsal articulations appeared somewhat more movable in normal condition. The muscular nutrition ap- peared normal, neither atrophy, nor flabbiness of the muscles be- ing noticed ; on the contrary, the leg-muscles appeared upon touch very solid and elastic ; the same could be said concerning the thigh muscles. The knee-tendon reflexes noticeably exaggerated, but rigidity in the joints was absent. The faradic electrical ex- citability of the muscles of the leg was fairly preserved, but some- what lowered in comparison with the muscles of the forearm, as, for instance, the contraction of peroneus with the coil-distance of 65 inches is of moderate strength, while the ulnaris gives a vivid contraction the distance of the coils being 75 inches. The tactile and the pain sensibility were preserved and ap- parently normal; the faradic current produced a painful sensa- tion in the lower limbs at the coil distance of 65 to 70 inches, • which is normal or almost normal, as the comparative examina- tion of a healthy person showed. The plantar reflexes were marked, likewise the abdominal reflex could be produced easily. The pupils were of normal size and reacted well to light; the pharyngeal reflex was marked. The organs of vision and hear- ing were normal. The speecli was monotonous, interrupted, scanning; the psychical condition normal. The expression of the face quiet, the facial and ocular nerves healthy, no headache ; the sleep was good, no complaint of any pain ; pressure over the tract of the sciatic nerve and the muscles of the thigh and legs pain- less. The diagnosis is quite difficult in the given case. The fact DISEASES OF TJ11-: XEKVOUS SVSTICM 42/ that in a j^rcat majority of cases acute ataxia depends upon affec- tion of peripheral nerves leads to the belief that this is one of the cases of multiple neuritis, the so-called tabes peripherica. But such a diagnosis is improbable, because there are no symptoms of neuritis (neither pains along the course of the nerves, changes -of sensibility, nor pareses, even in the area of the peroneal nerve, as the dorsal flexion of the foot was performed with force ; nor lowering of the reflexes). And there are facts which are against such a diagnosis, namely, the onset of the disease with meningitis, a noticeable increase of the reflexes and normal condition of nutri- tion of the muscles of the legs. Hysterical astasia-abasia was also absent (the patient's age, -the onset of the disease, scanning speech, ataxia upon moving the limbs in the lying posture). It is most probable to suppose here some Ventral lesi(ni of -the brain and spinal cord, as, for instance, of the cerebral cortex (cortical ataxia), of the cerebellum (cerebellar ataxia), of the pons Varolii and medulla oblongata (bulbar ataxia), and it is no ■doubt true that in the brain and the spinal cord there are some -other portions a lesion of which leads to ataxia. In order to determine the location of the morbid process producing ataxia in each separate case one must give heed to the character of the ataxia, to the concomitant symptoms and to .the aetiological factors as well. As to the character of the ataxia and concomitant symptoms, it is necessary to point out regarding cortical aia.via, that the Jatter is often unilateral (bilateral ataxia without idiocy, although -theoretically possible, occurs very rarely), quickly develops to a -considerable extent, gradually extends according to the distribu- tion of separate centers, at first the legs becoming paralyzed, then the arms and finally over the course of the facial and hypo- :glossal nerves. Besides ataxia still other symptoms of cortical lesion may ap- pear, as cortical epilepsy, paralyses and aphasia. In cerebellar ataxia the patient complains of headache ; in •walking he swings from one side to the other, as if drunk, be- cause of loss of the sense of balance, but when lying in bed he moves his limbs correctly, without manifesting any ataxia: the .arms do not 1)ecomc involved. In our case altb.oiiuli the loss ot the 428 DISEASES OF THE NERVOUS SYSTEM sense of co-ordination was very prominent, yet ataxia was noticed in the movements when the patient was lying down, not only in the lower, but also in the upper limbs. In bulbar ataxia all four extremities become involved simul- taneouslv with the appearance of bulbar symptoms, which was ab- sent in our case. It is most probable that in our case we had to do with ataxia of spinal ori(^iii, with that form which is the manifestation of disseminated inflaniniation of the spinal cord — myelitis dissemi- nata. As this morbid form is not described in the majority of text-books it is very little known to physicians. For this reason we deem it best to describe the disease more at lens^th, being guided by Leyden and Goldscheider's monograph in Nothnagel's Encyclopaedia*. Leyden and Goldscheider say that the picture of acute ataxia may be produced by two separate processes ; first, by polyneuritis^ and, secondly, by disseminated, insular affection of the central nervous system, particularly in the region of the spinal cord and medulla oblongata, pons X'arolii and cerebral peduncles. This latter form is described b\- Leyden and (ioldscheider under the name of acute (bulbar) ataxia. According to Westphal, who described the greatest number of cases of acute ataxia, the most characteristic symptoms of the disease in question ars the following : — {i)A peculiar disorder of speech: the patient's speech is slow, drawling, scanning. (2) Ataxia of the limbs, the muscular force being preserved or at any event only inconsiderably decreased. (3) Unimpaired sensibility. (4) Disorders of psychical condition in the form of excita- tion or weakening of the memory and even dementia. According to Leyden, myelitis disseminata (encephalomyeli- tis) presents two entirely different forms of disease — acute ataxia and paraplegia. The most noticeable symptom of the first form is acute ataxia spreading all over the four extremities, although not equally ; the voluntary movements are often not only ataxic, but also retarded^ ''Vol. X., Part II., page 404. DISEASES OF THE NERVOUS SYSTEM 429 languid ; the coarse strength of the muscles, if decreased, then only to a very inconsiderable degree ; actual paralyses occurring very seldom ; the muscles are generally relaxed. Sometimes to- gether with ataxia tremor is also noticed, especially upon active movements. ( )n ilie part of the eyes there is often nystagmus. Disorder of speech is noticed almost always ; it is scanning, drawl- ing, retarded, monotonous. The functions of the rectum and bladder are normal. Subjective disorders of sensibility and pains are absent, the objective examination detecting only inconsiilerable deviations from the normal standard. The muscular sense is in the majority of cases normal. Cutaneous reflexes are normal, the tendon reflexes may be exaggerated. The pupil-reflexes are not changed. The mental abilities are often weakened, as illustrated in the power of the memory, which sometimes limits the mental impairment. The course. The disease begins acutely or subacutely. In some cases after a foudroyant onset all symptoms quickly decrease, and after a few weeks complete recovery follows; in other cases after a seeming recovery relapses come on, and the process may end with the development of multiple sclerosis. Some cases as- sume a chronic course at once being transformed into a type of multiple sclerosis of uncertain duration. The pathological anatomy. Inflammatory foci of various, usually of inconsiderable, size are in some cases limited to the spinal cord, in others they also mvolve the bulb, pons V^arolii, cerebral peduncles and even sometimes the hemispheres. They are located in the gray, as well as in the white, matter. In general, the pathological process bears the character of perivascular inflam- mation. In the further course the inflammatory feci probably be- come transformed into the condition of sclerosis, that is, trans- formed into multiple sclerosis. Mtiology : — (i) Heredity is of no particular importance. (2) Trauma may be the accidental cause. (3) The chief setiological influences belong to the acute in- fectious diseases ; small-pox, typhoid fever, whooping-cough, erysipelas, measles, dysentery, influenza, malaria, rabies, tubercu- losis and probably also parotitis epidemica (mumps). The first symptoms of myelitis set in either during the 430 DISEASES OF THE XERVOUS SYSTEM highest development of the disease, or oftener in the period of recovery. (4) Of some importance are the intoxications, for instance, by CO and metals. (5) Sometimes no etiological relationship can be detected, such cases being described as "spontaneous myelitis." Returning to our case then, we will see that in its rapid onset, which simulated inflammation of the cerebral membranes ; in the pronounced ataxia of all four extremities while paralyses and disorders of sensibility were absent ; in the scanning, monot- onous speech, in the absence of muscular atrophies and increase of the tendon reflexes it entirely agrees with the description of Leyden and Goldscheider under the name of myelitis disseminata s. ataxia acuta (bulbaris). The termination of the disease in our case does not contradict this diagnosis ; the patient was dis- charged from the clinic, with considerable improvement, in Janu- ary. She could stand for a short time without being supported,, could walk around the bed, holding by its edge; could creep in the bed, without aid. In the spring she could walk without any support. As to the diagnosis of the causes of acute ataxise in general the same may be readily determined by the history. Diphtheri- tic ataxia may be diagnosticated with comparatively little diffi- culty inasmuch as it is preceded, and not rarely followed, by characteristic symptoms of paralysis of the soft palate and the pharynx. From chronic ataxia the acute forms differ mostly by the rapidity of development of the symptoms. The prognosis in acute ataxia is generally favorable as in the majority of cases complete recovery sets in in a few weeks or months ; in severe cases even a fatal termination may occur, for instance in diphtheritic ataxia due to paralysis of the heart. In myelitis disseminata the issue may be in chronic multiple sclerosis. Chronic ataxia in childhood is a symptom either of disease of the brain or spinal cord. In the former case the diagnosis is based upon the associated symptoms which usually show the pres- ence of a tumor in the cranial cavity or hydrocephalus. In such, cases ataxia is only of secondary importance. On the contrary. disi-:asf:s ftp the xervocs system 4^ it is the chief symptom in so-called Friedreich's disease, or hcrcch- tary ataxia, which in its anatomical features must be held as a combined systemic disease, because the autopsy always shows de- generation of the posterior and pyramidal columns simultaneously, and sometimes also of Clarke's columns and the cerebellar tracts. The leading; symptoms of this disease are : — ataxia, loss of tendon reflexes, nystaguius and tremor of the limbs during inten- tional movements. Ataxia in its character is somewhat like the cerebellar form, because in walking the patient sways from one side to another ; nystagmus is almost always present, but in some patients it is not noticeable during- the quiet condition of the eyes, but makes itself evident only upon movements of the eye-ball, for instance, when the patient is directed to follow an object moving before the eyes to the right or to the left side. A very important symptom of Friedreich's disease is also impairment of speech, which is monotonous and indistinct ; the tongue when extended manifests oscillating movements or twitchings. As to the distinction of this disease from a common tabes dorsalis which, however, hardly ever occurs in childhood, it is based upon the absence of some symptoms ver}^ characteristic of the latter. For instance, m Friedreich's ataxia disorders of cutaneous sensibility and of the muscular sense, optic atrophy, changes in the pupillary reaction and impairment of the functions of the bladder and rectum are absent, while there is present nystagmus which is not peculiar of tabes, and impairment of speech. As common symptoms for both these diseases there remain ataxia and absence of tendon reflexes. [O. Marburg, of Vienna, collected 34 cases of infantile and juvenile tabes. We speak of infantile tabes, if the disease mani- fests itself before fifteen years of age ; if it arises after this date, then it is denominated juvenile tabes. Of the 34 cases Marburg collected from literature 19 were females and 15 males, the ratio thus being 4:3, while in adults this ratio is reversed decidedly, i. e., the disease occurring oftener in males than in females as 10:1. The cause of infantile or juvenile tabes is syphilis (in the majority of cases). From the time of specific infection up to the appearance of the tabetic symptoms there is a period of from five to nineteen years (the same as in adults). 432 DISEASES OF THE NERVOUS SYSTEM All symptoms usually observed in adults are also characteris- tic of the juvenile form ; but the most important and the earliest symptoms of tabes in children are optic atrophy and vesical dis- orders. (3f the latter incontinence of urine occurs much oftener than retention. It may be dififerentiated from a vesical neurosis — nocturnal enuresis — by occurring also in the day time and by being accompanied by visual disorders. Crises and trophic dis- turbances are also frequent in children, but much less so than in adults. In addition to the 34 cases taken from literature Marburg adds one of his own : A ten-year-old boy contracted syphilis from the wet-nurse when one and a-half years of age. He was cured bv mercurial frictions (half a dram of blue ointment — 30 frictions) and was free from any disorders up to the eighth year of age, when his vision began to suffer ; and could not be relieved by glasses. Upon examination there were found : unequal pupils, with slui^^^ish reaction to light (on the left side) and complete absence of the reaction on the right side, the right papilla was pale (optic atrophy), accommodative reaction of the pupils — nor- mal. There was absence of the patellar reflex; slight tottering with closed eyes (Romberg's phenomenon) ; the mental condi- tion was entirely normal. The beginning of the disease thus oc- curred with the optic atrophy*. — Earle.] Intentional tremor, nystagmus, impairment of speech and ataxia occur also in sclerosis disseminata, which disease is very rarely met with in children. The substantial differences consist in the tendon reflexes being increased in sclerosis, the course of the disease being interrupted by apoplectiform attacks and consid- erable temporary aggravations. The diagnosis of Friedreich's disease may be assisted in many cases by the hereditary character of the disease, that is, by its occurring either in all, or at least in some, members of the same family. This sign is also peculiar of that form of ataxia which was described by Marie as Heredoataxie cerebelleuse (Hereditary cerebellar ataxia) , but in this form the tendon reflexes are retained or even exaggerated, the arms either do not become involved. *Otto Marburg: Infantile und Juvenile Tales {Wiener Klin. Wochen- schr., 1903, No. 47). nisiiASEs OF Tin-: nervous svsTK.\r 433 or very late, the muscles of the lower limbs are in the condition of spasm, there often develops optic atrophy, while aetiologicallv there is a substantial difference in the age in which the disease begins. Friedreich's disease begins in the age of from seven up to fifteen years, while cerebellar ataxia from twenty up to forty years. INFLAMMATION OF THE CEREBRAL MENINGES, In accordance with the aetiology, pathogenesis and clinical course four forms of acute inflammation of the cerebral meninges in children may be described : — ( 1 ) Purulent meningitis. (2) Tubercular meningitis, or acute tubercular hxdro- cephalus. (3) Serous meningitis, or simple acute hydrocephalus. (4) Epidemic cerebro-spinal meningitis. In the simple (non-tubercular) acute purulent inflanimatiou ■ — men'moitis acuta simplex — the pia mater over the convexity of the hemispheres becomes especially affected (hence the name lepto-meningitis convexa) ; pathologico-anatomically it is char- acterized by the formation of a purulent exudation, hence also called meningitis purulenta. The tubercular form of inflammation of the cerebral meninges dift'ers from the preceding, among other features, by the leading alterations being located in the membranes of the base of the brain, therefore the name meningitis basilaris. The presence of pus is in this case unnecessary, being frequently absent altogether and the inflammation manifested by the formation of a serous exudate, which principally accumulates in the subachnoidean spaces, between the optic chiasma and the bulb, as well as in the lateral ventricles which therefore become considerably distended in all cases. This form is also called acute hydrocephalus — hydro- cephalus acutus, and is especially notable because of the presence of extensive deposits of miliary tubercles at the base of the brain, accumulated mostly in the sylvian grooves — meningitis tuber- culosa. As tuberculosis is almost never localized solely in the cerebral membranes, deposits are therefore found post mortem in other organs, especially in the bronchial glands. It is, however, undoubted that acute hydrocephalus of in- flammatory origin (meningitis serosa) sometimes occurs in chil- 434 DISEASES OF THE NERVOUS SYSTEM dren (especially under two years of age) even without tuber- culosis, that is, in the complete absence of tubercles not only in the cerebral meninges, but elsewhere in the organism. In tuber- cular meningitis, as well as in this form, there may be pus to- gether with the serous exudation. This form is described in some text-books in a separate chapter under the name of simple (non-tubercular) acute hydro- cephalus — hydrocephalus acutus simplex s. non-tuberculous or in- fantile meningitis — leptomeningitis infantum (Huguenin), be- cause it is peculiar to childlKX>d. But as in the symptoms and the course a simple hydrocephalus differs in no way peculiar from the tubercular form, therefore it is not necessary to describe it separately ; it suffices to know that such a form does exist and that this may, contrar}' to tubercular meningitis, end with re- covery, so that one can by no means hold to a hopeless prognosis^ that is, to an absolutely fatal lesion, because the patient exhibifs symptoms of tubercular meningitis. Epidemic cerebrospinal meningitis — meningitis cerehro- spinalis epidcviica — is characterized by the formation of a puru- lent exudation on both the convexity and the base of the brain and, besides this, by affection also of the spinal membranes. Pathologico-anatomically these four forms strikingly differ from each other only in their typical manifestations, simultaneous- ly with which still different transitory forms are met with, as, for instance, in meningitis purulenta the purulent exudation may spread to the base of the brain and the choroid plexuses of the ventricles. Acute tubercular hydrocephalus (tubercular or simple) is sometimes accompanied by the formation of pus not only at the base of the brain, but also on the convexity of the hemispheres. In the simple purulent as well as in tubercular meningitis the inflammation may also involve the spinal mem- branes, as in epidemic meningitis. It is self-evident that the similarity may clinically be still greater and therefore it is no- wonder that in some cases it is very difficult to say with which particular form we have to deal. An important aid to diagnosis in such cases is : — /Etiology : — In distinction from .all other forms of inflamma- tion of the meninges tubercular meningitis never affects entirely healthy children inasmuch as its chief setiological factor is general DISEASES OF THE Nl-.K\()rS SVSTK^[ 435 or local tuberculosis. Therefore it is important for its (lia.i,Mi()sis to note the predisposition of a given child to tuberculosis. This disposition may be hereditary or acquired. To ascertain the former the physician inquires if there was not tuberculosis in the parents or the nearest relatives, and if some of the sisters or brothers did not die from a disease bearing some relation to tuber- culosis. In this regard it is most important to know if there were not cases of death due to meningitis. There are unfortunate families in which several children in succession, and at approxi- mately the same age. die from meningitis, although neither the father, nor the mother, suffer from tuberculosis. Hereditary disposition to tuberculosis in children may be the consequence of other diseases in parents, for instance, of an old syphilis. I know a family in which four children died from tul>er- cular meningitis, notwithstanding that the father and the mother seemed to be entirely well. The father had a scar upon the shoulder caused by an old caries apparently of scrofulous origin. Syphilis, many years before, was brought out in his history, but his then present condition was one of good health. After the death of the fourth child he, according to his physician's advice, underwent anti-syphilitic treatment by mercurial inunctions (blue ointment) and after one-and-a-half years two children were born who have survived the dangerous age and are at present entirely healthy. The family predisposition to tuberculosis may, in a given case, also be denoted by the death of brothers or sisters from measles and whooping-cough. In entirely healthy children these diseases usually have a favorable course, but they are dangerous in the presence of some predisposition to tubercidosis. The acquired disposition develops under the influence of all unfavorable conditions which are of importance as astiological factors of rachitis and scrofulosis, therefore, if the child shows- symptoms of this or that disease, then one may think that he- has some disposition to tuberculosis. The generally healthy aspect, in such instances does not prove the contrary, as under the in- fluence of rachitis there may develop in some parts of the body (bronchial glands) caseous (tubercular) foci which do not in any way manifest their presence for some time, but finally give.- rise to the auto-infection of the orqanism hv lubercio baciili. 436 DISEASES OF THE NERVOUS SYSTEM Such latent nests most often remain in the hronchial or mesenteric glands after old catarrhs to which rachitic and scrof- ulous children are so prone, therefore one must inquire if the child did not sufifer with repeated or chronic bronchites and diarrhaae. There are diseases after which the latent disposition to tuber- culosis suddenly appears as nienmgitis or acute miliary tuber- culosis, etc., and this fact (that is, that the attacks began to manifest themselves after such and such disease) may occasion- allv be of great value in the diagnosis, for instance, of typhoid from tuberculosis. Of prime importance among such diseases are measles, la grippe and whooping-cough, secondarily, different wasting diseases. Accidental causes are unnecessary in the incidence of tuber- cular meningitis, as the disease usually develops without any certain cause ; in other cases there are indications of exposure to cold or contusion of the head ( usually a very slight one which is hardly of any value). The age mostly favoring the development of tubercular men- ingitis is that from two to seven years, but nurslings and adults sometimes become affected. Contrary to this a simple serous meningitis ( simple acute hydrocephalus) most frequently (almost exclusively) occurs in small children during the first or second year of life. Another ^etiological ditTerence from the tubercular form consists in the simple variety affecting not only rachitic, but also entirely healthy children having neither an hereditary or acquired disposition to tuberculosis ; and it usually develops without any determinable cause. Oftener, however, 1 have met the condition in weak children presenting rachitic changes in the bones of the skull and chest wall, or in children who have repeatedly had eclamptic convulsions. Some authors ascribe the iniiuence of dentition as a factor disposing children to cerebral congestions and acute hydrocephalus. A simple acute purulent meningitis never develops in healthy children without evident cause, therefore if no suitable data can be found in the history, then this circumstance alone makes the diagnosis of simple purulent meningitis little probable, even nisF,.\SEs OF Till'; .\i:k\()Us system ^ly thougli symptoms so indicate. We usually have to do in sucii cases with cerebro-spinal meningitis of infectious origin. A healtln and strong child may come down with meningitis because of a contusion or severe cold of the head, or because of insola- tion. In other cases again meningitis develops because of ex- tension of an inflammation from neighboring parts or as a com- plication of different acute, infectious diseases. In the former case the most fre(|uent cause is acute or chronic otitis media, or again caries of tlie skull bones associated with other causes (periositis, gummata), erysipelas of the head, furunculosis. etc. As a complication of acute diseases meningitis most often occurs in croupous pneumonia, somewhat less frequently in scarlet fever, acute rheumatism, small-pox and pyaemia. Epidemic cerebro-spinal meningitis, as the name indicates, develops under the influence of epidemic, as yet unknown, con- ditions. The post mortem most often shows the intracellular diplococcus. The same microbe commonly occurs also in siwradic cases of cerebro-spinal meningitis : some authors refer the same to contagious diseases, but its contagiousness is at most not great. Let us ])roceeefore had measles or la grippe, or is suffering from whooping-cough, then this fact alone is in favor of a developing tuberculosis, making improbable the supposition of typhoid fever in the patient. Such a fever may last two or three weeks before the cerebral symptoms make themselves evi- dent, as, for instance, in one of my cases, a five-year-old boy, tuberculous fever with the symptoms of an insignificant bronchi- tis, which would disappear, and then reappear, started during whooping-cough and lasted one hundred and nine days, until vomiting and headache finally appeared. (About the peculiarities of tuberculous fever, as well as of its differences from typhoid, see the section on typhoid). An afebrile precursory period may also last from two up to twelve weeks. The onset of meningitis proper occurs with vomiting and headache. (The dift'erentiation of meningeal vomiting from gas- tric was mentioned in the section on vomiting, page 155). Vomit- DISEASES OF THE NERVOUS SYSTEM 439 ing rarely lasts more than five days and if an entire twenty-four hour period has passed without vomiting, then one may infer the same will not return. Vomiting is one of the most important symptoms of meningitis, especially because of its constancy as such. It almost never is absent ; so that in doubtful cases the absence of vomiting in the commencement of the disease almost excludes meningitis. Often there occur cases of meningitis in which the vomiting is not obstinate, for instance, a single attack. As to headache, this is not so severe in tubercular meningitis, as in purulent or cerebro-spinal ; it does not make an older child throw himself about in the bed, or cause him to groan and grasp his head, l)ut he usually complains of the same when asked what hurts him. This fact must be borne in mind in order not to exclude, in the differential diagnosis, a cerebral lesion only be- cause the headache is insignificant. In the onset of tubercular meningitis restlessness is not peculiar, on the contrary there is a slight apathy ; the child keeps quiet in bed, does not complain or ask for anything; he does not create the impression of being severely ill altogether, being only weak and unable to walk, mostly because of di::cincss. In young children acute hydrocephalus is seemingly accom- panied by more considerable headache, because during the first days of the disease there appears together with vomiting con- siderable restlessness, so that the child cries very much during the day time as well as at night. Such a restlessness is undoubt- edly of diagnostic value in the differentiation between meningeal vomiting and the gastric variety, in which the child remains com- paratively quiet. During the following days the most characteristic sign is the gradual and progressive increase of apathy to the point of somno- lency, which is transformed toward the end of the disease into complete coma. The increase of apathy is manifested by the child often falling into an apparently normal, quiet sleep. At first the usual call is sufificient to awaken the child, his conscious- ness being still well preserved ; he correctly answers questions and fulfills what he is ordered, but, being left alone, he very soon closes his eyes and sleeps again. It seldom happens that the child is very delirious in the first period of tubercular meningitis, or that he jumps from the bed, constantly talking, etc. (These 440 DISEASES OF THE NERVOUS SYSTEM symptoms, dependent upon involvement of the cerebral cortex, are more peculiar of purulent mening:itis of the convexity of the hemispheres). Later on the somnolency is deeper, the child awakes only upon painful irritations, still later he reacts to them only reflexly, and shortly before death the reflexes also disappear. The apathetic condition in nurslings is shown b}' the tendency to sleep, and therefore it is very characteristic of a beginning meningitis that the child, after having suffered several days (three to six) with vomiting, restlessness and poor sleep, begins to fall asleep even during the day, while vomiting either stops entirely, or becomes lessened. Somnolency, as a symptom of basilar meningitis, is of par- ticular value for the diagnosis of the initial period of this disease, in case it be not accompanied by fever, because in the contrary event it may be the direct consequence of elevated temperature of whatever nature. Thus, sonuiolence is indicative of a cerebral lesion only if its degree does not correspond altogether to the degree of fever, or if somnolency a])pears after the fever stops, that is, in the period of recovery from any febrile disease. Furthermore characteristic are the symptoms on the part of the digestive organs; the tongue is quite clean (in gastric vomit- ing it is usually thickly-coated) and from the very first day of the disease constipation sets in, which is especially interesting re- garding the diagnosis; the abdomen, despite the persistent con- stipation of many days' duration, not only does not distend, but even becomes softer with each day and shaUon'cr and tozmrd the end of the week it becomes retracted, "boat-shaped." (We do not know how to explain such a form of the abe partly due to the fact that the child from the very beginning of the disease does not eat anything, but this is not the only or the chief cause of the retracted abdomen. It is also impossible to ex- plain this occurrence by spasm of the bowels or of the abdominal musculature, but it is probable that the chemistry of intestinal digestion changes, so that little intestinal gas is formed.) Constipation is a quite important symptom in the diagnosis of meningitis, first, because it belongs among the constant evi- dences of this disease, and, secondly, because it is combined with the subsequent sunken abdomen, which is usually absent in catarrh i)isi:.\si-:s OF tiik ni-.rx'ous svs'n-:.\[ 441 of the sloniach and that of tlie l>o\vcls. also in typhoid, that is, in those (Hseases with wliieh acute hydrocephalus is most often confused in its initial period. Constipation is comparatively often absent durini;- menin,t(iti,s in nursling-s, which may be explained by the constipation in men- ingitis depending perhaps on irritation of the splanchnic nerve, and by the inhibitory nervous system in small children generally being in poor activity, so a priori one would not expect meningitis in small children to be so persistently accompanied by constipation as in older ones, which opinion is amply confirmed by observations. Hut the diagnosis is aided in such children by the gastric vomiting being necessarily accompanied l)y intestinal disorders in the form of dyspepsia or watery diarrhoea, so that if, despite the repeated vomiting in a nursling during several days (and the more if there develops an inclination to coiisfipatioii. or if a preceding diarrhoea stops), then this fact is hii^lily suspicious; moreover, if simultaneously the child be at the breast and any data of irritation of the stomach by a coarse food be absent from the history, then there can be no doubt of the meningeal origin of vomiting. Further in the diagnosis of the initial period of vomiting, there is of importance the course of the temperature. It happens very rarely that tubercular infiammation of the meninges occurs with normal temperature, or with fever higher than 39 degrees C. (102.2 degrees F.) ; usually there is found a suhfchrilc condition with oscillations from 37.8 degrees C. (100 degrees F.) up to 38.8 degrees C. (101.8 degrees F.). On one hand such a tem- perature is too high for a sim])le dyspepsia in nurslings, in which there is no fever ; on the other hand it is too low for typhoid. I am convinced that if physicians would more thoroughly appre- ciate the significance of the temperature then confusion between typhoid and meningitis would occur less frequently. That toward the end of the disease the temperature in meningitis may reach hyperthermic degrees (41 to 42 degrees C. — or 105.8 to 107.6 degrees F.) because of paralysis of the regulatory centers, is of no special value, because it occurs shortly before the fatal issue. One must also note that normal or even subnormal tempera- ture in the period of souiuoleucx does not exclude meningitis, 442 DISEASES OF THE NERVOUS SYSTEM although such appearance is much oftener met with during false meningitis, that is, during so-called hydrocephalus due to anaemia or cfidema of the brain. The pulse may in the first days of the disease be quickened, according to the fever, but at the end of the first week, and sometimes even earlier, it becomes retarded and irregular. The number of pulse-beats, in rare cases in children several years of age, may fall to fifty or sixty, but during fever, even slight, ninety beats may be held as a retardation, because in children five or six years of age a temperature of about 38.5 degrees C. (101.3 degrees F.) is usually associated with a pulse of about 120, and in nurslings about 140, so that in the latter 112 may be boldly held as a retarded pulse, and with more reason in that the vagus, as a nerve inhibiting the heart, in them acts poorly, so that a more pronounced retardation cannot be expected in the period of deeper somnolency. Especially after convulsions have appeared the pulse becomes accelerated more and more, reaching, before death, two hundred or becoming so weak and frequent that it cannot be counted. As to the irregularity of the pulse, the same is manifested first of all by disproportion of the strength and frequency of the pulsations, then by slight irregular beats due to the sudden stop- page of heart-activity, then the irregular beats become more con- . stant. The most insignificant irregularities cannot be noticed by the finger counting the pulse, but they are easily detected by the stethoscope, because the organs of hearing are in this regard more sensitive than those of touch. The irregular and retarded pulse may considerably aid the diagnosis of meningitis only when simultaneously there are other meningeal symptoms, for instance, apathy or somnolency ; but, by itself, such a pulse does not exhibit anything ominous, as it may also occur without meningeal lesion, for instance, in con- valescents after febrile diseases, in anaemia and in small children during sleep. With the beginning of the second week of the disease when the vomiting has ceased and the irregularity of the pulse and the somnolency are expressed more or less decidedly, then some new symptoms appear which finally clear up the diagnosis : deep sighing, symptoms on the part of the eyes, chewing movements DISEASES OF THE NERVdUS SYSTEM 443 'of the inferior maxilla and automatic uniform movements of this •or that extremity (most often the child begins to make continuous movement with the arm ; he lifts the same to the head, passes it down over the face and chest to the abdomen, again raises it to the forehead, etc., for half an hour or longer, several times a •day), also symptoms on the part of the vasomotors. Still later contracture of the neck, general convulsions and difiicult degluti- tion appear. The respiration is normal during the first days, but in the period of somnolency there are at times deeper sighings, often followed by long intervals (as if the child forgets to breath, as Barthez and Rilliet express it) ; sometimes quiet respiration is interrupted by monotonous, short cries (cri hydrocephalique, of Coindet) ; still later in the period of complete somnolency (the end of the second and the beginning of the third week) the respira- tion assumes the Cheyne- Stokes character. The eyes exhibit so many symptoms characteristic of men- ingitis that by them one can often recognize the disease froni a distance. First of all there is the immobile stare, which symptom is most valuable in the diagnosis of meningitis in small children in whom it appears quite early (the end of the first week) ; the •child rarely winks, the eye-lids are widely open, and the eyes look immovably into distance ; he does not fix upon any thing brought near, and probably does not see well as he does not wink upon the approach of the finger to the eye ; the pupils are wide and at the same time slowly react to light. Not infrequently oscillatory vibrations of the pupils are noticed, that is, under the influence of light the pupil contracts for a short time, but immediately dilates again, notwithstanding the lasting action of the light. As a good diagnostic method for the distinction of acute hydrocephalus from all similar diseases Parrot points out that considerable dilatation of the pupil may be caused by pricking the skin of the abdomen. I have had the opportunity to convince myself that this sign is constantly met with in the period of in- complete somnolence, but a pricking of the skin of the abdomen alone is unnecessary for this purpose, any painful irritation being sufficient. But a question arises here ; how especially cliaracter- istic is this symptom of meningitis? and does it not also occur dur- ing other diseases ending with somnolence? The decision of this question requires further observations. 444 DISEASES OF THE NERVOUS SYSTEM Then again we have two more symptoms on the ])art of the- eyes; strabismus (appears much later than the immobile stare) and changes of the fundus of the eye. If the ophthalmoscope- shows the presence of tubercles on the choroid, then the diagnosis of miliary tuberculosis is undoubted, but the trouble is that tuber- cles of the choroid occur very seldom, oftener oedematous papilla being found, but this symptom is not altogether pathognomonic- of acute hydrocephalus ; it denotes only a hindred blood circu- lation and increased blood pressure in the cavity of the skulls which may depend also upon a brain tumor, and on other causes as well. Symptoms denoting vasomotor disturbances appear compara- tively late. Two kinds of appearances are here included : — first,, quick change in the color of the face, and, second. Trousseau's sj>ots. In the first period of tubercular meningitis the face is pale,, but vasomotor disturbances occurring in the period of (|uite deep somnolence sometimes give rise to the sudden development of bright redness of one or both checks, quickly disappearing again. Not rarely one succeeds in ])ri>ducing such a ])lay of colors arti- ficially ; it is only necessary to trouble the child by something. To make Trousseau's spots appear one has to pass the finger in a line over the skin of the trunk, or employ some blunt in- strument, moderately pressing. After one-fourth to one-half minute a brig-ht red stripe is seen on the place of the line, which remains for quite a long time gradually disappearing from the margins. Although these spots constantly occur in the late period of tubercular meningitis, their diagnostic meaning is not very great, because they are also met with in other diseases, for in- stance, in typhoid. Contracture of the neck also belongs to the quite constant, but late, symptoms of tubercular meningitis. It may be of value- for the differential diagnosis from typhoid only because it is ac- companied by a comparatively low temperature, while l)v high, ones in t3'phoid (104 degrees F. and more). In the presence of contracture of the neck the passive flexion of the head is always very painful, producing a reaction on the part of the patient in the form of a cry or painful expression of the face, even in the period of very deep somnolence, when, for DISEASES OF THE NERVOUS SYSTEM 445 instance, the pricks of a needle are evidently not felt. As the recumbent posture on the back is associated with some pressure of the pillows upon the contracted neck in Ixinding the head, therefore, the child, despite the somnolency, instinctively assumes a position on the side, and for preserving the balance flexes the legs upon the thighs, that is, he lies on the side as if rolling; such a position being known under the name of "chien a fusil,'' is very peculiar of tubercular meningitis (in typhoid for instance, the patients remain on the back most all the time). There is also characteristic, in the general appearance of a patient suffering with meningitis, the considerable wasting of the body reaching in this disease the highest degrees in a compara- tively short period ; in the course of about two weeks the patient exhibits only skin and bones, so to say, that is, such a wasting as occurs in typhoid much later. General convulsions by themselves exhibit nothing typical of meningitis. One should bear in mind that, notwithstanding the •complete absence of a focal lesion of the brain, they may never- theless be unilateral, leaving later on circumscribed paralyses. Almost never does eclampsia set in from the very first of the disease, but usually three or four days before death. According to Barthez and Rilliet if the convulsions appear at the onset, being especially persistent, then they always denote the presence of large tubercles in the brain. The parents often question the physician whether the child will live long? If his torture will soon end? To determine the time of death is generally a hard task, and in tubercular men- ingitis the more so as its duration varies greatly ; but approximate- ly one may be guided by the following circumstances : — In the majority of cases acute hydrocephalus (tubercular or simple, im- materially) lasts two to three weeks. As long as the pulse re- mains retarded, a very quick death should not be expected, even if the somnolence be decidedly developed ; if the pulse begins to be considerably accelerated, then death is near, and if it reaches 180 to 200 beats, then the patient will hardly survive more than twenty-four or thirty-six hours. The impossibility of swallow- ing (not only during the convulsions, but constantly) sets in not earlier than twenty-four hours before the fatal event, but a rat- tling, bubbling respiration, a few hours before. Especially rapid 446 DISEASES OF THE NERVOUS SYSTEM is the course of meningitis when it develops in a child sufferings with pronounced tuberculosis. According to Rilliet and Barthez- the disease in such cases begins directly with convulsions followed' by somnolence and other evidences of the last stage. Tubercular meningitis in its different periods may be similar- to many diseases. In all doubtful cases one must first of all en- deavor to decide the question of the precursory period (that is, if there were corresponding symptoms in any given case) and if the child has an hereditary or acquired disposition to tuberculosis. To make a positive diagnosis of tubercular meningitis in the absence of the above-mentioned etiological conditions, one must obtain considerably more aetiplogical information than is required' when the patient himself, or his near relatives, have suffered from» this or that form of tuberculosis. It is impossible to recognize approaching tubercular meningi- tis in the prodromal period, because at this time there are no characteristic symptoms. That the child without any known cause loses his appetite and grows thin and pale does not prove any- thing, as such symptoms also occur in anaemia, mild stomach catarrh or with intestinal worms. The condition becomes more suspicious if besides this the child manifests symptoms of brain irritation ; if he complains of dizziness, becomes frightened in sleep, or grinds the teeth, such symptoms previously having been- absent. If the prodromal period runs with considerable fever then typhoid may be diagnosed (see the diagnosis of typhoid from acute- miliary tuberculosis). In the first period when the main symptoms consist in. vomiting, headache, apathy and constipation, the question may arise concerning a stomach catarrh, a beginning typhoid, and brain- congestion. About the distinction of stomach vomiting from the cerebral form see page 155, here we only add the following : — In a nursling, a beginning meningitis is often mistaken for dyspepsia, because in both cases, besides vomiting, restlessness of the child is alsO' observed. Opposed to dyspepsia there is : First, elevation of .temperature, usually accompanying a be- ginning meningitis, especially in small children. DISEASES OF THE nm=:rvous system 447 Second, the absence of dyspeptic stools. This symptom is extremely important, if present ; but as diarrhoea in small children may also be met with in meningitis, then one should remember that a contrary conclusion on this ground cannot be made. Third, the persistency of voiniting. Vomiting in dyspepsia usually stops very soon if the diet be regulated (for instance, forbidding cow's milk) and if corrective remedies be administered (bismuth, cerium oxalate, small doses of calomel) ; while in men- ingeal vomiting it is characteristic that it lasts persistently, not- withstanding the food of the child is most correct (even the mother's milk) and that it does not yield to drugs. It is still more typical if no diet error he found to he the cause of vomiting, that is, if vomiting appears in a child under the same food which he previously took very well. Fourth, the character of the cry. In dyspepsia the cry is violent, but appears in attacks, that is, appears suddenly and as suddenly also disappears, while in meningitis the child cries per- haps not so violently, but longer; he is restless day and night. Cry due to colics, like that of dyspepsia, occurs oftener the younger the child, mostly from one to three months ; meningitis, on the contrary, occurs after six months. Fifth, the further course. A few days after the appearance of meningeal vomiting the child becomes somnolent and later on other meningeal symptoms develop, of which a tense, some- times even protruded, fontanelle, immobile stare and sucking movements of the lips during sleep, usually occur earlier than the eclamptic convulsions, complete somnolence and the contracted neck. Still greater similarity to a beginning acute hydrocephalus is sometimes presented by cases of subacute gastritis in older children. This disease pursues a course either with normal, or slightly elevated, temperature, being sometimes characterized by the same symptoms as in a beginning meningitis, that is, by vomit- ing, mild headache, apathy, constipation and even irregular and retarded pulse. Such forms of gastritis, examples of which may be found, for instance, in Henoch's Text-book (third edition, page 297), in Rilliet and Barthez (Volume II., page 37), as well as in the first volume of the author's Lectures on Infectious Diseases in Childhood (page 231), oftener occur in children from four 448 DISEASES OF THE NERVOUS SYSTEM to seven years of age. The differential diagnosis between gas- tritis and meningitis cannot always be established in such in- stances upon a consideration of the symptoms alone ; and there- fore the etiological features, as well as the further course and the results of therapy, become of great importance. False men- ingitis (that is, gastritis) may be suspected in case the cerebral symptoms appear in a previously healthy child after some coarse faults in diet, or after a food to which the child is not entirely accustomed, as well as where we have to deal with a child who has been starved for a long time, or is convalescent from an acute febrile disease and the rapidly increasing appetite is incautiously satiated. On the contrary, gastritis is unfavorable if there are no causes therefor on the part of the diet. In any event doubt cannot last long, as the cerebral symptoms in gastritis disappear in a few days, increasing, however, in meningitis. Concerning the therai)y. a laxative may serve as a determi- nant, let it be calomel or something else. Cerebral symptoms due to meningitis will either remain unchanged after the bowels are moved, or changed very little ; while in the case of gastritis a rapid amelioration follows. Hence the rule that if the child manifests symptoms which resemble the first period of tuber- cular meningitis, then, first, one should be conservative as to the exast diagnosis, and, second, a laxative should be administered first of all. It may be said that in cases of gastritis no complete similarity to a beginning meningitis will be present, as some of the symptoms fail to show ; either the retarded pulse is absent, or apathy is not noticeable, and sometimes even vomiting does not occur. Again it is easier to recognize gastritis accompanied by men- ingeal symptoms when there are symptoms especially peculiar of gastritis, as jaundice, or, at least yelloivishncss of the conjunc- tiva, thickly-coated tongue, repulsive odor from the mouth, dis- tension and slight painfulness in the epigastrium upon pressure over the same and, finally, herpes labialis, which almost never occurs in cerebro-spinal meningitis, but very often where there is a foul stomach. Opposed to gastritis and in favor of meningitis there may be pointed out, in Henoch's opinion, irregular and at the same time retarded pulse, while an irregularity alone without retarda- DISEASES OF THE XERVOL'S SYSTEM ^i) tion is of no i;reat tliai^nostic nuIuc (in our ojjinion. even tlie sinniltaneous existence of l)oth these signs does not decide the question). Some autliors claim that the picture of a l)e|L;inning menin.^i- tis may be produced by intestinal zvoniis. In the case, for in- stance, of Saint Goglimelh, a boy aged nine years suddenly be- came sick with chills {38.5 degrees C. — 10 1.3 degrees F.) and repeated biliary vomiting; afterwards neck-contracture appeared, together with convergent strabismus, grinding of the teeth, out- crying and a half-comatose condition. After the ascarides (about one hundred) came away (in three days), the child promptly re- cove red '^ In literature such cases are described quite frequently, and there is nothing improbable in holding that irritation of the bowels by worms may cause a reflex action on the vasomotor system of the brain, thus producing circulatory disorders within the cranium. Much oftener one will see the elimination of worms (ascarides; at the onset of meningitis, but the anthelmintic treatment and effect does not influence in consequence the course of the brain disease. The same may also be said regarding dentition. The latter very often takes place during meningitis, but this process hardlv ever causes the complex of symptoms of acute hydrocephalus in the form of somnolence, retarded pulse, contracted neck, etc. It is true that in children disposed to convulsions dentition not very seldom is accompanied by eclampsia, but in such instances the picture of the disease does not resemble tubercular meningitis very clearly. The dependence of the cerebral symptoms upon intestinal worms or teeth is acknowdedged only when all symptoms rapidly disappear soon after the removal of the cause (expulsion of ascarides, appearance of the tooth). Such men of experience as Henoch and Cadet de Gassicourt, among others, admit the pos- sibility of cerebral hypenemia? simulating meningitis under the influence of dentition. If tubercular meningitis is the final stage of acute miliary tuberculosis, being in such case accompanied by considerable fever, at least in the beginning, then the question of typhoid arises. *Vratch," 1887, page 605. 450 DISEASES OF THE NERVOUS SYSTEM the more so inasmuch as typhoid also may be accompanied by various cerebral symptoms which simulate meningitis. Regarding the diagnosis of these typhoidal forms of meningitis from typhoid proper, we shall speak in the section on the latter, here men- tioning only that typical cases of tubercular meningitis dififer from typhoid very markedly in the temperature. Nervous symp- toms (somnolency, contracture of the neck, headache, etc.) in meningitis are accompanied by nearly normal temperature (usual- ly below 39 degrees C. — 102.2 degrees F.), while in typhoid fever symptoms manifesting a profound infection are coincident with considerable fever (about 40 degrees C. — 104 degrees F.). Of separate symptoms pro meningitis and contra typhoid we would indicate the retarded and irregular pulse (in typhoid the pulse is frequently also retarded, but it remains regular), re- tracted alxlomen, despite the constipation (in typhoid the abdomen is somewhat distended and diarrhoea is often present), paralyses of the facial and eye muscles, automatic movements of this or that limb, wide, non-reacting pupils, vacant stare. Great likeness to the initial period of meningitis may be presented by cases of otitis media. As even older children do not always complain of earache, this disease is therefor often overlooked. As in meningitis, there may be elevation of tem- perature, headache, vomiting, blunted consciousness, sudden cries, restlessness and even convulsions. In order not to fall into an error one must adhere to the rule of examining the ears of every child presenting symptoms of brain irritation. This is especially needful in a case where there is some ground for suspecting ear- afifection, for instance, when the patient has snuffles or sore- throat, or is sick with scarlet fever, measles, small-pox or pneu- monia. For diagnostic purposes Troltch recommends, in such cases, the resort to Politzer inflation of the ears. If the general condition improves considerably after that, then the existence of exudative otitis can scarcely be doubted. Valuable results may also be obtained from palpation of the ears (pain upon pressure over the tragus, or mastoid process, swollen glands just behind the external ear, or in the region of the parotid), and in older children examination of the sense of hearing. With the appear- ance of discharge from the ear all cerebral symptoms rapidly dis- appear. DISEASES OF THE NERVOUS SYSTEM 45 1 Finally, symptoms of meningitis may be caused by cerebral hyperemia, occurring in children under the influence of forced mental exercises, insolation, trauma and alcoholic drinks. Under the influence of this or that cause the child complains of headache, vomiting sets in, the temperature rises somewhat, somnolence ap- pears, as well as retardation and irregularity of the pulse and even contracture of the neck ; in a word, everything is as in the onset of meningitis, with only the difference that all these symp- toms rapidly disappear after a few days, and the child recovers. Similar cases also occur during some acute infectious diseases (pneumonia crouposa, influenza, typhoid, etc.). It is easy sometimes to mistake for tubercular meningitis cases of false meningitis of hysterical origin, to which we shall refer in discussing false meningitis. In the second period of meningitis, when all symptoms of brain compression (somnolence, paralytic and convulsive evi- dences, non-reacting pupils, etc.) are developed markedly, when, in a word, the existence of the cerebral disease is beyond doubt, then the diagnosis may be difficult only in regard to other cerebral lesions as : — (i) Acute hydrocephalus. (2) Meningitis arising in the vicinity of some new-growth, as solitary tubercles, gummata, sclerosis (Cadet de Gassicourt). (3) Acute purulent meningitis. (4) Anaemia and oedema of the brain. (5) Passive hypersemia and thrombosis of the sinuses. In all these cases the diagnosis is based not so much on separate symptoms, as on the history and the course. But before speaking about each process separately we offer a few words about lumbar puncture, recommended by Quincke, in 189 1, as a diagnostic and therapeutic remedy in some cerebral diseases. The technique of the operation consists in introducing the needle of a Pravatz' hypodermic syringe along the median line between the spinous processes of the third and fourth vertebrae, while, for the sake of greater convenience the patient should lie on the right side with the spine bent and the thighs abducted uptin the abdomen. The needle is introduced, in small children, two centi- meters deep, in older ones four centimeters. The needle thus enters the subarachnoidal space and the cerebro-spinal fluid im- 452 DISEASES OF THE NERVOUS SYSTEM niecliatelv begins to flow, which fluid may be accumulated, accord- ing to the case, in quantities of from five to sixty grams, with- out resorting to suction. [TremoHeres recommends for Quincke's hunbar puncture a platino-iricHum needle, on account of its superior flexibility. In children the jnmcture should be made in the middle line rather than laterally, between the fourth and fifth lumbar vertebrae. A properly carried out lumbar puncture ought always to yield some fluid. If only a small quantity is withdrawn, without aspiration, the patient being kept horizontal, no danger need be apprehended : at the worst, some \rdm in one or the other thigh, if a nerve be touched during the operation, and slight headache, may be anticipated. Lumbar puncture is sustained better liy patients sufl'ering from tubercular meningitis than by others, and its two-fold action in lowering the intra-spinal pressure, and diminishing the amount of toxine in the nervous system, often has at least a palliative efifect*.— K.\Kr.K | The fluid is examined microscopically for diag- nostic purposes and eventually decisive results may be obtained. For instance, a great quantity of pus corpuscles denote purulent meningitis ; in tubercular meningitis one sometimes succeeds in finding tubercle bacilli ; in cerebro-spinal meningitis the intracel- lular diplococcus (memingococcus intracellularis s. diplococcus intracellularis meningitis, of Weichselbaum ) is often found : in cases of meningitis developing in typhoid or in pneumonia the typhoid bacillus or pneumococcus has been observed, etc. As to the therapeutic importance of lumbar punction this is inconsider- able. In those cases where the communication between the cavi- ties of the ventricles and the subarachnoid space of the spine is not impaired, then lumbar puncture, as a palliative remedy, may improve the headache and thus give rest to the patient for a few hours. (i)SiMPLE ACUTE HYDROCEPHALUS is characterized by the same symptoms, and in many cases by the same course, as in the tubercular form. The single symptom which is especially peculiar to tubercular meningitis, namely, the presence of tubercles on the fundus of the eye, is more of theoretical interest, as it occurs very rarelv. ^Gazette des Hospitaux, Nov. "th and Nov. loth (Quoted from The Scottish Med. and Surg. Journal, Febr., 1904, p. 165). DISEASES OF THE NERVOUS SYSTEM 453 A simple serous incningitis may be supposed ouly if the cliil.l is under two years of age ; if previously to the meningitis he was entirely well, did not manifest symptoms of the precursory period . if no information concerning tuberculosis is given in the histor\- and, finally, if the disease ends with complete recovery. In some cases the diagnosis of non-tubercular acute hvdro- cephalus is assisted by peculiarities of its course. As a matter of fact, children are met with in seemingly perfect health, with gornl nutrition, and without hereditary disposition to tuberculosis, who are prone to cerebral congestion. Beginning with the fourth to the sixth month of life, with more or less prolonged intervals, they are attacked by eclamptic convulsions and at the same time with vomiting and fever. Such fits are repeated once or twice a month, but each time pass away leaving no trace, until, finally, after some such attack, a definite meningitis supervenes. It is especially easy to make a diagnosis of simple hydrocephalus in cases of protracted course, when the meningitis has continued longer than one month. Sometimes a slowly-developing hydro- cephalus becomes a chronic hydrocephalus '" rnds with complete recovery. (2) Circumscribed meningitis in die area of a new growth has no peculiarities in its course. Cadet de Gassicourt includes in this class all. cases of meningitis ending with recovery, that is. the diagnosis is made, so to say, post-date. Cadet de Gassi- court is in doubt regarding the existence of an idiopathic non- tubercular meningitis, that is, of a simple acute hydrocephalus which also sometimes ends with recovery. (3) For the diagnosis of acute purulent meningitis see the next section. (4) Under the name of aiuciiiia of the brain, or iivdro- cephaloid, we imderstand a symptom-complex which charat:- terizes a cerebral lesion in children exhausted by severe forms of diarrhoea. The anatomical features of this lesion may be re- ferred to the arteries becoming empt}- and the over-filling of the veins because of the weak activity of the heart ; to the oedema of the brain ; and partly to dropsy of the ventricles, due to the disturbed blood-circulation in the brain, and to the atrophy of the brain because of exhaustion (hydrocephalus ex vacuo). 454 DISEASES OF THE NERVOUS SYSTEM Hydrocephaloid is met with in both acute and subacute forms, differing- from each other by the rapidity of development of symp- toms. The acute form pecuHar to nurshngs appears as a sequel to infantile cholera, while the subacute form occurs in children of about two years and older as the result of a chronic diarrhoea. In the former case, several days after the persistent vomit- ing and diarrhoea, there sets in first of all, symptoms of irritation of the brain (restlessness, sleeplessness, constant rubbing of the head upon the pillow), collapse quickly comes on, and simultan- eously there are symptoms of depression of the brain, denoted by a verv small and frequent pulse, sunken eyes and depressed fon- tanelle. The child becomes somnolent and frequently exhibits local (contracture of the neck and the limbs) or general con- vulsions and. finally, dies in somnolency with symptoms of com- plete exhaustion. The whole disease lasts from five to seven days. The diagnosis from meningitis is based upon the history (the disease started with vomiting and abundant watery diar- rhoea), appearances of collapse (depressed fontanelle, general ex- haustion, subnormal temperature) and the velocity of the course. The subacute form of hydrocephaloid develops gradually, being, therefore, more like tubercular meningitis than the preced- ing form. The child suffers from diarrhoea for several weeks, he has become very thin, so that the skin may everywhere be pinched into folds, and the feet and the eye-lids often show ccdeiiiatous szuelling; he becomes irritable, suffers from sleeplessness, shud- ders upon hearing a marked noise ; in general he represents symp- toms of irritation of the brain. Sometimes even vomiting appears, but the pulse becomes neither retarded nor irregular even in the case where a few days later drowsiness appears, and, still later, a complete somnolency sets in with wide, faintly reacting pupils, but all the time the pulse remains small and frequent. In the period of somnolency there may be contracture of the neck or general convulsions; Trousseau spots, etc. ; in ,a word, a picture is obtained most resembling the late period of tubercular meningi- tis. Nevertheless, the diagnosis is, in the great majority of cases, not difficult if only it is known from the history that the child suffered from chronic diarrhoea, which caused severe wasting. Disi-:.\sE.s OF Till-: .\i:r\()L's system 455 ( )f llio various syniplonis whicli may Ik- of avail tor the (liti'cr- ential dias^nosis of hydrocephaloid from aculu hydroci-'plialus, the followiiiii' should he hornc iu mind: — Flydrocrplialoid. The temperature is below the normal (95-9 to 97.7 degrees F.). The pulse is always small, fre- quent and feeble, but regular. I'oiiiitiiig often absent. .Lute hydrocepJmUis. ihe temperature is subfebrile (100 to 100.7 degrees F.), or feb- rile. At the onset retarded, then ac- celerated, but in both cases irregu- lar; liefore death very frequent, llinad-likc. Always in the beginning of the disease and usua'ly repeated. Diarrha-a. which had existed be- fore the disease, lasts also in the period of development of cerebral symptoms and stops only shortly before death. The picture of general exhaus- tion not infrequently is accompa- nied by ccdcnia of the feet and face (Widerhofer ). The foiitanellc sinks. Absence of paralyses of facial muscles. Constipation almost always from the first days of the appearance of the meningeal symptoms; if there had been diarrhoea then this usual- ly stops. Qidema is absent even when there is severe wasting. The fontanellc is protruding and tense. Paralyses occur not infre(|uenily. (5) P.vssiVE HYPER.EMiA OF THE r.R.MX. accompanied by grave cerehral symptoms, most often occurs during whooping- cough in small children. An interesting case of such a kind is given by Henoch'''. Under the influence of violent attacks of whooping-cough in a child eclamptic fits began to appear, and then gradually other symptoms also developed in tlie form of strabismus, distant l(X>k, sucking movements with the lips, somnolence, contracture of the neck and extremities. After twenty ilavs death in a soporous condition. I'^or the completeness of similarity fever ( 38.4 to 39.2 degrees C. — loi.i to 102.5 degrees F.) due t<~> broncho-pneumonia, appeared eleven days before the fatal event. Henoch diagnosed tubercular meningitis and made a mistake. The ])ost mortem *Text-book, third German edition, page .425. 456 DISEASES OF THE XERVOUS SYSTEM showed only a marked oedematous hypersemia of the brain and its membranes caused by whooping-cough paroxysms and bron- cho-pneuinonia. Such a cause of cerebral s}mptoms may then only be sus- pected if accompanied by some other signs of weakened heart activity, as cyanosis of the face, coolness and, ])erhaps, cfidema of the extremities, and extremely small and frc(|uent |)ulse. In such patients retarded and irrci^itlar pulse is never present, as well as the irregular respiration with deep sighings ; on the contrary the ]:)reathing is ahd'ays slialloic and much acclerated (alx)ut 80 to 100 per minute). The same clinical picture may be obtained even without whooping-cough, provided there exist some other causes for the venous stasis in the brain, for instance, in the case of thrombosis of the vessels, so that one must be very careful with the diagnosis of tubercular meningitis in those cases where we have to do with a cyanotic patient or when the patient shows other signs of heart-failure, as well as in cases where there is some reason to suppose the possibility of development of thrombosis of the SINUSES. The latter process most often complicates otites associated with carious destruction of the temporal bone; in other cases the cause of thrombosis is blood-stagnation in the veins of the head, for instance, compression of the upper vena cava by en- larged glands, or weakened heart-activity under the influence of (liarrhcea and other exhausting diseases, among these also acute febrile processes. In some cases the thrombosis of the sinuses may be recog- nized during life-time, namely, if associated with different cere- bral symptoms of diffuse affection of the brain (vomiting, head- ache, somnolence, strabismus, contracture of the neck) there also appear some symptoms which especially point toward thrombosis of this or that sinus; as in case of impermeability of the trans- verse sinus a solid, oedematous swelling behind the ear (for the development of this symptom the thrombosis must spread to the post auricular veins) and the ischccmia of the external' jugular vein on the diseased side. (These veins are in children not gen- erally accessible to palpation, therefore, this sign hardly ever oc- curs in pediatric practice). In the thrombosis of the cavernous DISEASES OF THE NERVOUS SYSTEM 457 rsinus there may be a slis^ht protrusion of the eye-ball (due to stasis in the ()i)hthalmic vein), (edema of the e\e-lids and some- times of the entire half of the faee. In case the superior longi- tudinal sinus is closed then we have cyanosis of the face, dilata- tion of the veins extending- from the parietal to the temporal region and nose-bleed. Unfortunately, these characteristic symp- toms of thrombosis are far from being evident in all cases, there- fore the diagnosis often remains a mere supposition. Purulent inflammaiion of the pia mater of the brain .(mciii)ii::itis simples s. piintlciitaj. This morbid form differs from tuberctdar meningitis not so much by the (juality of the ;symptoms, as by their grouping and rapidity of course, as well as by the aetiology, which has been already spoken of. It is difficult to point out some symptoms of tubercular n>eningitis which would not be met with also in meningitis simplex. In distinction from tubercular meningitis characterized by a slow course and gradual •develo])ment of symptoms of brain pressure, purulent meningitis starts at once, that is, without any premonition, and very acutely, with chills, severe headache, vomiting and rapid elevation of temperature up to 40 degrees C. (104 degrees F.). In tubercular meningitis the child during the first week does not give the im- pression of being in a dangerous condition ; he only complains of a moderate headache and dizziness and, being in the state of apathy, but in complete consciousness, lies in bed entirely quiet : while in the purulent form of meningitis even at the end of the first twenty-four hours or during the second d^y, the patient is either very restless (throwing himself about in the bed), or is delirious ( jum|)s up and usually manifests symptoms of im- paired psychical condition and blunted consciousness). He pro- duces the i)}ipressioii of serious illness from the -rery first. In about three or four days the consciousness disappears entirely. local (in the face) or general convulsions and somnolence follow and toward the end of the week, or even earlier, death results. It is the rapidity of development of the symptoms and the ■quick occurrence of the fatal termination that constitutes the main difference between purulent meningitis and the tubercular form. xA.s to separate symptoms these, as alread\ stated, do not fur- nish any positive support in the diagnosis. 458 DISEASES OF THE NERVOUS SYSTEM Headache in the purulent form is from the very first of greater severity than in the tubercular inflammation ; z'oniiting and constipation are in both cases nearly the same, but the re- tracted abdomen is more pronounced in the tubercular form (per- haps, because the latter is of longer duration, as during the first days here also the abdomen is not much retracted). Symptoms of brain pressure in the form of a retarded and irregular pulse and wide, non-reacting pupils may be completely absent in simple meningitis (during the first days the pulse is always accelerated proportionally to the temperature, and full, while the pupils are narrowed) namely, in those cases where the choroidal plexuses are not involved in the inflammation and thus distension of the ventricles is absent. ( )n the contrary, there is also noted, in simple meningitis, a retarded and irregular jnilsc. but only because of fever not of such a degree. The involvement of the facial and eye nerves arising at the base of the brain, is more pronounced and of greater constancy in basilar meningitis than during inflammation of the membranes of the convexity of the brain. Fever in tubercular meningitis is moderate (about 38.5 de- grees C. — 101.3 degrees F.), and may be entirely absent in the period of highest development of the disease ; while in purulent meningitis fever from the very first is high (about 40 degrees C, — 104 degrees F.), remaining near this point until the very end- In general one can say that in their typical manifestations both these fomis dififer very distinctly from each other, but both are sometimes irregular, and then the differential diagnosis may be surrounded with great difficulties, especially if the history is deficient and aetiological elements absent. For instance, tuber- cular meningitis assumes a very rapid course, ending with death in a few days, if it develops in a child during the last stage of consumption (Barthez and Rilliet) or if the eruption of tubercles be accompanied by purulent inflammation not only of the base of the brain, but also of the convexity of the hemispheres. Then the correct estimation of the symptoms may be effected only in. connection with the history and the known causative conditions. On the other hand a simple purulent meningitis sometimes develops quite slowly, and spreading to the base of the brain (and DISEASES OF THE NERVOUS SYSTEM 459 sometimes even to the ventricles) gives the SNinptonis ut acute hydrocephalus. Such a course is frequently observed in connec- tion with chronic otitis with caries of the bone or even without the destruction of the latter. In such cases meningitis may be pre- ceded by more or less grave cerebral symptoms which depend upon disorders of circulation within the cranium as a result of thrombosis of the sinuses, or inflammation of the dura mater or, finally, upon abscess formation in the brain. In these conditions the cerebral disease may become protracted for a few weeks, re- maining nevertheless without an exact diagnosis. The aetiology here decides but little, because we have to deal with exhausted and scrofulous children, so that it is impossible to determine whether they were taken with meningitis under the influence of a tuberculous taint, or from some local disorder on the part of the ear. Diseases with which acute purulent meningitis may be con- founded are very numerous and hence diagnostic errors occur often. As has probably happened with many other physicians. I have often made mistakes by suspecting meningitis where it was absent. The reasons leading to a wrong diagnosis may be present in the course of all acute febrile diseases starting with severe fever, vomiting and general convulsions, especially those diseases in which the convulsions are repeated, and are accompanied by half-consciousness, delirium, or sopor, this being mosth' char- acteristic of grave scarlet fever, small-pox and inflammation of the lung apices. Touching the diagnosis of such cases I have spoken in the articles on eclampsia and pneumonia. Here I will but add the following : — All these three infectious diseases become likened to meningitis only in the severest instances, in which there is a very high initial temperature, rather little peculiar of meningitis, so that if on the first or the second day of the disease one finds a rectal temperature higher than 40.5 degrees C. ( 104.9 degrees F.), then this fact is strongly against meningitis. Of the above-mentioned diseases confounding a diagnosis scarlet fever first of all becomes defined. The early appearance of the rash causes the possible doubt of the physician to last not longer than twenty-four hours. In small-pox the rash does not appear until the third day, and if there are no data in the history 460 DISEASES OF THE NERVOUS SYSTEM concerning- the possibility of having- contracted sniall-pox, and if there is no prodromal petechial rash, then the diagnosis may be under doubt for three days. Signs of vaccination almost certainly exclude the severe form. Pneumonia of the summits of the lungs may not become clear until still later, for instance in from seven to nine days. Against meningitis and for pneumonia are the following data: — The absence of the cause of meningitis of the convexity of the hemispheres ; the onset of the disease with snuffles (in pneumonia developing from la grippe) ; very high tempera- tures (in jineumonia not infrequently 41 to 41.5 degrees or even 42 degrees C. — 105.8 to 106.7 degrees F., or even 107.6 degrees F.) ; absence of jjaralyses on the i^art of the nerves of the face and the eve, as well as of contracture of the neck ( these symptoms may also appear during pneumonia occurring with repeated con- vulsions, but in such connection they are very uncommon, while thev are fre(|uent in meningitis). The course of acute purulent meningitis is marked by progressiveness, and, if convulsions have alreadv set in. then death follows. The patient is worse each day, while in pneumonia the general condition for several days, despite the convulsions, remains in statu quo, and then, accord- ing to the decline of the inllammation, the cerebral symptoms graduallv or rajjidly disappear. The accelerated breathing is of no particular diagnostic value, as it is also observed during acute meningitis in small children. Convulsive forms of pneumonia occur almost exclusively in small children under two years of age. In other febrile diseases beginning w^ith convulsions dou!)t cannot obtain longer than one day, because eclampsia usually is not repeated, the consciousness clears very soon and thus there is no further resemblance to meningitis. Regarding headache one should bear in mind that if the same depends on high temperature it stops with the appearance of delirium and loss of consciousness, while in acute meningitis the child grasps at his head or screams even in the period of uncon- sciousness. Afebrile eclampsia, even if repeated and therefore accom- panied by sopor or some other cerebral symptoms, cannot be con- fused with acute meningitis, inasmuch as it is not accompanied by elevated temperature. DISEASES OF THE XER\'()US SYSIEM 4^) [ Of cerebral diseases the greatest likeness to acute purulent meningitis may be represented by some cases of epidemic cereliro- spinal meningitis (about which see below) and cases of Striim- pell's acute encephalitis, which has been spoken of in the section on spastic hemiplegia. During the first days Striimpell's encephali- tis can hardly be recognized, but after a few days, when all cere- bral symptoms disappear, and only hemiplegia remains, then the diagnosis is easily distinguished. A complete similarity to meningitis may be represented by nrccnua, that is, wherein the patient had nephritis previous to the appearance of the cerebral symptoms (headache, vomiting, general convulsions, loss of consciousness or delirium) ; but even if the history be unknown, the question may be cleared away by the examination of the urine. Finally, one should remember iiitlaiiiiiiatioii of the labyrinth which is also accompanied by symptoms of meningitis. This disease begins, while the patient is in complete health, with fever and vomiting, then follow other cerebral symptoms in the form of blunted consciousness, contracture of the neck, delirium and somnolency. After a few days the patient recovers, but remains deaf, and the gait is unsteady for several weeks. The peculiarity of such cases consists in the rapid termina- tion in convalescence and in the subsequent deafness of both ears. The anatomical basis of this disease is not yet quite definite ; some authorities, as, for instance, Troltch* hold it more probable that we do not have in these instances labyrinthine disease, but a circumscribed inflammation of the cerebral membranes, in the area of the exit of both auditory nerves, that is, of the floor of the fourth ventricle. It is very difficult, sometimes impossible, to recognize men- ingitis developing during some acute febrile disease which, by itself, because of the severe febrile condition, is accompanied by cerebral symptoms. The perplexity in the diagnosis is ex- plained by the fact that, as Huguenin** testifies, "We do ncit know of such a symptom which is constantly present in all cases and which does not occur in the same manner without men- ing-itis." *Gerhardt's Haudbuch, page 189. **Zii'insscii's Haudbuch. page 220 (Russian edition 462 DISEASES OF THE NERVOUS SYSTEM Of comparatively greater significance in the diagnosis of meningitis complicating an acute disease are : the quick onset of grave delirium, considerable contracture of the neck, paralyses of the eye-muscles and venous stasis in the retina. Perhaps in such cases as a sure criterion there will be Kernig's sign, con- sisting in that in meningitis the change of the recumbent posture to the sitting one is immediately accompanied by contracture of the calf-muscles. [Kernig's sign, consisting in it being impossible to obtain complete extension of the legs when the patient is in a sitting posture, was described by Kernig, of St. Petersburg, in the year 1884.* This condition was noted by the author in ojic case of purulent meningitis, complicated by nephritis, in six chronic meningites, in one case of tubercular meningitis and in thirteen cases of cerebro-spinal meningitis. Netter had 23 cases of meningitis ; twelve of cerebro-spinal meningitis, eight of tuber- cular, three of a mixed form, and in all these forms he observed the presence of Kernig's sign.** This sign thus seems to prove the presence of meningitis in any given case of involvement of the spinal membranes, although it has been noted in other morbid forms, as for instance, sciatica. Regarding the nature of this sign, some authors, as Bull,**'' Cippolino, Maragliano,**** explain it as an exaggeration of the normal phenomenon, while Friis views it as an irritation of the nerves coming from cauda equina and by their being compressed by the exudate. — Earle.] Epidemic cerebro-spinal meningitis. Meningitis cerebro- spinalis epidemica more resembles in its symptoms the tubercular form of meningitis. In typical cases it begins at once without any premonitory signs, with considerable fever, vomiting and severe headache ; soon followed by blunted consciousness, de- lirium, restlessness, then convulsions, sopor and, toward the end of the week, death. The clinical determination of these cases from meningitis purulenta simplex follows from the anatomical nature of the *Berl. Klin. Woch., 29 December, 1884. **La Semaine Medicalc, 1898, pp. 281-284. ***Berl. Klin. Wochenschr. Novemb. 28. 1885. ****Quoted from Piery; Lyon Medicale, April, 1903. DISEASES OF THE NERVOUS SYSTEM 463 lesion. This difference consists in that the symptoms of affec- tion of the cerebral meninges are compHcated by those on the part of the spinal cord in the form of early occurring contracture of the occipital and head muscles (usually from the second up to the fifth day), severe painfulness in the spine upon each move- ment and upon pressure over the spinous processes, especially in the lumbar and cervical portions of the vertebral column, de- cidedly developed hyperaesthesia of the skin (especially of the legs) and pains in the limbs (involvement of the posterior roots in the inflammation). It is true that contracture of the neck and hyperaesthesia of the skin are frequently met with also during other forms of meningitis (purulent and tubercular), but then not to such a degree and without the painfulness in the spine. As a characteristic of the disease in question may be noted an eruption of herpes zoster and attention is directed to the articula- tions, owing to the concurrence of acute synovitis. Although both these symptoms are unnecessary to the confirmation of cerebro- spinal meningitis, nevertheless they occur very often. Cerebro-spinal meningitis also differs from a common one by the peculiarities of its course. Only in severe cases of the latter does death set in after a few days from a single symptom- group onset. Usually the course of epidemic meningitis differs by great irregularity on the part of the fever, as well as on that of all other symptoms ; the disease appears to be liable to changes by way of amelioration and then new aggravations (wave-like course). After a few days from the beginning of the disease the temperature commences to fall with the simultaneous sub- sidence of the nervous symptoms ; then after a few days more an apparent relapse occurs, and thus the case can be protracted for a few weeks and even months. Recovery finally sometimes happens but it is rarely complete because there usually remain some paralytic sequences in the form, for instance, of deafness, blindness, mental derangement and paralyses of the limbs. In some cases the wave-like course of meningitis assumes a purely intermittent character simulating intermittens quotidiana (see malarial fever) ; such an intermitting course may be observed from the very first day of the disease. I had the opportunit\- of watching such a form in a ten-year-old child who became ill with vomiting and headache while in seemingly perfect health ; 464 DISEASES OF THE NERVOUS SYSTEM after a few hours the headache ceased, but on the following day it reappeared, commencing at four o'clock in the morning, accom- panied by violent restlessness and blunted consciousness. Then from five o'clock in the evening to midnight all symptoms disap- peared. Then a new restlessness came on with loss of conscious- ness and at three o'clock death resulted. Like all other epidemic diseases cerebro-spinal meningitis- exhibits great variations regarding the intensity of the disease. There exist all possible transitory forms between the most intense cases starting at once with convulsions and sopor and terminating with death in a few hours (meningitis sidcrans) and the mildest,, so-called atortive cases, which are characterized by headache, slight febrile condition and insignificant contracture of the neck. The diagnosis of these extreme forms, that is, the severest and the mildest cases, is possible only during the existence of an epidemic. I will mention two more symptoms which, while not very necessary or indicative of meningitis, may yet be of some aid when present. I refer to ( i ) the roseolae which usually appear upon the trunk, giving rise therefore to a suspicion of typhoid, especially if the spleen be simultaneously enlarged; and, (2) inflammation of the joints, which suggest acute rheumatism. In both events the diagnosis of meningitis may be made from the fact of the early appearance of the cerebral symptoms and their severe development. I point out, by the way, that in one of my cases of cerebro-spinal meningitis in a one-year-old child serous synovitis of both knee joints, with contracture of the legs, appeared from the first days of the disease (the fourth day) and lasted during the whole course of meningitis (many weeks), and some time after recovery ; the contracture of the legs required massage during a whole month after that. That cerebro-spinal or tubercular meningitis may be con- founded with cervical rheumatism is proven, for instance, by the- following case of Cadet de Gassicourt* : — A boy, four years of age, whose brother died from tubercular meningitis, took suddenly sick with repeated vomiting three days previous to entrance to the hospital; soon after there was con- *Arch. f. Kindcrkr. X B., page 397. DISEASES OF THE NERVOUS SYSTEM 4t')5 stipation, severe headache, restlessness, cry from pain. The ex- amination showed dehrium, apathy, sucking movements and j^rind- ing of the teeth ; the pulse, one hundred, irregular ; sighing res])ira- tion ; the temperature 39 degrees C. (102.2 degrees F.). Further, contracture of the neck and hyperaesthesia of the skin of the face made themselves evident ; the pupils were dilated, unequally ; the abdomen not retracted. The diagnosis was meningitis tuber- culosa (in view of the foudroyant onset, severe delirium, marked contracture of the neck, small retarded pulse and hypersesthesia). A more correct diagnosis, in my opinion, would have been cerebro- spinal meningitis. In the following two days there was increase of the contracture of the neck ; on the eighth day the general condition was without change, but Trousseau's cerebral spots appeared ; the patient emitted loud cries when he was seated in the bed, his head remained immovable ; upon examination of the neck a severe painfulness was found in the area of the fourth and fifth vertebrae; the head could be easily turned, but bending of it was impossible. The diagntisis then made was : rheumatismus cervi- calis. The further course in Cadet's opinion confirmed this diag- nosis, because toward the thirteenth day all symptoms disappear- ed, and in a few days the patient was discharged from the hospital in a healthy condition. [Besides the two above-mentioned valual)le methods of the diagnosis of meningitis there have lately been proposed some other procedures, of which we shall name only that of Widal, Sicard and Ravault ("c}to-diagnosis") and Uard's methods ("haemolysis"). The principle of the former consists in the fol- lowing : The normal cerebro-spinal fluid does not contain any cells, or if so a very small number (one or two in the field of the microscope) ; however, in cases of meningitis the cerebro- spinal fluid then contains an increased number of elements — lyin/^hocytcs. The investigators mentioned give an elaborate technique of examination of the spinal fluid for this purpose*, but here we quote the method employed by Hastings in Dana's cases ( New York) described in the Medical Record. January 21,, 1904, p. 124: "The spinal fluid is collected directly into sterilized centrifuge tubes to avoid cell contamination and *See Widal. Sicard. et Ravault: "A propos de Cytodiagnostic," Rr: uc Neurolgiquc. No. 6. 1903. 466 DISEASES OF THE NERVOUS SYSTEM ])hilic and oiIut i^ranulations. dryiiii;', fixing, and stainin<(^ as reconmK'ndcd by W'idal, arc necessary. Specimens drieil in the air and stained with Jenner's, Leishnian's, or Wright's stain g-ive i^ood results, but since the cytolof^ic formuhe are based u])on polynuclear. mononuclear, and epithelioid types of cells, the study of such preparations is of little value. While all types of normal blood cells, excepting the mast cell, have been found in s])inal fluid, the value of the differential count lies in the detc-nuinalion of the relative proportions of polynuclear and mononuclear ele- ments — thedetenuination of a polynucleosis or of a mononucleosis — and a division of the mononuclear forms into 'small' and 'large' is unnecessary." The second method, that of Bard "hsemolytic power of the cerebro-spinal fluid." is based on the power of the cerebro-spinal fluid under some conditions (abnormal) to dissolve red-blond corpuscles. The spinal fluid of the patient is diluted with distilled water in various quantities then mixed with one droj) of blood, shaken and centrifugated, when one should notice if the superja- cent fluid be colored or colorless : in the former case we have haemolysis, in the latter not. The degree of the hsemolytic power is judged from the amount of water added to the cerebro-spinal fluid to dissolve the drop of blood — the less water added the higher is the hemolytic power of the spinal fluid. This power is increased in cases of meningitis (Bard)*. Of other new methods of diagnosing meningitis and deter- mining the difl^erent forms thereof we refer the reader to special articles or to the general review of this subject made by Tre- molieres in the Gazette des Hopitanx, November 7th and Xovem- ber loth. 1903**. — Earlk. J Fal.se meningitis. L nder the name of false meningitis there are described in literature cases in which cerebral s\ niptoms simulating meningitis appear, while in reality there is no men- ingitis. The patient either soon recovers, or. if he dies, the necropsy shows the cerebral meninges to be entirel\ normal. In their origin and causes cases of false meningitis are very diverse and may be classified in three groups. *L. Bard: Des variations palholcigiqucs du pouvoir Iieiimlytiqiu' du liquide cephalorachidien (La Scmaiiic Med.. Jan. 14. 1903. pj). 9-IJ). **Sce an extensive abstract of this review in The Scottisli Mcdiriil and Surgical Jounial. Feljruary, 1904. pp. 164-167; also 167, 168. 468 DISEASES OF THE NERVOUS SYSTEM In the first we include cases of false meningitis arising vmder the influence of acute infcctioits diseases. The first place in this group belongs, undoubtedly, to croupous pneumonia in small children. It is a well-established fact that pneumoniae of the pul- monary summits are those which are most often complicated by cerebral symptoms, so that such symptoms are even described under the name of cerebral pneumoniae. They occur with vomit- ing, high temperature and repeated convulsions very like acute purulent meningitis, but usually terminating with rapid recov- ery. In the second place, among the acute febrile diseases, existing sometimes under the mask of meningitis, I put la grippe. Many opportunities have come to me of seeing cases of influenza which began with vomiting and headache, and which after that con- tinued with moderate fever, a])athy and constipation, in a word, simulating tubercular meningitis. In other instances influenza resembles acute meningitis. The illness begins either immediately with the attack of general con- vulsions, or with violent fever, headache and vomiting, followed by apathv, blunted consciousness, contracture of the neck, even strabismus, unecjual pupils, grinding of the teeth, general h3'per- sesthesia, retardation of the pulse, uneven breathing ; in a word, as a complete ])icture of an undoubted meningitis. But after a few days all symptoms disappear, and the patient rapidly re- covers. The diagnosis of these cases, before the period of im- provement, is hardly possible, even where the cerebral symptoms appear during a positive influenza, because it is beyond doubt that the latter may be complicated by a real meningitis of purulent or serous character. To the second group we refer cases of false meningitis due to some poisoning. Poisoning in childhood usually occurs acci- dentally, from immoderate doses of some drugs, as, for instance, opium and other narcotics, or remedies producing convulsions to which, among others, santonin, for instance, belongs. It is of practical interest that, among drugs which may give rise to the evidences of false meningitis, wine also be included. Only re- cently I observed the following very interesting case : — I had under care a thirteen-month-old child that became sick in April vvith fever and weakness. He was cured by wine, (port-wine) DISEASES OF THE NERVOUS SYSTEM 46*) which was ^iven every two hours, a tcaspoonful at a time. Soon afterwards ihc jiatient vomited two or ihrrc times, lie became lan.5>-uid and somnolent, so that the dose of wine was increased, and, with the onset of somnolency, I was called. The beginning of the disease with vomiting, followed by somnolency while the fever was moderate, without cough or any other local symptoms, all strongly pointed toward acute hydrocephalus. But the indica- tions, nevertheless, were not entirely complete; there were absent ■contracture of the neck, retarded pulse, deep sighing. T onlv told the mother that the child had some cerebral symptoms, but as to the further course I could not say. The treatment consisted in suspending the wine and administering valerian dro])s. The result was brilliant. Even upon the following day the child was -clamorous and restless, and after one or two days more entirely well. The diagnosis of such cases is not difificult if there be a minute •history ; but much more perplexity may arise in some forms of auto- intoxication of the organism, the most important form of which is unemia. This disease, in its convulsive stage, may completely simulate acute meningitis. Here the physician will not forget to -examine the urine. To the third group belong cases of false meningitis as a manifestation of some neurosis. No doubt some of these cases nia}" be ascribed to reflex influences, others are purely hysteri- cal. To reflex false meningitis belong cases of intestinal origin, of which we spoke in the section on tubercular meningitis. It is still a question whether these cases are of reflex origin ; it may be more reasonable to suppose auto-intoxication of the organism be- cause of absorption of noxious products from the towels. As a typical example of hysterical false meningitis the fol- lowing case is mentioned : — A girl, scrofulous in childhood, lost an older sister from meningitis. Having entered school she became languid and melancholy and two days later had a headache of two days" dura- tion, becoming confined to the bed. She could hardly sit up in bed and could not stand up at all because of dizziness. She was persistently constipated, and the pulse was retarded and not en- tirelv regular. The diagnosis of tubercular meningitis intruded 470 DISEASES OF THE NERVOUS SYSTEM itself, so to say, as in favor thereof we had the history (death of the sister from meningitis, scrofulosis in childhood), the exist- ence of a period of precursors and the initial vomiting, and finally the presence of such characteristic meningeal symptoms as head- ache, dizziness, weakness, apathy, retarded pulse and constipation. However, upon demonstrating this case to the students during a lecture, I could not be satisfied with the diagnosis of tubercular meningitis, because this was contradicted by the somewhat ex- tended and tense abdomen, as well as by the duration of the disease (since the time of vomiting there had already elapsed nineteen days), and neither contracture of the neck, nor somnolency, nor paralyses on the part of the eyes or in the distribution of other nerves passing over the base of the brain were present. It was also impossible to think of a reflex (or toxsemic) pseudo-meningitis due to constijiation, Ijecause, despite the laxa- tive which had been administered at the very beginning of the disease and the strict diet, the condition became much protracted. At the end of the lecture, and in the presence of the patient, I said that one should not become altogether discouraged in such instances, it being nu>st j^robable that in a week the patient would be able to walk. The treatment was directed towards the relief of the con- stipation, consisting of daily injections and a glass of Carlsbad water divided into three doses. The result of the treatment seemed to have confirmed the intestinal origin of the disease^ because one day later the patient began to stand up, and on the following day to walk. I think, however, that the relation here was, as is generally found in cases of so-called reflex paralyses,, not so simple. If, for instance, the paralysis of the legs disap- pears after the operation of phimosis or expulsion of worms, then it is believed that the phimosis, or the worms, caused the paraly- sis ; but there is another explanation. The intestinal worms and phimosis occur quite often, while paralyses, in connection with these diseases, are very rare ; it follows, therefore, that besides these causes a soil is needed also, that is, a j^articular condition of the nervous system, the essence of which is unknown. We compare such a nervous condition with that which we see in hysteria and learn that, perhaps not so much the intestinal worms or the phimosis, are the real causes of the paralyses, as hysteria,. DISEASES OF THE NERVOUS SYSTEM 47 1 and, since hxslirical children easily yield to suggestion, it is obvious then that expulsion of the worms or a phimosis operati<.>n, act not alone, that is, not by the way of removing the cause, but through the intluence of suggestion and auto-suggestion. As to our case, I l>elieve that we had the so-called pseudo-meningitis hysterica, which had developed under the iuHuence of some acci- dental stomach trouble and that the recovery took place, not be- cause of the Carlsbad, but through the aid of suggestion. The girl was taken before the clinic, which was altogether a strange experience for her, and was the subject of a lecture, dur- ing which she heard that she would be given some water, and daily enemata, and that she would be able to walk in a few days. As hysterical children easily yield to suggestion, so this patient responded to the circumstances, arose upon her feet and started to walk. The absence of the hysterical stigmata, as anaesthesia or hyperassthesia, of course, cannot exclude hysteria, because these stigmata are not constant ; the heredity of the patient because of lack of family history was not definite, but that the patient was "nervous," could be seen from the fact that her disposition be- came changed from the moment of her entrance into the school. Besides this the aunt, who came to take the patient from the hos- pital, told us that on the day previous to the vomiting something Strange happened to the girl — she was very excited and even suddenly began to sing in the school-room during the lesson. Such an eccentricity scarcely indicates a normal condition of the nervous system. In a word, my opinion as to this case is the following: — This was a case of hysterical astasia-abasia which, because of occasional vomiting and some quite common symptoms of hysteria, as constipation, retarded pulse and headache, appeared as tubercular meningitis, that is, the condition described under the name of pseudo-meningitis hysterica. A still more striking case was described by ( ^llivier"^'. A six-year-old girl, having a tuberculous father and being of a very weak constitution, suffered for eight days with constant head- ache. consti])ation and somnolency. ( )ne day she was found by Ollivier in the ])osture of "k' chien a fusil" : he noted iihotoplK)l)ia, "Rcz'iic )iu-iis. ih's maladies dc I'mf. 1891. pag^o 573. 472 DISl'lASl'lS 01-- Tllli NERVOUS SYSTEM cutaneous hypersesthesia, grinding of the teeth, retracted abdomen,, retarded and irregular pulse, dilated pupils, nystagmus ; later on- there appeared the hydrocephalic cry, convulsive movements in the limbs, delirium and finally somnolency. Some days after that gradual improvement appeared, and after six weeks the girl went away to the country. Ollivier looked upon this case as an example^ of recovery from tubercular meningitis ; but when later on the- picture of hysteria developed in the girl, (causeless laughing or crying, night terror, intercostal neuralgic pains, pain in the spine), then he changed his opinion and described this case under the- name of hysterical pseudo- (false) meningitis. These cases of hysteria differ from an actual meningitis by the absence of fever, changes of the fundus of the eye (cfidema papillae, neuritis optica), paralyses of the facial nerve and the eye nerves, unequal pupils, strabismus and of any local symptoms in general. I Peters refers to 17 cases of pseudo-meningitis in children from the ninth month to the thirteenth year. Eleven of these occurred hefore the fifth year ; seven occurred with typhoid ; three with influenza ; one with croupous pneumonia; two with gastro- intestinal disorder; two with mixed infections of intluenza and streptococcus. In 15 there was complete recovery; one case be- came an idiot and one died. The author considers the differential diagnosis between pseudo-meningitis and genuine meningitis, and believes the fol- lowing points important : ( 1 ) If convulsions occur in pseudo-meningitis they are tetanoid or tonic in character ; are restricted to certain groups of muscles, and are not followed by prolonged unconsciousness. (2) With the beginning of pseudo-meningitis, a reduction- of temperature occurs. (3) In the further course, bulbar symptoms, as irregular pulse and respiration, are absent. (4) The amount of cerebro-spinal fluid is not increased. (.0 Delirium is frequently observed. In four cases the author observed an acute psychosis following the pseudo-meningitis. Urcemiawa.s absolutely excluded in the seventeen cases.* — Earle.] *Russ. Arch f. Pathol., etc. Bd. XIII., No. 3 (Quoted from The Prac— tical Medicine Series of Year Books, June, 1903, ed. by Abt, p. 174). -f University of California SOUTHERN REGIONAL LIBRARY FACILITY 305 De Neve Drive - Parking Lot 17 • Box 951388 LOS ANGELES, CALIFORNIA 90095-1388 Return this material to the library from which it was borrowed. Foi _ THE LIBRARY //472s diagnosis of lyOii diseases of v.l children. Biomedical UC SOUTHERN REGIONAL i BftAH, i lllllll nil D 000 121 240 6 WS Ihl Fl472s 1901; I liili