W fearning anb 'guhox. ^ J LIBRARY I I Universityof Illinois. | ^ Cr.ASS. BOOK. VOLUME. ^ # Accession No. ON THE WASTING DISEASES OF INFANTS AND CHILDREN BY EUSTACE SMITH, M.D. FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS PHYSICIAN TO HIS MAJESTY THE KING OF THE BELGIANS SENIOR PHYSICIAN TO THB EAST LONDON CHILDREN'S HOSPITAL AND TO THE CITY OF LONDON HOSPITAL FOR DISEASES OF THE CHEST, VICTORIA PARK SIXTH EDITION PHILADELPHIA P. BLAZISTON'S SON & CO. 1012, WALNUT STREET 1899 PrirUed in Great Britain PREFACE TO THE SIXTH EDITION. In its original design this volume was not intended to be a manual for the nursery or a mere treatise on the hand-feeding of infants. The aim of the author lay far beyond this. It was his object to set forth in a handy and readable shape the principal forms which chronic interference with nutrition may take, not only in bottle- fed infants, but also in older children up to the age of puberty ; to describe these ailments from a clinical stand- point ; and to set out with much minuteness the methods by which they might be remedied and health restored. In all subsequent editions this end has been kept in view, and each new issue has embodied the results of increased experience in the treatment of these complaints. The last edition, the fifth, appeared ten years ago, and the book for some years has been out of print. The delay in re-publication, which has been much complained of, has been due to the many alterations required and the little time at the author's disposal to deal with them, for much of the pathology was out of date, and the whole required careful revision. In the present issue large portions of the book have been re-written, and a chapter has been added on the subject of subacute tuberculosis in infants. But many other changes and additions have been made, 66405 vi PREFACE especially in the pages devoted to treatment ; and the author now ventures to hope that the directions given as to food, medicine, and general management leave little to be desired for clearness and fulness of detail. The dietaries in the last chapter have also been revised. These dietaries were a new feature in the second edition, which appeared in the year 1870. It was the first attempt made to tabulate the meals of such young patients, and its usefulness has been generally acknowledged; indeed, its example has been followed by most of the manuals on the subject of children's diseases which have been pub- lished in recent years. In conclusion, the author would say that the whole work has been prepared with an eye to the needs of the young medical man who finds his practice to consist largely of cases which are strange to him from the mere age of the patients — of cases which his previous training amongst adult sufferers has little qualified him to treat with success. 15, Queen Anne Street, Cavendish Sqtjaee; June oth^ 1899. CONTENTS INTEODUCTION PAGE Wasting a sign of defective nutrition . . . 1 Importance of deteeting the cause of mal-nutrition . . 2 Wasting not always the first sign, and may even be absent in slight cases . . . . .2 Defective nutrition may be the result of acute disease . 3 Liability of badly nourished children to secondary acute diseases 3 Peculiarities of these secondary diseases . . .4 Insensibility of the nervous system in cachectic children . 4 Infrequency of reflex convulsions . . .4 Importance of detecting the secondary diseases . . 5 Information to be derived from examining the face of the infant 5 M. Jadelot's lines . . . , .6 Colour of face . . . . .7 Breathing . . . . . .7 Cry. . . . . . .7 Causes of large belly in infants . . . .8 Infrequency of mesenteric disease . . .9 Mode of examining liver and spleen . . .9 General treatment of wasting . . . .10 Uselessness of tonics so long as there remains any derangement of the stomach and bowels . . . .10 Importance of minuteness in giving directions about diet . 10 External applications . . . . .10 Frictions . . . . . .10 Anointing with warm olive oil . . . .11 Counter-irritants . . . . .12 Baths— Hot bath . . . . .13 Mustard bath . . . . .13 Cold bath . . . . .13 viii CONTENTS PAGE Internal remedies . . . . .15 Cod-liver oil must not be given in too large doses . . 15 Stimulants . . . . . .15 CHAPTEE I Infantile Atkophy. Causation . . . . . .17 Insufficient supply of food . . . .17 Variations in breast-milk . . . 17 Test of a good nurse . . . ,17 Unwise feeding . . . . .18 Dependence of nutrition upon powers of digestion . 18 Varieties of food required for perfect nutrition . 19 Differences between woman's and cow's milk . 20 Cow's milk cannot always be digested . . 21 Symptoms . . . . . .22 Two classes according to cause . . .22 Food suitable, but insufficient . . .22 Food unsuitable . . . .23 Wasting . . . . .23 Constipation . . . .23 Cause of inactivity of bowels . . 24 Ilatulence . . . .24 Colic . . . . .24 Ravenous appetite . . . .25 Eruptions on skin . . . .25 Thrush, its importance in prognosis . . 26 Inward fits . . . .27 Attacks of vomiting and diarrhoea . . 27 Aphthse . . . . .28 Nephritis . . . . .29 Otitis . . . •. .29 Treatment . . . . . .30 Suckling by mother or nurse . . .30 Rules for choosing nurse . . . .30 Directions for efficient suckling . . .31 Advantages of putting child early to breast after birth . 32 Times of suckling . . . .33 Artificial feeding . . . . .34 CONTENTS ix PAGE Sterilisation of milk . . . .35 Methods of preparing cow's milk . . .35 " Artificial human milk " . . . .36 Gartner's milk . . . . .36 Milk with lime-water . . . .37 Milk with barley-water . . . .37 Milk with gelatine . . . .38 Value of malt . . . . .40 Malted foods . . . . .40 Pancreatised foods . . . . .40 Milk laboratories . . . . .41 Variety in feeding . . . . .42 Frequency of meals . . . .43 Cleanliness of feeding-bottle . . . .43 Cow's milk may disagree . . . .43 Various milks compared . . . .44 Goat's and ass's milk . . . .44 Strippings " . . . . .45 Condensed milk . . . . .45 Peptonised milk . . . . .46 Modification of diet in case of gastric catarrh . . ' 46 Farinaceous foods . . . • . .46 Chapman's wheat flour . . . .48 Baked flour . . . . .49 Other foods . . . . .49 Weaning . . . . .50 Usual time . . . . .51 Must sometimes be anticipated . . .51 Method of weaning , . . .52 Reasons why a child may refuse breast . . 52 Diet after weaning . . . .54 General management of infants . . .55 Use of soap in the nursery . . . .55 Treatment of constipation . . . .56 Flatulence and acidity . . .58 Screaming fits . . . .61 Convulsions and colic . . .62 Thrush . . . .63 Aphtha . . . .64 Diarrhoea and vomiting . . .64 X CONTENTS CHAPTER II PAG?: ClIKONIC DiAREHCEA (ChEONIC INTESTINAL CaTAEEH). May be secondary to acute disease . . .66 Or may be primary . . , .67 Mode of beginning when primary . . .67 When disease established . . . .68 Character of the stools . . . .68 Other symptoms . . . ' . .69 Complications . . , . .70 Serous effusions . . . .70 Pneumonia . . . . .70 Exanthemata . . . . .70 Convulsions . . . . .70 Thrombosis of cerebral sinuses . . .71 Death without complication . . . .72 Diarrhoea may cease before death . . .72 Influence of the disease upon dentition . . 73 Diarrhoea in older children . . . .74 Lienteric diarrhoea . . . .75 Causation — In infants, bad hygiene . . .76 cold . . . .78 previous acute disease . . 79 In older children, worms . . .79 tubercular ulceration of bowels . 80 Morbid anatomy . . . . .80 Simple ulceration of mucous membrane . . 80 Tubercular or scrofulous ulceration . . .81 Diagnosis . . . . . .82 Prognosis — Unfavourable signs . . . .85 Favourable signs . . . .85 Preveiition . . . , . .85 Attention to diet . , . . . .86 Avoidance of cold . . . . .87 Influence of dentition . . . .87 Treatment — In infants . . , . .88 General management . . . .88 Washing bath forbidden . . . .89 Diet . . . . . .90 External applications . . . .95 Internal remedies . . . . .96 CONTENTS Xi PAGE Malt extract . . . . .97 Finkler's papain . . . . .97 Antacids . . . . . .98 Astringents . . . . .99 Nitrate of silver . . . . .99 Perchloride of mercury .... 100 Raw meat ..... 100 Tonics . . . . . .101 In older children ..... 102 Treatment of lienteric diarrlicea . . . 103 Illustrative cases . . . . . 103 CHAPTEE III Cheonic Vomiting (Cheonic Gasteic Cataeeh). Frequency of slight attacks of gastric disturbance . 105 Such attacks easily remedied .... 105 Chronic vomiting non-febrile . . . 105 Symjptoms . . . . . .105 Character of vomited matters . . . 105 Constipation ..... 106 Interference with nutrition . . . . 106 After a time vomiting almost constant . . . 106 Exhaustion ..... 107 Spurious hydrocephalus .... 107 Causation . . . . . .108 Diagnosis . . . . . .110 From tubercular meningitis .... 110 Treatment . . . . . .110 Warmth . . . . . .110 Attention to diet ..... Ill Return to breast ..... 112 Substitute for wet-nurse . . . .112 Exclusion of milk from diet . . . . 113 White wine whey . . . . . 113 Medicines ..... 116 Arsenic ...... 116 Cocain ...... 116 Calomel in small doses . . . .117 Stimulants ..... 117 Value of emetics . , . . .117 Treatment of spurious hydrocephalus . . .118 After-treatment . . . . . 118 xii CONTENTS CHAPTER IV PAGE KiCKETS Preliminary symptoms those of general malnutrition . 120 Symptoms of beginning .... 121 Deformities of bone .... 123 Bones of skull and face . . . .124 Distinction between rickety and hydrocephalic skull . 125 Cranio-tabes ..... 126 Dentition ..... 126 Teeth sometimes unaffected .... 127 Illustrative case ..... 127 Spine . . . . . .127 Thorax . . . . . .128 Deformities of pelvis .... 131 Arrest of growth of bones .... 133 Articulations ..... 134 Kelaxation of ligaments , . . .135 Other symptoms ..... 135 Enlargement of liver and spleen . . . 137 Intellect . . . . . .137 General behaviour of a rickety child . . . 137 Complications ..... 138 Catarrh and bronchitis .... 138 Diarrhoea . . . . .139 Laryngismus stridulus .... 140 Convulsions ..... 140 Chronic hydrocephalus .... 142 Scurvy ..... 143 Cause of death ..... 145 Favourable termination .... 145 Resumption of dentition .... 145 Fathology . . . . . ' . 147 Rickets a general disease . . . . 147 Microbic theory . . . . .148 Morbid anatomy . . . • .149 Ossification per verted . . . .149 Reconsolidation of rickety bone . . . 150 Analysis of rickety bone .... 151 Emphysema and collapse . . . • 152 Alterations in liver . . . • 153 spleen . . . .154 other organs .... 155 CONTENTS Xiii PAGE Urine ...... 155 Rickets and osteomalacia .... 156 Diagnosis ...... 156 Prognosis ...... 159 Importance of complications . . . 159 Causation ...... 160 Rickets not a diathetic disease . . . 160 Bad feeding and insanitary conditions . . 163 Connection between rickets and syphilis . . 164 Prevention . . . . . .164 Treatment ...... 165 Attention to digestive organs . . . 165 Diet . . . . . .166 Dry bracing air . . . . . 167 Warmth . . . . . .168 Cleanliness ..... 168 Tonics . . . . . .168 Cod-liver oil .... . 169 Value of mechanical supports . . . 170 Treatment of complications .... 171 Catarrh . . . • . .171 Diarrhoea ..... 172 Convulsions ..... 174 Laryngismus stridulus .... 175 Scurvy . . . . .176 CHAPTER V Inherited Syphilis. Appearance of first symptoms . . . 177 Before birth . . . . .177 At birth . . . . .177 Afterbirth . . . . .178 Fretfulness at night . . . .178 Snuffling . . . . . .179 Necrosis of nasal bones .... 180 Eruptions ..... 180 Seat . . . . . .180 Varieties ...... 180 Ecthymatous pustules .... 181 Mucous patches ..... 181 Cracks and fissures ..... 182 xiv CONTENTS PAGE Complexion ..... 182 Cry ..... . 182 Openness of fontanelle .... 183 Disease of bones . . . . .183 Separation of epiphyses .... 183 Nodes . • . . . .184 Enlargement of glands .... 184 Enlargement of spleen .... 184 General cachexia ..... 185 Paralysis ...... 185 Delayed symptoms ..... 186 Relapses ..... . 187 Morbid anatomy . . . . .188 Changes in the bones .... 188 In bones of skull ..... 190 Cranio-tabes ..... 190 Syphilitic dactylitis .... 191 Disease of mucous membrane . . . 191 Internal organs .... 192 Lungs .... 192 Liver .... 192 Spleen . . . .194 Heart . . . .194 Kidneys .... 194 Supra-renal capsules . . . 194 Diagnosis . . . . . .194 By general symptoms .... 194 Value of individual symptoms . . . 195 By examination of other children of the same family . 196 Signs of past disease in child . . . 19G Causation ...... 196 Transmission of taint from father . . . 197 Transmission of taint from mother . . . 198 Twins not always equally affected . . . 199 Other modes of infection .... 200 Prognosis . . . . . . 200 Importance of considering the intensity of the general cachexia ..... 201 Importance of certain special symptoms . . 201 Prevention ...... 202 Treatment ...... 202 Two objects . . . . .202 Treatment to be begun early . . . 203 CONTENTS XV PAGE Mercurial preparations .... 203 External applications .... 204 Ointment . . . . .204 Mercurial baths .... 205 To improve general nutrition . . . 205 Diet . . . . . .205 Cod-liver oil . . . . .206 Warmth . . . . . .206 Cleanliness ..... 206 Treatment of vomiting and diarrhoea . . . 207 Local applications ..... 208 Tonics . . . . . .209 CHAPTEE VI Mucous Disease. Character of the derangement . . . . 210 Symptoms ...... 210 Nightmare . . ... .210 Somnambulism . . . . .211 Incontinence of urine .... 211 Nervous restlessness .... 211 Appearance of tongue . . . .211 Bowels ...... 212 Foetor of breath ..... 212 Complexion ..... 213 Abdominal pains . . . . . 213 Dry rough skin ..... 213 Temperature ..... 214 Bilious attacks ..... 214 Worms a common complication . . . 214 Explanation of the symptoms . . . 215 Causation ..... . 216 Influence of previous diseases . . . 216 Whooping-cough .... 216 Susceptibility to chill .... 217 Second dentition .... 217 Diagnosis ...... 218 From tuberculosis ..... 218 xvi CONTENTS PAGE Treatment . . . . . .219 Diet . . . . . .219 Exclusion of starchy food .... 219 A dietary ..... 220 Allowed vegetables .... 220 Alcohol ...... 220 Restore action of skin .... 221 Warm clothing ..... 221 Internal remedies ..... 222 Alkalies ...... 222 Aloes ...... 222 Iron . . . . . .223 Purgatives ..... 224 Case illustrating treatment . . . . 224 Acids . . . . . ,225 Cod-liver oil . . . . . 226 Change of air . . . . . 226 CHAPTER VII Worms. Varieties . . . . . . 227 Description ...... 227 Oxyuris vermicularis .... 227 Ascaris lumbricoides .... 228 Tricocephalus dispar . . * . 228 Taenia solium ..... 229 Tsenia-medio canellata .... 230 Bothriocephalus latus .... 230 Mode of obtaining admission into human body . . 231 Symptoms . . . . . .233 Due principally to accompanying derangement of stomach and bowels . . . . .233 Emaciation ..... 234 Pain . . . . . .234 Disturbance of nervous system . . . 235 Convulsions ..... 235 Special symptoms with each variety of worms . . 235 Diagnosis . . . . . .238 From tuberculosis ..... 239 From tubercular meuingitis .... 240 CONTENTS ^ Xvii PAGE Treatment . . . . . . 240 Two objects ..... 240 To expel worms .... 240 Remedies required for each variety . . 240 Thread-worms .... 240 Long worms .... 241 Large thread-worms . . . 241 Tape-worms .... 244 To restore healthy condition of alimentary canal . 247 Treatment of prolapsus ani . , . 247 CHAPTEE VIII Tuberculosis. The tubercle bacillus .... 249 Mode of entrance into the body . . . 250 By the alimentary canal .... 250 By the air passages. .... 250 By the tonsils . . . • . . 250 Infection of lymphatic glands . . . 251 The " tuberculous diathesis " . . . . 251 The " strumous " type .... 252 Resisting power of the system . . . 253 Varieties of tuberculosis .... 254 General Subacute Tuberculosis oe Infants. Fathology ...... 254 Symptoms ...... 255 Interference with nutrition .... 255 Local symptoms rare .... 256 Temperature ..... 256 Mode of ending ..... 257 Diagnosis ...... 257 Prom inherited syphilis .... 259 CHAPTEE IX Tuberculosis of the Lungs. Pathology . . . . . .261 Mode of entrance of microbes • . . 262 Symptoms ...... 263 Varieties of shape of chest .... 264 h xviii CONTENTS PAGE The alar or pterygoid chest .... 264 The flat chest ..... 264 The pigeon-breasted chest .... 264 Chronic Pulmonary Tuberculosis. General symptoms ..... 265 Wasting . . . . . .265 Cough ...... 265 Haemoptysis ..... 266 Rapid breathing ..... 267 Chest pains ..... 267 Appetite ...... 267 Diarrhoea ..... 268 Influence of pyrexia .... 269 Mode of death . . . . ,269 Course of primary chronic tubercular phthisis . . 269 Course of pneumonic phthisis . . . 270 Symptoms of softening of deposit . . . 270 Slow development of pneumonic phthisis . . 271 Secondary acute tuberculosis .... 271 Fibroid induration of lung .... 271 Character of cough .... 272 Absence of pyrexia .... 272 Enlargement of liver and spleen . . . 273 Physical signs ..... 273 Examination of chest in a child . . . 273 Peculiarities of physical signs . . . 273 Percussion of the chest . . - . . 273 Auscultation ..... 275 Bronchial and hollow breathing . . . 275 Conduction of sounds by enlarged glands . . 275 Eeeble breath- sounds .... 277 Value of cavernous breathing . . . 277 Physical signs in chronic tubercular phthisis . . 277 In pneumonic phthisis .... 278 In fibroid induration of lung . . . 280 CHAPTEE X Cheonic Pulmonary Tuberculosis (continued). Diagnosis ..... . 282 Of chronic primary tubercular phthisis . . 282 CONTENTS xix PAGE Of tubercular phthisis complicated with catarrhal pneumonia 284 Of pneumonic phthisis . . . . 284 Sudden onset . . , . . 284 Insidious beginning .... 286 Of fibroid induration of lung. . . . 287 Of pulmonary cavities .... 288 From empyema .... 288 From dilated bronchi .... 289 Of fibroid phthisis . . . . .289 Prognosis ...... 290 Prevention ...... 293 Diet . . . . . .293 Fresh air . . . . . . 294 Dress . . . . . . 294 Exercise ...... 294 Residence . . . . . 295 Treatment ...... 296 Climate . . . . . .297 Air and exercise . . . • . . 297 Diet . . . . . .299 Attention to digestive organs . . . 300 Cod-liver oil and tonics . . . . 301 Special treatment ..... 302 Expectorants ..... 303 Antiseptic inhalations .... 304 Counter-irritation .... 305 Arsenic .... 305 Belladonna . . . . .305 Treatment of cirrhosis of lung . . . 305 CHAPTEE XI Tuberculosis of Lymphatic Glands. Consequences vary according to seat . . . 307 Often a local disease .... 307 Appearance of diseased glands . . . 308 Further changes ..... 308 Softening . . . . .308 Petrifaction ..... 308 XX CONTENTS PAGE Resolution and absorption . . . 308 Fibroid change .... 308 Danger from softened glands . , . 309 Tuberculosis of Bronchial Glands . . . . 309 Seat . . . . . .309 Symptoms ...... 310 General ...... 310 Frequency of catarrhs . . . .310 Special ...... 311 Pressure on veins ..... 311 Pressure on nerves . . . . .311 Cough .... . 312 Altered voice ..... 312 Dyspnoea ..... 312 Physical signs . . . . . 313 Percussion note ..... 313 The result of pressure .... 313 Auscultatory signs ..... 313 Complication with pulmonary phthisis . . . 314 Modes of termination .... 314 Diagnosis ...... 314 Earliest diagnostic sign .... 315 Illustrative cases ..... 316 Prognosis ...... 318 Tuberculosis oe Mesenteric Glands . . . 319 Symptoms . . . . . .319 General . . . . . .319 Local . . . . . . 320 Pressure on veins ..... 321 Ascites rare ..... 321 Modes of termination .... 322 Diagnosis . . . . » . . 322 From fsecal accumulation .... 322 From tuberculous masses attached to the omentum . 323 Existence of complications .... 324 Prognosis . . . . . .325 Treatment ...... 326 General ...... 326 Special . . . . . .327 Of tuberculous bronchial glands . . . 328 Of tuberculous inesenteric glands . • . 329 CONTENTS xxi CHAPTEE XII Diet of Childeen in Health and Disease. Diet in health ..... 331 Vvoxn birth to six months old. . . . 331 From six to twelve months old . . . 334 From twelve to eighteen months old . . . 337 From eighteen months to two years old . . 339 After two years ..... 340 Diet in disease . . . ' . . 340 In simple atrophy ..... 340 In chronic diarrhoea .... 342 In chronic vomiting .... 345 In rickets ..... 346 In raucous disease . . . . . 347 In pulmonary phthisis . . . .350 C OJSl THE WASTING DISEASES OF INFANTS AND CHILDIIEN INTRODUCTION WASTINGr is a sign of defective nutrition ; the waste of the body continues, but new material is intro- duced in quantity insufficient to supply the loss of tissue. Wasting may be temporary or persistent. Every devia- tion from health will affect, to a certain extent, the nutrition of the body, and, according as the interference with nutrition is more or less complete, the wasting goes on with more or less rapidity. The interference is great in proportion to the acuteness of the cause which pro- duces it. Any acute disorder, such as an inflammatory attack or an attack of acute diarrhoea, will produce an immediate pause in the nutritive process : the flesh at once begins to feel flabby and soft ; and a continuance of the purging, if the drain be severe, causes a visible loss of flesh, which is as rapid as it is alarming. On the cessa- tion of the acute attack, the flesh is recovered almost as rapidly as it was lost: a few days restore the child's 1 2 INTRODUCTION ordinary appearance, and with his flesh his colour and spirits return. On the other hand, in chronic disorders, emaciation proceeds much more gradually ; but nutrition, as it is slowly impaired, is also slow to be re-established. The present volume deals only with cases of slow impair- ment of nutrition, where the loss of flesh is gradual, and the wasting cannot be attributed, at any rate directly, to any acute febrile attack. In all such cases the cause should be carefully inquired for, as the defect in nutrition can only be effectually remedied by removing the cause which has produced it. This cause may be unsuitable food, the child being actually starving from his inability to digest and assimilate the diet with which he is sup- plied. He may be prevented from assimilating an ordi- narily digestible diet by some unhealthy condition of his alimentary canal ; or a constitutional defect, such as the existence of tuberculosis, or the poison of syphilis per- vading the system, may interfere with the proper nutrition of the tissues. It is extremely important to detect the earliest symptoms of defective nutrition. Wasting is not always one of the first signs, and may even be altogether absent if the inter- ference with nutrition is not carried to a high degree. Thus, a child may be exceedingly plump, and may perhaps excite admiration by his good condition, although at the same time he be suffering from the insidious com- mencement of rickets, which, if the causes producing the disease continue unchecked, will shortly assert itself un- mistakably. Acute disease is often a starting-point for mal-nutrition, either by awakening a dormant diathetic tendency ; or by leaving behind it a chronic derangement of the alimentary canal; or by impeding nutrition by some mysterions influence over nervous power. Thus measles not unfrequeiitly excites the manifestations of a previously latent tubercular tendency ; scarlatina and measles are apt to be followed by obstinate diarrhoea, INTRODUCTION 3 and diphtheria is often succeeded by a loss of nervous power, usually indeed local, but sometimes general and sufficiently serious to interfere with the working of all the functions of the body. In every acute disease there are, therefore, two dangers ; the immediate danger and the remote danger. The first presses itself upon our notice, and cannot be overlooked ; the second, obscured by distance, is apt to be disregarded. Acute disease always excites attention and receives imme- diate treatment, but it is not enough to rest satisfied with the cessation of pressing symptoms. There is always the danger that the defective nutrition, at first merely tempo- rary, may become confirmed ; in other words, that chronic disease may be established. One consequence of the weakly condition to which badly nourished children are reduced is their liability to second- ary acute diseases. In a child sulfering from the results of chronic interference with nutrition, from whatever cause, the power of resisting new injurious influences is very much impaired. In such a state he is constantly found to be affected by causes so slight as to pass almost unnoticed, and which in a healthy child would be com- pletely powerless to do harm. If the emaciation and debility of the child are very great, the secondary diseases may give very little evidence of their presence ; for an infant reduced by mal-nutrition to a cachectic state loses many of the vital characteristics of early childhood, espe- cially the intense excitability of the nervous system, which is so striking a peculiarity of healthy infancy. In a robust child we constantly find the whole system suffering vio- lently from sympathetic derangement set up by some trifling disturbance. A lump of indigestible food, or a slight impression of cold, will not unfrequently produce burning fever, and alarming nervous symptoms, as deli- rium, convulsions, or even a state approaching to coma. On the other hand, in an infant much reduced by long- 4 INTRODUCTION continued impairment of nutrition, the most serious dis- eases may give no signs of their presence. Pneumonia may exist with little fever and no cough, and a serious intestinal lesion without pain and with only trifling diar- rhoea. A good example of the insensibility of the nervous system to local impressions is seen by attempting the well-known experiment of gently simulating the genito- crural nerve. In a healthy child the finger-nail drawn lightly along the upper two thirds of the inner aspect of the thigh produces an instantaneous rise of the testicle of that side, by the action of the cremaster muscle which draws it up close to the external abdominal ring. In a cachectic child the same experiment is followed by no result whatever ; the cremaster does not contract, and the testicle remains motionless. In such cases, therefore, there is absence of the normal excitability of the nervous system so characteristic of healthy infancy. This insensibility of the parts of the nervous system concerned in the produc- tion of reflex movements is further indicated by the infre- quency of reflex convulsions in such children. In well- nourished children these are exceedingly common, and the natural nervous sensibility appears to be heightened by anything which causes a sudden weakening of the system, as severe acute diarrhoea, or great loss of blood. When, however, the debility is produced more slowly, the same result does not follow, and the excitability of the nervous system, instead of being exalted, is more or less completely destroyed. For this reason, acute diseases, attacking a child whose nutrition is thus seriously impaired, have very special features. They are distinguished by an absence of those peculiarities which we are accustomed to consider insepa- rable from the disorders of childhood, and resemble more the same diseases as they occur in advanced age. They begin more insidiously ; run their course more slowly ; INTRODUCTION 5 give rise to fewer symptoms ; and often end suddenly and unexpectedly in death. Although thus undemonstrative, they are not, however, on that account less dangerous ; indeed, the prognosis may be said to be serious in pro- portion to the fewness of the symptoms by which their existence is announced. By offering an additional obstacle to nutrition they still further weaken the already enfeebled constitution, and the disease, if it does not prove imme- diately fatal, is apt to hang on, gradually reducing the child more and more, until he sinks under its effects. It is difficult to over-estimate the importance of an early diagnosis of these secondary disorders. On account of their insidious beginning they are frequently overlooked, and it is often only by the more rapid debility they induce that suspicions of their existence are at last excited. As the infant is unable to communicate his ideas by speech, the eye should be practised to gather from the expression and gestures of the child the information which he can give in no other way. A careful perusal of the face is therefore of the utmost importance. By it we can ascer- tain the existence of pain, and can often distinguish the part of the body which is the seat of serious disease. Thus, pain in the head is indicated by contraction of the brows ; in the chest, by a sharpness of the nostrils ; and in the belly, by a drawing of the upper lip. M. Jadelot, a former physician to the Hopital des Enfans Trouves at Paris, was the first to draw attention to certain lines or furrows, which become marked on the face of a child suffering from serious disease, and the situation of which furnishes indications as to the part of the body to which it is necessary to direct our examination. The oculo-zygo7natic line, or furrow, begins at the inner angle of the eye, and passing outward underneath the lower lid, is lost a little below the projection formed by the cheek-bone. This, points to disorder of the cerebro- nervous system, becoming strongly marked in all those 6 INTRODUCTION diseases whose j^rimary seat is the brain or nerves, or in cases where those organs become affected secondarily to disease which has begun in other parts. The nasal line rises at the upper part of the ala of the nose, and, passing downwards, forms a rough semicircle round the corner of the mouth. Joining this at an angle about its middle is another line, called cjenal, which reaches from that point almost to the malar bone, and in certain faces forms the dimple of the cheek. These indicate dis- eases of the digestive passages and the abdominal viscera. The lahial line begins at the angle of the mouth, and is directed outwards, to be lost in the lower part of the face. It is seldom so deep as the preceding. It is a sign of disease of the lungs and air-passages. M. Jadelot attributed immense importance to these lines, and even stated that he had been enabled to discover the exact period at which the cough of pertussis assumed its convulsive character by the a23pearance of the oculo-zygo- matic line upon the child's face. Without, however, attaching to them the same significance which they assumed in the opinion of their discoverer, there is no doubt that they often furnish important indications, and are, there- fore, points to which attention should always be directed in the examination of a young child. The colour of the face should be carefully noted. Livi- dity of the lips and of the eyelids, if extreme, is a sign of imperfect aeration of the blood ; but a faint purple tint of the eyelids and round the mouth usually indicates nothing more than weak circulation, or a slight difficulty of diges- tion. * A peculiar waxy-yellow tint is seen in certain parts of the face in inherited syphilis ; and there is an earthy tinge of the face and whole body in many cases of chronic bowel complaint. Exhaustion is indicated by coolness and pallor of the face, by marked lividity of the eyelids and mouth, and, in extreme cases, by a half-closure of the eyes, so as to leave the lower part of the whites exposed, while INTRODUCTION 7 at the same time the fontanelle is deeply depressed. The state of the fontanelle should be always examined, for it forms a very important guide to treatment : if much de- pressed, stimulants should never be withheld. The breathing must be watched. If rapid and accom- panied by movement of the nares, there is usually bron- chitis or pneumonia, and a careful examination of the chesf should always be made. Unequal movement of the two sides of the chest in respiration generally indicates a serious lesion on the side at which the movement is least. If the respiratory action of the abdominal muscles be in- creased, attention is at once directed to the chest. If the belly be motionless, it is often the seat of an inflammatory complication. The cry of the infant varies very much in character. In cerebral affections it is sharp, short, and sudden. In lesions of the abdomen, exciting pain, it is prolonged. In inherited syphilis, it is high-pitched and hoarse. In inflammatory diseases of the larynx it is hoarse, and may be whispering. In inflammatory diseases of the lungs, and in severe rickets, the child is usually quiet, and un- willing to cry on account of the action interfering with the respiratory functions. The infant should always be completely stripped for examination. We can then at once observe the form and play of the chest, the state of the abdomen, the condition of the skin, whether hot or cool, dry or moist, and the conformation of his limbs. Besides, any eruption upon the skin is at once detected by this means. The large size of the belly in weakly children often attracts the attention of parents, and excites much anxiety. It is most commonly produced by accumulation of flatus, owing to the weakness of the muscular walls. It may be also due to displacement of the abdominal contents, such as occurs so often in rickets on account of the depression of the diaphragm forcing the viscera downwards from 8 INTRODUCTION beneath the cover of the ribs. The liver and spleen may be enlarged; and great masses of sarcoma occasionally spring from the kidney and other abdominal organs. Ascites may be present from tubercular or simple perito- nitis, from Bright' s disease, or, rarely, from disease of the liver. Tubercular peritonitis may also produce extreme tympanitis. Accumulations of faecal matter sometimes take place, and great enlargement of the mesenteric glands may occur, but these causes are rarely sufficient in them- selves to produce any remarkable swelling. If abdo- minal distension be noticed in such cases, the enlargement is due almost invariably to gaseous accumulation owing to fermentation of food. It must be borne in mind that great distension of the belly in an infant — distension so great as to excite the anxiety of the friends — is by no means necessarily a sign of illness. Careful mothers will often seek medical advice on account of swelling of the abdomen in their infants. If in such a case nothing abnormal, except the size, is to be observed, we may confidently assure the parent that there is nothing to fear. Even if the distension is considerable and is associated with wasting, the evident interference with nutrition is not to be taken as a sign that the abdominal enlargement is due to serious disease. Great accumulation of gas in the alimentary canal is the consequence of fermentation of food excited by digestive derangement ; gastric troubles necessarily hinder the introduction of nutritive material into the system, and in early life loss of flesh quickly follows any check to the process of nutrition. Still, it is not uncommon to hear the symptoms attributed to mesenteric disease," and great alarm is sometimes ex- cited in the minds of the j)arents by unfounded apprehen- sions as to the condition of the abdominal glands. It is well, therefore, to bear in mind that distension of the abdomen and wasting may be present together in a child INTRODUCTION 9 as a consequence of mere disorder of function ; that casea- tion of the mesenteric glands is not common under the age of three years ; and that, in any case, if an examination of the belly detects no obvious enlargement of these glands, we are not justified in referring the symptoms to any form of glandular degeneration. In examining the abdomen the size of the liver and spleen should always be investigated. These organs lie just below the surface, and their lower borders, if project- ing below the ribs, can be readily felt by placing the palm of the hand flat upon the belly and palpating with the tips of the fingers. It is not enough, however, to ascertain merely the inferior limits of these viscera. Both the liver and spleen may be enlarged although their lower borders project little, if at all, beyond the margin of the ribs. On the other hand, their inferior margins may be felt some distance below the edge of the ribs, from displacement downwards of the organs, although there is no actual increase in size. Therefore, having fixed the level of the lower border, we should, in the case of each, proceed to determine the upper limit by percussion. In this way we may find that the liver extends upwards to the third rib, and that the splenic dulness can be traced as far as the angle of the scapula. In the treatment of chronic wasting in a young child our first care should be to remove any derangement of the stomach and bowels. For this object a strict regulation of his diet is indispensable. In the great majority of such cases the cause can be distinctly traced to improper feed- ing, and therefore an alteration in the diet is the first stej) to a cure. Tonics given to a child whose bowels remain disordered are of little service, for, so long as the derange- ment of the alimentary canal continues, nutrition cannot be restored on account of the impediment thus presented to the digestion and assimilation of food. Directions on the subject of diet cannot be too precise ; 10 INTRODUCTION it is necessary to state distinctly not only the articles of food to be given, but the quantities to be allowed at each meal, and the frequency with which the meals are to be repeated. It is advisable to write down all such direc- tions, that misunderstanding may be avoided ; in fact, the same attention should be paid to this subject as is paid to the ordering of drugs. After the diet has been altered to suit the requirements of the case, more special treatment is called for, and the means at our command may be divided into two classes, viz. external applications and internal remedies. External applications are of great service in all chronic diseases, for it is important to restore as quickly as possible the healthy action of the skin. For this purpose, frictions, counter-irritants, and baths, hot or cold, may be used. Frictions can be employed with the hand alone, with stimulating liniments, or with cod-liver oil. By this means the circulation is rendered more vigorous, and the action of the skin is promoted. The feebleness of the circu- lation in most cases of chronic disease in the infant is shown by the coldness of the extremities. When these have been warmed by suitable applications, the beneficial influence is often very decided; pain in the belly ceases, and the child usually falls into a quiet sleep. Friction with stimulating liniments is merely a mild form of counter- irritation which can be applied generally, and has a more powerful influence in stimulating the circulation and pro- moting a flow of blood to the surface, than friction with the hand alone. It is useful in all cases where the debility is great. But it is not only the skin which is influenced by such manipulations. The subject of manual therapeutics has lately received fresh attention, and the impetus which can be given to healthy tissue change by a skilful kneading and working of the muscles and subcutaneous structures has been taken advantage of in the treatment of various INTRODUCTION 11 forms of chronic disease. Amongst others : in long stand- ing cases of chorea great benefit may be derived from energetic massage of muscle and manipulation of joints, so as to excite active muscular waste, while at the same time the increased tissue wants are satisfied by a copious dietary: in rickety children, whose backs are especially limp and powerless, very evident increase of strength quickly follows regular and vigorous shampooing ; and in obstinate costiveness important results can be obtained by systematic kneading of the abdomen combined with suit- able frictions. Rubbing with cod-liver oil is useful in weakly children, especially if the weakness is associated with irritability of stomach and poor digestion. By this means a consider- able amount of nourishment may be introduced into the system. But oily frictions, or the mere application of oil to the surface of the body, have another object besides that of supplying nourishment. When the oil, slightly warmed, is smeared over the body with a piece of fine sponge, and the child, wrapped in flannel, is afterwards placed in his bed or cot, one of the first effects noticed is a profuse general perspiration. This is accompanied some- times by a little erythematous eruption, which resembles the rash of measles. At the same time, any irritability of the nervous system is quieted, and the child soon falls into a tranquil sleep. A third effect is an increase in the quantity of all the secretions : the urine is more abundant, and the functions of the liver appear to be rendered more active, for, according to the observations of Bauer of Tubingen, the stools, from being green and sour- smelling, become yellow and natural. To produce these effects, it is not essential that cod-liver oil be employed. Other oils will be found equally effica- cious, and are, indeed, generally to be preferred, on account of the disagreeable smell of the fish oil, which is often a source of discomfort. Through its influence in promoting 12 INTRODUCTION the action of the Kskin, anointing with oil is of great service in all the diseases which are here treated of, and in cases where the weakness and emaciation are extreme, striking results sometimes follow the application, if it be repeated with sufficient perseverance. A warm bath, or a thorough sponging of the whole body with very warm water, im- mediately before the oil is applied, is useful in preparing the skin for the action of the oil, and adds greatly to its efficiency. In the application of counter-irritants to young children great care must be taken not to carry the counter- irritation too far. An irritant which, in a healthy child, would produce only a moderate degree of redness, will often, where the strength is much reduced, set up very great in- flammation, or even produce sloughing of the tissues. Such a result would not only still further reduce the child's little remaining strength, but would act as a direct irritant to the part for which it is intended to be a deriva- tive. For this reason counter-irritation should, as a rule, be general rather than local, being employed m the form of stimulating liniments and hot baths. Sometimes, however, a local counter-irritant is required. In these cases equal parts of flour of mustard and linseed meal should be used. Blisters are inadmissible for infants. For the hot bath, the water should be of the temperature of from 95° to 100° Fahr., and should be sufficient in quantity to cover the child up to the neck. After re- maining in the water for three, four, or five minutes, he should be quickly but thoroughly dried, and be then wrapped in flannel and returned to his cot. It is of great importance that he should not be left too long in the hot water. The effect of the hot bath is at first stimulating, but after stimulation comes reaction, and depression is induced. He must be, therefore, removed before the stimulating effect has had time to pass off. Children, especially when unwell, often show great repugnance to INTRODUCTION 13 the bath, and become much terrified at the sight of the water. In these cases it is convenient to cover the bath with a blanket ; the child, being placed upon this, can be lowered gently down into the water without seeing any- thing to excite his apprehensions. Sometimes a more powerful stimulant is required. In these cases the child should be wrapped in flannel wrung out of hot water, and upon which some flour of mustard has been sprinkled ; the whole being covered with a dry warm blanket. Or the mustard bath may be adopted. For this, some flour of mustard is mixed with cold water, and is put into a linen bag. The bag is then squeezed in the bath, and the water becomes strongly sinapised. The child is held in the warm water until the arms of the persons supporting him begin to prick and tingle. The quantity of mustard required for this bath is in the pro- portion of two ounces to five gallons of water. The immediate effect of the cold bath is directly con- trary to that of the hot bath. Its first effect is depressing, on account of the shock. In a few seconds, however, re- action succeeds to the temporary depression, the surface of the body glows, and the pulse becomes fuller and stronger. It acts, therefore, as a general stimulant and tonic, pro- moting nutrition, and giving tone to the body. If con- tinued too long, reaction subsides, and there is a sense of chilliness and languor, with loss of appetite, which may last for several hours. The shock is great in proj^ortion to the coldness of the water, and the degree of weakness of the patient. The addition of salt to the water makes it more stimulating, and increases the vigour of the reaction. On account of these effects the cold bath should be used with caution, and is inadmissible until the child is far ad- vanced towards convalescence. It then becomes a valuable means of invigorating the system. The water should not at any time be below the temperature of 60° Fahr., and should be used tepid at the first, the temperature of sue- 14 INTRODUCTION ceeding' baths being gradually reduced as the child gets stronger. Any chilliness or languor after the bath are signs that too cold water has been used, or that the bath has been continued too long. To be beneficial the whole process should be rapid. The child should be quickly sponged, and should then be dried briskly with a thick soft towel. The whole body should be afterwards well and firmly rubbed with the open hand to assist the re- action. In the case of delicate children, when a cold bath is used, it is advisable to prepare the skin for the action of the cold water by a vigorous shampooing of the spine and the body generally. By this means the skin is stimulated to resist the shock, and reaction is promoted. The shock is also diminished by allowing the child to sit with his feet and a few inches of his body in hot water (100°) while a pitcher of water at a temperature of 65° Fahr. is rapidly emptied over his shoulders. By the use of such precautions weakly children may make use of the cold bath without discomfort, and with the greatest benefit to their health. Of i7iternal remedies little need be said in this place, as full directions will be given afterwards in considering the treatment of the various diseases. The important point to remember is the uselessness of tonics so long as any derangement of the digestive organs remains uncorrected. In order that tonics may be beneficial, the stomach and bowels must be in a healthy state. It is only when digestion is restored that these remedies are admissible. They will then prove of extreme service, increasing the vigour of the stomach, and improving the tone of the whole body. To the general list of tonics cod-liver oil is an im- portant addition. It is, indeed, more a food than a medicine ; but for this very reason it should not be given in too large quantities. If too large a dose of the oil is given, only a portion becomes digested. The remainder INTRODUCTION 15 passes down through the bowels, and is seen unchanged in the stools, where it is at once recognised by its appear- ance and smell. In administering the oil our object should be to give as much as can be readily digested, but no more. For a child under two years of age ten drops will be a sufficient dose at the first. The quantity, after the first few days, can be gradually increased, but a careful watch must be kejyt upon the stools, and the aj^pear- aiice of any oil unchanged in the evacuations is a sign that the quantity must be reduced. For a child of this age we can seldom go beyond twenty drops for the dose, three times in the day. It must always be remembered that the oil is an addition to, not a sub- stitute for, other food, and is therefore only useful so long as it is well borne by the stomach. If it be found to impair the appetite, or to interfere in the slightest degree with digestion, its use should be immediately dis- continued. With regard to stimulants ; they are always required when the fontanelle becomes much depressed. The best form for infants is pale brandy, of which a few drops (five to ten) may be given in cold water or a little milk, as often as circumstances seem to demand the repetition. For older children the brandy-aiid-egg mixture of the pharmacopoeia makes the best stimulant. CHAPTER I INFANTILE ATROPHY INFANTILE atrophy, or simple wasting from insuffi- cient nourishment, is one of the commonest causes of death in infants under twelve months old. Many thou- sand children die yearly in London alone for the simple reason that they are fed with food which they cannot digest. And it is not only amongst the children of the poor that this form of marasmus is to be found. Infan- tile atrophy is common in all classes of life, for it is to faulty feeding, as a rule, rarely to actual want of food, that the wasting is to be ascribed. It may happen, however, that there is a real deficiency in the food supply. If an infant depend solely upon the breast of a mother whose milk, although abundant, is poor and watery ; or if suckling be protracted to a period when more substantial food is required, the nutrition of the child in either case must be unsatisfactory. When the mother is weak, anaemic, and evidently ill- nourished, her milk no doubt always suffers from the impoverished state of her blood ; but the converse of this is not always the case, for the milk of a woman may still be of very inferior quality, although in her health and general appearance she present no sign of weakness. MM. Yernois and Becquerel showed long ago that it is not women of the greatest muscular development who yield the richest milk ; but that, on the contrary, a robust figure may be inferior in milk-j^roducing power to one slighter and less apparently vigorous. VARIATIONS IN WOMAn's MILK 17 Analysis of breast-milk taken from different nursing mothers shows remarkable variations in the proportion of the several constituents. In the course of an inquiry, in which ninety-four samples were examined, Dr. A. H. Carter and Mr. H. D. Richmond found that the fat varied from 8*802 per cent, to 0'47 per cent. ; the proteids from 4*05 to 1-02 ; and the sugar from 8'89 to 4-38 per cent. On account of this wide diversity in the composition of human milk we cannot wonder that infants do not always thrive at the breast or that the choice of a wet nurse is often dis- appointing. The milk may be good enough in itself and yet fail to nourish the infant who takes it ; indeed, a breast- milk which suits one child may upset another, for if from excess of proteids or fat the milk prove too heavy for a child's digestion, the result as regards that particular nurseling cannot be satisfactory. Still, all we can do in choosing a wet-nurse is to ascertain the state of her health and the quality of her milk, leaving the suitability of her milk to the individual infant to be determined later by actual experience. For practical purposes we may make a guess at the goodness and quantity of the milk by inspection of the breasts of the mother or nurse. They should be pear- shaped, hardish, and mottled with blue veins. On pres- sure of the gland the milk should squirt out. The milk itself should be opaque and of a dull white colour. Under the microscope it should present fat globules of medium size, not too small. As a rule, the number of fat globules is a rough indication of the quantity of casein and sugar, although this is not always a trustworthy guide. The best test, however, of the goodness of the milk is derived from observation of the child. He should be watched while at the breast, and if he sucks vigorously, finishes the meal with the milk running over his lips, and requires to suck but a few times in the day, we may infer that the milk is sufficiently abundant. If, on the other hand, he 2 18 INFANTILE ATROPHY constantly requires the breast, sucks laboriously and with effort, occasionally desisting and crying peevishly, the milk is probably scanty. As an additional test, the infant may be weighed immediately before and after taking the breast ; the increase in weight should be from three to six ounces, according to his age. Even if the breast milk be poor or scanty, it is rare for infantile atrophy to arise from failure in the quantity of food supplied, as there is seldom any lack of readiness to make good the deficiencies of the breast. As a rule, it is not the quantity but the quality of the food which is at fault, for the inflow of nutritive material may still fall greatly short of the infant's wants, although the supply of food, as food, is liberal enough. We see this in cases where a child is brought up by hand, either wholly or partially, and fed with a food which is ill-suited to his limited digestive power. Here the diet substituted for the mother's milk, although nutritious enough in itself, supplies little nutriment to the infant. A child is not nourished in proportion to the bulk of the food he receives into his stomach. He is only nourished by the food he can digest. Weakness in a child otherwise healthy, while it shows a deficient degree of nutrition, and therefore calls for an increased supply of nourishment, calls at the same time for increased care in the selection of the Mnd of food. There is a difference between food and nourishment. A child may take large quantities of food into his stomach, but from weakness of his digestive organs, or from the indigestible nature of the food swallowed, may derive no nourishment from it whatever. On the contrary, it may cause great irritation and pain in the alimentary canal, and, setting up a febrile state, still further reduce the child whom it was intended to support. The tendency of mothers is to overfeed their children — to mistake every cry for the cry of hunger. Consequently, as the peevish- ness and irritability of the child increase in proportion to CAUSATION 19 the pain excited in the bowels, the food is made more and more " nourishing," until at last a violent attack of vomit- ing or of diarrhoea takes place, or a convulsive fit warns the parent that it is time to desist. Cases of steady emaciation will be constantly found due to this cause, especially in children who are brought up by hand. Amongst the poorer classes they are commonly fed upon farinaceous food as soon as they are born. This, of course, they are totally unable to digest. As a consequence, they dwindle and rapidly die, or if of particularly robust con- stitution, linger on, weak, ailing, and rickety, until an attack of bowel complaint, or other intercurrent disease, carries them off. The very fact that the secretion of saliva in the young child does not become established until the third month after birth, seems to indicate that before that age farinaceous articles of diet are unsuited to the infant, as saliva is one of the most important agents in the diges- tion of starchy foods. Besides, for perfect nutrition four classes of food are required — viz. albuminates, fatty sub- stances, carbo-hydrates, and salts. These are found in the most digestible form and the most perfect proportions for the young child in the casein, fat, sugar, and salts of - the human milk. The casein supplies the waste of the nitrogenous tissues, as the muscles, and probably the brain and nerves, and by its oxidation, when it has formed part of these tissues, contributes also to animal heat. The fat is essential to the formation of muscular and nervous tissues, and also aids by its oxidation in the production of heat. The sugar is probably entirely heat-giving. The salts form the necessary constituents of all tissues. In nutrition, it is important that tissue change should be rapid, and in young children, in whom development as well as growth is so brisk, this is of special importance. It is effected by the oxidation of old material, which is then removed, to be replaced by new matter. For rapid change, therefore, it is indispensable that no needless im- 20 INFANTILE ATROPHY pediment should exist to the free oxidation of the tissues. Now, starches, and sugars into which the starches are converted by digestion, have a greater affinity for oxygen than albuminates ; they, therefore, tend to appropriate the oxygen which is required for the removal of waste matters, and so to prevent the proper changes from taking place. For this reason alone, and without any reference to their indigestible properties, they form a very unsuit- able diet for a young child. Even those children who are fed entirely on cow's milk are not free from danger. By referring to the table ^ we see, in comparing the milk of the cow with human milk, that the former contains a considerably larger quantity of Water. Sugar. Casein. Fat. Ash. Woman's milk . 87-163 7*407 1-046 4-283 •101 Cow's milk . 88-549 4-898 2-792 3-310 •451 casein. On the other hand, the pro]Dortion of sugar and cream is less than that found in human milk. In adapt- ing it, therefore, as a substitute for the natural food of the child, it will be necessary to remedy these differences by dilution with water, and by the addition of a small quan- tity of sugar of milk. But this is not enough. There is another distinction between the two fluids which it is extremely important to take into consideration. On the addition of rennet, the casein of human milk coagulates into light, loose clots, formed by the aggregation of little flocculi, while that of cow's milk congeals into heavy, com- pact lumps. The same thing takes place in the stomach of the child, as is shown by producing vomiting in an infant directly after a meal by friction over the belly : the * Dr. A. V. Meigs, * Archives of Pediatrics,' April, 1884, CAUSATION 21 light, loose clots formed from human milk are then readily distinguishable from the dense masses of casein produced by coagulation of the milk of the cow. The difference in the digestibility of these two products is very evident. While the one is readily assimilated without any undue demand upon the digestive powers, the other tasks these powers to the utmost, and, unless a very moderate quan- tity has been taken, will undergo fermentation, and give rise to much flatulence, colic, and perhaps diarrhoea in its progress along the alimentary canal. Children are, no doubt, frequently found to thrive upon this diet, their digestive power being equal to the demands made upon it. Others, however, and by far the larger proportion, are not equal to this daily call upon their powers. They cannot assimilate this mass of curd. Con- sequently, unless rejected by vomiting, the meal passes through them undigested ; their wants are not supplied ; and they starve for lack of nourishment, although swal- lowing every day a quantity of milk which would be ample support to a stronger and healthier infant. Such children are exceedingly restless and irritable. They cry day and night ; at one time from abdominal pains excited by the presence in the bowels of this undigested mass ; at others from the hunger which the passage of this meal has failed to appease. The nurses say, very truly, that the child is ravenous," and that " the milk does not satisfy him ; " but the baked flour, the infant's biscuits, and the tops and bottoms " by which they propose to themselves to attain that end are by no means calculated to do so. In- stead of mitigating his distress, they aggravate it; and every additional meal, although it may quiet him for the time, forms a subject for future complaints. It is, how- ever, often very difficult to persuade mothers and nurses of the importance of what has been stated. They see that the child is wasting under the diet they have first adopted, and therefore insist that something more solid must be 22 INFANTILE ATROPHY required. It is necessary to impress upon them very strongly tliat a child may actually starve on the fullest diet ; and that the presence of large quantities of farin- aceous or caseous matters in the alimentary canal is not necessarily followed by any additional supply of nourish- ment to the tissues. In all cases where the food of a-n infant is said by nurses to be insufficient the stools should be examined, and if, as is so frequently the case, they are found to consist of pale, round, hard lumps, exhibiting in their interior the cheesy appearance so characteristic of a mass of curd, we may safely conclude that it is not too little that is being given, but too much ; and by taking the necessary care we may succeed in providing the child with a diet he is capable of digesting. Besides the weakness produced by the withholding of nourishment, there is an additional cause of debility in the constant attacks of vomiting and diarrhoea, to which this indigestible diet invariably leads. Each of these attacks reduces him more and more, and by weakening his digestive powers renders him less than ever able to obtain any nourishment from the food with which he is supplied. Symptoms. — The symptoms of simple wasting from in- sufficient nourishment may be divided into two classes, according to the nature and quality of the food taken : — Food suitable but insufficient. Food unsuitable. In the first of these classes there are no very striking symptoms. The infant gradually loses his plumpness ; his fat slowly disappears ; and the muscles get very flaccid and soft. He does not seem to grow. His face becomes pale, and his lips pale and thin. He is peevish as a con- sequence of his hunger ; takes the breast ravenously at the first, and then, if the secretion of milk is scanty, desists at intervals to cry passionately as if in vexation at his inability to obtain the means of satisfying his wants. His skin is moist, and he perspires readily and copiously. The SYMPTOMS 23 fontanelle is level or slightly depressed, At night he is exceedingly irritable and sleepless. In the daytime he will often lie quietly enough, holding both thumbs in his mouth, and sucking at them until the skin at the sides of the nail becomes raw and abraded. If the milk is poor but abundant, the child is usually very quiet and drowsy, passing almost all his time asleep, He may even sleep while at the breast — a sure sign that the milk is thin and serous. The bowels are usually confined, and the motions rather solid, although otherwise natural. No symptoms are found to indicate disease of any particular part of the body. In this class of cases nutrition is defective on account of the inferior quality and insufficient quantity of the mother's milk, and nothing is added to compensate for tliese defects. The remedy is, of course, to supply the deficiency. When the required nourishment is given, the wasting stops at once, the peevishness ceases, and the child, rapidly regaining flesh, becomes strong and healthy. In the second class of cases, where the food is bad in quality, we find the symptoms produced by the irritation of the digestive organs to which the presence of indigest- ible food necessarily gives rise. The child is dull and languid, his flesh becomes flabby, and he begins to waste. The skin is moist at the first, although afterwards it is apt to become dry, except about the head ; and the fontanelle is, or soon becomes, depressed. The face and body gene- rally are pale, and the complexion sometimes turns yellow- ish, assuming a half -jaundiced tint, which remains several hours, or even days, and then disappears. The tongue is clean, pink, and moist, and remains so long as there are no symptoms of acute digestive disturbance. The bowels are irregular and capricious ; constipation alter- nating with occasional attacks of diarrhoea. The common condition is constipation ; a stool occurring every second day consisting of hard, whitish lumps, covered with a 24 INFANTILE ATROPHY stringy iiiucus, and formed almost entirely of undigested food. Its evacuation is often attended with much strain ing, and may be preceded by some pain in the belly. The cause of this sluggishness of the bowels is the presence of mucus secreted in unusual quantities on account of the irritation to which the membrane lining the alimentary canal is exposed. This mucus, being coagulated by the acid resulting from the decomposition of the starchy food, covers the contents of the bowels, and also forms a tena- cious lining round the inner surface of the intestine. Consequently the bowels, in their peristaltic action, glide over the slippery surface of the masses of food, and lose their power of propelling these forwards towards the out- let. Sometimes, however, instead of being confined, the bowels are open three or four times a day, the stools being green, half-liquid, slimy, and extremely offensive. In either case the food which the child has taken passes through him without being digested. Flatulence is a source of great annoyance to the infant. It may cause paroxysms of violent pain, in which the face becomes white, the upper lip livid and everted, and the belly tense. The child utters piercing cries, at the same time drawing up the lower limbs suddenly and violently upon the abdomen. Even during sleep frequent startings and moanings, elevation of the corners of the mouth, and, if the pain be severe, a contraction of the brows, show that the child is suffering from abdominal pains. The smile which is sometimes seen upon the child's face during sleep is a result of the same cause, although, of course, to a much less degree. The wind is often evacu- ated in large quantities, or comes up as sour- smelling eructations, affording great relief. During the attacks of colic the action of the kidneys seems to be suspended, and the termination of the spasm is generally accompanied by a copious discharge of urine. The temper is exceedingly irritable. The i^ain and uneasiness from which these SYMPTOMS 25 children suffer, and which is constantly being renewed by every additional meal, makes them noisy in their lamen- tations to a degree which is almost unbearable. As the mothers say, "they wear one's life out." At night this is especially the case. At that time they are apt to be feverish, and are often seized with fits of screaming which nothing will appease and which sometimes con- tinue until actual exhaustion compels them to desist. Even then, however, the cries are renewed at intervals, as a fresh attack of abdominal pain rouses them from uneasy sleep. At these times the feet are usually cold, although the belly, hands, and cheeks may be dry and hot. But in spite of all this, or rather as a consequence of it, the appetite is usually enormous. The uneasiness pro- duced by acidity and flatulence will often excite in children a great desire for food ; and unless the uneasiness amount to actual pain, they will swallow ravenously whatever is offered to them. The amount of farinaceous matter an infant will consume in this way is sometimes very large ; and the fact that, in spite of such voracity, the child should still continue to waste, excites much wonder amongst his attendants. Attacks of nettlerash and strophulus, either separately or combined, are very common. With the appearance of nettlerash every one is familiar. Strophulus may be either of the red or the white variety. Red strophulus (red-gum) begins as a red blotch, the centre of which is slightly elevated. The redness soon fades, and the central elevation enlarges and forms a flattened papule, often of considerable size. These are seated on the face, neck, arms, and sometimes cover the whole body. White strophulus appears in the form of pearly white opaque papules, smaller than the preceding, and about the size of a small pin's head. They are seen usually on the face and arms. The presence of either of these eruptions (nettlerash or 26 INFANTILE ATROPHY strophulus) oil the body of a young child is a certain sign of digestive derangement. Thrush (parasitic stomatitis) is another consequence of the unsuitable diet to which the child is exposed, and is especially common in warm weather. The mucous mem- brane of the mouth becomes red ; then little concretions, transparent at first, afterwards pearly white, appear on the reddened surface, unite, and form patches varying in size, and looking like little bits of curd adhering to the tongue, and to the inside of the cheeks and lips. In very bad cases they line the whole interior of the mouth, and may extend into the fauces, down the gullet, and even, according to Parrot, into the stomach and -intestines. At the same time there is a little febrile disturbance, with some thirst ; usually vomiting ; and often a thin watery diarrhoea, from the irritation of deranged intestinal secre- tions. If, as frequently happens, the nates become red and excoriated by the discharges from the bowels, the thrush is said by nurses to have " gone through " the child. There is some tenderness of the mouth, and if the child be put to the breast in the course of tbis complaint, he often refuses to suck on account of the pain excited by the movement of the tongue and cheeks. The concretions are due to a cryptogamic vegetation, oidium albicans, which appears to be identical with the sacchoromyces mycoderma, or mould of wine. Its sporules multiply with great rapidity, and form tubular fibrils. These with an increased formation of epithelial scales, constitute the white patches seen on the mucous membrane. The plant finds a nidus in the altered secre- tions of the mouth. This is either a mild or a severe complication, according to the general condition of the child in whom it is found. If it occur in a child who has been reduced to a state of great weakness by a long course of improper food, it is of very unfavourable augury, for in such a case our hopes of SYMPTOMS 27 -improving his health dexjend upon the rapidity and com- pleteness with which new material for nutrition can be introduced into the system. Anything, therefore, which tends to prevent the introduction of nourishment tends to deprive the child of this his only means of recovery ; and the presence of thrush betrays a condition of the digestive passages extremely unfavourable to the ready assimilation of food. Moreover, the diarrhoea which is so apt to accompany the disorder, especially in weakly children, is another reason for regarding the occurrence of this com- plication, in such cases, with considerable anxiety. In stronger children, want of cleanliness, or temporary derangement set up by improper food, may give rise to thrush ; but here, if the strength is satisfactory, recovery is usually rapid : the concretions become greyer, then yellow ; fall off, and are not renewed. Another symptom of the irritation excited by unsuit- able food is that known in nurseries under the name of inward fits." The phenomena which constitute the con- dition denoted by this rather vague expression, are a blue- ness or lividity of the upper lip, which is rather everted, and may twitch ; a slight squint, or a peculiar rotation of the eye ; with contraction of the fingers, and twisting inwards of the thumbs. These symptoms should never be disregarded, as they are often the precursors of an attack of convulsions. If a great accumulation of food has taken place in the alimentary canal, or if the child has swallowed some sub- stance which is more than usually indigestible, or has been exposed to cold, the symptoms may become more alarming. The skin gets very hot, the face flushed, and there is violent vomiting of sour- smelling food, with mucus, pre- ceded by great retching. The efforts to vomit may con- tinue after the stomach has been emptied, and then green or yellow bile is thrown up. At the same time the bowels become very loose, and large, dark green, or putty-like, 28 INFANTILE ATROPHY offensive motions are passed, with great straining. The motions often contain little lumps, and each action of the bowels is preceded by much griping, during which the child screams, draws up his legs, and throws himself uneasily from side to side. The tongue is rather dry, and is thickly coated, white or yellow, with large, round, red or pink papillae scattered over its surface, peering through the fur. The belly is full, rather hard, and irregular to the touch. The child refuses all food, but is very thirsty ; he usually, however, vomits the fluid he has taken very shortly after swallowing it. Sometimes a convulsive fit ushers in this attack, and may be repeated several times. Occasionally these fits recur in such numbers, and with such violence, as to cause death by the exhaustion they induce. The vomiting usually ceases after the first day, or is repeated at longer intervals, but the diarrhoea con- tinues for two or three days, unless treatment be quickly had recourse to, and the motions change their character, becoming watery, and usually of a brown colour, still remaining extremely offensive. If the straining be great, there may be slight prolapse of the bowel, with a little blood in the form of red streaks in the motions. In children over twelve months old, such attacks are often accompanied by aphthae of the mouth. These are found on the tip of the tongue, round the anterior part of its margin, and on the inside of the lower lip. They consist of small circular superficial ulcers seated at the follicles of the mucous membrane. At the same time the lower gums are usually red, swollen, and shining ; they easily bleed, and may be ulcerated along the roots of the incisor teeth. There is also increased secretion from the mucous membrane of the mouth, with some salivation. The number of the aphthae varies from two or three to fifteen or even twenty. They are very rarely solitary, usually about five or six. When the attack subsides, the infant, unless a better SYMPTOMS 29 system of management be adopted, goes on as before, the wasting continues, and he becomes gradually weaker and more languid. The attacks of acute indigestion recur at short intervals, each, as it passes off, leaving him more prostrate, and less able to withstand the injurious influ- ences which are gradually wearing away his life. His face becomes wrinkled and old-looking ; his eyes dull and heavy; his expression languid, or peevish; and, as his debility increases, the griping pains to which he is still subject excite no longer a fretful cry, but only a plaintive moan ; or merely a contraction of the features without any sound. His emaciation becomes extreme ; his belly large ; his skin harsh and dry ; his fontanelle deejDly depressed ; and, finally, some secondary disease arises, and puts an end to his existence. Any acute disease attacking a child in such a condition is almost certainly fatal, for all resisting power has been starved out of him, and he falls a ready victim to a disorder which, in a healthy child, would be easily manageable, and quickly cured. A nephri- tis is readily set up in such impressionable subjects, and is a not uncommon complication towards the end. The renal condition may be due, as Czerny and Moser believe, to micro-organisms carried into the circulation from the alimentary tract. M. Simmonds avers that the middle ear is the source of the mischief. He found evidence of otitis media in twenty-eight out of twenty-nine necropsies ; and states that the tympanic cavity contained Friedlander's bacillus, Fraenkel's diplococcus, streptococcus pyogenes and other dangerous microbes. Consequently he asserts that middle ear disease with resulting degeneration of the kidneys must be one of the commonest causes of death in wasting infants. If the child has been brought up entirely by hand, and has been fed improperly from his very birth, he seldom lives longer than two or three months. If he has been suckled for some months before he begins to take the improper food. 30 INFANTILE ATROPHY he has greater j^ower of resistance; and although under the new diet he will soon become dull, and pale, and flabby, yet the effects upon his flesh and strength are less notice- able, and he usually drifts into rickets before any appear- ances have been thought sufficiently serious to require medical interference. Treatment. — The treatment of simple wasting from insufficient nourishment consists principally in so selecting the diet of the infant, with due regard to his age and capabilities, that he may be able to digest, and therefore to be nourished by, all the food he takes. To do this, we must be thoroughly acquainted with the scale of diet suited to a healthy child from his birth onwards ; we are then able to vary this diet according to the digestive power we find in our patient. The weaker the child, the more nearly does his condition resemble that of a new-born infant in his power of assimilating different articles of food, and therefore the earlier in the scale must we look for the nutriment suited to his wants. A short sketch of this subject will, then, not be out of place. The child ought, if possible, to be suckled by his mother, and every mother ought to make an effort to perform this duty. Should she, however, after repeated trials, prove unable to suckle, a wet-nurse must be provided, or the child must be brought up by hand. In choosing a nurse, attention should be paid to two points, — viz., the state of her health and the quality of her milk. With regard to her health, she should be examined for signs of phthisis, scrofula, or syphilis ; her breasts should be inspected, and the milk may be analysed to determine its proportion of proteids and fat. The best test, however, is the condition of her child, who should always be looked at. If he is healthy and thriving, the milk is in all probability of good quality ; but we have still to find out if it will agree with a new nurseling, and this can only be proved by actual ex- NURSING 31 periment. Much depends upon the percentage of proteids and the infant's power of digesting them. In cases where the child shows signs of discomfort after taking the breast or is subject to attacks of colicky pain, with a constipated state of the bowels, the percentage of proteid s in the nurse's milk is probably excessive. It was noticed by Messrs. Carter and Richmond that in most of the cases where the proteids exceeded 2*5 per cent, the milk disagreed with the infant. -If then, the first nurse prove a failure we must try another, and, if necessary, repeat the change again and asrain, for we cannot rest until we have found a nurse who is fitted in every way to make the infant strong and healthy. The time which has elapsed since the nurse's confine- ment — a point to which so much importance used to be attached — matters little provided she be not nearing the end of the normal period of lactation ; for after the first month the composition of the breast-milk remains fairly stationary. If any change occur it is rather in the direc- tion of a decrease in the proteids and ash and an increase in the sugar. The diet of a nursing woman should be liberal : a certain amount of fresh vegetables and fruit should be included in her meals, and she may take moderate quantities of wine or beer. Young mothers with a first child are sometimes awk- ward in the handling of their charge, and this is not unimportant. Infants held awkwardly to the breast often find a difficulty in retaining the nipple, and may refuse the breast and be very fretful on this account. The mother should not hold herself too erect, but should bend over the child so as to allow the nipple to fall easily into his mouth. The child should be placed partly on his side, and the mother should support the breast with the two first fingers of her unoccupied hand, so as to keep it steady while the child draws the milk. If the milk flows 32 INFANTILE ATROPHY too quickly and abundantly, as sometimes happens, it may cause vomiting from the rapidity with which it has to be swallowed. In these cases she should be taught to press gently with the two fingers which hold the breast, so as to regulate the flow. The new-born infant should be put to the breast a few hours after birth ; or as soon as the mother has recovered from the first fatigues of labour. This course has several advantages: it ensures the proper contraction of the uterus, for when the child has once taken the breast, no danger from after haemorrhage is to be apprehended ; the child has the benefit of the thin, watery colostrum which precedes the appearance of milk in the breast, and acts as a gentle laxative upon the bowels, clearing out the meco- nium with which they are loaded ; and the nipple is drawn out while the breast is still soft. If suckling is delayed until the secretion of milk has become regularly estab- lished, the breast is apt to be distended by its secretion, so as almost to hide the nipple. The child has then great difficulty in obtaining a hold of the nipple, and may besides suffer much pain trom the pressure of his face against the hardened gland. No food of any kind should be given to the child at this time. The practice of giving butter and sugar, gruel, &c., to a new-born babe is a mere cruelty, and must be strictly forbidden. The child should be put to the breast, even although there be no milk. There is always more or less colostrum, which forms a sufficient nourishment until the supply of milk becomes confirmed. Whether the mother is afterwards to suckle her child or not, she should endeavour at any rate to do so for the first month, during which time a fitting nurse can be secured, if a wet nurse be desired. The child should take the breast at regular intervals, every two hours during the day for the first six weeks ; and he should suck from each breast alternately. At night it is important that the mother should be undis- NURSING 33 turbed ; and besides, it is well to accustom the child to quiet during the hours of sleep. He should, therefore, be fed for the last time at 11 p.m., and be then put to rest in a cot in the nurse's room, until five o'clock on the follow- ing morning, when he may again take the breast. By this means the mother is ensured six hours' uninterrupted sleep. If, during the interval, he awakes and cries, he may be pacified by a small quantity of condensed milk diluted with water. After six weeks, the interval between the meals should be increased to three hours, or even longer, if the child shows no desire for the breast. It is as great a mistake to urge an infant to take nourishment as it is . to quiet him with the breast whenever he cries. The mother should be able to perceive when her child cries from hunger, and when from uneasiness or ill- temper. If the babe rouses himself and seems pleased at the sight of the mother, clenching his hands, and flexing his limbs, he is hungry. If he remains passive, he does not require the breast. If he cries peevishly, has a hot skin, and jerks his lower limbs uneasily about, he is troubled with indi- gestion, and the milk would only increase his discomfort. Indigestion is not so uncommon in infants reared at their mother's breast as might be supposed, for it is not every mother whose milk is exactly suited to her own child. If, as may happen, the proportion of proteids in her milk be too great for the infant's easy digestion, we find symptoms of abdominal discomfort, if not actual colicky pain, after taking the breast, and the bowels are costive with scanty clay-like stools. In such cases walk- ing exercise, stopping short of actual fatigue, should be recommended for the mother, and she should take plenty of farinaceous and vegetable matter with her meals. By this means the excessive quantity of proteids in her milk may be reduced. I have also found it useful to give a few ounces of plain barley water from a feeding bottle to the child just before he is put to the breast. 3 34 INFANTILE ATROPHY Up to tlie age of six moiitlis tlie breast must remain the child's sole nourishment, provided that the secretion of milk, and its quality, are found to be satisfactory. If not, and the child wastes, or does not grow, other food must be given in addition, as will be afterwards described. If the mother cannot suckle her infant, and a wet-nurse is not desired, the child must be " brought up by hand," feeding from a bottle. The hand-feeding of infants differs from suckling by demanding more attention on the part of the nurse, and some tact in accurately adapting the quality of the food to the powers and requirements of the baby. To be thoroughly successful there are two points which it is important to bear continually in mind. In the first place, we must select a diet which not only contains in itself all the elements of nutrition, but which also pre- sents them in such a form that an infant is able with perfect ease to digest and assimilate them. No food can satisfy the wants of the infant unless it contain material to supply the waste of the nitrogenous tissues : therefore a merely starchy substance, such as arrowroot, which enters so largely into the diet of children, especially amongst the poor, is a very undesirable food for infants, unless given in very small quantities, and mixed largely with milk. The second point to be remembered is that the digestive organs of an infant are excessively delicate, and liable to be deranged by apparently trifling causes. His digestive power is therefore subject to frequent varia- tions corresponding accurately to his state of health, and a diet which is appropriate one day may be unsuitable the next. Unusual irritability and fretfuliiess, abdominal discomfort and griping pains, vomiting or diarrhoea — any of these symptoms indicates that the digestive powers are for the time below par, and that some modification of the diet is required. Taking human milk as the natural and most perfect food for a young child, our object must be to make as HAND-FEEDING 35 near an approach as possible to this standard in the sub- stitute we proj^ose to adopt. The milk of some animals, notably that of the ass, resembles women's milk very closely ; but cow's milk, which is i^lentiful and cheap, is usually chosen, and when properly prepared and modified serves our purpose well. We must remember, however, that not only does human milk differ in composition from the milk of the cow, but that it differs also in another point which it is important not to lose sight of. The former is drawn straight from the gland pure and uncon- taminated by germs ; the latter has to pass through many hands before reaching the nursery. The risk of pollution is therefore great, and the milk is apt to contain microbes of various kinds, some of which may be highly injurious. Attacks of bowel complaints of great gravity, epidemics of diphtheria and scarlatina, and tubercular disease with its many fatal manifestations, may all owe their origin to impure cow's milk. Our first care, then, should be to destroy any existing organisms by heat. A temperature of 167° Fahr. is said to be sufiicient for this purpose, but I think it better to sterilise the milk in one of Soxhlet's sterilisers, or at any rate to boil it for twenty minutes in a water bath, before allowing it to be used. It is to be regretted that by this means we render the milk less per- fect as an antiscorbutic, for infantile scurvy may develop in hand-fed babies who are being reared on boiled or sterilised milk ; but this is a risk which it is worth while to run for the sake of avoiding the greater evil, especially as infantile scurvy, if it begin, can be easily put a stop to. Cow's milk has a higher specific gravity, and, as has already been stated (see p. 20), contains a larger proj)or- tion of curd, but less sugar and cream, than are found in human milk. These differences can be at once remedied by dilution with water, and the addition of cane or milk sugar in sufficient quantities to supply the necessary sweet- ness. The other and greater objection to this milk con- 36 INFANTILE ATROPHY sists in the much firmer clot formed by its casein when coagulated. It is this peculiarity which explains the difficulty often found by infants, especially in large towns, in digesting cow's milk, however diluted it may be; for the addition of water alone will not hinder the firm clot- ting of the curd. On this account methods of preparation which merely lessen the proportion of curd in cow's milk, and increase the proportion of sugar, cannot be relied upon to produce a perfectly satisfactory food for a young baby. No doubt by such means the proportion of curd and sugar normally existing in human milk may be faith- fully imitated ; but the curd retains its original property of firm coagulation, and although reduced in quantity is not rendered any the less difficult of digestion. It is for this reason that Dr. Frankland's plan of treating cow's milk is so often disappointing. By this method of pre- paration the milk is diluted with a third part of whey, and sugar and cream are added in such quantities as to imitate accurately enough the proportion of casein, sugar and fat contained in human milk. But the name of " artificial human milk" is not thereby justified, for the casein, although reduced in quantity, is no easier of digestion than it was before. Perhaps the closest imitation of breast milk is seen in Gartner's * Mother's Milk.' Cow's milk diluted with an equal quantity of sterilised water is placed in a rapidly revolving centrifugal separator, which divides it into two parts — a creamy milk and a skimmed milk. The former contains about half or rather less of the casein and almost all the fat, giving a chemical composition of proteids 1-76, fat 3*5, sugar 2*5, ash 0*35. It therefore only requires the addition of a small quantity of sugar (about 4 per cent.) to reach the closest chemical correspondence with human milk ; but there is still the difficulty of the firmness of the clot. Infants, indeed, often do as well upon this preparation as they do upon humanised milk ; but to PREPARATION OF COw's MILK 37 many the toughness of the cnrd-clot is a continual trouble. It is this which is the great obstacle to the efficient feeding of infants. In order to make cow's milk a satisfactory substitute for the breast during the first few months of life, it must be so treated that the casein is presented in a digestible shape to the infant stomach. This object may be effected in one of two ways. The first method consists in adding an alkali, such as lime-water, to the milk. To be of any service, however, the quantity added must be considerable ; one or two tea- spoonfuls — the addition usually made to a bottleful of milk and water — is quite insufficient to effect the object desired. Lime-water contains only half a grain of lime to the fluid ounce ; of this solution so small a quantity as two teaspoonfuls would be scarcely sufficient to neutralise the natural acidity of the milk. Lime-water, no doubt, acts by partially neutralising the gastric juice, so that clotting of the curd is in a great measure prevented, and the milk passes little changed out of the stomach, to be fully digested by the intestinal secretions in the bowels. To attain this object at least a third part of the mixture should consist of lime-water. For a new-born infant two tablespoonfuls of milk may be diluted with an equal quantity of plain filtered water, and then be alkalinised by two tablespoonfuls of lime-water. This mixture, of which only a third part is milk, can be sweetened by the addition of a teaspoonful of sugar of milk. If thought desirable a teaspoonful of cream may be added. The whole is then put into a perfectly clean feeding-bottle, and is heated to a temperature of about 95° Fahr. by steeping the bottle in hot water. When warmed, it is ready for use. The proportion of milk can be gradually increased as the child gets older. A second plan by which the casein of cow's milk can be rendered digestible consists in adding to the milk a small quantity of some thickening substance, such as barley- 38 INFANTILE ATROPHY water, gelatine, or even one of the ordinary farinaceous foods. The action of all of these is the same, and is an entirely mechanical one. The thickening substance sepa- rates the particles of curd, so that they cannot run together into a solid lump, but must coagulate separately into a multitude of small masses. By this means the curd is made artificially to resemble the naturally light clot of human milk, and is almost as readily digested by the infant. Although any thickening matter will have the mecha- nical effect desired of separating the particles of curd, yet it is not immaterial what substance is chosen. The question of the farinaceous feeding of infants is a very im- portant one, for it is, as has been already remarked, to an excess of this diet that so many of their derangements may often be attributed. Owing to a mistaken notion that such foods are peculiarly light and digestible — a notion so widely prevalent, that the phrase food for in- fants " has become almost synonymous with farinaceous matter — young babies are often fed, as soon as they are born, with large quantities of corn-flour or arrowroot, mixed sometimes with milk, but often with water alone. Now starch, of which all the farinae so largely consist, is digested principally by the saliva, aided by the secretion from the pancreas — two fluids which convert the starch into dextrine and grape sugar previous to absorption. But the amount of saliva formed in the new-born infant is excessively scanty, and it is not until the fourth month that the secretion becomes fully established. Again, according to the experiments of Korowin, of St. Petersburg, the pancreatic juice is almost absent in a child of a month old ; even in the second month its secretion is very limited, and has little action upon starch. It is only at the end of the third month that its action upon starch becomes suffi- ciently powerful to furnish material for a quantitative exa- mination of the sugar formed. Therefore, before the age infants' foods 39 of three months a farinaceous diet is not to be recommended as a food for infants, unless the starchy substance be given with great caution, and in very small quantities. If administered recklessly, as it too often is, the food lies un- digested in the bowels, ferments, and sets up a state of acid indigestion, which in so young and feeble a being may lead to the most disastrous consequences. In fact, the deaths of many children under two or three months old can be often attributed to no other cause than a purely functional abdominal derangement, excited and maintained by too liberal feeding with farinaceous matters. There is, however, one form of food which, although farinaceous, is yet well digested by even young infants, if given in moderate quantities. This is barley-water. The starch it contains is small in amount, and is held in a state of very fine division. When barley-water* is mixed with milk in equal proportions, it ensures a fine separation of the curd, and is at the same time a harmless addition to the diet. Instead of barley-water, gelatine f may be made use of, and will be found to answer the purpose well. Farinaceous foods in general are, as has been said, injurious to very young babies, on account of the deficiency during the first months of life of the secretions necessary for the conversion of the starch into dextrine and grape * To prepare the barley-water — put two good teaspoonfuls o£ washed pearl barley with a pint of cold water into a saucepan, and simmer slowly down to two thirds. Strain. It should not be allowed to boil violently. Barley-water does not keep fresh beyond a few hours. It should therefore be made at least twice a day. Once made, it must not be heated to boiling point or it will rapidly turn sour. t To prepare gelatine — put a teaspoonful of gelatine into half a tumbler of cold water, and let it stand for three hours. Then turn the gelatine and water into a teacup ; stand this in a saucepan half full of water, and boil till the gelatine is dissolved. When cold this forms a jelly, of which a teaspoonful is to be added to half a bottleful of milk and water. 40 INFANTILE ATROPHY sugar. If, however, we can make such an addition to the food as will ensure the necessary chemical change, farina- ceous matter ceases to be injurious. It has been found that, by adding to it malt in certain proportions, the same change is excited in the starch artificially as is produced naturally by the salivary and pancreatic secretions during the process of digestion. The employment of malt for this purpose was first suggested by Mialhe, in a paper read before the French Academy in 1845, and the sugges- tion was put into practice by Liebig fifteen years later. Many chemists now prepare malted foods. These differ from each other only in the proportion they contain of unconverted starch. For the young infant that food is most suitable in which the starch is most completely con- verted into dextrine. It is for this reason that Mellin's food is so valuable a resource. This food is found on analysis to contain absolutely no starch at all, the whole having been converted during its preparation into dextrine and glucose. A teaspoonful of Mellin's food, mixed with milk and barley-water in equal quantities, is, as a rule, readily digested by the youngest infants. It very rarely indeed happens that it is found to disagree. Instead of malt, pancreatine may be employed as the digesting agent of starch. This plan has been adopted with great success by Mr. Benger. In Benger's food the farinaceous meal, finely ground and well cooked, is mixed with pancreatine. When the food is added to warm milk or milk and water, the digestive principle not only converts the starch more or less completely into dextrine, but also acts upon the casein, reducing it to a form in which it is as readily digestible as the curd of human milk. The food is a very good one, and usually agrees well. In all cases, then, where a child is brought up by hand milk should enter largely into his diet, and during the first few months of life he should be fed upon it almost entirely. We may begin with a mixture of boiled cow's HAND-FEEDING. 41 milk diluted with three or four times its bulk of freshly made barley-water, and alkalised with lime-water or a pinch of bicarbonate of soda. For the first six weeks one to two ounces of this food may be given at each meal, sweetened to taste with a little white sugar or sugar of milk. As the child grows older the quantity allowed must be increased, and at the same time the proportion of barley-water may be reduced. No broad rule can be laid down as to the proportion in the meals of the several con- stituents, for these must vary according to the child's digestive power. We must proceed cautiously, making the changes step by step, and watching the effect with care. If the milk be not rich, a little cream can be added with advantage. Instead of using barley-water, the milk may be thickened by adding to each quantity of milk and water a teaspoonful of gelatine, or it may be alkalised with lime-water as already described, or we may use a mixture of milk, barley-water, and lime-water in equal proportions. When trouble arises it is, with most infants, in the digestion of the heavy curd of cow's milk that the difficulty lies. Therefore, it is of importance, if the milk seems not to agree, to reduce the quantity of curd by further dilution with freshly made barley-water ; but as by this means the milk is also made poorer in fat and sugar, these must be added afterwards in the shape of cream and sugar of milk. In America '*milk laboratories"^ have been established in various towns by the energy of Dr. Eotch, and at his initiative it is becoming the custom for the physician to • prescribe a milk to contain cream, sugar, and curd in certain definite proportions. The chief advantage of this practice lies in the elaborate precautions adopted to prevent the pollution of the milk by morbific germs, and in our know- ledge that the milk swallowed by the child is really of the strength ordered. In other respects the practice offers * A milk laboratory " of the kind referred to, has been established in London by the Walker- Gordon Company. 42 INFANTILE ATROPHY little advantage over the more homely rule-of-thumb methods prevailing in this country. There is one other point in the feeding of infants which requires mention, a point little regarded as a rule, but which, to my mind, is one of extreme importance. I lAean the question of variety in the feeding. It is desirable for the mere sake of avoiding monotony and giving help to the digestion to alter from time to time the form in which the meal is giv^en to the infant. We must remember that the hand-fed baby is being reared upon a diet which its stomach is not specially fitted to digest ; which is, indeed, but a make-shift in the absence of its natural food. Any help we can give is therefore of value, and the useful and handy stimulus of variety is one which it would be folly to make light of. The addition of a teaspoonful of malt extract or Mellin's food, by altering the taste, will often give the spur to a jaded appetite or sluggish digestion, and it is interesting to note how quick the stomach is to recognise the change. It is best to make the addition to each alter- nate meal ; but sometimes this is not a sufficient variety, and a third kind of food has to be used in rotation with the other two. I have even known cases where an infant could only be kept well and thriving by so arranging the meals that no one of them was repeated in quite the same shape during the course of the day. Having fixed upon the kind of food which is suitable to the child, we must next be careful that the meals are not repeated too frequently. If the stomach be kept constantly overloaded, even with a digestible diet, the effect is almost as injurious as if the child were fed upon less digestible food in more reasonable quantities. A young infant passes the greater part of his time asleep, waking at intervals to take nourishment. These intervals must not be allowed to be too short, and it is a great mistake to accustom a child to take food whenever he cries. After his meal the infant should sleep quietly for at least two HAND-FEEDING 43 hours. Fretfulness or irritability in a very young baby almost always indicates indigestion and flatulence ; and if a child cries and whines uneasily, twisting about his body and jerking his limbs, a fresh meal, although it may quiet him for the moment, will, after a short time, only add to his discomfort. During the first six weeks or two months two hours will be a sufficient interval between the meals. Afterwards the interval can be lengthened, and at the same time a larger quantity may be given at each time of feeding. No more food should be prepared at one time than is required for the particular meal. The position of the child as he takes food should be half reclining, as when he is applied to his mother's breast, and the food should be given from a feeding-bottle. When the contents of the bottle are exhausted, the child should not be allowed to continue sucking at an empty vessel, as by this means air is swallowed, which may afterwards be a source of great discomfort. The feeding aj)paratus must be kept perfectly clean. The boat bottle is to be preferred, and this should be washed out after each meal with water containing a little borate of soda in solution, and must then lie in cold water until again wanted. It is desirable to have two bottles, which can be used alternately. With some children, in spite of all possible precautions, cow's milk, however carefully it may be prepared and administered, cannot be digested. Soon after being swal- lowed it ferments, and either excites vomiting or produces great flatulence and discomfort, while the general nutrition of the child becomes slowly impaired. This incapacity for digesting cow's milk may be a natural peculiarity of the child, but more often it is a merely temporary infirmity. In the former case, which is fortunately a rare one, no amount of preparation seems capable of rendering the milk digestible. So long as it is being taken, the child wastes slowly ; he is restless and uneasy by day, and excessively fretful by night, and apjoears to be tormented 44 INFANTILE ATROPHY constantly by abdominal pains. In such cases, if there are objections to a wet nurse, recourse must be had to the milk of some other animal ; and preference should be given to a milk which contains a smaller proportion of casein than is found in the milk of the cow, such as goat's or ass's milk.^ Either of these will do and will often agree, especially if a third or a fourth part of barley-water be added; or a teaspoonful of Mellin's food may be dissolved in either of these milks diluted with an equal part of water. The addition of one or two teaspoonfuls of an aromatic water, as dill or caraway- seed f water, is also of service. It should never be omitted if there is much ten- dency to flatulence. Goat's milk often has the strong flavour peculiar to the animal, but this is not objected to by infants ; moreover, it may be removed to a certain extent by boiling. Ass's milk is sometimes found to have slight laxative properties, but in this case also boiling the * The relation of these milks to each other and to human and cow's milk is shown in the following tahle. The analysis of the first three milks is from Dr. Frankland's work, " Experimental Researches on Chemistry " ; that of goat's milk is by Mr. A. W. Stokes. Casein. Butter. Sugar. Salts. Woman 2-7 3-5 5-0 •2 Cow 4-2 3 8 3-8 •7 Ass 1-7 1-3 4-5 •5 Goat 2-87 5-13' 4-69 •87 t A perfectly useful caraway-seed water may be made in the nursery by boiling two teaspoonfuls of crushed caraway seeds, enclosed in a little muslin bag, in a pint of water, until the quantity is reduced to one half. TINNED MILK 45 milk will often remove the disadvantage. A milk which is very useful for infants and others who cannot digest ordinary milk is obtained by re-milking the cow after the ordinary daily supply has been withdrawn. The residuum thus obtained goes in some parts of the country by the name of strippings." ^ It is very rich in cream, but comparatively poor in curd. One part of this diluted with two parts of water will in almost all cases agree well ; or one part of milk may be replaced by barley-water if there appears to be any difficulty in digesting the casein. In cases such as these, condensed milk is often of great service. For a young baby it should be diluted with nine parts of water, and it is well, as Dr. T. M. Rotch suggests, to add a teaspoonful of cream to the bottleful. New- born babies, as a rule, do well upon tinned milks, and often thrive upon them when cow's milk disagrees. I prefer the unsweetened brands as less likely to give rise to acidity. Allen and Hanburys' No. 1 food, which is a desiccated milk, is a useful form. Still, it must not be forgotten that a tinned milk, however digestible it may be, is no efficient substitute for the fresh milk of the cow. Children who are fed for too long a time upon such foods often become rickety, and sometimes develop symptoms of scurvy. In no case should an infant be allowed to depend for nourishment upon preserved milk longer than is abso- lutely necessary. As soon as possible this food must be replaced by fresh cow's milk diluted with barley-water. In all cases where a difficulty is found in digesting ordinary cow's milk we should make trial of peptonised milk prepared according to the plan of Dr. W. Roberts. * " Strippings " or " af terings are drawn two or three minutes after the cow has been milked. In many parts it is the custom for the dairy-maid to go the round of the cows after the milking is over and draw off the " strippings." The quantity obtained varies with the animal; some cows giving more than others. It may be a few ounces or as much as half a pint. 46 INFANTILE ATROPHY In milk so prepared the curd is digested by the action of pancreatine. An important drawback to this method, when the ordinary directions are followed and a large quantity is prepared at one time, is the bitter taste given to the milk by the pancreatine. To overcome this objec- tion I order each meal to be prepared separately in the following way : — " Put the milk, or milk and water, into a small saucepan and heat over a spirit-lamp. When the temperature reaches 140° blow out the lamp and stir up with the milk a good pinch of bicarbonate of soda, and Benger's solution of pancreatine in the proportion of fourteen minims to each ounce of milk. Let the pan stand uncovered for twenty minutes." The milk is now ready for use and must be given at once. It can be sweetened by the addition of half a teaspoonful of extract of malt. So prepared, the milk is not bitter, and will often be taken readily and digested perfectly by babies who can take it in no other form. All infants are subject to passing attacks of gastric derangement which for the time lessen digestive power, and may obviously impair nutrition. These disturbances are the chief dangers met with in the hand-feeding of infants. If a food be persisted with after it has begun to disagree, a catarrh of the delicate mucous membrane is certain to be set up. When this happens a change in the diet is not necessarily followed by immediate improvement. The contents of the stomach swarm with bacteria, and an acid fermentation begins which is likely to go on as long as fermentable matter continues to be swallowed. A sour smell from the child's mouth is a certain sign that this fermenting process is in existence, and measures should at once be taken to bring it to an end. A reduction in the quantity of milk is an essential step in such treatment ; and if the case be a severe one, and the fermenting process active, it may be necessary, for a day or two, entirely to exclude milk from the diet. Its j^lace must be taken by PRECAUTIONS IN FEEDING 47 mixtures of freshly made whey and barley-water in equal parts ; veal broth (half a pound of meat to the pint) and barley-water (equal parts), or Mellin's food dissolved in whey or barley-water. To the latter fluids (whey and barley-water) I often add five or ten drops of one of the cold extracts of meat, such as Bovinine or liq. carnis, and think the addition a useful one. After a day or two, and when all signs of fermentation have ceased, the milk may be returned to, but it should be given cautiously at the beginning, and in small quantities ; and the first symptom of discomfort is a sign that the quantity must be reduced. In every case where milk is found to disagree, we should be careful to satisfy ourselves that it is really the milk which is at fault, and not its method of jjreparation, or the way in which it is given. Too large a quantity may have been given at once, or the meals may have been too frequently repeated ; or the food, originally sweet, may from keeping have turned sour. The practice of prepar- ing in the morning the whole day's supply of food is a very dangerous one. It rarely happens, at the close of the day, that such food is fit for the child's consumption.* Again, the whole secret may lie in a want of cleanliness of the feeding apparatus. Amongst the j)oorer classes, so common is this fault, that it is really the exception to find a perfectly clean feeding-bottle, and a large propor- tion of the deaths amongst their children may be traced to this carelessness alone. Even amongst the wealthier classes, in cases where the direction of the child's meals is left entirely to servants, the necessary cleanliness is not Dr. Baginsky, of Berlin, found that when human milk, cow's milk, condensed milk (Swiss), two varieties of farinaceous food, and two specimens of prepared infants' food, were separately exposed for twenty- four hours to a temperature of 67° Fahr., the two first remained un- changed, except that the cow's milk had become slightly acid. On the other hand, the Swiss milk, the farinaceous, and the infants' foods, although apparently fresh, had a strongly acid reaction, and exhibited under the microscope bacteria in active motion. 48 INFANTILE ATROPHY SO common as could be wished. The first care of the medical attendant when called to a child brought up by hand, should be to send for the feeding-bottle, and to satisfy himself by his sense of smell that it is fit for use. When a child is six months old, farinaceous food may be given without danger, and will indeed be a useful addition to his diet. The kind of food to be chosen is of considerable importance, and in the selection we have to consider not only what food is best in itself, but also what food is best digested by the child. The same food may not agree equally well with different infants, and in cases where our first trial is unsatisfactory, it may be necessary to change the food several times before we have found the one which is suited to the particular case. The farinae contain nitrogenous matter, starch and salts in varying proportions, and those of them are best suited as food for infants which approximate most nearly to milk, the natural diet of the child, in the relative propor- tion of their several constituents. Thus the relation of the nitrogenous, or nutritive element to the calorifiant, is in human milk as one to four ; in wheaten flour one to five ; in potatoes one to nine ; in rice one to ten ; and in arrowroot, tapioca, and sago, one to twenty. The calori- fiant matter exists in farinaceous substances in the form of starch, which during the digestive process becomes converted into sugar before being taken up by the ab- sorbent vessels. But that this change should take place, it is important that, by proper preparation, the starch granules should be brought into a suitable condition, so as to be readily acted on by the digestive organs. The food which is best in itself, and which generally is found to agree, is wheaten flour. The best form in which this can be given is the preparation of wheat known as ''Chapman's Entire Wheaten Flour." This is superior for the purpose to the ordinary flour, as it contains the inner husk of the wheat, finely ground, and is, therefore, FARINACEOUS FOODS 49 rich in phosphates, and in a peculiar body called cerealin, which has the diastasic property of changing starchy matters into dextrine. The flour is to be baked in the following way : — A covered earthenware jar filled with the flour is put into a slow oven. From time to time it is re- moved, and the contents stirred up from the bottom and sides so as to prevent the formation of hard lumps. When thoroughly baked the flour forms a soft greyish-coloured powder. A child of six months old will digest two meals a day of this flour, but seldom more, and in many cases a single meal of it will be found sufficient. For each meal one teaspoonful of the prepared flour is rubbed up with a tablespoonful of cold milk into a smooth paste. A second spoonful of cold milk is then added, and the rubbing is repeated until the mixture has the appearance of a per- fectly smooth cream. A quarter of a pint of hot milk or milk and water is then poured upon the mixture, stirring briskly all the time, and the food is ready for use. It may be sweetened with extract of malt instead of sugar. If the flour, prepared as described, be found not to agree, a smaller quantity can be given, or some other farinaceous food may be tried. Any of the so-called infants' foods" may be given to a young child, and sometimes one, sometimes another will be found to suc- ceed ; but in no case should farinaceous matter ^ be allowed, even when guarded with malt, oftener than twice in the day. If there be much constipation a teaspoonful of fine oatmeal may be given in the morning instead of the flour. After the eighth month a little thin mutton or chicken broth or veal tea may be given, carefully freed from all grease. After twelve months the child may begin to take light puddings, well mashed j)otatoes with gravy, * Most of the "infants' food" contain unconverted starch. In Mell.in's food, however, the whole of the starch is digested. This food therefore, may be given without danger at any age. 4 60 INFANTILE ATROPHY or tlie lightly boiled yolk of one egg ; but no meat should be allowed until the child is at least eighteen months old. The above description of the method of bringing ujd a child by hand is also applicable to cases where the child is being suckled on impoverished milk. In such cases the breast should be given only twice a day, his feeding at other times being conducted according to the rules laid down. A useful addition to the breast-milk, where an addition is required, during the first few weeks of life, is a mixture of cream with diluted whey. One tablespoonf ul of fresh cream, with twice the quantity of whey, diluted with two tablespoonfuls of hot water, may be given from a feeding-bottle every three or four hours. After a few weeks a tablespoonful of milk may be added, and this quantity can be afterwards gradually increased. The time of weaning is very important. To deprive a child prematurely of the breast is not without its dangers, but to persist too long in nursing is a fruitful source of evil. In ordinary cases, where the child is healthy, and the strength of the mother is sufficient for the task, twelve months should be allowed to elapse before the child is weaned. A longer continuance of suckling would make too great a demand upon the strength of the mother, and would be of no advantage to the child, who has by this time become well accustomed to other food. It is some- times stated, particularly by French authors, that the time of weaning should be regulated by the progress of dentition; that the child should not be deprived of the breast until the period has passed during which the acci- dents attendant upon dentition may be expected, — which time they fix at the evolution of the canine teeth. This, however, is not a very safe guide, as rickets, a common result of mal-nutrition, may postpone indefinitely the evo- lution of the teeth. In these cases, to continue the suck- ling would be to encourage the very evil which it is our WEANING 61 principal object to prevent. The existence of chronic disease in an infant reared entirely by the breast, so far from being an impediment to weaning, is, on the contrary, the very strongest argument in favour of a change of diet ; and the common objection of mothers that, on account of the child's weakness, they " dare not wean him," is the very worst objection that could be possibly urged, and is a sufficient proof that the suckling has already been con- tinued far too long. Human milk is the best food for infants, not on account of any specific property it possesses, but merely because it is the most digestible. When, how- ever, it is so poor as to be no longer nutritious, it ceases to rank as food ; and by pursuing this course we fill the child's stomach with a fluid which is incapable of nourish- ing him, but which, by satisfying his appetite for the moment, prevents his taking a meal which would be really beneficial. In every case we must attend, not to popular prejudice, but to the actual condition of the child. "Wasting in a non- syphilitic infant shows the necessity for some change in the diet. But this change does not, unless the child be twelve months old, consist necessarily in weaning. His condition may be owing to a too liberal, or to a too scanty, supply of food ; and we must make him depend more upon the breast-milk, or less upon that source of nourishment, according as to which of these two causes a history of his previous diet leads us to attribute his disease. In giving additional food to infants at the breast, a difficulty often arises from the repugnance of the child himself to this mode of feeding. Many children, parti- cularly those who have been suckled too frequently, and to whom the breast has been offered as a means of quiet- ing their cries, greatly prefer this way of taking nourish- ment to any other, and indeed continually refuse it in any other form. In these cases, should the mother's milk be poor in quality (which it often is, although very abundant) 62 INFANTILE ATROPHY it is bettor, if all other means fail, to wean the child suddenly, as this offers the only plan by which he can be efficiently nourished. This course, however, should only be resorted to when, in spite of great perseverance, we have not succeeded in attaining our object. A little judicious starvation will often do much. Although, if circumstances allow it, the child should be suckled for twelve months, yet it may be necessary to wean him at an earlier period, thus — If the mother's health suffers from nursing ; If from some cause, as pregnancy, or the occurrence of acute disease, her milk is rendered unwholesome to the child ; If the child is insufficiently nourished upon the breast- milk, and yet refuses to take additional food. In all these cases the ordinary time of weaning must be anticipated. A moment should be chosen for weaning when the child is not feverish, nor suffering pain from the actual cutting of a tooth. It is best to wean him gradually, lessening by degrees the number of the times he is allowed to take the breast, and continuing, for about a week, still to give it to him once a day ; after which this, too, must be stopped. If the child has been fed as directed, there is very little difficulty about weaning ; he maybe fretful for a few days, and even refuse his food, but by perseverance he becomes reconciled to his loss. Children sometimes wean themselves, seeming suddenly to take a dislike to the breast, although they are quite healthy and are apparently thriving upon the milk. This, however, may be sometimes occasioned by scantiness of the milk. Usually, when children refuse the breast, some cause may be discovered by which the process of sucking is rendered difficult or painful. Thus — Eetraction of the nipple may make it impossible for the child to obtain any milk until the nipple has been drawn CAUSES OF REFUSAL OF BREAST 53 out by a stronger child, by a cupping-glass, or by tlie mouth of the nurse. Pain, whether from colic, or earache, or other cause, will prevent a child from sucking so long as the pain is acute and distressing. In milder cases of abdominal discomfort, infants are, however, often particularly ravenous, as before explained. Thrush, or aphthae of the mouth, may have the same effect. Here the pain caused by the moA^ements of the mouth during the act of sucking is the reason of the refusal. Closure of the nares from syphilitic swelling and incrus- tation, or from measles, obliges the child to breathe entirely through the mouth. Here, whenever he attempts to take the breast, a sense of suffocation compels him to abandon the nipple. In bronchitis, pneumonia, and broncho-pneumonia, the child sometimes refuses the breast ; for there is laborious respiration, and both nose and mouth are wanted for air- passages. In tongue-tie ^ and cleft palate, there is a mechanical obstacle to sucking, in the impossibility of producing the necessary vacuum in the mouth. The former is readily cured by snipping the frsenum. The latter necessitates artificial feeding; but by an ingenious and simple con- trivance, designed by Mr. Oakley Coles, the impediment to sucking from a feeding-bottle can be overcome, al- though the child is still prevented from taking the breast. The plan consists in attaching to the nipple of the feeding-bottle a flap of elastic india-rubber, cut to fit the roof of the mouth. This flap, shaped like the bowl of a * By " tongue-tie " is here meant those cases where the frsenum is attached to the whole under-surface of the tongue as far as the tip. Such cases are exceedingly rare. The ordinary cases of so-called tongue-tie present no real obstacle to sucking, and need not be inter- fered with. 54 INFANTILE ATllOPHY teaspoon, is cut out of thin sheet elastic, and is sewn to the upper part of the stalk of the nipple where this projects from the shield. In the mouth of the infant the flap forms an artificial palate, against which the nipple is pressed during suction, and the fluid is thus prevented from passing into the nose in the act of swal- lowing. Infants who have been brought up at the breast with- out the addition of any other food are sometimes difficult to wean, as the new food does not always agree. Accus- tomed as such children are to the light human milk, the firm curd of cow's milk proves a heavy tax upon their digestive powers, and unless the change be made with care serious dangers may arise. In these cases the milk should be diluted with barley-water, or thickened with some infants' food. When the child has become accustomed to do without the breast-milk, he may begin to take the food which is hereafter to form his ordinary diet. Potatoes carefully mashed with a spoon, with gravy ; meat broths ; light puddings ; eggs very lightly boiled ; or a bone to suck, may be allowed. No meat, however, should be given till the sixteenth or eighteenth month, when he may begin with a very small quantity once in the day. The best kind is a small j)iece of roast mutton, without any fat or grease. This should be very finely minced, or even pounded in a mortar to ensure fine division, for a young child will not chew his food. With this he may drink plain water, toast- water, or milk-and-water. For further information on the subject of feeding chil- dren, see Chap. XI, Diets 1 — 11. In making the various changes in the diet, it is im- portant to watch the child carefully, so that too great precipitancy may be avoided. Any signs of laboured digestion should be carefully noted, and a simpler diet at once returned to. The child when awake should be BATHING AND HYGIENE 55 active and cheerful, and his sleep should be tranquil and undisturbed. While attention is thus paid to diet, all the other pre- cautions, indispensable to perfect health, should be ob- served. Cleanliness must be attended to, but every care must be taken , not to chill the child by dawdling over his bath. The water used should be hot (95° to 100° Fahr.), and the process must be a rapid one, soaping the child quickly all over the body, and then sponging off the lather without loss of time, while he sits in the hot water. He must not be allowed to play in the water or wait in the bath wet and evaporating, while the nurse busies herself with other matters, but must be lifted out at once, wrapj^ed in a warm towel, and dried without undue exposure. In the case of very susceptible children it is advisable instead of soaping the child in the usual way, to put him into hot soap-suds and sponge him quickly with the lather. Diapers, when soiled, must be changed at once and taken out of the nursery ; and after each action of the bowels the nates should be sponged with warm water and carefully dried. The nurseries should be large and well ventilated, and ought not to be in the neighbourhood of an open drain-pipe, however carefully this may be trapped or cut off from the sewer. Water-closets and housemaids' sinks just outside the nursery are a fruitful source of danger. The day- room must be kept as nearly as may be at a temperature of 65^ Fahr., and if possible should face the south, as sunlight is of great importance. The child should sleep by himself in a cot without curtains, not in the same bed with his nurse, and every means must be taken to keep the air about him fresh and pure. Whenever the weather permits he should be taken out. His outdoor dress should be warm, his legs should be well covered up, and as a further protection against the cold he should wear a flannel bandage round the belly. 56 INFANTILE ATROPHY From the sketch given in the preceding pages of the scale of diet suited to a healthy child, it is easy so to arrange the number and quality of his meals that a suffi- cient amount of nourishment may be given without over- tasking its digestive powers. When the diet has been properly regulated, the child is found rapidly to regain flesh, his peevishness and irritability disappear, and his health returns. Any digestive derangement which may occur should be at once attended to, and, as this is usually due to some deviation from the prescribed rules, a return to the proper diet will generally cause it quickly to disappear, especially if a gentle laxative be given at the same time. The constipation which is so common a result of im- proper food, often continues after the change of diet. In these cases if the child be at the breast, the mother may take an occasional saline aperient, and increase the quan- tity of fresh vegetables to her meals. Should this plan fail in relieving the child, a teaspoonf ul of castor oil can be given him ; or a few grains of magnesia may be adminis- tered, with syrup of ginger, in some aromatic water ; or a little manna may be dissolved in hot water, strained and added to the food in the bottle. If, after repeated attempts, we find that a daily action of the bowels cannot be ob- tained, without a daily repetition of the aperient, it is use- ful to give small doses of senna combined with a bitter tonic. Thus a third part of infusion of senna may be added to two-thirds of the compound infusion of gentian. Of this mixture a teaspoonful given two or three times a day will soon regulate the bowels, so that after a time the medicine can be gradually discontinued. The value of this remedy is increased by the addition of five drops of tinc- ture of belladonna and a quarter of a drop of tincture of nux vomica. In cases where the constipation is very obstinate ; where hard clay- coloured motions, often mottled with streaks of green, are passed at rare intervals, with violent and painful APERIENTS 57 expulsive efforts, two, three, or more drops of a solution containing one grain of podophyllin in a drachm of alcohol may be given to the infant in a little glycerine every night. This treatment restores the natural colour to the motions, removes the abnormal distension, and eases the colic. A less disagreeable remedy is sulphur. Curiously small doses of this drug will prove effectual if given regularly. In the case of most children half a grain given every night at bedtime will produce a regular action of the bowels. Another useful drug is the liquid extract of Cascara Sagrada. Like the others, this remedy is best given in one dose at bedtime. A young baby may begin with five drops in a teaspoonful of water sweetened with an equal quantity of extract of malt. If this dose does not produce a sufficient movement, it can be increased every night by one drop until the desired result is attained. The saline aperients are favourite remedies with some practitioners, but these salts should not be used indiscriminately. They are especially indicated in cases where the stools are habi- tually dry. When constipation results from this lack of moisture a few grains of the sulphate or carbonate of magnesia given two or three times a day will soon induce copious relief. Afterwards, one dose administered every evening will usually keep up a sufficient action of the bowels. Enemas should only be used when the constipation is obstinate with great accumulation in the bowels, and then only as a temporary measure. They may be given either alone, or as an aid to the action of purgatives taken by the mouth. Two or three drachms of castor oil, with six or eight ounces of thin, warm gruel, may be used for a child of twelve months old. In using injections, the tube must be well oiled, and must be very carefully introduced, remembering that the bowel inclines gradually to the left side. The fluid should be thrown up with moderate force. Other means of obtaining a satisfactory movement of 58 INFANTILE ATROPHY the bowels consist in the use of suppositories of castile soap or glyco-gelatine, and in frictions over the belly with a stimulating liniment. The addition of aloes to the lini- ment is said to render the effects of the application more decided ; thus, half an ounce of the compound tincture of aloes combined with twice the quantity of compound soap liniment forms a useful embrocation for this purpose. It may be rubbed into the belly every morning. Probably the value of this mode of treatment lies not so much in the liniment as in the friction. Methodical kneading of the abdomen has long been recognised as a useful remedy ill case of habitual constipation. But the rubbing to be effectual must be employed systematically. It should consist of firm pressure with the thumbs carried round the belly in the course of the large intestine, varied occa- sionally by circular friction round the umbilicus with the palm of the hand. Such manipulation carried out ener- getically (but not violently) every morning, for five or more minutes after the bath, will often induce regularity of action in a surprisingly short time. In children who suffer from habitual constipation, care should be taken to keep the body and limbs perfectly warm. A warm bath will often produce an action of the bowels when aperients have been given without any effect. If the child be old enough to take farinaceous food, a morning meal of milk thickened with a teaspooiiful of fine oatmeal will often render the administration of drugs unnecessary. Rhubarb should not be used as an aperient for children where the constipation is obstinate, unless combined with jalap or scammony, or some other purgative, on account of its after-astringent effects ; but for the same reason it is extremely valuable in the looseness of the bowels which is the result of acidity. Acidity is produced by fermenta- tion of the food in the alimentary canal, and gives rise to much flatulence, shown by sour- smelling eructations, and TREATMENT 59 griping pains in the belly. In these cases the feeding apparatus should always be examined. A want of cleanli- ness in the bottle is a common cause of this teasing de- rangement. If the griping is accompanied by constipation, the bowels should be opened by a gentle purge, as mag- nesia and senna, or castor oil, after which the following mixture may be ordered : — Sodse Bicarb., gr. iij, Tinct. Nucis Vomica), gutta ^, Tinct. Card. Co., mv, Sp. Chloroform., mj ; Aq. ad 5]. M. Ft. haustus. To be taken every six hours. Aromatics are very useful in these cases, and indeed should always be included in mixtures for children wherever there are any signs of intestinal irritation. The following case well illustrates the value of alkalies and aromatics, conjoined with a regulated diet, in the treatment of simple atrophy accompanied by constipation and flatulence. George M — , aged two months, has been pining away ever since birth. Is not half the size he was." Does not cry loudly, but " frets and pines." Is suckled, but the mother has very little milk ; is therefore fed besides on sago and corn-flour made with water. Child is bright-looking, but very small and thin. Fon- tanelle depressed. Lips rather pale. Nasal furrow not marked. Tongue clean, colour of rust of iron. Skin cool, not rough or harsh ; a little eczema about folds of groin. Anus a little red, but no cracks or fissures there. Does not snuffle. Is not sick. Bowels act once or twice a day. Motions in little light-coloured lumps with mucus, not offensive, passed with some straining. Moves legs uneasily, as if griped. Was ordered to be fed on milk and lime-water, in equal proportions, given every three hours. No other food ex- 60 INFANTILE ATROPHY cept breast-inilk. A flannel bandage to be applied round the belly. The following draught to be given three times a day : — ]Ji Sodae Bicarb., gr. iij, 8p. Chloroform i, mj, Aq. Mentha) Piper., ty\x, Aquam ad 5j. M. Ft. haustus. At the next visit, a week afterwards : — Continues to waste. Sometimes refuses the bottle and the breast, a,])- parently from the pains in belly. Belly very hard ; child wrinkles forehead, draws up the corners of his lips, and flexes thighs on abdomen. Bowels open twice a day with straining. Motions light coloured, solid, and smell sour ; no mucus. Feet examined, and found to be very cold. Tongue clean. Feet and legs to be warmly covered up. The milk and lime-water to be continued. 1^ Pulv. Rha^i, Soda3 Bicarb., aa gr. iij ft. pulv. To be taken at once . Bismuthi Carb., gr. ij, Pulv. Cretse Aromat., gr. iij, Glycerine, luv, Mucilaginis, rrtx, Aquam ad 5j. Ft. haustus. To be taken three times a di\y. On the following week : — Child very much better ; is beginning to gain flesh. Motions still light coloured and rather firm, two in the day. Still rather flatulent ; turns " deadly white " at times (when violently griped). To continue the same diet. Half a drop of Tinct. Capsici added to each dose of the mixture. After this the flatulence ceased ; the motions became natural ; and the child rapidly became fat and well. If the bowels, instead of being confined, are rather loose, with dark, slimy, offensive stools, a dose of powdered rhubarb and magnesia, three grains of each, should be FLATULENCE 61 given, and maybe followed by the above mixture, with the addition of half a drop of laudanum to each dose ; or the following may be given : — ^ Tinct. Opii, rrtss, 01. Ricini, miij, Glycerini, inv, Mucilag. Acaciffi, irtv. Aq. ad 5j. M. Ft. haustus. To be taken three times a day. This combination of castor oil with laudanum is especi- ally valuable in the screaming fits to which badly-fed children are so liable. If there is a sour smell from the breath, a few grains of prepared chalk may be substituted in each dose for the castor oil. At the same time all fari- naceous foods should be suspended for a day or two, and the diet be limited to milk and lime-water, or barley-water and milk. In all these cases of abdominal pain, the feet should be examined, for cold feet alone may be the cause of the griping. Chafing and warming the feet often stop a baby's cries ; and in the screaming fits " the soothing influence of gentle friction is very decided. Rubbing the body gently with the open hand quiets the child almost at once. If a return to the ordinary food is followed by the same flatulent condition, and this happens several times in suc- cession, the diet evidently does not agree with the child, and some alteration is required. Trials should be made of different kinds of foods, for, as already explained, the same food is not suited to every case. A malted food — especially Mellin's infants' food — is a great resource under such circumstances. Sometimes it is the milk which dis- agrees, and we are forced to discontinue it altogether, giving instead beef, veal, or mutton broth, thickened with some farinaceous food. Often, however, it is due to mono- tony of diet, and more variety should be introduced into the feeding (see Chap. XI, Diets 15, 16, and 17). When 62 INFANTILE ATROPHY the flatulence is obstinate, frictions with a stimulating liniment should be employed daily to the belly, the flannel bandage being removed for the purpose, and afterwards replaced. At the same time a mixture con- taining infusion of rhubarb, with a little tincture of myrrh, may be given twice or three times in the day, to give tone to the bowels, and increase their peristaltic action : — p. Infusi Rhaei, Tn.x, Syrupi Zingib., rav, Tinct. Myrrhse, mj, Aq. Menth. Pip. ad 5j. M. Ft. liaustus. To be takeu two or three times a day. If sickness accompanies the flatulence, a teaspoonful of ipecacuanha wine should be given to relieve the stomach ; after which a mixture containing bismuth and soda may be ordered : — Bismuthi Carb., gr. iij, SodsB Bicarb., gr. ij, Glycerini, inv, Mucilag. Tragacanth, rrtx, Aquam ad 5j. M. Ft. haustus. To be taken three times a day. Or the mixture containing bicarbonate of soda with spirits of chloroform (see p. 59) may be used. For ordinary attacks of colic. Dr. Boyd recommends ten drops of Sp. ^theris Nitrosi in a drachm of water. He states that a few minutes after this draught has been given a discharge of flatus takes place, followed by the passage of a large quantity of urine, and the distress of the child is at an end. But in some of these cases (and usually in those in which the pain is most severe) the colic is not easily controlled by antispasmodic remedies. Where this is the case I have found great benefit from Finkler's papain given in doses of one or two grains with an equal quantity of bicarbonate of soda with each of the meals. COLIC 63 When the colic is very severe, great alarm may be excited by the state of apparent collapse into which the infant is thrown. The child should be placed in a hot bath (100° Fahr.) ; the bowels should be relieved by an injection of warm water ; and a few drops of brandy or sal volatile should be given in milk or water. On being removed from the bath, the child must be carefully dried ; a hot linseed meal poultice, on which ten or fifteen drops of laudanum have been sprinkled, should be applied to the belly ; and he should be then wrapped up in warm flannel. If the fontanelle remain depressed, the brandy may be repeated, and a mixture containing codeia with sal vola- tile, spirits of chloroform and a little bicarbonate of soda may be prescribed : — P> CodeijB, gr. 3^, Sodae Bicarb., gr. ij, Sp. Ammon. Aromat., Sp. Chloroformi, aa nij, Aq. Anethi ad 5j. M. Ft. liaustus. To be taken every three hours. Convulsions may arise from this condition of the bowels, and can be treated in the same way. If, however, they continue, and are not relieved by the measures adopted, turpentine may be given, as recommended by Dr. Graves : — Jt. 01. Terebinth! noe, inj, 01. Ricini, luiij, Glycerini, irtv, Mucilaginis AcacijB, rn.v, Aq. Menth. Pip. ad 5j. M. Ft. haustus. To be taken every three hours. This acts on the bowels, and produces a copious discharge of urine. On recovery, great attention should be paid to the diet and bowels, that the symptoms may not return. Thrush is readily cured by attention to cleanliness. It should be . made a rule always to wash out the child's 64 INFANTILE ATROPHY mouth immediately after a meal, to prevent any accumu- lation of food or milk round the gums. This is readily done with a good- sized camePs-hair brush, or a piece of linen rag dipped into warm water. Attention to this point will prevent the appearance of thrush, especially if care be taken that the nipple of the mother is perfectly clean. When thrush has appeared, an aperient should be given, composed of one grain of grey powder and two or three of powdered rhubarb. The mother should be directed to cleanse the child's mouth frequently with warm water, and afterwards to apply a solution of borax in water sweetened with glycerine (5ss. to 3]) with a soft brush. If at the same time the following draught be given every four hours, the thrush, even although extensive, usually clears away completely in a couple of days. ^ Glycerin! Acidi Carbolici, Tinct. lodi aa, mss, Glycerini, inv, Aquam ad 5j. M. Ft. liaustus. If aphthae form, the same attention should be paid to cleanliness ; a powder of rhubarb and jalap, with a grain of Hydrargyrum cum Creta, should be be given to evacuate the bowels ; after which the following mixture may be prescribed : — Soda? Chloratis, gr. iij, Acidi Hydroclilorici Diluti, mj, Glycerini, mv, Aquam ad 5j. M. Ft. baustus. To be taken every four hours. When attacks of acute indigestion come on, with hot skin, furred tongue, thirst, vomiting, and diarrhoea, accom- panied by griping pain, all food must be stopped, and nothing be allowed but cold barley-water. The stomach should be relieved by an emetic of ipecacuanha, after the action of which a purgative of rhubarb and magnesia should be given to clear out irritating matters from the DIARRHCEA 65 bowels. A mixture of tincture of catechu with aromatic confection can then be given, or the following : — Zinci Oxidi, gr. j, Pulv. Cret£B Aromat.j gr. ij, Glycerini, ntv, Aq. Chloroformi ad 53« M. Ft. haustus. To be taken three times a day. If the diarrhoea continues after the tongue has become clean, half a drop of laudanum can be added to each dose of either of these mixtures, or a few drops of tincture of rhubarb may be given with half a drop of laudanum and a drop of sal volatile in an aromatic water. When the irri- tability of the stomach has subsided, milk and barley-water may be resumed, but with caution, lest the vomiting return ; and, after subsidence of the fever, great prudence should be exercised in returning to the ordinary diet. S CHAPTER II CHRONIC DIARRHCEA (CflRONIC INTESTINAL CATARRH) CHRONIC diarrhoea is a fairly common derangement in childhood, and often ends fatally. During the first two years of life a diarrhoea, when it becomes established, is very difficult to arrest, and even when the looseness of the bowels has been checked, many weeks of care may still be required to restore the alimentary canal to a healthy condition. In older children chronic diarrhoea is a less fatal disease, but it often lasts for months together, and by the interference with nutrition it occasions, may lead to very serious consequences. Chronic diarrhoea may either occur as the sequel of an acute attack or may begin insidiously. In the former case it is often secondary to some acute disease, as measles or scarlatina ; the exanthem being accompanied by a looseness of the bowels, which persists after the disease which originated it has passed away. Or it may begin as an attack of acute catarrhal diarrhoea, with fever, abdominal pains, and perhaps vomiting. This attack subsides for a time, but returns again and again until the chronic disease becomes established. This form of beginning is, perhaps, more common after the period of infancy has passed by ; but it is occasionally seen in quite young children. The insidious beginning is met with most frequently during the second year of life. This form of the derange- CHARACTER OF THE STOOLS. 67 ment is one which it is very important to recognise early, for if promptly treated it readily yields, but if allowed to continue, becomes very obstinate and difficult of cure. There is no fever, and at first no actual diarrhoea. The stools are not very numerous, numbering only two, three^ or four in a day — perhaps, even, only one in the twenty- four hours. They are pale, often of the colour and con- sistence of soft putty, and are sometimes evacuated with straining. The dejections may be preceded by some pain in the belly. At this stage the disease seems to consist mainly in increased peristaltic action of the intestines forcing along their contents too rapidly to allow of efficient digestion being performed. The motions are copious, and consist of curds and farinaceous matter from the milk and food which has been swallowed, mixed with some half -liquid faeces and, if there be much strain- ing, with mucus and blood. The blood at this time is in the form of red streaks, and results from the rupture of small vessels about the anus in the act of straining. In such a form it is a common accompaniment of diarrhoea in children where there is much tenesmus. The stools have often an offensive sour smell. The child looks rather dispirited and dull. His complexion is pale, with a muddy or sallow tint, and his feet are habitually cold. Still, he is fairly lively, and takes his food with appetite. This state of things may continue for a considerable time, often for several weeks, or even months. The child gradually loses flesh, and becomes paler and more languid ; but there is no actual diarrhoea. The nurses on being questioned, will say that the bowels are nicely open," and it often requires careful cross-examination of the attendant to discover the cause of the loss of flesh. In these cases, therefore, it is important to inspect the evacuations. After a time the stools become more frequent and more liquid; but vary considerably in appearance from day to day. At one time they are thin, watery, and brownish. 68 CHRONIC DIARRHCEA like dirty water ; at others, thicker and clay-coloured, like thin mud ; they frequently contain mucus, free, or mixed with a grumous matter, when they are called " slimy " by nurses, and almost always present little masses of undi- gested food. Occasionally they contain particles of grass- green matter, from altered bile or blood, in the latter case an indication of some additional irritation of the bowel. The smell becomes more and more unpleasant, and the stools sometimes have a putrid odour which is inexj^ressibly offensive. When the diarrhoea is regularly established, the tendency of the stools is to become more and more liquid, and less and less homogeneous ; but there is no regular progression from bad to worse. There are alternations of improvement and relapse ; sometimes the looseness is better for a day or two, and may even seem to have subsided ; a relapse then takes place, and the condition of the child is as bad as before. These variations in the intensity of the diarrhoea will often be found, in the earlier periods of the disease, to coincide with variations in the temperature and degree of moisture of the air. A damp, chilly day is usually accom- panied by increased severity of the symptoms, while on a bright, clear, warm day the disease is better. The patient begins early to waste ; but unless the evacua- tions are very copious, the emaciation does not proceed very rapidly. He gets pale, and, after a time, of a peculiar earthy tint, which is very characteristic. The skin is dry and harsh, the eyes are hollow, the lips pale and thin, and the fontanelle is depressed. His strength diminishes, and as the disease advances he seems to lose all power of sup- porting himself, and lies like a log in his cot, or on his nurse's lap. Still, the appetite is usually preserved, and he will often take food eagerly whenever it is offered ; but each meal is followed by a notable increase in the diarrhoea. His food, as the nurses say, seems to j)ass through him directly it is swallowed." The tongue is moist, often quite SYMPTOMS 69 natural, although sometimes the papillse at the edges and tip appear unusually red and prominent. The belly may be quite flaccid and soft, but often becomes swollen and tense from gas generated by the fermenting food. At these times there is some pain, shown by plaintive cries, by uneasy movements of the legs, and by elevation of the corners of the mouth. The abdominal wall is never re- tracted, and there is seldom any tenderness on pressure. If the diarrhoea continues, the wasting becomes more and more marked ; the bones project ; the cheeks get hollow ; the forehead becomes wrinkled ; and the aspect generally is that of a little, infirm old man. The wrinkling of the forehead is due to loss of elasticity of the skin, which retains the folds into which it is drawn. The buttocks and inner part of the thighs become red from eczema occasioned by the irritation of the urine and fsecal discharges. The appetite at this stage may be preserved or even increased ; but more often it becomes capricious, and the child, refusing milk and sop, craves for the more tasty articles of diet which he sees eaten around him. Sometimes, however, he refuses lo take any nourishment whatever. All this time there is no fever. Indeed, the temperature is lower than is natural, being often no more than 97*5° in the rectum. The stools are now excessively frequent, ten, fifteen, twenty, or even more, in the four-and- twenty hours. There is often very great straining with each evacuation, and the bowel may even prolapse. The motions often look like chopped spinach in a dirty-brown, stinking water, and may contain blood — not in bright red streaks, as at the first, but of a dirty, brownish-yellow colour, and mixed with mucus and pus. When this occurs and there is at the same time tenderness of the belly on pressure with gurgling, the bowel is probably ulcerated. There are certain complications liable to occur in this disease which often hasten the end. 70 CHRONIC DIARRHCEA Serous effusions may take place on account of the poverty of the blood, and the relaxed attenuated state of the coats of the vessels. They begin usually at the feet, which hang down as the child lies in his nurse's lap. The instep gets quite round, and feels doughy ; the skin over it is thin, and looks almost transparent ; the contrast thus presented between the thin wasted leg and the bulbous foot is very striking and peculiar. The backs of the hands and the fingers then become swollen, and occa- sionally the face and eyelids are also oedematous. Effusions may also take place into the serous cavities, the pleura, peritoneum, and pericardium. Hypostatic congestion of the lungs is very liable to occur, for, as the child lies constantly upon his back, stasis of the blood takes place in the most depending parts of his lungs. Death is not at all uncommon from this cause. Pneumonia is an occasional complication. It gives rise to fever, but in a feeble, wasted subject may set up no cough, or any of the other symptoms by which its presence is usually mani- fested. Probably the lung complication is often the result of microbic infection. The exanthemata are very apt to attack children the subjects of this disorder, either from the diminished resisting power of the system induced by the debility, or from such a condition as obtains in chronic diarrhoea being especially favourable to the reception of miasmatic poisons. Convulsions may carry off the child early in the disease. They are not, however, commonly seen in the later stages. Convulsions are very common in children in whom there is a sudden depression of the vital powers, and are there- fore frequently seen in acute diarrhoea, where there is a great and rapid drain upon the system. In these cases, however, where the debility is produced more gradually, although a greater degree of prostration may be reached, convulsions are rare, for the child then assumes some of THROMBOSIS OF SINUSES 71 the physiological characters of old age, and is much less liable to be affected by reflex stimuli. Thrombosis of the cerebral sinuses may be a cause of death. There is no doubt that inspissation of the blood resulting from the watery drain from the bowels must help greatly to retard the circulation through the cerebral sinuses. The speed of the blood current is further reduced by the feeble propulsive power of the weakened heart. These conditions must necessarily favour the formation of coagula in the channels of the brain, and where there is no trace of inflammation on the walls of the sinuses the plugging may be due to this agency alone. But in most cases other influences are at work. A common cause, as Marfan has pointed out, is infection. According to this observer, the meningeal hsemorrhages and thrombosis of dural sinuses, which are so apt to occur in the terminal stage of gastro-intestinal disorders in infancy, are due to the action of microbes or of the poison they generate. Micro-organisms may be carried into the blood directly from the bowel ; but Simmoiids lays stress upon the influence in this respect of otitis media. This physician has found inflammation of the middle ear to be common in all the nutritive disorders of early life, and holds that it is from this source that microbes reach the circulation and set up an infective phlebitis in the sinuses. It is to this phlebitis that the thrombi are commonly due. The child falls into a state of stupor, with dilated pupils, occasional strabismus, retraction of the head, fulness of one or both jugular veins, and sometimes paralysis of the facial nerve on one side of the face. Usually it is the longitudinal sinus which is blocked. On dissection it is found to be filled with a laminated, partially decolourised clot which adheres more or less firmly to its walls. The veins opening into the obstructed sinus are distended with blood. When the disease terminates fatally the child often dies 72 CHRONIC DIARRHCEA from one of the above causes. Sometimes, however, he sinks and dies without our being able to say that any of these complications are present. In these cases the emaciation becomes extreme. The eyes, deeply sunken in their sockets, have a dull, ghastly look ; the cheek-bones project ; the cheeks sink in ; the nose looks sharpened ; a furrow passes on each side from the upper part of the ala of the nose, and forms a rough semicircle round the corners of the mouth ; the lips are red, cracked, and covered with sordes ; and the inside of the cheeks and lips, and the surface of the tongue, become aphthous, or are coated with thrush. The tongue becomes dry, and, when free from thrush, is apt to have a granular appearance from projecting papillae. The complexion is dull and earthy- looking, and the skin seems tightened over the projecting bones of the face. The fontanelle is deeply depressed. The body generally appears to consist of little more than the bones covered by the dry, rough, flaccid skin; each rib stands out sharp and distinct on the wasted chest. The belly may be flaccid, but more usually is full and prominent, as the emaciated and relaxed walls yield before the pressure of the flatus in the bowels. The skin of the ' abdomen becomes of a dirty brown colour, or is speckled with brownish spots. The feet and hands are cold, and often look purple even when not actually cold to the touch. The child lies quiet, with eyes half closed and dim. Occa- sionally he draws up the corners of his lips, and wrinkles his brow as if to cry, but makes no sound ; but for this plaintive sign, and for his slow, quiet breathing, he might be thought to be dead. In these cases death takes place almost without a struggle, and it is often difficult to say at what precise moment the child ceases to exist. Sometimes for a few days before death the evacuations entirely cease, but no false hopes should be raised by this change if a corresj^onding amendment does not take place in the general symptoms. PROGRESS OF DENTITION 73 In cases of recovery the stools gradually become more homogeneous, more solid, and more faecal, and one great sign of improvement is the reappearance of bile in the stools. The child at the same time becomes less torpid ; his eyes get brighter; he grows intensely fretful, and manifests his uneasiness by crying. The reappearance of tears is a very favourable symptom, and one which allows us to entertain strong expectations of his ultimate recovery. He ceases to emaciate, and soon begins to regain flesh — very slowly at the first, and the earliest advance in this* respect is seen about the buttocks, which will be noticed to have become a little fuller and more rounded. The stools gradually lose their foetid character, get more healthy - looking, and constipation usually replaces the previous purging. Although the nutrition of the body is so much interfered with in this disease, and the child daily emaciates more a,nd more, yet if the patient be not the subject of rickets, the growth and development of the teeth may continue in spite of the general condition. In the case of infants who are cutting the incisors, these teeth usually appear without difficulty or apparent aggravation of the other symptoms. Nor does the eruption of each tooth appear to be accom- panied by any special improvement which can be attri- buted to that as its cause. Dentition goes on rapidly and easily, while the diarrhoea remains stationary, or slowly improves. These cases generally recover. In an infant of eight months old whom the author attended for this complaint, five incisor teeth made their appearance in the course of a month. The child got well. If the patient has arrived at a later period of infancy, the cutting of the canines and back molars often produces a distinctly injurious effect upon the intestinal derange- ment. Indeed, cases are sometimes met with which obstinately resist all treatment until the teething process has come to an end. Still, although the presence of an 74 CHRONIC DIARRHCEA infiamed and swollen gum may appear to increase the irritation of the bowel, chronic diarrhoea is not necessarily associated with dentition as its cause. As Dr. John Cheyne long ago pointed out, the disease is often seen in cases where there is no swelling or inflammation of the gums, no salivation nor any appearance of pain or tender- ness about the mouth, in cases where the child is cutting his teeth easily, and even in children of three months old, who have no teeth at all. We shall see that it may begin almost at birth. The preceding descrij^tion applies only to infants and children under two years of age. In older children chronic diarrhoea, although often an obstinate disease, is seldom a fatal one. The nutrition of the child is visibly affected, and he becomes pale, and thin, and delicate- looking. He is noticed to be easily fatigued, dislikes his accustomed walks, and often lies down during his play. At the same time the special consequences of irritable bowels are generally to be observed, and in bad cases night terrors, nocturnal incontinence of urine, unusual fretfulness and causeless crying, are sources of great anxiety to the parents, who attribute them at once to ''irritation of the brain." The child's appetite does not necessarily suffer; indeed, in some cases, it becomes unusually keen, so that the presence of parasitic worms is suspected. Often, however, it is capricious, and in rare cases may be lost altogether. The diarrhoea is subject to very great alternations. It is at times severe, so that the number of the evacuations rises to ten or twelve in the twenty-four hours. At other times for several days together it seems to be almost well, but the motions generally remain loose and slimy, although their number is reduced. At the best the stools consist of offensive pasty matter mixed with green or colourless mucus. When the bowels are much relaxed the discharge is darker, more watery, and often contains small lumps of ARREST OF GROWTH 75 lighter-coloured fsecal matter. These variations in the intensity of the diarrhoea will almost invariably be found to follow changes in the weather. A damp cold day increases the severity of the complaint, while dryer and warmer weather is followed by temporary improvement. In children past the age of infancy, and especially in those who have reached the age of six or seven years, chronic diarrhoea with proper care may be expected to get well. Still after recovery the children are left anaemic and weak and subject to relapse. Moreover, there is another curious consequence of the disorder, if it have lasted for a long time, which may be referred to. This is an arrest of growth. Three cases of the kind have come under my notice during the last few years. In each of these the patient had suffered from repeated attacks of long con- tinued looseness of the bowels which could be arrested by treatment, but tended to break out again and again after the smallest indiscretion. One of these, a little boy at the age of seven years and nine months, was 3 feet 6^ inches in height. A second, a girl of eight and a half, measured 3 feet 6| inches. A third, also a little girl, at ten years old, weighed only 26 lbs. 9^ oz., and measured 3 feet 3f inches in height. All these children are growing but very slowly. One of them in twelve months grew only seven- eighths of an inch. A form of diarrhoea is not uncommon, the peculiarity of which consists in the fact that the motions contain little faecal matter, but are composed almost entirely of undi- gested food mixed with mucus, so as to present a slimy appearance. These motions are passed very shortly after, or even during, a meal; the food taken appears to be forced with extraordinary rapidity along the digestive tract, and to be voided in almost the same state in which it was swallowed. The condition which gives rise to this looseness of the bowels is no doubt an unnatural briskness of peristaltic action. The intestines are in a state of 76 CHRONIC DIARRHCEA great irritability, so that food taken into the stomach is at once conducted along the ahmentarj canal with a rapidity which allows little digestion to take place during its passage. The bowels act three, four, or more times within twenty- four hours. There is almost always an evacuation in the morning on first rising from bed, and afterwards in the course of the day each meal is at once followed by a like movement of the bowels, the child having often to leave the table hurriedly, and frequently before the repast is actually concluded. Each motion is preceded by griping pains in the belly, and is characterised by excessive urgency, the patient having great difficulty to restrain his desire during the time necessary to enable him to reach the closet. These griping pains are not always followed by a stool, but may come on and go off at irregular times in the course of the day without any result. Sometimes, however, they are accompanied by a desire to go to stool, although no motion is actually passed. The tongue may be a little furred, but is usually clean, and is often red at the tip and sides, the redness being due to small crimson papillae, which are sometimes slightly elevated. This variety of diarrhoea is found in children of from three or four to nine or ten years of age. It often causes marked wasting, and the evident ill-health of the child excites great anxiety amongst his friends. Still, in many cases, special inquiry has to be made into the condition of the bowels, for as the evacuations are not numerous, the state of the digestive organs excites little attention, and the existence of looseness is often not even hinted at by the mother in her account of her child's illness. Causes. — Chronic diarrhoea may usually be traced to three different sets of causes, viz. unwholesome surround- ings, impressions of cold, and the occurrence of some previous acute disease. The disorder is very apt to attack children who are CAUSES 77 exposed to insanitary conditions, and the younger the infant at the time when these injurious influences are at work the more liable is he to suffer from their effects in this particular way. Improper food has already been strongly insisted on as a cause of defective nutrition in the child, and by the weakness which it invariably induces would alone render him less able to resist any other pernicious agencies to which he might be exposed. But, in addition, the con- tinued passage along the bowels of masses of indigestible food must cause constantly renewed irritation to his deli- cate mucous membrane, and, if the same diet be persisted in, must lead in time to diarrhoea. When due to this cause, there are three periods at which the disease is most usually found to manifest itself. If the child be brought up by hand, he may be subject to it from his very birth. In these cases the infant not only does not grow, but, as his fat gradually disappears, he seems even to become smaller and more puny. It is not uncommon for a mother to say, speaking of a child of two or three months old, who all his short life has been suffering from this complaint, " No food seems to do him any good ; he is smaller than when he was born." If the mother is able to nurse her child, he often goes on well for four or five months, but then being supplied with other and less digestible food, as an addition to the breast milk — food which is often ill- selected, and consists not unfrequently, of portions of the meals of his parents — he begins to waste, and the diarrhoea is set up. The third period at which this disorder is apt to show itself is the time of weaning. It is at this time that the simple food on which he has hitherto principally sub- sisted being withdrawn, he is so exposed to danger from the mistaken kindness of his attendants, who, confusing substantial with nutritious food, supply him with articles of diet which they consider suitable to Ms needs, because 78 CHRONIC DIARRHCEA they know them to be sufficient for their own. The length of time during which children amongst the poorer classes are suckled in this country also favours the result described. The infant is often kept at the breast long after there is any nourishment to be obtained from his mother's milk. The degree of weakness to which he is reduced by such a system enfeebles his digestive power, and prevents him even from assimilating such a diet as, were he in health, would afford him the nourishment he requires. Even while at the breast, the infant is not exempt from danger. Hired nurses, in whom the breast milk is not sufficient in quantity or quality for the child's support, will often feed him secretly with farinaceous or other food, in order that the deficiency may pass undetected. This is not an uncommon source of disease in very young infants. In these cases it is difficult to extort a confession from the nurse, but our suspicions are often verified by a micro- scopic examination of the stools, when starch granules will be found in large numbers. Bad air, want of sunlight, and want of cleanliness, are also fruitful sources of this disease, especially when, as is usually the case, they are combined with the preceding. The crowding together of children in rooms, where they live and sleep in a close atmosphere, is a frequent cause of derangements of the stomach and bowel. In an insti- tution with which the writer was for many years connected, founded for the temporary reception of single women with their offspring, it was noticed that when the occupants of the infants' sleeping nursery reached a certain number, one or two deaths were certain to occur from bowel complaints, and this in spite of all possible precautions in the way of ventilation, &c. It was only by making arrangements for distributing the number amongst several rooms that this mortality could be avoided. Chilling of the surface is another common cause of EFFECT OF CHILL 79 diarrhoea. Owing to extreme sensitiveness to changes of temperature in early life, children are very subject to catarrhs of their mucous membranes, and it often happens that it is not the mucous membrane of the throat or lungs which suffers, but that of the stomach and bowels. An intestinal catarrh once set up, predisposes to a second attack. In this way, by a succession of slight chills, a child may pass from one attack of intestinal catarrh to another, and may eventually die from a derangement which a little care and suitable treatment at the beginning would have arrested without difficulty. Infants who are " short-coated " in cold, damp weather, often owe the beginning of an obstinate diarrhoea to the same cause. This change, so dear to the heart of a mother, is often made recklessly, and without any care to suj^ply the place of the clothing which is withdrawn. It is not, therefore, wonderful that the child should suffer from the unaccustomed exposure ; for, if an infant, at an age when warmth is a pressing necessity, be suddenly deprived of the chief protection to its lower limbs and belly, the con- sequences may be expected to be serious. Older children also are often very sensitive to changes of temperature, and chilling of the surface is in them, too, a frequent cause of persistent looseness of the bowels. The infectious fevers, esjDecially measles and whooping- cough, no doubt often prepare the way for this disorder, as do pneumonia and most catarrhal complaints ; but in these cases, too, the exciting cause is probably a chill acting upon a system made exceptionally susceptible by the late illness. In some children the presence of the ascaris lumbricoides in the alimentary canal will give rise to diarrhoea which may continue for months, now better, now worse, and only be finally arrested by the expulsion of the worm. In these cases the diarrhoea is most troublesome at night, the 80 CHRONIC DIARRHOEA bowel during the day being much less disturbed, and is accompanied by great straining, and often by prolapsus ani. When arising from the causes which have been men- tioned, chronic diarrhoea is the result merely of a functional disorder of the bowels. It is a derangement rather than a disease, but may become serious if not promptly taken in hand ; indeed, in young and weakly subjects it often proves fatal. There is, however, another form of the diarrhoea found in older children, which is of constitutional origin. Young persons, like their elders, who are the subjects of pulmonary disease, are apt to suffer from secondary ulcera- tions of the bowel, and the chronic diarrhoea which is thus excited hastens the fatal termination of the illness. This variety of chronic diarrhoea is rare in infants : it is most commonly found after the age of three years. Morbid Anatomy. — The morbid appearances found after death are very variable. On opening the bowel there may be no obvious change to strike the eye, but, as a rule, we find the mucous membrane tinted of a dull grey colour, and on it we may notice a number of minute dark grey points giving the so-called " cut-beard appearance from pigmen- tation round the opening of the little follicles. Examina- tion with the microscope shows minute changes. Many of the small tubular glands have disappeared, and there is considerable cell proliferation in the adenoid tissue of the mucosa. With this there is formation of new connective tissue in cases of long standing. In the small intestine there may be some loss of villi. These changes are not uniformly distributed over the mucous membrane, but occur here and there irregularly. If there has been a recent acute exacerbation, we often find a patchy inflammation of the mucous membranes which may be limited to the tops of the longitudinal folds. Ulceration is rare except in protracted cases. The ulcers are shallow, and are often difficult to detect MORBID ANATOMY 81 except by looking sideways at the surface, for their bases are of the same colour as the parts around them. They may occupy either the summits of the longitudinal folds — when they are elongated and sinuous, or may be situated between the folds — when they are very small and circular. Mixed up with the ulcers we see solitary glands and follicles enlarged and elevated above the surface, looking like little transparent pearls. The base is often sur- rounded by a ring of congested vessels. This state of the follicle is the first step in the process of ulceration. After a time suppuration takes place, so that the contents of the follicle become purulent, and the follicle itself still further increases in size. Lastly, the purulent matter escapes ; the roof dies, and, becoming detached at the edges, leaves a sharply- circumscribed roundish ulcer. The pearly appear- ance of enlarged follicles is often seen during life on the inside of the mouth dotting the mucous membrane of the cheek. The mucous membrane, when much inflamed, is often exceedingly soft, and may be much thickened ; but in long- standing cases where there is great emaciation, the lining membrane becomes thin, and in some cases hardly seems to exist at all. These changes are sometimes found to extend into the small intestine, which may be inflamed or ulcerated for a short distance above the ilio-csecal valve ; but in the large majority of cases the lesions are limited to the colon. The mesenteric glands are sometimes swollen from excessive cell proliferation. The simple or catarrhal form of ulceration described above may be seen in young babies of any age ; but there is another variety which is met with in children of three or four years of age and upwards. Tuberculous ulceration of the bowels is common as a consequence of pulmonary and abdominal tuberculosis. The ulcers are usually found in the ilium, and occupy Peyer's patches and the solitary 6 82 CHRONIC DIAKRHCEA follicles — particularly those in tlie neighbourhood of the ilio-csecal valve. As the ulcers extend they pass beyond the boundaries of the patch and, meeting other ulcers, coalesce with them so as to form circular or oval breaches of surface. The latter lie transversely across the bowel. Tuberculous sores rarely rupture on account of the thick- ening of the tissues at the base and the adhesions which are formed with underlying parts. This form of ulceration is invariably joined with tuber- culous disease of the mesenteric glands, and is often only a part of a general distribution of tubercle throughout the body. Diagnosis. — If the child is seen early before the estab- lishment of actual diarrhoea, the nature of the derange- ment can be readily inferred from the course and nature of the symptoms and the character of the stools. In most cases, unless questioned closely upon the matter, the mother will not mention the state of the bowels, or will merely say that they are regularly relieved. Sometimes the enormous quantity of the alvine discharge attracts her notice ; but it is rare for information with regard to the state of the stools to be obtained without direct inquiry. In all cases, therefore, where a child, whatever its age, is becoming pale and thin, and is found to be losing strength, the condition of the bowels and the state of the dejections should receive careful attention. At this period of the derangement gradual loss of flesh, colour, and strength may be the only symptoms complained of. The appetite is often good and the spirits of the child may seem little affected. Sometimes, indeed, the appetite is unusually keen, and the mother will declare that she cannot think what is the matter with the child, for in spite of all the food he takes he gets paler and thinner. Tuberculosis is often suspected in these cases, and, indeed, the general appearance of the child and the vague- ness of the symptoms are calculated at first to convey a DIAGNOSIS 83 false impression as to the nature of the complaint. Still, the absence of pyrexia is a valuable negative symptom in excluding tubercle ; and the character of the stools amply accounts for the faulty nutrition of the patient. If the case be first seen after diarrhoea has become established, it is important to exclude, if possible, the presence of tuberculous ulceration of the bowels. To do so we must consider the age of the child, the circum- stances under which the purging commenced, and the existence of disease in other organs. If the derangement date from a few days after birth, or from the time of weaning, or if the patient be an infant who has been injudiciously fed, insufficiently clothed, or neglected and exposed to privation, the case is in all probability one of simple intestinal catarrh. Moreover, the age of the child furnishes in itself a strong presump- tion in favour of this view, for during the first year, or even the first two years of life, chronic diarrhoea is almost invariably catarrhal. In any case, after an examination of the whole body, we should not neglect to take the child's temperature by introducing the bulb of the ther- mometer into the rectum. In simple chronic diarrhoea the temperature is, if anything, lower than in health, and does not become elevated in the evening. If, then, we find that the heat of the body is not increased, we have just grounds for believing the case to be an ordinary one of chronic functional derangement. We must, however, be on our guard against drawing wrong inferences from the presence of fever. Teething, or other sources of irritation, may cause a rise in the temperature. Therefore, we should in all cases satisfy ourselves as to the condition of the gums, remembering that children sometimes cut their teeth at four months old, and that chronic diarrhoea does not delay dentition. The temperature of a teething child is often as high in the morning as at night, and varies from time to time capriciously. If diarrhoea is present, 84 CHRONIC DIAKRHCEA howev(;r, the pyrexia rarely lasts longer than twenty-four hours. Older children suffer also from chronic intestinal catarrh ; but in them, as there is stronger probability that the disease may be due to ulceration of a tuberculous nature, the other organs should be examined with peculiar care for signs of disease. The chest should be searched for evidence of pulmonary mischief, and the abdomen for enlarged mesenteric glands and signs of peritonitis. Ten- derness on pressure of the belly in the right iliac fossa, with a certain amount of tension of the parietes in that situation, would lead us to suspect the existence of ulcera- tion. The kind of stool most characteristic of this con- dition is that composed of dirty-brown fluid, with a deposit containing flaky matter, and small black clots of blood, with mucus and pus, the whole being intensely offensive. When the child, after cessation of the diarrhoea and the beginning of convalescence, suddenly ceases to improve, the presence of some complication should be suspected. If the temperature becomes febrile, the lungs should be examined for pneumonia, and the ears for otitis media. Prognosis. — The prospects of the patient will vary ac- cording to the cause of the diarrhoea, the age of the child, and the intensity and obstinacy of the purging. If there is pulmonary disease, with tuberculous mesen- teric glands, and especially if, in addition, signs of ulcera- tion of the bowels can be detected, recovery can scarcely be hoped for. In cases of simple chronic catarrh the prognosis is more serious in children under two years of age than in older children ; but even in an infant, chronic diarrhoea is not difficult of cure so long as the attacks of purging are intermittent, however short the intermissions may be. When the looseness of the bowels becomes a confirmed derangement the chances of recovery are diminished. PROGNOSIS 85 Still, even in these cases, if the infant be of good consti- tution, we may entertain hopes of a favourable issue. If there be hereditary taint, as syphilis ; if the child be suffering from rickets in any but a mild form ; or if he be much reduced in strength at the time when he first comes under notice, the prognosis is serious. When secondary to acute disease, the case is graver than when the derangement is primary and non-febrile from the first. The most favourable cases are those which are due unmistakably to error in feeding, or to neglect, provided treatment be begun before symptoms of exhaus- tion have set in. In such cases we may hope by careful treatment to arrest the purging, before any ulceration has been set up in the alimentary canal. The form of stool which is of worst augury is that which has been described as characteristic of ulceration in the bowels. The thicker and more homogeneous the mo- tions become, although they may at the same time remain intensely offensive, the more favourable is the prognosis. The occurrence of any complication should give rise to very great anxiety. Measles especially is apt to cause a sudden and violent increase in the intensity of the diar- rhoea ; and, moreover, its own course is often rendered irregular by the presence of the intestinal disorder, so that retrocession of the eruption and other alarming symptoms may ensue. The prognosis is also rendered very unfavour- able if the tongue become dry and rough, if thrush appear upon the inside of the mouth, or if dropsy occur. Amongst the favourable signs may be included — continuance of the natural process of dentition ; the appearance of tears ; and the occurrence of any eruption * (unconnected, of course, with any of the exanthema) upon the child's body, even although the diarrhoea may not at the time have undergone any visible improvement. Prevention. — Diarrhoea may be prevented by attention * Underwood. 86 CHRONIC DIARRHOEA to the diet and general management of the child. All indigestible food is calculated, in its passage through the bowels, to give rise to irritation, and therefore to cause an increased flow of watery fluid from the vessels of the intestines. It is unnecessary to repeat here the directions which have been already given for the feeding of young children, and the reader is referred to the section on the treatment of simple atrophy for full information upon this subject. It may, however, be remarked that the practice of giving to very young children sweet cakes and articles of confectionery between their regular meals, and as rewards for good behaviour, is one to be very strongly deprecated. Sweet cakes are especially to be avoided, as they are so apt to undergo fermentation in the alimentary canal. As cold is so common a cause of diarrhoea in children great care should be taken to shield them from this source of danger. But they should not, therefore, be confined too strictly to the house. Fresh air is as important to them as simple nourishing food. Healthy infants should be taken out at certain periods of the day whenever the weather permits. It is not so much cold as daw/p air which is dangerous to infants, and even in damp air, unless it be actually raining, a short expedition is not hurtful to a robust child, provided sufficient precautions be taken. The child should be warmly dressed, should be carried briskly along, and should not be allowed to remain out too long at a time. If there is any wind his face should be protected with a woollen veil. As an additional defence, a flannel bandage should be worn round the body next to the skin. This is an article of clothing no infant or young child should be without. It should be looked upon as a necessary part of his dress. The band should be sufficiently wide to cover the whole belly from the hips to the waist, and long enough to go twice round the body. It should be secured by " safety " pins ; and in fitting it AVOIDANCE OF CHILL 87 care should be taken to wrap the bandage tightly round the hips, so that it may not slip up and leave the lower part of the belly exposed. The band is more elastic if cut diagonally from the piece of flannel. Sudden changes of temperature are especially to be avoided, and a rapid change from cold to heat appears to be as prejudicial as a similar passage from heat to cold. It is, therefore, necessary to prevent an infant being taken too quickly to a hot fire after exposure to the cold of the outside air. The child should not be allowed to wait, clothed in his out- door dress, in a warm room, before taking his airing. He should be taken out directly he is dressed for the walk. While out, he should be kept in movement, and should not be allowed to remain motion- less in a current of cold air. If the weather is cold, damp, and gloomy, he should be brought back to the house after only a short stay in the open air. A pinched look about the face, with coldness and blueness of the extremities, are certain signs that he is no longer receiving benefit from his airing. If a perambulator be used, the child, on cold days, may rest his feet upon a hot water-bottle. During dentition the rules here laid down must be especially observed, for it is at such times, when the teeth are pressing through the gum, that diarrhoea is so com- mon. Many children are said always to cut their teeth with diarrhoea. Perhaps, however, dentition in these cases is not so entirely to blame as is commonly supposed. No doubt, during the cutting of the teeth, the bowels gene- rally are in a state of irritability, for we know that at these periods the follicular apparatus of the intestines is undergoing considerable development. The bowels then are ripe for diarrhoea ; there is increased sensitiveness to the ordinary exciting causes of purging ; but without the presence of these exciting causes diarrhoea is by no means a necessary result of such a condition of the alimentary canal. We find that looseness of the bowels is a more 88 CHRONIC DIARRHCEA common accompaniment of dentition in summer and autumn than in winter ; that is, at a season when the changes of temperature are rapid and unexpected, and when therefore the child is particularly exposed to sudden chills ; rather than at a time of the year when the tem- perature, though lower, is more uniformly low, and when precautions are more naturally taken against the cold. Moreover, when the early teeth appear the child is ceasing to depend for nourishment entirely upon his mother's milk. His digestive organs are, therefore, apt to be deranged by articles of diet unsuited to his age. Even if the diet be a suitable one for the infant when in health, it by no means follows that the same regimen will be found equally appropriate at a time when the febrile irritation set up by the advancing tooth has temporarily reduced his digestive power. His ordinary diet may then become indigestible, and therefore irritating to his bowels. Treatment. — The marked influence exercised upon chronic diarrhoea in children by variations in the temperature and degree of moisture of the air indicates an important means of checking the disease. The infant must be kept as nearly as possible in an equable temperature of from 60° to 65° Fahr. Free ventilation must be sustained by an open fire, or in warm weather by a lamp placed in the fender ; but all draughts of air should be carefully guarded against. Where prac- ticable, two adjoining rooms, having a door of communi- cation between them, should be chosen. The child may then inhabit them alternately, and during his absence the unoccupied apartment can be freely ventilated. Even where this convenience is unattainable, two rooms, although separated from one another by a passage, should be always made use of ; the child can be taken from one to the other without danger if wrapped from head to foot in a blanket. At night, air should be admitted into the room as freely as is consistent with the avoidance of draughts ; with TREATMENT 89 this object, the door of the room may be left open, or in dry warm weather the window may be opened for a short distance at the top. In damp weather, however, or in seasons when the temperature falls notably at sunset, this must be prohibited. If possible, the infant with his nurse should be the only occupants of the bedroom, and no cooking of any kind should be allowed in the nursery. If a flannel bandage have not been previously in use, it must be at once applied as directed above. This precau- tion should on no account be neglected. Flannel, which is a non-conductor, forms by far the most efficient pro- tection to the belly against sudden changes of tempera- ture. Chronic diarrhoea is, no doubt, frequently kept up by a succession of chills, just as a coryza or pulmonary catarrh may be prolonged almost indefinitely by the same means. By the use of this safeguard we at any rate ensure ourselves from having to deal with a series of catarrhs. For the same reason the feet and legs should be covered with woollen stockings. It is well known that cold feet have a very bad effect on an irritable stomach and bowels, and in children, otherwise healthy, often produce severe pain in the belly. In a child suffering from abdo- minal pains, the feet should always be examined, and if cold, it is usually found that on warming them the mani- festation of pain ceases. Great cleanliness must be observed. All soiled napkins must be removed from the room at once, and the bedding should be taken away every morning and exposed freely to the air. The nates should be carefully sponged and dried after each motion, and should then be dusted over with powdered lycopodium or, if the skin is abraided, with a powder composed of oxide of zinc and starch in equal proportions made antiseptic with a sixth part of boric acid. With regard to washing of the child's body, the utmost care must be taken not to expose the sensitive patient to cold. An ordinary washing bath is out of the question on 90 CHRONIC DIARRHCEA account of the lengthened exposure it entails. My practice in these cases is to order the child to be sponged for one minute by the clock in a bath of hot soap-suds. Such a washing, if done quickly, is the method the least likely to give him a chill. In bad cases where the patient is wasted and weak with a feeble circulation and cold extremities I forbid washing altogether, except local sponging after a stool, and order the feet, legs, and belly to be swathed thickly in cotton wool. 1 have kept children so wrapped up for six weeks or two months at a stretch, allowing mere local sponging of the face, hands, and nates ; and believe that by this means I have been enabled to bring to a successful issue cases which otherwise would have ended in a very different way. The next thing is carefully to regulate the diet. If the patient be an infant at the breast, who, besides his mother's milk, has been overfed with farinaceous food, or allowed to swallow unsuitable morsels from his parents' table, a strict limitation to the breast will often produce a surprisingly beneficial effect upon the derangement. If the infant has been fed artificially without judgment, the engagement of a good wet-nurse will often have a simi- larly favourable influence. If, however, this plan of treatment cannot be adopted, or if, as may happen it is not found to agree, other means must be resorted to. Thus, for an infant under six months old, the milk must be greatly restricted in quantity ; or if the child be much reduced in strength, may judiciously be excluded at first altogether from the diet. In most of these cases milk in any form appears to act as a positive irritant to the bowels, fermenting and turning acid directly it is swal- lowed. When this tendency to acid fermentation prevails it will be hopeless to attempt to arrest the derangement so long as the milk diet is persisted with. Our first care must therefore be to substitute for it a non-fermentable regimen, and our chief trust should be placed in fresh DIET 91 whey, weak veal or chicken broth, and barley-water. The latter, which on account of its consistence is very grateful to babies, may be mixed with an equal proportion of whey and of broth alternately, and given from a perfectly clean feeding-bottle. If the purging be severe, the mixture must be given cold, and in small quantities at a time. In such cases, instead of using the feeding-bottle, the food should be given with a teaspoon. By the above means a certain variety can be introduced into the diet ; and the successive meals should be so regu- lated that the quantity taken on each occasion, and the length of the intervals by which the meals are separated may be properly proportioned to one another and to the state of the patient. The more copious the diarrhoea, the smaller should be the meals, and the more frequently they should be repeated ; for any large quantity of liquid food taken at once would be directly absorbed from the stomach into the circulation, and, when the purging is severe, would by lowering the density of the blood, be immediately followed by an increase in the flow from the bowels. When the stools are frequent and watery, liquids should never be given in larger quantities than a tablespoonful at a time, and in bad cases one teaspoonful will be found sufficient. Beyond the age of six months the yolk of one egg un- boiled may be added to the diet. The egg is best digested when beaten up with a few drops of brandy and a table- spoonful of cinnamon-water. As with younger infants, the quantities to be given at one time must depend upon the strength of the child and the state of his bowels.. Farinaceous food, with the exception of barley-water, seldom agrees in these cases ; but if the child be over twelve months old, and the purging not very severe, we may, if desired, make cautious trial of baked or boiled flour, giving one teaspoonful with four ounces of milk and water. One of the malted foods is, however, to be preferred to unguarded farinaceous matter, especially the 92 CHRONIC DIARRHCEA form known as Mellin's food. This is very useful, and can be given dissolved in whey, barley water, or a mixture of both, or in thin veal broth. As the child improves, milk should always be returned to, but at first should be given with a sparing hand, for fear it should disagree. A good scale of diet for a child of nine months old, who is beginning gradually to return to milk food, is the following,^ consisting of five small meals in the twenty-four hours : — 1st meal. — One teaspoonful of Mellin's Food for In- fants dissolved in four ounces of sterilised milk and fresh barley-water, equal parts. 2nd meal. — Four ounces of veal broth, of the strength of a pound of meat to the pint of broth. 3rd meal. — Four ounces of fresh whey, containing a dessertspoonful of cream. 4th meal. — The unboiled yolk of one egg — plain, or beaten up with a tablespoonful of cinnamon- water, a little white sugar, and ten drops of brandy. 5th meal. — Same as the first. In this dietary the first and fifth meals contain a small quantity of milk. It is best to assist digestion by allow- ing only milk which has been previously sterilised or peptonised (see page 46). If this be found to disagree, the Mellin's food may be dissolved in barley water, alone or diluted with an equal quantity of weak veal broth, or weak veal broth alone may be given. In any case, the quantity of four ounces should not be exceeded, for it is wise, especially at the first, to be sparing rather than liberal in regulating the allowance of food. It is better that the child should be hungry than overloaded ; and so long as the stools retain their pasty character it is evident * See also Diets 14, 15, Ifi, and 17, Chap. XI. DIET 93 that the food taken remains in great part undigested. In these cases, and, indeed, in all cases where a special diet is recommended for children, a dietary, as given above should be written out by the medical attendant for the benefit of those to whose care the child is entrusted. No, only the kind of food, but the quantity to be given at each meal, and even the hour at which the meal is to be taken, should be duly set down, so that no excuse may be avail- able for neglect or misapprehension. Whatever be the diet adopted, our object is to keep up the nutrition of the body with the smallest amount of irritation to the alimentary canal ; and the food, whatever it may be, which will produce this result, is the food best suited to the case. Without attention to this point, all treatment by drugs is useless, for a lump of indigestible food will neutralize the effect of the most powerful astrin- gents. The successful adjustment of the diet — an adjust- ment in which the quality and quantity of food allowed for each meal are accurately adapted to the powers and requirements of the patient — is a matter which can be properly learned only by experience, and which often makes large demands upon the tact, the ingenuity, and the patience of the medical attendant. This experience every one should labour to acquire, for without it success can seldom be attained in the treatment of the chronic functional derange- ments of young children. In the case of children between eighteen months and two years old the derangement, as has been said, often begins insidiously. The bowels are relieved once or oftener in the day, but can hardly be said to be relaxed. The stools consist of light-coloured, pasty matter, which in exceptional cases may even be formed. They are always large, and are usually offensive. In this form of the derangement milk must be strictly excluded from the diet, and the quantity of starchy matter taken must be consider- ably reduced. Instead of ordinary bread, the child must 94 CHRONIC DIARRHOEA take malted bread or rusks or thin dry toast. Mellin's food is useful, made thick with whey. If desired, it may be flavoured with cocoatina. For dinner the child may take meat jelly, strong veal or chicken broth, or pounded raw meat, made as directed on a later page (see page 102). Yolk of egg often agrees well, and may be given lightly boiled, or beaten up with a teaspoonful of brandy. One of the disadvantages connected with this method of feeding is that after a time the child is apt to suffer from monotony of diet and absence of fresh food. The blood becomes deteriorated in quality, and symptoms of scurvy may show themselves. On this account fresh vegetable food^ should be always included in the diet. Spanish onion, f flower of broccoli, vegetable marrow, or young French beans, may be given. Each of these must be well boiled until thoroughly tender, and afterwards passed through a sieve. Every care should be taken to vary the diet as much as possible, as the patient soon tires of his food, and may lose his appetite in conse- quence. Finely-ground lentils, sold under the name of " Revelenta Arabica," will be found a useful resource, and are often well borne if prepared with a third part of finely ground malt. It will be necessary to continue the diet for many months, for the inability to digest milk and starch often continues for some time after the child has regained his flesh and strength. When milk is returned to, it should be given peptonised, as already directed. In the case of older children who share the ordinary ^ If, on account of the season of the year, fresh vegetables arc diffi- cult to obtain, or if the child refuse to take them, a teaspoonful of fresh lemon juice may be given him with a little water at dinner time. This rarely disagrees. t These onions form a useful addition to the diet of young chil- dren when properly cooked. They should be stewed for five or six hours, changing the water every hour. By this means all rankness is left behind, and the vegetable becomes a most delicate and digestible article of diet. EXTERNAL APPLICATIONS 95 meals of the household, it will be necesary also to make considerable restrictions in the amount of fermentable matter allowed. Potatoes, sweet biscuits, and farinaceous matters generally, sugar, jams, &c., should be excluded from their diet, and they should be fed upon bread and milk, freshly-made broths, with, at dinner-time, a little fresh meat and broccoli, or green vegetables. Puddings, as a rule, should be forbidden, but custard pudding may be permitted. For drink they should take toast-water, plain water, or milk and water. The abdomen should be protected by a broad flannel bandage, as already directed for infants. Care should be taken to keep the feet warm, and, unless the weather be fine and dry, the child should be confined to the house. External applications are exceedingly useful in this disease, for the secretion of the skin is usually suppressed at an early period. The hot bath may be used at first every night, with all the precautions already enjoined (see page 13), after which the whole body should be freely anointed with warm olive oil, and the child be well wrapped up in flannel. When the prostration becomes marked the mustard- bath may be ordered. In cases where ulceration of the bowel is suspected, and it is thought advisable to apply local counter- irritation, a poultice consisting of equal parts of flour of mustard and linseed- meal should be used. This should be applied at some distance from, and not directly over, the seat of disease — to the chest, and not immediately to the belly ; and its effect should be carefully watched, that the irrita- tion thus excited may be kept within due bounds. If the child is very weak, the mustard, after remaining on a few minutes, should be removed, and a hot poultice of linseed-meal should be applied in its place. When the tenderness of the abdomen is very great it is advisable to keep the whole belly constantly covered with a large hot linseed meal poultice. This must be changed frequently^ 96 CHRONIC DIARRHCEA but with great care that the child be not chilled in the process. The preceding directions embody the essential points in the treatment of chronic diarrhoea. It is upon the judi- cious arrangement of his food, the careful protection of his body from fresh chills, and the plentiful supply of pure air, that the recovery of the child depends. The question of drug-giving is one only of secondary import- ance. In every case, therefore, before any medicines are prescribed, the above-mentioned matters must be attended to. The medical attendant should, with his own hands, apply the flannel bandage tightly roimd the patient's hips and waist, laying the child down for the purpose, with legs stretched out, so that the flannel may be brought well below the projection of the hips, and thus be prevented from slipping upwards. With regard to internal remedies :^ — If the patient is seen at the first, before the diarrhcea has become esta- blished, and when there is nothing but pallor, languor, gradual loss of flesh, griping and tenesmus, with large, pale, sour-smelling stools, a small dose of powdered rhu- barb, with carbonate of soda, should be ordered, and then, when the bowels are relieved, a mixture containing tinct. opii. with bicarbonate of soda in some aromatic water : — 5b Tinct. Opii, gtta j, SodsG Bicarbonatis, gr. ij, Tinct. Zingiberis, r»tj, Aq. Chloroformi ad 5j. M. Ft. liaustus. To be taken three times a day. The opium at once renders the peristaltic action of the bowels more regular, and the stools become darker and less offensive in the course of a few days. The mixture containing tinct. opii. and castor oil, is also very useful if the tongue is furred : — * All the prescriptions given in this section are adapted to a child of twelve months old, unless otherwise stated. DIGESTIVES 97 p, Tinct. Opii, gtta. j, 01. Ricini, Glycerini, Mucilag. Acaciae, aa nw, Aq. ad 3j. M. To be taken three times a day. But it should not be used if the tongue is clean, and must not be continued longer than forty-eight hours if no benefit be found to result from its employment. Alteratives are in these cases of little value, for it is no use attempting to stimulate the functions of the liver by cholagogues. The large white putty-like stools consist, in great part, of undigested food ; and we shall best succeed in restoring the digestive power by antacids and aromatics, as directed above, and more than all, by the careful adaptation of the food, both in quantity and quality to the enfeebled powers of the child. It is in these cases that milk is seldom well borne, except in very small doses well diluted with lime-water, and it is often necessary to replace this by other articles of diet as already described. Sometimes these patients are greatly benefited by the administration of extract of malt, directly after each meal. If the bowels are not relaxed, malt extract is usually well borne, but in some children it has an aperient action which is injurious. Pepsine is another useful digestive. Three to five grains given to a child of eighteen months or two years old, with a drop or two of dilute hydrochloric acid and one of laudanum, directly before each meal, will be found of service. The dose of pepsine should be always combined with a small quantity of laudanum, so that the passage of food along the bowel may be sufficiently delayed to give the digestive time to exert its influence. Finkler's papain is a digestive of even greater value. It should be given in combination with an alkali, as in the following: — 7 98 CHRONIC DIARRHOEA Jto Papain (Finkler), gr. ss, SodjB Bicarb., gr. ij, Pulv. Trochisci Menth. Pip., gr. iij. M. Ft. pulv. To be taken three times a day just before food. When the purging sets in, if the stools are green, and slimy or watery, with a sour smell, it is best to begin with a dose of bismuth and chalk. To be of service the dose of bismuth must be a large one. The remedy is not absorbed into the circulation, and may be therefore given in large quantities to the youngest children without any danger. 1^ Bismuthi Carb., gr. x, Pulv. Cretse Aromat., gr. ij. M. Ft. pulv. To be taken every four hours. If there is much tenesmus, an injection containing four or five drops of laudanum, with five grains of bicarbonate of potash, to half an ounce of thin warm starch may be thrown up the bowel. Dr. Evanson strongly recommends the addition of the alkali, which, he says, greatly increases the efficacy of the injection. So long as the stools remain sour- smelling, antacids should be persisted with. An aromatic should always be combined with the antacid. This," says Dr. Underwood, ''is of more importance than is usually apprehended. I have known a careful attention to this circumstance alone happily suppress complaints in the bowels, which had long continued obstinate, though, in other respects, properly treated." In these cases, too, an emetic is often of great service. It is necessary to inspect the stools daily for signs of mucus or any increase in the looseness. Usually, in spite of all possible care, the motions will be found every now and then to be loose and slimy. When this occurs a powder containing two or three grains of powdered f ASTRINGENTS 99 rhubarb and double the quantity of aromatic chalk powder should be given every night, and in the daytime the child may take the castor oil and opium mixture already recommended. By this means the state of the bowels will be greatly improved in the course of a few days. If, when the tongue cleans, the diarrhoea continues, and the stools are found to consist of dirty-brown stinking water, astringents must be used. The best of these, without any doubt, is nitrate of silver. One-eighth of a grain should be given with one drop of dilute nitric acid and one drop of laudanum in aqua chloroformi every four hours. This remedy is valuable in all forms of chronic intestinal catarrh in children, but is especially useful in cases where the stools are very frequent and watery, and contain variously coloured mucous and blood ; or where the prostration is great, with aphthous ulceration of the mouth. In such cases it should be always resorted to. The ordinary astringents seem of little service ; and in many children gallic acid, dilute sulphuric acid, lead, hsematoxylon, and other similar remedies may be given perseveringly without producing any impression upon the derangement. Bismuth, however, in large doses (gr. X — XV to a child of twelve months old every three or four hours) will often check the diarrhoea at once, especially if given with aromatic chalk powder, as already recommended ; but the improvement is sometimes only temporary. Injections of nitrate of silver are valuable in the later stages, particularly if there are any signs of ulceration of the large intestine. The bowel should be first cleared out with warm water, and then an enema, containing one grain of the nitrate to five ounces of cold water, should be administered. Trousseau recommends that in bad cases it should be repeated twice in the twenty-four hours. 100 CHRONIC DIARRHCEA Astringent enemata must not, however, be continued too long. They should be suspended every two or three days in order to watch the effect, and in the interval enemata of simple starch may be used. The perchloride of mercury is a useful remedy in cases where very slimy motions are passed with much straining and pain, especially if lumps of coagulated mucus, com- pared by the attendants to " lumps of flesh," are found in the stools. Three to five drops of the pharmacopoeia solution may be given in water every hour or two hours sweetened with spirits of chloroform. Stimulants will be required as the child grows weaker, and must be given pretty freely when the sinking of the fontanelle and the other symptoms show that he is be- coming exhausted. Five or ten drops of pale brandy, or double the quantity of dry pale sherry, may be given in a spoonful of the food three, four, or six times a day, or even every hour, as required. Grood beef gravy free from fat, is also useful at these times. Not seldom, in spite of all our efforts, the child goes on from bad to worse. The diarrhoea resists all treat- ment, and continues obstinate, whatever be the measures adopted. In these cases the treatment by raw meat becomes a valuable resource. A piece of raw mutton free from gristle or fat, is finely minced, and is pounded in a mortar till it is converted into a pulp. The pulp is then rubbed through a fine sieve, to remove the blood-vessels and cellular tissue. Of the meat so prepared a teaspoonful is given at regular intervals four times in the day, and every day the quantity administered is gradually increased, until half a pound is taken each day in divided doses. If the taste of raw meat is greatly objected to, a thick mutton chop may be grilled quickly over a hot fire. Of this, the hardened outside is to be cut away and the soft juicy interior alone made use of for the meal. The meat usually at first causes the motions to have an intensely POUNDED RAW MEAT 101 offensive smell ; but this is of no consequence, and the parents should be warned of its liability to occur. The patients themselves often like the food, and take it eagerly. If, however, as may happen, they show any repugnance to it, the meat may be given in a small quantity of veal broth, may be diffused through jelly, or may be mixed with an equal quantity of cream, if the latter can be obtained perfectly fresh. As medicine, we must give at the same time the pepsine mixture, already recommended, with the addition of one drop of tinct. opii to each dose. There can be no doubt about the value of this remedy. Under its influence the stools become less frequent and less liquid, and although they remain for a time horribly foetid, yet they gradually assume more and more the character of healthy evacuations, while the other symptoms undergo a like amendment. For the first day or two the meat will be found in the motions almost unchanged, except for decomposition, the dejections consisting of colourless fibrine with a little cellular tissue and mucus ; but by perseverance we find that it begins gradually to be digested and less of it appears every day in the stools. When from this or other treatment the diarrhoea has been arrested, and the stools have become more healthy- looking, a tonic should be given, and the one best adapted to continue the improvement is the solution of the perni- trate of iron, which has besides a beneficial influence upon the alimentary canal. It is best given with dilute nitric acid : — Liq. Ferri Pernitratis, rrtj, Acidi Nitrici diluti, inja Glycerini, itlv, Aquam Anetlii ad 53. M. Ft. haustus. To be taken every six hours. Other tonics may afterwards be given, as the decoction of bark with syrup, the citrate of iron and quinine, cod- liver oil, &c. If the oil be given, its effects must be care- 102 CHRONIC DIARRHCEA fully watched. It is best to begin with a small dose, as ten drops in a teaspoonful of food three times in the day ; but if there be any smell of the oil in the stools, even this small quantity must be diminished. The constipation, which usually succeeds to the diarrhoea, should not be lightly interfered with. If two or three days have passed without any action of the bowels, a very small dose— about twenty drops —of castor oil may be administered, and may be repeated, if necessary, after four or five hours. As so much harm is often done in these cases of chronic diarrhoea by little indiscretions, it is of extreme importance that we should not allow improvement to make us relax in our attention or diminish our precautions. It is a good rule in all cases where the child is getting better to act as if he were getting worse, to redouble our vigilance rather than to relax in it ; for at any time a chill or a fragment of indigestible food may undo all that has been done, and throw the child back into a state from which it has required perhaps months of care to deliver him. After the cessation of the diarrhoea the child must not, however, be kept too low. As his digestive power in- creases, his diet should be improved in proportion. This is very important, as rickets is not an uncommon result of the impairment of nutrition produced by the disease, and is therefore favoured by anything which tends to prolong the weakly condition of the infant. In patients of three or four years old and upwards chronic diarrhoea usually excites less anxiety than in younger children, and responds more readily to treatment. If the diet be regulated upon the plan previously laid down (see p. 90), and a flannel bandage be properly applied to the belly, recovery usually follows quickly enough. For medicines the child may take an alkaline mixture, containing two or three drops of laudanum, and every other night for a week, a powder containing four to six grains of powdered rhubarb, with twice the quantity LIENTERIC DIARRHCEA 103 of aromatic chalk powder. Should the diarrhoea still per- sist, five drops of tincture of catechu in a teaspoonful of mucilage every hour, or a mixture containing gallic acid, dissolved in aromatic sulphuric acid, may be resorted to. The lienteric diarrhoea previously described, in which the evacuations occur frequently after a meal, and consist of undigested food, requires a different kind of treatment. This variety of diarrhoea is not to be controlled by the ordinary astringents, and is very much increased by aperients, as castor oil. Opium will, however, sometimes check it temporarily, but for its permanent cure the best remedies are arsenic and tincture of nux vomica in small doses. The following short cases will serve as illustrations of this form of diarrhoea, and of the treatment to which it is most readily amenable: — Master R., aged five years, had been subject for twelve months to prolonged attacks of diarrhoea, during which the bowels acted four or six times in the day. The motions usually followed a meal, and sometimes so urgently that he was obliged to leave the table before the repast was concluded. The motions were said to run from him," and to contain much slimy matter. There was no strain- ing, but the stools were preceded by some griping pains in the belly. He was fretful and rather thirsty, but slept well at night. He was losing flesh rapidly, although his appetite was large. The child was ordered to take two drops of tincture of nux vomica in a draught of citrate of potash three times a day before meals. A few days after- wards he returned very much better. The bowels were acting three times a day, not after meals. His appetite was more easily satisfied, and he had ceased to waste. A change was then made in his medicine to one drop of liq. arsenici chlor. in a nitric acid mixture before each meal, and he was not seen again. Elizabeth W., aged four years, had suffered for a long 104 CHRONIC DIARRHCEA time from repeated attacks of diarrhoea, each of which lasted for many weeks together. The motions were said to follow immediately upon taking food, and to occur sometimes in the intervals between the meals, so that the bowels were frequently acted upon five or six times in the day. The stools were slimy, and were passed without straining or apparent discomfort. The child was irritable in temper, and was very restless at night. Her appetite was capricious, and she was very fanciful in her eating. Her skin was exceedingly rough and dry. The tongue was clean, and over the surface were scattered light-red elevated papillae. She was first seen on January 7th, and was ordered to take one drop of liq. arsenicalis in a mix- ture containing citrate of iron and ammonia, with bicar- bonate of soda, three times a day. A warm bath was recommended every night, for the purpose of softening the skin and removing the dry epithelium scales. On January 14th the girl seemed better in herself, although the bowels were in the same condition as before. She had taken the medicine regularly, but each meal was still followed by the accustomed stool, and the child was still losing flesh. A mixture was then ordered containing laudanum and tincture of nux vomica — two drops of each to be taken before every meal. Considerable improvement followed the change of medicine : the appetite became very good, and the bowels, although still relaxed after each meal, did not act in the intervals, so that the daily number of evacuations was much reduced. The skin, owing to the nightly warm bath, had become soft and supple. One drop of liq. arsenici chlor. was then given three times a day in a nitric acid mixture, and the cure was soon complete. CHAPTER III CHRONIC VOMITING (chronic gastric catarrh) SLIGrHT attacks of vomiting, lasting for twenty-four hours, or even for several days, are not at all un- common in infants even while at the breast. The matters ejected consist of the food, of stringy mucus, and of bile ; at the same time there is some heat of skin, thirst, loaded tongue, and constipation or diarrhoea. These attacks, due to an acute catarrh of the stomach, always end favourably unless they are aggravated by much meddling. The only treatment required is an emetic of ipecacuanha wine to relieve the stomach, followed by a gentle purge, and by careful regulation of the diet. Sometimes it is necessary to forbid even the breast-milk for a time, and to restrict the infant to cold thin barley-water given with a teaspoon. These attacks are of little consequence. The child may get a little flabby and pale, but when convalescent a week of ordinary feeding restores him to his former state of health. The catarrh may, however, pass into a subacute stage, which is much more serious, and the vomiting then becomes chronic and persistent. This condition is often a very dangerous one, and always produces great wasting and prostration. Symptoms. — There is no fever. The child vomits at irregular intervals, throwing up the milk curdled and sour- smelling, and, at the first, tinged green or yellow from bile. The bile, however, soon disappears from the vomited matters, and clear fluid, like water, is ejected, alone or mixed with the food. On pressure of the epigastrium the 106 CHRONIC VOMITING child writhes as if in pain. The belly is full, often tympa- nitic, and gurgles when pressed upon. Eructations occur of foetid, sour gas, and the bowels are obstinately confined. An eruption of strophulus often covers the body and arms, and the complexion has often a sallow, half -jaundiced tint. The child gets thinner and paler, and is very fretful. The fontanelle becomes depressed. Some diarrhoea may at first alternate with the constipation, but after a few days the bowels become again confined, and the motions, when they occur, consist of round, hard lumps, very light- coloured, evacuated with great straining. The lumps may be covered with tough mucus. The tongue is coated with a thick layer of dirty-yellow fur ; it is not very moist, and dull red papillae of medium size are seen peering through the fur, here and there, on the dorsum of the tongue. The breath smells sour. The lips are dry and red. A furrow passes down from each side of the nose to encircle the corner of the mouth, so that the lips seem to project. The mouth is clammy and pai^ched, and the child takes the breast eagerly to relieve this parched feeling by the flow of milk, but rejects what he has swallowed very shortly afterwards. After the child has remained in this state for a con- siderable time, often with occasional intervals of improve- ment for several months, the vomiting becomes more frequent. It occurs not only after taking food, but also in the intervals of feeding, and seems to be excited by the slightest movement, or by a touch, so that the mere act of wiping the mouth may bring on a fresh attack of retching. The milk is thrown up uncurdled. Emaciation then goes on rapidly. The skin is dry and harsh, and hangs loose and flaccid ; the eyes get hollow ; the nose sharpened ; the cheeks sunken ; and the belly retracted. He lies with the knees drawn up on to the abdomen, and, when they are straightened out, returns them as soon as possible to their former position. Occasionally he moves his legs uneasily. SPURIOUS HYDROCEPHALUS 107 as if in pain. He is intensely fretful, breaking out into sudden cries, or, as lie becomes weaker, into a low, pitiful wail, which is even more distressing to hear, and never . seems to sleep, night nor day. The tongue is dry, and is still furred, so that it has a rough, granular appearance. In bad cases the whole body has an offensively sour smell. The smell j)roceeds not only from the breath, but is caused by acidity of all the secretions ; the saliva, the perspira- tion, and the urine being all intensely acid. The cutaneous secretion is, however, seldom in excess ; more usually the skin is inelastic and dry, and is in consequence rough and harsh to the touch, especially at the back of the arms and the belly. At length the child reaches a pitiable state of emacia- tion, and his strength is reduced to its lowest point. It is at this time that symptoms which have been called ''spurious hydrocephalus" often make their appearance. The child sinks into a drowsy state, and lies quietly upon his back with his eyes showing white between his half- closed purple eyelids. The pupils are slaggisli, and per- haps unequal ; the pulse is rapid and often intermittent ; the breathing is irregular ; the fontanelle is deeply de- pressed ; an earthy tint may spread over the whole body, and the face, hands, and feet are livid or lead-coloured. Warmth can be kept in the limbs only by cotton wool and hot bottles, and the rectal temperature is subnormal. At first the child may open his eyes now and then sleepily, as if not completely unconscious, but he seems unable to swallow, and soon passes into a state of decided coma. When thrush is noticed on the inside of the cheeks and lips it is a sign that the end is near ; and death is often preceded by faint convulsive movements. The terminal symptoms thus described are not peculiar to chronic vomiting, although they are especially apt to occur with that disease. They may be found in all cases where great exhaustion is induced from whatever cause, 108 CHRONIC VOMITING and are therefore not uncommon in chronic diarrhoea. In all these cases the fontanelle is deeply depressed, showing deficiency in the amount of blood circulating through the brain; the pupils are often dilated and im- movable, and there may be coma, with stertorous breath- ing. It must not, however, be concluded that cerebral symptoms occurring in a wasted, feeble infant are the consequence merely of sluggish circulation through the brain of impoverished blood. Parrot compared the con- dition to uraemia, and noticing the diminished secretion of urine observed when such cerebral symptoms are present, suggested a toxic origin for the phenomena. More recent observations tend to support the conclusion that cerebral symptoms and even cerebral lesions may be set up during g astro-intestinal derangements by toxic products. Marfan refers squinting, opisthotonos, and drowsiness to the action of microbes or microbial poisons, and asserts that the thrombi and intra- cranial haemorrhages may also be the consequence of toxi-infective processes of gastro-intestinal origin. From whatever cause they may proceed, there can be no doubt that the symptoms are of most unfavour- able augury, and show the condition of the child to be perilous in the extreme. In cases of recovery the vomiting becomes less frequent, and gradually ceases, although for some time it is liable to recur if much food be taken at once. The constipation, however, remains obstinate for some time after the cessa- tion of the vomiting. The child then begins to regain flesh, and often becomes exceedingly fat. Causes. — The complaint is common in infants of a few months old who have been weaned prematurely and fed with a diet they are unable to digest. Wet-nurses' chil- dren are often subject to it ; but the disorder is met with in all ranks of life when the infant's food is ill chosen or given without due care. A not uncommon cause of repeated vomiting is monotony CAUSES 109 of diet ; the child being fed morning, noon, and night on the same thing. It has already been explained (see p. 42) that in many hand-fed infants the digestion requires the stimulus of variety, and resents the repetition at every meal of the same food in exactly the same shape. If a change be made to another food, the vomiting stops for a few days, but only to return when the novelty has worn off, and the new food has ceased to please. In this way the derangement goes on as long as the same method of feeding is persisted with. Each change is followed by immediate improvement, and the vomiting ceases until the sameness of diet once more becomes wearisome, when the food is again rejected as it was before. Cold and damp are also fruitful causes of this complaint. The curious indifference shown by mothers to the warmth of their children's feet is answerable for many of the illnesses in a young family, and for not a few of the deaths. Whatever the weather may be, the indoor dress leaves the legs bare and often the thighs and abdomen as well. Sturdy children may endure the exposure without obvious harm ; but frailer subjects are often kept delicate and ailing by this means, even if they do not show more serious signs of illness. Even young infants still in their long clothes may suffer from cold feet without any reso- lute effort being made to amend their condition. The nurse says she ''cannot get the feet warm," and perhaps gives up all attempts to do so. Children who suffer in this way from exposure or neglect are always on the brink of an illness, and it requires but a mere trifle, such as a mild additional chill, to determine the outbreak. The crowding of infants together in close nurseries, or amongst the poor the stifling atmosphere of the one room in which a whole family is often lodged, is another common cause of the disorder. These causes have already been fully discussed under the head of chronic diarrhoea. 110 CHRONIC VOMITING Severe operations upon the child, siich as that for stone in the bladder, are often followed by an acid dyspepsia, which may lapse into obstinate vomiting ; a chronic catarrh of the stomach and bowels being set up, which may lead to death after the more immediate effects of the operation have been recovered from. Any cause, in fact, which lowers the easily-depressed general strength will reduce also the digestive power, and thus predispose to this complaint. Drugging with opiates by an unscrupulous nurse will sometimes keep up persistent vomiting in a new-born baby. Therefore, if we find the pupils to be contracted, the skin inelastic, the bowels obstinately costive, and notice that the child is unnaturally drowsy and apathetic, we should suspect such a cause for the indisposition, and advise very searching inquiry. Diagnosis. — The diagnosis of chronic gastric catarrh presents little difficulty. The frequent vomiting of offensive sour fluid, the emaciated condition of the child, and the long course of the complaint, leave little room for uncertainty. If the combination of obstinate vomiting with constipation, or the occurrence of cerebral symjDtoms, should give rise to suspicions of acute tuberculosis with secondary meningitis, the two diseases are readily dis- tinguished. The temperature of the body depressed instead of being elevated ; the sunken f ontanelle ; the rapid, feeble, but regular pulse ; the state of the belly, swollen rather than retracted — all tend to exclude the latter disease. Treatment. — Our first care must be to see that the child is warmly dressed and carefully guarded from cold. In the early stages of the disorder the gastric irritability is maintained from day to day by repeated chills. The child is half clothed or is carelessly exposed in his bath. Examination shows that the feet and legs are bitterly cold, and on enquiry we generally find that the child is being WARMTH 111 bathed at undue length, often in merely tepid water. It is important to explain to those concerned that any exist- ing catarrh greatly heightens the patient's susceptibility to changes of temperature, and that an impression of cold which would be powerless to originate a catarrh may be amply sufficient to keep up one already existing. It is best to forbid the bath for a time, and allow only local sponging, keeping the feet, legs, and belly well wrapped up in cotton- wool. It is advisable that the physician look into this matter for himself, and do not rest satisfied with the report of the nurse. If cotton- wool be applied, he should see that enough of it is put on to effect the object desired. It is not merely that the limbs must be wrapped up, but that they must be made and kept warm, for unless this prelimi- nary step be taken no treatment can succeed. It is well while the vomiting is urgent, to confine the patient to one or two rooms kept as nearly as possible at a temperature of 65° F. Fresh air should be freely admitted, and at night, if there is no fire, a lamp should be placed in the fender. The air of the nursery must not be contaminated by dirty linen. The child's clothes must be frequently changed, and soiled bibs and napkins must be removed from the room without unnecessary delay. Attention must next be directed to the proper feeding of the child. In cases where the vomiting has followed pre- mature weaning, the gastric derangement is evidently due to the change of diet. Inquiry should, therefore, at once be made into the kind of food which has been substituted for the mother's milk, and it will usually be found that farinaceous matters have been given largely in excess of the child's requirements or powers of digestion. In these cases the infant's food should be limited to peptonised cow's milk (see p. 46), or to equal parts of new milk and barley- water. The quantity allowed must be small at the first, but it can be gradually increased as the condition of the patient improves. 112 CHRONIC VOMITING If the case be not a severe one, and no fermenting process be going on in the stomach, such a change of diet, combined with other measures to be afterwards described, will usually succeed in restoring the digestive organs to a healthy condition. But when there is a sour smell from the breath or body of the child such treatment will be of little service. The sour smell is the result of fermentation of food, and denotes an intensely acid condition of the stomach. In such a case it is indispensable to improve- ment that all fermentable matters be excluded from the diet. Even cow's milk itself, however diluted and alka- linised, can seldom be borne, as it usually is vomited sour and curdled immediately after being swallowed. Still, woman's milk is sometimes well digested, and if the infant be young, a return to the breast may be followed by a rapid arrest of the vomiting — the stomach, which had rejected all other food, at once recognising the change of diet. Suckling must, however, be conducted with very great care. In all cases the child should take the breast at regular intervals, and should not be allowed to suck too long at one time, the amount of nourishment he is permitted to swallow being regulated on each occa- sion by the degree of irritability of the stomach and by the result which has followed the previous meal. If this has been rejected, the quantity allowed to be drawn at the next suckling must be diminished. When infants are very much reduced by constant vomiting the mere act of suckling appears often to excite retching. In such cases the nurse's milk can be given with a teaspoon. When a return to the breast is impracticable, or is not followed by the expected improvement — and, indeed, in many cases human milk seems to agree as little as the milk of the cow— the diet should consist of whey with cream,* * Fresh cream, one tablespoonful; whey, two tablespoonfuls; water, two tablespoonfuls. If the cream obtainable cannot be depended upon, a good substitute is the cremor hordeatus of Loeflund. DIET 113 or of equal parts of weak veal broth ^ and thin barley- water. In all cases of severe and obstinate vomiting a stoppage of the ordinary food and a resort to one of these mixtures, as a substitute for the milk diet, will almost certainly be followed by immediate relief. They should be given cold; and, if the vomiting be severe, a teaspoonful only should be allowed at one time. This may be repeated at intervals of ten minutes. It is only after the vomiting has been arrested that the child can be allowed to suck the food from a feeding-bottle. If a couple of days have passed by without any return of the sickness, a little milk may be added to the diet. This must be given at first with caution, and must be pepto- nised or diluted with an equal proportion of barley-water, and be aromatised by the addition of one or two teaspoon- fuls of cinnamon or car ra way water. The kind of milk which agrees best in these cases is that before referred to (see p. 45), under the name of strippings." It is rich in cream, but comparatively poor in curd, and is therefore much more digestible than the ordinary cow's milk. If this agrees, the quantity can be increased, and in the course of a few days, by gradual steps, the child may return to the ordinary diet of health. If the infant be much weakened, either by the length of his illness or the violence of the attack, white wine whey "t should be at once resorted to. The whey must be given perfectly cold, and at first in small quantities. If the vomiting be frequent, no more than one tea-spoon- * The veal broth should be of the strength of half a pound of veal to the pint of broth. t To make "white wine whey:" — Put a breakfast-cupful of new milk into a saucepan on the fire. When it boils add a wineglassful of sound sherry ; then boil again for a couple of minutes and strain off the curd. Afterwards replace in saucepan and simmer, skimming off the curd as it rises until the whey is clear. The whey may be sweetened with white sugar. The proportion of milk used may be varied according to the strength of stimulant required. 8 114 CHRONIC VOMITING ful can be allowed at one time. This method of feeding almost always agrees well, and the vomiting ceases yerj quickly. As the irritability of the stomach subsides the child may be allowed to take more and more of the whey, and after a few days may suck it from his feeding bottle like an ordinary food. In this way the infant will take large quantities of stimulant with very great advantage. When twenty-four hours have passed by without any return of the vomiting, a tablespoonful of fresh cream may be shaken up with the bottleful of whey. If this be well digested, a return may be made to the ordinary diet by cautious steps, as already described. Infants at the breast sometimes become the subjects of a chronic gastric catarrh, so that the milk, immediately it is swallowed, is ejected sour and curdled; and if the vomiting continue, as it is apt to do unless proper mea- sures be taken to arrest it, the nutrition of the child may be seriously impaired. If this derangement occur in a very young infant it is often wrongly concluded that the breast milk is unsuited to the baby, and he is ordered to be weaned. Such a step is, however, seldom if ever neces- sary. In mild cases the administration of an alkali with a stomachic such as nux vomica will often arrest vomiting, without any change in the diet being required. In very severe cases it will be prudent to forbid the breast for four-and-twenty hours, or even a little longer, until the vomiting ceases, but suckling may be afterwards resumed without danger. In the interval the child can be fed with whey and barley-water,* mixed in equal propor- tions, or with the whey and cream, as recommended above. * Barley-water is very useful in all these cases, for it is not only perfectly innocent, as a diet, but it supplies the necessary consistence to the food. A child will often refuse a liquid if it be made too thin. A food to be taken readily by babies must possess a suitable consist- ence. The barley-water must be made every six hours, and kept in a cool place outside the sick room. ILLUSTRATIVE CASE 115 The following is an illustration of this class of cases : — A. B., a fine child, aged eight weeks, was stated to have been persistently sick after food ever since its birth. He had been suckled for the first seven weeks, but had in- variably vomited the milk shortly after taking the breast. A week before the child came under my notice he had been weaned, and fed on condensed milk, diluted in the proportion of a teaspoonful to half a tumbler of water. This, however, he vomited, as he had done the breast milk. He was stated to smell sour occasionally, and when he vomited the ejected matters were discharged with con- siderable force, but without any retching. The bowels were loose, and the motions consisted principally of un- digested milk. The child looked pretty well, but had a slight yellowish tint of the skin. He was losing flesh fast. In this case the cause of the indigestion was evidently catarrh of the stomach, which dated from the time of birth. It was explained to the mother that her milk was not unsuited to the child, but that it disagreed temporarily, as did all other food, on account of the condition of the digestive organs. She was recommended to begin nursing again immediately; but, as her milk had partially dis- appeared, the breast was limited to two meals a day, and a supplementary diet composed of one teaspoonful of Mellin's food for infants, dissolved in one part of " strip- pings " and two of water, was ordered, every two hours. At the same time one quarter of a drop of the tincture of nux vomica was given with a few grains of carbonate of soda, three times a day, in cinnamon water. Under this treatment the vomiting soon ceased, the gastric derange- ment quickly subsided, and, as the secretion of breast milk returned in considerable quantity, the child after a short time required little food in addition to that furnished by his mother. In this instance the derangement was easily overcome : but sometimes the vomiting is not so readily arrested. If no milk could have been borne, the 116 CHRONIC VOMITING Mellin's food might have been dissolved in barley-water, or in equal parts of that and fresh whej. In all cases, then, of obstinate vomiting from a chronic gastric catarrh the question of diet is determined upon the simple principle of giving the digestive organs as much rest as possible. Food of the simplest character is given in small quantities, and if any fermentative process is going on in the stomach, it is at once arrested by stopping the supply of fermentable material. The vomiting which comes from monotony of diet is at once cured by giving more variety in the food. It is best to order three kinds of food to be used in rotation during the day and a desiccated milk food for the night, if required. Each meal must be prepared separately as it is wanted (see Diet 18, p. 346). With regard to the medicines to be employed : — If the child is seen early before the strength is much reduced, and we notice a sour smell from the breath with a thickly furred tongue, an emetic should be at once administered. A teaspoonful of ipecacuanha wine is the best form in which this can be given. Afterwards, when the stomach has been emptied of the acrid secretions and mucus, measures must be taken to quiet the gastric irritability and prevent any further formation of acid. By far the most valuable sedative in these cases is arsenic given in small doses. For a child of three months old a quarter of a drop of Fowler's solution of arsenic may be given three times a day, with two grains of bicarbonate of soda in a teaspoon- ful of aromatic water. At the same time the bowels, if confined, should be relieved by an enema of barley-water, containing half an ounce of castor oil, and they may be kept in regular action by one or two drops of a solution of podophyllin in alcohol (a grain to the drachm), or by suppositories of Castile soap placed in the rectum. In cases where arsenic does not succeed, cocain, one- STIMULANTS 117 eighth to one-fifth of a grain, may be tried dissolved in a teaspoonful of water, or one- sixth of a grain of calomel may be laid on the tongue every four hours, or one- sixth of a drop of tincture of nux vomica may be given with an alkali. Still, the actual drug to be employed is quite a secondary consideration. In bad cases our trust should be placed, not in the pharmacopoeia, but in energetic measures for stopping the fermenting process and assist- ing the escape of acid from the system. The obstinate vomiting is most surely checked by giving the stomach as much rest as is consistent with supporting nutrition. If the diet has been regulated as described, and if care has been taken to keep the child warm and ensure a proper relief from the bowels, the patient will, in all probability, recover, whatever be the drug made use of. When the child is much prostrated, as shown by the depression of the fontanelle, stimulants are always in- dicated. The white wine whey is here of great service, and if the infant be young should be always resorted to. For older children pale brandy may be used, given in doses of fifteen or twenty drops in a teaspoonful of the food or of plain water. When the prostration is great, the stimulant may be repeated every hour, or even oftener. If the child is at all weak, great caution must be exer- cised in the use of emetics. An emetic is only required when there is reason to suspect the presence of acrid secretions in the stomach. If, however, the tongue is clean, and there is no sour smell from the breath, an emetic is no longer indicated, and its employment would only increase the prostration. Vomiting is sometimes kept up by debility of the stomach, and this would be only increased by the exhibition of nauseating remedies. When the prostration, as shown by the condition of the fontanelle, is great, caution in the use of emetics is especially needful, as fatal syncope might follow their 118 CHRONIC VOMITING employment; and if the fontanelle is deeply depressed, they should on no account be made use of. When we are called to a child who presents the sym- ptoms described as spurious hydrocephalus, or to one who has been reduced by a long continuance of this derange- ment to a dangerous degree of prostration, our first care should be to endeavour to restore the circulation to the extremities by placing the feet as high as the knees in hot mustard and water. This is best done as the child lies on a pillow placed on the nurse's lap. If the weak- ness be extreme, the whole body may be immersed for three or four minutes in a mustard bath as high as the neck. On being removed from the bath the infant should be quickly dried and his limbs and belly thickly swathed in cotton wool. When returned to his cot hot bottles should be laid by his sides and at his feet and the most perfect quiet must be enforced. A napkin must be placed under the chin to receive all matters ejected from the stomach ; and when moistened, the cloth must be imme- diately removed and a clean one supplied in its place. At the same time the food should be limited strictly to white wine whey, or to barley-water mixed with an equal pro- portion of weak veal broth, given cold with a teaspoon. If the latter be used, five drops of pale brandy may be added to the spoonful of food as often as seems desirable. This state of serious prostration should excite the gravest apprehensions, for it is rarely recovered from. Mere weak- ness, however, apart from actual collapse, is no bar to re- covery. With proper measures success can often be attained even in the very worst cases of this derangement, but in young babies especial care must be taken to promote the circulation and encourage the free action of the skin. While the feet remain cold no treatment is likely to succeed. After the vomiting has ceased and the more urgent symptoms have been overcome, iron wine may be given TREATMENT 119 with a quarter or half a drop of tincture of nux vomica to the dose; and as the child improves, he must be taken out of doors whenever the weather permits, for a free supply of fresh air is a most important agent in the treatment of this as of all the other chronic diseases of children. CHAPTER IV RICKETS RICKETS, although one of the most preventable of children's diseases, is yet one of the most common. It begins insiduously, presenting at first merely the ordi- nary symptoms of defective assimilation, and attention is often not attracted to it until the characteristic changes occur in the bones which place the existence of the com- plaint beyond a doubt. Many of the symptoms described under the head of simple atrophy constitute a preliminary stage of rickets. They are not, as has been said, characteristics of this special disorder, but merely mark the process of gradual reduction of strength, and of interference with the assi- milative functions, which must take place to a certain degree before the disease can be established. This pre- liminary stage is not, however, always present. Rickets is the result of mal-nutrition ; any disease, therefore, which seriously interferes with the assimilative power, and causes sufficient impairment of the general strength, may be followed directly by the disorder under consideration, without any intervening stage. Reduce the strength to a given point, and rickets begins. Prolong this state of debility sufficiently, and the characteristic changes re- sulting from the disease manifest themselves. Any cause, therefore, which will reduce the strength to this point Jays the foundation of rickets. Symptoms. — The beginning of the disease is indicated by the occurrence of two very special symptoms : — EARLY SYMPTOMS 121 One of these is a curiously profuse sweating about the head, neck, and upper part of the chest. The perspiration is extreme : it will be seen standing in large drops upon the forehead, and often runs down the face. There is unusual moisture of the parts both day and night ; but if the child falls asleep, the quantity is instantly increased, and at night is sufficient to make the pillow wet. When awake, the slightest exertion or elevation of the tempera- ture excites it at once. At the same time, the superficial veins of the forehead are large and full, the jugular veins are distended, and the carotid arteries may sometimes be felt strongly pulsating. The irritation excited by this constant perspiration will often give rise to a crop of miliaria about the temples, the upper part of the forehead close to the roots of the hair, and at the back of the neck. While the head and neck are thus bathed in perspiration the abdomen and lower limbs are merely moist, sometimes quite dry. Another characteristic symptom is the dislike of the child to warm coverings at night. In the coldest weather he will kick off the bedclothes, or throw his naked legs outside the counterpane. The mother often notices this as one of the earliest symptoms, and will say that she has been obliged to wrap her child up in flannel to prevent his catching cold, as he will not remain covered by the bedclothes. These two symptoms occur early and precede any sign of deformity of bone. In some children the beginning of morbid change in the osseous structures is indicated by tenderness ; but in an uncomplicated case of rickets tender- ness is never a marked symptom. It is true that when the disease is pronounced the patient is often unwilling to be danced about; but this disinclination to play is not necessarily the consequence of tenderness ; at any rate it is seen in children who show no sign of distress at being handled. The dislike of violent movement is apparently 122 RICKETS due to the hurry of breathing it induces, for when their ribs are softened an increased demand for air is difficult to satisfy. Marked tenderness to the touch in rickets is usually a sign that the case is becoming comj)licated with scurvy. The special symptoms are accompanied by all the other phenomena which preceded the beginning of the disease. The bowels remain confined, or are more or less capricious, a day or two of relaxation being followed by an equal period of constipation. More often, however, there are three or four evacuations in the course of the twenty-four hours, accompanied by considerable straining- The stools consist of whitish, curdy-looking matter, mixed with mucus, and are extremely offensive. The food taken seems to pass almost unchanged through the alimentary canal, being, no doubt, forced too rapidly along from abnormal exaltation of the peristaltic action of the bowels, so that sufficient time is not allowed for digestion. A certain amount of abdominal discomfort appears to be common in these cases, for the child may often be noticed to turn round in his cot on to his face, and will sometimes fall asleep resting upon his arms and knees, with his head buried in the pillow. The urine becomes more abundant and deposits a calcareous sediment, or abounds in phos- phates. There is usually some thirst ; but the appetite is often voracious, so that the child very shortly after a meal will show a disposition to eat again. This is what we constantly meet with in cases of dyspepsia in the adult, where the peristaltic action of the intestines is unnaturally brisk. The child soon loses his power of walking, and sits, or lies about. He becomes dull and languid, and neglects his playthings. There is usually some emaciation ; but if the symptoms are not severe at the first, he may be plump in appearance, although his flesh feels soft and flabby. In the daytime he is drowsy, DEFORMITIES OF BONE 123 but at night is restless, turning his head uneasily from side to side on the pillow. The symptoms proper to rickets very seldom appear before the fourth month, and not commonly before the seventh or eighth. From my own experience I should say that the disease manifests itself most frequently between the seventh and eighteenth months, less fre- quently between the eighteenth month and the end of the second year, and rarely after the end of the second year. Still, we may find it beginning at a later period ; and Sir William Jenner mentions the case of a girl, aged nine years, who had then only just begun to suffer. At the time when general tenderness is first complained of the deformities of the bones usually attract notice. In the first place, the articular ends of the bones enlarge at the point of junction of the bone with its epiphysis. Both ends may suffer, but the change is necessarily more evident in the extremity which is superficial than in that which is more deeply placed. The ribs at their sternal ends are usually the first to be affected ; next the bones at the wrists ; and, as a rule, the enlargement is greater in the bones of the upper limbs than in those of the lower. The flat bones — the bones of the skull, the scapula, and the pelvis — become thickened ; and all the bones become softened. It is this softening of the bones which, owing to mechanical causes, leads to the distortions so charac- teristic of the disease. In a well-marked case of rickets we find all these changes ; but very commonly many of them are absent. Even when present they do not always occur to an equal degree ; in some cases the softening of the bones is more marked than their enlargement ; in others, the enlarge- ment is out of proportion to the softening. M. Gruerin has stated — he has even laid it down as an absolute rule — that the deformities of the bones begin from below up- wards, that the tibise become affected before the .thigh 124 RICKETS bones, the thigh bones before the pelvis, and so on to the arms and head. This, however, is not correct. In some cases we certainly find the legs and thighs bowed earlier than the other parts, but it is in children who have walked, or can still walk ; and in them the weight of the body determines the deformities of the lower limbs before the pressure upon the other bones has been sufficient to make them crooked. Besides, if a very heavy child be put on his legs at too early an age the tibiae may bend a little, although there is no reason to suspect the child of being the subject of rickets. The changes produced by the disease in the various bones are as follows : Bones of the head and face. — The skull is larger than it ought to be, and is of a peculiar shape. Its antero- posterior diameter is increased ; the f ontanelle remains open — often widely open — long after the end of the second year, the ordinary period of its closing; the thickening of the bones is most marked at the centres of the parietal bones, the bosses of the temporal bones, and at the edges of the bones outside the sutures, so that the situation of the sutures is indicated by deep furrows; the vertex is flattened, and the sutures are expanded or remain open. The forehead is high, square, and projecting, and is out of proportion to the face. This disproportion is exagge- rated by the arrest of growth of the bones of the face, particularly of the bones of the upper jaw and the malar bones ; therefore, while the forehead is larger, the face is smaller than natural. The projection of the forehead is due partly to thickening of the frontal bone, partly to expansion of the frontal and ethmoidal sinuses, and partly to enlargement of the brain. The shape of the lower jaw is peculiar. The normal curve has disappeared. Anteriorly the bone is flattened, but laterally, at the situation of the eye-teeth, it bends abruptly backwards at a sharp angle. This change is due, according to Pleischmann, CHANGES IN CRANIAL BONES 125 to the imperfect growth of the middle portion of the jaw. A curious deformity of the cranial bones is sometimes seen which closely resembles the " natiform " skull of in- herited syphilis, and is often mistaken for it. The frontal and parietal eminences become greatly exaggerated, and form prominent bosses, which surround the anterior fon- tanelle and constitute the " natiform " or hot cross-bun " shape of the skull. The bosses do not encroach upon the fontanelle so closely as in the specific disease, and the edges of the bones which bound the fontanelle can be felt to be thickened and not thinned as in syphilis. These differences are sufficiently distinctive in an ordinary case ; but sometimes we find a mixture of the two forms owing to rickets having become developed in an infant the subject of inherited syphilis. In such a case the part which each disease takes in developing the osteal deformity is not easy to determine. It is important to distinguish between the rickety en- largement of the skull and the expansion which takes place in hydrocephalus. In hydrocephalus there is greater dis- proportion between the skull and the face ; the enlarge- ment is more globular and regular, the antero-posterior diameter not being greater than the lateral ; the bones of the skull do not give to the finger the sensation of being thickened ; the fontanelle is more open, and if the accumu- lation of fluid be great, the bones at the sutures are more widely separated ; the sutures themselves are not bounded by a ridge of thickened bone. The fontanelle in hydro- cephalus is often, although not always, elevated ; in rickets it is depressed, partly on account of the debility, partly on account of thickening of the bones which forms its boun- daries. In rickets we find other well-marked symptoms showing the nature of the complaint. The two diseases are, however, occasionally combined. A moderate excess of fluid in the skull is not uncommon in rickets. In such 126 RICKETS cases the configuration of tlie head and body generally is that of rickets, while the fontanelle is large and elevated, and the sutures, if there be much fluid, are open and fluctuating. A curious condition of the skull, first detected by Elsasser, and known as craniotahes, may be present. On using gentle pressure with the tips of the fingers over the posterior surface of the head spots can sometimes be detected where the bone is thinned. The bone at these spots is elastic, feels like cartridge paper, and presents a concavity or depression, which varies in size according to the extent of the thinning. The usual size of these de- pressions varies from a linseed to a bean ; but one whose size does not exceed a line in diameter can be detected by the practised finger. These local losses of substance are confined to the occipital bone, of which any part may be affected except the protuberances. The frontal and parietal bones are, on the contrary, greatly thickened, often to double their natural depth. The progress of dentition is arrested. If the disease make its appearance before any of the teeth are cut, their evolution may be almost indefinitely postponed. If some teeth have already appeared, the further progress of den- tition is interrupted. This influence over the teeth is peculiar to rickets. In no other disease, in which general nutrition is affected, do we find any interference with the natural course of dentition. In a child greatly wasted by chronic diarrhoea, or improper food, the development of the teeth does not seem to be hindered by causes which exert so powerful an influence upon his general health ; and in tuberculosis and congenital syphilis, as a rule, the teeth are cut early. Often in rickets the teeth are not only late to appear, but are cut very irregularly. Sometimes the first tooth to pierce the gum is a molar. Although cut late the teeth are CURVATURE OF SPINE 127 cut with little effort. As a rule a rickety child suffers from dentition hardly at all. His teeth, however, speedily become black, decay, and drop early from their sockets. This is due to insufficient development of the dental enamel. It is not at all uncommon to see a rickety child of eighteen months or two years old with very few teeth as yet in his head, and those few black and carious. In some rare cases, however, we find dentition un- affected, and even particularly forward, although the other symptoms of rickets are well marked. Thus Herbert K. cut his first tooth when five months old, and at the age of one year and nine months dentition was completed. He could not stand until his seventeenth month, and when a year and a half old could not walk without assistance. It was only just before cutting his last tooth that he was able to walk alone. When seen, he was aged two years and nine months, a pale and rather weakly-looking boy ; wrists large ; tibiae bowed ; the teeth, however, were perfect and particularly sound. The spine is bent ; and the curvature is in proportion to the degree of muscular weakness, so that if there be much deformity it is a sign that this weakness is great. The direction of the curve varies according to whether the child can or cannot walk. If the child cannot walk, the cervical anterior curve is increased, and there is a pos- terior curve reaching from the first dorsal to the last lumbar vertebrae. This is an exaggeration of the ordinary curve which exists when a child sits unsupported on the arm of his nurse. If the muscular debility is very great the curvature may be so pronounced as to be mistaken for angular curvature. It is, however, readily distin- guished by holding the child up, supporting him with the hands under the arms : the weight of the body will then usually straighten the spine at once, particularly if gentle pressure is at the same time made on the projecting part. 128 RICKETS If the child is able to walk the dorsal spine is curved backwards, the lumbar forwards. As a consequence of the cervical curve, and the accom- panying weakness of the muscles, the head is no longer efficiently supported; it, therefore falls back, and the peculiarity of the attitude thus assumed as the child sits up in his cot is very characteristic of the disease. Lateral curvatures are occasionally seen, but they are far less common than the antero-posterior. Their direc- tion is determined by the position assumed by the child. If he is carried constantly on the left arm there is lateral curvature, with convexity to the left ; if on the right arm, the convexity is to the right. The thorax is curiously deformed. Flattened behind, projecting sharply in front, it presents an appearance which Grlisson compares to the prow of a ship, and which forms the condition commonly known as pigeon breasted." The ribs, as they leave the spine, are directed at first almost horizontally outwards, then bend sharply at an acute angle at the junction of the dorsal and lateral regions, and from that point j)ass forwards and inwards to unite with their cartilages. The cartilages curve out- wards before turning in to their articulations with the sternum, so that the breast-bone is forced forwards, and the antero-posterior diameter of the chest is unnaturally increased. The lateral diameter is greatest opposite the acute angle formed by the ribs ; least, at the points of junction of the ribs with their cartilages. This curving inwards of the ribs, and outwards of the cartilages, forms a groove on the antero-lateral face of the chest, which reaches from the ninth or tenth rib below, to the third, second, or even first rib above ; and the groove is deepest just outside the nodules formed by the enlarged ends of the ribs. The groove varies on the two sides in length and in depth, for the liver and the heart support to a certain extent the ribs under which they lie. Thus the DEFORMITY OF CHEST 129 groove reaches downwards to a less distance on the right side than on the left, on account of the liver ; and at the level of the fourth and fifth ribs it is shallower on the left side than the right, on account of the heart. The enlarge- ment of the ends of the ribs gives a peculiar appearance to the surface of the chest; a line of nodules is seen, on the inner side of the groove, looking like a row of large beads under the skin. Below the sixth rib the chest widens, as the walls are forced outwards by the underlying liver, stomach, and spleen. If we strip a rickety child and watch his breathing, we see that in inspiration there is sinking in of the chest walls. The lateral depressions deepen ; the sternum moves forwards ; the abdomen expands ; and a deep horizontal groove furrows the surface, dividing the chest from the belly, and marking the upper borders of the abdominal viscera. This recession of the chest walls shows the mechanism by which the deformity is produced. In the healthy subject when the diaphragm contracts, and the ribs are elevated in the act of inspiration, air rushes in through the glottis to expand the lungs, and to enable them to follow and remain in contact with the expanding chest walls. The atmospheric pressure is, therefore, overcome by the power of the osseous and muscular walls, aided by the pressure of the inspired air. In the rickety child, however, one of these agents is com- paratively powerless. The softened ribs can afford little assistance to the air within the chest in resisting the pressure outside : they therefore sink in at their least supported parts, and produce the lateral furrows which have been described, while at the same time the sternum is carried forwards in proportion to the recession of the ribs. Eokitansky held that chest deformity was due to want of power in the inspiratory muscles. Sir W. Jenner, however, has shown that the points of insertion of the 9 130 RICKETS muscles of respiration do not tally with the point of re- cession of the chest walls ; and that the horizontal de- pression at the base of the chest corresponds, not to the points of attachment of the diaphragm, but to the upper borders of the liver, stomach, and spleen. These organs support the parietes, and prevent any sinking in under the pressure of the air. A similar cause produces an apparent bulging of the prsecordial region during inspira- tion, for the heart supports the ribs behind which it lies, and prevents their receding to the same extent as the walls around. The influence of adenoid vegetations in promoting chest distortion must not be forgotten. These growths interfere greatly with the full expansion of the lungs ; and imper- fect pulmonary inflation cannot but weaken the resistance of the thoracic contents to external atmospheric pressure. In most rickety children with marked chest distortion, adenoid growths will be found on examination of the naso- pharynx. The clavicle is distorted. There are two great curves ; the principal one, forwards and rather upwards, is situated just outside the points of attachment of the sterno- mastoid and pectoral muscles. The second, backwards, is about half an inch from the scapular articulation. The humerus is sometimes curved just where the deltoid muscle is inserted. The radius and ulna are curved outwards, and also twisted. These deformities are ascribed by most authors to muscular action, aided by the weight of the limb. Sir W. Jenner, however, excludes altogether the first men- tioned cause from any share in the production of these distortions. They are due, he says, to the habit prac- tised by all rickety children, owing to their deficiency in muscular power, of supporting the body, while sitting, upon the open hands placed upon the bed or floor. The THE PELVIS 131 weight of the trunk is therefore, in a great measure, thrown upon the arms, and we see in consequence the deformities, of the clavicle, the humerus, and the bones of the forearm, which have been described. The curvature of the humerus is also aided by the weight of the forearm and hand when the limb is raised by the action of the deltoid. The weight of the arm on the humeral end of the clavicle — the sternal end being supported by its muscles and ligaments — will also assist in producing the disfigurement of the collar-bone. The scapula is very much thickened, and is said occa- sionally to be so deformed as to interfere with free motion of the shoulder- joint. The pelvis varies greatly in shape, but is more often triangular than oval. Pressure may be brought to bear upon it in many different directions ; thus it is pressed upon from above by the weight of the spine and the con- tents of the abdomen; from below by the heads of the thigh bones. The exact direction in which these com- pressing forces will act varies, firstly, according to the position of the child — lying, sitting, standing, or walking ; and secondly, according to the age at which the disease comes on, and therefore according to the degree of ossifi- cation of the bones, for the cartilages are less yielding than the bones themselves. The distortion of the pelvis thus produced is often very remarkable. In a child of four- and-half years old,^ in Avhom lithotomy was performed by Sir Henry Thompson, at University College Hospital, the outlet of the pelvis was so contracted as barely to allow a stone, measuring 1^ in. in length, | in. breadth, and | in. in thickness, to pass through in its long axis. The child died shortly after the operation from perito- nitis, and on examination of the pelvis the brim was found to be exceedingly contracted. Its shape was obliquely * An account of this case will be found in the ' Medical Times and Gazette' for December 5, 18G3. 132 RICKETS caudate : the sacral promontory was distant i in. from the left pubic ramus, | in. from the pubic ramus of the right side, and | in. from the symphysis of the pubes. Besides the softening of the bones there is, however, another cause which tends to keep the cavity of the pelvis narrow and contracted, as is explained afterwards. The femur is curved forwards if the child cannot walk. If he can walk it is curved, forwards and outwards, being an exaggeration of the natural curve. Sometimes the head of the femur is seen bent at an acute or an obtuse angle to the shaft. The tibia, before the child walks, is curved outwards, and the knees are then seen, as the child is held upright, to be widely separated from one another. After the child walks the weight of the body determines the bending. In these cases the distortion is seen principally at the lower third, and the curve is very abrupt, seeming to project over the foot ; or the bend may be outwards, projecting over the outer ankle. In these cases, also, the deformity can be explained otherwise than by the influence of muscular action. While the child sits in his mother's lap the weight of the legs and feet, pulling upon the lower end of the femur, pro- duces the forward curvature of that bone. As the child sits cross-legged on the floor or bed the pressure on the external malleolus causes the normal curve of the tibia to be exaggerated. The lower limbs are not, however, deformed in every case of rickets. If the child be unable to walk at the time when the changes in the bones begin, the lower limbs may escape distortion altogether. In such cases the muscles are excessively flabby, and the limbs, feeble and small, look too short for the body; but the bones themselves are straight. The upper limbs seldom share this freedom from deformity ; but, owing to the child's habit of supporting himself, as he sits, with his hands placed upon the bed or BONE SOFTENING 133 floor before him, usually present the characteristic dis- figurements which have been described. The changes in the bones may take place to any degree. Some may be more marked, others less, according to the severity of the disease, the age of the child, and the time at which treatment is commenced. If the premonitory symptoms have been very mild, tenderness may be altogether absent, and the affection of the bones be limited — at any rate, at first — to bending of the ribs, enlargement of the wrists and ankles, postponement of dentition, and abnormal openness of the fontanelle. The child, if able to walk, is still pretty strong on his legs; he is lively, often plump, and does not appear to suffer much from the disease under which he is labouring. If treatment be at once had recourse to nutrition is restored, growth and development begin again, and health quickly returns. On the other hand, if the general symptoms which precede the attack have been very severe, i. e.ii the debility resulting from the deficient nutrition is very great, the tenderness of the bones is a well-marked symptom, the softening usually precedes, and is out of proportion to, the enlargement of the ends of the bones, and all the distor- tions which have been described are the result. Again, the older the child when rickets first appears, the less likely is he to be affected early by softening of the bones ; while, if the child be very young, the bones usually soften very quickly. This, however, is perhaps merely a consequence of what has just been stated, for the younger the child the more likely is his system to be profoundly affected by malnutrition, and therefore the more severe will be the consequences of that malnutrition. Besides the softening of the bones, and the deformities which resiilt from it, there is another effect of the disease which is not less remarkable. This effect is the arrest of growth of the bones. Growth is arrested not only while the disease is in progress, but even after apparent restora- 134 RICKETS tion to health. In a rickety skeleton all the bones are found to be stunted in growth, and this, combined with the bending of the lower limbs, which must necessarily detract from the height of the individual, is the cause of the short stature of persons who, when young, have been subject to this disease. The arrest of growth affects some bones more than others, being principally noticeable in the bones of the face, of the lower limbs, and of the pelvis. As it affects the pelvis the want of growth is very im- portant from its influence upon child-bearing in after life. In the child the size of the pelvis and lower limbs is small in proportion to the rest of the body ; in the adult female it has so increased as to be relatively larger than the other parts of the bony framework. If then the growth and development of the pelvis are arrested, its brim and outlet do not undergo the usual expansion, but remain small and contracted, retaining the characters of the infantile pelvis. The obstacle to the passage of the foetal head, under such circumstances, becomes extreme, es23ecially if conjoined with deformities produced by softened bone, and usually requires craniotomy or embryotomy before the child can be extracted. This condition of the pelvis may also inter- fere with operations upon the child, as in the case of litho- tomy already referred to. According to Mr. Shaw, there is a correspondence between the degree to which the pelvis sulfers from this arrest of growth and development, and the degree to which the lower limbs suffer from the same causes; we can, therefore, by observing the amount of stunting of the lower limbs, make some estimate of the extent to which the pelvis is likely to be modified in size and capacity. The articulations. — As the ends of the long bones are enlarged the joints into which these bones enter must necessarily be enlarged also. They have therefore a knotted, bulbous look, an appearance which is aggravated by the atrophy of the muscles of the limb. In addition THE JOINTS 135 to this the ligaments which hold the bones together are relaxed : the joints are therefore loose and unsteady, and can be moved freely in directions which in a healthy state would be impossible. This looseness and mobility of the joints forms alone a great impediment to walking, even when the bones themselves are healthy ; and in fact the relaxation of the ligaments does not always bear a due proportion to the osseous changes. It is often an early symptom ; and we frequently see it carried to a high degree in cases where the disease in the bones is as yet comparatively trifling. In these cases, if we hold the child upright, so that the weight of the body rests upon the feet, we see that each lower limb forms an obtuse angle at the knee ; the knees touch ; the legs are directed outwards; and the foot is more or less everted, from relaxation of the ligaments of the ankle. In children in whom the disease appears at, or after, the end of the second year, this weakness in the joints is a very prominent symptom, and is often found where the limbs are perfectly straight and well formed. All the joints in the body are sharers in this ligament- ous weakness, for it is not confined to the articulations of the limbs. The fibrous bands which connect the vertebrae with each other and with the sacrum, the sacrum with the pelvis, are alike affected ; and it is a conjunction of all these various lesions, combined with the softening of the bones, and the weakness of the muscles, which pro- duces the inability to walk, and the difficulty of holding the body upright, which are so characteristic of the disease. The general symptoms continue while these changes are going on. There is no fever, but perspiration is profuse, and the tenderness increases in proportion to the softening of the bones. The appetite may remain ravenous, but more often it diminishes, and the child shows a disgust for food, or only exhibits a craving for beer, and the more 136 RICKETS tasty articles of diet. Sickness frequently occurs at tliis time, for attacks of gastric derangement often complicate the disease, and aggravate it. In these cases there is a sour smell from the breath ; the vomited matters are acid; the bowels either become constipated, or there is diarrhoea, with green, slimy, offensive stools, showing the participation of the intestinal mucous tract in the derangement. Emaciation is the rule in rickets, and if the disease be at all advanced, is invariably present. During the early stage, as has been said, a rickety child may be plump. Infants crammed with large quantities of fat-forming material, and at the same time deprived of a sufficiency of fresh air, are apt to get large and unwieldy, although they are not the less anaemic and feeble. A want of colour is noticed in the face ; the mucous membranes are pallid ; the muscles ill-grown ; the bones and ligaments weak ; and the child lethargic and quiet. After a time the digestive powers cease to be equal to the burden imposed upon them ; a gastric catarrh is set up, and the interference with the nutritive processes, thus established, soon induces a rapid loss of flesh. The fat disappears, and the muscles get more and more flabby and wasted. The loss of power in the muscles is, however, greater than can be accounted for by the wasting ; and if the disease be severe, the child may be incapable of supporting himself in the slightest degree. The face gets old-looking ; the eyes are large and staring^ and the general expression is placid, although rather languid. The respiration is quick and laborious, and if there be much softening of the ribs, and consequent reces- sion of the chest walls, the child's whole faculties appear to be concentrated upon the performance of the respiratory act. Such a child will give little trouble to his attendants ; in fact, the little creature has no breath to spare for idle lamentations, and cannot aft'ord to cry. ABDOMINAL ORGANS 137 The abdomen is very large, and often appears enor- mously distended when compared with the narrowed and distorted chest. This enlargement of the belly is due to depression of the diaphragm and diminished capacity of the thorax, which force down the liver and spleen below the level of the ribs ; to increased shallowness of the pelvis ; to the flabby condition of the abdominal muscles favouring the accumulation of flatus generated by the digestive derangement ; and in some cases to actual increase in size of the liver and spleen. The enlargement of the liver and spleen, when it occurs, is sometimes combined with enlargement and induration of the lymphatic glands all over the body. The superficial glands may be felt in the groins, the armpits, and the sides of the neck, as hard, round freely moveable bodies, varying in size from a pin's head to a sweet-pea. The spleen is more often enlarged than the liver, and some- times can be felt as a solid mass which passes obliquely downwards across the abdomen so as almost to touch the iliac crest on the right side. An enlarged spleen is accompanied by the characteristic anaemia and there may be slight oedema of the extremities. Examination of the blood shows decrease in the red corpuscles but no positive increase in the number of the leucocytes. Mental development in rickety subjects is generally said to be slow. There is no doubt that such children are late in talking and seem to be slow in picking up new words. I believe, however, that this apparent backwardness is often due, not to deficiency in mental capacity, but to the indolence which is apt to accompany anaemia and weak- ness, for in general intelligence I have not found a rickety child to be below the average. Apart from all the physical changes produced bj the disease, the behaviour of a rickety child is very charac- teristic, and is of itself almost sufiicient to warrant a diagnosis. The quiet, the repose about him, strike the 138 RICKETS observ^er at once. Such a child, if able to sui:>port himself, will sit for hours, his legs stretched out straight before him on the floor, perfectly contented if only allowed to remain unnoticed. All that he wants is to be let alone. A healthy child delights in movement : a rickety child is only happy when at rest ; his greatest pleasure consists in inaction. To look at him we are irresistibly reminded of the other term of life, for he apjjears to have anticipated at least one consequence of the weight of years, and to have combined the patient endurance of old age with the face and figure of a child. Complications. — The state of extreme debility to which a child suffering from advanced rickets is reduced natu- rally favours the occurrence of secondary diseases in general ; and it is usually to one of these that death is to be directly attributed, although, in some cases, the in- tensity of the general disease may be of itself sufficient to carry off the patient. Measles, whooping-cough, and scarlatina are very liable to occur, and often prove fatal ; but there are certain other diseases which are especially predisposed to by rickets, viz. : — Catarrh and bronchitis. Diarrhoea. Laryngismus stridulus. Tetany and convulsions. Chronic hydrocephalus. Scurvy. To catarrh and hronchitis are due a very large proj^ortion of the deaths in this disease. Bronchitis is an extremely fatal disease at all ages. The mucus which is thrown into the tubes impedes the entrance of air : but unless air can enter freely into the vesicular structure of the lung mucus cannot be expelled. In coughing to expel the mucus the lung must be filled with air to the utmost ; the contained air is then prevented CATARRHAL COMPLICATIONS 139 from escaping by closure of the glottis, and at the same time pressure is brought to bear upon the lungs by the muscles of expiration. The glottis is then suddenly opened and the air is driven out, carrying with it the mucus which obstructed the tubes. The forced respiration seen in persons suffering from bronchitis is merely the effort made to draw in the air past the obstructing mucus. A second impediment to the entrance of air into the lung is found also in the healthy child. It arises from the natural flexibility of the lower part of the thoracic parietes which yield to a certain extent in inspiration before the pressure of the external air. In advanced rickets, how- ever, this natural flexibility is greatly increased by the abnormal softening of the ribs, so that even when the lungs are healthy each inspiration is only effected by a distinct laborious effort. l^ow add bronchitis to this condition, and the impediment is extreme. Air cannot enter deeply into the lungs ; mucus cannot be expelled ; the air, however, in the lungs can be, and is expelled ; there is, consequently, collapse, and the child dies — not properly speaking from the collapse, but from that which caused the collapse, viz., the inability of the inspired air to pass the obstructing mucus. The extent to which the ribs are softened, and the amount of their recession in inspiration, are therefore of extreme importance as regards the prognosis of bronchitis when it occurs in rickety children. Diarrhoea. — Rickety children are especially liable to attacks of purging. This may be accounted for partly by their extreme sensitiveness to changes of temperature ; and partly by the unhealthy condition of the alimentary canal, which always precedes and accompanies the disease, and which a very slight additional irritation would easily aggravate into diarrhoea. These attacks are exceedingly dangerous. We know that even healthy children, seized with profuse purging, rapidly lose flesh, and soon beco 140 RICKETS exhausted. A few hours are sufficient, if the drain is severe, to cause a marked change in their appearance ; their features quickly lose the roundness of youth, and assume instead the pinched, drawn characters of age E/ickety children, already enfeebled, are still less able to withstand the depressing effects of the disorder, and fall victims to it all the more readily in proportion to the degree to which their strength has been previously reduced. Laryngismus stridulus, tetany and convulsions are not uncommon complications of rickets. An abnormal irrita- bility of the nervous system appears to be a peculiarity of the rickety constitution. In ordinary cases of defective nutrition no such nervous irritability is observed, nor is a convulsive tendency originated by long- continued weak- ness. In rickets, however, the frequency of convulsions and laryngismus stridulus is undeniable. The latter derangement is rarely met with apart from rickets ; while in the case of general convulsions nearly half the children thus affected are found to be rickety. =^ Some authors attribute the convulsive tendency to cranio-tabes. Lederer, out of ninety- six cases of laryn- gismus, found cranio-tabes in ninety-two. Jacoby has only seen one case of laryngismus stridulus unassociated with it. Yogel reports a case in which spasm of the glottis could be directly produced by pressure with the finger upon the softened spots. Hence it has been sug- gested that the spasmodic symptoms, which often come on at night, are the direct result of pressure conveyed to the brain as the child's head lies upon the pillow. What- ever may be the value of the explanation, the connection between laryngismus and rickets is exceedingly important as regards the treatment of these attacks. Most of the * Out of fifty cases of laryngismus noted by Dr. Gee, forty-eight were rickety, and of these nineteen had general convulsions; out of 102 children, in whom general convulsions occurred, forty -six were ty, *St. Bartholomew's Hospital Reports,* vol. iii, 1867. NERVOUS COMPLICATIONS 141 children in whom this conclusiv^e tendency is marked have carpo -pedal contractions. As dentition is backward in all these cases the laryn- gismus and the convulsions are frequently attributed to teething. The teeth, however, are quite innocent of any share in the production of these complications. They are backward as a consequence of the arrest of growth of bone, which is one of the characteristics of the disease. When the teeth do appear they are often cut with re- markable ease, and whereas the child had been formerly subject to convulsions, with or without apparent cause, the beginning of dentition is accompanied by no such phenomena ; the removal of the rickety condition, as shown by the eruption of the teeth, being coincident with the disappearance of the spasmodic tendency. In not a few cases I believe the nervous commotion to be the direct consequence of post nasal irritation. Adenoid growths in the naso-pharynx are common enough in infancy, and serious nerve worry may be set up by them. I have seen so many cases of laryngeal stridor and spasm put an end to by removal of these vegetations that when- ever these symptoms prevail I make it my first care to ascertain the condition of the nasal passages. The proneness to convulsions of the subjects of rickets must be always kept in mind, as by it we may sometimes explain the occurrence of eclampsia during the progress of various acute diseases. Thus, in whooping-cough a convulsive attack may be an event of the utmost gravity, as it may arise from cerebral embolism or announce the beginning of a serious inflammatory complication. In a rickety child, however, a nervous seizure in the course of whooping-cough may be induced by gastric derangement or some unimportant form of reflex irritation. If, then, in such a case we find well-marked signs of rickets, and notice after the fit that the expression of the patient shows no additional distress, and that there are no signs of lung 142 RICKETS complication, we may speak hopefully of his chances of recovery. The primary cause of the convulsive tendency in rickets appears to be the imperfectly nourished state of the central nervous system, the brain and spinal cord neces- sarily sharing in the mal-nutrition which affects all the organs of the body. Often — probably in most cases — as nutrition is restored, the convulsive tendency subsides, leaving the child free from any form of neurosis. It is said, however, that this perfect freedom from after ill- consequences should not be relied upon too confidently. Some observers profess to see a connection between con- vulsions in early childhood and epilepsy in later life, and hold that the damage suffered by the brain during the rachitic j)eriod may be something more than a merely temporary injury. Thus, Sir W. Growers found that 10 per cent, of a given number of epileptics had had convulsions in infancy. Dr. J. A. Coutts would place the percentage from his own observations as high as 17. As infantile convulsions are especially apt to occur in rickety children, it is assumed that in these cases the epilepsy was a natural expression of the cerebral mal-nutrition found in rickets, and was therefore a direct consequence of that disease. But evidence furnished by statistics such as these is by no means conclusive. So many children suffer from rickets in a more or less pronounced form that any disease which could be named, or even any accidental injury, might by such reasoning be ascribed to the after effects of mal-nutrition in infancy. Evidence of a more trustworthy character than this is required before such a conclusion can be accepted as the true one. Chronic hydrocephalus occasionally complicates the dis- ease between the ages of eight and eighteen months. The fluid may be in the lateral ventricles, in the arachnoid sac, or in both. It often appears to be a merely mechani- cal effusion, the serosity being thrown out to fill up the SCURVY 143 space left when the cranial cavity becomes enlarged with- out any corresponding increase in the size of the brain. In these cases the convolutions are perfectly natural, and show no signs of pressure. On account of the altered shape of the skull, hydro- cephalus is often suspected where it does not really exist. The differences between the ordinary rickety head, and the skull expanded by fluid in its cavity, have already been pointed out. (See page 125.) Scurvy is an occasional and important complication of rickets. The impoverishment of the blood to which the scorbutic symptoms are due may be dependent upon the same conditions which produced the primary disease, for scurvy and rickets may be both consequences of bad feed- ing and unhealthy surroundings. But while the latter is an outcome of general malnutrition, the former is the re- sult of the absence from the blood of some special consti- tuent. If this be supplied the child remains free from scurvy, however imperfect may be the nutrition of his system generally. When scurvy occurs, the disease ap- pears in children who have been fed largely upon con- densed milk and tinned foods. So long as the child is taking fresh cow's milk, he can never become scorbutic.'^ Scurvy, when seen in the child, presents peculiar characters. The gums are not always affected. The principal symptoms are dependent upon sub-perio steal extravasation of blood. This extravasation usually occurs at the lower parts of the thighs and around the knee joints. Sometimes, also, the ends of the long bones be- come separated from the shaft. As a consequence there is extreme tenderness of the limbs, which at once strikes ^ The statement in the text refers only to perfectly fresh cow's milk, which has undergone no manipulation in the nursery. I have seen well marked symptoms of scurvy in a child of twelve months'* old, who was being brought up on "artificial human milk," with an occasional meal of gravy or beef-tea and bread crumb. 144 RICKETS the observer as something quite beyond the usual tender- ness of a rickety child. The limb swells at the site of the lesion, and is excessively tender. The child seems to suffer from constant pain, for he lies moaning in his cot> and cannot bear the slightest touch upon the swollen part. The latter is seen to be enlarged and sometimes oedema- tous. It may occupy the whole of the thigh or leg, or may be more circumscribed. The upper limbs are com- paratively larely affected. In addition to the swellings, petechise and bruise-like patches may be present, and sometimes unhealthy-looking sores are noticed on the skin. If separation of epiphyses takes place, the child, instead of keeping his limbs flexed, as at first, allows them to lie stretched out as if paralysed. When this stage is reached, the pain and tenderness have usually greatly diminished. In exceptional cases the gums are spongy, but if the child be suffering from marked rickets, the gums are rarely affected to any great extent. Usually, certain general symptoms accompany the de- velopment of the local phenomena. The temperature rises to 101° or 102^^ in the evening, and the child sweats pro- fusely. His complexion is excessively pale with a sallow tint, and his debility is extreme. The urine may contain albumen, and is sometimes tinged with blood. The swellings first noticed sometimes disappear, to be followed by secondary swellings in other parts ; and sometimes the symptoms pass off completely for a time, to return after a period of months. When under appropriate treatment recovery takes place it is complete. The local thickening which persists after the swelling has subsided gradually disappears, and even the separated epiphyses become again united with the shaft of the bone. The conjunction of scurvy and rickets has been de- scribed by Filrst and others under the name of acute rickets." The scorbutic nature of the complication has, MODE OF ENDING 145 however, been amply demonstrated by Drs. Clieadle and T. Barlow. Besides the complications which have been mentioned, acute tuberculosis may occur in rickety children. This, however, is not a special complication of the disease, and is comparatively rare. When rickets ends fatally, death occurs as a consequence of one of the above complications. Tn extreme cases the child gets so weak that he can no longer support himself, but lies down or is propped up with pillows in his cot. He breathes with difficulty on account of the softened state of his ribs, and his face grows livid or lead coloured. In this state his power of resisting injurious influences is quite lost and his hold upon life feeble in the extreme. Any additional source of weakness — trifling enough, perhaps, in itself — may prove more than he can bear ; and he suc- cumbs to a little looseness of the bowels or to collapse of lung induced by a mild pulmonary catarrh. If the disease terminate favourably, the symptoms gradually subside, and finally disappear. The tenderness becomes less marked ; the bones cease to soften ; the child appears more lively, and takes an interest in what passes around him. As the softening of the ribs diminishes, his respiration growls less laborious, and he will then begin to amuse himself with his toys. The appetite improves, and gets less capricious ; the bowels are more regular, and the stools healthier-looking. The wasting ceases ; the child begins to gain flesh, while the belly decreases in size, and becomes less prominent. The head- sweats are less noticed, and his sleep at night is more tranquil, although for a long time he will continue to throw off the bed-clothes at night unless restrained. Dentition is resumed, and goes on rapidly and easily. The deformities of the bones gra- dually diminish ; the bones get very much straighter than would be expected from their former distortion, become exceedingly thick and strong, and the enlargement of the 10 146 RICKETS ends of the long bones becomes very remarkably reduced. The muscles also begin to be more developed, and increase rapidly in size. The increase in length of the bones, however, is not rapid, and the child remains more or less stunted, seldom when full grown reaching the average height. In cases of recovery from advanced rickets we some- times find that at the very time when the deformity of the chest is becoming obviously less the legs of the child begin to bend, although up to that period they had been straight. This seeming contradiction is apparently due to the fact that as nutrition improves and the disease sub- sides, muscular power increases. The child then begins to make more use of his legs. As soon as his strength allows he begins to get upon his feet, to stand and to walk. Consequently, his bones, as yet hardly consolidated, bend under the weight of his body. The rapidity with which dentition proceeds during recovery is sometimes very striking, and is well illustrated by the following case. Gleorge P. at the age of two years had but twelve teeth, and could not stand. The chest was much deformed, the ends of the long bones were enlarged, and the legs were very thin and flabby. Treat- ment was begun on November 29. On January 24 of the following year, the boy could walk across the room steady- ing himself by the different articles of furniture, and by May 16 could walk well and firmly without any assistance. The teeth appeared as follows : — By April 7, he had cut the two upper canines, and by May 16, the two lower canines ; by May 80, three back molars had appeared, and on the following day, June 1, the last remaining tooth pierced the gum. The treatment consisted in careful regulation of his diet ; in the administration of alkalies with drop doses of tinct. opii, to improve the condition of his digestive organs ; and afterwards, when the motions PATHOLOGY 147 were perfectly healthy, in iron wine with half-clrachm doses of cod's liver oil. Pathology. — Rickets is a general disease, and affects very widely the tissues of the body. Its influence is most manifest in the bones, which are always implicated, but we find, in addition, changes in the brain, liver, lymphatic glands, spleen, muscles, and often in every organ in the body. Rickets affects the bones in three ditferent ways. It interferes with their growth, not only temporarily, but permanently ; for children who have been thus affected never, as Mr. Shaw has pointed out, grow into average- size adults. It interferes with their development, delaying the pro- cess of ossification, and rendering the calcareous deposit irregular and incomplete. There is great proliferation of the cartilages at the end of the bones, and of the periosteum ; but here a pause takes place, and the further step in the process, the actual deposition of earthy salts, is very slowly carried on. But besides its influence over the growth and develop- ment of bone, rickets produces equally serious changes in bone already completely ossified. The previously hard bone becomes softened : it may be bent with ease, and can be cut with a knife, like a carrot. The softening is not due, as was at one time supposed, to a removal of lime- salts previously deposited. It is not that hard tissue becomes soft, but that new soft tissue is slow to harden. In healthy growth of a long bone new osseous tissue is being constantly added to the surface, while a correspond- ing absorption takes ]3lace from the interior. In rickets, however, although the proliferation of the periosteum is extreme, this new matter does not undergo the usual ossifi- cation. The natural enlargement of the medullary canal continues, however, as in health. But as the loss of bone from within is not compensated for by the normal forma- 148 RICKETS tioii of new osseous matter at the circumference, the pro- portion of bony tissue is constantly diminishing, while that of new soft matter proliferated from the periosteum is constantly on the increase. Many theories have been devised to account for the disease, and the structural peculiarities which arise from it ; but none of these can be considered satisfactory. The proliferation of the cartilages and the periosteum has been attributed to inflammatory action. The delay in the de- position of earthy salts has been explained by supposing them to be held in solution by free acids, chiefly lactic, existing in the blood of the patient, and generated by fermentation of food in the digestive organs. All this, however, is mere hypothesis. The inflammatory theory is corroborated neither by the anatomical characters nor the clinical history of the disorder; and with regard to the formation of acid, rickets is not always preceded by attacks of acid dyspepsia, nor is the increase of lactic acid or of phosphate of lime in the urine by any means a constant feature of the complaint. Besides, it is not only that the process of ossification is retarded : it is also perverted. Calcareous matter is found dej^o sited in abnormal situa- tions ; indeed, the process has been compared by Sir William Jenner to the petrifaction we see occasionally taking place in enchondromata. Mercoli advocates the microbic origin of rickets, and believes the disease to be induced by a process of auto- infection with ordinary pyogenic organisms. According to this observer, streptococci and staphylococci are absorbed from the alimentary canal into the blood and become arrested in the organs. They tend especially to visit the parts where the greatest functional activity is in progress. These, in the infant, are the nervous system and the epiphysial ends of the long bones. Mercoli, in his experi- ments upon young rabbits, found that the injection of these microbes into the bones and epiphysial cartilages set MORBID ANATOMY 149 up in some cases a common osteomyelitis. In others, however, it induced an osteomyelitis without trace of suppuration, but with hypertrophy of the ends of the long bones and articular cartilages, such as we find in rickets, with serious consequences to the general nutrition of the animal. Morbid Anatomy. — The enlargement of the ends of the long bones is a real hypertrophy. Great preparations are made for the process of ossification. The cartilage cells enlarge and subdivide, not only in the immediate neigh- bourhood of the calcareous deposit, but also at a consider- able distance from it. Hence the proliferating zone instead of forming a narrow reddish- grey strip between the carti- lage and the bone, such as is seen in natural ossification, appears as a broad grey band which may reach from a quarter to half an inch in width. A similar exaggeration of the normal condition is seen in the shafts of the long bones and in the flat bones. Here the proliferating layer of the periosteum is also unnaturally thick. It forms broad, flat uniform elevations on the surface of the bone, and these in the case of the cranial bones are sharply circumscribed. The newly-formed tissue is bright red from excessive vascularity. While every preparation is thus made for the reception of the calcareous deposit and the formation of osseous tissue, the actual conversion of the new material into bone takes place very slowly and imperfectly. The advancing bone, instead of penetrating in a regular line into the cartilage, developing medullary spaces in the normal manner, strikes up at different points, leaving the car- tilage at other points still uncalcified, and these may remain untouched by the earthy impregnation, forming specks of cartilage completely surrounded by bone. The line of medullary spaces also shows the same irregularity. We find them not only in their normal situation just below the margin of calcification, but also penetrating into the 150 RICKETS proliferating cartilage, far in advance of the line of earthy deposit. These spaces are filled with soft vascular tissue, and are apparently intended to supply nutritive material to both the proliferated and non-proliferated portions of the cartilage. The calcareous impregnation takes place in the cartilage cells before the matrix is attacked. The changes in it can therefore be observed with especial distinctness, on account of the absence of the usual deposition of granular cal- careous particles from the matrix at the border of ossifica- tion. The capsule of the cell becomes thicker and thicker, gradually encroaching upon its cavity. At the same time canalicular pores are formed in the thickened wall. At last a vacant, irregularly- shaped space, closely resembling a lacuna of bone, is all that is left of the cavity of the cell. Scattered through the matrix are often seen rough white particles like isolated masses of lime. These spots of provisional calcification " are sometimes sufficiently numerous to give a dotted appearance to a section of the cartilage. In the case of the flat bones and the shaft of the long- bones, when the sub-periosteal exudation becomes con- verted into bone, the trabeculse are at first extremely thin, and the new osseous tissue remains for a long period unusually porous and vascular. Eventually, however, it becomes denser, and is transformed into a tissue of extreme solidity and hardness. So long as the disease is in progress, the bones lose more and more of their firmness, getting softer and softer. This softening of the bones is due, as has been already described, to the gradual absorption of bony tissue from the interior, and the continued proliferation on the surface of new soft matter which is slow to calcify. The conse- quence is that the bones bend, or perhaps more commonly break on one side, like a stick of green wood. When the disease becomes arrested consolidation begins, CRANIO-TABES 151 and the bones acquire greater firmness and consistency. The process of consolidation has been compared to the calcification of callus in ordinary fractures. In the long bones calcareous nuclei, the rudiments of ncAv bony tissue, appear in the greasy gelatinous matter deposited beneath the periosteum at the circumference of the shaft. These enlarge and unite ; the layers of bone get thicker and thicker; and the new tissue, thus acquiring consistence, hardens gradually into a compact substance like ivory. In the flat and short bones the effused matter is partially absorbed, so as to restore the normal spongy tissue. The occipital bone sometimes differs from the other bones of the skull in being the seat of a special change. In the condition called cranio-tabes, spots are found in this bone where the osseous tissue is thin, transparent, of a yellowish-red colour, and contains scarcely any spongy substance. By holding the bone against the light the extent of the thinning can be readily seen. When looked at from the inside, depressions are found which correspond to the underlying convolutions of the brain. Yogel divides the process by which these changes take place into two stages ; a first stage, in which there is deficient deposition of phosphates in the external bony layers all over the skull ; and a second stage, in which absorption takes place in the softened parts where the pressure of the brain is felt. Sometimes the thinning of the bone is so extreme that the osseous tissue almost entirely disappears in the affected spots ; the pericranium and the dura mater then come into contact, having between them merely relics of bone still unabsorbed. Analysis of rickety bone shows that the bone contains 79 parts of organic to 21 of inorganic matter, the propor- tions thus differ very much from those existing in healthy bone, where the inorganic matters are largely in excess of the organic, being as 63 to 37. Moreover, the animal matter yields no gelatin on boiling, 152 RICKETS and at an advanced period of the disease is said by Simon to yield neither gelatin nor chondrin. Schlonberger and Friedleben have obtained perfect gluten from rickety bone. The softening of the ribs, and consequent deformity of the chest, produces certain morbid conditions in the contents of the thoracic cavity. The influence exercised by the softened ribs upon the course and termination of bronchitis has already been described ; but there are, besides, two special lesions of the lung, which are invari- ably present, and always in the same situation in every case of rickety chest-distortion. These lesions are emphysema and collapse. The emphysema occupies the whole length of the anterior border of each lung, extending backwards for about three-quarters of an inch from the free margin. The mode of its production is explained in the following way. At each inspiration the ribs sink in, and the lateral diameter of the chest is narrowed at the part corresponding to the line of union of the ribs with their cartilages. While, however, the lateral diameter is thus diminished, the antero-posterior diameter is increased by the thrusting forwards of the sternum. Air, therefore, is forced in excess into the lungs at that part so as to fill up the resulting space, and thus induces over-distention of the air vesicles. Collapse of the lung is produced by the recession of the ribs during inspiration. The collapsed portion forms a groos^e just outside the emphysematous part, separating it from the healthy lung. This groove corresponds to the line of nodules which represent the enlarged ends of the ribs, and which project inwards into the interior as much as, or even more than, they project exteriorly. During inspiration the ribs sink in, and the nodules are forced against the lung beneath them, so that they compress the pulmonary lobules at those points, and close them against the advancing air. WHITE PATCH " 153 These two lesions are, therefore, quite independent one of another ; and although they invariably occur if there is much softening of the ribs, yet they do not stand to one another in the relation of cause and effect. The collapse which is sometimes found to occupy the posterior and inferior parts of the lung and occasionally some parts of the upper lobes, is the result of plugging of a tube with mucus. The mechanism of this has already been described. It is only found in bronchitis. Another result of the rickety chest is the circumscribed opacity of the visceral surface of the pericardium, known by the name of " white patch." This, although uncom- mon in children generally, is very common in rickety children. Its seat is usually the left ventricle, a little above its apex, just at the point where the heart at each beat comes in contact with the nodule of the fifth rib. In this case friction against the bone is evidently the cause of the white patch, and this is a strong argument in favour of the attrition theory " generally. The same thing is often seen on the spleen, which, rising and falling with respiration, is rubbed against a projecting rib nodule. It is distinguished from the result of embolism by not extending deeper than the fibrous coating of the organ. Pathological changes occasionally take place as a result of rickets in the lymphatic glands, liver, spleen, and other internal organs. All the organs are tough and solid to the touch, and are heavy out of proportion to their size. The changes they undergo appear to be analogous to those which occur in the bones. They are not dependent upon any foreign growth or deposit in the tissues, but consist in an irregular hypertrophy of their fibroid and epithelial elements with, at the same time, a deficiency in their earthy salts. The liver is sometimes enlarged, but often it only seems to be so through the contraction of the chest which causes i ./ 154 RICKETS it to be pressed down from its natural position. Any increase in size is due in the majority of cases to a develop- ment of the fibrous tissue, and to a less extent of the cellular elements of the gland, with deficiency in the salts. Owing to these changes the density of the organ is greatly increased and it feels unusually firm to the touch. The diseased spleen varies very much in size. Some- times it can just be felt below the ribs ; but often it pro- jects downwards into the abdomen as low as the level of the umbilicus. It may measure as much as eight inches from above downwards, and four inches from side to side. The organ is hard and resistant, and its substance is tough and elastic, so that thin sections can be cut without diffi- culty. The changes which occur in it are due to fibrosis, as in the case of the liver. The trabeculse are seen to be swollen irregularly, and the threads forming the meshes are thicker than natural, often as thick as the spaces they enclose. At the same time there is abnormal development of the contents of the meshes, and the corpuscles are crowded together. The lymphatic glands, especially those of the mesentery, are apt to be enlarged and hard. On section they are white and opaque, from accumulation of their cellular and corpuscular contents. These changes are not present in every case of rickets ; a.nd the organs, even when enlarged, are not always increased in size as a result of the lesions above described. In rickety children who are much enfeebled and wasted by long- continued intestinal catarrh the liver is often found to be swollen from fatty infiltration. In other cases, if the child has suffered from chronic interference with the function of the lungs from repeated attacks of pulmonary catarrh, a chronic congestion of the liver is induced which gives rise to considerable enlargement. The spleen, again, may be simply hypertrophied, under- going a change similar to that which is often seen in cases MORBID ANATOMY 156 of inherited syj)liilis, or in children suffering from the ague cachexia. Like the liver, too, it may be swollen from chronic congestion. The brain is usually larger than natural : but the in- crease is apparently due in many cases to a true hyper- trophy. In a case noted by Dr. Gee, this organ weighed fifty-nine ounces ; it was of natural consistence, not toughened or hardened, and the grey and white matter appeared to retain their normal proportions. In another case, the brain weighed forty-two and a half ounces, and also seemed healthy, although of such unusual size. The disease is said to be in the neuroglia, not in the nerve elements. The voluntary muscles are small, pale, flabby, and soft, but do not owe this appearance to fatty degeneration, for there is no excess of olein. Under the microscope their fibres are softer and paler than natural, with the striae very indistinctly marked. The urine in rickets is pale. The amount of urea and uric acid is diminished ; but there is increase in the amount of the earthy phosphates. This increase is stated to be greatest at the beginning of the bone softening, and to become less marked when the disease is further ad- vanced and the bones are undergoing distortion. Free phosphoric and lactic acids have been observed, and it is not uncommon to find a sediment of oxalate of lime. In cases where sweating is profuse the diminished secretion of water by the kidneys may cause such concentration of urine that uric acid sand is deposited. This is especially likely to happen if the child be at the same time suffering from acidity, the result of fermentation of food. From the above description it will be seen that rickets is not merely a disease of the bones, but one which affects the tissues of the body very widely. Of late, considerable attention has been given to cases of bony deformity in the child, and it has been asserted that in some instances in 156 RICKETS which extensive osseous changes have been noticed in the young subject the lesion is more allied to osteomalacia than to true rickets. The two conditions are essentially dissimilar, for while in rickets ossification is imperfect from arrested calcification of new bone-forming material, in osteomalacia softening is the consequence of re-absorp- tion of the lime salts from bone completely ossified. Dr. Rehn of Frankfort has reported the case of a little girl, aged eighteen months, in whom there was much softening of the long bones, but the epiphysial ends were only enlarged to a very slight degree, and in the bones of the lower limbs were apparently normal. Those bones, also, were quite straight, and the whole skeleton was exces- sively thin. For these reasons Dr. Rehn was disposed to believe that the lesions ought rather to be classed under the heading of osteomalacia than under that of rickets, although a rickety element in the case, shown by a con- siderable formation of sub-periosteal deposit, was admitted. The question is one of great interest to the pathologist, but requires further observations for its elucidation. Diagnosis. — The early diagnosis of rickets is of great importance, for the disease if taken in time is cured without difficulty. Plumpness is no proof of the absence of rickets, for a child may be extremely fat, and yet rickety ; on the other hand, wasting is no proof of its presence, for a child may be reduced almost to a skeleton without presenting a single symptom of the disease. In a well marked case of rickets the head elongated from before backwards ; the square, straight, prominent forehead; the small face ; the beaded ribs ; the deformed chest ; the tumid belly ; the twisted, distorted limbs ; the immobility and quiet of the little creature as he sits — if he can sit — with bowed spine and head thrown back, gazing around him with vacant eyes ; all these character- istic symptoms leave no room for doubt as to the nature of the disease. DIAGNOSIS 157 It is only when the disorder is at its very commence- ment, or appears first about the end of the second year, that it. is liable to be overlooked. A mild form of rickets, consisting merely in a little enlargement of the wrists and ankles, slight beading of the ribs, arrested or late denti- tion, and a large fontanelle, is exceedingly common, even in wealthy families. The parents from these signs alone never suspect disease, and indeed the plumpness of the child, which is often very considerable, is the subject of much admiration. The absence of teeth is looked upon as an innocent peculiarity, and cases are quoted of rela- tions, male and female, in whom the same tardy dentition was observed. It is not until some complication arises, or the disease enters a new phase, that anything is noticed to excite alarm. But late cutting of the teeth is seldom a natural condition. In most cases of retarded dentition the symptoms of rickets may be noticed, and if the tenth month passes away without the appearance of a tooth, suspicions of the disease should always be excited. Lateness in walking attracts the attention of parents much more frequently than tardy dentition ; and children are often brought for advice on account of "weakness in the legs." In these cases, owing to the inability of the child to support himself, even for a moment, when held upon his feet, essential paralysis may be suspected. An examination, however, will show that although there is no power of standing, yet power of movement is by no means lost. The child draws up the legs when the soles of the feet are tickled, and the muscles, although weak, are not absolutely powerless. Other symptoms of rickets are also present. When the want of muscular power has increased to sxfili a degree that the child is incapable of movement, the incapacity is general, and is not confined to one or more limbs. Moreover, at this stage the deformities of bone are usually well marked, and the chest distortion is very great. 158 RICKETS Eelaxation of the ligaments, and consequent unnatural mobility of the joints, is almost always due to rickets. It is a common result when the disease occurs after the end of the second year, and may be present although there is no osseous deformity, and very little enlarge- ment of the ends of the bones. All the articulations are affected, but the knees and ankles seem to suffer most, as they bear the weight of the body. The yield- ing of the ligaments of these joints may be so great as to make walking difficult or even impossible ; but where the relaxation is extreme there is usually combined with it more or less softening and distortion of the bones. In rickety children, before cutting for stone, the size of the pelvis should be carefully studied, for narrowness of the outlet may create great difficulty in removing the calculus. By noting the degree of stunting and distortion of the lower limbs, a fair guess may be made as to the degree to which the pelvis is likely to have suffered from arrest of development and softening of its bones. An examination |jer amim will, however, at once remove any doubts : by the finger introduced into the rectum we can readily explore the entire pelvic cavity, and the size and capacity both of the brim and of the outlet can by this means be satisfactorily ascertained. There is one complication of rickets which it is very important to recognize early. This is scurvy. Spongi- ness of the gums, or any unusual tenderness of the limbs, should at once attract attention. In cases of advanced rickets there is almost always a certain amount of ten- derness; but if this symptom be present in an extreme degree, or be noticed in cases where the bone changes ann trifling and the general features of the disease little pronounced, it should at once suggest scurvy. Again, symmetrical local swelling of limbs, unaccompanied by fluctuation or redness of the skin, is a very suspicious sign, and one which should always make us examine the gums PROGNOSIS 159 and inquire into tlie feeding and general management of the patient. In cases where the scorbutic phenomena are very severe, and separation of epiphyses has occurred with symptoms of pseudo-paralysis, the case is distinguished from one of inherited syphilis by the absence of other signs of that diathetic disease. Prognosis, — The danger of rickets lies principally in the complications. As long as the disease remains simple, and the bone- softening is not extreme, the prognosis is very favourable. In estimating the danger of any particular case, atten- tion should always be paid to two points : The amount of chest distortion. The presence or absence of disease of the spleen, and glandular system generally. If the chest be much distorted, and the softening of the ribs great, there is always cause for anxiety. Owing to the difficulty of respiration in these cases, there is defi- cient aeration of the blood (shown by the lividity of the lower eyelid and of the mouth), and consequent deficient oxidation and removal of waste matter. The slightest catarrh, as has been before explained (see p. 139), adds a further obstacle to due aeration ; and catarrhs are always liable to occur, however carefully chills may be guarded against, owing to the extreme sensitiveness of a rickety child to changes of temperature. Under such circum- stances the patient's life is always in danger, for a slight cold, which in a healthy child would be scarcely worth notice, or which would be easily treated by domestic remedies, will be sufficient in a rickety child to cause fatal collapse of the lungs. If a child, the subject of this disease, begins to cough, no prognosis should be h until the movements of the chest during resiDira been carefully watched ; and here more useful in can often be gained by the eye than by the 160 RICKETS The danger is in direct proportion to tlie degree of reces- sion of the ribs during inspiration. Disease of the spleen and other internal organs does not add to the gravity of the prognosis so much as might be exj^ected. 'No doubt the child is less likely to recover his health than if these organs were perfectly normal ; but cases where the spleen is enlarged do not necessarily end fatally. On the contrary, such children often do well. On account of the danger of catarrh, disorders in which this derangement is a prominent symptom are of course especially formidable to rickety children. For this reason measles and whooping-cough are to be dreaded. Of the other complications, diarrhoea is the most serious. Convulsions are very common, but are usually harmless. Sometimes laryngismus stridulus causes death. The combination of moderate hydrocephalus with rickets is seldom attended with danger. Scurvy is a more serious complication ; but if recog- nised early and treated promptly with antiscorbutic reme- dies and appropriate diet, the symptoms in most cases will quickly disappear. No indication for prognosis can be derived from the age of the child. A slight degree of rickets is very common in infants of seven months old, and, when the causes which produced it are removed, it ceases as readily in them as in older children. The severity of the disease depends upon the intensity and the continuance of the causes of which it is the result. Causes. — Rickets is a general disease, for it affects the tissues of the body very widely ; but it cannot be included in the same class of maladies with acute tuberculosis, scrofula, and syphilis. The latter, which are often called thetic diseases, have special peculiarities which them very distinctly from a disease of pure mal- uch as rickets. A diathesis has been defined iracter of the constitution which tends to the CAUSATION 161 repeated expression of some form of ill-health, always in the same way.""^ In other words, it is a constitutional predisposition to repeated manifestations of a certain in- variable form of disease. Now, in rickets, there is, strictly speaking, no constitutional predisposition. It is the result of certain known causes, without which the disease cannot be produced, but under the influence of which any child whatever (with certain exceptions, to be afterwards noticed) will become rickety. That the disease occurs amongst the children of the rich as well as amongst the poor is no argument against this view, for wealth cannot buy judge- ment, and education is no guarantee against foolish indul- gence. We know that a child may be in reality starving, although fed every day upon the richest food, for he is nourished, not in proportion to the nutritive properties of the food he swallows, but in proportion to his ability to digest what is given to him. If, therefore, he be supplied with food which is unsuited to his age, the result is the same, whether he live in a palace or a cottage. Cases occasionally occur where the mother, exhausted by chronic disease, or other depressing cause, bears children feeble at their birth, and who very rapidly become rickety. But these are not true cases of constitutional predisposition. The child is born suffering already from the effects of deficient nutrition in the womb. He is then at once suckled with poor watery milk, or is brought up by hand and stuffed with all the hurtful trash with which the ignorance of mothers prompts them to supply the deficiencies of their milk. The natural result of such im- perfect nourishment follows, and rickets declares itself. But here the child can only be said to have been pre- disposed to rickets in the sense that he was born suffer- ing from a condition of which rickets is the final and most striking stage. Rickets does not produce malnutri- * * Science and Practice of Medicine,' by W. Aitken, M.D., Edin- burgh, 2nd edition, 1863. 11 162 RICKETS tion, but malnutrition produces rickets. The infant is not born weakly because be bas a rickety predisposition, but he falls a victim to rickets because he was born weakly. Moreover, for the full development of the disease, it is essential that the same causes by which nutrition was first rendered defective should continue in operation. If measures are taken to improve nutrition, this result does not follow, for when well cared for, and supplied with proper nourishment, the child in all cases becomes strong and healthy. Rickets is not a disease which must run its course. By judicious treatment it may be stayed at any point of its career ; and the treatment required is merely food — food which nourishes, and drugs which are not so much medicines as food under another name. Again, in the true diathetic diseases of childhood, here- ditary tendency plays a very important part, but in the case of rickets there is very little evidence of such a cause. Out of the thousands of rickety children there will no doubt be many, one or the other of whose parents was rickety before them ; but the same thing may be said of any other common disorder. It is always difficult where many conditions unite in the causation of a disease to separate the share which hereditary tendency takes in its production, but no special facts have yet been brought forward to show that rickety parents are more likely to have rickety children than parents who have been alto- gether free from the disease — the other conditions re- maining the same. Rickets, then, is not a diathetic disease in the sense in which tuberculosis and syphilis are diathetic diseases. Before the alterations in structure actually occur there is nothing in the appearance of the child to indicate the disease from which he is about to suffer. It is acquired under the influence of certain causes, lasts as long as those causes continue in operation, and, unless the struc- CAUSATION 163 tural changes are so extensive, and the general strength so reduced, as to forbid recovery, passes off when the causes are removed. These causes must be looked for in all those conditions which interfere with the proper nutrition of the child. Ill-health or weak constitution of the mother affecting the nutrition of the foetus in utero, and after birth of the child deteriorating the quality of the breast-milk ; improper feeding generally ; ill- ventilated rooms, damp, cold, dirt, want of sunlight, want of exercise. The continued in- fluence of these causes will produce the disease, or rather, will produce that unhealthy condition of the body of which rickets is the direct consequence. The preliminary stage, that which marks the beginning and progress of malnutri- tion, and in which the strength is being gradually reduced to the point at which rickets begins, may be long or short according to the degree of vigour of the child, and the degree of intensity with which the causes operate, or may even be absent altogether. Its place may be taken by any disease which interferes seriously with the assimilative power, and causes sufficient impairment of the general strength. We thus get another set of causes, which may either act independently of the others, or may most power- fully intensify their influence. Thus rapidly recurring attacks of diarrhoea, chronic vomiting, measles, bron- chitis, broncho-pneumonia, in fact, all the exhausting diseases, may have this effect. Too early weaning is sometimes stated to be a special cause of the disease. It is no doubt true that to deprive a young child of breast milk which he can digest, and to supply him instead with food which he cannot digest, is certain to be hurtful. In England, however, the tendency is rather to keep the child too long at the breast, to accustom him to look to that for his sole nourishment after the time when some additional food is required. In either case the supply of nutritive material is equally 164 RICKETS deficient, and the effect upon the health of the child must be equally unfavourable. The connection between syphilis and rickets is interest- ing. By some writers great importance is attributed to the influence of the former disease as a cause of rickets ; indeed, the late M. Parrot ventured so far as to declare that rickets was invariably the consequence of a hereditary syphilitic taint. The reasons for his belief adduced by this distinguished observer were founded principally upon morbid anatomy, especially upon a certain similarity of lesion noticed in the epiphysial ends of the long bones in the two diseases. There is no doubt that rickets often occurs in children the subjects of hereditary syphilis, just as it may arise in any case where the patient is enfeebled by mismanagement or disease ; but the clinical history of the two maladies is so different that in this country, at least, M. Parrot's doctrine has met with little acceptance. With regard to the influence of tubercle, rickety children, like the subjects of any other chronic disease, may fall victims to secondary acute tuberculosis ; and a phthisical mother may bear rickety children ; but a child in whom the tubercular diathesis is marked seldom, if ever, becomes rickety. It is also rare to find a case of rickets occurring in a family other children of which are the subjects of tuberculosis. Prevention. — If any of the former children of the family have been rickety, especial attention must be paid to the diet and general management of the new-born babe. The mother may still suckle the infant during the first month, but after that time she should give up all idea of rearing the child from her own breast, and a wet nurse should be provided. If from circumstances this is impossible, the breast-milk must be limited to two meals a day ; the child being fed at other times upon cow's milk and barley-water, or any other suitable diet, as recommended in an earlier part of this volume. At the same time, all the other pre- TREATMENT 165 cautions so essential to perfect health must be carefully observed. Perfect cleanliness, warm clothing, fresh air, well- ventilated rooms, sunlight, are all indispensable. If the parents reside in a cold damp situation, the child should, if possible, be removed to a neighbourhood where the quality of the air is drier and more bracing. For full particulars as to the best method of preventing the occur- rence of rickets the reader is referred to the section on the treatment of simple atrophy, where rules are laid down for the healthy feeding and management of young children. Treatment. — In the treatment of rickets, our first care must be to endeavour to restore healthy nutrition. This can only be done by attention to diet and to general hygiene, taking care at the same time to correct any disordered condition of the alimentary canal which may be present to interfere with the proper digestion and assimilation of the food supplied. This is indispensable as a first step, for to give tonics while the causes which have produced the disease, and sustain it, continue in operation, is a course which cannot possibly be attended with any good result. In almost all cases the bowels will be found to be rather relaxed, two or three stools being passed in the course of the day, consisting of offensive, putty-like matter, mixed largely with mucus, often greenish, and occasionally streaked with blood from the straining efforts with which they are evacuated. The foetor is due to decomposition of the undigested food. It is best to begin the treatment with a gentle laxative, such as a teaspoonful of castor oil, or a small dose of rhubarb and soda. The bowels having been thus relieved, alkalies should be given, with a little opium, in some aromatic water. The following prescrip- tion is useful in these cases, or some of the medicines ordered for a similar condition of the bowels in the treat- ment of simple atrophy may be adopted : — 166 RICKETS Tinct. Opii, irvj, Sodte Bicarb., gr. iv, Sp. Ammon. Aromat., Sp. Clilorof., mj, Aq. Cinnamomi ad 5ij. To be taken three times a day. The opium is of great use in diminishing the abnormal briskness of the peristaltic action of the bowels, and should never be omitted from the mixture so long as the stools present the appearances which have been described. Under such or similar treatment the motions will be found in a few days to assume a more healthy character ; griping, if previously present, will be diminished, or will have altogether ceased ; and the general condition of the patient will be much improved. At the same time the diet of the child must be regulated to suit the degree of debility to which he may be reduced, remembering that the greater his weakness, the more nearly does his diges- tive power resemble in degree that of a new-born infant. Full directions about diet have already been given in a former chapter (see Treatment of Simple Atrophy), and need not here be repeated. It may, however, be remarked that it will usually be found necessary very greatly to reduce the quantity of farinaceous matter which is being taken. Under the mistaken notion that such food is especially nutritious and easy of digestion, weakly chil- dren, whatever their age may be, are commonly made to depend for their support chiefly upon sago, arrowroot, tai:)ioca, and similar articles of diet. The amount of this food must be therefore considerably restricted, according to the rules already laid down, and its place should be supi^lied by milk, gravy, strong beef -tea, minced meat once cooked, yolks of eggs lightly boiled, &c., according to the age and strength of the child. Plenty of fresh air is indispensable to the successful * See Chap. XI, Diets 5, 6, 7, 8, 10, 11, and 18. PROTECTION FROM CHILLS 167 treatment of rickets. The child should be taken out regularly into the open air, and as he gets gradually stronger should pass more and more of his time out of doors. The quality of the air is of much importance, and sea- side places, where the air is dry and bracing, as Westgate, Scarborough, Brighton, and Eastbourne, are especially to be recommended. Rickety children are often kept confined to the house during the winter months on account of their tendency to chills, and it may be objected to the medical practitioner that whenever the child goes out he catches cold." In these cases it will be usually found on examination that the child's feet are habitually cold. If care be taken that the feet are thoroughly warm before the child leaves the house, and if at the same time the body and limbs are warmly wrapped up, the patient may be sent out of doors, all through the cold season, not only without danger, but with the greatest possible benefit to his health. In every case of rickets the belly should be kept covered with a flannel bandage ^ during the day, and the child should wear next his skin a flannel or pure woollen combination " garment. Stockings to reach up above the knee are to be preferred to short socks. It is more often within the house than without that the child takes cold. Not seldom it is in the night that the chill occurs. While asleep in his bed the patient sweats profusely. Inconvenienced by the heat he kicks off the bed coverings and throws his bare legs on to the counter- pane. As he lies thus exposed, his naked, perspiring body is as wet as if it had been dipped in water, and the evapo- ration which takes place chills the surface sufficiently to induce a very decided catarrh. I have known many an instance in which obstinate diarrhoea in a rickety subject has been kept up by this means. It is advisable, there- * The abdominal bandage has another use in retarding the too rapid descent of the diaphragm. This, when the bones are much softened, affords great relief. 168 RICKETS fore, in all cases where a rickety child is subject to frequent and mysterious catarrhs, to make inquiry into this matter, and to take measures to prevent the child uncovering his body in his sleep. Infants should be put into a loose flannel bag which can be tied under the arm-pits. In this they can kick about their limbs without risk of exposure. Older children may wear woollen " combinations." When these precautions are taken, the bed coverings must be light. More than one blanket will seldom be required. The copious perspirations to which these children are subject when asleep make it necessary to see that the bedding and sheets are not allowed to remain damp. The sheets must be dried carefully before the fire and not merely exposed to the air. I have known a gastro-intes- tinal catarrh to be maintained for weeks together for want of this simple precaution. On account of the free action of the skin it is important to attend to cleanliness ; but the washing bath must be conducted briskly lest the child catch cold. It is best to sponge him quickly in a bath of hot soap-suds. In this way the long — and to a sensitive baby dangerous — soaping process is avoided. When taken from the bath he must be wrapped up in a large warm towel and dried with as little exposure as possible. The bath should be given at night. The ventilation of the nurseries must be attended to, and in warm weather a lamp placed in the fender is useful to promote a free current of air. The influence of the preceding measures is usually most marked, and it is at this time that tonic medicines are so valuable. They ought not, however, to be given until, by suitable treatment, the motions have become healthy and the tongue clean. Iron is one of the most important medicines we have at our disposal. A good form for its administration is the following : — DRUGS 169 ^ Liq. Ferri Pernitratis, Acidi Nitrici diluti, aa tnj, Glycerini, mv, Infusum Caluinba3 ad 5ij. M. Ft. haustus. To be taken directly after food, three times a day. If the debility is very great, the ammonio- citrate may be given with sal volatile — Ferri et Ammonia3 Citratis, gr. ij. Spirit. Ammoniac aromat., Sp. Chloroformi, aa mij, Infusum Ci^lumbse ad 5ij. M. Ft. haustus. To be taken one hour before food three times a day. Or the tincture of the perchloride may be combined with dilute hydrochloric acid and spirits of chloroform in the same infusion. Chalybeate waters, such as those of Tunbridge Wells, are of service. Quinine ^ is very useful. It may be given either with dilute nitric acid or in the form of the double citrate of iron and quinine. Tannin is recommended by Dr. Alison. It may be given in doses of from half a grain to a grain, two or three times a day, in a little dilute nitric acid. The author has seen very marked improvement follow the use of this drug. The remedy, however, which justly takes the highest rank in the treatment of rickets is cod-liver oil. The influence of this drug in improving general nutrition is seen almost immediately : and when given under favour- able conditions — in cases, that is, where the deficient * Quinine is best given to young children in milk. Mr. Batterbury has pointed out that milk not only dissolves quinine, but also to a great extent disguises its bitterness. It has been suggested that the drug should be prescribed suspended in glycerine (one grain to the drachm), and that the nurse should be directed to administer the dose in a wineglassf ul of milk. 170 RICKETS sanitary arrangements which originated the disease have been corrected — the rapid change for the better in the general condition of the patient, and the quickness with which the more pressing symptoms disappear, will often be a matter of surprise. The oil may be administered in a tonic mixture, but it must not be given at first in too large doses. To begin with, ten to fifteen drops may be poured into each dose of the medicine, and the quantity can be gradually increased to a teaspoonful. Cod-liver oil may be usefully combined with iron, as in the following mixture : — 1^ Ferri et Ammonise Citratis, gr. ij, Tinct. Calumbse, mv, Olei Morrhuae, rrtx, Aq. Calcis ad 5j. M. Ffc. liaustus. To be taken after food, three times a day. During the administration of the oil the stools should be examined from time to time. Any smell in them of the oil is a sure sign that more is being given than can be digested, and the quantity must be reduced. With regard to the bone deformities : — If the tibiae are much bowed the child should be prevented as much as possible from walking until reconsolidation of the bones has sufficiently advanced. Careful watching, however, is required to prevent his getting upon his feet, for as his strength improves his delight in his newly-acquired powers is prodigious, and he seems anxious by incessant activity to make up for his previously enforced quiet. Light carefully padded splints should be aj^plied to the legs, and it is advisable that the supports should project below the feet, so as to render it impossible for the patient to stand. In recent cases, where the tibise are bowed forwards, or forwards and outwards, the plan may be adopted of forcibly straightening the bones, and then applying splints. This is done without difficulty in children under two years of age. If the bone should TREATMENT OF COMPLICATIONS 171 even snap in the operation the accident does not interfere with the process of cure, for union readily takes place. It must be remembered that this plan is only applicable to cases where the deformity has been rapidly developed and is still recent. When the tenderness has subsided, the spine, and back generally are much strengthened by careful shampooing. Each morning, after his bath, the child should be laid upon his face on the bed, and the whole back should be well and firmly rubbed with the open hand from the neck to the buttocks. The frictions should be continued for about ten minutes. In the evening the same process may be repeated before the child is put to bed. In cases where the ligaments of the joints are very weak and relaxed, a carefully applied elastic bandage affords the best support. The profuse sweating from the head can be controlled by belladonna, either given internally or applied locally as a liniment. If given by the mouth, care must be taken to give a sufficient quantity, remembering the great tolerance of children for this drug. Five drops of the tincture may be given at first three times a day to a child of twelve months old, or ten drops can be given in one dose at bedtime. If the sweating continues the quantity of bella- donna must be increased. Treatment of the complications. — The first symptoms of catarrh should always be attended to at once, for there is no complication which is so dangerous to rickety chil- dren. Prompt counter irritation to the chest should be at once adopted, and this is found to be more effectual when a mild irritant is kept applied for a long period to a large surface of the body. Thus, the chest may be enveloped in a poultice containing one part of mustard to five of linseed meal ; and this application may be kept in contact with the skin for a whole night together, even in the case 172 RICKETS of an infant. At the same time a saline diaphoretic mixture, such as the following, should be ordered : — Vini Antimonialis, rav, Sp. ^theris Nitrosi, mv, Liq. Ammon. Acetatis, rnxv, Glycerini, nv, Aq. Flor. Aurant.^ ^nx, Aq. ad 5j. M. Ft. haustus. To be taken every four hours. Our object is to produce as rapidly as possible free secretion from the bronchial tubes ; for the tough mucus which is first secreted lines the walls of the air-tubes, greatly diminishing their calibre, and also is apt to form plugs which, driven farther and farther into the tubes, act as valves, permitting egress, but forbidding ingress of the air. This is, as has already been explained, the cause of the collapse so often found after death occupying the posterior and inferior parts of the lung. The thinner the secretion, the smaller the liability to the formation of these plugs, and therefore the less the danger of collapse. When the cough has become quite loose, a few drops of sal volatile may be added to the mixture, and the stimu- lating expectorants generally are now admissible. If the debility is very great, a little wine or a few drops of pale brandy can be given every few hours while the mixture is being taken, but no stimulating expectorants should be prescribed until the secretion is copious. If there is much rattling of mucus in the chest during respiration, a teaspoonful of vinum ipecacuanhse may be given at once, and be repeated every ten minutes until vomiting is produced. An emetic, by its mechanical action, helps to clear the tubes of mucus. When diarrhoea occurs it must be checked as rapidly as possible, for the exhaustion it induces in a child already enfeebled is extreme. The following rules will be found TREATMENT OF DIARRHCEA 173 useful in these cases, and in the acute diarrhoeas of chil- dren generally. If the child is seen early, a dose of castor oil, by clearing away the irritant from the bowels, will usually arrest the purging at once. In any case, if the tongue be furred, it is best to begin the treatment with a mild aperient, such as castor oil, or rhubarb and soda. Afterwards the treatment must vary according to the character of the symptoms. Thus if the tongue is furred white or yellow, the skin hot, the belly hard, and the motions green and slimy, with much straining and griping pain, the following mixture will be of service : — 1^ Tinct. Opii, mj, Olei Kicini, iuiij> Mucillaginis Acacite, Glycerini, aa irtv, Aquam ad 3ij. M. To be taken three times a day. If the tongue is furred white or yellow, skin hot, the belly soft, the motions pale, frothy, and sour- smelling, without straining, an antacid is required, and a mixture containing chalk, catechu, and aromatic confection may be ordered. If with a clean tongue the motions are dark, watery, and stinking, with or without straining, the condition must be treated with opium, and astringents such as sul- phuric acid or tannin. If, in spite of this, the diarrhoea still goes on, the treat- ment recommended under the head of chronic diarrhoea must be resorted to. In all these cases the application of a broad flannel bandage to the belly should be insisted upon. When either of these complications (diarrhoea or catarrh) is present, the diet must be at once altered to suit the temporarily reduced power of digestion. 174 RICKETS In the case of convulsions and laryngismus stridulus the tendency to these nervous seizures is counteracted by the measures recommended for the general treatment of the rickety constitution. In proportion as nutrition becomes restored the proneness to convulsions also disappears. When called to a child suffering from a convulsive attack, we should at once give orders for the preparation of a warm bath (90° Fah.). While this is being done we can search for some local cause capable of explaining the nervous commotion. Scybalous lumps in the bowel should be removed by a copious enema ; irritation of the stomach must be relieved by a spoonful of ipecacuanha wine ; a tense swollen gum requires the use of the gum-lancet ; and signs of pain and tenderness about the ear suggest the employment of hot fomentations. If the tympanum be unquestionably inflamed, the aural meatus can be plugged with cotton-wool, while a leech is applied to the concha. A young child should not be kept for more than ten minutes in the warm water* Afterwards, if the fits con- tinue in spite of treatment, prompt measures must be taken to subdue the excitement of the nervous system. One of the best remedies in these cases is the nitrite of amyl, as recommended by Dr. A. E. Bridger. Whatever be the cause of the attack, the inhalation of one drop of the nitrite usually arrests it at once. If preferred, the remedy may be given by the mouth, and half a drop for a child of twelve months old, suspended in glycerine and mucilage, can be administered every half hour until the convulsions cease. Afterwards, a dose every three or four hours will prevent any return of the nervous troubles. The hypodermic injection of morphia is another useful method of controlling the eclamptic seizures. In this con- dition of the nervous system there seems to be a certain tolerance for the narcotic. For a child of twelve months old one twenty-fourth of a grain may be introduced under TREATMENT OF LARYNGISMUS 175 the skin, and the injection can be repeated every hour until the convulsive movements are at an end. To prevent the recurrence of the fits bromide of potas- sium or ammonium in doses of four grains, or the hydrate of chloral in doses of two and a half grains, may be given three or four times a day to a child of one yepor old. Chloral is also useful during the actual attacks. If the child cannot swallow, four or five grains dissolved in a little water can be thrown up the rectum. Laryngismus is quickly arrested, as a rule, by the chloral treatment. It is important that this complication be not spoken of too lightly, for it sometimes unexpectedly proves fatal. The derangement may often be cured at once by bathing the child's whole body two or three times a day with water of the temperature of 60° Fahr. It is well to remember that although fresh air is of extreme importance in these cases in forwarding the cure, the utmost care must be taken that the child before leaving the house is properly protected against the cold, for a catarrh greatly increases the gravity of the attacks. If the child be seen during the paroxysm, this may be usually made to cease immediately by applying a bottle of ordinary volatile smelling-salts to the patient's nostrils. In very bad cases it is important to pass the finger into the back of the child's throat, so as to bring forward the tongue, and release the epiglottis should the latter be incarcerated. It must not be for- gotten that laryngeal spasm is often the consequence of adenoid growths. If these vegetations are present they should be removed without delay. The large size of the head in rickety children often gives rise to a suspicion that the fits are due to hydrocephalus, and very active treatment is resorted to, sometimes with disastrous results. Kickety children cannot bear lowering measures at any time, and to reduce the strength while convulsions are actually present, is only to increase the number and the intensity of the fits. 176 RICKETS If symptoms of scurvy are noticed, the child should be placed without loss of time upon an anti- scorbutic regimen. All tinned and preserved foods should be at once discon- tinued, and fresh milk, raw meat-juice or pounded raw meat, and a proper proportion of vegetable should be substituted for his former unwholesome diet. The flower of broccoli, young French beans, vegetable marrows, asparagus heads, and Spanish onion, if thoroughly boiled and afterwards passed through a fine sieve, may be given safely to a child of twelve months old. A certain quantity of fresh fruit can be also allowed; and lemon juice is usually well borne by scorbutic infants. If the strength be much reduced, port wine or the St. Raphael tannin wine may be given, diluted with water. For medicine, the child should take cod's liver oil, and quinine dissolved in lemon juice and sweetened with syrup ; or five to ten drops of the tincture of perchloride of iron well diluted. For spongy gums Dr. Cheadle recommends the glyce- rines of tannin and carbolic acid (fifteen drops of each to the ounce of water) to be applied with a brush. The child should occupy well-ventilated rooms, and should pass much of his time in the open air. For local application to the limbs wet compresses closely applied and covered with oiled silk should be made use of. If the epiphyses have separated, splints will be required. CHAPTER V INHERITED SYPHILIS INHEEITED Syphilis, as it attacks the infant, presents a combination of the so-called secondary and tertiary stages of the disease, the primary stage being absent. The skin and mucous membranes invariably exhibit the cha- racters of secondary syphilis, and these external manifesta- tions are often combined with others indicating serious lesions of the bones and internal organs. The disease may first show itself in the child at three different periods, — viz. before birth, at birth, or after birth. If he/ore hirth, it occurs usually from the fifth to the seventh month of intra-uterine life. The child dies, and is born dead before the proper time. This disease is so common a cause of miscarriage, that when labour has repeatedly occurred prematurely our susj)icions should always be excited, and we should make inquiry as to the previous health of the parents, so that by the proper treat- ment of one or both the lives of succeeding children may be preserved. If at hirthy the symptoms are usually very severe. The child, although born alive, is emaciated, and looks shri- velled. He snuffles and cries hoarsely. A few hours after birth, an eruption of pemphigus appears, situated princi- pally on the palms of the hands and the soles of the feet. The bullae become filled with a semi-purulent liquid, and burst, leaving angry-looking sores. Spots of inflamma- tion, with abscesses, are scattered through the thymus 12 178 INHERITED SYPHILIS gland and through the lungs. The liver is indurated. The infant may linger on for a few days or weeks, bvit these cases almost always prove fatal. Although appearing at birth, the symptoms are not, however, always so marked as those described. The amount of flesh may be considerable, and the lesions of the internal organs may not be present. In such cases the child may recover, but the prognosis is exceedingly unfavourable. If after birth ^ the child is born apparently healthy. He is often plump, seems strong, and presents no symptoms by which even the most practised eye can detect the disease lurking in his system. Sometimes, however, although offering no distinct symptoms of disease, there is yet a something which seems to hint at the approach- ing outbreak. The face is rather old-looking; the skin inelastic and unnaturally pale ; the complexion dull and wanting in transparence. After a time, varying from two weeks to six or seven months, although rarely after the end of the third month, evident symptoms of the disease begin to be observed. Before this, however, there is one symptom which has been little noticed by writers upon this subject as a sign of the inherited disease, but which is seldom absent. This symptom is obstinate wakefulness at night. The child when put to rest is uneasy and fretful, he cries almost unceasingly, and cannot be pacified. During the day he is more composed, but every night there is a repetition of the same disturbance, and his uncontrollable complaints are a source of the utmost perplexity and distress to his attendants. The crying is possibly excited by nocturnal pains in the bones similar to those affecting adults before the outbreak of the constitutional symptoms. On the appearance of the rash the sleeplessness does not at once subside, but it soon disappears under the influence of specific treatment. The outbreak of the general symp- SYMPTOMS 179 toms may be determined by some febrile attack, as one of the exanthemata, the eruption of which subsiding leaves the syphilitic rash in its place. In almost all cases one of the earliest signs of the disease is snuffling. The mother in the beginning attributes little importance to this sym- ptom, and indeed does not usually mention it unless ques- tioned specially upon the point, when she replies that the child has " had a cold " for a few days. Soon the mucous membrane lining the air-passages becomes more swollen, but even then there is not much snuffling so long as the child breathes through his mouth. When, however, he takes the breast, his difficulty of breathing through the nose becomes at once apparent. Each inspiration is accompanied by a slight snore, and as the obstruction becomes more decided he can only suck at short intervals, desisting frequently and lying with the nipple in his half-open mouth, so as to obtain a supply of air before making another effort to draw out the milk. Occa- sionally he snorts violently as if in an attempt to clear away some obstruction, and this often causes serious alarm to the mother, who will complain that the child seems as if he were going to be suffocated when he takes the breast." After a time there appears from the nostrils a slight watery discharge, which may be tinged with blood. It is seldom profuse at first, and is often merely enough to give a glistening appearance to the openings of the nares. G-radually, however, it becomes more abundant, and acquires consistence, so that it forms crusts which block up the nasal apertures, and still further impede the pas- sage of the air. The discharge is intensely irritating, and scalds the parts with which it comes into contact ; producing cracks and little ulcerations about the nostrils and upper lip, which become encrusted with minute scabs. Diday, however, believes these external cracks and ulcers to be due to mucous patches, and to be independent of the 180 INHERITED SYPHILIS discharge : the discharge itself he attributes to mucous patches developed on the Schneiderian membrane. In severe cases the ulceration thus set up within the nose may perforate the septum nasi, or lay bare the nasal bones which may become necrosed. Fragments of these bones are sometimes found in the crusts thrown off. The bones may also become loosened and sink down, so that the bridge of the nose is flattened, and looks broader. In rare cases snuffling is the only symptom of the disease : some- times, but very rarely, it is completely absent throughout. Soon after the beginning of the coryza, an eruption is noticed on the skin. It is usually first seen about the arms and perinaeum in the form of flattened, slightly elevated spots, resembling very much in their colour the rust of iron, and which with a lens may be sometimes seen to be covered on their surface with minute scales. More commonly, however, no scales are visible, for as soon as formed they are softened by the natural moisture of the part and become detached. These spots are scattered over the perinseum, surround the anus, and speckle the scrotum or the labia. Sometimes the eruption begins as an erythematous blush, at first bright red, which covers the buttocks and perinseum, and may extend to the lower part of the belly. The colour soon gets more dingy, and has been aptly compared to the lean of ham. It becomes at the same time distinctly circumscribed, ending at its boundaries in an abrupt line. The coloured surface is scaly, and at its edges are seen the rust- coloured spots before described. The eruption is not limited to these parts ; it often invades the folds of the joints, particularly the armpits, extends to the sides of the neck or the chin, and may be sprinkled all over the body. Other varieties of the rash are also found, as ecthymatous pustules, papules, tubercular spots, mucous patches ; and ulcera- tions, the result of these eruptions, may also be pre- sent. MUCOUS PATCHES 181 When ecthyma is seen in any quantity, the aggregation of the pustules presents a very peculiar appearance, and the general aspect of a part covered with such an eruption differs entirely from that just described. The eruption is usually seated on the buttocks and perinseum, and the pustules are more or less closely aggregated, the colour of the part varying according to the degree to which the pustules are separated. When crowded together, the general tint is a deep purple — not uniform, but broken up into patches of purple, separated by intervals where the colour is red. When the pustules are more widely apart, each one is seen to consist of a violet-coloured blotch, crowned with a thick, blackish crust, and sur- rounded by a deep red or copper- coloured areola. If placed sufficiently closely, the adjacent areolae may join, so that all of the skin which is seen between the neigh- bouring pustules is of the same reddish or coppery hue. The scabs cover an ulcer, which is apt rapidly to deepen, and, unless checked by early treatment, may penetrate deeply into the tissues, and produce very serious results. The ulcerations which arise from the other forms of eruption are often linear, and are compared by Trousseau to the narrow grooves found in worm-eaten wood. They frequently leave linear cicatrices, which may exist for a long time an evidence of the past disease. Mucous patches, when they occur on the skin, are seen as round or oval, slightly elevated patches. They are soft, and something of the consistence of mucous mem- brane. Their colour is reddish or greyish, and the surface is kept constantly moist by a thin, offensive secretion. They are usually found by the side of the anus, at the commissures of the lips, about the genitals, between the fingers and toes, or anywhere else where the skin is espe- cially delicate and moist. When they occur on the mucous membranes, they are commonly seen as irregularly- rounded 182 INHERITED SYPHILIS white elevations, in the centre of which a point of excava- tion shows itself ; this spreads, so that after a very short time only a single ulcer is observed. It is not uncommon to find them on the arches of the fauces, but they seldom or never extend to the back of the pharynx. The skin of a syphilitic child is dry and parchment-like, and is often scaly, especially on the palms of the hands and the soles of the feet. Fissures are often seen between the fingers and toes, and may be found radiating from the anus and the corners of the mouth, and at the commis- sures of the eyelids. A kind of whitlow is occasionally present from specific inflammation and suppuration of the matrix of the nail. The nutrition of the nail being thus interfered with it gets dry, and falls off. M. Bouchut states that he has seen a case in which every nail, both on the fingers and on the toes, was thus affected. The hairs of the eyelashes and eyebrows often fall out ; the edges of the eyelids then become scaly. The colour of the face is yellowish, and has been compared by Sir W. Jenner to the colour of weak cafe-au-lait. It is diffe- rent from the earthy tinge often seen in chronic diarrhoea, and must not be confounded with it. This tint does not spread to the rest of the body, but remains limited to the face, where it is most marked on the more prominent parts, being less noticeable on the deeper parts, as the internal angle of the orbit, and the hollow of the lower lip. Besides this peculiar tint of the face, there is a very striking pallor of the body generally, which is very slow to disappear, even after the subsidence of the other symptoms. The cry of the infant is one of the most noticeable features of the disease ; it is hoarse and high pitched, and when once heard is not difiicult to recognise again. Its peculiar quality is, no doubt, due to an extension of the mucous patches to the larynx. Occasionally the DISEASE OF BONE 183 hoarseness is accompanied by attacks of laryngismus stridulus. As a rule the fontanelle in children suffering from this disease is very widely open. It appears as if the cachexia exercised some influence in retarding ossification of the bones. Strangely enough, however, the growth and development of the teeth do not appear to suffer ; indeed the contrary is found to be the case, for the teeth are often cut very early, and with remarkable ease. It is not uncommon to see the front teeth appear while the body is jet covered with the syphilitic rash. Disease of the bones has been lately shown to be common in hereditary syphilis, and should be always looked for. In the long bones it may be easily detected by placing the finger and thumb one on each aspect of the bone, and passing the hand downwards along the shaft. If diseased, the lower end of the bone is felt to be abnormally thick, and this thickening is best marked at the point of junction of the shaft with the epiphysis. The disease, when it occurs, occurs as an early symptom, and is said always to be present in dead syphilitic chil- dren, whether stillborn or not. It is never confined to a single bone, and usually attacks several. The bone which least often escapes is the femur, and then follow in order of frequency, the humerus, tibia, ulna, radius, fibula, the bones of the skull, the ribs, ileum, scapula, clavicle, os calcis, astragalus, metatarsal and metacarpal bones. Sometimes, notably in a case recorded by Kobner, the bone affection is the only evidence of the hereditary disease. The various lesions of bone are described in treating of the morbid anatomy of the disease. In severe cases suppuration takes place outside the joint, and the epijDhysis separates from the shaft. The child then presents very characteristic symptoms. There is complete immobility of the limbs, as if the bones had been fractured. The arms lie pronated by the side of 184 INHERITED SYPHILIS the body ; the legs are stretched out straight in the cot, and when the child is lifted np, hang loose, swaying from side to side. On examination, crepitation can be some- times produced between the shaft of the bone and the epiphysis. The joints are very tender to pressure, and if an abscess forms, become bent and stiff and exquisitely painful. Besides this disease of the articular ends of the bones, nodes may be present in the shafts of the long bones, giving rise to much tenderness and aching pain. In- durated deposits are also often found in the areolar tissue, tendons, and muscles. Enlargement of the posterior cervical glands is also a common lesion. In most cases of infantile syphilis enlarged and movable glands may be felt in the nape of the neck, immediately below the occiput. Sometimes the lymphatic enlargement is more general, and the liver and spleen can also be felt to be increased in size. I used to be of opinion, with Dr. Gee, that the amount of splenic swelling could be taken as a measure of the severity of the cachexia. In other words, that it was only in the more severe cases that enlargement of the spleen took place at all, and that if the swelling was considerable the danger was great. I have met with cases, however, which show that the spleen may be large and hard although the general symptoms are mild and the nutrition of the patient satisfactory. Some time ago Dr. A. Leete G-riffith sent me a well-nourished baby, aged four weeks, who had begun a fortnight previously to swell about the abdomen. The child's complexion was dingy. She snuffled a little and was slightly hoarse. A few scaly, coppery spots could be seen on the chin and in the left arm-pit. The veins of the epigastrium were full. The liver could be felt three fingers' breadths below the ribs : its consistence was soft. The spleen reached downwards for the same distance, and its substance was hard and resisting. There was no disease GENERAL NUTRITION 185 of bone. The mother had had sore throat and rash at an early period of her pregnancy. The baby was being treated with anti- syphilitic remedies. Four months afterwards Dr. Griffith wrote to me that the spleen had become greatly reduced in size, and that the child was going on well. She was being brought up at the breast. In this case the increase in size of the liver was pro- bably not a consequence of the constitutional disease, for the substance of the organ was normal in consistence, and presented no sign of induration. The spleen, how- ever, was large and hard, but still the cachexia could not be called severe, for the symptoms generally were excep- tionally mild. Nutrition was good, eruption was scanty, and the condition of the child was never such as to excite anxiety. The general condition of the infant varies, not according to the severity of any particular symptom, but according to the intensity of the general cachexia. The child some- times continues plump, and although pale and rather weak, seems to suffer comparatively little from the effects of the disease. But a satisfactory state of nutrition is the excep- tion and not the rule. In the large majority of cases the cachexia is severe ; and even when the more special sym- ptoms have passed away, the infant is apt to remain pale, wasted and old-looking, with perhaps a permanent stunting of the growth. Dr. Donkin has laid stress upon the inten- sity and persistence of this interference with the nutritive processes, and suggests that an explanation may possibly be found in a fibrosis of the pancreas such as is common in other of the internal organs. In inherited syphilis, as in the acquired form, many varieties of nervous disease are to be met with. Sudden hemiplegia has been ascribed by Dr. Hadden to arterial degeneration inducing thrombosis or haemorrhage. This observer, out of twenty-five cases of hemiplegia with acute onset, found two in which the children were certainly 186 INHERITED SYPHILIS syphilitic and eleven others in which suspicion of this disease was more or less strong. Dr. Abercrombie, out of fifty cases, attributed four to syphilis, and had strong sus- j)icions about two others. In addition to these acute cases, more chronic disease has also been ascribed to a specific taint. There is little doubt that cerebral sclerosis and dis- seminated sclerosis of the cord occurring in young subjects may have this origin ; and persistent cervical opisthotonos from basic meningitis is sometimes associated with sym- ptoms of the inherited complaint. A peculiar form of paralysis has been described which affects the anterior branches of the brachial plexus, and induces a more or less complete loss of power in the upper limbs. Sensibility, however, remains normal. Henoch has noted two cases in which all the muscles of the upper extremities were paralysed with the exception of the flexors of the fingers. Other signs of syphilis were present and under specific treatment the paralysis soon disappeared. In rare cases the symptoms of hereditary syphilis are delayed until the seventh, ninth, tenth, or even fourteenth year. Coppery, scaly eruptions may then appear, with discharges from the ears, nose, &c. Chronic interstitial keratitis may also occur at these times, and is symptomatic of hereditary syphilis. There may also be deafness from some morbid condition of the auditory nerves. The per- manent central' incisors (Hutchinson's teeth) are often im- perfectly developed. They are short and narrow and do not touch, so that a space is left in the gum on each side. At the same time the edges are uneven from atrophy of the middle lobe, so that a broad, vertical notch is left in the centre of the edge, from which a shallow furrow or groove may pass backwards on both anterior and posterior sur- faces nearly to the gum. The notching is usually sym- metrical, but not always, for sometimes only one tooth is affected. These symptoms may be found, not only when the disease is thus deferred, but also when it has appeared RELAPSES 187 at the ordinary time during infancy. They are not, how- ever, by any means constant. E-elapses are very liable to occur in children after the cessation of all symptoms, and when the disease is sup- posed to be cured. Probably many of the cases of so- called delayed syphilis are merely instances of relapse, the earlier symptoms of the disease having been unnoticed or misapprehended. When the relapse takes place at an earlier period it is most commonly observed in the form of mucous patches with large thickened elevated edges seated by the side of the anus, at the angle of the mouth, on the tongue, or between the fingers and toes. These may be combined with a return of the eruption on the skin. In cases where the disease reappears after an in- terval of years it usually manifests itself by more deep- seated lesions, such as are considered characteristic of the later or third stage : chronic interstitial keratitis occurs ; the permanent incisors appear notched and dwarfed ; there is deafness and more or less serious disease of bone. The following case, seen by the writer, under the care of the late Dr. Semple, affords a good illustration of relapsed syphilis : A girl, aged eighteen, suffered from chronic interstitial keratitis of one eye, applied for advice on account of " sore throat." On examination of the fauces extensive ulcerative disease was discovered, which had destroyed the whole of the soft palate, and the greater part of the bony roof of the mouth. The teeth were not notched, nor were there any nodes on the shin bones. On enquiry it appeared that the mother had been a healthy woman before her marriage, but that after the birth of her first child she had begun to suffer from sore-throat, and to have an eruption on the skin. The child snuffled, was covered with a rash, and died after a few weeks. The six following children died in the same way. They were all born at the full time, and ap- peared to be healthy, but a few weeks after birth each began 188 INHERITED SYPHILIS to snuffle ; the characteristic rash appeared ; and the infant wasted and died. The patient herself, although the eighth child, was the first who had survived. She had the ordinary symptoms of inherited syphilis soon after birth. At ten years old the eye became affected with keratitis. At the age of twelve she first began to complain of the affection of the throat, from which she had since been suf- fering. This case is fortunately an exceptional one. As a rule the symptoms cease after a time and never return ; nutri- tion goes on well, and the patient to all appearance is as strong as other children of his age. It may happen, how- ever, that recovery is less complete, and although there may be no actual relapses, signs may be noticed hinting at the past cachexia. Thus, nutrition is not quite satisfac- tory ; the body is stunted ; the complexion earthy ; the hair thin and brittle. Traces of thickened bone may be found, and sometimes the brain suffers so that the child becomes imbecile or epileptic. Morbid Anatomy. — Inherited syphilis in the child pro- duces very widely distributed lesions ; indeed, there is no part of the body which may not become affected as a consequence of this disease. The principal lesions are seated in the bones, the mucous membranes, and the solid internal organs. Syphilitic affections of the bones have been made the subject of careful study ; and it is to Drs. Parrot and Cornil of Paris and Taylor of New York that we are chiefly indebted for complete descriptions of these im- portant lesions. The long bones become affected by a special suppurative osteochondritis which attacks the epiphysial end of the bone. First, the layer of cartilage which is preparing for ossification increases in width so as to be twice or even four times its natural thickness and becomes particularly MORBID CHANGES IN BONE 189 transparent and soft. This increased thickness is due to a multiplication of the cartilage cells, which lose their natural characters and assume much the shape and size of the round granulation cells of syphilitic gummata. At the same time the intercellular substance is diminished. The layer of cartilage which is actually undergoing ossifi- cation, instead of being very thin, as it is in healthy bone^ is thickened unevenly, so that it shows on section as a broad uneven line. By the microscope, its ostioblasts are found to be replaced more or less completely by small granulation cells or spindle-shaped elements. The already ossified bone immediately in contact with the last layer is altered in colour on the surface, being marked with patches of white or yellow or gray splashed with rose. After a time destructive changes set in in the bony tissue. Parrot describes a " gelatiniform softening " in which the bone is replaced by a soft, rather transparent material of a yellowish or brown colour. When this dries, after death or exposure of the bone to the air, a cavity is left. A puriform matter, too, sometimes in- filtrates the cancellous structure, so that the canuUse disappear, and leave cavities filled with the pus-like sub- stance. The result of this lesion is to produce separation of the epiphysis with the ossifying layer from the shaft of the bone. This is followed by suppuration round the affected part, but the joint itself is not involved. Under the microscope, the puriform matter is seen to consist, not of true pus, but of small angular but still roundish elements which replace the natural lymphoid and myeloid cells. Another form of bone lesion, which Parrot has called ** periosteogenesis," begins as a periostitis, and attacks principally the humerus and tibia. Parrot has described two forms : — the osteoid, which may begin at the earliest period of life, and the spongioid or rachitic, which is seldom met with before the age of six Qionths. In the first — the osteoid form — a new osteoid growth 190 INHERITED SYPHILIS forms on the surface of the shaft beneath the periosteum, which is thickened and adherent to it. The new growth is white and chalky in appearance from infiltration of calcareous salts : and by its colour is readily distinguish- able from the bone beneath. It is composed of inter- lacing trabeculse, lying perpendicularly to the axis of the shaft, and in place of the bone corpuscles, which in normal osseous tissue are disposed regularly around the Haversian canals, contains many-sided stellate corpuscles which anastomose by their processes with the cells of the periosteum and with one another. The spongioid form consists of fibrous tissue, grey or yellowish in colour, and very vascular. These two forms of new growth may be combined in the same subject, lying in alternate layers. The bone beneath is either unaltered in structure, or is more porous and brittle than in the normal state from absorption of calcareous matter and the formation of furrows filled with medulla. The bones of the skull may be attacked by both forms of the disease. Grelatiniform softening is, however, com- paratively rare in this situation, and when present (which is only in the youngest infants) rarely penetrates deeply into the bone. The osteoid growths are more common, and attack the older children. These lesions occupy the frontal, parietal, and occipital bones ; but are especially frequent in the parietal in the neighbourhood of the an- terior fontanelle. The deformity which results is a very characteristic one. Four elevations, intersected by two furrows placed crosswise, are found, and a condition is produced which has been aptly compared to a hot cross bun." These osteophytes are thickened and porous, and the bones themselves may be lighter and more porous than natural. Another lesion is sometimes seen which is similar to the cranio tabes so common in rickety children. The bone is SYPHILITIC CTYLITIS 191 thinned in spots of varying size and may even be perfo- rated. This lesion is most common in the occipital bone, and is due to pressure as the child's head rests on the pillow. Dr. Taylor, of New York, has described a syphilitic dactylitis which attacks the bones of the hands and feet. This affection begins in the fibrous tissue and produces a slight enlargement of one or more phalanges or an entire digit. It excites little pain, but interferes to some extent with free movement of the joint. Another form sometimes occurs in which the disease originates in the bone and periosteum. This variety most often attacks the fingers. One or more of the phalanges becomes thickened and fusiform. If the swelling is injured the skin becomes swollen, red, and tense, and ulcerating discharges a soft detritus mixed with pus. Limited necrosis may follow and lead to shortening of the finger. If not injured, the swelling tends to resolve without breach of surface. The above described changes in the long bones may occur within a few weeks of birth, or even during intra- uterine life. The lesions of the cranial bones occur later than the others, and are comparatively rare under two years of age. The mucous membranes of syphilitic children are very liable to catarrh, and may be the seat of mucous patches, erosions, and ulcers. These lesions are often found on the inside of tlie cheek, lips, and fauces ; but are rare at the back of the pharynx, and, according to Dr. John Mac- kenzie, never spread into the gullet. Sometimes, however, they are found in the intestine. Mucous patches and ulcers also occur on the mucous membrane lining the air passages. In fatal cases they may be seen on the epiglottis and sides of the glottis, and sometimes extend into the larger air tubes. In some cases the vocal cords are de- stroyed by ulceration ; in others, they are the seat of warty growths. 192 INHERITED SYPHILIS In the interyial organs new fibroid growths appear, which may be diffused or circumscribed. In the lungs many different pathological conditions have been enumerated as dependent upon a syphilitic taint — so many, that in all probability sufficient care has not always been taken to discriminate between pulmonary disease occurring in a syphilitic infant and real syphilitic disease of the lung. A syphilitic infant may become infected with tubercle, as Hochsinger has proved by cases lately published, and may die, not from the inherited taint, but from extensive tuber- culous disease of the lungs. Therefore in cases of pul- monary consolidation occurring in a syphilitic infant search should always be made for the tubercle bacillus. A syphilitic pneumonia has been described in which the lung becomes the seat of a grey consolidation, which on section presents a smooth shining surface traversed by fine fibrous lines. It is very dense and tough. Under the microscope the alveolar walls are seen to be infiltrated with round cells, spindle cells, and fibrous tissue. This change is no doubt met with occasionally in syphilitic children, but that it is peculiar to subjects of this disease has yet to be proved. The new formation called "gumma" has long been recognised as a consequence of syphilis. In the lung gummata are seen as rounded masses, usually of the size of a nut, and yellowish- white in colour. Their consist- ence is firm at the circumference, but in the centre they are softer, and the interior is sometimes broken down into a small cavity containing ^^uriform matter. Micro- scopic examination shows the alveolar walls at the circum- ference of the tumour to • be infiltrated with nucleated cells which cause more or less compression of the alveoli. Nearer the centre round or oval cells are seen in a finely reticulated tissue. The central portion, if softened, con- sists of fatty molecular granules. The liver is hypertrophied and indurated, either gene- MORBID CHANGES IN THE LIVER 193 rally or partially, the enlargement being sometimes con- fined to one lobe, or to a part of one lobe. Specific disease of the liver, when it occurs, is an early sign of the cachexia. It rarely gives rise to jaundice or ascites. If the latter symptom be present, it is probably due to concurrent peritonitis. The hepatic lesion has always been considered to add greatly to the danger of the patient ; but Hoch- singer states that of forty- six syphilitic infants under his care in whom decided enlargement of the liver was noted, only sixteen died. In the others very speedy reduction of the size of the organ took place under specific treatment. The enlarged liver feels smooth and hard to the touch, and is usually accompanied by very obvious signs of digestive derangement. Sometimes the pressure of the enlarged liver upon the vena cava may produce extensive oedema of the lower limbs and of the scrotum. This was seen by the writer in a case in which the syphilitic symptoms appeared a fortnight after birth. There was obstinate constipation and vomiting, and the mucous membrane of the mouth was covered with thrush. 1'he heart and lungs were healthy. The infant rapidly sank and died. Gubler, who drew attention to this condition of the liver as a result of syphilis, describes the organ in highly marked cases as hypertrophied, globular, hard, and elastic. It is extremely resistant to pressure, and creaks under the knife when cut into. On section the natural appearance of the surface is seen to be quite lost, and in its stead we see layers of small, white, opaque grains on a yellowish uniform ground. 'No blood, but only a little yellowish serum, escapes on pressure. The capillary vessels are obliterated, and the calibre of the larger vessels is considerably diminished. These changes are due to the development of large quanti- ties of fibro-plastic tissue, which compresses the hepatic cells, obliterates the vessels, and consequently prevents the secretion of bile in the parts so affected. Sometimes the disease is confined to circumscribed deposits (gummata) 13 194 INHERITED SYPHILIS embedded in the substance of the organ, which is other- wise healthy ; but hepatic gummata are very rare in infants. The spleen is often enlarged, but seldom to any con- siderable extent. Dr. J. A. Coutts found definite increase in size of the organ in 62 per cent, of his cases. As in the liver, the hypertrophy is due to a diffused interstitial hyperplasia. Changes have also been observed in the heart and kidneys. These organs, even when healthy to the naked eye, are sometimes found, on closer examination, to be undergoing interstitial changes. In some specimens pro- duced by Dr. Coupland before the Pathological Society the heart showed, under the microscope, an almost uni- versal infiltration of small round cells amongst the muscular fibres ; and the kidneys, although presenting to the naked eye a normal appearance, were found to be undergoing similar changes. Huber has found the supra-renal capsules affected in some cases. In one well-marked example the capsules were large, greyish on the outside, translucent and thick, with numerous white, irregularly- shaped spots inter- sjDersed in the capsular substance. At the posterior surface of both capsules were irregular yellow thick knots, showing, under the microscope, fatty detritus. These affections of the internal organs do not seem to stand in any direct relation to the general symptoms. In cases where the latteV are very severe, and the influence of the disease upon nutrition is most powerfully mani- fested, the liver and spleen may present no sign of patho- logical change. In other cases, again, these organs may suffer severely, while the external characters of the disease are but faintlj marked. Diagnosis. — In a well-marked case of inherited syphilis, the wizened face, the snuffling, the peculiar complexion, the hoarse cry, the emaciation, the dry and parchment- DIAGNOSIS 195 like skin with the characteristic eruption scattered over the surface, the fissured lips and anus, form a collection of symptoms which when once seen it is impossible after- wards to mistake. We, however, constantly find cases in which many of the symptoms are absent. The child may continue plump, and be apparently in good condition; but here there is usually snuffling; rust- coloured spots are found about the perinseum, and fissures will be seen radiating from the anus and perhaps from the corners of the mouth. The general pallor of the skin is seldom absent, although the special " cafe-au-lait " tint of the complexion may not be noticed. The deep purple tint produced by a collection of ecthymatous pustules presents a very characteristic appearance, and one which it is difficult to mistake, especially when it is combined with the cracks and ulcerations about the anus, &c. The appearance alone of ecthyma in an infant should lead us to suspect syphilis. Scabies is the only other cause which is found to produce such pustules at this early age, and this is at once detected by the absence of the other signs of syphilis, by the fewer number of the pustules, and by the presence of the characteristic furrow peculiar to the acarus. We must be careful not to overrate the value of snuffling as a sign of the inherited taint. Standing alone, it may mean very little. Snuffling is common in young babies, and if accompanied by a profuse discharge from the nasal pas- sages is a familiar consequence of post-nasal catarrh dependent upon adenoid vegetations. Hoarseness, again, is a recognised indication of the same catarrhal state ; so that snuffling and hoarseness combined are not to be relied upon as evidence of syphilis. In the same way enlargement of the spleen may be due to a variety of causes, and may be joined with the two preceding symptoms in a child who is perfectly sound. In all cases of suspected syphilis we should notice the state of general nutrition, 196 INHERITED SYPHILIS and make careful search for spots. A syphilitic baby is generally thin and flabby ; his f ontanelle, as a rule, is widely open; his eyebrows and eyelashes are scanty or absent ; his teeth begin very early to appear. Dr. J. A. Coutts is of opinion that obstinate wasting unaccompanied by vomiting or diarrhoea, forms a sufficient justification for anti- syphilitic treatment ; but I should hesitate to treat a child for the specific disease upon this evidence alone. If in doubt in any case, after a careful examination of the child's whole body, we should inquire into the health of the other children, examine them for signs of past disease, and question the parents as to their own health, especially as to the occurrence of previous miscarriages on the part of the mother. When the cachexia has been pronounced, its consequences remain visible long after the disease has passed away. The physical development of the child may be unsatisfactory, and often his complexion is ashy or earthy in tint. Ves- tiges of local disease may be noticed, such as flattened bridge of the nose from long- continued swelling of the nasal mucous membrane when the bones are soft ; markings of the skin by little pits, or linear cicatrices, from former ulceration, especially about the angles of the mouth ; pro- tuberant forehead from specific disease of the frontal bone and the characteristic thickening of the cranial bones around the anterior f ontanelle. Cranio-tabes alone is no indication of syphilis, as it may occur quite independently of any specific taint. There may be interstitial keratitis of the eye, notching and dwarfing of the permanent teeth, and even deafness from disease of the auditory nerve. Often, too, the spleen is left swollen and hard. Moreover, it must not be forgotten that nervous derangements due to cerebral sclerosis or to arterial and other degenerations may be set up as a consequence of the inherited taint. Causation. — The disease may be conveyed from parents to children through the influence of the father, the mother. CAUSATION 197 or both together. Either alone may be suffering, for it can now be taken as proved that disease in one parent, where the infant is tainted, does not necessarily imply disease in the other. When the father is the source of infection the mother may bear a syphilitic child, but herself remain healthy ; or, again, the offspring of a healthy father may be infected by a diseased mother, the father remaining free. The father's power of transmitting the disease continues for years, and may long outlast all outward signs of the complaint in his own person. It appears certain also that the taint so transmitted is as active and intense after a term of years as it is in the beginning. It is true that when a syphilitic man and a healthy woman are the parents of many children the severity of the complaint is seen gradually to decline in each succeeding infant, but this is not necessarily a proof that the virus in the man is losing its power. All evidence tends to show that a man, as long as he is capable of transmitting it at all, will transmit the disease in as active a form in the latest as in the earliest period after contracting it. It seems rather, as Dr. Coutts suggests, that this seeming attenuation is due to the reabsorption by the mother of some product generated in the foetus — an antitoxin which is potent in proportion to the number of her previous pregnancies. By this means the mother may be made immune while retaining her health ; and Colles' law that the complaint is not conveyed from the child's mouth to the mother's breast may hold good without being in any way proof that the mother herself is a sufferer from the disease. But the actual infectiousness of inherited syphilis has been greatly exaggerated. Authentic instances in which the disease has been contracted by a healthy person from an infant so afflicted are few indeed. It has happened occasionally that a suckling at the breast has infected his nurse, and one case has come under my own notice in which a child 198 INHERITED SYPHILIS infected the nipple of its mother ; but such cases are ex- cessively rare, and the disease, as it occurs in the infant as a result of inheritance, may be said to be practically non- infectious. Mercurial treatment in the father has the effect, not perhaps of enfeebling the virus, but of destroying for a time the power of transmitting it ; but this power may return later when the influence of treatment has worn away. In connection with this point is the question. How soon should a man be allowed to marry after contracting the disease ? To this Mr. Hutchinson answers that prob- ably in the vast majority of cases the risk of transmission to children is over long before the end of two years," but other authorities would extend this term to three, four, or five years. Dr. Coutts fixes the term at two years after the disappearance of all active symptoms if treatment has been thorough," and this I think a reasonable con- clusion. In cases where the mother alone is syjDhilitic the infant is more severely affected than in cases where the father alone is diseased. Most authorities, however, agree in stating that the complaint in the mother must have dated from before conception, and that a syphilis contracted during pregnancy is not commonly transmitted to the offspring. Still we cannot feel sure in any individual case that the child will certainly escape. If both parents are diseased the infant is very unlikely to be spared, and is indeed, as a rule, infected more heavily than in cases where the complaint is inherited from one side only. Abortions are common, and in the children born alive a high death-rate is found. Kassowitz estimates this at 50 per cent. ; Coutts rates it more highly still. Statistics, however, on this subject are necessarily attended with some uncertainty, for disturbing influences, such as duration of disease and effects of treatment, have to be reckoned with ; but all observers agree that the TWINS UNEQUALLY AFFECTED 199 measure of infection is least wlien the father only is re- sponsible for the transmission, greater when the mother alone is infected, and most serious when both parents join hi conveying the taint. Still, as Dr. Coutts points out, the severity of infection is exercised more upon the foetus in utero than upon the infant after birth, and is not to be taken as an element in estimating the probable chances of recovery in a child who is brought for treat- ment at the usual age. In the case of twins born of parents the subject of this disease, the two children are not necessarily affected to an equal degree. Thus " Minnie H — , aged three months, very much emaciated, being, according to the mother's account, smaller than at birth. Snuffles, and has snuffled since she was born. Skin shrivelled and parchment-like, covered with pemphigus." Under treatment the spots disappeared, and the child at first seemed improving ; but she afterwards sank and died, having persistently wasted since birth. The second twin was seen on the day the first died. A very healthy-looking child, with good complexion, fat and vigorous. She has snuffled since birth, and on the buttocks are seen stains left by recent eruption. Was never thought sufficiently ill to require medical advice." These two cases of twins suffering from the same here- ditary disease are very interesting, as showing that the amount of disease inherited by the foetus in the womb is not determined solely by the amount of disease from which the parents may be suffering at the time. Some other causes must also operate. In the case of twins born of healthy parents we often find one to be more vigorous than the other, and it often happens that one will sink and die while the other remains strong and robust. So in the case of the inheritance of a constitutional disease, if the twins are, while in the womb, of unequal vigour, the one drawing to itself a greater proportion of nutritive material 200 INHERITED SYPHILIS than the other, the less vigorous foetus would no doubt have a less degree of resisting power, and would suffer to a greater extent than the other from the effects of a poison to which both are equally exposed. When the child is born perfectly healthy, he may still be infected after birth. He may contract the disease during lactation, the nipple of the mother or nurse having become the seat of a syphilitic sore from contact with the mouth of another child who is suffering from the disease. Whether the milk of a syphilitic woman is capable alone of communicating the disease to a healthy child is open to very considerable doubt. Again, accidental contact with purulent matter from a chancre, or with discharges from a secondary sore, may inoculate the child ; but whether the inoculating matter be primary or secondary, the sore thus produced in the child is always primary. With regard to the possibility of syphilitic inoculation by vaccination, which was long denied, there is no doubt, from authentic cases which have been published, that the virus has been transmitted by this means. Every case, however, in which the symptoms appear after vaccination must not be necessarily attributed to inoculation by tainted lymph. The first manifestation of the latent disease may be determined by anything which sets up a temporary febrile disturbance, and vaccination, therefore, may, like other things, be the stimulus exciting the outbreak of previously existing disease. Direct inoculation by a primary sore in the vagina during delivery, although possible, is not probable, and no well- authenticated instance of such inoculation having occurred has been recorded. Prognosis. — As a rule prognosis becomes more favourable with each succeeding pregnancy. This rule, however, is not absolute. Cases occasionally occur where the opposite conditions are found. Thus a man who has contracted the disease before marriage, and has undergone suitable PROGNOSIS 201 treatment, may at first beget a perfectly healthy child. Afterwards, however, although no fresh symptoms have appeared in the interval, he may beget other children who are syphilitic. There is no doubt that mercurial treat- ment has the power of rendering the poison of syphilis inactive for a time, and that in cases where the virus is still unexhausted it may lie dormant until time has lessened the influence of the remedy. Such cases are, however, ex- ceptional and rare. If we have noticed a gradual improve- ment in successive pregnancies, so that a woman who had borne children — at first prematurely, then stillborn at the full time, afterwards living but diseased — bears a child who has at first the appearance of health, we may reasonably infer that each succeeding infant has a better chance than its predecessor of outliving the disease. As a rule, the longer the time which elapses between the birth of a child and the appearance of the first symptoms the greater is the likelihood of his recovery. When the symptoms appear during the first two weeks of life the disease is almost always fatal. It is to the intensity of the general cachexia, and not to the severity of any particular symptom, that we must look in order to estimate the amount of danger in each case. The prognosis is serious in proportion to the degree to which nutrition is interfered with, and therefore anything which tends to increase this defect in nutrition tends greatly to increase the gravity of the case. Thus vomiting and diarrhcea add their own enfeebling effects to the general weakening influence of the original disease, and, where they occur, must be looked upon as very serious complications. There is, however, one special symptom which it is very important to take into consideration in forming a prog- nosis, as it may indirectly produce very serious results. This is the condition of the nasal passages. These pas- sages may become completely blocked up, jDartly by the 202 INHERITED SYPHILIS swelling of the Sclineiderian membrane, partly by the caking of the crusts formed by the dried discharge. Two dangers may arise from this source. As air can no longer pass through the nose, the mouth becomes the only channel by which air can be admitted into the lungs. It is therefore required for respiration, and cannot be spared for any other purpose. The child is consequently pre- vented almost entirely from taking nourishment, for while he sucks respiration has necessarily to be suspended. He can only take the breast by short snatches, and the amount of milk he receives is very inadequate to his wants. The danger of starvation is thus added to the other dangers of the case, and may exercise a very unfavourable influence upon the termination of the disease. A second danger re- sulting from the condition of the nose is that arising from absorption of the noxious gases produced by decomposition of the pent-up pus. Septicaemia may occur in this way. On the whole, we may conclude that if nutrition appears to be well performed, i. e. if the child continues plump, or does not sensibly emaciate, the prognosis is favourable. If he wastes, the prognosis is highly unfavourable. Prevention. — When a child is born suffering from syphilis, measures should always be adopted to prevent succeeding children from falling victims to the same disease. One or both parents should be subjected to suitable treatment, which should be continued sufficiently long to render it probable thai the next child will escape the effects of the virus. Even if a second pregnancy have already occurred before any treatment is adopted, we should still not despair, for cases are recorded which show that very favourable results may be obtained by this means. It is important, however, that the treatment be begun as early as possible, and be continued, if it can be borne, for three full months. Treatment. — In the treatment of syphilitic children we have two objects. We have to destroy the cachexia which TREATMENT 203 is weighing upon the child, and we have to sustain, and if possible to improve, the general nutrition of the body. The second of these objects is to some extent effected by the same means which accomplishes the first. As the intensity of the cachexia diminishes, nutrition usually improves in equal proportion ; and, therefore, in the milder cases a child is often found, as the symptoms disappear, to become strong and healthy under no other treatment than that required for attacking the trans- mitted taint. In the severer cases, however, nutrition is so lowered that after the cause of the malnutrition has been removed special means must be adopted to neutralise its effects. Treatment must be begun directly any symptoms appear to indicate the disease from which the infant is suffering. If the previous children have been syphilitic, a careful watch should be kept over the infant, and the first sign of the disease should be the signal for active interference. The treatment consists in giving a preparation of mercury either directly to the child himself or indirectly through the mother. In the latter case, as the remedy is conveyed by the breast-milk, the method can only be resorted to when the mother is nursing her baby, and has herself shown sym- ptoms of the complaint. But even when it can be employed this method of treatment is rarely satisfactory. In a diseased mother the supply of milk, as a rule, is scanty and poor, so that the drug reaches the infant in too minute quantity to be of much curative value. It follows, there- fore, that when, as often happens, the symptoms are severe, and we wish to bring the system as quickly as possible under the influence of the remedy, we have, in addition, to give mercury directly to the child. For this purpose the preparation which is most com- monly employed is the ordinary Hydrargyrum cum Cretri. Of this, one grain may be given at first every morning and evening. After the first week the dose should be gradually 204 INHERITED SYPHILIS increased every three days bj a quarter of a grain at a time, until two grains are taken twice a day. To prevent any irritating action on the alimentary canal, a grain of carbonate of potash, or a few grains of prepared chalk, may be added to each dose. If, in spite of this addition, any disturbance of the stomach or bowels be excited by the drug, the remedy should be omitted for a day or two until this derangement has subsided ; it must then be recommenced. Should the disturbance return, the grey powder must be changed for one of the other preparations of mercury. A solution of corrosive sublimate is a very convenient form in which to administer the remedy, and if given in moderate doses does not appear to exercise any specially irritating influence upon the gastric mucous membrane. Most infants will take twenty drops of the pharmacopoeia solution without inconvenience three times in the day. It may be sweetened with syrup. After the first week the quantity given should be gradually increased, if the medicine is well borne. Calomel in doses of from one twelfth to one sixth of a grain is sometimes employed, and where vomiting has been excited by the other prepara- tions, is occasionally effectual in calming the irritability of the stomach ; but it is itself liable to be attended with diarrhoea, and can seldom be continued long without this danger. Besides being given by the mouth, mercury may be also employed externally, so as to be absorbed by the skin, and this method forms a useful addition to the other modes of treatment. In cases where the internal use of mercury causes great disturbance, very valuable results are often obtained by this means, which allows of the treatment being continued while time is given for the irritation of the alimentary canal to subside. Still, mercurial frictions and baths do not always act as safeguards against gastro- intestinal derangements. The frictions are made with Unguentum Hydrargyri, half a drachm of which is rubbed TREATMENT 205 into the sides of the chest once a day ; or a flannel band smeared with the ointment may be applied ronnd the chest or belly. For the baths, corrosive sublimate is used, each bath containing half a drachm of the salt. This quantity may be gradually increased, by fifteen grains at a time, to a drachm, or a drachm and a half. The baths should be used every two, three, or four days, unless erythema be produced by their employment, when the quantity of the sublimate should be reduced, or the interval between suc- cessive baths should be increased. Besides the effect upon the system produced by the absorption of the mercurial salt, the baths are also beneficial by their local action upon the cutaneous lesions. Of the different ways of treating the disease thus de- scribed, we must employ one or another, or several together, according to the condition of the infant. The more intense the cachexia — i. e. the more complete the hindrance to nutrition — the more important does it become to bring the system as quickly as possible under the influence of the drug ; but, unfortunately, it is in these cases that the sus- ceptibility of the stomach and bowels to the irritating action of remedies reaches its height. Here, then, the ex- ternal plan of treatment becomes of extreme importance, and it must be aided by the cautious administration of mercury by the mouth, changing from one preparation to another as circumstances seem to require it. At the same time every effort must be made to improve general nutrition. The feeding of the infant is a point of extreme importance, and the quality of his food must be regulated with the utmost care. Weakened as he is by his constitutional complaint, the child's digestive power is small. If possible, therefore, he should be brought up at the breast ; but, unfortunately, the disease is one in which we are too often deprived of this resource, as the mother's milk is usually scanty or poor. Still, she should be urged to make every effort to nurse her infant, for in 206 INHERITED SYPHILIS his unhealthy state it is better that he be partially suckled than brought up entirely by hand. Whether or not he is to rely solely for his nourishment upon his mother's breast depends upon the satisfying qualities of her milk. The child must be carefully watched, and if he seem discon- tented after taking the breast, require to be nursed often, and show frequent signs of hunger, it will be necessary to make some addition to his food. The breast should be then limited to two meals a day, and in the interval the diet can be regulated in accordance with the rules laid down for such cases (see Chapter XI, Diet 3). When the breast- milk is thus supplemented by hand-feeding in a delicate child, we must remember that variety in the food is an aid to digestion which it would be unwise to disregard. Cod-liver oil is often of great service in these cases. Five or ten drops may be given two or three times a day, in a spoonful of the milk and barley-water, and, if this is well borne, the quantity may be gradually increased by a drop or two at a time. If, however, it causes sickness or uneasiness it must be stopped at once, to be returned to after a few days, and in smaller doses. If any of the oil appears unchanged in the stools the quantity must be re- duced. The child must be kept in an equable temperature of from 60° to 65*^ Fahr., partly in order to avoid the risk of cold, to which he is particularly susceptible while under the influence of mercury ; partly on account of the bene- ficial influence upon the disease of a moderately high temperature, for all writers upon this subject unite in re- commending warmth as an important aid to the other treatment. The utmost cleanliness must be observed. After taking food the mouth should be carefully washed out with a piece of linen rag dipped in warm water, to prevent any accumulation of milk round the gums and cheeks— a fruitful source of thrush. The napkins must be changed frequently, and the buttocks be carefully sponged and TREATMENT OF COMPLICATIONS 207 dried after each action of the bowels, for all unnecessary irritation of the skin must be avoided, and the continued contact of the urine and stools with the skin promotes the occurrence of the specific erythema. Besides, cleanli- ness is important in promoting the healing of mucous patches and other syphilitic sores about the anus. For the same reason the whole body should be bathed, at least once a day, with warm water, care being taken to dry the child thoroughly after each ablution. If vomiting occur, the internal use of mercury must be suspended; and should the gastric disturbance still continue, the child's nourishment must be limited to his mother's milk. If the vomiting does not subside by this means, all food must be forbidden, and the child be allowed nothing but cold barley-water, given at intervals with a teaspoon. These measures usually succeed in arresting the vomiting, and, in most cases, the mere sus- pension of the mercury is sufficient to produce this result. Should it, however, continue, a hot linseed-meal poultice containing a sixth part of mustard must be applied to the epigastrium, and. one sixth of a grain of calomel, with a few grains of powdered chalk, must be given every four hours ; or a mixture containing three grains of bicarbonate of soda to a teaspoonful of infusion of calumba may be ordered three times a day. When the vomiting is obsti- nate, the case becomes one of great danger. Diarrhoea is best treated by suspending the mercurial, and if this is not followed by stoppage of the disorder, a mixture of chalk and catechu, with aromatic confection, is usually sufficient to restore the bowels to their natural condition. Diarrhoea is seldom obstinate in this disease if the directions already given as to diet and avoidance of cold have been properly attended to. In cases where either of these symptoms has occurred great caution is necessary in returning to the specific treat- ment, giving the mercury in smaller doses, and assisting it 208 INHERITED SYPHILIS by the external application of that drug, either in the form of baths or ointment. Local applications are useful as aids to the specific treatment in furthering the disappearance of the local lesions. It is important to remove these local symptoms as quickly as may be, for although many of them do not sensibly affect the prognosis, yet others, as the condition of the nose, may exercise an unfavourable influence on the termination of the disease. Besides, so long as there are contagious sores upon the body of the child, his attendants may possibly become infected by direct con- tagion, and this danger should be removed as promptly as possible. In the third place, a healthy skin is indis- pensable to the successful employment of frictions, either with the mercurial ointment or with cod-liver oil. The baths of corrosive sublimate have, as has already been stated, a very favourable influence upon the cutaneous lesions, but there are other special applications which may be made use of in treating these affections. When the nostrils become blocked up by hard crusts, these latter should be gently removed, after being softened by warm water and cold cream. When the internal sur- face is thus laid bare, a little mercurial ointment may be gently applied to the mucous membrane lining the nostrils with a feather, or with a piece of linen rag rolled up into the form of a slender cylinder. A useful ointment for this purpose is composed of XJng. Hyd. Am. Chlor., Ung. Zinci, and Ung. Acidi Borici in equal proportions. Large crusts formed on the body should be removed by covering them with a thick layer of lard, and laying over this a hot bread-and-water poultice. This should be applied at night, and in the morning the softened scab can be easily detached, and the ulcer, when exposed, must be touched with the solid nitrate of silver. Mucous patches about the mouth or anus must be well touched with the same caustic. They must be kept very AFTER TREATMENT 209 clean as previously directed. Ricord orders the patches to be washed twice a day with a solution of chloride of soda, and after each washing a small quantity of calomel is to be applied with pressure. Mercurial treatment must not be continued too long, for the prolonged administration of this drug to young children produces a condition of intense anaemia which often persists long after the remedy has been abandoned. It is better not to continue specific treatment after the symptoms have disappeared. Afterwards it is advisable to give a tonic, as a mineral acid with bitter infusion, quinine, iron, cod-liver oil, &c. Iodide of iron is valuable in these cases, but it is best given, not in the form of the syrup, but by combining iodide of potassium with tartrate of iron in distilled water. This combination makes a perfectly clear solution, and is much preferred for children on account of the tendency of the pharmacopoeia syrup to set up fermentation and give rise to acidity. 14 CHAPTER VI MUCOUS DISEASE MUCOUS disease, a very frequent disorder amongst children, may be met with at any age, but is most common between three or four and ten or twelve years. The derangement consists in an increased secretion of mucus from the whole internal surface of the alimentary canal; it is a mucus flux which interferes mechanically with digestion and absorption of the food, and by its in- fluence in impeding general nutrition often excites sus- picions of the existence of tubercle. The symptoms vary in intensity according to the degree to which nutrition is interfered with. At first they are usually slight, but become more severe as the derangement becomes more marked. Thus the child gets languid and dull, he is disinclined to exertion, and complains of weariness and depression. He grows pale and loses flesh ; his spirits are low ; he ceases to take interest in his accustomed amusements, and sits listless and moody, sometimes crying without apparent cause. He is often drowsy in the day, but is restless at night, grinding his teeth ; and his sleep is often disturbed by frightful dreams, from which he wakes in great terror, crying and talking incoherently. The conduct of the child at night is often extremely perplexing to his relatives. Sometimes he will start from his sleep with a loud cry, and will remain for a considerable time under the influence of the most violent panic, uttering wild exclamations, and being apparently unable to recognise the familiar faces of those who are SYMPTOMS 211 endeavouring to soothe him. At other times he will rise from his bed still asleep, and will walk from room to room. In fact, most of the cases of somnambulism in children are due to this cause. IsTocturnal incontinence of urine is also not unfrequently complained of, and this, although in the beginning only occasional, may afterwards become habitual. Many other signs of nervous uneasiness may often be observed. As a rule, the child is excessively irritable and peevish. He is unreasonably exacting in the nursery, quarrels with his brothers and sisters, and may fall into violent fits of rage at the most trifling annoyance. His mother will say that he has become so naughty she cannot think what has come to the child." In the worst cases other nervous derangements may occur, such as squinting and stammering. The latter symptom is usually found to vary in degree according to the intensity of the general symptoms, and, unless it has persisted sufficiently long to lead to an acquired habit, usually passes off as the de- rangement subsides. The appetite, at first unusually keen, becomes gradually capricious, then fails almost entirely ; and each meal is followed after some little interval by flatulence and un- easiness. The appetite may, however, remain large, even after the emaciation has become extreme, and in some cases the hunger seems almost insatiable, the child very shortly after a full meal asking again for food. The tongue is generally flabby and indented at the edges by the teeth, but it has besides a peculiar appearance, which is very characteristic. This appearance is due to the mucus with which it is covered, for the glands of the mouth are as active in their secretion as those of the other parts of the alimentary canal. A glossy, slimy look is thus given to the organ, which is quite distinct from the moist appearance produced by saliva alone, and resembles more the aspect it would bear if brushed over with a solution of 212 MUCOUS DISEASE gum. This slimj look is not always general, but in sliglitly marked cases is limited to a spot in the centre of the dorsum, the rest of the surface and the sides having the ordinary aspect. The tongue is either perfectly clean, or is covered with a thin coating of grey fur. The fungi- form papillae at the sides of the dorsum are also unusually distinct. They are seen as large round or oval spots, seldom elevated, and varying in colour from pale red to deep crimson ; the depth of colour being in proportion to the degree of irritability of the digestive organs. If vomiting or diarrhoea supervene, their colour becomes bright red, and they then project slightly above the surface, peering through the thick coating of yellow fur with which the dorsum in such cases is usually covered. Sometimes a different appearance is presented, and the whole tongue is clean, with a glazed glossy look, as if entirely denuded of epithelium. The bowels may act regularly or be more or less costive. In the latter case there is some straining at stool, and light- coloured, pasty motions are evacuated, mixed, per- haps, with strings or lumps of free mucus. Even when the stools do not contain mucus habitually, it is common for large quantities of the secretion to be brought away by the action of a mild aperient. Sometimes we find consti- pation and diarrhoea to alternate with one another. Thus the bowels are obstinate for two or three days, or even for a whole week ; a violent fit of purging then sets in, with ten, twelve, or even more stools in the twenty -four hours ; after which, the accumulation having been discharged, the bowels become again confined. There is often an unpleasant smell from the mouth of the child, probably due to catarrh of the oral mucous membrane, and decomposition of the mucus and epithe- lium. In some cases, however, it is evidently dependent upon enlarged tonsils, which secrete a thick, bad- smelling semi-purulent matter. SYMPTOMS 213 The colour of the face undergoes rapid changes. There is usually some discoloration under the eyes, but a cha- racteristic symptom is sudden pallor, the child seeming as if about to faint. To use the nurse's expression, "he turns deadly white," and his ghastly apj^earance at this time often excites comment. Sometimes actual syncope occurs, for fainting fits are not an uncommon symptom of the derangement. The complexion is often remarkably sallow, having a half -jaundiced tint ; and this varies in degree from day to day, the colour being most dingy at the time when the nervous symptoms are most strongly marked. Thickness or muddiness of the complexion is often associated with acidity of urine and a free precipitation of urates. At these times, too, the child is apt to complain of headache, or of flatulent pains about the chest or belly. A stitch in the side is, indeed, a common source of annoyance. When asked to point out the seat of pain, the patient almost always places his hand over the left hypochon- drium. It will be remembered that the large bowel at this spot makes a very abrupt bend, and the angle thus formed is a common seat for the accumulation of flatus. Abdominal pains of a paroxysmal character are some- times met with. These are seated about the umbilicus. They are apt to come on in the early morning, before rising from bed, and are sometimes excited by taking food. They do not, as a rule, cause any feeling of nausea ; nor are they followed by looseness of the bowels ; nor is there any tendency, as in ordinary colic, to seek relief by bending the body. If the pains are very severe, the child may be noticed to turn white. In some children the skin ceases to act at a very early stage of the disease, and becomes rough and harsh, espe- cially about the chest, arms, and belly. In extreme cases the whole body may be covered with little scales of epi- thelium, which can be rubbed oH as fine dust. 214 MUCOUS DISEASE The lymphatic glands of the neck are liable to become enlarged on the slightest irritation. They do not, how- ever, necessarily suppurate or remain permanently swollen. The enlargement, after persisting for a variable time, may disappear completely. The temperature of the body is not raised. Often it is lowered, especially at the surface, and a prominent sym- ptom is the extreme coldness of the hands and feet. It is curious that the patient himself usually seems unconscious of this peculiarity, or indifferent to its discomfort, and will declare that his feet are warm when examination shows them to be quite the contrary. 'Not seldom from morning to night, and even after the child has been put to bed, his feet remain in the same cold, clammy state. The symptoms thus described do not proceed in any regular manner from bad to worse. It is usually found that the child is subject every few weeks to what are called " bilious attacks " — to violent attacks, that is, of vomiting and purging, lasting often for several days, during which large quantities of mucus are got rid of. The system being' thus relieved, the symptoms become for a time less severe ; the child sleeps better at night, and during the day is less languid, and more inclined to take exercise. The improvement is not, however, of long continuance ; for the symptoms returning, grow gradually worse until they culminate in another violent attack like the former. In this way the child may go on for months, gradually getting thinner and weaker, his condition ex- citing the gravest apprehensions amongst his relatives, especially as a short hacking cough is a not unfrequent symptom of this disorder, and increases their fears of the outset of consumption. Examination of the lungs, however, in an uncomplicated case of mucous disease will reveal no signs of pulmonary mischief. Worms, especially amongst the poorer classes, form a common complication of this derangement ; in which case EFFECT ON NUTRITION 215 the symptoms are all attributed to the presence of the entozoa. The creatures find in the alkaline mucus a congenial nidus ; but the disordered state of the mucous membrane is at least as important as are the parasites themselves ; and until the alimentary canal is restored to a more healthy condition, special anthelmintics frequently fail of success. The difficulty so often experienced in curing a child of worms is due to neglect of the measures necessary effectually to restrain this unnatural activity of the mucous glands. The subject of worms will, however, be more conveniently treated of in another chapter. It is easy to understand how nutrition must suffer in this disease. The mucus poured out into the stomach and bowels seems to act as a ferment, and to cause decom- position of the food with which it comes into contact. The products of fermentation are gas and acid. The gaseous accumulations excite the abdominal pains and side- stitch which are the source of so many complaints. The acid finding its way into the circulation is distributed through- out the body, and by keeping the tissues in a state of con- tinual irritation, is no doubt a cause of the unruliness of temper, the nocturnal excitability, and the excessive mus- cular restlessness which form such prominent features of the disorder. In the alimentary canal the excess of acid has a direct influence upon the digestion of food. It par- tially coagulates the mucus, so that the alimentary masses being coated more or less completely by thick slimy matter are not properly mixed up with the digestive fluids. A comparatively small part of the food which has been taken is therefore converted into a form in which it is capable of being absorbed ; and of that small part a still smaller is actually taken up by the absorbent vessels, on account of the thick layer of viscid mucus which lines the walls of the bowel, and prevents the veins and the lacteals from performing their functions. The large appetite so commonly found in these cases 216 MUCOUS DISEASE is, no doubt, in part, a manifestation of the want of nourishment felt throughout the system ; but it is pro- bably also, in part, a morbid craving excited by the stimu- lating action of the fermenting contents of the stomach and bowels. Causes. — In children there is naturally great activity of the mucous membrane lining the alimentary canal. As compared with the adult its secretion appears in them to be always in excess, and a very slight irritation is sufficient to increase it. The stools of young infants are in their natural state composed in great part of mucus, and any passing irritation, such as a meal of indigestible food, or a slight chill, causes at once a marked increase of the secretion ; the so-called slimy stools are then passed, con- sisting of thick viscid mucus, mixed up more or less intimately with the fsecal matter. In cases where the irritation is constantly renewed, as occurs in children who are habitually fed upon indigestible food, large quan- tities of mucus are passed, often coating the small faecal masses, or appearing separately as strings and jelly-like Lumps. Certain diseases are apt to leave behind them this condition of the bowels ; thus, measles and scarlatina may be sometimes followed by it. Whooping-cough is, how- ever, of all diseases the one to which this derangement can most commonly be traced, and there is a special reason why this should be so. In whooping-cough the bronchial mucous membrane secretes a tough stringy mucus in very large quantities, and there is at the same time a copious mucous flux from the stomach and bowels. The abundant thick mucus which is vomited at the termi- nation of the characteristic cough comes in great part from the stomach ; and the involuntary evacuations which are so frequently found to follow a paroxysm contain much of the same secretion. The tongue in all severe cases of whooping-cough will be found to correspond CAUSATION 217 exactly with the appearance of the organ described as characteristic of mucous disease ; in fact, an acute attack of this intestinal derangement is a constant accompani- ment of severe jDcrtussis. As the whooping-cough lessens in severity, the derangement of the alimentary canal frequently subsides ; but in many cases, especially if the child be weakly or be much reduced by the intensity or the long continuance of the disease, the flux from the bowels continues and becomes a chronic condition. It is for this reason that whooping-cough is so much to be dreaded in weakly children. The disease not only interferes with nutrition while actually in progress, but also leaves behind it a chronic derangement of the bowels which often pro- duces extreme emaciation, and may favour the occurrence of very serious complications. An explanation of the persistence of the digestive trouble is, I believe, to be found in the extreme susceptibility of the subjects of mucous disease to alternations of tempera- ture. With hands and feet habitually cold, a child can have little power of resisting the effects of chill; and, indeed, I have often noticed that any sudden change of weather, or the mere going out with cold feet into a raw air, has been followed by a return of the worst symptoms of the complaint. Owing to these slight but repeated chills, the stomach and bowels are kept in a state of con- tinual catarrh ; and the attacks of vomiting and purging may very possibly be nothing more than acute attacks of gastro-intestinal catarrh induced by some exceptional ex- posure to cold or damp. The commencement of the second dentition is a time at which this derangement is especially likely to be set up. Children are often found, as the early teeth begin to be displaced by the second crop, to grow pale, and thin, and languid ; indeed, so frequently is this found to occur, that the beginning of the second dentition is looked upon as one of the critical periods of early life. There is no doubt 218 MUCOUS DISEASE that, owing to the intimate sympathy existing between all parts of the alimentary canal, there is at the time of denti- tion a great tendency to an increased activity of secreting function and an increased susceptibility to disturbing influences. Diagnosis. — In a well-marked case the symptoms of this derangement present a remarkable resemblance to those of tuberculosis, with which it is so often confounded; the distinguishing points between the two diseases are there- fore of much importance. The most characteristic symptoms of mucous disease are the perceptible wasting ; the slimy appearance of the tongue ; the large quantities of free mucus in the stools ; the great want of regularity in the progression of the symptoms ; and the periodical occurrence of bilious attacks. If these conditions are observed to follow an attack of whooping-cough, or to occur at the time of the second dentition ; if they are accompanied by dry, rough skin and sallow complexion ; and if the temperature of the body is not raised above the natural level, we may conclude that the illness is due to the cause which has been described. With regard to the heat of the body, it must be remem- bered that a continued elevation of temperature is necessary to demonstrate the existence of tuberculosis. In mucous disease the temperature may be elevated temporarily by passing sources of irritation, and thus may be found to be high on two or three successive days. In these cases, therefore, some caution should be exercised in making a diagnosis, and further observations will be necessary before we can feel ourselves justified in giving a positive opinion upon the nature of the disease. Cases, however, of this derangement occur in which the temperature rises and remains elevated, perhaps perma- nently, although the symptoms in other respects correspond to those of mucous disease. Pneumonia is very apt to attack such patients, and it is not at all uncommon for TREATMENT 219 the deposit, remaining entirely or partially nnabsorbed, to undergo cheesy transformation and form the so-called pneumonic phthisis — one of the many varieties of pul- monary consumption. In such cases it is often a very nice point to decide upon the presence or absence of grey tubercle ; but by careful consideration of the history of the acute attack, and by minute observation of the seat and progress of the physical signs, a diagnosis can be generally arrived at (see diagnosis of pulmonary phthisis) . If the formation of grey tubercle occur at all in such cases, the coincidence must be looked upon as accidental, for mucous disease is quite distinct from the tuberculous diathesis, and independent of it. Treatment. — For the cure of this derangement the strictest attention to diet is indispensable. The morbid condition to be overcome is the excessive secretion of mucus from the whole lining of the alimentary canal ; and one of the most effectual measures for restraining this morbid glandular activity is the prohibition of all articles of diet capable of undergoing fermentation, and so of increasing the irritation of the mucous membrane. All farinaceous articles of diet, except bread, must be, there- fore, at once forbidden ; and even the bread should be con- siderably restricted in quantity, and should be eaten stale, or in the form of dry toast. Potatoes, peas, beans, turnips, carrots, parsnips, beetroot, fruit, cakes, and pastry must all be excluded from the diet, and the child should be nourished as nearly as possible upon meat, eggs, and milk. Too much food is not to be given at once, for all over- loading of the stomach is to be avoided. It is better to distribute the amount allowed over four meals rather than three, and these should be fixed at regular intervals through- out the day. A good scale of diet for a child over two years old is the following, given in four separate meals in the course of the day : 220 MUCOUS DISEASE First meal. — Fresh milk, diluted with a third part of lime-water, or alkalinised with from ten to twenty drops of the saccharated solution of lime. A small slice of dry toast or of dry stale bread with butter. Second meal. — A small mutton chop, or a slice of roast mutton or beef. Dry toast or stale bread. If the child be four or five years old he may take with this meal a little vegetable, as well-boiled cabbage, spinach, or broccoli. Third meal. — A cup of beef-tea or mutton-broth, free from grease ; or the yolk of a lightly-boiled egg ; dry toast. Fourth meal. — A cup of cocoa made with milk ; dry toast or stale bread with butter. It is not always easy to persuade children to submit readily to the deprivation of starchy food, for which, and especially for potatoes, there is often in these cases a great craving. So long, however, as the slimy appearance of the tongue, before described, continues to be observed, the above diet should if possible be adhered to. "When potatoes are once more allowed they must be well boiled, and should be afterwards carefully mashed with a spoon. Gravy may be poured over them before they are eaten. A good substitute for potatoes in these cases is the flower of cauliflower very well boiled. Other allowable vegetables are turnip-greens, asparagus, French beans, vegetable marrow, Spanish onions, lettuce and celery (stewed) . The diet may be varied by substituting for the mutton chop a little roast chicken or game. Well-boiled turbot, cod, sole, or mackerel may also be permitted.^ Alcohol may be given with advantage in many of these cases, and where the strength has been much reduced is of considerable service in improving the appetite and increasing the digestive power. Half a glass of dry sherry diluted with water may be taken at dinner, or double the quantity of light claret and water. * For tabulated diets, see Chapter XI, Diets 19, 20, 21. TREATMENT 221 When the derangement has existed for some time, and the general nutrition of the body is much lowered, the appetite may fail. In these cases it is often difficult to persuade the child to take nourishment, especially as his chief craving is for bread and butter, potatoes, and all the articles of diet which are particularly injurious. Meat is in these cases often extremely distasteful to him. A lark or a snipe will, however, by apj^ealing to his fancy, some- times overcome this dislike, and every means should be tried, by varying his diet within the prescribed limits, to induce him to take a sufficient quantity of food. At the same time every effort should be made to restore the proper action of the skin. At night the child must be bathed with hot water, and after being carefully dried must be anointed over the whole body with warm olive oil ; this process to be repeated regularly every evening at bedtime. In cases where the skin is especially dry and rough, it is well on the first evening to remove the hardened epithelium by a thorough washing with soap, using hot water softened by the addition of a handful of carbonate of soda. In the morning the child should have a warm sponge-bath. Under such treatment the skin will quickly recover its natural appearance, and become soft and supple. The child should be warmly clothed, and should take plenty of exercise in the open air ; if the weather be mild, almost the whole day should be passed out of doors. He should wear a shirt and drawers of flannel, or a pure wool combination " garment; and his belly should have the additional protection of a broad flannel binder. Moreover, very special care should be taken to keep the feet warm. The above measures — even if no medicines have been given at all — will after a very short time produce a marked improvement in the appearance of the child. The stoppage of starchy food, and especially of potatoes, will by itself remove a great many of the more distressing symptoms ; the restlessness at night, in particular, usually ceases at 222 MUCOUS DISEASE once. There are, however, certain medicines which should not be neglected ; but those most calculated to assist the object we have in view are not those which, under the name of tonics, are usually resorted to when from any cause healthy nutrition of the body appears to be in abey- ance. The best tonic is nourishing food. But that the food taken may be nourishing, it must first of all be digested ; and those medicines will be the real tonics which enable the alimentary canal properly to perform its functions. Our object, as has been before remarked, is to check as rapidly as possible the excessive secretion of mucus which prevents the food from being sufficiently mixed with the digestive fluids, and impedes the action of the absorbent vessels. Various medicines will accom- plish this result. Thus alkalies not only appear to have an influence in arresting the secretion of mucus, but also, by at once neutralising any acid formed by the fermen- tation of food, produce a raj^id change for the better in the general symptoms. The best form in which they can be given is the bicarbonate of soda with a bitter, as the infusion of calumba. To each dose may be added half a grain of iodide of potassium, to increase the salivary secretion, and twenty drops of the tincture of myrrh, which is found to have a powerful bracing effect upon the mucous membrane. The mineral acids — at any rate in severe cases of this derangement — often appear to be rather injurious than beneficial ; certainly the improve- ment under their use is not nearly so rapid as in cases where alkalies are used. The influence of the latter in improving the appetite, when that is failing, is most marked, especially if a drop or two of dilute hydrocyanic acid be added to each dose of the mixture, and will often succeed when dilute nitric acid has beeii given without any effect. Aloes is also a most valuable medicine. Under its use the amount of mucus appearing in the stools diminishes TREATMENT 223 rapidly ; the digestion improves ; and all the symptoms showing irritability of the nervous system — such as rest- lessness at night, bad dreams, startings, grinding of the teeth, moroseness, and ill temper — quickly subside. The effect upon the rest at night is usually most marked, the child beginning to sleep soundly after only a few doses of the drug. The most convenient form in which it can be given is the compound decoction, which, if well made, is seldom objected to by children ; the liquorice and the compound tincture of cardamoms it contains very effec- tually disguising the nauseous bitter of the aloes. It may be given in doses of one or two drachms twice or three times in the day. In such quantities, especially if taken between the meals, it does not act as a purgative, but merely produces a tonic effect upon the bowels, checking immoderate secretion. It must be stated, however, that the aloes appears to be more beneficial in winter than in summer. In warm weather it is apt to be too irritating, exciting looseness of the bowels. When such is the case the drug should be at once stopped, and a change be made to alkalies, or to some of the other preparations recommended. Decoction of oak bark in half- ounce doses is also often of service. In cases where the emaciation and debility are very decided, iron may be combined with the special treatment ; for although tonics, when given alone, are found to be of slight advantage so long as the functional derangement of the alimentary canal continues marked, yet, in combination with remedies directed especially to rectify that derange- ment, iron is often of much use. Thus the citrate of iron and ammonia may be given with sal volatile in the alkaline mixture, or a teaspoonful of iron wine may be added to each dose of the decoction of aloes, or the aloes may be combined with the tartrate of iron and potash, as in the following mixture : 224 MUCOUS DISEASE ]^ Ferri Tartarati, gr. v, Decocti Aloes co., Aq. ad §ss. M. Ft. haustus. To be taken three times a day one hour after food. During the course of the above treatment it will be necessary* to prevent the accumulation of mucus in the bowels by the occasional administration of an aperient. A tea spoonful of the compound liquorice powder may be given fasting, twice a week ; or forty to sixty drops of the liquid extract of Rhamnus frangula may be given in a wineglassful of water. If, as is so often the case, worms be present, special measures for their expulsion must be resorted to, as will be described in the following chapter. The following case well illustrates the rapid improve- ment which takes place when the above treatment is adopted. John R — , aged 11 years. Had an attack of scarlatina three years ago, and has since been persistently wasting. He was first seen on February 25th. " A very pale, thin boy, subject to occasional attacks of faintness, without, however, actually losing consciousness. Face has a care- worn look, and he is troubled with an occasional short hacking cough. Appetite very bad. Tongue thickly furred and slimy, with depressed large pink papillae covering its dorsum and sides. Bowels confined, acting about every other day ; stools hard and dark, the faecal matter often covered with mucus. Occasionally thread worms are seen in the motions. Sleeps very badly, and often seems to be * light-headed ' at night. Is not subject to attacks of purging. Never perspires ; the skin all over the body is exceedingly rough and harsh ; chest and belly covered with coarse, dry epithelium, which can be rubbed off as a ^ This drug", which is a variety of the buckthorn, but less drastic in operation tlian the ordinary Rhamnus cathartica, is a very safe and agreeable aperient for cbildren. ILLUSTRATIVE CASE 225 fine dust. Examination of the lungs and heart shows no sign of disease." The mother was directed to wash the boy at bedtime with soap and hot water containing soda, and afterwards to anoint his whole body well with warm olive oil. She was to repeat the oiling every night after bathing him with hot water. She was further ordered to give him a tepid sponge bath every morning. Diet to consist of meat, eggs, and milk, with a little dry stale bread. The following medicines were prescribed : — p, Pulv. Rhjei, Pulv. Jalapse, aa gr. vij, Pulv. Scammon., gr. x. Ft. pulv. iv. One powder to be taken every other morning. P> Deeocti Aloes co., Vini Ferri, aa 5ij. M. Ft. haustus. To be taken three times a day, directly after food. The improvement in this case was most rapid. In a week's time the skin had become naturally soft and supple, and the boy was beginning to gain flesh. His appetite improved, and he slept better at night. The increase in weight was very remarkable. He weighed on March 3rd, fifty-seven pounds ; on March 6th, fifty-eight pounds ; and on March 15th, sixty-two pounds. By this date (March 15th) the boy's appearance was quite changed; he had completely lost the care-worn look which had been so noticeable on his face at the first visit, and the cheeks were much fatter, although still pale. The body generally was much fatter, and presented a marked contrast to his former emaciation. The cough was gone; he slept soundly at night, perspiring a little, especially about the nose and mouth. The bowels remained costive, and the motions hard, but they contained very much less mucus, although there were still a few thread- worms in the stools after each powder, and occasional pains in the belly were 15 226 MUCOUS DISEASE still complained of. The tongue was much pinker, and had lost in a great measure its slimy appearance. We sometimes find that after the treatment has been continued for a certain time, the improvement becomes less rapid or even ceases. When this occurs it is advisable to change from alkaline to acid medicines. The necessity for the change seldom, however, occurs before the tongue has in a great measure lost its slimy appearance, and mucus has almost ceased to be seen in the stools. In such cases it is best to begin with a nitro-muriatic mixture with a bitter. Thus : — ^ Acidi Nitro-muriatici dil., miij, Tinct. Aurantii, inx, Aq. Chloroform i ad ^ss. M. Ft. haustus. To be taken before food, three times a day. Other acid preparations may also be used, as the Liquor Ferri Pernitratis in bitter infusion ; quinine with dilute nitric acid, &c. Cod-liver oil is of comparatively little value as long as the mucous flux persists. When, however, free secretion from the mucous membrane has been controlled, oil will aid in repairing the effects of malnutrition ; but it should be given only in moderate doses (20 to 30 drops). Change of air is of much service. Removal to a bracing seaside air, such as that of Brighton or Westgate, will often after a very short stay produce a very great im- provement in the symptoms and general appearance of the child. CHAPTER VII WORMS I^HE varieties of parasitic worms found in children are : — Nematodes — Oxyuris vermicularis, the small thread- worm. Ascaris lumhricoides, the long round- worm. Tricocephalus disjjar, the long thread-worm. Cestodes — Taenia solium, the common tape-worm. Taenia medio -canellata, the hooldess tape- worm. Bothriocephalus lahts, the broad tape- worm. Of these the two first- mentioned varieties are by far the most common species found in the child. The taenia is rare in children under the age of six years, and the both- riocephalus is seldom seen in England, although common enough in Switzerland and Russia. When found in this country, it is usually in persons who have resided abroad. Description.^ — The Oxyuris, or Ascaris vermicularis, belongs to the order Nematoda. The male measures one- sixth of an inch in length, and its caudal extremity is obtusely pointed. The female is from a third to half an inch in length, and has a long, gradually tapering capillary tail, which terminates in a three-pointed end. This has been supposed to act as a kind of holdfast. ^ The description of these worms is borrowed from Dr. Cobbold's work on Entozoa, London, 1864. 228 WORMS Both sexes have a more or less fusiform body, the anterior end being narrowed to form a somewhat abruptly truncated head. The mouth is tripapillated, leading into a triangular oesophagus. The integument is transversely striated, and is of a silvery white colour. The penis is single, simple, and very minute. The eggs are long, un- symmetrical, and measure about y 4V0 i^^- f I'om pole to pole, and -9^0 in. the greatest transverse diameter. The seat of the worms is the caecum, but they readily migrate thence into the sigmoid flexure and rectum. They are not found in infants at the breast, unless other food is being given at the same time with the breast-milk, but are exceedingly common in older children. The Ascaris lumhricoides, also a nematode, is much larger than the preceding. The male measures from four to six inches long, the female from ten to fourteen. The body, smooth, fusiform, and elastic, is marked by fine transverse rings, and tapers gradually towards either extremity. The mouth is tripapillated ; the tail is obtusely pointed. The male is distinguished from the female by a double penis, and by the arcuate form of its tail. The female is broader than the male, being about a quarter of an inch in diameter. These worms inhabit principally the small intestine, but often pass into the stomach and other parts of the ali- mentary canal. They are most common between the ages of three and ten years. Their number varies from two or three to twenty, thirty, or even more ; they are seldom solitary. The Tricocep/ialus dispar is not very common in England, but is sometimes found after convalescence from typhoid fever. The male measures an inch and a half in length, the female two inches. This worm is specially character- ised by an extremely long filiform neck, which occupies about two-thirds of the length of the body. The surface of the skin is smooth to the naked eye, but when magni- TAENIA SOLIUM 229 fied is found to have on one side a longitudinal band of minute wart- like papillae, at the borders of which the ordinary circular striae of the integument terminate. The tail of the male worm is curved, and has at the ex- tremity a short tubular penis -sheath armed with minute retroverted spines. The tail of the female is straight and blunt-pointed. The worm inhabits chiefly the caecum and the colon. The Tdenia solium belongs to the order Gestoda. Its length is very great, often ten, twenty, thirty feet, or even more. In breadth it is about a third of an inch at its widest part. The head, globular and about the size of the head of a small pin, is produced in front so as to form a short cylindrical proboscis, which is armed with a double crown of hooks numbering from twenty-two to twenty-eight in each circular row. The head is also furnished with four sucking discs, situated at the four angles. The neck is very narrow, and is about half an inch in length ; it is continued into the anterior part of the body, which is sexually immature, and presents only traces of segmentation in the form of fine transverse lines. These lines become gradually more and more widely separated, having short interspaces ; and eventually the imperfect segments become more distinctly marked, and true joints are seen. The earliest formed immature joints are very narrow ; and it is not until about the four hundred and fiftieth segment from the head that they become sexually mature. The mature segment is called pro- glottis." The total number of joints, in a worm ten feet long, is about eight hundred. A mature pro- glottis is about twice as long as it is broad. It is com- paratively thin and transparent, and is furnished with a branched uterus, which consists of a central, longitudinal stem, giving off from seven to ten branches on either side. Each joint has a common reproductive papilla placed at the border on one side below the middle line, but not 230 WORMS nniformly to the right or left in series. The male orifice is above the vaginal outlet. The penis is sickle- shaped. The Taenia solium is usually solitary. It is seldom seen in children under three years old. Its seat is the small intestine. The Tdenia medio -canellata resembles the preceding in every respect except in the head; the cylindrical pro- boscis and the double crown of hooks being absent. The Botliriocejphalus latus is the largest of the Xiestode worms which infest the human body. In length, it is often five- and- twenty feet, and it is about an inch in breadth. The head measures one-twenty-fifth of an inch in breadth, is blunt at the top, elongated, and slightly flat- tened from behind forwards. It is furnished with two laterally disposed slit-like grooves, but is destitute of hooks. The anterior segments, which are sexually imma- ture, are extremely narrow, and enlarge very gradually from above downwards. After reaching their greatest width in the centre of the body, they begin gradually to decrease in width, but increase in depth ; so that while in the central segments the width is much greater than the depth, being as one inch to one-eighth of an inch, in the joints near the caudal extremity the breadth and the depth are about equal, being frequently a quarter of an inch in either measurement. The body is flattened, but not so uniformly as is found in the Taenia solium, as it is rather thicker in the centre than at the sides. The total number of joints has been estimated at about four thousand, the first sexually mature one being the six- hundredth from the head. The reproductive orifices are in the middle line towards the upper part of the segment on the ventral aspect. The vaginal aperture is immediately below the male outlet, and both openings are surrounded by papilliform eminences. The uterus consists of a single tube, often MODE OF ADMISSION 231 folded regularly upon itself so as to form an opaque centrally- disposed rosette-like mass. The embryo is ciliated, and moves freely about in water. All these varieties of worm obtain admission into the human body by the mouth. The ova of the thread-worm are introduced adhering to fruit, cresses, and other articles of food. Sometimes, also, they are conveyed to the mouth directly by the child. The ova of the oxyuris are very numerous, and when exposed to the action of the gastric juice, the tadpole- shaped embryos escape from the eggs into the stomach. The creatures develop rapidly as they pass down the alimentary canal, and have reached maturity by the time the caecum is arrived at. The eggs deposited at this part of the digestive tract are not hatched, but escape in large numbers by the bowels. Dr. Cobbold states that children often carry the ova in large numbers under their nails ; for the excessive itching of the fundament, to which the presence of the parasites gives rise, necessitates much rubbing and scratching for its relief. By this means a continual supply of ova can be introduced into the mouth. From observations made by G-rassi, it seems probable that the common house fly may sometimes serve as the medium by which the eggs of parasitic worms are con- veyed to the human subject. This observer has shown by direct experiment that the insects are able to take in the ova of certain worms by the mouth and void them unchanged in the faeces. In this way eggs may be depo- sited directly upon the food shortly before the child swallows it. In the case of the Ascaris lumbricoides, the drinking of impure, unfiltered water is the ordinary method of admission. M. Davaine^ doubted whether the embryos ^ C. Davaine, "Recherches sur le Developpement et la Propagation 232 WORMS could become developed in the liuman intestine; but Heller states that the eggs may be hatched, and the embryos escape, and develop into the mature worm, while still in the alimentary canal of the person infested with them. Out of the body the embryos develop very slowly, for Davaine kept some alive for a period of five years without the embryos making any attempt to escape from their shells. The creatures have, however, a singular tenacity of life, for they cannot be destroyed by frost, and even, it is said, survive complete desiccation. In the case of the Taenia, each pro-glottis, or mature segment, is complete in itself, being furnished with male and female reproductive organs. When this has become impregnated, by contact with another pro-glottis, eggs are formed in it. In each egg is developed an embryo which remains unhatched as long as the ovum continues in the body of the parent. The segment, after its expul- sion from the bowel, moves about for a time until it bursts from the growth of the embryos in its interior, and the ova escape. Each embryo is provided with a boring apparatus, having three pairs of hooks at its anterior end. Unlike the other worms which have been described, the embryo of the tape- worm cannot pass through all the stages of its development in the body of the same individual. The creature does not develop directly into the perfect taenia, but passes through a stage of transition. This stage requires to be completed in the body of an intermediary. Thus, when eaten by some animal, such as a pig or a rabbit, the embryo breaks its shell, and, boring through the intestinal wall of the animal, lodges itself in the fatty parts of the flesh. It then drops its hooks and becomes the well-known Cysti- cercus cellulosse. When the flesh of an animal containing the Cysticercus is eaten, the parasite attaches itself to the du Tricocephale de rHoinme et de TAscaride Lombricoide," ' Comptes rcndus a I'Academie dcs Sciences/ t. xlvi, 21 Juiii, 1858. SYMPTOMS 233 wall of the bowel, and growing from its lower or caudal extremity, develops into the community of individually distinct creatures which is known as the perfect tape- worm. It appears, therefore, that flesh infested with the cysti- cercus is the ordinary source from which the taeniae are derived. Pigs are very liable to be so infested, and in rabbits it is exceedingly common, very few being found altogether free from tape-worm ; in these animals it is the Taenia solium. Oxen are sometimes infested with the embryo of the Taenia medio -canellata ; and in children treated for chronic diarrhoea upon the raw meat plan, and who become in consequence affected with tape- worm, as is said sometimes to happen, it is to this worm that their symptoms are due. Indeed, it may be said that in the human subject, of all the varieties of tape- worm, the Taenia medio -canellata is the one most frequently met with. The transitional stage of the Bothriocephalus latus, according to Dr. Braun of Dorpat, is completed in the body of the pike. Symptoms. — The presence of worms in children is usually accompanied by an unhealthy condition of the alimentary canal, which precedes their appearance, and continues after the worms have been expelled. Perhaps few of the symptoms — and they are very numerous — which are found while the worms exist in the body, can be directly attributed to the presence of these parasites, as they may all of them, or nearly all, be found also in cases where repeated purgatives have convinced us that worms are absent. They are, therefore, probably due in great part to the abdominal derangement which favours the develop- ment of the entozoa. This derangement has been already described in the pre- vious chapter. As a result of it, nutrition becomes impaired, and the 234 WORMS child wastes. The face becomes pn% and pale ; the lower eyelids dark, and sometimes leaden-coloured ; the pupils often dilated. There is itching of the nose and anus ; epistaxis may occur ; and the sense of smell is occasionally depraved or lost. The upper lip often swells ; the breath is foetid, especially in the mornings ; and salivation is sometimes noticed, the saliva running from the mouth on to the pillow during sleep. At night the child is very restless ; during sleep he starts, twitches, and grinds his teeth ; and he often wakes in great panic, crying and talking wildly. There is often a frequent dry troublesome cough, a symptom considered by Stoll very characteristic of the presence of worms ; and sighing, sobbing, and hiccough are not uncommon. The belly is swollen and hard. Pain in the abdomen is often complained of, the pain being usually confined to one or two points, especially about the umbilicus. In character it is tearing or cutting, although sometimes it is merely an uneasy creeping sensation, or a feeling of cold in the bowels. The pain is sometimes felt in the chest. The appetite is capricious. At one time there is con- stant craving, the hunger seeming to be almost insatiable ; at others the child refuses all food, and great anxiety is excited by the difficulty found in persuading him to take nourishment. Sudden attacks of nausea may come on with sour- smelling eructations, and vomiting may occur with expulsion of worms from the mouth. Lumbrici are not unfrequently ejected in this way. The bowels are much confined ; the constipation yielding readily to pur- gatives, but returning when the action of the medicine has subsided. Sometimes there is tenesmus, with con- stant ineffectual desire to go to stool ; and attacks of diarrhoea are very liable to come on, with very great straining, the motions passed being black, slimy, and extremely offensive. Micturition is often painful and SYMPTOMS 285 difficult, and the urine whitish or milky. Discharges of mucus may take place from the rectum, and in female children often from the vagina. The pulse is often small, quick or slow, and irregular. The temper is irritable, or the child is sullen and morose. Attacks of syncope are sometimes seen, and there may be passing delirium, or even profound stupor. Other dis- ordered conditions are enumerated as resulting from the presence of worms, as sudden blindness, loss of voice, squinting, or fixed state of the eyes, vertigo, general con- vulsions. According to Dr. Underwood, an attack of convulsions, accompanied by small pulse and hiccough, is an almost certain sign of worms. As the majority of these symptoms are due, not to the worms, but to the condition of the alimentary canal usually accompanying the parasites, the symptoms are severe in proportion to the abundance of the mucous flux. If this be copious, digestion is very greatly interfered with, nutrition is seriously impaired, and all the sym- ptoms arising from indigestion and irritability of the nervous system are strongly marked. Worms may, how- ever, be found in children in whom the alimentary canal is almost healthy. The general symptoms are in such cases exceeding trifling, and the appearance of the tongue differs widely from that described in mucous disease. It is then neither flabby nor slimy ; but is small and pointed, reddish at the tip, and is covered on the dorsum with a thin curdy fur. The papillae are still large, but are less conspicuous, and their outline, instead of being evenly and clearly marked, is very irregular. Certain special symptoms are associated with different varieties of worm. The Oxyuris vermicularis occasions violent itching at the anus. This is most marked towards the evening ; and the irritation not only prevents the child from going * See page 211. 236 WOE-MS to sleep, but may be so intense as to produce extreme distress. The irritation, propagated to neighbouring parts, may excite a mucous discharge from the vagina, and is sometimes a cause of masturbation. A common symptom where these small thread-worms are present is tenesmus, the desire to go to stool being frequent but ineffectual ; and the straining may cause prolapsus ani, which often continues after the worms have been expelled. Besides, the irritation propagated over the whole intestinal tract is apt to give rise to diarrhoea. Migration of the Oxyuris occasionally takes place, and cases are on record in which these worms were found in the vagina, uterus, urethra, oesophagus, and stomach. When the presence of the Oxyures is suspected, they will be often found on examination moving about in the radiating folds around the anus. The Ascaris lumhricoides gives rise to pain more or less severe, situated at one or two points of the belly in the neighbourhood of the umbilicus. Sudden nausea is apt to occur from the passage of the worm into the stomach, and it is sometimes expelled by the mouth. The lumbri- cus is more apt than the preceding variety to give rise to nervous symptoms ; and vertigo, convulsions, chorea, &c., sometimes seem to result from its presence. These sym- ptoms are usually ascribed to reflex irritation, but recent observations suggest that they are, sometimes at any rate, toxic in character from a poisonous substance contained in the parasites or secreted by them. The irritation of the lumbrici may give rise to a chronic diarrhoea, lasting often for months. The motions are scanty, offensive, of the colour and consistence of thin mud, and are evacuated with much straining and some- times prolapsus ani. They are more frequent in the night than during the day. A child of three years old lately came under the writer's notice, who had suffered for nearly eight months from persistent looseness of the SYMPTOMS OF LONG ROUND-WORM 237 bowels. The diarrhoea ceased after the expulsion of twelve lumbrici. The luinbricus is very migratory in its habits. The wanderings of these worms usually occur at night. At this time they become very active, and may pass out of the alimentary canal into passages communicating with it, or even into adjacent organs which have no direct communication with the digestive tube. Thus, they have been noticed in the common bile-duct, and in the gall- bladder, in two cases recorded by M. Gruersant, where the children died suddenly in violent convulsions. They have also been seen in the nasal passages, the larynx, trachea, the larger bronchi, in the vagina, and even in the urethra and bladder. Again, the worms may be found in abscesses communicating with the intestine, having escaped from the bowel by entering a pre-existing fistulous opening. The abscesses are generally in some part of the abdominal wall, usually the umbilical or inguinal regions, or in the substance of the liver. The passage of a lumbricus into the windpipe is a rare but very dangerous accident. This mishap has occurred more frequently than might be anticipated, for nine cases have been collected by Dr. Fiirst, of Vienna, and no less than sixteen have been recorded by Davaine. If the worm remain in the glottis, its presence gives rise to the most intense dyspnoea and complete loss of voice ; and the patient very shortly dies asphyxiated. If the parasite pass into the trachea or bronchus, there is dyspnoea occurring in violent paroxysms, and pain re- ferred to the front of the chest. Aphonia may persist or the voice may partially return. The irritation induced by the presence of the worm soon sets up bronchitis, and the child, if not carried off early by suffocation, usually succumbs more or less quickly to this complication. In such cases as these it is by no means easy to discover the cause of the sudden interference with respiration ; for the 238 WORMS only clue to the presence of a lumbricas would be the knowledge that the patient had previously suffered from these worms. If the access take place first at night-time, the symptoms would be probably referred to an attack of stridulons laryngitis. If in the day, the fact of the patient's freedom from catarrh, or any tendency to hoarse- ness, would perhaps suggest the presence of a foreign body in the windpipe, but the nature of the intruding substance could hardly be divined in the absence of special information. The Tdenidd produce sensations of weight, and sometimes of gnawing in the belly, rising occasionally to severe attacks of colic, accompanied by considerable swelling of the abdomen, especially about the umbilicus. The appe- tite is usually large, and there is progressive emaciation, which is more marked than in the other varieties. Vomit- ing and diarrhoea are rare. Cephalalgia is not common, but when it occurs it is often remarkably persistent. There is usually great lassitude, with sometimes cramps in the extremities. Fragments of the worm are passed in the stools. With the presence of the Tricoceplialus dispar no special symptoms have been associated. Diagnosis. — The only satisfactory proof of worms is their presence in the stools ; any symptom or any combi- nation of symptoms may be produced by other diseases, so that a purgative becomes the crucial test. It must be remembered, however, that although worms may be pre- sent, it does not necessarily follow that they have been the cause of the symptoms for which advice is required. Tuberculosis, rickets, or other constitutional diseases may exist at the same time, the presence of the entozoa being an accidental and often a trifling complication. In such cases the symptoms will continue after the worms have been expelled. The fact appears to be that the large majority of the DIAGNOSIS 239 symptoms are due to the derangement of the stomach and bowels which is almost always associated with the para- sites, and of which they appear to be rather a result than a cause, although no doubt the irritation they excite tends to encourage the derangement. When the mucous mem- brane of the alimentary canal is in a healthy state there is no nidus for worms, and it appears probable that a favour- able medium is essential to their development in any quantity. The required nidus is found in the alkaline mucus which is so abundantly secreted ; and in this they develop very rapidly. It is more important to detect the presence of some worms than of others. The taeniae pro- duce very great emaciation ; and the lumbrici, if present in large numbers, may cause serious interference with nutri- tion ; but the oxyures are of comparatively little moment, and unless the irritation be so great as to prevent sleep, are seldom attended with any great inconvenience. The symptoms attending the presence of worms may be so severe as to give rise to suspicion of the formation of tubercle. Thus, if a child has irregular attacks of fever ; begins to lose flesh ; sleeps badly, grinding his teeth at night ; becomes pale and heavy-eyed ; loses his cheerful- ness, and gets languid and dull ; has a capricious appetite, being sometimes ravenous, and at other times showing a disgust for food, with bowels alternately relaxed and con- stipated — in such a case the existence of tuberculosis may be suspected. If, however, the symptoms are due to worms, an active purgative will give evidence of their presence, and by clearing away a quantity of the tenacious mucus will cause an immediate improvement in the symp- toms ; afterwards suitable remedies and careful diet will restore the alimentary canal to a healthy condition (see Diagnosis of Mucous Disease, p. 218). In other cases, where the nervous symptoms are well marked, and are accompanied by a dilatation of the pupils, vomiting of watery fluid, constipation, and a slow, irregular 240 WORMS pulse, tubercular meningitis may be suspected. Here, however, the fact that signs of digestive derangement have preceded the nervous symptoms, the absence of headache and of fever, the readiness with which the constipation yields to a mild purgative, and the relief to the symptoms which follows the action of the aperient, will clear up the diagnosis. Besides, in these cases a history can often be obtained of the previous occurrence of similar attacks. In cases where abdominal pains are complained of by children a careful examination of the chest should always be made, as in them the pain of pleurisy is very commonly referred to the belly, and not to the thorax. Treatment.^ — In the treatment of worms, it is not suffi- cient to expel the parasites from the body, for so long as the unhealthy condition of the alimentary canal continues to provide a nidus for the entozoa, they may be reproduced again and again as often as they are driven out. There are, therefore, two indications to fulfil in the treatment o£ this complaint, viz. : — To expel the worms. To destroy the nidus by restoring the alimentary canal to a healthy condition. To expel the worms different measures must be employed, according to the variety of worm to be attacked. The oxyureSy which inhabit the caecum and lower bowel, are within the reach of injections, and are best treated by this means. Various enemata may be used ; thus, four or five ounces of strong infusion of quassia, to which twenty drops of Tinct. Ferri Perchloridi have been added ; the same quantity of lime-water ; or a solution of one drachm of common salt, dissolved in five ounces of distilled water, may be administered. Whatever form of enema be used, it should be given at bedtime, should be used tepid, and should be preceded by a large injection (30 oz.) of warm ^ All the prescriptions given in this chapter are adapted to a child of four years old. \ TREATMENT 241 soap and water, so as to empty the colon as thoroughly as possible. If these measures do not prove successful in removing the parasites, santonine may be given in conjunction with naphthalin and an aperient on several successive evenings, as in the following powder : — ]^ Santonini, gr. j, Naphthalin, gr. ij, Jalapin, gr. ij. M. Ft. pulv. Sig. To be taken at bedtime. The diarrhoea, which is so common when the oxyures are present, is readily arrested by a purgative, as castor oil, or the following powder : — p, Pulv. Rhjei, gr. viij, Pulv. Cretse Aromat., gr. ij, Hyd. cum Creta, gr. ij. Ft. pulv. Primo mane sumendus. This powder should be given every second or third morning, and every evening the injection should be re- peated, until no trace of the worms is found in the stools or in the returning enema. G-reat irritation of the rectum may be allayed by the injection of an ounce of thin warm starch, containing, if necessary, a few drops of laudanum, before the child is put to bed; or a towel wetted with cold water may be applied to the fundament while in bed. For the lumhriciis and the Tricocephalns disjpar the best remedy is santonine, which may be given either alone or combined with purgatives. A good combination is the following : — Santonini, gr. viij, Pulv. Zingib., gr. x, Pulv. Jalapse, 5ss, Sulphuris Loti, 5iss, Couf. Seunse, ^j. M. Ft. confectio. 16 242 WORMS Of this confection a teaspoonful should be given every morning. Or santonine may be usefully combined with calomel, as in the following powder : — Suntoniui, gr. j, Hydrargyri Subchlorid., gr. j. Ft. pulv. Mitte iij. Sig. One powder to be given every night. To be followed each morning by half an ounce of castor oil. When given alone, santonine is conveniently administered sprinkled on a slice of bread and honey, in doses of one or two grains, twice or thrice in the day. In such cases an occasional aperient will be required to carry off the dead worms. Santonine usually increases the flow of urine, and may give a reddish tint to that secretion. Another effect sometimes found to be produced by the drug is a peculiar perversion of the sight, in which all objects are seen of a green colour. This symptom is of no importance, and readily passes away when the drug is omitted, but it is well to warn parents of its liability to occur. It is, how- ever, necessary to know that some children are unusually susceptible to the action of santonine. A dose as small as four grains has been known, in a child of four years old, to i^roduce profound coma a,nd stertorous breathing, with depression which has lasted more or less for twenty- four hours. The drug is not very rapidly taken up by the absorbent vessels. Therefore in all cases where poisonous symptoms are noted a stiff aperient should be administered without delay to remove any unabsorbed portion of the drug from the bowels. At the same time the child should be plied with diuretics to hasten the elimination by the kidneys of the poison already absorbed into the circulation. Many other drugs have been recommended for the ex- pulsion of these worms ; thus mercury, antimony, granu- lated tin, nitrate of silver, and arsenic; kamala, kousso, assafoetida, tannin, valerian, and Corsican moss ; all these TREATMENT 243 drugs alone, or variously combined, have been used and found successful in these cases. Cov^hage (the hairs of the Mucuna jpruriens), in doses of thirty to sixty grains given twice a day in syrup or treacle, is a favourite remedy with some. The sulphites, especially the bisulphite of soda (ten grains three times a day with Tinct. Aiirantii), are stated by Dr. W. E»oe to have a powerful anthelmintic action, possibly, as he suggests, from the sulphurous acid set free by contact with acid secretions. The medicine has no cathartic action, and therefore an aperient is required in most cases to remove the worms killed by the remedy. In all cases, if the drug employed be not in itself purga- tive, it is well to combine it with some aperient, or at any rate to act gently upon the bowels, from time to time, so long as the remedy is in use. Violent purgatives are not needed, the repeated action of mild aperients being equally efficient in causing expulsion of the worms, without ex- citing so much irritation of the digestive canal. In cases where a sudden attack of dyspnoea with aphonia occurs in a child known to be suffering from a lumbricus, the absence of symptoms pointing to another cause for the patient's distress might lead us to suspect the intru- sion of a worm into the windpipe. If we feel satisfied as to the correctness of the diagnosis, tracheotomy should be performed without delay. The worm can then be extracted with the forceps. So long as we have to deal with worms such as the preceding, expulsion is easily effected, but a case of taiiiia presents more difficulty. Tapeworms are often exceed- ingly tenacious in their hold. This is especially the case with children, whose softer mucous membrane probably adapts itself more readily to the action of the suckers. Consequently, although yards of segments may be re- moved by means of an ordinary aperient, the small head almost invariably remains behind, and can only be dis- lodged by the use of special precautions. 244 WORMS In all cases of tape- worm, the alimentary canal contains a great excess of mucus, which protects the head of the worm from the action of the anthelmintic as this passes clown the bowel. For some time, therefore, before special treatment is had recourse to, the child should be put upon a non-farinaceous diet, as recommended in the pre- vious chapter, so as to diminish the amount of mucus, and as far as possible correct this derangement of the boAvels. For the week immediately preceding the administration of the vermifuge, the child should be forbidden even bread, and should take as a substitute Dr. Camplin's bran biscuits or the more palatable French gluten bread. It is well also, as Dr. Leslie Ogilvie has advised, to administer a dose of aperient salts on several successive mornings before the treatment is begun. After this preparation, the anthelmintic may be given with some prospect of success. The favourite drug for this purpose, and pro- bably the most effectual one for ordinary cases, is the liquid extract of male fern. The quantity required is con- siderable, but as its action is solely upon the worm, a large dose may be given to young subjects without hesita- tion, or any aj^prehension of doing injury to the child. The remedy is best administered pure, floating upon peppermint or other aromatic water. The mode of proceeding is as follows, and if the child be strong enough to bear the necessary fasting, this method seldom fails : — In the evening a dose of castor oil is given. On the following morning, if the bowels have not been relieved, a saline aperient is to be administered. After the action of the medicine the patient is ready for the special treatment. A drachm and a half of the oil of male fern is divided into two doses, of which one is to be taken at once and the remainder after one hour's interval. Then, after waiting another three hours, a second dose of castor oil is to be given. During the above treatment a rigid abstinence from all food is essential to success, and there- EXPULSION OF TAPE-WORM 245 fore, from before the first dose of the oil until after the worm has been expelled, somewhere about the middle of the following day, no food or drink can be allowed, except occasional sips of water if the patient is thirsty. It is doubtful whether the worm be killed or merely stupefied by the action of the remedy, and therefore it is well not ^ to delay too long the administration of the second dose of castor oil. This should be given not later than three hours after the fern extract. Sometimes the nauseous taste of the medicine causes vomiting. In such cases it is well to quiet the stomach beforehand by a small dose of laudanum or morphia, given half an hour before the administration of the anthelmintic. The morphia acts merely as a seda- tive, without interfering in any way with the special action of the medicine. Another successful vermifuge is kamala, which may be given either alone, in treacle, or made up into a draught in combination with the fern extract. Thus, mix up a drachm of powdered kamala with mucilage until an emul- sion is formed : then add a drachm and a half of fern extract and triturate in a mortar, gradually adding water to make a three-ounce mixture. Dr. Brunton recommends this to be given after a fast of twenty-four hours in the case of an adult. I have used this method in children of seven or eight years old, beginning the fast after a mid- day dinner, and giving the draught the following morning divided into two doses taken at an interval of three hours ; and have found the treatment well borne. Kamala is itself aperient, and this method does not usually require any additional dose to effect the expulsion of the dead worm. If, however, the creature do not appear within four hours of taking the second half of the mixture, a tablespoonful of castor oil may be given. A favourite remedy on the Continent is a decoction of the fresh bark of pomegranate root. The objections to its use in the case of children are the large quantity of 246 WORMS fluid which it is necessary the child should swallow, and the griping pains in the belly which are apt to follow the administration of the drug. M. Collin, who has given pomegranate bark largely, states, that in all cases where the medicine is used, the dose should not be preceded by a purgative, so that the segments may not be separated from the head of the worm. To prepare the decoction : — One pint of water is added to an ounce of the fresh bark, and after standing for twenty-four hours, this quantity is boiled down to one-half. The decoction is then divided into three parts, which are all to be taken in the morning fasting, with an interval of half an hour between each dose. If the worm does not come away in three hours, some castor oil should be given to aid its expulsion. The writer's own experience of pomegranate bark has not been encouraging, but M. Collins speaks in the highest terms of this method of treatment. Sometimes in children great difficulty is found in re- lieving the patient of this distressing parasite, and dose after dose of fern extract or other special medicine may be given without dislodging the head from its hold of the mucous membrane. In all such cases it is well to try the effect of the now neglected, but not the less valuable, vermifuge— oil of turpentine. This may be given either in one large dose, or in frequent smaller quantities. For a large dose, three to four drachms is given in the morning after the usual fast, and is followed in three hours by a spoonful of castor oil if no aperient effect has been already produced . The plan of administering the remedy in repeated small doses has been strongly advocated by Dr. Davies. For children of eight years of age and upwards he recom- mends half a drachm of oil of turpentine, with an equal quantity of honey, to be administered in a little mucilage and water every six hours. At the same time a powder of calomel, with compound scammony powder, is to be TREATMENT 247 taken every second morning. Dr. Davies states that he has never known taeniae in children to resist this treatment. A drop of oil of peppermint makes the turpentine mix- ture more palatable. As the segments grow from the head, we cannot be certain that the entire worm has been ex- pelled unless the head is found. This, therefore, should always be carefully searched for in the excretions. To fulfil the second indication of destroying the nidus, recourse must be had to the measures recommended in the preceding chapter (see Mucous Disease). The diet must be first carefully arranged, so as to cut off all articles of food which by their fermentation would give rise to acid, and so favour the abnormal secretion of mucus in the bowels. Alkalies, aloes, &c., should then be prescribed, as has already been directed. The treatment, however, must be varied according to the condition of the stomach and bowels, and need not be pursued in all its details in every case of worms. If there be little derangement of the alimentary canal, purgatives or injections to remove the worms, followed by a tonic, will be all that is required. It is only in cases where the secretion of mucus is in great excess, and the interference with digestion and assimilation of food is carried to a high degree, that all the measures given above are re- quired. The prolapsus ani, brought about by the great straining excited by the presence of worms, usually disappears when the worms have been expelled. Sometimes, however, it continues for weeks as a consequence of irritation at the lower part of the rectum. If this be so, the prolapsed bowel, after each action, should be first sponged with warm water, then painted over with a 10 per cent, solution of cocain, and be returned by pressure with the thumbs covered with a soft warm napkin. Prolapse may often be prevented by placing the child during defsecation in such a manner that his feet do not 248 WORMS touch the ground, and, at the same time, the edge of the anus can be supported by two fingers. The bowels must be carefully regulated so as to prevent constipation and consequent straining. The child should be warmly clothed, with a flannel bandage round the belly, and should take frequent exercise in the open air. CHAPTER VIII TUBERCULOSIS CHILDREN are very subject to tubercular disease, both ill its local and general forms. In them the tubercu- lar infection is more apt to pervade the system generally than it is in the adult ; and subacute generalised tubercu- losis is a frequent cause of death. The discovery by Koch of the tubercle bacillus has so transformed the pathology of tuberculosis that the views formerly held as to the incidence of the disease, and in particular as to the influence of heredity, have undergone considerable modification. In one sense, indeed, the dis- ease cannot be called an hereditary one, for however sus- ceptible the child may be to the bacillary invasion, and however fatal the disease may have proved to his kindred, without the entrance of the special microbe into his body he cannot become tubercular. On the other hand, there can be little doubt that the tissues of a child born into a consumptive family have but feeble resisting power against the inroads of the infecting agent, so that he falls an easy victim to its attacks. In this sense the child may be said to have an hereditary proneness to the disease. Again, as Cohnheim suggested, an infant may be born already infected with the bacillus, which remains dormant for months or years until roused into activity by insanitary conditions or other agencies adverse to health. This theory may explain cases of foetal tuberculosis, or of the complaint affecting new-born infants ; but such a source for the disease is admittedly an exceptional one. 250 TUBERCULOSIS The microbe may enter the body at any point, but in ordinary cases infection takes place either by the air- passages or by the alimentary canal. If by the air- passages the bacillus must be drawn in with the air ; but all observers agree that contamination of the air by exhala- tions from the lungs of phthisical patients is so feeble as to be practically of no account. All experiments tend to show that the bacillus is derived from dried sputum, which, becoming pulverised, is diffused through the dust of a room, and, as dust, is drawn with the air into the lungs. Some children, no doubt, become infected in this way, but in the large majority of cases it is by the alimen- tary canal that the microbe obtains admittance in early life. Milk forms a large part of a child's diet, and milk drawn from a tuberculous udder has been shown to be ex- ceptionally virulent. This, probably, is the commonest source of infection. Again, young children, as Dr. Dawson Williams reminds us, are in the habit of putting into their mouths any object they may pick up from the floor, and by this practice, no doubt, increase their chances of tuber- cular infection. But before entering the air-passages proper or the ali- mentary canal the bacillus may be intercepted earlier in its course while still in the pharynx. Dr. Woodhead, in 1894, expressed the opinion that the organisms maybe taken up by the lymphoid tissue of the tonsils and pharynx and carried to the cervical lymphatic glands without there being present any lesion of mucous membrane. In the following year M. Dieulafoy conducted some inoculation experiments which tended to confirm this opinion. Kecently Dr. Hugh Walsham has published a series of interesting observations which show that without symptoms pointing to the tonsils these organs may, and if the lungs are affected probably do, contain miliary and caseous nodules scattered through their substance. But whether they enter by the tonsil or the alimentary MODE OF INFECTION 251 tract the bacilli are taken up by wandering lymphoid corpuscles and the struggle begins. In a sturdy child the leucocytes can probably deal satisfactorily with a moderate invasion of the microbes, and the latter are destroyed. But in a child with low resisting power, or in a healthy one if the microbes are very numerous, the intruding organisms may gain the victory and be carried unharmed by the cells to the nearest chain of lymphatic glands. By this means the lymphatic glands in the neck and the mesenteric glands in the belly may become the seat of tuberculous en- largement. But it is not always the first set of glands which become affected. In the neck the microbes may pass the cervical glands and settle in those of the anterior mediastinum, leading, perhaps, to secondary disease of the lungs. In the abdomen Dr. Woodhead has been able to trace the course of the organism through the glands of the mesentery to those behind the peritoneum, and thence through the diaphragm to the posterior mediastinal and bronchial glands, and -eventually to the lung. In the case of the respiratory passages, when intro- duced by the air, the microbes become arrested in the alveoli or terminal bronchioles. Here they determine a cell growth which pervades the peri-bronchial tissue, and sets up a little patch of peri-bronchitis or broncho-pneumonia. When the microbe has obtained admittance into the body, the degree and form of disease that follows is very variable. The virulence of the organism, the intensity of the dose, the susceptibility of the child, and the healthy or other conditions in which he is being reared, all have their influence in determining the issue. The degree of disease set up is no doubt largely a question of dose, but the more susceptible the child the smaller will be the dose required to produce a corresponding effect. In former days much was said and written of the tuberculous diathesis," a special type of constitution which was held to be a family inheritance, and tended to favour, if it did not actually in- 252 TUBERCULOSIS duce, the formation of tubercle. The presence of this diathesis was indicated by certain pecuHarities of face and figure. Although in these days less is said than formerly on this subject, yet to deny that children of this type have a lessened power of resisting the invasion of the microbe is surely to reject the teaching of all clinical experience. Such children are tall for their age and slightly made ; the skin is delicate and transparent looking, allowing the superficial veins to be distinctly seen ; the face is oval and the features generally are regular. These children are often remarkably good-looking, with large, bright, intelligent eyes, long eyelashes, and soft silken hair. The limbs are straight, the wrists and ankles small ; the nervous system is highly developed and the general organisation delicate. The teeth are cut betimes ; they walk and talk early ; and the f ontanelle often closes before the end of the second year. There is another variety of physical conformation which used to be held to constitute the scrofulous type. It is, however, as subject as the preceding to tuberculous mani- festations, but these tend rather to assume the form of disease of the bones and joints, lesions which used to be called strumous," but are now known to be tubercular. They may lead, indeed, to every variety of tubercular infec- tion. In this type, the face is more rounded than oval ; the complexion is dull and pasty-looking, the skin thick and opaque. The face is not so comely as in the last type, although it is by no means necessarily ill-favoured. The features are large, the lips full, the alse of the nose thick, the nostrils expanded so that the nose looks broad. The tongue is often large. The ends of the long bones are full and their shafts thick. The fingers may be clubbed. The belly is large and prominent. In these children there is great activity of all the epithelial structures. The hair and nails grow rapidly ; the skin generally is rough and scaly ; and there is often a remarkable development of hair which is seen as a thick down on the forehead, cheeks, ears, METHOD OF EXTENSION 253 shoulders and down the spine. There is over- secretion from the nose ; the skin about the lips is subject to crack and become sore ; the eyes often look weak even when not in- flamed ; and there is a great tendency to ophthalmia, in- flammation of tarsi, catarrhs, certain skin diseases, to caries of bone, and to a low form of pneumonia. Although these several types present certain contrasted features, each must be regarded as disposing to tubercular infection, for although in the latter the disease tends, perhaps, to run a more chronic course, the children of either type, when attacked, may exhibit any of or all the consequences due to the entrance of the tubercle bacillus into the body. But in addition to this constitutional vulnerability of organs, the child's resisting power may be lowered by all the various causes which are able to impair the general health. Thus, previous disease, especially the infectious fevers ; insanitary surroundings, such as dirt and faulty ventilation ; privation generally ; mental suffer- ing and distress ; all these tend materially to weaken the defensive power of the system. But although deficient resisting power may increase a child's chances of infection, normal energy in defence may not protect him if the dose be adequate. This extension to other organs may occur by actual contact, as when the lung takes on the disease from a lymphatic gland which touches its surface. The gland softens and ulcerates through the wall of a small bronchus or little blood- vessel. In the first case it infects the lung only ; in the second its bacilli are distributed by the current of blood to all parts of the body. It is more common, however, for the organisms to spread from a more distant focus, whence they are conveyed to other parts by the lymphatics and blood-vessels. In infants, in whom a generalised acute or subacute tuberculosis is a common cause of death, the microbes are, no doubt, dispersed over the body by this means. 254 TUBERCULOSIS The varieties of tuberculosis which will be considered are : — Greneral subacute tuberculosis of infants. Chronic pulmonary tuberculosis. Tuberculosis of glands. General Subacute Tuherculosis of Infants. This variety of the disease may be met with at any period of infancy, but for the first few months after birth is com- paratively rare. It gets more and more common, however, as time goes on, and after the age of six months is a fre- quent cause of wasting and death. In the majority of cases the bacilli are conveyed by tuberculous milk, and reach the system through the medium of the . alimentary canal. Pathology. — In a generalised tuberculosis the granula- tions are widely scattered, and may be found after death in most of the organs of the body. As a rule, the lungs, liver, spleen, lymphatic glands, and pia mater suffer most commonly and severely ; but no part of the body can be said to be exempt, although some organs are attacked so seldom that tuberculosis in them is regarded as a patho- logical curiosity. Thus, in the gullet, the stomach, and duodenum the disease is rare ; but the rest of the alimen- tary canal is a common seat for the granulations, especially the neighbourhood of Peyer's patches. The focus or point from which the infection proceeds may often be noticed as a minute ulcer on the mucous membrane of the bowel, or a caseous nodule in a Peyer's patch, or a cheesy lymphatic gland. Sometimes, however, no such lesion can be dis- covered, for, as in the case of the tonsil, the microbes may make their way through the mucous membrane and lymphatic glands in connection with it, and leave no trace behind. From this point of entrance they may pass at once into the circulation, by way, perliajDS, of the lacteal^ SYMPTOMS 255 duct, and be swept off to distant parts of the body. Whether the disease set up is to be general or merely local i^robablj depends upon the size of the dose. If the microbes are numerous they may affect many organs ; if few, the lesions they bring about are more limited, so that the first sign of disease may arise from a single joint, a bone, or the membranes of the brain. Symptoms. — Infants who suffer from this form of tuber- culosis often present features which even at this early age can be recognised as characteristic. They are slim in build and small boned ; their teeth are cut early, the first incisor often coming through in the course of the fifth or sixth month ; the fontanelle is moderately open ; the eye- brows and eyelashes are well developed, and on their shoulders and S23ines we often see a thick, fine down. The disease begins, as a rule, very gradually. The child takes his food eagerly, but is noticed to get gradually thinner, although his appetite is good and his stools are in every way normal. His food, they say, does him no good. As a rule he is not peevish or fretful, for he is not in pain. There is no sign of flatulence or abdominal discomfort, but the fat gradually disap^Dcars from his body, his muscles waste, his face gets pinched and old-looking, or is anxious as if he were loaded with care. A characteristic sign is a slight pitting over the shin bones combined with an altered state of the skin, which will be noticed to be dry, dingy-looking, and absolutely inelastic. This inelasticity of skin is a not uncommon symptom in wasting babies, and is rarely absent in infants who suffer from severe purging ; but when combined with slight j)itting over the tibiae and a complete want of symptoms pointing to any fault in the digestive processes it ought to give rise to reflection. The urine in these cases has been said to be albuminous. It is difiicult to collect the urine in young infants, but in cases of the kind where I have succeeded in doing so I have not found albumen. I think, too, it is exceptional to note any 256 TUBERCULOSIS marked enlargement of the liver or spleen : indeed, until we approach the end of the period of infancy it is uncom- mon to find signs of tubercular mischief connected with any particular organ. It is rare for the lungs to show evidence of consolidation or for the abdomen to swell from tubercular inflammation of the peritoneum. Later, how- ever, especially towards the end of the second year, distinct implication of organs becomes more common, and, as in older children who suffer from tuberculosis, we may find a hard, swollen spleen, or spots of consolidation at the apices or elsewhere in the lungs, or signs of tubercular peri- tonitis. The temperature may be normal for days together, and if occasionally elevated is only moderately so, seldom rising higher (in the rectum) than 100' 5°. But in simple wasting the bodily heat, as a rule, is sub-normal, so that a rectal temperature of 99° to 100° in an infant whose lowered state of nutrition cannot be explained by any local derangement is a symptom of no little importance. It must be remembered that a moderate elevation of tempera- ture is much more characteristic of tuberculosis than high fever. A marked rise in the thermometer usually points to the presence of a catarrhal complication. It suggests, too, a thorough examination of the ears with a speculum and reflected light. Many of these infants suffer from otitis, either latent or accompanied by otorrhoea. In such cases the otitis is possibly tiiberculous, and may have been the immediate cause of the general outbreak. Until the disease is advanced there is rarely any sign of local derangement ; or if any such disturbance occur it yields readily to treatment. Thus, the baby, if bathed carelessly or exposed in any other way to chill, may catch cold like any other infant so treated. He may cough, with signs of pulmonary catarrh, or be troubled with vomiting or purging. But, as a rule, these catarrhal derangements are as amenable to simple remedies as if the infant were DIAGNOSIS 257 not the subject of serious disease. Often the tuberculous complaint runs its course without the occurrence of any such complication. The child continues to dwindle. His eyes get more hollow ; his face more pinched ; his expres- sion more pitiful; and his wrinkled forehead and the deep furrows round his mouth give him the look of a little old man. At last the emaciation becomes extreme, and the child dies more or less suddenly from pure weakness, with- out any complication having arisen. In other cases death may be preceded by the later symptoms of tubercular meningitis or by a lung complication such as broncho- pneumonia. In infancy tubercular meningitis is always a secondary complaint occurring at the close of a general tuberculosis. Under the age of two years it is most rare to meet with it in the primary form such as is common in older children. The same may be said of tubercular peri- tonitis, which at this early age is seldom met with apart from a general explosion of tubercle over the body. Diagnosis. — In this variety of tuberculosis the diagnosis lies rather in the absence of the symptoms which attend an ordinary case of marasmus than in the presence of any definite signs of disease. The child has a good appetite and takes his food well, but continues to waste persistently although his tongue is clean, his motions are normal in frequency and appearance, and his digestion seemingly in good order. In a case of infantile atrophy from functional disorder, the child vomits or suffers from diarrhoea, or his bowels, if not actually relaxed, are evidently disturbed. The motions are copious, often offensive, and are composed mainly of undigested food. In cases such as these there is evidently sufficient interference with digestion to account for the failure in nutrition ; and we are not forced to go beyond what we see and search for a deeper cause. But the tuberculous infant wastes although no sign of local disease can be detected or any failure in the digestive pro- cesses. We have, therefore, to fall back for an explanation 17 258 TUBERCULOSIS upon some underlying condition; and if we find a dry, inelastic skin, and slight pitting of the legs, we are justified in taking a very gloomy view of the child's chances of recovery. The diagnosis becomes more difficult in cases where temporary attacks occur of digestive derangement, for these may be held to account sufficiently for the failure in health. But here the results of treatment aiford a very important means of estimating the nature of the illness. Thus, if the diet be reconsidered and the nursery arrange- ments altered, and the child begins at once to improve, the absence of tubercle becomes exceedingly probable. The greatest difficulty occurs in cases where we find the child suffering from some temporary disturbance which raises the temperature of the body. In an uncomplicated case the temperature, as has been said, is normal or only very moderately elevated ; but still we cannot venture at once to exclude tuberculosis because the rectal temperature is high. We have to search for the cause of the fever and consider whether this in itself is sufficient to account for the infant's state. Our first care, of course, should be to examine the mouth for signs of teething ; but after the mouth all parts of the body, not forgetting the ears, must be subjected to careful scrutiny. As long as there is an adequate cause to account for the illness, we are not jus- tified in making a diagnosis of tuberculosis, although a history of prolonged wasting in a child whose family ten- dencies are not free from suspicion, should make us cautious in expressing an opinion. Progressive emaciation in an infant whose appetite is good, and digestion not obviously at fault, is a highly suspicious symptom ; and teething, or a complication such as otitis, which does not, as a rule, give rise to serious interference with nutrition, cannot be held to explain sufficiently the child's serious state : indeed, if accompanied by persistent wasting, otitis is an argument rather in favour of tuberculosis than against it. DIAGNOSIS 259 There is one other general disease which may be possibly confounded with tuberculosis. This is inherited syphilis. In certain cases of that transmitted disease (see p. 185), general wasting occurs without any sign of local mischief, or any symptoms characteristic of the complaint. But in a syphilitic baby the failure of nutrition is less extreme ; the skin is excessively pallid or has the peculiar cafe-au-lait tint ; the eyebrows and eyelashes are scanty or absent in- stead of luxuriant ; the fontanelle is large instead of small; the occipital glands can usually be felt, and we can often detect craniotabes. Moreover, a syphilitic child is generally restless and uneasy, especially at night, while a tuberculous baby, if he is only fed wisely and with regu- larity, will often lie for hours without making any com- plaint. Lastly, an enquiry of the mother as to miscar- riages and as to the health of her previous children will help us greatly in reaching a conclusion. As long as our doubts continue as to the nature of the illness we should make repeated examination of the various organs, especially of the lungs, to detect the earliest signs of local mischief ; for spots of consolidation forming at the apices or elsewhere about the chest would point very decidedly to tuberculosis. Still, when all is said, the diagnosis of subacute general- ised tuberculosis in infants must often be a very difficult matter. In many cases there is so much room for doubt that it is wise to be cautious in expressing a positive opinion. Amongst well-to-do children where the family tendencies can be ascertained, and we can be sure that the infant has been fed with judgment and tended with care, there is less liability to error. In a family of known consumptive proclivities a baby wastes in spite of treat- ment ; the stools are healthy looking and his food is appar- ently well digested. Here, if we can exclude syphilis, the probabilities in favour of tuberculosis are strong. If, in addition, we find slight pitting of the legs on pressure. 260 TTTBERCULOSIS we are justified in entertaining the most serious apprehen- sions. On the other hand, when the conditions of life are uncertain, and in poor families where the infant has been half starved and exposed to all kinds of privation, a consti- tutionally healthy child may be reduced by simple mal- nutrition to a state of extreme weakness and emaciation. In such a case we may well hesitate ; but the presence of large quantities of undigested curd in the motions would account in a measure for the child's loss of flesh, and the absence of pitting of the legs on pressure would give us further encouragement. Still, the likeness to tuberculosis is exceedingly close, and it is prudent to reserve an opinion until we have had an opportunity of seeing the effect of treatment. Many an infant who has been condemned as tubercular has shown a surprising improvement and quickly recovered under the influence of warmth and rest and a well-chosen dietary. Prognosis. — When a subacute general tuberculosis is esta- blished in the infant no treatment can be expected to suc- ceed. We may put a stop to intercurrent derangements, such as attacks of vomiting or looseness of the bowels, and in that way postpone the end ; but in the present state of our knowledge there is no known remedy which will arrest or delay the natural course of the complaint. Much, then, must depend upon the opinion we have formed as to the nature of the illness. As long as we are in doubt we may continue to hope for improvement ; but when we have satisfied ourselves as to the tuberculous nature of the disease we can only anticipate one result. CHAPTER IX TUBELIOULOSIS OP THK LUNGS young children pulmonary tuberculosis presents very special characters. The chronic form, with which alone we have here to deal, is rarely seen in infancy. It becomes more common as life advances, but it is not until the later period of childhood is reached that the complaint often shows itself in the form which is so familiar to us in the case of the adult. In the young child, although we may find the granulations collected at the apices as is the rule in older persons, they are often scattered irregularly over the lungs, so that the apices may be free while the lower lobes are more or less widely solidified. In many of these cases, no doubt, the disease is derived directly from a caseous bronchial gland in actual contact with the pul- monary tissue, and therefore starts from the root of the lung; but another explanation of the peculiarity lies in the fact that in early life pulmonary phthisis often succeeds to an attack of bronchitis or broncho-pneumonia. In cases where the disease follows measles this is almost invariably the course of events. The attack of measles is complicated with broncho-pneumonia, and the patient is left with a consolidation at the base of the lung which although at first simple may afterwards become tuber- cular through infection with the special bacillus. Pathology. — The microbes may enter the lung directly or indirectly. They may be drawn in with the air or may 262 TUBERCULOSIS OF THE LUNGS be carried to the chest from a distant part of the body. The point of entrance or focus from which infection proceeds may be a tubercular gland in the neck or else- where, a circumscribed patch of disease in bone or joint, or a minute ulcer of mucous membrane. When thus derived from a point of infection in the patient's own body the germs may spread thence to the lung by actual contact, or reach it through the medium of the lymphatics or blood-vessels. When the neighbourhood of the root is the first part of the lung to be attacked the disease is probably derived from a tuberculous bronchial gland which is surrounded more or less completely by pulmonary tissue. The gland undergoes caseation and softening and poisons the lung tissue in contact with it, so that the wall of a small air-tube or the coats of a little blood-vessel take on the same process and become infected with the bacillus. By this means the microbes pass into the air-passage or blood-current and are scattered through the lung. So, also, when the focus is seated at a point more distant from the chest it is through the medium of the blood-vessels in most cases, and by similar means, that infection is con- veyed. The extent of injury to the lung is no doubt fixed by the size of the dose. A large number of germs will be dispersed widely producing scattered lesions; a small number will give rise merely to a circumscribed nodule. In either case the microbes become arrested in the minute vessels ramifying on the vesicles and induce a cell pro- liferation, at first in the wall of the capillaries and after- wards in the cavity of the cell. When the microbes are drawn into the lung with the dust in the inspired air a little patch of peri- bronchitis or broncho-pneumonia is set up by the arrest of the germs in the alveoli or terminal bronchioles. In this way one lobule or many may be involved ; and if the dose of the infecting agent be large, extensive consolidations may be induced. Thus, we may find a whole lobe or even the complete lung SYMPTOMS 263" to be converted into a solid mass by closely packed tuber- culous nodules. When once set up the tubercular process tends to spread at its circumference so as to involve more and more of the organ. The changes it passes through are the same in the child as in tbe adult. The diseased tissue may undergo caseation and softening, or may be converted into a fibrous mass. These processes are common to all ages and need not be discussed here in detail. The distinctive features of phthisis as it affects the lungs of a child do not lie in any special peculiarity of pathological change, but are to be found in the un- familiar distribution of the lesions and the frequency with which the bases of the lungs are affected and the apices are free. Symptoms. — Although the discovery of the tubercle bacillus has established the unity of phthisical changes in the lungs, yet clinically pulmonary phthisis may be seen to fall into several well-defined types according to the manner in which it begins. There is the primary tuber- cular type, in which mischief is discovered at the apices of the lungs and granulations are scattered more or less thickly over the substance of the organs. There is the secondary type, in which the disease spreads by contact from a softening bronchial gland or is grafted upon a broncho-pneumonia. Lastly, there is the fibroid form, in which a lung becomes converted wholly or partially into a mass of fibroid tissue. In the child the latter variety is rarely a consequence of grit inhalation in the course of industrial labour, as it is in the adult, for young persons under the age of twelve years are not exposed to this source of illness. In early life fibroid induration of the lung is usually the sequel to an attack of broncho- pneumonia or (more rarely) to pleuritic inflammation. It is often present in conjunction with tubercular disease and may arise from it, but it may also have an in- dependent existence. 264 TUBERCULOSIS OF THE LUNGS Pulmonary phthisis is often seen in connection with a flattened, contracted, or otherwise mis- shaped chest ; and in families which have a marked tendency to tubercle the thorax often, perhaps usually, shows some deviation from the strictly normal type. From the time of Gralen a small chest has been recognised as constituting a special pul- monary weakness, for a small chest implies small lungs. The lungs being small the thorax is obliged to adapt itself to the size of its contents. The ribs become unusually oblique, the chest is lengthened, the shoulders fall, and, as a consequence, the scapulae project backwards at their lower angles like wings. The latter deformity has given the name of alar or pterygoid to this variety of chest. A thorax so elongated does not necessarily deviate in any other particular from a healthy type. The antero- posterior and lateral diameters, although lessened abso- lutely — for the chest, as has been said, is small — may yet retain their normal relative proportions. In many cases, however, the costal cartilages do not remain firm ; they consequently yield under the pressure of the air and become straight, and the antero -posterior diameter of the thorax is diminished. Aflat chest is thus produced which may or may not be combined with the alar deformity of the shoulder-blades. These two varieties of shape of the thorax may be considered to indicate a pulmonary weakness, an abnormal sensitiveness to unhealthy impressions which goes far to encourage the development of the phthisical disorders. In children born of consumptive parents the chest is very often misshaped in the manner described. There is a third variety which is a form of the pigeon- breasted thorax. It may be found in a healthy child born of a family without consumptive history, and is not distinctive of a phthisical tendency although it usually shows a special sensitiveness to changes of temperature. This variety is the result of adenoid growths in the naso- SYMPTOMS 265 pharynx. The ensiform cartilage is depressed so as in marked cases to form a deep pit in the epigastrium. At the same time the ribs in the infra-mammary region on each side are retracted, so that the breast-bone at its lower end is forced forwards and forms a distinct prominence. In childhood symmetrical retraction of the infra-mammary regions and depression of the ensiform cartilage are due almost invariably to naso-x)haryngeal obstruction. This variety of pigeon-breasted thorax is distinguished from the pigeon-breast we so often see in rickets by the difference in shape of the upper part of the chest in the two diseases. In rickets, where all the ribs are soft, the whole sternum projects, and the chest is furrowed laterally as high as the second rib. In the case we are considering the protrusion is confined to the lower end of the breast-bone and the retraction of the ribs to the infra-mammary region, while at the upper part the chest is flattened from before back- wards. Although it is common to find the chest in consumptive subjects more or less altered in shape, as above described, it does not necessarily exhibit any such peculiarity. Phthisis, unfortunately, is not confined to children who inherit a pulmonary weakness. In early youth, as in after life, a serious amount of disease may be found in a chest which to the eye presents every appearance of health. There are certain general symptoms which are common to all forms of pulmonary phthisis. In all of them nutrition is found to suffer. The child looks pale, loses his spirits, and becomes listless and languid. His appe- tite is capricious, and digestion is difficult and slow. He wastes with more or less rapidity ; is feverish in the night and often in the daytime, and is troubled with frequent cough. But while these symptoms are met with in all forms of consumption of the lungs, in different varieties of the disease they are found to vary greatly in intensity, and in particular cases single symptoms may 266 TUBERCULOSIS OF THE LUNGS be absent for weeks or montbs together. Thus, nutrition is interfered with much more strikingly in some cases than in others. In the primary tubercular form wasting takes place early, and the loss of flesh is rapid and extreme ; while in fibroid induration of the lung, unless the disease be far advanced, or be complicated by an inter- current inflammatory attack, nutrition may go on fairly well, and the weight of the body be but little reduced. Pyrexia, again, a constant symptom when the disease is primary, often subsides for a time when the tubercular mischief is grafted into a pneumonic consolidation, and in cases of uncomplicated fibroid induration may be absent altogether. Cough is usually one of the first signs to indicate any affection of the lungs : but in pulmonary phthisis it may be comparatively rare, and excite little notice until the disease has become considerably advanced. In the begin- ning slight, dry, and short, it becomes after a time moister and more prolonged ; but however loose the cough may be, it is seldom in children under seven or eight years old accompanied by expectoration, unless vomiting occur, as such children almost invariably swallow the sputum as it reaches the mouth. If, however, the cough produces vomiting, large quantities of purulent mucus, more or less thick and viscid, may be expelled. In cases of fibroid induration of the lung, with much dilatation of the bronchi, the cough may assume a convulsive character, like the cough of pertussis, but without the whoop. The paroxysms occur at long intervals, and end in violent retching efforts, during which large quantities of muco- purulent sputa are ejected. Such sputa are often very viscid and stringy, and have a very offensive smell, owing to long retention in the dilated air- tubes. Haemoptysis is a rare symptom, as the blood, like the phlegm, is almost always swallowed. Sometimes, however, severe hsemorrhage may occur at a late stage of the disease, SYMPTOMS 267 causing death. This is seldom seen except in cases com- plicated with great enlargement of the bronchial glands. In infants a discharge of blood from the lungs is hardly ever seen. In children of seven years of age and upwards, the sputa may be streaked with blood ; but haemoptysis, in the ordinary sense of the word, is uncommon, and, when it occurs, is seldom considerable. The respirations are usually increased in rapidity, rising often to thirty, forty, or even more in the minute. This acceleration is not necessarily accompanied by any feeling of dyspnoea, and unless the structural alterations occupy the greater part of both lungs, is seldom the cause of any discomfort to the patient. The rate of breathing is always quickened by the presence of pulmonary catarrh, and is largely influenced by the temperature of the body. An increase of heat necessarily hastens the rapidity of breath- ing, for more carbonic acid is formed, and more oxygen is required. Rapid breathing may also be an early sign of tubercle in cases where the physical signs are as yet unaffected. If unaccompanied by percussion-dulness or bronchial breathing, it is said, by Niemeyer, to be one of the first and most important symptoms of tubercular phthisis. Also, if in an advanced case of phthisis the breathing suddenly becomes rapid, although no change be noticed in the physical signs, or any increase in the pyrexia, we may strongly suspect that rapid extension of the disease is taking place. Vague chest pains and uneasiness about the shoulders are sometimes complained of by children, and if complained of spontaneously are of some importance. Such pains seldom last long at a time, but disappear and return irregularly. When the disease is advanced, the appetite often fails, but not always ; it may continue good almost to the last, and the more chronic the case, the more likely is the appetite to be preserved. A considerable degree of pyrexia 268 TUBERCULOSIS OF THE LUNGS does not necessarily destroy this relish for food — at any rate amongst hospital patients ; and it is not unusual to see a child eating his meals, apparently with full enjoyment, although his temperature at the time may be 102° or 103° Fahr. The habit of swallowing the sputum is, no doubt, a frequent source of derangement of the stomach; and loss of appetite, with looseness of the bowels, and other digestive troubles, must be frequently attributed to the irritation of acrid mucus thus imported from the air- tubes into the alimentary canal. Attacks of diarrhoea are very common, and help greatly to reduce the weight and increase the feebleness of the patient. If these attacks appear at a time when softening of a deposit is taking place, with ulcerative destruction of lung tissue, and continue obstinate in spite of remedies, they are probably due to tubercular ulceration of the bowels. Emaciation in cases of phthisis does not proceed with any regularity. Sometimes, even in the primary form, the weight of the body remains stationary for several conse- cutive weeks, or even undergoes a temporary increase ; but such a favourable sign is exceptional and seldom persists for long together. When the disease follows a broncho- pneumonia, wasting is by no means a constant feature. It is determined chiefly by the degree of pyrexia, the state of the digestive organs, and the presence or absence of inflam- matory complications. But a considerable degree of fever will not necessarily cause emaciation if the appetite be good and the digestion active. It is not uncommon to see a child actually gain in weight, although the temperature stands every night between 101° and 102° Fahr., and although examination of the chest shows that the pul- monary mischief is continuing to extend itself. In fibroid induration of the lungs, which in an uncomplicated case is not attended with pyrexia, the amount of flesh appears to be dependent very much upon the state of the weather, SYMPTOMS 269 and consequently upon the presence or absence of inter- current inflammatory attacks. Children suffering from this form of consumption are generally found to lose in bulk during the winter when catarrhs are acti\^e, and to regain flesh upon the return of more genial weather, when their liability to cold is diminished. In all cases of phthisis, a sudden increase in the rapidity of wasting combined with a rise in the temperature is a sign of the occurrence of some inflammatory complication. To an attack of intercurrent inflammation, death may be usually attributed ; but sometimes it is a consequence of long-continued fever, sleeplessness, and malnutrition. In such cases the child gets gradually weaker and thinner, and at last can hardly be persuaded to sit up in his bed even to take food. His appetite fails completely : aphthae appear upon the tongue, gums, and inside of the cheeks and lips ; the lower limbs become oedematous from the impoverished state of the blood ; and death ensues, often preceded by very distressing dyspnoea. While the above symptoms are common to all forms of consumption of the lungs, the mode of beginning and the course of the disease differ considerably in the several varieties. In chronic primary tubercular phthisis, the beginning is gradual. From the first the general health suffers, and throughout the general symptoms are severe. The mother usually complains that the child has been lately growing languid and dull ; that his appetite has failed, and that he is losing flesh. He is often feverish at night, and is troubled at times with a short cough. Cough in such cases is always a late symptom, and is preceded by signs of general disturbance of health. The course of the disease is comparatively rapid, and in ordinary cases its end may be expected within eighteen months of the first appearance of the physical signs. The child continues to waste. Pyrexia is usually persistent, 270 TUBERCULOSIS OF THE LUNGS and is accompanied by morning sweats. There is little desire for food. The digestive organs are weak and irritable : vomiting is frequently excited by cough, and the bowels are disposed to be relaxed. The voice some- times becomes hoarse from ulceration of the larynx (laryn- geal phthisis) ; but this symptom is less common in young subjects than it is in the adult. At length the child dies exhausted, or falls a victim to an intercurrent attack of pulmonary or meningeal inflammation. The pneumonic form of phthisis may either follow an acute attack of broncho -pneumonia, or may begin more insidiously by the extension of a catarrh from the smaller tubes to the alveoli. In the first case convalescence is slow and uncertain. The pyrexia does not subside as usual, or, if the temperature falls at first, it does not long remain natural, but after a few days the child is noticed to be again feverish at night. The cough continues ; and, in children who are old enough to expectorate, the sputa may be seen to be streaked with blood, although this is excep- tional. Nutrition, however, may go on fairly well, and the patient often regains weight, or at any rate at first does not sensibly emaciate. Such symptoms show that the unabsorbed mass left after the attack of inflammation of the lung has undergone cheesy degeneration, and is acting injuriously upon the tissue around, setting up an irritation which, if continued, will lead to breaking down of the deposit. But it must be remembered that these symptoms do not always follow an attack of pneumonia, in cases where the consolidating material has failed at first to be reabsorbed. So long as a cheesy mass remains indolent and untainted by the special microbe, it may give rise to no symptoms at all. In such a case, in young subjects, we may still hope for its removal, even after the lapse of a time which would have rendered so favourable a result in the adult impossible. . The occurrence of softening is usually marked by a SYMPTOMS 271 sudden increase in the severity of the general symptoms. The face flushes ; there is fever at night, followed by morning perspirations ; the languor and weakness are increased, and the expression of the child becomes dis- tressed and careworn. In cases of slow development of pneumonic phthisis, the extension of a catarrh to the alveoli from the smaller tubes is shown by a rise in the temperature. The child begins to be feverish at night. His breath becomes short. His cough is more frequent, drier, harder, and more dis- tressing, and, if there is any expectoration, the phlegm may be streaked with blood. These special symptoms, indicating lung irritation, may persist for a considerable time without any signs being noticed of general impair- ment of nutrition. At length, however, the appetite fails, digestion suffers, nutrition is interfered with, and the child wastes perceptibly. The j)hysical signs which accompany this state of things will be considered afterwards, but it may be mentioned here that although apparently trifling, they are not the less important, and must not be over- looked. Should secondary acute tuberculosis come on, all the symptoms are aggravated. Wasting proceeds with rapidity ; the feebleness increases ; appetite is completely lost ; and there is often great irritability of the digestive organs, with vomiting or diarrhoea. The cough becomes more dis- tressing, and the child breathes quickly, and often pain- fully from the occurrence of dry pleurisy. Death may be preceded by squinting, inequality of pupils, convulsions, rigidity of joints, and other symptoms indicating an advanced stage of tubercular meningitis. In cases of fibroid induration of the lung, there may be little about the child to excite attention so long as the disease remains in an early stage. Any symptoms which may occur are the result merely of the catarrhal attacks to which such a condition of the chest renders the child 272 TTJBERCULOSIS OF THE LUNGS peculiarly prone. In the interval of such attacks, the cough disappears, the appetite returns, and the health and strength generally appear to be satisfactory. It is when an increase in the cirrhosis has led to contraction of lung and dilatation of bronchi that the symptoms become characteristic. The dilated rigid tubes tend to retain their secretions. There is consequently a great accumula- tion of sputum, which putrefies, and is only with great difficulty evacuated. The cough occurs at rare intervals, in paroxysms lasting ten or twenty minutes, or even longer, during which the face is suffused, the eyes become red and watery, and the whole appearance is suggestive of a severe fit of whooping-cough. At the beginning of the paroxysm there is no expectoration, but, after a time, stringy muco-purulent matter begins to be discharged ; and the fit often ends in violent retching efforts, and the expulsion of large quantities of foetid sputum. Areolar fragments of elastic tissue, showing ulceration of lung, may be often detected microscopically in the expectorated matter. Owing to the indurated and contracted state of the lung, its circulation is more or less impeded. In bad cases there is, therefore, some hypertrophy of the right side of the heart, and a prominence of the superficial veins in the neck, chest, and limbs, which indicates an abnormal fulness of the systemic venous system. The fingers soon become clubbed ; and the face has habitually a congested turgid appearance, especially when the patient is suffering from a superadded catarrh. There is no pyrexia unless catarrhal pneumonia, or ulceration of the bronchial tubes, be present, as in the stage called fibroid phthisis. In an uncomplicated case of fibroid induration the temperature is natural, and perhaps as a consequence the digestion and appetite are good as a rule, and the appearance of the child is fairly robust. But, after the disease has existed for some PHYSICAL SIGNS 273 time, the constant drain upon the system, produced by tlie copious purulent discharges from the lungs, very com- monly gives rise to amyloid degenerations. The liver and spleen become enlarged, and there is often albumi- nuria with oedema of the extremities. Moreover, the ex- tension of the disease in the lung, and the occurrence of ulceration (fibroid phthisis), prove additional sources of weakness, undermining the strength of the patient. Con- sequently, in the later periods of the disease, the child becomes thin, haggard-looking, and feeble. His debility is increased by attacks of diarrhoea ; and, if he be not cut oif by an intercurrent pneumonia, he becomes more and more prostrated, and eventually dies worn out and exhausted. Physical signs. — An examination of the chest in a child must be conducted with as much care as if the patient were an adult. To do this effectually it is important that he be so placed as to occasion no difficulty or discomfort to the observer. Infants can be held up in the nurse's arms or be raised up to a convenient height by laying them upon a cushion placed upon the table. Older children may be seated upon a table or high music stool. In either case the patient should be completely stripped to the waist. In young subjects the physical signs present certain peculiarities which it is important to be prepared for. Thus, vocal vibration is generally altogether absent, both in health and in disease, and, even if present, is not to be relied upon as a help to diagnosis. Again, the chest in a young child is exceptionally resonant, and it is not always easy to detect variations in its sonority. A great mistake, often made in the examination of children, consists in using only one finger as a percussor. By using two fingers we can equally moderate the force of the blow, while at the same time we elicit a far greater volume of sound. An amount of dulness which escapes the ear, when percussion is made with only one finger, can often be 18 274 CHRONIC PULMONARY TUBERCULOSIS readily brought out when two fingers are employed. At the apices dulness is best detected in infants and young children at the supra- spinous fossae, and can often be discovered at these spots when in front the percussion note is perfectly healthy. Great care must, however, be taken to exclude all sources of fallacy in estimating the degree of resonance of the apices. One shoulder higher than the other, or a cramped position bringing the mus- cles attached to the shoulder into action, will produce a dull sound on percussion which is not due to the con- dition of the lung. In infants, in examining the supra- spinous fossae, it is advisable to place the child, stripped to the waist, on the nurse's left arm, so that his head and right arm hang over her left shoulder, the left arm of the child being round his nurse's neck. In this position the muscles of both sides are relaxed, and if the child remain quiet the results of percussion may be relied upon. Per- cussion should be made upon the two sides at the same period of the respiratory movement. Thus, if one side has been percussed during inspiration, it will be necessary to wait until another breath is taken before subjecting the opposite side to the same test. On account of the readiness with which false conclusions may be drawn with regard to the degree of resonance of the lung in children, it is best to require a considerable amount of dulness on percussion before making any positive infer- ence from the examination. Slight differences between the two sides should be allowed little weight, for a spot which ax3peared to be dull at one visit, may on the next seem perfectly healthy, the difference probably depending upon various degrees of expansion of the lung tissue at that spot. The dulness, although often situated at the apex, is not necessarily so. The whole chest should be carefully per- cussed both at the back and at the front. Dulness may be found in spots separated by tissue which yields a AUSCULTATION 275 normal resonance, or may be limited to an area in the middle of the lung or at the base. In fact, wherever catarrhal pneumonia may have occurred about the lung, a deposit may be left to impair the natural resonance at that spot. Of the varieties of the percussion note little need be said. To the tubular note no importance can be attached ; and the "cracked-pot" sound is a natural phenomenon if the chest be percussed during expiration, or when the mouth is open. In practising auscultation we must remember that coarseness and harshness of the respiratory murmur (puerile breathing) is a natural condition in the child, and that expiration is often prolonged, especially at the apices, without its being necessarily a sign of disease. Even from differences in respect to loudness and coarse- ness on the two sides we cannot prudently draw any positive conclusion. When, however, the intch of the breath- sound is raised on one side, we may rely upon such a change as evidence of disease, and may expect the respi- ration to become distinctly bronchial in the course of a few days. Even when the breathing at a particular spot is bron- chial or hollow, we have still to satisfy ourselves that the abnormal quality is not conducted from the throat or primary divisions of the air-tubes. In children who suffer from enlarged bronchial glands or adenoid growths, and even in some children who in such respects show no sign of disease, sounds from the large bronchi or the pharynx are conducted readily to the chest, and loud hollow breathing may be heard at the apices of perfectly healthy lungs. On this account it is important that, if possible, the child's mouth be open during the examination, as pharyngeal sounds are then less easily transmitted. On account of this ready passage of extraneous sounds to the chest, the use of the stethoscope is imperative to 276 CHRONIC PULMONARY TUBERCULOSIS insure accuracy of observation, as it is only by sucli means that we can limit the area under investigation and examine the lungs, so to speak, bit by bit. If the instrument is spoken of as a ''trumpet," children who are old enough to understand the term, seldom manifest much opposition to its use, especially if they are allowed to touch and l-)lay with it beforehand ; and infants in whom the chest disease is extensive are often remarkably quiet during examina- tion, being usually too much occupied by their own sen- sations to make any resistance to the operation. Over the seat of dulness the respiratory murmur is either weak and suppressed, or is bronchial, blowing, or cavernous, with increased resonance of voice and cry. As the tissue softens and breaks up, moist crackles are heard accom- panying the breath- sounds, or there is merely a click or two at the end of inspiration. This passes, as cavities form, into gurgling, or large bubbling rhonchus, more or less metallic. The stethoscopic signs differ in value according to the part of the chest at which they are heard. At the apices mere harshness of respiration is insignificant, and pro- longed expiration absolutely worthless as a means of dia- gnosis. Bronchial breathing is a natural condition between the scapulfB over the site of the principal divisions of the air-tubes ; and at the apices may be closely simulated by sounds conducted from the naso-pharynx. If this con- duction can be excluded, bronchial breathing heard at the supra- spinous fossae is often the sign of a cavity. In the case, however, of bronchial blowing and cavernous breath- ing, enlarged bronchial glands in contact on one side. with the air-tubes, and on the other with the chest wall, may, by their conducting power, simulate these varieties of re- spiration so closely, that from a single examination it is often impossible to give a positive opinion as to the condi- tion of the lung. It is only by a careful observation of the succession of these sounds that a conclusion can be VALUE OF CAVERNOUS BREATHING 277 arrived at. In the case of pulmonary consolidation and excavation the breathing becomes more and more distinctly metallic and cavernous, while (if the sounds are due to conduction) cavernous, bronchial, and harsh breathing will be found to alternate irregularly with one another. Bron- chial respiration is therefore more significant of consoli- dation when heard at the base of the lung than at the apex. The same may be said of feeble breath- sounds ; although merely weak breathing is so common in young persons at all parts of the chest, from insufficient expansion of the lung, that at a first examination too much importance should not be attached to it. If it be found to persist for several weeks, or if it occupy the whole of one lung from apex to base, it becomes a sign of considerable value. Cavernous breathing combined with dulness, gurgling rhonchus, and increased resonance of the voice and cry, 'usually indicates a cavity near the surface of the lung. But in every case where these signs are met with, we must not hurry to the conclusion that the lung tissue is exca- vated at that point. At the apex such breathing may be simulated closely, as we know, by sounds conducted from the pharynx ; and at the base it is by no means to be accepted in every case as a sign of ulcerative destruction of lung. Cavernous respiration heard at the lower lobe of either lung is more commonly the consequence of bronchi- ectasis than of a cavity ; but it may be also detected in cases where the sole pathological lesion present is a copious pleuritic effusion. The distinction between these conditions will be considered under the head of diagnosis. In the different forms of pulmonary consumption, the course of the physical signs is often fairly expressive of the nature of the disease. In chronic primary tubercular phthisis signs are late to appear, and at first may easily escape notice. Often, indeed, the slight evidence of disease obtained by a physical exa- 278 CHRONIC PULMONARY TUBERCULOSIS mination of the chest in a case where the severity of the general symptoms had attracted much attention, excites considerable surprise. A child who is described as having ailed for over three months, with hollow cough, evening fever, and loss of flesh and strength, may present on exa- mination merely a slight want of resonance at the apices of the lungs, with weak harsh breathing, and an occasional click in inspiration, changing to a faint dry crackle after a cough. In this variety, although one-half of the chest is first attacked, the opposite side becomes affected after a short interval ; and usually by the time any positive phy- sical signs are present, they are discovered at both apices. In most cases inflammation is soon excited in the part, and a secondary catarrhal pneumonia is set up which produces marked dulness and all the signs of consolidation. When this occurs, the existence of grey tubercle as the original factor in the disease may be overlooked ; although the pre- sence of mischief in both lungs, and the severe general symptoms, combined with a history of the beginning of the attack, should make the nature of the illness a matter of the strongest suspicion. Sometimes the tubercular disease remains uncomplicated with pneumonia. Disorganisation then goes on slowly : the breath- sound, although still feeble, becomes gradually blowing in quality, and eventually all the signs of a cavity are discovered at one apex. It is, however, rare for the inflammatory element to be absent. Far more frequently the disorganisation of the lung is effected through the breaking down of pneumonic cheesy matter. The signs are then much more marked, and are consequently more easily recognisable. When a pneumonic phthisis begins by the gradual ex- tension of a bronchial catarrh to the alveoli, the earliest signs are discoverable at the apex of the lung. There is some loss of resonance on percussion ; the respiration is high-pitched or faintly bronchial, and a click or dry crackle SEAT OF THE PHYSICAL SIGNS 279 is heard at the end of a deep inspiration. These signs may be discovered either at the front or at the back ; per- haps it is most common to meet with them first at the supra- spinous fossa. Soon, however, they begin to be noticed also above the clavicle. Thenceforth, unless measures be taken to counteract the evil, the progress of the disease is more rapid, and it is not long before evident signs of consolidation are found at the apex of the lung on one side of the chest. In this form of pulmonary phthisis the physical signs appear early, and precede any marked symptoms of general impairment of health. Such cases offer, therefore, a remarkable contrast to the tuber- cular variety of the disease which has just been con- sidered. When the phthisis results from an unabsorbed deposit left after an attack of acute catarrhal inflammation, or is due to infection by a caseous bronchial gland, its situation is indicated by percussion-dulness, and all the usual signs which accompany a solidification of the lung. In such cases the apex is not necessarily affected ; indeed, it is the exception to find the upper third of the lung involved in the disease. Far more commonly the signs are discovered at the base or in the middle third; and therefore, in a physical examination of the chest, every part should be thoroughly explored. But here again it is to be remarked, as in the former case, that, until the disease is far advanced, the physical signs often indicate a greater amount of mischief than a consideration of the general symptoms would have led us to expect. When softening takes place in the caseous mass, wherever this may be situated, attention should at once be directed to the apex of the opposite lung. A careful examination will probably detect a rise of pitch in the breath- sound at this point, with one or two faint clicks in inspiration, and, possibly, some diminution of resonance on percussion. As the softening process advances, these signs of secondary 280 CHRONIC PULMONARY TUBERCULOSIS lesion become more and more manifest, and by the time a cavity has become established at the original seat of disease, the apex of the lung, on the other side of the chest, usually furnishes distinct evidence of consolida- tion. In fibroid induration of the lung the physical signs are limited, usually throughout, to one side, and may be found at the upper part of the chest or at the base. In an early stage, little more is noticed than a wooden quality of per- cussion note, with slightly increased resistance, and harsh bronchial breathing. If there be accompanying catarrh, some coarse bubbling or crepitating rhonchus may be caught here and there about the chest and back. Yocal fremitus, if present on the sound side, cannot be felt over the affected part ; but the resonance of the voice at first is normal. As the disease proceeds, the lung becomes contracted; the bronchi dilate; and the chest falls in. On account of the diminished size of the lung, the circumference of the side is reduced. The chest is flattened at the seat of disease, and the heart and mediastinum are drawn towards the affected part. The apex-beat of the heart is, conse- quently, displaced, and the resonance of the opposite lung- passes across the middle line of the chest. There is little respiratory movement over the indurated lung, and vocal vibration is usually completely absent. The percussion note is wooden or tubular, with, in many cases, marked sense of resistance. The respiratory sounds vary according to the amount of secretion contained in the tubes. If there be much accumulation, the breathing is weak and bronchial, with little rhonchus, and but faint resonance of the voice. If, on the contrary, the dilated tubes are nearly empty, the respiration is loud and caver- nous, with much clicking rhonchus mixed up with creaking sounds, and vocal resonance is" intense and bronchophonic. As a rule, a.ttacks of catarrhal pneumonia are frequent. FIBROID INDURATION OF LUNG 281 The area of dulness is then extended, the sense of resist- ance to the finger becomes extreme, and to the stethoscope the breath- sounds are almost obscured by profuse, loud metallic crepitation. CHAPTER X CHRONIC PULMONARY TUBERCULOSIS (continued) T\IAGNOSIS. — In the diagnosis of pulmonary phthisis we have first to satisfy ourselves as to the special variety of the case before us, and then to determine the stage at which the disease has arrived. The task of classification is, however, not always an easy one, for the types of disease seldom remain separate and defined. On the contrary, they are apt to run into one another, and blend together, so as, in a great measure, to lose their distinctive characters. In uncomplicated chronic primary pulmonary tuberculosis the physical signs are slight at the first, and even in the child usually involve the apices of both lungs. In a well- marked case resonance is impaired; there is bronchial breathing ; and at the end of deep inspiration a faint crackle is heard, which becomes louder, and more dis- tinctly crepitating after a cough. These signs found at the apex on both sides of the chest, and continuing unchanged for several weeks, afford the strongest suspicion of the presence of tubercle. In many cases the signs are much less clearly defined, and it is often impossible at the first, or even after several successive examinations, to come to any positive conclusion as to the exact nature of the illness. To arrive at a diagnosis, we must take into account the family history. DIAGNOSIS 283 the special history, the conformation of body, and the general symptoms of the disease. Thus, if a child born of consumptive parents, and whose general build corresponds to the type which has been described as significant of the tuberculous diathesis, becomes languid, and mopes ; if he has irregular attacks of fever, loses flesh, complains of vague pains and oppression about the chest, and after a time begins to suffer from a short dry cough, we should suspect tubercular phthisis. If these symptoms have succeeded to an attack of measles or whooping-cough, our suspicions are strengthened ; but so long as percussion of the chest shows no dulness, and auscultation reveals nothing but harshness of respiration at the upper part of the lungs, with an occasional sibilant or sonorous rhonchus here and there about the chest, we should still hesitate to give a decided opinion. When, however, resonance at both apices becomes impaired, and bronchial breathing is heard with a faint, dry crackle at the end of inspiration, these signs, taken in conjunction with the suspicious general symptoms, can leave little room for doubt. There is one source of fallacy which it is important to be aware of. In children, especially in the younger sub- jects, who suffer from mild pulmonary catarrh, we often find little patches of pulmonary collapse. These patches are especially common at the apices, and cause slight dul- ness of percussion at the supra-spinous fossae. If, at the same time, the child is troubled with adenoid vegetations in the naso-pharynx, loud, hollow breath- sounds conducted from the throat are heard with the stethoscope over the dull area. The likeness to pulmonary phthisis is made more close by the anaemia and malnutrition which so often accompany the post-nasal growths; but the distinction is not difficult. The mere fact that adenoids are present should excite suspicion ; and when we find that the hollow respiration is greatly modified while the child holds the mouth open, and that the percussion signs vary from day 284 CHRONIC PULMONARY TUBERCULOSIS to day, coming and going capriciously, we may exclude tuberculosis of the lung with a high degree of certainty. In cases where from the ill- defined character of the physical signs we had been obliged to reserve an opinion as to the condition of the apices, the occurrence of double pneumonia at these spots throws considerable light ujDon the difficulty, and greatly increases the probability that the disease is tiibercular. At a later stage, when the tubercular disease has become complicated, and secondary catarrhal pneumonia has greatly extended the limits of pulmonary consolidation, it would be difficult, perhaps impossible, from a considera- tion merely of the physical signs to detect at first sight the tubercular origin of the disease. If the apices of both lungs are unaffected, the mischief is probably non-tuber- cular ; but if, as usually happens in cases of pneumonic phthisis when pulmonary disintegration is going on, both apices are involved, we cannot solve the question by mere physical examination. In such a case an accurate account of the child's illness is of the utmost importance, and from the history, the more rapid course of the complaint, and the greater severity of the general symptoms, we may often be justified in inferring ihat the case is not one of lingering broncho-pneumonia, but that the mischief took its origin in tubercular formation at the apices of the lungs. In pneumonic phthisis we can often succeed in dis- covering a distinct period at which the first symptoms were noticed. A child delicate, perhaps, but in his usual health, is seized with an attack of vomiting, followed by fever, cough, and general chest symptoms. The strength is not much reduced, and the breathing is but little oppressed, although it may be rather more hurried than natural. If the child be seen eaily, no dulness may be found on percussion, but there is more or less coarse crepitation SECONDARY TUBEK-CULAR PHTHISIS 285 heard at one or more spots about tlie chest, often, how- ever, at the apex of one lung — seldom at both if the disease be uncomplicated. The crepitation accompanies the expiration as well as the inspiration, and varies greatl}- in amount from day to day ; sometimes more being heard, sometimes less, and sometimes for a short time it is com- pletely absent. If any dulness be present, it is slight at first, and may not become more marked for several weeks. The breath-sounds are not necessarily altered in character. The temperature of the body rises at night to 102° or 103° Fahr., falling in the morning to about its natural level. After a time, often only after several weeks, the dulness becomes more marked, and then gradually increases in intensity and extent ; the respiration is bronchial or tubu- lar ; and the coarse crepitation, persisting, is heard over the whole of the consolidated part, but varies in amount as before, and occasionally is replaced for a time by a rhonchus of larger size. An attack of subacute catarrhal pneumonia, such as the above, running a tedious course, and leaving behind it an unabsorbed consolidation, may undergo complete resolution after a time, and, indeed, is often seen to do so. But often, too, tubercle bacilli find their way to the affected part, and the solidifying material begins to soften and disintegrate ; or the part becomes thickened with new fibroid tissue, and permeated with dilated bronchi. Disease thus induced may affect any part of the lung, but is usually confined to one side of the chest — at any rate, at first. Tubercular disease spreading from a caseous gland at the root of one lung often announces itself by the physical signs of a localised broncho-pneumonia. The signs, how- ever, in such a case are not found at the apex, but are seated lower down in the lung, often at the upper border of one of the lower lobes, and are first discovered about the middle of the scapular region on one side. Pneumonic phthisis, like the primary form, may have 286 CHRONIC PULMONARY TUBERCULOSIS a very insidious beginning. In cases where a pulmonary catarrh, spreads gradually from the larger to the smaller air- tubes, and from these to the alveoli, the main features of the disease present a strong similarity to those present at the beginning of chronic tubercular phthisis ; and it is necessary to make very minute inquiries to establish the difference. One of the chief points of distinction lies in the influence of the illness upon nutrition. In primary tubercular phthisis the general symptoms precede the special. Wasting and fever are present from the begin- ning. The child loses weight rapidly, and his haggard appearance attracts attention. It is only after a very distinct interval tha,t he is noticed to cough. In chronic catarrhal pneumonia exactly the opposite conditions pre- vail. The special symptoms are the first to appear. Cough and shortness of breath are remarked upon before any loss of flesh has excited observation, and although the tempera- ture is higher than natural, weeks often pass before any material impairment takes place in the nutrition of the child. Physical signs, when present at the apices in primary tubercular disease, are met with on both sides • but the comparatively trifling amount of structural change dis- covered by physical examination presents a remarkable contrast to the severe disturbance in the general condition, and forms an important element in the diagnosis. In pneumonic phthisis, on the contrary, the disease is at first confined to one side of the chest, and often proves on exa- mination to be far more extensive than the well-nourished state of the patient had led us to anticipate. Advanced pneumonic phthisis is often complicated with general disseminated tuberculosis. We may suspect this if we find great hurry of breathing, with an increase in the pyrexia, without any extension of the physical signs. There is usually also considerable irritability of the diges- tive organs with vomiting or diarrhcea. If in such a case FIBROID INDURATION OF LUNG 287 conyulsions occur with squinting, inequality of pupils, and other signs of intra-cranial disease, our suspicions are amply confirmed. In fibroid induration or cirrhosis the disease is limited to one lung. The affected side is retracted, often con- siderably ; the front of the chest is flattened, the respira- tory movement slight, and the heart more or less displaced. If the disease occupies the left side, the heart is drawn up- wards ; if the right side, the heart is drawn towards the middle line. Real elevation of the heart must not be con- founded with apparent elevation through unnatural obli- quity of the ribs occurring in long-chested children. There is dulness on percussion over the seat of disease — usually the middle third of the lung approaching more or less to the apex. The note is often tubular, and there is unusual parietal resistance. Auscultation shows harsh, bronchial, or blowing respiration, with coarse rhonchus and increa.sed resonance of voice, passing, as the bronchi dilate, into cavernous respiration, with gurgling and pectoriloquy. A systolic basic murmur is sometimes present, produced probably by pressure. There is no febrile disturbance ; on the contrary, the temperature is unusually low. In extensive consolidation of the upper part of one side only, the other side giving no — not even the faintest — sign of disease, the diagnosis lies between pneumonic phthisis and fibroid induration. The existence of retrac- tion of the affected side, the altered position of the heart, the flatness of the percussion-note, the great resistance, and the absence of fever, exclude the former disease. It is distinguished from chronic pleurisy with retraction by the resonance at the base, and by the signs of a cavity. It is not always easy to satisfy ourselves as to the exist- ence of a cavity in the lung, for, although present, it may give rise to no very positive signs ; and again, although absent, the physical signs usually indicative of excavation may be present. 288 CHRONIC PULMONARY TUBERCULOSIS In infants, and children of three or four years old, the signs of a cavity are often very obscure, consisting merely in bronchial breathing with fine bubbling rhonchus and bronchophony. Here no positive opinion should be hazarded. It must be remembered, however, that at such an age ulceration of the lung is not a common condition. In the case of older children, a dull, tubular, or tym- panitic percussion-note, with gurgling and bronchophonic resonance of the voice — signs usually indicative of a cavity — may be produced by dilated bronchi, and are occasionally very closely simulated in some cases of pleuritic effusion. Empyema, indeed, is frequently mis- taken for pulmonary phthisis, and the error is one which may be easily made. In many cases of empyema there is hectic fever, with wasting and great weakness ; there is failure of appetite, irritability of the digestive organs, cough and shortness of breath. An examination of the chest shows extensive dulness, with blowing or cavernous breathing, and, often, a crepitating friction- sound which may bear a near resemblance to rhonchus in the lung. In cases such as these we can scarcely be surprised if the patient is supposed to be consumptive. But a little reflec- tion should alter this oj^inion, and make us reconsider our diagnosis. The fact that disease in an apparently advanced stage is limited strictly to one side of the chest, should always excite our suspicions. If, then, we refer to the history of the complaint, and find that the illness began suddenly with pain in the side, followed, after a day or two, by cough ; if we note the character of the physical signs, and remark that the dulness is comj^lete with great sense of resistance ; that it is found both at the front of the chest and at the back ; and that however high it may reach upwards, it persists even to the extreme base below — we cannot but conclude that these features in the cases are not reconcilable with what we know of pulmonary consumption, DIAGNOSIS OF A CAVITY 289 but must be referred to some other cause ; and this cause there can be no doubt is pleurisy. Whether the cavernous signs be due to a dilated bron- chus or an excavation in the lung, it is not always easy to determine ; but with regard to the ultimate issue of the case it is of the highest importance to make the distinction. A child after an attack of catarrhal pneumonia recovers flesh slowly, and remains feeble with slight fever at night. An examination of the chest detects dulness and cavernous respiration with large metallic bubbling rhonchus and bronchophony at the lower part of one lung. Here it is of the greatest moment to determine whether such signs are a consequence of a dilated bronchus, with surrounding consolidated tissue, or of an excavation in the lung. In the one case the child may be expected to recover com- pletely ; in the other a return to health can scarcely be anticipated. If the signs are heard at the base, the probabilities are strongly in favour of bronchiectasis, especially if the apex of the lung is free from disease. If the area over which the abnormal signs prevail gradually increases in extent, our suspicions point to a cavity, for dilated bronchi usually remain unaltered, or tend to contract and become normal. Yery valuable information is a:fforded by the general symptoms. If the patient improves, regains flesh and strength, with a good appetite and a normal or only slightly elevated temperature, we may reasonably conclude that no lung disintegration is going on. In all cases a careful examination of the sputum should be made with the microscope, if any expectoration can be obtained, to search for fragments of elastic tissue. Such fragments, if areolar, are conclusive evidence of ulcerative excavation. It is necessary, however, to make many examinations of the sputum before deciding against the presence of the elastic tissue. * The search for elastic tissue is made a very simple process by 19 290 CHRONIC PULMONARY TUBERCULOSIS It is of course quite possible that the two conditions may be combined in the same lung, as we see in cases of fibroid phthisis where ulceration has started from the wall of the dilated tube. In such cases we get the local signs of bronchiectasis combined with the general sym- ptoms of pulmonary excavation. Thus, if the cavernous signs are heard at the middle or lower part of one lung the apex of which is free from disease ; if there be con- siderable retraction of that side with displacement of the heart; and at the same time if, without any signs of secondary catarrhal pneumonia, we find a high tempera- ture and general constitutional disturbance, the diagnosis of fibroid phthisis may be made without hesitation. The occurrence of ulceration is usually followed very quickly by secondary deposits in the apex of the opposite lung. Therefore, if in a case of fibroid induration we find any indication of disease in the apex on the other side of the chest, we should, from this sign alone, suspect the presence of ulceration. Prognosis. — A consolidation of the lung, left after an attack of broncho-pneumonia, may remain for a long time unabsorbed; but these cases are not cases of pulmonary phthisis, and may be expected to end in recovery. If the patient be placed in good sanitary conditions, so that special infection by the bacillus can be prevented, reabsorp- tion takes place and the mischief is quickly removed. As sputum is rarely brought up by a child, and we are usually deprived of the aid which an examination of expectorated matters would afford, we can seldom venture on a first visit definitely to exclude tuberculosis. A fair state of nutrition and good animal spirits on the part of the patient may enable us to take a favourable view of his boiling the sputum in a test-tube with an equal quantity of liquor sodjB. The mixture becomes perfectly clear, and fragments of elastic tissue, if present, sink to the bottom of the tube, whence they can be readily removed by a pipette. PROGNOSIS 291 prospects ; but it is not until a change for the better in the child's surroundings is followed by immediate im- provement, and the consolidation begins at once to be reabsorbed, that we can venture to dissipate the fears of the friends. When definitely established, pulmonary phthisis is generally fatal sooner or later, but the prognosis is always most serious in cases where there is a strong family tendency to the disease. Such cases are prone to go from bad to worse ; general nutrition suffers early and severely ; and the danger of the disease becoming dis- seminated and setting up an acute general tuberculosis is really urgent. In an ordinary case of pulmonary phthisis the course of the illness is very variable, with turns of improvement and relapse. G-reat caution should then be exercised in making a prognosis, for a child who is apparently in the greatest danger may suddenly begin to improve, and his more serious symptoms may for the time completely disappear. Such amendment is apt to excite amongst his friends hopes, seldom destined to be realised, of a complete recovery. This improvement often happens in cases where the local symptoms are temporarily aggravated by a bronchitic attack, but it may also occur in cases of apparently un- complicated local tuberculosis. When, however, the chronic disease is once fairly established, the apparent improve- ment is almost always speedily followed by a relapse, all the symptoms returning with increased severity. It is not often possible to obtain sputum for examination, for many children cannot be persuaded to expectorate the purulent matter brought up from the lung. If sputum can be obtained, the number and arrangement of the bacilli are said by some observers to be a measure of the rapidity with which the disease is progressing ; for in cases where the destructive process is rapid the bacilli are 292 CHRONIC PULMONARY TUBERCULOSIS numerous, and are arranged in groups and masses. This rule, however, is not invariable. In cases of rapid phthisis I have known the bacilli in the expectorated muco-pus to be very few in number. Pulmonary phthisis often lasts much longer than would be expected from the character of the physical signs. A child may continue in the same state, without much improvement or aggravation of his symptoms for years. It becomes, then, a question of much importance to decide in any given case upon the prospects of a lengthened course. The most favourable conditions are those where a child without any hereditary tendency to the disease becomes infected secondarily with the bacillus at the end of a lingering attack of broncho-pneumonia. This pneumonic form of phthisis when it attacks a constitutionally healthy child often, I think, ends in recovery if the consolidated area be limited in extent, and the patient live a healthy open-air life. In such a case the progress of nutrition must be watched with care. Absence of wasting and the occurrence of local contractions of the chest wall from the formation of fibrous tissue at the affected spot are sym- ptoms which should be noted with satisfaction. Even when it ends unfavourably, which in the poorer classes of the people it usually does, this variety of the disease is often very sluggish in its progress. It is, however, always liable to take on suddenly a more rapid course, and too great confidence should not be excited by the apparent inactivity of the disease. Fibroid induration is a still slower disease. In such cases the immediate outlook is far from being unfavour- able. In the case of primary tuberculosis of the lung very little hope can be given. The most favourable change appears to be its complication with cirrhosis ; by this means life is often prolonged for a considerable time. The PREVENTION 293 presence of tubercular lesions in other organs, especially the bowels, is very unfavourable. Diarrhoea is not unfre- quently the direct cause of death. Death may take place suddenly, without being jjreceded by any great aggravation of the other symptoms. Usually, however, it is ushered in by greater severity of the cough, sensation of oppression about the chest, lividity of the face, increased weakness, and all the signs of exhaustion. Pneumothorax is very rare in children. When a tuberculosis becomes generalised, death is often preceded by the symptoms of the third stage of tubercular meningitis. Prevention. — If the mother be consumptive, she should on no account be allowed to suckle her child longer than the end of the first month; a healthy wet-nurse should then be provided to take her place. So much has been said in the present volume as to the feeding and general management of young children that it will be unnecessary to repeat in this place the various rules for the diet, clothing, &c., of infants, which have been already laid down. The reader is referred to the chapter containing the treatment of simple atrophy, and to that on the pre- vention of diarrhoea, for full information upon these points. The diet of an older child should be so arranged that he may take as much as he can readily digest, but no more. Animal food should be given to him only once in the day, and should be either roasted or boiled; meat cooked a second time, as hashes, or stews, or meat fiied in grease, are less digestible, and should not be allowed. After the age of two years a child should take four meals a day : of these two should consist of bread and milk ; a third of meat, finely minced at the first, afterwards cut into small pieces, with a little potato carefully mashed, and gravy; a fourth of farinaceous pudding, or an egg slightly boiled. The milk should, if possible, be fresh 294 CHRONIC PULMONARY TUBERCULOSIS from the cow ; if not, a tablespoonful of cream should be added. It is important to accustom the child early to masticate his food thoroughly : this point should be always attended to. Children often wake hungry in the early morning; it is well in such cases to place, overnight, a piece of dry stale bread, or a plain biscuit, by the side of their bed, so that they may not be forced to wait without food until their breakfast is prepared. Well- ventilated rooms, fresh air, and plenty of exercise must, of course, be insisted upon. The skin should be kept perfectly clean by cold or tepid sponging over the whole body in a bath once a day, and should be after- wards excited gently to act by friction with hand. The dress should be warm but loose : tight waistbands, and, in girls, stays are exceedingly injurious. Nothing should be allowed to interfere with the free play of the chest. Pressure upon the ribs not only prevents a proper expansion of the lungs, but also is apt to cause displace- ment of the liver and stomach, and much derangement of the functions of digestion and respiration may be the consequence. The only way," says Dr. Underwood, " in which we can assist in forming a really fine figure, is to remove all restraint, and secure, as far as possible, so free an action to the muscles as will lead to their perfect development. By such a course we shall best promote the acquirement of a good carriage, which is infinitely more likely to be the result of a perfect balance of the muscles than of any mechanical support whatever." The j)receding remarks do not refer to the abdominal belt, which should always be worn until the child is, at any rate, three years old. The band covers the belly, but does not confine the ribs, if properly applied round the upper part of the pelvis. Children, both boys and girls, should be encouraged to exercise their muscles by outdoor games, and by gymnas- tic exercises suited to their age and sex. While, however, EARLY REMOVAL OF DISEASED BONE 295 plenty of fresh air and exercise out of doors are of extreme importance, unnecessary exposure of children to cold winds and damp air, with a view of hardening the system,'' is a practice which cannot be too strongly con- demned. The most robust children are exceedingly sensi- tive to changes of temperature, and in cold, damp air readily part with their heat and become pinched and blue, showing that they are suffering from the effects of cold. Many an attack of inflammation of the lungs has been excited by such a practice, and in children already predisposed to phthisis unnecessary exposure is one of the most certain ways of encouraging the tendency. A dry, airy situation should be always recommended. Dr. Buchanan has shown that phthisis is much more preva- lent amongst populations living on low-lying, impervious soils than amongst the residents of places more highly situated and where the soil is pervious. In the selection of a house this is a matter, therefore, of much importance. In children who suffer from caries, an operation for the removal of the diseased portion of bone should not be delayed. Pulmonary tuberculosis may be set up by bacilli transported from the affected bone, as has already been explained (see page 262). When the bone disease is cured, the child often becomes strong and healthy. Early attention must also be paid to the local inflammations and suppurations to which scrofulous children are so liable. Pent-up pus — whether collected in abscesses or filling the pleura as in empyema — should be evacuated without loss of time ; and tuberculous glands in the neck must be carefully watched and removed at once on any sign of softening. The child must be kept scrupulously clean, and any discharges from the ears, nose, or vagina should be at once treated by suitable applications. In cases where the shape of the chest is elongated and narrowed from before backwards, showing the small size of the lungs, every means must be taken, by exercises 296 CHKONIC PULMONARY TUBERCULOSIS carefully proportioned to the strength of the patient, to increase the capacity of the chest and invigorate the muscles of respiration. This is effected in a great measure by general exercise ; but, besides this, the more special exercises, as the use of the dumb-bells and of the chest-expander," are particularly valuable. Drilling, fencing, and other amusements which promote the acquire- ment of a good carriage, accustoming the child to throw back the shoulders and expand the lungs, are also of much service. By such means the capacity of the chest may be very much increased, and greater freedom be given to the play of the lungs. Treatment. — In the treatment of pulmonary phthisis three things are indispensable: a free supply of fresh air, avoiding chills ; a moderate amount of exercise, avoiding over-fatigue ; and plenty of nourishing food, avoiding repletion and indigestion. The child should pass as much time as possible out of doors during the day, returning, however, to the house before sunset; as the temperature often falls considerably at that time, and rapid changes of temperature are to be avoided. Cold is not so injurious as damp. These patients, if warmly clothed, often bear well and are benefited by cold air- Damp, however — at any rate the moist air of low-lying inland situations — is extremely prejudicial, and while the ground is wet the children should be kept indoors, or should only be exercised with very great caution. The moist air of the sea- side does not appear to be so injuri- ous, and many cases of pulmonary phthisis are greatly benefi.ted by a residence near the sea. For the winter months, and in cases where a change of air is advisable, it often becomes a question of considerable difficulty to decide upon the best climate to which the patient can be sent. In the early stage, before softening has begun in the lung, it may be laid down as a rule, that the best climate is one where the temperature is as low as can be CHOICE OF CLIMATE 297 borne. A warm climate, unless in exceptional cases, has no special advantage, and heat combined with moisture, as in Ceylon and Madeira, is as a rule positively inju- rious. A hot, moist climate is only of value in cases where there is excessive irritability of the bronchial mucous membrane, a condition which would be increased by warm dry air. In the earlier stages of tuberculosis this is, however, seldom a prominent symptom. The object of a change of residence in this disease is to obtain a climate where the patient can pass his time out of doors without incurring the risk of catarrh, and where, at the same time, the quality of the air is sufficiently invigorating. When the climate is damp as well as warm, the relaxing qualities imparted by the moisture usually cause so much depression, destroying the appetite and increasing the languor, as to counteract the benefit aiforded by the more genial air. In determining this question regard should always be paid to individual peculiarities. Some children will require a much greater degree of warmth than others, and it will be necessary to take into considera- tion the influence which differences in temperature have already appeared to exercise upon the health of the patient — whether he has seemed to be more benefited by heat or by cold — before deciding in any case upon the exact climate which offers the best chance of recovery ^ For the special advantages afforded by different localities the reader is referred to the many excellent works upon this subject which have been published. It may be re- marked, however, that dryness of soil and protection from north and east winds, during the winter and early spring, are always essential. The other conditions to be desired must be determined by the requirements of the particular case. In the later stages of the disease, when softening of the consolidating matter has taken place, and cavities have formed, a warmer climate is desirable; but even 298 CHRONIC PULMONARY TUBERCULOSIS in these cases there are great differences in different patients, and some will require a much less degree of heat than others. Unless there be great irritability of the bronchial mucous membrane, dryness of the air is of extreme importance, as a dry air, although warm, still possesses bracing properties. If the lungs are very irritable, a certain amount of moisture is of service ; and many places, both in England and abroad, are recom- mended for such cases. If, however, a suitable climate can be found in their own country, it is well not to send these patients too far from home. Invalids feel acutely the absence of home comforts, and in the last stage of the disease especially, when little good can be hoped for from travel, it is cruel to send them away merely to die. Moderate exercise while out of doors should always be enjoined, due regard being had to the degree of vigour of the patient. This is of great importance, for, unless the weather be warm, a proper action of the muscles is re- quired to stimulate the circulation and prevent the body being affected by the cold. Over-fatigue must, however, be carefully avoided ; and if there be any feeling of cold after a short stay in the open air, it will be necessary to return at once to the house. If the child be strong enough, pony or donkey exercise may be recommended. In cases, however, where the exertion required for riding is too severe, an open carriage can be substituted; and the child can occasionally take a short walk, returning to the carriage when fatigued. Care must be taken that the child is perfectly warm before he leaves the house. If he is chilly when he starts for his airing, his power of resisting external cold is very much impaired. Different exercises should be devised by which the muscles of the arms, chest, and back may be brought into action; and, where the strength permits, quiet outdoor games should be encouraged. Shampooing must not be forgotten; by DIET 299 this means the development of the muscles is aided and the action of the skin promoted. It should be practised every morning after the bath. Indoors, free ventilation must be maintained, while every care is taken to avoid draughts. In winter it is im- portant that the rooms be kept at an even temperature, and that the passages, if possible, bo warmed. If this is impracticable, some extra clothing should be put on in bad cases before the child is allowed to pass from one room to another. The action of the skin must be promoted by warm clothing, and by rapid sponging with water as hot as it can be borne. In every case of lung consolidation cold baths must be forbidden. The shock produced by the first contact with cold water at once drives the blood from the surface to the interior, and causes a sudden increase of the strain upon the vessels of the lungs as well as of the other viscera. Pulmonary congestion may be produced by this means, and the danger of haemoptysis is increased. The diet of the child should be arranged as described under the head of prevention, four small meals being preferable to three larger ones in the day. Plenty of new milk is essential, and should always be given undiluted if it can be borne. Sometimes, however, in these cases there is a tendency to acidity of the stomach. This can be corrected by the addition of lime-water, or of fifteen or twenty drops of the saccharated solution of lime to the milk. On account of the debility of the digestive organs, which is so common in this disease, it is necessary to exercise great care in the selection of the diet. The simplest articles of food are the best, as plain roast beef or mutton, with gravy, mealy potatoes well mashed, milk, and strong beef or mutton tea, free from grease. Clear turtle soup is exceedingly digestible and nutritious. If eggs are allowed they should be lightly boiled or poached, or they may be beaten up with warm milk. 300 CHRONIC PULMONARY TUBERCULOSIS Farinaceous food should enter into tlie diet, but, on account of its tendency to undergo fermentation and produce acid, its effects must be carefully watched, and no more should be given than can with safety be digested. Often the appetite is very capricious, and there is a disgust for meat and for the plainer articles of food, which it is very difficult to overcome. In such cases frequent changes should be made in the diet, tempting the appetite with a small bird, as a quail or a snipe ; with fish, as turbot, cod, or boiled sole, or with raw oysters. The addition of alcohol is often useful in stimulating the appetite : weak burgundy and water, or a large wine-glass- ful of light bitter ale, may be given to a child of six or seven years old, with one of his meals. The occasional administration of two or three grains of hydrargyrum cum creta with a little powdered rhubarb will often improve the appetite when this is failing; or a drop of dilute hydrocyanic acid with five grains of bicarbonate of soda may be given in a bitter infusion, as infus. chirettse, three times in the day."^ The mineral acids in bitter infusion are also of service, but in the case of a child the}^ are, as a rule, inferior in value to the alkaline medicines just mentioned. A careful watch must be kept over the condition of the bowels, for our hopes of improving the nutrition of the body depend entirely upon the accuracy of the per- formance of the digestive functions. Violent purgatives should be avoided. If there is constipation, an occasional dose of castor oil, or decoction of aloes, will be sufficient to produce an evacuation. The more common condition, however, is one in which there is a tendency to relaxation of the bowels, three or four light -coloured offensive motions being passed in the course of the day. In these cases opium is a most valuable medicine, and should be given with aromatic sulphuric acid if the tongue is clean ; * Suitable to a child five years old. COD-LIVEE, OIL 301 or, if there is inucli straining, with mucus in the stools and a furred tongue, it can be given with small doses of castor oil. When the digestive organs have been brought into a healthy state, cod-liver oil and tonics become necessary to continue the improvement. These are as beneficial now as they were injurious so long as there remained any functional derangement of the alimentary canal. Cod- liver oil is of immense service, but care must be taken to proportion the quantity given to the digestive power of the patient. At first half a teaspoonful is a sufficient dose ; it should be taken three times a day after meals in a little milk, orange wine and water, or, better still, in a cold infusion of orange-peel. The dose can be afterwards increased, but the stools should be examined from time to time for undigested oil. I prefer the common brown oil, and often order it to be taken in a teaspoonful of the pancreatine wine prepared by Messrs. Savory and Moore. This preparation is a valuable one for children who have only a limited power of digesting fats. The oil often agrees better when combined with a dose of creasote. At the Victoria Park Hospital we have found that the mixture of the two remedies seems to increase the digesti- bility of both. For a child of five or six years, I give a teaspoonful of the oil with five to ten minims of beech- wood creasote twice or three times a day after food. I have found no advantage from pushing the dose of either drug beyond this point. Under the head of tonics, iron takes the first place. It may be given as vinum ferri ; liquor ferri pernitratis with dilute nitric acid ; the ammonio-citrate ; the potassio-tar- trate ; reduced iron (in doses of half a grain twice a day) ; or the syrups of the phosphate or iodide. If the syrup be objected to, the iodide may be conveniently given as in the following mixture : — 302 CHRONIC PULMONARY TUBERCULOSIS P> Ferri Tartarati, gr. v, Potass. lodidi, gr. iss. Aquae destillatse, ^ss. M. Ft. haustus. To be taken three times a day. Iron has been objected to, as tending to produce irrita- tion and congestion of the lungs and haemoptysis. If, however, it is not given in too large doses, such effects in children are seldom seen to follow its employment. On the contrary, where the condition of the stomach and bowels is satisfactory, its use is generally followed with very great, if only temporary, advantage. Besides iron, other tonics may be given ; as quinine, which may be usefully combined with iron, as in the double citrate of iron and quinine (dose, five grains three times a day suspended in glycerine) ; decoction of cin- chona ; tannic acid, either in a mixture with dilute nitric acid, or as the decoction of oak-bark ; and the tincture of nux vomica. All these may be tried, and sometimes one, sometimes another, will appear to be beneficial. With regard to the special treatment of the lung affec- tion — so long as there is fever, with dry cough or scanty expectoration, and tightness or oppression of the chest, stimulant expectorants are inadmissible. No lowering measures should be employed, it is true; but while, on the one hand, we should avoid all means calculated to increase the depression of strength, we should not, on the other hand, be too eager to administer drugs, the action of which would be to increase the irritation of a mucous membrane already in a state of active congestion. Opium, although it allays for a time the irritability of the bron- chial tubes, must be given with judgment. It is unwise to hinder expectoration, for the secretions are retained in the tubes and act as a source of continued irritation. In such cases we shall best relieve the engorged state of the lung by the administration of remedies tending to produce a copious secretion from the congested mucous membrane. COUGH MIXTURES 303 The child should be confined to bed, or at any rate to one room ; his chest should be kept covered with hot linseed- meal poultices frequently renewed; and a mixture such as the following should be administered every three hours after food : — 5o Vini Antimonialis, mv. Villi Ipecaciianhse, miij, Sp. .3Etheris Nitrosi, Tax\^, Liq. Ammonise Acetatis, 5ss, Aq. Carui ad 5iij. M. Ft. haustus. After the cough has become looser, and the oppression of the chest has subsided, expectorants with small doses of morphia may be given three times a day : — Sp. Ammonise Aromat., mv, Vin. Ipecacuanhse, mv, Liq. Morphise, miij, Syrupi Limonis, 5ss, Aq. ad 5iij. M. Ft. haustus. And afterwards, when the secretion is free, and the fever has subsided, an astringent may be prescribed : — Jjb Liq. Ferri Pernitratis, Acidi Nitrici diluti, aa mij, Liq. Morpbise, -nuij, Oxymel Scillse, mxxv, Aq. ad 5iij. M. Ft. haustus. To be taken three times in a day after food. On account of the derangement of the stomach, which is so apt to be produced by even small doses of the nau- seating expectorants, such as ipecacuanha and squill, it is advisable to combine them with tonics when the state of the patient permits. In this way they are better borne by the stomach, and cause less impairment of the appetite. The alkaline mixture should not be continued too long : when the secretion is quite free, as shown by the looseness of the cough, the ease of expectoration, und the absence 304 CHRONIC PXTLMONARY TTJBERCULOSIS of fever, astringents are required to dry np the secretion, and give tone to the relaxed mucous membrane. Antiseptic inhalations have lately come much into favour. The air of the room at night may be impregnated with the fumes of tar, creasote, or carbolic acid, by means of a vaporising apparatus, such as Dr. E. J. Lee's useful " Steam Draught Inhaler." In the daytime various anti- septics may be inhaled for an hour at a time through a perforated metal respirator. Dr. Coghill, who has devised a convenient form of instrument, combines two drachms each of ethereal tincture of iodine and carbolic acid, with one drachm of creasote and one of rectified spirit. Ten drops of this preparation are poured upon a piece of cotton wool and used in the respirator. The inhalation may be repeated several times in the day. Its effect is to diminish the violence of the cough and render expectoration easier. With the same object ten drops of the oil of cinnamon may be inhaled through the respirator at frequent intervals throughout the day. This oil has been said to have a distinct germicidal effect upon the bacillus. However this may be there can be no doubt about its value in reducing secretion and quieting the attacks of cough. Its action is no doubt the same as that of the creasote already recom- mended. I usually continue its administration until the body of the patient is impregnated with the cinnamon odour. In cases where we have reason to believe the consolida- tion to be owing to cheesy pneumonic deposits, we must do all in our power to hasten the absorption of the caseous mass. Removal to a dry bracing spot is at once indicated, and as soon as possible the child should begin a course of alkaline medicines. Sir Andrew Clark recommends that the urine be kept alkaline for a time. The hypophosphites — especially the hypophosphite of lime — are of peculiar value in these cases. When softening of the deposit is suspected, and there is fever with wasting, the beneficial influence of these remedies is often very surprising. COUNTER-IRRITANTS 305 Counter-irritation in children must be used cautiously. So long as there is fever, with dry cough, &c., hot linseed- meal poultices are the best applications ; and these, com- bined with the measures described above, soon relieve the more acute symptoms. Irritants applied to the chest appear to be most useful when the consolidation is pneu- monic in character. In such cases a liniment of croton oil (5j in 33 of linimentum saponis) may be rubbed into a limited spot twice a day till pustulation, and then once a day for a week ; or the chest may be painted over the seat of disease with linimentum iodi. These measures are, however, only applicable when the pyrexia is slight; if there be much heat of skin counter-irritants must not be employed. In the last stage of the disease we must watch the state of the digestive organs, and endeavour to remove any con- ditions which would tend to increase the debility. If the cough produces retching and sickness, small doses of arsenic, such as one drop of Fowler's solution, given with dilute nitric acid and a few minims of liquor morphiae will usually afford relief. If haemoptysis occur, the child must be kept perfectly quiet in bed ; ten drops of the liquid extract of ergot should be administered three times a day, with laxative doses of Epsom salts if the bowels are not ulcerated, and fluids must only be given in small quantities. Profuse sweating is best controlled by belladonna given in sufficient doses. A night draught containing ten drops of the tincture may be given without hesitation to a child of four years old, and will have greater influence than smaller doses of the drug given more frequently. In cirrhosis of the lung and fibroid phthisis disinfectant and stimulating inhalations are of great service. When- ever an offensive smell from the breath indicates the presence of putrefying secretions in the air-tubes, inhala- tions of steam impregnated with creasote or carbolic acid (twenty drops to the pint of boiling water) should be 20 306 CHRONIC PULMONARY TUBERCULOSIS ordered ; and the air of tlie room should be thoroughly saturated with the fumes of creasote or other disinfectant by means of a vaporiser. Iron and quinine in large doses are well borne in these cases, and should be given with morphia. Emetics must not be forgotten. A quickly acting emetic, by producing violent contractions of the diaphragm, will often cause enormous quantities of offen- sive purulent matter to be brought up. If the loaded tubes are thus evacuated in the morning, the patient will pass the day in much greater comfort, and his appetite and digestion will be improved. Cod-liver oil — especially if given with pancreatine wine — is of much value in these cases. When dropsy comes on, tonics such as strychnia and iron should be administered at once. CHAPTER XI TUBERCULOSIS OF LYMPHATIC GLANDS iHRONIC tuberculous enlargement of the lymphatic glands is a common lesion in the child. It may affect not only the external glands, but also those occupying the thoracic and abdominal cavities. While, however, in the case of the external glands, no other ill effects follow than those necessarily attendant upon the presence of a local- ised tuberculous swelling, in the case of the bronchial and mesenteric glands other evils are induced. These bodies — enclosed as they are in cavities, and in contact with compressible organs — produce by their pressure, when en- larged, secondary disturbances which vary according to the organ whose function is thus interfered with, and according to the more or less yielding material of which the walls of the cavity are composed. Enlargement of the bronchial glands will thus produce more serious consequences — owing to the resisting parietes of the chest — than the same condition of the mesenteric glands which are confined by the more distensible wall of the belly. The manner in which the lymphatic glands become inoculated with the tubercle bacillus has been already ex- plained (see p. 251). Infection of the glands is the first stage in the progress of the microbes from the surface to the interior of the body. In many cases, fortunately, they go no further. If the resisting power of the system be adequate, and the number of the organisms not unduly 308 TUBERCULOSIS OF LYMPHATIC GLANDS large, no ill consequences follow. It may be said of all glands, but especially of those which occupy the cervical region, that in most cases the tuberculosis remains a mere local disease in the glands first attacked, and the system escapes general infection. The glands are not all equally affected. Some remain perfectly healthy, while others are diseased ; some which are diseased remain small, while others undergo consider- able enlargement. As seen in the neck, caseous tuberculous glands are round or oval, hard, uneven on their surface, and their outline is irregular. They are not tender, and the skin over them is colourless, and is not adherent. Sometimes several glands become enlarged and unite, forming a mass the separate parts of which are connected by thickened and condensed cellular tissue. Cheesy glands may remain for a long time unchanged, and while thus inactive are not necessarily hurtful unless they cause interference with function in neighbouring organs by pressure upon parts around. Sooner or later, however, one of two changes usually takes place : — either the cheesy matter softens, sets up inflammation around and is discharged ; or the fluid part of the caseous mass is absorbed, and the gland shrinks and becomes hardened by the deposition of earthy salts. The first of these changes is common in the glands of the neck, while in the mesenteric glands the usual termination is that by shrinking and petrifaction. In rare cases, complete reso- lution and absorption of the cheesy matter may take place ; or the gland may be converted into a fibrous mass by thickening of all the trabeculse of the reticulum. When a caseous gland softens, the process usually begins in the centre, although isolated points at the cir- cumference may first undergo this change. These, on section of the gland, are sometimes seen to be connected by prolongations of softening with the softened centre. THE BRONCHIAL GLANDS 309 Evacuation of the liquefied matter eventually takes place. In the cervical region the softened glands discharge their contents through the skin. The same thing may occur with the bronchial glands, but is not common. As a rule, the deeply seated glands, such as those of the mediastinum and mesentery, rupture into the nearest hollow viscus. The bronchial glands perforate the trachea or a large air- tube; while the mesenteric glands, when suppurating, empty themselves into the general peritoneal cavity, or into the intestine. Tuberculosis of the Bronchial G-lands. Judging from the facility with which the superficial glands swell up in the child, as a result of casual irrita- tion of neighbouring parts, we may infer that a similar enlargement will occur under like circumstances in glands more deeply placed. The bronchial glands are, no doubt, influenced by the presence of irritation in parts in which their lymphatics originate ; and in children who are subject to repeated attacks of pulmonary catarrh, or broncho- pneumonia, evidence of change in these glands can often be detected. The same thing is noticed in most cases of whooping-cough. When thus acutely enlarged, the swelling usually subsides as the irritation lessens. If it become chronic, the enlargement is due almost always to tubercular infection. Unlike the same lesion as it occurs in the neck, suppuration is rare, but few patho- logical alterations are more common in the post-mortem room than enlargement and caseation of glands in the mediastinum. The seat of the enlarged gland is at the bifurcation of the trachea, and therefore behind the first bone of the sternum and a little below it. Besides these, however, the glands accompanying the bronchial tubes into the interior 310 TUBERCULOSIS OF BRONCHIAL GLANDS of the lung may be also increased in size, althougli usually to a less extent ; and it is not uncommon to find them larger than natural as far as the third or fourth divisions of the air- tubes. A mass formed of these enlarged glands may occupy the anterior mediastinum, extending from the top of the sternum to the base of the heart. Tuberculosis of the bronchial glands is not confined to children in whom there is actual disease of lung. It may be found in subjects who have shown no sign of pulmonary derangement, and in whom the most careful examination of the lungs may fail to detect any evidence of pulmonary mischief. Still, we cannot view with indifference the presence of a tuberculous mass however strictly localised. The disease may spread directly from the gland to the lung tissue in contact with it, or may lead to a general infection of the system as has been already described (see page 253). Symptoms. — Children in whom this lesion exists are usually thin and pale. They are also generally languid and indolent, preferring quiet amusements to the more boisterous games, l^utrition is impaired as a consequence of the various catarrhal disorders to which their excep- tional sensitiveness to changes of temperature renders them peculiarly prone. Attacks of pulmonary and gastric catarrh, and of catarrhal diarrhoea, are frequent during the changeable seasons of the year. Owing to these attacks, the digestive organs are not very robust; but between them the child's appetite may be good, and the digestion fairly performed. A tuberculous gland, so long as it remains inactive, does not directly give rise to elevation of temperature ; but the child is subject to irregular attacks of fever, as a consequence of the catarrhal derangements above referred to. If softening in the cheesy mass occur, the event is at once marked by an increase in the heat of the body. SPECIAL SYMPTOMS 311 The special symptoms arising from enlargement of the bronchial glands are all pressure signs due to the encroachment of the swollen body upon the parts around. These special symptoms may best be grouped according to the causes which produce them. Thus the glands by their enlargement may press upon the blood-vessels, the nerves, and the air-passages. Pressure upon the superior vena cava or upon either innominate vein interferes with the return of blood to the heart. As a consequence, we find more or less lividity of the face and neck, and dilatation of the superficial veins, not only in those parts, but also over the front of the chest, and often in the shoulders and arms. A certain amount of heaviness and stupor may be produced by the interference with the return of blood from the brain ; and if the pressure be great, or the quality of the blood much impoverished, puffiness or even oedema of the face may be found, first appearing and being most marked about the eyelids. If only one of the innominate veins is exposed to pressure, the symptoms are limited to one side only. Enlargement of the veins of one side of the face and neck, with a prominent jugular vein on that side, should always lead us to suspect the existence of enlarged bronchial glands. The venous engorgement is especially noticeable during coughing. If the congestion is very great, rupture of small vessels may take place, and bleeding occur from the nose or into the lungs. The former is common, but the latter is difii- cult to ascertain, for children almost invariably swallow blood coming up from the lungs. In a child the discharge of blood from the mouth during coughing is seldom evidence of haemoptysis. It is almost always the result of epistaxis, the blood flowing down into the back of the throat through the posterior nares. When the nerves passing through the chest are com- pressed, one of the earliest indications of such pressure is 312 TTJBEECULOSIS OF BEONCHIAL GLANDS a peculiar character of the cough. The cough becomes spasmodic, occurring irregularly in paroxysms like those of pertussis, lasting only a short time, and ending some- times, although rarely, in a crowing inspiration. There is seldom any vomiting. Sometimes the cough is hoarse and dry ; at others it is moist with a rattling of mucus ; at others, again, its quality is unchanged, and presents nothing to attract attention. The voice, like the cough, may be altered in character, but not usually, unless the disease is far advanced. It may become hoarse or thick, or even partially extinct, and these different conditions frequently alternate with one another. Serious pressure upon the trachea or a large bronchus induces attacks of distressing dyspnoea. These attacks are usually spoken of as asthmatic." The face becomes livid, the countenance haggard, and the skin damp. As a rule the dyspnoea affects both inspiration and expiration, although it is more marked in the latter. With each breath there is a stridor, and the soft parts of the chest sink in deeply in inspiration. Exertion of any kind in- creases the dyspnoea. The voice is unaffected. When these symptoms are met with, especially if at the same time there are signs of pressure upon the vessels of the chest, we have reason to fear suppuration of the glands with the formation of an abscess. If this be the case, perforation of the air-passage is not unlikely to occur. The dyspnoea is then extreme with marked cyanosis ; the cough is convulsive, and the child clutches at his throat and shows every symptom of distress. The pulse and respiration become irregular before death. If pulmonary catarrh occur in a child who is suffering from the above symptoms, the lividity is deepened, the dyspnoea aggravated, the cough becomes more constant and hacking, and the apparent imminence of the danger excites the liveliest apprehensions. Indeed, if prompt PHYSICAL SIGNS 318 measures are not resorted to for the relief of the catarrh, death may take place with some suddenness. Physical signs. — The enlarged glands are seated at the bifurcation of the trachea, and therefore behind the first bone of the sternum. On percussion there is dulness at that spot, which may extend to a variable distance on either side and below. It sometimes reaches from the sternal notch as far as the base of the heart. Occasionally there is dulness also between the scapulae, but this is not always found, on account of the thickness of lung which lies between the glands and the posterior wall of the chest. If any enlarged glands lie underneath the anterior margins of the lungs, a cracked-pot " sound may be heard on per- cussion over the first three ribs. This, however, on account of the natural pliancy of the chest walls in children, is a common circumstance, and is not necessarily a sign of disease. The auscultatory signs are due partly to the effects of pressure of the enlarged glands upon the trachea and bronchi ; partly to the unnatural distinctness with which the breath- sounds are conveyed to the surface, for an artificial medium of conduction is formed between the tubes and the wall of the chest. When the lower part of the trachea is pressed upon, a loud stridor is heard during respiration. This stridor is usually intermittent. It is conducted to all parts of the chest, and to the stethoscope quite covers the normal breath- sound. Upon either bronchus pressure, if consider- able, causes weakness of the respiratory sound in the corresponding lung, especially at the base ; for a certain amount of collapse of the inferior lobes of the lung may take place, with sinking in of the lower part of the thoracic wall on that side. If without actual pressure the glands come into close contact with the bronchi on one side, and the chest wall on the other, the breath- sounds are tubular with long 314 TUBERCULOSIS OF BRONCHIAL GLANDS ringing rhonchus in front, and sometimes between the scapulae behind; powerful ^i^asi-pectoriloquous broncho- phony may also be produced. The vocal resonance also is bronchophonic. At the supra- spinous fossae the sounds may be weak, bronchial, or even cavernous, and these different conditions may alternate irregularly with one another. If, however, there be no disease of the lung, the hollow quality of the breath-sound is very much diminished, or may even be quite lost when the mouth is open. If the gland presses upon a large vein, such as the descending vena cava, or the left innominate vein, a hum will be heard with the stethoscope at that point, and compression of the pulmonary artery produces a systolic murmur, heard at the second left interspace. In cases where the glandular swelling occurs as a com- plication of pulmonary phthisis, the more prominent sym- ptoms are due to the condition of the lung ; so that unless the enlargement be great, the disease in the glands is apt to be overlooked. Moreover, in such cases the physical signs arising from the lungs are often perverted and ex- aggerated by this condition of the glands, as has already been described. The usual termination of enlarged bronchial glands is that by shrinking and petrifaction— a mode of termination which may be considered equivalent to a cure. In rare cases they soften and break down into a thick purulent fluid, which may be evacuated into the pleural cavity, or into a large vessel, causing fatal haemorrhage ; or, more commonly, into a bronchial tube. Softening of the glands is usually followed by a general infection of the system, and the patient dies of acute tuberculosis. Diagnosis. — In a well-marked case the signs of pressure upon the veins, the dulness over the first bone of the sternum extending to a variable distance on each side, and the paroxysmal cough, point conclusively to caseation VENOUS HUM 315 of the bronchial glands. The peculiarity of the cough is, indeed, often the first symptom leading us to suspect the nature of the disease. This is distinguished from the cough of pertussis, which it so much resembles, by the absence of crowing and of the terminal vomiting or glairy expectoration. Such a cough, if unaccompanied by the auscultatory signs of pulmonary disease, is very distinctive of enlarged bronchial glands. The absence of these auscul- tatory signs is very important in the diagnosis, as a morning cough of a very similar character is occasionally heard in cases of fibroid induration with dilatation of bronchi, and is sometimes also characteristic of catarrhal pneumonia. If in the intervals of the fits of coughing there is anything approaching to an asthmatic seizure, or the slightest percussion-dulness at the top of the sternum, little doubt can remain as to the nature of the disease. Alteration in the quality of the voice often accompanies the characteristic cough. If there is doubt in any case, the occurrence of signs of venous pressure at once changes our suspicions into certainty. Well-marked pressure signs are not, however, present until the swelling of the glands has become considerable. At an earlier period, and before the enlargement has be- come sufficiently great to cause symptoms so obvious, the diagnosis of the lesion is far from easy, as the symptoms by which it is accompanied are few and obscure. At this time much assistance can be gained from the following experiment."^ If the child be made to bend back the head, so that his face becomes almost horizontal, and the eyes look straight upwards at the ceiling above him, a venous hum, varying in intensity according to the size and position of the diseased glands, is heard with the stethoscope placed upon the upper bone of the sternum. ^ See a paper by the writer " On the Early Diagnosis of Enlarged Bronchial Glands," communicated to the 'Lancet' of Augnst 14th, 1875. 316 TUBERCULOSIS OF BRONCHIAL GLANDS As the chin is now slowly depressed, the hum becomes less loudly audible, and ceases shortly before the head reaches its ordinary position. The explanation of this phenomenon appears to be that the bending back of the head tilts forward the lower end of the trachea, which carries with it the glands lying in its bifurcation, and the left innominate vein, as it passes behind the first bone of the sternum, is compressed between the enlarged glands and the bone. In cases where this sign has been noticed there has often been some slight dulness over the manu- brium, leading one to suspect the existence of enlarge- ment of the glands ; and the occurrence of the hum thus produced the writer always considers to be evidence con- firmatory of the suspicion. The experiment does not succeed in cases of flat chest when there is no reason to suspect glandular enlarge- ment, nor can the hum be produced by the thymus gland in a healthy child. This gland is immediately behind the sternum in front of the great vessels ; enlarged bronchial glands lie behind the vessels in the bifurcation of the trachea. A swelling in front of the vessels does not appear to set up pressure upon the vein when the head is bent back in the position described. The writer has examined many children with a view to test this point, and in no case has the characteristic hum been produced except where there was reason from other symptoms to suspect the presence of bronchial glandular enlarge- ment. The following cases furnish good illustrations of the symptom in question : — Arthur P — , aged eight years, had had scrofulous disease of the knee-joint for twelve months. The cervical glands were enlarged, and his skin generally was harsh and dry. For two months his breathing had been short, although he had had no spasmodic attacks of dyspnoea. During the same time he had been troubled with a dry, ILLUSTRATIVE CASES 317 hollow cougli. There was slight dulness at the left supra- spinous fossa, and a little crepitating rhonchus was heard there at the end of inspiration. There was no dulness on percussion at the upper part of the breast-bone ; but when the boy held his head back so as to turn his face upwards to the ceiling, a loud continuous hum was heard near the left edge of the first bone of the sternum. This ceased when the chin was brought down again into the natural position. The boy had no swelling of the cervical veins, spasmodic cough, or other sign of enlarged bronchial glands, except the peculiar and characteristic hollow, almost cavernous breathing which is often heard in such cases, when the lips are closed, over the upper part of each lung. This, however, disappeared to a great extent when the mouth was open. Alice T — , aged six years, a pale, thin child, had been weakly for several months, and had been getting thinner. She had no cough to speak of. On stripping the child to examine her chest, it was noticed that the superficial veins at the upper part of the breast-bone and at either side were unusually visible. The veins of the neck were not distended, nor was there any enlargement of the cervical glands. The percussion note on the first bone of the sternum was, perhaps, a little high-pitched. When the child bent her head well backwards, a very loud con- tinuous roaring sound was heard over the first two sternal bones, and extended to the articulation of the second right costal cartilage. The sound ceased when the chin was depressed again. There was no dulness in the inter- scapular region behind. It would be easy to multiply illustrations of this sym- ptom, for slight enlargement of the bronchial glands is very common in children. In order that the hum be ca- pable of being produced in the vein, the glands of the chest must be moveable. If they are fixed, and at some distance from the sternum, the experiment fails. Thus, 318 TUBERCULOSIS OF BRONCHIAL GLANDS in a boy aged three years, the subject of Ij^mphadenoma, who died in the East London Children's Hospital, there was dulness at the upper part of the breast-bone, which was continued down in a pyramidal form as far as the base of the heart. No venous hum was heard on bending back the head. On examination of the body of this child, yellow flattened cheesy masses were found adherent to the inside of the sternum, and others, much enlarged and immoveable, were seen filling up the interval below the bifurcation of the trachea. In this case the alterna- tion in the position of the head did not set up pressure upon the vein, as the glands, being fixed, could not be carried forward against the vessel. The venous hum thus produced by bending back the head seems to be the earliest sign of enlargement of the bronchial glands, preceding dulness on percussion, and occurring long before the ordinary pressure signs on which the diagnosis of the lesion is usually made to depend. Prognosis, — Although the existence in the mediastinum of swollen bronchial glands is not without its danger, yet if the increase in size be moderate, without formidable pressure signs, and especially if the temperature of the body be natural, we have reason to hope that by suitable treatment the enlargement may be reduced before it has occasioned any ill consequences to the patient. The existence of lividity, dilatation of veins, and other signs of interference with the circulation, should excite anxiety ; and attacks of asthma, or of prolonged spasm of the glottis, are of very unfavourable augury. If in such cases the symptoms are aggravated by the presence of pulmonary catarrh the life of the patient is often placed in imminent danger. It should not be forgotten that acute tuberculosis may be the consequence of softening in these glands ; there- fore the temperature of the body should be always care- MESENTERIC GLANDS 319 fully taken, and any abnormal rise, without a cause being- discovered to account for it, should be viewed with con- siderable apprehension. Tuberculosis of Mesenteric Gtlands. Tuberculous enlargement of the mesenteric glands, or, as it used to be called, tahes mesentericay is seldom seen in children under three years of age, and even in older chil- dren is not a common disease. At any rate it is compara- tively rare to find enlargement of these glands so great as to be discoverable by the touch ; and unless they can be felt it is impossible to say with anything approaching to cer- tainty that they are enlarged at all. Unless enlarged, their influence upon general nutrition is probably insig- nificant ; for although they may not be quite healthy, they are no doubt sufficiently so to carry on their functions fairly well. Therefore if no increase in size can be dis- covered, they may be disregarded in estimating the pro- gnosis, or determining the treatment of the patient. When diseased the glands are sometimes separate, but often they unite to form an irregular nodular mass as large as the fist or even larger. The mass is situated in front of the vertebral column. If the mesentery is in- volved, the tumour is fixed ; if the mesentery is free, the mass can be moved a little to one side or the other. Symptoms. — In cases where the disease is moderate in amount, and is confined entirely to the glands of the mesentery without being complicated by chronic peritonitis or any lesion of the bowels, nutrition may be little if at all affected. The child may show a fair amount of flesh ; his spirits and appetite may be good, his temperature natural, and with the exception perhaps of slight want of colour there may be little in his appearance to suggest a suspicion of ill-health. If, however, as often happens, cheesy enlargement of the mesenteric glands is conjoined 320 TUBERCULOSIS OP MESENTERIC GLANDS with tuberculous ulceration of the bowels, there is generally diarrhoea, and the child shows all the signs of a chronic interference with the nutritive processes. He wastes, and grows pale and feeble ; his face looks haggard ; his sleep is disturbed ; his appetite is capricious, and there is often much thirst. At night the bodily temperature is usually higher than natural. The local symptoms are the only ones of any value in the detection of disease of the mesenteric glands. The belly is at first unchanged in shape, and even as the disease advances does not necessarily become more pro- minent. On the contrary, the abdominal wall is often natural ; and when swollen it may be soft and easily depressed; although it is apt to become tense at times from the accumulation of flatus, especially if there is any accompanying ulceration of the bowels. The wall may also be tense when the size of the glands is very consider- ably increased. The degree of tension of the parietes is very important as regards the detection of the enlarge- ment. If the tension be very great, a moderate amount of enlargement may escape notice, owing to the resistance of the abdominal walls, which will not allow the glands to be reached by the finger ; and a tumour which can be easily felt at one visit may at the next be completely con- cealed by the abdominal inflation, so as to be no longer detectable by the touch. In the commonest form of glandular enlargement in the mesentery the diseased glands are small, and can be felt as little tumours of the size of marbles lying deeply in front of the spine. To detect them we should place the child on his back, with his knees drawn up and supported by an assistant, his shoulders low, and his head raised so that his chin touches his chest. If now we make gentle pressure with a warm hand on the abdomen, moving our fingers round and round as we do so, very small lumps can be felt if the wall is flaccid. The glands are sometimes slightly SIGNS OF PRESSURE 321 moveable, if the enlargement is not sufficiently great to in- volve the mesentery in the swelling. There sometimes appears to be a little tenderness on pressure, but the tenderness is not necessarily a sign of in- flammation of the diseased glands, for it is found in cases where no trace of inflammation is discoverable on a post- mortem examination. When the glands reach a considerable size they may press upon neighbouring parts, so as to produce secondary derangements. Thus, pressure upon the nerves may cause cramps in the legs. Compression of the large venous trunks may give rise to oedema of the lower limbs, and dilatation of the abdominal veins. If this venous dilata- tion be very marked, the superficial veins being seen to ramify upon the abdominal wall and to join the veins of the chest wall, enlargement of the mesenteric glands should always be suspected in the absence of chronic peritonitis, or disease of the liver. Ascites is not a common result of the caseation of these glands, and is rarely produced by direct pressure, unless the portal vein be compressed by enlargement of the glands occupying the hepatic notch. Sometimes, however, we find cheesy degeneration of the mesenteric glands com- plicated by tubercular peritonitis. In these cases there is a rise of temperature, with increase of abdominal tender- ness, and colicky pains. The belly becomes tense from gaseous distension of the intestines ; and indistinct fluctua- tion is often felt from adhesion of the bowels one to another, with the addition of a little serous effusion between the coils. Vomiting is not constant, and diarrhoea, if previously present, is not interfered with. The amount of ascites is in these cases not very great, and the sym- ptoms of peritonitis generally are often far from being well marked. In ordinary cases cheesy mesenteric glands after a time diminish in size, and become small and hard by absorp- 21 322 TUBERCULOSIS OF MESENTERIC GLANDS tion of their fluid parts, and tlie deposition of calcareous salts. This may be considered the natural termination of tabes mesenterica. It is rare for the glands to soften, but such an exceptional result of the degeneration is occasionally seen. Adhesion may then take place between the gland and a coil of intestine, so that the softened matter is evacuated into the bowel. Diagnosis. — The diagnosis of enlarged glands in the mesentery can only be made satisfactory by the sense of touch. If we can hold the mass between the finger and thumb, proof of its presence is indisputable, and this proof is the only one which leaves no doubt upon the mind. Enlargement of the belly is no evidence of the glandular disease, for flatulent distension is in children a common accompaniment of ill-health. Wasting, again, is found in almost all forms of chronic illness; and diarrhoea is not necessarily connected with tuberculous abdominal glands. All these symptoms may be present in the case, but they are not characteristic of mesenteric disease, and we should not be justified in founding a dia- gnosis upon them. If, as has been said, the superficial veins are distinctly seen to ramify on the abdominal wall, and to join similar veins on the thoracic parietes, glandular disease may be suspected ; but nothing more than suspicion is allowed by such evidence. Any interference with the portal circula- tion will produce the same result, and when the abdo- minal wall is tense it is difficult to exclude hepatic disease. Even when by direct exploration the existence of a tumour in the belly has been ascertained, we have still to satisfy ourselves that the tumour is formed by enlarged mesenteric glands. The disease may be simulated by faecal accumulation in the colon, or by caseous masses attached to the omentum. Fsecal accumulations are much more superficial than DIAGNOSIS 323 enlarged glands, and are also distinguished by the absence of tenderness; by the situation of the tumour, which usually occupies the traverse or descending colon instead of the umbilical region ; and by the shape of the mass, which is elongated, the long axis being in the direction of the long axis of the bowel in which it is contained. Moreover, the masses can usually be indented by firm pressure with a finger. In doubtful cases a positive opinion should be reserved until the effect upon the swell- ing of a good injection has been tried. For a child of four years old, an enema of a pint or more of soap and water, or thin gruel, containing half an ounce of oil of turpentine and four ounces of olive oil, should be thrown up the bowel by a good syringe. The injection should be retained for a few minutes by firm pressure upon the anus, and then be allowed to escape. If the tumour is due to faecal accumulation, a quantity of pale, brittle lumps will be discharged with the returning fluid, and the swelling previously noticed in the belly will be found to have disappeared. If diseased glands are the cause of the tumour, the evacuation of gas and faecal matter will only make the presence of the enlargement more manifest, by removing the tension of the abdominal wall, and allowing of more efficient exploration of the cavity of the belly. In these cases an enema of sufficient quantity to distend the bowel is of more value than any number of aperients. It is well, also, to remember that faecal accumulation having once occurred, there is great liability to a second collection of the same kind ; therefore for some time afterwards a careful watch should be kept over the condition of the bowels. Between cheesy masses attached to the omentum and cheesy mesenteric glands the distinction is often very difficult, particularly if the seat of the tumour happens to be the umbilical region. When their seat is the omen- tum the masses are more superficial, are less nodular, and 324 TUBERCULOSIS OP MESENTERIC GLANDS have better defined edges than is the case where the glands themselves are diseased. They are usually also more freely moveable. In a case mentioned by MM. Rilliet and Barthez, a cancerous pancreas offered some resemblance to a mass of enlarged glands, but was distinguished by, amongst other signs, the presence of vomiting, jaundice, and abdominal pains. When we have satisfied ourselves as to the existence of caseous mesenteric glands it is important to ascertain if this be the sole lesion discoverable, or if it be complicated by intestinal ulceration or other abdominal mischief. Elevation of temperature, or any indications of marked interference with nutrition, would lead us to suspect the existence of some complication. The most common of these are tubercular peritonitis and intestinal ulceration. In the case of the former we find usually swelling, pain and tenderness of the abdomen, with great tension of the parietes and unequal sense of resistance on pressure of the abdomen. Often there is an obscure sense of fluctu- ation. Ulceration of the bowels is shown by local ten- derness of the belly with some tension of the parietes, combined with the discharge of offensive dark watery motions, containing a deposit of flaky matter, and mucus, with small black clots of blood. Diarrhoea is not, however, present in every case of ulceration of the bowels. The loose frequent stools are not dependent upon the ulceration, but are the conse- quence of the catarrh of mucous membrane which commonly accompanies it. This is apt to vary greatly in intensity ; and the diarrhoea may be better or worse, or may even become arrested for a time, without the breach of surface in the intestinal mucous membrane having necessarily healed. Therefore, even if there be no diarrhoea, the existence of fever with abdominal tender- ness (peritonitis being of course excluded), and of some PROONOSIS 325 colicky pain preceding the evacuations, should give rise to strong suspicion of the presence of intestinal ulceration, especially if the patient be subject to attacks of loose- ness in the bowels. If, in addition, there be evidence of chronic lung disease, the frequency with which tuberculous ulcers of the alimentary canal complicate cases of pul- monary consumption must not be forgotten. Prognosis. — The serious consequences usually associated with mesenteric disease are dependent, not upon the glandular enlargement, but upon the lesions by which it is apt to be accompanied. In an uncomplicated case, apart from the danger which is common to tuberculous glands in general, there is no extraordinary cause of anxiety in caseous degeneration of the mesenteric glands. Indeed, on account of their slight tendency to undergo softening, disease in these glands is perhaps less likely to be followed by ill consequences than a similar affection of any other glands in the body. In rare cases, it is true, where the increase in size is unusually great, the excep- tional dimensions of the tumour may form a special source of danger ; but if the enlargement is moderate and is the sole lesion discoverable, and the temperature of the child is natural, little anxiety need be excited, for so long as the nutrition of the patient remains good there is every reason to hope that the swelling of the glands may sub- side. If, however, the presence of wasting with fever indicates the existence of some complication, the prog- nosis becomes more serious. It is not uncommon for enlarged mesenteric glands to be conjoined with ulcera- tion of the bowels and chronic pulmonary disease. In these cases there is necessarily very great danger, and the progress of the case must be watched with serious appre- hension ; but the danger arises from the condition of the lungs and bowels, and can scarcely be said to be aggra- vated by the glandular enlargement. Tuberculous peri- tonitis is not necessarily fatal if the bowels are intact. 326 TUBERCULOSIS OF MESENTERIC GLANDS but if intestinal ulceration complicates the peritonitis, the patient generally dies. Treatment. — On account of the readiness with which the lymphatic glands, both internal and external, become enlarged in tuberculous children it is of great importance to remove as quickly as possible any local irritations, the continuance of which would lead to the glandular disease. All purulent discharges, skin eruptions, and ulcerations of the skin and mucous membrane must therefore receive prompt attention. " Little " colds must not be neglected, as disease of the bronchial glands is encouraged by pulmo- nary irritation ; and the possibility of caseous enlargement of the glands of the mesentery is an additional reason for keeping a careful watch over the condition of the stomach and bowels. In all cases where there is cheesy degeneration of glands, wherever these may be seated, prompt measures must be taken to improve the general health of the child. To effect this object the dietary should be constructed upon the principle which has already been so strongly insisted on in these pages, that, viz., of suj^plying a sufficient amount of nourishment to the body without undue labour to the digestive organs. This is best done by depending largely upon meat, eggs, fish, and milk, and carefully avoiding excess of farinaceous or other fermentable articles, such as would be likely to cause acidity of the stomach and indigestion. Change of air is of great importance. As soon as pos- sible the child should be removed to some bracing spot, where the air is dry and the soil porous. An inland place is to be preferred to the sea- side. Here the patient may pass his time out of doors whenever the weather permits ; and at night, if the season be temperate, and the air not too damp, his window can be open at the top, so as to insure fl:ee ventilation of the sleeping-room. For some directions upon the important subject of diet and general SPECIAL TREATMENT 327 hygiene the reader is referred to the chapter on chronic pulmonary phthisis. Amongst the means for improving the general health, cold bathing must not be forgotten. Cold douches have been found of special service in the treatment of caseous lymphatic glands ; and if proper precautions be taken, there is little danger of a chill, however apparently delicate the child may be. The best way of employing the cold bath is the following : — The child is made to sit with his feet and lower part of his body in water of the temperature of 100'^ to 101°, and is rapidly sponged with the hot water for one minute. A basin of water at 75° is then emptied over his shoulders as he sits in the bath, and he is quickly dried and dressed. The douche water may be made more stimulating by the addition of a packet of Brill's sea salt." Although the bath is taken before breakfast the child must not be fasting. All children, especially weakly ones, should have a slice of bread or a dry biscuit, and, if possible, a drink of milk, on waking in the morning. With regard to special treatment: — If the gland be external, and there be no signs of softening or suppuration, the liniment of iodine may be painted on the swelling every night ; or the oleate of mercury ointment may be made use of. This latter application should be rather weak (five per cent.), and should be smeared on the part, not rubbed in. It can be used twice a day for five days, then at night only, and afterwards every other day. Iodine ointment is sometimes very successful in removing caseous glands, but the application should be employed with caution, as it may produce sloughing. External treatment must be supplemented by sea air and the internal administration of iron and arsenic in full doses. The above measures are not set forth as the best method of treating chronic tuberculous glands, but they often represent all we can succeed in doing, for it is difiicult to 328 TUBERCULOSIS OF MESENTERIC GLANDS overcome the natural objections of parents to an operation in cases where the symptoms are not pressing and the danger of ill consequences seems to be remote. Still, there is no doubt that removal by surgical procedure of the diseased organs is the quickest and most certain way to obtain a cure. If the affected glands are few and mode- rate in size we may venture to sanction delay ; but this should be done on the understanding that the patient shall be sent at once to a bracing seaside j^lace, and put into the best conditions for recovery. If, however, many glands are diseased, and the patient is a delicate member of a family in which others have already suffered from tuberculosis, further delay would aggravate the risk, and we ought not to hesitate to urge the necessity of removal. This is the more important if there are signs of softening or suppuration. The danger of general infection of the system then becomes pressing, and an operation is impera- tive. When the bronchial glands are found to be enlarged every care should be taken to protect the patient against pulmonary catarrhs and other forms of chest irritation, so as to avoid any aggravation of the already existing evil. The chest should be carefully protected by thick flannel worn next to the skin. Children of both sexes should be provided with a closely fitting flannel under- garment, made to reach up to the neck. Thus guarded, the patient can pass a large portion of the day out of doors ; and the drier the air and more porous the soil of the spot in which he is living the better for his chances of improvement. The diet must be regulated with care, as already directed, and the cold bath, used with all needful precautions, must not be forgotten. Cod-liver oil is of great service in these cases, and the popular remedy — iodide of iron — has no doubt a certain value. This is best given made into a draught by combining iodide of potassium with tartrate of iron in distilled water, the syrup of the iodide, which is TREATMENT • 329 the more favourite form for its administration, being apt to ferment in the stomach and cause acidity. Instead of an iodide, iodine itself may be given, and the internal administration of tincture of iodine in small doses (two or three drops freely diluted) is preferred by some practi- tioners. Blisters, so often recommended in these cases, appear to be attended by but little benefit. The local application of iodine, on the contrary, is often very useful, and frictions with iodine ointment over the upper part of the chest, or painting with the liniment in the same situa- tion, should never be omitted, especially when the glands are of considerable size. In the severe asthmatic attacks little is to be done by antispasmodics, and the harassing cough is not to be con- trolled by narcotics. Energetic counter-irritation with iodine preparations has, however, sometimes seemed to be of service. When the glands of the mesentery are diseased our first care should be to remove any existing irritation of the intestinal canal. Where there is diarrhoea the motions should be inspected, and if the stools are found to consist of putrid- smelling dirty water, with a thick sediment con- taining shreddy matter mixed up with small black clots of blood, there is little doubt that the bowels are ulcerated. In these cases suitable treatment must be adopted, as recommended in the chapter on chronic diarrhoea. Small enemata of thin warm starch containing a few drops of laudanum are very useful. If tubercular peritonitis occur, hot linseed-meal poultices applied to the belly, and opium given cautiously by the mouth, form the best remedies. In cases where the glandular enlargement is uncompli- cated, fresh air, good diet, and cod-liver oil, as before directed, will do all that is necessary. In these cases a broad flannel bandage applied tightly to the belly, and worn well down over the hips, is an indispensable part of the treatment. CHAPTER XII DIET OF CHILDREN IN HEALTH AND DISEASE 0]^^ account of the importance of the subject of diet in relation to children, both in health and disease, the maintenance of their health, and the treatment of their several disorders being mainly dependent upon a proper regulation of their food, it has been thought advisable to devote a chapter especially to this subject. Directions upon this matter, to be of any service at all, must be plain, minute, and exhaustive, l^othing should be left to the discretion of the attendants. The articles of food, the quantity to be given, the hours at which the meals are to be taken, and, when necessary, the exact method in which the food is to be prepared, should be all accurately stated and written down, or mistakes will almost certainly be committed. In the following pages will be found dietaries, carefully arranged and tabulated, suitable to infants and children of various ages, both in health and disease. It should be stated, however, that the quantities given below are not intended to be invariable. It would be impossible to lay down rules which would be found suitable to all children. Some require and can digest much more than others ; the quantities, therefore, must be adapted in each particular case to the needs and capabilities of the child. The amounts of farinaceous food ordered can, however, seldom be exceeded with safety. FROM BIRTH TO SIX MONTHS OLD 331 Diet in Health. 1. PROM BIRTH TO SIX MONTHS OLD. Diet 1. If the child be suckled, and the breast-milk be found in all respects suitable, — No other food should be given. The child should take the breast every two hours for the first six weeks ; afterwards, every three hours, except between 11 p.m. and 5 or 6 a.m. In cases where the secretion of milk is slow to be estab- lished, and the quantity drawn is insufficient to supply the wants of the infant, the following food may be given as an addition to the breast-milk, until the secretion becomes sufficiently abundant : — One tablespoonful of fresh cream. Two tablespoonfuls of whey.^ Two tablespoonfuls of hot water. Half a teaspoonful of sugar of milk. This mixture must be taken from a feeding-bottle. Or, we may make use of condensed milk for a month or two, diluted with eight or nine times its bulk of water. Condensed milk should not, however, be depended upon as the sole food of the infant after the end of the third month. Diet 2. If the infant be brought up by hand : — For the first few days the mixture of whey, cream, and * Fresh whey is supplied in London to order by the Aylesbury Milk Company ; but it is better to make the whey at home by means of "Benger's curdling fluid," which makes a beautiful whey very quickly. Full directions are given on the bottles. 332 DIET IN HEALTH hot water (see above) may be given, but before the end of the week we should make a trial of cow's milk boiled in a water-bath or sterilised. Milk, one tablespoonful. Fresh barley-water, two tablespoonfuls. Water, one tablespoonful. Cream, a teaspoonful. Sugar of milk, a flat teaspoonful. Bicarbonate of soda, a small pinch. Or, Milk, one tablespoonful. Lime water, one tablespoonful. Water, two tablespoonfuls. Cream, a teaspoonful. Sugar of milk, a flat teaspoonful. The quantities of these ingredients may be varied from day to day or even from meal to meal, according to the state of the child's digestion. Probably in a very few days the proportion of milk will have to be increased ; but at first it is better to give too little than too much ; and if the stools contain lumps of curd and the child cry with colicky pains, the milk must be further diluted so as to reduce the percentage of proteids. If there be vomiting or a relaxed state of the bowels, we should lessen the quantity of cream. In any case as the child grows the allowance of milk in his meals must be increased, and by the end of the second month he should be taking a third part of milk, or even more if we find he can digest it. Our object is to give the child as much food as his system requires, but no more. It is important not to stint the infant, or he will fret day and night from hunger. On the other hand, we must be just as careful not to overload him with food ; still, if we proceed step by step, and the child show no sign of indigestion, we may progressively FROM BIRTH TO SIX MONTHS OLD 333 increase his proportion of milk without fear of upsetting his stomach. In the case of most hand-fed children it is found useful to introduce a certain variety into their diet, for by this means digestion is undoubtedly encouraged. With this object extract of malt may be used as a sweetener in alternate meals, or the following may be given in rotation with the others. It sometimes happens, indeed, that the infant can only be efficiently nourished on the condition that no two meals in the same day are composed of exactly the same materials. Milk and water with gelatine (see p. 38). Mellin's food, one teaspoonful. Milk, one part. Fresh barley-water, two parts. Cream, a teaspoonful. Peptonised milk (see p. 46). Allen and Hanbury's No. 1 food. Diet 3. If the infant be partially suckled, the breast-milk being poor and scanty, — The breast must be given only twice a day. For the other meals the child must be fed as directed in Diet 2. All these foods should be sweetened to taste with white sugar or sugar of milk, and if poor in fat may be fortified by a spoonful of cream. N.B. — It is important that the materials used should be perfectly fresh. Stale cream, whey, or barley-water is sure to disagree. 334 DIET IN HEALTH 2. FROM SIX TO TWELVE MONTHS OLD. Five meals in the day. Diet 4. First meal, 7 a.m. One teaspoonful of baked flour carefully prepared, with a teacupful of milk and Sweetened with a small teaspoonful of extract of malt. (See page 49.) Second meal, 10.30 a.m. ; and Third meal, 2 p.m. A tablespoonful of Mellin's food, in a breakfast- cupful of milk thickened with a teaspoonful of gelatine. Fourth meal, 5.30 p.m. Same as the first. Fifth meal, 11 p.m. Same as the third. For the second meal, twice a week, may be given the yolk of one egg, beaten up with a teacupful of milk. The method of preparing baked flour is given on page 49. Chapman's entire wheaten flour should always be used. It is much to be preferred for children to the ordinary wheaten flour, containing as it does the phos- phates of the wheat, and the cerealin, a peculiar body which changes starchy matters into dextrine. If there be constipation, a teaspoonful of fine oatmeal can be used instead. Sometimes in the case of infants of nine or ten months old Mellin's food with milk alone does not seem suffi- ciently satisfying. In these cases it is advisable to add to the meal a teaspoonful of baked flour. The flour is FROM SIX TO TWELVE MONTHS OLD 335 first rubbed up with the milk, as directed on page 49, and the Mellin's food is added afterwards. Diet 5. For a child about ten months old. First meal, 7 a.m. A tablespoonful of Mellin's food. A teaspoonful of Chapman's flour (bated). A breakfast-cupful of new milk. Second meal, 10.30 a.m. A tablespoonful of pearl barley jelly ^ dissolved in a breakfast-cupful of warm milk, and sweetened with white sugar. Third w.eal, 2 p.m. The yolk of one egg beaten up in a teacupful of milk, and sweetened with white sugar. Fourth meal, 5.30 p.m. Same as the second. Fifth meal, 11 p.m. Same as the first. Diet 6. To alternate with the precediiig. First meal, 7 a.m. Half a teaspoonful of cocoatina,t boiled for one minute in a breakfast-cupful of milk. * Put two tablespoonfuls of washed pearl barley into a saucepan, with a pint and a half of water, and simmer down to a pint. Strain away the barley and allow the liquid to set into a jelly. t In cocoatina a considerable portion of the fatty matter is removed. It is, therefore, more digestible than the ordinary cocoas, and far better adapted for an infant's diet. A dessertspoonful of Mellin's food may be added to this meal if thought desirable. 336 DIET IN HEALTH Second meal, 10.30 a.m. A breakfast-cupful of milk alkalinised, if necessary, by fifteen drops of the saccharated solution of lime, and thickened with a teaspoonful of isin- glass or gelatine and sweetened. Third meal, 2 p.m. A teacupf ul of beef tea * (half a pound of meat to the pint) thickened with barley and strained. A rusk. Fourth meal, 5.30 p.m. A tablespoonful of pearl barley jelly, dissolved in a breakfast-cupful of milk and sweetened. Fifth mealy 11 p.m. Same as the second. It is advisable, as a rule, to avoid giving intermediate meals, and therefore the meals should be made sufficiently large to satisfy all reasonable demands. If the child requires food before 7 a.m., on waking from sleep, a little milk may be given him. A healthy child, between ten and twelve months old, will require a pint and a half of milk in the twenty-four hours. * Beef tea is to be made in the following way : — Put half a pound (or a pound, according to the strength required) of rump steak, cut up into small pieces, into a covered copper saucepan, with one pint of cold water. Let this stand by the side of the fire for four or five hours, and let it then simmer gently for two hours. Skim well and serve. The meat used should be as fresh as possible — the fresher the better — and should be cleared beforehand of all fat or gristle. If this precaution be neglected, a greasy taste is given to the beef tea which cannot be afterwards removed by skimming. The saucepan used should be made of copper or tin. Iron saucepans should not be used unless enamelled. In re-warming beef tea which has been left to cool care must be taken to warm the tea up to the point at which it is to be served, and no higher. It should on no account be allowed to boil. FROM TWELVE TO EIGHTEEN MONTHS OLD. 337 3. FROM TWELVE TO EIGHTEEN MONTHS. Diet 7. First meal, 7.30 a.m. A rusk, or a slice of stale bread, well soaked in a breakfast-cupful of new milk. Second meal, 1 1 a.m. A drink of milk ; a plain biscuit or slice of thin bread-and-butter. Third meal, 1.30 p.m. A teacupful of good beef tea (a pound of meat to the pint) or of beef gravy, with rusk. A good tablespoonful of light farinaceous pud- ding. Fourth meal, 5.30 p.m. Same as the first. Fifth meal, 11 p.m. (if required). A drink of milk. Diet 8. (To alternate with the preceding.) First meal, 7.30 a.m. The yolk of a lightly boiled egg. A slice of thin bread-and-butter. A cupful of new milk. Second meal, 11 a.m. A drink of milk. A slice of thin bread-and-butter. Third meal, 1.30 p.m. A mealy potato, well mashed with a spoon, moist- ened with two tablespoonfuls of good beef gravy. A cupful of new milk. 22 338 DIET IN HEALTH Fourth meal, 5.30 p.m. A rusk or slice of stale bread, well soaked in a breakfast-cupful of milk. Fifth meal, 11 p.m. (if required). A drink of milk. The fifth meal, at 11 p.m., should never be given un- necessarily. The sooner a child becomes accustomed to sleep all night without food the better. When, however, he wakes in the morning, refreshed by his night's rest, he should never be allowed to remain fasting for an hour or more until his breakfast is prepared. A drink of milk or a thin slice of bread-and-butter should be given at once. Some children will take larger quantities than others at one meal ; but if the meals are made very large their number must be reduced in proportion. Many children between twelve and eighteen months old will be found to do well upon only three meals a day, as in the following : — Diet 9. First meal, 8 a.m. One teaspoonful of baked flour. One teaspoonful of fine oatmeal. Three-quarters of a pint of fresh milk. A little white sugar. Second meal, 1 p.m. The same, with the addition of the yolk of one egg. Third meal, 5 p.m. Same as the first. In this diet the baked flour and the oatmeal are first beaten up till smooth, with four tablespoonfuls of cold water, and are then boiled. The milk and sugar are then added, and the mixture is boiled till it thickens. FROM EIGHTEEN MONTHS TO TWO YEARS OLD 339 For the second meal the yolk of egg is stirred up in the saucepan and boiled with the rest. If the child requires anything early in the morning, or at 11 P.M., he may take a drink of milk, or a thin slice of bread-and-butter. A healthy child of a year to eighteen months old will usually take from a pint and a half to two pints of milk in the four-and-twenty hours. 4. FROM EIGHTEEN MONTHS TO TWO YEARS OLD. Diet 10. First meal, 7.30 a.m. A breakfast- cupful of new milk. A rusk, or half a slice of bread soaked in the liquid fat of hot fried bacon. Second meal, 1 1 a.m. A cup of milk and a biscuit. Third meal, 1.30 p.m. Underdone roast mutton, pounded in a warm mortar, a good tablespoonful. One well-mashed potato moistened with two or three tablespoonfuls of gravy. For drink, filtered water or toast- water. Fourth meal, 5.30 p.m. A breakfast- cupful of milk. Thin bread-and-butter. After the age of eighteen months it is well to omit the meal at 11 p.m. A healthy child of eighteen months old should sleep from 6 p.m. to 6 a.m. without waking. 340 DIET IN DISEASE Diet 11. (i^or a child of the same age.) First meal, 7.30 a.m. A breakfast-ciipful of new milk. The lightly boiled yolk of one egg. Thin bread-and-butter. Second meal, 11 a.m. A cup of milk. Third meal, 1.30 p.m. A breakfast-cupful of beef tea (a pound of meat to the pint), containing a few well-boiled aspara- gus heads when in season, or a little thoroughly stewed flower of broccoli. A good tablespoonful of plain custard pudding. Fourth meal, 5 30 p.m. A breakfast-cupful of milk. Bread-and-butter. These diets can be given on alternate days Between the ages of two and three years the same diets may be continued. Meat can, however, be given every day, and a little well- stewed fruit may be occasionally added . The morning and evening meals should always consist principally of milk. Diet in Disease. DIET IN INFANTILE ATROPHY. (For a child of two or three months old, brought up by hand, weakly and emaciated, in whom, milh with lime-water DIET IN INFANTILE ATROPHY 341 excites griping and flatulence, with occasional attacks of vomiting and purging. ) In these cases special attention must be paid to the cleanliness of the feeding-bottle. It is important, also, that meals consisting of milk or other fermentable matter be prepared in small quantities as they are wanted — to avoid fermentation. We can often succeed in rendering the milk and lime- water digestible by adding an aromatic — such as a tea- spoonful of cinnamon- water — to the food. If this do not succeed, one of the following diets can be tried : Diet 12. The child to be fed every two or three hours from a feeding-bottle with the following, in alternate meals : 1. One teaspoonful of Mellin's food for infants dissolved in a teacupful of new milk and barley-water (equal parts), with the addition of one teaspoonful of cinnamon or dill water. 2. Two teaspoonfuls of Mellin's food dissolved in a tea- cupful of fresh whey and barley-water (equal parts) . Bovinine, ten drops. If the amount of milk giveil above cannot be digested, as often happens, the proportion of barley-water used to dilute the milk may be increased to two-thirds ; or in some of the meals the milk may be altogether omitted. Instead, we may use barley-water, whey, or equal proportions of barley-water and weak veal or chicken broth, in which the Mellin's food can be dissolved. In the place of ordinary milk we may use strippings " (see page 45), or ass's or goat's milk. In the above diets the quantities given at each time of feeding must be proportioned rather to the strength of the 342 DIET IN DISEASE child than to his age. The more weakly the infant, the smaller and more frequent should be the meals. In cases where the weakness and emaciation are great, the child, for a few days, should be fed solely upon white wine whey. Afterwards, when the strength has begun to return, the wine whey may be given in alternate meals with peptonised milk. Diet 13. White wine whey (see page 113). Peptonised milk (see page 46). These foods to be given alternately in such quantities as the infant is found to digest without difficulty. It is best to begin with a tablespoonful every half -hour; but this quantity will soon have to be increased. As the meals get larger the intervals between them must be lengthened. If cow's milk, however prepared, causes indigestion and flatu- lence, a desiccated milk food will often agree with the stomach. In that case one of Allen and Hanbury's foods (No. 1 or No. 2) may be substituted in this diet for the peptonised milk. DIET IN CHRONIC DIARRHCEA. {For a child ten or twelve months old, who can hear milk; purging not very severe.) Diet 14. A teaspoonful of Mellin's food' for infants every three hours, dissolved alternately in milk and barley-water (equal parts), and in equal parts of weak veal broth and barley-water. If no milk at all can be digested, a good diet is the following : DIET IN CHRONIC DIAREHCEA 343 Diet 15. First meal, 7 a.m. One tablespoonful of Mellin's food for infants, dis- solyed in a teacupful of veal broth and barlej- water (equal parts). Second meal, 11 a.m. One dessertspoonful of cream in a teacupful of fresh whey. Third meal, 2 p.m. The unboiled yolk of one egg beaten up with fifteen drops of brandy ; a tablespoonful of cinnamon water ; and a little white sugar. Fourth meal, 5 p.m. Four ounces of veal broth (a pound to the pint) thickened with pearl barley and strained. Fifth meal, 11 p.m. Same as the first. After a week or ten days a little milk can be introduced into the diet, beginning cautiously, and only once in the day. Thus, for the first meal, milk may be substituted for the veal broth, and be added to the barley-water and Mellin's food. If this be found to agree, the same change may be made in the fifth meal. Another, consisting partially of milk, for a child of twelve months old : Diet 16. First meal, 7 a.m. One teaspoonful of cocoatina boiled for one minute with a teacupful of milk. Second meal, 10 a.m. A teacupful of veal broth (a pound to the pint) thickened with barley and strained. 344 DIET IN DISEASE Third meal, 2 p.m. A teacupful of milk alkalinised with fifteen drops of saccharated solution of lime. Fourth meal, 5 or 6 p.m. The yolk of one egg beaten up with brandy and cinnamon- water, as in Diet 15 ; or beaten up with a teacupful of veal broth and barley- water (equal parts). Fifth meal, 11 p.m. One tablespoonful of Mellin's food for infants dis- solved in a teacupful of warm milk. If the child be much reduced by the purging, the diet should be simpler in character, and the meals should be smaller, more frequently repeated, as in the following : — Diet 17. (For a weakly child of twelve months old.) First meal, 7 a.m. Four ounces of peptonised milk. Seco7id meal, 9.30 a.m. Four ounces of veal broth (half a pound to the pint) thickened with barley and strained. Third meal, noon. A tablespoonful of pearl barley jelly, dissolved in four ounces of whey. Fourth meal, 2.30 p.m. Four ounces of milk and lime-water (equal parts), with a teaspoonful of cinnamon-water. Fifth meal, 5 p.m. ' Two teaspoonfuls of Mellin's food for infants dis- solved in four ounces of barley-water. Bovinine, ten drops. DIET IN CHRONIC VOMITING 345 Sixth meal, 9 p.m. Same as the second. During the night whey or barley-water may be given, or one of the desiccated milk foods. If the purging be very severe, all regular meals must be discontinued. Any of the above varieties of liquid food may be selected ; and of this the child can take one tablespoonful every half-hour. Milk, however, is seldom found to agree ; but Diet 13 may be tried. DIET IN CHRONIC VOMITING. In this disorder the food must be given in minute quantities, one teaspoonful in many cases being all that can be retained at one time. This may be repeated every twenty minutes. In bad cases milk must be strictly for- bidden. Choice may be made from the following : — Diluted whey with cream, as in Diet 1. Yeal broth and barley-water (equal parts). One teaspoonful of Mellin's food for infants dis- solved in four ounces of whey and barley- water (equal parts), or in equal parts of weak veal broth and barley-water. White wine whey (see page 113). Whatever the food may be, it should be given cold, not lukewarm. If the vomiting be only occasional and not severe. Diet 17 may be tried, suiting the quantities to be given at one time to the degree of irritability of the stomach. Pan- creatised milk sometimes is well borne in these cases. If the infant be much exhausted, it is best to trust solely to white wine whey given cold, and in small quantities, at regular intervals. When the vomiting has ceased the infant may begin to 346 DIET IN DISEASE take regular meals, and milk can be returned to ; but frequent change should be insisted upon. It is best to order three foods to be given in rotation during the day, and for the night a desiccated milk food, such as Allen and Hanbury's No. 2 or Nestle' s food. Thus : — Diet 18. Benger's food with cow's milk. Savory and Moore's food with milk. Mellin's food with milk and barley-water (equal parts) . To be given in rotation. Nestle' s food for the night, if required. See also Diets 2, 4, 5, 6, and 16. DIET IN RICKETS. Here the kind of diet will depend in a great measure upon the condition of the alimentary canal. In almost all cases it will be found that farinaceous food has been supplied in excessive quantities, and the amount will have to be considerably reduced. If the bowels are relaxed, with loose, slimy, offensive motions. Diets 15 and 16 will be suitable. If the motions are healthy, Diets 5, 6, 7, 8, 10, 11, may be made use of, according to the age of the child. If the child be sixteen or eighteen months old the following is of service : — Diet 19. First meal, 7.30 a.m. A tablespoonful of Mellin's food for infants, dis- solved in a teacupful of milk. Half a slice of stale bread soaked in liquid bacon fat. DIET IN MUCOUS DISEASE 347 Second meal, 11 a.m. A breakfast- cupful of milk alkalinised by fifteen drops of the saccharated solution of lime. Third meal, 2 p.m. A good tablespoonful of well-pounded mutton chop with gravy, and a little crumbled stale bread or a rusk. Or a good tablespoonful of the flower of broccoli stewed until quite tender. A cupful of beef tea (one pound to the pint) . Thin bread-and-butter. For drink toast-water. Fourth meal, 6 p.m. A tablespoonful of Mellin's food, dissolved in a breakfast-cupful of new milk ; a rusk. Or (if no meat has been given) the lightly boiled yolk of one egg. Thin bread-and-butter. Milk and water. DIET IN MUCOUS DISEASE. (Farinaceous food is as much as possible to be avoided.) Diet 20. {For a child ahotd seven years of age and upwards.) Breahfast, 8 a.m. Three quarters of a pint of fresh milk alkalinised by twenty drops of the saccharated solution of lime. A thin slice of well-toasted bread. Fresh butter. A fresh egg, lightly boiled or poached. 348 DIET IN DISEASE Dinner, noon. A mutton chop without fat, broiled. Well-hoiled cauliflower or French beans, according to season. A thin slice of well- toasted bread. Half a wine-glassful of Hoff's extract of malt. Tea, 4 p.m. Milk and thin bread-and-butter. Sardines, or a little boiled fish. Supper, 7 P.M. A breakfast- cupful of beef tea (a pound to the pint). A thin slice of dry toast. Diet 21. (For the same.) Breakfast, 8 a.m. Half a pint of new milk, alkalinised with fifteen drops of the saccharated solution of lime. A slice of cold roast beef or mutton. A thin slice of well-toasted bread. Dinner, noon. A little boiled sole or turbot (without melted butter) . A thin slice of stale bread. Chocolate blanc-mange (made with gelatine, not cornflour) . A sherry-glassful of light claret, diluted with an equal bulk of water. Tea, 4 P.M. A poached egg on a thin slice of dry toast. Milk and water. Supper, 7 P.M. Three-quarters of a pint of alkalinised new milk. DIET IN PULMONARY PHTHISIS 349 Diet 22. (For the same.) Breakfast, 8 a.m. One teaspoonful of Cadbury's cocoa essence boiled for one minute in half a pint of milk. A slice of thin dry toast. A thin rasher of fat bacon, crisply broiled. Dinner, noon. The wing of a roasted or boiled fowl. A little well-boiled flower of cauliflower or well- stewed celery. A slice of thin dry toast or stale bread. Baked custard pudding. Half a wine-glassful of HofE's extract of malt. Tea, 4 p.m. Half a pint of alkalinised milk. A lightly boiled egg. ' A thin slice of dry toast. Supjper, 7 p.m. A breakfast-cupful of beef tea (a pound to the pint). A thin slice of dry toast. It would be unnecessary to occupy space by giving more diets of the same kind. The above will serve as illustra- tions of the kind of food to be recommended. Two of the meals should always consist principally of milk. For the other meals selection should be made from the following : — Meats :—Eoast or boiled beef ; roast or boiled mutton; roast or boiled fowl (without sauces) ; roasted pheasant, turkey, lark, snipe, pigeon, or quail. Fish: — Boiled cod, turbot, mackerel, or sole; raw oysters; bloater; kippered herring ; sardines. Eggs : — Boiled or poached. 350 DIET IN DISEASE Soup : — Clear turtle ; beef or veal tea. Vegetables: — Cauliflower; turnip greens; asparagus; young French beans ; Spanish onion, lettuce, or celery (stewed) . For drink : — Sound claret or burgundy diluted with water ; toast-water ; milk and water. DIET IN PULMONARY PHTHISIS. In pulmonary phthisis farinaceous food, and, indeed, all fat-forming material, is of value ; but usually the capability of digesting this food is not very great, as in almost all such cases there is a tendency to acid dyspepsia. In arranging the diet, therefore, the greatest attention must be paid to the capabilities of the child, so that no more be given him than he is able readily to digest. Diet 23. (For a child of seven years and upwards.) Breahfast, 8 a.m. Half a pint of new milk alkalinised with fifteen drops of the saccharated solution of lime. A lightly boiled egg. Thin bread-and-butter. Dinner, 12 or 1 p.m. A slice of roast beef or mutton with gravy. A mealy potato well mashed. Custard or batter pudding. For drink, an ounce of sound claret diluted with twice its bulk of water. Tea, 4 or 5 p.m. A teaspoonful of chocolate or cocoa boiled with half a pint of milk. Thin bread-and-butter or a rusk. DIET IN PULMONARY PHTHISIS 351 Supper, 7 or 8 P.M. Half a dozen raw oysters. Bread-and-butter. The ordinary cocoa is to be preferred for the third meal, if it can be digested. If it seems too heavy, cocoatina may be used instead. Diet 24. {For a child of the same age.) BreaTcfast, 8 a.m. Alkalinised new milk, as much as desired. A rusk, or bread-and-butter. A rasher of broiled bacon. Dinner, 12 or 1 p.m. A slice of boiled leg of mutton. A well-boiled carrot or turnip. A spoonful of savoury omelet. For drink, claret and water, as before. Tea, 4 or 5 p.m. Bread and milk. Supper, 7 or 8 p.m. A small basin of tapioca soup or of clear turtle soup. Diet 25. . {For the same age.) Breakfast, 8 a.m. Bread and milk. Dinner, 12 or 1 p.m. Roast or boiled fowl. A mealy potato. Chocolate blanc- mange (made with gelatine). Claret and water. For dessert, a good bunch of sweet grapes. DIET IN DISEASE Tea, 4 or 5 p.m. A lightly boiled egg. Thin bread-and-butter. Half a pint of milk. Or, the egg may be beaten up raw with the milk. Supper, 7 or 8 p.m. A basin of strong beef tea. INDEX. A. PAGE Abdomen, large, in infants . . . .8 „ „ causes of . . . .8 „ „ in rickets . . , 137 „ tenderness of, in ulceration of bowels . . 84 Abdominal bandage . . . .55, 86, 95 „ disease, cry in . . . .7 „ pain may prevent sucking . . .53 Accumulation of flatus in belly . . . .8 „ fsecal matter . . . .8 Acidity, treatment of . . . . .58 Acute diarrhoea . . . . .27 „ „ treatment of . . , .64 „ „ in rickets .... 139 „ „ inherited syphilis . . . 207 „ disease, dangers of . . . .3 „ „ secondary . . . .3 „ indigestion . . . . .27 „ „ treatment of . . . .64 Adenoid growths, a cause of chest distortion . . 130 ,, hollow breathing . . 275 „ „ laryngismus stridulus . . 141 Advantage of early suckling . . . .32 Air, change of, in mucous disease . . . 226 „ „ rickets . . . . 167 „ „ pulmonary phthisis . . . 297 Alcohol in mucous disease .... 220 Alkalies, their value in artificial feeding . . .59 ,, in chronic pulmonary phthisis . . . 304 „ in mucous disease .... 222 23 354 INDEX PAGE Aloes in mucous disease .... 222 Analysis of bone in rickets . . . . 151 „ human milk ... 17, 20 Anatomical characters of tuberculous glands . . 308 „ chronic intestinal catarrh . . 80 „ „ rickets . . . . 149 Anthelmintics ..... 240 Aphthse . . . . . .28 an obstacle to sucking . . . .53 „ treatment of . . . . . 64 Aperients for infants . . . . .56 Appetite in chronic diarrhoea . . . .68 „ pulmonary phthisis . . . 267 „ mucous disease .... 221 „ rickets ..... 135 „ wasting children . . . ^ .28 Aromatics in the treatment of infants' complaints . . 59 Articulations in rickets ..... 134 " Artificial human milk " . . . .36 „ feeding . . . . .34 Ascaris lumbricoides ..... 228 „ „ a cause of chronic diarrhoea . . 79 ,, „ admission of, into body . . 231 „ „ description of . . . 228 „ ,, migrations of . . . 237 „ „ symptoms produced by . . 336 „ „ treatment of ... 241 Ascites, a cause of big belly . . . .8 „ causes of . . . . .8 „ in tuberculous mesenteric glands . . . 321 Ass's milk . . . . . .44 „ analysis of . . . . .44 „ laxative effect of . . . .44 Asthmatic seizures in caseous bronchial glands . . 312 Astringents in chronic diarrhoea . . . .99 „ ,, pulmonary phthisis . . . 304 Atrophy, infantile . . . . .16 „ „ diagnosis of . . . . 257 Auscultation of chest in children .... 275 Auscultatory signs in caseous bronchial glands . . 313 „ „ fibroid induration of lung . . 280 „ „ pneumonic phthisis . . . 278 „ „ tubercular phthisis . . . 277 INDEX 355 B. PAGE Bacillus, the tubercle ..... 249 Baked flour . . . . . .49 Bandage, flannel, to belly . . .55, 86, 95, 167 Barley-water, preparation of . . . .37 „ usefulness of . . . 37, 39, 113 Bath, cold . . . . . .13 „ „ danger of, in phthisis .... 299 „ hot . . . . . .13 ,, mercurial ..... 205 „ mustard . . . . .13 „ warm, for constipation , . . . .58 „ „ colic . . . . .62 „ convulsions . . . .62 Belladonna, its effect in arresting perspirations . . 171 Belly, large, causes of . . . . .8 ,, „ in rickets ..... 137 „ „ weakly babies . . . .8 Bending of ribs in rickets .... 128 Benger's food . . . . .40 Bilious attacks in mucous disease .... 214 Bismuth in chronic diarrhoea . . . .98 Blisters for caseous bronchial glands . . . 329 „ inadmissible for infants . . . .12 Blood in sputum ..... 267 stools . . . . .69 Blowing breathing, value of . . . . 275 Bone, analysis of, in rickets .... 151 „ arrest of growth of, in rickets . . . 134 ,, caries of, a cause of phthisis . . . 295 „ deformities of, in rickets . . . .123 „ syphilitic disease of ... . 183 Bones, flat, in rickets, changes in . . . . 150 „ of face, arrest of development of . . . 124 „ skull, ossification of, in rickets . . . 151 „ ,, „ syphilis . . 183, 190 ,, reconsolidation of, in rickets . . . 151 Bothriocephalus latus ..... 230 „ ,, description of . . . 230 „ „ treatment for . . . 244 Bowels, tuberculous ulceration of . . .81 Brain, enlargement of, in rickets . . . 155 INDEX Breast, pigeon, in consumptive children PAGE . 264 „ „ rickets 128 „ refusal of 52 Breast-milk, analysis of . 17, 20 „ differences in 17 Breathing, bronchial, in phthi sis . „ cavernous, value of . . 277 „ harsh, in phthisis . 275 „ in tuberculous bronchial glands . 312 „ pulmonary pht lisis „ weak, in phthisis . 277 Bridge of the nose flattened in inherited syphilis . 180 Bronchi, dilated, diagnosis of . 289 signs of Bronchial glands, tuberculous . 309 >j sj y> altered voice from . 312 >} 3> )3 asthma from . oU j» 5> auscultatory signs of . 313 )> >y blistering for )) j> J> cough, character of 312 i> }j jj diagnosis of . 314 yy 3y >J douche, tepid, in treatment of . 327 yy yy » engorgement of veins from . 311 yy yy yy epistaxis from . 311 yy yy yy haemoptysis from . 311 yy yy yy hoarse voice from Q1 9 ol^ yy yy yy pressure on nerves from oil yy yy yy „ trachea from . 312 yy yy yy „ veins from . . 311 yy yy yy rupture of vessels in . 311 yy yy >y symptoms of . . 310 yy yy yy termination of yy yy J> venous hum from . 315 Bronchitis, an obstacle to sucking . 52 „ in rickets . 138 Buttocks, rash on, in inherited syphilis . 180 c. Calomel for chronic vomiting .... 117 „ inherited syphilis .... 204 Carpo-pedal contractions in rickets . . . 141 Casein of cow's milk, coagulability of . , 20, 30 INDEX 357 PAGE Casein of human milk, coagulability of . . ' .20 Catarrh in rickets . • . . . . 138 „ „ danger of . . . . 138 „ „ treatment of . . . . 171 „ of bowels . . . . .66 „ stomach ..... 105 Causation of chronic diarrhoea . . . .76 „ „ pulmonary phthisis . . . 262 „ „ vomiting .... 108 infantile atrophy . . . .17 „ large belly in infants . . .7 „ mucous disease .... 216 „ refusal of breast . . . .52 „ rickets . . . . . 160 Cavernous breathing, value of . . . . 277 Cavities in lung, diagnosis of . . . . 289 Cerebral disease, cry in . . . .7 ,, sinuses, thrombosis of . . . .71 Cestode worms ..... 227 Change of air in phthisis .... 297 „ „ mucous disease .... 226 „ „ rickets .... 167 Changes, morbid, in bones in rickets . . 124, 150 Chapman's flour . . . . .48 Characters, anatomical, of chronic intestinal catarrh . . 80 „ „ rickets . . . 149 Chest, deformed, in consumptive children . . 264 „ ,, rickets .... 128 „ examination of, in children . , . 273 „ expander, the , . . . . 296 „ shape of, in consumptive children . . . 264 „ small, in phthisis .... 264 Chronic diarrhoea . . . . .66 „ „ abdominal pain in . . .67 „ „ appetite in . . . .67 „ „ bad feeding a cause of . . .77 „ „ blood in stools in . . .69 „ causation of . . . .76 ,, „ complications of . . .70 „ „ convulsions in . . . .70 M J, counter-irritation in . . .95 „ „ dentition in , . . .73 „ diet in . . . .90 INDEX PAGE Chronic diarrhoea, diagnosis of . . . .82 ,, „ mode of death in , . . .72 „ „ morbid anatomy of . . .80 „ „ nitrate of silver for . . * . 99 „ „ oedema in . . , , 70 „ „ pneumonia in . . . .70 „ „ prevention of . . . .85 „ „ prognosis in . . . .85 „ raw meat in . . . . 100 „ „ serous effusions in . . .70 „ „ stimulants in . . . . 100 „ „ stools, characters of . . .68 „ „ thrombosis of cerebral sinuses , . .71 „ „ tongue in . . . 68, 72 „ ,y tonics in . . . . 101 „ „ treatment of . . . .88 „ „ ulceration of bowels in . . .80 „ hydrocephalus in rickets . . . . 125 „ interstitial keratitis in inherited syphilis . . 187 „ intestinal catarrh. See Chronic diarrhoBa. „ pulmonary phthisis. See Phthisis, „ vomiting ..... 125 „ arsenic in . . . . 116 „ „ causation of . . . . 108 „ „ diagnosis of . . . . 110 „ „ diet in . . . . Ill „ „ emetics in . . , . 117 „ „ modes of death in . . . 107 „ spurious hydrocephalus in . . 107 „ „ stimulants in . . . . 117 „ „ warmth, importance of, in . . 110 „ „ white wine whey in . . . 113 Cicatrices, linear, in inherited syphilis . . 182, 196 Cirrhosis of lung. See Fibroid induration. Clavicle, deformity of, in rickets .... 130 Cleanliness of feeding-bottles, necessity of . . . 43,47 Cleft palate an obstacle to sucking . . .53 „ feeding-bottle for . . . .53 Climate, change of, in mucous disease . . . 226 „ „ phthisis . . . .297 „ rickets .... 107 Colic, treatment of . . . . .62 Colour of face in chronic bowel complaint . . 6, 67, 72 INDEX 359 PAGE Colour of face in exhaustion . . . .6 „ „ indigestion . . . .6 „ „ inherited syphilis . , . 182 „ „ mucous disease .... 213 Coma from over-dose of santonine . . . 242 Condensed milk . . . . .45 „ „ inefficiency of, after second month . . 45 Consolidation of bone in rickets .... 152 Constipation in infants, cause of . . . .24 „ „ treatment of . . .56 Convulsions, reflex, rare in wasted infants . . .4 „ from indigestion . . . . 4, 63 „ „ „ treatment of . . .63 „ fj worms .... 236 „ in rickets ..... 140 „ „ treatment .... 174 Corrosive sublimate in inherited syphilis . . . 203 Coryza syphilitica . . . . . 179 Cough from cheesy bronchial glands . . . 312 „ „ fibroid induration of lung . . . 272 „ in pulmonary phthisis .... 265 Counter-irritants . . . . .12 „ in chronic diarrhoea . . .95 „ disease of bronchial glands . . 329 „ pulmonary phthisis . . . 305 „ precautions in using . . 12 Cow's milk, analysis of . . . . 20, 44 „ artificially digested . . . .45 ,, indigestibility of . . . .43 „ preparation of, for infants . . 37, 45 Cowhage for worms ..... 243 Cracked- pot percussion note .... 275 Cracks on skin in inherited syphilis . . . 182 Cranio-tabes in rickets ..... 126 „ syphilis ..... 196 Cream in artificial feeding . . . .50 Creasote, value of, in phthisis .... 301 Cry of infants, characters of . . . .7 „ in inherited syphilis, quality of . . . 182 Curvature of spine in rickets .... 127 Cysticercus cellulosse ..... 232 360 INDEX PAGE Debility of stomach a cause of vomiting . . • . 117 Decay of teeth in rickets .... 127 Deformities of bone in rickets . . . . 123 chest . . . . .128 clavicle ..... 130 „ femur ..... 132 humerus . . . . . 130 „ pelvis ..... 131 „ radius and ulna . . . . . 130 scapula ..... 131 skull . . . . .125 „ spine ..... 127 tibia . . . . .132 Delayed symptoms in inherited syphilis . . . 186 Dentition, care required during . . . .88 „ in chronic diarrhoea . . . .73 inherited syphilis .... 183 rickets ..... 127 „ progress of, no guide to weaning . .51 Derangement, digestive, accompanying worms . . 283 „ in mucous disease . . . 215 rickets . . 122,136 Description of worms ..... 227 Development of tsenia ..... 232 Diagnosis of chronic diarrhoea . . . .82 „ „ vomiting . . . . 110 „ dilated bronchi .... 289 „ enlarged bronchial glands . . . 314 „ fibroid induration of lung . . . 287 „ phthisis .... 289 „ inherited syphilis .... 194 „ mucous disease .... 218 „ pneumonic phthisis .... 284 „ rickets ..... 156 ,, tubercular phthisis .... 282 „ tabes mesenterica . . . . 322 „ ulcerated bowels . . . .84 „ worms ..... 238 Diarrhoea, acute . . . . .27 ,, „ treatment of . . . .64 „ „ in rickets .... 139 INDEX 361 PAGE Diarrhoea, acute, in rickets, treatment of . . . 172 „ chronic. See Chronic diarrhoea. „ lienteric . . . . .76 „ „ character of stools . . .76 „ „ nature of . . . .76 „ „ symptoms of . . . .76 „ „ treatment of . . . . 103 Diet after weaning . . . . .54 „ general directions on . . . .10 „ in chronic diarrhoea . . . 90, 342 „ „ vomiting . . . Ill, 345 „ infantile atrophy ... 34, 340 „ mucous disease .... 219, 347 phthisis .... 299, 350 rickets .... 166, 346 „ of wet-nurse . . . . .31 Dietaries ...... 331 Dilated bronchi, diagnosis of , . . . 289 Discharge from nose in inherited syphilis . . . 179 Diseased bone, early removal of . . . . 295 „ in inherited syphilis . . . 183 Displacement of liver and spleen ... 8, 137 Douche, tepid, in treatment of tuberculous glands . . 327 Drilling, use of, in expanding chest . . . 296 Dulness on percussion, value of . . . .273 Dumb-bells, use of . . . . . 296 Dyspnoea in enlarged bronchial glands . . . 312 E. Early symptoms of rickets . . . . 120 Ecthyma, syphilitic .... . 181 Effusions, serous, in chronic diarrhoea . , .70 Elastic bandage to loose joints . . . .170 „ tissue in sputum . . . . 289 Emaciation in chronic diarrhoea . . . .67 „ „ phthisis .... 268 „ „ vomiting .... 106 „ mucous disease ... . . 214 „ rickets ..... 136 Emphysema in rickets ..... 152 Empyema, diagnosis of . . . . . 288 Enema, astringent . . . . .99 INDEX PAGE Enema for constipation . . , .57 „ in diagnosis of faecal accumulations , , 323 Enlargement of liver in rickets . . . 137, 153 lymphatic glands . . 153, 308 „ mesenteric glands . . . 319 „ spleen in rickets . . . 137, 153 „ „ inherited syphilis . . . 194 Epilepsy as a sequel of rickets .... 142 Epistaxis from caseous bronchial glands . . . 311 Eruptions on skin from indigestion . . .25 „ „ in inherited syphilis . . . 180 Examination of belly in mesenteric disease . . 320 „ chest in children . . . 273 „ liver and spleen . . . .9 „ stools in cases of wasting . . 22, 69, 257 Exhaustion, signs of, in infants . . . .7 Expectorants, value of . . . . . 303 Expectoration, rarity of, in young children . . . 266 Expression of infants, importance of noting . . 5 „ in rickets ..... 136 External applications . . . . .10 „ in chronic diarrhoea . . .95 „ ,, vomiting . . . 118 Eyelids, lividity of , . . . .6 E. Face, colour of . . . . .6 „ in inherited syphilis . . 7, 182 Faecal accumulations, diagnosis of . . . 323 Farinaceous foods . . . . .48 „ injurious in mucous disease . . 219 Fat, percentage of, in breast-milk . . 17, 20 „ „ cows' milk . . . .20 Feeding, artificial . . . . .34 Feeding-bottle . . . . .43 „ cleanliness of . . . 43, 47 ,, for cleft palate . . . .53 Feet, cold, a cause of catarrh .... 167 griping pain . . .61 Femur, deformity of, in rickets .... 132 Fibroid induration of lung .... 263 „ „ causes of . . . • 263 INDEX 363 PAGE Fibroid induration, cough in . . . . 272 „ „ diagnosis of . . . . 289 „ „ dilated bronchi in . . 272, 289 „ „ expectoration in . . , 272 „ „ symptoms of . . . . 271 „ „ treatment of . . . . 305 „ phthisis, diagnosis of . . . . 290 ,, ,, sputum in . . . . 289 Fits, "inward'' . . . . .27 „ screaming, in infants . . . .25 „ „ ^ soothing effect of friction in . .61 Flannel bandage to belly . . . 55, 86, 95, 167 „ „ in rickets .... 167 Flat bones, changes in, in rickets . . . .150 Flatulence . . . . . .24 „ treatment of. . . . .59 Flatus a cause of big belly . . . .8 Flour, baked, mode of preparing . . . .49 Fontanelle, importance of examining . , .7 „ in chronic hydrocephalus . . . 125 „ exhaustion . . . .7 „ inherited syphilis .... 183 „ rickets ..... 125 Food, Melliu's, for infants . . . .40 „ improper, cause of diarrhoea . . .77 „ „ „ rickets .... 163 „ „ „ vomiting . . . 108 Frequency of suckling . , . . .33 Fresh air in the treatment of mucous disease . . 226 „ „ phthisis . . . 298 „ „ rickets . . . 167 Frictions . , . . . .10 „ for constipation . . . .58 „ rickets ..... 171 screaming fits . . . .61 „ mercurial ..... 204 oily . . . . .10 G. Genal line . , . . . .6 General management of infants . . * .55 Genito-crural nerve, stimulation of . . .4 INDEX PAGE Glands, bronchial, tuberculosis of . . . . 309 „ cervical, enlarged in inherited syphilis . . 184 „ lymphatic, tuberculosis of . . . 307 „ mesenteric, tuberculosis of . . . 319 Goat's milk . . . . . .44 „ „ analysis of . . . . .44 Good figure, best mode of forming . . . 294 Grey powder in inherited syphilis .... 203 Griping from cold feet . . . . . 61 „ pain, treatment of . . . .61 Growth of bone, arrest of, in rickets . . . 133 Gymnastic exercises ..... 296 H. Habitual constipation . . . . 24, 56 Haemoptysis in diseased bronchial glands . . .311 „ rarity of, in children . . . 266 Hair, fall of, in inherited syphilis . . . 182 „ growth of, in scrofulous children . . . 252 Hand-feeding of infants . . . .34 Hardening system, the . . . . . 295 Harsh respiration ..... 275 Heart, displacement of, in fibroid induration of lung . . 280 Hoarse voice in diseased bronchial glands . . . 312 „ „ infants . . . . .7 „ inherited syphilis .... 194 Hot bath . . . . . .12 „ in colic . . . . .62 „ constipation . . . .56 „ convulsions . . . .62 „ method of giving . . , . .13 Humerus, deformity of . . . . . 130 Hunger, sign of, in infants . . . .33 Hydrocephalus, chronic, in rickets . . . 142 „ spurious .... 107 „ „ treatment of . . . 118 I. Improper food a cause of chronic diarrhoea . . 77 „ vomiting . . 108 „ rickets . . . 163 INDEX 366 PAGE Incontinence of urine in mucous disease . . . 211 Increased peristaltic action of bowels . . .75 Indigestibility of cow's milk . . . .21 Indigestion, acute . . . . .27 „ „ treatment of . . . .64 Infantile atrophy . . . . .16 „ „ causation of . . . .17 „ „ symptoms of . . . .22 „ „ treatment of . . . .30 Infants, examination of cliest in . . . .273 „ general management of . . . .55 „ hand-feeding of . . . .34 „ secondary diseases in wasting . . .3 Influence of soils on phthisis .... 297 Inherited syphilis ..... 177 „ „ appearance of first symptoms . .177 „ chronic interstitial keratitis . . 186 „ „ complexion in . . . . 182 „ coryza in . . . . 179 cry in . . . . 182 „ „ delayed symptoms , . . . 186 „ dentition in . . . . 183 „ „ diagnosis of . . . . 194 diet in . . . .205 „ „ disease of bone . . . 188 „ liver. . . .192 „ „ „ spleen . . . 194 „ „ thymus . . . 177 „ „ ecthyma .... 181 „ „ erythema . . . , . 180 fall of hair in . . . .182 ,, „ fontanelle in , . . . 183 „ „ infection after birth . . . 178 „ influence of parents on . . . 197 „ „ local applications . . . 208 „ local peritonitis in . . . 193 „ „ mercurial baths . . . 205 „ „ „ inunctions . . . 204 „ „ mucous patches . . . 181 „ „ „ „ treatment of . . 208 ,, „ necrosis of nasal bones . . . 180 „ „ nodes .... 184 „ „ notched teeth .... 186 INDEX PAGE Inherited syphilis, paralysis in . . . . 186 „ „ prevention of . . . . 202 „ „ prognosis in . . . . 200 „ 3, relapses in . . . , 187 „ skin eruptions .... 180 „ „ splenic enlargement in . . . 184 „ symptoms of . . . . 177 tonics in . . . . 209 „ ,y treatment of . . . . 202 „ „ ulcerations in . , . . 181 „ „ vomiting in . . . 201, 207 „ „ wasting in . . . . 202 Injections in chronic diarrhoea . . . .99 Innominate vein, pressure on . . . 311, 316 Inoculation of syphilis . . ^ . . 200 Intellect in rickets ..... 137 Internal remedies, general remarks . . .15 Intestinal catarrh . . . . .66 " Inward fits " . . . . .27 Iodide of iron in inherited s^'philis . . . 209 „ „ disease of bronchial glands . . 328 J. Jadelot's lines . . . . .5 Joints, diseased, in inherited syphilis . . , 183 „ loose, in rickets ..... 134 Jugular vein, distended in disease of bronchial glands . 311 K. Kamala for tape-worms ..... 245 Keratitis, chronic, interstitial .... 186 L. Labial line . . . . . .6 Large belly in rickets ..... 137 ,, „ weakly children . . . .8 Laryngeal sounds, conduction of . . . . 276 Laryngismus stridulus in rickets .... 140 „ „ „ treatment of . . 175 Laryngitis, cry in . . . . .7 INDEX 367 Late talking in rickets ..... 137 walking in rickets. .... 135 Lateral curvature of spine in rickets . . . 127 Ligaments, relaxation of, in rickets . . . 135 Lime, hypophosphite of, in phthisis . . . 304 Lime-water to dilute cow's milk . . . .37 Linear cicatrices ..... 182 Lips, lividity of . . . . .6 Lithotomy in rickety children .... 131 Liver disease in inherited syphilis .... 192 „ enlarged, a cause of big belly . . .8 „ in rickets . . . 137, 153 „ mode of examining . . . .9 Local peritonitis in inherited syphilis . . . 193 Looseness of joints in rickets .... 134 Lungs, examination of, in infants .... 273 Lymphatic glands, enlarged, in rickets . . . 154 „ „ tuberculosis of . . . 307 M. Malformation of permanent teeth . Malt, value of. Malted foods . Massage, value of Maternal suckling Measles a cause of refusal of breast Meat for young children „ raw, for chronic diarrhoea Medicated milk in treatment of syphilis Mellin's food . Mercurial treatment of inherited syphilis Mesenteric disease, infrequency of „ glands, tuberculosis of. Method of hand-rearing of infants Migration of worms Miliaria from sweating . Milk, abundant, behaviour of child when " artificial human ass's condensed cow's, sometimes indigestible goat's . 368 INDEX Milk, human and cow's milk compared „ medicated, in treatment of inherited syphilis „ of syphilitic mothers „ pancreatised Mobility of joints in rickets Motionless belly in respiration Movement of nares in respiration . Mucous disease „ diagnosis of „ diet in . „ symptoms of „ treatment of Mucous patches „ treatment of Muscles, voluntary, in rickets Mustard bath .... „ for chronic diarrhoea „ chronic vomiting . N. Nares, movement of, in respiration Nasal bones, necrosis of . „ furrow .... „ obstruction a cause of refusal of breast Nematode worms Nervous sensibility diminished Nettlerash a sign of indigestion . Nipple, retraction of, an obstacle to suckling Nitrate of silver in chronic diarrhoea Nodes in inherited syphilis Notching of permanent teeth Nurse, test of a good O. Oculo-zygomatic furrow (Edema of face in caseous bronchial glands . „ feet and hands in chronic diarrhoea „ lower limbs in mesenteric disease Oil of male fern for tape- worm „ use of, for external application Opium a cause of vomiting PAGE 20 203 203 46 134 7 7 210 218 219 210 219 181 208 155 13 95 118 7 . 180 6 53, 202 . 227 3 . 25 . 52 . 99 . 184 . 186 . 17 6 . 311 . 70 . 321 . 244 . 11 . 110 INDEX 369 PAGE Ossification of bone in rickets .... 149 Otitis in infantile atrophy . . . .29 Over-feeding of infants . . . . .18 Oxyuris vermicularis ..... 227 „ „ treatment for . . . 240 P. Pain shown by expression of face . . , .6 „ in belly . . . . . .5 „ chest . . . . . .5 „ head . . . . . .5 Pancreatised foods . . . . .45 Papain, value of . . . . .97 Parasitic stomatitis . . . . .26 „ „ treatment of . . . .64 Patches, mucous ..... 181 „ „ treatment of . . . . 208 Pelvis, arrest of growth of, in rickets . . . 131 „ deformity of, in rickets . . . 131, 158 Pepsine, value of . . . . .97 Peptonised milk . . . . .45 Percussion, importance of two fingers in . . . 273 Perforation of septum nasi .... 180 Pericardium, white patch on . . . . 153 Peristaltic action of bowels increased . . .75 Peritonitis complicating mesenteric disease . . 321,324 „ in inherited syphilis .... 193 Perspirations in rickets . . . . . . 121 Pertussis a cause of mucous disease . . . 216 Perverted ossification of rickety bone . . . 148 Phthisis, fibroid . . . . .290 „ „ diagnosis of . . . . 290 „ pneumonic ..... 270 „ „ diagnosis of . ' . . . 284 „ „ physical signs of . . .278 „ „ symptoms of . . . . 270 „ „ treatment of . . . . 296 „ tubercular chronic primary . . . 269 „ „ causation of . . . . 261 „ „ diagnosis of . . . . 282 „ „ pathology of . . . . 261 24 INDEX PAGE Phthisis, tubercular chronic primary, physical signs of . 277 „ „ symptoms of. . . . 269 Pigeon-breast in phthisis .... 264 „ ,y rickets .... 128 Pneumonia a cause of refusal of breast . . .53 „ in chronic diarrhoea . . . .70 „ without symptoms . . . .4 Poisoning by santonine ..... 242 Pomegranate bark for tape-worm .... 245 Pony exercise for phthisical children . . . 298 Precautions against cold ... 89, 167 Premature weaning sometimes necessary . . .52 Preparations of mercury for treatment of inherited syphilis . 203 Pressure on nerves of chest .... 311 „ superior vena cava .... 311 „ trachea ..... 312 „ veins of abdomen .... 321 Prevention of chronic diarrhoea . . . .85 „ phthisis ..... 293 ., rickets ..... 164 „ transmission of syphilis . . . 202 Prognosis in caseous bronchial glands . , . 318 „ „ mesenteric glands . . . 325 „ chronic diarrhoea . . . .85 „ inherited s^^philis .... 200 ,, pulmonary phthisis .... 290 „ rickets . . . . . 159 Prolapsus ani, treatment of . . . . 247 Proteids, percentage of, in breast-milk . . 17, 31 Pulmonary phthisis — see FMMsis. Purgative enemata . . . . .57 R. Radius and ulna, deformities of . . . » . 130 Raw meat for chronic diarrhoea .... 100 Reconsolidation of bone in rickets . . . 145 Recovery from chronic diarrhoea . . . .73 „ rickets ..... 145 Red gum . . . . . .25 Reflex convulsions . . . . .4 „ „ rare in cachectic infants . . 4 Refusal of breast by infants . . . .52 INDEX 371 ■ PAGE Relapses in chonic diarrhoea .... 102 „ inherited syphilis . . . . 187 Relaxation of ligaments in rickets . . . 135 Respiration, harsh ..... 275 „ in rickets .... 129, 139 „ pulmonary phthisis . . . 275 „ weak ..... 275 Retraction of nipple . . . . .52 Rhubarb in treatment of acidity . . . .58 Rickets . . . . . .120 „ analysis of bone in . . . . 151 „ arrest of growth of bone in . . . 133 „ catarrh and bronchitis in . . . . 138 „ causes of . . . . . 160 „ chronic hydrocephalus in ... 142 „ climate for ..... 167 „ collapse of lung in . . . . 152 „ complications of ... . 138 „ convulsions in . . . . . 140 „ deformities of bone in . . . . 123 „ diagnosis of . . . . . 156 „ diarrhoea in . . . . . 139 „ diet in .... . 166 „ enlargement of ends of bones . . 12^, 134 „ „ liver and spleen . . . 153 „ epilepsy as a sequel of . . . . 142 „ general symptoms of . . . 121, 135 „ general tenderness in . . . . 121 „ intellect in . . . . . 137 „ laryngismus stridulus in . . . . 140 „ lithotomy in . . . . . 131 „ loose joints in . . . . . 135 „ mode of death in ... . 145 „ morbid changes in bones . . . 123, 149 „ ossification of bone in . . . . 149 „ pathology of . . . . . 149 „ pigeon-breast in .... 128 „ prevention of . . . . . 164 „ prognosis in . . . . . 159 „ scurvy in ..... 143 skull in . . . . .124 „ softening of bones in . . . . 123 „ spinal curvature in . . . . 127 372 INDEX Rickets, splints, value of „ sweating in talking late in . „ teething in „ tonics, time of giving „ treatment of „ walking late in . Rules for choosing nurse . 170 . 121 . 137 126, 145 . 168 . 165 135, 157 . 17 S. Saliva, time of first secretion of . . . . 38 Salts, their value in nutrition . . . .19 Santonine in treatment of worms .... 241 „ poisonous effects of . . . . 242 Scaly eruption in inherited syphilis . . . 180 Scapula, deformity of, in rickets .... 131 Schneiderian membrane, mucous patches on . . 180 Screaming fits in children . . . .25 „ treatment of . . .61 Scrofulous diathesis, type of . . . . 252 ,, pneumonia — See Pneumonic phthisis. Scurvy, complicating rickets .... 143 „ „ „ treatment of . . . 176 „ during treatment of chronic diarrhoea . . 94 Sea-air in rickets ..... 167 Second dentition a cause of mucous disease . . . 217 Secondary acute diseases in wasted children . . 5 Septum nasi, perforation of . . . . 180 Serous effusions in chronic diarrhoea . . .70 Shampooing, value of . . . . .14 ,, in rickets . . . . .171 Shape of chest in phthisical children . . . 264 ,, „ rickets .... 128 Sign of hunger in infants . . . .33 Silver, nitrate of, in chronic diarrhoea . . .99 Size of liver, to estimate . . . .9 ,, spleen . . . . .9 Skin, tint of, in chronic diarrhoea . . 67, 72 „ „ inherited syphilis . . . 182 „ ,, mucous disease .... 213 Skull, shape of, in hydrocephalus .... 125 „ „ rickets .... 125 INDEX 873 PAGE Slimy tongue in mucous disease .... 211 Snuffling in syphilis .... 179, 195 Soils, influence of, on phthisis .... 295 Somnambulism in mucous disease . . . . 211 Spasmodic cough in pulmonary cirrhosis . . . 272 Spine, deformities of, in rickets .... 127 Spleen, enlargement of, in inherited syphilis . 184, 194 „ „ rickets . . . 137 „ method of examining . . . .9 Spurious hydrocephalus ..... 107 „ „ treatment of . . . 118 Sputum, elastic tissue in ... • 289 Stethoscope, use of, in examining infants . . . 275 Stethoscopic signs in pulmonary phthisis . . . 275 Stimulants . . . . . .15 „ indications for giving . . . .7 Stomach, irritability of, in inherited syphilis . 204, 207 Stools, blood in . . . . .69 „ character of, in chronic diarrhoea . . 67, 69 „ examination of, in cases of wasting . . 22, 69, 257 " Strippings " . . . . . .45 Strophulus a sign of indigestion . . . .26 Suckling, first time of . . . . .32 „ frequency of . . . . .32 „ obstacles to . . . . .52 Sugar, its use in nutrition . . . .19 Supra-spinous fossa, blowing breathing at . _ . . 283 Symptoms of chronic diarrhoea . . . .67 „ „ phthisis .... 265 „ „ vomiting .... 105 „ infantile atrophy . . . .22 „ inherited syphilis .... 177 „ mucous disease .... 210 „ rickets ..... 121 „ worms ..... 233 Syphilis and rickets, connection between . . . 164 „ inherited — see Inherited syjphilis. „ miscarriage a result of . . . 177, 196 „ secretion of milk in . . . . 203 System, the hardening ..... 295 374 INDEX T. PAGE Tabes mesenterica, abdomen in . . . . 320 „ ascites in . . . . 321 „ „ cramps of limbs in . . , 321 „ „ diagnosis of . . . . 322 „ „ prognosis in . . . . 325 „ „ symptoms of . . . . 319 „ „ treatment of . . . . 329 Taenia medio-canellata ..... 230 „ solium . . . . . . 229 „ „ treatment for .... 244 Talking, late in rickets ..... 137 Tears, a favourable sign in chronic diarrhoea . . 85 Teeth, care required during cutting of . . . 88 „ early decay of, in rickets .... 127 „ late appearance of, in rickets . . . 126 „ malformation of permanent . . . 186 Teething in chronic diarrhoea . . . .73 „ inherited syphilis . . . .183 „ rickets . . . . . 127 Temperature in chronic diarrhoea . . . .69 „ „ vomiting .... 107 fibroid lung . . . . 272 „ pneumonic phthisis . . .270 „ tubercular phthisis . . . 269 Tenderness, general, in rickets .... 121 „ of belly in tabes mesenterica . . . 321 „ ,, ulceration of bowels . . 84 Test of a good nurse . . . . .17 Thigh bone, deformities of, in rickets . . . 132 Thorax, shape of, in phthisical children . . . 264 „ „ rickets . . . . 128 Thrombosis of cerebral sinuses . . . .71 Thrush . . . . . .26 ,, a cause of refusal of breast . . .53 „ treatment of . . . . .64 „ value of, in prognosis . . . .26 Thymus gland, disease of ... . 177 Tibia, deformity of, in rickets .... 132 Tint of skin, in chronic diarrhoea . . .6, 67, 72 „ „ inherited syphilis . . . 182 „ mucous disease .... 213 INDEX 376 PAGE Tissue, elastic, in sputum .... 289 Tongue in acute indigestion . . . .28 „ chronic diarrhoea ... 68, 72 chronic vomiting .... 106 „ mucous disease . . . . 211 „ spurious hydrocephalus . . . 107 Tongue-tie, an obstacle to sucking . . .53 „ rarity of true . . . .53 Tonics . . . . . .15 „ in inherited syphilis .... 209 „ mucous disc ise .... 225 „ rickets ..... 168 Trachea, pressure on . . . . . 312 Treatment, general, of wasting . . . .10 „ of acidity of stomach . . . .58 „ aphthae . . . . .64 „ chronic diarrhoea . , . .88 „ „ pulmonary phthisis . . . 296 « M vomiting . . . .110 „ colic in infants . . .62 constipation in infants . . .56 convulsions from indigestion . . .63 „ „ in rickets . . .174 „ diarrhoea in inherited syphilis . . 207 „ „ rickets .... 172 „ fibroid lung .... 305 „ infantile atrophy . . . .30 „ inherited syphilis .... 202 „ laryngismus stridulus . . . I75 „ mucous disease .... 219 « patches .... 208 „ prolapsus ani .... 247 „ rickets . . . . , 165 scurvy . . . . .176 „ spurious hydrocephalus . . .118 „ thrush . . . . .64 „ vomiting in syphilis . . , 207 „ „ gastric catarrh . . . no „ worms ..... 240 Tricocephalus dispar ..... 228 Tubercle bacillus .... 249, 261 Tubercular phthisis — see Phthisis. Tuberculosis secondary to pneumonic phthisis . 263, 270, 285 376 INDEX PAGE Tuberculosis secondary to rickets .... 145 Tuberculous ulceration of bowels . . . 81, 83 Turpentine in treatment of convulsions . . .63 M tape-worm . . . 246 Type of scrofulous diathesis . . •. . 252 „ tuberculous diathesis .... 252 U. Ulceration of bowels, diagnosis of . . . . 84 „ „ symptoms of . . .84 „ „ tuberculous . . . .81 „ nasal mucous membrane . . . 180 Ulcerations, linear, in inherited syphilis . . . 184 Unsuitable food a cause of chronic diarrhoea . . 77 „ 99 99 vomiting . . 108 „ „ infantile atrophy . . 16 „ „ rickets . , . 163 Urine, incontinence of, in mucous disease . . .211 ,, in rickets ..... 155 Urticaria, a sign of indigestion . . . .25 y. Vaccination an importer of syphilis . . . 200 Value of aromatics for infants . . . .59 Vein, portal, pressure on . . . . 321 Veins, pressure on, in tabes mesenterica . . . 321 Vena cava, superior, pressure on . . . . 316 ,, innominata, left, pressure on . . 311, 316 Vermifuges ...... 240 Venous engorgement of face and neck . . . 311 Vocal vibration in infants .... 273 Voluntary muscles in rickets .... 155 Vomiting, chronic — see Chronic vomiting. „ danger of, in inherited syphilis . . . 201 ,, in acute indigestion . . . .27 „ „ „ treatment of . . .64 „ in inherited syphilis . . . 201, 207 ,, „ treatment of . . 207 W. Walking, lateness of, in rickets . Warm baths for constipation 135, 157 . 58 INDEX 377 PAGE Warmth in chronic diarrhoea . . . .89 „ „ . vomiting .... 110 „ inherited syphilis . . . . 206 „ phthisis ..... 295 rickets ..... 167 Wasting, causes of . . . . .2 from over-feeding . . . .21 from vomiting .... 106 in chronic diarrhoea . . . .68 „ „ phthisis .... 268 „ mucous disease .... 214 ,, rickets ..... 136 Weak respiration, value of . . . . 275 Weaning, dentition no guide to . . . .51 „ diet after . . . . .54 „ method of . . . . .52 „ time of . . . . .51 Wet-nurse, diet of . . . . .31 „ rules for choosing . . . .17 „ test of a good . . . .30 Whey, use of, in hand-feeding . . 91, 112, 331, 343, 345 „ white wine ..... 113 Whitlow in inherited syphilis .... 182 Whooping-cough a cause of mucous disease . . . 216 Wind-pipe, lumbricus in ... . 237 Woman's milk, analysis of . . . .20 „ „ coagulability of . . . .20 „ „ difference from cow's milk . . .20 ,, ,, variations in . . . .17 Worms ...... 227 „ appearance of tongue in . . . . 235 „ cestode ..... 227 „ diagnosis of . . . . . 238 „ nematode ..... 227 „ symptoms of . . , . . . 233 ,, treatment of . . . . . 240 „ varieties of . . . . . 227 PRINTED BY ADLAED AND SON, BARTHOLOMEW CLOSE;, E.G., AND 20, HANOVER SQUARE, W. 25