THE UNIVERSITY OF ILLINOIS LIBRARY G18.9 Return this book on or before the Latest Date stamped below. Theft, mutilation, and underlining of books are reasons for disciplinary action and may result in dismissal from the University. University of Illinois Library IjSS L161— 0-1096 Digitized by the Internet Archive in 2016 with funding from University of Illinois Urbana-Champaign Alternates https://archive.org/details/americantextbook00star_0 f- Y. ^ AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHILDREN. INCLUDING SPECIAL CHAPTERS ON ESSENTIAL SURGICAL SUBJECTS ; ORTHOPEDICS ; DISEASES OF THE EYE, EAR, NOSE, AND THROAT ; DISEASES OF THE SKIN • AND ON THE DIET, HYGIENE, AND GENERAL MANAGEMENT OF CHILDREN. BY YMERICA.N TEA.CHERS. EDITED BY LOUIS STARR, M.D., Consulting Piediatrist to the Maternity Hospital, Philadelphia ; Late Clinical Professor of Diseases of Children in the Hospital of the University of Pennsylvania; Member of the Association of American Physicians and of the American Paediatric Society ; Fellow of the College of Physicians of Philadelphia, etc. ASSISTED BY THOMPSON S. WESTCOTT, M. D., Instructor in Diseases of Children, University of Pennsylvania ; Visiting Physician to the Methodist Episcopal Hospital ; Physician to the Dispensary of the Children’s Hospital ; Fellow of the College of Physicians of Philadelphia ; and Member of the American Paediatric Society. SECOND EDITION, REVISED. PHILADELPHIA: W. B. SAUNBEKS, 925 Walnut Street. 1 898 . Copyright, 1898, by W. B. S A U N D E RS. EUEOTROTYPED BY WE8TCOTT 8 l THOMSON. PHIUADA. PRINTED BY W. B SAUNDERS PHILAOA. PREFACE TO THE SECOND EDITION. To keep up with tho rapid advancGS in the field of paediatrics and to round into a more perfect treatise the work so admirably accomplished by the various authors, most of whom labored entirely independently of one another, the whole subject matter embraced in the first edition of this work has been care- fully revised , nei\ articles have been added ^ some of the original papers have been emended, and a number have been entirely rewritten and brought up to date. For greater accuracy in classification, the section on the Infectious Diseases has been rearranged so as to embrace Tuberculosis and INIalaria. The new articles include “Modified Milk and Percentage Milk Mixtures,” “ Lithaemia, and a section on Orthopaedics; those rewritten are “Typhoid Fever,” “Rubella,” “Chicken-pox, “Tuberculous Meningitis,” “Hydro- cephalus, and “ Scurvy ; while more or less extensive revision has been made in the chapters on Infant Feeding, Measles, Diphtheria, and Cretinism. The volume has been thus increased in size by fully fifty pages of fresh material. The editor records with profound regret the decease of two of his most valued collaborators— Dr. Charles Warrington Earle, of Chicago, and Dr. J. Lewis Smith, of New York — to whose pioneer work in paediatrics the medical profession owes a lasting debt of gratitude. The editor gratefully acknowledges the flattering reception accorded the first edition of the work, and expresses his thanks to Dr. Thompson S. Westcott for his most efiicient assistance in the preparation of the revision. LOUIS STARR. iii 684664 PREFACE. In the preparation of this volume the Editor’s object has not been to add unnecessarily to the number of encyclopedias already existing, but to present to the profession a working text-book which shall be closely limited to, while completely covering, the field of pediatrics. To make such a book useful to the practitioner, who must too often read as he runs, and to the student, who of necessity is unable to devote his study hours to one branch of medical science, but must divide them between many general and special subjects, it seems essential that certain conditions should be closely adhered to. These are — first, careful condensation, without omission, that the whole subject may be embraced between the covers of one readily handled volume ; second, limitation of the subject-matter to such practical points as Etiology, Symptomatology, Diagnosis, and Treatment including Feeding, Hygiene, Therapeutics and the Prevention of Disease, while avoid- ing, so far as possible, the insertion of references to journals or authorities, of more interest to those engaged in research than to those in active practice; third, the selection of a large stalF of collaborators from the most important medical centres of our country, to secure for each subject the care of the authority best fitted to portray it, to give the work broadness and stamp it with a national, rather than a sectional, imprint ; fourth, so to time the pub- lication that, without undue haste, each article contributed should have the same freshness, and the book as a whole be thoroughly abreast with the rapid advance which is constantly made in this branch of our profession ; finally, the addition of chapters upon certain subjects Avhich, though usually treated specially and separately, constantly come under the notice of those who work with, or study, the ills of childhood, such as diseases of the eye, the ear, the skin, the nose and throat, and the anus and rectum ; circumcision, tracheotomy, intubation, vesical calculus, venereal disease and allied subjects. These conditions we have endeavored to fulfil. VI PBEFA CE. In conclusion, the Editor desires to thank individually the collaborators he has been so very fortunate in securing, and to tender them, in advance, the greater share of whatever credit may attend the venture. His thanks are also due to Dr. Thompson S. Westcott for his most efficient and interested assistance. LOUIS STARR. 1818 Rittenhoxjse Square. Philadelphia LIST OF CONTRIBUTORS. SAMUEL S. ADAMS, A. M., M. D., Professor of Diseases of Infancy and Childhood, Georgetown University, Washing- ton, D. C. JOHN ASHHURST, Jr., M. D., Barton Professor of Surgery, and Professor of Clinical Surgery, University of Penn- sylvania. A. D. BLACKADER, M. D., Professor of Pharmacology and Therapeutics, and Lecturer on Diseases of Children, McGill University, Montreal, Canada. DAVID BOVAIRD, M. D., Clinical Assistant to the Chair of Diseases of Children, Bellevue Hospital Medical College, New York. DILLON BROWN, M. D., Adjunct Professor, Department of Diseases of Children, New York Polyclinic; Visiting Physician to Episcopal Orphan Asylum, New York. EDWARD M. BUCKINGHAM, M. D., Instructor in Diseases of Children, Harvard University. CHARLES W. BURR, M. D., Clinical Professor of Nervous Diseases, Medico-Chirurgical College, Philadelphia. WM. E. CASSELBERRY, M. D., Professor of Laryngology and Rhinology in the Chicago Medical College. HENRY DWIGHT CHAPIN, M. D., Professor of Diseases of Children in the New Y^ork Post-Graduate Medical School and Hospital. W. S. CHRISTOPHER, M. D., Professor of Paediatrics, College of Physicians and Surgeons, Chicago. ARCHIBALD CHURCH, M. D., Professor of Neurology, Chicago Polyclinic, and Professor of Mental Diseases ‘and Clinical Neurology in the Chicago Medical College. FLOYD M. CRANDALL, M. D., Adjunct Professor, Department of Diseases of Children, New York Polyclinic. ANDREW F. CURRIER, M. D., Assistant Gynaecologist, Skin and Cancer Hospital. New York ; Visiting Gynaecologist, Out-door Poor Department, Bellevue Hospital, New Y’^ork; Consulting Gynaecol- ogist, McDonough Memorial Hospital, New York. ROLAND G. CURTIN, M. D„ Consulting Physician to the Kush Hospital for Consumptives, St. Timothy’s, and Doug- las Hospitals, Philadelphia. vii vm LI^T OF CONTRTBUTORS. J. M. DaCOSTA, M. D., LL.D., Emeritus Professor of Practice of Medicine and Clinical Medicine, Jefferson Medical College, Philadelphia. I. N. DANFORTII, A. M., M. D., Professor of Principles and Practice of Medicine and of Clinical Medicine, North- western University, Woman’s Medical School, Chicago. EDWARD r. DAVIS, A. M., M. D., Professor of Obstetrics, Jefferson Medical College, Philadelphia; Professor of Obstetrics and Diseases of Infancy, Philadelphia Polyclinic. JOHN B. DEAVER, M.D., Assistant Professor of Applied Anatomy in the University of Pennsylvania ; Professor of Surgery in the Philadelphia Polyclinic. GEORGE E. DE SCHWEINITZ, M. D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia. JOHN DORNING, M.D., Instructor in Diseases of Children in the New York Post-Graduate Medical School and Hospital ; Attending Physician to Demilt Dispensary, New A'ork. CHAS. WARRINGTON EARLE, M. D., Late Professor of Diseases of Children, Woman’s Medical College, Chicago. WM. A. EDWARDS, M. D., San Diego, Cal. FREDERICK FORCHHEIMER, M. D., Professor of Practice of Metlicine and Diseases of Children, Medical College of Ohio. J. HENRY FRUITNIGHT, A.M., M. D., Attending Physician to St. John’s Guild Hospital lor Children, I\ew York. J. P. CROZER GRIFFITH, M. D., Clinical Professor of Diseases of Children, University of Pennsylvania. WM. A. HARDAWAY, A. M., M. D., Professor of Diseases of the Skin and Syphilis, Missouri Medical College, St. Louis. MARCUS P. HATFIELD, M. D., Emeritus Professor of Diseases of Children, Chicago Medical College. BARTON COOKE HIRST, M. D., Professor of Obstetrics. University of Pennsylvania. H. ILLOWAY, M. D., Professor of Diseases of Cliildren, Cincinnati College of Medicine and Surgery. HENRY JACKSON, M. D., Physician to Out-Patient Dej)artinent, Boston City Hospital. CHAS. G. JENNINGS, M.D., Professor of Practice of Medicine and Diseases of Children, Detroit C ollege of Meili- LIST OF CONTRIBUTORS. IX HENRY KOrLIK, M. I)., Attending Pliysician, Good Samaritan Dispensary, New York ; Adjunct Attending Physician, Mt. Sinai Hospital (Children), New York. THOMAS S. LATIMER, M. D., Professor of Principles and Practice of Medicine, College of Physicians and Surgeons, Baltimore. ALBERT R. LEEDS, Pn.D., Professor of Chemistry, Stevens Institute of Technolog)% Hoboken. J. HENDllIE LLOYD, A. M., M. D., Neurologist to the Philadelphia Hospital ; Physician to the Methodist Episcopal Hospi- tal and to the Home for Crippled Children, Philadelphia. GEO. ROE LOCKWOOD, M. D., Professor of Principles and Practice of Medicine, Woman’s Medical College of New York Infirmary. HENRY M. LYMAN, M. D., Professor of the Principles and Practice of Medicine, Rush Medical College, Chicago. FRANCIS T. MILES, M. D., Professor of Physiology, and Clinical Professor of Diseases of the Nervous System, University of Maryland. CHAS. K. MILLS, M. D., Professor of Mental Diseases and of Medical .Jurisprudence, University of Pennsyl- vania; Professor of Diseases of the Mind and Nervous System,' Philadelpliia Polyclinic. JAMES E. MOORE, M. D., Professor of Orthopedia and of Clinical Surgery, University of Minnesota. F. GORDON MORRILL, M. D., Visiting Physician to Children’s Hospital. Boston. JOHN II. MUSSER, M. D., Assistant Professor of Clinical Medicine, University of Pennsylvania. THOMAS R. NEILSON, M. D., Professor of Genito-urinary Surgery, Philadelphia Polyclinic. WM. PERRY NORTHRUP, M. D., Professor of Pjediatrics, Bellevue Hospital Medical College, New Y'ork. WM. OSLER, M. D., Professor ot the Principles and Practice of Medicine, Johns Hopkins University, Bal- timore. FREDERICK A. PACKARD, M. D., Instructor in Clinical Medicine, University of Pennsylvania, and Visiting Physician to the Children’s Hospital, Philadelphia. WM. PEPPER, M. D., LL.D., Professor of the Theory and Practice of Medicine in the University of Pennsylvania. FREDERICK PETERSON, M. D., Clinical Professor of Mental Diseases, Woman’s Medical College of the New York Infirmary. X LmT OF CONTRIBUTORS. WM. T. PLANT, M. I)., Emeritus Professor of Pa?diatrics, Syracuse University, New York. WM. M. POWELL, M. D., Attending Physician to the Mercer Memorial Home, Atlantic City. B. K. BACIIFORD, M.D., Professor of Physiology and Clinician to Children’s Clinic, Medical College of Ohio. B. ALEXANDER RANDALL, A. M., M. D., Clinical Professor of Diseases of the Ear, University of Pennsylvania. EDWARD O. SHAKESPEARE, A. M., M. D., Ph.D., Late Pathologist to the Philadelphia Hospital ; late United States Commissioner to In- vestigate Cholera; late United States Commissioner to the International Sanitarv Conference of Paris. FREDERICK C. SIIATTUCK, M. D., .Jackson Professor of Clinical Medicine in Harvard University. J. LEWIS SMITH, M.D., Late Professor of Diseases of Children, Bellevue Hospital Medical College, New York. M. ALLEN STARR, M. D., Professor of Diseases of the Mind and Nervous System, College of Physicians and Sur- geons, New A’ork. LOUIS STARR, M. D., Consulting Paediatrist to the Maternity Hospital, Philadelphia ; Late Clinical Professor of Diseases of Children, University of Pennsylvania. CHARLES W. TOWNSEND, M. D., Physician to Out-Patients at Massachusetts General, Children’s, and Boston Lying-in Hospitals. JAMES TYSON, M. D., Professor of Clinical Medicine, University of Pennsylvania. W. S. THAYER, M.D., Associate Professor of Medicine, Johns Hopkins University ; Resident Physician to the Johns Hopkins Hospital, Baltimore. VICTOR C. VAUGHAN, M. D., Professor of Hygiene and Physiological Chemistry, University of Michigan. THOMPSON S. WESTCOTT, M. D., Instructor in Diseases of Children, University of Pennsylvania ; Assistant Physician to the Children’s Hospital, Philadelphia. HENRY R. WHARTON, A. M., M. D., Lecturer on Surgical Diseases of Children and Demonstrator of Surgery, University of Pennsylvania; Surgeon to the Children’s Hospital, Philadelphia. J. WILLIAM WHITE, M. D., Professor of Clinical Surgery, University of Pennsylvania. JAMES C. WILSON, M. D., Professor of the Practice of Medicine and of Clinical Medicine, Jeflerson Medical College, Philadelphia. CONTENTS INTRODUCTION. Page THE CLINICAL INVESTIGATION OF DISEASE AND THE GENERAL MANAGEMENT OF CHILDREN. By Louis Starr, M. D 1 Feeding. — Bathing. — Clothing. — Sleep. THE CHEMISTRY OF MILK AND OF ARTIFICIAL FOODS FOR CHIL- DREN. By Albert R. Leeds, Ph. D 37 MODIFIED MILK AND PERCENTAGE MILK-MIXTURES. By Thompson S. Westcott, M. D 53 SEA-AIR AND SEA-BATHING IN CONVALESCENCE. By W. M. Powell, M.D 60 PART I. INJURIES INCIDENT TO BIRTH AND DISEASES OF THE NEW-BORN. By Edward P. Davis, A. M,, M. D 68 Caput Succedaneum. — Cephalhematoma.— Htematoma of the Sterno-cleido-mastoid Mus- cle. — Haemorrhage in the New-born. — Asphyxia. — Hemorrhages from Mucous Sur- faces. — Obstetric Paralysis and Injuries to the Nervous System. — Fractures and Dislo- cations of the Trunk and Extremities.— Umbilical Hemorrhage. — Umbilical Polypi. — Umbilical Hernia. — Gastro-intestinal Hemorrhage. — Icterus Neonatorum. — The Infections attacking the New-born. — General Septic Infection. — Erysipelas. — Acute Peritonitis in the New-horn. — Tubercular and Typhoid Infections. — Inspiration Pneumonia. — Tetanus. — Mastitis. — Infections of the Blood. — Melena Neonatorum. PART II. THE DIATHETIC DmEASES. LITH^EMIA. By B. K. Raciiford, M. D 94 HEREDITARY SYPHILIS. By Henry Dwight Chapin, M. D 103 XII CONTENTS. PART III. THE INFECTIOUS DISEASES. MEASLES. By Louis Starr, M. D 117 SCAKLET FEVER. By Marcus P. Hatfield, M. D 131 RUBELLA. By Wm. T. Plant, M. D 152 CHICKEN-POX. By Wm. T. Plant, M. D 156 VARIOLA AND VARIOLOID. By C. G. Jennings, M. D 163 VACCINIA. By Thomp.son S. Westcott, M. D 171 PAROTITIS. By’ Andrew F. Currier, M. D 177 WHOOPING-COUGH. By J. P. Crozer Griffith, M. D . . 182 TYPHOID FEVER. By F. Gordon Morrill, M. D 194 EPIDEMIC CEREBRO-SPINAL MENINGITIS. By Roland G. Curtin, M. D. . . 208 EPIDEMIC INFLUENZA. By’ Chas. Warrington Earle, M. D 214 ERYSIPELAS. By’ Frederick A. Packard, M. D 221 CHOLERA. By E. O. Shakespeare, M. D 231 DIPHTHERIA. By Dillon Broyvn, M. D 250 TUBERCULOSIS. By Wm. Osler, M. D., M. R. C. P 270 MALARIAL FEVER. By W. S. Thayer, M. D 303 PART IV. GENERAL DISEASES NOT INFECTIOUS. RACHITIS. By J. Lewis Smith, M. D 319 RHEUMATISM. By J. M. DaCosta, M. I)., LL.D 351 PART V. DISEASES OF THE BLOOD. AN.EMIA, SPLENIC AN.EMIA, LYMPHATIC AN/EMIA, AND LEUKAEMIA. By Frederick A. Packard, M. D 359 HA2MOPHILIA. By' Wm. Perry Northrup, M. D 377 PURPURA H.EMORRHAGICA. By Geo. Roe Lockwood, M. D 379 SCORBUTUS. By Wm. P. Northrup, M. D., and David Bovaird, M. D 389 CONTENTS. xiii PART VI. DISEASES OF THE DIGESTIVE ORGANS. - Page I. DISEASES OF THE MOUTH; II. DENTITION. By F. Forchheimer, M. D. 396 Stomatitis Catarrhalis. — Stomatitis Aphthosa. — Stomatitis Mycosa. — Stomatitis Ulcerosa. — Stomatitis Gangrenosa. — Stomatitis ^Crouposa and Diphtheritica. — Stomatitis Syphilitica. — Dentition. DISEASES OF THE PHAKYNX AND NASO-PHAKYNX. By W. E. Cassel- berry, M. D. 415 Aeute Pharyngitis and Naso-pharyngitis. — Simple Chronic Pharjmgitis and Elongation of Uvula. — Chronic Folliculous Pharyngitis. — Acute Folliculous Tonsillitis. — Peri- tonsillar Abscess or Suppurative Tonsillitis. — Hypertrophy of the Tonsils. GASTRIC CATARRH (ACUTE AND CHRONIC) ; GASTRIC ULCER. By A. D. Blackader, M. D. . . . • 441 MUCOUS DISEASE (CHRONIC GASTRO-INTESTINAL CATARRH). By W. A. Edwards, M. D 454 DIARRIKEAL DISEASES. By Victor C. Vaughan, M. D 463 Acute Intestinal Indigestion. — Chronic Intestinal Indigestion. — Milk Infection, Acute, Subacute. INFLAMMATION OF COLON AND RECTUM (DYSENTERY). By S. S. Adams, M. D 485 CHRONIC CONSTIPATION. By J. Henry Fruitnight, A. M., M. D 496 SIMPLE ATROPHY. By Louis Starr, M. D 503 DISEASES OF THE C^CUM AND APPENDIX. By John Ashhurst, Jr., M. D. 509 INTUSSUSCEPTION. By John Ashhurst, Jr., M. D 517 INTESTINAL PARASITES. By Chas. AV. Townsend, M. D 524 DISEASES OF THE LIVER. By John H. Musser, M. D 538 Jaundice. — Congestion of the Liver.— Fatty Liver. — Amyloid Disease of the Liver. — Syphilitic Inflammation of the Liver. — Suppurative Hepatitis. — Hydatid Disease. — Cirrhosis of the Liver. PERITONITIS, TUMORS OF THE PERITONEUM AND OMENTUM, AND ASCITES. By J. Henry Fruitnight, A. M., M. D 563 CONGENITAL INTESTINAL MALFORMATIONS, AND DISEASES OF THE ANUS AND RECTUM. By Henry R. Wharton, M. D 575 Pruritus Ani. — Syphilitic Affections of the Anus. — Vegetations and Warts. — Fistula in Ano. — Fissure of the Anus. — Stricture of the Anus. — Marginal Abscess. — Diph- theria of the Anus. — Proctitis and Periproctitis. — Ischio-rectal Abscess.-r-Ulceration, Stricture, and Syphilis of the Rectum. — Prolapsus of the Rectum. — Haemorrhoids. — Polypus and Naevus of the Rectum. — Malignant Diseases of the Rectum. — Wounds of, and Foreign Bodies in, the Rectum. PART VII. DISEASES OF THE NERVOUS SYSTEM. SIMPLE CEREBRAL MENINGITIS. By Thos. S. Latimer, M. D 596 SIMPLE CEREBRO-SPINAL MENINGITIS. By Thos. S. Latimer. M. D. . . . 605 XIV CONTENTS. Page TUBERCULOUS MENINGITIS. By James IIendrie Lloyd, M. D 610 HYDROCEPHALUS. By James IIendrie Lloyd, M. D 624 ABSCESS OF THE BRAIN. By Frederick Peterson, M. D 630 TUMORS OF THE BRAIN AND MENINGES. By Frederick Peterson, M. D. 634 THE AFFECTIONS OF THE NERVOUS SYSTEM DUE TO INHERITED SYPHILIS. By Chas. W. Burr, M. D 645 INFANTILE CEREBRAL PALSIES. By Frederick Peterson, M. D 649 SPEECH DEFECTS AND ANOMALIES. By Chas. K. Mills, M. D 658 IDIOCY AND IMBECILITY. By Chas. K. Mills, M. D 667 CRETINISM. By Chas. K. Mills, M. D 680 MYOTONIA, OR THOMSEN’S DISEASE. By Chas. K. Mills, M. D 687 ACROMEGALY. By' Chas. K. Mills, M. D 690 ATHETOSIS AND ATHETOID AFFECTIONS. By Chas. K. Mills, M. D. . . 694 INSANITY IN CHILDREN. By Chas. K. Mills, M. D 697 IMPERATIVE MOVEMENTS, HEAD-NODDING, ETC. By Chas. K. Mills, M. D 712 HEADACHE. By Chas. K. Mills, M. D 718 HYSTERIA. By James Hendrie Lloyd, M. D 727 CONVULSIONS. By' Frederick Peterson, M. D 741 EPILEPSY. By James Hendrie Lloy'd, M. D 747 CHOREA. By’ M. Allen Starr, M. D., Ph. D 754 TETANY. By Henry M. Ly'man, M. D 764 PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. By F. T. Miles, M.D. 768 FACIAL PARALYSIS, AND FACIAL HEMIATROPHY. By Chas. W. Burr, M.D. 774 . INFLAMMATORY DISEASES OF THE SPINAL MENINGES AND SPINAL CORD. By' Archibald Church, M. D 777 ACUTE ANTERIOR POLIOMYELITIS. By Archibald Church, M. D. ... 789 LANDRY’S PARALYSIS. By' Archibald Church, M. D 798 TUMORS OF THE SPINAL CORD. By James Hendrie Lloy'd, M. D 801 SYRINGOMYELIA AND HYDROMYELIA. By James Hendrie Lloyd, M. D. 809 HEREDITARY ATAXIA. By' Archibald Church, M. D 815 RAYNAUD’S DISEASE. By Thompson S. Westcott, M. D 820 PART VIII. DISEASES OF THE ItESnUATORY SYSTEM. DISEASES OF THE NOSE. By \V. E. Casselberry, M. D 826 Acute Rhinitis. — Simple Clironic Rhinitis and Purulent Rhinitis. — Hypertro])luc Rliinitis. — Atrophic Rhinitis. — Nasal Myxomata. — Hereditary Syphilis of the Nose and Throat. CATARRHAL LARYNGITIS (SPASMODIC CROUP). By H. Illoway, M. I). . 844 LARYNGISMUS STRIDULUS. By II. Illoway, M. D 857 FOREIGN BODIES IN LARYNX AND TRACHEA. By John B. Deavek, M.D. 865 CONTENTS. XV I’AGE TRACHEOTOMY. By Henry R. Wharton, M. D 870 INTUBATION OF LARYNX. By Henry R. Wharton, M. D 8!)1 PO.ST-NATAL ATELECTASIS. By S. S. Adams, M. D 809 BRONCHO PNEUMONIA. By William Pepper, M. D 904 CROUPOUS PNEUMONIA. By William Pepper, M. D 913 GANGRENE AND ABSCESS OF THE LUNG. By Henry Jackson, M. D. . . 919 BRONCHITIS. By W. S. Christopher, M. D 924 PLEURISY AND EMPYEMA. By Henry Koplik, M. D 9.35 PULMONARY EMPHYSEMA. By John Dorning, M. D 950 BRONCHIAL ASTHMA. By John Dorning, M. D 956 FIBROID PHTHISIS. By Frederick C. Shattuck, M. D 963 PAKT IX. DISEASES OF THE HEART. CONGENITAL AFFECTIONS OF THE HEART. By Barton Cooke Hirst, M. D 968 ORGANIC DISEASE OF THE HEART. By Floyd M. Crandall, M. D. . . . 974 Pericarditis. — Acute Endocarditis. — Chronic Heart Disease. FUNCTIONAL AFFECTIONS OF THE HEART (THE CARDIAC NEUROSES). By J. C. Wilson, M. D 986 PART X. DISEASES OF THE GENITO-URINARY SYSTE3I. HEMATURIA, PYURIA, ENURESIS, Etc. By E. M. Buckingham, M. D. . . 991 DIABETES MELLITUS, DIABETES INSIPIDUS, AND LITHIASIS. By James Tyson, M. D 999 ACUTE AND CHRONIC NEPHRITIS, AND AMYLOID DISEASE OF THE KIDNEY. By I. N. Danforth, M. D 1011 TUMORS AND OTHER ENLARGEMENTS OF THE KIDNEY. By Thomas R. Neilson, M. D 1027 Renal Cysts. — Hydronephrosis. — Pyonephrosis. — Perinephritic Abscess. — Tumors of the Kidney. VESICAL CALCULUS. By J. William White, M. D 1038 GONORRHOEA AND VULVO- VAGINITIS. By J. William White, M. D. . . 1053 PHIMOSIS, ADHERENT PREPUCE, PARAPHIMOSIS. By Henry R. Whar- ton, M. D 1057 PART XL ORTHOPAEDICS. By James E. Moore, M. D. 1062 XVI CONTENTS. PART XII. DISEASES OF THE SKIN. By W. A. Hardaway, M. D 1090 I. Disorders of the Glands: Sebaceotis Glands: Seborrhoea, Comedo, Aciie, Milium. Sweat-Glands : Hyperidrosis, Miliaria. II. Inflammations : Erythema Simplex, Erythema Multiforme, Herpe.s Iris, Erythema Nodosum, Relapsing Scarlatiniform Erythema, Eczema, Lichen Planus, Psoriasis, Pemphigus, Herpes Simplex, Herpes Zoster, Impetigo Contagiosa, Dermatitis Exfoliativa Neonatorum, Dermatitis Gangrenosa Infantum (Crocker), Urticaria Pigmentosa, Pityriasis Rosea, Prurigo, Furunculus. III. Haemorrhages: Purpura. IV. Hypertrophies : Lentigo, Ichthyosis, Molluscum Epitheliale, Verruca, Nsevus Pigmentosus, Sclerema Neonatorum, Scleroderma, Morphcea. V. Atrophies: Albinism, Leucoderma, Alopecia Areata. VI. New Growths: Kaposi’s Disease, Noevus Vascularis, Lupus Vulgaris, Scrofulo- derma, Syphiloderma. VII. Para-sitic Affections: Tinea Favosa, Tinea Trichophytina, Scabies, Pediculosis. PART XIII. DISEASES OF THE EAR. By B. Alexander Randall, A. M., M. D 1158 I. Affections of the External Ear : Eczematous Inffammations, Furuncle, Ceru- men Impaction, Foreign Bodies, Caries of the Wall of the Auditory Canal, Congeni- tal Atresia. II. Affections of the Middle Ear : Acute Simple Inflammation of Middle Ear, Acute Suppurative Inflammation of Middle Ear, Chronic Suppuration of Middle Ear. III. Affections of the Internal Ear. PART XIV. DISEASES OF THE EYE. By G. E. de Schweinitz, M. D 1178 I. Diseases of the Lids: Abscess and Furuncle, Hordeolum, Exanthematous Erup- tions, Blepharitis, Phthiriasis, Syphilis of the Eyelids, Tumors and Hypertrophies, Tarsitis, Blepharospasm, Ptosis, Lagophthalmos, Symblepharon, Trichiasis and Dis- tichiasis. Entropion, Ectropion, Milium, Molluscum Contagiosum, Sebaceous and Dermoid Cysts, Injuries of the Eyelids, Emphysema of the Eyelids. II. Diseases of the Conjunctiva: Simple Conjunctivitis, Purulent Conjunctivitis, Diphtheritic Conjunctivitis, Spring Catarrh, Follicular Conjunctivitis, GranularCon- junctivitis, Ecchymo.sis of Conjunctiva, Cbemosis, Tumors and Cysts, Tubercle, Injuries, Phlyctenular Kerato-Conjunctivitis. HI. DiSEASits OF THE CoRNEA : Ulcer, Kerato-malacia, Interstitial Keratitis, Injuries, Foreign Bodies. IV. Diseases of the Iris and Ciliary Body: Iritis, Gumma of Iris, Injuries to the Iris and Ciliary Region, S 3 'mpathetic Irritation and Sympathetic Inflammation. V. Diseases of the Lachrymal Apparatus : Dacryoadenitis, Dacryocystitis, I.nch- rymal Absce.ss. VI. Diseases of the Orbit: Periostitis, Celluliti.s, New Growths. VH. Congenital Cataract. VIII. The Refraction of the Eye in Childhood. IX. Strabismus, or Squint. AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHILDREN. INTRODUCTION. THE CLINICAL INVESTIGATION OF DISEASE AND THE GENERAL MANAGEMENT OF CHILDREN. By LOUIS STARR, M. D., Philadelphia. I. THE CLINICAL INVESTIGATION OP DISEASE. Early life may be divided into two periods — namely, infancy and child- hood. Infancy is the time elapsing between birth and the complete eruption of the milk teeth, an event that transpires about the end of the second year of life ; childhood extends from this age to the development of puberty, about the age of thirteen or fifteen years. Of the diseases that may occur during these periods a few are peculiar to the time of life, or are “children’s diseases” proper; others, while identical in class with the ordinary affections of adult and mature years, are variously modified in .symptoms and course by conditions inherent to early age ; but in all the clinical investigation is beset with difficulties which the student must be prepared to overcome. Thus, the absence of speech in the infant deprives us of the important assistance afforded by correctly described subjective symp- toms, and renders it necessary to look to the mother or nurse for the history of an illness. In older children the case is little better, since with them words are not prompted by sufficient knowledge to be of great service. Further, the wilfulness, dislikes, fear, and agitation of the child are impediments which must be overcome before a satisfactory examination can be made, and which will often tax the skill and patience of the physician to the utmost in the over- coming. Another source of difficulty lies in the activity of growth and devel- opment in infants, which renders them liable to be affected by slight causes, and makes disease sudden in its attack, short in its course, and intense in its symptoms. The rapid development of the nervous system especially leads to confusion. The nerves bind every portion of the frame in a sympathy so close that an affection of a single part may cause marked general disturbance, and local symptoms are often reflected, directing attention to organs very distant from those really diseased. Finally, the extreme excitability of the nervous system of healthy children often causes a trifling illness to assume an aspect of the greatest gravity ; while, on the contrary, the depression of nervous sensi- 1 2 AMERICAN TEXT-BOOK OF DIBEASEH OF CHILDREN. bility that attends chronic wasting diseases so obscures the symptoms that a dangerous intercurrent affection may appear trifling or remain altogether latent. On the other hand, to offset these difficulties, disease in the child is usually uncomplicated, rarely has its course and symptoms modifled by tissue lesions the result of previous affections, and never by vicious habits, such as the abuse of stimulants and narcotics, or by mental overwork and nerve-strain. The confusing element of misstated subjective symptoms is also absent, while cor- rect diagnosis is greatly aided by the facility with which physical examination of the whole body may be practised. In conducting the investigation it is well to proceed in three regular stages, as follows : 1st. Questioning the attendants ; 2d. Inspecting the child ; 3d. Physical examination. 1. Questioning the Attendants. When the patient is under eight or ten years of age, the only way of obtaining a knowledge of the previous history and of what may occur between visits is carefully to question the mother or nurse. The account must be patiently elicited, and credited with due reference to the narrator’s intelligence. It is well never entirely to discredit a statement without good reason, for many women, though weak and foolish in other respects, are excellent observers when their powei’S are guided by affection. Besides, being thoroughly acquainted with their children’s habits and dispositions, they wilt often detect deviations from health that the physician might overlook entirely. This part of the examination, particularly when the acquaintance and good-Avill of the child have not previously been obtained, should, if possible, be made before entering the sick-room. As there are certain points about which it is always necessary to he informed, the adoption of a deflnite order of questioning is advisable. The family history as far back as the parents should first be ascertained, inquiry being chiefly directed to the detection of chronic maladies and trans- missible diseases, as tuberculosis and syphilis. If any deaths have occurred, their causation should be investigated ; and an inquiry into the occurrence, or the reverse, of previous stillbirths is often important. Then an outline of the child’s life from birth up to the date of the illness in question must be obtained. This should include the following items : The manner of feeding diu’ing infancy — whether at the breast or from a bottle, and if the latter, the com- position of the food employed ; the date of commencement and the regularity of dentition ; the general state of health in regard to strength or weakness and liability to illness ; the time of occurrence and the nature of any prominent attack of illness, especially of the eruptive fevers ; whether vaccination has been performed or no ; the hygienic surroundings — for instance, the healthful- ness of the locality of residence, the sort of house and room occupied, and the character of the clothing and food. In older children, if at school, the time devoted to study, and if at labor, the nature and the hours of work. After this it is necessary to fix the time the attack in hand began. The occurrence of .some striking symptom, as convulsions or violent vomiting, often establishes this point beyond a doubt; but when there is any uncertainty the best ])lan is to question back, day by day, until a time is reached at which the child was ]>erfectly well, and to date the onset from this period. The most common of the general indications of commencing illness are disturbed sleep and irritability of temper. CLINICAL INVESTIGATION OF DISEASE. 3 The next step is to learn the mode of attack and the symptoms and course of the disease prior to tlie first visit. The questions now must be general, never leading. They must be sufficiently exhaustive to touch upon all the functions of the body, and when a trail is started it must be patiently followed to the end. Alterations in sleep, bodily strength, surface temperature, appe- tite, digestion, urine elimination, respiration, and so on, must be sought for, and the account of such deviations from the normal state as vomiting, diarrhoea, or cough will suggest further questions, as well as point out the path to be followed in the future examination. This portion of the investigation is closed by an inquiry into the treatment that may have been already adopted. 2. Inspecting the Child. When the eye and ear of the physician are trained to their work, valuable information can be obtained by simply looking at an ill child and listening to its cry or spoken words. Even while the child is lying asleep or sitting quietly in the nurse’s lap many fixcts may be learned ; but this portion of the exami- nation is never complete without an inspection of the naked body. The points thus ascertained consist in alterations in the expression of the face, in decubitus, in the appearances of the body, and so on, and may be designated th.Q features of disease. The relative position of the observer and patient during inspection is of importance. If possible, the former should stand with his back to, and the latter be so placed that his face is toward, a window or lamp. The light must never be strong enough to dazzle when the countenance is the object of inspection, as this causes distortion of the features. For convenience, the features of disease will be studied under different headings ; and since to appreciate them it is necessary to have a knowledge of the healthy aspect, both the normal and abnormal appearances will be described. Face. — The face of a healthy sleeping child wears an expression of perfect repose. The eyelids are completely closed, the lips slightly parted, and while a faint sound of regular breathing may be heard, there is no perceptible move- ment of the nostrils. Incomplete closure of the lids, with moi’e or less exposure of the whites of the eyes, is noted Avhen sleep is rendered unsound by moderate pain and during the course of all acute and chronic diseases, particularly when they assume a grave type. Twitching of the lids heralds the approach of a convulsion, and at such times, too, there is often oscillation of the eyeballs or squinting. A marked smile, due to contraction of the muscles about the mouth, signifies abdominal pain or colic, and pursing out of the lips and chew- ing motions of the jaw, gastro-intestinal irritation. Dilatation of the aim nasi, with or without noisy breathing, points to embarrassed respiration, the result of extensive bronchial catarrh, pneumonia, or pleurisy with effusion. When awake and passive the healthy infant’s face has a look of wondering observation of whatever is going on about it. As age advances the expression of intelligence increases, and every one is familiar with the bright, round, happy face of perfect childhood, so indicative of careless contentment and so mobile in response to emotions. The picture is altered by the onset of any illness, the change being in pro- portion to the severity of the attack. An expression of anxiety or of suffering appears, or the features become pinched and lines are seen about the eyes and mouth. Pain most of all sets its mark upon the countenance, and by noting the feature affected it is often possible to fix the seat of serious disease. Thus, contraction of the brows denotes pain in the head ; sharpness of the nostrils. 4 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. pain in the chest ; and a drawing of the upper lip, pain in tlie abdomen. As a rule, the upper third of the face is modified in expression in affections of the brain, the middle third in diseases of the chest, and the lower third in lesions of the abdominal viscera. Puffiness of the eyelids and a fulness of the bridge of the nose indicate dropsy, and should direct attention to the kidneys. When there is a tuberculous tendency the face is often oval, the features delicate, and the expression intelligent ; the hair fine and silky ; the skin smooth and trans- parent ; the temporal veins visible ; the eyelashes long and curving, the irides large and deep-colored, and the sclerotics pearly white or bluish ; finally, a growth of fine hair is often noticeable on the temples and in front of the ears. On the contrary, the face may be round and heavy ; the complexion doughy ; the upper lip SAVollen ; the nostrils wide and the aim of the nose thick ; the eyelids swollen and reddened at their edges ; the hair coarse ; and the lymphatic glands of the neck enlarged. A marked disfigurement of the face may indicate one of several diseases, according to its character. For example, broadness or complete flatness of the bridge of the nose is significant of constitutional syphilis. A large, square head and projecting forehead, with a face of natural size or smaller, show that the child has suffered from rickets. An immense globular head, overhanging forehead, and diminutive face, with eyeballs projected downward and irides almost concealed by the lower lids, are pathognomonic signs of chronic hydrocephalus. Decubitus. — The complete repose depicted on the countenance of a healthy sleeping child is shown also by the posture of the body. The head lies easy on the pillow ; the trunk rests on the side, slightly inclined backward ; the limbs assume various but always most graceful attitudes, and no movement is observable but the gentle rise and fall of the abdomen in respiration. In the waking state the child, after early infancy, is rarely still. The movements of the arms, at first awkward, soon become full of purpose as he reaches to handle and examine various objects about him. The legs are idle longer, though these, too, soon begin to be moved about with method, feeling the ground in preparation for creeping and walking. With the onset of disease the scene changes. In acute attacks attended with pain sleep is no longer restful. The infant is content only when rocked, fondled, or “walked” in the nurse’s arms. The older child tosses about uneasily in bed, or demands a constant change from the bed to the lap. During the waking hours the movements are purposeless, quick, and impatient, the position is constantly shifteil, and frequent whining complaints are made. As a contrast to this condition of jactitation, at the beginning of the specific fevers children often lie quiet and drowsy for hours. In chronic affections attended with debility the movements hecome slow and languid, and in stupor and coma there are perfect stillness and immobility. There are certain positions and gestures which have especial significance. Sleeping with the head thrown back and the mouth oj)cn is a frccpient accom- paniment of chronic enlargement of the tonsils. A tendency to “sleep high ” — that is, with the head and shoulders elevated by the pillow — indicates impaired pulmonary or cardiac function. So, too, does an upright position in the nurse’s arms, with the chest against her breast and the head hanging over her shoul- der — a posture assumed by young children. “ Sleeping cool ” — namely, rest- ing oidy after all the bed'-ciothing has hecn kicked off — is an early sym])tom of rickets. The position termed en clnen de funil is a symptom of the advanced stages of cerebriil disease, especially tubercular meningitis. The child lies upon one side, with the head stretched far back, the arms pressed close to the CLINICAL INVESTIGATION OF DISEASE. 5 sides and folded across the chest, the thighs drawn up toward the abdomen, the legs hexed on the thighs, and the feet crossed. Restless movements of the head or boring of the head into the pillow also point to cerebral disease. A retained position, as on the back or one side, together with short, quick breath- ing, points to some inhammatory change in the respiratory or abdominal organs. Persistent lying on the face is an evidence of photophobia. Of gestures, the fre(iuent carrying of the hand to the head, ear, or mouth indicates headache, earache, or the pain of dentition respectively, and constant rubbing of the nose is a feature of gastro-intestinal irritation. If the thumbs be drawn into the palms of the hands and the fingers tightly clasped over them, or if the toes be strongly flexed or extended, a convulsion may be expected. The presence of clonic contractions of the muscles, with unconsciousness, indicates, of course, a convulsion ; while irregular, badly co-ordinated, jerky movements — consciousness being retained — attend chorea. In infants the existence of colic is shown by repeated extension and retrac- tion of the legs, clenching of the hands into fists, flexion and extension of the forearms, and a writhing movement of the trunk. The fact of one limb remaining passive while the others are actively moved about naturally sug- gests motor paralysis. The Skin. — In the new-born infant the color of the skin varies from a deep to a light shade of red. After the lapse of a week this redness fades away, leaving the surface yellowish-white, and in a fortnight the skin assumes its typical appearance. Allowing for natural variations in complexion, the skin of a healthy child is beautifully white, transparent, and velvety. The cheeks, palms of the hands, and soles of the feet have a delicate pink color, and the general surface is rosy in a warm atmosphere, marbled with fiiint blue spots or lines in a cool one. As age advances the coloring becomes more pro- nounced, and until the completion of childhood the complexion is much fresher than in adult life. Lividity of the eyelids and lips is a sign of imperfect aeration of the blood and points to pulmonary or cardiac disease. Marked blueness of the wdiole face is a symptom of morbus cceruleus., and indicates a congenital malforma- tion of the heart. On the other hand, a faint purple tint of the eyelids and around the mouth shows weak circulation merely, or, more frequently, deranged digestion. A decided yellow hue of the skin and conjunctive is seen in jaun- dice ; an earthy tinge of the face in chronic intestinal diseases ; a waxy pal- lor in renal diseases ; and paleness in any affection attended with exhaustion. Brownish-yellow discoloration of the forehead is significant of inherited syphi- lis ; a bright, circumscribed flush on one or both cheeks, of inflammation of the lungs or pleura or of gastro-intestinal catarrh, according to its occurrence with or without an elevated temperature. In addition to the cutaneous lesions of the eruptive fevers, each having its special characteristics, an eruption of herpetic vesicles on the lips may be men- tioned as present both in pneumonia and in malarial fevers. Slight Avant of proper aeration of the blood is shown by blueness of the finger-nails ; a greater degree, by cyanosis of the wdiole hand. Deformity of the nails is a symptom of .syphilis ; clubbing of the finger-tips, of chronic lung disease ; and redness, SAvelling, and suppuration about the nails, of struma. The dropsy of scarlatinal nephritis causes a puffiness and cushiony appear- ance of the dorsum of the hands. Often, too, in this condition, the finger-ends are glossy as if smeared with oil, and there is an exfoliation of the epidermis about the nails. The last two symptoms frequently serve to confirm a retro- spective diagnosis of scarlet fever. 6 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Mode of Drinking. — By watching an infant taking the breast or bottle some knowledge can be obtained of the condition both of the mouth and throat and of the respiratory organs. If there be any soreness of the mouth, the nipple is held only for a moment, and then dropped with a cry of pain. When the throat is affected, deglutition is performed in a gulping manner, an expression of pain passes over the face, and no more efforts are made than required to satisfy the first pangs of hunger. Under similar circumstances older children drink little and refuse solid food entirely. An infant suffering from the oppression of pneu- monia or severe bronchitis seizes the nipple with avidity, swallows quickly several times, and then pauses for breath. In older patients the act of drink- ing, which should be continuous, is interrupted in the same way. If the finger be put into the mouth of a healthy baby, it will be vigor- ously sucked for some little time. The diminution of the act of suction dur- ing a severe illness is a sign of danger ; its re-establishment a good omen. In conditions of stupor and coma it is noticeably absent. The Cry. — Crying is the chief, if not the only, means that the young infant possesses of indicating his displeasure, discomfort, or suffering. Even long after the powers of speech have been developed, the cry continues to be the main channel of complaint. It may be accepted as a rule that a healthy child rarely cries. Of course, some acute pain, as from a fall or accident or blow, will cause crying in the most healthy child, but the storm is quickly over. Incessant, unappeasable crying is due to one of two causes — namely, earache or hunger — and the distinction may readily be made by putting the child to the breast or offering a properly-prepared bottle. The hydrencephalic cry, denoting pain in the head, is a sudden, sharp, very loud, and paroxysmal shriek. Crying during an attack of coughing or for a brief time afterward, and attended with distortion of the features, indicates pneumonia. In acute pleuritis the cry also accompanies the cough, but it is produced too by move- ments of the body and by pressure on the affected side. It is louder, indica- tive of greater suffering, and sometimes most difficult to check. Intestinal pain causes crying just before or after an evacuation of the bowels, and is associated with wriggling movements of the body and pelvis and with eruc- tation or the passage of flatus. Conditions of general distress or malaise predispose to fits of fretful crying, the paroxysms being excited by any dis- turbing influence, or even by merely looking at the little sufferer. when the cry has a nasal tone, it indicates swelling of the mucous mem- brane of the nares or other obstructing condition. Thickening and indistinct- ness occur with pharyngeal affections. A loud, brazen cry is a precursor of spasmodic croup. Hoarseness points to a lesion of the laryngeal mucous membrane, either catarrhal or syphilitic in nature. In membranous croup and in some cases of extreme exhaustion the cry is faint and inaudible. Finally, in severe croupous pneumonia, in extensive pleural effusion, and in rickets ordinary disturbing causes are inoperative for the production of fits of crying, and there is a seeming unwillingness to cry, on account of the action interfering with the respiratory function. The conditions of altered tone apply equally to the articulate voice in children who are old enough to speak. The cough, too, must not be disregarded. Many of its characters corre- spond with the voice and cry. It is brazen in spasmodic croup, suppressed in true croup, hoarse in laryngeal catarrh, and so on. But it has certain fea- tures of its own. In bronchitis it is more or less paroxysmal, evidently dry in the early stages, loose and rattling as the catarrh “breaks up.” In the CLIN IV AL INVESTIGATION OF DISEASE. 7 painful pulmonary affections, pneumonia and pleurisy, it is choked back, and whenever it occurs an expression of pain passes like a cloud over the face. In pertussis the peculiar spasmodic cough is the pathognomonic symptom. Cough is always unproductive — that is, unattended by expectoration — in children under seven years of age. The formation of tears rarely begins before the third or fourth month of life. Subsequently, an alteration in this secretion may be of aid in fore- casting the result of disease. The prognosis is bad when the tears become suppressed ; good when the secretion continues during an illness or when it reappears after being suppressed. There are several other sources of information which should be investi- gated before proceeding to the physical examination, although, strictly speak- ing, they do not come under the head of inspection of the child. These are the alterations in the odor of the breath, and the characters of the faecal evacu- ations, of the urine, and of material ejected by vomiting. The Breath. — The breath of a healthy child is odorless, or, as the nurse will say, “sweet,” except perhaps immediately after taking nourishment, when it may, for a short time, have the smell of milk or other food. Any persist- ent odor is abnormal. Any morbid condition of tlie system that prevents the elimination of meta- morphosed nitrogenous tissue through the mucous membrane of the intestines or retards the passage of decomposing detritus along the bowels will cause an offensive breath. Under this head are conditions characterized by high tem- perature, catarrhal inflammation of the gastro-intestinal tract, chronic debili- tating diseases, etc. The same result also frequently attends structural lesions of the kidneys. The reason for this is, that the system, in order to get rid of poisonous matter — for accumulated waste is poison — and to maintain the balance between the constant construction and destruction of tissue, must throw off elsewhere what the intestinal glands and the kidneys fail to excrete; so the lungs take on vicarious activity and the expired air becomes tainted. Purely local causes of halitosis also exist. These are decayed teeth, caries of the nasal and maxillary bones, ulceration of the mucous membrane of the mouth, nose, larynx, trachea, and bronchial tubes, and gangrene of the cheeks. Chronic poisoning by lead, arsenic, or mercury, though not very common in childhood, is another cause of ill-smelling breath. To speak in general terms, the breath may become sour, catarrhal, foetid, gangrenous, ammoniacal, and stercoraceous. Sour breath is present, in infants more especially, when there is gastric fermentation. Catarrhal breath has numerous shades of difference. In chronic catarrh of the pharynx there is a “ heavy ” odor, not noticeable far from the patient’s face. It is always most marked during and after sleep. Should there be associated follicular tonsilli- tis, the breath, while still heavy, becomes extremely offensive, with a scent somewhat like that of decaying cheese, and is very penetrating. This odor, too, is worse after sleeping. At the onset of acute catarrh of the stomach the breath sometimes has a vinous odor, at others it is sweetish, and again it has the same quality as after an inhalation of ether. Later in the attack it becomes sour or has the odor of sulphuretted hydrogen. What is known as a “ feverish breath ” has a heavy, sweetish smell. It is met with in diseases of high temperature ; thus, it is very marked and rapid in appearance in scarlatina. Foetor of the breath is observed in its mildest form in such affections as aphthm and ulcerative stomatitis. It is better developed in ozsena and necrosis of the maxillary bones. Decaying teeth give much the same odor, though it is less strong and penetrating. 8 XMEIUCAN TEXT-BOOK OE DISEASES OE CHILDREN. Noma gives rise to a gangrenous odor, and a patient so affected will fill the room in which he lies, or even a whole dwelling, with the most sickening stench. Cases of empyema, with ulceration of the lung and discharge of pus through the bronchial tubes, have an almost equally ofiensive breath, but here there is often a superadded flavor of garlic. Ammoniacal breath is observed only in patients suffering with uraemic poisoning. A purely stercoraceous breath is rare, and Avhen met with is an accomj)animent of fiecal tumor or of intussusception. The different metallic poisons give rise to no characteristic odor, and it is necessary to look to the clinical history to determine the special poison. The FiECAL Evacuations. — The daily number of evacuations natural for a child varies greatly with its age. For the first six weeks there should be three or four stools every twenty-four hours. After this time, up to the end of the second year, two movements a day is the normal average. Sub- sequently, the frequency of defecation is usually the same as in adults — once per diem. During the first period the stools have the consistence of thick soup, are yellowish-white or orange-yellow in color, with sometimes a tinge of green, have a faint fmcal, slightly sour odor, and are acid in reaction. In the second they are mushy or imperfectly formed, of uniform consistence through- out, brownish-yellow in color, and have a more fincal odor. The last two charac- ters become more marked as additions are made to the diet. After the comple- tion of the first dentition the motions have the same appearance as in adult life; they are formed, and brownish in color, with a decided fiecal odor. Many alterations occur in disease. The frequency of the movements may be increased, constituting diarrhoea, or lessened, constituting constipation. In the former condition the consistency is diminished, in the latter increased. Instead of being uniform throughout, the stool may be mixed, partly liquid, partly solid, indicating imperfect digestion, and curds of milk and pieces of undigested solid food may be mingled with the mass. Flaky, yellowish, or yellowish-green evacuations, containing whitish, cheesy lumps, are also met in cases of indigestion. Scanty, scybalous stools, dark-brown or black in color, and mixed Avith mucus, are characteristic of intestinal catarrh. Doughy, grayish, or clay-colored motions show’ a deficiency of bile. An intermixture of blood, altered blood-clots, and shreds of mucous membrane indicate some breach of continuity in the intestinal lining, such as occurs in follicular ente- ritis, typhoid fever, dysentery, and tubercular disease. Watery, almost odor- less stools occur in the latter stages of entero-colitis, most offensive, carrion- like motions in both catarrhal and tuberculous ulceration of the intestines, and sour-smelling evacuations in the diarrhoea of sucklings. The discovery of w’orms or their ova in the stools is the certain evidence of the existence of intestinal parasites. This outline of the changes that may take place Avill serve to show' hoAV much may be learned from the stools, and the importance of making a ]>er- sonal examination of them. The Urine. — It is impossible to make a definite statement as to the num- ber of times the urine is voided by a healthy infant in each tAventy-four hours. In any given case the fre(|uency Avill differ very much from day to day, depend- ing upon the tenq)erature of the surrounding air, the ainount of moisture that it contains, and so on. Sometimes it Avill be necessary to change the diaper every hour during the day and three or four times at night. Again, it may remain dry for six, eight, or even ten hours. Neither condition indicates dis- ease, and betAveen the tAvo extremes there is a Avide range of variation. Should the urine not be passed for twelve hours or more, a careful examination should CLINICAL INVESTIGATION OF DISEASE. 9 be made to discover and remedy retention. As the child grows older the fre- quency diminishes, and at the age of three years the number of voidings will be reduced to six or eight during the waking hours, and perhaps one at night. When the desire does arise during sleep, the child, if in a normal state, wakes up and demands the chamber, and never passes urine, unconsciously. Wetting the bed, thei’efore, or the involuntary passage of the urine during sleep, is indic- ative of an abnormal condition and requires investigation. Painful micturition points to inflammation of the urethra, a narrow preputial orifice, a highly acid condition of the excretion, or stone in the bladder. The urine of a healthy infant, while it wets, should not stain the diaper, the fluid being clear and almost colorless. It has a low specific gravity — 1.003 to 1.006 — and an acid reaction. As age advances the adult characters are more and more nearly approached, though during the whole of childhood the urine is paler and of lower specific gravity than in adult life. The normal daily amount excreted cannot be stated absolutely, but the following figures are approximate : Between two and five years, 15-2.5 oz. ; five and nine years, 25—35 oz. ; nine and fourteen years, 35—40 oz. Other characters of the urine in childhood will be considered under appropriate headings in subse- quent sections. Vomiting. — Both vomiting and regurgitation ai’e of ready production and frequent occurrence in infancAq on account of the vertical position and cylin- drical outline of the stomach at this period of life. Babies suckled at an abun- dant breast, and ivho are in perfect health, often vomit habitually. In these cases, the supply of food being large, the infant as it lies at the breast is apt to draw more than it can digest. The stomach rids itself of this over-supply by an act which more nearly resembles regurgitation than vomiting, and which must be regarded as an evidence of health rather than the reverse. There is no violent effort or retching; the material ejected is the breast-milk alone, either entirely unaltered or slightly curdled ; and there are no symptoms of nausea, such as paleness, languor, and faintness. In older children vomiting may also occur after the stomach has been overladen. If the act be followed by relief from the general disti-ess, headache, and epigastric pain, it must not be regarded as a symptom of disease. Vomiting attended with the train of symptoms embraced under the term nausea is not a pathognomonic symptom. It may indicate disease of the stomach, of the intestines, of the lungs and ]>leura, and of the brain, or it may be a prodrome of one of the eruptive fevers. Which condition is pres- ent can only be determined by watching the case. The character of the ejecta is more definite. For instance, the expulsion of mucus is a symptom of gas- tric catarrh. The regurgitation of mouthfuls of curdled milk, partially digested food, and liquid so sour that it causes a grimace to pass over the face, is an indication of dyspepsia, with fermentation and the formation of acid. The appearance of lumbricoid worms in the vomit — a not infrequent occurrence — of course shows conclusively the existence of these parasites in the alimen- tary canal. 3. Physical Examination. The methods of physical exploration in children are identical with those employed in adults, and the results do not differ in kind. Since, however, the object of exploration is to elicit the greatest amount of information with the least possible disturbance of the child, and as this very disturbance alters the character of some of the information obtained, it is w'ell to adopt a somewhat different order of examination, and one which at first sight may seem irregular. 10 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Thus it is best first to ascertain the character of the respiration and the pulse, then to strip the body to determine the degree of muscular development and the condition of the skin, next to investigate the physical condition of the lungs, heart, and abdominal organs, and last of all to examine the mouth and throat. In this order, then, the normal, as well as the more prominent abnormal, fea- tures connected with the different organs will be considered. The Respiration. — In children the respiration is chiefly abdominal in type, irrespective of sex, and it is not until just before the age of puberty that the movements in the female change, becoming superior costal. Consequently, in estimating the number of movements per minute, it is best to place the fingers lightly on the epigastrium. The count should always be made by the watch, and the most convenient time for the observation is while the child sleeps. Soon after birth the number of movements per minute is 44, between the ages of two months and two years, 35, and between two and twelve years, 23. During sleep the frequency is reduced about 20 per cent. Children under two years, while awake, breathe unevenly and irregularly. In sleep there is greater regularity. After the second year the movements become steady and even. All children, however, but particularly the very young, are subject to a great increase in the rapidity of respiration under excite- ment, either muscular or mental. Accelerated breathing may be caused by an elevation in the body temper- ature, by an interference with the blood aeration, and by thoracic or abdominal pain. As the increase in frequency may be unattended by any apparent effort or true dyspnoea, it is well to make a rule of counting the respirations in every case in which the diagnosis is doubtful. Diminished frequency is noted in certain brain affections, as in chronic hydrocephalus, and in the later stages of tubercular meningitis. In such cases the rhythm may be greatly altered — a tidal form being assumed ; this is termed “ Cheyne-Stokes respiration.” Another form of breathing, in which the alteration is mainly in the rhythm, is termed expiratory respiration. It is characterized by the pause coming between inspiration and expiration, instead of between expiration and inspiration, as is the normal rule. This alteration occurs most frequently in young children, and is an evidence of dangerous pulmonary embarrassment. Perfectly healthy children breathe through the nose, and so softly that it is difficult to hear the breezy sound of the ingoing and outgoing air. A dry, hissing sound or a moist sound of snuffling indicates partial obstruction of the nasal passages ; oral respiration, complete occlusion. Difficult breathing with prolonged inspiration — inspiratory dyspnoea — shows an impediment to the entrance of air into the lungs and indicates laryngeal obstruction, due, most commonly, to spasm or to the formation of false membrane. In such cases the inspiratory act is also attended by a loud, piping, or rasping sound. Labored breathing with prolonged wheezing respiration — expiratory dyspna>a — occurs when the escape of air is impeded. The causative lesion is to be found, not in the larynx, but in the lungs. It may be a bronchial catarrh with excessive secretion, emphysema, or asthma. In both forms of dyspnoea the movements are slow as well as difficult, and a combination of the two forms is met with in cases of marked laryngeal stenosis. Yawning, if it recur frequently, denotes great failure of the vital powers. The Purse. — To obtain any reliable data from the pulse it must be felt while the patient is perfectly quiet. The best time is during sleep, but if the child cannot be caught in this condition, advantage may bo taken of its ]da- cidity while nursing at the breast, feeding from a l)ottlo, or amused by a toy. CLINICAL INVEiSTIGATION OF DISEASE. 11 With very young infants.it is sometimes impossible to feel the beat of the radial artery, and it is necessary to ascertain the frequency of the pulse by directly auscultating the heart. After the second month palpation of the pulse at the wrist in the ordinary way presents no difficulties. The child’s pulse differs from the adult’s by being much more frequent, more irregular, and more irritable, and necessarily of smaller volume. The frequency, or the number of beats per minute, varies with the age. The following is the average rate : From birth to the second month 160 to 130 From the 2d to the 6th month 130 to 120 “ 6th “ 12th “ 120 to no “ 1st “ 3d year 110 to 100 “ 3d “ 5th “ 100 to 90 ' “ 5th “ 10th “ 90 to 80 “ 10th “ 12th “ 80 to 70 These figures represent the pulse in a waking but passive state. During sleep the frequency is less. Thus, between the second and ninth years there are about sixteen beats less per minute while asleep than when awake; between the ninth and twelfth years, eight less; and between the twelfth and fifteenth years, only two less. Below the age of two years the disparity is even greater. The irregularity of the pulse in childhood is confined to an alteration of the rhythm. It is most marked in infants, and is greatest during sleep, when the pulse is slowest. The feature of irritability — that is, the facility with which its frequency is increased by muscular activity and mental excitement — is greater in proportion to the youth of the child. A rise of 20, 30, or even 40 beats a minute is not uncommon in early infancy under the excitement of the slightest effort or disturbance. On account of these wide variations in health little symptomatic meaning need be attached to alterations of the rhythm and fre- quency while unassociated with other abnormal features. When so associated they become important in diagnosis. Increased frequency is a constant attendant of the febrile state. The extent of the increase corresponds with the degree of elevation of the temperature, though the pulse curve always runs higher than the temperature curve. The more frequent the pulse the higher the fever is the rule, but in estimating the prognostic value of the increase the law of the fever in question must be taken into consideration. For example, in scarlatina a pulse of 160 is usual and not indicative of special gravity, whereas in measles the same degree of accelera- tion would be abnormal and show great danger. Jaundice and parenchymatous nephritis are accompanied by a diminution in the rate. Irregularity is met with in diseases of the brain and heart, and sometimes in nervous and anaemic children". The Temperature must be estimated before removing the clothing, and a clinical thermometer must always be used. The instrument is usually placed in the rectum or groin ^ of the infant and young child ; in the axilla or mouth of an older and more controllable child. It should remain in position from one to five minutes, according to the delicacy of the instrument. During the first week of life the temperature fluctuates considerably. After that the puerile norm — 98.5° to 99° F. — is established, but until the fourth or fifth month it is greatly influenced by healthy causes of variation, the fluctua- tions ranging between 0.9° and 3.6°. By the fifth month regular morning and evening oscillations begin and certain definite laws are followed. There is a * The rectal temperature is normally 1° higher than the axillary ; that of the groin about 1° lower. 12 AMERICAN TEXT-BOOK OF DREARER OF CHILDREN fall in the evening of 1° or 2°. The greatest fall occurs between 7 and 9 p. M., and the minimum is reached at or before 2 A. M. After 2 A. M. there is a grad- ual rise, the maximum being reached between 8 and 10 A. M. Throughout the day the oscillation is trifling. These variations are independent of eating and sleeping. In disease there may be either a rise above or a fall below the noi’mal standard. Fever is always associated with an elevation of the temperature. Rapid and transient rises attend slight catarrhs and passing indigestions ; pro- longed rises, inflammatory and essential fevers. The degree of elevation marks the type of the pyrexia. This is moderate when the mercury stands at 102°, severe at 104° or 105°, and very grave above 107°. The duration of the ele- vation and the peculiar range of the oscillations — for there are oscillations in disease as well as in health — determine the nature of the fever. The febrile oscillations differ from the healthy in that the lowest marking is noticed in the morning, the highest in the evening. Variations in the typical range of any given fever are important prognostic omens: a sudden fall of temperature, together with improvement in the general symptoms, indicates the beginning of convalescence ; a similar fall, with an increase of the general symptoms, is a precursor of death. When the morning temperature is equal to that of the preceding evening, there is great danger ; if higher, greater danger still. Marked remission in continued fevers is generally a forerunner of con- valescence. Abnormal depression of temperature is occasioned by hmmorrhage and by the loss of fluids in profuse watery diarrhoea. It is also met with in anmmia, in atrophy from insufficient nourishment, in diseases of the heart and lungs attended by imperfect blood-aeration, and it constantly attends collapse and the death agony. A maintained temperature of 97° F. is dangerous in chil- dren, and for every degree of reduction below this point the risk to life is more than jmoportionately increased. The General Development. — The healthy child under two years of age is plump of body and round of limb, with well-developed fat cushions and firm flesh, and with the head and abdomen large in proportion to the rest of the frame. As age advances the figure gradually assumes the characteris- tics of adolescence. To be robust, the newly-born child must have a certain average size and ■weight. Subsequently, under normal circumstances, there is a regular rate of increase in both of these respects. At birth the length is about 19 inches. Growth is quickest in the first weeks of life. In the first year there is an increase of from 5 to 64 inches ; in the second, from 2| to 3^ inches ; in the third, from 2J'to 2| inches; in the fourth, about 2 inches; and from the fifth to the sixteenth year the annual growth amounts to from If to 2 inches. The average weight at birth is from 6 to 8 pounds. The daily increase in Aveight should range from 4 to f of an ounce. With these data it is (piite possible to estimate what should be the normal size and weight of a child at any age. Conse(juently, if, on being measured and Avcighed, he be found to fall short of the normal standard, it is proper to infer the existence of some fault in the nutritive processes — a conclusion still further borne out by a Avant of rotund- ity of outline and by flald)iness of the muscles. The age at Avhich the child sits erect, at which it Avalks, and at which the anterior fontanelle becomes ossified are points closely connected Avith the sub- ject of development and nutrition. For some time after birth the child, if noticed while sitting upon the lap, Avill be observed to hold the head and shoulders fonvard or to “stoop” a little, the spine from the cervical region CLINICAL INVEHTIUATION OF L>1SEASF. 13 to the sacrum forming a continuous curve, with the convexity directed back- ward. Toward the end of the eighth month the position begins to become more erect, and in a few W’eeks is perfectly so, the spine assuming an almost perpendicular line. Any marked delay in this change indicates general debility. At the end of the fourteenth month the child should be able to W'alk alone. The spine then assumes the S-like curve seen in healthy adults. A delay in walking may be due to systemic weakness or infantile paralysis affecting one or both legs. If the walking be done on the toes chiefly, if the gait be limping, and especially if knee-pain be complained of and manipulation of the limbs causes suffering, the chances are that hip-joint disease is com- mencing. The anterior fontanelle should be ossified or completely closed at some period between the fifteenth and twentieth months. The closure is much retarded in rickets, which is pre-eminently a disease of malnutrition. Hydro- cephalus has a like effect. In a state of health the opening, while still mem- branous, is level with the cranial bones or very slightly depressed. Conditions of systemic exhaustion cause marked sinking, and this depi’ession is one of the best indications of the necessity of stimulation. Bulging of the fontanelle is a symptom of chronic hydrocephalus. Conditions of the Skin. — In addition to the characters already described, the skin of a healthy child has a velvety smoothness and softness, a scarcely perceptible moisture, and a great degree of elasticity. “Mucous di.sease ” is attended with a dry, harsh skin, which is muddy in color, and covered, especially on the extensor surfaces of the arms and legs, by a more or less thick layer of exfoliating epidermis. Chronic abdominal affections, particularly tuberculosis of the intestines and mesenteric glands, lead to harshness, acridity, scurfiness, and a wrinkled appearance of the skin covering the abdomen and thorax, with enlargement of the superficial abdom- inal veins. Protracted diarrhoea, and, still more, vomiting combined with diai’rhoea, cause absorption of the subcutaneous fat and wasting of the mus- cles. The skin becomes too large for the body, is dry, harsh, discolored, and so inelastic that it falls into wrinkles over the joints when the limbs are moved, and if pinched up retains the fold for a long time. The condition of general atrophy popularly known as “marasmus” presents these features most strik- ingly. Dryness is a concomitant of the febrile state ; excessive moisture, of prostration and collapse. Eruptions appear upon the integument in the skin diseases proper, in the exanthemata, in constitutional syphilis, and in certain digestive disorders, ffidema of the subcutaneous connective tissue may be due to affections of the heart, liver, or kidneys. The cardiac variety usually shows itself first in the feet ; the renal, in the eyelids ; the hepatic, in the feet and legs, secondarily to ascites. While examining the surface it is well to look for enlargement of the super- ficial lymphatic glands and swelling of the joints. The former occurs in tuber- culosis and syphilis ; the latter, in rheumatism. Examination of the Abdomen. — To examine this portion of the body, the child, still stripped, must be placed on its back and kept as quiet as possi- ble. Palpation or percussion should never be made with cold hands. The abdomen of a healthy child is prominent, uniformly soft, yielding, and painless to the touch, and to percus-sion gives a tympanitic sound, varying in tone according to the region percussed. The tympanitic note is lowest in pitch over the epigastric and left hypochondriac regions, the seat of the stomach ; highest over the umbilical region, the position of the small intestine. In disease inspection reveals any disproportion in the size or form of the abdomen, the state of the integuments, of the superficial veins, and of the 14 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. umbilicus. Palpation shows the temperature, pliability, moisture, and tension of the walls, and the presence or absence of tenderness, of fluctuation, and of enlargement of the mesenteric glands and other solid viscera. Percussion serves to demonstrate the nature of enlargements, whether due to accumulation of gas or liquid or to solid growths. By it, also, the outline and size of the liver and spleen may be determined. Distention of the abdomen is, in the vast majority of instances, due to flatulence. In this condition the skin feels tense, the umbilicus is level or slightly prominent, there is no tenderness on pressure, and percussion is markedly tympanitic. Drum-like distention, with great tenderness, and muffled tympanitic percussion- note occur in general peritonitis. Uniform distention, again, may be due to ascites. The abdomen is barrel-shaped, painless to the touch, and there is extended fluctuation. Percussion is dull over the position of the fluid, but in nearly every instance there is an area of tympany which changes its position. Localized distention may be traced to gaseous accu- mulation, to enlargement of the liver and spleen, to ftecal accumulation, to circumscribed peritonitis, and to distention of the bladder. Collections of gas are always tympanitic on percussion. The extent of liver dulness is to be estimated by percussion, or palpation with the umrmed hand. An enlarged spleen may be felt by placing the fingers of the right hand on the back, directly below the twelfth rib and outside of the lumbar muscles, the fingers of the left on the abdomen, directly opposite, then bringing the hands toward one another. The fact that both the liver and spleen, though still unenlarged, may be more readily felt than natural when pressed downward by the dia- phragm, must not be overlooked. A ftecal accumulation is distinguished by the absence of tenderness, by the oblong shape of the tumor, by the situation in the region of the transverse or descending colon, to which its long axis cor- responds, and by its shape being capable of some modification by pressure. Percussion over such a mass is dull. Distention of the bladder gives rise to a bulging tumor in the hypogastric region, which is elastic to the touch and dull on percussion. A shrunken or scaphoid condition of the abdomen is met with in serious brain affections, notably tubercular meningitis, also in entero-colitis, follicu- lar enteritis, and dysentery. Tenderness to pressure indicates inflammatory lesion of the intestines. The presence or absence of this sign in an infant can be determined by forcing the attention, by bringing it before a strong light, for instance, and then making pressure on the abdomen. If crying be produced, there is tenderness ; if not, the reverse. Examination of the Chest. — The stethoscope and pleximeter are unne- cessary in examining the lungs. In the case of the heart the former may be occasionally required to localize murmurs. When used, it is better to give the instrument to the child to handle and become familiar with before ajq)lication. The thoracic end must never be adjusted without being warmed. The (luieter the patient, the more complete and satisftietory will be the results of the ex))lo- ration. Unfortunately, though, it is too often necessary for one to do the best possible in the midst of cries and struggling. However, by skilfully seizing opportune moments much reliable information may be gained. The steps of the examination are — first, insi)ection ; second, auscultation ; third, palpation ; and fourth, percussion, d’he reason lor making the order different from that j»ractised in adults is to place the most disturbing element last. Mensuration and succussion are infre(iuently resorted to in children. If retjuired, they are best postponed until the end of the examination. CLINICAL INVESTIGATION OF DISEASE. 15 Inspection . — The sitting posture, the child being stripped and in a good light, is the best for this process. Note is to be taken of the shape of the chest, the character of the breathing, and the position of the apex- beat of the heart. In the new-born baby the chest is nearly circular in shape ; later, the lateral diameter considerably exceeds the antero-posterior. The intercostal spaces are poorly marked, and the scapulm lie so close that their outline is scarcely perceptible. The circular shape of the chest allows of little lateral expansion, and for this reason the respiration is chiefly abdominal in type. Together with the movement of the abdominal walls, every act of inspiration is attended by a certain amount of recession of the lower part of the chest- walls, the yielding ribs being forced inwai’d by the pressure of the external air before they can be sufficiently supported by the expanding lung. The rise and fall of the cardiac apex can be seen — except when there is a great accumulation of fat — a short distance below and to the right of the left nipple. Disease may alter all of these conditions. The tuberculous diathesis is characterized by a small chest, and one which has either the alar or the flat shape. In rickets the thorax becomes irregularly triangular in outline. Em- physema causes a barrel-shaped chest, with stooping shoulders and round back. Pleuritis with large effusion produces bulging of the affected side, and some- times prominence of the intercostal spaces. After absorption has taken place there may be marked retraction, sinking of the interspaces, falling of the shoulders, and curvature of the spine toward the healthy side. Cessation of the costal respiratory movements indicates inflammation of the lung or pleura or a large pleuritic effusion ; cessation of the abdominal play, inflammation of the peritoneum or of the intestines : excessive ascites and gaseous accu- mulations produce the same effect. Rachitic softening of the ribs, and those diseases of the lungs which offer a direct obstacle to the entrance of air, are associated with a great increase in the normal recession of the lower portion of the chest on inspiration. The position of the apex-beat is altered Ijy car- diac diseases, by pleuritis, and occasionally by gaseous distention of the stom- ach. When the left ventricle is enlarged, it is shifted downward and to the left. Transmitted epigastric pulsation shows enlargement of the right ventricle. An extended impulse is not necessarily a sign of disease, since the chest-walls are so elastic in childhood that the normal impact of the apex is apt to affect a wide area. The effusion of pleurisy pushes the heart to the right or left, while the retraction, after absorption or evacuation, draws it in one or other direction. The apex is pushed upward and to the left in gastric flatulence. Emphysema, by pushing the heart away from the thoracic wall, diminishes or hides the impulse. Auscultation . — With infants the back of the chest is most conveniently ausculted when the child is held in the nurse’s left arm, with his breast against hers, his chin resting upon her left shoulder, his left arm around her neck, and his head kept in position by her disengaged hand ; the front, when reclining on the back on a pillow ; the sides, when sitting upright on the lap, first one arm and then the other being lifted up to allow the observer’s ear to be applied. Older children may be made to take the same position as adults. It is not suf- ficient to auscult the posterior aspect of the thorax alone, as is stated by some authors. The whole chest should be examined, particularly in doubtful cases. The signs of croupous pneumonia are most frequently discoverable at one or other base, posteriorly; the friction-sound of pleuritis at the junction of the middle and lower third of the chest, laterally ; and the signs of emphysema at 16 AMERICAN TEXT-BOOK OE DISEASED OF CHILDREN. the apices, anteriorly. Therefore, unless the exploration be thorough, import- ant lesions may be overlooked. In healthy infants the inspiratory act in ordinary breathing is superficial, and the respiratory murmur, as a consequence, feeble. If, however, a deep inspiration be taken, a frequent occurrence under excitement and during cry- ing, the murmur becomes loud, ov jyuerile. After the age of two years puerile respiration is habitual. The breathing is loudest over the anterior, lateral, and posterior inferior regions of the thorax ; faintest over the scapulaj and the prge- cordial area. Sometimes the expiratory element is wanting in young children over the loAver posterior portions of the lungs. In the interscapular region there is often an approach to the bronchial type of breathing. If the child speaks, cries, or coughs while the ear is applied to the chest, a muffled rumbling sound, the normal vocal resonance, will be heard. At the same time vibra- tion of the walls, the vocal fremitus, can be felt. The cardiac sounds are readily heard when the ear is placed on the prsecor- dia. In young infants the examination is somewhat difficult, but after the first year, the circulation becoming slower and more regular, there is little trouble in distinguishing the sounds, and even slight alterations in them. The first sound is longer and graver than the second, the rhythm is ordinarily quite regular, and the area of distribution is extended. Palpation . — In practising palpation the palmar surface of the well-warmed hand must be applied to the naked chest. This method of exploration is use- ful as a means of determining the number of respiratory movements, the degree of expansion of the thoracic walls, the position of the cardiac apex-beat, the presence or absence of painful regions and of pleural or bronchial fremitus, the existence of ffuctuation in the intercostal spaces, and the chai’acter of vocal fremitus. Permssion . — In percussing the different surfaces of the chest the child must be placed in the same position as for auscultation. When contrasting the two sides, percussion should be made in identical regions and during the same period of the respiratory movement. Babies when constrained or when disturbed hold their breath in the intervals of crying, and as they always do so at the end of an inspiration, this is a favorable time to seize for the compar- ative examination. The percussion strokes must be lighter than in the adult, but in other respects the operation in no wise differs. In health the resonance will be found to correspond closely with the res- piratory murmur. Thus in infants under one year, the respiratory murmur being feeble, percussion is rather insonorous, but so soon as jiuerile respiration becomes established the resonance is uniformly intense. With the excej)tion of this greater intensity the sound is exactly similar to that obtainable in adults. It is always attended, too, by a sensation of elasticity, appreciated by the finger used as the pleximeter. Different portions of the thorax possess, normally, different degrees of sonor- ousness. In front, the right side is markedly resonant from the clavicle down to the fifth inters])ace or the u])per border of the sixth rib in the mammary line, where the liver dnlness begins. On the left side the resonance is ecjually intense, but it is encroached upon by the gastric tympany, which extends upward as liigh as the seventh or sixth rib, as well as by the area of car- diac dulness. The latter is never so decidedly marked as in adults. Later- ally, both axillary regions are very resonant. 'I'he upjier portions of the infra- axillary regions are a degree less resonant, and the lower jiortions are dull on account of the presence of the liver on the right and the spleen on the left side. The superior border of the liver dulness is found in the seventh interspace, or CLINICAL INVESTIGATION OF DISEASE. 17 at the eighth rib ; that of the spleen, at tlie upper edge of the ninth rib. Gas- tric tympany may supplant the pulmonary resonance over the left infra-axillary region. Posteriorly, there is little resonance in the scaj)ular region, partic- ularly the su[)raspinous portions. Over the interscaj)ular space the sound improves, but it is less resonant than anteriorly or laterally. Over the infra- scapular regions the resonance is but little less pure than in front, until the tenth rib is reached on the right side and the liver dulness is again met with. On the left side the resonance extends to the very base, the posterior splenic dulness being detected with difficulty. The right base is, therefore, naturally less resonant than the left, and this difference is especially marked during expi- ration, the liver rising higher at that time. Affections of the lungs produce various alterations in the percussion sound. The chief of these are the substitution of tympany, of dulness, and of flatness for the normal resonance, and of increased resistance to the finger for elasticity. Cardiac diseases cause changes in both the extent and the shape of the area of praecordial dulness. Examination of the Mouth and Fauces. — This portion of the exami- nation is most apt to cause crying, but it must never be omitted. In infants gentle pressure of the fingers upon the chin is sufficient to cause wide opening of the mouth. An older child will frequently open the mouth when requested, but if he refuse, some smooth, flat instrument may be inserted in the mouth, and downward pressm-e made upon the tongue, when the jaws will be widely separated. The fauces can sometimes be seen by directing the mouth to be opened wide and the tongue to be alternately protruded and retracted, or a pro- longed sound of ‘■'•All ” to be made. With the refractory, and always with infants, the tongue has to be held down by a spoon-handle or tongue-depressor. The healthy oral mucous membrane has a deep pink color and is smooth, moist, and Avarm to the touch. The color is deeper on the lips and cheeks, lighter on the gums. The latter, up to the sixth month, as a rule, have a mod- erately sharp edge. Subsequently, the edge begins to broaden and soften, and the color of the investing mucous membrane deepens to a vivid red, and becomes hot as the teeth begin to force their way through. The first, or millc teeth — so called from their color — are twenty in number, all told, ten to each jaw; the two lower central incisors, the first of the set, make their appearance at some time between the fourth and seventh months, the others following at stated intervals.^ The permanent teeth, thirty-two in number, begin to appear about the sixth year. The tongue should be freely movable. It is pink in color, and the dorsum, or upper surface, marked in the centre by a slight longitudinal depression, has a velvety appearance, and is soft, moist, and warm to the finger. The hard pal- ate is roughened anteriorly by transverse ridges. The soft palate is smooth, and its mucous membane is paler than that of the rest of the mouth. The fauces, on the contrary, are redder. In the triangular recess between the half-arches of the palate the tonsils can always be seen. They should be about the size and shape of almond-kernels, and they present a number of circular open- ings, the orifices of pouches into which the follicles open. The uvula is short and tongue-shaped. The posterior wall of the pharynx should be red, smooth, and moist. Disease produces a great variety of changes in the mouth, tongue, and fauces. Fever makes the mouth hot and dry and causes the tongue to be frosted or coated. Affections of the gastro-intestinal tract are always attended by coating of the tongue, and the various appearances of this coating are of ‘ See article on Dentition. 2 18 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. important diagnostic and therapeutic significance. Inflammation of the mouth itself reddens the mucous membrane, makes it hot and tender to the touch, increases its moisture, alters the surface of the tongue, and leads to the forma- tion of aphthae, to ulceration, and even to gangrene. The eruptions of scar- let fever, measles, varicella, and varioloid make their appearance first on the mucous membrane of the palate and fauces. Finally, the conclusive evidences of diphtheria and of the various tonsillar affections are found in the fauces. Irregular dentition indicates faulty nutrition ; delayed dentition, rickets ; and certain peculiarities in the formation of the permanent teeth, constitu- tional syphilis. II. THE GENERAL MANAGEMENT OF CHILDREN. 1. Feeding. The whole question of feeding bears so close a relation to age that it is necessary to study it from the standpoint of the two stages of a child’s life already mentioned. An infant may be fed in one of three ways : 1st, from the mother’s breast ; 2d, from the breast of a wet-nurse ; and 3d, from a bottle by the method known as artificial or hand-feeding. 1st. Feeding from the Maternal Breast. — This, being the natural, is the proper method of nourishing the human infant ; and every mother who is able should nourish her child solely from her breast up to the age of eight months, and partially to the end of the first year, or, failing in either limit, so long as possible. The infant should be put to the breast as soon as the mother has recovered somewhat from the fatigue of labor — some four or eight hours after birth. Of course no milk can be drawn at this early date, but the babe gets a small quantity of colostrum, which aftbrds sufficient nourishment, and from its laxa- tive properties clears out the infant’s intestinal canal. This, too, is of great advantage to the mother, for it ensures proper uterine contraction, draws out the nipples, and encourages the formation of milk. Put the child to the breast every two hours while the mother is awake, and up to the fourth day there need be no fear of starvation. Usually on the fourth day milk is secreted and regular lactation commences. Before this time the administra- tion of gruel or any form of artificial food is more than useless, as it lessens the activity of sucking and frequently deranges the stomach. Many untrained mothers make a failure of nursing because they know nothing of the manner of giving suck ; of the length of time the child should be kept at the breast ; of the proper time for, and interval between, feedings ; and of the importance of regularity. While nursing the infant must be held partly on its side, on the right or left arm according to the gland about to be drawn, Avhile the mother must bend her body forward, so that the ni])ple may fall easily into the child’s mouth, and steady the breast and regulate the flow of milk with the first and second finger of the disengaged hand placed above and below the nipjde. Each of the breasts should be drawn alternately, and a healthy child may be allowed to nurse until satisfied. Usually during the first six Aveeks the breast is required every second hour from 5 A. M. until 11 l*. M., and in some cases once during the night; but this night-nursing should be given up as soon as possible, that the mother may secure essential repose. Begularity in meal hours is most important, ami a little perseverance will form the habit of waking to suck the breast with almost the precision of the clock. This rule, GENERAL MANAGEMENT OF CHILDREN 19 however, is not rigid, some infants requiring food less, others more, frequently. These exceptions call only be determined liy observation of individual charac- teristics, and every mother must early learn to distinguish the cry of hunger from that due to the pain of indigestion, and avoid the dangerous practice of resort- ing to constant feeding as a means of pacifying crying. After the sixth week the interval between nursings may be slowly increased until, by the fourth month, it reaches three hours. During this period, also, the time of lying at the breast may be gradually lengthened, for the quantity of milk secreted and the child’s appetite and capacity for food are all aug- mented as the days pass by. At the end of the sixth month feeding every fourth hour suits some children well, but as a rule the three-hour interval must be adhered to from the fourth month to the end of lactation. After the sixth or eighth month “mixed feeding” — breast- and bottle- feeding alternating — is advisable if the babe ceases to thrive on the breast alone. Otherwise, the maxim of not interfering with any course that is doing well is as applicable liei'e as elsewhere, and the breast may be relied upon entirely until the time comes for weaning. Should additional nutriment be required, the food must be selected with due reference to age and prepared in the same manner as in regular hand-feeding. The date of weaning cannot be fixed for all cases, since it depends upon the health of the mother and the development of the child. When the former continues to be robust and the child steadily grows and gains flesh, lactation can be prolonged until the tenth or tAvelfth month. If persevered in longer, the mother’s strength usually begins to fail, her milk is lessened in quantity or becomes poor in quality, the child’s nutrition suffers, and it grows pale, thin, and flabby, and may develop the disease known as rickets. Weaning may be accomplished gradually or suddenly. In gradual wean- ing about four weeks are required to prepare for the absolute withdrawal of the breast. For instance, if suck be given every three hours from 5 A. M. until 11 P. M., or seven times a day, there should be, during the first week of preparation, one artificial feeding and six nursings daily ; during the sec- ond, two and five, and so on until the breast is entirely withheld. Carefully prepared milk food, administered from a bottle, is the best substitute. At the age of ten months a mixture that ordinarily agrees Avell is — Cream f 5 ss. Milk f. 5 iv. Sugar of milk 3 j. Water f^iss. Should fever or disordered digestion occur during the period of prepara- tion, the number of artificial feedings must be reduced or the breast resumed until the disturbance be passed ; then the course may be begun again and car- ried to its completion. Sudden weaning is more difficult to accomplish, and is not advisable unless, while the breast is being presented, there is an absolute refusal to take artificial food, or unless the mother’s health becomes so affected as to render any further sucking a positive peril to the child’s life : attacks of erysipelas or of small- pox are instances in point. The physician is often forced to decide upon the advisability of premature weaning. His decision must be made cautiously and after thorough investi- gation of two propositions — namely {a) the effect of further lactation upon the health of the mother ; and {}>) the recpiirements of the child. (a) Lactation, being a physiological process, is not a drain upon the sys- 20 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. teniic strength so long as the functions of nutrition are actively performed, but under other circumstances it very freecific gravity of GENERAL MANAGEMENT OF CHILDREN. 21 1.031, an alkaline reaction, and show, when placed under the microscope, a number of minute, e({ual-sized fat-globules. Its quantity may be ascertained by weighing the child before and after sucking, the normal gain being from three to six ounces. There is, however, no better or more readily applied test of the quality of a nurse than the size, weight, and general development of her own child ; and if it be weak and ill-nourished, no amount of fitness in other respects can warrant her engagement. Even when a woman is found fulfilling in her single person all the required conditions — a rare thing, indeed — it does not necessarily follow that her milk will suit the babe to be suckled. Then changes and new trials must be made until the desired end be attained. 3d. Artificial Feeding. — There are many women who, no matter how Avill- ing, are completely unable to suckle their babies, and a vast number in whom the secretion of milk fails after a few weeks or months of lactation. These must resort to a wet-nurse or to artificial feeding. Usually, they select the latter method. To ensure success in hand-feeding — always a difficult task — it is important to make a detailed study of the following questions : a, the selection of a proper substitute for the natural food — the breast-milk ; b, the quantity to be given ; c, the method of preparation ; d, the mode of administration ; and, e, the means of preservation. a. Healthy breast-milk must be taken as the type of infants’ food, and the nearer an artificial substance can be made to approach it in chemical composi- tion and physical properties the more perfect it is. Normal breast-milk has a specific gravity of 1.031. It is a persistently alkaline fluid, having a some- what animal, usually disagreeable, and, very rarely, sweetish taste. It is bluish-white in color and thin and Avatery in consistence. It contains nitro- genous material (caseine), carbohydrates (milk-sugar and fat), salts, and water — all the elements essential to repair tissue-Avaste, to supply neAV material for groAvth, and to maintain body heat, or, in other Avords, to constitute a perfect aliment ; and these, too, are so proportioned in the combination as to most easily and completely meet the demands. In seeking a substitute for human milk one naturally turns to the domestic animals for the source of supply ; coavs’ milk is usually selected, because, being plentiful, it is easily obtained and cheap. Coavs’ milk (market milk) has a loAA'er specific gravity than human milk — ■ namely, 1.029; notAvithstanding this, it is richer-looking — that is, Avhiter and more opaque ; its reaction is slightly acid unless perfectly fresh from pasture- fed animals, when it may be neutral or alkaline. Its component ingredients are similar to those of human milk, but nitrogenous material exists in greater, the fat in someAvhat less, and the sugar in far less proportion. The nitrogenous material also differs in quality, containing a much larger jiroportion of albumin coagulable by acids. This difference is readily tested by adding rennet to the two fluids. In the case of coaa's’ milk the caseine is coa"ulated into large, firm masses, Avhile Avith human milk a light, loose curd is formed. In the stomach the acid gastric juice has the same effect, producing in the first instance a coag- ulum most difficult to digest ; in the other, one readily attacked and broken down by the gastro-intestinal solvents. These chemical and physical proper- ties of cows’ milk can be altered by various methods of preparation, and unless this be done there are few instances in Avhich it Avill not prove a poor substitute for the natural food. Condensed milk is frequently recommended by physicians, and largely used by the laity on their OAvn responsibility. It keeps better than cows’ milk, and is supposed to be more readily digested by young infants. The latter suppo- 22 AMERICAN TEXT-BOOK OF DIHEASEfi OF CHILDREN. sition is a mistaken one, and arises from the overlooked fact that condensed milk is always given dissolved in a large proportion of water, while cows’ milk is too frequently used insufficiently diluted or otherwise improperly prepared. Condensed milk contains a large proportion of sugar, forms fat quickly, and thus makes large babies ; sugar also counteracts the tendency to constipation — often a troublesome complaint in hand-feeding. These advantages are unquestioned, and, together with the ease of preparation, are those which place it so high in the esteem of monthly nurses. It is equally true, however, that as a food it contains too much cane-sugar, and not enough nutrient material to supply the wants of a growing baby. Infants fed upon it, though fat, are pale, lethai’gic, and flabby ; although large, they are far from strong, have little power to resist diseases, often cut their teeth late, and are very liable to drift into rickets. It must be remembered also that condensed milk, when long kept or when packed in imperfect cans, not unfrequently undergoes decomposition, and thus becomes utterly unfit for use. For a temporary change of diet, however, and as a substitute during travelling or under cir- cumstances in which sound cows’ milk cannot be obtained, it may be resorted to with advantage. The farinaceous substances so often selected, especially by the poor, to replace breast-milk, are not only bad foods, but have both directly and indirectly a delete- rious effect upon the processes of nutrition. They are bad for two reasons : First, they differ materially in chemical composition from human milk. For example, in arrowroot, which is the favorite, the proportion of the tissue-building to the heat-producing element is as one to twenty, while in human milk it is about one to five. Secondly, the heat-producing principle, starch, must be converted into sugar before it can be absorbed. This change is accomplished in the body by the saliva and pancreatic juice — secretions that are not fully established until the fourth month. While the starch lies undigested in the gastro-intes- tinal canal it is subject to fermentation, resulting in the formation of irritant products that rapidly induce catarrh of the mucous membrane — 'a condition directly interfering with the digestion and absorption of food. Again, perfect nutrition demands rapid waste and removal of effete tissues as well as repair of the same. This is effected by oxidation. Now, sugars are known to have a much greater affinity for oxygen than albuminates, and when the diet con- sists of farinaceous material the small amount of sugar formed and absorbed appropriates oxygen that otherwise would go toward the removal of waste, and so retards the necessary changes. Farinaceous food, as such, is never permis- sible before the fourth month ; earlier, it is only to be employed for its mechan- ical action as an addition to milk preparations. This will be mentioned later. The nutrient value of the cereals and their products as they exist in so-called “infants’ foods ” has been imperfectly determined. They are undoubtedly use- ful as mechanical attenuants, but it is very certain that none of them, unless prepared with milk, can permanently meet the demands of nutrition. At the same time, it is quite probable that the soluble albuminoid substances obtained by Liebig’s process have a food value of their own, making them more serviceable than the starches. h. The quantity of food to be allowed each day varies with the appetite and age, and the (question of the correct amount in a’ given case must be answered by observation. Nevertheless, it is well to have some guide. (See table, page 24 et seq.) After the twelfth month the quantity depends upon whether additions be made to the diet or milk food be used exclusively. When the daily amount reaches three pints, the limit of the capacity of the stomach is usually attained. GENERAL MANAGEMENT OF CHILDREN. 23 iind the greater demand for nutriment, as gi’owth advances month by month, must be met by adding to the strength of the food rather than by increasing its bulk. These two factors, strength and (quantity, are intimately associatecl throughout the whole period of infancy, and in the earlier months a mere increase in the latter is not always sufficient to maintain the balance of nutrition. c. The object to be accomplished in the preparation of cows’ milk is to make it resemble human milk as much as possible in chemical composition and phys- ical properties. To do this it is necessary to reduce the proportion of caseine, to increase the proportion of fat and sugar, and to overcome the tendency of the caseine to coagulate into large, firm masses upon entering the stomach. Dilution with water is all that need be done to reduce the amount of caseine to the proper level ; but as this diminishes the already insufficient fat and sugar, it is essential to add these materials to the mixture of milk and water. Fat is best added in the form of cream, and of the sugars either pure white loaf sugar or sugar of milk may be used. The latter is greatly preferable, as it is little apt to ferment and contains some of the salts of milk, which are of nutritive value. Firm clotting may be prevented by the addition of ati alkali or a small quantity of some thickening substance. Lime-water is the alkali usually selected. It acts by partially neutralizing the acid of the gastric juice, so that the caseine is coagulated gradually and in small masses, or passes, in great part, unchanged into the intestine, to be there digested by the alkaline secretions. As it contains only half a grain of lime to the fluidounce, the desired result cannot be attained unless at least a third part of the milk mix- ture be lime-water. Instead of lime-water, two to four grains of bicarbonate of sodium may be added to each bottle, or, better still, from five to fifteen drops of the saccharated solution of lime. This solution is made in the following way : Take of — Slaked lime 1 ounce. Refined sugar, in powder 2 ounces. Distilled water 1 pint. Mix the lime and sugar by trituration in a mortar. Transfer the mixture to a bottle containing the water, and, having closed this with a cork, shako it occasionally for a few hours. Finally, separate the clear solution with a siphon and keep it in a stoppered bottle. Thickening substances — attenuants, such as barley-water, gelatin, or one of the digestible prepared foods — act purely mechanically by getting, as it were, between the particles of caseine during coagulation, preventing their running together and forming a large, compact mass. To prepare the former, put two teaspoonfuls of washed pearl barley, with a pint of cold filtered water, into a saucepan ; boil slowly down to two-thirds and strain. The liquid ob- tained does not possess the disadvantages of farinaceous foods generally. To be efficient, it must be used as a diluent instead of, and in the same proportion as, water. Gelatin is prepared in the following "way : Put a piece of plate gel- atin, an inch square, into a half-tumblerful of cold water, and let it stand for three hours ; then turn the whole into a teacup ; place this in a saucepan half full of water and boil until the gelatin is dissolved. When cold this forms a jelly ; from one to two teaspoonfuls may be added to each bottle of milk food. When an “ infants’ food ” is used to act mechanically, care should be taken to select one in which the starch has been converted into maltose and dextrin by the process of manufacture. 24 AMERICAN TEXT- ROOK OF DIREARES OF CHILDREN. The following table and schedule will aid in the practical understanding of the method of preparing food : Table of the IiKjredients , Hours and Intervals of Feeding, and Total (Quantity of Food from Birth to the End of Seventh Month. Age. Cream. Whey. Milk. Water. Milk- sugar. Salt. Hours for Feeding. Intervals of Feeding. Total Quantity. During 1st week . From 2d to 6th fS'j boi'j gr. XX 5 A. M. to 11 P. M. Occasionally once or twice at night. 2 hours. week From 6th week to f.5'j fgss fsj gr. XX a pinch. 5 A. M. to 11 P. M. 2 hours. fjxvij. end of 2d inontii From 3d montli to f5ss f3x fix 3ss a pinch. 5 A. M. to 11 P. M. 2 hours. f§xxx. 6tli month • . During 6th and 7th f5ss fSjss 3j a pinch. 5 A. M. to 10.30 p. M. 2j hrs. fgxxxij. months .... f^ss f 3 iijss fSij .oj a pinch. 7 A. M. to 10 P. M. 3 hours. f^xxxyj. Throughout the eighth and ninth months five meals a day vdll be sufficient. First meal, at 7 A. M. — Milk f 5 vi. Cream fgss. j\I ilk-sugar 3 j. Water fSjss. Second meal at 10.30 a. m. — M ilk, cream, and water in the same propor- tion ; a reliable “infants’ food,” two teaspoonfuls. Third meal at 2 p. i\i. — same as second. Fourth meal at 6 p. M. — same as second. Fifth meal at 10 P. M. — same as first. This gives forty fluidounces of food per diem. Instead of “infants’ food,” a teaspoonful of “flour-ball” may be added. To make flour-ball, take a pound of good wheat flour — unbolted, if ])ossible ; tie it up very tightly in a strong pudding-bag ; place it in a saucepan of water and boil constantly for ten hours ; when cold, remove the cloth, cut away the soft, otiter covering of dough that has been formed, and reduce the hard-baked interior by grating. In the yellowish-white powder obtained almost all the starch lias been converted into dextrin by the process of cooking, and the jiroportion of the nitrogenous principle to the calorifacient is as one to five — nearly the same as human milk. Two meals of flour-ball daily — the second and fourth — are all that can be digested. To prepare these, rub one teasjioonful of the powder with a tablespoonful of milk into a smooth paste, then add a second tablesjioon- ful of milk, constantly rubbing until a cream-like mixture is obtained. Pour this into eight ounces of hot milk, stirring well, and it is then ready for use. The other meals should be composed of milk, cream, sugar of milk, and w'ater, as already given. Flour-ball is best suited for infants having a tendency to too frecjuent and licpiid fecal evacuations, as it has a somewhat astringent action, and is to be avoided in cases of sluggish bowels and constipation. Under the latter conditions a more laxative food, such as oat-meal, crushed wheat, or barley, should be employed, the (juantity of each being determined by the effect to be j)roduccd. Diet from the tenth to fourteenth month — five meals daily: First meal, 7 A. M. — GENERAL MANAGEMENT OE CHILDREN. 25 Milk f.Sviiiss. Cream fSss. One of the Liebig foods" 5 ss. (Or barley jelly oij-) Water . ' f§jss. Occasionally, about the end of the first year a child may require a more varied and substantial diet; for example: First meal, 7 A. M. — milk mixture as above. Second meal, 10.30 A. M. — a breakfast-cupful (f 5 viij) of warm milk. Third meal, 2 p. M. — the yelk of an egg lightly boiled, with stale bread-crumbs. Fourth meal, 6 P. M. — same as first. Fifth meal, 10 p. M. — same as second. On alternate days the third meal may consist of a teacupful (six fluidounces) of beef tea* containing a few stale bread-crumbs. A further variation can be made by occasionally using mutton, chicken, or veal broth instead of beef tea. As much more difficulty is experienced in feeding infants during the first twelve months than during the second, it would be well to pause here to con- sider what had best be done in case the food described should disagree. If, after feeding, vomiting occur, with the expulsion of large, firm clots of caseine, the effect of adding lime-water or barley-water must be tried, both being added in the same quantity as the ordinary diluent — water. Sometimes, particularly if there be diarrhoea, boiling makes the milk more tolerable ; condensed milk, too, can be employed temporailly, making, for an infant of six weeks, each portion of — Condensed milk 3j. Cream f§ss. Hot water fsiiss. Should further alteration be necessary, goats’ or asses’ milk may be substi- tuted for cows’ milk, the strong odor of the former and the laxative properties of the latter being removed by boiling. The milk should be used warm from the udder. “Strippings” is another good substitute for cows’ milk. It is obtained by remilking the cow after the ordinary daily supply has been drawn, and con- tains much cream and but little curd. One part of strippings to two of water or an equal measui'e of barley-water makes an easily digested mixture. The process of predigestion or peptonization enables us to overcome many of the difficulties encountered in bottle-feeding. Pancreatin is the agent to be employed. That manufactured under the name of extractum pancreatis by Fairchild Brothers & Foster of New York has proved most efficient in my hands. To accomplish artificial digestion put into a clean quart bottle five grains of extractum pancreatis, fifteen grains of bicarbonate of sodium, and four fluid- ounces of cool filtered water ; shake thoroughly together, and add a pint of fresh, cool milk. Place the bottle in water, not so hot but that the whole hand can be held in it for a minute without discomfort, and keep the bottle there for exactly thirty minutes. At the end of that time put the bottle on ice to check further digestion and to keep the milk from spoiling. The fluid obtained, while somewhat less white in color than milk, does not differ from it in taste : if, however, an acid be added, the caseine, instead of being coagu- ^ Beef tea for an infant is made in tlie following way : Half a pound of fresh rnmp-eteak, free from fat, is cut into small pieces and put, with one pint of cold water, into a covered tin saucepan. This must stand by the side of the fire for four hours, then he allowed to simmer gently (never boil) for two hours, and, finally, be thoroughly skimmed to remove all grease. 2G AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. lated into large, firm curds, takes the form of minute soft flakes or readily broken-down, feathery masses of small size. When the process is carried just to the point described, the caseine is only partly converted into peptone, but every succeeding moment of continued warmth lessens the amount of caseine until peptonization is complete. Then the liquid is grayish-yellow in color, has a distinctly bitter taste, and shows no coagulation whatever on the addition of an acid. “ Peptogenic milk powder,” prepared by the same chemists, has given me even better results than the pancreatin and soda. This powder contains a digestive ferment, pancreatin ; an alkali, bicarbonate of sodium ; and a due proportion of milk-sugar. The mode of employment is as follows : This mixture is to be heated slowly to boiling, ten minutes being occupied, and then quickly cooled. When properly prepared the resultant, so-called “humanized milk,” presents the albuminoids in a minutely coagulable and digestible form ; has an alkaline reaction ; contains the proper porportion of salts, milk-sugar, and fat ; is not bitter in taste, being but partially peptonized, and in appearance as well as chemical composition resembles human milk. The great advantages of partial peptonization are that the necessity for lime-water, barley-water, and thickening substances to keep apart the curd is done away with, and that, when the digestive disturbance requiring a careful preparation of food is removed, an ordinary milk diet can be gradually resumed by regularly diminishing the time artificial digestion is allowed to progx’ess. This changes the caseine in a less and less degree, until, finall}^ it is taken in its natural form. “ Sterilization” is another process of importance. As milk exists in the healthy cow’s udder it is aseptic — i. e. free from any poisonous or dangei’ous ingredient — but during milking and subsequent handling and transportation various foreign materials get into it and are apt to set up some injurious change. To deprive these accidentally introduced organic impurities of their activity — or, in other words, to sterilize — it is necessary to subject the fluid to high heat under pressure. Several admirable implements have been devised for conducting the process ; one of the most simple, made after a design of my own, is shown in Fig. 1. This apparatus is made of tin, and consists of an oblong case provided with a well-fitting cover, and having a movable perforated false bottom (d), which stands a short distance above the true one and has attached .a framework capa- ble of holding ten six-ounce nursing-bottles. On the outside of the case is a row of supports (b) for holding inverted bottles while drying, and at the proper distance below these a gradually inclining gutter (c) for carrying oft’ the drip. A movable water-bath (a) is hung to the side ; in this each bottle of food may be warmed at the time of administration. Ten graduated nursing-bottles are used, so that the whole supply of milk intended for a day’s consumption can be prepared at once. Each bottle is provided with a perforated rubl>er cork, which in turn is closed by a well-fitting glass stopper. Sterilization should be performed in the morning as soon as possible after ' Measure provided with jar only to be used when preparing, at once, the whole quantity of food to he given in a day. Take of — Milk . Water Cream Peptogenic milk powder GENERAL MANAGEMENT OF GUILD REN. 27 the milk has been served. The process is as follows : First, see that the ten bottles are perfectly clean and dry ; pour, into each six Iluidounces of milk ; insert the perforated rubber corks, without the glass stoppers, however; remove the false bottom and place the bottles in the frame ; pour into the Fig. 1. Author’s Sterilizer. case enough water to fill it to the height of about two inches ; replace the false bottom carrying the bottles ; adjust lid and put the whole on the kitchen range. Allow the water to boil, and, by occasionally removing the lid, ascertain that the expansion that immediately precedes boiling has taken place in the milk ; then press the glass stoppers into the perforated corks, and thus hermetically close each bottle. After this keep the apparatus on the fire and the water boiling for twenty minutes. Finally, remove the false bottom with the bot- tles ; pour out the water, replace and carry the whole, covered with the lid, to the nursery. Milk sterilized by this process will remain sound for many days : it is espe- cially useful in travelling, when fresh milk cannot be obtained ; for use in cities during the heat of summer, w’hen milk is most apt to undergo injurious changes ; for a temporary change of food in delicate children or for those suffer- ing from disease of the stomach or intestinal canal. It must be remembered, however, that the prolonged heating produces certain changes in the compo- sition of the milk which make it more difficult to digest, and that on this account many children do not thrive upon it. Another process of sterilization, suggested by Leeds, is free from this dis- advantage, and has proved most useful in my practice. It consists in heating the milk, rendered feebly alkaline with lime-water or sodium bicarbonate, to 155° F. for six minutes, or, better still, of applying the same amount of heat to milk with pancreatin and bicarbonate of sodium or with peptogenic milk powder. By the latter method the milk is both predigested and sterilized ; if not used at once, it must be momentarily heated to the boiling-point to check peptonization before the development of a bitter taste. According to Rowland G. Freeman, the problem that presents itself in the sterilization of milk for food is to devise a method w’hich shall destroy by efficient means the contained germs, and yet in the least possible degree interfere with its nutritive qualities. The experiments of Leeds show that 28 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. sterilization at the boiling-point of water causes the following modifications: the starch-li(}uefying feianent is destroyed and coagulated ; caseine is rendered less coagulahle by rennet, and is acted on slowly and imperfectly by pepsin and pancreatin ; j)roteid matters attach themselves to fat-globules, and ]>rob- ably bring about a less perfect assimilation of fat; while milk-sugar, by pro- longed heating, is completely destroyed. Koplik states that “from the temper- ature of 75° C. upward there is a separation of the serum-albumin of the milk ; the caseine loses its coagulability to rennet, and at 85° C. amounts of rennet which for the raw condition of milk are found sufficient to act cease to be eflfec- tive.” Ilueppe considers that from a physiological standpoint milk is best sterilized under a temperature of 75° C., while other experimenters have shown that temperatures lower than 100° C., if continued for a short time, will destroy a very large j^roportion of the germs, and will destroy with certainty many pathogenic germs which find their way into milk either from the cow or as external contaminations. Dr. Freeman, therefore, feels satisfied that Pasteurization offers the most rational solution of the question under consideration. The elaborate and recent experiments of Yersin, Granchier, Lidoux-Libard, and Bitter show that the bacillus tuberculosis in milk will be destroyed in ten minutes by an exposure to 75° C., in fifteen minutes to 70°, and in thirty minutes to 08°. Concerning other bacteria. Van Geuns found that a few seconds’ exposure to 60° would kill the cholera spirilla, the Finkler-Prior bacillus, the typhoid bacillus, and the pneumococcus of Friedliinder. It may, therefore, be concluded that a temperature of not less than 158° F. will render milk sufficiently germ-free for infant food, and that a temperature of less than 176° F. will not injure milk materially. Methods of Pasteurizing milk in bulk have been brought forward both in Germany and in this coun- try ; and now the procedure has been brought down to an easily-managed system for household use. This depends upon the theory that the tempera- ture of the milk to be treated may be raised to about the desired point (167° F.) by immersing a certain definite quantity of milk in a properly pro- portioned bulk of boiling water, the source of heat having been removed. The apparatus consists of two parts, a graduated ]>ail for the tvater and a receptacle for the bottles of milk. This receptacle consists of a series of seven or ten hollow zinc cylinders fastened together, which fits into the pail containing the boiling water. Each of these cylinders is large enough to hold one of the bottles of milk, the series of seven cylinders accommodating seven eight-ounce bottles, and the series of ten cylinders being intended for ten six- ounce bottles. When the bottles are in place water is poured around them to secure perfect conduction of the heat. After the water in the pail is thor- oughly boiling, it is removed from the stove and placed on a non-conducting surface, ’fhe cylinders are now introduced, and the pail covered and left standing for thirty minutes, after Avhich the milk is rapidly cooled in a I'efrig- erator or by cold Avater or ice and Avater. Milk thus ticated and put imme- diately into a refrigerator usually sIioavs no change for several days. Sometimes milk, in every form and hoAvever carefully prejiared, ferments soon after being SAvalloAved and excites vomiting, or causes great flatulence and discomfort, Avhile it affords little nourishment. With these cases the best ])hin is to Avithhold milk entirely for a time and try some other form of food. The folloAving are good substitutes : Veal broth lb. of meat to the ])int) f^iss. Barley-water f,5iss. GENERAL MANAGE. VENT OE CHILDREN. 29 Or, Wliej f.liss. Barley-water .• f'^iss. Milk-sugar oSS. For one portion ; to be given every two hours at the age of two months. A teaspoonful of the juice of raw beef every two hours will usually be retained when everything else is rejected. Such foods are oidy to be used temporarily until the tendency to fermentation within the alimentary canal ceases ; then milk may be gradually and cautiously resumed. When infants approaching the end of the first year become affected wdth indigestion, it is often sufficient to reduce the strength and (quantity of the food to a point compatible wfith digestive powers. For instance, at eight months the food may be reduced to that proper for a healthy child of six months or even less. Here, too, predigestion of the food is very serviceable. If a few grains of extractum pancreatis be added to a gobletful of thick, well-boiled starch gruel at a temperature of 100° F., the gelatinous mucilage quickly grow'S thinner, and soon is transformed into a fluid, the starch having been rendered soluble by the action of the pancreatin ; by still longer contact the hydrated starch is converted into dextrin and sugar. Advantage may be taken of this property to render the foods containing starch assimilable. Thus, to a mixture of barley jelly and milk — e. g. Barley jelly 3y, INlilk sugar Sj, Warm milk fsviij, add three grains of extractum pancreatis and five grains of bicarbonate of sodium, and keep warm for half an hour before administering. The same process may be employed with food containing oatmeal, arrow- root, or wheaten Hour, or in the case of meat broths, with a view of converting the starchy and albuminoid ingredients into digestible elements without mate- rially altering the taste. Returning to the regimen of the healthy infant, it will be found that after the fourteenth month far less change is reijuired in the food. Diet from the fourteenth to the eighteenth month, five meals per day : First meal, 7 A. M. — a slice of stale bread, broken and soaked in a breakfast- cup (eight fluidounces) of new milk. Second meal, 10 A. M. — a teacup of milk (six fluidounces), with a soda biscuit or thin slice of buttered bread. Third meal, 2 P. M. — a teacup of meat broth (six fluidounces), with a slice of bread; one good tablespoonful of rice-and-milk pudding. Fourth meal, 0 p. M. — same as first. Fifth meal, 10 p. M. — one tablespoonful of Mellin’s Food, with a breakfast-cupful of Tiiilk. To alternate with this : First meal, 7 A. M. — the yelk of an egg lightly boiled, with bread-crumbs ; a teacupful of new milk. Second meal, 10 a. m. — a teacupful of milk, with a thin slice of buttered bread. Third meal, 2 p. M. — a mashed baked potato, moistened with four tablespoonfuls of beef tea ; two good tablespoonfuls of junket. Fourth meal, 6 p. M. — a breakfast-cupful of milk, with a slice of bread broken up and soaked in it. Fifth meal, 10 p. M. — same as second. The fifth meal is often unnecessary, and sleep should never be disturbed for it ; at the same time, should the child awake an hour or more before the first meal, he must break his fast upon a cup of warm milk, and not be allowed to go hungry until the set breakfast hour. Diet from eighteen months to the end of two and a half years, four meals 30 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. a (lay : First meal, 7 A. M. — a breakfast-cupful of new milk ; the yelk of an egg lightly boiled; two thin slices of bread and butter. Second meal, 11 A. M. — a teacupful of milk, with a soda biscuit. Third meal, 2 p. M. — a breakfast- cupful of beef tea, mutton or chicken broth; a thin slice of stale bread; a saucer of rice-and-milk pudding. Fourth meal, 6.30 p. M. — a breakfast-cupful of milk, with bread and butter. On alternate days : First meal, 7 A. Jl. — two tablespoonfuls of thoroughly cooked oatmeal or wheaten grits, with sugar and cream ; a teacupful of new milk. Second meal, 11 A. M. — a teacupful of milk, with a slice of bread and butter. Third meal, 2 p. >i. — one tablespoonful of underdone mutton pounded to a paste ; bread and butter, or mashed baked potato moistened with good plain dish gravy; a saucer of junket. Fourth meal, 6.30 p. M. — a breakfast- cupful of milk, a slice of soft milk toast or a slice or two of bread and l)utter. When sickness supervenes, all that is ordinarily necessary is a reduction of the diet to plain milk or some easily digestible milk mixture. An important point, often neglected, is the matter of drink. Even the youngest infant requires water several times daily, and the demand increases with age. The water must be as pure as possible, and should not be too cold. In the heat of summer, however, bits of ice and water moderately cooled by ice can be allowed without harm. The foregoing schedule must, of course, be regarded only as an average. Many children can bear nothing but milk food up to the age of two or even three years, and, provided enough be taken, no fear for their nutrition need be entertained. If a child be thriving on milk, he is never to be forced to take additional food merely because a certain age has been reached ; let the healthy appetite be the guide. d. Success in hand-feeding depends quite as much on the administration as upon the preparation of the food. From birth up to such time as broth, bread, and eggs are added to the diet all the food should be taken from a bottle. Even after this, as the bottle is a comfort and ensures slow feeding, it may be allowed for milk preparations until the child, of his own accord, tires of it. The only feeding apparatus to be admitted to the nursery is the simple bottle and tip. The bottle made after my suggestion, and known as the “graduated nursing-bottle,” has an interior surface free from angles, so that it is readily kept clean, and is provided with a scale for the measurement of ounces and half-ounces. It is made of trans- parent flint glass, so that the slightest foulness can be detected at a glance, and may vary in capacity from six to twelve fluidounces according to the age of the child. Two should be on hand at a time, to be used alternately. Im- mediately after a meal the bottle must be thoroughly washed out with scalding water, filled with a solution of bicarbonate or salicylate of sodium — one tea- spoonful of either to a pint of water — and thus allowed to stand until next recjuired ; then, the soda solution being emptied, it must be thoroughly rinsed with cold water before receiving the food. The tips or nipples, of which there should also be two, must be composed of soft, flexible India-rubber, and a con- ical shape is to be preferred, as being more readily everted and cleaned ; the opening at the point must be free, but not large enough to permit the milk to flow in a stream wdthout suction. At the end of each feeding the nipjfle must be removed at once from the bottle, cleansed externally liy rubbing with a stiff brush wet with cold water, everted and treated in the same way, and then placed in cold w'ater and allowed to stand in a cool place until again wanted. Next to cleanliness of the feeding apparatus it is important to insist upon the separate preparation of each meal immediately before it is to be given. The GENERAL MANAGEMENT OF CHILDREN. 31 practice of making, in the morning, the whole day’s supply of food, though it saves trouble, is a most dangerous one. Changes almost invariably take place in the mixture, and by the close of the day' it becomes unlit for consumption. The food must be administered at a temperature of about 95° F. It may be heated by steeping the bottle containing the food in hot water or by placing it in a water-bath over an alcohol lamp or gas-jet. When feeding, the child must occupy a half-reclining position in the nurse’s lap. The bottle should be held by the nurse, at first horizontally, but gradu- ally more and more tilted up as it is emptied, the object being to keep the neck always full and prevent the drawing in and swallowing of air. Ample time — say five, ten, or fifteen minutes, according to the quantity of food — should be allowed for the meal. It is best to withdraw the bottle occasionally for a brief rest, and after the meal is over sucking from the empty bottle must not be allowed, even for a moment. e. For children residing in cities an honest dairyman must be found who will serve sound milk and cream from country cows once every day in winter, and twice during the day in the heat of summer. The milk of ordinary stock cows is more suitable than that from Alderney or Durham breed, as the latter is too rich, and therefore more difficult to digest. The mixed milk of a good herd is to be preferred to that from a single animal : it is less likely to be affected by peculiarities of feeding, and less liable to variation from alterations in health or different stages of lactation. The care of the herd and of the milk is of great consequence. The cows should be healthy, and the milk of any animal that seems indisposed should be excluded. The cows must not be fed upon swill or the refuse of breweries, glucose-factoi’ies, or any other fermented food. They must not be allowed to drink stagnant water, and must not be heated or worried before being milked. The pasture must be free from noxious weeds, and the barn and yard must be kept clean. The udder should be washed, if dirty, before the milking. The milk must be at once thoroughly cooled. This is best accomplished by placing the can in a tank of cold spring-water or in ice- water, the water being the same depth as the milk in the can. It is well to keep the water in the tank flowing; indeed, this is necessary unless ice-water be used. The can should remain uncovered during the cooling, and the milk should be gently stirred. The temperature should be reduced to 60° F. within an hour, and the can must remain in the cold water until the time for delivering. In summer, when ready for delivery, the top should be placed in position and a cloth wet in cold water spread over the can, or refrigerator cans may be used. At no season should the milk be frozen, and at the same time no buyer should receive milk having a temperature over 65° F. For transportation from the dairy it is safer for the family to provide two sets of small cans — one set to be thoroughly cleansed and aired, while the other is taken away by the milkman to bring back the next supply. So soon as this arrives in the morning, or in the morning and evening in hot weather, the milk should be emptied into separate and absolutely clean earthenware or glass pitch- ers, and these put at once into a refrigerator reserved exclusively for them. This may stand in some convenient spot near the nursery, but not in it, and especially not in an adjoining bath-room. With a good refrigerator there is no difficulty in keeping milk perfectly sweet for twenty-four hours in winter and for twelve hours in summer, except on intensely hot days ; then it may be necessary to scald, slightly boil, or sterilize the whole of the supply when received, in order to prevent change. Childhood. — Children who have cut their milk teeth may be fed for 9 32 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. twelvemonth — namely, up to the age of three and a half years — in the follow- ing way : First meal, 7 A. M. — one or two tumblerfuls of milk, a saucer of thoroughly cooked oatmeal or wheaten grits, and a slice of bread and butter. Second meal, 11 A. M. (if hungry) — a tumblerful of milk or a teacupful of beef tea with a biscuit. Third meal, 2 p. M. — a slice of underdone roast beef or mutton or a bit of roast chicken or turkey, minced as fine as possible ; a baked potato thoroughly mashed with a fork and moistened with gravy ; a slice of bread and butter; a saucer of junket or rice-and-milk pudding. Fourth meal, 7 P. M. — a tumblerful of milk and one or two slices of well-moistened milk toast. From three and a half years up the child must take his meals at the table with his parents, or with some reliable attendant who wdll see that he eats leisurely. The diet, while plain, must be varied. The following list will give an idea of the food to be selected : Every Day. Milk. Porridge and cream. Bread and butter. BREAKFAST. One Dish only Each Day. Fresh fish. Eggs, lightly boiled. “ poached. “ scrambled. Eggs, plain omelette. Chicken hash. Stewed kidney. “ liver. Sound fruits may be allowed before and after the meal, according to taste, as oranges, grapes (seeds not to be swallowed), peaches, thoroughly ripe pears, and cantaloupes. Every Day. Clear soifp. Meat, roasted or broiled, and cut into small pieces. Bread and butter. DINNER. Two Dishes Each Day. Potatoes, baked. “ mashed. Spinach. Stewed celery. Caulidower. Hominy. Macaroni, plain. Peas. String-beans, young. Green corn, grated. .Junket, rice-and-milk, or other light pudding, and occasionally ice cream, may be allowed for dessert. SUPPER. Erei'y Day. Milk. Milk toast or bread and butter. Stewed fruit. Fried food, highly seasoned or made-up dishes are to be excluded, and no condiment but salt is to be used. Eating, however little, between meals must be absolutely avoided. Keep a young child from knowing the taste of cakes or bonbons, or, having learned it, let him feel that they are as unattainable as the thousand other things beyond his reach, and he soon ceases to ask for them. Even a piece of bread' between meals should be forbidden. Ilis appetite then remains natural, and he will eat proper food at his regular meal hours. As to the (piantity, a healthy child may be permitted to satisfy his appetite at each meal, under the one condition that he eats slowly and masti- cates thoroughly. Filtered or spring water should be the only drink, tea, coftee, wine, or beer being entirely forbidden. In case of illness the diet must be redu(;ed in cpiantity and quality, accord- ing to the rules that are ap])licable to adults. 2. Bathing. During the first two and a half years of life a child ought to be bathed once every day. The bath should be given at a regular time, and it is best to GENERAL MANAGEMENT OF CHILDREN. 33 select some hour in the early moiming, midway between two meals — ten o’clock, for instance. The tub should be placed near the fire or in a warm room in winter, and away from currents of air in summer. It should contain enough water to cover the child up to the neck when in a reclining posture, and the temperature must be about 95° F. Upon undressing the child the first step is to wet his head; then he is to be plunged into the water and thoroughly washed with a soft rag or sponge and pure, unscented castile soap. After remaining in the water from three to five minutes the surface must be well dried and rubbed with a flannel cloth or soft towel ; then the body must be enveloped in a light blanket and the infant either returned to his crib to sleep or kept in the lap for ten or fifteen minutes until thoroughly warm and rested, and finally dressed. If there be repugnance to the bath, the tub may be covered over with a blanket, and the child, being placed upon it, may be slowly lowered into the water with- out seeing anything to excite his fears. In very hot weather, in addition to the morning full bath, the body may be sponged twice daily with water at a temperature of 90° F. ; this, contrary to what might be expected, has a greater and more permanent cooling effect than bathing with cold water. After the third year three baths a week are quite sufficient. An evening hour is now to be preferred, but the water must still be heated to 90°. About the tenth year cooler baths can be begun, from 72° to 75° being the proper temperature. The cold sponge or cold plunge is not admissible as a daily routine until youth is well advanced. The hot bath — 95° to 100° F. — is employed for various purposes, notably for a derivative action, to cause diaphoresis, to relieve nervous irritability, and to promote sleep. Whether a full bath or merely a foot-bath be required, five minutes is a sufficient time for immersion ; then, with or without drying, according to the degree of sweating desirable, the whole body, or only the feet and legs in case of a foot-bath, must be enveloped in a blanket, and the child put to bed. To render these baths more stimulating, from a teaspoonful to a tablespoonful of mustard Hour may be added, and the child held in the water until the arms of the nurse begin to tingle. It is important not to con- tinue a hot bath too long, lest the primary stimulating effect be followed by depression. Cold baths, by shocking the system, fii’st produce depression ; but this is temporary and is followed by reaction, during which the skin grows red and the pulse becomes fuller and stronger. They have, therefore, a general stimu- lant and tonic action, promoting nutrition and giving tone to the body. On account of the shock, the extent of which depends directly upon the coldness of the water, these baths must be used with caution, and are not to be employed in very young or feeble subjects. When giving a cold bath, the child must be stripped in a warm room, and thoroughly rubbed with the palm of the hand until the whole body, especially the spinal region, is reddened ; he must then stand in a tub containing enough hot water to cover the feet, and be rapidly sponged with the cold water. The temperature of the latter must never be below 60°, and the addition of half an ounce of sea-salt or a tablespoonful of concentrated sea-water to the gallon renders it more stimulating and ensures a complete reaction. After the sponging the surface must be thoroughly and quickly dried with a soft towel and shampooed Avitli the open hand until aglow. The cooled bath may be employed with advantage in extreme conditions of hyperpyrexia. The child is first immersed in water at 95°, and this is gradually lowered to 70° by the addition of cold water, the process occupying from fifteen to thirty minutes. 3 34 AMERICAN TEXT- BOOK OF JJIS EASES OF CHILDREN. 3. Clothing. Infants and young children have little power of resisting cold, and on this account re(iuire warm clothing. The condemnation of the fashion of allowing children to go, even while in the house, with hare legs and knees must he absolute. Occasionally during the most oppresive heat of a summer midday the legs may be left uncovered ; but with this exception the rule is to keej) the whole body encased in woollen underclothing. The thickness of this must vary, of course, with the season. Providing this be done, the outer clothing may be left to the taste of the mother ; but all garments should fit loosely, that the functions of the dift’ei’ent viscera may not be imj)eded by ])ressure. The best pattern of a winter night-dress is a long, ])lain slip, with a draw- ing-string at the bottom, to prevent exposure of the feet and liml>s should the child kick off the bed-covering. This should be made of flannel or the more easily washed canton flannel. In summer a loose muslin one may be put on, without the drawing-string. A flannel under-vest should always be worn at night, light gauze in summer and heavier wool in winter ; care must be taken, however, to have one for night alone, discarding that worn in the daytime. In inflxnts under a year old a broad flannel abdominal bandage, extending from the hips well up to the thorax, or, better still, a knitted worsted Itand shaped to fit the form, is very useful in keeping the abdominal organs warm, aiding digestion and preventing pain. All clothing should be changed sufficiently fre(iuently to ensure cleanliness. Shoes must be large, well shaped, and made of soft leather with pliable soles, so as to allow the feet to grow freely. When dressing a child for exercise in the open air in cold weather, the outer clothing must not be put on until just before leaving the house, and removed immediately on return. It is important to protect the head from cold in winter by a close-fitting, thick cap, and from the direct rays of the sun in summer by a broad-brimmed, light straw hat. Ilubljer shoes are necessary in wet weather to keep the feet Avarm and dry while walking out of doors. 4. Sleep. For some time after birth infants spend the intervals between being fed, washed, and dressed, in sleep, and thus pass fully eighteen out of the twenty- four hours. As age advances the amount of sleep reipiired l)econies less, until at two years thirteen hours, and at three years eleven hours, are enough. This matter, though, is perhaps more a (piestion of training than any other item of nursery regimen, and one cannot too soon begin to form the good habit of regularity in sleeping hours. So far as circumstances Avill admit, the follow- ing rules may be enforced : From birth to the end of the sixth or eighth month the infant must sleep from 11 P. M. to 5 A. M., and as many hours during the day as nature demands and the exigencies of feeding, washing, and dressing Avill ])ermit. From eight months to the end of tAVO and a half years a morning nap should 1)C taken from 12 M. to 1.30 or 2 P. M., the child being undressed and j)ut to bed. The night’s re.st must begin at 7 P. M. If a late meal be recjuired, the child can be taken u]) at about ten o’clock ; but if ]>ast the age for this, he may sleej) undisturbed until he Avakes of his oAvn accord some time betAveen 0 and 8 A. M. From tAvo and a half to four years, an hour’s sleep may or may not be taken in the morn- ing, according to the disposition of the subject; but in every case the beil must be occupied from 7.30 p. m. to 0 or 7 o’clock on the following morning. After the fourth year few children Avill sleep in the daytime ; they are ready for GENERAL REMARKS ON TREATMENT. :55 bed Ijy 8 i>. m., and should be allowed to sleep for ten hours or more. A later retiriim hour than 9 p. M. oujilit not to be encourao;ed until after the twelfth or fifteenth year. When feasible, different rooms should be used for the day nursery and the sleeping apartment. If an aj)artment has to be occupied during both the day and night, it must be vacated for half an hour or more in the evening and well aired before the child is put to bed. The temperature of the room must be as uniform as possible, the proper degree of heat being from (J4° to 68° F. 5. Exercise. A certain amount of muscular exercise is necessary for development and for the proper performance of the digestive functions. Infants before they are able to stand will use their muscles sufficiently if, when loo.sely clad, they are placed upon their backs in a bed and allowed to kick and turn about at pleas- ure. After the age of nine or ten months a healthy child will begin to creep ; at the end of a year he will make efforts at standing, and from four to eight months later will be able to walk by himself ; children, however, present great differences in this respect, and a delay of a few months must not be considered as abnormal. So soon as efforts at creeping are made there need be no fear that insufficient exei’cise whll he taken ; the care should be rather to prevent over-fatigue. Fresh air and sunlight are as necessary as muscular exercise. The child must be taken out of doors every day, weather permitting, after arriving at the proper age : this is four months for children born in the early fall and winter, and one month for those born in summer. In cool weather babies wdio are unable to walk should be taken out in a coach or in the nurse’s arms for an hour in the morning and half an hour in the afternoon, while the sun is shining. In summer they may pass the greater part of the waking hours in the open air, provided they be well protected from the direct rays of the sun. Children old enough to walk may spend a longer time in the air in winter, and may be out all day in summer. But until the fourth year it is better to let them play about at will than take a long set walk. Until well advanced in childhood the house is the safest place in damp and rainy weather, when there is a strong east or north wind blowing, and when the thermom- eter stands below 15° F. III. GENERAL REMARKS ON TREATMENT. It is difficult to formulate a precise, reliable, or handy posological table ; in fact, the Avhole matter of dosage for children is one of ex))erience, and with practice every one makes his own dose-list in his mind, and the proper amount of a given drug for a given age requires as little effort of memory as in the case of adults. Nevertheless, as a guiile to the student. Cowling's rule is serviceable — namely, the proportionate dose for any age under adult life is represented by the number of the following birthday divided by 24 — i. e. for one year, ^ ; for two years, -jU = -g- ; and so on. All powerful drugs must be given with caution to children, Imt opium re- quires the greatest care. Inffints bear it only in infinitesimal ])roportions, and in these its use is to be avoided as much as possil)le ; still, combined with cas- tor oil, it is a useful drug in bad cases of fiatulent colic, the average commen- cing dose in the first six Aveeks of life being not more than hlgU tincture (laudanum). After the second or third month the extreme susceptibility to the drug disappears, and of laudanum may be given for a dose. 36 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Bromide of potassium, a most valuable remedy in many diseases, must be given to infants with watchfulness, as it sometimes, even in small doses, pro- duces severe local inllammations of the skin and localized patches of soft, warty growths. Ijelladonna and arsenic are illustrations of an opposite tendency, for chil- dren are very tolerant of these drugs, particularly the first. A child of four or five years can readily take from two to five minims of tincture of bella- donna, and in cases in which it is necessary to administer arsenic to choreic children of six years and upward a commencing dose of five minims of Fow- ler’s solution may often be given three times daily, and a considerable increase in this be attained if required. Such initial doses are, however, occasionally productive of the symptoms of mild arsenical poisoning, and therefore it is well to begin with one- or two-minim doses and increase rapidly. This rule applies especially to children belonging to the wealthier classes, for these, like their parents, are much more sensitive to drugs than hospital patients — an undoubted physiological fiict of wide bearing. Alcohol is frequently indicated and is of great value, but it must be used with judgment. It is most useful in broncho-pneumonia, severe febrile condi- tions; in the prostration fcdlowing measles, diphtheria, and whooping cough ; and in the collapse that frequently attends severe thoracic or abdominal disease. All drugs should be made as palatable as possible. In conclusion, it must be remembered that children do not often require energetic treatment with drugs. Proper feeding and hygiene are of most importance in the management of disease in early life. Antipyretics . — Antipyrine especially, and phenacetin to a less degree only, must be used with extreme caution in the febrile aflections of early life, on account of their marked tendency to produce cardiac depression. Spong- ing the surface at proper intervals with tepid or cool water is a much safer method of reducing temperature, but in every instance the law of the temper- ature-curve of the disease under treatment must be taken into consideration ; and it is a safe rule not to interfere unless the temperature excess be great and maintained. For example, in pneumonia, a disease in which antipju'etic drugs are especially dangerous and most frequently abused, an evening temperature of 105° is to be expected, and unless maintained is neither cause for alarm nor for the use of a powerful drug that tends to sap the strength of the cardiac muscle, the very keystone of the bridge leading to I'ecovery. THE CHEMISTRY OF MILK AND OF ARTIFICIAL FOODS FOR CHILDREN. By albert R. LEEDS, Ph. D., Hoboken. I. The Chemistry of Milk. The peculiar adaptation of milk to the feeding of the young depends upon its unique combination of chemical and physical properties. It contains in well-balanced proportions the three essential elements of nutrition — the nitrog- enous, or tissue-building ; the carbohydrate, or heat-giving ; and the fats. Along with these are a sufficiency of saline substances to carry on the chemical metamorphoses of cell-formation, of secretion and excretion, and an ample supply of w’ater as the universal solvent. These substances are held partly in a state of solution, partly in a state of serai-solution, conferring upon milk its slightly colloidal consistency, and partly in suspension, producing its appear- ance of density and opacity. But it contains no waste material like the indi- gestible fibre and cellulose of flesh, fruit, and vegetables. Neither does it exhibit a development of one or two elements of nutrition at the expense of the third, as is the case with all other foods, — even eggs, which most nearly approach milk in this respect, not being excepted. Finally, almost no prepara- tion before, during, or after swallowing is requisite for the absorption of milk .through the rudimentary digestive apparatus of the young. The chemistry of woman’s milk can he well and effectively studied for our present purposes only in connection with that of cow’s milk. For at the very outset a peculiar difficulty is experienced in attempting to procure a sample of the former, which does not exist in the case of the latter. Some sort of a breast-pump or similar appliance must be used, and this unnatural process yields at the best but a partial sample. This fact explains many of the great and anomalous variations exhibited in the analyses. It also renders the con- clusions drawn from an isolated analysis of little value; and in practice it is wiser to base any conclusions as to the sufficiency and quality of the breast- milk upon the condition and yield of the gland, upon the physical condition and nutrition of the mother, and, most of all, upon the development of the child and its deportment in nursing. On the other hand, innumerable analyses of complete samples of cow’s milk exist, embracing every variety of breed, under every condition of climate, age, culture, and feeding. Cow’s Milk. — On no other article of food has such elaborate care been expended, both as to its production and chemical investigation. Most civilized communities have enacted laws to protect its purity, and recognize no evidence in courts of law except when substantiated by adequate chemical testimony. 37 38 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. Similar investigations are being constantly made with a view of so adjusting the feeding and the breed as to obtain the largest quantity of milk or the greatest richness, or both. Beginning with cattle of small, imperfectly- developed udders, the cow has become through generations of culture the incom- parable milk-secreting animal of modern nations, and has so far displaced the ass, goat, mare, and others that it is useless to consider their milk as an avail- able substitute. For similar reasons, the cow’s milk which must be considered from the standpoint of general dietetics is such sound, whole country milk as is ordi- narily supplied by reputable dealers. It is useless to quote the analyses of the milk of iVlderney, Jersey, and Guernsey cattle, obtainable only by the few; and when obtained, such milk, with its higher percentage of proteids and its greater liability to variation from idiosyncrasy in condition or health of indi- vidual cattle, is not to be preferred over that of the average milk of large herds properly bottled before being sent to market. So likewise as to the com- position of the “strippings” of the udder. They are not usually procurable, and their greater richness in fat and deficiency in casein can be better arrived at, even when ordinary whole milk is used, by appropriately modifying its composition. Limiting our consideration strictly to commercial bottled milk, it becomes of the greatest importance to inquire into the present conditions regulating its production and handling at the farm, during transit, and in delivery to the con- sumer. Hitherto, these conditions have fallen far short of the requirements which chemical and medical science should rightly impose upon milk as the prime article of artificial infant nutrition. The State laws have checked the adulteration of milk by addition of water and removal of cream, but as yet have done little, and that only incidentally, in the way of guaranteeing its wholesomeness and improving its quality. In fact, enlightened public senti- ment, assisted and directed by the medical profession, will do more in this direction than can be expected at present from the State. And the same remark is true of the efforts of the dairyman. What is being done and should be done is best exemplified by a recital of the provisions of a legal contract drawn up between a committee of certain medical societies in the vicinity of New York on the one hand and a competent dairyman on the other. The latter undertakes that his herd of Holstein and Jersey cattle shall be regularly and frecpiently insj)ected by a veterinarian selected by the committee and ]>aid by the dairyman. All cattle that are pronounced by the surgeon, for any cause whatsoever, disqualified to produce pure sound milk are forthwith excluded from the herd. Interbreeding more frecjnently than the fourth generation is interdicted. The cattle must be kept in a large, Avell-ventilated, well-lighted stable, with ample sj>ace and no overcrowding, with abundance of jture Avater for drinking and cleansing : with perfect drainage ; Avith dry cemented iloors ; with clean fresh bedding of hay ; and Avith arrangements for securing them in the stall Avhich .shall give ample liberty to the movements of the head and lor lying doAvn, but shall do aAvay Avith the necessity of chains or other fivstening. Se])arate stalls and partitions, as interferitig Avith ventilation and cleanliness, are done aAvay Avith. The coAV-stal)les must be removed from those in Avhich horses, chickens, and other stock are kej)t by so great a distance that the cattle can in no Avise come in contact Avith the other animals, d'hc coavs must be groomed daily, and the teats washed before each milking. The milkmen must perform their oAvn toilets before milking, being es])ecially required to thor- oughly cleanse their hands and to remove the dirt beneath the finger-nails, Avear- ing also unsoiled clothing. The feeding is to be regulated by the season in such CHEMJm'RY OF MILK AND ARTIFICIAL FOODS. 3y wise that the milk produced shall conform to the highest feasible standard of excellence. Ahumlance of wholesome pasture, hay, meal, fodder, and ensilage is demanded, but the refuse of glucose-factories, brewers’ grains, swill in any form, etc. are interdicted. There are also provisions in the contract that the cattle shall not be worried, heated, or driven, or milked except after proper interval after calving. The milking must be done with scrupulously cleansed vessels ; the milk filtered through fine metallic gauze, then cooled in a dust- free atmosphere in such wise as to lower the temperature as rapidly as possible, and also to permit the escape of the gases along with the animal heat ; and, finally, transferred to bottles rendered as nearly sterile by cleansing with boil- ing water and steam as possible. These jars, which must be entirely full, are closed by a metallic cover, sealed, transferred to boxes Avith a layer of ice on top of them, and delivered at an early hour in the day, the temperature of the milk never being alloAved to rise in the interval above 50° F. The dairyman further undertakes to pay for the services of a competent chemist and biologist, Avho shall frequently test the milk, and whose analyses and certificates shall accompany it. He also undertakes to have his stables, cattle, feed, bottling arrangements, etc. open at all proper times to inspection, and to comply Avith all other requirements of the committee Avhich they in their judgment shall deem essential to securing the highest attainable degree of quality and purity. The only obligation Avhich the committee assumes is that it permits the milk to be sealed Avith a label bearing the name of the dairy and the dairyman, and the legend “ Certified Milk,” and to be accompanied by the certificate of purity bearing the name of the committee, the chemist, biologist, and veterinarian. Milk in the human gland or coav’s udder, Avhen tul)erculosis or kindred dis- ease is absent, contains no bacteria. Indeed, by rejecting the first portions and exclmling floating particles in the air, sterile coav’s milk can be obtained, and contrivances to this end have been patented ; but they are quite imprac- ticable. So likeAvise is the proposition to sterilize all the milk before it leaves the farm by heating it at 280° F. for a sufficient length of time completely to destroy every spore Avhich might by any possibility be present. Consumers would not pay for the skill, time, and apparatus recpiired, and the process itself produces unfavorable changes in the milk. The first portion of this objection applies also to the proposition that the milking should be done directly into sterilized bottles, and the milk then Pasteurized by heating to a temperature of 160°-170° for tAventy minutes. Any of the bacteria present in the air, Avater, ground, or derived from the diseased or filthy condition of those Avho handle the milk at any time, or arising from the animals themselves, may possibly find their Avay into milk. And, inas- much as this fluid is an excellent culture-medium, they multiply Avith great rapidity. But these things demand suitable care for their prevention, and not a care involving the compulsory sterilization of all milk. The author believes that no more should be required of the dairyman than the reasonable precau- tions above detailed, Avhich self-interest also demands. Then a false security will not be placed in legal recjuirements sure to be evaded or neglected, and necessitating an army of skilled inspectors, veterinarians, and chemists to enforce. The fcAv ounces of milk needed for artificial nursing are best sterilized immediately before use, and this is best done in the course of the preparation essential to adapt it for infant feeding, either just before transfer to the bottle or in the bottle itself. By so doing, the fact, usually lost sight of, Avill be kept constantly in mind — that the same precautions as to the bottle, nipple, the walc-r used, the exclusion of floating particles from the milk, and the keeping of it in a refrigerator are as essential to preserving the sterility of the milk as 40 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. its sterilization in the first instance. Washing in boiling water cannot be trusted to remove the adherent skin of fat and casein on the milk-vessels; some soda must be used ; the rubber nipple should be turned inside out over the finger and scrubbed with a brush and precipitated chalk. Supposing that the present enlightened public sentiment has secured such a legalized system of sanitary cattle-inspection and milk-control as to make the reasonable precautions now exercised voluntarily by honorable dairymen obligatory upon all, bottled milk, which I shall term “sound dairy milk,” presents the following characteristics: In color it varies from white to yellow. Even when allowed to fall in drops from the end of a rod it exhibits a dense white opacity and consistency, the fluidity and bluish-white color of watered or inferior milk being absent. It is almost neutral, reddening litmus-paper very feebly. On standing, the cream rises in the neck of the quart bottle com- monly used until it forms a layer about two and a half inches in depth. These physical characters are all that need be noted. If they are absent, if the milk is thin and watery, if it has a bluish, blue, strong yellow, or red color, if it is stringy, lumpy, or glutinous, if it has a flat, stale, sour, or any abnormal taste or odor, — it is simply to be rejected, and its investigation left to the milk inspector and chemist. j\Iany analyses of such bottled milk afford me the following average results, which are given as preliminary to the still better figures that will come with “certified milk Fats 3.75 per cent. Lactose (milk-sugar) 4.42 “ Albuminoids 3.76 “ Ash 0.68 “ Total solids 12.61 per cent. In some of the States the legal standard calls for 12.5 j)er cent, of total solids and 3 per cent, of fat. It is much to be deplored that in other States, as in New Jersey, the standard demands only 12 per cent., and unless the fat falls below 24 the milk is assumed to be unskimmed. It was made thus low in order that no lack of care in housing and cleanliness, no inadequacy of feed- ing, no abstraction of cream from the evening milk (half-skimming), and no accidental or judicious Avatering should bring the owner or vendor under con- demnation of laAv. For the same reasons it is assumed that any milk Avhich has a higher specific gi’avity than 1.029 at 60° F. (100° on the lactometer scale) is pure, whereas the average of sound dairy milk should be 1.0297. Human Milk. — Having given the above general characteristics of coav’s milk, it is necessary to do the same for human milk, and then ])roceed to a more specific comparison of their resemblances and diflerences. And in the first place, Avhile all the conditions and environment are arranged to develop the milk-secreting function of milch cattle, in the human family, on the other hand, they are moi’e and more ignored as Avomen become burdened Avith the increasing duties and dissipations of modern society. The regular life Avith moderate enjoyments, exercise, and occupation, the sinqde nourishing diet, wdth abundance of fresh air and rest, Avhieh are most favorable to the milk- secretion, are sacrificed, Avith the result of arresting or diminishing the IIoav and deteriorating the quality of the milk. Stimulants, narcotics, inqu’ojier or highly-seasoned food, functional disorders Avith their attendant medicines, violent emotions and paroxysms of grief, anger, and jiain, render the milk unwholesome and sometimes dangerous. As a contribution to the chemistry CHEMISTRY OF MILK AND ARTIFICIAL FOODS. 41 of this subject I give in an accompanying table the results of 80 analyses of samples of milk obtained from women of different nationalities, age, stage of lactation, and physical constitution, but all living in a lying-in hospital under the same conditions and eating the same food. (See pp. 42 and 43.) The analyses are arranged according to the period of lactation, except in cases where several samples were taken, these following consecutively. Many hundred analyses would be required to determine what differences, if any, are due to nationalitv or to the physical characteristics of the mother — whether black, blonde, or "brunette, or, more minutely, the color of the eyes, hair, com- plexion, etc. But the influence of the j)hysical condition was pronounced, the best milk not coming from women of robust habit (Column I.), but from those whose nourishment appeared rather in the milk-secretion than in the flxttening of the mother (Column II.) : I. (6 cases). II. (6 cases.) Fats 3.71 .... 3.96 Lactose 6.94 .... 6.74 Albuminoids 1.44 .... 2.12 Ash 0.25 .... 0.22 Total solids . 12.34 .... 13.04 The reaction of every sample was alkaline, the alkaline reaction persisting during one or more days. The color varied from bluish-white through chalky- white to strong yellow, but the color was not a necessary index of the compo- sition : the milk of a German (No. 34), which was the richest in fats (6.89 per cent.), lactose, and total solids, was chalky-white in color, while that of another German (No. 8), which was yellow, was very low in fats, having only 2.31 per cent. Though the amount of lactose is more than a third greater than in cow’s milk, yet the taste can hardly be called sweet, and while the total solids (13.27) and the specific gravity (1.0313) are both higher than in cow’s milk, yet the consistency is much thinner. This is due to its much smaller content of albuminous matters, moi’e especially of the caseinous or cheesy material. The average amount of nitrogenous matters (albuminoids) is somewhat greater at beginning of lactation, but the difference is not very marked. In truth, the feature brouglit out by this long series of analyses, which over- shadows every other in significance, is the fact that there is no progressive change in the composition of milk during lactation, but after the function has been normally established the milk remains substantially the same during the entire period. This is what might be anticipated from what much larger expe- rience teaches in regard to cow’s milk, but it is at variance with notions com- monly entertained, and which have led to elaborate and utterly useless dieta- ries for infant nutrition. The child obtains more nutriment day by day, but it is by spontaneously increasing the quantity according to the best rule, which is that of normal appetite, and not by absorbing “ stronger and stronger food.” Comparison of Cow’s Milk and Human Milk. — Before proceeding farther, the general characteristics may advantageously be summed up in the following comparison : Sound Dairy Milk. Woman’s Milk. Reaction Feebly acid Persistently alkaline. Specific gravity 1.0297 1.0313 Bacteria Always present Absent. Fats 3 to 6 — average, 3.75 ... 2 to 7 — average, 4.13 Lactose . . . 3.5 to 5.5 — “ 4.42 . . . 5.4 to 7.9 — “ 7.0 Albuminoids .3 to 6 — “ 3.76 . . . 0.85 to 4.86 — “ 2.0 Ash 0.6 to 0.9— “ 0.68 . . . 0.13 to 0.37— “ 0.2 Table of Analyses of Samples of Milk from Women of Different Nationalities, Age, etc. 42 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. fH Total solids. o PH -t f-j X i-j r: »o I'* CO c: C'J o 1 -H CO 1 -H o :o t-H ^ C'i i-< ^ 13 2 22 S3 3h' ^ 2h' Zh a! ^ Jh ^ 3' ^ ^ 12. 13. Ash. CJ O') (M ^ ^ O f 05 fO 0) C O O X CJ X O') -r) fC O') 0) O') O') O') 1-t -H O') O') O') 0) O') CO O') ^ o c d c d d o d d c d c d d c o d c © © O) ^ LO 10 lO X rH X lO © CO © COrHC'irHO)COr-rHO)rHrHTHP-ti-H ©©©©©©©©*©©©'©©© "cS r-iio;05i-^LOCOXOt'-'i*coxO'^xtOrHi^"^0') '0')05:oi0i0!i-ic5':o>-i00 O 05 -i; CO 05 1-H CO O') 05 X -H 0) X O X 05 CO X . CO X I'- X 05 O') lO 05 CO O 'O d d ’t 0) co’ CO* CO CO* O') d CO O') d CO CO 0) O') **•? CO ^ d d o) d oi d d co* co d •II Lactose. lO O') 05 O CO ic O X X >-H 05 ^ X X X ■ 'O^ LO O') LO X LO AO lO X lO Tf -ij 05 CO CO O') 05 to LO 05 X '-f 05 CO LO **1* O') O . X -1^ O') ^ 0) 05 I'- O 05 d d d LO 1- d d d d d d d d i-’ i- d d d lo d d d 10. Albumi- noids. O 0) O') LO CO CO CO LO 0) X LO X fH ^ LO O LO CO CO lO * CO 05 -f lO CO CO CO -'f lO 0) LO 1H 05 O') X X --H X O 00 »-H l>. o ^ CO 05 . lO 1-H O') O') CO 05 O') 05 © *'!)< 0) 0) CO CO O') O') rH O') © 0) f- o) iH oi O') 0) iH o) rH c) oi O') »H o) ,-H O') »H 0) oj 0) Specific gravity. O') O) . 05 CO ©0‘)-t*C0rH0)0)©*H0')©©©iHO),-H©iH0')»H ©*^©tHTj<©0')CO©0)© COCOCOCOCOCOCOCOO)COCOCOCOCOCOCOCOCOCOCO cococococococococococo ©■©©©©©©©©©©©©©©©©©©© ■©©©©©©©©©©© 1 00 Color of milk. Yellow .... Dull white . . White White Willow Yellowish-white . White Yellow White Y^ellowi.sh-white . Yellow Yellow Yellowish-white . White Yellowish-white . Chalky-white . . Yellow . . Yellowish-white . Yelloivish-white . Chalky-white . . Yellow t-* Interval since nursing. 2 hours. 2 “ 5 “ 2 “ r, “ 3 “ 2 “ 2 20 min. 30 “ 4J hours. 2 “ 30 min. 30 “ 1 hour. 0 min. 1 hour. 0 “ 1 “ 3 hours. 0 “ 2 “ 1 hour. 1 “ .5 hours. 2 “ '^x •H' 0 O-l ID X CD ID X 05 D4 X l-» 05 04 CO CO CO ID CD d CO OXXi-HOJOl^l^OOOOit^iHCOt^OJLOXXlOrHi-iwC^ri OJriiHC4 0lOii-HrH04C004i-iCOOI^OJOJi-irHiH040JOJCOOiOi D4 04 04 04 04 04 04 CO 0 CO IH 04 00000000000000000000000000 d d d d d d d 0 C"> G4 ic CO X OJ CD COCDi-HiCl'-’^lDOO * O) rH X X . 0 1 H C4 1- 0 X * 0 CD , 1 — 1 I'* »— 1 • -ef 0 ID . CO 0 t* CD ID X 1-* 05 ^ 04 05 iH CO X »H iH '*r*^C4COC4C4lDlDCO ^ 'iT 04 04 CD ID CO CO Tf H" ^ -t CO rf CO* CD CD 04 H* *-H CO CO 0 1- 0 •H'COOJlCOOC'JCOO * ^ 0 CO 0 CD 0 . CD ^ X 0 1- ID 0 ’ 04 X . CO CO CO ■ ^ ^ 0 LO . CO 04 CO 0 0"4 0 CO ID 04 ID CD 04 0 CO 05 05 t- t- CD CD CD CC CD 0 1- t> X CD l> t> l> i> ID X l-.CDOXrHCD'H'OX ,-(OiH'CDi-'i'-**H’^Ob ■ 0 CO OJ X iD CO CD . ^ H* X 0 rH •4 0 05 04 0 tH 04 CO CO 0 0 CO 0 CO ID CD iH CO 04 CO 000 . ^ ^ ^ ^ rH rH ,-H ■ ,H rH . ^ ^ ^ ^ iH ^ rH ,-i rH 1-1 4) :||: ’ to * . <15 •% a 3 • a 5 ® a 3 ^ 41 D ■ ■ & ^ ■ . ^ ^ . , 00 . 4) * 41 4> . . . -H" . -H" . 4) D 0 0 . -H> -*J -H -u Yellow Chalky- ^ S 45 S r=i <1 • rl :r • • ■ 'ci ■© • . ; : '.% '. St !% !% :5 . • ^ • 03 OT .to . * . • T- . to :3 s ^ o o •'CO O'? iC 2 " 22 '*'* 2 ®'*'* 2 ^'*'" * CO -<» 1-1 ic C^l «H- CO (M OJ C4 Ht Oi Ci 10 10 L>^ ic C4 0^ K '«« !«pi ’Mp 4 «f 4 [Kt^tipiKt^pipiKPioisif^^^pi^ * '--H OJ CO LO CO X' X X >-H I- c ^ CJ filC ? : — a s HJWpqpQCQM . ^ ^ -a sucoppTJbJObtaa^SPPP 33 wSc^ 32 c 5 £SQ[ 3 w£ ■H> -H> - 4 J Co ‘pH . 2 ^ sS-gSSS P {y: bij bjc_^ P ?3 bt a ? JS fcij 3223 mSSQMc 3 i P • • S 3 3 ^ 3 ^ H H «: cc H 0 O o T* 'r O •- OCmmOk c a 2 ■“ ^ a: " - ^ S 2 a’a ■ S.® 3 ' ' S .2 3 s 322 -S~ 3 '® 3 '^— 3 S c 3 o “ - ^ „ - o 'S ^ ^ ^ *z: OxMx^OxOm H ‘h 4 ) ^ o .a a*-^rijHa‘r§cj ^hhX< 5 (^pears to exist in solution along Avith the lactallnimin as common salt. It is notcAvorthy that the lime is already relatively greater in the coav’s than in human milk, and it is open to serious question whether the practice of using coav’s milk alkalized by excess of lime is as desirable, in the case of normal digestion, as it Avas thought to be before the composition and properties of the constituents of milk were known. The following table presents the relative composition of CHEMISTRY OF MILK AND ARTIFICIAL FOODS. 47 the ash of cow’s milk (Fleischmann) and of woman’s milk (Konig), and also the percentages of each constituent (Bunge) : Cow’s Milk. Woman’s Milk. Potash 24.5 0.18 33.78 0.07 Soda 11 0 0.11 9.16 0.03 Lime 22.5 0.16 16.64 0.03 Magnesia 2.6 0.02 2.16 0.01 Oxide of iron 0.3 0.0004 0.25 0.0006 Phosphoric acid 26.0 0.2 22.74 0.05 8ulpliuric acid 1.0 — 1.89 — Chlorine 15.6 0.17 18.38 0.04 n. The Chemistry of Artificial Foods. Two methods have been followed in the attempt to solve the problem of artificial feeding. The easier, and that most generally adopted, which Avould also appear to be the more natural method, is that of attempting to produce a food which should resemble as closely as possible woman’s milk. The other method aims to produce a food or foods which should be especially adapted to the demands of nutrition for each particular infant in health or disease : it is open to great diversities of opinion, due to opposing clinical experiences, and is adapted rather to the treatment of special cases of dis- ordered digestive and other functions than to common use. By general con- sent the advocates of the first method have selected cow’s milk as the basis upon which to build. The difficulty of obtaining cheaply, readily, and of proper quality the milk of the ass, the goat, or of any other animal than the cow, has rendered the discussion of the possible advantages of such milk quite useless. Dilution. — The first expedient in connection therewith was that of dilution with water until the percentage of albuminoids and salts should approximate to that in woman’s milk. But no amount of dilution Avith Avater alone is adequate to prevent the separation of the curd in coarse, indigestible lumps in presence of the acid secretions of the stomach. The next device Avas the addition of an excess of lime-Avater, so as to partly neutralize the gastric juice and allow much of the milk to pass unchanged from the stomach and undergo digestion in the bowels. As the chemistry of the milk salts indicates, the excess of lime is abnormal, and its addition is an expedient to meet a thera- peutic condition connected Avith an over-development of acidity, and not to change the nature of the difficultly digestible casein itself. Predigestion. — To effect this latter change previous digestion Avith dilute acid and pepsin Avas resorted to, and latterly this gave place to the more suc- cessful digestion with pancreatin in alkaline solution. Both methods Avere confined to cases of greatly impaired digestion, and the predigestion Avas carried as far as possible. But inasmuch as in Avoman’s milk there naturally remains about one-fifth of the albuminoids in a caseinous condition, the most recent practice is that of using a limited amount of pancreatin, acting for so short a period that the process shall initiate the peptonization, and then be arrested by the destruction of the ferment. The casein is thereby left in such a condition that it separates on acidifying as a fine Avhite poAvder, Avhile the biuret reaction for the albuminates becomes strongly developed. Sterilization. — Recently the fact that Avoman’s milk contains no bacteria, Avhile cow’s milk usually contains large numbers and many kinds, patho- genic species possibly included, has been strongly insisted upon. To overcome this objection the practice of sterilizing the milk by repeated heating to a temperature above the boiling-point of water has been extensively folloAved. 48 AMERICAN TEXT-BOOK OF DI8EA^EB OF CHILDREN. So far as the destruction of all bacteria and their spores is concerned, the pro- cess is successful, but the clinical results which have attended the use of such sterilized milk have revealed serious drawbacks. It prevents the spread of zymotic diseases through the medium of milk ; it is efficacious in checking many gastro-intestinal disorders ; but its continued use is accompanied by a failure to afford adequate nutrition. Besides the destruction of the bacteria, the prolonged heating to or above the boiling-point brings about other changes which are in the nature of deteriorations. More especially the lactalbumin loses its solubility, and the fat-globules are made to coalesce with one another and some of the insoluble albuminous matter. For these reasons the appli- cation of continued heat in the process of sterilization is inadvisable, and is now being discontinued. Sterilization at a Low Temperature (Pasteurization). — In this process of preparation the milk is kept for a brief interval, ten to twenty minutes, at a temperature of 160°-170° F., or raised during heating continued for ten minutes just to the boiling-point. While this process will not destroy all the germs which are in the form of spores, it will destroy the spores of tubercu- losis, scarlet fever, pneumonia, and typhoid, and almost completely inhibit the existence of the developed spores, or bacteria, of every kind. Pasteurization with Partial Predigestion (Humanized Milk). — The adjustment of the lactose and the bringing about of a permanently alkaline reaction are effected by the presence in the diluted sterilized milk of such an amount of lactose and of the alkaline milk salts as will effect this I’esult. In order to raise the percentage of fat to that contained in woman’s milk, cream may be added, or some vegetable oil like olive or cocoa, or animal oil like that of cod-liver. At present, by the aid of the Leval separator, cream has become a commercial article easily obtained, and its use is more convenient and better understood than that of the other fat substitutes, which require to be further investigated. Inasmuch as it contains some casein and bactei’ia, due allowance must be made for both in the process of modification heretofore explained. In practice, by the use of a preparation of pancreatin, lactose, and alkaline milk salts originated by Fairchild Brothers & Foster of New York, and known as “ Peptogenic Milk-powder,” the author has found that with oi’dinary bottled milk, cream, and water a modified sterilized milk is obtained which corresponds so closely to woman’s milk that he has given it the name of “humanized” milk. The proportions recommended are — Milk h pint. Water | pint. Cream 4 tablespoonfuls. Peptogenic Milk-powder 1 large measure. The mixture is heated on a hot range or gas-stove with constant stirring, the heating being so conducted that at the end of ten minutes it is brought to the boiling-point. The temperature of 100° to 170° is high enough to destroy the ferment, and this temperature, continued for twenty minutes, kills the bacteria also. But it is so much easier to (juickly raise the temperature for a moment to the boiling-point, which also effects both objects, that the latter method is to be preferred when by a process of partial peptonization, as in the process described, the main portion of the albuminoids has been brought to a i)erma- nently soluble form. Tlie milk thus prepared is slightly alkaline and sterile. It contains, accord- ing to the author’s analyses, bottled market milk being used in its preparation, the following j)roportions of constituents: CHEMISTRY OF MILK AND ARTIFICIAL FOODS. 49 Fat .... Albuminoids Lactose . . Ash. . . . Total solids 4.5 per cent. 2.0 “ 7.0 0.3 “ 13.8 per cent. When lime is used to counteract not only the slight acidity of market milk, but also with the object of forming a soluble calcium caseinate which will not be decomposed by the acid of the gastric juice and curds of casein thereby pre- cipitated, the lime must be added in considerable quantities. A mixture of 2 ounces of milk, 2 ounces of lime-water, and 2 ounces of cream, to which a teaspoonful of sugar of milk has been added, contains only a grain of lime, a quantity too small to effect any notable chemical change of the casein. If this mixture is sterilized, it should be done at a temperature between 160° and 170°, since heating to the boiling-point causes some decomposition of the albuminoids in presence of alkali. “Condensed Milk.” — When condensed milk is used the pi’eceding remarks require to be somewhat modified on account of the different modes of preparing this substance. This will be readily understood by comparing the composition of (I.) milk condensed with added cane-sugar, mean of forty-one analyses; (II.) the same diluted with eight times its weight of water; (III.) Anglo-Swiss milk, preserved without added sugar; (IV.) American-Swiss, preserved; (V.) No. III. diluted with five times water. I. II. III. IV. V. Fat 12.10 1.51 13.21 11.55 2.64 Albuminoids 16.07 2.01 11.36 14.10 2.27 Lactose 16.62 2.08 15.29 13.04 3.05 Sucrose 22.26 2.78 Ash 2.61 0.32 1.78 2.09 0.36 Total solids 69.66 8.70 41.64 40.78 8.32 Water 30.34 91.30 58.36 59.22 91.68 When largely diluted with water, so that the percentage of albuminoids is approximately the same as in human milk, the fat and lactose are brought far below the quantity proper for infant nutrition*. Nor is the deficiency adequately supplied by the added sucrose of the milks condensed with this substance. Referring to these points. Dr. Louis Starr justly remarks : “ Condensed milk is frequently recommended by physicians, and largely used by the laity on their own responsibility. It keeps better than cow’s milk, and is supposed to be more readily digested by infants. The latter supposition is a mistaken one, and arises from the overlooked fact that condensed milk is always given dis- solved in a large proportion of water, while cow’s milk is too frequently used insufficiently diluted or otherwise improperly prepared. The author is con- vinced of the accuracy of this statement from a number of years’ close study of the subject. Condensed milk contains a large proportion of sugar, forms fat quickly, and thus makes large babies ; sugar also counteracts the tendency to constipation — often a troublesome complaint in hand-feeding. These advan- tages are unquestioned, and, together with the ease of preparation, are those which place it so high in the esteem of monthly nurses. It is equally true, how- ever, that as a food it does not contain enough nutrient material to suj)ply the wants of a growing baby It must be remembered also that condensed milk, when long kept or when packed in imperfect cans, not infrequently undergoes decomposition, and thus becomes utterly unfit for use.” Attenuation. — An entirely diff’erent method of increasing the digestibility 4 50 AMERICAN TEXT-BOOK OE DISEASES OE CHILDREN. of the casein is that of adding farinaceous or gummy substances, the action of which is not chemical, but mechanical, and depends upon the separation which they effect of the otherwise cheesy masses into a multitude of fine particles. Experiments in the laboratory of the author showed that when diluted cow’s milk, to which a solution of cane-sugar, graj>e-sugar, barley-water, starch-water, or gelatin had been added, was treated with acid, the precipitated casein car- ried down with it from one-third to more than twice its weight of the added substance. Gelatin more especially must be used in very small quantity, since otherwise it entirely arrests the precipitation of the casein. One of the simplest and best of these attenuants is barley-Avater, added to one-third its volume of milk. It may be prepared by boiling tAvo teaspoonfuls of pearl barley in a pint of Avater in an open saucepan until the bulk is reduced to tAvo-thirds, and then straining. Instead of barley, oatmeal may be used, or gelatin. To pre- pare the latter put a piece of plate gelatin an inch square into a half-tumbler- ful of cold water, and let it stand for three hours; then turn the Avhole into a teacup, place this in a saucepan half full of Avater, and boil until the gelatin is dissolved. When cold this forms a jelly: two teaspoonfuls are sufficient to thicken a mixture of three ounces of milk and five of Avater. Dextrinized Attenuants. — A gummy material like dextrin, or a gelat- inous substance, or a saccharine body, or a finely-divided starch like that occurring in barley- or oatmeal-Avater, along with more or less glutinous extrac- tive matter, is far better adapted to serve mechanically as an attenuant of the coagulated casein than farinaceous foods in their ordinary condition. Many different preparations are sold in which, by prior heating (dextrinizing) or by digestion with diastase, wheat and barley flours ai’e modified to this end. By the action of heat at 300° to 400° the principal substance Avhich is formed is dextrin, a body differing from starch by its being soluble and by having the physical characters of a gum. Diastase produces principally maltose along Avith dextrin. The flour selected for either treatment should be highly albuminous, made of wheat groAvn at certain seasons and of certain grades, and should be the best grade of that made by the roller process. Grouping together under the head of soluble carbohydrates the sucrose, dextrose, maltose, and dextrin originally present or made by treatment, the changes can be traced in the fol- loAving table. The first column gives the composition of a Avheat flour, the second the same after baking. The remaining columns exhibit similar products from other specimens of Avheat flour, the process having been carried further in some of the dextrinized foods than in others : Wheat flour. Same baked. Blair’s AVheat Food. Imperial Granum. Ridge’s Food. Schuma- cher’s Food. Water 9.02 7.78 9.85 5.49 9.23 6.26 1.01 0.41 1. 1.01 0.63 1.89 8tarcli iSolnt)le carbohy- 76.07 67.60 64.80 78.93 77.96 39.81 (Iratcs 5.66 14.29 13.69 3.56 5.19 36.57 Albuminoids . . . 7.47 7.16 10.51 9.24 13.54 fJum, cellulose, etc. undetermi’d 2.94 0.50 0.49 Ash U 1.06 1.16 0.60 1.44 By heating, the albuminous substances also become considerably more soluble in water. Wheat flour, which in its original condition yields a very considerable amount of crude gluten on Avashing, after baking leaves a much smaller quantity. For the same reason a baked Avheat flour may be mistaken CHEMISTRY OF 311 LK AND ARTIFICIAL FOODS. 51 for barley flour, whicli has a non-glutinous dough. Along with these analyses may he given that of Robinson’s Patent Barley, which is flour prej)ared from ground pearl barley, and “ABC” cereal milk, which is made from wheat and barley meal : Robinson’s Patent Barley. “ A. B. C.” Cereal Milk. Water 10.10 Fat J.97 Starch 77.76 Soluble carbohydrates 4.11 Albuminoids . . 5.13 Gum, cellulose, etc 1.33 Ash 1.93 9.33 1.01 58.42 20.00 11.08 1.16 Flour-ball. — Much has been written on the use of “flour-ball” prepared by long-continued boiling of superior wheat flour tied up tightly in a bag. A sample thus prepared by Dr. J. Lewis Smith and analyzed at his request afforded the following results. It was boiled for five days, fifteen hours a day, or seventy-five hours in all, the bag being taken out of the water over night. The original flour was white ; the boiled flour, after thorough drying and pulverizing, of a light-yellow color. Its taste was remarkably flat and insipid, the long-continued boiling dissolving out the fat, some of the soluble albumi- noids, and mineral matters. It is possible that very different results might have been obtained from a flour of different character and boiled for a much shorter interval (Dr. Eustace Smith recommends but ten hours) : Original Flour, Water 9.546 Fat 0.766 Starch 71.924 Soluble carbohydrates 5.120 Albuminoids 11.280 Gum, cellulose, etc 0.835 Ash 0.506 Same Boiled. 10.55 none. 72.362 5.178 10.520 1.028 0.42 Liebig’s Foods. — In the preparation of the flour by means of diastase (Liebig’s foods) equal parts of wheat flour and barley malt, a certain amount of wheat bran (added, it is said, for the sake of the adherent phosphates and nitrogenous matter), together with 1 per cent, of potassium bicarbonate, are mixed with sufficient water to make a thin paste. The mixture is allowed to stand at ordinary temperatures for several hours, and then heated to 150° until the conversion of the starch into maltose and dextrin is completed. It is then strained and the residue pressed and exhausted with warm water. The extract is evaporated in vacuum-pans at as low a temperature as consistent with rapid- ity of working, and then dried with stirring at a higher temperature, so as to be brought into pulverulent porous lumps. The author’s latest examinations of samples of foods belonging to this class are as follows : Mellin's Food. Horlick's Food. Savory and Water . . . 12.37 9.70 Moore’s. 8.34 Fat . . . 0.18 0.34 0.40 Albuminoids . . . 10.07 10.43 9.63 Soluble carbohydrates . . . 68.18 76.83 44.83 Starch ... 36.36 Gum, cellulose, etc 0.50 0.44 Ash . . . 3.75 2.20 0.89 The starch is absent when the process is complete, and such was the case with some of the samples tested ; in other samples a considerable portion remained. 52 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. The preceding foods are ordinarily employed with milk, the mixture being made at time of feeding. Still another class remains in which the dextrinized or malted dour has already been evaporated with milk, and which is prepared with the aid of w'ater oidy. They are of very difi’erent composition, as will be seen from the following table : Nestle’s. Anglo-Swiss. Gerber's. r o> 3 <; Fraiico-Swiss. Wells & Richardson’s j Lactatcd Food. Loeflund’s Cream Emulsion. Malted Milk. Water 5.00 0.50 6.78 5.68 4.43 7.76 24.32 2.18 Fat 4.25 4.91 2.21 5.81 3.70 1.64 15.32 5.30 Albuminoids 11.00 10.20 9.56 10.54 13.00 11.85 8.23 15.83 Soluble carbohydrates 40.91 40.43 44.76 45.35 40.09 39.00 49.43 06.99 Starch 30.86 29.48 35.00 30.00 30.86 36.43 Undet. 5.57 Cellulose, gum, etc 0.28 0.40 0.48 0.41 0.50 0.71 Ash 1.70 2.02 1.21 1.21 1.42 2.61 2.60 3.13 In the preparation of these foods the dour is drst made into a dough and baked. The resulting biscuit is then dnely ground and mixed with various amounts of condensed milk and dried by a slow heat at a moderate tempera- ture. This leaves a mixture in which the starch has been partly changed into dextrose, maltose, and dextrin ; the albuminoids of the dour have undergone the partial decomposition spoken of in the case of the farinaceous foods; the casein has been dried into sej>arate particles, and the lactalbumin has been coagulated. On the addition of water the saccharine and a small portion of the albuminoids dissolve ; the main portion of the albuminoids, the casein, and the starch, are left undissolved. In the actual preparation of farinaceous, Liebig’s, and milk foods for use in the feeding-bottle, the adjustment of the relative j)roportions should be such as to afford a ratio between the hits, albuminoids, and saccharine materials as nearly the same as that in human milk as possible. By making the cow's milk the principal article of the mixture, and basing the approximation on such a ratio as will render the albuminoids not very different in their gross amount from that in woman’s milk, foods of the following character may be obtained. Of course the constituents other than the albuminoids differ widely in their gross amounts, and what has been said before in relation to their relative values in nutrition must here be borne in mind also. Selecting one food of each class. Column I. represents a mixture of 3 parts of thoroughly dextrinized flour, 47 parts of cow’s milk, and 50 parts of water; Column II. the same relative amounts of Mellin’s food, milk, and water; and Column III. a mixture of 1 part of Nestle’s food and 6 of water: I. II. III. Fat 1.91 1.8C> 0.71 iSoInhle caibohydrates . . . 3.17 4.11 (>.8‘2 Starch 1.94 0.14 Albuminoids 2.27 1.89 1.83 Ash 0.3t) 0.43 0.28 Total solids 9.tF) 8.29 15.78 Water 90.35 91.71 84.22 MODIFIED MILK AND PERCENTAGE MILK- MIXTURES. By THOMPSON S. WESTCOTT, M. D., Philadelphia. Modified Milk. — Modified milk is a term applied to the product of a recently introduced method which aims to effect a recombination of the fats, proteids, and lactose of cow’s milk, so as to produce mixtures yielding any desired percentage of each of these three essential ingredients. While mother’s milk is to be taken as the type of what such a mixture should be, it is possible by this synthetic process to vary the percentage of any or all of its three elements to meet any desired modification. The method originated with Dr. Thomas M. Rotch of Boston, and was perfected with the collaboration of Mr. G. E. Gordon, a dairyman of wide experience. The result of their labors has been the establishment of milk-laboratories, the first of which was opened in Boston in 1891 ; and since that time other laboratories have been started in several of the principal cities of the Eastern and Southern States, in Montreal, and, most recently, in London. Each laboratory is supplied exclusively by a dairy under its absolute control, situated within a short distance by rail, so that not more than three to six hours shall intervene between milking and delivery at the laboratory. By this means the laboratory has complete supervision of the handling of the milk and the control of its herd of cows. No cow is accepteate, Signature, Jan. 1 st, I89t? (Dr. A. (B. C. For sake of illustration it may be .stated that a mixture conforming to the above prescription will be made up of cream, 7^ ounces; separated milk, 5 j ounces ; sugar solution, 9^ ounces ; lime-water, 2 ounces ; and distilled water, 15Ir ounces. A 3-G-2 mixture would contain cream 7^ ounces, sepa- rated milk 13^ ounces, sugar solution 7f ounces, lime-water 2 ounces, and distilled water 9^ ounces. It will thus be seen that for the same percentage of fat the (juantlty of cream remains constant for the same total (piantity, and that as the proteid percentage rises the (piantity of separated milk increases, the sugar solution undergoing a slight decrease because of the greater proportion of milk-sugar present from the larger (juantity of sep- arated milk. MODIFIED MILK AND PERCENTAGE MILK-MIXTURES. 55 The experience of a large number of physicians in feeding healthy infants on modified milk has enabled the Walker- Gordon laboratories to tabulate the average percentages and (juantities of mixtures that have proven satisfactory for varying ages, as follows : Theoretical Basis for Feeding a Healthy Infant. Age. Gastric Prescription. Capacity. Per ct. Per ct. Per ct. Fat. Milk-sugar. Proteids Premature infant, Drachms. 2-6 fl.OO 1 1.00 3.00 4.00 0.20 0.50 (l.50 4.50 0.75 Birth at term, Hours. Oz. 24 to 36 1 — 5.00 — 1st Week, 1 2.00 5.00 0.75 2d (( U 2.50 6.00 1.00 3d u 2 3.00 6.00 1.00 4th to 6th n 21-3 3.50 6.50 1.00 6th to 8th (( 3 -3f S.oO 6.50 1.50 8th to 16th u 31-41 4.00 7.00 1.50 16th to 24th u 4i-o| 4.00 7.00 2.00 24th to 32d u 5|-7 4.00 7.00 2.00 32d to 36th u 7 4.00 7.00 2.25 36th to 40th 7 -8 4.00 6.50 2.50 40th to 44th u 8 -8^ 4.00 6.00 3.00 44th to 48th u 81 4.00 4.50 3.50 48th to 52d 9“ 4.00 4.50 4.00 These figures, it must be remembered, are to be taken simply as averages, since the weight, as well as the age, of the child must be taken into account as a guide of its digestive capacity. Each infant’s needs must be studied before a satisfactory modification may be secured. If anything, these aver- ages are a little too high for any but infants in perfect health and with unimpaired digestion. Laboratory modification has given most satisfactory results in almost all cases where artificial feeding was required, but more especially in cases of chronic gastric or intestinal catarrh, where proteids are digested with difficulty and variations in their proportions from day to day keep the digestion constantly disturbed. Such an infant may fail to digest a modifi- cation containing 1 per cent, of proteids, but will begin to thrive when this percentage has been reduced for a time to 0.75, 0.50, or even lower. In such cases the physician is enabled to accurately vary the dosage of any one or more of the ingredients of his mixture. The method offers a decided advance upon any method hitherto introduced for the feeding of infants with a substitute for mother’s milk. It is at once scientific, accurate, and . rational. As a general rule, it may be stated that after a satisfactory formula has been found the strength of the food may be increased gradually, but as rapidly as the child’s digestion will permit. In reference to the changes in formula that may be required in any par- ticular case after a prescribed mixture fails to exactly suit the conditions, it may be permitted to quote Holt’s admirable summing up : “ If not gaining in weight, without special signs of indigestion, increase the proportion of all the ingredients ; if habitual colic, diminish the proteids ; for frequent vomiting soon after feeding, reduce the quantity ; for the re- gurgitation of sour masses of food, reduce the fat, and sometimes also the proteids; for obstinate constipation, increase both fat and proteids.” 5() AMERICAN TEXT-BOOK OF DISEASES (^F CHILDREN. As a corollary to this it may be added that, except in hot weather or in cases of pre-existing milk-infection, sterilization or even pasteurization is unnecessary, and that either of these processes may favor or directly cause constipation. Lime-water may also have the same effect. For a child with healthy digestion lime-water may often be omitted, at first tentatively, with- out any bad results. Home Modifications. — It is readily understood that milk-laboratories are as yet inaccessible to a large number of physicians, and that the ])rocess is somewhat costly. Fortunately, it is quite possible to apply its principles to home modification, provided the mother have ordinary intelligence and will appreciate the importance of scrupulous cleanliness in all the necessary manipulations. Several methods have been suggested. Fotcli {Pediatrics) uses gravity cream and under-milk, obtained by allowing a (juart of good milk (avei’aging 4 per cent, fat, 4.50 per cent, sugar, and 4 per cent, pro- teids) to stand in a jar in ice-water for six hours, and siphoning off’ 24 ounces from the hottom, Avhich leaves, according to his estimate, 8 ounces of a 10 per cent, cream in the jar. Holt, in his recent text-book {Diseases of Infaiic]/ and Childhood)., proposes dilutions of various percentage creams with solutions of milk-sugar varying in strength from 5 to 10 per cent. According to this method, 16 per cent., 12 per cent., or 8 per cent, cream and whole milk (4 per cent, fat) are used Avith solutions of milk-sugar of 5, 6, 7, 8. and 10 per cent, strengths. An important fact to be remembered is that cream is practically a su])erfatted milk, essentially differing otherwise from milk in containing a slightly lower percentage of proteids, Avhich vary from 3.20 for 20 per cent, cream to 3.90 for 8 ]>er cent, cream, as contrasted Avith 4.00 in the average Avhole milk from Avhich the creams are obtained ; and that the sugar percentage is also slightly less than that of the milk. Sixteen per cent, of butter-fat is about the strength of ordinary skimmed cream Avhich has had about tAvelve hours to rise. It averages 3.60 pro- teids. The 12 per cent, cream may be obtained by mixing tAvo parts of 16 per cent, cream and one ])art of Avhole milk, or by skimming average milk after standing in a jar in iced Avater for about six hours. It averages 3.80 proteids. Eight per cent, cream may be obtained by mixing one part of gravity cream and tAvo j)arte of Avhole milk, or by skimming the milk after standing four to five hours. Removal of the loAver milk by siphoning is less likely to disturb the cream layer, and thus partially dilute the cream. Eight j>er cent, cream averages 3.90 ju'oteids.' These percentages are approximately correct, ju’ovided the Avhole milk maintains a fairly constant average value of 4 ])cr cent, fat and 4 ])er cent, proteids. Variations here Avill of course disturb the cream percentages, hut for ordinary cases the results are sufficiently close. The sugar .solutions may be made by dissolving an ounce of milk-sugar in 20 ounces, 16^ ounces, 14^ ounces, 124 ounces, or lO ounces of boiled or distilled Avater to produce 5, 6, 7, 8, or 10 ))cr cent, .solutions respectively. The use of solutions of such varying strengths enables the modifications to he made Avithout the use of adilitional plain Avater, and thus simplifies the j)re]iaration. For comparison the folloAving tables of dilutions of cream liavc been accurately Avorked out : ' The percentage figures ii.sed l)y Rotcli and Holt, and also in the cream and whole-milk mod- ification later described, arc the standard analyses of the products of the Walker-( Jordon dairies. MODIFIED MILK AED PERCENTAOK MILK-MIXTURES. ,~>7 (Fat, 16.00 ; 1 part of Cream to — 15 parts ofc Sugar solution Table I. — Sixteen Per cent. Cream. Sugar, 4.20; Proteids, 3.60.) = Fat, 1.00 ; Sugar, 4.95 Proteids, 0.23 15 “ 7 » = “ 1.00; “ 6.82 0.23 9 “ 5 it = “ 1.60; “ 4.92 0.36 9 “ 6 n = “ 1.60; “ .5.82 U 0.36 9 “ 7 u = “ 1.60; “ 6.72 u 0.36 7 “ 5 ti = “ 2.00; “ 4.90 (( 0.45 7 “ 6 a = “ 2.00 ; “ 5.77 (( 0.45 7 “ 7 u = “ 2.00; “ 6.65 (( 0.45 5.4 “ 5 (( = “ 2.-50; “ 4.87 u 0..56 5.4 “ 6 u = “ 2.50; “• 5.72 0.56 5.4 “ 7 a = “ 2.50; “ 6..56 0.56 4.3 “ 5 H = “ 3.02; “ 4.85 (( 0.68 4.3 “ 6 (( = “ 3.02; “ 5.66 ii 0.68 4.3 “ 7 ii = “ 3.02; “ 6.47 u 0.68 3.6 “ 5 u = “ 3.48; “ 4.83 u 0.78 3.6 “ 6 u = “ 3.48; “ 5.61 u 0.78 3.6 “ 7 u = “ 3.48; “ 6.39 u 0.78 3 “ 5 = “ 4.00; “ 4.80 it 0.90 3 “ 6 u = 4.00; “ 5.55 0.90 3 “ 7 u = “ 4.00; “ 6.30 0.90 3 “ 8 = “ 4.00; “ 7.05 a 0.90 Table II. — Twelve Per cent. Cream. (Fat, 12.00; Sugar, 4.30; Proteids, 3.80.) 1 part of Cream to- Proteids, 0.32 11 parts 5% Sugar solution = Fat, 1.00; Sugar, 4.94 11 “ 6 U = “ 1.00; “ 5.86 “ 0.32 11 “ 7 u = “ 1.00; “ 6.77 “ 0.32 7 “ 5-7 u = “ 1..50; “ 4.91- 6.67 ; “ 0.48 5 “ 5-7 = “ 2.00; “ 4.88- 6.-55 ; ‘‘ 0.63 3.8 “ 5-8 ‘‘ = “ 2..50; “ 4.85- 7.12; “ 0.79 3 “ 5-8 a = 3.00; “ 4.82- 7.07 ; “ 0.95 2.4 “ 5-8 (( = “ 3..53; “ 4.6.5- 6.76 ; “ 1.12 2 “ 5-8 u • = “ 4.00; “ 4.77- 6.77; “ 1.27 Table III. — Eight Per cent. Cream. (Fat, 8.00 ; Sugar, 4.40 ; Proteids, 3.90. ) 1 part of Cream to- 7 parts 5-7% Sugar solution = Fat, 1.00; Sugar, 4.92-G.67 ; Proteids, 0.49 3 “ 5-8 U = “ 2.00; “ 4.85-7. 10 ; 0.97 1.6 “ 5-8 (( = “ 3.07; “ 4.77-6.62; “ 1.44 1 “ 5-10 (( = “ 4.00; “ 4.70-7.20; 1.95 Table IV. — Four Per cent. Cream (tvbole milk). (Fat, 4.00 ; Sugar, 4.50 ; Proteids, 4.00.) 1 part of Milk to — 11 parts 5-7% Sugar solution = 1 7 “ 5-7 3 “ 5-8 1 “ .5-10 3 parts of Milk to — 1 part .5-10% Sugar solution = 0.33; Sugar, 4.96- -6.79 ; Proteids, 0.33 0.50 ; U 4.94- -6.69 ; “ 0..50 1.00 ; (( 4.87- -7.12; “ 1.00 2.00 ; 4.75- -7.25 ; “ 2.00 3.00; u 4.62- -5.87 ; “ 3.00 It will be noticed that by these various dilutions of cream, and by inter- mediate dilutions not carried out in tlie tables, a large number of combina- tions of fat and sugar can be obtained, but that the ]>roteid percentage in any instance must bear the same ratio to the fat percentage as holds in the cream from which the dilution is made. Low or mean percentages of fat 58 AMERICAN TEXT-BOOK OF DIHEAEES OF CHILDREN. with high percentages of proteids cannot be obtained without additional proteids from skimmed milk. The practical value of the method therefore ends with a 1 : 1 dilution of whole milk. Finer variations in the relative proportions of fat and proteids, which are easily managed in laboratory modification, are thus impossible by the method of cream dilution. Modifications with Cream and Milk. — For the reasons just stated, as well as the greater convenience in using whole milk as a basis of the mi.xture, and making up the necessary fat-value with additional cream, the writer has for some time been using such a method for home modification. It has been found that most satisfactory results can be obtained by using a 12 per cent, cream and whole milk (averaging fat 4.00, sugar 4.50, and proteids 4). It is first necessary to decide upon the number of ounces of total mixture, and fix the proteid and fat percentages desired. Then the number of ounces of mixed milk and cream can be found by the proportion (1) 3.90 : P:: Q : x, in which Q is the total quantity of mixture, and P the proteid percentage : the value of .r gives the number of ounces of milk and cream re(piired to give the chosen percentage of proteids. The value of x being found, it remains to divide this quantity into two parts, C and 31. the first of which represents the quantity of cream required, the second the quantity of milk. This is readily done by means of the formula ( 2 ) in which Q represents the total quantity of mixture, F the fat percentage de- sired, and X the quantity of mixed milk and cream already determined by formula (1). The quantity of milk, 31, is at once found by subtracting the value of C from that of x. To illustrate : let it be desired to find the quan- tities of milk and cream to make a mixture of 40 ounces containing proteids 1.50 and fat 3.00. Formula (1) becomes 3.90 : 1.50 : : 40 oz. : x, whence :c = 15.4oz. Equation (2) becomes (7 = 120-61.6 8 7.3 oz. and consequently, 31 =8.1 oz. Taking the same example, let it be required to get 4 per cent, of fat. The total quantity of milk and cream will be the same as in the previous case, but the quantity of each Avill difl'er. Here, from formula (2), C= 12.3 oz., and conse(iuently 31= 3.1 oz. The remainder of the 40 ounces of total mixture is to be made up by the addition of boiled water, barley-water, oatmeal-water, or whatever' diluent is chosen. Lime-water, if desired, may also be added to the mixture in the proportion of 5 to 10 per cent. In the above examples 2 to 4 oz. of the diluent Avould be lime-water. It will readily be seen that the calculation of proteids is not ([uite exact, since the varying proportions of milk and cream cause variations in the average value of the proteids ; but, at the most, these vary only between MODIFIED MILK AND PERCENTAGE MILK-MIXTURES. 59 3.80 aud 4.00, so that an average of 3.90 very satisfactorily represents this value. It is also evident that this assumed constant factor cannot he used for a proteid percentage higher than itself; but as such a combination would consist almost entirely of whole milk, the constant (3.90) should be taken very close to 4.00. For instance, if a 4.00 fat and 3.90 proteid mixture were desired, the constant factor should be taken as 3.99, and it would be found from formula (1) that 39.1 oz. of mixed milk and cream would be needed, the proportions of 0.4 oz. cream and 38.7 oz. milk being obtained from the other formula. There are a few exceptions to the universal application of these formulse that should be noted. In proteid values lower than 1.00, 16 or even 32 per cent, cream may be re([uired ; ' in proteid values of 1.00 to 1.25, 16 percent, cream isrecjuired for fat values from 3.25 to 4.00 for the lower, and from 3.75 to 4.00 for the higher of these proteid percentages ; also, in the higher proteid percentages (2.25 to 4.00) skimmed milk, instead of cream, Avould be required for fat percentages lower than the proteid percentage. In practice, however, it is extremely rare to use a fat percentage lower than the proteid, so that this method of combination will be found to give most satisfactory w'orking results, which come closer to accurate percentages than either cream-and- undermilk or diluted-cream mixtures. The estimation of the quantity of sugar to be added for any desired per- centage is considerably simplified by the fact that, since the quantity of mixed milk and cream remains constant for the same proteid value, the sugar to be added is also constant for the same sugar percentage ; the variations in the fat percentage do not alter it. The quantity of dry sugar of milk to be added to the mixture to produce any desired percentage of sugar, S, is rapidly calculated from the formula (3) Sugar QXS- 4.40 a; 100 In the examples already given, to obtain a 6 per cent, sugar mixture there must be added about 1|- oz. of dry sugar. A distinct advantage of this method is that if the quantity of cream be kept constant and the milk gradually increased, the total quantity of mixture being kept constant, both the proteid and fat percentages are gradually increased by an equal increment. When the fat value surpasses 4.00, beyond which it is rarely desirable to go, a half ounce may be dropped from the quantity of cream and its loss supplied by a half ounce of milk. From this point an increase of two or three ounces of milk may be made before the fat value again rises above the point desired, when another half ounce of cream may be replaced Avith milk. By this means the strength of food may be gradually increased without necessitating frequent changes of formula. * When 16 or 32 per cent, cream is used, the denominator 8 in formula (2) should be made 12 or 28, and the constant factor in formula (1) should be changed to 3.80 or 3.45, to correspond. See papers on this method. Archives of Pediatrics, Jan., Feb., 1898. SEA-AIR AND SEA-BATHING IN CONVALESCENCE. By W. M. POWELL, M. D., Atlantic City. The difference between the air of an inland town and that of the sea-coast is that the latter is not only pure, but is saturated with sea-salts from the break- ing of the waves upon the shore and the dashing of spray, which is carried toward the land by air-currents. If the wind is blowing from the sea, this characteristic saline odor may be noticed for some miles inland, but during a ‘‘ land-breeze ” it is hardly perceptible, even upon the beach. E. Freidick, in the Southern California Practitioner^ quotes a large number of ob.servers Avho have demonstrated the presence of sodium chloride in the air at the seaside, and shows that while there is naturally a small proportion of salt in this atmo- sphere, the greatest part of it is due to the diffusion of minute particles of sea- water. The proportion of salt is increased during strong winds, Avhich bloAV the fine spray inland. The air of the sea has a peculiar odor which is difficult to define, but Avhich it is impossible to forget Avhen once it has been inhaled. This odor, which is caused by the evaporation of the extractive matter contained in sea-water, is stronger Avhen the waves dash upon rocks covered with sea-Aveed than Avhen they break gently upon a sandy shore. It is also more .perceptible during a storm than when the sea is calm. Upon the border of the ocean the air is under greater pressure than in places of greater elevation, and consequently it contains more oxygen. The range of the barometer, the thermometer, and hygrometer is reduced to a minimum. These focts are only too often neglected in our estimates of the qualities of sea-air ; they are, hoAvever, in a great measure responsible for the benefits derived by invalids during a residence at the sea-shore. Ozone is one of the constituents of the atmosphere Avhich is found in abun- dance on the sea and adjoining coast. Scbbnbein, its discoverer, believed it to be naturally formed out of atmospheric oxygen by the electrical discharges constantly taking place in the air. It is a most poAverful oxidizing agent, so destructive to organic miasmata that its mere jiresence is a Avarrant of the absence of such noxious elements. It is more abundant by the sea than inlaml, and in Avindy than in calm Aveather. It is Avell knoAvn that the climate of any place Avhere ozone is found in abundance must be healthy and exhila- rating ; hence we have at the sea-shore a pure air, containing oxygen in the form of ozone, besides finely divided sea-salts, as Avell as Avater Avhich is ren- dered stimulating liy the presence of the saiue salts. It most cases the breath- ing of this air has a marked invigorating effect, causing a great inqmivc- ment in the appetite, jiromoting digestion and almost immediately producing a delightful exhilaration of the entire system. “ No doubt can be entertained, in view of often-observed facts, that the eflect of exposure to sunlight upon animal life is directly invigorating; and Avhen Avith this is combined tlie con- stant inhalation of salt-air, and the daily application of salt water to the Avhole 60 SEA- A III AED SEA-BATlllNG. 61 Burface of the body and limbs, it is e:usy to seeAvby cbildreii should gain health and strength at the sea-shore.” — Packard. The tempei’ature on or near the sea may certainly lay claim to greater uniformity than is obtained in localities remote from the coast. During the summer months the heated air of the land may be replaced by the cool breeze from the sea, while in winter the temperature of the coast-line is raised by the admi.xture of the warmer air from the sea with the colder air of the land. It is estimated that the (iulf Stream in this latitude during winter imparts to the air in contact with it a tempei’atui’e of at least ten or fifteen degrees above that of the atmosphere of the earth, so that the ocean air in mixing with that of the land imparts to it an agreeable mildness which is unknown in the interior. Another favorable condition is found in the fact that the warmer air from the • sea holds a lai’ge amount of invisible acjueous vapor in suspension, and as this commingles with the colder air of the land, it is condensed, gives out its latent heat, and becomes visible in the formation of clouds, esjjecially at sundown. Thus that radiation of heat from the earth’s surftice into sjrace which always takes place on clear nights is prevented. We can therefore safely assume that the mean temperature of the sea-coast is neither so high in the summer nor so low in the winter as that which prevails in the interior. These facts are well illustrated in the following table, prepared by Sergeant W. D. Blythe from the reports of the United States Signal Office, giving for five well-known localities the mean temperature for each month and the year, computed from November, 1879, to December, 1884, together with the average temperature for each of the four seasons : Winter. Spring. Sunimer. ^ Autumn. Year. a> a 1 Average. S J. 1 Average. a Average. 0 j Nov. j Average. Amount. Atlantic City. N. .1. . . .S6.8 32.4 3.5.7 35.0 38.6 46.7 57.8 47.7 66.9 72.6 71.6 70.4 ( 68.8 58.5 44.5 57.3' 52.5 Barnegat, N. J 3G.4 31.9 35.1 34.5 38.3 46.0 57.2 43.8 655 70 0 71.1 69.9 1 68.0 57.7 44.2 56.6 52.0 Boston, Mass 31.4 26.4 30.1 29.3 33.9 43.6 55.3 44.3 65.8 69.9 68.8 68.2 i 63.5 51.7 40.0 53.4 48.4 New ’Vork C'ltv :n.4 30.0 33.6 32.7 36.7 47.0 59.3 47.7 68.3 72.t) 71.6 70.8 t 67.5 56.2 43.2 55.6 51.6 Philadelphia, Pa. . . . 36.1 31.7 37.1 35.0 40.2 49.9 62.6 50.9 71.5 75.1 73.7 76.8 69.3 57,7 44.6 57.2, 54.1 As a sea-breeze prevails on a large majority of the days during the summer months, the average summer temperature is much lower on the sea-coast than farther inland. On some days the difference is gi’eatly marked, and few of us have failed to experience the relief afforded by the first breath of sea-air after spending a day in the hot city. It is self-evident that the pleasantest climatic conditions are those which present the most even temperature, with only a moderate amount of wind and rain. The tables on the following page, compiled from the same source, give some interesting statistics of rainfall, temperature and wind at various well- known stations of the Signal Office. Touching the question of health, the national mortuary table offers important data. There we find that while such model cities of the interior as Koches- ter and Milwaukee, swept as they are by the cleansing winds of the great lakes, show a death-rate respectively of 23.39 and 24.52 per 1000; ■while Philadelphia, the healthiest, save London, of the world’s great cities, shows 21.20 ; and while nearly thirty people to the thousand die annually in Charleston — the death-rate among the resident population of a sea-coast town like Atlantic City is 12.5. There are only two places in the United States — Ashtabula, Ohio, and Los Angeles, California — where the death- rate shows any approximation to this last percentage. 62 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. Annual Precipitation, in inches and hundredths, ns recorded at the U. S. Weather Bureau Stations on or near the Atlantic Coast, 1882 to 1891, inclusive ; also the Average Annual Precipitations, com- puted from observations covering periods of from three to twenty-one years. Stations. 1882. 1883. 1884. 1885. 1886. 1887. 1888. 1889. 1890. 1891. Average amount. Asbury Park, N. J 55.03 51.64 3 yrs. 53.44 Atlantic (;itv, N. J 5^29 44.64 53.70 3845 44.80 37.76 44.10 38.43 33.04 43.04 18 “ 42.81 Baltimore, >Id 42.11 40.52 43.88 46.04 53.11 43.-59 43.53 42.35 46.96 54.21 16 “ 43.11 Barnegat (closed) 8 “ 00.20 Block Island, R. I 57.65 39.69 6a05 39.37 54.50 44.55 29.18 32.80 31 ..51 39.03 11 “ 44.4S Cape May closed) 10 “ 46.70 Charleston, S. C 57.01 51.35 60.22 67.93 6.5.94 44.61 4646 52.25 47.84 45.90 16 “ 58.92 Jacksonville, Fla 53.26 53.34 55.92 52.04 54.86 58.60 53.13 46.22 47.52 41.32 15 “ 51.04 Narragansett Pier, R. I .50.97 53.66 57.15 45.21 44.46 5 “ 52.38 New Orleans, La 50.18 69.85 60.01 64.18 54.83 64.97 45.15 48.45 47.17 38.62 23 “ 51.78 Newport (closed) 6 “ 59.98 New York City 46.61 38.a3 .55.84 42.32 46.73 4663 52.95 58.68 52.30 51.44 21 “ 45.76 Norfolk, Va 57.67 A1.30 45.05 43.25 34.33 47.74 56.(U 70.72 50.22 50.63 21 “ 52.21 Portland, Me 38.94 31.99 52.51 39.75 52.63 49.07 34.24 41.92 51.97 43.28 20 “ 42.68 Sandy Hook 32.14 42.09 52.72 38.42 closed. 12 “ 50.40 V/ashington, D. C 46 79 45.71 49.96 44.84 58.17 45.^ 61.83 41. .59 52.95 51.22 21 “ 45.06 Wilmington, N.C 52.29 64.00 62.70 60.42 56.43 51.47 55.07 59.31 41.33 48.00 21 “ 56.24 Monthly and Annual Mean Temperatures for 1889. Stations. Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec. Mean. Asbury Park, N. J. . . 36.2 28.5 40.4 49.1 62.5 69.6 71.5 70.8 66.6 51.9 45.6 42.1 52.9 Atlantic City, N. J. . . 37.6 29.5 38.8 48.6 59.0 66.2 71.8 69.3 64.4 51.8 47.0 43.6 52.3 New York City . . ■ • 37.6 28.0 41.5 51.6 62.0 70.4 73.5 71.5 65.8 52.0 46.0 41.4 53.5 Annual Movement of Wind, in miles, at Ih S. Weather Bureau Stations on the Atlantic Coast for ten years, ending Dec. 31, 1891. Stations. 1882. 1893. 1881. 1885. 1886. 1887. 1888. 1889. 1890. 1891. Avarage. Atlantic City, N. J. . . . Barnegat, N. J. . .... 86.498 117.564 80.769 128.939 75.232 125.081 76.150 124.061 79.553 closed 74.879 88.825 104.930 102.520 106.50 0 87.585 (4 years) 123.911 Block Island, R. I. . . . 132.595 130.575 127.478 122.608 125.698 132.975 147.384 148.944 (8 vear.s) 133.531 Cape Mav, N. J 123.041 128.330 134.584 closed (3 year.s) 128.653 Sandy Hook, N. J . . 122.601 128.933 139.149 144.879 138.672 closed (5 years) 134.847 Diseases benefited by Sea-air. — It is often asked. What diseased con- ditions are benefited by a sojourn at the seaside? and. What, if any, are acted upon unfavorably ? Dr. A. W. Bell, author of Climatolofiji and Mineral Waters of the United States, says that, considering the purity of the vapor and perfect solubility of the salt, it is difficult to conceive of any possible state of the human system under Avhich the inhalation of such air would be detrimental. I fully agree with this author, and believe that sea-air is pref- erable to any other during a tedious convalescence. I know of no place where children improve more quickly than at the sea-shore. T have stud- iey fright caused by a Avave striking the child. Warm sea-baths, folloAved by a gentle massage, are preferable. SEA- A IB AND SEA-BATHING. 65 Sea-air has a very grateful influence in inducing sleep. Often sick chil- dren brought to the sea-coast sleep the first night better than for many nights before. It will be foimd that many children who are not ill after a few days’ stay will complain of drowsiness and willingly take their afternoon nap. The obstinate bronchitis which so often remains for an indefinite time after whooping cough is frequently cured by a few weeks’ stay at the shore. In the paroxysmal stage of the disease, while the coughing spells are no less violent than elsewhere, children do not seem to lose flesh and color, no doubt because their appetite is kept up by the bracing effect of the clear atmosphere, and they are kept in the open air more than they would be in a city home. Cases of infantile paralysis make a slow but steady improvement during a long stay by the sea. Most diseases of the skin and the inflammatory dis- eases of the eye are not improved by sea-air, unless these troubles have a strumous origin, in which case a long stay, by improving the general health, will indirectly improve the local condition. Sea-bathing. — It is a popular belief that sea-bathing is both strength- ening and hardening ; and there is but little doubt that this opinion is well founded. It does not follow, however, that it should be practised by all with- out medical advice. Many hold that a plunge into water which is of lower temperature than air protects the system against attacks of catarrh and chill, and renders it indifferent to sudden climatic changes, whilst a few contend that perfect immunity from colds may be ensured by continuing the morning plunge throughout the year. We may say, without doubt, that sea-bathing, more than any other agent known, renders the body less sensitive to the influ- ence of cold and to the injurious effects of prolonged exposure; but this, of course, is due to its invigorating and strengthening properties alone, and not to the element of temperature. It is a remarkable fact that many persons who cannot profitably bathe in fresh water can do so in the sea ; and the explanation doubtless is that the abstraction of caloric from the body in salt water is less than in fresh, by rea- son of its greater density. Probably, also, the saline ingredients have a more stimulating effect upon the skin and induce a more energetic reaction. The most important characteristic of sea-water is its saline composition, and it is impossible to ovei’-estimate the influence of the sea-salts in marine meteorology. It has been estimated that the average quantity of saline matter in sea-water is 3 per cent., consisting of chloride of sodium, sulphate of magnesium, sulphate of sodium, also muriate of magnesium and lime, with salts of iodine and bromine. Many, however, estimate the saline ingredients at 4 per cent. The above constituents are uniform as to presence, but are unequal in quantity in various parts of the world, so that in the Baltic a pint of w'ater contains nearly forty grains of salt ; on the coast of Great Britain it contains more than half an ounce ; in the Mediterranean, much more ; and in some ports south of the e(iuator the quantity amounts to more than two ounces. It is in consequence of its saline character that sea-water does not evaporate from the skin so readily as fresh w'ater. Even when the body is carefully dried particles of saline matter remain adherent, and find their way into the pores of the skin — as may be proved by the application of the tongue to the surface — and keep up a tingling glow long after the bath is over. We all know that persons when soaked to the skin by salt water do not take cold as easily as when caught in a shower of rain. This is explained by the fact that the pungent action of the sea-salts so stimulates the cutaneous circulation as to enable it to resist the depressing effects of the cold produced by the evaporation of the fluid portion. Sea-bathing, besides having all the beneficial effects of an ordi- 66 AMERICAN TEXT-BOOK OE DIREASEII OE CHILDREN. nary cold batli, has others peculiar to itself. The contact of the salt water and of the salt which adheres after the Avater left by the bath has evaj)orated stimulates the skin, increasing the circulation and exciting the sudoriferous glands. The beating of the waves against the surface of the body affords a passive exercise, with some of the advantages of massage ; while to the more robust a healthful exhilaration and delightful active exercise are furnished by the plunge through the waves and the vigorous movements constantly required while in the surf. At the resorts in the neighborhood of Xew York and Philadelphia the sea- bathing season is usually considered to be between the first day of June and the last day of September, as in this interval the temperature of the water ranges higher than at any other season. The best time for taking a sea-bath is just before high tide. At that time the water has been somewhat warmed by passing over the hot sand. More- over, the bathing is safer, from the fact that the tide still coming in would tend to w'ash the bather to the shore if he should lose his foothold, and, as the water covers a portion of the beach which Avas exposed to vieAv a few' hours before, there is less risk from dangerous holes and quicksands. But at most sea-shore resorts it has been found more convenient to bathe at the same hour each day — namely, at about 11 a. m., or tAV'o or three hours after breakfast, when the morning meal is digested and the system is beginning to feel the effects of the conversion of food into force, and is therefore better prepared to Avithstand the shock of the cold plunge. It is unAvise, hoAvever, to bathe within two hours after any meal : Avhilst digestion is proceeding more blood is attracted to the digestive organs, in order that the process may be efficiently performed. But if Ave divei't a portion of the blood to the surface of the body by the action of the cold bath, digestion is suddenly interrupted, assimi- lation checked, and congestive headache, cramps in the stomach, etc. are caused. In order to ansAver several of the questions Avhich naturally arise, it is neces- sary to describe the phenomena, Avhich are as follows : On entering the Avater there is a shock, accompanied by a sensation of chilliness and shivering ; there is a respiratory embarrassment and a feeling of fulness in the head. Next follows a reaction, in Avhich all these symjAtoms are relieved, and there is an agreeable sensation of Avarmth. If the bath is unduly prolonged, there follows another sensation of chilliness : the teeth chatter, the fingers and lips become blue, the respiration irregular and rapid, and the pulse A\eak and small. In the sea-bath each w'ave reproduces in a less degree the first shock, and at the same time hastens the development of the second chill. From the above description it would appear that the proper duration of the bath is a period short of the second chill, and the length of this period must depend upon the temperature of the Avater, the force of the waves, the strength of the patient, and a number of other circumstances. I do not consider it AA'ise to alloAv children to remain in the water over five minutes, and then they .should be at once taken to their bath-house and not allowed to play on the beach in their Avet bathing-suits. Before entering the w'ater their heads should be wet, and they should be taken cautiously to the first line of breakers, Avhere, in a stooping posture, tbe Avaves may wash over them. If children are afraid of the Avater, they should not be forced. The proper Avay is to accustom them gradually to the sea. Have them dressed in their bathing-clothes and allow them to play on the beach, Avhen they Avill of their own accord go to the Avater’s edge and gradually find their Avay in. Many children do not dread the Avater, and they may do much in allaying the fears of the more timid. I think three or four sea-baths a week (}uite sufficient SEA- AIR AND SEA-BATHING. 67 for even the strongest child. A thorough rubbing down should always be given, and the child quickly dressed, and allowed to resume its play in a sunny spot unexposed to the wind. There is no advantage in taking an infant (under two years) into the sea, and the practice as usually carried out seems almost inhuman ; for these the heated salt-water hath is an excellent substitute. The Management of Children at the Sea-shore. — At all times of the year the sea-shore is most beneficial to sick children, but it has only been a comparatively few years since the practice of going to the sea-side resorts during the winter and spring months came in vogue ; previously, the three summer months wei’e the only ones considered advisable to spend by the sea. At the present time it is deemed almost as necessary to take a child convalescing from an illness to the sea-shore in the winter and spring months as in summer. In selecting a place of residence by the sea it is well to be near the surf. Houses situated at a distance from the beach are never as cool as those close to it. Therefore, in taking a sick child to the shore it is always advisable, especially during the summer months, to select a house in close proximity to the sea. Here the exhilarating breeze comes uncontaminated from the ocean. The clothing of the child during its stay at the sea-shore should be slightly heavier than that worn in the city or country ; hence it is always better to use woollen under-garments, light and loose in texture. Long stockings should invariably be worn, even in the warmest weather, as toward evening the air becomes several degrees cooler, and, if the breeze is blowing from the sea, at times almost cold. Little change need be made in the food of children during their stay. The advantages, claimed by some authors, of a largely marine diet have probably been over-estimated, and much blame has been attached by others to fish, oysters, etc. for the frequent disorders of the digestive apparatus from which adults suffer at the sea-shore. From my own experience, however, the acute attacks of indigestion that we occasionally see are usually brought about by the elaborate menu which is found at our largest hotels, in contrast to the plainer home table which most are accustomed to. On arriving at the sea- shore the appetite is naturally sharpened by the change of air, and over-eating is the result. Much thought should be given to the necessity of exercise. Children seldom need much urging, but the want of it among adults probably interferes with many of the benefits which othei’Avise would be gained. For very young children, next to the "walk in the nurse’s arms, the drive upon the beach should be recommended. The perfect evenness of the surface renders it possible to take a very ill child into the open air fre(iuently with the greatest benefit. One of the best forms of exercise for sick children is play- ing in the warm, dry sand. A spot should be selected where the sun does not beat too strongly, but which is at the same time perfectly dry. It is, as we all know, an unceasing source of amusement to children, and the harmless character of their little falls and tumbles during play often encourages them to efforts which they would not otherwise attempt. PART I. INJURIES INCIDENT TO BIRTH AND DISEASES OF THE NEW-BORN. By EDWARD P. DAVIS, A, M., M. D., Philadelphia. The mortality of the first year of life is variously estimated. Bernheim, from an extensive series of statistics, places it at 37^®^ per cent, of all chil- dren born. Winckel states that 10 per cent, of children born perish before the eleventh day of life; of these, per cent, perish during labor itself, 3^ per cent, die as a consequence of some injury received during labor, while P®’’ cent, perish from diseases contracted at or after birth. We shall first consider morbidity and mortality among children arising from injuries received at birth. Caput Succedaneum. The most frequent lesion sustained by the foetus during delivery is the formation of a tumor upon the head, usually known as caput succedaneum : this is commonly recognized after delivery as a somewhat boggy tumor, formed by infiltration of the scalp and fascia over the cranium, and usually situated upon the parietal bone opposite to that which came most in contact with the bony pelvis of the mother. The mechanism of its production is commonly thought to be as follows : In a normal presentation and position, the back of the child being to the left side of the mother’s pelvis, and the vertex occupy- ing the left anterior half of the pelvis, during the stage of expulsion the left half of the vertex of the child’s skull receives the greater portion of the impact of force during descent and rotation. The continued pressure upon this portion of the foetal skull temporarily checks the free circulation of blood and lymph through the tissues of the seal}) and fascia. There remains upon the opposite half of the vertex a portion of the head less pressed upon by the bony pelvis ; here, naturally, the blood and lyuq)h of the scalp-tissues are |ire- vented from circulating through the left side of the foetal head by pressure, and accumuhate and distend the tissues of the right half of the vertex. Tlie result is a tumor upon the side of the foetal head o])posite that which actually engaged during the first stage of labor. The }iosition which the child’s head occupied in the mother’s pelvis may then he reasonably inferred from the loca- tion of the caput succedaneum ; thus in the usual labor this tumor occurs in the right parietal region of the head. Should the child occupy a second })osi- tion, its back to the right of the mother, its vertex situated in the right ante- 68 INJURIES AND DISEASES OF THE NEW-BORN. 09 rior half of her pelvis, the caput succedaneum can be found upon the left parietal portion of the foetal head. Caput succedaneum is usually of no prac- tical importance, as it disappears in a few days after labor. The infiltrated con- dition of its tissues, however, forms an excellent field for the growth of infect- ing bacteria. Should the mother’s birth-canal be in a septic condition during labor, or should, through the carelessness of the nurse in washing the child, some injury occur to the tumor, the entrance of septic infection results in inflammation, and, in rare cases, in abscess of the scalp. The caput succeda- neum is larger the longer the labor lasts, is usually of a bluish-red color, and does not distinctly fluctuate or pit upon pressure. Occasionally the tumor embraces both parietal bones : this may be caused by long delay in the expulsion of the child, the head remaining for some time in the external genitals of the mother. Upon post-mortem examination extrav- asations of blood varying in size may be found in the vicinity of the tumor, and do not indicate criminal violence after birth. Two of these tumors may be found, a primary and secondary : the first is formed in the usual manner ; the second is produced while the head is upon the pelvic floor and after ante- rior rotation has occurred. If delivery then be delayed, a secondary tumor will form, and may be distinguished from the first by its situation in the median line. In shoulder presentations the tumor is found upon the shoulder which pre- sents. So far as the treatment is concerned, Bouchut suggests the application of a solution of ammonium chloride, a solution of camphor, or an alcoholic mixture containing camphor. If this does not secure the disappearance of the tumor, he would aspirate it. Winckel and other obstetric authorities incise the tumor if it persists beyond the sixth or eighth day, and make pressure upon the parts with salicylated cotton. If abscess forms, incision and irrigation with a J per cent, solution of creolin are indicated. Cephalhematoma. By cephalhaematoma Naegele, who first described it, designated a blood- tumor on the foetal head, called true cephalhaematoma when beneath the periosteum of the skull, and/a/se cephalhaematoma when beneath the aponeu- rosis of the scalp. Virchow explains the formation of cephalhaematoma by referring to the way in which the pericranium grows — namely, by proliferation of inner layers of the periosteum. If, then, the pericranium is separated from the cranium by the extravasation of blood, the bone-producing layers of the periosteum are still formed, but are prevented by the blood-clot from uniting with that portion of the bone for which they were intended. They join, hoAvever, to the bone at the border of the extravasated clot, where the bone is still attached. Fig. 1. Vertical Section through Cephalhsematoma. Much discussion has arisen as to the method of formation of cephalhae- matoma. Some ascribe its presence to traumatism only, while others seek an 70 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN explaiiiation in a pre-existing condition of the infant’s tissues. It is to be differentiated from caput succedaueum by several important distinctions. The latter arises during birth, is born with the child, appears upon that portion of the head turned during labor toward the excavation of the pelvis, is more prominent after difficult labors, has an ill-defined border, fre<[uently crosses sutures, is discolored in appearance, and doughy upon manipulation, and tends to disappear rapidly after delivei’y. On the contrary, cephalliaematoma does not occur, as a rule, after difficult labor, appears usually upon that parietal bone which did not present in the pelvic excavation, has a sharply-defined border, does not extend across sutures, does not discolor the scalp above the tumor, and usually gives the sensation of fluctuation in the centre of the mass. Cephalhmmatoma also tends to increase steadily in size for some time after labor. With such radical differences the pathology of these tumors must differ widely. That of caput succedaueum has been already given. In studying the pathology of cephalhaematoma we have been struck by the fact that instances under our observation have been, as a rule, in ill-nourished children born without especially difficult labor. In the wards of the Philadelphia Hospital we have frequently observed these cases in children born of ill- nourished mothers and poorly nourished at the time of birth. This leads us to believe that a pre-existing malnutrition lies at the basis of these tumors ; thus, cases are reported Avhere, in addition to the cephalhmmatoma, a profoundly anaemic condition of various organs of the child’s body was ])resent. In no case does this tumor occur as an extravasation of blood beneath the internal periosteum of the skull ; but extravasations of blood within the cranial cavity are also described under the title of “ intracranial cephalhaematoma.” Partridge describes two cases in which coagulated blood was found beneath the dura mater. No injury to the bones of the cranium existed in these cases, the brain-substance was softened, and the blood found beneath the membranes and at the base of the brain seemed to have been extravasated from the sinuses and from the laceration of minute blood-vessels. One of these children died very shortly after labor ; the other survived for several days. We recall a similar case wdiere delivery was easily effected by the forceps ; the child perished, however, in thirty-six hours after birth, and upon post-mortem examination blood w'as found extravasated beneath the membranes, while the underlying cerebral matter was softened. Here also no injury to the bones, membranes, or sinuses could be detected. Cephallnematoma is more frecjnently found in males than females, according to Burchard, in the j>roportion of more than three to one. The tumor is usually found upon the right side of the head. The children of primiparm are most liable to this complication in the proportion of three to one. As a rule, cephalhaematoma does not pulsate, although isolated cases are reported in which indistinct pulsation was observed. While fluctuation is usually present, it may be very obscure. This results from the presence of coagulated blood, as well as the breaking down of the clot in the centre of the tumor. It is observed that if the tumor be opened soon after formation, bright-red blood escapes ; later the blood resembles the fluid found after old extravasation. The deposition of bony material on the under surface of the periosteum occasions a crackling sensation when the tumor is palpated. The fluid escapes irregularly from beneath the tumor ; sensitiveness is very rarely a prominent feature. The bony ring surrounding the tumor forms gradually ; thus Bouchut observed a case before birth in which no ring was present. Semmel- weis is said to have seen cephallmematoma in a child delivered by Caesarean section. IXJURIES AND DISEASES OF THE NEW-BORN. 71 Several tumors may develop in the same individual ; thus we recall a case under observation in the I’liiladelphia Hospital in which double cephalhe- matoma appeared on the head of a male child born after a normal labor. Trij)le cephalhematoma has been observed by Oui after a precipitate birth in which Fig. 2. Double Cephalhematoma. the infant fell to the ground, the cord rupturing three or four centimetres from the umbilicus. Upon examination a tumor was found upon each parietal bone, and one upon the occipital. The tumors were treated by incision and evacua- tion under careful antiseptic ])recautions, and uninterrupted recovery ensued. The occurrence of cephalhsematoma is readily understood when the loose attachment of the pericranium to the bone is remembered ; Valleix found that in almost all infants ecchymosis between the pericranium and the skull is present after labor. It requires, then, but a constitutional liability to ecchy- mosis by reason of malnutrition to readily account for the occurrence of such tumors. Cephalhsematoma, again, may develop after birth as a surgical injury, as instanced in cases described by Treves and N^laton, as also in a re- markable case in a bleeder reported by St. Germain. Cephalhsematoma may be also produced by injudicious pressure exercised during the child’s toilette. Hiiter observed double cephalhmmatoma occurring on the fifth day after birth, and caused by the carelessness of a midwife, who, in washing the child, rubbed its head with undue force. The tumors persisted as long as the individual had charge of the child, but disappeared soon after she was discharged. No one cause can be invariably assigned for the production of cephalhae- matoma : the size of the mother’s pelvis seems to exercise but little effect, for Merttens in 21 cases found 6 in which the pelvis was normal, and only 5 in which slight pelvic contraction was present. In these cases the contraction was not of such natui’e as to interfere with labor. That the pressure of the pelvis has sometimes nothing to do with these cases is shown by Spiegelberg’s observation of a case of premature birth at six months, in which the child perished before the rupture of the membranes ; he was able to examine the head in utero., and detected the tumors before the expulsion of the child. He considered the tumors caused by interference with the oxygenation of the 72 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. foetal Llood, and oftentimes by premature efforts at respiration. Merttens reports a similar case in which he diagnosticated this complication before delivery. The foetus in this latter instance had a congenital hernia of the diaphragm, and hsematomata were found in other portions of the body. The diagnosis of cephalhsematoma in distinction from caput succedaneum has already been stated. Hernia cerebri may be present, but occurs usually in the occipital region and in the line of sutures. Pressure upon the hernia produces symptoms of positive disturbance of the nervous system. Aneurism presents a pulsating tumor of darker color, which neither has the appearance nor affords the history of cephalluematoma. The effort to class this affection among the hydrocephali is scarcely successful in the light of our present knowledge of both. Blood-tumors found in the occipital region in the dead foetus are often caused by difficult labor, and are dark in color from the decomposition of effused blood. In encephalocele direct examination of the head by palpation will enable the physician to make the diagnosis. Tumors in living children, the result of direct violence, are usually painful on pressure and lack the sharp outline of cephalhfematoma. Occasionally, in advanced rachitis, whei'e craniotabes is present, soft pieces of bone in the skull may simulate a blood-tumor when palpation is made through the scalp. The usual plan of treatment consists in making gentle pressure by a pad of antiseptic cotton conveniently held in place by a night-cap. Occasionally lotions containing dilute alcohol or some acetous preparation are employed, but there is no evidence of their positive value. It must be remembered that the tumor, as a rule, wdll have reached its largest size six or eight days after the birth of the child. Unless Imemorrhage be excessive and the tumor becomes rapidly very large, it may be let alone for the first ten days of the child’s life. Should infection occur and inflammation supervene, it must be freely opened at once, emptied of its contents, and the sac thoroughly disinfected, while continuous but gentle pressure is made by an antiseptic dressing. If no complication occurs, at the end of the first eight or ten days of the child’s life the scalp over the tumor should be shaved, the surface thoroughly disinfected, preferably with boric acid, and the tumor punctured with a bistoury or large trocar. After evacuating the fluid contents pressure by an antiseptic dressing is indicated. Some prefer free incision in j)lace of simple puncture. We have met with a case in which puncture and evacuation w'ere followed by reaccumu- lation of fluid, and in which it was finally necessary to open the tumor freely, empty it, and pack it with iodoform gauze, the gauze having to be renewed several times before adhesion between the bleeding surfaces took place. Occasionally the loss of blood in these cases is considerable ; as a rule, how- ever, haemorrhage is not a serious complication. The susceptibility of infants to poisoning by antiseptics should be remem- bered ill treating cephalhaematoma. Mercurial and carbolic solutions may be preferably replaced by solutions of thymol, 1 : 1000, or saturated solutions of boric acid. Iodoform gauze may be employed without hesitation as tampon material. Hjematoma of the Sterno-Cleido-Mastoid Muscle. A peculiar induration is fixaiuently observed in the sterno-inastoid muscle of new-born children, regarding which diftercnt beliefs have been held. Ana- tomical study of the subject shows that the lesion is an intramuscular fibrosis, caused by direct violence to the neck of the child, usually occurring at deliv- ery. Most of these cases result from delivery in breech ju'cscntation ; the INJURIES AND DISEASES OF THE NEW-BORN. 73 forceps causes some; and, rarely, the lesion follows spontaneous birth. Schmidt reports the case of a child, seven days old, delivered by the breech, in which the right sterno-mastoid was shortened, and the right half of the face smaller and flatter than the left. The report of a post-mortem examination upon a case pointing to a possible intra-uterine origin of this condition is made by Heusinger. The head was directed toward the left, the right sterno-mastoid muscle was 9 cm. long, the left only 6^, and was a soft, white, tendinous sub- stance. In 23,293 children examined at birth at the Paris Maternity, Guyon found 132 cases of monstrosity, but no case of torticollis, which militates against the congenital occurrence of hsematoma of the sterno-mastoid. In 64 post-mortem examinations Ruge found 13 cases of this complication. In a recent valuable paper Spencer describes 15 cases found in 300 autopsies ; his researches show that both sexes and the muscles of both sides of the neck are equally affected. Small, prematurely- born children are especially liable to this injury. Breech or footling presentation was observed in 10 of the 15. The forceps had been employed in 2 cases, while in 2 no instrumental aid was employed : in 2 of the bodies examined both muscles were affected. Spencer notes but two cases of contracted pelvis ; one of his cases was that of triplets, complicated by placenta praevia centralis, with extraction through perforation in the placenta. His microscopic sections show clearly rupture of muscular fibre, with extensive effusion of blood. It has been shown by Witzel that, as a consequence of this complication, contracting fibrous bands may form, giving rise to permanent wry neck. Jacobi believes that the forceps is frequently the effective agent in producing this injury to the foetus. H.®morehage in the New-born. A considerable number of cases of foetal death occurring within the first forty-eight hours after labor are preceded by obscure symptoms which render an exact diagnosis difficult or impossible. The intelligent study of such cases by post-mortem examinations shows us that haemon-hage is usually the cause of the fatal issue. As in the adult, haemorrhage may depend upon an alteration in the condition of the blood itself, and also upon direct mechanical injuries which result in its escape from the vessels. In the fii’st category of eases it has long been a familiar observation that syphilitic children, stillborn, show extensive disintegration of blood, with extravasation of blood-serum from the serous surfaces of the body. Children dying from acute infections on the part of the mother, and stillborn or perishing soon after, often display such a tend- ency to haemorrhage ; thus, small-pox, typhus, typhoid, scarlatina, and, as a rule, the acute infections as a class, predispose to the occurrence of haemor- rhage. There is also direct proof from bacteriological examination that the foetus in utero may be infected by various micrococci, and that this infection may result in haemorrhage and death at labor or very soon afterward. The occuri’ence of multiple punctate haemorrhages accompanying umbilical sepsis is a not infrequent illustration of this form of haemorrhage. In the recent litera- ture of the subject Tavel and Quervian report a case of multiple haemorrhage following umbilical infection by streptococci. Death occurred on the thirteenth day, the infection having occurred very shortly after birth. A thorough exami- nation of the specimens showed infection with streptococci and other bacteria to be the cause of the haemorrhages. These haemorrhages were found in the connective tissue beneath the epidermis, beneath the serous membranes and mucous membranes, and also in the kidneys. A .second illustrative case is also reported, in which, in a prematurely-born child, death occurred with .symptoms 74 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. of pneumonia. Examination revealed the fact that the pneumonia had been caused by infection with staphylococci. The peculiar form of the haemorrhage — namely, into the parenchyma of various organs — excluded hamiorrhage from mechanical injury. Further, the rapid and easy birth of a small foetus tended to exclude the possibility of mechanical injury. l>y far the most fre(iuent cause, however, of haemorrhage in the new-born is direct mechanical injury received during birth. Such injury is usually suspected after difficult extraction by the forceps or by version. As pel- vimetry is more extensively ])ractised the induction of premature labor will render these cases more and more infreresentation. Various forms of cerebral haemorrhage are described by other observers, and especially in cases following prolonged application of the forceps or forcible extraction after version. In our owm observation we recall the case of an infant delivered with axis-traction forceps without especial difficulty ; progress- ive feebleness of respiration, failure to nurse, and apparent exhaustion caused death in thirty-six hours after birth. On post-mortem e.xamination, over the parietal regions of the skull the tissues of the scalp Avere intensely congested, although no gross lesion, as rupture or fracture, could be discerned. Beneath these portions of the skull and scalp the cortex of the cerebrum Avas filled Avith punctate haemorrhages, and over the point of greatest convexity the brain- substance was materially softened. Similar cases, Avhich Avould not be found infrequent if post-mortem examinations in such patients Avere extensively held, are readily explained by the anatomy of the cranium and its contents in the neAV-born. VirchoAv and others have shoAvn that the blood-vessels of the infant’s brain are thin and small, and most readily injured by abnormal pres- sure. An interesting example of this fragility is found in cerebral hmmor- rhage following death from asphyxia, Avhere mechanical injui’y to the cranium can be excluded. In medico-legal practice Richardiere emphasizes the fact that such cerebral haemorrhage may be differentiated from haemorrhage occurring later in life by the absence of inflammation of the arachnoid and of the dura mater. Menin- geal haemorrhage in the neAV-born is often accompanied by subpleural ecchy- moses ; death usually results suddenly. A most valuable recent contribution to the literature of this subject is that of Spencer. In a total of 180 bodies exain- ined, 130 Avere in a condition Avhich enabled a critical examination of the tissues to be made: in 85 injuries to the brain Avere found, consisting of con- gestion and luemorrhage ; these conditions varied in severity, in situation, and in extent. (Edema Avas a fre(juent accompaniment. The children had been delivered in various Avays, and many of the cases occurred in children the subjects of disease. 4’iie accom])ariying plate shoAVS a typical condition of meningeal luemorrhage (Plate I.). Its fre((uency Avill be appreciated Avhen it is known that 4-j^ j)cr cent, of all lucmorrhagfis occurring in the ncAV- PLATE I. Visceral Hxnnorrliago in the Newborn (Spencer, Tranmctioii'i Ohi^tefriciO t>ociety, Jjmdmu vo! IW). LIBftAftY OF THE UHlVEHSfTY HF \lWm INJURIES AND DISEASES OE THE NEW-BORN 75 born are meningeal in character. Spencer also describes a case, similar to the one which we have mentioned, of hemorrhage into the substance of the brain. It is interesting to note that, so far as the causation of cerebral hemorrhages is concerned, the forceps is the most frequent agent in producing them, and next presentation by the breech or foot. As determining causes softness of the skull and relaxation of the sutures are of considerable importance. In Spencer’s cases, next in frequency and importance to haemorrhage into the brain comes parenchymatous haemorrhage into the liver, kidneys, and supra- renal capsules. Well-marked congestion was frequently observed; haemor- iliage was present in 28 per cent.. This haemorrhage was often upon the upper surface of the liver and followed birth in head presentations. Such haemorrhages usually appeared as blebs filled with blood. Of equal frequency Avas haemorrhage into the substance of the kidneys, usually beneath the cap- sule. Such cases Avere most frequent in breech presentations (Plate I.). The suprarenal capsules Avere also the seat of frequent haemorrhage. Injuries to the lungs in the form of congestion and haemorrhage Avere next in fre- (juency. Most often this took the form of subpleural bleeding ; less frequently, as hiemorrhafire into the lung-substance. These pulmonary apoplexies are often followed by pneumonia, and are a frequent cause of death. Such infants are usually cold and blue, Avith sub- normal temperature and feeble cry, and do not nurse. The abdominal and pelvic viscera, besides those mentioned, are also the frequent site of congestion and hgemorrhage. As regards the causes, Spencer recognizes a delicate condi- tion of the blood-vessels as of great importance. Alteration of tbe blood, already described, is also recognized, Avhile asphyxia predisposes to haemorrhage. Direct mechanical violence is a familiar exciting agent. Experience abundantly proves that most cases of severe haemorrhage arise where disproportion in size between the foetus and the pelvis exists; there can be no rational prophylaxis of these injuries that does not rest upon an esti- mate of the mother’s size and the relative size of the foetus. We cannot too strongly urge, as we have already done, that pelvimetry be uniformly practised by obstetricians, and that, in addition, an effort be made in all cases to estimate the relative size of the foetus and the birth-canal. To be of service to the patient such efforts at diagnosis should be made between the seventh and ei of pregnancy. So far as the treatment of the infectious disorders which attack the blood, resulting in hfemorrhage, is concerned, the faithful practice of antiseptic pre- cautions will diminish very largely these complications. The need for such observances is proven by the familiar fact that at the present time the mortality of infants in private houses is greater than in Avell-conducted maternities, the reason being that the practitioner considers the private house and the private patient objects for less anxiety than the hospital patient; neglecting antiseptic precautions because the patient is a private one the result is often disastrous. Asphyxia. Interference with the oxygenation of the foetal blood results in asphyxia. By far the most common and dangerous causes of this complication are those which arise while the child is still in the uterus, and Avhich have nothing to do with the access of the external atmosphere to the child’s lungs. When this is kept in mind, it Avill be seen that asphyxia is a complication of labor itself, not so much a condition arising at delivery and requiring subse- ghth months 76 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. queut treatment. The most frequent cause of this condition is pressure upon vessels of the placenta or umbilical cord, resulting in blood-stasis in the foetus; or occasionally sudden collapse and death on the part of the mother. The symptoms of asphyxia in the foetus are those of carbon-dioxide poisoning — a rapid, feeble pulse, pallid appearance of the surface of the body, with the phe- nomena caused by intense congestion of various organs, ending in heart-failure. Asphyxia has been variously divided, some writers describing an apoplectic form and others a pallid form. These are but variations of the same condition, and are distinctions without essential differences. During the first stages of asphyxia the phenomena of congestion predominate : the face of the cliild is suffused, the mucous membranes bluish, the heart-beat at first slow and more vigorous than normal, while the reflexes still I’emain. As the process goes on and congestion has been followed by engorgement and oedema, the surface of the body is pale, the pulse small, rapid, and feeble, while the mucous mem- branes have the peculiar grayish-blue appearance characteristic of impending death. In the first stages of asphyxia the pulse in the umbilical cord is pres- ent, and may be vigorous. In the second stage the cord is pulseless, and shares the pallid appearance of the foetus. The complications of labor which most frequently cause asphyxia are par- tial detachment of the placenta, compression of the umbilical cord, pressure upon any large portion of the foetal body, especially upon the head and brain, or the sudden death of the mother. So soon as the tissues experience what has been styled “hunger for oxygen,” there ensue reflex respiratory movements : by experiment these may be demonstrated to happen witliin the uterus before the rupture of the membranes ; they frequently occur during the second stage of complicated labor. They result in the inspiration of amniotic liquid or the secretions of the mother’s birth-canal ; if these respiratory efforts are vigorous and prolonged, inspiration pneumonia may I’esult — a catarrhal pneumonia caused by the inspiration of mucus or pus, developing, if the child survives, immediately after birth, and frequently j)roving fatal. The child before labor is in a condition of physiological apnoea. The blood of the foetus contains an excess of hmmoglobin at the moment of birth, stated by Cattaneo to be relatively 120^^^ per cent. No differences can be distin- guished between arterial and venous blood in the umbilical cord in the amount of haemoglobin contained. So perfect is the provision of nature for supplying the foetus with oxygen that anfemia on the jiart of the mother does not seem to influence the amount of haemoglobin in the foetal blood nor in the blood of the child immediately after birth. The ra])idity and ease with which the foetal blood absorbs oxygen is illustrated by the fact that in from thirty-six to forty- eight hours after birth the blood of the new-born contains its greatest amount of haemoglobin. Late ligation of the umbilical cord results in more hmmoglobin in the foetal blood. Curiou.sly enough, a small placenta increast's the amount of haemoglobin in the foetal hlood, while a large placenta diminishes it. At the moment of birth the circulation of blood in the placenta and the child is markedly interrupted, oxygenation is materially lessened, and the foetus undergoes a period of more or less danger. It can be readily understood how delayed labor, where the exhausted uterus in tetanic contraction j)resses upon the child and the placenta, may occasion death from asphyxia, and this without extensive gross lesions. Asphyxia, again, may depend upon defective muscular and nervous develop- ment in the foetus. As a i-esult, the fietus fails to make respiratory movements after delivery, and ])erishes from actual weakness. Diseases which affect the respiratory apparatus, either by structural changes or mechanical pressure, may INJURIES AND DISEASES OE THE NEW-BORN. 77 cause asphyxia. Pulmonary syphilis, enlargement of the liver, dropsy, and various tumors come under this head. These cases usually perish from atelec- tasis. The blood-vessels in such cases rupture easily, and small multiple haemor- rhages abound. Prognosis in cases of asphyxia depends upon the condition of the ner- vous centres. If the asphyxia is but partial, and the stage of congestion be present, as evidenced by the dark reddish-purj)le comjdexion of the child and the slow but full pulsations of the heart and umbilical cord, recovery in the majority of cases will ensue. If, however, the child is pallid, the heart- beat rapid and feeble, and the cord pulseless, the prognosis is grave. INIore than 1 per cent, of children born living perish from asphyxia ; while cases have been reported where children, born asphyxiated, subsequently developed serious pathological conditions of the nervous system. Recalling what has been stated regarding the richness of the foetal blood in haemoglobin, cases where children born asphyxiated have survived for hours, although thought to be dead, are readily explained. Beale described a case in which the mother died from post- partum haemorrhage shortly after delivery ; the midwife in charge reported the birth of dead twins, which she put in a basket in a shed ; on examination three hours afterward, one child was found breathing feebly. Efforts to establish respiration were fruitless. The temperature in the shed was very low, the weather being cold. Children have respired feebly eighteen minutes after birth and twenty-five minutes after birth in breech presentation. Beale reports successful efforts, lasting several hours, to resuscitate a child thought to be dead. A case is reported where a child was buried a foot under ground, and not exhumed for five hours, when evidences of life resulted from efforts at resusci- tation continued for two hours. It is curious to observe that the chances of recovery in asphyxia are much better when the infant is exposed to cold than when to heat, probably from the fact that a low temperature retards the metabol- ism of the cell-elements of the body, and thus the nervous centres retain their irritability longer. Treatment of asphxyia is prophylactic and curative. In prophylaxis the conditions which will result in prolonged labor should be anticipated and removed. Complicating factors which will subject the child to great pressure must also be obviated. The judicious use of the forceps is a direct prophylaxis against asphyxia, as are version and extraction. On the other hand, both of these procedures are direct causes of asphyxia in unsuitable cases. We must again repeat that no intelligent prophylaxis of asphyxia can be undertaken which does not include a preliminary examination of the mother’s birth-canal and an estimation of the relative size of the foetus and the mother. Prolapse of the umbilical cord, resulting in pressure and asphyxia, is best treated by anaesthetizing the mother and terminating labor, if possible, by manual inter- ference ; thus, the cord may be taken in the hand and passed up into the uterus, the head brought into a proper position, and delivery expedited by the forceps; or, if pulsation in the cord has ceased, version and extraction may be performed. There is no repositor for the cord comparable to the hand of the obstetrician, for the hand can recognize pulsation, can remedy coiling of the cord about the foetus, and may so change the position of the cord as to lead to the recovery of the foetus. In cases of contracted pelvis, or in disproportion between the foetus and the pelvis, operative procedures have for one of their purposes the saving of the child from asphyxia, which otherwise must prove fatal. So soon as the head is accessible during labor, the practitioner should ascertain, if possible, whether the cord is coiled about the neck ; if so, it should be gently drawn 78 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. down and loosened ; and if the head be horn, the cord tightly coiled about the neck, and a large body and shoulders hinder delivery, it is well to cut the cord and deliver the child I’apidly. The cord may be clamped with artery-forceps, or, better, tied. The diagnosis of cord around the child may sometimes be made before expulsion by hearing a murmur in the umbilical cord during auscultation of the abdomen. The treatment of the actual condition of asphyxia after delivery Mill depend largely upon the degree of asphyxia present. There are certain precau- tions which should be taken in every birth. The nurse should have ready a saturated solution of boracic acid to M’hich has been added a teaspoonful of glycerin to the half pint. This should be at hand in a small, clean earthen hoM’l. In the bowl should be a half-dozen pieces of old, soft handkerchief, two inches square. When the head is born, the physician turns the mouth and eyes of the child in such a position that they Avill not come in contact M’ith the discharges of the mother. The nui’se or physician should then thoroughly cleanse the mouth and fauces Muth the bits of linen soaked in the boracic solu- tion. Mucus or secretions in the child’s mouth will thus be removed, and one danger of asphyxia obviated. In the stage of asphyxia M'here congestion is the principal symptom, the stimulus of contact with the external air will often secure respiratory movements : spanking the child is a familiar method of procedure which undoubtedly has good results. In such cases the cord may be promptly tied and cut; and if the congestion be pronounced, it is M'ell to allow a drachm or tM'o of blood to flow from the foetal cord before ligation. The child should then be promptly inverted to favor the expulsion of mucus from the air-passages. If the heart-beat be good, a little cold water sprinkled upon the chest will usually result in the establishment of respiration. Should the heart-beat be good, but respiration not ensue, the child may be laid in a bath- tub filled with water at a temperature of 100 ° F., and passive respiratory movements may be instituted. Cold water also may be sprinkled upon the chest. In these cases a prognosis may be based upon the action of the heart ; if that be strong, the physician should not despair of securing respiratory move- ments. In the more severe forms of asphyxia the child can endure no loss of blood ; it may be promptly inverted and held in that position for several moments, its mouth being thoi'oughly emptied of mucus and secretions : passive respiration is then to be instituted, and to secure the actual entrance of air into the lungs the Schultze method is undoubtedly pre-eminent. It consists in taking the child with both hands, the child’s head raised betMeen the upper ]iortion of the palms, the fingers grasping the scapulae of the child, the thuml)s resting upon the anterior surface of the thorax. The child is then raised above the head of the physician until it turns a three-([uarter somersault ; it is then brought down with a swinging motion to M'ithin a short di.stance of the floor. When the body of the child is raised over the head of the physician expira- tion results: as tlie child swings foiMvard and doMinvard the action of gravity and the pressure of the physician’s hands result in a poMerful inspiratory action. The value of the Schultze method consists in its efiiciency in intro- ducing air into the lungs ; it is not, however, a stimulus to the reflex excitii- bility of the nervous system, and if this has been lost, an infant’s lungs may be filled with air and yet the cliild readily ])erish. The dangers of tliis method have been pointed out by Meyer and Ileydrich. Fracture of the clavicle with perforation of the lung and emphysema, are rej)orted by these observers as occa- sionally following this method of resuscitation. A manifest objection to the Schultze method is the disturbance and shock INJURIES AND DISEASES OE THE NEW-BORN 79 which must necessarily follow ; in deeply asphyxiated children, where the heart-beat is scarcely perceptible, it is preferable to practise the inverted posture, with the a])plicatiou of warm flannel to the surface of the body and the continuation of gentle respiratory movements. Air may be introduced into the lungs by mouth-to-mouth insufflation or by the passage of a tracheal tube. Lusk advises the use of the catheter, not only to remove mucus, but to favor direct insufflation ; or the chest-walls may be compressed to secure expiration. When circulation reappears, Silvester’s method is then of service, the tongue of the child being drawn forward. When heart-beats are perceptible, the warm bath, with sprinklings of cold water upon the face, is useful. Finally, he advises Schultze’s method to favor complete re-establishment of the circulation. Schultze claims for his method an immediate action in relieving overloaded blood-vessels, the swinging of the child producing empty- ing of the ventricles and favoring the return current from the pulmonary vein. The value of direct insufflation by the catheter, preceded by the removal of mucus, can scarcely be over-estimated. We recall a case in a foreign hospital where the assistant in charge had abandoned an asphyxiated infant as dead ; permission was given several American students to practise the passage of the balloon catheter, an English catheter having a rubber bulb at the distal end, whose compression and expansion favor suction and insufflation. To our surprise, the child became resuscitated under the use of the catheter, and ultimately recovered. Forest places the child first on its face, its head down, and expels fluids from the mouth by pressure upon the back. The child is then put in a bath or tub of hot water in a sitting posture, supported by one of the operator’s hands acro.ss its back, its head bent back- ward. The physician grasps the child’s hands with his other hand, carries them upward until the child is suspended by the arms, leans forward himself and blows air into the child’s mouth ; the infant’s arms are then lowered, its body is doubled forward, and its thorax pressed between the hands of the physician. Air is thus expelled. Especial advantage is claimed for this method from the fact that the hot w'ater maintains capillary circulation and tends to assist in promoting the action of the heart. Reynolds places the infant upon its back, head downward, resting upon the operator’s forearm, held nearly perpendicularly to the floor, retained in that position by his fingers hooked over its shoulders. In this position the child’s arms fall down- ward by the sides of its head, and their weight, aided by that of the thorax itself, draws the ribs into the position of complete expansion of the chest. The thorax is compre.ssed against the forearm by the other hand, and suddenly released, when a most satisfactory respiration is the result. This method combines a favorable posture for the escape of fluids from the trachea and for the afflux of blood to the brain, with a ready method of artificial respiration. Duke places the infant face downward, its thorax resting upon the open palm of the left hand ; the ribs are gently compressed by the other hand : the mouth is cleansed, and the finger pa.ssed down the pharynx to admit air. If this is not successful, the child is plunged into a hot bath. Richardson urges that the child’s body remain quiet during efforts to establish respiration. The feeble condition of the heart strongly contraindicates violent disturbance to the child. The position of the body should be horizontal. Air introduced should be warmed to 90° F. Manual respiration by Silvester’s or Hall’s method is recommended, and Richardson describes an apparatus composed of a pair of bulbs by which air may be pumped into the respiratory passages. Two pieces of tubing are passed to the nostril, and a bulb upon one injects air, while a bulb upon the other favors the discharge of mucus and vitiated air. 80 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. lie also describes a method of using a simple bellows in connection with a nasal tube. The treatment of asphyxia by tracheotomy is seldom successful ; there is rarely an impediment in the respiratory passages of the child which cannot be overcome by the introduction of the catheter. In reviewing the treatment of asphyxia we desire to call attention to the pathology of the affection and to the relative value of different methods of treatment. The removal of mucus from the nostril, trachea, and bronchial tubes can be most readily effected by suspending the child in an inverted position ; this favoi’s also afflux of blood to the medulla and respiratory centre. Gentle, passive respiratory movements should be employed, but so conducted as to give the child the least disturbance possible. The return of the circula- tion and the reflexes should be eagerly awaited, and so soon as these phenomena are present the prognosis becomes much more favorable. The w'arm bath and the application of a mild counter-irritant — cold water, spirits, simply a current of air from bellows directed against the epigastrium — usually cause respiratory movements. In strong children, when the reflexes are present and the heart-beat becomes perceptible, Schultze’s method, practised gently for a short time, is of value. Should the circulation fail, it is admissible to inject hypodermatically of a grain of strychnia and a few minims of tincture of digitalis. If mucus is not expelled by the inverted position, the use of the catheter with suction and insufflation is advisable. When respiratory efforts have become established, but repeatedly fail, a mild faradic current of electricity and the inhalation of oxygen under pressure are of decided value. One pole of the faradic battery should be placed at the back of the neck, and the other over the thorax and alternately over the epigastrium. Bonnaire obtained good results in foetal asphyxia by inhalation of oxygen — a procedure which we have repeated with like good results in foetal asphyxia and that of older children complicating pneumonia. As Lusk remarks, in cases of deep asphyxia patience, watchfulness, and a hopeful spirit are prerequisites of success. Following asphyxia, the infant is exposed to danger of death from inani- tion, and, as has been stated, from catarrhal pneumonia. The use of the incubator is of especial value in maintaining the circulation in these cases, and favoring the gradual expansion of the lungs if atelectasis be present. Winckel has obtained good results from the permanent hot bath at a tempera- ture of 98.6° to 100° F. every twelve to twenty-four hours. Such children are fed every two hours. The bowels are promptly emp- tied by rectal injections. Winckel has devised a bath- tub for such cases, an illus- tration of which is append- ed. We add also an illus- tration of a modification of Auvard’s incubator, which we have used successfully in the Philadelphia Hos- pital and in the Maternity Department of the Jeffer- son Hospital. The interior of the box is divided into two j)arts by an incomplete horizon- tal partition, jflaced about six inches above the Itottom of the box. In the lower part, which is intended for hot cans, two openings are necessary — one at Fig. 3. INJURIES AND DISEASES OF THE NEW-BORN. 81 the side, occupying the whole length of the side, closed by a sliding door opened at pleasure from either end, as a means of placing the hot cans. The Fig. 4. Incubator. J, b, lid with glass plate ; v, glass plate ; H, ventilating tube ; O, slide closing hot-air chamber ; M, hot-water cans. other opening is at one end of the box, closed by a door not fitting tightly, to admit a small amount of air. The upper part, arranged to receive the infant. Fig. 5. Interior of Incubator. is covered on top by a plate of glass, fitting completely, "with two buttons or knobs to admit of its being easily raised. On the top is also arranged a small metal tube containing a small rotary fan very easily moved by a weak current of air. In the opening where the two com- partments join a sponge is placed, wet with water to humidify the air, and a thermometer by which to regulate the temperature. Cases are not infrequently met with where death occurs soon after labor with 6 Fig. 6. Hot-water Can for Incubator. 82 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. symptoms of partial asphyxia : a clear diagnosis is often impossible, until post- mortem examination reveals partial heart-clot, syphilis, atelectasis, or lobular inspiration pneumonia as the cause for this mortality. Hemorrhages from Mucous Surfaces. The new-born infant often presents haemorrhages from mucous surfaces of the body. Among the most frequent of these is a discharge of blood from the vagina, occurring at birth and persisting afterward. An examination of the mucous membrane in these cases fre(j[uently detects a condition of capillary granulation which bleeds easily upon the slightest movement of the child. In a case recently under our observation at the Maternity Department of the Jefferson College Hospital an ill-developed female child presented this phe- nomenon at birth. A blood-count made of this child, and compared with that of a healthy infant, shows the following : Healthy Child . — Red corpuscles per cubic millimetre, 5,450,000, by counting forty squares (Thoma-Zeiss hmmocytometer). White corpuscles per cubic millimetre, ll,OO0. Pi-oportion of white to red, 1 : 495. Haemoglobin, 65 per cent, of normal. Blood-plates by objective, blood prepared by means of Hayem’s solution : the number Avas much less than the usual amount, which should be about 250,000. The red corpuscles were irregularly formed, some crenated, some small and granular, others apparently rolled or turned upon themselves, resembling very much a bread roll. While this irregularity existed, their appearance Avas that of normal corpuscles, and the percentage of haemoglobin (65) proved them to be almost normal. In children the per- centage of haemoglobin is not so great as in adults ; in the young or in any case Avhere the groAvth is rapid the red corpuscles are ahvays irregular in appearance, Avhich is not at all indicative of disease. The slight increase in red corpuscles is normal to the new-born. (Plate II. Fig. 1.) Anaemic Child . — Red corpuscles per cubic millimetre, 2,000,000. White corpuscles per cubic millimetre, 12,000. Proportion of white to red, 1 : 166. Ilmmoglohin, 35 per cent, of normal. By careful examination no blood- plates could be found. In this case the red corpuscles Avere irregular, crenated, granular, and many disintegrated. By actual count this specimen Avould give over five million red corpuscles per cubic millimetre, hut counting normal corpuscles Avould give only two million. The object of the count being to knoAv the number of oxygen-carriers per cul)ic millimetre, it would give a wrong idea to enumerate those disintegrated and diseased corpuscles. There was a slight increase in the number of Avhite cells, but their appearance Avas normal.^ (Plate II. Fig. 2.) The condition underlying such luemorrhage is that of anmmia or malnutri- tion of the blood, Avith resulting ecchymoses. In parts accessible to treatment, as the mouth, vagina, rectum, or bladder, injections of hot dilute crcolin solu- tion or boracic solution are indicated. Treatment of the aiuemia, hoAvever, by administration of food, by arsenic, inunctions Avith oil, and the administra- tion of olive or cod-liver oil Avill lesult in gradual recovery. Obstetric Paralysis and Injuries to the Nervous System. Direct injury to the nervous system received during birth has long been recognized as among the dangers to Avhich the infant is exposed. Paralysis of ' For the examination and description of the blood in these cases I am indohtcil to Dr. D. 15. K>’le, Instructor in the Examination of the Blood in the .Jellerson Medical College. Dr. AV. II. Wells, one of the ])hysicians to the .Jetlerson Maternity, ha,s prejuired the drawings illustrating the aj)pearance of the corpuscles. PLATH II. Pig. I. blood of Healthy Child one month old. Haemoglobin normal. Drawn from Thoma-Zeiss Haemocy- tometer. Objective J Reicherts. Blood-count liy Dr. Kyle; drawing by Dr. Wells. Fig. 2. % 1 € jSt — — . 1 y * L f A r €) w r ^ ■■ i % / \ * <0- i 1 © :®jy V # Blond of .\n:emie Child snlferin.g from Hiemorrhage from Mncons Membranes. Total corpuscles, 5,000,000, of which 2,000,000 wore normal. Blood-connt and drawing as in i)recedlng figure. fl lH£LI8RAHir , '" OFM .£ UNIVIERSITY OF IttIMftlS ^ ■t ' A- INJURIES AND DISEASES OE THE NEW-IiORN. 8.3 the facial nerve caused by pressure with the forceps upon the nerve at its fora- men of exit often follows instrumental delivery. The brachial plexus is also frefiuently injured by the same agent. Hemiplegia, idiocy, and impaired cere- bral development have been ascribed as conse(iuences of injury received at birth. The view previously held, that the forceps is a valuable agent for compressing the foetal head and exercising leverage and forcible rotation, has given place to the belief that the forceps is essentially a tractor, and that the mechanism of rotation depends upon the relation in size and symmetry between the head and the pelvis, and, as well, the resistance of the pelvic floor. Murray has shown by experiment and clinical observation that the foetal skull is com- pressible in an antero-posterior direction by the sliding of the occipital and frontal bones under the ends of the parietal bones. This compression is not accompanied by any appreciable increase of the transverse diameter. The antero-posterior shortening is compensated for by a vertical elongation of the skull, providing for the accommodation of the cranial contents. These con- clusions are, however, based upon the employment of axis-traction, without which such compensatoi’y elongation cannot be confidently assumed. Murray was also careful to avoid forcible traction. Under such circumstances it may be held that moderate pressure with forceps, resulting in compensatory elonga- tion of the vertical diameter of the foetal skull, need not be expected to cause paralysis, haemorrhage, or fracture. This pressure, however, must be gradually applied, and traction made in the axis of the pelvis ; otherwise a portion of the head will be forced against the promontory of the sacrum, and injury must result. When gentle axis-traction fails to cause the head to descend, a diag- nosis of disproportion between the head and the pelvis should be made, and efforts at forcible delivery should cease. The results of injudicious delivery with forceps are well illustrated by Lane. A boy sixteen years old, delivered at birth with forceps, exhibited a groove three and a quarter inches long from the right coronal suture to the lambdoid ; the floor of this groove seemed one-fourth of an inch below the scalp ; the left arm was weaker than the right, and its movements defective. The left leg was weak. Reflexes were exaggerated and clonus was present. The depressed portion of bone was raised ; the bottom of the depression encroached upon the area of the skull. Prompt amelioration of the epilepsy followed. Duchenne, Gueniot, De Paul, Rogers, and others have described injuries to the brachial plexus caused by forceps and by manual extraction of the child. Erb has clearly described injuries to the brachial plexus accompanying delivery in breech presentation. Hoedamaker describes injury to the fifth and sixth cervical nerves resulting from delivery in breech presentation when the arms become extended above the head. Feriberg describes a case of paralysis caused by pressure upon the brachial plexus during delivery after version ; paralysis was but temporary, the patient subsequently making a good recovery. The medico-legal aspect of injuries to the new-born child requires the dif- ferentiation of lesions received during birth by forceps or the pressure of the mother’s pelvis, and injuries occurring by precipitate labor without assistance or by the wilful act of the mother or an accomplice. Dittrich reports cases of depression in foetal bone, bounded by a well-defined ridge, following applica- tion of the force])s in cases of contracted pelvis. Kiistner describes funnel- shaped depressions in the foetal skull following forcible delivery by forceps. Von Hofmann has found a spoon-shaped depression the most frequent form of lesion in a considerable number of cases. Fracture of the orbital region of the skull has been observed by Lihotzky to follow forcible forceps delivery. Rup- ture of a meningeal vein and death from haemorrhage have been observed and 84 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. reported by Koft'er in the clinic of Gustav Braun. Kundrat reports an inter- esting case of depression upon the parietal bone of a new-born infant, with cerebral h?emorrbage, in which the evidence seemed to show that the lesion was caused by direct violence on the part of the mother after the birth of the child. Von Hofmann has further drawn attention to injuries to the fcetal cadaver which might occasion suspicion of intentional violence during birth. Naturally, defects in the ossification of the skull may result in lesions accom- panying normal labor and simulating injuries at birth. Fritscli describes the characteristics of injuries caused by precipitate labor, the child falling upon the fioor or ground, to he as follows : The fracture begins in a suture, and extends outward to the middle of the hone ; usually there is but one fissure, which ends where the hone is thickest. The parietal hone is most often aftected, the fissure ending in the parietal eminence. As a general distinction, it is to he observed that direct violence is accompanied by hemor- rhage ; that injuries examined immediately afterbirth, where fracture occurs, show frequently a well-defined border to the lesion, which tends to grow less sharp in contour if the child survives. Kundrat also lays stress upon the rela- tive breadth of the sutures as a factor in influencing limmorrhage during birth. A most interesting question arises as to the hearing of these injuries upon the future health and development of the chihl. Osier found, in the records of the Philadelphia Infirmary for Nervous Diseases, U cases of paralysis following forceps delivery ; in 6 of these it was reported that the forceps injured the child : some of them had scars following labor. In all cases the paralysis grad- ually appeared within a short time after labor. M. Allen Starr describes cases of brain-atrophy manifesting itself in hemiplegia, mental defects, and sensory defects, accompanied freipiently by epileptiform seizures, and result- ino; from congenital conditions or lesions occurring at birth. Sachs and Peter- son in 49 cases of congenital cerebral palsy found 16 in which some difficulty in labor occurred. These statistics are now more couq)rehensive than tho.se of Little and Gaudard, Wallenberg and Osier. Sachs and I’eterson, however, include all forms of cerebral paralysis and of tedious labor as well as instrumental delivery. Saelis has expre.ssed the o})inion that prolonged lal)or does more injury to the child's brain than the proper application of forceps. We have considered the prophylactic treatment of these conditions under that of the treatment of visceral haemorrhage. The (juestion arises, however, AVh at shall he done in a ca.se in which a child is horn and survives with such an injui’y ? Although we find no record that such a procedure has been at- tempted, yet tlie suggestion of Nancrede and other surgeons that depressed hone be elevateresent, or where the lesion is extensive and follows severe pressure, such should he the line of treatment. The succe.ss attained in operating immediately after birth upon cases of umbilical hernia gives encour- agement to the belief that surgical interference in these cases is justifiable. It is interesting to note a superstition common among the laity in some (juarters to the effect that the doctor by manual pressure and counter-])re.ssure is ex- pected to shape the head of the child during the first few days after its birth. Fractures and Dislocations op the Trunk and Extremities. The skeleton of the foetus may he fractured while in the uterus. Such fractures, however, must he carefully distinguished from congenital malforma- tion, which closely simulate fracture. 7\niniotic adhesions during the first and second months of intra-uterine life are the most freijiient cau.ses of these mal- INJURIES AND DISEASES OF THE NEW-BORN 85 formations. An apparent scar is often present in these cases, and must be referred to precipitate flexion of undifferentiated layers in the embryo. Spurious callus may be present, caused by defective development of the bone, although the amount of callus is less than after actual fracture. Sperling would dis- tinguish between malformation and fracture by the fact that in malformation the lingers and toes of the limb affected show defective development, while in fracture such defective development of fingers and toes is absent. Ilodgen de- scribes a foetal skeleton containing sixty-five fractures which he thinks were caused by muscular action during uterine life. He describes also, in a healthy child, a fracture of the clavicle, which was not discoverelace during the first three days after birth (Billiet, Silbermann, Dusser), though in a case of this author’s it occurred on the fourth and fifth days, and in two instances, seen by Billiet, the children were fifteen and twenty weeks old. Sex seems to play no special predisposing role, but the influence of morbid INJURIES AND DISEASES OE THE NEW-BORN 87 antecedents in the parents appears to be a factor of some importance. Pinard, Champetier, Auvard, and others have noted syphilis in the progenitors, but this is regarded by Gryiifeltt as only a cause acting indirectly in deteriorating the health of the parents. Hemophilia has certainly been proven in some instances. The pathogeny is quite as obscure as the etiology. The lesions observed at autopsies are the most variable. Ulcerations of the stomach and intestines have been found ; again, only a simple congestion ; while Other cases have shown a complete absence of visible lesion. Grynfeltt advances a theory suggested by observations of Billard, and confirmed by personal studies of the histology of the digestive mucous membranes of new-born infants. These show that the vascular supply of the mucous membrane of the stomach and intestines is exceedingly rich at this period of life. Adding to this state of physiological congestion a congestion or impeded circulation in the liver, he finds it easy to ascribe the cause of such htemorrhages to exaggerated tension in the portal area. This view, he believes, is supported by the fact that these haemor- rhages, at first sudden and profuse, quickly cease, thus resembling a true depleting loss of blood. The first symptom is usually the haemorrhage itself. Blood flows from the mouth following eiforts at vomiting, or from the rectum, more or less mixed with faeces or in clots ; quite often both phenomena are coincident, haemate- mesis being usually the earlier. When one alone occurs, haematemesis is by far the more frequent. In spite of the gloomy prognosis evidenced by the statistics of Dusser (43 deaths in 78 collected cases), a more hopeful view must be taken. In treatment, tannin in syrup of rhatany offers an efficient astringent potion. One and a half to two and a half grains of ergotin in mucilage are employed with satisfaction by Widerhofer of Vienna. Icterus Neonatorum. The physiological icterus of the new-born infant appears on the third or fourth day of life, is characterized by a yellowish pigmentation of the face and breast, persists for about a week, and does not seem to disturb the patient’s general condition at all. The urine is dark in color, containing bile-stuff, while the stools lack the color usually given by their mixture with bile. The cause of such icterus is thought by Birch-Hirschfeld to be swelling of Glisson’s capsule, commencing at the umbilical vein, and by oedema preventing the free discharge of bile through the hepatic vessels; hence the jaundice is hepato- genic. Hofmeier thinks icterus is caused by the enormous number of red blood-corpuscles which are formed in the liver and hinder the production and discharge of bile. The entrance of this coloring matter into the blood is furthered by catarrh of the duodenum and congenital stricture of the ductus choledochus. Ilalberstam found undissolved bile-stuff in the urine of children with icterus, and the epithelium of the kidneys infiltrated with the same coloring matter. The harmless character of this jaundice and its spontaneous disappearance should not make it a subject of anxiety to the physician or parents; it some- times is due to slight changes in diet or any temporary disturbance of the child’s general surroundings. Beyond the regulation of the bowels by the most simple laxatives, no treatment should be employed for this condition. Infective jaundice will be considered under the head of infections which attack the foetus. 88 AMERICAN TEXT-BOOK OF DmEAHES OF CHILDREN. The Infections attacking the New-born. The recognition of bacteria, ptomaines, and toxines as causes of disease has served to explain many disorders of the foetus and infant at birth not previ- ously understood. Most frequent of these infections are those by the micro- cocci of gonorrhoea and the streptococci of suppuration. Gonorrhoea in the mother affords the best of grounds for fearing gonorrhoeal infection in the new-born child. The most usual site of this infection is the conjunctiva, and ophthal- mia neonatorum is a familiar se(iuence of maternal gonorrhoea. The treat- ment of this disorder will be considered in another section of this book. We are interested, however, in the practical prophylaxis of such infection : if the practitioner could be absolutely positive that the mother had never been infected by the gonococcus, prophylaxis would be entirely unnecessary. In hospital patients, however, there is always room for suspicion ; and in private cases, although there may seem no ade(juate reason to fear such a comj)lication, yet its appearance will often surprise and disappoint the attending physician. No information will be gained in this matter from interrogating the patient : if she has ever been infected, her husband has certainly not told her the cause of the disorder, and her physician may have kej)t her in like ignorance. Furthermore, in women who have never been infected by the gonococcus there occurs at the latter portion of pregnancy a vaginal discharge which is capable of setting up a mild conjunctivitis in the infant. Hence a practical rule may be followed to advantage, that where a vaginal discharge j>ersists during the latter portion of pregnancy the use of antiseptic douches is certainly indicated. These douches may he, preferably, creolin or bichloride of mercury : the first has the advantage of impairing the natural condition of the mucous membrane of the vagina le.ss than does the mercurial ; it is also a safer substance to j)ut in the hands of a patient. On the contrary, its odor is disagreeable to some, and when used in a strong; mixture it causes considerable irritation and burning. In a strength of one teaspoonful to the quart the resulting mixture is seldom so irritating as to cause discomfort. The (quantity used should be not less than a quart, and the douche should be preferably taken while the patient is in the recumbent posture. The douche-bag should hang not higher than three feet above the patient’s body, and the force of gravity alone should be em])loyod in giving the douche. If bichloride of mercury be chosen, 1 : 5000 is sufficiently strong for such use. In })atients admitted to hospitals, suffering from the effects of previous gonorrhoea or having acute gonorrhoea, the treatment must be more radical ; here a preliminary thorough cleansing of the vagina should be made with green soap and creolin, the mixture containing 2 per cent, of the creolin: following this, creolin douches, four times in twenty-four hours for the ten days preceding labor, will be found of advantage. Should the mucous membrane not tolerate such frequent douches, the vagina may be tamponed with iodoform gauze containing 50 per cent, of iodoform, and the number of douches be reiluced one-half. In all hospital cases a preliminary douche of green soap and creolin may be u.sed to advantage; in ])rivate practice a j)re- liminary douche of bichloride, 1 : 5000, may also be employed to the advantage of mother and child. Aside from ophthalmia, gonorrluKa may infect the infant at birth npon other mucous membranes. Rosinski describes the results of interesting inves- tigations made by him u])on gonorrhnea occurring in the mouths of new-born infants. The lesions caused by this germ in the mouth develop only where the pavement epithelium has been removed. These cells are especially fragile PLATP] III, -I- Fio. 1. Fig. 4. Gonorrhoea of the Mouth in the Xcwborn (RosinsKi). IHtLIBRAttV OF THE UHIVERSITY of ItMHflIS INJURIES AND DISEASES OF THE NEW-BORN 89 in the young child, and hence the readiness with which infection occurs. It is interesting to note that in gonorrhoeal ophthalmia it is very rare to find that the lachrymal sacs become involved ; it is also true that the cylindrical epi- thelium of the naso-pharynx seems also to resist successfully invasion by the gonococcus. Clinical observation shows that these cases develop usually between the fifth and tenth day of life, resulting often from infection from the genital canal occurring at birth, and oftentimes through dii'ect infection at the hands of attendants. This is especially true where the epithelium of the mouth is destroyed through efforts at cleansing. These cases are remarkable for the fact that they affect the general health so little ; the children nursing w’ell and seeming free from pain. The lesions are yellowish plaques, surrounded by a border of pale-reddish tissue, in w'hich the process of healing usually begins upon the third day by a reaction zone of deeper color. The epithelium is renewed from the borders of the plaque, pus-cells being thrown off as the healing progresses. Scar-tissue is never developed in these cases. The accompanying plate gives an excellent idea of the appearance of the lesions. (Plate III.) The treatment of gonorrhoea affecting the mouth of the new-born con- sists in careful avoidance of injury to the epithelium ; the finger should not be inserted into the mouth of an infant suffering from this disorder : the affected surfaces should preferably be sprayed with a solution of hydrogen peroxide or a saturated solution of boracic acid. Such treatment is usually amply sufficient to secure the recovery of the patient. The infant’s general condition often requires attention in these cases, and its food and hygiene are matters of great importance. General Septic Infection. Streptococci, bacteria, and ptomaines of septic infection usually find entrance to the fcetal body through the granulating surfaces upon the umbil- icus ; the result is arteritis and phlebitis of the umbilical vessels, resulting in the formation of thrombi and the infiltration of the surrounding tissues with bacteria and ptomaines. Both umbilical arteries are usually involved, the infection extending from the umbilicus to the bladder. The umbilical ring may ulcerate, or may have healed entirely while the infection has proceeded within the abdomen. According to Weber and Runge, the tissue about the arteries is usually first involved ; the iliac vessels and the retroperitoneal con- nective tissue usually escape ; in two-fifths of cases Runge found pneumonia or pleurisy with small metastatic abscesses. Peritonitis and pyaemic metastases in the abdominal viscera and the joints have also been observed. In umbilical phlebitis the capsule of the liver and the liver itself become involved. Peri- carditis, pleuritis, and other pyaemic complications are often present. The symptoms of such infection are often obscure. The umbilicus may become inflamed shortly after birth ; the child has fever, is restless, holds its legs and thighs flexed, and often becomes jaundiced. Death may occur in convulsions, but occasionally recovery ensues. The treatment of umbilical septic infection is largely prophylactic : thorough antisepsis as regards the physician, nurse, and external genital organs of the patient, a suitable and cleanly dressing for the umbilicus, such as previously given, and scrupulous cleanliness while the cord is drying and becoming separated, render umbilical septic infection a rarity. If the child be too feeble to have the full bath for the first month of life, it is comparatively easy to allow the cord to remain undisturbed. Where, however, the child is bathed daily in the bath-tub, such of the cotton as may iME RICAN TEXT-BOOK OF DISEASES OF CHILDREN. !)() ^ become wet should be carefully removed, the cord repowdered, and fresh cot- ton applied. The constitutional treatment of an infant suftering from septic infection through the umbilicus consists in the reduction of excessive fever by judicious sponging with warm or cool water, and the free administration of dilute alcohol and nourishing food. While quinine, if it can be taken, is a useful auxiliary, yet alcohol is the drug of most importance for such cases. Infants suffering from severe infections often bear strychnia as a stimulant better than might be expected from theoretical considerations only. Erysipelas. The micrococcus of Fehleisen may obtain an entrance at the umbilicus, and erysipelatous inflammation of the subcutaneous and cutaneous tissues may result. This process may go on even to the extent of gangrene and sloughing of the affected parts. Cases of mixed infection resembling erysipelas may develop, complicated by diphtheria, as in illustrative cases reported by J. Lewis Smith from the records of the New York Infant Asylum. The infection may localize itself in multiple abscesses beneath the skin, or, extending to the peri- toneum, may cause death from acute peritonitis. The treatment of erysipelatous infection of the umbilicus and surrounding parts consists in thorough applications locally of peroxide of hydrogen, boracic acid, or thymol solution, 1 : 1000. Following this, eqtial parts of iodoform and boracic acid may be employed freely. When pockets of pus form, they should be promptly opened with a knife or scissors and thoroughly douched with an antiseptic. The child’s general strength must be assiduously supported by alcohol, food, and strychnia or quinine. As a stimulant in severe prostra- tion, hypodermatic injections of camphor in oil, or administration, by the mouth, of freshly-made English breakfast tea, with rum, will be found of ser- vice in some cases. Acute Peritonitis in the New-born. Acute peritonitis occasionally arises very soon after birth as a complication of erysipelas or from some pathological process developing in the intestine. The communication in lymphatic channels between the intestine and the peri- toneum seems unusually free in the infant, and as a result peritonitis rapidly supervenes. Cassell describes three interesting cases of this sort. Lorain, Quinquaud, and Silbermann have also reported illustrative cases of this dis- order. Tubercular and Typhoid Infection. There exists certain ground for belief that the foetus in utero may become infecteil by tubercle bacilli and also by the bacilli of typhoid. The first few days after birth may witness acute miliary tuberculosis or the development of a well-marked typhoid condition. As regards the former, the usual clinical signs of acute tuberculosis will be present: it must be remembered, however, that the infant rarely survives acute tuberculosis long enough for the formation of lung-cavities, and hence physical signs will often be lacking. The character of the fever, the rapid, uninterrupted course of the disorder, with increased dul- ness over the thorax, and the development of harsh and bronchial breathing, will usually enable the physician to make a diagnosis. INJURIES AND DISEASES OF THE NEW-BORN 91 While treatment up to the present time has been practically unavailing, it is of interest to note the experiments of Pinard in using injections of the serum of dog’s blood in these cases ; in a series of twenty-one infants so treated he believes that benefit has resulted, the remedy seeming to act as a powerful tonic and stimulant. The intra-uterine transmission of typhoid infection is well illustrated by a case recorded by Giglio. The presence of the typhoid germ was demonstrated in the tissues of an apparently normal foetus and placenta born forty-six days after the beginning of typhoid fever in the mother. The treatment of typhoid in the new-born is practically that in the adult, reference being had to the ease with which the infant is stimulated or de- pressed. The pi’ognosis in such cases is exceedingly grave. Inspiration Pneumonia. In prolonged labor, complicated by a septic condition of the mother’s birth-canal, premature inspiratory movements on the part of the foetus may result in the inspiration of septic material : lobular septic pneumonia may result, and, occurring soon after birth, frequently proves rapidly fatal. Here, again, the efforts of the physician lie in prophylaxis, in delivering the patient promptly, and maintaining so far as possible an aseptic condition of the birth- canal until labor shall terminate. Tetanus. The infant may become infected with tetanus, and this disorder may appear in well-marked type from the sixth to the ninth day after birth. The tetanus bacillus usually finds its entrance at the unhealed umbilicus. Brieger has shown the specific cause of this disorder, and Beumer and Peiper have con- firmed by clinical observation the identity of trismus and tetanus of the new- born with inoculative and wound tetanus. The mortality among infants is exceedingly large, and recovery is the rare exception. Appearing Avith symp- toms of restlessness, night-terrors, and frequent cries, the child often becomes nauseated, has slight diarrhoea, and is then attacked by trismus. This, at first intermittent, finally becomes persistent, and develops into tetanic contrac- tions of the entire body. Icterus is usually present. The disorder rarely lasts more than three or four days, the child perishing in collapse from twelve to twenty-four hours after the beginning of the convulsions. High temperature is usually present at the time of death. On post-mai-tem examination effusion of blood and serum in the cerebral tissues is frequently found. The violence of the convulsions may give rise to haemorrhages into the muscular interspaces or into the tissues of the mediastinum. In treatment hydrate of chloral and alcoholic stimulants give most pros- pects of relief. Holt has reported a case Avhich recovered under the free use of bromide of potassium. A specific method of treatment by the injection of a substance similar to tuberculin has not, so far as we know, yet been employed in this disease. There would certainly seem to be reasons for testing its value. Mastitis. Mastitis in the new-born infant is to be regarded as a mild septic infection when the di.sorder comes to the point of suppuration and phlegmonous inflam- mation. The mammary glands of new-born children frequently become engorged and tender, but this condition subsides if the glands be let alone and 92 AMERICAN TEXT-BOOK OF DISEASEl^ OF CHILDREN. protected from external violence. When, however, infection occurs, pus- formation may take place and a septic mastitis may result. Such a compli- cation, however, is exceedingly rare where antiseptic precautions are habitually taken in the treatment of labor cases. A distinction must be made clinically between simple engorgement of the breast and infection. In the former the child’s temperature remains hut little disturbed, its appetite is unimpaired, its rest remains practically as l)efore. If the glands be carefully hut gently washed with soap and water and bathed with bichloride, 1 : 10,000, a thin layer of absorbent cotton put over them, and a soft flannel bandage pinned snugly al)out the breast and supported over the shoulders by slioulder-straps or some other simple device, the glands may remain undisturbed for several days unless fever or restlessness indicates inflammation. On the other hand, where infec- tion is present and pus has formed, prompt emptying of the gland by incision, with disinfection of the cavity, is indicated. Infections op the Blood. Profound alterations of the blood and nutritive cellular processes in the new-born, the probable result of infection at birth, have been described under various names by different observers. Hecker and Von Buhl describe a disorder of infants horn in asphyxia characterized by cyanosis, vomiting, icterus, profuse parenchymatous haemor- rhage, accompanied by acute fatty degeneration of visceral epithelium and heart-muscle. Phosphorus- and arsenic-poisoning were excluded in diagnosis, and the malady was named “acute fatty degeneration of the new-born,’’ or Buhl’s disease. Its pathology is not perfectly explained, but it may be classed among the infective disorders resulting in the extensive disintegration of the blood. Acute Inemoglobinuria of the new-born was first clearly described by Winckel, who reported twenty-three cases of the disorder. It is characterized by swelling of Peyer’s patches and the mesenteric glands, blackish-red staining of the pyramids of the kidneys, with stripes of haemoglobin coloring, fatty degeneration of the liver and other viscera. Ilaematogenic icterus is present, the haemoglobin being extensively changed into bilirubin. The urine is dark brown-reddish in color, contains haemoglobin, epithelium, casts, and micro- cocci. Chemical poisons as a cause were excluderesent time vomiting is no longer a prominent symptom. They are now characterized by headache with nausea, and followed by a more or less pro- longed narcotism, during which the child falls into a dee]) sleep from which he awakens somewhat improved. In hrief, on(> may say that the gastro-intestinal paroxysms of his infancy are being transformed into true migraine. This substitution of one l\)rm of lithiemic jairoxysm for another is (piite characteristic of the disease. The disease may manifest itself in young infants by attacks of gastric pain, associated with rapid breathing, nausea, vomiting, and fever. 'I'lie LITII^^MIA. 97 gastric paroxysms may be so severe that all food is rejected for a period of from one to five days. The temperature may reach 104° or 105° F., but sometimes in the most severe cases the fever ranges between normal and 102° F. In these attacks the patient may be prostrated to the last degree, occasionally having a subnormal temperature. Toward the close of these acute attacks the infant or child may be much emaciated. Occasionally these lithmmic paroxysms are ushered in by convulsions, which may recur with such regularity as to become quite characteristic symp- toms of such attacks. These gastric paroxysms are self-limited. In dura- tion and severity they are influenced but slightly by medical treatment. The nausea and vomiting go almost as quickly as they came, but there is left more or less abdominal tenderness and gastro-intestinal irritation, from which the infant or child slowly convalesces. The stools following these attacks are putrid, and in young infants are sometimes oily in character. The interval between the attacks may be as short as one week, or months may intervene. In the less severe forms of lithsemia the infant or child may be quite well during this interval, but, unfortunately, this is not always so. Some of these lithaemic children remain pale and frail-looking at all times. They are peevish and hard to please ; they are as relentless as they are exacting in their demands. Lithaemic infants and children are mentally pre- cocious, and when ill and peevish between the acute attacks they exercise this precocity in devising ways and means to secure the constant attention of all around them. From the gastro-enteric type of lithaemia above described there are many variations. In children these attacks may occur, as they commonly do in adults, with little or no elevation of temperature. They may or may not be accompanied by convulsions, headache, gastric pain, or dyspnoea. The dys- pnoea when it does occur is an interesting symptom, since it is not due to pulmonary causes, but is, like all the other symptoms, toxic in origin and to be classed as a nervous symptom. In rare instances vomiting of blood may occur both in the child and the adult, but this symptom does not change the prognosis or delay the return of the digestive organs to their normal condi- tion. It is of importance in that such a lithaemic attack might be mistaken for gastric ulcer. In infancy, childhood, and adult life a chronic intestinal fermentation may be dependent upon a lithaemic condition, but in these cases the symp- toms which are always present as a result of chronic intestinal fermentation are at times aggravated into more acute attacks of gastro-intestinal disturb- ance. These acute gastro-intestinal attacks recur without apparent cause and at more or less regular intervals, in that way breaking in upon the milder gastro-enteric symptoms, which are constantly present. This type of lithaemia is, in the adult, commonly associated with great mental depres- sion. It may also here be noted that the pain from these gastric attacks is not uncommonly so severe in the adult as to demand for its relief the hypo- dermic use of morphine. The lithaemic attacks of infancy and childhood ai’e, fortunately, not so painful as they may be in later life. The gastro-enteric symptoms of lithiemia at all ages may vary in severity from a slight nervous dyspepsia to an attack of pain and vomiting so severe as not only to strike down, but even to endanger the life of, the patient. Nervous Symptoms . — Nervousness in a great variety of manifestations is to be observed in lithaemic individuals. It might almost be said that the entire symptomatology of lithaemia at all ages may be directly or indirectly referred to the nervous system. Infants and children with strong inborn lithaemic 7 98 AMFAIICAN TEXT-BOOK OF DISEASES OF ClIILDREX. tendencies have very unstable nervous systems. The increased refle.x excita- bility of these children predisposes them to general nervous irritability. They are commonly quick-witted, bright-faced, small and slender of stature, and Hit about with quick and nervous movement. But lithsemic, unlike tuberculous, precocity is not, as a rule, coupled with physical inferiority ; neither is litluemic precocity so fitful, so asymmetrical, and so short-lived as the tuberculous. Litluemic children, in fact, are, under ])i'oper restraint, capa- ble of the highest intellectual development in after-life. Eclampsia may be a symptom of lithfemia. In this connection the fol- lowing abstract of a case reported by Irving Snow to the American Pediatric Society in 1893 is of interest. This case was reported under the title “ Ga.s- tric Neurosis in Childhood,” and the clinical history of this child conforms in almost every particular to the gastro-intestinal form of lithaemia above described. The lithmmic attacks from which this child suffered commenced when it was nineteen months old. The most characteristic symptom of these attacks was the initial convuhmi. This was followed by from three to five days of fever and vomiting, and then rapid convalescence supervened. These spells were periodic ; they came and went without apparent cause at intervals of a few weeks. Convulsions continued to mark the onset of the attacks until the child was four years old, when the convulsions ceased, but otherwise the attacks were unchanged, except that they were more frequent and possibly more severe. After the cessation of the convulsions the attacks were characterized by “vomiting, fever, hypersecretion, and irritability of the stomach, which were independent of dietetic errors or of organic disease.” Follow'ing the report of this ca.se, similar cases were reported by Holt, Christopher, Rotch, Seibert, Forchheimer, and CailR, and the opinion was a common one that these cases were very frequently observed in practice, but that their etiology was obscure and their classification uncertain. I have here introduced the abstract of this case and the discussion which followed for the purpose of emphasizing the fact that eclampsia is not uncommonly associated with other well-marked lithaemic symptoms. I desire to emphasize this clinical relationship, since my laboratory experiments have demonstrated that eclampsia may be a symptom of lithaemia. The fact of greatest import- ance pertaining to lithaemic eclampsia is that these convulsions may continue to recur till finally we may have established the type of epilepsy which has been described as migrainous epilepsy. Migraine is one of the most common, as well as one of the most charac- teristic, symptoms of lithaemia in adult life, and it is but slightly less im- portant as a manifestation of this condition in childhood. These paroxysmal and commonly unilateral headaches occur at more or loss regular intervals without apj)arent cause ; they are sometimes as.‘re- cij)itating lithmmic j)aroxysms. If eye-strain exists, it should be corrected. If pelvic or rectal disease be present, it should be treated. In short, all rellex factors should, if ])ossible, bo removed before other treatment is com- menced. While I am coTivinced that the rcHex factors have had undue prominence given them in the study and treatment of litluemic j)aroxysms, yet I am not pessimistic enough to believe that they should be disregarded in the treatment of these conditions. Pelvic disease, 1 think, es])ccially de- mands treatment Avhen it occurs in cases where the lithmmic paroxysms coin- cide with the menstrual ])eriod. The failure of medicinal and dietetic treat- ment to cure certain lithmmic paroxysms may sometimes be due to the fact that there is present some eye, preputial, or ])elvic disease which continues to act as a potent rellex factor in calling forth these paroxysms. LITH^MIA. 101 The medicinal treatment of lithaemia should aim to cure constipation and to favor the elimination and promote the oxidation of the alloxuric bodies which are believed to be the rnateries morbi of this affection. In infants and children it may advantageously be begun with small doses of calomel and soda repeated at short intervals until catharsis begins. After a day or two of rest from medication our little patients may be given some form of elimi- native treatment. Volumes have been written on the drugs which are given for the purpose of eliminating the poisons of lithmmia, and there always has 'been, and possibly will be for some time to come, much confusion as to their comparative value. It is my belief that the salts of salicylic acid are the most valuable eliminative medicines we have. After the preliminary calomel course it is my custom to order some salicylate, the one selected depending upon the age of the child and the nature of the symptoms. Salol is especially useful. I have seen lithmmic infants suffering from chronic intestinal fermentation with gastric crises very much benefited by one grain of this drug after each nursing. Other antiseptics will not accomplish the same result, and it is not, therefore, simply a question of intestinal antiseptics. The salol in these cases must be continued for weeks or months in doses to suit the age of the child. If the lithiiemic manifestation be an eczema, salol is equally advantageous; in such cases I also commonly give a few grains of phosphate of sodium or benzoate of lithium dissolved in each portion of food. An infant two years of age may be given in this way twenty grains of the phosphate of sodium and three grains of the benzoate of lithium in twenty-four hours. In a word, salol, phosphate of sodium, and benzoate of lithium are the medicines usually relied upon in the treatment of infantile lithsemia. and great good can be accom- plished by their intelligent use in connection with such dietetic, hygienic, or local treatment as the special manifestations suggest. Should the phosphate of sodium fail to regulate the bowels (almost all of these cases are constipated), it becomes absolutely necessary to supplement this treatment with a laxative which will evacuate the upper intestine. Enemas and suppositories may be used as assistants to other laxatives, but they are not to be relied upon exclu- sively. I wish here to especially insi.st that this laxative treatment is as absolutely necessary in the lithmmia of infants and children as it is in adults. Salicylate of sodium may be advantageously substituted for salol in children over five or six years of age. The salicylate of sodium derived from winter- green is preferable, because it is more palatable and less irritating to the gastric mucous membrane. It should, if possible, be given in a little Seltzer water, which may for convenience be obtained in si])hon. The siphon of Seltzer should be kept in a cool place, and the water may be drawn into a glass con- taining the dose of salicylate. In this way it is possible to give the drug for an indefinite time without disgusting the palate or irritating the stomach. While the salicylates are our best remedies in all forms of litbmmia, the salts of lithium are also of value in certain manifestations of the disease. The natural lithia waters may be used, and it is much in their favor that these waters are tasteless, and therefore readily taken by infants and children. ]\Iuch of their efficacy, however, is due to the water itself rather than to the lithia it contains. Many lithsemic patients drink little, and will be greatly benefited by simply increasing the quantity of liquid taken in twenty-four hours. Mention has previously been made of the importance of giving newly-born infants water to drink, since it is often needed to dissolve and thereby favor the excretion of urates that might otherwise irritate the inflamed urinary passages. For the same reasons lithsemic patients of all ages are benefited by drinking water, and much of the benefit derived 102 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. from drinking sulphur and other waters at the springs comes from the large quantity of liquid taken, rather than the contained medicinal agent. Yet in giving full credit to water as a remedy one must not overlook the fact that many natural waters contain salts — lithia, for example — that are of real value in the treatment of lithEemia. Of the lithia salts, the benzoate and citrate are much to be preferred, and I would select the benzoate, as it gives the best results. For infants the dose is gr. ss-j three times a day dissolved in milk ; to older children it may be given in tablet form or dissolved in water. The citrate of lithium is somewhat less efficient, but more palatable, than the benzoate. The soda salts are of great value in the treatment of litluemia, and the mineral waters which are composed largely of these salts — such, for example, as Carlsbad — have a well-deserved reputation. The following prescription has long been a favorite with me for older children and adults : Sodii salicylatis (from wintergreen) . . . Sij ; Sodii phosphat., dry .^iv ; Sodii sulphat., dry 5iss. — M. Sig. A teaspoonful, more or less, in a small glass of Seltzer water before breakfast every morning or every second morning. It is important that dry salts be used in this prescription. The dose is to be regulated by the cathartic effect. Violent daily catharsis is not to be desired, but a decided laxative effect must be produced. In connection with this treatment I commonly use one of the following prescriptions : First: A one-grain salol-coated pill of permanganate of potash (Upjohn), which is to be given directly after each meal to all lithfemic patients having pronounced gastro-intestinal symptoms. (Sick headache and the gastro- enteric types of lithaemia belong to this class.) Second : A ca])sule containing from two and a half to five grains of salol and from one-twelfth to one-cpiarter grain of cannabis Indica, which is to be given after each meal to all patients in whom the lithaemic paroxysms are not associated with gastro-enteric symptoms. (Migrainous neuralgia and lithmmic epilepsy belong to this class.) These prescrij)tions are to be used in connection with the soda salts, and are especially adaj)ted for the treatment of lithaemia in late childhood and adult life. They are not suited to young children or to frail and wasted lithaemics of any age. Dilute nitro-muriatic acid and colchicum have long held a place among medicines which are of value in the treatment of litlnemia. Doth may be given to older children and adults, but are not to be employed in iiifants and young children. The dilute nitro-muriatic acid in five-droj) doses, well diluted, before meals, is a valuable remedy in the treatment of litluemic headaches in older children. The wine of colchicum in five- to eight-drop doses may be tried for the relief of jiainful litluemic ])aroxysms of any kind. P’or stout and vigorous patients the natural Avaters are of great value, especially those of the thermo-alkaline springs of Virginia and Arkansas and waters of the Carlsbad type. The Bedford Springs of Bennsylvaina, the Crab Orchard Springs of Kentucky, the St. Clair and Mount Clemens Springs of Michigan, the Saratoga Springs of Ncav York, and the West Baden and French Lick Springs of Indiana may also be recommended. HEREDITARY SYPHILIS. By henry DWIGHT CHAPIN, M. D., New York. No period of life is exempt from syphilis, which has been aptly styled “the least venereal of the venereal diseases.” It is a -chronic infectious pro- cess, doubtless of microbic origin, the ravages of which are modified by age, conditions of body, and envii’onment. The micro-organism most commonly associated with syphilis as a probable causative agent has been found by Lust- garten within the cellular protoplasm of syphilitic products. He describes it as a bacillus from three to seven micro-millimetres in length, with often a slightly wavy shape. Unfortunately, pure cultures have not been made of this bacillus, and the fact that the lower animals do not contract syphilis pre- vents the possibility of proof by inoculation. Syphilis in early life may be either hereditary or acquired. It is not neces- sary to consider acquired syphilis at length in a w-ork devoted to diseases of children, as it presents no essential differences from the same affection in adult life. It may be well to bear in mind, however, that syphilis detected in infancy is not necessarily inherited, but may be acquired. A primary sore upon the genital tract of the mother may infect the infant during birth, though the possibility of this has been denied. The nurse or attendant may have a primary lesion upon breast or lips. Much more common will be infection from some secondary lesion, especially a mucous patch upon the mouth or lips. There are many ways in which the blood or infective secretions of a syphilitic patient may come in contact with a solution of continuity in the skin or mucous membranes of an infant or child. In such a case a chancre will appear at the point of contact, followed in due time by the after-lesions of the disease. There are certain peculiarities in the effect of the syphilitic virus upon young proto- plasm which will be noted under the Morhid Anatomy. The subject will be here considered under the two heads of hereditary syphilis in infancy, and the taint as it is seen in childhood or when appar- ently delayed. Hereditary Syphilis in Infancy. The disease may be acquired from the father or mother, or from both parents, the poison being lodged in the spermatozoa of the male or the ovum of the female. Paternal Influence. — While it has been denied by some observers that the father alone can transmit syphilis, the consensus of opinion is in favor of the possibility of such transmission, which can and does take place. The chances of this transmission depend upon certain factors, such as the stage of the disease and the degree of its intensity, as well as the thoroughness with which treatment has been followed. Without mercurial treatment the sperma- 10.3 104 A 31 ERICA N TEXT-BOOK OF BISEASER OF CHILDREN. tozoa can usually transmit the syphilitic poison during the first year after pri- mary infection, and there is great danger to the foetus from syphilitic contagion up to the fourth year. The longer the duration of the disease, the less will he the danger to the offspring, owing to the periods of latency observed during its later stages. If the father be subjected to eaidy and thorough treatment, the probability of transmission of the disease will be much lessened, and such a possibility soon becomes lost with a reasonable lapse of time. If the father infect the mother, as frequently happens, there will be a double syphilization of the offspring, which will pi’obably be stillborn or soon succumb to an aggra- vated form of the disease.* Maternal Influence. — The influence of the mother upon the growth and development of the foetus contained within her uterus is. obviously very great, and hence when she is suffering from constitutional syphilis the disease is transmitted in an active stage to her child. The degree of such transmission depends, as noted above in the case of the father, upon the stage and severity of the disease and the nature of the treatment employed. During periods of latency the mother may bear healthy children, followed by abortions or syphi- litic infants caused by renewed manifestations of the disease. It has been con- sidered that the power of transmission is practically lost at the end of six years. As a general rule, it can be stated that the chances of infection of the foetus and the severity of the type, if infected, are in direct proportion to the activity of the syphilis in either or both parents. It has been said that if the mother contract syphilis before the eighth month of utero-gestation, she may transmit the disease to the foetus, although healthy at the time of conception. Dr. Taylor, on the contrary, denies that the syj)hilis of the mother, accjuired during pregnancy, can be conveyed to the foetus through the utero-placental circulation, as the disease is only communicated either by the sperm-cells or by the ovule diseased at the time of conception. One of the peculiar phenomena seen in connection with infants who are born syphilitic is that the mother may apparently be free from any taint of the disease. It has been a subject of much dispute whether these are instances of latent syj)hilis or whether the women are really healthy. Whatever the cause, these cases show immunity in contracting syphilis. In 1837, Colles wrote that “a new-born child afiected with inherited syphi- lis, even although it may have symptoms in the mouth, never causes ulceration of the breast which it sucks if it be the mother who suckles it, although con- tinuing capable of infecting a strange nurse.” The substantial truth of this dictum has not been seriously questioned during the many years that have elapsed since its enunciation, although varying explanations have been offered. Fourtiier states that the irioculation experiments of Caspari and Neumann have proved conclusively that the appai-ent immunity of the mother, Avho has borne a child syphilitic by its father, against the contraction of the disease from her offspring, is due to the fact that she has already been infected by syphilis dur- ing the intra-uterine period of the child’s life. Thus, conceptional syphilis is to be classed with the hereditary form of the disease, since there is here no ]>ri- mary lesion. This form of conceptional syjihilis may remain latent for years. Diday advances as an explanation of Colics’ law the ideatlnat all infectious dis- eases may certainly be mitigated to the ])oint of absolute protection by the methodically repeated inoculation of their essential cause (microbic) or of its products (toxic ptomaines, etc.), lloiichard considers that while the fix'tus retains the supposed pathogenic agent itself, the jiroducts dissolved in the blood find their way to the tissues of the mother and set up a nutritive change, ' Dr. F. K. Sturgis strongly denies the paternal transmission of .syphilis. HEREDITARY SYPHILIS. 105 resulting in what he calls a “bactericidal condition,” which renders difficult or impossible the development of the infectious agent when introduced by later inoculation, as from the lips of her child. The doctrine of syphilis being con- tracted by conception, sometimes called “choc en retour,” although having wide acceptance, is not acknowledged by all. Kassowitz believes that the women who appear healthy and remain so, even after giving birth to syphilitic children, ai’e really free from specific taint. Syphilis of the Placenta. — Dr. Frankel in 1873 published a paper in which he affirmed the existence of three forms of involvement of the placenta by syphili.s — i. e., endometritis decidualis, endometritis placentaris, and disease of the villous portion of the foetal placenta. This conclusion was based upon an examination of over one hundred placentae. Zilles in 1885 published the results of a study of three hundred placentae derived from Prof. Saxinger’s obstetrical clinic. He finds that placental syphilis can often be diagnosed microscopically, and that it oftenest happens in connection with foetal syphilis. The maternal portion of the placenta or the foetal part only may be affected, while, again, the whole of the placenta may be involved in the disease. Syphi- lis is one of the recognized causes of hydramnios. Morbid Anatomy. — The lesions of syphilis, while always essentially the same, will nevertheless be modified by age. Young protoplasm is active, and usually exhibits a marked reaction to irritative processes, so that the tissues are apt to be extensively involved in hereditary syphilis. The lesions may be broadly divided into those involving the skin and mucous membranes, the vis- cera, and the bones. Skin and Mucous Membranes. — The skin may be affected by erythema, maculo-papules, or papules. A vesicular and pustular eruption may occasion- ally be seen. Blebs or bullm often appear at birth in a severe type of the disease. Crops of boils, with well-defined, coppery-red bases, are apt to be symmetrically arranged when many are present, or asymmetrically distributed if only a few are seen. The distribution and course of the various eruptions will be noted more at length under Symptoms. In general, they develop quickly and spread over extensive areas of surface on account of the character of infant protoplasm, noted above, as well as from the activity of the circula- tion in the skin. The lesions of the mucous membranes may be in the form of catarrhal pro- cesses, of mucous patches, or of superficial or deep ulcerations. Any or all of these lesions may involve any part of the alimentary tract or of the respiratory tract. They are seen most commonly, however, in the upper part of these areas, in some part of the mouth or fauces in the former case, and in the nose and larynx in the latter. Still, they may likewise occasionally involve the intestine or trachea and bronchial tubes. Visceral Lesions. — The viscera are apt to be more extensively involved in hereditary than in acquired syphilis, the lesion being in the form of an inter- stitial hyperplasia more or less diffuse. Circumscribed gummy infiltrations are not so frequent. The growth of interstitial connective tissue, which grad- ually contracts, thereby partially obliterating the parenchyma of the organ, may involve the lungs, spleen, liver, pancreas, and testicle. Lungs . — Usually a portion of a lobe, but occasionally a whole lobe, may present a diffuse fibroid infiltration. The part involved is grayish-white in color and tough in consistency, and surrounded by an infiamed pleura. Linder the microscope there is seen to be thickening of the septa and compression of the alveoli by fibrous tissue, which is quite vascular. Occasionally a few rounded masses about the size of a hickory-nut may be noted. These gum- 106 AMERICAN TEXT-BOOK OE DISEASES OE CHILDREN. mata may break down in the centre into puriform matter, but they are not apt to exist in the same subject that the diffuse interstitial inflammation attacks. Spleen . — The spleen is generally more or less enlarged from a diffuse inter- stitial hyperplasia. There usually coexists a thickening of the capsule. Accord- ing to L)r. Gee, the severer the grade of syphilis the greater will be the hyper- trophy of the spleen. This enlargement may remain persistent for a long time after other symptoms have disappeared. Liver . — The liver, which is not infrequently affected, is hardened and enlarged from a diffused sclerosis. Occasionally the affection may be circum- scribed. The hepatic cells are compressed and the capillary blood-vessels partly obliterated by the pressure. As in cirrhosis in the adult, section of the liver is accompanied by creaking, and the cut surface presents a yellowish area, interwoven with whitish opaque streaks of fibro-plastic matter. The capsule of Glisson may be thickened upon the surface of the liver, and there may be local peritonitis. Gummata, in the form of small, circumscribed nodules, may be found in the tissue of the liver. They may be seen in association with cir- rhosis. These nodules are yellowish, with a tendency to soften in the centre. Pancreas. — Bii’ch-IIirschfeld has called attention to the fact that there may be hyperplasia of the connective tissue of the pancreas, which on section pre- sents the same fibroid appearance seen in the liver and other visceral organs thus affected. He found in a few cases the head of tlie organ more involved than the remaining part of the gland. Testicles . — An interstitial orchitis may affect one or both testicles, produ- cing hardening and slight enlargement of the glands. The hyperplasia may be uniformly distributed through the organ, or the latter may be irregularly involved. The epididymis is not usually affected. Atrophy of the seminal ducts may ensue. Sufficient change in the testicle to be detected clinically is not often seen in hereditary syphilis. Kidneys . — PaiTot has found small tumors, produced by infiltrations of round cells into the connective-tissue stroma, which com}>ress the tubules, and thus cause a colloid degeneration of the contained epithelium. If this process is extensive, it will eventuate in a general atrophy of the kidney. General nephritis may be seen in hereditary syphilis, hut it is difficult to say whether the latter is more than a predisposing cause of the former condition. Heart . — Gummata may be found in the heart. l)r. Coupland has rej)orted a case where the walls of this organ Avere thickened and hardened. Bone Lesions. — Wahlemeyer, Kbbner, Parrot, and B. W. Taylor have shown that various bony lesions are quite common in hereditary syphilis. Many of these lesions, that were formerly referred to rickets or scrofula, are now recognized as syphilitic. There are two principal Avays in Avhich tlie S])c- cific poison affects the bones in early life. In one instance the brunt of the disease and morbid change takes place at the junction of the shaft Avilh the epiphysis ; in the other, the periosteum covering the long bones is j)rineipally affected. Both of these varieties involve j)rincipally tlie long bones. Osteo-chondritis . — This inffammatory process is induced only liy syphilis, and may be the sole manifestation of the taint. Tlie lesion starts in the car- tilage joining the epiphysis Avith the diaphysis, Avhere normal groAVth in length of the bones takes place; hence deformity of the bone, due to a crijipliiig of its proper development, may ensue. The lesion most commonly affects the bones of the forearm, leg, arm, and thigh, although other bones may be involved, such as the metacarpal and metatarsal bones, the clavicle, sternum, and ribs. The number of the bones affected ajipears to depend, to a certain extent. HEREDITARY SYPHILIS. 107 upon the severity of the general poisoning. It has been found in stillborn infants that most of the long bones may be thus affected, and in those born living, if the bone lesion is multiple, recovery is uncommon. The cartilage affected first becomes thickened and soft from proliferation of cartilage-cells, and there is at the same time lessening of the intercellular substance. This may be felt as a sort of collar-like swelling at the end of the bone affected. The swelling may be visible if the child is not too fat. . If, as occasionally happens, one portion or side of the cartilage only is involved, the swelling will be felt not to completely encircle the bone, but as a circumscribed nodule. The disease is apt to be symmetrical and involve the distal oftener than the proximal ends of the bones. There is little change in the integument or sur- rounding tissues in many cases, as the disease is not apt to extend farther than the bone. In such a case the swelling may remain for a long time, accom- panied by little pain or disability. It may originally develop slowly or quickly, and its disappearance will usually promptly follow a proper mercurial treatment. In some cases, howevei’, degenerative changes may ensue, with a breaking down of some part of the swelling. If the morbid process continues, there will be softening, soon followed by ulceration of the skin. If suppuration keeps up, the cartilage will be desti’oyed and the epiphysis completely sepa- rated from the diaphysis. Even in these cases the joint is not apt to be involved, although cases of subacute synovitis, and even pus in the joint, have been reported. If the ulceration is extensive, the epi])hysis, when completely sepai’ated, may be extruded. When there is destruction of the cartilage and epiphysis, there will of course ensue ari’est of growth and consequent deformity in the limb. Parrot has descril)ed cases in which the skin remains unbroken after separation of the epiphysis, inducing a condition of paralysis in the affected part. Dr. Taylor describes cases in which, the intervening cartilage having been destroyed, the epiphysis is united to the shaft only by fibres of periosteum. This membrane may become much thickened, and form a more or less complete cylinder, uniting the two fragments with considerable firm- ness. Bony spiculm shoot from its inner surface between tlie two osseous sur- faces, and thus eventually bony union is secured. The SAvollen periosteum may gradually resume a more nearly normal thickness. Osteo-chondritis develops early in life, usually within the first month. The lesion may, however, occur later, when it is not apt to become multiple, and may be unsymmetrical in distribution. The question as to Avhether certain epiphyseal swellings may be due to syphilis or rickets will possibly arise. Other lesions of these two diseases will have to be sought after in order to aid in making a correct diagnosis. Such swellings are pretty surely syphilitic if they occur during the first six months of life, and at all times are relieved by mercurial treatment. Again, the epiphyseal swellings of rickets are always symmetrical, while those of syphilis may be unilateral. Periostitis . — This form of lesion occurs later in hereditary syphilis, usually after the child has begun to walk. It attacks by preference the femur, tibia, and bones of the forearm, occurring usually from the second to the fourth or fifth year. There is more or less enlargement of the affected bone. At an early stage of the disease the bones are attacked symmetrically, but later cir- cumscribed nodes may be placed unilaterally. Dacti/litis . — The phalanges and the metacarpal and metatarsal bones may be enlarged to several times their natural size. After an interval of time the skin may become inflamed and break down from the formation of an abscess. The proximal phalanges are more apt to be attacked than the distal, and sev- eral bones of each hand may be affected. There is not much destruction of 108 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN bone, even in severe cases, and, although the disease tends to run a slow course, it is always influenced favorably by treatment. Dactylitis is apt to occur in very young subjects, when it takes the form of a gummatous infiltration. (Fig. 1). Fig. 1. Syphilitic Dactylitis. Craniotahes . — The local thinning of portions of the cranial bones was formerly attributed exclusively to rickets, hut is now known to ensue as well in the malnutrition accompanying sy])hilis. As it is due to pressure of the thin skull between the brain and ]>illow, it is especially apt to involve the occipital bone. Carpenter considers that both craniotahes and Parrot’s nodes are often syphilitic manifestations, although they are more frequently regarded as evidences of rickets: 74 per cent, of bases of craniotahes are syphilitic, according to this author. Symptoms. — The symptoms of hereditary syphilis vary widely according to the extent of the poison. When the virus is conccntrateil, as in cases where both parents are syjihilitic, the foetus will be attacked by the disease in the uterus, and, as a result, we shall have abortion more or less early in the preg- nancy. As the disease abates in one or both parents the pregnancies will be longer in duration, until finally a])j)arently healthy infants may be born. In some cases the infant will present marked evidences of sy)>hilis at birth : often, however, the onset is delayed until later, and at birth there may be absolutely no manifestation of the disease. In IflS cases analyzed by Diday the first manifestation of symptoms occurred iii 80 cases before the completion of one month ; in dO before the completion of two months ; and in 15 before the completion of three months after birth. The remaining 12 cases showed the symptoms in intervals varying from four months to two years. The earlier the disease manifests itself after birth, the graver will he the nature of the attack. Very early syphilis is usually accompanied by emacia- HEREDITA RY 8 YPHILIS. 109 tion, eruptions of bullae, particularly upon the palms of the hands and soles of the feet, and an extreme degree of coryza, cracked and ulcerated lips, and evi- dences of visceral and bony disease. In the older cases there may be no interference with nutrition, and possibly one or two mucous patches may he the only active manifestation of the disease. In studying the symptoms it may be well to consider the disease as it shows itself in different structures and areas of the body. Skin . — One of the early symptoms appearing upon the skin will be the eruption of small round pink spots, disappearing on pressure, and usually appearing first on the lower portion of the abdomen. It may spread from this location and finally involve the whole body. Pigmentation of these spots may ensue, and they may present a dark-red, coppery discoloration. This latter change may be considered as having a diagnostic value. In hereditaiy syph- ilis the rashes often develop rapidly, and are apt to be less symmetrical than those seen in adults. They are likewise polymorphous, as several different forms of syphilide may be exhibited at the same time in a given case. A pap- ular syphilide may be seen in the form of small or large flat papules, symmetri- cally distributed over the surface. These papules are not so apt to group them- selves into lines and circles as in older subjects with syphilis. They are not so solid and deeply infiltrated as in the adult. Upon the palms and soles these papules may be very abundant and fuse together, presenting a thickened, dull- red surface. The vesicular syphilide is not common, and when seen is apt to be in very severe cases. The vesicles may be associated with pustules, and appear in closely-arranged groups about the mouth or chin or various other parts of the body, -especially the nates and hypogastrium. Pustules may form, especially on the face, buttocks, and thighs. The ulceration is deeper and the crusts darker in color than in impetiginous eczema. Pemphigus likewise appears in the severe forms of the disease. It most frequently attacks the palms of the hands and soles of the feet ; it may have a copper-colored areola and develop rapidly. Crops of indolent boils, symmetrically distributed and of a copper-red color, may appear in connection with other eruptions. They are more apt to be seen in badly-nourished infants. In some cases the only appear- ance of syphilis upon the skin will be a smoky discoloration, seen most dis- tinctly in the prominent parts of the face, such as the eyebrows, cheek-bones, and bridge of the nose. The nutrition of the skin is much affected in cases where the cachexia is marked ; it hangs in dry, loose folds, having an unhealthy, earthy appearance. Mucous Membranes . — The mucous membranes, as well as the skin, present the earliest manifestations of the disease. One of the most typical lesions is the coryza, which may be the first symptom noted. First, there may be a serous discharge which attracts little notice ; this, however, gradually becomes worse, and the nasal secretion takes on a purulent or even a bloody character, and may be sufficiently irritating to cause excoriations of the upper lip. The mucous membrane itself becomes thickened, and the inspissated secretion soon dries, forming crusts, which may completely block up the passage through the nostrils and seriously interfere with nursing. The secretion may likewise be offensive. In severe cases, particularly where cleanliness is not practised and the decomposing secretions are alloAved to remain in the nostril, there may fol- low ulceration of the mucous membrane, and possibly even necrosis of the adjacent bony parts. There is apt to be a flattening of the bridge of the nose, probably, to a certain extent, due to the interference with normal respi- ration. The inflammation may spread to the pharynx and larynx, although its action is likely to be limited to the Schneiderian membrane. no AMERICAN TEXT-BOOK OF DmEABES OF CHILDREN. Mucous patches will be seen in most cases of hereditary syphilis, and, although they appear most constantly on the mucous membranes, they may be present upon the skin, particularly at its junction with the mucous membranes, or upon those parts which are thin and exposed to various secretions. They may occasionally be seen on any part of the cutaneous surface of the body. They are oftenest seen in the mouth, about the nose, upon the scrotum, vulva, labial commissures, and occasionally at the umbil- icus. In the mouth the most frequent situations are upon the angles of the lips, inside of the cheeks, the pillars of the fauces, the tonsils, and the sides and dorsum of the tongue. They consist, in the early stage, of a slightly raised segment of mucous membrane, presenting a whitish surface and red margins. This may soon ulcerate. When the mucous patches appear at the angles of the mouth, deep fissures will often form at the corners of the lips, extending sometimes well out into the cheek. These fissures are sometimes called rhagades, and are diagnostic. The secretions on these mucous patches are very infective. When mucous patches appear on the cutaneous surface, they are slightly raised, with a macerated .appearance, and frequently seamed with erosions or cracks. In the late stages of hereditary syphilis mucous patches are not so numerous as in the earlier stages of the disease, but they frequently recur after the child is apparently restored to health. Disturbance of Nutritio7i . — The extent to which the general nutrition of the infant is disturbed will depend upon the severity of the attack. In grave cases there is atrophy of all the structures of the body, the infant presenting a weazen appearance, with a countenance resembling that of an old man. These cases are almost invariably fatal, and are caused by the blighting influence of the virus. In many cases, however, a failure of nutrition will ensue gradually, consecutive to gastro-intestinal disturbance. This may be due to actual specific disease of the liver, stomach, or intestines, or it may be due to indigestion and malassimilation only indirectly caused by feebleness from the cachexia. In bottle-fed babies digestive disturbances are marked and severe, infants upon the breast being much less liable to suffer. In some cases the infant will present very slight disturbance of the general nutrition, being plump and well-nourished throughout the course of the disease, which may be only manifested by mucous patches or mild evidences of the infection. Condition of the Blood . — A condition of profound anmmia is frequently seen, particulaidy in severe cases. Johann Loos states that hereditary syphilis is always associated with an anaemia which under some conditions may reach an extreme degree of intensity. This anaemia is characterized by a diminution in the number of the red blood-corpuscles, by quite a marked alteration in these corpuscles, the appearance of megalocytes and microcytes, and by the appear- ance of nucleated erythrocytes, sometimes in quite notable (juantity. It is always characterized by tbe constant existence of leucocytosis, Avhich may often become extreme, and by the appearance of myelo-placjues in the blood. This anaemia is a very important and significant symptom of the disease, and may directly occasion a fatal issue. He further states that there are only two diseases common to childhood in which the lesions of the blood suggest the changes just described, and these are splenic anaemia and severe forms of rachitis. A form of syphilis luemorrhagica neonatorum has been described by Bumstead and Taylor. There may be simply a limited subcutaneous effusion, or the mucous membranes may be the seat of the luemorrhage. Haemorrhage at the umbilicus shortly after birth may be due to this cause. Glandular Enlargements . — General adenopathy is not seen in the hereditary HEREDITARY SYPHILIS. Ill form of sypliilis. There may be enlargement of the chains of cervical glands consecutive to lesions in the adjacent mucous membranes, and occasionally there may be an affection of the inguinal, axillary, or cervico-maxillary glands without any deeper lesions being noted to account for their existence by septic absorption. The glands are hard, moving without pain in the areolar tissue under pressure by the finger. Some writers consider that enlargement of the epitrochlear glands is pathognomonic of congenital syphilis, but well- marked cases occasionally fail to show this sign upon careful examination. Boyiy Organs . — The fre(;[uency with which the bones are involved in hereditary syphilis has been noted in the morbid anatomy of the disease. In every case the long bones should be carefully examined for enlargement and thickening at the epiphyseal and distal ends. In cases where suppuration has taken place the epiphysis may be separated from the shaft, and crepitation will then be found upon careful handling. The joint itself may occasionally be involved in the inflammation, showing the well-known symptoms of arthritis. Where the bones are much affected there will be some disability of the limb, possibly extending to complete paralysis. Immobility in such a case is with- out doubt due to the affection of the bones. Dactylitis . — In the early period of the disease an enlargement of the phalanges is frequently seen, and occasionally also of the metatarsal and metacarpal bones. The proximal phalanx is more frequently attacked than the distal ; the affestion may spread to all of the phalanges, but is more apt to involve only one, which may be enlarged to double its normal size. This enlargement is the I'esult of specific inflammation of the bone and periosteum, and runs a slow course unless modified by specific treatment. There is not apt to be much involvement of the soft parts ; the integument will be reddish and inflamed, but there is little tendency to suppuration and ulceration. These swellings usually present a fusiform shape, 'with a hard, firm sensation to the touch. Teeth . — The appearance of the deciduous teeth is delayed in hereditary syphilis, as in rachitis. The first teeth may not appear until the tenth or tw’elfth month, or even later. These teeth are poorly developed and apt to undergo early decay. There is usually a similar delay 1ti the ajipearance of the second teeth, which present more pathognomonic changes, which will be noted in connection with late hereditary syphilis. Nervous Disturbances . — Lesions of the nerve-centres do not often appear in hereditary syphilis ; there may be, however, an occasional palsy due to a periphei’al cause. One form in connection with bony lesions has already been mentioned. There may be contractures and paresis, however, where no bony lesion can be noted. Henoch (juestions whether such affections may not be myopathic in their origin and independent of the nervous system. The following case coming under my observation illustrates a case of paralysis evidently caused by interstitial syphilitic myositis: An infant four weeks old, whose mother presented syphilitic lesions, was born healthy at full term. When seven days old it was noticed that the right leg was drawn up and apparently did not move ; also the right arm. There was complete loss of power in these members ; there was wrist-drop, and a loss of faradic and galvanic irritability in the extensors of the left Avrist. The muscles affected were rather hard and painful to the touch. There was an enlargement at the epiphyseal end of the left humerus. The paralysis completely disappeared in about tAvo months under specific treatment. Dr. Eustace Smith states that a form of real paralysis has been occasionally seen affecting the branches of the brachial plexus, causing more or less com- plete loss of power in the arm. 112 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Onychia . — Two kinds of onychia are noted in hereditary syphilis — the ulcerative and the nutritive. In the ulcerative form the pustule appears at the margin of the nail, which soon breaks down, leaving a sloughy surface, which may destroy the matrix. The surrounding skin presents a coppery discoloration. In the nutritive form, which is apt to appear later, the ulcer has a sloughy base, and presents a swelling around the periphery of the nail, which becomes thickened and brittle. Swelling and deformity of the phalanx may ensue. In a case recently observed, a child of two years, whose father had a specific history, presented immense bulbous masses upon the extremities of the thumb and middle finger of the right hand and the thumb and fore finger of the left hand. These were granular, warty masses about the size of hickory-nuts, with the nail protruding backward. When the infant was eight months old it appeared healthy, except that the finger-nails now involved Avere like claws and were reddened as if scalded. The trouble had continued until the nutritive changes produced the enlarged mass here noted. There had been a history of “snufiles,” abscesses on the buttocks, sore lips and gums, but at the time of the examination the only other manifestation of the disease was a large mucous patch in front of the scrotum. In the nutritive form of onychia the hypersemia of the matrix and the deformity of the phalanx, if not extreme, may disappear under specific treatment. Iritis . — This is an exceedingly rare affection in hereditary syphilis, but cases have been reported by Mr. Ilutchinson in infants varying in age from six Aveeks to sixteen months. It does not difier from the same manifestation in adults. Alopecia . — There may be loss of hair in the scalp, eyebrows, or eyelashes. The last form is the most pathognomonic, as there may be a deficiency in the nourishment of the hair of the scalp in rickets or any condition of cachexia in infants. General Irritability . — Syphilitic infants are very fretful, and the cry is of a peculiar high-pitched character. This fretfulness is particularly a])t to be present at night, at Avhich time the child is extremely Avakeful. In this, Iioaa'- ever, it does not differ much from rickets. Diagnosis. — A difficulty in the diagnosis of hereditary syphilis may obtain Avhere typical lesions are not Avell marked, or Avhere it is a question betAveen syphilis and scrofulous or tubercular lesions. In cases of marasmus, if there is no history of chronic indigestion, j)articularly if the infant have been fed at the breast, there is strong suspicion of syphilis. A careful examination for mucous patches Avill often throAV light on such a case. Chronic coryza is likeAvise a valuable sign in diagnosis. The following points of distinction betAveen .syjdiilitic and scrofulous lesions of the skin have been given by Dr. P. A. MorroAV : (1) Syphilitic lesions are general in their distribution ; they may occur ui)on any region of the body. Scrofulous lesions are more limited in their localization ; they have a special pi’cdilection for the neck or regions rich in lymphatic glands. (2) Syphilitic lesions are ambulatory and changing ; they disappciir and rea])pear clscAvliere. Scrofulous lesions are fixed ajid ])ermanent. (d) The color of sy]diilitic lesions is reddish-brown or “ lean-hani ” tint. The color of scrofulous lesions is brighter and more violaceous in hue. (4) Syphilis is distinct from scroiula in its objective appearances and mode of evolution. In the initial stage the syphilitic neoplasms are firm and hard; the scrofulous infiltrations are .softer and inore compressible. In the ulcerative stage the differences are more ])ronouiiceil ; the ulcers of syjihilis are cleaner cut, regular in contour, Avith perpendicular, firmly-infiltrated borders encircled by a pigmented areola ; HE RED IT A R Y S YRIIILIS. 113 scrofulous ulcers are irregular, with soft, undermined borders ; they are painless, bleed easily, and show slight tendency to spread. (5) The crusts of syphilis are bulkier, thicker, with a tendency to accumulate in layers, and darker in color ; the cicatrices are smooth and remain long surrounded by a pigmented areola. The crusts of sci’ofula are softer, more adherent; the cicatrices are elevated, irregular, biddled ; they retain their violaceous color for a long time. (6) The course of a syphilitic ulcer, though sluggish and chronic, is much more rapid than that of scrofula. (7) Absence of pain and local reaction characterize both syphilitic and scrofulous ulcers ; they are essentially lesions without symptoms. In connection with the bony lesions it is important to diagnose between syphilis and tubercular and rachitic affections. The folloAving points in diagnosis between syphilis and tuberculosis are given by Dr. Moitow : (1) Syphilis ex- hibits a marked predilection for the long bones ; its habitual localization is in the diaphysis, and almost always at its terminal extremity. Tuberculosis is almost e.xclusively situated in the epiphyses, rarely affecting the shaft. (2) In syphilis there is a marked enlargement of the bone by more or less volumin- ous osseous tumors or hyperostoses, with little or no involvement of the soft parts ; and in tuberculosis the tumefaction is due less to increase in the size of the bone than to oedematous infiltration of the soft structures. (3) In syphilis there is little tendency to suppuration and necrosis ; in tuberculosis the pyogenic tendency is marked. (4) In syphilis osteocopic pains, with tendency to noc- turnal exacerbation, are a pronounced feature ; in tuberculosis the pain is dull and heavy, not aggravated at night ; sometimes there is entire absence of acute painful symptoms. (5) The osseous lesions of syphilis rarely react upon the general system, while those of tuberculosis often determine a marked impair- ment of the general health, grave complications, hectic fever, cachexia, etc. In syphilitic dactylitis there is little involvement of the soft parts, the swelling being caused by the enlargement in the size of the bone. In tuber- cular dactylitis the swelling is due more to an oedematous infiltrated condition of the soft tissues than to enlargement of the bone. In the latter cases breaking down of the tissues and ulceration are more apt to ensue. The diagnosis between syphilis and rickety bone-lesions may be of great importance. Epiphyseal swellings occurring under six months are very apt to be syphilitic. In syphilis the epiphyseal swelling may be unilateral, but it is always symmetrical in rachitis. In doubtful cases the swelling must be sub- jected to specific treatment. It is Avell to remember, however, that rickets and syphilis may coexist in the same case. There is almost invariably enlargement at the costo-chondral articulations in all cases of rickets, which is absent in syphilis. Prognosis. — According to Kassowitz, one-third of all syphilitic children die before their birth, and among those Avho are born 34 per cent, die in the first six months of life. Fournier places the mortality, when derived from the father alone, at 28 per cent. ; from the mother alone, 60 per cent. ; when from both parents, 68| per cent. The earlier the symptoms appear after birth, the severer will be the type of the disease and theAvorse the prognosis. Involve- ment of the bones and viscera means a severe type of the disease. Infants fed upon the breast will have a much better chance than those artificially fed. In bottle-fed infants, particularly when the disease appears early, the prognosis is almost always fatal ; it is invariably so in hospitals and lying-in institutions. Any interference with digestion and assimilation, no matter from what cause, will necessitate a guarded prognosis. If the coryza is extreme and breathing much disturbed, the prognosis must be altered in proportion to the amount of 8 114 AMERICAN TEXT-BOOK OE DISEASED OE CHILDREN such disturbance, wliicli interferes ■with rest and the taking of food. If the digestion remains good, and particularly Avhen the manifestations of the disease are not severe, complete recovery takes place, and the infant may grotv up healthy and strong. Late Hereditary Syphilis. In some cases of hereditary syphilis the manifestations of the disease during infancy may be exceedingly mild, and, in fact, overlooked. It is possible in such a case that the poison may show itself in various "ways during the period of childhood. “ Syijhilis tarda ” is a term applied to those cases in Avhich the first manifestations of hereditary syphilis appear in childhood. The existence of such a condition Avithout any earlier evidence of the disease has been dis- puted. It is analogous to the discussion as to Avhether syphilis in the adult may present late secondary or tertiary symptoms Avithout being preceded by earlier lesions. Late hereditary syphilis may manifest itself either in certain active lesions plainly to be attributed to this condition, or by certain developmental defects that may easily be confused Avith scrofula, tuberculosis, or rickets. It may be well for us to note some of the more characteristic lesions. Bone Affections. — One of the commonest manifestations is a periostitis involving various long bones, especially the tibia, the ulna, the radius, and the humerus. Accompanying this periostitis there may be considerable thick- ening upon the surface of the bone, sufficient to induce a change in its form. The lesion may be multiple and symmetrical, although occasionally unilateral. It is attended often Avith little discomfort aside from occasional nocturnal pains. The nasal liones may be affected, producing much deformity by destruc- tion of the bony arch of the nose. In many cases not so severe there is marked flattening of the bridge of the nose and a Avide separation of the eyes. The frontal bone is apt to be large and fiat, Avith prominences someAvhat exagger- ated. There is also usually a very high palate arch. Dactylitis may be seen in this late stage of the disease, and sluggish SAvellings of the meta- carpal and metatarsal bones. The secondary teeth are affected in a Avay that has been considered pathognomonic. As is Avell knoAvn, IMr. Jonathan Hutchinson first called attention to this condition. The principal change is noted in the tAvo superior middle incisors, Avhich are small, peg-shaj)ed, and placed at such an angle that the cutting borders, if continued, Avould meet. They may occasionally be deflected outAvard, as in the accompanying illustration. (Plate IV.) The cause of this maldevelopment has been ex])Iained by Four- nier as due to defective growth Avithin the alve<)lus, Avhilc Hutchinson refers it rather to an early stomatitis or an alveolar periostitis often present during infancy. The incisors are aj)t to be notched at the loAver edge, as is Avell shoAvn in the plate, Avhich is taken from a case under the care of Dr. StoAvell. The enamel is usually eaten arvay in this ])ortion of the teeth. Dr. John N. Mackenzie has called attention to ulceration of the palate, Avhich is apt to take place in the centre, and be folloAved by caries or necrosis of the bone. There may be simultaneous or consecutive deep ulceration of the palate, pharynx, and naso-pharynx at anytime previous to the age of puberty. Large and indolent mucous ])atchcs may be present upon the cheek, tongue, gums, and especially about the corners of the mouth. The ulceration about the lips may leave long scars, ])articularly to be seen at the commissures of the lips. This is most beautifully shoAvn in the accompanying illustration of Dr. Sto- well’s case. (Plate V.) lirrcHINSON TEETH. FISS;rRES, OK KHAGAPES. (From Pr. StowelFs Case.) PLATE TV. m LIBRAfilf Of TH£ UNSVEASITr OF HER EDITA BY S YPHILIS. 115 Kidneys . — Fournier considers that chronic degenerative changes may take place in the kidneys, usually in the form of a parenchymatous nephritis and amyloid degeneration. Interstitial Keratitis . — There is frequently noticed an opacity of the cornea without much congestion of the conjunctiva. The opaque areas may, in severe cases, coalesce, and cover the whole cornea. Although primarily attacking one eye, it soon involves the other. There may coexist an iritis, presenting symptoms which are indolent in character without the severe pain and piioto- pliol)ia so often seen in many cases of iritis. It may be difficult to recognize the existence of iritis when the cornea is opaque from the presence of abun- dant interstitial keratitis. Deeper-seated troubles, such as choroiditis and reti- nitis, may occasionally occur. The G-enitalia . — Occasionally a painless enlargement of one or both testi- cles may be noticed, accompanied by a slight degree of hydrocele. This con- dition may sometimes involve the epididymis and the cord. When the testicle is thus involved, there are apt to be syphilitic lesions in other parts of the body, which will aid in diagnosis. In many cases all the evidence of syphilitic taint in childhood will be seen in arrested and perverted development. Such a child exhibits in its growth much retardation of development in comparison with other children of the same age. This may be particularly seen in the genital organs, the testicles at puberty being the size seen in very early child- hood, and in girls an absence of mammary development, delayed menstruation, and a non-appearance of hairs on the genital and axillary regions. Fournier has given the name “ infantilism ” to this defective physical and mental devel- opment. Such cases not infrequently develop epilepsy. The Treatment of Syphilis. The dictum of Dr. Holmes that the proper treatment of some diseases should be begun one hundred years before birth may be modified, in syphilis, to a treatment existing several months before birth. There is no doubt that parents who exhibit any specific symptoms or who have had syphilitic children should be subjected to constant specific treatment and oversight. Such treat- ment may avoid miscarriage, and possibly prevent the development of syphilitic disease in the infant. The treatment of the syphilitic infant resolves itself into specific medication directed to the actual poison of the disease and to means aimed to prevent the collateral loss of nutrition which is so common and so grave in these cases. Mercurial treatment may be applied by external or internal medication. The former is particularly adapted to cases where infan- tile diarrhoea and indigestion may, to a certain extent, contraindicate the intei’- nal use of mercury. Daily inunctions of mercurial ointment mixed with from four to eight times its quantity of vaseline or rose ointment are efficacious. It may be rubbed on the inside of the thighs or in the axilbn, using a portion about the size of a small hickory-nut. Or the ointment may be applied on a fiannel roller and bandaged about the child once a day. Before applying the ointment in this way the skin must be cleansed thoroughly with soap and tepid water. A little more cleanly method of local medication consists in applying five drops of a 10 per cent, solution of the oleate of mercury three times daily. It is certain that under external applications the specific lesions will frequently disappear. It is probable, however, that it will he found, as a rule, more satisfactoiy to employ internal medication. Mercury with chalk is one of the best prepara- tions, in doses of one-fourth of a grain to one or two grains twice a day. Dr. 116 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Jacobi prefers calomel, on account of the rapidity of its action, in doses of from gig- to ^ grain three times a day. Bichloride of mercury has many adherents. The liquor of Van Swieten is the form recommended by Pan-ot for internal administration. The formula is as follows : I^. Bichloride of mercury 1 part. Water 950 parts. Kectified spirits 100 parts. Sig. 5 to 20 drops in milk three times a day. The bichloride of mercury may be given in simple watery solution, which may be combined with milk, and hence readily taken by the infant. The dose varies from -g-^ to -gig- of a grain, according to the age and condition of the infant. If intestinal irritation be caused by the drug, a mixture of wine of pepsin and elixir of bismuth may be used as a menstruum. An important element in the management of these cases will be the local treatment, applied to mucous patches, excoriations, and especially to the coryza. Ulcerations and destructive processes in the nose may be largely avoided by keeping the nasal passages clean by tepid water or bland oil. A 2 per cent, solution of the oleate of mercury will be efficacious in the nose. Mucous patches or condylomata should be kept clean, and may be dusted with calomel and bismuth. Nitrate of silver may be applied to patches appearing in the mouth that are intractable to internal treatment. Where the bones are involved and evidence of gumma in any portion of the body is present, iodide of potash should be employed. In the visceral lesions this remedy likewise acts well ; and if the indications arise, mixed treatment, by combining the biniodide of mercury Avith iodide of potassium, may be em- ployed. The iodide of |)otassium is most efficacious, although the iodide of sodium may be administered with good results, d'he dose should be moderate, not averaging more than a fcAV grains. The general care of the nutrition of the syphilitic infant is most important. The chances for maintaining good nutrition are much improved by keeping the baby on its mother’s breast. If the mother is unable to entirely supply the infant Avith nourishment, the bottle may be employed, but never to the com- plete exclusion of the breast. The Avell-known fact that an infant cannot infect the mother, altliough the latter shoAvs no evie- MEASLES. 125 ciallv the continuance of high temperature for two days after .the appearance of the eruption ; and the peculiarities of the rash. It should be remembered, however, that the rash, though (juite characteristic in typical cases, is more apt ■ to be misleading, through its variations, than any of the other pathognomonic signs ; and it may be said of measles, as indeed of all other exanthemata, that a diagnosis must never be based exclusively upon the eruption. In the initial stage it is often difficult to differentiate between measles and an ordinary acute catarrh — a “severe cold.” The coryzal symptoms are identical : hoarseness and cough are present in both, and both are attended by fever. If such symptoms are developed at a time wdien measles is epidemic, the probabilities are strongly in favor of an attack of the disease. On the other hand, if the history of exposure to contagion is uncertain, it is best to withhold a decided opinion and wait for the appearance of the rash, which, it is well to recollect, shows upon the soft palate from twenty-four to forty-eight hours before it can be detected upon the skin. In this connection the buccal eruption described by Koplik, and already mentioned, may be of great assistance in establishing an opinion. It may be stated here that this element of uncertainty in the early diagnosis is much to blame for the ready and wide extension of the disease ; for, while contagion is freely given off by patients in the catarrhal stage, isolation is rarely practised until all doubt as to the nature of the attack is cleared up by the eruption. Sore throat, which is sometimes present, combined with fever, may suggest scarlatina, but the latter disease has a sudden onset, with vomiting, rapid and extreme elevation of temperature, and very frequent pulse, and without catar- rhal symptoms ; further, the characteristic eruption appears not later than twenty-four hours from the commencement of the attack. In the eruptive stage, when the color and grouping of the papules are typical, and the fever, coryza and cough marked, there is little room for error. When the rash appears in hard, isolated papules, variola may be suspected, a mistake not uncommonly made. In small-pox, however, the pi’e-eruptive stage is characterized by obstinate vomiting and severe pain in the back. When the eruption appears, the temperature abruptly falls and the active symptoms abate ; the papules themselves are harder than ever noticed in measles, feeling like pellets of shot under the skin, and by the second day those first appearing on the face are changed into vesicles. There is more difficulty in distinguishing the rubeolous eruption from the rash of rubella than from that of any other of the exanthemata. The points of distinction are the short, often featureless, prodromal stage of rubella, the comparative absence of catarrhal symptoms, and the fact that the papules are smaller and lighter in color, appear almost simultaneously on the face, the wrists, and the ankles, and thence extend over the body, showing no tendency to irregular grouping. Various skin eruptions, notably the early stages of acute and general eczema and syphilitic roseola, resemble the rash of measles, but the differences in clin- ical history and the entire absence of general symptoms render the distinc- tion easy. Prognosis. — Generally speaking, the percentage of fatality in rubeola is small. Nevertheless, in individual cases the prognosis depends upon the type of the epidemic, the age and previous condition of health of the patient, the nature of the hygienic sui-roundings, and the character aud severity of the complications. An attack, of whatever severity short of malignancy, occurring in a pre- viously healthy child over the age of two years, who is surrounded by the usual 126 AMERICAN TEXT-ROOK OF DISEA8EH OF CHILDREN. comforts of life and treated with ordinary skill, should almost invariably ter- minate in recovery ; and in such cases even the onset of so serious a compli- cation as catarrhal pneumonia is rarely fatal. Quite the reverse is true when the disease attacks children who are constitutionally feeble or debilitated by some antecedent acute disease, who are suffering from rickets or suppurative bone disease, who have chronic pulmonary lesions, who are subjects of the tuberculous diathesis, and who live in crowe at a. temperature of 100°, and contain about one tablespoonful of mustard to the gallon ; the patient is immersed up to the neck for three minutes, then quickly MEASLES. 129 dried and placed in bed between blankets or wrapped in a blanket and dried later. The bath may be repeated in two hours if necessary. In hot packing the child is placed between blankets, and then a blanket wrung out as dry as possible, after being wet with hot water or mustard and water (two teaspoonfuls to the gallon), is quickly wrapped about the body, care being taken lest it be too hot ; it may be renewed in half an hour. At times one or more of the symptoms of the disease may be so modified or e.xaggerated as to require special treatment. Headache, when violent, is usually attended by constipation, and can be relieved by unloading the bowels and by putting the feet in hot mustard- water (one tablespoonful to the bath) or applying a mustard plaster ( 1 part to 4 or G of flour) to the nape of the neck. For the purpose of evacuating the bowels enemata or glycerin suppositories should first be tried, and if these fail, a mild laxative, as calomel in broken doses or milk of magnesia with aromatic syrup of rhubarb, may be administered. Active purgatives should never be employed, on account of the decided diarrhoeal tendency of the disease. Should these measures fail to relieve the headache, resort must be had to bromide of potassium or elixir of the valerianate of ammonium. Moderate looseness of the bowels need not be interfered with, but if the purging be sufficiently violent and continuous to threaten the strength of the patient, a combination of rhubarb, bismuth, and chalk mixture may be prescribed, or, if the evacuations be very watery, it may be necessary to use a more powerful astringent, as oxide of zinc in doses of gr. every three or four hours. Disti'essing vomiting is best treated by causing the patient to drink tepid water, and, when the stomach has been relieved of altered food and irritating secretions, applying weak mustard plasters to the epigastrium. In this condi- tion, however, it is most important to pay careful attention to the feeding. When the eruption is delayed, appears irregularly, or retrocedes, it must be remembered that the condition depends upon some complication — broncho- pneumonia, for example — and that the true mode of relief is to relieve the internal inflammation which is the cause of the difficulty : hot mustard foot- baths or full baths, hot packs, mustard sinapisms, and stimulants are required. Liquor ammonii acetatis is a useful preparation in these cases ; it may be given in doses of one to two teaspoonfuls every two hours. When the rash itches or burns, fi’equent applications of fresh lard or vaseline will afford relief. At the acme of the eruption the temperature often runs up to 104° or 105° F. for a few hours, without corresponding severity of the other symp- toms. No interference is necessary for a temporary elevation of this sort, but for a persistently high temperature of twelve hours or more some antipyretic must be given or cooling baths resorted to. Antipyretics are still on trial, but the safest is phenacetin. This may be administered in an initial dose of 1 grain for any age between two and six years. If the temperature falls after- ward, wait and observe the extent of the depression; if not, repeat the dose after the lapse of an hour ; should this fail, gradually increase the amount to 2 or 3 grains. The first dose may be given when the temperature ranges above 103°, and the drug may be repeated as often as necessary to keep it below this point, the cardiac condition being carefully watched in the mean time. When baths are employed to reduce the pyrexia, water at a temperature of 95° to 98° F. should first be used ; if this fail, tepid or cold spongings may next be resorted to, and as a final resort the tepid or cooled bath may 9 130 AMERICAN TEXT-BOOK OF DIRE ABES OF CHILDREN. be tried. In giving the latter the child should be undressed as quickly as possible, and then immersed in a bath of 90° F. ; cold water is now rapidly added until the temperature of the hath is reduced to 80°. After a sufficient intermission — usually five or six minute.s — the body is quickly dried with a soft towel and the patient put back to bed between sheets. The effect of the bath is sometimes very powerful, and the child remains livid-looking and collapsed for some time. In such case small doses of brandy must be given in warm milk at short intervals and artificial heat applied to the feet. It is stated by some authorities that antipyretics ought to be employed whenever the temperature reaches 102° F. Such a rule is dangerous. There are many instances in which, with a temperature of 102°, the child is very ill, and this degree of fever may be judged to be more than usually detrimental. For these a bath, either tepid or cold, cold sponging, or phenacetin, may be recommended, but for one such case there ai’e many others that run a perfectly favorable course with a temperature even higher than this, and in which it is difficult to see what benefit could have accrued from antipyretics. Each case must be treated upon its own merits. When in doubt as to the propriety of using antipyretic drugs or baths, it is well to try the effect of moderately full doses of sulphate of quinine. It has been my own experience that this agent given by the mouth, or, better still, by the rectum, in suppositories of two to four grains every three or four hours, frequently reduces temperature, and, should there be much associated restless- ness, produces sleep. The treatment of convulsions, broncho-pneumonia, and other disorders which may be associated with or follow after measles does not differ from that employed when these affections occur idiopathically, and therefore requires no especial consideration here. Quarantine. — The rubeolous patient should keep his bed for eight or ten days and his room for three weeks ; then, if he be quite Avell in every respect, there is little danger in his mixing with his playmates. When one member of a household is attacked, it is necessary for the other children of the fixmily who have not had the disease to stop going to school or associating with other children, as it is probable that they also have contracted the malady, and, as it is infectious in its early stages, they may readily be the means of giving it to others. For the same reason it is unwise to send them away from home ; at the same time they must not come in contact with the case already developed. The convalescent should have a warm bath and fresh clothing before ming- ling with his associates. Scalding of the bed- and body-clothing and thorough airing and cleaning of the sick-room are all that is necessary in ordinary cases, though in malignant epidemics disinfection of the bedding and thorough fumi- gation of the chamber with sulphur should be insisted upon. SCARLET FEVER. By MARCUS P. HATFIELD, M. D., Chicago. Scarlet fever, or scarlatina, is a self-limited, contagious, microbic disease, characterized by fever, angina, and a typical eruption, and followed by des- quamation and recovery in about three weeks if the disease be uncomplicated. The health reports of all of our large cities show that scarlet fever is an endemic disease of childhood, never being entirely stamped out, and affecting now only a trivial percentage of the population, and then increasing into epi- demics of frightful mortality, often from causes as yet unknown to modern science. According to Busey, it is the most widely disseminated of the exanthemata of childhood, and, perhaps rightly, the most dreaded of all the diseases of children, whose susceptibility varies not a little with their age. Infants under six months, as a rule, escape ; 64 per cent, of all cases occur in children under six years of age (Murchison), after which susceptibility diminishes, though liable to as yet inexplicable variations, for children and nurses who have escaped half a dozen epidemics may succumb to the seventh after exposure apparently in no wise different from that which preceded it. One attack, as a rule, protects from a second, though well-attested returns are on record. The majority of those cases popularly reported as second attacks are usually due to errors in diagnosis. But it must also be remembered that frequent abortive attacks of sore throat are well known to occur in nurses or physicians attending cases of this disease. Scarlet fever may be complicated with other of the exanthemata, especially varicella. Cases of coincident scarlatina, variola, and measles are reported by Vogel. While the disease is not so infectious as measles, as shown by the fact that 42 per cent, of Budert’s unprotected children e.scaped infection during an epidemic in the isolated German village of Neundorf, it should be remem- bered that the contagiousness of scarlet fever varies greatly with the epidemic. Brush’s statement that the colored race possesses an immunity from this disease is erroneous, for the writer has seen scarlet — or rather royal purple — fever in a coal-black pickaninny, and in Chicago, at least, colored children enjoy like privileges in this respect with those of lighter skin. History. — It is more than probable that scarlet fever must have existed as far back as there have been masses of people crowded together in great cities ; but there are no earlier accounts of the disease than those of the seventeenth century (1610-18), when epidemics occurring in Spain and Italy were described by Mercatus, Heredia, and Syambatus (Bohn). About the year 1625 both sporadic and epidemic cases were met with in Breslau and described by a Dr. Boring, who is probably entitled to the honor of being the first German author to write on this subject. He was closely followed by Sennert’s description of 13 ] 132 A3rEBICAN TEXT-BOOK OF DISEASES OF CHILDREN. the disease at Wittenberg, later followed by like outbreaks at Brieg (1642), Scbweinfurt (1652), and in Poland (1664). Up to the time of Sydenbain scarlet fever Avas supposed to be a variety of measles, being known by such fanciful terms as “ ingrassius, rosalia, rubeolas, morbilli ignei,” etc. During the years 1670-75, Sydenham bad ample 0 ]>por- tunity to study the epidemics raging in the city of London, and difterentiated the disease from measles. The origin of the name is yet uncertain (Bolin). To Fotbergill (1750) justly belongs the credit of establishing the con- tagiousness of scarlatina, and the facts upon ivliicb depend all modern theories of its prophylaxis. But many Avriters believe that the disease lias steadily in- creased in virulence, until to-day it is the most prevalent and dangerous of all the diseases of childhood. Scarlet fever is supposed to have been brought to North America in 1735, spreading sloAvly from the coast inland, and so infrequently met Avitb that Dr. Rush, as late as the beginning of the present century, Avrote : “No physician Avould be likely to see it more than once in bis lifetime.” At first it Avas regarded as rather a trivial affection, but malignant epidemics SAvept through Kentucky and Ohio when the country Avas almost an unbroken forest. Then came a period of slight malignity, so that Professor Chapman of the L^niversity of Pennsylvania so late as 1833-36 positively denied the contagiousness of this disease. Etiology. — He Avould be a purblind physician Avho, in these latter days, would attemj)t to deny the microbic origin of scarlet fever, but it must as frankly be admitted that our knoAvledge concerning its exact etiology is as yet indefinite and conflicting. Klebs figures the peccant microbe and names it Monas scarlatinosum. Ecklund of Stockholm minutely describes another, which he is certain is the cause of scarlet fever, and proposes the name Plox scindens, a fuller description of Avhich may be found under the heading of Pathology. Edington of Edinburgh later isolated from the blood and epi- dermic scales of scarlet-fever patients another microbe, Avhich he and Dr. Shakespeare of Philadelphia unite in declaring to be the specific cause. But, Avhile it is disheartening that as yet Ave knoAV so little accurately con- cerning the bacteriology of scarlatina, there is much that is Avell knoAvn and proven beyond disjiute in regard to the s]>read of the disease and the nature of its contagion. First of all, it can be insisted upon that its contagium vivum is easily portable, tenacious in its ])OAver to do evil for years, and Avith great probability originating in some of the loAver animals. The horse, the dog, and the coav all have had their claims advanced as first OAvners of the scarla- tinal microbe, and during the Hendon epidemic some years since it seemed as if the (i(uestion had been decided in fiivor of the coav. Later and more accu- rate investigations, hoAvever, seemed to shoAv that the disease carried from the diseased teats of the infected coavs Avas scarlatinal only in the form of the rash communicated to human beings. There is also considerable dispute as to Avhich of the secretions may carry the scarlatinal virus. Some Avriters insist that the patient is a source of infec- tion from the initial sore throat until the last branny scales have droj>ped aAvay from betAveen the fingers and toes ; others, that infection may be carried so long as there is a specific otorrhoea. Undoubtedly, the micro-organism usually enters the system by iidialation, but there seems to be good reason for believing that it may be taken in Avith food (Smith), or carried from ))erson to person by inoculation of scarlatinal blood or blood-serum. It is, hoAvever, generally conceded that a, scarlet-fever jmtient is most dangerous during the stage of des(juaniation, and that the branny scales of this j>eriod M libra R y OF m WCRSITIf OF ILLIN 03 S Pr.ATE v: IMates illiistriitint? Till, .11 li'ini /liiliili s. 0 Pl.ATl^^ VI. 10 . 11 . Original imimre takan from llieskin, 1ml which wa.s a iicmly pure culture of llacillus !feurlutiua;. liacillus .\rhorcsccns Bacillus Snai-latiiia; afler a week’s growth. after l'.i days’ growth. to llie iiictlio(l.s of Ilrs. W. Allan Jamieson and .'Mexamler Kdiiigton. Vi'tUoil Jotiniul. m LIBRARY OF THt UWIVERSITY of SCARLET FEVE:R. 133 are the most frequent carriers of the contagion, though others claim like dangerous properties for mucus, urine, and the fmces. It is certainly true that the contagion of scarlet fever may be carried by almost every conceivable article of apparel or material used about the sick, for next to the variolous microbe the scarlet-fever contagion preserves its vitality for a longer time than any other of the exanthematous j)oisons. Dr. Holland relates an extraordinary case where the virus survived two generations, being packed away in clothing in a chest for thirty-five yeai’s, at the end of which time it communicated the disease to a grandchild for whom some of his grandfather’s clothing was made over. To the writer’s knowledge, the disease remained hidden in a fur cloak packed away for more than a year, and then communicated the disease to an entire logging community isolated for the Avinter in the wilds of Northern Michigan. Hence the exact origin of any given case of scarlet fever is often most difficult to accurately settle, especially when Ave remember the possibility of the disease being carried by books, letters, or toys from some previous case. Next to library-books, letters, clothing, and toys, milk seems frequently to be the medium of contagion. In one instance milk is known to have carried scarlatina to one-half of the families to Avhich it had been delivei’ed, although it had not been touched by the milkman or other members of the infected family (Taylor) ; and in another the disease Avas carried to all the families served save one, Avhich consisted only of elderly people (Bell). PoAvers and Klein still teach that the disease orio-inates from the sore teats of infected cattle suffering from bovine fever, but, after much heated discussion on the subject, it appears that the disease thus communicated is modified cow-pox rather than true scarlet fever (Hendon epidemic, 1885). The persistence of the scarlatinal virus in clothing and apartments after ordinary methods of disinfection is sometimes amazing. J. LeAvis Smith relates the case of a Sunday-school librarian who contracted the disease from books returned from an infected tenement-house. One month after his recovery the room in Avhich he had been sick and his clothing Avere disinfected Avith burning sulphur, and yet he succeeded in carrying the disease personally to his sisters after a journey of three hundred miles to an isolated country toAvn, to Avhich they had been quarantined. These sisters infected the room in Avhich they Avere confined, so that children visiting it, after its disinfection, in turn contracted the disease. The writer knoAvs of a building in the city of Chicago in which, in three successive years, the children of the families moving into the house con- tracted scarlet fever in spite of yearly domestic disinfections. Mode of Transmission. — Although it is usually believed that the scarlet- fever poison is not volatile and cannot be carried by the atmosphere solely, the case sketched in the description of Fig. 1, contributed by an intelligent medical student, apparently contradicts previous statements on this subject. Bacteriology. — IllingAvorth still claims, I believe, that the germs of scarlet fever are set free during the fermentation of animal and vegetable refuse. The inhalation of these causes them to lodge upon the mucous membi’ane of the throat, Avhere they propagate, and, by the reabsorption of their products, pro- duce the other lesions of scarlet fever. Almost all other authorities believe that there is a specific scarlet-fever microbe, Avhich requires a previous human being for its host. Repeated efforts have been made to isolate this micro- organism. As early as 1882, Ecklund of Stockholm thought he had discovered it in the form of colorless discoid corpuscles, about one-tenth the size of the red corpuscle, and found in immense numbers in the urine of scarlatinal patients. These he named Plox scindens. He states that he had found them 134 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN in vast numbers in the soil and ground-water of the island of Skeppsholm during an epidemic of scarlet fever there. Their presence seems to he well proven, hut their relation to scarlet fever is hy no means as definite. More Fig. 1. N W : — X X- ) X 4 C A X/ ) 3 C 5 S E The above rude map shows the relation of, and distance between, several houses in the township of Clare- mont, Minn., one inch representing a mile. In the house A lived Wm. Connell. During February of 1879 one of his children contracted scarlet fever through a letter that came from relatives in Toronto, Canada. About three days later a second child came down with the disease and died on the ninth day. The wind had been blowing from the north-east, and about this time my younger brother came down with the disease in house No. 4. Young James Connell was buried on the day after his death; and on that day the wind changed into the north-west, where it continued for .some time. The bed- ding and clothes of the Connells were hung on the clothes-line to air, and in about one week from that time the children in house No. 3 were taken with the disease. In house No. 2, thirty rods north, there were five children, in house No. 6 there were four children, and in house No. 5, two children. All of these escaped the disease. There was absolutely no communication between the houses on account of the cold weather and fear of the disease. Two years later there came an epi- demic of the disease in that vicinity of a severe type, and all the children in the neighborhood had the disease, except those that had had it two years previously.” hopeful are the results of Dr. Ellington of Edinburgh, who began in 1886 to make investigations of the blood and epidermis in human scarlet fever. He succeeded in isolating a diplococcus scarlatimie sanguinis and a bacillus scarla- tina. Inoculation of the bacilli produced in rabbits erythema and desquama- tion ; in calves, fever and a rash, followed by desiiuamation. Dr. Edington says “the bacilli measure 1.2 to 1.4 micro-millimetres in length and 0.4 micro- millimetre in width, and are found in the blood during the first two days only, in the desijuamating epidermis only after the twenty-first day, and ii\ the eighteen intermediate days they cannot be demonstrated in any of the tissues.” Ilis results have been confirmed by Dr. E. 0. Shakespeare, who jiroposes the provisional name of haciUus scarlatince for this micro-organism, and reports that, “ sown on gelatin-plates, it forms little points of liquefaction after several days. Sown in test-tubes of Koch’s jelly, it rapidly liquefies it, but with no distinct growth-formation. The fluid thus formed is crowded with the motile bacilli, but a pellicle is not formed until the liipielaction is well advanced.” This occurred in every case but one of the tubes made from the desijuamation if taken after the termination of the third week, but never before this. It also occurred in every tube made from scarlatinal blood if taken before the third day of the fever. Inoculation iqion rabbits jiroduced erythema, best marked in the old, and in from two to five days a fine desquamation, which lasted for a week to ten days. Temperature, 103°— 106° F. Similar results were obtained from guinea-])igs, except that the desquamation was more copious and the hair fell out if pulled upon. “A calf was then inoculated, and at the same time given some of the SCARLET FEVER. 135 culture in milk. The calf was in good health at the time, and had a tem- peratui’e of 99.5° F. Six hours from the inoculation the calf developed great sickness, and the temperature taken in the axilla registered 103 ° F. [This was at 10 p. M.] Tlie calf was then left for the night, but in the morn- ing was found dead. Small portions of the spleen and kidneys were taken from the animal, placed in Koch’s jelly, and allowed to incubate, and developed the characteristic bacillus previously described. A second calf was inoculated, when only one day old, with the bacillus, care being taken that the inocula- tion was made with the absolutely pure material. Previous to the injection the calf’s blood was examined, and found to contain no organisms. The inocula- tion was made in this case with a very carefully sterilized hypodermic syringe. At 6.30 P. M. this was performed, the temperature per rectum then being 99.6° F. At 10 P. M. the animal took milk freely, and the temperature re- mained practically the same. Next morning, temperature 104° ; sickness, slight diarrhoea, and great prostration, and the throat inflamed. In the after- noon the skin of the thorax, upper abdomen, and inner side of the foreleg pre- sented a general redness, increasing toward evening (T. 102.8°). The next morning the animal was better, but rash still vivid, throat and posterior part of the tongue inflamed (T. 102°). From this time the beast steadily improved, and on the sixth day des(juamation set in.” The same bacillus, according to Dr. Shakespeare’s report, may be obtained from the blood of a scarlet-fever patient during the first two or three days of the disease, and from the desquamating scales on the twenty-first day in an ordinary case; if malignant, they may be obtained earlier. These bacilli rapidly increase in warm milk, which they may thus infect. “ The rapidity of the growth of this organism — which is such if one in- oculate a flask of broth the diameter of which is two inches and a half, and if it be incubated, the pellicle will develop and cover it entirely over in the course of four hours — suggests an explanation of the short incubation of scarlet fever when furnished a proper pabulum.” Such, it seems to the writer, is a fair statement of our present knowledge on the subject, to be confirmed or reversed by later investigations. Pathology. — Aside from its bacteriology, still in dispute, there cannot be said to be any pathological changes pathognomonic of scarlet fever. Autopsies made upon those dying in the earlier days of the disease show only the local lesion of the throat and engorgement of various internal organs, especially the intestines and brain. Deaths occurring later are generally due to se|)ticiTemia or nephritis. The former are apt to show secondary pneumonia and metastatic abscesses, and the blood coagulates poorly and is prone to form clots in the right ventricle. The characteristic changes of pleurisy, pericarditis, endo- carditis, purulent meningitis, empyema, or pulmonary gangrene may be found in these cases. The kidney lesions are those of an acute exudative (Delafield) or glomerulo- nephritis (Welsh), the latter being the true post-scarlatinal nephritis. In such cases “ the liquor sanguinis and the red and white blood-cells escape from the renal vessels into the tubules. Swelling or necrosis of the renal epithelium, with changes in the glomeruli, occurs.” Macroscopically, the kidneys are large and flabby, and the cortex is thick and pale, with injected capillaries. The tubal epithelium is swollen and opaque. Hyaline cylinders identical with the casts are found in the convoluted tubes, and more abundantly in the straight tubes, along with irregular masses formed from the exuded blood-plasma. In the tubes are also red and white blood- cells. The glomeruli exhibit important changes. They become larger or more 136 AMERICAN TEXT- BOOK OF BIREARER OF CHILDREN. opaque, due to the swelling and growth of the cells on and in the capillaries, “ for the glomerular capillaries in their normal state are covered on their out- side by nucleated cells, and flat cells line their inner surfaces in places, not continuously. On account of these cellular changes, the individual capillaries in the glomerulus become indistinct, but the main divisions of the tufts are visible. In very severe cases the gi’owth of the cells on the tufts is so con- siderable that they form large masses of cells between the glomerulus and its capsule. The walls of the artei’ies in the kidneys may be thickened bv a swelling of their muscular coats, and the Malpighian bodies may stand out like grains of sand.” This connective-tissue growth Delafield considers characteristic, “involving not the whole of the kidney, but symmetrical strips or Avedges in the cortex, which follow the line of the arteries. These Avedges are small or large, fcAV or numerous, regular or irregular, in different kidneys, but in every wedge Ave find the same general characters : one or more arteries, of Avhich the Avails are thickened ; glomeruli belonging to these arteries, Avith a large groAvth of capsule ; cells compressing the tufts ; a growth of ncAv connective tissue in the stroma around and parallel to the arteries. Between the wedges we find at first only the changes of exudative nephritis ; later, a diffuse groAvth of con- nective tissue. If the nephritis is of acute type and longer duration, the tissue is denser and has more basement substance. Where the groAvth of the new tissue is abundant the tubes become small and atrophied. The exudation from the blood-vessels is very considerable, so that the urine contains large (quantities of albumin, many casts, and red and Avhite blood-cells” (Delafield and Prudden). The in-egular distribution of these kidney lesions, according to Bartel, explains the contradictory results often obtained by successive examinations of the urine. There may be parts of the kidney Avhich entirely retain their functions, and from these normal urine may be secreted. But that a scarlatinal dropsy may exist from beginning to end Avithout the presence, at any time, in the urine of either blood, albumin, or casts, is as improbable as that dropsy may occur Avithout nephritis (Bohn). Incubation. — Formerly a Aveek or ten days Avas given as the usual length of the stage of incubation ; later Avriters, hoAvever, fix it at tAvo to five days, and it may, in malignant cases, last not more than twenty-four hours. But it is often difficult to say exactly Avlien the stage of incubation ends and that of the initial sore throat begins. INIurchison’s table (Smith, p. 275)shoAvs that in the great majority of the cases reported by him the stage of incubation Avas within five days, and the latest Avriter on this subject .says that if the initial vomiting be taken as the conclusion of the stage of incubation, it Avill bo found to be under three days (Ashby, p. 248). Symptoms. — The onset of .scarlatina is u.sually so abrupt that its begin- ning may be fixed Avith considerable definitene.ss. There is possibly a pre- vious slight duskiness of the skin, chilliness and inalaise, but u.sually the first thing that attracts attention is vomiting, often Avithout any relation to a j)revious meal ; or there may be diarrhoea. Older children may not actually vomit, but complain of nausea, languor, headache, and sore throat, and feel chilly, although the face is fluslu'd, and the thermometer may sIioav a tem- perature as high as 103°-10r)° F. If such children are also droAv.sy, they may become delirious in their sleep. The ]»ulse is full and strong (12()— 160), the skin is hot and dry, and the throat feels stiff and uncomfortable, and, if examined, Avill shoAV a characteri.stic punctate redne.ss. Such is the ordinary onset of a typical case of scarlet fever, but there is no disease of childhood that is liable to Avider and more eccentric variations in its onset and course. PLATIO vri. SCARLET FEVL:R. 1»E LIBRARY OF THE UMIVEftSITr 0F ItHINfJjS SCARLET FEVER. 137 oscillating between the very slight abortive form and that frightful variety called by the French foudroyant, or scarlatina fulminans, fortunately rarely met with ; for in such cases the child succumbs, mortally poisoned from the very first by the virulence of the scarlatinal virus, without any prodromal stage or hardly any symptoms except those which may be referred to the nervous system. These dreadful cases often run their entire course in from thirty-six to forty-eight hours without eruption or sore throat, the only symptoms being nausea, dizziness, loss of consciousness, coma, violent delirium, or convulsions attended with abnormally high temperature (107°). Scarlatina simplex may be differentiated in twenty-four hours by the ap- pearance of the typical scarlatinal rash in the form of a scarcely perceptible scarlet flush or pin-point eruption, very closely resembling in color and stip- pling the shell of a freshly-boiled lobster. The eruption usually begins on the neck or cheeks or small of the back, and ought in forty-eight hours to spread nearly over the body, either as a well-defined blush or in scarlet patches — .scarlatina laevigata. Plethoric and blond children develop the rash most promptly, and in all cases its color is heightened by the Avarmth of the bed, by hot baths, or by crying. A characteristic Avhite line remains for a feAV seconds after drawing the edge of the nail or the point of a pencil over the rash. This typical line is supposed to be due to a paralysis of the vaso-motor Fig. 1. Temperature Chart in a Mild Case of Scarlatina. Patient 6 yrs. old. (After Ashby.) nerves of the capillaries in these congestive areas. Until the eruption is well marked the fever continues high, often dangerously so, as it is not unusual to find the temperature in impressible children marking 105°— 107° F. The pulse is quick and sthenic, except in cases of scarlatina maligna, where there may be general depression, delirium, and collapse from the very onset of the disease. The pulse, as a rule, is faster than the temperature Avould apparently call for, ranging from 130—150, its relation to the rash and temperature being well shown in the accompanying chart, taken from Ashby (Fig. 1). Pharyngitis, with more or less soreness of the throat, is always present, although it may not be sufficiently painful to cause the child to complain {scarlatina sine angina). The respira- tory organs, except the throat, are rarely involved, so that cough is generally absent. When present, it is due to faucial irritation, except where pneumonia occurs later as a dangerous complication. The tongue is the so-called straw- berry tongue — that is, covered with a white fur with bright red tip and borders. 138 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. When the papillae are greatly SM'ollen, they cause the granular appearance known as the raspberry tongue. Some writers speak of a pathognomonic sweetish odor of the breath Avhich may be detected at this time, but this is by no means an invariable symptom nor one upon which much reliance should be placed. In a simple, uncomplicated case the fever and all threatening symptoms moderate with the appearance of the rash, with the exception of a slight even- ing febrile exacerbation, and any variation from this rule betokens malignancy or some new complication. From the fourth to the sixth day desquamation ordinarily begins. Those areas which are fii’st reddened fade in like order, and, as the color disappears, Fig. 2. Temperature Chart of Malignant Scarlet I Temperature Chart of Malignant Scarlet Fever. Fever. Death in at hrs. (After Ashby.) | Death on 7th day. Hash indicated by *. the skin is found to be covered with loose branny scales. These scales drop off’ imperceptibly, e.xcept when from itching, as is apt to happen on the face and neck, they are scratched off', and the tender ejiidermis beneath becomes cracked. In such cases the scales may be thrown off in shreds, or casts of the entire lip, fingers, or palms of the hand may be shed. A like desijuaniation occurs from the membranes of the throat, trachea, kidneys, and intestines, though of course the epithelial scales in these localities are carried away in a softened, macerated condition. Out of 200 cases reported, 11 reaiFed their highest temperature on the first day, 76 on the second, 7i) on the third, 36 on the fourth, and only 2 on the fifth day. When the highest temperature is reached alter the filth day, or il the temperature has not fallen considerably by that time, some comjilication is certainly keeping it up, so that the thermometer ami violence ol the nervous SCARLET FEVER. 139 symptoms form a valuable criterion as to the danger of the child. A dull, apa- thetic condition is, as a rule, more to be dreaded than the usual restlessness, which is due to continued reflex irritation of the rash. In hypersesthetic chil- dren this produces twitching, or even eclampsia, which is graver the later it occurs in the disease. Variations. — We have previously described what might be considered a typical case of uncomplicated scarlet fever, but, unfortunately, uncompli- cated cases are so rare that there is no disease of wider variations in every symptom. The eruption may be so light as to escape detection, or, on the other hand, instead of the ordinary scarlatina laevigata, the eruption may appear in the form of small nodules (scarlatina papulosa), in which the papillae of the skin are swollen, and the whole body looks as if covered with goose- skin. Or, again, these papillae may become covered with vesicles, and we have that form of scarlatina which is known as scarlatina miliaria. Should these vesicles become merged together, they give an eruption to which the name of scarlatina pemphigoides seu bullosa is given. Such variations are found most frequently on the face, and are usually of grave import. Vogel reports excep- tional cases in which the eruption was intermittent in character, appealing only at certain times of the day, and for this he proposes the name of scarlatina intermittens. Lastly, we may find that fatal form to which the name of scar- latina petechialis seu hcemorrhagica has been given, where there is an actual extravasation of blood into the skin, and hence the popular name of “ black scarlet fever” by which it is sometimes known. In nervous children it is not infrequent to find urticaria accompanying scarlet fever, masking the character- istic I’ash. Vogel also reports a curious variation of scarlatinal rash in which ai’e found sharply-marked, isolated areas which remain milk-white in color, or at least much whiter than normal integument, due to a temporary paralysis of the arterioles similar in character to that which follows the thumb-nail mark on the normal scarlatinal flush ; but they are more persistent in character and are usually of unfavorable portent. Any intercurrent disease, as entero-colitis, which produces a determination of blood from the surface of the body, may greatly delay the appearance of the rash or render it so light that its dif- ferentiation will be difficult. Complications. — Throat. — The angina of scarlet fever may assume any form, from simple catarrhal injection to extensive necrotic destruction of tissue. Ordinarily, a bright red ffush, with punctate marks, such as might have been produced by a small brush dipped in red ink and dotted over the pillars of the fauces, is the earliest and one of the most characteristic symptoms of scarla- tina. This may proceed no further than to give slight difficulty in swallowing and to impart a nasal tone to the voice. But, on the other hand, and more frecjuently — especially if pharyngeal disinfection is not practised from the very first — the swelling becomes so great as to make swallowing almost impossible. In such cases fibrinous exudates appear on the tonsils and fauces, and should the inflammation not be limited to the palate and fauces, the exudate may ex- tend into the post-nasal cavities, the larynx, and even into the oesophagus and stomach. More frequently it proceeds through the Eustachian tube into the internal ear. (See Otitis Media.) The differentiation between the fibrinous exudate of scarlatina and true diphtheritic membrane is by no means easy, the more so since undoubtedly true diphtheria is not infrequently grafted upon the necrosis of scarlatinal angina ; but it may be helpful to remember that the exudate of scarlatina is yellowish and pultaceous, rather than the ashy-gray membrane of true diphtheria. Should the presence of Loeflier’s bacillus 140 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. be finally accepted as pathognomonic of diphtheria, the differentiation may then be made absolutely; whereas at present we must frequently remain in doubt, since the removal of the scarlatinal exudate leaves the superficial layers of the pharyngeal mucous membrane denuded and bleeding exactly as in diph- theria. A similar gangrenous process may jtroceed upward into the pharynx or along the Eustachian tube into the cavity of the middle ear, with all the perils of purulent meningitis which this implies. Similarly, as in true diph- theria, the exudate may pass downward into the larynx, where its presence is made known by a characteristic croupy metallic cough. If the exudate attacks the nasal cavities, this is attended by a profuse excoriating discharge, which soon grows purulent and offensive in odor. Adenitis. — All foians of scarlet fever are attended with inflammation of the lymphatic glands of the neck, and, as a rule, it will be found that the involve- ment of these glands bears a direct relation to the severity of the throat lesions. So we find all grades of adenitis, from the slight induration which may be found accompanying all varieties of scarlatina, to a brawny swelling of the glands and cellular tissue embracing the whole neck. Such extensive mischief betokens like serious necrotic processes taking place Avithin the pharynx, Avhere the poisonous debris clogs and inflames the lymphatic glands, their pi-es- sure and morbid processes inflaming contiguous tissues. This cellulitis may extend from ear to ear, until deglutition becomes difficult and wide opening of the mouth impossible. If relief does not come early by resolution, the widely- distended tissue gives way to suppuration or gangrene, and death from haemor- rhage or septicaemia occurs. Scarlatinal Ai'thritis is not infrequently met with in certain epidemics of scarlet fever during both the eruptive and the desquamative stage. This form of arthritis attacks by preference the knee- and elboAV-joints, and scarcely can be distinguished by its objective symptoms from ordinary articular rheumatism, being, like it, excessively painful. But arthritis rheumatica rarely ends in pyaemia or permanent articular osteitis, as arthritis scarlatinae is very prone to do. Diarrhoea and Djisentery are not at all infreciuent complications after the crisis of the disease, probably being caused by desciuamation of the intestinal epithelium, analogous to that Avhich undoubtedly occurs in the tubuli uriniferi at this time. Scarlatinal Nephritis. — Last and, justly, the most dreaded of the com- plications of scarlatina, is that form of nephritis Avhich so fre(|uently occurs during the course of the disease that it may almost be considered pathognomonic ; for a mild grade of renal catarrh is as constantly j)resent as is des(iuamation (Steiner). It is true this fretpiently escapes observation and ]>asses on to re- covery Avithout special treatment, but its existence is alAvays a ))otential cause of morbus Briglitii scarlatinosus, Avhich should be considered not as a distinct disease, but as an intensification of the previous catarrh of the tubules brought about by chilling of tlie skin, etc. (Bohn). Similar nephritic catarrh has been noted in measles, small-pox, ])!U'umonia, and other diseases, induced, as the Avriter helicves, by the ])assage through the kidneys of irritating ptotuai'nes generated in the body by the S))ecific microbes of these diseases. The excretion of these or aiialogous comjtounds through the skin very likely gives rise to the characteristic rash, hence analogous lesions might be inferred for the kidneys. It is a Avell-knoAvn fact that the lighter the cutaneous rash the more liable are the kidneys to be seriously implicated, pre- suinably from increased excretion of various ptomaines through organs noAV endeavoring to do the work of both skin and kidneys. Daily examination of SCARLET FEVER. 141 the urine should be made for at least two weeks in even the mildest cases of scarlet fever, and will show from the beginning of the eruption evidence of renal catarrh (epithelial debris and albumin), although the kidneys are appar- ently working normally. While the urine is high-colored and deposits copious urates. Dr. Gee claims that urea is not necessarily diminished. The chloride of sodium is lessened until the fourth to the sixth day, and phosphoric acid after crisis; while the urates or uric acid appear to excess during convalescence. In other cases the urine is cloudy, and contains fatty renal epithelia, more rarely hyaline casts, and red and white blood-corpuscles (only exceptionally albumin), all of which disappear usually with the disappearance of the erup- tion, but may progress to an actual catarrhal nephritis. This renal catarrh Bartel believes is due to a specific poison — ptomaine (?) — circulating in the blood, which poison irritates the tubules of the kidneys in its passage through the Mal- pighian tufts, either directly or from irritating properties imparted to the urine before its percolation through the tubuli uriniferi. Others claim that the source of this irritation lies in certain specific micrococci circulating in the blood, being analogous to diphtheritic nephritis, which Oertel thinks due to bacterial emboli. A diminution in the cpiantity of the urine is often the first thing that awakens the attention of the physician, if he makes it his duty, as he ought, to keep himself posted daily until the end of the third week. The normal amount of 800 to 900 c.c. per diem may fall suddenly to 100 or 50 c.c., or even less. Its color is yellowish-red, sometimes almost yellowish-green when cooled ; turbid, or clearing up on standing, depositing a cloudy precipitate made up of kidney cells and casts, urates, and uric-acid crystals in varying propor- tion. At times the urine is blood-red or smoky brown, from the blood it con- tains. Under the microscope the precipitate is found to consist of varying quantities of kidney epithelia, partly normal and partly swollen and distended, cloudy, and undergoing fatty degeneration. Besides these there may be vari- ous forms and phases of casts, lymph-corpuscles, red blood-corpuscles, and the crystals of urate of sodium and uric acid. The (quantity of albumin found in urine is decej)tive, since in certain epidemics of scarlatina, even where dropsy suddenly appears, often only faint traces of albumin may be found in the urine. Or albumin may be entirely absent during certain times in the day, or even for several days at a time, or during the greater part of the disease. Or, again, unmistakable albuminuria may be present while the urine is clear and free from all other abnormal elements. It may even happen that frequent analysis of the urine for days may fail to show either casts, epithelial cells, or crystals, while all of these, together with albumin, may be found at a subsequent exami- nation. Scarlatinal dropsy is often the first warning of the existence of any kid- ney lesion in mild cases which are supposed by parents, and even by the phy- sician, to be well along in convalescence. As a rule, the chief danger of scarlatinal nephritis lies about the end of the second week or during desquamation, though dropsy may appear as late as the fifth or sixth week. The first symp- toms noticed are slight oedema of the face and swelling of the eyelids. These are followed by puffiness of the backs of the hands and feet, sometimes uni- latei’al, with dropsical enlargement of the abdomen. In the case of children who have not yet been allowed to rise from their beds the anasarca is often most marked in the back and in the genitals, which may become frightfully swollen and sensitive. As a rule, the kidney complication is ushered in with a return of fever, or an increase in fever, if it still be present. But there is also a feverless nephritis, without subjective symptoms, loss of appetite, or anything abnormal that can be detected. In other cases there is only an evening 142 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. increase of temperature and pulse. Generally the skin is dry and ceases to desquamate. Pain over the kidneys is seldom complained of, unless questioned about or obtained by pressure. If the disease in the kidney is limited, there may be only a localized oedema, such as hydrothorax, hydrops pericardii, oedema of the lungs, or dropsical effusions into joints. This localized oedema may follow a brief apparent convalescence, during which children recover their appetite, and exhibit no features of illness, unless it be the persistence of slight lassitude and fever at night. After exposure to cold such cases develop anorexia, depression, and pain over one or both kidneys. The amount of urine is greatly diminished. It is concentrated, high-colored, and contains albumin and casts, and may not measure more than an ounce for the entire day, or may even be completely suppressed. About 6 per cent, of all scarlatina patients suflTer from post-scarlatinal nephritis, the course and duration of which depend directly upon the extent of the anatomical lesions of the kidney. Very light cases recover in a few days. Generally the anasarca and effusions increase for several days — say a week and over — breathing being hindered by the ascites and pleural effusions, and the nights are restless. Gildema of the lungs pro- vokes incessant coughing. Swelling of the genitals is often painful, but does not noticeably interfere with urination. Death may ensue suddenly from urm- mic convulsions when danger is least expected. Ashby attempts — and it seems wisely to the writer — to differentiate between septic and post-scarlatinal nephri- tis, either of which may be met Avith during the course of scarlet fever. The urine in the first contains no blood-corpuscles, but is highly albuminous, and is not attended with dropsy nor ui'mmic convulsions. Autopsy in these cases shows a distinctly softened, pymmic kidney, which contains minute abscesses, and is mottled in its cortex Avith injected blood-vessels and inspissated ]ius. Death occurs from pymmia, and not directly from the kidney lesions, Avhich are only a part of the more general process. In the second class of cases death results from urmmia. The lesions of the post-scarlatinal kidney have been fully described under Pathology. Sequelae. — Chronic nasal catarrh, ozaena, pharyngitis, or hypertro])hy of the tonsils, Avith acute attacks of quinsy, or suppurative otitis, Avith chronic otorrhoea and deafness, more or less complete, are among the dreaded reminders left after scarlatina, e.specially Avhere the angina has been malignant. In many such cases the tonsils become deeply excavated, and the soft palate sloughs; but even under these circumstances recovery is possible. Or, as has ])reviously been noted, diphtheritic-like membrane may cover the fauces, palate, and even spread on to the epiglottis and into the larynx. Death from exhaustion or hicmorrhage usually terminates such cases, or, if life is for a while prolonged, death comes later from septicaemia, often terminated by septic pneiimonia (seventh to four- teenth day). Put even septic pneumonia is not necessarily fatal, for recovery took place in one of the writer’s cases after the appearance of this secpiel sub- sequent to otorrhoea and cervical ab.scesses puration of the lymidiatics of the neck. This Avas followed by sloughing, exposing, in the triangle of the neck, a space bounded by the edge of the sterno-mastoid, the upper border of the thyroid cartilage, and the median line of the neck. Never- theless, under antiseptic treatment, the boy made a good recovery, although he was only six years of age and had previously been considered delicate. Broncho-pneumonia, pleuro-pneumonia, empyema, and peritonitis are among SCARLET FEVER. 143 the possible complications of scarlatinal nephritis. If the temperature runs high, the tongue becomes dry and brown, the urine scanty and albuminous, and death rapidly ensues. But milder cases are not hopeless if the urinary secretion can be re-established. Cardiac dilatation., endocarditis, and pericarditis are the more frequent heart-lesions that should be guarded against in every scarlatinal nephritis, for, conjoined with increased arterial tension and general malnutrition, they may bring sudden death either from heart hiilure or embolism. The possibility of such untoward termination to nephritis should never be forgotten, for no sharper reproach can come to the physician than the thought that had he allowed less work to be thrown upon a weakened heart he might have carried his patient into safe convalescence. Otitis, with perforation of the membrane, more than any other sequela, has too often been left a lifelong reminder of scarlet fever. In many of these cases little pain is complained of, although the fever remains suspiciously high until a purulent discharge from the ear makes its appearance. Mastoiditis or purulent meningitis may prove fatal, but in a majority of these cases no such complications take place, and the child recovers, more or less deaf or afflicted with a chronic otorrlioea. According to Batut, statistics in Belgium show that out of 1892 cases of deafness, 216 followed scarlet fever. Another observer found out of 400 cases 144 due to the same cause. Synovitis has already been referred to under the head of Arthritis, as liable to occur about the second week. Suppuration and pymmia are the chief dangers in these cases. Cerebral lesions, such as paralyses, blindness, aphasia, loss of memory, hemiplegia, etc., are among the sad sequelae of the uraemic convulsions of scarlatinal nephritis. Convalescence from severe cases of scarlatina is always protracted, the subsequent anaemia lasting for months or years, especially in scrofulous chil- dren, in whom the virulence of the poison is most lasting in its effects. Many of the most discouraging cases that come into the hands of the physician deal- ing largely with the diseases of children are those in which the child’s vitality has been undermined by malignant scarlatina. Such children frequently suffer for years from the so-called mucous disease of Eustace Smith or from renal incompetence. In other cases there is a chronic otorrlioea or offensive ozsena, which renders their lives miserable, and so saps their vitality that they succumb easily to intercurrent disease. This is especially true of those chil- dren in whom the functions of the kidneys have been seriously crippled by post-scarlatinal nephritis. Such a previous history always awakens serious apprehensions in the presence of diphtheria, typhoid, or any septic disease. Diagnosis. — The early diagnosis of a mild case of scarlet fever is often a matter of great difficulty, but it is a matter of no little importance to the patient, for such mild cases seem to be the ones most liable to nephritic com- plications. Since mild cases may communicate dangerous attacks to those more susceptible, it is always safe to give the well children the benefit of your doubt by isolating all suspicious cases. Nausea, pain in swallowing, and fever constitute a trio of symptoms sufficient to isolate a patient until a rash of some kind appears. This may be so light and transient, especially if there be coin- cident diarrhoea, that it may escape detection unless carefully watched for ; and even then there is an erythema scarlatiniforme that without previous history may deceive the very elect in pmdiatrics. In such cases, however, the throat does not show the characteristic stippling of scarlet fever, and a brisk emetic or purge brings the case to a speedy termination. The early differentiation of 144 AMERICAN TEXT-BOOK OE DISEASES OE CHILDREN rubella from scarlatina is often puzzling, but Jamieson calls attention to the fact that in rubella the characteristic tongue of scarlet fever is absent, while the mild catarrhal symptoms of the former are not ordinarily present in the latter disease. The eruption of measles is most distinctly patchy, and is preceded by several days of drowsiness and the symptoms of an ordinary cold. But in all doubtful cases isolate and wait for light, remembering “ that nephritis occur- ring after an anomalous rash makes it practically certain the primary attack was scarlet fever.” Broncho-pneumonia under similar circumstances justifies a diagnosis of measles. Prognosis in scarlet fever must be largely influenced by the character of the then prevailing epidemic and the general condition of the child. The viru- lence of the scarlatinal poison and the susceptibility of the one attacked deter- mine the degree of restlessness, jactitation, and delirium observed. Initial eclamptic attacks rarely occur, except in unusually nervous, susceptible chil- dren, and their occurrence is of very unfavorable portent. As a rule, the early and extensive implication of the cervical lymphatics is a forerunner of serious throat complications. Nasal diphtheria comj)licating scarlatina is of the gravest import, and the gravity is proportionate to the early age of the child, children under four years giving as high a mortality as 28 per cent. The younger the child the more guarded should be the prognosis, especially when associated with diarrhoea, which is regarded by Ashby as a very serious symptom. Where the temperature continues high (104°-106°), and there is much diarrhoea or extreme restlessness, or the angina is malignant, the prognosis is always grave. Drowsiness is always an unfavorable symptom, and a high tem- perature continued into the second week is sufficient ground for anxiety. Desquamation is seldom coni])leted before the sixth week, and is not always at an end in twice that time, Finlaj^son fixing the infective period of this disease as seven to eight weeks. The nephritis complicating or following scarlet fever is more dangerous than the primary disease. Where persistent vomiting occurs, not only on the first, but on subsequent days, the prognosis is corres])ondingly grave. Post-scarlatinal nephritis is the most favorable form of parenchymatous in- flammation of the kidneys, usually ending in recovery in two or three weeks by means of copious diuresis, but it is worth remembering that the excessive excre- tion of uric acid, which persists well into convalescence, may form gravel or calculi. As a rule, epithelial casts and detritus persist after the disa])))oar- ance of the albuminuria, sometimes for an exceedingly long time, especially in cachectic children. Death rarely occurs before the fourth day, and usually not later than the seventh, except from post-scarlatinal nephritis. Sudden death may result from rapid and uncontrollable increase of dro])sy, either into the j)critoncum, j)leura, pericardium, or ventricles of the brain, or from oedema of the lungs or glottis. Or, stopping short of immediately fatal results from oedema, the end may come more slowly from inilamniation of the lungs or ))ericardium, or still more slowly from gangrene of the genitals or from bed-sores. Or, as may be inferred from the above, the nephritis may a.ssume a chronic form. The relation betAveen the intemsity of the scarlatinal ruption and the dan- ger of subsequent nc})hritis is by no means constant, although the Avriter has come to dread its appearance in the lighter eases because these are the ones in which the care of the parents is apt to be relaxed Avith the ap])arent rapid con- valescence of the child. SCARLET FEVER. 145 Serious cerebral affections, such as paralysis, blindness, aphasia, loss of memory, hemiplegia, may remain as sequelae of scarlatina. Mortality varies widely with the epidemic. That in the Manchester Chil- dren’s Hospital varied from (J to 25 per cent, according to the epidemic, the average for ten years (1877-87) being 11.8 per cent. Of 10,000 cases reported by Collie, the mortality was 12.5 per cent, for all ages, that between three and four years reaching as high as 25 per cent. These figures, it must be confessed, are too high for the average American practitioner, but he may, like foreign physicians, be compelled to radically change his ideas on the subject. Brettonneau, for instance, up to 1799 thought scarlatina the mildest of all the exanthemata ; and so also the Irish physicians thought from 1804 to 1831. But Brettonneau was obliged to entirely change his views after encountering the fatal epidemic at Tours in 1824 ; and a similar o.utbreak in Dublin in 1831 completely revolutionized the views of the Irish physicians in regard to the fatality of scarlet fever. Treatment. — A hopeful fact, always to be borne in mind in any choice of treatment adopted in scarlatina, is that it is a self-limited disease, and that no remedy has yet been discovered that will either abort or greatly modify its course. The medical literature of the past twenty-five years teems with alleged specifics, but all of these by subsequent trials have been found no better nor worse than those proposed before them. Nevertheless, the intelligent physi- cian owes it to himself and his patients that he shall not desert them upon the rocks of medical agnosticism nor wreck them upon the snags of polypharmacy. If he cannot abort the disease, he may make its course less uncomfortable to his patient, and by careful foresight ward off many a threatening complication. Diet is not unimportant in scarlet fever, for our aim from the very begin- ning should be to tax the kidneys, already in a catarrhal condition, as little as possible with nitrogenous materials. Hence the ideal food for the scarlet-fever patient is koumyss, skimmed milk, or milk and Vichy. But the ordinary American child will not long tolerate such light diet, especially when rapidly convalescing, so we are usually forced to add to our diet-list broths, soups, light puddings, and baked apples, happy if thereby we reduce meats to a minimum. While the writer cannot agree with Jaccoud that a milk diet is an absolute safeguard against post-scarlatinal nephritis, it is true that a liquid diet and warmth should be carefully secured for at least four weeks. General Treatment. — If the initial nausea is vexatious, it may often be allayed by: I^. Aquae cinnamomi Liquor calcis . . . Tinct. gelsemii . . . Sig. Teaspoonful every hour For the high arterial tension and fever, tincture of aconite, given according to the plan of Ringer — i. e, a drop every quarter hour until arterial tension is decreased, and then given sufficiently to hold the pulse at that point every two or three hours — is very satisfactory. Chloral hydrate is a favorite with the writer, almost entirely displacing the tinct. ferri chloridi of his earlier practice, except in those cases where there is malignant angina from the beginning. In such cases nothing has been found superior to the tincture of the chloride of iron (one drop per dose for each year of the child’s age), with whiskey or brandy, given according to Dr. Chap- man’s plan. The surprising tolerance of such children for alcoholic stimulants 10 dd f.lj. f^ss. — M. 146 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. shows that their power is expended otherwise than in their usual effects upon the brain. Many such children will take f^ss of brandy every hour without showing any of the usual physiological effects. In ordinary cases, however, small doses of chloral hydrate seem to be all that is necessary to relieve rest- lessness, moderate the angina, and, to a limited degree, act as an antiseptic. For the first forty-eight hours such a prescription as the following has often proven most useful : I^. Chloral hydrate 3ss-j. Camphor water f§ss. Syrup of orange-peel f^iss. — M. Sig. To alternate with aconite as required. When the eruption is tardy in appearing, a hot salt or mustard bath will expedite matters, or, if these are ineffectual, packing in a sheet wrung out of hot water and sprinkled with mustard rarely fails. The throat is too often neglected, and yet here is the focus from which spread many of the dangerous complications of this disease. Local antiseptics may be a modern device, but Underwood came very near to the writer’s ideas when he wrote on this subject many years ago : “ The throat must be often syringed with .... though the quality is perhaps of far less importance than its being frequently made use of, which is absolutely necessary, especially in young children Even syringing the throat Avith hot Avater is found to administer immediate relief.” The local treatment of the throat Avith peroxide of hydrogen spray, as directed under the head of Prophylaxis, can hardly begin too early, and the same may be said of the inunction of the body with some antiseptic ointment. Quinine internally may be added later if there is evidence of failing strength. Cerebral symptoms, unless associated Avith scanty urine, may be rendered tolerable by the addition of bromide of potassium (grs. v-x) to each dose of the chloral hydrate mixture, Avitli a mercurial purge and the application of cold to the liead. Plienacetin is sometimes a great comfort in such cases, but the writer discourages the use of the other antipyretics in scarlet fever, excc))t as a last resort in abnormally high temperature. Even in these cases persistent sponging Avith cool Avater, or even cold affusion, ought first to be tried. Per- sistent droAvsiness ahvays aAvakes suspicion as to post-nasal complications, and emphasizes the necessity of nasal irrigation, frequently repeated. Scarlatinal arthritis in cachectic children may proceed to suppuration and destruction of the joints, but, fortunately, most of these cases are more pain- ful tlian dangerous, and yield promptly, like true rheumatism, to fair doses of salicin and codeine and Avrapping the affected joints liberally Avith cotton batting. Cervical adenitis is more free] non tly overtreated than neglected, for the SAVollen and tender glands apparently require immediate attention. And yet the trouble lies farther back, for the debris that blocks these inllamed glands comes usually from the pharynx. Hence efficient pharyngeal and nasal cleans- ing Avill do more for adenitis than poultices, lotions, or ointments. So-called energetic treatment too often precipitates the veiy troubles Ave are seeking to guard against. Instead of poultices and iodine, simple rest and Avarmth Avill often Avoi'k Avonders even in braAvny, SAvollen necks where suppuration apjtears inevitable. At all events, camphorated oil, ap))liedon absorbent cotton, should be tried before proceeding to more vigorous measures. Diarrhoea is apt to be (|uite persistent, and occasionally painful, Avhen once SCARLET FEVER. 147 it makes its appearance. So far, I have rarely seen it assume a dangerous aspect, for it usually can be held in check with paregoric alone or conjoined with bismuth in an emulsion. Scarlatinal Nephritis. — Individuals and epidemics of scarlet fever vary so greatly in their liability to nephritis that it is difficult to rightly estimate its prophylactic treatment. From 60 to 70 is given by various authors as the average percentage in dangerous epidemics, and from this it falls to 6 or 7 per cent, in ordinary cases. The writer believes that this latter proportion can be still further reduced by the proper care of children in the mildest form of the disease, for these are the very ones which give us the highest proportion of fatal cases of nephritis. It follows, then, that all children ill with scarlet fever should be kept in bed during the rash, no matter how mild it may be; and, furthermore, such children should be confined to warm rooms, or, better still, to bed, for four or six weeks from the appearance of the initial symptoms. At least twice a week during this time the urine should be examined, and upon the appearance of the slightest unfavorable symptom the child should be sent back to bed again if he has already been allowed to be about the room. But should these premonitory symptoms be disregarded, or if, in spite of these precautions, scanty albuminous urine and dropsical effusions appear, then the physician’s most energetic efforts must be directed toward making the skin or intestines temporarily assume, as far as possible, the functions of the kid- neys, throwing on the latter, at the same time, as little work as possible in the way of the excretion of nitrogenous refuse. (See Diet.) The copious use of water, if tolerated by the stomach, will act as one of the very best of the diuretics. Long ago Roberts placed pure spring water at the head of the list, and the writer has not yet found any diuretic to displace it, though lemon- juice, raspberry vinegar, or skimmed milk may be added without harm to induce the child to drink more freely of the water. Should the urine still remain scanty, then diaphoresis must be induced in order to increase the action of the skin — first, by means of baths, and then, if necessary, by drugs. A warm bath (98°-100° F.) for fifteen to twenty minutes is often grateful to the child, and, if supplemented by a flannel pack, is very efficient. The hot-air or steam bath, as described under the treatment of Acute Nephritis, may likewise be employed with success. Any of these methods will be assisted by the internal use of diaphoretics, chief of which are the preparations of jaborandi. Sips of a hot infusion of the leaves (3j to Oj) act both as a powerful diaphoretic and sialagogue. To avoid the latter action Smith prefers the alkaloid pilocarpine, to grain, conjoined with an alcoholic stimulant every four to six hours. Should this fail, the same writer speaks highly of the following prescription : I^. Potassii acetatis Potassii bicarbonatis Potassii citratis aa 3 ij. Infus. tritici repentis f. 5 viij. — M. Sig. Teaspoonful every three or four hours to a child of five years. More palatable and fiiiidy efficient is the following : I^. Liq. ammonii acetatis Syr. acidi citrici dd fsij. — M. Sig. Teaspoonful every hour in hot lemonade. 148 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Or, where there is considerable dropsical efiusion, this can be with advantage alternated with diuretin (gr. j-iv), given in a large amount of water. Dropsy usually requires, in addition, the free use of some hydragogue cathar- tic, of which the compound jalap powder (gr. v-x) is certainly the most efficient and unpleasant. Hence, when it is found impracticable to repeat the dose as often as required, it may be supplemented by a cream-of-tartar lemonade, made by dissolving a tablespoonful of the salt in hot water, diluting with an equal amount of cold, sweetening to taste, and adding sufficient claret or port to make agreeable. Most children will take this laxative readily. Or the following prescription of J. Lewis Smith may be employed : I^. 01. cinnamomi gtt. viij. Magnesii sulphatis 5 j. Potassii bitartratis 5 ij. — M. Sig. One teaspoonful repeated from two to four hours, until catharsis occurs. But the use of laxatives should he continued no longer than is strictly necessary, for their repetition brings anmmia, a result greatly to be deplored. After relieving the initial congestion of the kidneys, stimulating diuretics are helpful; and of these digitalis has justly a high reputation. The infusion is a reliable preparation, and may be given in connection with acetate of potas- sium, as in the following mixture : I^. Potassii acetatis Iss. Infus. digitalis f^vj. — M. Sig. One teaspoonful every four hours. Local treatment will also greatly help in relieving the fever and backache. Foreign writers speak highly of the use of leeches over the kidneys in these cases, but the majority of American ])hysicians are willing to rely u{)on the use of poultices or plasters. A large warm llaxseed poultice, containing mustard or digitalis, often acts like a charm. Smith prefers one made of 1 part each of powdered mustard and ginger to 16 of ground haxsecd, and advises dry cupping when the child is not frightened thereby. Sluggish kidneys may be gently stimulated by capcine plasters or some mildly stimulating embrocation, and a flannel bandage worn day and night. It ought never to be forgotten that while the liability to heart failure is not as great in scroved fatal from spasm of the glottis, due probably to hypenemia of the vocal cords. Various other affections have been noted as occasional complications of this disease, among which may be mentioned furunculosis, osteitis, synovitis, otitis media, and submaxillary and cervical adenopathy, at times associated with inguinal bubo, and rarely going on to suppuration. Varicella may complicate or be complicated by other infectious diseases: such combinations as varicella and pertussis, varicella and measles, varicella and scarlatina, varicella, measles, and pertussis, and varicella, measles, and diphtheria, are occasionally observed. Profuseness of the eruption alone may constitute a serious complication, as is illustrated by a fatal case in an infant of eight and a half months seen by Ni.sbet, who attributed its death to the fact that the eruption covered every portion of the body, producing the effect of an extensive burn. Secondary infections are not very unusual. Of these erysipelas is the most common, and is always a grave complication. In a circumscribed epidemic 160 AMERICAN TEXT- BOOK OE DIREAiiEB OE CHILDREN. of 15 cases Bologiiini observed 12 in which secondary infection of the vesicles hj staphylococci and streptococci took place during the stage of desiccation, causing the vesicles to enlarge to the size of bullae, which, breaking, gave issue to a thick creamy pus. In one case, the only one resulting fatally from abscess of the kidney, pure cultui-es of the streptococcus were obtained. All of these children had transient albuminuria, without other signs of nephritis. Varicella Gangraenosa. — Among the secondary infections should be con- sidered the rare condition Avhich is described under this name. It Avas first brought to notice by Hutchinson in 1882, and Avas for a time thought to be peculiar to varicella ; but subsequent observations have shoAvn that an identi- cal process may occur in connection Avith vaccinia, pemphigus, and other dis- crete pustular lesions. Dermatologists now describe the general aftection under the name of dermatitis ganyrcmosa infantum. Tuberculosis, rickets, and inherited syphilis seem to exercise a predisposing infiuence, but it has been occasionally observed in apparently healthy children. As seen in connection with varicella, it may begin while the vesicles are still present ; it is then observed first upon the head or upper portions of the body. It will be noticed that ulceration has begun beneath the crust, and often a pustular margin Avith an inflammatory areola is found, resembling closely a vaccinal pustule. The destructive process extends in depth and periphery until it forms a black slough reaching an inch or more in diameter. After a time separation of the slough occurs, leaving a sharply-cut oval or roundish excavated ulcer. When the vesicles have been closely aggregated several gangrenous areas may coalesce to form larger ulcers of irregular contour. When the gangrenous process begins as late as tAvo Aveeks or more after the onset of the disease, after the varicellous lesions have healed, the ulcerations are more apt to begin upon the lower portion of the body, especially upon the buttocks and thighs. Pinhead-sized maculo-pustules first appear, Avhich in- crease in size, rupture, and form crusts, under Avhich the gangrenous process begins as in the case of pre-existing varicellous lesions. In the severer cases, Avhich begin early in the course of the exanthem, Imcm- orrhage into the vesicle precedes the other changes; and, Avith this, hsemor- rliages from the nose, mouth, or stomach, as Avell as beneath unaffected por- tions of the skin, may be observed. Such cases run a rapid course, and ter- minate with symptoms of general pyaemia. Of the pathology of gangrenous varicella nothing definite is knoAvn. There can be little doubt, hoAvever, that it results from a secondary infection, in the milder cases probably Avith the ordinary pyogenic organisms ; and in the more malignant cases, such as those recently reported by LockAvood and Silver {Arcltives of Pediatrics, Sept., 1897), the coincidence of an acute blood-infec- tion may be reasonably presumed. Even in its mildest manifestations gangrenous varicella is a serious affec- tion, but in the virulent types associated with marked blood-dyscrasia the prognosis is wellnigh hopeless. Diagnosis. — It is usually only to settle this important question that the physician is summoned. Apart from variola or its milder manifestation, vario- loid, eruptive vaccinia and herpes zoster are the only diseases Avith Avhich varicella might reasonably be confounded. From eruptive vaccinia, apart from the history of a recent vaccination, varicella may be distinguished by its successive crops of rapidly developed vesicles, which Avill have almost disappeared before the vaccinal lesions could have reached the height of their development and shoAvn a marked areola. CHICKEN-FOX. 161 From herpes zoster, its more general distribution, which does not follow the course of certain nerves, and the absence of pre-eruptive pain, should serve to differentiate it. From well-marked variola and varioloid, varicella should be readily distin- guished by a consideration of the following points of difference : Chicken-pox. Only infants and young children affected. Invasion short; general symptoms usually very light. Febrile stage transient, commonly highest at beginning of the eruption. Eruption vesicular almost from the first. Eruption superficial ; never shotty. Seldom umbilicated. Vesicles not distinctly multilocular. Vesicles always discrete. Eruption little on face, hands, and feet. No pustular stage. Uninfluenced by vaccination or previous small-pox. Variola, All ages affected. Invasion three days ; general symptoms severe. Initial fever falls with appearance of erup- tion, to be followed by the secondary rise with pustulation. Eruption papular for 3 or 4 days. Eruption deep-seated : hard, shotty. Generally umbilicated. Vesicles always multilocular. Eruption often confluent. Eruption most on face, hands, and feet. Pustular stage never absent. Prevented by vaccination or previous small- pox. Mild and abortive cases of varioloid occur, however, and present the great- est difficulty in diagnosis. The invasion may be short, and so mild as to attract no attention ; the lesions may be few and scattered ; fever may be insignificant ; and the vesicles may abort before reaching the pustular stage. In such a case error in favor of the milder disease is easily made, and may be followed by most disastrous consequences. Only a most careful study of the history and course of development of the attack can lead to a satisfactory decision ; and if the patient should happen to be an adult, this fact should weigh decidedly in favor of the more serious disease. Prognosis. — As a rule, when occurring in a previously healthy child, chicken-pox rarely gives rise to anxiety as to its outcome. Among debili- tated, strumous, and syphilitic infants prognosis should be more guarded, lest the gangrenous complication supervene, the prognosis of which has been already stated. Treatment. — A disease whose course and duration are fixed, and whose ending is almost always favorable, requires little aid from medicine. The child should be confined to bed during the active stage of the disease, and if fever be high a foot-bath should be given at the start, followed by a simple diaphoretic febrifuge. Except in the case of very young children, whose digestion is liable to passing disturbance from the disease, no special restric- tion in diet need be made unless the fever remains high for several days. As a rule, the eruption causes little irritation, and needs no treatment except a soothing dusting powder upon the back and upon the parts kept warm by the clothing. Upon the face large vesicles may be punctured early, and covered with a thin film of collodion to protect them against injury or secondary infection from scratching. For similar reasons the child’s hands should be disinfected and the nails kept clean and well trimmed. In all cases the urine should be watched, and from time to time during the course and convalescence should be examined for albumin or other evi- dence of nephritis. If convalescence be protracted’ and the child exhibit evidences of anaemia or disturbed nutrition, iron and cod-liver oil, with a bitter tonic, should be prescribed, with perhaps a change of air, preferably a short sojourn at the seashore. 11 162 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Gangrenous varicella demands a much more rigid treatment. Constitu- tionally, the strength must be kept up by nourishing diet and by liberal stimulation, according to the indications, with some suitable preparation of alcohol, with strychnine, and with quinine. Locally, the gangrenous lesions must be treated with antiseptic and deodorizing washes, such as solutions of permanganate of potassium, peroxide of hydrogen, or bichloride of mer- cury, and kept covered with a protective ointment containing iodoform, ichthyol, or some other drug of this class. Quarantine. — With a disease ordinarily so benign little effort is usually made to carry out quarantine. In many children’s hospitals epidemics of varicella run their course unchecked, usually for want of sufficient facilities for isolation ; and ordinarily the disease seems to have little disturbing effect upon the children except in the rare instances where a gangrenous compli- cation occurs or among the athrepsic babies, as already pointed out. In family practice a period of three weeks from the beginning of the disease may be considered a sufficient time for isolation. As with other infectious diseases, a thorough cleansing of the body and scalp and a change of clothing should be ordered before the child is allowed to mix with his playmates again. Without such precaution the danger of infecting others may last for some time, as was instanced in a case coming under the author’s observation where the disease was communicated to an infant by a child who had recov- ered from an attack fully four weeks before the only occasion of their meeting and playing together. VARIOLA AND VARIOLOID. By C. G. JENNINGS, M. D., Detroit. Variola, or small-pox, is an acute, specific, highly infectious disease, characterized by a typical range of temperature and a specific inflammation of the skin appearing usually on the third day of the disease as a papular eruption, which quickly becomes vesicular and finally pustular. The pustules desiccate, and leave permanent cicatrices wherever suppuration has invaded the deep tissue of the skin. Etiology. — The nature of the contagium of variola is unknown ; analogy, however, points to a micro-organism as the infectious principle. There is no evidence of the development of the disease de novo, each case being transmitted from a parent case in another individual. Individuals of both sexes and of all ages, unprotected by vaccination, are subject to the disease. Even the foetus in utero does not enjoy immunity. The disease is transmitted by direct contact, through the medium of infected articles and through the air. While scarlatina, measles, and other exanthemata will infect at the distance of only a few feet, small-pox has a striking distance that is very much greater. In the Sheffield epidemic (1887) the influence of the Sheffield hospital could be traced over an area having a radius of four thousand feet. One attack, as a rule, renders an individual immune. In countries where the disease is prevalent a second attack is not uncommon. The writer saw a negro woman, ill with discrete variola, who was sadly disfigured by two previous attacks. The disease prevails most extensively among unvaccinated communi- ties. The negro race is particularly susceptible. The disease is most infective during the periods of suppuration and desiccation. Although apparently inde- pendent of climate, small-pox is a disease of the winter and spring. Pathological Anatomy. — The characteristic anatomical lesion of variola is found in the skin and mucous membranes. Small areas of congestion appear in the skin. The vessels of the corium dilate and become tortuous, and the connective tissue in the centre of the congested areas is thickened by oedema. Coagulation necrosis of the epithelial cells quickly follows, with thickening of the epidermis. These changes form the papules. Serum is poured out between the necrotic cells, and a vesicle forms. The changed cells form a meshwork in which the fluid is enclosed. Trabeculm bind down the centre of the vesicle, while its periphery continues to distend, producing umbilication. Pus-cells form rapidly in the vesicle, and in a few hours it is transformed into a pustule. Inflammatory injection and thickening of the connective tissue surrounding the pustule now take place. If the necrotic process is confined to the superficial layers of the skin, resolution takes place without pitting. If the deep tissue is involved, a cicatrix results. Desiccation of the pustule follows, leaving a crust of dried cell-ddbris and pus adhering to the skin. Then the epidermis re- 163 164 AMERICAN TEXT-BOOK OE DmEASES OF CHILDREN forms under the crusts, the inflammatory injection and infiltration subside, the crusts drop off, and resolution is complete. The process in the mucous membrane is the same. Perfect pustules, how- ever, are rarely seen, because the macerated roof yields early to the pressure, and an aphthous-looking ulcer results, often covei-ed by a pseudo-membrane. In hmmorrhagic small-pox the pustules contain blood, and extravasations may occur in the skin and mucous membranes at any point, and in the substance of all the organs. More or less intense congestion and septic inflammation may be found in the brain, liver, lungs, kidneys, and spleen. Incubation. — The duration of the period of incubation of variola is, on the average, twelve days. Exceptionally it may be shortened to ten or length- ened to fifteen days. When transmitted by inoculation the disease appears on the eighth day or sooner. During the period of incubation the child, as a rule, shows no symptoms. Symptoms. — The clinical history of small-pox may be divided into four stages : Invasion ; eruption ; secondary fever ; desiccation or decline. The stage of invasion is ushered in abruptly. Older childi’en complain first of chilliness, and often there is a distinct rigor. The phenomena of severe fever quickly follow. In addition to the usual symptoms of fever there are headache of unusual severity, persistent vomiting, great prostration, and severe backache. In younger children and infants the disease begins with fever, great nervous irritability, and vomiting. Very often convulsions mark the onset of the disease. They may be frequently repeated, Avith inter- vals of stupor or delirium. The skin is dry or perspiring ; the tongue coated, with dark-red edges. The bowels may be constipated, but often a sharp diarrhoea is present during the whole of the invasion stage. Abdominal pain and tenderness are frequent. Respiration is rapid. The pulse is full and quick, ranging from 120 to 160. The temperature ([uickly reaches a high point, ranging from 102° to 105° F., or higher. The high temperature is maintained during the invasion stage with but slight remissions. The maxi- mum temperature of this stage is usually reached just before the appearance of the eruption. Partial paraplegia, numbness, and incontinence of urine and fmces, are sometimes seen in children. In children more fre(piently than in adults initial or accidental rashes appear about the second day, and cause much difficulty in diagnosis. The initial rash may be erythematous, simulating scarlatina or erysipelas ; or macular, simulating measles. It is very evanescent, and usually ushers in an attack of varioloid. A number of observers have noted that the areas of skin affected by the prodromal rash escape the variolous eruption. Petechim from one-twelfth to one-fourth of an inch in diameter are sometimes seen in this stage of the disease scattered over the lateral thoracic and lower abdominal regions. This rash is often of grave ]>rognostic significance. The average duration of the stage of invasion is three days. In grave cases it is often shortened to two, while in varioloid it is often j)rolonged to four days. As a rule, the longer the incubation stage the milder will he the suhse(|uent course of the disease. Notable exceptions to this rule are the delayed rashes of cases complicated by severe internal diseases, and, as Moore observes, of cases showing an early lucmorrhagic tendency. The Stage of Eruption . — On the third day of the disease, with the vari- ations noted above, the true rash of small-pox begins. The eruj)tion shows first on the face, (juickly extending to the scalp and nock. Exceptionally it covers the wrists early. After the face and neck, it next invades the trunk, extremi- ties, and finally the palmar and plantar surfaces, taking from twenty-four to VARIOLA AND VARIOLOID. 165 forty-eight hours to cover the cutaneous surface. Rarely, in very young infants, the rash appears first about the lower part of the abdomen and on the inside of the thighs. Other e.xceptions to the usual sequence are sometimes met. The rash is most abundant on the face and on the back of the hands. It shows early and abundantly on irritated areas of skin. The eruption begins as small, slightly raised, pale-red macules, and passes through four stages of development — viz. macules, papules, vesicles, and pustules. The macules in a few hours become fine, conical papules, pin-head in size and larger. The papular stage continues for two days. The w'ell- developed papules are hard and sliotty to the sense of touch, “ feeling like grains of shot underneath the skin.” Gradual augmentation in the size of the papules takes place. On the third day a minute vesicle appears at the apex of the older papules ; it rapidly grows, and transforms the papule into an umbili- cated vesicle with cloudy contents. By the fifth day of the rash the fluid in the vesicles becomes turbid, and by the sixth day it is distinctly purulent. The eruption has now' reached the pustule stage, or stage of vxaturation. The mature pock is globular and about the size of a pea. The increase of the con- tents has distended the chamber and removed the umbilication. The pustule is, in fact, a small abscess. It is usually surrounded by a swollen, red, inflam- matory zone, the halo of the pustule. Synchronous with the development of the cutaneous eruption a true vario- lous exanthem appears upon the mucous membranes. The visible mucous membranes are nearly always affected, and, in severe cases, the rash extends throughout the whole alimentary and respiratory tracts. The urethra, vagina, and conjunctivfe are often invaded. With the appearance of the eruption a remarkable amelioration in all the symptoms takes place. The temperature rapidly falls, often reaching the normal point or a little above on the fifth or sixth day. This fall of the tem- perature is pathognomonic of the disease. The pulse loses its rapidity and the gastric and intestinal irritability subsides. In cases of severity the remis- sion is less marked, and the severe symptoms of the incubation stage persist with but little relief. In discrete small-pox convalescence often sets in after three or four days of the mild febrile movement which follows the sharp decline of the beginning of the eruptive period. In children, with the beginning of the vesicular stage the eruption in the mouth and throat becomes a source of distress and danger. The vesicles rup- ture, and a streptococcus pseudo-membrane covers the resulting erosions and often extends over a large area of mucous membrane. Nasal and pharyngeal obstruction results, with distressing symptoms, and if the larynx be invaded, croup with dangerous stenosis may supervene. In typical variola the maturation of the rash is accompanied by the onset of the secondary fever or fever of suppuration, which is of indefinite duration and varies in intensity with the severity of the attack. The child becomes restless and there is mild or active delirium. The temperature ranges from 101° to 104° F., w'ith morning remissions and evening exacerbations. The pulse is quick and hard. Often the symptoms assume the typhoid type, with low delirium or stupor, a rapid, feeble pulse, and subsultus tendinum. A tem- perature that frequently rises above 104° during the stage of suppuration is of grave significance. (See Fig. 1). The stage of desiccation or decline begins on the twelfth or thirteenth day of the disease. The pustules begin to dry up, the inflammation and swelling of the skin subside, the temperature gradually flills, and there is a general improvement in all the symptoms. Many of the pustules rupture and the 166 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. exuded contents form discrete or coalesced crusts. Cicatrization goes on under- neath the crusts, and they finally drop off, leaving dark, violaceous blotches that Fig. 1. Temperature Chart of Variola of Moderate Severity. are gradually changed to white, irregular, depressed cicatrices. The ivhole course of the disease occupies from three to five weeks. Based upon the distribution and amount of the rash, variola is classified into — (1) Discrete variola, in which the rash is scanty and the individual lesions are more or less separated from one another by healthy skin. The disease is rarely dangerous to life, its symptoms are mild, and its course is often interrupted before the development of the pustular stage. The secondary fever is absent or of short duration. (2) Confluent variola, which is marked by an eruption that covers almost the entire cutaneous surface and invades the mucous membi’anes with great severity. The pustules upon the hands and face “run together, so that the epidermis is raised by a milky, sero-purulent secretion;” on other jiarts of the body the eruption is more or less discrete. The invasion stage is severe, and the rash ajipears as early as the second day. Severe vomiting and diarrhoea, stomatitis, salivation, pseudo-diphtheria, great and jiainful swelling of the face, hands, and feet, pymmic abscesses, high fever, violent delirium, and great pros- tration are marked features of this type of the disease. The mortality is great, and convalescence is very slow and often interrupted by serious se((uehe. In addition to these chief varieties we recognize — (3) Hcemorrhajiic variola, a malignant form of the disease, characterized by profound alterations of the blood, leading to the formation ot petechial blotches and ccchymoses and more or less profuse luemorrhages from the mucous membranes. VARIOLA AND VARIOLOID. 167 (4) Varioloid is variola modified in its course, duration, or intensity by vaccination, previous attacks of variola, or inherited insusceptibility. The invasion stage of varioloid is more irregular in duration than that of unmodi- fied variola, and the symptoms may be so mild as to escape observation, or so intense as to simulate the onset of grave variola. Three types of variation in the clinical history of varioloid may be distinguished : («) After an invasion stage of the severity of typical variola a copious eruption appears. With the appearance of the rash, however, a rapid defervescence begins, and the eruption is aborted in the papular or the vesicular stage. If it go on to the pustular stage, the pustules quickly run their course without causing much discomfort to the patient, and leave only faint cicatrices or none at all. Or, {b) the dis- ease runs a course typical in all respects, but the pustules are few in number and the accompanying symptoms very mild. Again, (atients, and were rich in the microbe. The investigations of Ca])itan and Cliarrin in this field have been more extensive than others, and liave to a great degree furnished a basis for other work. They first examined the blood, saliva, and urine from six cases. In the blood were found small, mobile microbes in great numbers, most of them being spherical, but some rod-shaped. Similar bodies were found in the saliva, while in the urine they detected neither albumin, sugar, nor microbes. In 1881, after a study of the blood in thirteen additional cases, they were able to confirm their previous discoveries. They jiarticularly de.scribed a bacterium two to three thomsandths of a millimetre long and also a small micro- coccus, the microbes appearing singly, doubly, and in chains, (biltures of the microbes were successfully made, but inoculations of dogs, rabbits, and guinea-i)igs were negative. These discoveries were verified by Yddrenes, Bouchard, Netter, and Boinet, the latter finding the microbes in the blood of fifteen patients, also in pus from an abscess of the nucha. Ollivier found the microbes in saliva, urine, and blood from three subjects, and suggested that failure in the inocula- tion of animals was due to the insusce})tibility to parotitis of all s))eciesof animals PAROTITIS. 179 upon which experiments had thus far been conducted. He believed that we could now see in parotitis not the simple effect of cold, or a manifestation of the rheumatic diathesis, or a propagation of a phlegmasia of the mouth, but an infectious disease caused by a specific agent and propagated by the diffusion of that agent. Jaccoud has expressed himself almost equally hopefully. In the simple or immediate form, which is the usual one in most epidemics, the contamination of the atmosphere with the infectious elements, especially in schools or barracks, in which the air-supply is deficient, explains its dissemina- tion. This statement harmonizes with the fact that it is most prevalent in damp and cold weather when the windows and doors of houses are closed and the tend- ency or the necessity is to remain in-doors. The elements of the disease are also carried from house to house in the clothes of physicians and visiting friends. This explains the prevalence of epidemics in sparsely-settled localities. Infec- tion is probably acquired in respiration, and those who are mouth-breathers are the more susceptible. Whether the long period of incubation which follows the reception of the infective influence means retention of the elements in the ducts of the salivary glands or in the glands themselves, or whether there is a process of germination within the blood and localization in the glands, we do not know. The latter is the more reasonable hypothesis from the analogy with other infective germs which are known to develop in the blood. As in all other infectious diseases, the intensity is governed partly by the activity of the infec- tious elements and partly by the resistance of the individual. In the secondary, metastatic, or symptomatic variety of infectious parotitis the inflammation is a complication of a pre-existing disorder. The list of diseases in which it may play such a role is a long one, including the infectious diseases in general, besides nephritis, pneumonia, meningitis, and surgical injur- ies of all kinds ; for in all of them sepsis, and hence infection, are possibilities. As an evidence of extensive or general systemic infection it is a symptom of grave significance. With the diathetic diseases, tuberculosis, syphilis, and rheu- matism, its significance is less grave than with the acute infectious diseases. In this variety we c.annot refer to a specific microbe as its origin. Some of the conditions with which it may be associated have such origins (diphtheria, pneumonia), and whether the complicating parotitis is due to the irritating effect of such specific germs which have been retained within the gland, or whether it is caused by those germs (streptococcus, staphylococcus) which produce severe inflammation wherever localized, we do not as yet know. Incubation. — The period of incubation of parotitis is a long one, but it varies with the resisting power of the individual and the virulence of the infective material. The long period of incubation, with the complicating con- ditions which may arise in the mean time, may delay the determination of the diagnosis. J. Lewis Smith regards the disease as primarily a systemic infec- tious one, with an incubation period of nine to twenty-one days ; A. Jacobi fixes it at two to three weeks ; Dauchez, at fifteen days ; Roth, at eighteen days ; and Nicholson reports a case in which an interval of six weeks elapsed between the involvement of the two parotid glands. Symptoms. — The long period of incubation may be attended by symp- toms of impending trouble. This is especially true with young children. There may be malaise with moderate rise of temperature for several days, and with very young children there may be convulsions, especially if digestive dis- order coexist. With glandular swelling come also induration, sensitiveness, pain on motion of the neck or jaw, loss of appetite, restlessness, and insomnia. With the progress of the inflammation infiltration of the gland and the sur- rounding tissues increases, and fever is more pronounced. These symptoms 180 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. may continue for a ■week, and gradually subside, or the duration may be less prolonged. The induration will gi’adually disappear and normal conditions be resumed, or the gland may be permanently enlarged or it may atrophy. In a certain number of cases abscess or gangrene will ensue, the gland will be destroyed, and the final result be fatal ; but in the great majority these are cases in which the system is so saturated with septic products that the outcome would be fatal even if parotitis did not exist. The inflammatory action which involves the parotid glands may include also the other salivary glands, and even the cervical lymphatic glands. These com- plications are frequently overlooked, being overshadowed by the more exten- sive and apparent affection of the parotids. The appearance of an individual with parotitis is sufficiently characteristic : there is glandular swelling, with hardness and pain ; the swelling may be considerable or inconsiderable, and of course the disfigurement of the face and neck will be governed accordingly. The pain is constant and severe, especially in young children ; deglutition is dif- ficult and often impossible on account of its painfulness. If abscess develops, the pain has the acute throbbing character of abscess-formation everywhere. Pain in the contiguous structures of the ear is almost always a marked feature of the disease, and the nearness of the carotid artery and cerebral meninges introduces elements of danger which must always be remembered, for serious results in this quarter are by no means unknown. Considering the possibilities of serious consequences, the small percentage of fatal cases when the disease is uncomplicated is quite remarkable. Complications. — In the traumatic form, in which the inflammation is a simple one, complications are unusual. The inflammation subsides, as such conditions do elsewhere, the result being resolution in the mild cases and sup- puration in the severe ones, especially if the tissues have been bruised and broken. In the epidemic infectious form complications are extremely common, the genital organs being most fre([uently implicated. Thus with males there is often an involvement of the testicles, spermatic cord, and inguinal glands ; with females, the mamnim, ovaries, labia majora, and inguinal glands. These complications may not be evident until the symptoms in the parotid gland have begun to subside. In a recent epidemic in which one hundred and seven- teen cases were observed by Demme, two were fatal from gangrene of the paro- tid glands; in three there was abscess of the cervical glands; in two there was acute nephritis. Musgrove and Slagle each saw a fatal case complicated with ui’femia. P. Smith saw two cases which were followed by insanity, and Par- rott one which was complicated with orchitis and meningitis. F. W. Brown records an e{)idemic of twenty cases in a boys’ school, ten of Avhich were com- plicated with orchitis. Jackson observed four cases complicated with influenza. This latter complication is more frecjuent than is generally supjmsed. The writer recently saw such a case in an infant fourteen months old. Among the secpiehe of the disease JoffVoy mentions peripheral neuritis, with paralysis of the extremities lasting four months. Botch and Moure each saw two cases of deafness ; and Dufour, inflammation of the lachrymal glands. The evidence is therefore abundant that we have in parotitis an infectious disease with multiple localization. Treatment. — If the disease be, as it appears, an infectious one, we have, as yet, no method of treatjuent for aborting it. When the symptoms are apparent, the indication is to relieve them as they arise. The ])ain may bo soothed by small doses of Dover’s ))owderor paregoric, or pbenacetin combined with salol. Hot apj)lications to the inflamed ])arts are always grateful, ami the surface may be kept moist with anodyne liniments, ’fhe bowels must be PAROTITIS. 181 kept open, fever may be reduced with aconite, and the diet must be fluid and concentrated. Hot liquids will usually be preferable to cold, and will be more quickly assimilated. The skin should be kept active by daily -warm baths, by alcohol, and by gentle friction. The opiates suggested will usually be sufficient to relieve restlessness and induce sleep. As soon as the acute symptoms have subsided the nutrition should be improved as rapidly as possi- ble, and a tonic of iron, quinine, strychnine, and arsenic will be indicated. Quarantine. — An important practical question is that relating to the time in which patients with infectious parotitis should be isolated. This especially concerns children who are attending school. A recent paper by Rendu is devoted to this aspect of the subject. His studies have led him to believe that the time of greatest danger of contagion is at the close of the incubation period, at least twenty-four hours before the disease can be diagnosticated. Sevestre and Comby had reached this same conclusion. If this be a fact, Rendu’s opinion that it is irrational to keep children out of school three weeks after the symptoms of the disease have subsided is a just one, and teaches that isolation should be limited to a period included between the time when the first symp- toms appear and the time when the active symptoms have subsided. WHOOPING-COUGH. By J. P. CROZEH GRIFFITH, M. D., Philadelphia. S 3 monyms. — Pertussis ; Tussis convulsiva ; Hooping cough ; Chin cough. Whooping-cough is a zymotic, contagious disease of childhood, character- ized by a catarrh of the respiratory mucous membrane and a peculiar paroxys- mal cough. No description of any disease resembling pertussis can be found in the writings of the Greeks, Romans, or Arabians, and it seems probable that the failure to mention such a peculiarly characteristic disorder is proof that it did not then exist at all, or at least in parts of the world with which medical writers were acquainted. In fact, no account of it is found until Baillou, in 1578, described an epidemic which occurred at Paris, and spoke of it as an affection not previously known. Little or nothing more was heard of it for about a hundred years, when Willis tussis puerorum convulsiva” in such a manner that its nature and its identity with the pertussis of the present day can admit of no doubt. Epidemics did not become frequent until the eigh- teenth century, but the disease then rapidly sjiread, and by the middle of that century had become widely diffused. From that period onward it has been steadily on the increase, until it constitutes at present one of the commonest diseases of childhood. Etiology. — There are certain factors which seem to exercise a decidedly predisposing influence iqion the development of pertussis. There is a very distinct tendency shown for it to occur in epidemics, which appear at intervals of about two years, yet with no great regularity in this respect. The disease may, however, occur sporadically, although such cases are always the result of some preceding case. In the larger cities it is practically endemic, although at times greatly more jirevalent than at others. The previous occurrence of the disease in an individual precludes the de- velopment of a second attack. Nevertheless, undoubted exceptions to this rule have been occasionally reported, though they are certainly rare. Whooping-cough is more prevalent in the civilized portions of the world, but its absence from any region seems to depend rather on the fact that it has not yet been carried thither than on any conditions of climate or of race which are unfavorable to its existence. The influence of season has been much disputed, and the evidence is conflicting. It is certainly no powerfully predisposing factor. The station in life and the general hygienic conditions existing appear to be without influence, except in so far as the ill-ventilated houses of the poor may possibly favor the increase of the germs in number or in virulence, even as the crowding and lack of isolation certainly favor their diffusion. The previous state of the health seems to possess some predisposing power. 182 WHO OPING- CO UGH. 183 Most observers agree that weakly, sickly children more readily contract whooping-cough than do those in good health. It is a well-recognized fact, also, that there is an intimate association between epidemics of measles and of whooping-cough, and it is very widely believed that the existence of the first disease strongly predisposes to the later development of the second. Whether or not the association is an accidental one is still unsettled. The actual pres- ence of any other disease is certainly no bar to the occurrence of pertussis. As with other infectious disorders, there exists a certain individual suscepti- bility to it. Some children never contract it, though often exposed. Age exercises a powerful influence on the development of whooping-cough. By far the greater number of cases occur before the sixth year. After this time the frequency of occurrence diminishes very rapidly, and after the tenth year it is comparatively infrecjuent. West estimates that over one-half the cases develop under the age of three years. It is sometimes seen in adults, but this is rather uncommon ; the rarity being due partly to the fact that so many have suffered from it while children, and partly to a lessening of the susceptibility with advancing years. It is not common during the first six montlas of life. It is, however, distinctly more liable to occur at this time and up to the age of one year than are the other infectious disorders of child- hood. There are even a few well-authenticated cases reported in which it appeared to have been contracted during foetal life. It has been widely stated that girls are more liable to develop whooping- cough than are boys. Statistics, however, are somewhat at variance, but certainly show that there is no very material difference in the number of each sex attacked. The sole exciting cause of pertussis is contagion, and so powerful is this contagiousness that by far the greater number of children exposed to the disease will contract it. It is contagious during any part of its course, but particularly in the paroxysmal stage. It is least so in the terminal stage. The nature of the infectious principle can best be discussed when considering the pathology of the affection. As a rule, actual contact with, or close approach to, the sick child is neces- sary for its development in a second case, but even a momentary exposure of this sort is often sufficient to ensure an attack. Several observers have claimed that the disease does not spread readily in w’ell-ventilated and roomy hospital wards. My own experience has not been at all in accord Avith this. The infectious germs appear to be located in the secretion of the respiratory tract, and are spread by this and by the expired air. Cases have been reported which show that whooping-cough is mediately contagious through a third party or through handkerchiefs or clothing which have presumably been infected by the sputum of a patient. It is probable, however, that the disease is rarely contracted in this way. The contagiousness of pertussis extends slightly to the lower animals, and cases are on record in which these have contracted it from the human subject. The path by Avhich the germs enter the system is not certainly known. Although nearly all the evidence is in favor of the respiratory tract, the few published cases of pertussis in the new-born indicate the possibility of their entrance in other ways, as by the foetal circulation. Pathology. — There are no post-mortem appearances characteristic of per- tussis. The most constant change found is redness and swelling of the mucous membrane of the respiratory tract, with the presence of a considerable (juantity of viscid mucus. There is often observed a tendency to congestion of various parts of the body, due to the disturbance of the circulation which naturally 184 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. attends the paroxysms. There are also found the various lesions correspond- ing to the complications which have existed during life. The nature of pertiussis has been a much-mooted question, and is not even yet entirely settled. It has been frequently claimed that the disease is a functional disturbance of either the pneumogastric, phrenic, recurrent laryngeal, or sympathetic nerves or of the medulla. According to this view, it is simply a neurosis. Other writers have viewed it as a simple bronchial catarrh due to cold merely, with which is associated a certain nervous element. En- largement of the tracheal and bronchial glands has also been urged as the cause of the disease, through their irritating pressure upon the terminal fila- ments of the pneumogastric nerve. The eminently contagious nature of whooping-cough, its occurrence in epi- demics, the existence of a period of incubation, and the immunity from second attacks seem to prove beyond a doubt that it is to be classed among purely infectious disorders. Although this is the view Avhich has recently found very general acceptance, it is by no means a new idea. Even Linnaeus attributed pertussis to the presence in the nose of the larvae of insects. Poulet dis- covered bacteria in the expired air of patients with pertussis. Letzerich found a micrococcus in the sputum which he believed to be the specific germ, and was able to produce the disease in animals by introducing the secretion into the trachea. Deichler claimed that there was always present in the sputum an organism of the nature of a protozoon which possessed amoeboid motion. But, although other investigators have repeatedly described various organisms as existing on the respiratory mucous membrane, the researches of Afanassiew in 1887 have attracted the most attention. This observer isolated a short bacillus, which he named the bacillus tussis commhivcp, and of which he was able to obtain pure cultures upon various media. Animals inoculated upon the respi- ratory mucous membrane with these cultures exhibited some of the symptoms of the disease and developed catarrhal conditions of the respiratory tract, with a tendency to broncho-pneumonia. These observations have been confirmed by others, and a toxine has also been reported as present in the urine of patients with pertussis which is identical with that ju’oduced by Afanassiew’s bacillus. Even though it be admitted as most probable that some micro-organism is the cause of the malady, it is by no means clear how the symptoms are pro- duced or where the principal seat of the infection is. Some writers have claimed that the trigeminal nerve is in a sensitive state, and that it is the irri- tation of its terminal filaments by the infectious catarrhal process on the nasal mucous membrane which brings on the paroxysms by a reflex action. Others, again, have stated that the bronchial mucous membrane is the portion of the respiratory tract chiefly involved, and that the terminal filaments of the pneu- mogastric are those irritated. The careful investigations of Meyer-Iliini and of V. ITerff, however, indicate that the catarrhal inflammation is most j)ro- nounced in the mucous membrane of the nose, larynx, and trachea down to the bifurcation, but especially so on the posterior wall of the larynx in the inter-arytenoid region, the so-called “cough region.” In the production of the cough it would seem ju'obable that a small (juantity of mucus, perhaps arising from below, accumulates upon the surface of the “cough region,” and there irritates ])owerfully the hy))er-sensitive filaments of the superior laryngeal nerve. Through a reflex action a series of clonic spasms of the exj)iratory muscles is then set up. At last the crowing insj)iration occurs, this (lei)cnding upon a spasm of the glottis, which, in its turn, j)rocecds from an irritation of the convulsive centres in the medulhi. This process is repeated again and again until the offending secretion is expelled. WHO OPING- CO UGH. 185 The presence of this secretion does not seem, however, to be an essential to the production of the cough, since paroxysms may be brought on by excite- ment and other causes. This appears to indicate that the irritation of the superior laryngeal nerve may be central, due to systemic infection. A great preponderance of the nervous element of the disease over the catarrhal is further shown by the greater frequency Avith which the paroxysms occur at night, since this condition very possibly depends upon a less degree of resistance of the respiratory centre during the night, and a consequent greater ease with Avhich convulsive expiratory efforts are brought about. We therefore clearly have to do in Avhooping-cough with an infectious, catarrhal process Avhicli affects particularly, and produces an unusual sensitive- ness in, the mucous membrane presided over by the superior laryngeal nerve. But still more prominent is a great excitability of the nerve itself and of the other nei’vous portion of the respiratory apparatus, this being probably due to the circulation in the blood of some noxious substance, the product of the in- fecting germs, which possesses a special potver over the portion of the nervous system Avhich controls cough. The apparent value in many cases of local treatment directed to the respiratory mucous membrane indicates that the abode of the germs is in this region, whence the poisonous products of their growth are absorbed. On the other hand, the existence of pertussis in the new-born, the result of foetal infection, points to the presence of the microbes themselves in the circulation and in other parts of the body besides the respi- ratory tract. From this point of vieAV their situation in the latter region would be a localization entirely secondary to the general systemic infection and, so to speak, excretory. Which of these theories is correct cannot as yet be deter- mined, although the resemblance of the disease to other infectious disorders cer- tainly supports the latter view. Incubation. — A period of incubation precedes the development of the symptoms. Its exact duration cannot be easily determined, since the onset of the disease is so insidious, and statements vary in regard to it. It is clearly somewhat variable in length, and probably lasts from two to seven days, wdth an average of three to four days. Symptoms. — It is customary to divide the course of the disease into three stages : 1st, the catarrhal or premonitory stage ; 2d, the paroxysmal or con- vulsive stage ; and 3d, the terminal stage or stage of decline. This classifica- tion is convenient, but somewhat artificial, since the stages only very gradually pass into each other, and their duration cannot, therefore, be accurately deter- mined. 1. Catarrhal Stage . — There is little in this Avhich is characteristic of the disease. The child gradually begins to exhibit symptoms of a severe cold, with malaise, perhaps slight hoarseness, stoppage of the nose, tickling in the throat, sneezing, irritation of the eyes and a dry, annoying cough. Fever is generally slight and apt to come on in the evening only. Although it has been claimed that the elevation of temperature is an evidence of the infection, it is more likely that the degree of fever is dependent solely upon the intensity of the catarrh. Under treatment there may be a temporary improvement in some of the symptoms, but all of them soon return in force, and the cough particularly is troublesome and gradually grows worse in spite of medicine given. As days pass by it shows a greater tendency to occur in long, severe paroxysms, and is also much more annoying by night. On examination of the chest only a very few rfi,les may be heard. Nothing, indeed, is found to account for the severity of the cough. Sometimes, though less commonly, the first stage is characterized 186 AMERICAN TEXT-BOOK OF BBSEARES OF CHILDREN. by a severe bronchitis, with corresponding auscultatory signs and the presence of high fever. The duration of the first stage averages about two weeks, but it is subject to great variations. Sometimes only two or three days elapse before the child begins to whoop. The younger the age, the shorter, often, is the duration of the catarrhal stage. In some instances the disease never passes beyond the first stage, the diagnosis in such cases depending largely upon the existence of the affection in other members of the family. 2. Paroxysmal Stage . — The complete development of the paroxysmal cough marks the beginning of the second stage. The exact time of onset is, as already stated, often difficult of determination. Except for the rarer cases in which the whoop never occurs, it is convenient and most customary to date the paroxysmal stage from the first appearance of this symptom. The paroxysm of pertussis — or the “ kink,” as it is frequently called — is very characteristic. Just before it begins the child seems anxious and irri- table, or perhaps very quiet. It experiences some sort of a warning sensation, as a pain in the region of the sternum, or nausea, or a tickling in the nose, or a similar sensation in the larynx with an irresistible desire to cough. It at once drops its playthings, runs to its mother or nurse, or grasps some near object for support; or, if asleep, quickly rises, sits upright, and begins to cough. Sometimes, however, the cough seems to come suddenly, without the premoni- tory sensation. The cough consists of a number of short, explosive expiratory efforts very rapidly following one another, and without any inspiration between them. These continue so long and are so violent that the face becomes turgid and cyanotic, the tongue is protruded and driven against the teeth, saliva flows from the mouth, the eyeballs are ])rominent, the eyes water, and the pulse becomes rapid and small. The paroxysm lasts a few seconds until at last both cough and all respiration cease. Then comes a peculiar, loud, crow- ing inspiration, the tvhoop., which is the result of the air passing through the spasmodically closed glottis. Immediately there begins another series of expiratory efforts, to be again followed by the whooping inspiration ; and this process repeats itself several times. The later series of expulsive efforts is accompanied by abundant expectoration of ropy mucus and very often by vomiting. As the paroxysm ceases the CAUinosis disappears, and the child is often left pale and exhausted for a short time ; but if it is strong and other- wise well it soon resumes its play. Sometimes a crowing ins])iration imme- diately precedes the first series of expirations. Occasionally, too, after the attack seems to be over there is a ])eriod of rest for a moment, and the whole process is then repeated. A series of paroxysms may thus continue for as long as ten to thirty and even more minutes. The usual duration of an attack, hoAvever, is from a few seconds up to one or two minutes, ff'he swell- ing of the face, the puffiness of the eyes, and some degree of blueness of the tongue persist more or less between the paroxysms, and may constitute (juite notable features of the disease. In l)ad cases the ])avoxysnis may be attended by haemorrhage from the mouth or nose or beneath the conjunctiva or else- where. Involuntary voidance of urine or ficces may be occasioned by the vio- lence of the attack. The fre(iuency of paroxysms and their intensity vary greatly. In mild ca.ses there may not be more than six to twelve in the twenty-four hours, while in the severer ones tliey may number from forty to eighty. They are always more numerous at night. An attack of coughing is often brought on by exercise, crying, singing, loud speaking, eating or drinking, excitement of any kind, a sudden change of temperature in the air, or the breathing of air WHO OPING- CO UGH. 187 overloaded Avith carbonic dioxide. Depression of the tongue Avitli a spatula, producing gagging, is very apt to bring on an attack. The general condition of the patient does not suffer materially in mild cases. Sometimes, however, there is much exhaustion from the frequent coughing and the loss of sleep, or vomiting may so regularly folloAV the paroxysms that the nutrition suffers greatly and emaciation becomes marked. In the milder cases vomiting does not at all interfere with the appetite, and the child is soon ready to eat again ; so that quite sufficient food is retained for the bodily needs. More or less fever may occasionally be present in the second stage, espe- cially at night, but, as a rule, fever is absent, and if continuously present makes the existence of some complication probable. The urine in whooping- cough sometimes contains sugar and frequently albumin. It was at one time claimed that it was ahvays saccharine. Auscultation of the chest in the interval between the paroxysms reveals nothing abnormal, or only the presence of a few mucous rales. During the whooping inspiration nothing at all, or at most only a very feeble inspiration, can be heard. During the expiratory efforts, too, very little respiratory sound is audible, and scarcely more than the sensa- tion of a series of impulses can be perceived. The total duration of the paroxysmal stage is exceedingly variable. In general terms it may be given as from three to six Aveeks, hut it may last a shorter or a much longer time than this. 3. Terminal Stage . — The second stage merges so gradually into the suc- ceeding one that no exact boundary between them can be recognized. The third stage may be said to begin Avhen the severity of the disease is clearly diminishing. The attacks noAv groAv less frequent and less severe ; the Avhoop- ing and vomiting persist for a time, but gradually disappear ; and the cough, although still paroxysmal, groAvs distinctly looser and of a more catarrhal nature, and finally assumes the character of that of simple bronchitis. Hem- orrhages occur much less frequently, if at all ; the bronchial secretion is noAV more muco-purulent, and the general health, if previously affected, improves. Finally the cough disappears entirely and the disease is over. The duration of this stage is very variable. It may last from about ten days up to several months, depending upon hygienic and other conditions. Thus the approach of the Avinter season is liable to prolong it indefinitely. Not infrequently, after all cough has ceased and the child has appeared Avell, the development of a nasal or bronchial catarrh may be attended by a return of the paroxysms. Such a return cannot, hoAvever, be properly desig- nated a part of the third stage. Complications and Sequelae. — Of the very numerous complications of pertussis those connected Avith the respiratory tract are most prominent. Bronchitis may be so in excess of the degree of catarrh usually present that it constitutes a complication. This is not an infrequent occurrence. Atelectasis very often develops in young children. It may affect only a small part of the lung or may be more extensive and threaten life, and is especially apt to be Avitnessed in Aveakly and rachitic children. Widespread broncho-pneumonia is one of the most common and most dangerous complications of Avhooping- cough. It usually comes as a result of atelectasis, but sometimes independ- ently of it, and tends to run a very tedious course. As it develops the paroxysmal nature of the cough is very liable to diminish or disappear. Like atelectasis it is particularly prone to be seen in Aveakly children or Avhen measles has immediately preceded pertussis, or in children who have been sub- jected to improper hygiene, especially exposure to cold. Pleural effusion. 188 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. empyema and croupous pneumonia are of less frequent occurrence ; pneumo- thorax is rare ; emphysema is common, but is generally only temporary. Sometimes, however, it is permanent throughout more or less of the lungs. Emphysema of the subcutaneous connective tissue has been reported but is very uncommon. (Edema of the glottis is sometimes seen. The coexistence of pseudo-membranous laryngitis is to be regarded as accidental. A complication so frequent that it almost deserves to be called a symptom is the occurrence of a superficial yellowish-gray ulceration over or at the sides of the frmnum of the tongue. It is probably produced by the forcible impulse of the tongue against the lower incisor teeth during the act of coughing. It has occasionally been seen in other disorders than whooping-cough. Vomiting is generally to be regarded as a symptom of the disease, but the irritability of the stomach may become so great that it constitutes a genuine and very troublesome complication. In such cases vomiting is very frequent and takes place after every slight cough. Loss of appetite, indigestion, and diarrhoea are common complications, the latter being of a somewhat chronic nature, with the evacuation of considerable mucus. Prolapse of the rectum may result from the violence of the cough, and hernia may be brought about in the same way. Hemorrhages from various parts of the body occur during the paroxysms. Bleeding from the nose and mouth is so frequent that it is to be included among the symptoms of the disease. Subconjunctival hemorrhage is not uncommon. Bleeding from the ear is a rare complication and hemorrhage from the lungs is also unusual. Ilematemesis, in which the blood comes origin- ally from the stomach and is not previously swallowed, is certainly exceptional. Hemorrhage into the skin occasionally occurs. Hemorrhage into the meninges or within the brain is not an unusual complication, and is doubtless the cause of many instances of convulsions and other cerebral symptoms. Convulsions are a dangerous complication and are not infrequent, particu- larly in young subjects. A persistent spasm of the glottis may sometimes cause death. Hemiplegia, aphasia, sudden blindness and other evidences of cerebral disturbance may be occasional complications. General oedema of the skin has sometimes complicated the disease. Acute nephritis has been quite often reported. Whooping-cough may be associated with diphtheria, varicella, scarlatina, or, in fact, any of the infectious diseases, but particularly with measles. The latter combination especially renders the )>rognosis more unfavorable. Rachitis, anaemia and other constitutional maladies may complicate per- tussis and influence its course unfavorably, or they may develop as sequels to it. Tuberculosis is a sequel very liable to arise in those who are predisposed to it or whose general nutrition has greatly suft’ered during the first disease. Its usual seat is the bronchial and intestinal glands or in some of the patches of broncho-pneumonia, but from these foci a more or less widely-s])read infection may start. Epilepsy, various paralyses, aphasia, blindness, deaf-mutism fol- lowing rupture of the drum-membrane, disseminated sclerosis and other con- ditions have been reported as occasional setpiels. Some of them are to be viewed as accidental merely. Diagnosis. — In the early stages of the disease the diagnosis can seldom be made with any certainty. The absence or scarcity of ])hysical signs in the lungs, combined with the very harassing cough, which is markedly worse at night, renders the case sus])icious. 'I'liis is especially true if whooping-cough be jwevalent at the time, or if there be a history of exposure to contagion. If the cough assume a decidedly paroxysmal character, the diagnosis becomes still WHO OPING- CO UGH. 189 moi’e probable. The occurrence of the whoop is usually conclusive, and even in those cases where this at no time develops, the nature of the cough, with such attending symptoms as vomiting, injection of the conjunctiva} and the like, makes the diagnosis hiirly easy. Severe acute bronchitis of the smaller tubes may sometimes be attended by a very spasmodic cough and may simulate pertussis closely ; but the presence of numerous rd.les, with decided fever and dyspnoea, and the absence of more than a slight Avhoop will aid in distinguishing it. The same difficulty in diagnosis, and for similar reasons, may exist in cases where pertussis closely follows measles, since the severe bronchitis already present may appear to account fully for the severity, and even the paroxysmal nature, of the cough. The development of broncho-pneumonia during the first stage of pertussis may render the later diagnosis very difficult, since it is apt to modify greatly the character of the cough or even to prevent entirely the occurrence of the whoop. Tuberculosis of the bronchial glands may produce a paroxysmal cough much resembling that of pertussis. It is to be distinguished by a history of previous wasting and ill-health, the chronic course without distinct stages, the imperfect development of the paroxysms, which are unattended by abundant mucous expectoration or vomiting, and the presence of fever. Sometimes evidences of tuberculosis of the lungs are also present. A prolonged third stage of pertussis may readily simulate pulmonary tuberculosis, and, indeed, it may be possible that the latter disease is developing as a sequel. Only the later course of the case can decide. Prognosis and Mortality. — Although the prognosis is favorable in most cases, yet pertussis is a far more dangerous disease than is ordinarily supposed. In England and Wales 120,000 persons died of it between the years 1858 and 1867, and 85,000 succumbed in Prussia between 1875 and 1880. Dolan ranks it third among the fatal diseases of childhood in England, and says it causes one-fourth of the annual mortality among children in London. Smith esti- mates that during fifty years there were 4840 deaths from it in New York City, or 1 in every 7 6 deaths fi’om any cause. The relative mortality, as compared with the number of cases of the disease, is also larger than is commonly believed. Statistics vary regarding it, but it may be said to range from 3 to 15 per cent. It is upon the great frequency of the complications that the high rate of mortality depends, for, if uncomplicated, the disease is not often dangerous. The younger the child the more unfiivorable is the prognosis. The mortality is very much greater under two to three years of age than after this period, while after the fifth year it is trifling. The prognosis is rather more unfavorable in females than in males, owing possibly to a less degree of strength of constitution pos- sessed by the former. The patient’s previous general condition and the amount of care received while sick affect the prognosis very materially. The children of the poor, badly nourished and neglected as they so fre(juently are, are con- sequently apt to suffer most. Rachitis or any other constitutional debilitating disorder influences the course of the disease unfavorably. The presence of the winter season increases the danger through the greater liability of respira- tory complications. On the other hand, the heat of summer brings on debili- tating intestinal disorders. As already stated, convulsions and broncho- pneumonia are frequent and dangerous complications and the cause of many deaths. Many cases pass safely through the attack, but die from the sequelae. Some become marasmatic and die without the exact cause being discovered, although many of these are undoubtedly tubercular, Other cases show definite symptoms of tuberculosis of various parts of the body. 190 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. Treatment. — Prophylaxis . — In view of the highly contagious nature of the disease pro2)hylactic treatment should be carefully carried out. Children who have not yet suffered from it should be rigidly kept from the slightest inter- course with those who are even suspected of being in the first stage of the malady. Inasmuch as there exists the greatest possible carelessness on the part of parents of the sick i-egarding the danger to others, it is better that unin- fected children be removed entirely from the neighborhood whenever feasible. Particularly is this true in the case of delicate infants. How long the danger of infection continues and how long quarantine must be maintained are not absolutely certain. It is admitted that the infectiousness diminishes during the third stage, and it may be assumed that by the end of two months after the onset of the disease the danger has entirely ceased. A still better criterion, however, is the entire cessation of the cough. If, after the child has been apparently entirely well for a brief period, the cough, Avith or Avithout the Avhoop, returns, it is probably safe to consider that the risk of infection is over in spite of this. It often happens that the Avhoop Avill thus return at intervals during months, or even for a yeai’, Avhenever slight bronchitis is contracted. Quarantine during this entire period is manifestly unnecessary and impossible. The same is true of those cases Avhich continue to Avhoop once or tAvice a day for an indefinite time. In such Ave may consider that after tAvo, or at most three, months the disease itself is over, and that simply a neurosis remains: the “habit,” so to speak, of Avhooping persists. Although Avhooping-cough seems in nearly every instance to be communi- cated by the breath only, yet, to avoid the possibility of transmission in other Avays, disinfection of the clothing, bed-linen, and the like should be carried out systematically, and the rooms used should receive a final disinfection before being inhabited by other chiklren. Treatment of the Attack. — The hygienic treatment of pertussis is of the utmost importance. Inasmuch as air loaded with carbonic dioxide has been proven to bring on paroxysms of cough, children should be kept in fresh air as much as possible. At the same time the very great sensitiveness of the respiratory mucous membrane must be borne in mind, and all possibility of taking cold must be avoided. In Avinter, therefore, it is often best to confine the patient to the house except on dry and still days. Where possible it is well to utilize tAvo airy rooms, one of Avhich shall be thoroughly ventilated and then Avarmed while the other is in use. The child can be changed from one to the other several times a day. The clothing should be Avarm enough to prevent chilling and consequent taking cold. The food should be nutritious, easy of digestion and assimilation, and fre(juently administered in cases Avhere vomiting is a prominent symptom. In some cases of this kind it may be neces- sary to employ nutrient enemata. It sometimes happens that change of climate Avill act most favorably uj)on the course of a case of pertussis. This is particularly true of the thinl stage if unusually prolonged. The host of remedies recommended for pertussis is proof in itself that none of them constitute an infallible cure. Kather, hoAvcver, than decry all medi- cation, as is the habit Avith some, Ave should remember that negative results in the hands of one jdiysician cannot vitiate positive re.sults Avith any certain method of treatment in the hands of another conqtctent observer. Nothing is more certain than that, although no medication is curative in all instances, many different methods of treatment are of undoubted value in different cases. Where, therefore, Ave fail Avitb one, another must be tried in the effort to dis- cover the remedy useful for the particular case. It must akso be borne in mind J I ^IIO OPING- CO UGH. 1!)1 that to test the value of a remedy we must give it in sufficiently large dose, and further that it must he administered at the height of the disease, and not when the third stage has already commenced, at which time almost anything may seem to do good. In the mild cases, where paroxysms are but few and of little severity, it is best to omit all medication intended to control the disease, and simply to keep a careful supervision over the patient. In severer cases, however, treatment is demanded. The condition existing in each individual case, — and, to a less extent, the stage of the disease — will exert an influence upon the choice of drugs to be employed. During the first stage, when the cough is hard and tight, with little expectoration and without full development of the paroxysmal character, the medicines to be selected are those useful in an ordinary bronchial catarrh. The same plan of ti’eatment may be needed in the second stage, while in other cases the copious expectoration permits the freer use of sedatives. But inasmuch as the cough from the outset does not depend upon a simple bronchial catarrh, it is oftener better to begin the employment of remedies directed against the peculiar nervous character of the disease as early in the case as the diagnosis can be made. This need not interfere with any symptom- atic treatment indicated. When the third stage is well under way attention must be paid principally to the accompanying bronchitis. Stimulating lini- ments to the chest may be useful, and tonic remedies are often demanded. An attempt to consider all the drugs which have been employed for the treatment of pertussis would be so much a Avaste of time and space that only the most important of them can be mentioned here. Belladonna is one of those best and longest known and most widely used. Sometimes doses of moderate size suffice, but in other ca.ses it is necessary to give it in increasing amounts until constitutional effects are seen. It often does great good, and often, too, entirely fails to relieve. The initial dose for a child of two years may be tAvo minims of the tincture or one-tAvelfth of a grain of the extract three or four times a day. Alum is sometimes of distinct benefit, particularly Avhen the abundance of the secretion appears to be tbe cause of frequent paroxysms. It may be given in doses of tAvo grains every three or four hours at tAvo years of age. It may sometimes be combined advantageously Avith belladonna. Quinine has been Avidely used Avith varying results. On the Avhole, it may be con- sidered a useful remedy. When given internally the doses should be rather large — as one grain every two to four hours at tAVO years of age — to produce an effect upon the disease ; but there is risk of disturbing the digestion with it. It may be administered Avith advantage in suppositories, or, if by the mouth, disguised in syrup of ;yerba santa or syrup of licorice. Chloral is often use- ful to produce sleep at night. Tavo to four grains maybe given at bed-time to a child tAVo years old. There is some evidence that, administered at inter- vals during the day, it exerts also a direct influence upon the cour.se of the disease. It can be exhibited either by the mouth or by enema. Its power of depressing must not be forgotten. Opium is frequently of the greatest service in obtaining temporary relief. Comparatively restful nights can often be pro- cured by means of its administration at bed-time. It should, hoAvever, be re- served for the severest cases. Bromide of potassium or of some other base has been much recommended, and is often of distinct value. It lessens the nervous irritability, and in this Avay diminishes the frecjuency and intensity of the paroxysms. Its administration should be started immediately if evidence of nervous disturbance indicate impending convulsions. The dose at tAvo years of age may be two to five grains, repeated according to the demands of the case. It may often be advantageously combined Avith belladonna. Cannabis 192 AMERICAN TEXT-BOOK OE DISEABEB OF CHILDREN. Indica has been much used, and is probably one of the most reliable means of treatment. Asafoetida is still a favorite with many. Carbolic acid, in doses of one minim at two years of age, has been found of service in many instances, but its to.xic properties must not be forgotten. Peroxide of hydrogen lias been highly praised, as have terpene hydrate and infusion of wild thyme. Ouabaine has been highly recommended. The dose is one-thousandth of a grain every three hours at five years of age. It is a powerful respiratory paralyzer. Among the most important of other drugs which have been recommended for internal administration, and which have doubtless proved of service in some cases, are pilocarpine, lobelia, resorcin, grindelia, castania, drosera, cam- phor, quebracho, hyoscine, turpentine, benzole, carbonate of iron, and conium. Antipyrine, first recommended by Sonnenberger, has been used with excellent results by so many that its value in the disease is now beyond ques- tion. Although, like other remedies, it often fails to relieve, many of the reported failures with it are doubtless due to the fact that it was not given in sufficiently large dose. Children bear it suiqirisingly well, and bad results following its administration are rare. The initial dose should be small, and the amount gradually increased until a child two years old receives one to two grains, or even more, every three hours. In a desperate case of pertussis in a four-months-old child under my care, in which three-quarters of a grain of antipyrine, given every three hours, failed entirely to relieve, an increase of the dose to one grain every three hours rapidly brought the patient from a condition of the greatest danger to one of comparative health. The child had suffered from very frequent and violent attacks of cough, followed by spasm of the glottis of so long duration that intense cyanosis with entire apnoea and loss of consciousness repeatedly resulted. Within forty-eight hours after the treatment had been instituted the little patient had passed an entire night and and until afternoon on the next day with but a single paroxysm. Phenacetin will sometimes be of service in cases where antipyrine has failed, and the I’everse. of course, also holds good. Acetanilid has sometimes proved of use, but is less often employed and of less value than are its two cogeners. Bromoform, one of the newest remedies for pertussis, was first recom- mended by Stepp in 1889, and has been largely used. It may be given in doses of from two to four drops three or four times a day at two years of age. It can be dropped upon moistened sugar or given in a mixture with alcohol, syrup, and water. ]\Iy experience Avith it, although satisfactory to some extent, has not been as much so hitherto as publislied results had led me to hoj) 0 . Some cases improved, but oftener small doses failed to be of service, Avhile larger ones rendered the patient so sleepy and stupid that the remedy had to be abandoned. Nevertheless, the large number of re|)orted cases in Avhicli the results have been extremely good indicate that the rcTuedy is certainly of great value. Local treatment of the respiratory mucous membrane has been largely em- ployed. One of the most popular methods is the insulllation of ([uinine in the form of a fine powder. This may be ap))lied directly to the larynx by the physician tAvice ar day, or nasal insiilllations may be made by the attendants several times daily. Excclkmt results have been obtained in each Avay. About one grain of (juinine should bo used at a time. Resorcin has been highly recommended by Moncorvo. A 1 per cent, solution may be applied to the pharynx and the oj)ening of the larynx, or a ])OAvder may be insiilllated into the nose, using one-half to one graiii at a time for this purpose several times each day. The local application of a solution of cocaine luus heen advo- Jf Y/O OPING- CO UGH. 193 cated, but is not without danger, as reported cases have shown. It has, however, often been of service in mitigating the severity of the disease. The solution should be of the strength of from 1 to 4 per cent. With the steam or hand-ball atomizer the fauces and nares may be sprayed with the substances mentioned or with a weak solution of morphia. Bromide of potassium in solution is sometimes of much service, and tannin can be employed in the same way. Peroxide of hydrogen, in the dilution of one part in five, may be sprayed in the nares and upon the fauces, and very excellent results have been claimed for it. Benzoin, boric acid, salicylic acid, iodoform, tannin, and other drugs, in powdered form, have found their supporters as useful agents for nasal insuf- flation. Benzoin is one of the best of them. Good effects can also be secured with boric acid. Various volatile substances may be used with the atomizer in the form of vapor from boiling water. Carbolic acid is one of the best of these, and it is often of great advantage to allow the sick-room to be permeated by it. The action upon the cough is probably due in part to the anaesthetic effect of the carbolic acid, and largely to the influence of the moist atmosphere of the room, which loosens the mucus and facilitates its expectoration. Thymol, eucalyptol, and turpentine may be vaporized in a similar way. Chloroform and ether have been recommended for their general anaesthetic effect. Remarkable results have been reported from the fumigation of the sick- room by burning sulphur. The child is to be washed in the morning, dressed in clean clothes, and placed in another room. The night-room is in the mean time thoroughly fumigated with the sulphurous vapor, closed during five hours, and then aired. The patient sleeps in this room at night. A single employment of this procedure has been effective in some cases. The inhalation of the air in the purifying-rooms of gas-works is a method of treatment formerly much in vogue. The employment of the pneumatic cabinet has likewise been recommended. The use of the constant electric cur- rent has been advocated by several clinicians. The routine administration of emetics, once a popular procedure, is no longer in favor. Complications demand, of course, treatment applicable to them individually. 1.3 TYPHOID FEVER. By F. GORDON MORRILL, M. D., Boston. Synonyms. — Enteric fever; Slow fever; Fall fever; Gastric fever; Infantile remittent fever. Definition. — An acute, infectious, continued fever, due to a specific cause, and characterized by prostration, wasting, enlargement of the spleen, inflam- mation of Peyer’s patches and the solitary follicles of the intestine, and an eruption of rose-colored spots, which disappear on pressure being applied, and return rather slowly when it is removed. In children the solitary fol- licles rarely ulcerate, the eruption may be absent, and it is sometimes im])os- sible to demonstrate enlargement of the spleen. The word “’typhoid,” first suggested by Louis on account of the supposed resemblance of the disease to typhus, has met with general acceptance in America and England, while in France the term “ dothi^nent^rie ” is frequently used by those who object to “typhoid” as misleading. “Enteric fever” is perhaps preferable, as sug- gesting the specific lesions of the disease, and is fre(juently employed as a substitute for the original name by precisians or by medical writers for the purpose of avoiding constant repetition. History. — Previous to 1840 it was believed that children were exempt from typhoid, although good descriptions of cases (some with autopsies) had been published by Abercrombie, West, and others. During that year, how- ever, Rilliet and Taupin published results of separate and independent investigations of enteric fever in children, and the fact of their susceptibility to the disease has since then become generally recognized. Later on it was proved that while typhoid is rare in infancy, it may occur in children at any age. Even so close an observer as Bouchut denied in 1867 that the disease ever occurred during the first year of life ; but as a matter of fact the sj)ecific micro-organism of typhoid has been found in the liver and spleen of an infant who breathed only twelve hours, and whose birth took place during the fourth week of the disea.se in the mother ; and in similar instances the specific intestinal lesions have been discovered. So it may be stated that, in childhood at least, no age is exempt. Etiology. — As to tlie age at which children are most susceptible to the infection, statistics vary, but the risk probably increases from birth up to the tenth year, and then remains about the same until puberty is attained. The influence of sex is not apparent, although more boys than girls find their way into hospitals. The distribution of the disease is (piite impartial, no climate being exempt. In America it is everywhere the prevailing fever. The influence of season is very marked, a large majority of cases occurring during the late summer and early autumn months. A dry hot summer increases the prevalence of ty])hoid — a fact which Bettenkofer attributes to the more thorough drainage of the soil into wells and springs, which are low, 194 TYPHOID FEVER. 195 and the water of which is, of course, concentrated ; while Baunagarten sug- gests that at such times the poison is more easily disseminated in the air. Neither of these e.xplanations is quite satisfactory, while each contains an element of truth. Family predisposition to contract the disease is not infrequently observed. A marked instance of this susceptibility is cited by the late Charles Warring- ton Earle (in his article on typhoid fever publi.shed in the first edition of this book), where seven persons of one family contracted enteric fever by visiting an infected room or nursing other cases so caused. As a rule, the previous condition of health plays but an insignificant part in the etiology of typhoid, which is directly caused by absorption from the alimentary canal of the specific micro-organism (named after its discoverer, Eberth), which is a short, thick bacillus Avith rounded ends and containing glistening spots Avhich remain unstained when subjected to the ordinary process. It occurs singly or in chains, and its appearance varies in accordance with the medium in which it is grown. The variety of ways by which different authorities say it can be distinguished from the bacillus coli communis is suggestive of the fact that there is a great liability to error ; and in this connection it is proper to state that it is claimed that the Eberth bacillus has been found in the fecal evacuations of persons free from any suspicion of typhoid, and who had never had the disease. That the bacillus is often swallowed with impunity is un- doubtedly true — the soil must suit the seed, as in other infections. Whether the Eberth bacillus can remain inactive in the alimentary canal for any con- siderable length of time, and then suddenly cause disease (as does the Klebs- Loftler bacillus in the throat and nose), remains to be proved. Be this as it may, the poison finds entrance to the body through the nose or mouth, and usually in articles of food or drink. Water that has been contaminated by the discharges of those having the disease is by far the commonest source of infection. E.xamples of this contamination through cess-pools, drains, and the washing of excreta for a considerable distance into streams and reservoirs are too Avell known to bear repetition here. In Paris the river Seine has a firmly established reputation as a conveyer of the enteric bacillus. When the usual sources of supply for certain quarters of the city fail, Seine water is substituted, and an epidemic of typhoid follow'S with unfailing regularity in the course of two or three weeks from the time when it is turned on. The bacillus groAvs rapidly in fresh milk, Avhich is a frecjuent source of infection, and is sometimes responsible for outbreaks confined, in the main, to children. Washing the cans in infected Avater is the usual explanation of the contami- nation. Any article of food or drink may be infected by the person having the disease, or, indirectly, through carelessness on the part of the attendants. Oysters may absorb the micro-organism from drainage, the bacillus retain- ing its characteristics perfectly Avell after a fortnight’s sojourn in sea-Avater. Freezing does not destroy its vitality, and ice may thus act as a carrier of the disease. In vieAV of the infinite variety of Avays (food, drink, bedding, toys, books, utensils of all sorts, and probably the air Ave breathe) in which the bacillus, moist or dry, may be distributed, it is a matter of surprise that the disease is not even more prevalent, as it doubtless Avould be if eA'ery one swalloAving the poison Avere susceptible. After entering the alimentary canal, the micro-organism penetrates the mucous membrane and gives rise to profound constitutional disturbance, together Avith characteristic changes in the intestines and other organs. The 19G AMERICAN TEXT- BOOK OF DIBEABEB OF CHILDREN. length of time which may elapse after exposure before the symptoms mani- fest themselves varies within wide limits. It is fixed by the Clinical Society as “eight to fourteen, sometimes twenty-four, days.” Liberal as this rule is, there are well-marked exceptions to it. In a recent epidemic near Boston two children were taken obviously sick, with Avhat proved to be typhoid fever, forty-eight hours after drinking for the first and only time infected milk, to which the source of trouble was clearly traced. In other instances five days covered the period of incubation in children, and a somewhat longer period in adults of the same families. Morbid Anatomy. — The post-mortem appearances which enteric fever causes in adults will be mentioned only for the purpose of contrasting them with lesions of the same organs as observed in children. Rose spots usually disappear after death, while accidental eruptions (sudamina, etc.) persist. The duodenum may be slightly congested, while the changes in the jejunum and ileum are usually due to hyperplasia, and not (as in adults) to ulceration. Beyer’s patches and the solitary follicles are surrounded by zones of congestion, but induration is rarely perceptible to the touch ; in other words, the congestion is not sufficiently intense to interfere seriously ■with the blood-supply, and for this reason ulceration, except to a slight degree, is seldom present. Whatever the intestinal lesions may be, they are seen in greatest number in the immediate vicinity of the ileo-ciecal valve. According to the combined statistics of Pfeiffer and Montmollin, lesions of the intestinal mucous membrane, varying from the (usual) superficial con- ge.stion to deep ulceration with perforation, were present in 72 per cent, of their cases. ‘ Ulcerations, when seen, rarely exceed ten or twelve in number, and their superficial character contrasts strongly with similar lesions in adults, which so fre(|uently involve the submucosa, and may be so confluent in the neighborhood of the ileo-caecal valve as to form an eschar of great size. Instances of deep ulceration are rare in children, but when present are due to the same process as in adults, which reaches its height in eight or ten days, and then undergoes a retrograde change or produces necrosis. Retro- gression is fortunately the rule in children, and ulceration seldom reaches the muscular coat of the intestine, wdiich in adults usually constitutes the floor. Perforation is very rare, hut does occur. As a rule, the solitary follicles do not ulcerate : they are swollen and often jiresent the appearance described by French writers — a beard of two days’ growth. In rare in- stances they ulcerate, and I find in the records of the Boston Children's Hospital one case in which this lesion was present in the solitary follicles of the ciccum, extending several inches below the valve. The mesenteric glands are swollen, particularly in the vicinity of the ileo-c;ecal valve, and the intensity of this condition does not necessarily cor- respond to the extent of the intestinal lesions. Peritonitis, with or (rarely) without perforation, is observed very excej)tionally. The spleen is certainly of normal size in some cases, but, as a very general rule, is swollen and hypenemic. If death occurs at a late stage of the disease, it may be soft, and has been known to fracture (ante-mortem) on ])alpation. Ha'inorrhagic infarcts are common. The liver may be hy])er:emic and enlarged in severe cases, or it may be soft and the bile colorle.ss ; but, as a rule, hej)atic lesions ai’e slight and insignificant as compared with those of adults. ' It must be borne in mind tliat this estimate a))|ilies to fatal ea.ses, in wbieli intestinal lesions are naturally much more frequent and serious than iu those who survive. — F. (i. M. TYPHOID FEVER. 197 The brain is singularly free from important pathological changes, and even in cases where nervous symptoms have been decidedly marked, nothing beyond a congestion of the pia mater and (to a slighter degree) of the brain- substance, together with extremely moderate distention of the arachnoid, is observed. The heart is pale, and often softened by granular or fatty degen- eration of its muscular fibres. Passive congestion of the lungs is common, and patches of broncho-pneumonia of the deglutition type are not rare. The kidneys may show signs of granular degeneration, but rarely of true ne- phritis. The voluntary muscles, particularly the pectorals, recti abdominis, and adductors of the thighs, may be in the same condition as those of the heart just described. This of course may be the case after any prolonged sick- ness, and is not peculiar to ty])hoid fever. Ulcerations of the laryngeal cartilages, periostitis, osseous necrosis, and suppurative parotitis are extremely rare, but have all been observed. In the case which I have referred .to as appearing in the Children’s Hospital records Eberth’s bacillus Avas found in the lungs and in great abundance in the spleen, liver, and kidneys. Symptoms. — After a variable time from the date of exposure the child begins to lose its interest in play, shows signs of lassitude, and is inclined to lie doAvn. Headache, anorexia, chills or chilly sensations, nausea, epistaxis, pain in the back or legs, diarrhoea (or constipation) may be present. This condition of things may continue for a Aveek, or even longer, before the child takes to bed and is obviously sick. More rarely the onset is sudden and accompanied Avith Ammiting. In either case, in the absence of any suspicion of typhoid infection, the patient’s condition often passes as the result of indigestion or having “ taken cold.” But the usual remedies fail to giA'e I’elief — the symptoms persist, and are so marked as to make it evident that no temporary indisposition can account for them satisfactorily. The arbitrary date of the commencement of the “ run ” of the fever is noAV fixed. The degree of constitutional disturbance Avhich typhoid gives rise to in children is usually much less than that which it causes in adults ; but it is sufficiently well marked, as a rule (in America, at least, Avhere the abortive and extremely mild types are comparatively rare), by the end of a Aveek to enable one to make a diagnosis. The child lies with flushed cheeks and an expression of marked apathy, Avhich remains present until the fever subsides, and occasionally for days after the temperature has become normal. The abdomen, flat at first, becomes SAvollen and tender on pressure, particularly in the right iliac fossa. Sometimes abdominal pain is voluntarily complained of. The spleen is apt to be SAvollen, and its lower edge can be felt (usually beloAv or under the false ribs, but occasionally more toAvard the front) in a majority of cases. Rose spots may be visible on the abdomen, the loAver portion of the thorax, the inner surfaces of the thighs, or betAveen the shoulder-blades. A moderate diarrhoea may be present, but constipation is more frequently the rule during the first Aveek after the child comes under observation. The urine is scanty and high-colored. Bronchitis or, rather, cough, is not uncommon. The skin is usually dry and hot, but perspiration is exceptionally observed during the early stage. The lips are dry and scaly. Sordes may collect on the teeth and gums if care is not observed. There is no characteristic appearance of the tongue, Avhich is almost ahvays moist, red on the tip and along the edges, and coated with a yellow deposit Avhich is variable in thickness and distri- bution, sometimes covering the entire upper surfiice, or being confined to tbe anterior half or to the lateral portions only. Anorexia is complete, but the 198 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. child takes kindly to cool licifuids. Sleep is apt to be disturbed, and mild delir- ium is not uncommon during the night. The pulse beats from 120 to 140 per minute, and the temperature reaches 104° to 105° F. (oftener the former) at night, with morning remissions of 1.5° to 3° F. As the disease progresses emaciation becomes marked. Diarrhoea and abdominal pain, which may precede or follow the loose discharges, are common, but constipation may continue until the case terminates. Attacks of nausea lasting two or three days may occur. Prostration and apathy are more profound, and there may be retention of urine. Toward the end of the second week of the child’s confinement to bed in mild cases, or a few days later in those of average severity, the tempera- ture begins to descend by lysis (often preceded by very marked morning remissions), and soon reaches the normal point. Convalescence now begins : the appetite becomes ravenous, and, if no relapse occurs, complete recovery in all but the matter of physical strength soon follows. The aiifemic pallor and weakness caused by enteric fever are very marked. The child’s first attempts to walk with its attenuated legs bear testimony to the severe con- stitutional disturbance it has passed through. The hair falls out to a greater or less extent, and this, together with a perceptible increase in height (typhoid stimulates the growth of the long bones), causes the patient to pre- sent a curious aspect. The usual features of an average case having now' been roughly outlined, special symptoms and complications will be considered : Relapse . — A recrudescence of fever from no ajiparent cause is not un- common. It is apt to occur a very few days after the beginning of convales- cence, and usually lasts a day or two only. True relapse, due to reinfection after a perceptible period of apparent convalescence, is usually of sudden onset, and occurs with varying frecjuency in different epidemics. At the Boston Children’s Hospital 17 per cent, of 100 recorded cases have had a relapse on the (average) thirty-third day after the first symptoms of the orig- inal attack were noted. The mean duration of these relapses was seventeen days. Of those affected, 12 w'ere girls and 5 were boys — a fiict which cor- roborates, in a modest w'ay, Montmollin’s statement that the frequency of relapse is influenced by sex. As a rule, the relapse is neither so long nor so grave as the original fever, but occasionally it may be severe enough to cause death. A second relapse may occur. This happened in 4 of the 17 cases I have referred to, and all of them recovered. Instances of a third relapse have been recorded — the greatest number which I have seen mentioned in connection with the typhoid fever of childhood. lutercurrent rcla])ses are not very uncommon, and an unusually prolonged pyrexia may often be accounted for in this w'ay. The symptoms of relapse differ in degree only from those which the patient has already had. liespiratorjj System. — Ej)istaxis is rather common, and of no importance save from a diagnostic standpoint. It was noted in 5 j)cr cent, of 70 cases by Forchheimer, and in 20 per cent, of the 100 cases which I have mentioned. Cough is fre<{uent, and is usually caused by slight bronchial catarrh or some ordinary affection of the up))er respiratory tract : 1 find it noted in 30 per cent. Well-marked signs of bronchitis are somewhat rare. Broncho- pneumonia (often of the deglutition variety) occurred in 7 per cent., and in 1 fatal case the Eberth bacillus was found in the inflamed lobules. Conges- tion of the bases is usual in j)rolonged cases, and would be even more common if children did not voluntarily change ])osition far oftener than do adults. Frank pneumonia is extremely rare, although typhoid patients are by no TYPHOID FEVER. 199 means proof against other infections. Ulceration of the vocal cords and necrosis of the laryngeal cartilages, with resulting stenosis, have been observed. The ordinary forms of sore throat are common enough, and diphtheria can be readily contracted during the course of enteric fever. Digestive System. — The lips are dry and apt to crack if the child is allowed to pick at them. Herpetic eruptions are not common. The gums may he soft and swollen. The brown tongue so often observed in adults is seldom seen. The organ may be dry and red, but soreness is seldom present. The bowels are usually constipated at first, and diarrhoea is apt to come, if at all, during the second week. There may be seven or eight discharges in twenty-four hours, which mayor may not be of the familiar “pea-soup” variety. This condition usually subsides rather slowly under appropriate treatment, but is apt to recur. Involuntary discharges are rare excepting in very young children. Abdominal pain on pressure increases during the second week. Intestinal haemorrhage (as would be naturally expected from the rarity of deep ulceration) is seldom observed. It was noted in 4 per cent, of the 100 cases mentioned. In 2 of these it consisted of small quantities of blood passed with each evacuation for several days, and both recovered. In 1 instance it was slight, but the case was one of intense typhoid infection, Avith many lesions of the internal organs, and the bleeding caused death from ex- haustion. An autopsy failed to reveal the vessel from which the blood had escaped, in spite of a very careful and prolonged search. In the fourth case two profuse hsemoriliages, which occurred within tAventy-four hours, Avere speedily followed by perforation, peritonitis, and death. Perforation (said to be more common than haemorrhage) is rare. Professor d’Espine (of Geneva) has seen but one case. It is apt to occur, if at all, at a late stage of the dis- ease, and has been observed in one instance five Aveeks after the beginning of convalescence. Peritonitis Avithout perforation has been observed by J. C. Wilson, J. Simon (of Paris), and other leading authorities, but is extremely rare. Usually it is the direct result of perforation, and if the rupture takes place at a point Avhich is in contact Avith a solid viscus or a coil of intestine, the peritonitis may be limited and recovery follow. OtherAvise the contents of the alimentary canal escape, and speedily cause acute general inflammation of the peritoneum (accompanied by pallor, clammy SAveats, abdominal disten- tion, small and frequent pulse), Avhich proves (ptickly fatal. Enlargement and suppuration of the parotid gland have been observed by various author- ities. The Skin. — Rose spots, if present, usually make their appearance Avithin a Aveek after the disease is fairly established. As a rule, they are not so Avell marked in children as in adults, and are less common and numerous in America than in Eui’ope, Avhere an abundant eruption is regarded as a good omen. Ashby and Wright state that they are absent in only 25 per cent, of all (English) cases. I find them noted in 53 per cent, on the (average) tAvelfth day after the first appearance of any symptoms of the disease. In rare instances they are seen during a relapse, Avhen careful daily investigation has failed to discover them during the original attack. Furunculosis may occur at a late stage or during convalescence. Sudamina and eruptions resembling rose spots, but failing to disappear under pressure, are common — more par- ticularly the latter. The nails become fissured transversely from temporary cessation of growth. Wilson mentions a faint diffuse erythema of the legs during the first Aveek. Acute otitis media Avith perforation (unless relieved by incision) occurs in a certain percentage of cases, and this may or may not influence the range of the temperature. In 40 cases Avhich entered my Avards 200 AMERICAN TEXT- BOOK OF DISEAHES OF CHILDREN. during the fall of 1896, it was observed 5 times. Bed-sores are easily avoided, except in the severest cases. The Spleen . — It is probable that the spleen is enlarged to some extent in all cases at some period of the disease, although this cannot always be demonstrated by percussion or palpation. The fact that this organ has been found to be of normal size in a few cases which have been autopsied is no proof that it had not been enlarged during the acute stage of the fever. To palpate the spleen the child is made to lie upon its right side, with the knees hexed and drawn up, and the fingers are gently but firmly pushed upward under the false ribs ; then, if the patient can be induced to take a deep breath, the lower edge can often be felt. Percussion of the oi-gan, unless the results are corroborated by palpation, is not satisfactory. In 40 recent cases at the Children’s Hospital the spleen was palpable in 23. The enlargement usually disappears very soon after the temperature becomes normal. If it remains, relapse may be expected. Splenic enlargement is of course not peculiar to enteric fever, but may be present in any infectious disease. Bartliolow cites a case of rupture of the organ from slight violence, and the fact that at autopsies it has been sometimes found to be a mere bag of pulp shows the possibility of such an accident being caused by too vigorous efforts to detect a symptom which is rarely essential to enable one to distinguish typhoid fever from other diseases. Hepatic enlargement is very seldom of sufficient extent to be noteworthy. The Urine. — Ehrlich’s diazo reaction, a description of which is hardly needed here, has been found present in 136 of 196 cases of enteric fever (Osier). Its diagnostic value is much impaired by the fact that it is not infre((uently seen in other acute febrile affections. In 50 selected cases Dr. J. Bergen Ogden of Boston found that the reaction was ])resent between the (average) fourteenth and twentieth days of the disease, and remained so for from six to eight days. Nervous System . — Complete indifterence to surroundings is the rule, and delirium, if present, is usually of a mild and harmless tyj>e. Occasionally a child will try to get out of bed, and is somewhat difficult to manage, and mechanical restraint is reipiired in rare instances. Mild delirium, associated perhaps with night-terrors, is not at all unusual, and is easily controlled by ajjpropriate means. Trembling of the hands and twitching of the facial muscles are rare. I have seen this in the form of a one-sided affection, and the movements reseml)led those of chorea. Retention of urine is less com- mon than in adults. Hypermsthesia of the lower extremities and pain in the feet and ankles are sometimes ol)served, but any marked degree of ])eripheral neuritis is extremely rare; and the same may be .said of cerebral meningitis. Ominous brain-.symptoms (active delirium, intense cephalalgia, strabismus, vomiting, and retraction of the head) have been known to disappear in a few days. Mental disturbances (delusions, melancholia, etc.), which appear in exceptional cases during the course of enteric fever, .sometimes continue long after convalescence has been established, but they tend to di.sappear as the child’s sti'cngth becomes restored, and seldom last more than a few weeks. Transitory aphasia atid hemiplegia have been noteil at a late ])eriod of the disease. It may be said, in a general way, that all nervous .symptoms occur- ring during typhoid in children are likely to disa])j)ear in time. The Heart and Ihilse . — Slight myocarditis with a feeble apex-beat and softened first sound, accompanied by a feeble and j)crhai)S dicrotic ]udse, arc common. In severe cases the pulse intermits or becomes irregnbir, and in those in which the condition of the heart is the direct cause of death the TYPHOID FEVER. 201 sounds may assume a foetal rhythm, -which precedes a fatal termination for a day or two only. The average rate of the pulse is from 120 to 150, and its curve (juite closely follows that of the temperature on the chart. A slow pulse Avith a high temperature is occasionally observed for a day or two, but the reverse is extremely rare. In 3 of the cases which I have mentioned a pulse of 180 was recorded, and 2 of them proved fatal. Endocarditis and pericarditis are seldom seen. Temperature . — It is said that the temperature during the initial stage lacks the characteristics Avhich are of such essential aid to the diagnosis of Fig. 1. Showing temperature of initial stage. (Boy aged 5 years.) enteric fever in adults, but an instance in Avhich an accurate record of the temperature Avas kept for several days before the diagnosis was made does not confirm this statement. As may be seen by reference to Fig. 1, the tem- perature rose steadily and reached 102° F. in forty-eight hours, Avhen morn- ing remissions promptly occurred, Avhile the evening temperature continued to mount higher. The remissions average about 1.5° F. after the disease is Fig. 2. Showing marked morning remissions during the last days of a short case, also slight recrudescence of fever. (Boy aged 6 years.) fairly established, and may be counted on Avith a considerable degree of cer- tainty. During the feAV days preceding convalescence they often cover from 2° to 3° F., this corresponding (to a degree Avhich the comparative insig- nificance of the intestinal lesions Avould lead one to expect) to the second stadium as seen in adults. During this short stage of marked remissions the morning temperature may be normal for two or three days before convales- 202 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. cence is attained, as shown in Figs. 2 and 3. Lysis is the general rule, but occasionally the termination is somewhat abrupt, as it is apt to be in the abortive cases of adults. The average highest temperature observed in 100 cases at the Children’s Hospital was 104.5° F., and this was noted on the (average) twelfth day from the first appearance of symptoms. The extremes Fig. 3. Showing morning remissions a few days before convalescence. (Boy aged 12 years.) were 101° and 107.8° F., the latter case recovering. In 5 of 7 fatal cases a temperature of 105° F. or more was reached. As regards the duration of the fever, a normal morning temperature was observed on the (average) twenty-fourth day, and a normal evening tempera- ture on the (average) twenty-ninth day after the first appearance of symp- toms. This of course applies to pyrexia as a symptom per se, and not to the child’s general condition, convalescence being not infrecjuently well under- way before an absolutely normal temjierature could be recorded. A fiill of temperature accompanies any considerable luemorrhage. Fig. 4 shows the descent attending two evacuations of coffee-colored blood (at least eight ounces Fig. 4. Showing sudden fall of temperature after each hamorrliage. (Boy aged 10 years.) each time) occurring on successive days. In one instance a sudden depres- sion (6.8° F.) from no apparent cause was noted, and slow recovery followed. Examination of a number of four-hour charts of cases in which neither anti- pyretics nor cold baths were used shows that during the acute stage the lowest temperature is recorded at 8 a. m., and the highest from twelve to TYPHOID FEVER. 203 Fig. 5. RESPIRATIONS TEMPERATURE ' o o o o o o o fourteen hours later. A sliglit remission occurs after midday and midnight. Fig. 5 shows the tempera- ture, pulse, and respiration of a case of double relapse, together with the number of evacuations daily, the patient eventually recovering. Diagnosis. — It is usually a sufficiently easy matter to recognize enteric fever in a child when the disease has become fairly established, but during the first four or five days, in the absence of other cases in the neighbor- hood, it is fre(iuently impos- sible. The symptoms may correspond to those caused by digestive troubles, or by some fancied exposure to “taking cold,” or by ephem- eral fever due to an unknown cause. In hospitals the pa- tient is seldom seen until there is good evidence of serious illness. The diseases with which typhoid is most likely to be confounded are — tuberculous or epidemic meningitis, acute miliary tuberculosis without brain- symptoms, frank pneumonia, and malaria. Tuberculous meningitis is liable to oc- cur in hospital patients under constant observation for disease of the hip or spine, and the records of cases of this kind show that night-cries, a well-marked tache cerebrale, and in- ecjuality of the pupils (aside from the peculiarities of pulse and temperature) are the earliest signs which are of essential aid in making a differential diagnosis. Ep- istaxisand bronchial catarrh are of diagnostic value in favor of typhoid, while vomiting and headache are more persistent in tuber- culous meningitis. The temperature of an established case of enteric fever - to w £ % s; to 1 00 * oS g to 5 C3 o o 2 s 's.l 1 < >- i i ^ to !I! w CO 1 > & Mk !?] r tc v> oc 1 o 2 !^i 1 J g oo 1 (C. «o CO o o -- - - w -g- r - w V "***'^"**4>^ 1 W C.-1 Cn lO o> oJ to -o -1 T So 00 o s to s \J^ o 1 — o to CO lO - i\ Si g to » O. - i 00 » CO fO 1 j Ut o iC to i o (\ to ' ' «« CC CO Uk vt CT ; Cl o» o» - i 1 ^ Cl -0 - i 1 1 . s 00 - i \ \ w CO w i \ 1 £ o 1 1 1 2 2 w ■ ' r g 1 i w CO w 1 o z 4k V L 1 1 « \j u c» o w 1 1 c> r 1 r Ci 00 » * \ 1 1 CO s - n r" o o - ! > ■j: 1 zl £2 to - ?© to - CO g - 11 ' if - 1 1 1 th 8 - > 1 § to . 1, - « 'i CO o o Showing respiration, pulse, and temperature of a case with double relapse. (Boy aged 8 years.) 204 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. differs from that of a beginning tuberculous meningitis, Avliich is very irreg- ular and seldom reaches 104° F. until unmistakable signs of brain-trouble are present. A very quick pulse with a low temperature is common enough in tuberculous meningitis, but rare in typhoid, in which disease the pulse follows quite closely the temperature-curve on the charts. Irregularity of the respi- ratory rhythm is sometimes observed in tuberculous meningitis. In any event, a tapping of the spinal arachnoid or an e.xamination of the blood (to be spoken of later on) soon clears up cases which may remain doubtful in the absence of other well-marked diagnostic signs. The onset of well-marked cerebro-spinal fever is sudden, and accompanied by intense cephalalgia, dilated or contracted pupils, which fail to respond to light, and reti'action of the head and neck — symptoms rarely present in the typhoid of children, and almost never in the early stage of the disease. As a matter of fact, one is much more apt to mistake a “cerebral” frank pneu- monia for cerebro-spinal meningitis than the latter for an enteric fever. In acute general tuberculous infection the abdomen is usually Hat, the temperature irregular, while the family history of the patient and the pres- ence of enlarged superficial glands may aid in diagnosis. Bronchial catarrh is common to both miliary tuberculosis and typhoid, and, so far as the spleen is concerned, a considerable enlargement may be present in either. Rose spots, epistaxis, and splenic enlargement may all be absent in enteric fever, and the resemblance to general tuberculosis may be so close that only an examination of the blood can conclusively settle the question. Malaria in children is very apt to be accompanied by quotidian (double tertian) paroxysms, which may cause it to be confounded with typhoid. But the absence of rose spots and abdominal tenderness, together with the effect of one fair-sized dose of quinine (administered immediately after a paroxysm), quickly decides a question which is otherwise easily answered by an exami- nation of the blood. Frank pneumonia may closely resemble enteric fever when the physical signs of consolidation fail (as they sometimes do) to develop for several days. The temperature of the two diseases is very similar (barring the usual irregu- larity of the morning remissions in pneumonia) ; abdominal pain is common in either ; and in the absence of rose spots, abdominal tenderness, and en- largement of the spleen, Widal’s blood-test may be required to enable one to reach a conclusion. “ Cerebral ” pneumonia, as I have before remarked, is more likely to be confounded with epidemic meningitis than with typhoid ; but apex-pneu- monia may come and go with few if any signs jiointing to pulmonary trouble. The evie removed from infected localities. Almost every remedy in the medical category has been tried to abort this disease: bloodletting has had its votaries, and others have highly extolled the virtue of mercurials in the earlier stages; emetics, again, have been recom- mended, but all have largely been abandoned. The plan pursued by most recent authorities is to treat the disease symptomatically. EPIDEMIC CEREBROSPINAL MENINGITIS. 213 In the first stage we have a congested condition of the meninges of the brain and spinal cord : the indication is to aid in the reduction of the quan- tity of the blood in the meningeal blood-vessels ; first, for the purpose of reliev- ing the symptoms, and, secondly, to reduce the inflammation and modify the inflammatory products. One of the difficulties of administering medicine by the mouth is the common symptom of vomiting, which is sometimes very per- sistent. Venesection should not be practised in children. Some of the German writers use early local bloodletting by wet cups and leeches. Dry cups to draw blood from the internal congested vessels without removing it from the body are of great value. The external application of cold to the head by ice, ice-water cloths, cold-water cloths, is useful, and some have used hot baths to the body, hoping to draw blood from the centre to the periphery. Hot mustard foot- baths can be used with advantage to relieve the pain in the head and back. If the stomach should bear it, potassium bromide and ergot may be adminis- tered ; if not, the former may be given by enema, the latter hypodermatically, for the purpose of favorably influencing the capillary congestion. For the pain in the muscles the antipyretics have been used ; phenacetin is probably the safest and best of all. It should be used in small, frequently-repeated doses, and its use should be discontinued if the patient becomes weak or exhausted. A mustard plaster, one part mustard to three of flour, placed over the spine, often relieves the pain in that location, and counter-irritation to the nape of the neck diminishes the pain in the head and relieves the delirium. Care should be taken not to raise a blister, which would seriously complicate the case. Liniments over the same region — turpentine or chloroform — may be used for similar purpose. Belladonna seems to afford relief to the neuralgic pains and muscular spasms. Dr. J. M. DaCosta highly lauds the use of hyoscine hydro- bromate for the muscular spasms in this disease. For insomnia early in a case chloral may be cautiously used in conjunction with potassium bromide. Chloral sometimes causes cerebral excitement, and when this occurs it should be dis- continued. Opium has always been used with the happiest results. It has been recorded that in some cases large doses of opium are tolerated. The salicylates and gelsemium will allay the pains in the trunk and limbs, but will not relieve the pain in the head. A dark, quiet room should be selected for the patient in any stage ; this is of great importance where there is cerebral excitement. In the second stage the exudate is thrown out ; it may be serous, plastic, or even sero-purulent ; the blood-vessels are dilated and engorged. Absorptive remedies are now to be used. Potassium iodide to produce absorption of the exudate, and oil of turpentine internally have been used late in this stage for the same purpose, with seeming good results. Arsenic and iron are of great use during convalescence to improve the blood. Stimulants, especially for chil- dren, should be used with great caution, as an excess will irritate the brain and excite the circulation in either the first or second stage. Hypophosphites, espe- cially with strychnine, are beneficial during convalescence. Cod-liver oil when digested often produces the happiest results. In the later - stages of convales- cence massage is of great importance to stimulate the circulation in the mus- cles and nerves. Electricity is indicated for paralysis or weakness of the nerve- trunks. For the same purpose alternate hot and cold affusions to the weakened parts, and exercise, carefully regulated as to time and amount, greatly assist in strengthening the muscles and nerves. EPIDEMIC INFLUENZA. By CHAS. WARRINGTON EARLE, M. D., Chicago. Influenza is a general infectious disease producing catarrhal difficulties of either the respiratory or gastro-intestinal tract, or painful symptoms referable to the nervous system. In addition to the symptoms thus indicated, it is attended with prostration out of proportion to the apparent involvement of the organs named, and is liable to be followed by sequelse which affect pro- foundly the further usefulness and comfort of the unfortunate victim. This disease has been recognized and described in our country for two hundred and fifty years, the first epidemic occurring about 1647. Other epidemics have taken place from time to time, and have been referred to by writers under dif- ferent names ; but the disease, as it affects us particularly, and its history, as we understand it at the present moment, have come to us in the three consecu- tive epidemics of 1890, 1891, and 1892. At the time of writing (January, 1893) only a few sporadic cases have taken place during this year, and they have not been severe. We cannot yet speak of an epidemic of 1893. During the period referred to, great attention has been given to the study of the disease by our profession, and, in certain instances, by governmental authorities. Etiology. — It has not been believed until recently that the causes of this disease are really known. Certain hypothetical causes have been advanced, such as air, contagion, local conditions, general influences, etc. But during the last three or four years very close investigations in regard to its etiology have been made. The reports of the British medical government clearly show that the spread of the disease depends upon human intercourse, and that it spreads no faster tlian human beings, parcels, or letters can travel. Bacteriological investigations have been carried on witli great accuracy during this time. Filatow' wrote fully concerning the liistory and symptoms of the disease under consideration, and Seifert investigated the bacteriological history three or four years ago ; but particular investigations have been carried on during the past year in the Berlin Institute by Drs. rfeifi’er, Kitasato, and Canon; and Sternberg remarks that there is good reason to believe that the bacillus discovered by these investigations is the specific cause of the disease. The following rdsumd from Dr. Sissley of London gives much regarding the etiology of the scourge under discussion : (1) The first case of influenza in a town is generally a patient wlio has come from an isolated place. (2) Isolated cases precede the epidemic. (3) Influenza extends along the lines of human intercourse. (4) Isolated persons, such as prisoners and inmates of asylums and con- vents, often escape the disease. (5) The number of those aflected in an e{)idemic increases till a maximum is reached, and then declines, as in the case of other contagious diseases. 214 EPIDEMIC INFLUENZA. 215 There is no doubt that nursing children three or four months of age feel the influence of la grippe. Dr. Townsend of Boston has placed on record a case where the mother had an attack of influenza about the time of her con- finement, and the child in a few hours after birth began to sneeze and had all the symptoms of this infection ; and an English observer records the case of an infant who died on the third day of its life from this disease. It is somewhat difficult to diagnosticate influenza in very young infants, but it is fair to sup- pose that, when the infection is present in the house and parents and nurses are under its influence, if infants present unusual symptoms of fever, exhaus- tion, and the involvement of one of the three systems which are usually select- ed by this infection, the disease is due to the poison of influenza. The exact point at Avhich the infection may gain entrance to the system has probably not been ascertained. That it may enter through either the aliment- ary canal or the lungs there is no doubt, and in all probability these are usually the points of entrance. One observer believes that the conjunctiva is in many instances the structure through which the poison attacks the system. Influenza and Diphtheria. — The marked similarity between the remote effects of the poisons of diphtheria and influenza is very great, and it is quite possible that the pathological findings in influenza may be quite as numerous and significant as we already know they are in diphtheria. We possibly do not know the exact cause of influenza, but we are certainly warranted in assuming that there is a most profound toxic effect in influenza as Avell as in diphtheria. The depression is profound, the recovery slow and tedious, and the involvement of the nervous system in both diseases is extremely signif- icant. The action of these two poisons upon the heart is somewhat similar. Every practitioner of experience has noticed the slowness of the pulse and its irregularity, and in some instances death has occurred in such an unexpected manner that we could attribute it to nothing less than degeneration of the heart-muscle. Pathology. — There are but few special post-mortem findings known to this disease which are of value to us as relating to children. Nearly every study has been based upon examinations made in adults, and the records of autopsies made solely and particularly to find the results of influenza on the tissues of the young are extremely meagre. Ashby and Wright state that at the post- mortem no grave lesion is found, but there is usually venous congestion and marked injection of the venous capillaries;” and Vargas of Barcelona, whose opportunities for seeing many cases profoundly sick with influenza have certainly been very great, after remarking that rapid deaths are usually due to severe attacks affecting the nervous system, says that while Ave cannot state that there is an apoplectic form, in some cases the post-mortem revealed the venous plexus congested, and also cerebral haemorrhages. The same author also asserts that in cases Avhere the gastro-intestinal symptoms predominated there was tumefaction of Beyer’s glands and of the solitary follicles. In 115 references to influenza found in the British Medical Journal of 1891 and 1892, not one speaks particularly of the pathology as it is found in children. And in the works of Filatow and Uffelmann, both wi’itten in 1892, absolutely nothing is said regarding this part of our subject. The special effects of the poison of influenza upon the tissues of the young have yet to be described. Incubation. — This may be only a feAV days, possibly only a few hours, or, on the contrary, the influence of the poison may be felt for weeks before the active development of the disease. Others who have studied the disease believe that two or three days is the usual time of incubation. 21 () AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Clinical History. — The disease aifects more particularly one of three groups of organs: First, the respii’atory and circulatory apparatus; second, the gastro- intestinal canal ; third, the nervous system. Sometimes the infection localizes itself in the respiratory tract, spending its energy there, and the patient will pass through a severe catarrhal bronchitis or a pneumonia with such general prostration as to endanger his life; or the disease manifests itself as a catarrhal inflammation of the stomach and bowels, with a tendency to collapse on account of the extreme weakness which is induced ; or, closely following the severe headache, which indicates that the nervous system is the first to be attacked, have come threatened convulsions and meningitis. We have these organs affected singly, or in some cases a complication involv- ing almost all of them, such as a bronchitis with gastro-intestinal disturbance, or a gastro-intestinal disturbance with great nervous prostration. The invasion is rapid, and the disease is frequently ushered in with a chill followed by delirium and rapidity of pulse. The face in many cases is red from the commencement of the disease, and there is earache, vomiting, and an increase in temperature. The fever is not high in the majority of cases, but occasionally an unusually high temperature is noticed. In a majority of cases, at some time during the disease, the temperature is subnormal, varying from one-half to two degrees below the standard of health. This condition of tem- perature is undoubtedly a result of the action of the poison upon the general nutrition, the imperfect action of the lungs which is present in many cases, and the general depression of the vital forces. There is also loss of weight. This has been particulaidy brought out by Hansen of Copenhagen, who con- cludes that, while in some cases there is simply a standstill, in many there is an absolute diminution in normal Aveight. It is fair to conclude that this evidence of waste — in other Avords, Avork — represents the conflict betAveen the poison of influenza and its subjects. In some cases this diminution of Aveight is noticed when there are no other signs of the disease present. And finally there is a very pronounced general weakness never before experienced by the patient, and in no one organ or system of organs is it more noticeable than in the circulatory apparatus. The pulse is usually accelerated, sometimes very rapid, and the heart, in many instances, never regains its strength and vigor. Special Features. — Mespirntori/ Symptoms . — A catarrh of the respiratory organs takes place Avith great frequency, and in its various phases extends to every part of this system. Sometimes the upper breathing apparatus is attacked first, and the disease rapidly spreads and involves the I’est. The eyes are usu- ally red and suffused, and in many cases not only is the middle ear involved, but disease of this organ remains as a seciucl for a long time. A general catar- rhal bronchitis is frequently present, and in some instances pneumonia Avith all its characteristic symptoms. There is in many cases, early in the disease, an apparent localization of the infection in one or both of the lungs, threatening a. pneumonia, but this usually clears up in a very short time, and the disease be- comes diffused throughout both lungs. Very often there may be only a severe and perplexing cough, without any physical signs. Respiration is sometimes sIoav, and in a fcAv cases breathing for a fcAV seconds has absolutely stopped. These peculiar paroxysms have been repeated .several times during the day, and in a few instances life has been preserved during these attacks oidy by artificial respiration. Thoracic pains are sometimes intense, and call for the external application of anodynes. Circulatory Symptoms . — There is Tisually from the first a rapidity and weakness of the heart, and syncopal attacks occur in many eases. Hepre.ssion in the action of this organ and failure in its supply of nerve-force seem entirely EP ID EM IC IN FL UENZA . 217 out of proportion to all other symptoms. While in many cases the temperature and pulse seem fair, there is an unusual muscular weakness and a tendency to syncope. I have not noticed organic heart disease, hut cyanosis has been present in a few cases, and in many instances palpitation and short breathing are not only noticed during the active history of the disease, but also inter- minably follow its unfoi’tunate victim. G astro-intestinal Symptoms . — The tongue is frequently flabby and coated, and shows indentations of the teeth, indicating malnutrition. The appetite is often entirely absent, and persistent vomiting takes place in many cases. Herpes labialis is sometimes noticed, as also sordes. Diarrhoea to such an extent as to become exhausting is frequent; constipation is sometimes present. In some cases the diarrhoea and vomiting are so frequent and persistent, and the child becomes so rapidly collapsed, that if the case occurred in the summer a diagnosis of cholera infantum would undoubtedly be suggested. As the result of this great withdrawal of fluids from the body, the eyes and fontanelles are greatly depressed, and the child becomes restless and rapidly goes into collapse. Nervous Symptoms . — Extreme irritability and fretfulness are found in the majority of childish patients. Headache and joint and muscular pains are frequent and sometimes intolerable. In many cases there are noticed an indif- ference and a hebetude which closely simulate a typhoid condition. Convul- sions take place in a small percentage of children, and congestion of the brain with drowsiness may be noticed. In one case which came under my observation the child did not close its eyes for four nights. It was not uncon- scious, but indifferent, and wanted to be left alone. In a few cases meningitis will seem imminent, and the diagnosis will sometimes necessarily be held in abeyance. In some children afflicted with influenza there is developed an obstinacy which is truly remarkable ; they sometimes resist the slightest touch, and refuse all examination on the part of the physician. This peculiarity is regarded by some observers as of diagnostic importance in differentiating from typhoid fever. Temperature . — In addition to what I have already said, I have noticed that the fever may be very high and yet recovery take place. On the other hand, a temperature of 101° to 102.5° F. may persist for a period of two or three months. In these cases I have suspected and have repeatedly examined for evidence of tuberculosis, and have not found it, the patient finally making a good recovery after this long period of sickness. In general, we may make the statement that the temperature is more irregular in influenza than in any- other disease. Complications and Sequelae. — These are numerous and varied, and attack nearly every function and organ of the body. Glandular enlargements are frequent. Inflammation of the parotid gland may take place. Abscess of the antrum and inflammation of the connective tissue of the neck have been noticed. Tuberculosis and tubercular meningitis may follow in a few cases. Conjunc- tivitis may remain, and catarrhal inflammation of the middle ear, resulting often in perforation and profuse discharge, will be noticed. At times this involvement of the middle ear, while always a serious complication, may even threaten the life of the patient. Diseases of the skin are sometimes noticed, such as erythema, herpes, and urticaria. Among the more general diseases that have been observed are rheumatism, chorea, nephritis, and periostitis. Children having a tendency to rickets have been known to develop the disease after having had an attack of influenza. Among the complications which I have noticed, and which I have not seen 218 AMERICAN TEXT- BOOK OF DISEASED OF CHILDREN. recorded, is purpura. Of this I have seen four cases, all in young people, and attended with extreme weakness and with evidence of more or less hlood- change. As is not unusual in adults, acute mania has been observed to follow the disease occasionally in children, but genei’ally ends in complete recovery. Dr. Julius Althus, in an extensive article on mental affections after influenza, gives cases illustrating neurasthenia, hypochondriasis, melancholia, delirium from inanition, homicidal tendencies, and general paralysis. lie believes that the psychoses observed after epidemic influenza are far greater than those after any other infectious disease. Diagnosis. — From the rapidity with which it seizes the patient, influenza might be mistaken for sunstroke, an acute poisoning, or malignant malaria. It can be confounded with all diseases of the respiratory apparatus, with typhoid fever, and with meningitis. From a simple catarrh, influenza will be distinguished by the fact that it is epidemic, and that there is greater prostration, which continues for a longer period of time, than in the first-named disease. The temperature is also higher, and there is a tendency to catarrhal difficulties — at first local, hut rapidly spreading to other portions of the body. A mild catarrh, with severe neuralgia and with unusual pain in the limbs, should be diagnosticated as influenza if this disease be prevalent. The same may be said in regard to an irri- table stomach, with diarrhoea and an unusual prostration. This in a time of epidemic should certainly he classed as influenza. From pneumonia and bron- chitis, simple or capillary, we differentiate influenza by the absence of the usual physical signs, altliough at the commencement of the gi’ippe in many cases there will he symptoms of pneumonia, and it seems as if localization had indeed taken place ; but fre([uently in a few hours this becomes diffused, and a general bronchitis with the excruciating pain and prostration belonging to influenza is detected. From typhoid fever influenza is differentiated by the fact that no rose-spots appear and no enlarged spleen is found, and the catarrhal condition, more par- ticularly in the respiratory tract, predominates over all other symptoms. If diarrhoea exists in influenza, it will be noticed that a cough and a catarrhal state of the air-passages has preceded its development. The fever in influenza is irregular ; in typhoid it is so regular and constant that it almost makes its own diagnosis. It is not usual to notice the apathetic facial exj)ression that we have in typhoid. The face, however, is usually flushed in influenza — more frecjuently pale in the continued fever. There are no rose-spots in influenza, no tenderness and gurffliim in tlie right inguinal region. From meningitis influenza can usually he diagnosticated by carefid obser- vation of the eye and by the want of the rigidity of the muscles Avhich we find in meningitis. The disease of the l)rain usually develops rapidly, and if death does not take place it disappears quickly. I must, however, say that the differentiation of meningitis from certain forms of la gripj)e is attended with great trouble, and a diagnosis must in some ca.ses be withheld. When the fever persists after all other symptoms of influenza have subsided, and there is a cough with gradual emaciation, the closest care must he taken that a tuber- cular disease does not come in. Particular attention should he given to nutri- tion, and every means should be taken to diagnosticate the disease early. Prognosis and Mortality. — In this connection an interesting toj)ic might be discussed as to whether one attack of influenza jn-otects from suhsecpient attacks. I do not think that this (piestion at j>resent can be fully answered, but the general statement can be made that many families j)articularly afllicted EPIDEMIC INFLUENZA. 219 in 1889 did not develop the disease in 1890 or 1891. There are those who are immune from the disease, and others in whom it has developed three con- secutive years. The mortality is different in different epidemics, and the character of the epidemic must be considered, as in all other infectious and contagious diseases. In some epidemics children are particularly liable to contract the disease, while in others adults seem to be selected. And again in a more general epidemic it has been noticed, as I can personally attest, that children often are not attacked until the disease has prevailed for some time. When the attack is moderately sevei’e, I regard it a dangerous malady for a child, particularly if he has anaemia or any vicious constitutional tendencies. Death has taken place in twenty-four hours. It may come from almost every complication, but, in the main, exhaustion and bad nutrition bring about the fatal result. Death may come with such rapidity that in summer insolation is suggested, and at other times malignant malaria. In the fulminant variety with rapid death, the severe symptoms will be referable to the nervous system, while throughout the entire history of other cases the poison selects the respiratory or gastro-intestinal tract, and death comes as it does in those diseases when not complicated w’ith influenza. But it must be remembered that there is always a tendency to col- lapse and a prostration out of proportion to other symptoms. The length of time consumed in convalescence from this disease is wonder- ful. The pains and general weakness do not disappear for weeks ; and I may add that many of the sequelae remain for years, and not only produce suffer- ing, but shorten the life of the individual. Treatment. — I have no particular remedy or combination of remedies to suggest. I think, however, that care should be taken to prevent the contagious element from spreading and gaining a hold on the community, and, in view of the great mortality and the immense money loss which this disease causes, it appears to me that the time will come when it will be regarded as the duty of all municipal authorities to assume such control of the disease as science suggests. Let the people understand that it is a contagious disease, and instruct them how to prevent its spreading by contact. All handkerchiefs and cloths used bj”^ the patient must be immersed in some antiseptic fluid, and all cuspidors and articles of furniture which come in contact with the germs of the disease should be carefully disinfected. A generous diet must be insisted upon, some stimulation, and a conservation of all the strength of the patient observed from the outstart. For the general pain which pervades the entire system, which sometimes is the first and most prominent symptom, nothing has given me such good results as phenacetin and salicylate of sodium. The catarrh of the respiratory tract which speedily prostrates young children should be early treated with stimu- lants, including the ammonia preparations and the ordinary expectorants. The gastro-intestinal catarrh must not be neglected, but should receive attention from the first. It is a clinical fact, wdiich must have been observed by many, that in some of the neglected cases there is just as profound and general col- lapse from the copious diarrhoeal discharges and vomiting, which we sometimes see in this form of the disease, as from those which take place in severe cases of cholera infantum. They should, then, have attention from the very first. For the extreme fatigue and depression not only alcoholic stimulants, but the effervescing waters with quinine, should be administered. If the stomach is particularly irritable, let the quinine be administered by inunction or by the rectum. Children take eagerly and with good results whipped egg-albumin 220 AMERICAN TEXT-BOOK OF DISEASED OF CHILDREN. with sterilized water and a little stimulant and sugar. Champagne is excel- lent for the depression which is so evident among these little people. When there is great prostration following the involvement of any of the three systems we have mentioned, the carbonate of ammonium, camphor, and musk, fortified by the conjoint use of digitalis and nux vomica, are indicated. When the patient begins to pass out from the more painful and acute mani- festations of the disease, in addition to a generous diet a tonic composed of the compound syrup of hypophosphites, extract of malt, and pepsin cordial, equal parts, with a very small amount of elixir of bark, iron, and strychnine, acts efficiently. ERYSIPELAS. By FREDERICK A. PACKARD, M. D., Philadelphia. Erysipelas is an acute, specific, contagious, inflammatory disease of skin and mucous membranes, accompanied by marked general symptoms, and cha- racterized by peculiar local lesions at the seat of inoculation, by its tendency to spread, and by the presence in the affected area of a micrococcus that is capable of reproducing the disease in other individuals. The word “erysipelas” is probably derived from ipodpo^, red, and TTsXXa, skin. Numerous qualifying words have been used to signify the point of involvement, the course of the disease, the appearances presented by the local lesion, the age at which the disease occurs, etc. The terms “ traumatic ” and “ idiopathic ” have been used to distinguish cases wherein there is or is not an antecedent obvious wound of the skin at the seat of the local lesion. No qualifying words should be used as implying an essential difference in the pro- cess, as it is a disease sui generis, no matter under what circumstances it may occur. History. — Erysipelas has been known from the time of Hippocrates, but the descriptions of the disease given by most writers prior to those of the last century show that many diverse diseases were included under this name. When humoral pathology occupied men’s attention, this, in common with many other maladies, was supposed to be the outward expression of morbid humors in the body. At a later date it was looked upon as a simple dermatitis; still later, as a simple lymphangitis. The contagiousness of the disease was pointed out by Lorry in 1777. A microbic origin was first suspected by Martin in 1865. The question of priority in demonstrating this origin is still a matter of dispute. Between 1868 and 1870, Nepveu and Hueter described the occur- rence of microscopic organisms in connection with the disease. It need only be stated here that the description given by Nepveu corresponds more closely than does that of Hueter to the micro-organism now established as the cause of the disease. Since 1870 many observers have studied the disease from a bacteriological aspect, but it is especially to Fehleisen that we owe our present knowledge of the life-history and etiological role of the micrococcus described by him in 1882. Etiology. — The disease is limited in its occurrence to no part of the civil- ized world, but its favorite habitat is the temperate zone. It but rarely occurs in the tropics, being less rare in regions far removed from the equator. In Greenland, for example, occasional widespread epidemics have occurred. The predisposing effect of season can be readily seen by the accompanying chart (Fig. 1). It will there be found that by far the greater number of fatal cases in Philadelphia occur during the latter part of the first and the early portion of the seeond quarter of the year ; that is, during the early spring months. Allen analyzed 566 cases applying for treatment, and obtained practically the same result. 221 222 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. It appears to be most prevalent among the poorer classes. This may be due to several causes — the greater liability to injury, frequency of chronic Fig. 1 . QUARTER 2".“ QUARTER 3"P QUARTER 4T“ QUARTER superficial inflammatory troubles, lack of cleanliness, want of ordinary sanitary precautions, and neglect of proper isolation amongst those attacked. The ((uestion of age as a predisposing factor is difficult to determine, as only fatal cases appear in the reports of hoards of health. Of 12,r)56 fatal cases of the di.sease in England between the years 18(52 and 18(iS, there occurred under one year of age 31 per cent. ; under five years, 5.0 ])or cent. ; under fifteen years, 2.0 per cent. ; under twenty-five years, 4.2 )>er cent. ; under forty-five years, 12.4 per cent. ; under sixty-five years, 20.0 ]>er cent. ; above eighty-five years, 1.4 per cent. In Philadelphia, during the period between 1874 and 1801, there occurred 1253 deaths from erysipelas. Of these, 380 were in children under one year of age, 35 between one and two, 23 between two and five, 25 between five and ten, 0 between ten and fifteen, tlie remain- ing 784 cases occurring in those past the latter age. All that can be said, therefore, is that no age is exeni))t. The large number of fatal eases occurring in the first year of life may be due to the almost uniform fatality of the disease during the early part of that ))criod, and cannot bo taken as an index of tlio actual number of cases occurring in infants. I JR YSIPELAS. 223 What part filth and defective drainage may play in its production has not been definitely settled. In the older hospitals of Europe frequent epidemics have occurred ; but it is not alone in these that erysipelas appears, new and apparently sanitary institutions being also the scene of its occuiTence. A well-known and oft-quoted instance of the effect of polluted air is that which occurred in the Middlesex Hospital, where a defective drain was on two occasions the apparent cause of an outbreak of the disease, starting in the bed nearest to its position in the wall. It is said to be frequent in the immediate neighborhood of badly-kept stables. The most important etiological factor is contagion. The contagious principle has but a limited area of infiuence, as is shown by some of the histories of local epidemics within hospital wards, wherein patients upon one side of a ward have been aflected seriatim on both the right and left of the individual first attacked. Those in attendance upon a case are apt to contract the disease. One attack seems rather to predispose to, than to protect against, a recurrence, due probably to the fact that some breach of the surface produced by a chronic affection admits the poison. The contagious principle is the streptococcus erysipelatis. Although pre- vious investigators had discovered micrococci in the local lesion, the most careful and conclusive work upon the subject was performed by Fehleisen, hence the micro-organism is fi’equently spoken of as the streptococcus of Fehleisen. By him it was found in the lymphatic vessels and spaces of the skin and subcu- taneous cellular tissue, and in the superficial layers of the corium. It occurs as a single cell or in the form of diplococci or chains of various length. The individual cell measures about 0.3j« in diameter. It is readily cultivated upon gelatin and blood-serum, where the colonies form as dull-white, round points, closely marginated or fusing at points pf contact. It grows well at the tem- perature of the human body, is facultatively aerobic, and develops well in vacuo. Not only has the inoculation of pure cultures been successfully practised upon animals, but the disease has been inoculated upon human beings as a therapeutic measure. In order that the parasite may gain access to the lymph-spaces, it is essen- tial that some breach of the surface should exist. This means of entry may be supplied by some wound accidentally received or purposely inflicted, by the unhealed navel of the new-born, scarifications made for purposes of vacci- nation, the local lesion of vaccinia, the ulcers of varicella, solutions of continuity produced by eczema, intertrigo, ecthyma, or pemphigus, or by ulcers resulting from chronic inflammation of the mucous membranes of the mouth or upper air-passages. It is owing to the frequency of lesions at the points of union of skin and mucous membrane that the local manifestations frequently begin at those situations. Pathological Anatomy. — After death the body-heat is maintained for a long time, and, according to Eulenburg, there is a post-mortem rise of tempera- ture to a point .9° C. (1.5° F.) above that observed before death. At the seat of the local lesion the vivid color gives place to a mere yellow- ish discoloration, and much of the swelling observed duilng life disappears. When the skin is incised there exudes a varying quantity of more or less discolored serum. The skin and subcutaneous tissue are somewhat thickened and cannot be readily separated. ^Microscopical examination of the affected skin shows that beyond the peripheral margin there are numbers of micrococci in the lymphatic vessels. As sections are made from without inward, the greatest histological changes are seen at the visible margin of the patch, where there are much serous infiltration separating the cells, and infiltration by round 224 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. and wandering cells, many micrococci being contained in the latter. From this point the alterations progressively diminish as the part earliest attacked is reached, until complete restitutio ad integrum is found to have occurred. The hair-shafts are unaltered, hut there is serous and cellular inhltration of the root-sheath, and micrococci may be found in the space between the latter and the root. In lately-developed vesicles upon the surface no micro-organisms are to be found, but in those of longer existence various forms abound. In phleg- monous erysipelas there is an admixture of the staphylococcus pyogenes with the streptococcus erysipelatis. The mucous membranes that are affected show the same appearance as does the skin, save for the normal structural differences in the tissue. ‘ Attacking the larynx, the disease produces marked swelling in the parts around the glottis. Oedema of the rima glottidis may be present. The trachea and bronchi may be of a brillant red color, with paler areas corresponding to the cartilaginous rings. Three forms of pulmonary lesion may be found : (1) an accidental croupous pneumonia, with the ordinary appearances of that lesion ; (2) intense congestion, either general or limited to diseased branches of the bronchial tree, with scattered areas of red or gray hepatization within the congested area ; (3) an acute infective interstitial pneumonia from bacterial embolism, with subsequent dissemination of micrococci in the interlobular connective tissue. In cases Avhere the disease has spread from the ,air-passages the alveoli contain large numbers of leucocytes and many micrococci, instead of the fibrin and epithelial cells seen in croupous and catarrhal pneumonia. Inflammation of the jtleura may be found from extension of tbe disease through the chest-wall or as secondary to subpleural pulmonary lesions. The pleural cavity may contain serous or purulent exudate. The sti’eptococcus has been found in pleural exudate. Suppurative anterior mediastinitis has been observed. Pericarditis is rarely seen, but endocarditis, affecting chiefl}^ the free borders or the Avhole of a leaflet of the valves of the left side, is occasionally present. Granular degeneration of the myocardium also occurs, due doubtless to the elevation of temperature. The endothelium of the blood-vessels has been found to be SAvollen, granular, and Avith indistinct nuclei. Tutschek reports a case of thrombosis of the abdominal aorta. The streptococcus has been found in the blood of the skin, subcutaneous adipose tissue, and in the capillaries of the lungs, liver, spleen, and kidneys. The stomach may exhibit marked engorgement of its vessels, the intestinal tract patchy redness. Multiple minute duodenal ulcers have been seen. In the large intestine the typical erysipelatous local lesions may be found in cases Avhere the disease has spread from the perineum through the anus to the rectal mucous membrane. The liver may be large and congested in rapidly fatal cases ; in those of longer duration it is more often pale, soft, and the seat of fatty degeneration. Many observers have found the strejitococcus Avithin the organ. By most authors the sjdeen is said to be increased in volume, as Avould be expected from the freciuency of its enlargement during life in non-fatal cases; but Denned found it small, soft, and hyjiememic. Peritonitis is comparatively rarely found, most instances of its occurrence being in the neAV-born, Avhere the abdominal Avail has been the seat of the ju’imary process. In spite of the prominence of cerebral symptoms during life, there are but seldom found any marked structural alterations Avithiu the eraiiiuiu. The membranes may be anaemic or their ves.sels intensely engorged Avith blood. Actual meningitis is rarely seen. An instance is reported by Osier of nienin- ER YSIPELAS. 225 gitis and thrombosis of the lateral sinus in a fatal case of facial erysipelas wherein the process could be traced along tlie trunk of the fifth cranial nerve. From the frequent presence of albuminuria it is to be expected that in fixtal cases the kidneys would show structural alterations. In five cases examined by Denned these organs showed nephritis in degrees varying with the duration of the case. Langer has reported a fatal case of erysipelas of the scalp occurring in a seven-weeks-old boy, and complicated by hmmoglobinuria, wherein the kidneys showed infarcts and miliary abscesses. In the articular inflammatory exudate that sometimes occurs Schuller found the streptococcus. Symptoms. — In spite of the fact that in six cases purposely inoculated by Fehleisen the initial chill occurred in from fifteen to ninety-one hours, the incubation for cases accidentally inoculated may be reckoned as requiring a period of from three to seven days. The onset may be sudden, the first symptom being a chill with rigor. In other cases feelings of languor and vague discomfort in the part that later becomes the seat of the local lesion may precede the occurrence of chill. In young children the occurrence of an initial convulsion is not infrequent. The attack may begin with severe inflammation of the upper air-passages or throat, the skin lesion not appearing for twenty-four or thirty-six hours after the first signs of illness. The temperature rises rapidly to 102°, 103°, or even 105° F. The affected area soon becomes the seat of burning, smarting pain. The local appearances at this time may merely amount to slight redness and glossiness. In a short time there is slight elevation of this reddened area above the sur- rounding healthy surface, the color deepens in shade, and there are pitting and pain upon pressure. The color is readily dispelled by pressure, but quickly returns upon the Avithdrawal of the finger. The pain becomes more intense, and there is a sensation of stinging and stretching in the affected part. The tongue is coated, there is anorexia, thirst may be marked, varying degrees of cephalalgia are ]>resent, while nausea is a frequent source of complaint. Vomit- ing is not frequent in cases of ordinary severity. At this stage the pulse is usually full, bounding, and rapid. Upon the second day the temperature-chart shows a slight morning remission. The redness and swelling extend from the original site to cover a larger area ; the eyes may be invisible from swelling of the lids, the ears swollen and distorted, and the lips thickened. Cephalalgia becomes intense, especially if the scalp be invaded ; insomnia and delirium fre((uently appear. Albuminuria, with a copious deposit of amorphous urates, will usually be found after the first few days. On the second or third day the local appearances of the part fii'st attacked reach their highest degree of devel- opment. Thereafter the redness and swelling of that part subside. Meanwhile the local process may have steadily advanced from the point of its original appearance until large areas of skin are involved. When extension ceases the temperature rapidly falls, the pulse becomes less bounding and its frequency diminishes, pain lessens, the associated symptoms rapidly subside, and the patient enters upon convalescence. During convalescence the affected skin has a faint yellowish discoloration and is the seat of desquamation, the epidermis separating in branny scales or in large flakes, and in cases where the scalp has been invaded the hair falls. Albuminuria may persist in lessening degree for several days after the cessation of other symptoms. Important variations from this ordinary type occur and require separate consideration. Erysipelas of the new-born begins either at the navel or at a point nearer to the symphysis pubis. Thence extension rapidly occurs until the skin of the whole abdomen, that of the extremities, or even larger portions of surface, may 15 226 AMERICAN TEXT-BOOK OF DmEASEB OF CHILDREN. be involved. The infant exhibits extreme restlessness and has high fever, may vomit frequently, and soon passes into an asthenic condition that speedily ends in death. In other cases the process extends along the still patulous umbilical vein, reaches the liver, and may lead to fatal peritonitis. After the early days of infancy are passed the disease shows the same characters in children as in adults. Where the mouth, tonsils, pharynx, or nares are primarily attacked, the local appearances are those of an intense inflammation of the })art affected, but swelling is more marked than usually occurs with ordinary inflammation, and the tendency to spread to adjacent structures and the skin is a peculiarity of great diagnostic importance. From the nares it may extend to the lachrymal duct and attack the skin near the internal canthus. From the upper air- passages the process may extend to the bronchi or to the lungs, producing the symptoms and physical signs of an intense bronchitis or pneumonia. In the primarily laryngeal form hoarseness begins early, and may be rapidly followed by symptoms of sufibcation due to the intense swelling of the mucous membrane. The eruption exhibits certain peculiarities Avorthy of further study. Exten- sion usually takes place most rapidly in one direction, but not in an even line, as flame-like tongues of redness frequently jut out in advance. The area of redness and SAvelling is bounded by an abrupt fall to the level of the healthy surface. Extension from the face usually occurs upAvard, reaching the hairy scalp or even passing backAvard to the nape of the neck or to the trunk. From the trunk it may spread to the extremities or head, and vice versd. One striking peculiarity of the eruption is its liability to terminate at natural boundaries — the borders of the hairy scalp, the various folds of the face, the groin. Where the underlying bone is close to the surface the eruption is fre- quently absent ; thus the chin may be spared, Avhile the rest of the face is much swollen. Conversely, where the skin is but loosely attached to under- lying structures — as in the scrotum, labia majora, and eyelids — SAvelling is very marked, and gangrene may occur from interference Avith the circulation. Besides redness and SAvelling, other appearances are usually present in the affected area of skin. Vesicles, or even bullre Avith clear or muddy contents, are apt to form. Pustules are rarely seen, but in some regions Avith resisting skin a verrucose appearance may be presented from cellular infiltration. Minute points or (piite extensive areas of gangrene may occur. The bursting of the vesicles and bullte causes the formation of yelloAvish or broAvnish crusts. After the active process in a part has subsided the surface is covered Avith bran-like scales, large flakes of detached epithelium, and crusts of varied hue. The hair may fall very rapidly, leaving the scalp bare, smooth, and shining. The temperature-curve folloAvs (piite accurately the extension and subsidence of the local process. After the latter has entirely sul)siiled there may remain an elevated temperature, OAving to the presence of irritation or actual inflam- mation of various organs. Cavafy has reported five cases, and 1 have seen one, of erysipelas of the face Avithout pyn'xia. Not only may the uri)ie contain aH)umin and an excess of urates, l)ut hya- line and granular tube-casts may also be ])rcsent. These disap])ear after the ce.s.sation of the disease in the majority of cases. Their presence may be the evidence of the rekindling of a pre-existing disease of the kidneys, in Avhieh case they Avill usually ])ersist or even increase as time passes. Complications and Sequelae. — d’he lung is perhaps the most fre(|uent seat of complication in erysipelas. Ihicumonia of the ordinary type is of not Ell YSIPELAS. 227 infrequent occurrence, or the specific process may attack the lung-stmcture. Pleurisy (with or without effusion), empyema, peri- and endo-carditis at times occur. Pleurisy occurred twice in eight cases purposely inoculated by Fehleisen. Previously-existing nephritis is apt to be awakened into activity, and urmmia may be the immediate cause of death. Ilmmoglobinuria may be a compli- cation, as in the case reported by Joseph Langer. In facial erysipelas suppu- rative inflammation of the orbital connective tissue is much to be dreaded, and is frequently fatal from extension to the cerebral meninges through the optic foramen or sphenoidal fissure. Amblyopia or complete amaurosis may result from pressure upon the optic nerve or vessels of the eyeball. Obstinate vomit- ing is at times a serious complication. Diarrhoea frequently occurs, and the stools may contain blood. After the active signs of disease have disappeared superficial abscesses frequently form. Erysipelas is, according to Gowers, rarely followed by paralysis. Optic neuritis, optic atrophy, or thrombosis of the retinal vessels may follow com- pression of the optic nerve and ophthalmic blood-vessels in cases of orbital cellulitis. Amblyopia may be due to retinal hemorrhages, detachment of the retina, or opacities in the vitreous. In 9209 cases of adventitious deafness analyzed by W. B. Post, erysipelas was the alleged cause in 36. Diagnosis. — In ordinary cases the diagnosis is readily made. The sudden onset of marked constitutional symptoms coincidently with or rapidly followed by the red, elevated, painful lesion of the skin, the peculiar qualities of the latter, and, in particular, the tendency to spread, sufficiently stamp the disease. When the mucous membranes are first attacked it may be impossible to make a positive diagnosis until the skin becomes affected ; but here also the rapid and continuous spread of the disease along the mucous membrane, together with the intense swelling and brilliant redness of the part, should suggest the erysipelatous nature of the inflammation. Where the poison has entered through the lesions produced by eczema of the hairy scalp, such as is so frequently seen in the neglected children of the poor, the cause of the constitutional symptoms may be only discovered upon the extension of the local process to the forehead, neck, or ears. From simple erythema the diagnosis is made by the tense swelling, the sharply-defined border, the more marked ambulatory character of the lesion, the fever, and other marked systemic symptoms of erysipelas. From angeio-neurotic oedema this affection differs in all points save the fact of the presence of swelling. From ordinary urticaria it may be distinguished by the rapid appearance and reappearance of “hives,” and by the occurrence of the eruption simultaneously in different portions of the body. The local appearances of acne rosacea sometimes closely resemble those of erysipelas, but the clinical history, the rapidity of extension, and the constitutional symptoms of the latter disease clearly differentiate the two affections. From malignant oedema the diagnosis must be made by the method of spreading and the local appearances peculiar to the two diseases. Malignant oedema more frequently occurs at points where the skin is particularly thin than does erysipelas. Prognosis. — In uncomplicated cases the usual result is in complete and rapid cure. In the new-born (that is to say, in those under the age of fifteen days) the disease is practically always fatal, owing in part to the lack of resist- ing power in those so young, in part to the ease with which extension occurs, and in great part to the liability to the occurrence of phlebitis of the umbilical vein and of peritonitis. In older children complete cure usually results. 228 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Among especially unfavorable occurrences may be mentioned suppuration in the orbital space, gangrene, signs of inflammation of the lung, pericardium, or endocardium. When optic neuritis, optic atrophy, or thrombosis of the retinal arteries occurs, the prognosis as to return of vision is unfavorable. Permanent baldness but seldom results, in spite of the complete alopecia that often is present immediately after the attack. Treatment. — In this disease the same rules in regard to isolation should be followed as in other contagious diseases, save only in the degree to which it should be practised. Occurring in the medical wards of a hosj)ital, it may not attack other individuals, providing that the beds are in not too close appo- sition. The contagiousness of erysipelas is not sufficient to warrant the exclu- sion of cases from medical wards that are properly separated from the surgical and obstetrical departments. It is sufficient that the patient be so placed that he may be surrounded by those having no breach of cutaneous or mucous sur- faces. In surgical and obstetrical wards cases of erysipelas should be excluded, and the occurrence of an attack should be the signal for immediate isolation. No safer means for the jirevention of the disease exists than the use of thoroughly antiseptic methods as regards the wards, the operating-room and its appurtenances, the persons of operators and assistants, and the dressings employed. Where attacks recur in an individual any existing lesion that may give entrance to the poison should receive careful and prompt treatment. In the case of a self-limited disease, and one that rapidly subsides without warning, deductions as to the efficacy of any particular line of ti’eatment must be most carefully drawn. The methods em])loyed in erysipelas are too numer- ous to be here enumerated ; suffice it to mention a few of those that have stood the test of prolonged use by various observers. A mercurial purgative is advantageous in the early stages and before the institution of any line of treatment. But two drugs deserve mention as hav- ing any effect upon the course of the disease — tincture of the chloride of iron and jaborandi. After prolonged trial tbe first of these seems to have some influence in modifying the severity and shortening the course of the attack. It is best given in large doses, 5 to 15 drops, every three or four hours accord- ing to the age of the child. Under its use there is usually found a rapid cessa- tion of extension of the local process and subsidence of the general sym])toms. Jaborandi, or its alkaloid j»ilocarpine, was first recommended by DaCosta, and has had numerous advocates since the announcement of its value in erysi])elas. In children, however, it must be given with caution and in doses carefully graduated to the age of the child, the object being to give by hypodermic injection an initial dose of pilocarpine sufficient to ])roduce a ])ronounced sweat, and thereafter to give every four hours doses of the fluid extract of jaborandi sufficient to maintain a gentle diajiboresis. In adults the method is decidedly beneficial, but in cbildren its use ro(juires caution and careful watch- in" bv an intclliitent attendant. The almost purely mechanical rules that govern the extension and limita- tion of the local jirocess have led to various attemjits to substitute artificial boundaries for those of nature. For this end jiressure apjilied in advance of the lesion has been extensively emjiloycd by means of tight bandages of elastic material, by the ajijilicatioii of strips of adhesive jilaster, and by collodion. In many situations no form of pressure is practicable save that by collodion ; but tbe depth to which the constriction by collodion reacbes is too slight to oiler any obstacle to the spread of the jirocess. Where the other methods are avail- able tbe ajiplication of constricting bandages siilliciently tight to accomjflish the object in view is apt to be too painful for their long continuance. As, ER YSIPELAS. 229 however, this does not preclude the employment of other methods of treat- ment, it should be tried wherever practicable. Attempts have been made to stay the spread of this specific inflammation by the px’oduction of simple inflammatory exudation. For this purpose incis- ions were made or the solid stick of nitrate of silver was applied to the skin beyond the alfected area. Scarification of the healthy skin beyond the edge of the patch has been, and is still, used by some for the same purpose. Hueter first introduced the injection of 2 per cent, carbolic-acid solution under the skin threatened with attack. In some cases it seems to have limited the pro- cess, but the method is not always successful. It is, however, rational. As applications to the diseased area many materials have been recommended, such as flour, lycopodium, or other bland powders, white paint, lead-water and laudanum, cold water, vinegar and water, turpentine, and tar. These are now but seldom used, except white paint and lead-water and laudanum. The exclu- sion of air of itself seems to relieve much of the discomfort and pain. On this account any emollient application is agreeable. To the fatty base various sub- stances may be added. One of the most agreeable is the hydrochlorate of cocaine in the proportion of 10 grains to the ounce. This usually relieves pain very markedly. Resorcin in the strength of a drachm to the ounce may be used. Koch recommends the application, by means of a bristle-brush, of a mixture of creolin 1 part, iodoform 4 parts, and lanolin 10 parts. Spraying of the affected surface with a solution of corrosive sublimate has been recom- mended, but greater relief of discomfort, Avith more likelihood of reaching the deeper parts, can be obtained by the use of constant applications of emollient preparations. The diet should be nourishing and easily digestible. Milk should consti- tute the basis during the acute stage of the disease, but eggs, broths, and soft milk foods may be given, except Avhen fever is so great as to interfere with the process of digestion. In all cases occurring among the debilitated, and par- ticularly in very young children, stimulants will be almost invariably re(i[uired. The amount to be given depends upon the age and condition of the patient. For extreme elevation of temperatui’e the application of cold externally by means of sponging with cool or cold Avatei’, the Avet pack, or the cool bath should be employed. Where the hyperpyrexia resists these measures, or Avhere they cannot he properly applied, antipyrine, acetanilid, or, better still, phena- ■cetin, may be cautiously tried. The drugs mentioned should only be employed with extreme care and in minimum effectual doses. For delirium bromide of potassium or sodium may be given, either by mouth or rectum. Cold applications to the head may be sufficient to mode- rate the symptom. Opiates are to be used only as a last resource and Avith great circumspection, not only because of the danger attending their use in childhood, but also because of the liability to insufficiency or actual inflam- mation of the kidneys in this disease. Impending suffocation from SAvelling of the rima glottidis may require tra- cheotomy. Any purulent collections that may form should be promptly released by the knife. After the subsidence of the disease tonics Avith haematinics will be required. The alopecia that occurs in some cases usually requires no special treatment, but friction of the scalp and the use of cantharidal preparations Avill hasten the groAvth of the hair. Therapeutic Use. — A few words must be added regarding the use of ery- sipelas as a therapeutic measure. For many years back there are to be found reports of cases wherein an intercurrent attack of erysipelas was folloAved by 230 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. an amelioration or complete subsidence of the primary affection. The fre- quency of this phenomenon led to the intentional inoculation of erysipelas for the cure of various affections that were resistant to other measures of treatment, were inaccessible to the surgeon’s knife, or whose existence was incompatible with that of erysipelas. Among the affections alleged to have been cured by such an attack of erysipelas or by the intentional inoculation of the streptococcus of Fehleisen may he mentioned various lymphosarcomata, epitheliomata, lupus, and various other chronic superficial ulcerations, keloid, neuralgia, various psychoses, acute polyarthritis, and pulmonary tuberculosis. The antagonism between erysipelas and diphtheria has led to the inoculation of the former upon the latter disease. While many favorable reports as to the action of erysipelas in the reduction or complete removal of sarcomatous and carcinomatous tumors are to be found, there are others where either no result has been obtained or where recurrence of the growth has taken place, or even death has been brought about by the erysipelatous attack. The cases of neuroses and neuralgia that are found to have been relieved by an attack of the disease can be duplicated by those wherein cure has resulted after many different mental or physical impressions. In regard to the superficial skin lesions, the favorable action of erysipelas may be explained by the local influence of the inflammation produced as part of the latter. As to the favorable result in a case of pulmonary tuberculosis reported by Chelmonsky, it can only be said that further evidence must be brought forward before any definite curative influence of erysipelas upon this pulmonary lesion can be acknowledged. Attractive as is the theory of the antagonistic action of the bacterial products in one disease upon its own micro-organisms or upon those of another malady, it seems as yet unjustifiable to purposely add to the existing affection a disease which, while usually ending in recovery, not only may of itself prove fatal, but which is often observed as the final and fatal complication of many long- standing cases of incurable disease. CHOLERA ASIATICA. By EDWARD O. SHAKESPEARE, A. M., M. D., Philadelphia. This disease would be most properly designated as cholera infectiosa epi- deiuica, for in this term a definite idea of its chief characteristic and of its most marked tendency would be included. Cholera Asiatica is an exceedingly dangerous specific human disorder, pri- marily of the digestive tract, occasioned directly by the ingestion, entrance into the small intestine, and exuberant multiplication there of special minute vege- table parasites, the spirilla cholerae Asiatics, the so-called “comma bacilli” of Koch. The special poison elaborated by the growth of the parasites in the intestines attacks the epithelial lining of the latter, ultimately reaches the cir- culation and the nerve-centres, and causes the complex phenomena which cha- ractei’ize the disease. The intestinal contents, the vomit, and the stools of the attacked contain these specific parasites in enormous numbers, and they are infectious so long as the latter retain their vitality and power of reproduction ; so long as their infectious quality persists they are capable, under favorable circumstances, of causing an attack of the same disorder in another exposed, susceptible person, and of giving rise to a local or widespread epidemic of the same disease. For the latter reason does the danger to the public always outweigh in magnitude even that to the individual attacked. Cholera Asiatica is endemic in the lower tw'o-thirds of the presidency of Bengal, roughly corresponding to the delta of the Ganges and the Brahma- pootra ; it becomes epidemic in other parts of Ilindostan and of the world only periodically, after more or less irregular intervals of entire absence. During the intervals of epidemics, except as scattered cases shortly preceding or fol- lowing such visitations, and as an essential part of the latter, it does not exist outside the endemic area : it has no more affiliation with or relation to our somewhat common so-called summer cholera — otherwise termed cholera nostras, cholera morbus — than it has with some acute attacks due to arsenical poison- ing, to ptomaine-poisoning from ingestion of decomposed food, or to acute per- nicious malaria, or to still other very different disorders, all of which, never- theless, not infrequently present very similar symptoms and terminations. Etiology. — Although abounding filth of the surroundings — that is, of the district or the locality, of the domicile, of the home-life, and of personal habits — favors infection and the subsequent development of an individual attack, and the initiation, continuance, and spread of an epidemic of cholera Asiatica, neither a personal seizure nor an epidemic outside that endemic area which is the natural home of this disease can occur (not even when the person or population wallow in every sort of reeking abomination), unless the special infection be first introduced. In other words, no amount of filth is capable of producing a spontaneous generation of the specific infection which is the active 231 232 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. cause of this disease ; nor, without the activity of this specific cause, is any other agency or influence capable of producing the disease. The active specific cause of cholera Asiatica is the presence and multipli- cation in the intestinal canal of the subject of numbers of very minute vege- table parasites, certain well-defined species of bacteria known as the spirillum cholerte Asiaticae discovered by Koch in 1883, and because of their usual resemblance under the microscope to the written comma, and of the name of its discoverer, commonly called the “ comma bacilli of Koch.” The term “bacillus” as applied to this vegetable micro-organism is, how- ever, a misnomer, for the species is now I’egarded by nearly all competent authorities as a member of the group of spirilla. As commonly encountered in the intestinal contents or vomit of a victim of the disease, and in artificial culture media when growth is recent and rapid, if a fresh preparation be placed under a microscope of very high power and e.xcellent definition, this micro-organism is usually so actively mobile as to defy distinct vision. If the fresh preparation has been made from a recent pure culture, and there be plenty of fluid under the thin cover-glass, the movements of the comma bacilli remind one of the rapid, darting, zig-zag movements of the individuals of a swarm of small flies, and of the impossibility of distinct vision of any one of the swarm. If, however, a smear-preparation from such a culture be made, and after drying and flaming in the usual manner, this be properly stained, mounted, and e.xamined, it Avill be seen that each form is more or less curved — a few almost imperceptibly so ; a few others nearly as much as a semi-circle ; the greater number having a curvature rej)resenting an eighth or a quarter of a circle. The length may vary from one-seventh to one-fourth the average diameter of the red blood-corpuscle of man, the width being about a fourth its length. Examined critically it can often be seen that, instead of form- ing a segment of a circular ring, the individual form is in reality a portion of a spiral. The ends are blunt but rounded, sometimes slightly tapering, then presenting an outline similar to the fennel-seed. When proper methods of stain- ing are used each end of the “ comma bacillus ” is found to be furnished with one or more flagella, which act as motive organs. Cultivated in bouillon by the hanging-drop method, besides the above-described forms there are usually seen a variable number of more or less long ami complete s])irilla. Old cul- tures in bouillon, in gelatin, in agar, and in other media nearly always contain the comma and s])iral forms, and intermingled with these are frequently other shapes, Avhich many authorities regard as involution forms. Chief among the latter are spherules of a diameter from that of a cross-section of the comma to that of a red blood-corpuscle of man, and even greater. It is pretty certain that neither the comma nor the spirillum forms contain spores ; vacTioles have been mistaken for them. In the vomit and intestinal contents of the attacked the comma forms are always present for a munber of days, and short and incomplete sj)irils may sometimes be demonstrated in smear-preparations. The comma bacillus of Koch multiplies commoidy by two modes, each of which, however, constitutes essentially a process of fission : a, the comma doubles its length, and then divides into two ; />, before dividing the comma continues its elongation into a longer or shorter spiril filament, which nlti- matelv becomes segmented in order that finally the segments may separate to form new and scj)arate commas. Of these two ])roccsses of multiplication, the former is by far the more rapid. Elongation and division of the one comma into two have been actually observed under the microscojte to take place in twenty minutes. With such a rate of multiplication demonstrated, one can easily form some adecpiate conception of the otherwise inconceivable rapidiry of PLATE Vlll. Fio. 1. I’iioto-microgia])li : Smear preparation from ptire culture of comma bacillus of Koch. X 12Uh. Fig. 2. Photo-micrograph ; Smear preparation from (old) pure culture in gelatin of comma bacillus of Koch, showing oogonia of Ferrdn or involution forms of other authons. X 1200. Fig. 3. Photo micrograph : Uelatin-plate colony of comma bacillus of Koch. X &0. B’ig. 4. Photograi>h : Gelatin tube-culture of comma bacillus of Koch, 72 hours old, surface inclined. Natural size. lit£ LIBRARY OF TH£ UNIVERSITY OF III IMOIX CHOLERA ASIATICA. 233 propagation and enormous poAver of dissemination in river-water of the specific infectious principle of Asiatic cholera contained in the discharges from the hoAvels of a few cases, numerous examples of Avhich the history of this disease affords ; one of the most striking being the most recent — namely, that of the river Elbe in 1892. Of other possible modes of multiplication, only two may he merely mentioned here: that by intervention of so-called arthrospores of Huppe, who claims that these reproductive bodies approach the tenacity of life and the power of resistance of genuine spores ; and that of so-called “ dogonia ” of Fer- ran — both modes being a form of multiplication by budding. The multiplication of the comma bacillus of Koch in artificial culture media has been found to vary greatly under different constitution of media and varying conditions of temperature, etc. During the development and continued growth of these organisms in artificial culture media, chemical com- binations are split up and various new chemical products formed, as the neces- sary accompaniment of the nutrition, life, or death of the microbes ; and these resultant ncAV chemical products vary in quantity or composition, or both, Avith the varied chemical and physical complexion of the culture media, the external conditions of temperature, moisture, free oxygen, light, etc. Thus it seems to be now pretty clearly established that in artificial culture, among many other characteristics, the cholera microbe Avill not develop at a temperature beloAV 57^° F. or above 107f° F. ; that freezing, unless it be prolonged, does not kill this microbe, but places it in a state of hibernation, as it were, ready to resume again all its vital and pathogenic functions with the return of sufficient heat ; then, on the conti’ary, Avhen a temperature of 1074° F. is exceeded the vital functions of the microbe are more and more inhibited permanently, if the tempera- ture be continued, until a point is reached, at about 140° F., where the life of the microbe is destroyed absolutely in a very feAV minutes ; that multiplication is more rapid in fluid media of suitable constitution ; that the culture fluid, as a rule, possesses more virulence AA'hen the inoculated microbes are very recently obtained from an active case of cholera than Avhen a long time has elapsed ; that the j)res- ence of peptone in the culture medium seems to materially increase the develop- ment of the virulent poAver of the microbe, especially Avhen free oxygen and light are excluded ; that there is scarcely any fluid or solid moist nutrient material of animal or vegetable composition, of a neutral or slightly alkaline reaction and not containing a substance possessing antiseptic properties, upon or in Avhich it will not groAV ; and there are at the same time many fruits and vegetables upon the pulp or surface of which the microbes of cholera will not only live for hours and days, but Avill multiply there even Avhen the object gives a slightly acid reaction. This microbe Avill live and multiply enormously for a time in pure Avater, in foul water, even in seAverage, and in sea-water ; it Avill live for a considerable time and multiply enormously in milk, whether fresh or previously steidlized ; it is capable of living and multiplying for a time in vari- ous common beverages and on various common articles of food. It Avill retain its vitality, sometimes multiply exuberantly, on various textile fabrics of vegetable or animal nature for days, and in some cases weeks and even months, if tliey be not thoroughly desiccated or exposed to the sun’s rays, and contain no antisep- tic susbtance ; if such fabrics be kept decidedly damp or wet, the germ is capa- ble of enormous multiplication, and of retaining its infectious and reproductive poAver to a virulent degree for indefinite periods, lasting for weeks or months, provided the sunlight does not fall upon it. If, however, these fabrics are thoroughly dry before the microbe is placed upon them, and remain or quickly become thoroughly dry afterward, it soon dies — more quickly still if exposed to the sunshine or bright reflected light. Whilst the propagative poAver of the 234 AMEltlVAN TEXT-BOOK OF DISEASES OF CHILDREN. cholera niicrobe outside the human body, under favorable circumstances, is so enormous as to be almost incredible, fortunately for man it is, of all the dangerous pathogenic microbes known, the most susceptible to restraining or destructive influences. Whilst it is too often true that an individual, a community, a city, a whole nation, or even a continent, presenting favorable conditions for the free propagation of the infection, oftentimes suffers consequences Avhich in their swiftness, gravity, and manifold relations may be appalling, yet there is no infectious epidemic disease which can so certainly and so easily be warded off or arrested as can Asiatic cholera. Mention has already been made of the ingestion, entrance into the small intestine, and e.xuberant multiplication there of the “ comma bacillus of Koch ” as necessary conditions precedent to an attack of Asiatic cholera. Even with these it is probable that there must be one more condition before a serious attack follows — namely, susceptibility to the disease on the part of the individual. Since desiccation is one of the sure and rapid means of killing the microbe of cholera, and since the comma bacillus does not exist in the lungs or intestinal organs, in the blood, lymph, or muscular tissue, or in the nervous system of a person suffering an attack of cholera, it is obvious, a priori, that the active infection of this disease is neither inhaled nor does it enter through the cuta- neous surfaces. But in this matter we are not obliged to rely upon inductive reasoning, for there is not a single example known of either mode of infec- tion in the clinical history of cholera or in laboratory experience with this dis- ease. The cholera microbe must be sivalloived and pass from the stomach into the small intestine alive and endowed with vigorous powers of propagation and pathogenesis, before cholera can be naturally produced in man. There are various means and modes by which the infection of cholera may be introduced into the oesophagus of man. It may be conveyed by various fluids imbibed, such as water, milk, beer, weak tea, etc. ; by various articles of food, such as raw vegetables, bread, butter, fruits, meats, etc. ; by contact of the mouth with hands in some way soiled through careless handling of objects contaminated with numbers of the microbe, such as the clothing worn by the sick, the bed-linen used by them, the vessels containing the vomit or stools, etc. ; by water used for lavatory purposes or the washing of dishes or other food-receptacles ; by water used for washing the mouth and teeth, etc. The corollary of all this is that Asiatic cholera is not ac(juired by inhalation or mere contact with persons suffering from the disease, or with things contam- inated with the infectious principle. INIoreover, there seems to be a natural insusceptibility on the part of many to an attack of cholera, although they be undoubtedly exposed to the infection. Numerous examples of this personal immunity are furnisheil by every great epidemic, especially when the outbreak has been caused by contamination of the common supjdy of drinking-water. Furthermore, there is incontrovei’tiblo evidence to prove that there is an ac({uired immunity of variable duration following a natural attack of Asiatic cholera, whether the latter liave been grave or mild. Indeed, it is pretty cer- tain that a natural attack so light as to have escaped recognition is capable of proilucing such an immunity. That an immunity can be ac(piircd artificially by means of inoculations of various kinds and in various ways now seems to be an established fact. I need only mention in this connection the ])ioneer work of the Spaiiish physician, Dr. J. Ferran in 1884 and 188r>, and alter him the investigations of Petri, Bricgcr, W asserman, and Kitasato, Klemperer, Klebs, and llafkine, which with those of others constitute a body of experi- mental data so convincing as to leave but little, if indeed any, room for rea- sonable doubt. Whether or not an attack of cholera follow introduction of the CHOLERA A SI A TIC A . 235 special contagium vivum into the stomach of man may depend upon one or more of several conditions. The acid gastric juice of the stomach is, when present in sufficient quantity relative to the number of cholera microbes, capable of quickly killing them. Hence at times when the stomach is properly func- tioning and the number of the cholera bacilli swallowed is not excessive, there is far less probability of these microbes passing the pylorus alive and still retaining their vigorous pathogenic powers than when either there is little or no acid in the stomach or but little relative to an excessive number of comma bacilli introduced. Then, again, the factor of personal susceptibility — or, if we prefer its complement, we may say the factor of personal immu- nity — may intervene (after the cholera microbes have passed into the small intestine alive, virulently pathogenic and in sufficient numbers, with certain limitations), either to render an attack of cholera more certain of development and more violent, or to prevent it entirely, or to render it milder, respectively, as the case may be. Thus there is strong reason to believe that in Asiatic cholera as in other infectious diseases, whether the degree of susceptibility or the degree of immunity of any person be great or little, the dosage of the infectious material is a matter of importance for the generation or the violence of an attack. Any degree of immunity can be overwhelmed by an excessive dose, and any degree of susceptibility can be rendered insufficient by too small a dose. These considerations explain why it is that of so many exposed to the infection of cholera only a comparative few suffer an attack which is recognized as such. They also explain why a few foolhardy persons, whose skepticism seems to be greater than their power of discrimination, have ostentatiously swallowed voluntarily, in former times, some of the intestinal discharges of cholera victims, and in later times, some quantities of pure culture of the cholera microbe, and have lived to preach their false doctrine. When a sufficient number of vigorous pathogenic cholera microbes is intro- duced, into the stomach and passes wdth vital properties unimpaired into the small intestine of a susceptible person, an attack of infectious cbolera may be developed. In such a case the cholera microbes multiply enormously, and often with great rapidity, in the small intestine. With their growth there, under favorable conditions not yet well determined, a virulent specific chemical poison is generated. Whether this poison be essentially a ‘ptomaine analo- gous to the highly-poisonous vegetable alkaloids, as some contend, or a species of virulent albumose, as others maintain, or a special pathogenic enzyme, as a few affirm, or possess other characteristics, or be a combination of two or more of these, it would be unprofitable to discuss in this place. Whatever the nature of this specific chemical poison may be, it is pretty certain that when generated in sufficient quantity it attacks primarily the epithelium of the mucous membrane of the small intestine, exciting in it the phenomena of irritation and degeneration in varying degrees — according to the concen- tration of the poison and the susceptibility of the person — from initial cloudy swelling all the way to complete fatty degeneration and desquamation. The irritant poison penetrates beyond the epithelium and excites in a susceptible person a round-celled infiltration of the connective tissue underlying the epi- thelium ; it may even exert its irritant powers upon the submucous layer of connective tissue, and sometimes its influence may even extend outward into the muscular and subserous coats of the intestine calling forth in them vary- ing inflammatory phenomena. Klebs pointed out that autopsies of rapid cases of cholera showed invariably the inner surface of the small intestine to be covered with a very tenacious coating of mucus, and the experience of most observers confirms him. Another characteristic is that the serous mem- 236 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. brane of the small intestine is likewise the seat almost always of a viscid cover- ing, consisting mainly of degenerated and proliferated endothelium. The inflammatory action in the mucous and submucous coats of the small intes- tine may become so intense as to result in more or less extensive necrosis. Very generally the mucous membrane is hyperaemic. This hyperaemia may be very diffuse or it may be limited to larger or smaller areas. It is usually most marked in the region of the ileo-cmcal valve and around the Peyer’s glands. The Peyer’s glands and the solitary follicles are usually infiltrated and prominent, and this is so common that some French authors have regarded cholei’a as a specific psorenteritis. The infiltration of these glands may in some instances be so intense as to end in necrosis and ulceration. Notwithstand- ing the fact that the chemical poison of cholera attacks locally, first, the intes- tinal epithelium, and then the subjacent layers of connective tissue, sometimes even to the point of denudation and limited destruction of the latter, the cholera microbe itself never penetrates the coats of the intestine except when they are denuded, and then does not pass beyond the most superficial portion of the exposed connective tissue : it never enters the lacteals or reaches the general circidation. The chemical poison, however, Avhich is produced in the intesti- nal canal by the grow'th of the cholera microbes therein, does not limit its action to a local attack upon the intestinal epithelium or upon the subjacent tissues ; but it is taken up by the intestinal absorbents or the capillaries of the villi, and enters the general circulation of the blood to be distributed to every organ and tissue in the body, to develop in the susceptible its secondary or constitutional action. It may be said, therefore, that cholera infectiosa epi- demica is essentially a specific systemic intoxication. It may not always hap- pen that the Avhole or the greater portion of the specific poison Avliich j>ro- duces an attack of Asiatic cholera has been generated Avithin the intestinal canal of the victim ; there is strong reason for the belief that exceptionally, at least, the offending material ingested already contains, before swallowing, a sufficient quantity of the specific chemical poison of cholera to produce an attack of the disease. It is probable that at least some of those attacks Avith a violent onset in a very feAv hours after exposure to the infection have resulted in such a manner, especially if the autopsy shoAv, as it sometimes does, very little alteration of the intestinal mucous membrane. I can conceive, for example, hoAv milk diluted Avith Avater contaminated with cholera dejecta, and then alloAved to stand for several hours in a Avarm place, can act as a (jnick and fatal poison Avhen SAvalloAved in large (juantities. In such a case it Avould matter not if the bacteria Avere killed in the stomach by the action of the gas- tric juice; the preformed chemical ])oison of cholera Avhen absorbed from the intestine and circulated in the bloocl might, if in sufficient (juantity, still be capable of causing a violent, and even a mortal, attack of cholera. The stools from such a victim of the cholera poison might still contain some (|uan- tity of that poison, but could not, in the absence from them of the living pathogenic comma bacillus of Koch, be infectious. In other Avords, from such a victim a ncAv case of cholera could not arise, much less an ejiidemic. Furthermore, although the sym))toms, course, termination, and post-mortem appearances observed in such a case Avould naturally be those characteristic of cholera, yet a culture test of the stools Avould neces.sarily be negative in result, and therefore mi.sleading as to the origin of the attack, if not, indeed, of its nature. A priori., it is just among young children, Avho consume habitually large quantities of milk, that Ave should look for the largest pro])ortion of such toxic non-contagious attacks of cholera. Symptoms. — For convenience of description in part, and in part also CHOLERA ASIATIC A. 237 because the common course of the attack furnishes the basis of the division, clinical writers have been in the habit of discussing the symptoms of Asiatic cholera under four periods : a, the prodromal period ; 5, that of serous evacu- ation ; c, that of algidity or collapse ; d, that of reaction. a. The prodromal period, or period of incubation, varies in duration from a few hours to perhaps five days. Probably its average length may be most accurately reckoned at forty-eight hours. It is the time which elapses between the ingestion of the infectious material and onset of pronounced symptoms. During the early part of the period, sometimes during the whole of it, the subject is apparently in his accustomed health, whilst in the latter part of it, and occasionally throughout its entire length, and increasing in severity toward its transition into the next period, there may be a general feeling of distress in the abdomen, or even a tendency to nausea, with or without tenderness, restlessness, rumbling, and increased peristaltic movement of the intestines sometimes visi- ble or palpable through the abdominal walls ; laxness of the bowels or decided diarrhoea, with colored semifluid, feculent, or decidedly fluid, usually painless, sometimes copious, evacuations. All of these symptoms may be present, or only one of them, or they all may be absent. There is nothing at all dis- tinctive in their character which is in any way suggestive of their special nature. They excite suspicion only when it is known or suspected that the person may have been exposed to the infection of cholera, or when the disease is present in the locality. There is no indication of systemic intoxication dur- ing this period. The cholera microbe has merely reached the small intestine, and is more or less quietly gathering its forces for the active attack. It is engaged in multiplying itself and in generating its specific poison. The assault on the epithelial lining of the small intestine may have actually begun, and some breaches in its integrity have been accomplished ; sufficient of the chemical poison may have been generated for the production of some hypersemia of the mucous membrane, or even for the excitement of some infil- tration of the subepithelial connective tissue ; but there has been as yet no sys- temic absorption of the specific chemical poison ; the action of the special poison is still local, although there may be experienced a degree of prostra- tion out of all proportion to the diarrhoea present. b. The period of serous evacuations may be regarded as that of sys- temic intoxication, and its duration may last from a few hours to a day or two. The prodromal diarrhoea, if it have existed, now usually assumes more gravity. The discharges become more frequent, copious, and fluid. Often, but not always, every trace of color disappears from the stools. The latter now fre- quently present the well-known rice-water aspect : they are thin, very watery, and hold in suspension more or less minute whitish flakes or shreds in great numbers ; they look like a watery gruel, in fact closely resemble the aspect of barley-water or macaroni-water. They may sometimes still be slightly colored, and they are not infrequently frothy or somewhat bloody. In fact, there is many a case of cholera Asiatica where the stools are bilious or lack entirely the familiar rice-water appearance. Often the desire to evacu- ate the bowels is sudden and absolutely uncontrollable, and the contents of the lower colon and rectum are sometimes expelled with great force without pain and in enormous quantity, satui’ating the bed and covering, or deluging the clothing if the patient be still up and moving around. Nausea and vomiting are now usual accompaniments. At first the vomit may be bilious ; later it assumes the rice-water or gruel aspect. The amount of fluid discharged from the anus and mouth is often excessive. Prostration quickly becomes extreme, and thirst intense. The cry for water is constant, yet it is rejected by the 238 AMERICAN TEXT- BOOK OE DISEASES OF CHILDREN. stomach almost immediately after it is swallowed. The enormous exudation of fluid into the intestinal canal reduces correspondingly the volume of the lymph in the tissues and organs, and of the blood in the circulatory system. The tis- sues become abnormally dry and shrunken, and the blood markedly thickened. The number of the corpuscles of the blood is relatively much increased per cubic centimetre ; it is sometimes nearly doubled. The heart has not of itself the power to propel this thickened fluid with sufficient vigor to prevent venous stagnation. At first the pulse is very frequent for a time ; indeed, palpitation may add to the general distress and anxiety of the patient : besides being accelerated, the pulse is usually at the same time small, feeble, and soft. Later the heart’s action becomes more and more enfeebled, until the pulse is nearly or quite lost at the wrist, whilst the apex-beat may also nearly or quite disappear, and the heart-sounds themselves decidedly change their character — the systolic sound being greatly weakened, or even replaced by a faint blowing murmur, and the second sound lost entirely. The loss of fluid is shown in the deeply sunken orbits, glazed corner, the pinched expression of the face, the wrinkled condition of the palmar surface of the hands and feet — the washer-woman’s hands — and the general emaciation, which often becomes extremely marked. The impeded circulation of the blood is evidenced by the moi’e or less lividity, which is most marked around the eyes, the ears, the lips, and the ends of the fingers. The surface temperature sensibly falls below the normal, sometimes markedly ; on the contrai’y, the rectal temperature is usually considerably above the normal. The temperature under the tongue is commonly subnormal, and the tongue itself often feels cold to the touch. Whilst the cutaneous sur- face is objectively cold, the patient himself wdll frequently complain of intense internal heat. The voice becomes weak, hollow, and husky. The intellect may be clear or clouded. Sometimes there is great restlessness and jactita- tion ; at other times there may be entire calm and hebetude approaching to stupor. Oftentimes cramps in the extremities and trunk may be absent or mild and fleeting, or they may be so violent as to cause agonizing pain to the patient. In the early part of this period there is marked diminution of urine associated with albuminuria, and fre(iuently, granular tube-casts. Very soon, however, secretion of urine is completely suppressed. While the blood is robbed of chloride of sodium and serum by the exudation into the intestinal canal, it is overladen with urea, which the kidneys fail to remove, and there is proportionately more of its salts in the central nervous system than anywhere else in the body. We have said that this period should be regarded as that of systemic intoxication. The specific chemical poison elaborated in the small intestine during the enormous multiplication of the comma bacillus of Koch, has at at length been taken up by the intestinal absorbents or has entered the net- work of intestinal capillaries, and has reached the general circulation of the blood. From this moment the scope of its action is no longer localized in the small intestine, but is now extended throughout the whole system. The ])resence of this specific poi.son in the blood of the susceptible, works changes in the complexion of this vital fluid, some of which are readily vis- ible. We have already s])oken of the relative increase of the corpuscular ele- ments due to loss of fluid. There is, however, a material change in the red corpuscles, probably duo to the effe(!t of the special chemical poison : many of the red corpuscles are much paler than normal, and also much smaller ; some have been broken up into very small particles, which by reason of their form and frc(|uent arrangement in j)airs and chaplets have been mistaken for micro- cocci. The s{)ecific gravity of the blood is much increased ; there is little or CHO LERA A SIA TIC A . 239 no tendency of the red corpuscles to adhere together, and there is little ten- dency to the formation of large clots when allowed to stand ; if there be any separation of serum, it is very slight. The blood when drawn from the veins is very dark, almost black in color and tarry in consistence. This abnormality of the blood does not, of course, reach its height at once with the commencement of this stage, but progresses with the continuance and severity of the exudation of the fluids into the intestinal canal during this period. The blood becomes so thick and the heart’s action so weak that the flow in the veins becomes exceedingly slow or seems to be arrested entirely toward the end ; it sometimes will not flow from an incision. The left side of the heart may contain but little blood, and the large arteries, which are often spasmodically contracted, are nearly empty. The right side of the heart, on the contrary, is full oftentimes to over-distention. The lungs are usually found, post-mortem, to be quite pale, bloodless, and retracted well against the spinal column. In the mesenteries the arteries are much contracted, while the veins are greatly dilated, and there is usually also capillary engorgement. In fact, this condition of strong contraction and emptiness of the calibre of arteries, wide dilatation and fulness of the veins and capillaries, is observable nearly everywhere. There are often also small ecchymoses, aud sometimes rather extensive extravasations, particulaidy at the mucous surfaces. Oedemas, how- ever, are not to be met with ; notwithstanding the numerous stagnations of the blood-current in veins and capillaries, the flow of fluids of the blood into the intestinal canal is so gi’eat, and the consistency of the blood has become so thick, that everywhere else than at the mucous surface of the intestines the tendency to fluid exudation has been completely arrested. The ecchymoses above mentioned are more abundantly scattered over the mucous aud serous surfaces than elsewhere, although they may exist even in the muscular tissue. The toxic influence of the specific chemical poison in the blood is probably most marked upon the central nervous system (including the sympathetic gang- lionic system), and upon the liver and kidneys, especially the latter. The mechanical results of loss of such an enormous qauntity of body fluid may in some part account for the seriousness and severity of the symptoms of this and the following period ; but doubtless the action of the chemical poison in the blood upon the nervous system, the liver, and the kidneys is even superior. The first onslaught of the poison upon any important internal organ after reaching the blood naturally falls upon the liver. This organ is generally smaller than nox’mal, flaccid, and anremic, and contains less glycogen than normal. The outlines of the lobules are more or less indistinct ; the interlobular network of blood-vessels may or may not be dilated and filled with blood ; the radiating cellular trabeculte of many lobules are decidedly narrowed, while the inter-tra- becular blood-capillaries of some portions of acini are dilated and filled with blood-corpuscles. The hepatic cells of many acini are granular and difficult to stain. Some investigators contend that there is actually some atrophy of the liver. The gall-bladder, the cystic and common ducts are distended with a thin brownish or greenish fluid, whilst the interlobular biliai’y network is not appreciably altered. Whilst the biliary ducts and gall-bladder are full, the intestinal end of the ductus communis choledochus is usually practically imper- meable, and the intestines rarely contain any bile. The spleen is contracted and often flabby. Next to the intestinal lesions in cholera the kidneys show the greatest pathological changes. The effect of the cholera poison in the blood falls heavily upon these emunctories. Granular degeneration of the se- cretory tubules of the cortex soon becomes marked, but is irregularly distri- buted at first. After this pathological process has continued for some time, 240 A ME JU CAN TEXT-BOOK OF DISEASES OF CHILDREN. fatty degeneration of the tubular epithelium becomes general and intense, and associated sometimes with parenchymatous inflammation. The suppression of urine is therefore not alone due to the mechanical effects of thickening of the blood. c. The -period of algidity or collapse may follow after a few hours of con- tinuance of the period of serous evacuations, and may last for some or many hours until death or reaction ensues. In this desperate condition prostration is e.xtreme ; the voice is gone ; respiration is very feeble, shallow, and fitful ; the pulse has vanished and the heart almost ceases to beat ; so also the nausea, vomiting, and cramps, the frequent enormous forcible evacuations of the bowels, whilst, instead of the latter, the contents of the intestines dribble away from the anus, whose sphincter is inactive. Profound stupor or coma is the rule. The general lividity is intense ; the coldness of the skin is like that of marble. The vital forces are nearly overwhelmed by the great losses of fluid sustained, by the effete substances which are accumulated, and by the special cholera poison. During this period the vital spark flickers very faintly ; life hangs trembling in the balance. The pathological conditions are essentially those of the previous period, intensified. d. The period of reaction may be short or prolonged, and directly follow either of the three preceding. It may last from three or four days to as many weeks. When it follows immediately upon the prodromal period, convalescence is usually rapid and short, and the wmnted health is soon perfectly re-established. In such a case there is, after all is over, of course, great doubt that the attack was choleraic at all. The finding of the comma bacilli of Koch in the stools is the only certain criterion of what its true nature has been. When the period of reaction immediately follows the period of serous evacuations, it is usually the more definite the more serious the symptoms and pathological lesions during the latter period have been. If there have been great altera- tions of the mucous membrane of the intestines, profound general intoxica- tion, with great destruction of the red elements of the blood and marked de- generations in the liver and kidneys, we may expect to witness a more or less prolonged, complex, and dangerous pei’iod of reaction. In fact, as a rule, more patients die during than before reaction, when the latter follows immedi- ately the period of serous evacuations. The gravity of the symptoms and general condition of the patient may slowly ameliorate or quickly improve, or one set of alarming symptoms may simj)ly be substituted by another set, which, although not so frightful to the laity, will be regarded by the experienced phy- sician as only a prolongation of the critical struggle between the very evenly balanced forces of life and of death. The evacuations from the stomach and bowels decidedly lessen in freciuency and co])iousncss ; the stools lose their barley-water aspect; the bile reappears in them, and they assume gradually the common characteristics of an ordinary diarrhoea, sometimes stained with blood; or if the local destructive effects of the cholera pi)ison have been drastic, there may be grafted upon the diarrhma a more or less pronounced dysenteric condition with bloody stools and tenesmus. The characteristic aro- matic sperm-like odor of the rice-water stools may now change to the foul, stinking odor of decomposition, and the flatulence which was absent during the ]>receeding period may become annoying. T'he voice becomes stronger, resijiHition more steady and fuller. Tiie heart gradually regains its lost powers ; the pulse begins again to be felt at the wrist ; the surface tempera- ture again goes toward the normal and (jiiickly [)asses above it ; the shrunken countenance begins to discard the IIij)poeratic ex])rcssion, the sunken orbits to fill up and the glazed eyes to brigliten ; prostration becomes less marked, CirOLERA ASIATltA. 241 thirst less intense ; the secretion of urine is slowly re-established, at first con- taining much albumin, granular casts, and large quantities of urea; appetite and digestion are slowly recovered as a rule. In fortunate cases the restora- tion to health and to the proper exercise of all the bodily functions may be rapid and complete. But in other cases anmmia, due to the great injury to the elements of the blood, may be protracted ; or the functions of the mucli-damaged kidneys may be slow of re-establishment ; or the destruction of intestinal epithelium may leave denuded patches in the subepithelial layers of connective tissue, and thus occasion prolonged irritation and even serious dei'angement of the processed of digestion, and at the same time furnish numerous points of entrance for various septic micro-organisms. In truth, a secondary septic fever, as the result of systemic invasion in this manner, is not at all uncommon in this period : it is vulgarly called the typhoid stage of cholera. When the patient passes through the period of serous evacuations and that of algidity or collapse, the period of reaction usually differs only in degree from the condition above described. It can be now readily understood why almost as many victims succumb during the period of reaction as during the periods of specific action of the cholera poison. Even after convalescence has been established impaired health may persist for a long time, evinced by chronic amemia, stubborn disorders of the digestive apparatus, and easily dis- turbed bowels. Before convalescence is fully confirmed, and even for some time afterward, imprudences of diet sometimes precipitate a dangerous relapse. Special Phases of Cholera . — In a virulent epidemic of cholera the cases of very sudden and violent attacks, which do not seem to have been preceded either by a prodromal period or the one described in section b, are sometimes numerous, and they are most frequently encountered near the commencement of the outbreak. These attacks have been variously named foudroyant, toxic, asphyxic. In description of these foudroyant attacks we cannot do better than quote the recent language of Dr. N. J. Simpson, the health officer of Cal- cutta : “ On these occasions the suddenness of the attack, the number affected, and the virulence of the disease would incline one to think that the specific organisms had already elaborated outside the human body a strong poison which acted on the victim almost immediately after being swallowed. Under the most favorable conditions for the elaboration of such a poison there will not, as far as can be ascertained, be the usual twelve to forty-eight hours’ period of incubation ; on the contrary, patients will be brought into hospital in a dying state, though taken ill only a short time previously ; some will die before reaching the hospital ; and the ratio of mortality is likely to be 75 to 85 per cent. The descidption given by Dr. Jamieson in 1817 seemed to me until some time ago somewhat exaggerated, when the cases seen during an outbreak at a large pilgrimage convinced me of the correctness of Jamie- son’s accounts as applied to exceptional outbreaks. He says : ‘ Sometimes there was no vomiting, sometimes no purging, sometimes no spasm tlu’oughout, sometimes all these symptoms were simultaneous, and the vomiting and purg- ing took place together, as if caused by sudden contraction of the alimentary canal in its whole extent. In some rare cases the virulence of the disease was so powerful as to prove immediately destructive to life, as if the circula- tion were at once arrested and the vital powers wholly overwhelmed. In these cases the patient fell down as if struck by lightning, and instantly expired. Others, again, sank after making one or two feeble efforts to vomit and draw- ing a long and anxious inspiration ; some recovered from the insensibility pro- duced from the first shock, and afterwai’d went through the regular course of 16 242 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. the disease.’ In these and similar cases a virulent poison is the best expla- nation of the symptoms and apparent absence of the period of incubation, and of the destructive nature of the disease.” Another phase of cholera still more rarely met with is what has been termed cholera sicca. In this there is no vomiting, no purging, but the other symptoms may be little different from those already described. The autopsy shows, however, that there has never- theless been great exudation of fluid into the intestinal canal, for the latter is greatly distended with it from end to end. Special Complications of Cholera . — I have already spoken of frequent occurrences of ecchymoses, especially on the mucous and serous surfaces. Cutaneous petechise and eruptions are not uncommon in the period of reaction ; they appear less frequently during that of serous evacuations or algidity. These eruptions, more often observed on the face, neck, and forearms than elsewhere, are usually more or less punctate, the puncta being slightly elevated and having a tendency at times to aggregate into irregular groups. These spots vary somewhat in color, but most frequently the points are dark or black. In some rai'e cases the vitality of the skin seems to be in a degree impaired, as indicated by a disposition to ulcerate upon small provocation ; for example, bed-sores may sometimes develop early and become an exceedingly trouble- some complication. The cause of these eruptions is unknown, but if we were to express a mere conjecture, it would be that they may be due to innumer- able minute thrombi and emboli — small clots which have formed during stasis of the blood. Diag-nosis. — The differential diagnosis of Asiatic cholera by means of its symptoms alone is, during the absence of an epidemic of the disease, one of the most difficult feats the clinician is ever called upon to perform. Indeed, it is held by some of the most skilful and renowned clinical diagnosticians in the world to be an utter impossibility to make a certain diagnosis ; and it is, and always has been, the common experience of the whole world that the saddest, and for the public health the most deplorable, mistakes are very often made even by the most exj)erienced. And yet there is no single one of the whole category of diseases with respect to which a mistake in diagnosis of a first case may, and sometimes does, entail such an endless series of incalcula- ble public calamities. There is not one of the symptoms, and of the groups of symptoms, met with in some period of an attack of Asiatic cholera, which does not perfectly resemble those of some disease which is more or less common. Among these commoner affections for which Asiatic cholera may be mistaken clinically are cholera morbus, arsenical poisoning, pernicious inter- mittent fever, and poisoning from consumption of various articles of food in special states of decomposition or fermentation. Of course during the prevalence of an epidemic in a locality, the physician of that place Avill wisely regard and treat every case ju’csenting the symptoms common in Asiatic cholera as an undoubted case, ami will not hesitate to handle it as such ; for the community will uncjuestionably uphold him. it is, however, just when the physician is most uncertain — namely, in dealing with those doubtful cases which precede and follow the e])idemic — that the real interests of the community and of the general public demand the greatest cer- tainty of diagnosis ; but then, as a rule, the people are unwilling to submit to restraints. Fortunately, through the discovery of Koch in 1888 and 1884, w'e now possess the means of making an absolutdy certain differential diagnosis of cholera infectiosa epidemica, and witbotit reliance upon clinical symptoms, which may be misleading, or upon trustworthy knowledge of the j)revious history or relations of the patient, which may be difficult or impossible to obtain. The CHOLERA ASIATIC A. 243 presence or absence in the stools of the suspect of the comma bacillus of Koch promptly and definitely settles the matter. This can be determined within forty- eight hours by resort to the microscopic and biological tests. These tests, however, should never be relied upon when made by a tyro. They are too difficult of application to be trusted to the inexperienced. To describe here the methods of procedure would therefore be useless, for the experienced bac- teriologist does not need such instruction, whilst the unskilled would need much more to be rendered capable. During times of great danger of the introduction of Asiatic cholera into a locality all cases presenting the symp- toms of cholera should be handled as suspicious until a differential diagnosis by means of the microscopic and biological tests be made by a thoroughly competent and experienced bacteriologist. Prognosis. — The outcome of an attack of cholera depends very much upon what period of the seizure medical advice is had, very much upon the slowness or rapidity with which grave symptoms appear and persist, very much sometimes upon the pexdod of the epidemic at which the attack happens, and very much upon the constancy of intelligent care in handling the case from first to last. Wise and prompt treatment of the first stage usually aborts the attack almost in the beginning, and is followed by scarcely any mortality. In the vast majority of such cases the attack never gets beyond the stage of premonitory diarrhoea, and convalescence is usually rapid and complete. The prognosis of a seizure which has passed into the second period, or that of pro- nounced serous diarrhoea, is grave ; the mortality varies greatly, from 25 to 60 per cent, of attacks, by reason of the varying susceptibility of patients, vary- ing doses of the specific poison, varying promptness, persistency, and wisdom of treatment. The prognosis of an attack of Asiatic cholera in the period of algidity or collapse is ti’uly desperate, and the mortality has usually been frightful, not infrequently having reached 80, 90, and sometimes 100 per cent. The prognosis of an attack which has reached the period of reaction varies greatly according to the damage which may have been done the intestinal lin- ing, the secretory elements of the kidneys, the glandular elements of the liver, and the elements of the blood, and in proportion to the accumulations of effete material and of specific poison in the blood and tissues. It is sufficiently serious to require careful nursing and wise medical direction ; v/here septic poisoning has been engrafted upon the cholera attack, it is often grave. Speaking generally, the mortality of epidemics of Asiatic cholera is usually greatest in the early course of the outbreak in the locality, and is limited almost entirely to those who neglect to invoke the aid of the physician until the attack has become exceedingly grave. The general mortality among the attacked may vary between 20 and 80 per cent., according to the virulence or mildness of the type of the disease, the total average being nearly 50 per cent. If the patient is seen early and is promptly, judiciously, and constantly cared for, the danger of a fatal issue is usually not great. Treatment. — Although the gross number of attacks of Asiatic cholera and the wide spread of pandemics of the disease among civilized nations have lessened considerably, thanks to better hygiene and improved methods of pre- vention, yet the percentage of deaths to attacks remains about the same now as it was many decades ago, and is not very materially lower under mod- ern and civilized systems of therapeutics than it has been under antiquated and serai-civilized or barbarous modes of management. Knowledge of efficient methods of treatment of cholera has by no means kept pace with that of the etiology and prophylaxis of the disease. In the early stages of this disease the skilful physician is all powerful ; in the latter stages he is almost 244 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. impotent. Hence the paramount advantage of prompt and judicious medical treatment. Tkeatment in the Premonitory Period. — During the prevalence of Asiatic cholera in a locality, every disturbance or derangement of the ali- mentary canal should be corrected without loss of time. Indigestion or abdominal distress should receive without any delay the careful attention of the physician, who should not fail to impress upon his clientele the urgent necessity of scrupulous obedience to his instructions. The first thing to do is to remove any apparent cause of the disturbance ; place the patient upon a lighter diet, fluids by preference ; absolutely interdict any e.xercise which tends to overheat or fatigue ; insist upon clothing during the day which will keep the trunk and extremities warm, and, during the night, which will prevent chilling of the abdomen and the legs. One article of clothing should consist of a broad flannel binder around the abdomen and loins next the skin, kept on day and night. The first appearance of diarrhoea should be the signal for active treat- ment. One or two stools during the twenty-four hours more than the usual num- ber habitual to the individual when in health, or a single copious watery stool, should require the patient to be put to bed at once and kept recumbent, not only during the continuation of looseness of the bowels, but for a day or two after this condition has entirely disappeared. All solid food should be rigidly interdicted, and nothing but broth, bouillon, or whey, allowed to be eaten. In fact, an approach to abstinence is far more desirable than risk of overfeeding. The looseness of bowels or diarrhoea must be arrested as soon as possible, but in doing this it is much better to avoid powerful astringents and strong opiates if it can be done without them. In the choice of the remedy it should be borne in mind that the nature of the disturbance is that of a specific infection of the small intestine by the comma bacilli of Koch, associated with, and greatly favored by, a rather decided alkalinity of the intestinal fluids. The rational treatment would therefore seem to be the administration of some combination of acids, disinfectants, and sedatives. Of the acids which may be employed in proper doses are sulphuric, hydrochloric, lactic ; of the intestinal disin- fectants, naphthaline, salol, calomel, salicylate of bismuth ; of the sedatives, paregoric, lloft’man’s anodyne. Aromatic sulphuric acid and paregoric in proper doses may be given and repeated p. r. n. This may be alternated or not with naphthaline or salol, alone or in the same powder with salicylate of bismuth, or with naphthaline and calomel together. It Avill be found in the great majority of cases that this simple treatment will prove efiective. Instead of the mineral acids, lactic acid is preferred by many. Dujardin- Beaumetz uses — 1^. Lactic acid prts. 10, Syrup “■ 20, Tinct. of citron “ 2, Water “ 1000.— M. Sig. For the adult three teaspoonfuls, with or without 20 drops of pare- goric added, at intervals of a half hour, or longer as the case may require. As a drink instead of water, it is well to use an acid lemonade with a view to lessening the alkalinity or rendering acid, if {)ossiblc, the reaction of the contents of the small intestine, in order to iidiibit the growth therein of the specific microbe. Sulphuric, hydrochloric, or lactic acid — say, one ]>art to the thousand of sterilized water, sweetened — may be employed for this pur- pose. CHOLERA ASIA TIC A. 245 Should the diarrhoea persist or increase in severity in spite of the simple treatment above mentioned, recourse must be had without loss of time to more active medication. Stronger anodynes and decided astringents are called for. Chlorodyne may be used, or Lausedat’s drops, as follows : I^. Tr. Valerianae aether TTLc. Tr. opii Ttlxx. Essentiae menthae piperit gtt. v. Spts. aetheris comp TTLc. — M. Sig. Five to eight drops for a child of six years. Or something like the following may be tried : I^. Acid, tannici Plumbi acetat da gr. iij. Pulv. opii gr. ss. Oleoresinae capsici gr. ij. — M. Ft. pil. No. XII. Sig. One pill every one to four hours, p. r. «., at the age of six years. On the principle of clearing the bowels of irritants and altering the secre- tions, some begin the treatment of this period with a large dose of calomel, followed in a few hours by castor oil combined with naphthaline. Treatment of the Period of Serous Diarrhoea or Systemic In- toxication. — Although such early treatment as indicated above will, as a rule, prove effective in the prevention of full development of an attack, there are some cases which seem to be doomed, in spite of prompt and judicious attention, to advance into the period now under consideration. Moreover, it it is usually not until this period that the physician is called. The conditions now to be contended with are those which have already been pointed out. For the vomiting and thirst cracked ice and sinapisms to the epigastrium ; for the coldness, envelop the whole person in hot flannel blankets, with bottles of hot water next the skin, and immersion in a hot bath for flfteen or twenty minutes at intervals of two to four hours ; for the cramps, friction by rubbing with the palms of the hands : if the pain be violent it may be allayed by inha- lations of ether ; for the prostration and restlessness, cardiac stimulants and nervous sedatives ; for the purging, chiefly intestinal antiseptics and correc- tives ; for the loss of fluid, hypodermatic or intravascular injections of saline fluids ; as against the special poison in the intestinal canal, irrigation of the colon with large injections of saline fluids. Among the legion of remedies which have been tried and often been found wanting, the favorite East Indian compound called chlorodyne has been about as useful as any. Lausedat’s drops, already mentioned, may take the place of chlorodyne. The remedies mentioned in treating of the prodromal period, es- pecially the acids and antiseptics, may still be useful in the early part of the stage now under consideration. A powder which has been often used in former epidemics to combat coldness, prostration, and collapse has the following com- position : I^. Bismuthi subnitrat 3j. Plumbi acetat gr. iij. Camphorfe gr. ij. Oleoresinae capsici gr. j . — M. Divide in chart. No. XII. Sig. One every hour or two. 246 A3IE1UCAN TEXT-BOOK OF DISEASES OF CHILDREN. Macnamara, the great Anglo-East-Indian authority on cholera, says : “ I think water, though urgently demanded by the patient, should be refused (cracked ice is recommended instead). I would restrict the opium to three gi’ains ; it is unwise to give more, although we are wellnigh certain that much of it has been vomited If the vomiting is very severe, a single dose of twenty grains (for the adult) of calomel will sometimes relieve this symptom. A mixture may be added, each dose of which contains two grains of acetate of lead and fifteen drops of dilute acetic acid, to be taken every second hour, and fifteen drops of dilute sulphuric acid in water every alternate hour, so that the patient should take a draught of first one mixture and then the other every hour. In this way the alkaline stools become acid, and perhaps destroy the cholera organism in the intestinal canal. HoAvever this may be, these acids seem to be beneficial in the treatment of cholera I believe that alcohol is positively harmful in any stage of cholera.” Unfortunately, in this stage of cholera medication by way of the stomach is alw’ays impeded, very often rendered almost useless, sometimes quite impos- sible of effecting an impression, by reason of the vomiting and the failure of absorption in the intestines. If the little that is not rejected by the stomach succeeds in reaching the intestine, it so often happens that none of it is absorbed ; pow'erful drugs may lie and accumulate in the latter, to cause actual harm when the stage of reaction is ushered in, and with it restoration of the function of intestinal absorption. Neither can ordinary rectal injections of medicine be depended upon, for the same reason. The sluggishness, sometimes practical stagnation, of the little lymph still remaining in the tissues, after the continuous di-ain of copious watery evacuations from the bowels, usually lessens, often quite nullifies, the customary results of hypodermatic medication. When such a condition arises, as it unhappily too often does, what other resources has the physician left to him ? There are still three which, used judiciously and skilfully, are powerful to restore marvellously — at least for a time, sometimes permanently — the suspended functions. I refer to intestinal, to hypodermatic, and to intravascular irrigation. Entcroch/sis, first introduced by the late Prof. Cantani of Naples during the former cholera epidemic in Italy as a means of treating all stages of the disease, consists essentially in irrigating the rectum, colon, and, if possible, also the small intestine, with large (luantities of a warm, astringent, antiseptic, sedative fluid. The following is Cantani’s formula for an adult : Boiled water or infusion of chamomile . . 2 quarts. Tannin to 21 drachms. Laudanum 30 to 50 drops. PoAvdered gum-arabic 1|- ounces. The temperature of this mixture when introduced should be sufficiently above the normal to aid in restoring heat to the body. Of course the quantity injected should vary according to the age of the patient and other circum- stances in the judgment of the physician. The best time for administration is immediately after an evacuation. lljipodcrmoclysis, also first introduced by Prof. Cantani as a means of treating especially the stages of serous diarrhoea and of algidity or collapse, consists essentially in the introduction hypodermatically of a large (juantity of warm saline fluid for the purpose, primarily, of re))hicing the fluid lost through the intestinal drain ; secondarily, of washing out from the blood and tissues much of the effete material and sj)ecific })oison which have accumu- CHOLERA A8IATICA. 247 lated in them. Cantani’s formula for an adult consists of 2 quarts of boiled water, 2J ounces of pure sodium chloride and a drachm and a half of sodium carbonate. The quantity to be injected each time varies according to age, the apparent amount of fluid lost, and other circumstances. The amount for an adult is one to two and a half quarts. The temperature of the solution when injected should be 100|-° F., unless that of the rectum be very low, in which case it has been sometimes raised as high as 109|^° F. The most successful time for resort to hypodermoelysis is at the first indications of insufficiency of water in the body, such as Hippocratic countenance, wrinkling or discoloration of the skin, cramps, coldness, etc. Intravascular injections of saline fluids, a procedure as old as the history of cholera in Europe, has had a renewed trial during the present visitation of the disease. Injection into veins and into arteries has been practised especially at Hamburg, and each method of procedure has its champions. Some variations in the constitution and proportions of the saline fluid used occur, but the following may be regarded as a standard : sodium bicarbonate 1 part, sodium chloride 6 parts, boiled water 1000 parts. The temperature of the fluid when injected varies according to circumstances from 100|^° F. to 104° F., more frequently the latter. The quantity administered has sometimes been very considerable, averaging for the adult one to two quarts. The injec- tion may be repeated in a half hour to four hours, as the condition of the patient demands. Of the relative advantages and disadvantages of the hypodermatic and intravascular irrigations, it may be said that the former is slower and usually more permanent in its action than is the latter. There may occur occasions, however, in the treatment of the algid period, when the matter of time will decide which method shall be tried first. It seems to me that it is mainly in rapidly-sinking cases in that period, that intravenous injection should be given the preference, to be followed at the second injection by hypodermoelysis. The hypodermoelysis has the further advantage of being far simpler of application. Only one skilful person is required for this operation ; indeed, the attendants can readily be instructed to perform it very safely in the absence of the physi- cian. On the contrary, the physician requires at least one skilled assistant to safely perforin the intravascular injection. In all these operations strict antiseptic or aseptic precautions must be observed. For enteroclysis there is needed a large fountain syringe with a long flex- ible tube with a cock, to which a moderately stiff but flexible terminal portion two or three feet long is attached. The tube, quite full of the fluid, must be passed up into the colon and worked along its interior as far as possible ; the fluid should be let flow slowly, avoiding very sudden distention of the gut, and should be retained as long as possible. For hypodermoelysis a fountain syringe with a long flexible tube, furnished with a cock, answers the purpose ; with another shorter tube, one end attached to the cock, the other having a needle-pointed canula, a little longer, stronger, and with a somewhat wider calibre than the ordinary hypodermic needle. The tube and canula are first perfectly filled with the fluid, and then the canula is inserted well in between the skin and deep fascia of the flanks, buttocks, or interscapular region. The fluid should be made to flow slowly, allow- ing fifteen to twenty minutes for the introduction of one quart. The slight tumor should be made to disappear, as it will, by gentle kneading or massage. For intravascular injections of saline fluids any good transfusion apparatus suffices. 248 AMERICAN TEXT-BOOK OF BIREARES OF CHILDREN. Lavage of the stomach to stop vomiting is a most etFective procedure, and sometimes succeeds in arresting this distressing symptom when nothing else will do it. Indeed, it would seem to be a very useful associate of enteroclysis, for it seems that to clear the stomach of the offending rice-water fluid is only second in importance to washing it out from the intestine. Boiled water hold- ing in solution boracic acid has been satisfactorily used for this purpose. Treatment in the Period of Algidity or Collapse. — In this stage of the disease, where absorption is practically suspended, little is useful beyond enteroclysis and hypodermoclysis or intravascular injections of fluids, and efforts to communicate heat. The vast majority of cases in this stage die in spite of every effort of the physician, but there is certainly more success to be expected of this mode of treatment than of any other at present known. Treatment in the Period of Reaction. — The treatment in this stage IS essentially expectant and symptomatic. Each condition enumerated in the sections on Symptomatology and Etiology will suggest to the experienced the particular line to be followed. One of the most important things to avoid is pointed out forcibly by Macnamara, whom I can do no better than to quote in conclusion : “ When reaction comes on, we must be careful not to fall into the error of over-feeding the patient under the mistaken idea of supporting his strength ; he will not die of exhaustion if small quantities of milk and arrow root are administered frequently for two or three days, together with ivarm beef-tea enemas. But enteritis may certainly be induced if food beyond the simplest and smallest quantities be allowed. The patient requires rest and the most careful nursing after a severe illness like cholera.” Prevention. — Whilst the physician is often impotent in the treatment of cholera, in prevention he may be, if he will, all-powerful. It is not our pur- pose to discuss this subject from the standpoint of a state or community; we shall consider the matter solely from the side of the individual : First, what those ministering to the sick should do to prevent the spread of the disease ; second, what the individual who may be exposed to the infection should do to safeguard himself from an attack of cholera. 1. The Duties of those Attendant upon the Sick. — I wish to say in the beginning that, whilst there is scarcely any infectious epidemic disease which is so capable as cholera of working great injury in various ways to the com- munity, if the attendants upon the sick are ignorant or careless in applying the princi])les of prevention, yet there is no such disease which can so easily and certainly be limited to those attacked if only these principles be constantly and scrupulously applied. As I have said elsewhere, Asiatic cholera can he dwelt with and handled with absolute impunity if only the j)roper precautions be never once forgotten or neglected. Tliere is, therefore, not the slightest danger in administering to the sick if carefulness he the rigid rule. It lias already been pointed out that it is only the evacuations from the stomach and bowels of a jierson suffering an attack of Asiatic cholera that contain the original infection. To promptly and thoroughly disinfect these and everything soiled by them or contain- ing them is to render the spread of the disease from the person attacked impossible. The evacuations should Avithout any delay he treated in one of the folloAving ways : a, water that is boiling should he jioured upon them carefully, so as not to splash, in such amount that the volume of the water is four times that of the evacuations, or a strong solution of jiotash soaj) may bo used in the same way; /i, or fresh milk of lime (Avhitc Avash), of tAvicc the volume of the evacuation, should he poured upon the latter and the mixture gently stirred ; c, or a similar quantity of a freshly-prepared solution (5 per cent, strong) CHOLERA A STATIC A. 249 of chloride of lime may be used in the same way ; or a similar volume of 5 per cent, solution of carbolic acid may be thus employed. Which- ever one of these means be chosen, it is essential that the vessel be im- mediately covered from the flies and allowed to stand fifteen or twenty minutes before emptying ; and it is also essential that the disinfected evacuations be emptied into a pit in the earth, the bottom of which is covered with a layer of quicklime, and be covered immediately with another layer of the same mate- rial, care being taken that the location of this pit does not jeopardize water- courses, springs, or wells. Clothing or other textile fabrics soiled by the evacuations should be disinfected as soon as possible. They should be at first soaked in a disinfectant solution — say, a mixture of strong potash soap and carbolic acid of 5 per cent, strength — for an hour or more, and then boiled. It is better to burn bedding rather than attempt its disinfection. The floors of the sick-room should first be sprinkled with chloride of lime, and then mopped over with a cloth moistened in a chloride-of-lime solution. Any article of furniture which may have been contaminated should be carefully disinfected. Finally, it would be well to disinfect the room itself, after all is over, by means of sulphur fumes, 3 pounds to the 1000 cubic feet of space, for eight to ten hours. No one should be allowed in the sick-room except the necessary attendants, who under no consideration should eat or drink in this room. The patient should be fed from a set of dishes which should be disin- fected immediately after use, and kept separate from those of the rest of the household ; the remains of the patient’s meal should be disinfected and destroyed. After handling the patient or anything that he has soiled, the attendants should immediately first disinfect and then carefully wash their hands : this thorough ablution should be performed invariably immediately before eating. After vomiting or an evacuation of the bowels the mouth and the parts around the anus should be wiped with a cloth wet with solution, 1 : 2000, of corrosive sublimate. If convalescence supervene, the patient should be kept isolated for a week, and the stools should be disinfected during that time. If death occur, the corpse should at once be enveloped in a sheet soaked with corrosive sublimate, 1: 500, and cremated or buried without delay or funeral cortege. Finally, promptly notify health officials of every suspect or known case of cholera. 2. Individual Precautions for the Exposed . — No water or milk should be used or consumed, which could by any possibility be contaminated, unless recently boiled. No cold or uncooked food should be eaten which could possibly become contaminated. Such things as salads should be avoided. Unripe or over-ripe fruit should be eschewed. Alcoholic stimulants are per- nicious. In fact, excesses of all kinds predispose to an attack. Regularity in eating, sleeping, exercise, and all other habits, contributes to safety. Keep all the bodily functions well regulated ; avoid fatigue and chills. The use of a broad flannel waist-bandage next the skin day and night is beneficial in guarding against abdominal congestions. Quickly correct the slightest intesti- nal disorder. DIPHTHERIA. By DILLUN brown, M. D., New York. Diphtheria is an acute, contagious, and infectious disease, the most characteristic and constant feature of which is a pseudo-membranous exu- date on, or a superficial necrosis of, a mucous membrane or some part of the skin which has been denuded of its epithelium. Although a comparatively recent disease in this country, it threatens to be the scourge of the large cities. Less than a century ago but few isolated and poorly-understood cases were seen, but the disease has spread very rapidly during the past fifty years, and in New York City alone the mortality from diphtheria and croup has exceeded fifty thousand in twenty-five years. And this number does not include many cases which were reported as deaths from pneumonia, nephritis, heart failure, etc., which ivere really complications of diphtheria. There is no guide to the virulence of diphtheria. It is one of the most dreaded, one of the most fatal, and one of the most common diseases of child- hood. At the onset it is impossible to say whether the disease will be mild or malignant. A case beginning with high fever and profound constitutional disturbance may go on to a rapid I’ecovery ; while, on the other hand, an apparently mild case will grow depressed and weak, and slowly die. Neither does the amount nor character of the exudate give any certain prognosis. Indeed, the clinical symptoms vary to such an extent that many mild cases are not even recognized unless some post-diphtheritic complication ensues ; but, although these mild cases may be of small danger to the individual, they are all diphtheria and all ecpially contagious, and may be the origin of the most malignant ones. Etiology. — It has been well recognized that certain cases of croupous inflammation are not true diphtheria. This list includes the chronic membra- nous exudates seen in certain forms of fibrinous bronchitis, cystitis, enteritis, etc., the acute superficial necrosis of the mucous membranes due to direct heat, as a scald, or an intense irritation from the application of ammonia. However, excluding these, there remain many doubtful cases ; but modern bacteriological research seems to have solved this problem, and ])roven beyond much doubt that there are at least two forms of pseudo-membranous inflam- mation, the one a true diphtheria, due to the Klebs-Loefller bacillus, and the other, which may include several varieties, a pscudo-dij)hthcria, due usually to a streptococcus. True diphtheria is the product of the Klebs-Loefiler bacillus, either alone or associated with other bacteria, and it is primarily a local disease with many secondary manifestations, due to the absorption of the j)tomaines or j)oisons which result from the growth of this micro-organism. The follmving obser- vations seem to establish these propositions as fairly well proven : 1. This bacillus is present, usually in large numbers, in the false membrane 250 DIPHTHERIA. 251 of all typical cases of infectious diphtheria, and is rarely or never found in other inllammations of the mucous membrane of the throat or in the healthy throat. 2. This bacillus is always found at the place of local infection, and never found in the blood or any of the internal organs, even though they may be the seat of marked secondai’y changes. On the contrary, streptococci and other bactei'ia may be found in the blood and internal organs. 3. Pure cultures of this bacillus when injected into the mucous membrane of susceptible animals produce a typical diphtheritic inflammation, even to paralyses and organic lesions. 4. Inoculation of animals with the toxalbumin of this bacillus produces the sepsis, the paralysis, the visceral lesions, and all the secondary constitu- tional symptoms of diphtheria, Avithout the membrane. 5. Clinically, surface diphtheria, Avithout participation on the part of the lymph-vessels, is apt to exhibit little or no fever ; the disease does not run a typical course ; one attack does not offer security against its recurrence in the future ; and Avhenever the diphtheritic infecting agent finds a foothold on the body — as, for example, by inoculation — it ahvays excites a local affection at the point of entrance ; and from this local infection the general infection Avill develop, the extent and rapidity of which depend upon the anatomical rela- tions of the affected parts, their characteristics, and their power of absorption. The hypothesis that diphtheria is at first a general disease of the blood, with secondary manifestations on the mucous membranes, is hardly tenable in face of the foregoing facts. The chief arguments brought forward in support of this theory are its similarity to certain of the infectious diseases ; its epi- demic occurrence ; the fact that constitutional symptoms may be present for hours and days before local symptoms are discovered; the marked susceptibility of children ; the great disproj)ortion often seen betAveen the general symptoms and the apparently trifling local changes ; the multiplicity of the localizations, and the fact that efforts to conquer the disease by destroying the pseudo-mem- brane Avith strong caustics have been for the most part AAdthout result. IIoAvever, these observations simply prove that diphtheria may be a general infectious disease, but they do not explain hoA\' this infection takes place. Neither clin- ical observations nor post-mortem examinations have ever been able to present enough facts to settle this question ; but, fortunately, modern bacteriological research, Avith inoculation experiments on living animals, has determined it very conclusively. Besides true diphtheria, we frequently meet with an allied pseudo-mem- branous inflammation Avhich cannot be distinguished from it clinically, except that it runs a milder course. Bacteriologically, hoAvever, the Klebs-Loefiler bacillus is alAA'ays absent, and streptococci, and often other bacteria, are found in great abundance, not only in the exudate, but even in the blood and internal organs. The differential diagnosis is very important, as a knoAvledge of Avhich disease we have to deal with modifies somewhat the treatment, and greatly the prognosis. Not only do we have a croupous inflammation which is not a true diph- theria, but Ave can have a true diphtheria in Avhich the membrane covers so little space that there is apparently no fibrinous exudate. This was clearly demonstrated by Jacobi in his article on “ Follicular Amygdalitis and every observer must have seen cases in Avhich an apparently catarrhal follicular amygdalitis quickly proved itself to be a diphtheritic one, or, after recovery, showed its true nature by a characteristic diphtheritic sequel — a paralysis of some muscle or group of muscles. 252 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Accepting the microbic origin of diphtheria, we must still take into account the many conditions that materially modify the course of this affec- tion, which is one of the most variable and uncertain of all the contagious diseases. It is doubtful if a normal mucous membrane can be infected by the bacillus, and it is certainly true that a lesion favors its development. This also applies to the toxalbumin of the bacterium, large amounts of which can be swallowed without danger by susceptible animals that have healthy and intact mucous membranes. Age is ordinarily an important factor in influencing the occurrence of the disease ; and, though it may occur at any time of life, it is essentially a disease of childhood. Individual or family predisposition has some influence. It occurs by marked preference in connection with those diseases which produce lesions of the mucous membranes. Cold and dampness favor its occurrence, partly by their tendency to excite catarrhal affections and thus offer an opportunity for infection, and partly by the more favorable conditions for the growth of the bacillus which are present during such weather. All the windows and other sources of ventilation are shut, and the rooms, especially in tenements, where the disease is most common, are stifling and hot. Insanitary conditions un- doubtedly favor the development of this germ. Klebs-Loeffler Bacillus. — In the membrane of true diphtheria this bacillus is always found, either alone or associated with other bacteria. It is rarely or never found in the blood or internal organs, although the strepto- coccus, which is often associated with it, may appear in the blood, the lymphatics, or the viscera. On the surface and the most superflcial portions of the exudate the bacillus is found mixed with numerous other micro- organisms. In the middle or deeper portions the only organisms pi’esent are the Klebs-Loeffler bacilli, either alone or associated with streptococci. In the deeper layers there are only a few bacilli, and in the mucous membrane, as a rule, none. These bacilli are “ moderate-sized rods, usually slightly bent, averaging nearly as long as the tubercle bacilli, but twice as broad, and usually with rounded ends. According to the rapidity of growth, the soil, and other con- ditions, the form and size of the micro-organisms vary, and the differences are striking. The bacteria are sometimes enveloped in a more or less capacious membrane ; sometimes the contents divide into a number of pieces, separated by transverse divisions ; one end of the rod is frequently thickened like a club, or both ends may be clubbed, or one or both ])ointed. The bacilli are immobile and have no spores. The l)est staining agent is Loeffler’s alkaline methyl-blue. Some forms stain uniformly, others in various irregular ways, the most common being the appearance of deeply-stained granules in a slightly-stained bacillus or of darkly-stained ends with a paler centre. The bacilli are very often in pairs, never in chains ; they are semi-anaerobic, and thrive at a somewhat high temperature, 20° to 42° 0.” “The Loelller bacilli can be cultivated uj)on all the ordinary culture media, but grow most vigorously on a mixture of blood-senun and nutrient bouillon, as given by Loefflcr. On this, solidified, the bacilli grow as large, round, elevated, grayisb-white colonies, with the centre more opaejue than the somewhat irregular periphery” (I’ark). The most ready method of detecting this bacillus is to detach a small piece of membrane and place it for five minutes in a 2 per cent, solution of boracic acid, then to draw the jiiece of membrane along the surface of sterilized blood-serum in a test-tube, and maintain it at a temperature of 37° PLATE IX. 1 Fig. 1. — Loeffler bacilli. X 650. Fig. 2.— Pseudo-bacilli. X 650. Fig. 3. — Involution forms of the LoefiOer bacillus. X 650. Fig. 4. — A. Pseudo-bacillus. B. True bacillus. C. Pseudo-bacillus. (Natural size.) From photographs taken by Dr. Henry Koplik, Carnegie Laboratory, New York. USE LIBRARY OF THE HWIVERSJTY OF A COMPENDIUM OF INSANITY. By John B. Chapin, M.D., LL.D., Physician-in-Chief, Pennsylvania tal for the Insane; Late Physician-Superintendent of the Willard State Hospital, New York; Honorary Member of the Medico- Psychologfical Society of Great Britain, etc. J2mo. 234 pagfes. Illustrated. Cloth, $1.25 net. ^ ^ ^ ^ ^ The author has given, in a condensed and con- cise form, a compendium of Diseases of the Mind, for the convenient use and aid of physi- cians and students. It contains a clear, concise statement of the clinical aspects of the various abnormal mental conditions, with directions as to the most approved methods of managing and treating the insane. ^ ^ ^ ^ ^ ^ The book will supply a real need, insomuch as heretofore the physician and student have had no brief manual on this important subject, and have been compelled to search through the larger treatises for just such practical information as this book contains. The work will also prove valuable to the mem- bers of the legal profession and to those who, in their relations to the insane and to those supposed to be insane, often desire to acquire some practi- cal knowledge of insanity presented in a form to be understood by the non-professional reader. CHAPIN'S INSANITY THE SURGICAL COMPLICA- TIONS AND SEQUELS OF Principles of Surgery and of Clinical Surgery in the Jefferson Medical Col- lege, Philadelphia; Corresponding Member of the Soclete de Chirurgie, Paris; Honorary Member of the Societe Beige de Chirurgie, etc. Oc- tavo. 400 pages. Illustrated. Cloth, $3.00 net. ^ ^ This monograph is the only one in any language covering the entire subject of the Surgical Com- plications and Sequels of Typhoid Fever. The work will prove to be of importance and interest not only to the general surgeon and physician, but also to many specialists — laryngologists, ophthalmologists, gynecologists, pathologists, and bacteriologists — as the subject has an important bearing upon each one of their spheres. The author’s conclusions are based on reports of over J 700 cases, including practically all those recorded in the last fifty years. Reports of cases have been brought down to date, many having been added while the work was in press. «.?* J* KEEN ON THE SURGERY OF TYPHOID FEVER TYPHOID FE- VER. By Wil- liam W. Keen, M.D., LL.D., Professor of the . DIPHTHERIA. 253 C. for twelve to twenty-four hours. At the end of this time, if the bacilli are present, characteristic small white rounded colonies are visible along the track of inoculation. They can then be stained and examined. To get a j)ure culture a second or third preparation must be made. To overcome the diffi- culty of obtaining serum for the culture medium, Sakharof suggests the use of slices of hard-boiled eggs placed in sterilized test-tubes, and Johnston sug- gests the use of hard-boiled eggs from which a part of the shell has been removed with ordinary forceps, so that the shell-membrane can be peeled off and the inoculation made at that point. To guard the culture against contam- ination, the egg can be placed u])side down in a common egg-cup, the interior of which has been sterilized by allowing a flame to enter it for a second or twm. The pseudo-diphtheria bacilli is a term applied to a group of micro- organisms which closely resemble the true diphtheria bacilli, both in appear- ance and in producing a pseudo-membrane, but they are without pathogenic propei'ties in guinea-pigs, and they do not grow on gelatin at ordinary temperatures. However, for bedside diagnosis it is wiser to consider all cases as true diphtheria that give colonies of bacilli resembling the Klebs-Loeffler. The ptomaine, or poison, produced by the diphtheria bacillus is of a proteid nature, precipitated by alcohol and soluble in water. When pure, it is a white amorphous mass and extremely poisonous. It is not at all, or but little, absorbed by healthy and intact mucous membranes ; but when inoculated into a susceptible animal it produces all the symptoms of a diphtheria without the exudate. Mode of Infection and Propagation. — There is no doubt that in the vast majority of cases the inoculation takes place through some lesion of the mucous membrane or of the skin. Therefore, it would be hard to over- estimate the value, as a prophylaxis, of attention to all lesions, no matter how slight, of the mucous membrane of the upper air-passages. Every catarrhal condition should receive prompt and efficient treatment, and bad teeth, accumulated secretions, or any other source of local irritation should be removed as soon as possible. The germ is usually propagated through the surrounding air, and brought in contact with the mucous membrane during respiration. Less frequently the disease may be propagated by the direct deposition of diphtheritic matter by inoculation or through some article of food. It has been known to have been communicated from some of the domestic animals. The contagion may be spread by contact with the person or clothes of those sufi'ering from the disease, and may also be spread by bed-clothes, furniture, and other articles in the sick-room. Too much care cannot be taken to prevent those surround- ing the sick from spreading the disease, and there is no doubt that phys- icians themselves frequently carry the disease from one patient to another. This is clearly shown from the large number of cases which occur in their own families. Incubation. — In experimental diphtheria the duration of the incubation period is short, varying from twelve hours to three days ; but when diphtheria is contracted in the usual way — by inhaling air which contains the contagion — this period may be much longer, varying from one day up to twenty. How- ever, in the latter case this only means the interval between exposure and the appearance of the disease, for there is no means of knowing exactly when the contagion entered the mucous membrane, and how long it had remained harm- lessly upon it, waiting for the development of some lesion through which to infect it. It is obvious, therefore, that all observations based upon the inter- val between exposure and the appearance of the disease must be uncertain. 254 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN This period also depends not only upon the quality and quantity of the infecting material itself, but also upon the structure and texture of the tissues and their power of resistance — a power which is often greatly modified by strep- tococci and other bacteria which may be associated with the true diphtheria bacilli. When the Klebs-Loeffler bacilli are implanted upon a normal mucous membrane, they do not grow, but these associated streptococci produce an acute purulent discharge, with redness and swelling. Thus they prepare the lesion for infection by the Klebs-Loeffler bacilli. Anatomical Changes. — The local pathological changes of this disease occur on a mucous membrane or some abraded portion of the skin. The changes found on the inflamed mucous membrane are as follows : The surface becomes hypertemic and swollen, and presents the usual manifestations of a catarrhal inflammation. After a short time, usually a few hours, it is covered with a whitish or yellowish layer, which forms the pseudo-membrane so characteristic of the disease. This membrane may represent a fibrinous exudate which can be easily peeled from the surface beneath, or it may represent a true necrosis, so that the exudate is an integral part of the mucous membrane and cannot be separated from it. Many of its characteristics depend upon its anatomical position and the type of epithelium upon which it is located. It looks to the naked eye like coagulated fibrin, but under the microscope it is seen to consist of proliferated epithelial cells held together by a fibrinous network. In its physical and chemical properties it closely resembles fibrin. The surface beneath the exudate may show all grades of inflammation, from a mild catar- rhal to an ulcerated one. The false membrane is found oftenest on the tonsils, uvula, soft palate, and ba'ck of the pharynx, the nasal passages, the larynx, and trachea ; le.ss commonly on the conjunctiva, at the border of the anus, or in the vagina ; rarely in the bronchi as a primary aflection, but not uncom- monly as an extension of the same process from the larynx and trachea ; and very rarely in the oesophagus, the intestinal tract, or the ear. Besides these local pathological changes other organs of the body may become affected as the result of the absorption of the toxalbumin. The adjacent lymph-nodes are swollen and inflamed, but they rarely become the seat of a suppurative inflammation ; the surrounding tissues are infiltrated with serum containing scattered pus-cells. The hmgs show areas of intense congestion, with h.nemorrhages into their tissue. They may exhibit oedema, bi’oncho-pneumonia, catarrh, atelectasis, emphysema, ecchymoses, and large infarctions ; and the bronchi may be lined with false membrane as far as the smaller branches. These changes, however, are mostly observed as complications of laryngeal di])htheria. The pleura may be hyperaemic and inflamed, with luemorrhages, and in many cases the pleural cavity will contain an exce.ss of fluid. The kidneys, in experimental cases, are moist and hyjxM’iicmic, and the adrenals are congested and may l)e luemorrhagic. Fatty changes occur in the epithelium of the tubes and glomeruli, and hyaline alterations in the glomer- ular capillaries and in the smaller arteries, lliomorrhages, ])arenchymatous ami interstitial nephritis, are common lesions observed in the kidneys in albu- minuric cases. The spleen and the liver may be enlarged and congested, with ha'inorrhagcs into the capsule and tissue. There may be ])rose]it smaller or larger masses of necrotic cells, and in some cases there is a fatty degeneration, and occasionally, in j)rotracted cases, a hyaline or a waxy one. The heart may .show in the siibstaime of the muscle large and small haemorrhages and ccchymoscs. When death is due to asphyxia without DIPHTHERIA. 255 general poisoning of the whole organism, the muscular substance of the heart itself may be normal ; but when there has been a general poisoning it has usually undergone a granular and fatty degeneration, and there may be other septic changes, as, for example, an endocarditis. In both the parietal and visceral layers of the pericardium there may be small and large haemorrhages and ecchymoses ; there may be an excess of fluid in the pericardial cavity ; and in rare cases there may be an emphysema of the pericardium as a consequence of the extension of a subpleural emphysema into the loose cellular tissue between the folds of the mediastinum. The blood, as in most severe forms of septicaemia and poisoning, is but slightly coagulable, sticky, brown, or rather livid, and the blood-vessels contain a greatly increased number of leucocytes. The mucous membrane of the intestinal tract and of the bladder may rarely become directly infected, and under such circumstances they present the characteristic pseudo-membrane and other changes which take place in the pharynx, etc. However, when secondary changes occur in consequence of general infection, cell-infiltration and hemorrhages are the usual ones, and in one reported case such extensive hemorrhage from the great omentum occurred that a considerable quantity of free blood had collected in the peritoneal cavity. The layers of the peritoneum may be injected and be the seat of ecchymoses, and the peritoneal cavity may contain an excess of serous fluid. The fibres of the muscles show degenerative changes, and the thyroid may be congested and ecchymotic. The earliest change in the brain and spinal cord is venous hyperremia, both in the vascular linings and in the substance itself. Later in the disease come extravasations, with the subsequent softening of the surrounding tissue, and finally vaidous degenerative changes. Extravasations into the substance of the spinal nerves have been seen, as well as granular degeneration of the nerves of the soft palate and other parts that have suffered from a diphtheritic paralysis. S3maptoms and Diagnosis. — The characteristic feature of the disease is the pseudo-membrane. There are cases of pseudo-membranous inflammation which are not diphtheria ; but, excluding the chronic cases and those due to great heat, as a scald, and to the application of an intense irritant, like am- monia, it is often impossible to distinguish between the true and the false diphtheria, except by a bacteriological examination. The only positive test is the presence of the Klebs-Loeffler bacillus, either alone or associated with streptococci or other bacteria. In a certain proportion of cases it is very difficult to distinguish between the true and the pseudo-bacillus ; and in all doubtful cases, at least for the present or until inoculation experiments can be made, it is wiser to consider them as true dijihtheria. Clinically, cases of follicular amygdalitis are frequently diagnosticated as simple catarrhal or puru- lent inflammations, when they are really diphtheritic. All such cases should be isolated and treated in every respect as true diphtheria until the diagnosis is made certain either by a bacteriological examination or the appearance of new evidence which will show the true nature of the disease. The diagnosis, even of a membranous inflammation, may be obscure from its location. It may be confined to the posterior nares, the larynx and trachea, or even the intestine, the bladder, or other positions where the local changes cannot be seen. The constitutional symptoms Avhich are the result of the poisoning due to the absorption of the toxalbumin produced by the specific bacilli vary greatly, and depend not only on the amount and rapidity of the absorption, but also 256 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. upon the susceptibility and condition of the patient. In simple and uncom- plicated cases there is usually little or no fever. The symptoms may vary from this to evidences of the most profound poisoning. The temperature may be high and irregular, the pulse rapid or, in certain very fatal cases, abnormally slow. There is languor and loss of appetite, and an amount of prostration out of proportion to the fever and the local inflammation ; the skin dry and hot; and, according to circumstances, typhoid symptoms may show themselves, or there may be delirium with great restlessness. Relapses are fre(iuent, and one attack does not protect against a subsequent one. The lymph-nodes which are in anatomical relation with the local process, as well as their surrounding tissues, may be swollen and tender, but they seldom undergo a suppurative change. The degree of enlargement and inflam- mation depends upon the amount of absorption, and of course this depends not only upon the character of the local process, but also upon its relations with the neighboring lymphatics. The heart’s action is usually rapid, and may be feeble, during an attack of diphtheria; and this condition often continues for some time after the disap- pearance of all local evidences of the disease. The pulse may be irregular both in force and rhythm. Another condition, usually appearing late in the disease, and often when the local process is apparently improving or has entirely cleared up, is for the feeble pulse to become progressively slower until the beats num- ber less than forty, sometimes less than thirty, to the-minute. These cases, which are nearly always fatal, together with those having the feeble, rapid pulse of profound sepsis and exhaustion, may be classed as examples of slow heart failure. But there is still another condition which usually appears after all the alarming symptoms are gone ; that is, a sudden failure or paralysis of the heart. Endocarditis most frequently involving the mitral valve may occur, and is accompanied by fever, prmcordial pain, attacks of syncope, a systolic murmur, and ante-mortem heart-clots, which majr become free and enter the circulation, producing the usual phenomena. In most cases there is a rapid destruction of the red corpuscles of the blood, and a relative increase of the white corpuscles. Hence the anaemia which appears early and rapidly increases as the disease advances. Albuminuria is a common complication, and appears usually on the third to si.xth day, but may rarely appear as early as the first day or as late as the fifteenth. The amount of albumin varies greatly, from a slight cloudiness, on boiling, to complete consolidation. The urine usually appears normal, but it may be scanty and dark, and in rare cases dark-colored or smoky from the presence of blood. There may also be present in tlie sediment gran- ular, hyaline, epithelial, and blood casts. The duration of the renal complica- tion varies from a day or two to a week or two, but it may occasionally become chronic. It is seldom attended with oedema, but vomiting and other uriemic symptoms are not so rare. It is impo.ssible to distinguish between the albu- minuria of true and of false diphtheria, but in diphtheria there arc some characteristics which distinguisli it from the same coin]flication of scarlet fever. The tonsils are tlic most frequent location of the disease, and when confined to them it runs a mild course, ibccause they have little or no comiection with the lymphatic system, and they do not contain a large number of blood-vessels. The chief difficulty in diagnosis is to distinguish between a sim))le follicular amygdalitis and a diphtheritic one. The secretion from a catarrhal amygda- litis may cover the tonsils with a coat which closely resembles pseudo-mem- brane, but it can be easily washed away with a syringe, and in most cases a careful examination will show its true character. DIPHTHERIA. 257 The pharynx, soft palate, and mouth may be involved ; and here it is a more serious condition than when confined to the tonsils. The lymph-vessels are very numerous : those of the uvula connect with the deep facial glands ; of the tongue, with the deep cervical and the submaxillary glands ; and of the floor of the mouth, with the submaxillary glands. The difi’erential diagnosis lies between true diphtheria and false diphtheria, exudates as the result of an intense heat or irritation, ulcerative and gangrenous stomatitis, or occasionally herpes and aphthae. The main differential symptoms pointing to diphtheria are, besides the history, the characteristic pseudo-membrane, the thin, brown- ish, acrid discharge, the sweetish and musty fetor, the glandular swellings, the tendency to haemorrhages, the slight fever and marked prostration, the albu- minuria, and the sequel of paralysis. In doubtful cases the only positive dem- onstration is the presence of the pathognomonic bacilli. In the nares diphtheria is very serious on account of the abundant lymph- and blood-supply, and the consequent increased facilities for absorption of the poison, and on account of the conformation of the nasal passages, which inter- feres with their thorough drainage when swollen and inflamed, and which makes thorough local treatment very difiicult. The greater supply of lymph- vessels is in the inferior portion of the nasal cavities, and these vessels con- nect with the deep facial and posterior submaxillary glands. It is often very difiicult, and may be impossible, to see the pseudo-membrane in the posterior nasal cavities in children. Theoretically, it is very simple to use a rhino- scope, but practically it is quite another matter, and it is often impossible and usually impracticable, even in a tractable child. The symptoms which help to a diagnosis are the thin, acrid discharge more or less stained with blood, the evidence of nasal obstruction, the enlarged cervical glands, the bad odor to the breath, the tendency to haemorrhage, and the frequent signs of general poi- soning. When the epiglottis, larynx, and trachea are involved, the main danger comes from the mechanical obstruction to respiration and the extension of the disease to the bronchi. Constitutional symptoms are usually absent, partly on account of the protection afibrded by the very numerous mucous glands, and partly on account of the absence of lymphatic glands and the scant supply of lymphatic vessels. These vessels connect with the bronchial glands. After death from laryngeal diphtheria these glands are found more or less enlarged. The diagnosis by means of the laryngoscope would be very valuable if it were practical. In the vast majority of cases it is not only impossible, but it is unnecessary and cruel. There is undoubtedly a membranous laryngitis which is not diphtheria, but the differential diagnosis cannot be made either from the symptoms or the character of the membrane. It can only be made by a bacteriological examination, which will show the presence or the absence of the Klebs-Loeffler bacillus. The difi’erential diagnosis lies between a membranous laryngitis and a catarrhal or a spasmodic one ; and while this is not usually so very difiicult, certain cases will present phenomena which keep the diagnosis obscure, unless the membrane is actually seen through the laryngoscope or is coughed up. Again, cases which, in the beginning, are catarrhal and run a typical course, may later become infectetl and run the usual course of a membranous inflam- mation. Again, confusion may be caused by those rather rare cases in which the membranous inflammation begins below and ascends to the larynx. In the uncomplicated cases of membranous laryngitis, excluding the ascending ones, there is little or no fever ; the onset of the disease is gradual, and it grows progressively woi'se ; there is hoarseness, and after a time complete 17 258 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. aphonia ; the stenosis is, at first, slight and only on inspiration, but after a while, usually two to four days, the stenosis becomes extreme, and attends both inspiration and expiration ; the respiration and the cough, which in the beginning may be noisy and croupy, gradually become more husky and sup- pressed. Spasmodic attacks may occur in connection with the disease, but this is not a prominent feature of its clinical history. The cases of ascending diphtheria of the trachea and larynx are very fatal, and, fortunately, uncommon. There are no constitutional symptoms, and the only evidence of sickness which can be detected is a slight bronchial or tracheal catarrh, until the process reaches the subglottic division of the larynx or the chink of the glottis, when laryngeal symptoms are seen, and stenosis appears and increases so rapidly that the patient becomes cyanotic within an hour or two, and soon dies unless immediate relief is given by intubation or tracheotomy. Even after operative interference the patient, in most cases, dies from extension of the disease to the bronchi, and usually within two days. In doubtful cases the appearance of membrane in other locations, or the existence of an epidemic of diphtheria, favors the diagnosis of a membranous laryngitis. If with this the temperature is low, not high ; the stenosis increases progressively, not spasmodically ; the onset is gradual, not sudden ; the laryngeal symptoms are of long, not short duration, — the diagnosis of membranous laryngitis is very clear. There are numerous evidences of stenosis of the larynx besides the noisy respiration, as this latter symptom may be present in many other conditions. The most characteristic features of lai’yngeal obstruction are the deep reces- sions of the soft parts of the chest in inspiration, the blue or leaden hue of the skin and mucous membranes, the aphonia, the restlessness, and the abnormal frequency of the respirations ; but none of these symptoms are constant. The soft ])arts of the chest-walls may project and make the chest barrel-shaped if the obstruction is greater on expiration ; the skin and mucous membranes may appear blue if the stenosis increases rapidly, but this color becomes a leaden white if the obstruction is of slow progress ; the voice may be clear in sub- glottic cases ; and in advanced cases the restlessness is supplanted by a con- dition of stupor from carl)on-dioxide poisoning. The only constant and reliable guide as to the presence and the amount of laryngeal obstruction is obtained by auscultation of the chest and listening to the respiratory sound. This gives an accurate guide as to the amount of air entering the lungs. The other diseases which should be considered in making a diagnosis are abscess of or about the larynx, tumors of the larynx, retro))haryngeal abscess, certain cases of naso-pharyngeal obstruction, foreign bodies in the air-pas- sages, etc. ; but the diagnosis should not be difficult if a careful examination is made. In the bronchi a membranous inflammation is rarely or never primary, but is .secomlary to a similar one in the larynx or trachea. It may extend to the finer bronchial tubes, or even into the air-cells themselves, and result in a bronclio- pneumonia, with pulmonary collapse or emphyseTua. Its symptoms are, in a case of laryngeal diphtheria, a sudden rise of temperature — often very high — rapid respiration, marked dyspnoea, and cyanosis; and, although the phys- ical signs in the chest are often obscure and masked by tlie laryngeal disease anil pulmonary complications, there is less air entering the lung on the affected side, a,nd the respiratory sound is dry and “ boardy.” Diphtheria of the conjunctiva, the ear, the intestinal tract, the genito- urinary organs, abraded jiortions of the skin, and wounds has occurred, usually DIPHTHERIA. 259 as a secondary process, but occasionally as a primary infection. The symptoms are those of an ordinary inflammation in those parts, to which are added the pseudo-membrane and other characteristics of this disease. Diphtheria may, of course, complicate any disease, but the most frequent association is with scarlet fever, measles, and those diseases which present a catarrhal condition of the mucous membranes, and thus favor a fresh in- fection. The skin eruptions which occur in diphtheria are septic manifestations, and may be of three kinds. The mildest and most transient closely resembles a scarlet-fever rash, but disappears more rapidly and does not desquamate. The second type is a purpura hmmorrhagica, and is usually associated with septic and grave forms of the disease. The last type, also seen in scarlet fever, usually follows a purulent septic infection, and occurs in cases which have a high mortality. There is an increase of temperature and the invasion is gradual. The eruption appears as red or dark-pink blotches, with sharply-defined mai*- gins. The color fades on pressure with the finger, but quickly returns. It appears first over the prominent bony points, such as the ankles, finger-joints, elbows, outer sides of the feet, etc., but always has a tendency to become gen- eral. Its disappearance is followed by a profuse desquamation, and usually this is quickly followed by a return of the eruption. Sequelae. — Besides the chronic catarrh which is left at the site of the pseudo-membranous inflammation, and the anaemia, the most frequent and char- acteristic sequel of diphtheria is paralysis, which develops from one to five weeks after all evidence of the acute disease has gone, though it may make its appearance during the course of the primary affection. It is a true multiple, peripheral neuritis, and resembles very closely, both clinically and pathologic- ally, the neuritis of alcohol, lead, and other poisons. The duration of the paralysis usually varies from two to six weeks ; it may last several months, and in exceptional cases has persisted for years. It is more frequent in adults than in children, and the severity of the original disease seems to offer no guide as to the severity of the paralysis or the probability of its appearance. Recovery usually takes place, and, while the location and the order of involvement differ greatly, the course is usually as follows: The soft palate and pharyngeal muscles, giving a nasal tone to the voice and a tendency to regurgitation of food through the nose during deglutition ; the muscles of the tongue, lips, and face; the ocular muscles, as shown by strabismus and disturbances of vision; the lower extremities ; the upper extremities; the larynx, recognized by modifications in the character of the voice or by obstruction, usually on inspiration ; the muscles of the neck, with inability to control the position of the head; the muscles of the trunk, with loss of power over the body; the intercostal muscles, the diaphragm and other muscles of respiration, with inter- ference with their function ; the heart, usually fatal, but may not be; the walls and the sphincter of the intestines or bladder. There has also been observed paralysis of the special senses, giving temporary amaurosis, deafness, and im- pairment of taste and smell. The paralysis of diphtheria may be divided into two classes; first, a true multiple neuritis, with loss of tendon reflexes as the result of poisoning by the toxalbumin ; and second, other types of paralysis, as a result of haemorrhages or degenerative changes in the brain or spinal cord. The first type occurs only in true diphtheria ; the second may occur in true or false diphtheria or as a result of many other septic conditions. Prognosis. — The prognosis is always better when the Klebs-Loeffler bacillus is absent. In 159 observations on cases of pseudo-membranous inflammation 2G0 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. made by Park at the Willard Parker Hospital of New York, the Loeffler bacillus was found in 54 cases, and in the other cases streptococci were the most abundant bacteria, and often the only ones. The mortality in true diphtheria was 46| per cent. ; in pseudo-diphtheria, 5| per cent. ; intubation in diphtheria, 71 J per cent. ; intubation in pseudo-diphtheria, 28 J per cent. ; adults in diphtheria, 36 per cent. ; adults in pseudo-diphtheria, 2 per cent. The prognosis varies, not only according to the age and condition of the patient, to the symptoms, and to the anatomical location of the disease, but also according to the character of the prevailing epidemic. The danger is greater the larger the surface involved and the more the exudate approaches a septic or gangrenous type, as shown by broken-down masses of exudation, the sweetish foul odor from the mouth, the yellowish or brownish secretion from the mouth and no.se, which is both fetid and acrid, and the swelling and tender- ness of the lymphatic nodes and the surrounding cellular tissue. However, the prognosis must always be a guarded one, since the subsequent course of the disease can never be predicted ; and even after it has apparently terminated in I'ecovery a relapse may take place, the infection may extend to the larynx or nose, or sudden death may result from paralysis of the heart. Another class of cases result in death, after all local manifestations of the disease have disap- peared, from a slow exhaustion. Such a condition might be called diphtheritic marasmus, the chief characteristic of which is the distaste for all food and the progressive and extreme emaciation. The prognosis in nasal cases is more serious, for reasons already given, while in laryngeal cases the prognosis is very grave from the great danger of asphyxia ; and, even if this be overcome, from the ease and frequency with which the membranous inflammation extends into the bronchi. Unfavorable prognostic signs are pallor, prostration, vomiting, limmor- rhages, marked weakness of the pulse, with excessive rapidity or slowness, fetor, purpura hmmorrhagica and septic blotches on the skin, persistent high fever, restlessness, delirium, and anorexia. The importance of albuminuria depends upon its character and the gravity of the symptoms which are asso- ciated with it. Diphtheritic paralysis usually ends in recovery, and is danger- ous only when it involves the heart or the muscles of resj)iration or degluti- tion ; and even in these cases its danger depends u[)on its degree. Prophylaxis. — The first recjuisite, after the aj)pearance of the disease, is complete isolation of the patient, either in a hospital devoted to contagious diseases or in a separate room in the house, preferably on the top floor, and containing as little furniture as possible. Separate dishes and other utensils should be kej)t for the sick-room, ami everything that it is necessary to return to other parts of the house should be thoroughly disinfected before it leaves the room. All discharges should be received in ve.ssels containing a strong solu- tion of copperas or corrosive sublimate. The clothing, towels, etc. should be put in a solution of sulpliate of zinc (4 ounces) and common salt (2 ounces) in boiling water (1 gallon). Water-closets, ))rivics, etc. should be lil)erally treated with coj)peras solution (IJ pounds to the gallon). During the con- tinuance of the disease it is of great service to keep the room filled with some antiseptic vapor, as carbolic acid, eucalyj)tus, or turpentine ; but I have found that most good in preventing the spread of the disease is obtained by sub- liming fifteen to thirty grains of calomel in the room every hour. After recovery the patient should be thoroughly cleansed and disinfecteil, and dres.sedin clothes that have not been exposed to infection. In any event, as much as possible of the exposed clothing, furniture, etc. should be destroyed, and the rest thoroughly disinfected, either by the methods previously described or by naphtha or super- DIPHTHERIA. 261 heated steam. The walls, bed, and furniture should be ■washed with a strong solution of corrosive sublimate, and then, after closing the room tightly, sul- phur should be burned in it in the presence of an excess of moisture — about three pounds of sulphur to every thousand cubic feet of air-space. After this it is well to advise that four to eight ounces of calomel be sublimed. Other members of the family should be kept from school and church ; they should be removed to a different house if possible, away from the infection, and their naso-pharyngeal cavities and teeth should be kept clean by means of antiseptic washes, sprays, and gargles. At all times, and especially during an epidemic or after exposure to it, the mucous membrane of the respiratory tract should be kept in as healthy a condition as possible by keeping it clean and free of lesions. The physician should protect his clothing as much as possible on entering the sick-room by a linen gown, and before seeing another patient, especially a child, all parts exposed to the infection should be thoroughly aired ; or, better still, he should disinfect himself and put on fresh clothes, leaving the dis- carded ones exposed to the open air or to the fumes of subliming mercury. One of the chief causes of the spread of diphtheria in New York City is the laxness, and almost criminal carelessness, of the authorities in our dis- pensaries for the poor. It is almost a daily occurrence in the large dispensa- ries for a contagious case to be packed in a small, hot room with a number of other children, most of them ill and in good condition to contract the infec- tion. Treatment. — There is no disease in which a greater variety of treatment has been recommended — from the expectant, which lets the patient absolutely alone, to the active treatment, which requires him to be disturbed every few minutes. It is impossible to lay down any routine plan : we have no specific for the disease, and each case should be treated on general principles and according to its individual indications. The general condition and strength of the patient should be improved as much as possible. There should be plenty of sunlight and fresh air in the sick-room, which should be kept at a uniform tempei’ature of about 70° F. The clothes and bed-linen should be kept clean and pure by frequent changing. The skin should be kept in good condition, and special care should be taken of the digestion and nourish- ment. Gi’eat stress should be given in advising the recumbent position and avoiding all exertion, but, of course, this is often impossible in children. Internal Treatment. — Alcohol and food are of the greatest value, and too much stress cannot be laid on the importance of their proper use. The diet should, as a rule, be a liquid one, and consist of such food as is easily digested. Cows’ milk, pure and fresh, is undoubtedly the best, but to aid digestion or to prevent som’ing and other fermentative changes it may be peptonized, or lime- water or an antiseptic may be added to it. To give variety to the diet or to meet special indications other wholesome and nourishing articles may be included, as beef juice, eggs, etc. The food should always be given at regular intervals, about once every three or four hours, and in definite quantities. It is always harmful to compel a child to take more food than it can digest, and any drug Avhich interferes with the proper digestion and assimilation of the food is positively harmful, and its use should be avoided. Alcohol, as brandy, whiskey, champagne, wine, or in some other form, should be given rather freely from the beginning, and there is more danger from giving too little than too much. A three-year-old child can take from one to ten ounces of whiskey in twenty-four hours, and in bad septic cases this amount may be greatly increased with advantage. Other valuable stimulants are carbonate of ammonium, camphor, musk, strychnia, digitalis, and the large 262 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. number of heart stimulants and tonics ; but alcohol, in one of its many forms, is by far the best and safest. The remedies which are given internally in the treatment of diphtheria make a long list, but most of them are of doubtful value, and many of them interfere with the digestion or do positive harm in other ways. Tincture of the chloride of iron is the most ])opular one. Locally it is a powerful astring- ent and antiseptic, but internally it seems to me that the theoretical benefit which it produces is, in many cases, more than counterbalanced by the diges- tive disturbances which follow its use. Chlorate of potassium has an excellent effect in healing lesions of the mucous membranes, but internally, especially in large doses, it is positively dangerous, not only by its irritating effects on the stomach and intestines, but also by its dangerous action on the kidneys and heart. The mercurials, especially the corrosive and the mild chloride, are undoubt- edly valuable, but most of the good resulting from their use is obtained from their local effect on the pharynx, and their local effect in the digestive tract by preventing fermentation. The corrosive sublimate should be used in large and frequent doses, and always well diluted. Turpentine, chloride of ammonium, iodide of potassium, antimony, the salicylates, bromine, benzoate of sodium, balsam of copaiba, cubeb, quinine, pilocarpine, and many other drugs are enthusiastically advised by different writers ; but in the light of recent knowledge of this disease it is difficult to understand how any benefit could be obtained by their internal adminis- tration. High fever should be reduced by sponging and baths, and the antipyretic drugs, antipyrine, acetanilid, phenacetin, etc., should be avoided, because they all increase the depression of the wmak and degenerated heart. The bath, if used, should not be cold, but begun at 95° F. and gradually reduced to 80°, or even 70° in bad septic cases. Stimulants internally, hot applications to the extremities, and a warm sponge-bath are valuable in overcoming any bad effects of an over-cold bath. However, it is seldom wise to reduce the temperature of the bath below 70° F., and the best antipyretic effects are obtained in this manner. The patient should remain in the bath until the temperature, taken in the rectum, begins to fall, when he should be imme- diately removed and put to bed. In laryngeal cases, and in cases with enlarged and tender lymphatic glands, cold applications, and even the ice-bag, often seem to be of benefit to the local process. Exhaustion, reflex vomiting, collapse, diarrhoea, haemorrhages, and other complications should be treated symptomatically and promptly ; but their appearance can often be prevented, and every effort should be made to attain this end. For exhaustion and collapse alcohol in large doses, both by mouth and under the skin, is the best remedy, but digitalis, nitro-glycerin, strych- nine, cani])hor, and musk are useful. In the rapid heart failure of diphtheria, with an irregular and fluttering pulse, nothing is ecjual to a moderately large dose of morphine, given hypodermatically. It is a powerful stimulant, and quiets and steadies the heart. For the I’eflex vomiting there is nothing more satisfactory than the oil of wormwood, given as follows : H*. Olei absinthii gtt. j to ij. Sodii bicarbonatis ,^j. Aquae menthac piperitic ad f.^iv. — M. Sig. One teaspoonful for a child three years old, every half hour until the vomiting ceases. Shake well before using. DIPHTHERIA. 263 When the vomiting is due to uraemia or to irritation of the stomach other appropriate measures should be taken. For the diarrhoea, when due to local irritation in the bowels, give an active cathartic, by preference calomel or castor oil, to remove from the digestive tract the cause of the irritation, and follow this by an antiseptic to prevent further fermentation. The following answers very well : Hydrargyri chloridi corrosivi g*"- j- Bismuthi subnitratis 3iv. Aquoe anisi f^iv. — M. Sig. One teaspoouful in water every two hours until the discharges are black and lose their fetor. Shake well. In severe hfemorrhages, especially from the nose, it may be necessary to apply local astringents or even to plug the nares with cotton. However, this should be avoided when possible, and many cases, being caused by an irregular and weak heart or a passive congestion from a weak right ventricle, can be stopped by the use of alcohol, digitalis, or nitro-glycerin, according to the indications. Local Treatment. — It must be acknowledged that the best and most sat- isfactory results in diphtheria are obtained by local treatment. The chief points to be considered in deciding upon a plan of treatment are — 1. The most convenient method of applying the medication — by spray, irrigation, insufflation, gargle, inhalation in the form of vapor, or by direct application with a swab. This will vary according to the medication employed and the location of the disease. For naso-pharyngeal cases the most satisfac- tory and thorough method is by irrigation with a fountain syringe. Through the nostrils the whole naso-phai’yngeal cavity can be most thoroughly cleansed, and with less difficulty than by any other method. The child should be kept in a horizontal position when possible, and a rubber sheet arranged to catch the discharge. At each irrigation it is necessary to use enough of the solution to thoroughly clean the naso-pharynx — about one pint. This should be done every two hours, and in all cases often enough to thoroughly clean the diseased surface and bring the germicide in direct contact with it. In adults it is very satisfactory to use the irrigation through the mouth. In children this is often impracticable, but, when necessary, pass the nozzle of the syringe back be- tween the teeth and cheek, so that the stream will enter the pharynx behind the last molar tooth. If the child be intractable and exhaust himself to a dan- gerous degree by fighting against the treatment, it may become necessary to clean the surface by giving internally plenty of water, either alone or with a weak antiseptic or a mild alkali, and applying the germicide by inhalation in the form of vapor, either by the sublimation of fifteen to forty grains of calo- mel every hour or two, or by keeping the air of the room saturated with steam which is impregnated with turpentine or some of the volatile antiseptics. The following is an excellent combination : I^. Acidi carbolici flj. 01 ei eucalypti f^ij. Spts. terebinthinae l5viij. — M. Sig. Add a tablespoonful every half hour to about a quart of water, which is kept simmering over a flame. In laryngeal or bronchial cases, although an application may be made 264 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. directly to the larynx with a swab, the only satisfactory method is by means of the inhalation of a medicated vapor. The spray, while of value, usually does not go beyond the oral cavity, and seldom or never reaches the posterior pharynx. Through the nose it does better service. The swab, except in very careful and experienced hands, is liable to be too harsh and tear off membrane, thus opening up fresh avenues for infection ; and in the grave cases, the nasal ones, it is almost useless. The use of the gargle is limited to adults and older children, it is not thorough, and it tires the patient very quickly. 2. The medication to be employed. There are two indications to be met : (a) the clearing away of debris and dead tissue, which may be the cause of much fetor and secondary septic complications, and which may also prevent the germicide from reaching the bacilli ; and (b) the destruction of the living bacilli and other bacteria which are producing the disease. A third indication would be to neutralize or to destroy any of the unahsorbed toxalhumin which may be present. With our present knowledge of the properties of this poison it would be difficult to decide upon any practical rules, but we may be sure that its mechanical removal by irrigation is of value. We know that it is taken up very slowly from the infected tissues, often giving symptoms of fresh absorption after all the bacilli have disappeared ; therefore the importance of keeping the surface of the mucous membrane clean after all evidence of the disease has gone. (a) The most efficient drug for the removal of broken-down membrane, dead tissue, pus, and other ddbris is the peroxide of hydrogen, although it has apparently no destructive effect on the living bacilli. For this purpose it is certainly superior to any other means, although there are some preparations which are of great value as adjuncts — e. g. a saturated solution of borax in hot water, and the solvents, like pepsin, trypsin, and papayotin. The ordinary fifteen-volume solution of peroxide should be used, either in full strength or diluted with lime-water, which removes some of its acrid and irritating quali- ties without impairing its efficiency. It should be used freely, and in most cases a mixture of one part of the ordinary fifteen-volume solution with two or three parts of lime-water is effective. The best method to apply it is by irriga- tion with a fountain syringe, using about half a pint each time, and often enough to keep the diseased surfaces clean. There are several objections to its use. One is the difficulty of obtaining a fresh and active solution. This objection has been, in a great measure, overcome by Squibb of Brooklyn, who has made it po.ssible to freshly prepare this solution at the time of use. A serious objection to Sejuibb’s method is the long time required to prepare the solution. How- ever, it is always well to te.st tlic activity of the solution before de])ending upon it. Another olq'ection, and an important one, is its irritating effect upon the mucous meml)ranc. It causes pain, and, as a result, objections to its use on , the part of the patient ; it also ju’oduces fresh lesions in the healthy mucous membrane, thus ofl’ering new places for infection. In my early experience with the drug, these objections and the greatly increased number of cases in which the diphtheritic ])rocess extended to the buccal mucous membrane, the gums, the tongue, and lips, .seemed to make its use of very doubtful value, and probably harmful. However, these faults (;an he obviated in a great degree by diluting the solution with a!i alkaline water, and, after its use, by irrigating the same surface with a saturated solution of borax in hot water. If it is desirable to use the solution of j)oroxide without diluting it, neutralize the excess of acid with an alkali. DIPHTHERIA. 265 (b) To destroy the bacilli almost every caustic, astringent, digestive fer- ment, essential oil, and germicide has been lauded, and brilliant results claimed for each. Unfortunately, most of these reports are not based upon enough observations to be of much value ; and it is apparently not recognized that nearly every case of tonsillar, most cases of pharyngeal, and many cases of naso-pharyngeal diphtheria recover under any kind of treatment. Of all the germicides, the mercurials seem to have the most destructive effect on the Klebs-Loeffler bacillus, and carbolic acid, either alone or combined with eucalyptus and turpentine, on the streptococci and other bacteria which produce the false diphtheria. As it is often so difficult to distinguish between them — and, in fact, both forms are so frequently combined — it is better to use locally both the carbolic acid and some mercurial preparation. Therefore, always keep the room moderately filled with steam that is impregnated with the mixture of carbolic acid, eucalyptus, and turpentine. In naso-pharyngeal cases, after the thorough cleansing of the surface with the peroxide and the borax solution, use in the cavity a solution of bichloride of mercury, 1 : 1000, either by irrigation, with a swab, or by spray. No metallic utensils should come in contact with the mercury solution, as it corrodes them. If, for any reason, it is impossible to use the irrigation or spray, the local effect of the mer- cury may be obtained by subliming the mild chloride and allowing the child to inhale the fumes. In laryngeal cases dependence must be placed upon inhalation, as it is im- practicable and dangerous to use the laryngeal applicator. The inhalation most destructive to the Klebs-Loeffler bacillus is the fumes obtained by sub- liming calomel. The child should be well wrapped up, so that only the face is free, thus exposing the least possible surface of the skin to the action of the mercury. It should then be placed in an ordinary croup-tent, and the calomel sublimed in such a manner as to fill it ■with the fumes. The best apparatus for this purpose is the ordinary steam-spray, in which the boiler is replaced by a strip of tin upon which the calomel is put. Another good arrangement is to put a small alcohol lamp in the bottom of an ordinary chamber, and cover it with a pie-pan or strip of metal to hold the powder. The same end may be attained with a hot stove-lid, a shovel of red-hot coals, and in other ways. According to circumstances, fifteen to forty grains of calomel should be burned in this manner every one, two, or three hours. It is not necessary to wake the child for treatment, and if the smoke causes much coughing and irritation, sub- lime it less rapidly by lowering the flame of the lamp. It usually takes about ten minutes to sublime fifteen grains, and if care be taken to obtain pure calo- mel, or, better yet, calomel which has been recently sublimed and recondensed, the irritation from the fumes is usually very slight. This treatment does good not only by its local effect in the larynx, but by keeping the bronchi pi’otected, and thus preventing the most common and fatal complication of laryngeal diph- theria — the extension of the disease to the bronchi. This treatment, which was first suggested by Corbin of Brooklyn, is not only of great value after operative interference, by preventing the extension of the disease to the bron- chi, but its early use will in many cases obviate the necessity of an intubation or a tracheotomy. Besides this, it keeps the sick-room disinfected and helps to prevent the spread of the disease. The attendant should be cautioned to inhale the vapor as little as possible, as it is surprising how frequently the nurse becomes salivated and how seldom the patient is at all affected. However, this treatment seems to have a depressing effect on some patients, although there are seldom any other evidences of mercurialization ; but it should be remembered that in infants and young children mercury is not liable to produce salivation 266 AMERICAN TEXT-BOOK OF DISEABEII OF CHILDREN as in adults. Its effects are shown rather by marked anaemia and depression, with signs of irritation of the intestines and the kidneys. The operative treatment of diphtheria wdll be considered elsewhere, but the following suggestion may be of value in overcoming one of the most serious complications that arises — namely, loose membrane in the trachea or bronchi. Its removal by aspiration, by tubes of large calibre, and by numerous kinds of forceps has been attempted, but with little or no satisfaction. The most suc- cessful method in my own practice is to insert a small laryngeal applicator, the cotton on which is covered with a very sticky substance like Canada balsam. Upon its withdrawal more or less of the membrane remains adherent to it, and after several trials and in many cases the loose membrane is all brought out. Antitoxin. — In discussing the value of any treatment for diphtheria it is necessary to consider this disease separately as it involves the larynx and as it involves the naso-pharynx. For all therapeutical purposes we have practically two distinct diseases, although the cause may be the same. In the laryngeal type the danger is from asphyxia, either from laryn- geal obstruction or, when this is overcome, from an extension of the mem- branous inflammation to the smaller bronchi ; and the danger from sep- sis is not great, because of the meagre lymphatic supply in this region and the small area of the surface from ivhich absorption of toxins can take place. On the other hand, in naso-pharyngeal diphtheria the danger from mechanical obstruction is slight, and the fatal cases are, almost without exception, the result of the absorption of poisons through the abundant lymph- and blood-supply. This is especially true of the nasal cases, as in this region not only is the blood- and lymph-supply very abundant, but it is almost impossible to obtain good drainage when the nasal mucous mem- brane and the turbinated bones are swollen. Again, in laryngeal cases the disease is rarely the result of a mixed infec- tion, but naso-pharyngeal diphtheria, as we see it in practice and not in the laboratory, is fre(piently due to a mixed infection. The importance of this from a therapeutical point of view is evident when we consider the difference between infection by Klebs-Liiffler bacilli and by streptococci. The point is that in streptococcus infection the germ itself finds its way into the blood and viscera, but this is rarely true of the bacillus in Klebs-Lbfller infection. In one case you have a toxin only to fight, and in the other you have both the germ and its toxin. Although w'e admit that there are many unsolved therapeutical problems in connection with the antitoxin treatment of naso-phari/niieal diphtheria, there can be no doubt of its almost specific value in the /fvi/7ihysicians, and, since the antitoxin days, the diagnosis has been confirmed in nearly every case by a bactcriolojiical examination by the New York or Hrooklyn Hoard of liealth. DIPHTHERIA. 267 Intubation Cases. No. Recovered. July, 1885, to September U 1886, 37 7 = = 18.9 per cent. Sept. 1886, 1887, 65 = 23.0 1887, U 1888, 89 . 28- = 31.4 tl 1888, u 1889, 95 . 31 - = 32.6 cr minute. 4'he cotigh is fixuiuent, dry, and very troul)lesome. As the dyspnoea becomes more marked thccolor of the face changes. TUBERCUL 0SI8. 281 and there is slight cyanosis. Though the fever is high and the symptoms grave, there are rarely severe cerebral manifestations. There may be slight diar- rhoea, but the abdomen is not specially distended ; the spleen is easily pal- pable. The whole clinical picture is that of an acute broncho-pneumonia. The physical examination shows hurried respiration, and there may be retraction of the lower zone of the thorax ; the percussion note is clear, even hyperresonant, and auscultation at first shows signs of a general bronchial catarrh, chiefly of the smaller tubes. Subsequently, as the case progresses, there are areas in which the resonance is higher in pitch or even tympanitic, and in places distinct blowing breathing may be heard, or even the signs suggestive of cavity. The course of the disease in this type is much more rapid, and the child may die at the end of a week, or even earlier, with the signs of an acute suf- focative catarrh — more commonly in from ten to twelve or fburteen days, usually from a progressively advancing asphyxia. Diagnosis. — The diagnosis of acute tuberculosis in children may be very easy or beset with the greatest difficulties. The family history should be taken into account ; the surroundings of the case, particularly whether there have been instances of tuberculosis in the same house or occupying the same room. Much more important is the previous history and personal condition of the patient. Inquiries should be made about whooping-cough and measles, diseases not infrequently followed by acute tuberculosis. Sometimes a history of failing health or of protracted catarrh may be obtained. The most evident cases are those in which there are signs of local glandular or bone tuberculosis. Sometimes the acute affection follows an operation on the tuberculous glands of the neek or the opening of a joint abscess, or even of a so-called cold abscess, or, in very rare instances, the tapping of a pleural effusion. In the typhoid type, when the features are well developed, the simulation of ordinary enteric fever may be extremely close. Here, if from the outset a careful temperature record be kept, it will usually be found that the fever is much more irregular in tuberculosis, and early in the disease there may be quite marked morning remissions. As noted before, in a few instances the temperature may be low, even subnormal, in the morning. The genei’al features of infection are much the same in both diseases. The absence of typhoid rash, unless it is there, which is usually present in children, and very distinctive, is a most important nega- tive sign. Expectoration is rarely obtained, but should the child vomit, sputa should be looked for in the vomitus, since it sometimes happens that an acute miliary tuberculosis takes its origin in a small focus of disease in one lung, fi’om which tubercle bacilli may reach the sputum. The examination of the urine is important, but Ehrlich’s reaction is pres- ent as frequently in acute tuberculosis as in typhoid fever. Pus in the urine should be carefully examined for bacilli, since instances of general infection have resulted from urogenital tuberculosis. The profound infection associated with malignant endocarditis may simulate that of acute tuberculosis. The special heart-signs, if present, and embolic features, would be important distinguishing marks. The diagnosis of the catarrhal or broncho-pneumonic type will be more fully considered when speak- ing of the acute tuberculous broncho-pneumonia of infants. Prognosis. — The prognosis is always unfavorable. Here, however, may be mentioned a type of acute tuberculosis recognized by Empis, Landouzy, and others, which they call typho-tuherculose or typho-hacillose, and which may be either the first manifestation of the invasion of the organism with the bacilli or the expression of an acute, but aborted, tuberculosis, following some local tuberculous process. The clinical aspect is really that of typhoid fever, and 282 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. the temperature curve would not appear to give any definite criterion. Unless, in fact, there is some local tuberculous focus, I do not see how this form can be recognized, and many of the cases reported by Aviragnet in his monograph are not at all convincing. That there may be, however, either early in a tuber- culosis, or as a secondary event in a local process, an infection of the system with the toxines is extremely likely. In adults it is not very uncommon to find a tuberculous focus completely overlooked in a general infection believed to be typhoid fever, and in which the secondai’y development of miliary granu- lations seems scarcely sufficient to account for all the symptoms. (2) Chronic Diffuse Tuberculosis. This, one of the most common forms of tuberculosis in children, is charac- terized anatomically by the gradual development of tubercles in many different parts of the body : they are not, however, the miliary granulations of the acute tuberculosis, but coarse, grayish-yellow tuberculous masses, varying in size from a pea to a walnut. In the lungs, for instance, there are caseous tubercles of all sizes, areas of caseous bi’oncho-pneumonia, some of which have undergone softening; but cavities are not common except in children above four or five. The bronchial glands are often greatly enlarged and caseous, and sometimes present abscesses. The abdominal organs show extensive tuberculosis. The spleen is greatly enlarged, and on section presents numerous grayish-yellow tuberculous masses, varying in size from 2 to 10 mm. The liver is enlarged and may show miliary tubercles on the capsule, but in many instances there are coarser yellowish-gray masses which have developed about the bile-capil- laries, and which, having softened in the centre, present a yellowish-green bile- stained pus. The small intestines may show tuberculous ulceration to a greater or less extent. The mesenteric glands are usually enlarged and caseous. The kidneys may show coarse tubercles, sometimes an intense tuberculous pye- litis. In the brain there may be either an acute terminal meningitis or there are coarse tuberculous nodules scattered throughout the substance, particularly in the cerebellum. The chronic diffuse tuberculosis is much more frequent in infants than in children above the age of two. The symptoms are those of a progressive enfeeblement of the nutrition, as a rule ivithout fever, and with manifestations in different organs varying with the degi’ee of tuberculization. The affection may set in acutely as a bronchitis or a broncho-pneumonia, the symptoms of which gradually subside. Very often the condition follows whoop- ing-cough, measles, or acute gastro-intestinal catarrh. Less frc(|uently it is insidious, and the child presents simply progressive failure in health. The appearance of the child is that of marked cachexia. It is thin; the skin is loose and pale, sometimes covered with fine scales, and occasionally pigmented. The eyes are large, and the expression often bright and animated. The thorax is thin, the ribs readily noted, and there may or may not be the signs of coexist- ing rickets. The abdomen is usually tumefied, and both the liver and spleen are enlarged. When the abdominal features are marked, the clinical picture is that really of some cases formerly described as tabes mesenterica. The superficial glands may be enlarged and hard. Cough may be jiresent, usually dry, and very rarely there is ilyspnoea. The physical signs thoroughout the lungs are either dulncss in the interscajmlar regions or scattered areas of defec- tive resonance with bronchial rales and blowing breathing. The apjietite is poor, the digestion feeble, vomiting is freipient, and diarrluea is common. Not only may there be no fever, but the temperature may even be subnormal. Death usually results from some complication, cither a secondary invasion of pneumococci or streptococci, or an acute meningitis. TUBERCUL OSIS. 283 The diagnosis may present difficulties if one does not constantly bear in mind, in the first place, the frequency of tuberculosis in infants, particularly in institutions ; and, secondly, the fact that this diffuse form, which is very common, may pursue its course without fever, and only perhaps toward the close show signs of active disease, now of the meninges, now of the lungs, or, again, of the intestines. This cachexia of the chronic diffuse tuberculosis of infants must be distinguished from that of rickets, of chronic gastro-intestinal catarrh, and of syphilis. In rickets the changes in the bones and cartilages, in athrepsia the marked gastro-intestinal disturbance, and the, as a rule, more enfeebled and senile look of the child, serve as distinguishing features. The absence of enlargement of the spleen and liver or of the lymph-glands is an important negative sign. A greater difficulty exists in distinguishing some of the cases of profound syphilitic cachexia, as here the superficial glands may be enlarged and the spleen and liver hypertrophied ; but, on the other hand, the history, the facies, the skin-rashes, rhagades, and, above all, the prompt improvement under antisyphilitic treatment, are important points of differen- tiation. m. Localized Tuberculosis. (1) Tuberculosis of the Lymph-glands. ( a ) Tuberculous Polyadenitis. — The lymphatic system may be the chief seat of the disease, and the glands, internal and external, or the lymph-sacs (serous surfaces), may present advanced tuberculosis without much involvement of the viscera or other parts. This is more often the case than we have here- tofore supposed. In some instances of general tuberculous infection in young children there may be what Legroux calls micro-polyadenopathy, which in doubtful cases may give an important diagnostic hint. More recently Lesage and Pascal have described cases in children in which there was progressive involvement of the lymphatic glands, usually at first those of the groin, then those of the axilla, and lastly the cervical and internal groups. They regard the affection in some of the cases as due to cutaneous tuberculosis; in others they believe the disease to be congenital. The symptoms of this form of gen- eralized enlargement of the superficial lymph-glands are progressive cachexia without much fever and without signs of disease of the lungs or of the abdom- inal organs, and frequently a ravenous appetite. The cases must be carefully distinguished from the general slight enlarge- ment of the lymph-glands in syphilis, and from the rare cases of Hodgkin’s disease in children, in Avhich, however, the enlargement is much greater and the involvement of one group is generally much more marked. It must not be supposed, however, that every case of general moderate enlargement of the superficial lymph-glands in children is due either to tuberculosis, syphilis, or Hodgkin’s disease. Following the infectious fevers, and associated with chronic catarrh of the upper air-passages, I have seen on more than one occasion enlargement of the glands of the neck, of the groin, and of the axillae — a condition of the superficial lymph-apparatus comparable to the swelling of the Peyer’s follicles and of the mesenteric glands found so frequently in children dead of one of the infectious diseases, or, in fact, of any prolonged illness. (b) Cervical Adenitis. — The drainage-areas of the lymphatic glands of the neck embrace the superficial and deep structures of the head and neck 284 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. The most important groups are the superficial cervical, beneath the platysma, which drains the side of the head and neck and face and external ear, and the deep cervical along the carotid sheath, which drains the mouth, the tonsils, palate, pharynx, and larynx. In addition there are the submaxillary and suprahyoid groups draining the lower gums, the front of the mouth and tongue, and the chin and lower lips. Tuberculous adenitis of the glands of the neck, so extremely common, which fortunately often remains a local and curable affection, was regarded as one of the most typical and characteristic manifestations of scrofula. Cornet’s obser- vations upon the presence of tubercle bacilli in the dust of cities and of rooms show how widely spread the vii’us is, and how liable we are in crowded cities to inhale, and even to swallow, bacilli with the dust. Whether the bacilli are capable of passing through the healthy mucous membrane is perhaps doubt- ful, though there are experiments which would seem to prove the liability of infection through the healthy mucous membrane of the intestines. More prob- ably the slight catarrhal troubles about the naso-pharynx, so frequent in chil- dren, open, as one may say, the portals and allow the bacilli to reach the lymph- glands. Preliminary irritation and enlargement of the glands in eczema of the scalp and in sore throat in children may weaken the powers of resistance. Here, no doubt, if the tissue-soil be unfavorable, they may exert no influence whatever, but with that vulnerability of tissue, regarded by former w’riters as the characteristic feature of scrofula, the bacilli find a suitable nidus, and a local tuberculosis is the result — a process characterized usually by extreme chronicity. The glands may enlarge rapidly at first and become soft and painful ; more commonly, they swell slowly, and can be felt as firm rounded masses freely movable beneath the skin. They may gradually subside and undergo spon- taneous healing. In other instances the glands increase, areas of softening are found, the process involves the skin overlying the gland, which becomes red, and finally ulcerates, discharging a clieesy matter and a thin watery sero-pus. The sore thus left is very indolent, does not tend to heal; the skin about it is livid and undermined. Many of the glands may suppurate in this way, and when healing ultimately takes place tbe sides of the neck are disfigured by irregular, unsightly scars. In the neck of young or old these are usually a certain sign of healed tuberculosis. It is to be borne in mind that involvement of the cervical glands may be due to extension of tuberculous processes from the axillary glands or even from carious cervical vertebrm. When the glands are large and growing actively there is fever; death very rarely follows, and even aggravated cases in children may recover. In some instances the general nutrition is very slightly disturbed. Tuberculous adenitis of the cervical or axillary groups may precede the devel- opment of tuberculosis of the pleura or of the lung. (c) TRAcnEO-BKONClilAli (5LANDS. — Within the tliorax the groups of lymph- glands are of great importance. The sternal are ])laced along the course of the internal mammary vessels; the intercostal along the heads of the ribs, and sometimes extending outward; the anterior mediasti)ial grou]) between the lower part of the sternum and the pericardium; the cardiac grou]) in the inter- pleural space about the arch of the aorta; aiid, lastly, the tracheal glands on either side of the windpipe, and the bronchial ]>ro))er, continuous with them, which surround the main bronchi and ]>ass deeply in the hilus of the lung. There are also glands in the posterior mediastinum along the thoracic aorta, and oesophagus. Tuberculosis of the tracheo-bronchial glands is extremely TUBERCULOSIS. 285 common. Observations of Loomis (Jr.) show even that in apparently normal glands bacilli may be present and the gland-tissue infective. Certainly in a very large proportion of all cases of tuberculosis in children it would appear that the first infection was in these structures, while common experience shows, contrary to the so-called law formulated by Parrot, that the glands may be involved without any local lesion in the lungs. Of 125 cases examined by Northrup, the bi’onchial glands were tuberculous in every case; 42 had cheesy masses in the bronchial lymph-nodes only, with recent tubercles in the lungs and elsewhere ; in 13, it was limited to the bronchial glands alone. The glands may present gray miliary tubercles, large, unpigmented, cheesy areas, foci of softening with suppuration, or old calcified masses. In the long-standing cases there is much sclerosis and pigmentation. The different groups may be very differently involved; thus the tracheal may be much affected without great involvement of the bronchial nodes proper. More commonly all the glands are involved, and very often those deep in the hilus of the lung form large caseous masses uniformly surrounding the main bi’onchus and its divisions, and penetrating deeply between the lobes of the lung. When the glands sup- purate the abscesses may perforate in different directions. The effects of these enlarged glands are very varied, and for full details the reader is referred to the elaborate section in the Traits of Barthez and Sannd (tome 3). It is suf- ficient here to say that there are instances on record of compression of the superior cava, of the pulmonary artery, and of the azygos vein. The trachea and bronchi, though often flattened, are rarely seriously compressed. The pneumogastric nerve may be involved, particularly the recurrent laryngeal branch. More important, really, are the perforations of the enlarged and softened glands into the bronchi or trachea, or a sort of secondary cyst may be formed between the lung and the softened bronchial gland. Perforations of the vessels are much less common, but the pulmonary artery has been opened. Per- foration of the oesophagus has been described in several cases. One of the most serious effects is infection of the lung or pleura by the caseous glands situated deep along the bronchi. The infection may, as is often clearly seen, be by direct contact, and it may be difficult to determine in some sections where the caseous bronchial gland terminates and the pulmonary tissue begins. In other instances it takes place along the root of the lung, and is subpleural. Among rarer sequences may be mentioned diverticula of the oesophagus follow- ing adhesion of an enlarged gland and its subsequent retraction, and, in the case of the anterior mediastinal and aortic groups, the fi’equent association of tuberculous adenopathy and pericarditis, either by contact or by rupture of a softened gland into the pericardium. Symptoms. — In the great majority of instances there are no indications whatever, and even in enormous enlargement pressure-signs may not have been present. Authors differ extremely in their views on this point. Many hold, and I think correctly, that the manifestations, as a rule, are very slight. Com- pression of the veins leading to dropsy, dilatations of the veins causing cyano- sis, and haemorrhages are referred to by Barthez and Sannd. Alterations in the character of the heart-sounds and attacks of paroxysmal dyspnoea are des- cribed by the same writers. The latter come on suddenly, often at regular hours, frequently in the afternoon, and there is extreme oppression with rapid breathing, cyanosis, and cold sweats, almost like an attack of severe croup. These paroxysms may succeed each other, and they have been ascribed not so much to pressure at the bifurcation of the trachea as to compression of the vagi, causing in this way laryngeal spasm. More definite, undoubtedly, is the com- pression of one or other bronchus, causing feeble breathing on the side most 28G AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. affected, with sibilant and fine rales. Usually, ho’wever, when the glands are very much enlarged the lung is also involved, and it may be difficult to say how far the alterations are due to the changes in it. Still less reliable is the infor- mation obtained on percussion, for the dulness in the upper part of the sternum and in the interscapular spaces is, when present, by no means a positive sign. The thymus may cause sternal flatness on percussion ; and behind, unless the glands are enormously enlarged and the child very thin, it is difficult to deter- mine any special modification of the resonance in the interscapular space between the first and third dorsal vertebrae. [d) Mesenteric Glands (Tabes Mesenterica). — The glands involved are those of the mesentery and the gastro-hepatic omentum and the chain of retroperitoneal glands along the aorta ; more rarely those of the pelvis. Tuberculous disease of these glands is extremely common ; thus of 127 cases of fatal tuberculosis in children, noted by Woodhead, these structures were in- volved in 100, while Ashby states that of 103 consecutive post-mortems on children dying of tuberculosis, in 62 there w'as tuberculous ulceration of the intestines; in 71, cheesy mesenteric glands; in 55, both ulcers and cheesy glands ; in 7, tuberculous ulcers without involvement of the glands ; and in 16, cheesy glands without ulcers. Of 144 children in which the mesenteric glands were tuberculous, only 44 showed neither ulcerations nor tubercles in the intestines (Barthez and Sann4). In a great many instances the condition is found accidentally in children who have died of other diseases. Unquestionably, as is indicated by these figures, the infection in many of these cases is primary in the glands. Lesion of the intestines is not necessary. Some experiments have shown that the bacilli may gain entrance through a healthy mucosa. A special interest relates to the possibility of infection by the bacilli in milk, more particularly as it is well known that in animals experimentally fed with infected milk primary tuberculosis of the intestines, with extensive disease of the mesenteric glands, has been produced. The question will be referred to again on the subject of primary tuberculosis of the intestines. The cases fall into four groups : (1) Very slight tuberculous affection of a few glands (which may be the only ones), met with accidentally in children who have died of various dis- orders. (2) In the chronic generalized tuberculosis, in both the acute and chronic pulmonary tuberculosis, and in the more chronic forms of tuberculosis of any of the organs in children, the mesenteric glands may be found enlarged and caseous. There are instances, too, in which the aft'ection of the mesen- teric and retroperitoneal glands with those of the thorax constitutes the chief lesion. In both these groups the disease of the glands does not necessarily cause any sym])toms pointing to abdominal disorder. (3) In a third group there are signs of chronic intestinal catarrh or ulcer- ation and very marked disturbance in the general nutrition, 'riicse cases are seen chiefly in children between the ages’ of eighteen months and five years. The abdomen is distended, tympanitic, usually a little painful on deep pressure, hut no nodules are felt. The diarrhoea is the most troublesome symp- tom ; the stools are frecpient, brownish or yellow-brown in color, containing mucus, not often blood. The diarrhoea is variable, and may sometimes })orsist for several weeks. There is usually slight fever, hut the general wasting and debility are the most characteristic features, fl'he name tahex mexenterioa is often applied to this condition. The course is chronic and may extend over a TUBERCULOSIS. 287 year or two, leading to the most extreme emaciation. It is sometimes very difficult to determine whether actual tuberculous disease of the bowel is present or not, as a chronic intestinal catarrh may lead to just such a condition of extreme debility and wasting. In the diagnosis of these cases much stress can be laid upon the presence or absence of tubercles in other parts. (4) And, lastly, there are cases in which with ulceration of the intestines the mesenteric glands are greatly enlarged, and in addition the peritoneum is involved. Here the diarrhoea, the slight fever, the malnutrition, and progres- sive wasting are as in the previous group; additional symptoms are associated with disease of the peritoneum, in which nodular masses may be felt, and there may be considerable ascites. These cases will be referred to more particularly under Peritoneal Tuberculosis. (2) Tuberculosis of the Intestines and of the Abdominal Organs. (rt) Tuberculosis of the bowels. — The small intestine is most frequently involved ; thus, of 141 children presenting tuberculous ulcerations in the gastro-intestinal canal (Barthez and Sann^), in 134 the small intestine was involved; in 60, the large intestine; in 71, the small intestine alone. It is remarkable, considering the comparative rarity in the adult of tuberculous dis- ease of the stomach, that in this series it should have been met with in 21 cases. That tuberculosis may originate in the alimentary canal is shown experimentally by the feeding of guinea-pigs with cultures of the bacillus and the feeding of calves and pigs with the milk of tuberculous animals. There are now many series of cases demonstrating the facility with which animals may be infected through this latter source. That the intestinal lesion may be primary in children is acknowledged. The comparatively large number of children with caseous foci in the mesenteric glands is very suggestive. On the other hand, instances of primary intestinal tuberculosis are not very common. In a great majority of the cases the tuberculous lesions are part of a general infection, and are undoubtedly secondary. The ulcers are situated chiefly in the ileum, involving the solitary and agminated follicles of Peyer. The tubercles may be seen as small granulations in the submucosa ; sometimes the whole ileum may present a remarkable appearance from the grayish-yellow nodular tubercles, the size of split peas, occupying the submucosa and the mucous membranes. The caseation and necrosis lead to ulceration, which may be very extensive, involving at first Peyer’s patches, but ultimately extending beyond their limits. The tuberculous ulcer has the following characters : It is “ transverse to the long axis, rarely ovoid, often irregular in outline ; the edges and base are infiltrated, often caseous ; the submucosa and muscularis are also involved in the tuberculous process ; and, lastly, colonies of young tubercles or well-marked lymphangitis may be seen on the serosa.” Primary tuberculosis of the bowel is, as stated, rare; but in children with extensive ulceration in the ileum and very slight lesions of other parts the dis- ease may be regarded as primary ; thus in a child aged nine who was admitted to my wards with dropsy and emaciation after an illness of six months’ duration, there were only a few small foci in the lungs, while the intestines showed most extensive disease. About 50 cm. below the duodenum there was a large circling ulcer, the edges of which were undermined, the bases irregular and worm-eaten, and containing necrotic, grayish material. The peritoneum over it was thick and opaque. Throughout the whole of the ileum there was a series of these girdling ulcers at varying intervals. The caecum presented a very 288 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN large, deep ulcer, while the mesenteric attachment about the ileum formed a large tumor-mass from the extent of the involvement of the glands. The peritoneum presented scattered tubercles and the mesenteric glands were enor- mously enlarged. In a few instances tuberculous disease of the bowels extends from a chronic tuberculous peritonitis in which the coils of the intestine become matted toge- ther, caseous and suppurating foci develop between the folds, and perforation may occur in several places. Symptoms. — The symptoms of intestinal tuberculosis are very varied. The most common indication is a persistent diarrhoea. It is not always, however, proportionate to the extent of the ulceration, and large ulcers in the ileum may exist with constipation. When the ulceration is extensive in the large intestine the diarrhoea is usually profuse and obstinate. The mode of onset is variable. In a few instances of general tuberculosis there is diarrhoea from the start. In a large number of cases the existence of intestinal complication is not suspected until the signs of disease in other organs are well marked ; and in perhaps a majority of the secondary cases the diarrhoea is rather an event of the latter part of the illness. Of other symptoms, haemorrhage may occur, or peritonitis from extension — a condition not very uncommon, and often associated with disease of the mesenteric glands. The abdomen in these cases is usually enlarged and painful, and the nodular masses may be felt. In a few instances there are gastric symptoms, which do not necessarily indicate ulceration in the stomach, but there may be loss of appetite and occasional vomiting, and there are instances on record of profuse hmmatemesis or melmna from ei’osion of an artery. The outlook is unfavorable, and death may be caused by the severity of the intestinal symptoms, or more rarely by the accidents, such as perforation or hemorrhage. Recognition is rarely difficult, except in the primary cases, which are regarded at first as simple entero-colitis. Usually, however, when well es- tablished, the diagnosis is easy, particularly when other organs become in- volved. In suspected cases the stools should be carefully examined for tubercle bacilli. {b) Tuberculosis of Liver. — In all cases of acute miliary tuberculosis granulations are found in this organ ; sometimes they are extremely minute and are only detected microscopically. The liver is usually somewhat enlarged, pale, and fatty. In more chronic cases, particularly the diffuse generalized tuberculosis of young children, the tubercles may attain considerable size and develop about the finer bile-ducts. They undergo rapid softening, and give a very remarkable appearance to the liver, which is in extreme cases almost honeycombed with tuberculous abscesses, varying in size from a pea to a marble ; the ])us is usually bile-stained. Occasionally large, coarse, caseous masses are found forming iri'cgular tumors, most frequently in association with perihepatitis or tuberculous ])ori- tonitis. The so-called tuberculous cirrhosis of tlie liver does not, I believe, occur in children, though there may be in chronic cases of tuberculosis a marked increase in the connective tissue of the organ. (c) Tuberculous Peritonitis. — Tuberculosis is one of the most common causes of peritonitis in children. It is more common about tlie eighth and tenth years, and attacks boys more frequently than girls ; thus of 8G cases analyzed by Rarthez and Sannd, there were from TUBERCULOSIS. 289 1 to 21 ■^2 yrs 11 cases. 3 to (4 26 a 6 to 101 u 40 u 11 to 15 u 9 (( The ratio of frequency in children may be gathered from the large statis- tics of Aldibert, who found in 326 cases of tuberculous peritonitis, 52 in chil- dren. As in the adult, the disease may be primary, but in a majority of the cases it is secondary to tuberculosis of the intestines, mesenteric glands, or of the genitalia. Morbid Anatomy. — Tubercles in the peritoneum are not infrequently met with in the bodies of children dead of tuberculosis. Ashby noted them 38 times in 105 post-mortems on tuberculous children. They occur either as (1) the gray granulations with or without e.xudation, serous or sero-fibrinous. Sometimes the entire peritoneum is found studded with (2) firm, hard, fibrin- ous tubercles surrounded by a pigmented and firm connective tissue. In both of these varieties the process may be latent, and the condition is met with acci- dentally post-mortem. More frequently (3) when symptoms have been present, the tubercles are in the form of caseous nodules, yellow-gray in color, often forming flattened tuberculous plaques. The exudate is purulent or sero- purulent, the coils of intestines are much matted together, and between them there may be large caseous masses. It may be impossible to separate the coils, and in advanced cases extensive ulceration occurs, with multiple perfora- tion of the intestine. There are three anatomical points of special interest in these cases : First, the effusion may be sacculated and form a definite tumor ; sometimes the process is confined to the cavity of the lesser peritoneum ; in other cases it is in the pelvis, less frequently in the middle portion. The cysts may be multi- or mono-locular. Second, there are cases in which occlusion of the intestine has resulted, sometimes from compression of the coils by the large caseous masses ; more frequently by the bands of connective tissue in the healing of the process. Aldibert has found five instances of this sort in children. Lastly — and much more frequently in children than in adults — there is peri- umbilical suppuration. The intensity of the inflammation is in the central portion of the abdominal cavity, adhesions take place, and a definite cyst is formed, usually purulent, which projects at the umbilicus, and often opens spontaneously, leaving a fistula, sometimes stercoral, which persists for months but may ultimately heal. Symptoms. — The symptoms of tuberculous peritonitis are extremely varied, and it is very difficult to give a clear and definite picture of the disease. For convenience three clinical types may be considered ; (1) The Ascitic Form . — The symptoms may come on acutely with a diffuse eruption of miliary tubercles. So abrupt is the onset that cases have been mistaken for acute enteritis, or even for acute obstruction or hernia. More frequently the onset is subacute, and ascites gradually develops. Fever of some degree, indigestion, and diarrhoea are present, and there may be abdominal pain ; but in many instances the process is latent, and the enlarging abdomen is the symptom for which the physician is consulted. The effusion, indeed, may proceed to considerable degree without fever, and with no symptoms other than those of gradually-failing health and progressive emaciation. Intestinal dis- order occurs in some instances, diarrhoea, colicky pains, or often attacks of diarrhoea alternating with constipation. The local symptoms are by no means characteristic. The abdomen is distended, the skin thin, the superficial veins 19 290 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. enlarged. Percussion gives dulness in the flanks, which is movable, resonance in the umbilical region, and there is a well-marked fluctuation wave. Palpa- tion may be entirely negative ; no nodular masses are felt. The liver and spleen are not often enlarged. It may be extremely difficult, or (^uite impossible, unless there are tuberculous lesions in other regions, to speak definitely of the nature of the gradually-developing ascites. The clinical picture is very similar, indeed, to that of the cases of ascites from cirrhosis, and an identical condition is met with in the rare cases of simple chronic peritonitis in children. The ascites may demand tapping, but the fluid reaccumulates rapidly. The exudate may be encysted, forming a prominent tumor in the epigastric or umbilical regions (in which case the effusion is probably within the lesser peri- toneum), or it may be situated in the pelvis or in the flank, and simulate very closely cystic ovarian disease. This form is not very uncommon in children, and very good results have followed operation ; of nine instances in the litera- ture, all recovered. This ascitic form, developing slowly, and ultimately presenting the picture of a chronic ascites or an encapsulated exudate, is by far the most favorable variety, and cases may recover spontaneously or after operation. (2) The ulcerative form is much more serious. The peritoneum here con- tains larger caseous masses which break down, and there is a diffuse purulent peritonitis. The coils of intestines are matted together, nodular tuberculous masses develop on the parietal and visceral layers, the glands are greatly en- larged, and in protracted cases extensive ulcerations occur. The onset in this form is usually gradual, but the abdominal symptoms are pronounced. The child complains of colicky pains, diarrhoea, and chronic indigestion. The abdomen is enlarged and painful. The condition on examination may be entirely different from that of the ascitic form. The outline is often symmetrical, not flattened in the flanks ; nodular projections may sometimes be seen beneath the skin. Unless there is a very extensive purulent effusion there is no movable dulness. There is a flat tympany or there are alternating areas of resonance and dulness. On palpation there is a boggy, doughy feel, and nodular masses may be felt in different regions. The liver and spleen may both be enlarged. In this suppurative form the effusion may he general, or it may be encysted either in the upper abdominal region or in the pelvis. One form of this encysted suppurative variety requires special consideration — namely : Periumbilical TnbercAilous Abscess. — This is seen most frequently in chil- dren, and is in reality a localized suppurative peritonitis, which points at the navel and frequently opens and discharges. The condition is almost constantly tuberculous in the child. There may be a fistula discharging pus for weeks or months, and recovery may ultimately take place. In other instances the fistula communicates with the howel. In the case of a colored child, aged five, operated uj)on hy my colleague. Dr. Ilalsted, there was distention of the abdo- men, markeil protrusion of the umbilicus, and here a spontaneous opening dis- charging yellowish material for months, fl'hen the opening healed and the condition of the child improved. At the time of the operation there was a large, prominent, cone-shaped, umbilical tumor. The child died some time after the operation ; creamy pus was found between the intestinal coils, and there were many tuberculous ulcers in the intestines. There was an extensive caseous salpingitis. There are instances also of perihepatic tuherculous abscesses. (3) Chronic Adhesive or Dr if 7b(berculous Peritonitis. — In a. very consider- able number of all cases of tuberculous peritonitis there is little or no serous or purulent exudate, but the tubercles are surrounded with a fibrinous lymph TUBERCULOSIS. 291 and they tend rapidly to cicatrize. The growing tubercles may not have caused any symptoms, and the condition is found accidentally post-mortem, and in adults has often been met with in exploratory laparotomies for various condi- tions. In long-standing cases the tubercles are hard, firm, often surrounded by deeply pigmented fibroid adhesions. In some of these instances the tuber- culosis of the peritoneum is localized; thus it has been found in a hernial sac alone, or in the region of the caecum and appendix, or on the epiploon. There are instances in which this membrane has been gradually curled and rolled until it forms a ridge-like tumor lying across the upper portion of the abdomen. This chronic adhesive form is not so frequent in children as in adults. The symptoms are very indefinite. The abdomen is usually distended and tym- panitic, everywhere resonant, sometimes distinctly painful on pressure. In protracted cases the omentum may be felt as a firm ridge in the upper portion of the abdomen. The general symptoms are very variable. There may be wasting and cachexia, sometimes with marked fever, though these chronic adhesive forms are not infrequently afebrile throughout, or the temperature, indeed, may be subnormal. With the exception of the colicky pains there may be no symptoms directly from the peritoneum, but the cases are very often complicated with tubercles in other parts, and the mesenteric glands or the lungs may be extensively diseased. These are cases in which spontaneous recovery is not infrequent. Diagnosis. — A gradually developing ascites in a young child with moderate fever is in itself very suggestive of peritoneal tuberculosis. Doubtless very many of the cases of simple ascites with recovery belong to this disease. The condition is to be distinguished from ascites due to disease of the liver and from chronic simple peritonitis. Cirrhosis of the liver, syphilitic or sim- ple, is a rare disease in children. The local symptoms may give us no clue, but after withdrawal of the fluid the liver in a cirrhotic case may be felt to be unusually hard, and perhaps small, and possibly, when due to syphilis, irregu- lar. The general symptoms are more important. In cirrhosis there is more frequently a slight jaundice. The fever and gastro-intestinal symptoms are not so marked. An encysted exudate is always in favor of tuberculosis. A simple chronic peritonitis, though rare, occurs in children, and, even after the exploratory laparotomy, the diagnosis may not be clear, inasmuch as there may be small nodular fibroid bodies scattered over the membranes. It is very important in these cases to have a careful microscopical examination made, in order to determine the presence of bacilli, or, if the nodules are very firm and fibroid, the experimental test should be made. It is quite possible that some instances of reported recovery in peritoneal tuberculosis after laparotomy may have been instances of this chronic simple peritonitis with fibroid nodules. The ulcerative form with suppuration and the development of nodular masses in the peritoneum with fever and a marked cachexia, rarely offers the slightest difficulty in diagnosis. It is to be remembered, of course, that the suppurative forms also may be encysted, and the periumbilical abscess with umbilical fistula, simple or stercoral, is almost constantly tuberculous. Prognosis. — The pi’ognosis is often good, particularly in the ascitic and chronic adhesive varieties. Many instances, no doubt, in which the ascites has gradually disappeared have been tuberculous, and even in the ulcerative variety, when the abscess has discharged at the navel, recovery has followed. The operation of incision and drainage has certainly favored recovery in a con- siderable number of cases. Treatment. — The general treatment of tuberculosis will be discussed at the end of the section; here reference will be made more particularly to incis- 292 AMERICAN TEXT-BOOK OE DISEASES OE CHILDREN. ion and drainage in tuberculous peritonitis. The results which have been obtained are exceedingly satisfactory, even if we suppose, as is probable, that many cases relapse and are not fully healed at the time of reporting. The figures given in the monograph of Aldibert are extremely interesting: in the ascitic form, of 32 instances in which laparotomy was performed, there were 3 deaths and 29 recoveries, 4 of which had persisted for more than one year. This demonstrates the impunity with which the abdominal cavity may be opened, and the large percentage, at any rate, of those which are benefited immediately by the operation. In the chronic adhesive form an operation is really not indicated, as in the majority of the instances the tuberculosis is in pro- cess of healing, but there are cases in which pain, associated with the adhesions, has been relieved by an exploratory incision. In the ulcerative variety, when generalized, the results have not been so satisfactory, but many instances with an encysted purulent fluid have been opened and drained successfully. The drainage favors the process of cicatrization in the tubercle, lessens the tendency to effusion, and exerts a fiivorable influence on the whole process. Of the 52 cases in chikh’en in which laparotomy was performed, there were 45 recoveries and 7 deaths. Of these 45, 9 had persisted for moi’e than a year, and 2 for more than two years (Aldibert). (3) Tuberculosis of the Lungs. In speaking of acute miliary tuberculosis and of chronic diffuse tuberculosis we have considered affections in which the lungs are almost constantly involved — in the one case the seat of miliary granules ; in the other of larger, coarse, grayish-yellow tubercles. We shall speak in this section more ])articularly of those forms in which the lungs are so involved, that the clinical features are those of an acute or of a chronic pulmonary disease. Two grou{)S of cases may be recognized : the acute tuberculous broncho-pneumonia, and the chronic ulcerative form, the first corresponding to the acute galloping phthisis, and the other to the chronic phthisis, or, as we call it now, chronic pulmonary tuberculosis. ( a ) Acute Tuberculous Broncho-pneumonia. — In infants 'and children we very rarely see pulmonary tuberculosis set in with the clinical picture of an acute lobar pneumonia. Personally, I never rememl)er to have met with an instance, such as is not very rare in adults, in which the tuberculosis came on abruptly, and at first ran the course of an ordinary lobar pneumonia, with pain in the side, high fever, and rapid consolidation of an entire lobe. Such cases are, however, on record, and it is only the absence of the crisis, the persistence of the local signs, the gradual softening, and the development of hectic and progressive debility which lead to a revision of the diagnosis. It is to be remembered that while clinically the physical signs may be those of a lobar affection, anatomically it is clearly seen that many groups of lobules are involved, separated by strands of air-containing or collapsed lung-tissue. These pseudo-lohar cases are almost impossible to differentiate during life. Tuberculous broncho-pneumonia is common in children from the sixth month to the fifth year. A large proportion of the cases occur after the sec- ond year. The disease is most common in children in institutions, in those debilitat'd by })revious illnesses, and more particularly in convalescents from one of the infectious diseases — measles, whooping-cough, scarlet fever, or diphtheria. It is most freejuent perhaps after measles aTid whooping-cough. Its se(|uenco in the latter disease has been common knowledge in the profession since the days TUBERCULOSIS. . 293 of Willis, whose axiom, “ Tussis convulsiva vestibulum tabis,” has been quoted through two centuries. Children the subject of chronic naso-pharyngeal catarrh and tonsillitis, and mouth-breathers seem more prone to the affection. But it is to be remembered that it may develop in perfectly healthy, well- nourished children. And lastly, like miliary tuberculosis, it may be a terminal process in cases in which local tuberculous disease exists in other parts — the skin, bones, lymph- glands, or the urogenital tract. Morbid Anatomy. — The condition varies considerably with the inten- sity and duration of the process. The lungs may be voluminous and crepitant, with firm and nodular masses scattered throughout the lobes. On section these are seen to be peribronchial nodules ranging in size from a pea to a walnut. Some of the more recent are reddish in color ; the older are grayish-yellow, with, perhaps, central softening. Many of these peribronchial nodules are seen to be composed of aggregations of tubercles undergoing caseation. In the very acute cases the process is more extensive in the upper lobes or central portion of the lungs, certain parts of which may be almost solid and scarcely contain any air. The consolidation may indeed look uniform, but on section it is noted that the process is not actually diffuse, as in a lobar pneumonia, but the general consolidation has arisen from the involvement of a very large num- ber of the lobules, groups of which are separated by strands of reddish col- lapsed tissue. The consolidated areas have undergone caseation, and may in places have softened, forming cavities. The older the process the more exten- sive usually are the areas of caseation. Though primarily tuberculous, many of these cases show a mixed infection, and there may be areas of simple broncho-pneumonia due to streptococci, staphylococci, or pneumococci. The pleura may show many nodules or a fresh, fibrinous exudate, sometimes a sero- fibrinous or even purulent exudate. The bronchial and tracheal glands are enlarged, tumefied, and studded with tubercles or unifonnly caseous, not infre- quently having softened to form definite abscess. The glands at the hilus may be greatly enlarged and extend deeply between the lobes, and in some in- stances there would appear even to be an invasion of the lung-tissue from these deeply-placed large caseous glands. The other organs may present a few scattered tubercles or there may be a generalized miliary tuberculosis. As in other forms of broncho-pneumonia, the essential lesion is a bron- chitis and peribronchitis excited by the tubercle bacilli, with inflammation of the contiguous air-cells, which become filled with epithelial products, the so-called catarrhal alveolitis. The accompanying phenomena of atelectasis and emphysema occur just as in simple broncho-pneumonia, and the distinguishing features are the caseation and necrosis with the presence of the bacilli. Much discussion has taken place upon the relation of broncho-pneumonia to tuberculosis, and some French observers have maintained that in many instances the form following measles and diphtheria, and which anatomically looks simple in character, is in reality tuberculous and due to the bacilli. It may be difficult sometimes to determine whether a given patch of broncho- pneumonia is tuberculous or not, but as a rule, macroscopically, there will be seen small tubercles or areas of caseation, while in stained sections the bacilli are readily demonstrable. The simple broncho-pneumonia in some cases pre- cedes the tuberculous, particularly after measles, scarlet fever, diphtheria, and whooping-cough. In institutions it is by no means uncommon to meet with cases in which broncho-pneumonia has gradually subsided, and then symptoms have developed pointing to fresh invasion, and ultimately death follows Avith the lesions of an acute, recent, tuberculous broncho-pneumonia. Sometimes the 294 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. infection is less intense, and a subacute or chronic pulmonary tuberculosis is established. In cases of tuberculosis consecutive to broncho-pneumonia we find the lesions of two sorts : simple, inflammatory, non-tuberculous, such as peribronchial suppuration, dilatation of the bronchi, lesions of the alveolar epi- thelium, and peribronchial and peri-alveolar sclerosis ; then, in addition, there are the true tuberculous processes, peribronchial nodules, tuberculous infiltra- tion, and caseous areas (Mosny). In other instances the tubei’culosis precedes the broncho -pneumonia. This is met with particularly in children the subject of latent tuberculosis, in whom, following one of the infectious diseases, a simple broncho-pneumonia develops. According to Mosny, the lesions may be seen as an alveolitis surrounding the tuberculous peribronchial nodules, or foci of simple and tuber- culous broncho-pneumonia occur scattered throughout the apices of the lung. It is a broncho-pneumonia dependent upon pneumococci or streptococci invading a lung already the seat of local tuberculosis. Symptoms. — Clinically, tuberculous broncho-pneumonia scarcely differs in any feature from the simple form. The onset may be acute in a previously healthy child, but more frequently the disease sets in during convalescence from one of the infectious diseases. In the tuberculous form the fever is sometimes not so high and not so persistent, showing more variations throughout the day. Cough and dyspnoea are prominent symptoms. The physical signs are those of broncho- pneumonia. The localization of the lesion is more commonly at the apices of the lung, where there may be signs of consolidation with fine crepitant and sub- crepitant rales. There are no physical signs of any moment in difterentiating a simple from a tuberculous broncho-pneumonia, and indeed even the local- ization of the disease at the apex, upon which so much stress is laid, is not of very much value, since we frequently find in young children a tuberculous process beginning at the base or in the central portions of the lung. In the course of the disease, however, indications of great value develop ; thus toward the end of the second w'eek there are more marked oscillations in temperature, often with profuse sw'eats. The child emaciates rapidly, and there may some- times develop signs indicating softening. In the acute cases the duration is from three to five weeks. Throughout the course of the disease there may be no single indication of much value in definitely determining the nature, and we often have to depend more on the general features of the case. Careful imjui- ries should be made as to heredity ; also the personal history immediately preceding the onset. Sometimes inq)ortant information may be gathered by a systematic examination of the child. There may be a tuberculous adenitis, local bone disease, or a tuberculous testis. Simple broncho-pneumonia tends as a rule to recovery ; in excej)tional cases, however, it becomes subacute, aaul ultimately chronic. In the more subacute and chronic cases tuberculous broncho-pneumonia may present large areas - of caseation, which give the physical signs of consolidation, perhaps of an entire lobe. In such instances softening and the signs of cavity not infrecpiently develop, and give very definite indications of the nature of the process. As the little patients rarely expectorate, examination for bacilli can seldom be made. Sometimes, if vomiting occurs, portions of mucus may be picked out, and important evi- dence in this way obtained. (/>) Chronic Pui.monary Turerculosis. — In infants and very young children we find the lungs either involved in a generalized tuberculosis or the seat of an acute tuberculous broncho-j)neumonia. After the sixth or eighth TUBER CUE 0SI8. 295 year cases are not very uncommon in which the picture resembles that of chronic tuberculosis pulmonum of the adult. Morbid Anatomy. — The lesions are similar to those met with in the tuber- culosis of adults — miliary tubercles, peribronchial nodules, caseous blocks, areas of softening and of fibroid induration, and cavities of various sizes. We do not see so frequently the invasion of the lung from the apex downward. The chief seat of disease may be in the central portion of the lung, or even at the base. As already mentioned in speaking of tuberculosis of the lymph- glands, the groups along the trachea and about the bronchi may be greatly enlarged and caseous, forming on section a very striking feature in the chronic pulmonary tuberculosis of children. Indeed, in some instances the process seems to spread directly from the deeply-placed glands in the hilus of the lung, which may be enormously enlarged, uniformly caseous, and the organ may be directly invaded from them. Large areas of caseous pneumonia are not uncom- mon, and often present foci of softening. Small cavities are by no means infre- quent in chronic pulmonary tuberculosis of children, but very large excavations are rare ; thus in the 205 cases noted by Barthez and Sann^ there were 77 cases with excavation, chiefly, too, in the upper lobes. In the analysis by Leroux of the cases of the late Professor Parrot, in 219 children under two years of age there were 57 instances in which cavities existed. In 5 of these the children were under three months. In long-standing cases hard, firm, fibrous tubercles are found, and sometimes cretaceous nodules. The primary lesion in a great majority of instances is a tuberculous broncho-pneumonia, taking its origin in the smaller bronchioles, leading to peribronchial nodules and subsequent peribronchial alveolitis. S 3 rmptoms. — The general symptomatology of chronic pulmonary tuber- culosis in the child is similar in essential details to that of the adult, but pre- sents, however, as might be expected, certain peculiarities. The onset is gener- ally more abrupt, and the first symptoms may be those of a broncho-pneumonia at the apex. The child may have been in failing health or come of a markedly tuberculous stock, or there may have been local glandular or bone disease. Occasionally failing health, with repeated attacks of chills and fever, may arouse the suspicion of malaria, but this mode of onset is not so frequent as in adults. Some cases follow a protracted naso-pharyngeal catarrh with recurring bron- chitis. Progressive failure in health and strength, cough and fever, are the first symptoms to attract attention. There is loss of a]>petite, but rarely the extreme anorexia which we find in some cases of pulmonary tuberculosis in older subjects. Cough is rarely absent among the initial symptoms, and, Avith variations, persists. It is short and dry at first, subseciuently looser. It may be distributed equally throughout the day or is most troublesome at night, and paroxysms of coughing may return at fixed hours, so that the case may be mis- taken at first for whooping-cough ; but there is never the noisy crowing inspira- tion. Expectoration is absent in very young children. Children above the age of ten can often be taught to expectorate. The sputum is mucoid at first, with grayish-yellow streaks ; sometimes it is more sero-mucoid, and in the later stages more definitely purulent. Haemoptysis may be said to be infrequent in children under ten. Certainly it is very rare at the onset. It is usually small in amount. The terminal haemoptysis, common in the adult, but rare in chil- dren, results from the rupture of an aneurism in a small cavity or erosion of a branch of the pulmonary artery. The fever of onset and during the early periods is remittent, the daily excursions slight — a range between 102° and 104° is common. Subsequently, Avhen the disease is Tiiore extensive and soft- ening has taken place with the formation of cavities, the temperature is more 296 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. hectic in character, and the morning observation may be normal or subnormal, while in the evening the thermometer may register 103.5° or 104°, or even higher. Chills are not very common. Drenching sweats are frequent, par- ticularly toward the close. Dyspnoea may be present at the onset and during the early stages, and may be due in part to the fever, sometimes to the presence of a diffuse bronchitis. Marked inci’ease in the respirations, wdtli cyanosis, indicates very rapid progress in the disease. In protracted cases, just as in the adult, there may be very extensive destruction of the lung without the slightest dyspnoea. The child may complain of pains in the chest, usually associated with pleurisy. In a majority of instances the disease is painless throughout its course. Qvisling states that an early sign is tenderness on percussion of the affected side, or on pressure in the intercostal spaces, particularly in the first space at the apex. Progressive Aveakness and wasting are very pronounced symptoms, and there is usually progressive pallor. Frequently the abdominal viscera become involved, and there is diarrhoea due to tuberculous ulceration, and the liver and spleen may become enlarged. The urine does not often shoAV changes, but as the disease progresses albumin is common and a secondary nephritis may develop. A child may come under observation Avith general anasarca, due partly to the anmmia, partly to the renal condition, and the pulmonary tubercu- losis may be entirely overlooked. Physical Signs . — Inspection frequently shows in advanced cases an extremely thin chest, Avith marked intercostal spaces. Deformities due to mouth-breathing or to rickets are not uncommon. On the affected side the respiratory movement may be decidedly less marked, or the clavicle may stand out prominently ; or there may be subclavicular depression at the affected apex — a sign usually of a chronic process. In very long-standing cases Avith much fibroid change there may be flattening of the affected side, Avith depression of the shoulder. By palpation one appreciates any differences in expansion on the tAvo sides, and the differences in the tactile fremitus, and it may be of value in eliciting painful points. Percussion . — In the early condition, Avhen the tubercles are scattered or the areas of broncho-pneumonia are limited, there may be no change in the per- cussion note. Indeed, the emphysema about the affected areas may cause slight hyper-resonance over tlie part affected. Extensive involvement at one apex usually gives loss of resonance l)eneath the clavicle, Avhich may amount to dul- ness and is accoiiq)anied Avith marked increase in the resistance. Absolute flatness is rarely met Avith. Skoda’s resonance, the fiat tympany, is not fre- quent. The crackeil-pot sound has very little value in chihlren, as it may sometimes be elicited in a thin-Avalled healthy subject. Auscultation may give only the signs of bronchial catarrh, pi])ing rfiles and moist sounds, but Avhen there is definite diilness there is usually cluinge in the character of the respiratory sounds, Avhich have lost their vesicular cha- racter and are harsh, broncho-vesicular, or delinitely bronchial. Somclimes Avith defective resonance there is enfeeblement of the respiratory murmur, Avith prolongation of expiration. The auscultatory ])henomena are often very deceptive. Diffuse bronchitis may lead us to suppose that there is much greater involvement of the lung than in reality exists. In very young infants signs of cavity are rarely present, but in older children in advanced cases, Avith hectic and emaciation, tlic metallic sjilashing or anqihoric (juality of the rilles, Avith the loud cavernous breath-sounds, leaves no doubt as to the existence of a vomica. In children, moi’c frtniuently than in adults, Ave are deceived by the TUBERCULOSIS. 297 so-called pseudo-cavernous signs. Over an area of slightly defective resonance or of positive dulness inspiration and expiration are cavernous, the rales large and resonant, and the wliispered voice may be conveyed intensely to the ear. In acute cases with high fever one is not so apt to be deceived ; these signs are also met with in broncho-pneumonia and in pleurisies. Course. — The coui-se of chronic pulmonary tuberculosis is more rapid in children than in adults, and a majority of cases die in from six to twelve months. The disease is marked, now by intervals of improvement, in which the fever lessens and the severity of the symptoms subsides, now by aggravation of the local and constitutional condition, sometimes wdtli attacks in which the fever and dyspnoea increase, and the child may become quite cyanotic. Some of these intercurrent attacks simulate closely acute tuberculosis, but often pass away at the end of a week or ten days. In the chronic cases they probably indicate the invasion of other portions of the lung. Occasionally, in a case of chronic pulmonary tuberculosis extensive fibroid substitution takes place, with gradual retraction of the affected side, depression of the shoulder, and all the signs of so-called fibroid phthisis. Usually in such instances there is dulness at the base and side with modified resonance, and cavei’nous signs at the apex. When involving the left lung, the heart is drawn over, and there may be a very extensive cardiac pulsation from the second to the fifth interspaces. A child may gradually regain a fair measure of health and for years live a tolerably comfortable life, troubled only by one or two spells of coughing through the day. There may be dyspnoea on exertion, and gradually the terminal phalanges become clubbed. Haemoptysis is rare, but occasionally terminates the case. Diagnosis. — Progressive emaciation with hectic and cough in a child should always ai'ouse the suspicion of chronic pulmonary tuberculosis. In the early stages the condition is usually that of tuberculous broncho-pneumonia. Care- ful and repeated physical examination may be necessary to establish the diag- nosis, and one should take into consideration carefully the condition of the other organs. The position of the physical signs at the apex or central portions of the lung, the increased fremitus, the moist sounds, are all suggestive, and frequently one may trace the progressive character of the lesion. The disease most frequently confounded is empyema, but here the movable dulness, the bulging of the intercostal spaces, and the absence of fremitus are valuable points. Auscultation is an extremely fallacious guide, and in several instances the persistence of a loud, almost cavernous, respiratory murmur at the base has led the practitioner astray. When in doubt the exploratory needle should be freely used for the purpose of diagnosis. The differentiation of chronic simple broncho- pneumonia sometimes gives a great deal of trouble, and the time element alone may determine whether we have to do with a tuberculous process or not. These are the very instances in which any fragments of sputum should be carefully sought for and examined. In a paroxysm of coughing the child may bring up a mouthful of food, and with it the expectoration, which should be carefully picked out and examined for tubercle bacilli. Prognosis. — The prognosis in a large majority of the cases is bad, particu- larly when hectic is established and there is disorganization of one lung. On the other hand, when cases are seen early and placed under suitable conditions recovery may take place. The large number of individuals whose lungs and bronchial glands present traces of old tuberculous processes shows how con- siderable a proportion of all those who are infected must survive. We do not see many cases of chronic pulmonary tuberculosis in children between the ages 298 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. of six and fifteen, for the reason, no doubt, that the tuberculous broncho- pneumonia is so often an acute process, carrying off the victim before it has assumed the characters of a chronic affection. (4) Tuberculosis of the Pleura. This is usually secondary to existing disease in the lung or in the bronchial glands. A certain number of acute serofibrinous pleurisies in children may be, as in the adult, due to tuberculosis ; but the cases, as a rule, run a favor- able course, and unless the child has definite manifestations of tuberculosis in other parts the assumption in any given case is of course purely gratuitous. Purulent pleurisies in children are most commonly associated with lobar or broncho-pneumonia, but in a certain proportion of the cases the process is tuber- culous. The disease is usually latent, and failing health, pallor, and shortness of breath are the symptoms for which relief is sought. The general symptom- atology and diagnosis of tuberculous pleurisy are practically those of the simple forms which are elsewhere considered. (5) Tuberculous Pericarditis. This is by no means rare in children, and cases have been reported in infants under a year. In 65 cases collected from the literature by Brackmau, 19 were in children. The disease is associated in almost all instances with tuberculosis of the mediastinal or bronchial glands. An enlarged and softened gland may perforate the pericardium and produce an acute sero-fibrinous or suppurative inflammation ; and no doubt a considerable number of all the cases of so-called idiopathic suppurative pericarditis have been due to this cause. The tuberculous process may slowly invade the pericardium from the medias- tinal glands, and produce a chronic adhesive pericarditis, leading to great thickening of the membranes and gradual hypertrophy of the heart. The patient may die with all the symptoms of cardiac dropsy. (6) Uro-genital Tuberculosis. ( a ) Tuberculosis of the Kidneys. — As part of a general diffuse tuber- culosis these organs are very fretpiently affected — more commonly, indeed, than in adults. Usually there are scattered gray tubercles or coarse yellow nodules in the cortical substance. Sometimes, however, the lesion is jirimary, and one or other kidney is extensively diseased. The affection in these cases appears to begin in the papillm and calices, gradually invades the substance, and may ultimately destroy the entire organ, converting it into a series of excavations containing a cheesy material. When confined to one kidney, this (known as the scrofulous kidney) is sometimes met with in children, the other kidney being healthy and greatly enlarged. When there is extensive tuberculous ])yelo- nephritis there is often pain over the kidney; the urine contains j)us, very rarely blood. Irregular fever and chills are common. Frc(juent micturition may lead to the diagnosis of cystitis, with which, of course, it is fiauiuently associated; but it is to be borne in mind that in connection with either calcu- lous or tuberculous pyelitis frc([uent micturition may be a marked sym{)tom. Sometimes the tuberculous organ is large enough in a child to be ])alj)able. Tuberculosis rarely produces so extensive pyonejdirosis as tlmt due to stone. The diagnosis can rarely be made from calculous pyelo-nepliritis excc{)t by the detection of bacilli in the urine! TUBERCULOSIS. 299 Tuberculosis of the ureters ami bladder, very rare as a primary affection, is nearly always secondary to disease of the pelvis of the kidney, sometimes to disease of the prostate. {h) Tuberculosis of the Testis. — Disseminated miliary tubercles may be present in the testicles, but primary tuberculosis of these organs is not at all rare in children. Dreschfeld has reported an instance of congenital tubercu- losis of the testis. Many cases have been reported of late years. Of 20 cases by Jullien, 6 were under one year, and 6 between one and two years. Both organs may be affected. The disease most commonly develops in the tunica albuginea or in the epididymis, and may lead to the formation of hard circum- scribed tumors. In other instances the process may be more diffuse. When the nodular masses are large the testis may have a dumb-bell or double outline from enlargement of the epididymis. It is a serious affection in children, usually associated with tuberculous disease in other parts. Its existence should always be borne in mind, as in obscure abdominal or thoracic affections the presence of nodular masses in the testicles is of great help in diagnosis. The lesion may gradually heal. The cheesy masses may break down and suppurate, and, forming adhesions to the skin, the pus discharges, and the organ may become much enlarged — the condition formerly known as strumous orchitis. (c) Tuberculosis of the Fallopian Tubes, Ovaries, and Uterus. — These parts are rarely affected primarily in children. It is not very uncom- mon in generalized tuberculosis to find, even in infants, a double salpingitis. IV. Prophylaxis. While the possibility of inherited transmission from an infected mother cannot be denied, we have to face the fact that in a large proportion of all cases of tuberculosis the infection is at the gateways of the body — namely, in the bronchial and mesenteric lymph-glands — and we have here a clue to the two chief sources of danger. To ensure freedom from contamination through the air the greatest care should be taken to prevent tuberculous patients spitting about in a careless manner. Every part of the expectoration should be carefully collected and boiled, and the patient’s handkerchiefs should be thrown into boiling water. Tlie liability of children to infection from this source is very much greater than that of adults, possibly on account of the intimate relations which the child has to the members of the family, more particularly the mother should she happen to be diseased. The habit of young infants, as they creep about, of putting everything in their mouths enhances greatly the liability to con- tamination. The second danger to be avoided in children is the use of milk from tuber- culous animals. Experiments have shown the readiness with which young pigs and calves become infected when fed on the milk of tuberculous cows. We have, unfortunately, no reason to believe that children are less susceptible than calves. Fortunately, the health authorities have at last awakened to the importance of careful inspection of dairy herds. The safeguard lies in the use of boiled milk, unless the source is known to be free from all possibility of contamination. The infection through meat is probably a very slight danger in a community. Individual prophylaxis is of almost equal importance. A child born of delicate parents or in a family in which tuberculosis has prevailed should be reared with the greatest care. Very special pains should be taken to guard it against catarrhal affections of all sorts, particularly of the nose and throat, and 300 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. on the first indication of mouth-breathing a thorough examination of the naso- pharynx should be made and any adenoid vegetations removed ; and if the tonsils are at all enlarged, it is better to have them cut out. The child should live in the open air as much as possible, and the nursery should be thoroughly ventilated, more particulaidy at night. The meals should be at regular hours, the food plain and nutritious. Every encouragement should be given to take fats, and milk and cream should be used freely. It is a good practice for the mother to sponge the throat and neck of the child night and morning ■with cold water. The trifling ailments should be carefully watched. The convalescence from measles, scarlet fever, diphtheria, and whooping-cough should be specially guarded. As the child grows older a systematically regulated exercise or course of pulmonary gymnastics may be taken. V. Treatment, Fortunately, a very large proportion of all cases of tuberculosis recover. Many instances of adenitis and disease of the bones heal spontaneously. Even in pulmonary tuberculosis it is remarkable how often we find post mortem evidences of healed lesions, the percentage in some series being as high as 38. In fact, one may say that in a very large number of all cases in which the bacilli find a lodgment in the glands and in the solid organs, the conditions not being favorable, the growth remains local and tends to heal spontaneously. The essential point in the treatment of tuberculosis is the main- tenance of nutrition at the highest possible grade. To aid in this three meas- ures are to be practised : First : A life in the fresh air and sunshine. The importance of environ- ment is well shown in Trudeau’s experiments with inoculated rabbits. Those confined in a damp, dark place succumbed rapidly ; those allowed to run wild recovered or showed very slight lesions. By far the most important single element in the treatment of tuberculosis of all forms is the constant inhal- ation of fresh air. The good effects obtained at Gbbersdorf, Falkenstein, Saranac Lake, Uavos, and Colorado are due primarily to the fact that the j)atients live a life in the open air and sunshine. Even in cities much can be done by insist- ing upon open windows night and day, except, of course, in the very inclement seasons. It is an easy matter to protect the patient from draughts, and neither fever, cough, nor night-sweats contraindicate in any way fre.sh air. This is in reality the very essence of the climatic treatment of tuberculosis ; that other considerations, such as moisture, barometric j)ressure, temj)erature, etc., are secondary is well shown by the fact that cases of various types of tuberculosis recover completely at places so diametrically oj)positc as Colorado Sj)rings and Torquay, 'fhe regions of high altitudes with low barometric pressure are cer- tainly more stimulating, and, according to daccoiid, are better for eases of early j)ulnionary tuberculosis. Cases of l)one and gland tuberculosis do remarkably well at the Adirondacks and in Colorado, d’he level regions with low barometric pressure, such as Riviera, Florida, atid Southern California, are reputed to be more sedative in their action and better for tuberculosis in the more advanced grades and with high fever. The second imj)ortant measure is feeding, and the outlook in any case, par- ticularly of pulmonary tuberculosis, depends very much upon the stability of the digestive powers. In no way does the open-air treatment do more good than in im])roving the appetite and digestion. A highly nitrogenized diet, consist- ing of broths, eggs, milk, and meat, should be taken. In children the milk TUBERCULOSIS. 301 diet is particularly to be commended while fever persists. Raw meats scraped, various meat extracts, and peptones may be used when the digestion is feeble. In tuberculous children it is sometimes extremely difficult to manage the diet, and many patients have an aversion to the very articles of food which seem best adapted. Gavage can rarely be resorted to with any advantage in them. Third, the use of such remedies as cod-liver oil, hypophosphites, and arsenic, which improve the general nutrition. Other measures are frictions, rubbing, and bathing, all of which stimulate and improve the general metab- olism. Treatment directed to the Tuberculous Processes. — The specific treatment by the tuberculin of Koch, which consists of a glycerine extract of the cultures of tubercle bacilli, has been practically abandoned, though the good results obtained in the hands of Trudeau and othei’S with Hunter’s modification raise the hope that something yet may be accomplished by its use. Anti- bacillary medication is as yet unknown, and the introduction of various anti- septic agents by inhalation, subcutaneously, or directly into the local lesion has not been followed by very brilliant results. The direct action of iodoform on local tuberculosis is of great interest, and the remarkable effects in joint tuberculosis should encourage a more widespread use in other forms of the disease. Creasote is a remedy which is believed to have a beneficial action on the tuberculous processes. It probably has no definite antibacillary action, though it is stated to influence powerfully the secondary and associated infec- tions so common in tuberculosis. It seems rather to act as a general nutritive stimulant, improving the appetite, diminishing the fever, and promoting tissue- metabolism and, according to some, sclerotic processes. It is probably at present more widely used than any other single remedy. It has been a faVo- rite with some practitioners for many years, and its reintroduction has been due to the poweiTul advocacy of Sommerbrodt, Bouchard, and others. It should be given in large and increasing doses, beginning in young children with a minim three times a day, and increasing to five or even ten minims. It may be given in perles, or in pills or in mixture; in the latter a convenient way is with tincture of gentian, alcohol, and sherry. As a rule, it is well borne by the mouth. It may also be given in the form of inhalations, the so-called vapor creasoti consisting of creasote, 80 minims, light carbonate of magnesium, 30 grains, water to one ounce; a teaspoonful in a pint of water at 140°. Inha- lations with this are strongly recommended. Intrapulmonary or intratracheal injections of crea.sote in oil have been practised. The active principle of it, guaiacol, has been much used, both by the mouth and hypodermatically. Given in solution, it may be made up with tincture of gentian, rectified spirits, and sherry. Hypodermatically, it is used with sterilized olive oil, 5 per cent, solution ; 1 or 2 per cent, iodoform may be employed with it, and 1 cc. of the mixture injected, gradually increasing to 3 cc. or even 4 cc. One rarely sees bad effects from creasote : the beneficial results are most marked in indi- viduals who can take large quantities and who can enjoy the associated action of fresh air and a good diet. Creasote without these accessories is not of very great service, as witnessed in ordinary hospital practice. Patients are remarkably tolerant of it, and one rarely sees any ill effacts. Other balsamic substances, such as eucalyptol, terebene, terebinthine, thymol, and menthol, have been recommended. Symptomatic Treatment. — In this we shall refer more particularly to pul- monary tuberculosis. The fever of tuberculosis is serious and obstinate. It will be found in the early stages that the combination of rest with fresh air is the most beneficial. 302 AMERICAN TEXT-ROOK OF DISEASES OF CHILDREN. The child may be wrapped up and taken into the fresh air for the greater part of the day. We have no thoroughly satisfactory medicinal means for reducing the temperature. Antipyrine, antifebrin, and acetanilide, if used at all, must be given with great care. Quinine and salicylic acid are still used by many practitioners. When the temperature is persistently high in the early stages of tuberculous broncho-pneumonia, cold in various forms will probably be the most efficient measure, and by careful sponging the temperature may be reduced several degrees. The most satisfactory antipyretic is found in the fresh air, more particularly the change to a resort such as the Adirondacks or Colorado. In the chronic pulmonary tuberculosis of children, when the fever is of a hectic type, sweating is a very troublesome and disagreeable symptom, for which atropine, aromatic sulphuric acid, and tincture of nux vomica may be used. In young children great care should be taken to prevent the chilling of the body after a profuse night-sweat. For the cough, if troublesome at night, paregoric or small doses of Dover’s powder may be used. Codeine or, in extreme cases, small doses of morphine may be given. Where there is marked tenderness on the chest or pleuritic complications the cough is sometimes relieved by mild counter-irritation or the application of a warm poultice. Inhalation of terebene and oil of eucalyptus may sometimes diminish the profuse expectoration. Haemoptysis in the pulmonary tuberculosis of young children is usually a terminal and fatal symptom, quickly beyond treatment. The diarrhoea may demand very careful regulation of the diet, and if pro- fuse the acetate of lead, alone or with opium, may be used. Preparations of tannin and gallic acid are also beneficial. In all tuberculous processes there is a more or less marked tendency to anmmia, and many patients improve quickly under the administration of iron. Careful attention should be paid to the gastric symptoms. If the digestion is poor, dilute hydrochloric acid may be used, and if heartburn and pain be present some time after eating, the carbo- nate of sodium or the alkaline mineral waters. MALARIAL FEVER. By W. S. THAYER, M. D., Baltimore. Synonyms. — Intermittent fever ; Swamp or Marsh fever ; Paludism or Paludal fever ; Fever and ague ; Chills and fever. The term “malaria,” which has been applied in a general ivay to a variety of febrile and non-febrile processes, must now be limited to a certain definite class of febrile affections which we know to have a specific infectious origin. The specific micro-organisms which are the cause of these processes belong to the class of protozoa and inhabit the blood of the infected individual. Etiology and Pathology. — The geographical distribution of the malarial fevers is a point of considerable interest, particularly inasmuch as it is not entirely constant. In Europe, France, Germany, and England are compara- tively free from malarial fever, while in Southern Russia and Italy the disease is very frequent. In many parts of Africa and India some of the severest forms of malaria are seen. In this country there are various localities in which malaria is endemic, particularly in certain regions in the Southern States, in Louisiana, Mississippi, Arkansas, and Texas. In the Ioav, marshy lands along the coast throughout the Southern and Central States there are many places in which malarial fevers are common. In parts of New England malaria also occurs, particularly in the Connecticut Valley, while of late a considerable number of cases has been seen along the course of the Charles River in Massachusetts. In New York City the disease is rare, though certain low- lying districts in the neighborhood give rise to a number of cases. In Phila- delphia the disease is perhaps more frequently seen, but most of the cases in that city come from outlying districts. In parts of Baltimore also malarial fever occurs, though a great majority of the cases come from the districts bor- dering on Chesapeake Bay. In the Western States malaria is less common, but in certain parts about the Great Lakes it is more or less prevalent. A very interesting point in connection with the geographical distribution of malarial fever is the manner in which the disease wanders from one region to another, diminishing greatly in intensity or almost dying out in a district where it has formerly been endemic, and developing perhaps in a region ivhere it has been for many years an unknown disease. An instance of this is the appearance during the last five or six years of malarial fever along the basin of the Charles River in Massachusetts, where it had been for many years unknown. Again, in districts in which malarial fever has for years been endemic there seem to be cycles in which the intensity of the process increases and diminishes. Malarial fever is particularly prevalent in low, swampy, and badly-drained districts, and especially in areas which are rich in vegetable matter and have 303 304 AMERICAN TEXT-BOOK OF DmEASEB OF CHILDREN. been allowed to fall out of cultivation. It is much more prevalent in tropical or semitropical regions, and is more severe in climates Avhere the moisture is considerable. It has been thought that winds have possibly some connection with the carrying of the contagion ; for instance, in some malarial districts the residents on one side of a stream may be relatively free from the disease, while those upon the other side, toward which the prevailing winds blow, may suffer considerably. The danger of contracting malarial fever is apparently greater among those living in the lower stories of a house than in the upper. In temperate climates the frequency of the malarial fevers varies greatly with the seasons. The majority of cases occurs in the late summer and fall, though a certain number develops in the spring and early summer, while in the winter it is very rare. In tropical climates, where the disease occurs all the year round, the greater number of cases is seen in the fall and spring months. The Specific Micro-organism. — All our accurate knowledge of the causal element of malarial fever dates from the discoveries of Laveran in 1880. While studying malarial fever in Algiers, Laveran discovered certain pig- mented bodies in the blood of affected individuals. These bodies had long been observed by others, and by some accurately described, and even pictured, but, while the older observers considered them to be altered blood-corpuscles, Laveran recognized them as parasites, and asserted that they were the definite exciting agent of malarial fever. These discoveries have been confirmed by numerous other observers in Italy, the United States, Russia, Germany, and India. In this country Councilman, Abbott, Osier, James, and Dock have made valuable observations. Laveran and his school have published careful and accurate descriptions of the different forms of the parasite, which may be seen in the blood, but they assert that they are unable to associate any definite types of organism with distinct types of fever. From the observations which have been made, however, by the numerous Italian observers, led by Golgi, there can be to-day little doubt that certain definite types of the organism are associated with certain definite types of fever. In this country, as in Italy, there are several main types of fever : (1) The milder forms of intermittent fever, which form the great majority of the cases in the spring and early summer, but which occur at all malarial seasons : (a) tertian and double tertian ((juotidian) fever ; (h) quartan fever, with its combinations. (2) The more severe, often more or less irregular, fevers which occur here, as in Italy, more commonly in the later summer and fall — the mstivo-autumnal fevers of the Italians, the trojfical malaria of the Germans. This tyj)e of fever includes the so-called remittent malarial fevers as well as most of the cases of pernicious malaria and of the malarial cachexiae. Some of the Italian observers have attempted to divide these fevers, again, into (c) (piotidian fever, and (d) malignant tertian fever. In this country, however, we see probably only the quotidian type. With each of these types of fever is associated a dis- tinct type of the specific micro-organism. ((n) Tlte Parasite of Tertian Fever . — Golgi was the first observer who accurately described and differentiated the organisms of the tertian and of the (juartan forms of malarial fever, and his admirable observations have remained practically unassailed. If we examine the blood from a case of tertian lever just after the paroxysm, we find in certain of the red blood-corpuscles small round, colorless bodies (Fig. 1, which aj)pear to have a slight dej)res- sion in the centre, and when stained in dried specimens show a paler central area with a darker perijdiery. These bodies, examined in the fresh specimen. MA LA RIAL FE I ^ER. 305 show active amoeboid movements. A few hours later the organism will be found to have increased somewhat in size, and to contain a few fine brownish pigment-granules which dance actively under the eye (Fig. 1, ^), the motion probably being due to undulatory movements in the protoplasm. On the day between the paroxysms the bodies will be found to have about half filled the red corpuscle (Fig. 1, ®). They are still actively amoeboid, and the number of pigment-granules has considerably increased. The red cor- puscle at this stage will be seen to be a trifle larger than its unaffected neighbors, and to be considerably decolorized. On the day of the paroxysm Fig. 1. 12 3 4 The Parasite of Tertian Intermittent Fever (drawings made from the blood of patients in the Johns Hop- kins Hospital, with the camera lucida. Winckel, 1-14 oil Immers. lens, 4 eye-piece) : 1, 2, 3, hyaline intracellular amceboid bodies, seen during the febrile stage of the paroxysm ; 4, 5, half-grown bodies seen on the day between paroxysms ; 6, the .same, further advanced ; 7, full-grown body seen during the paroxysm; 8, segmenting body seen during the paroxysm; traces of the red corpuscle still seen about the organism ; 9, 10, segmenting border further advanced ; 11, 12, extracellular pigmented bodies, regenerative forms ; 13, flagellate body (somewhat diagrammatic, not drawn with the camera lucida). the organism has entirely filled and almost destroyed the red blood-corpuscle, which is represented only by a faint pale rim about the full-grown parasite, if indeed it has not entirely disappeared (Fig. 1, The pigment-granules may show at this stage a very active motion, but the amoeboid movements of the organism as a whole are but little marked. At the time of the paroxysm an interesting change takes place ; the pigment gathers together in a more or less solid clump, usually in the centre of the organism, while the rest of the protoplasm looks somewhat granular and shows a suggestion of 20 ;30G AMERICAN TEXT-BOOK OE DmEARE^i OE CHILDREN lines radiating outward from the centre (Fig. 1, *). This appearance gradu- ally changes, the lines becoming more distinct (Fig. 1, ^), until finally we see the central clump of pigment surrounded hy from fifteen to twenty small ovoid or round glistening segments, each one having a central more refractive spot, and resembling strongly the hyaline bodies which we see immediately following the chill (Fig. 1, i®). This segmentation of the organism is always coincident with the paroxysm, and the presence in the blood of a segmenting body is a sure indication that the paroxysm is present, or is about to occur. Immedi- ately following the paroxysm fresh hyaline bodies apj)ear in the red corpuscles. Though the invasion of the corpuscles by these fresh segments has never been actually observed, the evidence that this occurs is so strong that wm can safely accept it as a fact. Besides these forms we see not infrequently small or large extra-cellular pigmented bodies ; that is, organisms resembling exactly those within the red blood-corpuscles, excepting that they are free in the blood-cur- rent (Fig. 1, These may be seen at times to break up into several smaller bodies, while at other times they may show a long, tail-like, non-motile process, containing sometimes a few pigment-granules. They are probably organisms which have escaped from the red corpuscles, or full-grown bodies which have broken up ; they are considered to he degenerative forms. At times also Ave find the so-called flagellate bodies. Their development from the pigmented organism may indeed be observed, the pigment of the full-groAvn body becoming very actively motile, then collecting in the centre of the organism, Avhile several long, thread-like flagella burst out of the body and move actively about among the surrounding corpuscles (Fig. 1, ^ ®). Some- times Ave may see one of these flagella which has broken away from the organ- ism and is moving rapidly through the field. This is also thought by the Italians to be a degenerative process. The characteristics of this form of organism, Avhich is observed in tertian fever alone, are so marked that Avith a little study of the parasite one can make a definite diagnosis of the type of fever from an examination of the blood alone. {b) The Parasite of Quartan Fever. — Quartan fever is not at all common in this country, but in the fcAV cases Avhich the Avriter has observed the organisms differ distinctly from the tertian parasite, and shoAv accurately the characteristics described by Golgi. Here the first stage of the organism is similar to that observed in tertian fever, excepting that the amoeboid move- Fig. 2. j 2 8 4 6 G 7 The Parasite of Quartan fever (drawings mainly after Marehiafava, lliKnanii, and MannalioiKl: 1, liyaline anueboid intraeellular laxly ; 2, 3, 4, fu'rther stages in Uie ^rrowth of the body ; f>, fnll-(tro\vn form ; 0, 7, segmenting bodies. ments are not so active. As tlie )>ody develops the rods and clumps of pig- ment are hirger and darker th:in those in tertian fever, Avhilo the aimx'boid jL C* MALARIAL FEVER. 307 rooveraent of the organism is relatively slight. The full-grown forms are materially smaller than in tertian fever, while the red blood-corpuscle, instead of being expanded and decolorized, appears at times shrunken about the body, and of a somewhat deeper old-brass color (Messingfarbe). In segmentation the organism divides into from six to ten different parts instead of twenty or thirty, as in the tertian form (Fig. 2, (c) The Organisms of the yEstivo-autumnal Fevers . — The organisms asso- ciated with the mstivo-autumnal fevers have been carefully studied, but much remains to be done, particularly in this country. Thei'e is some difference of opinion as to whether there are not two types of organism associated with these fevers. Some Italian observers divide them into the quotidian and the malignant tertian organisms. The differences made out by the Italians are, however, very slight, and have not been observed in this country. In the first place, we see just after the paroxysm small hyaline bodies which may or may not be actively amoeboid ; these can sometimes be distinguished from those appearing in the initial stage of either tertian or quartan fever, in that they are genei’ally somewhat smaller and have oftentimes a charac- teristic ring-like appearance (Fig. 3, In the early stages — during the first week, for instance — of an attack of this form of fever we may see only the hyaline, unpigmented forms, but commonly, if we observe carefully, we may see, some time after the exacerbation of temperature, shortly before the beginning of another, bodies which are a trifie larger than these smallest hyaline forms, and which contain one or two very minute pigment-granules lying near the periphery (Fig. 3, ^). Just before or during the paroxysm we may see Fig. 3. 12 3 4 5 6 7 g J Parasites seen in .Estivo-auturanal Fever— tropical malaria. (Drawn with the camera lucida from the blood of patients in the Johns Hopkins Hospital ; Winckel, 1-14 oil immersion lens, 4 eve-piece.) : 1, 2, 3, hya- line, ring-like amoeboid bodies seen in the blood toward the end of the paroxysm ; 4, the same further developed ; 5, C, disc- and ring-shaped bodies with one or two small pigment-granules, seen shortly before a paroxysm ; 7, full-grown body with central pigment-granules, seen during paroxysm ; 8, full- grown body with central active pigment-corpuscle crumpled and shrunken ; 9-12, crescentic and ovoid bodies with coarse central pigment. 9 and 11 show remains of the corpuscle (from a case of chronic malaria with normal temperature). bodies with a small central clump of motile or non-motile pigment-granules lying usually in cells which are more or less shrunken and crumpled, and of a deeper color than the normal corpuscles (Messingfarbe). These bodies are -308 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. generally not half as large as the red corpuscle (Fig. 3, After the first week or ten days of the disease, or after treatment has been begun, we see, however, certain very characteristic and easily recognizable forms which are only seen with this type of fever. These are, first, round or ovoid bodies about the size of a red blood-corpuscle, a little smaller or a little larger, Avith clear, rather highly refractive, waxy-looking protoplasm, and coarse dark pig- ment-granules, Avhich are usually collected in a ring or a mass in the centre of the organism (Fig. 3, 9> i o. i 'ppg granules are usually very slightly motile. At one side of the body we often see a small bib-like attachment which may show a slightly yelloAvish color. On examination this pi’oves to be the remains of the red blood-corpuscle in which the organism has developed. In association with these ai’e seen crescentic bodies (Fig. 3, the protoplasm of Avhich shoAvs the same characteristics as that in the forms above described, Avhile the pigment is collected in the middle in a similar ring or bunch, and is but slightly motile. On the concave side of these crescents one may also often see a bib-like attach- ment, just as in the ovoid forms. At times during the examination of the fresh specimen Ave may see the change from an ovoid body into a crescent take place. The development of these forms from the hyaline bodies can be folloAved out on careful observation. They are thought by some to be a resting stage of the organism. Segmenting bodies are almost never seen in the circulating blood of this form of malarial fever, though the presence of the round intra- cellular bodies Avith central pigment is a sure sign that segmentation is going on elsewhere. It has been found by the Italians that after the accumu- lation of a fcAV pigment-granules the organisms seek the internal organs, where segmentation takes place. The bodies are still small and contained within the red corpuscle. The pigment gathers in the centre, as in the other types of segmentation, Avhile the segments are very small and rarely more than tAvelve in number. During the paroxysm Ave may see large numbers of leuco- cytes containing pigment granules and clumps Avhich are probably the remains of segmenting organisms. Flagellate bodies may be observed here as in the tertian and quartan fevers, but only Avhen ovoid and crescentic pigmented bodies are present. They may be seen to develop from the round bodies Avith central pigment. Careful studies concerning the morphological characteristics of the malarial parasite have shoAvn that it belongs to the class of Protozoa, and is possessed of a nucleus containing one or more nucleoli. At the time of sporullation this nucleus divides — according to some directly, according to others by karyokinesis. Pathological Anatomy. — In the acutely fatal cases of malarial fever (pernicious malaria) certain fairly characteristic changes are found in the various organs. The brain may shoAv fcAv changes. At times, hoAvever, there may be a slight subpial oedema, Avith hypermmia of the cerebral substance and per- hajts punctate lucmorrhagcs. Melanosis may be entirely absent. Micro- scopically, hoAvever, the changes arc most characteristic. The cerebral eajtil- laries are croAvded Avith malarial jiarasites, Avhich may be in all stages of development, though generally one of these ])hases is most marked. At times the organisms may not be so numerous, but free clumps of ])igment may be found, and large endothelial cells and leucocytes containing j)igment-cliimps and red corpuscles. There is usually a marked granular and fatty degen- eration of the endothelium of the vessels, a change upon Avhich the ])unc- tate haemorrhages may dej)cnd. These lesions are particularly marked in the comatose forms of pernicious malaria. In other forms the cerebral lesions may be much less marked. MA LA III A L FE VER. 309 The spleen is always enlarged : the capsule is tense ; the parenchyma is cyanotic, of a slaty -gray color, and almost diffluent. In some cases of acute malaria death may occur from rupture of a greatly enlarged sjtleen. The pulp contains enormous numbers of red blood-corpuscles, many of which contain parasites. It also contains numerous large white elements rich in protoplasm, containing usually a single bladder-like nucleus, and at times coarse granula- tions. These elements are usually laden with pigment, which at times has the same arrangement as it does in the body of the parasite itself. Sometimes these cells may contain the entire red corpuscle with the organism. There may be free pigment in the intercellular spaces of the pulp. The small mononuclear elements and the lymphocytes of the follicles never contain pig- ment. The capillaries are usually filled with the plasmodia, while the splenic veins show relatively few, though they always contain large cells enclosing pig- ment or the remains of red blood-corpuscles. The liver has usually a slaty-gray color. There is always cloudy swelling, while microscopically small areas of necrosis have been described by Guar- nieri. The capillaries are filled with leucocytes which contain numerous pig- mented bodies. Relatively few plasmodia are found in the blood-corpuscles in the vessels. Numerous liver-cells are found containing clumps of hmmatin and altered red corpuscles — a condition similar to that which has been found in pernicious anmmia, which, as Bignami suggests, may exj)lain the polycholia which is commonly found in subjects who have died of pernicious malaria. On this probably depends the icteroid hue in severe malaria. The lungs show in their capillaries numerous cells containing pigment-clumps and well-j)reserved parasites, though it is unusual to find pigment in the endo- thelial cells, in the capillaries, and smaller veins. In the areas of broncho- pneumonia which may occur, polynuclear leucocytes are chiefly found, while the large pigmented cells take no part apparently in the active inflammatory process. The vessels of the kidneys contain relatively few organisms. The glomeruli may be considei'ably pigmented. There may be marked degeneration of the epithelium of the capsules, and at times changes in the parenchyma, especially areas of necrosis of the epithelium of the convoluted tubules. The other viscera show no especially characteristic changes excepting at times the melanosis. In the more chronic forms of malaria and in malarial cachexia the anmmia is usually particularly marked. The spleen is always enlarged and very firm. There is a marked thickening of the capsule, which is often adher- ent to the neighboring tissue. On section the spleen is generally of a dark brownish-gra}^ color, the fibrous tissue throughout the organ being greatly thickened. The liver is considerably enlarged, and usually has a grayish- brown or slaty color. Microscopically, Kupfer’s cells and the perivascular tissue may contain much pigment. At times there is a considerable increase in the connective tissue. The kidneys show no particular characteristic changes, though there may be considerable pigmentation ; the pigment is most marked about the blood-vessels and the ^lalpighian bodies, and sometimes in the region of the convoluted tubules. There are no characteristic changes in the other organs, excepting the slaty-grayish pigmentation. Symptoms. — As may be gleaned from what has already been said con- cerning the specific organisms, malarial fever occurs in several maiij types : (1) The milder intermittent fevers, which form the majority of all cases in the more temperate climates, and occur in the warmer climates more commonly in the spring and early summer : {a) Tertian intermittent fever and its combi- nations ; (h) Quartan intermittent fever and its combinations. (2) The more irregular, sestivo-autumnal fevers, which usually show quotidian paroxysms. 310 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Tertian Intermittent Fever. — This is by far the coumionest form of malarial fever in this country, and ivitli the (juartan fever forms the mildest type of the disease. It is the t\’})e of the intermittent fever of the spring and early summer, though it may be seen at any time of year. It shows often no particular tendency to increase in severity, while in many instances, under j)roj)er care and change of climate, spontaneous recovery may oc- cur. It dej)ends, as we have seen, upon the invasion of the blood by an organism which ])asses through its cycle of ex- istence in forty-eight hours. The febrile paroxysms occur Avhen these parasites have reached their full develoj)ment and bevin segmentation. These periods occur with considerable regularity at intervals of forty- eight hours one from another. In older children the parox- V’sms may usually be divided into three stages : first, the chill; secondly, the/tu’cr; and thirdly, the sweating. d'he child, who may have been feel- ing fairly well beforehand, be- comes stuldenly uneasy, may begin to yawn, or may have an attack of vomiting ordiarrhaui, which is followed or accom- panied by a well-marked rigor, associated with cyanosis and coldness of the extremities. The temperature rises to a con- siderable height, ]) 0 ssibly to 108° F. This stage lasts for a varying time, from ten min- utes to an hour. As the chill ceases the patient passes into a stage in whicli there is marked Hushing of tlie skin, with great heat and dryness. 'I’lie child complains bitterly of thirst and headache, and is usually very fretful. There may be, as in the first stage, renewed attacks of vomiting or diarrhaui. This stage, after lasting for a vari- I'Tg. 4. MALARIAL FEVER. 311 able length of time, from half an hour to three or four hours, is followed by profuse sweating, the temperature falling within an hour or two to a normal or even a subnormal point. With the SAveating the child may seem exhausted and Aveak, but shortly aftenvard appears again perfectly Avell. Such an attack as this differs but little from the intermittent fever of adults, and indeed above the age of six the differences are very slight. Under this age, hoAvever, there are marked differences in the paroxysm. Very com- monly in young children both the first and the third stages, those of the chill and SAveating, are absent. The first stage is then generally represented by a slight restlessness, the face looks pinched, the eyes sunken, the finger-tips and toes may become cyanotic and cold, Avhile the child may yaAvn or stretch itself. Oftentimes there is nausea or vomiting, and possibly diarrhoea. This may be the only manifestation of the first stage, though it may be folloAved by slight or sevei’e nervous symptoms. These begin usually with a slight spasmodic tAvitching of the eyelids or of the extremities, and may go on to general convul- sions. The chill in the adult is vei’y often represented in the young child by the convulsion — a fact Avhich is as true in all other acute febrile processes as in malarial fever. This stage lasts usually for a short time, not more than an hour or so. The temperatui’e rises rapidly, possibly to 108° F. ; then comes the period of fever, during which the child is much flushed, is restless, thirsty and fretful, Avhile, as has been already said, various gastro-intestinal disturbances may occur. The fever remains at its height for an hour or tAvo ; afterAvard there is a gradual fall of temperature, unaccompanied by sweating. In many instances, besides the slight coldness of the hands and blueness Fig. 5. Double Tertian (quotidian fever). of the finger-tips, and a somewhat pinched expression of the face in. the first stage, the first and the third stages of the attack may be entirely lackincr. Pure tertian fever is rare in children, as the process is almost always a double infection ; that is, the blood contains two sets of organisms, which attain maturity on alternate days, and give rise to quotidian paroxysms. If, 812 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. as is unusual, the case is one of pure tertian fever, the child may seem per- fectly well on the day between the attacks. Physical examination during the very first attack may reveal little or nothing, but usually by that time, and always after one or two paroxysms, an enlarged spleen may be made out. If a child has had more than two supposed malarial paroxysms and the spleen is not distinctly enlarged, we have almost sufficient evidence to put aside the diagnosis of malarial fever. Herpes labialis is a very common accompaniment. Anaemia is usually noticeable if the process has lasted for any length of time. The discovery of the specific organism in the blood is the one diagnostic point. The paroxysm in tertian malarial fever may last altogether from twelve to fifteen hours, though com- monly it is much shorter, the fii’st stage lasting from ten minutes to an hour, the second stage from an hour to three or four hours, and the third stage a varying length of time. As the length of time Avhich the tertian organism requires to attain its full growth is almost exactly forty-eight hours, the attacks dependent upon one group of parasites occur almost regularly forty- eight hours apart, though in some instances Ave may find a tendency to antici- pation or to retardation in the attacks. This point can only be determined by observation, so that one cannot definitely prophesy the hour at Avhich an attack Avill occur until he has seen several paroxysms. It is easy to see that in the quotidian cases, Avhich depend upon the presence of a double infection, the chills on the alternate days may occur at different hours, one group of organisms segmenting perhaps at ten o’clock, and the other at two. Usually, hoAvever, these differences are slight. Not infrequently Ave find the history of tertian attacks at first, and later on daily attacks of fever. Tlie common- est time for the paroxysm in tertian fever is in the early part of the day, betAveen eight in the morning and two in the afternoon, though they may occur at all hours either of the day or night. Irregularities in the course of the fever, no matter what the type may be, are much commoner in children than in adults. Quartan Fever. — This form of fever is rarely observed in this country. Out of about 500 cases of malaria treated at the Johns Hopkins Hospital in four years, it only occurred tAvice. Here the length of time required for the development of the organism is seventy-tAvo hours, and the paroxysms occur every fourth day. The nature of the paroxysm does not differ from that observed in tertian fever. As one may easily see, complex attacks of fever may arise from a double or triple infection Avith quartan organisms. Thus we may have a daily paroxysm due to a (juartan infection, or, on the otlier hand, paroxysms on tAVO days in succession, Avith one day intermission, a triple or a double infection. The diagnosis of (luartan fever may be made by a skilled o1»server from one examination of the blood by the discovery of the characteristic quartan organism. The iEsTivo-AUTUMNAL Fevers. “Tropical Malaria.” “Ferris Irregularis.” — Tlie malaria occurring in tlie late summer and fall is often of a much more severe ty]>e than that occurring in the spring, and, as has been sliown by the Italian oliservers, most of these cases are due to a different type of the specific organism. It is in the later summer and fall that Ave see most of the cases of apparently irregular fever, and the so-called remittent malarial fever. The typical malarial cachexia, Avhilc it may folloAV any form of intermittent fever, usually results from this type of malaria. Most of the pernicious forms also come under this heading. The So-cal1;EU Irregular Remittent Fevers. — d'ho recent Italian observers, asserting that there is in reality no actual irregularity, divide these MA L A HI A L FK VER. 313 fevers into the quotidian, in which a daily paroxysm occurs, and the tertian, in which the paroxysm occurs on every other day ; but in both instances there is a greater tendency to irregularity in the time requii’ed for the development of each brood of organisms. On the one hand, there is often a very marked tendency for the paroxysms to anticipate one another, or there may be a retardation, while again the attacks do not present themselves in so clean-cut and regular a form as in the spring fevers. They may be much lengthened out, so that one attack may follow another without the temperature ever actually reaching a normal point. Most of the cases of this type of fever seen Fig. 6. jEstivo-auturanal fever. (Quotidian.) in this country show a distinct daily paroxysm ; it is doubtful whether we see in America the “malignant tertian fever” of the Italians. The attacks may differ little from those in the ordinary tertian form, excepting that they are often more severe and of a somewhat longer duration, so that the afebrile periods are shorter or even absent. On the other hand, the onset may be very gradual, with daily exacerbations of temperature, accompanied by restlessness, flushing, often vomiting or diarrhoea, and headache, but Avithout chills or perhaps even sweating. The attacks may be prolonged and run into one another, so that a remittent temperature results. There is often delirium or droAvsiness and somnolence ; the spleen is always enlarged. In this condition the diagnosis from typhoid fever or meningitis may be impossible without an examination of the blood. Such cases as this, however, do not generally go on to recovery Avithout treatment, but tend to become pernicious, the paroxysms increasing in severity till death. Malarial Cachexia. — T he fever in some instances may never rise as high as it does in the paroxysms of tertian fever, nor may the immediate symptoms of the paroxysm be as striking, and the attention of the physician is often called to the patient for the first time Avhen the stage of malarial cachexia has been reached. The child may then shoAV a pitiful appearance. It is pale, of a salloAV, parchment-like color, and often much emaciated. The skin is dry, the face has a drawn, pinched look, the eyes are sunken; there may be marked symptoms on the part of the digestive tract, frequent attacks of vomiting and 314 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. diarrhoea. The fever may stand in the background. Indeed, in some of these cases there may be for weeks relatively little fever. The spleen is always enlarged. Malarial cachexia does not exist in children without an enlarged spleen. In all instances, no matter Avhether our attention is called to the child on account of the fever or of the gastro-intestinal derangement, an examination of the blood will show the organisms, usually those characteristic of the jcstivo- autumnal or tropical malarial fever, the small hyaline bodies, and the pig- mented crescents and ovoid forms. Malarial cachexia may follow all forms of the disease, and not infrequently is seen in improperly treated cases of tertian fever or in those who have been subject to repeated attacks, but it is much more commonly seen in this type of fever. Pernicious Malarial Fever. — It is in the pestivo-autumnal fevers that we see more commonly the pernicious forms of malaria, though these are rare in temperate climates. In these cases a previously healthy child may begin to show a slight restlessness, with a pinched expression of the face and some blue- ness of the extremities. An attack of vomiting or diarrhoea may occur, which may be followed suddenly by severe convulsions and a very rapid rise in tem- perature, which may be as high as 108°. The convulsions may continue or the child may pass into a dull, comatose condition, the pupils being fixed and possibly irregular; in this condition it may remain until death ensues. In some instances the whole attack may be represented by a condition of coma with collapse, possibly with little or no rise in temperature. These severe attacks are rare in this country, and it is not at all improbable that in regions in which severe malarial fever prevails many non-malarial attacks are ascribed to this disease. The definite diagnosis can only be made by the discovery of the parasite in the blood. Some of the most severe of these attacks are prob- ably due to the infection ivitli several groups of the organisms at once, so that segmentation is going on continuously. Affections of Other Viscera sometimes Associated with INIala- RIAL Fever. — Respiratory Ajaparatus . — In all forms of malarial fever bron- chitis is a common complication, as it is, indeed, Avith any acute febrile afi’ec- tion. This is particularly true in children. The appearance of a profuse coryza in the absence of the siveating stage has been noted. Alimentary Tract . — In almost all cases of malarial fever in children symp- toms are present on the part of the stomach and intestines. Vomiting in the first and second stages of the paroxysm is extremely common, while diarrhauis are also very frequently seen in all forms of malaria, particularly in the more remittent forms and in the chronic cachexia, where it is probably generally due to a secondary infection to Avhich the debilitated child is more readily subject. Little is to be noticed on the part of tlie circulation. Kidneys . — Slight all)uminuria may often l)c observed, and in rare instances baematuria occurs. Malarial lucmaturia is generally considered a grave symj)tom. It is probably, however, a rare condition, except in districts Avhere tlie severest forms of the disease are common. Many of the so-called malarial haematurias are due to other causes. The literature of malarial fever contains numerous references to “malarial pneumonia,” “malarial l)ronchitis,” “malarial neuralgia,” “malarial diar- rlncas,” and the like, most of which, in the light of our present knowledge, have ])robably little or no comiection with malarial fever. It is easy to understand that the child debilitated by a severe malarial fever may more readily fall a victim to a variety of other diseases. In this way probably the gastro-intestinal and bronchial disturbances so commonly observed are to bo exj)lained. That there is any such thing, for instance, as a specific malarial MA LA III A L FE VEIL 315 pneumonia is wholly out of the ([uestion. The chills which may occur sometimes with some regularity in the course of many of the specific fevers are commonly attributed to a malarious influence. These inferences are for the most part unjustifiable. In rare instances a patient who is subject to an acute or chronic malaria may develop typhoid fever at the same time, or the converse may occur, but these instances are few and far between, and the great majority of instances of chills occurring in typhoid fever have no connection Avhatever with malaria. Pneumonia may develop during the course of a malarial attack, but it is due in these cases to its specific cause. The examination of the blood is our one safe clue to the ex))lanation of such complications. Diagnosis. — The Milder Tertian and Quotidian {double tertian) Fevers . — The diagnosis of malarial fever in children may be made, in the first place, from the character and periodicity of the attacks ; secondly, from the enlargement of the spleen, which is always present after the first or second attacks; and thirdly, by the presence of the malarial organism in the blood. In some instances there may be relatively few parasites, but the careful examination of several fresh specimens of the blood will always reveal the organism if present. Even in the absence of definite data with regard to the attacks, the diagnosis may be made by the type of organism found. The commonest type, as has been said, is the double tertian, quotidian fever. The commonest condition with which malarial fever is confounded is tuberculosis in its various forms ; the hectic evening temperature is often ascribed to malaria. Most pediatrists may, I fancy, remember more than one instance where after a diagnosis of malarial fever evidences of pulmonary, abdominal, or even glandular tuberculosis have developed. The absence of definite signs of tuberculosis, the splenic erdargement, and the anmmia, which may be marked, speak in favor of the malarial nature of the affection, while the absence of malarial organisms in several specimens of fresh blood, even in the presence of marked febrile paroxysms, is a sure sign of the absence of malarial fever. The same rules of diagnosis apply to quartan fever. The characteristic organism of that type will be found on examining the blood. FEstivo-autumnal Fevers . — It is the more irregular and remittent fevers and the malarial cachexiae which give the most trouble to the diagnostician. The regularly intermittent fever may not here give us our clue to the diagnosis. On the other hand, the presence of a considerable anaemia in association with a markedly enlarged spleen, which is always present in this form of fever, will lead us to suspect the proper diagnosis, which will be con- firmed by the discovery of the small ring-like hyaline intracellular organisms, and, if the case has lasted a week or more, the ovoid and crescentic pigmented bodies in the blood. This form of fever may often be confounded with tuber- culosis. It may also simulate very closely, from the physical examination alone, leukaemia or the anaemia infantilis pseudo-leukaemica of Von Jaksch. In some instances where the paroxysms tend to run into one another and pro- duce a more or less remittent fever, the differentiation of the process from fever may be impossible from the physical examination alone. The frequent herpes, the large size and prominence of the spleen, as well as the rapidly developing anaemia, may be suggestive, but here, as elsewhere, the examination of the blood alone gives us our certain diagnosis. In the absence of an examination of the blood, the chronic cachexiae may be considered to be the result of the concomitant gastro-intestinal derangements or of the bronchitis, while in many instances the atrophy, the dyspepsia, and the diarrhoea may be found to depend upon the presence of the malarial organisms in the blood. In the cases of 316 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. severe pernicious malarial fever the examination of the blood is also our only safe clue to a diagnosis. Methods of Examination of the Blood. — The examination is best made witli fresh specimens. The lobe of the ear is punctured with a sharp, spear-pointed lancet; a very small cut is all that is necessary. This may be done behind the back without tlie child seeing the instrument, so that it may not be alarmed, w’hile if the instrument is sharp the process is almost painless. In some instances it may be done while the child is asleep, without even awakening it. After wiping away the first drop or two of blood, a perfectly clean cover-glass is brought into contact with the tip of a small drop of blood, and allowed to fall immediately upon a freshly-cleaned slide. If the slide and cover-glass have been washed in alcohol just before using and are perfectly clean, the drop of blood wdll spread out regularly under the glass, and the corpuscles may be seen lying side by side free from crenation or any other artificial changes. Pressure on the cover-glass may spoil the specimen. It is best to hold the cover-glass in a forceps in order to avoid any injury to the cor- puscles from the moisture of the hand. The specimen is then examined at best with a oil-emersion lens, and a 2, 3, or 4 eye-piece. A 4 eye-piece w ith an 8 objective, or a Zeiss E or F, will answer tbe purpose well, though an oil- emersion lens is clearer and better. In this manner all forms of the organism may be seen while yet alive. When it is impossible to examine the fresh spec- imen, dried and stained specimens may be used. A small drop of blood is taken upon one cover-glass, which is then allowed to fall upon the second glass. The drop immediately spreads out, and the twm glasses are separated by being gently drawn apart. These specimens are allow'od to dry in the air. They may be kept for almost any length of time before examining. There are numerous different methods for preparing and staining the sjiecimen. As satisfactory a method as any is to place the glass in a solution of absolute alcohol and ether, equal (juantities, for a half to one hour, or the spec- imens may be heated for from one to two hours at 100°-120° C. The specimen may then be stained in a concentrated a(pieous solution of methylene blue for about a minute, washed in water, dried between filter-pajier, mounted in balsam or oil, and examined. The red corpuscles remain unstained. Only the nuclei of the leucocytes, the malarial organisms, and occasional blood- platelets take up the blue coloring. In case a double stain is desired, one may make use of two solutions: Solution 1. Eosin 1 part; 70 per cent, alcohol 100 parts ; Solution 2. Saturated aqueous solution of methylene blue. After preparing the specimen in absolute alcohol and ether as before, place it in Solution 1 for from fifteen seconds to half a minute, wash in water, dry between filter-paper ; place it then in Solution 2, Avliich has been diluted one-half with water, letting it stain for from one half to one minute ; W'ash in water, and dry. By this method the red corj)uscles and the eosinojfiiilic granules in the leucocytes are stained red by the eosin, while the miclei of the leucocytes and the malarial parasites are stained blue. Good results may be obtained by Bomaiiowsky’s method : saturated acjueous solution of methylene blue, 1 part, 1 per cent. a(|ueous solution of eosin 2 jtarts. Do not shake or filter the mixture. Blace the sjiecimen (heated as above) in this mixture for two to three hours, and then in water for one to two hours, and dry. The jiarasites are stained blue. In this manner any jiractitioner who jio.s- .sesses a microscope may, w’ithout much labor, make the diagnosis of malarial fever. The exainination of the fresh specimens will jmiliably be found to be more sati.sfactory, and the observer who studies oidy stained sjieciinens must bew are of certain mistakes which one who is not familiar with the examination of MALARIAL FEVER. 317 the blood may readily make, such as the confusion of the blood-plates, the hmmatoblasts of Hayem, with the malarial parasite — a mistake which certain good observers have recently made. Course and Prognosis. — Excepting in the acute pernicious cases the prog- nosis in malarial fever is good, provided the case is recognized and properly treated. If untreated the fever may take one of three courses : tl) Mild cases may go on to spontaneous recoveiy ; (2) The paroxysms may gradually diminish in intensity, the fever becoming less marked, while grave anaemia develops, and the patient passes into the con- dition of chronic cachexia ; (3) The paroxysms may increase in severity, assuming finally a pernicious Treatment. — Prophylaxis . — In a malarial district certain prophylactic measures should be taken with children as well as with adults. The child should be kept in the house after sundown and should be carefully kept away from those regions in which experience has shown that malaria is present. Sleeping on the ground floor of houses in malarious districts should be avoided. Medicinally, we possess in quinine one of the few specific drugs which are at the command of the physician. In almost all cases of malarial fever we may expect with confidence a complete recovery after the use of quinine. There is only one form of malarial fever, and that rarely seen in this country, the acute pernicious malaria, in which Ave cannot entirely rely upon this drug. In the milder forms of the disease, the tertian and quartan fevers and their combina- tions, small doses of quinine are rapidly efficacious. One or two grains of quinine (.065-. 13), three times a day in children under six years of age, will be folloAved by the rapid disappearance of all symptoms. The best time to administer a single larger dose of quinine is immediately after a paroxysm. In the more chronic and irregular forms, which are so apt to occur in the later summer or fall, the forms in which the smaller organisms are found, much longer treatment and larger doses of quinine may be retjuired. Ordinarily, however, doses larger than two or three grains (0.13-0.2) three times a day are not required under five or six years of age. Relatively large doses of quinine may, however, be well borne, and in cases of pernicious malaria must be admin- istered. Ferreiera states that he has given doses as large as 15 grains in infants under one year of age without noticing ill effects ! In pernicious cases the quinine must generally be administered hypoder- matically. A good preparation is the muriate of quinine and urea. In ordinary cases it is probably better to give smaller doses several times a day than it is to give one large dose with the idea of “ breaking up” the fever. In some children it is very difficult to administer quinine by the mouth, on account of the difficulty in disguising the taste, and because in some cases it is constantly vomited. In some cases in infants the drug is with difficulty retained. Here small doses should be given and often repeated. In these instances it may be administered by the rectum ; the dose under these circumstances should be about double that by the mouth. The administration of quinine through the skin by means of ointments is probably of little value. In cases of the more chronic sestivo-autumnal forms of malaria, associated Avith crescent organ- isms in the blood, the treatment by quinine may have to be continued for a considerable length of time. The crescents may- be found in the blood for months. The fever, however, if the case is truly one of malaria, will surely yield to the treatment after a few days. Much has been written about those 318 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. forms of malaria both in children and adults which do not yield to quinine. These cases are probably not true malarial fever, as examination of the blood will show. Few cases of fever in this country do not yield within a few days to treatment by quinine. By this it is not said that relapses may not occur ; tliey are frequent in cases where the treatment has been continued too short a time. In some of the acute forms of fever, and more particularly in the more chronic forms and in the malarial cachexia, the anaemia and various gastro- intestinal disturbances may also demand our attention. In most instances, with proper attention to the diet, the gastro-intestinal symptoms will disappear after the disappearance of the fever. The anaemia, however, may require extended treatment with various preparations of iron, and even in the severe cases with arsenic, which is particularly well borne by children. The adminis- tration of arsenic, which is common in chronic malaria, has its chief value in its effect on the anaemia. Various other drugs have been tried in malarial fever, some of which have some influence on the attacks. The most important of these are preparations of eucalyptus and, of late, methylene blue. None, however, approach quinine in eSicacy. One attack of malarial fever does not, unfortunately, render the patient immune. On the other hand, he seems, if anything, to be more readily subject to fresh attacks, and in some instances these attacks may be so frequent and prolonged that a removal of the child to a proper climate is necessary. PART IV. GENERAL DISEASES NOT INFECTIOUS RACHITIS. By J. lewis smith, M. D., New York. Rachitis is a constitutional disease, but its most conspicuous anatomical characters pertain to the osseous system. The gross nutritive changes which it produces in the bones and cartilages, causing deformities, are well known to physicians and the laity. In addition to these anatomical changes in the skeleton, typical cases exhibit a lack of tonicity with stretching of the liga- ments, causing the knock-knee and flat-foot; weakness of the muscles, resem- bling paralysis and sometimes mistaken for it in severe cases ; reflex irritability, rendering rachitic patients liable to laryngismus and tetany ; undue perspi- ration ; anmmia and proneness to catarrhal inflammation ; and certain anatomi- cal changes in the spleen and liver in aggravated forms of the disease. These many and divers anatomical and functional characters indicate the constitutional or general nature of rachitis. Therefore theories which restrict rachitis to the osseous system are inadequate and erroneous. Rachitis is pi’obably an ancient disease. It is said that an old statue of .®sop, who was thrown from a precipice by the indignant Delphians 564 years before Christ, exhibited rachitic deformities ; and Hippocrates, born 460 years before Christ, is believed to have alluded to it in his treatise on the Articu- lations. Occasionally expressions in the works of Celsus and Galen in the second century of the Christian era have led writers on rickets to believe that they also had observed the deformities produced by this disease. But rickets was first investigated in a scientific manner by Whistler, Glisson, and their contem- poraries in the middle of the seventeenth century. During the last feiv years many excellent monographs have been written on this malady, and its causa- tion, pathology, and treatment are better understood than formerly. Frequency. — Rachitis is a widespread disease, but it is comparatively infre()[uent in rural localities, where families enjoy the hygienic retjuirements of pure air, sunlight, and a plentiful diet of good quality. It is most common in crowded and badly-fed families in city tenement-houses, where antihygienic conditions prevail. Mild cases of rickets, not manifested by any prominent signs or .symptoms, are often overlooked, so that the physician is not summoned, or, if he be sum- moned and have not given particular attention to this disease, he, in not a few instances, does not detect its presence. In the absence of deformity, which occurs later, the fretfulness, tenderness of surface, and perspirations are likely 319 320 AMERICAJy TEXT-BOOK OE DISEASES OF CHILDREN. to be attributed to other causes than the correct one. Hence, according to my observations, rachitis is more common in its milder forms in the asylums and dispensaries and in the tenement-houses of New York, and probably in other American cities, than is commonly believed by the laity, and even by physi- cians who have given little attention to the disease. A few years since in one of the New Y"ork asylums my attention was directed to a rachitic child in whom the anatomical characters of rachitis had become so pronounced that they attracted the attention of the nurses. Prompted by the occurrence of this case, which had developed during my attendance in the asylum, I made an exami- nation of all the infants, and found, what I had previously not suspected, that about one in nine presented unmistakable signs of rachitis, though in a mild form and for the most part in its commencement. The late Dr. John S. Parry of Philadelphia stated that at least 28 per cent, of the children between the ages of one month and five years who came under his observation in the Phila- delphia Hospital, during the three years preceding the publication of his paper in 1872, were rachitic. According to Dr. Gee, whose observations were, how- ever, made as far back as 1867 and 1868, of the patients under the age of two years in the London Hospital for Sick Children, 30.3 per cent, were rachitic ; and Ritter von Rittershain, whose observations were also made several years ago, stated that of 1623 out-door patients under the age of five years brought to the Clini(jue at Prague, 504, or 31.1 per cent., manifested this disease. Recently Prof. Henoch of the University of Beilin has stated that he had seen many thousand cases of rachitis, and he adds that its spread in the large cities of Northern and Middle Europe is enormous. He states that his obser- vations in regard to the frequency of rachitis in dispensary practice correspond with those of Ritter, as many as 31 per cent, being rachitic. In Manchester also, with its large number of operatives, Ritchie’s statistics show that of 728 out-door patients 219 were rachitic. The curator of the New Y"ork Found- ling Asylum for the last ten years informs me that he believes, witliout the accuracy of statistics, that as many as 20 per cent of the cadavers examined by him in the dead-house have presented the anatomical characters of rachitis, usually in a mild form. The recent large emigration from Europe of destitute families, living from choice or necessity in filth and degradation, who for the most jiart remain in the cities, occupy small, dark, and dirty apartments, and whose food is of the poorest (quality and often insuflicient, greatly increases the number of rachitic children in New Y"ork and probably in other American cities. In the out- door dej)artment of Bellevue, to wliich many thomsand immigrants from the lowest class of European society carry their sick children for treatment, rachitis is not infrecpient ; and the fact has been observed in this institution that a larger proportion of severe cases attended l)y marked deformities occur in the Italian families than in those from other ])arts of Europe. In families of American parentage it is generally admitted tliat rachitis is more prevalent in the negro than in the white race. Although this disease occurs most frequently in the families of the destitute and poorly fed, nevertheless children of well-to-do families occasionally sulh'r from it, even in an aggravated form, in c()iise(iuence, I think, usually of igno- rance on the part of ])arents in regard to the dietetic reaper on rachitis, in Avhich he said that the results of feeding young animals in the Zoological Gar- dens strongly su])port the view that a deficiency of animal fats and earthy salts are the most efficient agents in producing rickets. lie states that in the Zoo- logical Gardens the young monkeys taken from their mothers and fed with a vegetable diet, chiefly fruits, became rachitic. Such diet is destitute of animal fat, and is deficient in proteids and earthy salts. Two young bears were fed with rice biscuits, and occasionally with lean meat, which they licked, but rarely ate. Fat, proteids, and lime salts were practically excluded from their food. The bears died of extreme rickets while still young. Cheadle also states that more than twenty litters of lions had died successively of rachitis, and the next brood were fed with cod-liver oil, pulverized bones, and milk. In three months all signs of rickets had disappeared. The addition of fat and bone- salts caused the chatige, and after eighteen months, when the last observa- tions were made, the brood of young lions were strong and healthy. They had received in every respect the same treatment as the litters that had })erished, except as regards the diet. The latter had been fed with the carcasses of phi horses, which are destitute of fat and whose bones resisted the lions’ teeth. The theory that lactic acid is the causal agent in rachitis has been strongly advocated by Dr. C. lleitzmann, formerly of Vienna, but now of New Tork. lie administered lactic acid by mouth and subcutaneous injection to five dogs, seven cats, two rabbits, and one squirrel. The lactic acid administered to the dogs and cats, with “restricted administration of calcareous fo()leen, and probably also of the liver, occurs chiefly in decidedly anaemic subjects. The Abdomen is Protuberant from various causes, fi’he lateral depres- sion of the thoracic walls causes the liver and spleen to descend a little lower in the abdominal cavity than natural, producing at the base of the chest anteriorly Harrison’s groove, which is transverse and corres))omls with the insertion of the diaphragm. The enlargement of the liver and spleen, the feeble tonicity of the intestinal muscular fibres, and conseejuent distention of the intestines with gas, and the rachitic shortening of the spinal column, BA CHIT IS. 327 which causes approximation of the ribs and pelvis, necessarily produce abdom- inal protuberance. The Kidneys and Urine . — Observations thus far have not detected any structural change or disease of the kidneys attributable to rachitis, except that this organ is enlarged in some cases. Moreover, the records of the urine are so conflicting that more exact and more numerous examinations of this excre- tion are required before any positive statement can be made in reference to its composition. Dr. C. H. Flagge has seen two cases in which there were large quantities of uric acid in the urine. Ephraim also mentions an increased elimi- nation of uric acid up to 18 per cent. Ephraim likewise, as well as Marchand and Lehmann, state that there is an increase of phosphate of lime and the occurrence of lactic acid in the urine. Brain and Spinal Cord. — It is not improbable that the symptoms of rachitis which are referable to the nervous system, such as laryngismus strid- ulus, tetany, convulsions, and weakness or paralysis of the extremities, may be largely due to the pressure exerted in places upon the cerebro-spinal axis by its bony covering. Hence we will postpone their consideration until we have described the changes produced by rachitis in the osseous system. Changes in the Osseous System. — A knowledge of the normal anat- omy and normal development of the osseous system will enable us to better understand the changes which occur in this system in disease, and especially, which concerns us at present, in rachitis. Hence we will give a brief rdsumd of the anatomy of the skeleton in health before we consider the changes pro- duced in it by rachitis. i Osseous System in Health . — In health and when fully developed, bone consists of animal matter (chiefly gelatin) and earthy salts, in the proportion, by weight, of about one part of the former to two of the latter. The following is the analysis, which may be regarded as approximately correct, of healthy human bone of the adult: Animal matter 33..‘10 f Tribasic phosphate of calcium 51.04 I Carbonate of calcium 11.30 Earthy salts, .j Fluoride of calcium 2.00 I Phosphate of magnesium 1.16 I. Soda and chloride of sodium 1.20 100.00 In childhood the bones are softer, more elastic, and less likely to fracture than in the adult. Of the earthy salts in bone, it is seen that the phosphate of cal- cium is the most abundant, and it is the most important. Hence it is termed “bone earth.” The phosphate of calcium, combined with animal matter, pro- duces a hard compound. The enamel of the tooth consists chiefly of phos- phate of calcium (88J per cent.), while the softer egg-shell consists chiefly of the carbonate of calcium. The strength of bone is remarkable, being, according to Holden, when compared with Avood, nearly three times that of the elm or ash, and double that of the oak. It is elastic on account of the animal matter which it contains. If a long bone be placed at right angles upon a hard sub- stance, and the projecting end receive a blow from a hammer, the latter will rebound. The Arab children are said to make bows of the camel’s ribs. If a longitudinal section be made through a long bone, we observe a hard or compact outer part, and in the interior the medullary canal, containing mar- row. In birds of flight the hollow of the bones contains air instead of mar- row, and this air communicates with the luno-s. 328 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. The hard or compact portion of hone, though solid like a stone, consists of layers in close apposition, so that there is no interval between them. On approaching the joints the internal layers of the compact structure separate from each other, forming the cancellous tissue, so that the compact wall becomes thinner. If the earthy salts be removed by an acid, the animal matter remain- ing is found to consist of layers, which can he separated from each other. In inflammation the afflu.x of blood and the exudation cause separation of the layers and enlargement of the hone. The cancellous tissue occupies the interior of the bone, and is most abun- dant in its articular ends. The bony layers in the cancellous structure are separated from each other, so as to form cavities, which are strengthened by cross-plates like latticework. In the adult the marrow in the interior of the shafts of the long bones is yellow, consisting of 96 per cent, of fat, but in the articular ends of the long bones, in the ribs, cranial bones, and short bones, the marrow has a reddish tinge, and it consists of about 75 per cent, of water and about 25 per cent, of albumin, without fat or only a trace of it. This kind of marrow occurs in all the bones of the foetus and the infant, and it contains cells with many nuclei, designated “myeloid cells.” Holden says that bones are as minutely provided with blood-vessels and nerves as are the soft tissues. Near the extremities of the long bones are numerous minute openings through which blood is conveyed to and from the cancellous tissue. On the shafts of the long bones are slight grooves parallel Avith the shafts, at the bottom of Avhich are minute holes, scarcely visible, through which blood is conveyed to and from the compact tissue. The blood Avhich sup])lies the osseous tissue is con- veyed througli these holes by minute arteries from the vessels of the periosteum, and is returned by veins to the periosteum. Near the middle of the shaft of the long bone is a distinct canal passing obliquely through the shaft. This canal contains the nutrient artery of the medulla, dividing, after entering the medul- lary cavity, into tAVO bi-anches, one passing upAvard and the other doAviiAvard. The blood-vessels sup|)lying the different jiarts of the bone from these various sources intercommunicate. Other bones than the long bones are siqipliod Avith blood in a similar manner, and the nutrient vessels are accomjmnied by nerves, as in other parts of the system. The microscope is recjuired in order to reveal the minute anatomy of bone. It is found to consist of canals, termed the Haversian, and around each canal the bone is arranged in concentric layers, like the concentric rings of a tree. BetAveen the rings are dark spots, designated lacuna', arranged concentrically, noAv knoAvn to he minute reservoirs containing blood. Minute lines are seen connecting the reservoirs Avith each otlu'r and Avith the adjacent Haversian canal. The lines are minute blood-vessels, and through them the blood is con- veyed to every part of the hone. They are designated canaliculi. d’lu'V con- nect externally Avith the vessels of the periosteum, and internally Avith the vessels of the medullary membrane or endosteum. In the intersjiaces betAveen the lacume and canaliculi, in the animal matter, an inlinite nuiuber of osseous granules is deposited, consisting mainly of phosphate ami carbonate of lime. AlteratioHK inihe (hnoouH SiiHfem in /i<(cliitis . — For convenienee of descrip- tion the course of rachitis as regards the osseous system is divided into three j)eriods : (1) That of proliferation and altered nutrition of cartilage and periosteum; (2) That of curvature and deformity; (3) d'hat of reconstruc- tion. 1 . Anatomical Characters in the Stage of Proliferation and Altered Nutrition. — The long bones in normal groAvth increase in h'ngth by the formation of hone in the cartilage hetAveen the diajdiysis and ei)iphysis, and II A CHITIS. 329 in thickness by the development of bone from the vascular and cellular under- surface of the periosteum. As regards the flat and short bones, growth in the thickness occurs from the periosteum, and growth in breadth occurs from the development and ossiflcation of the cartilaginous borders and edges, which correspond with the epiphyseal cartilage of the long bones. If we e.xamine the epiphyseal cartilage of a long bone during normal ossifi- cation, we observe, beginning at the distal end, a white zone, consisting of the hyaline matrix, in which are the usual cartilage-cells. This constitutes most of the cartilage. Underneath this, and nearer the bone, is the zone of prolifer- ation, the cartilage in which is softer and more yielding than that of the distal zone, in consequence of cell-formation and absorption of the matrix to make way for cell-groups. Each cell in the proliferating zone has divided into two cells, and each of these cells into two other cells ; and the division has been repeated, so that eight cells instead of one are observed, surrounded by a com- mon capsule. The capsule becomes distended by the cell-multiplication and the swelling of each cell, the size of which is considerably greater than that of the parent cell. Near the bone, along the extremity of the diaphysis, the cell- groups, enclosed in their capsules, nearly touch each other, the matrix having been for the most part absorbed. The end of the diaphysis is covered with a layer of these cell-groups about to undergo ossification, with almost no inter- vening matrix. The proliferating zone has very little depth. It appears to the naked eye as a very thin, scarcely perceptible layer of a reddish-gray color upon the end of the shaft. It is so thin that it but slightly increases the thick- ness of the cartilage. In rachitis the state is different. The zone of proliferation, instead of being confined to a single or at most double layer of cell-groups, consists of many layers, involving nearly the whole epiphyseal cartilage. The cells, still enclosed in their capsules, undergo a more frequent division than in health, so that, instead of groups of eight cells, as in the normal state, each group con- sists of tliirty or forty cells enclosed in the distended capsule. Therefore in rachitis the proliferating cartilaginous zone is a broad cushion, very soft, of a grayish translucent appearance, causing the characteristic swelling ol)served around the joint. Over the distal end of the proliferating cartilage there may still be a zone, though perhaps of little depth, of normal cartilage like that in health. While the changes described above occur in the cartilages, the ossifying process is arrested or rendered abnormal. We ijideed perceive an effort in the direction of bone-formation. The Haversian canals, surrounded by capillary loops, extend from the bone into the proliferating zone of cartilage. Their extension is effected by absorption of the matrix and appropriation of cell- groups which lie in their way. The cells in these groups, as they enter the Haversian system, become much smaller by rapid segmentation, forming medul- lary cells. We also find, as further evidence of the attempt at bone-formation, granules and masses of lime scattered through the cartilage, and here and there spiculae and nodules of true bone springing up from the bony substance of the shaft. Some of the canals are prolonged far into the cartilage — nearly, indeed, to its free surface — but most of them terminate in its lowest portions. We have stated that the growth of bone in thickness occurs from the under surface of the periosteum. In health a soft, vascular germinal tissue springs from the periosteal surface, rapidly receives lime salts, and is transformed into bone. This germinal tissue, consisting largely of capillaries rising from the fibrous tissue of the periosteum, is a very thin substance, barely visible, transient, and constantly changing from its conversion into bone. 330 AMERICAN TEXT-BOOK OF DIBEASEB OF CHILDREN. In rachitis this vascular subperiosteal tissue, not undergoing, or undergoing slowly and imperfectly, the osseous transformation, and at the same time increas- ing more rapidly than in health under the irritating influence of the rachitic disease, becomes a thick layer. Its color and appearance ax’e like spleen-pulp, so that the older observers supposed that there was hmmorrhagic extravasation between the pei’iosteum and the bone. Thei’e is, however, no extravasation of blood, unless it accidentally occurs from the numerous delicate capillaries. The resemblance to extravasated blood or spleen-pulp is due to the abundant growth of large and thin-walled capillaries from the under surface of the perios- teum, as shown by the microscope. This vascular outgrowth is, for the most part, quite uniform over the shafts of the long bones, while upon the cranial bones its thickness is much greater in one locality than in another. The attempt at ossiflcation also appears in this tissue. Lime salts are scantily and loosely deposited through it, forming osteophytes, vascular and fragile, rather than true bone. The question naturally arises. How does I'achitis affect bone which is already formed when the rachitic state begins? Virchow’s answer is the following: “Rachitis has by more accurate investigation been shown to consist, not in a process of softening in the old bone, as it has previously been considered to be, but in a non-consolidation of the fresh layers as they form : the old layers being consumed by the normally progressive formation of medul- lary cavities, and the new remaining soft, the bone becomes brittle.” We have seen that in healthy bone the earthy salts are in excess of organic matter nearly in the proportion of two to one, but in rachitis the proportion is reversed, the organic matter being much in excess. The following table gives analyses of rachitic bones by Marchand, Davy, Boettger, and Friedleben: Case I. . Case II. . Case III. Case IV. Femur. Radius. Vertebra. Inorganic. Organic. Inorganic. Organic. Inorganic. Organic. . 20.60 74.40 21.24 78.76 18.68 81.32 . 37.80 62.20 20.00 80.00 32.29 67.71 . 20.89 79.11 . 52.85 47.15 As might be expected, the relative proportion of the inorganic matter (the earthy salts) and the organic matter varies greatly in different cases. In severe rachitis many bones are .affected. It is stated that there is no bone in the entire skeleton that may not suft’er, but in mild cases only a few are involved, at least to such an extent .as to produce structural changes ajxpreciable to touch or sight. Rachitic bone, when the dise.ase is still in its active period, presents a bluish or dusky-red appearance from its increased vascularity. After a variable time — weeks or months .according to the severity of the disease — deformities begin to appear. 2. Anatomical Characters of the Stage of Deformity. — Characters or THE Rachitic F(ETUS. — S])iegelberg’s description of the rachitic foetus cor- rcs])onds for the most part with what 1 observed in the one whose skeleton is rej)resented in a foregoing p.age. According to this writer, the body and limbs .are plump, the latter short and curved, the abdomen large and prominent, and the head sometimes hydrocephalic. The skin is well developed and mov- able, the adi[)ose tissue sufficient, the liver large, the epijthyses swollen and soft, the short and curved diaphy.ses sometimes broken ; the rotundity of the thorax is preserved, and the sternum is not carried forward, since there has been no respiration. The ribs in softness and liability to fracture correspond with the long bones of the extremities. The sternum, most of all the bones, PLATE XI, RACHITIS. m LIBRARY CF M ilNIVEBSITr OF U MfW’S BA CHITIS. 331 shows the delay in ossification ; the clavicle is among those least affected. The cranium may be represented by a membranous bag with plaques of bone, or the cranial bones may be formed and in shape, but thickened and softened ; the sacral promontory is pressed forward and downward ; the ilia flattened and widened ; the pubic arch increased. Characters of the Rachitic Child. — In typical rachitis the bone sel- dom retains its normal form or shape : its projecting points are rounded, and as soon as it softens it begins to yield to pressure exerted upon it. Hence the curvatures so common and characteristic. The portion of a long bone which is formed after rachitis commences contains so little earthy matter that it bends readily in its fresh state either by muscular action or by the weight of the trunk “ in the manner,” says Vogel, “ of a quill or willow stick.” The interior of the bone, which was formed before rachitis began, and which contains nearly or quite the normal proportion of lime, is likely to break instead of bending, but, as it is surrounded on all sides by the soft tissue, the fi’agments are not displaced, and probably do not crepitate. So scanty is the calcareous deposi- tion in typical cases that, says Trousseau, “ the bones .... can be cut with a knife with as much ease as a carrot or other soft root,” and the dried specimen weighs from one-sixth to one-eighth of the weight of normal bone. One writer states that the dried rachitic bone is sometimes so porous from the small amount of lime which it contains that it is possible to respire through it as through a sponge. In ordinary cases the bones which exhibit most strikingly the rachitic change, and which, therefore, should be examined carefully in making the diagnosis, are the cranial bones, the ribs, and the radius — the sternal ends of the ribs and the lower end of the radius. It is seldom that these bones do not give evidence of the disease if it be present, and in greater degree than other bones. They are the first to be affected to an extent that is appreciable to the observer. Changes in the Cranial Bones . — In these bones interesting and important alterations occur. Their edges, which correspond with the epiphyseal cartilages of long bones, undergo proliferation, and become thickened like the latter. This thickening and the delayed union of the sutures produce grooves which can be traced by the fingers between the bones, and which are sometimes appreciable to the sight. Rachitis causes enlargement of the cranium, but the enlargement seems greater than it really is, on account of the retarded growth of the facial bones. In a discussion on rachitis in the London Pathological Society, reported in the London Lancet (1880, ii, 1017), it was stated that in seventeen rachitic children with an average age of 4.72 years, the average cir- cumference of the head was 21.22 inches, while in the same number who were nou-rachitic, and whose average age was 6.05 years, the average circumference was 19.95 inches. The retarded ossification is manifested not only in the open sutures, but also in the large size and patency of the fontanelles, which are not closed until long after the usual time. The anterior fontanelle in the healthy infant is closed at about the fifteenth or sixteenth month, but in the rachitic it remains membranous a longer time : in some cases it is still membranous as late as the third or fourth year. Since examination of the anterior fontanelle aids in determining whether or not rachitis be present, it should be borne in mind that in the normal state this space increases in size till the seventh month, when it is at its maximum, and that after the ninth month it becomes progressively smaller. Ossification in severe rachitis is retarded for a longer period than is stated above, for Gerhard relates a case in which the anterior fontanelle had not entirely closed at the ninth year. 332 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. The shape of the rachitic head varies. In general, instead of its normal rounded form it approaches a s(juare shape. Another type is sometimes observed in which there is no marked angularity, but in which the antero-posterior diam- eter is enlarged. In the square head the forehead projects, and both the frontal and parietal protuberances are unusually prominent. The sutures are depressed to a certain extent, as has already been mentioned, and the anterior, lateral, superior, and posterior surfaces are more flattened than in health. The undue prominence of the frontal and parietal eminences is largely due to the exaggerated proliferation of the periosteum and to the vascularity and infiltration under- neath. Enlarged veins are seen ramifying in the scalp, Avhich in marked rachi- tis supports a scanty growth of hair. The free perspiration from the scalp, and in some cases the activity of its sebaceous follicles, will be mentioned elsewhere. Craniotabes. — Thinning of the cranial bones in places, so that the brain lacked pi’oper protection, had long been noticed in the examination of rachitic heads, but the injury that resulted to the infant Avas overlooked until pointed out by Elsasser. Craniotabes occurs for the most part in infants under the age of one year, and a large proportion are under eight months. Its occurrence in the foetus, as shoAvn by a case published in the Netc Yorh Obstetrical Journal in 1870, and by Ileitzmann’s case, has already been alluded to. The factors in producing this thinning are rachitic softening of the bones and pressure from the brain Avithin and from the pilloAv Avithout. Consequently, the portions of the cranium in Avhich the thinning is most pronounced are the posterior and lateral, the occipital bone and the posterior half of the parietal. If the infant lie in its crib chiefly on one side, on this side the craniotabes occurs, Avhile those portions of the cranium Avhich are not pressed upon exhibit no thinning or a less degree of it. The soft spots in the cranium are yielding Avhen pressed upon, and in the cadaver they are seen to be translucent Avhen the bone is held to the light. There are in some instances simple de])res- sions like erosions in the bone, a continuous but thin bony layer remain- ing. In other cases, such as have been particularly examined and studied by physicians, the bony absorption has been complete over areas of greater or less extent. On examining a child for craniotabes it should be borne in mind that the margins of the cranial bones, even Avhen there is no thinning, but thicken- ing from the cartilaginous proliferation, are flexible in the rachitic. The ]ires- sure must be made in a direction aAvay from the sutures to ascertain Avhether craniotabes has occurred. The |>iessure should at first be made lightly and cautiously Avith the fingers, for if there be total absence, unless of very little extent, deep and forcible pressure might injure the brain, since so soft and del- icate an organ, covered only by scalp and dura mater, badly tolerates pressure. If the first examination detect no soft place, the fingers may be pressed more firmly against the scalp, Avhen, if the bone be much thinned, so that there is only a small layer of lime salts underneath, it Avill be found to yield. The sen- sation communicated to the fingers Avhen there is an o])en space in the cranium, and the dura mater ami scalp are in contact, has been likened to that ex))e- rienced Avhen pressing u])on a fully-distended bladder. At a meeting of the London Pathological Society, reported in the Lancet for November, 1880, Dr. Lees presented statistics to shoAV that craniotabes is one of the lesions of inher- ited syphilis; but Avliether it does sometinies re.sult from inherited syphilis or not, the evidence that there is a cranial softening Avhich is strictly rachitic, and Avhich occurs in those who have not inherited syjfliilis, aj)pears from re)H)rled observations to be conclusive. Chatajes in the Vertebra^ etc. — The short bones Avhich participate in the rachitic disease become softei' and more yielding, and their cancelli are filled liA CniTlS. 333 ■with a reddish pulpy substance. In many rachitic cases the vertebrae are but slightly involved, so that no deformity of the spinal column results; but occa- sionally, when many bones are affected, the vertebrae and intervertebral carti~ Fio. 2. Head of a Rachitic Child in the New York Infant Asylum. This child also had laryngismus stridulus. lages soften, and spinal curvatures result. The curvatures are due to the weight of the shoulders and head on the spinal column. They are, with some devia- tions, an exaggeration of those present in the normal state. Rachitic curvatures of the spinal column are therefore mainly antero-posterior, often with more or less lateral deflection. When there is much curvature the vertebrie become wedge-shaped, narrowed upon the concavity and thickened upon the convexity. The in- tervertebral cartilages are also more or less changed by the pressure, being thinned where the vertebrae approximate to each other on the concave aspect of the curvature, and of normal thickness or thicker than normal upon the convexity. The accompany- ing wood-cut exhibits the appearance and nature of rachitic spinal curvature continuing into adult life. Rachitis, having occurred at the usual age, resulted in the permanent deformity here illustrated. In extreme cases, fortunately rare, the functions of important organs may be seriously impaired by the curvature and consequent compression, as they are in Pott’s disease. Thus, according to Miller, the aorta has been so doubled upon itself as to materially dim- inish the flow of blood to the lower extremities, so that their nutrition was sensibly impaired. The effect of so great curvature upon the heart and lungs must obvi- ously be detrimental. At first the spinal curvatures disappear when the child reclines or is lifted by the axillae so as to raise the head and shoulders from the spine ; but when the deformity has continued so long that the vertebrae and cartilages have become Rachitic Spinal Curvature in an Adult (from a specimen in the Wood Museum, Belle- vue Hospital). 334 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. ■wedge-shaped, it remains for life or can only be rectified slowly and with difficulty by mechanical appliances. As seen in the wood-cut, the common curvature in the dorsal region is backward (kyphosis), while to compensate the patient instinctively carries the neck forward, with the head thrown back, causing cervical lordosis, a similar anterior curvature being common in the lumbar region. Lateral curvature (scoliosis) may or may not be present even when there is considerable antero-posterior flexure. Scoliosis is sometimes produced by the nurse in carrying the infant habitually over one arm. Changes in the Maxillce . — Fleischmann has investigated the changes which rachitis produces in the maxillary bones. Stunted growth of the facial bones, generally, has long been known, and has been remarked upon by various writers ; but, according to Fleischmann, other interesting changes occur in the jaw-bones which affect the direction and position of the teeth. According to this observer, the arched shape of the lower jaw becomes polj'gonal, and the direction of its alveoli also changes, so that they incline inward. This devi- ation in the arch and in the alveolar border of the lower jaw, which begins in the region of the canine teeth, necessarily causes softening of the jaw. Com- mencing soon after, a change is observed in the upper jaw-bone from the zygo- matic arch forward, so as to cause length- ening of this bone, changing the shape of the arch and the position of the teeth. The external incisors, instead of being in front, have a lateral position, and when the jaws are closed the superior incisors and molars overlap the corre- sponding teeth of the lower jaw in front and upon the sides — a condition opposite to that seen in the jaws of old ]>eople. Fleischmann attributes these changes in the lower jaw to the action of the mas- seter and the mylo-hyoid muscles, and perhaps the genio-glossus, and to pressure of the lip, the deficiency of earthy salts in the bone rendering it more easily acted on by the muscles. The change in the upper jaw-bone he attributes largely to lateral j)ressure of the zygo- matic arches. Changes in the Rihs . — The ribs are easily affected in rachitis. The swell- ing of their anterior ends, Avhere they unite with the costal cartilages, ])ro- ducing the “rachitic rosary,” has been already alluded to as one of the first and most conspicuous signs of rachitis. 3'hc costochondral articulations are enlarged in all directions, appearing as nodules under the skin. If at an autopsy an opportunity of inspecting the pleural surface of the articulation occur, the nodular prominence is seen to be even greater and more distinct than under the skin (Fig. 4). The deformity of the thorax, consequent upon softening of the ribs, is interesting. Commencing with the S])ine, the ribs extend nearly directly out- ward ; at the union of the dorsal and lateral portions they make a short curve forward and then turn inward, also with a short curve, toward the sternum Fig. 4. Rachitic Child with characteristic deformity of head and ril)s. (From a patient in the New York Foundling Hospital). BA CHITIS. 335 (Fig. 5). This abrupt bending of the ribs, which in their softened state has been caused by atmospheidc pressure during respiration, produces a depress- ion in the thoracic wall at about the point where the ribs and their cartilages unite. A groove extends on the antero-lateral aspect of the thorax from the second or third rib downward and a little outward. In some cases the costo- chondral articulations are in the line of greatest depression in the thoracic walls ; in other cases they are a little inside or outside of the deepest part of the groove. The transverse diameter, therefore, of the anterior half of the thorax is less than that in the normal rotund form of health. This neces- sarily diminishes the antero-lateral expansion of the lungs in inspiration and causes unusual prominence of the sternum. Hence the expressions “pigeon- breasted,” “resemblance to the prow of a ship,” etc. applied to this deformity. The presence of the heart renders the depression or groove less on the left side between the fourth and sixth ribs than on the opposite side, since this organ affords partial support to the chest-wall. On the other hand, the depres- sion on the right side below the sixth or seventh rib is, on account of the support given by the liver, less than on the left side. But on the left side, as well as on the right, the lower part of the thorax, that below the eighth or ninth ribs, widens, being pressed outward and supported by the abdominal viscera. This give^ rise to an antero-lateral furrow or groove near the base of the chest, sometimes designated Harrison’s groove. The ribs with their attached muscles are important agents in respiration, but their soft and yielding nature in the racbitic retards, and to a great Fig. 5. extent prevents, the lateral expansion of the thorax which is necessary for normal and full inspiration. The action of the respiratory muscles and the pressure of the air from within descending along the air-passages is not sufE- 336 A3IEBICAN TEXT-BOOK OF DISEASES OF CHILDREN. cient to fully overcome the external atmospheric pressure in the absence of the proper resiliency of the ribs. Consequently ■with each inspiration we observe more or less sinking of the thorax on each side, just as when a moderate obstruction to the entrance of air exists in the larynx or trachea. As the ribs become firmer from the deposit of lime salts, respiration is more regular and normal. Changes in Bones of Upper Extremities . — Although swelling of the lower end of the radius is one of the earliest signs of rachitis, the bones of the upper extremities are less frequently curved and distorted than those of the lower extremities. The clavicle sometimes softens and bends, pro- ducing two curvatures — one backward near the scapula, and another, of larger radius, nearer the sternum, directed forward and a little upward. Careful examination shows, in some rachitic patients, thickening of the margins of the scapulae like that of the cranial bones. The humerus is occasionally bent, and usually at the insertion of the deltoid in consequence of the powerful action of this muscle in raising and supporting the arm. The radius and ulna are bent outward and twisted. This deformity is attributed by Sir William Jenner to the fact that rickety children support themselves Avhile in the sitting posture upon the palms of the hands pressed upon the fioor or couch. Supporting the weight of the body in this manner not only, in his opinion, causes bending of the ulna and radius, but also aids in producing the deformities of the humerus and clavicle. Changes in the Bones of the Pelvis . — The deformities of the pelvic bones resulting from rachitic softening are very important in the female infant, since pelvic deformities during the procreative period are the common cause of tedious or instrumental labor and stillbirth. These deformities, which elon- gate some and contract other axes of the pelvis, necessarily occur when the rachitic child is in the erect position, since the pelvic bones supj)ort the weight of the trunk, head, and shoulders. A common defoi'inity produced in this manner is the carrying forward of the jiromontory of the sacrum, which sus- tains the weight of the spine. There is, moreover, twofold pressure from below — that caused by the heads of the thigh-lmnes in standing, and that exercised by the tuberosities of the ischia in sitting. Both these forms of ])ressure have a tendency to narrow the outlet of the pelvis. lienee the marriage of the female who has been rachitic in infancy may involve serious consequences. Fig. 6. Fio. 7. Fio. 8. Rachitic neformities of tlie Pelvis (from specimens in Wood's Museum). Many of the tedious instrumental labors in the families of the city poor, which severely tax the patience and endurance of young jiractitioncrs, arc attributable to rickets in earlv life. BA CHITIS. 337 Changes in the Bones of the Lower Extremities . — The curvature of the femur is usually forward or forward and outward. The neck of the femur sometimes bends by the weight of the body or by use of the legs, so that the Fig. 9. Fig. 10. Rachitic Deformities of the Femur (Wood's Museum). Fig. 11. Fig. 12. angle which it forms with the shaft is changed. The accompanying wood-cuts show the rachitic bend of this bone in an adult, years after rachitis had ceased and when the bone had become consolidated by the new deposition of lime salts. (Figs. 9 and 10.) The curvature of the tibia and fibula varies in different cases. In those under the age of one year it is likely to be outward, so that the knees are sep- arated from each other. In those old enough to stand, the weight of the body usually determines a forward bending of these bones. In one case in my prac- tice an anterior curvature, so abrupt that an angle of about 70° was formed, existed about five inches above each ankle. This patient, although old enough to walk, almost con- stantly sat during the day with the feet extended beyond the sofa, so that the edge of the latter corre- sponded with the abrupt curvature or angle of the legs. It seemed that the weight of the feet, unsup- ported beyond the edge of the sofa, had caused these curvatures, especially as the case was one of very marked rachitic softening of the different bones. Still, tibial and fibular bending at this point has been noticed by different observers, who have attri- buted it to the weight of the body in walking. Vari- ous other curvatures besides those mentioned occur in the bones of the lower extremities, the direction in which the limbs bend being determined by the par- ticular circumstances of the case. In mild cases of rickets most of the deformities described above may be lacking, but in typical cases certain of them stand out prominently, so as to be readily detected by one familiar with the disease. In all such cases the nature of the malady is apparent, for the changes that occur are not only conspicuous, but pathognomonic. Rachitis produces another important effect on the skeleton. Its growth is stunted, not only during the rachitic period, but subsequently, so that those who have been rachitic in childhood, unless very mildly, have less than the average stature in adult life. The stunted growth is apparent, though ample allowance be made for curvatures. The arrest of development is greater in some bones than in others. It is greatest in the bones of the face, pelvis, and lower extre- mities. Stunted growth of the pelvic bones of the female infant, conjoined 22 Rachitic Deformities of the Femur, Tibia, and Fibula (Wood’s Museum). 338 AMERICAN TEXT-BOOK OE BIBEABES OE CHILDREN. with the deformities alluded to above, may seriously affect her subsequent life, for the stunted development of the pelvic bones, like the deformities mentioned above, constitutes a valid reason for avoiding marriage. As a rule, the older the child is when rachitis begins, the less is the skeleton affected and the less, consequently, is the deformity. Effect of Rachitis on Dentition . — As might be expected from the nature of rachitis, dentition suffers severely. The delay in dentition has been con- sidered elsewhere in this paper. Teeth which appear during the rachitic state are frail, deficient in enamel, and crumble readily. They decay and break before the usual time. If certain teeth have appeared before rachitis begins, several months elapse before others cut the gum. It is even said that a child who has rachitis severely for a lengthened period may never have a tooth, and may remain toothless for life ; but I have never observed such a case. Ordinarily, when the rachitic state ceases and the health is fully restored dentition goes on in the normal way. 3. Anatomical Characters of the Stage of Reconstruction. — This stage will be better understood if we recollect what has occurred during the first and second stages. The very vascular periosteum is drawn tightly over the convexities, the pressure upon which diminishes the hyperremia and the amount of exudation underneath. Over the concavities the periosteum is loose : it is hypermmic tvith abundant new capillaries, the interspace between it and the bone being filled with the exuded soft material having a gelatiniform appearance. The reparative process goes forward rapidly, the deposition of lime salts being more abundant upon the concave surfaces, where there has been free exudation wdth no compression of the capillaries, than elsewhere. The lime salts are deposited from the blood. Consequently, from the increased capillary circulation and hypermmic state of the periosteum produced by rachi- tis, the earthy material is rapidly deposited wherever there is an open space under the periosteum and where the caj)illaries are in a state of enlargement. Hence the reconstructed bone is thicker and firmer upon the concave aspect of the long bones than elsewhere, and thinnest upon the convex aspect, where the periosteum is more tense and its capillaries more or less compressed. Normal ossification does not at first take place during the reparative stage. The deposition of the earthy salts is designated by some writers as a petrifac- tion rather than a true bone-formation. Trousseau likens it to the formation of a callus upon a fracture. A deposition occurs of lime salts more compact than ordinary bone. The term “ eburnation ” has been applied to this new osseous formation, and I have designated it osteo-sclerosis. It resembles, as regards its hardness and morphological appearance, the enamel of the tooth rather than true bone, the Haversian canals and lacunie being small and im- perfectly formed. Of course after complete recovery tbe sub.se(jue7>t formation of bone is normal. Recovery from rickets is grarogressive in its develojuucnt, occupy- ing months, there is an acute form which is attended by more marked febrile movement and tenderness than occurs in the usual type, and in ivliich the articular swelling appears more quickly. (Sec p. 350.) Treatment. — HYGIENE. — We recali the recent statement of Prof. Henoch of Berlin that the sju'ead of rachitis has been enormous in the cities of Central and Northern Europe. The poor of these cities, among whom this disease largely prevails, are emigrating in large numbers to the United State.s, but, as I have observed in the asylums and dispensaries of New York, the severest forms of imported rachitis come from Southern Europe (Italy). Evidently, as long as the influx of this class of foreigners continues, and the pre.sent insani- tary conditions exist in our cities causing rachitis in the native born, this will continue an iiiquutant disease, impairing the health and vigor of coming generations. It is evident from the nature of rachitis that succe.ss in prevent- ing it and in curing those who unfortunately exhibit its characteristic signs RA CHITIS. 343 requires beyond anything else the employment of proper hygienic measures. The details of the hygienic requirements may seem prolix and tedious, but we cannot expect any marked diminution of rachitis until they are better known and heeded by the masses. The fact that inheritance is one of the recognized causes of rickets renders it very important that the parents be in good health. The mother especially should avoid all agencies or influences which impair the general health during the procreative period. She should, so far as possible, encourage good appetite, take plain, easily-digested, and nutritious food, and lead a quiet, regular life, with sufficient out-door exercise to promote, so far as practicable, a state of perfect health. Country residence, with quiet exercise in the open air, a diet consisting of fresh vegetables, meats, fresh and abundant milk, eaidy retirement to bed and sufficient sleep, are much more conducive to the health of the mother and her child than are the excitement and irregularities of city life. We have seen that there is sufficient clinical and experimental evidence that the common and predominating factor in causing rachitis is the use of a faulty diet, but general insanitary conditions are also potent agents. The foul air and noxious effluvia of the crowded tenement-house, so conducive to disease and fatal to infants in New York, should, if possible, be avoided. Even if poverty compels a residence in the small and dark apartments of a tenement-house, crowded by families, many of them entirely neglectful of sanitary measures, yet parents solicitous for the welfare of their children can do much to diminish the insani- tary influences which surround them. Out-door air is everywhere available, and every child after the age of two or three months, unless suffering from acute disease, should in ordinary weather be in the open air one or more hours each day, as a means of improving its digestion and of producing a more vigorous state of the system. Any mother or nurse capable of the care of a child should be able to employ such measures as will prevent its taking cold while in the open air. The room occupied by a child, whether rachitic or not, should be at a uni- form temperature of about 70° to 73° F., and it should receive the sunlight or the full daylight, which is often excluded by faulty construction. The under- garments worn during infancy and cliildhood should be of wool, thin and light during the summer, thicker and heavier in the winter. No intelligent mother need be told of the need of personal cleanliness of her child as a means of promoting its health as well as comfort. This is a hygienic measure, and we need not repeat that the more complete the sanitary conditions the less the lia- bility to contract rachitis or any disease dependent on cachexia. Bathing of children should always be before the fire or in a warm room. The bath for an infant under the age of six months should be at about 90°. As the age increases the temperature of the bath should be gradually reduced to 80° in the second year, to 75° in the third year, and to 70° subsequently. The bath should be short, only long enough to ensure cleanliness. For weakly infants it is sometimes best to dispense with the general bath, and employ the sponge instead. I see no advantage in the use of saline or medicated baths. After the bath the extremities should be warm, and to ensure a better peripheral cir- culation friction of the surface by warm flannel or otherwise, or the application of warmth to the limbs, is often useful. The extremities of a child should always be warm, for the normal warmth of the surface not only promotes nutri- tion of superficial parts, but it tends to prevent internal congestions and inflam- mations, to which the rachitic are especially liable. A child that habitually has cool extremities cannot be at the maximum of health, and this is often the state of the poorly-fed and poorly-clad children of the tenement-houses. The 344 AMERICAN TEXT-BOOK OE DmEASER OF CHILDREN. measures to promote their normal circulation and warmth, such as exercise as far as practicable, artificial heat, exclusion of cold by woollen garments, friction of the limbs, either dry or by the use of mildly stimulating lotions, should be employed. But while the hygienic measures which we have detailed are important as means of invigorating the system and rendering it less liable to rachitis as well as other cachectic diseases, we repeat that the most common and ])Otent cause of the malady which we are considering is a faulty diet, so that in the endeavor to prevent and to cure rachitis special attention must be given to the feeding. Clinical experience abundantly demonstrates the fact that in order to pro- mote healthy nutrition the food of the infant should be breast-milk until the age of ten or twelve months; and subsequently, until childhood is well advanced, its food should consist largely of cow’s milk, properly preserved and prepared. We need not state that human milk varies in its composition according to the health, diet, mode of life, and temperament of the individual who furnishes it. Many mothers ])ossess the requisite moral traits to be good wet-nurses, and do all in their power for the welfare of their infants, but have an inadequate lacteal secretion. Many mothers, not only in the tenement-houses, but in the Avell-to- do class, are unable to furnish sufficient breast-milk, and their infants, unless they receive supplementary food, suffer from malnutrition and are liable to become rachitic. I have seen during the last year infants wet-nursed by their mothers, fretful, wasted, and at the verge of starvation, applied every half hour to the breast during the hours of wakefulness. Mothers, deprived of the needed sleep and sacrificing their own health in the constant endeavor to pro- vide for the wants of their infants, usually have insufficient milk, as in the cases alluded to. Under such circumstances a medicine designated nutrolactis, which consists largely of the Galega officinalis, has been employed in the New York Infant Asylum with apparent benefit as a stimulator of the lacteal secretion. But if suckling by the mother continue inadequate and her infant be under the age of six months, a wet-nurse should be employed. If this be inqmssible, supplementary feeding will be needed. In normal and sufficient wet-nur.sing the infant should go to the breast at regular intervals of about two hours, but at longer intervals at night (ten times in twenty-four hours). It should obtain what nutriment it recjuires in ten or fifteen minutes, after which it falls into a (juiet sleep. This allows the mother time and opportunity to rest and recuperate between the nursings, so that she furnishes milk more al)undant and of better quality than when she is worried and anxious and ileprived of needed sleep. The subject is so important that we may be allowed to repeat what we have elsewhere stated: An iiifant that draws the breast at short intervals of two hours obtains not only more milk, but richer milk, than when the intervals are longer. Tliere is no more important, and fixuiuently no more ])crplexing, duty of the physician than to direct the alimentation of infants. Ma-ny mothers express the determination to wean for trivial reasons, and are found to be giving one of the commercial foods without consulting the physician. On the other haml, many mothers .seriously declare that their babies are ravenous nursers, and that their breasts furnish an abundance of milk, when only a few thin drojis can be obtained by the breast-|mmp, and the appearance of the nurslings jdainly indicates innuti'ition and progressive emaciation. In such cases addi- tional nutriment is of course rc(i[uire(l. The practice, which is too common, of early weaning with insufficient reason and without consulting the j)hysician, is very misebievons. y\cnte and transient ailments of the mother may cause some (liminution in her milk, but BA CHITIS. 345 usually her health is not so injured by a short sickness that she is incapaci- tated for wet-nursing ; of course the continued loss of appetite, with progressive debility and anaemia, may be such that prompt weaning is imperatively required. If it be impossible to wet-nurse the infant, or if it have reached the age of ten or twelve months, at which time weaning is proper, it will be necessary to determine what food shall be given. In New York City — and the same is prob- ably true in other cities — the infant should not be weaned in the hot months, since the change of diet from the natural to the artificial at this time is very likely to cause that fatal disease, the summer diarrhoea. The infant should be first removed to the country before weaning, or, if removal be impossible, wean- ing should be postponed until after the heated term, even if it be at the age of fifteen or sixteen months. But with a large proportion of infants after the age of six months the mother’s milk is not sufficient, and it is necessary to supple- ment the wet-nursing by the use of other foods. Notwithstanding the many commercial foods designed for infant feeding, I have every year been more and more convinced that cow’s milk, prop- erly prepared, furnishes the best substitute for human milk, and should be used to make up the deficiency when the latter is insufficient, and be the main food or the basis of the food employed after weaning. I have observed the occurrence of rachitis in children whose diet consisted chiefly of certain proprietary foods ; and, in looking over the composition of these foods, one of the chief causes of this result appears to be the small amount of fat which they contain. Thus, according to Prof. Leeds’s analyses, Mellin’s Food contains only 0.15 part in 144.74, and Nestlfi’s Food only 1.91 parts in 139.69, whereas human milk contains 3.90 per cent, of fat, and cow’s milk 3.66 per cent, of fat. Especially in the selection of food designed to prevent or cure rachitis our choice should fall on cow’s milk next to human milk. But cow’s milk contains five times more casein than human milk, and is slightly acid, whereas the latter is always alkaline. In the country, cow’s milk obtained fresh and with proper attention to cleanliness in its manipulation may not require sterilization by heat. But that received and used in the city, exposed more or less to an atmosphere containing numerous microbes, it is well to sterilize by steaming for a period not exceeding twenty-five minutes. For infants with feeble digestion, who are suffering from innutrition, digestion of cow’s milk can be promoted by pepton- izing by the peptogenic powder of Fairchild in the manner well known to the profession. Inasmuch as observations relating to the causation of rachitis, which we have quoted elsewhere, show that deficiency of fat in the food is a common cause, I recommend, especially if any rachitic symptoms appear, the use of the upper half or third of the can or bottle of milk, since this contains a large percentage of cream. A properly-prepared farinaceous substance, mixed with milk, not only has nutritive properties, but also, by mechanically separating the particles of casein, tends to prevent the formation of curds in the stomach. But as young infants digest starch with difficulty, a flour, as barley, wheat, or oatmeal, in which the starch is to a great extent converted into dextrin, or, better, into glucose, may be advantageously added to the milk, especially for infants over the age of six months. The conversion of starch into dextrin may be effected by a high heat, and into glucose by the action of diastase. If a heaped teaspoonful of barley flour be boiled in twenty-five teaspoonfuls of water, and when it is lukewarm ten or fifteen drops of diastase (Forbes) be added to it, the gruel in a few min- utes becomes much thinner from the digestion of starch, and it is a useful adju- vant to the milk employed in the nursery, especially for infants over the age of six months. 346 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. But while healthy development in infancy and childhood requires a careful choice of food suitable for the stage of growth and development, the frequency of the feeding and the amount of food given are also matters of importance. There can be no doubt that many infants are under-fed, some even to starva- tion, and some infants are over-fed. MINI. Vernois and Becquerel, in a careful examination of 89 infants wet-nursed by mothers apparently in good health, ascertained that 15 were insufficiently nourished. Did space permit I might relate instances in which infants were applied to the breast even more fre- quently than the prescribed rules allow by affectionate and devoted mothers or by wet-nurses supposed to have sufficient milk, and yet they continued to lose flesh and strength, were almost constantly fretful, and were finally reduced to a precarious state by insufficient nutriment. On the other hand, overfeeding sometimes occurs to the detriment of the child. A half century has elapsed since the most distinguished New England physician of his day. Dr. James Jackson, called the attention of the profession to the frequent, green, and unhealthy stools, showing imperfect digestion occurring in children from over- feeding. Among the cachexiae developed from abnormal digestion and malnu- trition we recognize rachitis as one of the most frequent. A few years ago Drs. Chadbourne, Parker, and myself made observations in the New York Infant Asylum and New Y"ork Foundling Asylum in order to determine hoAV much food children require at different ages. Those selected for observation were well nourished, and they w'ei’e accurately weighed before and after each nursing or feeding. Eleven infants under the age of three weeks, who took the breast, Avitli three exceptions, twelve times in the twenty- four hours, Avere found to take on the average 12.55 ounces of the breast-milk in the day and night. Therefore, according to these statistics, infants under the age of three Aveeks, nourished at the breast and suckled tAvelve times in the twenty-four hours, require only one ounce, or not more than one ounce and one drachm, at each nursing; and the very small size of the stomach at this age shoAvs that it cannot receive much more than this Avithout distention. After the third Aveek the amount of food required for healthy nutrition gradually increases. Children, like adults, in good health and Avell nourished, do not all require or take the same amount of food. Some need more food than others, but tlie folloAving table indicates, I think, nearly the quantity recjuired during the first tAvelve months of infancy, either of breast-milk or of food prepared so as to resemble as closely as possible breast-milk in consistence and nutritive proper- ties. It will be observed tlmt this table resembles closely that prepared by Prof. Rotch of the Harvard Medical School, and published in his instructive paper on infant feeding in the Cyclopa‘dia of the Diseases of Children: Quantitji of Food required in the First Year of Infancy. At each Feeding. Number of Daily Feedings. Total Daily Amount. During tlie first week 10 10 oz. At the third week 10 I.") oz. At the sixth “ 8 It) oz. At tlie third month 8 24 oz. At the fourth “ 7 28 oz. At the sixth “ 6 8t) oz. At the tenth to twelfth month . . .8 oz. 6 40 oz. The daily average of food for each child in an aggregate of tAventy-eight healthy children between the ages of two and three years Avas as folloAVs: Bread, 7.5 oz. avoir. ; butter, .98 oz. ; meat (beef), 4.6 oz. ; potatoes, 3.9 oz. ; milk, 32.6 11. oz. The daily average for each child in an aggregate of twelve children betAveen the BA CHITIS. 347 ages of three and six years was as follows: Milk, 48.6 11. oz. ; beef, 12.1 oz. avoir. ; rice, 13.0 oz. ; bread, 10.3 oz. ; butter, 1.08 oz. The daily average for each child in an aggregate of twenty-four children between the ages of four and ten years: Roast beef, 12.46 oz.; bread, 10.23 oz. ; potatoes, 10.03 oz. ; butter, .99 oz.; milk, 38.5 11. oz. The prevention and the cure of rachitis require strict enforcement of the details of hygiene. Hence the above facts relating to the mode of life and diet of children should be observed in order to prevent cachexia and promote a healthy growth. Medicinal Treatment. — Medicines which aid the digestion and assimila- tion of properly-selected foods are sometimes useful. Irritability of the stomach, imperfectly digested stools, flatulence, colicky pains, etc. indicate faulty diges- tion, which may be improved by pepsin given with each feeding. Tonic reme- dies designed to improve the appetite and digestion, of a kind suitable for the age and condition of the patient, are often useful. In anaemia one of the readily-assimilated preparations of iron should be given. The complications which are so common require special management. The laryngismus stridulus, eclampsia, and tetany should be promptly treated. The bronchial catarrh to which rachitic infants are liable may be best treated by remedies like the following: I^. Ammonii chloridi 3j. Syr. Tolutan fgij. — M. Sig. Dose fifteen drops every hour or two hours for an infant of six to ten months. I^. Ammonii chloridi Ferri et ammonii citratis dd ,3ss. Syrupi fgj. Aquae fsiij- — M. Sig. Give one teaspoonful every two to four hours to a child of one year. Some of the rachitic cases with protracted bronchial catarrh, especially those which also exhibit scrofulous symptoms, may be most relieved by the syrup of the iodide of iron and cod-liver oil administered three times daily, with the inhalation of moist air containing turpentine vapor. In the protracted intestinal catarrh of rachitic infants I have observed the best results, so far as medicine is concerned, from the following prescription : I^. Subnitrate of bismuth S'j-iij- Essence of pepsin (Fairchild’s) f^j. Distilled water fsiij. — M. Sig. Shake bottle; give half to one teaspoonful, according to the age, every two hours. But a remedy is needed which will act promptly in the cure of rachitis so as to prevent the evil consequences which its continuance is sure to produce. It is the opinion of many of the best clinical observers who have had ample experience that this has been discovered in the daily use of minute doses of phosphorus. Wegner fed young and growing animals (rabbits and fowls) for months with small, non-poisonous, and easily assimilated doses of phosphorus, with the result, he believes, of expediting ossification and producing firmer bone. 348 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. He states that under the influence of phosphorus the large marrow spaces diminish, by the formation of true bone, to the size of the Haversian canals in normal bone. According to Wegner, the administration of flnely-divided, non-poisonous doses of phosphorus for a prolonged period to older fowls pro- duced to a considerable e.xtent the conversion of cancellous into compact bone of normal chemical composition. Kassowitz has recently promulgated his views at some length on the pathology and treatment of rachitis. He states that the lime salts are not needed, since the ordinary food contains suf- cient lime ; nor should the farinaceous foods be restricted. He adds that phosphorus in small doses restricts the formation of vessels in the growing bones of small animals. Hence it is useful as a means of overcoming the hyperjemia. Kassowitz administers about of a grain in a teaspoonful of cod-liver oil, the dose, of course, varying according to the age of the infant. The distinguished psediatrist of Vienna, Dr. Widerhofer, says of this remedy that its employment “ impresses him with the belief that it is not without benefit in the second year of life and upward.” He thinks that it may be useful in the hardening of long bones, but he has not been able to obtain good results in craniotabes. Starker gives an analysis of 23 rachitic cases treated by Prof. Thomas of Freiberg in his clinic. He used the following formula : 1^4. Phosphor! 1 centigramme (about grain). 01. morrhuiB 100 grammes (about 3 ounces). — M. A coffee-spoonful was administered twice daily, but variations in the dose accord- ing to the age are not stated in the report, the patients being between the ages of a few months and four years. Improvement occurred in the general condition in 18 cases ; in the cranial development in 15 cases ; in dentition in 14 cases ; in the shapes of the epiphyses in 21 cases ; in locomotion in 17 cases ; but strict attention was bestowed upon the hygiene, and especially upon the diet. Soltmann states that good results occurred from the use of phos- phorus in 70 cases which he had under observation, and in no instance were unfavorable results noticed. W. Meyer obtained similar results in 42 cases. He regards phosphorus as a specific for rachitis. When properly given it always, says he, produces positive results. Petersen has treated 200 cases with jihos- phorus, and regards it as a specific. Sigel concludes, from the observation of 40 cases in private practice, that constitutional treatment is of the greatest importance, but instead of the administration of iron, lime, etc., phosphorus should be prescribed. Unruh also made many observations in the treatment of rachitic cases by phosphorus in the Dresden Hospital in 1885 and 1880, and considers it more efficacious tlmn other remedies. Toplitz of Breslau treated 518 cases with phosphorus combined with cod- liver oil. No ill effects were observed, and in all the cases imj)rovement occurred in the general condition. Of 208 cases of craniotabes, 176 were cured in eight weeks. In 58 cases of laryngismus stridulus the attacks ceased iji eight to fourteen days, after having continued for months under other forms of treatment. Dentition Avas also promot('d. In America, Dr. A. Jacobi, who has had a large clinical e.xpcriencc, also highly recommends phosphorus in the treatment of rachitis. The dose should be small, even minute, not more than Tj-J-g- to y-J-g- of a grain, according to the age, three times daily. As regards my oAvn observations, I am not able to e.xpress a positive oj)inion as to the value of the phosphorus treatment, for reasons Avhieh 1 think also apply to many of the cases embraced in the favorable statistics of the dis- RA ClIITIS. 349 tinguished observers mentioned above — to wit, the simultaneous use of cod- liver oil and improvement in the diet and general hygiene. The following prescriptions may be employed — first, the oleum phospho- ratum, made according to the following formula:. Phosphorus 1 part. Ether 9 parts. Almond oil 90 “ — M. One minim contains of a grain of phosphorus. Or, secondly, the following, known as Thompson’s mixture : I^. Phosphori g^-j- Alcoholis (absolut.) TTL cccl. Spts. menth. piperit TTLx. Glycerini f5ij. — M. Sig. Six drops, increased to 10, three times daily, to a child of two to four years. Ten minims contain of a grain, and thirteen minims contain y^^ of a grain. Phosphorus should, I think, be given after the meals, in order to prevent irritation of the stomach. Dr. H. H. Pui’dy, physician to the large class of children’s diseases in the out-door Department at Bellevue, has preserved statistics of the treatment of rachitis during the last year. The cases which furnish the statistics numbered about 80, and he gives a rdsumdof the results of treatment as follows : “ Some were given cod-liver oil alone, some, cod-liver oil with phosphorus, and others, phosphorus alone, and of course all the mothers were given instruction in feed- ing and hygiene. Those infants that received only phosphorus were the slow- est to improve. Indeed, in several cases this method of treatment was aban- doned because of the absence of the signs of improvement. The group treated with cod-liver oil did the best. In fact, all of the infants that could tolerate the oil derived much benefit from it. The group that were given cod-liver oil with phosphorus did very well, but seemingly no better than those that were given only cod-liver oil. The preparation that seems to be the most beneficial is one that is used at the Church Hospital and Dispensary. It is an emulsion of cod-liver oil made with the yolk of eggs. The formula for the emulsion is : Bii. Yolks of ten eggs. Cod-liver oil Oij. Syrup of wild cherry Oj. Sherry wine Oj. — M. Sig. One or more teaspoonfuls administered three or more times daily.” In my opinion the treatment by phosphorus is still tentative, notwithstand- ing its recommendation by so many distinguished physicians ; and the old remedies, cod-liver oil and iron, should not be abandoned, although trial may be made of phosphorus at the same time. Care should be taken to prevent deformities while the bones are soft and yielding. The patient should not be encouraged to stand or use the limbs until they become firmer. He should lie upon a soft and even mattress. Uniform support of body and limbs is requisite in order to prevent curvature. In craniotabes the pillows should be soft, and care should be taken that the yield- 350 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. ing parts of the cranium be not unduly pressed upon. Profuse perspiration may be relieved by sj)onging with vinegar and water. The patient may be bathed in water a little cooler than the body, and rock salt may be added to the bath. The attacks of laryngismus stridulus, eclampsia, and tetany which so fre- quently complicate rachitis should be promptly treated by the remedies which are appropriate when they occur under other circumstances. Constipation may be treated by enemata of glycerin and water if not relieved by change of diet. The surgical treatment of rachitic deformities is sometimes important, but Prof. Ogston of the University of Aberdeen and other surgeons who have given special attention to this subject state that in young patients these deformities frequently diminish during growth, so as to cause little inconvenience in adult life. The measures employed by surgeons in order to cure or minimize the deformities are fully set forth in surgical treatises. [Acute Rickets. — It is now generally accepted by American and English observers, that the condition sometimes described as “acute rickets” is in reality scorbutic in nature. This is certainly true of the cases reported by Moller, Bohn, Forster, and Senator. The case of Flirst, quoted by Dr. Smith on page 342, which showed diffuse cylindrical swelling of both tibise and of the left femur, is certainly very suggestive of scorbutus, despite the fact that the statement is distinctly made, “no scorbutus, no stomatitis.” In this case it can only be said that “'acute rachitis ” is “not proven.” — Ed.] RHEUMATISM. By J. M. DaCOSTA, M. D., LL.D., Philadelphia. I. Acute Rheumatism. Acute rheumatism, or rheumatic fever, is a specific febrile malady characterized by inflammation of fibrous tissues, particularly those surrounding the joints, of which many are apt to become aflTected simultaneously or in suc- cession. There is also in rheumatism a strong tendency for the serous mem- branes, especially those of the heart, to become involved, and in children we frequently find these bearing the brunt of the disease while the articular affection is very slight. Etiology. — The cause of rheumatism is the accumulation of some poison- ous matter in the blood which irritates specially the fibrous and serous tissues. The most commonly held opinion is that this poison is lactic acid, though the evidence is far from conclusive. The lactic acid may be the result merely of the morbid process, not the cause. Though sought for, specific micrococci have not been demonstrated, nor has the origin of acute rheumatism in disorder of the nervous system been proved. But, whatever the remote cause, it is certain that chilling of the surface is in the majority of instances the immediate cause producing the attack. A history of exposure to cold and damp can be almost always obtained. In instances, on the whole infrequent, the poison of scarlet fever produces pain, swelling of the joints, and even cardiac symptoms indistinguishable from acute rheumatism. The most potent predisposing cause of acute rheumatism in the young is hereditary tendency. Out of 492 cases Cheadle found a distinct history of its occurrence in near blood relations in 173. The strong hei’editary tend- ency is also illustrated by the experience of Steiner : of 12 children of a mother who had suffered from acute rheumatism and heart complication, 11 had the disease before they were twenty years of age. Besides the complaint running in rheumatic families, I have noticed that the children of gouty parents develop rheumatism in greater proportion than found in those free from gouty taint. With reference to sex, unlike what happens in adult life, acute rheumatism is more common in girls than in boys. It is not often seen before six years of age. Yet August Seibert met with rheumatism in 13 children under one year of age, and cases of its occurrence in very young infants are recorded by Henoch, Senator, and Koplik. A case of acute rheumatism in an infant eleven days old is reported by Guthrie, and two remarkable instances of its manifesting itself soon after birth are mentioned by Jaccoud : one showed itself three days, and another twelve hours after birth, the mothers at tlie time being ill with acute rheumatism. I have myself met with a case of acute rheumatism under two years of age. This happened in a girl the daughter of a 351 352 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. highly gouty father. She has now grown to womanhood, having had three severe attacks of rheumatic fever, but without the heart becoming affected. Morbid Anatomy. — The joints show an injected synovial membrane, and there is effusion of fluid into them and into the surrounding tissues ; the fluid contains blood-cells and sometimes leucocytes. Minute haemorrhages into the membrane are not uncommon ; the cartilages are swollen, but it is very rare for them to suppurate or to ulcerate. Near the affected joints and tendons fibrous nodules similar to those found on the valves of the heart ai’e met with, and the parts around the joints, as Henoch has called attention to, may be infiltrated with inflammatory exudation that even becomes as hard as bone. Nodules growing from the bone, a nodular periostitis, have been described by Angel jMoney. In the heart inflammatory lesions are usual, both in endocardium and in pericardium. The pericarditis in the acute rheumatism of childhood, Cheadle has pointed out, frequently extends to the anterior mediastinum, the connective tissue of which becomes extensively thickened. The extent of pericardial effusion is not generally great, but there is much plastic exudation in the membrane. Fibrinous coagula are found in the heart and great vessels. Pleurisy with or without effusion is often seen. Symptoms. — The symptoms of acute rheumatism in childhood are the same as those of adult life : redness and swelling of the larger joints, pain, fever, per- spiration, heart involvement. But these symptoms do not occur in the same degree. 'Ih.e joint affection is apt to be slight — certainly the swelling and red- ness are — while stiffness and tenderness may be marked. The joints become successively involved, but in children it is not uncommon to find the rheu- matic inflammation limited to a very few joints, such as the ankles or the wrists. Even there it may be pain and tenderness rather than swelling that arrests attention. It is on account of the slight joint affection that acute rheu- matism in children is often overlooked, and the pain and tenderness are attri- buted to a fall or a sprain until the damaged heart tells the story. The fever is not high or long-continued; it is seldom above 102° F. Of those terrible cases with high temperature — temperature reaching from 107° to 110° — of which I have met with many in adults, I have never seen an instance in childhood. Fagge observed in 14 cases of the dreaded complication notone less than eighteen years of age ; Wilson Fox, in 22 cases none less than seven- teen years ; Barlow records a fatal case in a girl of thirteen. Hyperpyrexia is certainly most unusual ; and so are the cases with delirium and other signs of cereln’al disorder, and the cases with typhoid symptoms, whether associated with high temperature or not. Where the febrile rise is high and j)rotracted there is apt to be delirium, and the morbid signs generally dejumd upon a heart affection, especially j)erica.rditis. The tongue is not so coated .as it is in adults ; the urine is high-colored, dense, with an excess of lithates. From among the usual symptoms of rheumatic fever we miss in children the j)rofuse acid sweats. The skin is moist, but not bathed in perspiration. The heart Hipnptoniif of the rheumatic fever of childhood occur very com- monly ; indeed, in children endocarditis and ]>ericarditis are more usual attendants on acute rheumatism than in adults. Endocarditis shows itself by incre.ased restlessness, hurried breathing, dry cough, uneasiness or pain in the cardiac region, a rise in temperature or at least a sustained fever tempera- ture, and the development of a murmur, which is generally at or near the apex and systolic. This mitral murmur is followed by an accentuated second sound, or its reduplication, at the apex ; in rarer instances in place of a mitral an aortic murmur is present; in yet rarer inst.ances there is a diastolic aortic murmur, or a diastolic or a presystolic mitral murmur. The imj)ulse is some- RHEUM A TISM. 353 ■what increased in force, slightly in extent, but the percussion dulness, diffi- cult to ascertain in a child, is not distinctly altered. The pulse becomes more tense, and its heats are not e(jual. As the case advances, impaired pul- monary resonance and fine rales indicative of congestion may be noticed, and restlessness and anxiety and irregularity of the circulation augment. Where ulcerative endocarditis takes place, recurring chills like those of malarial fever, followed by high temperature and profuse sweats, are apt to occur. And both in this form and in the simple form of endocarditis masses of fibrin may be washed from the vegetations into the vessels of the brain or elsewhere, and cerebral embolism or embolic pneumonia or other kinds of embolism thus happen. Besides the marked forms of endocarditis we may encounter only dulness of the first sound, giving it a murmurish character, without decided genei’al symptoms attending the ill-developed cardiac changes. These are instances of mere swelling and slight inflammation, and rarely result in persistent alteration of the valves, as the cases with well-defined murmur commonly do. Then, again, it must be borne in mind that there are many cases in which the general symptoms are so slight that the endocarditis readily escapes detection. Indeed, it is alone the recognition of the changes in the heart-sounds that makes sure of the presence of the malady. Pericarditis, owing to the greater difficulty of its recognition, is more often overlooked than endocarditis. This is especially the case in very young chil- dren, in whom, however, it is not common. It may occur at any stage of rheu- matism: sometimes it precedes the joint affection; often it pursues a sub- acute, irregular course, subsiding and breaking out anew as fresh joints become involved. The symptoms are those of endocarditis, but there are greater restlessness and distress, more marked signs of nervous disorder, a tendency to higher temperature, more cardiac pain. The physical signs are the same as in the adult ; prominent among them is the friction-sound, fol- lowed, when effusion takes place, by increased percussion dulness, by dispro- portionate distinctness of the sounds at the base as compared with those of the apex, by muffled sounds at the apex, and its upward displacement. It is much more difficult in children than in adults to make out the dulness, or to deter- mine its triangular shape or its existence in the fifth interspace to the right of the sternum; and very often the dulness is of irregular shape, and dependent upon thick layers of plastic pericarditis, indicating its existence by coarse friction and by the sounds of the heart being much the same at the apex and at the base. This form of pericarditis without liquid effusion is, indeed, com- mon in childhood. So is pleurisy as an attendant upon acute rheumatism common, and not only single pleurisy, likely then to be left-sided, but double pleurisy. One of the dangers o'f left-sided pleurisy is that the inflammation is apt to spread to the pericardium ; at all events, whether from contiguity or from simultaneous action of the rheumatic poison, pleurisy and pericarditis are often combined, and both may be of the exudative plastic variety rather than attended with effusion. Still, effusion does happen in rheumatic pleurisy, and may be of slow absorption or become purulent. Pneumonia rarely complicates the pleurisy ; when it does, it may only reveal itself by rise of temperature, with- out marked cough or expectoration, and by the physical signs. Cheadle believes that these are different from those of pneumonia in the absence, except in the embolic form of the malady, of fine crepitation. Chorea bears a very close relation to the rheumatism of childhood. Rheu- matic children are very apt to be irritable, nervous, emotional children, and 23 354 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. therefore with nervous systems predisposing to chorea. The chorea associated with acute rheumatism has, in my experience, most generally shown itself toward the end of the attack and when the acute symptoms have disappeared. In the majority of instances there has been pericarditis or endo-pericarditis. Sometimes the choreic movements begin at the height of the malady, or the chorea even precedes the joint affection. It must further, in estimating the relation of chorea to rheumatism, be borne in mind that chorea does not always follow an acute attack, but may come on in those of rheumatic taint, without previous well-defined rheumatic manifestations. Cutaneous erujAions are often seen in the rheumatism of childhood. The most common form is erythema, which appears on the limbs and the body, and is of the papulated or marginated form, or shows itself as urticaria, less often as erythema nodosum ; in rare instances it is purpuric and associated with sub- cutaneous hemorrhages. Barlow has pointed out that the erythematous rashes may appear simultaneously with pericarditis, or precede this and the articular symptoms. But more important tlian these rashes, and much more strictly linked to rheumatism, are the fibrous nodules. Of extreme rarity in adults, they are not uncommon in children. They are mainly to be found about the joints, are hard and painless or slighly tender on pressure, of size varying from a pin’s head to a cherry, and are chiefly to be ascertained by the touch. They come and go in a few weeks, though they may last for months. It is not unusual to have them appearing in crops, and, though these subcutaneous nodules may project from the surface, the skin over them is not discolored. They are almost constantly associated with endocarditis or with pericarditis, and Avhen abun- dant and frequently recurring imply a progressive cardiac affection. Among disorders we frequently meet with in the rheumatism of child- hood is tonsillitis. It is often antecedent to the rheumatic attack or occurs in its course, and is combined with decided rise of temperature and pain in swallow- ing. It is not followed by either ulceration or suppuration. The ancemia that attends the rheumatism of childhood is very pronounced, and persists long after the attack. Where successive rheumatic seizures occur it becomes more and more decided, and is often associated with marked irrita- bility of the nervous system and emotional disturbance. In its persistence it may become a factor in the mischief wrought by a heart disease and in the development of dropsy. Diagnosis. — The diagnosis of acute rheumatism in a child is more difficult than in an adult, because the joint affection is often very slight, and may be nothing more than mere stiffening attended with moderate fever, or pain in moving certain muscles and tendons. Under these circumstances we have to lay great stress on the family history, on the character of previous seizures, on the occurrence of attacks of tonsillitis. Signs of endocarditis or pericar- ditis, or pleurisy, or erythematous rash, or nodules, would bo conclusive. In .some instances, too, epistaxis, an occasional sy!iq)tom of ^he rheumatism of childhood, is very significant ; so is chorea. Endocarditis or pericarditis in a doubtful case would be, however, the most certain of ])roofs. When the joint affectioji is distinct, scarlatinal rheumatism is the disease most likely to be confoutided with ordinary acute rheumatism. As regards the symptoms I know no difi’erence ; heart affections in scarlatinal rheumatism are less common, but they arise. I have sometimes thought the absence of sweating diagnostic, but the acid sweats of rheumatic fever are also often absent in the rheumatism of childhood. Nothing but the ajitecedent his- tory makes the case absolutely certain. The severe pain and the swelling BIIEUMA TISM. 355 of the joints sometimes observed in cerebro-spinal fever may cause this to be mistaken for rheumatism. But the violent headache, the retracted head, the rosy or petechial eruption, the irregular temperature and pulse, are very different from the combination of symptoms noticed in rheumatic fever. In its earlier stages rickets may mislead, on account of the swelling near the joints, the pain, the sweats, the fever. Yet the absence of redness of the joints, the size of the epiphyses, the undisturbed heart, the cachexia, the pale urine, and the fact that the Avrist-joints are apt to be the ones first disturbed, or that the swelling shows itself chiefly on the dorsum of the foot and on the back of the hand, are full of significance. From pymmia, rare in children, rheumatism differs by the irregular fever of the former, the SAveats, the great pain and sAvelling that are found in only one or in a feAv joints, and the course of the disease. There is a pymmic arthri- tis to Avhich infants are liable, that ToAvmsend has Avell described, Avhich runs an acute course, is mostly confined to the hip or knees, and in Avhich the effusion speedily becomes purulent. Its occurrence in infants at the breast or when gonorrhoeal ophthalmia or vaginitis is present also distinguishes it. Scurvy may present pain and swelling of the joints; the absence of fever and the condition of the gums tell us that it is not rheumatism. In congenital syphilis the state of the bones near the joint may lead to the thought of rheuma- tism, but the characteristic eruption, the snuffles, the emaciation, the enlarge- ment of the spleen, the rarity of fever, and the fact that the symptoms arise in early infancy are diagnostic. The diagnosis of the most dreaded affection in rheumatism, the endocar- ditis, presents the same points for consideration as it does Avhen it is not of rheumatic nature, and is discussed in another part of the volume. I Avill only here mention hoAv important it is to remember the antemic state that rheuma- tism develops in the young, and not to regard every murmur arising in its course, and especially Avhen it has nearly run its course, as organic and as likely to lead to permanent valve-injury. These soft, systolic blood-murmurs are unconnected Avith change in valve or in muscular texture, and gradually pass away. Course and Duration. — The course of acute rheumatism in childhood depends very much upon the complications, especially upon the cardiac lesions. Nor do we find as many frank cases running their course in a definite time ; the cases are mostly subacute, with subsidences and fresh outbreaks. On the other hand, in infants there are instances of very rapid progress. Jaccoud’s cases in infants soon after birth terminated, one in eight days, the other in little more than tAvo Aveeks. As a general rule, the rheumatic fever of child- hood lasts betAveen tAvo and three weeks. Slight cases, Steiner estimates, get well in from ten to fourteen days. Goodhart’s results in ten cases, of Avhich he stated that the longest duration was four days, is not the general experience. It is difficult to be precise in this matter of duration, since much depends upon hoAV early the patient has come under treatment and hoAv Avell he responds to treatment. Under the salicylates Ave see the duration often much abridged, in instances particularly of joint affection Avithout internal lesions. Where the heart is affected the case frequently runs on for five or six weeks. Frank relapses are not common. But a succession of subacute attacks in rapid suc- cession, affecting the joints but slightly while adding to the mischief in the heart, is not uncommon. Prognosis. — This is favorable ; few die in the disease. Certainly this is true of the first attack ; if the attacks be repeated, there is much more danger during the acute seizure. And the danger, again, depends rather upon the 356 AMEUICAN TEXT-BOOK OF DBiEAfiEH OF CHILDREN. condition of the heart than upon the mere recurrence of the rheumatic fever. The liability to cardiac disease increases with the number of attacks. Yet this does not always hap])en. I have mentioned a case in which three severe attacks happened without heart im])lication ; and A. Clark tells of one in a boy of twelve in which ei<:ht attacks occurred, the heart remainins; sound. Such instances are, however, very exceptional. Age has something to do with the prognosis. Of cases between one and ten years of age, 83 per cent., McPhe- dran calculates, have heart lesions ; between ten and twenty, 69 per cent. In 54 fatal cases of rheumatic heart disease Sturges encountered none under two years of age ; 42 out of the 54 happened between six and twelve years. Embolism and thrombosis are rare, but very grave. The chief concern where cardiac affections exist is as regards the amount of mischief that will remain after the acute symptoms have subsided. A murmur indicative of mere roughening of the valve may in the course of a few months disa])pear. But very often it persists, and gradually, if the lesion have been moi’e than mere roughening of the valve, the signs of hypertrophy with dilatation become manifest. This may not happen from the first attack ; but during slight recurring rheumatic seizures — slight at least so far as the joints are con- cerned — the heart affection is little by little added to ; or this is aggravated by a more severe attack, in which a fresh extensive endocarditis occurs. From pericarditis we may have the same consequences as in adults — adherent peri- cardium with hypertroj)hy or dilatation ; considerable effusions are very rare. Bheumatic pericarditis by itself has a better prognosis, both at the time and in its ultimate consecjuences, than endocarditis. But with reference to the latter it must be borne in mind that it is mostly associated with some pericarditis, really an endo-pericarditis ; for few are the cases where endocarditis of rheu- matic origin alone exists. Persistent anmniia after rheumatic endocarditis or pericarditis is always a bad sign. The hypertroj)hy or dilatation, which under any circumstances happens more rapidly in children than in adults, gains at increased rate. The frequent occurrence of fibrous nodules is a sign of danger, as fresh mischief is apt at the same time to be wrought in the heart. It is then here, as it is throughout in acute rheumatism, the heart, after all, that chierty determines the prognosis. Chorea is rarely a serious complication. The joint affection mostly passes off’ com])letely ; rheumatic thickening and anky- losis are very seldom seen in childhood. Treatment. — The treatment of acute rheumatism in a child is the same as in the adult. The greatest care must be taken to keeji the ])atient at rest and from l)eing chilled, and with this view the child should be kept in bed in a flannel night-dress or l)etween blankets. The diet should be at first chieffv farinaceous, with bread and moderate amounts of milk ; later in the disease broths and fish may l>e allowed. Of medical remedies, the most ju’ominent is salicylic acid or its conq)ounds ; among these, salicylate of sodium or of ammonium is well adapted. The dose to a child five years of age is thirty to forty grains in divided doses in twenty-four hours; to a child of ten, sixty to eighty grains. It may be given in syrup of orange, or in simple syrup with spirits of lavender. The salicylates relieve the joint affection and the pain, and their action is rapid; after the third or fourth day the dose may be dimin- ished one-half or more. If no result be seen from them in three or four days, they are not likely to j)roduce any, and some other remeily had better be administered. Nor ought they to be trusted to wliere heart complications exist. Further experience, indeed, both in children and in adults has only added to my conviction, cxpre.ssed some years since, that the salicylates neither prevent pericarditis or endocarditis, nor benefit its course after it has set in. 'I’heir RHEU3rATISM. 357 chief use is where there is much pain and the joint affection decided; and it is always well in any case to give also alkalies from the start. When the circulation becomes depressed, or buzzing in the ears or giddiness occurs, the salicylates should be at once discontinued. Salicin is by some recommended as less objectionable, in doses of from five to eight grains every third or fourth hour to a child of five, after the salicylates have been administered for a day or two, or even from the beginning. Under any circumstances, in instances of heart complication or where a heart lesion has existed from a previous attack, the alkalies are vastly prefer- able remedies. It is, indeed, to decided doses of the alkalies that we must trust. Fifteen to twenty grains of bicarbonate of sodium in simple syrup and mint- water every third or fourth hour to a child eight or ten years of age, or two drachms of the acetate of potassium in divided doses in the twenty-four hours, form the proper average dose. These alkalies should be administered until the urine becomes alkaline or neutral, and then enough be ordered to keep it neutral. Quinine is very valuable. It may be given in decided doses when the tem- perature tends to run high, as, however, it is not apt to do in children unless there be endocarditis or pericarditis. In doses of about six grains daily to a child five years of age it is an excellent remedy when the more acute symptoms have subsided, whether the alkaline or the salicylate treatment be the one pursued. Opium is another remedy of great value. It allays restlessness and pain and procures sleep. In coexisting endocarditis or pericarditis it may be directed in small, continuous doses, and is indispensable. The bromides relieve rest- lessness and excitability, and are not without influence on the course of the disease. Conjoined to chloral, they give rest at night; and Goodhart lauds the combination of five grains of the bromide of potassium and one or two of chloral as almost a specific for the nightmare of rheumatism in young children. The treatment of the main internal lesions, the endocarditis and the peri- carditis, is discussed in another part of this volume. I will only here speak of my favorable experience in pericarditis with brandy or whiskey in decided quantities, and with opium. The pleurisy is treated as all pleurisies are ; the iodides are especially applicable to the plastic form. The salicylate of sodium has been recently highly spoken of in this kind of pleurisy ; I have had no experience with its use. In the tonsillitis of rheumatism the salicylates give quick results. The local treatment of rheumatism consists in wrapping the affected joints in cotton wool, or, where they are very painful, in a flannel bandage saturated with a solution of nitrate of potassium, one to two drachms to the ounce, to which laudanum, twenty drops to the ounce, has been added. For lingering swelling of the joints the rubbing in of iodine, ten to twenty grains to half an ounce of lanolin and half an ounce of belladonna ointment, is well adapted. During convalescence iron is strongly indicated ; and there should be then, as always in rheumatic children, the greatest care exerted with reference to warm clothing, to the food being of easily digestible kind, and to the avoidance of exposure to cold and damp as well as to fatigue and over-exertion. n. Muscular Rheujvtatism. This is met with in children, as it is in adults, mostly following cold and exposure, especially exposure to draughts, or fatigue. The disorder is generally subacute, and attended with but little constitutional disturbance. The prom- 358 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. inent symptom is pain in moving the parts involved. It is very rarely a general disorder, but is limited to particular groups of muscles. We find it in the del- toid ; or in the muscles of the loins, as lumbago ; or giving rise to stiff neck, as torticollis ; or involving the intercostal muscles and restricting the acts of breathing, as pleurodynia ; or in the muscles of the head, as cephalodynia. Wherever it is, it has the same characteristics — pain on motion, slight tender- ness, little if any fever. Not unfrequently the urine is high-colored and full of urates. Diagnosis. — In the diagnosis of the affection we have to distinguish it from neuralgia. The stricter limitation of the pain of neuralgia to particular spots, and its passing along special lines of nerve-distribution, the far less influence motion has on it, form, bi’oadly speaking, the traits of distinction. We must also not be misled in considering as muscular rheumatism “growing pains,” or the pains of aching muscles after unusual exercise. Prognosis. — The prognosis is always favorable. The main object, when the immediate attack has been remedied, is to prevent recurrences. Treatment. — Rest of the affected muscles, the application of warmth by hot fomentations or the hot-water bag, the use of liniments containing chloral, chloroform, or opium, are all beneficial. Atropine and morphine hypoder- matically, so valuable in adults, cannot be so generally employed in children. Diaphoretics are always serviceable ; a combination of nitrate of potassium and Dover’s powder is eminently so ; and in lingering cases the bromide of ammo- nium or the iodide of potassium or of ammonium is of distinct benefit. So is the continuous current. Jacobi considers that the best preventive is the habit- ual use of cold water. m. Chronic Rheumatism. Chronic rheumatism, as we see it in adults, is rare in children ; certainly long-continued stiffness of muscles and chronic enlargement of joints are rare. As already pointed out, recurrence of short attacks with stiffness and pain is the form in which the persistency of rheumatism in childhood much more generally shows itself. The few cases that present the same appearances noticed in the chronic rheumatism of adults may be mistaken for rheumatoid arthritis — a disease which is not unknown in childhood, though it is rarely spoken of. The previous history of the case, the occurrence of rheumatoid arthritis in those of feeble health, the wasting of the muscles, the enlarged, crepitating, or fixed joints with the gradually developing characteristic distortion of the fingers and toes, and the absence of all tendency to cardiac affection, are significant in the distinction. In the treatment of chronic rheumatism the chief remedies are the iodides, the muriate of ammonium, and arsenic, with great attention to general health and thorough protection by dressing warmly. Using iodine to the affected joints or rubbing them with ammoniated liniments, or, if there be effusion or bony thickenings, small blisters applied from time to time, will give the best results. Good is also done by massage, and by warm baths with carbo- nate of sodium dissolved in them, or by a recourse to the suljihuretted and alkaline mineral-water springs that have been found to be of real service in the chronic rheumatism of adults. PART V. DISEASES OF THE BLOOD. ANAIMIA, SPLENIC ANT]MIA, LYMPHATIC ANTIMIA, AND LEUKAEMIA. BY FREDERICK A. PACKARD, M, D., Philadelphia. While in most respects the blood of infants and children resembles that of adults, there are in the blood of the new-born a few variations from the adult standard which require mention. During the first twelve days of life the blood has a somewhat venous appearance when seen in bulk. In the new-born child the red blood-corpuscles are of much more unequal size than they are in older children and in adults, the largest of them being larger, and the smallest, smaller. During the first four days of life there are to be found a varying number of nucleated red cells. These soon disappear, although some observers claim that they are to be found up to the second or third year. Owing, presumably, to the ready solubility of the hmmoglobin in young infants, numerous “shadows,” or red blood-cells that have lost their haemo- globin, are present. The red cells are more easily affected by reagents than is the case in adults, moisture in particular causing them to very readily assume the spherical form. The number of red cells is proportionally larger in the newly-born, the count varying, according to different observers, from 4,300,000 (Bouchut, Dubrisay) up to 7,500,000 (Gundobin) per cubic milli- metre. The daily variations in their number are very marked. There is marked increase in the number of colorless blood-cells in young infants as compared to adults. The subject of the relative number of the dif- ferent forms has been most carefully studied by Gundobin {Jahrb. f. Kinder- heilk. u. phys. Erziehung, Bd. xxxv. Hft. 1 and 2, Jan., 1893). According to this author, the I’elative percentage of lymphocytes in sucklings is three times as great as in adults, while the neutrophiles are relatively twice as small in number. From the seventh to the tenth day is the period at which the rela- tive and absolute numbers attain the proportions maintained in later life. The amount of hmmoglobin is greater in young infants than in adults. This relative increase is maintained for some weeks, at the end of which time it begins to diminish, until at about the middle of the first year it has reached its lowest point, thereafter slowly increasing to the normal of adult life. The specific gravity is said to be high immediately after birth (1.066), but it soon sinks to a little below that of adult blood. Plethora. — It is now granted that, while this term may be used as a con- venient means of describing certain conditions, it is not accurate, in so far as 360 AMERICAN TEXT-BOOK OE DISEASES OE CHILDREN. it implies an actual increase of the total mass of blood or of its corpuscular elements. The term was employed to indicate a condition formerly supposed to be due to “full-bloodedness,” but now known to be a condition wherein the appearance of vascular turgescence is due not to any over-richness in blood, but to local changes in the superficial vessels. That a relative increase above the normal of the number of red blood-corpuscles can exist is true only in conditions where the watery constituents are decreased, as in cholera. To this condition the term “plethora ” is manifestly inapplicable, the loss of fluid merely increasing the number of corpuscles in the drop. ANEMIA. Anemia is a condition of the blood due to a decrease in its richness in either corpuscular elements or haemoglobin, either from primary disease in the blood-making or blood-destroying organs, or, secondarily, from general or local disease that interfei'es with normal absorption, metabolism, atid assimilation, or is productive of abnormal loss of nutritive material from the body. In the above definition anaemia is spoken of as a condition instead of as a disease, since in the vast majority of instances it is merely a symptom of some well-recognized disease of the whole body or of individual organs. The anae- mias produced by morbid processes that are recognizable as distinct diseases are spoken of as secondary, whereas those occurring without apparent cause save disease of the blood-making or blood-destroying organs are spoken of as primary. In the latter class we must still place chlorosis, progressive per- nicious anaemia, splenic anaemia, lymphatic anaemia (Hodgkin’s disease), and leukaemia. SECONDARY ANEMIA. Etiology. — Our knowledge of the process of blood-formation and blood- destruction is not sufficiently advanced to explain tbe production of anmmia in all cases in whicb it occurs. Where actual escape of blood from the blood- vessels takes place, the explanation is, of course, manifest ; but it is far froin evi- dent in exactly what manner prolonged high temperature, loss of albumin from continued suppuration or Bright’s disease, the rheumatic poison, and certain toxic influences produce decrease in the richness of the blood in ct>rj)uscles or haemoglobin. In childhood the chief causes of secondary anaemia, aside from those operative e(|ually in adult life, are due to imju’oper hygiene as to diet, exercise, and ventilation. A fretjuent cause is mucous disease, which seems to act by preventing the proper digestion, absorption, and assimilation of nutri- tive material. Improper articles of diet and improj)erly ])repared food may act in practically the same way; that is, by a failure to supply imtritive material proper to tbe needs of the body, d'oo rapierative treatment. The degree of asthenia and the extent of the anaemia offer some means of forming a prognosis as to dui'ation. Treatment. — In early cases, where su))orficial glands are alone attacked, the chance of cure by surgical means should not he neglected. In cases of doubtful nature, where the diagnosis l)etween this affection and an essentially local disease of the affected glands is difficult, the safest course is to avail ourselves of surgical means of cure. Of drugs, arsenic is the only one upon which dej)endence can be placed. It should he administered in ascending doses untd the point of tolerance is reached. Iron is of secondary value as a luematonic, but may be combined with arsenic, j)referably in tlie form of the officinal syruj) of the iodide of iron. External apj)lieations to the affected glands can oidy be of value where the integrity of the skin is in danger. Tracheotomy may be necessitated by ])ressure ii))on the trachea or if the enlarged glands interfere with the nerve-supj)ly of the vocal cords. LEUKEMIA. 373 LEUKAEMIA. Leuk^.mia is a disease of the blood-making organs, characterized, clin- ically, by the symptoms of anaemia, excessive increase in the number of white blood-cells, and a tendency to haemorrhagic extravasation ; pathologically, by enlargement of the spleen and lymphatic glands and by changes in the bone- marrow, either separately or in combination. The condition of the blood in this disease is mimicked in health after eat- ing (physiological leucocytosis) and in various organic diseases wherein there is an intense local lesion (pathological leucocytosis), as in pneumonia, empyema, etc. The term “leukaemia,” however, must be limited to cases wherein leuco- cytosis is more or less constant, is of marked degree, and is associated with the characteristic lesions of spleen, lymph-glands, or bone-marrow. As to the nature of the disease there is much diversity of opinion. The terra “leukaemia” is at present the most applicable, because non-committal, name that we can apply to it. Various divisions have been made in respect to the part chiefly or solely involved in the disease — splenic, lymphatic, or medullary (myelogenous). Rarely is any one form present alone, but the cases usually fall into the classes lieno-medullai’y or lieno-lymphatic. Cutaneous, intestinal, and tonsillar forms are curiosities. The disease bears, in many respects, a close resemblance to sarcomatosis. Etiology. — The precise etiology of the disease has not yet been decided. It is preceded by malaria and syphilis in a number of cases sufficient to render it possible that these diseases have at least a predisposing influence. Trauma in the splenic region has been followed by its appearance. Some of the more acute cases pursue a course that is strongly suggestive of an infectious origin. Fermi, Powlowski, Bonardi, Kelsch and Vaillard, Klebs, Roux, and others have reported the finding of various micro-organisms in the blood or tissues of cases of the disease. Negative results were reached in Westphal’s case in an attempt to obtain cultures from the spleen during life and from the blood and bone-marrow after death. Gilbert unsuccessfully attempted to inoculate healthy dogs with lymphatic glands from a dog affected with the disease. Mosler failed to produce the disease by the injection of leukmmic blood into dogs and rabbits. Bollinger met with a similar result in attempting to pro- duce the disease in healthy animals by the injection of blood from leuknemic animals of the same species. Apparent infection occurred in Obrastzow’s experience, where an attendant upon a case died after fourteen days’ illness with purpura, hfemorrhages, fever, albuminuria, and a proportion, in the blood, of one white to nine red blood-cells. The disease is seen at all ages from birth up to the seventy-fifth year. It is most fre([uent between the ages of thirty and fifty years. It is not rare in childhood, many cases having been reported in infants less than two years of age, while Sanger has reported its existence in a stillborn child. It is more common in males than in females. Heredity has not been proven to be an etiological factor. Horses, oxen, dogs, pigs, cats, and mice suffer from a sim- ilar affection. Symptoms. — The usual symptoms that impel the patient to seek advice are the general weakness, the pallor, the shortness of breath, haemorrhages from the mucous membranes, the enlargement of the abdomen, or the super- ficial lymphatic tumors. The disease usually arises gradually, so that, as a rule, marked changes in the organs and blood have occurred before the patient is brought for treatment. 374 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. The symptoms produced by the abnormal condition of the blood are similar in the different forms of the disease, but the examination of the patient yields results varying with the type. Breathlessness upon exertion is usually a very marked feature. It may be accompanied by marked vertigo upon change of posture. The bodily strength is impaired to a great degree, but in some cases it is remarkably well preserved in view of the serious changes in the composi- tion of the blood. Haemorrhages may have occurred from the nose, throat, stomach, or intestines, or there may be haemorrhagic extravasations beneath the skin. Haemorrhages in the fundus oculi may produce sufficient interfer- ence with vision to attract the attention of the patient. Edes has recorded a case wherein priapism Avas the first symptom. During the course of the disease occasional rises of temperature may be noted. Upon examination there is found more or less pallor of skin and mucous membranes. The pulse is soft and compressible, with increased rate. If the anaemia be marked, there may be heart! a haemic murmur over the position of the apex-beat or in the second left intercostal space. The lungs usually present no morbid signs save toward the close of fatal cases, when oedema, congestion, or a fiuid accumulation in the pleural cavity may be found. In some cases there is found in the lung what clinically resembles lobar pneu- monia, but histologically is found to present features diffeilng from the ordinary form. Diarrhoea may be persistent, and in some cases a species of dj^sentery is present. Vomiting is not a frequent symptom. The occasional occurrence of hmmatemesis has been mentioned above. The urine is usually unaltered save for an increase in the amount of uric acid excreted. On the part of the nervous system we may have no symptoms. Vertigo and cephalalgia are at times marked. Death may occur from intracranial hpemorrhage. Vision may be much impaired, due to the presence, as revealed by the ophthalmoscope, of retinal hemorrhages or of leukemic deposits. Hearing may be impaired. Suchamick has noted a peculiar brownish discolora- tion of the nasal mucous membrane in one case. The usual course of the disease is slowly progressive, covering a period of months or years. There have been reported some cases running an extremely rapid course, as in that of Guttmann, where a fatal termination occurred after an illness of four and a half days. The examination of the blood is all-important in determining the nature of the disease. The constant feature is an increase, both relative and absolute, of the Avhite corpuscles. This may attain to an extreme degree, the relative number of Avhite to red colls having even been as tAvo to one in a case rejiorted by Robin. The average ratio of Avhite to red cells is as one to fifty or tAventy, in cases Avithout great reduction in the latter elements, as opposed to one to 500 or 700 , the average ratio of health. The variotis forms of Avhite blood-cells are present in different proportions in the lieno-niediillary and in tbe lymphatic varieties. In tbe former tbe eosinophilous cells of Ehrlich are the predominant form, Avhereas in the acute lym])hatic variety the lym])hocytes form the main ])roportion of the colorless elements. Where the lymj)hatic, splenic, and medullary varieties exist together in the same ])aticnt, the ])ropor- tion of the forms of leucocytes Avill produce variations from the tAvo tyj)cs mentioned. Myelocytes may be present in largo numbers. Charcot’s crystals are said to form after the blood has remained upon the slide for a short time. In the sj)lcnic form a ])rominent feature is the gradual eiibirgcmcnt of the spleen. This occurs to a varying degree, the organ in extreme cases even leuk^i:mia. 375 reaching to or beyond the median line of the abdomen. The splenic enlarge- ment takes place chiefly in a diagonal direction, downward and toward the right. When the hand is placed over the mass, a rub may be felt and tender- ness be elicited by pressure. Spontaneous pain or sense of pressure may be an annoying symptom, while the weight of the organ may produce dis- oi’der of digestion or marked constipation. When the marrow of the hones is affected, there may be tenderness over the affected parts, with localized swellings on the shafts of the long bones or the ribs or sternum. The lymphatic glands are less frequently involved than is the spleen. The superficial glands show enlargement and can be readily felt, or even seen as isolated groups or chains. The deep glands of the abdominal cavity may be affected. Morbid Anatomy. — The skin is pale, the subcutaneous fat usually much diminished. The blood has a chocolate color, or may even almost resemble sanious pus. When clotted it has a greenish-yellow color. On the serous membranes there may be areas of haemorrhagic extravasation. In the serous cavities there is usually an excess of fluid. The heart is frequently found distended with clotted blood. The lungs present no constant changes, although posterior congestion is often seen. Rarely are there any changes in the thymus gland. The spleen is almost invariably enlarged to a greater or less degree. Adhesion to neighboring organs is common, explaining the sharp attacks of pain sometimes experienced in the left hypochondriac region. The organ is usually symmetrically enlarged, is of increased density, and on section may show either a brownish color throughout the surface, or there may be scattered areas of a white color due to localized infiltration with lymphoid cells, either in the Malpighian follicles or in the pulp. Haemorrhagic areas may be present. The spleen may enlarge so rapidly as to cause a rupture of its capsule. The intestines show at times evidences of lymphoid infiltration, either in the glands of Peyer or in other parts, by thickening without ulceration. The tonsils, pharynx, and stomach have been found to show signs of the over- growth of lymphoid tissue. Lymphoid tumors have been found in the liver in sufficient number to notably increase the size of the organ, while the kidneys also may present whitish areas of lymphoid infiltration, as in the case reported by Friinkel. The lymphatic glands of the superficial sets or of deeper parts, as near the root of the mesentery, are in some cases much enlarged, although rarely to so great an extent as in pseudo-leukaemia. The maiTow of the bones is affected in a considerable number of cases, chiefly in conjunction with splenic involvement. In these cases it is found to be of a puriform appearance or to be of a dark-red color. Haemorrhagic areas may be present. The shaft may be found expanded and the wall thinned. Microscopically, the marrow shows large numbers of nucleated red blood-cells, eosinophiles, and myelocytes. Diagnosis. — The only diseases with which leukmmia is apt to be con- founded are pseudo-leukfemia, splenic anaemia, and scrofulosis. From these the diagnosis may readily be made by an examination of the blood. The numerical increase of the white blood-cells is alone sufficient to make the dia- gnosis, save in cases of non-leukaemic leucocytosis. From this the diagnosis cannot be made with certainty by the haemocytometer alone, as in leucocytosis the relative increase of white cells may be greater than in some cases of leukaemia. For the differentiation of these two conditions we may employ the 376 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. method of differential staining according to Ehrlich’s procedure. While some question has been raised as to the value of the eosinophile cells as diagnostic criteria, this objection cannot now be said to be of weight save in the lym- phatic variety, where the cells having eosinophile granules are not present in large number. Prognosis. — The prognosis as to recovery is grave, although cases have been known to recover. The disease is usually fatal within a few years. In some cases of acute lymphatic leukaemia, as in the case reported by Guttmann, death may occur within a few weeks or days. Treatment. — Rest is of prime importance. The dietary should be selected with care, and should be suited to the digestive power of the individual. Arsenic is almost the only drug that can be said to he of any real value. It should be pushed up to the verge of tolerance, and its use should be per- sisted in until either it is evident that no result is being obtained or until the patient is, mayhap, relieved of the disease. Quinine should be tried in cases giving a malarial history, hut it will rarely he productive of much benefit. Injections of arsenic into the spleen are not likely to materially benefit the patient, and are not without risk. Westphal’s case died after a puncture of the spleen for diagnostic purposes, the organ being surrounded by a large blood- clot at the autopsy. Splenectomy cannot be considered justifiable, in spite of Franzolini’s successful case, in view of the large mortality attending the operation. HAEMOPHILIA. By william PERRY NORTHRUP, M. D., New York. II.®M0PHIL1A is a tendency to obstinate bleeding ; inherited ; often asso- ciated with swelling of the joints. Etiology. — The hsemorrhages may be traumatic or spontaneous in origin. Certain families are known as “ bleeders,” the hminorrhagic diathesis manifest- ing itself at any time from early infancy to the end of life. Hereditary trans- mission takes place mostly through the mother and to her male offspring. If a woman descended from bleeders marry a healthy man, the sons will inherit the haemorrhagic diathesis, the daughters escaping. In the succeeding generations the sons in whom haemophilia is manifest will not transmit the diathesis, whereas the daughters, who show in themselves no signs of it, will transmit the diathesis again to their sons. The maternal transmission so continues to many generations, the haemorrhagic condition appearing in the males, the females escaping, but transmitting the diathesis to their sons. Bleeders usually have large families, some of whom may escape the disease. They are to be found in all localities, in all conditions of life ; are healthy in appearance, commonly having fine, soft skins. The Hebrew race is said to be particularly liable to it. The real cause of haemophilia is unknown. It is believed that the condi- tion has in some individual instances been acquired. Pathological Anatomy. — The post-mortem findings do not explain the nature of the affection. An unusual thinness of the walls of the vessels has been observed, though the microscope fails to reveal any essential and constant alterations. The tissues are blanched from loss of blood. Petechiae and bruised patches are frequently observed upon the surface of the body. The swelling of the joints is due to haemorrhages into the articulations and the surrounding tissues. Occasionally there is evidence of joint inflammation. At present it has not been determined whether the haemorrhage is due to some fault in the walls of the vessels, or whether there is some peculiarity in the character of the blood on account of which thrombi are not formed. Symptoms. — At birth there is nothing in the appearance of the child to indicate the peculiarity of his inheritance. He is usually healthy and bright, and may in the first year develop no signs of haemophilia. The severing of the umbilical cord does not usually give occasion for obstinate bleeding, and not until his growth and sti’ength lead him into accidents, such as bruises, cuts, scratches, and punctures, does the haemorrhagic tendency become apparent. Epistaxis is the most common experience which calls attention to the diathesis. This may be acute, obstinate, and alarming. Besides, there may be petechiae, ecchymoses, haematomata, interstitial and external bleeding, traumatic or spon- taneous. A common symptom is swelling of the joints clo.sely resembling rheumatism. It is not uncommon to find haemorrhage of the gums at the eruption of the second crop of teeth. Slight cuts give rise to troublesome haemorrhage, slight 377 378 AMERICAN TEXT-BOOK OF DmEAIiES OF CHILDREN. blows to marked ecchymoses, and a blister may contain blood instead of serum. Prolonged and dangerous bleedings may follow the extraction of a tooth in spite of the application of the strongest styptics. The bleeding is from the capillaries, most often an oozing, which may con- tinue from hours to weeks. The subjects of haemophilia are very sensitive to cold, and suffer from joint-pains apart from those dependent upon hsemoi’rhage. Such patients pass through the exanthemata and other diseases of childhood without special dangers, and have no marked proneness to phthisis. Sloughing and gangrene are not uncommon accidents of this condition. Prognosis. — From the nature of the disease it must be considered a con- stant menace to life. However mild the tendency in the infant, the prognosis should be considered very serious. Of 152 cases of hmmophilia traced by Grandidier, more than half died before completing the seventh year, and only 19 attained majority. The exhaustion of repeated haemorrhages, or, more commonly, the draining away of blood by continued oozing, may destroy life. The most difficult of control and the most frequently fatal are the haemorrhages following extraction of teeth or from epistaxis. There are examples of bleeders who have attained a good age and led busy lives. To this class belongs a very busy practitioner of the writer’s acquaint- ance, who is never without fresh petechias of the face, and constantly carries a large red handkerchief for accidental epistaxis. In females the prognosis is good, neither menstruation nor childbearing being complicated by this capricious example of atavism. Treatment. — Prophylaxis avails somewhat to diminish the accidents of haemorrhage. The system may be fortified by abundant fresh air and tonics, by judicious exercise and general hygiene. The child should be guarded, so far as possible, from bruises, cuts, and punctures. Vaccination, though not historically accounted a dangerous procedure in bleeders, should be accom- plished rather by scarification than by incision. Slight operations should be seriously considered before they are undertaken, and every needed means of haemostasis should be at hand. The extraction of teeth should be avoided. Nearly every practitioner has had at least one trying experience with obstinate haemorrhage from such cause in a person not haemophilic, and can well under- stand the importance of this advice. It is well to have the diet properly regulated for haemophilics, giving vege- tables and generally wholesome mixed meals, without excess of meat. The bowels should be regulated so as to correct any tendency to a “full-blooded ” condition. Where premonitory symptoms indicate an imj)ending luvmorrhage, it is well to relieve the bowels by a mercurial purge, followed by a saline. In case of luemorrhage treatment will necessarily be modified by the region in which it takes jdace. Cuts and bruises should ihe cleansed and bound uj), with ice, perchloride of iron, or nitrate of silver applied to the ])oint of bleed- ing. In epistaxis the nasal cavities maybe treated by irrigating the ]iarts with cold water or by an absorbeiit-cotton ])lug saturated with peroxide of hydrogen ; if need be, the cavities may be tightly plugged with cotton soaked in an iron solution. If the luemorrhage arise from the socket of an extracted tooth, apply crystals of subsulphate of iroTi or a cotton pledget soaked in IMonsel’s solution, or apply caustics. I hemorrhages from the bowel should be treated with opium to secure (juiet and rest, and by cold-water injections. lhemo{)hilics should be dressed warmly, should avoid cold, damp climates, and all so-called rheumatic surroundings. The joint alVections may be treated much like similar conditions in chronic rheumatism, perfect rest and soothing applications being primarily indicated. PURPURA HEMORRHAGICA. By GEORGE ROE LOCKWOOD, M. D,, New York. Under the term “ Purpura Hsemorrhagica ” we include a clinical group of cases characterized by the association of purpura with hemorrhages from any of the mucous membranes, less frequently into serous membranes and joints or into the substance of the viscera. First described by Werlhof in 1775, it is often known as “ Werlhof ’s disease.” It is also known as “morbus macu- losus.” A careful study, however, of the cases embraced by this definition shows such a variety in their clinical course and in their etiological factors that it seems impossible to regard them even as different types of the same disease. Their symptoms, in a general way, maybe alike, but in some cases they appear suddenly and peracutely without assignable cause, associated with symptoms of acute sepsis, often causing death within a few hours or days. In other cases without known cause the symptoms appear subacutely, and are less marked, the constitutional symptoms being mildly septic in character. In still others the symptoms occur either as a complication of some coexisting disease or as the result of a well-known cause. It seems better, therefore, to regard the term purpura hsemorrhagica as one purely clinical in its scope, including a number of cases distinct in their clinical course, pathology, and etiology, but which present, in common, symptoms of sufficient similarity to be included under one general name. The study, then, of purpura hsemorrhagica is rendered more clear by dividing the cases of this disease into two groups : I. essential, and II. symptomatic pur- pura hcemorrhagica ; the essential group including those cases in which the disease begins without known cause, the hgemorrhages and purpura being asso- ciated with more or less marked septic symptoms, and running a course resembling that of an infectious disease ; the symjdomatic group including those cases in which the symptoms arise from a well-known cause (as poisoning from over-use of potassium iodide), or as a complication of a severe blood or infectious disease (as in profound anmmia or in the exanthemata). The essential cases seem to the author to constitute the only true group to which the term purpura hsemorrhagica should be rightly applied, and these will therefore be described more fully than the symptomatic cases, wdiich should more properly be classed among the symptoms of the diseases which they complicate. I. Essential Purpura Hemorrhagica. This form occurs both subacutely and acutely, the former being far the more common, and about which we know most. 379 380 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Subacute Purpura Hemorrhagica. Tliis variety of the disease is seen more frequently in females than in males. While no age is exempt, it usually attacks children and young adults. Food deficient in quantity and quality, poor hygiene, and a weak, sickly constitution predispose to the disease, but not as markedly so as in scurvy. Often it attacks those who are healthy, well fed, and Avell housed. There is rarely a family history of any hiemorrhagic disease, although in two cases in young girls under the author’s observation the father of each had been subject to severe attacks of epistaxis in early life. The subacute cases occur in two clinical forms : (1) ordinary cases, and (2) cases of Henoch's disease. Ordinary Subacute Cases. — This form usually begins with prodromal symptoms, anorexia, malaise, chilly feeling, and irregular rise in tenqierature, especially at night. These may precede the onset by several days or even weeks. In other cases there is no prodi'omal period. When the disease is fairly developed we have both Inemorrhagic and constitutional symptoms. Symptoms. — Hcemorrhagic Symptoms. — There appear pui-puric spots, usually first noticed on the extremities, though they may be generally dis- tributed. Their size varies from that of a pinhead to that of the palm of the hand. In severe cases we may have large areas of ecchymoses, which may be extensive enough to cause gangrene of the skin. Successive crops of purpura appear during the disease, and they may be often produced by rubbing or scratching the skin. Rarely W'e have associated with the purpura and ecchy- moses haemorrhagic vesicles and bullae. There are free haemorrhages from any of the mucous membranes — nose, mouth, gums, bronchi, stomach, intestines, and pelvis of the kidney. There may be also metrorrhagia. The most frequent sources of haemorrhage are from the nose, pelvis of the kidney, intestines, and uterus respectively. These haemorrhages occur spontaneously, and not from traumatism alone, as is the case in haemophilia. They may be moderate in their severity or profuse enough to cause the death of the patient. Pain and swelling of the joints, especially those of the hands, feet and knees, are frequently noticed. The symptoms are identical with those of ])ur- pura rheumatica. There may be swelling of the fibro-serous tissues about the joint, or the joint-cavity may be filled by an efi’usion either serous or fibrino- serous. In severe cases the joint may become ankylosed or an arthritis may be caused. The primary symptoms are due to haemorrhages either into or around the joints. Internal haemorrhage may occur at any time and into the substance of any of the viscera, especially the brain and its membranes, the sujirarenal cajtsules, or the lung. These internal haemorrhages, however, ai’c rare in the subacute form, though more common in acute cases. The gums may be normal or swollen, although this is denied by many writers. They may be covered by blackish scabs, and may bleed even when they are not swollen. The teeth, however, are not loosened as in scurvy. In no case are ulcers of the intestine, due to submucous hinmorrhages, ever seen. Free haemorrhage from the skin does not occur. Although the kidneys are frequently the source of hinmorrhage, nephritis has not been observed. Constitutional Symptoms. — d'hese ap])car in varying intensity, and are duo both to the anaemia from the haemorrhage and also to moderate scjisis. A dis- tinct chill at the onset is rare, but chilly feelings are common and may continue through the attack. The temperature varies from 100° to 103°, or even 104°, being higher in severe cases and in children. It is higher at night. After the P URP UR A IPmrORRIIA GICA. 381 severity of the attack is over the temperature gradually returns to normal ; a sudden fall in temperature, with a subsequent rapid rise, is noted in cases of sudden severe haemorrhage, especially if such occur into the viscera. The pulse is of low tension and somewhat rapid. It may become rapid, small, and weak. Attacks of syncope are common. General anaemic symptoms are always present, even in cases in which the haemorrhages are slight, but they are more severe when the hemorrhages are profuse. They appear early in the attack and continue throughout its dura- tion; after the attack subsides the recovery is long and tedious, and often it takes weeks or months before the blood returns to its normal condition. E.xamination of the blood during the attack shows rapid diminution of the number of red blood-corpuscles, and a corresponding diminution in the amount of haemoglobin. The white cells are at first increased in number, as is the case after acute haemorrhage, but later their number steadily diminishes, even during early convalescence, wdiile the number of red corpuscles and the amount of haemoglobin are steadily increasing. These points are well shown by the records of blood-examinations made in a case reported by Osier : 1st day, 2d day, 8th day, 14th day, 50th day, 70th day, Number of red cells. 5.350.000 (107%) 3,000,000 (60%) 2.500.000 (50% ) 3.000. 000 (60%) 4.000. 000 (80%) 4.250.000 (82J%) Number of white cells. 8,000 12,.500 12,.500 7,000 2,500 Per cent, of haemoglobin. 95 50 37 47 62 72 Prostration is a prominent symptom, and is always more marked than can be accounted for by the haemorrhage and constitutional symptoms. It remains usually for some weeks after all other symptoms have disappeared. In severe or long-continued cases it may be so profound that the patient passes into the “ typhoidal condition,” with rapid and feeble pulse, dry brown tongue, stupor alternating with mild delirium, or even coma and death. The spleen and liver are usually enlarged during the attack. The enlarge- ment of the liver in some cases is well marked, and may be distinctly appre- ciable for weeks or months after the subsidence of the disease. The conges- tion and enlargement of the liver often cause a mild catarrhal jaundice, which, added to the anaemic appearance of the patient, gives a bright fawn-yellow color to the skin. The duration of the attack varies from a few days to several weeks, but the disease may be protracted for weeks, months, or years by the appearance of similar attacks (or “relapses” of some authors). These attacks may recur at regular or irregular intervals, their usual number being four or five. In one unique case under the author’s observation the attacks have persisted for fifteen years, the patient showing no signs of improvement at the end of this time. The next case of longest duration is one reported by Ilryntschak, in which the attacks lasted for seven years. Nature and Pathology. — For the blood to escape from its vessels and cause haemorrhage we must naturally conclude that the vessel-wall must first rupture. As this does not normally occur, except from traumatism, we must also conclude that its wall is weakened either from inflammation or from degeneration due to disease, to poor blood-supply, to toxic blood, or to thrombi. Much light has been thrown on this subject by Silberman, who gave fifteen 382 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. dogs small steady doses of pyrogallic acid until there appeared areas of stasis in the small arteries, capillaries, and veins. After pressing out the stasis-blood he injected fibrin ferment into the arteries. The dogs had abdominal tender- ness, purpura, bloody vomiting, and bloody stools. Autopsy showed in the hsemorrhagic areas thrombi in the small arteries and veins, whose walls had undergone hyaline degeneration with areas of necrosis, thus allowing the free escape of blood. ^lany attempts have been made to discover a specific bacterium, but before the time of Letzerich the examinations Avere so incomplete as to be entirely Avithout value. Letzerich, hoAvever, in 1889 made scientific bacterial exam- inations, and discovered a bacillus Avhich he believes to be the specific germ of the disease. Although his experiments have not been corroborated by others, their success still remains of the greatest value. Ilis patient Avas a girl sufler- ing from the subacute form. Bacterial examinations, scientifically performed in every detail, showed in the purpuric spots the presence of long bacilli capable of groAvth in gelatin, the pure cultures of Avhich, injected into the abdomen of rabbits, reproduced the original clinical symptoms in all of the tAvelve cases, and in these a bacillus Avas found identical Avith that in the pure culture injected. An examination of the purpuric spots in the rabbits shoAved dilatation of the capillaries, emigration of Avhite cells, and rupture of the capil- lary Avail, permitting the escape of red cells. The capillaries Avere filled Avith the bacilli Avith abundant spore-groAvth. (The bacilli and spores had been previously described by Petrone, in his examinations of a case of Werlhof’s disease, but he considered the disease to be due to a mixed infection.) L pon squeezing the section Letzerich found that little plugs resembling hyaline casts containing bacilli emerged from the capillaries, and these he con- sidered the result of the action of the bacillus in its j)roducts upon the fibrino- plastic elements of the blood. The liver in the rabbits Avas regularly enlarged, and the portal capillaries were almost occluded by an extraordinary groAvth of the bacilli. Letzerich considers the li\'er to be the breeding-place of the bacilli, the liver being to this disease Avhat the spleen is to malarial fever. If he be correct in his conclusions, it explains both the scattering of the lesions — a bacterial embolism of the ca])illaries causing hyaline thrombi Avithin them with rupture of the capillary Avail — and also the tendency of the disease to relapse. While conducting his exj)eriments Letzerich Avas himself seriously attacked by this disease, attributing his infection to handling his cigar Avhile at Avork. This case of infection seems to })rove the advisability of disinfection after an attack. Prognosis. — This is generally good, almost all patients recovering from the ])rimary and secondary attacks. Recovery, hoAvever, is sloAv, the amemia and prostration often lasting for months after the disa])pearance of other symp- toms. The occurrence of the secondary attacks cannot be foretold. In rarer cases the disease terminates fatally, the cause of death being either ))rofound anamiia, fatty degeneration of the heart, Avith or Avithout dilatation, from long- continued ameniia, visceral haemorrhages, or exhaustion. Treatment. — This is unsatisfactory, both in shortening and mitigating the attack and in the ])revention of subseciuent relapses, as there is no sj)eci(ic knoAvn that acts in this disease as quinine does in malarial fever. Our treat- ment, then, must be entirely symptomatic, and consists in treatment during the attack and projdiylactic treatment destined to ])revent future attacks. The treatment during the attack consists in efl’orts to check the hivmor- rhage and in the relief of constitutional sym])toms. 'I’o check the luvmor- rhages no one drug is certain. We employ, in turn, a number, until Ave liml P URP UR A IIuRMORRHA QIC A . 383 one that is efficacious, but we may run through the entire list of haemosta- tics without result. The drugs which are most frequently used are aromatic sulphuric acid, ergot, turpentine, digitalis, quinine, and gallic acid. During a haemorrhage the patient must be kept absolutely quiet, even if morphine be required for this purpose. In all cases and at all times care should be taken to guard against traumatism, over-exertion, and excitement. Alcohol and highly-seasoned food may also give rise to a haemorrhage. Epistaxis may be checked by astringent sprays or by plugging the nares. Uterine haemorrhage should be treated by firm tamponage. If the joints be affected, salicylic acid is often of service. The pain may be relieved by anodyne applications, as lead-and-opium wash, ichthyol or iodine ointment, or by the application of heat and cold. Firm compression is often grateful. Constitutional symptoms are treated on general principles. The patient must be put to bed and on a low diet during the attack. Later he may be about the room, and a more generous diet may be allowed, vegetables and vege- table acids and fruit being especially indicated. In all cases the patient should be kept quiet and free from excitement or exertion. The bowels must be kept open, and any digestive errors corrected. Should the pulse become rapid and feeble, cardiac stimulants are indicated, especially digitalis and strychnine. Alcohol in large doses should not be used. During the close of the attack tonics are to be given, quinine, strychnine, and arsenic being the best combination. Iron is contraindicated, as, by experi- ence, we know that its early administi’ation may bring on a fresh attack. If the anaemia be marked during the attack, arsenic is the drug most efficient. It is to be given in increasing doses to the point of tolerance, then stopping its use for a day or so, and then increasing its dose as before. If symptoms of sudden profound anaemia occur, we apply warmth to the body, hot applications over the heart, and give cardiac tonics, especially opium in small, repeated doses. Inhalation of pure oxygen gas is of the greatest service. In severe cases we employ, in addition, rectal or hypodermatic injec- tions of a warm sterilized saline solution. Several pints can be given in this way with great improvement of the symptoms, although this may be but tem- porary. Arterial transfusion is not to be used, because of the danger of trau- matic hpemorrhage. Elevation of the foot of the bed and ligatures applied to the extremities are often followed by good results. The prophylactic treatment employed during and after convalescence is intended to lessen the chances of subsequent attacks. The patient must live and work in airy, sunny rooms and take graded exercise in the open air, for fresh air and moderate exercise are of the first importance. The plumbing must be in perfect sanitary condition. The diet should be wholesome and varied, and every digestive error corrected. For the anaemia, arsenic in small continued doses is by far the best treat- ment. It should be continued until the blood becomes normal. It mav be combined with quinine and strychnine. Iron is not to be used at first, but several weeks after the primary attack has subsided it should be given in sm: ill doses at first, then slowly increasing. Should a relapse threaten, the iron must at once be stopped. Prostration is to be treated on general principles by rest, fresh air, graded exercise, and change of climate. The climate most suitable is one in which the air is light, dry, and bracing ; and the location must be inland, as we find that the disease more extensively prevails on the sea-coast. As the disease is probably due to an infectious specific germ, and as the sub- 384 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. sequent attacks are also probably due to reinfection, it seems certainly better to disinfect the room and the clothes of the patient after the illness. The more ■\ve study this disease, the more we incline toward such disinfection. Henoch’s Disease. — The severe form of the subacute cases was first described by Henoch, and is known as “Henoch’s disease” or “Henoch’s purpura hsemorrhagica.” This form occurs with greater frequency in children, especially between the ninth and twelfth years. It has been observed, however, between the third and forty-si.xth years. It occurs five times more frequently in males than in females. It is a rather rare form. Symptoms. — There is usually a short prodromal period with malaise, slight fever, and sometimes with pains in the joints. The onset is manifested by the appearance of purpura, in severe cases accompanied by ecchymoses, these differing in no way from those described under the first form. Immediately after the purpura, appear the severe abdomi- nal symptoms which characterize the disease. There is marked pain and ten- derness over the abdomen, the pain being of a colicky character, with exacer- bations of great intensity. The abdomen is rigid and retracted. There is severe rectal tenesmus with bloody stools and severe vomiting, the vomited matter being either like that of acute gastritis or containing blood. These abdom- inal symptoms seem to be due to submucous hiemorrhages or to hmmorrhagic infarctions caused by thrombi in the small blood-vessels of the gastro-intestinal wall, which become degenerated and rupture, allowing free luemorrhage. Patches of intestinal ulceration result in rare cases, and rupture into the peri- toneal cavity with fatal peritonitis may occur even after apparent recovery. These symptoms continue with great intensity for one or two days, and then gradually subside. They may continue longer, but in such cases there are periods of temporary improvement. Joint symptoms may appear as in the first form. Ilfematuria is seen in one-fifth of the cases. The spleen is usually enlarged, and there is a slight rise of temperature during the attack. After such an attack the patient is liable to have a series of similar ones, usually at short intervals. There are generally four or five such, but their number has been recorded as bigh as twenty. The nature of the disease is unknown. No specific micro-organism has as yet been found, but as the reported cases are few, it is possible that in time one will be discovered, either Letzerich’s bacillus or some other bacterium pro- ducing the same results. The duration varies according to the length of the attacks, their number, and the intervals between them. It is usually six to twelve weeks, but may be limited to a week or be extended to nine months. Prognosis. — This is fairly good, being better in cbildren (mortality, 5 ])er cent.) than in adults (mortality, 25 per cent.). The po.ssibility of intestinal ruj)ture and peritonitis, though rare, must be taken into account. Treatment during an attack is purely symptomatic. Between the attacks we improve the general condition in every way. Acute Puri'Uka Ha^mokkiiaoica is far more rare than the subacute form. The same symptoms are ])rosent, but run an acute and more severe course, overwbelming tlie patient by their violence and the raj)idity of their onset. The acute form differs, moreover, from the subacute in the severity of se])tic symptoms, in the fre(iuency of visceral haimorrhages, and its disposition to attack pregnant women. AVe can P URP UR A IlyRMORRHA GIGA . 385 broadly subdivide the acute cases into three groups : (1) cases with marked sepsis ; (2) cases with visceral haemorrhages ; (3) cases complicating preg- nancy. 1. Cases with marked Sepsis. — These present both severe haemorrhagic and septic .symptoms, but the latter are so predominant that the course of the disease is essentially that of acute septicaemia. The attack usually begins by a chill or chilly feelings, with a rise in tem- perature to 103° or 104° F. Haemorrhagic symptoms soon develop, purpura and haemorrhages from any of the mucous membranes. These are severe, and are not readily controlled by treatment. Septic symptoms are marked from the onset — severe prostration, mental apathy, stupor, or semi-coma, alternating with periods of restlessness, anxiety, and mild delirium, and finally, in fatal cases, complete coma. The temperature remains high, 103° to 104°, but in severe cases it may rise to 105° or 106°. The pulse becomes rapid, feeble, and irregular ; and the patient usually dies early in the disease, either from sepsis or from acute anaemia. The following case, personally observed, illustrates most typically the clin- ical course of this form : L. M , female, nineteen years, had always lived in most affluent circumstances ; had never been sick except from slight ansemia for the past two years. Father when a boy would bleed severely from slight causes. No further hiemophilic history. March 7th, 1 A. M., slight chill without rise in temperature. Very nervous and anxious. 12.45 p. m., marked chill, fever rising to 103.5°, and epistaxis becoming more and more profuse in spite of every effort to check it. March 8th, 1 p. m., first seen by author. T. 98.4°; P. 130, irregular and weak; marked pallor of skin ; prostration profound ; complete mental apathy, though her mind was clear when she was aroused. New purpuric spots appearing. Gums normal. No evidence of endocarditis nor of any other appreciable disease. Spleen enlarged ; epis- taxis still continuing, the blood being dark and not coagulating. Profuse uterine haemor- rhage. Haemorrhages were checked by plugging posterior and anterior nares with cotton dipped in collodion and by firm tamponing. 8 p. m., T. 102.8° ; P. 130-180, weak and irregular; semi-coma, alternating with periods of restlessness and mild delirium. Still slight haemorrhages from nose and uterus in spite of former treatment. 10 p. M., about a pint of warm sterilized saline solution was given by rectum and by hypodermatic injections, with slight but temporary improvement. Cardiac tonics, whiskey, and digit- alis were freely administered. March 9th, 9 A. M., T. 104.8°; P. 148; R. 32. Large offensive tarry stool of altered blood. Injection of saline solution continued. 6 P. M., complete coma. T. 106.2° ; pulse weaker and flickering. March 10th, 2 a. m., she died, two and a half days after the onset of the disease. No autopsy was permitted, and bacterial examinations could not then be made. Etiolog-y. — There is no known cause for this disease. It occurs more fre- quently in men than in women. The average age of the males affected is twenty-eight years ; of the females, twelve years. It has been observed, how- ever, between one and seventy years of age. The average duration of the attack is about one week, although it may last from one to twenty days. Prognosis. — The prognosis is bad, 75 per cent, of the cases terminating fatally. Treatment consists in — (1) checking the haemorrhages by plugging the nares, by firm tamponage, or by the use of haemostatics, as described in the sub- acute form. (2) In controlling the sepsis. This is often more than we can do, although in some cases alcohol in large doses seems to do good. (3) In the treatment of dangerous symptoms. Heart-failure is to be treated by hot appli- cations over the precordium and by cardiac stimulants. The restlessness and anxiety are best controlled by opium given in small doses. Profound anaemia 25 386 AMERICAN TEXT-BOOK OF DISEASED OF CHILDREN. is to be treated by external warmth, rectal and hypodermatic injections of a warm sterilized saline solution, elevation of foot of the bed, and ligatures applied to the extremities. Arterial transfusion is contraindicated. 2. Cases with Visceral Haemorrhage. — In these cases the brain and the suprarenal capsules are the organs most frequently involved. In the brain cases the disease begins with the ordinary symptoms of acute purpura hmmorrhagica. After several days these are followed by those of meningeal or cerebral haemorrhage, usually multiple, and without any especial seat of selection. It is seen far more frequently in males than in females. Illustrative Cases: 1. Girl, aged two years. For two days diarrhoea and vomiting ; then purpura, fever, and collapse. Death in a few hours from multiple haemorrhages into the medulla. (Zlielchauer, Berl. Min. Wochensch.., 1869, No. 17.) 2. Young man. General acute symptoms. Death on fourth day from haemorrhages into left Sylvian fossa, pons, and ventricles. (Kurkowski, V. und H. Jahreshericlit, 1885, ii. p. 493.) In cases of haemon-hage into the adrenals the course of the disease is exceed- ingly acute, and death results in a few hours after the onset. Illustrative Cases : 1. Soldier, aged twenty-two. Purpura ; haemorrhage from mouth, lungs, and kidneys. Death in seven hours from adrenal haemorrhage. (Bourrieff, V. und H. Jaliresher.., 1878, ii. p. 275.) 2. Male, aged two years and nine months. Purpura, fever, and collapse. Death in fifteen hours from adrenal haemorrhage. (Wolff, Berl. Min. Wochensch., 1879, No. 18.) 3. Cases Complicating Pregnancy. — In the cases in which the disease attacks pregnant women we have the ordinary acute symptoms at first, fol- lowed by miscarriage and post-partum haemorrhage. It may also follow labor at term. The disease runs a rapid course, and recovery is rare. I llustrative Cases : 1. Female, aged twenty-one, six months pregnant. Purpura four days ; then rapid onset of increasing purpura, with hiiemorrhages from nose, gums, kidneys, and stomach. Miscarriage sixth day, with post-partum haemorrhage. Death on eighth day, four days after the acute onset. (Puech, Annales de Gyn^cologie, xvi., 1887, p. 273.) 2. Female, aged thirty. Five previous normal labors. Seven months preg- nant. Purpura, with miscarriage in a few hours with post-partum haemorrhage. Death on second day. (Phillips, Brit. Med. Journal, Nov. 13, 1886.) 3. Female, aged thirty-two. Seven previous normal labors. Seven months pregnant. Purpura, hemorrhages from nose and mouth. Miscarriage on third flay, with placental hemorrhage. Recovery in two weeks. (Phillips, loc. cit.) When we study these acute cases together, we are struck with their similar- ity to the class of acute infectious diseases. The absence of assignable cause, the rapidity of the onset, the multiplicity and scattering of the lesions, the enlarge- ment of the liver and spleen, and tlie constitutional synqitoms out of propor- tion to the lesions, seem to prove by analogy the assertion that we are dealing with an acute infection, the nature of which is at present unknown. Compar- ing these cases, however, with those of the subacute form, the identical symp- toms are found in each, and it seems most ])robablo that in both forms we arc dealing with the same disease in all essential features, difl’ering only in the intensity and rapidity of the infection. As the infection in the subacute cases seems to be due to the presence of Letzerich’s bacillus, it is more than po.ssible P URP UR A HuPMORRHA QIC A . 387 that the acute cases may be due to a more intense infection by the same germ. Much attention has been called to the relationship of essential purpura haemor- rhagica to two diseases of the haemorrhagic group — purpura simplex and pur- pura rheumatica. Purpura simplex is due to a variety of causes. In some cases the cause is apparent, as in severe anaemia, debility, after certain drugs, or occurring in infectious diseases. In other cases no cause can be found and the nature of the disease is obscure. In either we may have mild or severe constitutional symptoms. In purpura rheumatica we have not only simple purpura, but also pain and swelling of the joints. Formerly it was regarded as a separate disease from purpura simplex, but of late efforts have been made to associate them, purpura rheumatica being considered either as a purpura occurring in rheumatic sub- jects, thus accounting for the joint symptoms, or as a severe purpura simplex, in which hemorrhages occur in and around the joints. The author regards the latter supposition as the more correct, as in all hemorrhagic diseases, pur- pura hemorrhagica, as well as scurvy, multiple sarcoma, etc., the joints may be affected, together with the appearance of purpuric spots. If this view be correct, why regard them as separate diseases? Is it not justifiable to consider purpura rheumatica as an intenser form of purpura simplex with haemorrhagic joint lesions? If purpura haemorrhagica be due to an infection, may not the cases of pur- pura simplex occurring without known cause, and cases of purpura rheumatica not associated with rheumatism, be considered as lighter forms of the same infec- tion, especially as in some cases of subacute purpura haemorrhagica, purpura or purpura with joint symptoms may be the most marked features, the free haemorrhages being of very slight importance, often not appearing for several days after the other symptoms? Even in the acute form is this seen, as the case of Puech’s, cited on the preceding page, illustrates, the purpura alone existing four days before the onset of acute symptoms. In support of this theory may be cited cases of secondary purpura haemor- rhagica, such as those occurring after the administration of certain drugs, in which small doses in some patients produce merely purpura, while large doses cause, in addition, free haemorrhages and marked constitutional symptoms. The only difference seems to be that in one case we are dealing with a cause unknown, though probably bacterial, while in the other the cause is known, and by its intensity we have all grades, from simple purpura to purpura haemor- rhagica, even of an acute type. II. Secondary Purpura Hemorrhagica. Under this class we include those cases of purpura and free haemorrhages which complicate some existing disease or to which a definite cause can be assigned. In nearly all of these cases we may have either a simple purpura or purpura haemorrhagica with constitutional symptoms of a mild or severe charac- ter, in some even running a fatal course. Only a brief mention can be made of these cases. (1) Cases due to the Administration of Certain Drugs, potassium iodide, chloral, quinine, and salicylic acid being the ordinary drugs causing such a result. There is a great difference in their action in different patients, some developing no symptoms, others a simple purpura, while in still others we have a striking exhibition of spreading purpura, free and internal haemorrhages, with coma, collapse, and even death. These various types can proceed from the 388 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN same cause acting more intensely upon some patients than upon others, either from a maximum of cause on the one hand or the minimum of personal resist- ance on the other. (2) Cases which Accom'pany or closely Follow Severe Infectious Diseases, such as acute atrophy of the liver, snake-bites, typhoid fever, pneumonia, and the exanthemata (“black measles,” etc.). In these cases we have various grades, from simple purpura up to acute purpura hfemorrhagica. Many authors attrib- ute such a complication to an added infection of essential purpura hsemor- rhagica complicating the primary disease. Henoch, for example, reports a case of a child with lobar pneumonia in whom a supposed infection of pur- pura hmmorrhagica occurred tM’O days after crisis, causing death from collapse in twenty-four hours. If a drug like potassium iodide will so disorganize the blood or render pervious the blood-vessels, why may not the poison of an infectious disease produce the same result without supposing an added infection of a new disease ? It is no argument against this view that purpura hsemor- rhagica may appear after the crisis, because we know that a temperature crisis does not mark the end of the disease, but only, as Fraenkel has recently demonstrated in pneumonia, the end of the fever-producing quality of the infecting germ. (3) Cases of Severe Jaundice may be accompanied by purpura and haemor- rhages. These seem to be due to the disorganization of the blood from the cholaemia. (4) Cases of Profound Ancemia, Leukaemia, or Pseudo-leukaemia, and of Exhausted and Cachectic Conditions. — In these we may have simple purpura, purpura haemorrhagica, or continued haemorrhage after operations or injuries. We do not know whether to attribute these luemorrhages to blood-changes or to changes in the wall of the small arteries. (5) Cases of New-born Infants with Congenital Syphilitic Changes in the Arterial Walls, producing purpura, bloody sweating, and free haemorrhages, especially from the umbilicus. (6) Cases of Neiv-born Infants unthout Syphilitic Parentage. — This form, according to Partridge, occurs in about 1 per cent, of cases, with a mortality of 60 to 75 per cent. He attributes its causes to the change of functional activities and to the altered circulation, allowing a brief interru])tion of the nutrition of the vessel-walls sufficient for the transudation of their contents. (7) Cases complicating Malignant Endocarditis, the purpura and haemor- rhages being probably due to embolism of the capillaries by vegetation-frag- ments, and their subsefiuent degeneration .and rupture. (8) Cases of 3Tultiple Sarcomata, with Purpura, with free haemorrhages, purpura, rheumatic pains, and fever. It is hard to say whether these result from malignant cachexi.a, with blood-changes, or from emboli of siircomatous fragments lodging in the small blood-vessels, causing their degeneration and rupture. (9) Cases occurring after Fright, Deep Emotion, Hysteria, and Hypnotism. In these c.ases the haemorrhages seem to be due to v.aso-motor relaxation or to enfeeblement of the arterial walls sufficient to allow of the escape of their con- tents. This latter explanation is warmly endorsed by Weir Mitchell. SCORBUTUS. By WM. perry NORTHRUP, M. D. and DAVID BOVAIRD, M. D., New York. Infantile scurvy is a constitutional disease produced by improper feeding, characterized by swelling, disability, excessive tenderness and pain on motion in the lower extremities, and spongy gums : it is further charac- terized by rapid recovery under corrected regimen. The first case of infantile scurvy was reported by Jalland, and the report summarized in VircJiotvs Jahresbericht for 1873, but England has been the source of most of the reported cases and most of the literature of scurvy in children. To W. B. Cheadle and Thomas Baidow of Great Ormond Street Hospital is due the credit of “ having first shown on clinical grounds the true affinities of this form of infantile cachexia’’ (Cheadle), and of demon- strating the anatomical nature of the disease from post-mortem examinations (Barlow). Prior to the work of these observers infantile scurvy had been regularly regarded as acute rickets or gone astray as purpura haemorrhagica. The first case of infantile scurvy in the United States was met with upon the autopsy table of the New York Foundling Hospital. A second was soon afterward recognized in consultation, treated, and recovered. At the time of the publication of the first edition of this work 11 cases Avere on record, and were made the basis of the first article on infantile scurvy in an American text- book. In 1894, 36 cases were collected and reported by Crandall and North- rop. Since that time cases have been reported from all parts of the country. One observer alone (Botch of Boston) has seen 60 or 70 cases. The subject of infantile scurvy can, therefore, rightly claim the attention of the general practitioner. Etiology. — The cause of scurvy in children is persistent feeding Avith improper foods. Examining the dietaries of scorbutic children, Ave find enumerated almost everything that could possibly be employed as food for a child — all manner of proprietary foods, condensed milk, porridge, oatmeal- and barley-Avater, various mixtures of cow’s milk and cream. They agree only in one respect : they all lack or have been deprived of the quality Avhich we designate as fresh or “live.” When milk or cream has been given it has regularly been deprived of this quality by sterilization. For some time there has been active debate whether prolonged sterilization of the food could of itself cause scurvy. The Avriter has recently seen 2 cases of typical scurvy developed in children fed upon perfectly proper milk mixtures Avhich had been sterilized by prolonged boiling. Both recovered promptly on the same food Avhen the over-steriliza- tion was stopped : moreover, one of them has noAv gone for several months upon the same food unsterilized, Avithout any return of the symptoms. Like experience has been recorded by Starr and Holt. Scurvy among nursing infants is very I’are. In the first case met with 389 390 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. in this country the child had been nursed by a woman who suckled her own child as well. The latter thrived ; the foster-child developed scurvy. There is little doubt in such a case that the child was starved into scurvy. Southgate has also recorded a case of scurvy in a nursling. Moreover, the analysis of the milk made in this case shows it to have been rich in quality. In the light of all other observations we can only say that this case stands uni(jue and unexplainable. The patent baby-foods are, by all means, the most frequent offenders in the production of scurvy. The measure of the responsibility of any partic- ular one seems to rest only on the extent of its popularity. Those most widely used are most often met with in the scurvy records. As the number of reported cases increases the stronger becomes the indictment against the patent foods. There seems no greater surviving fal- lacy in medical practice than the routine feeding of infants with patent prod- ucts of commercial firms. Condensed milk deserves to rank with the other proprietary foods. Surroundings seem to have little influence upon the production of this cachexia. Most of the reported cases have been observed in private practice. In the great majority the surroundings have been good, in many luxurious. The affection has been met with in all parts of the land, both in cities and in the country, along the seaboard and on the mountains of Montana. Per- sistent feeding with improper food can produce scurvy anywhere. The dis- ease is usually met with after the sixth month and under two years, but these limits cannot be regarded as absolute. It takes time to develop scurvy, DO matter how bad the diet, and after the second year the diet usually becomes so general that all danger is removed. We are still unable to reach the ultimate cause of scurvy. It seems un- questionably to be deprivation, but of Avhat has not yet been determined. All that we can say is that the missing elements are found in fresh milk and fresh fruit-juice. Pathology. — The lesions of infantile scurvy are well set forth in North- rup’s report of the autopsy on his first case. The child was emaciated, its eyelids swollen and ecchymotic. The gums were prominent, spongy, dark, covered with dried blood, the lips blood-stained. The pale, thin face, with two black eyes, gave a most striking appearance to the dead baby. The main interest lies in the condition of the legs. Left thigh symmetrically enlarged, larger than the right, although both were obviously above normal in size. Left femur was normal at its upper extremity, epiphysis, and end of shaft. The lower half was invested by a black, grumous, subperiosteal layer of blood two or three millimetres thick. The lower epiphysis was detached ; the lower end of the shaft macerated, eroded, and soft, lying loose in the black, disintegrating blood-clot. The femur of the right leg was sur- rounded for its lower two-thirds by a thinner, black, subperiosteal blood- layer. The lower epiphysis was not detached, though both it and the shaft were congested. No hannorrhage into joints. The right and left tibim were surrounded by a thin, dark, hanuorrhagic layer beneath the ])eriosteum, and the proximal j)ortions of both were congested. The fibula and bones of the upper extremity were normal. Microscoj)ical examination of the bone dis- closed no syphilitic or rachitic changes, and no inflammatory changes in bone or periosteum. The softened, macerated bone gave no evidence of suppuration, but there was moderate congestion of the fellow-femur and U[)per extremities of the tibia. A small amount of blood, dark and dis- integrated, was found in the intestines ; no lesion discovered. 'I'hc accom- SCORE UTUS. 391 panying illustration (Fig. 1) was drawn from a specimen which consists of a lateral half of the side less affected. To this we need only add that subperiosteal hemorrhages may occur upon any of the bones — those of the upper extremity, of the cranium, of the thorax. There may also be hemorrhages from various mucous membranes — the nose, the Fig. 1. stomach, bladder, etc. Symptoms. — The characteristic symptoms of infantile scurvy are the swollen, spongy, purple, and easily bleeding gums, and extreme pain on motion, tenderness, swelling, and dis- ability in one or both lower extremities. Ex- amination of the affected extremities reveals a fusiform or cylindrical swelling about the long bones. The affection is usually most marked about the femur, but the bones of the leg or ankle may be involved. The affection is usually bilateral, but not symmetrical, one extremity presenting more marked changes than the other. In a few cases the upper extremities have been involved, but these cases are rare, and in almost all thus far repoi’ted there was an antecedent affection of the legs. The joints themselves are not involved in the process. The affected limbs are usually held in a semi-flexed position (Fig. 2), and no attempt is made to use them, so that the disease is often mistaken for a paralysis. This disability is spoken of as pseudo-paralysis. “ Rheumatism of the legs ” is another favorite diagnosis for this scorbutic affection of the ex- tremities, but, as already noted, the joints themselves are not involved in infantile scurvy. The pathological lesions already described ren- der these symptoms readily explicable. In addition to the characteristic symptoms, subcutaneous ecchymoses or hmmorrhages are of frequent occurrence. They may be seen upon any part of the body, but are especially characteristic about the orbit, giving the little patient a typical “black eye.” Hgemorrhages may also occur from mucous membranes other than the gums, so that there may be bleeding from the nose, stomach, intestine, or bladder ; but such haemorrhages are seen only in the severer types of the cachexia. For weeks before the development of the evidences of scurvy the child may suffer from gastric or intestinal disturbances, with vomiting, colic, diar- rhoea, or constipation. In the severer cases a sallow, muddy complexion, due to severe anaemia, is often met with. The examination of the blood shows the changes of simple anaemia. Many of the cases are marantic, but scurvy may also be seen in children who have suffered from no gastric or intestinal disorder and are well nourished and ruddy. The affection of the gums is seen only about the teeth. If the child has no teeth, the gums will appear normal. In the report of Crandall and sicians and Surgeons, N. Y.) 392 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. Nortbrup the condition of the gums was noted in 32 cases. Of these, 2 had no teeth ; the gums were normal. Of the remaining 30, 24 had what was termed “spongy ” gums, 3 had ulcerated gums, in 3 they were described as “bleeding.” In 34 other cases of which the records are available, 31 had spongy gums ; in 3 the gums were normal. Of the latter, 2 had no teeth. ()ne, although it had two teeth and presented a typical scorbutic affection of the extremities and subcutaneous ecchymoses, had no mouth-symptoms whatever. The affection of the gums, although regularly present, cannot, therefore, be considered essential to the diagnosis. The constitutional disturbance of scurvy may be of any degree of severity, depending upon the gravity of the affection and the time of observation. In the mildest cases the baby may appear perfectly well, except for the pain on motion of the extremities. In the severer types there are marked anaemia, emaciation, fever, and prostration, which may result in death. Fever, if Fig. 2. present, is usually slight, but may reach 102° or 103° F. It is apparently dependent upon accompanying disturbances, and not ujion the scurvy itself. Relation to Rickets. — The relation of scurvy to rickets has long been the subject of debate. Previous to the work of Rarlow and Cheadle infantile scurvy was regularly described as “acute rickets,” and in the early days of observation rickets was sujijiosed to constantly precede or accompany the appearance of scurvy. In the report ])reviously (|Uoted rickets was referred to nineteen times. Five cases showerocess going on u])on their cheek. This is, hoAvever, not the rule, and Avhen it does occur it is folloAvcd in a short time by general symptoms shoAving the severity of the local process, d'he temperature is some- times very high, becoming hectic in type, but not infixupiently it becomes sub- normal before death. The pulse is small, easily conqyressed, Aveak, and rapid. The appetite is diminished, and diarrluea is the rule, most intractable in its nature and ])robably due to infection from the ])i’ocess in the mouth. Catar- rhal pneumonia, due to inhalation of septic material, is common, and di])htheria DISEASES OF THE MOUTH. 407 has been observed in several cases. Exhaustion comes on, and then the child becomes apathetic, refuses food, and dies in collapse. Haemorrhages are rare, because the blood-vessels are filled with thrombi. Prognosis. — This is very bad, the mortality ranging from 70 to 90 per cent, of all cases affected. Complications make the prognosis absolutely fatal. Treatment. — Of the general treatment, always of great importance, little new can be said, as the physician has already done all in his power to avert a gangrenous process by keeping up the strength of the patient. When noma sets in stimulants should be used methodically and systematically ; food should be given in as condensed a form as possible. If feasible, rectal alimentation may be tried, but this, as a rule, is not very satisfactory for children. The local treatment is of prime importance, and, as the mortality is so great, even the most heroic treatment can be adopted with complacency. The prin- ciple of local treatment is to destroy the infiltrated zone and the healthy tissue surrounding it for some distance, so as to make an artificial line of demarca- tion. Nitrate of silver in stick, dilute muriatic or other acids, chloride of zinc, and many other remedies have been recommended for this purpose. To the author it seems that the best and most active method of destroying this tissue is to be found in the use of the thermo-cautery of Paquelin or the galvano- cautery ; and lately several cases have been reported in which success has followed these applications, although it is far too early to draw positive con- clusions. As soon as the gangrenous nature of the disease has been established the operation must be performed. A loss of time, even of hours, means con- siderable loss of tissue. Again, delay may make the operation one of great magnitude, in that blood-vessels may have to be tied which before the exten- sion of the process could be safely cut with the galvano-caustic knife. Under anaesthesia, when possible, necrotic tissue should be removed, and then every- thing that seems gangrenous should be destroyed. After this a certain amount of healthy tissue should be cauterized. If gangrenous spots appear the next day, the operation should be repeated, and so on ; applications can be made daily. The wound is to be treated according to surgical rules, and plastic operations should be put off as long as possible, because, in tlie first place, they do not offer much chance of success when done early, and, in the second place, noma sometimes recurs as the result of these operations. In conclusion, it must be stated that, whatever has been done and will be done, the results must be bad, because the process is one developed in a patient very much reduced, in whom the least complication is likely to prove fatal. VI. Stomatitis Crouposa ; Stomatitis Diphtheritica. Croupous stomatitis may be produced by a variety of causes, both chemical and bacterial. Primary croupous stomatitis is certainly a very rare affection, although it may occur. As a rule, the croupous membrane develops contem- poraneously with a membrane upon the tonsils. In very severe cases the membrane has been found upon the cheeks, the tongue, and even upon the lips. The lymphatic glands are not much involved, and as the mouth-process is commonly only part of another of more importance, little more will be said in this connection. The important thing to establish is the ab.sence of the Loeffler-Klebs bacillus ; this will make the diagnosis absolute. At the present time the whole subject is being investigated, but enough has already been done to show that all false membranes are not diphtheritic. Diphtheritic stomatitis does occur as a primary affection, although it is 408 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. not very common. When primary in the mouth, the membrane usually develops upon the lips, and may extend thence to any part of the mouth. As a rule, the tonsil is the primary seat, and thence the membrane spreads to the soft palate, the tongue, the cheeks, the lips, and the gums. There is but one positive method of making the diagnosis of diphtheria, and that is by proving the presence of the Loeffler-Klebs bacillus by cultures, and then making inoculative experiments upon lower animals. In primary diphtheritic stomatitis this would become imperative; in the secondary form there are, fortunately, still left for the clinician combinations of certain symptoms that make it possible to diagnosticate the disease without consulting the bacteri- ologist. Salivation usually occurs, and the odor from the mouth is fetid. Some- times diphtheria of the mouth, when primary, runs it course most insidiously, and is overlooked or not recognized until further complications develop. The membrane lasts from three to six days, sometimes longer, and then either drops off or ulcerates away ; in either instance there is left a denuded place. Hmmoi’- rhages are common, either slight or otherwise ; when not due to mechanical irritation they are matters of anxiety. In some instances luemorrhage has been so great as to cause death ; in others only a slight loss of blood seems sufficient to produce a fatal termination. The prognosis depends largely upon the form, whether primary or secondary ; it is very much worse in the latter than in the former, but even in the primary form may become very grave by extension. The author has seen two cases in which a primary diphtheritic stomatitis has become a laryngeal one. Treatment is that of diphtheria. When possible, the membrane must be removed if this proceeding be not accompanied by violence, so that infec- tion of healthy membrane be produced. Constitutional treatment is of the utmost importance, in order to counteract the tox-albumins produced by the bacillus. For this purpose corrosive sublimate, administered internally in full doses frequently repeated, seems to be the favorite. In the septic cases much good can be done by fre(iuent local applications without violence. Vn. Stomatitis Syphilitica. Syphilis produces stomatitis only in an indirect manner, either by causing a specific deposit, which, in its turn, ))roduces the disease, or by rendering the mouth in such patients more sensitive to agents wliich ))roduce stomatitis. The three stages of syphilis are develo])ed in the mouth. Primary lesions are very rare, but infection does take ])lace from syphilitic wet-nurses, and when this occurs the lesion in the moutli of the child does not differ from the same lesion in the adult, d'he secondary manifestations are most common, and any part of the mucous membrane may be their seat. Upon the lips we find the following forms: sy})hilitic fissures, ])apules, pla((ues, and erosions. The fissures (rhagades) are most common, and are generally found at the corners of the mouth or upon the upper ami lower lips. They are syjdiilitic infiltrations which have been sj)lit near their middle, so that at the corner of the mouth one part of the infiltration lies nearer the uj)per lip, the other nearer the lower, and the split .seems a continuation of the commi.ssure. Upon the lip rhagades usually end in the mucous mend)ranc. Sometimes these fissures are present in such great numbers that they disfigure the mouth, and by the pain which they produce cause great annoyance to the {)atient. When they heal they leave cicatrices which, in their turn, may ])ermanently disfigure the mouth. The characteristics of the.se fissures are the infiltration, the split, and the lack DENTITION. 409 of tendency to spontaneous healing. Papules are most common at the commissure and the free border of the lips ; they may also be split, and then resemble the former variety. As a rule they look like condylomata lata in similar positions ; they are elevated, their surface is moist, the centre has a tendency to break down, and unless they involve the mucous membrane they do not cause pain. The remaining forms may be found upon any part of the mucous membrane ; they cover more space, are not chai’acterized by the same amount of infiltration, but usually produce more pain and more salivation. Upon the tongue we most commonly find plaques muqueuses and syphilitic ulcers. Their localization depends largely upon irritation, either from a sharp tooth or other cause. The healed ulcers leave cicatrices, but the characteristic appearance of the tongue, as it is found in the adult after syphilis has run its course, is exceedingly rare in children. In the early stages of syphilis we find a decided enlargement of the circumvallate papillae, and a loss of the filiform papillae, so that the tongue looks “shaven.” The so-called geographical tongue (wandering rash, ringworm, lichenoid condition) has nothing in com- mon with syphilis and bears no relation to it. Treatment. — As in all forms of syphilis, so with stomatitis syphilitica — gen- eral treatment is of most importance. When deformity or danger to life is threat- ened, that method must be used which produces the quickest effects. The manifes- tations in the mouth, as a rule, yield rapidly to constitutional treatment, but local prophylaxis and treatment must not be lost sight of, as being accessory and highly important. Cleaidiness is absolutely necessary to prevent saliva- tion as well as to aid in recovery. All sources of irritation must be removed and the teeth must be kept in good condition. Frequent applications of silver nitrate are best for ulcers, erosions, or losses of substance. Corrosive sublimate is preferable when there is considerable infiltration, either in weak solution as a mouth-wash, or in stronger solution applied with a brush, in which case it is apt to produce pain. The weak solutions should be applied two to four times daily ; the strong ones (as high as 12 per cent.) are caustic and should be used with great caution. When children are old enough an application of emplas- trum hydrargyri with lanolin (1 j)art of lanolin to 2 parts of the emplastrum) upon chamois gives better results than either of the former remedies in rhagades at the corners of the mouth. In cases of stomatitis mercurialis, potassium chlorate or any remedy containing tannic acid, such as tannin itself or tincture of rhatany or catechu, is very serviceable. n. DENTITION. Nearly all diseases of childhood have been ascribed to teething ; even at the present time authors will be found who do not hesitate to work out the most improbable relations of teething to disease. But, be this as it may, there is no one who does not admit that some children may have teeth without any great amount of disturbance, or, indeed, that teething may go on without pro- ducing any symptoms at all. This latter form of teething would be called normal ; the abnormal form has been called dentitio difficilis. It is proper to state that medical authorities are much divided as to the importance of teeth- ing as an etiological factor of disease, and that they can be divided into three classes : those claiming that almost any disease can be produced by teething. 410 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. those claiming that no disease is produced by teething, and, lastly, those who state that some few diseases may follow the eruption of teeth. The first class states that normal teething occurs in only 20 per cent, of all children. Although teething in healthy and teething in unhealthy children is a better division from a clinical standpoint, we will, for the present, follow the division as given above. The greater part of teething is accomplished before the child is born. At about the seventh week of foetal life the epithelium Avithin the mouth is thick- ened, forms a ridge, and at the same time dips into the embryonic tissue about to form the jaw. This epithelial process is called the enamel-germ ; it grows so as to surround a flask-shaped cavity, which it lines ; partitions develop into this, forming ten cavities for each jaw. A papilla is now developed, which, pushing up toward the embryonic tooth, forms a complete mould for the enamel- germ to rest upon, and this is called the dentine-germ. We noAV have the beginnings of the ten temporary teeth in the form of the partitions, the enamel- and dentine-germ, and the papillm. The connective tissue around these primi- tive teeth has at the same time been forming into the dental sac, an investing membrane for each tooth. In the partitions, as well as in the rest of the jaw, bony tissue is being formed ; the teeth become farther separated from each other, and by this deposit of bone the alveolus is formed, lined by the dental sac coherent Avith the gum along the border of the jaAV. This process of devel- opment has taken the Avhole period of foetal life, so that the child comes into the world Avith all its temporary teeth fully formed Avithin the jaAV. The per- manent teeth are formed, in so far that the enamel-germ is developed from the enamel-germ of the temporary tooth as a small sac, from Avhich subsequently the development goes on, as already desci’ibed for the temporary teeth. The topographical relations of the teeth at birth are as folloAV's : above, the tooth-sac, the submucous connective tissue, and the mucous membrane itself ; on either side, the tooth-sac and bony tissue. There is no bony tissue to impede the tooth on its Avay to the oral cavity ; all that it needs to overcome is the sub- mucous coat, the mucous membrane, and the dental sac, which is very thin. Not enough stress can be laid upon the fact that the o])ening of the alveolus is wider than necessary to allow the tootli to pass through. Calcification of the fangs begins, and as the tooth becomes elongated by means of this, it is sloAvly forced in the direction of least resistance, the mouth. Pressure is directed toAvard the mouth ; the papilla cannot be pressed upon, for the simple reason that Avhere, during groAvth, blood-vessels come in contact with l)ony substances, absorption of the latter is produced, the blood-vessels not being affected. It is possil)le that, as KassoAvitz has pointed out, the groAvth of the blood-vessels causes the alveolus to be moved constantly, and that this groAvth acts as another cause for the coming through of the teeth. Calcification of the fangs usually begins in the loAver incisor teeth at birtli, beginning in those teeth first Avhich are first to make their appearance in the mouth. The order of teething can be described as occurring in tliree Avays. Unfor- tunately, there is as yet no unanimity among authors as to the most common method. The first is the appcaraTice of the teeth in j)airs, principally in rela- tion to the incisors. The second is the ap})earance of the first two incisors, then all the other incisors, and then the molars. The third, Avhich we believe to be the most common order, is the appearance of the first tAvo loAvcr incisors, then the four upper incisors, then the first molars, and Avith them the remain- ing two lower incisors, as folloAvs : DENTITION. 411 I. Two lower central incisors 5-7 months. II. Four upper incisors 8-10 “ III. Four first molars and two lower lateral incisors . 12-14 “ IV. Four canines 18-20 “ V. Four second molars 28-34 “ It will be borne in mind that this table represents average times, and that the time for eruption depends upon a great many different causes. The nation- ality, heredity, climate, and general development of the child may either retard or accelerate the appearance of teeth. Certain diseases, especially rickets, have a well-marked retarding influence, but because a child is late in teething it must by no means be taken as positive evidence that he has rickets. The time of eruption depends, first, upon the distance the tooth has to travel from the dental sac to the mouth ; secondly, the amount of calcification in the fangs ; and, lastly, the condition of the rudimentary organs. Increased calcareous deposit would compensate for length of distance, and possibly for deficiencies in the rudimentai'y organs ; but frequently no compensation can take place, and the teeth are left permanently deformed as well as late in appearing. Premature teeth may occur from several causes : some change in the embryonic structure may result in the production of teeth without fangs, which are attached only by mucous membrane ; or the deposit of calcareous material may be too early or too great; or, finally, more than twenty primitive teeth may have been formed, one or more of which project into the cavity of the mouth. Premature ossification of the bones of the skull is said to be accom- panied by premature teeth, and in this case Jacobi claims that the upper incisors then appear first. The latter view, however, still requires verification. Premature teeth must not be interfered with unless there is a special indication for their removal, because it may be possible that no second tooth shall appear until the permanent one comes through ; and, furthermore, their removal is not unattended by danger (luemorrhage). The most urgent indication for removal is to be found in their being in the way of nursing ; they may produce fissui’e of the nipples or may make nursing so painful to the mother that serious consequences follow. The teeth are retarded by the constitutional diseases, rickets and syphilis — these forms of general disturbance of nutrition resulting in cachexia and in long-continued fevers or chronic diarrhoea. Acute febrile disturbances, such as the exanthemata, may not have any effect upon the temporary teeth, and yet show distinct tracings upon the permanent teeth ; or the group coming through at the time of fever may not be delayed at all, and yet the next one will be delayed some time. A food-supply defective in calcareous material has been frequently accused of delaying teething. This is, theoretically, correct ; but, as a matter of fact, when the salt material of the food is diminished to such an extent as not to be able to supply the small amount demanded for teething, life can no longer be sustained by such food. Our own experience has been that none of the proximate principles of which teeth are composed, when administered inter- nally, have any effect upon the appearance of the teeth. There is but one remedy which seems to hasten teething, and that one affects rachitic children principally, though not exclusively ; we refer to the internal administration of phosphorus. The permanent teeth appear in about the following order and times : 412 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. First Molars. Incisors. Bicuspids. Canines. Second Molars: Third Molars. 6 years. 7-8 years. 9-10 yeai-s. 12-14 years. 12-15 years. 17-25 years. In regard to the symptoms produced by teething, it can be definitely stated that in a healthy child teething goes on without producing symptoms of any sort. In children reduced by malnutrition, affected by hereditary syphilis or rickets, and in those extremely nervous either as a result of hereditary or other causes, there are symptoms which can be divided into two groups : first, local ; secondly, remote. The local symptoms are pain, heat, irritation, not infre- quently stomatitis catarrhalis. All these may occur in healthy children, but are manifestly of little importance, as they produce little if any general reaction, and are certainly very rare. At times children may become a little fretful or cross, and in the evening have a slight rise of temperature. As a rule, however, the teeth which have long been expected by the anxious watchers make their appearance without premonitory signs, so that the wise physician will hesitate before he prophesies Avhen a tooth is to appear. Salivation cannot be looked upon as a symptom of teething, as it usually occurs from two to three months before the first incisors appear, and is physiological. The salivation occurring during teething is due to stomatitis. The pain can only be very slight, and can be judged by analogy with that produced during the appearance of the second teeth. In an unhealthy or over-sensitive child this, however, may be sufficient to produce restlessness or peevishness. That the pain cannot be very great must be accepted also from anatomical facts : the nerve-filaments covering the tooth have either been absorbed or rendered insensitive by continuous pressure upon them. The papilla cannot be taken into consideration at all, as it has been shown that the teeth could not in any Avay press upon it. The symptoms in I’emote parts have to be analyzed carefully, and much cool judgment may be reijuired to find their cause. The tendency at the pres- ent time is to accept fewer and feAver symptoms as due to teething ; but for convenience Ave have grouped them under the folloAving headings : symptoms on the part of the nervous system, the digestive apparatus, the skin, the respi- ratory apparatus, the genito-urinary system, and the organs of sjiecial sense. The principal symptom on the part of the nervous system, still adhered to by many, is convulsions. It is claimed that they are of a reflex kind, the tooth being the irritant producing an abnormal afferent impulse to the medulla. Theoretically, this can be taken into consideration, l)ut in practice convulsions are not produced by teething, least of all as the result of a reflex mechanism. Tonic contractions of muscles of a local nature may easily be jiroduced by an increased afferent impulse, but the most painful lesions involving the fifth pair of nerves in the reflex arc are not folloAved by generalized muscular contractions. In the alimentary canal Ave find the boAvels partici))ating in the general hyper- sensibility of the child. There is no evidence to shoAV that boAvel lesions are produced by teething, either as the result of SAvalloAving an imaginary excess of saliva or othenvise. The most pernicious doctrine tliat exists is the one that intestinal disease is due to teeth. An over-fed or badly-fed child — and at the time of the eruption of the canines it is most liable to be both — if suffer- ing, generally has an irritable intestine; and very likely substances Avhieh should not enter the circulation may j)ass into it from the intestine, and the result Avill be stools changed as to ((uantity and ([uality. 'fhis, in the lat- ter instance, is a curative act, and tlisappears as soon as the ray, or for self-medication, even alone or DISEASES OF THE PHARYNX AND NASO-PHARYNX. 417 following an astringent gargle, we find the following emollient very soothing to highly inflamed mucous surfaces : I^. 01. pini Canadensis .... m V. 01. eucalypti m ij- 01. gaultheriae m y- Thymol gr- ss. Menthol gr- j- “ Vaselin oil” q. s. ad fsj. — M. Sig. Use with a double-bulb atomizer. A laxative is usually indicated, even though the bowels may be stated to be regular. Apart from this, little constitutional treatment is required, other than may seem appropriate for any associated conditions. n. Simple Chronic Pharyngitis; Elongation op the Uvula. Simple chronic pharyngitis occurs but rarely in childhood, and is then dependent upon diseases of the nose, tonsils, or digestive organs, and the most rational line of treatment, and the only one likely to result successfully, is that indicated by the primary affection. The same is true in part of elongation of the uvula, but only in part, since radical treatment directed to this organ will occasionally be required. Relaxation of the velum palati and pai’esis of its muscles are usually asso- ciated with lengthening of the uvula, and the disability is due to chronic or recurrent acute inflammation of the nose, naso-pharynx, or pharynx. Frequent necessity to dislodge mucus by “hawking” is somewhat instrumental in its production. Symptoms. — The chief symptom is a harassing cough, which is found especially annoying on retiring and rising and at times of acute inflammation of the throat. It often causes the child to be treated indefinitely for bronchitis or other in- Fig. 1. visible disorders, when a critical inspection of the pharynx in a state of quietude would dis- close the palate lying on the base of the tongue. Extreme elongation has even served to excite attacks of laryngismus stridulus. Rarely the uvula is bifid, a congenital defect which pre- disposes it to elongation. Treatment. — Concerning the treatment, palliation may be secureain. Of late years, antipyrine or phenacetin has been often substituted advan- tageously for the aconite and bromide mixture. A saline laxative is nearly always needed. Local sprays by a hand-atomizer are of the greatest benefit when the child is old enough to tolerate them. An alkaline and antiseptic lotion (See Acute Pharyngitis) is to he preferred. Tliis should he S])rayed every three hours through the mouth, and also through the nose, into the naso-pharynx, thus cleansing that cavity, as well as the fauces, of the viscid muco-purulent matter which accumulates and conduces to much discomfort. Hydrogen peroxide, diluted to the point of freedom from ])roduction of smarting sensation, is also an excellent local spray, especially if used alter- nately with the one above mentioned ; and either or both of these may l)e msed following a preliminary spray of 1 per cent, solution of cocaine hydrochlorate, which serves to control pain and suj)er-irrital)ility of the fauces. Generally speaking, it is best to avoid the use of cotton swabs and brushes. Gargles may he sul)stituted for s])rays when necessary, or made to su})plement spraying, and for use as a gargle the formula for spray above referred to should be diluted doubly as much as for use in a spray. With very young children the naso-pliarynx ami fauces can be readily cleansed by the .same .solution freely diluted, Avarmed, and injected gently in small ((uantities by a small syringe or an ordinary medicine-dropper through the nares. DISEASES OE THE PHARYNX AND NASO-PHABYNX. 421 V- Peritonsillar Abscess, or Suppurative Tonsillitis. This condition is also termed acute parenchymatous tonsillitis, phlegmonous tonsillitis, quinsy, etc., but of these terms the best is peritonsillar abscess, because it is descriptive, since the suppuration does not occur in the tonsil itself, but in the cellular tissue around it or above, behind, in front, or to the outer side of the gland. The disease is comparatively rare in early childhood, but about 3 per cent, of all cases occur under ten years, and about 6 per cent, under fifteen years, of age. Etiology. — The direct cause of suppuration here, as elsewhere, is infection by specific pathogenic micro-organisms from some source, either from within or without the body. The predisposing causes are exposure, the rheumatic diathesis, chronic ton- sillitis, and acute folliculous tonsillitis. Symptoms. — A chill or chilly sensation is followed by a temperature of 102° to 105° F., and consequent febrile symptoms. About the same time a sense of soreness and fulness is perceived in one side of the throat, followed by lancinating pains which dart through to the ear, and, later, by a deep-seated throbbing pain as suppuration ensues. On inspection the swelling is seen to extend to the median line of the throat, and even far beyond, in severe cases projecting upward into the naso-pharynx and downward along the side of the pharynx, sometimes leaving only the smallest chink available for respiration and deglutition. The latter function is painful, and the diet must be confined to liquids, for the reason, also, that the lower jaw' is “set” so that the mouth can be opened only about half an inch. Viscid mucus accumulates in the partially occluded pharynx and in the naso- pharynx, causing suffocative attacks and necessitating painful efforts to clear the tln^oat. Indeed, for a night or two the patient cannot assume a recumbent position or sleep uninterruptedly, as voluntary efforts are required to maintain patency of the throat. The uvula becomes oedematous, and the opposite tonsil is usually somewhat swollen, often suppurating later, although simultaneous suppuration of the two sides is rare. Diagnosis. — During the first twenty-four hours the disease cannot be dis- tinguished with certainty from folliculous tonsillitis, wliich, indeed, often pre- cedes the peritonsillar abscess. Later, the diagnosis is established by the characteristic distortion of the throat, as represented in Fig. 3, in which it is seen that the tonsil itself is not the chief seat of swelling, but that this gland is projected inward by tumefaction in the cellular tissue of the velum palati. Prognosis. — This is favorable, except in cases of rare complications, such as oedema of the larynx, extensive burrowing of pus, or hiemori’hage. Treatment. — During the first twenty-four or thirty-six hours an effort should be made to abort the disease, ami to this end the internal and local medicinal treatment is much the same as that described for folliculous tonsil- litis — a saline laxative, the immediate administration of salicylate of sodium in full doses because of the common dependence of the disease on the uric-acid diathesis, and tincture of aconite with potassium bromide as an adjuvant. The same alkaline and antiseptic spray which is recommended for folliculous ton- sillitis should be used every hour or half-hour, and in the same manner, spray- ing through the mouth, and to a less extent through the nose. In the early stage of the affection the application of cold externally by means of Leiter’s coil would assist in aborting the suppurative inflammation were it as feasible with restless children as with adults. As soon as it becomes evident that sup- 422 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. puration must occur, a hot poultice, applied externally over the corresponding part of the neck, will both ease the pain and hasten the formation of pus. At the earliest moment that pus is indicated with reasonable certainty by fluctuation or an effort at “ pointing ” the abscess should be punctured, prefer- ably by a long, slightly curved, double-edged bistoury devised for the purpose, or, in the absence of this instrument, by an ordinary sharp-pointed bistoury. The puncture should not be made into or through the tonsil itself, but some- what above and to the outer side of the gland into the anterior surface of the velum, where the pus actually is located, in the cellular tissue of the velum palati and palato-glossal fold (Fig. 3). Fig. 3. Peritonsillar Abscess : a, point for puncture. VI. Hypertrophy of the Tonsils. The exact function and size of normal tonsils are questions of interest which are answerable only in a general way. Histologically, they possess the structure of both a lymphatic and a mucous gland, and, anatomically, they are in close connection by lymph-channels Avith the cervical lymphatic glands. The inference is that they are lymphatic glands, possessing the function of similar glands elsewhere located, Avhich by virtue of their position in the fauces have been endowed also with mucous elements for lubricating purposes. The natural size approximates that of an almond-kernel. Etiolog-y and Pathology. — The predisposing cause of enlargement of the tonsils is a peculiar diathesis now termed “lymphatism,” the local manifestations of which include also enlargement of the naso-pharyngcal tonsil, or “adenoids,” and of the muco-lymphoid glands of the pharynx and base of the tongue. This diathesis is certainly not identical Avith scrofula, even in the limited sense to which that term is noAv restricted, for lymj)hatism freciuently manifests itself in children avIio are otherAvdse robust, yet the condition seems allied to, and often conjoined Avith, scrofula. Climatic inc(iualities furnish adequate exciting causes. Tn the usual form of the disease, that of mere hypertro])hy, there is simply an overgroAvth, both in size and number, of all the natural elements of the gland — the lymphoid bodies, crypts and folliclc.s, mucous glands, and connec- tive tissue. Another variety of hypertrophy of the tonsils, named by llosAvorth the hyperplastic form, Avhich is rare in children, but common in adults, results from repeated attacks of acute inflammation and consists chiefly of hypei’idasia of DISEASES OF THE PHARYNX AND NASO-PHARYNX. 423 the fibrous connective-tissue element, with a less degree of enlargement and multiplication of the lymphoid bodies. Such tonsils are dense and fibrous, while those of the first type are soft and friable. Between these two types, exist all degrees of variation, both in contour and texture. Symptoms. — Moderate enlargement only will occasion a tendency to recur- rent attacks of acute tonsillitis, and any degree of hypertrophy unquestionably predisposes the child to diphtheritic infection and increases the gravity of the latter disease when it occurs. The effects of mechanical obstruction to respiration occasioned by enlarged tonsils, either alone or especially in conjunction with enlargement of the naso- pharyngeal tonsil, will be described in the article on Naso-pharyngeal Adenoid Hypertrophy, and I need only mention here the more prominent features. Mouth-breathing can be caused even by enlarged faucial tonsils alone — by their projection backward and upward into the pharynx in such a way as to interfere with the passage of air inspired through the nose. Moiith-breathing in turn causes deformed development of the facial bones and muscles and an idiotic expression of countenance and mental stupidity ; also, deformed develop- ment of the chest and thoracic weakness. The recumbent position and absence of voluntary muscular control to keep the throat open aggravate the obstruc- tion to both nasal and oral respiration at night, so that the patient is frequently awakened or thrown into a nightmare by a sense of dyspnoea. Deglutition and mastication are impaired in proportion to the extent of the disease, although it is probable that deficient oxygenation of the blood and disturbed rest at night, together with subsequent thoracic deformity, are the chief factors in seriously stunting the development of the child. Treatment. — Abscission is the only satisfactory method of treatment when the enlargement is sufficient to occasion the symptoms of mechanical obstruc- tion. It is probable that the syrup of iodide of iron so far tends to correct the underlying constitutional dyscrasia as to prevent recurrence after operation, and even to cause partial reabsorption of very slight and recent overgrowths; but we have never been able to discern therefrom any permanent reduction of tonsils which were greatly or even moderately enlarged. Local astringents are wholly inadequate. Ignipuncture or galvano-cautery puncture affords only palliation for the milder cases. We have repeatedly found it necessary to abscise tonsils after months had been spent with this somewhat painful and ineffective mode of treatment. The wire snare is an excellent means of abscission when the child is anaesth- etized, as when combining this operation wdth that for “adenoids;” but other- wise it is slow and painful, and, like the galvano-cautery snare, it requires more time and quietude for adjustment than are available with young children when not anaesthetized. An anaesthetic is not usually necessary when the faucial ton- sils alone are to be abscised, although it is decidedly best to administer ether when the combined operation for removal of the faucial tonsils and naso-pharyn- geal “ adenoids” is to be made. Also, with unusually excitable or obstreperous children ether may be administered. The tonsillotome is still the best implement for children who are not anaes- thetized, because of the rapidity, precision, and comparative ease with which this method can be practised. With older children it is best to use a prelim- inary spray of 5 per cent, cocaine solution. Younger children are apt to be terrified by spraying, and it is best to omit it. The pain is not really great. The Mathieu tonsillotome is well adapted to the purpose, especially for children, and it is the one now in general use. The mechanism is very 424 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN ingenious, being fitted with a fork attachment which is designed to transfix the tonsil, and withdraw it from its bed by the same motion of the operator’s fingers which draws the ring-knife home. The much-vaunted iSIackenzie ton- sillotome is an unnecessarily cumbersome instrument. The author has described elsewhere a simplified instrument which he has Fig. 4. JIathieu's Tonsillotome. used for years with the utmost satisfaction. It is the Mathieu guillotine, so constructed as to do away with the fork attachment (Fig. 5). In place of the fork he uses, held in the other hand, a specially con- structed vulsellum (Fig. 5), hy which the tonsil can be grasped, drawn out of its bed, and abscised at the point desired with much greater accu- racy than by the fork attachment (Fig. 6). He has found the action of the fork to be largely accidental, dependent on the size and shape of the tonsil and the amount of gagging by the patient — that now it determines too deep an Fig. 5. abscission, and, again, misses the tonsil entirely, especially if this happens to be rather small or fiat. In other words, the new instrument, assisted by the vulsellum, will abscise many tonsils that could not lie satisfactoi'ily grasjied by the old mechanism, and it will abscise all tonsils witli a reasonable degree of accuracy at the proper line. One can also by this instrument more easily avoid wounding the anterior and posterior pilLars, which eliminates one of the sources of ])ersistent hamior- rliage. The instrument therefore conduces to safety by virtue of greater ])os- sible precision in operating. It is less formidable in appearance and is easy to use. No tongue-depressor is necessary, the liody of the tonsillotome answering this purpose, at the same time that the vulsellum prongs grasj) the tonsil to draw it from its bod into the ring of the tonsillotome. The projier line or point for abscission 1 believe to be close to the base of the gland, but not so close as to constitute a total extirjiation. A stump should be left, but one not much larger than the normal gland, and not of suf- DISEASES OF THE PIIARYJSfX AND NASO-PHABYNX. 425 ficient size to protrude from or •widely separate the pillars of the fauces. A total extirpation would seem unnecessarily hazardous on account of difficulty of access to bleeding vessels should Imemorrhage occur, and I cannot think that hjemorrhage is any less prone to occur after total extirpation, as recently stated, than after abscission. On the other hand, when a considerable portion of the gland is left, only the cortical layer being removed, redevelopment of the growth is common. Very large and densely fibrous tonsils in older children are best removed Fig. 6. by the galvano-cautery snare, since they are especially apt to bleed if cut, and are difficult to abscise by a cold wdre. In rare instances hsemorrhage even then occurs, either primarily when the wire is overheated, or second- arily on the separation of the slough. The chief objection to the method for general use is the intense inflammation of the fauces which is liable to follow it. This can be, in part, but not wholly, obviated if one is careful not to singe the pillars, which, however, are not so easily avoided in the use of the cautery snare. To this end. Dr. Jonathan Wright has adapted the frame of the Mackenzie tonsillotome to galvano-cautery purposes by substi- tuting for the steel blade a wire mounted on compressed paper and to be con- nected with a battery. Consideration of this subject would not be complete without reference to the views of Dr. Harrison Allen of Philadelphia, as advanced in a recent essay before the American Laryngological Association. He believes “ that abscis- sion should be restricted to the removal of the superficial or cortical part of the tonsil, and in preference to the treatment by amputation of the whole mass; that after removal of such cortex, should the crypts be closed, he would search 42(j AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. for hidden canals, and when found pass a probe or director through them and freely divide the overlying tissues, incising thus the tonsil in any direction and to any required depth. After this is done the separate coarse lobules can be severally taken up by forceps and removed, care being taken to avoid touching enveloping folds of mucous membrane.” It is evident that this would be an impossible method with most young children, because of tediousness, but it may be advantageously utilized with older patients. The only serious objection to abscission of the tonsils is the rare possibility of troublesome haemorrhage, which has seemed to a few extreme conservatives to justify avoidance of the operation; but a greater risk is assumed in every phase of life, in travel, and in pursuit of business and pleasure. It is stated that Elsberg made the operation eleven thousand times with but two cases of even alarming haemorrhage, and Morell Mackenzie, whose experience must have been enormous, ordy once met with a case in which the bleeding appeared actually to endanger life. Only one authentic case of death of a child from haemorrhage after tonsillotomy is recorded in modern literature, and it is prob- able that this case need not have ended fatally but for a deception of the ope- rator relative to the seriousness of the haemorrhage, by reason of the blood being swallowed by the young child and not expectorated ; wdiich caused the adoption of a less vigorous treatment than otherwise would have been used. When one considers the number of cases, beyond computation, of tonsil- lotomy in children, and the few reported cases of haemorrhage, one must regard it as among the safest of even minor operations. The treatment of severe haemorrhage may consist, first, of a trial of the astringents and styptics. The most popular of these is Mackenzie’s mixture of tannic and gallic acids: I^. Acidi tannici 3vj. Acidi gallici oij. Aquae f 5 j . — M. Sig. Sip and swallow half-teaspoonful quantities at short intervals. If this fail, it is probable that any simple astringent or vaso-contractor will fail. Ice, held in the mouth and swallowed, is also an efficient remedy. Pressure may be successfully applied by grasping the tonsil firmly between the thumb, held within the mouth and enveloped in three or four layers of linen, and the fingers held over the corresponding part of the neck. It must be main- tained sometimes for an hour or more. When the simpler expedients fail, then the bleeding points and surfaces should be accurately located and thoroughly seared by the actual cautery, or the galvano-cautery if at hand. For this purpose one needs several small sponges mounted on long sponge-holders, which, if not at hand, may be sub- stituted by wooden sticks (sponges arc much more effective than absorbent cotton) ; also, a small surgical retractor, like a tracheotomy retractor, in the absence of which a palate hook, or even a bent probe, will serve. An assist- ant is desirable to hand and clean the sponges. Under the illumination of a head rellector, the throat should first be well sprayed with a T) per cent, solution of cocaine, and sponged clear of clotted blood ; the bleeding surface can then be exposed to view by holding aside the anterior pillar by means of the retractor, when by rapid sjionging the bleeding points can be discerned and then cauterized. As a substitute for the galvano-cautery one may use a thick wire heated DISEASES OF THE PHARYNX AND NASO-PHARYNX. 427 to redness over a gas-flame. We have used this means successfully with adults, but have never had occasion to apply it with children. If necessary, however, we would endeavor to do so with young children by first administering chloro- form and inserting a Whitehead gag, as in operation for cleft palate, placing the patient with the shoulders elevated and the head pendent, so that blood could not gravitate into the trachea. When the hsemorrhage is comparatively slight exact cauterization of the bleeding points by solid nitrate of silver is eft’ective. Torsion is applicable only when a spurting artery can be seen. As a last resort, may be mentioned ligation of the external carotid artery, as advised by Delavan, in preference to ligation of the common carotid, which latter might permit haemorrhage to continue by collateral circulation through the circle of Willis. VII. Retro-pharyngeal Abscess (Retro-pharyngeal Lymph- adenitis). It is now well established that retro-pharyngeal abscess arises ordinarily not in caries of the cervical vertebne, but in suppurative inflammation of the lymphatic glands which are imbedded in the posterior pharyngeal Avail. In harmony with accepted views of the origin of pus elseAvhere, the source of this inflammation must be infection, either from Avithin or without the body, by some one or more of the pathogenic micro-organisms which produce sup- puration. Children are especially prone to inflammations of the lymphatic system. Cervical lymphadenitis is common among them. Frequently it is tuberculous, but often it is not, and usually the acute suppurative variety results from infec- tion by a previously existing tonsillitis. So also Avith retro-pharyngeal abscess: it is most reasonable to regard it as a secondary infection of the pharyngeal lymphatics from inflammation of exposed and associated muco-lymphoid glands, like the faucial and naso-pharyngeal tonsils. But, Avhatever the source of infection, whether primary or secondary, the initial stage of retro-pharyngeal abscess is retro-pharyngeal lymphadenitis. Moreover, the lymphadenitis may be of a non-suppurative type, or the disease become arrested in this stage, undergoing resolution Avithout the formation of an abscess. Bokai reports a case of retro-pharyngeal lymphadenitis in a child eight months old, in Avhich tracheotomy was necessitated by the supervention of alarming symptoms of sufibcation. The posterior Avail of the pharynx showed diffuse hard SAvelling without fluctuation, and a deep incision into the mass had yielded no pus. After the tracheotomy resolution was quickly established. This simple lymphadenitis has been but rarely observed in this country, but Bokai, in addition to 400 cases of abscess, mentions 112 cases of simple retro- pharyngeal lymphadenitis as having passed under his observation in the Pester Kinderspital. (See note at end of this chapter.) In rare instances the source of infection may be rhinitis, communicated through the nasal lymph-channels, or, still more rarely, a suppurative otitis ; but, as previously intimated, folliculous and suppurative forms of tonsillitis, as well as those forms of tonsillitis and pharyngitis Avhich are symptomatic of the exanthemata, may reasonably be regarded as the most frequent causes of retro- pharyngeal lymphadenitis, Avhich in turn may proceed to the formation of an abscess. Cases which originate in any of these ways are grouped by Bokai under the term “ idiopathic and of 204 cases analyzed, he placed 189 in this class, in contradistinction to only 7 cases secondary to caries of the vertebrae. 428 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. 7 cases from burrowing of pus from abscess in the neck, and 1 case of trau- matic origin. Symptoms. — The disease may commence quite insidiously or it may cul- minate rapidly. Attention is directed to the throat by a deep-seated pain, dysphagia, and, later, by dyspnoea. When located low down in the laryngo- pharynx, a comparatively small abscess may speedily occasion suffocative symp- toms. Critical inspection or palpation of the throat will disclose a swelling of the posterior pharyngeal wall, which may be either in the median line or somewhat to one side. Diag’nosis. — The disease is distinguished from oedema of the glottis by inspection, which reveals pharyngeal instead of laryngeal swelling, and from both diphtheritic and spasmodic lai’yngitis in the same manner ; moreover, in both forms of croup the voice is impaired, which is not the case in retro- pharyngeal abscess. Prognosis. — The affection usually terminates in recovery in from five to fifteen days, the abscess discharging spontaneously in many instances. In a considerable proportion of cases, however, prompt recognition of the disease and evacuation of the pus is necessary to avert a rapidly-fatal issue by suffo- cation, or, in rarer cases, to prevent burrowing of the pus into the oesophagus, larynx, mediastinum, or pleural cavity. Treatment. — As soon as pus has formed it should be evacuated by making an incision as near the median line as possible, and then the head of the child should be inclined well forward to prevent the pus from running into the larynx. An ordinary bistoury will suffice for the incision. An exploratory puncture may be made at any time to determine the presence of pus. In Bokai’s expe- rience tracheotomy has been but rarely necessary, but it should be ])romptly performed if puncture of the swelling does not relieve the suffocative symptoms by evacuation of pus. The syrup of iodide of iron and nutritive tonics are indicated. Vni. Naso-pharyngeal Adenoid Hypertrophy. • This disease, which is variously known as “adenoid hypertrophy in tlie naso-pharynx,” “adenoid vegetations,” and “third tonsil,” in multiplicity of cases and gravity of consequences will bear comparison with any other affec- tion of the upper respiratory tract. In the normal state isolated and aggre- gated muco-lymphoid follicles of the same adenoid structure as those in the pharynx are imbedded throughout in the mucous and submucous tissues of the naso-pharynx. Histologically, each in its simj)lest form consists of a depression of the mucous membrane lined with its epithelium ami enveloped in a stratum of reticular connective tis.sue, entangled in which are numerous lymphoid cells, lymphoid bodies (closed follicles), and lymphatic and other vessels. IMorphologically, they arc closely related to the faucial tonsils, which are com- pound aggregations of the same. At the vault of the pluirynx a number of these follicles are grouped together, forming a compouml gland analogous to the tonsils, and known as the third tonsil, the pharyngeal tonsil, or the tonsil of Luschka. In the normal state this is not of sufficient size to deserve such appellation, but when hypertro])hied, as it frequently is, it hears some resem- blance to the faucial tonsil in a state of enlargement. Several sorts of aggre- g.ation are distinguishable clinically by rhinoscopic ins])Oction. Of these the more common are: (1) {\\c jitnhriated varietij., in which the growth is conq)osed of several cock’s-comb-like masses closely ])aekcd together ; (2) the stfalaetitie fov7n, in which multiple j)car-shaped bodies are pendent, like stalactites, from DISEASES OF THE PHARYNX AND NASO-PHARYNX. 429 the vault of the pharynx, and to which the name “ adenoid vegetations” is most truly applicable ; (3) the individuate variety^ in which the mass is made up, in large part, of but a single neoplasm, of firmer consistency, smoother surface, and more or less irregular contour according to size and degree of impaction. Regarding consistency, this is found to vary in accordance with the amount of fibrous tissue in its composition. In the fimbriated and stalactitic forms the adenoid element predominates, rendering them friable and soft to the touch, while the individuate variety often contains much fibrous tissue, which gives it greater density and tenacity. Between these forms are encountered all degrees of variation both in contour and texture. Etiology. — Children of syphilitic and tuberculous parents and those other- wise the victims of scrofulosis are predisposed to it, but children in other respects robust are also affected. The term “ lymphatism ” has been introduced as a recognition of an under- lying dyscrasia which is characterized by hyperplasia of this and other muco- lymphoid structures, including the faucial tonsils. Climatic inequalities fur- nish adequate exciting causes. Symptoms. — The space of the naso-pharynx is designed to serve as a common area of air-communication between the five openings which enter it. The Eustachian tubes open into it, one on each lateral wall posterior to the nasal choange, and upon perfect patency of these openings, together with free nasal respiration, the power of hearing is dependent ; for ventilation, with nor- mal air-pressure in the cavity of the middle eai‘, is essential to correct auditory sense. The adenoid excrescences, when large, are forcibly compressed between the lateral walls of the naso-pharynx or they overlap the tuber of the Eustach- ian orifice from above, acting in either case as a stopper to one or both openings ; or else the vegetations which are crowded in above and behind the Eustachian tubes de- form and close the orifice by forcing its upper projecting lip downward to meet the lower border of the rim. Fig. 7, accurately drawn from nature, is a typical representa- tion of an average case, in which the naso- pharynx is seen to be occupied by a fim- briated adenoid mass which occludes, in large part, the posterior nasal choange, and so presses downward the upper lip of the tuber of the left Eustachian orifice as to practically close the channel to the middle ear. Again, even with lesser hypertrophy, the accompanying catarrhal state is prone to extend by continuity of surface along the Eustachian tube, and to excite exudation or suppurative inflammation of the middle ear. Deafness, therefore, is frequently a deplorable symptom, and one which is liable to become permanent unless speedy relief be afforded. Into this space open also the posterior nares, the natural respiratory pas- sage being vid the nose and naso-pharynx. Adenoid hypertrophy, therefore, serves as a plug to the posterior nasal openings, and obstructs nasal respiration completely or in part according to the degree of glandular enlargement. From this point we find it a matter of exceeding interest to trace the origin and development of each successive step in the series of deformities consequent upon this condition. The plugging up of the posterior nares necessitates oral breath- ing, and the constantly open mouth interferes with the normal adaptation of Fig. 7. Naso-pharyngeal Obstruction by Adenoids. 430 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. certain facial muscles, which in turn effects radical changes in the contour of the soft and developing bones of the face, the whole resulting in a physiognomy characterized by a vacant, stupid, almost idiotic expression of countenance, which can be better illustrated by a photograph from nature than described (Fig. 8). The hanging lower jaw causes the face to appear elongated. The nose is pinched or its aim distended, Avhile the angles of the mouth and eyes have a drawn appear- ance. Moreover, the air-cavities in commu- nication with the nose, as the frontal, maxillary, sphenoidal, and ethmoidal sin- uses, which are essential to the proper ex- pansion of their respective bones, cease to develop when the circulation of air through the nose is interfered with, thus altering nature's intent regarding the dimensions of the face and head, and still further deforming the physiognomy. Aug- mentation of atmospheric pressure upon the buccal surface of the palate process, and the impact of air-currents to and fro durino; mouth-breathing, together with the diminution of intra-nasal air-pressure inci- dent to nasal obstruction, gradually force upward the centre of the hard palate, and change thus the obtusely rounded Romanesque arch into one of Gothic shape — the pointed or high-arched palate commonly existing in association with long- Fio. 9. Iligh-nrched Palate. Fig. 8. DISEASES OF THE PHARYNX AND NASO-PHARYNX. 431 continued and excessive adenoid development during childhood (Fig. 9). Ele- vation of the palatal arch lessens the traverse diameter of the jaw, and causes it to grow pointed in front — the so-called V-shaped indenture ; and with the resulting contraction of the alveolar process, the teeth, especially those near the point, are crowded into various grotesque aggregations or are rotated on their axes — a condition depicted in Fig. 9, drawn from a typical case, in which the two central incisors overlap, and the two lateral incisors undergo a quarter rota- tion and stand at right angles to the alveolar process. It is proper to state that this relation of mouth-breathing to deformed indentures is questioned by some dental authorities, who attribute the elevation of the palatal arch solely to a perverted production of the permanent teeth. The association between the adenoid hypertrophy as a cause of mouth-breath- ing and the high-arched palate is, however, so constant that an etiological relationship is most probable. Next, elevation of the palatal arch must produce contortion within the nose, for the septum, composed of the vomer, the perpendicular plate of the ethmoid bone, and its cartilaginous portion, is unequal in power of resisting compression to the bones by which it is incased. Designed by nature to fill vertically the Fig. 10. Fig. 11. natural space between the roof of the nose and its floor, the abbreviation of this space by elevation of the palatal arch through the instrumentality of naso- pharyngeal adenoid hypertrophy cannot result otherwise than in forcing the septum to provide for itself by bending and curving laterally in various directions — a condition which is dia- grammatically I’epresented in Fig. 10. The septal deflection acts as an additional impedi- ment to nasal respiration and drainage, and becomes a potent factor in the evolution of hypertrophic rhinitis or that form of nasal catarrh characterized by enlargement of the turbinated bodies (Fig. 11). Headache is also complained of, although a sense of mental obtundity and heaviness is more usual than absolute pain in the head. Finally, not only, as before said, do these un- fortunates look stupid, but they really are stupid, and exhibit abundant evidence of mental hebetude, with inability to fix the attention, to learn, to memorize, or to reason. Three varieties of thoracic deformity are observed to accompany obstruc- 432 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. tive naso-pliaryngeal adenoid hypertrophy, the association of one or other form, in advanced cases, being so constant that a direct causal relationship, although difficult of absolute demonstration, can reasonably be assumed. For the induction, however, of two of these forms, the “pigeon-breast” deformity and the “barrel-shaped” chest, the intermediation of still another symptom, bronchitis, seems essential ; but adenoid hypertrophy is an etiological factor in the production of chronic bronchitis. Especially in neurasthenic individuals it is exquisitely sensitive to reflex-producing impressions, and its irritation may result, reflexly, in spasm of the glottis, cough, asthma, and pare- tic vaso-motor bronchitis. The third variety of thoracic deformity, the “flat chest,” is due directly to obstruction by the adenoid groAvth itself, and is an indrawing of the chest- walls, especially a shortening of the antero-posterior diameter, which results from an insufficient air-supply to the lungs. The chest becomes flat and thin (Fig. 12), has a sunken appearance over the lower part of the sternum, perhaps a deep concavity at the ensiform cartilage, wdth depressed intercostal spaces. Fig. 12 . Flat-chest Deformity (Hooper). Rachitis, so often associated with depraved nutrition, is doubtless the pre- (lisj)osing condition to all of these forms of chest deformity. Treatment. — For pronounced hy])ertropliy the only satisfactory method of treatment is removal by surgical means. Many mctliods by cautery, snare, curette, and forceps, without general anaesthesia, have been described. With older cliildren it makes little difl’erence which of these methods is employed, so that the object is thoroughly accomplished. With young children, however, who will not hold still, most of them are inapplicable, and others border on the barbarous. The young child should be completely amesthetized by ether, and then placed in the sittiiiff position on the laj) of an assistant, with its head against the left shoulder. The mouth is kept open by a gag similar to those furnished with sets of intubation instruments, 'fliree or four ])airs of forceps, either the author’s (Fig. 13) or other modification of liiiwenberg’s instrument, being in readiness, the left index finger is passed behind the velum, followed by forceps held in the other hand; a portion of growth is located, gras])ed, and DISEASES OF THE PHARYNX AND NASO-PHARYNX. 433 Fig. 13. removed, when, without withdrawing the guiding finger, quickly a second, third, and even fourth pair of forceps are used, and thus several pieces extracted before active haemorrhage ensues. Instantly, then, the patient is tilted well forward Avith the head pendent to permit the blood, while flowing actively, to escape by the nose and mouth. In a fcAv seconds the gush is over, the patient can be raised, the remaining blood cotton-swabbed from the pharynx, and the procedure repeated, and still again repeated, until the naso-pharynx is completely cleared. As a final stage remaining shreds are ’ thoroughly scraped by the finger-nail. Little fear need be entertained of blood running doAvn the trachea. That Avhich trickles slowly will course along the oesophagus into the stomach, and at times of rapid floAV this danger Avill be obviated by the method of tilting the child well forward to permit of escape through the nose. Other- Avise the blood is liable to gush into the trachea rather than to be SAvalloAved, assertions to the contrary notAvithstanding ; for the function of deglutition during profound anmsthesia is suspended. Rapid and persistent cotton- SAvabbing may suffice, but is not so completely effective, and it prevents the reapplication of the anmsthetic during the bleeding interval, so prolonging the operation. The patient should be kept in bed until the folloAving day, and during healing the parts should be cleansed by syringing through the anterior nares Avith an antiseptic alkaline solution. When the adenoids are small and soft, sufficient palliation perhaps, but not an absolute cure, can be effected by thorough and rapid scraping with the cleansed finger-nail, used as a curette, Avithout the administration of ether. Gottstein’s knife and Hartmann’s curette, Avhen deftly plied, can also be made effective without anaesthesia, but are apt to terrorize both the child and its parents. Syrup of iodide of iron, internally, tends to correct the underlying dyscrasia — lymphatism. IX. Cleft Palate. True cleft palate is a congenital fissure in the roof of the mouth, of variable extent. The so-called acquired cases differ therefrom in presenting an unequal, ragged, or incomplete cleft, such as would be produced by the destructive ulcer- ations of syphilis. The extent of congenital cleft may vary from the slightest manifestation, that of a bifid uvula, to the grossest form of conjoined cleft palate and hare-lip, in Avhich the fi.ssure involves not only the velum palati and hard palate, but penetrates one or both sides of the alveolar arch and upper lip, with the presence of a separate intermaxillary structure. This article, 28 434 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. however, will not embrace the subject of hare-lip except incidentally (Figs. 14, 15, 16). Fig. 14. Bifid Uvula. Fig. 15. Cleft Palate. Fig. 16. Cleft Palate and Hare-lip con- joined. Etiology and Pathology. — Nature fails to complete her design as origin- ally intended, and the defect doubtless dates from an early period of intra-uterine life. It is assumed that the same causes which produce rickets in childi’en are prone to effect cleft palate. A deficient supply of phosphates in the diet of the mother, or failure on her part to thoroughly assimilate the phosphatic elements, may be regarded as an exciting cause. Vander Veer states that “ several years ago the lions in the Zoological Gar- dens of London were fed upon flesh containing too large hones for them to break and swallow, as is their custom. The young born while this method of feeding was pursued were observed to have cleft palates, and lived but a short time. The lions were then fed upon small animals, whose bones they could break easily, and the young born afterward had perfectly-formed palates.” Intermarriage and unfortunate “ maternal impressions ” are also state and 20 will convey his idea. Next, the introduction of the sutures, by far the most difficult part of the operation. I prefer silk sutures, and consider them much superior to silver wire and shot, as they are softer in the mouth, and seemingly do not produce the same amount of irritation and annoyance to the child. Two colors, white and black, should be used, as all the stitches should be passed before tying, and if these colors alternate confusion of the ends need not occur. The well-curved 438 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. Fig. 18. Warner-Langenbeck Method of Closing Small Bony Clefts, flap prepared on one side only. Figs. 19 and 20. Method of Closing a Wide (flcft of the Hard I’alate (after Uavles-Colloy). DISEASES OF THE PHARYNX AND NASO-PHABYNX. 439 needle, having been threaded, is introduced on one side (the patient being recumbent), from below upward, or what would be, if the patient were upright, from behind forward (Fig. 21). To facilitate passing the needle the flap is held and drawn tense by forceps. The thread is then caught from the eye of the needle by a blunt tenaculum (Fig. 21), one end drawn all the way through, and the needle passed back and drawn off the other end. Fig. 21. Fig. 22. a End of suture, a, is next passed through loop, b, which is used only to draw end o through the flap of that side. Ends a and c are subsequently tied. This procedure is easier than if the needle were previously passed in the reverse direction, as is usually recommended. Having passed the suture on one side, one must pass a double thread on the opposite side, drawing up in like manner with a tenaculum the two free ends, which leaves the loop below (Fig. 22); the needle is then drawn back as before and disengaged. Then through the loop is passed the lower end of the single suture, and, by means of the double thread, it is pulled through the opposite side. In passing the stitches great care should be taken to engage sufficient tissue, not getting them too near the edge, and also to have them passed as nearly as possible at points opposite each other. Before tying the sutures special care should be observed to see that the edges of the flaps are clean and free from clotted blood. Then, commencing anteriorly, the sutures are tied first by means of a slip-knot pushed down by the finger, the suture well tightened, and again tied by an ordinary knot. As the sutures, one after anothei’, are thus tied, see that the edges are not turned in so as to bring mucous-membrane surfaces together instead of freshened edges. Failure to unite by primary union is probably due to incomplete division of the muscles more frequently than to any other one cause ; but the good health of the child, the careful paring of the edges, and placing of the sutures are also essential points. If, however, complete union should not result at the first oper- ation, we certainly should operate a second or a third time. It is rare indeed, with ordinary care and skill, that partial union will not be produced at the first trial, and this will encourage both parents and surgeon to persevere to a complete result. 440 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Concerning now the subsequent treatment of the patient: At the completion of the operation, before the patient has revived from the anaesthetic, a hypo- dermic of morphine should be administered. This to prevent, as far as possible, vomiting and excessive crying — in other words, to maintain quietude of the parts. I consider it best, although all authorities will not be in accord with this opinion, to keep the patient partially under the influence of morphine during the first three days, for the same reason. The stitches may be removed from the sixth to the tenth day. Some of them by the sixth day will have ulcerated out on one or both sides, but this matters not when primary union is secured ; and if primary union is not secured, the stitches will not hold the parts together after the third or fourth day. But as a matter of precaution, to give some strength to the newly-formed union, the stitches may be left until the time stated. To facilitate their removal an anaesthetic should be administered. [Note. — Since going to press the author has observed an instructive case of retro- pharyngeal lymphadenitis in an infant four months of age. The child was convalescing from infectious pseudo-membranous tonsillitis (folliculous) when dyspnoea commenced, and increased for two weeks, when suffocation was imminent. Voice was unimpaired and inspection of the fauces, negative, but palpation disclosed a hard tumor projecting from the posterior pharyngeal wall in the median line, low down and pressing upon the opening of the larynx. Three punctures into this tumor failed to evacuate pus. Trache- otomy was immediately performed. Resolution was complete ; at the end of two weeks the tube was withdrawn, and the child recovered.] GASTRIC CATARRH AND GASTRIC ULCER. By a. D. BLAOKADEB, M. D., Monteeal. I. Acute Gastric Catarrh. Acute gastric catarrh, otherwise known as acute gastritis, gastro-aden- itis, acute dyspepsia, or gastric fever, is an acute inflammation of the glandular tissue of the stomach interfering with its digestive functions, and generally due to the presence of irritating ingesta. The attack is attended with pain, ano- rexia, and nausea or vomiting; frequently also by general pyrexia. It is occasionally complicated by reflex nervous symptoms of a more or less serious character. Associated disorder in other portions of the alimentary canal may be met with. While occurring at any age, artificially reared infants and deli- cate children are especially prone to this disorder. Etiology. — During infancy the stomach appears to be peculiarly liable to disturbance of its functions. It is the period of its most rapid development, and not only does it increase in size, but it has to assume more varied duties. At the same time, the demands upon it, incident to the very rapid growth of the body at this period of life, are proportionately larger than at a more advanced age. Infants fed at the breast generally escape, but not always. Occasionally errors in diet on the part of the mother, violent disturbance of the nervous system, or the appearance of the catamenia, may produce such changes in maternal milk as to render it less digestible, and thus bring about an attack of acute catarrh in the infant. It is, however, among those who have been artificially fed from the early days of infancy that disturbances of this character most frequently occur. The essentials of artificial feeding in in- fancy, — a milk, practically sterile, containing the proper amount of albuminoids, fats, and sugars, fed to the infant in proper amounts, at a proper temperature, and at due intervals, so as to permit perfect digestion with a short period of rest for the stomach, — have not yet been generally attained, even in our more intel- ligent families ; while, among the poorer classes, how often does the infant’s food fail in every one of these details ! During infancy, also, appear the reflex nerve- disturbances generally attributed to dentition. Certainly at this period acute disturbances of the stomach are more frequently met with than either before or after. By the end of two years the powers of the stomach are more developed; the demands of the system less exorbitant; any irritation accompanying denti- tion is past; and, under a careful dietary, attacks of acute catarrh should be infrequent. The rich and varied table diet often injudiciously allowed after this age may, however, conduce to an attack. Generalizing, we may say that any excess in the amount of food, too great variety in its character, the use of such stimulating food as highly-spiced dishes, pickles, or sauces, irregularity in the meal hours, or the unregulated and un- limited eating of fruits, cakes, or sweetmeats, especially between meals, may in 441 442 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. children bring on an attack of acute indigestion. Food or drink, too hot or too cold, quickly taken, may also occasionally be an exciting cause. Closely associated with errors in the dietary as an etiological factor is the imperfect mastication so often given to food. Children require to be taught to masticate, and their teeth from the time of their first appearance should claim the careful attention of the attendants. There is not, however, in all children an equal susceptibility to disturb- ance. Some appear to have particularly vigorous stomachs which tolerate much abuse, while it is only Avith the greatest care that attacks can be averted in others. In some a predisposition to weak digestion is distinctly hereditary. Anmmic children are peculiarly prone to attacks. The close association be- tween rickets and disorders of digestion has long been recognized. The scrofulous and rheumatic diatheses are also predisposing factors. Unsanitary conditions of life markedly impair the digestive poAvers, and thus favor an acute disturbance ; especially is this true of Avant of exercise in the open air. The acute ailments and specific fevers of childhood frequently leave the mucous membrane of the alimentary canal in a Aveakened condition, from which it takes time and a very careful dietary to thoroughly recover. Of this class of disease Ewald says : “ Although the gastric symptoms are relegated to the background by other manifestations, yet in those cases Avith dyspeptic dis- turbances, in Avhich we are enabled to examine the organ soon after death, Ave will find the anatomical changes of acute gastritis.” In some children the sudden checking of the cutaneous circulation, by chill from imprudent exposure, may occasionally interfei’e Avith the process of diges- tion and bring about an attack. Eustace Smith thinks this a very frequent cause of trouble. In our more severe climate children are more perfectly clothed in flannel than in England, but in children Avith Aveak stomachs I have frequently noticed an attack of gastric catarrh brought on by getting the feet damp. Unless due care be exercised, one attack may predispose to others. Pathology. — Our knoAvledge of the minute changes in the mucous mem- brane in acute gastric catarrh has, until lately, been very limited ; so much so, that some Avriters have questioned the propriety of admitting this among the list of actual diseases. In his recent Avork EAvald protests against the use of the word “ catarrh ” as creating an erroneous conce])tion. “ The structure,” he says, “ of the gastric mucosa, better designated the glandular layer, tunica glandularis, is such that it is out of the (picstion to call it a mucous membrane in the ordi- nary meaning of the term It is simply a peculiar feature of the inner layer that the protoplasm of the epithelium of the excretory ducts pos- sesses in a remarkable degree the pro])erty of being converted into mucus. . . . . Dr. Beaumont’s investigations on his patient, St. Martin, shoAved that every catarrh, even the mildest, Avas accompanied by a disturbance of the secretion of gastric juice ; consecpiently by an afl'ection of the glands them- selves. The inllammation is thus not catarrhal, but j)arenchymatous and inter- stitial. It has nothing in common Avith a catarrh oxee])t the “lloAV,” the secre- tion of a more or less abundant, but ahvays alkaline, transudate iTito the cavity of the stomach. INIisled by the term “catarrh,” avo are too ])rone to under- estimate the importance of these processes, particularly Avhen they arc chronic, and by thinking, for exam))le, of a chronic pharyngeal catarrh, Ave lose all proj)er standards of comparison.” Macrosco])ically, the mucous membrane in acute catarrh ap))oars SAVollen and reddened. In severe cases slight Incmorrhages, or even small erosions, may occur; the submucosa may be oeileniatous. Microsco])ically, there a])]iears an infiltration of the interstitial tissue Avith leucocytes ; the differentiation between GASTRIC CATARRH AND GASTRIC ULCER. 443 the parietal and the principal cells can no longer be made out, while all the cells may alike be seen to have become granular and cloudy, and in part separated from the membrana propria of the glands. The mucous cells are especially abundant in the pyloric region, and extend down deeply into the ducts of the glands. Symptoms. — Cases of acute gastric catarrh have been divided into two classes, the febrile and the afebrile, according as they are, or are not, accom- panied by pyrexia. The division is a convenient one. The febrile are much the more severe. The afebrile run a short, mild course, and are as a rule unaccompanied by serious symptoms. The onset of an attack is generally sudden. Within an hour or two after the error in diet the child shows signs of being unwell. If an infant, after a short sleep it awakes crying and apparently in pain. Its thighs are flexed on the abdomen. It moves restlessly from side to side, and whines piteously or cries bitterly. The temperature will be found more or less elevated, 102 ° to 104°, the pulse and respiration quickened, the tongue furred, the abdomen distended, and pressure on it evidently increases the child’s distress. The bowels at this time may, or may not, show signs of disturbed action. Vomiting generally occurs early, with some temporary relief. After this the infant, if allowed, may eagerly take the breast or its food again, only to reject it, curdled and sour-smelling, after a short interval. If the ejecta be carefully examined, there will be found a marked deficiency of hydrochloric acid, and in its place the presence of lactic and butyric acids. Vomiting may recur several times ; at the last, watery, sour-smelling mucus, perhaps more or less bile-stained, being ejected. There is now complete anorexia. The infant is restless and feverish, if not actually crying with pain, and its sleep is much broken and disturbed. Under proper treatment the attack is generally of short duration, and in twenty-four or forty-eight hours a few loose movements carry away any of the offending material that has escaped into the bowel ; the fever subsides ; the infant again sleeps quietly ; but for a few days it is less eager for its food, which it is inclined to take more slowly and in smaller quantity. In older children the attack manifests itself by a feeling of listlessness, with more or less drowsiness. The child will give up its play and prefer to lie down. Uneasy pain in the epigastrium is soon complained of, with a feel- ing of nausea and headache. If the child fall asleep, it is a very disturbed sleep, from which it frequently awakes in a fright, complaining of bad dreams. Dark circles may now be noticed under the eyes ; the face is generally pallid unless the fever runs high. In that case a peculiar pallor about the upper lip and the aim nasi is very distinctive of irritation of the stomach. The tongue is coated heavily toward the base, but the tip and the edges are red ; the skin is dry ; the pulse is quickened ; the temperature may be high — 103° to 104° — but if so it reaches its height early ; the abdomen is distended, pressure over the epigastrium increasing the uneasiness ; and the breath is generally heavy or sour-smelling. The secretion of saliva is increased, so that during sleep it may dribble on the pillow. Vomiting may occur, but not so generally as in infants. When it does, there is usually much retching, and toward the close biliary matters, with watery mucus, are ejected with much straining. The bowels are constipated and the urine scanty and high-colored, with an abundant sediment of lithates. The headache is generally frontal, although sometimes temporal. In some cases an associated pharyngitis may be noticed ; in others a few herpetic vesicles appear on the lips. In mild cases the attack subsides in a day or two, but in the more severe forms the fever may persist for four or five days, leaving the child in an exhausted state, from which, however, under careful 444 AMERICAN TEXT- BOOK OF DmEASES OF CHILDREN. dietary, it generally recovers rapidly. Occasionally an attack of acute gastric catarrh is followed in a few days by catarrhal jaundice. The inflammation has probably extended down the duodenum, blocking the common bile-duct. Such cases are usually of short duration. Although, in general, an attack of acute gastric catarrh may give us little anxiety, at times w'e have associated reflex symptoms of a very alarming char- acter. The convulsive seizures of infancy, dependent so freciuently upon gastric or intestinal irritation, are fiimiliar to all and recjuire prompt treat- ment. The danger of cerebral hmmorrhage during such an attack should always be borne in mind. In older children more alarming, because more unusual, symptoms of reflex irritation are occasionally met with. In some instances localized or diffuse clonic muscular movements have tlieir origin in gastric irritation. Symptoms closely resembling those of meningitis have been reported by Seibert. Fraen- kel relates the case of a child four years old Avho shortly after eating a large amount of table food lost the power of movement and sensation on the right side. Complete recovery follow'ed on the next day. Henoch records a case of complete aphasia in a child which passed away an hour later after the vomiting of some undigested fruit. Such cases, however, are rare, and should always receive the most careful attention on the jnart of the physician, lest, instead of being reflex, they arise from a distinct and all-important lesion. Diagnosis. — In most instances, w’ith a distinct history of some error in diet, no serious difficulty will be experienced in arriving at a guarded conclu- sion. The sudden onset, the tenderness over the epigastrium, the relief afforded by vomiting, and the rapid subsidence of the symptoms will in a day or two enable us to assure the parents that no more serious trouble need be appre- hended. In cases attended with fever, however, it is always wise to speak more or less guardedly at the first. The onset of scarlet fever should always be excluded. In this disease we have as an early symptom a definite amount of congestion of the fauces, followed frequently by some enlargement of the glands at the angle of the jaw. The irregular erythema, sometimes appearing for a few hours in disorders of the stomach, should be distinguished from the scarlatinal eruption with its more regular development and longer duration. In doubtful cases, for such will arise, isolation for twenty-four or forty-eight hours will solve the problem. Tonsillitis and diphtheria may, with care, be easily excluded. An attack of acute catarrh may closely resemble the onset of pneu- monia. J. Lewis Smith relates a case in Avhich the high temperature and ex- piratory moan simulated a pulmonary inflammation, but was ])romptly relieved by the expulsion of some orange-pulp. In cases such as these careful attention must be paid to the pulse, the respiration, and the tem[)erature. In typhoid fever the rise is more gradual; we frecjuently meet with an initial bronchitis, the prodromata are more marked, and some enlargement of the sphum may be made out. In acute gastric catarrh the onset is more sudden, and the disten- tion of the abdomen more marked, thai\ is general in typhoid fever at an early stage, while tenderness is noted in the epigastrium, not in the iliac region, and the temperature falls after a few' days. In delicate children the possibility of tuberculosis must always give us anxiety. We have no absolute symj)tonis by which we can exclude this disease. A slow pulse may occasionally be met with in gastric disorder from irritation of the vagus. The vomiting of meningitis is, in general, indistinguishable in its character from the vomiting of mere gastric irritation, and the condition of the tongue is no certain guide. Under these circumstances a careful watch for localizing symptoms will be renjuired, and a very guarded opinion must be given. GASTRIC CATARRH AXI) GASTRIC ULCER. 445 Prognosis. — The prognosis of acute gastric catarrh must be regarded as very favorable. Only in delicate infants, whose hold on life is extremely frail, will the disturbance of nutrition or the gastric irritation threaten immediate serious results. Such an attack may be the beginning, however, of a gastro- enteritis, which may prove fatal. Convulsive seizures are always serious. Relapses are common in artificially-fed infants and in older children unless due care be exercised. Treatment. — In acute gastric catarrh the first important indication for treatment would appear to be the removal of the oft'ending material in the stomach. Nature in many cases effects this spontaneously by the induction of vomiting. Should we see the case early, before vomiting has taken place, we may favor it by the administration of ipecacuanha, either in the form of a powder, or of the wine or syrup. If some hours have elapsed, however, a large portion of the offending stomach-contents may have escaped through the pylorus, and a gentle but prompt purgative is then called for. The following are suitable prescriptions under the circumstances : I^. Hydrarg. chloridi mitis gr. ij— iv. Sodii bicarbonatis gr. xij. — M. In pulv. iv. divid. Sig. One every three hours until a free evacuation of the bowels is secured (for a child of three years). Or, I^. Hydrarg. cum ci’eta gi"- vj. Sodii bicarbonatis gr. viij. Pulv. rhei gr. viij. — M. In pulv. ii. divid. Sig. One to be given immediately (for a child of three years). Or, I^. Sodii et potassii tartratis gr. xxx. Sodii bicarbonatis gr. iij. — M. In pulv. vj. divid. Sig. One to be given every hour in a ■wineglassful of hot water until a free evacuation is secured (for a child of three years). In those cases where vomiting is troublesome and persistent minute doses of calomel, or of calomel and soda, may be given dry on the tongue. My own preference is for the triturate of a tenth of a grain, or of the tenth of a grain of calomel with a grain of soda, to be given hourly until eight or ten doses have been taken. This generally checks vomiting and secures a free evacua- tion of the bowels within twelve or twenty-four hours. It probably serves also to check to some extent the development of bacteria in the stomach. Should pain in the epigastrium be complained of, a warm poultice of linseed-meal, either pure or with a proportion of mustard, applied over this region, will be a source of much comfort. After the first acute symptoms have passeer by Ayres {Med. News, vol. lix.. No. 1, 1891, p. 1) on chronic gasti’o-intestinal catarrh in relation to the etiology of some cases of insanity. Microscopic Appearance of Matters Passed. — They are very similar to the masses passed in cases of membranous enteritis, and are made up of opaque white solid masses, moulded or flattened, and small flocculent pieces of semi-translucent membrane. The tubes, branching membranes, casts, and fine network membranes are not seen in mucous disease. The description I have elsewhere given of membranous enteritis (in Keating’s Cyclopmdia, vol. iii. p. 166) also applies to the mucous masses voided in chronic gastro-intestinal catarrh. Under a low-power objective the masses are seen to be due to the formation of mucous and epithelial matter (the cells having undergone fatty degeneration), and granular debris. H. B. llare states that these matters are similar in chemical reaction to pharyngeal mucus, that they may possibly contain a trace of albumin, but no fibrin. Their surface may be seen to be composed of opaque and translucent parts ; the former appear as rounded ridges marking oft’ the latter into regularly arranged hexagonal or polygonal crypts. Clark has observed that the product of diseased action on mucous mem- branes occurs in three varieties : first, clear, jellylike, and imperfectly mem- branous ; second, yellowish, semi-opaque, flaky, and usually membranous ; third, yellowish-white, dense, opaque, distinctly membranous, tough, and rather adherent to the subjacent surface. Morbid Anatomy. — The morbid anatomy of the disease seems to be a thickening of the intestinal mucous membrane ; there may be evidences of ulceration or enlargement of the glandular follicles of the colon or small intes- tine, the sigmoid flexure, and the descending colon, together with the lower part of the ileum. Diagnosis. — As I have elsewhere remarked, if mistakes arise in the diag- nosis of the aft’ection, they are in all probability due to the carelessness of the observer rather than to any obscurity in the manifestations of the usual clinical phenonema of the disease. The mucous masses may resemble and have been mistaken for ascaris lum- bricoides; indeed, the parasite may be present in the discharges, as it finds in the mucus-loaded intestine a peculiarly acceptable habitat. The white, shining, detached pieces have been mistaken for segments of the various tape-worms, tmnia mediocanellata, tmnia solium, and bothriocephalus latus. The lienteric discharges of dysentery have also been erroneously considered as illustrations of this disease; in scarlatina and tubercular disease mucous deposits are sometimes passed per anum. The disease, however, of all others, with which we are apt to confound mucous disease is general or pulmonary tuberculosis: here it is that a carefully recorded series of temperature records is invaluable. In tuberculosis w'e find a continued elevation of temperature, while in mucous disease the temperature is 458 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. usually normal ; at all events, it is only elevated during the height of a paroxysm, remaining high for two or three days and returning (quickly to the normal. Smith makes the statement that in some cases the temperature rises and remains elevated, perhaps permanently, although the symptoms in other I’espects correspond to those of mucous disease. I have never met such cases. He con- siders that these subjects are j)eculiarly prone to pneumonia, and that the deposit, only partially absorbed, undergoes cheesy transformation and forms the so-called pneumonic phthisis. Under these conditions I must confess that the differen- tial diagnosis between mucous disease, pneumonic phthisis, and tuberculosis would indeed be a diiiicult problem to solve. Prognosis. — Most cases run a prolonged and tedious course, with many recurrent attacks and exacerbations, extending sometimes into adult life. Abso- lute recovery rarely occurs. Treatment. — The_ child that is the subject of mucous disease must submit to a constant supervision of its daily life. Its diet, regimen, and personal hygiene are of vital importance. The little patient must have a daily bath, first Avith castile soap and Avarm Avater, then a general sponging Avith alcohol, folloAved by an inunction of olive oil. In this Avay the peculiarly harsh, dry, and scaly skin can be restored to its normal function as one of the excreting organs of the body. The diet ahvays merits the most painstaking care; indeed, without a correct and suitable diet all other methods of treatment Avill inevitably fail. All sources of irritation are to be removed ; easily-digested or even pre-digested food should be supplied, and the medical attendant should satisfy himself that undigested particles of food are not irritating the alimentary canal. The folloAving diet-table is taken from Eustace Smith (fifth edition, 1888), and is applicable to a child of seven years of age and upAvard: Breakfast, 8 A. M. Three-quarters of a pint of fresh milk alkalinized by twenty drops of the saccharated solution of lime; a thin slice of Avell-toasted bread; fresh butter; a fresh egg lightly boiled or poached. Dinner, noon. A mutton chop Avithout fat, broiled ; Avell-boiled caulifloAver or French beans, according to season; a thin slice of Avell-toasted bread; half to one Avineglassful of sound sherry, diluted Avith tAvice its bulk of Avater. Tea, Jf. P. M. Same as breakfast. Supper, 7 P. M. A breakfast-cupful of beef-tea (a pound to the pint) ; a thin slice of dry toast. Or Ave can adopt a diet-table that I suggested in a lecture before the Univer- sity Training-School for Nurses, Avhich is that of the North-eastern Hospital for Children, London : Milk Diet. Fish Diet. Full Diet. Breakfast, 7 a. m. . Milk, pint; bread, 2 ounces, with butter. Milk or cocoa, )unt; bread, ounces, with Imtter. Milk or cocoa, Yt pint; bread, 2Yi ounces, with butter. Dinner, 12 m. . . . Milk, ]unt : rice or other milk pudding. Fisli, boiled, 2'/^ ounces; l)otatoes, mashed, 3 ounces; bread, 1 ounce ; milk pudding. Koast, boiled, or minced mut- ton, or roast or minced beef, 2Y ounces; mashed jiotatiies, •1 ounces, to alternate with green vegetables; bread, 1 ouiiee; milk pudding. Tea, 3.30 p. ji. . . . Milk, 54 Piiit ; bread, 2 ounces, with butter. Milk, Yi pint; bread, 2Yi ounces, with treacle or tiutter. Bread, 2!^ (mnees, witli butter, treacle, or drlpi)ing; milk, ' , Piid- , , , Supper, C p. M. . . Biscuit (cracker) or slice of broad and butter. Bread, 2 ounces, W'ith but- ter, or cracker. Bread, 2 ounces, with butter, or cracker. In the more serious forms Jacobi adheres to a very strict diet. He says : “ No 3IUC0US DISEASE. 459 raw milk, no boiled milk, no milk at all in any mixture, in bad cases.” In the very worst cases total abstinence is recommended by this writer for from one to six hours; afterward the following combination is allowed: Five ounces of barley-water, one to two drachms of brandy or whiskey, the white of one egg, salt, and cane-sugar; a teaspoonful every five or fifteen minutes, accord- ing to age or case. Jacobi in his terse way remarks: “That never are the common sense and tact of the intelligent practitioner more thoroughly taxed; no printed rule ever supplies or substitutes brains.” If the appetite be capricious, these strict dietetic rules cannot of course be adhered to ; we must then endeavor to supply such a variety as will tempt the appetite and check the tissue waste. If the stools show a mass of milk curds, milk must be diluted, predigested, or altogether prohibited. The various preparations of predigested food may now be resorted to : milk, milk-gruel, milk-punch, effervescing milk-punch, beef-tea, and oysters may all be prepared in this manner. Raw beef-juice, beef-tea, consommfi, chicken, mutton, or veal broth are preparations upon which we may often place absolute dependence. Farinacea as a rule must be excluded, although we occasionally have to allow a little rice pudding, tapioca, or flour-ball by way of a variety. It is somewhat odd to note in this connection that Burnet in his valuable little book on Foods and Dietaries recommends the farinaceous substances as a suit- able diet in mucous diarrhoea. Alcohol is not by any njeans contraindicated, and may be administered as wine-whey or a combination of milk, egg and brandy. English writers advise well-diluted light sherry or light claret. Among medicinal agents many and varied plans of treatment have been suggested. Recently much attention has been paid to intestinal antisepsis, but it is interesting to note that so recent and reliable a writer as Osier, in his Practice of Medicine, considers that “ we are still without a reliable intes- tinal antiseptic. Neither naphthaline, salol, resorcin, salicylates, nor mercury meets the indications.” This has not been our clinical experience, nor indeed has it been that of the general practitioner. Dujardin-Beaumetz recommends the following formula as a satisfactory intestinal antiseptic : I^. Salol Bismuth! salicylatis Sodii bicarbonatis aa gr. cl. Sig. Divide in capsul. No. xxx. One capsule before breakfast and before dinner. Droixhe considers salol as a remedy easily administered and without toxic action, and ranks it among the approved intestinal antiseptics. Car reras suggests resorcin in the following formula : I^. Resorcin Syr. aurantii Aq. citronellm Sig. Three teaspoonfuls every three hours. . . . gr. ij-vij. . . . f^j. q. s. ad f^iv. — M. The same author suggests that when the child is fed exclusively upon 460 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. milk the dejecta may be very acid ; in this case some such mixture should be given as — Bismuth, phosphat. aut subnitrat Sodii bicarbonat Pepsinge Pulv. ipecac, comp Divide in chart. No. iij. Sig. One every hour or two. Creolin has been recommended in the following combination ; gr. XXX. gr. XV. gr. yij. gr. j-iv. — M. Creolin Ttlviij. Sacchari gr. Ixxv. — M. Divide in chart. No. x. Sig. One every two or three hours. I^. Creolin gtt. i-ij. Syrupi f^j. Aq. menthae piperit fsij. — M. Sig. Teaspoonful every two hours. Schwinz also endorses creolin. Naphthaline may be given to young children in doses of ten centigrammes every two hours. Pure naphthaline never causes accidents even when used in large doses. It may be given per rectum in a mucilaginous mixture which will hold it in suspension but not dissolve it. Bouchard thinks naphthol is superior in its action to naphthaline. Constipation may exist sometimes to a stubborn degree : 'mild saline laxa- tives may be exhibited, or a simple enema may occasionally be administered, and will usually cause the expulsion of large masses of mucus. Irrigation of the stomach is generally agreed upon by all writers to be a most efficacious method of dealing with the more chronic examples of the disease. Osier speaks of it in the warmest terms in cases of the most obstinate gastro-intestinal catarrh in children. This method must be combined with the irrigation of the large bowel. The last-quoted authority states that a pint will thoroughly irrigate the colon of a child aged six months, and a (juart that of a child of two years. When the temperature is high, ice-cold water may be used for this purpose. Booker has had a large experience in stomach-washing. Ilis apparatus is the one proposed by Epstein. A soft Nelaton’s catheter. No. 8, U, or 10, is attached by a short glass tul)e to a common rubber tube two feet long, with a 2 ounce (62 grammes) glass funnel fitted into the distal end ; a pitcher contain- ing a half-gallon (2 litres) of tepid Avater is placed in a convenient position. It is only witliin a short time that the plan of Avashing out the stomach, Avhich Avas inaugurated by Kussinaid for diseases of that organ in adults, has been applied to children. The difficulties connected Avith its application are few, and the dangers, even for the youngest and AA’cakest infants, easily avoided. Kussmaul’s a])paratus for irrigating the stomach consists merely of a N(?laton’s catheter, a long rubber tube, and a funnel, and this simple apparatus Avill accomplish all that is necessary. Escherich’s apparatus has greater advantages, however, and is preferred. The time required for irrigation of the stomach is MUCO m DISEASE. 461 usually four or five minutes, from half a litre to a litre ami a half of water being usually re(iuired before the return fiow is clear. If there is gastric or intes- tinal catarrh, a few drops of a 6 per cent, solution of benzoate of sodium and a few drops of tincture of opium may be given hourly after each irrigation. Irrigation is contraindicated only in very feeble children and when collapse is impending. The same apparatus is also used for intestinal irrigation, except- ing that a larger and stiller catheter, with much larger lateral opening, is employed. It may be introduced, if necessary, to a distance of 27 centi- metres, and the entire large intestine washed out. Ehring’s experience in this method of treatment in 850 cases has been rapid cure in 68.7 per cent, of cases, moderate success in 1-4.58, failure or death in 16.73. This writer further considers that the indications for this treatment exist in all cases of intestinal catarrh. Riemschneider reports the results obtained in 140 cases by this method, and is favorably impressed with the results obtained by washing out the stomach with Escherich’s apparatus; he follows the irrigation of plain water by an irrigation of a 3 per cent, solution of benzoate of sodium. Of these cases a quickly favorable result was obtained in 89, a slowly favorable one in 31 ; in 20 the result was fatal. Seibert in treatino; 1404 cases of gastro-intestinal catarrh used stomach- washing in 521 cases, and states that the results were most gratifying both in stomach- and bowel-washing.* Von Ziemssen recommends cutaneous electrization of the stomach with very large electrodes, for half an hour before meals. This treatment is supple- mented by faradizing for a short time with the wire brush the skin of the abdomen, cheek, and back. Massage of the stomach and intestines is also of value, although of less importance than electricity. Electrization of the intestines is accomplished with large electrodes, one occupying the entire abdominal surface, the other the entire dorsal surface ; and the electricity must be of increased intensity, owing to the great size of the electrodes. The subjective results of this treatment are increased appetite and loss of abnormal abdominal sensations. When the excretion of mucus is excessive the alkalies will assist materially in arresting its secretion : we usually select the bicarbonate of sodium ; this may be combined with twenty-drop doses of tincture of myrrh, as suggested by Smith, or the powdered myri-h which Maxson speaks so highly of, given in divided doses of from 9 to 12 grains a day, either in capsules or with mucil- age of acacia, glycerin, and liquorice. Podophyllin and aloes are much lauded * Dr. W. Soltan Fenwick cites the dangers of washing out the stomach : 1. Convulsions and tetany. Probably because, in a case predisposed to convulsive seizures by the chronic absorption of certain morbid products from the dil.ated stomach, the irritation of a gastric tube may con- stitute an efficient exciting cause. 2. Syncope and sudden death. ,\ny sudden alteration in the gastric pressure can, in certain cases, bring about a reflex condition of shock. 3. Perforation. The using of a gastric catheter for the purpose of investigating the chemical contents of the stomach in cases of acute gastric ulcer is a useless and mischievous procedure. 4. Hsemorrhage. Danger may arise from a too rapid evacuation of the contents of a dilated stomach. 5. Injury to the ffisopliagus or to the walls of the stomach. 6. Poisoning. From the use of antiseptics through the tube. Cases are cited illustrating each division. He concludes that the stomach is washed out for all sorts of symptoms, some of which are manifestly not to be benefited by this procedure. And in cases in which it fails to do good it is likely to be productive of harm in removing products of digestion whose manufacture has caused the stomach a considerable amount of labor. The indiscriminate use of this method in every case of disordered digestion will prove to be a curse rather than a benefit, and will eventually throw discredit upon the whole method of treatment. Booker says stomach-washing is contraindicated in children aflfected with heart disease, serious bronchitis, or pulmonary trouble. If the tube continues to excite vomiting and strong resistance, it is doubtful if advantage follows its use. 462 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. by the English writers ; our preference has been for some of the milder laxatives. We have obtained good results from the following combination : Pulv. rhei Sj. Magnesii carb oiij. Pulv. zingiber 3ss. Elixir simp q. s. ad fsviij. — M. S. Teaspoonful night and morning for child of five years. Some cases do well upon the acids, nitric, hydrochloric, or nitro-muriatic. Strychnine, ipecacuanha, and gentian in pill is sometimes a happy com- bination. Belladonna, Dover’s powder, quinine, subnitrate and subcarbonate of bismuth have all been suggested. Quinine may be given in two-grain sup- positories combined with a sixth of a grain of opium, as suggested by J. C. Wilson. When the gastro-intestinal tract is in condition to receive it, iron becomes a valuable adjunct : we select either the tincture of the chloride combined with nux vomica and dilute phosphoric acid, or the dried sulphate of iron with aro- matic syrup of rhubarb. Arsenic, copaiba, bromide of potassium, turpentine, cod-liver oil, oxide or nitrate of silver by mouth or by high injection into the bowel, chloride of ammonium, sulphate of zinc, bichloride of mercury, chlorate of potassium, oxide of zinc, blisters, nux vomica, ergot, are among the drugs recommended by various writers. Gold has been suggested as follows: I^. Auri 20 grammes. Mellis 125 grammes. — M. Sig. One coffeespoonful in the morning and two in the afternoon. Antiquedad states that hydrotherapy, sulphate of quinine, chlorate of potassium, and revulsion are the means which will be found most efficient in the treatment of intestinal catarrh in childi’en. It is quite useless to order cod-liver oil while the alimentary canal is covered with mucus ; Avhen we have modified the mucous discharges, oil then becomes a valuable drug. These children, however, cannot assimilate large doses. Much is to be gained by a residence in a suitable climate. We can for- mulate no rules, boAvever, as to the locality to be chosen ; each case is a rule unto itself. My practice has been to leave the matter of selection of a climate to a great extent to the patients themselves, with, however, a ju’omise that the local- ity must be such as to permit of an almost constant out-door life, the greatest number of clear sunny days, and the least variability of thermometric range. It must also be understood that the patient will spend several years at the place of selection. DIARRHCEAL DISEASES. By victor C. VAUGHAN, M. D., Ann Arbor. There are many difficulties in the way of a satisfactory classification of the diarrhoeal affections of infancy. The gravest symptoms in the most speedily fatal cases are often accompanied by the most superficial lesions ; while, on the other hand, symptoms so mild that no anxiety is awakened may result from marked and extensive pathological changes. Cases which are apparently iden- tical clinically often reveal diverse lesions. It is therefore apparent that the pathological alterations do not form a suitable basis of classification. The variations from the normal condition found after death are dependent more upon the length of the continuance of the diarrhoea than upon the primary exciting causes. The majority of cases of infantile diarrhoea which continue for four days or longer might be designated, in a classification founded upon morbid anatomy, as entero-colitis, and, moreover, the extent of the inflam- matory changes is measured largely by the duration of the diarrhoea. In cases terminating fatally within four days, in previously healthy children, even the superficial epithelium may be normal, while in other of these cases there may be some desquamation of this layer. The cases Avhich terminate fatally after from seven to ten days usually show more marked inflammatory changes. The mucous membrane is swollen, the villi are prominent and pur- plish, and the solitary and agminated follicles are congested and projecting. In more protracted cases the inflammatory process involves the deeper layers, and ulcerations in every degree, from the most superficial to those extending down to the muscular coat, may appear. It would be as unscientific to attempt a classification of the diarrhoeas of infiincy founded upon pathological anatomy as it would be to designate acute, subacute, and chronic arsenical poisoning as desquamative, catarrhal, and ulcerative gastro-enteritis. Having thus discarded all cla.ssifications founded upon morbid anatomy, what shall Ave select as a basis for the differentiation of the various forms of diarrhoea in infancy ? The fundamental object in any classification must be to enable the physician to treat his patient most successfully. The giving of names to diseased conditions enables us to group, systematize, and most advantageously use the information which Ave may possess, or may in the future ac(iuire, concerning the etiology, symptomatology, and treatment. Cer- tainly in the class of diseased conditions noAv under consideration a classi- fication founded upon etiological factors Avill be of greatest service in treat- ment. But the question which arises here is this : Do we at present know enough of the causes of these diseases to attempt a classification based upon etiology ? In answer to this I reply that, Avhile there is yet much to learn on this point, I propose to offer a provisional classification founded upon what I believe to be the most impo*rtant factors in the causation of the diarrhoeas 463 464 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. of infancy, because I believe that such a classification, imperfect as it must at present be, will be of greater service to the practitioner than one based upon the morbid anatomy, which, as we have seen, is determined more largely by the duration of the diarrhoea than by the nature of the exciting cause. In attempting this classification w'e have the following facts to aid us: (1) Some of these diarrhoeas are independent of seasonal influence. They occur as frequently in winter as in summer, while the prevalence of other forms is so plainly limited to the hot season that they are now quite universally designated as “summer diarrhoeas.” (2) Those which are apparently independent of sea- sonal influence do not differ from similar diseases in adult life, save in the greater susceptibility of the infant and in the greater delicacy of its organiza- tion, thus rendering the disease of more serious imj)ort in the child than in the adult. On the other hand, the so-called “summer diarrhoeas” are so generally limited to the first two or three years of life that they may be regarded as peculiar to that age. Improper or excessive feeding, acting upon the delicate organization of the child’s digestive apparatus, may cause diarrhoea even when there are no toxi- cogenic micro-organisms present. A small quantity of some indigestible sub- stance in the intestines may increase the peristaltic movements and lead to frequent stools. Taube and Escherich have shown that in the young child stomachic digestion is of less importance than intestinal digestion, and that the stomach is more of a receptacle into Avhich the milk is received for coagulation than a digestive organ ; thus we have the most favorable conditions for the growth and activity of the bacteria which are introduced Avith the food. The same investigators find that the younger the child the less active is digestion in the stomach, and that in this organ the milk is coagulated and passed through the pylorus undigested. Ilammarsten has shoAvn that this is the case in j)up- pies and young rabbits, and Ilofmeister and Tappeiner shoAved that the stomach does not absorb soluble substances as ra])idly as does the mucous membrane of the small intestines. ZAveifel states — and in this he is supj)orted by Ilammar- sten — that the proteolytic activity of the pancreatic juice is relatively Avell developed in the neAv-born. The absorption of fats is dependent upon the j)ancreatic juice and the bile, and the teaching of Ererichs, that the milk- sugar is absorbed from the stomach, is noAv knoAvn to be erroneous. This constituent of milk, as has been shoAvn by Dastrti, is digested by a ferment found in the mucus of the small intestine. These experiments convince us that the dige.stion of milk by the infant is ne.arly, if not (juite, altogether accom- plished in the small intestine, and explain Avhy indigestion in the infant induces diarrhoea. The diarrhoea Avhich results from temporary indigestion Avill be described under the title of Acute Intestinal Indigestion. The continued ingestion of material indigestible in character Avill produce inflammatory processes leading to ])athological lesions, and this condition Avill be considered in this paper under the hea(l of Chronic Intestinal Indigestion. It must noAV 1)C admitted that the so-called “summer diarrlia'as ” of iidaney are ilue to the growth and multiplication of bacteria and the formation of chemical poisons by these Ioav forms of vegetable life. Since these harmful organisms are, in the great majority of cases, taken into the body in the milk which constitutes the .sole or chief food of the infant, I Avill describe the symp- toms and lesions due to these causes under the title of Milk Infection, and this will be subdivided, according to the severity and duration of the symptoms, into Acute and Subacute Milk Infection. 1 would jirefer the term “ milk-jioi.soning ” for the last tAvo of these forms DIARBHCEAL DISEASES. 465 of diarrhoea, but, bearing in mind the fact that “milk-poisoning” has long been used to cover another affection, I have been debarred- from using it. There are, moreover, certain advantages in the adoption of the words “milk infection.” These bring out more prominently the part played by bacteria in the causation. I wish to positively deny that I have been led to drop the old nomenclature and adopt a new one for the sake of introducing a novelty. I believe that the advance in our knowledge of the causation of these dian’hoeas justifies the change, and that the use of the terms here suggested will, in the first place, give the physician a better idea of the cause and nature of the trouble with which he is dealing, and, secondly, it will tend to make parents more attentive to the character of the food supplied their children. This simple classification will, as a whole, I believe, be of most service to the practitioner, and the object of this paper is to aid the physician in treat- ment, and not to instruct the pathologist in morbid anatomy. It must not be supposed, however, that the writer believes that this classification is perfect, or that a diarrhoea originating in one of the above-mentioned causes may not be influenced by other etiological factors. A child with a simple irritative diarrhoea is by no means immune to milk infection, and every physician knows that the intestines of an improperly-fed child furnish the best-known culture- tubes for the growth of certain harmful bacteria. For these reasons the prog- nosis in a case of intestinal indigestion will be influenced by the greater or less probability of there being engrafted upon this abnoi’mal condition the more serious element of bacterial poisoning. Acute Intestinal Indigestion. Synonyms. — Simple diarrhoea ; Irritative diarrhoea ; Mechanical diarrhoea. The number of cases of this disease is large, but, unfortunately, the physi- cian is not frequently consulted concerning them until they have become chronic or until the supervention of bacterial poisoning renders the symptoms more grave and excites alarm. The idea that frequent stools are beneficial during teething has led to neglect of these cases, and has been an important factor in increasing infantile mortality. The prompt recognition and treat- ment of acute intestinal indigestion are most valuable prophylactic measures against the more serious intestinal disorders. Measured by the good which can be accomplished by proper treatment, this disease is second to none of the diarrhoeal affections in importance. Etiology. — Excessive feeding is a frequent cause of intestinal indigestion. Children fed artificially are more likely to be overfed than those nursing from the breast, for two reasons : In the first place, the supply is not so easily exhausted, and, in the second place, the child obtains the food more easily ; indeed, the milk is often poured into the child’s stomach ad nauseam. To these might be added the fact that the child is often given the nursing-bottle when the busy mother would not stop to nurse it herself Again the system needs so much water, and too many mothers and nurses seem to be wholly ignorant of the fact that a babe might relish a little water at times. The over- loading of the stomach throws upon the digestive organs more work than they can do, and the undigested portions act as foreign bodies. Improper feeding is another fertile source of mischief This is not the place to discuss infant-feeding, and readers are referred to the special section upon that subject. It may be remarked, however, that the custom of giving the babe a taste of various things on the table is a pernicious one. The milk of the healthy mother contains all the nourishment needed by the nursing 30 4G6 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. infant, and should constitute its sole food at this period of life. But, unfor- tunately, the mother is not always healthy, and she may on account of sick- ness, excessive menstruation, or other causes be unable to supply the demand either in proper quality or quantity. In these cases the knowledge of the most intelligent physician is often found to be too limited. The cause of the imperfect digestion may be in the child itself. It may have tuberculosis or some other wasting disease, or the digestive organs may be functionally incapacitated by some temporary ailment. The employment of predigested food may be resorted to for the time, but its continued use is not wise. The digestive organs, like all the organs of the body, are enfeebled if relieved of their physiological duties. The too rapid absorption of peptones may be harmful, and physiologically it is questionable whether proteids which have been completely converted into peptones are ever largely utilized in the body in building up tissue. It is probably fortunate that in the great majority of instances artificial digestion is incomplete and the supposed peptones are actually albumoses. Symptoms. — Restlessness, flatulency with abdominal pain, and sometimes vomiting, are the first symptoms of this form of diarrhoea. Then frequency of stool, often accompanied by griping pain, follows. The appearance and other physical characters of the discharges vary with the severity and con- tinuance of the attack. At first they appear quite normal, and their frequency is the only thing to attract attention. Then they become more Avatery, but are not mucous, as they are Avhen the disease becomes chronic and inflammatory, nor serous, as they often are in acute milk infection. The stools ai’e sometimes green, and this may give rise to alarm, but this color is often due to trivial causes, and too much importance has sometimes been attached to it. After a free discharge the child becomes less restless, and may fall into a quiet sleep, from which, hoAvever, it is soon aroused hy abdominal pain, which continues until the howels are again relieved. A feAV hours ol this pain tells upon the features ; the countenance becomes pale, and its continuance for a few days lessens the rotundity of the limbs and makes the muscles soft and flabby. If the intestinal irritation be severe, convulsions may occur. Elevation of tem- perature is seldom observed in this form of diarrhoea, or if it does appear it is evanescent. The pulse is accelerated during the paroxysms of {)ain, but is usually normal during the intervals. Thirst is an accompaniment, and may be great when the stools are frequent and Avatery. Prog-nosis. — This form of diarrhoea is not in and of itself fatal. Unless the cause of the irritation be removed, inflammatory processes are induced in the intestine, and a chronic diarrhoea results, or bacterial invasion, finding favorable soil, may speedily develop an alarming condition. Treatment. — The prompt and judicious treatment of this form of diar- rhoea is in the majority of instances highly satisfactory. The administratioi) of all food should be forbidden for a number of hours, 'fhe exact period of this prohibition may vary with the symjitoms in the individual case, but. as a rule, tAventy-four hours Avill not be too long. The child Avill be restless and Avill cry from thirst, Avhich should be j)rovided for by suspending bismuth sub- nitrate in sterilized Avater, from tAvo to five grains to the drachm, and ordering that this be given in do.ses of a teaspoonful or more every hour Avhen the child is aAvake. The undigested food remaining in the intestines should bo removed, and the best agent for the accomplishment of this purpose is castor od, a tea- spoonful of which should be given to a child one year of age. Some physi- cians prefer rhubarb (one to two drachms of the syni])), and others recommend magnesium sulphate, but I am sure that there is nothing Avhich is more certain DIARRIKEAL DISEASES. 4G7 and pleasant in its action than castor oil. It may be asked whether or not the administration of the laxative is regarded as essential in every instance. I have seen many children improve rapidly without it. In these the irritating sub- stance has been swept out of the intestines by the diarrhoeal discharges, and a small dose of opiate is all that is needed ; but it is impossible to tell in a given case whether this fortunate removal has been accomplished by unaided nature or not, and the more certain method is to administer the laxative. After the laxative has had its effect, earlier if there be great pain, an opiate in very small doses, to be repeated, if desirable, after each evacuation, is generally beneficial. The opiate may be given in the form of the tincture, the deodorized or the camphorated tincture. The custom of introducing opium into compound prescriptions ordered for children is to be condemned. It is a common pi’actice with many physicians to write a prescription containing an opiate, bismuth subnitrate, pepsin, and chalk mixture. The pepsin is use- less, because the administration of food has been prohibited, and it cannot have any digestive effect upon that which is already in the intestines. The syrup in the mixture may ferment and be harmful, and the chalk is without value, while the bismuth should be given more freely than the opiate. For these rea- sons the opiate should not be incorporated in a mixture, but should be prescribed by itself ; and this holds good whenever opium is employed in any form of diarrhoea in infants. I have said that the dose of the opiate should be small — simply enough to allay the abnormal peristalsis of the intestines. From five to ten drops of the camphorated tincture or a half minim of either of the other tinctures will usually suffice for a dose for a child one year of age. After twelve hours of this treatment the condition of the child will usually be found to be much improved, but the diarrhoea will return as soon as the improper feeding begins. It is well to order the continuation of bismuth subnitrate at longer intervals for some days, and the physician must give his attention to the cha- racter of the food, which must now be resumed. He must endeavor to ascertain wherein the feeding was at fault, and thus avoid a repetition of the trouble. If the child is nursing and the harm has come from the giving of additional food, such addition must be forbidden. If the mother’s milk is at fault, and if this cannot be improved, the selection of a good wet-nurse is the best thing that can be done. If neither of these is practicable, or if the child has been artificially fed, the selection and preparation of the best food suited to the case must be undertaken. For aid upon this point the reader is referred to the sec- tion on infant-feeding. Chronic Intestinal Indigestion. Synonyms. — Chronic diarrhoea; Chronic irritative diarrhoea; Chronic intestinal catarrh ; Chronic entero-colitis. Etiology. — Chronic intestinal indigestion, with consequent diarrhoea, is a common affection of infancy. The undigested food ferments, and the products of this fermentation, acting as irritants upon the sensitive mucous membrane, induce a catarrhal condition which is most marked in the ileum and colon, where ulceration not infrequently results. All this may occur without the aid of toxicogenic germs, and probably without the intervention of any adven- titious bacteria whatever, since those normally present are capable of accom- plishing these results when digestion is arrested or markedly retarded. Chronic intestinal indigestion may occur at any season of the year, but it becomes of more serious import during the hot months, when toxicogenic germs abound and the chances of their invasion are greatly increased. It is self-evident that 468 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. this affection is more common among those infants artificially fed than among those who draw their sole and sufficient nourishment from the breast of a healthy mother. It is equally plain that it is most prevalent among those suffering from debilitating and wasting disorders, either inherited or acquired, such as syphilis, tuberculosis, rickets, or chronic broncho-pneumonia; and among those who have had their vitality impaired by an acute infectious disease, such as pertussis, scarlatina, or measles. Children who suffer from neglect, insufficient clothing, and exposure to cold are also prone to this affection. Some children seem to be born with an inability on the part of the intestines to properly digest and absorb food. I have seen such a child weighing less when sixteen months of age than at the time of birth, and yet recovery resulted, and the child, now eight years of age, weighs as much and is as robust as the average. Frequent attacks of acute indigestion lead to the chronic form, though it is probably true that the majority of cases of chronic indigestion develop insidi- ously and without any marked preliminary acute attack. Symptoms. — The discharges from the bowels become, as a rule, gradually more frequent, increasing from one to tAvo, to from four to six or more per day. The child usually becomes nervous, fretful, and fails to sleep Avell. Flatulency is a more or less marked symptom, and Avhen great the distention of the boAvels may cause severe pain. The stools are generally (juite characteristic in certain particulars. In consistency they may be semi-solid or more Avatery, or they may vary in this respect from time to time. The odor is quite invariably dis- tinctly offensive. So marked and common is this that the stools are frequently designated as putrid. The presence of undigested food is indicated by the color. Lumps of coagulated casein and masses of unchanged fat may be seen. With the progress of the disease and the development of inflammatory changes, mucus appears, pus may be detected Avith the microscope, and, Avhen hard lumps are present, they may be streaked Avith blood. The color Avill vary Avith the kind of food and the extent to Avhich it fails to digest. Pale, putty-like stools are common, Avhile the presence of a large amount of fat may render the excre- tions gray or even Avhite. The green stools are quite common in this affection, and in some instances at least this coloration is due to the groAVth of chromo- genic bacteria. There are likely to be periods of exacerbation, when the number of evacuations becomes much greater and their consistency thinner and more Avatery. At these times the pain usually becomes more severe, and fever, Avith vomiting and increased restlessness, makes the case more alarming. The diarrhoea, more or less marked, may continue for Aveeks. In rare instances the incre.ased frequency of the discharges may be borne by the child for a long time in a surprising manner. The rotundity of the limbs is not lost, and the infiint may not only hold its oAvn, but may gain slightly in Aveight. Such cases, however, make the exceptions. Usually the child loses day by day. Emacia- tion becomes marked, the muscles of the limbs and the trunk melt aAvay, and the head appears by contrast to be abnormally large. The gradual loss of sub- stance and strength may end in exhaustion and death. IIoAvevcr, this is not common, death in the majority of instances resulting not from the disease itself, but from the intercurrence of milk infection. In cases terminating favorably recovery is nsnally a sIoav and gradual pro- cess, liable to many partial relapses. The child becomes less fretful and gives less evidence of pain. The stools decrease in number, and become more like the normal in form and color. The putrid odor is likely to be the most per- sistent evidence of the diseascrove beneficial. I do not claim that any absolute rules can be founded upon the above-mentioned facts, because fermentation of one of these food-constituents naturally and necessarily prevents the complete digestion of the other ; but 1 do hold that the ])hysician gains no information by continuing a mixed diet, and, although he may be in error in his first trial, he has made, as it were, a physiological test, and he is now better j)re])ared to treat the case rationally. Many physicians recommend the em])loyment of artificially digested milk, but my experience has led me to ju’efer the selection of an exclusive diet of either carbohydrates or proteids ; ami by this 1 do not mean the emjdoynient of halfway measures, but the exclusion of one of these food-principles should be complete. Moreover, there are, as I have stated. DIARIillCEAL DISEASES. 471 grave physiological doubts about the capability of the organism to utilize pep- tones in the repair of wasted tissue. The physician must never lose sight of the fact that chronic intestinal indi- gestion is accompanied and may be caused by lowered vitality and general loss of tone. Tonics are indicated, and the best of these is an abundant supply of pure, fresh air. Removal from the crowded city and its contaminations to the better air of the country, and especially to that of the mountains, is often of the greatest service, and should be urgently recommended to parents who are able to provide for such a change. Arsenic and nux vomica may be used, but they are poor substitutes for fresh air and improved sanitary surroundings. Alcohol in the form of port or sherry is often advantageous, and cod-liver oil is of service in protracted cases. The occasional administration of la.xative doses of castor oil or from two to three grains of calomel will be of service. Opiates are to be avoided as far as possible, and are never indicated save in the painful exacerbations which may occur. Much has been written concerning the use of intestinal antiseptics, but only a few of these are of any real value. The same is true of astringents. Bismuth subnitrate has both antiseptic and astringent properties in a mild degree, and of all such drugs it has best preserved its reputation. It should be given in large doses, fifteen grains or more, six or eight times per day, and, as in acute indigestion, it should be kept free from combination with opiates. Sodium salicylate and salol in some cases seem to be of benefit. The lesions in the small intestines are best reached by the administration of the lai'ge doses of bismuth subnitrate, while those of the large intestine are most successfully treated by enemata. These should be employed three or four times per week. First, the bowels should be irrigated with warm water con- taining a little castile soap until they are completely emptied. This must be thoroughly done, and in order to secure this thoroughness the physician must either do it himself or trust it only to a trained nurse or assistant. The hips should be elevated, and a large-sized flexible catheter attached to a fountain syringe should be passed into the colon. The passage of the catheter will be facilitated by allowing the water to flow at the time. Fi’om three to four quarts of water should be used, the excess returning by the side of the tube. After the large intestines have been cleansed in this manner, one-half pint of w'ater, containing from one to two drachms of bismuth subnitrate in suspension, should be injected and left in the bowel. Instead of the bismuth, thirty grains of tannic acid may be used. The temperature of the w'ater, both that used in the irrigation and for the injection, should be that of the body. The possibility of the intercurrence of serious complications should always be borne in mind and place the medical attendant on his guard. The frecfuency with which relapses occur necessitates continued attention to the diet, sanitary surroundings, and general health of the little patient for weeks and months after apparent recovery. MILK INFECTION. The diarrhoeas which prevail among infants during the summer, especially in cities and among the poorer classes, produce a fearful mortality; conse- quently, they have given rise to much discussion concerning their nature and causation. The theories which have been advanced to explain the origin of these diarrhoeas have included nearly everything which a lively imagination 472 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. could suggest. Learned arguments have been made to show that the most important etiological factors lie in mysterious and unknowable meteorological or telluric conditions; while, on the other hand, the keen perception of a medical genius detects “that the fatality of the disease has been appreciably increased by the introduction and universal use of the child’s carriage.” The limit set upon the writer of this paper by the editor will not permit indulgence in an historical sketch of these varied theories, nor will it allow of any argumentative discussion. I shall have to content myself with a bare statement of those etio- logical factors the existence of which has, in my opinion, been demonstrated. These diarrhoeas are due to toxicogenic (poison-producing) bacteria. There is not a specific micro-organism, as there is in tuberculosis, but any one or more of a large class of germs, the individual members of which differ from one another sufficiently morphologically to be regarded as distinct species, may be present and may produce the symptoms. Only a very brief summary of our knowledge concerning the intestinal bac- teria can be given here, while the reader is referred for more extended informa- tion to the works of Escherich, Booker, Baginsky, and Jeffries. The intestinal contents during foetal life ai’e sterile, and remain so for a short time after birth. However, wfithin a feAV houi’S after birth bacteria find their way into the intes- tines. The meconium contains quite constantly two species of bacilli and a micrococcus. One of these bacilli is a long, slender rod with a bright, glisten- ing spore, and is known as the “head-bacillus.” The other appears to be identical with bacillus subtilis. The micrococcus is a large circular or ellip- tical organism. Breslau taught that this is taken in with the air which the child swallows immediately after birth, but Escherich thinks that these bacilli found in the rectum find entrance through the anus. IIoAvever, these bacteria wholly disappear with the last passage of meconium. The normal bacterial flora of the healthy nursing child is yet more limited, so far as species are concerned, the number being two — the bacterium lactis aerogenes and the bacterium coli commune. These are known as obligatory “ milk-faeoes ” bacteria, and are constantly present. The upper part of the duodenum is quite free from bacteria. Lower down, the small intestines con- tain large numbei’s of the bacterium lactis aerogenes, while in the lower ])art of the ileum the bacterium coli commune appears, and grows more abundant in tbe colon, throughout the whole length of which this germ is found. Other “inconstant” bacterial forms are found in the large intestines of the healthy milk-fed child. Both the bacterium lactis aerogenes and the coli commune are pathogenic to some of the lower animals when injected subcutaneously. Whether either of these ever develop pathogenic ]n’o])ertics in diseased con- ditions or not is a fjuestion which has been much discussed, but which cannot be considered as positively settled at present. The contents of the intestines in the so-called .summer diarrhoeas of infancy swarm with bacteria of many species, and some of these proiluce most power- ful poisons. These bacteria multiply outside of the body, and are dis.seminated widely and abundantly only when the atmospheric temperature reaches <)0° F. or higher. This is the reason for the restriction of these diarrhaais to the hot months of summer. The most suitable culture-medium for the growth of these bacteria is milk, and this is the food with which they most commonly find their way into the intestines of the child. A knowledge of these facts has led to the employment of the most effective prophylactic measures for these diarrhoeas. fi’hese measures may be grouped into (u) tho.se which ])revent the contamination of milk, and those which destroy any germs with which the milk has ali’eady DIARRHCEAL DISEASES. 473 been contaminated. Since these diarrhoeas are limited to children artificially fed in Avhole or in part, our prophylactic measures are devoted exclusively to cow’s milk. Some years ago I formulated the following rules concerning the care necessary to prevent milk undergoing these putrefactive changes : (a) The cows should be healthy, and the milk of any animal which seems indisposed should not be mixed with that from the healthy animals. (h) Cows must not be fed upon swill or the refuse from breweries or glucose- factories, or upon any other fermented food. (c) Milk cows must not be allowed to drink from stagnant pools, but must have access to fresh, pure water. (c?) The pasture must be freed from noxious weeds, and the barn and yard must be kept clean. (e) The udders should be washed, then wiped dry, before each milking. (/) The milk must be at once thoroughly cooled. This is best done in the summer by placing the milk-can in a tank of cold water or ice-water, the water being of the same depth as the milk in the can. It would be well if the water in the tank could be kept flowing, and this will be necessary unless ice-water is used. The tank should be thoroughly cleansed each day to prevent bad odors. The can should remain uncovered during the cooling, and the milk should be gently stirred. The temperature should be reduced to 60° F. or lower within an hour. The can should remain in the cold water until ready for delivery. (^) Milk should be delivered during the summer in refrigerator cans or in bottles about which ice is packed during transportation. Qi) When received by the consumer it must be kept in a clean place and at a temperature some degrees below 60° F. If all the milk used in the artificial feeding of infants could be obtained and marketed with the care demanded by the above rules, milk infection would be practically unknown and the sterilization of the infant’s food would be unnecessary. However, since it is impossible for the city consumer to know that the milk, which has been transported through a long distance and has passed through the hands of sevei’al dealers, has been kept from infection, the only safe plan for him to adopt consists in the sterilization of all of that which is fed to children. There is no doubt in the mind of the writer that whole- some, uninfected milk in the raw state is a better food for the infiint than cooked milk. The heat of sterilization robs the nuclein of the milk of its vital properties, as can be demonstrated by experiments. But I am equally positive that it is better to feed the city child upon sterilized milk than it is to use that which, with the prevailing ignorance and carelessness of dairymen and dealers, is likely to be infected. The risk in using unsterilized milk is too great, and the question with the parent or physician is not, Am I giving the child the best food ? but. Am I giving it a poison ? The choice is easily made when the matter is looked at in this light. The toxicogenic germs grow and multiply in the milk both before and after it has been taken into the alimentary canal of the child, and elaborate chemical poisons which induce the diarrhoea and other untoward symptoms. The num- ber of these poisons is probably as great as that of the bacteria which produce them. While they may differ in the intensity of their toxic properties, all are gastro-intestinal irritants, just as we have a number of metallic poisons which act in a similar manner. Some of these poisons have been isolated and their effects upon the lower animals have been studied. Tyrotoxicon, first found in poisonous cheese, later in ice-cream and other milk-products, has been isolated from a sample of milk a part of which had been administered to a healthy child 474 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. and had caused a severe choleriform diarrhoea. This is a most potent j)oison, inducing severe and continued vomiting and purging with speedy prostration, and death within a few hours if the quantity administered is sufficient. Post- mortem examination shows but little change. The mucous memhraiie of the small intestine is bleached and softened, anil possibly deprived here and there of its superficial epithelium. These are the symptoms and the post-mortem appearances in the choleriform diarrhoea of infants. In 1890 proteid poisons were isolated by the writer fi-om cultures of three of the toxicogenic germs found by Booker in the intestines of infants suffering from milk infection. These proteids are highly poisonous, and when injected under the skin of kittens or puppies they cause vomiting and purging, and, when employed in sufficient quantity, collapse and death. Post-mortem examination shows the small intestine pale throughout and constricted in places. The heart has been invariably, so far, found in diastole and filled with blood. A small amount of the proteid from bacillus a:, dissolved in water, was injected under the skin on the back of a kitten. Within one half hour the animal began to vomit and purge, and death resulted within eighteen houi’S. The small intestines were pale, contracted in places, and contained a frothy mucus. The stomach was distended with gas, and contained mucus stained yellow with bile. The liver w'as normal, the spleen and kidneys ■were congested, and the heart was distended. Another kitten was treated with the pi'oteid from bacillus a, dissolved in water. The vomited and fecal matters in this case wei’e green. The animal died after fifteen hours, and presented appearances practically identical with those mentioned above. A third kitten Avas treated with some of the proteid from bacillus A, sus- pended in Avater, and presented substantially the same symptoms and post- mortem appearances. Concerning the amount of one of these proteids necessary to produce a fatal result in the animals experimented upon the folloAving tests Avere made: Fifteen milligrammes of the dry proteid from bacillus a was injected under the skin of the liack of a guinea-pig. This caused death Avithin tAvelve hours. Of tAvo kittens treated Avith fifteen milligrammes of the a proteid, one died after forty- eight hours, and the other recovered after tAvo days of vomiting and }mrging. Tavo pujipies of about five pounds Aveight had each forty milligrammes, and after serious illness of tAVO days speedily recovered. During these tAvo days of vomit- ing and purging these dogs Avere constantly shivering as Avith cold, but the rectal temperature stood at from 102.5° to 103.5° F. Baginsky and Stadthagen have isolated from cultures of the “Avhite lique- fying germ” obtained by the former from diarrhmal stools a poi.sonous proteid which produces in mice, after about five hours, slight dysjina'a. The coat becomes rough, the animal sits Avith drooping head, and Avhen forced to move does so sluggishly, butAvithoiit any evidence of paralysis. The marked ajiathy increases, and death results after tAvo or three days. Section shoAvs an infiltra- tion about the place of injection, congestion of the spleen, liver, and perito- neum. The intestine is hypcra'inic throughout its entire length, and its iijiper portion contains a reddish-broAVTi Iluid. The same bacterium produces a poisonous ba-se. With our present knoAvledge of infected milk and the chemical poisons which may be generated tlierein the causation of the summer diarrlux'as in infancy has been divested of the mystery Avhich formerly obscured our vieAVS. Uninfected milk improperly administered may, as Ave have seen, cause intestinal DIARRHCEAL DISEASES. 475 indigestion, and thus prepare the way for milk infection ; but it can never directly induce the severer forms of diarrhoea Avhich make infantile mortality so alarmingly great. The relation between these forms of diarrhoea may be likened to that between catching cold and infection with tuberculosis. The popular idea is that tuberculosis originates in frequent colds, but the physician knows that this is not true, and that the only causal relation between the tAVO is that Avhich grows out of the loAvered vitality, lessened resistance, and greater susceptibility. If parents were Avilling to pay for Avholesome, uninfected milk half the fancy price Avhich they readily give for some prepared baby food, their children would be better nourished and disease among them Avould be less frequent. Acute Milk Infection. Synonyms. — Cholera infantum ; Choleriform diarrhoea. Etiology. — Fortunately, this form of milk infection is not so common as those of a milder type. It practically never occurs among children fed exclu- sively from the breast. The exceptions to this, if there be such, must arise from the introduction of powerful toxicogenic germs into the alimentary canal in some unusual manner. There are recorded cases in Avhich, after a night of debauch, the milk of a Avet-nurse has proved intensely poisonous to the child. It may possibly happen that an infant creeping about a filthy apart- ment, and investigating every object upon which it can lay its hands, by the sense of taste or by sucking its dirty fingers, may thus infect itself. It may also happen that a like misfortune may result from bacteria taken from the exterior of the breast of a filthy mother. HoAvever, as stated above, these are unusual methods of infection, and the rule holds good that choleriform diarrhoea is limited to the artificially fed. The diligent researches of able bacteriologists — among Avhom Booker and Jeffries in this country and Escherich and Baginsky in Germany deserve men- tion — have fiiiled to discover a specific micro-organism in cholera infantum. Booker found bacteria belonging to the proteus group most frequent in these cases. As has been stated, the writer found tyrotoxicon in one sample of milk, the administration of Avhich to a healthy child was folloAved Avitbin tAvo hours by the development of a most violent form of this kind of poisoning. This demonstrates that the poison may exist preformed in the milk at the time of its administration. Holt has observed that cholera infantum “ is most frequently engrafted upon a mild dyspeptic diarrhoea.” This is undoubtedly often the case, but it so happens that in the writer’s experience the violent symptoms have suddenly appeared in previously healthy children, and Christopher makes a similar observation. It certainly is an error to say that acute milk infection begins as a mild diarrhoea. The former may supervene on the latter, but one is no part of the other. Choleriform diarrhoea never occurs save in the hot months of summer, at a time when poison-producing geians are most abundantly distributed. The cause is invariably in the food, and the poisons which induce the symptoms are not known to originate in any other food than milk or some milk preparation. I saw one case in a child fed upon condensed milk, and the mother noticed when she opened the can that the ends Avere distended by accumulated gases, and the first feeding from this can Avas folloAved by severe vomiting and purging. Bacteria Avere abundant in the contents of the can. Another case resulted from the first feeding from a can of a baby-food preparation. Every case of this affection is one of poisoning from the elaboration of chemical products by the growth of 476 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN bacteria in milk. There may be enough of the poison in the food at the time of its administration to develop the symptoms as quickly as they would result from the giving of a poisonous dose of arsenic, or the greater part of the toxic substance may be generated by the growth of the bacteria in the alimentary canal. Symptoms. — No one can see a little patient sulfering from acute milk infection wuthout being deeply impressed with the similarity of the symptoms with those induced by some powerful gastro-intestinal irritant. The child, which may have been perfectly well or suffering from some mild form of diar- rhoea, suddenly begins to vomit and purge. These symptoms may continue almost incessantly until death results within a few hours. The color leaves the face, and a deathly pallor spreads over the countenance. The eyes sink into their sockets, while anxiety and alarm make themselves visible in every feature. Any food-contents of the stomach are soon removed by the vomiting, but this distressing symptom continues, and mucus colored Avith bile is thrown off. The frequency of the vomiting is increased by the administration of food or drink. The stools at first contain formed fecal matter and undigested food ; then they become more watery and copious, and at last they are composed almost solely of blood-serum. At first they are yellow or green, but as they become more abundant they lose all color. The odor is peculiar and musty. Thirty or more stools may be passed in the severer cases within tAventy-four hours. So long as the stools contain undigested food they may be acid, but the serous passages are alkaline. The flesh rapidly disappears, and there is no other dis- ease, Avith the exception of Asiatic cholera, in Avhich the Avasting proceeds more speedily and exhaustion results more quickly. The skin is usually cool and clammy, but the rectal temperature is elevated, usually from 102° to 104° F., and in the severer cases it may read as high as 107° or 108° before death. The pulse is Aveak, thready, and rapid. The respirations are shalloAV, irregular, and hurried. At first the child cries, then only moans, and later falls into a comatose condition, but there may be great restlessness, Avild delirium, and con- vulsions. Thirst is usually great, and everything offered is swalloAved and almost immediately vomited. The abdomen is not distended, but is usually retracted. Sometimes the vomiting and purging suddenly cease, and the parents are rejoiced at this apparently favorable turn. IIoAvever, it may be but the precursor of death. The physician is not cheered by the cessation of these symptoms if the child remains in a stupor, for this is most likely to deepen into coma. In rare instances the child quickly passes into an algid state in Avhich the temperature is subnormal. This indicates that the amount of the poison absorbed is large and the chances of recovery are small. In these cases the child lies in a stupor, Avith the eyelids half open and the eyes apparently cov- ered Avith a film. The angles of the mouth are retracted and the lips open. The fontanelle is depressed, the pulse Aveak, and the respiration irregular. The urine is scanty and there may be conqilete suppression. In other cases the symptoms are not .so grave as those indicated above. The stools are not so frequent and copious, and the vomiting not so incessant. The little patient may brighten up at intervals, and sufficient of the poison may be removed by the vomiting and purging to give great relief and load to speedy recovery. Cases of acute milk infection terminate either in death or in marked im- provement within forty-eight or at the most seventy-tAvo hours. The improve- ment may be rapid and conq)lete, or it may reach a certain j)oint and there remain comparatively stationary. DTA RRHCEA L DISEASES. 477 Diagnosis. — There is only one disease which presents symptoms with which those resulting from acute milk infection can be confounded. This is Asiatic cholera, and at times of the prevalence of this foreign scourge a differential diagnosis between the two cannot be made without the aid of a bacteriological study of the stools. At all other times the suddenness of the onset, the inces- sant vomiting, the frequent and copious watery stools, and the speedy prostra- tion are so striking and characteristic that there can be no hesitancy in making a diagnosis. It is true that some writers have tried to confound acute milk infection and sunstroke. The points of similarity are the suddenness of the prostration and the high temperature, but in the former of these there is a dif- ference. The prostration of sunstroke is like a lightning flash, while in milk infection it develops only after a few hours. In thermic fever there may be one or two copious discharges from the bowels, but frequent purging does not occur and the stools are never serous. The attempt to make acute milk infec- tion identical with thermic fever arose from our former ignorance of the exist- ence of the powerful poisons which may be elaborated in milk, and the idea does not now find any support. Prognosis. — It is quite necessary that the physician appreciate the gravity of these cases of acute milk infection. The usual termination is in death. The physician who speaks too hopefully in the first hours of the attack is likely to find himself disappointed in a very short time. The more persistent the vomiting and purging, and the more marked the nervous symptoms, the less are the chances of recovery. If the stools become less frequent and less watery, and if at the same time the pulse grows less frequent and stronger and the nervous symptoms improve, hope may be indulged in, but in the most favorable cases there is always the possibility of a relapse into the subacute form, and so long as this continues danger is imminent. Unfortunately, the name “cholera infantum’’ has been made to cover all the diarrhoeas prevail- ing during hot months, and the physician must not be led astray by the reported success of various methods of treatment. Treatment. — These ai’e cases of acute poisoning, and prompt, energetic treatment is demanded as truly as if the child had swallowed a toxic dose of arsenic or antimony. It is certainly true that the physician who hesitates or temporizes loses his patient. The first thing to be done is to positively forbid the further administration of the poison. Not a drop of milk should be given. This is a sine qud non in the treatment. This prohibition of milk must be absolute. Sterilized milk is not to be thought of, and even the breast of the mother or wet-nurse must be denied. Pi’epared baby foods should be thrown out of the window. The most dangei’- ous foe with whom the doctor has to contend in the treatment is the grand- mother or other good-hearted old lady, who knows just what will agree with the baby, and wbo persists in giving it food as soon as the doctor turns his back. The most valuable ally that he can have is a trained, conscientious nurse who will carry out directions to the letter. The second thing to do is to remove so far as is possible the poison already in the alimentary canal. Take a lesson from nature. The vomiting and purging are attempts to eliminate the harmful substance, but, like many other attempts on the part of nature, they are ineffectual and exhausting. Washout the stomach and intestines on the first appearance of the symptoms. Do not postpone these measures in the hope that resort to them may not be necessary. What would be thought of the physician who when called to see a person who had swallowed a drachm of white arsenic should say, “ Well, the symptoms are not at present alarming ; I will call around after a few hours, and if it be 478 AMERICAN TEXT-BOOK OE DmEASES OF CHILDREN necessary I will then wash out the stomach”? Acute milk infection is poison- ing with a substance more powerful and deadly than white arsenic. The wash- ing of the stomach and intestine will not exhaust the little patient half so much as the continued vomiting and purging, and the artificial measures are much more effective. The bowels should be thoroughly irrigated with warm water and Castile soap, not less than a gallon of the water being used. After the large intestine has been cleansed in this manner, an injection of cool water, con- taining fifteen to thirty grains of tannic acid to the pint, should immediately follow. Some of the poisons formed are, as we have seen, proteids which are precipitated by tannic acid, but until the great mass of proteid in the large intestine has been removed no good can be expected from this agent. The object of the tannic-acid irrigation is to render inert any soluble poisonous pro- teids which may remain in the intestines after the first washing. The stomach should be washed Avith Avarm Avater containing a teaspoonful of common salt to the pint. After this organ has been thoroughly cleansed, from three to five grains of calomel should be administered. These irrigations should be repeated as soon as the vomiting or purging returns. These may appear to be heroic measures, but the strength of the patient is conserved thereby to the extent to Avhich the vomiting and purging are allayed. The calomel is given for its antifermentative action and in order to reach the small intestines, Avhich are inaccessible by the processes of irrigation. After the vomiting has been allayed by irrigation, stimulants may be given by the mouth. I prefer Avhiskey to all other alcoholic stimulants. Brandy, if pure, Avould be equally good, possibly better, but unadulterated brandy is a rare article in this country, Avhile good Avhiskey is easily obtainable. The stimulant is best given in ice-cold Avater (the Awater should be boiled, and then ice-packed about the container ; the ice should not be put in the Avater) containing 0.1 per cent, of hydrochloric acid. This dilute acid may be used at any time to allay thirst. I agree Avith Holt that the hypodermatic use of very small doses of morphine and atropine (one-hundredth of a grain of the former ami one eight-hundredth of the latter) may be of benefit as a heart stimulant, but the dose must not be repeated too frequently. I have feared digitaline too much to try it in these cases, nor have I emj)loyed sparteine. When the temperature is above 103°, an ice-cap on the head is desirable, and in some instances it seems to favorabljr affect the vomiting. When the tem- perature goes up to 104° or higher, some more efficient means of reducing it should be resorted to. The use of the coal-tar of the 38 children who had died of “dysenteric convulsions,” and in the other 3, en- D Yt^ENTER I". 487 cephalitis. Busey verified by his cases the I’esults obtained by Bouchut. Cere- bral anaemia, which is the commonly accepted cause of convulsions or death, may be found alone or coexisting with thrombosis of the sinuses of the dura mater. Busey has also observed, in a few fatal cases in very young children, oedema of the lower extremities and discoloration of the skin of the feet and legs, which he attributes to the formation of thrombi in the pelvic veins, causing venous stasis and serous transudation into the subcutaneous tissues. The following reports of necropsies illustrate some of the principal maci’O- scopic lesions of dysentery : Child, aged fourteen months, great emaciation, muscles flabby, and rigor mortis deficient. Lungs . — Hypostatic congestion of lower lobes. Heart . — Large ante-mortem clot in right auricle, and a smaller one in left auricle. Glands . — Mesenteric glands enlarged and congested. Intestines . — Patches of congestion in lower part of small intes- tine. Large intestine much thickened and deeply congested throughout its course. A few superficial ulcers, especially near the ileo-csecal valve. Busey’s case. Necropsy twenty-four hours after death. Aged two years, emaciated, abdominal walls retracted, and rigidity slight. Brain . — Weight 2 pounds 51 ounces, anaemic, effusion into arachnoid cavity (estimated) 1 pint, slight in ventricles. Black clots in all the sinuses, and a large white fibrinous thrombus at the junction of the right lateral with the petrosal sinus. Heart . — Weight If ounces ; effusion into pericardium; white fibrinous clot in superior vena cava extending into right auricle and firmly attached to base of tricuspid valve. No blood in either ventricle, and valves intact. Lungs . — Weight ounces, float in water ; left normal, right contained in middle lobe a cheesy mass as large as a hen’s egg ; this lobe was firmly attached to pleura. No tuber- cular deposits. A cheesy bronchial gland as large as a pigeon’s egg. Abdomen . — Abdominal walls thin and destitute of fat. Omentum contains but little fat. Mesen- teric glands slightly enlarged and congested. Small intestines contain faeces, and nothing abnormal noted. Patches of intense inflammation all along the tract of large intestine from csecum to anus. Liver anaemic, buff-colored ; gall-bladder distended. Large deposits of pus at lower extremity of either kidney. Weight IJ ounces each. Fig. 1. Showing Dysenteric Ulcer of Colon. Microscopical Appearances. — There is considerable loss of surface epi- thelium and of that lining the tubular glands. The glands frequently contain pus-cells and degenerated epithelium. The interglandular tissue is infiltrated 488 AMERICAN TEXT-BOOK OF BI8EASEH OF CHILDREN. ■with serum and pus-cells. The mucous membrane softens, and necrosis extends for a considerable distance into it. Here the glands are broken down, their confines are lost and they may fall out or remain incarcerated in cast-off epithelium, mucus, and pus. There may be ulceration accompanying these changes. The ulcers are shallow and Avithout •n'ell-defined borders. They result from softening, suppuration, and exfoliation of the tissues into the sub- mucosa or even doAvn to the muscular coat. The solitary follicles are S'wollen to the size of two or three millimetres in diameter, and vary in color from transparent gray to opacpie Avhite. The swelling is due to an increase of round- cells or hyperplasia of lymphatic tissue. Large epithelial and pus-cells, mingled Avith lymphocytes, may be seen in the nodules. If the destructive process continue, the epithelium over the lymph-nodules breaks doAvn and an ulcer is formed. The lymph-nodules then appear elevated, Avith a central depression. Symptoms. — The onset may be sudden, Avithout premonitory symptoms, accompanied by one or more chills or preceded by diarrhoea. The tempera- ture is usually elevated tAvo or three degrees, depending upon the intensity of the inflammation ; the pulse soon becomes rapid, small, and compressible ; the strength is rapidly diminished ; and the flice presents a pinched, pallid, and anxious expression. The tongue is moist and covered Avith a Avhitish fur. There is seldom abdominal pain or tenderness on pressure. There is constant desire to go to stool, Avith pain and straining during and after evacuation. The stools, which at first contain fiecal matter, soon become small, frequent, odor- le.ss, and consist of blood, mucus, and pus. Sloughs are rarely seen. The stools vary in number from eight or ten to forty or fifty in the tAventy-four hours. As the inflammatory process advances to ulceration the stools contain shreds, resembling “ Avashed raAv meat,” mingled Avith blood and pus, and may be pa.ssed involuntarily. The straining noAv becomes more severe, and prolapse of the rectum frequently I’esults from it. The abdomen becomes tympanitic, and tenderness marked along the entire course of the colon. The tongue becomes dry, Avith broAvn centre and red margin. Vomiting may supervene, and prove to be intractable. The pulse becomes rapid, thready, and intermit- tent, and .syncope threatening. The respirations become sighing and the voice inaudible. The eyelids are partially closed, and the pupils are Avidely dilated. The child becomes restless, and tosses from one side of the bed to the other, and delirium or convulsions may be present. The urine is high-colored and scanty, or there may be total siqipression, Avith vesical tenesmus. If examined microscopically, the typical “dy.senteric stool” contains traces of ingesta, various kinds of bacteria, fat, epithelial cells, round cells, mucus, bloo(l-corpuscles, and pus-corpuscles mingled together. Cases. Nellie E , aged eighteen months, had heen suffering several days AA'ith loose bowels. The evacuations becoming frequent, small, bloody, and slimy, the parents called in a physician, lie found that she had a dozen or more dysenteric stools daily, accompanied by great tenesmus, and that there was marked prostration. The disease yielded to treatment, and she recovered in three days. .lohn B , aged tAventy-two mouths, had had frequent bloody discharges for sev- eral days, and had been dosed with numerous remedies for “summer conqdaint” which had been ])rescrihed by other physicians for other i)Cople’s children. As he rajiidly grew worse, I was summoned. Found him runniug about the room, hut he would freciueutly assume the s(]uatting i)osition and strain. lie had had tAveuty bloody, slimy, offensive stools, and as many of “a stain of blood and slime,” during the previous tAventy-four hours. The paiti did not seem to he so severe, hut he Avould strain until drenched Avith persjiiration. He could not he kept it) laal. Finally, his symptouis hectime .so much worse that he Avas held by one of his |iareuts, hut not in recumheuev. This modified rest did but little good, as the rectum Avas soon prolapsed to about half an inch. After DYSENTERY. 489 exhausting the usual methods of treatment the disease succumbed to suppositories of cocaine and ergotin, on the eighth day of my service. Lottie E , aged four years, was seen forty hours after the dysenteric symptoms began. She was now having frequent, oifensive, muco-sanguinolent stools, accompanied by exhausting tenesmus. The pulse was frequent and small, and the temperature was not 100° F. The symptoms rapidly grew worse and she seemed liable to die at any moment from cardiac failure. The rectum protruded, became oedematous, and blood exuded from the mucous membrane. The prolapsed gut seemed to be about two inches in length. On the ninth day of the disease the dysentery yielded to treatment, but the prolapse lasted for a week longer. Dimple G , aged seven years, had been sick for five days with dysentery. The bloody discharges had increased in number, the pain had become more intense, the desire to stool more imperative, and the evacuations were characterized as small, bloody, and slimy. She was suffering from strangury produced by turpentine stupes, which had been used for several days. S^he had had two hundred and eighty-one bloody, slimy stools in thirty-six hours (four hundred and sixty-three during the five days of her illness). Dr. D. obtained this history, and the following day called me in consultation. She now had the appearance of being extremely ill. Her pulse was small, frequent, and com- pressible ; the eyes were sunken and the pupils dilated ; the cheeks were pale and sunken, and the lips livid and pinched; the tongue was slightly coated and very dry, and thirst was intense; there was nausea, but not vomiting, although she had vomited in the early part of the illness; the abdominal walls were flabby, and there was no pain upon pres- sure over the abdomen. She had not slept for several days, and was continually begging for sleep. The discharges were involuntary and had become so frequent that cloths were kept under the nates to catch them ; they were small, bloody, and offensive. There was great pain and straining. The voice was almost inaudible, and the respiration was sigh- ing. Cerebral ansemia was well marked. She had frequent attacks of syncope, although not permitted to raise her head from the pillow. Her condition was so critical that a physician remained in her room. Stimulants and food were systematically given until the stomach and rectum refused to retain them, when brandy and, finally, ether were given hypodermatically. The attacks of syncope became more and more frequent, and she died of exhaustion and heart failure seventy-two hours after the first consultation. Diagnosis. — In sporadic cases of dysentery there may be some difficulty in differentiating it in its early stage from acute intestinal catarrh, but when the characteristic stools have once made their appearance all doubt will dis- appear. In dysentery the stools contain mucus, blood, pus, and small masses of faecal matter, and are odorless or have a “fresh-meat odor;” tenesmus is always present, a small quantity is expelled from the bowel after a violent effort, and the patient is bathed in a cold, clammy sweat, is exhausted, and probably faints. In acute intestinal catarrh the evacuations are larger; the blood, when present, is in streaks and not mixed with mucus; the pain is more intense and paroxysmal ; and tenesmus is seldom present. The differentiation of sporadic from epidemic dysentery can be made by the prevalence of the latter in the community. Prognosis. — The prognosis in acute catarrhal dysentery in children is usually favorable. The ordinary duration is from eight to ten days, but it may prove fatal in twelve, twenty-four, forty-eight, or seventy-two hours. The favorable symptoms are absence of foul odor, diminution in frequency and improvement in the character of the stools, and disappearance of tormina and tenesmus ; the absence of nervous depression and of anxious and care- worn expression of countenance ; and increase of heart-power and arterial tension. The unfavorable symptoms are increased blood-loss, ashy aspect of counte- nance, nausea, vomiting, hiccough, tympanitic and tender abdomen, nervous depression, sleeplessness, tossing about the bed, moaning, delirium, convul- sions or other marked cerebral disturbances, and suppression of urine. When convulsions appear, death is not far distant. Busey observes that in many cases death takes place under exactly similar circumstances — viz., one, two, or 490 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. three convulsions, followed by coma and death, and in none of his cases did consciousness return after the first convulsion. II. Amcebic Dysentery.* This form, which is also known as tropical dysentery, is characterized by the presence in the stools of the amoeba coli (Losch), amoeba dysenterioe (Coun- cilman and Lafleur). It is this form which occurs in such fatal epidemics in the tropics. “ The amoeba is a unicellular, protoplasmic, motile organism, from ten to twenty micro-millimetres in diameter, consisting of a clear outer zone, ectosarc, and a granular inner zone, endosarc, containing a nucleus and one or more vacuoles. It was fii’st described by Lambl in 1859, and subse- quently by Losch, who considered it the cause of the disease ” — (Osier). The disease is not infrequently seen in Europe and North America, but its home is in tropical and subtropical countries. The most frequent source of infection is unquestionably the drinking-water. Morbid Anatomy. — Like the other varieties, the lesions are situated in the colon, but in some cases they are also found in the lower portion of the ileum. These lesions consist in ulcers, which result from infiltration into the submucosa. At first small elevations appear along the mucosa ; the mucous membrane covering them sloughs off, exposing an ulcer with a grayish -yellow floor. Councilman divides these ulcers into four forms : (1) “ Twicers character- ized by cellular infiltration, softening, and cavity-formation in the submucosa; these have a small opening in the mucous membrane and often communicate with neighboring ulcers by passages in the submucosa. (2) Ulcers with slight undermining of the edges, representing simple excavations in the thickened submucous tissue. (3) Twicers with smooth sides and clean bases. (4) L^lcers with extensive adhering sloughs.” These simply represent different stages of the same process. The non-adjacent mucosa remains unaffected. Osier says the microscopical examination shows a notable absence of the products of purulent inflammation. In the infiltrated tissues polynuclear leucocytes are seldom found, and never constitute purulent collections. On the other hand, there is proliferation of the fixed connective-tissue cells. Amoebm are found more or less abundantly in the tissues at the base of, and around, the ulcers, in the lymphatic spaces, and occasionally in the blood- vessels. “The lesions in the liver are of two kinds: firstly, local necroses of the parenchyma, scattered throughout the liver and possibly due to the action of chemical products of the anucbm ; and, secondly, abscesses. These may be single or multij)le. When single they are generally in the right lobe, either toward the convex surface near its diaphragmatic attachment or on the concave surface in proximity to the bowel, hlultiple abscesses are small and generally sup(>rficial. In an early stage the abscesses are grayish-yellow, with sharply defined contours, and contain a spongy necrotic material, with more or less fluid in its interstices. The larger abscesses have ragged, necrotic walls, and contain a more or less viscid, greenish-yellow or reddish-yellow ])urulcnt material mixed with blood and shreds of liver-tissue. The older abscesses have fibrous walls of a dense, almost cartilaginous toughness. A section ot the ab.scess-wall shows an inner necrotic zone, a middle zone in which there is great proliferation of the connective-tissue cells and compression and atrojdiy * The writer has dejuaided almost entirely u|)on llie valnal)le contril)iitions of L. Kimnett Holt, Osier, and halleur and Couneilinan in iire])arinf; the sections on aimehic and diphtheritic dysentery. D YSENTEB Y. 491 of the liver-cells, and an outer zone of intense hyperjeniia. There is the same absence of purulent inflammation as in the intestine, except in those cases .in which a secondary infection with pyogenic organisms has taken place. The material from the abscess-cavity shows chiefly fatty and granular detritus, few cellular elements, and more or less numerous amcebne. Amosbm are also found in the abscess-walls, chiefly in the inner necrotic zone. Cultures are usually sterile. Lesions in the lungs are seen when an abscess of the liver — as so frequently happens — points toward the diaphragm and extends by con- tinuity through it into the lower lobe of the right lung. The gross and micro- scopical appearances are similar to those of the liver.” Symptoms. — Sometimes the onset is sudden and at other times gradual. The severer forms are characterized by a sudden onset. The diarrhoea inter- mits, while loss of strength and emaciation are progressive. Moderate fever is usually present, although some cases are unattended by this symptom. In some, tormina and tenesmus and nausea and vomiting ai’e marked at the onset, while in others they are not observed. Twelve or fourteen grayish-yellow stools, containing blood and mucus are voided daily. This condition persists for weeks. The amoebm are found in great numbers in the stools during the diarrhoeal attacks, but gradually decrease, and finally disappear as the attack subsides. Diagnosis. — This form is differentiated from the catarrhal by the frequent exaggeration and remission of the diarrhoeal symptoms, but more especially by the presence of amoebae in the stools. Prognosis. — The duration varies from six to twelve weeks. The progno- sis is not as favorable as in the catarrhal form ; and convalescence is slow, owing to the depletion, the relapses, and the chronic tendency. m. — D iphthebitic Dysentery. Diphtheritic or croupous inflammation of the intestinal tract is the most fatal variety. It usually begins in the intestine, but may result from diphtheria situated in the mouth, pharynx, or nose. Morbid Anatomy. — Macroscopically, there is nothing significant in the appearance of the intestinal contents unless patches of pseudo-membrane ai*e found upon Avashing. The stools vary in color from yelloAvish-green to greenish- broAvn, and consist of mucus, ftecal matter, occasionally digested blood — seldom pure blood — and perhaps pieces of pseudo-membrane. The lesions are situated over the entire colon and the loAver portion of the ileum, but are most numerous near the cmcum. The intestinal wall is greatly thickened and the rugm are obliterated. Small grayish-white, opacjue masses are seen upon the congested mucosa. These masses cling to the surface, and can only be removed by tearing off a portion of the mucous membrane. These small areas may coalesce and form a patch Avhich involves the greater part of the intestine, converting it into a thick, inflexible tube. Where the membrane is extensive it is marked by numerous transverse and longitudinal fissures, which give it the appearance of separate patches. The mucous membrane devoid of the patch is intensely congested and roughened, or the only changes may be confined to the diphtheritic areas. Microscopical Appearances. — There is infiltration of the mucosa, and in some cases, of the submucosa. The pseudo-membrane is composed of fibrin, necrotic cells, and sometimes blood-corpuscles. The tubular glands are usually unrecognizable, but their remains may often be detected in the necrotic masses. The thickening of the intestine is due to the infiltration of the submucosa, the 492 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. dense mass of fibrin, the engorged blood-vessels, and extravasations of red blood-corpuscles. Ulcers are seldom present in children, but when found are usually of the follicular variety. Symptoms. — This form is not seen in infants and is uncommon in children. In some cases the onset is insidious, and may be mistaken for the catarrhal, while in others it is abrupt and alarming. The symptoms are similar to, but more severe than, those of the catarrhal or amoebic. The pathognomonic symptom is the presence of pseudo-membrane in the stools. Treatment of Dysentery. Prophylaxis. — Acute catarrhal dysentery may often be avoided by promptly and energetically treating the simpler forms of intestinal disease. It too often happens that disorders of digestion are regarded as trifling, and skilled assistance is only summoned when the signs of severe anatomical lesions become manifest. Hygiene . — Personal and domiciliary hygiene should be carefully supervised. The child should be bathed at least once a day, and in very hot weather twice. His clothing should be changed sufficiently often to protect him from sudden variations in temperature ; especially is this true during the cool nights of autumn. If not already too ill, he should be removed from the heat of the city to some salubrious resort in the mountains or at the seashore. If circumstances compel him to remain at home, he should be placed in a room where pure, fresh air will be admitted freely. An occasional sponge-bath of equal parts of alcohol or bay-rum and water wull prove to be grateful, and will reduce the body heat as well as allay nervous irritability. The infant’s diapers should be removed and placed in a disinfecting solution as soon as soiled, and in older children the evacuations should be immediately disinfected. For this purpose solutions of carbolic acid, 1 : 20, corrosive sublimate, 1 : 500, milk of lime, or some other germicidal drug must be kept in some convenient place. It is none the less important that the hygiene of the premises should be scrupulously watched and every means possible used to prevent the accumula- tion of filtii. Rest . — Rest in the recumbent posture must be enjoined from the start. The stools should be passed in this posture, as any other ivill increase the pain and straining. Dietetic. — The diet should be prescribed in the very beginning, and but little discretion given to parent or nurse. The nursing infant should continue at the breast unless some condition of the mother, or of her milk, contraindicates it. In all others sterilized, Pasteurized, or ])eptonized milk, beef-tea, beef- juice, or mutton-bi’oth, or all alternately, should be given in small (juantities at frequent intervals. Care should be taken not to overfeed, lest harm be done. When the blood and mucus have disappeared from tlie stools, we may gradually but cautiously return to a more liberal and mixc'd diet. A liberal supply of natural mineral water, distilled water, or boiled eity water must be allowed. If the child refuse or is unable to swallow, food must be administered by yavaye — a method not at all difficult, and attended with satisfactory results. Medicinal. — There are no specifics for this disease, although different remedies have been specially recommended by different writers. Some believe the best results are to be obtained from ipecacuaidia, others from opium, pur- gatives, or vegetable or mineral astringents, while, latterly, many rely uj)on the administration of intestinal a.ntisej)tics, as salol, mercuric chloride, naph- D YSENTEB Y. 493 thol, and sulphocarbolate of zinc. While it may be admitted that all of these methods have their advantages in individual cases, still, no one has proved to be uniformly successful in the hands of those who treat the greatest number of cases. Usually the first indication for treatment is the removal of undigested or indigestible food from the alimentary tract. For this purpose the mild saline purgatives are especially indicated, or a stronger purgative, as for a child aged 6 years : I^. Pulv. ipecac. gi’- Mass, hydrarg gr. ss. iij- Pulv. aromatic, comp Sacchar. alb . . . .gr. V. Ft. chart. No. X. One evei’y two hours. Tinct. opii deodorat Olei ricini gtt- xij. Pulv. acaciae Sig. Aquae rosae q.s. ad f§ij. — M. Sig. Tablespoonful every two hours. As soon as the scybala and undigested masses have been removed this treatment should be suspended. Of the mineral astringents the subnitrate of bismuth, in large doses, holds the highest rank. The author has, at times, received benefit from the follow- ing, which is both astringent and antiseptic : I^. Plumbi acetatis gr- iv. Acidi acetic q. s. Acidi carbolic gr- ij- Liquor, calcis q. s. ad f^ij. Mix the first, third, and fourth, and add enough of the second to make a perfectly clear solution. Sig. Teaspoonful every three hours. If the pain and straining are intense, relief may be derived from the following : I^. Cocain. muriat gr- j- Ext. ergot, aq. . gr- x. Ext. opii aq gr- ij- Aristol gr- V. Olei theobrom q. s. — M. Ft. Suppos. No. X. Sig. One every two or three hours. Stimulants are imperative, but should be administered with great care. The dose of whiskey or brandy must be regulated by the age of the child and the exigencies of the case. When these fail, the more powerful and diffusible cardiac stimulants should be given, perhaps hypodermatically. Local. — In the light of modern science the most rational treatment of dysentery is intestinal irrigation. By it the irritating contents of the colon and rectum are washed out and the pain and straining are mitigated, and in 494 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. some cases entirely relieved. A distinction has been drawn by Dr. W. W. Johnston, of Washington, D. C., between intestinal irrigation and injection. The former is more correctly the application of a running stream to the intlamed gut, in which the fluid has free egress, while in the latter the fluid is intro- duced to painful distention. In the former a second tube permits a free out- pouring and in the latter the fluid must escape between the nozzle of the syringe and the anal sphincter or be forcibly expelled by the di-sabled intestine after the tube is withdrawn. The former is preferable when the lesions are below the sigmoid flexure, and the latter when they are above it. To irrigate the rectum a double injection-tube, attached to a fountain syringe, should be passed fi’om three to five inches into the bowel, through w'hich a current of water is kept flowing at the pleasure of the operator. As the passing of such an instrument is nearly always attended with great pain, it is better to use tw'o soft rubber cathetei’s, well oiled ; the larger is attached to the tube of the syringe, while the smaller is used as the escape-pipe. Pres- sure on the flexible tubes by the operator’s fingers Avill regulate the inflow and outflow of the fluid. To irrigate the entire colon in a child of eight or ten years it is necessary to inject one or two pints immediately after a stool, but an infant I’equires much less. The author has never succeeded in injecting such large quantities into the bowel, but has obtained very satisfactory results from small quantities by forcing it to be retained for a short time, by pressing a napkin against the anus. This fluid must be slowly injected, so as to allow the inflamed and infiltrated coats to adapt themselves to the increased tension. The irrigating apparatus being ready, the child is placed on his left side, with the hips on a plane higher than the body, or, still better, in the knee- chest postui’e, so as to favor the inflow. The first irrigation should be given by the physician, who will thus instruct the nurse to follow his particular method. When the pain and tenesmus are severe, and the introduction of the tube intensifies both, the rectum may be partially or completely anaesthetized by suppositories of ice, aristol, europhen, or cocaine, or by the injection of a 2 or 4 per cent, solution of cocaine or carbolic acid. The frequency of irrigation is best determined by the number of stools, the object being to prevent the patient from having stools by washing out the intestinal contents through the tube. At first the irrigation should be given after every stool ; then, as tlie pain and tenesmus lessen and the blood and mucus decrease, it must be given at longer intervals; and, finally, when the movements border on the natural, a daily irrigation for a foAv days may jirevent a relapse. Hot or cold water, either plain or holding in solution one of the numerous antiseptics, may l»e used as the irrigating fluid. In some cases very hot water will afford marked benefit, while a large number, in the author’s experience, have received almost immediate relief from cold or ice-Ava,ter. The temperature of the water must be gradually lowered when irrigating the infant’s bowel, as the shock from ice-water might prove fatal. Every writer has a favorite antiseptic for dysentery, but mercuric chloride, 1 : 10,000, is most extensively employed. The bowel must be (piickly and thoroughly emptied of this fluid to insure protection against its })ois(mous effects from absorj)tion. Some of the other antiseptics are carbolic acid, boracic acid, hydrochloric acid, salicylic acid, aseptol, thymol, sulphocarbolate of zinc, nitrate of silver, alum, ([uinine, and creolin. While it is advisable to use some antiseptic solution in the graver forms, the great benefit to be derived from irrigation in catarrhal dysentery is the cleansing. D YSENTER Y. 495 In amoebic dysentery, Councilman and Lafleur have used solutions of qui- nine, 1 : 5000, 1 : 2500, 1 : 1000, in five cases. In 3 cases improvement was marked, in 1 the injections were suspended owing to a fatal complication, and in the other the amoebae did not decrease during the quinine injections. Lbsch found by experimentation that solutions of quinine, 1 : 5000, would kill amoebae outside of the body, so Councilman and Lafleur were led to use it by intes- tinal irrigation. The patient should be placed in the knee-chest posture, and a half-pint or a pint of the quinine solution injected thrice daily, the enema being retained for fifteen minutes. These writers claim that the enemata kill the amoebae in the intestine, but have little or no effect upon those in the tissues. In diphtheritic dysentery the same rules of treatment that are recommended in the other forms are applicable, but must be more vigorously employed. Irrigation with solutions of mercuric chloride, silver nitrate, or hydrogen peroxide seems to be the most rational procedure. CHRONIC CONSTIPATION. By J. henry FRUITNIGHT, A. M., M. D., New York. Chronic Constipation, or the absence of a regular, periodical expulsion of fajcal excrement from the bowels, is very prevalent in infancy and early childhood. In childhood a daily evacuation should be the rule, whilst in infancy two, three, and sometimes even four, motions are usual. Excluding acute bronchitis, habitual constipation is the most common ail- ment met with in early life. It is rather an aberration from the normal func- tional activity of the bowels than an essential disease, but if not relieved may in time seriously affect the general health of the patient by interfering with the functions of other organs and with the processes of nutrition, and, as an ulti- mate result, life even may be endangered. It often proves a very intractable disorder, and, despite all that is done, it may continue throughout the period of childhood, interfering with healthy development as well as with comfort. Children who are artificially fed are more prone to constipation than those who are suckled at the breast. Etiology. — The cause of the constipation may exist in the person of the patient, or the condition may be the result of some extraneous infiuence. We will first speak of the former. In the child the small intestine is comparatively longer and its lumen nar- rower than in the adult, and its walls are feeble and not so thick. Again, the ascending and the transverse colon are shorter, while the descending colon is longer relatively than in the adult. Finally, the many curves of the intestinal canal, the deep cul-de-sac in the sigmoid fiexure just above the rectum, and the contracted conformation of the pelvis in children, with the conseijucnt crowding of the intestines into a relatively small space, are well known. All of these anatomical peculiarities act as causal factors. Another element of importance in infancy, but which lessens in force as the child develops, is feeble peristalsis, due to the imperfectly-developed state of the muscular coat of the intestines. A diminution in the amount of intestinal secretions, especially of the bile, favors the occurrence of constipation, for under such conditions the fiecal mass becomes hard and scybalous, anil is aj)t to be too long retained. Then, too, if fermentable food be taken, large quantities of ilatus are generated and pain and abdominal distention attend the constijiation Certain j)athological conditions, obstructive in nature, are often jiresent. Amono; such conditions are tumors, congenital malformations, and uterine retro- flexions; constricting bands resulting from acute or chronic peritonitis; intes- tinal displacements, stenosis at the ileo-c:ecal valve, and a nest of lumbricoid worms. Local disorders seated in the rectum may also cause constijiiition. Chief among these is fissure of the anus, for in this disease, as pain is jirodiieed when defecation is attempted, the patient refrains from the act of evacuation and the constipated habit is gradually formed. CHRONIC CONSTIPATION. 497 In diseases of the central nervous system, as tubercular meningitis, hydro- cephalus, microcephalus, and myelitis, which interfere with the innervation of the abdominal and intestinal structures or which produce a spastic contraction of these parts, constipation is generally present. The various constitutional dyscrasiae, as tuberculosis, rachitis, syphilis, and the like, may, by weakening the muscles engaged in the act of defecation, act as causes. Any condition depriving the organism of water in large quantities renders the faeces dry and predisposes to sluggish bow'els : profuse perspiration and the polyuria of diabetes come under this head. Want of attention in infancy and the neglect to respond to the calls of nature on the part of older children are potent factors, for by repeated stimulation and over-distention of the rectum by its contents, its muscular activity is worn out and an atonic condition is the result. Constipation sometimes results from diarrhoea. In such cases it is due to atony and paresis of the muscular envelope of the intestines caused by e.xcessive and persistent irritation. Insufficient peristalsis, accumulation of faeces, dilatation of the entire bowel or of certain parts, accompanied by reflex symptoms due to interference with other functions of the body, are additional factors conducing to this result. Some authors say that all cases of habitual constipation are accompanied by a considerable amount of chronic irritation and subacute inflammation of the cmcum and colon and neighboring cellular tissue. The elfect of this is to reflexly arrest peristalsis. We will now consider what may be called the extrinsic causes of constipa- tion, or those which operate from without the body. Constipation in infants at the breast may be the consequence of a constipated habit on the part of the mother. In such cases the maternal milk may be deficient in fat, sugar, or .salt. In older children improper food is a very frequent cause. On the one hand, food may be given to the child which after digestion leaves very little residue in the bowel, so that no stimulation of the intestines is produced for the expulsion of its contents. On the other, too coarse foods may be given, and the residue may be so great that by constant over-stimulation of the muscular coats of the intestines their tonicity is exhausted. Excess of farinaceous foods will act in this manner, and all foods that are prone to fermentation by pro- ducing accumulations of gas will hinder free action of the bowels. Lack of moisture in the intestinal contents, resulting from scanty ingestion of water, is another factor ; and still more potent are the indiscriminate use of medicinal agents, especially castor oil and spiced syrup of rhubarb — laxatives having a secondary astringent action — and the repeated use of enemata, which destroy the natural sensibility and reflex activity of the rectum. In older children an in-door, sedentary life, negligence in regard to the for- mation of a regular habit of evacuating the bowel, and a faulty posture at stool are active in producing the constipated habit. In regard to the last element, it may be said that in the physiological act of defecation the individual should assume such an attitude that every muscle of the back and abdomen Avhich causes the bowel to be quickly and thoroughly emptied of its contents may be brought into action. Pathology. — The pathological condition to be found in constipation varies from a simple hypermmia to a catarrhal or even ulcerative condition of the mucous membrane of the intestines. Yet in many cases nothing whatever is to be discovered in the intestinal canal. The intestinal walls are apt to become thin, and some authors maintain that fatty degeneration of the muscular coat of the intestines supervenes, resulting in a lo.ss of contractility and expulsive power. A swollen and distended condition of the bowels and a chronic inflam- mation, with induration and thickening in the region of the caecum, are occa- 32 498 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. slonally met with. Ilernige, particularly umbilical, prolapsus ani, varicocele, fissure, cystitis, and haemorrhoids may be the results of the violent and oft- repeated straining, and the liver may be pressed upward and congested from interference with the portal circulation. Symptoms. — When constipation is due to obstruction, fiecal matter accu- mulates above the occluded point and produces distention of the abdomen, accom- panied by eructations of gas, vomiting, impaired appetite, and a consequent deterioration of the general health. If the intestinal contents be composed of hard masses or contain coarse, undigested material, there is danger of complete obstruction which will place the patient in a very perilous position. In mild cases of functional constipation there is simply a retention of the faeces in the rectum or lower bowel ; then there are no marked symptoms with the exception of a sensation of fulness, distention, and weight in these parts. Generally speaking, the symptoms vary in degree according to the grada- tion from the mild to the very grave forms of the disorder, but it is surprising how frequently even severe cases of constipation are unattended by serious symptoms. Very often, in consequence of local irritation from the retained faeces, a conservative purging is excited, and the patient suffers alternately from diarrhoea and constipation. The bowel, however, is not always fully emptied of its contents when such a diarrhoea occurs, and the retained faeces in time undergo decomposition, with the generation of noxious gases, which in turn distend and irritate the bowels and cause severe colic. Faecal and gase- ous distention also interferes with the action of the diaphragm, and produces labored respiration or even great dyspnoea; it may also obstruct the venous circulation in the viscera and interfere with the cardiac action and the circula- tion in the thoracic cavity, leading to palpitation of the heart, irregular pulse, and vertigo. Again, pressure upon the abdominal and portal venous systems hinders the return circulation from the lower extremities, and produces slight cedema of the ankles and feet; finally, obstruction of the portal ducts and vessels, with attendant resorption of bile, may give rise to jaundice. In aggra- vated cases of chronic constipation the pressure of the retained fiieces m.ay cause inflammation of the mucous lining of the gut, when abdominal tender- ness and fever will be noted. Sometimes the inflammation extends to ulcera- tion, or even perforation, with their attendant symptoms. When a constipated patient attempts to evacuate his bowels, he will expe- rience great tenesmus, and the expelled mass may be streaked with blood and smeared with mucus, indicating that the lining membrane of the rectum has suffered in the violent effort at expulsion. In infants constipation is accompanied by fretfulness ; the little patient draws up his legs in pain, and, if he be nervously irritable, is very prone to an attack of eclampsia. In all cases of lonff-standinji retention the fluid elements of the feces are reabsorbed, to be eliminated from the body by other emunctories. When this occurs the blood becomes contaminated, and there is impairment of the gene- ral health, with the production of such sym])tonis as languor, a foul breath and furred tongue, headache, nausea, and more or less complete anorexia; irri- tability of temper or hypochondriasis and moroseness. The abdominal ner- vous plexuses also are aft’ected, and the sufferer, when old enough, complains of formication, fatigue, and pain in the abdomen and lower extremities. Diagnosis. — While the recognition of the existence of constipation is of course very easy, it is often a difficult problem to detect the condition — the actual disease — leading to the functional disorder of the bowels ; and tliis CHRONIC CONSTIPA TION. 499 problem must be correctly solved before successful treatment can be inaugu- rated. Such conditions as hernia, hiTemorrlioids, and continued tenesmus should always lead one to expect the presence of the constipated habit. On the other hand, all children Avho have small or infrequent fmcal evacuations are not con- stipated, as such features may be noticed when the food is too concentrated or is allowed in insufficient quantity. Prognosis. — Simple idiopathic chronic constipation never endangers life. If, however, the condition depends upon some structural abnormality, the prognosis is more grave. In its consequences, both immediate and remote, constipation is of serious import. It will lead, as has been said, to fissures, hemorrhoids, and other local troubles ; it impairs the general health, and if not attended to early a lifelong habit is formed. Treatment. — To secure, if possible, the removal of its cause should be our first consideration in the treatment of constipation. If, on account of struc- tural or pathological reasons, this be impossible, our efforts must be directed to the minimization of its ill effects. In nurslings drugs should, as far as possi- ble, be avoided, attention being paid to the food and to the diet of the mother or nurse. If the mother’s milk be deficient in fat, sugar, or salts, her diet should be so modified that a larger quantity of these principles are presented for assimilation ; she should also partake of laxative foods. If the child be nourished by a wet-nurse, the same ends may be accomplished by a change to one who is in an earlier stage of lactation and whose milk contains more fat and less albumin. When, in spite of these measures, the constipation con- tinues, some simple laxative is indicated. I frequently use a little molasses or melted sugar and butter or sweet oil in teaspoonful doses. If the constipation be due to an insufficiency of fluids, as indicated by dry and brittle motions, it is wise to insist upon the child’s being given water several times daily — an item often overlooked by parents and nurses. Sometimes oatmeal-water may be substituted for plain water with advantage, particularly in older children taking a mixed diet. When these simple measures fail, the next resort is to suppositories or enemata, which act by local stimulation of the rectal muscles. Suppositories should be conical in shape and made either of soap or molasses candy, or should contain either gluten or glycerin. I prefer those containing glycerin, as being most prompt and efficient in action. But whatever variety is selected, it should be well oiled before insertion, and then gently introduced and pushed up well beyond the internal sphincter. Glycerin may also be used by injection, in the proportion of ten to twenty drops to two fluidrachms of water. Such an injection is followed in from five to ten minutes by a full and painless motion. The efficiency of the glycerin is due to its hygroscopic action ; it abstracts water from the mucous membrane of the rectum, inducing hypersemia of the part and increasing peristaltic action through nervous excitation. Cold-water injections are also recommended. These may be given at first three times, then twice, and finally once, daily until a cure is effected. The addition of a little table salt increases the activity of these enemas. As to the bulk of the injection, one or two fluidrachms will usually suffice in infants. Too large enemata not only dilate the bowel and paralyze its muscular coats, but may also give rise to much pain, and even interfere with the respiration and circu- lation. If it be necessary to resort to drugs, the most simple are to be chosen, as small doses of calomel, castor oil, solution of citrate of magnesium, carbonate of magnesium, and phosphate of sodium, in properly graded doses. The last 500 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. remedy lias given me great satisfaction in doses of one to five grains according to the age of the patient. I frequently administer it in the following com- bination : Sodii phosphatis gr. xxiv. Syr. manme f.^iiss. Aq. anisi q.s. ad fsiij. — M. Sig. One teaspoonful three times daily, for a child under one year old. Calomel may be given in one-sixth grain doses several times daily, but must not be employed habitually ; laxatives that can be used more freely are carbonate of magnesium in one- or two-grain doses in a little milk or aromatic water, and the solution of the citrate of magnesium in doses of one to four fluid drachms. Older children must be trained to the formation of the habit of regular daily evacuation of the bowels at a fixed time. Neglect of this very important rule is very often the cause of constipation persisting through adult life, with its disagreeable train of symptoms. Attention should also be directed to the posture assumed in the act of defecation, in order that all the necessary mus- cles may be brought into play. It is important, too, at this age to encourage outdoor exercise, and to so regulate the diet that the child Mull receive plenty of water and an abundance of laxative food. In this class belong fruit, either in its natural state or cooked, oatmeal or cracked-wheat porridge, corn and brown bread, green vegetables, molasses, etc. Farinaceous foods must be restricted, but milk may be taken freely if the digestion be good. In the proscribed list come cheese, uncooked dried fruits, fruits having numbers of small seeds, and spices. In the administration of medicine select the particular one that agrees best with the patient; seek the appropriate dose to secure an evacuation; then gradually reduce the dose until the constipation is ended. One of the most useful drugs is calomel, given alone or in combination with poM'dered rhubarb, half a grain of the former to one grain of the latter. This may be repeated several times daily, but care must be taken not to administer calomel repeat- edly in either tuberculous or rachitic children. If any rectal irritation be present, compound licorice powder combined with sulphur is very useful. If flatus be present, carbonate of magnesium combined with asafoetida will afford relief. The fluid extract of cascara sagrada in one- or two-drop doses is a very good remedy. Dr. Earle of Chicago recommends “in the case of a child tM'O years of age to clean out the bowels with two or three grains of calomel com- bined with a little compound licorice powder, followed for a fcM’ days with car- bonate of magnesium 3ij in f^j of water, one to three teaspoonfuls daily until the bowels are relaxed. Then give non-astringent iron preparations, nux vomica, and possibly magnesium sulphate or cascara, until the cure is complete.” It has also been suggested that small doses of ipecacuanha, either alone or combined with calomel, are very useful. When there is great distention of the bowels it will be of advantage to bandage the abdomen in order to assist in the restoration of muscle-tone. The colon may be punctured with a hypodermatic needle when its distention is so great that collapse is imminent from heart displacement. When there are large collections of fiecal matter in the colon, the more active cathartics must be exhibited, accomj)anied by irrigation of the hovel through a rectal tube. If the fieces are very hard, it is advisable to add to the fluid injected inspissated ox-gall in the proportion of 3ij to the pint. I frequently add to the ox-gall The T reatment of Disease BY Physical Methods. By THOMAS STRETCH DOWSE, M.D., F.R.C.P. Formerly Physician-Superintendent Central London Sick Asylum; Physician to the North London Hospital for Consumption and Diseases of the Chest; to the North-west London Hospital and to the IVest-end Hospital for Epilepsy and Diseases of the Nervous System; Associate Member of the Neurological Society of New York, etc. From Author’s Preface. ^ — It is interesting and — to my practical, uncon- ventional, and utilitarian mind — satisfactory to find that the profession is gradually but surely, giving greater attention to the treatment of disease by physical methods — especially chronic disease. With regard to massage, 1 am still of opinion that it is an important physical aid in the treatment of diseased states. This conviction has grown upon me by practice, by experience, and by working out in detail its influ- ences and their results, upon aberrations of function and deranged physiological processes. That it is readily adopted by some and abused by others (where intuition is narrow and of an inferior order) can be well understood from more than one point of view: it was the case with the introduction of modern nursing, with ovariotomy, and with Listerism. Such abuse has 'always been showered upon innovations and innovators in medicine, but in spite of detraction I am convinced that both massage and electricity will live and flourish and take their proper and justifiable position in the treatment of disease. CONTENTS BY CHAPTERS. 1. MASSAGE: ITS PRINCIPLES.— II. MASSAGE: ITS METHOD OF APPLICATION.— HI. MA.'^SAGE OF THE HEAD AND NECK, AND THE PARTS IN ASSOCIATION THERE- WITH.— IV. MASSAGE AND INDUCTION, FARADIC MASSAGE OF THE SKIN.— V. MUSCL^ AND NERVE.— VI. MASSAGE OF VENOUS AND LYMPH CIRCULATIONS.— j _ VII. THE WEIR-MITCHELL TREATMENT.— VIII. MASSAGE OF THE CHEST AND ABDOM;En.— IX. MASSAGE IN NERVOUS EXHAUSTION, NEURASTHENIA, AND HYSTE- RIA.— X MASSAGE OF THE SPINE AND BACK.— XL MASSAGE IN JOINT, BONE, AND BURSAU AFFECTIONS.— XII. MASSAGE IN :.i EEPLESSNESS, PAIN, DIPSOMANIA, MOR- PHINOMANIA, AND MELANCHOLIA.— XIII. MASSAGE IN THE WASTING DISEASES OF CHILDREN, AND IN THE DISEASES OF SEDENTARY, CHANGING, AND ADVANCED LIFE.— XIV. THE NAUHEIM OR SCHOTT TREATMENT IN DISEASES OF THE HEART.— XV. ELECTRO-PHYSICS.— XVI. ELECTRO-THERAPEUTICS, MOTOR POINTS. “ It would be well for the invalids of this country if every physician in it could be induced to obtain and study carelully this valuable work.” — Inter- national Medical Magazine. “The subjects of massage and electricity are well and thoroughly presented.”— iVew York Medical Journal. “ This work should be in the hands of every gen- eral practitioner in order that he may understand how thoroughly rational and scientific a method of treatment for chronic affections we have in mas- sage, and give his patients the benefit of it.” — Pkiladelphia Medical Journal. Small 8vo. 424 pages. 80 Illustrations. Cloth, $2.75 net. For Sale by McIntosh battery &, optical go 92=98 State Street, Chicago, III. 1 Sexual Neurasthenia (NERVOUS EXHAUSTION,) Its Hygiene, Causes, Symptoms and Treatment, WITH A CHAPTER ON DIET FOR THE NERVOUS, By GEORGE M. BEARD, A.M., M.D., Formerly Lecturer on Nervous Diseases in the University of the City of New York; Fellow of the New York Academy of Medicine; one of the Authors of “ Medical and Surgical Electricity,” etc. Edited by A. D. ROCKWELL, A.M., M.D., Formerly Prof, of Electro-Therapeutics in the New York Post-Graduate Medical School'and Hospital; Fellow of the New York Academy of Medicine; one of the Authors of “ Medical and Surgical Electricity,” etc. The philosophy of this worh is based on the theory that there is a special and very important and very frequent clinical variety of neurasthenia (nervous exhaustion) to which the term sexual neurasthenia (sexual exhaustiou) may properly be applied. The long familiar local conditions of j^eilital debility in the male — impotence and spermatorrhoea, prostatorrhoea, irritable prostate —which have hitherto been almost universally described as diseases by themselves, are philosophically and clinically analyzed. These symp- toms, as such, do not usually exist alone, but are associated with other local or general symp- toms of sexual neurasthenia herein described. The subject is restricted mainly to sexual exhaustion as it exists ill the male, for the reason that the symptoms of neurasthenia, as it exists in females, are, and for a long time have been, understood and recognized. Cases analogous to those in females are dismissed as hypochondriacs, just as females suffering from now clearly explained uterine and ovarian dis- orders were formerly dismissed as hysterics. I'his view of the relation of the reproductive system to nervous diseases, is in accord- ance with facts that are verifiable and abundant: that, in men as in women, a large group of nervous symptoms, which are very comm >n indeed, would not exist but for morbid states of the reproductive system — From Dr. Beard' s Introduction. t The Causes and Symptoms of forty-three cases are given. Dr. Rockwell’s work of revision has been carefully done, and everywhere accords with the theory and practice of his late colleague. The Treatmeut of neurasthenia occupies con- siderable space especial advocacy being gi'en to electro-iherapeutics. | THE THEKAPEUTIC GAZETTE siys: “ It is true, as pointed out by the editor. Or. Rockwell, there are a large number of cases of sexual neurasthenia, with or without complications, continually presenting them- selves to the physician for treatment. It is also true, as he points out, that no one has succeeded better than Dr. Beard in delineating the symptoms or describing the diagnosis and treatment for this class of patients. ANNALS OP GYNECOLOGY AND PEDIATRY says : “ We are glad to welcome a new edition of this excellent book A new method of electrical treatment, styled depolarization, is advocated and the arguments well supported. The chapter on diet and the formulas will also furnish many suggestions to the thoughtful physician who finds nervous pro-tration one of the most difficult diseases he has to treat.” I ALBANY HEDICAL ANNALS says : "The pres- ent volutne is too well known to require extended notice It treatsof an important branenof the general subject, and carries many suggestions) to physicians who have much to do with the v.irious phases of hypo- chrondriasis. It constantly enforces the need of general treatment, and its usefulness is emphasized by a con- venient classification of the disease, with illustrative cases, and the addition of numerous formultc, which have stood the test of the author’s great) experience. ” Dr. Rockwell's work of revision jhas been con- scientiously done, and everywhere accords with the theory and practice of his late colleague. He describes a method of electrical treatment, ‘ for want of a better name, termed the depolarizing method,’ which has served him well in many obstinate cases.” 8vo. 308 Payees. Fifth Edition, Cloth. Price, 82 net. FOR SALE BY McIntosh battery & optical co., 92=98 State St., Chicago, III. CHRONIC CONSTIPATION. 501 the following mixture, which stimulates the bowel to relieve itself of its con- tents, and also helps to carry off flatus: 01. terebinthime fsj. Tr. asafoetidae, 01. ricini aa f^iv. — M. Sig. Add to a quart of warm water, and use for irrigation. The suds of ordinary brown washing soap may also be added to this mix- ture. If the rectum be impacted, instrumental and manual assistance must be given; injections of small quantities of yeast have been also used with suc- cess. Gradual dilatation of the sphincter has also been successfully employed. If constipation be accompanied by the symptoms of indigestion, the diet should be revised; pepsin with muriatic acid and cascara or taraxacum should be pre- scribed. I again desire to call attention to the phosphate of sodium ; in older children it may be given in doses of from five to eight grains dissolved in water. The constipation which succeeds a diarrhoea requires the use of tonics. Of these, strychnine stands first in efficacy, administered either alone or in the favorite combination of iron, quinine, and strychnine. When atony of the mus- cular coat occasions the trouble, nux vomica combined with belladonna, ergot, and phosphorus are very valuable remedies. As each case must be treated on its own merits, many of the cathartic remedies which have not been alluded to by name will undoubtedly meet spe- cial indications in special cases. Thus when there is an interference with the hepatic functions the following is an excellent prescription : Resinae podophylli gr-j- Alcohol f.^iss. Syr. rubi idaei q. s. ad fliij. — M. Sig. A teaspoonful to a dessertspoonful every morning, according to the obstinacy of the constipation. When a copious evacuation is desirable the following is recommended: Tr. nucis vomicae . '. . Tr. belladonnae . . . Inf. sennae Inf. calumbae .... Sig. One teaspoonful for a dose. . . . mxij. . . . ITLxxiv. . . . f5j. q. s. ad fsiij. — M. The constipation which attends the various diathetic conditions demands individual attention, but by no means to the exclusion of the diathesis itself. Cod-liver oil and the syrup of the iodide of iron, both somewhat laxative in nature, are especially useful in these cases. A very good formula is that pre- scribed by Dr. J. Lewis Smith : I^. Olei morrhuae fsij. Liquor, calcis, Syr. calcii lactophosphatis . ... dd f^j. — M. Sig. Give from one-quarter to one teaspoOnful three times daily, accord- ing to age of child. For anaemic children mineral waters containing iron are beneficial. Thus Friedrichshall is serviceable, as it has a tonic and laxative effect, and also 502 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. favors the elimination of uric acid. In such cases a mixture of sulphate of magnesium, sulphate of iron, and tincture of nux vomica is also serviceable. Galvanism has its use in the treatment of constipation. The negative pole is passed well up into the rectum, and the positive along the course of the colon over the abdomen, for the negative pole excites local contraction, and the positive pole peristalsis. Galvanism is to be preferred to faradism, being more efficacious. In conclusion, attention must be directed to one of the most important measures used in the treatment of chronic constipation — namely, massage of the abdomen and its contents. The technique of massage in children, though it differs in no essential particular from the same procedure in adults, should be modified in conformity with the position of the digestive organs at the various periods of the child’s life. As the main cause of constipation in children, exclu- sive of the weak muscular coat of the bowel, resides in the descending colon, it is rarely necessary to practise the manipulations on the right side of the abdomen. The application of massage for as short a time as three minutes has been known to produce the desired effect, and the sitting should not last more than ten minutes. It may be repeated two or three times a day. The method of application is as follows: The operation is preferable before nursing or feeding, excepting when the child is very fretful or when the abdominal walls become very tense on handling. In such cases it can be accomplished during the act of feeding, for when the walls are very tense nothing can be effected. The hands should be clean, warm, and dry. The resistance and rigidity of the muscles will deter- mine the amount of pressure to be used. The production of pain should be avoided ; hence the pressure should be gradually made, and until the child becomes accustomed to it the manipulation should be very gentle. The finger- tips placed upon the skin of the abdomen are moved about with the skin over the intestines, but not rubbed. For the first two or three minutes concentric circles are described by the manipulation in the region of the umbilicus ; then in a similar manner the descending colon is treated, more pressure being made in the downward than in the upward movement. More manipulation is re- quired in the left iliac fossa than elsewhere, for obvious reasons. The caecum and ascending colon may at times also require to be manipulated in the same way. In older children sudden tapping of the abdominal Avails with the finger- tips, which will excite an instantaneous contraction of the abdominal muscles, has been found to be of value. The results obtained by massage have been very gratifying, and it should always be added to whatever other ti’eatment may be instituted at any period of infancy or childhood. SIMPLE ATROPHY. By LOUIS STABR, M. D., Philadelphia. Simple Atrophy, or the slow wasting commonly termed “ marasmus,” is a familiar occurrence in hand-fed babies, and one of the most frequent causes of death in early infancy. It is a condition in which there is extreme wasting of the soft tissues of the body, either without special organic lesions or with catarrhal inflammation of the mucous membrane of the gastro-intestinal canal. Etiolog-y. — Wasting usually occurs during the first twelve months of life, though it may begin in the second year, and is most frequently encountered among children of the poor. It arises both in breast-fed babies and in those brought up by hand, being in either case due to insufficient nourishment. The child wastes because he is starved. Food can be insufficient in two ways : first, when it is supplied in amounts too limited to meet the demands of the system ; and second, when it contains a minimum of the elements essential to. nutrition or presents them in a form ill adapted to the feeble digestive powers of infancy. For example, nursing infants waste in consequence of feeding either from a breast that yields too little good milk, or from one that secretes abundantly a poor, watery fluid entirely unfit for nourishment. With artificially-fed children, on the other hand, it rarely happens that the quantity of food is too small ; the fault lies, rather, in the direction of quality. Undiluted cows’ milk, milk thickened with starchy materials, farinaceous foods, and even table food — meat, vegetables, and bread — are given to babies a few weeks or months old. Now, all of these are highly nutritious, but the digestive apparatus is not sufficiently developed to prepare them for absorption. They are strong foods, adapted to nourish and strengthen much older children and adults, but as the infant cannot appropriate them, he starves no less surely, if more slowly, than when taking no food at all. Such aliment also, while remaining undigested in the stomach and intestines, under- goes fermentation, with the formation of irritant products, causing vomiting or diarrhoea — conditions that still further lower the vital powers and hasten atrophy. It is often possible to trace the disease directly to want of cleanliness in the feeding apparatus, and especially to the use of a form of bottle that has until lately been very popular in this country, as it is still in England. This bottle has, in place of a plain gum tip, an arrangement of glass and rubber tubing of small calibre. One extremity of the rubber tubing, which is eight or nine inches long, terminates in a small nipple-shaped tip and bone shield ; the other, after penetrating an ornamental rubber cork, is fitted to a bit of glass tubing long enough to extend quite to the bottom of the bottle. By this plan the trouble of holding the bottle and keeping it at a proper angle during feed- ing is avoided. This seeming advantage, though, is counterbalanced both by the minor drawback that the child, left to itself, is apt to continue suction long 503 504 AMERICAN TEXT-BOOK OF DISEASED OF CHILDREN. after the bottle is exhausted, thus swallowing a quantity of air, and by the greater disadvantage that the tubing can never be kept clean. For a number of years the author made it a rule to ask for the bottle of every hand-fed infant presented for treatment, and few days passed without his seeing several of the complicated contrivances referred to. In almost every instance, notwithstanding the most careful and frequent cleansing, a sour odor could be detected, and if milk were present it contained numerous small curds ; while in cases of carelessness the odor was intolerable, and the interior of the tubing was encrusted with a layer of altered curd. With simple bottles and tips, on the contrary, alterations in the character of the milk and coating of the interior of the tips were very infrequent. As there is little difficulty in keeping the bottles themselves clean, there can be only one reason for this difference — namely, in the simple instrument the nipple is readily removed and as easily inverted and cleaned, but in the other there is no way of cleaning thoroughly the twelve or more inches of fine tubing. The latter cannot be inverted, and the passage of a stream of water or of a stiff brush only imper- fectly removes the milk clinging to the interior. This, of course, soon under- goes decomposition, and in this state quickly inaugurates change in the next supply of milk placed in the bottle. It is evident that a constant supply of food, no matter how good originally, thus rendered acid and partially curdled, must, like an excess of farinaceous or other unsuitable food, produce irritation of the alimentary canal, interfere with the processes of nutrition, and lead to a state in which the features of wasting and disordered digestion are com- bined. The custom of preparing in the morning, without sterilizing, a supply of food sufficient for the Avhole day is another fruitful cause of atrophy. If this be done, no matter how carefully the mixture be proportioned or how Avell adapted to the age and digestion of the child, it becomes unfit for consumption after standing eight or ten hours. The change may or may not be appreciable to the senses, but test-paper will always show acidity and the microscope demon- strate the existence of actively-moving bacteria. Again, food upon which a child has thrived for three or four months, perhaps, can become unsuitable, and conse- quently lead to wasting, if the digestive powers be suddenly reduced by an inter- current disease. Wasting, Avhile it is less serious in babies suckled at the breast, frequently occurs in a modified form under these circumstances. There are several addi- tional causal factors. Thus, an infant may be given to a Avet-nurse Avhose OAvn baby is much older than her foster-child. In this case the milk is too strong, for it is a Avell-knoAvn fact that as lactation advances human milk bcomes pro- portionately richer in curd and cream, and the nursling, unable to digest and assimilate it, ceases to thrive, and may even, in conseijnence, sufter from indi- gestion or diarrhoea. Human milk is also afl’ecteiration and j)ulse are regular in rhythm ; the temperature, as a rule, is subnormal ; there is no hydrencephalic cry ; and the antecedent history and the course arc different from the tuber- cular disease. Prognosis. — A vast number of cases die annually in our large cities, yet the results of appropriate management are often rapidly and surprisingly PLATE XIII. CASE OF SIMPLE ATROPHY, set. tbree months. Weight at birth, 4 lbs. ; weight on admission to Children’s Hospital, 3)/^ lbs. I'ed on a mixture of cane-sugar and water. (Died twelve hours after admission to hospital.) ]«£ LIBRAHY OF M UMIYERSirr OF IkyM DISEASES OF THE EYE. A Hand- book of Ophthalmic Practice. By G. E. de Schweinitz, M.D., Professor of Ophthalmol- ogy, Jefferson Medical College, Philadelphia; Pro- fessor of Diseases of the Eye in the Philadelphia Polyclinic. Octavo. 679 pages, illustrated. Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. SECOND EDITION, REVISED. The book has been thoroughly revised and much new matter introduced. An Appendix has been added, containing a full description of “ It is a very useful, satisfactory, and safe guide for the student and the practitioner, and one of the best works of this scope in the English lan- guage .” — Annals of Ophthalmology. the method of determining corneal astigmatism with the ophthalmometer of Javal and Schiotz, “ The book will recommend itself by its tbor- oughly practical tone, its clearness and terseness of language, and its modernism .” — New York Medical Journal. and the rotations of the eyes with the tropometer of Stevens. The chapter on Operations has been entirely rewritten and very much enlarged. De SCHWEINITZ ON DISEASES OF THE EYE A MANUAL OF PHYSIOLOGY. With Practical Exercises. For Students Lately Examiner in Physiology, Uni- versity of Aberdeen, and of the New Museums, Cambridge University; Pro- fessor of Physiology in the Western Reserve University, Cleveland, Ohio. Octavo. 800 pages, profusely illus- trated. Cloth, $3.50 net. ^ ^ ^ This work is written in a plain and attractive style that renders it particularly suited to the needs of students. The systematic portion is so “ It will make its way by sheer force of merit, and amply deserves to do so. It is one of the very best English text-books on the subject.” — London Lancet. treated that it can be used independently of the practical exercises, which constitute an important feature of the book. The directions for the “ of the many text-books of physiology pub- lished, we do not know of one that so nearly conies np to the ideal as does F’rof. Stewart’s volume .” — British Medical Journal. performance of the experiments are clearly and fully given, and wherever necessary are illus- trated by diagrams or drawings. v* v* STEWART’S PHYSIOLOGY and Practitioners. By G. N. Stewart, M.A., M.D., D.Sc., SIMPLE ATROPHY. 507 successful. Patients should never be given up unless there be extreme wasting and prostration, or unless the symptoms of spurious hydrocephalus arise, convulsions occui’, or obstinate chronic vomiting or diarrhoea be developed. Treatment. — For the arrest of wasting from insufficient nourishment, the first and main thing to be attended to is the diet. Without entering at length into this subject,^ it may be stated, as a uniform rule, that in selecting a diet the object should be to fix upon one suited to the age and digestive powers of the child, so that he may be able to digest, and, therefore, be nourished by, all the food consumed. Generally, infants under twelve months who have to be either partially or entirely “brought up by hand” do well upon cows’ milk, diluted with lime- water or with barley-water. Often it is well to sterilize the milk, or — a method which has been most uniformly successful in my hands — to add to the milk mixture peptogenic milk powder, and subject to a temperature of 155° F. for six minutes. The food should be administered from a bottle capable of holding half a pint, made of colorless glass, so that the least particle of dirt can be seen, and provided with a soft India-rubber tip. Unless sterilized or Pasteurized, the whole quantity of food intended to be given in a day should never be prepared at once, but each portion must be made separately at the time of administration. Thus, a bottle of the sort described, absolutely clean, may be filled with a mixture of one part of lime-water to two or three of sound milk, or with one part of barley-water to two or three of milk, to either of which may be added from one to two tablespoonfuls of cream and a tea- spoonful of pure sugar of milk. The bottle must next be placed in hot water until the contents become warm, when it is ready for the child. The degree of dilution of the milk and the proportion of cream added vary with the age and feebleness of digestion, but it is upon the latter that we must chiefly base the composition of the food. Lime-water is the preferable diluent when there is frequent vomiting or acid eructation. Both it and barley-water are of service in preventing the formation of large, compact curds — an object that is even better accomplished by peptogenic milk powder, and by the process of partial predigestion. In some cases it may be necessary to discon- tinue milk foods entirely, putting the child temporarily upon weak broths or raw beef juice. After digestion has been brought into good condition, the food may be cautiously increased to a standard suitable for a healthy child of the same age. At eight or ten months from two to four fluidounces of thin mutton or chicken broth, free from grease, may be allowed each day in addition to the milk ; at twelve months, the yolk of a soft-boiled egg, rice and milk, and carefully mashed potatoes moistened with gravy ; and at the end of the second year, a small quantity of finely-minced meat. Once daily the patient should be bathed in warm water, or at least sponged over with warm water, and every morning and evening a teaspoonful of warm olive oil or of cod-liver oil should be rubbed into the skin over the abdomen and chest. At the same time the belly must be completely covered with a soft flannel binder, and the feet and surface generally kept warm by woollen clothing. In this way attacks of colic, if not entirely prevented, are rendered much less frequent and severe. If there be intertrigo, cleanliness and the free use of oxide-of-zinc oint- ment usually suffice to effect a cure. Of medicines, bicarbonate of sodium, pepsin, pancreatin, nux vomica, and cod-liver oil are perhaps the most useful. Cod-liver oil should not be given ^ For the details of diet and general management, see Introduction. 508 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. until the digestive powers have been brought into a comparatively normal state by proper food, antacids, and digestants and the general tone increased by tincture of nux vomica. The oil is most easily borne when given in emulsion, and may be advantageously combined with lactopbosphate of lime or with the hypopbospbites. Such symptoms as constipation, diarrhoea, and vomiting demand, of course, appropriate treatment. DISEASES OF THE CiECUM AND APPENDIX. By JOHN ASHHURST, Jr., M. D., Philadelphia. Inflammatory Affections of the 0.®cum and Appendix. Under the names of typhlitis, perityphlitis, appendicitis, csecitis, perityph- litic abscess, etc. are included by systematic writers certain cases of inflam- mation, usually severe and sometimes ending in suppuration or in general peritonitis, met wdth in the right ilio-lumbar region. While these cases are met with at all ages, they are sufficiently common in children to make their consideration proper in a work devoted to the maladies of childhood, and they are so often attended with danger and lead to such serious consequences that their importance can hardly be overestimated. The terms typhlitis and ccecitis are strictly applicable to inflammation, catar- rhal or parenchymatous, affecting the caecum (blind gut) or caput coli ; peri- typhlitis to an inflammation of the areolar or connective tissue behind the caecum, where this portion of bowel is usually uncovered by peritoneum ; peri- typhlitic abscess to a collection of pus occurring in the same region ; and the somewhat barbarous term appendicitis to an inflammation of the pouch or diverticulum known as the appendix vermiformis. Without denying that the caput coli itself may be primarily the seat of inflammation, as indeed may any portion of the intestines, constituting the grave condition enteritis, and while acknowledging at least the possibility of a true perityphlitis, per- haps leading to extra-peritoneal suppuration, there can, I think, be no doubt that in the large majority of instances the appendix vermiformis is the part primarily involved, and that the resulting abscess, when pus is formed, is intra-peritoneally situated, though fortunately, in most cases, walled off by adhesions which prevent the general infection of the peritoneal cavity. Morbid Anatomy. — The pathological lesions found in cases of inflamma- tion of the caecum and appendix are quite variable. In the majority of cases the inflammation does not advance beyond the stage of lymph-formation, and even after repeated attacks (for the disease is often recurrent) the parts will be found indurated and thickened, and matted together by dense adhesions ; but there will be no abscess. In other instances, and particularly when the patient is tuberculous, pus will form at an early period, usually as the result of ulcer- ation and perforation of the intestinal wall, but sometimes without perforation, simply from the intensity of the inflammation. Foreign bodies, such as grape- seeds, etc., are occasionally found lodged in the caecum or appendix, or loose in the surrounding abscess ; but more commonly what are supposed to be foreign bodies are really concretions of earthy phosphates with faecal matter and inspis- sated mucus, or of inspissated mucus alone. The caecum from its shape and position is apt to become the lodging-place for concretions of this character, which set up irritation and may lead to ulceration of the caecal wall, while small 509 510 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. concretions may enter the appendix, or, as is more commonly the case, the mouth of the appendix becoming occluded hy catarrhal inflammation and thickening, concretions form in situ by inspissation of the retained secretion of the part, which in the normal condition is poured into the caecum, and forms a natural lubricant for the faecal mass in its passage through the large intestine. When pus forms in these cases, it may make its way into an adjoining segment of bowel ; may become more or less thoroughly encysted and form a fluctuating tumor in the iliac fossa ; may burrow in various directions, coming to the sur- face in the lumbar region above the iliac crest, or, ])assing downward in the course of the psoas muscle, below Poupart’s ligament; or, finally, may infect the general cavity of the peritoneum, causing diffuse purulent peritonitis, which quickly proves fatal. In exceptional cases the pus has been known to perfor- ate the diaphragm, causing pleurisy and empyema, or to enter the hip-joint. Etiology. — The causes of typhlitis and appendicitis may be divided into the predisposing and the exciting causes. Among the former may be men- tioned sex, these affections being much more common in the male than in the female, in the proportion, it is said, of six to one ; age, most cases occurring in early life ; the presence of tubercle, tuberculous patients being not only more exposed to appendicitis than the non-tuberculous, but the disease in them more quickly running on to suppuration, and convalescence after an operation, should such be necessary, being effected more slowly and with more interrup- tions ; and habitual constipation, the retention of fiecal matter in the crecum, which is sometimes distended to an enormous size, maintaining a constant source of irritation, and exposing the intestinal wall to the dangers of ulcer- ation and perforation. The exciting causes are the entrance of foreign bodies into the appendix — seeds, pins, hairs, etc. ; the ingestion of indigestible food ; exposure to cold or wet ; falls, blows, or strains of the abdominal parietes ; and the abuse of drastic purgatives. Symptoms. — The symptoms of typhlitis and appendicitis are variable and often deceptive. Sometimes beginning with a chill, the early symptoms are more often those of enteritis generally, pain, vomiting and constipation, fever, and tenderness with some fulness in the region of the inflamed part. The pain is usually greatest in the right iliac fossa, but is sometimes referred to the navel, and may even be most marked on the left side of the abdomen ; but even when the pain is misplaced, the greatest tenderness will, unless general peritonitis be impending, be found upon the right side, and especially at a point distant an inch or an inch and a half (in the adult two inches) from the anterior supe- rior spinous process of the ilium, and in a line drawn from that })oint to the umbilicus. This tender spot, which is known as “ McBurney’s point,” corre- sponds to the position of the appendix, and, as already mentioned, it is the appendix which is jirimarily involved in the large majority of cases. At a later period, when pus has formed, the “soft spot” which precedes pointing of the abscess may sometimes be detected in precisely the same locality. Coin- cidently with the develo})nient of tenderness in the right iliac region, gentle jialpation will reveal a fulness, followed at a later stage by tenderness and tumefaction, in the position of the caecum ; and in order to relieve the inflamed part from pre.ssure of the superjacent tissues, the patient will usually secure relaxation of the abdominal wall by lying on his back, slightly turning to the right side, and with the right knee drawn up. d'he vomiting is often distressing, attended with considerable effort, and aggravates the pain hy succussion of the infhuued parts: the ejected matters consist at first of the contents of the stomach, and afterward of the intestinal juices with bile ; faecal vomiting does not, as a rule, occur, even when general DISEASEyS OF THE CFECUM AND APPENDIX. 511 peritonitis follows, this being a point of some importance in the diagnosis of these conditions from intussusception and other forms of mechanical obstruction of the bowel. The constipation in appendicitis and typhlitis is not complete : there may be an occasional discharge of flatus ; evacuations may be secured by the use of enemata, and the administration of salines may cause even free catharsis without modifying the other symptoms of the disease. The fever is not very intense, the temperature varying from 101° to 102° F., and is accom- panied with a quick pulse, furred tongue, and intense thirst : when suj)pura- tion occurs the fever may assume a hectic type, and in the cases which ter- minate unfavorably the tongue becomes brown and dry, sordes accumulate about the lips and teeth, and the patient passes into a decidedly “typhoid” condition. When suppuration occurs the symptoms undergo some modification. The pain and tenderness are usually increased ; rigors may occur at irregular inter- vals; the tumefaction in the right iliac region becomes someAvhat boggy, the overlying integument being perhaps congested and slightly oedematous ; a “soft spot” may be observed; and, if the pus be not evacuated, fluctuation, with ultimately pointing, as in abscesses elsewhere. There are sometimes pain in the right knee and ankle, and oedema of the leg. The pus in these cases commonly has a strong faecal odor from proximity to the bowel, even though no perfora- tion be discoverable. Diagnosis. — The diagnosis of appendicitis and typhlitis can usually be made without difficulty if the symptoms be carefully noted, the affections in regard to which confusion is most likely to occur being enteritis, intestinal obstruction, psoas and iliac abscess, and hip disease. Enteritis — by which term is meant inflammation involving all the coats of a segment of intestine — is well described by Sir Thomas Watson as “peritonitis with something more.” It may occur in any part of the bowel, not being limited to the right iliac region, and the localizing symptoms of appendicitis — McBurney’s point, etc. — are therefore wanting. The paralysis of the gut is more complete, constij)ation consequently being more absolute, with no discharge of flatus, and the vomit- ing, if relief be not afforded, soon assuming a faecal character. Typhlitis, using the term accurately, is of course a form of enteritis, but when the inflam- mation is limited to the caecum the symptoms are less severe than when a larger portion of bowel is implicated. Mechanical obstruction of the intestine in children is usually of the character of intussusception, though internal strangu- lation by bands or diverticula is occasionally met with. In the latter condition the pain would be felt mainly at the seat of obstruction or more commonly at the umbilicus; there would be no fever, the temperature more probably being subnormal, sometimes even after the development of peritonitis; there would be faecal vomiting, with absolute constipation and inability to pass wind; gen- eral tympany, from paralysis of the bowel allowing gaseous distention ; partial suppression of urine ; and the patient would pass into a state of collapse, sooner or later according to the position and closeness of the strangulation. In intus- susception there might be fever from secondary inflammation of the affected bowel ; there would be a tumor, but instead of occupying the right iliac fossa, it would be found in a median position or upon the left side; there would, in acute cases, be a discharge of blood and mucus from the bowel ; and digital exploration of the rectum would, in children at least, probably detect the lower end of the invagination. Psoas abscess is usually, though not invariably, accompanied by evidences of preceding disease of the spinal column, is not attended by pain or marked tenderness, and presents no intestinal complica- tions ; iliac abscess, if depending upon ovarian or periuterine inflammation and 512 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN situated on the right side, may more closely simulate appendicitis; but even here the distinction may be made by observing the absence of bowel symptoms. In hip disease the peculiar and characteristic deformity and malposition of the limb, varying with the stage of the disease, will suffice, when present, to clear up the diagnosis ; in appendicitis, though extension of the limb may cause great pain, it is not accompanied by the arching of the lumbar spine observed in hip disease, and the joint may be moved, without causing suffering, in other directions. In the rare cases in which an abscess, originating in appendicitis, opens into the hip-joint, causing secondary disease of that articulation, the symptoms would be confused, both maladies then, in fact, coexisting in the same subject; but under ordinary circumstances the absence of intestinal symptoms in the one case, and the absence of joint symptoms in the other, ought to prevent the possibility of error. With regard to the special diagnostic importance of “McBurney’s point,” a good deal of difference of opinion prevails among practitioners, and the tend- ency at the present time is to consider it of but little value. For my own part, I am disposed to place considerable reliance upon this symptom, and believe that the detection of induration and tenderness, or at a later period of a “soft spot,” in this particular situation is, while perhaps not pathognomonic, at least strongly significant of disease originating in the appendix. Tumor of the kidney, perinephric abscess, carcinoma of the bowel, and abscess of the abdominal wall have been mistaken for appendicitis, but careful examination and investigation of the history of the case ought to prevent an error in this direction. The diagnosis of perforation of the caecum or appendix may be made when symptoms of suppuration occur, or when the spread of pain and tenderness to the left side of the abdomen indicates the threatened implication of the peri- toneum generally. Fortunately, before or immediately after the occurrence of perforation, adhesions usually form and seal off the affected part from the rest of the peritoneal cavity, and even where this does not occur, an interval of some hours, or even a day or two, may intervene before the development of univer- sal peritonitis, giving an opportunity for prompt surgical intervention which may save life even in this emergency. Prognosis. — The prognosis in appendicitis and typhlitis is in the large majority of cases favorable. Under judicious treatment the acute symptoms will subside in from four days to a fortnight, although a certain amount of induration and tenderness may persist for a much longer period. The patient is now apt to become intolerant of the regimen and rest which has been hitherto enforced, and resumes his ordinary diet and manner of living, with the result that relapse occurs; and this se([uence of events may be repeated indefinitely. The reason that recurrence of appendicitis is so often met with is, I believe, that the patients will not persist in treatment until completely recovered. If thoroughly cured, a second attack is not, according to my exj)crience, to be par- ticularly dreaded. When perforation occurs the prognosis becomes more gloomy. In the rare cases, if such exist, in which the opening is in the cmcum behind the peri- toneum, a burrowing abscess will result, and convalescence will, under the most favorable circumstances, be tedious. If the perforation be intra-peritoTieal, peritonitis, local or general, is inevitable ; in the former case, the infected area being separated by adhesions from the general cavity, recovery after o))eration may be hoped for ; in the latter, though by prompt intervention a^ patient may occasionally be snatched, as it were, from the very jaws of death, yet the large majority will perish ; diffuse sup{)urative peritonitis is almost always a fatal DISEASES OF THE CHJCUM AND APPENDIX. 513 affection. In tuberculous patients the prognosis, cceteris 'paribus^ is always less favorable than in others. Treatment. — The treatment of appendicitis and typhlitis may be either prophylactic or curative. As preventive measures, care should be taken to avoid constipation by regulation of the diet, by encouraging defecation at a fixed hour daily, and, if necessary, by the use of laxatives. The patient should be warmly clad, especially around the abdomen, should keep the feet dry, and should avoid exposure to cold and wet generally. When the disease actually occurs, the indications for remedial treatment are — (1) to keep the inflamed part at rest ; (2) to relieve the congestion ; (3) to prevent pain ; and (4) to maintain the patient’s nutrition without overtaxing the impaired powers of digestion. If suppuration occur, the pus must be promptly evacuated by incision and drainage. The first indication is met by keeping the patient in bed and by avoiding the use of purgatives, which under these circumstances can only do harm. The constipation and consequent accumulation of fmcal matter in these cases are owing to paralysis of the bowel, more or less com- plete, due to its inflamed state ; or, in other words, are a residt, not a cause, of the inflammation. This is a distinction w'hich often the friends of the patient, and sometimes even the physician, seem unable to comprehend ; they cannot understand that the patient is not ill because his bowels are not moved, but that his bowels are not moved because he is ill. In saying this I am not unmindful of the fact that salines, in small but frequently repeated doses, are often used in these cases, and that the patients sometimes do well under this treatment ; but the benefit is due to the action of the remedy as an indirect means of effecting depletion and di’ainage, and if this could be accomplished without catharsis it would be so much the better. The second and third indi- cations are met by the application of leeches (if the symptoms are very urgent), and by the use of warm cataplasms and the administration of opium. The fourth indication is met by careful feeding with peptonized milk or other liquid nutriment, or, if the patient vomit, by employing nutritive enemata. The course of treatment may then be established as follows : The patient being strictly confined to bed, a few leeches are applied over the seat of greatest pain, draw- ing from two to six fluidounces of blood according to his age ; if for any reason leeching be thought unadvisable, a small blister may be applied, and the part afterward covered with mercurial and belladonna ointments, equal parts, spread upon lint, and over this in turn a warm flaxseed or elm poultice. Enough opium should be given to relieve pain, either by the mouth in the form of the deodorized tincture, or by suppository ; or morphia may be given hypodermat- ically if preferred. Belladonna may properly be combined with the opium, and is also to be used locally with the mercurial ointment, as already described. When the pain has entirely ceased, but not before, if the bowels do not move spontaneously in the course of twenty-four hours, a warm enema of olive oil and soap-suds may be administered ; if this fail, and if there be no tendency to vomiting, small doses of the Epsom or Rochelle salt — from half a drachm to a drachm — may be tentatively given every hour or two hours, the enema being repeated twice daily ; if there is nausea or vomiting, the saline should be omitted, and calomel in minute doses (gr. — jL)? '""'th bicarbonate of sodium (gr. j-ij), may be given instead. Administered in this way, and the patient being still kept under the influence of opium, I doubt if these medicines cause any increase of peristalsis, and the good which they undoubtedly do is, as already mentioned, due to the serous flow from the congested and inflamed bowel to which they give rise. After the subsidence of all acute symptoms the salines may be continued in 83 514 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN reduced doses, so as to cause two or three passages from the intestines daily, and the local use of mercury and belladonna, or a belladonna plaster, should be continued until the swelling and tenderness have disappeared, when the remain- ing induration may be treated by painting the part with tincture of iodine every day or every other day, according to the effect produced, maintaining mild but persistent counter-irritation without blistering. During the early stages the right lower limb may be flexed over a pillow to relax the abdominal wall, but as soon as possible it should be brought flat, and, if there is any tendency to permanent contraction, weight-extension should be applied to keep the limb in proper position. In the large majority of cases, unless the patient be tuberculous, prompt and persistent ti’eatment on the lines above indicated will suffice to effect recovery. After convalescence the patient should live by rule, avoiding indi- gestible food, and observing all the precautions referred to in speaking of prophylaxis. If, however, instead of yielding to treatment, the symptoms persist, and the evidences of deep-seated suppuration — fluctuation, superficial oedema, or a “soft spot” — are manifested, no time should be lost in resorting to an exploratory operation. So important is promptness under these circumstances that it has been maintained that in every case the physician should associate with himself a surgeon to watch the patient from the beginning of the attack, so that there may be no delay when the critical moment arrives. I am not prepared to say that this is always necessary, but I do say that if a physician undertakes the management of a case of appendicitis alone, he should possess the tactus eruditus which will enable him to recognize suppuration as soon as it occurs. I have more than once been called to patients who had been treated many days, if not weeks, by practitioners Avho had not detected the presence of pus, the signs of which Avere yet, to the surgical sense, quite obvious. Operations for Appendicitis. — It was formerly recommended, Avhen suppuration was believed to have occurred in cases of cmcal or appendiceal inflammation, to verify the diagnosis by the introduction of an exploring needle ; but the feeling of modern surgeons is against the use of this instru- ment, as being very apt, on the one hand, to miss striking the purulent col- lection, and, on the other hand, if it should reach the abscess, apt to infect the peritoneal cavity as it is AvithdraAvn ; and a careful incision of moderate extent is, I have no doubt, safer in every Avay than the blind thrust of a needle- point, as well as more likely to discover the seat of suppuration. Before making the incision the abdominal Avail should be thoroughly cleansed and purified, but Avith great care and gentleness, as it AV'ould be (juite possible for a vigorous antiseptic scrubl)ing to break through the limiting adhesions and diffuse the contents of an abscess through the ))eritoneal cavity. Opera- tors differ as to the best line for incision : Avhen it Avas believed that the purulent collection Avas formed outside of the peritoneum, the rule, as laid doAvn by Willard Parker, Hancock, Buck, and Sands — Avho may be regarded as the pioneers in this branch of surgery — Avas to make the incision above I’oupart’s ligament, as in tying the external iliac artery, and endeavor to reacb the abscess by cautiously working upAvard and pushing the serous membrane out of theAvay ; but since it is tioav generally recognized that, as taught by Weir, the abscess is actually intra-peritoncal in origin, the marginal incision is no longer thotight important, and surgeons aim to roach and evacuate the })us by the most direct route. If the case is so far advanced that fluctuation is manifest, the incision should be made Avhere this is most perceptible; but under other circumstances the best position, I think, is in the general direc- disease:^ of the caecum and appendix. 515 tion of the right linea semilunaris, taking care that a j>art of the wound shall he through the so-called “ McBurney’s point,” which, as already mentioned, corresponds to the usual situation of the appendix. Some operators prefer to place the incision more laterally, believing that they thus secure better drain- age, but, upon the whole, in most cases, I prefer the anterior position. The first cut, about four inches in length, should pass through the skin and superficial fascia, and the deeper layers are then cautiously divided upon a director, all bleeding being checked before the abdominal cavity is opened. When the peritoneum is reached, it is cautiously raised with forceps and nicked by the edge, not the point, of the knife held sideways — as in the operation for strangulated hernia — the wound being then carefully erdarged with blunt- pointed scissors guided and guarded by the finger as a director. As soon as the cavity is opened a gush of pus will usually serve to confirm the diagnosis, but if this does not occur the surgeon should cautiously explore with his finger and a blunt director in the neighborhood of the caecum until the seat of sup- puration is discovered. After evacuation of the pus the cavity is carefully but thoroughly w'ashed out with hot distilled water, and the surgeon then searches for the appendix, which, if found, should be removed. Often this can be done without difficulty, the organ, enlarged and thickened, being readily separated by the finger from its adhesions and brought out at the wound ; its neck should then be tied with two strong carbolized silk ligatures, and divided between them. If, hoAvever, the appendix cannot readily be found, it is better to allow it to remain than unduly to prolong the operation by hunting for it, nothing being more deleterious in abdominal surgery than prolonged delay and unnecessary manipulation of the viscera. After a final washing with hot distilled water, a full-sized drainage-tube, of glass or rubber, should be introduced, carried to the bottom of the cavity, and secured with a stout ligature or safety-pin. Some surgeons merely pack the wound with iodoform gauze, instead of introducing a tube, but my own preference is for the latter practice. As to the choice between glass and rubber, my rule is, when the abscess-cavity is completely w’alled off from the general peritoneal surface, to use a rubber tube, wdiich is shortened from time to time as the wound heals ; but when the peritoneal cavity is opened, I employ a glass tube, armed with a rubber-dam and containing a rope of absorbent cotton, which is renewed as often as it is saturated without disturbing the dress- ing applied to the rest of the wound, the tube being at the same time sucked out with a long-beaked syringe until the secretion becomes of a pale straw color, and is reduced to a minimum, when the tube is finally removed. A few sutures may be applied to the extremities of the wound, but it should not be tightly closed, being rather allowed to heal firmly by granulation and cicatrization. There is little or no danger of consecutive hernia in this situation, and if there is any communication with the bowel, faecal fistula will be less apt to fol- low in an open wound than in one which has united only superficially. Faecal fistula, however, contrary to the doctrine formerly held, is really a rare com- plication after the operation for appendicitis, and is not to be dreaded unless some grave constitutional condition, such as general tuberculosis, interfere with the healing of the wound. All surgeons are agreed as to the propriety of operative intervention in cases of acute appendicitis in which suppuration is believed to have occurred, but some go further, and enthusiastic operators advise that the appendix should be removed after recovery as a means of preventing recurrence of the disease. I have myself operated under these circumstances, and successfully, but I think 51 G AMFAUCAN TEXT- BOOK OF DISEASES OF CHILDREN. that there are very few cases in which such a course is justifiable. The time to perform an operation in itself danj^erous — and opening the peritoneal cavity is dangerous, gynaecological and surgical enthusiasts to the contrary notwith- standing — is when a greater and imminent danger may be averted by so doing, and not when the patient is well ; and when we consider that the very extensive statistics of the London Hospital show that 90 ]>er cent, of all cases of appendicitis end in recovery without operation, we may well hesi- tate before submitting a patient to a mode of treatment equally needless and heroic. The only circumstances which seem to me to justify an operation after convalescence are when the patient has had repeated attacks at decreasing intervals and of increasing severity, and when he is going to be so placed that skilled surgical assistance will not be available in the event of further recurrence. Non-inflammatory Affections. The caecum has occasionally been found in a hernial protrusion {coecal hernia)., as has the appendi.x, the latter particularly in the variety of rupture incorrectly called congenital, in Avhich the bowel escapes into the patulous vaginal process of peritoneum. Caecal hernia is often irreducible through the formation of adhesions between the portion of gut uncovered by peritoneum and the adjoining structures. The appendix, even when not itself diseased, sometimes acquires adhesions to other parts, and may then cause internal strangulation., a loop of bowel being caught beneath the appendix and con- stricted as if by a fibrous band. Should such a condition be discovered during an operation for intestinal obstruction, the appendix should be divided between two ligatures, or, which would be better, excised, so as to prevent the possi- bility of a recurrence. Malignant growths are met with in the csecum, though not often in children, and may be treated on the same principles which guide the surgeon in dealing with similar affections in other portions of the bowel. INTUSSUSCEPTION. BY JOHN ASHHUEST, Jr., M. D., Philadelphia. Intussusception, or invagination of the bowel, is by far the most frequent cause of mechanical obstruction of the intestine met with in childhood, though internal strangulation by an adherent appendix or by Meckel’s diverticulum, or more rarely by a band of organized lymph left from a previous peritoni- tis, occasionally occurs. Invagination, as the name implies, consists in an ensheathing of one segment of bowel within another, the invaginated part being almost always from a higher portion (that is, farther from the anus) than that into which it is received. Thus, the jejunum is invaginated into the ileum, that into the cfecum and colon, etc. The much rarer condition, that in which the lower segment is received into the upper, is called retrograde intussuscep- tion. It is not uncommon for this affection to occur among the multiple invagi- nations which arise during the act of dying, but direct intussusceptions are those which are met with during life, and which call for treatment. Every complete intussusception involves three layers of bowel, and each layer consists of all the intestinal coats ; the outer layer is the sheath, or receiving layer, the intussuscipiens ; and the internal or entering layer, together with the middle or returning layer, constitutes the invaginated part, or intussusceptum. The apex of the intussusception is at the junction of the inner and middle layer — the lowest point, therefore, of the intussusceptum ; while its neck is at the junction of the middle and external layers — the uppermost part of the intus- suscipiens. Double intussusceptions are occasionally met with, five layers of gut being then involved, either a second intussusceptum having been forced into the first, which then constitutes its sheath, or the intussicipiens with its contained intussusceptum being in turn invasrinated into a fresh portion of bowel, which then forms a second sheath. Still more rarely triple intussuscep- tions, involving seven layers of bowel, have been found. Locality. — In rather more than one-half of all cases of intussusception the invagination occurs about the junction of the small and large intestines: usually the caecum, and afterward the colon, is inverted, the ileum pushing before it the ileo-caecal valve, which is thus found at the apex of the intussusceptum ; much more rarely the ileum slips through the valve, which then constitutes the neck of the intussuscipiens, and the intussusceptum grows by successive invagi- nation of fresh portions of small intestine. The former variety is known as ileo-ccecal, and the latter as ileo-colic intussusception. In somewhat less than one-third of the whole number of cases the invagination is limited to the small intestine {ileal or jejunal intussusception), and in the remainder, or about one- sixth, to the large intestine {colic intussusception). Except in the ileo-colic variety, in which the neck remains fixed, an intus- susception increases at the expense of its sheath, which becomes gradually inverted, the apex of the intussusception remaining constant while its neck is 517 518 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. continually changing ; in the ileo-colic variety fresh portions of ileum keep passing through the valve, and the neck therefore remains unchanged while the apex varies. As the entering layer carries the mesentery with it into the sheath, a certain amount of traction is exerted upon one side of the intussus- ceptum, and as a result the intussusception becomes curved or even sharply flexed upon itself, and at the same time the apex becomes displaced toward the mesenteric side of the intussuscipiens, both of these conditions tending mechani- cally to render the occlusion of the gut more complete than it would be other- wise. The extent of bowel involved in an intussusception varies from a few inches to six or more feet. Though an invagination usually begins on the right side of the abdo- men, its increase, in the most common or ileo-cmcal variety, is mainly at the expense of the large intestine ; and therefore by the time it has acquired suf- ficient size to be recognized by palpation the tumor will be chiefly on the left side, and eventually the ileo-csecal valve with the apex of the intussusceptum may be protruded from the anus : even when this does not occur, the apex, in children at least, can very commonly be detected by digital exploration of the rectum. Morbid Anatomy. — The adjacent serous layers in an intussusception soon become more or le.ss closely united by adhesions, which, if firm, render the invagination irreducible. These adhesions may join the two layers of the intussusceptum to each other over a considerable space, or may be limited to the region of the neck ; they are very seldom found exclusively at the apex. The sheath of the intussusception may become ulcerated from pressure, and even perforation may occur ; but more commonly, beyond a certain amount of congestion and inflammation, no marked changes are found in this layer. The intussusceptum, on the other hand, is usually more or less completely strangu- lated, and becomes gangrenous, when, if there are firm adhesions at the neck, the dead portion may be separated and evacuated as a whole or in segments through the anus, the patient eventually recovering. Under other circum- stances, the adhesions being defective, fmcal extravasation into the peritoneal cavity may occur, the death of the patient following ; or the adhesions, while preventing death at the moment, may form the starting-point of a stricture, which in turn, at a later period, may cause fatal obstruction. Post-mortem inspection in a case of intussusception reveals the elongated tumor caused by the invagination, u.sually on the left side of the abdomen, with an apparent absence of that portion of bowel which is invaginated. The outer layer or sheath of the intussusception is usually of a gray color, doughy in feel, and sometimes ulcerated from distention, while the intussusceptum, when exposed, is found of a deep-red color, resembling a clot of blood, or black and gangrenous. The intestine above the seat of obstruction is commoidy much dilated, and filled with faecal matter and gas, while that below is collapsed and shrunken, and is either empty or contains a small (juantity of blood and mucus. There is sometimes general peritonitis. Etiology. — Nothnagel has investigated experimentally the causes of intus- susception, and describes juiralj/tic and a spanmodic variety, the latter being the more frc(juent. Differing from the ordinary doctrine, he believes that the invagination is caused by the normal gut being drawn over the s])asmodically contracted part, rather than by that being mechanically driven into its sheath. Treves also adverts to the influence exercised by the longitudinal muscular fibres of the bowel, acting from the contracted j)art as from a fixed point, and thus drawing the uncontracted ])art over the other. Age and sex are usually s})okeri of as predisposing causes of invagination, the large majority of eases IN T ass US CUP rioN. 519 occurring in male children; the great relative length of the colon in infancy, together with the width of the mesocolon, doubtless favors the displacement of the gut, and in some degree accounts for the freciuency of intussusception in the early periods of life. Impaired general health, diarrhoea, the presence in the bowel of undigested or irritating food, polypoid growths, strictures and tumors of the intestine, and previously existing adhesions, are often predisposing causes of more or less importance. The exciting cause is increased and irreg- ular peristaltic movement, no matter how produced. Symptoms. — The chief symptoms of intussusception are pain, nausea and vomiting, tympanitic distention of the abdomen, fever, tenesmus, with discharge of blood and mucus by the rectum, the presence of a tumor (usually on the left side), and a corresponding depression or flattening on the right side. Abdom- inal pain is usually the first symptom manifested, occurring suddenly, of a very intense character, referred mainly to the umbilicus, the child writhing and drawing up its limbs in agony, and accompanied by vomiting of whatever may be in the stomach, and often by a liquid faecal discharge, evacuating the con- tents of the bowel below the seat of obstruction. The pain is not constant at first, but occurs at irregular intervals, each paroxysm being commonly attended by a discharge of bloody mucus from the rectum, but as the case goes on the pain becomes continuous, though even then marked by exacerbations. The cause of the pain is at first the mechanical squeezing of the invaginated bowel by its sheath; afterward the increased peristalsis of the intestine above, endeavoring to force its contents through the part which is occluded ; and finally, the extreme distention of the upper bowel and the inflamed condition of the intussusception itself and of its peritoneal covering. A sudden cessa- tion of pain in the last stages indicates the occurrence of gangrene, which may be followed by discharge of the sphacelated portion and recovery, but is more often the immediate precursor of death. Abdominal tenderness, local- ized at the seat of invagination, is developed in connection with the pain as soon as inflammation of the affected portion of bowel has set in. The vomiting in intussusception is a very prominent symptom, being present, according to Dr. Fitz’s statistics, in 70 per cent, of all cases, but is, I think, less distressing, in the early stages at least, than in cases of internal strangula- tion. When secondary enteritis occurs the vomiting increases, but even then comparatively seldom assumes a fiecal character. The vomiting diminishes again with the approach of collapse. Tympanites is not very marked in intussusception, being, according to Dr. Fitz, only present in the minority of cases. Indeed, there is often a marked depression in the right iliac fossa {signe de Dance) from the displacement of the caecum toward the left side. Fever is not present at the beginning of an intussusception, but is observed in connection with the occurrence of secondary enteritis, the thermometer ris- ing to 102° or 103° F. This is of some importance in aiding the diagnosis between invagination and internal strangulation, the temperature in the latter condition sometimes remaining subnormal even after the development of gene- ral peritonitis. Partial suppression of urine often accompanies the fever in intussusception, and appears to depend more on the acuteness than on the local- ity of the disease. Unlike other forms of intestinal obstruction, invagination is not necessarily accompanied by constipation, though in the acute variety, owing to the lateral displacement of the gut from traction of the mesentery and to secondary enteritis, faecal discharges are absent. In chronic intussusception, however, there may be little interference with defecation, and in acute cases there is a 520 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. constant desire to go to stool (tenesmus), with frequent discharges of blood and mucus. This symptom Mr. Pollock considered to be almost pathognomonic. The tumor is a very characteristic symptom of intussusception, and, as already mentioned, is usually found on the left side. In this it differs from the tumor of faecal impaction, which is almost always found on the right side, and which may often be made to pit by deep pressure over its surface. The right side in intussusception is, as mentioned above, often depressed and flat- tened (Dance’s sign), and the tumor is painful and tender to the touch. It can frequently be detected by introducing the finger into the rectum, and sometimes comes so low as to protrude from the anus. Chronic intussusceptions are sometimes met with, and have been particu- larly studied by Rafinesque, who finds that 70 per cent, occur in the region of the ileo-caecal valve (GO per cent, ileo-caecal, 10 per cent, ileo-colic), and that the remainder are equally divided between the large and small intestine. The symptoms of chronic invagination are much less distinctive than those of the acute variety, the tumor changing its shape and locality from time to time, faecal evacuations being often continued, diarrhoea sometimes alternating with constipation, and the pain and vomiting occurring at perhaps long intervals. Diagnosis. — Intussusception has been confounded with simple colic, appen- dicitis, enteritis, dysentery, faecal impaction, and other forms of mechanical obstruction. From colic it may be distinguished by the paroxysmal character of the pain, the vomiting, and the tenesmus, with discharge of bloody mucus. The detection of a tumor, either on the left side of the abdomen or by rectal exploration, would further demonstrate the nature of the affection. From appendicitis and consequent suppurative peritonitis, the diagnosis can be made by noting the symptoms just referred to, and by further observing that in those afi’ections there are tympanites, tenderness, and fulness in the right iliac fossa (as contrasted with the depression in invagination), and an earlier development of fever. In enteritis there is also fever from the beginning, with constipation, but without bloody discharges and without any well-defined tumor. I have known the convexity of the lumbar vertebrae, as felt by abdominal palpation, to be mistaken for the tumor of intussusception, but the error could hardly be made except by carelessness. The tenesmus, pain, and evacuation of blood and mucus are the only points of resemblance between intussusceptioji and dysentery, while the mode of attack and course of the sev- eral afl'ections are entirely different. \w fa>cal impaction there is a tumor, hut usually on the right side, and it can be indented by firm pressure, while the peculiar evacuations of invagination are wanting. The only form of mechan- ical obstruction, apart from intussuscej)tion, which is likely to be met with in children is internal stranyulation, and in that condition the ])rofound and early collapse, the low temperature, and the stercoraceous vomiting will clear up the diagnosis. Prognosis. — The prognosis in cases of intussusce])tion is always grave in the extreme, Leichtenstern’s statistics showing a death-rate (in acute cases) of 73 j)er cent., and Fitz’s smaller figures one of G!) per cent. The most favorable termination is in s))ontaneous reduction of the invagination, which can, as a rule, only be eft’ected during the first few days of the attack, before the forma- tion of adhesions. If reduction fails, there remains a chance for recovery after sloughing of the intussusception, tlie mortality in cases in wliich this occurs being oidy 41 per cent, while in those in which sloughing is absent the death- rate is 85 per cent. Even when slougliing does occur, however, and the patient recovers from the immediate risks of the process, he is by no means free from the danger of ulterior complications, the cicatricial contraction and adhesions INTUSS USCEPTION. 521 which follow often, as already mentioned, laying the foundation for future obstruction by stricture or internal strangulation. The prognosis of chronic intussusception is also very grave : while the immediate risks to life ai’e less than in the acute cases, there is not the same hope of recovery by sloughing and evacuation of the invaginated part, and, unless relief be afforded by an operation, a fatal result must be anticipated. Treatment. — The indications for treatment in acute intussusception are to put the bowel completely at rest ; if the case is seen at an early period, to attempt reduction ; and, if the invagination has already become irreducible, to sustain the patient’s strength until separation of the strangulated part may occur, when recovery may be hoped for. The first indication is met by the free use of opium, preferably in combination with belladonna. These remedies are best given in the form of the extract, by suppository, and of the former one-twelfth of a grain, and of the latter one-twenty-fourth, may be adminis- tered to a child of two years, every hour or two hours according to the urgency of the symptoms. Morphine and atropine may be used hypodermatically instead, but the rectal administration is, on the whole, I think, to be preferred. Advantage may also be derived from the employment of anodynes locally, and the abdomen may be covered with belladonna and mercurial ointments spread upon lint or flannel and reinforced by a warm poultice. In the attempt to effect reduction the physician may employ large injections of warm water, or, which is, I think, better, Avarm olive oil ; inflation with atmospheric air or various gases ; and manipulation or abdominal taxis. The injections may be given with an ordinary hand-ball syringe or with a fountain syringe (gravity injection), the patient being etherized and held in a semi-inverted position, with the hips higher than the shoulders, and the trunk elevated at an angle of about 45°. The height to which the reservoir which supplies the fluid should be raised will be about eight feet in the case of an infant, and not more than tAventy feet in that of an adult. The quantity to be injected may vary from one to six quarts according to the age of the patient. The injections are best administered through a large rectal tube, so that the force of the current may, if possible, be directed immediately upon the apex of the intussusception, and not expended upon the wall of the boAvel. Care must be taken not to allow the fluid to escape alongside of the tube, by pro- viding this, as suggested by Mr. Lund, with an India-rubber collar, Avhich may be firmly pressed against the anus, or by wrapping it with cotton or lint, which is introduced within the sphincter to accomplish the same end. Inflation with atmospheric air may be practised through the long tube or long-nozzled bellows, the same precautions being taken against escape of the air alongside of the tube as in the use of enemata. Professor Senn recom- mends the employment of hydrogen gas as preferable to atmospheric air, the gas being supplied from an India-rubber balloon holding four gallons, which is sloAvly but steadily compressed by the operator. Carbonic-acid gas is preferred by Libur, date, and Ziemssen, and is furnished in a nascent state by suc- cessively injecting solutions of bicarbonate of sodium and tartaric acid. Abdom- inal taxis Avas introduced as a mode of treatment in these cases by Mr. Jonathan Hutchinson, and consists in systematically compressing and kneading the belly from below upAvard, the patient being etherized and in an inverted posi- tion. In combination with the use of enemata it has occasionally proved an efficient remedy, but its employment is necessarily attended with some danger of injury to the boAvel, and should therefore, it seems to me, be resorted to with caution, and only during the early stages of the case. Reduction by one or other of the methods mentioned is most likely to be 522 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. accomplished during the first two days of an intussusception, and may occa- sionally be effected as late as the fourth day, but after that period should not be attempted, the physician’s efforts being then directed to sustaining the patient through the processes of sloughing and evacuation of the strangulated intussusception. In this stage the use of opium and belladonna should be continued ; little or no food should be given by the mouth, but the patient should be systematically fed by means of nutritive enemata. To relieve thirst, which is often distressing, water may also be given by enema, and the patient may suck small pieces of ice. If the abdomen becomes very much distended, the stomach may be carefully washed out through a stomach-tube, thus allaying vomiting and evacuating the liquid contents of the upper portion of the small intestine ; or gas and fluid may be withdrawn by puncturing a distended seg- ment of bowel with the fine tube of an aspirator. Puncture of the boivel, practised in this way, entails a certain risk of faecal extravasation, but is fol- lowed by less shock than enterotomy, which, however, may be preferred when the patient’s condition does not forbid it. Enterotomy — or, as it is sometimes called, N^laton’s operation — consists in making an incision, usually in the right iliac region, and opening the first distended coil of intestine which presents itself. This may be done in two ways : if it is not desired to establish a false anus, a knuckle of bowel is gently drawn out through the wound, and, having been packed around with sterilized gauze, is opened, preferably by a transverse incision, and allowed to discharge itself outside of the abdominal cavity ; if the evacuation is not suificiently complete, a full-sized drainage-tube may be introduced into the gut, and the surgeon sits by the patient, keeping the bowel under observation, if necessary, for several hours, until the faecal flow has entirely relieved the tension ; the tube is then removed, the opening in the intestine closed Avith a Lembert’s suture, the bowel replaced, and the external Avound closed and dressed in the ordinary manner. If it be thought better to establish temporarily a false anus, the bowel should first be stitched to the abdominal parietes, then carefully opened, and the edges of the incision again stitched to the external Avound so as to prevent any possibility of faeces escaping into the cavity of the peri- toneum. If the case does Avell, after the separation and evacuation of the gangrenous intussusceptum the false anus may be alloAved to close, as it usually Avill Avithout difficulty as soon as the natural passage is restored. If the open- ing degenerate into a faecal fistula, a plastic operation may be recjuired for its relief. The mode of treatment above described is that Avhich I Avould recommend in cases of acute intussuscejition. Laparotomy., Avhich may he recpiired in cases of chronic invagination, does not seem to me desirable in cases of the acute variety, and is shoAvn by statistical investigation to have no efl’ect in diminishing the death-rate of the disease. Thus, Avhile Leichtenstern’s collec- tion of 557 terminated cases, taken all together, gives 151 recoveries and 40G deaths (73 j)ercent.), the tables ])ublished in the fifth edition of my Surgery give 95 cases treated hy laparotomy, Avith 2(1 recoveries and G8 deaths (1 undeter- mined), shoAving an almost identical percentage of mortality. Fitz’s statistics present the operation in a still less favorable light, 51 cases treated Avitliout operation having given IG recoveries ami 35 de:tths (G9 per cent.), Avhile 3G operated on gave only G recoveries and 30 deaths (83 per cent.). The ol)jections to the operation in acute cases are that there is, as has been seen, a reasonable chance of recovery Avithout it, and that the early age at Avhich intu.ssusception usually occurs renders operative interference' peculiarly danger- ous. I am Avell aAvare that a feAv brilliant results from laparotomy in infants INTUSS USCEPTION. 523 have been recorded by Mr. Hutchinson, the late Dr. Sands, of New York, and other operators, but these cases should be regarded as surgical curiosities, show- ing what infants may sometimes safely endure, rather than as furnishing pre- cedents for future guidance. In chronic intussusception the circumstances are somewhat different. As the strangulation of the intussusceptum is not sufficiently complete to offer a chance for recovery by the process of sloughing, when the surgeon finds that reduction cannot be effected the operation may be properly resorted to, particularly as in these cases the patients have usually passed the period of infancy. When the bowel protrudes through the anus, the plan sug- gested by Howse, and successfully employed bj' Mikulicz, Willard, Fuller, and others, may be tried, the protruding portion being held from retracting by strong pins, and then cut off ; but under other circumstances laparotomy is the proper measure. Laparotomy for intussusception may be thus performed : The patient having been etherized and the abdominal wall carefully cleansed, an incision is made directly over the tumor if one can be recognized, but otherwise in the median line. The wound is carefully deepened until the peritoneum is reached, when this is opened with every precaution against injury to the bowels or other viscera. If the intussusception is found, the invaginated gut is brought out through the incision, the I’est of the intestine being gently pressed back with warm towels or sponges, since the exposure and chilling of large portions of bowel always produces an unfavorable effect on the patient. Careful attempts at reduction are then to be made by gently compressing and pushing upward the invaginated part from below, this being at once safer and more efficient than efforts to withdraw the gut by traction from above. If the intussuscep- tion is not immediately found, the surgeon introduces his hand, through the incision, which in this case would be median, and explores the right iliac fossa, as recommended by Mr. Treves, finding the cmcum, and then searching upward or downward according as that part is empty or distended with fieces. In examin- ing the small intestine the direction in which the search should proceed may be determined, as suggested by Mr. Head, by observing the relations of the mesentery, which is attached to the posterior wall of the abdomen from the left side of the second lumbar vertebra, obliquely downward . to the right sacro- iliac symphysis. If reduction cannot be effected, the surgeon may proceed to the establishment of a false anus immediately above the seat of invagination, or, if the state of the patient should permit more prolonged manipulation, lie may excise the intussusception bodily (enterectomy), and restore the continuity of the bowel either by direct suture {circular enter or raphy) or by Prof. Senn’s method of lateral anastomosis, as may be thought best. The latter procedure or one of its modifications — for a description of which the reader is referred to special works on surgery — is ordinarily preferable, as recjuiring less time than the end-to-end suture. The subsequent treatment is to be conducted as after laparotomy for other causes, as has been described in the article on Diseases of the Appendix. INTESTINAL PARASITES. By CHARLES W. TOWNSEND, M. D„ Boston. The older writers on the diseases of children devote a good deal of space to the subject of intestinal worms, particularly to the symptoms supposed to be caused by them, and to their treatment. Text-books of to-day dwell more upon the natural history of these animals — an extremely interesting subject — but are apt to pass very lightly over the practical considerations of symp- tomatology and treatment. Although intestinal worms, like the teeth, have with propriety been dethroned from their high position as etiological factors in many of the diseases of children, we must not be carried too far with the swing of the pendulum and disregard entirely the parasite as a causative agent. Among the laity, Avith exceptions among the upper classes, Avorms still hold a very important position, and it is essential, therefore, that Ave should look at the subject fairly, and not pass it off as of very minor importance. There are no intestinal parasites peculiar to infancy and childhood, although the round- and pin-Avorms are so mucli more common in children than in adults that they are often spoken of as peculiar to children. Omitting several varieties that are rarely encountered and are of no practical importance, the species of worms that are found in children are as follows : Ascaris lumbricoides, round-Avorm ; oxyuris vermicularis, pin-Avorm ; two species of tape-worms, tmnia mediocanellata, beef tape-Avorm, and Benia solium, pork taj)e-Avorm ; and the unimportant trichocephalus dispar. All of these are Nematode worms, Avith the exception of the tienim, Avliich belong to the group of Cestodes. As these parasites have different habits and habitats, and each requires a special treatment, it Avill be necessary to consider them individually. I. Ascaris Lumbricoides (Round-aatorm). The male round-Avorm is from four to six inclics in length, the female about ten inches. It is of a yelloAvish-Avhite color, more or less tinged Avith red in the fresh state; as usually shoAvn, })reserved in alcohol, it is of an ivory Avhite. The Avorm is cylindrical in sliaj)e, tapering to a j)oijit at both ends. The mouth is situated hetAveen three li))s furnished Avith line teeth at the anterior extremity of the body. The anus is about an inch from the posterior extremity, and the vulva in the female is anterior to the middle. The sexes are easily distinguished by their relative size and by the fact that the posterior extremity of the male is curved, that of the female being straight (Fig. 1, u and l>). From earth-Avorms, Avhich 1 have knoAvn to be presented by patients Avith the intention of deceiving, they may be distinguished by their color and by the fact that earth-Avorms, being annelids, hjive plairdy-marked segments. Female lumhricoids Avhich have been carelessly handled and subjected to pres- INTESTINA L PA RASITES. 525 sure often show the ovaries hanging out like a bunch of small worms, and may deceive the superficial observer. The ova of the round-worm are produced by the females in great quantities, Fig. 1. Round-worms and Pin-worms (% Natural Size), a, Male Round-worm; 6. Female Round-worm; c. Female Pin-worm. and pass off in tlie faeces, where they can easily be found with the microscope. They are oval in shape, about of an inch long, with dark granular con- tents and thick transparent coats, which are often stained yellow by bile (Fig. 2 ’")- The proper habitat of tbe adult ascarides is the small intestine, but they are of a wandering disposition, and have been found in the stomach, oesopha- .fus, and mouth, occasionally getting up into the posterior nares and coming out anteriorly, or going down into the larynx or even into the lungs. They also wander down into the rectum, and are expelled with the faeces or slip out unattended. They have even escaped into the peritoneal cavity through per- forations made, not by them, as was once supposed, but by ulcerations. They have been known to pass into the pancreatic and biliary ducts. When in large numbers the worms are often coiled together into balls in the intestines. The ova do not develop until they have passed out with the faeces, and have again found their way into the child’s gastro-intestinal canal, when the embryos 526 AMERICAN TEXT-BOOK OF BISEASES OF CHILDREN. rapidly come to maturity. Outside of the body they resist destructive agencies with great obstinacy, and it is said may retain their vitality for years. Method of Infection. — As the ova are produced in such countless num- bers — Davaine having found some three thousand eggs in a hit of feces as large as a grain of wheat — and as they are so resistant to outside destructive agencies, it is not surprising that they should be very common among the classes of individuals where personal cleanliness is not cultivated. As children are greater barbarians in their personal habits than adults, it is natural that ascari- des should be much more often found among them. The habit children have of putting their fingers as w’ell as toys and other objects into their mouths might easily lead to self-infection with ova from parasites in their owm intestines, as well as with ova from elsewhere. In the country, infants creeping about the floor may be infected by the dust brought in on the shoes from manure-heaps. Among the upper classes ascarides are certainly very much less common, and they are rarely seen in the adult. Here, where habits of cleanliness are Fig. 2. Comparative size of eggs of Intestinal Parasites: a, Tsenia Solium; b, Trcnia Mediocanellata; c, Ascaris Lumbricoides ; d, Trichocephalus Dispar; e, Oxyuris Vermicularis. (After Strumpell.) cultivated, infection would be more likely to come only through drinking-water or food. If the contents of privies are used in the garden for manure, the contained ova may readily find their way into ivater used for drinking or be served with salads or other uncooked vegetables. By proper filtration of the water or by cooking of vegetables, this danger can be escaped. Symptoms. — It is not uncommon to find numerous intestinal worms in the lower animals without any evidence of ill effect, and it is frecjuently the case that we discover lumbricoides, in greater or less numbers, in the dejec- tions of children who are well in every way and have presented none of the classical symptoms of worms. It is certainly tlie case, therefore, that, while the round-worm is confined to its proper place — the small intestine — even if it be in great numbers, it may be. and generally is, entirely harmless, and has no apjireciable effect on the condition of the child, producing no symptoms. The amount of nourishment it e.xtracts for itself is hardly wortli considering unless the worms e.xist in great numbers. On the other hand, when we consider the high state of nervous tension that exists in the child, and the ease with which reflex phenomena arc produced, it is reasonable to suppose that the jiresence of the living worms in the intestine may cause certain reflex symptoms, and in that way interfere with the general health. The common symptoms ascribed to round-worms by the laity are general lassitude, with nervous fidgeting, picking at the nose, offensive breath, abdominal pain, headaches, feverish attacks — called “worm fever’’ — and lack of flesh, notwithstanding a fair, or at times ravenous, appetite. The bowels are irregular, there being either constipation or diarrluea with mucous discharges. There INTESTINAL PARASITES. 527 may be vomiting and disturbed sleep with grinding of the teeth. This is the common and exact picture of a child debilitated by improper feeding and an insufficiency of fresh air and exercise — a child that is cooped up with many others in close school-room air, and whose whole life is poorly managed from a hygienic point of view. That such chihh’en sometimes have ascarides is not surprising when we consider the ease of infection, but that the parasites are the cause of their condition is certainly not the case, although the nervous symp- toms may undoubtedly be aggravated by them. It is probable that these debilitated children, with plenty of mucus in their intestines, are more desir- able habitats for the round-worms, so that the parasites thrive in this class and retain their foothold, while healthier children more easily get rid of them. The symptom, picking the nose, is often spoken of by mothers as if it were pathognomonic of worms. This is not the case ; it is simply a nervous trick common to debilitated children, as is often proved by the unproductive admin- istration of anthelmintics. My experience is that in the majority of cases where round-worms are found, their presence is unsuspected and their dis- covery accidental. Having once been found, it is common enough for almost any symptom to be attributed to them by the mother. Numerous cases have been reported, however, where the connection between the worms and severe nervous symptoms, such as convulsions, chorea, aphonia, etc., seemed to be very intimate, the nervous symptom being relieved on the evacuation of the parasites. One such case is recorded among those in the Boston Children’s Hospital : Kate M , four years old, had had two convulsions before she came under observa- tion. She was in good general condition, and no reflex cause could be found for the con- vulsions except round-worms, which she had passed from time to time. She was given santonin : a quantity of worms were expelled, and she remained well for six months, when she had another convulsion. Worms were again brought away, but she came hack a month later, reporting occasional attacks of twitching and tremors, but no real convul- sions. Anthelmintic treatment again expelled round-worms, and she was lost sight of for three years, during which there was no history of worms or nervous phenomena. At the end of this time she again applied for treatment for attacks every two or three weeks of flushing and pallor, pain in the belly and convulsions. Santonin was again given, bringing away worms and giving relief as before. There is a certain mechanical danger from ascarides, owing to their habit of wandering. A number of cases have been recorded of these worms entering the cystic and common bile-ducts, giving rise, in the latter case, to jaundice. They have even penetrated to the hepatic ducts and caused abscesses of the liver. They have also been found in perityphlitic, hernial, and tubercular abscesses connected with the intestine, having wandered into these abscesses after their formation, and possibly in some cases contributing to the irritation and suppuration there. That they may cause perforation of the normal intestine is not the case, but when we consider their stiffness and activity during life, and their sharply-pointed extremities, it does not seem uidikely that they might break through an ulceration which needed only the last straw, so to speak, but which otherwise might have healed. Another danger from round-worms arises from the fact that they sometimes ascend — with or without the aid of vomiting — into the fauces, whence they may be drawn into the larynx and cause suffocation and death. If the worm be drawn into the trachea or a bronchus and is not expelled, death is not immediate, but ensues in three or four days from gangrene of the lung. The fact that a child is found dead with a lumbricoid in the larynx does not, however, necessarily prove that this was the cause of death, for these worms 528 AMERICAN TEXT- BO OK OF DISEASES OF CHILDREN. not infrequently wander away from the intestine after death from other causes. In the majority of cases when the worm ascends to the fauces it is expelled through the mouth, or more rarely, through the nose. When the parasites are collected in great numbers in the intestine, they may mechanically cause congestion of the mucous membrane, and even obstruc- tion of the bowel, or volvulus. In these cases the worms ai’e found tightly twisted together, forming an obstructive ball. Ilillyer, in the Lancet (1892, ii., p. 773), relates an interesting case of this sort, where there were at the same time extreme nervous symptoms : A child, five and a half years old, never strong, began to have severe abdominal pains, for which castor oil was given with the result of causing vomiting, but no action of the bowels. Three round worms were found in the vomitus. The child then became unconscious, the eyes wide open, the pupils dilated, the skin cold and clammy. Death ensued on the following day. At the autopsy the ileum was found oecluded at a point fifteen inches above the ileo-caecal valve by a tightly-wound ball of eight round worms. Forty-two worms in all were found in the intestine. There was extreme congestion of the intestine above the obstruction and at that point. Below the obstruction the bowel was empty, above it was distended. Diagnosis. — This can never, and should never, be made without seeing the worms themselves or their eggs. Mothers in their anxiety often mistake shreds of mucus for worms, so it is essential that the physician should see the suspected parasites in every case. As was stated above, debilitated children with mucus in their dejections are the ones that present symptoms popularly thought to be diagnostic of worms. The ova are so numerous that they are easily found in the sediment of liquid stools; this can be scraped from the napkin or taken up with a pipette, or the residue examined after filtration. If the stools are not naturally liquid, they can be stirred up with water. A method suggested by Epstein is simple and effective, — viz. the introduction of a N^laton catheter into the rectum. The small amount of faeces that will cling to the eye of the catheter is more than sufficient for microscopic examination. The power generally used for urinary sediments — i. e. about 330 diameters — answers for these examinations. The eggs, which have been described above, are easily recognized (Fig. 2, c), and readily distinguished from the smaller, sharper, oval eggs of the ])in-worm and the round eggs of the tape-worm. Treatment. — Although ascarides, as a rule, cause no discomfort and arc in no wise detrimental to the host, when Ave consider the various accidents, some of them fatal, Avhich may be caused by them, as well as the obscure nervous symptoms which occasionally owe their origin to this source, it is certainly wiser to treat all cases as soon as they are discovered, and to get rid of the worms. Of the remedies that can be used for round-worms, it is hardly Avorth Avhile to mention more than three. These are santonin, spigelia, and chenoj)odium. All of these have the poAver of killing or benumbing the i)arasitcs, but re(iuire the aid of cathartics to cause their exf)ulsion. Santonin, made from Levant Avorm-seed, is ])robably the most Avidely used of all anthelmintics. It is the common basis of proju'ietary Avorm-lozenges. Care should be used in its administration, as it is extremely poisonous in over- doses, several fatal cases having been reported. In poisonous doses it ])roduce3 gastro-intestinal irritation, dizzine.ss, tremor, yelloAv vision, dilated )nij)ils, and loss of consciousness, with, at times, convulsions. Santonin is an almost taste- less white poAvder, nearly insoluble in Avater. It can be given in poAvder mixed with sugar, or made up into lozenges. The dose at the age of tAvo years is INTESTINAL PARASITES. 529 J to J grain; at six, 1 grain; and at twelve or fifteen, 2 grains. It should be given morning and night, or in some cases three times daily, with the addition of a cathartic — calomel, castor oil, or cascara cordial — every second day as long as lumbricoids continue to be passed. When it is remembered that very grave symptoms have been caused by a dose of 4 grains to a child four years old, and that a feeble child of five has been killed by 2 grains of santonin, it is easily seen that care must be used in its administration, and that there is danger in its indiscriminate use. Spigelia, or pink-root, one of our native plants, is also an efficient and, in proper doses, entirely safe drug. The freshly prepared fluid extract of spigelia and senna^ of the Pharmacopoeia of 187 0 combines the necessary cathartic with the anthelmintic in a manner both efficient and pleasant to the taste. The dose is half a teaspoonful for a child of two years, a teaspoonful for one from four to ten years old. It should be given two or three times daily, depending on its effect upon the bowels. Oil of chenopodium is the third remedy for ascarides, and is said to be safer and less irritating than the others. It can be given on sugar in doses of five drops to a child of three, and ten drops to one of ten years, three times daily. A cathartic is required, as with the other anthelmintics, and should be given every second or third day. n. OxYURis Vermicularis (Pin-worm, Thread-worm, Seat-worm). This is a small worm, as the first two of its common names would imply. (Fig. 1 shows the comparative size of pin- and round-worms.) The female is from a quarter to half an inch in length ; the male, only about a third as large, measures from ^ to of an inch. Its color is nearly white, its shape fusiform, tapering to a fine point in the female, having a blunter and generally curved tail in the male. The mouth is situated in the middle of the blunt end, and is surrounded by three slightly projecting lips (Figs. 3, 4). The eggs are ovoid in shape, more pointed at one end. They measure 0.053 mm. in length by 0.028 mm. in breadth, are considerably smaller than the eggs of ascaris, and have a thinner and smoother coating (Fig. 2, e). This worm inhabits the rectum and large intestine throughout its entire course, as well as the loAver end of the small intestine. The eggs are passed out with the faeces in great numbers, and, when swallowed, the embryo is set free in the digestive tract and descends to the colon, rapidly developing into the adult worm. The number of these parasites in one individual may be so enormous that the whole mucous surface of the colon and rectum becomes coated with them, as if with a layer of pus. In the caecum, where they are undis- turbed, the sexes are about equally divided. In the rectum and in the stools the females preponderate, as, owing to their larger size, they are less easily destroyed than the smaller more fragile males. The great- preponderance of females is also partly apparent, as the males, from their minute size, are often overlooked. Pin-worms are frequently seen alive outside the anus in the folds of skin, sometimes getting into the groins, and in little girls they often crawl into the vagina. Method of Infection. — Auto-infection is constantly taking place in chil- dren having pin-worms. The irritation caused by the worm leads them to scratch about the anus ; numerous eggs become lodged under the finger-nails, and are later taken into the mouth and stomach. It is very common to find ‘ This can be written for directly. Its formula is as follows : H . Ext. spigeliae fl., f5x. ; Ext. aenme d., f^vj.; Olei anisi, ti\,xx. ; Olei cari, tr^xx. 34 530 AMERICAN TEXT-BOOK OF RISE ARES OF CHILDREN. several children in one family suffering simultaneously. Food and toys that are handled by these children become carriers of the infection. Vegetables and drinking-water may also be infected, as in the case of round-worms. Symptoms. — The oxyuris gives rise to a very evident symptom in nearly all cases — namely, an intense itching about the anus, which leads the patient to scratch vigorously, causing bleeding and Fig. 3. in some cases setting up an eczema. The Fig. 4. Oxyuris Vennicula- ris: a, Male, Nat- ural size; 6, The same enlarged, (after Beneden). itching occurs most severely in the early part of the night wdiile the patient is in bed. It is thought to be due to the move- ments of the worms in the rectum, and is entirely relieved by their removal from this point, even if they remain in quanti- ties higher up. In fact, it is probable that the parasites while in the small intes- tine produce no appreciable symptoms. As a result of the itching the sleep of the child is disturbed, and various slight nervous symptoms may be induced. Grind- ing of the teeth, crying out in sleep, invol- untary twitching, and insomnia are com- mon. In one of my cases pavor nocturnus was apparently caused by the reflex irri- tation of the worms ; and in a very sensitive child it is probable that reflex convulsions or chorea might ensue. As a result of the disturbed rest and of the more or less constant irritation, the patient is often debilitated, peevish, and nervous, and, like all nervous children, apt to acquire the trick of picking the nose, and to have occasional reflex feverish attacks. He may, however, escape wdthout a symptom. In two of the pin-wmrm cases at the Boston Children’s Hospital fainting was a prominent symptom. One of these, a girl of ten years, was said to have “worm-fever” about once a month. passed great quantities of the parasites As a reflex cause of incontinence of urine these parasites hold a well-recognized place. In eight of the hospital cases incontinence existed. In girls vulvo-vaginitis is sometimes caused by the irritation of the worms that have found their w'ay into the vagina ; this, in turn, is also a cause of incontinence of urine. Nine instances are recorded among 48 cases at the hospital. As 34 of these cases were in girls, this makes a jiroportion of 27 per cent, of vulvo- vaginitis from this cause. The great preponderance of females in this list, 34 to 14, may be j)artly explained by the urgent symptom of vulvo-vaginitis call- ing them to the hospital for treatment. Curiously enough, the same prepon- derance of girls is also found in the round-worm cases — 11 girls to 5 l)oys. Masturbation in either sex may he caused by the irritation. One of my cases had a rectal polypus, prohaldy due to rectal irritation. Prolaj>se of the rectum may be set up by the straining. As to the age at which these worms are chiefly found in children, 35 of the 48 cases at the hosj>ital occurreil in chil- dren between two and seven years old, inclusive. The youngest was an infant of twenty-one months. At this time she had fainting attacks and size ; b, The same en- larged. (After Bene- den). INTESTINAL EARASITES. 531 As bearing on the frequency of worms in general, and of each species in particular, I have examined the out-patient records of the Boston Children’s Hospital, and find that out of 5200 medical patients of all kinds, there were 65 where the diagnosis of worms was made on the evidence of the parasites themselves. My general impression was that the round-worms were more common than the pin-worms in children, and this is so stated by Councilman in the Cyclopcedia of the Diseases of Children. A much larger number of the latter were seen at the Children’s Hospital, however, owing no doubt to the more urgent symptoms they produce, and the general absence of symptoms in round-worms. Forty-eight of the 65 cases had pin-worms, and only 17 round- worms, 3 of these being afflicted with both varieties. The remaining four had tape-worms — in 1, Tpenia solium ; in 1, Tgenia mediocanellata ; and in 2 the species was not accurately determined. Diagnosis. — As in all cases of intestinal parasites, the diagnosis can only be made with certainty by the discovery of the worm itself or the ova. The history of anal pruritus in a child should always lead one to suspect the pres- ence of pin-worms, and the anus and its neighborhood should be carefully searched. By the use of an enema large numbers of the worms may be brought to light. By examining under the microscope scrapings from beneath the finger-nails, the folds about the anus, or the detritus scooped out from inside the anus with a grooved director or catheter, the eggs are often found in large quantities, and are easily recognized, as described above. In all cases of incontinence of urine, masturbation, and leucorrhoea the oxyuris should be thought of and sought for. As in the case of lumbricoids, intestinal mucus, which in greater or less quantity is mingled with faecal discharges, has often been mistaken by the nurse or mother for pin-worms, as is illustrated by the following case : Allen M , three and one-half years old, was brought to my clinic at the Boston Children’s Hospital with the history of having passed great quantities of pin-worms in the last few days. His symptoms, which the mother attributed to the worms, were vomiting, slight diarrhoea, with feverishness and general debility. He had a similar attack a year ago, and was thought to have passed worms then. Examination in the folds about the anus failed to reveal any worms, and a microscopical examination of detritus from under the finger-nails, outside the anus and inside the anus was negative as regards the finding of ova. The mother brought next time some of the fieces which she believed to be swarming with the worms. The faecal mass when placed in water showed plenty of stringy mucus, which, gathered in thread-like clusters, certainly simu- lated very closely actual pin-worms. There was in this case undoubted irritation of the intestine, giving rise to various symptoms suggestive of worms, and to an extra secretion of mucus. The irritation, however, was due to an improper diet, not to w'orms. Treatment. — As long as any worms remain in the bowel there is a con- stant source of infection. Treatment must therefore result in the complete expulsion of the parasites, or we shall have, what is often unfortunately the case, a relapse or return of the trouble. Besides this, measures must be taken to prevent reinfection from the old sources after cure. If the worm confined itself to the rectum, as is erroneously believed by some, treatment from below with injections would be simple and effectual. This treatment, although giving relief for a time, is of course entirely inadequate, as many of the worms are out of reach in the cmcum or even in the lower part of the small intestine. The proper method, therefore, is to make the attack both from above and below. By the mouth may be given either santonin, spigelia, or chenopodium, with a cathartic, in the manner already descril)ed in the treatment of ascarides. Cathartics which produce free watery discharges are found to be particularly efficient in the treatment, even without a previously administered vermicide. 532 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Epsom salts, Seidlitz powder, or Hunyadi water are therefore to be recom- mended, but are all unfortunately distasteful to children. The syrup of raspberry disguises very well the taste of Epsom salts in a 25 per cent, solution, thus : I^. Magnesii sulphatis oiv. Syrupi rubi idsei • fgij. — M. Sig. A tablespoonful containing one drachm of the salts. The vermicide and cathartic may be given by the mouth two or three days in the week. Once a day the rectum should be washed out with a copious enema of cool soapy water. By using a soft-rubber catheter attached to the nozzle of the syringe the enema can be introduced higher up, and will be more effectual. Plenty of water should be used, so as to distend the folds of the rectum and colon in which the w'orms are lodged. Cold water alone is effectual in washing out and killing the w’orms, but the addition of castile soap makes it less irri- tating to the bowel and more fatal to the worm ; and this addition is all that is necessary if the injections be given thoroughly. Other substances are often used in solution in the enema for their destructive effects on the worm. These are common salt, quinine, (juassia, alum, tannin, etc., but it may be doubted whether these solutions are any more effectual than properly given injections of soap and water. Where there is relaxation and protrusion of the rectum an astringent injection is of use, as, for example, one drachm of sulphate of iron to one j)int of infusion of quassia; or a solution of tannin ciin be given, in the proportion of a heaping teaspoonful to a pint of water. All irritating injec- tions should be avoided, and dangerous ones, like solutions of corrosive sub- limate, had better not be used. As the worm or its ova may live in the folds about the anus, these parts should be carefully scrubbed with soap and water and anointed with an anti- septic ointment. Boric-acid ointment, as in the following prescription, besides destroying worms, is of use in allaying the irritation or eczema caused by their presence : 1^. Acidi borici ... ,^j. Ulei rosjB gtt. iij. Vaseline 5j- — M. Even after a complete cure, obtained by the expulsion of all the worms, reinfection is likely to take place unless certain ])recautions are taken. The bed-clothing, the blankets, as well as the linen, may contain the eggs of the oxyuris ; the toys undoubtedly have some lodged in their crevices ; and the carpet or floor may be more or less infected, for it must be remembered that a small bit of fiecal matter spilt from a vessel or na])kin may contain thousands of eggs. The room and its contents should therefore be almost as thoroughly cleaned as in the case of one of the exanthemata. The bed-clothing shoidd bo boiled, the toys destroyed, the carpet and rugs thoroughly beaten, and the floor and furniture scrubbed with soap and water. The neglect of this undoubtedly accounts for the freciuent failures to cure this troublesome affection. m. T^nia (Tape-worm). The common tape-worm is from twenty to fifty feet in length, of a white color, and composed of numerous flattened segments, each of which, except INTESTINAL PARASITES. 533 those near the so-called head, is a complete hermaphrodite. Nourishment is absorbed through the body-walls from the contents of the intestinal canal, in which the whole worm lies immersed. The “head” is a modified segment about the size of the head of a pin, and it is by this organ with its suckers or hooks that the worm retains its hold on the intestine. The segments near the head are not much broader than a piece of thread, but they rapidly increase in size and become from one-quarter to one-half an inch broad at the other ex- tremity of the worm. Varieties. — The two species commonly found in this country are the beef tape-worm, Tcenia mediocayiellata, and the pork tape-worm. Taenia solium. Fig. 5. Fig. 6. Taenia Mediocanellata. Head and Mature Seg- ment, Enlarged (Heller). Two Other species may be mentioned, as they are sometimes encountered : Taenia nana and Tceyiia cucumerina. Another species, belong- ing to a different genus, Bothriocephalus latus., is found only in certain parts of the continent of Europe. The beef and pork tape-worms (Figs. 5 and 6) are easily distinguished by their heads, and less readily by the sexually mature segments. The pork tape-worm has a circle of hard chiti- nous hooks on the head, with four sucking disks, and the head itself is somewhat pointed. The head of the beef tape-worm is not pointed, and is provided with four suckers only, being devoid of the circle of hooks. This species may also be distinguished by the sexually mature segments or proglottides which are passed from the anus. In the pork tape-worm the lateral branches of the uterus (Fig. 6, 5), are only eight to twelve in number, and quite thick, while in the beef tape-worm the side branches are finer and are much more numerous, being twenty or thirty in number (Fig. 5, h). These can be seer by flattening out the segments between two microscopic slides and holding them up to the light. The addition of glycerin makes them more transparent. 534 AMERICAN TEXT-BOOK OF DIBEASEB OF CHILDREN. Tcenia nana has of late years been found to be very numerous in Italy, particularly in Sicily. It lias been found in Egypt, and also in England. With so many Italians of the poorer class constantly coming to this country, its occurrence here is to be expected. It especially attacks children, and may occur in great numbers in one individual. It is very small, being only ten to fifteen mm. in length. The bead is armed with four suckers and a rostellum •with books, which can be protruded or entirely withdrawn. Severe nervous symptoms are sometimes caused by this worm. Ta'tiia cucumerina is another rare form of tape-worm which especially infects children, being aci^uired by them from dogs. Life History. — The ova are produced in each segment in great numbers, and those of the two common varieties of tmnia are easily distinguished from the eggs of the round and thread-worms by their smaller size and spherical instead of oval shape. The eggs of T. mediocanellata are slightly larger than those of T. solium, which are about of an inch in diameter (Fig. 2, a and b). The tape-worm lives in the small intestine, firmly attached to the mucous membrane by the suckers and hooks on its head. While the head is attached to the upper part of the jejunum, the other extremity, in the common species, may reach nearly or quite to the ileo-caecal valve. The pork tape-worm is generally found singly, while two or more beef tape-w'orms may occur in the same indi- vidual. The worm grows by a process of breeding or segmentation from the segments close to the head. As these become farther and farther removed from the head by this process, they become larger and sexually mature. The first sexually mature segment of T. solium is about the four hundred and fiftieth from the head. Some of the ova are extruded from the lower mature seg- ments, and pass oft’ with the faeces, but most of them escape from the anus still contained in the ripe segments, which break off entire. These segments, be- sides passing out in the fmcal mass, may slip out of the anus into the under- clothing; and this happens so frequently that attention is usually called to the presence of the Avorm in this Avay. For the development of the eggs another host is utilized, this host being the hog in the case of T. solium, and cattle in the case of T. mediocanellata. In the case of the hog, Avith its fondness for grubbing around iti heaps of ofTal and manure, infection easily takes place. Cattle may be infected in a similar Avay Avhile cropping grass that has been fertilized Avith human fmces. In the aiiimaTs stomach the thick outer coatings of the ova are dissolved, the embryos are set free, and proceed at once to pierce the stomach-Avalls, and, carried along in the blood-current, bury themselves in the muscles, the liver or other viscera. Here they develop into cysticercus cysts, Avhich in the pork tape-Avorm are a little larger tlian a jx'a, in the beef ta))e-Avorm somcAvhat smaller. Within these cysts the larval tienia or scolex groAvs, tlie head l)eing formed Avith a shorr neck and a flask -.shaped body (Fig. 7). These cysts remain ([uiescent for from three to six years, after Avhich they die and become calcificent posture is assumed and the legs drawn up. The patient may lie on the right side. If pain be present, it is increased by keeping on the left side. The abdomen is usually distended by flatus, or in certain affections by ascites. If the liver be enlarged, the right lower third of the thorax is distended, as well as the con- tiguous portion of the abdomen. If there is much enlargement or if acute pain is present, the movement of the right lower half of the thorax is limited. The epigastrium is distended. The swell iiig of the hepatic area may corre- spond to the entire organ or may be localized. In abscess and hydatid disease tumors may be detected in the left lobe of the liver, along the lower border of the right lobe, or as swelling with projection of the ribs at points corre- sponding to the convex surface of the liver. Hence the epigastrium, the right hypochondrium, and right lumbar region, and the mid-clavicular, mid-axillary, and scapular lines along the upj)cr border, are the favorite seats of election DISEASES OF THE LIVER. 541 of tumors. In abscess the superimposed skin may be reddened. The appear- ance of the veins over the surface must be noted. Palpation . — By palpation the position of the lower border of the liver and the character of its surface are determined. The former is easily ascertained if the abdomen is not too much distended and if the child can be kept quiet during the examination. The normally large left lobe must not be mistaken for a tumor. The liver moves with respiration, and this fact must be ascer- tained in order to exclude the presence of tumors in the abdomen due to other causes. Fmces in the transverse colon must be excluded by the administration of purgatives. The surface of the liver, as well as its edge, may be soft, as in fatty liver, or indurated, as in amyloid disease. In both the edge is smooth ; in cirrhosis it may be sharp, but is invariably hard. Bosses may be detected due to cancer, hydatid disease, or abscess. In hydatid disease they are soft and may fluctuate ; in abscess they are hard at first, then become soft and fluctuating. A friction vibration is sometimes detected by the palpating hand in cases of perihepatitis, and the peculiar fremitus may be elicited in hydatid disease. Oedema of the surface is observed occasionally in abscess. Percussion . — By this means the size of the liver, whether diminished or enlarged, can be accurately determined, and the degree of enlargement ascer- tained. Marked deviations from the normal boundaries of percussion, as indi- cated above, serve to distinguish the changes. It must not be forgotten that to define the upper border deep percussion must be employed, and, to define the lower border, light percussion. The colon must be emptied of faeces, and the character of the evacuations noted. Affections of the pleura, particularly effusions, must be excluded. When a pleural effusion is present there is a uni- form bulging of the side, the respiratory movement of the liver is restricted, and a depression is sometimes seen between the effusion and the liver if that organ be pushed down. By percussion it is found that the dulness of effusion is movable, and that its upper limit is S-shaped or horizontal. The rational symptoms of pleurisy aid to distinguish it. When the liver is enlarged the ribs are everted. In determining the outline of the liver by percussion it is well to ascertain if it be regular or not. When the liver is enlarged in its entirety the normal shape is not departed from. If the enlargement is due to hydatid disease or abscess, the outline is irregular. The area of dulness may extend out from the normal liver in positions indicated by palpation. Sometimes tbe enlargement, though uniform, occurs in one direction only ; thus in abscess or hydatid dis- ease of the convexity the increase in dulness is upward and to the right ; in hydatid disease of the centre, downward. Both affections may be limited to the left lobe, and then an increase in size of the corresponding area is noted. Diagnosis. — By means of physical examination, with a study of rational symptoms, simulated enlargement of the liver is excluded. Apparent increase in the size of the liver, as determined by palpation and percussion, may depend upon congenital change in the shape of the liver or upon displace- ment of this organ by the deformities of the chest, due to rickets or to caries of the vertebrae. Congenital change in shape is recognized by the fact that it is noted soon after birth, and that, while it is persistent, symptoms of hepatic disease are absent. Apparent enlargement of the liver upward — dulness extending to the fourth rib in front — may be due to tumors in the abdomen or to ascites ; or the normal liver dulness may be continuous with the dulness due to sarcoma of the kidney, to tuberculous disease of the omentum, to an ovarian tumor, or to encysted or free fluid in the peritoneal cavity. 542 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. If fluid be present, the dulness may change if the jratient turns on the left side ; the lower border can then be defined. If the fluid be encysted, diagno- sis is more difficult. A history of previous peritonitis or a history of tuberculo- sis, with associated development of the disease in other organs, with fever and emaciation, is suggestive of tuberculosis, which is usually the cause of encysted fluid as well as omental disease. A tumor of the right kidney may be dis- tinguished from an enlarged liver if the tumor be rounded, if the fingers can slip between the tumor and the liver, if a tympanitic note, indicating the presence of the intestine, be found to run across the surface of the kidney, if the tumor do not move with respiration, and finally by urinalysis. The physical examination is not complete unless the characteristics of the organs adjacent to the liver are observed. Without such examination no diagnosis can be made nor rational treatment conducted. Operative exploration of the liver, accomplished by means of the aspirator or hypodermic syringe, properly sterilized, is useful to confirm the diagnosis of hydatid disease or of abscess of the liver. By this means three kinds of liquid may be withdrawn — serum, pus, or hydatid fluid. The former, serum, does not occur in the liver ; either the pleura or the space underneath the dia- phragm yields it ; but its presence does not exclude hepatic disease, for serous inflammation may complicate the liver affection. Cases are recorded in which, after emptying the pleura of serum, deeper exploration through the diaphragm yielded pus. The association of pleurisy or empyema and sub diaphragmatic abscess with hepatic disease must not be forgotten. By the aspirator clear laudable pus may be withdrawn. It often contains crystals of leucin and tyrosin, and, it is said, the characteristic liver cells. If such cells can be recognized, it is proof positive that the pus was originally in the liver. The pus may be so mixed with blood as to appear reddish-brown, like anchovy sauce. In this case, on microscopical examination, the amoeba dysenterica is sometimes found in the purulent fluid. The abscess is then secondary to dysentery. Hydatid fluid is clear, alkaline, of low specific gravity, contains sugar, a trace of albumin, and a large amount of chloride of sodium. Succinic acid has also been detected. On microscopic examination booklets, echinococcus membrane, sometimes scolices, and often hmmatoidin crystals are found. It is to be remembered that hydatid cysts may suppurate; pus will then be secured by aspiration, in which the remains of the echinococcus cyst are present. In diseases of the liver in childhood an accurate diagnosis can be made only by a consideration of the personal history of the patient, of the previous diseases from which he suffered, of the evolution of the disease the nature of which is to be solved, the subjective symptoms and physical signs of the ail- ment, and the condition of all the organs and structures of the body. A sys- tematic pursuit for all the facts, as embraced above, is necessary in the study of disease of any portion of the body; but the liver, more than other organs, is sulqected to onslaughts of morbid action that ])rimarily develop elsewhere ; hence previous ailments must l)c investigated and the integrity of all the tissues carefully ascei'tained. For the differential diagnosis of the various affections this is essential. Of the hepatic affections discussed in this work, congenital disease of the gall-ducts, some forms of congestion, and hydatid disease are the oidy ones that are not secondary to affections of other organs. A diagnosis is facilitated not only by imjuiring into the integrity of the various organs of the body, but also by securing definite information regard- ing the occupation, habits, residence, and all other conditions of life of the patient. Illustrations could be advanced in any disease, but it suffices to DISEASES OF THE LIVER. 543 point out the value of the knowledge of alcoholism in cirrhosis, of exposure to phosphorus in yellow atrophy, of residence among dogs in hydatid disease. Jaundice. Etiolog’y. — As seen most frequently in childhood, jaundice is due to obstruction of the bile-ducts — the hepatogenous form — resulting from pressure upon the ducts, or obstruction within them. Pressure upon the Ducts. — Organic disease of structures adjacent to the ducts which might press upon them is very rare in childhood. Obstruction within the Ducts. — Alfections of the mucous membrane are abnormal processes very liable to occur in infancy. When the lining mem- brane of the ducts, and particularly the portion of the common duct known as the pars intestinalis, is the seat of catarrh, the membrane swells and causes obliteration of the lumen. Jaundice therefore occurs. Congenital obliteration of the ducts is also found to be a cause of jaundice. Gall-stones do not occur in childhood, and the wandering of worms into the duct is rare. It is seen, therefore, that the obstructive or hepatogenous form of jaundice is due in the larger proportion of cases to catarrh of the ducts and sometimes to obstruction of them by round-worms. The causes of hcematogenous or non-obstructive jaundice are also few in number. Yellow fever, malaria, epidemic jaundice, and pymmia may be pos- sible causal factors ; poisoning by phosphorus, the use of ether or chloroform, mercurial poisoning, and snake-bite are rare possibilities. No cases of acute yellow atrophy in childhood have been reported. Jaundice is a symptom, not a disease. It is recognized by symptoms and general physical signs. Symptoms. — Icterus, or the yellow hue of skin in jaundice, is usually first noticed by the nurse or mother. The color varies from lemon-yellow to olive- green or a bronzed hue. In obliteration of the ducts it is most intense. It develops gradually, usually on the face first. In the obstructive form it is general. The conjunctive are deeply colored ; the mucous membranes are tinted ; the secretions are bile-tinged ; the sweat stains the linen yellow’. The urine is loaded with bile-pigment. It is brownish-yellow or has a greenish tinge. When shaken in a test-tube a yellow froth rises to the surface. By the nitrous acid test the play of colors characteristic of reaction with bile-pigment is seen. While the tissues and secretions are bile-tinged, the fpeces are deprived of the pigment. They are pale or slate-gray in color, very offensive and pasty. The temperature is frequently subnormal. Prostration occurs, and anminia arises. The influence of the bile on the nerve-centres or their peripheral terminations is seen in the character of the pulse, the occurrence of itching, and the grave cerebral phenomena to which the term cholesterminia has been applied. The pulse-rate is much diminished ; it often falls to two-thirds or one-half of the customary frequency. Itching is a most distressing symptom and is caused by the bile-pigment irritating the peripheral cutaneous nerve- filaments. Often the body, particularly the trunk, is covered w’ith scratch- marks. The skin is liable to eruptions, as erythema and boils. Ordinary cases of jaundice frequently show some irritability of temper and mental depression. This may be followed by drowsiness and by stupor ending in coma. In children convulsions are frequently seen. In malignant cases the typhoid state usually closes the scene ; the pulse becomes rapid, fever occurs, the tongue is dry and brown, sordes collect on the teeth, and there is sub- sultus tendinum with low delirium, and sooner or later convulsions and coma. 544 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Here too htemorrliages occur, the leakage being subcutaneous or into the mucous membranes, and appearing as nose-bleed, haematemesis, or melsena. Epidemic jaundice occurs at times in children. Denton reports a small epidemic among children of the same school. The symptoms were sudden vomiting, headache, vague gastric pains, with prostration, and in three or four days intense jaundice. Duration, ten to twelve days. Ilennig, after a study of three house-epidemics of infectious icterus, concludes that it is a general acute, specific, infectious, miasmatic, non-contagious disease. It may be spo- radic, epidemic or endemic, and appears to have a relation to typhoid fever and to typhus. The infectious agent arises outside of the human body. The disease runs a favorable course and never relapses. Raven believes ordinary catarrhal jaundice may be infectious, and reports an instance in which one child of a family became icteric from exposure, and that four others of the house developed the affection, apparently by contagion. Diagnosis. — The diagnosis of jaundice is not difficult. The greenish- yellow hue of chlorosis, with the pearly conjunctive, would suggest an exam- ination of the blood, the result of which would distinguish chlorosis and jaundice. Similar examination would enable an exact diagnosis of pernicious (idiopathic) anemia to be made in cases resembling jaundice in the straw- colored skin and the conjunctive made yellow by the deposition of fat. The rarity of Addison’s disease in childhood is such as to preclude the possibility of an error in diagnosis. The same may be said of malignant disease of the abdominal viscera. Malaria, hoAvever, occurs at any age ; but the rational symptoms, the plasmodia and pigment in the blood, and the condition of the spleen aid in the diagnosis of the paludal disorder. Varieties of Jaundice. — Jaundice in the New-Born. — In the new- born infant jaundice occurs in mild form during the first week of life on account of ligation of the cord and consequent alteration of blood-pressure in the liver, and in malignant form in (1) congenital obliteration of the biliary passages, and (2) pylephlebitis secondary to inflammation of the umbilical vein. Simple jaundice in infants rarely produces grave symptoms. The .skin, the conjunctiva, and the mucous membranes show a yellow discoloration, vary- ing in degree in different cases. The urine is loaded with bile-pigment. The child sleeps more than in health, and may not arouse when feeding should take place. The bowel movements may be pasty and white. Such jaundice begins twelve or twenty-four hours after birth. It lasts two days to a fort- night. The infant usually remains well nourished. It is due to low tension in the blood-vessels of the portal circulation (after ligature of the cord), whicli causes ra|>id absorption to take place from the bile-capillaries in which the tension is higher. Quincke thinks it is due to patency of the ductus venosus. Icterus neonatorum is to be distinguished from the pseudo-jaundice that oc- curs after birth due to a destruction of red cor])uscles in excess of the ])owers of the liver to discharge them from the body in tlie bile. In this condition the conjunctiva is not injected, the stools arc not clay-colored, and the urine does not contain much pigment. The discoloration fades like a bruise from yellowisli rcil to flesh color. It is said late lig.ature of the cord allows a portion (one-half) of the blood in the phiccnta to flow into the infant’s body, and therefore this distends the fictal vessels by .so much. This fact is of importance if, as Parks states, distended blood-vessels exhibit more intense jaundice. The treatment of the mild jaundice of infants is very simple. The bowels should be opened by a mild laxative, such as calomel or gray powder in minute DISEASES OF THE LIVER. 545 doses, or a few grains of calcined magnesia. The kidneys should be kept active by nitre or citrate of potassium well diluted. The child should be aroused to be fed, and the effects of the jaundice on the nerve-centres should be carefully watched. Ammonia in the form of the muriate or the aromatic spirits should be given, as in the following prescription ; I^. Ammon, chloridi g’'- j- Syr. acaciae fsss. — M. Sig. A coffee-spoonful every two hours. Or, I^. Spt. ammon. aromat fsj. Syrupi f^vij. — M. Sig. One-half teaspoonful every two hours. Spirits in the form of whiskey in hot water may be given if there be depression. Hot water, sweetened, can be given with advantage in copious drafts, particularly when fasting, for its effect on the liver and kidneys. There does not seem to be any reason against the use of gentle massage and faradism ; both are vaunted in catarrhal jaundice in later life. Exter- nally mild sinapisms, with light friction, must be employed if the circulation fails ; and the extremities must be kept warm. Jaundice due to Congenital Obliteration of the Bile-passages . — Four forms of obliteration have been noted : First, that in which no passage exists between the liver and duodenum ; second, in which there is one permeable canal, but no exit from the gall-bladder ; third, in which both cystic and hepatic ducts are obliterated ; and, fourth, in which obliteration has taken place below the junction of the cystic and hepatic ducts. Congenital malformation, with narrowing of the lumen of the parts on account of defective development, may exist to such degree that it leads to sluggish discharge of bile, which causes irritation of the ducts. A catarrhal process is set up, and leads to complete obliteration. The process is slow, but the obliteration is finished in some cases during intra-uterine life ; in others not until a few months after birth. In a few cases the inflammation of the ducts and the surrounding parts has led to localized peritonitis. In all cases, “biliary” cirrhosis of the liver has developed secondarily. The condition is rare. Dr. John Thomson was able to collect 64 cases. We are indebted to his monograph for the following facts : The parents of the children affected with obliteration of the bile-ducts are usually healthy. Syphilis in the parents is not an important factor. In several instances more than one child of the same family was affected, and in a large number of instances nearly all the children of families in which one case occurred had infantile jaundice or were subject to digestive disturbances. The character of the labor did not seem to influence the occurrence of the disease. At birth the affected child presented no abnormal appearance, except jaundice. In 2 out of 60 cases the lesions of congenital syphilis were seen. Boys were affected more frequently than girls. Jaundice is the most pronounced symptom. It is most frequently present at birth, hut may not develop until one, two, or six days after, and may be delayed beyond a fortnight. It soon becomes of a greenish hue, and it progressively deepens until the final termination. The urine contains bile coloring matter. The meconium may be normal or colorless. When it is normal the obliteration has taken place late in uterine life or not until after birth. The motions are whitish-gray at first or become so immediately after 35 646 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. the meconium is passed. At times green matter is voided with the stools. It may be due to mercury which had been administered or to micro-organisms in the heces. Ne.xt to jaundice, the occurrence of spontaneous hfemorrhages is the most frequent and characteristic symptom. They occur subcutaneously, from the umbilicus, the bowels, the stomach, the nose, and other portions of the body. The occurrence of limmorrhage is of very bad prognostic omen, death usually occui’ring a short time afterward. Usually in jaundice the blood-corpuscles are so reduced as to create the hsemorrhagic tendency, but Thomson believes haemorrhages occur because of some change in the blood-vessels produced by an excess of ptomaines in the blood, the function of the liver by wdiich these poisonous materials are destroyed being in abeyance. With or without haemorrhage, convulsions frequently take place. These phenomena are of frequent occurrence in other forms of jaundice, and are not peculiar to the affection under consideration. Progressive and easily recognized enlargement of the liver and spleen takes place, with the development of the grave phenomena indicated. Emacia- tion and exhaustion rapidly progress, and death ensues from slight intercurrent disease, from coma or from exhaustion. The diagnosis is not difficult ; the prognosis of a fatal termination is posi- tive. The duration is from one week to four months. Two cases recorded by Thomson lived to the eighth month. Treatment is without curative results. Jaundice due to Inflammation of Umbilical Vein . — Icterus may occur in infants because of inflammation of the umbilical vein, with secondary pyle- phlebitis. The stump of the cord is swollen and may exude pus, or the navel is ulcerated and inflamed. Ilmmorrhage is likely to arise. The skin is discolored around the navel, and the parts are tender. The liver is enlarged, and may be tender over the surface. In rare cases a localized or general peritonitis occurs. The attack may be ushered in with a convulsion, which is apt to recur. The infant is restless and cries very much. The desire to nurse is lost. Vomiting occurs, and often diarrhoea soon sets in. Foci of infection arise in other structures — the joints, the brain, the lungs. The joints become painful on movement and are sw'ollen and red. After the convulsion, or perhaps without it, fever sets in with the customary phenomena. The temperature is high and may be intermitting ; the jnilse is very rapid, the respiration increased; cough may be present; jaundice is not very intense. As the temperature rises the liability to convulsions increases, and death follows the convulsions, occurs in coma, or may take place from exhaustion. After death aseptic pleuri.sy, pericarditis, peritonitis, or menin- gitis may be found, or similar inflammation of the kidneys observed. The fever, the local signs and symptoms, and the jaundice render the diagnosis easy. In a few cases the local signs are not noted, under which circumstances the difficulties are greater. The prognosis is most grave. I’he treatment is simply .symptomatic. Prevention of this fatal illness of the new- born must be sought in strict antiseptic dre.ssings of the cord. Often a cord bleeds after the first ligature. The second tying is most dangerous unless done with projier precautions. The writer had a, case of this character in which infection took place from and at the hands of a dirty nurse. Before ligating the cord dirty rags were applied to attempt to control the luemorrhage. Jaundice in WinckeXa Disease . — Jaundice is seen in that, fatal aih'Ction of the new-born known as Winckel’s disease, or acute lin'inoglobinuria. Cyanosis and luemorrhage occur with the luemoglobiniiria, but the liver and spleen do not enlarge. DISEASES OF THE LIVER. 547 Jaundice in Later Infancy and Childhood. — Icterus occurs at any period of childhood and in both sexes. It is usually of the so-called catarrhal form. Errors of diet, improper food, excesses, irregular meals, improper cloth- ing, exposure and chilling of the extremities, leading first to gastro-intestinal catarrh, are common causes. The onset is gradual, being preceded by the symptoms of acute or subacute catarrh of the stomach and duodenum. There is some tenderness in the epi- gastrium and the right hypochondriac region, the liver is enlarged and may extend an inch or two below the normal line, and the chai’acteristic signs and symptoms of jaundice are present. The hue does not change to the green or bronzed yellow of malignant jaundice. Hemorrhages do not often occur. A moderate degree of fever is observed for a short time. The course may extend over three or four months. The diagnosis is not generally difficult. A history of long-continued improper feeding or of a sudden attack of vomiting, etc. from improper food or from cold, is usually elicited. The gradual development of the jaundice, with relatively slight constitutional symptoms, with moderate fever only, aids in the recognition of the character of the affection. The causal presence of worms or hydatid cysts in the ducts cannot be distinguished during life. The prognosis is good. Treatment . — If fever be present, rest in bed must be enjoined. The extremities must be kept warm. Mild counter-irritation over the epigastrium, by means of sinapism or frictions with stimulating liniments, may be em- ployed ; massage is also beneficial. Gerhard advises compression of the gall- bladder or gentle manipulation in that region. Faradism has also been advised. The diet must be bland and free from saccharine or amylaceous articles. Milk diluted with an alkaline or carbonated water or with lime- water and taken hot, koumyss if vomiting be present, junket, and animal broths, such as beef-tea, mutton-broth, and chicken-tea, may be administered. After the acute symptoms have subsided semi-solids may be used. Prepara- tions of milk and eggs, beef-jellies, oyster-broth, and clam-broth are appe- tizing. Light fish may be selected as convalescence proceeds, and sweet- breads, broiled beefsteak, and the white meat of ehicken. If there be much gastric disturbance, sedatives must be used. Calomel in small doses, calomel and bismuth, effervescing alkaline waters, carbonic- acid water, citrate of potassium in officinal solution favorably made, are of service. If there be pain, minute doses of magnesia may be added to the mercurial powder, or paregoric may be given with the citrate of potassium : I^. Liq. potassii citratis f.5ij Tr. opii camph fgj. Sig. One-half to one teaspoonful every two or three hours. Ilydrochlorate of cocaine in solution sometimes allays the vomiting. If there be constipation, an enema sufficient thoroughly to evacuate the bowels frequently relieves the vomiting. Afterward, if necessity requires, the bowels should be opened by a mercurial, as calomel or gray powder, in small, fre- quently-repeated doses, or by the citrate of magnesium, or a saline purgative, as Hunyadi, Friedrichshall, Bedford, or Saratoga water. When the acute symptoms are ameliorated, it remains to treat the catarrhal inflammation of the duodenum and ducts and the symptoms due to the jaundice. In the treatment of catarrh the diet, as indicated above, must be persisted in ; small doses of bismuth may be continued. Nitrate of silver in small dose. 548 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. with opium if pain be present, is a valuable sedative which modifies the catarrhal process. In young children it may be given in solution and should be administered on an empty stomach : Argent, nitrat gr. ss. Mucilag. acacim fsij. — M. Sig. Teaspoonful three times daily to a child under two years. Oxide of zinc, in doses of one-twelfth of a grain every three hours, is also useful. Small doses of ipecacuanha are often, after acute symptoms have subsided, of service. One-fourth to one grain of the powder three times daily is praised highly by many. Phosphate of sodium is a most valuable drug in catarrhal jaundice. Ten grains three times a day in milk for an infant or half-drachm to one drachm for a child of ten, in hot water, and taken fasting, proves of inestimable benefit. It may be used with other remedies. Chloride of ammonium is much used, particularly in India ; one to five grains of the drug every three hours is frequently followed by surprising results. It may be administered in syrup of licorice or in syrup of orange. It does appear to dissolve toughened mucus, to allay congestion, and to pro- mote secretion from the glands in the tubes. Pilocarpine in doses of one-sixteenth of a grain has been recommended. It seems to have been of great benefit to adults. After the tongue cleans, or, as is often the case, its epithelium is restored and the papillae assume a normal aspect, the sedative remedies may be dis- continued and a weak bitter or an acidulated bitter may be given : I^. Acid, hydrochlorici dil TTLxxxij. Infus. serpentariie fsij. — M. Sig. Teaspoonful in water before meals. For more chronic cases dilute nitric acid internally and the local pack of nitric acid are often serviceable. If the jaundice be of malarial or gouty origin, quinine in the former, or colchicine in the latter, has been often prescribed. Finally, to treat the catarrhal process, the method of Krull is strongly insisted upon : Two to four pints of water are injected into the colon two or three times daily. The temperature is raised at each enema, 'fhe first enema is given with the water at a temperature of 59° F. It is made two or three degrees warmer until enemata at temperature of 72° are given. Krull and others testify warmly to its beneficial effects in children. The writer has seen most surprising results in adults, and, as no harm can result from its use, would not hesitate to use it in children. Of the symptoms of jaundice requiring csjiecial attention, itching may be mentioned. Sponging with sedative lotions is of service. Ten drops of car- bolic acid to a pint of water, a solution of the bichloride of mercury, 1 to 3000, hot solutions of alkalies, as bicarbonate of sodium or borax, a drachm of each to the pint, may be employed. l^ilocarpine is recommended by Goodhart. lie preferred to give it hyjio- dermatically ; if j of grain shouhl be given to children over four years old. Since it was advised by (Joodhart a number of jihysicians have com- mended its use. Internal diaphoretics of domestic origin at times are of DISEASES OF THE LIVER. 549 service. An infusion of sage or hot drinks, with a stimulant, excite perspira- tion and relieve the itching. Intestinal dyspepsia with flatulency and painful digestion require some medication. The diet should in a measure prevent the development of these symptoms ; nevertheless, they occur. Preparations of pancreatin given an hour after meals, with an alkali, will aid much in digestion. If they are not of service, such drugs as correct fermentation in the intestines must he adminis- tered. Of these, salol, naphthalin, and thymol are of great service, while creasote, carbolic acid, and charcoal may be given with advantage. Salol may be administered in powder or compressed pill. Naphthalin and beta-naphthol should be given in gelatin-coated pill or capsule. The coating does not dis- solve until the drug reaches the intestine, and hence is of great advantage. Creasote or carbolic acid may also be given in pill or in emulsion with syrup of acacia. A prescription like the following generally overcomes the disagree- able symptoms : I^. Creasoti T- Carbonis lig gr- j- Pancreatin gi’- j- Bismuthi subnitrat gr. iij. — M. Ft. chart. No. i. Sig. Take after meals. Or, I^. Acidi carbolic! gtt. iv. Sodii bicarb 3j. Spiritus chloroform! fsij. Pulv. acaciae Sacchari albi «d gr. xx. Aquae q. s. ad f.^iij. — M. Sig. A teaspoonful after meals or every three hours. In selecting creasote the drug made from the beechwood must be used, and willow charcoal is preferable to the animal form. The cerebral symptoms of jaundice can only be overcome by hastening the elimination of bile and at the same time supporting the patient. Stimu- lants must be used ; preparations of ammonia, alcohol, and caffeine are to be selected. The preparations of ammonia are probably the best. Of course the patient must be nourished, and, if necessary, caffeine and cocaine may be resorted to. Both are advantageous stimulants, because they cause increased secretion from the kidneys, which are chiefly concerned in eliminating the bile. The poison without doubt sets up nephritis. It is necessary to guard against this complication if possible. Creating diaphoresis by jaborandi or the hot vapor-bath brings about this result. The kidneys may be relieved also by local applications, and particularly by the use of dry cups. In the case of more or less persistent jaundice these organs should be relieved quite frequently in the manner just suggested. The alkaline waters that may be selected for their beneficial effects upon the liver should also have diuretic properties. If they are not sufficient, the citrate of potassium or cream of tartar lemonade may be given. The slow pulse, the subnormal temperature, and the prostration that ensues in jaundice are to be treated in accordance Avith the general principles of the management of these conditions. If haemorrhages occur, turpentine or erigeron may be administered internally. Sulphuric acid and the acetate of lead are 550 AMERICAN TEXT-BOOK OF DISEASEB OF CHILDREN. also valuable astringents. The blood is always reduced in jaundice, the red corpuscles diminished in number. It is possible the systematic inhalation of oxygen may prevent this diminution, or at least combat symptoms depending upon it. It certainly is worthy of trial. Congestion of the Liver. Both the active and passive forms are seen. Active congestion is acute, and is induced by an exaggeration of all circumstances which increase the physiological congestion that takes place under the stimulus of food. Over- eating, the eating of rich food, the abuse of stimulants, are liable to cause an acute attack of hepatic congestion. Excess of heat may superinduce an attack in hot climates. The symptoms are much like those of catarrhal jaundice, with the physical signs of enlargement of the liver. The jaundice is not intense. The face becomes sallow and cachectic if jaundice be absent. The patient loses in health and strength. Some pain is complained of in the hepatic region, which is tender on palpation. The liver is enlarged uniformly in all direc- tions, often extending two inches beyond the normal boundaries ; the edge can be felt and is smooth and rounded ; the surfaces also are smooth. In a few cases the gall-bladder is enlarged, and can be detected in the right hypo- chondriac region to the left of the midclavicular line in a line drawn from the acromion process of the right shoulder to the umbilicus. With the removal of the cause the symptoms disappear, and by the end of a month the functions of the gastro-intestinal tract are restored and the liver is reduced in size. In some cases enlargement of the organ and the peculiar complexion of the patient continue for a longer period. Passive Congestion . — The passive form of congestion is associated with disease of the heart and lungs and chronic malarial poisoning. The pro- nounced symptoms are due to the disturbance of these organs ; along with congestion in other organs the liver becomes engorged with blood, and hence gradually enlarges. The shape of the enlargement is similar to tliat in active congestion. The edge of the liver is likely to be sharper and more indurated. No nodules can be detected on the surface. In the right midclavicular line the lower border may extend to the level of the umbilicus, and in the median line the left lobe may extend three-fourths the distance. Fre(juently the upper border cannot be so readily made out, because of the occurrence of effusion into the right pleura. The rational symptoms are those of mild gastro-intes- tinal catarrh. The tongue is furred ; there are nausea, loss of appetite, and intestinal dyspepsia ; vomiting and constipation may occur, or there may be diarrhma. A slight form of jaundice is developed. Albuminuria is observed, and the urine presents the appearance of congestion of the kid- neys. On account of the interest centred in the condition of the heart and lungs passive congestion of the liver is fre(iuently overlooked. Diagnosis. — The diagnosis of active and passive congestion of the liver is made without difficulty. The presence of a cause for the congestion, together with the mode of onset, are jn-onounccd factors in the diagnosis. Prognosis. — In the acute forms the prognosis is generally favorable. In chronic congestion the prognosis is modified by the knowledge of the cause of the congestion. Treatment. — The removal of the cause is essential to the successful man- agement of active congestion of the liver. Correction of errors in diet, in habits of life, or in occupation often suffices to relieve the affection. The gastro- DISEASES OF THE LIVER. 551 intestinal symptoms are treated as in catarrhal jaundice. More stress must be laid on the use of purgatives for depletion. The alkaline waters and the mercurials are of benefit. Phosphate of sodium is useful : it may be given in hot solution on an empty stomach either at night or on rising in the morning. The hygienic and dietetic management employed in catarrhal jaun- dice is of use in active congestion of the liver. In hot climates, if such con- gestion occur, two drugs are used and lauded. The chloride of ammonium in 3- to 5-grain doses, every two or three hours, relieves the discomfort and appears to remove the engorgement of the organ. Ipecacuanha is used for a similar purpose. The drug must be given in large doses, administered twice in the twenty-four hours ; 5 grains to children under five years of age is admissible. In order that vomiting should not be caused by the drug, the administration should be preceded by a few drops of the deodorized tincture of opium and a sinapism applied to the epigastrium. Twenty minutes after the application the drug may be given. After the more acute symptoms have subsided bitter tonics should be prescribed. If, however, there is pronounced gastric catarrh, small doses of calomel or bismuth or nitrate of silver, as advised in catarrhal jaundice, may be administered. One of the mineral acids, especially dilute nitric acid, in small doses, is given after the subsidence of the acute symptoms, particularly if the liver does not diminish in size. Passive congestion of the liver is treated by alleviating the symptoms due to the engorgement, and by the employment of measures and remedies to relieve the primary cause of the disease. Fatty Liver. Enlargement of the liver due to fatty infiltration or degeneration occurs in the course of other diseases or on account of improper habits of the patient. In children it is always an intercurrent affection. Tuberculosis and wasting diseases generally are associated with fatty infiltration. The wasting that attends gastro-intestinal catarrh is associated with fatty liver. This is par- ticularly the case if the catarrh results from the excessive use of sugar and starchy food. The enlargement is due to an accumulation of fat in the liver, and not to degeneration of the structures. It is said that children who are closely confined and have become anaemic are liable to this disease. Symptoms. — The subjective symptoms are negative. Enlargement of the liver, which is uniform in all directions, is observed. The organ is of doughy consistency and the edge is rounded. The surface is smooth and pain- less on palpation. Jaundice, ascites, and other symptoms due to hepatic dis- order do not occur. Treatment. — The treatment depends upon the cause. If enlargement from fat accumulation is found in children who tend to be obese, and who have been indiscreet, strict hygienic and dietetic management must be invoked. The carbohydrates must be excluded from the diet ; out-door exercise must be carefully planned, and if it cannot be indulged in, massage and Swedish move- ments must be directed. Sea-air has been advised in cases of this character. Amyloid Disease of the Liver. In this form of liver disease the organ is enlarged and but few hepatic symptoms of a subjective character are observed. The affection is associated with amyloid disease in the spleen, kidneys and intestines. The degenera- tion occurs in the course of phthisis, chronic bone disease, prolonged suppura- tion, and rickets. It may occur at any age throughout childhood. 552 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Symptoms. — Anaemia is a prominent general symptom, and the pallor of the face is striking. The liver is enlarged in all directions ; undue prominence of the abdomen in the course of any of the above-named affections should lead to an examination of this viscus. In addition to the enlargement of the liver, the spleen is also found to be enlarged. The liver sometimes attains a very large size ; it may be twice or three times the normal weight. The surface is smooth, the edges hard and rounded. No pain attends palpation. The external veins may be distended ; but jaundice does not occui', and ascites only results from diseases in other parts of the body, generally from the con- dition of the kidneys. Diarrhoea is usual, and haemorrhage from the bowels may also take place. Diagnosis. — The nature of enlarged liver occurring in the course of the diseases previously indicated can usually be determined without much dif- ficulty. The diagnosis is rendered more positive by the detection of similar disease in the spleen and by the occurrence of albuminuria and polyuria due to amyloid disease of the kidney. The recognition of amyloid disease should be attempted in all cases in which operative measures for the relief of bone disease or suppuration is contemplated. Any grave operation will be contraindicated by the presence of this complication. Treatment. — Notwithstanding the frequent suggestion by prominent authorities of the use of alkalies and the preparations of iodine in the treat- ment of this affection, there does not seem to be any drug which modifies or changes the course of the disease. The removal of the cause, if possible, is the most rational method of treatment. The few symptoms that are caused by the functional derangement or enlargement of the liver are to be treated. It must not be forgotten that in some cases it is almost impossible to say how much amyloid disease is present or to what extent the enlargement of the major organs within the abdomen is due to congestion. The symptoms and etiology may point with certainty to the presence of amyloid disease. If in such cases the heart be weak or there be organic disease, venous congestions of the viscera may also take place ; and apparently hopeless amyloid disease may be cured by recognition of this pathological fact, and hence by resorting to removal of the cause by the administration of digitalis, strophanthus, and other heart-tonics. Syphilitic Inflammation of the Liver. The morbid process above indicated due to the special specific poison is seen in the congenital forms of the disease in childhood. Two forms of inflam- mation occur — one in which the disease is limited or in large part confined to the capsule; the second, in which the connective tissue of Olisson’s capsule is the seat of inflammation. Symptoms. — The symptoms are generally seen in children who have the characteristic appearance of face, trunk, and extremities of congenital syphilis, elsewhere described in this book. The skin eru])tions, coryza and other mucous inflammations, anmmia, emaciation, and malnutrition, and, later in life, the appearance of the teeth, complexion, and shape of head, render the recognition of congenital sy])hilis comparatively easy. In jierihepatitis there is much pain over the liver, breathing is difficult, and tlicre is fever. The temperature rises to 100° or 101°, the pulse is frequent, the countenance distressed. Relief to the ])ain takes place when the patient assumes the upright position and crouches forward, or when he lies on his back with the legs drawn up. The marked tenderness interferes with palpation and DISEASES OF THE LIVER. 553 percussion. When the pain subsides the organ is found enlarged and the edges hard. After a week or ten days the more severe symptoms abate and convalescence is rapid unless the patient he broken down by previous bad health. Recurrence takes place on exposure or fatigue or without apparent cause. In another group of cases the shrinking of new-made connective tissue begins, and soon the organ is grasped in the toils of fibroid overgrowth, con- traction takes place, and all the symptoms of portal obstruction arise. Jaundice may be the only manifestation of infantile hepatic syphilis. It is in all probability due to perihepatitis, with compression of the gall-duct, or to enlarged glands, which likewise compress it, or, most frequently, to adhesive inflammation of the portal vein. Syphilis may be the cause of cirrhosis of the liver. The symptoms are twofold — one due to the congenital taint with possible associated lesions in other structures ; the other, to portal obstruction. The latter symptoms do not differ from those of portal obstruction in cirrhosis of the liver of alcoholic origin. Diagnosis. — The diagnosis of syphilitic disease of the liver is detei’mined largely by the association of the lesions and well-known appearances of congen- ital syphilis, with symptoms indicating inflammation and functional disorder of the liver. Often the symptoms, and particularly the objective ones, are not obvious. The apparent alteration in size of the liver is not demonstrable ; there is little if any pain, and features of portal obstruction are not observed. Jaundice may be the only symptom present. It is well to bear in mind that persistent jaundice in childhood without apparent cause, certainly if the gastro- intestinal tract be free from catarrh, may be of syphilitic origin. The thera- peutic test often aids in making a diagnosis. Treatment. — The treatment is largely that of the cause, the remedies applied for the relief of congenital syphilis being indicated. In addition to the constitutional treatment the pain, jaundice, ascites, and other symptoms are to be relieved by methods previously indicated in this paper. Suppurative Hepatitis. Two varieties are seen. In one the abscess is single, and in the other multiple ; in the former the suppuration in nearly all the cases is secondary to trauma ; in the latter suppurative pylephlebitis has occurred on account of suppuration in the portal area. Symptoms. — The symptoms in the two forms differ entirely. In traumatic abscess, after the injury there is much pain in the hepatic region and symp- toms of perihepatitis. The parts about the seat of injury are swollen, and the external surface may show the signs of a blow. After the injury the pain may diminish and the child be apparently well, when a recurrence of the local symptoms will arise; or the effects of the injury may not subside in the usual time. Pain in the region of the liver will be complained of, and on examina- tion the organ is found to be enlarged. The enlargement is not uniform. It may be upward only, or, as is most frequently the case, be indicated by exten- sion of the lower border of dulness downward. On palpation the hepatic region is painful ; oedema over the most painful part or over the hepatic area or the area of enlargement may be observed. If the abscess be developing in the right or left lobe, an undue prominence may be seen in the right hypo- chondriac or in the epigastric regions respectively. It will be noted to move with respiration and to be continuous with liver dulness on percussion. 554 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. With the development of the local signs of enlargement and inflammation gen- eral symptoms arise. The fever, which may have been due to trauma, does not disappear, and indeed becomes more pronounced. It assumes a remittent or even distinctly intermittent type, and may be preceded by daily rigors and followed by exhaustive sweats ; prostration ensues, and there may be a loss of flesh. The tongue is furred, appetite lost, vomiting may occur, and diarrhoea is frequently present. If the inflammation be seated on the convex surface of the liver, breathing is interfered with and cough may be present ; both respiratory acts will in all probability be attended with pain. The pain is then noted in the sixth or seventh interspace in front or the seventh or eighth interspace behind. It may extend to the right shoulder, and in some cases pain in this position alone is complained of. As previously intimated, sometimes the symptoms of suppuration, with local signs of inflammation, do not develop until a long time has elapsed after the injury. The general symptoms may arise before local signs of inflamma- tion are evident. Between the injury and the development of the symptoms the child is not in good health. Loss of appetite, languor, inability to exert himself as was his former habit, with loss of flesh and strength, are very likely to be present. Multiple abscess of the liver is usually preceded by a history of suppura- tion, and therefore a point of infection somewhere in the portal area. An appendicitis is one of the most fre(i[uent affections which precede this form of suppuration. It is thus seen that active abdominal symptoms may be present prior to the development of symptoms indicating involvement of the liver. If in the course of such symptoms jaundice arises and the liver becomes enlarged and painful, we may well suspect that the inflammation has spread to the portal vein. The type of the fever may also change. It becomes dis- tinctly intermittent, and daily chills attend it. The onset of jaundice is chai’acterized not only by the discoloration of the skin, hut by the develop- ment of symptoms of the typhoid state. Delirium of a low muttering character soon occurs, deepening into stupor. The tongue becomes dry and brown, sordes collect about the teeth and lips, and subsultus is seen. In some instances convulsions occur ; in others death takes place from exhaustion. Diarrhoea, if not previously present, is sure to arise. The stools are offensive and watery, and contain light-colored fecal matter. The urine contains bile- pigment, soon becomes scanty and high-colored, and is found to contain albu- min and to have blood, epithelial, and granular casts. The nephritis may become so marked as to be a serious, indeed fatal, complication. The patient usually lies on the right side, and when he assumes the opposite position complains of a heavy, dragging sensation. The skin is sallow, the complexion muddy. The facies is quite characteristic. Waring describes the appearance as follows : Countenance expressive of anxiety, shrunk, collapsed, pale, livid, or parchment-like. Diagnosis. — If the symptoms of suppuration just indicated arise after trauma or the occurrence of suppuration of the portal area, diagnosis is not difficult. The cases of suppuration secondary to worms in the he])atic duct, or to suppurative inflammation of the ducts, extremely rare in childhood, are recognized with difficulty. The absence of a focus of su])puration in any other portion of the body Avhen hectic symptoms arc present should determine the necessity of careful examination of the liver. Bnlargemcnt, either general or local, may be made out by careful percussion. The exploratory needle may render positive a suspicion of hepatic suppuration, but the negative results of puncture do not exclude abscess. Friction-sound at the base of the right DISEASES OF THE LIVER. 555 lung, with diminished expansion of that side, may call attention to possible hepatic suppuration. Reference has not been made to abscess of the liver occurring in the course of dysentery. The writer has not been able to find any recorded cases of this association in childhood, though there is no special reason why it should not occur. In cases of dysentery it is important to interrogate as to the condition of the liver, and, on the other hand, in acute liver affections the presence or absence of dysentery is to be ascertained. Amoebm in the stools, in pus from an abscess, or in expectoration would confirm the diagnosis of this form of abscess of the liver. Prognosis. — In multiple abscess of the liver the prognosis is very grave, such cases terminating fatally. In single abscess, if the pus can be reached by aspiration or by the knife, the prognosis is much more favorable. If the abscess be beneath the diaphragm in the upper portion of the right lo-be, the issue is much more doubtful than when superficial. Treatment. — The management of a case falls entirely into the hands of the surgeon. In multiple abscess of the liver no measures are of avail. In single abscess or where the number is limited to three, free incision must be made and may result favorably. If the abscess be situated along the margin of the ribs or in the epigastric region, the operation is simple and reparation takes place rapidly. The writer has seen two such cases recently in the Phila- delphia Hospital. An abscess of the convexity of the right lobe must be reached through the pleural cavity. Excision of the ribs is necessary, and isolation of the pleural cavity quite essential. After pus is secured and the cavity drained and irrigated, a drainage-tube must be inserted and the case treated by the usual surgical methods. Recently the writer reported a case under his care in which Dr. Willard performed the operation above indicated most successfully. Hydatid Disease. This is a comparatively rare affection in this country. It seems, however, to be on the increase ; ivithin the last two years the writer has seen six cases, and knows it to have been more common in the experience of others. In children it is even more rare than in adults. W"ith the exception of a child under twelve at the University clinic, no cases have come under the writer’s observation. In the literature of the disease few if any cases are reported under tivo years of age. The liver is one of the organs most frequently affected. In childhood it appears to be the organ selected in 70 per cent, of the cases. In the recent exhaustive work of Graham a few cases only are recorded. He states that within a period of one year he observed hydatids in ten children, their ages varying from five to eight years. The youngest case that he refers to is one operated on by Thomas, a boy aged tivo years and one month. This disproves the statement of Leuckart, who at the time of his publication believed the youngest cases recorded to have been four and six years of age respectively. There is, therefore, no immunity for children if their associations are such as to cause infection. The infection may occur very early in life, but the slow growth of the cyst makes it possible that they are not recognized for years. Moreover, in childhood, as Graham remarks, “ the organs in which the cysts are situated are less likely to be so completely affected as is the case in the adult subject where the pressure changes are more permanent.” Space will not permit a discussion of the mode of development or infection of the human species. The growth in the child and the manner of its infec- 556 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. tion do not differ from the same in adults (for description of which recent text- books on pathology contain sufficient information). Symptoms. — The cyst in the liver may develop and reach a large size without recognition. Attention is first called to its presence by the occurrence of mechanical symptoms ; the abdomen enlarges or there are enlargement and swelling of the liver region. On examination, if the liver be the seat of the disease, it is found to be enlarged. The enlargement may be uniform ; usually, however, it takes place in a particular direction. If the growth springs from the convex surface of the liver, the area of dulness extends higher in the axillary region and behind in the scapular line. If it begins in the right lobe, and the lower portion thereof particularly, the extent of dulness is increased downward toward the umbilicus. Sometimes the tumor is confined to the left lobe of the liver, and hence is recognized in the epigastric region. The prom- inence in the epigastric region or below the ribs in the mammary line is smooth and tense on palpation ; sometimes fluctuation can be detected. In a moderate proportion of cases the so-called hydatid fremitus is elicited, if the left hand be placed over the tumor and another portion tapped quickly and forcibly with the right. The tumor is painless, and there is no tenderness on pressure. The patient suffers from distention. There is interference with respiration, so that fre- quently he is compelled to sit up in bed in order to alleviate the dyspnoea. The general health is usually unaffected. In some cases the cyst is in such relation to the hepatic duct as to cause compression jaundice. The jaundice usually develops gradually. In rare cases the cyst breaks into the hepatic duct ; some pain follows this accident, and on account of the obstruction by the cystic contents jaundice develops. If the patient comes under observation after rupture of tbe cyst has taken place, the diagnosis is rendered more obscure. The enlarged cyst has been dispersed, and therefore most of the signs of tumor disappear. Suppuration of the cyst sometimes takes place, and in addition to the symptoms due to hepatic pressure those of pymmia arise, — rigors, periodical elevations of temperature, sweats, and great prostration. Jaundice occurs either because of the pymmia, or, if it be intense, because of obstruction of the ducts and probably suppurative cholangitis. The outcoTne of cases of hydatid disease varies. The liability to rupture is the same at all periods of life ; perforation may take place into the stomach, the colon, the pleura and bronchi, or in some cases externally. It has been said that in a few cases where this accident has occurred recovery has taken place. The perforation may also take place into the pericardium or the vena cava; when this accident occurs death takes place suddenly. Diagnosis. — A diagnosis is not usually difficult. Irregular enlargement of the liver, the surface of which is smooth and painless, or the presence of a tumor of the same character connected with the liver, probably fluctuating, in an indiviilual otherwise in good health, usually indicates the j)resence of this disease. If the cysts are multij)le, and the surface of the tumor, fherefore, irregular, the diagnosis is more difficult. J’he health is usually retained, and the benign nature of the enlargement thus inferred. Syphilitic disease of the liver and carcinoma must be excluded in adults. The rarity of the latter afl’ection in childhood and the al)sence of a primary focus of malignant disease, with retention of health and strength, exclude cancer. In syphilis the enlargement of the liver may be irregnlar and a. distinct boss recognizable. J’his usually occurs in tertiary syphilis, a form not seen in childhood. In congenital syphilis involving the liver large prominences are not seen. Nevertheless, in both DISEASES OF THE LIVER. 557 instances it is well to resort to exploratory puncture, and, if syphilis be sus- pected, to the treatment as a test in diagnosis. If suppuration takes place in the cyst, it cannot be distinguished from abscess unless it be known before the accident that there was a painless enlargement of the liver without fever. In adults dilatation of the gall-bladder has been mistaken for hydatid. This con- dition does not occur in childhood, and hence need not be considered. Hydro- nephrosis has also been mistaken for hydatid disease. The condition is not common in children, but can be distinguished by the results of exploratory puncture. When the cyst extends upward, it is often difficult to distinguish it from a pleural effusion. The same physical signs in the lower part of the right chest may be present as in effusion. Frehrichs believed that the direc- tion of the upper line of dulness is significant in hydatid disease of the liver. It does not take the S curve, as in effusions, but reaches the highest point at the angle of the scapula. Sometimes empyema complicates a hydatid cyst, as in cases reported by Murchison. The cases that are most difficult of diagnosis are those which have ruptured into the lungs before coming under observation. The appearance of booklets in the sputum is characteristic. Reference has been made in the beginning of this article to results of exploratory puncture in cases of suspected hydatid disease. The fluid with- drawn has special properties which render the recognition of the disease abso- lute. Prognosis. — From results of observation at the post-mortem table we see that a number of cases of hydatid disease of the liver undergo spontaneous cure. These cases, of course, are not recognized during life. If the disease is recognized and the tumor is accessible, the prognosis is very good. The results of treatment are generally quite favorable. Treatment. — Internal medication is of no avail and need not be discussed. Surgical procedures are necessary. Electrolysis has been used, but since the advent of antiseptic surgery has fallen into disuse. Medicated injections are not in high favor. Iodine, carbolic acid, solution of bichloride of mercury, and permanganate of potassium have been used, but the treatment is open to objections. Indeed, at the present time all methods except free incision are discarded as more or less dangerous. The uncertainty that attends the intro- duction of the trocar and the possibility of infection render such methods more or less hazardous, while the difficulty of completely emptying the cyst renders it liable to recur after the fluid is withdrawn. Recamier’s method of opening into the cyst by caustics or the thermo-cautery has been employed. The method is tedious and painful, and not without danger. The treatment by direct incision and evacuation of the contents of the cyst has been rendered possible by the developments of abdominal surgery. Incision should be made over the most prominent part of the tumor in the manner of performance of a laparotomy. After the cyst is exposed it should be attached to the edges of the abdominal incision ; it is then opened by the knife and its contents evacuated. The daughter-cysts may be evacuated by forceps. Too much force must not be used. In order to secure complete evacuation irrigation of the cyst-cavity must be employed. A drainage-tube is then inserted and the patient dressed as in an abdominal operation. If the cyst grows from the upper surface of the liver, it must be evacuated by pass- ing through the diaphragm. One or two ribs should be resected, the pleura stitched to the diaphragm, and evacuation then brought about by the previous method. In oases that have been operated upon a form of urticaria known as the hydatid rash is sometimes seen. It is said that the fluid of a hydatid cyst 558 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. will not cause peritonitis. Any portions of the cyst-wall that are left behind or any of the daughter-cysts will cause suppuration. Cirrhosis op the Liver. Through the writings of Palmer Howard, of Edwards, of Hatfield, and others we have learned that in its etiology, clinical course, and mode of termina- tion cirrhosis of the liver in childhood does not dilfer from that in adult life. Etiology. — Alcoholism is a very constant factor in its causation. The habit is usually fostered because of the delicate state of the child in early infiincy, coupled with the belief of ignorant parents that rum contributes to its development. It is true some children from their swaddling-clothes have an appetite for liquor, and when not discouraged are likely to develop all the lesions of alcoholism. Syphilis, as already mentioned, is another prominent cause. In Howard’s cases an adhesive pylephlebitis took place primarily, followed by secondary cirrhosis. In some of the recorded cases chronic heart disease was the causal factor. The infectious fevers, as scarlatina and measles, play an important part. Tuberculosis is attended by a form of cirrhosis both when the liver is involved in the tuberculous disease and iiulependently of it. Howard and othei’S believe that ptomaines and products of imperfect digestion may be productive of this affection. In rickets there is often found enlarge- ment of the liver which is due to an overgrowth of connective tissue. Hypertrophic or biliary cirrhosis is rarely seen in childhood. It is due to chronic obstruction of the biliary passages, and hence is present in congenital obliteration of the ducts. From the recorded cases collected by the above-mentioned authors, cirrhosis of the liver has been found to occur more frequently in males than in females in the proportion of two to one. The largest number of cases occur between the ninth and thirteenth years. It is found, however, at birth, and may occur at any period subsequently. Symptoms. — In the early stages of the disease capillary congestion is noted in the face. This may increase. As the disease advances the face becomes drawn, the parts free from stigmata are pale, or a sallow, muddy com- plexion is seen. The symptoms due to obstruction are usually most prominent. Gastro-intestinal catarrh is ol)served. Mornino; nausea and retchino; with dischai’ge of mucus take place, the appetite is poor, the bowels irregular, alternating attacks of diarrhoea and constipation take place, and the bowel movements usually contain considerable mucus. Ila'inorrhages from the lower end of the oesophagus, the stomach, or the intestinal tract may occur, and are very characteristic symptoms of cirrhosis. In gastric hmmorrhage the vomiting has no relation to food, and is not associated with symptoms of gastric ulcer. In tlie later stages of the disease hmmorrhages occur from the nose or the mouth, and purpuric spots develop. They are due to the state of the blood. Hmmorrhoids are frequently present. Jaundice occurs in about the same degree of frequency as in the cases of adults. It is usually slight, and may disappear and reeur two or three times in the course of the disease. Slight fever is seen in many cases. 'Phe temper- ature rises to 101° and 102° in the evening. It may be present for a long period of time, and as the end approaches disappear entirely. The urine is high-colored, of high specific gravity, and contains an excess of urates and uric acid. Frequently nephritis develops in the course of the affection. Albumin is then found, and the urine contains hyaline and granular casts. The specific gravity always remains high, and there is an excess of DISEASES OF THE LIVER. 559 lithates. From time to time sugar may be detected, but a persistent glycosuria is not likely to arise. On physical examination, when the disease is somewhat advanced, further evidences of portal obstruction and attempts at compensatory circulation are seen. The venules along the base of the thorax, extending across the chest in an arc, following the attachment of the diaphragm, are very distinct. The external veins, particularly tlie epigastric and mammary, are particularly dis- tinct. If compensation does not take place, ascites develops, and after its development the feet may swell. The spleen is frequently enlarged, but its size often cannot be determined when ascites is present. The liver is found to be enlarged if the case is seen in the early stage, and it may be slightly tender on palpation. Subsequently it diminishes in size, or the small size is at once noted. The diminution of the left lobe is particularly noticeable. With the walls relaxed the edge and surface can sometimes be felt rough and gran- ular. Some cases are not attended by atrophy. Thus there may be much fat in the liver, and, notwithstanding the connective-tissue overgrowth, the organ remains enlarged. Fatty atrophy of the liver is the name applied to this form. In “ biliary cirrhosis” the liver is enlarged and smooth. Jaundice is permanent, and the other symptoms of cirrhosis are present. On account of the organic disease of the liver auto-intoxication takes place with ptomaines or products of imperfect digestion. Low delirium, deepening into stupor, with the ocurrence of frequent convulsions, or noisy delirium fol- lowed by convulsions, show the effect of the toxine on the nervous system. Jaundice is not necessarily present when these symptoms develop. Diagnosis. — The disease may be far advanced, and not recognized because of the absence of symptoms or signs. A boy aged fifteen years died in the Presbyterian Hospital of typhoid fever. He had been under the observation of the writer for nine years. Acute rheumatic fever with endopericarditis was the reason of the first consultation ; valvular disease continued. The patient had been in poor health, and the parents were wmnt to give him spirits. This had been continued more or less until the fatal illness occurred. At the autopsy cirrhosis of the liver in an advanced degree was discovered. The appearance of the face, the symptoms of portal obstruction, and the physical signs of atrophied liver are points on which the diagnosis is based. The occurrence of subacute gastritis with morning vomiting, of luemat- emesis, and of malmna, without the physical signs of a small liver, are never- theless most suggestive, particularly if the patient be poorly nourished, with a di’awn, pallid countenance, and especially congestion of the cheeks — venous stigmata. If ascites, enlargement of the spleen, and jaundice supervene, the diagnosis is absolute. Treatment. — We can never tell Avhether the enlarged liver of the early stage of cirrhosis is one in which congestion predominates, or, on the other hand, one in which the overgrowth of connective tissue is in excess. If the former, we know that there are measures which markedly influence the engorge- ment. If the latter, it is possible a further increase may be averted by proper hygienic and prophylactic measures. It is our duty, notwithstanding the uncertainty, to relieve engorgement. External depletion by cups and leeches, purgatives in quantity to ensure three to six liquid stools a day, Rochelle salts, citrate of magnesium, and saline waters, are to be used. The waters of such springs as Saratoga and Bedford in this country, and Carlsbad in Germany, are beneficial. Counter-irritation in mild degree is likewi.se of value. If leeches or cups are inadvisable, stimulating liniments may be employed. The diet is to be carefully selected. A milk diet is for a time the most satisfactory. 560 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Stimulants and rich, stimulating articles of food, fats, sugars, and starches are to be avoided. Waters are to be used abundantly; they may be taken hot in large bulk (a glassful) when the patient is fasting to hush the liver. Phosphate of sodium may be advantageously added to waters to produce a depurative effect. At hrst small doses of calomel or mercury with chalk should be given for a few days. A furred tongue, nausea, constipation, with pasty stools, indicate its use. From time to time it should be repeated. Iodide of potassium has been said to relieve the engorged liver in the early stage of cirrhosis, but the chloride of ammonium is a better drug, in doses of five to ten grains in syrup of licorice or in emulsion, given every four hours. The treatment of the second stage is entirely symptomatic. Gastro- intestinal catarrh, hgemorrhages, ascites, jaundice with its resulting phenomena, and finally the distressing symptoms of the cirrhotic cache.xia, require in turn, or too frequently at the same time, careful therapeutic and dietetic management. Whatsoever the symptoms may be, the diet plays a most important part. The class of food referred to above is to be selected ; from time to time a strict course of milk diet may be instituted. Again, with the ascites most prominent, a dry diet should be advised. The condition of the stomach and bowels very largely determines the character of diet. If there be much intestinal dyspepsia, albuminoid food should be administered. Meats chopped fine and made into a pulp can be given for a long period of time. In order to create free discharge of the products of digestion, large quantities of water should be taken once or twice a day. The disadvantage of a continuous meat diet ai’ises in the possible development of scurvy. This may be counteracted by the use of lemon-juice once or twice in twenty- four hours. The gastro- intestinal catarrh is treated by the same class of remedies as are indicated and have already been detailed in the management of catarrhal jaundice. Haemorrhage from the stomach is to be treated by rest, the use of cracked ice, the external application of the ice-bag, the administration of food by the rectum, and the use of astringents. An opiate should always be given to quiet the agitated patient. Morphine hypodermatically or dry on the tongue may be selected, or the deodorized tincture of opium combined with the chosen astringents used. Gallic acid is one of the preferable astringents ; aromatic sulphuric acid may also be employed. Both should be given well diluted in iced water : I^. Tr. opii deodorat Acid, sulphuric, aromat act fi^j. — M. Sig. Eight to ten drops every two, three, or four hours, M'ell diluted. The acetate of lead alone or with bismuth is a valuable astringent. Ilamamelis may be given in the form of the iluid extract well diluted ; twenty drops is a sufficient dose, and may be given every one or two hours to a child of ten. Astringent preparations of iron usually are advised — the sulj)bate, the chloride, and the pernitrate. They sliould bo given in small doses fre(]iicntly repeated. If nausea and vomiting are not present, ergot might be used; the writer, however, has never had any benefit from its use ; indeed, gallic acid and the aromatic sul|)huric acid have been sulficient to control the bleeding. Intestinal lucmorrhage may be treated by astringents by the mouth or by enemata. If bleeding be from the rectum or the lower portion of the colon, weak solutions of alum or of salts of iron by eneimi arc of special value. The solution should be cold if the bleeding is from lucmorrlioids. One-balf drachm of Monsel’s solution to three ounces of water are the ])roper ])ropor- DISEASES OF THE LIVER. 561 tions for enemata of this character. Ice may be used in the rectum, as well as ice-water. By the mouth the astringents advised for gastric haemorrhage can be used. It is best to administer them in such form that they will be dissolved in the intestine; a one-grain pill of Monsel’s salt may be given every half hour or hour. The pill should be hard. Acetate of lead in pill may also be given. In this class of cases aromatic sulphuric acid has been sufficient in the writer’s experience. Turpentine has been advised by com- petent authorities, and may be given in capsule in doses of two or three drops every two hours. The oil of erigeron is also considered to be a valu- able styptic. If the ascites be not too great or of too long standing, it may be removed by dry diet and diuretics. Alkaline diuretics are particularly of service. Cream-of-tartar lemonade and infusion of scoparius are excellent diuretics. Saline waters which act on the kidneys and the bowels are of great service. Gentle catharsis may be maintained without fear of exhaustion if salines be used. On account of the tendency to intestinal catarrh, irritating cathartics should not be employed. At times the effusion seems to come to a standstill ; the bowels have been sluggish, and the internal viscera apparently loaded with stagnated blood from passive congestion. A brisk cathartic often relieves engorgement and starts up absorption of the exuded fluid. In children the compound jalap powder is the best of the class. It should be given in doses of twenty grains ; the amount may be increased if necessary. If the simple diuretics and cathartics are of no avail, four measures are to be considered and may be tried : 1st. The use of calomel with diuretics, as in the well-known pill of calomel, digitalis, and squills. It may be given in accordance with the following formula : Ilydrarg. chlorid. mit. . . . Pulv. digitalis Pulv. scillrn Ft. pil. No. i. Sig. To be taken every three hours After this combination is administered for ten days it should be withdrawn and squills and digitalis given alone. It then may be resorted to again, the frequency of its use depending upon the effect of calomel on the bowels. 2d. Caffeine is a valuable diuretic, particularly if stimulating effects are desirable. Dose 1 to 3 grains to a child under ten. The hydrochlorate of cocaine is another drug of the same class, and seems to have been of service. 3d. Copaiba. This is a most valuable drug in ascites. Its diuretic effect is decisive and usually permanent ; it is to be given in capsule ; three minims is sufficient for a child, to be taken every four hours. 4th. Paracentesis. Paracentesis should be employed early and frequently, if after a short trial the remedies above indicated do not lessen the amount of effusion. No hesitancy should arise on account of danger, as no accidents or complications are likely to occur. A number of cases have been reported in which frequent tapping has cured the ascites, and thereby arrested for a time at least the progress of the hepatic disease. The treatment of jaundice need not require further consideration, for it has been discussed fully in a previous portion of this article. The symptoms of the cirrhotic cachexia which ensue in the latter stages of this malady are alleviated by careful nursing, attention in detail to diet, and the administra- 3 « gr- *• er. -I. gr. i.-M. 562 AMERICAN TEXT-BOOK OF DTSEASES OF CHILDREN. tion of remedies which secui’e full functional activity of the various organs of the economy. This particularly applies to the circulation. Cardiac tonics are indicated. Stimulants should not be withheld, and now are of service to counteract prostration, aid digestion, and increase the strength of the heart and circulation. All measures that can be invoked to relieve exhaustion, improve anaemia, and aid nutrition should be resorted to. The administration of concentrated food — animal broths, meat extracts, etc. ; the inhalation of oxygen ; the use of stimulating baths and lotions ; measures to prevent the development of bed-sores, — each or all may be used as indications demand. Proper clothing, in order that the extremities and abdomen may be kept warm, must be insisted upon. At this stage multiple haemorrhages and pur- pura are liable to ensue. The internal administration of astringents, but more particularly of turpentine, or the oil of erigeron, appears to check their devel- opment. PERITONITIS; TUMORS OF THE PERITONEUM AND OMENTUM; AND ASCITES. By j. henby fbuitnight, a. m., m. d., New Yoek. I. Acute Peritonitis. This affection is an acute inflammation of the serous membrane lining the abdominal cavity and covering the abdominal viscera. It is characterized by a tendency to effusion, by adhesions through coagulable lymph, and by the deposition of purulent or sero-purulent fluid. Such an inflammation may be confined to a portion of the membrane, when it is said to be circumscribed or local, or it may involve the whole surface of the peritoneum, and thus become general. At the onset only will it be circumscribed or limited, for, unless checked, it quickly manifests a disposition to extend over the whole of the inner surface of the peritoneal sac. Etiology. — Peritonitis may occur during intra-uterine life, in the new- born, and during infancy and childhood. In early life idiopathic peritonitis is not a very frequent disease, since at this period the peritoneum is not so sus- ceptible to inflammation as the serous membranes of the thoracic and cranial cavities. When it occurs during intra-uterine life, it is always traceable to syphilis in the parents. It may cause the death of the foetus in utero, or the child may be born suffering from the disease or its consequences. So far as is known, no symptoms in the mother serve to indicate the existence of peri- tonitis in the foetus. If it be not fatal before birth, the resulting adhesions are very apt to interfere with the development of the intestines or to cause a con- striction of a portion of the bowel. In the new-born, acute peritonitis is most frequently the result of septic or pyiemic processes. It is usually caused by an unhealthy inflammation of the umbilicus or by the absorption of septic matter at that point. (See Diseases of the New-born.) In infancy and childhood an attack may be traced to exposure to wet and cold. Thus, wetting and chilling of the feet, damp beds,’ chilly winds, sudden alterations of temperature, rapid cooling of the heated body, and excessive fatigue may be enumerated under this head as causes of acute peritonitis, just as they may act in the production of inflammation in other structures. Very often traumatism may serve as the exciting cause, and here may be enumerated contusions, direct blows upon the abdomen, and the wounds of cutting or blunt instruments produced accidentally or surgically, as in paracentesis abdominis. Again, various mechanical causes (which are in reality traumatic in their nature) may operate in its production, such as intestinal invagination, stran- gulated hernia, displacements of some of the internal organs, or laceration or unusual stretching of the peritoneal membrane. In like manner, peritonitis 56.3 564 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN may be caused by the extrusion of foreign matters into the serous cavity, as in ruptured hepatic or splenic abscess, rupture or perforation of the stomach, bile-ducts, spleen, uterus, urinary bladder, ureters, or some part of the intes- tines. It may follow or accompany acute disease of some organ by contiguity of structure ; and here may be mentioned gastritis, splenitis, hepatitis, dysen- tery, ulcerations in typhoid fever, and ulcerations of the vermiform aj)pendix, appendicitis, and the like. Numerous instances have been encountered where an empyema perforating the dia])hragm has set up acute j)eritonitis ; and this result has been observed even in the absence of perforation, the lymphatics acting as the channel of communication. In gilds purulent vulvo-vaginitis has frequently caused acute peritonitis by an extension of the inflammation through the uterus and Fallopian tubes. At times also it may result from pressure and ulcerative absorption caused by tumors and malignant growths. The sudden retrocession of a cutaneous eruption has sometimes been closely fol- lowed by an attack of peritonitis, and it is on record that lumbricoid worms have penetrated the bowel and thus acted as an exciting cause. Finally, it may occur as a complication of, or a sequel to, rheumatism, erysipelas, pernicious intermittent fever, and the various exanthemata. It has been quite well established that in the develojmient of peritonitis micro-organisms, rendered operative by any of the before-mentioned local disturbances, must be regarded as the essential causes. When, experimentally, non-pathogenic microbes, even when combined with small amounts of chemical irritants, are injected into the peritoneal sac, purulent peritonitis is not pro- duced, but only a serous inflammation. On the other hand, when pathogenic micro-organisms are introduced even in very small quantities, severe tibrino- purulent peritonitis ensues. The micro-organisms which produce peritonitis are those found in pus, the staphylococcus, and the stre])tococcus. Before they can increase in number a ]>receding or accompanying change in the peri- tonuem is necessary. If the absorptive powers of the peritoneum be greatly changed, the microbes will effect a j)utrefaction of the intra))eritoneal fluids, and as a consequence will produce a general putrid infection of the whole system. Pathological Anatomy. — The transparent and shining appearance of the membrane is lost. This is accompanied by a diminution of the lubricating secretion, rendering the serous membrane less moist. The subj)eritoneal ves- sels become turgid with blood, are visible through the thin membrane as an interlacing network, and when they are greatly distended the peritoneum jire- sents a velvety appearance. At times the blood exudes through the coats of the vessels, when puncta or phonies of sanguineous effusion are seen. Later, if the disease progresses, the serous secretion is increased in (piantity and altered in character, being composed of li(|uid serum and a more solid or glutinous material known as coagulable lyinpb. It may ha|)pen, however, that the eflu- sion is entirely conq)oseil of serum ; or, on tlie other hand, sei'iiin may be alto- gether absent. In metastatic peritonitis or in attacks of asthenic character the effusion may be puriform or distiiictly j>iirulent, while in stlu'iiic cases thedejmsit of lymph may vary from a very thin layer to a thickness of several lines, and it is usually of a yellowish color. When abundant, it may be fouml in layers, smooth or corrugated, or it may exist as bands of adhesion uniting the vis- cera with each other or with the parietal peritoneum. At first villous in ap])oar- ance, it afterward becomes smooth and denser, and finally assumes a structure similar to true jieritoneal membrane. When once formed, ])lastic lymph acts as an irritant to the serous surfaces with which it may come in contact — a fact which serves to explain how inllammation is so apt to be diffused over the entire PERITONITIS. 5G5 peritoneal surface. When health is restored these bands of adhesion may partly or entirely disappear. If they continue they may cause little inconve- nience, though it may happen that, by their topographical relations, they may interfere with the functions of the organs to which they adhere. In chil- dren the effusion is most commonly purulent ; it may be merely puriform, decidedly purulent, or simply sanious. Ulceration may occur through the abdominal walls or through the diaphragm into the lung or bronchi, or again through the digestive tract, the bladder, the vagina, or through the psoas muscle, permitting pus to escape from the peritoneal cavity by one of these various channels. When peritonitis exists as a sequel to scarlet fever, measles, rheumatism, or other fever, the serous fluid is in excess, whilst the plastic lymph is incon- siderable in amount or nearly absent. The results of an attack, while at times causative of further disease, may in other cases be protective against more serious accidents : adhesions may supervene which will seriously interfere with the functions of the organs or parts which are bound down or united by these bands ; on the other hand, as in some cases of perforation, this same inclina- tion to plastic exudation may be conservative of life, the deposit being a means by which nature seeks to effect reparation. Symptoms. — The earliest and most pi’onounced symptom of peritonitis is pain. At first the area of pain may be limited ; afterward it will extend over the whole abdomen. The pain is accompanied by high fever and decided con- stitutional disturbances, such as rigors and general malaise. Pressure over the abdomen and augmented action of the abdominal muscles, as in deep inspira- tions, coughing, sneezing, expectoration, and the like, will aggravate the pain. The lightest weight cannot be borne upon the abdomen ; hence the little patient assumes a position which will relax the abdominal walls as much as possible, and lies quietly on his back with his knees bent and thighs flexed. The belly is hot, rounded, and tense, almost invariably swollen and tympanitic from accumulation of flatus due to paralysis of the muscular coat of the intestines. Sometimes flatus may be readily passed per anum, at others not ; and in this case symptoms of intestinal obstruction are simulated. The bowels are usually con- stipated, though diarrhoea is occasionally met with. Vomiting is nearly always present from beginning to end, and is aggravated Avhenever food is taken, until the presence of bile and fgecal matter in the ejecta may be almost sug- gestive of some mechanical bowel obstruction. The skin is hot and dry ; the temperature, as a rule, is elevated, ranging from 101° to 105° F., but it becomes subnormal if the attack terminates in collapse. Inflammation of the peritoneum, however, may coexist with a nor- mal or subnormal temperature, and this very frequently happens in the puru- lent cases. The pulse is small, feeble, rapid, and wiry. The respirations are accelerated, short, incomplete, and jerky, and are costal in type, the abdominal wall remaining motionless. The tongue is coated and the breath is foul. The face is expressive of great suffering and anxiety, and when the attack is very severe, the alse of the nose are drawn upward, the nostrils are dilated, and the lips are parted, so as to expose the teeth, producing the expression known as risug sardonicus. The urine is scanty and high-colored, and often contains albumin. When the attack is to terminate in recovery all these symptoms gradually diminish in intensity, whilst the countenance, which lias been so truthful an exponent of the patient’s condition, once more becomes placid and natural. If the attack is to eventuate in death, the pulse becomes quicker and more thready, the general surface cold and clammy, the extremities chilled, and the breathing 566 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. shallower and more rapid, until life goes out from failure of the general vital forces. In a few cases incoherency of speech or active delirium is present toward the end, hut most generally the mind remains clear and logical to the last. The fatal issue of an attack may take place in two or three days, though frequently the patient may live until the sixth, seventh, or eighth day. Diagnosis. — Peritonitis in its severer forms is readily recognized, but when subacute or circumscribed, or when it is secondary or exists as a complication, it is not so easy of diagnosis. In young children it is especially difficult to determine its presence because of the uncertainty of exact localization of pain. In erratic cases also pain may be absent, and thus we will be hampered in diag- nosis. The diseases simulating acute peritonitis are gastritis, enteritis, colic, rheumatism, neuralgia, renal calculus, and lead-poisoning. The diagnosis must depend upon the severity of the symptoms, special attention having been paid to the history of the case. If there be persistent vomiting of all fluids and solids, with the presence of sharp paroxysmal pain, accompanied by tenderness on pressure upon the abdomen, with cessation of the abdominal respiratory movements, a frequent, wiry pulse, and fever, the diagnosis of acute peritonitis may be made with reasonable certainty. Prognosis. — In the generalized form prognosis is always grave. It has been said that there is no more fatal disease, recovery taking place in rare cases only. The more pronounced the symptoms are, the more doubtful will be the prospect of recovery; and if the patient shall have passed into the stage of collapse, a fatal termination is usually to be expected. An acute peritonitis which is metastatic in origin or which is due to perforation is gen- erally fatal. Diarrhoea is of evil portent, and constant vomiting with complete obstruction of the bowels is a very grave symptom. Although the general prospects of recovery are so slight, yet patients apparently moribund have been known to get well. The attack may last but a few days, or even only from thirty-six to forty-eight hours, and very rarely indeed longer than a week. Treatment. — The cause of the attack will determine the treatment to be followed in a given case. Unfortunately, however, the physician will not always be in a position to know accurately what this may be or what exact anatomical lesions may exist. The patient must be confined absolutely to bed. All food and drink must be stopped, only cracked ice or iced water to moisten the mouth being permitted. This interdiction of all ingesta must be impera- tive, in order to avoid the harassing and painful vomiting. Nutrition can he maintained until the cessation of vomiting by the use of enemata or supposi- tories containing appropriate substances, as broth, milk, egg-albumin, stimu- lants; later, when the vomiting shall have been overcome, the food should be limited to twelve or fifteen ounces (best predigested) per diem. Ice pills may be given to control the vomiting, also iced champagne in small doses fre- quently repeated, as well to soothe the feeble stomach as for its stimulating effects. Locally, various remedies have been employed. Soft flannel cloths saturated in a solution of tincture of iodine in castor oil and apj)lied over the belly have been highly recommended. Local bloodletting by the ap])lication of from four to twelve leeches to the surface of the abdomen is often very valuable in the initial stage. The inunction of mercurial ointment to the abdo- men was formerly much in vogue. Stupe.s, made by stee])ing flannels in a pint of hot water containing ten to twenty drops of spirits of turpentine and sjn’inkled with laudanum, are often of great service. Light flaxseed-meal poultices, dashed with oil of turpentine or laudanum and laid upon the abdomen, have in my hands been of great value. Care should be takeji that the jumltices be PERITONITIS. 567 not too hot, lest the integument be burned. By some physicians cold appli- cations, such as the ice-bag or cold-water coil, are preferred, but children almost always resist their use. As to the methods of internal treatment — whether by saline purgatives or by opium — a difference of opinion still exists among physicians of equal skill and eminence. It will be safe to abide by the following conclusion; When an attack of acute peritonitis is recognized almost at the moment of its inception, salines by their rapid and complete depletion may abort an attack. The peri- toneum will be drained of the products of inflammation, the formation of bands and adhesions will be prevented in consequence of the increased peristaltic action of the bowels, whilst, clinically, pain will be relieved as quickly as by the atlministration of opium. On the other hand, if the case is not seen by the physician until some hours after the commencement of the attack, and especially if grave doubts exist as to the cause of the disease, opium and external methods of depletion must be used. It need scarcely be said that in perforative peritonitis the purgative treatment must not be thought of at all. In case it has been decided to administer a purgative, either a seidlitz pow- der or some other mild saline or calomel is to be preferred for children. When opium is to be given — which should always be the case when there is intense pain, tenderness, constant vomiting, and a distended and paralyzed condition of the bowels — it should be given in quantity sufficient to relieve pain, to reduce the frequency of the pulse and respiration (the latter to about twelve movements per minute), and to make the little patient slightly drowsy. Two to five minims of the deodorized tincture of opium, or one to four grains of Dover’s powder, may be given every four hours, according to indications, at the age of six years. The effects of the opium must, of course, be narrowly watched, for, as is well known, children are very susceptible to its action. In older children morphine may be given either per orem or by hypodermatic injection in doses of from one-twelfth to one-sixth of a grain. The tincture of belladonna is frequently combined with the opium. Excessive tympany can be relieved by the use of laxative enemata in which spirits of turpentine or tincture of asafoetida has been suspended ; or, in case of their failure, the long rectal tube may be used. Free stimulation must be resorted to early, and such alcoholics as brandy, whis- key, and champagne are to be preferred. To these may be added, to assist in keeping active a flagging circulation, such cardiac stimulants as sparteine, strophanthus, and digitalis ; these, if vomited, must be given by the rectum or under the skin. Later, when the attack promises to terminate favorably, every effort must be made to build up the system and to increase nutrition by the exhibition of tonics and easily-assimilated, nourishing food. As soon as the diagnosis of acute peritonitis has been made, the question of opening and draining the peritoneal cavity will present itself. Ilei’e, again, differences of opinion are encountered. Some advocate an early and immediate operation, whilst others claim that, as cases recover without operation, it is better not to risk the added dangers of surgical interference. It may be con- sidei’ed proper to operate in the following forms of peritonitis : First, in the fulminating forms of the disease, which are characterized by a rapid advance of the symptoms, excessive vomiting and tympanites, feeble pulse, and great restlessness. Secondly, in cases in which collapse seems imminent in spite of treatment, and which present a decreasing temperature and a rapid pulse con- stantly growing feebler. Thirdly, in cases in which pus is present in the abdominal cavity, or in which a tumor is located in, or adjacent to, the abdomen. Fourthly, in cases in which the peritonitis is the result of perforation or ulcer- ation of any of the abdominal viscera. And fifthly, when the peritonitis is 568 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. due to intestinal obstruction. In older children the chances of success are greater than in the younger ones. A certain number of cases will be met with in which the diagno.sis will be (questionable. It will, at times, be doubtful whether the exudation be purulent or composed only of lymph, and whether the inflammation has been general from the first, or has spread from the csecum or other localized inflammatory area. In such cases it is held to be justifiable oO perform an exploratory operation, which may, under some circumstances, be •'he means of saving the patient’s life. To discuss the method of operation and the questions of drainage and irrigation is not embraced in the scope of this article, and for such details the reader is referred to the works on operative surgery. n. Chronic Peritonitis. As a chronic affection peritonitis, with the exception of the tubercular variety, is rare. As early as 1838, Wolff published a study upon chronic peritonitis, and stated it to be an extremely common affection in children ; but as all of his one hundi’ed cases Avere reported cured, it seems likely that a large proportion were incori’ectly diagnosticated. Since then until quite lately the subject has received but little consideration at the hands of medical Avriters, and the opinion has gained ground that all chronic peritonitis, almost Avithout exception, is tuber- cular (West). This view, hoAvever, has been considerably modified by the more recent studies of Baginsky, Vierordt, Henoch, and others, and it is noAV accepted that the peritoneum, just as Avell as the pleura, may be the seat of a simple chronic inflammation Avith serous exudation. Chronic })eritonitis may sometimes be the sequel of an acute attack of the disease, but it is more frecjiiently an independent affection. Etiology. — Most of the j)atients are females — a fact that suggests a possible connection in some cases betAveen the peritoneal inflammation and a vulvo- vaginitis, Avhich is by no means uncommon in little girls. Barely a history of traumatism may be elicited, as in a case reported by Henoch, confirmed by post-mortem after a course of six weeks. In another group of cases a preced- ing exanthem may be the apparent etiological factor, as seemed to be likely in two cases — one observed by Fiedler, and the other by Henoch — both occurring after measles. The complete cure, after several tappings, in Henoch’s case leaves little doubt of its true cbaracter. Symptoms. — 1’he synqAtoms of non-tubercular chronic qieritonitis are rather obscure. The abdominal pain is a])t to be slight, Avhilst the con- stitutional symptoms are variable. Usually the health fails gradually ; the appetite becomes caj)ricious ; there is alternate diarrlnx'a and constipation, the former of Avhich may or may not be accompanied by pain ; sleej) is disturbed, and the skin is hot and dry at night. Subse(juently, pain or a sensation of tightness in the abdomen is conqflained of, and after a time efl’usion of fluid takes j)hw;e, fluctuation may be discovered on examination, and the cutaneous veins are turgid and well defined. The jtain noAv becomes more marked ; it is usually not hjcalized, but shifts about from one spot to another ; generally there is tenderness on qu'essuro over the abdomen ; still, the ap|>etite may be fairly good, the tongue tolerably clean, and tbe boAvels not ))articiilarly irregular. As the effusion accumulatos dyspnoea appears ; the pulse is aeccderated : even- ing and morning exacerbations of temperature are observed : the ehild rapidly loses strength, becomes much emaciatcal from ju’ofuse diarrha'a, and eventually dies of exhaustion. Yet cases ])resenting all the symptoms of chronic peritonitis have been knoAvn to recover, the effused fluid and other products of inflammation being gradually removed by absorption. PERITONITIS. 569 Diagnosis. — When ascites is the only symptom, it will be necessary to dif- ferentiate between an effusion due to simple chronic peritonitis and one caused by obstruction to the portal circulation. The latter condition is comparatively rare in childhood, whether it be due to cirrhosis of the liver or adherent pericardium and mediastinitis ; and the chances are immensely in favor of the presence of a chronic peritonitis. The ascites due to cardiac disease can be eliminated by careful e.xamination of the heart. Since, in the beginning of the disease, the symptoms simulate those of chronic intestinal catarrh, one must be careful to distinguish between this affection and chronic peritonitis. Tlie differential diagnosis between chronic and tubercular peritonitis will very often be impossible. The point of greatest value, however, is the general state of the patient : in the simple form the general nutrition and well-being of the child suffer but little as long as digestion is not greatly disturbed nor the effusion overwhelming ; while in the tubercular variety the early emaciation is striking. Search for bacilli in the effusion, even in tubercular cases, is often disappointing, and hence a negative finding does not exclude the more serious disease. Prognosis. — This must be guarded, for, while most cases are decidedly unpromising, a certain proportion recover. The history and progress of a given case must give us the cue. Treatment. — As the disease usually begins with an intestinal catarrh, our treatment must be directed toward that condition. The child must be placed under the best hygienic surroundings. Plenty of sunlight and, when possible, country air or a sojourn at the seashore, are to be insisted upon. The clothing should be carefully regulated to meet the exigencies of the case, the weather, and other external conditions ; and a flannel bandage must be constantly worn about the abdomen. The patient should be kept at rest, and it is a good plan, in the warm weather, to wheel his couch into the open air as often as possible. The diet should be bland, but nutritious. Moderate quantities of under- done chops or steak, fish, fowl, and eggs are all allowable; so also are milk and cream if they do not disagree, but starchy foods are better avoided. Abdominal pain may be relieved by hot opium fomentations or inunctions of belladonna ointment; when these fail or in protracted cases, blistei’s or stimulating liniments, tincture of iodine, compound iodine ointment, and iodide of potas.sium ointment are useful applications. Frequently in these cases the application to the abdomen of a mild mercurial preparation, such as an oint- ment of the yellow oxide of mercury, about twenty grains to the ounce, will do good service. In the way of medicines the mineral acids and preparations of pepsin are useful as aids to gastric digestion ; and to combat the intestinal catarrh, bis- muth, sulpho-carbolate of zinc, the bitter vegetable tonics, and alkalies should be administered. The internal use of iodine is also beneficial. This may be administered in the form of iodide of potassium in guarded doses, which must be discontinued on the first indication of disordered digestion ; but a preferable form is the syrup of the iodide of iron, in doses of from five to thirty drops, according to the age and tolerance of the patient, several times daily. I usually order it to be given in cod-liver oil, which is convenient and efficacious. If the ascitic effusion shows no tendency to disaj)pear by absorption, tapping by means of a very small trocar and canula should be resorted to, the fluid being allowed to drain away very slowly. It has been advised that during the first few weeks the fluid be drawn off once in twenty-four hours, the amount varying in quantity from one to two pints; then every two, every three days. 570 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN and, finally, once a week. Gradual improvement, it is said, usually takes place under this treatment. When the disease has defied every method of treatment, especially if the fluid returns quickly after repeated tappings, permanent drain- age of the peritoneal cavity has been recommended. If pus be present, incision and drainage should be practised. Recently coeliotomy and washing out of the peritoneal cavity have been advocated by some surgeons as a routine treatment. In some instances it may even be justifiable to perform an exploratory opera- tion. However, in those chronic cases in which the symptoms are not urgent and the child is not failing, it will be the part of wisdom and prudence not to interfere surgically, but to wait on nature’s efforts, supplemented by medical measures, to effect a restoration to health. m. Tumors of the Peritoneum and Omentum. Tumors of the peritoneum and omentum, though rare in children, are occa- sionally met with. Carcinoma of the peritoneum has been encountered in early childhood and even in foetal life. It may be primary, and then is often congenital, but it is much more commonly secondar}". Scirrhus is the usual variety, and generally occurs in diffused nodules. The primary form is difficult to detect; the second- ary, much less so, because its presence Avill be suspected when symptoms refer- able to the peritoneal cavity occur in the course of cancerous invasion of some other portion of the body. Sarcoma of the peritoneum has also been met with in childhood, but it is of very rare occui’rence. This variety of neoplasm may grow to such an extent as to involve the omentum, mesentery, and other parts in addition to the peritoneum ; in fact, both carcinomatous and sarcomatous growths are apt to involve both peritoneum and omentum. Lipomata may also grow from the peritoneum. They are encapsulated, and have no connection with any other organ. Serous cystic tumors of the peritoneum also occur. These cysts are com- posed of pseudo-membrane, which during their evolution and organization in- cludes a portion of the fluid exudation and receives an internal serous invest- ment; they are attached to the peritoneum either by means of a thin neck or by a broad base. Cystic tumors of the peritoneum are difficult to detect, and must be differentiated from cysts of the omentum, from cysts of the various abdominal viscera, and from ascites. Tumors of the omentum are quite rare in early life. Omental cancer is usually of the colloid variety, and it may grow to an enormous size. Carci- noma, however, is seldom limited to the omentum, the ])eritoneum being usually involved simultaneously. Again, when scirrhus invades the ])eritoneum the omentum usually suffers from the same disease. Cysts and hydatid tumors of the omentum are met with in children, the former not infrecinently. The cysts are usually dermoid in nature, though sini])le serous cysts are encountered. Both varieties, but especially the dermoid, may suppurate. S3maptoms of all varieties of tumors, whether involving the omentum or the peritoneum, or both, are rather vague, particularly in their incipiency. Later, when they have grown larger, the so-called prcssnrc-sym))toms develop and aid us in making a diagnosis. Even then it is very difficult to make a correct differential diagnosis, the pressure-symptoms chiefly aiding in locating the site of the tumor, without throwing light uy)on its character. Cancer of the peritoneum and omentum ))roduces the signs of a diffuse, more or less acute peritonitis with efl’usion, the so-called cancerous ])eritonitis. PERITONEAL TUMORS AND ASCITES. 571 In the earlier stages of the disease the patient will complain of paroxysmal pain, which later will be more persistent. Lipomata are attended by no spe- cial symptoms beyond the growth of a painless tumor. Growths confined to the omentum are movable and occasion no functional disturbance of the intes- tines. In cystic tumors, either of the omentum or peritoneum, the abdomen is apt to be enlarged; if the tumor be superficial, it will be movable on palpa- tion and give signs of fluctuation, which must be distinguished from the fluctu- ation of ascites. If the patient live long enough and the growth attain the proper size, true ascites will supervene. Pain, of course, will be most promi- nent in the cases of cancerous tumors. In time, whatever may be the nature of the tumor, but particularly in the cases of carcinoma, the general system suffers, nutrition is impaired, the patient is easily fatigued, his appetite fails, and, if the growth cannot be removed, a cachectic condition develops which at last terminates in death. Prognosis is most favorable in cystic tumors, less so in lipomatous and hydatid growths, and fatal in the carcinomatous. Treatment of cancerous tumors consists mainly of palliation of symp- toms. Anodynes and opiates to control the pain are indicated, and, if the ascites become burdensome, paracentesis is to be performed. Attention to the general condition of the patient, sustaining his strength with good food and tonics, together with the observance of well-established hygienic principles, will embrace all that can be done for these unfortunate suft’erers. Operative measures are not to be advised in these cases. Operation, coeliotomy, has been more successful in cases of sarcoma, lipoma, hydatid growths, and particularly in cystic tumors. Cystic tumors may be ex- cised or they may be aspirated and drained. As drained cysts are apt to refill, the radical operation, excision, is to be preferred, and it must always be resorted to when suppuration takes place. The proper treatment for pressure-symptoms will be suggested by their characters in individual cases. IV. Ascites. Ascites is an accumulation of fluid — usually serous — within the peritoneal cavity ; occasionally chylous ascites occurs, but in children this variety is extremely rare. Essentially considered, ascites is not a disease. It is a symp- tom of either general dropsy or some local disease of the abdominal viscera, and consists of a transudation of liquid into the peritoneal cavity in conse- quence of disturbed circulation in the liver or of pressure exerted upon some portion of the portal circulatory system. Etiology. — The most common cause of ascites in children is cirrhosis of the liver, which, in turn, is most frequently due to syphilis. It may also arise from a simple osmosis of the watery constituents of the blood, in which case it is but a local expression of a general hydrmmia superinduced by some cachexia, and it is then often associated with hydrothorax or general anasarca. Again, it may result mechanically from an obstruction to the venous circulation caused by cardiac, pulmonary, or peritoneal disease. Neoplasms of the abdo- minal cavity, whether malignant or benign, and particularly lymphatic tumors situated in the hilum of the liver, will also cause it by mechanical interference with the circulation in the viscera. Bright’s disease and acute nephritis ; organic heart disease ; atelectasis pul- monum and emphysema; enlargement of the spleen and profound anmmia caused by malarial poisoning; the pressure of lardaceous lymph-glands upon 572 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. the portal vein and inferior cava; and occasionally chronic tubercular perito- nitis, which interferes with the circulation in the peritoneum, — are other etio- logical factors. Interstitial nephritis is not so apt to cause an ascites as a general anasarca. Benign tumors in the abdominal cavity are exceptionally accompanied by ascites, malignant tumors constantly. Pathology. — The pathology of ascites is comprehended in the lesions involved in the primary affection. The changes in the peritoneum itself are slight and inconstant. Sometimes this membrane has simply a reddened appearance, but not infrequently it is pale and devoid of any signs of inflammation. Symptoms. — The constitutional disturbance attending the formation of an abdominal effusion usually passes unnoticed, but it may be ushered in with chil- liness, nausea, headache, vomiting, colicky pain, or a brief, intermitting diar- rhoea. Pain is absent unless the effusion is caused by jieritonitis. When effusion has reached a certain point, the tenseness of the abdominal walls is apt to cause indigestion and irregularity of the bowels; the skin becomes dry and has an ashen or clayey look ; and the navel protrudes and may be encircled by a plexus of dilated veins, termed “ caput Medusae.” In very large effusions the skin of the abdomen becomes stretched and glistening, and at times fine white striae, similar to those which are ol)served upon the abdomen of a ])regnant Avoman, make their appearance. The character of the pulse depends upon the primary disease ; still, it is generally feeble and easily compressed. Provided no inflammatory disease coexists, the temperature is normal. The urine is variable in quantity, though usually diminished; then it is high in color, and may contain albumin and fibrinous casts. As a result of mechanical interfer- ence Avith the return circulation from the loAver extremities ascites is very fre- quently attended by oedema of the feet and ankles. Large effusions, croAvding against the liver, spleen, and kidneys, and forcing the diaphragm up to the second and third ribs, cause anaemia of these organs and collapse of the base of the lungs, Avith consequent general anasarca. Finally, painful and difficult micturition or incontinence of urine, together Avith difficulty in evacuating the bowels, Avill ensue. The constant croAvding upAvard of the diaphragm and liver causes dyspnoea, hydrothorax supervenes, and at last the child, unable longer to assume a horizontal position, dies either from asthenia or asphyxia. Physical Examination. — Palpation and percussion reveal fluctuation indicative of the presence of fluid, Avhich varies in position according to the postui’e assumed by the patient. Thus, Avhilst standing, the abdomen is largest in its lowest part ; Avhen prone it spreads laterally, and if the patient be turned on either side it falls toAvard the more dependent. In any of these positions percussion ])ractised over the uj)permost part of the abdomen, to Avhich the gas- containing intestines ahvays float if entirely free to move, gives a clear tyni])an- itic note, and by successively altering the patient’s posture the tympany readily moves from point to point, Avhile the dulness due to the fluid also changes its place. Wave-like fluctuation is another valuable sign. Diagnosis. — The diagnosis of ascites is comparatively easy, yet it must not be forgotten that in children other conditions are often encountered Avhich produce an enlargement of the abdomen. Naturally, the smaller the effusion the more difficult is it to make a diagnosis. When the abdomen is distended by a sufficiently large amount of fluid, Avave-like fluctuation and movable dulness can readily be obtaiiu'd, and haive no doubt of the diagnosis. Small effusions, although ahvays obscure, are most readily detected Avhen the patient sits or lies on one side. In addition to detecting the presence of ascites, it is necessary to determine PERITONEAL TUMORS AND ASCITES. 573 the nature of the antecedent disease, as upon this prognosis depends. When tile fluid is large in amount and movable, atrophic cirrhosis of the liver may be suspected. If the eflusion be small and immovable and loculated, the cause is most probably tubercular jieritonitis. This disease is chai’acterized by the presence of disseminated nodules, and its sym|)toms are tenderness upon pres- sure, pain, and fever, possibly conjoined with indications of tubercular disease in some other organ. Prognosis. — Though not always a hopeless condition, the prognosis is not very encouraging. Provided the primary cause upon which the ascites depends be removable, as in malaria or alcoholism, and the liver is not completely invaded by the disease, we may hope, by removal of that cause and by proper treatment and hygiene, to effect a cure of the abdominal dropsy. Treatment. — In the milder degrees of ascites treatment consists in the administration of diuretics, diaphoretics, and hydragogue cathartics. Acetate of potassium, combined with digitalis and compound spirit of juniper, acts fav- orably. A very efficient combination is the following : I^. Magnesii sulphat Potassii bitartrat dd 5ss. Aquae cinnamomi f5iii- — M. Sig. A tablespoonful every three or four hours, according to its effect upon the bowels. When great general anasarca coexists with the ascites, threatening inter- ference with respiration and circulation, in addition to the free purgation hot vapor baths are to be recommended. These may be applied in the following manner: The patient, completely divested of clothing, is laid upon a blanket, and immediately several bricks, which have been in the mean time thoroughly heated by immersion in pails of hot water, and then enveloped in flannel cloths, are placed at the shoulders and feet. Care must be taken that they be neither too hot nor put too near the body, lest the skin be scorched. Another blanket is then thrown over the patient. The upper corners of the superim- posed blanket are brought over and tucked under the opposite shoulders, while the other end of the upper blanket, with the lower end of the underlying one, are lapped together under the heels of the patient, and the head alone is left to protrude from this improvised sack. This hot pack is maintained for at least twenty minutes, producing profuse diaphoresis and usually greatly amelio- rating the symptoms. The patient and his friends are apt to complain loudly of this heroic treatment, but I can recollect several instances where by its use the child was saved from imminent death ; and often it will accomplish the end sought when all other measures have failed. A strict milk diet is to be enjoined as a rule. When, however, hydrgemia is prominent, iron, tonics, nutritious food, and good air, with a proper obser- vance of all recognized hygienic rules, are indicated. In ascites depending upon atrophic hepatic cirrhosis squills, digitalis, calomel, and iodide of potas- sium will be of service. In this variety, however, the ordinary diuretics usually have but little effect. Here Basham’s iron mixture is highly spoken of — viz. : I^. Tinct. ferri chlorid Acid, acetic, dil dd foj. Liq. ammonii acetat. . f,5vi. Aqum q. s. ad f^vj. — M. Sig. Tablespoonful three times daily for a child of six years. 574 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. If, despite this treatment, the fluid continues to accumulate, paracentesis abdominis must he practised. This operation should not he performed too soon, nor should we delay it to the last moment. The proper time is when remedies fail after a fair trial and when, in spite of treatment, the patient’s general health daily deteriorates. Ordinarily this operation is simple and free from danger. Either an aspirator or fine trocar and canula may he used, hut I prefer the latter. This tapping can he repeated as often as the exigencies of each particular case may require. If fluid reaccumulates within three or four days, a retapping should be postponed as long as possible ; if, however, a num- ber of weeks elapse before the peritoneal cavity is refilled, the operation may he correspondingly deferred to that time. Permanent drainage by means of a rubber tube under proper antiseptic precautions has been highly commended by Dr. A. Caill^, whenever, after one or two tappings, the ascitic fluid rapidly reaccumulates. When all other meas- ures of treatment are futile, this method of permanent drainage should be utilized. While the operation of paracentesis is very trifling, every antiseptic pre- caution should be employed. In order to produce local anaesthesia a hypoder- matic injection of three to five minims of a 2 to 4 per cent, solution of cocaine may be made at the proposed point of operation, or the same result may be obtained by the rhigolene spray or the application of ice and salt. The linea alba, below' the umbilicus, is the usual point of election except for loculated effusions. In the latter case, as distended veins ramify extensively over the abdominal wall, caution must be used not to wound any of them with the trocar. As the fluid escapes pressure is kept up by means of a many-tailed bandage: this lessens the risk of syncope and secures a thorough evacuation of the fluid. If the puncture has been made at the side of the abdomen, the patient must lie on the opposite side for some little time, so that the wound may cicatrize properly. This will obviate the occurrence of a fistula, a sequel which w ill prove a source of great annoyance to the patient, inasmuch as leak- age soils the clothing and provokes cutaneous inflammation. CONGENITAL INTESTINAL MALFORMATIONS AND DISEASES OF THE ANUS AND RECTUM. By henry R. WHARTON, M. D., Philadelphia. I. Congenital Malformations of the Intestines. Congenital malformations of the small intestine are met with much less frequently than those of the rectum and anus ; in the Vienna Foundling Hos- pital only 9 anomalies of this nature were found among 150,000 infants. The malformation may consist of a stenosis or atresia of the gut ; or the bow’el may terminate in a cul-de-sac at the point of obstruction, and beyond this point again begin in a cul-de-sac, the remaining portion of the intestine being well developed ; or the bowel may have a diverticulum given off which attaches it to the abdominal walls, and this may contain a fistula opening upon some portion of the body ; or, finally, the defect may consist in an abnormal shortness of the intestinal canal. Holmes mentions two cases of congenital occlusion of the small intestine in which the diagnosis was satisfac- torily established, and Dr. W. Craig reports a case of congenital malformation of the small inte.stine in a child who lived seventy-two hours, and in whom the autopsy show'ed an obstruction of the small intestine at the upper fifth of the ileum. The intestine in this ca.se was distended above the point of obstruc- tion, and upon opening the bow’el it w'as found that it ended in a cul-de-sac ; further examination of the gut beyond the point of obstruction showed that the intestine began in a cul-de-sac, and the intervening space betw^een these two pouches was occupied by a band of fibrous ti.ssue. The most frecjuent position of congenital occlusion of the small intestine is the duodenum near the point at which the biliary duct and pancreatic duct open, or at the point where the duodenum becomes jejunum under the transverse mesocolon. Malforma- tions of the ileum are most common near the ileo-cfecal valve, or a short distance above it, where the ductus omphalo-mesentericus is given oft'. Among the congenital malformations of the small intestine may be mentioned that condition knowm as Meckel’s diverticulum, which consists in a cylindrical or flask -shaped appendage attached to the ileum a metre or more above the ileo- csecal valve, and is a remnant of the omphalo-mesenteric duct. Another form of this defect consists in the presence at the umbilicus of a reddish tumor covered with mucous membrane, which has been described as a umrty tumor of the umbilicus, congenital mucous polypus of the umbilicus, and as adenoma of the umbilicus. Congenital malformations of the large intestine are also of infrequent occurrence, but may involve the colon, the sigmoid flexure, or the rectum. The malformations of the large intestine may consist of an occlusion of the 570 AMERICAN TEXT-BOOK OF DISEAHEB OF CHILDREN gut at any portion of its length ; or the gut may exist in a rudimentary condi- tion. The latter defect is most apt to be associated with Meckel’s diverticulum, with a fyecal fistula between the ileum and the fissure above the umbilicus, or with a fiecal fistula between the small intestine and some portion of the abdominal walls. Atkin I’eports the case of a child who died two days after birth, and in whom, upon autopsy, the rectum and colon were found to be in a rudimentary state, smaller than an ordinary quill ; in this case the parts had remained in the condition in which they exist in the early embryo. The various congenital malformations of the small and large intestine are probably largely to be attributed to accidents in development due to a com- plicated disposition of the intestinal tract of the embryo ; and it is also likely that foetal j)eritonitis plays an important part in the production of these deformities. Theremin is of the opinion that many of these anomalies are due to clianges in tlie peritoneum Avhich have taken place early in foetal life. Symptoms. — The symptoms arising from congenital malformations of the large or small intestine are simply those of intestinal obstruction in a more or less marked degree, which depends upon the completeness of the occlusion ; and all observers are agreed as to the absence of any definite symptoms accurately localizing the seat of the lesion. The vomiting of whitish mucus, with ob- struction of the bowels, in the case of a new'-born infant, points to an occlu- sion high up in the small intestine, and if the obstruction exists in the jejunum or ileum, this may be I'eplaced by the vomiting of meconium. In such a case the symptoms would in no wise differ from those consequent upon the presence of an occlusion situated in the region of the rectum or anus. If a fiecal fistula is present, the symptoms of obstruction will not be so marked, and the position of the fistula may serve as a guide to the situation of an intes- tinal malformation. Diagnosis. — As before stated, the localization of the lesion is often most difficult. In a newly-born child who presents swelling of the belly with vomiting and obstruction of the bowels, the anus and rectum should first be examined to exclude the possibility of malformation of these parts; a soft catheter should be passed into the rectum, and if, upon injecting water, meconium is brought away, it can be inferred that the obstruction exists at a higher point of the intestinal canal. Prognosis. — The prognosis is always unfavorable : complete occlusions of the duodenum or of the high portion of the jejunum must necessarily prove fatal in a short time ; but when the obstruction is incomjdete or occupies a position low down in the small intestine, or if associated with a fixical fistula, the patient may survive for sometime, even for years. Comj)lete occlusions are usually fatal within a few days unless relieved l)y ojierative treatment. Treatment. — In cases of complete ol)struction operative treatment must be resorted to j)romptly. U}> to tlie present time the results obtained have not been encouraging; but with the improved techniejuo of abdominal opera^ tions more favorable results may be looked for in these cases. As before stated, tlie diagnosis of the seat of the lesion is often inqiossible; but as in cases of complete occlusion the result is necessarily speedily fatal, it seems wise to attenqit an exploratory operation with the hope of affording relief or hring- ing about a cure. A median laparotomy, unless there is some definite symp- tom present which points to the exact seat of the obstruction, should be the operatioti selected. If upon opening the abdomen the occlusion is found situ- ated in the duodenum or high up in the jejunum, the case must bo abandoned as hopeless, unless it be found jiossible to excise the occluded jiortion of the bowel and bring the ends together by sutures (circular enterorrajihy), or to make PRACTICAL POINTS IN NURS- ING. For Nurses in Private Practice. By Emily A. M. Stoney^ Graduate of the Training -School for Nurses, Lawrence, Mass.; Late Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely illustrated. Cloth, $1.75 net. SECOND EDITION, REVISED. The author explains, in popular language, the entire range of private nursing as distinguished from hospital nursing, and the nurse is instructed how to meet the various emergencies that arise. A valuable feature of the work will be found in the directions for improvising everything ordi- “ There are few books intended for non-profes- sional readers which can be so cordially endorsed by a medical journal as can this one.*'^T/iera~ peutic Gazette, **Awork that the physician can place in the hands of his private nurses with the assurance of benefit .” — Ohio Medical Journal. narily needed in the sick-room. The Appendix contains much information of great value to the nurse, including Rules for Feeding the Sick; Recipes for Invalid Foods and Beverages ; Dose- list ; and a complete Glossary of Medical Terms and Nursing Treatment, ^ ^ ^ ^ STONEY'S NURSING A Text-Book of DISEASES OF WOMEN. By Henry J. Garrig;ues, A.M., M.D., Profes- sor of Gynecology in the New York School of Clinical Medicine ; Gynecologist to St. Mark's Hospital, New York City. Octavo. 728 pages; illustrated. Cloth, $4.00 net ; Sheep or Half Morocco, $5.00 net. SECOND EDITION, REVISED. GARRIGUES' DISEASES OF WOMEN The first edition of this work met with a most appreciative reception by the medical press and profession both in this country and abroad, and “One of the best text-books for students and practitioners which has been published in the English language. — Thad. A. Keamv, Professor of Clinical Gynecology y JSIedical College of Ohio, was adopted as a text-book or recommended as a book of reference by nearly one hundred col- leges in the United States and Canada. The author has availed himself of the opportunity “ One of the few really good books on gyne- cology for the general practitioner.” — New York Medical fournal. afforded by this revision to embody the latest advances in the treatment employed in this im- portant branch of medicine. v't MALFORMATIONS OF THE RECTUM AND ANUS. 577 an attempt to establish the continuity hy the procedure known as lateral intes- tinal anastomosis. If the occlusion is due to a membranous septum, this may be exposed by incising the gut, and after it has been perforated or cut away the intestinal wound should be united by Lenibert’s sutures and the abdominal incision closed in the usual manner. If the occlusion exists low down in the small intestine or in the large intestine, circular enterorraphy or lateral anas- tomosis may be employed, or an artificial anus may be made by bringing the gut to the abdominal wound, securing it there, and opening it. This latter procedure would seem to be the wiser one, as it requires much less time to accomplish it, and if the patient survives, after he has attained some age an attempt may be made to establish the continuity of the intestinal canal by lateral anastomosis. If a faecal fistula is present and there are no marked symptoms of intestinal obstruction, no operative treatment should be insti- tuted ; but if the patient exhibits symptoms of intestinal obstruction, the fis- tula should be dilated or incised, and, if relief be obtained, further operative treatment should be postponed until a later period. n. Congenital Malfoemations of the Rectum and Anus. Congenital malformations of the rectum or anus occur, according to various observers, in the proportion of 1 case in 10,000 births. Pathology. — These malformations result from arrested development of the parts in early foetal life. At its earliest commencement the alimentary canal consists of a simple sac or bag developed from the innermost layer of the blas- toderm, partly within and partly without the body ; and as development pro- ceeds this communication between the two portions of the sac is shut off, and the portion within the abdomen consists of a simple tube, the mesenteron, which terminates at the anterior extremity of the embryo in a blind pouch, while at the posterior extremity a similar pouch is formed. The cul-de-sac 78 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. ureter, vagina, or urethra opens into the rectal cavity ; 8. The rectum is totally absent. 1. Congenital Narrowing of the Rectum or Anus, without Com- plete Occlusion. — This variety of malformation is probably more common than is generally supposed, as it escaj)es notice if the narrowing is not sufficient to produce marked .symptoms of obstruction ; and probably in many cases of this nature, in which the stenosis is not extreme, the efforts of the child in passing the faeces bring about the necessary amount of dila- tation. As the stenosis may not be sufficient to prevent the escape of the semifluid fmces of infant life, the condition may not be detected for some time, and it is only as the child becomes older and the faeces become more consistent that accumula- tion takes place in the rectum and attention is directed to the malformation (Fig. 1). Treatment. — The treatment of this variety of congenital stenosis is best conducted by gradual dilatation, which may be carried out by the daily introduction into the bowel of graduated bougies, or by the introduction of the oiled index finger of the mother or the nurse, which is by far the best of all bougies for this purpose. 2. Complete Occlusion of the Anus by Membranous Diaphragm or by Well-formed Skin. — In this form of malformation closure of the anus may be caused by a diaphragm of mucous membrane or skin, which appears to be due to the adhesion or skinning over of the surface of the anus, tlie rest of the proctodreum being normally formed (Fig. 2). Treatment. — The treatment consists in making a cru- cial incision at the position of the anus, opening the rectal pouch, and evacuating the fmces and trimming off the edges of the mucous membrane and skin. The wound should be dusted with iodoform and dressed with a pad of antiseptic gauze, and the subse(juent management of the case consists in keeping the anus well dilated for some time to prevent cicatricial contraction. 3. The Anu.s i.s Absent, and THE Rectum ends in a blind pouch at a point more OR LESS distant FROM THE PERINEUM. — Til this variety of malformation tlie rectal poucli may terminate near the skin, or it may end high up in tlie pelvis and the space between it and the perineum be filled with cellular tissue, or in other cases a distinct fibrous cord can be traced from the The Anus is absent, and termination of tho rectum to the skin (Fis;. 3). Blind Pouch (after Ball). Treatment. — In the treatment ot this maltormation — and, in fact, of all forms of imperforate rectum in which complete occlusion exists — the duty of the surgeon is very clear ; he should, as soon as po.ssible, attempt to reach the rectal pouch by a perineal incision. The earlier this is attempted the better, for delay in operating certainly con- duces largely to a fatal result. 1 cannot sub.scribe to tho opinion of those who advise delay until the rectum is distended with ficces and gas, which may make Fig. 3. Fig. 2. Complete Occlusion of the Anus by Membran- ous Diaiihragm or Skin (after Ball). Fig. 1. Congenital Narrowing of the Rectum and Anus. 3IALF0BMATI0NS OF THE RECTUM AND ANUS. 579 the position of the rectal pouch more apparent, but which is not unattended with the risk of rupture of the intestine and exhaustion of the patient ; and it has also been shown that by delay the meconium becomes reduced in bulk through the absorption of the fluids. It should be remembered that the rectum in infants descends in the hollow of the sacrum and is close to the bone, and except at its upper portion is uncovered by peritoneum posteriorly ; in front its peritoneal investment descends to a much lower level, and its close relation in tins aspect to the genito-urinary tract is an additional reason for the selection of the posterior region for exploratory operation. Various operative measures have been recommended and resorted to in cases of imperforate rectum. Puncture ivith a Trocar Canula . — The introduction through the perineum of a trocar and canula was formerly advised, and by its use 1 have seen the rectum reached and meconium evacuated ; but subsequently it is usually found necessary to enlarge the wound made by the instrument to secure free exit of faecal matter, so that the procedure possesses no advantage over the perineal incision, and has the disadvantage that the rectal pouch may be entirely missed by the trocar and important structures injured by its blind introduction. Perineal Operation . — This is considered the best operation to undertake in these cases, since, if successful, it leaves the patient with an anus in the normal position, and often with fair control of the bowels, for the anal sphincter is frequently well developed in spite of the malformation of the rectum. In per- forming this operation the child should be placed in the lithotomy position, and the incision should be made in the median line of the perineum from the root of the scrotum to the coccyx. The tissues should be divided slowly, any bleeding vessels being secured as they are met with. The surgeon should explore the w'ound with the finger during the operation, to discover, if possible, the bulg- ing of the rectal pouch, and should be careful to make the deepest incisions posteriorly. In a female infant the finger introduced into the vagina during the operation may give the surgeon some information as to the position of the rectum ; or if the mass of fibrous ti.ssue in which the rectum sometimes ter- minates is seen or felt, it may serve as a guide to the position of the rectal pouch. Nearness of the tuberosities of the ischium is a sign of absence of the rectum ; and if it is found that the vagina or bladder fills up the concavity of the sacrum, it is an indication of a high termination of the rectal pouch. The incisions may be carried with safety to the depth of an inch and a half or two inches, and when the rectal pouch is reached it should be incised. After the meconium has escaped the wound in the rectum should be sufficiently ■enlarged, and, if possible, its edges should be brought down and sutured to the skin of the perineal wound, care being taken in passing the sutures and in introducing a drainage-tube to leave no pocket around the bowel for the accumulation of discharges. The suturing of the edges of the bowel to the skin is a most important procedure, and one which diminishes largely the amount of contraction in the neAvly-formed anus ; it may, however, be found impossible to bring down the edges of the rectal wound to the skin in cases where the rectum terminates high up in the pelvis. In such cases a large flexible catheter or a metallic tube may be introduced and held in place by tapes ; but it is difficult to keep it in position, as it is apt to be dis[)laced by the straining efforts of the child. Verneuil has suggested excision of the coccyx in the early part of the operation, which facilitates the search for the gut, and in case it is found this procedure enables the surgeon more readily to attach the edges of the rectal pouch to the skin. The dressing of the wound should consist in dusting the parts with iodoform and applying a pad of anti- septic cotton, to be held in position by means of a T bandage. 580 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. When tlie surgeon lias carried his dissection up into the pelvis as far as he considers it is safe, an inch and a half or two inches, and has failed to reach the rectal ])ouch, he should then consider the advisability of abandoning the attempt to reach the gut through the perineum, and should endeavor to open the intes- tine either in the left groin (Littre’s operation), or in the left loin behind the peri- toneum (Amussat’s ojieration), or in the right groin (Huguier’s operation). Of these operations, that in the left groin is to be recommended, as it opens the bowel near its natural termination. If the surgeon decides upon this operation, he should make an incision from one and a half to two inches in length, half an inch above and parallel with Poupart’s ligament, beginning at a jioint opposite the junction of the middle with the outer third of this structure. Or an incision suggested by Ball, following the line of the linea semilunaris, stojtping just short of Poupart’s ligament, may be substituted for the former incision. The skin and muscular layers being cut through, the fascia transversalis and peri- toneum may be pinched up together, and a small opening made in them, through which a director should be passed, and the two can then be divided with one incision. It is sometimes difficult to determine whether the bowel presenting in the wound is the small or large intestine ; this can be ascertained by gently drawing out a coil : if it be the small intestine, it can be drawn out with ease, and the mesentery will show that it is not the portion of the bowel sought for, and it should be replaced. On the other hand, the large intestine cannot be so readily drawn out, and its mesocolon, if it have one, would be found attached to the left side. The bowel should ne.x;t be secureil to the edges of the wound by several sutures of fine silk or catgut, which should be intro- duced by passing a curved needle through the skin and parietal peritoneum near the edge of the wound, and then transfixing a portion of the bowel ; after which the needle .should be made to transfix the peritoneum and skin again, being brought out a short distance from the point of insertion ; the stitches should then be secured. Sutures should be applied in this manner on each side and at the extremities of the incision, after which the gut should be incised to a sufficient extent and the meconium allowed to escape. After the escape of the latter the wound should be carefully cleansed, and the edges of the gut incision may be attached to the skin by a few silk sutures. The surgeon may introduce the finger or a flexible rubber catheter into the opening in the gut to ascertain, if po.ssible, the point of termination of the rectal pouch ; and if it is found to be near the upper portion of the perineal incision, he may deepen the latter on a guide introduced through the artificial anus. It has, however, been found better to rest satisfied with the relief afforded by colotomy, and to post- pone for a time the attempt to form an anus in the perineal region, for the majority of cases in which this has been attempted have been followed by a fatal result. Attempts to acicomplish this result .some months after the per- formance of colotomy have been more satisfactory, iis is seen in cases reported by Byrd and Krbnlein. When the patient has attained some age, and an examination through the artificial anus in the left groin shows that the rectal pouch terminates well down in the pelvis, a director or rubber catheter may be introduced through the colotomv wound and made to enter the pouch, and project at the anus, if it be ju'esent, or at .some point of the perineum. This may then be cut down upon as a guide, and the gut may be opened and sutured to the .skin if the edges can be drawn down to that point. If the surgeoTi .should prefer to make an attempt to open the bowel in the left lumbar region, the best guide to the position of the colon is a line half an inch posterior to a point midway between the two su]>erior spinous processes of the ilium ; if he fails to find the large intestine, and distended small intestine MALFORMATJOm OF THE RECTUM AND AN UN 581 Fig. 4. shows itself in the wound, it is better to open this and stitch it to the wound, rather than to abandon the case and allow the patient to perish by intestinal obstruction. The results obtained by the various operations for the relief of the symp- toms due to imperforate rectum show that, in point of safety and as a matter of comfort to the patient, the perineal operation is to be preferred. Cripps has collected 100 cases of the various operations for the relief of imperforate rec- tum ; his table, although exhibiting a high rate of mortality, 50 per cent., shows that the largest number of recoveries followed the perinea! operation, and the next in number were those cases in which the colon was opened in the iliac region. The expediency of an operation for the establishment of an arti- ficial anus, either in the perineum or in the groin, in young children with impei-forate rectum, is evidenced by a number of Avell-attested cases in which the patient lived for years afterward in comfort. 4. The Anus is Normal in Appearance, but Ends in a Cul-de-sac, AND THE Rectum Ends in a Blind Pouch at a very little Distance ABOVE THIS Point. — In this form the anus and rectum may be separated by a membranous partition of greater or less thickness, oi- a portion of the bowel may be impervious, or there may be multiple obstructions, or the anal portion may communi- cate with the vagina in the female and the rectum end in a cul-de-sac (Fig. 4). The variety of malformation in which the anus is normal, but is separated from the rectum by a membranous partition of greater or less thickness, is not uncommon. It is apt to escape notice for some time, as the anus is normal in appearance, and it is only ivhen the nurse or mother notices that the child passes no faeces and the belly becomes swollen, or vomiting begins, that the nature of the trouble is suspected. The introdiiction of the finger or probe into the anus will soon reveal the nature of the trouble. An attemjit should at once be made to reacb tbe rectal pouch by an incision through the anus backward toward the coccyx, and if the gut be found it should be brought down and sutured to the edges of the anal wound. This jirocedure is much safer than puncture through the anus, which the surgeon might feel tempted to employ if the partition between the two cavities did not seem very thick. If it be found impossible, after a careful dissection in the perineal region, to find the rectal pouch, the surgeon should abandon this operation, and attempt to reach the gut by an incision in the left iliac region. Anus ends in a Cul-de-sac, the Rectum ends in a Blind rouch (after Mol- IRre). Fig. 5. 5. The Anus is Absent, and the Rectum Ends BY A Fistula at any point of the Perineum or Sacral Region. — The rectum may open at some portion of the perineum or sacral region, or it may terminate in a narrow channel under the raph^ of the perineum and open at the ]irepuce or at the symphysis pubis, or may end in several fistulm at different points (Fig. 5). Such patients may have satisfiictory evacuations through the fistuhv, and may live for months or years without sufl’er- ing much inconvenience from the deformity. Treatment. — If a child so suffering shows evidence of discomfort by reason of the fiieces not passing sufficiently freely through the fistula, this should first be dilated or increased in size by incision, and if relief Anus is absent ; Rectum ends by a fistula at the prepuce (after Ball). 582 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Fig. 6. from the symptoms be obtained, no further operation should be attempted as long as the child remains in comfort. When the patient has attained an age when a more radical operation can be undertaken, the fistula may be explored with a probe or director, and the position of the rectal pouch ascertained if possible ; if it be in a favorable position, a perineal opening should be made to reach the rectum, and when it has been found the bowel should be opened and its edges brought down and sutured to the edges of the perineal wound. The fistulous tract should be laid open or touched with the actual cautery, and allowed to heal by granulation. 6. The Anus is Absent, and the Rectum Ends in the Vagina, Blad- der, OR Urethra. — These malformations, according to the point of termina- tion of the rectum, are classified as atresia ani vaginalis, atresia ani vesicalis, and atresia ani urethralis. Leichtenstern’s statistics show that 40 per cent, of rectal malformations are of this nature. This tendency of the rectum to ter- minate in the genito-urinary tract is remarkable when we consider the definite separation which exists between the rectum and the genito-urinary tract in the adult : it is attributed by Ball to the method of development of the proctodaeum, or a tendency to reversion to the cloacal type of birds and lower animals. Atresia Ani Vaginalis. — In this form the rectum terminates in the posterior walls of the vagina, either by a small or large aperture. The opening may be situated immediately within the fourchette, or may be located high up in the canal (Fig. 6). If the rectal opening is sufficiently large, the patient does not exhibit any symptoms of intestinal obstruction, and the nature of the deformity is only ascertained upon inspection of the parts, when it is found that the anus is absent, and that fiecal matter escapes from the vulva. Treatment. — If the patient suffers no inconvenience, operative treatment maybe postponed until shehas attained some age, when the greater development of the parts will conduce to a favorable result. Operations for the relief of this variety are the most satisfactory in their results of all those that have been devised for the cure of congenital malformations of the rectum. When an operation is de- cided upon, the one which is followed by the best results is performed in the following manner: A director is passed through the vaginal opening into the rectum and is jnished backward, its point being made to project as near as pos- sible to the normal position of the anus; this is cut down upon from the ])or- ineum and the rectum is exjiosed and incised. The rectal wound being then sufficiently enlarged, the gut is dissected loose and its edges are brought down and secured to the skin by sutures. By this dissection of the rectum and bring- ing down of its edges, the opening into the vagina, if it be a low one, is oblit- erated. If a high opening into the vagina remain after the anus has been established in its normal ])osition, an operation may be undertaken later to clo.se this recto-vaginal fistula. An ingenious o]>eration, devised by Kizzoli, for the relief of this malformation is performed as follows: An incision is car- ried from the lower margin of the toward the coccyx, care bein of the rectum with its vaginal orilice is now abnormal anus is transplanted to its natural situation and secured in that posi- tion by a few sutures, after which the perineal and vaginal wounds are brought together by deep sutures. Atresia Ani Vcsicalis. — In this variety the rectum communicates with the Anus Ree- ls absent turn ends in the vagina- (After Ball.) vaginal anus backward through the jierineiim ^ taken not to ojien the intestine; the terniination vaginal orifice is now carefully dissected out, and the MALFORMATIONS OF THE RECTUM AND ANUS. 583 bladder, either by a narrow orifice near the base of the organ or by an open- ing near its fundus (Fig. 7). The absence of the anus and the escape of fiecal matter intimately mixed with urine at the time of urination would point to the nature of this very serious malformation. Treatment. — In the treatment a staff may be intro- duced through the urethra into the bladder, and an incis- ion made through the perineum into the neck of the bladder, as in lithotomy, and continued into the rectum. As the result of this operation the immediate symptoms of obstruction may be relieved, but the patient is left with a urinary and faecal fistula. Ball suggests a laparo-colot- omy, and, when the colon has been found, its complete division, with closure of the lower portion and the bring- ing out of the upper portion at the wound, and securing it in that position to establish an artificial anus. This operation, although attended with greater immediate risk, has the advantage of leaving the patient with control over his urinary excretion. Atresia Ani Urethralis . — In this form the rectum com- municates with some portion of the urethra, allowing the escape of a small amount of fecal matter, which passes more or less in the intervals between urination. The urethral opening is usually so small that feces cannot escape in sufficient quantity, and the symptoms of intes- tinal obstruction are soon developed (Fig. 8). Treatment. — The treatment consists in attempting to find the rectum by means of perineal incision, opening it, and bringing down the edges of the gut and suturing them to the skin. 7. The Anus and Rectum are Normal, but the Ureters, Vagina, and Uterus Open into the Rectal Cavity. — As this is a malformation in which occlusion of the bowel does not exist and life is not endangered by its presence, no immediate operation is called for. Where the ureters open into the rectum, no operative interference could be of any avail, but in that form in which the vagina or uterus opens into the rectum, and the child has attained some age, an operation to close the fistula and replace the oi’gans may be attempted. 8. The Rectum is totally Absent. — This differs from the third variety of malformation only in the amount of rectum which is wanting, and its exist- ence may be suspected in those cases in which an exploration of the pelvis by perineal incision fails to reveal the presence of the rectal pouch. This con- dition is to be treated by laparo-colotomy, in the left inguinal region, and the formation of an artificial anus. 9. The Large Intestine is totally Absent. — This condition is often associated with a fecal fistula at the umbilicus or some other portion of the body, and its treatment consists in securing a free exit of feces from this fistula by dilatation or careful incision, or by the formation of an artificial anus if no fistula be present. Fig. 8. The Anus is absent; the Rectum ends in the Urethra. (After Ball.) Fig. 7. Anus absent; the Rec- tum ends in the Blad- der. (After Ball.) 584 AMERICAN TEXT-BOOK OF DmEASEti OF CHILDREN. . ni. Diseases of the Anus. Prukitus Ani. This affection is occasionall}'^ seen in chihlhood, and is characterized by a painful itching in the region of the anus, which causes the child constantly to scratch the part, so that the skin in the vicinity becomes thickened, eczema- tous, and moist from exudation as a result of the constant irritation. Pruritus ani may result from various causes — from the presence of oxyuris vermic- ularis in the rectum, from eczema of the anus, from pediculi or scabies, or from the presence of a vegetable parasite, as is the case in eczema margina- tum. In other cases in which the itching is not attributable to any of the above-named causes it can often be traced to improper diet or chronic constipation. Treatment. — Where the condition can be traced to the presence of eczema, the parts should be frequently bathed with hot Avater and washed carefull}^ with green soap, and one of the folloAving lotions may be used : R. Acidi carbolici TTf-xx. Liquor, calcis f.P'j- — Or, R. Acifli carbolici f^ss. Glycerini f 5 j. Aquae (ps. adfsvj. — M. Or the following ointment may be ajiplied : 1^. Lng. picis liquidae ,^j. Uhg. zinci oxidi ,^iij. Ung. aqiue rosae .^iv. — M. When the itching can be traced to the j)resence of parasites, cither animal or vegetable, the tise of some of the antiparasitic lotions or ointments appro- priate for the individual case Avill rapidly effect a cure. Where the condition is dependent u])on errors in diet, a change of diet Avill often be followed by satisfactory results. Where the trouble arises from chronic consti})ation, a change of diet should be made and laxatives should be administered, or ene- mata or suppositories of glycerin should be employed. Syphilitic Affections of the Anus. Mucous patches and moist papules occur with comjiarative frequency in the region of the anus as the result of congenital syphilis. Allingham sj)eaks of numerous cracks or fissures of the mucous membrane of the anus in chil- dren suffering from hereditary syphilis. Condylomata may a))pear upon these syphilitic lesions: they are acuminateerforating ulceration of the mucous membrane of the rectum, or from an ischio-rectal abscess opening into the rectum or through the skin in the vicinity of the anus, and also from wounds involving the rectum or anus. Diagnosis. — This affection is usually not difficult to diagnose if the finger be introduced into the rectum and a probe passed into the external opening, when, by a little careful manipulation, the probe may be made to enter the bowel if the fistula be a complete one. In the incomplete form of fistula known as internal rectal sinus, careful palpation of the tissues surrounding the anus will often reveal an indurated mass of tissue which indicates the posi- tion of the internal fistula, and the finger introduced into the rectum may also feel the orifice of the internal opening ; while the discharge of pus with the stool points to the existence of this affection. In the form of incomplete fistula known as external rectal sinus, if the finger be introduced into the rectum and a probe passed into the external opening, it can be felt at some point to come near the wall of the bowel. In children it should be remem- bered that, in certain cases of disease of the bones of the spine, of the sacrum, or of the pelvis, the purulent matter passing through the connective tissue about the rectum may find its way to the surface and perforate the skin in the neighborhood of the anus ; or it may open into the rectum and escape by the 586 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. anus. A careful examination of the patient, however, will reveal the origin of the pus and show that it is not a case of ordinary fistula in ano. Treatment. — The treatment of this affection consists in the free division of all the tissues between the internal and external opening of the fistula, and is accomplished as follows: A director having been passed into the external open- ing of the fistula, the finger is introduced into the rectum, and when the point of the director is felt it is passed through the internal opening and brought out at the anus ; the superimj)osed tissues are then divided with a bistoury. The track of the fistula should next be carefully explored to discover the presence of any branching sinuses running off from it, and if these be found they should be freely laid open. The wound resulting should next be touched with the solid stick of nitrate of silver, or curetted, irri- gated with a solution of bichloride of mercury, and packed with strips of iodoform gauze ; this dressing should be changed at intervals of a few days, and the wound is to be allowed to heal by granulation. In cases of incomplete external fistula the director should be introduced into the external opening, and where its point comes in contact with the gut, guided by the finger in the rectum, it should be made to perforate, and its point brought out at the anus. The superimposed tissues are then divided, as in the operation for complete fistula. In the variety of incomplete fistula known as internal rectal sinus, the position of the fistula being located as before described, an incision should be made through the skin at this point, and a director introduced and made to enter the rectum, its end being; brought out of the anus. The sub- sequent treatment of the case diflers in no wise from that of the complete fistula. Another method of treatment in incomplete fistula of either variety is to lay the sinus freely open down to the bowel without dividing the sphincter, and to pack the wound with iodoform gauze : in this way a cure may often be brought about. In any case of fistula in which the internal communication is very high up in the rectum, and its division by the knife is considered unsafe by reason of the luemorrhage which may result, an elastic ligature may be introduced through the external opening by means of an eyed probe and brought out at the anus, after which the ligature is tied and allowed to cut its way out, and the wound resulting is treated like that following division of the tissues by the knife. Fissure of the Anus. Fissure of the anus is an affection in which there exists at some portion of the mucous membrane of the anus a small linear ulcer, which causes great j)ain at stool or after the bowels have been moved. This aftection is considered infre- quent in childhood, but I am of the opinion that its presence is not so unusual as is generally supposed, and feel sure that a careful inspection of the anal region in children who complain of pain at or after stool will often show its presence. Allingham and Curling mention cases which they have met with in quite young patients, and I have myself seen cases of this affection in children. K jellberg of Stockholm among 9098 children found 128 cases of fissure of the anus, 'fhe majority of these children were less than one year of age, and in 73 eases the patients were less than four months old. Jacobi thinks fissure of the anus a much more common affection in children than is generally siqiposed, and believes that many of the fretful children who sleep badly and cry constantly, and often present symptoms similar to those of vesical calculus, suffer froni' fissure of the anus. Diagnosis. — Fissure of the anus should be suspected in cases where pain is experienced during or after stool and where the stool contains a few drops of DISEA^SES OE THE RECTUM. 687 blood. In such cases a careful inspection of the part will usually reveal the presence of a fissure. The rectum should at the same time be examined with the finger for the presence of polypus, which frequently coexists with fissure of the anus. Treatment. — The treatment of this affection in children can generally be successfully accomplished by an application of a 20-grain solution of nitrate of silver to the ulcer, or by lightly touching the surface with the solid stick of nitrate of silver, and afterward keeping the parts well covered with an ointment composed of thirty grains of iodoform or aristol to the ounce of vaseline, the bowels being kept in a soluble condition. In cases which are found intractable division or stretching of the sphincter may be resorted to. Stricture of the Anus. This affection may be congenital or may result from an operation in the vicinity of the anus. The treatment of stricture of the anus consists largely in gradual dilatation of the contracted orifice, either instrumental or digital; if this fails to relieve the condition, a careful incision of the contracted parts should be practised, and subsequent dilatation should be employed for some time. Marginal Abscess. This affection consists in circumscribed suppuration starting in the mucous follicles of the anus, or from a fissure of the anal margin, and is a much more common and less serious affection in childhood than ischio-rectal abscess. Although painful, it is not apt to result in the formation of a fistula in ano. The treatment consists in making a free opening with a bistoury, and to accomplish this the tip of the finger should be passed into the I’ectum to steady the abscess-cavity and make it more prominent before it is incised ; the wound should then be dressed with iodoform gauze or with lint saturated with car- bolized oil, and usually heals promptly. Diphtheria of the Anus. This affection is occasionally seen in children suffering from diphtheria of the pharynx, and usually develops late in the disease and in cases in which the system has been profoundly impressed. The deposit of diphtheritic membrane may involve the anus and extend on to the buttocks, and to the mucous mem- brane of the vulva in female children. The prognosis is extremely unfavorable, and the cases which have come under my personal observation have all terminated fatally in spite of treat- ment. The treatment consists in the employment of such constitutional remedies as are appropriate for diphtheria, and the local application to the affected sur- face of a solution of bichloride of mercury, 1 : 2000 or 1 : 4000, followed by the use of an ointment of iodoform. rV. Diseases of the Rectum. Proctitis. Inflammation of the rectum, or proctitis, is an affection frequently seen in childhood. It may result from injury to the mucous membrane by the faeces or by materials contained in the faeces, or it may follow from traumatism received 588 AMERICAN TEXT-BOOK OF DISEASED OF CHILDREN from without. It is recognized in two forms — acute catarrhal and chronic catarrhal proctitis. Acute Catarrhal Proctitis . — In this affection the inflammatory symptoms are limited to the rectum, and the disease is characterized by great tenes- mus and the freciuent passing of bloody mucus, at first mixed with fteces. In addition to these symptoms there are usually present oedema of the mucous membrane of the anus and of the lower portion of the rectum, and vesical irritation ; and as a result of this condition and the constant straining there is often observed a partial prolapsus of the rectum. Many of the symptoms presented are those of acute dysentery, but the abdominal pain and the consti- tutional features of the latter affection are generally wanting. Treatment. — The patient should be kept in a recumbent posture, and small doses of castor oil or one of the saline cathartics, either sulphate of sodium or of magnesium, or one of the natural mineral waters, should be administered to secure free evacuation of the bowels. The diet should be restricted to milk, animal broth, and eggs. If, after the bowels have moved, tenesmus continues, an enema consisting of a few drops of tincture of opium and starch-water should be injected into the rectum ; or a rectal sup- pository containing powdered opium grain J, extract of belladonna grain iodoform grain 1, should be administered, and if the patient shows signs of exhaustion stimulants should be employed. The disease is usually of short duration, and under treatment the symptoms generally subside in a few days. Chronic Catarrhal Proctitis . — This disease usually results from the acute affection, and is characterized by the absence of pain and tenesmus, although in some cases in which ulceration of the mucous membrane of the rectum exists there may be discharged a small (juantity of blood and muco-purulent matter. Treatment. — The diet should be regulated as in acute proctitis, and if the evacuations are not sufflciently free the bowels should be moved by the adminis- tration of a saline cathartic. The local treatment should consist in the use of enemata of nitrate of silver, to 1 grain to an ounce of water, Avhich should be gradually increased in strength until they begin to cause pain ; suppositories of iodoform and extract of belladonna may also be emj)loyed with advantage. Periproctitis. Periproctitis is an inflammatory condition involving the connective tissue surrounding the rectum. It may result from septic causes or direct injury, or may arise from the introduction of foreign matter through ulceration or per- foration of the rectum. Abscess or gangrene of the cellular tissue may result, with subsequent involvement of the skin ; erysipelas also may attack this region, giving rise to erysipelatous periproctitis. Treatment. — In this affection, as soon as the swelling and induration can be detected, free incision should be made through the skin and into the cellu- lar tissue outside of the margin of the anus, and the wounds thus jiroduced irrigated with a solution of bichloride of mercury, 1 : 1000 or 1:4000, or touched with a solution of chloride of zinc, 15 grains to the ounce. The sur- faces then should be dusted with iodoform, and covered with a bichloride-gauze and cotton dressing. If the parts are found to be gangrenous, a charcoal or an antiseptic poultice should be applied, and the patient should be given alcohol and tonics with a liberal diet. ISCIIIO-RECTAL ArSCESS. Ischio-rectal abscess consists of a purulent collection in the loose cellular tissue surrounding the rectum. It is a most painful and serious affection, and DISEA8E.S OE THE RECTUM. 589 is the most frecjnent cause of fistula in ano. It may arise from injuries of the rectum, either from within or from without, from phlebitis or periphlebitis of the hsemorrhoidal veins, or from the escape of faecal matter into the cellular tissue through ulcers perforating the rectum. The most characteristic symp- tom of ischio-rectal abscess is a sense of fulness in the lower portion of the rectum, with throbbing pain, which is increased at the time of stool. Where this affection is suspected a careful examination of the rectum with the finger will often disclose a bulging of the rectal wall at some point, and this is often accompanied by swelling and oedema of the skin near the anus ; the presence of fluctuation in this region will often be revealed upon palpation. Treatment. — This form of abscess demands prompt and free opening, and by this treatment alone is the pain relieved and the risk of the formation of a fistula in ano avoided. In opening these abscesses I usually follow the practice of Allingham, who recommends that the patient should be etherized and placed in the lithotomy position. An incision should be made at a little distance from the anus parallel with the sphincter, the abscess-cavity laid freely open, and the finger introduced into the wound to break down any secondary cavities or loculi. If it is found that there has been much undermining of the tissues, incisions should be made at right angles to lay all cavities freely open. The abscess- cavity should then be irrigated with a solution of bichloride of mercury, 1 : 2000 or 1 : 4000, or with a 1 : 40 solution of carbolic acid ; and the wound should next be carefully packed with lint saturated with carbolized oil, 1: 30, or, as I prefer, with iodoform gauze. An external dressing of iodoform or bichloride gauze and a pad of bichloride cotton is then applied to the wound and held in position by a T bandage. This dressing need not be disturbed, uidess it become loose or soiled, for several days, when the cavity should be irrigated and a few strips of gauze laid lightly in it. The wound should he allowed to heal by granulation. If the bowels do not move in one or two days, a gentle lax- ative may be administered. By this method of treatment the cavity of the abscess rapidly heals, and a cure results without the formation of a fistula in ano. Ulceration of the Rectum. Ulceration of the rectum is not a common affection in childhood, but it sometimes results from chronic dysentery or chronic catarrhal proctitis. The treatment consists in the local use of injections of nitrate of silver, grain J to 1 to the ounce of Avater, and in the use of suppositories of iodoform. A restricted diet should also be enjoined, and the bowels should be regulated. Stricture of the Rectum. This affection may result from the presence of new growths, from the con- traction following wounds of this organ, the result either of accident or opera- tion, and also from congenital malformations of the rectum ; inherited syphilis is mentioned as occasionally causing congenital stricture of the rectum. The treatment consists in gradual dilatation of the rectum, either instru- mental or digital ; if the condition be due to the presence of growths, their removal should be accomplished if possible : and if due to inherited syphilis, antisyphilitic treatment is indicated, in addition to the local measures. Syphilis of the Rectum. Lesions of the rectum, due to inherited syphilis, are occasionally seen in childhood. A case of gummatous infiltration of the coats of the rectum in a child ten years of age, at the same time exhibiting well-marked symptoms of 590 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN inherited syphilis, has been described by Ball ; and Oser of Cracow has re- ported two cases of gummatous infiltration of the intestines in children suffer- ing from congenital syphilis. The treatment of syphilitic lesions of the rectum consists in the adminis- tration of mercury or iodide of potassium, as in the treatment of corresponding syphilitic lesions in other parts of the body. Prolapsus of the Rectum. Prolapsus of the rectum consists in the protrusion of a portion of the rectum through the anus, and occurs in three varieties: 1. A portion of mucous mem- brane protrudes from the anus (partial prolapsus) ; 2. The entire thickne.ss of the walls of the rectum is included in the prolapse (complete prolapsus); 3. There exists an invagination as well as a prolapsus of the rectum. This affec- tion in some one of its varieties is very common in childhood, and the frequency of its occurrence may be accounted for on both anatomical and pathological grounds. The looseness of the attachment of the submucous connective tissues of the walls of the rectum is a well-recognized anatomical fact; and this con- dition is an important factor in the production of prolapsus. The straightness of the coccyx in children is also said to favor its production. In infiints and young children the great amount of straining that seems to be required to bring about satisfactory evacuations is also productive of this affection ; this straining has been ascribed by Jacobi to the anatomical fact that in children it is not uncommon to find two or three angular flexures in the lower part of the colon. The habit so common with mothers and nurses of placing children upon the chamber utensil and allowing them to spend a large por- tion of time in that position is certainly, to my mind, a frequent cause of the (leveloj)ment of prolapsus, and is a custom which cannot be too severely condemned. In many cases the constant straining due to the presence of vesical calculus or rectal polypus, or to a contracted prej)uce, may be an important factor in the production of this affection. Improper diet, or the custom of allow- ing children to eat at all hours during the day — and as a result of this over-feeding the pro- duction of a large number of pa-ssages — may also be mentioned as a cause. That improper diet and over-feeding ])roduce ])rolapsus of the rectum is, in my mind, very clearly proved by the fact that at the Children’s IIosj)ital of Phila- delphia we often have children admitted to the wards for operation who have suffered from this affection for months : under the use of tonics, proper diet, and regulation of the bowels they fail to further present prolaj)sns, and arc thus soon relieved of the condition without operative interference. Mr. Holmes of London makes a similar observation as to his experience in this affection. Symptoms. — The characteristic symptom is the protrusion, during defeca- tion, of a reddish-purple ma.ss covered with mucous membrane : it is unac- companied by ]>ain, and usually undergoes s))ontaiicous reduction as soon as the straining efforts cease. In the partial variety of prolapsus of the rectum little inconvenience is experienced, uidess the ])rolap.scd portion of the bowel is allowed to remain out for some time, when it may become congested or ulcerated; the latter condition is more likely to occur in cases of complete j>ro- Fig. 9. Prolapsus of the Rectum. (After Bryant.) DLSEASES OF THE RECTUM. 591 lapsus. When the prolapsus is of the third variety and is accompanied by invagination of the rectum, the symptoms of obstruction of the bowel exist, and gangrene of tlie protruded mass may occur. Death has resulted in such cases from obstruction as well as from peritonitis. Diagnosis. — Prolapsus of the rectum is likely to be confounded only with haemorrhoids, which is an extremely rare affection in childhood, or with poly- pus of the rectum. The appearance of the prolapse is very characteristic: the annular fold of tissue surrounding the whole anus with its depressed central orifice, and the fact that after reduction of the mass no tumor can be found in the rectum, would exclude the presence of polypus. The cases most likely to give rise to error are those of intussusception in children where the intussusceptum protrudes from the rectum, and resembles in appearance a prolapsus. Such cases have been found with prolapsus of the rectum ; hut if the surgeon makes a careful examination of the protruded mass, and takes into consideration the previous history of the case, such as sudden pain and collapse or the occurrence of more or less obstruction of the bowels, with the passing of blood and mucus preceding the appearance of the tumor through the anus, he will not be likely to confound the two affections. Treatment. — The palliative treatment of this condition consists in return- ing the mass through the anus as soon as possible. This is best accomplished by placing the patient across the knees and making gentle pressure with the fingers over the Avhole mass of the tumor for a few moments, to return the contents of the bowels and the fluids effused in the tunics, and then pushing up the central portion first with the finger. Little difficulty is experienced in effecting this reduction in recent cases, but where the prolapsus has been down for some time and inflammatory effusion has taken place, it may be necessary to administer an anaesthetic befoi’e the reduction can be satisfactorily accomplished. The preventive treatment consists in not allowing the child to make prolonged straining efforts on the chamber-utensil or to have the bowels moved in a sitting posture. A child who is subject to prolapsus of the rectum should have the bowels moved while in the recumbent position on the bed-pan, or on the side, or in a standing posture ; and the nurse should support the perineum and anus by two fingers placed one on each side of the anus, or by forcibly drawing the skin of the buttock to one side while the child is passing the stool. When the affection depends upon the presence of a vesical calculus, a contracted prepuce, or a rectal polypus or parasites, producing great straining efforts, the removal of the cause will usually effect a cure promptly. The importance of carefully regulating the diet has been pre- viously mentioned, and care in this respect alone may bring about a cure. Enemata of astringent solutions, such as decoction of oak bark, a solution of alum, or cold water, or suppositories containing extract of nux vomica and ergot, have been employed ; and of these the enemata of decoction of oak bark, or of cold water, are most satisfactory. In cases where these various palliative measures have failed to relieve the condition, I think the safest and, in my experience, the surest method of treatment is that recommended by Allingbam. This consists in the application of nitric acid to the mucous mem- brane of the protruded gut. The child’s bowels having been previously opened by the administration of a small dose of castor oil or by the use of an enema, he is etherized, and the surface of the prolapsed bowel is carefully cleansed and dried of mucus by wiping it with absorbent cotton ; the whole surface of the mucous membrane is next painted with nitric acid applied with a swab, care being taken not to allow the acid to come in contact with the adjacent skin. A pledget of oiled cotton or lint is next introduced into the central depression 592 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. of the prolapsed mass, and by pressing it upward with the finger the mass is reduced. Finally, a pad is placed over the anus and held in position by bring- ing the buttocks together over it by means of broad strips of adhesive plaster. The bowels should be kept ((uiet for two or three days by the administration of a small amount of oj)ium ; and at the end of that time they should be opened by a laxative. The introduction of the oiled cotton or lint I have found in pi’actice unnecessary, as it is ajjt to be passed by straining when the patient recovers from the anjesthetic ; hence I generally omit its use, and merely coat the cauterized surfiice of the bowel with olive oil or vaseline before reducing it. The recurrence of the prolapsus may take place with the first few passages, but a permanent cure generally results from one apj)lication of the nitric acid. Should this, however, not be the case, cauterization may be repeated in a few' weeks. The ligature and the clamp and cautery or actual cautery have been employed in the treatment of this afiection, but as their use is attended with danger in cases of complete prolapsus of the rectum, and as I have never seen a case in a child in which the simpler and safer procedure, cauterization by nitric acid, has failed to give satisfactory results, I do not think their em]»loyment is to be recommended. In cases of prolapsus of the rectum in which invagination has occurred and the patient is suft'ering from obstruction of the bowels, if the mass cannot be returned under ether an arti- ficial anus should be made in the left iimuinal region ; and if the child survives after the invaginated portion of the gut has been removed by sloughing or other means, an attempt may be made to close the faecal fistula in the inguinal region, and thus allow the faeces to escape through their natural channel. HEMORRHOIDS. Haemorrhoids are vascular tumors w'hich occupy the low'er portion of the rectum, and arise from dilatation or proliferation of the blood-vessels. They may be either internal or external, and are covered either by mucous mem- brane or skin. Haemorrhoids are uncommon in childhood, but are occasionally seen, and may consist either of dilated veins or well-marked venous tumors. Allingham records a case of well-marked haemorrhoids which he saw in a child three years of age. I have myself seen several cases in (juite young children, and have seen recently with Dr. Starr a child three years of age who suffered from well-marked venous haemorrhoids, which protruded and bled at stool, and presented symptoms severe enough to call for operative interference. Ball also has observed several cases in young children, 'fhe symptoms presented by haemorrhoids in children are similar to those in a-dults, and consist in pro- trusion of the tumors and bleeding at the time of defecation. Treatment. — As luemorrhoids are apt to occur in strumous children, the administration of iron and cod-liver oil is often followed by decided benefit, and locally the use of astringent ointments and the regulation of the action of the bowels may be followed by marked amelioration in the condition. If, however, the tumors continue to bleed and to be protruded at stool, oj)crative treatment is indicated, and the masses may be removed either by the use of the ligature or, as I prefer, by the clamj) and cautery. Polypus of the Rectum. Polypus of the rectum is a much more common disease in childhood than hiemorrhoids, and is characterized by the presence of a follicular tumor springing from the mucous membrane of the rectum at a. point an inch or an inch and a half above the anus ; it is attached by a pedicle. The form of DISEASES OF THE RECTUM. 593 polypus most commonly seen in childhood is of the follicular or adenoid variety, and resembles in structure the normal mucous membrane of the rectum, from which it originates ; but fibrous and cystic polypi have also been observed. Mr. Thomas Smith has recorded three cases of disseminated polypi of the adenoid variety occurring in young persons, and Cripps also reports cases of multiple polyj)i springing from the surface of the rectum and colon. A rectal polypus is of a bright-red color when first extruded, but becomes darker and more venous in appearance after it has been protruded for some time and its circulation has been interfered with by constriction of the sphincter. The growths may be either single or multiple, and have pedicles varying from i to 2 or 3 inches in length. Polypus of the rec- tum is comparatively rare in children : Bokai found 25 cases of this growth in 65,970 pa- tients, and Jacobi says that he sees from 1 to 3 cases annually among 500 children. A rectal polypus is apt to produce expulsive efforts with ^After^aU.f^ Prolapsus, tenesmus, and give rise to a sense of fulness or distress in the lower part of the rectum, and to be accompanied by the escape of glairy or bloody mucus or of blood. Diagnosis. — The diagnosis is usually not diflBcult, as the growth is apt to present at the anus or to protrude from it during defecation, and a careful examination with the finger will disclose the presence of a pedicle to which the growth is attached. Polypus of the rectum is likely to be con- founded with haemorrhoids or prolapsus of the rectum, but a careful inspec- tion and examination of the parts will disclose the nature of the trouble. Before examining a case of suspected polypus of the rectum it is well to give an enema, and when this is passed the growth is apt to be brought to the lower portion of the rectum or may present at the anus. In examining for polypus it is well to introduce the finger as far as possible into the rectum, and, as it is withdrawn, to make the examination of the walls with a sweeping motion, by which mani- pulation the pedicle of the polypus may be hooked upon the finger. Treatment. — A polypus of the rectum may be seized with the fingers or forceps and twisted off, and the stump may be touched with nitrate of silver or with nitric acid; but I think the better method of treatment is to grasp the polypus and draw it out of the anus, so as to expose its pedicle, and to sur- round this with a ligature close to the mucous membrane, care being taken not to make sufficient traction to invert the wall of the rectum, which might thus be included in the grasp of the ligature. The ligature should next be firmly tied, and the tumor removed by dividing the pedicle in advance of the ligature. If a number of polypi exist, the same procedure should be repeated for each growth. AnGEIOMA or NiEVUS OF THE ReCTUM. This is also a rare affection. Mr. Howard Marsh has reported the case of a girl ten years of age who suffered from rectal haemorrhage, in whom an exami- nation revealed a naevoid growth in the lower portion of the rectum ; and Mr. Barker has also published a case of this nature. Treatment. — The treatment of naevus of the rectum consists in the use of 38 594 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN the ligature to strangulate the growth, or the application of nitric acid or Paque- lin’s cautery. Malignant Disease of the Rectum. Malignant disease of the rectum is very rarely met with in childhood, but may occur either in the form of cylindrical-celled carcinoma or of sarcoma. Allingham, Quain, Cripps, and other observers have reported a few cases occur- ring in childhood. Treatment. — The treatment consists in the excision of the growth if its situation be favorable for such a procedure; or linear rectotomy, which consists in freely dividing the growth together with the lower portion of the rectum, including the sphincter, may be practised with benefit, if obstructive symptoms are present. If the growth involves the high portion of the rectum and excision is not possible, colotomy should be performed. Wounds of the Rectum. Wounds of the rectum may be caused by substances which reach the rectum through the alimentary canal, or by bodies introduced through the perineum or the anus ; these wounds may be lacerated, incised, or punctured. Lacerated or punctured wounds may result from patients falling upon sharp bodies which enter through the perineum or anus, or from fragments of broken bones of the pelvis, causing in many cases extensive laceration of the parts about the rectum as well as of the rectum itself; they may be complicated by injuries of the bladder, vagina, or peritoneum. Lacerated wounds of the rectum may also result from the careless or forcible introduction of the nozzle of an enema-syringe ; and laceration of this organ in children who have been sub- jected to unnatural intercourse should also be mentioned. Incised wounds of the rectum may result from operations upon this organ or from its acci- dental incision in the operation of lithotomy. Treatment. — The treatment of incised or external lacerated wounds which involve only the lower portion of the rectum consists in controlling bleeding by the application of ligatures to the bleeding vessels; in washing the wound thoroughly ■with a solution of bichloride of mercury, 1 : 4000 ; in dusting the wound with powdered iodoform ; and in providing for the escape of discharge by the introduction of a drainage-tube or catgut drain, and in bringing the edges together with catgut sutures. A gauze dressing should then be applied, and the bowels kept quiet for a few days. In punctured or internal lacerated wounds of the rectum which do not extend high enough to involve the bladder or ])eritoneum it is better, in order to secure free drainage, to convert the internal punctured or lacerated wound into an open wound by the division of all the tissues, including the external sphincter and the skin. The wounds should then be washed w'ith a solution of bichloride of mercury, packed lightly with iodoform gauze, and allowed to heal by granulation, the dressing being changed as often as it becomes soiled. In a case of lacerated w'ound of the rectum coni])licated by wound of the bladder, perineal cystotomy should be j)erfornied to ju-ovide for the free escape of urine, and free drainage secured by division of the anal sphincter and the introduction of drainage-tubes if necessary. If a punctured wound of the rectum involves the peritoneum, with injury to the contained viscera, laparot- omy should be performed, the wounds of the viscera should be sutured, and the peritoneal cavity irrigated, drained, and closed. DISEASES OF THE RECTUM. 595 Foreign Bodies in the Rectum. Foreign bodies may enter the rectum from the alimentary canal or may be introduced through the anus. A great variety of foreign bodies have been thus introduced either by accident or design. Patients sulfering from foreign body impacted in the rectum will have ineffectual attempts at defecation, wdth the passage of mucus, which is often blood-stained. In a case presenting these symptoms a careful exploration w'itli the finger will enable the surgeon to ascer- tain the presence, the exact location, and the character of the foreign body. Treatment. — The removal of the foreign body should be accomplished with the least possible injury to the walls of the rectum. It is well first to anaesthetize the patient, and then inject into the rectum a few ounces of olive oil. When the character and position of the foreign body have been ascer- tained, it may be dislodged with the finger and removed by forceps. Where the body is irregular in shape or possesses sharp edges or angles which may cause injury to the surrounding parts, retractors or a bivalve speculum should be introduced to secure free dilatation of the anus and lower portion of the rec- tum and facilitate removal without injury to the rectal walls. Where the foreign body consists of a large mass of inspissated material, fragmentation should be resorted to in order to secure its satisfactory removal. If the foreign body has remained in position for some time and ulceration has resulted from its presence, a solution of nitrate of silver, 10 grains to the ounce of water, should be applied to the ulcerated surface, and suppositories of iodoform should also be introduced into the rectum. Extensive ulceration of the rectum following the long-con- tinued presence of a foreign body may be followed by stricture, and the pos- sibility of this condition should be guarded against by judicious dilatation by the finger or bougies. PART VII. DISEASES OF THE NERVOUS SYSTEM. SIMPLE CEREBRAL MENINGITIS. By THOMAS S. LATIMER, M. D., Baltimore. By simple meningitis, leptomeningitis, or purulent meningitis, is usually meant inflammation of the arachnoid and pia mater. Writers distinguish an arachnitis, but as this probably never occurs apart from inflammation of the pia or dura it may be considered an unnecessary refinement. Varieties are men- tioned dependent on the situation, grade, or nature of the inflammation, and whether primary or secondary, or according to the character of the exciting cause. All practical purposes are subserved by dividing simple meningitis into acute, subacute, and chronic forms, whilst considering in their appropriate places those peculiarities in each form incident to locality and origin. All forms of meningitis have much in common, and a description of anyone form is in great part a description of all ; more especially is this the case in the clinical history and in the treatment ; it is therefore expedient, to avoid need- less repetition, which the space allotted to this article does not permit, to dis- cuss the pathology and etiology of the different forms, and subsequently the clinical history and treatment, which are essentially the same in all. Simple cerebral meningitis may be defined as inflammation of the arach- noid and pia mater of non-tubercular origin. Etiology. — Simple meningitis is said to occur in utero (Guersant) and to be quite frequent in the new-l)orn. According to Kamskill, its period of greatest frequency is prior to the second year, becoming less so from that time until after fourteen, when it again becomes more common, especially between sixteen and forty-five. Gowers places the period of greatest freipiency between the ages of one and ten years, including, however the tubercular form. It is essentially a disease of early childhood,' and is more common than is admitted by tho.se who refer all liasilar iidlammations to a tubercular origin. In the po.st-mortom observations of Drs. Gee and Barlow, recorded in St. Bartho- lomeiv's Hospital Reports for 1878, are 0 cases of non-tubercular meningitis, anil in 41 po.st-mortem examinations by Dr. Goodhart, in cases which he says without examination would have been .set down as tuberculous, 8 w'ere non- tubercular. Sex may be admitted among the ])redisposing causes, since Barent-Duehate- let and Martinet found it to be three times as frequent in males as in females. The occupations peculiar to men and the sjiorts of boys, involving exposure to vicissitudes of weather and to mechanical violence, may account in great part .596 SIMPLE CEREBRAL MENINGITIS. 597 for this difference, without assuming that there exists any liability or immunity due to sex per se. Injuries to the head, extension of middle-ear inflammation or of any adjacent disease, the special cause of many specific diseases, like pneumonia, scarlatina, erysipelas, and measles, ordinary pus-producing organisms, emboli and thrombi — may all be exciting causes. An inherited or acquired predisposition is per- haps not uncommonly present, but less often than in the tubercular form. Rheumatism has been supposed to be a frequent cause, but its importance has doubtless been over-estimated. Symptoms closely simulating those of mening- itis often arise in the course of acute rheumatism when post-mortem examina- tion reveals no trace of inflammation. Trousseau absolutely denied the inflam- matory nature of these cases, which he called neuroses. Two of the most characteristic symptoms of meningitis, vomiting and headache, are also com- monly absent. Doubtless rheumatism is sometimes a cause of true simple meningitis, but all the symptoms may arise from hyperpyrexia alone. Sup- purative endocarditis or any other septic trouble may occasion it, as in the cases following operation for imperforate anus referred to under Pathological Anatomy. Those cases arising from adjacent disease may be limited to the convexity, while those occurring in the course of acute specific diseases may affect the base also, though a preference for the convexity is recognized in all non-tubercular forms. Pneumonia is frequently associated with simple meningitis and the pneumo- coccus is found in the inflammatory exudate. Huguenin states that at Zurich it is a frequent complication of pneumonia, and Chvostek found it four times in 220 cases in Vienna. The most common cause of this affection is extension from some local adja- cent disease ; middle-ear inflammation is a frequent antecedent. Cases have occurred in which suppuration of the eyeball was primary, the inflammation extending along the sheath of the optic nerve. In some instances no imme- diately exciting cause is apparent. Fagge relates several cases occurring in Guy’s Hospital in which a diseased temporal bone was found post-mortem, but the meningeal inflammation appeared to start in one instance from a blow with a bolster, and in another an attack of sunstroke preceded the cerebral symp- toms about seven days. Moxon gives a prominent place to syphilis as causa- tive of meningitis, and Fagge says 5 cases, in which it occurred without other syphilitic lesions within the calvaria, were found among the records of Guy’s Hospital. This writer appears to approve the notion that the direct rays of the sun may pi’oduce simple meningitis, or that even its reflection from the pages of a book while reading is a sufficient cause ; but this is scarcely credible. Pathological Anatomy. — When death occurs in the early stage of lepto- meningitis, intense hyperaemia with extreme dryness and opacity of the mem- branes — from distention of the lymphatic sheaths of the vessels — over the whole or part of the brain may be the only lesion. If death occur after a few days’ duration, effusion of fluid admixed with cellular elements will be found on the arachnoid, in its sac and infiltrating the pia mater. Abercrombie relates a case in which it was so abundant between the dura and arachnoid as to distend the anterior fontanelle. Usually, however, the quantity of fluid exudate is not large. When life has been prolonged to the fifth or sixth day, the quantity of fluid is sensibly diminished, and a little later disappears. A membrane-like deposit of yellowish hue is found on the arachnoid ; the pia in greater or less partis eovered and infiltrated with “ concrete pus,” which is also found around the vessels and in the sulci of the convolutions (Ramskill). The nerve- 598 AMERICAN TEXT-BOOK OF DmEASEB OF CHILDREN. sheaths may be reddened and bathed in semi-purulent lymph, which at times is punctiform and resembles tubercular granulations. In long-standing cases this may undergo caseation or induration. The nerve-trunks may be in different stages of hypermmia, softening, and disintegration. The dura and arachnoid may be firmly adherent, the arachnoid and pia almost always. The ventricles may be invaded, their lining membrane inflamed, the orifices of communication occluded, and the chambers distended with serum or pus, sometimes to the extent of producing a true hydrocephalus. In rare cases they may contain false membrane. More frequently they contain a flocculent fluid of variable quantity, sometimes sufficient to distend the ventricle and compress the cortex. The subjacent brain-substance may be (edematous and softened. This condition is not always associated with unmistakable evidence of inflammation of their lining membrane ; indeed, the inflammatory changes in the ventricles are rarely, if ever, well marked. In those cases where inflam- mation is most pronounced the effusion is seldom limited to the ventricles, but may invade the cord and escape into the brain-space. Great distention of all the ventricles may occur without inflammation, from simple occlusion of the channels of communication with the space around the brain (Gowers). Rilliet relates a case in which the convexity of one side was covered with false mem- brane, whilst the pia of the opposite side was simply cedematous. Cases of pneumonic origin are usually bilateral and limited to the cortex ; those extending from local foci — purulent otitis, caries, etc. — are unilateral, and may be associated with thrombi of the sinuses or with abscess (Osier). Septic cases and those associated with specific diseases are apt to be bilateral. The base is often involved in the inflammatory process. An interesting case of basilar meningitis following an operation for imperforate anus, reported by W. T. Howard, Jr., in a child of three months, is related in Osier’s Practice of Medicine, in which the ventricles were distended Avith pus containing a coccus and the bacterium coli commune ; the ependyma Avas softened and infiltrated Avith pus. Dr. Hilton Fagge also reports a case, occuring in Guy’s Hospital, of a meningeal inflammation following six days after an operation for imperforate anus, attributed to sepsis, though the meningitis Avas the only evi- dence of pyrnmia. Dr. Fagge says the presence of subdural j)us may usually be taken as an evidence of extension from Avithout, though in many cases no subdural pus is found. The pia is usually SAVollen and ocdematous, filling the sulci ; the inflammation may extend along the vessels to the cortex, which becomes infiltrated, softened, and so adherent at times that the pia cannot be removed Avithout cortical laceration. The Avhole surface of the cortex may be bathed in pus or deej)ly infiltrated Avith leucocytes, and Huguenin says “sup- puration of the brain-substance may reach such a point as to give rise to a diffused yelloAv-gray maceration visible to the naked eye” ((pioted from Fagge’s Practice). The amount of blood in the vessels may be greatly diminished from pressure of the exudate and thickening of their walls. Symptoms. — Simple meningitis of childhood usually begins abruptly Avith well-marked rigors. Prodromic syiuptoms are much less fnajiient than in the tubercular form. The patient is petulant and irritable Avhen disturbed, but inclined to apathy at other times, more especially in later stages and Avhen the convexity is especially involved. Violent delirium Avith or Avithout convulsions may be an early symptom. When convidsions occur ('arly, they are apt to recur often during the progress of the trouble. The delirium may be quiet and the convulsions slight or absent. Pyrexia (juickly supervenes, and is usually high: a temperature of 103°-105° F. is not uncommon in the first Aveek. It is sometimes very slight, occasionally scarcely apj)reciable, and in the last stage SIMPLE CEREBRAL MENINGITIS. 599 the temperature may be subnormal. The pre-mortal temperature is sometimes as high as 106°-108° F. The pulse may be frequent and tense, usually so in the beginning, or slow and irregular, sometimes as slow as 60, 50, or 40 per minute, or just before death it may rise to 160-180 per minute. Henoch considers an intermittent pulse characteristic of meningitis. It is of more significance in childhood than in infancy, but at no time has it the diagnostic value imputed to it. The extreme variation in frequency and quality of the pulse is probably its most significant character. Respiration is usually but little disturbed, but is sometimes sighing, may be quickened at first and subsequently irregular and slow, and toward the close the Cheyne-Stokes rhythm may be present. When the lesion is in the posterior fossa, respiration is slow, labored, accompanied by cyanosis, and may stop suddenly. Headache is perhaps the most constant symptom, and is seldom lacking. It is often associated with great tenderness of the scalp and subjacent region, and is sometimes circumscribed, but the localization bears no constant relation to the site of the inflammation. The meninges of one side may be inflamed and the pain and tenderness be on the other ; but when the pain persists in a circum- scribed area it commonly indicates the site of the inflammation. Cases of simple meningitis sometimes run their entire course without pain, and when pain is present it seems to have no constant relation to the intensity or extent of the inflammation. Hyperaesthesia of the nerves of the special senses of sight and hearing, indicated by extreme aversion to light and noise, is almost invariably present. This may be associated with acute general hyperaesthesia. The pupils are at first contracted ; as the photophobia diminishes they become irregular ; one may be contracted and the other dilated, or at times contracted, at times dilated ; finally, both become dilated and vision is impaired or lost ; optic neuritis is present in many cases, especially when the base is involved. Noises at first greatly disturb the patient. This sensitiveness to sound is at times so great that the most softly modulated speech occasions signs of petulance and distress. As the end approaches this gradually passes away, and deafness may ensue. The intelligence is sooner or later affected ; the patient is irritable and petulant when questioned or otherwise annoyed ; incoherent speech and delirium are often early symptoms. Other nervous symptoms present at this time are subsultus, carphologia, inco-ordinate efforts at locomotion if this be attempted, and projectile vomiting. The tache c^r^brale is well marked, but is without diagnostic significance. Occasionally the patient emits short, sharp cries that do not always appear to be due to pain, though in older children they often seem to increase the headache. General convulsions may occur independently of the site (Gowers), and eventually give place to coma. Rigidity of the muscles of tbe neck, with retraction of the head, is an early symptom of diagnostic value ; it is more frequent in inflammation of the base than of the convexity. When the base is the site of the lesion, local spasm may occur in simple as well as in tubercular meningitis. Rolling up of the eyes, oscillations of the globes, strabismus, most marked when the eyes are moved, are frequently present in the first stage ; later they may give place to paralysis, sometimes limited to the face or a small part of it, sometimes to a single extremity ; or complete hemiplegia is present. 600 AMERICAN TEXT-BOOK OF DISEASED OF CHILDREN. Vomiting is so commonly present and of such distinctive character as to possess diagnostic significance. It is projectile, unaccompanied by gastric pain or tenderness, nausea, or retching. It may persist throughout the disease, but is most characteristic in the early stage. It occurs independently of the site, but is more common in inflammation of the base. It is not present in all cases. The tongue is usually somewhat furred, hut presents nothing character- istic. The bowels are constipated in a large proportion of cases, and the abdomen is retracted or boat-shaped. Finally, all the active symptoms subside ; the headache, photophobia, acoustic sensibility, general and local hypermsthesia, and active delirium, all give place to coma and general collapse. The pupils are dilated, the pulse weak and irregular and the skin cold and clammy. Cheyne-Stokes respiration is established, the sphincters are relaxed, the faeces and urine are voided involuntarily, and death speedily ensues. Subacute Leptomeningitis is peculiar only in the relative mildness of the lesions and the slowness with wdiich it develops. It sometimes, though rarely, succeeds to the acute form, but more commonly is subacute from the beginning. The same lesions of milder grade are present, and are due to the same exciting and predisposing causes. Hydrocephalus is perhaps more frequent and extensive; active delirium is frequently substituted by a more quiet form and a condition of mental torpor. The patient is less irritable, the photophobia and acoustic sensibility is less, and paralyses are slower to appear. There is but little propriety, how- ever, in recognizing a subacute form ; it is merged by such insensible grada- tions, on the one hand, into the acute, and on the other, into the chronic form, that there is little to distinguish it. A latent form is also described, but in the judgment of the writer it has no well-established claim to recognition, and will not therefore receive further consideration. Chronic Leptomeningitis. — Chronic leptomeningitis may succeed the acute form, but is of extreme rarity except as a result of syphilis or chronic alcoholism, causes not likely to occasion it in childhood except through inher- itance. The symptoms are less clearly distinctive, and the difficulty in diagnosis therefore greater, than in the acute form ; consequently it may often be over- looked and the frecjuency of its occurrence underestimated. If, as Goodhart has remarked, we accept cervical opisthotonos as evidence of meningitis, it may not only be very chronic, but also intermittent, and, we may add, more fre- quent than commonly supposed. Its clinical history is not to be separated by sharply-drawn lines from that of the acute disease. It is essentially the same in character, but of slower development and more protracted stay, and all the more characteristic symp- toms are of less intensity. An apathetic condition with headache and a dis- position to vomit, a pulse at first slow, soon becoming quick and irregular, double vision, strabismus, and irregularity of pu])ils, may usually be found if sought for. The favorite site of chronic infantile meningitis is the ))osterior fossa, and the most characteristic symptoms are local and dependent on the seat of the inflammation. Drs. Gee and Barlow observed cervical o))isthotonos in most cases. In some cases of raj)id development it may l)o attended or ju-eceded by convulsions, vomiting, pain, and fever; in others the retraction of the head is slowly induced, unattended by these ])hcnomena. Rigidity of the limbs and epileptic convrdsions may occur later, together with oscillations of the globe or strabismus, and occasionally hydrocephalus (Gowers). When the orifices of SIMPLE CEREBRAL MENINGITIS. 601 the fourth ventricle are closed with lymph, paralyses, facial and hemiplegic, may complicate the later period. The pia is usually thickened from increase in its connective tissue ; a similar condition is found in the walls of its vessels, and from them may extend to the cortex, inducing such changes as may lead to insanity and idiocy. The pia and arachnoid may be glued together, oede- matous and opaque, and the sulci be filled with serum or sero-purulent fluid or oedematous membrane. The Pachionian bodies are increased in number and size. Chronic lepto-meningitis is much moi’e frequently associated with syphilis than is the acute form. A swollen and oedematous optic disk, or optic neu- ritis, may aid the diagnosis, but cannot confirm it. One is a little at a loss to understand why the cause of the meningitis should be supposed to determine a difference in the symptoms, except in so far as these are due to associated disease. The extent, intensity, and locality of the menin- geal inflammation, with the nervous susceptibility of the individual, will deter- mine the symptoms, which will be much the same whatever the cause. Diagnosis. — The positive indications of simple meningitis are found in the symptoms already mentioned, though they may any or all of them occur with- out meningeal lesion of any kind whatever. The general cerebral symptoms are valuable according to their degree and combination, rather than by their mere presence. “The significance of the headache depends on its intensity; of the delirium, on its coexistence with headache; of vomiting, on its causeless character and persistence; of general convulsions, on their association with other symptoms; of infrequency of pulse, on its combination M’ith pyrexia that usually accelerates the heart” (Gowers). It is not to be distinguished by its symptoms from tubercular meningitis, though in general it may be said to be more frequently dependent on some pre-existing local disease, to be more abrupt in its invasion and rapid in its progress in acute cases, and to be more frequently associated with active delirium. It is probably more dependent on some local lesion or association with specific disease than is the tubercular form. In the latter the presence of the tubercle bacilli or of septic materials from degenerating tubercles, with peculiar smsceptibility, is alone sufficient for its development. The presence, therefore, of tubercle in other organs, the detec- tion of tubercle bacilli, and a tubercular fiimily history are of greater value in the differential diagnosis than any supposed difference in symptoms directly due to the meningitis. Though clear evidence of tubercle elsewhere may be wanting, slow invasion, early childhood, and the absence of distinct local cause make for a tuberculous origin. When the base alone is the site of the inflam- mation, the pi'obabilities are strongly in favor of the tubercular form. Inflam- mation of the middle ear or labyrinth, with or without suppuration, may give rise to symptoms that cannot be distinguished, except by their duration, from meningitis. The detection of an otitis, therefore, may lead us to believe in the existence of meningitis originating from it, or to hope that the symptoms are solely due to it and will end in recovery under proper treatment. And in cases that recover under such circumstances, the diagnosis must remain permanently in doubt, since many cases of simple meningitis have been thought to recover. It is also not altogether unlikely that the characteristic symptoms may arise as a reflex result of lesions of the most varied character in remote parts of the body. From the cerebral form of pneumonia simple meningitis may be dis- tinguished by the physical signs of the former and the detection of the pneumo- coccus. But it must be remembered that although pneumonia may exist with- out meningitis, with analogous cerebral symptoms, yet pneumonitis and true meningitis may coexist and be due to the same cause. I know of no way to 602 AMERICAN TEXT-BOOK OF BIEEASES OF CHILDREN. distinguish cerebral symptoms occurring in pneumonia without meningitis and those occurring under like circumstances with it, except by their duration ; and even this in many cases is the same, since pneumonia with marked cerebral symptoms often runs a speedily fatal course. Perhaps, instead of trying to differentiate them, it would be best to consider both as local expressions of the same constitutional state. Pymmia may present symptoms closely resembling meningitis, especially when associated with thrombus of the lateral sinus and jugular vein, as in a case I’eported by Dr. Frederick Taylor. Dr. Wilson Fox also relates a similar case, and Dr. Andrew two instances of pyaemia with cerebral symptoms not distinguishable from meningitis; both of these recovered, however, so it can- not be said they were not cases of true meningitis, unless it be assumed that acute simple meningitis never recovers. Those cases of typhoid fever likely to occasion difficulty in diagnosis are characterized by the predominance of cerebral symptoms and the absence or slight nature of those peculiar to the alimentary canal ; but in typhoid fever headache precedes delirium, usually ceases with its advent, and is sufficiently accounted for by the pyrexia — not so in leptomeningitis. Photophobia and auditory hypersensibility may occur in either, but they are far more acute in meningitis. In typhoid fever vomiting seldom has the distinctive cerebral character, and rigidity of the neck and local paralyses seldom occur. The invasion of typhoid fever is rarely so abrupt ; the pulse is not so irregular. Prognosis. — In all cases of leptomeningitis but little hope can be reason- ably entertained of recovery when no error in diagnosis has been made ; but errors of this kind happen in the experience of the most astute and well- informed physicians. Moreover, cases apparently free from doubt have recov- ered in sufficient number to warrant hope, but hope only, for nothing in the condition of the patient serves as a reasonable basis for expectation of recovery. The cases which do best are those having their origin in injuries, necrosis, caries, suppurative otitis, and other removable causes, and those that arise in the progress of syphilis. The majority even of these will terminate fatally after the inflammation is well established, but much may be done, by the early removal or correction of such causes, to prevent the establishment of meningitis. Those in which the indications are that both the convexity and base are affected run a rapidly fiital course. Patients in whom no reasonable cause exists may be expected to succumb, more especially if the pulse soon becomes irregular and Aveak, accompanied by nausea, Avith convulsive seizures folloAved by profound hebetude. When light and noise no longer disturb ; Avhen the pupils become persist- ently dilated; the skin cold, pale, and bathed in pers])iration ; Avhen involuntary evacuations occur ; paralysis local or general becomes established, and coma or a semicomatose condition supervenes, — all hope may be abandoned. Treatment. — The treatment in simple cerebral meningitis and in simple cerebro-s))inal meningitis is essentially the same. A much larger j)ro])ortion of cerebral cases are due to local conditions that may be treated by surgical measures, and Avhenever they do arise from removable causes surgical treat- ment should be instituted Avithout delay. Suppurative otitis, Avith or Avithout necrosis or caries of the temporal bone, is so often causally related to meninge.al inflammation that these lesions should ahvays receive efficient attention before the induction of the graver evil. It has happened to the Avriter to Avitness tAvo cases of supposed leptomeningitis in adults, Avith fatal terminations, supervening on chronic suppurative otitis that had followed scarlatina, many years before. Had the aural trouble been efficiently treated, the meningeal inflammation SIMPLE CEREBRAL MENINGITIS. 603 would in all probability have been averted. Doubtless many similar cases have existed, and, in view of the great fatality of the secondary affection and the impunity with which surgeons of the present day invade the meninges, and even the substance of the brain, they should in future disappear from our records. All cases of injury to the skull that carry with them even a reason- able suspicion of injury to the meninges or brain should, in the judgment of the writer, be ti’ephined, bone-fragments elevated or extracted, blood-clots removed though the membranes have to be incised for that purpose, and all the parts thoroughly cleansed. Analogous procedures are no less imperatively called for in diseased conditions than after injury. Cases of syphilitic origin should receive the specific treatment proper to that disease, with a not unreasonable hope of recovery if the treatment be begun early. Apart from these special indications for treatment, there is but little to be expected from any means at our disposal beyond the alleviation of suffTering. Drugs appear to exert no infiuence on the course of the disease, and it may be doubted, even in those cases of supposed leptomeningitis that have recovered, whether the remedies administered have contributed to this result. Bleeding, local or general, and blisters are still strongly advocated by German writers and by many others. Apart from relief of hyperaemia of the cerebral vessels, one sees but little benefit to be derived from them, and it would seem that this might be better accomplished by such remedies as amyl nitrite, which increase the vascular area and so lower blood- pressure without the same impairment of strength as follows bloodletting. Mercury and the iodide of potassium have been warmly and ably advocated as efficient therapeutic agents in this disease, but they so often appear to be entirely without effect that the writer is sceptical of their value except in cases of syphilitic origin. Nevertheless, excellent results of treatment with these agents have been reported by most competent observers. Ramskill in Reynolds’s System of Medicine thus summarizes the treatment: “It resolves itself into three great remedial measures : first, bloodletting ; second, hard purging; third, applications of cold water or ice to the head.” Abercrombie’s cases also give strong support to the efficiency of these measures. Case 69, aged eleven, after an illness of five or six days was in a comatose condition, notwithstanding free purging, blistering, and the use of mercury to salivation ; was immediately relieved and made a good recovery after one bleeding from the arm. Case 72, aged twenty-one years, was reduced to a condition of stupor from which he could scarcely be roused, and continued in this way for eight or ten days notwithstanding repeated bleed- ing, blisters, and cold applications. But, after taking full doses of castor oil every three hours until purgation was induced, he was on the same evening relieved and made a good recovery (quoted in Fagge’s Practice). A brisk purge in the beginning and from time to time during the progress of the trouble will do much to alleviate suffering, and at times seems to have a decidedly beneficial effect. Cases, not a few, are recorded, especially by the earlier writers, which seem to date improvement, rapidly progressing to recovery, from such measures as free catharsis, bleeding, local or general, blisters applied to head or back of neck. Whilst it is difficult wholly to discredit such state- ments or to deny to the agents employed the remedial potency claimed for them, yet it is equally difficult to conceive how with such means such ends could be attained. When remedies of this class are serviceable at all, it must be in the early stage before inflammatory exudation, infiltration, or degenera- tive changes have occurred to any notable extent ; and one cannot wholly G04 AMERICAN TEXT-ROOK OF DISEASES OF CHILDREN. shake off the doubt that they were cases of erroneous diagnosis, or at least belong to that rare class of cases that would have recovered without medical interference. An entirely different class of remedies is found in those drugs of anodyne and hypnotic properties which allay vomiting, soothe pain, subdue or lessen active delirium, procure sleep, and contribute in many ways to make tolerable for patients and friends the last days of those for whom in a large majority of cases we can hope to do no more. And, in the opinion of the writer, relief in these particulars is the extent of the power of drugs to be useful in this disease. First rank in this group of remedies may still be boldly claimed for opium and its derivatives, and especially for morphine, which, because of the small dose required, the facility with which it may be administered hypodermatically, and its almost uniform strength and efficiency, takes precedence of all other drugs. The bromides of sodium and potassium, antipyrin, antifebrin, sul- phonal, and many other similar remedies are at times of great usefulness. The occasional use of chloroform by inhalation when convulsions occur gives prompt relief to some of the most distressing symptoms, and is, I believe, as free from danger as any other remedy when judiciously employed ; but nothing can be so confidently relied on to relieve pain, to procure sleep, to quiet delirium, and to arrest vomiting as morphine ; and this it does at as little cost to a feeble heart as any other drug that may be used ; nor do I think is the tendency to coma materially, if at all, increased by its judicious administration. But more valuable than any of the remedies yet mentioned is repose of body and mind as perfect as may be had by the mere exclusion of disturbing causes. The room should be darkened ; no one not indispensable to the comfort of the patient should be admitted ; no loud talking or other noises should be allowed within hearing ; and no needless questioning by anxious friends. In cerebral cases the head should be shaved as soon as the nature of the trouble is clear. Ice or ice-cold water should be almost continuously applied to the head and — in cerebro-spinal cases — to tlie back. It should be begun early and continued steadily, and in cases of active delirium this may be supplemented by iced applications to the large arteries — brachials and carotids. When coma appears, all depressing remedies should cease, although occa- sional recoveries are recorded even in this stage, as in Abercrombie’s cases, already quoted, and in Sir Thomas Watson’s case of recovery on the application of a blister to the entire shaven scalp after the appearance of coma. It is certainly more reasonable to expect good from the judicious use of stimulants in this stage or at any time when the heart-beat is feeble or intermittent. Throughout the disease, as far as practicable, the strength of the patient should be maintained with the most nutritious diet. SIMPLE CEREBRO SPINAL MENINGITIS. By THOMAS S. LATIMER, M. D., Baltimore. Simple or Sporadic Cerebro-spinal Meningitis occurs under pre- cisely the same circumstances as simple cerebral meningitis, and is attended by the same lesions, except in so far as the anatomical and physiological character- istics of the part invaded necessitate a difference. Nor can it be maintained in the present state of knowledge that any essential difference exists between this and other forms of cerebro-spinal meningitis. The tendency of recent observations and opinion is to the conclusion that epidemic cerebro-spinal meningitis (cerebro-spinal fever) has its origin in a specific germ, probably the •diplococcus lanceolatus, and observations have not yet sufficiently multiplied to enable us to say whether or not this organism is also present in all sporadic cases. How’ever this may be, it is clear that the two forms arise under some- what different circumstances, and present such clinical differences as may be seen in other diseases, such as dysentery, that prevail at times epidemically and at times sporadically — differences chiefly of intensity in the symptoms and in the extent of the lesions, the epidemic prevalence implying a concurrence of suitable conditions in the individual and in the auxiliary associated conditions by which he is surrounded, and not necessarily any difference in the immediate exciting cause. In this restricted sense, then, we may still speak of simple cerebro-spinal meningitis as distinguished from cerebro-spinal fever. There are also cases occurring from injury, from sepsis, from local extension, from tuberculosis or syphilis, that probably have no causal connection with the pneu- mococcus, and may with more propriety be designated “simple” than may sporadic cases that appear to be closely connected with this particular organism. Etiology. — The causes of simple cerebro-spinal meningitis are precisely the same as those of simple cerebral meningitis, and need not be again con- sidered. They are injuries, extension from adjacent disease, pyiemia, specific diseases, childhood, sex, season, vicissitudes of temperature, and those general malhygienic conditions that predispose to inflammations in general. Menin- gitis is not, however, limited to any class, and may occur among the rich and poor alike. Efforts have been made to connect it with particular articles of food, but without much success. Fatigue from over-exertion seems to be a favoring condition observed most frequently in the adult. Pathological Anatomy. — This disease may be an extension from simple cerebral meningitis, in which case the anatomical changes heretofore described in basilar inflammation will be present, and to them must be added those due to invasion of the meninges of the cord ; or it may originate in the cord and extend up to the cerebral meninges, which would not of course alter the nature of the lesion, only the order of occurrence of its symptoms ; or it may occur simultaneously in both regions, the anatomical characters remaining the same. These characters are — great hyperaemia in the first stage, to which soon suc- 605 606 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN ceed swelling and hypertrophy of the walls of the vessels of the pia mater, sometimes also of the brain and cord, and with this oedema and cellular infil- tration of adjacent parts may coexist. Sometimes the exudate may be small in amount and consist of serum, white corpuscles, and plastic material, by which in the last stage, if the patient survives, the membranes may be bound together, or the pia and surface of the brain or cord ; or it may be of large quantity and purulent, filling the canal and bathing the pia and underlying structures in a grayish-yellow or distinctly purulent fluid, which may fill the entire space between the dura and arachnoid. The infiltration may occasion opacity of both pia and arachnoid. The spinal meninges are usually exten- sively involved, owing probably to the readiness with which septic elements ai’e diffused in the spinal fluid. The spinal fluid is more or less flocculent from the presence of exudation elements, or it may be, as before said, distinctly purulent. A true myelitis may, and not unfrequently does, coexist, in which case paralyses occur of a more permanent character than when the meninges alone are involved. The arachnoid is probably never affected alone, but it is always involved in the inflammation, which may also extend to the dura and to the spinal nerves, to which latter circumstances some of the most character- istic spinal symptoms are due ; but they by no means always share in the inflammation. According to J. Simon, the meningeal inflammation may usually be looked upon as an index to the more important changes that occur in the cerebral and spinal tissue, “ and hence it is that the essential phenomena of the disease during life consist in disturbances, more or less grave, of the functions of these all-important organs.” Other organs and tissues pi-esent little or no pathological change, except perhaps the skin, and the lesions here found are commonly limited to the fulmi- nant cases, which are found almost exclusively in the epidemic form of menin- gitis, and have therefore been fully described in another section. Symptoms. — In this affection the convexity is seldom involved, and the symptoms are for the most part those characteristic of inflammation of the base and of the cord, more especially of the cervical region of the latter. The special senses ai’e not affected to the same extent as in cerebi’al meningitis, although vision is sometimes impaired ; irregularities of the pupil and strabis- mus, with oscillation of the globe, are usually present in minor degree, but intense photophobia is rarely a marked symptom. Deafness is quite common, and may be permanent ; in many cases it is due rather to inflammation extending to the labyrinth and middle ear than to direct lesion of the auditory nerve. Optic neuritis is present in most instances when vision is affected, and may terminate in permanent l)lindness in cases that recover. Keratitis, retinitis, opacity and ulcerations of the cornea, and oj)acity of the lens may all occur, but are not characteristic. Pain is invariably present, esj)ecially in the occipi- tal and cervical regions, and is associated witli general cutaneous hyper- aesthesia ; all movements of the patient occasion suffering, a.ssociated with rigid- ity of the spinal extensor muscles, sometimes affecting also the muscles of the chest, abdomen, and jaws, producing a sense of constriction and slight trismus. This hypenesthesia and muscular contractio7i is ])robal)ly due to tlie involve- ment of the roots of the spinal nerves in the iidlammatory process. The retracted neck and back, at times a-mmniting to decided ojiisthotonos, is in part voluntary, due to a disposition to relax, as far as may bo, irritable muscles (Radcliffe); in part I’eilex, from irritation of the sensitive fibres of the posterior roots distributed to the j)ia; and in ]>art from direct irritation of the anterior nerve-roots, or to all these combined. When the j)atient is perfectly SIMPLE CEREBROSPINAL MENINGITIS. (>07 at rest, considerable intervals of almost complete relaxation exist, but all efforts to restore the normal decubitus are commonly attended with recurrence of the abnormal position and rigidity. Most intense pain in the head and cervical region is an early and continuous symptom ; it seldom entirely intermits, but severe exacerbations are of frequent occurrence. Pain in the back and loins is often present — always when the lower segment of the cord is invaded. The thighs are flexed upon the pelvis and the legs upon the thighs. Firm pressure over the spinal column does not occasion pain, a point of distinction between meningitis and spinal irritation. Local paralysis with facial distortion is not infrequently present, and in the later stage the patient may become hemi- plegic, which usually implies the extension of the trouble to the substance of the brain or cord. Active delirium generally exists, sometimes as an early symptom, occasionally associated with convulsions, frequent^ ending in coma. Reflex irritability is always present in the early stage, but is less marked than in tetanus. Vomiting is a troublesome symptom in most cases, and is difficult to con- trol. The vomit consists of ingesta, bile, or a glairy greenish fluid. The bowels are usually constipated and the abdomen retracted, but diarrhoea not infrequently occurs, with tympany. Whilst this paper is in progress the writer is attending a case of well-marked sporadic meningitis in Avhich diarrhoea induced by purgation continues, together with decided tympanites. The tongue presents nothing characteristic. It may be unchanged, slightly furred, or covered with sordes in the last stage. Appetite is no doubt impaired, but the desire for food is controlled in a measure, owing to the trismus and cervical contracture Avhich efforts at swallowing, together Avith the necessary movements, induce. Thirst is an invariable symptom and is with difficulty appeased. Pyrexia is present to a very variable extent ; it may be scarcely appreciable, or it may range as high as 105° and 106° F., and in the last stage is usually highest. With pyrexia the usually febrile pulse and respiration are associated, but marked dyspnoea may be superadded from paralysis or rigidity of respiratory muscles Avhen the doi'sal region of the cord is included in the inflammation. In cases complicated Avith pneumonia additional respiratory difficulty may be due to this cause ; this is, hoAvever, a rare complication except in the epidemic form. The pulse is almost ahvays quickened, ranging from 80 or 90 to 120, and in' the first stage may have considerable tension, Avhich is lost at an early period, a diminished arterial tension being one of the characteristic features of the disease. Very much more frequent pulse is recorded, and at times it falls as low as 50, but these instances are altogether exceptional. The kidneys rarely sIioav any distinct lesion, but the urine is often increased in quantity, and occasionally contains a small amount of albumin. Retention of urine from spasm of the sphincters or paralysis of the detrusor muscles is sometimes associated Avith reflex spasm and irritable attempts to urinate. Involuntary, not necessarily unconscious, voiding of mane and fleces also happens. Diagnosis. — The positive indications of simple cerebro-spinal meningitis have already been mentioned. Briefly stated, they are headache, pain in neck, back, and loins, Avith general cutaneous hyperaesthesia, exaggerated sensibility to light and sound, irregular pupils, oscillations and distortions of the eyeball, folloAved at times by blindness and deafness, paralysis of cranial or spinal nerves, delirium, convulsions, and coma ; vomiting Avithout apparent gastric cause, obstinately persisting ; trismus and cervical contractures Avbich may extend to nearly all the muscles of the body ; pyrexia of inconstant degree, 608 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. iind respiratory labor of varying and uncertain extent. From the epidemic form it is to be distinguished by its sporadic occurrence, its less rapid progress, its perhaps more extensive involvement of the spinal membranes, its usually less acute course, and the comparatively infrequent cutaneous lesions, espe- cially of purpuric or hmmorrhagic character. It probably is more frequently causally related to local troubles of eye and ear, bone lesions, trauma, and sepsis. Perhaps if a clear distinction is to be permanently maintained between the simple and epidemic forms, it will come to rest on the absence of the diplococcus lanceolatus in the former and its presence in the latter. With typhoid fever it may be confounded, but the distinction is not diffi- cult. The severe persistent headache and spinal pain, the cutaneous hyperses- thesia, the exaggerated sensibility of special senses, trismus, muscular contrac- tures, uncontrollable vomiting, constipation, — all early symptoms, — are suffi- cient for diagnosis before the later symptoms of each make error impossible. With tetanus it has little in common but retraction of the head and slight opisthotonos, trismus, and thoracic constriction. In meningitis the back is less bowed, less rigid, and the contracture less easily induced ; the trismus is seldom severe, often wanting, and rarely persists, whilst in tetanus a touch or a breath of air induces rigid opisthotonos, and trismus is an early, severe, and persistent symptom. In doubtful cases, if any such occur, the detection of the micro-organism of tetanus will resolve the doubt. Cases of tubercular origin are to be distinguished alone by the invasion of other organs and by the family history, a more protracted course and an initial period of latency, with a less acute career. Prognosis. — This is always grave, but a fair proportion of sporadic cases recover under judicious treatment. When the symptoms relate chiefly to the cord, a reasonable hope may be entertained, but when paralysis of ci’anial nerves, stupor, Cheyne-Stokes respiration, coma, and collapse occur, the issue is no longer uncertain. In some instances death has ensued in five hours, in from twenty-four to thirty-six hours not infrequently, but this has always been in fulminant cases, which are rare in the simple form. In sporadic cases life may be protracted several weeks, and in subacute cases sometimes many months ; the usual period is about from ten to twenty days. Cases that recover are of longer duration than those that terminate fatally, but eveti in favorable cases the patient may be maimed for life, blind, deaf, paralytic, or with intelligence permanently impaired. Iri young children and in adults near middle age the mortality is greater than in youth. Death may be due to asthenia from continued suffering, bed-sores, and inability to partake of food; or it may be more rapidly induced by respiratory difficulty from involvement of the res])iratory centre, or by associated pneu- monia ; or convulsions may be followed by coimi, collaj)se, and speedy death. Treatment. — 'I’hesame treatment advised in cerebral meningitis is advisa- ble in cerebro-spinal meningiti.s — 1. e. perfect rest, exclusion of light and noise, of visitors, and all causes of disturbance; removal of the cause when known and practicable; the occasional use of a brisk mercurial or other purge; li<(uid food and stimulants administered per rectum if not retained by the stomach ; free and continued use of cold to the shaven head and back — ice ))referred ; the careful but efficient use of anodynes, of which oj)ium and its derivatives are best, and in the early stage such remedies as the iodide and bromide of potassium with ergot. When the affection is chiefly or wholly spinal, Hramwell speaks in terms of high commendation of the iodide, a,nd of ergot in the second stage, and also of the use of blisters and of tincture of iodine applied along the spine in the region implicated. Pain, cutaneous hypermsthesia, and muscular SnrPLE CEREBROSPINAL MENINGITIS. 609 contractures indicate sufficiently clearly the site of the inflammation by the correspondence of these symptoms with the distribution of the nerves whose roots are aflected; attention to the bladder and rectum is of course always requisite. Paralyses may require special measures in accordance with the com- mon rules of treatment, but Bramwell suggests caution in the use of electrical stimulation during the period of meningeal irritability. 39 TUBERCULOUS MENINGITIS. By JAMES HENDRIE LLOYD, A. M., M. D., Philadelphia. Tuberculous meningitis is an inflammation of the membranes of the brain due to the specific action of the tubercle bacillus. It is characterized by the formation of tubercles in, and an inflammation of, the pia arachnoid, with effusion at the base of the brain ; by some secondary cerebritis, and even softening of the brain-substance ; and by effusion into the ventricles. Etiology. — The essential cause of tuberculous meningitis is of course the bacillus of tubercle, first demonstrated by Koch. In the vast majority of instances — probably in all cases, in fact — the infection of the brain-mem- branes is secondary to a primary infection in some other jiart of the body. This primary infection may be in the mesenteric or bronchial glands, in chronic ear disease, or in some other bone di.sease, such as spinal caries or tuberculous disease of the hip-joint. It is not uncommon in these cases to find tuber- culous infection also beginning in the lungs, or even in the spleen and kid- neys. In some of these latter instances, however, the infection is possibly not primary, but, as in the case of the meninges, secondary. Thus in a number of cases seen by me at the Home for Crippled Children the patients had had long-standing chronic disease of bone, and the infection of the lung-tissue, as well as of the brain-membranes, was evidently secondary and recent. Heredity is a predisposing flictor, just as it is in all forms of tuberculous infection. In many cases it is possible to elicit a family history of tubercu- losis, and in cases in which this family history cannot be traced there is always a justifiable suspicion of it. It cannot be denied, however, that tuber- culous infection of the membranes of the brain, as well as of other organs, may occur in rare instances in patients in whom there is no hereditary pre- disposition to it. As the disease is due to the invasion of a bacterium, it might possibly occur in a person whose family history showed no trace of it. Among predisposing causes age is undoubtedly the most imjmrtant. The great majority of cases occur in children. The disease is most frcciuent be- tween the ages of two and seven years. Its frequency diminishes rapidly after the fifteenth year. It is a comparatively rare disease in adult life, although it is possibly rather more frequent in long-standing cases of pul- monary tuberculosis than is generally supposed. Some of the brain-symp- toms, for instance, occasionally seen in phthisis are no doubt due to infec- tion of the meninges. This conqilication may readily be overlooked at the autopsy, at which time attention is ajit to be directed too exclusively to the thoracic and abdominal organs. Sex is not an important factor in predisposing to tuberculous meningitis. Boys are usually supposed to furnish a rather larger number of cases than girls. Trauma has not been satisfactorily demonstrated to be an exciting cause. 610 TUBERCULOUS MENINGITIS. 611 This disease is usually supposed to attack by preference weakly and deli- cate children, but this can readily be explained by the fact, already stated, that it rarely if ever occurs except as a secondary infection, and consequently only in those cases in which the health has already been impaired by an infection of some other organ by the tubercle bacillus. In searching for a cause of tuberculous meningitis in any given case the utmost care must be exercised to determine, if possible, the existence of a focus of tubercle in some other organ. This may readily be overlooked by a careless observer. A few broken-down bi’onchial glands, a small unabsorbed patch from a precedent pneumonia, an uncured otitis media, or a small focus of caries in a bone may have been the starting-point for the infection. Symptoms. — Tuberculous meningitis is usually described as a disease of progressive stages. This is rather an arbitrary or artificial methorodrome. As already explained, it is usually due to the fact that the patient is already suffering from some primary tuberculous infection. This may be present in caseating glands or in a focus of tuberculous bone-disease, such as otitis media or spinal caries. The decline in health, in fact, is jtrobably rather due to this ])rimary infec- tion than to the involvement of the brain-membranes. When this latter occurs the characteristic symjitoms, in some form or other, such esj)ecially as headache and vomiting, usually soon manifest themselves. Thus the initial impairment of health probably indicates merely that the patient’s system is beginning to offer less resistance to the tubei’culous invasion, and this dimin- ished resistance is the immediate cause for the determination of the infection to the brain-membranes. In very many cases, however, the onset of tuber- culous meningitis is rather abrupt, a j)eriod of initial ill-health being en- tirely absent or so slight as to escape observation. In such instances the true significance of the earlier symptoms, such as headache, vomiting, and slight mental changes, may be entirely overlooked, these symptoms being attributed to some other disorder, especially gastric or intestinal derange- ment. This initial ill-health, when it occurs, varies so much that it is diffi- cult of description. It may consist of fluctuations of temperature, impairment of appetite and assimilation, loss of flesh, asthenia, and slight mental phe- nomena, such especially as irritability, peevishness, and unprovoked ex])lo- sions of ill-temper. The child under the.se circumstances is noted by the parents and attendants to be losing ground; the physician’s advice is asked, and the cause for the obvious failure of health may be sought for dur- ing a short period in vain. In such cases the onset of the characteristic G12 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. symptoms of tuberculous meningitis may be insidious and deceptive in the extreme. Slight headache may occur, and this in young children is not always easily recognized. Gastro-intestinal symptoms may begin to present themselves, such as occasional vomiting and more or less persistent constipa- tion, and the meaning of these may he entirely misconstrued. In such a case a convulsion may he the first grave symptom to attract the physician’s attention and to arouse his suspicions. Headache is usually a very early symptom in tuberculous meningitis, and one of the most persistent and characteristic. In very young children, as already said, it may not be easily recognized. Its presence may be suspected from an occasional sharp cry of pain, especially when the child is moved or disturbed. The patient may indicate its presence also by movements of the hands toward the head, by di’ead of light, and by a disposition to remain abnormally quiet and apathetic. The peculiar cry of the child suffering with tuberculous meningitis has been noted by most authors, and has even been named the hydrocephalic cry. It is probably an expression of severe pain in the head, and is so characteristic that it should always excite susj)icion. The child sometimes gives utterance to this cry in the midst of perfect calm and repose. The cry then has a sort of explosive character, and is usually piercing and harassing. In older children complaint of the head- ache is usually an early symptom, and is often urgent and persistent. The patient seeks the dark, dreads to be disturbed, and often begs piteously for relief. In some few cases, Iiowever, as I have seen, headache, while pres- ent, is not always so severe and prominent in the early stages. On close questioning, how'ever, the pre.sence of this symptom can usually be deter- mined. The child says that its head aches, and will often raise the hand to the region where the pain is most intense. It is not unusually referred to the frontal region : it may, however, be more generally diffused, the patient being unable to state accurately just where it is most severe. This is partly due, no doubt, to the inability of young children to localize and describe accu- rately their subjective .symptoms. The headache of tuberculous meningitis does not manifest itself only during the waking hours: in many cases it is evidently present during sleep, and the nights are disturbed by an occasional loud and agonizing cry, which the patient emits unconsciously. This hydro- cephalic cry, witli its peculiar explosive character, occurring during sleep, is especially characteristic and suggestive. Headache, even in cases in which it is not ])rominent in tlie early stages, is almost sure to become a marked symptom as the case progresses. It is not always disguised even by the stupor which eventually comes on. Vomiting is an important symptom in tuberculous meningitis, but it is one the true significance of which is often overlooked in the early stages. It is frecpiently unaccompanied with nausea, and may then be ])ropulsive or spontaneous in character. It is one of the most constant syuq)toms of the disease, and, as a rule, is more marked in the early than in the later stages. Harrier, (juoted by Meigs and Pepper, found it absent in only 15 out of 80 cases. Sometimes, in fact, the vomiting is the first really well- marked symptom of the disease. In these cases it may bo so persistent as to lead to the belief that it is caused by some obstinate gastric or gastro- intestinal disorder. I'hus in one case, the history of which 1 know, the vomiting led to a diagnosis of cholera morbus, which was rendered more plausible by the fact that the boy, aged about eight years, had had a few loose stools and that the case occurred in midsummer, 'rids patient was hurried to the seashore, and a true diagnosis was not made until the onset ANOMALIES AND CURIOSITIES OF MEDICINE. By George M. Gould, A.M., M.D., and Walter L. Pyle, A.M., M.D. Im- perial octavo. 968 pages, handsomely illustrated. Cloth, $6.00 net; Half Morocco, $7.00 net. ^ An encyclopedic collection of rare and extra- ordinary cases, and of the most striking instances of abnormality in all branches of medicine and surgery, derived from an exhaustive research of medical literature from its origin to the present day, abstracted, annotated, classified, and in- dexed. As a complete and authoritative Book “A most remarkable and interesting volume. It stands alone among medical literature, an anomaly on anomalies. It is a book full of reve- lations from its first to its last page, and cannot but interest and sometimes almost horrify its readers .” — American Medico^Surgical Bulletin. “One of the most valuable contributions ever made to medical literature. Every page is as fascinating as a novel .”— Medical Jour- nal. of Reference it will be of value not only to members of the medical profession, but to all persons interested in general scientific, sociologic, and medicolegal topics ; in fact, the absence of any complete work upon the subject makes this volume one of the most important literary inno- vations of the day. ^ ^ ^ ^ ^ GOULD AND PYLE’S CURIOSITIES OF MEDICINE A Clinical Text-Book of SURGICAL DIAGNOSIS AND TREATMENT. By J. W. Mac- donald^ M.D. Edin., L.R. C.S. Edin.^ Professor of the Practice of Surg;ery and of Clinical Surgery in Hamline Uni- versity^ Minneapolis, Minn. Octavo. 800 pages, handsomely illustrated. Cloth, $5.00 net ; Half Morocco, $6.00 net. This work aims in a comprehensive manner to furnish a guide in matters of surgical diagnosis. It sets forth in a systematic way the necessities of examinations and the proper methods of making them. The various portions of the body are then taken up in order and the diseases “ The work is brimful of just the kind of prac- tical information that is useful alike to students and practitioners .” — Cincinnali Lancet-Clinic. and injuries thereof succinctly considered and the treatment briefly indicated. Practically all the modern and approved operations are de- scribed with thoroughness and clearness. The work concludes with a chapter on the use of the Rontgen rays in surgery. ^ MAOXINALEKS SURGICAL DIAGNOSIS AND TREATMENT TUBER CULO US MENINGITIS. 613 of stupor, accompanied by convulsions, indicated clearly the true nature of the disease. In the later stages of tuberculous meningitis the vomiting may gradually disappear. This symptom is supposed to depend upon irrita- tion of the roots or intracranial trunk of the pneumogastric nerve. It is not such a common symptom in meningitis from other causes at the convexity or other regions of the brain vhere the vagus is not involved. In most cases the vomiting is not continuous, but occurs in paroxysms not more frequently than two or three times a day. It usually takes place without warning and without nausea, and thus has the essential characteristics of cerebral vomit- ing. It occurs independently of the presence of food in the stomach, and the matters vomited are merely such as haj)pen at the time to be in that viscus. Occasionally, indeed, there is little if any food in the stomach, and the material rejected is merely a little fluid or mucus. Constipation is very rarely absent in tuberculous meningitis. It is regarded by some observers as even more important than vomiting as a symptom of this di.sease. It is sometimes so aggravated and obstinate that the wonder is that its significance should be mistaken. In combination wdth the early headache and vomiting it forms a group of symptoms that should be unmistakable. This association of vomiting with obstinate constipation gives a peculiar aspect to these cases, which is entirely^ different from what would be seen if the symptoms were due to gastro-intestinal irritation. This distinc- tion is still further emphasized by the fact that in tuberculous meningitis there is great retraction of the abdomen. The scaphoid belly, associated with obstinate constipation, is seen in the majority of cases of tuberculous meningitis. When present it is a symptom that can always be relied upon, although its absence is not necessarily a sign that tuberculous meningitis is not present. Constipation, as a rule, is not a very early symptom of the disease ; at least, it is not conspicuous until the lapse of a number of days. For the first few days it may naturally attract but little attention or may be thought to be due to some trifling or temporary cause. It is exceedingly intractable to drugs, and in some cases there may be great difficulty in securing a movement of the bowels. The cause of this symptom has not been accurately determined. It is possibly due to involvement of the pneumo- gastric nerve.' Convulsions are rarely absent at some stage of tuberculous meningitis. There is no positive law, however, about their occurrence. As already said, a fit is not usually an initial symptom of the disease. It may, however, be the first symptom to arouse the .suspicion of the practitioner. I have known of cases in which the correct diagnosis was not made until the occurrence of a convulsion. As a rule — to which, however, there are some exception.s — convulsions do not occur in the first stage of tuberculous meningitis. They usually do not appear until there is some slight evidence of involvement of the psychical faculties, such as is shown by apathy, drowsiness, or even stupor. Hence it may be said that convulsions do not occur much before the middle or end of the second week. The intensity and frequency of these con- vulsions vary greatly in different cases. In some there may be but one, two, or three seizures during the wdiole course of the disease, and these may occur at intervals of some days. In others the attacks are more frequent. The indi- vidual seizures vary also in their intensity and duration. Sometimes the con- vulsive attack is distinctly /oca/ in character — i. e. it may be confined to a few * According to Landois and Sterling, stimulation of the vagus increases the movements of the small intestine. Hence we might infer that the obstinate constipation .seen in tuberculous meningitis is an evidence of paralysis of the pneumogastric nerve. 614 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. muscles or muscle-groups ; thus the muscles of the eye, eyelids, or face may alone be involved, or may be involved more and for a longer time than the mus- cles of the extremities. This is due probably to irritation of the cortical cen- tres that preside over the affected muscles. In most cases, however, the con- vulsion is general and accompanied by profound unconsciousness, and may be succeeded by a long period of coma. In some instances the convulsive attack is more marked on one side than on the other, and in these there may be slight paresis of the affected side remaining after the fit. In a few instances convulsions succeed each other with great frequency, .so that the child passes rapidly from one to another, and may even present a condition not unlike epileptic status. In this state the temperature rises and the danger to life is imminent. It is not unusual, in fact, for a prolonged con- vulsive seizure to be the immediate cause of death. Alterations in the circulation are very common in tuberculous menin- gitis. In the very early stages there is simply increased rapidity of the pulse. This is in no wise characteristic, and therefore may simply be re- garded by the practitioner as an indication of the general weakness and ill- health into which the patient is passing. Later, however, the pulse assumes an entirely different character, and then furnishes one of the most striking symptoms of the disease. This alteration consists in a slowing and irreg- ularity of the heart’s action. The pulse falls fre((uently as low as 60, and in rare instances even to 50 or lower. With this slowing of the heart there occurs also a disturbance of the rhythm of its pulsation. The heart beats irregularly, the intervals between its pulsations vary, and the indi- vidual pulsations also vary in. their force. Thus a few regular rhythmical pulsations of even force may be followed by a feeble pulsation at a longer or even shorter interval than normal, or several of these feeble and irregular beats may occur. This symptom is seldom absent in tuberculous meningitis. It may not, however, be ecjually apparent at all times, and should therefore be watched for with the utmost care. If the physician does not satisfy him- self of its presence during his visit, he should instruct the nurse or attendant to look for it at frecjuent intervals during the day. If he finds a suspicious slowing of the pulse, he should especially be on the lookout for this highly characteristic irregularity. Changes of posture affect the pulse under these circumstances. It may for a time become more rapid, and then be followed by a period of slowing, during which the irregularity may be noted. The importance of this symptom is very great, and in cases otherwise doubtful it may furnish the conclusive sign of the presence of the disease. It is probably not seen in all its well-marked characteristics in any other disease of child- hood. When it occurs after an initial period of headache, vomiting, and con- stipation, even though no convulsion has occurred, it may be regarded as pointing unerringly to the diagnosis of tuberculous meningitis. Toward the termination of the disease this slowing and irregularity of the heart gives place to increased fre(pu'ncy and feebleness. The ])ulse then rises to 140, 160, or even higher, and toward the end may be so raj)id and feeble as scarcely to be countable at all. The tem{)erature in tuberculous meningitis is exceedingly irregular. In the early stages it fluctuates from normal to 101° or 102° F. Later it takes a higher range, and seldom falls to the normal point. It cannot, however, be said to pur.sue a characteristic range, such as occurs in tyi)hoid fever. Toward the very end it mounts still higher, and at the moment of death may roach 104° or 105°. This range of temperature is well shown in the accom- panying chart from the case of a girl aged eight years who died on the lif- TUBERCULOUS MENINGITIS. 615 teenth day of the disease (Fig. 1). This chart shows also the characteristic variations in the pulse-rate. On some days, it will be noted, the pulse was as low as 80, but later it became as rapid as 200. In some few cases the tem- perature, instead of mounting toward death, falls to an abnormally low point. Thus in a case reported by Gee the temperature on the day of death fell to 79.4°. In these cases the breath feels cold to the hand, the pulse is imper- ceptible at the wrists, and yet, according to Gee, the appearance of the patient is very misleading and may even resemble that of a healthy child. In my observation reduction of temperature below' the normal point in the last stages of the disease is rather rare. It w as well shown in the case of an Fig. 1. NOV. C. -43° -41° -40 -39 -38 -37 L-36 Temperature Chart from a Case of Tuberculous Meningitis (Methodist Hospital). Italian girl aged ten years who died recently in the nervous wards of the Philadelphia Hospital (Fig. 2). While the range of temperature in tuber- culous meningitis is not characteristic, still a careful study of it in doubtful cases is of the first importance. This is so especially in cases in which it is necessary to make a differential diagnosis between this disease and either typhoid fever or tumor of the brain. The very irregularity serves to exclude typhoid fever, and the extreme fluctuations are unlike anything that is seen, as a rule, in cases of tumor of the brain. The mental changes occurring in tuberculous meningitis are not without significance, especially in the early stages. Most authors speak of these 616 AMERICAN TEXT-BOOK OE DIHEASEH OF CHILDREN. changes as being in some degree characteristic. A very early change in tone, as it were, of the patient’s mind may be observed, especially by those to whom the child is well known, as parents and nurses. In addition to the peevishness and fretfulness not uncommonly seen in ailing children, the patient with tuberculous meningitis not unfre(iuently gives vent to sudden and even uncalled-for explosions of ill-temper. In very little children this symptom, associated with evidences of headache, fluctuations of temperature, vomiting, and constipation, may be of some value in helping to a diagnosis. On the other hand, these children sometimes in the early stages become unusually rpiiet and apathetic. They appear to be in a dream-like state, or, as Meigs and Pepper have well called it, a state resembling mild ecstasy. In Fig. 2. C. Temperature Chart from a Case of Tuberculou.s Meningitis, showing subnormal temperature (I’hiladel- ])hia Hospital). this condition their thoughts seem wandering and far away, and a distinct im{)re.ssion must be made to recall the child’s attention to itself or its sur- roundings. From this condition it is but a stej) to true delirium, -somnolence, and stupor. As a rule, the intellectual faculties are not seriously involved in the early stages of tuberculous meningitis. The child does not pass into delirium and stupor until well on in the second week. Fxcejitions, of course, may occur according to the activity and extent of the infection of the brain-membranes and to the resistive power of the child. In a few cases, for instance, some delirium or mild wandering of the thoughts occurs in the very early stages, particularly when the headache is intense, and more especially on waking. Raving delirium, however, is not common. In fact, the most conspicuous TUBERCULOUS MENINGITIS. 617 mental change is somnolence with a tendency to pass into a stupor or a soporose state. In this state the child will often lie quiet and uncomplain- ing for hours, making known few if any of its wants. Occasionally, it will utter the ci’y of pain indicative of headache, although this tendency dimin- ishes as the disease advances. Still, the child can be roused, although, as a rule, it dislikes exceedingly to be disturbed, and cries out, resists, and gives evidence of pain in the head and of dread of light. It wdll usually, however, with a little urging, respond to (juestions and do as it is bidden. Thus it will put out its tongue and take medicine or food. As the case advances, however, the stupor increases and it becomes more and more difficult to excite the child’s mental reflexes. Long, loud, and repeated urging is necessary to induce the child to respond. Finally, after some days of such slow' and gradual progress that it is difficult to establish the limits of the various steps, the condition passes into one of profound coma, from w'hich the child never rouses. This terminal coma is sometimes of rather unexpected length. When it is once deeply established it is usually associated with such well-marked symptoms of failing vitality, such as rapid pulse, emaciation, and shallow respirations, that the attendants are inclined to anticipate speedy dissolution ; but this expectation is not always realized. Patients, for instance, who seem scarcely able to live over twenty-four hours will sometimes linger for a period of days or even a week or more. Various palsies, especially of the muscles supplied by some of the cranial nerves, are encountered in tuberculous meningitis. The muscles of the eye are most fre(juently affected. Thus a very common symptom is strabis- mus, due to a palsy of some of the orbital muscles. There may be, for instance, an internal strabismus, due to paralysis of the sixth nerve, or an external strabismus with ptosis and dilatation of the pupil, from paralysis of the third nerve. Ine(iuality of the pupils, in fact, is a very constant symptom in this disease, but it is not necessarily associated with the evi- dences of paralysis of the trunk of the third nerve. It is sometimes due, no doubt, to an involvement, by pressure or otherwise, of the nuclei presiding over the iris — i. e. the foremost nuclei of the third nerve beneath the anterior portion of the aqueduct of Sylvius and in the wall of the third ventricle. Of other cranial nerves involved, the commonest are probably the seventh and the tenth. Facial paralysis or paresis is occasionally seen. The slow and irregular action of the heart is possibly due to some involvement of the roots of the tenth or pneumogastric nerve. Unilateral paralysis of the tongue, due to tuberculous meningitis, is probably extremely rare. In some cases paralysis of the limbs occurs; this is especially noted when there have been severe and long-continued convulsions, the convulsion being followed by a hemiplegia or a monoplegia. These symptoms are probably due to an invasion of the cortical centres by irritating toxins, or even by the meningitis itself, or to pressure upon the motor tracts downward through the peduncle and pons, or to interference with the circulation passing upward to the inter- nal capsule through the anterior perforated space. Paralyses of the leg and arm are not nearly so common as the palsies of the cranial nerves, and when they occur it is usually late in the disease. In some cases, instead of distinct paralysis following a fit, there may be a state of rigidity or of spastic pax’esis. This is due evidently to a continuously irritating action of toxins upon the nerve-centres. A spastic state, moreover, is not infrequently seen in tuber- culous meningitis independent of a convulsion. It may sometimes appear rather early in the disease, and then usually attends or follows a fit. Opis- thotonos is occasionally seen toward the end of the disease ; it is very rare 618 A3IERICAN TEXT-BOOK OE DISEASES OE CHILDREN. in the early stages. It is sometimes intermittent or paroxysmal and varies in degree. In exceptional cases the retraction of the head is extreme, pre- senting the condition known as retrocollic spasm. In a patient recently seen in the Philadelphia IIosj)ital this symptom was continuous for days, the child lying on its side with its head retracted to its full extent, so that the occiput rested on the shouldei’s, and when the child was placed on its back, the face was directed fully toward the head of the bed. In some cases tremor, oi', more accurately, a slight ataxia, occurs, especially in the hands, arms, legs, and feet. Optic neuritis, or congestion of the optic papilla, is occasionally present in tuberculous meningitis, and would probably be seen oftener if it were more fre(iuently searched for. Tubercles in the choroid are occasionally seen. According to Oliver, tuberculous meningitis is more prone than other forms of meningitis to cause changes in the optic nerves. Changes in respiration may be noted. In the somnolent or stuporous condition this is especially so. The respirations become unequal in depth and irregular in rhythm. Occasionally the interval between inspirations is very prolonged, and then breathing will be resumed with a long sighing expiration. Toward the end the respirations may be rapid and shallow. True paralysis of the bladder and rectum is not seen, but incontinence of urine and fmces may occur, owing to the mental state. Progressive emaciation is usually present in all cases of tuberculous men- ingitis, and when the disease is unduly protracted this emaciation, with pallor of the skin, becomes quite marked. In some cases, however, the nutrition is fairly well pre.servcd, although, as a rule, it is difficult to induce these patients to take sufficient nourishment to repair the waste going on in the system. To recapitulate briefly, the symptoms may be grouped with more or less accuracy, so that the disease presents several stages. In the first stage, including the prodromal period of ill-health, there may be noted slight mental changes, such as extreme irritability, with headache, vomiting, fluctuating temperature, and obstinate constipation. Occasionally in this stage a convulsion occurs, but this is rare. In the second stage these symptoms are aggravated, except that the vom- iting is no longer such a 2)ronounced symptom. Delirium now supervenes, and the child passes into a stuporoins- or somnolent state. The characteristic slow and irregular pulse appears, a convulsion may occasionally occur, ocular palsies are seen, and the whole appearance of the case suggests more unmis- takably the presence of grave cerebral disorder. The third or terminal stage is marked by increasing stupor, pa,ssing into coma. The .slow and irregular pul.se may continue for a time, to be suc- ceeded by a very raj)id pulse toward the end. An occasional convulsion may occur, and this may be followed by more or le.ss prolonged monoj)legia or hemiplegia. Ocular palsies are more conspicuous and permanent. Spastic states are j)resent. Opisthotonos and retraction of the head may be present. Vomiting no longer occurs, as a rule. Incontinence of urine and ficees may come on. Food is rqiceted, or difficult to administer because of involvement of the mmsclcs of deglutition. The fateful aspect of the case inerea.ses. The temperature ranges higher or falls abuormally low. Profound coma super- venes, and the child dies either from gradual paralysis of all its vital func- tions or from a convulsion. Prognosis. — In tuberculous meningitis the prognosis is invariably unfavor- able. A few authors (Jacobi and others) claim to have seen an occasional TUBER CULO US 3IENINGITIS. 619 recovery, but such cases must always leave a doubt as to the accuracy of the diagnosis. They only serve at least to emphasize the rule that tuberculous meningitis is one of the most unerringly fatal diseases of childhood. Duration. — This disease, as a rule, is rather rapid in its course. Few cases linger beyond the fourth week. Some are fatal within the first ten days, especially if severe convulsions supervene. The average duration of the disease is probably about twenty to twenty-five days. Diagnosis. — Tuberculous meningitis may be mistaken for simple infantile convulsions, digestive disorders, typhoid fever, brain-tumor, and hysteria. It is occasionally simulated by pneumonia. It may remotely simulate a few other disorders, but the resemblance is so slight as scarcely to demand notice here. Infantile convulsions or convulsions occurring in young children should always suggest the possibility, at least, of tuberculous meningitis. If they occur in children who have previously had them, this possibility is of course more remote. A convulsion in a young child may be due to numerous causes, such as indigestion or a beginning exanthem. The only rule is to watch patiently for the cause, which in most of these instances will usually present itself. In a case of commencing tuberculous meningitis the diagnosis Avould be established especially by the onset of headache, vomiting, constipation, fluctuations in temperature, mental changes, and by the persistence of these symptoms. A careless observer might mistake the obstinate vomiting of tuberculous meningitis for an evidence of gastro-intestinal disorder. But the other symp- toms, such as headache, constipation, and fluctuating temj)erature, as well as the persistence of these symptoms and the mental changes, should indicate that the disease is not due to gastro-intestinal infection. In the very early stage, however, a mistake is readily made. Typhoid fever and tuberculous meningitis may closely simulate each other in young children. The differences in the temperature range, however, are well marked, while in typhoid fever, although headache and vomiting may occur, they are usually associated with some looseness of the bowels, and the slow and irregular pulse of tuberculous meningitis is not noted. The charac- teristic eruption of enteric fever, when present, is a determinative sign. Tympany, so common in typhoid fever, is not seen in tuberculous meningitis. Great care, however, is undoubtedly required to distinguish these two dis- eases, and this can only be done in some cases by patient study during a number of days. From brain-tumor, especially a tumor of the cerebellum, tuberculous men- ingitis may be distinguished by its more abrupt onset, its shorter duration, its fluctuating temperature, its slow and irregular pulse, and its obstinate constipation. The headache and vomiting, which might cause it to resemble a cerebellar tumor, are usually of greater intensity at the beginning and of briefer duration in tuberculous meningitis. In this latter disease, moreover, there are not the cerebellar ataxia and other disorders of motion so commonly seen in cases of tumors beneath the tentorium. Optic neuritis, while not un- noted in tuberculous meningitis, is not such a prominent symptom and does not lead to such distinct post-neuritic atrophy as is seen in cerebellar tumor. Hysteria, which simulates so many diseases, might possibly itself be simulated by tuberculous meningitis in the child. A little care in observa- tion, however, should clear up the diagnosis. The persistent headache, vom- iting, slow and irregular pulse, obstinate constipation, and elevation of tem- perature would be against hysteria in a child, while an absence of some of the 620 AMERICAN TEXT-BOOK OE DISEASED OE CHILDREN. characteristic mental and physical stigmata of the great neurosis Avould usually be noted. It must he recalled, however, that hysteria may compli- cate grave organic diseases, and this might be so in the early stages of tuber- culous meningitis ; but the symptoms just enumerated should guard the physi- cian against error. Pneumonia in young children, especially if complicated with marked cerebral symptoms, may simulate tuberculous meningitis. The crucial test is of course the detection of the physical signs of the pneumonia. The brain-symptoms, while intense in pneumonia, are not associated with the characteristic slow and irregular pulse. On the other hand, tuberculous meningitis is more apt soon or late to present ocular palsies and convulsions with paresis. In the early stages, however, the main reliance should be placed upon the physical signs, the raj)idity of respiration, the evidence of pain in the chest, and a rather higher and more persistent range of tem- perature. Quincke’s operation of lumbar puncture has given some satisfactory results. Fiirbrinon, or irritation of, the sensitive dura mater. It may be in any part of the head, but is usually TUMORS OF THE RRAIN AND MENINGES. 637 frontal or occipital, without reference to the seat of the tumor. Occasionally the pain is distinctly and constantly localized at one place, and here there may be tenderness of the scalp and head on percussion, this being under such cir- cumstances of value as a localizing symptom. The pain is dull and continuous or intermittent and severe. Infants probably suffer less, owing to the greater distensibility of the skull ; and in them pain may be inferred from restless- ness, irritability, sharp cries, sleeplessness, and burrowing movements of the head. Nausea and Vomiting. — These symptoms are noted in from one-fifth to one-fourth of the cases. They are commoner in children than in adtdts. The vomiting may occur without nausea, irrespective of the taking of food, and intermittently or more or less continuously. It may be associated with vertigo, and frequently accompanies severe headache. It is often brought on by move- ment of the body. It is most common in cerebellar tumor. Vertigo. — This symptom is not uncommon, and is particularly frequent with cerebellar neoplasms. As it accompanies so many divers affections out- side of the cranial cavity, it cannot be regarded as of great diagnostic value. Optic Neuritis. — The optic nerves are affected, according to Starr, in 80 per cent, of cases of brain-tumor, and hencQ this constitutes one of the most significant objective symptoms. It must be always looked for, since neuritis may exist to a very great extent without visual defect. Usually double, it may at first appear in one eye, and generally one disk is more affected than the other. This symptom, too, is more common in tumors of the cerebellum and at the base of the brain. It must be remembered, however, that it occurs in other disorders beside brain-tumor, such as meningitis, hydrocephalus, and abscess. Optic atrophy may follow the neuritis. Convulsions. — Spasms are of frequent occurrence in the brain-tumors of childhood. They may be slight [petit mal) or severe, limited to certain mem- bers, or general, infrequent or frequent — tAventy to thirty per day. General convulsions have no significance as to the seat of the lesion, nor can partial epilepsy (Jacksonian) always be relied upon to indicate the situation of the tumor. Mental Changes. — In at least half of the cases some psychical disturbance is manifest. This is naturally much varied according to the amount of brain injury and the age of the child. It may show itself in mere fretfulness and irritability, or there may be dulness, lethargy, hebetude. In some cases there may be delirium, maniacal excitement, or an enfeeblement of the mental pro- cesses amounting to dementia. Somnolence is a common symptom in children. As the disease progresses this often deepens into coma. Tremor., insomnia., fever, neuralgia, slow or rapid pulse, disturbances of respiration, and constipation, are symptoms occasionally observed in certain cases, but from these no significant deductions can be made. Increase of head- temperature, local or general,' as measured by the surface thermometer, has not yet been sufficiently studied to be practically available as a symptom in brain- tumor. Localizing Symptoms. — After due and careful consideration of these general symptoms, we must examine the focal manifestations, which are either irritative or destructive. Localizing symptoms depend altogether upon the seat of the tumor, whether adjacent to the motor area of the cortex (partial epilepsy) or in the motor tract (monoplegia or hemiplegia) ; in the sensory areas or tracts (anaesthesia, hemianaesthesia, hemianopsia, etc.) ; in motor or sensory speech-centres or tracts (aphasia in various forms) ; or, finally, impinging upon cranial nerve nuclei or trunks (paralysis of cranial nerves). 638 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Gradual onset and spread are the rule in brain-tumor. There are occa- sional exceptions, since a secondary meningitis or a haemorrhage in the new growth may produce a sudden exacerbation ; and there are in rare instances intermissions, remissions, or even retrogressions, in the course of its develop- ment. Usually the symptoms of cerebral or cerebellar tumor are unilateral, whereas those of neoplasm at the base affecting the cerebral axis are often bilateral. The relative frequency with which tumors affect the various parts of the brain may be learned from the following table : Site of Tumor. Number of Cases. Cerebellum 105 Pons Varolii 42 Centrum ovale 41 Basal ganglia and lateral ventricles 30 Corpora cpiadrigemina and crura cerebri 25 Cortex cerebri 23 Medulla oblongata 7 Fourth ventricle 0 Base of brain 8 Total 287 From this it will be seen that tumors of the cerebellum are slightly in excess of those of the cerebrum proper (105 to 94), while the remaining 88 cases were of new growths in the structures about the base of the brain (crura, pons, and medulla). Tumors of Cortical and Subcortical Regions. — These are mostly tubercles, sarcomata, gliomata, and cysts. It is difficult to differentiate cortical from subcortical tumors, the symptoms being about the same, and neoplasms in either portion tending by extension to involve the other. The manifestations will vary according to the functions of cortical centres or descending tracts involved. A study of Figs. 1 and 2 will show what functions will be destroyed by tumors affecting the different portions of cortex there represented, while in Fio-. 3 the tracts of fibres Avhich convey impulses to and from these various centres are shown. The chief points to be noted in relation to new groAvths here may be briefly stated as follows : Fig. I. Scheme of Localization in Cortex of Convex Surface of neminpheTc. TUMORS OF THE BRAIN AND MENINGES. 639 Tumors of the Frontal Lobe often present no marked symptoms. If they impinge downward upon the olfactory bulb, they may give rise to loss of the sense of smell. There are often mental changes, such as difficulty in concen- Fig. 2. trating attention, of thinking connectedly, of exercising self-control, of com- prehending wdth ease, or of acquiring and retaining new knowdedge. Some- times there is great mental torpor and enfeeblement amounting to imbecility. Fig. 3. Scheme of Position of Fibre-tracts descending from the various areas. Temporal Lobe Occipital ^ Lobe ~ > Frontal Lobe But irritation from the frontal cortex may extend backward to the motor areas, and thus produce hemi-epilepsy or general convulsions. If the tumor exerts much pressure backward or extends into the motor area or tracts, paresis or 640 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. paralysis of the opposite side of the body, beginning often as a monoplegia, is developed. Tumors Affecting the Third Frontal Convolution of the left hemisphere in right-handed persons give rise to motor aphasia, and occasionally agraphia, of imperfect type. In a slowly-growing lesion, like tumor, the opposite hemi- sphere may often gradually compensate for the loss of function in the affected side. This matter of aphasia, however, is not so important a localizing symptom in children as in adults. From studies I have made of hemiplegia in children I have been led to conclude that during the first years of life (perhaps up to eight or ten years or more) the two hemispheres share equally the motor and sensory functions of speech, and that it is only during adolescence that the left hemisphere (in right-handed persons) takes upon itself gradually the greatest part of this burden. Tumors about the Fissure of Rolando^ or Motor Area., cause convul- sions or paralysis of the side opposite to the lesion, affecting later the face, arm, or leg, or all together, according to the size and exact position of the growth. These local spasms are known as partial or Jacksonian epilepsy. When the spasm precedes paralysis, the probability is that the cortex is first affected. When the paralysis precedes the onset of spasm, we may reasonably conclude that the neoplasm began to develop in the white matter beneath the cortex. There may be some anaesthesia in connection with the paresis, for it is generally believed that the motor area subserves sensation also to a great extent. In all of these cases it is important to study the character and manner of onset of the spasms, whether partial or general. The aura of the epileptic attack is often of great value in determining the exact seat of the lesion. This aura may be a sensation of numbness or tingling, arising, for instance, in the fingers, hands, or toes. Seguin has given to this phenomenon the name “signal symptom.” It indicates the starting-point of the cortical excitation. The order of extension of the spasm after the signal symptom must also be noted, for it indicates the path of extension of the discharge along the cortex. In the paralyzed parts the deep reflexes are of course exag- gerated, as in all forms of cerebral palsy, and there is no actual atrophy, though disuse often leads to a diminution in the size of the affected mem- bers. Tumors of the Parietal Lobe, like those of the frontal, often give no localizing symptoms, though the studies of M. Allen Starr and Dana are (piite conclusive as to the frequency of sensory disturbances (muscular, tactile, pain, and tem- perature sense) in lesions at this point. Thus at times paraesthesia and anes- thesia may be found in the opposite limbs. But irritation may extend from the parietal area forward to the motor, and thus produce, as in the case of fron- tal neoplasms, partial or general convulsions. And by progressive extension the tumor may invade neighboring structures, and thus give rise to focal mani- festations (motor symptoms by forward extension, hemianopsia by downward extension to the visual tract). In adults tumor in the inferior parietal lobule of the left side produces word-blindness, but this indication is of doubtful value in children. We do not yet possess sufficient information on this point to make any definite statements. The same is apjilicable to the matter of affec- tions of the auditory speech-centre indicated in Fig. 1. Tumors of the Occipital Lobe, in addition to general symptoms, give rise to the very important oTie of blindness of a half of each eye opposite to the the lesion (homonymous hemianopsia). 'I’lie blindness is opposite to the lesion, but of course the affected half of the retina of each eye is on the sanie side as the lesion. From the occipital cortex, also, discharges may extend forward to TUMORS OF THE BRAIN AND MENINGES. G41 the motor area and produce convulsions, as in a case now under the care of Starr and myself, where a lesion (hmmorrhage at birth) in a girl of fifteen has given rise to hemianopsia and genuine epilepsy. A tumor by continued growth may afl'ect parts forward, such as the sensory tract (hemianmsthesia) and even the motor (hemiplegia). Tumors of the Temporo-sphenoidal Lobe will be apt, especially in chil- dren, to cause no definite localizing symptoms. The sense of hearing has its centre in the first and second temporal convolutions, and smell and taste have been assigned to the tip of this lobe. In adults it is probable that the form of sensory aphasia known as word-deafness may be produced by lesion in one part of the left temporo-sphenoidal lobe. We have still much to learn in this connection in the pathology of childhood. Tumors of the Basal Ganglia, Lateral Ventricles and Island of Reil, by their encroachment upon the internal capsule, through which so many important tracts pass (see Fig. 3), are prone to give rise to marked and wide- spread symptoms, such as hemiplegia (when anterior part of capsule is affected) and hemianaesthesia and hemianopsia (when the posterior part of the capsule is involved). Other than these no definite localizing symptoms will be noted in children. At times other structures (such as the cranial nerves) may be affected by pressure or distortion by tumors in these regions. Tumors about the Crura Cerebri give rise to a variety of symptoms according to the parts affected and the extent of the lesion. The crus contains the motor and sensory tracts, and the two third nerves (motor oculi) rise from the crura very close together (Fig. 4). Thus if one crus is involved, there will Fig. 4. OPTIC NERVE Tovrtti Nerve Fifth Nerve Structures at Base of Brain, to show topography. be complete hemiplegia of the opposite side (occasionally hemiamesthesia also), and third-nerve paralysis on the same side (ptosis, etc.). This is called alter- nate or crossed hemiplegia. The optic tract is near at hand also, and if 41 642 AMERICAN TEXT-BOOK OF DmEASEH OF CHILDREN. affected, which is seldom, will give rise to homonymous hemianopsia (probably with hemiopic pupillary inaction). There may be unilateral incoordination. If the tumor be interpeduncular, some of the symptoms here mentioned will be bilateral. Optic neuritis is apt to develop early in these cases. Tumors of'the Quadrigeminal Region are among the rarities. Some fibres of the optic nerve enter the corpora quadrigemina, and the centre for the reflex to light lies in them. Contiguous to them lie the nuclei of all of the motor nerves of the two eyes (third and fourth and fibres of sixth). Nothnagel has made a study of tumors of this region based upon 10 cases collected bv Bernhardt and 4 cases of his own, so that the symptomatology is pretty well established. There is staggering gait, resembling cerebellar titubation, and a progressive double ophthalmoplegia. The ataxia may be the earliest symptom. When this is followed by the condition of immovable bulbi, we may be quite sure of our diagnosis. The ocular paralyses may be unequal on the two sides. Nystagmus has been observed in but one case. As the tumor develops, hydro- cephalus is produced by pressure upon the aqueduct of Sylvius. A hemiparesis and liemiamTesthesia, or irregular paralytic and amesthetic symptoms, may be produced by extension of the growths toward the crus on either or both sides. The optic neuritis and blindness observed are due to the same causes at work in conjunction with neoplasms elsewhere. Three years ago I observed a case of quadrigeminal tumor in a little girl at the New York Polyclinic. Her first symptom was staggering gait. Then there was gradual development of oculo- motor paralysis and blindness, and finally slight hemiparesis. At the autopsy I found a tubercle the size of a hazel-nut in the quadrigeminal region. There was also tubercular meningitis, and a feiv small tubercles in the cerebellum. The case has been reported by Sachs. Tumors of the Pons VAROLiigive generally distinctive localizing symp- toms, because of the cranial nerves which arise from or are adjacent to it. Thus the third nerve rises from the crus close to its upper border, the fifth from its lateral aspect ; the sixth lies upon it ; the seventh and eighth have their super- ficial origin below its lower border. In the interior of the pons are the motor and sensory tracts for both sides of the body, and the nuclei of several nerves (fifth, sixth, and seventh). If unilateral, the tumor is apt to give rise to crossed paralyses or alternating hemiplegia and alternating amesthesia. In the upper half of the pons a tumor involving part of the crus may cause ptosis and external strabismus, and aimesthesia upon one side, hemiplegia upon the other. In the lower part the growth may produce internal strabismus (sixth nerve), facial paralysis, and deafness, associated, possibly, with j)aralysis of the arm and leg of the opposite side. If the tumor affects the root or trunk of the sixth nerve, as may be the case in neoplasms growing from the base of the skull, the loss of power is only in the muscle supjdied by that nerve. But if the nucleus of the sixth nerve be involved, there is a peculiar disorder of both eyes ; that is, a loss of power in the internal rectus of the oj)posite eye also, which is only shown in the impossibility of conjugate movement of the two eyes toward the side of the lesion, since the external rectus of one eye and the internal rectus of the other habitually act together. There is in such lesions a conjugate deviation of both eyes to the side opposite to the lesion. A lesion may be so j)laced in the pons tlnit none of the cranial nerves are involved, and oidy a hemiplegia is j)roduced, indistinguishable from a capsular hemiplegia. If both motor paths are involved, we may have a j)araplegia. Such a lesion is generally accomj)anied by cranial nerve involvement on one or possibly both sides. Both sensory and motor paths may be involved in j)rimitive lesions, but TUMORS OF THE BRAIN AND MENINGES. 643 these patlis are rather widely separated by the deep transverse fibres of the pons, and in such cases the lesion must he large. Tumors affecting the Medulla Orlongata are prone to give rise to striking symptoms, such as dysphagia, disturbances of the respiration and ])ulse, severe vomiting, polyuria, glycosuria, etc., from involvement of important nerves (glosso-pharyngeal, pneumogastric, hypoglossal, and spinal accessory), and widespread paralyses and ainesthesias from their impinging upon the great motor and sensory tracts contained in the medulla. These symptoms are gen- erally bilateral. In growths affecting either pons or medulla all sorts of combinations of symptoms may be observed, too numerous to be described here. The genei’al symptoms, such as headache, vertigo, and vomiting, are common, but convul- sions are rare. Tumors of the Cerebellum are among the most common of the intra- cranial growths in children. In the middle lobe they produce cerebellar tituba- tion, a staggering gait much resembling that of a drunken man. Vertigo is also an important symptom, and is more severe and continuous than that caused by growths elsewhere. If the middle peduncle of either side be involved, the staggering is more to one side than the other. Tumors of the hemispheres of the cerebellum give rise to no focal symptoms unless they impinge upon the middle lobe or the peduncles. Cerebellar neoplasms by extension are apt to injure cranial nerves about the pons or medulla. Hydrocephalus is often observed : it is due to pressure upon the fourth ventricle or veins of Galen. Tumors at the Base of the Brain in the anterior, middle, or posterior fossae are diagnosticated by the symptoms characteristic of pressure upon or destruction of the important structures already mentioned. Differential Diagnosis. — The presence, site, and nature of a neoplasm must be determined by the facts given in the preceding pages. Brain-abscess is differentiated by its own peculiar symptoms, described in another part of this volume. Tubercular meningitis sometimes presents symptoms similar to those of intracranial neoplasms, particularly when chronic. Ordinary forms are easily distinguished. Chronic hydrocephalus and cerebral htemorrhage, when unusual in character, may simulate tumor, but careful study of the mode and order of development of their manifestations will generally serve to distinguish them. Prognosis. — The prognosis is death unless the tumor be removed. M. Allen Starr gives the average duration of life as two years. Death occurs ordinarily by gradually increasing coma, sometimes with convulsions. Occa- sionally haemorrhage in or about the tumor (especially in gliomata) may terminate life. At times a sudden meningitis (in tubercular forms) brings about a fatal end. Sudden death from unknown cause may occur. Treatment. — It is evident that medicinal treatment of intracranial tumor must be in most cases merely palliative. Gumma of the brain being a growth almost never met with in children, the question of antisyphilitic treatment need not be discussed here. While it is always wise to make use of antitubercular treatment in cases suspected to be of this nature, it is doubtful if much can be done to diminish the extent or stop the progress of such neoplasms. The routine treatment with cod-liver oil, tonics, fresh air, and the like, should certainly be carried out. It is possible that tuberculin or tuberculocidin may after a time be made available for such cases, but as yet the subject is too new to form any pronounced opinion. Klebs’s experience with tubercu- locidin in tubercular disease of the lungs, skin, bones, and joints is pro- mising. (344 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. It is usual in most cases of brain-tumor, of whatever nature, to employ iodide of potassium in 10- to 20-grain doses, three times daily after eating, in an abundance of menstruum (water or milk). Arsenic is occasionally as useful. In all cases there are symptoms requiring treatment, such as headache, intra- cranial pressure, insomnia, and convulsions. Antipyrin (2 to 10 grains accord- ing to age), cannabis Indica (f to 3 minims of the fluid extract), and morphine (■gV iV grain) are good agents in headache due to this cause. Intra- cranial pi’essure may be relieved to some extent by purges, prolonged warm baths, the hot wet pack, and wet leg compi’esses. These remedies may quiet headache, vertigo, and vomiting, and will relieve insomnia. The bromides are often useful for insomnia, pain, restlessness, and vomiting, and are always indi- cated, combined with chloral, in cases with a tendency to convulsions. The question of surgical interference will arise, for in this lies the only hope of effective relief against impending death. The (luestion of the uses and value of cerebral surgery in children is still under consideration. Operations on the brain in children are more dangerous than in adults. The mortality is very great. There is a greater difficulty in diagnosis and localization in chil- dren. There is a larger percentage of cases of multiple tumors in childhood. Some 25 per cent, of the tubercular tumors of childhood are multiple. Con- siderably more than half of the neoplasms of the brain in childhood are situated in structures in the posterior fossa of the skull, and this region deserves the name of the surgical noli-me-tangere much more in children than in adults. Infiltrating tumors, of no well-defined limitation, are not uncommon. Thus we are forced to the conclusion that we must be much more conservative in advising sui’gical procedures in the brain-tumors of children than we need be in those of adults. When we have pretty certain evidence of the presence of a solitary new-growth in the cortex or centrum ovale of the cerebrum, w'e may attempt removal with a fiiir hope of accomplishing a good result. The large percentage of tumors with a recedivial tendency must, however, not be for- gotten. The whole matter of brain surgery as regards children is still in an experimental stage. THE AFFECTIONS OF THE NERVOUS SYSTEM DUE TO INHERITED SYPHILIS. By CHARLES W. BURR, M. D., Philadelphia. It has long been known that inherited syphilis may lead to disorders of the nervous system, but the matter was little studied until recent years. Many cases have been reported, and a review of the literature shows that as in the acquired disease any part of the nervous system, central or peripheral, may be affected. It is noteworthy, however, that in children born alive the nervous system is much less frequently the seat of disease than are the other organs. The exact percentage cannot for obvious reasons be determined. We have no positive data concerning the proportion of stillborn or aborted syphilitic infants with lesions of the nervous system. Much remains to be learned of the pathol- ogy of the disease, and the present paper will be confined, in large measure, to its clinical aspect. Fournier claims that persistent lieadache with nocturnal exacerbations is one of the most frequent symptoms. Accompanying it, indeed often its only evi- dence, are extreme irritability, sleeplessness, and spells of screaming. Demme records a case in which the following cycle recurred : headache followed by anger, then torpor, and finally diabetes insipidus. Convulsions are very com- mon, and are probably one of the most frequent immediate causes of death. They are usually bilateral, and with tonic and clonic contractions. Laryngis- mus and tetany, though most apt to be due to rachitis, sometimes occur. Bar- low and Bury record the case of a child who had ten to twelve fits daily from the fourteenth day to the seventh month. In another case which came to autopsy at the fourth month extensive meningeal changes were found ; and in a third, there were no cortical changes in the convexity, but symmetrical gum- mata were present on several cranial nerves. In this last case there were con- vulsive seizures in which the mouth was widely opened and the child became very dusky. A few cases of apparently idiopathic epilepsy have been recorded in which the only discoverable cause was inherited syphilis. Gowers cites eight, in six of which the fits began after infancy. Abner Post relates an interesting case in which the attacks began with vertigo, the patient feeling as if she were in a boat which was rocking violently. They lasted about half an hour, and were followed by nausea and vomiting. There was never unconsciousness. The attacks occurred as often as three times a week, and disappeared under the use of iodide of potassium. According to Fournier, the condition is apt to be accom- panied by pain in the head, noises in the ears, dimness of vision, vertigo, and intellectual failure. In the greater number of cases there are added to the fits, sooner or later, other symptoms of cerebral or spinal mischief. The differential diagnosis between tuberculous meningitis and syphilis is 645 646 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. often impossible unless a history of hereditary taint or evidence of it can be found. According to Horatio C. Wood, a general indefiniteness of symptoms and slowness of progression should arouse suspicion, especially if the absence of the pulse retardation indicates that the vault rather than the base of the ci’anium is in fault. Stoeber gives the following points in diagnosis : Tuber- culous meningitis is rare under one year ; there is seldom palsy at the beginning ; pyrexia is present ; and the pulse is slow. Syphilis, on the other hand, may occur soon after birth ; palsy is often present from the first ; frequently fever is absent, and the pulse is irregular. Stoeber further regards retraction of the abdomen, projectile vomiting, constipation, delirium, contractures, and rapid wasting as characteristic of the former disease. Too often, however, diagnosis can only be made when it is no longer needed. Recovery means syphilis, as it is more probable that an error in diagnosis has been made than that a tuber- culous case has recovered. Hemiplegia is infrequent. In Osier’s series of 120 cases only 1 presented a pretty definite history of syphilis. On the other hand, in Abercrombie’s series of 50 cases at least 4 Avere syphilitic. Barlow and Bury report an inter- esting case in which there was at first loss of speech Avith right-sided paresis. After about four months of mercurial treatment the patient recovered almost completely, only to be again attacked, this time by left paresis and loss of speech. Finally there was complete recovery. The authors believe that there Avas endoarteritis of symmetrical branches of the middle cerebral arteries and degeneration of the cortical centres, especially of the third frontal, on both sides. A case of left-sided hemiplegia in a girl ten years old, described by Hughlings-Jackson, is made doubly interesting by the fiict that two years before she had had chorea confined to the same side. Marfan relates a case in a child four months old in Avhich recovery folloAved tAvo Aveeks’ mercurial treat- ment. Ordinarily, one-sided fits precede the palsy, and (juite often convulsions continue in the palsied members ; but it may come on Avithout convulsions — without, indeed, Avarning of any kind. The child simply falls unconscious, and returns to consciousness palsied. In rare cases even consciousness is not disturbed. On the other hand, there may be restlessness, vomiting, and head- ache. The presence or absence of aphasia depends of course upon the situation of the lesion. The most common anatomical basis of cerebral syphilis is endoarteritis and thrombosis Avith sclerosis and meningeal thickening. Angel Money, hoAvever, shoAved a specimen to the Pathological Society of London in Avhich there Avere atrophy and sclerosis of the left hemisphere Avithout disease of the arteries or membranes. Gummata are very rare. Rumpf cites but tAvo, and M. Allan Starr in a table of 299 brain tumors occurring in persons under nineteen years of age records ojie only, and that in a youth of eighteen. It is very probable, hoAvever, that the small, yelloAv, and indurated foci found in various parts of the brain by Chiari and others are gummatous. Chronic hydrocephalus is sometimes of syphilitic origin. Rufl’er in a care- ful revieAV of the literature says that it is mentioned as the cause in 20 per cent, of the cases. Mendel regards it as a frequent cause. Lancereaux speaks of a syphilitic Avoman who gave hirth to several hydrocephalic children. The anatomical cause of the condition is, according to Sandoz, inllammation of the ventricular ependyma and plexuses. In some instances, as in a ease reported by Negree, instead of the usual thinning of the cranial bones they are much thickened. Heubner reports a case in Avhich the enlargement of the skull Avas found post-mortem to be due not so much to dilatation of the ventricles as to a pachymeningitis luemorrhagica. SYPHILITIC NERVOUS AFFECTIONS. 647 Paraplegia may result from disease either of the cord and its membranes or of the spinal column. Fournier records a case of hyperostosis affecting several of the dorsal vertehnn and causing symptoms of compression myelitis. Many signs of syphilis were present, and the patient improved under specific treatment. Laschkewitz cured in two months a palsy of all the extremities due to a similar condition in the cervical region. We have no positive know- ledge whether distinctly syphilitic lesions occur in the spinal cord in the inher- ited disease, or whether the inheritance acts only as a strong predisposing cause. So far as we have been able to learn, no autopsy has ever been made in a case of purely cordal inherited syphilis. Dixon Mann reports a case in a boy fifteen years old who, after two years of progressing weakness in the legs, became completely paraplegic and anaes- thetic. Muscular rigidity, increased reflexes, girdle pain, paralysis of the bladder, and a slight bed-sore were present. Fever was absent. The patient recovered after four months’ treatment. The author considered the symptoms to be due to thrombosis with circumscribed softening. In none of the cases of Friedreich’s ataxia recorded in Griffith’s paper, and in none which we have seen, is there clear evidence of inherited syphilis, while almost all of the few known cases of locomotor ataxia occurring in chil- dren had distinct hereditary taint. Remak and Foui’nier detail several such. Moncorvo relates three cases of disseminated sclerosis, two of which im- proved under specific treatment. Ozenne relates a case of latent infantile syphilis which was treated for some time for infantile palsy, and which pre- sented the symptoms of that disease, except that fever was continuously pres- ent. A month’s specific treatment resulted in recovery. True acute anterior poliomyelitis rarely occurs in children with such hereditary taint. Eustace Smith describes a peculiar form of palsy which affects the anterior branches of the brachial plexus. It causes a more or less complete palsy of the arms, sensation and temperature remaining normal. He quotes two cases from Henoch in which the flexor muscles of the fingers alone retained slight traces of contractility. Under specific treatment the palsy disappeared. In some cases a peculiar twisting of the head backward has been noticed when the child has been placed in a sitting position. Some years ago Sinkler reported cases of chorea occurring in syphilitic children, and others have been reported since. The total number is, however, so very small — in Rachford’s 61 cases, for example, there being only 1 with a syphilitic family history — that the relation cannot be more than coincidental. The peripheral nerves are quite apt to be affected, the lesion being either gummatous or inflammatory. Nettleship reported to the Pathological Society of London a case of a girl in whom there was palsy of the third, fifth, and sixth nerves on one side. She was under observation for four years, during which time the condition persisted. Hutchinson relates two cases of ophthal- moplegia externa, in one of which optic atrophy was present. Bury and Barlow speak of two cases in which the seventh nerve was involved. In one there was found post-mortem symmetrical gummata on the third, sixth, seventh, and eighth pairs. Lawford reports two cases of ocular palsy, and quotes one from von Graefe in which there was complete palsy of the third nerve. It is probable that the form of deafness described by Hutchinson as occur- ring within a few years of puberty, and being bilateral, painless, and without discharge, is often due to disease of the internal ear or the nerve. The most remarkable case of spinal-nerve disease is that reported by Omerod, in the person of a woman twenty-three years old with a tumor of the median nerve, probably gummatous. 648 AMERICAN TEXT-BOOK OF DISEASED OF CHILDREN. Examination of the cases given above will show conclusively that inherited nervous syphilis is not a disease confined to infancy, but that, on the contrary, the symptoms may first appear at puberty or even later. Idiocy is rarer than would be expected. The probable explanation is that given by Fournier — namely, that the lesions which would cause it are apt to be fatal. Shuttleworth and Beach found syphilitic taint in only 28 of 2380 cases which they investigated. Ireland regards it as rare. Mental disturbance coming on after infancy is more common. Many cases present the same symp- toms as are found in birth-jialsy — spastic paralysis, fits, and weak-mindedness. According to Barlow and Bury, juvenile dementia is more often due to syphilis than is usually recognized. Under the title of “ general paralysis occurring about the period of puberty ” Wiglesworth speaks of eight cases, the two most prominent causative factors being hereditary and congenital syphilis. Mendel reports a case of mania with hallucinations occurring in a child fifteen years old. Diag’nosis depends entirely upon the history and the presence of signs of syphilis. There are no pathognomonic symptoms. There is a form of syphilitic pseudo-paralysis, the so-called Parrot’s disease, which may be supposed to be of nervous origin if careful examination is not made. The apparent palsy, wdiich may be monoplegic or diplegic, comes on spontaneously after birth with- out fever or convulsions and unaccompanied by any trophic changes. Exami- nation will reveal that there is hyperostosis of the long bones or crepitation at the epiphyses from spontaneous fractures. Parrot believed the condition to be almost always incurable, but this has been disproved in quite a number of cases. Treatment is the same as in the acquired disease. INFANTILE CEREBRAL PALSIES. By FREDERICK PETERSON, M. D., New York. The infantile cerebral palsies are symptoms of a variety of pathological lesions in the brain, just as in adult life such paralyses depend upon processes of different kinds taking place in various regions at different levels in that organ. We may have a monoplegia of the face, arm, or leg, or a hemiplegia^ or a double hemiplegia (diplegia) ; or we may have the two lower extremities affected {paraplegia), for the amount of pai’alysis depends upon the extent of the lesion. The cerebral palsies of early life, then, are symptoms merely, and our most important duty in connection with them is to discover the nature of the lesion which causes them, and to localize the seat of the pathological pro- cess within the brain. But while the paralysis is the paramount symptom of the destructive process occurring in the brain, there are many concomitant clinical conditions which it behooves us to recognize and study. As a basis for this article I shall make use of a paper by Dr. Sachs and myself, published in the Journal of Mental and Nervous Disease for May, 1890, in which one hundred and forty cases were analyzed ; and, in addition, shall include the results of my personal observations of considerably over one hundred cases studied at the Vanderbilt Clinic, in my nervous wards at Charity Hospital, and in private practice, making a total of about two hundred and fifty cases. There have been added to the literature since 1890 many valuable articles, clinical, pathological, and therapeutic, dealing with these palsies, from which \ have drawn liberally such material as has been deemed useful. The French are the earliest contributors to the study of these palsies. In 1827, Cazauvielh published a paper upon the palsies appearing shortly after birth, and described the pathological conditions which he found in the brain in six autopsies. He speaks of a primary idiopathic agenesis and of a form of agenesis secondary to a variety of cerebral disorders. Duges, Breschet, and Cruveilhier about the same time and later contributed to the study of the atrophied brains of children, though Cotard did more than other Frenchmen to elucidate the pathology of the infantile cerebral paralyses. He found cere- bral atrophies to be accompanied by yellow plaques, cysts, cicatrices, cell-infil- trations, defects, and primary or secondary diffuse lobar sclerosis. The earliest German writer upon this subject was Henoch, who in 1842 wrote De Atrophia Cerebri ; while the earliest English writer to describe these palsies was Little; and the earliest American, Sarah McNutt. While these are mentioned as the pioneers in the unravelling of the mysteries surrounding these disorders, there have been contributions of enormous importance by many authors of different nationalities. Kundrat in 1882 produced an able dissertation on porencephaly, a name given by Heschl to the defects of brain-substance found in many such cases. Kundrat differentiated between congenital and acquired porencephaly, 649 650 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. and ascribed the origin of tliese defects to anfemic necrosis from circulatory disturbances. Audry added much to our knowledge of porencephaly by the collection of 103 cases, while Bourneville, Richardi^re, Wuillamier, and Jen- drassik and Marie, on the other hand, earefully studied lobar sclerosis. Striimpell endeavored to e.xplain most cases of spastic hemiplegia of children by his theory of an acute porencephalitis, but this theory is now altogether rejected in the light of recent research, especially that of Sachs. Heine, Benedikt, Bernhardt, Wallenberg, Kast, Iloven, Mdbius, Feer, P. Marie, Gaudard, Gibotteau, Ross, Hadden, Gowers, Abercrombie, Ashby, and Freud and Rie, in Europe, have all at various times made valuable additions to our clinical and pathological knowledge of these disoi’ders. In America, Weir Mitchell, Hammond, Sinkler, J. Lewis Smith, Knapp, Lovett, Gibney, J. Madison Taylor, and Imogene Bassette have materially increased the literature of the subject, while the monograph of Professor Osier is a rich storehouse of clinical and pathological facts relating thereto. Statistics. — The relative frequency of the cerebral palsies of early life, as compared with the infantile spinal palsies, is in the proportion of more than one of the former to two of the latter, so that it is a much commoner malady than has generally been supposed. Boys are somewhat more frequently afflicted than girls. In 452 cases collected to determine the relative frequency of the various forms, there were 332 cases of hemiplegia, 73 of diplegia, and 46 of paraplegia. Cerebral monoplegia is extremely rare, there being only 1 in this entire number. In hemiplegia the right and left sides are about eijually affected, the difference in fevor of the right being very small. Thus, of the 332 cases of infantile hemiplegia, 175 were of the right and 157 of the left side. In bilateral hemiplegia or diplegia usually all four extremities were affected, but occasionally only three (both legs and one arm). As contrasted with the cerebral palsies of adult life, the enormous frequency of diplegias and paraplegias in the cerebral palsies of early life is striking. As regards the age at onset, most cases of diplegia and paraplegia are con- genital, while most cases of hemiplegia are acquired after birth. Two-thirds of the accjuired palsies have their onset during the first three years of life. But it is worth wliile to remember that at least 17 per cent, of infantile hemi- plegias are congenital. With Sachs, I found 5 cases where the hemiplegia occurred at the age of eight years, and 4 cases between eight and fifteen years of age ; while Osier gives 14 cases with an onset between the ages of four and ten years. It is a fact, however, that cerebral palsies are often congenital in origin, though the symptoms may not become apparent until some three or four months after birth, so that (loubtless many are ascribed to the first year of life which had their origin during intra-uterine existence or at the time of labor. Etiolog'y. — The infantile cerebral palsies fall naturally into three groups : I. Those which have their inception during intra-uterine life; II. d’hose which result from injury at parturition ; III. Those which are acejuired subsecpient to birth. The palsies of prenatal or'igin are numerous. Trauma to the mother diu’ing gestation is a frequent cause of injury to the cerebrum of the foetus. Serious diseases affecting the mother while carrying the child are common causes, particularly such as are septic in character or interfere with the normal circulation. Thus, fevers like typhoid, pneumonia, urannic conditions, convul- sions, and similar affections have in my experience resulted iii maldevelo))ments of the foetal brain. Fright also has seemed, in one or two cases, to have brought about such a catastrophe, and doubtless other j:)sychical strains may INFANTILE CEREBRAL PALSIES. 651 produce like results. Premature birth at the seventh or eighth month was a coincidence in four or five congenital cases. Syphilis is extremely rarely a cause in congenital cases. The chief cause of the cerebral paralyses occurring during parturition is undoubtedly tedious labor. Delivery is especially apt to be slow in primiparae, and the older the primipara the more tedious is the labor usually. In such cases the long-continued pressure upon the head is apt to work mischief to the child’s brain. While instruments are often employed in precisely these con- ditions, and sometimes themselves cause injury to the cranium, it is quite cer- tain that the effects of compression in tedious labor are more commonly the cause of congenital paralysis and idiocy than the application of forceps — a point that the obstetrician should keep in mind. The third group of cerebral palsies of children, the acquired paralyses, have a great variety of etiological factors, chief among which are the acute infectious diseases of childhood, giving origin to about 20 per cent, of all cases. These palsies may follow measles, scarlatina, small-pox, typhoid fever, whooping-cough, vaccinia, pneumonia, cerebro-spinal meningitis, gastro- enteritis, and tonsillitis. In pneumonia and whooping-cough the strain and engorgement produced by the coughing are probably important factors in the production of the palsy. Other causes of the acquired palsies are simple fright, trauma to the skull, hereditary syphilis, the status epilepticus, and infantile convulsions. There is no evidence of the existence of an acute polio-encephalitis analogous to poliomyelitis. Symptoms. — Onset with co'uvulsions is exceedingly common, the convul- sions sometimes being a concomitant symptom of the brain lesion, and some- times the actual cause. Since so large a proportion of the cerebral palsies of early life are due to lesions affecting the cortex, it is not surprising that con- vulsions should be so frequently observed. For the same reason coina is very common at the onset of the paralysis. The repetition of convulsions as the disorder progresses, especially in the form of epilepsy, is the strongest indication of involvement of the cortex in the pathological process. The/orm of the paralysis is either monoplegia, hemiplegia, bilateral hemi- plegia, diplegia, or paraplegia. The first mentioned is extremely rare. In hemiplegia the leg recovers more rapidly than the arm, ^Is in the adult, but in rare instances the leg is, and remains, more affected than the arm. While the face is frequently included in the paralysis, it rarely continues to be paralyzed, but is among the first parts to recover. Traces, however, of facial paralysis may often be discovered in these cases on close investigation. Strabismus is found at times in all the forms of infantile cerebral palsy. In children that have learned to talk, ap>hasia may accompany the palsy, probably quite as frequently a left as a right hemiplegia, for the motor speech- centre does not seem to be specialized in the left hemisphere during the early years of life. But a defective development of articulate speech is common in all forms, and particularly in the congenital cases and the earliest acquired cases. I have observed hemianopsia in two or three cases of infantile hemiplegia, and Henschen has noted several such in his great work. Freud has described two. In the great majority of cases the reflexes on the affected side (knee-, elbow-, ankle-, and wrist-jerks) are exaggerated, but in about 5 per cent, they may be normal, diminished, or absent in the paralyzed extremities. Some- times they are difficult to obtain on account of rigidity and contractures. This is especially true of ankle-clonus and the triceps-jerk. Frequently the deep reflexes are exaggerated also, as in the adult, in the normal as well as in the 652 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Fig. 1. paralyzed extremities ; nevertheless, they are more marked in the parts involved in the palsy. Morbid movements are remarkably common in the paralyzed muscles of hemiplegic and diplegic children. The most frequently observed of these motor disturbances is athetosis, occurring in some 20 per cent, of all cases of hemiplegia, and occasionally in diplegia. Next in point of frequency are asso- ciated movements ; that is, the more or less exact imitation by the paralyzed hand and fingers of voluntary movements made by the normal hand and fingers, and vice versa. Such associated movements are to be observed in healthy children, the tendency in childhood being to make use of the two hands simultaneously ; hut in cerebral jialsy this tendency is often so greatly exaggerated that such nicely co-ordinated movements as are required in writing and buttoning, when executed by the sound hand are closely imi- tated by the affected hand. Choreiform, movements are found in some 5 or 6 per cent, of the hemiplegics, but are much more rare in diplegia. Ataxia, rhythmical contractions, tremor, and tetanoid contractions are occasionally to be noted. Nystagmus is found apparently only in cases of diplegia. I have remarked nystagmus in three, and Osier, in two such cases. I have recently described as present in two congenital hemiplegias a hitherto unnoted morbid movement to wdiich I have given the name post-hemiiAegic polymyo- clonus. The movements are neither choreiform nor athetoid, but are constant clonic contractions of most of the muscles in the limbs affected, not occurring synchronously, and the rhythm being about that of paralysis agitans (five per second). All of these move- ments indicate interference with motor conduction due to lesions in some part of the voluntary and inhibitory tracts. Rigidity and contractures are striking symptoms in almost all these palsies, and for this reason they often fiill into the hands of the orthopaedic surgeons, who are besought to remedy the rigidly-flexed elbows, wrists, knees, and the various deformities that interfere with locomotion. Adductor spasm in the thighs, causing cross-legged progression, is nearly constant in diplegia and paraplegia. Talipes equino-varus is the most frequent pedal deformity in hemiplegia. Double talipes eiiuino-varus is observed at times in both diplegia and paraplegia. Rarely talipes eo(uinus and talipes equino-valgus are to be found in hemiplegia. While rigidity with contracture is the rule in all of these forms of infantile cerebral palsy, occasionally, but very seldom, cases will be met with in Avhich the muscles are all completely flaccid. The chief trophic disturbance encountered in these cases is retardation in growth of the jiaralyzed members. The paralyzed limbs do groAv, but at a much slower rate than the sound extremities. Hence the disjiroportion is often very striking. The earlier the onset of the palsy, the greater is this dis- proportion. Another peculiarity that T have noted is that the groAvth of the whole organism is to a certain extent interfered with, the injury to the brain seeming to stunt development and to prevent the patient attaining his normal stature. The patients are more or less undersizeil and dwarfed, 'fhis point Avas particularly made evident to me in a case of hemiplegia. 'I'he mother brought to me her two boys, twins, six years of age, for the examination of the INFANTILE CEREBRAL PALSIES. 653 one affected. One 'vvas a tall, well-built lad ; the hemiplegic boy was small- bodied and fully seven inches shorter than his healthy brother. In all of these cases the muscles of the paralyzed and undeveloped extremities react normally to the faradic current. In many cases the aSected limbs may be blue and cold, as in paralysis of the spinal type. A very rare phenomenon in these cases is a hypertrophy of the muscles, usually combined with athetosis. Epilepsy is undoubtedly the worst feature of these cases, affecting as it does over 45 per cent, of all forms. In the hemiplegic form fully one-half of the Fig. 2. Fig. 3. Right Hemiplegia, with contracture and retarded growth of arm. contracture and retarded develop- ment of paralyzed side. cases suffer from epilepsy, in diplegia 30 per cent., and in paraplegia 36 per cent, of all cases. In most of them the epileptic seizures are general, but about 15 per cent, of the cases of infiintile cerebral palsy suffering from epi- lepsy exhibited the Jacksonian type of seizure. I have observed petit mol in two or three cases. A very important fact has been brought out in this con- nection, and that is that many cases that have been diagnosticated as epilepsy alone are, upon close and careful investigation, found to present traces of a palsy often so rudimentary in character that it has escaped attention. In all cases of what appears to be idiopathic epilepsy search should be made for the residua of paralyses. There are undoubtedly cases of genuine epilepsy having its origin in similar pathological processes which beget the palsies of early life, yet in which no vestige of the organic lesion may be discovered at all. It would naturally be expected that as most of the lesions causing cerebral paralyses in early life are cortical, the epilepsy would be Jacksonian rather 654 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. than general, but the contrary is the case. The reason for this is that the original focal lesion disappears, and a general atrophy and sclerosis take its place. Feeble-mindedness, imbecility, and idiocy in connection with these palsies are more frequently observed even than epilepsy. The proportion of mental enfeeblement is in a direct ratio to the extent of the pathological process, and hence in the diplegias and paraplegias a large degree of imbecility and idiocy is Fig. 4. Paraplegia: Photographed in Epileptiform Convulsion. usually encountered, for here both hemispheres are involved. In hemiplegias, on the other hand, idiocy is relatively rare, though the lower degrees of feeble- mindedness and imbecility are to be noted in nearly one-half of all cases. Among the physical defects, or stigynata degeneration is, are often found various cranial deformities, such as asymmetry of face and skull, microcephalus, leptocephalus, macrocephalus, and cranium proganaeum. The Gothic palate, imperfectly developed or supernumerary teeth, hirsuteness, and deformed ears are other physical evidences of imbecility and idiocy at times encountered. I have, in a paper with Fisher, called attention to the flattening of the skull often observed on the side opposite the paralysis in infantile spastic hemi- plegia. Patholog-ical Anatomy. — It is seldom that cases of infantile cerebral palsy come to autopsy at the time, or near the time, of their onset, while there are large numbers that have been carefully studied and described after the late secondary pathological changes have become manifest. But it is precisely the initial lesion that it is very important to understand. For a full discussion of the pathology I would refer the reader to the original paper written by Dr. Sachs and myself, and in particular to the chapter on “ Cerebral Haemorrhage, Thrombosis, and Embolism,” by the former, in Keating’s Cyclopa’dia of the Diseases of Children. At the post-mortem examination the physician usually finds atrophy of a part of the brain, evidences of sclerosis, one or more cysts, or the condition known as porencephalus. All of these are terminal conditions. Cysts are secondary, as a rule, to haemorrhage. Porencephaly may follow upon hmmor- rhage, uj)on anaemic necrosis, or upon other long-antecedent ])rocesses. Atrophy and sclerosis, too, are the results of a variety of initial lesions, such as limmor- rhage, thrombosis, and embolism. While it is barely possil>le that encephalitis may be a forerunner of some of these terminal conditions, there is not suflicient evidence of the existence of the polioencephalitis of Striimpcll to establish it as a fact. We may group the pathological processes, after Sachs, as follows: INFANTILE CEREBRAL PALSIES. 655 Groups. I. Paralyses of intra-uterine onset . . . . II. Paralyses occurring during labor . . . III. Paralyses acquired after birth . . . . Pathological Changes. Large cerebral defects (true porenceph- aly). Haemorrhages of intra-uterine origin (soft- ening? ) Agenesis Corticalis. Meningeal Hemorrhage (very seldom intra- cerebral). Kesulting conditions: meningo-encephal- itis chronica ; sclerosis ; cysts ; atrophies ( porencephalies). Meningeal ILemorrhage (very seldom intra- cerebral); Embolism; Thrombosis (in ma- rantic conditions and occasionally from syphi- litic endarteritis). Kesults of these vascular lesions: cysts; softening ; atrophy ; sclerosis (diffuse and lobar). Chronic Meningitis. Hydrocephalus (seldom the sole cause). Primary Encephalitis (Striimpell) (?) The pathology of the congenital cases is very clear. In a certain number of cases there is defective development, so that often large portions of the brain are wanting. These defects are possibly due to vascular disorders during foetal life. In other cases the defects are circumscribed, and the chief seat of these lesions is the motor areas. That haemorrhages in the foetal brain during gesta- tion may occur is proven by a case of Cotard. Sometimes the defects are not gross and large, but evident only upon close scrutiny, or are even microscopic. Such instances are the confluence of Assures, simplicity of conflguration, exposure of the island of Red, and the like. In these the chief feature is defect in the highest nerve-elements, the cortical cells, a veritable agenesis corticalis. In all such cases of defective development, whether gross or micro- scopic, idiocy is a marked symptom, while epilepsy is rarely if ever present. The absence of epilepsy may therefore be cautiously considered as an evidence of the nature of the lesion ; it seems to prove a simple maldevelopment, an active process being thus excluded. Meyiingeal hoemorrhage is the chief cause of all cases of cerebral ]>alsy occurring during labor, although at autopsy the conditions found may be chronic meningo-encephalitis, sclerosis, cysts, atrophy, or poi-encephaly. These haemorrhages are produced by the compression which the head undergoes in the pelvis during parturition. In this connection I cannot forbear referring to the recent researches of Herbert R. Spencer. Among 130 stillborn children he found! cases of thrombosis of the longitudinal sinus, 1 of intracerebral haemor- rhage, and 53 of haemorrhage from the pia and arachnoid : 29 times there was bilateral haemorrhage, 10 times in the right side of the brain only, 10 times in the left, 7 times into the lateral ventricles, and 6 times limited to the base of the brain. He finds the frequency of central haemorrhage greatest with for- ceps delivery, next with breech presentation, and least with natural head pre- sentations. He believes that softness of the skull-bones and their increased mobility may be determining factors in the production of haemorrhage. In 30 cases he found haemorrhages into the spinal canal and cord, and I cannot but believe that some, though a very small percentage, of the cases of pai’aplegia especially, and perhaps diplegia, may be due to cord lesions at birth after all, and not to cerebral lesions. Otherwise it is difficult to explain the great inteh 656 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. ligence and freedom from epilepsy, athetosis, and the like, of a select few of the palsies of these forms. As regards the third group, or the acute acquired palsies, hcemorrhage, embolism., and thrombosis are the chief causes of cerebral paralysis in children after their birth, just as they are in the adult. We have apoplexies in child- hood as in later life. I have named these causes in the order of their frequency. Sachs and myself collected and analyzed the results of 78 autopsies in infantile hemiplegia as follows : Lesions Found. No. of Cases. Terminal conditions : Cysts, atrophy, sclerosis 40 Porencephaly 2 Hseniorrhage 23 Em hoi ism 7 Thrombosis 5 Tubercle 1 Total 78 It would be impossible to determine the initial lesion in the terminal condi- tions cited in the above table, but doubtless most of these also were vascular in their nature. Iltemorrhage in children and adults differs both as to cause and position. In adults, as is well known, the bursting of miliary aneurisms in atheromatous vessels is the common cause of hmmorrhage. Miliary aneurisms, as well as large ones, are occasionally found in children, but in them fatty degeneration of the vessel-walls, as described byA^on Recklinghausen, is more frequent. In adults haemorrhage generally takes place in the neighborhood of the internal capsule ; in children, in the meninges and about the cortex. Exceptionally, intracerebral haemorrhages do occur in childhood. In the paralyses following acute rheumatism, endocarditis, and scarlet fever, it would be natural to suspect an embolic process, as in the adult ; and in hereditary syphilis and marantic conditions thrombosis would be the lesion most likely to supervene ; but as compared with haemorrhage both embolism and thrombosis must be looked upon as rather infrequent causes. The pathological process here described as so common in children may occur, it must be remembered, without producing paralysis ; for where other parts than the motor areas are involved other symptoms may result, such as epilepsy alone or the various degrees of idiocy. A beautiful case in point was one sent to the Vanderbilt Clinic some two years ago, a young girl with epilepsy and a left homonymous hemianopsia, congenital in origin, showing undoubtedly a cortical lesion over the right occipital region (reported by M. Allen Starr). Differential Diagnosis. — The hetniplegic, diplegic, or paraplegic form of the paralyses, the rigidity, the exaggerated rellexes, tlie normal electric reaction of the muscles, the ab.sence of actual atrophy in the liiiibs, llie presence of epilepsy or idiocy or of morbid movements of one kind or another, usually serve to easily distinguish this disorder from infantile sj)inal paralysis. It would be only in some of the mildest types of either of these affections, or in the case of a monoj)legia, that any difficulty might present itself; and even here some one or two of these indications would suffice for a diagnosis. It is a fact, however, that in many cases of epilepsy, athetosis, chronic chorea (especially hemi- chorea), and in some of imbecility or idiocy, a hemiparesis is often overlooked. Prognosis. — Death as a result of infantile apoplexy is very rare. The duration of life in such j)alsies is generally short. Few cases of diplegia and paraplegia reach the age of twenty years. A eertain small number of hemi- plegics may attain the age of forty years. In most cases it may be stated that INFANTILE CEREBRAL PALSIES. (>07 the face will recover, ami that the leg will become sufficiently useful for loco- motion. In the bilateral palsies the prognosis as regards walking cannot be (juite so favorable. Except in the severest forms speech will he recovered more or less perfectly. After the laj)se of a few months an idea can be obtained as to the mental state, and as to whether imbecility or idiocy is to be appre- hended. The probability of epilepsy is the feature in prognosis requiring the greatest exercise of judgment. Epilepsy may not apj)ear for a year or two after the onset of the paralysis, and the statistics already given as to the enormous percentage of these cases thus affected must be borne in mind. Treatment. — In cases seen shortly after birth, showing symptoms of cere- bral lesion, quiet and careful handling are the chief indications. Minimal doses of bromide of potassium or chloral, or chloroform inhalation may be employed if convulsions occiu’. In the initial stages of the acute acquired palsies we treat the infantile apoplexy in much the same manner as we would apoplexy in the adult. Absolute quiet, cold applications to the head, and emptying of the bowel are the first steps in treatment. In a few days the bromides may be used to ensure greater rest to the brain, and subsequently, combined with an iodide, continued for some time, though not so long as to interfere Avith nutrition. In the chronic stages relief is generally sought for secondary conditions, such as deformities from contractures, and idiocy and epilepsy. Excellent results are achieved by tenotomy and orthopaedic apparatus properly applied for the cor- rection of the various deformities, particularly of the loAver extremities. In one case in this city athetosis in the right arm Avas so extreme that the limb Avas amputated at the shoulder, to the great relief of the patient. Electricity (especially the faradic current) may be used to exercise the paralyzed muscles, and, combined Avith massage, may go far to prevent and remedy contractures. The epilepsy is treated Avith the usual agents, the bromides, chloral, and the like, though, it must be confessed, Avithout much success. To remedy the mental defects very much can be done by careful manual and intellectual training. In fact, surprising results are often achieved in the development of the mind, speech, capabilities, and character of these cases Avhen placed in schools especially adapted for such purpose, as is evidenced by the ex])erience at Bicetre and some of the private schools in this country. As regards surgical procedures in any of these cases, either for relief of epilepsy or for the improvement of the mental condition, the most that can be said at the present time is that, upon the Avhole, little or nothing is to be ex- pected from trephining, craniectomy, and the like. Possibly future experience may justify operative interference in a small percentage ; but the great majority of infantile cerebral j>alsies are better left to the treatment of the family phy- sician, to the ox'thopaedic surgeon, and to the developmental infiuences of special schools. M. Allen Starr states, in a very recent paper, that he has collected some fifty ca.ses of operations in these and allied conditions (like microcephalus). Many of these he publishes in a list, and an examination of his table shoAving the results obtained is certainly not very encouraging. In addition to these, Sachs gives notes of three of his OAvn cases operated upon, all hemiplegics with epilepsy, in tAvo of Avhich the seizures returned after operation in three and six months respectively, and the other Avas not seen after three months, up to which time no attacks had supervened. Wildermuth, hoAvever, reports tAvo cases of hemiplegia Avith epilepsy, in Avhich the seizures seemed to have ceased, one having not been observed for three years and the other ten months subsequent to operation. Besides the apparent futility of cerebral surgery in most of such cases, children do not undergo these operations Avith as little danger as adults, and the proportion of deaths in the cases thus far published is rather large. 42 SPEECH DEFECTS AND ANOMALIES. By CHARLES K. MILLS, M. D., Philadelphia. Physicians are frequently consulted with reference to absence, deficiency, or peculiarity of speech in children at different ages from birth to puberty, but particularly in those under six or seven years old. Healthy infants acquire articulate speech at varying ages, according to inherited qualities, the general health, the influence of some acute disease, or the surroundings of the child. The child of deaf and dumb parents, or one placed wdiere it hears or sees but little, or one not much thrown into the company of talking adults or older children, may be delayed in the initial stages of articulate language. Some- times at the age of nine or ten months unusual precocity is shown. Ordinarily, about the end of the first year or the beginning of the second, parents and physicians look for some decided efforts at speaking, and when eighteen months or two years have been reached without these, anxiety begins to be experienced and inquiries to be made. The problem presented is by no means a simple one. The physician must carefully weigh a number of fiicts and must investigate from a variety of standpoints. Starting with the peripheral apparatus of speech and proceeding toward the central nervous system, he must examine into the muscles ami nerves of articulation, phonation, and respiration ; the external and internal apparatus of hearing, the nuclear centres of several of the cranial nerves ; and the hearing, speech, and visual centres of the cerebrum and their commissures. He must fully consider the mental status of the child, and if this be settled adversely, the rest may need little attention ; but if not so decided, then, step by step, each of the parts and processes concerned dii'ectly or indirectly in the mechanism of speech must receive close scrutiny. Is the child idiotic or imbecile? Is it suffering from aphasia, congenital or acquired at or since the time of birth ? Is the speech loss due to brain arrest? Is the child simply backward in speech ? Is it suffering from some functional or hysterical affection ? Is the child a deaf-mute, and, if so, what is the character of this deaf-mutism ? Is it dependent upon jieriosteal or hone disease ? Is it the result of old or recent inflammatory disease of the ear, either primary or the sequel of some acute infection, as scarlet fever or measles? Is the deficiency of speech due to paralysis of any of the nerves or muscles of articulation? Is it a spasmodic affection of these nerves and muscles? What is the shape and size of the oral cavity, and, if deformity of the vault of the palate, of the pharynx, or of any part of the oral cavity be present, is it or is it not associated with true idiocy and imbecility? Is, as mothers .so often wrongly imagine, the child tongue-tied, the frivnum being .so attached as to prevent free movements of this organ ? Are adenoids or other growths or enlargements present ? 658 SPEECH DEFECTS AND ANOMALIES. 659 Speech Defects due to Idiocy or Imbecility. Difsphrasia, a term applied by Kussmaul (Ziemssen’s Cycl. Pract. Med.') to defective or absent speech due to intellectual impairment, is more frequent in children than any of the varieties of aphasia, but is of course usually then an accompaniment of idiocy or imbecility. The child cannot speak, or talks imperfectly or foolishly because of an absence or deficiency of ideas ; it does not speak, as Griesinger has said, because it has nothing to say. It does not know anything that would be ordinarily transmuted into language. Even in idiocy the cortical organs of speech, considered as special areas, are doubtless often arrested or diseased, but in addition other parts of the brain concerned in mentation may be lacking or altered. As is well known to those connected with institutions for the feeble-minded, not a few cases with some intelligence cannot by the greatest perseverance be taught to speak ; some can be taught a few words and sentences, but cannot get beyond a certain point, which is limited by their ability to assimilate knowledge. Others perhaps can be taught, parrot fashion, to repeat Avords or even phrases or sentences of the meaning of which they have no idea. Many interesting observations upon the development of speech have been made in all such institutions. Physicians Avill be called upon to give opinions not only as to arrest of mental growth, but also as to the capabilities of future development in such children ; and such opinions can be only of value Avhen they are based upon a close study of the conditions present at the time of examination, and of the life and family history of the child. Mierzejewsky, cited by Kussmaul, has described in great detail the history of an aphasic idiot Avho lived to be about fifty years of age, and whose mental poAvers and speech Avere about as developed as those of a one or one and a half year old boy. He could only give utterance to a fcAv of the simplest syllables. Ilis brain Avas examined, and resembled in the shape and the arrangement of the convolutions that of a human foetus of the ninth month. The methods of diagnosticating idiocy and imbecility will be considered in the next section, and it Avill therefore not be necessary to call further attention to this subject here. Aphasia. The term “aphasia” is sometimes carelessly applied to almost any variety of speech disorder, but it is best restricted to the description of complete or incomplete loss of speech from a local cerebral affection. It is conveniently divided into motor or expressive and sensory or receptive aphasia, and these have special forms, some of Avhich need to be borne in mind even in studying the disorders of speech from Avhich children suffer. Sensory aphasia has several varieties, as word-deafness and Avord-blindness, which define themselves, and apraxia or mind-blindness, in Avhich the ability to recognize the use or mean- ing of an object is lost. Aphasia may be both sensory and motor, as Avhen the receptive and emissive sides of the brain are both involved in disease. Agraphia is loss of power of Avriting; amimia, inability to express thought by signs and pantomime. Besides varieties of aphasia resulting from cortical lesions, others may be due to destruction or interference with the commissures or lines of connection betAveen various centres, and these are knoAvn in gen- eral terms as paraphasias or conduction aphasias. Alexia is abolition of the power of reading, as agraphia is that of Avriting; dyslexia refers to difficulty or fatigue in reading; paralexia, to the misuse by transposition or substitu- tion of either words or syllables, while paramimia is the misapplication of signs 660 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN or pantomime. Whether a child can have alexia, dyslexia, agraphia, or amimia will of course depend on its accjuirements — on its ability to read, to write, to talk, or to express itself by gestures or pantomime. Children under six or seven years old would need to be studied from different standpoints from those over this age, and children between six and ten would need a consideration which would differ for those from ten to fourteen. True aphasia is sometimes congenital : a deficiency of speech not depend- ent upon lack of general intellectual power may be present, or, in other words, a distinction can sometimes, althoufih perhaps rarely, be made between a dys- phrasia and an aphasia of j)renatal origin. Broadbent (cited by Kussmaul) has reported an interesting case of congenital aphasia in an intelligent boy. When twelve years of age he understood everything that was said to him and did what he was told to do, but could not, as a rule, say anything but “Yes,” “ No,” and “ Father” and “Mother,” pronouncing the last two words imper- fectly. He used also an indirect expression in answer to all (juestions ; occa- sionally he uttered a few other words, such as “All right!” “Thank you,” and he had other interesting peculiarities. A few cases have been reported which seem to show that the arrest of the organs of articulation was the particular condition present, as one in wliich the idiot could utter only a few scarcely intelligible words, but could express himself well by an animated and intelli- gible pantomime, and w'as even able to report on different things that occurred in the asylum. Aphasia the result of acute lesions occurring after birth is rare in children as compared with adults, as hremorrhage, embolism, and thrombosis are of infre- quent occurrence in childhood. Of the three, embolism as an accompaniment of rheumatism or endocarditis is probably the most common. When a lesion does invade the speech-areas of the brain on the left side, the other hemisphere more quickly assumes the lost function than in adults. Sachs (^Keating' s Cgcl. Dis. of Children) records seventeen cases of hemijilegia with aphasia. His experience is in accord with that of Bernhardt, who found that aphasia in children accomjjanied left as well as right hemiplegia. Other acute causes of aphasia in children are meningitis, tumor, and abscess. Occasionally in tubercular meningitis a form of aphasia or paraphasia may be developed, and this j)articularly when the tubercular deposits or conglomerates are in and around tlie Sylvian fossa. Sometimes in basal meningitis in children, owing to inflammation and exudation in the ])ons-oblongata region, a form of dysarthria or articulatory paralysis will show itself. The position and size of a neoplasm will determine how far speech or any of its elements or tributaries will be afl’ected. Word-deafness may be present when the first and second left temporal convolutions or the white matter beneath and near these areas are invaded, although such word-deafness may soon in part be recovered from if the right liemisj)here bo intact. Word-blind- ness in a child that can read or write may result from a tumor situated in the zone where the left parietal borders tlie anterior occipital region. Of course a tumor of any descrij)tion involving the hinder part of the left third frontal will cause more or less motor aphasia in a child that has ac(|uired speech, and may arrest the development of the faculty in one of tenderer years. When the island of Beil is invaded, either aphasia or paraphasia may result. Intracranial abscess sometimes is the cause of word-deafness or some other variety of aphasia in children. Such cases are usually associated with aural disease, as when ))urulent disease of the mastoid or of the tympanic cavity leads to meningeal inflammation and abscess of the tenqnu’al lobe. SPEECH DEFECTS AND ANOMALIES. G61 Aphasia usually with, hut sometimes without, monoplegia or hemiplegia may be a (;onse(]uence of hereditary syphilis. These cases may have several attacks of aphasia with partial paralysis, sometimes affecting different sides of the body. The lesions are usually the outcome of endarteritis or chronic meningitis, particularly leptomeningitis, and in some cases they are forms of cortical sclerosis with atrophy. The child will often show some of the other well-known evidences of inherited taint, as notched or pegged teeth, crack- ing of the corners of the mouth, flattening of the nose and face, or interstitial keratitis. It is important to recognize the syphilitic origin of these cases, and to treat them accordingly with mercurial inunction, calomel, iodide or bichloride of mercury, or the iodides of sodium or potassium. In children, as in adults, aphasia has been noticed in the course of typhoid and other fevers : probably in most of these cases the affection is not due to a local lesion, such as a clot or the closure of a vessel, but to a toxic influence exerted by the poison of the disease on the brain. Bassetle {Jour. Nerv. and Ment. Dis., July, 1892) has reported two cases of this kind, one in a girl nine years of age, who in the second week of typhoid fever became markedly deaf without middle-ear complications, and also had partial hemiplegia. The para- lysis passed off, and she began to recover her speech about the sixth week. Another, a girl of five years, ceased to speak for eleven days. Children, through fright or other cause, sometimes suddenly become speech- less. Hysterical children also have attacks of mutism. Langdon Down (cited by Ashby and Wright in Diseases of Children) records the case of two brothers, who had spoken well and understood two languages, completely losing the power of speech at the second dentition. In rare cases children who are not idiotic, and who are not suffering from either central or peripheral disease, are nevertheless exceedingly slow’ in learn- ing to speak, and in particular for a long time may fail to acquire the proper method of articulating and pronouncing certain letters and sounds. Some- times such childi’en are otherwise intelligent, and eventually develop up to the full standard of mental health and activity. In some remarkable cases chil- dren, even to the age of ten or twelve, have habitually made use of only a few’ letters. Deferred or retarded speech development must be distinguished from congenital or acquired aphasia of more permanent type. According to Bastian, cases allied to congenital idiocy are observed, in which, oAving to some intra- cranial lesion occurring before, during, or soon after birth, the child’s mental condition is greatly degraded as well as his motor power. In some of the less severe examples of this type speech is merely deferred, perhaps until the fourth, fifth, or even sixth year, and may become after a time established in a natural manner. Bateman {Aphasia, or Loss of Speech, 2d ed., 1890) mentions a case of this tardy development of the faculty of speech which came under his observation. The child never spoke at all until he was six years old, and it was thought that he Avould remain dumb. At six years of age he began to talk, and Avas able to receive an education suitable to his condition in life, but he grew’ up to manhood a person of feeble intellectual and also of feeble physical poAver. Echolalia and Copeolalia. In the affections knoAvn as echolalia, coprolalia, and by various other names, convulsive or choreic movements are associated with a sudden explosion of speech. The patient with a grimace, contortion, or violent movement of some kind suddenly bursts into obscene, profane, or absurd expression. This GG‘2 A3IERICAN TEXT-BOOK OF DISEASES OF CHILDREN. expression may be the echo of something overheard — hence the name, echolalia — or it may be a spontaneous outcry. It is not simply a hysterical affection, controllable and curable, but is a true monomania, the affection of speech being beyond the patient’s volition ; it could properly be discussed under morbid impulses as well as here. One patient of mine, a hoy twelve years old, at times, without warning, would in a street-car or other public place, as well as in private, suddenly give utterance to a filthy expression two or three times, accompanying it with a violent movement of the head, shoulders, and one arm. Deaf-mutism. Deaf-mutism must be carefully distinguished from aphasia and other affec- tions of speech. While some cases are congenital and associated with more or less profound idiocy, the number of these, according to good authority, does not equal those which can be fairly attributed to disease and accident after birth. Even congenital deafness and dumbness are sometimes due to peripheral causes, as to periostitis, ostitis, or imperfect development of the petrous bone. The semicircular canals or other portions of the internal ear may be wanting or altered by intra-uterine disease. Colloid degeneration of the labyrinth is said to be a frequent cause of the absence of hearing, and various diseases of different parts of the auditory apparatus, particularly of the internal and middle ear, may occur before birth. These cases must be separated from those of mutism or deaf-mutism associated with idiocy. A diagnosis may sometimes be made by careful physical examination and a study of the mental condition of the patient. Purulent otitis or, what is more difficult of decision, Voltolini’s labyrinthine otitis, or some other form of labyrinthine non-purulent inflamma- tion, may cause absolute deafness, and owing to this deprivation the child may be supposed to be mentally deficient. Indeed, such a child may, under unfa- vorable circumstances, fail to develop to any considerable degree. A process of experimental training of the senses which are left will sometimes enable a decision to be reached in a comparatively short time. The patient who is simply deaf-mute, from whatever peripheral cause, will under proper incitements be able to fix his attention and show intelligent interest in his surroundings. The exact age under which a child will lose its speech because of loss of hearing cannot be absolutely fixed ; but when total deafness is caused by purulent disease of the ear or other destructive affections before the age of six or seven years, the child is likely to become mute as well as deaf uidess special training has at once been started, and even in spite of this a certain degree of loss or imperfection of speech Avill result. The original capacity and the acquirements of the child at the age Avhen deafness occurs will of course have a bearing upon the (juestion of deaf-mutism. Occasionally children who have had scarlet fever, measles, or infectious diseases at the age of two or three years, and have become totally deaf in conseciuence, are supposed to be idiotic. Such children, if naturally intelligent, will exhibit great interest in everything that comes within the range of the senses that are left. Slow or stupid chil- dren deprived of hearing and speech, particularly if treated with neglect or indifference, will sometimes sink into a state of inertia which simulates a true imbecility or fatuity, leaving them with defective mental powers. A physician should be acquainted with the usual time Avhen a child of average mental capa- city acejuires the ability to respond to general sounds and noises, and then to special sounds, voices, and eventually to definite words, and also when it first gives vent to feelings of pain or pleasure, when it makes special response to particular sounds, when it imitates sounds connected or not connected with SPEECH DEFECTS AND ANOMALIES. 663 ■' itleas, and when, finally, speech becomes a method of expressing centrally initiated thought, no matter how elementary this may be. It is not as difficult, as at first sight might appear, to learn to follow and analyze such processes of development and to determine as to their retardation or advancement. Mothers acquire great facility in this way by comparison of the progi’ess of their dif- ferent children. Preyer (T/m Mind of the Child., part I., transl. by H. W. Brown, 1889) has made a practical study of the development of the different senses and mental faculties, based largely upon the close study of his own child. According to him, the new-born are always deaf, because of temporary local conditions, such as lack of air in the tympanic cavity, collections of liquid or gelatinous substances in the middle ear, and closure by foreign matter of the external auditory canals. Whether this be absolutely true or not, it is certain that all healthy children in a few hours or in a day or two at least react to impressions of sound. Of fifty children who were tested by Mollenhauer, ten, less than twelve hours old, reacted to a brief disagreeable sound. Preyer was not con- vinced until the first half of the fourth day that his child was not deaf. In the eighth week he showed pleasure at piano-playing, and in the ninth the sound of a repeating watch aroused his attention to the highest pitch, while in the eleventh week he moved his head in the direction of the sound heard ; and soon this was always done with great promptitude and certainty. After a half year he enjoyed single notes and military music, and soon he showed evidence of intellectual advance. After the first year the child rapidly advanced in his exhibition of logical activit}^ in connection wdth hearing. The statement that children from three to four months old possess normally very slight capacity for hearing must be pronounced false, according to Preyer, for long before the third month the human voice is heard by the normal infant, and before the close of the first week normal children react to the stimulus of loud sound. Kussmaul distinguishes three periods in the development of articulation. Within the first four months, and about the time of the earliest movements of prehension, children give vent to spontaneous sounds indicating their feelings of joy. These are chiefly lip and vowel sounds, but sometimes they are also lingual and palate sounds. In a second period these savage noises, are grad- ually crowded out by the conventional sounds of the national language, but even these are of a very simple character. Some of them are imitated and some are not. With the commonly used words ma, ma., and pa, the child at first does not connect any idea, but by degrees learns to do this. At a third stage speech becomes an expression of thought, a child learning to associate certain definite objects with the words acquired by practice. All this may be accomplished in the most elementary way by the end of the first year. “Sounds such as m-m, ha-ha, da-da,'’ say Ashby and Wright, “may be repeated in a meaningless sort of way, but before long are applied to persons and things. During the second year the vocabulary increases fast, and the child quickly imitates and repeats the words it hears, so that by the end of the second year it not only uses a number of words, but can string together a few nouns and adjectives or has learned the meaning of short sentences. At this period, and for the next year or two, words are indistinctly or improperly pronounced, with a tendency to clip them short or to drop consonants. Some consonants present greater difficulty to the young child than others, and are constantly dropped out of words ; thus s, especially when it precedes another consonant, is omitted, as cool for school, kweek for squeak, no for snow. Difficul- ties often arise with the aspirate dentals, as th and sh. Ruth becomes roof ; the vibratory consonant r is a great stumbling-block, and the distinct pronun- 664 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN ciation of it is perhaps never ac(juired ; grub is apt to become gwub, and roof, woof. Affections of Speech due to Peripheral Paralysis. After acute infectious diseases, and particularly after diphtheria, palatal or pharyngeal paralysis may he present. Occasionally an attack of diphtheria is overlooked or supposed to he some other throat affection, and even so-called latent cases sometimes result in forms of paralysis. Facial paralysis in children would be determined by the appearance of the face, and indeed the affection of speech in such cases is usually very slight. Lingual paralysis of peripheral origin is rare both in adults and in children. Stuttering and Stammering. The presence and meaning of stuttering and stammering in children may demand careful consideration. Boys are much more likely to be afflicted with this disorder than girls. Stuttering can be distinguished from stammering, although this distinction is often not made. According to Kussmaul, individ- ual sounds are difficult for the stammerer, but not for the stutterer, with the latter the syllabic combinations offering the greatest obstacles. In stuttering a spasm accompanies the impeded utterance, but not in stammering ; and greater nervous embarrassments underlie stuttering. Other differences are given by Kussmaul, but the one which is perliaps of the most ]>ractical import- ance in making a differential diagnosis is that stammering is often accompanied by anomalies of the tongue, lips, and articulating organs in general, while malformations, defects, paralysis, etc. are rarely observed in connection with stuttering. It is important for the practitioner to study the duration, possi- bility of improvement, and underlying causes of such defects when presented by young children. Llsually stuttering does not show itself so as to attract attention before the age of six or seven, although rare cases have been observed in young children. Sometimes stuttering or stammering is a temporary affec- tion, coming on in children who have been overworked or undernourished or both, who have been subjected to unusual strain or excitement, or who have had an attack of fever; and in the last case it may or may not lie curable. Some forms of stuttering are distinctly hysterical, and may be relieved l)y attending to the general nervous health of the patient. The condition of the tongue and mouth of a little patient who has been attacked with a spasmodic chronic dis- turbance of speech should not be overlooked, as now ami then some affection of the tongue, lips, and palate may be the cause of the difficulty. A spasm of the muscles of articulation and deglutition may cause an affection of speech that will simulate ordinary stuttering. Putting aside all these causes of tem- porary and, it may be, remedial forms of spasmodic utterance, the vast majority of cases will be found to depend upon some original ilefect in the central nervous a])paratus. By prolonged and careful training a few of these cases can be cured, others can be helped, while a large percentage are absolutely beyond remedy. Deformities and Defects in the Mouth and Pharynx. Sometimes in children who arc not mentally defective the palate, and even the jaws, may be of some ])articular shape, interfering to some extent with easy and perfect speech. The possibility of such cases should always be remem- bered, but, on the other hand, it should be clearly before the physician that SPEECH DEFECTS AND ANOMALIES. 605 among the commonest somatic evidences of idiocy and imbecility are the shape and condition of the palate and jaws. In some types of congenital idiocy both upper and lower jaw may be narrow, the roof unusually vaulted or gothic, while in others the vault may be unusually low and flat. All varieties of palatal deformity or aberration are present in various types of idiocy. Teeth also are likely to be imperfect in such cases, and the tongue may be disobedient to the behests of the will. A fair judgment of the mental status of such a child and the meaning of its defective speech can often be reached by a study of the.se peculiarities and deformities of the head, face, mouth, tongue, teeth, jaw, and palate. Mothers are always much inclined to regard a defect of speech in their children as due to what is popularly called tongue-tie. In rare cases a fr?enum which reaches too ftir forward may be present and cause some interference with the pronunciation of a few sounds ; in still rarer cases the tongue itself may be congenitally short or deformed, but such conditions are easily determined or dismissed by careful examination. Adenoid Growths. Adenoid growths of the vault of the pharynx may be the cause of diffi- culties and peculiarities of speech, as well as of interference with hearing even to the extent of deafness. It will happen now and then that a child of two, three, or four years of age, supposed to be idiotic or imbecile, will in reality be suffering from adenoid deaf-mutism, the lack of mental development being apparently due to privation of two of the most important channels of communication Avith others. In all doubtful cases careful examination of the mouth should be made. Even if the deafness be not curalde, great relief Avill be afforded to the parents by tbe knoAvledge that the child is not idiotic, and special efforts can be made at training and education in accordance with the principles and methods which bear the most fruit in dealing Avith deaf-mutes Avho are not primarily deficient in mind. Various impediments in enunciation and pronunciation may also result from the peculiar obstruction produced by these papillomata Avhen of large size. The voice is often considerably changed, and in enunciating certain letters muffling may occur; but hasty opinions should not be given as to the future simply because of the discovery of these growths, as they are sometimes present in idiotic children or in stammerers or stutterers. Bad Habits of Speech. In studying cases of imperfect or nervous utterance attention should be given to the subject of bad habits of speech. Children, through carelessness, through the foolish management of those around them, or of their oAvn motion, may acquire certain habits of speech which will cling to them to such an extent as to become serious impediments in the Avay of development of good methods of speaking. Among these habits are frequently hesitating, unduly repeating, drawling or hurrying, using babyish or foolish expressions. Children should be coaxed or disciplined out of such habits Avhen once acquired, but it is far better not to let them take possession of the child. Treatment of Speech Defects. The treatment of different forms of defective speech must depend upon the nature and degree. Aphasia from an acute lesion, such as haemorrhage or 6(50 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. embolism, or as one of the effects of inherited syphilis, may often be benefited by time, medicine, and training. The medicinal treatment, after the first period of rest and care during the apoplectic stage, would be chiefiy the use of absorbents and tonics, such as iodides, arsenic, iron, and strychnine. Diligent efforts should be made to train an aphasic child. Even some cases of congenital origin can under appropriate and persistent training be much improved. Here the diagnosis as to the presence or absence of true idiocy, and as to the degree of mental deficiency, is of great importance in deciding as to how far to push the treatment by efforts at education and training. In aphasia coming on gradually with more or less dementia in a child previously bright, or at least ordinarily intelligent, the probability of inherited syphilis should always be considered Avith the view of judiciously using iodide of pota.ssium, iodide of iron, and similar remedies. The diagnosis of acquired deaf-mutism having been made, institutional or very careful individual treatment should at once be given. The oral system of educating deaf-mutes is particularly valuable for such patients, and much advance in the direction has been made in recent years. Great patience and skill are recjuired even in acquired deaf-mutism. Some congenital cases improve, others make no advance, the former being cases in Avhich the causes, whether prenatal or at the time of birth, have acted upon the organs of hearing or their encasements, and not upon the brain as a whole. It is said to be Best to commence the instruction of congenital deaf- mutes at the age of about six years, but neglect of some training even before this age may at times be a great disadvantage. Practically, instruction should be begun as soon as it is possible to engage the attention of the child, but the amount of this instruction should be carefully considered. Where there are special impediments of speech, instruction directed to the relief of these may be successful. Of course all local surgical conditions should be carefully attended to, such as the rare cases of attached fnenum, and those conditions which are more common, such as enlarged tonsils and naso-j)haryngeal adenoids. Cleft palate and other forms of hard or soft palate must receive the attention of the surgeon and surgical mechanism. Stammering and stuttering can occa- sionally be greatly benefited by treatment, although in some cases all methods prove to be discouraging failures. The greatest attention should be paid to the maintenance of the Best physical health, as By good food, careful hygiene, mus- cular and respiratory gymnastics. Systems of respiratory and vocal exercises are given in special works on the subject. Such treatment must necessarily be in the hands of one who has specially trained himself to carry it out. IDIOCY AND IMBECILITY. By CHARLES K. MILLS, M. D., Philadelphia. Idiocy. — Three great classes of mental arrest or deficiency are known as idiocy^ imbecility, and cretinism. Idiocy is an affection, either congenital or acquired in very early life, characterized by extreme mental deficiency, although it may be of varying grades of severity. Sometimes the idiot scarcely rises in brain power above the level of the lower animals, or he may be able to some extent to take care of himself, or again he may be capable of limited intellectual improvement. The mental deficiencies of idiocy, as a rule, go hand in hand with physical infirmity. “The term idiocy,” says Langdon Down (Tuke’s Diet. Psychol. Med.), “has a very vague significance. It is associated in many minds with one type only of mental and physical condition, very often an imaginary type or one which rarely exists. It will be well to break down such contracted views and to efface the incorrect and distorted image. Looking around a large assemblage of children whose mental condition brings them under this generic term, it is very evident that they can be broken into well-marked groups, and that instructive life-pictures may be drawn of typical representations of this inter- esting class. Looked at en masse, they would give the impression of being heterogeneous to the last degree, but it will be found on closer investigation that it is possible to arrange them into groups with strong natural affinities among the constituents, and that in many cases a very remarkable family like- ness may be traced.” The terms “imbecility” and “feeble-mindedness ” may perhaps be regarded as nearly synonymous in common medical usage. Although between idiocy and imbecility no absolute line of demarcation can positively be drawn, a dis- tinction is made for some practical purposes in clinical medicine and medical jurisprudence; but it is not correct to attempt to differentiate idiocy and imbe- cility by regarding the former as congenital and the latter as due to some cause acting after birth. Imbecility, like idiocy, may be congenital, developmental, or accidental, but true imbecility is nearly as often congenital as idiocy. Im- becility is therefore best defined as an affection congenital or acquired very early, and characterized by mental deficiency less in degree than idiocy. It must be distinguished from dementia, which in rare cases comes on in children who have been born with average capability and intelligence. Under congen- ital imbecility Clouston {^Clinical Lectures on Mental Diseases) places cases which show every degree of mental deficiency, from the smallest amount of mental weakness down to idiocy. Such imbeciles may, according to this authority, have attacks of maniacal excitement or of melancholia; they may become dangerous and even homicidal ; they may after an attack have secondary stupor, or may become demented as compared with their primitive condition; and they are often terrible masturbators. The clowns and fools of all ages would, as a rule, come under the head of imbeciles. 667 6G8 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. The medico-legal aspects and bearings of idiocy and imbecility should not be entirel}'^ neglected in general medical works, as not infrequently the family physician is the first to be called to give an opinion, which may have present or future importance, with reference to the mental status of the child under his care, although the more difficult and intricate problems associated with ques- tions as to the mental capacity of the idiotic and feeble-minded are generally submitted for final decision to medical and legal experts. Ingenious efforts to frame legal definitions of idiocy which would stand the test of experience and practice have from time to time been made. The idiot, for example, has been designated by judicial authority as one who from his nativity l)y a perpetual infirmity is non compos mentis; or one who cannot count or number twenty pence, or tell who was his father or mother, or how old he is, so that it may appear that he hath no understanding of reason what shall be for his profit or what shall be for his loss; but if he have sufficient understanding to know and understand his letters, and to read by teaching or information, he is not an idiot. The defects and shortcomings of this ingenious definition are evident even to careless examination, and have often been indicated both in courts of law and by writers. The whole question of the legal relations and consequences of true idiocy can he dismissed with the assertion that if it has once been clearly established by competent mental and physical examination, it deprives the subject of the legal right and capability of performing acts which will stand in law and e(iuity, and also relieves its subject from civil and criminal respon- sibility. It is simply a matter of careful determination in a given case. It is somewhat different, however, when the issue is that of imbecility or of back- Avardness. The elder Seguin and others have erected a class of haclcward children, in Avhom functional torpidity or backAvardness of the nervous apparatus is present, while not sufficiently abnormal to be classed as idiots or even imbeciles. These children are behindhand in mental development, and in some physical develop- ment is also retarded. They do not learn to creep or to Avalk until a much later period than others. Probal)ly most of them could be classed. Avere it not for the sensitiveness of those to Avhom they belong, Avith the highest grades of imbeciles. Such children shoAv a tendency to he behind their felloAv-children in school .and Avork, and even at phay and in their sportive relations Avith other children. They become the butts and slaves of their hetter-e(iuip])ed compan- ions, by whom they are teased and hazed, and in various Av.ays have their lives made a burden. Moral Imbkcility. — M oral imbecility is an affection sometimes classed under juvenile insjinities evcl(ypmental. — 9, Eclamj)tic ; 10. Epileptic; 11, Syphil- itic; 12, Post-febrile (also accidental) ; h, AeeidenUd or Aapiired . — 13, Toxic; 14, Traumatic ; lb. Emotional; 10, From mixed causes.” Strumous or scrofulous forms of idiocy can be clearly placed to the strumous PLATE XIV. Fig. 1. CoiiKenital Trtiot of Low Grade. Fig. 2. Epileptic Imbecile. Fig. 3. Insane Imbecile. Fig. 4. Congenital Idiot of Low Grade. m LIBRARY OF Tht UMIVBSITY of ILLINOIS *'. !■ " ‘ « TUBERCULOSIS OF THE GENITO- URINARY ORGANS, Male and Female. By N. Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surg;ery and of Clinical Surgery, Rush Medical College; At- tending Surgeon to the Presbyterian Hospital, Chicago. Octavo. 317 pages, illustrated. Cloth, $3.00 net. ^ Tuberculosis of the male and female genito- urinary organs is such a frequent, distressing, and fatal affection that a special treatise on the subject appears to fill a gap in medical literature. In the present work the bacteriology of the sub- ject has received due attention, the modern re- sources employed in the differential diagnosis “ An important book upon an important sub- ject, and written by a man of mature judgment and wide experience. The author has given us an instructive book upon one of the most import- ant subjects of the day .” — Clinical Reporter. between tubercular and other inflammatory af- fections are fully described, and the medical and surgical therapeutics are discussed in detaiL The opinions and views of surgeons of large experi- ence have been freely quoted, and in appropriate places the author has related the results of his own extensive clinical observations. ^ SENNAS GENITO-URINARY TUBERCULOSIS DISEASES OF WOMEN. A Hand- book fof Students and Practitioners. By J. Bland Sutton, F.R.C.S. Eng., Sur- geon to the Chelsea Hospital for Women ; Assistant Surgeon to the Middlesex Hospital, London ; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to the Chelsea Hospital for Women, Lon- don. Handsome volume of 436 pages, illustrated with JJ 5 engravings. Cloth, ^2.50 net. A concise yet comprehensive guide to the study of gynecology in its most modem development. The work will prove useful to students for The book is very well prepared, and is certain to be well received by the medical public.” — BHt^ ish Medical Journal. “The text has been carefully prepared. Noth- ing essential has been omitted, and its teachings are those recommended by the leading authori- ties of the ^?i)^''—Jouryial of the Amencati Medi* cal Associatiofi. examination purposes, and will also enable the general physician to practice this important de- partment of surgery with advantage to his patients and with satisfaction to himself. J* J* SUTTON AND GILES' DISEASES OF WOMEN IDIOCY AND IMBECILITY. 673 or scrofulous diathesis ; they belong to the congenital class. The primarily neurotic are those with bodies comparatively well developed and with signs of irregular nervous action. The term “choreic,” as applied to idiocy, has been used in several ways — as descriptive of the motor phenomena presented by the patient ; or of idiocy resulting in a child born of a mother choreic during pregnancy ; or of cases m which violent or persistent chorea seems to induce idiocy in the developing child. Congenital idiocy due to inherited syphilis is probably but not certainly rarer than a form of juvenile dementia, which usually develops some years after birth, and is described in another section. Some syphilitic children are idiotic from birth, and in these cases treatment is generally as useless as in cases due to other causes, while in syphilitic juvenile dementia specific treat- ment may be very efficient. Shuttleworth applies the term “toxic idiocy” to idiots who Avithout bodily deformity suffer from malnutrition of the brain, which he supposes to be due to some unknown toxic influence. Emotional or excitable idiocy is that which shows shrinking, fear, apprehension, excitement as its chief features. Etiology. — A bad heritage is the great predisposing cause of idiocy. The idiot’s ancestor may not have been insane, imbecile, or idiotic, but in the majority of cases some constitutional taint or tendency, as syphilis, struma, or tuberculosis ; some toxic affection, as alcoholism; some form of mental disease or defect; some neurosis as epilepsy, hysteria, neuralgia, or neurasthenia, or some organic disease of the brain, as meningitis, sclerosis, softening, or haemorrhage, will with sufficient investigation be found to have been present in near or remote progenitors. Intemperance, alone or combined Avith other causes, such as epilepsy or insanity, has been shown by reliable statistics to be one of the com- monest predisposing causes. Far too freciuently imbeciles of high, or in some cases of comparatively low grade, marry, with degenerate offspring as the result. Numerous studies of heredity in connection Avith this question of the causation of idiocy have been made. According to ShuttleAvorth and Beach (Tuke’s Diet. Psychol. Med.), the most frequent combination of tAvo causes of insanity is that of insanity with epilepsy. Even deaf-mutism, Avith perhaps in most cases the addition of some other loAvering agency, has resulted in idiocy and imbecility in the second and third generation. By the authors above quoted syphilis Avas found certainly to be the predisposing cause in 17 per cent, of more than tAvo thousand cases. Good authorities place 2 per cent, as covering the cases of syphilitic idiocy, although others would put it much higher. The question of consanguineous marriages has been much discussed in connection Avith the causa- tion of both insanity and idiocy, and authorities are somewhat at variance ; but it may be regarded as certain that the marriage of relatives in one or both of whom mental or neurotic defects or constitutional or toxic conditions are present will predispose to idiocy and imbecility as to other degenerative diseases. It is better, as a rule, that relatives should not intermarry, as few stocks are absolutely without taint or weakness. Bad health in the mother and impressions made on her during pregnancy, the father’s health or condition at the time of procreation, age or premature senility of parents, and acute diseases during pregnancy, — all have some etio- logical importance. Among causes acting at the time of birth are prolonged and difficult labor in mothers Avith small or deformed pelves; injuries by instruments or other manipulations or by the umbilical cord, and suspended animation from whatever cause. The use of instruments is, however, a much less frequent 43 G74 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. cause of idiocy, infantile paralysis, and convulsions than is commonly supposed. They are often used after the injury has been done by long-continued pressure. The promj)t and skilful use of forceps sometimes saves life and health for both mother and child, oftcner than the reverse. In these pressure and forceps cases skull depressions and hemorrhages sometimes occur. The causes acting after birth are comparatively few, but among these are injuries from falls or blows, convulsions of unknown origin, fright, febrile diseases, and in rare cases the ingestion of to.xic substances. Symptoms. — To briefly give the symptomatology of idiocy in general is an almost impossible task. The signs and symptoms will vary widely with classes, and to a certain extent, in considering the varieties of idiocy, I have already described its symptomatology ; but certain physical and mental characteristics belong to almost any form of idiocy, and from studying these the practitioner of medicine, even without special knowledge of the subject, may be able to come to a conclusion as to the nature of such a case at an early period. Much can be learned as to the physical features of idiocy by mere inspection, and much more by careful and detailed investigation. The size and shape of the head and face and defects of feature may prove serviceable in coming to a decision. I have already spoken of varieties dependent on the shape of the head to which special names have been given, as microcephalic, and brachycephalic. Unusual smallness or largeness of the head, or, what is more common, deformity or asymmetry in its shape, is often the first to attract attention. In some types of idiocy, as the Mongolian, a remarkable deficiency of the posterior part of the cranium is often observed ; in others it may be that one side of the head, or even one special region of the cranium, will show marked depression or arrest. In almost every instance of true idiocy some peculiarity of face or feature is present : this may be abnormal position or separation of the eyes ; deformity, unusual size, or peculiar implantation of the external ear ; depression or flattening of the nose, or general asymmetry of the face. The oral cavity of idiots has been the subject of much investigation, and great varieties in the shape of the mouth and pharynx are found ; it is high and gothic ; or low and flat ; or irregular ; or a cleft or partially cleft palate is pres- ent ; and sometimes the entire buccal and pharyngeal cavities are contracted as well as irregular in shape. The greatest possible variations in the shape, size, and implantation of the teeth are to be observed : they are notched or pegged or serrated ; they overlaj) and are irregularly crowded : frequently they decay at an early period. The jaws may be too narrow or may fail to be properly apposed to each other ; occasionally, instead of being small, the lower jaw is prognathiaii — of unusual size and projection. The tongue may be too large, or even too small, and frequently refuses to obey the behests of the will. The head cannot be held erect or is carried badly. The control which the patient has over ocular movements and facial expres- sion is often of great value to the diagnostician. Strabismus is common, and this may be of one eye or both, or of an alternating or varying type. Of other simple tangible phenomena, drooling or slavering is an important manifestation. Inability to stand or walk at the usual age may lead to suspicion as to the true condition, and even if the child can walk his carriage and gait may be very significant. Some idiots stoop, some have a lopsich'd method of progression; many are slouching in station and in walk; some run when they should walk, or walk when they should run; the gait is often ataxic or incoordinate, or, rather than this in a technical sense, it may be simply maladroit or awkward. The hands and arms are not used with the same precision, accuracy, and adap- tation of means to ends as by other children. IDIOCY AND IMBECILITY. 675 Below the head and neck defects and peculiarities may be as various as above. Curvatures and twistings of the trunk, asymmetry in the develo{)inent of the legs and arms; Hexures, curvatures, or other deformities ot the limbs; knock-knees or bow-legs or parrot-toes, and numerous other deformities, mal- positions and arrests, may be present. According to the variety of idiocy there may be paralysis, with or without local spasm or contracture, in limbs or face ; sometimes this is one-sided — that is, monoplegic or hemiplegic; sometimes both legs, or both legs and one arm, or all four limbs, may be involved in the pare- tico-spastic condition. The skin may be harsh or dry or coarse; it may show evidences of impaired or imperfect circulation m coldness or duskiness of the extremities, in blotches or discolorations, or even in a tendency to trophic affections; such as ulcerations and eruptions. Not seldom the hair is scanty or coarse or badly nourished, and the nails may be of bad shape or abnormal in appearance. The sexual organs may show unusual smallness or deformity or peculiaidty of some kind. Speech may show many varieties of defect and aberration, and these have to some extent been considered in another section. The incapacity to attend to what is said or what should be done is one of the first things to attract attention to an idiotic child. At an age when infants and small children ordi- narily attend to many matters of passing interest, such a child cannot be made to fix its attention even by the most strenuous efforts; indeed, a close study of this faculty will perhaps throw more light than anything else upon the degree of mental development in children. Self-will, undue emotionality, lack of ordinary obedience, impetuous and unreasonable behavior, inattention to natural wants and demands, are all points of importance in the mental investi- gation of supposed idiocy. While some or many of the physical peculiarities enumerated may be present in cases of idiocy, it must not be forgotten that in some types at least they are nearly all wanting. In the so-called accidental idiocy, for example — that which has resulted from injury at the time of or after birth — there may be a striking absence of the usual physical defects and deviations. Such children are some- times scarcely to be distinguished in head, face, form, attitude, or movements from those retaining their mental faculties, although the traumatism may have left its mark in depressed skull or paralytic or spastic limbs. Pathology. — Many facts with reference to the pathology of idiocy will be found discussed under such heads as the cerebral paralyses of childhood, hydrocephalus, brain atrophy or hypertrophy, porencephaly, sclerosis, cortical arrest, cysts, softening, limmorrhage, embolism, thrombosis, chronic menin- gitis, meningo-encephalitis, and encephalitis ; while many of the symptoms peculiar to idiocy have been or will be considered under such headings as speech defects and anomalies, nystagmus, athetosis and athetoid affections, and epilepsy. Idiocy has no fixed pathology, but numerous exceedingly interesting patho- logical appearances and conditions have been reported, as anaemia and hyper- aemia of the brain ; hypertrophy and atrophy, general and partial ; softening, usually local ; sclerosis of various forms ; hydrocephalus and porencephalus, meningitis, and tumors ; thickening of the arteries; thrombosis of the sinuses; asymmetry or unusual simplicity of the hemispheres and convolutions; alter- ations in the relative amount of white and gray matter of the brain. Disease of other organs than the cerebrum is often associated with cerebral disease, as, for example, atrophy, tumors, and cysts of the cerebellum, or spinal affections, C7G AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. such as poliomyelitis ; congenital arrest of development of the pyramidal tracts ; descending sclerosis ; chronic myelitis ; or pseudo-hypertrophic paralysis. Wilmarth (^Alienist and Neurologist., October, 1890), has given the results of the study of one hundred brains, and his condensed statement pre- sents in an unusually interesting and practical form the pathology of most cases of idiocy. I had the opportunity of studying some of the brains and skulls which are included in this list of cases. Sclerosis with atrophy, 12 ; scleroso-tubereuse, 6 ; diffuse sclerotic change, 7 ; degenerative changes in vessels, ganglionic cells, or medullary substance, not constituting the true sclerosis, 15 ; hydrocephalus, 5 ; general cerebral atrophy, 2 ; non-develop- ment in various forms, 16 ; infantile hemorrhages, 1 ; extensive adhesions of membranes from old meningitis, 3 ; angeiomatous condition of the cere- bral vessels (with degenerative changes), 1 ; glioma (with sclerosis), 1 ; porencephalus, 1 ; and 31 cases where actual disease or imperfect development of the brain proper was not demonstrated ; there was hypertrophy of the skull, 6 ; acute softening (recent), 2 ; demi-microcephalic, 2 ; 1 brain was above the usual weight, but the convolutions were large and very simple in their arrangement. In 75 cases, or in all in which injections of chloride of zinc or extensive destruction had not made weighing valueless, the brain was carefully weighed. The average w’eight was 38.3 ounces; in 14 cases the weight was below 30 ounces ; thickening of the skull to an extent to constitute hypertrophy was found in 8 instances ; while in 8 the skull was unusually, thin, not including cases in which there was distention from hydrocephalus. An attempt at a pathological classification of idiocy might be made, although this undoubtedly would contain many imperfections. The classes will be sometimes found to blend and commingle, cases will repeat themselves under difterent headings, and other objections will appear; but, on the whole, such a classification will indicate in a general way the groups as they would be found in any large institution. The most important of these classes are as follows: 1. Idiocy due to gross organic lesions, the history of which can be deter- mined with more or less accui’acy — lesions such as Imemorrhage, embolism, thrombosis, tumors, meningitis, meningo-encephalitis, and encephalitis. 2. Idiocy due to various forms of sclerosis, as the difiuse, multiple, or disseminated ; sclerosis with atrophy, and lobar or tuberous sclerosis. 3. Idiocy due to arrest of cortical development, a true agenesis corficahs, or absence of normal cells, whieh has been well studied and described by Sachs of New York [Aour. Nerv. and Ment. Dis., August, 1892). 4. Idiocy due to large cerebral deficiencies, but sometimes originating in haemorrhage, thrombosis, embolism, sclerosis, meningitis, etc. — such conditions as general atrophy or hypertrophy, porencephalus, and hydrocejihalus. 5. Idiocy due to inherited or congenital syphilis, which jierhaps might be included under some other subdivision, but the cases are supjiosed by some autboT-ities to have a peculiar history and special apjiearances, and therelore may be placed for practical purposes in a separate group. 6. Idiocy of toxic origin, under which head would be included cases result- ing from acute poisoning or following infectious diseases, sueh as measles, scarlet fever, etc. Diagnosis. — The diagnosis of idiocy will oidy be difficult in early inlancy and in a few rare cases, d'he facts to be learneil by observing whether or not the child pursues a regular, or at least an average, method of development have already been considered with reference to the sense of hearing, the IDIOCY AND IMBECILITY. G77 acquirement of speech, and the development of ideas, when discussing anom- alies and defects of speech. Difierent children of the same family or healthy children who are known to the physician can be compared with the one alleged to be idiotic. Careful consideration must be given to the question of normal retardation or mere backwardness, or the existence of a true insanity, such as syphilitic dementia. The diagnosis of idiocy and imbecility is always most assisted by a careful study of the ])hysical conditions presented by the child — the shape and size of the head, which have already been discussed ; the condition of the eyes and the ocular muscles ; the appearance of the palate, jaw, and tongue; the presence or absence of drooling; ataxic, athetoid, or choreic movements ; peculiarities of expression ; deformities of the eai', nose, or mouth ; ungainly, limping gait ; paralysis or contractures, or both in the same case. The more marked and numerous these arrests and aberrations of bodily development, the more likely it Avill be that the diagnosis of idiocy is correct. In every part of this article mental disturbances and deficiencies are under consideration, and it is only necessary to say here that such faculties as attention, memory, and inhibition should be particularly studied. Prognosis. — The prognosis of idiocy as to cure is of course altogether bad, but it should be remembered that improvement can be made in the condition of idiots even of comparatively low grade. They can be made more comfort- able, happier, less offensive, less destructive, and even, in a limited number of cases, more useful, by care, discipline, education, training, and, to a limited degree, by the use of nutrient and medicinal agencies. “ During the fifty years over which efforts for the amelioration of the imbecile have extended,” says Shuttleworth ( Psych. il/eJ.), “the sanguine prognostications of early enthusiasts may not have been realized, but neverthe- less a large percentage of benefit has been recorded. An imbecile, however well trained, will always need some kindly aid and consideration from those with whom he is associated. It is not to be expected he will be able to manage his own affairs or compete in the labor-markets of the world. Placed in a niche, however, where he can without molestation exercise his acquired talents, he will in many cases turn out more or less remunerative work ; and, failing this, he will, in consequence of having some resources within himself, cease to he a nuisance to his friends. Even the improvement of habits by systematic training is not to be despised in relation to the comfort of the family ; and it must be borne in mind that the idiot left untrained is sure to deteriorate. A review of twenty years’ experience at one of the large English institutions furnishes the follow- ing results : Of patients discharged after full training, 10 per cent, are self- supporting, whilst another 10 per cent, would be so if they had obtained suit- able positions, and about 20 per cent, were reported as useful to their friends at home.” Treatment. — In considering treatment the subject might be variously sub- divided, as into prophylactic and direct; into hygienic, educational, gymnastic, and medicinal ; into measures for the affection itself, and for diseases and con- ditions that are intercurrent or resultant. Habitation, diet, and clothins: should be carefully selected ; and in doing this particular attention should he paid to the variety of idiocy and to the diatliesis from which it may have resulted. The ventilation of rooms at night and proper beds and clothing should receive attention. Cleanliness must be enforced by bathing, which can also be used as an invigorating and strengthening measure. All idiots should have exercise graded to their physical condition and powers ; mistakes may be made in attempting to do too much in this direction or by not duly considering their differences from other children. Systematized gymnastic exercises or calis- G78 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. thenics can be used with great advantage, both for physical development and to a limited extent to promote mental power, and to a larger degree to add to the happiness of these defective children. Whether or not an idiotic child should be removed from its home to an institution is a question that the physician must fre([uently meet, and in general terms it may be said that a Avell-conducted institution, as a rule, is the best place, both for him and for other members of the family. The danger of being made worse by contact with others — an argument which is so often used against sending a patient to an insane hospital, and occasionally with force — does not apply, or to an exceedingly limited extent. In institutions of large size the defective children can be .so classified that their training can be carried out sys- tematically and without much jarring and strain, or, if incapable of any im- provement, so that they can be cared for and their happiness promoted in the best possible manner. The presence of an idiot in a family is often painful and deteriorating both to parents and to other children. Home treatment may be pursued where parents have large means and the care and training of an idiotic child can be managed apart from the rest of the family. For the wealthier classes the institutions which take only a small number of children, if these are conducted on thoroughly scientific as well as humane principles, offer some advantages. Amusements, exercises, and social intercourse are all regulated to excellent purpose in institutions like those at Elwyn, Pennsylvania, at Vine- land, New Jersey, and at Barre, Massachusetts. The educational treatment or training of the feeble-minded has received much attention in recent years. In 1801 the first great incentive was given by Itard to this method of bettering the condition of the idiotic by his inter- esting account of his own experiences with a child that had been found savage in the woods, but to the elder Seguin {Idiocy mid Its Treatment by the Phy- siological Method, 1866), the greatest of credit is due. He was truly the first apostle of the idiot. Volumes have been devoted to this most interesting subject, but to these I can scarcely do more than refer. This training and education should be patiently directed to the development of the deficient senses; to the training of the hands and feet; to the improvement of carriage and gait; to stimulating the slow and to braking the morbidly active; to the development and improvement of speech ; to arousing attention, imitation, imagination, comparison and judgment; and to the awakening and cultivation of the moral senses and power of control. Not much can be said about the medical and surgical treatment of idiocy. Attention should first be directed to the probability of the idiocy being due to such possibly remedial causes as inherited sy])hilis or traumatisms. The iodides of potassium and sodium, hydriodic acid, and various mercurial prepara- tions may be tried in cases presumably due to inherited syphilis, but too much must not be expected, as syphilis in the progenitor has established a condition of arrest rather than an active and removable lesion. It is different in infantile and juvenile dementia due to syphilis, which have been treated of in another article ; here the treatment may ])romise much, and, as the dift’erentiation is sometimes difiiciilt, it may sometimes be enqdoyed as a diagnostic measure. Everything should be done to ])romote the nutrition of the idiot — malt, maltine, cod-liver oil, and nourishing food for the strumous ; the same with preparations of iodine, arsenic, and tonics in general for the rachitic; digestants like pepsin, pancreatin, the mineral acids, and stomachics for those of weak digestion ; astringents, antifermentatives, and intestinal tonics for those afllicted with diarrhoeas and dysenteries; lime-juice, vegetable acids, bitters, (|uinine, iron, and fresh food for the scorbutic; ointments for the skin, washes for the mouth, IDIOCY AND IMBECILITY. G79 lotions for the eyes, — but these will not be to the working of a cure, but to the relief of annoying and depressing symptoms and conditions. For convulsions, bromides, chloral, sulphonal, antipyrine, and similar inhibitors of cortical exci- tability, guarded by arsenic and supported by nutrients, may be administered. For excitement trional and tetronal have been found valuable. What to do with backward children is often a serious problem. They certainly should not be sent to the institutions for the idiotic and feeble-minded, nor can they always with advantage be kept at schools of ordinary or high grade. When their parents can afford the expense, it is best, for a time at least, to have them instructed by tutors or to send them to small schools, with the understanding that special attention shall be paid to them, and that their instruction shall be regulated as far as possible in accordance with their needs and capabilities. The physician should be careful not to be too hasty in his prognosis or prophecies in reference to such children. A practical point worth while to be always borne in mind is that sometimes mental backwardness, like physical backwardness or peculiarity, is due to the rachitic diathesis. Just as in well-defined types of rachitic pseudo-paralysis, the hony and other forms of arrest or deformity will yield to an abundance of good air, good food, and treatment with such preparations as cod-liver oil, arsenic, iron, and iodides in various forms, so some cases of intellectual slowness and torpor will be greatly improved or cured by similar measures. For evident cranial depression and fracture trephining may be resorted to, though in long-standing cases the outcome is generally doubtful. The surgical treatment of idiocy has recently received an impetus through the ope- rations performed first in France by Lannelongue (A’ Union Medicale, July 8, 1890), in England by Horsley {JBrit. Med. Jour., September 12, 1891), and in this country by Keen {Med. News, Nov. 29, 1890, and Amer. Jour. Med. Set., June, 1891), and others. At the French Surgical Congress in 1891 twenty-eight cases of craniectomy were reported, with but one death, and con- siderable improvement was claimed in some of the cases, but a careful reading of the reports of cases shows that the real benefit has not been great. The best method of training moral imbecility must be sometimes considered. In most genuine cases, education or philanthropy, kindness or cruelty, the sugar-plum or the whip, the Sunday-school or the reformatory, the asylum or the penitentiary, will equally fail ; or perhaps I should not say equally, as in a few instances some strengthening of the weak and imperfect coordinating centres may be possible. To the typical case, to the vast majority of cases that would come under this designation, belongs the term incorrigible. Some of the most practical and most experienced authorities, as Tuke and Kerlin, believe that education in its ordinary meaning should be largely withheld from this class. The former says of them : “ The early detection of these cases is not difficult: they should be subjects for life-long detention; their existence can be made happy and useful, and they will train into comparative facility and harmlessness if kept under a uniform, temperate, and positive restriction. The school-room fosters the ill we would cure : in teaching them to write we give them an illimitable power of mischief ; in educating them at all, except to physical work, we are adding to their armament of deception and misdemeanor.” As Kerlin puts it, we should refuse them the ordinary routine of education, because “ we believe that in educating moral imbecility we are training experts for the later role of so-called moral insanity.” CRETINISM." By CHARLES K. MILLS, M. D., Philadelpjiia. Cretinism is a form of arrested ph^^sical and mental development, chronic and usually endemic, characterized by peculiar appearances and malformations, but especially by smallness of stature, distortion or deformity of the fiice, head, and body, unhealthiness of the skin, enlargement or absence of the thyroid gland, or fatty growths above the clavicle. The derivation of the word “cretin” is involved in curious uncertainty. Its origin has been assigned, for example, to creta, chalk ; to cretira, stupid, silly ; and to Chretien, Christian, because cretins are supposed to be as happy as Christians ought to be. In different regions and by different writers cretins have been called by various names, as cagots ; but the cagots are not true cretins, but a proscribed people living in Bearn and Gascony who may at one time have suffered from a form of leprosy. In Germany cretins are called Kreidlmgs and Kretins ; in Austria, Gacken and Trotteln ; in Italy, Gavas, Totolas, Cristiani ; and in South America, Bovos and Tontos (Tuke). Cretinism is endemic in various countries, but nearly always in mountain- ous regions, as in the Pyrenees and Alps, in the Highlands of Scotland, and in the Himalayas. In this country a few cases are occasionally found together, as in the mountains of Vermont and California, but the affection is chiefly of interest to American physicians as a sporadic disease. Probably it is found to some degree all over the world. In a few countries in which it is most prev- alent, as in Switzerland, France, Italy, and Spain, it often shows a curious tendency to limit itself to particular spots, even in a region of the same general climatic and geological features — to blight one valley or village, while another close by, and apparently not different in environment, escapes. While pro- nounced cretinism is rare in this country, cretinoid cases are seen with more frequency ; and by cretinoid cases, in this connection, I do not refer to ordinary cases of myxoedema, although Sir William Gull described myxoedema under this term, but rather to cases which I now and then see in which neither myxoedema nor true cretinism is jiresent, but in which the patient in face, head, expression, stature, skin, mental cuipacity, or other points reminds one of the cretin. Symptoms. — The symptomatology of cretinism and cretinoid disease can perhaps be best presented by first ilescribing one or two cases. One studied by me at the New Jersey Home for the Feeble-minded, a girl aged nine years, was the seventh child, born after difficult labor, but seemed strong until she was sixteen or eighteen months old, and until this time was bright and active and did not seem defective. At this time she had a severe fall. He r mother was a hard-working woman ; the father had rheumatism and was unable to Avork, and at times was a hard drinker. She had one brother ' This article lias been carefully revised for the jiresent eilition by Wm. G. Spillcr, M. I). 080 CRETINISM. . 681 and three sisters living and healthy. She was a well-marked cretinoid case, with flat face and open mouth, the tongue filling it, but not protruding. She had a soft, but not large, swelling above each clavicle. Her mental condition was very low. She never gave a direct answer to any question, and had no words at her command ; but she knew her own name, could feed herself, and could walk a short distance with assistance. She was almost as broad as she was long. I have seen a fair number of such cases of cretinoid idiocy, but generally of much higher grade, in private and hospital practice and in the institutions for the feeble-minded both at Elwyn, Pa., and at Vineland, N. J. In the nervous wards of the Philadelphia Hospital is a typical example of sporadic cretinism, which I have frequently studied and discussed before my classes. A description of this case has been published by Lloyd {Inter- national Clinics, 1892). The cretin, thirty-five years old, was born in the outskirts of Philadelphia. He has a myxoedematous face with large lips and hypertrophied, protruding tongue; small limbs, even as compared with his body ; protuberant belly ; the sexual apparatus of a small child ; no hair about the pubes or on the face, and a scanty supply on the head ; bad teeth and gums ; eyelids red, tumid, and nearly closed ; the skin yellowish- white and dry, and sweating only on the forehead and forearms. His height is 35J inches. He can walk a little, but is very weak on his limbs. Knee- jerks and the reflexes are normal; sensation seems to be everywhere preserved, and sight and hearing likewise appear to be good. The thyroid gland is wanting, but above the clavicles on each side is a soft mass, probably a fatty growth. While his mental capacity is very low, it is more than his appearance and lack of speech, which is confined to a few words, would indicate. He is observant of much that goes on in the wards, understands much that is said to him, recognizes physicians and old friends, and is appreciative of favors. He has lived along with scarcely any change during the many years that he has been in the hospital, escaping intercurrent disease. His temperature is almost constantly subnormal, and during one week in which it was carefully taken, he being in his usual health, it never reached the normal but once, and most of the time ranged below 97.4° F. (The plate representing this case is from Lloyd’s paper.) For many years in the neighborhood of the hospital was another example of typical sporadic cretinism, presenting most of the features of the case just described. In describing the above case I have practically given the symptomatology of cretinism. The word stunted describes the conditions, physical and mental, better than any other. The cretin is small in stature except in very rare cases ; thus Lombroso has described a family of cretins of unusual stature. The head is frequently contracted from the front backward or in some way is asymmetrical. In typical cases the features are striking — short, flattened nose ; eyes wide apart ; puffy, drooping lids ; small face and protruding tongue. Not only temperature, but pulse and respiration, and all the vital processes, are sluggish ; digestion, secretion, and excretion go on torpidly ; menstruation is established late or not at all. Speech varies much in different cases, and efforts have been made to classify cretins with reference to their possession of this faculty, the lowest grade con- sisting of those who are deprived entirely of language or have so little as to amount to nothing. Cretins of this class lead little more than a vegetative life, and are not capable of being improved much by education, training, or change of environment. By a study both of their speech and of their mental deficiencies in general they are sometimes placed in two higher classes than 682 .AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. the one just described. In one the cretins have some language which is capable of being extended ; they improve somewhat by imitation ; they have limited powers of reproduction, but they have little spontaneity or real intel- ligence, and generally their efforts are confined to matters absolutely necessary to their existence and comfort. A higher class of semi-cretins often possess a fair amount of physical and mental development. They can take care of families, which, unfortunately, they sometimes have, and they are capable of considerable intellectual improvement ; in a few cases, indeed, they have so little the characteristics of true cretinism that they are only to be recognized as belonging to these people by one or two peculiarities. A peculiar class of cases of foetal or congenital rachitis has been observed, the children being born with deformed bones, beaded ribs, etc., the bones in some cases being soft. By some the terms infantile osteomalacia and cretinism have been applied to these cases, chiefly because they have failed to present the macroscopic and microscopic appearances of rachitis. They have been described by Bode, Barlow, and Marshall of Preston, who are referred to by Ashby and Wright. Through the kindness of Dr. D. T. Lain^ of Media, Pa., I had the oppor- tunity of seeing an interesting case of this rachitic pseudo-cretinism. The child was three years and seven months old. The sutures were closed, and the head showed a prominence in the right parietal region, and also a large depression in the frontal bone of the same side. The face was broad, eyes wide apart, nose flattened, eyelids drooping, and she had slight right internal strabismus. The bones of the upper arm were slightly curved ; the lower ends of the radius and ulna enlarged and knobbed, these bones being also slightly bent; the ribs were beaded or irregularly knobbed and the chest contracted ; the bones of the legs showed some bowing and curving. The spine showed a rachitic dorso-lumbar curve, more prominent on the left. Liver and spleen were greatly enlarged. The child could barely sit up and hohl up her head, and had never been able to stand alone. In appearance she reminded one at first glance of a cretin, and was probably a case of infan- tile osteomalacia. She weighed eight pounds when born, sixteen when five months old, ten when one year of age, and thirty at the time of observation. When born she was very dark-skinned and hairy all over the body. During most of her life her bowels had been much disturbed, and she had one attack of convulsions when about five months old. She cut her first teeth at fifteen months. During the year previous to the time that I saw her she had slept from twelve to fifteen hours out of the twenty-four. As a rule, she was not cross and cried very little. The family history was not good. The maternal great-grandparents were cousins ; the maternal grandmother had paralysis agitans ; the paternal grandmother had “bowel consumj)tion.” Etiolog-y. — Cretinism is especially prevalent in high mountain-ranges remote from the coast; wet or undrained soil appears to have some inlluonce in its development; and water charged with lime and magnesia is common in the regions in which it is endemic. Practically, the ultimate cause of cretinism is unknown. Brissaud says that goitrous parents necessarily have cretinoid children. Although goitre may he present and cretinism absent, it is undoubtedly true that where goitre exists to any large extent cretins arc likely to be found. When the goitre is not ])re.sent, and even in some cases where it is, peculiar soft, fatty growths may he found in various parts of the body, but usually above the clavicle. In the Philadelphia Ilos])ital ca.se goitre was absent, and also ap])arcntly the thyroid, hut soft movable masses were found in the neck. By some these are regarded as distinguishing the PLATE XV. SPORADIC CRETINISM. TWE LIBRAfiir OF THE ONIYEflSJTlf OP ILLINOIS CRETINISM. 683 sporadic from the endemic and epidemic forms of the disease, but this is a mistake. Pathology. — The pathology of cretinism is ill-defined. The statements of Virchow regarding the premature ossification of the several parts of the bones at the base of the skull have frequently been misunderstood. Ordi- narily, these parts remain separate until puberty, but, according to Virchow, in cretins synostosis may occur at a very early period; this, however, is not the cause of cretinism. While this osseous peculiarity has been found in many cretin skulls, in some instances of undoubted cretinism it has not been present, and Ewald also says that it is by no means pathognomonic. Various changes have been found post-mortem and under the micro- scope which are of minor importance ; the brain-membranes, and partic- ularly the dura, are sometimes thickened and adherent, as it is in not a few other forms of arrest ; great variety in the shape and arrangement of the convolutions is found, the tendency being to undue simplicity and small- ness of size of important regions : the important fissures of the brain are ill defined or in unusual positions, and shallowness of the fissures is common. Asymmetry of both the cerebrum and cerebellum has been noted, and a few observations have been made on the relative thickness of the different layers of the cortex, showing great abnormalities in this respect ; but all these are conditions frequently found in the feeble-minded, and are in no way peculiar to cretinism. Much more important are the alterations observed in the thyroid gland. Barker (cited by Osier, Amer. Journ. of the Med. Set., 1897) found changes in this gland in a case of sporadic cretinism confirmatory of those observed in previous cases of endemic cretinism. The thyroid gland in most cases of sporadic cretinism is small or absent, and no statement regarding its normal appearance is of great value unless microscopic examination has been made. Goitre is usually associated with endemic cretinism, and seems to be in causal relation. It is of little moment whether the gland is pseudo-hypertrophied, atrophied, or absent, for if its functions are seriously affected early in life, the cretinoid appearance is likely to be presented. It is proper to state that, according to Hermann Munk, our views in regard to the importance of the thyroid gland in the animal economy must be greatly modified. The gland is not essential to life, although its removal endangers life ; again, the symp- toms Avhich are supposed to result from its removal do not always follow its extirpation. Diag-nosis. — While cretinism may be, and usually is, regarded as a form of idiocy or imbecility, or closely related to these affections, it differs from them in several essential particulars, as has been shown by various authori- ties. The cretin is not necessarily born to this state, although after several generations the offspring are likely to be cretins or cretinoid cases. For a long time the individual may show no sign of cretinism, although doubtless having within him the potentiality of the disorder. Removal from a given locality to a higher situation, even during the pregnancy of the mother, will sometimes prevent the development of cretinism. It differs from idiocy in being so often endemic, in the comparative improvability of some of its grades, in the presence of symptoms not seen in cases of ordinary idiocy, and in its apparent dependence upon conditions of air, water, or soil. It may be occasionally important, as in the case of Dr. Lain^ referred to under Symptomatology, to distinguish between true cretinism and osteo- malacia, as treatment in either case may be of very great service if begun sufficiently early. The diagnosis can be made by a close investigation for 684 AMERICAN TEXT- BOOK OE DISEASES OE CHILDREN. the well-known signs of rickets, such as enlarged liver, beaded ribs, and soft or deformed bones, though it must be remembered that the administration of the thyroid gland to ci'etins may cause softness of the bones. The idiotic 'myxoedemateuxe of Bourneville, as shown in the picture of the “Pacha” of the Bicetre, is so similar to the case of cretinism at the Phila- delphia Hospital that one photograph might almost answer for either case. Many of the distinctions which are made between myxoedematous idiocy, cretinoid idiocy, juvenile my.xoedema, endemic cretinism, sporadic cretinism, Fig. 1. Dr. J. I’. West’s ease of infantile inyxoeclenia, before treatment. and even some forms of infantilism, are artificial ones. Ewald says there is no distinct difference between sporadic cretinism and infantile myxaulema. The cachexia strumipriva, which develops after removal of the thyroid gland in youth, has the typical features of sporadic cretinism. All these conditions just mentioned are closely connected with absence or degeneration, total or partial, of the thyroid gland, and the clinical apjiearance varies according to the degree of development of the gland and the ago at which the first symp- CRETINISM. 685 toms present themselves. The cretinoid type is most marked when the func- tion of the gland is insufficiently performed at the period of greatest develop- ment of the body. The endemic cretin comes into the world as the offspring of goitrous parents or is himself goitrous, and his appearance necessarily differs from that of the sporadic cretin who has attained a certain degree of develop- ment before the thyroid gland has become functionally inactive. Although many writers hesitate to say that these various diseases mentioned are one and the same, most recognize the close clinical connection between them. Fig. 2. Dr. J. P. West’s case of infantile myxoedema, after six months’ thyroid treatment. Infantilism must fretpieiitly be regarded as a forme fruste of infantile myxoedema, and, indeed, it is not uiicoumion to find evidences of the latter disease in cases in which the adult development has been delayed. Idiots of the Mongol type are also closely related to cretins. Prognosis. — The prognosis of cretinism depends largely on the persist- ency of treatment and the age at which this is begun. In such a case as the one at the Philadelphia Hospital little or nothing could be expected, but 686 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. when the cretin is treated in early childhood persistently and carefully, the results are frecjuently most brilliant (Figs. 1 and 2). Treatment. — Cretinism, once fully developed, always leaves its stamp upon the individual, but even a low-grade cretin is capable of a surprising degree of mental improvement, as has been demonstrated by the enthusiastic philanthropic efibrts of Guggenhuhl and others in Europe. In cretinism the physical and mental arrest or deterioration go hand in hand to a greater degree than in idiocy, although, of course, in the latter the truth of this a.ssertion wdll be measured somewhat by the peculiar form of idiocy which is under consideration. Monographs and even treatises have been written to show that cretinism is due to this or that atmospheric, telluric, or other cause. Perhaps in a w’ork of this kind it is better to dismiss any consideration of this matter, e.xcej)t as it may bear upon the prophylaxis of the disease. It has been found by abundant experience that the tendency to cretinism is combated by making careful selection of drinking waters which are contaminated with peculiar salts, as magnesium, iron, etc. ; also, that the removal of the mothers who are pregnant, or of the young children who are born in the neighbor- hoods where cretinism has a tendency to become endemic, to remote and higher districts will sometimes prevent the development of the affection. Experimental investigations have shown that a myxoedematous condition develops after removal of the thyroid gland, and transplantation of the thyroid gland from one animal into the abdominal cavity of another in which the gland had been removed has been attended with beneficial results. Act- ing on these suggestions, a number of physicians were led to experiment with the feeding of the raw thyroid gland of the sheep. The dish w’as most unpalatable to many, and a disgust was often created which was fre(iuently sufficient to interfere with the administration of the remedy. Tablets were then manufactured, and in this way the remedy is now more easily given. Wonderful changes have been observed, and even cures, in cases in which the treatment was commenced early in childhood. Osier begins the admin- istration with a grain of the desiccated gland three times a day in young cretins, and watches for increase in the pulse-rate and the appearance of fever. Older patients may take five grains daily, and this amount may be increased. After a satisfactory degree of restoration has been attained one or two five-grain tablets a Aveek are sufficient to prevent relapse. A physi- cian should not rest content after giving a prescription for the administra- tion of thyroid gland, but the effects of the treatment should be carefully w'atched. Not infrecpiently very unpleasant symptoms arise. Tachycardia, pyrexia, insomnia, tremor of the extremities, exoj)hthaIuiia, polyuria, albu- minuria, and glycosuria — in fact, a complete picture of Graves’ disease — have been observed after excessive doses of thyroid gland. Occasionally the rapidity of groAvth produced by the administration of the gland may lead to curvature of the legs, and this condition has been observed in an extreme degree. General hygienic measures should not be forgotten. MYOTONIA, OR THOMSEN’S DISEASE. By CHARLES K. MILLS, M. D., Philadelphia. Myotonia, or Thomsen’s disease, like other family forms of disease, such as Friedreich’s ataxia and several types of dystrophy, should receive attention in a treatise on diseases of children ; for, although it may develop after puberty, it is most frequently detected before the age of ten years, and it has been observed and studied even in infants. The name by which it is best known is derived from Dr. J. Thomsen of Schleswig-Holstein {Arch. f. Psych., 1876, vol., vi.), who wrote of the affection as occurring in himself and in numerous members of his own family in different generations, although before his time it had been described by Leyden and had been referred to by Sir Charles Bell. In 1886, Erb published a valuable monograph on this subject and a few other articles of more or less value have appeared during the last ten years, one of the most important of these by G. W. Jacoby {Jour. Nerv. and Mental Pis., March, 1887). I recorded a case under the title of “Myotonia and Inertia on Voluntary Effort” {Intern. Clinics, April, 1891), and, although this patient was first seen by me when he had reached the age of nearly forty years, he could trace back some of the symptoms of the affection to childhood. When a boy ten years old his father had taken him to a medical college to get advice about his hands, which were even then in some way afflicted with weakness or with clumsiness and difficulty in using them. His feet were also slightly affected in childhood, and he was somewhat stiff" in his movements. Symptoms. — The special symptom of myotonia, or Thomsen’s disease, is a tonicity or stiffness of the muscles, with inertia or inhibition of movements coming on with voluntary effort after a long period of rest, the morbid phe- nomena not being present or not attracting attention during the latter period. The prompt and easy performance of all movements is sooner or later interfered with by the spastic state. After the muscles have been used for a short time the stiffness may pass off, so that the patient who has the greatest difficulty in initiating movements will soon be able to walk with increasing ease, and once fairly afoot may continue to walk without trouble for hours; but after an inter- val of rest the whole morbid process will be repeated. As a rule, the muscles of the face are not affected, but this is not invariable, and in one of the cases of myotonia reported by me some of the most striking phenomena were exhib- ited by the muscles of mastication, and in a second case of myotonia and athe- toid spasm the facial contortions and snapping of the eyelids were very marked. These cases were adults, although in one of them the affection had originated in childhood, and was probably congenital. Usually the phenomena are most marked in the lower extremities. Sensation is not affected. Trophic changes are not present, but the muscles are bulky, although their strength is not commensurate with their size. Erb and Jacoby have called attention to the peculiar changes in the mechanical and electrical excitability of the muscles. 687 688 AMERICAN TEXT-ROOK OF DISEASES OF CHILDREN. Erb believes that Thomsen’s disease may be diagnosticated by a few clo- sures of the galvanic current and a few blows with a percussion hammer, but this is doubtful, except perhaps in absolutely typical cases. The electrical response has been termed the myotonic reaction. In examining patients for this a large electrode is placed upon the sternum or back of the neck, and another of smaller size in the palm of the hand. Using a galvanic current of sixteen or eighteen cells and allowing the current to flow, a tonic spastic condition of the muscles of the arm occurs. In a little while, particularly after changing the poles with the commutator, curious wave-like contractions take place in a serial, rhythmical order. These undulations move upward or downward according to the position of the anode and cathode — downward when the anode is in the hand, upward when the cathode is in the same position. They move inward from the negative to the positive. Erb has compared the single waves to those produced by a stone falling in water. He considers that the best places for the application are the flexors of the forearm, the palm of the hand, or the volar surfaces of the wrist-joint and nape of the neck. The amount of current requisite for the production of the phenomena varies from six to twenty mil- liamperes (Jacoby). Briefly, the peculiarities of the so-called myotonic reac- tion are increase and change in the faradic muscular response, while the excita- bility of the nerves to this current remains normal. Similarly, to the galvanic current the muscles show increased excitability and qualitative changes, the nerve-reaction not being affected. With Jacoby, I have not been able to verify the difference between nerve and muscle application. The mechanical as well as the electrical excitability of the muscle is changed, so that in a typical case tapping on the muscles will cause unusual response, a slight blow, for instance, producing a marked grooving or furrowing of the muscles. Etiology. — Heredity is the most important factor in the production of the common types of myotonia. It is pre-eminently a family disease, although not infrequently, instead of a family history of the affection clearly myotonic in character, the ancestors, direct or collateral, may have sufi’ered from some form of neurotic degeneration or may have been the subjects of some con- stitutional taint or toxic affection, as alcoholism. In one family, that of a patient recorded by Bernhardt, consanguineous marriages were frequent, but these may simply have intensified a pre-existing tendency. It is more often a disease of males than of females. Fright, intense emotion, and injuries, have been assigned as exciting causes. Of the cases occurring after puberty, Gowers records one as having resulted from prolonged and severe exertion continued for two years in a man without hereditary tendency, and the same author cites a lightning stroke as a clearly proved exciting cause. Pathology. — No autopsy suj)porteroperly regarded as on the borderland between mental health and disease. They are perhaps best regarded as examples of partial or quasi-insanity ; that is, forms of mental disease which in a certain manner and degree have the attributes of insanity. They are abortive or imperfectly-developed mental disorders. Sometimes they are as transient in duration as they are limited in phenomena ; but in other instances the few elementary deficiencies or disturbances may persist without much change or increase through life. Many of these cases, like the morbid impulses just treated of, belong under the head of paranoia. They have been described as morbid fears or phobias, as morbid doubts, as emotional mono- manias, and even as forms of neurasthenia. They are fundamentally depend- ent upon the domination of the mind by morbid concepts and insistent ideas. They are sometimes observed among young children, although more common after than before the period of puberty. Morbid fear may be tbe result of functional disturbance or disease in a normally constituted individual, but the cases which afford the most striking instances of morbid fear or phobia occur in those who have not been subjected to any physical or mental strain sufficient to break down a healthy organization. Persistent fear of the monomaniacal type occuring in children is rarely due to overwork or fatigue, as at school, as is frequently supposed. The real cause is generally in a child’s progenitor or progenitors. They are cases of the class referred to by Oliver Wendell Holmes, the cure of which should have been begun two hundred years ago. These quasi-insanities or pliol)ias have been much divided and subdivided; not infrequently several of the so-called varieties are jn-esent at the same time in the same case. Among the forms of morbid fear which have been described by particular names are j}athophoI>ia, or fear of disease; mysophohia, the fear of contamination, defilement, or pollution ; ayoraphohia, the fear of open squares or places ; claustrophobia, the fear of closed or narrow places ; toj)o- jihohia, the fear of places in general; monophobia, the fear of being alone; jjyrophobia, the fear of fire; astrophobia, the fear of lightning; and hydropho- or fear of hydrophobia. Some cases belong to a class which may be described as panto 2 >hobia, or fear of everything. A few cases have been observed in comparatively young children. Hurd (cited by Stearns), reports an interesting case from an account written by the patient herself. When about twelve years old she began to have strange fancies, as fearing the blood flowing from a cut finger would harm those who came near her. Subse(iuently, dressing, walking out of doors, eating, were all greatly interfered with through the same morbi(l ideas. She feared contagious diseases because she might communicate them to others. The insistent idea changed from time to time, but seemed to sjming always from the emotion of fear. She eventually recovered. Hammond cites from King, of Sedalia, Mis- souri, an interesting case of pyrophobia in a boy of ten years. Day and night he was infested with fear of this kind. On one occasion, when the morning INSANITY IN CHILDREN. 705 ■was cool, he succeeded, after a contest with his mother, in opening the stove- door and pouring a bucket of water on the fire. He is said to have been cured by quinine, the bromides, and the use of evaporating applications to the head. A few cases in comparatively young children have been reported and some have come under my notice. A boy eleven years old, developed what was practi- cally a pantophobia, although his disorder exhibited itself chiefiy as a patho- phobia, or fear of disease. He was kept almost constantly under the care of physicians. Sometimes his morbid ideas revolved round real affections of slight importance; sometimes his fears and suffering were due purely to morbid con- ceptions and insistent ideas. Now his eyes were the source of morbid dread; soon his limbs were the seat of rheumatic pain ; he narrowly escaped laparotomy for typhlitis, probably of psychical origin ; to a moderate degree he suffered from mysophobia, spending unusual time at his ablutions, teeth cleaning, in dressing, and in the care and arrangement of his clothes. Anything in the nature of a symptom or a disease mentioned in his presence was likely to take possession of him. His morbid notions and apprehensions were fed and encour- aged by the unceasing attentions of members of his family. He was practically cured by taking him from his home-surroundings, disregarding his complaints, forcing him to do things on time and after the manner of others, at the same time carefully but not obtrusively looking after his general health. Another boy at the age of ten began to develop the scrupulous and myso- phobic type of monomania ; in fact, he was, as so many of these cases are, an illustration of the admixture of several of the so-called classes of morbid fears. He was constantly worrying about many things he said and did in his inter- course with others. If left alone, he would spend hours in bathing and wash- ing himself, and often imagined he had been polluted or would contaminate others. The symptoms were in many respects like those of the lady described by Hammond, and to whose case he first applied the term mysophobia, who could touch nothing without being irresistibly impelled to wash her hands, and who in many other ways was tormented by the fear of contamination. This boy improved greatly under mental discipline, out-door exercise, and careful tonic medication. These cases of morbid fear, particularly when they assume the form of patho- phobia or dread of disease, are sometimes incorrectly regarded as examples of hypochondria or hypochondriacal melancholia, but they differ from the latter as monomania or paranoia differs from mania or melancholia. Paketic Dementia. — From its nature and pathology paretic dementia is essentially a disease of adult life. It usually arises in patients more than thirty years of age, and is most common between the thirtieth and fortieth years; but occasionally it is observed in the aged, and in very rare instances in the young. The youngest paretic dement observed by Spitzka in 346 cases was eighteen years old. Other cases, however, still younger, have been reported, as one by Turnbull {Jour. Mental Science., October, 1881) in a boy of twelve years, who was first observed by the reporter at the age of eighteen years. Up to the age of ten he had been healthy and apparently like other boys, but at this age he had an attack of hemiplegia, which passed off in a week and left him with a certain amount of stupidity. He continued to perform his duties as a messenger- boy, but from the age of twelve a mental weakness increased gradually but dis- tinctly. His symptoms, as described, were certainly those of general paralysis, except that he had not delusions of grandeur. The boy died in less than a year after his admission to an asylum, and the post-mortem findings were those usually seen in cases of paretic dementia. 45 706 AMERICAN TEXT-BOOK OF DIREAfiES OF CHILDREN. Etiological Varieties, and General Etiology . — A form of juvenile dementia., the result of inherited syphilis, sometimes occurs, arid it is necessary to separate this from idiocy and imbecility, whether of syphilitic or other origin, which may be done by remembering that the dementia usually comes on after the child is four or five years old, and therefore when the mental condition has been determined not to be that of idiocy. In rare cases, however, it happens that a juvenile or infantile dementia occurs when tlie child is two or three years old, so young that its true mental status has not been fully determined. With this word of caution as to the possibility of inherited syphilis showing itself in a child otherwise healthy in the first year or two of life, most of the cases of this form of dementia will be comparatively easy of recognition. A family history of syphilis will often, but not always, be obtained ; often the upper incisors will be pegged and notched, while cicatrices at the angle of the mouth and the characteristic physiognomy will be present ; and sometimes the child will have attacks of keratitis, choroiditis, or iritis, or a history of snuffles or of a rash, and sometimes epilepsy will have developed. Febrile and post-febrile insanity is, on the whole, not rare in children. Many cases have been put on record. They have been arranged byNasse into three classes — those coinciding with the fever, those which are apparent con- tinuations of the fever, and those developing during convalescence. Accord- ing to Spitzka {Keating's Cycl. Diseases of Children), the latter group is more benign in character and prospect than the other two, and is most often found in adults, the first two groups being more frequent in children. Of course delirium is an accompaniment of most fevers, and this is more pronounced and sometimes of a peculiar character in childhood ; but, setting aside ordinary febrile delirium, mental disorder sufficiently intense and persistent to be classed as insanity is of comparatively common occurrence. The fevers during which or after which insanity is most likely to develop are typhoid, scarlatina, measles, rheumatism, and diphtheria. Owing to the intensity of the psychical pheno- mena, the true nature of typhoid fever in the child or adult is sometimes over- looked. Most cases of febrile and post-febrile insanity recover in periods varying from a few days to a few weeks or months. Rarely, however, a true dementia is originated, and when this does result the child is sometimes left weaker in mind and less capable of development than before the attack. Under the head of reflex insanities might be included a large variety of cases, chieffy illustrations of mania, which has been attributed, and apparently with correctness, to splinters in the great toe, to a carious tooth, to ascarides and other varieties of intestinal parasites, to rectal and jireputial irritation. In one case seen by me in consultation a tajie-worm was the apparent cause, as the .symptoms disappeared when the parasite was discharged. Affections of the nose and throat and digestive disturbances are other assigned causes of juvenile insanity; probably such causes simply act as e.xcitaiits in children who are predisposed by heredity to mental disease. Some of the conditions which are regarded as causes are really due to the mental condition. Spitzka refers in this connection to the functional disturbances of the digestive ap])aratus in girls about the age of puberty, who go on from slight dyspeptic symptoms until they get an aversion to food, and sometimes even delusions about eating, so that they may actually starve to death, forceil feeding being resorted to too late. Masturbational insanity, as occurring both in children and adults, has been both overrated and underrated, but, on the whole, the tejidency has been to the former rather than the latter. Some alienists deny that this vice is ever the true (aiuse of insanity, holding that it like the insanity is due to the neuro- pathic state of the individual, or that at the most, it is merely a concomitant or INSANITY IN CHILDREN. 707 aggravating cause. My experience leads me to believe that while, as is known to almost every one, the vice is extremely common, especially among hoys, it only in rare instances is the true cause of mental disease, hut that these in- stances must he recognized. Of recent writers, Spitzka has laid the most stress upon the existence of masturhational insanity, and has ably described it from his point of view. According to this writer, the typical masturhational psy- chosis occurs between the thirteenth and twentieth years, and therefore at a time which just removes the subject from consideration in an article on diseases of childhood proper ; but occasionally the same symptoms and conditions are observed before puberty, although before this period Spitzka believes that the dementia is more like a true imbecility, and that infantile insane masturbators are more liable to epileptiform attacks than to outbursts of mania. Juvenile insanity may be dii’ectly inherited, but far more frequently, it is the tendency rather than the psychosis which is inherited. Besides syphilis, which has already been considered, alcoholism exerts its sinister influence in this as in so many other directions. Neurasthenia, hysteria, chorea, epilepsy may be present in the immediate ancestors. Other causes are great heat or cold, exposure to the sun, .variations in temperature, and fright which acts unexpectedly, especially to excite the maniacal or hysterical forms. Injuries to the head are of so much importance as to almost warrant the creation for pur- poses of convenience of a class of traumatic juvenile insanities. In many of these traumatic cases the mental affection is of the maniacal type, and is often associated with epileptic or vertiginous attacks. Sometimes insanity originates in connection with disease of the heart or some form of kidney affection, although these causes, and particularly the latter, act much more frequently in adult life. Poor food, bad ventilation, and bad hygiene generally, may be auxiliary causes. Diagnosis. — Much that has already been said in the general consideration of the subject, and also in connection with the discussion of special varieties of insanity, will assist in the diagnosis. In the first place, insanity in childhood must be distinguished from idiocy and imbecility, or the existence of both in the same case must be determined. The delirium which ushers in or accom- panies a continued or ephemeral fever must not be set down as insanity, the febrile disease being overlooked, although, as has been considered, the occur- rence of true febrile insanities must be borne in mind. The distinction between vice and insanity is not always easy to make either in the child or in the adult. I agree with Tuke {Diet. Psychol. Med.), that it is difficult to lay down rules to differentiate moral insanity from moral depravity ; each case must be decided in relation to the individual himself, his antecedents, education, surroundings, and social status, the nature of certain acts and the mode in which they are performed. Hysterical excitement or mania may be difficult to distinguish from mania of either toxic or unknown origin, but the past history of the child, and the presence of certain hysterical stigmata, such as aphonia, convulsions, or paresis, will be of great assistance in making the diagnosis. The existence of epileptic insanity can often be determined by a close investigation of the history of the case, which will sometimes unexpectedly reveal the fact that the child has had at least serious petit vial during the day and probably spasms during the night. Every child who has sudden and unaccountable outbursts of extreme violence should be watched for a time both day and night with the view of deter- mining as to the existence of larvated epilepsy. It is sometimes highly important to decide as to the type of insanity from which a child is suffering. If the symptoms point to paranoia or primary delusional insanity, even if of an imperfectly developed form, the prognosis will not be as favorable as if the child is suffering from true mania or melancholia. The mode of onset, the condition 708 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. of the logical faculties, the amount of emotional manifestation, will aid in the diagnosis, and the trained observer will recognize in the paranoic child that the changes are fundamentally those of temperament and character. Transient morbid fears and doubts must not be always regarded with great apprehen- sion. Children, like adults, are subject when neurasthenic to such fears and doubts, but these only arise to the importance of mental disease when persistent, progressive, and of peculiar character. Their importance should be neither overrated nor misunderstood. Paretic dementia is so rare in children that its diagnosis has not much practical importance ; the only point of interest would be, in a case which simulated general paralysis, to decide whether it might not be one of juvenile dementia due to inherited syphilis, rather than a true paretic dementia of unknown origin. Much help will be given in the diagnosis of the latter by a study of the physical evidences, such as interstitial keratitis, cho- roiditis, acute iritis, and optic neuritis. The eye should always be carefully examined in suspected cases. The occurrence of deafness independently of acute aural disease is important. Notching and pegging of the incisor teeth, fissuration of the corners of the mouth, llattening of the bridge of the nose, and changes of the knee-jerks may be other physical evidences. Prognosis. — On the whole, the prognosis of insanity in childhood is good, but differs somewhat with the varieties. The transitory psychoses, mania, melancholia, circular, choreic, hysterical, and cataleptoid insanities generally recover under appropriate treatment. The rare cases of primary delusional insanity, and the more numerous instances of morbid perversions, impulses, and propensities, while they may be recovered from in whole or in part, are likely to lay the foundation or to be the precursors of serious mental affections later in life. This, however, is not the invariable rule. Young patients suflfering from morbid fears or phobias, worried and driven by insistent ideas, may be much benefited, and sometimes permanently relieved, by a treatment which con- sists more in moral management, discipline, and general hygiene than in the use of medicines. These cases also sometimes become instances of life-long mono- mania of mild or severe type. Dementia due to inherited syphilis may be arrested if recognized sufficiently early. True paretic dementia is practically hopeless in the child as in the adult. Some cases of masturbational insanity are rescued ; others pass into incurable dementia, or at least to a lower plane of mental life. Treatment. — “Great care,” says Tuke iOf - cit.), “ has to be given to the surroundings of the patients, especially in acute mania. If the patients have to keep in bed, the quiet of being in a room without noise or without exciting im- pressions is to be preferred to isolation in a cell, but one scarcely ever can do without the padded room. Lukewarm baths, with cold showers on the head and back if wanted, are very useful, because of the good they do to the skin, which is in many ])laces injured.” In the treatment of mania at home every effort should be made, in the first place, to remove sources of irritation and excitement. The child should be ke))t in a room away from the rest of the family, and noises and to some extent even light should be excluded. The bowels should be thoroughly opened if they show any tendency to constij)a- tion, but sometimes the reverse is the case. Attention should be given to the action of the skin and the kidneys, using diaphoretics and diuretics, either alone or in combination with some of the remedies to be presently mentioned, for the more striking manifestations which arc present. Food should be sys- tematically urged upon the patient, although in some ca.ses the tendency may be to cat too much rather than too little. It will rarely be necessary in mania, or even in mehuicholia, in children, to resort to feeding either with the INSANITY IN CHILDREN. 709 nasal or the stomach tube, but this should be done rather than to let the child go for several days with little or no food. The food should be of a digest- ible character, and should be such as can be easily taken or given to the patient, as milk, broths, milk toast, egg custard, soft boiled eggs, or tender meat. Sleeplessness and e.xcitement are among the most important indications to be met Avith in the mania of children by such remedies as chloral, bromides, conium, hyoscine, or other preparations of hyoscyamus, sulphonal, opium, can- nabis Indica, acetanilid, antipyrine, chloralamid, amylene hydrate, paraldehyde, somnal, urethan. Of these the most valuable in the treatment of acute mania in children are the bromides, chloral, hyoscine hydrobromate, conium, sulpho- nal, and opium. The doses should be proportioned to the age of the child, bearing in mind, however, that larger doses can be borne than in children not suffering from extreme mental excitement. It is a good plan to combine bro- mides and fluid extract of conium, Avith or Avithout chloral, in one preparation, to be given four or five times daily, and in addition to use one or tAvo doses of about to of a grain of byoscine hydrobromate tAvice daily. The com- bination of bromides Avith tincture of cannabis Indica Avill be sometimes found very serviceable. The melancholia of children is generally of brief duration. It should be treated, in the first place, by rest and change : a trip to the seashore or to the country or mountains will sometimes be quickly efficacious. All the secretory and excretory glands and organs should he kept in good condition. Fruits, laxatives, mineral Avaters, salines, syrup of figs, and preparations of aloin, strychnine, and belladonna, combined with cascara or podophyllin, will serve a good purpose in regulating the boAvels. Opium is of more service in melan- cholia than in mania, and may be used in small doses combined Avith bromides. Squibb’s deodorized tincture of opium is excellent. Food should be regularly administered, and even in children the very careful use of stimulants may prove advantageous. The preparations of malt Avill be found preferable. Various combinations of tonics and digestives Avill prove of .service, among the best being nux vomica with liquor pepsin, the compounds of calisaya, iron, and strychnine, and arsenic in the form of FoAvler’s solution administered with the compound syrup of hypophosphites. The treatment of choreic insanity is practically the treatment of a bad case of chorea, plus that of mania. In a severe case seen in consultation, a girl eight years old developed chorea shortly after an attack of scarlet fever, and the movements were incessant, violent, and uncontrollable ; the patient sleepless and at times semi-delirious. Arsenic, cimicifuga, bromides, and mor- phine had been used Avithout effect, but the folloAving treatment AV'as successfully adopted: At first she was ordered Squibb’s fluid extract of conium and Fow- ler’s arsenical solution, each 5 minims, well diluted, every two hours ; and also hydrobro'mate of hyoscine, grain -gV, every tAVO hours until some effect was produced. Clysmic Avater Avas ordered to be taken freely, and poultices Avere used over the kidneys. The choreic movements abated someAvhat, but after two doses of hyoscine had been administered she had a hysterical convulsion, the tongue became very dry, and her delirium increased. The hyoscine and arsen- ical solution were discontinued in about twelve hours, and she was then ordered Squibb’s fluid extract of conium and tincture of digitalis, each 5 minims, every two hours, Avith neutral mixture. This treatment was kept up steadily for forty-eight hours. One dose of chloral, 30 grains, and bromide of potassium, 60 grains, was given by rectal injection. The poultices and clysmic water Avere continued, and a purgative was also administered. The chorea showed marked 710 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. improvement in forty-eight hours. The conium and digitalis were continued, hut with gradually decreasing frequency, for a week. Two or three doses of chloral, of 10 or 15 grains, were given in the latter part of the day. Great attention was paid to the administration of nourishment, chiefly in the form of milk. In epileptic insanity, or when epilepsy is suspected, hromides should be administered, guarded by arsenic, and at the same time nutrients, such as cod- liver oil and the preparations of malt, and also tonics in small doses, should be given. The remarks made in another chapter about the treatment of moral imbecility will apply with almost equal force, at least in most cases, to the treatment of moral insanity; but the cases Avhich have been referred to as arising from trau- matisms, toxic diseases, and blood-poisoning should be borne in mind when considering the question of treatment. Doubtless some of these may he amen- able to surgical or medicinal treatment. When children are found to suffer from instinctive perversions and morbid impulses, they should be watched with the greatest care ; they should be kept as far as possible from temptations ; their moral training should receive particular attention, and as far as possible they should lead healthful out-door lives, great care being observed as to the choice of their companions. In some cases these jjerversions and impulses pass away at puberty or adolescence. The treatment of children who are the victims of morbid fears and doubts, of pathophobias, mysophobias, pyropho- bias, and the host of other phobias, is worthy of careful thought. While the tendency which has led to these disturbances is usually inherited, much may he done to prevent their full development, and in some instances the affections may pass away under appropriate treatment. Such children often require to he removed from their home-surroundings, as almost invariably mis- takes are made by their ])arents and guardians either in the direction of too much sympathy and coddling or of too much harshness or want of ap])reciation of the disorder. They should be prevented from constantly thinking about themselves, their aches and ailments, and if any real disease be present, it should receive appropriate but not too anxious consideration. They should be disciplined to act ])romptly in all cases — to act twice before thinking once. By no one better than hy Clouston has the treatment of masturhational insanity as occurring in youths been discussed, and some of his advice and rules are applicable to the disease in childhood. The ))aramount indication is to brace up the youth mentally and morally. As soon as the child can he reached by judicious instruction, efforts should he made to strengthen both hodily and mental inhihition. The mistake should not be made of unnecessarily calling the attention of young children to their genital organs and sexual feelings; occasionally parents and jdiysicians err in this direction. A healthy child should be let alone, and too much anxiety and interference should not he shown because of some physiological sexual manifestation. Ordinary attention to he.alth will often suffice to keep a child straight. My own view, as already stated, is that mental disorder in children from masturbation may occur, but is not common, and that the habit sometimes weakens children who are mentally and physically deficient from other causes. The physician or ])arent should not take for granted, as is done so often, that a large majority of the nervous and mental symptoms and affections of children are attrihutahle to this vice. Some mothers and fathers seem to live in constant worriment ahoTit this matter, and are always susf)ecting their children of self-abuse. Clouston’s ))articular suggestions with reference to the treatment of this form of insanity must of course be (lualified by considerations of age. “Avoid flesh,” he say.s, “as the INSANITY IN CHILDREN. 711 incarnation of rampant, uncontrollable force, sexual and otherwise. Be much in the open air, work hard. Finally, so fill up and systematize the time that none is left for day-dreaming.” Spitzka holds that painful corporal punishment should follow every attempt by infants at touching the privates or executing friction, as to no other argu- ment is so young a child accessible. It is doubtful whether this advice is of universal application, but it is perhaps best followed in some cases. As soon as children are old enough appeal can be made to the sense of shame and of self-respect. Any local source of irritation, such as adherent prepuce, irri- tative affections of the genito-urinary apparatus, and worms in the alimentary canal, should of course be removed, although this last source of trouble is likely to be overrated. IMPERATIVE MOVEMENTS IN DEFECTIVE CHIL- DREN: ALSO HEAD-NODDING, HEAD-SHAK- ING, HEAD-ROTATING, HEAD-BANGING, AND NYSTAGMUS IN INFANTS. By CHARLES K. MILLS, M. D., Philadelphia. Under various but similar names, such as head-nodding, head-jerking, head-rotating, and head-banging, certain acute affections in infants and young children have been described. The reports of these cases show that they differ in character, and to such an extent that for the practical purposes of prognosis and treatment distinctions must sometimes be made between different varieties. Among the authors who have contributed to our knowledge of this subject are Henoch, A. Baginsky, S. Gee, Stephen Mackenzie, and, more than all, W. B. Hadden {Lancet^ June 14, 1890, and St. Thomas' Hospital Reports, 1890) and for most of the facts contained in this brief sketch I am indebted to the valuable papers of the last named. Imperative Movements in Defective Children. — Before considering the affections described by Hadden, it should be borne in mind that in well- known organic affections of the nervous system, so-called imperative move- ments, due to dominating conceptions and insistent ideas, may be present either in children or adults. These may take the form of the salaam or bowing spasm, of snapping the eyes, of contortions of the fice, of shrugging of a shoulder or shoulders, or of some I’epeated movements of the arm, trunk, or leg ; or, again, they may be some peculiar combination of movements executed together or in succession. They may in other rare instances be shown as an irresistible tendency to touch some special point or to handle an object in some particular way. Occasionally such imperative movements are asso- ciated with explosive expressions which may be of profane or obscene character, and to these I have referred in discussing speech-defects and ano- malies. Among the idiotic, interesting instances of imperative and automatic movements are observed. At the New Jersey Home for Feeble-minded Children at Vineland one little epileptic patient has at frequent intervals attacks of head-shaking, nodding, and jerking. Another girl has curious recurring rhythmical movements which can be started by music or by beat- ing monotonou.sly .some object, as a fan or desk. Holding one hand open with the little finger of the other, she rapidly vibrates the fingers of the ojien hand or, standing squarely on her feet, she continues for a long time a semi- rotary movement of the trunk, at the same time to-ssing the head from right to left and bending the body from side to side. At the Pennsylvania Training School for Feeble-minded Children at Elwyn is, or was, a little patient familiarly spoken of as “The Dervish.” The 712 IMPERATIVE MOVEMENTS, HEAD-NODDING, ETC. 713 boy was of small stature and weight, a demi-microcephalic epileptic and mute idiot. At all times he was subject to certain automatic tricks with his hands, putting them and twisting them into various positions. Periodically, almost every day, he gave exhibitions of the habit which had led him to he called The Dervish. He commenced by tattooing his chin with his left hand ; next he deliberately and delicately touched the fingers of his left hand to the wrist of his right, made two or three salaams, and then impulsively gyrated the body from left to right. Sometimes peculiar movements are associated with ordinary epilepsy in children not imbecile or idiotic. At least some of the cases particularly described in this article may have some alliance with eclampsia nutans of the salaam convulsion form, to which affection the terms nodding spasm, spasmus nutans, and eclampsia rotans have also been applied. Head-nodding, and Head-jerking. — The cases particularly described by Hadden in his series of papers on “Head-nodding and Head-jerking in Children, commonly associated with Nystagmus,” are, in his own words, “ characterized by nodding or lateral movements of the head, either singly or associated with one another or with movements of rotation. Further, these movements of the head may be almost constant, or may occur more especially during effbi’ts at fixation or during excitement, always ceasing during sleep or when lying down. In most cases there is nystagmus of one or both eyes, vertical, horizontal, or rotary, often occurring simultaneously with the onset of the head movements, but sometimes preceding or following them. The nystagmus is much more rapid than the head movements, and has an inde- pendent rhythm ; it is aggravated by attempts at fixation or by forcibly restrain- ing the head, and may even be induced, when previously absent, by these means.” Hadden’s first observations were based on an analysis of twelve cases. His second series included nine cases of which he had kept notes, although in all he had seen fourteen since the publication of his first series. His deductions from an analysis of twenty-one cases can be summarized as follows : Pure nodding, like the movements of a mandarin doll, is rare ; in others the movements were lateral, although combined or alternated nodding or rotation w'as common. He sees no reason for subdividing the cases into nodding and shaking as separate classes, as one of these movements may replace the other. The movements are chiefly seen when the child’s attention is attracted to an object, and are increased each time it makes a new effort at fixation. They cease during sleep and when the child is lying down and when the eyes are covered. The asso- ciated nystagmus is rapid and of short range, and is not constantly present, the movements of the eyeball being usually horizontal or combined with some rotation. In one case the head-nodding and nystagmus were vertical, and in another the nystagmus was confined to one eye and associated with side-to-side movements of the head. The pupils were almost always normal. Hippus or oscillation of the pupil was present in some cases. No unhealthy ophthalmoscopic appearances were found. In nearly half of the cases the children had a tendency to cock the head on one side or to hold it in some other unusual position when looking at an object. In a large percentage of cases they had attacks as if conscious- ness was in abeyance — seizures much resembling in character the descriptions given of petit mat or epileptic vertigo. Convulsions were present in a few cases, and attacks of convulsive laughter were observed in one child. Rickets was present in nine out of the twenty-one patients. Head-banging. — An affection has been described by Gee (Nt. Bartho- 714 AMERICAN TEXT- BOOK OF DmEAHEti OF CHILDREN. lometv’s Hosj)ital Reports, 1886), as head-banging, in which children have a habit of turning on their faces at night and banging their heads into the pillow. According to Gee, the affection is perhaps a habit. As fcAV of these cases have been recorded, I give Gee's brief account of three cases : “ I. — Gilbert G , two and a half years old when seen with Dr. Donald Hood, had been affected thus for two or three months past. At night in bed, both when awake (half awake? ) and when sound asleej), he would turn over on his face and bang his fore- head into the pillow. In this way he sometimes behaved nearly all night long ; in which case, it need hardly be said, he awoke very weary. He never had convulsions of any kind ; indeed, no disorder, past or present, other than head-banging. A year and a half afterward this disorder continued when he was not tied down in bed. He had never suffered from nightmare or sleep-walking. (Four months after the last notes the patient’s mother told me that he continued to bang his head at night when not tied down. Even when tied down he rolls his head from side to side, being asleep. Put asleep with a younger brother, the latter began to bang his head also ; separated, he, the younger child, lost the habit. The first boy continued healthy and cheerful.) “ II. — George H , five years old, a patient of Sir. Patten’s, was backward in un- derstanding and speaking, but there were no signs of cretinism. He was a first child, born at full time after a long labor in which no instruments were used. He had knock- knees and splay-feet, but his dentition was very regular. He was restless, but clean in his habits, and never wet the bed. There were no other signs of disease. He never had convulsions of any kind. Head-banging began when he was two and a half years old (that is to say, as soon as he could hold his body uj>), and it had continued until the time when he was seen. He used to turn over on to his face and bang his forehead into the pillow about six times in succession. The act was seldom repeated in the same night, and seldom occurred more than one night in four. He was fast asleep at the time, but was easily roused. “ III. — -Francis C , two and a half years old, had been subject for six months to banging his head on the pillow at night for two or three hours at a time. He had an inguinal hernia; he had erections of the penis at night; he masturbated, and the fore- skin was adherent; otherwise the child seemed well. A year afterward Mr. J. Lucas Worship wrote this about him : ‘ While he was staying in Sevenoaks, about a month ago, he was better of knocking his head about, but the nurse said that whilst at home it was as bad as ever. He was a great deal in the meadows, and slept well from being in the open air so much, which he was unable to get while living at home in the town. He was operated upon for his phimosis, which is all right now, and he does not mastur- bate since then.’ ” At the meeting of the Pennsylvania State Medical Society in May, 1893, two interesting cases of head movements were reported, the first by Dr. J. C. Gable of York, Pa., to whom I am indebted for notes. The patient was a girl ten months old, well developed and apparently healthy at birth. The family of the child was of more than ordinary intelligence, but had a j)ronounced neurotic and tubercular taint. The mother suffered from chorea when a young girl. The paternal grandparents died of pulmonary tuberculosis, and an aunt suf- fered from an attack of tubercular arthritis of the right knee, which eventually necessitated a thigh amputation. When the doctor was first called to see the little patient he found her suffering from singular and seemingly very distressing semi-rotatory, oscillatory bowing or bobbing movements of the head. These were somewhat varied in character and degree, hut continued with a monotonous, rhythmical regularity, as long as the child remained awake, during a month, and then gradually began to diminish, and ceased entirely in about eight weeks. There was no nystagmus, nor any other sjiecial symjitom except a somewhat demented e.xpression of face, which caused the anxious parents to fear that the child was suffering from unsoundness of mind, until assured that its complaint was a special and a rare form of chorea, which yielded to zinc treatment and proper hygienic measures. The second case was re))orted by Dr. J. C. McAllister of Driftwood, Pa., who ahso has kindly furnished me with brief notes. The child was horn in Aj>ril, IMPERATIVE M0VE3IENTS, HEAD-NODDING, ETC. 715 1892, with forceps delivery, the labor being the first and quite difficult; but the baby was, however, a strong and well-nourished boy, and no history of nervous trouble in the family could be obtained. In February, 1893, when the child was about ten months old, the doctor was consulted for the relief of choreic movements of the hands and arms, and also for certain nodding and rotatory movements of the head. Aside from this, constipation was the only symptom. Bromide of potassium and Fowler’s solution were prescribed for the movements, and the constipation was also treated. After a few weeks the bromide was stopped, but the arsenical solution was increased to two drops four times a day. The infant had a long prepuce, and the doctor performed circumcision, April 26, 1893. The movements of the hands ceased under the use of the arsenic before the operation, but the other movements continued until after the cir- cumcision, when they gradually disappeared. Nystagmus. — Nystagmus may be described as a constant involuntary movement of the eyeballs, which is usually horizontal, but sometimes ver- tical, and even in rare cases may be in a slightly oblique direction ; and rarely also the vertical and horizontal oscillations may alternate regularly or irregularly, or a vertical movement may be present in one eye and a hori- zontal in another. The commonest form of nystagmus is that in which the movement is bilateral, horizontal, and consentaneous. Nystagmus is present in several organic affections of the nervous system, as in disseminated scle- rosis, and to a less degree in other forms of sclerosis, diseases of the cere- bellum, and hereditary ataxia. It is sometimes due to local affections of the eyes which interfere with sight, as opacities of the cornea or of the lens or humors of the eye. It is very common in albinism, and is, as is well known, of frequent occurrence among miners. As an affection of children it is chiefly of interest as it occurs either in rare cases of cerebellar or other form of brain tumoi’, or as it occurs associated with head-jerking and head-nodding, described in this article. Nystagmus seems to be an essential element in a majority of these cases, and Hadden describes and discusses these movements as fol- lows : “ This is very rapid, about four to six movements per second, and of very short range. One mother said it was ‘ like Perry’s pens at the underground stations,’ and this homely description is not inapt. Nystagmus is not usually constant ; not infrequently it has to be induced by making the child fix objects here and there, by forcibly restraining the movements of the head, or by placing the child on its back. On two occasions it was especially well marked when the child was put to the breast. I verified this by personal observation. “ The movements of the eyeballs are usually horizontal, combined with some rotation. As a rule, the movements of the head and eyes are in the same direction, but this is by no means invariable. In my solitary case of head-nodding the nystagmus was vertical, whereas in another patient there was vertical nystagmus limited to one eye, associated with side-to-side move- ments of the head. “ There is occasionally a relation between nystagmus and the position of the eyes or evident ocular state. In one case the nystagmus was exaggerated on extreme conjugate deviation to the right. In two instances the nystagmus was chiefly evident when the eyes were directed upward, and in one of these it was generally horizontal, and tended to become vertical when the eyes were turned upward. The nystagmus may vary in direction apart from this ; in two instances the nystagmus was sometimes vertical, sometimes horizontal, and sometimes rotatory.” 716 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Nystagmus may be the only form of movement present in cases exactly similar in nature to those in which the head movements are also pi’esent ; as Had- den put it, the disorder may be indicated by nystagmus alone just as there may be tabes dorsalis without ataxia or paralysis agitans without shaking. He gives one instance in which nystagmus alone was present for a year, but after this the patient showed occasional slight movements of the head. Etiology. — In some of the reported cases a decided predisposition to neu- rotic disorder was present. In six out of the twenty-one cases a history of con- vulsions in other children of the same family was obtained. Rickets was pres- ent in the family in three instances, and decided evidences of rickets were shown in nine out of the twenty-one of Hadden’s patients. The afl'ection often appears to be due to reflex irritation from the alimentary canal or from denti- tion. Henoch attached great importance to dentition as a cause, but on it Hadden does not lay so much stress. Head-jerking occurs sometimes at an age before the process of teething has begun, and a history of injury to the head, usually by falls, has been present in a large number of cases. The affection is more common in females than in males. In the majority of cases it begins between the ages of six and twelve months. Usually the head movements and nystagmus occur simultaneously at the onset. Pathology. — The pathology of the cases of imperative movements described is that of the idiocy or imbecility with which they are associated. With refer- ence to the nature of head-nodding cases, Hughlings Jackson has suggested that they are a variety of spinal chorea, a symptomatic condition allied to canine chorea; but Hadden believes that the seizures point to instability of motor- centres above the nuclei in the spinal cord and fourth ventricle, and he would therefore attribute the disorder to a functional or other disturbance of the cere- bral cortex. The child lias acquired certain voluntary or purposive movements of the head and eyeballs, but these have not as yet become thoroughly organ- ized and fixed in the psycho-motor areas of the brain ; hence a dissolution takes place because of the inability of the strained cortical centres to stand the work to which they have been too early subjected. He compares these head movements to the tremors in the head which often occur in aged people and those seen sometimes in adults. Diagnosis. — The chief point in the diagnosis of these cases is to distin- guish between the different varieties of head movements, particularly as to their occurrence in children otherwise healthy or diseased. Imperative or auto- matic movements suggest the presence of idiocy or imbecility, and should lead to a study for these affections. Knowing that epilepsy is an accompaniment of some forms of repeated head movements, the existence of this disease should be determined or dismissed. Bearing in mind a few important facts of this character, the explicit and careful descriptions afforded by Hadden and Gee will serve to identify these curious cases. Prognosis. — As a rule, these little patients recover, the disorder lasting for varying periods. Sometimes the movements will pass away in a few weeks, and at others several months or even one to two years may ehvpse before recovery takes place. Nystagmiis is said to persist longer than the head move- ments, and shows a greater tendency to recurrence. One case was observed by Hadden for two years and a half, nystagmus not being present. In making a prognosis a distinction must be made between the acute and curable cases, such as have been reported by Hadden, Gee, and others mentioned in this chapter, and the patients suffering from idiocy, imbecility, epilepsy, or other serious IMPERATIVE MOVEMENTS, HEAD-NODDING, ETC. 717 forms of mental or nervous disorder, who are the victims of imperative and automatic movements described in the beginning of the chapter. Treatment. — Any sources of reflex irritation should be carefully attended to, but in this, as in many other cases, reflex irritation has been made a scapegoat for ignorance or imperfect knowledge. The general health of the child should be carefully looked after, although in some of the reported cases this seems to have been very good. The somewhat frequent occurrence of rachitis should give this constitutional condition an importance in connection with therapeutics. Fatty and albuminous foods in easily-digested form should be given ; cod-liver oil in some of its various combinations, as with lime or malt ; maltine with pepsin and pancreatin ; iron, particularly in the form of the powder or the carbonate ; glycerin, cream, peptonized milk, and such nutrients as are commonly chosen in rachitic cases, may prove of service in some instances, as are also such medicinal remedies as Lugol’s solution of iodine; Donovan’s solution of arsenic, mercury, and iodine; Fowler’s solution of ai’senic, the syrup of the hypophosphites, and similar strengtheners and builders. Iodide of iron, tartrate or malate of iron, and phosphate of sodium may prove useful. Among the remedies which are supposed to have some influence upon the disorder bro- mides hold the first place, but they should be given with care, and not in the same doses as in undoubted epilepsy. Five to seven grains of bromide of potassium or sodium, with two or three minims of tincture of belladonna, or one minim of the fluid extract of conium, may be used with advantage, and at times this dose may be increased until a decided impression is made. Sulphonal or chloralamid in small doses is worthy of trial. The children are usually not old enough to have their eyes refracted. In view of the theory that the condition is allied to canine chorea, and in the light of the suggestion of II. C. Wood {Jour. American Med. Assoc., February 25, 1893), that in chorea, and par- ticularly canine chorea, the inhibitory apparatus which controls motor power in the spinal cells is weakened to a greater extent than is the discharge power, and also that quinine has a great controlling power over choreic movements in the dog, the importance of at least trying quinine in increasing doses in the treatment of these movements is suggested. HEADACHE. By CHARLES K. MILLS, M, D., Philadelphia. The term “headache,” which defines itself, is used to describe pain due to causes either outside or inside of the cranial cavity. Its general synonyms are cephalalgia and cephaliea, and for one of its most common varieties the synonyms are migraine, megrim, hemicrania, or sick headache. Headaches in children are less frequent in occurrence, fewer in varieties, and less severe in type than in adults. Headache is most frequently a symptom of some recog- nizable functional or organic disease, and its occurrence in many affections, such as infectious fevers, will not, of course, here receive consideration. The wisdom of discussing headache separately has been (juestioned, and with good reason ; but it may be the ruling feature of a case which is presented to the doctor for diagnosis and treatment, and if it is banished from the picture little is left except to the most critical research, although even in such a case care- ful study will generally show that it is simply a symptom of some rheumatic, dyspeptic, hysterical, inflammatory, or other morbid state. The mechanism of pain in the head is worthy of brief attention. It is a well-known fact, although one often overlooked, that the brain substance is practically insensitive, and pain in the head, even when the result or the accompaniment of disease of the brain, is not due directly to lesion of its tissue. The brain of man and of the lower animals can be excised without giving rise to any sensory response, although the gentlest electrical ap})lication to a motor centre may excite the liveliest movement. Nerve end-organs, which are an essential portion of the apparatus of sensibility, are ivanting in the brain itself. Disorders of sensibility due to disease of the brain tissue are referred to more or less distant parts of the body. The membranes of the brain play an important role in intracranial pain, as has been shown by Duret {Brain, April, 1878), Ferrier {Brain, January, 187J), and others. The dura is highly endowed with nerves of sensation derived from the trigeminus, and in rheumatic or neuritic headaches and in those due to organic disease the ])ain is frequently dependent upon direct involvement of these nerves. The pia or pia-arachnoid membrane is not so largely supjdied with sensory nerves as the dura. The pia is largely an immense network of vessels, whose supply is from the gangliated nervous system, and is concerned in head pain through varia- tions in pressure and tension within the cranial cavity, as well as to a less degree by direct nerve irritation. Inflamed arteries and veins cause j)ain, ]>rob- ably through their direct or indirect influence upon nerves of sensation. Blood charged with toxic matter also causes pain both by direct and indirect irritation of nerves. In explaining headaches it is necessary, then, to consider neural or membranous inflammation, alterations in pressure or tension, and toxic states of the blood. 718 HEADACHE. 719 The varieties of headache which best deserve to be ranked as special types are (1) migraine, and (2) the headaches of organic intracranial disease. Other so-called varieties are usually based upon etiological considerations, and will be considered under that heading. It is indeed of (questionable propriety to class migraine as a headache, and this is only done because it seems to be the most practical method for physicians likely to use a general treatise on diseases of children. The disease is migraine, and headache is only one of a series of important phenomena — visual, gastric, motor, and mental ; but it is the symp- tom which causes the patient the greatest suffering and for which he appeals for help. Migraine. Migraine, megrim, hemicrania, or sick headache is by no means uncommon in children. Sometimes very young children have mild attacks of sick head- ache ; these at first come very seldom, and apparently only under special excit- ing causes, as over-eating, excitement, or exhaustion ; and at first the intervals between the paroxysms may be many weeks or months, but gradually they become shorter. At first, also, the attacks can be scarcely recognized as genuine sick headaches, pain not being prominent, but as years progress they become more prolonged and severe ; still, under the age of puberty, however clear may be the type, migraine does not nsually assume the severity and intensity which it shows after this period. I have seen a few instances of migraine in children under six years of age. A boy, now ten years of age, began to have mild attacks of migraine at the age of three, at first having only two or three attacks a year, but these gradually became more and more frequent, until now he aver- ages a spell about once a month. A history of migraine is present in four generations — in the mother, and in the maternal grandfather and great-grand- father. Three other children in the same family are not affected in the same way. The child in other respects is unusually robust and free from disease. Symptoms. — Except that the symptoms are less pronounced and severe and have fewer concomitants, the phenomena of migraine in children are prac- tically the same as in adults. It perhaps shows less tendency to recur at regular periods. The child may suddenly or unexpectedly exhibit an indis- position to play, may look pale and troubled, may complain of nausea or of being chilly, or may speak of disturbances of sight ; then the pain comes on, and at first is often confined to one temple or at least to one side of the head. Soon it becomes more and more severe, and the little patient, without urging, is glad to go to bed in a quiet room. The pain may last for hours or the better part of a day, or in some instances in young children it is relieved in an hour or two, usually by vomiting, followed by sleep. The migraine of childhood is not so likely to occur early in the morning as in adult life. The visual pro- dromes are comparatively common in children, although they may be absent. They may take the form of photopsia, as balls or rims of fire or zig-zag colored lines, or hemianopsia, or general obscurity of sight. The more complicated and profound cerebral phenomena sometimes seen in adults, such as amnesic aphasia, hemiparesis, monoamesthesia, and hallucinations of sight or great mental per- turbation, may be present, but are not as common in children as in adults. Putnam (cited by Sinkler, St. Louis Med. Review, October 29, 1887), has recorded a case of a patient in whom, in boyhood, migraine was represented by repeated attacks of numbness and tingling in the right side of the face and right half of the body, with aphasia and hemianopsia, followed by a trifling headache or none at all ; but later in life he had attacks of pain. The pain of migraine is usually one-sided, and may be confined to the supra-orbital or 720 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. temporal region. The attacks are usually much the same, except that they grow in severity as the years advance. Nausea and vomiting are of frequent occurrence, but not invariable. Etiology. — Heredity is the most important predisposing cause of migraine, as of some other forms of headache. Of exciting causes, excessive fatigue, mental or nervous exhaustion, and indigestion are the most important. Dis- orders of digestion are often placed in the front rank of exciting causes, but it may be forgotten that the nausea and vomiting are frequently of central origin. Rheumatic weather seems to have an influence in precipitating attacks of migraine. Pathology. — The pathology of migraine is practically unknown, as no theory which has been advanced has well withstood the attacks made upon it. It does not explain its true pathology to show that attacks may be induced or excited by eye-strain, or disordered digestion, or intestinal putrefaction. These attacks are certainly sensory explosions, analogous in their methods of exhibi- tion to the spasms which result from discharges of the cortical motor centres. Migraine, as has been claimed, has many of the appearances of sensory epi- lepsy. Cortical discharges of the visual cerebral centres would best explain the curious and frequent visual prodromes. Whatever may be its pathology, it is, as a rule, a cerebral alfection. Anstie regarded migraine as a variety of neural- gia of the first or ophthalmic division of the trigeminus ; and in favor of this theory is the occurrence of certain local trophic aifections, such as herpes zos- ter, ulceration of the cornea, and changes in the color of the hair ; but cases of neuralgia or neuritis of branches of the fifth nerve, not instances of true migraine, are sometimes confounded with the latter. In the so-called tic- douloureux and in other less severe forms of painful disease of the branches of the trigeminus, trophic disorders are frequent. True migraine and trigeminal neuralgia or neuritis may be present in the same case ; indeed, the affections sometimes blend in the same person. Migrainous subjects are vulnerable to the same influences as are neuralgics and neuritics ; but these and similar facts do not prove that the disorders are identical. Much stress has been laid upon the exact state of the vessels of the brain during attacks of migraine. Accord- ing to one view, in one form of hemicrania the blood-vessels of one side of the brain or of a limited area of the brain are in a spastic state, while in another variety a paretic state of the vessels exists. To explain the pain Du Bois- Reymond held that the spa.sm of the vessels caused pinching of the nerves in their sheaths. Diagnosis. — A clear understanding of the usual prodromata and of the method of progression of the symptoms is the best key to the diagnosis of migraine. It is perhaps most likely to be confounded with headache of organic origin, particularly with tumor and meningitis. The ophthalmoscope and various localizing symptoms which will be spoken of hereafter will greatly aid. Hysterical or imitative headaches in children may occasionally closely simulate migraine, particularly in children whose parents are victims of the disease. Prognosis. — 'I'he prognosis of migraine as to cure is bad. Usually the attacks become more frequent as tlie child grows older. Treatment. — For attacks of migraine in children energetic active treat- ment does not seem as necessary as in adults. As soon as the prodromes appear the child should be placed in a quiet, darkened room, away from sources of irritation and depression. Phenacetin, nnti])yrin, antifebrin, and caffeine are among the most useful remedies for the jibridgement or the mitigation of the attacks. P'our or five grains of antijiyrin or antifebrin, with two or three minims of tincture of digitalis or tincture of strojihanthus to protect the heart. HEADACHE. 721 may be given every hour or two until three or four doses are taken. Caffeine, or the citrate of caffeine, in doses of one to two grains every half hour, will sometimes abort an attack if given early. Once an attack has fully developed, it is, as a rule, best to let the patient alone or only to use external applications, as of hot ■water to the head or feet or menthol or chloral-camphor or mild gal- vanization to the forehead and head. An emetic of ipecacuanha is sometimes efficient, and the administration of a large dose of this drug may afford relief even when it does not produce emesis. The treatment of migraine during the intervals of the attacks is of con- siderable importance. Everything should be done to keep the child in the very best general condition. Cannabis Indica has been much praised for adults, giving it in increasing doses, beginning with one-tenth or one-twelfth of a grain three times daily, and continuing the treatment systematically for months ; but its use for children, like that of other narcotics, is not to be encouraged. Arsenic, quinine, iron, hydriodic acid, and the hypophosphites are of benefit, particularly in debilitated cases ; but it is not my experience, as it seems to have been of others, that migraine in childhood is likely to occur in subjects who are weak, anaemic, and sedentary. The most robust and hearty child of a family may be the sole victim of the disorder, although this is not invariably true. Great attention has been paid in recent years to the relief of eye-strain in the treatment of this affection ; and, while the favorable results of ocular treatment have been overstated, measures directed to the eyes should not be neglected. Hypermetropia, myopia, and astigmatism should be corrected if sufficient in degree to clearly cause discomfort or annoyance. The eyes should be examined under atropine, and the correction should be as complete as possi- ble. Tenotomy or partial tenotomy may need to be performed, but too much in a curative way should not be expected from these measures. In particular, children who are going to school and paying close attention to their studies should have their eyes investigated. Imperfectly ventilated and badly-lighted school-rooms and house-rooms probably count for much as exciting causes of migraine. Some children suffer from forms of headache which have many of the characteristics of migraine, but cannot be said positively to belong to this type. These children, most commonly young girls at school, have attacks of head- pain, accompanied with nausea or with both nausea and vomiting, which compel them to rest and cause them to be irritable and worrisome. These headaches are often associated with constipation. They are sometimes entirely relieved by a change from a sedentary to an open-air life. They recur so frequently that the term “recurrent headache ” has been used in describing them, although this expression has been applied also to other forms of headache. They differ from typical migraine in the absence of prodromes and in their lesser severity. They might perhaps be termed migranoid cases. Like typical migraine, such headaches are often observed in children of neurotic heredity. Headaches due to Organic Disease. Intracranial tumor, meningitis, abscess, and, in very rare instances, aneu- rism, may be the cause of headache in children. Headache is rarely absent in brain tumor, and sometimes causes extreme suffering, but occasionally a growth may be present without this symptom. The tumors which are most likely not to give rise to pain are the gliomata, probably because these neoplasms are not usually connected with the brain membranes, and also because owing to their soft 46 722 AMERICAN TEXT-BOOK OE DISEASES OE CHILDREN. structure, they exert comparatively little pressure. Much of the horrible pain commonly present in intracranial tumor is dependent upon irritation of branches of the fifth nerve in the dura, and this does not always occur in gliomata, because, as has been stated, they may be unconnected with this membrane. In several instances I have observed cases of gliomata of the cerebellum in which pain was unimportant; but it remains true that in children, as in adults, head- ache is a very common symptom of an intracranial growth. In infants and very young children, the sutures still remaining open, the pressure within the cranium is not increased to the same extent as in adults by a developing tumor. The location of pain in the head is sometimes, although rarely, a guide to the position of the growth, but at the best it is an uncertain guide. A constant occipital pain may indicate a neoplasm in the posterior fossa, but often this will be deceptive. Patients with cerebellar tumor may complain of severe frontal pain. In tumors pain in the head is usually increased by percus- sion, and in some instances this pain will be greatest over the seat of the disease. Tuberculous growths or conglomerations are common in tuberculosis in chil- dren, and in these cases more or less tuberculous meningitis is present, so that the diagnosis of the cause of the headache, as between an isolated growth and a meningitis, becomes difficult. The headache of tubercular meningitis is often of great intensity, and this disease may be accompanied, like other affec- tions of the cerebral membranes, and particularly of the dura, with vertigo, nausea, vomiting, and screaming or crying ; but, while this is true, headache is not an invariable accompaniment of cerebral meningitis, and particularly of lepto-meningitis of slow development. Occasionally the source of a severe headache is a cerebral or cerebellar abscess, which is usually of rapid development, as long-latent abscesses are not likely to occur in children. Such abscesses are commonly found in association with disease of the middle or internal ear, and the pain will be more or less referred to the location or neighborhood of this organ. The diagnosis of tumor, meningitis, or abscess as the cause of a head- ache will be made by a careful study of the accompanying conditions. The most common of these will be, first, such general symptoms as optic neuritis, nausea, vomiting, vertigo, monospasm, or convulsions, mental irritability, or depression, apoplectiform attacks, and paralysis of cranial nerves or of the face or limbs, hypersesthesia, anaesthesia; and, according to the seat of the growth, special phenomena, such as hemianopsia, or cerebellar titubation. As tumors of the cerebellum are somewhat common in children, the particular symptomatology of growths in this location should always be borne in mind. These symptoms, in addition to the headache, vertigo, vomiting, hyperacsthesia, optic neuritis, etc., just described, are, or may be, unsteadiness in station or gait; nystagmus; sometimes internal squint; frequent blindness; sometimes deafness ; enlargement of the head from acquired hydrocephalus ; rigidity of the muscles of the neck with retraction of the head ; loss of knee-jerk, or occa- sionally striking peculiarities of the knee-jerk. Sometimes pain is marked in the neck and back. These symptoms point particularly to tumor of the middle lobe of the cerebellum. Among organic headaches may be classed those which are due to inherited syphilitic affections, hut which are not nece.s.sarily either growths or meningitis. The headache which accompanies the epileptic paroxysm also must not be over- looked in considering this class. As is well known, it may either ])recede or follow the e])ilcptic fit, or it may be ])resent with .slight attacks of petit mal which are scarcely observed. Catarrhal headache of inflammatory origin, HE AD A CHE. 723 according to Allen {Med. News, March 13, 1886), is seen occasionally in acute congestion or inflammation of the frontal sinuses. The pain, which is severe, is usually confined to one side, hut it is rare in children. Etiological Varieties of Headache. The predisposing causes of headache in children are few, the exciting causes are many, and numerous classes or varieties of headaches have been erected, based chiefly upon etiological considerations. These etiological varieties may be indefinitely extended, and it is chiefly for this reason that authors differ so much in their classifications of headache. Even the headaches of children have been subdivided into numerous classes, as into the so-called school-headaches ; the headaches of the period of growth ; anaemic, hyperaemic, and neurasthenic head- aches; headache of the eye-strain and of genital irritation ; and so on through a long list, according to the inclination or views of the classifier. The causes of organic headaches have necessarily been given in the course of their general discussion. The great predisposing cause of migraine, as has been stated, is heredity; the exciting causes are those also of headache of any type, as exces- sive fatigue, mental or nervous exhaustion, disorders of digestion, changes in the weather, badly heated and ventilated rooms, lack of exercise, impoverished or altered blood (anmmia, hypermmia, or toxmmia), overwork, excitement, undue exposure to heat or to cold, eye-strain, gastro-intestinal disorders, genital irritation, nasal or pharyngeal catarrhs, or aching teeth. A close consider- ation of the causes or alleged causes of headache in children will show that in addition to migraine and organic headaches we might conveniently erect the following etiological varieties: 1, anaemic headache; 2, reflex headache; 3, hysterical headache ; 4, neuritic headache. Anaimic Headache. — Anaemic headaches sometimes occur in children, although with not nearly the same frequency as in adults, and especially in women. A few children seem to inherit an anaemic diathesis, just as others are congenitally rachitic. These children are pale in skin and mucous mem- branes, sometimes to the extent of being chlorotic ; they lack in strength and in nerve energy; they are neurasthenic as well as anaemic. It is rare, in children, to see a neurasthenic or exhaustion headache not associated with impoverished state of the blood ; and therefore the distinction between a neuras- thenic and an anaemic headache can be more sharply made in the adult. The diagnosis of an anaemic headache is to be made by a careful investigation for the evidences of anaemia, even to the extent, if necessary, of a blood-count. It is well to remember that every pale-faced child is not anaemic, and also that some children who are well supplied with fat may have poor blood. Reflex Headaches. — While too much stress is laid upon reflex action as the source of innumerable maladies, it plays an important part in many cases of headache, as in the production of other symptoms. When a child complains of headache after study or use of the eyes at close work, as in drawing, writing, or sewing, the eyes should be investigated. Serious defects of refraction may be present, particularly hypermetropia with astigmatism, and these, if sufficient to cause strain, should be at once corrected. Children who indulge in over-eating or careless eating sometimes suffer in consequence from headaches, which are relieved by spontaneous vomiting or by the use of emetics or cathartics; but it must be remembered that true migraine in children is associated with nausea and vomiting, and that the gastro-intestinal disorder in these cases is a concomitant rather than a cause of the headache. Perhaps too much stress has been laid on sexual irritation as a cause of headaches in children, but that it may be occasionally causative cannot be doubted. Allen 724 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. {loc. cit.) has presented some points of practical importance in connection with reflex headache, in association with chronic nasal catarrh, which have a bear- ing on the headaches of childhood. These reflex headaches are said by him to be almost entirely restricted to the temple and the vertex. Sometimes nausea is present, and sometimes if a })robe, passed into the nose, is made to touch the middle turbinated bone, vertex pain will instantly follow. The inner wall of the orbit is often peculiarly sensitive, and the nasal mucous membrane is in a state of intense inflammation. The reflex headaches of chronic nasal catarrh are sharply separated from the headaches of cerebral disease by the absence of any symp- tom referable to cranial sources, the lack of evidence, as furnished by a history of the case, that the complaint is of central origin, and the complete control of the pain by local treatment. Allen distinguishes reflex catarrhal headache from sick headache of gastric origin by the absence of furred tongue, and from the temple pains of eye-strain by its persistence after the correction of errors of refraction. Such headaches may be the cause of nervous prostration. Reflex headache may also have its origin in the pharynx or even in decayed teeth. Hysterical Headache. — A frequent form of headache, even in children of tender years, is the hysterical headache, or what might perhaps be better termed, in most instances, the imitative headache. Most children, and particu- larly those of the precocious and afl'ectionate type, are fond of sympathy and coddling. They are very close observers of the sufferings and peculiarities of others. They have slight pains and aches, and these become headacbes appar- ently of very great severity. Often a child who comjflains of vertical head- ache, or of headache associated with inability to stand the light, or of great pain over the eyes or in the back of the head or neck, will be found on close inquiry to have a father or mother, and especially a mother, who is subject to similar aches and pains. Just as hysterical and hystero-epileptic convulsions, aphonia, paresis of one or more limbs, and even hysterical blindness, may be simulated or mimicked by the child of a neurotic parent, so headache and other pains and aches in children are even more frequently to be traced to the same source. Neuritic Headache. — Some children, usually of neurotic, rheumatic, or arthritic heredity, suffer from pains in the head and face which are accompanied by tenderness and pressure over exposed nerve ends and trunks, and also are commonly increased by pain on movement of the scalp. These mild but annoy- ing head pains are due to forms of subacute or chronic neuritis, which may or may not be associated wdth slight inflammation of other tissues. Head ])ains and headaches of this kind are much influenced by the weather. Even when external tenderness is not present, pains in the head may be due to inflamma- tion of the branches of the fifth nerve in the dura, or in the grooves or fora- mina of the skull, or in the scalp. These cases usually yield rapidly to anti- rheumatic or antineuritic treatment. Since the occurrence of the recent pro- longed epidemic of influenza many cases of chronic headache or of chronic head and face pains have been observed, chiefly in adults, but now and then in children. Most of these have been due to a lingeriim neuritis or to the want of tone in nerve centres, left w'ounded or vulnerable by the ravages of this disease. Diagnosis and Prognosis. — The diagnosis of headache in general relates chiefly to the differential diagnosis of its varieties already considered. When pain in the head is jirescnt, the general diagnosis of headache is made, the only point of imjiortance being to distinguish as to whether it is due to intracranial or extracranial causes. The points already given under the general varieties of headache will serve in the main for their differentiation. 1 would simply lay HEADACHE. 725 stress upon the necessity of separating those forms due to pronounced organic disease from migraine and from functional types, such as the hysterical, the neurasthenic, and the rheumatic. Proper but not undue attention should be given to the question of reflexes. The prognosis of headaches has already been sufficiently considered in speaking of its different varieties. Treatment. — The treatment of the headaches of children will depend largely upon the special variety. The treatment of migraine has been discussed ; that of organic headache will be largely of the underlying disease. For the relief of these headaches two classes of I’emedies should be employed : first, those for the immediate relief of pain ; and, secondly, those to improve the state on which the headache depends. For the immediate relief of pain the best remedies are phenacetin, antipyrin, antifebrin, bromides, chloral, sulpho- nal, chloralamid, codeine, hyoscine, ether, chloroform, and preparations of opiutn. These remedies should be used in doses proportioned to the age of the child, although it should be remembered that children suffering from violent pain, wherever located, will stand larger doses of hypnotics and narcotics than those in health or those who are suffering from non-painful diseases. In brain tumor and meningitis phenacetin and antipyrin in combination will sometimes afford great relief. For the constitutional or the acquired organic conditions on which some headaches depend, mercury, the iodides, hydriodic acid, arsenic, and similar constitutional measures will be found most beneficial. In most cases mercury is best used in the form of minute doses of the bichloride. As not a few children Avho suffer from chronic headache are both anmmic and neurasthenic, it is of great importance first, to pay attention to these conditions, and the best treatment for adults will not always answer in these cases. Preparations of iron and arsenic should be given, but care should be taken in their selection. Among the most useful iron preparations are the malate, the citrates of iron and quinine, the ammonio-citrate of iron, the lactate of iron, powdered iron, and dialyzed iron. Palatable preparations can be readily chosen with a little care. Arsenic alone or in some combination will often be found extremely useful. I prefer small doses of Fowler’s solution alone or in combination with the compound syrup of the hypophosphites. In these anaemic children most careful attention should be paid to the quality of the food and to the manner of givino; it. Much headache in American chil- dren and in adults is associated with the dyspeptic troubles which are so com- mon in this country, and which are not infrequently due to the use of the fry- ing-pan and to other evil methods of preparing food. Children with their fresh and vigorous digestive organs do not suffer so much in this way as adults, and particularly those who have reached middle age or who have passed into the decline of life ; still, the matter is one of practical importance and should not be overlooked. The diet of children inclined to be dyspeptic and to suffer from headache should be plain, wholesome, nutritious, and easily digested. It is not well to train children to depend upon digestives, such as pepsin and pancreatin, although occasionally their use may be necessary. The stomachs of children are greatly helped sometimes by the administration in small doses, before meals, of bitter tonics, such as chamomile, quassia, columba, gentian, or cascarilla, which are best given in the form of infusion or small doses of the fluid extract. The exciting cause of a reflex headache should always be attacked. Eyes, ears, teeth, nose, pharynx, stomach, liver, or genital organs should receive therapeutic attention if necessary. The removal of adenoids has resulted in great benefit to children suffering from headache and inability to study or fix their attention. Some striking instances are also on record of headaches due 726 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. to decayed teeth, writers even going so far as to declare that these and visual defects are the most common causes of headache. For hysterical or imitative headaches moral treatment and the improvement of the general condition of the patient by tonics, nutrients, good food, gym- nastics, bathing, and out-door exercise will prove most beneficial. Neuritic or rheumatic headaches should be treated with the salicylates, which are often usefully combined with small doses of bromides and iodides. Of local applications for the relief of headache in children, the most important are the use of menthol, chloral and camphor, ointments of aconitia, hot, cold, or ethereal applications, galvanism, and head massage. Sinapisms to the back of the neck and hot or stimulating foot-baths are good old-fashioned remedies which may prove of great service. HYSTERIA. By JAMES HENDRIE LLOYD, A.M., M. D., Philadelphia. Hysteria in children has probably existed always. Peugniez tells us that in an old fresco of Dominicain the painter represents a saint curing a child possessed of an evil spirit. The patient is not drawn from imagination, but from life, for he is in one of the classical attitudes of the grand attack. With arms extended in the position of the cross, eyes rolled upward, and trunk con- vulsed in opisthotonos, he exhibits the disease in one of its most common forms. It was only because of the ancient Hippocratic definition of hysteria, which attributed the great neurosis to disorders of the womb, that for such a long period it was not recognized or acknowledged before puberty. For two thou- sand years this error ruled the medical world, and had for a kindred error the belief that hysteria is not observed in men. Lepois was undoubtedly the first writer to note the frequency of hysteria in children. After his time scattered references to the subject appeared, but still the old pathology prevailed even to the time (1846) of Landouzy’s treatise. Briquet’s statistics in his classical monograph on hysteria inaugurated the modern epoch of scientific investigation which secured the recognition of this form of the disease. It is, however, to Charcot and the contemporary school of the SalpStriere that we owe the most light upon this subject. In the masterly demonstration of hysteria in both sexes and at all ages given by this school we recognize for the first time the unity and individuality of this disease. Hysteria is henceforth no longer a vague label, of indeterminate value, for an incongruous mass of phenomena, seen exclusively in women, which most writers have by tacit agreement united to call “ protean.” Far from being changeable and indeterminable these phenomena are shown to be constant and subject to a strict arrangement: far from being confined to one sex or age or country, they are shown to be dis- tributed well-nigh universally; and far from being typical only in the adult female they are seen probably nowhere to more advantage than in children. In addition to the writings of Charcot, we may make special mention of the thesis of Peugniez and the treatise of Gilles de la Tourette, to both of which we are indebted for invaluable information. Other notable theses are those of Clopatt d’ Helsingfors and Mile. II. Goldspiegel, quoted by Tourette. The annual contributions of Bourneville on hysteria, epilepsy, and idiocy are of great value. In the English language the most complete paper on hysteria in children is by Dr. Mills {Keating's Gyclopa>dia of Diseases of Children, vol. iv.). All these papers contain copious references and bibliographical lists, which, combined, bring the whole subject easily within the reach of the student. It is our design in this paper to present a concise arrangement of this sub- ject somewhat after the manner of the French school, and to illustrate it with our own clinical observations. We may premise, also, that while we hold hysteria to be a morbid entity, with a well-defined etiology, symptomatology, 727 728 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. and prognosis, we recognize that, as in the cases of so many other diseases, it is modified to some extent in childhood. It shall be our especial aim to empha- size this fact. In the statistics of Briquet, hysteria in children occurred as follows in 87 cases : In childhood (exact age not given) 31 cases, At 5 years 3 “ From 6 to 7 years 6 “ “ 7 to 8 “ 11 “ “ 8 to 9 “ 6 “ “ 9 to 10 “ 9 “ “ 10 to 11“ 4 “ “ 11 to 12 “ . • 17 “ Total, 87 cases. According to Briquet, this table constitutes one-fifth of his own observations in patients of all ages ; hence 20 per cent, of his cases occurred in patients before puberty. This proportion is probably not exceeded in any other gen- eral nervous disease, unless it be in chorea. Briquet’s patients seem to have been girls. Cloplatt’s statistics are the most complete up to date : Girls. Boys. Total. In early childhood (exact age not given) . . ... 19 1 20 At 3 years 1 1 4 (( ... 1 1 2 5 a ... 4 2 6 6 u ... 3 2 5 7 ... 15 4 19 8 u ... 16 6 22 9 a 7 22 10 a ... 18 15 33 11 u 17 41 12 u ... 22 13 35 13 ... 27 16 43 14 a ... 12 8 20 15 a 3 3 176 96 272 According to this table, the disease is almost twice as frequent in girls as in boys. It increases almost steadily in frequency from the third year to the thirteenth. Etiology. — The most common causes of hysteria in children are heredity, exhaustion and anaemia from acute disease, trauma, disturbing emotions, imi- tation and defective education. The subject of heredity has two aspects according as the transmission is between similars or by transformation. By the first is meant transmission of the disease from an hysterical parent to an hysterical child ; by the latter, transmission of hysteria from a parent suffering with some grave nervous dis- ease, as epilepsy or insanity, to the child. The latter aspect, although not the more common, is far the more important of the two. This indirect heredity illustrates the kinship of many of the great neuroses, and demonstrates the necessity for a scientific investigation of remote causes. Briquet was the first to give this subject exhaustive treatment. According to his table, 351 hysterical patients had 1103 near relatives Avhose records were attainable; among these relatives were found 214 cases of hysteria, 13 of epilepsy, 1(! of insanity, 1 of delirium tremens, 1 of paraplegia, 3 of somnambulism, 14 of convulsive diseases, and 10 of apojilexy. This is almost 25 jier cent, of HYSTERIA. 729 cases of grave nervous disease in the immediate families of the patients. A “control” table of statistics based upon the cases of 167 non-hysterical women showed less than 3 per cent, of such nervous affections among 704 near relatives. Hence the percentage in the first class is more than eight times greater than in the latter. Bourneville. claims that alcoholism in the father is a not uncommon cause of hysteria in young children. Children not infrequently present hysterical symptoms during the prog- ress of, or convalescence from, acute disease. This is so especially in cases of the infectious diseases, and the complication may obscure the diagnosis in some cases not a little. The symptoms then observed are apt to be inter- paroxysmal. Other toxaemias also, such as those caused by lead, mercury, and alcohol, may produce hysteria, but to these causes children usually are not exposed. Trauma, next to heredity, is most important as an exciting cause of hysteria, and the symptoms of the grand neuroses which it is especially apt to excite are among the most intractable and simulate most closely organic affections. These symptoms are paralysis, contracture, tremor, and persistent localized pain or tenderness. This cause is often conspicuous in the so-called neuroses following accidents on the railroad and by machinery ; but in children very trifling accidents may cause hysterical phenomena. Exciting or depressing emotions may provoke hysteria in children who are predisposed. Fright is one of the most common of these. Disappointment, chagrin, loss of near relatives have all acted thus. Sometimes vexations of a quite trifling character are sufficient. In former ages, more than at present, religious excitement claimed many victims for the grand neurosis. The chap- ters of this part of its history were often written in blood. Demonology, witch- craft, and possession were often but phases of hysteria complicated with super- stition and fanaticism. The revolting epidemic of Salem witchcraft; in this country was begun by some hysterical children in the kitchen of a New England parson. Imitation and suggestion w'ere, and are, the potent factors in these epi- demics. Somewhat similar but harmless epidemics, due to these causes, are still seen occasionally in schools and convents. Finally, a defective or unwise education has much to do with the produc- tion of hysteria. The child that is constantly indulged, never corrected or controlled, taught to regard itself and its own wishes as always first, allowed to excite the emotions and imagination with fictitious literature, not disciplined to self-control, to self-denial, to duty and to the cultivation of the higher moral and intellectual faculties, is the child that is most apt to display the symptoms of hysteria. It must not be inferred, however, that hysteria is necessarily per- verseness, selfishness, and simulation. This is a too common error, and one which unjustly attaches to hysteria a certain measure of opprobrium and con- tempt. It is true, rather, that in some of the finest minds a defective educa- tion leaves undeveloped the essential qualities of self-knowledge and self-control. This conduces to hysteria. On the other hand, as Briquet has pointed out, excessive severity and cruelty to children, as seen especially among the lower classes, may be the exciting causes of the disease. Symptoms. — The symptoms of hysteria divide themselves naturally into two groups — (1) the Paroxysmal, and (2) the Interparoxysmal. We shall con- sider these in turn. (1) Just as in epilepsy, so in hysteria, the convulsive phenomena too often attract the attention of the medical observer to the exclusion of even more significant symptoms. The hysterical paroxysm is regarded as in some sort 730 A3IEBICAN TEXT-BOOK OF DISEASES OF CHILDREN. the essential element of the disease, the acme toward which all the other elements tend. Its bizarre character is no doubt the cause of this. As we shall see, however, the more permanent but less conspicuous symptoms of hysteria are often the more trustworthy, and sometimes the only, signs of the disease. The hysteric fit has several grades, but as the less are included in the greater, being but modifications or abortive attacks, it is best to limit the description to the typical spell. This grand attack of hysteria has, rather unfortunately, been called hystero-epilepsy. This is a misnomer, because the fit has nothing of epilepsy about it. The term seems to signify a union of the tw'O diseases, but such is not its true meaning, because such a union does not exist in the grand attack which we call hystei’o-epilepsy. It is hysteria — nothing more nor less. If a distinctive term were required, it would be better to speak of the attack as hysteria major, just as in epilepsy we distinguish the grand and the petit mal. The term hystero-epilepsy is unfortunate, moreover, because both diseases sometimes occur in the mine patient. But in these cases the fits are always distinct. The French speak of these as cases of hystero- epilepsy with separate crises. The hysterical paroxysm usually has prodromes. These especially are mental symptoms, and are noted and interpreted rather more easily in children than in adults. The child presents a change in disposition ; this change is usually from gay and amiable to moody and choleric. The immediate exciting cause is sometimes evident, but not always. In the latter case the origin or point of departure of the fit may be in some mental state, some auto-suggestion, which we shall study later. In this mental prodrome the child shuns society, appears sad, melancholy, or irritable, and cannot be drawn readily from its self-absorption. The paroxysm is preceded immediately by an aura. These aurm, as in epilepsy, are either sensory or motor. The most common is the sense of a ball rising in the throat, causing a feeling of suffocation. This may be quite alarming to the child, who clutches Avildly at his throat in evident terror, crying that he cannot get his breath. This aura is called the globus hystericus. Another, equally characteristic, is the cephalic aura. This consists of loud bruits, or beating, throbbing, and hissing sounds in the ears ; of acute pain, sometimes as of a nail driven into the head, hence called clavus ; and ol dimness of vision, and even vertigo. Other common aurm are the ovarian and the testicular. Ovarian tenderness not uncommonly precedes the fits. This may be spontaneous in women rather than in little girls. We have observed one case in which the patient called the physician’s attention to ovarian pain, Avhich proved to be only the precursor of an hysterical fit. Most freipicntly this ovarian tenderness may be elicited by pressure, and thus in confirmed cases the attack maybe elicited by sinqdy pressing firndy on the ovary. The aura, once started, seems in these cases to set going the whole associated mechanism of the fit. Similar results are claimed in boys by pressure on the testicles. Immediately after the aura the fit proper begins. It is customary, for con- venience of description, to divide this into j)eriods. The French school ob- serves four of these: first, the epileptoid period; second, the period of grand movements; third, the period of passionate cxpre.ssion; fourth, the period of delirium. W’e have convinced ourselves in our own clinical observations of the general accuracy of this division, but think, with Bcugniez, that the third period is most likely to be waTiting in the cases of children. The first (or epileptoid) ])criod may closely simulate true epilepsy, with which, however, it has no identity in any respect. It begins with a tonic stage, in which the patient usually lies supine with the limbs extended anti rigid. HYSTERIA. 731 but with fingers and toes flexed. Deviation of the eyes is conspicuous; usually there is lateral conjugate deviation, the eyes being rolled slowly either to the right or left; in some cases, however, as in the one to be reported later in this paper, convergent deviation occurs. The teeth are held forcibly together, the breath is heavy and slow, then rapid, the neck is swollen (more so than in epi- lepsy), and the face is sufi'used. The heart’s action is already becoming rapid. Sensation is usually blunted, and even abolished in some areas. The conjunc- tival reflex, however, is usually preserved in this stage. Consciousness is obtunded, and even lost in some cases, but in our observation consciousness is not aft’ected so profoundly as in epilepsy. The tonic phase gives place rapidly to the clonic. The muscles of the face, trunk, and extremities begin to tremble, and then to be agitated with a succession of shocks. During this, or even during the preceding stage, the patient may turn over on his side or even pre- cipitate himself from the bed. This clonic stage ends usually rather abruptly with a long-drawn breath, and is succeeded by a brief period of repose, during which the patient lies Avith closed eyes as if asleep. The second and third periods of grand and passionate movements have not been observed so commoidy by English and American Avriters, possibly because they have not studied these cases so methodically as the French. We have no doubt of the importance of the second period, especially in the cases of boys and girls. It explains many bizarre co-ordinate movements in children which exist sometimes as unsuspected abortive or atypical cases of hysteria. This period of grand movements begins abruptly. The patient throws himself into many and curious attitudes. Among the most common of these is the position of extreme opisthotonos, in Avhich he rests upon his head and feet, Avhich are at the ends of an arc of a circle. Other movements, too numerous and com- plicated to describe here, occur. Some of these have received special names, as the movement of salaam. Some of these movements are finite complex and apparently purposive, and may be elaborately automatic. These are more common in confirmed cases, and are probably the product of suggestion and auto-suggestion. They may persist, Ave believe, as isolated phenomena some- times, or as a kind of abortive attack. Charcot calls these phenomena clown- ism.” We shall narrate a case briefly in this paper. The third, or period of passionate movements, is the least common in chil- dren. We do not, in fact, quite see the necessity for this subdivision, because these movements naturally groAv out of those of the second period, Avith Avhich, in fact, they are sometimes blended and confused. They are still more com- plex movements, or rather expressions of passions, and as such are not common in children, in Avhom passions are not yet elaborated, and such as do exist receive simple expression. In these passionate moods the patients betray fear, anger, resentment, etc. ; and it is notable that if they attack they usually attack some one Avhom they dislike. We recall the case of a colored girl (in Avhose race hysteria major is not uncommon) avIio in this period of the grand attack struck savagely a felloAV servant, with Avhorn she had had a quarrel a short time before. These passionate movements, in fact, are ahvays the expres- sion of some pre-existent mental state, Avhich persists as a mental picture — or “hallucination,” as the French say. The fourth and closing period of the convulsive attack is the period of delirium so-called. This delirium, Avell portrayed in children and young per- sons, is also the expression of a mental state, Avhich is usually reproduced in every succeeding fit in the same patient. This mental state is one usually of fear and sadness, so that the period of delirium is characterized by tears, sobs. 732 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. cries, incoherent pleading, and appeal. These subside gradually and the attack is finished. These grand attacks may be complicated with somnambulism and cata- lepsy, and they may present various atypical and abortive forms, such as choreiform movements. Somnambulism has several traits that ally it to the hysterical status. In it we see a profound unconsciousness and abolition of will-power, leaving the patient under the influence of dreams and hallucinations, and extraordinarily susceptible to suggestions from without. A somnambulistic state has been observed sometimes as a complication of the hysterical paroxysm or as a post- paroxysmal phenomenon. Profound lethargy also supervenes sometimes in the fourth period. Catalepsy is another psychosis, which, while not essentially hysterical, has yet something in its nature that affiliates it with hysteria. Cata- leptoid symptoms ai’e not uncommonly seen in various periods of the grand attack, for they are not confined to any one period. They may be elicited sometimes by suggestion. We have done this in the tonic stage of the epilep- toid period by elevating the patient’s arms, and thereby have suspended the fit temporarily or even suggested a new turn in it. Among the most interesting products of hysteria are the cases of so-called “ chorea major.” This is another misnomer, for which the Germans especially are responsible. This chorea major has nothing choreic about it ; it is entirely hysterical. To understand its true position among the hysterical symptoms we may recall what was said above — viz. that the grand attacks may present various atypical forms. As Peugniez has shown, the attacks are not always complete. One period alone may appear, having an exaggerated development and leaving the other periods in the shade. Sometimes merely an aura, as the globus, is felt, and the attack aborts. In other cases the period of delirium, with tumultuous emotions, has such a large place as to appear to constitute the whole attack. Thus we believe it is in some cases with the period of grand movements. These movements become stereotyped as it Avere on the child’s brain at the moment of the extreme susceptibility or “ suggestibility ” that characterizes him at this ci’isis. They become further (levelo}>ed, in successive fits or even between fits, into most extraordinary combinations of movements and cries. These movements are sometimes apparently purposive, sometimes of the nature of an acc^uired dexterity or trick, or, again, they may be most elaborately automatic, the patient’s Avill and personality seeming to have noth- ing to do with them. These complex movements may be propagated readily to others, and thus they may give rise to epidemics in schools and religious communities which resemble the dancing manias of the Middle Ages. The writer saw and recorded one such case in a boy, in Avhom there Avas an elabo- rate syndrome of spasm, rotation, and catalepsy, undoubtedly hysterical in origin, and Avhich Avas cured by a slight operation on the foreskin.' (2) The interparoxysmal syni])toms of hysteria, Avhich form the second main group, are even more important than those of the paroxysm itself, for upon them must often depend the diagnosis of the disease from grave organic affec- tions. Their study is too often neglected. They are the ])erinanent markings of hysteria, .and hence have been called the Htigvuita. 'riiese stigmata aro sensory, motor, visceral, mental, and nutritional, and may bo considered here in the order named. The changes in sensation are varied in hysteria, but some of them are almost ahv.ays present. Ilyperaesthesia and hyper, algesia arc common. The ' For a full disoiission of tlie history of this phase of the subject see Kichcr’s Etudes ClinKjuca mr I’ JfijsteroEpilepsie, I’aris, 1881. HYSTERIA. 733 former is usually distributed in a characteristic way, and gives origin to the well-known hysterogenous zones. These zones are points or areas on the skin, pressure on which is usually painful and may excite the manifestation of other hysterical symptoms, especially the eonvulsion. This acute sensitiveness, how- ever, does not appear to he confined entirely to the skin, but to include the subjacent organs, as for instance, the ovaries. The most common of these hysterogenous points in our observation are over the ovaries and at points along the spine. Others describe them as in the testieles, at the juncture of the ribs to the sternum, and at other points on the trunk. Pressure on a hysterogenous zone is a common means of exciting the eonvulsion of hysteria major, and when at its height pressure on the same region will often stop it. Hyperalgesia exists as various forms of neuralgia : some of these are the accompaniments especially of traumatic hysteria. We had such a case under observation in which pain at a circumscribed area in the dorsal spine in a girl, following a fall, simulated the early stage of spinal caries. This case occurred in the Home for Crippled Children, and the diagnosis was so uncertain for a time that the child was put in a plaster jacket. This seemed to make a bene- ficial mental impression, and the patient recovered rapidly. Among these traumatic cases that simulate organic disease are those in whieh the hypei’al- gesia becomes fixed in one of the joints, as the hip or knee. Anaesthesia is one of the most important stigmata of hysteria. So common is it that it is doubtful if it is ever entirely absent in pronounced cases, and yet so little observed is it that even the patient himself is often ignorant of its presence. It may be very profound, and accompanied with coldness and vaso- motor changes in the part. During the dancing manias and religious crazes of the Middle Ages and later, it was observed that a pin-stick would not bleed. This was a mark of especially evil augury to superstitious minds during some of the witcheraft plagues. It is now one of the best-recognized marks of hysteria. The distribution of the anaesthesia varies. One of the most com- mon types is hemianaesthesia. This extends from the top of the head to the sole of the foot, and is often accompanied with anaesthesia of the special senses — sight, hearing, taste and smell — and of the mucous membranes. Another type is the distribution in geometrical figures, in which case the patient has areas of anmsthesia of various shapes and sizes scattered over the body. Still another is the monoanaesthetic type, in which an area of anaesthesia covers the arm and hand like a gauntlet or the leg and foot like a stoeking. This latter distribution is often accompanied with paralysis of the member. This asso- ciation with paralysis and the peculiar sharp demarcation of the anaesthesia at right angles to the long diameter of the limb serve to characterize this form very clearly. The hemianaesthesia of hysteria sometimes displays a peculiar phenomenon called transfer. Under the influence of some external agent, as electricity or a magnet, or even by suggestion or auto-suggestion, the anaesthesia passes from one side to the other. This change, however, is usually of short duration, for, as a rule, the affection soon returns to its first seat. The affection of the special senses is often marked in hysterical hemi- anaesthesia. There may be hemianopsia toward the anaesthetic side, and deaf- ness and loss of taste and smell on the same side. The most significant changes are in the eyes. First of these in importance is the concentric narrowing of the visual field. In the normal eye the visual field is not extended equally in all directions, being widest toward the temporal side, next toward the lower segment, next toward the higher segment, and least extended toward the nasal side. In the hysterical patient these relative proportions are apt to be maintained, the centre of the normal field being the centre of the abnormal 734 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. one, but the field itself is very notably contracted. In some cases, however, the relative proportions are not maintained, the contracted field being a round or oval area around the normal centre. This contracted field may be very small in some patients. Another significant change is in the perception of colors. In the normal eye the fields for colors are not the same. The widest field is for blue, then come the fields for yellow, red, green, and violet in the order named, violet having the smallest field. These fields for color are practically concentric. In the hysteric eye the violet field disappears first, being “ squeezed out at the centre,” as .some one has expressed it. Then the other fields con- tract gradually and disappear in the order named, with the important exception that the red usurps the place of the blue field — i. e. it becomes the widest and the last to disappear. In fact, red is a very persistent color-perception in the hysteric, and is supposed by some French observers to play a part in the hal- lucinations and mental states of these patients. Other affections of the eye are amblyopia in various grades, and the curious phenomenon knoAvn as monocular diplopia or polyopia, in which the patient sees with one eye two or more images of the same object. The motor symptoms of hysteria are of two orders : those that depend upon the absence of function, and those that characterize its perversion. Paralysis is of the first order, and contracture and tremor of the second. As Richer has pointed out, these disorders of motility are very apt to appear as isolated phenomena in juvenile hysteria, and sometimes at a very early age. Hysterical paralyses present a variety of forms, but these forms are not as significant as their mode of onset, their clinical history, and their termination. The most common are hemiplegia, paraplegia, and monoplegia. Very fre- quently the paralyzed part is also anaesthetic — a very uncommon phenomenon in similar paralyses due to central nervous disease. In some cases there is no anaesthesia. Paraplegia is more common in children and young persons than hemiplegia. In hysterical hemiplegia the fiice often escapes ; but if the face be invaded, it is more frequently some of the eye-muscles that are involved, in the form not of a paresis but of a blepharospasm. The paralyzed limbs may be flaccid or spastic. The onset of these paralyses usually is sudden. Their most common causes are trauma, emotion, and the hysterical fit. In the case of a young woman observed by the writer a paraplegia developed brusquely during a highly emotional love scene. In one of Bourneville’s cases a paraplegia followed a grand attack of convulsions. During the paralysis the convulsions ceased, but after it disappeared they returned. The duration of these ])aralyses varies, but not infrequently they disappear as suddenly as they come, and sometimes as a result of mental impre.ssion. In the above case observed by the writer the faradic current cured the disease promjitly. Sometimes a paralysis suddenly quits one limb or group of muscles and appears in another, as in the transfer scene in hemianaesthesia. A peculiar form of hysterical paralysis is loss of power of co-ordination — the so-called astasia-aba.'iia . The most common contractures in hysteria in children are as follows : par- tial or complete contracture of a limb, intermittent torticollis, spasm of the orbicular muscle, and paraplegic contracture. The position a.ssumed by the contractured limb varies according as the contracture occurs in the armor leg: in the case of the arm the limb is usually flexed, while in the case of the para- plegic form the limb is extended, the foot being in the position of plantar flexion. The hysterical contracture may be very persistent, enduring for years. In childhood, as Richer observes, the contracture may appear, disappear, and HYSTERIA. 735 reappear with a sort of periodicity ; in other cases it may pass from one seat to another. The causes of contracture are the same as those of paralysis. Tremor is a rather rare motor disorder in hysteria, and is more common in adults than in children. It may be caused by trauma, but it occurs sometimes spontaneously. It generally presents the type described by Rendu of a rather fine tremor increased by voluntary movement. The visceral and internal disorders of hysteria are numerous and quite important. We prefer to consider them here as a separate class, although some authorities include them under disorders of motility. Among the most common is aphonia, which as an affection of the larynx may be included here. It is caused most frequently by emotion, and is sometimes an isolated symptom. It may be complete, but more frequently the voice is not entirely lost, but only sinks to a whisper. It may appear and disappear suddenly. Rapid respiration is seen sometimes in hysteria, and may confuse the dia- gnosis, because it suggests some affection of the lungs or heart. It is a rather rare symptom, and is probably more common in adults than in children. It presents the superior costal type of breathing, and the respirations may be as rapid as seventy to the minute. Dyspnoea is not present, nor any accelera- tion of the heart, as a rule. The only typical case of this affection seen by the writer occurred in a young woman during a long convalescence from a serious surgical operation. Hysterical anorexia and vomiting are occasionally seen, and may constitute the most serious symptoms of the disease. They may bring the patient to the verge of the grave ; in fact, in a few cases they have actually caused death. The vomiting is of a peculiar type which may serve to distinguish it. It is caused usually by a spasmodic movement of the oesophagus, by which the food is regurgitated without having entered the stomach. This has been called oesophagismus. In extreme cases this spasm continues at intervals without the ingestion of food, as in a case seen by the writer and reported elsewhere, in which the patient regurgitated only a frothy saliva. She kept a napkin constantly under her chin as she lay in bed, to receive the ejecta. She was emaciated to an extreme degree. In her case the symptom was caused by the shock produced by swallowing supposed poison accidentally. Paresis of the intestine, causing immense dilatation of the tube and conse- quent distention of the abdomen, is seen occasionally in hysteria. Affections of the bladder are not uncommon. Hysterical ischuria and painful tenesmus are observed, the latter, especially in women, being associated with a vaginismus. In young girls this is rare. The consideration of the mental stigmata of hysteria has been reserved for this place, because, while these stigmata are the very first in importance, and constitute really the essentials of the disease, they can best be described after the sensory, motor, and visceral disorders which they serve to interpret. Hys- teria is a psychosis. Without a study of the disease from this standpoint it is futile to attempt to understand it. But this subject is deep, complex, and, to some, repellant. Moreover, we have space here only to indicate its outlines.' It is necessary first to reject the idea that the hysterical child is a simulator and a liar. It has been a too common error, due to the writings of Legrand du Saull and others, to confuse the mental stigmata of hysteria with those of imbecility, degeneracy, and moral perversity. Hysteria and degeneracy are distinct, and, while the two may coexist in the same patient, just as may hysteria and epilepsy or hysteria and tabes, it is inexcusable to confound * An early paper by the writer on “ Hysteria — A Study in Psychology” was an attempt to state this aspect of the subject. (See Am. jour, of Servous and Ment. Dis., Oct., 1883). 736 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. them. We must expect and search for distinct and characteristic mental stig- mata in hysteria, and we believe, with Gilles de la Tourette, that such exist and may be recognized. With this author we recognize a mental impression- ability, a proneness to take and act upon suggestions, as the real character- istic of hysteria. But even more than he, we wouhl insist upon the hysterical automatism, in which there seems to be a dissociation of the higher mental faculties, as the will and intellect, from the lower emotional and impulsive states. This dissociation of mental faculties is more apparent than real : a more exact statement would be, that the hysterical child reacts to a morbid association of ideas, which permits it to develop the various physical stigmata. It is of first importance to recognize this, because by the proper use of sug- gestion — i. e., education — much can be done to counteract the effects of this evil “dislocation” of the mental faculties. Suggestions come to the hysterical child either from without or from within ; they doubtless, by the law of asso- ciation of ideas, tend to form in each successive grand attack a more complicated web. Hence it is that many of the physical stigmata — paralysis, anmsthesia, etc. — either originate in or are aggravated by a seizure. Suggestions from Fig. 1. Case of Hysteria— (Harriet B ). First stage under Hyimotism. without, as by trauma, moral shock, etc., act often between or independent of the paroxysms. Sometimes in children the paroxysm jiborts, and there nuiy be a true “psychical eiiuivalent ” (as in epilejisy), in which some of the most astounding of the hysterical combinations may appear. In children, too, the attack may pass off in some of the jisychical prodromes, but these jirodromes HYSTERIA. 737 may be followed by the dreamlike or delirious states of the fourth period. To these dreamlike states and states of reverie, as well as to their congeners, the nightmares and night-terrors not uncommon in hysterical children, Tourette justly attaches great importance. They influence remarkably the mental state between the attacks, as well as the physical stigmata. The auto-suggestion in traumatic cases is often reinforced by these dreams and nightmares. Changes in nutrition are not marked or characteristic in hysteria. It is commonly said that anaemia is observed, but this is not in any sense character- istic, but only a result of the anorexia which is sometimes present. In other words, it is only an anaemia from malnutrition. The normal hysterical patient between paroxysms, unless anminic, does not present changes in the blood. The observation of the ancient writers, that the blood would not flow freely from an hysterical patient, w'as correct, but the fact depended upon alteration in the vessels of an anaesthetic limb, and not upon any alteration in the blood. Ac- cording to the table prepared by Gilles de la Tourette, the proportion of red blood-corpuscles, of haemoglobin, and of urea in the blood of hysterical patients is practically normal. During and after the paroxysm it is probable that some transient alteration would be found. The following case, from the writer’s clinic in the Philadelphia Hospital, illustrates some of the foregoing descriptions : Harriet B , aged seventeen, English. The patient has a history from early childhood of headaches and fainting-spells. At twelve years she was severely burned Fig. 2. Fio. 3. Ansesthesia in Geometrical Figures. (From author’s case of hysteria in a girl, drawn by Dr. Riesman.) 47 738 AMERICAN TEXT-BOOK OE DISEASES OE CHILDREN. about lier body and limbs by her dress catching fire. She had her first fit at about fourteen under the following circumstances: A week before the attack she had slept with a very sick relative who was raving in a wild delirium all night. After returning home she constantly talked of this experience, which had evidently made a deep im- pression on her mind. On the night on which the fit occurred her father had stayed with the same relative until a very late hour, and then, going home, knocked on his daughter’s door and awakened her. The child opened the door, was much frightened, and fell to the floor in a violent fit. Thereafter for a while she had as many as from nine to fourteen seizures a day. A physician who saw her in one of these said she was hysterical, and stopped the fit by slapping her in the face with a wet towel. Some of the seizures were nocturnal. On admission the patient was observed to be a tall, well-developed girl, with a marked English accent.* She had many scars due to extensive burns. (These happened some years before her first convulsion). On the fifth day after admission she had a grand attack, lasting about twenty minutes ; it came on spontaneously. She uttered a loud wailing cry for a minute or two, then became motionless in tonic spasm, wdth the eyes rolled up and respiration suspended. Then there was bilateral squint and extreme dilatation of the pupils. The period of tonic spasm was succeeded suddenly by one of slight clonic movements, complicated with spells of crying, sobbing, and choking. The patient was evidently conscious during part of the attack. During subsequent attacks she exhibited grand and passionate movements, and the fit was sometimes followed by a lethargic state. She can be thrown into one of these seizures by causing her to gaze fixedly at an object held before her, as, for instance, a lead-pencil. The patient was found to have hysterogenous zones over the ovaries and over the upper dorsal spine. Pressure on these produces an attack as follows: The patient be- comes rigid, with some flexion of the elbows and knees. The eyes become suffused, the face Fig. 4. 90 Pontraction of the Visual Fields in Hysteria. Field of O. S. (From author's case ; drawn by Hr. Kicsman ) ' This case furnishes a commentary on tlie claims of some English writei's tliat hysteria, as descrihcil in France, docs not exist in Fngland. This patient is a typical English girl, born in Birmingham, and drops her A’s nnmi.stakahly. Yet she exhibits the grand attack as perfectly as though she were in La SalpCtriere- HYSTERIA. 739 Fig. 5. flushed, and a rapt expression appears. The breathing is hurried and the pulse rapid The eyes converge in internal strabismus and the pupils dilate. The arms maybe placed in any position, and remain flxed in true cataleptoid rigidity (see Fig. 1). The hysterical symptoms are seemingly interrupted at times by the catalepsy. _ The tonic stage lasts for a long time. The clonic stage is of rather short duration, and is marked by treniors and clonic movements of not very wide range. Grand movements are observed in some attacks. The seizure ends in a paroxysm of tears and sobs. A lethargic state follows. Between the paroxvsms the patient has marked ansesthesia, both in geometric areas and in islets (see Figs. 2 and 3). Sensation is blunted in the buccal and lingual mucous membranes. There is no thermo-ansesthesia. There is some vasomotor weakness, shown by a bright erythematous flush extending for an inch or two around the mark of the sesthesiometre. The visual fields are narrowed concentrically (see Figs. 4 and 5), but the color fields are not modified in a typical way. It is to be noted finally that this patient has had a few seizures strikingly like true epilepsy, in which she is unconscious, froths at the mouth, and bites her tongue. These have occurred mostly at night, and their exact nature therefore is difficult to be deter- mined. But it is possible that the patient has “ separate crises,” i. e., both hysteria and epilepsy. Diagnosis. — In general terms it may be said that in the diagnosis of doubt- ful cases of hysteria the main reliance must be placed upon the presence of some of the permanent stigmata. It is frequently said that hysteria simulates all diseases, but the truth is that it simulates none exactly. The stigmata of the disease, if it is present, can usually be found. Epilepsy is the disease most closely counterfeited by the grand attack. But this resemblance is seen in the first period only, the periods of grand move- ments and passionate attitudes not being seen in epilepsy. When the attack aborts in the first period, the likeness to epilepsy may be striking, and it may be necessary to base the diagnosis upon the stigmata. The possible asso- 740 AMERICAN TEXT-BOOK OF DISEAREH OF CHILDREN. ciation of the two diseases in one patient (“separate crises”) must not be forgotten. Paralysis due to organic disease may be simulated by hysteria. Para- plegia especially may be so simulated. The history of the case and the detec- tion of other hysterical signs can usually determine the diagnosis. The same may be said of hysterical joint-disease. The so-called “ traumatic neuroses ” are in large proportion hysterical, as a proper study of the stigmata will usually demonstrate. The most common error is to confuse hysteria with degeneracy and moral perversity. It is commonly said that the hysterical patient has one or more of such syndromes as folie du doute, morbid scruples, mysophobia, agaro- phobia, impulse to set fire, to commit suicide, to make murderous assault, or that he is guilty of se.xual perversions. It is needless to say that these are the stigmata of degeneracy, not of hysteria. The hysterical child is not a moral imbecile. While hysteria may coexist with degeneracy, as with numerous other morbid states, it is not part of it. The various internal and visceral disorders, as hysterical breathing, anor- exia, vomiting, phantom tumors, etc., may usually be diagnosticated by a pro- cess of exclusion, the history of the case, and the presence of one or more hysterical stigmata. Treatment. — The treatment of hysteria in children must be partly moral and partly physical. Among the first we include especially education, and secondarily isolation. We have not space to discuss the subject of education, but after what we have said already of defective education as a cause of hys- teria, and of the peculiar impressibility of the hysterical brain, it is enough simply to indicate the sovereign necessity for a sound moral and intellectual rdgime for these cases. Unfortunately, it is often difficult to procure it. In some cases, if a good training cannot be obtained permanently, the influence of an evil one may be combated temporarily by isolation. To remove tbe patient from unwholesome domestic surroundings is tbe first requisite for a cure. Among tbe physical agents the most important for children are gymnas- tics, hydrotherap}', and vigorous tonic treatment. Gymnastics and hydro- therapy are much used by French practitioners, and with signal success. They probably act partly by their moral effects, both direct and indirect, as, for instance, by substituting wholesome impressions for morbid ones, and by divest- ing the mind of the unhealthy complexus of ideas which underlies the hys- terical state. This vigorous restorative treatment, unless contraindicated by special conditions, is better adapted for hysterical children than is treatment by rest and by measures adapted to pamper and enervate them. In anaemic states, secondary to anorexia, forced feeding and iron may be indicated. But anaemia, being a secondary condition, will usually improve, even without drugs, on the hygienic plan above suggested. As a rule, few if any drugs are indicated, but as it may be necessary to use some of them lor their moral effect, the least injurious ought to be carefully selected. Bromides and sedatives ought to be avoided. To abort or control the paroxysm a cold douche, jiressure on a hysterogen- ous zone, a hypodermatic injection of morphine, or an emetic, have all been recommended and tried. Morphine, however, is not proper for these cases. In the cases of children suggestion skilfully used will sometimes abort paroxysms and diminish their frequency. The suggestion of an operation will sometimes act thus. Too much solicitude and too persistent holding and controlling the patient should be avoided. CONVULSIONS. By FREDERICK PETERSON, M. D., New York. Eclampsia is a term often used synonymously with convulsion. Eclampsia is a series of violent contractions of a limited number or of many muscles, clonic generally, sometimes mingled with more or less tonic spasm, paroxysmal in character, and accompanied, when severe and general, by loss of consciousness. Convulsions are to be looked upon not as a separate and distinct disease, but as merely a symptom of a great variety of morbid conditions affecting the most di\ers portions of the animal economy. The constant repetition of convulsive seizures at irregular intervals is often considered as a distinct disease, but, in the light of recent research, epilepsy too is now regarded merely as sympto- matic of many pathological states which give rise to katabolic discharges in epileptogenetic centres. But while eclampsia is only a symptom, it is one of so pronounced a char- acter that it merits, and indeed requires, special consideration as regards its point of origin, etiology, nature, and treatment. Convulsions occur at all periods of life, but are so common in infancy and childhood as a symptom of disturbance in nervous centres that, as West says, convulsions in children correspond with delirium in adults ; and Trousseau goes even farther in saying that there are some children who have convulsions as easily as some persons have delirium or dreams. They are more common under the age of two years than at any other period of early life. Males are more frequently affected than females. Seat of Origin of Eclampsia. — Convulsions, whether local or general, have their origin in katabolic discharges of nerve-cells, either in the cortex or at the base of the brain. J. Hughlings Jackson has taught that there are three levels from which such discharges may occur : from the cells of the ponto- bulbar region ; from the Rolandic area ; and from a level (purely speculative on his part) which he conceives to exist in the frontal lobes and to represent the highest control of sensory-motor functions. Whatever may be the merits of his highest-level theory, I believe that from a practical point of view we may consider eclampsia as originating either in the ponto-bulbar region or the Rolandic cortical area, and generally the latter. Jackson thinks laryngismus stridulus is a convulsive discharge from the ponto-bulbar region, while Semon believes it to be cortical. The former would also classify as ponto-bulbar con- vulsions the respiratory fits induced in animals by asphyxia, the seizures pro- duced by convulsant poisons (such as nitrous oxide, curare, absinthe, camphor, and uriemia), and those resulting from injuries to the cord and sciatic nerve in guinea-pigs. Lately he has been modifying his earlier views, for now he inti- mates that, though the primary discharge in these cases occurs from the ponto- bulbar level, the higher centres may also at the same time be implicated by intermediation of the ascending sensory fibres. For my own part, I see no 742 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. reason why poisons, for instance, circulating in the blood may not discharge cortical centres simultaneously with ponto-bulbar centres. Whatever may be the ultimate idea attained as to the different levels, the seat of the discharge in convulsions is undoubtedly in the ganglion cells of the brain, and the molecular disturbance in these cells necessary to the discharge is determined either by direct irritation at these centres (from morbid states of the blood or vascular apparatus, trauma, neoplasms) or by indirect irritation (reflex). I submit a diagram of the two chief epileptogenetic centres. (Fig. 1). There is no form of eclampsia generated from the ganglion cells in the spinal cord. Fig. 1. Left Hemisphere. Right Hemisphere. Showing, schematically, the two convulsive centres — one the cortical, the other the ponto-bulhar, ami their relations and connections. They may bo acted on directly by lesions of the centres tliemselve.s or by vascular or blood states. They are more coniinonly acted upon reilexly by irntatioiis conveyed along sensory fibres from remote parts. Etiology. — Infants are always particularly liable to present the convulsive symptom, because of the incomplete state ol development of the nervous system. An infant is a bundle of nerves and nerve-centres and reflexes in a state of great activity, prepared to receive, store up, and re-energize a worldful of new CONVULSIONS. 743 impressions suddenly thrust upon it. While the nervous system of the adult has acquired the steadiness of long habit and has but to repair waste, that of the infant has all the delicacy and instability of newly-formed and highly- impressionable protoplasm, and, besides having to preside over the processes of repair, it must govern the growth of the whole organism. The lower centres at birth are more developed than the higher ones, and control is therefore much more imperfect ; yet at the same time the healthy child rarely suffers from eclamptic seizures. It is the child with a hereditary neurotic and unstable nervous system, or with acquired nervous instability, that is prone to fall a victim to convulsions. Most authors are united in the belief that there is an inherited convulsive tendency, that some families are more predisposed to the development of convulsions in infancy than others, and that various neurotic conditions in the parents, such as drunkenness and epilepsy, may give origin to this tendency in their offspring. Rickets is one of the strongest predis- posing causes, and the rickety condition is exceedingly common in children that suffer fi’om convulsions, the coincidence occurring in 30 to 40 per cent. (Gee, Morris J. Lewis, and others). Ansemic conditions and exhaustion or general debility from any cause pi-edispose to eclampsia. The exciting causes are chiefly reflex, either from irritation in the fifth nerve (dentition) or in the visceral sensory distribution (gastro-intestinal dis- orders). Many of the exciting causes act directly upon the convulsive centres (febrile and toxaemic conditions). These are given as typical exciting causes. Whether the purely physiological condition of dentition is the sole exciting cause in the cases usually ascribed to that period, or whether there may not be other causes operative during this important epoch of early life, cannot always be definitely determined. Improper feeding, over-feeding, and disturbances of digestion are very frequent causes of convulsions. Instances of improper feeding are not often so remarkable as one that came under my observation lately, where an infant of nine months was given a dinner of corned beef and cabbage. This was promptly followed by convulsions lasting seven hours, and these by a hemi- plegia from a meningeal haemorrhage. Gastro-intestinal disorders of all kinds are frequent precursors of convulsions. Worms no doubt often give rise to eclamptic symptoms, but not so commonly as is popularly believed. Convul- sions complicate many of the acute infectious diseases, and are probably due to toxines of bacterial origin circulating in the blood. In the intermittent fever of children convulsions usually take the place of the chill. In certain districts it is common to speak of malarial eclampsia as a very fatal disorder. Convul- sions complicate pneumonia occasionally, but rarely after the age of two years (Holt). Fever from any source is a prolific cause. Infants seem to be very susceptible to the influence of lead, convulsions sometimes following the thera- peutic administration of this metal (Eustace Smith). The so-called “uraemic” conditions frequently give rise to convulsions, though it is well to remember that we do not know what poison in the blood is the exciting cause, and that we do know that urea itself is innocuous. In .3 to 5 per cent, of cases of whooping-cough eclampsia is a complication. Fright, terror, anger, burns, scalds, morbus caeruleus, earache, laryngeal irritations, and organic diseases of the brain and spinal cord are to be borne in mind as more or less frequent, causes of infantile convulsions. Pathology. — Often after death from convulsions no morbid changes are to be found at all in the central nervous system. Usually there are signs of death by asphyxia, such as engorgement of the meningeal and cerebral veins with dark blood. Sometimes the passive hyperaemia is so intense that effusion of blood 744 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. takes place, or oedema may be present. Some authors have described anaemic conditions of the brain after death from convulsions. The pathology is of course not obscure when actual organic foci of disease are discovered. Outside of the central nervous system the most various pathological condi- tions are found at times in the heart, lungs, and abdominal viscera, this depend- ing naturally upon the varying nature of the exciting cause. Symptoms. — The simplest form of spasm is the respiratory spasm, known by several names, such as laryngismus stridulus, spasmodic croup, spasm of the glottis, child-crowing, and inward spasm. It is a local spasm, affecting gener- ally the glottis, but in severe cases all of the respiratory muscles may take part in the morbid movement. In mild cases there is a slight stridulous or crowing sound made by the infant during inspiration through the spasmodically con- tracted glottis; in severe forms this sound becomes more intense, and the child may become pale or blue before the obstruction gives way. The paroxysms may appear at any time without warning, sleeping or waking, when being fed, or when laughing or crying ; hut the usual onset is at night. The attacks last from a few seconds to a few minutes, and terminate in a coughing or crying spell. Sometimes rigidity of the limbs, opisthotonos, or even general convul- sions may accompany the laryngeal spasm. These seizures may occur once or several times in one night, and be repeated on following nights, the child being apparently well in the intervals. In general convulsions there are at times prodromal symptoms, but more often none. The prodromal signs are restlessness, starting and crying in sleep, grinding of the teeth, twitchings of the face or extremities, flexions of the thumbs, and the like. These are often, however, unimportant. There is con- siderable variation in the extent and severity of eclampsia in children, from slight jerky movements of the head and face and carpo-pedal contractions, to a condition not differing from epilejitic fits. Then in some of the graver cases there may be a cry ; consciousness is lost ; there is at first a tonic contraction, often not so long as in epilepsy ; then follow vigorous clonic movements of the face, eyes, tongue, jaw, arms, hands, thighs, and legs, which gradually diminish in extent as the nerve-storm abates, until the child becomes wholly quiet, and remains dazed or in a deep sleep or stupor for some minutes or a half hour afterward. There may be frothing at the mouth. The tongue is sometimes caught between the teeth and bitten. The pupils maybe contracted or dilated, anrefer canq)hor and caf- feine to other heart stimulants in this condition. The dosage of these remedies must depend entirely upon the severity of the symptoms and u{)on the age of the child. It may be necessary to give to a child of eight years ten grains of the salicylate of sodium every two hours for several days; it may not be neces- sary to give more than ten grains three times a day. Exalgin is to be given in three-gi’ain doses every four hours in a severe case, and three times a day in a mild case. With children I prefer to use these remedies in capsules, as the disagreeable taste is then avoided. If there be no history of rheumatism, it is well to think of the possibility of malarial infection as a cause of chorea. If there be a daily periodical rise of temperature, with or without a chill, or if an examination of the blood CHOREA. 763 reveals the presence of the malarial plasmodium, a dose of calomel, followed by Warburg’s extract in capsules, or quinine in capsules, kept up for a week, will be efficacious in cutting short an attack of chorea. Arsenic is the chief remedy for chorea not complicated by rheumatism or by malaria. Fowler’s solution is the best preparation to use, being tasteless. It is to be begun in three-drop doses three times a day, the number of drops being increased daily one drop until physiological effects are produced. These are a puffiness of the eyelids noticeable on waking in the morning, and slight nausea or griping pains with diarrhoea. It is possible in some children to reach a dose of fifteen drops of Fowler’s solution three times a day without the production of these effects; many children take ten drops three times a day without dis- comfort. It is my rule to keep on increasing the dose until the physiological effects appear. When this occurs the medicine is to be stopped for twenty-four hours, and then resumed at the dose just below that which produced poison- ing; and this dose is to be kept up regularly so long as treatment is needed. Arsenic should always be given after eating and well diluted with w’ater. There are some children who cannot take it in efficient doses without producing poisonous effects. In these reliance must be placed upon the hygienic rules already laid down, and if the chorea is very severe chloral may be given, the condition of the heart being carefully regarded during its administration. In some cases which do not yield readily to arsenic it is well to employ chloral in combination with it, giving from five to ten grains three times a day. In some cases tincture of cimicifuga is of service. A few cases of chorea present very severe symptoms, the spasms being so extensive and violent as to throw the patient about in bed and even to prevent sleep. In these the use of a combination of bromide of potassium and chloral (bi’omide 30 grains, chloral 15 grains), given two, three, or even four times a day by the rectum, is advisable, while at the same time arsenic is used by the mouth, being given in eight-drop dose in milk. A few patients are kept awake by the movements and rapidly become exhausted: in these cautious administration of chloroform by inhalation may be necessary in order to secure the needed sleep. The hypodermatic use of hydrobromate of hyoscine in dose of grain for a child of eight years, once in twelve hours, may be tried in very violent cases. Sulphonal and chloralamide are valuable hyp- notics in such cases. In addition to the foregoing treatment of the disease, it is usually necessary to remove the condition of anaemia which is present in the majority of cases, and therefore iron must be given in any form which may be preferred. The solution of the albuminate of iron is perhaps the best form to use for children, although the chocolate lozenges containing iron may also be given freely. Every form of nutritious food, especially milk and cream, and cod-liver oil, if the child can be made to take it, is also indicated. When medicinal treatment appears to be of little service, a change of air, especially a change to the sea-shore, is often of very great benefit. The sea air is much more conducive to recovery than mountain air, though sea-bathing is not to be recommended. In any case a certain amount of open-air life should be enforced during the treatment. TETANY. By henry M. LYMAN, A. M., M. D., Chicago. Tetany is a functional disease of the nervo-muscular apparatus, charac- terized by the occurrence of paroxysmal tonic spasms that involve certain groups of muscles, and that in severe cases may extend to nearly all of the voluntary muscles of the limbs and body. The nerves that are concerned in the production of these contractions exhibit a considerable increase of elec- trical and mechanical excitability. The functional character of the disease has led many observers to doubt the propriety of dividing it from other functional spasmodic disorders. The infrequency with which it is encountered in certain localities and among cer- tain races has also created a degree of scepticism regarding the disorder as a separate entity. But this lack of unanimity is principally due to the fact that tetany prevails chiefly among women and children who belong to neurotic fiirailies and are subject to unfavorable conditions of living. It will be observed more fre([uently by physicians in general practice than by those whose expe- rience is limited to office and consultation practice. Etiology. — Tetany occurs most frequently among children during the period of first dentition ; it is especially connected with gastro-intestinal dis- orders which interfere with nutrition, and is associated with an exaggerated excitability of the nervous system at the period of life when those tissues are naturally more unstable than during later years. For somewhat similar reasons it is not infrequent among young people near the age of puberty. The influence of sex is not very decided ; it is less conspicuous than are the influences that are derived from ancestral sources. The children of nervous, weakly parents are particularly liable to the disease. Constitutional causes and diathetic influences which favor the development of scrofula, arthritism, and rickets are powerful predisposing causes of tetany. The disease is, in fact, closely allied to those spasmodic tendencies that are so commonly wit- nessed among rachitic children. It is nndoulitedly due to insufficient diet and to the other predisposing causes of rickets that the disease is so often encoun- tered among children in or])han asylums, foundlings’ homes, and similar con- gregations of ill-conditioned infants. Among the exciting causes of tetany, exposure to cold exhibits great prominence. The disease is more often experienced during cold weather than in summer. Exposure to cold and wet has been noticed as an antecedent of the disease, and its manifestation is sometimes accompanied liy articular swell- ings that are highly suggestive of rheumatism. When a predisposition to tetany exists, almost any irritation of the cuta- neous or mucous surfaces of the body may excite an attack of the disease. It is therefore frecjuently observed during the course of infantile diarrhoea 764 TETANY. 765 and other irritative disorders of the alimentary canal. Among female patients its occurrence is closely connected with menstrual disorders, pregnancy, and lactation. It has been observed as a sequel of various infective diseases, but it is probable that in such cases the infection merely lowers the resistance of the nervous system, so that morbid manifestations of various character are more easily excited. When a predisposition has been established, almost any active disturbance of a peripheral character, or even of a psychical origin, may suffice to arouse a paroxysm. Symptoms. — The occurrence of an attack of tetany is usually preceded by certain premonitory symptoms of nervous disturbance. Occasionally the patient complains of dizziness, determination of blood to the head, humming sounds in the ears, and flashes of light before the eyes. Various perversions of sensation in the limbs may be also experienced. When, finally, the attack is matured, it is upon the fingers and toes that the force of the paroxysm is usually expended. The muscular spasms are generally bilateral, and in ordi- nary cases they are limited to the flexor muscles of the fingers, wrists, and toes ; the extensor muscles escape more frequently than the flexors ; sometimes the muscular groups of the forearm, upper arm, leg, and thigh are involved. In certain rare instances the muscles of the abdomen, thorax, neck, face, eyes, tongue, pharynx, diaphragm, and bladder may participate in the tonic spasm. The tips of the fingers and thumbs are frequently drawn together into the conical position assumed by the accoucheur when about to introduce the whole hand into the vagina. The great toe is flexed and bent laterally under the other toes, which are also drawn down into the position of plantar flexion. Occasionally the toes and fingers are spread apart, instead of being tightly drawn together. The upper arm is drawn against the side of the thorax, while the forearm is partially flexed and crossed over the front of the body. The legs are usually extended, but the thighs are adducted, and are sometimes flexed upon the body. When the muscles of the trunk and of the neck are invaded respiration becomes difficult, and suffocation sometimes appears immi- nent. When the paroxysms succeed one another intermittently, the phenomena of tetanus are closely counterfeited, though, fortunately, the comparative brevity of the attack and the rarity of a fatal termination mark a decided difference between the two diseases. During the course of the paroxysm the peripheral nerves of sensation exhibit various disorders. Sensations of cold, heat, numbness, and formica- tion are not uncommon. Neuralgic pains and a feeling of soreness in the con- tracted muscles are often experienced, together with headache, dizziness, and other cerebral symptoms of sensory disorder. Three cardinal symptoms deserve notice: Trousseau many years ago remarked that pressure exerted upon the large arteries and nerves of the limbs of a patient would be often followed by the development of a paroxysm of tetany. In this way a latent predisposition may be aroused to active mani- festation of the disease. This phenomenon is more easily produced in the upper extremity than in the lower. Occasionally the paroxysm may be excited by pressure upon the carotid artery and the sympathetic ganglia in the neck. A second characteristic depends upon the increase of electrical excitability in the motor nerves of the body and limbs. When applied to the nerves, very weak faradic currents are sufficient to excite muscular contractions. The application of galvanic currents also indicates great increase of excitability, so that tetaniform contractions of the muscles can be aroused by currents which ordinarily would scarcely be noticed. This inordinate sensitiveness to 766 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. electrical excitation is frequently manifested in latent cases where the fully- developed paroxysm has never been experienced. The increased excitability of the motor nerves is further indicated by their behavior under the inHuence of mechanical stimulation. A slight tap upon the trunk of a nerve is often sufficient to arouse a paroxysm, even though the muscles themselves cannot be thus thrown into contraction by direct percus- sion. When the facial nerves are involved the muscles of the face may be easily brought into a state of spasmodic contraction by tapping upon the trunk of the nerve at its point of emergence from the bony canal, or by draw- ing the point of the fingers across the face from the external angle of the orbit to the styloid foramen. Besides the various disturbances of sensation that have been already noted, painful pressure-points are sometimes discovered over the spinous pro- cesses of the vertebrm. The duration of a paroxysm may vary from a few minutes to many hours, or even two or three days. In cases of such long duration muscular spasm persists even during sleep, though its intensity is considerably diminished. The number of paroxysms during the course of an attack is also subject to great variation. A single paroxysm sometimes terminates the attack, while in other cases the spasms follow one another at brief intervals, almost like the paroxysms of genuine tetanus. Pathological Anatomy. — Since tetany rarely proves fatal, the oppor- tunity for investigation of its pathological anatomy is seldom offered. It is probably a functional disease of the whole nervous system, but many of the morbid processes that have been described are the results of predisposing dis- eases, or of the convulsive paroxysms to which the patient has been subjected, rather than causes of its phenomena. Among these, undoubtedly, are the slight haemorrhages that have been noted in the membranes of the cord and in the cord itself. The various conditions of hyperaemia and actual inflamma- tion that have been sometimes remarked are also of the same accidental or complicating character. The reflex nature of the symptoms and their produc- tion by irritation of the peripheral nerves render it probable that the disease has its principal seat in the spinal cord, though the reflex arcs in which the cranial nerves are included sometimes display evidence of disturbance in a way that indicates an extension of disorder throughout the entire length of the nervous axis. Tlie occurrence of the disease after diarrluea and other wasting discharges suggests the idea that this inordinate excitability of the nervous centres is in some way connected with malnutrition and with the exaggerated irritability that is thus induced. It is not impossible that these conditions are de])CJident upon an infection that has invaded the tissues of the sj)inal cord. The occurrence of the disease after extirpation of the thyroid gland has aroused a suspicion that tetany, like myxoedema, may be due to an auto- intoxication with mucin. But these speculations have not yet emerged from the I’ealm of hypothesis. Diagnosis. — Tetany may he easily recognized by the occurrence of paroxysmal tonic contraction in particular groups of muscles, usually the flex- ors of the extremities, and by the increased reaction that takes j)lace after electrical or mechanical excitation of the peripheral nerves. By attention to these phenomena the disease may be readily distinguished from tetanus, a dis- order which, moreover, usually commences with trismus — a symptom that is rarely observed in tetany. Similar facts of dissimilarity serve to distinguish tetany from the convulsive jtaroxysms of hysteria, and from the spasmodic movements that arc sometimes witnessed in writer’s cramp and the allied pro- TETANY. 767 fessional neuroses. The spasmodic attacks that sometimes occur as a conse- quence of ergotism very closely resemble tetany, and should probably be considered as belonging to the same class of toxic disturbances of the nervous system. Prognosis. — The disease is seldom fatal, but sometimes it persists for a considerable period of time. In such lingering cases a certain degree of muscular contracture and weakness is occasionally evident on careful examina- tion, even after the cessation of spasmodic attacks. Mechanical or electrical excitation of the nerves may then suffice to arouse a more or less complete paroxysm. Treatment. — In the management of tetany special reference must be made to the underlying causes of the disease in each individual case. Disorders of the alimentary canal require appropriate treatment ; all exhausting discharges, such as haemorrhage, diarrhoea, excessive menstruation or the opposite condi- tion, prolonged lactation, inordinate perspiration, etc., demand attention. Rheumatic and tuberculous patients require the treatment that is appropriate to such diathetic conditions. Electricity has been employed with but indifferent success. Countei’-irri- tants of all kinds have been applied to the spine, and hydropathic treatment has also been prescribed with varying degrees of benefit. For the relief of the paroxysm the various narcotics are generally recommended. Bromide of sodium, cannabis Indica, hyoscyamus, belladonna, chloral, ether, chloroform, valerian, oxide of zinc, and the opiates have been exhibited with temporary advantage. In severe attacks it is advisable to administer etber by inhalation and to employ non-volatile remedies by hypodermatic injection. Calabar bean and curare are too powerful and uncertain for administration in this disease. The principal object of treatment should be the improvement of the general health of the patient and the removal of all unfavorable conditions that inter- fere with nutrition. For this reason hygienic measures and dietetic manage- ment are more important than specific medication for the palliation of symp- toms. PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. By FRANCIS T. MILES, M. D., Baltimore. The essential feature of this disease is a progressive loss of power in certain definite muscles and groups of muscles, and its most characteristic and distin- guishing symptom (from which it has received its name) is the increase of volume and apparent hypertrophy in some of the weakened muscles. Symptoms. — It is a disease of early childhood, the great majority of cases occurring before the tenth year. It is but seldom that its invasion appears to begin about or after the time of puberty, and it is probable that the eye of one accustomed to the disease would have discovered indications of it long before that time. As a rule, the first symptom that arrests the attention of the parents or nurse is the seeming clumsiness manifested by the child in using his legs. A slight trip or jostle causes him to fall, and then he gets up slowly. He walks with a straddling, inelastic gait, ascends steps laboriously, clinging to the banisters and pulling himself up. Sooner or later (in some cases it is the first thing to attract attention) certain muscles begin to develop out of proportion to the rest, and are hard and elastic to the touch. Usually the first muscles to show this increase of volume are those of the calves of the legs, with which are generally associated the glutei, one or more of the divisions of the quadriceps extensor, and the erector spinae in the lumbar region. But the hypertrophy affects other muscles than those of the lower limbs. Thus the infraspinatus is very commonly much enlarged, frequently the deltoid, and even the biceps and triceps are sometimes involved. The escape of the muscles of the hand and forearm, which have been but very rarely described as implicated in this affection, gives a distinctive peculiarity to this form of muscular paralysis. The neck and face do not show an absolute immunity, and cases of hypertrophy of the sterno-mastoids, temporals, masseters, and even of tlie tongue, have been recorded. In a case of Bergeron’s all the muscles except the jiectorals and sterno-mastoids were increased in volume, thus giving to the child an appearance of great athletic develoj)ment. In marked contrast to the Herculean proportions of tlie muscles is their strength, which is almost always so greatly diminished that they arc incajiable of performing their rc(juired functions. After a time tliese muscles cease to increase in size, and tlien begins a diminution of their volume, wliicli may go on to complete atroj)hy, wdth corresponding absolute loss of power. But by the side of these enlarged and feeble muscles w'e observe others whose jiower is diminished more or less while they retain their normal size, or are from the first involved in a process of atrophy. In the lower extremity this loss of power is manifested in the flexors of the hip, which, though out of reach of direct observation, are thus evidently invaded by the disease. The extensors 768 PSEUDO-HYPERTROPHIC PARAL Y8IS. 769 of the hip and knee may be under-sized or atrophied, and always much weakened. The flexors of the knee are but rarely affected. Of the muscles of the upper extremity, those of the shoulder-girdle are generally more or less atrophic, especially (indeed, almost without exception) the costal portion of the great pectoral and the latissimus dorsi. Less frequently, but not uncommonly, the biceps and triceps are small and weak. If we attempt to lift the child by placing the hands under its arms, we find that the shoulders yield against the weight of the body, and are dragged almost to the back of the head. This mixed and variable picture of hypervolumi- nous and atrophied muscles would seem to indicate that the pseudo-hypertrophy is, as it Avere, an acci- dental factor, and that the intrinsic nature of this disease is the pi’ogressive loss of power in certain muscular groups. Indeed, cases have occurred in which all the motor symptoms of pseudo-muscular hypertrophy Avere present, but in which the diseased muscles that caused these symptoms presented no alter- ation of volume. In the Avords of Charcot : “ The hypertrophy is not, all things considered, an essential element in the constitution of the affection called pseudo-hypertrophic paralysis.” We will return to this point farther on. On account of the Aveakness of the muscles involved, the attitude in standing and the manner of Avalking in this disease are peculiar and characteristic. In a state of health, Avhile standing erect the centre of gravity of the body falls slightly in front of the point of support, and the hip- and knee- joints are not in a position of complete extension ; so that to maintain the equilibrium and to prevent the flexion of those joints a sustained action of the erector spinae and the extensors of the hip and of the knee is demanded. In the disease under consideration an involuntary effort is made to relieve these en- feebled muscles by tliroAving the centre of gravity very far back. To do this the lumbar concavity is increased as much as possible, so as to throw the weight of the head and shoulders behind the hip-joint, thus producing a marked lordosis, Avith a corresponding protrusion of the chest and belly. The knee- joints are fully extended (locked), so that the weak quadriceps extensors are at rest, Avhile the base of support is broadened by the wide separation of the feet. The lordosis disappears Avhen the child is seated ; but in an advanced stage of the disease, when the erectors of the spine are greatly Aveakened, a kyphosis may for the time take its place. When standing the patient may be able to raise himself on his toes, but cannot spring from the floor. In ordinary natural walking, while one foot is off the ground and is being pro- pelled foi’Avard the centre of gravity of the body falls much nearer the median line than the supporting foot, and, indeed, it continues to move toward the opposite side until the advancing foot reaches the ground and receives the weight of the body. During this time the w'eight of the body is sustained upon the head of the fixed femur, principally by the glutei muscles. In pseudo- hypertrophic paralysis, these muscles being too weak to perform their task, the patient relieves them by throwing the body far over to the side of the sustain- 4V Fig. 1. Pseudo-hypertrophic Muscu- lar Paralysis. 770 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. ing foot, thus "bringing the weight over the point of support, while the other leg swings forward. This manoeuvre, being repeated alternately for the two limbs, gives a peculiar and characteristic swaying motion of the body from side to side in walking. This false position of the trunk and the weakness of the extensors of the knee hinder the foot being projected forward to the length of a full step, and, instead of the heel touching the ground first, as is usual in walking, the ball of the foot or the toes first descend, giving the appearance of an attempt to step softly. This stepping on the toes is sometimes caused by a contraction of the muscles of the calf, which may occur early in the disease. Very characteristic and almost pathognomonic of this disease are the manoeuvres executed by the child in getting into the erect from the recumbent position. They were first and with great clearness described and explained by Gowers. The weak extensors of the hip and knee are not equal to the work of extending these joints and giving the erect position to the body against the Fig. 2. 4. Postures in rising to the Erect Position (Gowers). weight of the head and shoulders. The child, therefore, unable to assume the sitting position, takes that of “all fours,” thus throwing the weight upon the hands and arms, while the legs are being straightened. lie then works his hands backward along the floor until he gets to a position from which with an effort he can grasp the legs above the knee, and then, by alternately clas]iing them at a higher level, he thrusts the trunk into a more and more erect posi- tion, until by a final push he jerks the spine into tlie position of lordosis already described. To use the common and appropriate phrase, he “ climbs up his legs.” We have already said that the hypertrophied muscles after a time lose their volume and become atrophied. This may not take place until after many (ten to fourteen) years, and does not affect all of the hyjicrtrojdiied muscles at the same time. Those of tlie upper extremity are generally the first to undergo the change, the muscles of the calf lieing the last to lose their volume. In- creasing weakness more and more circumscribes the movements of the patient, until at last he can no longer walk or stand, although the movements of the arms and hands may still, in a measure, be retained. Now contractions oi the wasted muscles set in, and joints, as tlic knee and elbow, are fixed in the po.si- tion in which they are usually maintained. The ankle-joint takes the jiositiou PSEUDO-HYPERTROPHIC PARAL YSIS. 771 of pronounced talipes equinus, partly from fixation in the position in which un- supported it hangs, and partly from contraction of the muscles of the calf. From loss of power in the spinal muscles there may result lateral curvature. The tendon reflexes, as a rule, show no change, except that they grow more feeble as the muscles become weaker, until they are finally lost.^ The sphinc- ters are unaffected. Fibrillary contractions have been observed so rarely as to make it presum- able that they are caused by some intercurrent trouble, such as neuritis. While the electric reactions are gradually diminished and lost, they are qualitatively normal, and in the very few cases in which degenerative reaction has been described it is probably due to some secondary cause similar to that which causes the fibrillary contractions in certain reported cases. Sensation is nor- mal, and mental impairment, although occurring in some instances, does not seem to be a consequence of the disease. A symptom which might be referred to an affection of the vaso-motor nerves is the bluish mottling or marbling of the skin of the lower limbs which is sometimes seen. There is no evidence of any disturbance of the sympathetic nerves. The disease runs a chronic course, it may be of ten or tAventy years’ dura- tion, and does not itself directly cause the death of the patient. This termina- tion is usually the result of some intercurrent respiratory trouble, to Avhich the enfeebled condition of the patient gives force. Etiology. — Hereditary influence can be traced in a large majoritvof cases, and exclusively through the mother, who, without being herself a subject of the disease, may nevertheless transmit this developmental defect to her off- spring. Males are much more frequently affected than females, and in the latter it tends to develop later in life and progress more slowly. The disease may be considered as a congenital affection, for even Avhen it develops after the period of childhood, as it sometimes, though rarely, does, there is reason to assume that the defect of muscular development has merely lain dormant during the earlier years of life. No other etiological factors, as syphilis or alco- holism, have been recognized in the causation of the disease. For a long time after pseudo-muscular hypertrophy had been observed and fully described clin- ically, it was considered a disease of spinal origin, a myelopathy. But more recently the opinion that it is a primary disease of the muscles, an idio- pathic myopathy, has received a very general sanction from pathologists. It is recognized as one (and the most frequent) form or type of a group of myo- pathic atrophies, or muscular dystrophies, of Avhich Erb’s juvenile type, the facio-scapulo-humeral or infantile type, and it may he Leyden’s hereditary type, are the most distinctively marked forms : “ The infantile type is characterized by the early facial paralysis, the juvenile type by the time of its development (early youth) and localization of the atrophy (in the muscles of the shoulder- girdle) ; the pseudo-hypertrophic type by its development in early childhood and the predominance of the lipomatous condition of the muscles; the heredit- ary type (Leyden’s) by its heredity.” While these forms of muscular atrophy are fairly separable clinically Avhen well marked, there are numerous transition forms Avhich cannot be easily clas- sified. Not infrequently the different types occur in members of the same family, and arise presumably from the same inherited defect. As Erb has shoAvn, there are no greater differences amongst these varie- 'The writer has recently seen a case of psendo-niuscnlar hvpertrophv in a bov nine years old, in which the knee-jerk was abolished, although he could still walk, and the partly hyper- trophied quadriceps extensor could extend the knee almost completely when the patient was seated. 772 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. ties than there are amongst the individual cases of any one variety. Thus in the pseudo-hypertrophic form we have fairly constant atrophy of the muscles of the shoulder-girdle and arm — i. e. those characteristically affected in the juvenile type; and in some cases described by Erb there was atrophy of the muscles of the face, the mark of the infantile type. Indeed, Erb sug- gests that many cases haVing the clinical aspect of the pseudo-hypertrophic form, afterward, as the adipose matter is absorbed, take on the appearance of the juvenile type of muscular atrophy. Pathological Anatomy. — The essential feature of the pathological anat- omy in this disease is a degenerative change in the muscular tissue itself ; and this change is probably the first which takes place. Pieces cut from the living muscles (which are much to be preferred to morsels extracted by the “ har- poon”), and properly prepared, present the following microscopic appearances: The muscular fibres in cross-section are seen to have lost their polygonal out- line, to have become rounded in contour, even to be complete circles. Amongst fibres of normal size there are those which are hypertrophied, and others which show atrophy in varying degree, even to the point of complete disappearance. The abnormal increase in volume of the muscular fibres would, from recent observations (Erb), appear to be an essential feature in the muscular atro])hies, and it may be that it is a condition of the fibres which very generally precedes their atrophy. At any rate, such hypertrophied fibres are rarely, if ever, wanting in pi’eparations of muscular tissue taken from these diseases. This increased volume of the fibres cannot be explained by their contraction after excision, since it is seen when precautions are taken to counteract this. In addition, the fibres show a splitting in the longitudinal direction and the for- mation of vacuoles in their interior. The muscle-nuclei are sometimes more, sometimes less, but always considerably, increased. The alteration of the connective tissue must follow very closely, if it is not coincident with, that of the muscular fibres. A proliferation with increase of its nuclei goes on juarij with the muscular atropliy, until finally it becomes excessively developed. In pseudo-hypertrophic muscles the connective tissue is not only increased, but is crowded with fiit-cells. It is this condition, in- deed, to which they owe their increased volume and hardness. In muscles primarily atrophied, and in the pseudo-hypertrophic muscles after they have undergone atrophy, there is little or no adipose matter, only a greater or less amount of connective tissue (connective-tissue cirrhosis of Erb). In muscle preparations from the dead body the microscopic appearances are practically the same as those seen in j)ieces from living muscles. It is of great importance to observe that the microscopic ap})ea.rances in muscles taken from the different types of muscular dystrophy do not differ more from each other than do those in preparations obtained from different cases of the same type, nor, indeed, than those in different specimens from the same individual. Not only do the pathological changes in the muscles bear a very close rescmbhuice in all the types of muscular dystrophy, but these changes as closely resemble those found in other forms of muscular atrophy, as, for instance, the spinal atrophies and those attending arthritic disease. “ The j)roof for or against the ])ure myopathic nature of the progressive muscular atrophies cannot at ))resent be furnished by histological research.” Investigations of the nervous system, both central and peripheral, have in such a large majority of cases given a negative result that the reports of lesions of the spinal cord, though made by coni])etent observers in recent cases, will scarcely change the generally acce|)ted opinion that the muscular dystrophies do not depend on discoverable nerve lesions. The (piestion, however, has PSE UD 0-HYPER TR OPHIC PA RA L YSIS. 773 arisen, and still awaits its answer, as to whether the muscular dystrophies are absolutely myopathic, or whether functional disturbances (“dynamische Stbrung ”) in the trophic mechanism of the cord, too subtle to be ascertained by our present methods of investigation, may not set up at first hand nutritive changes in the muscles. Some considerations certainly point in the direc- tion of classing these diseased conditions of the muscles with the tropho- neuroses. Diagnosis. — When the disease has advanced to a point where the athletic proportions of the hypertrophied muscles stand in strong contrast to their weakness, and where, moreover, along with these over-developed muscles, we have others which are atrophied, there can be little difficulty in making the diagnosis. Gotvers claims diagnostic importance for the “condition, which is seldom absent,” “ of enlargement of the infraspinatus, with a wasting of the latissimus and lower part of the pectoralis.” In cases where the enlargement of the muscles is slight, or, as in some instances, where they retain their normal size, the difficulty may be greater. The peculiar position in standing, and, still more, the makeshift movements of the patient in rising from the recumbent position, are almost positive evidence of the disease, whose main characteristics depend on the invasion and weakening of the muscles employed in these acts. From a progressive chronic neuritis, which might cripple these muscles, the diagnosis would most likely be made by the absence of fibrillary contractions and of degenerative reactions, both of which symptoms belong to neuritis. A history of other members of the family having suffered with atrophy of the muscles would be strong confirmation. Congenital spastic paraplegia, in which the muscles sometimes exhibit a considerable volume, is distinguished from pseudo-muscular hypertrophy by the muscular spasms and the increased myo- tonus, which shows itself in an exaggerated knee-jerk, and often in ankle-clonus. The different types of muscular dystrophies may be distinguished among them- selves by marks already given. Pro^osis. — In this disease no hope can be entertained of recovery, and very little of delay in its progress, which in children is infallibly to utter help- lessness, with all the intercurrent risks incidental to that state. The best cared-for will generally live longest, but the great majority never attain adult years. In girls the outlook is somewhat more favorable as to length of life. Cases where the disease has not developed till later years have been seen to progress more slowly, and even to come to a standstill before the power of standing and walking was lost. Treatment. — It is in vain that we look for any drug which will exert direct influence on the diseased processes in the muscles. Tonics, arsenic, cod- liver oil, etc., can only benefit indirectly by improving the general nutrition. In children, as soon as the disease is suspected, or, indeed, in all the children of a family in which any one of the muscular dystrophies has shown itself, a scrupulous and untiring enforcement of all the rules of health with regard to diet, fresh air, and exercise should be observed. Gowers argues with con- vincing force on the probable benefit of judicious exercise of the affected muscles. The cold mottled limbs would indicate the employment of massage. Electricity, so far, seems to have exerted no beneficial influence. For the con- tractures so marked in the last stage of the disease, tenotomy is unhesitatingly to be employed. This is especially demanded in the contractures of the calf- muscles, which sometimes occur early in the disease and render walking or standing impossible. FACIAL PARALYSIS AND PROGRESSIVE FACIAL HEMIATROPHY. By CHARLES W. BURR, M. D., Philadelphia. I. Facial Paralysis. Facial Paralysis, Bell’s palsy, or mimetic paralysis, is due to injury or disease of the motor portion of tlie seventh cranial nerve or its nucleus. Etiology. — Cases occurring at birth are due frequently to pressure of the forceps upon the nerve at its point of exit from the skull; or even if forceps are not used and the labor is normal, though much prolonged, paralysis may ensue. In the latter case it is due to pre.ssure exerted either by the promontory of the sacrum or by the ischiatic sjunes. A few cases have been reported which were caused by the pressure of intrapelvic tumors. The causes acting after birth are the same as those which occur in adult life, but the affection is not nearly so common in infiints as in older people. The most common cause is cold, which acts by setting up a neuritis — the so- called rheumatic palsy. Ear disease, especially if caries of the bone and sup- puration be present, is a common causative factor. It is undoubtedly true, however, that the affection may develop when only the lining membrane of the tympanum is inflamed, without accompanying bone disease. Tumors, meningi- tis, or fracture of the base of the skull are occasional causes. Surgical opera- tions in the region of the ramus of the jaw are quite frequently followed by palsy due to division of the nerve. A blow in the same region may have a like effect. Certain acute infectious diseases — as, for example, diphtheria — may be causative. Very rarely it occurs in acute infantile spinal palsy. Non-trau- matic cases, in Avhich the onset is sudden and the palsy complete, and in which there is no evidence of cerebral disease, must be due to Inemorrhage in the nerve-sheath or Fallopian canal. Gowers has seen two cases, and Wilks and Moxon have found the Inemorrhage after death. Symptoms. — Often there is preceding pain in the car or over the entire side of the head, and a slight swelling may be present in the region of the parotid gland. The onset is rapid — rarely, as stated above, sudden. The child may be put to bed well and wake up affected. Usually in from a few hours to a few days the palsy reaches its height. There is ordinarily little or no constitutional disturbance. In very young children the signs of palsy may be very slight, on account of the greater quantity of adipose tissue, the greater elasticity of the skin, and the smaller muscular development. There may be when at rest only a slight drooping of the angle of the mouth. When, however, the infant cries or laughs, the deformity becomes marked. The affected side remains motionless, the eye cannot be closed, the cheek and ala of the nose fall in and out with inspiration and expiration, and the mouth is drawn strongly toward the sound 774 FACIAL PARALYSIS AND HEMIATROPHY. 775 side. Most often the tongue and soft palate are unaffected, and the child experiences no difficulty in nursing. Taste may be lost in the anterior half of the tongue on the affected side. The reaction to electricity depends upon the severity of the attack and the time which has elapsed since the onset. In a typical case reaction of degeneration appears after a time. After some months in severe cases, but not in those in which the palsy remains complete, contrac- tures develop on the affected side, making it on first view appear to be the sound side. Examination during movement, however, reveals that the diseased side moves much less. The contracture causes, furthermore, a Avrinkle which has no analogue on the sound side. It must be remembered that in some cases only a part of the nerve may be palsied — only the mouth or only the orbicularis palpebrarum — and also that both nerves may be affected. Diag-nosis. — The palsy is unmistakable, and the only question is whether the lesion is central or peripheral. If the lesion be situated above the nucleus, there is never lasting, but sometimes transient, palsy of the eyelid. Emotional movement is less impaired by central disease than voluntary movement. Re- action of degeneration is never present in central disease, and is never absent in peripheral disease unless the palsy be very slight. In the former the reflexes are present, in the latter they are lost. If taste be lost, the lesion is within the Fallopian canal. In disease of the nucleus the orbicularis oris is not affected. Prognosis is excellent in the cases due to pressure at birth and in those from diphtheria. Gowers justly lays great stress on the prognostic value of the electric excitability of the nerve. If, he says, it is not below normal at the end of ten days, recovery will probably follow in a few weeks. If at the end of a fortnight it is absolutely lost, the palsy will certainly last several months. Treatment. — The first indication is, of course, to remove the cause if pos- sible. In recent cases, due to cold, hot fomentations should be placed in front of and below the ear. Blisters should be applied over the mastoid process or occiput. Hot baths and free purgation are very useful. Galvanism is useful when the condition has become chronic. The positive electrode should be placed below the zygoma, and the negative moved gently over the muscles. The least amount of current sufficient to produce muscular response should be used. But little can be done to influence contracture. Daily gentle massage of the face is at least harmless. n. Progressive Facial Hemiatrophy. Progressive Facial Hemiatrophy — also called Neurotic facial atrophy. Facial trophoneurosis, Prosopodysmorphia — is a chronic progressive disease characterized by wasting of the skin, fat, connective tissue, bone, and some- times, but to a less degree, the muscles of one or very rarely both sides of the face. Etiology. — The disease, while absolutely rare, is far more frequent in females than in males. Of 92 cases collected by Hermann Steinert, 60 occurred in the former, .30 in the latter, and in 2 the sex was not mentioned. It is most apt to occur in early life. In 29 cases the onset was before the tenth year, 24 began between the tenth and twentieth years, while only 22 occurred between the twentieth and fiftieth years ; in 1 the onset was at sixty years. Traumatism seems to exert a positive causal influence, as in quite a number of cases injuries to the face, the jaw, or the head preceded but a little while the first symptoms. It sometimes follows an acute infectious disease. Symptoms. — The major symptom, wasting, may begin either diffusely or 776 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN in one spot, spreading thence slowly, and involving skin, subcutaneous tissue, the muscles mayhap, and the bone. The atrophy is most marked in the bone if the disease begins during the period of active growth. Usually the process stops abruptly at the middle line, making the face look as if it were made up of halves from different people, but it may involve both sides, and even extend, it is alleged, to the shoulder and arm. The skin on the wasted side is thinner and paler. The hair may become simply gray, finer, and smoother, or it may fall out. The alveolar processes waste and the teeth are shed. The lower jaw becomes both thinner and shorter. The orbital fat disappears and enophtbal- mos develops, but the eyeball is not affected. There is sometimes an associated hemiatrophy of the tongue. Pain and numbness are not uncommon, but anaes- thesia is rarely present. Anidrosis, weakness of the carotid pulse, and loss of the power to blush are occasional symptoms. There is never marked difference of the smTace temperature of the two sides of the face. The special senses are never affected. There are no changes in the electrical reactions of nerves or muscles. The diseased side in well-advanced cases may produce an expression mimicking the drawn features of old age. The disease follows a slowdy pi’ogressive course, sometimes extending over many years, or it may, after reaching a certain stage, cease to progress. Pathology. — The pathology of the condition remains as yet almost entirely theoretical. Mendel has made one autopsy in which he found an interstitial neuritis of the trifacial from its origin to the periphery. In an atypical case of Horner a tumor was found pi’essing on the Gasserian ganglion and the trifacial nerve. Taking all things into consideration, it is probable that the future will show that disease of this nerve stands in close causative relation to the affection. Diagnosis in a well-developed case is easy. The only conditions with which it can be confounded are congenital facial asymmetry due to torticollis, facial paralysis, and facial bemihypertrophy. These need only be named to avoid error. Treatment has so far been absolutely valueless. On theoretic grounds Dercum in 1891 recommended section of the various branches of the trifacial. He holds that the condition dejiends not upon failure of trophic nerve stimulus, but upon a radical perversion of that stimulus. INFLAMMATORY DISEASES OF THE SPINAL MENINGES AND SPINAL CORD. By ARCHIBALD CHURCH, M. D., Chicago. I. SPINAL MENINGITIS. Spinal Meningitis is an inflammation of the covering membranes of the spinal cord. The varieties of meningitis ordinarily described have been somewhat arbi- trarily based upon anatomical considerations. As the dura or the softer mem- branes are principally involved, the terms pachymeningitis and leptomeningitis are respectively employed, but a sharp division is impossible clinically, and is not found post-mortem. For purposes of description we may consider — 1st, Pachymeningitis, or external and internal inflammation of the dura; and 2d, Leptomeningitis, or inflammation of the pia. But inflammation of the inner surface of the dura must from contiguity involve the leptomeninges more or less, so that the con- ditions are usually associated, and meningitis originally external may Anally invade the pia. Association with myelitis is hardly less frequent ; mixed forms, therefore, or meningo-myelitis, are common, and are to be classed as the thecal or cord symptoms may predominate. Pachymeningitis Externa. Pachymeningitis externa, or external dural meningitis, is due to chronic irritation and inflammatory conditions invading the spinal canal, and is there- fore secondary to other morbid states. Thus, vertebral tuberculosis, Pott’s dis- ease, abscesses and new growths near the spine, inflammation and purulent col- lections in the pleurae, mediastinum, peritoneum, and pelvis, may be the source of the meningeal thickening, which gives rise to symptoms mainly by irritation of the sensory and motor nerve-roots which pass through the area of disease. When the thickening becomes extreme, as it rarely does, it may be sufficient to compress the cord itself and give rise to pressure symptoms and the spastic paraplegia of a cross-myelitis. Thei’e is local tenderness over the spine, shoot- ing or constant pains in the di.stribution of the irritated nerves, twitching of their muscles, hyperaesthesia in their cutaneous areas, which may go on to anaes- thesia and muscular palsy if the nerves be sufficiently compressed or inflamed to cause their complete degeneration. Anatomically, the dura is found hyperplastically thickened, with much adventitious fibrous tissue, and is frequently covered by a caseous or purulent deposit or involved in a new growth. The various findings, of course, depend upon the nature of the primary disease. When the thickening is extreme, the soft membranes are adherent to the dural tumescence and may be indistinguish- able. The cord then shows a constriction, and may, in severe cases of long 777 778 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN standing, be very considerably reduced in size at the place of disease, with inflammation and degeneration. The diagnosis is usually not difficult if the primary disease is recognized. It may be confounded with a myelitis, with which late in the case it is often associated; but the clinical history shows a preponderance of pain, spasm, and irritation, a chronic course, and an early absence of paralysis ; while in myelitis the _apid onset, the absence of pain aside from the girdling sensation, and the promptly developed paralytic state with early bladder and bowel symptoms, are distinctive. Owing to the serious nature of the causal conditions, the prognosis is bad and treatment is practically surgical. The pachymeningitis externa associated with Pott’s disease is perhaps the least grave, as the proper orthopmdic and surgical management of such cases frequently, in very marked instances, is followed by practical recovery, even when the cord has been notably com- pressed. Pachymeningitis Interna. Pachymeningitis interna, or internal inflammation of the dura, is described as hypertrophic and hsemon’liagic. In reality, these forms are but stages of one and the same process, the thickening and hypertrophy following upon the organization of the hmmorrhagic exudate; and the term hmmatoma of the spinal dura mater has been sometimes used. The condition is a rare one, and usually the cerebral meninges are similarly affected. It is most commonly found in general paralysis of the insane, and consequently is practically unknown in childhood. The portion of affected dura presents on its inner surface a very consider- able thickening, which may be a layer of reddish-brown exudate or consist of a lamination of fibrous tissue, the apparent result of the organization of suc- cessive haemorrhagic exudations, and may attain sufficient size to constrict the cord. The softer, more recent, and reddish or brownish layers consist of fibrin and blood. Its distribution is fre(|uently extensive, but in some instances it is confined to a comparatively short vertical extent of the spinal envelope, and is then more frecjnently situated in the cervical region. This circumscribed cei'- vical form was first described by Charcot and JoffVoy. Syphilis, trauma, alcoholism, and exposure are regarded as competent causes, and hence it occurs, as a rule, in adult males, though some cases in childi’en are recorded. The condition is essentially chronic and of slow onset. At first, irritation of nerve-roots gives I'ise to local pain and hyperaesthesia over the spine and in the peripheral distribution of the S])inal nerves of corresponding origin. This is followed, months or years later, by gradual loss of poAver, atro})hy, and anaes- thesia in the corresponding parts, and, as compression upon the cord is pro- duced, spastic sym))toms ap|)ear below, with increased reflexes, rigidity, and paraplegia leading to exhaustion and death. Some cases present stationary periods, and a few recoveries arc claimed. The diagnosis is difficult when a general distribution and cerebral synqitoms are Avanting. Diseases of the spine, progressive muscular atrojiliy, cross-mye- litis, tumor, and external pachymeningitis must be excluded. An operation may be required to do this, and as it ])resents, except in syjihilitic cases, the best chances of favorably influencing the condition and preventing destruction of the cord, in the desperate situation that is ])resentcd and Avith the courage given by asepsis, it may the more reasonably be resorted to early. Where sy])hilis is strongly suspected sj)ecific treatment should be persistently tried. INFLAMMATION OF SPINAL MENINGES AND CORD. 779 Acute Leptomeningitis. Acute leptomeningitis, or inflammation of the spinal pia mater, is due to infection, usually involves the inner surface of the dura, and extends to the substance of the cord. Etiology. — The infection of cerebro-spinal meningitis in epidemics of the disease falls sometimes only on the cord, and the infective nature of the attack is obvious. In those cases, however, that are attributed to exposure, “ insola- tion,” rheumatism, and other occult conditions, the infection is less readily comprehended, but in all probability is equally in operation, being favored by the physical conditions mentioned. The association of cases with septicaemia, pyjemia, and other infectious blood-states points to the same conclusion, and in the lympli and spinal fluid of these cases abundant pathogenic organisms have been observed. In some instances the spinal trouble is an extension from the cerebral meninges, the cervical portion of the cord being usually the only part involved. Injuries resulting in traumatism of the membranes by vertebral dislocations, strains, and severe concussions may incite a leptomeningitis over a limited area, from which it may extend or in which an infection may find a suit- able field for development. Surgical operations upon the spine and penetrating wounds may afford access to and furnish the infection. Tuberculosis is a com- mon cause, but the resulting meningitis is rather less acute, as is the case to a greater degree in syphilitic inflammation, which has a marked tendency also to remain localized. Pathology. — The disease is usually of wide extent, the infection travelling rapidly tlu’ough the arachnoid spaces, and finding in' the spinal fluid an excellent medium for its propagation and extension. Congestion of the pia, of the ad joining inner surface of the dura, and of the cord, marked by increased vascularization and an increase of spinal fluid, passes into inflammation, Avith dulness of the mem- branes, opacity, thickening, and an exudation of large quantity, varying in color from an opalescent to a puriform, and of corresponding consistency. The microscope shows the diapedic elements of inflammation and often numerous bacteria, including at times those closely resembling the pneumococcus of Fried- lander. Tubercles here correspond to their histological and bacterial characters on other serous surfaces. For a time the somewhat resistent pial covering of the cord and nerve-roots protects these structures, and especially in the purulent form of the disease ; but usually the periphery of the cord and the roots shoAV the inflammatory invasion, Avith corresponding changes in the nerve-fibrils, neu- roglial frameAvork, and vessels. In cases reaching a convalescent or chronic stage adhesions form betAveen the cord and the dura, obliterating the arachnoid space over more or less extensive areas, distorting the nerve-roots, and some- times changing the outlines of the cord itself, Avhich, if softening in its substance has taken place as a result of the rneningo-myelitis, presents degenerations of its conduction tracts and localized destruction of its gray matter. Large quan- tities of spinal fluid usually mark these late cases, causing, Avith the irregular adhesions, a sacculated condition of the dura. Symptoms. — The abrupt onset of the disease may be preceded by a day or two of malaise and slight anorexia; but sometimes no invasive period is present, and a sharp chill is followed or attended by great pain in the back and darting pains around the body or down the limbs. In children, vomiting or convulsions may be present, and the former is a common symptom. Tenderness is at once developed over the spine, easily detectable, when not prominent, by the use of a sponge dipped in hot water or by sharp percussion Avith the finger. Spasm and rigidity of the muscles appear at once, causing stiffness of the neck 780 AMERICAN TEXT-BOOK OF BISEA8EN OF CHILDREN. and back, sometimes notable retraction of the bead ; fixation of the limbs upon the body more or less marked, with a tendency to flexed attitudes ; retraction of the belly from implication of the abdominal muscles; and sometimes difficulty of breathing, by involvement of the chest musculature aside from the dyspnoea, Cheyne-Stokes’ respiration, and cardiac symptoms of medullary implication. The cramps in the muscles are painful, and yet tenderness and hyperaesthesia in the limbs prevent manipulations and passive movements. The rectum and bladder are the seat of similar spasms which may cause constipation and reten- tion of urine, with frequent annoying and ineffectual expulsive contractions of these viscera. Pulse and temperature are fickle, sometimes being subnormal, sometimes in- creased, and more often divergent ; for instance, a subnormal temperature with an accelerated pulse. The lack of uniformity in their range is especially valu- able in diagnosis, even when the cerebrum is apparently not involved. A tem- perature of 103° F. is not uncommon. Vaso-motor paralysis is usually shown by the vivid, persistent, but slowly-developed line which follows every stroke of the finger-nail or similar object upon the skin, and from the same cause the limbs may be congested and even slightly oedematous. At first, for a day or two, reflexes are inclined to be increased, and later may be wanting. Cases which outlast the acute symptoms develop pai’alysis, anaesthesia, atrophy, and contractures in proportion as the cord and nerve-roots are affected. Paraplegia may result, presenting the features of a cross-myelitis with bladder paresis, bed-sores, increased reflexes, and spasticity. Symptoms vary with the location of the disease, but its tendency to involve the entire spinal aj)paratus is marked, and indications of its effect upon all spinal segments are to a greater or less degree present in a majority of instances. Some regions situated in the focus of the inflammatory action show early and emphatic involvement; those at a distance may be disturbed very little; and yet in some purulent cases, where the dural sheath is greatly distended through its entire length with the large accumulation, the pia prote(;ts the cord and nerve-roots from infection, so that pressure symptoms alone may be present. Course. — Some cases terminate fatally within a day or two ; others last a fortnight, and may then end fiitally or recover. The nature and virulence of the infection are a determining factor, as is the location of the disease — exten- sion upward or early involvement of the high levels of the cord tending to an early fatal issue. Complete recovery is rare, and the conditions resulting from myelitis are of long duration, and may even last a lifetime. The tubercular and syphilitic varieties, as already indicated, less raj)idly run their course, and the latter is capable of material modification by treatment. Diagnosis. — The diagnosis depends upon the rapid onset, the pain in the back, the radiating pains, the rigidity, the increase of pain on voluntary move- ment, the hyperaesthesia-, and the fickle tem])crature and pulse. From myelitis it is distinguished by the paralysis and lack of pain which characterize the cord lesion, but the frequent association of the two is to bo always kept in mind. Ihemorrliage into tbe subdural space, from the irritation of the rierve-roots, pre- sents very similar symptoms, but is extremely rapid in the onset, usually follow- ing traumatism or a strain, and develo])s meningitis in ar short time thereafter. Ihemorrliage into the spinal cord gives instantaneous symptoms and immediate paralysis, and is practically devoid of jiaiii. d’he rigid form of tetany may present a very close counterfeit, but its long duration, remissions, and amen- ability to spinal sedatives, with absence of spinal tenderness and shooting pains, and with the possible history of previous attacks and the usual irritability from pressure upon nerve-trunks and arteries, should difl’erentia-te it. fl'etanus INFLAMMATION OF SPINAL MENINGES AND CORD. 781 may be mistaken for spinal meningitis. The early trismus, the excessive hyperaesthesia, the fever of onset, the paroxysms of spasm, and the frequent history of traumatism point the way to diagnosis. Muscular rheumatism and strain present a very superficial resemblance. Prognosis. — The outlook as to life is always serious and grave in propor- tion to the acuteness of the onset, to the virulence of the infection, to the implication of the upper portion of the cord, and to the height of temperature. The estimate is also to be guided by the previous condition of health and the age of the patient, children and the aged quickly yielding to the disease. Traumatic and surgical infection is less serious than auto-infection by leuco- maines. The possibility of the removal of sources of infection cuts some figure as to ultimate results, providing the patient survives the acute stage. The late results, due, for the most part, to permanent changes in the cord, are usually beyond the hope of marked improvement. Treatment. — Complete and absolute quiet is to be insisted upon, and the patient maintained upon the side or face, if possible to do so without increasing the cramps. The partial knee-elbow position over a mound of firm pillows will often be found vei’y comfortable, and at the same time will afford the best opportunity for local applications. These at first should be sti’ongly counter-irritant, as the thermo-cautery, blisters, or detergents like leeches, vigorous dry-cupping, or wet-cups in robust or plethoric individuals. Should myelitis be associated, less active measures are indicated, and the skin must not be broken or highly irritated, owing to the tendency to bed-sores. A hot bath and pack at the onset with active catharsis have seemed to do good. Seda- tives, especially spinal sedatives, are frequently required to control the spasms, and anodynes to relieve the pains. A thorough course of mercurial inunc- tions over the spine has strong advocates, the quantity used being sufficient to produce slight ptyalism. Owing to the reflex irritability, these rubbings must often be impossible, and the therapeutic value of mercury in the acute stage of non-luetic cases is open to question. Iodide of potassium and ergot are also at this time of little or no value. The ice-bag to the spine is one of the most serviceable measures, but is rarely tolerated long by the patient, and its intermittent application is useless. It should always be tried. As the active stage subsides, light cauterizations with the Paquelin apparatus, mild sinapisms applied for six or eight hours, and the hot spray douche seem to assist the reparative efforts of nature. Cerebral symptoms usually mean the implication of the brain coverings, the spinal features become of secondary importance, and the treatment is that of cerebro-spinal meningitis. The paralysis, con- tractures, and other late results of the myelitis are to be managed in accord- ance with the rules of practice in that disease. Chronic Leptomeningitis. The chronic form of inflammation of the soft membranes is usually the sequential stage of an acute attack, but may follow alcoholism, syphilis, or tuberculosis. Its origin as a primary affection is open to some doubt, but a very slowly-developed leptomeningitis may follow concussion, though it is impossible in such a case to exclude immediate slight histological injuries of which the later inflammation is a natural development. The formerly much- used term “chronic meningitis,” which was given to every group of obscure subjective symptoms referable, however remotely, to the spine, only needs mention to be condemned. The symptoms are practically those of the acute form much reduced in in- 782 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. tensity, and are dependent upon similar causes. Pain in the hack predomi- nates, and spasm is insignificant or absent. The radiating neuralgic pains are especially j)ronounced, and parmsthesim are prominent. Their distribution de- pends upon the nerve-roots involved and the location of the inflammation, which is much more circumscribed than in the acute form. The late manifes- tations are those due to neuritis originating in the roots, and myelitic symptoms are comparatively infrecjuent. The anatomy of the disease is very little known, as opportunity for post- mortem examination rarely occurs, but a more or less extensive fibrous thick- ening may be found, and adhesions between pia and dura which constrict the nerve-roots and may girdle the cord. Degeneration of the spinal nerves travers- ing the lesion is not rare, and this accounts for the herpetic and other cuta- neous symptoms of neuritis which are occasionally noted. The prognosis will be guided mainly by the effect of treatment, but a com- plete recovery is very rare. Each case must be carefully estimated by itself. The treatment in syphilitic cases consists in the heroic management of that disease, and iodides and mercury are also the most efficient drugs in non-luetic cases. General measures are of avail, and persistent counter-irritation over the spine is the most valuable local measure. Sometimes rest in bed and the ice-bag to the spine are of distinct value. Sedatives and analgesics are often required. n. MYELITIS. Myelitis, or inflammation of the sjiinal cord, is a generic term covering a con- dition presenting many varieties of a more or less arbitrary character, depend- ing upon the mode of onset, the portion of the cord involved, the duration of the disease, and the exciting cause. Thus it is acute, subacute, or chronic ; transverse, diffuse, focal, disseminated, central, or annular ; parenchymatous or interstitial ; and compressive, traumatic, secondary, syphilitic, infectious, etc., the adjectives sufficiently de.scribing the modifications. The forms of myelitis constituting the so-called system lesions, poliomyelitis, locomotor ataxia, and other circumscribed scleroses, are described under separate headings. The clinical variations of the disease are multiform. So widely do the several tracts and segments of the cord vary in function that their im])lication gives rise to the most diversified symptomatology, for the comprehension of which a fair knowledge of the anatomy and ])hysiology of the cord is requisite. Acute Myelitis. Acute Myelitis, acute softening of the cord or transverse myelitis, is the most ordinary form, and not a rare disease. Etiology. — While the disease may appear at any age, it is very rare in children ; males from eighteen to forty years furnish the large majority of cases, syphilis, exposure, and muscular effort playing an important j>art in precipitating tile malady. Next to trauma, syjihilis is the most freciuent cause. Ilenedict and Erb, indeed, are disposed to assign to the syphilitic cases a clinical entity; but the only variations are those attributable to the infection, the nature of the syjihilitic process, and its jiartial response to treatment in some cases. Lead, mercury, and other chemical poi.sonings are at times ]irovocativo of myelitis. Acute infections, saprmmic and pyogenic conditions, may lead to it, the last sometimes producing an abscess of the cord. Pressure from hiemor- INFLAMMATION OF SPINAL 3IENINGES AND CORD. 783 rliage, pachymeningitis, tumors, fractures, dislocations, and from Pott’s disease, very rarely from a thoracic aneurism, may incite it, and it has been attributed to sexual excesses. Wounds of the cord or in the neighborhood leading to infection, minute luemorrhages in the cord from strains, violence, concussion, and arterial disease, thrombosis or embolism, may originate the softening. Whether concussion unattended by immediate histological injury to the cord is capable of producing myelitis or not is a mooted question, but the groAving tendency is to look upon the material and anatomical factors as requisite to its develop- ment. The annular form, and sometimes other varieties, are due to extension from a meningeal inflammation. Pathology. — The inflammatory process may be very slight or absolutely destructive in intensity. If the lesion be examined early, there will be found hyperaemia and swelling of the’ adjacent pia mater and of the affected portion of the cord. Later, the condition depends largely upon the amount of blood effused ; in some instances the disintegration of the cord is such, and the ex- travasation of blood so considerable, that the gross characters of a clot only are found. In other cases softening is so pronounced that the cord is diffluent and of a creamy consistence and appearance. From the haemorrhagic element “red softening,” comparable to that in the brain, may be found, and this, by the resorption and change of the coloring matter, later becomes yellowish. In time the affected area, through the removal of the fat and the deposition of adventitious fibroid elements, looks grayish and translucent and is shrunken in outline. Thus, after some lapse of time, the cord may be reduced to a narrow filament. In these prolonged cases upward and downward, secondary, sclerotic degenerations in the Avhite columns ensue. Peripherally, the muscles innervated by the involved cord-segments rapidly waste and degenerate, and dystrophic bed-sores are common even at an early stage. Implication of the nerves controlling the bladder frequently results in cystitis, leading to nephritis and uraemia. Microscopically, the findings vary greatly with the intensity, form, and dura- tion of the disease. When the cord has become entirely disintegrated and dif- fluent such examinations are of little value. In the mildest forms the vascular changes are the most noticeable, the blood-vessels being widened, crowded with the formed elements of the blood, and the perivascular spaces greatly distended Avith leucocytes. Minute extravasations are common. The gray substance of the cord is more granular than in health, its cells distorted, SAvollen, and devoid of processes Avhen the condition is marked. Corpora amylacea and globules of myelin are common. In the Avhite portions increase and alteration in the neuroglia are found. Spider-cells are frequent. The fibres shoAV SAvell- ing of the axis-cylinder, and the myelin has a tendency to break up. At points of pressure the fibres are shrunken and may entirely disappear. In the parenchymatous forms the nerve-cells present the principal changes, the inter- cellular substance and interstitial material showing practically no change, and the vascular condition is less marked. In cases of long duration both fibres and cells give place, in large part or completely, to an actual increase in the fibrous elements of the interstitial structure, and new fibroid tissue is deposited. The resulting ascending and descending degenerations shoAV sclerotic features similar to those in the system lesions, and sometimes a more active inflammatory process extends a short dis- tance up or down the cord, occasionally folloAving the central canal, Avhich may show dilatation, proliferation of the epithelial lining, and more or less dis- tortion. The distribution of the inflammation in the cross-section of the cord is 784 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. subject to no rule. In some cases it is scattered in random foci, in others confined to a few principal points ; or the entire cross-section may be involved, and the gray matter does not, relative to its proportions, seem to be especially selected. Symptoms. — The onset, except in traumatic cases, is gradual, but in the course of a few hours or days or weeks paraplegia may become complete. Very rarely, and usually only in syphilitic forms and those due to slowly-devel- oped pressure, there are prodromata for weeks or months before the attack, con- sisting in temporary weakness, tingling and radiating pains ; but ordinarily a feeling of numbness and weakness in the legs is experienced, the lower extrem- ities feel heavy and unmanageable : in a few hours they refuse to bear the weight of the body, and in a few days may become completely paralyzed. During the first week the temperature may be elevated a degree or two, but very rarely attains a height of 104° F. Delirium and convulsions have been seen occasionally in children, and more rarely in adults. The reflexes, where directly related anatomically to the affected segments, are lost early and permanently, and below that level are increased after a few days, unless the cord has been entirely destroyed at the inflammatory focus, when they are abolished. Pro- vided the posterior roots and meninges are involved, pain in the back and limbs is a prominent symptom, but rarely is of an excruciating character at the onset. At the upper level of the inflammation some pain is the rule, which gives rise to a band or girdle sensation and a zone of hyperaesthesia about the abdo- men or chest. This sign, with the paralysis, definitely localizes the upper limit of the lesion, but if it be in the lower cervical region this sensation passes down the arms and is not so sharply defined. Lesions in the cervical region are also marked by implication of the cilic-spinal centre, with consequent dilatation of the pupil. Continuous priapism is then, too, a usual occurrence, and the inter- costal muscles and heart may be affected. Below the lesion, and depend- ing upon its intensity, there are variations in sensibility to all forms of stimu- lation, from slight blunting to the usually complete anmsthesia. Sensations of drowsiness and aching in the paralyzed and anmsthetic limbs are sometimes mentioned; and cramps and drawing up of the limbs frec^uently occur early, and later are the rule. Distinct muscular atrophy related to the portion of the cord Fig. 1. Showing Flexion, Cro.'‘S-leg from Adduction, (Jontmetions causing Drop-foot and Ued-sores. affected takes place, but in the trunk is not readily discernible. The paralyzed limbs during the first few days are abnormally w:irm, but soon present a sub- normal temperature : sluggish circulation :tnd emaciation enstie, with anlema of the feet and legs if the limbs are left any length of time in a petident posi- tion. If the lesion is low down, the atrophy is a marked feature and the re- INFLAMMATION OF SPINAL 3IENINGES AND CORD. 785 action of degeneration is present. Under the influence of pressure bed-sores form on prominent portions of the body and limbs, and this very early. In some cases within the first week immense sphacelization may take place over the sacrum, which cannot be explained by pressure and the moisture from the urine, but implies a dystrophic condition of cord origin. Bed-sores of this nature are especially liable to form when the lumbar cord is the seat of the disease. Course. — The onset, as already indicated, is moderately rapid, as a rule, and in the course of a few days the complete picture of paraplegia is presented. Although the case may stop short of this at any point, it may, on the other hand, rapidly progress to the formation of bed-sores, the development of cystitis, and rapidly progressive exhaustion, often terminating in a fatal issue. Non-fatal cases come to a standstill after two or three weeks, and if nutrition and strength are maintained impi’ovement slowly takes place, sensation and motion gradually reappearing and increasing for a year or two. A complete, or apparently complete, recovery is rarely seen. For the most part, secondary degenerations, upward in the posterior columns of the cord and downward in the lateral tracts, cause inco-oi’dination on the one hand and spastic symptoms on the other — a combination suggestive of ataxic paraplegia, and no doubt sometimes confused with that disease. The implication of the pyramidal tracts leads to the spasms, tremors, and cramps which form such prominent features of these late cases, and gives rise to the spastic gait when walking is pos- Fig. 2. Fig. 3. Chronic Myelitis, showing station and rigidity, with partial flexion and adduction of thighs. sible, and to the flexed limbs, adducted thighs, and crossed legs of the bed- ridden cases, as shown in Figs. 1, 2, and 3. In these later stages the condi- tion is often spoken of as chronic myelitis. 50 786 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Diagnosis. — Regarding the location of the lesion, the best guide will be the upper level of anaesthesia and the hyperaesthetic girdle. After a few weeks increased superficial and deep reflexes occur below the disease, while those reflexes whose arcs are involved in the softening disappear. Thus, if the umbilical or mid-abdominal reflex is absent, those below being present and exaggerated, and a girdle sensation is present just above the navel with anaesthesia below, the lesion is at the tenth dorsal segment and opposite the body of the ninth dorsal vertebra, the guide to which is the eighth dorsal spine. With this the distribution of paralysis should also agree. The intimate and usual association with myelitis of some more or less local- ized meningitis is to be constantly in mind, as the obtrusive symptoms arising therefrom may serve to very much embarrass the diagnosis, especially in the beginning, and mislead the judgment as to the future of the case. The nature of the lesion must be determined by a careful study of the clinical history and a careful clinical examination of the patient for spine disease, for neoplasmata in other locations, for tuberculosis, for syphilis, and for injuries. Prognosis. — While the prognosis is always grave as to ultimate recovery, and early in a given case must be carefully guarded as to the probability of a fatal termination, there are certain facts which modify the estimate. A dorsal myelitis is less serious than a lumbar, and very much less than a cervical involvement. The more sudden and complete the onset, the greater tl)ie probable damage to the cord. High temperature and early bed-sores are extremely ominous. Serious involvement of the bladder and bowel, implying lumbar cord lesions, are distinctly unfavorable. The reappearance of sensa- tion in the anaesthetic area is hopeful, and usually followed by some return of voluntary motion. When improvement has distinctly commenced, it may be expected to continue for a year, and progresses even two years or more in some instances. Secondary degenerations mean an ataxic parajdegic condition. Myelitis depending upon Pott’ s disease or upon pressure may reasonably be expected to make a fair recovery if the causal condition can be removed. Indeed, it is marvellous to what an extent the cord may be slowly compressed, and eventually regain functional activity with disappearance of all the para- plegic symptoms. Wlien the myelitis is due to active syphilis or to j)ressure by a syphilitic neoplasm, some considerable improvement under treatment is the rule, but an absolute recovery the extreme exception. This is especially true when the luetic lesion is confined to the cord itself. Treatment. — The patient should be put at once to bed, and kept on the side, or, better, when possible, upon the face. This can usually be accom- plished by building up a mound of pillows under the thorax and abdomen. In this position the bowels and bladder can be readily evacuated and the patient easily managed. A brisk cathartic should be administered and the bladder carefully watched, the catheter being avoided as long as possible, and used under the stricte.st rules of cleaidiness when finally it is necessary. The tendency to retention of urine, with cystitis, and its unfavorable significance, cannot be too much insisted upon. To the sj)ine counter-irritation with mild sina])isms is desirahle. Here the dystrophic tendency must be borne in mind, and blistering or severe irritation below the line of inflammation absolutely avoided. A mustard ))laster four inches wide and two feet long, made of one })art mustard to ten of flour and thoroughly mixed, can be apj)lied for hours and with benefit. The use of ergot and other drugs to control the circulation is of doubtful value, but may be tried if the stomach is tolerant. The mechan- ical causes of the disease must be met surgically. When ])resent, except in syphilitic cases and Pott’s disease, nothing but operation promises any reason- INFLAMMATION OF SPINAL MENINGES AND CORD. 787 able relief, and operation under strict aseptic methods adds practically nothing to the gravity of tlie situation. When bed-sores appear or the tendency to their formation is marked, a water- or air-bed kept at a proper temperature is useful, but, unfortunately, is rarely available. Great care to protect the skin from discharges and uncleanliness of all sorts, with frequent applications of alcohol and unirritating dusting powders, and repeated changes of position, will do very much to obviate these dangerous complications. After ten days or two weeks systematic passive movements, massage, and the use of faradic elec- tricity should be adopted to prevent the wasting and tendency to contracture. When, later, the contractures may be very pi’ominent, splints should be em- ployed. As sensation and slight voluntary motion return, a carefully guarded system of mild exercises should be instituted. The intelligent use of the fara- dic wire brush to the anmsthetic parts sometimes is of distinct benefit in hasten- ing sensory improvement, which in turn is usually followed by more or less volitional activity. Some syphilitic cases yield promptly to large doses of iodide of potassium and mercury, and nearly regain the condition of health. A certain residuum of impairment is always left, however, when the cord has been actually invaded. Other cases fail to respond to this line of treatment even when heroic doses are employed. One should not be satisfied in an adult to stop short of an ounce of iodide a day if smaller doses fail to make an impression, and by guai’ding the stomach with Vichy and the bowels with bismuth this can usually be accom- plished without much difficulty. In children the dose must be proportioned to their age. The bladder and bowel, except when the lumbar centres are destroyed, tend to regain some power and control, which can be assisted by rendering their contents unirritating and by encouraging regular habits regarding their evacu- ation, with the use of faradization to strengthen the sphincters. Everything conducing to the general healthy tone of the individual assists directly and indirectly the local disability. Chronic Myelitis. Chronic myelitis is usually the terminal stage of an acute softening, and but very rarely, if ever, is a primary condition. Its separate consideration is only warranted by the fact that it is often mistaken for primary spastic paraplegia, for ataxic paraplegia, rarely for locomotor ataxia, and that its treatment requires description. Its diagnosis depends on its long duration and the history of an acute, or at least tolerably rapid, onset, on the involvement of bladder and bowels, on the paraplegic distribution of sensory and motor deficiency and wasting, on the absence of pupillary symptoms, lightning pains and inco-ordi- nation, on the presence of rigidity, increased reflexes and contractures, and on the evidence of old bed-sores. The treatment consists practically in the use of everything that will elevate the general tone; in guarding against bed-sores, cystitis, contractures, and wasting ; in the use of massage, electricity, hot and cold spinal douches, and counter-irritation in the form of flying blisters and the thermo-cautery ; in operation for pressure conditions from tumor or bone ; in appropriate suspen- sion and fixation in Pott’s disease; in the persistent use of antisyphilitics in luetic cases, and in operation when these do not succeed or a gummy tumor is reasonably suspected. Exercises to develop the impaired muscular power, pas- sive movements, and volitional efforts against resistance are valuable. The sphincteric paresis can also be improved by the passive and active movements 788 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. recommended by Brandt in prolapsus uteri, -which serve to strengthen the pelvic floor, and consist for the most part in having the patient adduct and abduct the flexed thighs while lying on the back and raising the pelvis from the bed, the motions being resisted by the attendant. Continued and often- repeated voluntary attempts to contract the sphincters, as in restraining faeces, should be encouraged. Late in the disease, when it has become stationary, tenotomies and appropriate apparatus may enable an otherwise bed-ridden patient to get about. The tendency toward some improvement during the first two or three years should be kept in mind, and everything done at this time to assist the reparative efforts of nature. PATHOLOGICAL TECHNIQUE: A Practical Manual for Laboratory Wort in Path- ology, Bacteri- ology, andMor- bid Anatomy, with Chapters on Post-Mortem Technique and the Performance of Autopsies. By Frank B. Mallory, A.M., M.D., Assistant Professor of Pathology, Harvard Uni- versity Medical School; Assistant Pathologist to the Boston City Hospi- tal ; Pathologist to the Children's Hos- “ I have been looking forward to the publica- tion of this book, and I am glad to say that I find it to be a most useful laboratory and post-mortem guide, full of practical information, and well up to date.”— William H. Welch, Professor of Pathology y Johns Hopkins University^ Baltimore^ Md. pital; and James H. Wright, A.M., M.D., Director of the Laboratory of the Massachusetts General Hospital; Instructor in Pathology, Harvard Uni- versity Medical School. Octavo. 397 pages, with 105 illustrations. Cloth, ^2.50 net. MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE A Text-Book of DISEASES of W^OMEN. By Charles B, Penrose, M.D., Ph.D., Professor of Gyne- cology in the Uni- versity of Pennsyl- vania ; Surgeon to the Gynecean Hospital, Philadelphia. Octavo. 529 pages, handsomely illus- trated. Cloth, $3.50 net. ^ In this work, which has been written for both the student of gfynecology and the general prac- titioner, the author presents the best teaching “ I shall value very highly the copy of Penrose’s ‘Diseases of Women ’ received. I have already recommended it to my class as THE BEST book.”— Howard A. Kelly, Professor of Gyne- cology and Obstetrics y Johns Hopkhis University, Baltimore, Md. PENROSE'S DISEASES OF WOMEN of modern gynecology untrammelled by anti- quated theories or methods of treatment. In most instances but one plan of treatment is “ The copy of ‘ A Text-Book of Diseases of Women,’ by Penrose, received to-day. I have looked over it and admire it very much. I have no doubt it will have a large sale, as it justly merits.” — E. E. Montgomery, Professorof Clin~ ical Gynecology y Jefferson Medical College, Phila- delphia. recommended, to avoid confusing the student or the physician who consults the book for prac- tical guidance. v-** ^ ’J* ACUTE ANTERIOR POLIOMYELITIS. By ARCHIBALD CHURCH, M. D,, Chicago. Acute Anterior Poliomyelitis, also known as myelitis of the anterior horns, atrophic spinal paralysis, infantile paralysis, or the essential paralysis of children, is a febrile disease the activity of which falls upon the anterior horns of the gray matter of the spinal cord ; it is marked by rapidly developed and extensive paralysis, a portion of which remains permanently, and is usually followed by atrophy of muscle and often by non-development of bone, and by deformity. Etiology. — It is a disease almost peculiar to childhood, and, though cases occurring in adult life have been recorded, it is probable that many of these late instances have been cases of peripheral neuritis, the diagnosis of which has only of late years been generally made. The great majority of cases occur before the tenth year of age, and three-fifths are encountered before the fourth year, being equally divided for the first three years of life. As it is comparatively rare during the first six months, the latter half of the first year of life is therefore the most susceptible period. The coincidence of the first dentition at this time has given an altogether undue importance to the role played by the eruption of teeth as a probable cause. At one time ex- posure to cold was considered an active etiological factor, but Sinkler of Phila- delphia found that over four-fifths of all cases occurred during the hot months from May to September inclusive, with a heightened frequency during the hottest months, July and August. Heat may therefore be considered as a predisposing or favorable condition for the evolution of the malady. It is to be remembered, however, that slight colds among children are as frequent in warm weather, from draughts when lightly clad, as in winter. In nearly every case the history of a fall or blow of some sort is brought forward by the parents, too frequently resulting in casting unmerited blame upon the nurse or others in charge of the child. It must, of course, be admitted that a concussing force applied to the spine might lower resistance to the disease, but there is no good reason for attaching great weight to slight traumatism. In a numerous list of instances the disease is said to have followed acute diseases, such as the exanthe- mata, but in many such cases the initial fever of the poliomyelitis was probably mistaken for some other complaint, and a careful study of these reports reveals such a lack of detail that they must, as a rule, be accepted with caution. In others the original ailment is stated to have been obscure or atypical, and as a matter of fact the diagnosis of anterior poliomyelitis is very difficult during the initial fever, and, until paralysis is apparent, differs but little from the febric- ula of indigestion or other slight ailments. Pathological Anatomy. — It is only since 1865 that the lesion in this disease has been known. In that year Provost thoroughly described it, and his findings have been invariably confii-med by workers in this field. Owing 789 790 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. to the fact that only rarely does death occur in the very early stages of the disease, or is then attributed to other causes, the initial appearances and con- ditions are practically unknown, but can from later observations be fairly well indicated. As a rule, the anatomical changes are limited to the anterior horns of gray matter, only involving the neighboi-ing white tracts of the anterior and lateral columns by the extension of the inflammatory or haemorrhagic processes which take place in the cornua, and which result in a softening and disintegra- tion of their elements. The large motor and trophic cells either completely disappear or only a few shrunken representatives are left ; in milder cases slight alterations in the cells alone are found. Later, from the shrinkage of the neuroglial tissue and from the deposition of other fibrous elements, a de- pression is found in the implicated part of the cord, and granular disintegration of the involved nerve-elements is present. When the pyramidal tract is in- volved, descending degeneration may take place, though this is uncommon, and when present is usually slight in transverse extent. The muscles depending for innervation upon the affected cornual cells i-apidly waste, and the sarcode ele- ments in extensive cases entirely disappear, nothing but the fibrous tissue being left. In less-pronounced cases individual fibres or groups of muscle-bundles are destroyed, or sometimes merely a diminution in size is found ; and rarely isolated muscular fibres are encountered which show a true hypertrophy, prob- ably of a compensatory character. Where the bones are affected, they are smaller, smoother, less well marked by muscle insertions, more compact, showing less cancellated structure, and are consequently more fragile. The peripheral nerves arising from the affected anterior horns show de- generative changes of a corresponding degree. Sometimes in extensive cases nothing but fibrous cords are left, but usually all the fibrils are not destroyed, the cross-section of the nerve-trunk showing many normal elements. This, of course, is to be expected, as the sensory fibres which enter the cord by the posterior root are not implicated in the central lesion ; but the same is true of sections of the anterior roots close to the cord, and the sympathetic fibres in the anterior roots also escape. Examinations of the brain are usually negative. In some extreme cases of e.xtensive peripheral distribution of long standing the corresponding cortical motor area has been found smaller or undeveloped. A number of cases are on record in which an acute I>olyneuritis has ap- parently coincided with the spinal attack, but these cases require more study, and the presumption is that the tenderness in the nerve-trunks in such cases is due to the degenerative process in the motor-fibi’es and the attending irri- tation of the adjoining sensory bundles which furnish the nervi nervorum. Pathology. — The acute onset, the short duration of the fever, its com- paratively uniform range, and the immediate paralysis point to a systemic infection, or, to adopt the expression of Gowers, “a blood-state,” which finds its local expression and its anatomical manifestation in the anterior sj)inal gray matter. The elective action of certain drugs upon the spinal centres leads naturally enough to the supposition that a ptomaine or leucomaine might have a similar selective tendency, as, for instance, that of diphtheria is known to have for the peripheral nerves, or of hydroj)hobia for the central apjiaratus. This idea receives some support from instances in which more than one case occurred at the same time in a given family ; and several practical endemics of the disease are on record. The whole (juestion is yet undecided, but the in- fection theory would seem to be the best working hypothesis. Symptoms. — Usually without apparent provocation the child is found to be feverish and ill. A temperature of 100° to 102° F. has been frequently noted, and this febrile invasion-stage lasts from a few hours to a few days, when ACUTE ANTERIOR POLIOMYELITIS. 791 paralysis and flaccidity of one or more limbs are detected. It is not rare, how- ever, for the child to go to bed apparently well and to awake paralyzed in the morning. The febrile movement may be attended by vomiting and diarrhcea, by convulsions of a generalized character, or by delirium and difluse cerebral manifes- tations. As soon as the paralysis is noted the case is usually recognized. Most writers state that rarely there is a complaint of pain in the afflicted members, but the rule is that sensation in all its phases is entirely normal. It is probable, however, that early dyssesthesia, owing to the age of the patient and a lack of caralyzed and the weakness has involved the trunk and uj)pcr limbs. The breathing becomes 798 LA N DRY'S PA RA L YSIS. 799 superficial from involvement of the diaphragm, and difficulty of swallowing soon appears. In severe cases every voluntary muscle below the face is com- pletely paralyzed and relaxed. Cerebral and mental symptoms are absent until the dyspnoea or cardiac failure is pronounced and induces them. The sphincters are, as a rule, not relaxed; there is no tendency to bed-sores or dys- trophy ; the tendon and superficial reflexes are usually present ; the electrical responses are normal ; and sensation, together with the special senses, is not perverted. If a fatal issue do not occur, the symptoms of paralysis slowly recede in the reverse order of their appearance, and when they have distinctly subsided from the upper levels recovery may be anticipated. In some cases the onset is reversed, the upper extremities first showing weakness ; and, indeed, the ordinary type may be infinitely modified, as can be readily understood from the varying anatomical distribution of the organic lesions in well-authenticated observations. In one case falling under the writer’s attention, where the clinical history was typical, complete wasting of isolated muscle-groups in all four extremities occurred, and was persisting four years later, without any appearance of ultimate improvement. Parmsthesia and dysaesthesia are not rare. Loss of reflexes has been noted. The progress of the paralysis may stop at any point, and then recede. A temperature of 101° to 103° F. has been rarely observed, but as a rule it does not rise above the normal. Course. — The course from inception to fatal termination may be very brief, less than two days, and fatal cases usually end within ten days. Prolonged cases may only I'each their acme in a month. After a stationary period of vary- ing length in the hopeful cases, improvement takes place usually in a I’etreat- ing order, but convalescence is slow and may require months. On the other hand, it may be rapid, or, as in the case mentioned above, permanent injury may result. Diagnosis. — The diagnosis in some cases must necessarily be extremely difficult, but in the typical form is readily made, providing the existence of this rare disease is kept in mind. It rests upon the method of invasion, the pure motor paralysis, the negative conditions as to reflexes, sensation, and electrical reactions, and the history of some possible toxaemic state. Some cases are com- plicated by hysteria, which is capable of greatly obscuring the diagnosis. When slight electrical changes and paraesthesia are present, it is impossible to exclude neuritis, and the integral character of the peripheral disease in some instances has already been pointed out. In general myelitis we have all spinal cord- functions involved. In meningitis the pain and rigidity are distinctive. Prognosis should always be grave, since even in the irregular and pro- longed cases one cannot foretell at what moment bvdbar symptoms may appear, and the main danger to life depends on their presence. Rapidly-ascending symptoms imply a speedy termination, but there is no invariable rule. Only when the tide has turned and symptoms are receding can one entertain a rea- sonably hopeful prognosis. The presence of neuritic conditions or of electrical changes implies a prolonged convalescence and some doubt as to ultimate recov- ery. Where cerebral symptoms appear, they are of bad import, signifying either profound toxic conditions or the near approach of death from cardiac and respiratory failure. Treatment will be directed against any general toxic condition present or reasonably suspected. The salicylates, tincture of the chloride of iron in full doses, bichloride of mercury to the point of toleration, thorough cleansing and disinfection of the alimentary tract, supportive diet, conservation of nervous energy and strength, are valuable. To the spine a narrow sinapism the whole 800 AMERKJAN TEXT-BOOK OF DISEASEB OF CHILDREN, length of the back, frequently repeated, is of service ; even the thermo-cautery is advised by some. Full and frequent doses of ergot or ergotine have strong advocates. The paralyzed limbs should be gently massaged to improve circu- lation and give comfort. When swallowing becomes difficult or impossible, feed- ing by the stomach, nasal, or rectal tube must be adopted, and the preference is for the nasal tube, providing care be exercised to avoid passing it into the larynx. During convalescence massage, electricity, local douches, tonics, generous diet, and general measures are the main reliance. TUMORS OF THE SPINAL CORD. Bv JAMES HENDRIE LLOYD, A. M., M. D., Philadelphia. Under the head of Tumors of the Spinal Cord will be considered tumors not only of the cord itself, but also of its enveloping membranes. The latter are the most common. Tumors originating in the bones of the spine, if they make pressure upon the cord, are very similar clinically to tumors of the mem- branes, but they are exceedingly rare.^ Tumors of the spinal cord and its membranes are comparatively rare at all ages, but they are not unknown among children. Thus in a table of 50 cases of cord-tumors analyzed by Dr. Mills and the author, 14 per cent, were in patients under twenty years of age. Four were in the first decade of life, and three in the second. Etiolog-y. — The causation of tumors of the spinal cord is usually very obscure, just as it is for tumors of other parts of the body. The nature of these growths, as will be seen, varies, and the causes that produce them vary as well. Syph- ilitic and tuberculous tumors are of course caused by their respective infections in the blood and tissues. Carcinomata and sarcomata have here, as elsewhere, a totally unknown essential cause. Gliomata and myxomata are equally obscure in origin. The gliomata originate always in the neuroglia, and are probably the product of a proliferation of germinal tissue which has remained in an embryonal state. They are most apt to occur in the central gray matter and in the posterior gray commissure in the neighborhood of the central canal. In this region they break down and form cavities to which the term “syringomye- lia” is applied. As this process is now recognized as a distinct disease, it has been described apart. Other cysts, simulating tumors, may be caused by small haemorrhages, and possibly by emboli. Parasitic growths, such as echino- coccus, have been found in the spinal cord. As a direct exciting cause trauma has been regarded by many as not infre- quent. Where there is predisposition to a cancerous growth or a syphilitic deposit it is possible that trauma may so act. Exposure to cold, sexual excess, and overwork have probably nothing to do with the origin of tumors of the cord. These growths are apparently about equally divided between the sexes. In the table already referred to it is seen that 22 cases occurred in males, 21 in females, and in the remaining 7 the sex is not recorded. Symptoms. — The symptoms of tumors of the spinal cord may be con- veniently classified according as they are sensory, motor, trophic, visceral, and intracranial. They may then be grouped according to the level of the cord at * Mr. Wright of Manche.ster removed a fibro-sarcoma of the neck which had invaded the spinal canal by way of one of the intervertebral foramina, causing pressure symptoms. (Reported by Thorburn, Surgery of Spinal Cord, p. 168.) 61 801 «02 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. which the tumor occurs. This twofold plan will be adopted here for the sake of both clearness and brevity. Finally, a comparative study of symptoms will be made under a separate head for the purposes of diagnosis. It is doubtful if a distinction can always be made in diagnosis between the meningeal and medullary growths. In some cases, however, this may be possible. The tumors springing from the membranes are more likely to cause pain as an initial and persistent symptom than are tumors within the substance of the cord. They cause pressure symptoms later. It is probable, too, that the early symptoms caused by them are more distinctly local, because they press upon and irritate or destroy a comparatively small area of the cord at first. The sensory symptoms of all tumors of the cord and its membranes are sooner or later conspicuous. Pain, as has just been said, is common. This pain may be limited in the early stages to one or few nerve-trunks, in one of the limbs or in the abdomen, for instance, simulating neuralgia, or it may radiate from the spine in association with stiffness of the muscles of the neck or back. It is often an urgent and distressing symptom. Hyperaesthesia, which is closely allied to pain, may appear in the course of the disease. In cases in which the lesion is unilateral this hyperaesthesia may exist in the paralyzed side: in other cases its distribution is variable and its duration uncertain. Hyperaesthesia, and especially pain, may exist along the spinal vertebrae, and localized pain may sometimes be elicited by tapping vigorously on the spine at and near the seat of the tumor. Parmsthesia, or perverted sensibility — as, for instance, burning and pricking sensations and formication — is closely allied to hyperaesthesia, and may appear like it, especially in the early and middle stages. Anaesthesia is a very common symptom of these tumors, yet the time of its appearance, as w'ell as its distribution, varies greatly according to the site and progress of the neoplasm. As with pain, its early distribution may be quite limited; for instance, it may be confined to the area of distribution of one or few nerve-trunks or to one limb. This limitation of the early symp- toms, whether motor or sensory, is a characteristic of these growths. The anaesthesia may be associated with pain in the affected area — the ana-sthesia dolorosa. In the later stages of the disease the anaesthesia is more widely extended, and may be profound. Thus it is often complete in the trunk and limbs below the seat of the tumor. Thermo-ana\sthesia may be observed in some forms of cord-tumors: perhaps it would have been oftener reported if it had been oftener looked for. In the central gliomata, especially when they form cavities, as in syringomyelia, anaesthesia to heat and cold is a common symp- tom ; it is then associated with analgesia, while tactile sensation is preserved, thus forming a “dissociation” symptom which is (juite characteristic. This thermo-anaesthesia is probably not a common symptom of meningeal growths; in fact, it is doubtful if it ever appears as a result of them, esj)ecially in this dissociation. Analgesia, or loss of pain-sense, may be seen in some cases of tumor of the cord. It may be associated, as above noted, with loss of tem- perature-sense, or it may exist alone. It is always an accompaniment of pro- found anmsthesia. A not uncommon symptom is the girdle-sense. This consists of a feeling of constriction, as of a cord tied around the part. Its location varies with the seat of the tumor. Thus it may be felt around the neck, chest, waist, or abdo- men, and a rare case is reported in which it was felt even in the legs. The motor, like the sensory, symptoms of tumors of the spinal cord vary in kind and extent according to the seat and stage of growth of the lesion. TUMORS OF THE SPINAL CORD. 803 Like them, too, they are apt to be very limited when they first appear, and to gradually extend. This mode of appearance and extension is very character- istic of a neoplasm at some point in the spinal canal. The earliest motor symptom may be a paresis or a cramp of the muscle, or these may alternate or exist at the same time. Paresis may be limited at first to a muscle-group, whence it may gradually extend to involve a limb or the limbs of one side or both lower limbs. Before, however, it has spread thus far, it will most prob- ably have deepened into a paralysis. When this paresis has well advanced, contractures in the affected muscles appear. These contractures distort the limbs, and often become so firmly set that they can be overcome only with great difficulty, and perhaps only with great pain to the patient. The tone of the muscle and the state of its reflex activity to a tap on its tendon vary accord- ing to whether its centre in the cord is involved in, or is below the seat of, the tumor. In the foimier case the muscle is flaccid and its reflex lost, while in the latter case, the centre in the cord being cut off’ from the inhibitory centre in the brain-cortex, the myotonus and the tendon reflex are much exaggerated. Muscular atrophy may be caused by tumors of the spinal cord, according to the well-known pathological law that a muscle wastes when its trophic centre in the cord is destroyed. Hence in cases of these tumors the atrophy usually occurs in limited muscle-groups, or in one limb, or possibly in both arms if the cervical enlargement is affected, or in both legs if the tumor is in the lum- bar enlargement or cauda equina. Hence a not uncommon type of motor dis- order is seen in cases of tumor of the cervical region ; in which cases, the trophic centres in the anterior horns being destroyed, a muscular atrophy in the arms results, while, the descending motor paths in the lateral columns being injured, a spastic paresis, without atrophy, but with increased knee-jerks and with ankle-clonus, is seen in the legs. When the process in the cord is rapidly destructive, the atrophied muscles present very soon, as a rule, changes in their electrical reactions. During the very early stage, or stage of irritation, the electro tonus may be increased to both currents, but sooner or later this is diminished, while modal changes occur ; and in very rapid or advanced cases, in which the anterior horn has been quickly destroyed, the true reactions of degeneration may occur. In slowly jirogressive cases, in which the horn is destroyed very gradually, the qualitative changes may not appear in a typical manner. Spasms, twitching, and contractures of the affected muscles are frequently seen. Cramps in the back and limbs are sometimes complained of. Con- tractures, as already said, are usually secondary to advancing paresis. Fib- rillary contractions, so common in progressive muscular atrophy, are rarely seen : in the table of fifty cases referred to they are mentioned only once. Epileptic convulsions do not occur. In the only case to which the author has a reference the fit must have had some origin not recognized. Tetanoid cramps and spasms, opisthotonos, torticollis, and scoliosis are all symptoms which may arise in the course of tumors of the spinal cord. Ataxia is not a common symptom of these tumors. This may be because tumors occupying the exact region of the lesion of locomotor ataxia — ^. e. the posterior columns, horns, and root-zones — must be exceedingly rare. Various trophic lesions may occur. These lesions are identical with those caused by other affections of the spinal cord producing transverse or exten- sive destruction. The most important are bed-sores. These bed-sores may be attended in time with septic infection of the blood, and thus cut short the patient’s life. Other trophic lesions are oedema, glossy skin, maculae, and 804 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. bronzing of the skin, and perhaps in some cases more destructive lesions. Vaso-motor involvement has been noted by some observers. Flushing of the skin and excessive sweating are among these phenomena. Alterations in tem- perature in the paralyzed parts occur. The most common permanent alteration, especially when paraplegia is complete, is a slightly subnormal temperature. Early in the case the more paralyzed parts may present an increase in tem- perature. The visceral symptoms of tumors of the spinal cord depend to some extent upon the location of the growth. The most common is paralysis of the blad- der. It is the most common because the centre for the bladder is low in the cord, and consequently is cut oft’ from volitional control by tumors at almost all levels. When the tumor is in the lumbar enlargement the centre for the bladder may be destroyed, causing complete paralysis, both direct and reflex, of the viscus. When the tumor is above this level, however, the reflex irrita- bility of the bladder may be retained for a while. In the former case retention is much the more common ; in the latter, incontinence. Later, in all cases, retention, with overflow, is apt to be the rule. Paralysis of the sphincter ani is caused in exactly the same way as that of the bladder. In lesions in the cervical region embarrassed breatliing and rapidity of the heart’s action may occur. Choking sensations are sometimes experienced. Vomiting is not a common sym])tom. Intracranial symptoms are, from the very nature and seat of the growth, not common in tumo*s of the spinal cord, but they are not unobserved. Vertigo has been recorded in one case in which the tumor was high in the cervical cord. Changes in the optic disk have also been seen in similar cases. Head- ache is noted in only three instances in the table of fifty cases already referred to. Alteration in the pupil might be caused by paralysis or irritation of the sympathetic centre in the cervical cord. Mental symj)toms are not caused by tumors in the spinal canal excej)t as secondary phenomena due to pain, weak- ness, and abandonment of hope. Among other secondary symptoms are cystitis and pyelo-nephritis. Priapism has been reported in a few cases. Tumors of the spinal cord })resent several clinical types according to the area and the level occupied by the new growth. In some cases in the early stages one lateral half of the cord is first and most involved. Such a case j)resents the type first described by Brown-S^cpiard.* There are paralysis and loss of muscular sense, with hypermsthesia, on tlie side of the lesion, and anaesthesia, and possibly analgesia, on the op{)osite side. This distribution deperids on the fact that some of the sensory fibres decussate at or about the level of their entrance into the cord. A notable absence of sensory symptoms occurred in a ])atient of the author’s. A carious spot in one of the cervical vertebi'ae caused hemiplegia without any sensory involvement whatever. The case exactly resembled hemiplegia of cerebral origin. An oj)cration was per- formed by Dr. Deaver. Other types depend upon the level of the cord at which the tumor occurs. The favorite sites for these tumors are the cervical and lower dorsal regions. Of the bO cases in Mills and Lloyd’s table, ‘22, or almost one-half, were included entirely or in part in the cervical cord ; 4 were in the n]>per dorsal region ; P2 ’ Tlie author gives a place in the text to a description of this type, altliongh lie knows that ri'cent experiment tlirows mncli donlit njion tlie accuracy of the claim to any such clinical lind- ings. Tims (iotch (“ Recent Research on the Spinal ( lord,” Liivr^xml d/ed.-f VoV. ,/m/r/i , .Ian., 1893) says; “Recent physiological research shows that, in opposition to the views formerly advocated hy many neurologists; the path for sensory conduction is almost entirely on the same side ;is that of the entering .sensory nerves.” TUMORS OF THE SPINAL CORD. 805 in the lower dorsal ; and of the remainder, 4 were in the lumbo-sacral region, 3 in the filuiu terminale and cauda equina, and the rest were of doubtful location or nature. The type presented by a cervical tumor is often quite characteristic. Pain is located in the neck, arms, and upper part of the back. Torticollis or retrac- tion of the head may occur. Anmsthesia is variously distributed according to the region most involved. The anterior cornua, entire or in part, on one or both sides, may be destroyed, and conse(i[uent atrophy of muscles in the arm or arms, Avith altered electrotonus, may be observed. Paraplegia, begin- ning perhaps as crural monoplegia, is sure sooner or later to appear ; and this is of the spastic type, with increased knee-jerks and ankle-clonus, but without muscular atrophy in the leg muscles. Complete anmsthesia in the trunk and legs supervenes ; paralysis of the bladder and bed-sores complete the picture. Tumors in the dorsal region present the type of a simple transverse lesion slowly advancing to paraplegia and anaesthesia, with bed-sores, incontinence, and cystitis, but without involvement of the neck and arms. The signs of irritation, such as neuralgic pains, girdle-sense, and zone of hyperaesthesia at the level of the growth, are sometimes very characteristic. Dyspnoea, due to partial paralysis of respiration, may be caused by tumors in the cervical and upper dorsal region. Tumors in the lumbar region and in the cauda equina give a still dif- ferent type, depending upon the fact that the trophic cells in the anterior horns, the anterior nerve-roots, and the nerve-trunks are implicated. Hence, in addition to paraplegic symptoms and neuralgic pains about the lower part of the trunk and in the legs, there may be muscular atrophy, reactions of degen- eration, and abolished tendon-reflexes in the legs, and possibly an irregular dis- tribution of anaesthesia in areas supplied by nerve-trunks in the cauda equina most involved. Moreover, the reflex centre for the bladder in the lumbar cord being destroyed, obstinate retention, with overflow, may occur. In tumors limited entirely to the cauda equina the symptoms are simply those of neu- ritis — i. e. neuralgic pain, often intense, anaesthesia, muscular atrophy with reactions of degeneration, abolished reflexes, and paralysis. The distribution of these symptoms will depend entirely upon the distribution of the nerves implicated. This distribution may be very irregular, and by this irregularity constitute a distinct type. Paralysis of the bladder may occur in these cases. Morbid Anatomy. — According to the table already referred to, the most common forms of tumor of the spinal cord are the sarcomata and the structures allied to them. Thus, of 50 cases, 12 are described as sarcomata and gliomata ; 9 are distributed in the list among myxomata, psammomata, and fibromata, of which number it is fair to assume that some at least were structurally similar to the sarcomatous type ; while of the 2 described vaguely as “ cancer,” and of the 6 unclassified, a proportion would probably have been found to be sarcoma or glioma on more exact observation. Carcinoma occurred but once, parasitic growths three times. Syphilitic growths were found in 5 cases, massive tubercle in 4. Dr. Herter, in a contribution to the pathology of solitary tubercle of the spinal cord, has analyzed 26 cases. His study shows that the affection is a disease of adolescent and early adult life, 20 of these cases occurring before the age of thirty-five. In all but one the massive tubercle was solitary. In most of the cases tubercular disease existed in other parts of the body and antedated the cord lesion. Hayem, however, quoted by Herter, reported a case which he regarded as primary. 806 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Secondary lesions are usually found in cases of tumors of the spinal cord. Meningitis and oedema of the membranes, also inflammatory exudate, are occa- sionally noted. The cord is usually compressed, its substance softened both above and below the tumor. Secondary degeneration occurs in the system- fibres of the cord. Haemorrhages have been observed. Cysts may be formed, or the central canal may be dilated (hydromyelia). Gummata and carcinomata have caused erosion of the vertebrae. Diagnosis. — Tumors of the spinal cord may be confused with haemor- rhage, pachymeningitis, transverse myelitis, spinal caries, fractures of the vertebrae, neuritis, and hysteria. Haemorrhage into the spinal canal or spinal cord, unless the result of violence, is extremely rare. When it happens from diseased blood-vessels it is very sudden, and the symptoms attain almost at once their maximum of inten- sity. Compression and destruction of tissue may be sufficient to cause para- plegia in a few hours. It is possible that some of the early symptoms, due to compression, might abate in time, and that the permanent results would be focal with secondary degenerations. The usual result, however, is death. Pachymeningitis, especially in the cervical region, is very difficult to distin- guish from a tumor. It causes, perhaps, on an average, more acute pain and stifi’ness in the neck than does tumor, and it is more widely distributed in vertical extent. Transverse myelitis also closely simulates tumor. In some of these cases the lesion is very limited in vertical extent. The onset of myelitis, however, is not usually so gradual as that of tumor, and this is probably the best dis- tinguishing point. Another distinction is the degree of pain. In myelitis pain is sometimes not very severe. Cases are seen in which the girdle-sense and a zone of hy{)eriiesthesia are the nearest approach to it. The writer has seen also white softening of the cord, very limited and entirely transverse, cause symptoms very similar to transverse myelitis, the absence of pain being very conspicuous. Spinal caries in its early stages may resemble a tumor, but the cases must be very rare in which a deformity of bone cannot be detected comparatively soon. As a rule, pressure-symptoms do not appear until long after the defor- mity is a])parent. Fractures of the spinal vertebrm are indicated by the history, even though deformity is not very apparent, as is sometimes the case. It is not probable that coJifusion could often arise between this, or any other form of trauma in which the history were known, and tumor. Neuritis might simulate a neoplasm in some cases ; in fact, neuritis is one of the symptoms of tumor of the spinal cord. When it is caused, however, by a tumor within the spinal canal, it is not likely to be the only symptom ; thus evidence of compression is soon made manifest. Multiple neuritis is not aj)t to be confined to the arms : in a case in which it were, compression symj)tonis iti the legs would be wanting. If confined to the legs, it would not cause para- plegia with involvement of the bladder, etc. But such a distribution of mul- tiple neuritis is rare. It is usually apparent in both arms atid legs, in which case confusion with tumor is hardly possible. It is customary to say that hysteria simulates all diseases, but this state- ment is based iipon superficial observation. Bloccj is nearer the truth when he says that hysteria does not simulate any disease perfectly — that there is always something wanting. To detect this missing element is often the rather easy forte of the expert. No rule can be given in brief space. It may be said, however, that the symptoms most dependent upon organic change are most apt TUMORS OF THE SPINAL CORD. 807 to be wanting in cases simulating tumor or other organic disease of the cord ; excessive knee-jerks, very free ankle-clonus, muscular atrophy, and the reac- tions of degeneration are not usually seen. In fact, the latter two symptoms are never seen. But more important even than to detect the negative evidence is to observe the positive symptoms of hysteria itself. These are the so-called stigmata, which in probably all cases simulating grave organic disease can be detected. Among these stigmata are hemiansesthesia, including the special senses, concentric narrowing of the visual fields with alteration of the color fields, segmental anaesthesia in paralyzed limbs, tremor, and convulsive phenom- ena. Transfer and suspension of symptoms by suggestion (hypnotism) may be obtained. The mental stigmata, emotional, lethargic, etc., are often charac- teristic. Prognosis. — The prognosis of tumoi's of the spinal cord is not quite so bad as formerly, because, in some cases at least, surgery may come to their relief. The success of surgery will depend primarily, of course, upon the successful localization of the growth and upon its situation at an accessible part of the spinal canal. Even then some permanent damage may have been done by the neoplasm before its removal. The prognosis, if dependent upon treatment by drugs, is uniformly bad. No exception to this rule can be made in favor of a syphilitic tumor, because syphilitic lesions large enough to be called tumors are not, in the autlior’s experience, removable by such means. The duration of these cases varies. Some cases are rapidly fatal, last- ing only a few months ; others are reported as lasting for more than three years. Treatment. — As has just been said, treatment by drugs offers no hope in any cmse of tumor of the spinal cord. While we believe that the syphilomata are no exception to this rule, we- should, nevertheless, give the patient very active antisyphilitic treatment if he had a clear history of syphilis. We should do this in the hope that the lesion were not truly a tumor, but rather a more dif- fused process, such as pachymeningitis, and that it had not yet irreparably damaged essential portions of the cord. When the syphilitic neoplasm has become sufficiently massive to be worthy of the name of tumor, it has usually produced, and will continue to produce, such destruction of the nerve-elements that repair on the one hand, and arrest on the other, cannot be obtained by drugs. The writer says this from personal experience, not exactly with syphi- litic tumors of the cord, but with their congeners, meningeal gummata within the skull. In several cases, in which progressive erosion of the bone occurred, no perceptible influence was exerted by tlie so-called specifics. Surgery offers the only rational treatment of these cases, but this remedy must be used with rare caution after the most painstaking diagnosis, and with the clear understanding that success may not be obtained. The following points, according toThorburn, must be considered in all spinal lesions: First, the cura- bility without operation ; second, the dangers of the operation ; third, disas- trous results, such as weakening of the vertebral column ; fourth, the selection of appropriate cases. In the case of a spinal tumor it may be said, in reference to these four points, that, first, the case is not curable without operation ; second, that the dangers of the operation are not so great as the risk of going without it ; third, that the spine would not be weakened seriously, except in the very rare event of extensive erosion ; and, finally, that the selection of appropriate cases depends entirely upon the successful diagnosis and localiza- tion of the tumor at as early a stage of its growth as possible. Hence, the operation is not only advisable, but, it would seem, in properly selected cases, imperative. Tumors of the spinal cord have been successfully localized and 808 A Af ERIC AN TEXT-BOOK OF DISEASES OF CHILDREN. removed. Such an operation was performed by Mr. Horsley on a man with myxofibroma in the upper dorsal cord. The symptoms were complete para- plegia, motor and sensory, of slow development, accompanied with attacks of agonizing pain. Although degeneration of the lateral pyramidal tracts had existed, as shown by intense spastic paraplegia, every indication of this is reported by Dr. Gowers to have since passed away. In cases in which, for any reason, surgery is declined or ignored, and exclusive reliance is placed upon other treatment, the most important, and, in fact, only useful, means to give comfort to the patient are the water-bed and opium. Antiseptic treatment of bed-sores is important. SYRINGOMYELIA. By JAMES HENDRIE LLOYD, A. M., M. D., Philadelphia. Syringomyelia is a disease of the spinal cord, characterized by the growth of a gliomatous tissue, which breaks down and forms a cavity, usually in the mid-region of the gray matter. Syringomyelia has been recognized within only a comparatively recent period. The word was coined by Ollivier m 1837, and applied by him to all canals or cavities in the cord. Every such canal or cavity was considered pathological until Stilling demonstrated the normal central canal. Virchow and Leyden used the word “ hydromyelia ” to designate cavities in the cord, which they claimed were always dilatations of the normal central canal. Simon, in 1875, pointed out the pathological process which interests us here. He demonstrated that cavities, quite apart from the central canal, may occur in the cord in the midst of a newly-formed gliomatous tissue by the breaking down of which they are caused. He proposed to reserve the term “ syringo- myelia” for this special form of cavity; and this specialization is now accepted by most writers. Syringomyelia therefore has come to be regarded as the pro- duct of a gliomatosis. The word “hydromyelia,” on the other hand, may be restricted to the dilatation of the central canal, which happens occasionally as a secondary phenomenon in various cord lesions, and which is different, both anatomically and clinically, from true syringomyelia. Of late years a quite voluminous literature of syringomyelia has grown up. Among monographs we may note especially that of Bruhl, which brings the subject quite up to 1890. Since that time some reports of cases, proving the accuracy of the symptomatology of the disease, as verified by the post-mor- tem findings, have appeared.* Doubt lingered in the minds of many for a long time whether syringomyelia could justly be regarded as a disease-entity, but these accumulating observations in very recent years must effectually silence all criticism. Etiology. — Syringomyelia is much more common in males than in females. Bruhl found the proportion as 28 to 8. Roth is reported as saying that the disease is three times more common in males than in females. The disease appears usually at a comparatively early age. Charcot, quoted by Bruhl, says that the first manifestations appear between the fifteenth and twenty-fifth years. In some cases the time of the d^but of the disease is uncer- tain. The author’s case was in a male, and appeared first about the twenty- seventh year. From the above facts it is seen that syringomyelia, while not exactly a dis- ease of childhood, is usually a disease of adolescence or early adult life. It ^ See report of a case by the author, with photographs of sections of the spinal cord, Univ. Med. Mag., Philada., March, 1893. 809 810 AMERICAN TEXT-ROOK OF DISEASES OF CHILDREN. probably has close affiliations with at least one well-recognized disease of child- hood — viz. hereditary ataxia or Friedreich’s disease. Traumatism and exposure to cold seem to have been exciting causes in some cases. The infectious diseases also have appeared to be the starting-point. Syphilis and alcohol do not seem to be causes of this disease. According to Bruhl, syringomyelia is a disease probably of evolution, a congenital affection having its origin in an anomaly of development of the epen- dyma. We shall refer to this subject again. Pathology. — Cavities in the cord, as already said, are the results probably of several pathological processes. Thus they may be formed by the dilatation of the central canal, this dilatation being an accompaniment of some other morbid state, such as inflammation, haemorrhage, or neo{)lasm. They result sometimes perhaps from small haemorrhages into the substance of the cord. Some recent authors, notably Hoffmann, still classify all these varieties, and make, as it were, one general group of them. We believe this is wrong. Most of such cavities are merely accidents or terminal products left by various patho- logical processes. The true syringomyelia is, in our opinion, a process sui generis, and is in no way identical with the other members of the rare and heterogene- ous groups alluded to. We accept the theory, adopted tK)w by Schultze, Bern- hardt, Simon, Westphal, Charcot, Dejerine, and others, that syringomyelia is the product of a true gliomatosis, which occurs usually in that region of the cord that is developmentally the weakest — i. e. the region of the posterior gray com- missure and posterior median septum. This proliferation of neurogliar tissue leads to the formation of a cavity by tbe gradual softening and absorption of the new grow’th. Its usual site in the gray commissure and posterior septum sug- gests that it may result from an anomaly in the development of that region of the cord last formed by the folding over of the medullary folds in the embryo. According to this theory, the central canal is not necessarily the starting-point of the process, although it may be involved ultimately in it. In the author’s case this profuse overgrowth of neurogliar tissue was a conspicuous feature, while the central canal, as marked by a mass of epithelial cells, was entirely distinct from the cavity. In another case, however, published recently by Dr. James Taylor, the cavity w'as lined in some places with epithelial cells, proving conclusively that the central canal had become included in the syringomyelia. Morbid Anatomy. — The cavity is usuafly largest in the cervical region, whence it extends downward to various levels in different cases. In some cases it trends to one side. It may extend as far as, or even into, the lumbar enlargement, but this is not the rule. In many cases the lumbar enlargement, with exceptions yet to be noted, is normal. At its seat of greatest extent the cord may be literally a hollow tube. In the fresh state the cord is flat or ribbon-like, and gives to the finger a sense of fluctuation.^ There is usually not much, if any, evidence of inflammation. The integral parts of the cord are much distorted and even injured by the syringomyelia. The cavity (sec Fig. 1) occupies the central gray matter or commissure, the anterior, or white (;om- missure, usually escaping. The normal central canal may exist apart, in which case it is apt to be disfigured, and perhaps only recognizable by its c))ithelial cells, or it may be included in the cavity, in which case the latter is lined at places with columnar epithelial cells. The cavity is often widely extended laterally, and may run down the posterior horns or even the j)osterior median septum. It pushes before it the gray matter, which is seen in the author’s case to be stretebed around the ends of it. The anterior horns are distorted, and ' In two ca.ses observed post-mortem by tbe writer, this macroscopic appearance was very striking. YRING OM YE LI A . 811 the multipolar cells in them are in many instances atrophied. 'I’lie posterior horns, the posterior root-zones, and the posterior columns are especially liable to injury. The horns and root-zones may be distinguished only with difficulty, and the posterior columns present various stages of degeneration. The lateral Fig. 1. Cervical Region of the Spinal Cord from the author’s case of Syringomyelia. (Vniv. Med. Mag.) pyramidal tracts are often very much degenerated, as are, also, tlie direct pyramidal tracts. The cavity itself is usually surrounded by a newly-formed tissue. This is seen, under the microscope, to be a densely felted tissue, with fibrils making innumerable meshes. It is rich in neurogliar nuclei. Some writers point out a lining membrane to the cavity, composed apparently of a comparatively more densely felted layer of gliomatous material. Blood-vessels are scattered but sparsely through this tissue. Above and below the region of Fig. 2. Upper Dorsal Region of the Spinal Cord from the author’s case of Syringomyelia. ( Vniv. Med. Mag.) greatest extent of cavity the morbid anatomy varies. System-lesions may extend in either direction according to their nature. The medulla oblongata is variously affected. It may be the seat of nuclear degenerations identical with those of bulbar palsy. In the author’s case one pyramidal tract was degenerated through the decussation, and the ascending cerebellar tract on one side, as well as the funiculi gracilis and cuniati on each side, was deeply sclerosed. Below the cavity the lateral pyramidal tracts are often degenerated to their extreme limits in the lumbar enlargement. The lumbar enlargement, even when it apparently escapes invasion, may exhibit, on close microscopical search, the presence of gliomatosis in a small area in the gray commissure. The anterior horns in the lumbar cord, unless the cavity extends thus far, are not affected. 812 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. Symptoms. — The symptoms of syringomyelia may be divided into two classes, according as they are dependent upon lesions, first, of the gray matter of the cord, and second, of the white matter. The first class includes the essen- tial symptoms ; the second, those that are secondary to them. These essen- tial symptoms may be subdivided into three groups, according to the region of the gray matter affected. The first probably of these essential symptoms to appear is a characteristic disorder of sensation. This presents a type. It is an analgesia, or loss of pain-sense, combined with thermo-ansesthesia, or loss of power of distinguish- ing heat and cold, Avithout true tactile anaesthesia and loss of muscular sense. This peculiar type has been called by Charcot the dissociation symptom of syringomyelia. It is inore typical of the disease than any other one symptom- group, and is truly typical of no other affection, although occasionally seen in hysteria. These sensory changes usually show a segmental distribution. They are sometimes hemiplegic in type, sometimes monoplegic, but usually distributed only to segments of the limbs or trunk. Exceptions and variations occur. Thus in the author’s case zones of anaesthesia Avere found on the shoulders and about the Avaist. Occasionally areas of hyperaesthesia exist ; thus, in this same case, Avhile one side presented quite typically the “dissociation” symptom, the other Avas the seat of hypersesthesia. The zone of anaesthesia to heat and that to cold do not ahvays exactly correspond. The analgesia of syringomyelia is often very profound, so that the patients may be (juite insensible to most destruc- tive trophic or traumatic lesions, to Avhich reference will be made later. The exact affected region of the cord that gives rise to the sensory symptoms is probably the posterior gray commissure and parts of the posterior horns. The essential motor-symptoms of syringomyelia depend upon a progressive atrophy of the cells of the anterior horns of the gray matter. As the cervical enlargement is invaded much more commonly than the lumbar, it folloAvs that the arms rather than the legs are the parts involved in the consequent mus- cular atrophy. This progressive muscular atrophy is usually of the atonic variety — i. e. the muscles are not spastic and do not sIioav exaggerated myo- tonic and tendon refiexes. This is the type called Aran-Duchenne. There are exceptions to this rule, however', as in the author’s case, in Avhich the tonic or spastic type, Avith exaggerated reflexes, was present. The affected muscles exhibit fibrillary movements. Reactions of degenei’ation are not seen in these muscles, although in advanced cases (piantitative changes occur', and in exti'eme cases ver'y little if any response can be elicited by either cur't'ent. This Avasting often begins itr the hand — for instance, itr the thenar and hypotherrar eminences. It may be the first symptom to attr'act the patient’s attention. Loss of poAver is pr'oportionate to the atr'ophy. One hand may be affected befor'c the other. The Avasting irr the muscles of the shoulders and ar'ins may become extr'eme. The biceps, deltoid, infra- and supra-s))inati and loAver jrar't of the tra))ezius may he almost entirely lost. The foreai'in and deeper neck-muscles also may be much affected. The Aveakness of the neck-muscles may become so extreme that the head falls foi'Avard on the chest, and eveir reeprir'es an assistant to sup- pot't it Avhen the j)atient sits upright. Ti'emor has been observed not unfre- quently, especially in the hands and fingers. The third group of essential symptoms is a sorneAvhat arbitr'ar'y one. It is composed of those synq)toms that are claimed by some Avriter's to depeird upon the irrvasion of the rnid-r'egion of the centt'al gray matter. Br'uhl includes in this gr'oup tr'ophic lesiorrs, scoliosis, vaso-motor disturbances, Aveaktress of the sphincters, oculo-motor disorders, and involvement of the bulb. Without *S’ YRING DM YELIA . 813 criticising this grouping we may accept it for convenience in clinical descrip- tion. Whatever their exact origin, it is certain that some at least of these symptoms are common in this disease. The trophic lesions occur in the skin and in the bones and joints. The skin may show hypertrophies, callosities, ulcerations, various eruptions and maculae, or may be glossy in places. The nails of the fingers and toes are sometimes involved. They become thickene’d, have transverse ridges, and may even fall off. Panaris, or whitlow, is an obstinate and destructive lesion in that form of the disease first described by Morvan and named for him. These whitlows are painless and chronic, and they often destroy the ends of the affected fingers. Abscesses may occur in various places. Arthropathies are not unusual in svringomyelia. They are very similar to those occurring in locomotor ataxia. They cause great deformity of the joints affected, with exudation within the capsule, increase in the articular surfaces, denudation of bone, stalactites, etc. Any one of the lai’ge joints, either the knees, shoulders, elbows, hips, or ankles, may be involved : occasionally more than one joint suffers. Fragility of the long bones, leading to easily-produced fractures, occurs. Deviation of the spine is a very common affection in syringomyelia. Bruhl says it is present in 50 per cent, of cases. The most common form of deviation is scoliosis. In the author’s case this scoliosis was so marked in the neck that it presented the appearance of torticollis. It is most marked usually in the dorsal region. Kyphosis is the next form in frequency, and lordosis the last. Scoliosis may be an early symptom of the disease. Many theories have been advanced to account for this symptom, but that of Roth, who attributes it to an atrophy of some of the transverse muscles of the spine, appears to us the most reasonable. Vaso-motor disturbance may be shown by oedema or coldness of the extrem- ities, or by burning sensations in them, by excessive sweating and by persis- tence of lines, marks, or maculae left after contact of objects with the skin. Pilocarpine by injection, according to Dejerine, is delayed in its action, and causes much more abundant sweating in the analgesic regions than in other parts. Affections of the sphincters are certainly rare in syringomyelia. They might occur in extreme cases in which the cavity in the cervical region was so expanded as to act as a total transverse lesion. Yet in the author’s case, in which the expansion was extreme, there was no interference with the inner- vation of either the bladder or bowel. Pupillary and oculo-motor symptoms have been reported. The sympathetic centre in the cervical cord may be either paralyzed or irritated, causing con- traction or dilatation of the pupil as the case may be. When the bulb is involved, the symptoms of bulbar palsy may appear. In Taylor’s recent case the aqueduct of Sylvius was dilated, probably causing, by involvement of the underlying nuclei of the third nerve, the nystagmus which his patient had. The second class of symptoms observed by us includes those caused by involvement of the white matter of the cord. These are, hriefiy, the symp- toms, first, of lateral sclerosis ; and, second, those of posterior sclerosis. It can easily be understood that a widely-extended destructive process, like syringomyelia, in the cervical region, must involve inevitably some of the fibres in the white matter. The extent of this involvement of course varies. The most common is lateral sclerosis. This produces, as is well known, spastic paresis in the legs. The knee-jerks are exaggerated, ankle-clonus is present, the gait is feeble, the muscles are spastic, but not wasted, and the innervation 814 AMERICAN TEXT-BOOK OF DKEASER OF CHILDREN. of the bladder and rectum is not affected. The symptoms of posterior scle- rosis, or locomotor ataxia, are not so common. Ataxia, however, and sway- ing with closed eyes, may be present, possibly dependent upon involvement of Clark’s column and the ascending cerebellar tract. Fulgurant pains are rare. The brain is not involved in typical cases of syringomyelia. The author once saw, however, a diffuse gliomatous lesion in the mid-brain and cerebellum which strongly suggested an identity, in all but position, with the gliomatosis of the cord. Diagnosis. — The diagnosis of syringomyelia rests upon the recognition of certain groupings of the various symptoms already described. The most com- mon grouping is that of muscular atrophy, especially in the shoulders and arms, spastic paresis of the legs, the “dissociation ” sensory symptom, and a variety of trophic disorders. The most characteristic of these symptoms is the pecu- liar disorder of sensation. Hysteria may simulate this sensory change, but it does not present true muscular atrophy. Anterior poliomyelitis does not cause sensory changes. Amyotrophic lateral sclerosis is undoubtedly identical in some reported cases with syringomyelia. Tumors of the cord and localized myelitis may closely simulate the disease, and can best be distinguished by the history of the case and a careful study of the sensory and trophic disorders. Trophic changes may be conspicuous, and direct the attention from other symptoms. Thus, destructive whitlow', described as Morvan’s disease, is a type of syringo- myelia. Friedreich’s ataxia has some analogies with syringomyelia : Griffith’s statistics prove that 25 per cent, of autopsies in the former present cavities in the cord. Cases of precocious locomotor ataxia ought to be most carefully studied for the symptoms of central gliomatosis. Finally, hemiplegia and monoplegia have been caused by syringomyelia ; they could probably be distin- guished by sensory and trophic symptoms. Prognosis. — The course of syringomyelia is slow, but its termination is never favoral>le. IMany patients die from some intercurrent affection. Treatment. — There is no specific, or even palliative, treatment for such an inveterate degenerative process as that which produces syringomyelia. It is possible only to treat some of the isolated symptoms, to preserve the strength, to guard against accidents, and to avert the tendency to death by intercurrent disease. HEREDITARY ATAXIA. By ARCHIBALD CHURCH, M. D., Chicago. Hereditary Ataxia, or hereditary ataxic paraplegia, also known as Fried- reich’s disease, is a form of spinal sclerosis appearing usually before twenty years of age, with marked hereditary features. It is usually characterized by generalized ataxia beginning in the legs, by nystagmus, and by impairment of speech, and pursues a chronic progressive course. As compared with Friedreich’s description of this interesting disease pub- lished in 1863, this scant definition is too brief; hut succeeding groups of cases observed in various parts of the world, practically of a similar nature, have shown that features of the malady at first insisted upon as essential are not invariably present or even usual. Cramped by the rigid lines of the early description, many observers have either slavishly followed, seeing only what had been before pointed out, or, if finding marked variations, regarding them as unusual and anomalous. Even Ladame so late as 1890 erected a clinical criterion which does not include a very fair proportion of these cases, although at that time some two hundred had been published, and probably very many more overlooked because of the false standard of measurement that was, and still is, followed. Gray, for instance, in his recent work, states as a “cardinal symptom ’’ that “ the knee-jerk is always absent,” and Gowers looks upon the report of a case beginning at sixty-six years of age as a coincidence to be rele- gated to a foot-note. As a matter of fact, aside from the ataxia and perhaps the family history, no single item can be insisted upon in every case, yet the symptom-group is a very striking one, and the numerous variations are merely the expressions of an unsystematized and widely-distributed lesion. Etiology. — The most striking fact in this disease is its transmission from generation to generation, either in the same form or by related sclero-neurotic disease, and the increasing susceptibility that is encountered in the later gene- rations, where it numbers many members of the same immediate family and shows a distinct tendency to appear at a constantly earlier period of life. In this way may be explained the fact that many of the progenitorial cases have been misunderstood, overlooked, or misclassed. In this connection I wish to refer to the instructive family tree published by Sanger Brmvn,' and here reproduced by his permission. (Fig. 1). Nonne describes a somewhat similar group, and the one post-mortem obtained showed only an abnormal smallness of all the parts of the spinal cord, a deficient development which had not taken on sclerotic degeneration. Occasionally a generation escapes this disease, but atavism is likely to occur. The developmental defect is therefore strongly pro- nounced, and constitutes the background of the picture. It is as if portions of the nervous system, especially of the spinal cord, were incapable of maintain- ing their functions in accordance with the demands of growth and active life, ^Chicago Medical Recorder, Feb., 1892. 816 816 AMERICAN TEXT-BOOK OF DIHEASEB OF CHILDREN. and underwent regression, producing the sclerotic changes to be described later. The developmental periods of life are those at which it is most likely to Fig. 1. or the present age. t indicates deceased. 'I'ho la.st number indicates ihe age at onset. appear — the seventh and eiglith years of ago, the age of puberty, and at about twenty, the age of full physical and sexual strength. Hut it soinotinios is con- genital, and may ajipear at any period of life. This is clearly shown in the PLATE XVI. 1, 2, 3, 4. The F. Family.— Showing Apathetic Facies Increasing with Duration of Di.sease : 1. Tina F., Five years old, nnatt'ected. 2. Oscar F., Eight years old, affected one year. 3. Frederick F., Seventeen years old, affected three years. 4. Rose F., Twenty years old, affected five years, helpless. I TilE LIBRARY OF THE UWIVEflslTV OF ILLINOIS PLATE XVri. 5, 6, 7. The S. Family.— Showing Facies: 5. Ella S., Nineteen years old, affected two year.s, slightly. 6. Miles S., Twenty-five years old, affected four years, cannot walk. 7. Hugh S., Twenty-nine years old, affected fourteen years, helpless. 8. Lucy R., Sixteen years old, affected one year, shows mask-like face. 9. Alfred W., Nineteen years old, affected four years. A sister similarly affected at sixteen years of age met an accidental death at twenty-one. 8 and 9 have increased reflexes and double ankle-clonus. 2, 3, 4, 5, 6, and 7 have knee-jerks abolished. 3, 4, 6, and 8 show nystagmus in the photographs. In 2, 3, 4, 6, 7, 8, the head was so much afi'ected that it required to be supported by pillows to make a four-second photographic exposure. IHE LIBRAfir OF THE OHIVEBSiry OF ILLINOIS HE REDITAR Y A TAXI A . 817 remarkable series of Brown and of Nonne, in the cases reported by Wells, and in the instances of Everet Smith. The sexes are about evenly affected, though in some family groups males or females greatly predominate, and it is somewhat more liable to be transmitted through the females than by the male branches, probably because the males affected early do not marry, and in later cases are impotent. Pathological Anatomy. — With the exception of a few cases, notably one reported by Menzel, post-mortem changes in the nervous matter have been con- fined to the spinal apparatus, including the posterior nerve-roots and an occa- sional peripheral nerve, and to the cranial nerves, especially the hypoglossal, optic, and motor-oculi, and their centres in the medulla. In Menzel’s case gross changes were traced into the cerebrum and cerebellum, and the latter was markedly atrophied. Very few autopsies are on record, however. The change in the spinal cord is histologically practically identical with that in ataxic paraplegia and locomotor ataxia, for a full description of which the reader is referred to articles on those diseases. Dejerine and Letulle, however, basing their observations on a single case, claim that the sclerosis in this disease is peculiar in being confined to neux’oglial hyperplasia without vascu- lar changes. The distribution of lesions is the matter of most interest, for upon it depends the prepondei'ance of symptoms in any given case. In eveiy instance subjected to a post-mortem examination, except Nonne’s, the postero- internal and postero-external columns have been found involved throughout the entire length of the cord. In the large majority of cases the pyramidal motor-tracts in the lateral columns have been sclerosed, and this process has, at different levels in different cases, invaded the anterior horns, the anterior columns, the direct cerebellar tract, and the posterior roots. The tract of Lissauer and Clark’s columns usually escape. It is this multilocular distrilni- tion of the sclerosis which gives rise to such a variety of clinical manifestations and accounts for the confusion in literature. It is apparent that as the poste- rior columns or the pyramidal tracts are principally involved, the locomotor and spastic symptoms will vary, just as occurs in ataxic paraplegia. It is not incredible that even knee-jerks lost early in a case may later reappear, or myotatic irritability of a highly exaggerated type subsecjnently diminish or entirely fail.' The lesion lias been traced through the medulla and pons involving the post-pyramidal nucleus. In the posterior columns it is that of an extremely intense tabes, and the involvement of the posterior roots is also analogous, but less marked. In the lateral columns it is that of spastic para- plegia plus the involvement of the cerebellar tract, the anterior direct motor- tract, and the frequent implication of the anterior horn. Symptoms. — Unsteadiness upon the feet, a tendency to tumble, and clumsiness are the first noted indications. Ordinarily the symptoms advance slowly. As a rule, and in the type of Friedreich, the knee-jerk is lost very early, but the writer now has two cases under observation in which it is greatly exaggerated, and in both of them there is ankle-clonus. A number of Brown’s cases also show increase of myotatic excitability, and the same thing has been not infrequently recorded. The superficial reflexes may be present or absent. Sexual power is frequently undeveloped or disappears, though in one of the cases under the writer’s care, where the deep reflexes are prominently increased, sexual inclination is pronounced. As the case advances the ataxia increases, though standing with the eyes closed is often possible when the gait is sprawling and extremely bad. The trunk may be involved, so that, in sitting on a chair without arm or back suppoi’t, marked swaying is ' In one of the writer’s cases an ankle-clonus is rapidly diminishing. 52 818 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. present. The gait is simply staggering. The stamping of tabes is rarely seen, and even in the cases marked by clonus and exaggerated knee-jerks the Btilf-legged gait of spastic cases is absent or only slightly present. Eventually, the upper extremities and the neck are involved, so that the patient becomes practically helpless, and the head, under very little control, rolls around on the shoulders. From the implication of the musculature of vocalization speech is characteristically modified. It is drawling, with the accent and modulation misplaced, hesitating, sometimes slightly explosive ; in a word, ataxic. Usually early, and almost invariably late, in these cases nystagmus is present. It is readily overlooked if the patient be not examined carefully. It is not constant, subsiding when the line of vision is directly forward, and only occurring when the eyes are moved. Early in the disease it is necessary to have the eyes turned sharply outward, upward, or outward and upward to demonstrate it. The nystagmic movements are of comparatively short range, unequal in length, and tend to subside as the eyes settle down to the new posi- tion, seeming to the writer to be part and parcel of the general lack of balance in the entire voluntary muscular apparatus. A few instances of temporary strabismus and diplopia are on record. Pupillai-y symptoms and optic atrophy are absent in the Friedreich type, but frequent in Brown’s cases. There is not much pain, even in the markedly ataxic types ; the lightning pain of locomotor ataxia, the girdle sensations, and the visceral crises are absent, but dull rheumatoid aching, pain on starting micturition, and painful cramps at night are not infrequent. Until late in the course of the disease errors of sensation are slight or absent. Slight amesthesia, retardation in the transmission of sensations, variations in sensitiveness relative to temperatui’es, pressure, and electricity, have all been occasionally noted. Muscular power is ordinarily greatly reduced, but paralysis only appears very late, and is comparatively of moderate extent. Sometimes there is dis- tinct atrophy, owing either to the involvement of the anterior horns or to an occasional peripheral neuritis, and it is only in these cases that any notable changes in electrical responses are found. After the patient is bedridden gen- eral emaciation ensues. A coarse tremor is sometimes present, and choreoid movements of head and limbs of an ataxic character, ceasing when the part is 8up})orted, are common. The facial appearance of these cases, when the disease is moderately well developed, has not received sufficient attention. The lines of expression are lost, the jaw drops, the mouth is partly open, the eyelids droop and look heavy, the whole expression or lack of expression is of apathy, and even of imbecility. In some families the change in the face has been the first intimation to their relatives, familiar with the type, of the invasion of the malady, though an intel- ligent examination would prol)ably have sooner discovered it. This facies is imperfectly shown in the series of photographs published herewith. When pleased or disappointed, emotions are tardily and clumsily or grotcscjuely shown in their faces, which shortly return to an a])j)earance of blankness. The mind is not necessarily impaired, but mental enfeeblemcnt has resulted in some cases, and the enforced inactivity leads, perhaps naturally, to some hebetude. The drooping head, the scoliotic spine, and clubbed foot, which are common, are other evidences of muscular weakness and lost synergism. Sexual attributes are greatly delayed in the younger cases or fail entirely to develop, giving the patient a childish appearance and bodily formation. Course. — The disease is essentially chronic, and very rarely the immediate cause of death, which results from intercurrent maladies, to which the inac- tivity of the patient in some instances no doubt conduces. Some cases have HEREDITARY ATAXIA. 819 lasted over forty years, and some have terminated in two or three. As in other respects, there is in this regard a striking similarity among the members of any family group, but it is not unusual to see the younger members of such a family attacked at an earlier age and in a more active manner. Some cases present long-stationary periods or even temporary slight improvement under treatment and bettered conditions of life. The progressive tendency, however, toward physical helplessness is apparently invariable ; and even after the patient is bedridden life may last many years with oi’dinary care, as there seems to be no especial liability to bed-sores or other dystrophic condition. Occasionally acute myelitis has terminated the case. Diagnosis. — The diagnosis hangs upon the youth of the patient, the slow onset, the history or presence in the family of other similar cases or of in- stances of spinal or cerebral sclerosis (among which paretic dementia should be included), upon the ataxia, the nystagmus, the halting peculiar speech, and possibly upon the facial appearance. Absence of locomotor pains, of pupillary symptoms, of acquired syphilitic infection, and of pronounced sensory disturb- ances are negative conditions of corroboratory value. Treatment. — The prognosis is always grave, as has already been implied, and treatment seems to be of exceedingly little value. A course of arsenic, of massage, of stretching the spinal column, especially by Benedickt’s method, have all apparently caused slight amelioration in progressing cases. Those measures recommended in tabes should be tried, and cauterization with the thermo-cautery over the spine repeated at intervals of two w'eeks may be em- ployed for a prolonged period. A light touch of the smallest point opposite each vertebra is quite sufficient and not particularly painful. General measures to maintain the physical state are of course always in order. With young patients it is well to allow a reasonable amount of instruction, as they are often dependent upon themselves for entertainment during long years of helplessness. RAYNAUD’S DISEASE. By THOMPSON S. WP:STC0TT, M. D., Philadelphia. In a thesis published at Paris in 1862, Maurice Raynaud first called atten- tion to a complex of symptoms to which, for want of a more satisfactory title, he gave the descriptive name “Local Asphyxia and Symmetrical Gangi’ene of the Extremities.” This essay was founded upon the clinical histories of 25 cases collected from various sources, only five of w hich came under his personal obser- vation. Some of the cases drawm from other sources dated back many years and w’ere very inadequately reported, but Raynaud succeeded in presenting a clinical picture that was at once recognized by his contemporaries, and wdiich soon took a place in medical literature as a new disease worthy to be named for the author who first described it. In tliis and later studies Raynaud defined the disease as “ a neurosis characterized by enormous exaggeration of the the excito-motor energy of the gray parts of the spinal cord which control the va.so-motor innervation.” The stage of cyanosis he considered as due to a spas- modic closure of the arterioles of the parts affected, with a regurgitation of venous blood into the capillaries; and if this condition was continued sufficiently long, gangrene of more or less gravity supervened. This gangrene, which is often strikingly symmetrical in its distribution, he distinguished from all other varieties of local death as not being due to embolism, thrombosis, or changes of an inflammatory character in the intima of the blood-vessels. There can be no doubt that many of the cases subsequently described under this name, and indeed some of those collected in Raynaud’s original thesis, do not jiroperly come within the definition laid down by this author. So recent a writer as Sturmdorf, of New York (^Medical Record, Aug. 1, 1861), goes .so far as to ((uestion the existence of such a disease, which, he state.s, cannot be diagnos- ticated during life ; for, “ admitting the possibility of excluding all other con- ditions capable of producing gangrene, w'e must exclude” that form of “endar- teritis [Meigs] whose presence could be demonstrated only on the post-mortem table, and wdiose ab.sence is a sine qua non to the acceptance of Raynaud’s disease in the sen.se of its author’s conception.” It is ((iiitc probable that modern pathology may succeed in disproving the existence of Raynaud’s disease as a morbid entity, but it is certain that there are a siitlieient number of ca.ses on record — and, curiously etioiigli, many of them are in children — which bear out in all es.sential resjiects the original clinical picture. The leading characteristic of the disease consists of jiaroxysms of more or le.ss continuous and coiiqiletc spasm of the arterioles id’ the extremities, usually occurring, with a fair degree of symmetry, upon like parts of the two hands or two feet, or upon both hands and feet, or — and tliis less frequently — upon other symmetrical regions, siieh as tlie ears, sides of tlie nose, or but- tocks. This sjiasm, if sufficiently long continued, gives rise to more or less extensive trophic changes, or even deatli of the parts involved. 820 RA UD'S DISEASE. 821 Symptoms. — As originally described by Raynaud, this affection may be conveniently divided into three principal stages : 1, Local Syncope ; 2, Local Asphyxia ; 3, Gangrene. The first stage, local syncope, may be transitory, or even wanting altogether, but when the disease assumes its severest form the second and third stages always occur in the order named. Local Syncope. — This term was employed by Raynaud to designate a condition, usually of one or more fingers or toes, which in its slightest manifesta- tion is not incompatible with health. The patient, usually a female of neurotic temperament, after exposure to slight cold, or even under the influence of moral emotion, observes one or more of the fingers become pale and cold. The skin assumes a dead-white or parchment-yellow color, cutaneous sensibility is quickly abolished, and the digit feels icy-cold and dead. While tactile sensi- bility may be for the time abolished, the heat-sense may still, in a mea.sure, be maintained. At times a cold perspiration may cover the affected part, while at others it is dry and shrivelled as if frozen. This spasm of the arterioles, with the consequent temporary abolition of local circulation, which is popularly known as “the dead finger,” is insignificant from its transitory duration, being succeeded by a variable period of usually very painful reaction, in which the blood gradually returns to the pai’t. It is simply an exaggerated form of what so commonly occurs after the hands have been exposed to a low tempera- ture when confined in tight kid gloves. This, the slightest and in some cases the only stage of the disease, has been but rarely observed in children. Local asphyxia, or cyanosis, may be preceded for a time by more or less frequent occurrences of local syncope, or may be the first manifestation of the disease. In the latter case the onset is generally sudden, but sometimes is pre- ceded by parsesthesise or pain, usually limited to the fingers or toes about to be affected. After exposure to a more or less marked depression of temperature, or even without appreciable cause, one or more fingers or toes become cold and usually somewhat swollen. The particular phalanx or phalanges will be found to have assumed a dusky or cyanotic tint and to feel icy-cold to the touch, while the whole limb is colder than the rest of the body. Tingling or shooting pains of varying severity are felt, and hypersesthesia or ansBsthesia of the parts may be observed. The cyanosis affects most intensely the distal portion of the phalanx, but it may extend in decreasing degree as far upward as the wrist- joint or ankle, or may even pass beyond, while venous marblings maybe traced far up the limb. This condition may affect one phalanx or several in vary- ing degree, either upon a single limb or upon both hands or feet, or even upon all four extremities. When both hands or both feet are affected, the degree of cyanosis is generally more marked upon one side ; and in some paroxysms in the same patient the asphyxia may be confined to one member alone, while in others both feet or both hands or a hand and foot are affected. In any particular case, however, in the successive paroxysms local asphyxia generally involves the same phalanx or manifests the same order and inten- sity of involvement of several phahanges. After a variable duration the cyanosis gradually passes away and the parts regain their color ; this reaction may even be excessive, and redness and burning pain be noted. Such parox- ysms vary greatly in severity and duration. In some instances the attack passes off in a few seconds, to be frequently repeated at the slightest exposure to a change of temperature ; while in other cases it is prolonged for several hours or even several days. Pain is also a very variable symptom, some patients experiencing little discomfort during the asphyxial attack, while others complain bitterly of intense burning sensations in the part. As with the preceding stage, local asphyxia may be the most serious manifestation of the 822 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. disease, and in this case we find it occurring at irregular intervals, but often as frequently as several times daily, usually during the winter months, being pro- voked by the slightest exposure to cold. A symptom frequently noted during this stage is hfemoglobinuria, to which attention has been lately directed principally by the observations of Barlow and Southey in England. Shortly after the beginning of a paroxysm of local asphyxia the child may pass very dark urine, which is found to contain albumin, and responds to the guiacum test for hmmoglobin. Both Southey and Barlow report cases of this kind in which, during some of the paroxysms, the urine was found to contain no blood-corpuscles, but showed fine granular brown debris and a profusion of oxalate-of-lime crystals. This phenomenon does not occur after every attack ; but it has been observed that a copious deposit of urates may at times replace the loss of haemoglobin. It is most likely to occur when the attack is preceded by yawning, drowsiness, nausea, or pain in the belly referred to the ensiform cartilage, which are the symptoms preceding haemoglobinuria due to other causes. when an attack of local asphyxia has lasted several days, the nail ceases to grow, and the occuri’ence is marked upon the nail by a transverse striation of variable distinctness. When paroxysms have fre(piently occurred, the affected digits may become I’ather soft and flabby from an increase in the sub- cutaneous fat. General symptoms are very slight, and fever, if present, does not usually exceed 100° F: if higher, it is attributable to other causes. A stage of local erythema has been said sometimes to replace the asphyxia! stage, being ascribed to an irritation of the vaso-dilator nerves; but it has rarely been followed by gangrene, and would seem more properly to be classed as the erythromelalgia of VV'eir Mitchell. In rare cases the tip of the nose or the ears, and occasion- ally other symmetrical regions of the body, may be affected with local asphyxia, but the symptoms are the same as in the more common variety. G.\ngrene. — When local asphyxia persists sufficiently long, the vitality of the part suffers. Small blebs form upon the tips of the affected digits, partly at the expense of the outer layer of corium ; these rupture, discharging a serous or sero-purulent, often blood-stained, fluid, and leave an excoriation which heals with some little loss of substance. When this process has attended repeated attacks, the fingers or toes exhibit numerous little white cicatrices, and become somewhat conical in shape, with distorted nails and shrunken parch- ment-like skin. In the severer cases the destructive process may involve a more extensive portion of one or more digits. In this event there are no phlyctenuhie, but the part at once assumes a dark violet or blackish color, and passes tlirougli a condition similar to senile gangrene, with subsequent elimina- tion of the sphacelus — a process re(juiring usually two or three weeks. And thus the patient may pass through an attack with the loss of one or more distal phalanges, or even more extensive portions of the member. Loss of a portion of the margin of the external ear may thus occur, but similar loss of substance of the tip of the nose has rarely, perhaps never, been observed. Many cases of symmetrical gangrene of greater severity tlian here described have been reported as Raynaud’s disease witliout .seemingly good grounds. Some of these have .shown concomitant constitutional symptoms wliicli throw grave doubt upon their accepted pathology; and in others, again, ergotism or vas- cular disease has not been .satisfactorily excluded. As .seen in cliildren, where the ground is considerably clearer, the most carefully studied cases have rarely shown lesions more serious than tlioso above de.scribed. Etiology. — As far as its occurrence in children is concerned, sex or age RA YNA UD'S DISEASE. 823 seems to have little influence. It occurs most commonly during the winter months, often being excited by exposure to the slightest depressions of tempera- ture. Heredity seems to play some part. Raynaud observed a female infant who exhibited a marked disposition to local asphyxia during the first five months of life, at a time when her mother was passing through attacks of dry gangrene of all the extremities. A neurotic family history must be accepted as a powerful predisposing cause, since many victims of this disease show a distinct nervous inheritance. Makins saw symmetrical gangrene in a brother and two sisters whose mother had died of progressive muscular atrophy ; and Colman and Taylor report local syncope in a girl of ten years, whose mother was extremely neurotic, and whose maternal grandfather and grand-uncle had suffered from similar local syncopal attacks. As regards previous conditions of health, in some cases the disease has followed upon acute and depressing ill- nesses ; but in others no such exciting cause could be assigned. Pathology. — Raynaud ascribed this affection to an exaggerated vaso-con- strictor irritation dependent upon an increased excitability of the vaso-motor centres of the cord, since, according to his observation, galvanization of the cord modified the arterial spasm, and in one case, carefully studied by himself and Galezowski, there was a remarkable coincidence between the perij)heral circulatory disturbances and like phenomena observed in the retinal vessels. Weiss, however, inclined to the theory of peripheral irritation arising in the skin, viscera, or the brain, and thus ascribed many of the cases observed in neurotic women to uterine or ovarian irritation. As the disease is rarely in itself fatal, no satisfactory pathological study has as yet been possible. The most import- ant addition to our recent knowledge of the disease is the occurrence of inter- mittent hsemoglobinuria. Of ten children suffering from local asphyxia and symmetrical gangrene, as reported principally by English observers, at least eight at some time during the course of the disease exhibited undoubted evidence of blood coloring-matter in the urine. Dickinson, the chief English authority on renal diseases, states that the two conditions, Raynaud’s disease and inter- mittent haemoglobinuria, seem so to approach each other and mingle as to render it impossible to make a distinct demarcation betw'een them. Abercrombie holds that we are warranted in believing that both paroxysmal haeinoglo- binuria and Raynaud’s disease are symptoms of a more general affection, and he suggests that the jaundice sometimes found after attacks of hsemoglo- binuria (and also after attacks of local asphyxia) is the result of arterial spasm of the hepatic vessels. But it seems more probable, as Barlow believes, that this jaundice is due rather to breaking up of blood coloi’ing-matter elsewhere in the circulation. Several observers have noted that during a paroxysm of intermittent hsemoglobinuria blood drawn from a cold extremity showed changes in the red corpuscles, which exhibited a decided tendency not to form rouleaux and appeared markedly crenated, with granular masses in the surrounding serum. In a very interesting case of a boy of twelve years, who manifested both intermittent haemoglobinuria and local asphyxia of the extremities, with gangrene of the tips of the ears, Myers found that blood taken from ears and hands during an attack of hsemoglobinuria showed changes similar to those just described. It is thus seen that in this case blood-changes, local asphyxia and gangrene, and haemoglobinuria occurred in the same patient. This association with paroxysmal hmmoglobinuria at once suggests a rela- tion to malarial infection — a relation which, in not a few cases at least, is borne out by the existence of previous malarial attacks in such patients. Hereditary syphilis also has obscured the earlier history of several children suffering from well-marked Raynaud’s disease ; and it is doubtful how much of the symptoms 824 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. in these cases could be attributed to specific endarteritis capable of causing vascular obstruction. It is noteworthy, perhaps, that both Boas and Murri, as well as Flensburg more recently, mention syphilis together with ague as prob- able etiological factors in the production of haemoglobinuria. Course, Duration, and Results. — As observed in children, symmetrical gangrene pursues a more benign course than in adults. Local asphyxia may be the only stage, and the disease may be a regular accompaniment of cold weather, disappearing as summer approaches, to recur the next winter. Parox- ysms may occur frequently during the day on the slightest exposure to cold, or they may be seen at irregular and longer intervals. Other cases may termi- nate speedily in gangrene, and leave the child with deformed fingers or toes and only a tendency to blueness of these extremities after exposure to severe cold ; while, again, the repeated occurrences of superficial sloughs may result in painful conical fingers with blunted tactile sensibility. Diagnosis is comparatively easy, provided satisfiictory exclusion can be made of cardiac or vascular disease, diabetes, frost-bite and ergotism. From chilblains it may be distinguished by the history, by the absence of itching, and by the presence of pain during spasm which passes off after relaxation. Its localized character at once serves to exclude congenital cyanosis. Prognosis . — As regards life prognosis is almost always good. Only in one or two reported cases in very debilitated children has a fatal result been traceable to exhaustion from the disease. The prospect of its duration as a chronic or subacute condition or as a periodical visitation is not to be disposed of so easily, and there seems to be no means of judging upon this point at any- time during the earlier paroxysms of the disease. The occurrence of luemo- globinuria, so far as yet observed, has not proven more than a curious episode without much serious import. It is possible, however, that aggravated forms may occur in which a more profuse loss of blood may seriously affect the out- come of the case. Treatment. — When the milder stages of this disease are first manifested much may be done to prevent the more serious results of repeated ])aroxysms. If the general health and constitution of the child be satisfactory, and the symptoms seem to depend entirely upon exposure to cold, great care must be exercised to guard against all chances of chilling of the surface or the extrem- ities. He should not be sent out into the open air until he has partaken of food; woollen underclothing and stockings must be constantly worn. If the child is ill-nourished or cachectic, a plentiful supply of nourishing food and appropriate constitutional treatment must be secured. Imperfect circulation of blood and coldness of the extremities certainly predispose to attacks of local asphyxia, and therefore douches may be ordered, the eft’ect of which must, however, be carefully watched. A rapid s])onging in a bath of water at a temperature of about 100° F. may be followed by a douche of colder water of about 70°, etnptied upon the back and shoulders as the child sits in the warm water. This bath, wliich is best given in the morning, together with a few minutes’ exercise with a ski))ping-rope or football after breakfast, will do much to keep the extremities warm during the day. By this means attacks of local asphyxia may be prevented : but if they should occur care must be taken not to employ the bath while any blueness of tlie extremities is noticeable, nor for some hours after the subsidence of a paroxysm. Raynaud was the first to call attention to the heneficial itilliienee of gal- vanism applied in the form of descending currents either to the spine or down the affected extremity. In the former case the ]>ositive ])ole is applied over the fifth cervical vertebra, the negative near tlie commencement of the cauda RAYNAUD'S DISEASE. 825 ■equina ; while in the latter the negative pole is applied to the closed fingers or the toes. Barlow has obtained most satisfactory results by placing one elec- trode on the upper part of the limb and the other in a basin of warm salt water in which the affected extremity is immersed. As many elements as the patient can bear should be used, and the current should be made and broken at fre- quent intervals. The stance should be given daily for about ten minutes. Shampooing is often valuable in conjunction with galvanism, especially in the chronic forms in which the extremity of the limb undergoes atrophy. Beyond an appropriate tonic treatment little is to be expected from internal medication. Quinine is the only drug whose use in some cases has apparently produced beneficial results, as might be expected from the frequent association with symptoms which suggest the probable etiological importance of malarial infection. This drug should certainly be given a fair trial in every case. Nitrite of amyl has been tried during the asphyxic stage upon theoretical grounds, but without any observed effect. If pain is severe, much relief will be experienced from the local use of chloroform liniments. In some cases, curiously enough, cold applications, like the ice-bag, give greater relief than warmth. When gangrene has begun the limb should be maintained in an elevated position, well wrapped in cotton, and kept clean with an antiseptic wash. Stimulants may be required in this stage, and occasionally hypnotics and seda- tives to secure sleep, allay restlessness, and alleviate pain. When the line of demarcation has formed, dry hot applications should be kept to the part to favor the process of elimination and repair. In rare cases the destruction of tissue may be so great as to demand a more or less formal amputation. PART VIII. DISEASES OF THE RESPIRATORY SYSTEM. DISEASES OF THE NOSE. By W. E. CASSELBERRY, M. D., Chicago. I. Acute Rhinitis. Acute Rhinitis, colloquially tei’med “ cold in the head,” is an acute inflammation of the mucous membrane lining the nasal cavities from the ante- rior nares to the naso-pharynx. It is prone to extend to adjoining mucous surfaces, and usually embraces the naso-j)harynx, at least to some degree, and thence invades, not infrequently, the middle ear. Etiology. — Reasoning from analogy and from its pathology and clinical history, we must regard acute suppurative rhinitis as an infection by pathogenic micro-organisms, although germs specific to this particular form of suppuration have not, as yet, been identified. This statement, however, will bear indefinite qualification, which we must limit to two phases: 1. Some special predisposing condition of the part is essential to infection. 2. It follows certain exposures with such regularity and precision that we must infer a causal relationship between chilling of the body and rhinitis. A draught between the shoulders, permitting the feet or other parts of the body to become cold and damp, or too rapid checking of the perspiration, causes, through the intervention of the vaso- motor nervous system, a sudden turgescence of the nasal vessels, especially of of the turbinated bodies. In the majority of instances this congestion is but transitory, passing off in a few minutes or a few hours, and followed merely by increased mucous secretion ; but in other instances it does not subside, but augments in violence, and is followed in from twelve to twenty-four hours by a rauco-purulent, and then almost a purulent, discharge. The congestion of the nasal vessels occasioned by thus “taking cold” evidently favors a microbic invasion of the mucous membrane by impairing, in some manner, its powers of resistance. Instances are not wanting of direct infection of one person by the discharges of another — an accident which is apt to happen among children by the use of handkerchiefs in common. Suj>purative rhinitis in infants is also attributable to direct infection from the vaginal discharges during birth. Symptoms. — A sense of stuiliness in the nostrils, with burning and dry- ness, together with slight febrile reaction, is succeeded in a few hours by an acrid watery discharge, which later leads to a free muco-purulent secretion. A simultaneous congestion of the frontal sinuses, which occasions headache, is frequent, but this does not argue pressure by accumulated muco-purulent secre- 826 DISEASES OF THE NOSE. 827 tion within these cavities, for actual empyema of the frontal sinuses is very rare. Mere swelling of the orifice of the Eustachian tube will occasion tinni- tus aurium and impairment of hearing, and a direct extension of the inflamma- tory process to the middle ear is, seemingly, the cause of nearly all cases of abscess of the cavity of the tympanum. Certain individuals, and even certain families, manifest a decided predisposition to this complication. Associated conjunctivitis is common, and, at times, the external nasal appendage appears swollen, fiorid, and excoriated by the irritating discharges. Treatment. — It is much too customary to permit this acute inflammatory disease of a delicate part of the body to progress without efforts to mitigate and abbreviate it. Such a course is fraught with immense possibilities of ultimate damage, chronic catarrh of the nose and accessoi’y organs being thereby estab- lished. Many remedies are of real service, but a multiplicity of recommenda- tions is confusing and tends to lessen confidence in any one line of treatment. We will therefore describe simply our owm methods of dealing with these cases. If it is sought to abort the attack of rhinitis, a single average-sized dose of Dover’s powder, proportionate to the age of the child, is given at bed-time, also a laxative if needed. The patient is especially well covered in bed, outside night air is excluded, and the temperature of the apartment maintained during the night at 60° to 69° F., but no effort is made to produce profuse perspiration. The follow'ing day, or even the first day if called upon to prescribe before evening, this formula will meet the indications: 3^. Tr. aconiti TH^ij- Tr. belladonnae TTLxxiv. Morphinm sulphatis i- Pota.ssii bromidi 3 j. Spts. menthse piperitm ITIxx. Aquae q. s. ad fsiij. — M. Sig. Adult dose, one teaspoonful every hour, to be lessened for children according to age. O O The same ingredients could readily be prepared in the form of a capsule, pill, or compressed tablet. Local treatment is of the utmost importance, and the following mixtures render satisfactory service by atomization: Spray No. 1. I^. Cocainae hydrocliloratis.gr. ij. Sodii boratis gr. xx. Sodii bicarbonatis . . . gr. xx. 01. eucalypti TThj. 01. gaultheriae .... Plj. Thymol gi’-j- Menthol gr. ss. Glycerin! f,5ss. Aquae . . . . q. s. ad f^j. — M. Sig. Dilute, adding one or two tea- spoonfuls to one ounce of warm water for use as a spray. Spray No. 2. I^. Cocainae hydrochloratis . gr. ij. 01. pini Canadensis. . . TTIv. 01. gaultheriiB lUij- 01. eucalypti Ulij- Thymol gr. ss. Menthol gr. j. “Vaselin oil” ... . f^j. — M. Sig. Use wdth double bulb (Davidson) atomizer, either alone or follow- ing the use of Spray No. 1. For young children, who are often terrified by spraying, may be substituted a small syringe or an ordinary medicine-dropper used as a syringe, with which 828 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. to project, gently, either of these solutions through the nostrils. Spraying or gentle syringing in this manner may be performed twice or three times daily, or even every three hours in severe cases. The cocaine can be omitted from either spray formula, if there be any objection to its use, wdthout seriously impairing the effectiveness of the remedy. All solutions for nasal use should be somewhat warm. Of the many iidialations, we will mention only camphorated steam as a domestic remedy of power. It is conveniently used by placing a pint of steam- ing hot water in a glass fruit-jar and adding two fluidrachms of spirit of cam- ])hor. A funnel, preferably of glass, is then inverted to cover the mouth of the jar, and the rising steam is inhaled through the nostrils as it escapes from the small end of the funnel. So used, especially during the evening, for a half hour, it conduces to a comfortable night’s rest and facilitates recovery. n. Simple Chronic Rhinitis and Purulent Rhinitis. Recurrent attacks of acute rhinitis establish, in children and young people especially, a chronic inflammation of the mucous membrane, which is charac- terized by variable degrees of proliferation of the epithelium, and by muco- purulent secretion, which is often profuse. The disease is not accompanied by material enlargement of the turbinated bodies or distention of the erectile tis- sues, and stenosis is not a prominent symptom ; which differentiates it from hypertrophic rhinitis. Etiology. — Bosworth plausibly contends that children are particularly prone to inflammation of the epithelial lining of mucous membranes, and that the epithelial proliferation of muco-lymphoid glands becoming organized with- out desquamation accounts for enlargement of the tonsils, etc., while an allied inflammation in the nose, with rapid desquamation of the epithelium, con- stitutes the most important element in purulent rhinitis. The disease bears no constant relationship to scrofula, tuberculosis, or syphilis, since it affects chil- dren who are otherwise robust quite as frecpiently as it does the subjects of these dyscrasioe. Inattention to hygienic matters, leading to freciuent attacks of acute rhinitis, and ftiilure to treat the same effectively, are potential factors in the establishment of this form of catarrh. Symptoms. — A profuse muco-purulent discharge from both nostrils, swell- ing and redness of the external nasal appendage, and excoriation, with incrus- tation of the anterior nares, are the chief manifestations, a too j)rofuse dis- charge being the sole complaint in the milder cases. In the course of years, if the purulent type of rhinitis he not arrested, the mucous glands atrophy, the secretion grows less but thicker, and tends to accu- mulate in crusts. In other words, the disease passes gradually into the atrophic form of rhinitis, which is the successor to purulent rhinitis perhajis more fre- quently than to hypertrophic rhinitis, although commonly credited to the latter disease. On the other hand, if simple chronic rhinitis does not assume the purulent type, it is prone to pass gradually into hypertrophic rhinitis. Diagnosis. — Hypertrophic rhinitis is accompanied by more nasal obstruc- tion and less secretion, although it is sometiTnes difficult to draw the line between these two affections, however distinct one ty])e may be from the other ; indeed, in rare instances the two pathological processes are seemingly associ- ated. Hereditary syj)hilitic rhinitis can be excluded by rhinosco])ic exami- nation, and the purulent discharge occasioned by a foreign body in the nose is commonly unilateral, and the object can be discovered by the probe. DISEASES OF THE NOSE. 829 Treatment. — The first indication and most important point in the treat- ment of purulent rhinitis is to maintain absolute cleanliness of the nostrils. Muco-pus must not be permitted to accumulate and decompose in the sinuosities around the turbinated bodies, thus perpetuating the disease. In not too invet- erate cases thorough cleansing by means of an antiseptic alkaline and mildly astringent spray, used three or four times daily with a hand-ball atomizer, is all that is necessary to effect a cure. The following modification of Dobell’s solution answers this purj)Ose admirably : Sodii boratis gr. xv. Sodii bicarbonatis gr. xv. 01. eucalypti Tffj. 01. gaultherire TTlj. Tl'yraol gr.j. Menthol gr. ss. Glycerin! fsss. Aqine q. s. ad fsj. — M. Sig. Dilute, adding two teaspoonfuls to one ounce of warm water for use as a spray. The patient should be directed to use the spray several times at intervals of five minutes, especially during the morning and evening toilet, and to cleanse the nose by “blowing” in each interval. If a more active astringent is necessary to check the hypersecretion, sul- pho-carbolate of zinc, two to five grains to the ounce, may be used as a spray following the cleansing solution. In young children, who are terrified by spray- ing, these solutions, well wai’med, can be used by means of a small syringe. Where the purulent type of the disease is complicated by the presence of hypertrophies of the turbinated bodies, deformity of the septum, adenoid vegetations, etc., any of which obstructions will impair the drainage and cause a muco-purulent discharge, surgical treatment appropriate to this special cause or complication is usually indicated. However, the case should not then be regarded, strictly speaking, as one of simj)le rhinitis. m. Hypertrophic Rhinitis. This is a chronic inffammation of the mucous and submucous tissues of the nose, characterized by enlargement, especially of the turbinated bodies, which encroach upon the normal lumen of the nostrils and cause impairment of nasal respiration and drainage. The disease is stated to be rare with children, espe- cially under ten or twelve years of age, but we are convinced that a mild form, or early stage, of the affection is very common at all ages. Pathology. — Advanced hypertrophic rhinitis is characterized by enlarge- ment and proliferation of all the elements which compose the turbinated bodies : the epithelial surface is thickened ; the adenoid layer, which lies between the epithelial and submucous layers, is wider, and the lymph-corpuscles and fibrous connective-tissue bundles are more numerous ; the acinous mucous glands are increased in number and size. The submucosa, which is composed largely of blood-vessels of a venous character — sometimes called a venous plexus — is par- ticularly affected, the vessels being enlarged, more numerous, their walls thick- ened, and the intervascular connective tissue proliferated. The blood-vessels are more or less continually congested, causing “erection” of its structures, and they are no longer capable of complete “retraction” under favorable 830 AMERICAN TEXT-BOOK OE BISEASEB OE CHILDREN. influences or under the action of cocaine, but shrink only moderately or but little. As Bosworth truly remarks : “ These are changes which can only ensue during the lapse of years;” and to this extent we would not, therefore, expect to encounter them in children. However, in children and adolescents persistent eidargements of the turbinated bodies can and do present themselves in conse- quence of mere dilatation and engorgement of the vessels of the submucosa, without any considerable degree of cell-proliferation. Complete retraction in this fonn is possible, either spontaneously on one or both sides at intervals, or by means of cocaine, the mucous membrane shrinking close to the bony base. This condition is occasionally referred to as a vaso-motor paresis, permitting over-distention of the vessels of the turbinated bodies and other parts affected ; or, again, it is designated by Ingals as a distinct affection under the name of “ intumescent rhinitis.” But I am disposed to view it simply as an early stage, or, at most, a variety of hypertrophic rhinitis, for cases which present each degree of gradation between this and the advanced stage of the disease above described are continually encountered. In addition to the intumescent type, even somewhat advanced grades of hypertrophic rhinitis are certainly met with in children. Etiolog’y. — The most prolific source of hypertrophic rhinitis in young chil- dren is adenoid vegetations, which by partial occlusion of the posterior choanae interfere with the proper drainage and evaporation of nasal secretions, the irri- tation of retained and decomposing seci’etions serving to excite proliferative changes in the nose. It would seem, also, that the same dyscrasia — lympha- tism, which predisposes certain children to hypertrophy of the tonsils and to naso-pharyngeal adenoid hypertrophy — favors the development of hypertrophic rhinitis. Clinically, these conditions are frequently conjoined, and it is cer- tain that they sustain some dependence upon each other, for removal of the “adenoids” is often followed by subsidence of the nasal hypertrophies. Recurrent acute rhinitis is another potent factor in the development of hypertrophic rhinitis, and, therefore, whatever serves to excite acute rhinitis must be accorded etiological consideration in reference to hypertrophic rhinitis. Symptoms. — Nasal stenosis, or obstruction on one or both sides, is the most prominent symptom, together with many indirect effects due to the stenosis. As a rule, one side of the nose is stopped at a time, the two sides alternating in this respect, sometimes changing with great rapidity and without apparent cause. Again, absolute stoppage of one or both nostrils may manifest itself only under certain conditions, as during railroad travel or otherwise from inha- lation of dust, from superheated apartments, and from exposure to a cold, damp atmosphere — conditions which necessarily arise so commonly as to cause much annoyance to the patient. d’he secondary results of nasal stenosis are a nervous restlessness, which is excited in many by the sense of obstruction and pressure in the nose, inability to sleep soundly at night or intellectually to apply themselves persistently by day, together with headache and reflex j)ressure sym))toms, such as hemicrania, or nervous sick headache, asthma, spasm of the glottis, and even e])ileptoid seizures. The most frerpient of the reflex nasal symptoms in childhood are asthma in association with bronchitis, and spasm of the glottis in association with laryngitis; in fact, so common, in childhood, is dependence, at least in part, of chronic bronchitis with asthmatic symptoms ujxm nasal stenosis and adenoid vegetations that the closest scrutiny ainl attention should be given to the upjter respiratory tract in all such cases. Plethora of the blood-vessels of the nasal mucous membrane tends to develop DISEASES OF THE NOSE. 831 a like plethora in the bronchial mucous membrane, and anaemia induced in the turbinated tissues tends to effect an anaemic state of the bronchial tubes. The physiological relationship between the two regions — the nasal erectile tissues being designed to warm and moisten the inspired air — demands, through the vaso-motor system, an intimate correspondence between their blood-supplies. As might therefore be expected, a pathological correspondence also obtains, and, without enteidng into a discussion of the hypothetical details of nervous mechanisms, we simply state the oft-observed fact, that turgescence and vaso- motor paresis of the nasal erectile tissues may occasion vaso-dilation, congestion, and inflammation of the bronchial mucous membrane. The term “reflex” is doubtless often misappropriated, yet it has a deflnite signiflcance, and the pathological reflexes which originate in nasal or naso- pharyngeal irritation, and terminate in cough, laryngeal spasm, or asthma, fol- low much the same pathway as the physiological reflex known as sneezing. The nasal branches of the ophtlialmic division of the fifth nerve and the nasal branches of the anterior palatine, descending from Meckel’s ganglion, which is in connection with the superior maxillary division of the fifth nerve, conduct the sensory impression to the medulla. It is there reflected to the respiratory, pneumogastric, and other centres, whence the deep inspiration, forced expira- tion, and the coincident spasm of the pharyngeal and laryngeal muscles, termed a sneeze. This mechanism, of course, varies somewhat with the different pathological reflex acts. But nasal irritation does not in every case result in reflex phenomena. Evidently, still other conditions are essential, which must be sought in func- tional derangement tending toward special susceptibility of certain nerve-cen- tres, including those wrought upon by peripheral nasal irritation ; and in clironic inflammation or a predisposition to acute congestive states of particular organs, which unquestionably favors the development in that organ of the ultimate link in the reflex chain. Thus, one affected with bronchitis would suffer the more readily from asthma, excited reflexly by nasal irritation ; laryngitis predis- poses under like conditions to spasm of the glottis, and digestive derangements to migraine. So, in the completed cycle, three factors obtain — nasal-irritation, superexcitable nerve-centres, and a susceptive peripheral organ. But the nasal irritation is the initial link without which the peculiar reflex is not excited, and to which the other factors are subservient. Another symptom of hypertrophic rhinitis, secondary to this stenosis, is compulsory mouth-breathing with its many deplorable consequences — e. g. dry- ing out of the mouth and pharynx, facial deformity, and mental obtundity — a symptomatic sequence which has been sufficiently elaborated in the article on “Naso-pharyngeal Adenoid Hyperti’ophy.” Also, concerning secondary impairment of hearing, what is said in that article pertains equally to this disease. A very annoying symptom, and one which may first attract attention, is dysphonia ; in fact, such children are constantly declared to be tongue-tied and the lingual frmnum cut without benefit, when the real defect in speech lies in occlusion of the nares or naso-pharynx. Diagnosis. — This is established by direct rhinoscopic examination ante- riorly and posteriorly ; the latter, however, is not always possible with young children. The turbinated bodies appear red, turgid, and swollen, but they occupy their natural positions and maintain their normal I’elations to each other and to surrounding parts ; by which fact this disease can readily be distin- guished from nasal polypus. A polypus occupies one of the spaces beneath. 832 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. between, or beside the turbinated bodies ; it is, moreover, movable, and is of paler color than the inflamed mucous membrane. Treatment. — When dependent upon adenoid vegetations, the surgical re- moval of these growths in children usually results in subsidence of the hyper- trophic rhinitis. Resolution will be favored in these cases, however, as well as in the milder forms of the disease not secondary to naso-pharyngeal adenoid hypertrophy, by the use twice daily of an antiseptic, alkaline, and mildly astringent spray or lotion, formulated as prescribed in the section on “ Simple Chronic Rhinitis.” This is especially important as a cleansing measure in cases in which some degree of hypertrophy is conjoined with the suppurative type of rhinitis. Refined petroleum products, variously known as “ albolene,” lavolene, benzoinol, etc., are just now extensively employed in many combina- tions in all forms of rhinitis, but antiseptic, alkaline, aqueous solutions are certainly more effective when the parts are to be cleansed of muco-purulent accumulations. Petroleum sprays are, however, often soothing and protective to the parts, especially at times of acute and subacute exacerbations, and may be used in such cases following the atjueous spray twice daily, or used alone Avith patients Avho have no retained muco-purulent secretions. “ Vaselin oil,” being more viscid than the whiter products, and yet sufficiently fluid to be con- verted into spray by a good double-bulb hand-atomizer, is best adapted to this use, and may be prescribed in the following combination : I^. 01. pini Canadensis 01. gaultheriae 01. eucalypti Thymol Menthol “ Vaselin oil” Sig. Use Avitli a double-bulb atomizer. . . . mv. • • . mij. • . . mij. . . . gr. ss. • • • gr- j. q. s. ad fsj. — M. A more astringent spray is occasionally beneficial, although strong astrin- gents are not well borne by the nasal mucous membrane : I^. Zinci sulphocarbolatis lodi Potassii iodidi . . . Menthol 01. gaultheriae . . . Glycerini .... A(jum Sig. Use with atomizer.^ . . . gr. V. • ■ • gr. j. • • • gr. >j. . . . gr. j. . . . miij. . . . f.oj. (j. s. ad f.y. — M. I’ersistent use of these remedies, together with the surgical removal of ade- noid vegetations and enlarged faucial tonsils, and liygienic guards to ))revent frequent “cohls,” will effect a recovery in tbe majority of cases of hy])ertrophic rliinitis of children. A minority, liowever — wliich includes, esj)ccially, the older children — will not yield to this treatment, and will require reduction of the hypertrophy by means of the electro-cautery in order to overcome the nasal stenosis. One should not hesitate to ado))t this method in suitable subjects, for the results are very satisfactory and the disadvantages trivial ; but consider- able technical skill is necessary to oisurc eiitire safety ; conso(iuently it should not be attempted l>y one who is unfamiliar with intranasal operating. ‘•‘Vaselin oil” or albolene can be substituted tor the glycerin and water in tins formula. DISEA^^ES OF THE NOSE. 833 Five per cent, cocaine solution on cotton is first placed in contact with the whole length of the inferior turbinated body for ten minutes. The knife elec- trode is commonly used, but we })refer, as better adapted to the purpose, the ordinai-y point electrode, which we curve slightly upon the flat, using the sur- face of the platinum end, and not the very point, with which to burn. This makes a broader eschar than the knife electrode, it is less apt to occasion luemorrhage, it requires less space in transit through the nostrils, and it adapts itself better to the curved contour of the tuibinated body, permitting appli- cation farther toward the ])Osterior end of that body. The cocaine retracts the erectile structures and temporarily provides space through which the unheated electrode is passed ; the length of the platinum tip is pressed against the turbinated body, commencing as far posteriorly as one can see, and then, when at white heat from the battery, it is drawn slowly for- ward, marking its passage by the production of a white linear eschar. Through this same linear eschar, in order to deepen it, one now' draws the instrument a second and a third time. Many will direct that the electrode be employed at a cherry-red heat, but during use the point is sunk in a moist tissue, and what is a white heat in the atmos])here is no more than a cherry heat wdien in contact with the moisture of the turbinated body. The two nostrils should never be treated at the same sitting, and more than one linear cauterization should not be made at one time, although it may be well to draw the electrode two or three times along the same track in order to obtain sufficient depth, as the subsequent cicatri.x, in addition to breaking up the free continuity of blood-vessels and substituting a certain overplus of tissue, should serve also to bind down the neighboring portions by attachment to the bony base. Bad cases require six to eight applications of the cautery at intervals of one to two weeks, two or three on each lower turbinated body, and others of less extent on the middle bodies. Antiseptic cleansing sprays should be used dur- ing the intervals. Moderate sepsis has followed this operative treatment in a few instances ; consequently it is best to see the patient on the second and fourth day after operating for the purpose of effecting absolute cleanliness. The best substitute for the galvano-cautery when this is not available is chromic acid, which may be used by fusing a bead on the end of a probe and applying it much as one would the electrode. It is apt to produce excessive breadth and insufficient depth of eschar. IV. Atrophic Rhinitis. This disease, termed also dry catarrh, ozaena, and fetid rhinitis, is charac- terized by atrophy of the mucous membrane, of the underlying cavernous struc- tures, and of the bony projections within the nose, which leads to increased spaciousness of the nostrils ; also by atrophy wdth impairment of function of the mucous glands, by reason of which the muco-purulent secretion becomes inspissated and accumulates in the form of crusts, which, in turn, undergo decomposition and occasion fetor. Etiologry. — Frankel first promulgated the theory that atrophic rhinitis was a sequel to hypertrophic rhinitis, a late stage of that disease ; and his views have seemingly been adopted by most other writers, a few guarding this dictum by stating that this disease can also arise independently. In a discussion before the American Laryngological Association in 1891, I made this statement : “ With regard to the transition of hypertrophic rhinitis into atrophic rhinitis, .... I have never seen a case in which distinct hyper- trophy had passed, definitely, into the atrophic condition.” 834 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. The life-histories of the two affections are dissimilar. Atrophic rhinitis is common in childhood and early adult life, becomes rare after thirty-five years of age, and is very infrequently observed in patients exceeding forty years of ^se- ll ypertrophic rhinitis of the early intumescent variety is not uncommon in childhood and early adult life, but the disease does not become firmly estab- lished, with permanently organized infiltration of the turbinated bodies, at least until maturity; and in the vast majority of cases the quantity and density of infiltrated tissue continues to increase until advanced age. Since it is conceded that about ten years’ duration of the hypertrophic type is usual before transition into the atrophic type, it is apparent that this theorj’- leaves us without an adequate explanation of the many cases of atrophic rhin- itis which occur in early life. The few cases which are explicitly reported by competent observers as having undergone this transition were doubtless illustrations of coincidence, in which, notwithstanding the previous existence of hyperti’ophy, some other unnoticed or obscui’e intercurrent cause had served to effect the atrophic change. Bosworth has advanced the most I’ational explanation of the etiology of atrophic rhinitis in designating “ suppurative rhinitis of children ” as the real cause — a view which harmonizes with the life-history of the disease, and Avhich is con- sistent with the undoubted occurrence of the coincidence above mentioned ; for it is possible for one already the subject of hypertrophic rhinitis to acquire, in addition, the suppurative type of rhinitis, Avliich latter may terminate in the atrophic state in spite of the previously existing hypertrophy. Bosworth’s theory, moreover, is of sj)ecial value from a pro])hylactic stand- point, since it teaches us the importance of promptly suppressing chronic sup- purative rhinitis, viewed as a cause the ultimate effect of which, atrophic rhinitis, is, itself, difficult of suppression. Bosworth says, in brief, that the predominating morbid condition of puru- lent rhinitis is desquamation of epithelium ; that as long as this desquamation is confined to the superficial epithelial cells the disease is attended with a thin and fluid muco-purulent discharge, but that, sooner or later, the desquamative process extends to the epithelial lining of the muciparous and follicular glands; the glandular function is then impaired, and the muco-purulent discharge becomes thick and firmly adherent, in the form of crusts and scales, to the sinuosities of the nose. Further, that this film of desiccated mnco-pus, in drying, contracts, and embraces the underlying turbinated tissues in a grasp which necessarily must interfere with the circulation of blood — a condition which limits glandular action still more and conduces to general atrophy. llereditai’y predisposition to atrophic rhitiitis is often pronounced. For instance, a patient, aged twenty-two, has develoj)ed the disease dviring the last two years ; her mother, for some years deceased, suffered from the disease in a typical form ; the patient’s child, aged three years, is likewise affected. Pathology. — The prominent features of the atroj)hic process are thus summarized by Bosworth: First . — Decrease of covering epithelium, with profuse desquamation. Second . — Decrease of the adenoid layer, Avith lack of blood-vessels, together with destruction of the acinous glands. Third . — A total disappearance of the venous sinuses of the submucous layer of the membrane.” Symptoms. — Crust-formation and fetor are the most ])rominent syni])- toms of the disease, although other sccomhiry manifestations are numerous. The crusts may accumulate only in thin scales or in large masses of horny consistency, which may even occlude the nostrils at times, being firmly DISEASES OF THE NOSE. 835 adherent and impacted in the sinuosities of the nares, until by decomposition and softening of the layer adjoining the mucosa they are finally cast loose and expelled in large ])ieces by blowing, often leaving abraded surfaces behind. The fetor varies in intensity in different cases, but is rarely entirely absent, and in its severe forms is so horribly nauseating and penetrating as to contaminate the atmosphere of an entire room in a few minutes, and to necessitate comparative isolation of the patient. The fetid odor is apparently due solely to decomposition of the incrusting secretion m situ, but there is reason to believe that this decomposition may extend to the secretion which is still in process of elaboration in the substance of the glands themselves, although this is difficult of absolute demonstration ; for, however thoroughly one may cleanse the parts, fetor, persisting, might still be caused by small invisible particles of crust in the accessory cavities, ethmoid cells, or sphenoid sinuses. In advanced cases, commonly, the sense of hearing is impaired, the patient’s own sense of smell obtunded, the external nose broadened, its alse thickened, and the physiognomy lacking in acuteness of expression. The disease extends after a time to adjoining suiTaces, constituting atrophic naso-pharyngitis and atrophic pharyngitis. The naso-pharynx becomes so incrusted that the fetid masses must be literally pried out with probes and for- ceps. The pharynx presents a capacious, glazed, and dry aspect characteristic of the disease. Much more rarely even the larynx and trachea become in- volved, crusts accumulating in these passages to the point of occasioning dyspnoea. Diagnosis. — On rhinoscopic examination, both anteriorly and posteriorly, one is impressed by the spaciousness of the nasal cavities and the presence of scales or crusts. After thorough cleansing the mucous membrane appears smooth and thin, although oftentimes congested and abraded in spots from the irritation of long-retained incrustation. In advanced cases the turbinated bodies appear merely as rudiments. The disease is likely to be confounded, especially in childhood, with heredi- tary syphilitic rhinitis, which is also accompanied by fetor and incrustation. Unfortunately, by reason of the fetor the term “ ozfena ” has been applied to both diseases ; consequently it is a bad name for either affection, especially since it refers only to the symptom fetor. In atrophic rhinitis there is uniform atrophy and incrustation without deep destructive ulceration. In syphilitic rhinitis the atrophic process, if present at all, is not uniformly distributed, the nostrils being contorted by deep ulceration and destruction, with subsequent cicatrization, of various parts. Reference may be made to the section on hereditary syphilis of the nose for additional details. Prognosis. — Atrophic rhinitis requires persistent thorough treatment over a period of from four months to two years, in order to effect recovery even in young subjects and in recent cases. Both patient and physician are prone to become discouraged and to abandon treatment, much to the disadvantage of the former. Old, inveterate cases must continue cleansing measures for years, as part of the toilet, with the same regularity that is given to the teeth. In the worst cases the difference between persistent treatment and total inattention is the difference between the lot of an acceptable member of society and that of a social outcast. The fact that the disease is rarely ob.served at an age of over thirty-five to forty years argues a natural predisposition to recovery as life progresses, and should operate as a further incentive to persistent treatment. 836 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Treatment. — Tlie first essential to successful treatment is absolute and continuous cleanliness of the parts. The crusts must not he allowed to form, much less to undergo decomposition. One of the most efficient means to this end, especially for young children, is the nasal douche. I believe it to he justifiable, for the sake of efficient treatment of this particular disease, to assume the slight risk of inffammation of the ear possible by this instrument. This risk, with proper use of the instrument, is remote in comparison with the danger to the same organ from atrophic rhinitis inefficiently cleansed. The original instrument of Thudicum was of glass, but the ordinary soft-rubber bag gravity douche, fitted with a nasal noz- zle (Fig. 1), answers the purpose still bet- ter. It should be suspended from a nail over a convenient basin at such a moderate height that the bottom of the bag is only about three indies above the level of the nose as the head is held over the basin. The patient must maintain breathing by the mouth, well opened : when on applying the nozzle to one nostril the liquid will gravi- tate gently and slowly into one nasal pas- sage and out through the other, the oral respiration sufficing to close the naso-phar- ynx from the oro-pharynx by the velum pnlati. Not force, but thorough maceration, is requisite to detach the crusts ; therefore one to two pints of ffuid should be gently and slowly used twice daily as a part of the morning and evening toilet. The liquid employed should be alkaline, to facilitate solution of the crusts ; antiseptic, to counteract the fetor ; and stimulating, to encourage regeneration of the atrophied glands. These qualities are provided in the following formula: R. Sodii bicarbonatis .oiij- Sodii boratis .^iij. Extract! pini Canadensis Iluidi . . . f.sj- Glycerini f.siv. A((iue (). s. ad fsviij. — M. Sig. To be diluted according to tolerance, adding one ounce to the pint or (juart of warm water for use Avith the nasal douche. With older children, who can be taught the necessary mani])idation, War- ner’s post-nasal douche (Fig. 2) should be substituted for the anterior douche of Thudicum, on account of greater safety relative to the ear. The same solution in the same proportion can be used with it. One must first draw up a part of the li({uid through the instrument into the rubber ball; then insert the curved nozzle through the mouth, behind the velum palati, into the naso-y)harynx, and S(}ueeze the ball, thus expelling its contents forward through the nasal passages. This procedure should be repeated until half a f)int of li(juid is thus used morning and evening. Children Avho Avill not tolerate either of these means can conveniently have the nostrils syringed by an ordinary soft-rubber-tipped ear-syringe. Peroxide of hydrogen has the proj)crty, by ra{)id oxidation, of disin- Fig. 1. Anterior Nasal Douche and Method of Using it. DISEASES OF THE NOSE. 837 Fig. 2. tegrating niuco-purulent matter, and, when sprayed into the nostrils, it will thus assist materially in loosening the desiccated secretion. It should be used a few minutes before the employ- ment of either form of douche, of a strength just insuffi- ciept to cause smarting, sprayed by a powerful double- bulb hand-atomizer. On account of variability and instability of the drug, an exact strength cannot be named, but a 20 to 40 per cent, solution of a 10- to 15- volume peroxide of hydrogen is suitable. The patient should receive treatment, preferably, from one to three times weekly in the office, at which time any resisting crusts should be detached by a cotton probang, and more actively stimulating and antiseptic medicaments applied. Of these, the powder insufflation of dithymol iodide (aristol) is one of the most satis- factory. For the excoriation and incrustation around the ante- rior nares and over the cartilaginous septum, which is often one of the most annoying features with children, the following ointment, thoroughly used each night, being inserted into the nostrils as far as the finger wdll reach, gives the most satisfactory results: Hydrargyri oxidi fiavi “Vaselin” §j. — M. Sig. For local application. Sprays of “liquid vaselin,” with which antiseptic and stimulating medica- ments, such as thymol and menthol, may be incorporated, are also serviceable at times, tending to retard crust-formation. Of extraordinary measures, electricity is advocated by Delavan of New York, and “vibratory massage” by Braun of Trieste. Cod-liver oil and syrup of iodide of iron are seemingly the most useful internal remedies, although neither can be relied upon to the exclusion of local treatment. V. Nasal Myxomata. Nasal myxomata, or mucous polypi, are connective-tissue neoplasms wdiich originate from the mucous and submucous tissues of tlie nose. The disease does not exist as a primary affection — a dictum wdiich is more emphatically, albeit less elegantly, expressed by stating that polyps wdll not grow in healthy noses. They are always associated with, and caused by, some other nasal malady. Indeed, the removal of such associated maladies together with the polypi is the “keynote” to the proper and effective handling of the patient. Polyps are stated to be rare with children, but are probably only relatively so, since the diseases wdiich influence their development are somewdiat less usual in young children than in adults. We have observed them in children from the age of eight years upward. Recognition of the exact points of origin of the neoplasms is essential to a clear understanding of their etiology and treatment. In the outer wall of the middle meatus of the nose is the ethmoidal fissure, or hiatus semilunaris, the antero-inferior boundary of which is a sharp-edged ridge of hook-like curve, and hence termed the unciform process of the ethmoid 838 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. bone (Fig. 3). The fissure itself communicates through its upper end with the frontal sinus, and through its lower extremity, the ostium maxillare, with the antrum of Highmore. All of these parts lie high up beneath the middle * Fig. 3. Kepresenting the Outer Wall of the Left Nasal Fossa, with the middle turbinated body turned upward to show beneath the hiatus semilunaris (printed in deep black), to the edges of which polyps are fre- quently attached. turbinated bone, which, in the natural state, hangs down over them like a curtain. To summarize ZuckerkamU’s post-mortem observations of forty-two distinct growths, he found that two-thinU originated from the middle meatus, find that, approximately, two-thirds of this number Avere attached to the edges of the hiatus semilunaris. With this knowledge, and judging from the superficial position of the neojdasm and the direction of its })cdicle toward its attachment, we can be reasonably cc'rtain of the deep jioint of origin even when such is not visible, and can often destroy the very root of the growth by insin- uating a properly-curved cautery jioint-electrode to the spot. Etiology. — The most common complication, acting also in a causal relation to nasal polypus, is hypertrophic rhinitis. Of course, additional factors are necessary to influence the perversion of a simple Iiyperjilasia of the mucosa into one of myxomatous type. Stenosis, whether induced by hypertrojihy of the inferior turbinated bodies, DISEASES OF THE NOSE. 839 septal deflections, or excrescences, results in defective drainage. Muco-purulent secretion, imprisoned and decomposing in the middle meatus and around the middle turbinated body, excites irritation and furnishes the most favorable soil for polyp grow th. Very narrow nostrils, because more readily stenosed, are predisposed, in this manner, to myxomata, and peculiar curvatures or deformities of the septum and middle tui’binated bodies, by obstructing drainage, have a like effect. A tendency to vaso-motor paresis of a diathetic or hereditary nature, wdiich, in certain subjects constitutes the basic lesion of bronchial asthma, will in the same individual underlie the development of nasal myxomata. The influence of hypertrophic rhinitis on the etiology and treatment is well illustrated in the following history : Miss T , fet. ten years. Total obstruction of the left nostril of one year’s duration. Enormous hypertrophy of the inferior turbinated bodies. Numerous polypi were closely impacted between the turbinated bodies and the septum ; they proceeded from the middle meatus, and were continuously im- bedded in a mass of thick, viscid muco-purulent secretion (Figs. 4 and 5). The Fig. 4. Polypi in the Middle Meatus, caused by hypertrophy of the inferior turbinated body (child aged ten years). Fig. 5. Lateral View of the Same (Fig. 4). polypi seemed secondary to the hypertropic rhinitis and defective drainage. On the right side hypertrophy was present, but was insufficient to obstruct the drainage, and no polypi were visible. Operations first by the cold wire snare resulted in the removal of numerous growths during repeated sittings, but without improvement. The polypi developed as rapidly as removed, springing up like mushrooms in the soggy soil maintained by the imprisoned secretions. The inferior turbinated body was next cauterized along its entire extent, being reduced in front almost to a rudiment, where it previously interfered with vision, instrumental passage, and drainage. One was enabled then to trace the tumors to their exact seat of attachment in the immediate vicinity of the hiatus semilunaris, and to thoroughly eradicate them by reaching that position with a cautery point. No recurrence. Cure complete. Again, Miss R , aet. twelve years. Has had catarrhal symptoms for some years, with adenoid vegetations and obstruction to the left nostril. Exami- nation Feb., 1893. A single polypus proceeds from the left middle meatus, and is traceable in the direction of the hiatus semilunaris, to which it is evi- 840 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. dently attached (Fig. 6). The inferior and middle turbinated bodies are hyper- tropliied, and obstruct drainage from the middle meatus. In Fig. 7, taken from an older subject, is depicted the manner in 'wliich a septal exci’escence, by serving as an obstruction to respiration and drainage, Fig. 6. Single Polypus in the Middle Meatus, caused by hyper- trophic rhinitis (child aet. 12). Fig. 7. septum. especially when conjoined with hypertrophy of the opposite turbinated body, as illustrated, may dam up the secretions in the middle meatus and encourage the growth of polyps. Septal excrescence often originates during the developing period of child- Fig. 8. hood, and is a deformity of the seyitum narium characterizt'd by an exuberant and jirojecting growth of bone ami cartilage along the sutural lines of the com- ponent bones and cartilages of the septum narium. The most freijuent location DISEASES OE THE NOSE. 841 is the sutural line of the vomer and the superior maxilla and cartilaginous septum just within the anterior nares and close to the floor of the nose (Fig. 8). Necrosing ethmoiditis of Woakes also figures as a persistent cause and com- plication of nasal polypus. It involves the nasal tributaries of the ethmoid bone, especially its process, the middle turbinated body, which usually appears cleft asunder, leaving a fissure down its centre, from which will protrude the polypi. This is illustrated in Fig. 9, which was taken from a patient, aged twenty years, who had suffered since childhood. Empyema of the antrum of Highmore, although rare with children, is also a prolific source of nasal polypus in adults, apparently caused by the constant presence of fetid pus in the middle meatus as it escapes from the antrum through the hiatus semilunaris. The form, aspect, and consistence of a myxoma has been compared to a grape-pulp. The natural shape is pyriform, but this is often varied by pressure. When small, it is sessile, but it becomes pedunculated by gravity as development proceeds, and the point where the pedicle is confounded with the tissues of attach- ment is known as the “root.” The color varies accord- ing to vascularization from gray to yellow and from yellow to pink and red. Patholog’ical Histolog’y. — A typical myxoma, or “myxoma hyalinum,” resembles in structure the vitre- ous body of the eye and the gelatin of Wharton of the umbilical cord. Micro- scopically, there are observed either a few roundish cells, as in the vitreous body, or scattered fusiform and stellate cells which send off anastomosing trabeculae, as in Wharton’s gelatin, or both together, and these are imbedded in a large quantity of a homogeneous gelatinous mucin containing intercellular substance. But myxomata rarely appear in this purely typical form, the “ myxoma hyalinum ” being prone to transformation into allied histological structures or to be represented from the beginning by one of its modified forms. Of these, the most common is the myxo-fibroma, which contains a greater but variable quantity of fibrous tissue. Those which are ordinarily called myxomata usu- ally contain enough of the fibrous element to include them, strictly speaking, within the class of myxo-fibromata. Symptoms. — The chief symptom is nasal stenosis, which increases with the development in size and number of the polypi until complete obstruction of one or both nostrils results. Mucous or muco-purulent discharge, cephal- algia, aural complications, and other symptoms of a catarrhal nature, together with those incident to mouth-breathing, are observed. To quote the words of a sufferer : “ It affects the sight, the hearing, the taste, and the smell, of course.” Spasmodic asthma, paroxysmal cough, and sneezing attacks are among the reflex phenomena which are occasionally excited. Diagnosis. — For diagnostic purposes it is usually only necessary to look with a good light and to feel with a probe in order to establish correspondence with the physical characters just described, but more rarely an accurate know- ledge of all pathological states is essential to a precise diagnosis. Treatment. — The treatment consists first in the establishment of free nasal passage for respiration, drainage, vision, and instrumental manipulation, and, to this end, in the reduction of hypertrophied turbinated bodies, and removal when Fig. 9. 842 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. necessary of septal excrescences by means of the nasal saw. Adenoid vegeta- tions, if present, should he removed. While this work is progressing such polypi as can be reached should be removed, and others as rapidly as access is gained. This is done preferably by the cold wire snare. But the real success of the treatment, after having gained access to the polypi, consists in tracing them to their points of attachment, and in thoroughly cauterizing these so-called roots ; if not at the same sitting, then at the next, remembering meanwhile the exact spot. Knowing the hiatus semilunaris to be a favorite point of origin, those polypi which proceed fi’om beneath the middle turbinated body should be followed up by insinuating to this point a fine electrode slightly curved on the fiat. The permanent success of the treatment will depend upon the possibility, in individual cases, of thus reaching the deep points of origin, and upon the establishment of good drainage in the nose. VI. Hereditary Syphilis of the Nose and Throat. Hereditary syphilis manifests itself in children at any time from birth to four months of age. It has, of course, originated during intra-uterine life, and simply progresses to the point of becoming particularly apparent in the upper respiratory tract during the period stated. In rarer cases it seemingly thus manifests itself first at the age of puberty, or, indeed, at any time pre- vious to this age, but in these cases it is doubtful whether the slighter symp- toms at the earliest period of life have not simply been overlooked. From birth onward the disease passes through stages Avhich in their symp- tomatology and pathology are identical with the secondary and tertiary stages of acquired syphilis. Thus, soon after birth syphilitic rhinitis is manifested by coryza, which, as the disease progresses, gradually develops into a muco- purulent discharge, the acrid secretion causing excoriation and incrustation at the margins of the nostrils. It is pi’ohahle that infiltration of the superficial layers of the mucosa by embryonic cells, and subsequent degeneration of the same into “mucous patches,” also occur; but a satisfactory examination of the interior of the nose is impossible at this early age, and a definite diagnosis of this stage may he depemlent upon the concomitant symptoms of syphilis. The disease, however, usually runs a rapid course, and the later manifestations, which correspond to the tertiary symptoms of the acr depths of the tis- sue or upon its surface, and is seemingly occasioned by the cutting oft’ of the blood-supply to this lowdy-vitalized material by pressure exerted in all direc- tions by the cells themselves. The cartilaginous septum narium soon disap- pears, the vomer is attacked, the nasal hones aJl'ected, and fhe external nasal appendage sinks backward and downward, ac(juiring the “saddle-hack ” deform- ity or “flat nose.” One or both ahe are not uncommojdy destroyed, and suh- se((uent cicatrization may obliterate the nasal orifices. In fact, there is no limit to the horrors of this disease when left unchecked, necrosis continuing until death is caused by haemorrhage or meningitis. DISEASES OF THE NOSE. 843 In the throat favorite points of attack are the velum palati and the junc- tion of the velum with the hard palate, as well as the palatal processes of the palate bone and of the superior maxillary bone. Thus, the cavities of the nose and mouth are caused to communicate by perforations of greater or less extent. The pillars of the fauces and the posterior pharyngeal wall are by no means exempt. The ulceration being deep, the following cicatrices must be exten- sive, and are found to be thick, dense, and prone to extreme degrees of con- traction, so that they appear, oftentimes, stellated or twisted and contorted into various shapes. They are comparable to, but worse than, the cicatrices which follow deep burns. In this way the pharynx and velum become adhe- rent, the throat being contorted and twisted apparently into one cicatricial mass, which may leave but a minute opening between the pharynx and naso-pharynx. Crusts accumulate in the nasal cavities, and the fetor is intense, occasioned both by the decomposing incrustations and necrosis of bone. Treatment. — The patient should be placed as rapidly as possible under the influence of mercury, which is best done by inunction with mercurial ointment. In many cases mercury alone seems superior to the potassium iodide or the mixed treatment. Attention to the bowels and care of the general health are not to be omitted, nutritious diet, fresh aii‘, and tonics being indicated. The local treatment is of the utmost importance. The ulcers must be kept absolutely clean and free from decomposing discharges. The means to this end are the same as those detailed in connection with atrophic rhinitis. As a topical application to the ulcers we value most highly the following solution : I^. lodi, Acidi tannici, . . . Potassii iodidi . . . Glycerini Aquae Sig. Apply by a cotton swab Under this treatment it is a veritable pleasure to watch the absorption of infiltrated masses and the cicatrization of the ulcers. . . . (Id . . . fsss. q. s. ad fBj. — M. CATARRHAL LARYNGITIS (SPASMODIC CROUP), By H. ILLOWAY, M. D., Cincinnati. Catarrh.\l Laryngitis, termed also spasmodic laryngitis, pseudo-croup (false croup), and acute laryngitis, is an acute inflammation of the mucous mem- brane lining the larynx, and not infrequently involves that of the trachea. The disease may present itself with varying intensity ; clinically, three distinct forms have been recognized — the mild, the severe, and the I’cr// grave. In addition to the usual symptoms we may have — and this is more especially true of the severe form — paroxysms of dyspnoea manifesting themselves, which by some are regarded as true laryngeal spasms. The catarrhal laryngitis with the paroxysms of dyspnoea superadded, which is frequently treated as a distinct disease, has been designated laryngitis stridulosa, angina stridulosa, and spasmodic laryngitis; it is also called pseudo-croup or false croup, to dis- tinguish it from true croup or pseudo-membranous laryngitis. Catarrhal laryngitis is a disease that occurs at all periods of child-life from birth up to the fifteenth year. Pseudo-croup is seen with greatest frequency between the second and fourth years. It is rarely seen before the secoml year, and still more rarely after the fifth year. It attacks children both strong and weak, and does not make much distinction between the children of the rich and those of the poor. It is said that boys are more prone to the disease tlian girls; there are, however, no sufficiently reliable statistics upon this point, as this disease has been confounded by many writers with laryngismus stridulus (spasm of the glottis), for which this statement holds good. Catarrhal laryngitis presents itself either as an idiojiathic affection or as a secondary and symptomatic one, and then usually in the course of some general disease. It occurs with greatest frequency in the colder months, about the beginning and end of winter. In certain latitudes, where the winters are rather milil and the snow melts very quickly and the streets are thus wet and slushy, it prevails throughout the whole winter. The sudden setting in of cold, wet days in summer may cause an outbreak of catarrhal laryngitis. Etiology. — The principal etiological factor is taking cold. A very young child may contract a cold by sitting on a cold floor, by throwing oft" the coverlet at night after the temperature of the room has cooled considerably, by a sudden transference from a very warm to a cold room, more particu- larly a cold draughty hall, or by being taken out on a cold, windy, blustery day; older children take cold by going out insufficiently clothed, by taking off top-coats in the street after having become heated at ])lay, by wading in water or in snow. Cold air inspired directly, and especially whilst the vocal organs are violently exercised, as in screaming or yelling, is not an infreipient cause of laryngeal catarrh. In some instances I have attributed attacks of pseudo- croup to the cold, moist atmosphere created in the bed-room by a floor scrubbed late in the evening and not thorougbly dried before the child was jnit to bed. VA TARRIIA L LA R YNGITIS. 845 In some children a predisposition to catarrhs of the upper air-passages un- doubtedly exists as the result of a faulty physical training, faulty domiciliary hygiene, and perhaps improper diet in combination with some of the other factors. Scrofulous, weak, antemic children, with proneness to coryza and to inflammatory affections of the tonsils, are more especially liable to attacks of pseudo-croup. A characteristic of this latter form of catarrhal laryngitis is the tendency to recurrence: children who have once had an attack of spasmodic laryngitis are liable to have a like attack after every, even very slight, expo- sure. After the fifth year, especially if placed under more favorable hygienic conditions, they soon outgrow this tendency ; I have, however, observed in- stances where children have remained croupy as late as their ninth year. It is this afl’ection which people really mean when they speak of their children having had three, four, or more attacks of croup. Whilst catarrhal laryngitis may be of the mild or severe type from the onset, the grave form is always an acute progression, chiefly due to neglect, of one or the other milder form. The child is allowed to play around at its will despite hoarsene.ss and cough, to expose itself to draughts, to get wetted by rain, till all at once the symptoms of the grave type manifest themselves. The majority of the cases of this character observed by me were due to premature exposure after an attack of measles, before the catarrhal laryngitis that usually accom- panies that disease had fully subsided. Laryngo-trachitis is frequently but part of a general inflammatory con- dition extending downward from the nose to the bronchi ; more rarely it is due to the upward extension of a tracheo-bronchitis. Occasionally it is due to the exciting influence of local irritants. The in- halation of hot steam, a very dusty atmosphere, and irritating vapors are not infrequent causes of catarrhal laryngitis. Baginsky reports a case where the prolonged inhalation of coal-gas produced a violent laryngo-trachitis. As a symptomatic expression of a general affection catarrhal laryngitis occurs in measles, scarlet fever, variola, and erysipelas. It may appear as a complication in typhoid fever, in broncho-pneumonia, and in pulmonary phthisis. Pathology. — The most reliable data concerning the coarser anatomical changes occurring in this disease have been obtained by laryngoscopic exami- nation. The principal features of a catarrhal laryngitis are hyperaemia, swelling of the mucous membrane, and rather abundant muco-purulent secretion, some- what viscid in character and found adhering to various sections of the laryngo- tracheal mucous membrane. Diffusion and intensity of the hypersemia may vary greatly. The inflammation may be confined to the entrance of the larynx or to the epiglottis (angina epiglottidea) ; it may be more marked in the mid- dle portion of the laryngeal cavity ; it may attack only the vocal cords and the posterior commissure, or it may be diffused over the whole of the larynx. The color of the mucous membrane may range from that of a slight vascular in- jection to a deep dusky red. The vocal cords may present an almost normal a|)- pearance, their lustre perhaps somewhat dimmed ; they may be more or less hyperaemic, or they may appear as two large rolls of deep red color by reason of marked swelling of their under surface. The tumefaction also varies in extent — sometimes so slight as just to prevent free movement of the vocal cords, at other times so great as to cause marked stenosis. The epithelium is exfoliated in patches, and shallow erosions there appear ; in other parts it will be seen swollen up and forming grayish circumscribed elevations. Small ulcers are sometimes seen, the result of destruction of the epithelial covering and of bursting of distended muciparous follicles. The secretion is at first scant, and if the catarrh be of the mild form and remain limited to the vocal cords, may 846 AMERICAN TEXT-BOOK OF DIREABEB OF CHILDREN. continue so throughout the whole course of the disease. Usually it is at first viscid and transparent like glass ; later on, by the addition of cell-detritus, it becomes turbid and yellowish gray. In the severe forms of catarrhal inflammation of the larynx the epiglottis presents a characteristic change of form ; the incurvation of its lateral borders, which to a certain extent is normal in childhood, becomes greater, and fre- quently gives it the appearance of a deep-red swollen stump, which can be seen even without a mirror by simply depressing the tongue. In the trachea the vascular injection is rarely a diffused one; only in the more intense forms do we find the whole mucous membrane deep red and velvety. Ordinarily the redness is here found in patches ; the tracheal rings can be readily recognized, and the mucous membrane covering them is less injected, paler than that of the interspaces. In the grave form the inflammation frequently involves the submucous tissue. For greater lucidity and better comprehension the various types will now be considered separately. I. The Mild Form (Laryngitis Oatarrhalis Simplex; Supraglot- Tic Laryngitis). Symptoms. — The main features of the disease are the change in the voice or cry and the cough. In young infants it is only the cry that is altered, whilst in older children the speaking voice is also changed ; they are hoarse. This hoarseness may be very slight, only noticeable to those familiar with the child, or marked and apparent at once to every one. There is almost never aphonia ; however, in infants who cry and scream a great deal aphonia may result from this. Older and more intelligent children may complain of a tick- ling or burning in the larynx or about the sternal region. Pressure over the cricoid cartilage or over the trachea usually produces manifestations of pain. There is not much cough ; it is chiefly due to voluntary efforts at expulsion of mucus. The cough is dry at the outset, but very soon becomes looser and softer, an indication of the resolution of the catarrhal process. It never has the barking tone of the severe type. Respiration remains unchanged. There are no paroxysms of dyspnoea. Generally there is greater hoarseness and more cough in the morning just upon awakening and in the evening. Fever is most frequently wanting ; when it does present itself, it is usually of slight degree. There is but little disturbance of the economy as a rule ; the child eats, phays ami sleeps about as usual. Acute rhinitis is almost always present ; at times some redness and swelling of the ])haryngeal mucous membrane may be noted. In some instances the child may complain of earache, which, how- ever, very soon disappears, or he may complain of a “cracking” in the ear, heard in the act of swallowing. Occasionally some bronchial catarrh may be present, as indicated by rales heard over the thorax. Laryngoscopic examination discloses a moderate hyperacmia of the larynx or a more intense hypenemia of the larynx and trachea. In the majority of cases it is limited to the supraglottic portion of the larynx. The posterior por- tion of the vocal cords, the posterior commissure, and the mucous membrane of the ventricular bands are the ])rincipal seat of the catarrh. There is but very little or no swelling of the mucous membrane. Course and Duration. — Under fair conditions the disease runs a very rapid and favorable course, ending in recovery. Its duration, dependent some- what u])on the degree of intensity, is from three to eight days. Either from CA TA RlillA L LA It YNGITIS. 847 neglect of the primary affection or from some inherent idiosyncrasy the disease may become chronic ; this, however, is rather a rare occurrence in young children. An acute progression into the severer forms is not very frequent. Complications. — Bronchitis or catarrhal pneumonia may develop in the course of a catarrhal laryngitis as a result of the downward extension of the inflammatory process. Diagnosis. — The diagnosis is not difficult. The hoarseness of the cry or of the voice, the cough, and the tenderness over the larynx will clearly indicate the seat of the affection. The mildness of the special symptoms, the absence of fever or its low degree, the undisturbed condition of the general economy, and the coincident rhinitis will indicate the type. Prognosis. — The prognosis is always favorable ; recovery is the rule. Treatment. — The treatment is simple. The child must he kept in the house and if possible in one well-ventilated room, the atmosphere of which is maintained at an equable temperature. If the room be heated by a stove, a pot of water should be kept constantly thereon to moisten the air. Attention must be paid to the child’s clothing that it shall be sufficiently warm, lest he should be chilled every time the door is opened or if he should happen to run out into an adjoining room or hall. If the bowels are co.stive, a laxative — e.g. a dose of castor oil — must be administered. When children object to taking oil or do not retain it upon the stomach, I have found the following formula answers the purpose very well : I^. Mass, hydrargyri grs. ij. Syr. mannae f^v. Syr. rhei aromat fsiij- — M. Sig. One teaspoonful every two hours till bowels are moved (for a child from two to four years old). Or this, I^. Aquse laxativm Viennensis (Ph. G.)‘ . . . . f .Ij. Syr. rhei aromat Sig. One teaspoonful every two hours till bowels are moved. For the local process in the larynx mild demulcent drinks are given, as warm milk sweetened, or milk and seltzer water, or oatmeal- or barley-water sweetened. Of medicines, some preparation of ammonia (I prefer the carbon- ate on account of its more agreeable taste), of ipecacuanha, or of both com- bined, or a combination of syrup of ipecacuanha and syrup of senega, will be of great benefit. For example: I^i. Ammonii carbonatis grs. ij-v. Syr. ipecacuanhae f^ij-^ii). Syr. senegae f^ij-^iij. Syr. tolutan q. s. ad f.5j. — M. Sig. One teaspoonful every two hours (for children from two to five years old). * Very much like the infusum sennee compositum of the U. S. P. ; instead of Epsom, Elochelle salts are used. 848 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. For children under two years I use the following formula: 1^. Ammonii carbonatis grs. ij. Mucilag. acaciae fsij- Vin. ipecacuanhse gtt. xxxv. Syr. senegse f 3j. Syr. tolutan (j. s. ad f ,li. — M. Sig. One teaspoonful every two hours. Externally a stimulating embrocation, as camphorated oil, with or without the addition of a little turpentine or of tincture of ginger, or amber oil, may be applied. If the child be of sufficient age and of sufficient intelligence, an inhalation from a steam atomizer of a mild solution of sodium bicarbonate in glycerin and water (a few drops of carbolic acid can be added to the solution for its antiseptic properties) may be given twice a day. In very young children inhalations cannot he satisfactorily administered, and are therefore useless. The rhinitis that is usually present should receive prompt attention. The nose should be sprayed every four hours ; for this purpose either a 1 or 2 per cent, solution of menthol in albolene or some astringent solution, like the following, should be used : Ih- Cocaine hydrochlorat grs. ij-iij- Acid, tannic • grs. v. A(j. destillat fsiv. Hydrogen peroxide fsj. Glycerini f.^iii. — M. Sig. Use as a spray. If fever be pre.sent, a few small doses of quinine will allay it. The choco- late (juinines (for very young children I have them powdered and administered in milk) are, hy reason of their tastelessness, excellent for this purpose ; two to four tablets may be given every four hours. If the cough is very troublesome at night, one-half to two grains of Dover’s powder or five to fifteen drops of the syrup of Dover’s powder, according to the age of the child, or a few doses of the bromide of ammonium, will procure a good night’s rest. Throughout, the diet should be a bland but nutritious one. II, The Severe Form ; Spasmodic Laryngitis (Laryngitis Stridu- LOS A ; Pseudo-Croup ; Catarrhal Croup). Symptoms. — The characteristic feature of the disease usually sets in sud- denly. The child has been asleep for three or four hours, sleeping quietly, when, either with preceding manifestations of restlessness or suddeidy, it wakes up with a suffocative attack. It coughs ; the cough is short, barking, deep-toned ; between the coughs the deep inspirations have a stridulous, crowing sound. Great anxiety is nianifeste . f5j. Aq. destill — M- Sig. Two teaspoonfuls with an equal quantity of water in cup of steam atomizer. ■ gr- vj. . gr. xij-xxij. — M. 856 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. After the imminent danger has been averted one or the other method of treatment can be employed. If antimony be selected, it should be the wine that is directed, and in such small doses that it cannot produce retching or emesis, so as not to dislodge the tube. Intubation is, in my opinion, to be preferred to tracheotomy for the middle and poorer classes, as it is almost im- possible for them to give the necessary attention to the patient that is required after the operation. The tube can be removed in from twelve to twenty-four hours. During the attack the child must be kept in bed in a well-ventilated room, the atmosphere of which should have a certain amount of moisture ; after sub- sidence of the attack, although he may be allowed to be up in the room, great care must be taken that he shall not run out or expose himself in any way. Convalescence being fully established, the warm drinks may, to a great extent, be withheld and the moisture of the room markedly lessened. The inhalations can be continued for some time, a weak astringent solution (alum 1 per cent.) taking the place, later, of the soda solution. An accompanying bronchitis or coryza must not be neglected. Prophylactic Treatment. — With children who have a tendency to catar- rhal affections of the upper respiratory tract a prophylactic treatment should be instituted early. They should be accustomed in the summer months to cold bathing, cold sponging, and cold frictions. If possible, they should be taken to the sea-shore or to the mountains for the summer. In winter, after being washed with warm water, the face, neck, and hands should be sponged off with cold water (just as it flows from the hydrant) ; after their warm bath (which should always be given in a warm room) the body should be well rub- bed with cold water or cold alcohol and water, and thoroughly dried. They should not be allowed to keep on topcoats or hats or shawls whilst in the house, or to run out of the house insufficiently clad. They should be dressed properly and not made sacrifices to the vanity of their parents, especial attention being paid to their foot-gear that it be water-proof ; during wet or snowy weather the shoes should be changed two or three times in the day. Their diet should be plain and wholesome, and not too stimulating. They must not be overburdened with studies. They .should be allowed sufficient exercise in the fresh air, even on very cold days, but with the direction that as soon as tired they must come into the house to rest : they must not rest out of doors. If the children are annemic or have a scrofulous taint, the proper remedies must be administered. LARYNGISMUS STRIDULUS. By H. ILLOWAY, M. D., Cincinnati. This condition — termed also Spasmus glottidis (spasm of the glottis) ; Asthma Millarii ; Asthma thymicum Koppii (thymic asthma) ; Asthma rachiti- cum — consists of paroxysms of spasmodic closure or narrowing of the glottis, causing complete or almost complete arrest of respiration, and occurring at longer or shorter intervals. Laryngismus stridulus is a neurosis of the larynx, that organ being gener- ally in a healthy state. It is an affection entirely distinct from spasmodic laryngitis (pseudo-croup), with which it has been identified, especially by many English writers. It is not to be confounded with true infantile asthma, which is an entirely different disease. Neither must it be confounded with internal convulsions (inward spasms), though it is true that spasm of the glottis may occur in inward spasms, and, vice versd, inward spasms may occur in the course of a protracted case of laryngismus ; in either instance, however, it is more in the nature of a complication which adds to the dangers of the primary affection and makes its prognosis more unfavorable. The paroxysm sets in always during inspiration, and is produced by spastic contraction of the muscles which normally possess the function of narrowing or closing the glottis — the adductors, the two thyro-arytenoids, the two lateral crico-arytenoids, and the arytenoideus muscle. This abnormal muscular action is the result of irritation, either direct or reflex, of the laryngeal recurrent nerve, or of the vagus above the point where the laryngeal recurrent is given off. Escherich, in his address before the Tenth International Congress, clearly indicates his belief that laryngismus stridulus is not a morbid entity, but merely a symptom of another affection — namely, latent tetany. He claims to have found the characteristic symptoms of the latter disease (Trousseau phenomenon, etc.) in all the cases presenting themselves for treatment for laryngospasm. Loos by his investigations confirms the views of Escherich. He also affirms that in all cases coming under his observation for laryngospasm he found, like Escherich, the characteristic symptoms of tetany. In his summary he says that it remains to be proven whether we ever have laryngospasm independent of the other symptoms of tetany. The disease is somewhat frequent in France ; more prevalent in England and Germany. From the latter country we have the greatest number of cases reported. According to good authority, it appears to be much more frequent in certain localities there than in others. In this country it is exceedingly rare, and but few American physicians have the opportunity of studying it by personal observation. This rarity is, I believe, readily explained by the fact that pap-feeding to infants is almost entirely unknown here. 857 858 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Laryngismus stridulus is essentially a disease of infiintile life, from birth to the close of the first dentition — two and a half years. The period of most fre- quent occurrence is, according to Friedreich, from the fourth to the fourteenth month. Barthez and Rilliet have observed the spasm almost exclusively be- tween the third week and the eighteenth month ; Flesh, between the fifth week and twenty-first month. Of 226 cases of laryngospasm observed by Steiner, 174 were in their first year, 52 in their second or third year. Salath^ saw four cases of laryngospasm in new-born infants ; Bowen, a fatal case in an infant six days old. The majorify of cases occur undoubtedly between the fourth and eighteenth months. This, however, does not preclude the occurrence of the disease at a much later period of child-life : Steffen reports a case of spasm of the glottis in a boy eight years old; Salath^, one of a child of twelve years. As regards sex, it is the consensus of observers that male children are more liable to the disease than female children. This is very clearly demonstrated by Steffen : of 554 cases compiled by him, 386 were boys and 168 were girls. The greater number of children attacked are rather stout and present a bloated appearance, as if they had undergone the stuffing process; much less frequently are really ati’ophic children affected. Most of them are markedly nervous; they do not sleep very well, cry a great deal and without cause, have a tendency to holding-breath spells, have very bad tempers, and want to be carried around the greater part of the time. The disease is most prevalent in the cold months of the year, winter and early spring, especially in March. Some would have this frequency due to the greater prevalence of catarrhal conditions at these periods. According to Flesh, it is due to the fact that children are kept much more confined to the house during these months. The experience of Mr. Robertson seems to fully cor- roborate this: he recommends “the free exposure of the infant out of doors for many hours daily to a dry cold atmosphere, and, if the air be dry, the colder the better.” It is more frequent in northern than in southern latitudes. Etiology. — The etiological factors of this disease can be properly divided into two groups: the constitutional and the local. Constitutional Causes. — Rickets. — Two-thirds of the children affected with laryngospasm present the stigmata of rickets, and some of these can be detected as early as the third month. The causal relation between the consti- tutional state and the laryngospasm is therefore apparently established ; as to its nature, opinions differ. Elsiisser believed that it lay in the craniotabes. This view has, however, been sufficiently controverted by the observations of many that the paroxysms occur not oidy when the child is lying down, but also when it is held up upon the arm or sitting up in its chair, and no pressure upon the head made. Furthermore, in many cases craniotabes has been found altogether wanting, although other .symptoms of rickets were present. In children afflicted with rickets the general nervous irritability is morbidly exaggerated. This Steffen holds responsible for the laryngismus. Moreover, by reason of the characteristic change in the shape of the thorax the respira- tions are more superficial and necessarily more fre()[uent. Now, if, by any cause, as an attack of coughing, screaming, great fright, swallowing the food too has- tily, sudden awakening or being awakened, sudden change of temperature from warm to cold (when the child is carried from a warm to a rather cold room), the uniform rhythm of respiration is interrupted, a hypenemia. of the brain and medulla is j)roduced, and the conditions favorable to the production of a spasm of the larynx developed. P'lesh admits the very frecjuent coincidence of laryngi.smus and rickets as set forth, but does not believe in the causal relation of the latter to the former. LA R YNGISM US STRII) UL US. 859 For him, not the rachitis, but the factors that gave rise to the cachexia, are the causes of the laryngeal spasm. “Faulty nutrition and injurious food, this and nothing else, are the/o«s et origo of spasm of the glottis.” Heredity . — Instances have been reported where the greater number or nearly all of the children of one family were affected wdth this neurosis. An hereditary predisposition has therefore been presumed. The cases, however, really prove nothing more than a continuance of the same vicious mode of nur- ture that called forth the disease in the first child ; for in other instances, where already two or more children had been affected, better attention to hygienic requirements and correct feeding kept all the subsequent children free there- from. The supposed special hereditary influence as an etiological factor has been discarded by most authors. Local Causes. — Dyspepsia; over-filling of the stomach; intestinal catarrh; over-distention of the intestines by faecal masses; great flatulence. Kopp’s theory that the disease is always due to enlarged thymus gland has been proven untenable by Friedleben and others. In rare instances it may be the etiolog- ical factor. Bronchial or tracheal glands enlarged or undergoing caseous degeneration, diseases of the heart, and enlarged liver are occasional causes of the spasm. Material diseases of the brain do not, according to Steffen’s observations, produce spasm of the glottis. Kyll quotes a case from Corrigan of Dublin which, despite all treatment, had lasted over three months. Acci- dentally it was discovered that pressure over the third and fourth cervical verte- brae was very painful and produced loud cries from the child. Two applications of four leeches, at an interval of two days, over the painful point removed all the symptoms and the child made a perfect recovery. Dentition is banished by many from the category of causes. Nevertheless, it is not at all improbable that in such vitiated states of the system, with per- version of many of the physiological functions, as the majority of the children present, the process of teething has a certain causative influence in the produc- tion of morbid phenomena. Catarrhs of the larynx, trachea, or bronchial tubes cannot of themselves produce spasm of the glottis by reflex irritation, but when they supervene in cases where it already exists they will aggravate it, and even recall it if it be disappearing. Mantel reports the case of a rachitic infant eight weeks old, in whom a very much thickened, congested, and elongated uvula appeared to be the cause of the spasm ; its removal, after other measures had failed, was followed by per- fect recovery. J. II. Bx’yan reports the case of a child suffering since its second week with tonic spasms of the larynx. The epiglottis was found irregular in outline and bent backward over the lai’yngeal cavity. The child also had a phimosis, and was fed upon undiluted cow’s milk. The spasm was attributed to a binding of the epiglottis, causing the aryteno-epiglottic folds to come almost into apposition, so that a slight stridor was produced on inspiration. With reference to this last point, it is well known that a certain amount of recurvation of the epiglottis is normal in young children, and cannot be regarded as a cause of the spasm. This seems confirmed by the results of the treatment in the case just referred to. On diluting the milk and relieving the phimosis by gradual dilatation the respirations lost their spasmodic character and became normal. Whether the phimosis had any direct effect in the production of the cramp remains to be determined by further observations: that it may give rise to morbid nervous phenomena is well known. In easily excitable children violent and prolonged crying, undue exertion 860 A 31 ERICA N TEXT- BOOK OF DISEASES OF CHILDREN. in running so as to materially interfere with the respiration, are capable of pro- voking a mild attack of spasm of the glottis. In a small number of cases, and more particularly of those occurring after the third year, no special cause for the cramp can be discovered. According to my observation, a hot, vitiated atmosphere in the sleeping apartment, whole families sleeping in one room, two, three, or more children in one bed, with doors and windows tightly closed, will account for some of these. In support of this view I would recall here the influence of this factor in the production of trismus. Pathology. — The structural changes found upon necropsy vary consider- ably. In so far as the spasm itself is concerned, the results are entirely nega- tive, nothing abnormal having as yet been discovered either in the nerves or the muscles of the larynx. In the majority of cases the rachitic changes in the bones and soft tissues present themselves. Craniotabes is frequently found wanting. Various morbid changes are found in the brain, mainly those due to the cachexia. In rare instances softening of the medulla oblongata has been seen. In the larynx traces of catarrh have been found ; occasionally a croupous exudation upon the larynx and trachea; very rarely ulceration. Bronchial or tracheal glands enlarged or undergoing caseous degeneration are sometimes found. The thy- mus gland is occasionally voluminous and juicy. A variable degree of pul- monary emphysema, as the result of the spasm, is always present. Various cardiac lesions have been noted. The stomach is not much affected. In the jejunum and ileum the solitary glands and Beyer’s patches are enormously swollen, broad, and pale ; concomi- tantly we have hyperplasia and sometimes caseation of the mesenteric and retro- peritoneal glands. The liver presents evidences of fatty degeneration. Symptoms. — A typical paroxysm presents the following picture : Sud- denly, without any prodroma on the part of the larynx or the other respiratory organs, the child, wlio has just been sleeping nicely or has been lively and play- ful upon its mother’s arm, in its chair, or has perhaps been a little fretful and crying, is seen to gasp for breath. It becomes rigid ; the head is thrown back and the neck arched forward. The face, more particularly about the nose and mouth, l)ecomes pale, cyanotic, or dusky red. The aim nasi are distended, and the forehead is covered with a cold perspiration. After a few seconds to a quarter of a minute a few whistling or crowing inspirations are heard ; arrest of respiration again follows, lasting from a few seconds to a minute, when the whistling sounds are again heard. After two or three more repetitions of this alternate crowing inspiration and arrest of respiration the crowing insj)irations are followed by expirations, the child can soon cry out lustily, normal respira- tion is established, and the paroxysm is over. These whistling or crowing sounds are made by the entrance of air through the narrowearents. In children past thirty months a favorable ]>rogTiosis can getierally be made. Treatment. — This can best l)e considered under two heads : 1. I’he tem- porary relief of the spasm. II. The cure of the underlying j)athological condition. I. From the brief duration of the s])asm the physician is hut rarely present when it occurs; and only accidentally, or if the ))aroxysms recur at short inter- vals, may he ha{)pen to witness it. The treatment, therefore, for the temporary relief of the s])asm lies mainly in the hands of the mother or nurse, and she should be properly instructed. In light cases it is not necessary to intervene at all ; otdy when the j)aroxysm is of longer duration or when it is made up of a series of attacks should measures for its arrest be instituted. 'I'he tongue should be lookeil aft(>r to see that it is not eiirleil l)ack over the laryngeal orifice, as occasionally happens. A large evacuating enema shouhl be given at LA R YNGIS3IUS STRID UL US. 863 once. The child shouhl he placed in a seniirecumbent position, all clothing loosened, and an ahundance of fresh air provided. Cold water may he splashed into the face and upon the chest, or sinapisms applied to the back of the neck and to various parts of the chest to excite respiration. A piece of ice wrapped in a cloth and applied over the epigastrium and lower part of the sternum has occasionally proved effective. Ammonia or ether may be held to the nose. Chloroform inhalations, recommended by Simpson, West, and others, are not regarded with much favor, probably for the reason that it is a dangerous remedy to leave in the hands of laymen, and for the further reason that when the respiration is completely arrested it can do no good. Morphia is highly spoken of by Henoch. It is given until drowsiness is produced, then stopped. A rectal injection of chloral hydrate, gr. v, in milk of asafoetida, f^ij, will very frequently prove effective. Pressure on the pneumogastric nerve, on the carotid arteries, is recommended. The fauces may be tickled with the finger or Avith a feather until emesis results. Morrell Mackenzie recommends putting a pinch of snuff into the child’s nose to produce sneezing. If the paroxysm be of great severity, cyanosis marked, and apnoea persist- ent, the child may be placed in a warm bath (temperature 9.5° F.), whilst cold Avater is dashed from a height upon the head and face ; or the child’s feet can be placed in a hot mustard foot-bath and a cold compress applied to the head. If the apparatus be at hand, the application of a strong induction current to the phrenic nerve, or of a galvanic current to vertebrae and thorax or over vertebrae and larynx, may prove beneficial. If the danger be imminent, intu- bation should immediately be resorted to ; if that alone prove ineffective, air can be bloAvn into the lungs through the tube and expiration promoted by pressure on the sides of the thorax. Tracheotomy is not in favor. Flesh, Avho has had a lai’ge experience, deprecates, as a rule, all interfer- ence Avith the child, with the exception of the evacuating enema. He asserts that all the other various measures resorted to are not only not beneficial, but positively injurious. As soon as the child can SAvalloAv the best remedy to be administered is musk, as tincture, in doses of 10-15 drops, or after the folloAving formula (Mackenzie) : I^. Moschi gr. iss. Sacchari albi Pulv. acacise dd gr. ij. Syr. aurantii florum 111 xx. Aquse adfsj. — M. Sig. For one dose, to be given every two hours. Tincture of castor and tincture of valerian are also recommended. In the interval, to prevent recurrence, or at least to modify the severity and frequency of the paroxysms, numerous remedies have been recommended : musk, castor, valerian, bromide of potassium, bromide of sodium, and chloral hydrate are the most effective. The selection of the remedy Avill depend in a great measure upon the condition of the child; in feeble children chloral hydrate should rather be avoided ; in dyspeptic cases the bromide of sodium will be preferred. Scarification or lancing of the gums is of no benefit, and therefore unnecessary. Care must be had that the child be not vexed or irritated, especially for the first forty-eight hours after instituting treatment : its wishes should be com- plied Avith and its Avhims humored. Some friendly face should be Avith the 864 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. child when it goes to sleep, and more particularly when it is about to wake up, so as to avoid all fright. Proper attention must be paid to the ventilation of the room and to all other hygienic requirements. The child must be taken out into the fresh air whenever the weather permits ; the experience of Robert- son in this respect has been already referred to. II. The principal point to be kept in view is undoubtedly the cure of the underlying pathological condition. All authors agree that the diet must be strictly regulated and all farinaceous food prohibited. All aliment must be given in fluid form, as thin as water. The only articles permitted are milk and beef tea. If the child be at the breast and the supply be ample, no other food must be given. If bottle-fed, the bottle must be put aside and the child fed with a spoon or feeding-cup. The milk must, at first, be diluted one half with water. It is of the greatest importance that the number of meals and the intervals at which they are given be properly regulated. In children under four months six meals per day at intervals of three hours are allowed ; over that age, only five meals per day are given. If possible, nothing should be given in the night ; if the child wake up and cry for its accustomed food, a little water can be given it, and after a while it will fall asleep again, and thus in two or three nights the habit of taking food at night may be broken up. As to quantity, at the outset not more than one half of the normal (juantity, according to the child’s age, should be given at one feeding. As the digestion improves, as shown by the improved character of the stools, the milk is diluted but one-third, and the quantity gradually increased, until the child gets about the full (juantity for its age. When the stools have become normal and have continued so for some time. Flesh recommends, for children over six months old, the addition to the beef tea of a small quantity of boiled lean beef finely chopped, and claims for it great restorative powers. After there has been no recurrence of the stridor for weeks, and not till then, a lit- tle zwieback or dry roll may be allowed ; at first but very little, and if well borne gradually increased. No .solid food must be given till after the child has passed its second year. The remedies employed in conjunction with this treatment are, in rachitic cases, cod-liver oil and phosphorus. Of the latter agent Baginski says that in some cases it has proved remarkably effective, inhibiting the paroxysms even before any effect upon the rachitis was noted. Where marked amvmia exists some preparation of iron is indicated. For enlarged glands the .syrup of the iodide of iron or iodide of iron and manganese must be prescribed. Local causes must be properly attended to ; complications must be treated according to their nature. FOREIGN BODIES IN THE LARYNX, TRACHEA, AND BRONCHI. By JOHN B. DEAYER, M. D., Philadelphia. The entrance of a foreign body into the larynx or any of the more remote portions of the air-passages is, fortunately, a condition of somewhat rare occur- rence. When such entrance does happen, it is, in the majority of instances, by way of the mouth, but it may also occur through penetration of' the walls of the larynx or trachea. The infrequency of such accidental lodgements as may occur through the normal opening of the larynx is directly due to the rapidity with which the orifice is closed by the epiglottis. A foreign body having, however, entered the cavity of the larynx, it is very likely to have its downward progress arrested by the apposition of the contig- uous borders of the aryteno-epiglottidean folds and the true vocal cords, and to be expelled from this position by the cough Avhich its presence excites. On the contrary, it may, owing to relaxation of the vocal cords, pass through the glottis, and into the trachea or one or other of the bronchi. It is rather exceptional for a foreign substance to enter the larynx during deglutition, except where there is paralysis of the gustatory muscles, such as may follow diphtheria, or where, as the result of ulceration, there is a partial or complete destruction of the epiglottis. Strong inspiratory efforts Avhile feeding or Avhile the mouth contains any substance are most frequently responsible for the entrance of par- ticles of food or other material into the larynx. A sudden attempt to breathe, laugh, or speak, a sneeze, or a sudden blow, all favor the occurrence of such an accident through relaxation of the muscles. The amount of obstruction occasioned by the entrance of a foreign body into the air-passages depends upon the character as well as the size of the object. If of organic nature, such as a bean, pea, or grain of corn, the obstruction Avill be progressive, owing to swelling through absorption of moisture. Of inorganic materials, the most frequently met with are pins, needles, buttons, coins, and teeth. The situation and mobility of tbe foreign body are dependent upon its general characteristics, such as its shape, size, and Aveight, and the amount of force Avith Avhich it enters. Statistics show that the most common location is in the trachea, next in the larynx, and lastly, in the right bronchus. The right bronchus is more commonly the seat of obstruction than the left, for the reason that it is the larger and arises higher, and that the septum at the point of bifurcation inclines to the left. Symptoms. — The symptoms excited by the entrance of a foreign body into the air-passages are — violent convulsive cough, a sense of suffocation, fear of impending death, and pronounced dyspnoea. If the body is retained but does not entirely occlude the passage-Avay, these symptoms recur with less- 55 865 866 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. ened severity in the form of a short, harsh cough attended with pain referred to the lower part of the neck, and increased expectoration, which may or may not be bloody. If the position of the foreign body is changed by respiration, the symptoms recur at shorter intervals. The body not being expelled with' the subsidence of the symptoms is an evidence of impaction. A foreign body which has been lodged in the air-passage for a considerable period may sud- denly give rise to symptoms of obstruction due to displacement from the seat of impaction. The symptoms excited by the presence of an irregular, angular, or sharply-pointed mass are always more severe; the cough is increased, the interval between the spasmodic attacks is shortened, and the pain is more commonly referred to the larynx. In addition to these symptoms there are evidences of inflammatory disturbance, such as elevation of temperature, in- creased pulse-rate, increased secretion and expectoration, and dyspnoea with pain and tenderness over the seat of lodgement. Symptoms suggestive of incipient pulmonary tuberculosis consequent upon the presence of an unsuspected and impacted body have suddenly abated upon the expulsion or removal of the same. In case of impaction, constant pain, generally located in the upper part of the chest, or a dragging sensation referred to either side of the chest, coupled with the above symptoms, may aid in locating the body. There may be also huskiness of the voice, stridulous breathing, and a cough resulting from deep inspiration, which may be accompanied by mucous or muco-purulent expectoration. If a bronchus be entirely occluded, the lung of the corresponding side may collapse, in which case the normal respiratory phe- nomena Avill be absent. As a result of the extension of the inflammation by contiguity, the lungs may become involved, and the character of the expecto- rated material will be changed, becoming darker and more offensive. Paroxysms of cough, night-sweats, loss of sleep, and great depression will folloAv and death from exhaustion probably result. When the foreign body is smooth, rounded, and movable, but little inconvenience may be experienced from its ])resence, and if in the person of a child old enough to describe his sensations, he may complain simply of a feeling of something moving in the Avindpipc. Diagnosis. — The character of the symptoms and a careful inquiry into the history of the case will materially assist in forming a diagnosis. In the absence of any history of the entrance of a foreign body, the abru])t onset of symptoms of suffocation in a child previously Avell is sufficiently significant to suggest the character of the obstruction. Acute laryngitis and croup are conditions which may simulate to some extent obstruction by a foreign body, and may call for careful examination in making a diagnosis. In the case of a foreign body the voice is not necessarily changed unless the offending substance be located in tbe larynx, in Avhich case there is aj)lionia ; in croup the voice is harsh and high-pitched. In croup or acute laryngitis there is stridulous breathing, Avhich becomes more marked as the case advances ; this is not true of a foreign body. In the latter case, the respiratory embarrassment is more pronounced on expira- tion, while in croup the difficulty occurs on inspiration. To distinguish obstruction by a foreign body in the air-passage from one in the pharynx or oesophagus, it Avill suffice to make a digital examination of the ])harynx or an exploration of the ocsojffiagus Avith the oesophageal bougie. In a case of impaction of a partial ])latc of artificial teeth in the conimencement of the oesophagus, Avhere I Avas obliged to perform oesophagotomy for its removal, the symptoms were believed to be due to its ])rescnce iii the larynx. The intro- duction of an oesophageal bougie immediately cleared up the doubt as to loca- tion and position in this particular case. 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By Lawrence Wolff, M.D. Third edition, enlarged by some 300 Essential Formulae, selected from eminent authorities, by Wm. M. Powell, M.D. (Double number, $ 2 . 00 .') 10. ESSENTIALS OF GYN^dECOLOGY. By Edwin B. Cragin, M.D. Fourth edition, revised. 11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, M.D. Third edition, revised and enlarged. {$ 1.00 net.) 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. By C. E. Armand Semple, M.D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. By Edward Jackson, M.D., and E. B. Gi.eason, M.D. Second ed., revised. 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, M.D. Second edition. 16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, M.D. Colored “ Vogel Scale.” (75 cents.) 17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, M.D. (^i . 50 net.) 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. Second edition, revised and enlarged. 20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, revised. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. SllAW, M.D. Third edition, revised. 22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D. Second edition, revised. ($ 1.00 net.) 23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., and Edward S. I.awrance, M.D. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D. Second edition, revised and greatly enlarged. Pamphlet containing specimen pages, etc. sent free upon application. W. B. SAUNDERS, Publisher, 925 Walnut Street, Philadelphia. FOREIGN BODIES IN LARYNX AND TRACHEA. 867 it was found at the autopsy that an opening into the larynx had occurred as the result of ulcerative perforation. While oedema of the glottis may result from the presence of a foreign body, yet it may arise as an independent condition, following injury to the larynx, or the swallowing of chemical irritants of any kind, or it may accompany tubercular, syphilitic, or some other form of ulceration. The diagnosis between foreign body and oedema of the glottis rests largely on the history of the case and upon digital examination, by which is detected swelling of either the epiglottis, the glottis, or of both as the case may be. Further, as mentioned before, the respiratory embarrassment in foreign body is more marked on expiration, Avhile in oedema of the glottis, if seen early, the embarrassment occiu’s on inspiration only, and in the later stages during both inspiration and expiration. Laryngeal obstruction associated Avith lymphatic enlargement of the deep ' chain of cervical glands gives rise to a series of symptoms, the onset of which are gradual, and consist in the presence of a tumor of sIoav groAvth, Avith some constitutional evidence of a tubercular diathesis. The symptoms of aj>parent obstruction in this class of cases are not due so much to pressure upon the air- passage as upon the laryngeal nerves. The advantages to be derived from a laryngoscopic examination in children are practically nil, unless anaesthesia be employed, and even under these con- ditions may prove unsatisfactory. The urgency of the symptoms in the case of a foreign body Avould contraindicate an examination of this kind in the majority of cases, because the manipulation necessary to accomplish it Avould be attended by more risk than the operation for removal. In those cases where the immediate symptoms of obstruction subside consequent upon the impaction or the lodgement of the body, an examination may be attempted. Auscultation may be of value in locating the position of the mass, Avhich, if in the larynx, may create rough sounds synchronous Avith respiration. In con- nection Avith the other symptoms of obstruction, if in the trachea, the body may be detected moving Avith respiration, and even heard to strike against the Avail of the Avindpipe, Avhile, if in a bronchus or one of the bronchial tubes, the normal vesicular murmur upon the corresponding side is aljsent or modified. Prognosis. — The presence of a foreign body in the air-passages subjects the patient to great danger. For the first seventy-tAvo hours at least the greatest danger is from suffocation, as the body is liable to be forced into the larynx and cause total obstruction. Thereafter the risk is from haemorrhage, inflammation, ulceration or abscess, septicaemia, and death from exhaustion. When the substance becomes impacted in a bronchial tube the irritation excited by its presence may involve the parenchyma of the lung, causing a local pneumonia Avhich is sometimes folloAved by j)ulmonary abscess. Other organs may become involved through the extension of inflammation by con- tiguity of tissue — namely, the pericardium, the pleura, and the liver. Treatment. — All cases of foreign body in the air-passages giving rise to urgent symptoms call for prompt and, in most instances, radical treatment. Nature alone should not be depended upon to expel the offending mass ; neither should delay be encouraged in the event of the subsidence of the symp- toms, granting that there be no doubt as to its presence. To induce vomiting by the administration of emetics or by mechanical means, is fraught Avith, to say the least, some risk, and may cause obstruction by impaction in the glottis. If emetics be employed, everything necessary for immediate operation should be in readiness. The practice of inverting the patient and employing succus- sion with the hope of dislodging the body should be practised only under 868 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN exceptional circumstances, and resorted to only when no other means are at hand. This form of treatment, like that by emetics, is open to the objection of danger from immediate suftbcation. The class of cases in which either of these means is most likely to prove successful is where the obstruction is due to lodge- ment of the mass in the pharynx or oesophagus. Here, however, if the body cannot be extracted through the mouth or forced into the stomach by the intro- duction of an oesophageal bougie, it is not likely that emesis or inversion and succussion will succeed in dislodmnof it. CD O The diagnosis of the presence of a foreign body having been established, the advisability of immediately opening the windpipe, in the event of extraction through the mouth not being feasible, I believe cannot be too strongly urged, as the imminent risk of suftbcation is thus removed and the safety of the patient increased. For if the body is not expelled after the windpipe has been opened, impending suffocation is relieved. During the time necessarily consumed in opening the windpipe the respirations, which are already embarrassed, may cease. Should this occur, the operation is to be hastily completed and artificial respiration resorted to. If possible, an anaes- thetic, preferably chloroform, should be administered to prevent pain and allay spasm. With the child anaesthetized the surgeon works to a better advantage, both to himself and to his patient. If time is not a factor, the interval between the paroxysms of dyspncea is the most favorable for operation, as in this period the child is comparatively comfortable, and the operator can work without undue haste. The mere opening of the windpipe does not entail much risk if performed during the period of calm ; in fact, less than when done for other conditions. With the extraction of the foreign body the chief source of danger is removed, and if done early the necessity for the introduction of a tracheal tube may not be called foi’, thus simplifying the case, and lessening, particularly, the chances of post-operative pneumonia. On the location of the foreign body depends the choice of operation. If diagnosed as occupying the larynx, laryngotomy is advisable on account of its simplicity, the rapidity with which it can be performed, and its aftbrding a more thorough command of the interior of the larynx. If the body is too large to be extracted through this opening, which may be the case in very young children, the space may be enlarged by cutting the cricoid cartilage, and, if necessary, prolonging it into the trachea, making a laryngo-trache- otomy. The entrance of air through this opening may cause tlie body to be expelled upon expiration through either the incision or the mouth. If the mass is supposed to be located in the upper part of the trachea the high opera- tion is preferable, wliile if situated lower down in the trachea or in a bronchus the lower operation will be necessary. Occasionally the foreign body, if sharply pointed and impacted, may be detected from without, and then an incision may be carried directly down upon it. In performing any operation on the air-passages the child shoidd be brought under the effect of the aiuTcsthetic before being placed in the customary ])osition. A free incision should be made in the median line of the neck, and the trachea or the crico-thyroid membrane exposed, as the case may be, by care- fully dissecting down upon it. The mistake which I think is often made is that of too small an incision through the skin and fascim. A free incision not only affords more room, but gives the operator a better o])portunity of recog- nizing the anatomical landmarks, and of eomipleting the operation with rapidity and safety. In the high ojieration of tracheotomy the middle lobe (isthmus) of the thyroid gland is to be displaced downward or diviiled between two ligatures. In the low operation the anomalous position sometimes FOREIGN BODIES IN LARYNX AND TRACHEA. 869 held by the vessels iimst be borne in mind ; also the difficulty which may be experienced in dealing Avith the thyroid plexus of veins. Upon the exposure and division of the tracheal fascia (the last layer of the structures overlying the trachea) air enters between it and the trachea, giving rise to an emphy- sematous condition by Avhich is occasioned a sound not unlike the entrance of air into the trachea when opened, and this may mislead the operator. A free incision should also be made into the trachea, thus allowing the entrance of a large volume of air, which favors the expulsion of the body. Immediately upon opening the trachea there escapes a frothy mucus or a muco-purulent secretion, depending upon the length of time the foreign body has been pres- ent. The tracheal wound should be retracted, when, if the body is not seen or expelled, an attempt to favor its expulsion should be made by exciting cough by irritating the lining membrane with a feather or a camel’s-hair brush. If the body be not expelled by either of these means, an attempt to locate and to extract it should be made. Should this fail, inversion and succussion may be resorted to, this practice not being objectionable after the windpipe has been opened. The finger, with well-smoothed nail, undoubtedly offers the best means of locating the foreign body when the size of the windpipe is suf- ficient. The sensation communicated to it is far more accurate than that obtained through the medium of an instrument. When this manner of pro- cedure is not feasible, the location of the foreign body may be attempted by the introduction of an English catheter without the stylet, a tracheal probe, or the curved laryngeal forceps. The body having been located, its extrac- tion with a pair of laryngeal forceps should follow ; when it holds a transverse position in the air-passage, a blunt hook may facilitate its removal. If the foreign body be retained, despite all efforts for its removal, a tracheal tube should not be introduced, but the wound in the trachea is to be kept widely open by retractors retained in position ; or the edges of the tracheal wound, including the skin and fascia, may be transfixed by sutures, the ends of which are left long and tied at the back of the neck. During this time the patient must be constantly Avatched, so that if the body appears at the bottom of the wound, it can be removed. A foreign body in the larynx too large to be extracted through the Avound made in the crico- thyroid membrane or the windpipe may call for partial or complete division of the thyroid cartilage (thyroidotomy). The propriety of introducing a tracheal tube after operation Avill depend upon the amount of injury the larynx or trachea has sustained. When the operation is completed Avithout the intro- duction of a tube, I should advise against suturing the trachea. If the foreign body occupies a bronchus, its extraction can only be safely accomplished by means of low tracheotomy, and the subsequent use of Dur- ham’s flexible laryngeal forceps or a stout flexible wire bent in the shape of a blunt hook. The hope of opening a bronchus through the chest-wall, as a preliminary to extraction, has been clearly demonstrated by experiments upon animals to be both a useless and a fatal procedure, especially in the light of the cases where a foreign body has been expelled from a bronchus several days after the operation of tracheotomy. TRACHEOTOMY. By henry R. WHARTON, M. H., Philadelphia. The operation of tracheotomy consists in opening the trachea by an incis- ion through the tissues in the anterior region of the neck, as nearly as possi- ble in the middle line, and is a surgical procedure which is adapted for the relief of dyspnoea due to laryngeal or tracheal obstruction. The operation may be reciuired to relieve the dyspnoea dependent upon membranous or diph- theritic laryngitis, or oedema of the mucous membrane of the larynx or trachea from inllammation due to burns or scalds, or to the inhalation of irritating gases, or the swallowing of corrosive liquids. The operation may be indicated to relieve dyspnoea arising from growths in the larynx or trachea; from growths external to these organs, but causing pressure upon them ; and it may also be required for the removal of foreign bodies from the larynx or trachea, as well as for the relief of dyspnoea due to their presence. Tracheotomy may also be called for in cases of fracture or laceration of the larynx or in cases of spasm of the glottis. The indication for operation in all of these cases is a form of obstructive dyspnoea Avhich threatens life. The most reliable symptoms of tracheal or laryngeal obstruction are reces- sion of the anterior and lower portion of the chest-walls, forcible retraction of the tissues of the epigastrium and of the suprasternal notch, and of the supra- clavicular and intercostal spaces during inspiration. Where these symptoms are marked there exists some serious mechanical obstruction to the entrance of air into the lungs. A child suffering from well-marked obstructive dyspncea has more or less suppression of the voice, and presents lividity of the lips, blue- ness of the finger-tips, and, as the dyspnoea increases, becomes restless and cannot breathe in a recumbent posture, is unable to sleep, sits up in bed, clutches at his throat as if to remove the offending substance, and presents a jiic- ture of distress which, w’hen it has once been observed, cannot well be forgotten. By the change of position the auxiliary muscles of respiration are brought into play ; and the restle.ssness and inability to sleej), except at short intervals, are explained by the well-known fact that in normal sleep the action of the dia- j)hragm is diminisheil, but, when obstructive dys])noea is ))resent, its action is exaggerated, so that sleep is impossible. A mistake should not be made in confounding labored breathing, which is always present in cases in whieh there exists mechanical obstruction to the entrance of air into the lungs, with fre- (juent breathing, which depends upon diminished air-capacity of the lungs. I call special attention to this symptom — labored breathing — as I am freciuontly called to see cases to ])crform tracheotomy w'here the mistake is made in con- founding these two forms of dyspnoea. The operation of tracheotomy is considered by some surgeons a minor, by others a major operation ; but my own experience leads me to consider it a delicate and anxious one, for the condition calling for its performance is one 870 TRA CHEOTOMY. 871 which involves a vital function ; and, although the operator may often be sur- prised at the facility with which the trachea is exposed and opened, yet in other cases presenting apparently similar conditions he may at each step be met with difficulties which render it a most formidable surgical procedure. I think Mr. Marsh places the operation in its proper position when he says that tracheotomy should be regarded as a delicate operation which requires coolness and caution in its performance, rather than one which is very difficult or dangerous. I am decidedly of the opinion that in this operation coolness in the operator is a matter of the first importance, and that, in spite of the alarming symptoms that may be presented, the judicious surgeon will not allow himself to be unduly hurried in its performance, bearing in mind the fact that in cases of obstructive dyspnoea, except in certain very rare instances, death comes on slowly, that there is generally more time than at first appears, and that precipitated action at the beginning of the operation may cause much time to be lost before its completion. Tracheotomy is most frequently called for in young children, and in this class of patients certain anatomical conditions are present, such as shortness of the neck, abundance of adipose tissue, great vascularity of the parts, a relatively larger size of tlie isthmus of the thyroid gland, and the possible presence of the thymus gland; all these conditions render the trachea difficult to expose and open. The time at which tracheotomy should be performed in cases of obstruc- tive dyspnoea is a point upon which there exists some diversity of opinion. Some operators insist that it should be undertaken as soon as the dyspnoea is well marked, while others postpone surgical interference until the symptoms have become so urgent as speedily to threaten life. I am of the o])inion that the operation should not be performed until the dyspnoea is marked and increasing, unless it be due to the presence of a foreign body or a growth in the air-passages, or to an injury of the larynx or trachea, under which cir- cumstances there is no reason to delay. In cases of dyspnoea due to mem- branous laryngitis or inflammatory conditions of the larynx or trachea, I think the surgeon should be largely guided as to the proper time for interference by the urgency of the dyspnoea and the constitutional condition of the patient. When a patient presents the marked symptoms of dyspnoea wdiich have been previously pointed out, and in addition exhibits extreme restlessness and ina- bility to sleep, I think nothing is to be gained by delaying the procedure, for I have never seen such cases recover without operative interference. If, how- ever, he can sleep for a few minutes at short intervals, although the symp- toms of obstruction are present — I am in favor of postponing the operation, since under such circumstances I have seen very urgent cases recover without tracheotomy. Another question on which the surgeon is consulted is the advisability of performing tracheotomy in very advanced cases. Here, if an examination of the patient sliows that he is not dying of cardiac failure and auscultation of the chest reveals the fact that air is entering the lungs, even though there may be evidence of extension of the membrane into the bronchial tubes, I consider that the urgency of the symptoms presented certainly demands the performance of the operation ; for in a number of these most unpromising cases, where the patients have been app.arently moribund at the time of operation, I have seen recovery follow. The operation usually prolongs life even if it does not save it, and generally prevents the patient from dying by a most distressing form of death — strangulation — for in my experience death from recurrent obstruc- tion after tracheotomy is comparatively rare, the majority of cases perishing from pneumonia, from heart failure, or from general adynamia. Many cases 872 AMERICAN TEXT-BOOK OF DISEASED OF CHILDREN. of croup are unquestionably allowed to die without operation where, possibly, tracheotomy might have averted the fatal issue; for there is, unfortunately, among the people a tendency to attribute death, if it results after the operation, to the surgical procedure itself, and not to the disease which necessitated its performance. It is often difficult for this reason to obtain the consent of parents to have the operation performed upon their children, but this opposition may generally he overcome by a candid statement as to what may he accomplished by the j>rocedure. I think there is also among the profession too much tend- ency to look upon tracheotomy as a last resort, and after it has been performed to relax the local and constitutional treatment of the case ; hut this is mani- festly unwise, for the operation simply fulfils one of the indications in the treat- ment — viz. to remedy the imperfect air-supply ; and it does not supplant previous appropriate constitutional or local measures. It may be laid down as a safe rule of practice that tracheotomy is indicated in all cases of persistent and increasing dyspnoea due to mechanical obstruction of the larynx or adja- cent parts of the trachea. Anatomy of the Anterior Region of the Neck. In the operation of tracheotomy it is essential that the operator should bear in mind the anatomical structure of the anterior region of the neck. In cut- ting down upon the trachea in the middle line of the neck from the cricoid cartilage to the sternum, as soon as the skin has been divided the superficial fascia is exposed, and beneath this is the deep cervical fascia, Avhich encloses the sterno-hyoid and sterno-thyroid muscles. The veins of the neck are most important in their relation to tracheotomy, because they are often irregular in distribution, and from the fact that in all forms of pulmonary obstruction they become greatly distended, and injuries to them may he followed by very profuse haemorrhage. Upon opening the superficial fascia a large superficial venous branch, the superficial anterior jugular vein, may be met with, or there may he two veins running parallel with the trachea on each side of the median line, which communicate by a large transverse branch at the lower part of the neck ; they are usually placed one on each side of the median line ; one may he larger than the other, or one may cross the median line and empty into its fellow. A large plexus of veins also surrounds the thyroid isthmus, opening above into the superior thyroid and below into the inferior thyroid vein. The innominate vein on the left side occasionally rises above the level of the ster- num, and has been exposed and injured during the operation of tracheotomy. The sterno-lii/oid and sterno-thyroid muscles are most important landmarks in this operation. At their u))per attachment they are not (jiiite in contact, and as they descend the neck they are further separated ; the space between them, which occupies the median line of the neck, is a most important guide to the operator. The arteries of the neck Avhich are of most importance in the operation are the crico-thyroid artery, a branch of the superior thyroid, and the thyroidea ima, an irregular branch from the aortic arch or from the innominate. In children the innominate artery occasionally rises into the pretracheal space, and this vessel was once exposed by Liicke below the isthmus of the thyroid in per- forming tracheotomy. ^ITie isthmus of the thyroid gland is a very imjiortant structure in the operation of tracheotomy, and varies much in size in dift'erent individuals. It is generally largely developed in children, often covering the second or third rings of the trachea, ami in some cases extending higher and covei’ing. the cricoid cartilage. 2'he thymus gland, in children under two years TRA CHEO TOMY. 873 of age, may be exposed in opening the trachea below the isthmus of the thyroid gland ; I have myself seen it present in a number of cases in young children. The trachea begins at the lower border of the cricoid cartilage and terminates opposite the fourth dorsal vertebra, although its surgical limit is the upper border of the sternum. It is most superficial near the cricoid cartilage, is sur- rounded by loose cellular tissue or the tracheal fascia, and is more movable in children than in adults. Its size varies in different individuals of the same age, being larger in male than in female children. The diameter of the trachea under eighteen months of age is about 4 mm. ; from two to four years, 6 mm. ; from eight to twelve years, 10 mm. Tracheotomy in Diphtheritic or Membranous Laryngitis. In children suffering from membranous or diphtheritic laryngitis obstruc- tive dyspnoea is most common ; and it is in this class of cases that the surgeon is most frequently called upon to perform tracheotomy. Indications for Operation. — In diphtheritic or membranous laryngitis the symptom calling for operative interference is a form of obstructive dyspnoea characterized by suppression of the voice, great difficulty in inspiration, lividity of the lips, depression of the suprasternal and supraclavicular spaces, sinking of the lower part of the chest, inability to breathe in the recumbent posture, great restlessness, and inability to sleep. These symptoms being present and increasing, I think that the operation of tracheotomy is urgently indicated. Prognosis of Tracheotomy in Diphtheritic or Membranous Laryn- gitis. — It is to be expected that the prognosis under the above conditions is more unfavorable than in cases where the operation is undertaken for the relief of dyspnoea due to simple inflammatory affections of the larynx or to the presence of foreign bodies in the aii-passages. This is not remarkable when we con- sider the fact that, in addition to the local condition of the larynx or trachea which necessitates the surgical interference, there exists a most grave consti- tutional disease which is very fatal in childhood, even in cases where no symp- toms of obstructive dyspnoea are developed. An examination of large collec- tions of recorded cases best shows the results following tracheotomy in this class of cases. Cohen, in the study of 5000 tracheotomies for croup and diphtheria, found that about 1 case in 4 recovered after the operation. Krbnlein reports 504 similar cases, with 29.2 per cent, of recoveries. Chaym, in 1000 trache- otomies, gives the proportion of recoveries as about 1 in 4. Mastin, in a col- lection of 863 tracheotomies for diphtheritic croup in the United States, shows that the recoveries Avere about 26 per cent. At the Children’s Hospital of Philadelphia the percentage of recoveries in all cases of croup operated upon to the present time has been about 43 per cent. Lovett and Munroe, in a col- lection of 21,853 tracheotomies for diphtheria and croup, drawn from all sources, show that there were 6135 recoveries and 15,552 deaths, or about 28 per cent, of recoveries. The statistics of individual operators are often more favorable in a limited number of cases, some being able to show more than 50 percent, of recoveries ; but such statistics are manifestly unreliable, as addi- tional cases would probably very markedly diminish the proportion of successes. In a series of 5 tracheotomies for diphtheritic laryngitis I have had 4 re- coveries, while in 6 operations preceding this series the result was uniformly fatal. In 15 tracheotomies recently performed at the Children’s Hospital there were 8 recoveries — a result which even the most enthusiastic advocate of the operation could not hope to sustain with additional cases. In recent years it 874 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN seems the results of tracheotomy for diphtheritic laryngitis have been more favorable, depending possibly upon better judgment as to the time of the operation and the greater care ■which is exercised in the details of after-treat- ment, as ■well as upon the improved constitutional treatment of the disease. By comparison of a large number of operations for diphtheritic or membranous laryngitis, it will be seen that the proportion of recoveries is very similar ; that is, about 1 recovery in every 4 cases. Age in the Prognosis. — The age of the patient is a very important factor in the prognosis. In infants and very young children recoveries are not very numerous after the operation, yet there have been enough successful cases to show that age alone is not a contra-indication to tracheotomy in this class of patients. A successful case is reported by Scoutetten in an infant of six weeks, one at two months by Steinmeyer, at three months by Annandale, at five months by Croft, at six months by Kisler ; and from this age to two years a number of successful results have been reported. Krdnlein, in 85 cases of tracheotomy in children under two years of age, reports 11 recoveries. Chaym, in 997 cases in children two years of age and under, found that only 15.5 per cent, recovered. Archambault, of the Childi’en’s Hospital of Paris, presents some statistics bear- ing upon the results of this operation at different ages : Of 976 cases in children “■ 8^2 “ “ “ 736 “ “ “ “ 497 “ “ “ “ 547 “ “ from 1 to 3 years of u 3 “ 4 “ “ “ 4 o 5 u u “ 5 “ 6 “ “ over 6 years of age. age, 104 recovered. “ 175 “ 174 “ “ 148 198 It will be seen from these facts that very early age affects the prognosis unfavor- ably, but it also must be borne in mind that the disease for which the operation is performed is itself more fatal in infants and young childi’cn. Instruments Required for Tracheotomy. — In an emergency tracheotomy may be performed with very few implements, but if the surgeon has the choice he will find it convenient to have the following instruments at hand : 2 Small scalpels, 1 Short grooved director, 1 Tenaculum, 3 Aneurism needles, which may he used as retractors, ll’airof artery forceps, 4 Ilfcmostatie forceps, 2 Pairs of dissecting forceps, 1 Sharj)-pointcd tenotome. 1 I’air of tracheal forceps. Tracheal dilator. Tracheotomy-tubes and tapes. Flexible catheter. Ligatures, Needles, Feathers, Sponges, Sutures. The scalpel should he small and narrow in the blade, so that it shall obscure as little as possible the operator’s view of the wound. The grooved director should be shorter and slightly broader than the one generally tised (Pig. 1), and it should have a bevelled extremity, which allows it to pass with ease through the different layers of tissue. The ordinary director is usually too long to use with satisfaction in the short necks of children. Ilmmostatic forcej)s ai’e most useful to teni])orarily secure vessels which bleed profusely ; they may also he useful in claiu])ing the isthmus of the tliy- roid gland on either side, where it is to be divided to expose the traeliea under similar circumstances. Tracheal forceps may also be of great use after the trachea has been opened or the tube has been introduced, (Fig. 2), to remove loose shreds of membrane. TRACHEOTOMY. 875 A sharp-pointed tenotome is the knife I prefer in opening the trachea ; its sharp point enables it to be thrust easily into the trachea, and its short Fig. 1. cutting surface and narrowness of blade are additional advantages, as they enable the operator to see exactly where he is cutting. Of tracheal dilatoi’s, either Gobling-Bird’s (Fig. 3) or Trousseau’s (Fig. 4) are the best forms. They can be slipped into the tracheal wound, and thus its edges can be held apart until the trachea is cleared of membrane before the tube is introduced. Golding-Bird’s dilator, which is a self-retaining one, is, I think, a very valuable instrument. Tracheal dilators may be improvised from bent hair- pins or pieces of wire, which may serve the purpose when ordinary dilators cannot be obtained. Silk or silver sutures may also be passed through the edges of the tracheal wound and used as dila- tors. Soft or pliable feathers may be introduced into the trachea or larynx to remove mucus or membrane with little risk or injury to the parts. The best feathers for this purpose I have found to be the tail feathers of the turkey. Tracheotomy-tubes . — Tubes of various sizes should be at hand; and it is well to remember that the best tracheotomy-tube is one which fits the trachea neatly and inflicts the least possible injury upon it. To ensure this, the part of the tube within the trachea should lie exactly in the axis of the trachea, and its free extremity should be capable of as little movement as possible. The instru- ment now in general use is a quarter-circle tube, which is made of silver and consists of two tubes — an outer one which is attached to a movable collar which fits to a shield, to which tapes are fastened to secure it in position, and a movable inner tube which closely fits the outer tube. The mov- Author’s Tra- cheotomy Director. Fig. 2. Fio. 3. Golding-Bird’s Trach- eal Dilator. able collar, which allows the tracheal portion of the tube to change its position during the movements of the trachea and neck, was suggested by M. Roger, and is a modification which has ensured both comfort and .safety in the wearing of this instrument. I usually employ a tracheotomy-tube which is of the same calibre throughout, and does not taper toward the lower extremity, as is the case with many of those sold in the shops. I also prefer the non-fenestrated tube ; the ordinary instrument usually has a fenestra in the outer tube, but I have never been able to see any advantage in this, as it is generally placed at such a position that it is not continuous with the tracheal canal when the tube is in position ; and I think its presence is even a decided disadvantage, as it may be difficult to introduce the inner tube by the bulging of the tissues into it. The tube which I have found most satisfactory is the quar- ter-circle tracheotomy-tube made of silver, as above described, and pro- vided with a fenestrated guide, which materially facilitates its introduction (Fig. 5). 870 AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. To diminish the risk of erosion of the trachea or mucous membrane many other forms of tracheal tube have been devised, notably those of Durham, Fig. 5. Cohen’s trated Parker, Morant, and Baker. The latter has devised and used flexible tubes made of vulcanized red rubber. Professor Little recommends a non-fenestrated tube constructed of aluminium, ■which has the advantage of great lightness. Tracheotomy-tubes constructed of hard rubber have also been recommended by some surgeons, but in my experience they are too bulky and are not adapted for use in recent cases, though they may be employed with advantage in cases ■where the tube has to be worn for a long time. The size of the tracheotomy-tube to be employed in an individual case is a matter of some importance, as the calibre of the trachea varies with the age and sex of the patient, being smaller in female children than in males of the same age. The safest rule of practice is to introduce a tube which fits the trachea comfortalily. I usually find that a No. 2 tracheotomy-tube fulfils this condition in children under two years of age; in those from two to four years of age a No. 3 or 4 Avill usually be found satisfactory. The fear of in- jury to the trachea by the continued presence of a tube has caused some sur- geons to substitute for it a tracheal dilator made of wire; such devices have been suggested by Watson, Bigelow, and Packard. The latter surgeon has constructed such a dilator which is self-retaining and has somewhat the mechan- ism of the eye-speculum. Experience with the use of these substitutes has been very limited, and I am inclined to think they will prove only of value for temporary use. Choice of Operation. — There are two points at which the trachea may be opened, constituting respectively the high and low operations. In the high operation the trachea is opened above the isthmus of the thyroid gland, and in the low operation the opening is made helow this structure. The high opera- tion is generally selected in children, because at this ])oint the trachea is most superficial, and for this reason is more readily exjiosed and opened. In the high operation the cricoid cartilage is frequently divided with the upjier rings of the trachea. The low operation cannot be executed so rajiidly, and is certainly much more difficult in its performance, because of the relatively greater depth of the trachea, the large size and number of veins exposed, and the proximity to the large arterial trunks. In young children the extreme shortness of the neck sometimes prevents the satisfactory adjustment of the tracheotomy- tube when the low oj)eration is performed. I call to mind the case of a young child in whom I did a low o])eration, where the lower extremity of the tube came in contact with the bifurcation of the trachea, and it was only after I had the tube shortened that the child could wear it with comfort. Many operators prefer the low operation : Cohen expresses himself decidedly in its Fig. 4. POSITION OF PATIENT FOR TRACIIEOTOMA’. PLATE XVIIT. ' V.-;.' ■'t- ' -' : , : * THE LIBRARr OF THE university UE ILLINOIS * V ' v- TRACHEOTOMY. 877 favor in case the tube is to be worn for a long time or where the operation is (lone for a foreign body impacted in the Ijronchus. I am myself decidedly in favor of the high operation in cases of diphtheritic or membranous laryngitis when the tube is to be worn only for a short time, and I would therefore recommend those who have had little experience with the procedure to employ the high operation, on account of the greater ease and safety of its perform- ance, save in the exceptional conditions referred to by Cohen. Position of the Patient for Tracheotomy. — In the operation of trache- otomy it is a matter of the first importance that the patient be placed in such a position that the neck shall be brought into the greatest prominence, to render the trachea more superficial and give the greatest amount of space between the sternum and the chin ; and it is surprising with how much more ease the operation will be accomplished if the patient be placed in this posi- tion. The most satisfactory exposure of the neck may generally be obtained by laying the child upon his back upon a firm table and placing beneath the shoulders a small round cushion or an empty wine-bottle or an ordinary wooden roller-pin wrapped in several towels (Plate XVIII). In this position the head is allowed to drop down, coming in contact with the table ; the trachea is pushed upward, and becomes more prominent, and the anterior portion of the neck is more accessible to the surgeon. The nurse or an assistant should secure the head by applying the hands to its lateral aspects, thus ])reventing the child fi’om moving it during the operation, and an assistant should also control the movements of the body and arms of the child by holding them firmly against the table. This is much better than securing the arms by pinning a binder around the chest, and does not restrict the already embar- rassed respiratory movements. The same result may be obtained by drop- ping the child’s head over the edge of the table and having it held in this position. Use of Anaesthetics in Tracheotomy. — As to the use of anaesthetics in the operation there is much difference of opinion among surgeons : many operators of large experience express themselves as decidedly opposed to the use of an anaesthetic on the ground that it is unnecessary and its employment increases the danger of the operation. On the other hand, many surgeons of equally large experience commend anaesthesia, not only as facilitating the ope- ration, but also as not interfering with the success of the procedure. INIy own experience leads me to agree with the former class of surgeons, and I think there is a growing tendency to discard the use of anaesthetics in this operation. In operating in cases of diphtheritic or membranous laryngitis, I never use an anaesthetic. I have seen cases, which were breathing fairly Avell before its administration, after its use suddenly become so much obstructed that the operation had to be much hurried, and the trachea opened rapidly even before it was thoroughly exposed — a procedure which is always attended with danger. The unfortunate cases in which I have seen death occur during the operation have generally been those in which an anaesthetic had been used, and in which tlie above-named complication occurred, necessitating the hurried opening of the trachea, often followed by profuse haemorrhage. Tracheotomy itself is not painful when the dyspnoea is well marked, and after the incision in the skin is made little pain is experienced in the subsequent steps of the operation. In this connection I mention the observation made by Brown-Sdquard that an incis- ion of the tissues of the anterior region of the neck causes anaesthesia of the surrounding parts, and hence it is only the first incision which gives rise to pain in tracheotomy. Mr. Hewitt in a recent paper very well explains the danger in the use of an anaesthetic in cases of obstructive dyspnoea. He says that 878 AMERICAN TEXT-BOOK OF DIREASES OF CHILDREN. “in such cases cyanosis is kept at bay, not only by compensatory increase in the activity of the nerve-centres wbicb preside over normal respiratory move- ments, but also by the co-operation of the centres wbicb preside over muscles ■wbicb take little or no share in ordinary breathing. During ordinary sleep the activity of the diaphragm is lessened, the centres wbicb preside over it enjoying comparative rest; while in obstructed dyspnoea the patient to a greater e.xtent depends upon the increased action of the diaphragm, so that natural sleep is generally impossible except at short intervals. These vicarious centres will certainly fall victims to the anmsthetic sooner than the automatic or superior centres. The anaesthetic will not therefore respect vicarious func- tion, and the muscles will become paralyzed in the usual secjuence, and the patients will become more embarrassed in their breathing or the breathing will cease altogether.” If an anaesthetic be used, chloroform is probably preferable to ether, as it is not so apt to cause vomiting, and it may be used with safety in operating at night, when close approximation of a light may become necessary. The Operation of Tracheotomy. — The child being placed in the position described, the head steadied, and the movements of the body controlled by assistants, tlie operator should take his position either on the riglit side of the patient, or, as I prefer, at the head of the patient, for in this position it is easy to keep the incision exactly in the median line of the neck. The surgeon then shoidd make himself familiar with the landmarks of the neck ; and having located the position of the cricoid cartilage with the finger, he makes an incision in the median line two or two and a half inches in length, the position of the cricoid cartilage being the middle point. There is no disadvantage in a long incision, which gives the operator a good view of the tissues through wliicli he is to pass ; there are many disadvantages in a too short incision. Tlie first incision should divide the skin and expose the superficial fascia; upon ex])osing this the operator will occasionally see parallel with or directly under the line of incision a large vein lying in the superficial fascia, the superficial anterior jugular vein. This should be displaced, and next the fascia should be picked up with forceps, nicked with the point of a knife, raised upon a director, and divided freely. In the early steps of the 0])eration the surgeon should take care to see that the wound is kej)t directly in the median line of the neck, for this' is the line of safety, and he should be careful also, as the M Ound increases in depth, not to make the incisions so short tliat it becomes funiiel-shaped, .so that a sufficient space of the trachea cannot be exposed to view. IN hen the deep fascia is reached, it .should be picked up and divided u))on a director, and any large veins in the line of the wound sliould he carefully displaced, or, if this be impossible, should be clamj)cd by lucmostatic forceps or ligatured on each side and then divided between the forcejis or ligatures. The operator should next search, having the wound well sponged, for the muscidar space between the .sterno-hyoid and sterno-thyroid muscles: this can generally be found without difficulty, and the muscles should then be separated with a director or the handle of a knife, and the isthmus of the thyroid gland will be exposed. The mmscles should then be held aside with retractors ]daced one on each side, the aneurism needles previously mentioned serving well for this purpose. In regard to the u.se of retractors at this point, a caution is not out of place: the operator should place them himself and allow the assistant to hold them. I once almost lost a case in which, after exposure of the ti'achea, while I had turned aside to pick up a knife, my assistant replaced one rcUraclor which had slipped ; in doing so the movable trachea was caught in the grasj) TRA CirEOTOMY. 879 of the retractor and drawn to one side, completely shutting off respiration. When I attempted to find the trachea to open it, I could simply feel the anterior surface of the vertebme at the bottom of the wound, and it was only when I lifted the retractor and allowed the trachea to spring back to its normal position that 1 was able to open it. Other operators have had the same experience. Mr. Durham mentions a case, and Mr. Howard Marsh also one, in which the trachea and great vessels were hehl aside by an assistant until the surgeon had exposed the cervical vertebrse. It is well for the operator to con- stantly explore the Avound Avith his finger, to locate exactly the position of the trachea, and to ascertain the presence of any anomalous arterial branch. The isthmus of the thyroid gland being exposed, it is generally found sur- rounded by a venous plexus, and occupies a position over the first three tracheal rings, or it may extend even higher and cover the cricoid cartilage. At this point of the operation the surgeon may find that the isthmus of the thyroid gland, if large, bulges up and fills the Avhole Avound, and he should endeavor to displace it either upAvard or doAvnAvard ; this it is often possible to do Avithout difficulty. But should it be found firmly fixed, and the trachea cannot be ex- posed either above or beloAv it, it may be cut through after being ligatured or clamped on each side to j)revent haemorrhage. A procedure recommended by Bose, Avhich I have employed with advantage in several cases, may also be made use of — namely, a transverse incision is made across the cricoid cartilage to divide the layer of cervical fascia by Avhich the isthmus is bound doAvn, and a director is then passed in, and the isthmus is displaced doAvnAvard Avithout difficulty. After displacing the isthmus of the thyroid gland upAvard or doAvn- ward, as the case may be, the trachea, yelloAvish-Avhite in appearance, covered by its fascia, should be exposed. This fiiscia should be torn through Avith a director or the handle of a knife, so as to bare the surface of the trachea. On this point all authorities agree — namely, the importance of thoroughly clear- ing the trachea of its fiiscia before opening it, as by sO doing it is easier to incise it and to introduce the tracheotomy-tube. In breaking up this fascia the operator can feel it crepitate under the finger from the suction of air draAvn in Avith each inspiratory movement. When the surgeon has the trachea exposed, he may then take time to see that the Avound is free from hmmorrhage, and may replace the retractors so as to expose as large a portion of the trachea as possible ; for, be the case ever so urgent, he noAV feels assured that he can open the trachea in a moment if the breathing should cease. The trachea should next be fixed Avitli the point of a tenaculum introduced a little to one side of the median line; and an incision made in the median line from beloAv upAvard for a distance of half to three- fourths of an inch. Some surgeons object to the use of a tenaculum to fix the trachea, as it arrests respiratory movements, but prefer to use the tip of the finger as a guide to steady the trachea before it is incised. I ahvays use the tenaculum in this Avay, and see no disadvantage in its use if the trachea is not fixed for too long a time before the opening is made. The operator may find it of advantage, especially in cases where the trachea is deeply situated, after fixing it with a tenaculum, to lift it slightly from its bed, thereby bringing it more prominently into vieAV and making it more superficial in the wound, thus facilitating its safe incision. I prefer in opening the trachea to employ a sharp-pointed tenotomy knife: the sharp point allows it easily to be thrust into the trachea, and the narrow blade obscures the operator’s vieAv of the Avound to the least possible extent. The knife should not be introduced so deeply into the trachea that the posterior wall or the oesophagus may be injured: both of these accidents have occurred by 880 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. a too deep thrust of the blade. The operator should also be careful not to make a too superficial incision, which might divide only the trachea and the mucous membrane, while the false membrane, if it be present, is not divided; and the cavity of the trachea therefore not opened: under such circumstances, if the tracheotomy-tube is hurriedly introduced, it may pass between the trachea-wall and the false membrane, and no relief from the dyspnoea will be obtained. I have seen this accident occur and death result from it. I have already spoken of the importance of keeping in the median line in exposing the trachea, and I think it of e(|ual importance to have the incision into the trachea itself in the median line, for these wounds are said to heal more promptly ; and, if the wound be made to either side of the median line of the trachea, the tube does not fit well, and its lower extremity may cause damage to the lateral aspect of the trachea. It is often a matter of great difficulty to introduce the tracheotomy-tube in a case where the tracheal incision is far out of the median line; and if this is found to be the case, I think it is wiser to make a second incision in the median line, disregarding the previous one, which generally heals without difficulty. As soon as the ti’achea is opened there is usually thrown from the wound, with the first expiratory effort, mucus or false membrane; this should be wiped away with a sponge, and the tracheal dilator introduced. It is well to remem- ber that the tenaculum should not be removed until the tracheal dilator or tracheotomy-tube is placed in position, as it is often difficult to introduce either of them into the movable trachea after the tenaculum has been removed. It is not unusual, after the trachea has been opened, to have a sudden arrest of respiration ; the entrance of a large body of air, according to Cohen, seems, as it were, to surprise the lungs. This is apt to produce great alarm to one not familiar with the circumstance, as it looks like a cessation of breathing; it is. especially trying to the operator when he is about to congratulate himself upon the completion of an anxious o]>eration. This arrest of respiration is usually only momentary, and if the child’s face and chest be slap{)ed with a wet towel, or artificial respiration be employed, normal respiratory movements will soon be re-established. The trachea being opened and the tracheal dilator being introduced, any membrane which ajipears at the wound should be removed with a sponge or forceps, and the trachea should be explored both above and below the wound foi‘ the presence of false membrane, which should be removed with forcejis, a fe;ither, or a camel’s-hair brush. This removal of membrane from the trachea has been urgently insisted upon by Pilcher, I’arkcr, and others ; and I think that it is largely owing to the great care which is exercised in this ])articular that the results of traclieotomy in di))htheritic cases in the last few years has been so much more encouraging. Mouth-suction of the wound, which has been frequently employed by sur- geons to restore respiratory movements and clear the trachea of membrane, has been so often followed by disastrous results that it cannot be too strongly con- demned. This procedure is no more efficieiit in removing membrane or re-es- tablishing respiration than the use of the force))s, brush, or feather, or the employTiient of artificial respiration made in the ordinary manner. For the purpose of clearing the trachea Parker has devised a, tracheal aspirator, which consists of a glass or celluloid cylinder three or four inches in length by three- (|uarters of an inch in diameter, to the one extreTuity of which is attached a flexible tube and to the other a7i India-rubber tube with a mouth ))iece at the end. d’he cylinder may be jiackcal with antise))tic cotton, which will act as a filter and prevent any infected material from reaching the operator’s mouth. A TRA CHEOTOMY. 881 flexible catheter may be employed for the same purpose with good results. The membrane is usually loosely attached, and can be removed with forceps or a flexible feather, particularly if a little of Parker’s soda solution be brought in contact with the inner surface of the trachea. The peroxide of hydrogen may also be employed with satisfaction for the same purpose. After removing the membrane, Mr. Watson Cheyne recommends that the raw surface be touched with a solution of bichloride of mercury 1 : 500 ; he also introduces into the trachea or larynx above the tube strips of lint sat- urated with a solution of bichloride of mercury 1 : 2000, and washes the wound with a similar solution of 1 : 500. Having cleared the trachea of membrane, the tracheotomy-tube should be introduced. This can be accomplished without difficulty if a fenestrated guide be employed, and if the wound in the trachea has been made in the median line; the tube is secured in position by the tapes attached to the shield, which are tied around the neck. The tapes should be firmly tied by several knots, so that there may be no possibility of the child untying them when not watched by the attendant, as in such an event the tube may become displaced when there is no one at hand competent to replace it. These knots should be tied on either one or other side of the neck, and not posteriorly, where their pres- ence would cause the child discomfort as he rests upon his back. The immediate results of the operation are, as a rule, most encouraging : the patient, who previously exhibited the most distressing symptoms by reason of his extreme dyspnoea, now becomes quiet; the color improves, the respi- ration becomes natural, and it is not an unusual occurrence to have him fall into a quiet sleep before he is removed from the operating table to his bed. Complications at the Time of Operation. — The principal complication at the time of operation is haemorrhage, which may be either arterial or venous. Haemorrhage should be prevented by great care in avoiding the wounding of any vessels of considerable size : if their injury is unavoidable, they should be immediately ligatured, or, if the case is too urgent to admit of delay, they should be secured by haemostatic forceps, and after the trachea has been opened they can be permanently secured by ligatures. Sudden Arrest of Respiration . — Cessation of the respiratory act during the operation is a most dangerous symptom, and one which calls for prompt action on the part of the operator. The surgeon’s duty under the circumstance is to open the trachea as rapidly as possible — even through a pool of blood, as described by Mr. Durham — introduce the tracheal dilator, and make artificial respiration : by such prompt action many cases may be saved, and bleeding vessels may be ligatured or secured by forceps after the trachea is opened. Mr. Durham very wisely says that in those reported cases in which much blood is lost during the operation, and which are abandoned before opening the trachea because of the cessation of respiration, death is not the result of haemorrhage, but of failure to complete the operation. Blood in the tra- chea after the operation may seriously embarrass the breathing, but if the tracheal dilator is introduced, it may be removed by the use of a brush or feather. After-Treatment of Cases of Tracheotomy. — The operation of trache- otomy relieves the patient of the immediate danger of death by strangulation, yet there still exist the same indications for local and constitutional treatment as were present before it. This fact is often overlooked by physicians, who, ob- serving the improved condition of the patient after the operation, are too apt to relax their efforts in this direction. I know of no cases in which a successful issue more directly depends upon care and watchfulness in their after-treatment 66 882 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. than those in which tracheotomy has been performed to relieve the obstructive dyspnoea consequent upon diphtheritic or membranous laryngitis. The patient should be under the charge of an attendant or nurse who is skilled in the management of such cases, and is able to recognize and meet such complica- tions as may arise. After the operation the patient should be placed in a room free from draughts, Avith a temperature of 70° to 75° F., and the air of the room should be rendered moist and warm by a vapor of steam. At the Chil- dren’s Hospital of Philadelphia there is an apartment especially arranged for the treatment of cases after tracheotomy ; it is fitted with a steam apparatus, by means of which in a few minutes it can be filled Avith a vapor of steam and maintained at an even temperature. I think the large number of successful results of the operation at that institution is greatly due to this feature of the after-treatment. In private practice it is difficult to obtain these conditions, and as a substitute a frameAvork may be fastened over the bed, over Avhich sheets can be stretched, forming a tent ; under this Avater may be kept boiling in a pan or vessel, or lime can be slaked ; the vapor from the latter Cohen con- siders one of the most efficient solvents of the false membrane. A steam or hand atomizer should be used at frequent intervals, the spray being directed over the opening in the tracheotomy-tube. I have found great advantage from the use of Parker’s soda solution, which is as folloAvs : I^. Sodii carbonatis Glycerini f.lij. Aqum q. s. ad fsvj. — M. To this solution a small quantity of carbolic acid maybe added, without in any way affecting its solvent action on the false membrane or mucus. I am so firmly convinced of the utility of this solution that in all cases I have it con- stantly used in the steam or hand atomizer, and also have it introduced into the tracheal tube by means of a feather or brush. The use of the steam spray and the soda solution is especially important in cases in Avhich there is little tend- ency to expectorate mucus or false membrane — dry cases — or in those in Avhich the inner tube is found clogged Avitli inspissated mucus or membrane. Peroxide of hydrogen in 15-volume .solution, either used in full strength or diluted to one-half, one-third, or one-fourth, is also used Avith advantage in these cases. It has a decided action upon the membrane, and it may be applied Avith a brush, feather, or spray. It is a good omen if the child coughs or expectorates false membrane after the tracheotomy-tube is introduced, for moist cases in Avliich these conditions obtain, as a rule, are much more favorable than dry cases or those in Avhich there is little tendency to expectoration. This clinical observa- tion Avas, as far as I know, first made by Cohen some years ago, and I have since personally seen numerous inslances Avhich attested its accuracy. In a series of cases reported by Lovett and Monroe all those in Avhich there Avas sup])ression of the discharge from the tracheotomy-tube, Avhich Averc classed as ass into the larynx and set up coughing, which interferes with the taking of a sufficient (juantity of nourishment. As many cases in which this operation is eiiq)loyed re(juire large (quantities of food from the nature of the di.sease for which the oj)eration is performed, I think the difficulty of proqierly nourishing the patient constitutes the most serious objection to this oqieration. Children, as a rule, while wearing an intubation-tube, have difficulty in swallowing liquids, but there are occasionally seen cases in which li([uids are swallowed without difficulty ; therefore it is well to make a trial as to the feeding before PLATE XX. METHOD OF FEEDING INFANT AFTER INTUBATION, WITH THE HEAD LOWER THAN THE BODY. ]J1£ LIBRAHf OF TN£ UNIYEhSlty Of ILUNOIS INTUBATION OF THE LARYNX. 897 a special diet is ordered for any individual case. It is remarkable to observe how some children wearing intubation-tubes will learn to swallow with the tube in place. I have seen children who at first were unable to take liquid nourishment in a few days change their manner of swallowing, so that liquids could be taken without discomfort. If, upon trial, it is found that there is difficulty in swallowing liquids, I first order a diet of semi-solids, such as corn- starch, mush, milk-toast, rennet, puddings, soft-boiled eggs, and, as patients soon e.xperience thirst, I order for them pieces of ice to be swallowed, or give enemata of water, an ounce to an ounce and a half, I'epeated at intervals. In young children, in whom a milk diet is essential, it will often be found that the child can swallow well if fed from a nursing-bottle, the head being dropped over the nurse’s lap, so that it is lower than the body (Plate XX). This useful expedient was suggested by Casselberry of Chicago, who found that with the patient supine and the head loAver than the body fluids could not pass into the larynx, but would be forced up the oesophagus into the stomach. If, however, all expedients fail as regards methods of feeding, as will be found in some cases, recourse must be had to the introduction of food by nutritious enemata. Removal of Intubation-tubes. — The tube usually remains in place for some days, and is often coughed out as the swelling of the laryngeal tissues subsides. If the breathing is carried on satisfactorily, it need not be re- placed ; but it is well to remember that for a few days the dyspnoea is liable to return, so that the reintroduction of the tube may be necessitated ; and the surgeon should be within reach during this time. If the tube has not been coughed out and the child’s general condition is improved, the temperature having a tendency to reach the normal mark, at the end of three or four days I usually remove the tube ; and if there is no return of the dyspnoea I do not reintroduce it, but have the case carefully watched, for the patient is not safe from recurrent dyspnoea for two or three days. If dyspnoea be present upon the withdrawal of the tube, I replace it promptly, and do not make another attempt at its permanent removal for two or three days. Usually in from five to ten days it can be dispensed with, although I have recently had a case in which the tube could not be permanently removed until the fifteenth day. After the expulsion or removal of the intubation-tube I continue to use the soda spray for two or three days, and the child must be carefully watched, so that it is not exposed to cold. I have noticed that in all cases in which recovery has followed intubation of the larynx there was present a considerable amount of hoarseness of the voice ; but this in a few weeks finally disaj>pears. As the same intubation-tube may be used in many different cases, I think it most essential that every tube which is used should be thoroughly sterilized as soon as it is removed from the patient by being cleansed and boiled for a few minutes. The removal of the intubation-tube is, I think, often more difficult than its original introduction. The child should be placed in the same position as described for its introduction ; the mouth-gag should be used to sej)arate the jaws ; the index finger of the left hand, being protected, should be passed into the mouth and placed upon the head of the tube ; the extractor should then be passed into the mouth, and with the finger on the head of the tube as a guide, the blades should be passed into the opening of the tube. The tube is grasped by pressing the lever which separates the Idades, and, having a firm hold upon the tube, it is withdrawn by depressing the handle upon the chest of the patient. It is sometimes difficult to pass the blades into the opening in the tube, and during the withdrawal the blades may slip, losing their hold upon the 57 898 AMERICAN TEXT-BOOK OF DmEA^iES OF CHILDREN intubation-tube. If this accident occur, the tube can usually be hooked out of the mouth by the linger, which should follow it during its withdrawal. Intubation of the larynx has added another very valuable surgical pro- cedure to the treatment of dyspnoea arising from diphtheritic or membranous laryngitis and oedema or spasm of the glottis, and, although it does not entirely supersede the operation of tracheotomy in all cases, it is now employed in many cases Avhere tracheotomy was formerly resorted to. Cases which seem to me favorable ones for intubation are those of membranous or diphtheritic laryngitis, where the obstruction comes on rapidly, and is probably largely due to oedema of the mucous membrane of the larynx. Children under two years of age are usually better subjects for intubation than for tracheotomy. Intubation also seems well adapted for cases of dyspnoea due to oedema of the larynx from burns or scalds or from the swallowing of corrosive liquids or the iidialation of irritating gases,’ unless there is at the same time marked oedema of the epiglottis and fiuices. Cases unfavorable for intubation are those of diph- theria, in which there is much swelling of the tonsils and fauces, with profuse deposit of membrane ; also those in which the dyspnoea comes on slowly, point- ing to a gradual deposit in the larynx of a Avell-organized membrane, d'he great advantages offered by intubation are, that the operation itself is com- paratively free from danger, it is a bloodless operation, and the consent of the parents for its performance can usually be obtained without difficulty ; the inspired air enters the lungs warm and moist ; and if this operation fails to relieve the patient it does not preclude a subsequent tracheotomy. Although some statistics have been presented from the Boston City IIos})ital showing that the prognosis in cases of tracheotomy after intubation is not favorable, my personal experience has been different, for I have resorted to tracheotomy in a number of patients in whom a fair trial of intulnition had failed to relieve the dyspnoea, and tlie results following the operation were in no wise less satis- factory than those in which tracheotomy had primarily been performed. Intubation in Stenosis of the Larynx. — The introduction of an intuba- tion-tube for the purpose of relieving chronic stenosis of the glottis has been employed successfully in many cases; it has been proven that the tube in these cases can be worn for a considerable time without harm or inconvenience. It has been employed in cases of chronic .syphilitic stenosis, in cases where there is difficulty in dis])ensing with the tracheotomy-tube from granulations growing in the region of the tracheal wound (see p. 888), in cases of cicatricial stenosis, swelling of the mucous membrane of the larynx below the cords, bilateral paralysis of the abductors, paresis of the cords from disease, or where there is dread of having the tracheotomy-tube removed. In such cases the mani))ula- tion for the introduction of the intubatiori-tube is similar to that in acute cases, with probably the difference that more force is justifiable in the introduction. The tube should bo changed at intervals, a larger size being re(|uired from time to time. In chronic cases little difficulty is usually exi)erienced in feeding the patients, as li(juids are generally taken without difficulty after the first day or two. POST-NATAL ATELECTASIS. By SAMUEL S. ADAMS, M. D., Washington, D. C. Post-natal Atelectasis is a condition of the lung in which the once- inflated alveoli become emptied and collapsed from partial or total absence of air in them. It occurs in weakly infants and young children, and varies in extent from a few lobules to an entire lobe or even a whole lung. It is claimed by some that it is a common condition in foundlings and in wasted infants who die during the first year of life. Etiology. — The predisposing causes of post-natal atelectasis are such as weaken the constitution, whether they operate before birth, as inherited vices, such as syphilis, scrofulosis, malformations, etc. ; at birth, as premature delivery or injuries received during parturition; or after birth, as rachitis, improper feeding, neglect, exposure, as in foundlings, unsanitary habitations, and debilitating diseases. The exciting causes are such as prevent air from entering the alveoli, and permit them to collapse after the residual air has been rarefied, absorbed, or expelled. They may be classified as intrathoracic and extrathoracic. The most frequent intrathoracic cause is bronchial catarrh, more especially of the smaller subdivisions, in which the lumen of the tube is obstructed by the resulting exudation and the ingress of air prevented. Gairdner of Glasgow has explained the mechanical action of a plug of mucus in a bronchiole in gradually diminishing the entrance of air to the area supplied by it, and the resulting collapse of the alveoli. This ball-valve shuts out the air at every inspiration, but allows the expulsion of that within the alveoli. If this obstruc- tion be not displaced, the pressure exerted by the atmosphere upon the thoracic walls and the contractile force of the pulmonary tissues cause the alveoli to collapse. It may also be caused by whooping-cough, the paroxysms expelling the residual air and decreasing the power of the inspiratory forces. Measles is cited by some as an etiological factor, but the more immediate cause is probably the attendant bronchial catarrh. Effusion into the pleura or pericardium may cause collapse of the pulmonary alveoli in varying degrees proportionate to the pressure exerted by the fluid and the resistance of the lung. The lodgement of foreign bodies, as beans, peas, seeds, or metallic or porcelain substances, in a bronchus may prevent ingress of air and lead to alveolar collapse. Among the extrathoracic causes are spinal curvature, deformity of the chest- wall, constricting clothing, and solid or fluid tumors in the abdominal cavity. Any one of these might be sufficient to compress the lung to the degree of col- lapse by diminishing the capacity of the thoracic cavity. It may also be of cerebral or spinal origin. Disease of the brain, cord, or nerves which paralyzes or over-stimulates the respiratory centres or prevents the transmission of nerve- force may produce atelectasis by impeding the inspiratory or increasing the 899 ‘)()0 AMERICAN TEXT-BOOK OF DIREA8EB OF CHILDREN Force of the expiratory muscles of respiration in a weakly or rachitic infant. Finally, it may originate independently of affections of the air-passages, as from the exhaustion of long-continued illness, constant dorsal decubitus, diarrhoea, or ileo-colitis. Pathology and Pathological Anatomy. — Post-natal atelectasis, unlike the congenital form, is a pathological condition in which the expanded lung- alveoli return to the ante-natal state, from arrest of function owing to some mechanical impediment to the ingress of air. The extent of the collapsed area is either circumscribed or diffused, depending upon the calibre of the obstructed bronchus. It is usually situated at the postero-inferior margin of the lung parallel to the spinal column ; or it may involve a whole lobe or a whole lung. When it complicates bronchial catarrh, it occui’s in small, scattered areas, cor- responding to the ramifications of the obstructed bronchus. In pericardial and pleuritic effusions of moderate extent the lower lobes are involved, but if the exudation is abundant the entire lung may be collapsed from compression. The atelectatic lung-tissue, being devoid of air, is shrunken, depressed below the level of the surface of the lung, is of irregular outline, and dark- brown, violet, or reddish-blue in color. On section the collapsed tissue appears dark-red and smooth, and a serous or bloody fluid exudes from it. From its resemblance to flesh it is called “ carnification.” It is firm, dense, tough, without crepitation, airless, and sinks in water. If the collapse be recent, the alveoli can be re-inflated by removing the obstruction and blowing into the bronchial tube. If bronchial catarrh be present, the mucous membrane is swollen, soft, and hyperjemic, and the tube is filled with thick, tenacious muco- pus forming a complete plug. Around the affected areas are air-vesicles in a state of compensatory dilatation. This physiological emphysema is only found when the child has had sufficient strength to increase the inspiratory efforts, and is but rarely seen in the feeble. Symptoms. — The atelectatic areas may be so small, so scattered, or so obscured by the adjacent compensatory emphysema as to be wholly overlooked, although frequent and careful physical examinations may be made. This is especially true of cases in which there is no rece.ssion of the chest-wall, and where the neighboring alveoli are so distended as to increase the vesicular murmur and intensify the percussion resonance. As post-natal atelectasis usually happens to emaciated and puny infants, the general symptoms vary according to the extent of the lesion. In mild cases the infant is indifferent to its surroundings, gives vent to a whining ex- piration, is slightly cyanosed, and refuses its nouri.shment ; but these symptoins quickly disappear upon the dislodgement of the occluding mucus plug. In severe cases restlessness and sleeplessness ai’e well marked ; there is evidence of distress and exhaustion depicted upon the face ; the features are pinched ; the eyeballs are sunken and without shimmer, and the livid eyelids droop ; the mouth is drawn and the lips are livid ; and the head and fiice are bathed in a profuse, cold, clammy pers])ii-ation. The tongue is dry, swollen, and purple ; the appetite is lost, the infant refusing to nur.se, suck the bottle, or take food from a s])oon ; the bowels are normal, uidess there be some gastro-intestinal derangement. Collapse is often rapid and pronounced, but is not always fatal. 'I'here may be convulsions, in one of which the infant may die, though they are not necessarily fatal. The })ulse is accelerated and small, ajid its tension decreases as the atelectatic area increases. Cough, though not always j)resent, is due to bronchial catarrh. The integument is dusky, and hecomes livid and clammy as the di.sease ])rogresses. fl'he temperature is normal or .subnormal even when atelectasis occurs during the course of a febrile disease. POST-NA TAL A TELECTASIS. 901 Physical Signs. — It is not surprising that this disease is so frequently confounded with pneumonia, when we remember that its physical signs are indicative of more or less consolidation of lung-tissue, with a catarrhal inflam- mation of the bronchial mucous membrane. So the physical signs vary with the extent of tissue involved. Inspection . — The nares dilate with the respiratory movements, which are superficial and rapid, varying from 60 to 90 per minute, and their normal ratio to the pulse is lost. Inspiration is slower and more labored than expiration, and is followed by a pause. Retraction of the chest-wall varies with its elas- ticity and the extent of the collapsed lung beneath. If a considerable area of lung is involved, the chest-wall yields to atmospheric pressure, resulting in depression of the supraclavicular and intercostal spaces, with a deep furrow over the affected area. The deformities of the chest-wall are exaggerated if spinal curvature or rachitis exists. Auscultation . — The vesicular murmur is feeble or absent unless there is compensatory emphysema around the atelectatic areas. Bronchial respiration and bronchophony are present when a large collapsed area surrounds a bron- chus. When fine crepitant rales are present, they indicate an extension of the catarrhal process to the neighboring bronchioles and alveoli. Percussion . — Dulness is usually found at the base of the lung posteriorly, but is often slight or entirely absent, and if the neighboring alveoli are em- physematous the percussion resonance may be greatly exaggerated. The dul- ness may extend upward parallel with the spinal column ; it may remain station- ary, or it may be transient or change with the position of the infant. If it is due to compression from a collection of fluid in the pericardial, pleural, or abdominal cavity, the signs of this causative factor may be defined. If it is coincident with bronchial catarrh, whooping-cough, diarrhoea, typhoid fever, or any exhausting ailment, the symptoms of the primary affec- tion will be present. Duration. — The duration of life is uncertain, and in some infants it is surprisingly long. Some die very early from asphyxia or in a convulsive attack, while others linger for weeks or months to die of slow asphyxia or exhaustion. Diagnosis. — If the atelectasis is in scattered areas, it is seldom recognized, and even if large areas are involved, it may be overlooked unless frecjuent and careful examinations are made. It is most common in the feeble and emaciated infant, and is directly caused by some disease which impedes the respiratory movements. It frequently accompanies broncho-pneumonia, pertussis, measles, or some long-continued and exhausting disease. The respirations are rapid and shallow, dyspnoea is progressive, cyanosis marked, and exhaustion increasing. Auscultation reveals an absence of vesicular bi’eathing and the presence of bronchial respiration and bronchophony, and there is dulness on percus- sion over the affected area. A differential diagnosis is generally difficult, owing to the similarity of post-natal atelectasis to other diseases. Some of the physical signs of croupous or broncho-pneumonia are often observed in atelectasis, but the characteristic general symptoms of these two diseases are either indistinct or absent. In pneumonia the temperature is high, and is frequently accompanied by delirium or convulsions ; the pain is acute ; the face is flushed ; the skin is hot and dry ; there are fine crepitant riles and per- cussion dulness over a large area ; and retraction of the chest-wall during inspiration is absent. In atelectasis there is a normal or subnormal tempera- ture ; pain is absent ; the face is livid ; the skin is cold and wet ; rales are 902 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. only present when bronchial catarrh exists; dulness is in small scattered areas; and the chest-wall retracts during inspiration. While it is possible to confound atelectasis with acute miliary tuberculosis, still there are so many well-defined symptoms, as the previous history, cough, great fluctuation of the daily temperatui'e, emaciation, and exhaustion, which precede the stage of solidification in tuberculosis, that the differentiation should be made with a degree of certainty. Atelectasis should not be mistaken for pleuritic effusion, as the absence of bronchial breathing, bronchophony, and vocal fremitus, taken in conjunction with the alteration of the line of dulness with the changing position of the patient, will settle the diagnosis. In doubtful cases aspiration would be the determining factor. Prognosis. — The prognosis is always grave, and recovery is extremely rare, owing to the low vitality of the infant. If it complicate bronchial catarrh or broncho-pneumonia in a puny, rachitic infant, atelectasis is fatal. Convulsions greatly jeopardize life. If somnolence, increasing cyanosis, superficial and hurried respirations, and refusal to take nourishment supervene, the prognosis is unfavorable ; but if intelligence return, cyanosis disaj)pear, the respirations become stronger and deeper, and the child take nourishment liberally, the chances are favorable to recovery. When complicated by whooping-cough, general pulmonary emphysema, broncho-pneumonia, tuberculosis, or pleurisy, it is fatal. When caused by compression, as in hydro-, pvo-, or ])neumo-thorax or tumors, the prognosis depends upon the removal of the cause. When dependent upon the presence of a foreign body in a bronchus, recovery is conditioned upon its dislodgement. It must he remembered, however, that in some cases the infant may recover from the immediate effects of atelectasis to die later of cheesy pneumonia or phthisis. Treatment. — This being a disease which is superinduced by the lack of resist- ance of the enfeel)led infant, the prime factor in the treatment is to improve the general health so as to enable it to repel all causes that depress the vitality. To this end personal and domiciliary hygiene shouhl be carefully regulated. In seasonable weather the infant should be taken in his perambulator into the open air ; removal into the country, or, when practicable, to the mountains or seashore, is advi.sable. An occasional tepiil, alcoholic, or moderately cool sponge-bath will prove beneficial. Sleep shouhl be encouraged at stated times, care being taken not to permit too much. The clothing must be of the ]>ro])er quality and (juantity, and shouhl permit of the freest movements of the chest. Very feeble infants may be wrapped in cotton-wool. The domicile must be scrupulously healthful in having pure air by free ventilation and the best sani- tary e([uipment. The temperature of the room must he from 70° to 77)° F. Care should he taken in supervising the (juality and (juantity of the infant’s food. If the nursing infatit has progressively emaciated and weakened, the mother’s milk needs attention, if bottle-feil, the management is even more })erplexing, but the proportion of alhuminoids, fat, and sugar can be changed until a combination is found that will be digestible anil nutritious. Froths atid beef-juice may jirove valuable adjuvants to the milk diet. If the infant be too weak to nurse, or even to swallow, navaiie or stomach-feediim is indieated. When the stomach will not retain food, the strength must he sustained by con- centrateil nutritious enemata. ’I’liere are no sj>ecifics for the cure of atelectasis, but its different ))henomena must be met promptly and energetically. When seciuidary, the treatment must he directed to the primary affection. If a, foreign body he lodged in a bronehus, rOST-NA TAL A TELECTASIS. 903 its removal by operation is recommended. If the obstruction is a plug of ropy muco-pus, it may be removed by active emesis induced by teaspoonful doses of syrup of ipecacuanha, one or two grains of the sulphate of copper dissolved in water, or the hypodermatic injection of apomorphia. Cardiac and resj)iratory depressants, especially preparations of opium, must be positively interdicted, while cardiac and respiratory stimulants must be judiciously administered. The cardiac stimulants of most importance are strophanthus, sparteine, nitro-glycerin, camphor, musk, and ammonium car- bonate. Brandy, in frequently repeated doses, is one of the most efficient stimulants. The force of the respiratory movements can be increased by 3-^ to grain of atropine sulphate, which stimulates the respiratory centre. Compressed air or oxygen may be inhaled, but neither has proved to be par- ticularly beneficial. Convulsions must be treated by hot mustard baths and antispasrnodics. Finally, to ensure any hope of success, the infant requires the most careful handling, the most rigid regimen, and the most judicious dosage. BRONCHOPNEUMONIA. By william PEPPER, M. D., Philadelphia. Broncho-pneumonia — also known as catarrhal pneumonia, lobular pneu- monia, and capillary bronchitis — is an inflammatory disease of the terminal bronchioles and air-vesicles of the lung, affecting scattered groups of lobules. Though in the main a catarrhal inflammation of the bronchioles and air-sacs, the interventricular and peribronchial tissues are also involved, and the term “catarrhal pneumonia” is therefore not altogether accurate, nor are the other terms by which it has been designated wholly appropriate in all cases. The disease varies widely in its course and duration, often proving fatal in a few days, at other times becoming a lingering chronic affection, leading to secondary changes or creating a tendency to subsequent tuberculous infection. Etiology. — Broncho-pneumonia is in the great majority of cases a sec- ondary disease, and, as a rule, bronchitis is the primary cause. This may be either a simple bronchitis or that which occurs as a part of infectious diseases, prominent among which are measles, whooping-cough, diphtheria, influenza, and typhoid fever. The manner in which a bronchitis affecting the smaller tubes might lead to a broncho-pneumonia is readily appreciated, but will be considered more minutely in the description of the morbid anatomy. A most important cause is tuberculosis affecting the bronchi and lungs. In all cases of chronic phthisis there occur from time to time attacks of localized broncho-pneumonia, from which the patient recovers, or there may be more widespread and fatal attacks. The primary focus of tuberculosis is sometimes so small as to have escaped detection, and in such cases the broncho-pneumonia is apt to be looked upon as of the ordinary type. Broncho-pneumonia may also arise ivithout bronchitis as a primary disease of obscure origin, or as a result of inspiration of irritants from the mouth, nose, or upper respiratory passages, ami in the new-born it may be the result of respiration of the liquid secretions of the genital tract during birth. The specific cause of the inflammation is probably, in most cases, the pneumococcus of Friinkel, but the staphylococcus and streptococcus pyogenes, the bacillus of Friedliinder, or, as we have seen, the tubercle bacillus, may be the excitant in certain cases. Of the predisposing causes of catarrhal pneumonia, by far the most important is the age of the patient. A study of mortality statistics of young children shows ])neumonia to be second only to infantile diarrhoea as a cause of death, and in children under five years it is the lobular form of pneumonia which is found in the great majority of cases. It is especially during primary dentition that broncho-pneumonia occurs, and most of the fatal cases in par- ticular occur before the age of two years. The preponderance of this form of pneumonia during the early years of life is to be explained partly by the anatomical condition of the lungs, and partly by the marked tendency to catarrhal processes generally in infants. 904 BE ONCHO-PNE U MON I A . 905 In addition to age, malhygienic surroundings exercise a powerful influence on the prevalence of the disease, and particularly is this the case in times of •epidemics of measles, diphtheria, and whooping-cough, when children of the poorer class are especially exposed and are apt to sufl'er from improper care. The disease is most common during the winter and spring, and particularly at times when the weather is changeable. Previous conditions of health, aside from the infectious diseases, exercise some influence, and children suffering with rickets or scrofula are prone to be attacked by the disease in its most fatal form. Morbid Anatomy. — As stated before, the more important part of the pathological changes is the catarrhal inflammation of the lining of the smaller bronchioles and air-vesicles, the epithelial cells rapidly desquamating and accumulating within. As a rule, the cells are cast off singly, and lie inter- mingled with a smaller number of leucocytes or red corpuscles. In more rapid and virulent cases the epithelial lining may be detached in large flakes, and sometimes there is considerable diapedesis of red blood-corpuscles, giving the section a decidedly haemorrhagic appearance. The latter, however, is rare. As the disease continues the cellular desquamation and exudation increase, and at the same time a more or less copious outpouring of mucous secre- tion occurs, until the bronchioles and air-vesicles become completely filled. Beginning in the terminal bronchi, the inflammatory process advances, and invades the adjacent air-vesicles in several ways. In the first place, there is always a direct extension of the inflammation to the surrounding peribronchial tissues, which are seen to be invaded by round cells and to be the seat of active cellular proliferation. The secondary peribronchial inflam- mation gradually spreads to the walls of the adjacent air-vesicles. Thus it is seen that the peribronchial and perivesicular involvements are important elements in the morbid anatomy, and in cases where the disease becomes chronic these secondary changes lead to the induration processes characteristic of chronic broncho-pneumonia. The extension from the bronchioles to the alveoli is, however, also effected in other ways. There may be a continuous inflammation extending along the epithelial lining, or the irritating matters within the tubes may be directly conveyed by the strong inspiratory efforts following a paroxysm of coughing. These inspired substances may directly excite vesicular inflammation, or by obstructing the terminal bronchial tubes may first produce areas of collapse of the lung-tissue. The occurrence of pulmonary atelectasis in the course of bronchial catarrh and broncho-pneumo- nia is entirely a mechanical result of the obstruction of the tubes. In some cases the obstructing material acts as a ball valve, permitting the air to pass out, but not re-enter the affected area. More frequently the expiratory efforts expel the air through partially obstructed tubes, but the weaker inspiratory force proves inadequate to refill the vesicle ; and finally, in cases where there has been complete obstruction of the tubes, the air enclosed within is gradually absorbed. In any case, the vesicular structure collapses, the blood-vessels become surcharged with blood, and the most favorable conditions for inflamma- tory action are thus supplied. When the disease begins to undergo resolution the cellular material within the vesicles suffers fatty degeneration, and with the mucous secretion is expectorated or absorbed coincidently with resolution of the peribronchial inflammation. In cases, however, in which chronic pneumonia results, the peribronchial connective-tissue hyperplasia undergoes fuller organization, and induration follows in consequence. The bronchial walls are thickened, and 900 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN not rarely show fusiform dilatations, the result of traction of the newly-formed connective tissue. The macroscopic appearance is highly characteristic in most cases. The involvement of scattered lobules of both lungs in itself is a most distinctive condition, though sometimes by confluence a whole lobe may be affected. In such cases the distinction from croupous pneumonia becomes one of great diffi- culty if, as sometimes happens, the vesicles contain fibrinous exudate and the incised surface presents a granular appearance. Even in these cases, however, it will be noted that the process is not entirely a uniform one, and that there is a certain tendency to lobular limitation. Examination of the pleural sur- face of the lung shows a moderate deposit of lymph over areas which have reached the periphery. The inflamed lobules project slightly from the surface, and have a dark-red or in later stages a grayish appearance, which at once dis- tinguishes them from the depressed, blue-black, and indurated spots of atelec- tasis. The latter may be small and lobular or more extensive, and the}" are most frequently seen posteriorly along the spinal column or anteriorly in the middle lobe of the right lung or the lingula of the left. In the early stages they may usually be distended by inflating the lungs through a tube, but later, as inflannnatory changes occur within them, this becomes difficult or impossible. The incised surface of the lung presents a similar picture. The distinct lobular invasion is again ({uite evident, and the atelectatic areas are recognized by the same characters as on the pleural surface. The lung is smooth and airless in the affected portions, or in rare cases may be slightly granular when the exudate contains fibrin. The smaller bronchi are distended with clear viscid mucus or turbid yellowish muco-pus. The lobules adjacent to the affected ones are emphysematous, as are also the anterior margins and the upper lobes of the lungs, and occasionally subpleural emphysema may be seen. Iti one instance I found pneumothorax resulting from rupture of the pleura in such a case. When resolution takes place, the inflamed lobules become lighter in color, the exudate softens, and is finally removed. More rarely abscess or gangrene may result, or chronic broncho-pneumonia may occur in lingering cases. The termination in cheesy pneumonia, of which much was formerly written, is per- haps always the expression of tubercular infection, either primary or consequent upon the broncho-pneumonia. Symptoms. — d’he onset of broncho-pneumonia is rarely marked by decided symptoms. If the primary measles or whooping-cough has not been entirely recovered from, a slight increase of the existing fevei’, with acceleration of the pulse, dyspnoea, and a change of the cough to a, short and hacking character, may be the only symptoms to indicate beginning trouble. Iti cases in which broncho-pneumonia arises primarily the same symptoms follow an initiatory stage of bronchitis. The fever rises gradually, reaching the maximum in three or four days, and is throughout the disease markedly irregular, the diurnal excursions ranging from three to four degrees. In ordinary eases the evening maxima are from 103° to 104.5° E., but it is not unusual to find higher temperatures, and in one case which recovered 1 have seen it reach 107°. The decline of the temperature, like the ascent, is gradual, and for a longtime during convalescence feverishness may be noted tOAvard evening. With in- crease of the fever the j)ulse-rate accelerates to 130 or 140 beats j)er minute, and in exceptional cases a rate of 200 may occur. l)ys])iioca, however, is a more decided synq)tom, the ratio between the res])iration and judse not infre- ((uently becoming 1 to 2, or even less than 2. The ahc of the nose dilate with each inspiratory effort, the base of the chest sinks in, and the child mani- BROXCIIO-PNE UMONIA . 907 fests by its expression that pain is felt in the side. When areas of the lung collapse, there are paroxysms of more decided dyspnoea, the expiration becomes more grunting, and duskiness or decided cyanosis of the skin makes its appear- ance. The cough at first is sharp and short, and is attended by grimaces and a cry of pain ; later it is heard to be locfser, and in children over seven years of age there may be muco-purulent expectoration. In younger children the Chart of Temperature, Pulse and Respiration of Broncho-pneumonia in a patient two years and two months old ; recovery. sputa are swallowed. With the fever and dyspnoea there is nearly always a complete loss of appetite, but excessive thirst. Nursing infants are unable to retain hold of the nipple for more than a moment or two on account of dyspnoea, and older children refuse food entirely. The child becomes fretful and irritable, but sometimes the urgency of dyspnoea may be such that it suffers itself to be taken up or examined without complaint. The general strength rapidly declines, and, as the interference with respiration continues, a soporose or somnolent condition or complete stupor presages an early death unless relief be afforded. Not infrequently vomiting is present at the onset or during the course of the disease, and with diarrhoea may still further add to the general depression and the unfavorable outlook. In cases in which resolution occurs the symptoms gradually ameliorate, the fever subsides, and in the course of a few days or a week convalescence is established. In less favorable cases, after subsidence of the urgent symptoms, the disease may linger and become chronic, or from the start it may assume a {MW AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN chronic type. In such cases there is persistent, irregular pyrexia, with cough, dysj)Moea, and acceleration of the pulse, and the general health of the patient becomes more and more dej)ressed. Physical Signs. — At the inception of the disease the physical signs of bronchitis affecting the smaller tubes will nearly always be present. At first there are heard on auscultation numerous drv rales throughout both lungs; later, coarse moist rales make their appearance, but the pulmonary resonance remains unaffected. The physical signs of the developed disease are by no means distinctive. Defective expansion and an up-and-down type of breath- ing are manifest, and with each inspiratory effort the base of the chest may be seen to recede. At the same time, careful percussion of the lateral and pos- terior portions of the lungs may detect localized patches of dulness, but this is by no means constantly the case. In not a few the percussion note is hyper- resonant, perhaps from associated emphysema of the unaffected lobules, or, on the other hand, the extent of dulness is rendered considerable by coexistence of lai’ge areas of atelectasis. Vocal fremitus is slightly increased over the con- solidated areas when the bronchial tubes are not unduly filled with mucus, but over the collapsed portions it is usually wholly absent. Auscultation shows the continuation of the preceding bronchitis, but in addition to these coarser dry and moist rales there is also heard fine moist crackling over the consolidated areas. These fine subcrepitant rales are heard on inspiration and expiration, and are perhaps the most suggestive sign of the disease. The breath-sounds themselves vary widely with the condition of the terminal bronchi and the degree of distention. Sometimes the sounds are weak and faintly blowing, at other times harsh and clear, but only rarely do we find the distinct bronchial breathing of croupous pneumonia. It will be noted, then, that the signs of broncho-pneumonia are in no sense characteristic ; but when to the rales of bronchitis there are superadded fine subcrepitant rales, with harsh or somewhat blowing breathing, and areas of even indistinct impairment of resonance at the postero-inferior portions of the lungs, the evidence is fairly clear as far as physical examination is concerned. Complications and Sequels. — As has been said in the descri])tion of the pathological anatomy, j)ulmonary collapse is a more or less constant fixctor in the disease, and is therefore hardly to be looked upon as a complication. Yet in some cases the extent of the atelectatic areas is so great, and the attending dyspnoea and appearance of suffocation so severe, as to merit the j)lace of com- plicating symptoms. It is in such cases that the old title “ suffocative catarrh” finds a not inapt application. Pleurisy, so commoidy ])resent in slight degree, rarely becomes a troublesome complication, though some observers, among them myself, have met with purulent effusion. Abscess and gangrene rartdy follow broncho-pneumonia, but are most apt to do so in as[)iration and deglutition pneu- monias, in which the inflammation from the beginning may take on a serious character. Subpleural em))hysema and ])neumothorax are rare coni])lications. The most dreaded secpiel of broncho-pneumonia is tuberculosis. In some of the cases the broncho-jmeumonia is undoubtedly tubercular from the beginning, but in any case the vulnerability of the system is so heightened by the attack that subse(juent infection becomes an easy matter, and fre(juently occurs. The marked nervous symptoms during the course of broncho-pneumonia or toward its termination may suggest meningitis, but it is more probable that in the majority of such cases the symptoms are due to hyperamiia of the meninges or the toxjemic state of the patient rather than to actual meningitis. The termination of protracted cases in chronic pneumonia has been alluded to before. BRONCHO-PNE UMONIA . 909 Diagnosis. — In the first place, it is essential to recognize the development of pneumonia during acute bronchitis at the very earliest moment. It may be suspected when there has been a sudden increase of fever and acceleration of the pulse and respiration, but such might occur independently of broncho- pneumonia. If, however, in addition to these symptoms, fine subcrepitant rSles and blowing breathing be heard, and percussion detects small areas of impair- ment of resonance, pneumonia may be diagnosticated with considerable cer- tainty. The disease when fully developed may readily be confounded with croupous pneumonia in cases in which the confluence of lobular involvement has led to a considei’able area of consolidation. This, however, is rarely the case, and even when it does occur the consolidation is not so definitely localized in one lobe, and scattered patches will probably be found in the other lung. In ordinary cases the dulness, the vocal fremitus, and bronchial breathing are not developed to nearly the degree Avhich they commonly attain in croupous pneu- monia, and in typical cases there could scarcely be the possibility of confound- ing the one disease with the other. The difficulty, however, of making accurate physical examinations in young cliildren is often considerable, and in such cases the history of the disease is of greatest assistance. The gradual onset and the marked irregularity of the fever, the existence of a preceding Itron- chitis, and the character of the sputa when present, are in all cases highly suggestive of broncho-pneumonia, as the abruptness of the attack and the greater regularity of the temperature curve give strong evidence of croupous pneumonia. The diagnosis from pleurisy with effusion presents little difficulty, altogether aside from the fact that the latter disease is rare in children under six years. The coexistence of moderate pleuritic effusion may, however, be difficult to recognize. In such cases the decided dulne.ss and the variation of its outlines with changes in the position of the patient, and the more distant and muffled character of the breath-sounds, may serve to indicate the actual pathological conditions ; but the complication so rarely occurs that its recognition hardly merits further study. IVlore commonly, plastic pleurisy accompanies lu'oncho- pneumonia, and may confuse the physical signs, but careful study of the degree of dulness, compared with the auscultatory phenomena, will in these cases usually point to the proper diagnosis, and the evidence of great pain in the side would still further .strengthen this opinion. In cases in which nervous symptoms or gastro-intestinal disorders become prominent, it may happen that the underlying pneumonia is wholly overlooked. Such an error can oidy be avoided by a critical study of the symptoms in every case, particularly by close observation of the rate of the pulse and respirations and by careful and repeated examination. Prognosis. — Broncho-pneumonia is always a most serious disease, the mortality ranging from 30 to 50 per cent., according to the nature of the cases and the surrounding conditions. It is most fatal in children under tAvo years, and the form which occurs in the new-born from aspiration of irritating or infectious particles during the transit through the maternal passages is almost invariably fatal. In children over two years of age the mortality grows pro- gressively less with the age of the patient. The cases Avhich complicate whooping-cough are most apt to be fatal or lingering. Rickets or other debili- tating diseases and the occurrence of gastric disturbances, diarrhoea, marked nervous symptoms, and pyi’exia, all make the prognosis highly unfavorable. Duration. — The duration of ordinary cases is generally from fifteen to twenty-five days; milder cases may terminate in a week or ten days. Chronic 910 AMERICAN TEXT- BOOK OF DISEAHEH OF CHILDREN broncho-pneumonia is uncertain in duration, ranging from a few to many months. Treatment. — It is difficult to lay down fixed rules for treatment in a disease in which so much depends upon the actual extent and nature of the pathological changes and upon the reaction of the patient. In many cases of bronchitis or of infectious diseases attended with bi’on- chitis, it will be possible to prevent the development of broncho-pneumonia by careful attention to hygiene and by strict insistance upon every detail of treat- ment. It will be necessary in such cases to maintain an even temperature of 70° or 72° in the sick-room, to avoid all drafts, and to adapt the clothing of the patient according to his powers of resistance. In very young children the mouth should be carefully cleansed with some simple mouth- wash like glycerin and boric-acid solution, and older children should in addition be directed to expectorate the sputa. When pneumonia has actually become established, the hygienic details of the sick-room must be still more strictly maintained. The temperature of the room must be kept as nearly as may be at an even point, and it is always well to have the air moistened by allowing water to steam at the hearth or over a flame. In severe cases a tent of sheets may be erected over the bed and steam from a boiler be directed into it. A light woollen shirt should he worn, and the chest will reijuire special protection. Formerly fla.xseed j)oultices were in common use in the treatment of pneumonia, but they are so apt to become cold and disordered, and their constant application is attended by so much risk and disturbance of the patient, that their use is now generally abandoned. The best protection is afforded by a jacket of cotton or wool batting, lightly (juilted and covered on the outside with oiled silk. This may be so constructed as to be easily applied and removed without the slightest disturbance of the patient, and it is so light as to cause little discomfort by its weight. Practically the same thing is accomplished by stitching cotton batting on the inside of a light merino shirt, and oiled silk outside, but the jacket is more convenient. It is unnecessary in ordinary cases to change the jacket oftener than every seven or eight days. The use of counter-irritants, such as turpentine stu))es, mus- tard plasters, and blisters, while occasionally advisable, has, as a routine treat- ment, fallen into disrepute ; but the repeated application of tincture of iodine diluted with alcohol, so as not to {>rove too irritating, is often attended by good results. The diet of the patient should be at once light and nutritious, so that the digestive functions may be kept in the best possible condition, and at the same time the patient’s strength j)reserved. Milk, gruels, light broths, arrowroot, and egg albumin dissolved in water or milk answer the recpiirements, and are the most suitable foods obtainable. In addition to j>roper regulation of the diet, it is sometimes desirable to administer a mild laxative at the onset or dur- ing the course of the disease if constij)ation be present ; I)ut it must be remem- bered that gastro-intestinal irritation is apt to complicate the case, and noth- ing must be done which might invite its occurrence. Minute doses of mercury wi th bicarbonate of sodium or Dover’s ])owder, or the mildest salines, may be of value, and in certain cases may exercise a happy regulating influence on the gastro-intestinal system, ))rovided that free purgation is not induced. For the condition of the lungs themselves expectorants are highly important. During the early stage, when bronchitis is marked and the s])uta tenacious, small doses of ipecacuaidia or ajxmiorphine, in combination with alkalies like citrate of pota.ssiuin, arc useful. Such a combination as the following is readily taken by children, and rarely fails to render the mucous secretion less tenacious : BE ONCHO-PNE miONIA . 911 R. Potassii citratis 3iiss. Syr. ipecac l‘5ss. Syr. limonis AqiuTe (td q. s. ad fsiv. — M. Sig. Two teaspoonfuls every three or four hours, for a child of five years. A small dose of aporaorphine — a sixteenth or a twenty-fourth of a grain — may be added with advantage in case the mucus is unusually tenacious. Generally, howevei’, recoui’se must soon be had to the more stimulating expec- torants. The ammonium salts, the chloride and carbonate, in combination with squills or senega, are the most desirable. In cases in which depression is marked the carbonate is preferable to the chloride, and when painful cough is urgent minute doses of morphine or paregoric may be added to the mixtures. Opium, however, should never be given with such freedom as to benumb the sensibility, and in the later stages of the disease should be avoided if possible. In some cases, where the stomach is particularly irritable, the aromatic spirits of ammonia may be better retained than other preparations, and is acceptably administered in combination with brandy or other stimulant. The following combination is especially valuable for children, being pleasant to take and more stimulating than such as contain the chloride of ammonium : R. Ammonii carbonatis gr. xlviij. Pulv. acacite et sacchari au q. s. Spt. lavandulse comp foij. Aqum q. s. ad f§iv. — M. Sig. A teaspoonful in water every two or thi'ee hours, for a child five years old. The general strength of the patient, and particularly the respiratory function, require special attention. To this end quinine in small doses and alcoholic stimulants are highly l)eneficial, but for respiratory and muscular stimulation no drug compares with strychnine in efficiency. E. g. — 1^. Quinime sulph gr. xxiv. Strychninm sulph gi’- i- Acid, muriat. dil gtt. xvj vel gtt. xxxij. Glycerini fsiij- Li(j. pepsini q. s. ad f§iv. — M. Sig. A teaspoonful in water every three or four hours, alternating with the expectorant remedies, for a child of five years. In cases where the stomach is non-retentive quinine may be given in sup- positories of two or three grains each. The use of such expectorant and tonic treatment usually suffices to keep the bronchi free and to prevent the occurrence of atelectasis ; but when tliese unwelcome accidents make their appearance and suffocating paroxysms occur, active treatment must be instituted. The admin- istration of emetic doses of ipecacuanha, five grains of the powder in a little syrup, is an old method of treatment which serves admirably to clear the respiratory passages. In some cases it may he well to combine alum or sul- phate of zinc with the ipecacuanha, but the preparations of antimony formerly so commonly used are depressing agents which had better be avoided. When vigorous emesis fails of the desired purpose, a warm bath or alternate hot and cold douches may be resorted to, and stimulants given by the mouth and 912 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. hypodermatically. In all cases in wliicli the strength of the child is greatly affected it is necessary to change the position from time to time, so that hypo- static congestion may he avoided. Fever in catarrhal pneumonia does not usually call for active treatment, from the fact that the pyrexia is not constantly maintained at a high point, but such is not always the case. In the vei’y early stages a few doses of the tincture of aconite, a half or one drop repeated every hour or two, are of dis- tinct value ; and in the later stages small doses of antipyrin or phenacetin exert a powerful influence on pyrexia. The use of either aconite or more active antipyretics must always be most cautious, and the first indication of general depression would call for the immediate withdrawal of the medicines. Unquestionably the use of hydrotherapic measures is most valuable in controlling fever, in stimulating the general and respiratory tone, and in quieting the nervous system. The patient may be carefully sponged with lukewarm or cold water or wrapped in sheets wrung out in water, or he may be placed in a bath of temperatui’e varying according to the age. With very young children the temperature of the water should be near that of the body, and gradually cooled after the patient has been placed in it ; in older children the initial tem- perature may be 85° or 80°. After removal from the bath the skin should be lightly dried with a towel or woollen cloth and the patient wrapped in a blanket. Excessive nervous symptoms are to a large extent controlled by sponging or bathing, but in cases where this is inadequate small doses of chloral may be given in enemata, or asafoetida in 5 grain doses, may be added to the quinine suppositories. In more chronic cases the general health and the respiratory action should be maintained by the closest attention to daily life and by administration of suitable tonics. During convalescence of acute cases renewed exposure must be avoided, and the child should receive cod-liver oil, arsenic, iodide of iron, or other tonics ; and, if possible, a change of climate is of material advantage. CROUPOUS PNEUMONIA. By william PEPPER, M. D., Philadelphia. Croupous Pneumonia — designated also lobar pneumonia and fibrinous pneumonia — is a specific inflammatory disease of the lungs, characterized by fibrinous exudation into the vesicular structure and consolidation of the lung, presenting a characteristic clinical course and terminating by self-limitation in seven to ten days. The croupous pneumonia of children differs from that of adults only in some of the less important manifestations, in the situation of the lesion, and in the smaller mortality. Etiology. — One of the most important causes of croupous pneumonia is exposure to cold. The history of a large majority of the cases Avill disclose the fact that the child has suffered chill from exposure, and the study of mortality statistics shows that tivo-thirds of all cases occur during the winter and spring. Cold cannot, however, in the light of recent knowledge, be looked upon as the exciting cause of the disease, though there are still some who maintain that a small number of idiopathic cases from exposure do exist. Age is an important factor in determining the form of pneumonia. The croupous variety, though it does sometimes occur in infants at the breast, is rare before the age of three, and in children is most common between five and ten. On the other hand, broncho-pneumonia is a prevalent disease in chil- dren under three or two, its frequency being explained by the great tendency to catarrhal processes manifested in young children. The previous health of the child is another point in which the croupous form differs from broncho-pneumonia. Unlike the latter, it affects children who are robust and in good health. Rilliet and Barthez said that in only one-quarter of the cases was the child in good health before, but this may have arisen from confusion with broncho-pneumonia, and in the statistics of private practice of Dr. J. F. Meigs and myself there w'ere but 7 of 52 cases secondary to previous diseases. Of the diseases upon which croupous pneu- monia may be consequent, pulmonary tuberculosis, measles, whooping-cough, influenza, and typhoid fever maybe named; but in all of these in children under three years of age broncho-pneumonia is more apt to occur as the com- plication. Malhygienic influences may induce pneumonia, either by causing exposure or by reducing the power of resistance in some other manner. The exciting cause in a great majority of all cases is the pneumococcus of Friinkel. This lance-shaped coccus usually occurs in pairs as a diplococcus, and is surrounded by a transparent capsule. It has been found in a very large percentage of cases of croupous pneumonia, but also in the catarrhal form, and it seems to bear close etiological relations also to cerebro-spinal fever, to middle-ear disease, and to endocarditis. The pneumococcus is a normal con- stituent of the saliva ; and it is held that after exposure to cold or similar 58 913 914 AMERICAN TEXT-BOOK OF BISEABES OF CHILDREN. predisposition the micro-organism gains greater virulence or the lungs become less resisting. There are, however, other micro-organisms which occasionally seem the causative agents. Among these the bacillus of Friedlander, the bacillus of influenza, the streptococcus pyogenes, and staphylococci are promi- nent. The evidence in favor of contagiousness of pneumonia of both forms is fairly convincing, though the contagiousness is slight. I have seen a local epidemic in a children’s hospital in which the disease crept from bed to bed around the ward, and similar instances are common in the recent literature of the disease. Morbid Anatomy. — The stages in the morbid anatomy are exactly the same as in the adult, but more frequently there is a coexistence of the several stages in the child, so that when one part of the lung is newly congested another may show the most advanced consolidation or beginning resolution. The stages are those of congestion, consolidation, red and gray, and resolution. During the first stage the lung is swollen and red, and the surface of a section is smooth and moist. The fluid which flows from the cut surface contains air and is bloody. In the stage of consolidation the lung becomes solid or hepa- tized ; it is friable, so that the finger easily tears through it, and the surface is granular and dry. The granular appearance is due to the fibrinous exudate which fills up the air-vesicles and smaller bronchioles. Microscopically, the vesicles are seen to contain a fibrin network enclosing leucocytes, red corpuscles, and a few desquamated cells of the lining membrane of the vesicle ; and the blood-vessels of the intervesicular septa are over-full. In the first stage of consolidation, that of red hepatization, the number of red corpuscles is very great, but in the stage of gray hepatization they have largely been removed. During resolution the exudate rapidly undei’goes softening and is expectorated or absorbed. More rarely, termination in abscess-formation or gangrene results, or chronic pneumonia may follow as a sequel. As in adults, ci’oupous pneumonia of children is a lobar process, but it is far more frequently a bilateral disease in children. The lobe most frequently affected is the lower lobe of the right lung, as in adults. Apex pneumonia, however, is as common a disease in children as it is uncommon in adults, and some writers claim the right apex as the more frequent seat. In every case in which the pneumonic consolidation reaches the pleural surfiice of the lung there is a certain amount of plastic pleurisy. More rarely effusion of liquid occurs, and I have seen extensive empyema result. In some cases there is also a concomitant bronchitis. This condition is occasionally found in croupous pneumonia of adults, but with not nearly so great frequency as in children. Symptoms. — The onset of croupous pneumonia in children, as in adults, is usually abrupt, but there may be a short prodromal period during which the child is drowsy or restless and chilly, or coughs slightly and com)»lains of pain in the side. As a rule, however, the onset is decided, a j)aroxysm of vomiting or convulsions, with rapid rise of temperature, at once calling attention to the seriousness of the malady. Rigor may be present, but distinct chill, such as is so constantly noted in adults, is rarely met Avith. Instead of this, con- vulsions and vomiting, especially wlien indiscretions in diet have preceded the onset, are very common in young children. The temperature rises rapidly, and in a few hours may reach 104° F. It continues during the course of the disease with moderate daily remissions, and declines at its termination by rapid crisis. More rarely decided remissions and gradual decline may mark CBOUPO US PNE I IMOJVIA . 915 the case. With the rise of temperature great rapidity of pulse is noted, but even greater relative rapidity of the respirations, and in bad cases dyspnoea is a most urgent symptom. The child lies on the affected side, and from time to time is seized with paroxysms of sharp, short cough. In young children the grimaces and cry give evidence of the pain experienced during coughing, and older children complain of pain in the side or abdomen. Expectoration is rarely seen excepting in children over seven years, when it may occur, and presents the characteristic haemorrhagic or rusty character so commonly seen Chart of Temperature (rectal), Pulse, and Respiration in Croupous Pneumonia of the apex of the left lung in a patient three years old; recovery. in the pneumonia of adults. The child may be restless and irritable, and insist upon being constantly changed from the nurse’s arms to the bed ; but when the disease is most severe and dyspnoea is marked, complete apathy is apt to be developed. The face is flushed, and particularly a bright red spot may be seen on the cheek or region of the zygoma of one or both sides ; the aim of the nose dilate with each inspiratory effort ; herpes is often seen upon the lips. The tongue is coated, the appetite is lost, and in certain cases vomiting and diarrhoea may persist throughout the disease. Ordinarily in mild cases, when convulsions or delirium have been present at the onset, they rapidly dis- 91 G AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. appear with full development of the disease, but in severe cases nervous symp- toms may take a prominent place throughout the case, and in some malignant forms death may occur in convulsion before the appearance of the ordinary symptoms of the disease. In bad cases as the disease nears a fatal termination the respiratory efforts become more and more rapid and irregular ; the pulse becomes more rapid and weak ; duskiness or cyanosis may develop, with increasing drowsiness and stupor, and the child may die convulsed or comatose. In favorable cases the temperature rapidly declines about the seventh to the tenth day, and during the early days of convalescence remains subnormal. Coincidently with the decline of temperature the dyspnoea becomes less urgent, the pulse gains in force, the nervous symptoms, if marked, soon disappear, and conv^ilescence pro- ceeds. Sometimes, however, convalescence is rendered tedious by diarrhoea or stomatitis or by tendency to slight recrudescences of the fever. Varieties. — Though, as a rule, the symptoms in croupous pneumonia have a typical and regular course, there are occasional cases in which the manifes- tations are so irregular as to warrant the description of certain clinical varie- ties : (1) Cerebral pneumonia is a type in which from the onset excessive pyrexia and nervous symptoms, such as delirium, convulsions, or coma, so dominate the case that the underlying disease might readily be overlooked, and the existence of meningitis be suspected, especially as cough and other pul- monary indications may be wholly absent. Such cases are most frequently observed in children debilitated by previous disease, and very often the pneu- monic changes affect the apex of the lung. The relation of apical involve- ment to severity of nervous symptoms has, however, been greatly exaggerated. (2) Abdominal pneumonia is a less common variety, in which vomiting and diarrhoea, with marked abdominal pain, are prominent symptoms. In some cases these may be so decided as to indicate the existence of gastro-enteritis, or, when pain and abdominal distention are excessive, of acute peritonitis. In a small number cf cases, especially of basal pneumonia of the right side, jaundice is noted, and to such the term “bilious pneumonia” has been applied. (3) Wandering pneumonia, or 'pmumonia migrans, bears so close a similarity to broncho-pneumonia that the distinction requires the greatest care. The disease affects one portion of the lung after another, and gives to the case an irregular and lingering nature cjuite unusual in the croupous form of pneumonia. By the completion of the disease consolidation may have been present in every part of the lung, but the consolidation is usually not well marked. Physical Signs. — The physical signs are often less distinctive than in adults, and it is especially to be remembered that the apex is almost as fre- quently the seat of the disease as the base, and that bilateral pneumonia is a much commoner condition in young children than in adults. In a typical case, however, the signs are (piite decided. The res))iratory expansion is often seen to be lessened on the aflected side; percussion and auscultation give evi- dence of the consolidation of the lung. Dulness on percussion is never so decided as in older persons, and sometimes the emphysematous condition of the lung surrounding a centrally located pneumonia may cause the percussion note to be hyper-resonant or tympanitic. In these cases deep jK'rcussion may reveal the true condition of things, or tlie consolidation may sul)sequently extend to the surface of the lung. On auscultation the typical cre])itant liile of pneumonia may be heard in a minority of the cases, either with ordinary breathing or during the deep inspiratory efforts after coughing. In 31 cases of the late Dr. Meigs and myself, the crepitant lale was heard in but 10. CR OUPOUS PNE UMONIA . 917 Subsequently, when consolidation is complete, the breath-sounds become decidedly bronchial, as we found in 46 of 57 cases ; and the vocal resonance and fremitus may be found increased over the affected areas. The latter, how- ever, are untrustworthy signs and difficult to determine. In children under five or six it is not unusual to find evidences of bronchitis in addition to the signs of consolidation, and coarse moist rales may persist throughout the case. In any case moist rales become prominent during resolution and give evidence of the softening of the exudate. The physical signs are subject to wide variations in certain atypical cases. Thus the existence of a large pleui’itic exudate of plastic nature would render the dulness decided, without altering the breath-sounds otherwise than by muffling them to a greater or less extent. In the rare cases in which liquid effusion occurs this condition becomes still more marked, and the auscultatory signs may be completely obscured. Wandering pneumonia is apt to be pecu- liar, not only in its migratory character, but also in the incompleteness of the consolidation, so that but a small area of dulness may be detected. Complications and Sequels. — Pleurisy is a constant accompaniment of pneumonia which reaches the surface of the lung, but is usually of no great severity. Effusion may, however, supervene, and in the pneumonias of measles, scarlet fever, and typhoid fever, purulent effusion is occasionally met with. Pericarditis may also occur, either alone or following the pleuritic complication. The excessive nervous symptoms of cerebral pneumonia frequently create the suspicion of meningitis, but this does not actually occur so frequently as the symptoms would indicate. In such cases also hyperpyrexia becomes so decided as to amount to a complication. The occurrence of jaundice has been alluded to in the reference to abdominal pneumonia. Nephritis is a complication met with in a certain proportion of cases, and one which materially increases the gravity of the disease. It is much commoner in the pneumonia of children than in that of adults. Abscess and gangrene of the lung are rare .sequels, as is also chronic indurative pneumonia. Diagnosis. — The sudden onset of pneumonia with vomiting and convulsion and high fever simulates very closely the onset of scarlatina. The distinction is, however, rarely difficult if the excessive rapidity of the pulse, the soreness of the throat, and the early appearance of a rash in scarlet fever be kept in mind, and the physical examination for the signs of pneumonia be carefully applied. When the disease is fully developed it may be extremely difficult to dis- tinguish it from broncho-pneumonia, especially from cases of the latter which become lobar by confluence. On the other hand, a wandering type of croup- ous pneumonia with imperfectly developed consolidation may simulate an ordi- nary form of broncho-pneumonia, but the diagnosis is sufficiently detailed in the description of that disease. Acute meningitis is often suspected when profound nervous symptoms make their appearance, and indeed the latter may obscure the underlying pneumonia. In such cases only a careful physical examination will reveal the existence of pneumonia; and, as for a complicat- ing meningitis, it must be remembered that such is far less common than we might suppose from the symptoms. The abdominal type of pneumonia is sometimes mistaken for gastro-enteritis, peritonitis, or even acute ileus, and is only recognized by careful study of the breathing of the patient and by the physical signs. Pleurisy with effusion is distinguished by the decidedly dull or flat percus- sion note and the movable character of this dulness ; by the absence of breath- sounds, rales, and vocal fremitus ; and by the milder character of the symp- 918 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. toms. At its onset pain is more severe than in pneumonia, but fever and the general depression of the child are decidedly less marked. Prognosis. — Primary croupous pneumonia of young children is a disease of little gravity compared with the same disease in adults or with broncho- pneumonia of children. Of 60 cases, nearly one-half of them under two years, Baginski lost but 4. In secondary cases, however, the prognosis is much more grave, and in those dependent upon primary septic diseases the mortality is very high. As a rule, marked dyspnoea, high fever, and pro- nounced nervous symptoms are indications of evil omen ; but common experience has shown that in this disease, of all others, a favorable termination may fol- low the most desperate case. Complications, such as pleurisy or pericarditis and extensive involvement of one or both lungs, naturally make prognosis more unfavorable. It is to be remembered also that croupous pneumonia tends to relapse, and that second attacks at remote periods are not unusual. Treatment. — The seriousness of the disease requires that the patient be at once placed at rest in bed. The room should be kept at an even tempera- ture of about 68° to 70°, and drafts must be carefully avoided. It is always well to protect the chest by a jacket made of cotton batting lightly quilted. The food must be light, but nutritious ; broths, junket, and milk, as a rule, prove most acceptable. Sufficient water should be permitted to relieve thirst. The medicinal treatment need not genei’ally be a vigorous one, care being taken, however, that the strength of the patient be properly maintained. In the early stages small doses of tincture of aconite in combination with the solution of ammonium acetate or with sweet spirits of nitre serve to control the tempera- ture and to quiet excessive action of the heart. If, however, fever becomes more decided, aconite will prove inadequate, and recourse to stronger antipyretics may be necessary ; but hydrotherapic measures are more efficient. Sponging with cool water and the cohl pack or bath are the safest and surest means of controlling temperature, and when carefully used give rise to no unpleasant consequences. The prejudices on the part of parents may, however, j)revent their use, in which case small doses of antipyrin or j)henacetin become neces- sary. When cough and pain in the side are troublesome symptoms, opium may be given in quantity sufficient to allay the irritation, guarding carefully, how- ever, against excessive opiate effect. In severe cases, where general depres- sion and cardiac weakness are marked, recourse must be had to stimulating remedies. Brandy or whiskey may be used in liberal quantity, and carbonate of ammonium is useful in cases in which the cough is tight and irritating. For the support of the heart digitalis is unquestional)ly the most reliable remedy, though care must be taken lest it prove disturbing to the stomach. In cases of extensive or double pneumonia, in which the strength of the child is profoundly affected and the heart and respiration losing force, stimulation must be pushed to the utmost. In such cases the hypodermatic administration of strychnine and of such diffusible stimulants as ether and aromatic spirits of ammonium may help to carry the child over the crisis, and the inhalation of compressed air or oxygen may prove of signal service. Throughout the disease the general systemic tone is well maintained by the use of (piinine in suppositories, to which asafietida may be added in case nervous symptoms become pronounced. If asafietida does not suffice, chloral by enema may be trieyrexia is a distinct and co-ordinate symptom produced by the same factors which cause the bronchial catarrh. No definite tenq)erature curve can BRONCHITIS. 929 be ascribed to bronchitis ; it follows the other conditions present, and in the severer forms runs high. The facies of severe bronchitis resembles that of broncho-pneumonia ; that is to say, the countenance is anxious, the alae of the nose dilate, the lips may become cyanotic, and in general the countenance indicates distress. Under such conditions it is perhaps true that broncho-pneumonia is usually present to a greater or less degree, but this is certainly not always the case, as this facies is sometimes found in bronchitis which has invaded only the larger tubes. Nevertheless, the prognosis, whether broncho-pneumonia be found upon physical examination or not, is grave in accordance with the facies just described. Nervous symptoms are often very marked in the severer forms. Great rest- lessness occurs not only as a result of the difficulty of respiration, but also as a toxic symptom. Ataxic features are occasionally noticeable, and drowsiness deepening into coma is at times seen. A toxic or so-called febrile dyspnoea is often met Avith ; that is to say, a dyspnoea which is out of proportion to the mechanical conditions present, and apparently due to the same or a coincident cause as that producing the fever. The grunting expiration, noted above, is often of this type ; it usually occurs Avhen the rate of respiration is not greatly increased, and, while present during the Avaking hours, disappears during sleep. The bronchitis Avhich is caused by the putrefaction of bowel-contents is essen- tially toxic. Often mild, it may be very severe and accompanied by great acceleration of respiration, by dyspnoea, and by marked head symptoms. An uncomplicated case of this kind is relieved by the action of a suitable purga- tive, the most marked symptoms disappearing at once, leaving no doubt of the toxic origin. The cough which accompanies enlargement of the bronchial glands is usually dry and harassing, and often assumes a croupy character. Not infre- quently, hoAvever, the accompanying bronchitis is severe, and may continue for Aveeks or even months Avith a profuse bronchial secretion, showing little or no tendency to recovery. This is but one phase of the condition which Dr. B. K. Rachford^ designates by the term “scrofulous bronchitis.” He describes it as follows : “ It is, as a rule, recurrent, coming on during the cold and disagreeable winter months and disappearing during the summer months. It is characterized by marked anaemia, and as a rule by other Avell-knoAvn signs of scrofula, such as enlarged external lymphatics, chronic coryza, etc. In these cases of scrof- ulous bronchitis there may be extensive tubercular disease of the deep-seated lymphatics of the abdomen or chest, Avithout any evidence Avhatever of external scrofulosis. In such cases the Avell-marked anaemia and the possible family history of tuberculosis Avill be of material aid in diagnosis.” This form is very often jnistaken for pulmonary tuberculosis, but it may extend over a very prolonged period Avithout the production of pulmonary phthisis, although it tends to that tei’mination. The prognosis is about the same as in other forms of glandular tuberculosis. Bronchitis is accompanied by a great variety of symptoms referable to other organs and variable, inasmuch as the associated features are determined by the particular causes which produce the bronchitis, and necessarily must vary with them. Chronic bronchitis in children does not differ sufficiently from the same condition in adults, either in its symptoms or treatment, to require separate consideration. Prognosis. — Prognosis as to duration should be guarded, as it depends upon the cause which has produced the disease. Those cases which we are com- ' Personal communication. S9 030 AMERICAN TE:XT-BOOK OF DISEASES OF CHILDREN. pelled to recognize clinically as idiopathic bronchitis usually, when mild, termi- nate in three or four days, and even when severe rarely last more than a week or ten days. A bronchitis which is caused by typhoid fever will last from ten days to three weeks, and disappear with the disease which it accompanies. In the case of pertussis the bronchitis may be prolonged (juite indehnitely. In measles, while it may disappear in four or five days, it not infrequently lasts several weeks. Bronchitis of purely intestinal origin, usually disappears imme- diately upon the removal of the bowel-contents. Prognosis as to severity is determined by a number of factors, but ordinarily it is good. It is customary to say that the prognosis in bronchitis of the larger tubes is more favorable than in bronchitis of the smaller tubes, and in general this is true, but by no means is it always so, as some of the most severe attacks, so far as fever, depression, and other nervous symptoms go, are those in which the large tubes only are affected. The age of the patient is always an important element in the prognosis. The infant with bronchitis is to be regarded as always in danger, as broncho-pneumonia may readily supervene. The exciting causes of the attack must also be taken into consideration. Bronchitis symptomatic of a general infection, such as measles, is very likely to be commensurate with the other symptoms so far as severity is concerned. The presence of enlarged bronchial glands is to be taken as indicating a prolongation or recurrence of the trouble, and as paving the way for a possible termination in pulmonary phthisis. The condition of the child’s nutrition determines to a very considerable degree the severity of an attack. Where the nutrition is below par, j)articularly where rickets is well marked, the disease is apt to prove very severe, and to take upon itself suddenly severe nervous symptoms or to lead to the develop- ment of broncho-pneumonia. Marasmus and gi’eat weakness from any cause, interfering with the prompt expulsion from the tubes of the accumulating secretions, are conditions unfavorable to the satisfactorv progress of the case. The cough fer se is of but little aid in prognosis. It may be very severe in children who are evidently but slightly ill, and, again, may be nearly absent in cliildren who are in great danger. The character of the respiration is of more importance from a prognostic standpoint. Whenever it becomes rapid, or its rhythm is interfered with, or the grunting expiration appears, or dyspnoea manifests itself, the prognosis should be guarded. Witli improvement of the respiration in rate and rhythm a more favorable prognosis may be made, 'fhe temperature is often an important guide : the higher the temperature, other things being equal, the graver the prognosis ; the lower the temperature, the better the outlook. Witli a pulse that tends to irregularity irrespective of the temperature and respiration-rate, the prognosis is not favorable. But more important than all these symptoms is the condition of the Itraiii, delirium in any of its forms having its usual grave significance. Intense cardiac depres- sion, and sleeplessness, or, on the other hand, somnolence, all are indicative of severe and threatening conditions. Diagnosis. — The diagnosis involves the recognition of the existence of the broncliial catarrh itself, and the determination, so far as possible, of the etiological factors. The existence of bronchitis is ordinarily recognized with- out any difficulty. The history of cough, with bronchial secretion of recent origin, is usually enough to establish the diagnosis. An examination of the chest, which should always be made, Avill decide. In the earlier slage.s, before the secretion has become established, sil)ilant and sonorous rales are heard. Not infre(}uently, however, these rales are very scanty, and not always beard on both sides of the chest. Ijater the rales become moist and more numerous. When the smaller tubes are invaded, small and even subcrepitant rfiles are BRONCHITIS. 931 heard. At no time in an uncomplicated bronchitis is there any modification of the percussion note. The severer forms are to be differentiated from pneumonia. This can only be done by the detection of the consolidated pneumonic area by percussion and auscultation. The consolidated area is expected to show dulness on percussion, and bronchophony and bronchial breathing on auscultation. But "when the area is small and centrally located, these signs cannot always be made out. Fortunately, it is not of the highest importance to determine these conditions exactly, because the prognosis and treatment will not be essentially modified by the presence of a small area of pneumonic consolidation. Pleural effusion, whether serous or purulent, does not always present specific symptoms indicating its nature, but is often shown only by a cough which may readily be mistaken for that of bronchitis. The physical exami- nation will always differentiate these conditions. The presence of bronchitis being once established, the search for the etiological factors begins. The existence of one of the exanthemata as a causative factor is usually readily made out by the history and appearance of the child. Pertussis, however, is difficult to determine before the occur- rence of the convulsive stage. It may be suspected, however, if the cough be very severe and the disease be prevalent. Influenza usually presents its neural- gic and other nervous features. The character of the stools should always be carefully inquired into, and if there be any suspicion of putridity of the bowel-contents, the fact should be noted as a possible factor in the case. The condition of the nutrition should be carefully studied, particularly in infants, and if the history shoAvs the occurrence of profuse sweating, especially about the head at night, Avith great restlessness and a tendency to lie uncovered, if there be beading of the ribs, recurrent bronchial attacks during dentition, and occasional laryngismus stridulus, rickets is to be diagnosticated. Treatment. — The treatment of bronchitis includes attention to the local conditions in the chest, to the general constitutional disturbance, and to the removal, as far as possible, of the causative factors. It is not convenient, hoAvever, to divide the description of the treatment Avith strict reference to these three factors, but rather to consider the matter someAvhat in the order in which the various steps are undertaken in actual practice. The very mildest cases require no treatment Avhatever, but they should always be Avatched, particularly in infants, so that interference may be made as soon as necessary. It is good practice to commence the treatment of every case of bronchitis in infants and young children Avith the use of a laxative, the reason for this being that the intestinal tract of the infant so commonly contains putrid faeces which do not ahvays manifest themselves by special signs. In older children some signs of bowel disturbance may be Avaited for, but in severe cases the character of the boAvel-contents should always be investigated by tbe aid of purgatives. Besides their action on the boAvels, purgatives deplete the liver and prepare that organ to receive some of the blood Avbich has been determined to the bronchi. The most available laxatives are castor oil and calomel. Calomel, which is preferable in the infant, should be administered in three doses, of one grain each, at intervals of four or five hours. When putrid faeces are found, all animal food should be prohibited for one or tAvo days, and such intestinal antiseptics as naphthaline and salol administered. Expectorants are often of great service in the earlier stages of bronchitis, but, as a rule, they are abused. Their sole use is to cause an increase in the bronchial secretion. When the secretion is scanty, and the rales few and dry, 032 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. and the cough, in consequence, frequent and harassing, expectorants aiford relief. But when the secretion has become thoi’oughly established, and auscul- tation shows the rales to be abundant and moist, then expectorants are of no further use, and it is better to withhold them. The best expectorants are ammonium chloride and potassium iodide. The following formula may be employed for an infant from three to six months of age : I^. Ammon, chlorid gr. xvj. Syr. tolutan Aq. destillat dd f§j. — M. Sig. One teaspoonful in a little water every two or three hours. Ipecacuanha is widely used. It is of peculiar value because, besides increas- ing secretion, it tends to dilate the cutaneous capillaries. When the secre- tion is excessive and the efforts at coughing inadec^uate to remove the ac- cumulation, emesis affords much relief. For this purpose ipecacuanha is valuable. The modern coal-tar antipyretics have a marked effect in bronchitis. They appear to act almost as specifics, diminishing the amount of secretion, lessening the severity and frequency of the cough, and I’elieving pain, without acting like opium in simply covering up symptoms. Of these, the safest probably is phenacetin. For an infant from six months to two years of age the follow- ing formula will be found useful : I^. Phenacetin gr. xii-xxiv. Caffeine Div. in chart. No. xii. Sig. Give one powder every four hours. The smaller dose may be used at six months and the larger at two years. For younger infants the dose should be reduced, and for older children slightly increased. These powders are advantageously alternated with the calomel powders given at first. Here, as elsewhere, phenacetin should he used cau- tiously, withheld entirely from weakly children, and never continued over a long period. In severer cases the inhalation of antiseptic vapors seems at times to be useful. For this purpose it is convenient to evaporate turpentine or oil of eucalyptus from a water-bath in the patient’s room. Particularly in the l)ronchitis of infants and young children is the cough salutary, and it should l)e laid down as a cardinal rule that no effort should be made to .smother it. Narcotics and antispasmodics distinctly iticrease the tend- ency to pneumonia. But it is not ahvays possible to dis()enso entirely with the use of opium. In some very severe cases, where there is great restlessness, a single full dose of opium to produce sleep is occasionally necessary. Used in this way, the best results to the patient are obtained with a minimum of danger. Certain means very commonly employed in the treatment of bronchitis and pneumonia have for tlieir object the relief of internal congestion by the pro- duction of a dilatation of the cutaneous capillaries. These are the poultice jacket, the cotton and oiled silk jacket, local counter-irritation, and the inter- nal use of sweet sjnrits of nitre, alcoliol, and aconite. Redness of the chest- wall is readily obtained by thorough friction Avith camphorated oil or an oint- ment of turpentine and lard. It is rarely necessary to use mustard. The BRONCHITIS. 9.33 agent selected should be well rubbed on twice each day, and the redness main- tained by the use of the poultice jacket or the jacket of cotton batting and oiled silk. When poultices are used, two should be made — a smaller one to lie upon the front of the chest, and a larger and heavier one to cover the back and sides of the chest and lap over the front poultice. As their object is to keep the skin red, they must be as Avarm as can be borne, and changed often enough to prevent cooling. The advantage of two poultices is to be found in the chang- ing. The^ one at the back does not cool as rapidly as the front, which must be the thinner, so as to embarrass the respiration as little as possible. Hence the front poultice requires changing oftener than the back. Poultices Avhich are allowed to become cold constitute an element of danger, and therefore should not be used on patients when the nursing is inferior. They ai-e disadvantageous also to very Aveak children, to whom their Aveight is a burden. When properly employed their action is of the greatest service, and they should ahvays be used in properly selected severe cases. As a substitute for the poultice the chest may be enveloped in a thick layer of cotton batting, and this covered with oiled silk. This dressing, while inferior to poultices, is yet so convenient and so serviceable that it should ahvays be employed, in conjunction with camphorated oil, even in quite mild cases. The principal utility of alcohol in bronchitis has seemed to the writer to be due to its poAver of relaxing the cutaneous capillaries. For this purpose it is best administered in rather small doses at frequent intervals, and in the shape of whiskey or some light, non-astringent wine. Sweet spirits of nitre, so commonly employed in febrile conditions, is often of great service in bronchitis, particularly Avhen there is fever. It dilates the cutaneous capillaries, acts as a diaphoretic, and by its diuretic action no doubt assists in the elimination of toxic principles. When bronchitis is produced by any of the specific fevers the cause cannot be directly removed, but treatment directed to the amelioration of the corn- plexus of febrile conditions relieves the bronchitis, as it does the other mani- festations of the poison. In those specific fevers which are best treated by the application of cold the presence of bronchitis is not to be regarded as a contraindication of the means. Convalescence from bronchitis is ahvays worthy of attention, and after severe cases, where the bronchial glands are considerably enlarged, treatment of this stage is highly important. Fortunately, proper medical attention at this period produces excellent results and prevents much subsequent trouble. In the treatment of broncho-adenitis cod-liver oil is a most important agent. It is usually desirable to administer it plain, and by most infants it is Avell borne. Its use should be continued for three or four Aveeks, and even longer if the trouble does not yield readily. When the bronchial glands are enlarged a coexisting anaemia will usually require the use of iron. This agent is best administered as the reduced iron or the freshly-prepared saccharated carbonate of iron. In either case the dose should be large. Reduced iron in 5-grain doses three times a day to a child tAvo years old will give better results than smaller doses. For very young infants iron is best administered in the shape of freshly-expressed beef-juice, which may be given in teaspoonful doses three times a day. The iodides may at times be used advantageously, and of these the best are the syrup of hydriodic acid and potassium iodide. The latter should be given in small doses, J grain to 1 grain, three times a day, and Avell diluted. The syrup of the iodide of iron is rather disappointing in its action. It is often desirable to use creasote or guaiacol, particularly where the 934 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. glandular enlargement is very pronounced and general tuberculous infection is feared. The following is a convenient formula for a creasote emulsion : Creasoti (beechwood) foj. Pulv. acaciie gr. xv. A(p dest TTLxlv. Glycerini q. s. ad f^ss. — M. Sig. Four to eight drops in port wine three times a day. Ordinarily it is not desirable to commence treatment of the broncho-adeni- tis along these lines until after the subsidence of the acute attack of bronchitis. Cases presenting nutritional deficiencies call for treatment both during and after the attack. In most instances the innutrition in infants is due to rickets, and cod-liver oil and iron act almost as specifics. Salt baths and out-door exercise are also valuable, and should never be omitted. In older children, the subjects of scrofulous bronchitis, the underlying nutritional deficiencies particularly call for treatment. In these cases cod-liver oil, iron, and iodine, while of service, are often disappointing, and do not yield the satisfactory results obtained by their use in less severe cases, where enlargement of the bronchial glands constitutes the principal departure from the normal. In the severer cases of this type relief can only be obtained by removal to a warm climate or to the sea-shore. In the experience of the writer the Florida coast has afforded great relief to such patients. PLEURISY AND EMPYEMA. By henry KOPLIK, M. D., New York. Pleurisy, or pleuritis, occurs in infancy and childhood usually as a second- ary, and rarely as a primary, disease. There are certain forms in which the pleura is inflamed without any appreciable exudate ; such are called dry or fibrinous pleurisies. Other forms combine the above with an exudate of fluid — serous, sero-purulent, or purulent — into the pleural cavity. These forms are called pleurisy ivith effusion, or sometimes, less accurately, subacute pleurisy. When the exudate has a sero-purulent character or is visibly puru- lent, the pleurisies have been called empyema. Empyema in this article will, for the sake of uniformity, be called purulent or suppurative pleurisy, while those pleurisies which have a protracted course and are due to neo})lasms will be referred to only. Frequency. — Pleurisy is a common disease of infancy and childhood. The greatest number of cases occur before the fifth year of life (Simmonds). The succeeding five years (five to ten years) show the next greatest frequency. Our statistics upon pleurisy in childhood are incomplete, for the reason that authors have not unreservedly exposed their material for criticism. Only favorite methods have been published, to the exclusion of unfavorable results. This has caused much confusion. Israel has tabulated 206 cases, of which 59 were purulent (29 per cent.). Mackey gives purulent cases in children 40 per cent, as against 5 per cent, of the Avhole number in adults. In 240 cases 140 were boys (Simmonds). On the other hand, Hofmokl, who has a great pedia- tric surgical practice in Vienna, tabulates 60 cases, of which 42 were females. Thus, combining both statistics, the boys would still show the greater frequency. The left side is more frequently the seat of disease. Of 175 cases collected by Simmonds, 103 were on the left side, whereas of the 60 tabulated by Hofmokl, 33 were on the left side. Pleurisy is generally a unilateral disease. Of 175 cases, only 7 were bi- lateral (Simmonds). This is fortunate in infancy and childhood, where exudates reach a large amount in a very short time. With these youthful patients the natural resiliency of the chest combines with others factors to make even enormous exudates comparatively well borne, as contrasted with a similar con- dition in later life. In the adult the resistant chest-wall tends to cause greater pressure-effects and displacements of important viscera. Pathology. — The pleura is a connective-tissue structure, made up of elastic fibres in a fibrillar membrane, containing branched connective-tissue cells and covered with a layer of flat epithelium, called, in this membrane, endothelium. In inflammations of the pleura which are not dependent upon and accompanied by a neoplastic growth (tubercle or carcinoma), the changes take place at the surface. The most frequent pleurisies are those acute processes which invari- 935 93 () AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN ably accompany the several forms of acute pulmonitis. They occasion but few sym])toms per se, and only in the event of a fatal termination of the primary pulmonary disease do they come to the autopsy table. In these forms of pleurisy the changes may be so trifling as to be indicated only by a slight injection of the surface of the pulmonary pleura and a loss of its characteristic lustre. Here and there a few fibrinous threads or adhesions may be found coursing over the surface of the membrane or running from the costal to the pulmonary pleura. This is the so-called dry pleurisy, pleuritis sicca. In other cases there is a more e.xtensive formation of flbrin, which becomes dif- fused over the whole surface of both the pulmonary and costal pleura ; and this formation may become so marked as to cause a distinct thickening of both these surfaces. In some forms in children the amount of fluid is small com- pared with the immense thickening of the pleurm. Some writers have main- tained that in these fibrinous exudates the primitive endothelium may be found upon the original pleural surface, beneath the exudative product ; others, that the fibrinous exudation is coated with the original endothelium (Delafield). The pleura itself may be but little altered, the only change being that its lymph-spaces and blood-vessels are dilated, and there may be a diapedesis of leucocytes. In other forms of pleurisy the fibrinous exudation at the surface is also combined with a serous exudate into the cavity of the pleura. This serum is variable in amount : it usually contains leucocytes, in many cases bacteria, as will be shown later. It may be quite clear, turbid, or opaque, yellow or greenish in color and creamy or thin in consistency. In acute processes in children large masses of fibrin may be found floating free in the cavity of the pleura (metapneumonic cases). In many instances the adhesions are so great as to bind down the lung at various places, thus enclosing the exudate in quasi-capsular formations. Even in acute cases the fibrinous coating on the surface of the pulmonary and costal pleura contains newly-formed blood-ves- sels. Ilmmorrhages into the pleural cavity may rarely occur as a part of such conditions as scurvy and true morbus Werlhofii, and then the serous or purulent exudate becomes a so-called haemorrhagic one. In some cases the fibrinous coating on the pulmonary pleura may be so thick as to seriously imj)air the function of the lung. In cliildren, however, this is not common, except as a se(pience of tubercular processes ; so that a marked pleurisy, suppurative or fibro-serous, may be followed by a complete restitutio ad integrum. It is rare that in acute processes the lung is in any way compromised. It is only in prolonged, unrelieved pleurisy that this occurs, and thus there may be perforation of the exudate with erosion of the pulmon- ary or costal pleura {pleuritis yiecessitatis). Small purulent extidates, unrecog- nized during the illness, may thus perforate after all fever has ceased and the patient is apparently well. In tubercular inflammation of the pleura, besides the production of fibrin, serum, clear or hmmorrhagic, and pus, there may be considerable thickening of the costal and pulmonary pleura, caused by the inflammatory exudate, which, as well as the pleura, is infiltrated with tubercle. In these cases the serous or purulent effusion may be enca])suled by adhesions, while the lung is crippled and bound down by layers of inflammatory tissiie. In these forms of pleurisy the anatomical changes are progressive. In acute fibrinous pleuri.sy the exudative products on the surface of the pleura are organized into new con- nective tissue or partly disappear, but the pleura is restored to its original condition. Again, ab.sorption takes place in those cases where the exudate does not demand artificial relief. In children the adhesions form an important part PLEURISY AND EMPYEMA. mi of the process in acute pleuritis, while in other forms the pleura may remain permanently thickened by the formation of a surface layer of new connective tissue, which may persist through life. There are non-tubercular forms of pleurisy where, after the acute process has run its course, the pleura remains thickened by newly-formed connective tissue ; and this not only involves the pleural tissue proper, but also continues to extend and involve, through the lymph-vessels, the interlobular tissue of the lung itself, causing a species of cirrhotic changes. In these cases, which are prolonged, the lung-tissue is seriously compromised. In the exudates of the pleura there is a constant interchange of fluids through the vessels of this membrane (Gerhardt). Drugs may find their Avay from the general circulation into the pleuritic fluid. Iodine and salicylic acid have thus been found. Moreover, the amount of leucocytes, red blood-cells, and endothelial cells in the exudate is constantly varying, so that a serous effusion may result from a hsemorrhagic one, and an opaque purulent from a serous. The amount of fluid effused in children is usually considerable, and may reach 1000 or 2000 c.cm. (Simmonds). Hofmokl in several cases evacuated as much as 2000 to 5000 c.cm. The chemical composition of pleural exudates may be of clinical interest. The specific gravity varies from 1028 to 1032 (Bartels, quoted by Gerhardt). Some authors have attempted to formulate prognostic signs from the specific gravity of the pleural exudate, but few would accept such a line of thought to- The amount of albumin varies from 0.06-2.68 per cent, in non-inflam- matory to 2.40-6.90 per cent, in inflammatory exudates ; extractives and salts in non-inflammatory exudates, 1.08 percent., in inflammatory, 1.18 per cent. ; the chlorides average 0.67 per cent, in both. Among the foreign sub- stances, urea, uric acid, leucin, tyrosin, glucose, glycogen, cholesterin, xanthin, and medicinal agents have, at various times, been found, proving that the fluid in the pleural cavity is in direct touch with the general circulation and lymph- atic system. Etiology. — Primary pleurisy, occurring without any exciting cause in the chest or elsewhere, is rare in children. There are numbers of cases in Avhich an acute effusion of inflammatory character takes place without any previous symptoms of illness or external exciting causes. Our data upon this very interesting and important question are still incomplete. Such a case came under the notice of the author in a boy aged six years, in whom a pleural effu- sion was present for a week without any previous symptoms. The liquid was serous in character, and did not contain any micro-organisms. There was no tubercular lung disease and no history of other illness. In these clinical cases the etiology is very obscure. The author has elsewhere published cases of infants where illness began acutely, nothing having been found except a ton- sillitis follicularis. The chest showed no pneumonia or pleurisy at first. Within a week, however, a purulent effusion was found in the chest. In these cases it is impossible, inasmuch as recovery takes place, to establish the primary cause. In those cases which come to the autopsy table after the disease has existed a long time the pulmonary changes are no more conclusive. Primary pleuritis, if it does occur in children, must be rare. There are so many avenues of infection that to satisfactorily exclude all these has as yet not been possible. Pleuritis in infancy and childhood is therefore mostly second- ary to diseases of the lungs. All acute forms of pneumonitis — lobar pneu- monia and broncho-pneumonia — may give rise to pleuritis. The greatest num- 938 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. ber of cases has been traced to this cause. Of 84 cases of pleuritis tabulated by Siinmoiids as occurring in children, 31 were caused primarily by pneumonia (meta-pneumonic pleurisy). The infectious diseases, measles, scarlet fever, pertussis, typhus, typhoid, diphtheria, forms of tonsillitis, retro-pharyngeal or mediastinal abscess, may precede and directly cause an attack of pleurisy. In these cases a pneumonitis generally precedes the pleurisy or is present at the same time. Such a pleurisy is to be classed under the heading of complications. It may be serous or purulent, but is generally microbic in origin, as will be shown later. In the new-born the class of cases included under the heading of septico-pysemia are sometimes complicated by a pleuritis, usually suppurative and of a j)rogressive, fatal type. In these instances the pleuritis is simply caused by the same microbic agent, which enters at the umbilicus or elsewhere. Such cases have been published by the author. The acute bone diseases, such as osteomyelitis, may be complicated by purulent pleurisy; so also may septic Avounds in any distant portion of the body, as the foot (Koplik). Tubercular disease of the lung or tuberculosis elsewhere; echinococcus (Simmonds) or abscess of the liver ; any abscesses in the mediastinum ; forms of endocarditis ; and abscesses in the abdominal cavity or involving any of the viscera, — may cause pleuritis. A case of perityphlitis in the author’s practice, in a girl eight years old, after running an acute coui’se was followed by chronic peritonitis with multiple abscess-formations in the abdominal cavity, and was later complicated by pleuritis on the right side. As no autopsy rvas allowed, it was impossible here to trace a direct connection, but such has been done by other authors. In many cases of pleuritis, as in other diseases, it is possible to find as the only exciting cause an exposure to cold or dampness. This has occurred so often, and with such apparent connection, that most authors look upon cold and dampness as undoul)tedly exciting toward any pulmonary or pleural inflammation. At least they are not Avithout influence. A reduction of con- stitutional resistance by these agents opens the avenues for the activity of Avell- knoAvn exciting agents (microbic). Traumatism of all kinds, even Avithout a lesion of the external surface, may act like cold in exciting pleurisy. Compression of the chest- Avail or a bloAV may not directly cause it, but certainly many cases folloAv so closely upon such accidents that an intimate connection seems to be the inevitable deduction. It is conceded upon all sides that there are evanescent forms of pneumonia in children lasting only a fcAV days. It is easy to conceive that a pleuritis may have been preceded by such a pneumonia, the symptoms of the primary disease being masked by those of the main condition, the effusion in the chest. The etiology of pleurisy has been greatly elucidated, in recent years, by the bacteriological studies of Weichselbaum, Fra-cnkel, Ehrlich, and Time. These authors liave busied themselves Avith the study of pleuritic exudates and their relationship to processes Avhich affect the lung. They directed their atten- tion to the adult cases. In 1891 the author made a series of bacteriosco})ic studies in children, Avhich, Avith certain peculiar exceptions, bring the ))leurisies of children much into the line of those of the a-diilt as to causation. AV’e knoAV that Avhen the lungs are the seat of bronchitis, broncho-pneumonia., or lobar pneumonia, a number of micro-organisms play an important role during the course of the inflammatory processes. Time, in a series of studies, established beyond (juestion that these inicro-organi.sms (notably the di))lococeus j)neu- moniae) can be found not only in the lung-structures, but especially in the lymph-spaces of the tissue of the pleura and on the surface of the j)leura itself, PLEURLSY AND EMPYEMA. 939 even in most evanescent inflammatory reactions of that structure. This once accepted, it is easy to explain how micro-organisms, which are per se caj)ahle of exciting suppuration, when they once gain the surface of the pleura will cause inflammatory response of that structure. Such is, in fact, the case. If we examine the acute pleuritic exudates in children, we find they resolve them- selves into groups. The most interesting group is that in which the effusion, whether serous (clear) or purulent and full of fibrin clots and flocculi (sup- purative), shows the presence of the diplococcus pneumonim of Fraenkel or the streptococcus lanceolatus. This micro-organism is the accepted exciting factor of both lobar (Fraenkel) and lobular pneumonia (Weichselbaum). It is found in both serous and purulent exudates (meta-pneumonic pleurisies), and this in pure culture. So constant is this that we can group such pleurisies by themselves, and both clinically and bacteriologically accept the diplococcus as the connecting link between the process in the lung and the pleuritic inflam- mation. It is not always possible to trace clinically the ])neunionia and pleurisy in secjuence, for in many of these cases the pneumonia is so slight as to play but a secondary clinical role. In other cases the direct clinical sequence of pneumonia followed by pleurisy can be satisfactorily established. In another group of cases the pleuritic effusion, if examined bacterioscop- ically, is found to contain staphylococcus pyogenes aureus, and in other cases the streptococcus pyogenes. The exact etiological role played by these micro- organisms is not very apparent. It is true we can justly conclude that by their presence in the pleural cavity they have been direct excitants of the pleuritic inflammatory reaction. It is not clear, however, how they gain access to the pleural cavity, and whether the pleuritis was preceded by, or was concomitant Avith, some form of pneumonitis. These organisms are found in the lungs during a lobar or broncho-pneumonia. In certain forms of broncho- pneumonia following or complicating the infectious diseases, the streptococcus pyogenes is found as a chief exciting factor of the pneumonitis. This has been well established by Babes, Prudden, and Northrup. But there is a class of pleurisies in children Avhich are not secondary to the acute infectious diseases, and in these the staphylococcus and streptococcus have been found (Koplik). The most probable conclusion in such cases is that there may have been some element, such as an exposure or traumatism, Avhich favored the invasion of the pleura through the lungs. In many cases we could assume, in spite of the absence of the streptococcus lanceolatus or Fraenkel’s diplococcus, that % broncho-pneumonia might have existed, and the staphylococcus or ordinary streptococcus, which always exists in these cases in the lung as a mixed infec- tion, may have gained access to the pleural cavity to the exclusion of the primary excitant, the diplococcus pneumoniae. In many pleuritic efl’usions, both serous and purulent, the most careful examination of the exudate fails to give any microbic elements, and in these we are left to surmise the etiology. The serum and pus of such cases have been injected into animals without arriving at any satisfactory conclusion. It is possible that a proportion of these cases are tubercular, but it Avould be a very extreme view to assume that all those cases of pleuritic effusion in which no micro-organisms are found are tubercular. For this is at variance with clinical experience. Many of these negative exudates have been assumed to be due to acute primary pleurisies brought about by cold, exposure, or trauma. The clinical regularity Avith Avhich an exposure or traumatism can be shown to have been folloAved by pleurisy leads us to assume that, though of itself it may not be able to produce inflammation of a structure, it can so devitalize a part or organ as to make the latter a ready prey to the action of microbic 940 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. agents. On the other hand, we know that in the healthy individual the upper air-passages are the seat of micro-organisms which, isolated from their habitat, are pathogenic (the streptococcus of sputum). Yet in the healthy unexposed individual these micro-organisms are harmless. We thus have that class of pleurisies in which the staphylococcus of various kinds and the chain coccus have been found, as well as part of the class in which no micro-organisms have been established, as still to be more satisfactorily elucidated. The question of 'primary fleurmj in children is also very difficult to ap- proach. We know of pleurisies which, clinically, are very acute in onset, and in which the effusion within twenty-four hours reaches such an extreme gross quantity as to cause by its presence alone (juite serious symptoms. In these cases the effusion may be serous, or it may from the outset be purulent. In many of them no previous history of lung trouble or any traumatism or exposure has preceded. These are the cases which have been described as acute primary pleurisy. While allowing the former classification to stand, the w'riter must express his conviction that future work will reveal some primary etiological fiictor outside the pleura itself. The pleural cavity is such an isolated space, much like the joints, that it is difficult, in the light of our present knowledge, to conceive of its primary inflammatory reaction similar to that taking place in the lung in pneumonitis. In the septic pleurisies the micro-organism which has been found in children is the streptococcus, probably the streptococcus pyogenes (Koj)lik). In the tubercular pleurisies, whether the effusion be serous or purulent, the tubercle bacillus can be found, but only with great difficulty. In many cases, as has been shown by Ehrlich, it is absent. In the purulent exudates the staphy- lococcus and streptococcus may be found as mixed infections, or they may be absent. Symptoms. — There are two distinct sets of cases in children : those with an acute and those with an insidious onset. If the invasion be acute, we have a picture which differs but little from the onset of a pneumonia, and as in the majority of cases- such a pulmonary process is coexistent, it is easily seen how the symptoms of one condition may be masked by the other. A chill, is the rule only in older children, while in infants cerebral symptoms, convul- sions, or stupor may usher in the disease. The fever is quite high — 103° to 105° F. ; and the pulse very much increased — to 140, sometimes 180 beats. There is marked dyspnoea, and even in infants the face has an anxious expres- sion. The urine is diminished, and in the course of a few days we have all the symptoms — dryness of tongue, loss of appetite, and prostration — which accompany any acute disease Avith fever. The cough, which may be j)resent from the beginning, is distressing, for the infant cries whenever it coughs; but, as is the rule in infants and children of all .ages, there is no expecto- ration. After the acute symptoms have subsided a slight elevation of temper- ature may persist, with a remittent curve, sometimes only about one-half degree above the normal, with an evening rise of one or two degrees, but never quite re.aching the normal. This, with dyspiioca and pain, though less than at first, and more infrequent cough, continues the clinical picture during the sub- .acute stage. The effects of the illness arc shown by pallor instead of the febrile flush of the onset, and, if the case continue without relief, even for two or three weeks, by m.arked emaciation, especially in those patieiits suffering from a purulent exudate. In the other class of cases the onset is more insidious. The child may have at first a marked febrile movement for a few hours, and as this passes away it is apt to disarm susj)icion. The child is not (juite well ; it has a remittent PLEURISY AND EMPYEMA. 941 curve of febrile movement, and, if older, will complain of occasional pain in the side. The cough may be so slight as to be unnoticed. Yet the increasing pallor, languor, and evident illness will bring the patient to the physician, who will not suspect a pleurisy unless a systematic physical examination reveal fluid in the chest. The fever is, in most acute cases, high in the beginning, and, though it is not uniformly so from day to day, it still reaches in some cases a maximum of 105°, and then may remit a degree or two. When pleurisy is accompanied by pneumonia, the temperature, as in this disease, continues uniformly high, 103° —105° F., until the eighth, ninth, tenth, or thirteenth day, when a flill will occur with an attempt at crisis. At this period the axillary temperature may reach 99°-99.5°, but it will not fall to the normal level. In the following days, should the pleurisy continue, as in most of these cases it does, the curve begins to rise gradually to 101° or 102°, and will remit in the morn- ing. These cases are quite characteristic. In dry pleurisy without effusion there is scarcely any fever. The pulse is accelerated, being sometimes as high as 180, and especially so in paroxysms of coughing. The tension varies, but in children the heart, though pressed upon by effusion, generally is equal to the new condition in the chest. It is only in fat, flabby children and those suffering from dyscrasiae that, with a rapidity and threadiness of pulse, even from the outset, we notice instead of the usual flushed appearance a pallor of the skin and a cyanosis of the mucous surfaces, as of the lips. Dyspnoea is generally the most apparent symptom in children. The dilated nostrils and the drawing inward of the infrasternal region both indicate a disturb- ance of the re.spiratory function. When the chest is touched, pain is evinced by uneasiness and greater dyspnoea. The mother will say that the child cries when taken hold of nnder the arms in the usual way. The babe will favor the side affected by lying upon it, and suckling the left breast, if the right side be the seat of trouble (Henoch). Older children will sometimes indicate the portion of the chest in which the pain is located ; in other cases they will mislead by indicating the epigastrium or abdomen as the seat of pain (diaphrag- matic pleurisy). The cerebral symptoms not only mislead, but may puzzle the physician for days, until the effusion becomes large enough to detect. These symptoms resemble those in pneumonia — convulsions, somnolence, vomiting, in older children cephalalgia arid epileptiform seizures. Physical Signs. — Inspectio7i of the chest in children who suffer from any form of pleurisy, whether eft'usion be present or not, reveals a lack of movement on the affected side. This is quite apparent in even very young infants, and is in striking contrast to the motion of the opposite side in all the various grades of dyspnoea which may be present in individual cases. If there be a quantity of exudation or fluid in the chest, there is, in addition to lack of motion, a very marked bulging of the affected side. By this is meant bulging as a whole. The individual intercostal spaces do not always bulge in infants. On the contrary, the chest may be full of fluid, and a retraction of the spaces, increasing on inspiration, may exist. It is of little practical value to calcu- late the amount of increase in circumference of the affected side. This will vary with the amount of fluid present. Palpation reveals but little if the form of pleurisy be dry and the effusion slight. On the other hand, if the effusion be considerable, a most valuable sign is furnished by the complete absence of vocal fremitus in older children. In infants the absence of the cry-fremitus gives evidence of the same con- 942 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. (lition. Tliis is one of the most constant signs of pleurisy with effusion in children, where, above all other things, the physical signs to he detailed are constantly varying. It has been the practice of the author to rely largely upon fremitus and a certain resistance to percussion, which will he noted later, in deciding upon the presence of an effusion. If the healthy side he the seat of bronchitis, a peculiar rale-fremitus may be felt on this side, but this is only of negative interest. Percussion. — The percussion-note over thickened pleura is dull ; over fluid, flat. But, as has been hinted, in children these signs show the most marked variation. There is nothing characteristic in the signs obtained by percussion. The chest in an infant is so resilient that much depends upon the force used and the skill of the examiner to bring out the recjuisite note. A layer of fluid may exist between the lung and the chest-wall, and skilful percussion will reveal dulness, while more forcible percussion brings out the pulmonary note of the underlying lung. If the chest be fllled with fluid, the note will he flat ; and this is another reliable sign. In chests where the fluid fills out the lower por- tion of the pleural cavity the pulmonary resonance will be obtained above, while below there will be noted dulness varying to flatness, depending upon the thickness of the layer of fluid between the lung and the ])ercussing finger. The resistance to the percussing ju’culiarlg wooden in character, especially in children. The resonance upon the unaffected side of the chest is increased, and sometimes tymjmnitic. Auscultation may reveal rales or friction-sounds, bronchial voice, and bron- chial breathing, or all these may be absent, the breathing being simply puerile and the voice but little changed. Nothing is so deceptive as the auscultatory signs in pleurisy. If no effusion be present, we hear friction-sounds in children resembling for the most part the fine crepitations of pneumonia, and even when the chest is full of fluid these crepitations may be quite loud. These may be confined to small areas in dry pleurisy, or in pleurisy with eflusion may be diffused over the whole chest. This is what tends to confuse the examiner. The voice in dry pleurisy is not changed. In pleurisy with all varieties of effu- sion the voice may be normal, even Avhen the chest is full of fluid. Again, as stated, it may be bronchophonic. The breathing may he heard above the level of fluid, and be diminished, absent, or bronchial, below. Again, breath- ing may be heard with equal ilistinctness over a side which is full of fluid, as over the unaffected side. In most cases we must rely mainly upon fremitus and percussion. In children sometimes, though v.arely, the fluid will not a])pear in front of the chest, though it exists over the whole side posteriorly. The lung seems to have been pushed up and forward, instead of against the spinal column. In such cases increased resj)iratory murmur and tympanitic resonance will be obtained over the apex of the lung in front. It is quite common to see the routine remark that disjflacements of viscera, notably of the liver and heart, are common in children suffering from pleurisy with effusion. 'I'his is not strictly true. In young ehildnui, Avhere the chest is very easily expaaided by the accumulated fluid, the effu- sion must he exceedingly large before downward displacement of the liver will be apj)reciated. Older children also may carry large amounts of fluid without marked displacement of the liver, though it can, in some eases, he distinctly noted. In younger children effusion upon the left side may displace the apex of the heart toward the sternum, hut this is not aj)t to occur, except as the result of very large effusion. In the adult the displacement of the liver in right pleurisy, and of the heart in left, is quite a constant sign. PLEURISY AND EMPYEMA. 943 In conclusion, the author Avould lay stress upon the immobility, bulging of the affected side as a whole, lack of fremitus, and ffatness, combined with a ])ccu- liar resistance to the percussing finger, as the leading reliable signs of acute chest effusion, which may be corroborated by change in the voice and breath- sounds. In children, as in adults, the effusion of pleurisy accumulates in the most dependent part of the thorax, behind, adjacent to the vertebral column. In children 100 grammes of effusion can be thus discovered by percussion at the lower and inner portion of the chest-wall, adjacent to the spine (Gerhardt; Piorry). Accumulation of the fiuid takes place thus in an oblique area, growing deepest toward the median and tapering at the axillary line. Small effusions in meta-pneumonic pleurisies may be encap.suled and give a localized area of dulness or flatness. In tubercular pleurisies this is also very often the case. In infants and young children the fine distinctions of change of position of small exudates can hardly be made out, as in the adult, on account of the restlessness of the patient. Diagnosis. — The diagnosis of pleuritis in children is not difficult in the majority of cases, but there is a percentage in which care must be exercised before diagnosis can be positive. Dry pleurisy is diagnosed by the presence of pain and the physical signs of local dulness and friction-ra,les. Localized encapsulated pleurisies must be diagnosed by the circumscribed dulness or flatness and the change of fremitus over a circumscribed area, with perhaps a change in the voice and respiratory sounds. If an effusion be of considerable size, the diagnosis is difficult when the layer of fluid is so thin as not to mask the pulmonary resonance and give only dulness ; but even here the fremitus Avill be absent. In marked effusion the complete loss of fremitus, immobility of the affected side, and flatness, with a certain wooden resistance to the percussing finger, are quite characteristic. It is well not to rely too much upon vocal resonance or respiratory murmur. In order that an effusion may not be overlooked, it is important to think of the pos- sibility of its existence in every case, and to exclude it only after careful exami- nation. It is of little moment if a delay of twenty-four or forty-eight hours occur when the symptoms are not of a pressing character. But every practi- tioner sees cases in which fiuid must have been present for weeks without being recognized. In children the exudate at a very eaily period, even from the onset, is likely to be purulent, and it can be easily seen how inq)ortant it is to discover the character of an exudate as soon as possible. Aside from pressure effects, the presence of a purulent exudate is dangerous on account of its tendency to burrow inward toward the lung, eroding the j)leura, or to rupture externally. If there be doubt as to the presence of fluid or as to its nature, these facts should be determined as soon as possible. For this ])urpose a hypo- dermic ex])loring needle should be used in the following manner : The mother holds the babe in her arms in the usual w'ay, the posterior part of the chest is bared, and the area of most complete dulness or flatness is determined. This part is first tvashed carefully with alcohol, and then with corrosive sublimate (1 : 5000). A long exploring needle, a little larger than the ordinary hy])oder- mic needle, but stronger and stouter, having been attached to a well-cleansed hypodermic syringe, is rapidly driven into one of the intercostal spaces, the higher the better. On the right side, where the liver will present itself to the entering point of the needle if too low, the puncture should not be lower than the eighth space, in line with the angle of the scapula. The chief point, how- ever, is to enter at the area of greatest dulness or flatness. Having pushed in the needle about one-half an inch, the piston of the syringe should be drawn. 944 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN The whole operation should he rapidly done, and the mother should be warned to hold the child firmly, for any sudden movement might cause the needle to impinge against the rib and break off — an accident which has occurred. This little operation should be over before the child has ceased to experience the pain of the entry of the needle. If no fluid be found the needle is rapidly withdrawn and a piece of rubber plaster placed over the point of puncture. The author has never had an accident in many such operations, and it requires but ordinary cleanliness and care. It secures to the patient the benefit of an absolute diagnosis. Sometimes we may be absolutely certain of fluid, and yet be unable to prove it with the needle. In such cases the needle has entered an adhesion of the pleura, and at the next sitting, if still in doubt of the diagnosis, the needle should be entered at another point. It is unwise after inserting the needle to thrust it up and down the chest-wall or pleural space. In this way the lung may be wounded, and emphysema, hmmorrhage, or irreparable injury be caused. While the needle is in the chest it should be held so lightly that any sudden unexpected movement on the part of the child will not afford leverage to the needle against the rib, for if this occur the needle is apt to break. When fluid is obtained its character should be carefully determined, and the presence and significance of contained bacteria should be investigated. The busy practi- tioner may not have time to do this, but the author has devised a very simple bulb' for the withdrawal and transportation of such fluids. As far as prognosis and even treatment are concerned, it is of self-evident importance to determine as early as possible whether an exudate is pneumonic, tubercular, or doubtful. The presence of chain cocci, staphylococci, or the diplococcus pneumoniie in a serous exudate will prepare the physician for the advent of a purulent effusion, and the practical knowledge thus gained may be of vital importance to the patient's future happiness. In the presence of a suspected effusion it was previously, and still is among some, the custom to temporize. It was argued that an exploring needle was likely to cause a serous fluid to become purulent through the entrance of air or some few micro-organisms. But the most ordinary cleanliness will render this almost impossible. The author doubts very much if an effusion was ever changed in character by careful hypodermic exploration. A slight amount of air, or a few staphylococci, if through some carelessness introduced into a serous exudate on the point of a needle, can scarcely change the character of fluid filling the chest. The serous portion of exudates, like those in joints, hydroceles, etc., is actually capable of annihilating the life of micro-organisms in fixed ratio (Buchner; Prudden). Moreover, serous efl’usions, formerly thought to turn purulent through some accident, are really purulent and con- tain the rnicrobic element of pus from the outset, although they appear serous to the eye. While advocating caution, the author recommends a fearless resort to so valuable a guide as the hypodermic exjdoring syringe. The tubercular cases alone offer the greatest difliculties of diagnosis, for, as has already been shown, some serous and purulent exudates which contain no micro-organisms may be tubercular, as may even those that contain staphylococci or streptococci. But, fortunately, in children tubercular j)leurisies are not the most common forms. Haemorrhagic pleuritic exudates are very rare in children. They are generally caused by grave disease — tuberculosis, sarcoTna, carcinoma, or morbus Werlhofii. The cases of pneumonia which are com))licated with pleurisy are the most trying to the practitioner. Here on the eighth, ninth, tenth, or thirteenth day ' American Journal of the Medical Scknceif, 181 ) 2 . PLEURISY AND EMPYEMA. 945 no complete crisis takes place. The temperature falls to within even one-half of a degree of the normal in the axilla, but dulness persists in the lower part of the chest or flatness appears over its whole extent. This condition is fre- quently mistaken for so-called unresolved pneumonia. Prognosis. — In children the prognosis in pleuritis is good. In the form occurring after pneumonia or that caused by the staphylococcus or streptococ- cus (non-septic), with effusion into the chest, recovery is rapid as soon as the fluid is evacuated, and much depends upon early diagnosis. In suppurative pleurisy, if allowed to remain unrelieved the pus will burrow, usually exter- nally. The effusion then may infiltrate the soft tissues of the thorax, after eroding the pleura, and point as an abscess at the side anteriorly or posteriorly. Sometimes such an exudate, when on the left side, may receive an impulse from the heart, and thus is occasioned the so-called pulsating pleurisy. Such effusions have been mistaken for aneurisms, but lack of expansile pulsation and the history of the case will guide in the diagnosis. The tumor disappears when the chest is aspirated. If the pulmonary pleura becomes eroded by a pur- ulent exudate, the perforation takes place into the lung, and the pus is more or less quickly expectorated. Even in such cases, though unrelieved by any additional measure, recovery has taken place, as in a case elsewhere recorded by the author. Tubercular pleurisies do not recover completely in children; fistulous suppurating cavities with retraction of the chest result. In some cases the pleurisy has been so extensive as to cause retraction of the lung, its utility being impaired by the binding of thick pleural plates, which leave behind a large suppurating pleural sac. The septic cases are, as a rule, fatal, though in fortunate instances recovery takes place. Hofmokl treated by resection 60 cases, in which recovery was complete in 26. Twenty-eight cases were fatal ; 13 of these were tubercular, 6 were complicated with pneumonia, 3 died through pericarditis, 3 with peritonitis, 1 with amyloid degeneration of the organs, 1 with heart failure, and 1 with neo- plasm. These cases were evidently more unfavorable, as to general character of the pleuritis, than is common. Complications. — The most dangerous complication of pleuritis is peri- carditis, which in most cases is fatal. The occurrence of lobar or lobular pneumonia as a complication has been dilated upon elsewhere. The septic cases may be complicated by endocarditis or suppuration of other serous surfaces, such as the peritoneum or that of the joints. Gangrene of the lung may cause severe putrid inflammatory reaction of the pleura, and thus the pleural cavity may contain gases with purulent exudation (pyopneumothorax). In these cases a peculiar physical sign, known as the succussion sound, may be elicited by shaking the patient. Sudden death from heart fiiilure may occur, but this must be rare. The right heart, however, may become weakened to such an extent as to allow the formation of thrombi, and their entry into the circulation may cause sudden death. Contraction and retraction of the chest-wall always follow, to a certain extent, in those forms of pleuritis which have been left to nature. ISIany of the deformities of the chest observed later in life are due to pleuritis in child- hood. The perforation of an empyema into the lung, with its evacuation through a bronchus, has already been referred to as having rather a favorable prog- nosis, even when not relieved by operation. As a rule, however, such cases are best treated by external incision, although evacuation may be expected by the bronchus. Again, perforation may take place through the chest-wall ; 60 946 AMERICAN TEXT-BOOK OF DmEAEEE OF CHILDREN. liere a large boggy infiltration of the tissues of the chest or adjacent abdominal wall takes place, constituting the condition known as empyema necessitatis. Treatment. — It is difficult to formulate methods of treatment of pleuritis, a disease in which the successful issue depends greatly upon judgment founded upon experience. Those cases of pleuritis in which the process is circumscribed, and in which the effusion in the pleural cavity is but slight, have pain as the main symptom. The fever is generally marked, and requires, as a rule, but ordi- nary methods. In children the pain is best relieved by some mild opiate, like Dover’s powder in proportionate dosage, or in combination with phenacetin and salol. The latter has the advantage of controlling to a degree the febrile move- ment. The author has seen but little advantage from the time-honored appli- cation of iodine to the chest, nor has he seen much result from the internal administration of the iodide of potassium. The latter is apt to disturb the stomach, which at this time has largely to be depended upon to maintain nutrition. The author would also advise against the use of external blisters of all kinds, if for no other reason than the unnecessary pain which these agents cause, and from the danger of infection in a Aveakened constitution if the skin be broken. When there is a moderate effusion of a serous character, even though this effusion contain micro-organisms, yet if thei’e is still no tendency to turbidity, it is quite proper to make an attempt to favor absorption. Therefore, without weakening the patient, care should be taken that the bowels are freely opened from day to day, while the strength of the heart must be maintained. The most useful combination of drugs in these cases is one of digitalis and calomel. There is undoubtedly a very firm foundation for the belief that activity of the kidneys will diminish a pleural effusion Avhich is not due to renal or cardiac disease. The fluid extract of digitalis should be used, in proportionate dosage, in a separate mixture, Avhereas the calomel may he used in powder form. The author generally gives both together. The supporting effect of digitalis upon the circulation is aided by the diuretic effect of the calomel. Large doses of the latter drug are unnecessary; small doses should be used at first and increased, given at three-hour intervals. Salivation, or even dosage to its limit, is injurious. Where the chest is full of an exudate which is quite clear, but which causes few symptoms of pressure, absorption may be hastened by aspiration of a small quantity to begin with, trusting to drugs and nature for the rest. In children this is rarely necessary, so quickly docs the circulation, if supported, respond to the demands made upon it. There are cases of pleurisy in Avhich a clear serous exudate of a ]mcumonic character may increase so rapidly and cause such dangerous dyspnoea and pressure effects, that Avithin a short space of time it may be necessary to relieve the patient by aspiration. Even Avhen aspiration is effectually carried out, in some cases reaccumulation at once occurs. Such exudates are not turhid, but clear, and may contain micro- organisms. If reaccumulation occur in spite of diuretics, the (jiiestion of a radical procedure always presents itself. The author must support the vieAv founded upon experience, that such cases can be most effectually treated by permanent drainage. The operations Avhich are at our disposal for this end Avill be taken up later. F'rom this it Avill be seen tlnat the author reg.ards aspiration as a palliative measure, after the performance of Avhich the little ))atient must be Avatched as closely as before the operation. In children aspiratioji does not bear the same relative therapeutic value in pleuritis that it does in the adult. Its immediate performance entails as much cai-e, causes as much anxiety, as a more radical PLEURISY AND EMPYEMA. 947 procedure, and with less satisfactory results. In most cases not only does reaccumulation occur, but the effusion, at first serous, becomes purulent — not because it has been infected by aspiration, but rather through the progress of the pleuritis, as previously explained. Radical procedure may therefore be required in rapidly reaccumulating serous exudates, causing pressure effects, whether these contain micro-organisms or are free from such. In small and large purulent exudates absorption rarely occurs spontaneously. To temporize with a purulent exudate is to harm the patient. With purulent exudates we include also those serous exudates which were formerly treated expectantly : they are slightly turbid, and contain, to the eye, a few flocculi, but, if examined bacteriologically and microscopically, will be found to contain leucocytes and micro-organisms. To temporize wdth such so-called serous exu- dates is to be finally disappointed in finding them more distinctly purulent after a short period. In formulating diagnoses we must remember also that exudates which are in part purulent tend to separate into a serous layer above and a thick purulent layer below. Our needle may withdraw serum from a chest w'hich contains a fully-developed purulent exudate. In the simple aspiration of the chest we should be guided by the case, and with our needle avoid the proximity of vital organs. The sixth space in front, the seventh in the axillary line, and the eighth behind are those generally selected. Yet sometimes, fluid being low in level, a change may be demanded. The point of the needle should enter near the upper border of the rib, and should not be passed too deeply into the chest for fear of wound- ing the lung. The operative procedures which may be considered to be radical in their nature, and which now have the confidence of clinicians are — incision, with insertion of drainage-tubes ; siphonage of the pleural sac ; excision of the ribs with insertion of drains. Incision . — This operation is practised in the fifth space if in front, in the sixth in the axillary line, and if behind, the ninth .space is chosen. Kbnig advises the higher point. Behind and on the right side we consider the pres- ence of the arch of the liver. The incision is made near the upper border of the rib, 5 to 8 cm. long. This operation is popular with the practitioner, because it involves but little technical skill, and once the incision is made, a drainage-tube is easily inserted. In children, however, where the intercostal spaces are narrow, sur- geons do not look with great favor upon simple incision, for the reason that it is difficult to retain a tube of any great size in the wound. The opposing ribs are constantly pressing the sides of the tube together, and in this respect the drainage is imperfect. Moreover, the constant movements of the patient and the chest are apt to dislodge the tube completely, and in the intervals of dress- ing the wound the opening into the pleural cavity becomes distorted, so that attempts to replace the tube give much pain or even fail completely. Many cases will, however, do well with simple incision ; yet the fact remains that in other cases a secondary operation, which has for its object the removal of a piece of rib, has to be performed in order to obtain drainage. The author has seen cases treated by incision, and thought to have recovered, in which reac- cumulation occurred after removal of the tube, and necessitated a secondary resection of the rib. Resection . — In all cases of purulent exudation it saves much of the strength of the patient if efficient drainage be obtained from the outset. This is secured by the operation of resection of one of the ribs of the affected side. In this way sufficient space is obtained for the insertion of a drain of considerable size, but 948 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. this drain is not pressed upon by the adjacent ribs, and is not generally dis- placed, or, if displaced, is easily readjusted. The seventh, eighth, ninth, or tenth rib is chosen, as demanded by the indi- vidual peculiarities of each case. The skin incision is made about 10 cm. long, and 4 to 6 cm. of the rib is taken away with the bone forceps, after care- fully reflecting the periosteum. The opening is then made into the pleural space — through the j)eriosteum, or by a separate incision which passes through the intercostal space below. The latter saves the Avhole periosteum intact, and ensures reproduction of the bone without the least deformity. As in simple incision, the opening may be made in the axillary or post-axillary line, or behind in line with the angle of the scapula. On the right side the incision for resection should not be made too low% as the arch of the liver will eventually intei’fere with the retention of the drainage-tube. After the rib has been resected and an opening made, some operators introduce the finger and break up adhesions betw’een the lung and chest-w'all to free any encapsuled collections of pus which may be present. This is to be deprecated, because in unskilful hands the lung itself is apt to suffer injury. In'igation of the cavity is not necessary either at or after the operation. Such a pi’ocedure may cause fatal syncope, or, if not attended with accident, certainly does tend to prolong inflammatory processes going on in the chest. Moreover, on account of the retention of some of the irrigating fluid, an exudate at first of good character may become putrid. In those suppurating pleurisies which, from various causes, such as the perforation of a gangrenous or tubercular pulmonary focus, become putrid, or have from the first been putrid, irrigation at long intervals with Thiersch’s solution or simple boric-acid solution or permanganate of potash is admissible. Resection of the rib has of late been confounded wdth Estlander’s operation. The latter operation is one undertaken to secure retraction of the chest-wall against a crippled lung, and should not in any way be associated with the comparatively simple procedure of removing an inch or so of one rib to give space for the insertion of a drain in ordinary acute purulent pleurisies. Though much has been said on the subject of valvular drains (Phelps), which px'event the entrance of air into the pleural cavity, and are sup- posed to favor expansion of the lung while securing complete drainage, there seems to be little gained by their use. In the ordinary suppurating pleurisies the customary surgical dressings seem to answer very well in taking up and keeping aseptic any purulent discharge from the pleural cavity. The free filtration of air into the pleural sac is not attended Avith any ill efl’ects. It is difficult to conceive Iioav a discharge can l)ecome putrid from the admission of air alone into the pleura. There must l)e other elements present to cause such a bad result ; and these will be found in inefl’ectual drainage Avith retention of old discharges in the pleural sac, or in some necrotic focus adjacent to the pleura and opening into it. It was formerly customary to make counter-openings in tlie chest to favor drainage, but this has been found to be undesirable. Siphonaffe . — To some the ojieration of resection Avill ahvays be a grave procedure, and there has been a constant effort to find some substitute Avhich would be more satisfactory than simple incision, yet not so com])licatod as resection. This has resulted in perfecting an operation Avhicli depends on the principle of siphonage, through negative pressure, to drain the pleural cavity. The Buelau operation, to Avhich reference is made, consists of the introduction of a drain through an opening in the intercostal space ; this PLEURISY AND EMPYEMA. 949 drain is connected with tubing which empties into a siphon-bottle, under the surface of an antiseptic fluid. The operation requires (a) a trocar exactly 6 mm. in calibre, fitted with a cannula ; {b) a new disinfected Jacque catheter, fitted accurately to the cannula and ])assing through its lumen with ease, yet not loosely ; (c) attached to this catheter, by means of glass tubing, a rubber tubing 75 cm. long. A small incision is made in the skin of the intercostal space, where the trocar is to enter. The trocar and cannula are then inserted, the trocar with- drawn, and the Jacqtie catheter, with its blunt extremity cut squarely off. is introduced for about 15 centimetres into the chest. The cannula is now with- drawn over the Jacque catheter, escape of chest-contents being for the time prevented by pinching the catheter. The catheter is now connected with the tubing, which is led into a bottle filled one-third with an antiseptic fluid. The pleural exudate thus escapes into the bottle beneath the layer of anti- septic fluid, and air is prevented from entering the chest. Among the advantages claimed for this operation by its advocates are its simplicity and the prevention of entrance of air into the pleural sac. The negative pressure in the pleural sac is also maintained, and the siphonage favors expansion of the lung. The siphoning exudate is under constant observation through the glass tubing and bottle, and when recovery sets in its advent can be noted by the cessation of the discharge. There ai’e no dressings except the adhesive plaster, which retains the catheter in the chest. The results of this operation, especially with children, in the hospitals of Hamburg have been so gratifying as to make certain surgeons there its enthusiastic advocates. Scheede, on the other hand, fears that unruly children will displace the tube in the chest. The advocates of the siphon method maintain that this is not likely to happen. Their results are certainly equal to those of surgeons using other methods, and should bring the operation into favorable notice. PULMONARY EMPHYSEMA. By JOHN DORNING, M. D., New York. Pulmonary Emphysema is an abnormal accumulation of air within the vesicles or in the extravesicular connective tissue of the lungs. The varieties of this malady are — I. Interstitial, interlobular, or extraves- icular emphysema. II. Vesicular or alveolar emphysema, subdivided into a, compensatory or vicarious emphysema ; 6, substantive, idiopathic, or hyper- trophic emphysema. III. Atrophic emphysema. As this last form occurs only in advanced life, no further allusion will be made to it here. I. Interstitial Emphysema. — In this condition there is an accumulation of air in the connective tissue of the lung. It is usually the result of some violent expiratory effort, such as would occur in a severe case of pertussis. When the escaped air extends beneath the pleura, small air-bubbles appear on the surface of the lung, showing the outlines of one or more lobules. Some- times large bullae are seen. In unusual cases the air may burrow along the larger bronchi into the mediastinum and up into the subcutaneous tissue of the neck. Interstitial emphysema, as a rule, gives rise to no symptoms, and unless it extend to the neck is not a serious malady. II. Vesicular or Alveolar Emphysema. — a. Compensatory Emphy- sema. — As the term would imply, this is a condition in which the vesicles of one portion of the lung are abnormally distended in consequence of the crippling or non-expansion of some other part of the organ. Etiology. — It is this form of emphysema rather than the substantive form that is to be observed in young children. Indeed, cases of typical substantive emphysema are extremely rare in early childhood. In the genesis of compen- satory emphysema there probably exists in most of the cases as a predisposing factor a defect in the nutrition of the pulmonary tissue. Thus with the same exciting causes in operation it is much more likely to occur in rachitic subjects than in children whose nutrition is perfect. The immediate causes include any mechanical obstruction to free respiration that would give rise to increased pressure within the vesicles. In jirotracted bronchitis, particularly when the finer bronchial tubes are affected, the swollen mucous membrane and the accu- mulation of viscid mucus interfere with the entrance of air into the correspond- ing lobules, causing a partial or complete atelectasis of the parts involved. This will leave an unoccupied space in the chest-cavity which becomes filled by the hyj)erdistention of adjacent lobules. This is the inspiratory theory. Again, as is so often observed in pertussis, in conse(juence of obstruction to the free egress of air through the glottis with extra-violent exjjiratory efforts, the retained air is forced in the direction of the least resistance, the apices and anterior borders, causing an over-distention of the vesicles in these regions — the expiratory theory. In the vicinity of solidified areas of lung-tissue, as in pneumonia or tuber- 900 P ULMONA R V EMPHYSEMA . 951 culosis, emphysema is usually discernible. When one lung is compressed by fluid in the pleural cavity, the other lung by reason of its increased function becomes over-expanded. Pleuritic adhesions that prevent the normal expan- sion of the apex and posterior border of the lung necessitate over-distention of other parts of the organ, especially the anterior and inferior borders. In addition to other complications, emphysematous distention of parts of the lungs is to be found in membranous croup. In advanced rachitis the plia- bility of the ribs and costal cartilages favors the development of emphysema in the anterior margins of the lungs. Inflation of the lungs in the asphyxiated new-born child by blowing into its mouth has been said to give rise to emphysema. Such a cause must be quite exceptional, judging from the manner in which lungs that have been removed from the body collapse after forcible inflation. Pathology. — In the majority of cases of compensatory emphysema com- plicating acute bronchitis and pertussis recovery evidently takes place. In these cases there has undoubtedly been simply a hyperdistention of the pul- monary air-vesicles without any structural changes in their walls. The same may be said of the inordinate inflation of the lung of the non-affected side in acute pleurisy with effusion, where there has been a rapid absorption of the accumulated fluid. Where the affection is associated with tuberculous infiltra- tion or old pleuritic adhesions, dilatation of the air-vesicles, with thinning of their walls and other structural changes characteristic of substantive emphysema, may be found to exist. From this we may conclude that the longer the dura- tion of the immediate causes of compensatory emphysema, the more likely is a true emphysema to develop. Symptoms. — A diagnosis of compensatory emphysema cannot, in most instances, be made either from the symptoms or by physical exploration of the chest. In fact, there are no distinctive signs of the affection unless consider- able of the lung be involved, and its existence is generally assumed. Bulging of the supraclavicular space during the severe expiratory efforts of coughing, and a falling-in during inspiration, have been regarded as indicative of an involvement of the apices. Where one side of the chest is filled with fluid the hyper-resonance of the opposite side with the exaggerated vesicular murmur would suggest the belief that the one lung is performing the work of the two, and that the vesicles are abnormally distended. If extensive pleuritic adhe- sions exist, a prolonged low’-pitched expiratory murmur may be heard over certain portions of the lung, but especially at the anterior border. In this latter situation the same character of respiration may be detected in rachitic subjects with marked chest-deformity. Treatment will be considered under Substantive Emphysema. b. Substantive Emphysema. — This is a chronic and generally incurable malady, characterized by an abnormal distention of the pulmonary vesicles, with structural changes in their walls. Etiology. — Well-marked substantive emphysema in young children — that is, under the age of ten years — is extremely rare. After this age it is occa- sionally observed, but not until adolescence is it encountered with any fre- quency. Authorities differ materially in their views regarding the causation and nature of this disease. From the frequency with which it is found to run in families it would, in a measure, appear to be of an hereditary nature. Jack- son investigated 28 cases, and found that 18 were born of parents one or the other of whom had suffered from emphysema. Greenhow collected 42 cases, 23 of which appeared to be of an hereditary tendency. The histories of many cases of emphysema in the adult show that there have been frequent respiratory 952 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. affections from early life ; still, in other instances where the disease has been extensive, no account of previous attacks of bronchitis can he elicited. Increased air-pressure within the pulmonary vesicles, due to forced and long-continued inspiration or expiration, is by some investigators considered at least the exciting, if not the primary, cause of emphysema. According to the inspirator}^ theory of Laennec as modified by Hutchin- son, Trauhe, and Gairdner, emphysema is a result of bronchial catarrh. The presence of a tumefied mucous membrane and viscid mucus in the bronchioles prevents the entrance of air into the corresponding lobules, giving rise to areas of collapse, and to fill up the deficiency so caused the neighboring lobules become hyperdistended. The theory of expiration as maintained by Jenner and Mendelsohn would seem to afford a more adequate explanation, than does the inspiratory theory, of the part mechanical distention of the air-cells plays in the production of substantive emphysema. During forced expiratory efforts with a closed glot- tis, as occurs in violent attacks of coughing or severe straining, the air is driven in the direction of the least resistance — namely, the apices and anterior borders of the lungs. It is in these situations that the greatest degree of dila- tation is usually found. There are cases, however, where the disease is diffused throughout the lung, without a history of previous cough or increased ex{)iratory pressure. C. J. B. Williams claimed there w’as a fatty degeneration of the lung-tissue that aided in bringing about the pathological changes observed in emphysema. Fatty matter has been found in only a small number of cases. Jenner taught that the most frequent anatomical change in the lung was fibrous degeneration resulting from slight but long-continued congestion. Delafield believes substantive emphysema to be a chronic inflammation of the lungs, a pneumonia, and the dilatation of the air-vesicles a mere result of this inflammation, and not the essential lesion : the inflammation, he states, is of the same type as that which so often attacks the endocardium, the inner coat of the arterie.s, the liver, and the kidneys — a chronic inflammation attended wdth the production of new fibrous tissue, and at the same time with atrophy and disappearance of normal tissue. It is (juite evident that increased air- pressure within the vesicles does not exclusively account for the presence of substantive emphysema. Indeed, it seems doubtful if it can be considered as anything more than an exciting cause or as aggravating the disease when it has already been established. We think it may reasonably be inferred that chil- dren who suffer with frequent prolonged attacks of bronchitis are likc'ly to become the subjects of emphy.sema later in life, not only because of tlie j)ul- monary disturbance induced by the increased intralobular ])ressure, but on account of the existing condition which predisposes the child to the rej)eated bronchial catarrhs ; for in such children there is unque.stionably a vidnerability of the tissues the outcome of some defect in the nutrition. Pathology. — In the rare cases of substa-ntive emphysema that occur in early life most of the changes that are to he observc'd in the adult are [)resent, only in a less degree. On opening the tliora.x the lungs do not colla])se. They have a peculiar cushiony feel and ])it 071 ])i-e.ssui’e. The color is |)ale gi-ayish or yellowish gray. The aii'-vesicles j)rese7it varying degi’ees of dilatation. ^Pheir walls ai'e in some parts of the lung thinned, iii othei's thickened. Coale.scence of neighboring vesicles and oblitei-ation of the capillaries occur in .soiiie ii7- stances. The epithelium of the air-cells presents degenerative chaiiges. In the b)'onchial tubes may be seen evidence of clu-onic bi-onchitis, witli dilata- tion of the bi’onchioles in sonie advanced cases. There may be sonie hypei'- r ULMONA R Y EMPHYSEMA . 953 trophy of the right ventricle, and less fre(iuently a secondary dilatation. The secondary lesions of emphysema do not usually occur until long after childhood. Symptoms. — Substantive emphysema not infrequently is present in the adult without giving rise to any subjective symptoms. This being the case, the more abundant reason there is why, with its less extensive development, it may exist in the young subject without thus manifesting its presence. When rational symptoms are present, they resemble, in a milder form, with the exception of those dependent upon secondary lesions, which are absent, those observed later in life. Dyspnoea is probably the most marked symptom. At first it may be expe- rienced only during unusual exercise; later, it becomes more constant, and is aggravated by even slight exertion, attacks of bronchial catarrh, and by dis- tention of the stomach by a hearty meal or by the accumulation of gas from indigestion. Asthmatic attacks are of not infrequent occurrence. Off and on during the winter there is more or less cough. Physical Signs. — Inspection . — The typical barrel-shaped chest of emphy- sema is seldom observed in children. There may, however, be a slight increase in the antero-posterior diameter. This will be more noticeable when associated with rachitic deformity of the thorax. Posteriorly, the curve of the spine may be increased, giving the back a rounded appearance. This must not be con- founded with rachitic curvature of the spine. There is some increased exer- tion in respiration, but the rigidity of the chest, due to ossification of the costal cartilages, seen in advanced adult cases is absent. There may be some retrac- tion of the upper abdominal region, owing to the powerful action of the dia- phragm on the loAver ribs. Jenner has observed falling in of the supraclavic- ular region during inspiration in cases where the apices were affected. Fiirst considered expansion of this region during severe cough as a characteristic sign. Palpation is negative. Percussio7i . — Pulmonary resonance may remain unaltered. In older child- ren, when it is changed, it is of a vesiculo-tympanitic quality. In young child- ren the great elasticity of the thoracic walls and the smallness of the organs to be examined favor the transmission of resonance from the distended intes- tines, so that, unless there be very marked distention of the thorax, sufficient to displace the liver downward, percussion will be of little value. Thus it is the extent, and not the intensity, of the pulmonary resonance that is to be considered. Auscultation . — The respiratory murmur is usually feeble and of a low pitch. Expiration is prolonged. When bronchitis is present sonorous, sibilant, and mucous rales are heard. The heart-sounds are generally clear ; the second sound may be accentuated in older cases. Prognosis. — Recovery from compensatory emphysema, if the malady has not existed for too long a time, may be expected. Perfect restoration of the lungs, however, when substantive emphysema has once become established, is not to be looked for. It never of itself proves fatal ; still, it may be a com- plicating factor in bringing about a fatal issue. It is claimed by some that in cases of short duration with but limited involvement of the lung, under favor- able circumstances recovery maj" take place. Not infrequently, improvement, even to the extent of an apparent cure, may be observed, but later in life, in most instances, it will be found to have been only temporary. At one time it was erroneously believed that emphysema protected the subject against tuber- culosis. Treatment. — In children the treatment should be mainly prophylactic. As malnutrition is evidently a predisposing factor, everything pertaining to the {)54 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. diet and hygiene, even from early infancy, should receive due consideration. In this way the exciting causes of the disease may be prevented, or, should they develop, the patient will be in a better condition to withstand them. When the affection is present it is infinitely necessary that measures be adopted toward the improvement of the general health. The whole body should be protected by woollen underclothing. The cold sponge bath, used only to an extent that will produce a proper reaction, is a general tonic of umiuestionable value. By maintaining a healthful condition of the skin it lessens the liability to repeated bronchial catarrhs. An abundance of out-door air, with exercise regulated to suit the physical endurance of the patient, is an essential part of the treatment. An equably dry climate with an altitude of not over a thousand feet is very desirable. The diet should be principally nitrogenous. The value of milk is too well appreciated to need more than mere mention. The quantity of food taken at one time should not be great enough to cause any embarrassment of the respiration. Cod-liver oil, particu- lai-ly if rachitis be present, should be administered. When the pure oil is given, begin with small doses, five to ten drops three times a day, and increase grad- ually until a full teaspoonful is reached. The emulsion of cod-liver oil, either simple or in combination with malt extract, is in some cases preferable to the plain oil. In the way of medicinal treatment iron in some form should be used when there is any evidence of anmmia. Of the different preparations, the tincture of the pomate is for children one of the most acceptable both to the palate and the stomach. A child three years of age may be given from five to eight drops in a little plain or sweetened water three times a day ; at ten years, ten to twenty drops. The citrate or the tincture of the chloride may also be used. In older children either Basham’s mixture or the ethereal tincture of the acetate of iron can be recommended. Strychnine has been thought to possess some specific virtue in the treatment of this disease. That its action is anything more than that of a general tonic seems doubtful. Care should be taken in prescribing the drug for young chil- dren. Tincture of nux vomica is a safer preparation, and may be administered in from one-half to two-drop doses at six years of age. Arsenic in the form of Fowler’s solution, in from one-half to two-drop doses at eight years of age, is a general tonic of some value. The mechanical treatment by compressed air, while valuable in certain cases in the adult, is less practicable, and may be positively harmful, in children. All the exciting causes of compensatory emphysema or those that aggra- vate the substantive form, if not preventible, should be mitigated as much as possible. For the chronic bronchitis that so often coexists with substantive emphy- sema iodide of potassium is generally recognized as a drug of great worth. In many cases favorable results may be obtained by combining it with linseed oil, as follows: I^. Potassii iodidi oi.b 01. lini Pulv. acacim 01. gaultherim Syrupi . . . A(p (lest. . . . f.^ij. (j. s. ad f.^vj. — M. Ft. emulsio. Sig. 4’easpoonful three or four times a day at ten years of age. P ULMONA R V EMPHYSEMA. 955 Another drug of marked excellence where there is much bronchial secretion is terebene. At eight or ten years of age it may be given thus : Terebene f3ij. Tinct. opii camph f^ss. 01. menth. pip gtt. vj. Syr. acacim q. s. ad fsiij. — M. Sig. Teaspoonful every four hours. The treatment of the complicating asthmatic attacks will be considered in the article on Bronchial Asthma. BRONCHIAL ASTHMA. By JOHN HORNING, M. D., New York. Asthma is a peculiarly distressing form of paroxysmal dyspnoea, accom- panied by wheezing respiration and characterized by a freedom from all mani- festations of the affection in the intervals of the attacks. Etiology. — It seems to be generally conceded by writers on the subject that those who suffer with asthma inherit a tendency to the disease. In many cases there is an ancestral history of gout instead of asthma. According to the statistics of Thery and Hyde Salter, asthma is more common among males than females. It is of frequent occurrence during childhood. Of Hyde Salter’s 225 cases, 71 developed the disease during the first decade. It is said to be more common in the upper than in the lower walks of life. In a certain class of cases the cold season seems to exert some predisposing influence on the malady. The exciting causes may be divided into those which act directly upon the nervous mechanism of the lungs, and those which are reflected from more I’emote parts or organs. It is to be borne in mind that the exciting causes are only operative when there is a predisposition to the disease. In some instances no definite ex- citing cause can be discovered. Umemic, cardiac, gouty, saturnine, and mer- curial asthma are thought to be the result of an indtation of the respiratory centre in the medulla oblongata by vitiated blood. Irritation of the pneumo- gastric nerve along its course, as by the j)ressure of enlarged bronchial glands, may give rise to paroxysms of asthma. Eustace Smith has rarely failed to find evidence of swelling of the bronchial glands in the cases he has seen of asthma in the child. The enlargement of these glands is a result of bronchial catarrh. The asthma observed in the subjects of congenital syphilis, the so-called syphilitic asthma, can very likely be explained by a syphilitic enlargement of the bronchial glands. Bronchitis, either alone or associated with emphysema, is generally recognized as an e.xciting cause of asthma. Such cases may be accounted for either by a direct irritation of the terminal fila- ments of the pneuraogastric nerve or by the concomitant swelling of the bron- chial glands. The inhalation of various ii-ritants, as dust, the pollen of plants, smoke, gases, certain vapors, and the emanations from certain animals, arc well known to excite asthmatic attacks. In this connection idiosyncrasy plays a j)rom- inent part. Some individuals are susceptible to only a few or perhaps but one of such irritants, and what will excite a paroxysm in one j)atient will have no influence on another. Thus, one patient cannot bear the ))erfume of some particular flower, as the rose, Easter lily, or heliotroju' ; another cannot tolerate the presence of a cat, horse, or dog ; and a third dare not 966 BItONClIIAL ABTHMA. 957 encounter the air of certain localities. It is a well-known fact that a change of residence may either bring on the attacks or entirely prevent them. Sudden changes in the barometrical pressure, with strong easterly or northerly winds, are particularly detrimental to some asthmatics. Indigestion, overloading the stomach, or the ingestion of certain articles of diet not infrequently precipitates a paro.xysm. In some rare instances intestinal worms are said to be an exciting factor. Asthmatic attacks may he induced by polypi in the nose. Volto- lini of Breslau was the first to direct attention to this fact, and his observations have been confirmed by later investigators. Hypertrophy of the mucous membrane over the turbinated bones and nasal septum has been shoAvn by Daly, Harrison, Roe, Allen, Hack, and others, to be a source of reflex irrita- tion in provoking paroxysms of asthma, more especially hay asthma. Skin eruptions, notably eczema and urticaria, have been included in the category of exciting causes. West has “never known eczema to be very extensive and very long continued without a marked liability to asthma being associated with it.” Cases have been observed where asthma and eczema have coexisted or alternated with each other, and the cure of one has been coincident with recov- ery from the other. It would seem not unreasonable to assume that where urticaria or eczema and asthma coexist or alternate Avith each other, instead of there existing a reciprocally etiological relation between the two, both are dependent upon some common cause. Pathology. — Thus far, no well-defined post-mortem alterations have been discovered that would place the pathology of bronchial asthma, if it really be a distinct affection and not merely a symptom, without the domain of specu- lation. There is a number of theories regarding the nature of this afi’ection, the most plausible of which are : 1st. That it is due to spasm of the bronchial muscles — the most popular theory at the present time. This theory is based upon the experiments of Williams and Longet, who, after the discovery of muscular tissue in the walls of the finer bronchi by Reisseisen, found that electrical irritation of the lungs and pneumogastric nerve produced contraction of the bronchial tubes. Among the advocates of this theory are Romberg, Bergson, Trousseau, Hyde Salter, Paul Bert, and Biermer. 2d. The next theory, and one having many supporters, is that the dyspnoea is due to a sudden tumefaction of the bronchial mucous membrane Avith exuda- tion, the result of turgescence of its blood-vessels caused by the action of the vaso-motor nerves (Weber), fiuctionary hypersemia (Traube). Stoerck adopted this theory from having, during the paroxysm, observed Avith the laryngoscopic mirror an acute hyperpemia of the laryngeal and tracheal mucous membrane, which disappeared after the attack had subsided, and he consequently inferred that the same condition existed in the smaller bronchial tubes. 3d. Another vieAV regarding the nature of this malady is that it is depend- ent upon a catarrh of the bronchioles (bronchiolitis exudativa). This theory is based on the presence in the sputum of certain peculiar spiral structures described by Curschmann (Fig. 1). Leyden discovered in the sputum of asthmatics certain elongated octahedral crystals (Fig. 1), which he believed, by their irritation of the terminal nerve- filaments in the bronchial mucous membrane, induced bronchial spasm. These crystals have been found in pneumonic expectoration, and hence, while not pathognomonic, they may be of some diagnostic value in differentiating bronchial asthma from other forms of dyspnoea. Symptoms. — In the majority of instances the asthmatic attack occurs without any premonition whatever ; sometimes, hoAvever, certain sensations are 958 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. experienced which to those who have previously suffered are pretty sure evi- dence of an approaching paroxysm. The premonitory symptom may be a depression or exaltation of spirits, a chilly feeling, a sense of constriction of the chest or throat, flatulent distention of the abdomen, itching of the skin, Fig. 1. Curschmann’s Spirals and Leyden’s Crystals (Striimpell). the voiding of a large quantity of clear urine, or some other functional dis- turbance peculiar to the individual. Not infrequently an acute catarrh of the upper air-tract precedes the attack. The paroxysm generally comes on after the patient has retired for the night ; still, it may occur at any hour of the day. It commences with the characteristic wheezing, and soon the patient is awakened by a distressing sense of lack of breath, which becomes more and more urgent until he is finally compelled to assume a position that will facilitate an easier entrance of air into his lungs. He may sit up in his bed or in his chair, with his hands grasping his knees, his shoulders elevated, and his head thrown backward, so that all the muscles of respiration and their auxiliaries may act to greatest advantage ; or, he may find greatest relief by kneeling before his cot or chair with his head resting on his hands or a pillow. Often the desire for breath is so pressing that the sufferer will rush to an open window in the hope of obtaining relief. The face assumes an anxious expression, pallid at first, and as the dysjincea increases changing to a dusky liluish hue. The eyes are prominent and have a staring expression, the nostrils are widely dilated, and the mouth is partly open. The skin becomes moistened with perspiration as the distress increases. The respiration, particularly expiration, is noisy and wheezing, and may be heard in the adjoining apartment. Inspiration is short and jerky, expiration very much prolonged. The number of respirations is seldom much increased, and may be even less than normal. Speech, beyond monosyllables, is impossi- ble. Notwithstanding the laborious efforts in breathing there is merely an up- and-down movement of the ribs, with but little or no exjiansion, the thorax being fixed in the position of full insj)iration. The pulse is small, rapid, and tliready in proportion to the intensity of the dys])iioea. There is no elevation of the temperature. If the attack be prolonged, the surface temperature falls below normal, the extremities become cold, clammy, and bluish, and death seems imminent. As the paroxysm subsides there is more or less cough and expectoration, whether they have previously existed or not. In some cases the exjiectoration consists of rounded masses of tenacious mucus ; in others it is profuse and watery. Sometimes streaks of blood are fiund. In some rare and severe cases haemoptysis has been known to occur. BRONCHIAL ASTHMA. 959 After the paroxysm there is usually considerable exhaustion, and the patient soon falls asleep. On awakening, with the exception of a little soreness of the respiratory muscles, no discomfort is experienced, and the patient afterward enjoys his usual health. The duration of the attack may vary from a few hours to several days, with remissions and exacerbations. The pai’oxysms vary in frequency. They may recur as often as once a week or there may be an interval of months between them. Ordinarily there is no regularity in the recurrence of the attacks. A periodicity, however, is sometimes noticed, and is probably due to some con- dition operative only at particular times. Physical Signs. — During the paroxysm inspection shows an expanded and barrel-shaped thorax, with but little respiratory motion. Inspiration is short and quick, expiration prolonged and violent. On percussion more or less hyper-resonance is obtained; in mild cases it is slight, but when the attack is severe and of long duration it is usually quite marked. Auscultation reveals, in severe cases, diminution or suppression of the vesicular murmur. In mild attacks the respiratory murmur may be exaggerated and jerky. All over the chest may be heard an ever-changing variety of sonorous and sib- ilant rSles. They are piping, cooing, wheezing, and often musical in their nature. They are louder during expiration. Toward the close of the parox- ysm moist r^les are to be heard, or, if bronchial catarrh exists, they may be detected from the beginning of the attack. Prognosis. — Uncomplicated asthma is, per se, rarely if ever fatal. In general the prognosis is better in young subjects than in adults. Hyde Salter makes the statement that “ in young asthmatics the tendency is almost invariably toward recovery.” The prognosis may be said to be favorable when the attacks are dependent upon some removable cause, when mild and occurring at long intervals, when there is no hereditary predisposition, and when there is freedom from complications. Diagnosis. — The rational and physical signs of an uncomplicated paroxysm of asthma are so distinctive that, if properly appreciated, there should be little or no difficulty in reaching a correct diagnosis. The affections which it is thought may possibly be mistaken for bronchial asthma are the various forms of obstruction in the upper air-passages, as for- eign bodies in the throat; retro-pharyngeal abscess; diphtheritic and false croup; oedema of the glottis; neoplasms of the larynx ; spasmodic contraction of the adductors of the larynx or paralysis of the abductors; tracheal stenosis or foreign body in one or the other of the main bronchi ; bronchitis, pneu- monia ; emphysema ; pulmonary oedema ; pleuritic effusion ; cardiac disease ; uraemia, and spasm of the diaphragm. In obstructive dyspnoea from any cause the difficulty in breathing is during inspiration, while in asthma it is during expiration. There is also inspiratory recession at the episternal notch and epigastrium not observed in asthma. In the former there is the absence of wheezing in the chest, and the dyspnoea is continuous instead of paroxysmal, as in asthma. Changes in the quality of the voice will exclude the latter affection. Examination of the throat with the finger or mirror will enable one to determine the exact nature of the obstruction. Occlusion of a main bronchus will cause a diminished intensity or absence of the respiratory murmur on the affected side. The dyspnoea of bronchitis and pneumonia comes on gradually and is attended with some degree of fever ; the respirations, particularly in pneumonia, are rapid and often short and catching. In asthma the onset is 9G0 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. more sudden, there is no elevation of temperature, and the respirations are either but slightly or not at all increased in frequency. Some difficulty may be experienced in distinguishing between emphysema and asthma on account of their frequent coexistence. Each may induce the other. Emphysema more often exists without asthma than does the latter affection without some degree of the former. In emphysema the dyspnoea is remittent rather than intermittent as in asthma. It is aggravated by physical excitement, and hence is more likely to occur during the day than at night. In pulmonary oedema the increased frequency of the respiration, with perhaps some dulness on percussion, the presence of large and small moist rales all over the chest, the profuse and watery expectoration, and the absence of wheezing will ordinarily distinguish it from asthma. In pleuritic effusion the usual dul- ness on percussion, the limitation of the diminished respiratory murmur to the area occupied by the fluid, the detection of aegophony, and the absence of the characteristic dry rales of asthma will suffice for a diagnosis. Cardiac asthma is not very common in children. It, however, resembles bronchial asthma in that it may be paroxysmal in nature, intense in degree, and may come on at night. It generally follows cardiac excitement. The absence of the varied musical sounds in the chest and of the prolonged expira- tion, and the presence of a cardiac lesion capable of inducing dyspnoea, will be of some assistance in distinguishing the one from the other. Dyspnoea due to ursemia need never be confounded with bronchial asthma if the precaution is taken to examine the urine of every case coming under observation. Spasm of the diaphi-agm may be distinguished from asthma by the sudden, abrupt inspiration, the hiccough, and, after a few seconds, the quick, violent expiratory effort. Treatment. — The treatment of asthma comprises the management of the paroxysm and the treatment of the patient in the intervals between the attacks. If possible, the exciting cause should be discovered and removed. For instance, if clearly dependent upon an overloaded stomach or the presence of some indi- gestible substance in the alimentary canal, an emetic or an enema will afford prompt relief. To relieve the patient during the attack, in the absence of any apparent and removable cause, it generally becomes necessary to have recourse to some sedative or depressant. The numerous drugs recommended vary so in their action upon different subjects that not infrequently a number have to be tried before the one is found that gives the greatest relief. The one drug that is most frequently successful in cutting short the paroxysm is morphine admin- istered subcutaneously. In young children, however, it is rarely necessary to use it, as some one of the remedies to be mentioned will usually be found to be sufficiently effective. In later childhood, if given, the greatest caution should be observed, as children are markedly susceptible to the toxic influence of morphine. To a child ten years of age from ^ to of a grain of the sul- phate, combined with of a grain of atropine sulphate, may be given hyjK)- dermatically. Next to morphine in abating the asthmatic paroxysm comes chloroform. The relief is speedy, but ofteTi only temj)orary, so that repeated inhalations are usually required. In the writer’s experience chloral hydrate is superior to chloroform at any period of childhood, in that its effects, though less prompt, are more lasting. At five years of age 5 grains dissolved in at least 1 drachm of some simple menstruum, may be given, and repeated in forty minutes if there be no abatement of the dyspmea. If it cannot be taken by the mouth, 10 to 15 grains dissolved in half an ounce of water may be injected into the rectum. BRONCHIAL ASTHMA. 961 The fumes of nitre-paper (charta jiotassii nitratis), a very popular remedy, will often cut short a mild attack and give considerable relief in a severe one ; sometimes it has no effect at all. The remedy is prepared by dip- ping a sheet of absorbent paper into a saturated solution of nitrate of potas- sium and afterward drying it ; the dried pa}>er is then cut into pieces of the recpiired size and is ready for burning. The patient should be placed in a small room or in some kind of an extemporized tent, so that he can inhale the fumes of the burning paper. It acts promptly if at all, at first exciting some cough, but in a few minutes alleviating the distress. Inhalation of the smoke of Datura stramonium and Datura tatula is often serviceable. In young subjects it must be used with care, and the inha- lation stopped as soon as the sight or intellect becomes confused. Lobelia and belladonna, either separately or combined, are beneficial in some cases. Tobacco, while an excellent remedy in adult cases, is too powerful a depress- ant to be recommended in children. The nitrite of amyl and nitro-glycerin do good, but they have not yielded such results as would be expected from our knowledge of their physiological action. If used at all in children, they must be given with due caution. Quebracho and Grindelia robusta have been advo- cated, but their action is uncertain. Iodide of ethyl is thought to be efficacious (Germain Sde). Eight to tAvelve drops by inhalation is a fair dose at eight years. Pilocarpine, ^ to ^ of a grain hypodermatically at five years, has been advocated by Berkart. Coffee and alcohol are useful in the adult ; but it is questionable if it would be wise to have recourse to them, particularly the latter, in children. Intense mental emotion, as a sudden alarm or a pleasurable surprise, will frequently at once check an asthmatic paroxysm. During the intervals of the attacks every effort should be made to discover and remove the exciting cause. Hypertrophied turbinated bodies should be reduced, nasal polypi extirpated, adenoid growths in the naso-pharynx removed, and catarrh of any part of the respiratory tract relieved by appropriate meas- ures. Particular attention should be given to the diet, especially when the asthmatic attacks bear any relation to the state of the digestion. As a rule, it is best to allow only a light and easily-digested supper, and that early enough in the evening to be digested and passed from the stomach before retiring. When there is no apparent exciting cause the general condition of the patient requires attention. The value of an out-door life, in the open country if possible, the daily cold sponge-bath, the protection of the body by suitable clothing, and a nutritious diet in the asthmatic subject is too well appreciated to require more than mere mention. All those afl’ections that directly or indirectly cause enlargement of the bronchial glands are to be most sedulously guarded against. Cod-liver oil, beginning with small doses and gradually increasing, shoidd be administered in most cases. Iron is frequently indicated. The tincture of the pomate of iron in from 5- to 10-drop doses at five years of age is an acceptable and easily-digested preparation for children. The tincture of the chloride or the syrup of the iodide may be given if the digestion be good. In many cases arsenic renders good service. It is best administered in the form of liquor potassii arsenitis (Fowler’s solution), beginning at the age of five years with 1 drop in water three times a day, and increasing gradually to 4 or 6 drops. On the supervention of toxic symptoms the drug should be dis- continued for a time. Iodide of potassium is lauded as possessing some special beneficial action in asthma. If given to the point of tolerance and continued for a long period of time, it often yields good results. In some cases, however, it utterly fails. 61 9G2 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Quinine and strychnine have their respective advocates. The former will prove valuable where there is a malarial complication. In small doses they are both tonics. Change of climate or locality will relieve some patients. Asthma is such a capricious malady that it would be next to impossible to select any particular locality and guarantee immunity from the attacks. Some city patients are benefited by removal to the country, those living in the country by going to the city, dwellers at the sea-coast by a change to the interior, and those living inland by a residence at the sea-board. The fact of the matter is, each patient must select his own climate. FIBROID PHTHISIS. By FREDERICK C. SHATTUCK, M. D., Boston. This affection — otbenvise known as chronic pneumonia, interstitial pneu- monia, cirrhosis of the lung, or fibroid induration of the lung — is a process not uniform in origin, generally unilateral, very chronic in course, resulting in the substitution of connective for pulmonary tissue in a more or less con- siderable area, usually associated with bronchial dilatation, and often, at some period in the case, with tuberculosis. Etiology. — This condition — for, in the great majority of cases at least, it is a condition rather than a disease — is not very common at the best, and is, in its fully-developed form, very rare in children, though its origin may date back to childhood. Of 30 fiital cases with autopsy collected by Bastian in Reynolds’s System of Medicine^ only 2 were under fifteen years of age, 3 from fifteen to twenty, while more than one-half of the cases succumbed between twenty and forty. The age of both children was seven years, and one of them was reported by Sir D. Corrigan in his original paper on “ Cirrhosis of the Lung,” published in 1838 in the Dublin Journal. In Wilson Fox’s great posthumous work on “ Diseases of the Lung and Pleura ” will be found references to other cases in children. That the affection should be rare in children is not surprising, inasmuch as inflammation, like nutrition, in the young is a more active process than in adults, and is less likely to lead to the formation of organizable products than in later life. The power of complete repair is also greater in children, and in them, if recovery takes place, it is less likely to leave permanent or progressive changes behind. The literature of the subject would seem to show that in children pneumonia and broncho-pneumonia are the affections which are most apt to be followed by fibroid changes in the lung. Of the two, the latter is probably the more frequent antecedent. That simple bronchitis may pave the way to connective-tissue growth seems probable. It is certain that pleurisy may do so, though this origin is probably more frequent in adults. The thick false membranes may then serve as the starting-point for a growth of connective tissue into the contracted lung itself, while bronchiectasis gradually comes about as a result of frequent cough, and also as a means of equalization of the atmospheric pressure within and without the chest. Other things being equal, the older the person the more rigid the chest-wall and the less can it collapse. The space which the firm adhesions prevent the lung from reoccupying must thus be filled in a measure by dilatation of the bronchi, of some of the air- vesicles, and even of the blood-vessels and lymphatics. There is another sequence of events which is certainly more common in adults, if indeed it ever occurs in children. The arrest of an ordinary ulcer- ating pulmonary tuberculosis, with the formation of abundant connective-tissue growth in which the bacilli are, as it were, bottled up, is here alluded to. The writer has seen some conspicuous examples of this. The report of one of them, 963 964 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. with autopsy, may be found in the Boston Medical and Siirf/ical Journal, 1880 . The fibroid phthisis which results from irritation by i)articles of dust, as in miners, grinders, ])ainters, and the like, is not ai)t to be encountered in children, and is a bilateral aflection. The view is expressed by Striimpell, Osier, and other recent writers that most cases of fibroid phthisis either are or have been tuberculous. That this is true of some cases there can be no ({uestion ; but further investigation is needed to enable us to determine how large the proportion is. or whether, indeed, such destructive processes ever go on without the aid of the tubercular bacillus. That many of the inflammations of serous membranes, including the pleura, formerly believed to be sim|de or due to exposure to cold, are really tubercular, seems now to be well established. And the origin of .some of these cases of fibroid phthisis in pleurisy has been already alluded to. The dis- covery of the true criterion of tuberculosis is still too recent to permit the accumulation of sufficient positive evidence to establish the relation of fibroid phthisis and ])ulmonary tuberculosis. In the older reports, if no miliary tubercles or caseous masses were found after careful search, the case was classed as non-tubercular. I have not met with any reports of thorough microscopic ex- amination of these cases of late years. But we have learned since Koch’s great discovery more than we knew before as to the multiplicity of the lesions following the local and general action of his bacillus, and also more as to tiieir frequent self-limitation, and, indeed, curability. Pathological Anatomy. — The striking morbid featui’e of this affection is the presence of connective tissue in the lung with corresponding destruction of the true parenchyma. The changes are generally unilateral, and may be so even when the primary process — broncho-pneumonia, for instance — is essen- tially bilateral. The lower are more freciuently affected than the upjier lobes. Bands of fibrous tissue may traverse the affected part, and these bands are, for obvious reasons, less likely to be pigmented in the young than in adults. Or the distribution of the connective tissue may be more uniform, producing an a])pearance which has been compared to that of the uterus after delivery. I’eri- bronchitic thickening is pi-actically always present to a greater or less degree, as is also bronchial dilatation, resulting in the formation of cavities of greater or less size. Another mode in which cavities are formed or increased in size is through ulceration, the accom])animent of the growth of tubercular bacilli or the result of the irritation of retained and deconi))osing secretion, or both at once. Miliary tubercles, caseous masses, or calcified (lej)osits may be seen by the naked eye. The microscoj)e may reveal tubercular bacilli in active growth in the secretion or the ti.ssues, or safely im))risoncd within the eonneetive tissue. Here and there within the disea.sed portions there may be macroscopic or mi- croscoj)ic islets of relatively normal or of emphysematous lung-tissue. The microscope may also demonstrate within the indurated lung or the thickened ])leura dilated blood- and lym])hatic-vessels. The affected lung may l)e moderately or very greatly dimini.shed in size, with corresponding contraction of the chest, ap])roximation of the ribs, drooj) of the shoulder, and twist of the vertebral column. The fdeura is rarely if ever s])ared ; it may contain an encapsulated collection of fluid, more probably sero-fibrinous. Adhesions vary considerably in thick- ness and density ; they may l)c cartilaginous, and so firm that the lung must be cut out of the chest at the autop.sy. It seems reasonable to supjtose that when the process started in the pleura, the thickening of that membrane is more eon- FIBROID PHTHISIS. 905 spicuous than when it started in the lung itself and secondarily affected the pleura, as does every inflammatory process of the lung or of the chest-wall which approaches one or the other layer of the serous cavity. The sound lung, or sound portions of both, is the seat of compensatory hypertrophy ; perhaps of emphysema, either confined to the edge or more widely distributed. Adhesive pericarditis is common as a result of extension of inflammation from the pleura, especially when the left lower lobe is the seat of the disease. The heart itself is often more or less drawn out of place, and the right chambers are apt to be dilated and hypertrophied in extensive disease of long standing, in consequence of the augmented internal pressure to which the cavities are subjected by reason of the increased resistance in the pulmo- nary circulation. If compensation has failed in the right ventricle, the common secondary results of such failure are shown by general and visceral venous stasis. Symptoms and Course. — Cough and expectoration are practically con- stant, though they vary widely in degree and severity in different cases or in the same case at different times. The character of the expectoration is not distinctive. If notable cavities of bronchiectatic or other origin are present, their existence may be suggested by a more or less periodically profuse ex- pectoration, by profuse expectoration in certain positions of the body, or by the separation of the sputum on standing into an upper frothy, a middle serous, and a lower layer of purulent masses. The presence of tubercle bacilli is suggestive of a recent infection from without or of a fresh outbreak from within. If ulceration is going on, elastic fibres may be found. Haemoptysis is extremely common, is often repeated, and usually moderate in amount. It may, however, as in ordinary phthisis, arise from a good-sized vessel travers- ing the wall of a cavity, and then be so profuse as to be the immediate cause of death. Dyspnoea may be absent while the patient is at rest, but very marked after but slight exertion. Constant fever, with its attendant emaciation and constitutional disturbance, is absent. The process in itself is not a febrile one, and a rise of temperature which may be found at any time is attributable to some secondary or compli- cating affection. General nutrition may be excellent, and the fat layer notable. Clubbing of the tips of the fingers and toes anil incurvation of the nails may be more marked in this than in any other condition, save, perhaps, congenital heart defects ; this is an infallible indication of chronicity. In a word, the appearance of the patient may be, in the main, that of one in perfect health, from which a wide deviation is found to exist when the clothing is removed from the chest and a physical examination is made. It does not seem advisable under the circumstances to enter here into a detailed account of the physical signs, which are so similar to those of a case of chronic tuberculosis. I shall therefore briefly touch only on those which are most striking and distinctive. Inspection is apt to show a disparity in size and mobility between the sides of the chest ; unilateral shrinkage, the droop of a shoulder, and curvature of the spine I’eaching their highest expression in those cases originating in or complicated by extensive pleural changes. Palpation, auscultation, and per- cussion reveal the presence of consolidated lung containing secretion, perhaps of cavity formation. As contrasted with ordinary phthisis, these changes are more apt to be found at the base than at the apex. Cardiac pulsation may be visible over unusually large or in unwonted areas, according as retraction of the lung away from the heart, or adhesions to the pericardium and retraction of the heart itself, or both together, may happen to have operated in the case in 9G(j AMERICAN TEXT-BOOK OF DIHEASE^ OF CHILDREN. hand. Sometimes, however, the heart is unduly overlapped by the hypertro- phied healthy lung, and its pulsations may then be obscured. Although the right heart is apt to be, often markedly, hypertrophied and dilated, the fact that it is so must be often a matter rather of inference than of direct signs fur- nished ])y the examination of the organ itself. The explanation of this fact lies in the altered mutual relations of the lungs and heart under the influence of the disturbing factors mentioned above. Cardiac murmurs bear no con- stant relation to the condition. If, for any cause, the compensatory hypertrophy of the right ventricle fails, the characteristic evidences of stasis in the pulmonary and systemic veins are superadded to those of the underlying condition — cyanosis, distention or pul- sation of the jugulars, anasarca, ascites, enlarged or tender liver, the urine of passive I'enal congestion, and the like. The course of the affection is essentially chronic, and, on the whole, pro- gressive, though a}>parently stationary periods, perhaps of considerable duration, seem to occur. Intercurrent attacks of broncbitis are not rare, and certaiidy do nothing to retard progress. Death may occur from failure of the cardiac compensation, hsemoptysis, exhaustion, or from intercurrent disease. Diagnosis. — This can seldom present any great difficulties, provided that a good history can be obtained and a careful physical examination be made. The combination of a history of chronic cough and expectoration, with repeated hsemoptysis; the physical signs of pronounced lung destruction, usually unila- teral, often with cavity-formation ; and hypertrophied and dilated right ventricle, with the maintenance of a surpilsingly good condition of general nutrition, presents a picture which is perfectly characteristic. The very small respiratory margin is also noteworthy. Chronic pleurisy with great thickening of the mem- brane and contraction of the side is perhaps more liable to give rise to error than any other afi’ection. The history of the case, but, above all, the signs of pronounced pulmonary changes, and the occurrence of limmoptysis, are the chief aids in the difl’erentiation. The good general nutrition, the absence of fever, and the duration and mode of onset of the trouble are sufficient to exclude ordinary pulmonary tuberculosis. The thoracic physical signs of cancer of the lung or pleura might be similar; but the course and duration are quite different. Congenital syphilis of the lung is of pathological rather than clinical interest. Acquired syphilis of the lung is very rare in children : it is also rare in adults, but resend)les clinically ordinary phthisis more than the fibroid variety, which, moreover, is not amenable to mercury and the iodides. Prognosis. — There can be no question that the expectation of life is cur- tailed by this condition. Probably Dr. Oliver Wendell Holmes did not have it in mind wdien he said that the way to ensure length of days is to acquire an incurable disease. And yet its owners may live many, many years, fl'lie danger is rather from intercurrcnt disease than from the fibroid induration of the lung itself. If the patient’s circumstances permit, he will naturally lead a more careful life than if he were sound in all parts. In a case of the writer’s, proving fatal at twenty-eight years of age, the onset dated back presumably to measles at the age of seven, and yet the patient worked as a shoeblack in a damp, narrow, and suidess alley in all sorts of weather until shortly before his deatli from ha'mo)»tysis. Had he been able to take care of himself, it is j)roba- ble that he might have lived many years longer. Treatment. — It is obvious enough that little can be done to repair damage already done, fl’herapcutic effects must, therefore, in tlie main, be directed to staying the progress of the affection as far as po.ssible, and to ward- ing oft" intercurrent diseases, which may either promote the extension of the FIBROID PHTHISIS. 967 fibroid growth or carry off the patient. Hygienic measures are thus vastly more important than medicinal agents. The limitation of the respiratory capacity is such in most cases as to preclude residence in high altitudes. Climatic change has for its object an abundant supply of fresh, pure air with lessened risks of colds and bronchitis. The amount and character of exercise are to be determined by the peculiarities of each case. Tonics and stimulants are to be given if the appetite and digestion seem to retjuire them. Expecto- rants may be needed from time to time. Narcotics and hypnotics, except occasionally and in the last stages, are to be avoided as far as is possible. Iodide of potassium may render good service in promoting recovery from bron- chitis, but cannot be expected to have much influence on the connective tissue growth. Failure of compensatory hypertrophy of the right heart calls for cardiac tonics, as when it occurs under other circumstances. In a word, it should be our aim to keep our patient in the highest possible condition of health, treating him rather than his disease. PART IX. DISEASES OE THE HEART. CONGENITAL AFFECTIONS OF THE HEART. By barton COOKE HIRST, M.D., Philadelphia. Cardiac anomalies of pre-natal origin, like other developmental abnormal- ities, cannot be easily classified in a thoroughly satisfactory manner. Osier gives an etiological division into (1) those affections due to defective develop- ment, (2) those resulting from intra-uterine endocarditis; and (3) those that are caused by a combination of both causes. The same author employs, however, the following general classification : I. Conditions in which structures normal to the foetus persist during extra-uterine life, such as ojien foramen ovale, per- sistency of the Eustachian valve, and patency of the ductus arteriosus. II. True anomalies of development, as absence or imperfection of the ventricular septum, absence of the auricular septum, anomalous division of the truncus arteriosus, transposition of the great vessels, and numerical variations in the valve segments. III. Conditions caused wholly or in part by endocarditis, as extreme stenosis of the cardiac orifices, puckering, thickening, and adhesion of the valve segments. The writer will employ Baginsky’s classification, somewhat modified, as follows : 1. Patency of the foramen ovale. 2. Defect of the ventricular septum. 3. Anomalies of the right and left auriculo-ventricular orifices. 4. Stenosis and atresia of the pulmonary artery. 5. Persistence of the ductus arteriosus. 6. Stenosis of the aorta. 7. Transposition of the arterial trunks. 8. Numerical anomalies of the valve segments. 9. Ectopia cordis. 1. Patency of the Foramen Ovale. — Much attention — more than it deserves — has been bestowed upon this affection of the heart. Of itself, it does not entail, as a rule, any disadvantage ujion the individual. A patent foramen ovale has been discovered in many persons dying of a variety of diseases, in whom, during life, there was no evidence of heart embarrassment. Uidess there be associated anomalies, congenital or acquired, increasing the pressure in the right auricle, the blood will not How in any quantity from right to left auricle, even though the foramen be open, and consequently the arterial blood 9R8 CONGENITAL AFFECTIONS OF THE HEART. 9()9 will not be vitiated to any appreciable extent. If pressure be increased in the right auricle by a contracted auriculo- ventricular septum or by an obstacle to the escape of blood from the right ventricle, then the stream may be deflected into an abnormal course, the heart be embarrassed by extra work, and the blood in the aorta become mixed. The child will be cyanotic, and its life will very likely be cut short. If the size of the patent foramen is increased by a defect in the anterior muscular septum between the auricles, as well as in the membranous septum, the anomaly is a very serious one. I have had an opportunity to make a post- mortem examination in two such cases. In both the children lived but a few hours after birth, and they were intensely blue. In one the cyanosis reached a grade I Imve never witnessed before or since. The cause of a patent foramen ovale is either an absence or defective development of the membrana fossae ovalis or a defective institution of respira- tion. Normally, the opening is closed by the increased blood-supply to the auricles incident to the beginning of respiration. Should the latter act be imperfectly performed, as in atelectasis, the mechanical force to close the fora- men by pressure upon its valve — with the subsequent adhesion of its free edges to the rim of the oval fossa — is lacking. More frequently, however, in infants that survive birth the membrana fossae ovalis is lacking or ill developed, and the foramen consequently cannot be closed. It is claimed by Sansom that patency of the foramen can be diagnosticated during life by cyanosis without heart murmur, or by cyanosis with systolic and presystolic murmurs over the cartilages of the third and fourth ribs. But if one remembers that there are many other causes of cyanosis in the new-born infant besides heart defects, and that an open foramen uncomplicated by other anomalies may very likely present no symptoms at all, the difficulty of making this diagnosis may be appreciated. As interesting anatomical conditions under this head, but without clinical sig- nificance, are to be noted perforations of the valve of the foramen ovale and small slit-like openings under the valve where it has not adhered to the rim of the opening. The last are very common. 2. Defect of the Ventricular Septum. — This anomaly is most fre- quently associated with other abnormalities of the heart, as stenosed orifices and vessels, or defect of the auricular septum. It is not at all uncommon in its lesser degrees, but total defect is rare, and, when present, is associated almost always with defect of the auricular septum, constituting the so-called reptilian heart or cor biloculare. The defect is most frequently found in the anterior muscular portion of the septum, as shown by Rokitansky, and not in the median membranous portion, where it formerly was believed to be most frequently situated, but is in reality very rarely found. The effect of an unnatural open- ing between the ventricles is a propulsion of some of the blood from the left ventricle into the right during the former’s contraction. Should the latter suf- ficiently hypertrophy to dispose of the extra amount of blood thrown into it, there need not necessarily be striking symptoms of heart defect. But should the hypertrophy not be sufficient, there results an embarrassed respiration and an obstructed venous circulation, with cyanosis and transudation of serum into connective tissue and body-cavities. As Baginsky points out, the cyano.sis is due to this cause, and not to the mixing of arterial and venous blood. The diagnosis of defect in the ventricular septum can be made, it is a.sserted by Roger and Sansom, by a loud .systolic murmur over the praecordial region and between the shoulders, not transmitted to the vessels. The existence of a ventricular septum defect is unfavorable to the life of the infant, mainly on account of the associated anomalies. Sansom, however, records a case in a 970 AMERICAN TEXT-BOOK OE DISEASES OE CHILDREN child that lived eight and a half years, and Johnstone another that lived seven years. 3. Anomalies of the Right and Left Auiuculo-ventricular Ori- fices. — These consist in stenosis and valve defects, mainly, the result of an intra-uterine endocarditis of the right and left heart-cavities. Osier claims that the endocarditis is secondary to developmental anomalies and is almost always of the chronic, sclerotic type, and very rarely of the verrucose or warty variety. He describes a typical specimen as presenting thickened valve seg- ments, which are shrunken and smooth. In the case of the auriculo- ventricular valves the cusps become united and the attached cliordm tendineie are thick- ened and shortened. In the semilunar valves all trace of the segments usually disappears, leaving a stiff’, membranous diaphragm perforated by an oval or rounded orifice. Valve defects from endocarditis are more commonly found upon the right than upon the left side. We shall first, therefore, glance at the anomalies of the right auriculo-ventricular orifice. There is usually a thickening of the tricuspid valve as well as of other portions of the endocardium. The right ventricle is small. If the disease leads, as is not very uncommon, to complete atresia of the orifice, the circula- tion is only possible in a roundabout way, and then only when there is a defect in the ventricular septum. The blood flows from the right to left auricle, and from the left ventricle, in part, into the right, and so into the pulmonary artery. The left ventricle, from the additional work thrown upon it, is dilated and hypertrophied. In case of associated stenosis and insufficiency the right heart is dilated and hypertrophied. Cardiac murmurs, systolic and diastolic, with a thrill imparted to the thoracic wall, are loud and distinct, the heart’s action is labored, the cyanosis is marked, and passive congestion everywhere is pro- nounced, leading on slight provocation to haemorrhages. In addition to the abnormalities resulting from disease in the tricuspid valves, developmental anomalies may be found, as an imperfect separation of the cusps, so that there is a circular opening between auricle and ventricle, with an annular diaphragm surrounding it. On the other hand, there may be four cusps instead of three. The most common cause of abnormality in the left auriculo-ventricular orifice is a left-sided endocarditis. If stenosis of the orifice is well marked, the blood in the distended left auricle flows back through the patent foramen ovale into the right auricle, thence into the right ventricle, and so, by the ductus arteriosus, into the aorta. The left ventricle, becoming functionally more or less useless, undergoes atrophy, sometimes to a very marked degree. When the child is born the determination of blood to the lungs, and the increased amount flowing to the left auricle, embarrass the heart extremely. Congestion of the lungs, extreme cyanosis, and an early death is the result. As in the right orifice, there may he the developmental anomalies of imj)erfect differentiation of the cusps or their division into three iristead of two segments. 4. Stenosis and Atresia of the Pulmonary Artery. — Osier divides the anomalies of the pulmonary orifice into stenosis, atresia of the orifice and of the artery, and stenosis of the conus arteriosus. Stenosis of the pulmonary artery is one of the commonest and most im- portant congenital defects of the heart. A child may live some length of time — may, in fact, reach adult life — with a serious narrowing of the pulmonary orifice and with enormously dilated and hypertrophied heart-cavities and mus- cles, without special symptoms until some extra strain is imposed upon the heart, especially by congestion of the lungs, when sudden death is likely to CONGENITAL AFFECTIONS OF THE HEART. 971 occur. On the other hand, intense cyanosis and embarrassed respiration and circulation may be manifested from the first, and the infant may live but a few hours. The continued existence and development of the infant depend upon the hypertrophy of the heart. If this be truly compensatory, the child may thrive surprisingly well, even in grave cases. The prognosis as regards duration of life is better than in any other form of congenital heart defect of serious character. One individual reached the age of fifty-seven, and 16 per cent., according to Assmus, survive the twentieth year. But the tenure of life is always uncertain, for any sudden call upon the heart for extra work may prove fatal. And these cases are particularly liable to have grafted on them, at some time after birth, a fungous or infectious endocarditis that may be the immediate cause of death. Moreover, individuals affected with a contracted pulmonary orifice are peculiarly liable to tuberculous disease. The cause of this anomaly is almost invariably an intra-uterine endocarditis, but it may possibly be a developmental defect. The symptoms are cyanosis, with signs of embarrassed circulation and respiration. The body warmth is likely to be very imperfectly preserved. The slightest exposure of the extremities leads to a remarkable frigidity, and the infiint manifests signs of discomfort or suffering in consequence, unless it is too apathetic to take note of its surroundings. A mental and physical apathy very likely characteidzes the individual throughout life. As already stated there may be no special symptoms, even in bad cases, or at most, attacks of dyspnoea, lividity and heart palpitation fi’om time to time. On auscultation a loud systolic murmur is heard over the second and third ribs to the left of the sternum, and at the apex, which is not transmitted to the carotids. A thrill is imparted to the thoracic wall, the area of cardiac dulness is much increased, and the anterior wall of the thoi’ax is protruded in later life. Complete atresia of the pulmonary orifice and of the artery, while rarer than stenosis, is not very uncommon. The condition is due to defective development, and not to disease. If the atresia is of early appearance in embryonal life, there is a wide opening between the auricles and advanced atropliy of the right ventricle. The blood ffows from the right auricle to the left auricle, and in part to the lungs by the medium of the ductus arteriosus. If, as is likely, there is a defect in the ventricular septum, the aorta may arise equally from both ventricles, or even belong more to the right; in which case the latter is much hypertrophied and dilated. The symptoms are more pro- nounced and the prognosis much worse than in stenosis. There is intense cyanosis, great dyspnoea, the child becomes very often convulsed, and dies usually in a few hours. Stenosis of the conus arteriosus forms, according to Assmus and Osier, a considerable portion of the cases of obstruction at the pulmonary orifice. The former collected 47 cases of the kind. The condition is due to faulty develop- ment. By a constriction of the lower portion and dilatation above, a sort of accessory auricle may be formed. There are almost always other defects of development, as a defective ventricular septum. The symptoms are those of stenosis of the pulmonary orifice. 5. Persistence of the Ductus Arteriosus. — By the fourteenth day, or within the first four weeks at least, the ductus arteriosus is closed by an overgrowth of the cells in its inner wall. Occasionally, in consequence of puerperal infection of the new-born with infected thrombi, or on account of defects in cardiac development, or as a result of the imperfect institution of respiration and an anomalous pulmonary circulation, the duct remains patent. It has been my experience, in making post-mortem investigations upon the 972 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. bodies of young infants, that a slight degree of patency is by no means uncommon during the first year of life. It is frequently easy to pass a small probe through the duct or to s(jueeze a drop or two of blood through, but in such cases the duct, of course, plays no part of practical importance in con- veying the main-stream of the blood. The clinical symptoms of an efficient patency of the ductus arteriosus are rapid hypertrophy and dilatation of the right ventricle, dilatation of the pulmonary artery, increase in area of cardiac dulness, long-continued systolic murmurs, thrill of the anterior chest-wall, protrusion of the upper part of the sternum, attacks of dyspnoea, cyanosis or, perhaps, an almost cadaveric hue, a disposition to bronchitis and congestion of the lungs, and anasarca. Atheromatous processes in the pulmonary artery are common in individuals who live some years. The prognosis is not favorable. Of sixteen cases 7 died in childhood, 5 lived from nineteen to thirty-four years, and 4 to between forty and fifty. 6. Stenosis of the Aorta. — Obstruction at the aortic orifice is the result of developmental defect or of endocarditis, as in the case of obstruction at the pulmonary orifice. Stenosis is rarer, while atresia is relatively more common, at the aortic than at the pulmonary orifice. As in the right side of the heart, the conus arteriosus may be narrowed, but the condition is rare. Stenosis of the aortic orifice is a much more serious condition than narrowing of the pul- monary orifice. Of 33 cases, only 1 survived the first month. Stenosis of the conus arteriosus, on the other hand, does not seem so serious, for the majority of cases have been observed in adults. The aorta itself may be narrowed at the insertion of the ductus arteriosus. In this case the blood cur- rent finds its way to the lower portion of the trunk and the lower extremities by a roundabout course through the dilated subclavian arteries and by their branches anastomosing with the intercostal and epigastric arteries. The arteries of the upper portion of the body may be demonstrated to be much larger and fuller than in the lower, as in a comparison between the radial and crural pulses. The prognosis of this developmental defect is good. The indi- vidual may live to advanced old age. 7. Transposition of the Arterial Trunks. — This anomaly is not of great interest to the practitioner, for it is usually associated ivitli other grave developmental defects that make extra-uterine life unlikely, and, of itself, it leads to an early death. The vitiated blood flowing from the right auricle into the right ventricle is distributed by the aorta springing from this ventricle again to the body, while the aerated blood from the left auricle is conveyed baek again to the lungs. Continued existence at all is usually explained by an o]ien foramen ovale or by a communication between the pulmonary veins and the right side of the heart. Osier describes an example in an eight-months’ faUiis, in which there was a partial transposition, the right ventricle giving off a small branch to the lungs, and the major part of its stream into the thoracic aorta, while from the left side sprang an arterial trunk that divided into the innomi- nate and left carotid arteries. Children thus affected are deejdy cyano.sed, have dyspnoea, are prone to haemorrhages and rapid cooling of the skin and the ex- tremities. They are apathetic and die early, fl’wenty out of twenty-five cases did not survive the first year. A number of cases has been collected by Rauchfuss and Von Etlinger. 8. Numerical Anomalies of the Valve Seuments. — 'Phe valve seg- ments may be diminished in number by failure of development or as a result of endocarditis. Of itself this anomaly has little importance clinically, but it is often associat(Ml with other defects, as in the ventricular sejitum. and is com- monly followed by sclerotic changes in the valves. Su{)ernumerary valves are CX)N({ ENrrAL AFFECTIONS OF THE HEART. 973 not uncommon. As many as five semilunar valves have been observed. This is not likely to be accompanied by other abnormalities of the heart, and may have no clinical significance. 9. Ectopia cordis is the result usually of fissured sternum and thorax, and is commonly associated with a congenital fissure of the whole anterior body- wall. The heart may also be displaced upward into the neck or downward into the abdominal cavity. Other rare congenital malformations of the heart are found in acardia, ill-developed heart, double heart, bifid apex, and absence of the pericardium. Symptoms. — The symptoms of all congenital heart defects have a certain general resemblance, as has been noted in their description under the appro- priate divisions. Cyanosis is common, more or less, to them all. Indeed this term was long regarded as practically synonymous with congenital anomalies of the heart, but in the writer’s experience the following conditions, arranged in the order of their frequency, have all been responsible for it : Pneumonia (often syphilitic); premature birth ; asphyxia; atelectasis; degeneration of the blood ; malformation of heart and blood-vessels ; interference with the nerves of respiration ; malformations of respiratory tract ; congenital pleurisy, and partial occlusion of the trachea. Treatment. — The treatment of congenital heart defects comprises hygienic management, protection from cold and physical exertion, and the administration of the heart tonics to tide over attacks of threatened cardiac failure and to help the development of a compensatory hypertrophy. Medicinal treatment alone, however, is of little avail, except to meet temporary indications. If compen- satory hypertrophy is not soon established to a satisfactory degree, the nrospect of life is bad. ORGANIC DISEASES OF THE HEART. Bv FLOYD M. CRANDALL, M. D., New York. Diseases of the Heart during childhood present, in their general out- lines, conditions very similar to those seen in the adult. In their details many and important difl'erences occur. In the following pages these differences receive the chief attention, it being taken for granted that the reader is con- versant with the diseases of the adult heart and their methods of detection. The following peculiarities are observed in the normal heart: I. The apex lies higher in the chest and more to the left than in the adult, being outside the nipple line. II. The apex-beat in the infant is usually difficult of detection; in the child it is more clearly visible, and can be detected by touch more readily than in the adult. III. The area of dulness is comparatively large, so that the normal heart may, without caution, be considered hypertro))hied. IV. Murmurs are heai’d over a comparatively wide area, being frequently audible over the entire chest. y. The rate may be increased and the rhythm disturbed by slight causes, so that rapidity and irregularity are of but little importance. AH. In rachitic children, owing to deformity of the chest, the apex may appear in an abnormal position. VII. Prominence of the pmecordia is sometimes marked. Cardiac disease during early life is also modified by the fact that the heart is undergoing numerous changes in growth and develojnnent. These are not constant, but occur chiefly at certain periods. The relative weight of the heart is greatest at birth, the right side predominating slightly over the left. During the first seven years there is an increase in volume of about 80 per cent. Between seven and fourteen the increase in actual volume is barely 10 per cent. There is then a very ra|)id increase of almost 100 per cent. These changes necessarily modify to a marked degree any diseased condition which may be present, and are of especial importance as regards prognosis and treatment. I. Pericarditis. Inflammation of the pericardium during childhood jiresents but few jiecu- liarities pathologically. At this period of life inilanimation of the serous mem- branes is more frequently marked by efl’iision than in the adult, and the peri- cardium Jiresents no excejition to the rule. Fluid forms with great rapidity, and is jirone to lie jmrulent. Endocarditis is a common acconqianimeiit of pericarditis, and the walls of the heart are always more or less weakened. Not infrequently jiericardium, endocardium, and muscle are all involved. Sturges, in extensive jiost-mortem observations, invariably found acute rheumatic endo- 974 DISEASES OF THE HEART. 1(75 carditis accompanied by more or less pericardial inflammation or adhesion, and believes that endopericarditis is the most common cardiac affection of early life. It is (juite possible, however, that conditions present in cases so grave as to permit of post-mortem observation may not be as frequently {)resent in the less serious cases which survive. Etiology. — Pericarditis is seldom a primary affection. It may result from injury or the extension of inflammation from a neighboring organ, but more commonly occurs in the course of rheumatism or one of the infectious diseases. While rheumatism causes by far the greater number of cases, rheumatic peri- carditis is not as common proportionately as in adult life. Scarlet fever, empyema, and pneumonia are frequent etiological factors. In young infants purulent pericarditis sometimes occurs as a result of septicmmic conditions at the umbilicus. Rheumatic pericarditis develops early, and sometimes precedes the articular symptoms. In scarlet fever the pericai’dial inflammation com- monly develops during the second or third week. Symptoms. — The subjective symptoms of pericarditis are usually obscure, and vary with the different stages of the disease. The early stage is frequently insidious and passes unrecognized. The most frequent symptoms are pain and palpitation. Pain may be confined to the praecoi’dial region, or may be reflected into the shoulder or referred to the region of the stomach. It varies in inten- sity from a simple uneasiness to a sharp, lancinating pain. The patient some- times assumes a characteristic position, with the head elevated and the body thrown somewhat toward the left. The trunk is held rigidly quiet, while the legs are moved freely. The pulse is full, and there may be slight fever and a hacking cough. When effu.sion occurs the pain gives place to a sense of oppre.ssion. Res- piration becomes labored, and the countenance assumes an anxious expression or a look of actual suffering. The face is livid or ashy pale. Dyspnoea is marked when the head is lowered. The pulse is weak, irregular, and inter- mitting. In fatal cases, as the effusion increases, attacks of syncope occur, hiccough develops, and delirium appears, followed by coma and death. In less severe cases prgecordial heaviness and dyspnoea may be the only symptoms. Physical Signs. — In the early stages the heart’s action is usually forcible, but irritable, and often irregular. Percussion shows nothing except, perhaps, tenderness. A friction-sound is heard upon auscultation, the point of greatest intensity being, as a rule, under the fourth rib, just at the left of the sternum. This point varies with the position of the patient and with full inspiration. The sound is superficial, and has but a slight area of diffusion. It is fre(piently double, and usually creaking or rubbing in character, but may be crackling or even blowing. It sometimes so closely simulates the mitral regurgitant mur- mur as to be indistinguishable from it. Friction-sounds are more frequently absent in children than in adults, and rarely, when present, remain more than one or two days. The early detection of pericarditis in children is often one of the most difficult problems in the domain of physical diagnosis. In the stage of effusion the difficulties in diagnosis are but slightly dimin- ished. Owing to the thinness and yielding character of the chest-wall both the apex-beat and the normal heart-sounds may be readily detected when con- siderable fluid is present. In some instances the pulse is full and fairly strong, while the apex-beat is feeble or imperceptible. Occasionally an undulating impulse may be felt under the palm when the actual point of impact cannot be determined. Prominence of the pnecordia is sometimes extreme. The area of percussion dulness is enlarged, but it is impossible to make definite state- ments as to its exact shape and extent. It is modified by the shape of the 970 AMERICAN TEXT-BOOK OF DIREARE8 OF CHILDREN. chest, by pleuritic adhesions, and by pulmonary consolidation. If no adhesion or other lesion be present, the area of dulness assumes a somewhat pyramidal shape, being broad laterally at the lower portion and extending well up to the first rib. There is danger of mistaking an extremely dilated heart with feeble im])ulse for a pericardial effusion. Ilotch, who has made a most careful series of observations upon the subject, calls attention to the fifth right interspace as a region of great importance in deciding between these two conditions. While with a dilated heart partial dulness may extend to the right of the sternum in the second or third interspace, it rarely appears in the fifth, and absolute dul- ness never. Even a small amount of effusion, on the other hand, finds its way into the fifth interspace, causing absolute dulness. Upon the left of the sternum the area of dulness in the two conditions is almost identical. In the late stages, when recovery takes place, there are no physical signs by which pericardial adhesions may be positively detected. Intermittent or disturbed cardiac action following a pericarditis without evidence of an endo- cardial lesion offers strong presumption that such adhesions exist. According to Sturges, a rubbing exocardial sound does not preclude the possibility of pericardial adhesion. Prognosis. — In infancy pericarditis is a serious and usually fatal disease. During childhood the tendency is to recovery. Not infre(iuently the course is ra|)id, complete resolution taking place within ten days. In other cases, while ultimate recovery is complete, it is long delayed. In still others adhesions remain which seriously cripple the heart. When the formation of fluid is rapid, embarrassment of the heart’s action becomes alarming and sudden death may occur. Myocarditis is a frequent and serious source of danger. The longer the effusion is present the greater this danger becomes. The dilatation resulting from myocarditis is sometimes extreme, but if the child is in fair general condition hypertrophy follows, and is usually fully compensatory. Treatment. — Any constitutional condition to which pericarditis may be secondary should be brought under control as (juickly as possible. Pain and cardiac irritability should be at once relieved. For this purpose opium stands without a rival, and is the most important agent in the treatment of pericarditis. Sufficient should be given to relieve ])ain and maintain a mild continuous effect through the early stages. Though it may be administered more freely than in endocarditis, the condition of narcotism should never be induced. Stimulants are indicated when the pulse becomes feeble and weak. In attacks of syncope (|uickly-acting stimulants like lloff’man’s anodyne are demanded. Digitalis aids materially in maintaining the integrity of the heart-muscle, and in most cases is a drug of much value. Occasionally, when there are extensive adhesions, it causes palpitation and increased irregularity, and must be discon- tinued. Locally, poultices or large hot anodyne a|)plications are preferable to the ice-water coil. Blisters should never be employed. Absorption is sometimes hastened by mercurial ointment ajqilied upon llannel over the pnveordia. Nutrition should be maintained at the highest jiossible point, but over- loading of the stomach must be carefully guarded against. After the acute stages tonics are usually indicated, for pericarditis is eminently a disease of the weak, amcmic, and feeble. Absolute rest cannot be too strongly insisted upon. Care in this direction should not be relaxed while the slightest evidence ol impaired canliac action remains. In no other condition is weakening of the heart-muscle so corumon. Weeks, oi’ even months, must sometimes elaj)se before active exerci.se can be safely i)ormitted. When the amount of fluid becomes so great as to seriously threaten lite. DISEASES OF THE HE ART. 977 paracentesis is demanded. Death, however, very rarely results from pressure. Urgent symptoms are often transient, and (lisaj)pear without mechanical inter- ference. Much has been said regarding the harmlessness of the operation, hut it is not without serious dangers. It should be resorted to, howevex’, when the fluid is found to be pui-ulent or so excessive in (piantity as to endanger life. Dieulafoy’s or Potain’s aspirator should be employed with a Fitch needle, which has a protector to be pushed over the point after it is introduced, thus avoiding the danger of punctui'ing the heart-wall. The fluid should be com- pletely removed. The fifth intercostal space, just to the left of the sternum, is the point usually advised as the seat of puncture. Rotch, howevei', pi’opo.ses the fifth intercostal space of the right side as preferable, since it would here be impossible to puncture a dilated heart — an accident which might occur on the left side. n. Acute Endocarditis. Inflammation of the endocardium is a frequent disease of early life. During foetal life the right side of the heart is usually involved, after birth the left side. During childhood the sei’ous membranes are especially sensitive, and there is a mai'ked tendency in the connective tissue to cell-pi’oliferation. Morbid changes are chiefly confined to the valves and chordae tendineae, but in some instances the whole endocai’dium is implicated. As a rule, the fibi’ous structure of the valves beax's the brunt of the attack. The valves ax’e simply folds of serous membrane bound together by fibx-ous tissue. Inflammation is attended by px’olifex’ation of cells within the endocardium, pushing it up into papillax’y elevations, and also by px’olifex’ation of the fibx’ous tissue itself. This latter clxange is the xnost characteristic and important process in endocardial inflammation. The whole valve becomes thickened and stiff, and the chordae tendineae are affected in a similar manner. Nodules are most numex’ous along the edges of the valves, whex'e they form x’ows of x’eddish semi-translucent beads. As they lie directly in the blood-curx’ent, fibrin is gradually deposited, forming the so-called vegetations. They may become so lax'ge as to cause serious mechanical interference with valvular action, or poxTions may be detached and swept into the circulation. Even when these vegetations are quite numerous they may undergo x’esolution and disappear, but when marked hyperplasia of connective tissue has occurred, the almo.st inevitable result is contraction, with consequent puckei’ing, thickening, and distortion of the valves, shox’tening of the chordae, or narrowing of the valvular openings. Etiology. — Sex cannot properly be called an etiological factor of endo- carditis, although twice as many gilds suffer from heart disease as boys. A boy who has rheumatism is as liable to a cardiac complication as a girl, but girls are more subject to rheumatism than boys. Of my own cases, 38 per cent, were boys, 62 per cent, girls, the px-epondex’ance of girls being greatest under eight years. Age is a mox’e important factor. Endocarditis occurs in infancy, and even in intra-uterine life, but it is rare under five years. It is probably more com- mon during the three years between eight and eleven than at any other similar period of life. Rheumatism is by far the most important exciting cause of endocardial inflammation, but in children that disea.se is so uncertain in its manifestations that it is readily overlooked. In the majority of cases it appears in a form which in the adult would be designated as subacute. But the mildest and most transient attacks are not infrequently accompanied by inflammation of 62 J)78 AMEIUCAN TEXT-BOOK OF DISEASE, H OF CHILDREN. the endocardium, which would be overlooked without physical examination. No attack of joint-pain in a child is too mild to preclude the possibility of an accompanying endocarditis. I have seen it develop during the course of torti- collis in a child of rheumatic parentage. Among 117 cases of cardiac disea.se, I found rheumatism, either antecedent, concui’rent, or subsequent, in 82 per cent. A definite family history of rheumatism was obtained in 57 per cent., excluding grandparents. Attention has been directed to the importance of subcutaneous fibrous nodules in the diagnosis of rheumatism, and it is believed that similar nodules form at the same time on the cardiac valves. While they are strongly suggestive of endocarditis, they give no jjositive evidence of that condition. I have seen a profuse crop of nodules develop without the slightest evidence of cardiac disturbance. While the intimate association of chorea and heart disease is well known, the exact etiological relationship is still uncertain. Occasionally endocarditis developing during a choreic attack di.sappears as the chorea subsides ; more commonly it leaves a permanent lesion. In the great majority of eases the murmur is not functional, but organic, and is due to well-defined })athological changes in the valves. Thirty per cent, of my cases of cardiac disease suf- fered at some period of their lives from chorea, but 24 per cent, gave also a clear history of rheumatism. Although in the remaining eases no positive history of rheumatism could be obtained, there is ground for belief that the endocarditis of chorea is, in fact, rheumatic. Scarlet fever is occasionally coni])licated by endocarditis. In rare instances it appears early in the disease, but more commonly develops during the stage of des(|uamation. It usually appears in patients showing evidence of nephritis, and is probably due more to urmmia than to the poison of scarla- tina. Diphtheria, measles, erysipelas, and septiemmia are occasionally com- plicated by inflammation of the endocardium. Symptoms. — Endocarditis is a very obscure disease. The symptoms are few in number and occur in no flxed order. They may be wholly wanting, and the disease may run its course without presenting any apjtreciable syni])tom. The .symptoms of the acute disorder during which it develops often mask or wholly obscure those of the cardiac coni])lication. When accompanying a rheumatic attack there is fre((uently an increase in temperature, or slight fever appears if none has previously been pre.sent. The cliild seems more ill than the arthritis would account for. There may be a jieculiar restless, anxious expression, with a tendency to cyanosis. The heart’s action is disturbed and the pulse becomes very rapid The symptoms depend largely upon the amount of myocarditis present. If the muscular ti.ssue is much involved, palpitation, priecordial distre.ss, cyanosis, and dy.spncca will be marked. In milder and more common cases none of tliese .symptoms are present to draw attention to the heart. Amcmia is a very constant accompaniment of endocardial inflam- mation, and develops rapidly. The ajipearance of subcutaneous fibrous nodules should always lead to a jihysical examination of the heart. The tendency to recurrence is a marked filature of endocarditis. An endo- cardium that has once been inflamed is far more sensitive thereafter to irritating blood-conditions. Fresh attacks are readily lighted up by slight causes. The occurrence of an emboli.sm first directs attention to the heart in some cases. The spleen is the organ most freijuently afl’ected. The most distinctive .symptoms result from embolism of the brain, the middle cerebral artery of the left sifle being commonly the seat of lesion, with resulting hemijilegia and aphasia. Embolic pneumonia occurs in the child as in the adult. Physical Signs. — The signs obtained by jihysical examination arc the DISEASES OF THE HEART. 979 only means of positive diagnosis. An endocarditis may, in rare instances, be present for several days, or even run its course, without developing a murmur. Occasionally abnormal sounds, as roughness, muffling, or prolongation of the first sound, precede an actual murmur. In most cases the murmur is heard only at the apex. It is systolic, soft, and blowing, differing from the ordinary mitral regurgitant in its limited area of conduction. It is more intense at the apex, hut it is not transmitted far to the right, and is rarely audible behind. It usually appears early in an attack of rheumati.sm, and is organic. It some- times disappears, leaving no valvular lesion. A similar murmur occasionally appears late in the course of typhoid fever, and is probably due to muscular insufficiency the result of anmmia or myocarditis. The murmur of scarlatina, chorea, and rheumatism is usually entirely different in character. Other sounds are heard at the apex much more frequently in children than in adults. Of these reduplication of tlie second sound is most important. Reduplication of the second sound at the base is frequently heard in Bright’s disease of the adult, but as heard at the apex in children it is probably due to asynchronous action of the mitral and tricuspid valves, the re.sult of stiffening of the mitral. It is almost a certain forerunner of a mitral obstructive mur- mur. Sometimes a soft blowing murmur is heard immediately after the second portion of the double sound. This gradually increases in length and intensity, and develops the well-known rumbling murmur of mitral stenosis. In very rare instances an aortic murmur develops early in endocardial intlammation, either alone or in connection with a mitral murmur. The same is also true of tricuspid regurgitation. When acute endocarditis is engrafted upon an old valvular lesion, its diag- nosis is especially difficult. If the patient has been under observation and the character of the murmurs is known, diagnosis is easy. Marked enlargement of the heart is strong proof of an old lesion. Extreme subjective symptoms of cardiac disease, especially oedema, are rarely seen in primary endocarditis, but in chronic heart disease the symptoms are all aggravated by a fresh endo- cardial attack. The character of the murmur may furnish some aid in diag- nosis, but cannot be relied upon. A soft blowing murmur is usually recent ; if harsh, musical, or rough, it is probably old. Prognosis. — As endocarditis is not an idiopathic disease, the prognosis depends largely upon the condition with which it is associated. A first attack is rarely the direct cause of death. It is extremely variable in its course. It may pass away, leaving no lesion or murmur, but more frequently a valvular lesion is left behind. If the pulse becomes feeble, and the child loses strength and grows rapidly anaemic, the prognosis is bad. It is bad if recurring attacks of rheumatism appear or if fibrous nodules recur in successive crops. Endo- carditis appearing during the course of a septic disease is usually ulcerative in character, and the prognosis is extremely unfavorable. Early involvement of the aortic valves is also unfavorable. It is not wise to give a too favorable prognosis at first, especially as to duration, for exposure or lack of rest will materially prolong an attack. Duration is more uncertain in children than in adults. Loudness of the murmur is of but little importance, but the greater the number of murmurs the more serious is the condition. The murmur appearing during chorea occasionally disappears as the choreic movements sub- side. This is sometimes apparent rather than real. After a time a murmur which has almost disappeared may return and continue permanently — a result that is probably due to the lighting up of a fresh valvulitis, conse(|uent upon the occurrence of a mild rheumatic or choreic attack. On the whole, the ulti- mate prognosis is rather better in children than in adults. Tissue-growth is so 980 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN rapid and compensation becomes so com{)lete that an endocarditis of not excessive severity may produce but little permanent injury. Treatment. — The constitutional disease with which endocarditis is asso- ciated should receive prompt attention. In the treatment of rheumatism it is not sufficient to direct our efforts simply to the control of the arthritis and relief of pain. The possibility of endocarditis must also be considered. The ideal treatment is that which controls the arthritis, reduces fever, relieves the pain, and, above all, prevents cardiac complications. In my experience the ordinary treatment with salicylate of sodium has not fulfilled these requirements, for it has not perceptibly removed the danger of endocardial inflammation. A patient fully under the influence of the salicylate will not infrequently develop a cardiac murmur — an accident which occurs much less fre(juently under the alkaline treatment. In view of the great susceptibility of the endocardium in childhood a judicious combination of the salicylates and alkalies offers the safest and most efficient treatment. If endocarditis develops, the salicylate should be dropped or administered with the utmost caution. Treatment for the purpose of affecting the endocardium directly is of but little avail, yet much may be accomplished by drugs. It is important that the ra[)idity and irritability of the heart be lessened, and that a condition of cardiac rest be attained as far as possible. Aconite lessens the rapidity, but it also weakens the force, and with children is an unsafe drug. Digitalis must be used cautiously. In acute endocarditis developing in an old cardiac case it is often of supreme value. When the heart’s action is tumultuous, but rapid and Aveak, it may be given with the most satisfactory results, as it reduces the frecjuency, increases the force, and corrects the irregularity. A child of six years may take four drops of the tincture every four hours for one or two days, when the dose should be diminished. Opium is also of great value in rheu- matic endocarditis. It not only relieves the articular pain, thus rendering general bodily (juiet possible, but it has a most hapj)y effect in steadying and (juieting an irritable, irregular, and rapid heart. Tavo minims or more of the deodorized tincture may be given every four to six hours at six years. When pericarditis is also present opium is the sheet-anchor. Stimulants should-be avoided until definitely indicated. When dilatation is marked they are de- manded, and must be administered freely. When the fever has abated a tonic is indicated, for amemia appears early, and is freiiuently persistent and extreme. Citrate of iron and quinine is admirably adapted to these cases, and may be given in doses of three to four grains three times a day. The bitter wine of iron is also an excellent jirejiaration. One or tAvo drops of FoAvler’s solution may be added, but full doses of arsenic are inadvisable. When the fever ranges high during the acute stages, quinine may be given in moderate do.ses, but antipyrine and acetanilide are too depressing to be employed Avith safety. Phenacetin is, pcrhajis, admissible. Administered in small doses it is an excellent analgesic. Absolute rest and jirotection of the surface from cold and dampness are of far more importance than medicinal treatment. Without these precautions treatment is of little avail in preventing permanent valvular lesions. The child should Avear a flannel jacket or night-dress, and be ])laced betAvecn flan- nel blankets instead of the usual sheets. Even in mild cases of acute endo- carditis strict rest should be enjoined and insisted upon long after every rheu- matic and cardiac symptom has di.sapj)eareon exertion are almost constant. Both syni{)toras are more continuous, and depend less upon exertion than in the case of mitral disease. Aiuemia is very common; it is persistent and often extreme. Physical signs differ but little from those observed in the adult. Aortic Reguroitation. — This is the most infreciuent left-side valvidar lesion. It rarely, if ever, occurs alone in childhood, and in hut one instance have I heard a double aortic murmur without an accompanying mitral. The symptoms are somewhat more marked than those of simple aortic stenosis, for it appears only after extensive endocardial inffammation, and is an additional burden to an already disabled heart. Tricuspid Regurgitation. — This condition is more frequently detected by the pathologist than by the clinician, because in the young it is extremely difficult of differentiation from mitral regurgitation. In early infancy a mur- mur heard with greatest intensity at or just to the right of the apex is pre- sumably tricuspid. If the lesion is serious, right-side enlargement Avill be present, which may be detected by an area of dulness at the right of the sternum and by epigastric pulsation. When added to mitral and aortic disease the symptoms are distinctive. Visceral enlargements and dyspepsia are invariably present, but jugular pulsation is not constant. Palpitation, dyspnoea, cough, pain, cyanosis, and oedema develop to form the last stage of a fatal malady. Prognosis. — The elements of prognosis are numerous and complicated. Murmurs alone usually furnish insufficient evidence upon which to base an opinion. The action of the heart, the condition of liypertrophy or dilata- tion, the completeness of compensation, and the general physical condition of the patient must all be taken into account. The social condition, surround- ings, and mode of life are important factors and must be duly considered. Parental discipline is also an element of great importance. In a Avayward and uncontrolled child the prognosis is decidedly Avorse than in one under firm and judicious disci])line. On the Avhole, the prognosis may be said to be better in the child than in the adult. The period from ten to fifteen years is a critical one. The remarkable increase in the volume of the heart at the time of puberty has already been re- ferred to. A patient sometimes progresses satisfactorily till this age is reached, Avhen the Avhole aspect of the case is changed. Compensation becomes imper- fect, the child grows anmmic, and gives evidence of impaired nutrition. Devel- opment is retarded, though there may be groAvth in height, the child being thin and Avithout strength or vigor. Sometimes he develops into a fairly healthy youth, but in other cases, going from bad to Avorse, finally succumbs. For- tunately, the majority of patients pass safely through this trying period, often without perceptible inconvenience. Such children, if a mitral regurgitation only is present, usually develop into healthy men and Avomen and never show symptoms of cardiac disease. The etiology aids somewhat in prognosis. The more distinctly rheumatic the patient, the Avorse the prognosis, for recurring attacks of endocarditis are to be feared. Failure of compensation resulting from an attack of rheumatism or scarlet fever is of far greater importance than that developing from muscular strain, amemia, over-study, or nervous excitability. Among symptoms cya- nosis and oedema are of the most serious import. If mitral regurgitation alone is present and the child is strong and Avell- nourished, the probability of maintaining compensation is good, provided recurring attacks of endocarditis can be jirevented. The prognosis turns almost entirely upon this last contingency, and this, in turn, depends in large measure upon the personal and family history as regards rheumatism. Hence J)84 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. the history is a matter of decided importance in prognosis. Mitral stenosis is always a grave condition, but is somewhat less serious in young children than in adults, largely because the pulmonary arteries adapt themselves more readily to the abnormal strain placed uj)on them. Compensation sometimes becomes perfect, and remains so, but when the lesion is extreme, it does not admit of com])lete and permanent compensation. When pulmonary symptoms are marked the prognosis is especially bad. In aortic disease, if obstruction alone is pres- ent, without rheumatic history, the prognosis is very favorable. The murmur may entirely disappear. If, on the other hand, it is associated Avith a mitral murmur and a rheumatic history is obtained, the case is a grave one : the dis- ease is the result of an extensive endocarditis, Avhich will probably recur to cause more and more distortion of the valves. Aortic regurgitation is a far o O more serious condition than aortic stenosis, and when both murmurs accompany a mitral the prognosis must be very guarded. Tricuspid regurgitation is always a serious condition, and the prognosis is unfavorable. Treatment. — The successful management of cardiac disease requires, on the part of the physician, a clear conception of its various stages and an under- standing of the exact condition of his patient. If the compensation is perfect, there will be no symptoms of heart disease and nothing to treat. All that can be accomplished in any case not suffering from acute inflammation is to estab- lish compensation. If that is already accomjdished, it is the height of impro- priety to treat the patient for heart disease. The error must not be made upon the other extreme, however, that the physician has no duty in the case. The child should be kept under observation, for the condition of compensation may be at any time changed to that of heart failure. Nutrition should be main- tained at the highest possible point by diet and properly regulated outdoor exercise. The child should be especially guarded against exposui’e to the exanthematous diseases, and, above all else, should be protected from conditions which tend to precipitate an attack of rheumatism. If that disease does de- velop, it should receive prompt and vigorous treatment. Anaemia is a condition full of peril in heart disease, for Avhen it is extreme compensation is not long maintained. It should be combated by iron, arsenic, cod-liver oil, the vege- table bitters, and a generous but simple and digestible diet. The question of exercise is one of the greatest importance. ATolent games may do irreparable harm, while, on the other hand, if the child be debarred from reasonable out- door exercise, heart flxilure may develop from anaiinia and impaired general nutrition. Quiet games and ))lays are to be definitely prescribed, Avith the strictest injunction against football, baseball, and all games requiring violent muscular exertion and running. The clothing should also receive the jihysician’s attention, flannels being prescribed for both summer and Avinter. If failure of compensation ajipears, absolute rest should be rigidly enforced. The cause should be sought and removed if possilile. fl'he ajipetite usually disajipears utterly, and the stomach becomes irritable and enforced alimentation is necessary. If the stomach rejects milk and limc-Avater, animal broths, or koumyss, it may retain milk ))eptonized for tAvo hours, to Avhich a little lemon- juice )iiay be added. If this is rejected, nutritive enemata of completely ))0])- tonized milk must be given every four to six hours. Aledical treatment Avill prove of little avail if the child is permitted to lose strength from lack of nourishment. Among drugs digitalis still holds its })Osition as first and most important, but it )niist be employed judiciously. Much harm may result from lack of judg- ment and nice discrimination in the use of the cardiac stimulants and sedatives, lly increasing the force of the systole, prolonging the diastole, and contracting DISEASES OF THE HEART. 985 relaxed arterioles digitalis restores the balance of the circulation when deranged by valvular lesions or weaknessof the heart-muscle; in other words, it re-establishes compensation. Its use is indicated when the heart’s action is rapid, feeble, and irregular and the pulse shows low arterial tension. Rational symptoms offer more reliable indications for its use than do the physical signs, but both should be duly considered. Dys])noea, cough, cyanosis, oedema, and scanty urine are indicative of failing heart-power, and call for a cardiac stimulant. Mitral regurgitation is the valvular lesion for which digitalis proves most generally useful. With mitral stenosis irregular heart action is sometimes aggravated by its use. In that case convallaria may prove efficient. When an aortic murmur is present digitalis is not so frequently efficacious as in mitral disease alone. If compensation is good, its use may cause alarming symptoms, and in any case it should be prescribed cautiously at first. Iron, strychnine, and the alkalies are, as a rule, more efficacious. In tricuspid regurgitation digitalis must be used with exti'eme caution. The tincture is the preparation most commonly employed, the dose varying according to the age and cardiac condition from one to five or six minims. It is often very badly tolei’ated by the stomach. The solid prep- arations cause far less gastric disturbance, and may be usually continued for weeks without trouble. The dose of the pow'dered leaves is from one-fourth grain to one-half grain, and of the extract one-fourth of these amounts. In case of great restlessne.ss on the part of the child, with palpitation and cardiac distress, a sedative may be required. Bromide of sodium should be first tried in doses of three to ten grains every six hours. If this be unavail- ing, opium may be cautiously administered, paregoric being selected for younger children, and the deodorized tinctui’e for those of more advanced years. Exces- sive palpitation, with dyspnoea appearing in paroxysms, is often quickly relieved by a few drops of compound spirits of ether combined with a small dose of opium. If the urine becomes scanty and oedema appears, a hot digitalis poultice should be applied across the loins. This is made by boiling two ounces of digitalis leaves in a pint of water, and then stirring in sufficient linseed meal. Digitalis should be administered freely, and in this condition the infusion is most effectual. At the same time the bowels should be freely acted upon by calomel. The compound diuretic pill for children who can swallow' it often relieves the symptoms with marvellous rapidity. It consists of equal parts of calomel, digitalis, and squill ; one-third to one-half grain of each may be given at twelve years. For younger children the tincture of digitalis and tincture of squill may be combined with spirit of nitrous ether or citrate of potas- sium. THE FUNCTIONAL AFFECTIONS OF THE HEAHT (THE CARDIAC NEUROSES). By J. C. WILSON, M. D., Philadelphia. The functional affections of the heart include those motor and sensoi'y derangements which occur in the absence of demonstrable anatomical changes in the organ. The qualifying adjective “functional” is used in its ordinary sen.se, to denote the absence of anatomical lesions demonstrable during life or after death. It is appropriately em])loyed in this connection to designate disorders not primarily of the heart itself, but rather of its innervation. Hence these affections are also properly spoken of as cardiac neuroses. It is imjiortant to note that all the morbid phenomena observed in func- tional disorders may and frequently do attend the structural diseases of the heart. The functional affections of the heart which occur in childhood are — A. Motor: 1. Derangements of rhythm. a. Arrhythmia. h. Rapid heart — tachycardia. c. Slow heart — bradycardia (brachycardia). 2. Momentary arrest — syncope. B. Sensory: Subjective sensations referred to the proecordia. a. Heart-consciousness. b. Distress. c. Pain. C. Motor and Sensory combined: Palpitation. Etiology. — The influences which predispose to affections of the heart are the same in childhood as in adult life. They consist in («) a weak and delicate organization associated with an impressionahle nervous system ; {h) aniemic conditions ; (c) lithaeinia and allied derangements of metabolism and excretion ; and {(1) morbid conditions directly affecting the nervous system, as organic diseases of the brain and cord, chorea, e[>ile})sy, and the acute and chronic infections. To this list must be added adenoid hypertrophies of the pharyn- geal vault. Certain of these conditions are inherited, others acquired. Thus the chil- dren of nervous or insane parents, those begotten of elderly persons, those born prematurely, those who have in infancy been exposed to privation and neglect, or who have suffered from serious or j)rotractcd disease, are esjiecially prone to functional disturbances of the heart. To a less extent is this true of the !»8fi FUNCTIONAL AFFECTIONS OF THE HEART. 987 children of gouty families and of the offspring of tuberculous and syphilitic parents. The tendency to functional cardiac trouble, rarely observed in early infancy, usually shows itself at the aj)proach of the seventh or eighth year. The exciting causes include (A) those acting upon the nervous system ; (a) directly, as intense mental emotion, fever, anger, passionate grief; or (Z») reflexly, as dentition, gastro-intestinal irritation from indigestion, intestinal worms, foreign bodies in the intestinal canal ; and (B) those acting, by means of mechanical disturbance of the circulation, upon the heart, as violent exer- cise or exertion, especially after meals. Functional derangements of the heart are much less frequent in childhood than in adult life, for the reason that the Pandora’s box of vicious habits, the brunt of which the heart must sooner or later bear, is only opened by degrees, and, happily, not often early in life. Symptoms. — In genei’al terms the symptoms of the functional disorders of the heart in childhood, as in adults, consist in derangement of the motor functions and abnormal sensations referred to the praecordia. These motor and sensory derangements are not always associated. More commonly the move- ment of the heart is deranged, its action being accelerated, retarded, or irregu- lar, without abnormal sensations ; occasionally deranged rhythm of frequency occurs in connection with praecordial distress or pain or a sense of oppression, and in comparatively rare instances prmcordial pain occurs in the absence of perturbation of the movements. Angina pectoris is not a disease of childhood, nor is it common to encounter the agonizing pains of pseudo-angina early in life. When the functional disorder is paroxysmal or of a high grade of intensity, it is usually accompanied by increased frequency and shallowness of respira- tion, and very often by pallor of the face and slight cyanosis. Especially is pallor associated with the temporary arrest of the heart’s action known as fainting, a condition also usually preceded by momentary nausea. The child, ignorant alike of the existence of his heart and of its functions, uncomfortable as he may be in other respects, escapes the anxiety and mental distress which in the adult forms so important an element in the paroxysmal functional aft'ections of this organ. When the derangement is not paroxysmal, but persistent, the rhythm of the respiration is not usually disturbed. It is to be borne in mind that in childhood both the respiration and the action of the heart are normally far less constant in rhythm than in adults, that they are more readily deranged by slight causes, and that the action of the heart is often irregular during sleep and much influenced by inspiration and expiration. The pulsus paradoxus, in which the heart-beats during inspiration are more frequent, but less full, than during expiration, may often be observed in perfectly healthy children during sleep. Physical examination yields a limited number of definite signs. The fre- quency of the lieart’s action and the degree and character of the arrhythmia are recognized upon palpation. By this method of examination we also detect, especially on palpation, the change in the character of the impulse, which is increased in force. We observe also by this means and by inspection that the impulse is extended. We determine by the position of the apex-beat, and may confirm by percussion, the observation that the heart is not enlarged. Upon auscultation the first sound is found to be sharp and valvular and short- ened in duration, while the second sound remains distinct or is accentuated. In very rapidly-acting or very irregular hearts transient murmurs, usually mitral systolic, sometimes develop. 988 AMERICAN TEXT-ROOK OF DISEASES OF CHILDREN. Arrhythmia. — The various forms of arrhythmia are encountered in the functional cardiac affections of childliood. The paradoxical pulse, as has been mentioned, is frequently observed in healthy children during sleep. When encountered during the waking hours it is more frequently a manifestation of organic than functional derangement of the heart. The rhythm of the foetal heart, embryocardia, a condition in which the acoustic properties of the two sounds are almost identical and the pauses nearly equal in duration, frequently occurs when the heart’s action is rapid. Other forms of arrhythmia, as the alternate heart-beat in which strong and weak contractions occur with regular alternation, the bigeminal and trigemi- nal pulsation in which the ventricular contractions occur in series of two or three separated by an interval or by feebler contraction, the gallop rhythm and dicrotism, are rarely observed. The disturbances of rhythm in which with rapid action there is irregularity, not conforming to definite type, are the most common. This condition in its more marked degrees has been described under the term delirium cordis. With less rapidity of action there may be recog- nized, upon physical examination, short series of three or four forcible heart contractions followed by great irregularity and feebleness of action, this succes- sion being irregularly repeated. True intermission or the missing of a car- diac beat — “heart dropping,’’ as it is frequently called, a condition common in adult life — has not come under my observation in childhood. Rapid Heart i^Tachycardia ). — The action of the heart, normally 130 to 140 per minute in the new-born, gradually decreases in frecpiency until the end of the third year, when it ranges about 90. It is readily accelerated by slight causes. Great increase in the rapidity of the heart’s action is encoun- tered in fevers. Rapidity of the heart is also induced by violent emotion and undue exercise. The rapid action thus induced may sometimes persist for hours or days. The paroxysmal tachycardia occasionally encountered in adults does not occur in children. Slow Heart (Bradycardia, Brachycardia ). — This condition is not com- mon in childhood. Slowness of the pulse, the rate falling to 60 or somewhat below it, is, however, occasionally encountered during convalescence from the acute infectious diseases, in acute rheumatism, in disorders of the digestive system, in jaundice, and in anaemia. Slowness of the heart’s action has been observed in post-epileptic coma. Sy'NCOPE occasionally occurs in nervous and inqiressionable children. It may result from sudden shock or intense excitement. On several occasions I have known children of six or seven years of age to faint at the sight of blood. I have .seen a hoy of seven faint at the sight of the denuded spot upon his arm caused by vaccination. A healthy girl eight years old, of shy and timid di.sposition, fainted at the dinner-table upon being suddenly addressed by a person whom .she did not know. For .some hours she remained (juiet ujion the sofa, the pulse-rate not exceeding 60. Actual lo.ss of blood, even wlien slight, ))rofuse diarrhoea, extreme fatigue, and severe pain are capable of ]U’o- diicing syncope in iuqn-essionable children. Heart Consciou.sness is fortunately extremely rare in children. The most tumultuous action of the heart may take place apparently without suh- jective sensations. It occasionally luippens, however, that older children com])lain of the beating of the heart without ])ain under conditions of excite- ment or fatigue ami in the absence of over-action amounting to palpitation. Rrtecordial Dlstress is occaisionally encountered. It is usually rellcx in character and caused by gastro-intestinal irritation. As a nde it is transient. I’UYECORDiAL Pain is rare. A remarkable instance of distressing jira'cordial FUNCTIONAL AFFECTIONS OF THE HEART. 5t89 pain in a lad has come under my notice. The patient was the feebler one of twins, and suffered in various ways from the reflex nervous disturbances due to adenoid vegetations in the pharyngeal vault. Among these were attacks of pain in the region of the heart, unaccompanied by disturbances of rhythm or over-action, and occurring in paroxysms repeated on several successive days. Palpitation may be defined as over-action of the heart with abnor- mal prnecordial sensations. These sensations are always distressing and very freatients have paroxysms only in Avinter. In considering the etiology, it must be remembered that malaria once contracted may give rise to symptoms Avitbout fresh exposure, and may be irregular in its course. On the other band, the reports from the South, Avbere it is common, sboAv malarial bmmaturia only Avben acconi])anied by Avell-marked malarial .symptoms. Some cases of paroxysmal Imematuria have lasted for long periods and have recovered. Paroxysmal brnmaturia may result from physical exercise, being perhaps analogous to the so-called physiological all)uminuria of soldiers after forced marches. Herringbam also mentions mental exercise as a cause, and reports a case Avbere it Avas brought on many times in an adult by Avorry or excitement. Lannois reports the case of a patient Avhose first attack Avas at the age of nine years, and Avbo had not recovered at thirty-tAvo. Paroxysms Avere excited by gymnastics, railroad travelling, light Avork, and es])ccially by long Avalks. They ahvays disappeared Avith rest and light diet. At first there Avas but little blood, and that disappeared the next day. At one time albuminuria persisted a fcAV days. During the height of j)aroxy.sms the microscope shoAved red blood-celks, many leucocytes, ami renal e])ithelium. The ]>eculiarity of this case is its long duration. There Avere no malarial phenomena nor any history of malaria or syphilis, nor had the patient been in the tro])ics. Since childhood he had occasional pain in the side, Avhich led Lannois to suspect some obscure disease of the kidney. Among badly-fed children .scurvy occasionally causes Inemorrhage into the ' 1 am not criticising the dose.s in (jiie.stion : no one has .a riglit to do tliat Avilliout llie experience in malaria that Southern pliy.sicians have. r YURIA—CIIYL UlilA— ANURIA. 995 urine as well as elsewhere. The diagnosis of scorbutic haematuria includes the diagnosis of scorbutus. (See article on Scurvy.) It is conceivable that haeinaturia may occur in natural bleeders, but I cannot find the report of a case within ten years. The treatment of haematuria will be indicated by the exciting causal con- dition. Pyuria. Pus may enter the urine at any point. When it occurs it results from some underlying cause, but it is seldom found in the urine of children, because they seldom have the diseases that cause it. It is said, indeed, that boys may have a non-venereal urethritis from debility. Mild vulvitis and vaginitis from this cause are rather common. Cystitis and pyelitis are vei’y occasional sequelm of several acute diseases. They may be occasioned by the irritation of drugs and of saccharine urine. The presence of calculi is possibly the most frequent cause of this rather uncommon symptom. Ohyluria. Chyluria is especially a disease of certain tropical and subtropical regions, but enough cases of European and North American origin have been reported, particularly in the southern parts of the United States, to prevent our considering it absolutely tropical. As it lasts a long time and does not absolutely disable the patient, it may be imported anywhere. Prout reports a case at eighteen months. Cases are either parasitic, apparently the most common, or non-para- sitic. Hunt reports a tx’aumatic case, probably due to rupture of a lymphatic in the kidney. The urine remained chylous but a short time. At first it smelt of milk, afterward of sour milk. The same and also a putrid odor have been observed in other cases. Parasitic chyluria is due to the presence of a minute parasite, the filaria sanguinis hominis, itself the product of a parent parasite, the filaria Bancrofti. The filaria sanguinis hominis probably estab- lishes a fistula between the lymphatics and the urinary organs. It is found in the blood, but, as a rule, only in the late afternoon and night, though by changing the meal hours it may be found at other times. Although usually a parasite of warm countries, it was found by Weiss in the urine of a child who had never been out of Illinois. Patients are not generally very ill, but chills and abnormally high or low temperatures are reported, and the disturbance to nutrition from prolonged and occasionally profuse haemorrhage leads to debility. Attention is generally first attracted by the presence of chyle, which may merely make the urine turbid or as white as milk. Blood may precede it. The presence of urinary casts is the exception. Elephantiasis may be a complication, and chyle may exude from swellings in various parts of the body. Cases may last continuously for years or may intermit. Suzuki, by limiting diet, and especially by omitting meat and fat, decidedly lessened the chyle in the urine. Grimm found that he could regulate the amount of chyluria by regulating the fiit ingested. In his case there was enough coagulation to cause pain in the bladder, but no renal colic. He therefore concludes that chyle entered the urine between the ureter and the urethra. Sigmund mentions a case in which advantage was taken of a pro- lapsed bladder to see clear urine issuing from the left ureter. Anuria. Complaint is sometimes made that the urine of a little child, generally a baby, is suppressed. This may depend on congenital malformation or an acute 096 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN renal disease, but usually it is a symptom of short duration and no danger. There is often slight fever and a history of imperfect digestion, possibly of difficult dentition. A liberal supply of drinking-water is the only treatment reatients groAv older, Avhen sleep becomes less sound than in early childhood. Beeovery at puberty is more often attributed to some obscure iniluence of maturity on the genitals. In favor of this vieAV it may be said that some Avomen recover at INCONTINENCE OF URINE. 997 the time of their marriage. Whatever the reason, however, many recoveries do occur about the time of puberty. Many patients are debilitated, and debility often, if not the only causal factor, is nevertheless one so powerful that on its removal the child recovers. A large proportion of such patients in my former dispensary service were anaemic, and recovered as soon as given enough iron. These cases were not sufficiently followed up for me to speak as to relapses ; but patients, after long and varied treatment without result, do sometimes get well, and stay well, on proper attention being paid to the general health. Such at- tention does not, of necessity, exclude other treatment. I have notes of the case of a boy treated with belladonna, strychnine, and electricity many times during some years, but with no permanent result, he being always in poor health. When eleven years old, while at the seashore, as badly off as ever and without treatment, he learned to swim, and returned permanently relieved, and with a taste for athletics for which he had been formerly too weak. Whether such incontinence as this is caused simply by a weak sphincter, itself a part of a generally weak system, or whether by a neurotic condition due to anjemia, is a matter upon which one may speculate. Certainly, some of the subjects are neurotic. Possibly both explanations hold good — sometimes one, sometimes the other, and sometimes both together. Nux vomica and its equivalent, strychnine, are often used successfully. They have a good effect on many neurotic people and are general tonics. They are espe- cially indicated Avhen we know the sphincter to be Aveak. This may occur if the child has been compelled to hold its Avater too long, as sometimes happens at school. Cold douches to the perineum are probably local in effect, and the same is true of electricity and massage. Good results are claimed for all of them. Electricity is generally used in the form of faradization, Avith one pole on the lumbar part of the spine and one in the urethra, the vagina, or on the perineum, the sittings lasting a feAv minutes each day or every other day and the current being as strong as the child Avill bear. I object to introducing the electric or any other sound into the child’s urethra or vagina — especially in girls approaching puberty — if it can be avoided, and therefore prefer the peri- neum. This care, perhaps excessive, combined Avitli a possible bad selection of cases, may partly account for my non-success Avith this treatment. Certainly, I in common Avith others have not obtained the good results claimed. Local massage has its advocates. Some good results have been reported, but this method, like all others, has its failures. Sanger massages the sphincter by introducing a probe into the bladder and exercising gentle pressure backAvard and from side to side. The danger of teaching masturbation is, I think, to be considered. There is a class of cases in Avhich the urine is sometimes passed Avith great force, evidently from some other factor than a Aveak sphincter. There are grounds for believing many of them to be hereditary ; many are neurotic. I have met in one family* of three children, one case of somnambulism, tAvo of chorea, and one of nocturnal incontinence, the last ejecting the stream violently by day. Chorea is itself supposed to be a cause. It is assumed that there is want of co-ordination betAveen sphincter and detrusor. In other Avords, such cases are choreic. Such considerations lead to treatment designed to allay irritability of the bladder, by the use of belladonna, potassium bromide, and ergot. Belladonna, originally given by Trousseau in a single night dose, has since been administered in three daily doses. Baruch gave it in the late after- noon and early evening in a series of cases, thus avoiding the probably unneces- sary morning dose, and better graduating that in the evening. This is of 998 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. some importance, as it is often necessary to approach a poisonous dose ; that is, to get some effect on the pupil ; and also because the continued use of this drug is not always innocuous. At least, I believe that I have seen gastric dis- turbance and general malaise result from its prolonged use. It is, however, in many cases the most efficient treatment known, and is perhaps to be preferred where we can make no probable diagnosis of the underlying cause. Relief is sometimes temporary, sometimes permanent. Epilepsy is responsible for a certain number of cases. So is the general disturbance attending the onset of acute disease. Ergot, by lessening conges- tion in the spinal cord, is sometimes of use where there is a very irritable bladder. Children whose mode of life affords frequent opportunity for micturition, make use of it, and thus accustom the bladder to contract when not very full. In such cases a dry bed can sometimes be secured by gradually training the bladder to contain greater amounts, thereby educating the sphincter. This plan must not be carried out too heroically, or a strained instead of a strength- ened sphincter will result. It is said that sleeping on the back, by causing urine to press upon the most sensitive part of the bladder, is an exciting cause, and may be relieved by elevating the foot of the bed. Urine loaded with uric acid, urates, oxalates, or phosphates may cause incon- tinence, as well as an irritable bladder ; hence the urine should always be examined. Albuminuria is said to be a cause. I have met with diabetes in a child, where the real diagnosis would have been overlooked but for the routine examination for sugar in this affection. Possibly the effect of ptomaines on the brain may be to produce incontinence in some children, as it does night-terrors in others. Whatever the explanation, attention to the digestive organs is some- times of great use. The influence of phimosis is exaggerated. I have met with several cases in circumcised Jews, Avhile half of Townsend’s cases wei’e in girls. Fur- thermore, patients have been operated on without relief. Yet phimosis is sometimes a cause. Patients previously carefully treated without result do sometimes get well immediately after circumcision or even after breaking up adhesions between prepuce and glans. Phimosis is merely one of several con- ditions giving rise to reflex incontinence. Among others are a small meatus, rectal polypi and fissures, pin-worms, hardened fmces, and even, in one reported case, a brass button in the nose. Masturbation is said to sometimes result in incontinence. Davenport rej)orts a case, and refers to another, in which malposition of the orifices of the ureters ivas the cause. Among palliatives is avoidance of drinking large quantities of liquid late in the day. This must not be overdone, for a too concentrated urine may be as irritating as one too abundant. Regular habits of life seem of some use. I had opportunity to observe a boy admitted to the hospital on the day that an epidemic of measles l)cgan there. As he had been exjmsed, it was not thought desirable to begin treatment until he had had the disease, lie had regular diet and hours with no excitement. Peforc the incubation period was over the incontinence had ceased, lie did not contract measles, and after a reasonable time of observation was discharged. This symptom, then, arises from the most varied causes and repays careful study of tlie individual. The general health is never to be lost siglit of. Hopes of relief are reasonable, but it is never to be {)romised, and we are not justified in assuming treatment to be successful until after a lung lapse of time. DIABETES MELLITUS, DIABETES INSIPIDUS AND LITHIASIS. By JAMES TYSON, M. D., Philadelphia. I. Diabetes Mellitus. Diabetes Mellitus is a constitutional disease especially characterized by the secretion of an abnormally large amount of urine charged 'with sugar. While in adults there is good ground for admitting at least two forms of dia- betes mellitus, a mild and a severe form, in children I have as yet met only the latter, of which the course is more rapid than in adults. Etiology. — The etiology of diabetes in children is even more obscure than in adults. In both heredity is an acknowledged influence, but Avitli this ex- ception the cause of diabetes in children may be said to be unknown. In adults, Avhile in the majority of cases a sufficient cause is sought in vain, there are certain well-recognized influences, such as prolonged overwork, anxiety, and grief, Avhich favor its causation : these agencies cannot operate in children. The sex-relation of diabetes is reversed in children as compared with adults, it being more common in girls than boys. Morbid Anatomy. — In the matter of morbid anatomy, too, we are unable to And lesions which can be held responsible for the disease. Rather are they the result of it. It is true that recent studies have shown an increasingly close relation between diabetes and pancreatic disease, originally pointed out by Lanceraux a number of years ago. Extirpation of the pancreas, according to Von Mehring, Minkowski, and Lepine, is invariably followed by diabetes if the extirpation is complete; and although De Dominicis, to whom we are indebted for the original experiment, and De Renzi and E. Reale deny this, it is still true that this operation is followed by glycosuria in a vast majority of cases, while every year furnishes autopsies in Avhich pancreatic lesions are far more common than any other. At the same time, typical cases of diabetes are con- stantly occurring in which there is no pancreatic disease. Among anatomical lesions — in addition to those of the pancreas — which are found in connection Avith diabetes, may be mentioned enlargement and hardening of the liver, cirrhosis, dilatation of its capillaries, amyloid changes in its cells ; hyperaemia, and even .slight grades of parenchymatous inflamma- tion, of the kidney ; tuberculous foci and cheesy degeneration of the lungs ; and a variety of lesions of the nervous system, especially in the neighborhood of the medulla oblongata, among Avhich tumors and traumatic lesions are the most common. Symptoms. — In children, as in adults, a frequent desire to pass water, with increase in quantity, intense thirst, and sometimes great appetite, are the symptoms which commonly first attract attention. Examination of the urine discovers the presence of grape-sugar or glucose, and a specific gravity 999 \(m AMERICAN TEXT- BOOK OF DISEASED OF CHILDREN. usualljj higher than normal, 1030 and upward, although a lower specific gravity does not preclude the presence of sugar in considerable amount. Rapid emaciation, shrinking and dryne.ss of the tissues, and constipation are early associated. If we add the peevishness and restlessness which grow out of these conditions, and occasional intense itching of the genitalia, we include most of the symptoms which occur in children. The neuralgic pains and rheumatic coni])lications, the lung involvement so often seen in adults, are not com- monly ])resent in children. Cataract I have met in a single case, a boy of si.xteen. It was double. The state of the urine, which contains sugar and is increased, varies as it does in the adult. In a little girl four and one-third years old, under my care for some time, whose case may be considered a fair examj)le, the quantity ranged from 65 to 200 ounces (1950 to 6000 cc.) in the twenty-four hours, and the proportion of sugar from 13 to 34 grains to the ounce (3 to 7.5 per cent.), the specific gravity 1018 to 1040. Toward the close of the disease diacetic acid and aceton are found in the urine, and death by diabetic coma is not unusual. Concurrent with the diaceturia and acetonuria are a diacetaemia and acetonaemia. Albuminuria occurs in a certain number of cases of diabetes in children, as in adults, from two causes : first as the result of irritation of the tubular structure of the kidney by the sugar-charged urine, and second as a coin- cidence. Pneumonia is prone to occur, as in adults, tuberculosis to a less degree, but gangrene I have not met in children. The suggestion that in a large number of these cases the albuminuria is due to the excessive quantity of eggs con- sumed in the diabetic diet I do not consider sustained by the facts. Diagnosis. — With such a train of symptoms as those noted there should not be much delay in recognizing diabetes mellitus, even without an examina- tion of urine. All cases, ai-e not, however, so clear, and such examination is always necessary to a j)roper study of any case. The occasional confusion due to the reducing effect of uric acid on the proto-salts of copper should be borne in mind. The darker hue and scantiness of the uric-acid urines should excite suspicion, while the absence of all other symptoms of diabetes should protect against error. The tests for sugar at once most delicate and to be relied upon are the cop- per tests, and of these the most satisfactory is the solution known as Fehling’s.' In using Fehling’s solution for qualitative te.sting take 1 cc. of the solution and dilute with four times its bulk of water; boil the mixture thus obtained, and, if it remain clear, it is fit to be used in completing the test. If, however, there should be a precipitate of the red suhoxide on boiling before any urine is added, the solution is spoiled and a fresh one should be obtained. If the fluid remain clear after the first boiling, the urine should be added, drop by droj), until a bulk equal to the original mixture of Fehling’s solution and water is ob- tained; and if no yellow or red precipitate takes place, the urine may be said to be free of glucose. It is scarcely necessary to say that the gray floccu- ' Fehling’s solution istlui.s made: Dissolve 34.(l.S9 grains of ))ure ervstallized sulphate of cop- per in 200 cc. of distilled water; 17.3 grams chemically pure crystallized neutral sodic-potassiuin tartrate in 480 grams of solution of caustic soda of sj). gr. 1.14; and into this basic solution ])our the copper solution, a little at a time ; then dilute the resulting mixture to 1 litre with distilled water. The tendency of Fehling’s solution to deteriorate is well known. This may he obviated by substituting glycerin or mannitc for the tartaric acid, hut more ctlectually by dis- solving the sodic-jiotassium tartrate in 4S0 grams of .solution of caustic soda and diluting to .hOO cc. : the cojiper in .500 grams of distilled water; and keeping the solutions scp.arate until such time as they are wanted, when 1 cc. of each will furnish 2 cc. of Fehling’s solution. DIABETES MELLITUS. 1001 lent precipitate of phosphates which sometimes occur should not be mistaken for a precipitate of suboxide of copper. A sufficiently accurate quantitative test may be made with Fehling’s solution thus used if it be remembered that it is of such strength that if the cupric oxide be exactly reduced — that is, if the color is exactly removed by an e({ual bulk of urine — that particular specimen of urine contains one-half of 1 per cent, of sugar ; if the color is removed by half of the bulk of urine, the sample contains 1 per cent.; and if twice the bulk of urine is required, the sample contains of 1 per cent. ; and so on. Moreover, if, as is usually tlie case, it is necessary, by reason of the large percentage of sugar, to dilute the urine, the proportion should be 1 to 9 of water. Then we proceed as before, multiplying the result by 10. When it is remembered that it is impossible to judge accurately of the progress of any case of diabetes mellitus without a quantitative analysis for glucose, the importance of having an easy clinical quantitative method will be appreciated. In the absence of Fehling’s solution the original form of the copper test sug- gested by Trommel’ may be thus used : The urine is first alkalized by about one- fourth its bulk of liquor potassse, and then a drop or two of a preferably weak — say 1 to 30 — solution of cupric sulphate should be added. A precipitate ensues, but if sugar be present the first drop or two of the copper solution is redissolved on shaking. The addition should therefore be continued until a slight excess remains, when heat is applied, and in a few seconds a precipitate of the yellow cuprous hydroxide occurs. This subsequently loses its water and becomes the red cuprous oxide. Of the remaining tests for sugar it will be sufficient to give the fermenta- tion test, which is easy and serves a quantitative as well as a qualitative purpose, while it has fewer sources of error than any of the other tests. The objections to it are that it requires several hours for its operation, and that quantities less than a half of 1 per cent., or grains to the ounce, cannot be detected. The simplest method of its application is as follows : Having taken the specific gravity of the sample to be tested, fill a four-ounce bottle with the urine, to which add a small piece — say the size of a pea — of German yeast or a teaspoonful of brewer’s yeast, after which shake thoroughly ; put aside in a warm place, temperature 60° to 80° F., for at least twelve hours. At the end of this time, sugar, if present, will have been converted by fermentation into carbonic acid and alcohol, and the specific gravity proportionately low- ered. For practical purposes it may be allowed, as originally ascertained by Dr. Roberts, that for every degree of reduction of specific gravity on the urin- ometer there is 1 grain of sugar to the fiuidoimce. Thus, if the original specific gravity is 1040, and the specific gravity after fermentation 1020, there are 20 grains to the fluidounce. From this the percentage may be ascertained by multiplying such difference by .23. Thus in the illustration named the per- centage would be 4.6. The matter of the selection of a specimen of urine for analysis is of the greatest importance. It goes without saying that the most suitable sample is a portion of the whole twenty-four hours’ urine collected for the purpose. But it is evident that it is often — indeed, almost always — impo.ssible to do this. Then my practice is to take two samples for analysis — one a portion of that passed on rising in the morning, the other a portion of that first passed after the evening meal, usually that passed at bed-time. If pains be taken always to examine samples thus selected under the same conditions, comparisons may be made from day to day or week to week which suffice for clinical purposes. Prognosis. — The prognosis is unfortunately very bad in children. The \m'lA3IEmCAN TEXT-BOOK OF DmEAHES OF CHILDREN. only case of a child I have ever known to recover was a girl of twelve under the care of a friend. Life may, however, be prolonged for a time by careful attention to dietetic, hygienic, and medicinal treatment. The course is, however, always much more rapid than with adults, and the fatal termination comes sooner. Treatment. — In children, as with adults, the most efficient treatment is the dietetic, and the greatest difficulty is that of getting a substitute for bread. Of the various so-called gluten flours and breads, so far as I know, the only ones made in this country which contain so little starch as to justify the name pure gluten or almost pure gluten are the gluten flour of Theodore Metcalf & Co., of Boston, Mass.,^ and the No. 1 gluten biscuit and No. 1 gluten meal of the Sanitarium Food Company of Battle Creek, Mich. No new prep- aration of gluten should be acce])ted for what it claims to be unless the claim is sustained by analysis. In England and France diabetics are more fortu- nate, as they can secure flour, bread, and biscuits containing a minimum amount of starch. The great objection to all ])ure gluten preparations is that they are more unpalatable than the bread made of flour from Avhich the starch has not been removed. But it should be made clear to the friends of the patient that he must make his choice of the two evils. It is not always necessary that the purest attainable gluten preparations should be used in mild cases, as in these a certain amount of starch is assimilable ; but such latitude must be based on trial of fixed quantities of the given breads associated with careful (juantitative analyses of the urine selected as directed. To such the so-called “ bran bread ” made out of unbolted flour, in which the ratio of starch is of course less, and oatmeal gruel with cream, may be allowed. Unfortunately, mild cases of diabetes are not commonly found in children. Among the substitutes for the white flour so much used is almond flour, and it is totally without objections, so far as its composition is concerned. The patient is apt to tire of it as of anything else from exclusive use, and fair digestive capacity is required. Various other flours have been suggested. One of these is the flour of the soya bean {Soya hispuht), a native of Japan, but now extensively grown in Europe, said to contain only 4 per cent, of starch. It is, moreover, very rich in nitrogenous substances. From this are made bread and biscuit. A flour known as poJuhoskos contains a small quantity of starch, and is a suitable food for most diabetics. Fro7ncntine is another of these flours made from the embryos of wheat, which, so far as I knoAV, is not yet obtainable in this country. Like the soya flour, it contains a considerable quantity of oil, Avhich not only renders pannification difficult, but disposes to early ran- cidity. Efforts are also being made to isolate for the same ])uri)ose legumine, the caseine of the leguminous vegetables. The substance so isolated is known as embryonine. ' The following are the directions suggested by Dr. John A. JeflHes in common use for making gluten biscuit out of the Metcalf flour : Gluten flour t ‘‘up- Best bran, ])reviouslv scalded 1 ‘’'iji. Baking powder . . ' 1 teaspoonful. (Or the equivalent of bicarbonate of soda and cream tartar.) Salt h) taste. Eggs t\vo. Milk or water 1 t'tip. Mix with a rpoon. DIA B E TES MEL LIT UN. 1003 The appended table is one wliicli has been my guide for many years, and I believe it includes most of the articles admissible : Food and Drink Admissible in Diabetes Mellitus. — Shell-fish . — Oysters, mussels, and clams, raw and cooked in any way, without the addition of flour. Fish of all kinds, fresh or salted, including lobsters, crabs, sardines, and other fish in oil ; fish-roe, caviar. Meats of every variety except livers, including beef, mutton, chipped dried beef, tripe, ham, tongue, bacon, and sausages ; also poultry and game of all kinds, with which, however, sweetened jellies and sauces should not be used. Soups. — All made tvithout flour, rice, vermicelli, or other starchy sub- stances, or without the vegetables named below as not allowed ; animal soups not thickened with flour, such as bouillon, beef-tea, and broths. Vegetables. — Cabbage, cauliflower, Brussels sprouts, broccoli, green string beans, the green ends of asparagus, spinach, tomato, dandelion, mushrooms, lettuce, endive, coldslaw, olives, cucumbers, fresh or pickled, radishes, sorrel, young onions, water-cresses, mustard and cress, turnip tops, celery tops, arti- chokes, gherkins, okra, parsley, or any other green vegetables. Fruits. — Cranberries, plums, cherries, gooseberries, red currants, straw- berries, acid apples, lemons, oranges sparingly, all without sugar. Acid fruits may be stewed with the addition of bicarbonate of sodium instead of sugar. Bread and cakes made of gluten, soya, almond floui’, inulin, “ poluboskos,” fromentine, or embryonine, with or without eggs and butter. Griddle-cakes, pancakes, biscuit, porridges, etc., made of these flours. In cases requiring less stringency the so-called “bran bread,” made of unbolted flour, the crust of bread, and oatmeal porridge with cream. Eggs in any quantity, and prepared in all possible ways, without sugar or ordinary flours ; butter and cheese. Nuts. — All except chestnuts, including almonds, walnuts, Brazil nuts, hazelnuts, filberts, pecan-nuts, butternuts, cocoanuts. Condiments. — Salt, vinegar, and pepper in moderate quantities. Jellies. — Xone but those unsweetened, except by saccharin. They may be made of calfs-foot or gelatin and flavored with wine. Brinks. — Coffee, tea, and cocoa-nibs, with milk or cream, but without sugar; also Vichy, Vais, and Carlsbad waters, carbonated waters, and all mineral waters freely ; lemonade without sugar, acid wines, including claret, Bordeaux, Rhine, and still Moselle wines, diluted Avith Vichy or similar waters, very dry sherry ; unsAveetened brandy, Avhiskey, and gin. No malt liquors, except those ales and beers Avhich have been long bottled and in which the sugar has largely been converted into carbonic acid and alcohol. Saccharin may be used for SAveetening. To be Especially Avoided. — Potatoes, Avhite and SAveet, rice, beets, cari’ots, turnips, parsnips, peas, and beans ; all vegetables containing starch or sugar in any cjuantity ; SAveet Avines, including slierry, Madeira, port, and cham- pagne. The hygienic treatment of diabetes mellitus is important. The patient should be bathed fi’equently, and brisk friction should succeed the bathing in order to stimulate the circulation. Out-door life and muscular exercise, short of tliat .sufficient to excite fatigue, should be insisted upon, the idea being to stimulate every proce.ss Avhich may result in the oxidation of sugar. For a like reason the sleeping-room should be Avell ventilated and the purest air supplied to it. The medicinal treatment of diabetes is limited, as there are fsAv drugs AMERICAN TEXT-BOOK OE DISEASES OE CHILDREN. having power to control the defective assimilation resulting in sugar excretion. The most efficient of these is undoubtedly opium and its preparations and alka- loids, any one of which possesses this power. Codeine is, however, the prepa- ration usually selected, because it is less apt to produce the harmful effects of the other chief alkaloid, morphine. It is, however, much more expensive. While generally better borne than morphine, it does sometimes nauseate as well as constipate. That it controls the sugar output is abundantly proven. Moreover, I have reason to believe from my own experience that it occasionally happens that where sugar has disappeared during treatment by codeine, it does not return after discontinuance. It is desirable, however, to put off the use of opium, as a rule, until other measures and drugs fail. If the efficiency of opium in diabetes be based upon its sedative action, then the bromides should also be useful, and it does occasionally happen that they serve a good purpose ; but in my experience they are of limited utility. After opium, arsenic is perhaps the drug which has longest maintained its reputation as a remedy in diabetes mellitus, but its usefulness, like that of most drugs, is limited to the milder cases. There is no better preparation than Fowler’s solution, of which the dose is so easily regulated. The action is unex- plained, although a reasonable theory has recently been advanced by Cuth- bertson of Chicago, who says it is partly local upon the stomach, bowels, or respiratory organs, and partly on blood-cells, increasing their activity, and therefore the oxidation of sugar. The dose must be regulated by the age, from a drop to five drops three times a day, increased until slight oedema of the face results. It is often combined with lithium carbonate, 1 to 5 grains, by which its efi’ect is sometimes increased. The bromide of arsenic, originally recommended by Clemens, is sometimes given, but I have not found it more efficient than Fowler’s solution. The preparation commonly used is Clemens’s solution of bromide of arsenic, of which the dose is 2 to 5 minims, the smaller dose for children. Ergot is a drug which is sometimes efficacious, but I value it less highly than I used to. That it sometimes exerts a controlling effect I have not the least doubt. The best form is the fluid extract in doses of five minims to a drachm. That the coal-tar series of antipyretics, including antipyrine, antifebrin, phenacetin, and sulfonal, prominently brought forward by the French school of physicians, have in the milder forms of diabetes a controlling influence, I can also assert from my OAvn experience. As claimed by the French school, their efficiency is increased by combinations with alkalies, sodium carbonate being commonly used in the ]>roj)ortion of twice the dose of the antij>yretic. Thus, if 15 grains of antipyrine are given, 30 grains of sodium bicarbonate are added, and these doses are recommended by Dujardin-Beaumetz and Germain- See for adults. They are bulky and a])t to derange the stomach, and the}' should not be given after meals. My method has been to give the com- bined drugs in e(iual doses before meals. For children they .should be much .smaller — 3 to 10 grains of the drug, with an ecpial ([uantity of .sodium bicar- bonate. If the antipyretic is given alone, it may be given after meals, although a somewhat larger dose is then required. Salicylate of sodium has some re])utation, and may be used, especially when the diabetes is associated with rheumatism. Alkalies alone, doubtless, have an effect in the diabetic process, and it is this constituent to which the alkaline mineral waters of Vichy, of Vais, and of Carlsbad owe their chief efficiency. None of the negative mineral waters in this country, so much vaunted by their owners as specifics, have in my expe- DIA BE TES INSIPID US. 1005 rience any efl’ect ■whatever. Persons visiting the sources of these waters may be benefited, but the associated diet, and not the waters, is the efficient agent. A great many remedies have from time to time been suggested as useful in diabetes, and I have tried most of them as opportunity presented, generally with negative results. One of the most recent of these is jambul {Sijzygium jambolanuni). A careful and systematic trial by myself in three cases has resulted in signal failure. The dose given is from ten drops to a drachm. The latest of these remedies is creasote, which I have not yet tried. It is recommended by Audibert as producing e.xcellent results where diet did not seem in any way to influence the intensity of the glycosuria. The quantities used were : first 2, then 4, and finally 6, grains daily for adults. The gly- cosuria steadily diminished in one case in spite of the fact that the patient, despairing of any results, deliberately neglected all dietetic rules. n. Diabetes Insipidus. Diabetes insipidus is a nervous affection, mainly functional, characterized by the secretion of a large amount of urine of low specific gravity. While diabetes insipidus is a much rarer disease than diabetes mellitus, it is believed to be relatively more frequent in children than the latter. Out of 70 cases collected by Roberts, 22 were under ten years of age, and 13 between ten and twenty ; out of 85 by Strauss, 21 were under ten ; and of 87 by Von der Heijden, 7 were under ten and 19 between ten and twenty. Etiology. — Nervous influences, such as those which produce hysteria — viz. shock, fright — are the principal causes of diabetes insipidus. Thus a boy of ten years, recently treated by myself, was choreic at various times prior to the attack of polyuria, and was very nervous throughout the illness, from which he recovered. Morbid Anatomy. — No definite morbid anatomy has been found asso- ciated with simple polyuria. The kidneys have been found sacculated in various degrees, more likely as a conse(iuence of the enormous accumulation of liquid filling the bladder and pressing backward through the ureters upon the kidney structure, causing its atrophy. Tubercular and gliosarcomatous tumors in the neighborhood of the floor of the fourth ventricle have been found. Symptoms. — The chief symptom is a profuse polyuria associated with a proportionate thii’st. The quantity of urine exceeds that of all ordinary cases of diabetes mellitus. The boy of ten referred to would pass a quart at a single sitting, while the frequency of the desire to pass water made it impos- sible to attend school. The specific gravity is proportionately low, generally 1002 to 1006, and I have known it to be scarcely above 1000. For the twenty-four hours’ urine the other constituents remain usually normal, while albuminuria is much more rare than in diabetes mellitus. As a natural result of such a condition there is great dryness of the skin and mucous membranes. On the other hand, there is never that extreme emaciation seen in children with diabetes mellitus, and the patients are often fairly well nourished. This is favored by the fact that the appetite is apt to be increased, from which, indeed, derangements of digestion may result. Other nervous symptoms frequently attend or precede diabetes insipidus, such as chorea, restlessness, and sleeplessness. Diagnosis. — The diagnosis of diabetes insipidus is easy. The enormous quantity of urine passed, its low specific gravity, and the absence of sugar, if maintained for any length of time, can mean nothing else. It is barely \0m AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. possible that the milder forms might be confounded with chronic interstitial nephritis in adults, hut in children this seems impossible. The presence of a trace of albumin should, however, lead to an exhaustive examination of the urine for casts and other signs of interstitial nephritis — a very rare disease in children. Prognosis. — The prognosis in my experience is generally favorable, the patient sooner or later getting well. Treatment. — Cases under my care have usually yielded sooner or later to ergot or gallic acid, the former in beginning doses of 10 minims of the fluid extract, or less according to age, and increasing until results are obtained or full doses reached without effect. Gallic acid may be given in 5-grain doses at the beginning and increased. For antipyrine and antifebrin great efficiency in the treatment of this affection has recently been claimed. While I have as yet had no opportunity to try them, my experience with these drugs in diabetes mellitus leads me to expect that they will be even more efficient in diabetes insipidus. The same reasoning leads me to e'xpect that bromide of potassium would be useful, as it sometimes is. Valerian is one of the older remedies for simple polyuria, and it can be easily understood why it should be useful in nervous cases. The older ])hysi- cians used powdered valerian and valerianate of zinc, but at the present day the moi’e elegant preparation of elixir of the valerianate of ammonium, in doses of half a drachm, a drachm, or more according to age, should be substituted. The exceedingly disagreeable smell of the substance is in the Avay of its gen- eral use. Opium is also recommended in diabetes insipidus, but has made for itself no reputation like that it has attained in saccharine diabetes. A blister at the nape of the neck or on the epigastrium was suggested by Roberts, and might be expected to be of service by its impression on the ner- vous system. The constant galvanic current would be reasonably useful from the same standpoint, and is recommended by Seidel and Kuelz, the former of whom apj)lied daily one pole of a strong battery over the loins near the spine and the other as deeply as possible over the hypochondrium. In the matter of drinking water a moderate restriction should be exercised in diabetes insipidus, but to cut down the amount of water largely is a cruelty unjustified by the results. The cry for water is a demand to make up a loss from the economy by the kidneys. It is an effect, and not a cause. Yet it is possible to carry drinking to excess after a habit is once acquired, and for the effect thus to become the cause. To prevent this a reasonable oversight should be exercised. m. Lithiasis. Litiiiasis is the deposition of certain solids of the urine in the urinary tract, any portion of which, from its beginning in a Malpighian capsule to its terminal expansion, the bladder, may be tlie seat ot such deposit, dlie sediments thus ])reci])itated include, in the order of treciuency, first, uric acid and its compounds of sodium, j)otassium, and ammonium; second, oxalate of lime ; and, third, the j)hos])hates of calcium, magnesium, and ammonium. A clot of blood or fragment of foreign matter may be the nucleus of calculi thus formed. They may be so minute as to be barely visible to the naked eye, constituting mnd or fjravel, or they may be a couple of inches or more in diam- eter, when they are spoken of in common language as stones in the kidney or bladder. As stated, the most freejuent sediments are uric acid, which are often found in the shape of red sand in the very first urinary discharges of the new-born LITHIASIS. 1007 Calculi impacted in the Ureters. From a boy of 5 years (Tyson). inflammation. They thus become surrounded by alkaline urine, whence phos- phates are deposited in concentric layers around the uric-acid or oxalate-of- lime nucleus. It has been said that calculi may form in any part of the urinary tract. Hence they may be found imbedded in the kidney, circumscribed and encap- sulated in the centre of the organ. Thus situated, they may grow by accretion until they have almost destroyed the entire organ. Ailing up its pelvis and cal- yces, converting the entire kidney into a pus-sac ; or they may even make their way through the capsule of the kidney into the perinephric tissues, and thence infant. Calculi may form, consisting of pure uric acid or its compounds, but they are seldom large. Less common are small stones of pure oxalate of lime. More commonly large stones consist of nuclei of uric acid or oxalate of lime, around which phosphates are deposited in concentric layers. Phosphates rarely form the nuclei of stones. The alkaline reaction of urine, which is necessary to the deposit of phosphates, is not common in children fed on milk. It is not until vegetable substances are added to the diet that the alkaline reaction becomes conspicuous. More frequently the alkalinity necessary to the pre- cipitation of phosphates is the consequence of organic matter generated in inflammatory processes, especially those excited by calculi themselves. This occurs as soon as they reach a sufficient size to act as irritants producing local Fig. 1. \(m AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN down into the pelvic cavity. Appended is a drawing of a remarkable specimen occurring in the practice of the writer in a boy of five years, twice success- fully operated upon for stone in the bladder, the first time when but three years old. lie perished finally of exhaustion. The necropsy only revealed the extent of the mischief. The stone in the left ureter was spirally spindle-shaped, and measured 5.5 cm. long and 1.5 cm. wide in the thickest part. The stone in the right ureter was 10.5 cm. long and 1 cm. through at its thickest part. The bladder also contained a small stone 2.5 cm. long and ranging in diameter from .5 to .75 cm. Etiology. — It would scarcely be profitable to attempt to discuss the causes why in one child there is a tendency to deposit uric-acid sediment, or why in another under apparently the same conditions an oxalic-acid lithiasis should exist. The conditions which favor phosphatic deposits have been mentioned. Whatever may be the cause of each, there can be no doubt that in every case the deposit of sediments is favored by a reduction in the amount of water sep- arated by the kidneys — a condition which depends largely on the amount of liquid ingested. The reaction of the urine, whether acid or alkaline, also plays an important role. Phosphatic sediments are never spontaneously deposited from an acid urine, nor uric acid from an alkaline urine. The law cannot be so sharply laid down with regard to oxalate sediments, crystals of oxalate of lime being deposited in alkaline as w’ell as acid urines, although I believe the reaction of urine containing them is most frequently acid. Calculi may present themselves at any age, and probably begin their formation sometimes even before birth. At any rate, large stones have been removed from the bladders of children in the first year after birth — too large, it would seem, to have been produced in the short time which had elapsed since birth. Symptoms. — The symptoms of lithiasis in the child vary very greatly according to seat and degree. For convenience, such symptoms may be divided into those caused by sand or gravelly deposits, those caused by calculi in the bladder of such size as to justify the term “stone,” and those caused by calculi impacted higher up in the urinary tract, in the pelvis of the kidney and in the ureters. Sand or Gravel in the Bladder . — A simple peevishness or fretfulness or other evidence of pain in an infant, with retractions of the limbs, may be caused by gravel, evidence which is confirmed by red-pepper-like sediment on the napkin or an unusually dark staining of the latter by urine. The same condi- tio:i in an older child may give rise to more intelligible manifestations of dis- comfort, which may be located in the lumbar region, in the groin, or in the urethra. A very common mode of manifestation of discomfort in the latter situation and in the neck of the bladder is traction upon the prepuce, which often becomes elongated in conse(juence. At this early age a fre(}uent desire to pass Avater, and especially wetting the bed at niglit, should lead to examina- tion of the urine, the presence Avherein of uric-, acid or oxalate-of-lime sediments would, together with dark color and high specific gravity, add further probability of the presence of such a cause. Stone in the manifests itself by very much the same sym])toms, though intensified, especially the disjmsition to draw upon the ju’epuce .and frequency of micturition. Tenderness in the region of the kidney will be found Avhere the pelvis is the seat of detention of the calculus, and not infre(|uently bulging, and even fluctuation from the ])resence of pus, may be detected. Abdominal palpation shonld not be neglected, as enhargenients of the kidney are very apt to be anterior in direction. Examination of the urine may give negative LITIIIASIS. 1009 results, or it may show the presence of the crystals already mentioned ; more fre(;[uently the secretion contains evidence of irritation of the bladder in the presence of mucus or pus, while a trace oi albumin will attend the presence of pus. When mucus or pus is absent, the microscope may still discover mucus threads or so-called mucus-casts, which always mean irritation of the genito- urinary passages short of what is sufficient to produce mucus or pus in the urine. Such urines, if not already alkaline when passed, readily become so, and the alkalinity thus produced tends to make the urine viscid and glutinous. AV here the alkalinity takes place in the bladder in the presence of pus, this glairy material is formed in the viscus, and micturition becomes difficult or impossible. Such a set of symptoms will of course suggest the use of the bladder-sound, by which a stone is commonly readily recognized. The continuance of symptoms of such severity as are caused by the larger stones soon affects the general health of the patient, as attested by feverishness and gradually growing emaciation, which may terminate in death. Diagnosis. — This is successful according as the lines of investigation may be thorough or otherwise in the examination of urine, palpation, and the use of the sound. Prognosis. — This is generally favorable, the use of appropriate solvent medicines and diet being sufficient to correct the states wherein only gravelly sediments are present ; while the surgeon’s knife even more promptly removes the stone from the bladder or kidney, nephrotomy to-day saving many lives which would have formerly been lost. It is only, for the most part, those cases which have advanced too far, or which present the peculiar conditions presented in Fig. 1, which are beyond the reach of any remedy, and gradually wear out the patient. Treatment. — As soon as a stone of size sufficient to be recognized by a sound, or by localized pain or tenderness in the kidney itself, is discovered, there is but one course to be pursued. The case must be handed over to the surgeon. At the present day no intelligent physician expects to dissolve away a stone by medicinal treatment. From the physician’s standpoint, treatment is therefore limited to such cases in which the lithiasis is confined to gravelly sediments. Of these there can be no rational treatment except after a thorough chemical and microscopi- cal study of the urine, and, although symptoms may be relieved without such study, the success attained is accidental, and reflects no credit on him who employs it. The management demanded by different conditions is often dia- metrically opposite. If, on examination, the urine is found highly acid in reaction, depositing uric-acid sediments, the treatment is pre-eminently by alkalies. It does not much matter what alkalies are used. They should, however, be associated with an abundance of liquid, in order the better to furnish a solvent for the uric acid. The liquor potasste of the U. S. Pharmacopoeia is an excellent remedy in doses of 5 to 20 minims, the dose being adapted to the age of the patient and administered three or four times a day. The object should be to alkalize the urine, and in testing it a time of day should be selected when the urine is most likely under ordinary circumstances to be acid. Such a time is the early morn- ing before food is taken. Milk is an admirable medium for liquor potassae. The salts of potash are also useful, and there is less danger of an overdose. The citrate and carbonate are equally efficient in doses of 5 to 15 grains three or four times a day, or oftener if necessary to secure an alkaline reaction. With alkalinity established, uric acid cannot be precipitated. On the other hand, care must f.4 \()IQ A3IE RICAN TEXT-BOOK OF DISEASES OF CHILDREN. be taken to avoid the opposite extreme — having escaped Scylla, to steer clear also of Charybdis. If the urine be made too highly alkaline, the phosphates will fall and the sediments of these urinary constituents arise. The alkaline mineral waters, of which the imported Vichy waters are the type, and even negative mineral waters, are useful in the uric-acid lithiasis. The new substance, piperazine, is an admirable solvent for uric acid in doses of 3 to 5 grains for children. On the other hand, if we have an alkaline urine to contend with and per- sistent phosphatic deposits, we must seek to make the urine acid. This, unfor- tunately, is not so easy. There are very few medicines which have this tend- ency. Benzoic acid and boric acid are the only ones, and neither of them is well borne in large doses by children. But they should be given in doses of 1 to 5 grains every three hours, or often enough to secure the acid reaction sought for. Oxalate of lime, unfortunately, is insoluble in both acids and alkalies. At the same time, it is sometimes formed under the same conditions as uric acid. The same general plan of treatment may be carried out. Oxalate-of-lime sediments frequently attend dyspeptic states, which are successfully treated by acids, especially nitromuriatic, which should be cau- tiously administered in combination with suitable doses of tincture of nux vomica, or even strychnine, with pepsin or pancreatin. Where the composition of gravel cannot be determined, it is a great deal better to give an abundance of distilled water than the alkalies and alkaline mineral waters, by which we only add fuel to the flame if it happens that we are dealing with phosphatic gravel. As to diet, if the gravel be uric acid, meats and albumens should be limited, as they tend to produce an acid urine and uric-acid sediments. On the other hand, milk and vegetables tend to alkalize the urine. Abundant experience has taught me that not only during childhood, but also during infancy, parents are too indifferent about giving their children pure water to drink. Children should be encouraged to drink water between meals, and infants should be given pure water to drink two or three times a day. They soon grow fond of it, and in this way liquid is furnished to flush out the excretory channels of the economy, and to dissolve the solids which can only he removed in solution. In children, no less than in adults, pain must be relieved by ap])ropriate anodynes. The milder preparations of opium, as paregoric, should be made to suffice, because of the danger of the stronger preparations. The sup- pository is a convenient and effectual medium. Phenacetin will often relieve the milder, and sometimes even quite severe, degrees of pain, especially if it be renal. Five to ten grains may be given at a dose. 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Philadelphia ; Pathologist to the Orthopardic Hospital and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph Hospital, etc. *,* There will be published in the same series, at short intervals, carefully-prepared works on various subjects by prominent specialists. Pamphlet containing specimen pages, etc. sent free upon application W. B. SAUNDERS, Publisher, 925 'Walnut Street. Philadelphia. ACUTE AND CHRONIC NEPHRITIS, AND AMY- LOID DISEASE OF THE KIDNEY. By I, N. DANFORTH, M. D., Chicago. I. Acute Tubal Nephritis. Synonyms. — Acute catarrhal nephritis ; Acute desquamative nephritis ; Acute croupous nephritis ; Acute parenchymatous nephritis ; and Acute Bright’s disease. Etiology. — In adult life e.xposure to cold and wet is the most common cause of acute tubal nephritis, but it is a curious and interesting fact that the disease is veiy rarely produced in children in this way. My experience quite accords with that of Ralfe, who says, “ I have never yet succeeded in obtaining a history of exposure to cold and wet in a case of acute nephritis occurring in childhood.” The usual causes are acute febrile diseases, especially the exanthe- mata ; septic diseases, like diphtheria and erysipelas ; and traumata, such as burns, scalds, and injuries involving the nervous centres. Certain drugs in use among children, notably cantharides and turpentine, are capable of inflam- ing the kidneys, and I have known the extravagant use of highly-flavored confections produce the same result. Symptoms. — The symptoms of a w'ell-marked case of acute nephritis are always pronounced and aggressive. The patient is sometimes seized with an initiatory chill, but if this is absent pyrexia is always present, the temperature ranging from 100° to 103°, or even 104°F., and maintaining this altitude for from six to twelve days. The pulse is frequently tense, and has a peculiarly quick, short, nervous beat, thus giving expression to the cardiac irritation characteristic of the uraemic state. The tongue is coated, the appetite lost, and the bowels constipated. There is generally deep dull pain in the lumbar region, due to the swollen condition of the kidneys. Headache is a prominent symptom, vertigo is not uncommon, transitory strabismus sometimes occurs, and if relief is not promptly obtained uraemic convulsions supervene, to be fol- lowed by partial or perhaps profound coma, with probably dilated, but certainly uncontracted, pupils. If the coma is not complete, obstinate nausea with violent retching will probably occur ; that is, the vomiting of uraemia. The urine is diminished in quantity from the first, and this significant symptom progresses until complete suppression may occur. The reaction is usually acid; the specific gravity increases from 1.025 to 1.040, in the early stage, but diminishes later ; the color varies from pink to a vivid red, the intensity of the color denoting roughly the quantity of blood present, for it rarely happens that acute nephritis is not attended by well-marked haematui’ia. Albumin is always present in large quantities, at least one-quarter, and frequently three-quarters, by volume ; that is, when a specimen of urine is 1011 \{)V2 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. tested by heat and nitric acid in a test-tube and allowed to stand for twelve hours, the albumin will occupy from one-quarter to three-quarters of the space. A copious sediment will fall when the urine is set aside ; this is made up of hyaline, epitlielial ami blood-casts, free blood-globules, many of them crenated, renal epithelium, graiiular urates, and amorphous matter. In the early stage blood-casts will predominate ; later on, epithelial and hyaline casts Are more abundant, and before convalescence is established some fatty or granular casts may appear, although they are usually few and far between, unless the case falls into a chronic condition. Di’opsy appears very early in the case, generally manifesting itself first in the lower eyelids, cheeks, or the loose tissues of the neck ; it then invades the feet and travels upward, reaching the scrotum or labiae, then the abdominal cavity, and it may be the pleural or pericardial cavities. (Edema of the lungs may occur; the glottis may be distended with fluid, threatening or even causing death by asphyxia, although this can generally be avoided. As already intimated, the heart's action is rapid and the systole is quick, powerful, and “ angry,” because of urremic irritation and increased arterial tension. The foregoing account of symptoms relates to a well-marked typical case. Of course mild cases occur, when the symptoms are much less pronounced ; but it is also true that cases of greater severity and more rapid progress are occa- sionally seen, which generally prove rapidly fatal from acute uraemia. Morbid Anatomy. — The kidney is swollen, not hypertrophied, but dis- tended with blood and also by the contents of the convoluted tubes. Dickin- son relates a case in which the capsule of both kidneys was ruptured by the intense distention caused by congestion, but this is a very exceptional occur- rence. The color of the kidney is much darker than normal, and the stellate veins stand out with great distinctness. If the organ be laid open lengthwise, blood will drip freely from the cut surface, and it will be seen that the cortical substance is apparently much increased. The Malpighian bodies sometimes project above the level of the incised cortex, and may be felt as little rounded bodies under the finger. Microscopic section shows the small vessels much dilated, especially those of the glomeruli ; in fact, these are in many instances ruptured. The convoluted tubes are much distended by casts, blood-globules, cast-off epithelia, and granules or crystals of urinary salts, and the straight tubes are in less degree distended by similar contents. If the disease passes into the chronic stage, of course the kidney will show. granular or fatty degen- eration. Diagnosis. — The diagnosis of acute nephritis can scarcely be said to pre- sent any difficulties. The rapid invasion, early occurrence of dropsical effusion, arterial tension, and especially the scantiness of the urinary secretion, together with its pink or red color, at once indicate the nature of the illness. Of course an examination of the urine Avill at once remove all doubts. Acute nej)hritis may be complicated with, or rather preceded by, chronic nephritis, but a microscopic examination of the urinary sediment will at once reveal the characteristic fatty or granular casts, which will establish the real facts in the case. Moreover, a careful in(|uiry into the history of the patient will result in the discovery of symptoms indicating ]»re-existing renal disease. Cyanotic induration of the kidneys may possibly be mistaken for acute nej)hritis, but a careful examination of the heart will clear up the doubt, since this disease is almost invariably associated with some obstructive lesion of the cardiac valves, especially the mitral. Careful imjiiiry will also develop the fact that the disease has existed for a length of time which rules acute nephritis out of the question. As cyanotic induration is not very uncommon in children. IM.ATE XXI. TUBE-C.VSTS AND DIUNARY SJ;DIMENT.'<. Fig. 1. Hyaline Cast, Lithic-Acid Crystals, Granular Eiiithelia (Acute Tubal Nejihritis). X 150 diainete Fig. 2. Epithelial Ca.st, Lithic-Acid Cry.stals (Acute Tubal Nephritis). X l.'iO diameters. Fig. 3. One Epithelial and Two Hyaline Casts (Chronic Interstitial Nephritis). X 150 diameters. Fig. 4. Hyaline Cast and Renal Epithelia, stained (Chronic Interstitial Nephritis). X 150 diameters. Fig. 5. Waxy Cast (Amyloid DeKcneration). X 150 diameters. SECOND EDITION. FIRST EDITION EXHAUSTED IN FIVE MONTHS. A TEXT-BOOK OF THE PRACTICE OF MEDICINE BY JAMES M. ANDERS, M.D., PH.D., LL.D. Professor of the Practice of Medicine and of Clinical Medicine in the Medico- Chirurgical College, Philadelphia ; Attending Physician to the Medico- Chirurgical and Samaritan Hospitals, Philadelphia, etc. ^ ^ A Magnificent Octavo Volume of 1287 Pages. Illustrated with Four Colored Plates and Numerous Engravings. Prices: Cloth, $5.50 net; Sheep or Half Morocco, $6.50 net. ^ ^ PRESS NOTICES. “It is a work by which many will profit, for it is both comprehensive and reliable. The work of Dr. Anders is a good one.” — Vor/e Medical Joiinial. “ The book is a good one, and for the average general practitioner will be of dis- tinct service for its detail of treatment.” — Bulletin of the Johns Hopkins Hospital. “ Dr. Anders has produced a very creditable book — one that has come to stay and deserves a wide distribution.” — Canada Medical Beco?'d. “ We have gone over the book carefully and with much pleasure. We thank the author. We feel that he has added to our literature a book of real value — a thoroughly useful book.” — Brooklyn Medical Journal. “ For clearness of method, conciseness of expression, continuity and crystalline clearness of thought, we have never seen its equal from the pen of an American author. It has never been our lot to more heartily commend and praise a book.” — Georgia Journal of Medicine and Surgery. “It is an excellent book, thoroughly up to date, and a reliable guide to the general practitioner.” — Canadian Practitioner. Sent postpaid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut Street, Philadelphia, Pa. (SEE OTHER side) Anders' Practice of Medicine. PROFESSIONAL COMMENTS. "It is an excellent book, — concise, comprehensive, thorough, and up to date. It is a credit to you; but, more than that, it is a credit to the profession of Philadelphia--to us." Professor of the Practice of Medicine and of Clinical Medicine ^ Jefferson Medical College^ Philadelphia* "I consider Dr. Anders' book not only the best late work on Medical Prac- tice, but by far the best that has ever been published. It is concise, system- atic, thorough, and fully up to date in everything. I consider it a great credit to both the author and the pub- lisher. " President (j/ Hie Illinois Homeopathic Medical Association. ACUTE TUBAL NEPHRITIS. 1013 it should always be borne in mind when renal symptoms are under investi- gation. Prognosis. — Acute nephritis is always a grave disease, and is by no means free from danger. Yet, if recognized early and treated appropriately, there are few serious diseases that yield better results. Of course, I am now speaking of uncomplicated diseases. But the danger is greatly increased if the child has cardiac insufficiency, bronchitis, tuberculosis, or any other organic affection. If proper treatment be not instituted until inflammatory exudation has been poured into the tubes and capsules of Bowman, the chances of recovery are diminished, although the case is not hopeless. Sup- pressio urinse and uraemic convulsions indicate a condition of extreme danger, but I have seen several perfect recoveries even after these untoward symptoms have appeared. Children are more apt to recover than adults ; in fact, granted an otherwise healthy child, an early diagnosis, and prompt and vigorous treat- ment, the great majority of cases will recover without damage to the kidneys. Treatment. — Promptitude without precipitation and vigor without rash- ness should guide the physician in the treatment of acute nephritis. It is fre- quently the case that a judicious blow at the right time saves a life, and, on the other hand, it is equally ti'ue that hesitation and delay cost the life or blight the future of many a child. If the child be strong and vigorous and the attack be violent, it will be wise to apply three or four leeches over each kidney, or, if the leeches cannot be obtained, blood should be taken by means of cups. The amount must of course depend on the age and strength of the child, but two ounces would be none too much to take from each renal region if the child be from six to eight years of age and in vigorous health at the time of the attack. Immediately following the bleeding a large hot linseed cataplasm should be applied, so as to entirely encircle the body at the level of the kidneys. If the poultices be covered with rubber cloth or oiled silk, they need not be changed oftener than every six hours. It is very important that they be made to “fit” the body closely, and if a little powdered mustard be incorporated in each poultice, it Avill be an improvement. But no stimulating applications, like turpentine stupes, should be employed in the early stage of the disease. The practitioner should next turn his attention to the all-important neces- sity for securing elimination of the urinary factors by other agents than the kidneys. Fortunately, the alimentary tract and the skin afford ample means for accomplishing this. A vigorous cathartic should be given, and I am much in favor of administering from one to three grains of calomel, and following it in three or four hours with an appropriate dose of solution of citrate of mag- nesium. The bowels should be kept loose for several days or until the danger from the acute invasion has passed ; and this for two reasons : first, for the purpose of compelling the bowels to take up a portion of the work of the kid- neys, so that the latter may have the benefit of a season of physiological rest ; secondly, for the purpose of using the vast alimentary area as a “ derivative ” surface. Cathartics produce more or less hyperiemia of the intestinal mucous membrane, and if the circulatory current is “determined ” toward the intestine, it is proportionally drawn away from the engorged kidneys — a result that is very desirable. I have many times .seen the good results of this practice, and am therefore confident that it iS something more than a mere theory. Of course the most useful cathartics are those which produce free watery evacuations. The skin is also a vast eliminating organ, and the reciprocal relations existing between the skin and kidneys are well known to physiologists. The physician should take full advantage of this fact in the treatment of acute nephritis, and AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN. encourage copious as well as constant diaphoresis. For this purpose jahorandi, or its alkaloid pilocarpine, and the hot-air or vapor bath are both prompt, efficient, and certain. I have seen such excellent results from the use of hot dry air that I do not hesitate to urge its employment in every severe case of acute nephritis. My method is as follows : The patient, all but his head, is placed in a “ tent ” (made by supporting the bed-clothes upon arches or semicircles of half-hoops or bent Avire) and the bed-clothes are drawn closely about the neck, so as to exclude cold air and include hot air ; the perforated tin box (1) is then placed under the bed-clothes by the side of the patient Fig. 1. Apparatus for the Administration of the Hot-air Bath. The top aiul inner side of the box are made of perforated tin. and about six inches away from him ; a current of hot air from a spirit lamp (3) is now conducted into the perforated tin box (tvliich acts as a “register” or “radiator”) through the tin pipe (2), as shown in the figure. The result is usually very copious diaphoresis, tvliich may be maintained for many successive hours, or even days in cases of emergency. In one case which seemed well- nigh hopeless, the hot-air apparatus tvas kept in action almost constantly for ten days, and the patient made a perfect recovery. In some cases the hot dry air evokes sensations of “faintness” or “ smothering Avhen this happens the heat should be increased very slowly, so as not to alarm or excite the patient. Now and then a case will be encountered which will not bear dry heat at all, while moist heat will bo tolerated with both comfort and benefit. A few heated bricks, wrapped in Avet cloths and ))laced around the patient under the tent, Avill produce active diaphoresis. This method, however, is less effi- cient than dry heat, and the latter Avill almost invariably be tolerated after a few trials. In jaborandi Ave have a most poAverful and certain diaphoretic, and one which is entirely safe if used at the j)roper time and place. In practice the {CUTE TUBAL NEBIIRITIH. 1015 alkaloid pilocarpine, the active principle of jaborandi, will be found the most convenient and efficient and by far the easiest of administration. In cases of unusual danger, where copious or excessive diaphoresis is imperatively necessary, ])ilocarpine in connection with the hot-air bath is invalualde. But a proportionally larger dose must be given to a child than to an adult. To a child of seven or eight years one-eighth of a grain of the nitrate of pilo- carpine will be a medium dose, and if copious sweating does not commence in half an hour the dose should be repeated. It may be given either by the mouth or hypodermatically, although in an urgent case the latter method should be adopted, and it is always preferable. In a given case experience will soon determine what dose shouid be . employed. When bronchial catarrh is present, pilocarpine is said to have produced profuse and even fatal transudation of fluid into the bronchial tubes, so that patients have been “drowned” in their own secretions. I have seen no such results, and I believe the danger of this acci- dent has been overestimated ; but where any considerable pulmonary or bron- chial lesion exists I place the j)atient in the hot-air bath ten or fifteen minutes before giving the pilocarpine, so that the flow of blood shall be predetermined toward the surface of the body. Three very desirable results follow the use of pilocarpine in acute nephritis : namely, the reduction of arterial tension, the reduction of the temperature, and the free elimination of urea by the skin, as shown by its enormous increase over the normal amount in the perspiration (Bartholow). In cases of danger, where dropsical effusions threaten the heart or lungs, or where uraemic symptoms are imminent, or where progressive coma indicates transudation into the intracranial cavities, the hot-air pilocarpine sweat should be repeated daily, or even twice in the twenty-four hours, until the immediate peril is averted. Here and there a case Avill be encountered in which the hot-water bath — placing the patient in the bath-tub with the water at the temperature of 95° to 105° F. — will answer best, because both the dry air and steam are equally repugnant. When this is the case, by all means let the hot bath be employed, but let it also be remembered that the hot dry air is therapeutically the most efficient, because it produces the most copious diaphoresis ; the steam-bath is next best, while the hot-water bath possesses the least eliminative power. It would be a waste of time to discuss the older and now wellnigh obsolete diaphoretics in view of the certainty which follows the use of those already mentioned. While the above methods of treatment are being pushed, certain internal remedies may be used as adjuncts for the purpose of lowering temperature, lessening arterial tension, calming nervous excitement, and unloading the kidneys of the products of exudation and waste. These various indications may be met by such remedies as aconite, codeine, or the bromides, and the potassic salts, especially the acetate or citrate, or the acetate of sodium. I fre- quently prescribe some such mixture as the following : Tr. aconit fess. Codeine gi’- U- Potass, citrat 3iij. Glycerini fsi j . Aquae cinnamom q. s. ad flviij. — M. Sig. A dessertspoonful every two hours in half a glass of pure water. This formula is intended for a child of seven or eight years of age ; of course the quantities must be increased or diminished according to age. In some AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. cases it will be found that the codeine provokes nausea ; when this happens, sodium bromide or potassium bromide may be substituted. In other cases the potassic citrate will cause gastric eructations or troublesome flatulency; thisAvill call for the use of }>otassic acetate or sodium acetate in its place. The above formula is given simply as a suggestion ; it must be varied so as to suit the indications as they arise. The practitioner should first have a clear and definite comprehension of what he wishes to accomplish ; then, and then only, can he set about an intelligent adaptation of means to ends. If the foregoing measures are promptly and vigorously carried out, it is not probable that urmmic convulsions will supervene ; but if they roper in a, case of enteritis ; so, under similar conditions, a mild diuretic may be jirojicr in a case of ne])hritis ; but in neither case can the remedy be reganled as curative of the lesion. In nephritis, as we have seen, the renal tubes become occluded ACUTE TUBAL NEPHRITIS. 1017 by fibrinous casts, and experience has demonstrated that tliese casts are solu- ble in the alkaline salts of potassium. It is therefore advisable to administer 10 grains of the citrate of potassium, dissolved in half a glass of water or lemonade, every three hours, it being Avell known that citric acid and the citrates are converted into alkalies after ingestion. If there be any serious indication of cardiac exhaustion, digitalis may be combined with the potassium, but not unless it is clearly indicated. I am persuaded that the indiscriminate and ill-judged use of digitalis and other cardiac tonics is productive of more harm than good. It should be remembered that digitalis and other cardiac tonics are not direct but indirect diuretics, acting by virtue of their power of increasing arterial tension. But the potassic salts are “direct” diuretics; that is, they actually increase elimination of the factors of the urine, especially urea, the most important of them all. Thus they subserve two useful purposes : they remove from the occluded tubes the plugs of fibrin and other material, and they rouse the dormant epithelia of the convoluted tubes into action wdthout unduly exciting them. The vegetable potassic compounds, more particularly the citrate or acetate, may very properly be continued in medium doses until the albumin has disappeared from the urine. One of the constant results of nephritis is anmmia, frequently of a very pronounced type. This is due to loss of blood, loss of albumin, but perhaps quite as much to the body waste which attends pyrexia and the. cessation of assimilating power. No acute disease produces such rapid and extreme anjemia as acute nephritis. It is important that it be recognized early., before the anaemic or “ run-away ” heart is developed, which is so prone to result in valvular disease and a life of suffering. The remedies ai’e rest in the recum- bent position, appropriate food (of wdiich I shall speak presently), and the chalybeate tonics. Of the latter, the “ mistura ferri et ammonii acetatis ” (otherwise known as “Basham’s mixture”) or the ferri et potassii tartras, or the ferrum dialysatum have given me the best results, and I have mentioned them in the order of their comparative value. Basham’s mixture is an elegant diuretic tonic, usually very well borne and easily assimilated. It can be given as soon as the temperature falls to the normal point, and thus the practitioner can anticipate and prevent the extreme anaemia so sure to' follow if the case be allowed to drift on. When the urine is scanty and the sediment abundant, it is an excellent plan to combine equal parts of a saturated solution of potassium citrate with Basham’s mixture, of which a teaspoonful every three hours may be given to a child eight years old. A very good formula is the following : I^. Sol. potassii citratis (sat.), Mist, ferri et ammonii acetatis .... da f.^ j. Glycerini f.^j. Aqure q. s. ad fsiv. — M. Sig. A dessertspoonful every three hours in water. I am much in the habit of adding glycerin to diuretic formulte, because it seems in some unexplained manner to promote their action. At a later period, when the kidneys no longer require any specific medication and a stronger tonic is desirable, the potassic tartrate of iron may be substituted in doses of from 3 to 5 grains three times a day. No other therapeutic measures will be required unless special complications arise : if this be the case, they must be met according to the indications in each particular instance. The diet of a child suffering from acute nephritis, or, in fact, any lesion inducing renal inadequacy, is of the utmost importance. Both theory and 1018 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. experience concur in the necessity for excluding a nitrogenous dietary. In the early stage of acute nephritis all solid food should be cut ofl‘. This exclu- sion should extend also to broth, beef-tea, soups, and all forms of liquid diet of which beef or mutton forms the basis. The ideal food is milk, and during the period of invasion this should be taken sparingly. Milk and water (half and half) is an excellent combination, as it combines nutrition with a natural diuretic. As the kidneys regain their activity and fever subsides pure milk may be given, together with bread, oatmeal, or crackers. A little fruit, as a baked apple or the juice of an orange, may also be allowed, but the diet should be increased slowly and cautiously, and flesh food must be prohibited until the casts and albumin have been absent for several consecutive weeks, and even then it should be given only in small quantities once a day. A few general suggestions may not be improper. The patient — be he child or adult — should not be discharged as “cured,” but should be kept under observation long after all signs and symptoms of trouble have disappeared. If frequent examinations of the urine are kept up, as they should be, the practi- tioner will be surprised every now and then to find a little albumin and a few small structureless hyaline casts appearing, even after they have been absent for many weeks. So long as this is the case there is great danger of a sudden return of the acute symptoms with a fatal result, or of the supervention of chronic nephritis, with equally sad, although less sudden, consequences. It is therefore the duty of the physician to ■warn pai’ents of the lurking perils, and to exercise a personal supervision over the patient until health is fully restored. Again, muscular exercise is dangerous to a patient recovering from acute nephritis, because it strains the heart and loads the urine with nitrogenous products of disassimilation, thus throwing work upon the kidneys which they cannot safely do. The patient should therefore be kept quiet for a much longer time than seems necessary to parents and friends. Lastly, the patient should be warmly clad and carefully guarded fi’om exposure to wet and cold. Woollen garments and confinement within doors should be insisted upon until the child’s symptoms and the weather give concurrent testimony that gentle exercise in the open air may be cautiously entered upon. To some these suggestions may seem superfluous, but to observe them will do no harm, while if they are neglected the lives of helpless children may pay the fearful penalty. n. Chronic Tubal Nephritis. Synonyms. — Chronic dift’use nephritis ; Chronic catarrhal nephritis ; Chronic croupous nephritis; Chronic parenchymatous nephritis; and Chronic Bright’s disease. Etiology. — Acute nephritis is the most common cause of chronic nephritis in children. Scarlatina stands next in order ; then comes exposure to cold and wet, especially when combined with malarious or other unhealthful sur- roundings, as is so frequent among the children of the neglected poor. Long- continued suppuration, although more likely to produce amyloid degenera- tion of the kidneys, may cause chronic tubal ne])hritis, probably, as Bartels suggests, because “something is developed in these collections of pus which is taken up into the blood by absor))tion and excreted by the kidneys, and which, during its excretion, excites an inflammation of these excretory organs.” Nearly twenty years have elapsed since these words were written, and we do not yet know what that “ something ” is, but in the light of modern pathological research we can easily understand that the toxic derivatives of chronic suppuration might easily worry the kidneys into chronic inflammation. CHRONIC TUBAL NEPHRITIS. 10 ] !) Diphtheria must certainly be regarded as a cause of chronic as well as of acute nephritis, and so must measles, but less frequently. Few cases of diabetes mellitus terminate without the supervention of chronic tubal nephritis. Finally, anything which demands constant overwork of the kidneys, or which results in a slight but long-continued irritation of them, may prove the ground- Avork of chronic tubal nephritis. Symptoms. — The symptoms vary very much in different cases, being modified by the rapidity with which the disease progresses. When the progress is rapid the symptoms are more pronounced, and vice versa. In a typical case of chronic tubal nephritis the first symptom attracting attention is likely to be great debility and Avell-marked anaemia. The pulse is small, rapid, and feeble, and anaemic cardiac murmurs are common. There Avill probably be no rise of temperature, or, if any, very slight and inconstant. The digestion is impaired, the tongue coated, and the bowels torpid or loose and irregular. FolloAving these symptoms, and frequently coincident with them, is dropsy, generally first manifested on the dorsum of the foot and around the ankle-joints, or perhaps it is first seen in the swollen and transparent eyelid. There is also a marked pallor or waxy appearance of the face, Avhich is quite chai’acteristic. The dropsy extends up the loAver extremities, invades the abdomen, may reach the chest and oppress the lungs and heart, so as to become a source of serious danger, although this can generally be avoided. The disease is usually divided into three stages ; this division, though some- what arbitrary, is convenient. During the first stage the urine is generally scanty, dark, and turbid ; of variable, but with a tendency to high, specific gravity (1020 to 1025), and heavily loaded with albumin (2 grams or more to the litre), as determined by Esbach’s “ albuminometer ” — the best, because the simplest, apparatus yet devised for the practical quantitative estimation of albu- min. After standing, the urine deposits an abundant precipitate composed of hyaline and epithelial casts, with occasionally a blood-cast, renal epithelia, and granular matter of indeterminate origin. Chemical examination will show the percentage of urea to be much less than normal, while the chlorides, sulphates, and phosphates, though diminished somewhat, are nearer the normal point. With the development of the second stage the urine increases in quantity, but becomes pale in color, sometimes all but colorless, of Ioav specific gravity (1005 to 1010), less turbid, but not quite clear, and the sediment diminishes very much in quantity, and also becomes nearly colorless. But the quantity of albumin remains large, rarely falling below IJ grams to the litre, and the solid excreta are still markedly deficient. The casts also change. The blood- casts disappear entirely ; the hyaline casts increase in number, and many of them are large and someAvhat distorted, shoAving that they are formed in tubes which have shed their epithelium. The epithelial casts present a granular cloudy appearance, and their borders are eroded or “nibbled,” shoAving that fatty change has commenced in the epithelia and that the Avails of the tubes have become roughened and irregular. As the disease progresses an occasional wave of renal hyperaemia may occur, Avhen the urine again becomes scanty, dark, and cloudy, and the casts characteristic of the first stage reappear, but intermingled Avith these Avill be found the granular casts Avhich belono; to the second stage, so that no serious confusion as to the diagnosis need occur. With the commencement of the third stage the urine again becomes scanty and cloudy, but is still pale and Avatery. The albumin does not diminish, but is more likely to increase. The casts noAv become “fatty ; ” that is, they are large, short, irregular, with rough borders, and contain fine fatty granules, minute drops of fat, and epithelial cells in an advanced state of fatty degenera- WIO AMERICAN TEXT- BOOK OF DISEASES OF CHILDREN. tion. During this stage periods of {)artial or incomplete suppression of urine are apt to occur, followed by urminic convulsions, succeeded by coma, or per- haps sudden death without coma: or drowsiness may gradually steal over the patient, until it becomes coma ending in death. Meantime the dropsy becomes general, the limbs swell almost to bursting, the abdomen becomes distended with fluid, the thoracic cavity gradually fills, pulmonary oedema with impeded respiration occurs ; the heart labors violentl}’ until it suddenly fails from ex- haustion, and death ensues. It must not, however, be inferred that all cases present these distressing symptoms. In the majority they are either not wit- nessed at all or are easily anticipated and prevented. Diagnosis. — Chronic tubal nephritis may be confounded wdth («) chronic interstitial nephritis ; (6) amyloid disease of the kidney ; (c) cyanotic indura- tion of the kidney. (a) Chronic interstitial nephritis is very rare in children, but it is not diffi- cult to differentiate it from tubal nephritis. Chronic interstitial nephritis (renal cirrhosis) is characterized by its slow and insidious development ; by the increased volume of urine ; by its low specific gravity and small amount of albumin ; by the absence of dropsy, except in the last stage ; by the early de- velopment of cardio-vascular tension ; and, generally, by well-marked lithajmia. None of these symptoms are present in chronic tubal nephritis. (b) Amyloid disease of the kidney is most likely to occur in children, and, as it sometimes occurs in connection wdth tubal nephritis, a certain diagnosis may be impossible. The distinctive features of amyloid disease are an increased quantity of urine with a comparatively large amount of albumin ; absence of leucocytes and epithelial cells, but the presence of numerous small hyaline casts which are perfectly structureless, but some of wdiich are likely to give the characteristic reaction wdth iodine. There is usually considerable disturb- ance of the digestive tract, wdth hypertrophy of the liver and spleen, and this disease is almost always caused by and associated wdth syphilis, tuberculosis, or some chronic disease involving suppuration. These diagnostic points are quite sufficient to distinguish an uncomplicated case of chronic tubal nephritis from an uncomplicated case of amyloid disease. (c) Cyanotic induration of the kidneys only occurs where there is some obstructive lesion of the organs of circulation wdiich retards the movement of blood through the kidneys and produces venous stasis. There is little albumin in the urine ; the casts are few, generally small, and of the hyaline variety ; dropsy is generally limited to the lower extremities ; respiration is difficult ; much exercise is impossible ; and the cii’culation is much embarrassed. None of these peculiar features belong to chronic tubal ncjihritis. But careful atten- tion to the history and constructive symptoms of the latter almost invariably enables the practitioner to arrive at a correct diagnosis. Morbid Anatomy. — In a given case the morbid appearances wdll depend entirely ujion the stage at which the examination is made. 1 shall briefly de- scribe the macroscopic and microscopic changes which are peculiar to each of the three stages, wdiich are themselves founded upon the anatomical changes so uniformly present. During the first or hyperiemic stage the kidney is either of normal size or only slightly enlarged ; the capsule is somewhat cloudy, but strips off easily, leaving the surface of the kidney smooth and red or jmrple. On section blood oozes from the cut ves.sels, and the cortex is seen to be relatively increased. The vessels in the “ boundary layer ” are turgid and frequently tortuous, and the vasa recta stand out as well-ilcfined red lines running tow'ard or into the apices of the cones. Between the straight vessels numerous white or grayish CHRONIC TUBAL NEPHRITIS. 1021 lines will be seen ; these are the straight tubes occluded and distended by casts and epitbelia. Microscopic study of a section of the cortex will show that the blood-vessels are dilated and tortuous — that the convoluted tubes are stuffed with fibrinous casts, perhaps blood-globules, and enlarged epithelial cells, some of which are in a state of ‘‘cloudy swelling.” The second or hypertrophic stage results in considerable, and sometimes extreme, eidargement of the kidney ; the capsule is but little changed and strips off’ easily, leaving the sui’face generally smooth, but with here and there a slight cicatrix-like depression. Its color is variable and mottled, showing pale grayish or whitish spots or islands surrounded by interlacing groups of “ stellate ” vessels, which are beautifully displayed. The pale spaces are the dis- tended fatty convoluted tubes lying near the surface. On laying the kidney open longitudinally it will be seen that the cortex is increased, but pale or yellowish, and that it is anaemic rather than hypertemic. The Malpighian bodies are not enlarged and prominent as in the stage of hyperaemia. The vessels in the boundary-layer are thickened and enlarged, but not distended with blood. The cones or pyramids have undergone no essential change. This is the so-called “ large white kidney” or “large fatty kidney.” The microscope shows the convoluted tubes distended with epithelia in an advanced state of fatty degeneration ; they also contain granular casts and fine fatty granules which have not fused into drops. The Malpighian bodies are some- what enlarged, and the space between the glomerulus and the capsule of Bowman is apt to be occupied by exuviated epithelial cells in a state of fatty transformation. The walls of the blood-vessels may be somewhat thickened, but not markedly so. It will be seen that the “ hypertrophy ” is more apparent than real, and that it is mainly due to the distention of the tubuli contorti, each one of which occupies far more space than it does normally. The connective tissue is not materially increased. The third or last stage is very appropriately known as the stage of “ atrophy.” The kidney is small, shrivelled, mottled, but the predominant color is gray or grayish yellow. It is never red. The capsule is generally slightly thickened, but strips off easily, except that here and there it may bring a small bit of the kidney with it. The surface of the organ is no longer smooth, but broken by alternating elevations and depressions. On section it is seen that the cortex is wasted or atrophied, while the medullary portion is not materially changed. The cut surface is frequently oily to the touch, and if it be scraped with a scalpel, drops of oil will appear upon the blade. Microscopic sections show many of the tubules shrivelled and wasted — many others dis- tended with fatty casts, free fat-drops, and epithelial cells in complete fatty degeneration. The walls of the blood-vessels are much thickened, and the connective tissue is somewhat increased, but has not entered upon the con- tractile process which produces cirrhosis. It should also be observed that the kidney is pale throughout its entire extent, which fact differentiates it from the “cirrhotic kidney,” to be considered px’esently. Prognosis. — During the first or inflammatory stage recoveries are common. They ought to be more so. An early and correct diagnosis and an appropriate line of treatment, administered with some faith in its efficacy, are indispensable to the successful treatment of chronic nephritis. Unfortunately, the impression is quite too general among the profession that chronic Bright’s disease is always incurable, and impressions ingrained for years are apt to become dogmas. Nevertheless, chronic tubal nephritis, at any time up to the actual develop- ment of the second or degenerative stage, is a curable disease, and especially so in children, in whom the constructive forces are at their best. 1022 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. After the development of the second stage, or that of pseudo-hypertrophy, the prognosis is far less favorable, yet not absolutely hopeless. I have seen recoveries take place when all the symptoms indicated the inception of fatty changes in the kidney. Each day’s delay renders the prognosis less hopeful, and as the hyaline casts diminish and the fatty casts increase in numbers the prognosis increases in gravity. With the development of the third stage, or that of atrophic wasting, all hope of recovery ends. As functional organs the kidneys are now practically destroyed. Distressing symptoms may be relieved and life may be prolonged, but that is all. Yet the physician must be sure of his diagnosis before he abandons hope, and in the practice of medicine it is far better to err on the optimistic than on the pessimistic side. The disappearance of hyaline casts or their very infrecpient appearance, the prevalence of large irregular fatty casts, which are short, broken, and loaded with fatty epithelium and fat-drops, together with progressive diminution in quantity of the urine, are the most reliable diagnostic fiictors. Treatment. — The treatment of every case of chronic nephritis should stand by itself, and should be carried out in accordance with a well-digested plan founded upon an accurate determination of the stage of the disease. During the first stage, where the condition of the kidneys is something similar to that in acute nephritis, the chief object is to place the inflamed organs at rest. The patient should therefore be kept as (piiet as possible and carefully guarded from exposure to cold. The bowels should be kept freely open by means of saline cathartics. The skin must be actively stimulated and made to do vicarious duty by means of hot air and pilocarpine. The kidneys should be relieved of tube-casts and other obstructive material by the use of the potash salts, much as indicated in the article on Acute Tubal Nephritis. In fact, the general indications are practically the same, and the same measures should be employed, only less vigorously. The diet should be the same — namely, milk in some form with a little fruit — and the patient should be urged or tempted to drink water freely. A little fish, a bit of broiled (juail, or a chicken’s wing may occasionally be allowed for the purpose of varying the monotony, but grills and roasts must be forbidden. The child should be kept warm and the inner garments should be of wool. I particularly insist on woollen stockings — a point that will surely be neglected by mothers and nurses unless insisted upon by the medical adviser. As the case progresses toward recovery chalybeate tonics are indicated, and I advise the employment of those already mentioned in the article on Acute Nephritis, to which reference may be had for details. During convalescence the patient should he carefully watched, and it must not be forgotten that convalescence is not jierfect recovery. Albuminuria will disappear slowly, and will reappear after long intervals of absence, tlius show- ing that the renal vessels have not yet recovered their tonus ; the heart will retnain irritable and weak for a long period ; and the haemogenetic power of the little patient will be recovered slowly. Hence careful but not ostentatious or over-oificious watching will he rc(juired for several months after all symj)- toms have disappeared. When the disease becomes chronic, as indictated by the symptoms denoting “fatty kidney,” the treatment will be .somewhat different. The kidneys must now be relieved as much as possible by bringing the skin and intestinal tract into ])lay. Minute doses of pilocarpine — of a grain for a child of six or eight years — may be given four times a day. A warm salt-and-water bath three times a week, followed by smart friction, is a very useful adjunct to the CHRONIC TUBAL NEPHRITIS. 102:} pilocarpine, the bath of course being given in a warm room. If the skin is rough and dry, it is a very good plan to rub the child with fresh and well- warmed olive or sweet almond oil after each salt bath. These measures may be continued indefinitely. Cathartics must be employed frequently, but wisely. Violent catharsis is rarely required ; gentle stimulation of the bowels is frequently needed, and is very useful, both for its derivative and its eliminant effect. The saline cathar- tics are most useful, but an occasional cholagogue, like the following, Avill not be amiss : 1^. Resin, podophylli g*’- .]• Ilydrarg. chlorid. mit gi’- x. Sodii bicarbonatis gr. xxx. — M. Ft. chart. No. X. Sig. One powder to be given every third night. Diuretics should be used sparingly , and not with any expectation of “ cura- tive results.” The acetate or citrate of potassium, and the bitartrate in the form of “imperial drink ” [U. S. P.], are the safest and most efficient. They should be given freely diluted. Cardiac tonics will doubtless be rec^uired as the case progresses, but they should be reserved until they are actually needed, as their premature employment exhausts the heart-muscle unnecessarily. Of the various heart tonics, digitalis and strophanthus are the most reliable. The chalybeate tonics will be indicated, and the mixture of the acetate of iron and ammonia, the potassio-tartrate of iron, and the new'er preparation called “ fer- rum dialysatum,” have my preference in the order written. Special symptoms Avill require attention. Di'opsy, if excessive, demands active diuretics, as squill, apocynum cannabinum, or that excellent preparation, “ Trousseau’s diuretic Avine,” Avhich consists of — Junip. contus., 3x ; Pulv. digitalis, sij ; Pulv. scillm, 3j‘ ; Vini Xerici, Oj ; macerate for four days, and add potass, acetatis, 5iij ; express and filter. Dose, one teaspoonful in water every three hours for a child of six or eight years, (Tyson’s Bright's Disease a7id Diabetes). Ilydragogue cathartics and active diaphoresis must be employed in con- junction Avith the diuretics ; among the former, calomel and jalap, concen- trated solutions of salines, and elaterium are the best, in about one-third the dose of an adult for a child from six to eight years old. As to diaj)ho- retics, the hot-air apparatus (see page 1014), Avith pilocarpine, stands first ahvays ; but the hot bath or warm pack, aided by pilocarpine, may be employed for the w'ant of something better. It may be found necessary to make minute punctures through the skin of the ankle or dorsum of the foot, so that the dropsical fluid may drain away. I prefer the point of a sharp tenotomy blade for this purpose. If uraemic symptoms appear, they must be treated as already indicated. PVaemic asthma is likely to arise ; it may be temporarily relieved by nitrite of amyl, spirits of chloroform, elixir of valerianate of ammonium, or any other antispasmodic at hand, but it is a consefjuence of uraemia and calls for increased elimination. Insomnia may be relieved by sulphonal, chloral, somnal, or any of the newer hypnotics. I am accustomed to giving paregoric to children with chronic Bright’s disease who are kept aAvake by distressing symptoms, and Avith the happiest effects, although the practice is not in strict accordance with therapeutic orthodoxy. 1024 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN rn. Amyloid Disease op the Kidney. Synonyms. — Waxy kidney ; Lardaceous disease ; Depurative disease. Etiology. — The most common causes of amyloid kidney are syphilis ; exhaustive and long-continued suppuration, especially if associated with necro- sis of the vertebrne, as in Pott’s disease, or of disease of the large joints, as in coxalgia ; phthisis pulmonalis ; chronic ulcerative disease of the bowels ; and chronic albuminuria. As some of these affections are not uncommon in children, it follows that they are liable to amyloid disease of the kidney. The most perfect or complete specimen that I have ever seen occurred in a girl of ten years, who was fairly worn out with repeated abscesses due to Pott’s disease. Amyloid disease rarely occurs in a child under five years, for the reason that the above-named causes rarely exist prior to that age ; yet Dickinson cites a case of amyloid spleen in a boy two and a half years old who had an exhausting: abscess of the thigh. Pathological Anatomy. — In the early stage the kidneys are about normal in size and present little change except to the experienced observer, who will note a peculiar paleness, together with a translucent appearance, Avhen thin sections are held between the eye and a strong light. The capsule is non- adherent. When the kidney is laid open no essential change in the relative proportion of cortex and medulla is seen, but all parts appear pale and com- paratively bloodless. If a few drops of an iodine test-solution be applied, mul- titudes of mahogany red or reddish-brown points will appear, thus locating the infiltrated Malpighian bodies. At a more advanced stage the kidneys are enlarged, sometimes consider- ably' though not to an extreme degree, unless amyloid disease and chronic tubal nephritis coexist. The pale waxy or bacony appearance will now be very apparent, and the iodine reaction will extend to the convoluted tubes, the vessels of the labyrinth, and the vasa recta. In the last stage the kidney is atrophied, contracted, and deformed. The capsule is thickened and adherent, the cortex is wasted, and one is reminded of the cirrhotic kidney, except that the latter is red or brownish red, while the one under discussion still preserves its pale waxy appearance. Microscopic sections show the glomeruli, the capillaries of the labyrinth, the vasa recta, and most of the tubules infiltrated with the characteristic Avaxy material. The application of the iodine test-solution* enables the observer to accurately differ- entiate the infiltrated from the normal structure. Prognosis. — As a clinical fact, amyloid disease is incurable. In a given case, if the cause can be effectually and permanently removed before the kid- neys are damaged beyond the power of carrying on their functions, life may be prolonged indefinitely. Moreover, if the patient be a child of six or eight years, subsequent growth and development may practically restore the structure and function of the diseased organs. So much for theory. In practice Ave generally find that the cause cannot be removed; that the liver is almost sure to be infiltrated Avith amyloid deposit to quite as great an extent as the kidneys; and that in most cases the spleen suffers as well. In other words, Ave are taught that, under certain conditions, amyloid disease is curable, but in practice those fortunate conditions are hardly ever met Avith ; hence the disease is .scarcely ever cured. ‘ I recommend the following formula : li . lodi . 11 .). vj Potassii iodidi (Tlycerini . . Aquie (lest. . CHRONIC INTERSTITIAL NEPHRITIS. 1025 Treatment. — Obviously the most important thing is the discovery and removal of the cause. As I have already said, if this can be accomplished, the progress of the disease may be arrested and the patient may live out his days. In clinical e.xperience this can rarely be done. The next best thing is to reduce suj)puration to the minimum, and secure free drainage and asepsis for sup- purating cavities ; to remove dead bone if it exists, and encourage the process of repair if possible ; to adopt the most approved treatment for tuberculosis if present, including change of climate when it is necessary and practicable ; to institute antisyphilitic treatment when indicated ; and, in fine, to search out and remove the cause if possible. We possess no specific agents for the cure of amy- loid disease. The iodides — especially of iron and potassium — have been highly recommended and much employed, but I have never seen any positive results follow’ their use. Theoretically, 1 should expect more from arsenic or the chlo- ride of gold and sodium. Diuretics must be given if symptoms of suppression show themselves. Diarrhoea, which is likely to be troublesome, must be treated on general principles. Anaemia — always pronounced in amyloid disease — should be combated by iron, malt, cod-liver oil, arsenic, and especially by a liberal diet, w'hich may be safely given unless nephritis should complicate matters. If dropsy becomes troublesome, the diaphoretics, diuretics, and cathartics already recommended will answer every purpose. Uraemia is not likely to occur, as the functional pow’er of the kidney is destroyed so slowly that the system acquires “toleration;” but if it occurs it must be treated promptly and vigorou.sly as already indicated. If nephritis arises, it will require the prompt employment of the measures recommended in a previous article ; it is of course a dangerous complication and one of not very infrequent occurrence. Other complications may arise, just as they may in the course of any other chronic disease, and must be met and treated according to the indications presented in each individual case ; but the physician should remember that the elim- inating power of the kidneys is more or less damaged, and he must exercise due care in the use of certain drugs, like digitalis, which have a cumulative tendency. rV. Chronic Interstitial Nephritis. Synonyms. — Renal cirrhosis; Gouty kidney; Granular degeneration; Contracted kidney ; Renal sclerosis, etc. Etiolog-y. — Among the most frequent causes of interstitial nephritis are rheumatism and gout (more correctly called lithaemia), alcoholism, lead-poison- ing, valvular disease of the heart, malaria, mental strain, heredity, and chronic lesions of the genito-urinary tract. As these causes are hardly ever active in childhood, it follow’s that cirrhotic kidney is exceedingly rare under puberty. All authors to Avhose Avritings I have access agree that it is not a disease of childhood. I have never seen a case in a patient under thirty. Bartels records one case at eighteen years, and Dickinson one “between eleven and tAventy years.” Suppurative interstitial nephritis, pyelo-nephritis, or “ surgical kidney,” may occur in children, hut it does not fall Avithin the scope of this work. It is of course possible that heredity or cardiac disease may cause con- tracted kidney in childhood, but in clinical experience we rarely meet with such cases. Symptoms. — The following are the four classic symptoms of interstitial nephritis, and I may mention them in the order of their occurrence : (1) increased arterial tension, with a sharply accentuated second sound of the heart : the increased arterial tension is easily recognized by examining the pulse ; (2) the 65 1020 AMERICAN TEXT-BOOK OE DIBEASEH OF CHILDREN. small amount of albumin present (rarely more than 1 to 2 per cent, by volume) or its entire absence for considerable periods of time ; (3) the small number of casts, their small size and structureless or hyaline appearance, and their form, which is in many instances twisted or distorted; (4) the appearance of albumin- uric I’etinitis, which is a late and very characteristic symptom. These four symptoms are so nearly always present in interstitial nephritis, and so uniformly absent in other forms of renal disease, that they may be regarded as ])athognomonic. Early in this disease the urine is pale and watery, increased in quantity, and of low specific gravity (1005 to 1010). Pathological Anatomy. — Chronic interstitial nephritis results in the pro- duction of the “small red,” “contracted,” or “ cirrhotic” kidney. The kid- neys are contracted, atrophied, rough or nodulated, and dark red or brownish red. The capsule is thickened, and when pulled off tears away portions of the kidney with it. On section it is observed that the cortex is very much wasted, and the medulla somewhat so. The arteries are enlarged, tortuous, prominent, and unyielding or inelastic. The organ is indurated and condensed. Micro- scopic sections show a great increase of the connective tissue, with Avasting and distortion of the tubules and the smaller blood-vessels. Broad bands of con- nective tissue will be seen between the remaining tubules and suri’ounding the Malpighian bodies. Many minute cysts will be seen which are due to dilata- tions of the tubuli mainly, but partly to dilated Malpighian bodies. Prognosis. — Chronic interstitial nephritis is incurable. The damage done by overgi’owth of connective tissue cannot be repaired. Yet it is quite pos- sible to arrest the further increase thereof, and thus practically arrest the disease and prolong life indefinitely. Much depends upon the patient’s habits, environment, temperament, age, and social condition. Under fiivorable cir- cumstances so much can be accomplished that, so far as the patient is concerned, a practical cure may be expected. But the physician must not forget the inveterate tendency of connective tissue toward mischief Avhen once aroused, and he must regard the disease, although latent, as still present and ready to break forth at any unusual provocation. Treatment. — 1 reaffirm and refer to all that I have said in the foregoing pages regarding habits, dress, exercise, and food and drink, except that the dietary may include a little fish or fowl or a small allowance of almost any kind of game once a day. Medical treatment should be directed to the arrest of the further development of pathological connective tissue in the kidney. For this purpose the remedies most efficient in my experience are bichloride of mercury, iodide of potassium, and chloride of gold and sodium, in small doses long continued. I use but one of these I’emedics at a time, but alter- nate them at intervals of two or three Aveeks. If the kidneys falter, diure- tics are indicated, and I have found the lactate of strontium a prompt and efficient diuretic in this form of Bright’s disease. It may be given in doses of 5 grains three times a day to patients from six to eight years old. Diure- tine sometimes ansAvers very Avell, but is (juite likely to fail altogether. Of course the {)otash salts may be given Avitb every expectation of good results. Chalybeate tonics are indicated in most cases, and the tincture of the chloride of iron is particularly adaj)ted to our Avants. If combined Avith .syrup of lemon (1^. Tr. ferri chloridi, f^j ; syr. limonis, adf.^ij. — INI.) it makes a very ])alatable mixture, and Avill be readily taken by cliildren. Heart fiiilure, uraemia, and other conqdicating .symptoms must be met and treated as already indicated in the foregoing articles. O O TUMORS AND OTHER ENLARGEMENTS OF THE KIDNEY. By THOMAS R. NEILSON, M. D., Philadelphia. Tumors of the kidney are met with in infancy and childhood with suffi- cient frequency to make the subject one of great importance from a clinical point of view. In the allotted space the different varieties of these tumors, or those diseases of the kidney which may constitute tumor, will of necessity be considered somewhat briefly. But, while no extended discussion of the subject can be attempted, the effort will be made to present as compactly as possible the essential facts. In addition to solid growths — neoplasms — certain other affections, cysts, hydronephrosis, pyonephrosis, and perinephritic abscess, may give rise to enlargement in the renal region. These will be first taken up. Renal Cysts. Congenital Cystic Degeneration of the Kidney. This condition may cause tumors of considerable dimensions. It sometimes results in destroying the life of the foetus or in premature birth, and so great may be the size of the tumor that delivery is impossible and embryotomy is required. In less-marked cases the child may live a few months or even a year or two, and may not give evidence of the affection by the presence of tumor, but sooner or later is likely to perish either from unemia or from exhaustion. In this disease the kidney is studded with or changed into a con- glomeration of cysts of varying sizes, filled with a fluid usually clear, but sometimes turbid, and containing urea and urinary salts. Both kidneys are, as a rule, affected. The condition is generally accompanied by defects of development of the urinary apparatus, such as absence of the pelvis of the kidney or the ureter, exstrophy of the bladder, and malformations of the genitalia, as ivell as vices of comformation of the extremities, hare-lip, cleft palate, etc. The origin of the affection has been explained by Virchow as due to an imperforate con- dition of the straight tubes of the papillie, resulting from a prenatal inflam- mation caused by impaction of the ducts with uric acid and the urates, and leading to retention of secreted urine and dilatation of the uriniferous tubules. Another view of the etiology has been taken by Koster, who considers the condition to be due to defective development. The accompanying abnormalities of the urinary organs, as well as of other parts of the body, ivould seem to favor this theory, at least in some cases. Cystic degeneration is not likely to call for surgical treatment. Even 1027 1028 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. tliough there should be marked symptoms caused by the dimensions of the tumor, the strong probability of both kidneys being affected and the fatal tend- ency of the disease would interdict any radical interference, and even aspira- tion could offer but slight temporary relief, if any at all. Paranephric Cyst. Another variety of renal cysts which may be met with in children is one which grow's in the cellulo-adipose tissue surrounding the kidney, the cyst not being primarily connected with the kidney. Morris, in his work on Surgical Diseases of the Kidney, mentions an interesting case of this kind reported by Mr. Cmsar Hawkins, observed in a boy six years old. In this instance the cyst developed from an imperfect third kidney, and reached great proportions, extending from the lower border of the thorax to Poupart’s ligament. The cyst seemed to be like the simple renal cysts met with in adults, and was filled with a clear fiuid which contained neither albumin nor urinary salts. Paranephric cysts may be of congenital origin, as in the case just referred to, and xsometimes they maybe due to traumatism. They may communicate secondarily, by a fistulous tract, with the pelvis of the kidney or the ureter. The diagnosis of the tumor from other forms of renal cyst and from hydrone- phrosis must be difficult, if not sometimes impossible. Treatment. — These cysts should be evacuated with the aspirator, and the procedure repeated if the fluid should reaccumulate. If, after this has been tried, the cyst should rapidly fill up again, it would be better to cut down upon it and incise it, securing it to the margins of the wound in the integument, thus maintaining drainage. Hydatid Cysts of the Kidney. The ova of the ta?nia echinococcus, a diminutive species of tapeworm infesting some of the lower animals, notably dogs, sheep, and swine, are some- times transmitted to man in food and drinking water, and give rise to what are known as hydatid cysts. In the kidney hydatids are not so frequent as in the liver, the statistics of Davaine, quoted by Roberts, shoiving the proportion to be 1 to about 5J. Pathology and Symptoms. — Hydatid of the kidney may be met with at any age, although less often in children than in adults, and is unilateral, involving the left oftener than the right kidney. Palpable tumor is produced in somewhat less than one-half of the cases. The cyst, surrounded by a capsule of fibrous tissue and having in its interior the characteristic daughter cysts, usually develops in the parenchyma of the kidney, but sometimes between the organ and its capsule, and, as it grows, encroaches on the kidney tissue, causing more or less atrophy. Sometimes several hydatids are found in the same kid- ney. These cysts tend to rupture and discharge their contents, and this may take place into the pelvis of the kidney, which is the usual jflace, into the intestine, or into the lung. The peritoneum is generally pushed forward by the tumor, and rupture into its cavity never occurs. Unless the cy.st has attained j)ro])ortions sufficient to constitute a tumor, or uidess it should rupture and discharge its contents in the urine, there may be no evidence of its presence. The tumor generally occupies the loin, is globular in outline, and more or less fluctuating. The thrill or fremitus supposed to be peculiar to hydatids is a very uncertain .symptom of the disease in the kidney, having seldom been observed in recorded cases. Rupture of the cyst into the TUMORS OF THE KIDNEY. 1029 pelvis or ureter is manifested by pain in the lumbar region, together with a sensation of something having given way. Then, as the vesicles descend through the ureter, symptoms similar to those caused by the passage of a renal calculus will he provoked. The vesicles may become impacted and obstruct the ureter, giving rise to distention of the kidney with urine; or, reaching the bladder and escaping into the urethra, they may obstruct that channel and cause retention of urine. The escape of the hydatid vesicles, or of portions of the laminated cyst-wall, or of the peculiar booklets of the echinococcus in the urine positively establishes the presence of the affection. In some cases pus has been noticed in the urine during the discharge of the cyst. After once evacuating itself the tumor may subside, or, on the other hand, it may fill again and empty itself as before, and this may happen at greater or less inter- vals for a long time, even many years. Should the cyst undergo suppuration, fever and other evidences of constitutional disturbance will result. Diagnosis. — A renal tumor is easily recognized as an hydatid cyst when vesicles, particles of cyst- wall, or booklets appear in the urine. In the absence of this evidence the tumor may readily be mistaken for hydronephrosis, other varieties of renal cyst, or pyonephrosis. Hydatids differ from malignant tumors of the kidney in their slow development and the absence of constant pain and cachexia. Prognosis. — The disposition of these cysts to rupture and discharge their contents by the urinary channels or to disappear without evacuation makes the prognosis usually good. If, however, the tumor continues to increase in size, it may lead to serious, sometimes fatal, results from destruction of the paren- chyma of the kidney or from pressure upon other organs. Suppuration, either in or about the cyst, is a grave complication, and death may follow rupture into the pleural cavity or the bronchi. Treatment. — With the object of destroying the life of the parasite certain anthelmintics, such as oil of turpentine, male fern, and the like, have been exhibited, but there is no evidence of their efficiency. When hydatids are dis- charged in the urine, alkaline diluents should be freely given for the purpose of increasing the secretion of urine, and thereby favoring the Avashing out of the pelvis and ureters. Beraud is mentioned by Roberts as having had a case in which the administration of nitre caused an increase in the discharge of vesicles. Renal colic induced by the escape of hydatids into the pelvis and ureter should be treated as when due to other causes. If the cyst does not discharge, but continues to increase, or if it should sup- purate, or if, from obstruction of the ureter, sudden distention of the kidney should occur, surgical interference Avill be called for. Under these circumstances, while aspiration may afford relief, the best prospect of success is offered by cutting down to the tumor, opening the cyst, and suturing its edges to the external wound. Hydronephrosis. The term “ hydronephrosis ” signifies dilatation of the kidney and the ureter from some hindrance to the outflow of urine. The affection may be either unilateral or bilateral. Its causes may be divided into congenital and acquired. When the cause is congenital, it does not necessarily folloAV that the hydrone- phrosis is present at birth ; it may not develop for some years later. In extreme cases the condition has caused dystochia, necessitating embryotomy. Etiology and Pathology. — The obstacle which leads to the formation of hydronephrosis may be any one of several. Thus an excessive angulation of UYiii AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. the junction of the ureter with the pelvis of the kidney, a twisting contrac- tion, imperforate condition, or valvuhition of the ureter, compression of that duct by an abnormal supernumerary renal artery, and obstruction of the urethra by a septum of mucous membrane, are all recognized causes, falling under the congenital class. As acquired causes may be named obstruction of ureter from injury due to the passage of a calculus or from traumatism from without, stone in the bladder, vesical tumors, stricture of the urethra, phimosis, and habitual frequent micturition. Floating or movable kidneys are sometimes hydronephrotic. The proportion of cases in which there is tumor is small, but the distention sometimes reaches enormous dimensions. The appearance of the sac varies, sometimes being quite thin and pellucid, while at others it is thick and opacjue. The accumulation of urine first distends the pelvis of the kidney ; then the calyces becomes dilated, and by degrees the resulting compression causes absorp- tion of the renal substance, until none, or but a mere trace, of it remains. The tumor thus formed is a cyst, sometimes, but not always, subdivided by fibrous septa. Its contents differ in the majority of instances from normal urine. Often a fluid resembling water is found ; in other instances it may be brownish ; and, again, colloid material may fill the sac. The fluid may contain no salt but chloride of sodium ; or uric acid and its salts, oxalate of lime, and the phosphates may be present, as may albumin, pus, muco-pus, and epi- thelial cells in some cases. Symptoms. — When the affection is limited to one kidney, and the sac so small as not to produce tumor, it may give rise to no definite symptom ; on the other hand, occasionally there may be lumbar pain, thirst, frequent micturition, or intermittent anuria. When both kidneys are hydronephrotic, urmmia may result. When tumor is present, it is situated in the first place in the loin or flank ; later it becomes more prominent in the abdomen, and may even reach such a size as to extend from the median line in front to the vertebral column behind, and from the hypochondriac region above to the iliac region below. A very large tumor will by its presence create considerable pain, and in those cases in which the trouble results from an obstruction in itself painful there will naturally be much suffering. The tumor on percussion is dull, and on palpation is soft and fluctuating, and sometimes a lobulated condition of its out- line may be noticed. The abdominal viscera may be variably displaced according to the size as well as the direction in which the cyst extends, and symj)toms referable to its pressure on the different organs or the diaphragm may result. Sudden subsidence of the tumor, either comj)lete or partial, may occur synchronously with the passage of a large amount of urine. The urine under these circumstances is of a lower specific gravity than normal, and may occasionally contain pus, muco-j)us, or even blood. Ilydronephrosis is some- times intermittent. Diagnosis. — In the few cases in which the abdominal tumor subsides during the discharge of a large (piantity of urine the diagnosis ))resents little difficulty. Under other circumstances hydrone])hrosis may resemhle renal, ova- rian, hepatic, or splenic cysts, ])yonephrosis, }>erine])hritic abscess, and ascites. There may be considerable difficulty in making the diagnosis from renal cysts, exce{)t in the c.ase of hydatids, when vesicles appear in the urine. Ovarian cysts may be distinguished by their relation to the colon, which is generally behind them, and by the ab.sence of dulness on percussion of the loin. In ascites the area of flatness on pcrcu.ssion changes on alteration of the patient’s position, while in hydronephrosis it remains fixed. Pyonephrosis and peri- nephric abscess present a history of pyuria or the constitutional signs of sup- TUMORS OF THE KIDNEY. 1031 puration, aud oedema and re were under one year old, 17 between the ages of one and three, 18 between three and five, 0 between five and eight, and 4 between eight and twelve years of age. As to .sex, in 40 cases in which it Avas stated 22 were females and 18 Avere males, d'he tumor is unilateral as a rule. When both organs are the scat of groAvths, cxcc])t in cases of congenital myosarcoma, the involvement of one organ is secondary to the disease in the other. Of 80 cases, the right kidney Avas the seat of the neophnsm in 14, the left in 12, and both Avere involvetl in 4. TUMORS OF THE KIDNEY. JO;35 The great majority of these renal tumors in children are sarcomata. Out of o2 cases, 43 were instances of sarcoma, while 9 were designated as encephaloid carcinoma. The variety of sarcoma most often found is the round-celled, both large and small, the spindle-celled variety being less frequent. These growths, which are first usually encapsuled, hut which, owing to their rapid develop- ment, soon extend through their capsule, may begin at the hilum and either spread around and envelop the kidney, or they may extend into the kidney, which ultimately becomes stretched out as a thin layer over the tumor. More often they originate in the cortex, being separated from the surrounding renal tissue by a capsule until the latter gives way, when the sarcoma extends through- out the kidney. In addition to the round-celled and spindle-celled, other varieties of sarcoma which have been found are adenomo-sarcoma, in which the sarcomatous tissue and that of the glandular substance of the kidney are com- bined ; myxo-sarcoma, in which the elements of mucous tissue are combined with sarcoma; alveolar sarcoma; and myo-sarcoma and rhabdo-myoma. Tumors of the last-named kind are of congenital origin, and consist of a mixture of striped muscle tissue and sarcoma tissue. They may be either unilateral or bilateral, sometimes reach a very large size, and are rapidly fatal. Owing to special characteristics, certain sarcomata have been described as fibrous and fibro-fatty tumors. Sarcomata of the kidney grow rapidly and are highly vascular, extravasa- tions often taking place into them. They frequently break down in places and form cysts containing blood and clots. The variety of carcinoma which has been most frequently met with is the encephaloid, although any of the varieties may be found. Encephaloid cancer of the kidney has sometimes attained immense proportions. The gi’owth may invade the entire kidney, being disseminated throughout it and producing a tumor possessing the general outline of the organ, or it may develop from one part of the organ and have an irregular outline. The origin of the growth is traced to the intertubular connective tissue, its epithelium being derived from proliferation of the normal renal epithelium. Like sarcomata, carcinomata grow I’apidly. It is doubtful whether some of the tumors specified in the older classification as encephaloid cancer Avould not now be placed under the heading of sarcoma. Lymphadenoraata have been occasionally observed in the kidney, but are secondary to disease in the lymphatic system. It is possible that a growth of this kind might be mistaken for a round-celled sarcoma. Malignant growths of the kidney spread by means of the lymphatics and veins. Carcinomata are particularly apt to involve and extend by the veins. Secondary formations soon take place. The lumbar glands are early infected. The tumor may by pressure cause erosion of the vertebrse, and, opening the spinal canal, involve the meninges, and even the cord itself, by direct extension. Symptoms. — In addition to tumor, which is the symptom most invariably present, malignant disease of the kidney causes pain, emaciation, cachexia, frequent perhaps involuntary micturition, hrematuria, and various symptoms resulting from pressure of the growth. The tumor, if detected early, will be found confined to the loin, where it causes more or less fulness or prominence. In some recorded cases the growth has attained an immense size, occupying the whole abdominal cavity, pressing upward the diaphragm and embarrassing the thoracic organs. Again, in other cases it may be very difficult, if not impossible, to detect a palpable tumor, even though metastasis has taken place. Pain in the lumbar region is an early indication, but while in older children, as in adults, it is an important AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. sign, it is very doubtful if in very young subjects it could be relied upon, as it is not likely that it would be intelligently located. It is dull in character and usually constant, although occasionally paroxysmal, differing, however, from the pain due to renal calculus in not being either aggravated by motion or relieved by rest. Hgeniaturia is not always noted as a symptom. When it does occur it is constant, and although in some cases it may not be alarming, the bleeding may, on the other hand, be very severe. Sometimes clots may obstruct the urethra or may distend the bladder, or, again, may become wedged in the urethra. The Imemorrhage may be due to the calculus from which the tumor may have arisen, or it may result from the neoplasm involving and extending into the pelvis of the kidney and then ulcerating. The tumor, as it grows, may encroach upon and compress the nerves of the lumbar plexus, giving rise to pain, and even to paralysis in the jjarts supplied by its branches. From pressure upon the veins within the abdomen oedema of the lower extremities and engorgement of the superficial abdominal veins are produced. Other symptoms due to the pressure of the tumor are constipation, jaundice, anorexia, and vomiting. The urine will be found normal unless the growth has involved the pelvis of the kidney, when it may contain blood, blood-casts, albumin, epithelium, pus, or portions of the ulcerating tumor. Although convulsions have taken place in a few cases, ursemia rarely, if ever, occurs. Diagnosis. — The salient symptoms of renal neoplasms are rapidly-increasing tumor and pain. If to these hfematuria be added, the diagnosis should not be difficult. If the tumor be large, however, there may be some difficulty in deciding whether on the right side it is not a cyst or enlargement of the liver, or on the left whether it is not an enlarged spleen, particularly as renal tumors, as well as those of the liver and spleen, are affected by the movements of respi- ration. The examination will usually be more satisfactory if the child be under ether or chloroform anaesthesia. The relation of the ascending colon on the right side and the descending colon on the left to these tumors is an important point. Unless the growth be very large or has extended in one particular direction from the kidney, the colon should be found in front of it. In cases where the tumor is very large the bowel may be pushed aside, either inward or downward. Another point of distinction is that renal tumors can usually be traced deeply into the loin. Other affections with Avhich these growths may be confounded are cysts of the ovai’y, fincal accumulations, and perityphlitic abscess. Ovarian cysts should have the boAvel behind them and not in front, and are generally easily made out by rectal or vaginal exami- nation ; and perityphlitic abscess Avill usually present constitutional symptoms, which, together with the history, will clear up any doubts that may exist. Prognosis. — Malignant disease of the kidney can of course terminate in only one Avay. The child may live but a few weeks after the appearance of the groAvth, or he may live a year perhaps, the average being six or seven months. In children these neoplasms are usually softer, groAV faster, and exhibit their malignant nature more speedily than in adults. Treatment. — The (juestion as to Avliether operative treatment should be resorted to in malignant renal groAvths is one that can l>e ansAvered only after considering the merits of each particular case. Nephrectomy is of course to be thought of only in those cases in Avhich, so far as examination can deter- mine, the disease is in all j)robability confined to the kidney, under Avhich cir- cumstances there may be some possibility of the removal coin])letely eradieating it, or, if it fails in that, of somcAvhat ju'olonging life. A review of the literature of the subject shows the results of nephrectomy TUMORS OF THE KIDNEY. 1037 for renal tumor in children to be not very flattering. The late Prof. S. W. Gross collected IG operations upon children between sixteen months and seven years of age. Of these, 9 died and 7 recovered from the operation. Of the latter, 5 were known to have died from recurrence of the disease at times varying from five to sixteen months after the operation, while in the remaining 2 the result was not ascertained. Dr. Gross considered nephrectomy to be positively contraindicated in sarcoma in children. Dr. Marie B. Werner has tabulated 31 operations, including some of those collected by Gross. An additional case is mentioned by Newman in the table in his “ Lectures to Practitioners on the Surgical Diseases of the Kidney.” Of these 32 cases, 16 survived and 16 perished from the operation. Recurrence is known to have taken place in 8 of the 16 cases which I’ecovered from the operation, the shortest time before death occurred being two months, and the longest eight months. In the other eight cases the ultimate result was not ascertained. One of them died a year and a half after the operation, but the cause of death is not stated. Butlin, in his work entitled “ The Operative Surgery of Malignant Disease f says of nephrectomy for sarcoma in children that “ not one thoroughly success- ful case can be claimed, and it is probable that the operation will fall into dis- repute.” Judging by the ultimate result in those cases of operation in which it was ascertained, there can be no doubt that the weight of evidence is unfavorable to nephrectomy for malignant disease in children. If there be any hope of success from the operation as a radical measure, it must be when it is performed at a very early period of the disease. Each case, however, must be judged on its own merits. If the operation is to be undertaken, there should be absence of evidence of dissemination of the disease, and the general condition of the child should warrant so severe a procedure. If resorted to, nephrectomy should be performed by the abdominal incision, since the space in the loin in children is insufficient to permit the safe removal of a tumor even if it be of moderate size. The risks of the operation are very considerable, hmmorrhage, shock, collapse, and peritonitis being the imminent dangers encountered. Owing to the high degree of vascularity of these growths the danger of pro- fuse bleeding during their removal, especially if adhesions have to be broken up, is very great. In cases which do not permit of operation all that can be done is to attempt to affiord some palliation for the symptoms to which the tumor gives rise. Pain should be subdued by the administration of opium and the local use of bella- donna plaster, or opium, chloral, chloroform, aconite, and belladonna in lini- ment. Hmmorrhage will call for the employment of hminostatic remedies, such as gallic acid and ergot. Morris speaks highly of ferric alum for this purpose. VESICAL CALCULUS. By J. william WHITE, M. D., Philadelphia. Varieties of Calculus found in Children. — The uric-acid calculus is by far the most common kind found in children. Statistics by different authors variously place it from two-thirds to five-sixths of all stones. It was first described by Scheele in 1776. It may be composed exclusively of uric acid, or it may be mixed more or less with oxalate of lime and the urates of ammo- nium and sodium either in its intimate structure or in alternating layers. It is generally oval, rarely very large, and sometimes quite smooth, though more often granular or slightly tuberculated. The color varies from a light fawn — almost white — to a brownish or blackish red. There are two forms — the lami- nated and the amorphous — although a stone may contain layers of both. The laminated variety, when cut through the centre and polished, resembles an agate ; but, besides the concentric curved lines, radiating lines may often be seen extending from the centre to the ])eriphery. This variety is very hard, and when broken splits into angular and often sharp-pointed fragments. The amorphous uric-acid calculus is structureless or sandy on section, and generally of a dirty reddish-yellow color. It is sometimes quite soft and breaks into irregular fragments. Next in frequency to the uric-acid stone comes the oxalate-of-lime or mul- berry calculus, first described by Wollaston in 1797. It is generally round, covered with blunt points or spicules, very hard, and varies in color from a dark gray to a brownish black. Urate of ammonium occasionally occurs as a calculus, but is usually in combination with uric acid. When it does occur it is flattened, oval, smooth, or granular, brittle, and of a clay color. The mixed or fusible phosphate, the ammoniaco-mafpiesian phosphate, phosphate of calcium, carbonate of calcium, cystic oxide, xanthic oxide, fib- n'noRS, /ntty (urostealith), and indiyo calculi are extremely rare, or never occur in children as pure calculi, although some of them may enter into the composi- tion of a stone with uric acid. Stone in children may be small or larye, from a few grains' to an ounce or more; soft or hard, depending upon its composition and the length of time it has taken to form; sinyle or multiple ; free or attached to the hladdcr-walls, either by a band of lymph or by being caught in one of the folds of mucous membrane. It almost always has its origin in the kidney, unless it be formed around some foreign body which has been introduced into the bladder. 'I’he 'Sir Henry Tliompson objects to giving a concretion of less tlian 20 grains in weight the name of “calculus” or “stone.” While there maybe some jiractical advantage in this limitation in the case of adults as regards especially the signilicance of statistics, there can he none in children. 1038 VESWA L CA L C UL CS. lo;i9 experiments of Rainey, Ord, Vandyke Carter, and others have sliown that urinary calculus is not an accidental agglomeration of solids, crystalline, and auior[)hous, in a cement of mucus,” but that it is a “ massive crystallization of urinary ingredients in a colloid substance,” the formation of which occurs in ohedience to a fixed law. Although the frequency of the uric-acid calculus is doubtless due to the excess of uric acid in the urine of children and to the presence in the kidneys of infarctions which are almost entirely composed of uric acid, and which Virchow has shown to be very common, almost constant, during infancy, yet it must be remembered that some colloid substance, as mucus, albumin, pus, etc., has to be present or no stone will be formed, and the crystals will pass out with the urine in the well-known cayenne-pepper or brick- dust deposit. Etiology. — As just stated, the two chief causes of stone are crystals in the urine and the presence of a colloid substance. How far the production of these two causes is influenced lyy heredity it is very difficult to state. That stone is occasionally found with exceptional frequency in certain families there can be no doubt, but before its occurrence is assigned to heredity it should be remembered that there may be some local cause equally affecting all the members of a family and peculiar to their place of residence, not to their physical condition. Cadge, some years ago, made the following interesting remarks as to this point : “ In five instances I have operated on brothers, and in four other in- stances I have operated on one brother, and other surgeons on another. Mr. Clubbe of Lowestoft has given us a curious history of a stone-family : Three brothers were cut for stone by Mr. Clubbe ; a fourth passed a stone ; a fifth child died, aged thi’ee months, with every symptom of stone ; a female child now has vesical irritation and bloody urine. The father and mother are con- stantly passing large quantities of lithic acid ; the grandfather passed one stone, and the grandmother seven ; a great-uncle was cut for stone, and six uncles and four aunts all suffer either with fits of gravel or from lithic deposits ; and, to finish, a cousin passes calculi. There is considerable historical testimony in favor of this hypothesis. We know that Montaigne and his father both died of stone in the bladder, and we remember how he moralizes on the incompre- hensible wonders of the hereditary transmission of mental and bodily resem- blances and infirmities. The celebrated minister Sir Robert Walpole and his brother Horace (who once represented this city in Parliament) were both afflicted with stone ; and their mother also had stone.” It is probable that gout and rheumatism increase any tendency to the for- mation of stone, as they are usually accompanied by acid urine, with an increase in uric acid and the urates. As gout is hereditary, the tendencies to stone, which it produces, may also be hereditary. But gout, as a rule, is an inherit- ance of the rich, brought on by generations of over-eating and drinking, and yet it is a remarkable fact that the children of the rich are singularly free from calculus, while the children of the poor make uj) more than one-half of the cases of stone in the tables of statistics. Deschamps, at the close of the last century, said that during the thirty years in which he treated people afflicted Avith calculus, he had yet to see the child of a rich man affected with stone. Sir William Fergusson is quoted as saying that he had but once receiveroper diet for such a case should be chosen from the folloAving articles : fish, ])oultry, bread, all cereals, green vege- tables, salads, fruits, and eggs. Sugar and the different kinds of fats are harmful, as is an excess of the dark meats. Over-eating is especially and j)articularly to be avoided. Highly-seasoned articles of food are even more objectionahle with children than with adults, as they tend to excess in eating, and in addition often cause acute indigestion or, Avorse still, a chronic acid dyspepsia. ’V\\e solvent Ireatmetd of stone has but little to recommend it. Brodie tried injections of dilute nitric acid ; Roberts has experimented Avith potassium citrate and acetate; (Jarrod, with the lithia salts; Vogt, Avith piperazine; VESICAL CALCULUS. 1045 Beale, with ammonium carbonate, etc. Electrolysis has also been tried even more unsuccessfully. All these procedures are more objectionable in children than in adults. Vesical injections of all kinds are relatively more irritating on account of the greater delicacy of the mucous membrane. The administration of large doses of alkalies and diuretics by the mouth are almost certain to interfere with diges- tion, and thus do more harm than good. In the presence of e.xcess of uric acid or urates or oxalates in the shape of crystals, the free use of water, and of small doses of lithia with potassium carbonate, is of great value in jn’ophylaxis ; carbonated “ lithiated Vichy” Avater, a commercial product, is often agree- able and useful, but is sometimes disliked by children on account of its effer- vescence. Anatomy of the Urinary Organs in Children. — This may be briefly alluded to before describing the operative treatment of stone. In the infant the bladder is egg-shaped, having the larger end resting in the pelvis. There is no marked fundus or base to the bladder in the young child, and it is situated mainly in the abdomen. As the pelvic cavity increases in size the bladder gradually descends into it, and the infant about this time assuming the perpen- dicular attitude, it has been thought that the weight of the urine tends to make the lower part more capacious. Observations upon the dimensions and position of the bladder will naturally vary Avith the empty or distended state of the organ. Through childhood until toAvard puberty, Avhen the organs of generation are developed and the neighboring parts assume their normal adult relations, the urinary bladder is always so loosely attached to the pelvic Avails that, although it may have settled into the pelvis, it will requix’e very little force to push it upward into the abdomen. This lax condition of the bladder-attachments is of great importance in the consideration of surgical interference in this region. In the young child the anterior wall of the abdomen, from the symphysis pubis almost to the umbilicus, is in close relation to the bladder, and the neck of the bladder and urethral orifice are about on a level Avith the upper border of the pubic symphysis. The peritoneum is reflected entirely over the posterior surface of the blad- der in the child. The recto-vesical pouch usually embraces the prostatic region very closely, and is liable to injury in children during the operation of litho- tomy, causing peritonitis, the most frequent fatal termination in that operation. The anterior surface of the bladder is always uncovered by the peritoneum in childi’en. The capacity of the bladder in inflincy is smaller than in after years, and this may account for the frequency Avith Avhich young children micturate. The frostate gland is very small in children. According to Sir Henry Thompson, this gland “ at the age of seven years weighs only about thirty grains, and betAveen eighteen and tAventy years it Aveighs two hundred and fifty grains, or nearly nine times as much.” The urethra., in males, appears to increase sloAvly in length from birth until puberty is reached. Its canal is more dilatable than was formerly supposed in both adults and children. The meatus is often constricted, so that only a small- sized catheter or sound can be introduced, but if the orifice is incised quite a large instrument will readily pass. The membranous part of the urethra in children is relatively very long, OAving to the smallness of the prostate gland at that period of life. In sounding the bladder in a child it should be remem- bered that the urethra lies close to the rectum, and that its walls are exceed- ingly thin and delicate. The degree of curvature of the urethra is greater in the child than in the 104G AMERICAN TEXT-BOOK OF DISEASES OE CHILDREN. adult, but there are variations in this respect naturally following, as do those pertaining to the contiguous parts, upon grow'th or inunature development. In the female the urethra is imbedded in the anterior w'all of the vagina, W'hich is sometimes of large size in childhood, and corresponds to the upper part of the prostatic portion of the male passage. It is very distensible.^ The Operative Treatment of Stone. — Three methods for removal of stone from the bladder of male children are open to the operator: 1. Supra- pubic lithotomy ; 2. Perineal lithotomy ; 3. Litholapaxy. The statistics of these operations (see next page) indicate unmistakably the rejection of the first as a routine method in children. It should be reserved for those calculi w hich are both too large for the perineal operation and too hard for crushing — a very rare combination. A comparison of the two other methods is, how’ever, of much practical importance at this time, the statistical evidence having only recently justified positive conclusions.^ Until comparatively recent times the very low mortality of perineal lith- otomy in children in the hands of skilful operators made it seem a w’ork of supererogation to seek for a better method of operation. A safer could scarcely be found. A high rate of mortality after lithotomy was almost always due to deaths among elderly adults. Fergusson and Velpeau, and, later, Freyer, Thompson, and others, objected to the crushing of stone in boys on account of the undeveloped condition of the genito-urinary organs, the smallness of the bladder, the narrowmess of the urethra, and the liability to laceration of the vesical and urethral mucous membrane. No instrument had been invented by which litholapaxy could be performed with safety in male children. Other objections were advanced from time to time, mainly, however, relating to the same anatomical points, and (before the introduction of lith- olapaxy) to the difficulty of getting rid of the fragments, but the majority of them are now', in the light of the modern improvements in lithotrity, without applicability. Anaesthesia has made the “extreme sensibility” of the part and the “indo- cility ” of the patients of little moment. Otis has shown that in children, as in adults, the “small diameter of the urethr:»” may be greatly increased with entire safety. He says that the proportionate relation between the circumfer- ence of the urethra and that of the penis, Avhich he has already demonstrated in adults, holds good in children. Thus, with a circumference of penis of one and a half inches, as in a child from two to three years of age, the size of the urethra w'ould not be less than sixteen millimetres in circumference; and this urethral calibre increases or diminishes about two millimetres for every (juarter inch added to or subtracted from the penile circumference. It is but fair to mention that Morelli has called attention to a fact u])on which some of the success of the Indian surgeons may dej)cnd — viz. the very early age at which the children of tropical and Eastern countries reach full sexual development. This may permit the use of larger instruments on an average at a given age than would be possible in Europe or America, and would facilitate and extend the possibilities of litholapaxy. yVntisepsis during and after the operation has minimized the danger of laceration of the mucous membrane; instruments have been made which are at the same time small enough to j)ermit of their introduction into the urethra ’ For furtlier information I may refer to McClellan’s Anatomy, from which the above account has been condensed. ^As iny opinion, arrived at a few years ago (Mfdkul Nenv, May 17, 18iK)), remains unchanged, and has indeed been strengthened by later ex))erienee, I may he excused for stim- marizing here the views then expressed and making such additions as seem important. VESICA L CAL C UL US. 1047 and bladder of young infants, and strong enough to deal with very large and very hard calculi ; Bigelow has overcome the difficulty of getting rid of the frag- ments; and the argument from statistics is at least neutralized by the records of Keegan and Freyer. Cabot has given the most recent statistics of the three operations, made up from a series of published cases and from otliers obtained by him. As all tlie cases were operated upon after 1878, and as they are classified according to age, they are especially valuable for the purpose of this paper. They may be compared as follows for children under fourteen: Suprapubic lithotomy, 591 cases; 74 deaths; 12.52 per cent, of mortality. Perineal lithotomy, 539 cases; 16 deaths; 2.96 per cent, of mortality. Litholapaxy, 241 cases; 4 deaths; 1.66 per cent, of mortality. Recurrence. — In the face of these figures and of the foregoing facts there is but one argument remaining which, to my mind, has any weight as urged against the operation of litholapaxy in children, and that is the alleged greater probability of recurrence. As regards the two great classes of operative procedures for the removal of calculus — the cutting and the crushing operations — all forms of lithotomy as compared with all forms of lithotrity and at all ages, there can be little doubt that the statistical evidence in relation to recurrence is at present in favor of lithotomy. But it should not be accepted without reservation. Many of the tables, notably those of Sir Henry Thompson and of Mr. Cadge, are based on an experience extending over many years and antedating the introduction of litholapaxy. Those tables make the proportion of recurrence after lithotrity about 1 in 7 or 1 in 8, and after lithotomy about 1 in 20 ; but, like so much of the statistical matter which our text-books and journals contain, they are useless or misleading at the present day. The two principal causes which lead to recurrence are — a. The failure to remove every portion of stone at the first operation ; b. The new formation of stone in the kidney and its descent into the bladder. In the tables of Mr. Donald Day, based on the records of the Norwich Hospital, the first class includes two-thirds of all the cases of recur- rence. But circumstances have altered. The employment of a large-sized evacuating-tube, the immediate and thorough emptying of the bladder, the minute pulverization usually possible with completely fenestrated lithotrites, the increased knowledge of the great tolerance of the bladder to prolonged manipulations if they are gentle and skilful, have all combined to place the question of recurrence upon a very different level, and to make the collection of a new set of statistics as to recurrence absolutely necessary before venturing to draw any positive conclusions. But if, for the sake of argument, we investigate existing statistics on this subject, we find that the great majority of cases of relapse or recurrence have taken place in patients past middle life, and especially in very old persons with enlarged prostates and feeble or atonic bladders. It will be recognized at once that these conditions do not prevail in children. The prostate is undeveloped; the bladder is almost an abdominal organ; no pouch exists at the fundus ; sacculation is nearly or quite unknown cystitis is a comj)ara- tively manageable complication ; the expulsive power is proportionately greater than in the male adult, in Avhom a “physiological atony” is not at all infre- quent. In addition to the reasons above given for not anticipating the forma- tion of new calculi in children around nuclei of vesical origin, it may be rea- sonably expected th,at the conditions favoring the development of renal calculi ' Fergusson said that even in adults “sacculated stones” were generally met with by young litliotomists. 1048 AMERICAN TEXT-BOOK OF DISEASED OF CHILDREN. will be more easily treated and controlled in children than in adults. Cer- tainly among well-to-do people who can carry out a proper system of diet and medication it is fair to suppose tliat the lithic diathesis, of whatever variety, will he more readily combated in children whose diet and drugs and mode of life can l)e rigidly administered than in adults with fixed and often very pre- judicial habits. Mr. Cadge expressly states that this was true in his own cases, and adds that he has no personal experience of lithotrity in children. Jacobson at one time asserted that this important matter — the percentage of recurrences after litholapaxy — had been left undealt with by Keegan, then the chief advocate of this oj>eration in male children. Keegan, in reply, says that in his monograj>h on the subject (1886) he did not deal with this point, because then he had only had 58 cases in male children and boys. Later (1890), the operation having been on trial for more than seven years, and he having collected 145 cases, 110 of which he had per- formed himself, he felt competent to consider the question, and said : “ As to the outcome of this practice and experience, I have arrived at the conclusion that recurrence of stone does not follow litholapaxy in male children any oftener than it does lateral lithotomy, provided that the former operation be skilfully performed. It will be conceded that recurrence of stone after lithola])axy, when performed on adult and aged male patients, is less than that which in former days followed the now obsolete lithotrity of many sittings. But it must be admitted that recurrence of stone does occasionally follow litholapaxy in old patients. When, however, we come to investigate the causes of this recurrence, we find that the main factors which bring it about in aged patients do not exist in the case of male children and boys.” He states that he began in 1881 to use litholapaxy, and tliat of the 145 cases operated on since hut one boy has returned with a second calculus. Freyer records 8 cases of recurrence in 65 children, the average age of whom was seven and a half years. For these reasons, while admitting that the question of recurrence is still sub judiee, 1 am distinctly of the opinion that there is little probability that there will be enough dift'erence betw'een the pi'oportions of relajises in children after lithotomies and after litholapaxies to justify any decided preference on that ground alone. The position of litholapaxy in children is moreover strengthened by a review of the history of lithotomy, which, unlike the operation with which Ave contrast and compare it, has undergone but little change for many years. The improvements in suj>raj>ubie lithotomy have, it is true, rendered it applicable to a much wider range of cases, and it is equally true that its most favorable results have been attained in children ; but thus far, as we have seen, the statistics of suprapubic lithotomyiji children do not coni])are favorably with those of either litholapaxy or lateral lithotomy. This is probably due to the fact that in a large proportion of cases the operation Avas selectt'd only after litholapaxy had been attem])ted and failed, or else Avas originally chosen on account of the unusual character of the calculus. It is true that MacCormac has reported 38 cases of su])rapubic lithotomy without a death, but they Avere from scattered sources and did not constitute a consecutive series. There is no means of knoAving hoAvmany unsuccessful, and therefore unreported, cases occurred during the same ])eriod. It will probably ahvays be employed in ])reference to lateral or median lithot- omy in cases of extremely large or exceptionally hard stones; but Avhen Ave remember that Freyer has removed by litholapaxy a calculus Aveighing 808 grains from a boy of nine, and Keegan one of 700 grains (and of uric acid) VESICA L CA L CUE US. 1049 from a boj nine and a half, it is evident that neither size nor hardness offers an insuperable bar to the latter operation. Median lithotomy in children, although advocated by some surgeons, is objectionable on account of the greater danger of wounding the bulb or the rectum, and the difficulties in obtaining space tlu-ough which to pass the finger into the urethra and the bladder. It is indeed true that the passage of the finger is not absolutely necessary, although it has always been one of the time- honored rules of lithotomy not to withdraw the staff until the finger is in con- tact with the stone. I have, however, frequently seen Dr. Agnew, when operating on young children, introduce a pair of very small lithotomy forceps along the groove of the staff, separate them, and seize the stone, and then, after the removal of the staff, extract the calculus, the finger never having been in the bladder. I have used the same manoeuvre myself with success. I sup- posed it was original with Dr. Agnew (and believe he was of the same opinion), but I found that Mr. Cadge recommended almost precisely the same method as both safe and efficient, adding, “ I dare say it has been adopted by others, but I do not find it alluded to in modern text-books.” It must be remembered, however, that its adoption places the surgeon in almost the same situation in regard to the possibility of leaving debris or unnoticed stones in the bladder as he occupies after a litholapaxy. If the stone is soft and breaks down under the forceps, or if there are multiple calculi, he will be dependent on the touch and sound elicited by the vesical explorer, just as after the other operation. If, then, the introduction of the finger be dispensed with in either median or lateral lithotomy in children, these operations lose one of their alleged advan- tages — viz. the assurance of the absolute removal of all calculous fragments. If it be insisted upon, it constitutes in a small proportion of cases an unavoid- able source of both difficulty and danger. Sir William Fergusson, Keith, Thompson, Cadge, and many others have recorded occasional trouble with this step of the operation. The latter surgeon remarks, apropos of Fergusson’s case : “ He was a master of the art of operative surgery ; if the difficulty occurred to him, we may conclude that it is not unlikely to occur to any of us.” Lateral lithotomy in children, in addition to the special difficulty due to the smallne.ss of the parts, the high position of the bladder above the pelvis, the delicacy and mobility of the deep urethra and the vesical neck, has one pos- sible contra-indication which should not be lost sight of. If the incision be prolonged a little too far backward, the left ejaculatory duct can hardly escape division and subsequent obliteration ; and although this may not be a serious accident in cases in which the integrity of the opposite half of the genitals, the testicle, duct, etc., is unimpaired, yet it leaves the patient entirely dependent on that one side for fertility if not for potency. Mr. Teevan has reported four cases of sterile hmsbands among lithotomized patients. Langenbeck and Sir William MacCormac have called attention to the same danger, and Keegan believes the lateral operation to be frequently followed liy emasculation. Dennis quotes Dr. Charles Leale in relation to several cases coming under his own observation, in which such patients grew up with shrill voices, atrophied testicles, ab-sence of hair upon the face, etc. ; in fact, with all the character- istics of eunuchs. The evidence as to this point is as yet fragmentary and inconclu.sive, but is of sufficient importance to de.serve careful consideration, although Ehrmann characterizes the fear of sterility as a “ bugbear.” The objections to perineal lithotomy in children are, however, at least as weighty as any that have been urged against litholapaxy. The ease and satisfaction to both patient and surgeon with which the latter 1050 AMERICAN TEXT-BOOK OF DmEAtiE^ OF CHILDREN. operation may be performed I can best illustrate by a brief abstract of one of the earliest of my own cases : C. W , a small boy, aged five and a half, was brought to me by bis fiitlier in October, 1889, on account of nocturnal incontinence of urine. lie had a long, tightly-adherent prepuce with ])in-point aperture. It “ ballooned ” at each act of urination. I circumcised bim, gave small doses of belladonna and bromide of sodium, and dismissed him, apparently cured, in November. In January he was brought to me again by his nurse, who told me that his symptoms had returned. I then sounded him for stone, but failed to find it. Insisting (according to my invariable rule in such cases) upon a second exami- nation before giving a positive opinion, I easily found a calculus. I recom- mended crushing, and after a little delay the parents consented. On February 20th, the child being etherized, I drew off the urine and injected three ounces of warm boric-acid solution (fifteen grains to the ounce) into the bladder. I then enlarged the meatus ‘ and introduced a Weiss fenestrated lithotrite. No. 16 French. This went in with ease. The stone was readily seized and broken. I spent twenty-five minutes in pulverizing it, paying especial attention to gen- tleness of movement and to the avoidance of rude or unnecessarily wide sepa- ration of the jaws of the instrument. A No. 16 tube was then introduced and a Bigelow evacuator employed. In about eighteen minutes,^ as no more frag- ments or dust could be perceived, the tube was withdrawn and the bladder carefully explored with a vesical sound. Nothing was discoverable. The time of operation was forty-three minutes; weight of dried calculus, 170 grains. The child was sitting up in bed on February 22d, and was out of bed, playing about the room, on February 25th. The nocturnal incontinence persisted for a week or ten days, and then disappeared entirely. There was no fever, bleeding, chill, or other alarming symptoms. The parents were nervous, consented reluctantly to this operation, and would certainly have postponed a lithotomy for a long time, much to the child’s detriment. This is a typical case of litholapaxy in a young boy. I have now' had many such cases, and have never had a moment’s anxiety about the little jiatients. It can scarcely be wondered at that after his expei’ience Keegan writes that he would as soon think of cutting an old man for the removal of a small stone as of ])erforming lateral lithotomy on a boy whose urethra Avould readily admit the passage of a No. 8 (No. 15 French) lithotrite, and whose stone was neither abnormally large nor hard. Nor is it surprising that Freyer says that, lithotomy in the adult having been practically blotted out of his practice, he looks forward confidently to lithotomy in children meeting with a similar fate. Freyer .says: “When, in 1885, Keegan first showed that Bige- low'’s operation was capable of successful extension to the case of male children, I lo.st no time in procuring the necessary instruments and apjdying the opera- tion to such cases. In tw’o ]>apers I placed before the profession full details of ' Otis rcootmiiends performing the nieatntoniv long enougli before tlie lithohi])axy to allow the parts to heal. This is certainly desirahle for some reasons, hut in nervous ehiklren its advan- tages are counterbalanced by the need for two fixed a])pointments, two ojierations, ete. 1 have never found any harm resulting from the jilan 1 here followed. ^ The jiressnn' on the rubber bulb during the process of evacuation should be slight and frequent rather than slow and vigorous. Prof. Bigelow himself called my attention to the much greater value of tlie former method, and 1 have repeatedly verified the correctness of the state- ment. Not only is the danger of driving back into tbe bladder sharp fragments of stone mate- rially lessened, but the swiftness and elleetiveuess of the outward current are much increased. I so often see an entirely unnecessary degree of force exjiended in the working of the bulb during this stage of a litholajiaxy, even by expert operators, that it seems worth while to make this note. VESICA L CA L C UL US. 1051 49 cases of litholapaxy undertaken by me in male children or boys below the age of puberty. Since then G7 males of fifteen years and under, suftering from stone, have come under treatment, and in GG of these I have performed litho- lapaxy — in all with complete success. In only one instance was it necessary to have recourse to lithotomy (suprapubic). The greater my experience of litholapaxy amongst male children becomes, the more I am fascinated by this operation. Though the average number of days such cases were kept in hos- pital was five and a half as a rule, these little patients may be seen playing about the day after the operation, perfectly happy and untroubled by urinary symptoms of any kind.” Cadge, MacCormac, Jacobson, Kingston, Keyes, Hunt — indeed, most recent writers — press the conviction, though in less sweeping terms, that the field of litholapaxy in children is likely to be considerably enlarged in the near future. I have once, in a patient of Dr. E. L. Duer’s, been compelled to abandon the operation on account of the impossibility of inserting the evacuator, although a lithotrite of equal calibre had gone in easily. Walsham and Mar- shall have called attention to the necessity of having a number of sizes of lithotrites and evacuating tubes, as they had both found great difficulty toward the end of the operation in children in introducing an instrument which had passed easily at its commencement. This is the only experience of the sort I have had in a child. The patient, aet. ten years, passed 40 grains of detritus, and a few weeks later I removed a calculus weighing 240 grains by the lateral operation. Convalescence was then uninterrupted. Basing my opinion on the fiicts mentioned in this paper and on my personal experience, I believe the following conclusions to be justifiable : 1. In every case of calculus in male children' litholapaxy, on account of ease of performance, low mortality, speedy recovery, and absence of danger of emasculation, should be the operation of predilection, division of the meatus being freely resorted to if that portion of the urethra offers an obstacle to the introduction of instruments. 2. The lithotrite and evacuating-tube should be of a size which can be inserted into the bladder without much effort or over-distention, and great gentleness should be observed in passing these instruments. Keegan says : “ When I advocate litholapaxy as being the best operation, in my opinion, for the great majority of stones occurring in male children and boys, I do so with a very important reservation — viz. that no one should attempt to per- form it in boys until he has first gained some practical experience of it in adult males. The surgeon who meets with cases of stone only at rare intervals during his career will be acting more wisely if he adheres to lateral lithotomy or suprapubic cystotomy. It is his misfortune, and not his fault, that he has not been afforded many opportunities of gaining a practical familiarity with the use of the lithotrite.” 3. The instruments should be withdrawn and reintroduced as seldom as pos- sible, the stone being finely pulverized before the lithotrite is taken out at all. In seeking for or attempting to seize the stone care should be taken to avoid such wide separation of the blades as will bring the male blade in frecjuent contact with the vesical neck. The crushing should invariably be done only after rotating the blades into the centre of the bladder. Every particle of the calculous dust should be evacuated. 4. Rest in bed, milk diet, and sterilization of the urine by boric acid or ‘ These remarks apply almost as well to adults. 1052 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN salol given internally, both before ami after the operation, are valuable adju- vants. During the operation every antiseptic precaution should be observed. Southam very properly emphasizes the importance — «, of this preliminary sterilization of the urine by the administration of salol and boric acid, and if need be by irrigation of the bladder; and b, the avoidance of shock by thorough protection of the patient against surface chilling. 5. The exceptional cases of calculi which are both large and hard may be best treated by suprapubic lithotomy, but neither unusual size nor a moderate degree of density should of itself alone be thought positively to contraindicate litholapaxy. (3. Perineal lithotomy has now a very limited field, and should be emjdoyed chiefly in those cases of stone thought to be of small or medium size, in Avhich no lithotrite, however small, can be introduced with safety.' Operative Treatment for Stone in Female Children. — Surgical opinion in regard to the choice of operation in female children has not as yet become so definitely established. The possible methods are — a. J'aginal Lithotomy, which is attended with much disturbance of the parts, requires over-stretching of the vagina, section of the fourchette. destruction of the hymen, etc., and which, even in good hands, has not infrequently been fol- lowed by a permanent vesico-vaginal fistula. b. Dilatation of the Urethra. — This is easy and safe in the case of small stones, but in larger ones, and especially if incision of the urethra is required, is extremely liable to be followed by incontinence. c. Suprapubic Lithotomy. — This is at ])resent the operation of choice Avith many surgeons. Jacol>son thinks it would be wiser to make use of it in all but the very smallest stones. He adds : “ I Avould refer my readers to a case of suprapubic operation by Mr. BarAvell in a child aged nine, from Avhom a stone weighing two and a half ounces Avas successfully removed. It is interesting to note that Mr. BarAvell Avas led to adopt the suprapubic operation from his having had Avithin seven months no less than three cases of vesico-vaginal fistnlae originating in the e.xtraction of calculi during infancy and youth by difl’erent surgeons.” d. Litholapaxy . — The statistics Avhich are sloAvly accumulating (chiefly from Indian sources) tend to shoAv that this Avill be the operation of the future, but cases of stone in female children are so rare comparatively that the figures thus far available cannot be regarded as conclusive. The difficulty of crushing in such small bladders has been alluded to, but it is usually not greater than in the case of males. If a lithotrite and a fair-size evacuating-tube can be inserted without over-distention of the urethra, there Avoiild seem to be no a-priori rea- son Avhy the operation should not be as successful in females as in males. The details of the performance of the various operatioiis in both male and female children belong to the systematic Avorks on general and operative surgery, and need not here be considered. It may be remarked, finally. hoAvever, that an improvement in results scarcely less than that found in other branches of surgery has folloAved the in- troduction of antisepsis into genito-urinary Avoi'k, and that, Avhichever operation is selected in a given case of vesical calctdus in a child, the little ])atient is on the averaim safer to-day than he Avas in the hands of even the most skilful operator tAventy-five years ago.^ ^An American Text-Bonk of Surgery, 1892. ’‘I desire to acknowledge iny (ildikatioii to Dr. Itokert (i. Le Conte for tlie collection of inucli statistical matter ni)on wliicli .some of the above statements are based and for further aid in the prejianition of this article. GONORRHCEA AND VULVO VAGINITIS. By J. william WHITE, M. D., Philadelphia. I. Gonorrhcea in Male Children. In male children specific urethritis does not differ materially in its course, symptoms, and complications from the same disease in the adult. The cause is often some sexual relation established between the child and an adult female for purposes of sexual gratification of the latter, even though the boy may be so young that intromission is impossible. In other cases mediate contagion has occurred by means of dirty clothing, towels, or cloths used by older persons of the same household, etc. In others, chiefly in boys near the age of puberty, the disease is acquired in the customary manner — i. e. during actual or at- tempted intercourse. Symptoms. — The usual symptoms, purulent discharge, ardor urinse, chordee, frequent urination, etc., are present. Of the complications, phimosis and balano-posthitis are more common than in the adult, owing to the rela- tively excessive length of the prepuce and to the delicate character of the mucous membrane lining it and covering the glans. Cystitis is not uncom- mon ; epididymitis is more so. Prostatitis, as might be expected, is almost unknown, or at least cannot be differentiated from vesical inflammation. The intensity of the urethritis and the severity of the symptoms are both rather greater than in the average case in the adult, and the accompanying constitu- tional disturbance is much more marked. Diagnosis. — As such cases are not infrequently the basis of legal pro- ceedings, the physician should be especially guarded in pronouncing upon the character of the disease in any given instance. While specific urethritis can usually be traced to one or the other of the causes above named, there are many cases of simple urethritis which are clinically indistinguishable, and the non-specific nature of which can only be recognized by the absence of a his- tory of infection on the one hand, and by the existence of a sufficient trau- matism, such as the passage of instruments, the ejection of a calculus, etc., on the other. I have seen severe urethral inflammation follow retention and decom- position of smegma beneath a long, tight prepuce, the orifice of which was so small that “ballooning” occurred with each act of urination. In such ca.ses a small quantity of urine is always retained beneath the foreskin, and cleanliness is impossible. In comparison, however, with the number of cases in which this condition exists in children the frequency of occurrence of urethritis as a result is extremely small, and caution should be observed in attributing a par- ticular urethritis to this cause. While bacteriological investigation will throw much light upon the etiology of a case of this kind, our information is not yet definite enough to enable us to predicate absolutely upon the presence of the gonococcus the specific char- 1053 \{)U A3IER1CAN TEXT-BOOK OF DISEASED OF CHILDREN. acter of the inflammation. It renders it liighly probable that the disease is the result of infection, direct or indirect, from another person having the same disease, but it is not yet safe to say more than that. Competent observers, such as Bumm, assert that in the normal urethra a diplococcus is found having all the peculiarities of the gonococcus. If this be true, even if it occurs with great rarity, it is apparent that it destroys the diagnostic value of the gonococ- cus in medico-legal cases. A knowledge of its presence is, how'ever, of use clinically, as indicating an inflammation of more severe type than the simple urethritis in which the infection has been exclusively with staphylococci or streptococci. Treatment. — The child should be kept in bed. If there is marked phi- mosis, the prepuce should l)e slit up the dorsum, or, if the oedema and inflam- matory exudate are not too extensive, a formal circumcision should be per- formed. The organ should be wrapped in cloths wet with lead-water and laudanum, and the constitutional disturbance controlled by mild laxatives, small doses of aconite, and full doses of potassium bromide. An excellent formula is the following, the doses of which are proper for a child five years of age: I^. Potassii bromidi .... 3j- Acid, borici gr- xlviij. Tinct. aconiti miij- Tinet. belladonnm . . . mxij. S])ts. jetheris nitrosi . . . f.5iij- Mist. pota.ssii citrat. . . . Sig. Dessertspoonful in water every two hours. The diet should consist almost exclusively of milk. When the inflammatory symj)toms have subsided the use of injections mav be begun. They should be from one-half to two-thirds of the strength required for the adult, and the excellent rule applicable to the latter should not l)e deviated from — viz. to avoid the production of pain by the free dilution of the injection to any necessary extent. It is often w^ell to begin with a lead-and-laudanum injection, substituting the extract of opium for the tincture: I^. Ext. opii acj gr. vj. Li(j. plunibi subacetat. dil Ewj- — M. Sig. Use locally. Later, an antiseptic and astringent injection like the following may be employed with advantage : I^. Hydrarg. chlorid. corros gr. Acid, boric ,^j. Zinci sulpho-carbolat gr. xij. Licp hydrogen peroxid f.o««- A([u?e rosic f^vss. — M. Sig. Use locally. These injections should he given by a nurse immediately after the child has urinated. From half a drachm to a drachm is a sullicient quantity to throw in at one time. GONORltHCEA AND VUL VO- VAGINITIS. 1055 During the subsiding stage the internal administration of salol will be of use, and if an irregular febrile movement persists, as is sometimes the case, full doses of (juinine night and morning will be of great value. n. VuLVO-VAGINITIS, The vulvo-vaginitis of children may be — a, Catarrhal or irritative ; 6, Gonorrhoeal. a. The catarrhal form is caused by any simple irritant, the commonest causes being the prolonged contact of the parts with filthy diapers, the retention of urinous and sometimes of fmcal matter between the labia, all forms of dirt, seat-worms, etc. It may be excited by any traumatism or by an attempt at rape. It is an almost pure vulvitis, the vagina being but slightly involved and the urethra very rarely. It is characterized by the ordinary symptoms of inflammation, heat, swell- ing, redness, pain or itching, and sometimes by extensive excoriation or actual ulceration. h. The gonorrhoeal form is much more severe. There is free purulent dis- charge, much swelling of the external genitalia, intense hyperaemia of the mucous surfaces, which bleed readily when touched, ardor urinae, pelvic and abdominal pain, and often some endometritis, with tenderness and swelling of the uterus. The constitutional symptoms are quite marked. The fever often has a high range and is very persistent. The local conditions are apt to be rebellious to treatment. Diagnosis. — The diagnosis between these two conditions is often a matter of the gravest importance, not so much perhaps to the little patient as to others who may be suspected of being the source of infection. The clinical diagnosis will be based upon the pi'esence or absence of the causes of catarrhal vulvitis enumerated above, and upon the extent and charac- ter of the symptoms. The catarrhal variety is not markedly contagious, ace on the att’ected side will be found larger and of a diflferent shape from that of the opposite side. Rachitic curves are usually antero-posterior, and are accompanied by otlier characteristic symp- toms of rickets. Curvature due to Pott’s disease is usually antero-posterior, but when it is lateral is accompanied by the peculiar gait, the inability to stoop, the pain, and other characteristic symptoms. Prognosis. — The prognosis of lateral curvature is good so flir as life is concerned, but otherwise it is bad. There is a per- sistent tendency to an increase of the de- formity, which is very difficult to overcome by any known method of treatment. Treatment. — In the early stage, while the spine is still ffexible, treatment is most likely to be beneficial, but it is far from satisfactory at any stage. Mechanical sup- port is rarely helpful in these cases ; on the contrary, it is likely to do more harm than good. In a few exceptional instances, where the deformity is increasing very rapidly, a plaster or paper jacket will be beneficial. In the vast majority of cases, however, the greatest benefit is to be derived from intel- ligent gymnastic exercises and massage. A child can be taught at a very early age to swing by his hands and to bend the spine in the opposite direction from the curvature or in such a manner as to unbend it. If a skilled masseur is not at hand, the ])hysician or parents should unbend the spine daily. The child should be undressed and ])laced in such attitudes by the hands of the attend- ant as will have a tendency to overcome the deformity. This exercise should be kept up for at least fifteen minutes eveiy day. By j)ersistent effort in this direction the deformity may be overcome in a mild case, and in every case it may be ))revented from becoming as severe as it otherwise would. The child should be taught to avoid those attitudes that would naturally have a tendency to increase the curvature. PoTT’s Disease, or Tuberculosis of the Spine. Pott’s disease is a destructive disease of the bodies of the vertebra', and is tuberculous in character. It was first clearly described by Percival Pott in 1779. Etiology. — fi’liis disease occurs, in the vast majority of cases, in childliood. fi'he writer’s experience leads him to disert'dit the ]H)pular belief that heredity is a prominent cause, for the disease occurs V(>ry commonly in healthy chil- dren of healthy [)arents. ’flu' parents usually ascrilu' it to souu' real or imaginary injury. While it can rarely be traced directly to an injury, every Fm. 3. Left scoliosis. OR TIIOPyEDICS. 1065 experienced ortliopiedist lias met with some cases that evidently originated in this way. It occurs freijuently as a seiiuel of the exanthemata and other diseases of childhood. In the writer’s experience measles is the most fre- quent forerunner. The disease usually begins in one small spot near the anterior part of the body of the vertebra, but it may begin in more than one vertebra at the same time. Patholog'y. — The bodies of the vertebrae become gradually softened and break down in cheesy ddbris ; this allow's the spine to bend forward, caus- ing the characteristic deformity, which is usually antero-posterior, with the convexity backward. When only one vertebral body is affected the angle I of deformity is quite sharp, but is more Fig. 5. Dorsal Pott’s disease. Characteristic position in dorsal Pott’s disease. obtuse when a number are involved. In either case, how’ever, the angle is more acute than that in any other spinal disease. The intervertebral disks are destroyed by the granulation-tissue, but are probably never the original seat of disease, as was once believed. When the disease is in the lower dorsal or lumbar region, an abscess may form and follow the psoas tendon, pointing just below Poupart’s ligament. In the cervical region a retropharyngeal abscess may form. Paralysis may occur as a result of pressure due. as a rule, to thickening of the meninges by inflammatory deposits. The bone does not jiress upon the cord even when the deformity is marked, and the cord rarely becomes diseased. When recovery takes place the ddbris is absorbed, and the vertebne are joined together by bony formation, causing complete ankylosis. Symptoms. — Generally the first symptom of Pott’s disease is a disposition upon the part of the child to lie down instead of playing about as usual. He 1066 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. is restless at night, and after a time comj)lains of pain, particularly at night. The pain is usually located in the abdomen, and is often accompanied by symptoms of indigestion that may be very misleading. The gait becomes peculiar and characteristic, so much so that one accustomed to observe these cases will readily recognize one on the street. The child holds his spine rigid and walks with great care, often keeping the knees slightly hexed to lessen the jar. This restriction of motion or rigidity of the spine is not alto- gether voluntary, but is largely due to involuntary muscular spasm — a symp- tom common to all tuberculous bone-lesions near joints. Deformity comes on quite early ; it is often the first, and may be the only, symptom noticed before bringing the child to the physician. It usually appears as a sharp projection or knuckle com- posed of one or more spinous processes. This disease occurs most frequently in the dorsal region, next in the lumbar, and least often in the cervical region. When it occurs in the cervical region the chin is thrown for- ward in a characteristic manner ; the patient may have a choking sensation and experience difficulty in swallowing; at times there is an irritating cough and pain in the chest ; when sitting the elbows are rested on the arms of the chair and the head supported in the hands. If the disease is in the dorsal region the shoulders are elevated and the neck seems short (Fig. 4). There is pain in the abdomen, which becomes distended, and symptoms of indigestion are prominent. The ])atient supports his weight upon his elbows when sitting, and rests his hands upon his thighs when standing (Fig. 5). When the lumbar region is affected the de- formity is a lordosis or bending forward, and is caused by contraction of the psoas muscles. The patient throws his shoulders back in order to keep his e([uilibrium (Fig. 6). The pain may be in the abdomen, but is more likely to be in the lower extremities. The bladder and rectum may be irritable. Complications. — The important complica- tions of Pott’s disease are ])aralysis, abscess, amyloid changes in the liver and kidneys, and tuberculosis of the lungs and cerebral meninges. ParaJiisis is of rare occurrence except in untreated cases. It may affect both the upper and lower extremities, but is usually confined to the latter. It occurs most freipiently with dorsal Pott’s disease and rarely affects the sensory nerves. Since the paralysis is due to pre.ssure from inflaiumatory deposits, and not to bony ])ressure, the danger of this complication does not increa.sc with great deformity. It may occur when the deformity is very slight. With this form of paralysis the knee-jerk is exaggerated and ankle- clonus is marked. The bladder and rectum become aff’ecte T>Dm>)ar Pott’s disease: lordosis. OR THOPyRDICS. 1067 Abscess may occur in any region, but is most common when the disease is in the lumbar region. A psoas abscess is rarely due to any other cause, so it may be considered as almost conclusive evidence of Pott’s disease. Lumbar and retropharyngeal abscesses occur, but not nearly so fre()uently as psoas abscess. The complication is not nearly so common in children as in adults, because in the latter the disease is more frequently located on or near the surface of the bodies of the vertebrae. It is usually a late symptom of the disease, and is apt to be preceded by increased pain and other evidences of poor health, but occasionally it comes on so insidiously that it is the first symptom noticed. These so-called abscesses are, in reality, rarely true abscesses, because they, as a rule, contain neither pus nor pyo- genic germs, but they were given the name of cold abscess before their pathology was understood ; and the name is so well established that it would be difficult to change it. The contents vary from a thin, watery fluid to a thick, cheesy mass. If at any time pyogenic germs are introduced into a cold abscess, it at once becomes a true abscess. Amyloid changes of the kidneys and liver are liable to occur as a compli- cation in old cases of Pott’s disease where there have been discharging sinuses. They do not differ in any way from the changes following prolonged suppuration from any cause. Pulmonary tuberculosis occurs as a complication, but less frequently in children than in adults. Tuberculous meningitis has been, in the writer’s experience, the most com- mon cause of death in Pott’s disease. It comes on late, beginning with very severe headache, high temperature, delirium, and other symptoms character- istic of meningitis, and ends fatally in ten days or two weeks. Diagnosis. — It is important to make an early diagnosis of Pott’s disease, in order to begin intelligent treatment and to prevent deformity. When a child develops a peculiar gait, shows a disposition to lie about, or complains of persistent pain in the abdomen, its spine should be examined. It should be stripped and made to walk up and down the room. If it holds its head, shoulders, or arms in a peculiar manner, and walks as if it were afraid to move, Pott’s disease should be suspected. Place the child prone upon a table, flex the knees so that the soles are turned upward, grasp the ankles alternately, and make an effort to over-extend the thighs. If disease is present in the lower dor.sal or lumbar region, this effort at over-extension will cause a spasmodic jerking of one or both thighs forward toward the table. This symptom is known among orthopaedists as psoas spasm, and is consid- ered a valuable aid in diagnosis. Turn the child upon its back, flex its hips so as to relax the abdominal muscles, and make deep palpation over the abdomen with the points of the fingers. In this way a psoas abscess may be felt long before it can be seen. Have the child stand up, drop an object upon the floor, and ask him to pick it up : if Pott’s disease is present, he will not bend the spine and pick it up as a healthy child would, but will bend his knees and hips and crouch down, keeping the spine rigid. This is quite characteristic of Pott’s disease. Pain is usually a prominent symptom, beginning quite early. It is felt at the distribution of the spinal nerves coming from the seat of the disease more than in the spine. In cervical and upper dorsal disease the pain is often accompanied by a peculiar grunting respiration that is very distinctive. The pain from dorsal disease is in the abdomen, and often leads to mistakes in diagnosis, for there are usually other symptoms pointing to the digestive tract as the seat of disease. When in the cervical region this disease may be 1068 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. mistaken for wry neck. In Pott’s disease the face is turned toward the affected muscles, while in wry neck it is turned away from them, and the condition is not a painful one. Deformity is the most characteristic symptom of a well-established Pott’s disease. In all but the lumbar region it is backward. Nothing is to be learned by palpation, for there is not even sensitiveness. It is to be differ- entiated from the deformity of rickets. In Pott’s disease the angle is sharp and cannot be straightened out, while in rickets the deformity is more of a curve, and will partly or entirely disaj)pear when the child is laid upon its face. With a rachitic curve the other symptoms of rickets are present. Paralysis of Pott's disease is to be recognized by the e.xaggerated reflexes and by the presence of the deformity and other symptoms of this disease. The peculiar attitudes the child assumes in attempting to lift the weight from the sore spine should be I’emembered. lie holds his head with his hands in cervical disease, and supports his weight on his elbows in dorsal dis- ease. Hip-joint disease may be suspected Avhen ])soas contraction is present. In hip-joint disease, however, there is tenderness about the joint, and motion is restricted in every direction, while in psoas contraction from Pott’s disease the joint is not tender and motion is restricted in extension only. In the few cases in wdiich abscess is an early symptom it may aid in diagnosis. Psoas abscess should not he mistaken for hernia or appendicitis. Prognosis. — This disease is decidedly chronic, the average duration being about three years. The natural tendency, however, is toward arrest. Prob- ably 25 per cent, of the cases terminate fatally. Few die from the disease per se, but from complications, such as tuberculous meningitis, phthisis, abscess, and amyloid disease of the liver and kidneys. The deformity of Pott’s disease has a persistent tendency to inci’ease. Even with the best of treatment existing deformity cannot be overcome, and an increase cannot always be prevented. Abscess often runs a remarkably benign course, but it necessarily adds to the gravity of the disease. The paralysis of Pott’s disease ends in recovery, in the vast majority of cases, within one year. Some recover even after three years. Treatment. — The great principle in the treatment of this disease is rest. In tuberculous disease of bone, nature will bring about a cure in the major- ity of cases, aided by rest alone. Under its influence abscesses often dis- appear and paralyzed muscles regain their strength. There is little to be gained by the administration of drugs, save to meet indications as they arise. Pain is best relieved by rest secured by a proper mechanical appliance. Opiates are to be avoidetl in this as in any other chronic disease, because they usually do more harm than good, and are very liable in the end to add to the patient’s suffering. In many cases of Pott’s disease the ]>atient’s gen- eral health is good. Drugs are to he avoided under such conditions. The bowels should ))0 kept regular, and disturbances of digestion met just as if Pott’s disease did not exist. When tlie strength is failing, l)cef ])e])tonoids and plenty of good rich milk should be given, and if at all ])racticable the child should be taken out of doors and kept out as many hours as possible. In some very severe cases the best treatment is prolongeil rest in bed, sup- plemented always by a ])roper s])inal support. It is really surprising to see how well and strong these little sufl'erers become under this treatment, but it is only recommended when ambulatory treatment cannot bo employed. The best means of carrying out this plan is by a jiiece of canvas stretched over a light iron frame (Fig. 7). The canvas must have an opening through ORTlIOl\i:i)ICS. 10G9 wliich a bed-pan can be used, and the whole frame may be taken up and the child carried out of doors if desired. Various materials ai'e employed for mechanical support in Pott’s disease. The general practitioner can meet every indication with the above-mentioned Fig. 7. The stretcher bed. Fig. 8. stretcher splint, by plaster of Paris, or some form of steel brace. A plaster- of-Paris jacket meets the indications admirably in the lumbar and lower dorsal regions. Objections are made to it only by those who do not know how to use it. For the upper dorsal and cervical regions a steel brace, with proper head-piece, is the best appliance. A jilaster cast with a jury mast can be used in these regions, but the writer has found that practitioners with limited experience in this direction find it difficult to apply the jury mast properly. A plaster cast should never be ap- plied when sinuses are present, because it is impossible to keep it clean (Fig. 8). The mistake made by inexperienced persons in applying a jacket is that they get it too bulky. It should not be any heavier than thick pasteboard. For a child, from four to six plas- ter bandages, four inches wide and six yards long, are sufficient. Before applying the plas- ter a close-fitting, armless knit shirt should be put on the child. The anterior superior spinous processes of the ilium and the prominent sj)inous processes of the vertebrie should be surrounded by rings of cotton or felt, so that the cast will not touch them. The child’s arms should be lifted up and enough extension applied to its head to make the spine as straight as possible. It is a mistake to lift the child off its feet. The ordinary extension apparatus sold by all instru- ment-makers is the best appliance, but a very satisfactory one can be improvised by an in- genious practitioner. The plaster bandages should be made of the best dental plaster and crinoline ; commercial plaster and cheese-cloth are not suitable materials. An ordinary wash- basin will not hold enough water to properly moisten the bandages ; a larger vessel should be filled with warm water and the bandages placed in it, one at a time, a sec- ond one being put in just as the first is taken out. The roller should be placed on end in the water, and as soon as bubbles cease to rise it should be taken out and gently squeezed between the hands to remove the sur- ITaster jacket. 1070 A2IERICAN TEXT-BOOK OF DISEASES OF CHILDREN. plus water. Beginning Avell down on the pelvis, the bandage is applied around the body, with just sufficient tension to make it fit comfortably and without wrinkles. About three turns should be placed directly over one another to form the lower end of the cast. After this each succeeding turn should lap over about half the width of the last one, until the jacket reaches well up under the arms, where about three turns should be a}>plied directly over one another. A sufficient number of bandages are applied in this systematic manner to make the jacket of the desii’ed strength, remembering that the tendency is to make it too heavy. At the lower end the jacket should reach as far down as possible without interfering with the fle.xion of the thighs ; at the upper end it should not be so tight under the arms as to be uncomfortable. It is not e.xpected that the jacket will afford support by pressure under the arms, but by supporting the body as a whole. The ends should be trimmed off to the desired length before the jacket is entirely hardened. A common pocket-knife is the best instrument for this pui-pose. When good plaster is used the jacket will be solid enough to su])port the child by the time the trimming is done. Each jacket can be worn from one to three months, when it should be replaced by a new one. In all cases of Pott’s disease above the seventh dorsal vertebra a head- support should be applied, and this is best accomplished by means of a steel brace. A steel brace can be employed with great satisfaction for disease in any part of the spine, but it is sj)ecially well ada])ted to the u])per end. The general practitioner will find that the variety of brace kiioAvn and illustrated in surgical-instrument catalogues as “ Washl)urn’s brace” will give satisfac- tion (Fig. 9). Braces with crutches under the arms are to be avoided, because the patient cannot bear sufficient weight u))on the axilla to be of any service; they also cause the patient much unnecessary pain, aird are altogether unsat- isfactory (Fig. 10). The Washburn brace acts upon the ])rinci])le of a lever, the weight being at the pelvis, the fulcrum at the defoiunity, and the j)ower at the shoulders. OR THOPjEDICS. 1071 It consists of a padded steel pelvic band, to which are attached two steel uprights, one on either side of the spines of the vertebra;, and a cloth apron, which is spread over the front of the body, holding the uprights close against the back. To the upper end of the uprights are attached padded strips of webbing tvhich pass around under the arms and buckle to a cross- piece over the scapulae, holding the shoulders back. The uprights are padded opposite the deformity. The pelvic band acts as a fi.xed point ; the uprights make pressure upon the transverse processes of the diseased ver- tebrae, and the straps over the shoulders, with the aid of the spring in the steel uprights, pull the shoulders back, thus lifting the weight from the diseased bodies of the vertebi’ae and throwing it upon the healthy parts. The brace acts as a splint does to a broken leg, holding the whole spinal column as one piece, thus securing the desired rest for the diseased part. Should an abscess appear, so long as it is not large and is causing no symptoms it should be let alone. If, however, it is inci’easing rapidly in size, if it is causing symptoms from pressure, or if the patient’s health is failing, it should be operated upon. It is far better in any case to let a cold abscess alone than simply to open it and leave it to itself. The writer has obtained the best results by evacuating the abscess with a trocar and cannula, washing out Avith bichloride solution and injecting iodo- form emulsion. Every antiseptic precaution must be employed in this operation, because the introduction of pyogenic germs into these cavities, causing a mixed infection, is a A'ery serious matter. The iodoform emulsion should be 10 per cent., and from two drachms to two ounces may be injected. A second operation any time after tAvo Aveeks may be necessary. The paralysis of Pott’s disease requires the same care as paraplegia from any other cause. The bladder and boAvels must be cared for and bed-sores avoided. The mechanical support must be continued. These cases usually recover in about a year, and, in the Avriter’s experience, get Avell just as promptly Avithout special medication. Ohronic Joint Disease. It is noAv Avell understood that chronic joint diseases are generally tuber- culous. They are ahvays liable to be folloAved by deformity and permanent disability, and require mechanical treatment. They are therefore classified under the head of orthopaedic surgery. The greatest advance made in this department of surgery is the establishment of the fact that tuberculosis of bones and joints is essentially a local disease, and should be treated as such. They very rarely prove fatal, except Avhen they become complicated by a general tuberculosis or a tuberculosis of the brain, lungs, or some other vital organ. The natural tendency of tuberculous joint disease is toAvard recovery, and Avhen assisted by proper mechanical or operative treatment the prognosis is favorable in from 90 to 95 per cent, of the cases. The old idea Avas that this disease is constitutional in character, and it Avas ti’eated accordingly. The belief still prevails that the disease is hei’editary, but the facts do not support this belief, for the children of healthy parents as Avell as those of diseased ones are subject to the affection. The family history Avill not help establish the diagnosis, and may even be misleading, because the mere fact that some ancestor of the child had tuberculosis does not prove that an arthritis occurring in the child is tuberculous. On the other hand, the fact that the child’s ancestors Avere free from tuberculosis does not enable us to exclude this affection in the child. 1072 AMEBIVAN TEXT- BOOK OF DISEA^EB OF CHILDREN. Tuberculous joint disease may begin either as a synovitis or an osteitis, and it is often difficult to differentiate between them. Fortunately, the treat- ment is the same in either case. In children the majority of cases begin as an osteitis, and the tendency is for the disease to extend to all the tissues of a joint, so that it becomes a tuberculous arthritis. The great principle of treat- ment is prolonged rest, which is best secured by some mechanical device. Usually when the joint is kept perfectly (juiet for a sufficient length of time nature will bring about a cure. There is no special medication for this dis- ease. Local applications may, at times, help to relieve pain, but they have no curative effect. Hip- JOINT Disease. The hip is the most frequent seat of chronic joint disease. It is tuber- culous in chai’acter, and generally begins in the head of the femur near the epiphyseal line. Etiology. — Usually the exciting cause is not known, but it is certain that in some cases it is traumatism. As a rule, it is not the puny, delicate child of the family who develops hip-joint disease, but the active, stirring one — the one, in short, who is most subject to traumatism. Injury thus causes a locuss minoris resistentice which affords a culture-field for the tubercle bacillus. Symptoms. — Generally the first symptom is a limp. The child will be noticed to limp when it first gets about in the morning, and to get better as the day advances. Deformity appears early, and is usually flexion with adduction and apparent shortening, but it may be flexion with abduction and apparent lengthening (Figs. 11 and 12). Atrophy is an early and con- stant symptom. I’ain is apt to be present early. It is most marked on tlie inner side of the knee or on the anterior surface of the thigh. It is (juite exceptional that it is referred to the joint itself. Limitation of motion is the symptom most depended iq)on by orthopaedists in making the diagnosis. By pi’oper examination it may be found at a very early period. Involun- tary muscular spasm is an im])ortant symptom found upon manipulating the joint. The general health of the child is often fairly good, but there may be emaciation from persistent pain and loss of sleep. There is no marked febrile reaction, although a temperature of 99° or 100° F. is not uncommon. Later in the disease an abscess may form, and may appear at any jioint about the joint, but is seen most frequently in front. It is generally preceded or accompanied by an unusual amount of ])ain, but sometimes comes on so insidiously that it becomes (juite large before it is noticed. Pathology. — If treatment is ])cgun early enough, it is po.ssible to pre- vent the disease from breaking into the joint, and thus save the motion in the limb. In many cases, unfortunately, this has ha])pened l)efore the child is brought under treatment, and the bone and other joint-structures are breaking down. The disease, unless prevented by j)roj)er treatment, extends to all of the structures of the joint. Diagnosis. — When a child limps and complains of pain .about the knee or hip a careful examination of both the joints should be made. It is un- fortunately a very common experience of every surgeon to have a child brought to him with well-advanced hip disease which has been diagnosticated and treated for rheumatism. 'Phis mistake should never bo made, because rheumatism is an acute febrile disease usually affecting several joints at once. ORTHOPEDICS. 1073 For examination tlie cliild must be stripj)ed of all clothing, and made to •walk back and forth before the examiner, that he may locate the limp. If the hip is affected, the patient swings the body when stepping forward with the affected limb, making as little motion at that joint as possible. The thighs should next he measured. If hi])-joint disease is present, the thigh on the diseased side is from half an inch to an inch smaller than the other, and the gluteal fold is usually absent as a result of atrophy of the muscles. Older writers placed much value upon deformity as a characteristic symp- Fig. 11. Hip-joint disease just beginning, showing slight flex- Abduction and apparent lengthening, ion and disappearance of gluteal fold. tom, hut it is very important to make a diagnosis before marked deformity is present. The child should next be laid upon its hack upon a table (a bed is too soft). Try to bring the popliteal space of the affected side and the lumbar spine in contact with the table at the same time. If this can be accom- plished with ease, hip-joint disease can he excluded, because even at an early stage some flexion is present, although it may not be noticed when the child is standing; and when it is present the popliteal space and lumbar spine cannot be made to touch the table at the same time. Place the palm of the hand first upon the sound limb and gently roll it on the table, then roll the lame limb in the same manner. If hip-joint disease is present, it will require more force to roll the afflicted limb, and the limb will not roll so far on account of the restriction of motion in the hip-joint. Next grasp the 68 1074 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. ankle of the sound limb and flex the leg on the thigh and the thigh upon the body, noting the natural resistance ; the hip-joint should then be put through all its natural motions to note the amount of normal resistance and to gain the confidence of the child. The lame leg should now be taken and put through the same motions, and if hip-joint disease is present, it will re- quire more force to flex and rotate the hip, and there Avill be involuntary spasm of the muscles about the hip. There is, in short, restriction of motion and spasm. When this examination is made with care and gentleness, these signs can be found at a very early stage, and are quite characteristic, since no other disease will cause spasm and limitation of motion in every direction. Rough manipulations must always be avoided, because they obscure the symp- toms and may do harm. Prognosis. — From 90 to 95 per cent, of cases of this affection will recover under treatment, and the majority will have a useful amount of motion in the joint. By recovery we mean that the disease will disappear. Very rai'ely the joint is left in an almost perfect condition. Usually, how- ever, there is some shortening and deformity, with more or less permanent limitation of motion. In untreated cases the deformity is apt to be great, and complete ankylosis is not infrequent. Abscesses add to the gravity of the case, but do not make recovery with a satisfactory result impossible. The length of time required to bring about a cure varies greatly in different sub- jects*; a very few will recover in one year, many in two and three years, and some continue for five years. Treatment. — When the diagnosis is made there must be no delay in beginning treatment, for it is only by early detection and promj)t treatment that the best results are obtained. Medicine is of little or no value for the disease per se, but may be necessary to meet indications as they arise. The great point is to secure perfect rest for the diseased joint : it must neither move nor bear weight : this is best accomplished by some mechanical device. Pain is best relieved by securing perfect rest ; opiates are to be avoided. An effort should be made when the ca.se is not too chronic to overcome some of the de- formity. When the child is suffering severely a very excel- lent way to begin treatment is to put it in bod and apply extension by means of a weight and pulley until the acute j)ain has subsided ; then some mechanical de- vice should be substituted and the confinement to bed discontinued. 'I'he amount of weight required in ex- tension varies from two to six pounds, or from half a brick to tw'o bricks, according to the age of the child, the object being to secure continuous extension. The relief afforded is another good gauge of the weight to be employed, most surgeons erring in using too much, 'file weight is best applied by means of an ordimu’y Buck’s extension, as ))ictiired in all works on surgery. The adhesive straps should always exteiid above the knee, and the chihl must not be alloweil to slide down so as to come in contact with the foot of the bed. Some patients do best if extension is ke])t u]) by means of an extension-brace throughout the treatment, but most cases do equally well if the joiiit is simply fixed without extension. 'I'he best exten- sion-brace is the long hip-splint consisting of a padded steel waistband and a Fig. 13. ORTHOPAEDICS. T075 long steel bar, capable of being lengthened or shortened, extending from the waistband to a point just below the sole of the shoe (Fig. 13). Tmo ))erineal straps are attached to the waistband upon which the patient sits instead of stepping on the foot of the diseased side. The lower end of the brace is attached to the leg by means of adhesive straps which have buckles attached to them, and straj)s attached to the horizontal part of the brace which passes under the foot. These straps are buckled into the buckles, and the length of the bar made such that, when the child stands upon the brace, the foot will Fig. 14. Fig. 15. Taylor’s long hip-splint applied. Plaster-of-Paris splint for hip-joint disease. swing clear of the cross-piece and of the floor. The shoe on the sound side must be elevated so as to make the length of the leg eijual to the length of the brace. The perineal straps must be so adjusted that the waistband rests between the trochanter and the crest of the ilium, and so that there is a gentle pull upon the leg all the while, forcing the head of the femur away from the acetabulum. A child can walk very comfortably upon a brace of this kind without the aid of crutches (Fig. 14). A very convenient and efficient method of treating hip-joint disease is to 1076 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. apply a plaster-of-Paris splint from the ribs to the knee (Fig. 15). The shoe on the unaffected side should be elevated at lea.st two and a half inches, and the child should walk with crutches. The elevation of the shoe should always he sufficient to prevent the patient from bearing weight upon the lame limb, as he is very prone to do as soon as it gets a little better. The plaster will last longer if it is reinforced by light strips of wood over the fold of the groin, where it is most likely to break. The splint should not be heavy, and should be changed every three or six weeks, according to circumstances. Sole leather softened in cold water and fitted to the body from the ribs to the knee makes a good splint. A paper pattern may first be fitted and the leather cut by this. The softened leather can then be fitted to the body and held there by plaster bandages until it is perfectly dry and hard. Particular care must be exercised in every case that weight is not borne upon the diseased limb, for a splint of any kind would be of little value were the patient allowed to use the joint. It will be necessary to continue treatment for from one to three years, or for six months after all ])ain and spasm have disappeared. The parents should be informed from the first that the treat- ment will necessarily be long, and that even when the case is doing well there will be acute exacerbations, continuing from a few days to as many weeks, during which the child will suffer more and in every w'ay seem worse. During these exacerbations the treatment should be in no way changed, save that the patient should be kept as quiet as possible. An abscess may appear at any time after the first few months, and always adds to the gravity of the disease, but it does not follow' that a good, useful joint may not be secured. As long as an abscess is small and is causing no symptoms it should be let alone, for it will do no harm and may disappear entirely. Should it increase rapidly, should the child’s general health begin to fail, or should it give rise to any decided symptoms, it must be evacu- ated. Some very good authorities advise asj)iration, but the w'riter has not been satisfied w ith this. It is better to empty it through a good-sized cannula, and after washing thoroughly with a bichloride solution to inject from two drachms to two ounces of a 10 per cent, emulsion of iodoform. It is not good surgery to open these cold abscesses and drain with rubber tubes. In a very few' instances the disease will grow' worse in spite of the best treatment. In these and in some cases that first come under treatment after the disease is w'ell advanced the joint should be excised. This oj)eration is indicated when the disease grows rapidly w'orse in spite of proper treatment, when the child’s health is failing rapidly, and when there are sinuses and other evidences of extensive disease of bone. The operation is not a very dangerous one, and yields good and at times brilliant results, for, as a rule, in a few w'eeks or months the child recovers. Unfortunately, however, the ultimate results are not nearly so good as in cases treart of the fore- head and corresponding parts of the occiput in boys above three years, on the teijiples in girls, and on the cheeks in infants. They are densely packed and often grouped, and accompanied by seborrluca of the seal)). AVarmth and moisture seem to be the exciting causes. T. C. Fox has made similar obser- vations. Treatment. — Cleanliness and the free use of soa]) and Avater are all that is required in the way of ))reventive treatment. To remove the comedones Avhen present, friction Avith a green-soap lather is usually elficacious : I^. Saponis olivae praep., vel saponis viridis . . . oj. Alcoholis f.^j. A()uic ().s. adfsiv. — M. Sig. Apply with llannel rag. In some cases it may be necessary to express the plugs Avitli a comedo- extractor. DISEASES OF THE SKIN. 1093 Acne. Although Chambord and others have reported a few cases of acne in young children, practically the disorder does not make its appearance until puberty. The acne due to the ingestion of the iodides and bromides and to the use of tar is not a true form of the disease. Milium. Milia are small white or yellowish papules, varying in size from a pinhead to a split pea, that occur for the most part under the eyes, on the forehead, and over the cheeks. It is a tolerably common affection in infants, and constitutes the strophulus alhidus of Willan. Etiology. — The etiology is not always clear when occurring in infancy. Milia are often congenital. They also follow in the wake of other diseases — namely, pemphigus, lupus, ei’ysipelas, etc. They are usually regarded as due to retention in one or several of the acini of an oil-gland, but Robinson thinks that two causes may be operative in their production : in one instance “ it is a case of miscarried embryonic epithelium from a hair-follicle or from the rete,” while in milia following pemphigus, lupus, etc., the contents consist of fatty epithelium and cholesterin, the epithelium being often arranged in concentric layers around a central fat-nucleus. Prognosis. — F avorable. Treatment. — The electrolytic puncture, as originally suggested by the writer, is not demanded, nor would it be tolerated, in infantile cases. More or less vigorous friction with soap and water is all that is needed. SWEAT GLANDS. Hyperidrosis. Hyperidrosis is a functional affection of the sweat-glands, giving rise to hypersecretion of their contents. It may be acute or chronic, general or local, limited or excessive in amount. Universal hyperidrosis is usually symptomatic, occurring in connection wnth acute febrile states or dependent upon general diseases of a debilitating character, such as phthisis, rickets, etc. In the last- named disease, however, the sweating is most abundant about the head. Gen- erally in babies tbe profuse local and general sweating is induced by injudicious clothing and excessive heating of living apartments, and when the.se unhygienic conditions are kept up, intertrigo and eczema are not infrequent sequelae about the genitals and between the folds of the skin. Generalized eruptions of sudamina from the same causes are also encountered. Hyperidrosis of the palms and soles and axillae often develops during child- hood, and sometimes is clearly congenital and occasionally hereditary ; hut it does not follow that all of these localities are involved at the same time, for usually the disorder is limited to one region or the other, the palms and soles being more apt to suffer together. When the palms and soles are affected — that is, if the sweating be at all abundant — the skin becomes sodden and macerated, and from the feet the odor is often disgusting. This condition, known as bromidrosis, is more frequent, however, in the adult. Etiolog-y. — Aside from the more or less physiological sweating due to high temperature, faulty innervation apparently plays the chief role in hyperidrosis. Cutler regards it as a functional affection of the sympathetic system. Foetid perspiration is due to the presence, according to Thin, of the bacterium foetidum. 1094 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Prog-nosis. — Sweating of the feet is more controllable than that of other parts. Upon the whole, the prognosis of hyperidrosis should be guarded. Treatment. — The treatment of general sweating is based upon the causal indications, and need not be dwelt upon here. The debilitating sweating about the head in children may be much mitigated by directing them to lie on hair pillows instead of the usual feathers. Among specific remedies may be men- tioned belladonna, atropine, agaricin, and ergot ; but their effect at best is only temporary. Crocker highly extols precipitated sulphur, given in milk, twice a day. If it proves too laxative, it may he combined with the compound chalk- and-cinnamon powders. The local applications are numerous. Among the most satisfactory are a 1 per cent, solution of quinine in alcohol, belladonna salve or liniment, tannin dissolved in bay rum (gr. viij to f^iv), salicylic acid in alcohol (3j-f5iv), and various dusting powders, composed of zinc, starch, boracic and salicylic acids. For sweating of the hands Pringle recommends pure silicic acid (terra silicea). For foul-smelling perspiration of the feet dusting the stockings with boracic acid is valuable. The following powder, as suggested by Van Harlingen, is to be commended : Pulv. acidi salicylic 3ij. Pulv. zinci carb. prtecip sij. Pulv. magnesire ustte 3ij. Pulv. amyli Svijss. Pulv. talci oX- — H. Sig. Dusting powder. Ilebra’s plan, although troublesome, is eminently successful. Briefly, it consists in wrapping the feet and toes, the latter separately, in cloths spread with diachylon ointment, which should be changed twice daily, and the parts rubbed dry before each reapplication. This should be kept up for two weeks, water being absolutely interdicted during the treatment. Strapping the parts evenly and firmly with soap or lead plaster often suffices. Miliaria. Miliaria, lichen tropicus, or prickly heat, is an acute inflammatory affection of the sweat-glands, resulting in papular, vesico-papular, vesicular, and even pustular, lesions. It is a very common disorder in young children, and is usually seated upon the trunk, although the face and other {)arts of the body are also attacked. The subjective symptoms are very annoying, and consist of sensations of intolerable burning and stinging. The rash comes out sud- dcnly, often after profuse sweating, and generally subsides in a few days with slight des(iuamation ; hut if the cause is kept uj) successive crops will appear. According to the lesion present — and this a])j)arently depends ujhhi the inten- sity of the process — the eruj)tion has been variously designated — viz. m. vesic- ulosa or ruhra (the “ red gum ” of the nursery), m. papulosa or prickly heat, etc. The non-inffammatory variety is m. crystalUna or sudamina. Furuncu- losis and eczema are not infretiuent secpiehe of neglected or ill-treated cases. Etiology. — Intense heat is the common factor, and therefore miliaria is most frequently encountered in summer. Sudamina are noted in connection with states of general debility and in febrile disorders, but also as a conseciuence of excessive sweating. In sudamina the sweat collects between the dee{)est laminae of the horny layer ; the sweat-duct is obstructed, with consecpient DISEASES OF THE SKIN. 1095 rupture of the wall and formation of a vesicle. In miliaria there is vascular congestion about the ducts, increased secretion, and more or less efl’usion into and about the sudoriparous organs. Diagnosis. — Siulamina are non-inflammatory in character ; which fact, taken in connection with the history of the case, will be sufficient for their differentiation from varicella. The lesions of eczema papulosum are larger than those of miliaria papulosa, are more persistent, and the pruritus is more intense. The vesicles of vesicular eczema are more closely set than those of vesicular miliaria ; they rupture readily (in miliaria the vesicular contents usually dry up without rupture) and give rise to the peculiar sticky discharge. Treatment. — In relapsing cases tonics ai’e sometimes demanded, and more especially change of climate. Ordinarily, attention to diet, which should be of a plain, non-stimulating sort, with proper clothing and, at the height of the attack, some mild refrigerant mixture, is all that is required in a general way. Children in summer should be kept well powdered with borated talcum or similar preparation as a preventive measure. During the outbreak the speed- iest relief is secured from the use of the calamine-and-zinc lotion : 1^. Zinci oxidi 5 ss. Pulv. calaminae prmp Biv. Glycerin i fgj. Liq. calcis fs^ij. — M. Sig. Shake and mop on freely. If the itching be intense, from two to five minims of carbolic acid may be added to each ounce of the mixture. Anderson’s dusting powder is u.seful : I^. Pulv. amyli 3vj. Zinci oxidi Siss. Pulv. camphorae 3.ss. — M. Sig. Dusting powder. INFLAMMATIONS. Erythema Simplex. In simple erythema the skin presents variously-sized, diffused or circum- scribed, hyperaemic lesions that fade temporarily upon pressure, and are usually without sensible elevation above the surrounding surface. Subjective symp- toms are trivial, and consist for the most part of slight burning and tingling, or they may be absent entirely. An altogether unnecessary confusion has enveloped this subject, owing largely, perhaps, to errors in diagnosis, but also, to some degree, it has arisen from the cumbersome and pedantic nomenclature which has been applied to comparatively insignificant differences in the appear- ances of the lesions. Simple erythema may be conveniently divided into two main classes — namely, idiopathic erythema and symptomatic erythema. Idiopathic Erythema. This variety of the disorder is excited by the influence of external irritants acting upon the skin, and passes readily into a true inflammatory state. Ery- Um AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. thema caloricum is set up by the agency of heat and cold ; erythema trauynat- icum arises from pressure, rubbing, etc. ; and erythema venenatum is produced by the action of animal and vegetable poisons. Two other forms of erythema, both very common in children, are e. intertrigo and e. pernio, or chilblain. Erythema Intertrigo. — Intertrigo usually occurs in the groins, in the folds of the neck in fat babies, and wherever, in fact, the skin surfaces come in con- tact ; and it is all the more readily induced by the irritation of the sweat-secre- tion and by urinary and faecal discharges. Intertrigo is always at first a simple hyperaemia of the skin, but when neglected the skin becomes hot and ten- der, the epidermis macerated, a profuse, malodorous, muciparous discharge is present, and in bad cases fissuring, and even ulceration, may occur. The eruption is very common, at times appearing suddenly, and, under simple treatment, disappearing again as rapidly ; but if maltreated it may run a long course. In some instances it is symptomatic of grave internal disorders. Intertrigo naturally occurs most frequently in summer, but this is by no means the rule with children. Relapses are frequent. Diag’nosis. — Intertrigo is easy to recognize. Tilbury Fox says it is to be distinguished from eczema by the nature of the characteristic discharge, which does not stiffen linen. The erythematous syphilide of infancy is apt to attack, like intertrigo, the buttocks and genital regions ; but, aside from the color and the general concomitants of syphilis, the diagnosis is facilitated hy remembering that intertrigo confines itself to the region of the diaper ; the syphilide runs down toward the heels. Treatment. — The preventive treatment demands absolute cleanliness, the use of a bland soap (Eichoff's superfatted thymol soap, for example) and a simple dusting powder, such as oxide of zinc and lycopodium {z ij“3'^.i)- For the curative treatment it is necessary to keep the parts separated by the inter- position of thin layers of absorbent cotton, and to apply some remedy that is both astringent and antiseptic. The following is a good example of a powder : Thymol gr. j. Pulv. zinci oleatis ,sj. — M. Sig. Dusting powder. A modification of La.s.sar’s paste serves an excellent purpose, besides thoroughly protecting the surfaces from irritating discharges : I^. Acidi salicylici t?’’- x. Bismuthi subnitratis Amyli «d,oiij. Ung. aq. ro.sm q. s. ad .^j. — M. Sig. Smear gently over the affected parts. Of late the writer has used Pick’s paste with much satisfaction : 1^. Pulv. tragacantlue gr. xv. Glycerini Tffxxiv. A(iu3e fsj- — M. This makes a transparent adhesive dressing, called by its originator linimon- tum cxsiccans. By adding to it 10 per cent, of oxide of zinc and 1 per cent, of carbolic acid there will result a most admirable ])roparation. Erythema Pernio, or Chileeain. — Chilblains are prone to occur in chil- DISEASES OF THE SKIN. 10‘>7 dren with poor circulation, and especially in weakly, anaemic girls. The lesion." consist of erythematous patches of various sizes and shapes, and attack by jjref- erence the heels, toes, sides of the feet, fingers, knuckles, ears, and tip of the nose. The spots are light red in the beginning, but later on become bluish - red. The burning and itching that accompany their development are much aggravated by warmth. The surface of the patches in bad cases may vesicate and result in the formation of large blebs, possessing serous or sero-sanguin- olent contents ; or the parts may become denuded and slough. Treatment. — The internal treatment is symptomatic, but, as most of the eases occur in the Aveakly, tonics and general hygienic measures are urgently •demanded. Woollen stockings and loose shoes, without elastic sides, are to be preferred, and the habit of “ toasting ” at fires and registers is to be prohibited. Friction with snow or cold water should be tried in threatening cases, and after- ward soothing, somewhat astringent, lotions pre.scribed, such as the lotion of zinc and calamine. Pick’s paste is also useful at this stage. Later, if the ■erythematous condition has become fully developed, stimulating local treatment becomes necessary. The unbroken surface may be painted with iodine or with oil of peppermint, pure or diluted. Jackson recommends — I^. 01. cajuputi . . . Liq. ammon. fort. Lin. saponis comp Sig. Local use. In very chronic patches Pringle recommends painting with a solution of nitrate of silver (gr. xvj) in spirits of nitrous ether (f.sj), or a 5 per cent, solution of salicylic acid in traumaticin. Ulceration and sloughing, when they occur, should be treated on general surgical principles. Symptomatic Erythema. The symptomatic erythemata are very numerous and are due to a great variety of causes. It is well for the practitioner to remember that many general diseases — e. g. variola, diphtheria, measles, scarlatina, and vaccinia — are often preceded, accompanied, or follow'ed by erythematous rashes. The scarlatini- form i-ash that is not infrequently seen in connection Avith septicaemia, the puerperal state, etc. is also, according to Crocker, an accompaniment of malarial disorders in children. However, it is necessary to bear in mind that quinine in susceptible subjects induces an erythematous rash. Various other drugs are capable of evoking congestions of the skin. Erythema Infantile. — This form of erythema, also called ro.seola infantilis, is comparatively frequent, and possesses an importance out of proportion to its severity on account of the confusion in diagnosis to which it gives rise. Tem- porary congestions of the skin are quite common in teething children and in those sulfering from alimentary derangements. The eruption is usually rose- olous ; that is to say, made up of variously sized and shaped patches and blotches having a general resemblance to the rash of measles. iMuch of wdiat is called “.scarlatina” is undoubtedly this symptomatic erythema. Accompanying the eruption there is usually some slight elevation of temperature, together with some redness, without swelling, of the palate and fauces. This infantile erythema is an ephemeral atfair, and its only importance is of a negative sort. The diagnosis, however, is at times difficult to the inex- dd f^ij. . f.^iij. — M. 1098 AMERIVAN TEXT-BOOK OF BIREASES OF CHILDREN. perienced. It is to be differentiated from scarlet fever by the fact that in the latter affection there is a high temperature, great heat of skin, glandular engorgement, the characteristic state of the tongue and throat, and the location of the eruption — symptoms that are absent in infantile erythema — while the catarrhal prodromal stage, the fever, the maculo-papular rash on the mucous membranes and the skin, are significant of measles, and not of erythema. Kiitheln is manifestly the result of contagion, two or more children in the family perhaps being simultaneously attacked : the glands behind the neck are aj)t to be swollen, the eruption is less evanescent and is more papular than erythematous. New-born babies are often attacked with an eruption made up of minute red papules seated on a hypermmic base, which may be made to fade away under pressure. The back and chest are the usual sites of the rash. It lasts but a few days, and disappears with slight des(iuamation. The mucous mem- branes are not involved, and there is no fever. Treatment. — The internal treatment of the various erythemata is purely symptomatic. A little calamine lotion or a dusting powder is all that is required locally. Erythema Multiforme. Erythema multiforme is an exudative affection of the skin in which various erythematous, papular, vesicular, bullous, tubercular, and nodose lesions may a])pear separately or coincidently. Preceding the outbreak of this eruption, the patient may experience more or less malaise, gastric disturbance, sore throat, rheumatic pains, and fever. Crocker, wdio has paid much attention to the skin diseases of children, says that the fever and general symptoms are more marked in them than in the adult, the lesions are more severe, and when vesicles form their contents are prone to become purulent and leave cicatrices. However, the lesions are not so apt to be multifoimi. There are, nevertheless, exceptions to this rule, for often the general symptoms are insignificant, especially when the eruption is limited in extent. The local subjective symptoms consist mainly of sensations of burning and tingling;. ^ O ^ When the disease assumes the erythematous form, the hiding of the centre of the patch leaves a ringed appearance that has been called e. annulare; or concentric rings, one forming within the other, will leave in their wake, as the effusion becomes absorbed, a variety of diflerent colors, thus justifying the rather fanciful term of e. iris ; or these advancing rings, meeting others, become broken into various lines, producing e. gyratum ; or, made up of widely diffused patches ivitli an abrupt and sharply-defined border, it is called e. tnarginatum. As usually seen, however, the disease makes its appearance in the form of discrete or aggregated fiat papules, varying in size from a }>in- head to a sj)lit pea ; in color they are bright red or purplish. Often the lesions are consi(lerably larger (c. tuherculatwn), in which case they have a deeper or violaceous line that is quite characteristic. Vesicles or bulhc may form in connection with any of the above-mentioned lesions, thus constituting e. vesiculosum and e. Imllomm. The backs of the hands and feet are common sites of the eruption, ]>ar- ticularly for the papular and tubercular types ; but the whole surface is often involved. Slight des(juamation and pigmentation may occur as seipiela;. The usual duration of the disorder is from two to four weeks ; but the general symptoms usually abate at the appearance of the eruption. Relapses are common, especially in the spring, and in a few rare instances, reported by Fox, DISEASES OF THE SKIN. ion?) Jackson, and the writer, the disease has relapsed at irregular periods for many years. Many authorities look upon erythema iris and erythema nodosum as inde- pendent affections, but the wi'iter regards them as clearly allied to, if not iden- tical with, erythema multiforme. Herpes Iris. — It is usually symmetrical, and occurs preferentially on the backs of the hands and feet, but especially the former. There may be one or more patches ; sometimes the whole body is afiected, even the mucous mem- branes. The eruption consists of an erythematous base, upon which is seated a conical vesicle ; both vesicle and areola increase in diameter, and presently the outer border of the latter is elevated into an annular ring by fresh effusions, while the central vesicle undergoes absorption and leaves in its stead a pur- plish stain. Here the process may terminate, or else successive rings may form, and the various shades of color thus produced give the rather hinciful rainbow effect. Various other modifications have been noted. Erythema Nodosum. — Before the eruption is developed the patient may complain of the general symptoms observed in connection with other types of e. multiforme. The lesions consist of isolated, painful, inflammatory nodes that vary in size from a hickory-nut to an egg or orange. They are usually red at first, but as they decline take on the various shades of a common bruise. They may be well or ill defined, and are at first hard and tense, but later become softer, thus closely simulating abscesses. The favorite site of the eruption is the front of the legs, but it may appear elseivliere. Sensations of burning and tingling are usually present. The disorder may last two to four weeks. Relapses are not infrequent. Etiology. — The various types of erythema multiforme avoid the extremes of life as a rule ; the ages between ten and thirty are most obnoxious to its attacks. It seems to occur as the result of the most diverse causes — e.g. changes of temperature, disorders of digestion, as sequelae of vaccination, in connection with epidemic influenza {la grijipe ) ; and, as regards e. nodosum, it apparently bears some etiological relationship to rheumatism. The explana- tion would seem to be that these various erythemata are of angeio-neurotic origin, and that under favoring conditions toxic and other agents influencing the central nervous system produce these explo.sions in the vascular and nervous organs of the skin. The rash is undoubtedly due to a vaso-motor disturbance, inducing the usual phenomena of inflammation, with a variable aimount of exudation. Haemorrhage into the lesions also occurs. Diagnosis. — Erythema multiforme is to be distinguished from urticaria by the stability of the eruption, the greater variety of the eruptive elements, and the less degree of itching. The papules of papular eczema are smaller, more pointed, last longer, and are intolerably pruritic. The nodes of syj)hilis should not be confounded with e. nodosum. Attention to the history of the case, the possibility of ulceration, and other concomitants of syphilis should sufficiently emphasize the differences. Prognosis. — In the majority of cases the prognosis is favorable. Under no circumstances is the disease dangerous to life, but the relapses are not always easy to control. Treatment. — The prodi’omic symptoms of erythema multiforme should be treated on general principles. There is no specific remedy for the disease as a whole. Hygienic measures and tonics are demanded in the anaemic and stru- mous. In rheumatic cases the salicylates are indicated. The calamine-and- zinc lotion, with or without the addition of a little carbolic acid, is a good local 1100 AMERICAN TEXT-ROOK OF DISEASES OF CHILDREN. application. In e. nodosum the legs should be kept elevated, and the same lotion applied, or a lead-and-opium wash. For e. tuberculatum of the hands the unguenturn vaselini plumbicum (see under Eczema), spread on muslin and neatly bound, gives relief. Relapsing Scarlatiniform Erythema (Fereol). Under the title of “ erytheme scarlatiniforme desquamatif recidivant ” Fereol and Besnier describe a form of disease that occurs in children and young adults, and which really should be discussed along with the other varieties of exfoli- ative dermatitis. Usually, after a prodromic stage of one or two days, in which the patient feels unwell and has slight fever, a scarlatiniform erythema appears, first on the trunk, and in a few hours, or perhaps not for a couple of days, it spreads over the whole body. In some cases the rash is localized to particular parts of the surface, or it may be widely diffused, but with areas of normal skin between the patches. The oral mucous membranes are also injected. There is some burning and itching present, but the skin remains supple and shows no infiltration. After a few days — one or two — the process comes to an end, and free des(iuamation occurs. At the end of a week or two the disease has generally run its course ; on the otlier hand, there may be repeated recrudes- cences and the disorder may be kept up for weeks. Relapses are frequent, especially after vicissitudes of weather or from other general or local exciting causes. It is non-contagious and does not occur e])idemically. Diagnosis. — The distinction between this affection and scarlatina is at times difficult ; but in scarlet fever the prodromic symptoms are usually more severe, the eruption comes out first on the neck, chest, and flexures of the joints, the fauces are tumid, the tongue has the strawberry-like appearance, the glands at the angles of the jaw are swollen, and, finally, des(iuamation does not occur nearly so soon. As additional points it may be remembered that this disorder usually gives the history of relapses, and that it is neither due to nor causes contagion. Treatment. — -This should be directed toward the mitigation of the general and local symptoms — namely, antipyretics and soothing inunctions. Eczema. Eczema is an inflammatory, non-contagious disease of the skin, character- ized by multiformity of lesion and the pre.sence, in varying degrees, of itch- ing, infiltration, and discharge. It may be acute, subacute, or chronic, and undergoes various secondary changes, such as scaling, crusting, Assuring, and dense thickening of the skin. It was formerly held that eczema w'as invari- ably a vesicular di.sease, and that, therefore, the other ty])es which it presents represented other diseases, such as impetigo, lichen, etc. We now fully recog- nize the fact that it is a truly protean affection in its manifestations, although pos,sessing a {)athological unity in its essential features that is unmistakahle. This view has been very fruitful from the standpoints of diagnosis and treat- ment. So far from eczema being a vesicular disease, it may run its course without the ajtpearancc of a single vesicle. On the contrary, the disorder is characterized by a polymorphous eruption, consisting of erythema., ]>a pules, vesicles, and pustules. All of these lesions are not necessarily present at the .same time, although to a limited extent they may be, and one form of ele- mentary eruption m.ay become transformed into another ; but, as a rule, one or another of them may .so predominate as to establish the anatomical general DISEASES OF THE SKIN. 1101 type of the eczema ; as, for example, eczema erythematosum., e. papulosum, e. vesicidosum, e. pustulosum. In practice, however, the disease is more often encountered in its suhacute or clironlc phases, and a brief consideration of these secondary changes will he necessary. Eczema rubrum or madidans may develop out of any of the elementary types of the disease, and consists of a raw, red, and weeping surface, the result of exposure of the rete, due to shedding of the upper layers of the epithelium. The itching is very severe. This form of eczema is common on the faces of children. Scaly or squamous eczema may also follow upon any of the element- ary forms of the disease. It appears mostly in patches of variable size, which are red, scaly, and infiltrated ; and finally, owing largely to situation or dura- tion of the disease, the eczematous surface may become of board-like hardness, or warty, or cracked and fissured. The chief subjective symptom present in eczema is itching ; in fact, it constitutes the disease. The pruritus will vary considerably in degree, some- times being slight and easily tolerated, or, again, it may be agonizing in its intensity. Eczema bears a close resemblance to catarrhal states of the mucous mem- branes, both in its tendency to repeated relapses and, objectively, in its habit of exudation or discharge. This exudation has the property of stiffening and slightly staining linen or cotton fabrics with which it comes in contact. It is not correct to assert that eczema is invariably a “ wet disease,” for some cases may remain dry throughout ; nevertheless, even a papular or erythematous eczema may be made to weep through the inffuence of scratching or other iri’itation. Although eczema in children, especially in those under five years, is a very common disease, the writer fails to see wherein it differs essentially from the same disorder occurring in the adult, although this opinion is one very com- monly entertained. Such differences as exist are rather of causation and loca- tion than in clinical expression. In a general way, it may be said that eczema occupies certain situations more often in the child than in the adult — the scalp and face, for example — and that the eruption is more acute, of a more inflam- matory type. All of the elementary lesions of the disease — e. g. erythema, papules, vesicles, and pustules — are seen in children, and often a commingling of them all, although it must be allowed that pustular eczema is of more fre- quent occurrence in children than in adults. Eczema rubrum and eczema squamosum are frequent, but leathery-like infiltration is i-elatively uncommon. Among other features of importance connected with infantile eczema may be noted secondary glandular swellings, cutaneous abscesses, particularly in the scalps of ill-nourished, strumous children, and post-eczematous furunculosis. The implication of the lymphatics, those in the neck being principally involved, as a result of eczema capitis, w'as formerly regarded as a sure indication of scrofula; and in eczema occurring after vaccination, with coincident glandular swelling, it was held as proof positive of the introduction of struma by the inoculated lymph. As a matter of fact, this adenitis is purely sympathetic, and is more apt to occur from the irritation set up by pediculi. It is excep- tional for the glands to suppurate. A brief summary of some of the more characteristic features of the eczema of children will now be appropriate. Generalized eczema is uncommon in childhood, although there may be present, scattered over the body and limbs, infiltrated patches of variable size, sometimes scaly or composed of aggregated papules exhibiting moist and exco- \UY2 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. riated surfaces. The disease also attacks the hands, feet, and legs and the flexures of the joints. Eczema intertrigo, or that form of the disease found in the groin and between other opposing surfaces of skin, is frequent, but not attended with much itching. The surfaces are very red and moist, and are apt to emit a most disagreeable odor ; moreover, the eruption may spread from these locali- ties to the contiguous portions of the thighs, back, and abdomen. The writer’s experience is in agreement with that of Bulkley in regarding the face as the region most frequently first affected. The primary lesions are usually papules, which run together to form exuding, reddened and crusted patches that are intolerably itchy. In this situation the disease is more prone to relapse than elsewhere, as every varying condition of the system is promptly reflected upon a part especially rich in its vascular and nervous supply. A very common starting-point also is the scalp, where it is often evoked by the nurse or mother in the effort to clear away the sebaceous secretion that clings to the new-born infant. From this region it may spread to the forehead, ears, and face, and the well-known picture of the typical crusta lactea, or milk crust, is presented. The itching is excessive, and the little sufferers, if old enough, make frantic efforts to get relief by scratching ; while infants will rub the face and head against the pillow or the mother’s breast. In neglected cases eczema rubrum is soon developed. Etiology. — Eczema is one of the most common of all skin diseases, and it is most frequent during childhood.' Even within this period — nay, up to the tenth year — the disease is most freciuently developed during the first five years, and, accoi’ding to Crocker’s statistics, one-third of all cases in children begin within the fir,st year of life. Leaving out of consideration for the present the essential nature of the ecze- matous process, it may be said that eczema is a catarrhal inflammation of the skin, which may be evoked by a great number of exciting agencies, both internal and external. With children these influences are often sufficiently obvious. It is not uncommon to find that eczematous parents have eczematous chil- dren, but, nevertheless, the disease is not inherited in the sense that syphilis is; it is rather the transmission of a predisposed and vulnerable skin than the inheritance of a diathesis. The ill-nourished and strumous are especially jirone to eczema, particularly of the pustidar type, with swollen glands, ciliary blepharitis, and otorrhoea as concomitants ; and such children, according to Unna, may subsequently develop local or general tuberculosis.^ It will be found equally true that depressing influences of all sorts, unhygienic surround- ings, insufficient or improper food, both for the child and the nursing mother, may be regarded as causative factors of no slight importance. It is no uncom- mon thing for eczema to follow in the wake of the eruptive fevers, especially measles, in this latter instance often assuming the form of eczema tarsi. Vaccination is often held resj)onsihle for inducing eczema, but so also may the operation of piercing the ears for earrings. As stated above, various dietetic errors induce the disease by provoking gastric and intestinal disorders. The mother’s milk may be of an inferior quality from lack of proper nourishment on her part, or it may be at fault from too great indulgence in rich food and stimulating liquids. Over-feeding * In the writer’s ))ractice, out of a total of 0724 cases of skin disease of all classes, there were 2148 patients with eczema, or 81.40 per cent. In .8000 cases of eczema analyzed hy Bulkley, 907 occurred during the first ten years of life, and 07ti of these were observed in children live years old and under; that is, one-quarter of the whole numher could he regarded as infantile. This latter statement must l)c taken with many reservations, at le.ast from the standpoint of American experience; for many tuhercular children never develop eczema at all, and many children with so-called tuberculous eczema never get tuberculosis. PLATE XXIV. IKE LIBRAKf 0F TH£ rnim%m of illibqss DISEASES OF THE SKIN. 1103 is more apt to evoke eczema than under-feeding in children. Very few chil- dren are properly fed, and it is no uncommon thing to find very young infants allowed everything that appears on the table. The writer has long maintained that oatmeal is a pernicious food for the ec.zematously disposed, especially the hastily-cooked article reinforced by rich cream and great quantities of sugar. Jamieson of Edinburgh doubts that oatmeal in itself can initiate an eczema, but he thinks it is quite probable that it can light up an imperfectly cured eczema or perpetuate one already existing, as any other cause of eczema may. Spoon-fed babies are more apt to develop eczema than those nunsed by healthy mothers, but here also it is to be remembered that they are liable to disorders of the alimentary canal. The local and refiex irritations of the eruption of teeth plays no inconsid- erable role amono; the exciting causes of eczema, but to regard teething as the sole cause of the disease is unscientific, and the reassuring advice often given that the disease will recover after teething is frequently not fulfilled. Any form of external irritant may provoke an eczema — e. g., cold, heat, bad soap, hard water, rough under-garments, etc. Seborrhoea is a prolific source of the disease, and the effort to remove the seborrhoeal exudation, espe- cially from the scalp of infants, is perhaps one of the most common causes of the disease in that situation. The agency of micro-organisms is probable, especially in localized forms of the affection where the cutaneous secretions have undergone decomposition. From the foregoing considerations it Avill be seen that there is no one cause for eczema. Whatever the essential nature of the disease may be, it is obvious that the eczematous subject has a specially vulnerable and susceptible skin, and that under given conditions the disorder may be evoked by any cause, internal or external, that will arouse this susceptibility. Diagnosis. — Papular urticaria, the so-called lichen urticatus, bears a general resemblance to papular eczema. In lichen urticatus the papules are larger and more discrete, and the presence of the ordinary urticarial wheal may be detected at some period of the case ; moreover, the urticarial papules never run together to form the characteristic scaling, infiltrated, and weeping patch of eczema. Scabies and eczema are usually confounded by the inexperienced. Both itch severely, and in both multiform lesions may be present ; but in scabies contagion can nearly always be made out, the other children in the family or the mother being similarly affected, and the eruption occupies certain preferen- tial localities — namely, between the fingers, the flexor surfaces of the wrists and arms, including the axillae, the lower part of the trunk, both before and behind, and in older boys the penis. In children of some age the eruj)tion will not be found on the face or feet, but in infants both of those regions may be affected. It is safe to say that a generalized multiform itchy eruption, occu- pying portions of the body that are normally moist and warm, either from the pressure of garments or from contact of contiguous parts, is almost necessai'ily scabies. The characteristic burrow, or cuniculus, is more readily demonstrated in the child than in the adult. Various forms of the syphilide, especially the papular and pustular, are liable to be confounded with eczema. In general it may be said that the spe- cific eruption is most apt to be seen about the mouth, nose, and genitals, and that the individual lesions are larger, less acute in aspect, and of a darker color, besides often presenting a circular arrangement. The weazened appearance of the child, the presence of snuffles, and the discovery of mucous patches are important aids in diagnosis. Moreover, syphilitic eruptions do not itch. WOA AMERICAN TEXT-BOOK OF DIBEASES OF CHILDREN. Pediculosis capillitii bears some resemblance to pustular eczema of the scalp, but the dermatitis is usually confined to the occiput, .whereas eczema is apt to involve the whole head, and a little search will easily discover the pediculi or their nits. The possibility of confounding eczema Avith ringworm and favus should be borne in mind. (See those diseases.) Treatment. — Before entering upon the subject of treatment it is Avell to take notice of the opinion still lingering among the laity, and occasionally entertained by physicians, that the cure of the disease may be attended with the most serious consequences. This apprehension — a revival of the old humoralistic theory of peccant humors — both modern science and accumulated experience unite in pronouncing absolutely baseless. Hebra acutely suggested that Avhen the protest against a cure comes from a medical man, it is (juite likely that it is due to failure on his part to elfect it. In the matter of internal medication it may be distinctly stated that there are no specifics for the affection. In every instance a searching investigation must be made for possible exciting causes or probable complications. Routine is to be avoided and each case managed on its merits. It not infrequently happens that the little patient is in apparently perfect general health, the disorder being due to external causes, and no treatment beyond the necessary local applications is demanded. Even in such cases proper attention to diet will prove beneficial, and all the more beneficial if a connection can be established between the eruption and dietetic errors. If the child is being suckled, the mother should abstain from stimulating foods and drinks, but if, on the other hand, she is ill-nourished and anaemic, her condi- tion should receive appropriate attention. As regards the child itself, if old enough to be fed, the strictest attention should be paid to the character of the food and to the time and freciuency of meals. The usual stuffing with unwhole- some and indigestible food should be strictly forbidden, and the physician Avill find it wise to write out carefully prepared diet tables. The writer has long been in the habit of using the admirable tables, prepared for different ages, to be found in Dr. Louis Starr’s valuable work on the diseases of the digestive organs in children. We would reiterate the statement, already made above, that oatmeal, especially when served with cream and sugar, is harmful to ecze- matous children. Corn grits with salt and butter are just as nutritious and apparently harmless. The condition of the alimentary canal must be strictly inquired into, so that constipation, gastric and intestinal catarrhs, or other complicating disorders may receive proper attention. An occasional minute dose of calomel will prove useful in nearly all cases. Anaemic and strumous children, Avho usually suffer from pustular eczema, are much benefited by the use of iron, ])articularly the syrup of the ioared. Soothing salves should ahvays be spread on suitable strips of muslin and bound on the parts, but Avhen stimulation is desired the remedy may be rubbed in with the finger. When it is desired merely to protect the parts with a bland unguent, the unguentum atime rosa' is very beneficial : a little bismuth (.^^ij-^j) may be added Avith advantage. I’o increase its astringency and to allay pruritus the following combination may be advised : DISEASES OF THE SKIN. 1107 Bismuthi subnitratis 3iv. Zinci oxidi 3ss. Acitli carbolici ITlx. Vaseliiii 5 ij. — M A standard preparation of great value is the unguentum vaselini plum- bicuin : Eniplastri diacbyli §ss. Vaselini 5ss. — M. These should be melted together by gentle heat and stirred until cold. In subacute and moderately thickened eczema, and in the pustular form of the disease, there are few better preparations. In the great majority of cases of eczema in children, as ordinarily encoun- tered — that is to say, cases in the subacute stage with slight infiltration and intense itching — there is nothing comparable to the zinc-and-tar salve : I^. Zinci oxidi Sj. Ung. picis liquidte . . . . . oij- Ung. aquae rosae oij. Lanolini oiv. — M. Sig. Local use. This should be applied on strips of muslin, hut, as children will not usually submit to the face-mask or other bandaging, it does almost as well to smear it on gently with the finger repeatedly during the day and night. To get good results with this ointment it is absolutely essential that the prescription should go to a pharmacist accustomed to the preparation of ointments. Undertheu.se of this ointment, so promptly does it relieve itching, the Avriter has been enabled in a large measure to abstain from the harsh methods of physical restraint sometimes advocated.^ It is a safe rule even in seemingly chronic eczema to commence with one of the milder preparations, but if the case prove obstinate, we may then proceed to more stimulating applications, as follows : I^. Hydrarg. ammoniati . . . Liq. carbonis detergentis . . Lanolini Sig. Apply two or three times daily I^. 01. rusci Ung. zinci oxidi sj. — M. Sig. To he rubbed into the parts. ' Bulkley (Eczema and its Manaf/ement) makes the following sensible remarks on the appli- cation of ointments: “ The first application of any ointment may be resisted by the child, and may seem not to give relief ; but if a suitable application has been selected, and if it is renewed as often as it falls off or is brushed off, relief will soon be obtained, and the child who fir.st resisted the application will shortly crave it. This matter of the constant protection day and night of eczematous surfaces from the irritating action of the air and external contact must be insisted upon, and carried out at all hazards with rigid severity. Attendants will often neglect it, and the application will often be intentionally removed in anticipation of the visit of the physician, or when inconvenient on account of ordinary matters of daily life. A single neglect, for even a short period, followed by scratching and irritation of the skin, can result in more damage than can be repaired by long treatment.” It may be added that a single washing of an eczematous skin will be equally injurious. gr. X— XV. ITtxx-fsss. 5j.-M. UmA3IERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Pastes . — These preparations are very useful when there is neither too much crusting nor too great infiltration ; moreover, they are very valuable when an adhesive and protective application is required, as they are not readily sci’atched off or washed away by secretions. They find their principal utility in irritable j)apular and erythematous patches and in eczema intertrigo. Las- sar’s well-known formula is as follows : I^. Acidi salicylic! 3ss. Zinci o.xidi Amyli odovj. Vaselini sij. — M. A small amount of tar may be added to secure greater stimulation. This paste is also valuable : I^. Resorcini . Lanolini . Vaselini . Zinci oxidi Pulv. amyli gi’- oij. 3ij. dd 3ij. — M. Pick’s linimentum exsiccans may also be mentioned under this head : I^. Pulv. tragacanth gr. xv. Glycerini TTLxxiv. Aqiue f. 5 j. — M. The writer is in the habit of adding to this 10 to 15 per cent, of oxide of zinc and 1 per cent, of carbolic acid or 3 to 5 per cent, of tar. Thus combined, this preparation is of the greatest merit, particularly in cases similar to those mentioned as suitable for pastes in general. The various glycerin jellies have been almost entirely discarded in its favor. Plasters . — The plaster and salve mulls of Unna, made by Beiersdorf of Hamburg, are very beneficial in suitable cases. The salve mulls are made by incorporating the required remedy, such as lead, mercury, zinc etc., with a base made of benzoated suet and lard, and sj)read on one or both sides of undressed muslin. The plaster mulls are made of gutta-percha faced with some adhesive substance containing the remedy, and backed with muslin. The salve mulls may be used in subacute cases when a fixed dressing is necessary ; the plaster mulls are to be employed only when there is considerable infiltration. In these latter cases the writer's modification of Pick’s soap plaster does just as well, and is much less expensive: I^. Empl. plumbi .^xxv. Pulv. saponis ?)iv. Aquae

A3IERICAN TEXT-BOOK OF DISEASES OF CHILDREN. preceded by slight fever, but more often this symptom is absent. Crocker is authority for the statement that in tlie febrile cases the eruption appears in successive groups for about a week, but that when unattended by elevation of Fig. 1. Impetigo Contagiosa (after Lesser). temperature the cutaneous manifestations are more limited, and the course of the affection is less definite. The lesions begin as small, isolated, acuminate vesicles that slowly increase to the size of a split pea or silver quai-ter-dollar, that are surrounded for a short time by a slight erythematous halo. The contents, at first serous, soon become sero-purulent, and the fully-formed flat or slightly umbilicated vesico-pustule dries to a thin, straw-colored granular crust. As by this time the erythematous ring around the lesions has faded away, the crusts have the appearance of being “stuck on” (T. Fox). When the crusts drop off the underlying surface is red and has the appearance of a burn, but there is no loss of substance. Jackson calls attention to another variety of the disease, in which the lesions consist of large blebs of an irregular oval shape and several inches long, but usually other typical forms are found elsewhere. Impetigo contagiosa is generally seen on the face and hands. The lesions may be discrete or else coalesce into patches. Itching is not marked. The disorder runs no special course ; it may last two or three weeks, or by repeated auto-inoculations a considerably longer time. Etiology. — Children are the usual subjects. It is contagious, and often many children in the same house or neighborhood, especially among the indigent, are simultaneously attacked. The writer has known of dozens of cases in a single poor settlement. It is apt to a]>pear in summer. A number of different fungous elements have been described as occurring in the crusts, but definite results are l.ackin ba,d reputation in this regard, such a,s oatmeal, buckwheat cakes, j)ork, pastry, and e.specially strawberries. Inte.s- tinal worms often excite the disease in children. Malaria is known to set up DISEASES OF THE SKIN. 1121 an intermittent type of the disorder. iNIany medicines also induce it, especially the preparations of cinchona. While it is true that in dispensary practice the papular urticaria of infancy is often caused by bites of insects and other irri- tating local influences, the writer believes that the majority of cases are due to gastro-intestinal disturbances the result of injudicious diet. Diagnosis. — The ordinary type of urticaria is readily recognized. Occa- sionally, when the eruption occupies the greater part of the body in continuous sheets and with accompanying fever, scarlatina may be suggested ; but the his- tory of the case, the absence of the scarlatinal throat implication, and the dis- covery of isolated urticarial wheals somewhere on the body will usually clear up the diagnosis. Papular urticaria, especially if commingled with ecthymatous lesions, bears a close likeness to scabies ; but the localization of the eruption in the latter disease, the absence of burrows, and the freedom of other members of the same family from a similar eruption furnish sufficient grounds for the distinction. Prognosis. — The prognosis of the acute cases is favorable if properly managed. Papular urticaria is exceedingly obstinate often lasting for mouths, but even these cases eventually get well. Treatment. — In all cases the cause must be assiduously sought out, and, if possible, removed. Acute attacks are generally due to gastric disturbance from injudicious diet, and a brisk emetic, followed by a laxative, will be apt to bring about a speedy recovery. The more persistent attacks, kept up by repeated exacerbations, are rare in children. Above all, the diet must be care- fully regulated. Quinine is of much value when malaria is suspected. Phena- cetin will often cut short an att.ack. The usual empirical remedies, such as atropine, ergot, pilocarpine, and salicylate of sodium, are scarcely demanded. In the chronic papular form it is first necessary to remove all sources of external irritation, and, secondly, to clearly indicate the proper method of diet to be pursued. Constipation should be relieved, and appropriate remedies prescribed for any gastric irregularity that may be present. There is a great variety of measures recommended for the local treatment. Among the household remedies may be mentioned lotions of soda, vinegar (pure or diluted), and the application of cologne-water or other spirits. The calamine-and-zinc lotion, as previously given, with carbolic acid (gr. ij to f^i) is especially valuable. Menthol in solution (.^ss-f^iv) is also a good antipruritic. In lichen urticatus the same preparations may be employed. Fox recom- mends the following : R. Liq. plumbi subacetatis f.lss. Liq. carbonis detergentis fsijss. — M. Sig. Add a teaspoonful to a pint of water. The same authority advises a dilute white-precipitate ointment or paste for the pustular form. Urticaria Pigmentosa. This is a rare form of disease, only a few cases having been observed in this country. It begins within the first six months of life in the form of wheals that come out suddenly, singly or in numbers. The lesions are brownish-red, split-pea sized tubercles, and in the beginning are surrounded by a delicate pink areola ; subsequently, however, they increase in size and assume a buff color. The course of the disease is chronic, and while the first lesions are under- going involution new ones are constantly forming, so that all the varied stages 71 \\2'2 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. can be seen at the same time. Urticaria pigmentosa affects principally the trunk and neck, then the head, face, and limbs. It may or may not itch. In the pruritic variety factitious urticaria is common. The disease is usually arrested at puberty. The cause of the affection is unknown, and the treatment purely symp- tomatic. PiTYEiAsis Rosea. Pityriasis rosea is a trivial disorder, its only special importance arising from the liability to confound it with grave affections. It is claimed by some writers that the cutaneous eruption is preceded by some elevation of temperature, but this symptom is by no means constant. Brocq states that he has observed that the more general eruption is preceded by a single patch that makes its appearance about the waist, neck, or arm. The lesions in the beginning are minute pinkish papules, which soon enlarge into circular or oval macules having slightly depressed centres and a defined raised border. They are covered with somewhat greasy yellowish or yellowish-white scales. When the patches, by peripheral extension, have reached a diameter of one-half to three-quarters of an inch, the centre assumes a yellow-parch- ment hue, while the extending scaly margins are distinctly reddish. The patches may remain discrete, or they may run together and produce irregular gyrate areas : these bizarre outlines are also formed by the central recovei’y and peripheral extension of the single lesions. The skin is but little thickened, a,nd pruritus is, as a rule, insignificant. The eruption is usually found on the trunk, but it may migrate over the body generally with the exception of exposed parts. Papules, ringed patches, and patches that are undergoing involution may be present at one and the same time. The disorder is self- limited, and tends to spontaneous recovery in from two weeks to two months. Etiology. — English and continental writers state that this affection jirin- cipally attacks young children, but this is not true in the writer’s experience, although he has been brought much in contact with the skin diseases of infants and young persons. It occurs in quasi-epidemics, especially in the spring and fall, but considerable differences of opinion exist as to its contagiousness, and neither has its parasitic nature been satisfactorily demonstrated. Diagnosis. — Pityriasis rosea is distinguished from the .scaling circinate syphilide by its more inflammatory color and the absence of pigmentation ; besides, along with the syphilide would be found other evidences of syphilis. Its resemblance to seborrhoea of the body is superficially close, but in sebor- rhoea the eruption is usually found only over the sternum and between the shouhlers, while in pityriasis ro.sea it is not so limited ; moreover, the scales of seborrhoea are thicker and greasier, and there is often a history of considerable chronicity. Pityriasis rosea differs from ringworm in its wider distribution, the absence of papules, vesicles, or pustules from the borders of the patches, and the absence of the tricophyton fungus in the scales. Prognosis. — The disease undergoes sj)ontaneous arrest Avithin from a fort- night to two or three months. Treatment. — Internal treatment is useless ; indeed, treatment of any sort is unpromising. The calamine-and-zinc lotion is agreeable when itching is a symptom, and ointments of sulphur and boracic acid may be prescribed. A pigment of salicylic acid has seemed to be serviceable : I^. Acid, salicylici gr. x-xv. Liq. gutta-pcrchse f.\j. — M. DISEASES OF THE SKIN. 1123 Prurigo. Prurigo is a chronic inflammatory disease of the skin characterized by an eruption of pale j)apules accompanied by severe itching. This disease begins in infancy, the lesions first consisting of urticarial wheals, to which the papules succeed. The papules are quite small, and, as it w'ere, bur- ied in the skin, so that they are more easily felt than seen ; their color is in the beginning that of the surrounding skin, but in time, as the result of scratching, they become of a darker hue. The most noticeable feature of prurigo is the intense itching, which at times becomes unbearable. The dis- ease is most marked upon the extensor aspects of the limbs, while the flexor surfaces, the genitals, the scalp, and the face are rarely attacked. Various secondary changes in the skin are to be noted, such as infiltration, pigmentation, desquamation, etc. A severe form of the malady (prurigo ferox) is marked by intercurrent attacks of wheals, severe dermatitis, pustulation, scabbing and deep pigmentation, and enlargement of the lymphatic ganglia, especially those of the groin. In a few cases prurigo directly causes death by the constant worry and loss of sleep, setting up a condition of marasmus ; but usually it is not fatal. Etiology. — By some writers prurigo is regarded as a neurosis of the skin. Others do not admit it is an entity, but think it onl}' a group of symptoms caused by the action of various irritants upon a sensitive skin. Prurigo is mainly found among the poor, who cannot have its earlier manifestations treated. The disease is not so rare in this country as it was at one time supposed, a number of cases having been recently reported by Zeissler. Diagnosis. — Unless the whole course of the disease be taken into consider- ation, together with the lesions actually present at any one time, there is danger of confounding prurigo with eczema, scabies, and pediculosis. Careful atten- tion to the history and to the situation of the lesions will usually enable a diagnosis to be made. Prognosis. — The earlier in a case treatment is begun, the better the chance of cure. In cases of very long standing, though a cure may not be efl'ected, the condition may be much benefited. Treatment. — The diet should be carefully regulated, all those articles which are calculated to provoke a nettle-rash being eliminated. The general health will often demand tonics and cod-liver oil. Some cases seem to have improved under ansenic. Bromide of potassium, carbolic acid, cannabis Indica, and the salicylates have been used for their effect upon the itching. Pilocarpine and atropine are both well recommended, but since they act best when given hypodermatically, they are rarely ever used in children. Locally, bathing in quite warm baths, follow'ed by the inunction of an ointment, will probably yield the best results. The ointment may contain tar, sulphur, naphthol, or salicylic acid in quantities varying with the condition of the patient. Furunculus. A furuncle is a circumscribed phlegmonous inflammation occurring about a hair-follicle or a gland of the skin. The appearance of a boil may be preceded by a slight tingling or itching of the skin. In a short time a small red papule will be noticed, which is very sensitive to pressure and is accompanied by a burning sensation. The skin immediately around the papule becomes hard and swollen, and thus a hemispherical nodule is formed, varying in size from a pea to a w'alnut. The color of the boil itself is a \VU AMERICAN TEXT-BOOK OF DISEASED OF CHILDREN. dull red or purplish, while the skin in the immediate neighborhood is of a brighter red. The furuncle at this stage is firm and hard to the touch, very tender, and accompanied by a dull throbbing pain. Within a week or ten days pus accumulates in the boil, and if it is not opened the skin ruptures, giving exit to a more or less free discharge. Lying in the centre of tlie fur- uncle is now exposed the core, a whitish necrotic mass, which if left alone comes away of itself in a few days. As soon as the pus is evacuated the pain in a boil ceases, and when the core has separated the hardness in the surround- ing skin gradually disappears, while the small cavity remaining fills by granu- lation. A scar results, which is at first of a violaceous hue, but in time becomes white. Occasionally a boil stops short of suppuration and resolves : this is known, in popular parlance, as a blind boil. Furuncles may occur singly, or numbers may be on the body at the same time. In some cases the affection is indefinitely prolonged by the appearance of one crop after another, constituting the condition known as furunculosis. Boils may occur on any part of the body except on the palms and soles. In children they are common on the back, the head, the eyelids, and in the axilla. When a boil occurs in a ceruminous gland in the auditory canal, there is great pain on account of the denseness of the tissues in that region. When boils are single or in small numbers, there is, as a rule, no constitu- tional disturbance, but in furunculosis appetite and flesh may be lost, while sleep is disturbed by the pain. A furuncle always commences about a hair-follicle, a sebaceous gland, or a sweat-gland. The severe inflammation causes the death of the follicle or gland, which then constitutes the core. Etiology. — Boils may be the result of local injury, such as bruising or pressure, as on the buttocks from prolonged sitting. They often occur in depraved conditions of health, as after scarlatina or measles. In summer they often accompany prickly heat. Boils are contagious under certain conditions, such as sleeping in the same bed with a j)erson affected. They may arise dur- ing the course of any pruritic disease, probably from inoculation of the skin by scratching. The pus from a boil will ju’oduce other boils if inoculated upon another part of the body or upon another person. The virus may be carried from one person to another by flies. These facts, together with the observation that pus-cocci are always found in boils, seem to warrant the conclusion that the disease is due to the presence of a micro-organism. Diagnosis. — The only disease of infancy with Avhich furuncle is apt to be con- founded is that rare syphiloderm described by Barlow, in which several circum- sci^ibed abscesses in the skin occur; but here the inflammatory symptoms will be less severe, other symptoms of syphilis will be pre.sent, while the abscesses possess no core. In children carhuncle is a rare affection, and can be differ- entiated from furuncle by the fact that it has several centres of suppuration, wdiich in turn become so many openings. Prognosis. — The prognosis of furunculus is, as a rule, favorable. Whenever suppuration occurs permanent scarring is the result. In furunculosis the prognosis must be guarded, as in sotiie cases successive crops of boils occur in spite of the best-directed thera))eutic efforts. Treatment. — In the treatment of furuncle the first step is to look for and to correct any condition of general health which might act as a ))redisposing cause. All local conditions which may l)c pre.sumed to favor the development of boils should be removed. Various remedies, such as yeast, sulj)hide of calcium, hypophosphite of sodium, have been advised for internal administration in the treatment of DISEASES OF THE SKIN. 1125 furuncle, but their effect upon the local condition is, to saj the least, proble- matical. A great many different drugs have been recommended as possessing the power to abort boils : the apex may be cauterized with a solid stick of nitrate of silver ; Guigeot advises painting with tincture of iodine till quite a thick layer covers the boil ; boric acid in saturated solution may be frequently sprayed upon the affected surface, and by this means some authorities claim excellent results ; the following formula is given by Jamieson ; Tr. iodi Acidi tannici 3ss. Pulv. acacipe oSS. — M. This mixture is to be painted upon the boil and the surrounding skin in successive layers, each one being allowed to dry before the next is put on. till a thick coating is obtained. Unna’s carbolic-acid-and-mercury plaster will sometimes cause a boil to disappear : a piece of the mull a little larger than the boil, with its centre cut out to avoid pressure on the sensitive apex, should be applied, and renewed every twenty-four hours. Hypodermatic injections into and around the boil, as well as electrolytic puncture, may succeed in arresting the process, but these methods are too painful to be of use in children. One of the best methods of treating a boil consists in applying a pledget of absorbent cotton saturated with per cent, carbolic-acid solution, over which is placed a piece of rubber tissue large enough to cover the cotton and a small area of the surrounding skin ; even if this does not prevent suppura- tion, it will be found to give relief. Poultices in their ordinary forms are to be entirely discai’ded, as they favor the development of other boils around the ones to which they are applied. The skin for some distance around a furuncle should be frequently anointed with an antiseptic ointment, to prevent the inoculation of the neighboring hair- follicles. The following is an appropriate formula : 3^. Acidi boraci gr. xx. Zinci oxidi ,^ij. Lanolini .^j. — M. As soon as pus is collected in a boil a free opening should be made, the cavity washed out with some antiseptic solution, then dusted with iodoform, and an antiseptic dressing applied. In the treatment of furuncles in the auditory canal. Cholewa recommends inserting into the ear a plug of absorbent cotton which has been moistened with a 20 per cent, solution of menthol in olive oil. Spencer inserts a cotton plug, having first applied to the boil an ointment of extract of arnica, extract of belladonna, and moi’phine. HEMORRHAGES. Purpura. The term “purpura” is applied to certain conditions in which haemor- rhages occur in the skin or mucous membranes. The lesions of purpura may be of a bright red or of a livid bluish hue. They do not disappear upon pressure. The individual haemorrhages vary much in size, and from this fact various names have been applied to them, as petechiae, where the extravasations occur AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. in the form of minute points ; vibices, where they occur as streaks ; ecchymoses, where they occur as larger spots or blotches. At times haemorrhages are com- bined with other lesions of the skin ; thus we may find blood eff^used into a papule or a bulla. Occasionally blood finds its way into the sweat-glands, whence it is extruded along with the perspiration, giving to it a haemorrhagic appearance — haematidrosis. Haemorrhages occur in the skin under such manifold conditions that any classification upon an etiological basis is impossible. Clinically, three forms are found with sufficient frequency to warrant a description as special diseases. The mildest form in which the affection occurs is known as purpura simplex. The person affected is usually in good health when the disease manifests itself : the lesions appear suddenly upon any part of the body — in children especially about the neck, upper portion of the trunk, and arms. Tlie eruption is com- monly made up of petechim, though streaks and larger spots may also occur. The haemorrhages usually remain discrete, and when sufficiently copious may cause a slight elevation of the skin. The duration of the disease is prolonged by the repeated appearance of fresh crops of the lesions. Each crop, as resorp- tion occiu's, passes through the different changes in color that we remark in a bruise. There are no subjective symptoms. The condition is most likely to be confounded with flea-bites. In purpura rheumatica the extravasation of blood into the skin constitutes the most remarkable feature of the disease, and for this reason it is classed among Imemorrhages. The appearance of the skin affection is preceded by malaise ; pain in the joints is complained of, and frequently swelling may be detected. After a day or two a petechial eruption shows itself upon the sur- face. In its general characters this eruption does not differ from the lesions found in purpura simplex, except that there is a tendency to localization about the affected joints. The disorder may be indefinitely prolonged by relapses, and sometimes passes into a condition simulating purpura lunmorrhagica. The heart may become implicated during the course of the malady, with a resulting lesion of the valves. Henoch and Couty have described a form of purpura which occurs most frequently in children, and is characterized by pains in the joints, vomiting and intestinal pain, and a localized oedema of the skin. (See Purpura Hmmorrhagica.) While purpura rheumatica is at its height there is often a moderate rise in temperature. The most severe form in which purpura occurs is as purpura hmmorrhagica (morbus Werlhofii). . In this affection we find, in addition to the phenomena of purpura simplex, bleeding from various mucous membranes and lunmor- rhages into various internal organs. The disease may develop suddenly or be preceded by symptoms of an indefinite kind, such as headache, loss of appetite, lassitude, etc. The lunmorrhages into the skin are fre(iuently larger than tho.se found in purpura simplex, and effusion of blood occurs also in the mucous membranes, as indicated l)y its escape from the moutli, iio.se. anus, vagina, and urethra. Bleeiling occurs also in the parenchyma of the organs, and when the brain is thus affected speedy death may result. The serous cavities often con- tain blood. The disease is usually accompanied by a moderate fever. When the amount of blood lost is not largo, recovery may follow, but relapses are not uncommon. For purpura haemorrhagica as it occurs in the new-born the designation purpura neonatorum has been given. The disease hardly warrants a special description, since it presents symptoms similar to those found in jmrpura haemorrhagica, its only point of distinction being that it occurs within the first few days of life. DISEASES OF THE SKIN. 1127 Etiology. — In those cases in which haemorrhage into the skin is merely a secondary or symptomatic phenomenon a cause for the afi'ection can often he ascribed. Illustrations of such cases would he the purpura that often occurs with the specific fevers, as measles, scarlatina, and malaria; or where certain drugs, such as quinine or iodide of potassium, have been ingested ; or in cases where we may be able to determine some decided obstruction to the blood- current, as some valvular heart trouble ; or where a congenital or acquired weakness of the vessel-walls may be supposed to exist, as in hnemophilia, rickets, or syphilis. In those cases in which the effusion of the blood seems to constitute the chief feature of the disease the etioloo;v is far from being definitely determined. In that form which manifests itself in the new-born babe it has been supj)osed that the violent changes which then occur in the circulation may account for the phenomenon. Of late years the presence of various forms of micro-organisms has been invoked to explain the occurrence of purpura. Petrone injected blood from patients with purpura into rabbits, and produced a general hmmorrhagic state. Letzerich found a bacillus which, injected in pure culture into rabbits, occasioned hfemorrhages. Several other investigators have made somewhat similar observations. Hanot and Luzet found in the body of a foetus, the mother of which was dead of purpura, strep- tococci of identical characteristics with those found in the mother. These observations, though as yet too recent to be wholly relied upon, serve to show that there may be certain cases of purpura which are acute, infectious diseases; and this assumption is corroborated by the clinical history in some instances. Diagnosis. — The diagnosis of purpura rarely presents any difficulty, as the lesions differ from those caused by inflammatory conditions in not disap- pearing under pressure. A fleabite differs from a petechia in having a central point, indicating its traumatic origin. Scurvy may be distinguished from pur- pura haemorrhagica by the fact that it is caused by a diet deficient in vege- tables, that it attacks more than one of those so situated, and that in it we find a spongy condition of the gums, loosening of the teeth, and brawny swelling of the limbs. Prognosis. — Care must be exercised in giving an opinion as to the course and ultimate result even in simple cases of purpura, as the complications which may arise are manifold. As a rule, the simple forms recover, though the attack may be prolonged by relapses. The prognosis in purpura haemorrhagica is always grave. Treatment. — Mild cases of purpura will require no special treatment. In all cases rest in bed is of prime importance, as in this way further haemor- rhage is best guarded against. When the haemorrhages from the mucous cav- ities threaten danger, an effort should be made to arrest them by means of tampons, hot and cold watei’, or a spray of perchloride of iron or other as- tringent. In the way of drugs to be administered internally, turpentine, acetate of lead, dilute sulphuric acid, ergot, and iron have the best reputation. A combination that has proved of service to the writer is the following : I^. Ext. ergotae fld Tr. ferri chloridi, da f^ss. — M. Sig. Three to ten drops in water, t. d. In purpura rheumatica the salicylates may benefit the affection of the joints. WI'i^ A3IERICAN TEXT-BOOK OF DISEASES OF CHILDREN. HYPERTROPHIES. Lentigo. Tlie affection known as lentigo, or freckles, consists in the appearance, mostly upon exposed surfaces, of variously-shaped, usually small, yellow, brownish, or black spots. Freckles are most common on the hands and face, but may occur on covered parts. As a rule, the affection appears in the second decade of life, though Wilson mentions congenital cases. The spots are prone to become darker and more numerous in the summer, while in the winter they may almost disappear. In its pathology a freckle is a circum- scribed hyperpigmentation situated in the rete. Etiology. — Lentigo is rarely seen before the sixth or seventh year. It affects especially those of a light complexion. Exposure to the effects of sun- light is, by universal consent, the most common cause, though, that it is not the only one is shown by the occurrence of freckles on parts not exposed. Treatment. — Freckles may be temporarily removed by many stimulating ointments and lotions. One of the best of the former is — I^. Ilydrarg. ammoniati Bismuthi suhnit. . Ung. aq. rosae . . Sig. Apply at night. In cases where the pigment is very black, pricking each freckle, very superficially, with a needle attached to the negative pole of the galvanic bat- tery often hastens its disappearance. Freckles, though they have disappeared, are prone to return under exposure to exciting causes. Ichthyosis. Ichthyosis is a congenital disease characterized by dryness and scaliness of the skin, and at times l)y the development of thickeneil warty patches. Two principal varieties are described, though their dift’erence is of degree and not of kind. Ichthyosis simplex affects the general sui’fiice, but is often most marked on the extensor sides of tlie limbs. Often there is only to be noticeitting on ])res- sure. (For the differential diagnosis between sclerema neonatorum and sclero- derma the reader is referred to the article on the latter subject.) Prognosis. — The disease is nearly always fatal. Encouragement is, how- ever, offered by the few cases that have recovered. Treatment. — An effort should be made to bring the temperature of the child to the normal by enveloping it in cotton wool, or, better, by jilacing it in DISEASES OF THE SKIN. 1133 an incubator. As nursing is impossible, nourishment must be maintained by otlier methods. Milk with brandy may be administered per rectum or by means of a catheter passed into the stomach through the nose. Money reports success in two cases by inunctions of mercury. Scleroderma. Clinically, scleroderma presents itself as a thickening and induration of the skin. A limited area or the whole surface may be involved. The disease may occur on any part of the body, but shows a preference for the upper portions — the head, the thorax, or the upper extremities. The malady may come on acutely, and in a few days involve the entire surface ; but more commonly the progress is so slow that the person affected does not notice the presence of the disease till the skin is already hard and stiff. Sometimes the real infiltration is preceded by oedema. When fully developed the affected area is to the touch dense, hard, and will not pit on pressure. The skin can- not be picked up from the underlying structures, nor slid about, as in the nor- mal state. The diseased area is usually on the same level with the healthy integument, and passes so gradually into it that no line of demarcation can be seen. Generally, the surface is somewhat paler than normal, though it maybe a uniform or mottled brown from increased pigmentation : it is most often smooth and shining, with the markings of the natural skin obliterated, but in some instances it is scaly. Around the border of the area there is sometimes a zone of hypermmia. The movement of all the parts affected is limited by the rigid skin, so that the face is expressionless, the neck cannot be easily turned, respiration is hindered, and the joints ai’e not I’eadily flexed. Sensation may be increased or diminished, but pressure on the diseased skin is acutely pain- ful. The mucous membranes may become involved, as may also the muscles. Having persisted in this stage for an indefinite time, the affected skin may become normal, or it may pass into the second or atrophic stage. It then becomes tbin, parchment-like, of a dull-white color, Avith tehangiectic vessels shoAving here and there, and is stretched tensely over the underlying structures. The pres.sure thus caused brings about atrophy of the tissues beneath, so that the face may resemble a skull Avith only tbe skin stretched over it, and the limbs seem made up of only skin and bones. Various distortions of the hands and extremities occur, and ulceration over bony prominences is common. During the course of scleroderma, endocarditis and pericarditis may develop. There is frequently no disturbance in health till the disease has persisted for a long time, Avhen a state of marasmus may appear and death result. In chil- dren the disease is prone to run an acute course, and does not so often ter- minate in atrophy. The denseness of the skin in scleroderma is due to an increase in the connective-tissue elements. The changes are found chiefly in the corium and subcutaneous tissue. There is at times an increase of pigment in the rete. Around the vessels are found masses of cells the exact origin of which is unknoAvn. In a case examined by M^ry there Avas a development of connective tissue in the muscles of the limbs and in the heart. Etiology. — The cause of scleroderma is not knoAvn. Obstruction of the lymph-channels has been suggested, but this remains an hypothesis. Various observers have detected lesions of the central or peripheral nervous system in connection with scleroderma. The disease seems to have folloAved exposure to cold, and it has been remarked after erysipelas. Diagnosis. — The only disease of childhood with which the first stage of scleroderma can be confounded is sclerema neonatorum : here the time of IViA AMERICAN TEXT-BOOK OF DIREAUFX OF CHILDREN. development will suffice to distinguish, as the youngest child in whom sclero- derma has been reported was thirteen months old. In the atrophic stage scleroderma most resembles Kaposi’s disease, but the history of scleroderma, w'hich l)egins as a thickening of the skin, Avill, in most cases, differentiate it from this affection, which begins with ])igmentation and atrophy. (For other points of difference see Kaposi’s Disease.) Prognosis. — It is impossible to give an opinion as to the result when the case is seen in the first stage. When atrophy has occurred it is permanent. Treatment. — The body should be clothed Avith flannel, and e.xposure to cold, Avhich always seems to aggravate, guarded against. The general nutri- tion should be cared for by a generous diet and the exhibition of cod-liver oil and tonics. Hot baths often give comfort to the patient. The suppleness of the skin may be increased by vigorous inunctions of oil. Massage has seemed of service in some cases. The constant current has been recommended by some authors, and in a circumscribed patch of scleroderma in an adult Brocq used electrolysis Avith apparent improvement. Morphcea. The affection of the skin knoAvn by the name “morphcea” is thought by some dermatologists to be only a circumscribed scleroderma. IIoAvever this may be, the disease presents enough clinical peculiarities to entitle it to a separate description. The lesions of morphcea consist of variously sized spots, streaks, or hands W'ith sharply-defined borders surrounded by a zone of dilated ca])illaries, Avhich zone is often of a violet hue. The affected area is frequently of a Avaxy-Avhite color, so that it has been likened to a piece of old ivory let into the skin, but at times the color may be pinkish, yelloAv, broAvn, purple, or even black. The patches are, as a rule, not raised above the level of the surrounding skin. Gen- erally, the surface is smooth and the skin is not adherent to the underlying tissues, so that it may readily be picked up, Avhen it is found to be slightly thickened ; sometimes in one part of a patch there exists thickening, Avhile in another the skin is thinner than normal. The disease occui’s frequently upon the breast, and may affect any part of the body. Sometimes several patches are grouped along the course of a nerve. At times the disease presents itself as a number of small atrophic pits in the skin. The subjective .symptoms are insigniflcant, being limited to slight itching. Occasionally, the centre of a patch Avill be insensitive. The disease persists for months or years, and then may di.sappear, leaving the skin normal ; or the final result may be an atrophy of the skin, and even deeper structures. Crocker found in the earlier stages of morphcea a consider- able infiltration, in the corium, of cells Avhich later become connective tissue, and by their contraction cause atrophy of the blood-vessels and glands. Etiology. — The disease may occur at any age beyond tAvo years. It is thought by many to be a neurotic affection, and certain facts lend countenance to this belief, as its occurrence Avith other (listurl)ances of the nervous .system, such as hemiatrophia facialis, canities, alopecia areata, etc., and its being often distributed along a nerve-trunk. Diagnosis. — Leucoderma (lifters from morjflicca in not jn-esenting any alteration in the texture of the skin, tliere being simply an absence of j)ig- ment. The atrojfliic spots of lepro.sy shoAv marked amesthesia, and the con- comitant symptoms will aid in the diagnosis. Keloid is more vascular and DISEASES OE THE SKIN. 1135 denser than morphoea, is redder, and its lesions present the well-known claw- like ])rocesses. Prognosis. — Although morphoea has a tendency toward recovery in the course of time, with no permanent damage to the skin, yet in view of the cases followed by atrophy the prognosis must be somewhat guarded. Treatment. — No internal medication has any eflect on the lesions of mor- phoea, and thus far local remedies may be said to be equally futile. ATROPHIES. Albinism. Albinism is a congenital absence of pigment : it may be total or partial. When general, not only the skin, but also the hair, the iris, and the choroid lack their normal coloring matters. Pei’sons thus affected are termed albinos, and present the well-known characteristics of a pink skin, white hair, and pink irides. Frequently nystagmus may be observed in albinos, from the irritating effect of the light upon the unsheltered retinae. These persons are often poorly developed, both physically and mentally. Albinos are quite frequently the offspring of negro parents. Partial albinism is most common among negroes, and occurs as limited areas in which the pigment of the skin is absent. Should these areas be found in hairy regions, the hair also lacks its coloring matter. In rare cases partial albinism spontaneously recovers by a new deposit of pigment in the affected part. Leucoderma. Leucoderma is an acquired diminution of the pigment of the skin. It usually occurs as one or more round or irregular-shaped areas, in which the skin is of a much whiter color than the surrounding integument. Such patches of skin vary in size from a quarter of an inch in diameter up to several inches, and their borders are strongly defined from the healthy skin by aline of abnor- mally deep pigmentation which surrounds the leucodermic plaque. Hairs grow- ing on the affected areas may be white or may retain their natural color. Save for the absent pigment the diseased skin is quite normal. Leucoderma is generally symmetrical, and occurs most frequently on the neck, face, backs of the hands, and about the hips. The disease tends to slowly progress, till in the course of time the whole body may become involved. When leucoderma has thus extended over a whole member, it is often thought to have recovered, as the contrast with the healthy skin can no longer be remarked. As a matter of fact, the pigment is rarely if ever restored. The disease appears to grow worse in summer, because at this season the pigment of the normal skin becomes darker. Etiology. — Leucoderma usually develops between the ages of ten and thirty, though the writer has seen it in a child four years old. Beyond the fact that the malady seems to be due to some disturbance in innervation, noth- ing is known as to its etiology. It is sometimes secondary to other diseases, such as morphoea, alopecia areata, and eczema. Diagnosis. — From the congenital absence of pigment known as partial albinism leucoderma is distinguished by its history, its symmetry, and its pro- AMERICAN TEXT-BOOK OF DIHEASES OF CHILDREN gressive tendency. From inorplioea it will be differentiated by the fact that in the former disease there is a change in the structure of the skin. From the white spots which occur in nerve-leprosy, leucoderma can be told by the fact that the macules of lej>rosy are anmsthetic and often scaly. Prognosis. — There is little hoj)e of recoverj^ though in time, by the spread of the disease, the effect is rendered less startling. Treatment. — No drug, either internally or locally, has any effect upon the disease. The most that can be done is to remove the hyperpigmented border and thus relieve the contrast. (For the various means of accomplishing this see Treatment of Lentigo.) Tatooing or staining the patches with walnut- juice may be tried Avhere the cosmetic effect must be cared for. Alopecia Areata. Fig. 2. Sometimes, after certain premonitory symptoms, such as headache or burn- ing. or itching, the hair is lost from the scalp in one or more circumscribed spots ; more freijuently, however, these sensations are absent, and the patient’s attention is first attracted by the peculiar and striking areas of baldness. The patches are usually quite white and perfectly smooth, and give the appearance of slight depression. There may be one or many bald spots, and they may vary in size from a dime-piece to that of the palm, the larger areas usually resulting from coalescence of the smaller ones. Sometimes the loss of hair is general, but this must be rare in children. The disorder runs a chronic course. It may persist from a few months to several years. When recovery sets in, the returning hairs are white and downy, but gradually attain their normal size and color. Etiology. — The disease is comparatively frequent in children. It is some- times noted to occur after various illnesses, but more often there is no such history. xV blow on the head, or, in the adult, persistent neuralgia, is occa- sionally apparently responsible for limited areas of the disease. By some authorities it has been regarded as con- tagious (llillier and others), but cer- tainly in the majority of instances this is not so, and it is likely that the re- corded cases of such character are susceptible of some other e.xplanation. Neither has the parasitic theory been maintained. The writer is in agreement with most dermatologists in looking upon alopecia areata as a trophoneurosis. Diagnosis. — Tlie disease is so strik- ing: that its recognition is a matter of little difficulty. Bingworm of the scalp bears the closest resemblance, but in this latter affection the jiatches are not smooth and glistening, but are covered with grayish scales, and scattered over the surface are to be seen the stumps of broken-ofl' hairs ; besides, if any doubt arise, the microscope will soon settle the (|uestion. Favus, syphilis, and cer- tain forms of folliculitis would also be differentiated. Prognosis. — The alo|)ecia areata of young peojile generally tends to spon- Alopocia Areata. DISEASES OF THE SKIN. m? taiieous recovery, although undoubtedly imich hastened by approj)riate treat- ment. Treatment. — There is no special internal treatment beyond attention to any obvious defects of the general health. In rebellious cases small doses of arsenic might be tried. Locally, the demand is for thorough and persistent stimulation. The following, briskly rubbed in twice a day, is useful ; I^. Acidi salicylic Bj. Sulphuris prtecipitati ,oj. Vaselini 5j. Olei rosae

atient should be kept under observation for several months, and at the first sign of relapse treatment should again be actively instituted. 3ss. gj.-M. DISEASES OF THE SKIN. 1151 Tinea Trichophytina. The trichophyton fungus grows in the skin, hair, or nails ; in each situ- ation it gives rise to such peculiar clinical phenomena as to merit a special name. As seen on the skin the disease is known as tinea circinata, or ring- worm of the body. The most common sites of the eruption are the ex- posed surfaces — the face, the neck, the hands. The first evidence of the disease is usually a small, faint red, slightly raised, scaling spot ; this soon begins to spread peripherally, while at the same time healing occurs in the centre ; thus there is produced a ring of small scaling papules enclosing a healthy area of skin. The border goes on enlarging till it reaches the size of a dollar, when the disease may spontaneously disappear, or remain station- ary for an indefinite time. Often there are several such rings close together ; as they enlarge their borders touch, and, disappearing where contact occurs, leave gyrate figures. Occasionally several rings may be found, one within the other. If the inflammation excited be severe, we may see the border composed Fig. 5. Trichophyton tonsurans in hair-shaft and follicle (after Kaposi). of vesicles or pustules instead of papules. Occasionally the centre fails to clear up as the border grows, and thus plaques of reddened, somewhat thick- ened, scaling skin occur. Rarely the disease involves the nails, when they become rough, lustreless, and brittle. Tmea tonsurans, or ringworm of the scalp, is almost never found in the adult, being essentially a disease of childhood. It occurs as one or more circu- lar scaly patches, in which the stumps of broken hairs may be seen, not lying in one way, as is natural to the hair of the scalp, but pointing in all directions. The color of the affected scalp varies, in dark complexions being a dirty gray, while in blonds it is a faint red. When the hair becomes diseased, it loses its lustre and is very brittle, so that it readily breaks off. The loss of hair in \\r>2 AMERICAN TEXT-BOOK OE DISEASES OF CHILDREN the patches is occasionally complete, and the scalp is left smooth and shining, so that the disease is indistinguishable from an alopecia areata. In a rare form of the disease, known as tinea tonsurans disseminata, there occur scat- tered over the scalp small clumps of diseased hairs. Sometimes small pustules may be seen around some of the hairs in an affected area ; this resembles what occurs in a more severe form in kerion, which is an acute folliculitis, giving rise to a circumscribed, doughy swelling, studded over which may be seen the widely-gaping diseased follicles. When pressure is made upon such a swelling, a thick muco-purulent material exudes from the follicles, which have usually lost their hairs. Ringworm of the scalp is not accompanied by subjective symptoms. Untreated it may continue indefinitely. Etiolog’y. — The cause of ringworm is the trichophyton fungus.* It is an odd fact that it attacks the scalp almo.st always oidy in children, while the general surface may be affected at any age. The fungus exists in the lower animals, and may be transferred from them to man ; it grows only in the epi- dermic structures, and is not found in living tissues. Diagnosis. — Tinea circinata must be distinguished clinically from syphilis, eczema, psoriasis, and seborrhoea. In syphilis the concomitant symptoms will generally suffice for differentiation ; the border of the circinate syphilide is more sharply defined and of a darker red color than the border of ringworm ; the erythematous syphilide is widely diffused and scaling is absent. In eczema the itching forms a marked feature, and the disease, as a rule, does not present the sharply-defined border of tinea circinata, while exudation and crusting are more marked ; furthermore, when tinea occurs in solid plaques, so as to resemble eczema, it is often pre.sent simultaneously on the scalp. The lesions of the circinate form of psoriasis present a heavier scaling, and the disease may often be found occupying its characteristic sites on the knees and elbows. In seborrhoea the scales are thick and greasy, and on their removal patulous sebaceous ducts may be seen. Tinea tonsurans may be confounded with alopecia areata and eczema, pso- riasis, and seborrhoea affecting the scalp. In eczema the patches are not sharply limited, crusting and itching are ])resent, and the hairs are only matted to- gether, not broken, as in tinea. In psoriasis the scales are thick and abun- dant ; the hairs are not affected ; and the disease may be found elsewhere, occupying its favorite sites. Seborrhoea usually affects the whole scalp ; the scales are greasy ; and, though the hair is thin, no broken or twisted stumps are seen. Ordinarily tinea presents a very different appearance from alo]>ecia areata with its smooth shining patches of ])erfectly bare scalp ; in those cases of tinea mentioned above, which very closely resemble alopecia areata, often some affected hairs may be discovered at the border of the patches, and a microscopical examination may reveal the true nature of the disease. In every case of tinea the surest way of avoiding mistakes is by a micro- scopical examination. Scales should be removed or hairs drawn and placed in a few drops of liquor potassm upon a slide and covered with a cover-glass; after a few hours the scales or hairs will be rendered trans])arent enough to permit the fungus to be seen. The trichoi)hyton fungus occurs as smooth- bordered branching mycelia, and as conidia, single or in chains (Fig. 5) ; in the hair both forms may be found in the inner root-sheath and in the substance of the hair itself. Prognosis. — Ringworm of the body is readily curable. On the scalp it may last indefinitely unless the treatment bo kept up with untiring patience and vigor. * Kecently Sabouraud and others liave described four varieties of the trieboidiyfon fungus. DISEASES OF THE SKIN. 1153 Treatment. — The treatment of tinea circinata is purely local ; it is usually readily cured. Often a few applications of tincture of iodine will suffice, or one of the following:; ointments may be used : I^. Acidi salicylici gr. xxx. Sulphuris prmcip 3 j. Vaselini 5 j. — M. Sig. Rub into affected area once or twice daily. I^. Ilydi'arg. ammoniati gr. xx. Lanolini 5 j. Olei olivm f3ij. — M. Sig. Apply twice a day. I^. Cupri oleatis 3ss-j. Vaselini 5 j. — M. Sig. Apply twice a day. In the treatment of tinea tonsurans the entire armamentarium of the physician will sometimes be required to bring about a cure. As a preliminary step the hair should be cut short and all scales removed. Epilation, though not absolutely necessary, is no doubt of assistance, and should be practised in all inveterate cases ; many advise removing the hairs from the area immedi- ately surrounding the patch of tinea, thus hindering its spread. During the whole course of treatment the head should be washed daily with soap and water, and then sponged with a saturated solution of boric acid. In young children, the disease in the beginning will often yield to a simple ointment like the following : II. Sulph. prfecip 3j. Ung. aq. rosce 3ij. Lanolini 3vj. — M. Sig. Apply twice a day. Coster’s paint may be applied to the patch with a stiff brush every four or five days, the formula of this is : I^. Iodine 3ij. Colorless oil of wood-tar 3v. — M. In an epidemic recently treated, the application of a 1 per cent, aqueous solution of rosanilin hydrochlorate, rubbed in well once a day, served to check promptly the disease in its early development. Of the mercurial preparations, the oleate and white precipitate are the most efficacious. They may be prescribed in the form of ointments varying from 2 to 5 per cent. In the experience of the writer the most valuable drug in the treatment of chronic cases is chry.sarobin. It may be used in the form of an ointment slightly modified from that recommended by Hutchinson : I^. Chrysarobini Ilydrarg. ammoniati gr. xx. Liq. carbonis detergentis Hlxx. Lanolini 3 j. Olei olivae f3j. — M. Sig. Rub in at night. 73 \\h\ AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN Chrysarobin must always be used with caution on account of its tendency to excite severe inflammation. Crocker thinks highly of the use of croton oil in cases of limited extent in children over six years old; it may be used in a liniment with olive oil, 1:10, rubbed into the patch until inflammation is excited ; or it may be pricked into the diseased follicle with a needle ; the suppuration which the croton oil excites destroys the fungus. Of late much has been said in favor of the employment of electric cata- phoresis in the treatment of tinea tonsurans. The positive sponge electrode is saturated with a 1 per cent, solution of corrosive sublimate and applied to the patch, while the negative electrode is placed upon some other part of the body. When the fungus has invaded only a few follicles or remains in a limited number in spite of treatment, the electric needle may be introduced and the follicle destroyed. In kerion the hairs should be pulled and some soothing antiseptic ointment applied. In any case of tinea tonsurans treatment is to be actively continued as long as any hair-stumps can be detected. Scabies. This disease is not so common in this country as on the Continent. The lesions seen in scabies are due to the ravages of the itch mite (acarus scabiei). It is only the female which attacks the skin, the male merely remaining upon the surface. The female burrows under the epithelium for the purpose of laying her eggs. She lives about two months, and lays in this time about fifty eggs, which hatch in two weeks, The itch-mite selects those parts of the skin in which to make her burrow where the epithelium is not very dense, as between the fingers, flex- ures of the joints, axilhc, about the genitals, etc. Tlie lesions found in scabies are those directly due to the presence of the mite and secondary ones duo to scratching. The burrow is the most characteristic lesion. This consists of a small, fine, black, ziczag line, from one-eighth to one-half an inch long, lying just beneath the upper layers of the epidermis. It is often difficult to find the burrows, as scratching the acarus may be seen lying at one end of the burrow as a small white speck. The presence of the itch-mite excites various grades of inflainination : papules, vesicles, and pustules will be found intermingled on those parts of the body where the skin is thin and where warmth and moisture exist. In Fig. 6. and bathing destroy them. Sometimes DISEASES OF THE SKIN. 1155 infants in arms the face is often involved, as it is kept warm by pressure against the mother when the child nurses ; the feet and buttocks may present the lesions of scabies, as they are protected by the warm clothing. Itching is severe, and we usually find various lesions as the result of scratching — scratch-marks, crusts, furuncles, and pigmentations. None of the lesions of scabies show any tendency toward grouping, but are scattered irregularly over the surface. In severe cases nearly the whole body may be involved, while in very mild ones only a few scattered papules or vesicles may exist. If not treated, the disease may persist for years. Etiology. — Though markedly contagious, the disease does not seem to be communicated by ordinary contact, but only by prolonged exposure, such as wearing infected garments or sleeping in infected beds. No age, sex, or social condition is exempt, but filth and infrequent bathing give the acarus a better chance by leaving its burrow undisturbed. Diagnosis. — Scabies might be mistaken for an eczema, but eczema does Fig. 8. Fig. 7. Larva (after Anderson). Male Acarus (after Anderson). not present such multiformity of lesions, is not apt to be so widely dissem- inated, and the individual elements are aggregated or grouped. The finding of the burrow, and more especially of the acarus itself, is proof positive of scabies (Figs. 6, 7, 8). Prognosis. — The prognosis of scabies is always favorable. Treatment. — The disease is readily cured if the treatment be properly carried out. Before any local application is given the patient should receive a hot bath, with thorough rubbing, using green soap. Probably the most generally successful remedy in the treatment of scabies is sulphur. The fol- lowing ointment should be well rubbed in over all the afiected parts of the body morning and evening for three days : Sulphuris pnecip ."iij-vj. Vaselini .^vj. 01. rosm <|. s. — M. The same under-clothing and sheets should be used until the treatment is completed ; then the patient takes a hot bath with soap, puts on fresh under- clothes, and sleeps between clean sheets, all that he has previously used being boiled ; his outer garments should be ironed with a very hot iron. Um AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. Mauy other remedies have been recommended, and a few of the most use- ful formulae are added : Styracis li(juidi . Adipis Sig. Rub in twice a day 1^. Sulphuris prmcip. Balsami Peruv. . Vaselini .... Sig. Rub in twice a day Kaposi advises the use of naphthol. It is of the utmost importance, no matter what method of treatment may be used, to prevent reinfection by attention to the rules in regard to clothing and bedding above laid down. If, when specific treatment is completed, the skin remains inflamed and irritable, some soothing ointment should be used ; the following answers very well : I^. Zinci o.xidi Ung. aq. rosm .... Lanolini Sig. Apply as often as necessary Pediculosis. In the children of the poor the head-louse is very common, and occasion- ally the pubic-louse may be found on the hairs of the eyebrow or on the lashes. On the head the louse (Fig. 9) is most apt to confine itself to the occip- ital region ; here the irritation it causes, together with scratching, soon sets up a dermatitis, which may range from a few scattered pustules to a condition in which the whole region is covered by crusts and e.xudes a thick, sticky liquid, which mats the hair and by its decomposition gives rise to a disagreeable odor : this purulent matter may be conveyed to other parts of the body upon the fingers, and thus set up a pustular eruption. The lymph-ganglia of the neck, which communicate with the lymphatic chan- nels of the scalp, are apt to become enlarged, tender, and in poorly-nourished children may suppurate. If the hair be long, so that it hangs ii])on the neck, a similar dermatitis may be caused in that region. Whenever we find a pustular eczema confined to the occipital region of a child, we should at once look for pediculi. If these are present only in small numbers, it is often easier to discover the eggs or nits than the louse. Usually one or two nits will be attached to a single hair, though sometimes many are found upon one shaft; they appear as small white specks firmly attached to the side of a hair. They may be mistaken for crusts, but a hair j)asses through the centre of a crust, and a crust may be easily brushed away, while a nit is firmly Fig. 9. Male Pediculus Capitis (after Ktichen- meister). • 3j- • 3ij. • 3vj. f.5j. Sj.-M. 3j- 3SS. 5j— M. DISEASES OF THE SKIN. 1157 glued to the shaft. In the rare cases where the pubic louse has infested the eyebrows or lashes of a child, the most noticeable signs of its presence are the punctate hfemorrhages in the surrounding skin, caused by the bite of the insect. In these regions the pediculi and their knits may be found upon the hairs close to the skin. Etiology. — Pediculosis is contracted by contact with a lousy person or some object containing pediculi, such as hats, caps, and other articles of clothing. Treatment. — In children the hair should be cut short and the crusts soft- ened w’ith olive oil and removed. The head should then be thoroughly anointed with petroleum, the parents being warned not to allow the child to approach a lamp or fire while the coal-oil is on the hair. The petroleum, having re- mained on all night, should be w’ashed off the following morning with soap and water. Two such applications, made on successive nights, will kill the pediculi, but the nits ’ are more difficult to destroy. To remove them, in cases where the hair cannot be cut off, it should be taken up in small bunches and carefully sponged with vinegar; this softens the glue which attaches the nits to the hair-shafts, so that they may be readily removed with a fine-toothed comb. The treatment as above detailed, if carefully carried out, will be found entirely satisfactory. If for any reason petroleum cannot be used, the follow- ing ointment may be applied for several days : I^. Hydrarg. ammoniati gr. xx. Vaselini sj. — M. Whatever method of treatment may be used, a dermatitis will still remain, which should be treated by soothing ointments. PART XIIT. DISEASES OF THE EAR. By B. ALEXANDER RANDALL, A. M., M. D., Philadelphia. The organ of hearing is, in its normal function, one of the most important of the body, especially in the child, since it is the seat of the sense which is second to the sight only, if at all, as the link between the individual and his fellows, and through the help of which a very large part of his education is acquired and his value as a worker made available. Loss of hearing reacts sadly upon most adults in cutting them olf from easy intercourse, and is very apt to engender a suspicious and discontented frame of mind ; while in the child it is still more serious, since it bars, to a greater or less degree, so many channels of learning, sympathy, and practical usefulness before they have even begun to convey their wealth to the forming mind. The diseases of the ear are of great importance, also, because of their frequency and seriousness — facts which are all too little understood or accepted — for they endanger life, as well as function, much oftener than do the more noticed lesions of the eye, which are probably little more numerous. They are far more insidious and readily overlooked in children than in adults, since complaint is rarely made of any subjective symptom except pain; and only slowly will parents generally appreciate that the alleged “slowness” or “stupidity” of children, and their habit of “asking over again,” are due to a real physical infirmity. Add to this the weighty fact that in childhood are quietly laid the foundations for most disqualifying and steadily progressive forms of deafness, which are little amenable to later treatment, and the importance becomes manifest of their recognition at the earlier period, when they can be successfully combated. Embryologically, the organ of hearing arises in three distinct portions, the first being the otic vesicle, which forms as a pouch from the epiblastic surface, develops to form the labyrinth, and becomes distinctly nerve-tissue in part and intimately connected, by the auditory nerve, with the brain ; the second is the mucous cavity, extending out and back from the pharynx in the line of the closed second branchial cleft to form the Eustachian tube and tympanic cavity, including the so-called mastoid antrum and the communicating cells ; while the third portion is a cutaneous projection and pouch growing outward and in, respectively, to form the auricle and the external auditory meatus. Mesoblastic tissues remain as barriers between these parts, yet serve to link them together — the tympanum having the drumhead with the malleus separating it from the external ear, and the bony lahyrinth-capsule with the membranes of the fenestra constituting the division between it and the internal ear. Physiologically and pathologically, this distinction is maintained; the 1 1 .’’>8 DISEASES OF THE EAR. 1159 internal ear remaining as the sound-receiving apparatus, in contrast to the conducting apparatus external to it : and disease shows that the labyrinth inclines to share in brain disorders ; the tympanum remains part of the upper air-passages, involved in most of the lesions of that tract; while the external ear sulfers little except from the disorders of the cutaneous surface. Clinical work, likewise, maintains the divisions thus defined, and our methods of study fall largely into the three forms of topical, pneumatic, and acoustic measures according as the external, middle, or internal ear is aimed at. Treatment of the aural disorders is principally on the same lines ; and, in spite of the incom- pleteness of the demarcation in some instances, this forms the most natural and advantageous division of our subject. In the study and treatment of the ear in children some care is generally requisite as to the holding of the patient. If small, he is usually best held in the lap of an adult, as the mother, with head resting upon her breast and the ear to be examined turned toward the physician. One arm passes around the child’s waist from behind and holds the hands, while the other is ready to steady the head or meet any other requirement. Some throwing back and twisting of the head may be expected ; but the physician’s hand in drawing and holding the auricle outward, backward, and down or up, as the config- uration of the parts may demand, can take points of counter-pressure for his hand upon the child’s head and do much to steady it. In mopping and other manipulations the movements of the child should be followed as closely as possible, especially if the ear is painful, for much roughness and restraint may be thus avoided. The active struggles and screaming of a child cease most acceptably in many instances as the applicator actually enters the ear, and perfect quiet is maintained until it is withdrawn, as though the child, in anticipation of something awful, were reserving its powers to do justice to the occasion. With older children quiet can often be obtained by allowing them to stand or sit free, while the examination is directed first to the unaffected ear, the nose, and the throat, and they are plied with questions, jesting as well as serious. Moderate stillness yielded spontaneously is generally better than that which can be enforced by the efforts of three or four strong adults, and considerable patience in winning confidence and obedience will usually prove good policy ; but if restraint has to be enforced, it should be as overwhelming as possible, so as to demonstrate the futility of resistance and the real gentleness of the treatment, for it is generally fright or wilfulness, rather than pain, that is the disturbing element. Facility in the measures of examination and treatment, especially without instrumental aids, counts for a great deal, since every speculum, tongue-depressor, or other instrument may be an object of terror as well as a probable source of discomfort. The unaided view into a canal may be restricted and incomplete, yet if the light spot can be seen and no redness is visible along the handle of the malleus, tympanic inflammation may be excluded ; and flakes of epidermis, etc. along the walls may then be let alone, which would be pushed up before a speculum and require removal before any view could be obtained. Affections of the External Ear. The external ear, although tangible and prominent, is far less important for our consideration than the middle, and furnishes hardly 25 per cent, of aural work ; and the labyrinth suffers so rarely that less than 10 per cent, of ear diseases affect it, leaving the mucous membrane of the tympanum to bear the responsibility of quite two-thirds of all aural disorders. Yet access to the 11 GO AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. deeper structures is partly through the auditory canal, and the disorders and study of this portion may best be first considered. The auricle, as a skin-covered projection of fibro-cartilage, is open to ready inspection and palpation for its study, and its position exposes it to trauma as well as to various cutaneous affections. Its congenital malformations oi distor- tion, reduplication, or defect are of interest rather as curiosities than as path- ological conditions, and, except for appearance’ sake, rarely concern the aural surgeon. Supernumerary auricles or auricular appendages may be removed if conspicuous ; the persistence of the branchial cleft, as the so-called “ aural fistula,” may call for a tiny jdastic operation to close it ; huge auricles may be brought to more reasonable dimensions by the excision of a wedge-shaped seg- ment, or very prominent auricles may be fastened more closely in by excising a crescentic flap behind them. These are mere matters of surgical common sense. Minuteness of the auricle or absence, congenital or traumatic, may tempt the surgeon to plastic efforts ; but it must be remembered that without cartilaginous fi’amework any semblance of an auricle is quite hopeless, and that transplanting of cartilage, except from the adjacent meatus, has always proven a failure. Upon the hearing, these conditions are practically without influence, and any rash experimentation is unjustifiable. The habit of piercing the ears for ear-rings is responsible for some of the lesions of the auricle, aside from the tearing of the lobules from traction upon them; for the services of an itinerant vender of ear-rings are sometimes followed by a surprising group of cases of abscess of the lobule, apparently affecting in a neighborhood every little girl who had not previously been subjected to the rather barbarous custom. Although usually limited and without diffused infec- tion, these abscesses deserve some surgical care, for their healing may be slow and disfiguring. The infiltration may be of less passing nature, and there may result a fibroid or so-called keloid tumor, which tends to grow rather persist- ently and to recur after removal. These are rather uncommon, except in the negro. The malignant tumors are too rare, even in adult life, to demand notice. Dermoid cysts, probably congenital, may occur in the sulcus behind the auricle, and cyst-like perichondritic effusions or luiematomata may fill the concavities of its anterior aspect as the result of trauma. The inflammatory lesions of the auricle are almost always of an eczematous character. Herpes is rarely met and hardly distinguished with certainty, except by the occurrence of severe pain for hours or days before the visible lesions. True erysipelas is very rare, though not infrequently simulated by a severe eczema. Specific lesions may take almost any form, though generally pustular or rupiah Eczematous Inflammations. — These are usually secondary to some irri- tant, such as an excoriating purulent discharge from the tympanum ; and the main measure of treatment is protection from the cause, wliich should be re- moved if possible. The eczema is generally marked in the furrow back of the auricle, where fissuring may be deep and inveterate, and cicatrization may bind the auricle tightly down upon the mastoid ; but fissures of the lobule and intertragus notch may be deep and ili.sfiguring. The dyscrasia, conveniently though vaguely termed “ strumous,” is apt to underlie and strongly influence the condition ; and similar lesions of eyelids, nares, and lij) are apt to be pre.sent, with swelling or su])puratio!i of the ailjacent glands. For its cure eczema often demands long, varied, and laborious treatment. Internally such tonics as cod-liver oil, hypophosphites, and iodide of iron are called for, with close attention to the hygienic surroundings. The diet must be regulated, the perversions of appetite, which have often been encouraged by giving cakes DISEASES OF THE EAR. and candy to still the fretful child, must be corrected, tea, coffee, and other inappropriate food forbidden, and simple but genei’ous nourishment given. Locally, cleansing to the verge of meddling is called for as often as the lesions become crusted, since healing is generally tardy or absent beneath the inspis- sated discharge. Alkaline solutions or peroxide of hydrogen ■will soften the crusts and permit their removal with little violence, and while all rude hand- ling is detrimental, it is generally less so than pei'initting the pathological tissue to remain bathed in pus and protected from medication beneath its incrustation. Any of the many lauded measures may prove promptly successful or largely futile, but a routine treatment, with a bland calomel ointment (gr.xx— xl, ad vaseline sj), has usually served me excellently. In the very moist forms free painting with silver nitrate may make a better beginning, and drying powders, such as boric acid, may be used on the eczema, as well as in the suppurating tympanum from which the irritation has often proceeded. The ichthyol oint- ment has decided value in reducing the swollen lymph-glands, and may be well used upon the infiltrated aural surfaces, especially after visible lesions are about gone, yet thei'e remains a rigidity, which is often a useful diagnostic sign. Furuncle. — Circumscribed inflammation of the external canal is less common in children than in adults, who are more inclined to scratch the irri- tated and itching surfaces caused by eczema. Yet it is met at times, as is a similar lesion of the auricle. Its painfulness raises its imjwrtance beyond any- thing due to its influence upon the function, although it may close the canal by swelling in a way to muffle hearing and to conceal and possibly seriously obstruct a deeper suppuration. Diagnosis may remain uncertain, and call for treatment as though a tympanic lesion were certainly present. Cleansing with hydrogen peroxide, rubbing in of a salve of the yellow oxide of mercury, and firm pressure by a conical cotton pledget, will generally secure prompt resolu- tion ; but sometimes this cannot be borne, and must be substituted by the rather agreeable and pain-relieving hot douche. The poultice or moist warmth in any form is to be deprecated, and the warmth or actual heat furnished by a salt-bag or hot-w'ater bottle must be relieved of any macerating effect by the thorough drying of the ear after douching. No single measure is as valuable in aural treatment as this hot douche, serving as it does to clean a'way secre- tion, to reduce swelling by relieving stasis, and to soothe the pain ; and it is as applicable to the acute tympanic inflammation as it is to the external suppura- tion of the canal, xnd is especially appropriate in the mixed cases. Any sort of syringe, gently used, will serve, the bulb and nozzle of soft rubber being often best ; but a medicine-dropper or a teapot will do nearly as well, and the temperature should be as high as the patient can be induced to bear. Careful use of the cotton-carrier, under illumination by the forehead mirror, should follow, if possible, in order to remove the moisture, to press out secretion from any open furuncle, to disclose and possibly dislodge any cerumen mass or un- suspected foreign body (recent or long present) which may be hidden beyond the swelling, and, as a probe, to demonstrate the most swollen and tender point as a preliminary to incision. It can also seek for uncovered bone beneath a discharging opening ; for it must not be forgotten that the furuncle may lead to caries of the wall of the canal ; and, still more important, that burrowing of pus from deeper localities, in antrum or attic, may appear externally as fur- uncle-like lesions. The knife may shorten treatment and is indicated to release pus, but, without prejudice to the result, it can often be dispensed with, to the patient’s great mental relief. When used, the smaller and sharper the blade the better, a cataract knife-needle being admirably suited to this and similar incision.s, which may be almost painless when pointing is well marked. A 1102 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. series of furuncles is to be expected, and prognosis and treatment given accord- ingly. Whether to be ascribed to dyscrasia and demanding tonics, or regarded as a matter of microbic auto-inoculation to be combated by rigid antisepsis, both local and general measures are indicated to forestall or control this tendency. Cerumen Impaction. — This is also much less common in the child than in later life, associated as it so often is with a chronic tympanic catarrh. It is almost invariably a sign of lessened, not increased, secretion of wax, with change in its consistency, so that it tends to mass in dark scales or lumps instead of passing constantly out in tiny, light, unnoticed flakes. Those who suffer are often victims of misplaced efforts at cleanliness, for Nature is given no chance to displace the material as it forms, but meddlesome attempts to hasten the process push back and pack inward the emerging masses. The epithelium seems to grow most rapidly at the centre of the drumhead, and to tend to push outward from this point to the margins and then along the meatus walls ; so an. outward march of the lining skin and all that rests upon it is generally discern- ible, the slow progress of which is aided, as the exit is approached, by the movements of the jaw. Many have probably felt at times a little tickling in the ear, and found that a wax-flake had been ejected by the spring of hairs upon which it had been pressed. The movements of the auricle, also, whether accidental or by its own muscles, serve to dislodge any clinging masses. Formed, as the cerumen is, only in the outer two-thirds of the canal, it can only by interference be pressed into the deeper parts, although the epidermal debris which serves to increase the collection can arise in the neighborhood of the tym- panic membrane. So long as the mass does not absolutely occlude the canal, sound-waves may pass through an invisible crevice and the hearing remain perfect ; but the hygroscopic mass can easily swell, if only through atmospheric moisture, and thus give I’ise to sudden deafness. If there has been displace- ment of the mass, as in the movements of the head upon the pillow, pressure upon the drumhead or other sensitive point may also be suddenly caused, with most varied and possibly severe, reflex attacks of vertigo, coughing, or symp- toms of more remote and inexplicable character. The unsuspected presence of these masses should never be forgotten, and both ears looked into, not only in aural patients, but in all nasal and many other obscure cases. Treatment. — This consists in syringing away the collection with hot water. Previous instillations of oil or glycerin are to be deprecated as rarely useful and not always harmless ; and medicinal additions to the syringing fluid do little, if anything, to increase its efficiency. Plain water is about as good a solvent of cerumen as can be found, and its value increases with its temj)erature. At the same time, the dizziness or faintness which syringing oftener than other aural manipulations is apt to cause is less probable or severe if the fluid be Avarm. The water must be thrown with well-controlled and well-directed force ; so the canal must be straightened by traction, illuminated with the forehead mirror, and the stream directed along one wall, especially up and back, in the attempt to insinuate it beside the mass. The syringe is to be emptied with gently increasing force, and after the first ounce or so, the fluid ought to be stained with dissolved cerumen, the softened lumps should follow, and soon the re- sidual mass, softened and reduced in size, a.))pears in the exit, and may be ha.stened out, if it clings there, by a touch of the probe. If fair employment of the syringe has not been thus successful, with good illumination and a steady hand the mass may be touched Avith a ])robe, such as the cotton-carrier, and gently loosened, Avhen the syringing Avill probably succeed. When the epidermal element is large and the solubility correspondingly small, considerable instru- DISEASES OF THE EAR. 1163 mentation may be needful ; but it takes a skilful hand to employ forceps or curette safely or effectively. A small sharp spoon is a most useful instrument, for with it a channel can be excavated in the centre or side of the mass, por- tions displaced so as to be easily grasped and withdrawn by the forceps, or the whole engaged and adroitly extracted. Yet it is decidedly dangerous, and the Fig. 1. The Aural Syringe in Use. blunt ear-spoons more so than the sharp ones, since the operator is apt to pre- sume upon the supposed innocuous character of the former. First and last, and often between-times, the syringing is to be relied upon as the really appropriate measure ; and, well used, it will rarely need much help in securing complete removal of impacted cerumen at the first sitting. On clearing the canal some con- gestion of the walls and drumhead is usually seen, with excoriation, perhaps, if the pressure of the mass has been ill borne or the manipulation rough in re- moval. The canal should be gently dried with absorbent cotton on the cotton- carrier, any excoriated surfaces lightly dusted with boric acid, and the exit filled with a flake of cotton in order to exclude the dust and too rapid move- ment of the air. A repeated visit should be called for, to make sure of prompt restoration to normal ; while any tympanic catarrh should be appropriately treateis- wall, throwing into one open cavity the canal and tympanic chambers. The oval window is seen, as in life, to be empty; the facial canal above it is open and va- cant, and a third opening is into the hori- zontal semicircular canal. 1174 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. of an otitis media, altliougli the aural symptoms may be slight and fleeting. When the nerve is actually destroyed, restoration is not likely, and the canal may prove a path for infection. (See Fig. 10). Burrowing of pus may so easily take place out along the bone, instead of through it, that its presence upon the surface should never be accepted as proof of a bone-lesion, but the region must be carefully searched for sagging LargeSequestrurn.showingmuchoftheoiUersurfaeeof mastoid. lesion may, therefore, be ab- for, in order to lay open the tract throughout as soon as it is detected, and stimulating measures, especially the hot syringing, should be vigorously warmly advocated as capable of decalcifying and aiding to remove any dead portions of bone, Avhile energetically stimulating the growth of healthy granulations. Chronic Cat.\rriial Inflam.mation of the Middle Ear may remain as the result of one or more acute attacks, but more fretpiently is an insidious and progressive disease due to continuous nasal trouble, directly or indirectly acting through the Eustachian tube. These slit-like canals arc normally closed, yet open readily in yawning, swallowing, or forced respiration, and servo to venti- late the tympanum and maintain eijuality of pressure upon the inner and outer surfaces of the drundiead. Nasal catari'h may lead to violent nose-blowing, with undue distention of the tympanum ; but much oftenor the SAvelling of the mouth or lumen of the Eustachian tube both guards the ear against this and also precludes the normal transmission of air. The unrencwed air in the drinn- cavity is al)sorbed, the tympanic meml)rane ])resscd in by the preponderating external pressure, and swelling or hypersecretion of the lining mucous mem- brane, or transudation through it, results from the partial vacuunt. In still other cases the tul)e is duly ])atulous, aixl nasal obstruction gives rise to suction at every act of swallowing, just as in the “ Toynbee experiment ” with the nose held closed. Whether thus medially, or through direct extension of inflamma- tion by continuity, the tympanum becomes involved in a low grade of inflam- Fig. 10. of the walls of the canal, es- pecially above, or other indi- cations of subperiosteal bur- rowing. Up and back, near the drumhead, where but a thin lamella separates the antrum from the meatus, a rounded protrusion, more gen- erally of reddish color, may be found as the result of pur- ulent collection, which has come around or through the bony plate ; and the relations of the Shrapnell membrane are such that suppuration in the attic may pass out along the wall, instead of perforat- ing the membrane. Bone- to follow unless prompt relief of the condition is obtained. Incision freely down upon the bone is called employed. Weak acid solutions, best in 75 per cent, glycerin, have been DISEASES OF THE EAR. 1175 mation tending toward sclerosis. So marked is tins tendency that some cases may well, from their start, be designated as sclerotic ; yet such are rarely recog- nizable in early childhood, and the hypertroj)hic form is here the most import- ant. Slight congestion of the whole tract is usually present, as indicated by the distended vessels visible along the malleus handle; infiltrations take place in limited or diffused areas of the drumhead or other parts of the tracts, lead- ing to fibrous or chalky deposits; and, more important still, the ligaments of the ossicles and the less constant reduplications of mucous membrane about them undergo stiffening and contraction. The pull of the tensor tympani upon the malleus handle may thus be exaggerated through the affection of its tendon sheath, increasing the depressed or retracted condition of the drumhead ; and the stapes, which is often surrounded by bands of tissue, becomes anchored firmly in its niche or undergoes true ankylosis of its foot-plate in the oval windotv. The effect of this in hindering the due transmission of aerial sound- waves is evident, for the drum-membrane is stretched too tightly to respond properly to the lower tones, the conduction through the chain of ossicles is hin- dered, and the cardinal factor — the slight piston-like movement of the stapes — is reduced or prevented. Pain of a neuralgic character is sometimes present, possibly through the sharp pressing inward of the drumheads, and subjective noise or vertigo is apt to be added to the deafness. Even in childhood chronic tympanic catarrh may be very obstinate and require long and persistent treatment. The naso-pharynx is to be put in the best practicable condition, with reduction of turbinal hypertrophies, shrinkage or destruction of “adenoid vegetations” of the vault of the pharynx, and reduction of the tonsils by astringents, cauterization, or excision. My routine nasal treatment is to spray clean the nares with a detergent alkaline solution, such as Dobell’s, mop the pharynx-vault with glycerole of iodine on the bent cotton-carrier, give a protective spray with a 10 per cent, menthol-camphor solution in alboline, and dust lightly with calomel. Inflation of the tympanum can usually be satisfactorily done with the Politzer method, the patient aiding by puffing out the cheeks or saying “ Huck ” at command. If water is given to aid the swallowing effort, the sip should be small, the inflation made as the larynx is seen to rise, and the physician will be wise to stand out of range of the probable spluttering. If the collapse of the drum-membrane be consider- able, its distention may be painful, even by gentle inflation ; and it is well to have the fingers thrust into the ears to compress the air in the canals and miti- gate the pressure. The air blown in may be advantageously medicated by filling the bag from a bottle containing a little iodine or other stimulant. The pneumatic speculum is of decided value, not only in studying the condition of the drumhead, but also as an excellent means of using massage. Any fulness, pain, or discomfort caused by inflation may be thus promptly relieved, tinnitus and deafness much lessened, and a rational method of relieving the worst fea- tures of the trouble readily inaugurated. Its effect can be continued and increased by “tragus-pressure,” or pneumatic massage, done Avith the finger- tip moving in and out while hermetically closing the canal. Valsalva infla- tion had better not be taught, as it is very liable to be abused, but this other measure is generally as useful and probably wholly harmless. Affections of the Internal Ear. Lesions of the internal ear are fortunately rather rare in children. Con- genital defects are hard to prove during life, but may be assumed when other malformations are present, with no evidence of disease and where no hearing 1176 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. has ever been detected. When deafness is total, labyrinthine lesion is almost certain, since disease of the conducting apparatus can hardly abolish the func- tion of the organ. Acquired Labyrinthine Deafness is usually syphilitic, except in the cases of necrotic destruction or exfoliation as the result of tympanic suppuration ; and evidence of the inherited taint should be sought in the eyes and teeth. Even when no sign of interstitial keratitis or other ocular syphilis is found, and the teeth are well formed and spaced, the facies may have a pinched expression, with precocious marking of the naso-labial lines, which is quite characteristic. The loss of hearing is generally sudden, and, although considerable tympanic trouble may be present to confuse the diagnosis, the routine treatment of the middle-ear lesion will prove it to be too slight to be a probable cause of the profound deafness, and alteratives will have distinct influence in improving the hearing. Tuning-fork tests are not very reliable w'ith young patients, even when intelligent enough to understand what we wish to learn, and the objec- tive methods are of uncertain value. It is claimed that through long stetlio- scopic tubes connecting the ears of patient and observer the tuning-fork on the vertex can be better heard from the less-aftected or normal ear if the lesion is labyrinthine, but on the more affected side if tympanic. The contrary is sometimes, if not generally, true. The Galton whistle is of value in testing if any hearing be present, as it can be concealed in the hand and soundeil at various pitches in pi’oxiinity to the ear without attracting any notice unless its sound be heard. Yet the question of total deafness may remain undecided, and the history throw little light upon diagnosis, especially in children who do not talk. Sounds accompanied by concussion, even of the air, are apt to be noticed, and calls and phrases may be comprehended in spite of abolition of hearing; but any words spoken beyond accidental semblances of “ma-ma,” etc. may be taken as proof that some hearing is or has been present. Cases of labyrinthine deafness due to extravasation or sudden exudation, and accompanied by the Meniere symptoms of vertigo, etc., are very rare in chil- dren, and usually unilateral. It is still a question how far acute bilateral otitis interna is mistaken for cerebro-spinal meningitis, the intracranial symp- toms of which are merely reflex, and recovery takes place with surpilsing promptness except for the persistence of total deafness. Such cases do occur, but more often tlie lesion is doubtless in the floor of the fourth ventricle, witli destruction of the auditory tracts ; and any labyrinth lesions later found are due to atrophic degeneration. Whether syphilitic or not, the treatment of these disorders is about the same. A full mercurial impression should be obtained with all possible prompt- ness, and the alterative effect of this drug and iodine ivell maintained. Mer- curial inunction is generally safest and most convenient in children, the oint- ment being given in drachm or half-drachm pellets, of which one is to be rubbed once or twice daily upon the belly and covered with a flannel band, a new surface being taken each time till the Avaist is encircled. rilocarj)ine has some curative value, but is probably much less safe or certain than mercury. When hearing is lost in early life, from whatever cause, speech is either not learned or is very apt to be lost, and the child becomes a deaf-mute. Yet some trace of hearing is present in the majority of those in the mute institu- tions, since the deafness is usually tympanic ; and ac(|uired, as it often is, after some language has been learned, this only needs preservation and cultivation. A considerable projtortion can be taught to sj)eak intelligibly and read the lips of others ivith facility. The process is slow and diilicult; so it should be begun early and with rigorous exclusion of the easier but far less useful sign- DISEASES OF THE EAR. 1177 language. Any remnant of hearing may be of immense aid, and it should be made as good as possible by treatment; and the vocal apparatus should in like manner be put in the best practicable condition, that it may add no needless impediment to the acquisition of useful speech. Mechanical aids to the hearing may be of value to the mute as well as to other deaf persons, both for hearing the sounds of the words spoken to them and their own voices in speaking. The appliances are of two principal forms — either a trumpet to receive in the expanded mouth a larger number of sound-waves than the ear itself could catch, and transmit them by air-conduction to the auditory apparatus, or else of the “dentaphone” type — an elastic surface to respond to the vibrations and convey them by bone-conduction. Each has its limited value and its applicability to individual cases; and it is claimed that they sometimes greatly facilitate that exercise of the auditory apparatus which can occasionally work a slow but immense improvement in apparently hopeless cases. A similar therapeutic idea has led to use of the phonograph as a means of exercise or massage, especially by the believers in infinitesimals — perhaps “proved” by the fact that the attenuated sounds of telephone and phonograph can work harm to diseased ears. Numerous improved forms have been devised, all promising wonders as soon as, like perpetual-motion machines, a missing cog shall be adjusted. PART XIV. DISEASES OF THE EYE. By G. E. de SCHWEINITZ, M. D., Philadelphia. In the following pages only those diseases of the eye are recorded which the general practitioner of medicine and surgery is likely to encounter, and which do not demand the use of instruments of precision for their detection and study. Diseases of the Lids. Abscess and Furuncle of the Lid. — An abscess of the lid, sometimes called phlegmon, appears as a localized red elevation, which may arise in debil- itated children without ascertainable cause, and also results from exposure, injury, or diseases of the orbit. The affection may terminate in the formation of a slough or “core,” and then receives the name ‘■\furuncle” and in sub- jects of poor nutrition may be complicated with gangrene of the surrounding integument. Treatment. — Pointing should be favored by the application of moist heat with compres.ses of lint steeped in hot, slightly carbolized solutions. As soon as fluctuation is detected, or even earlier, the abscess should be incised with a knife thrust through it parallel to the muscle-fibres, and the cavity kept clean with a solution of bichloride of mercury or with peroxide of hydrogen. Nourishing food and tonics, as quinine and iron, are indicated. Hordeolum, or Stye, is a small furuncle on the margin of the lid caused by a circumscribed inflammation of the connective tissue, or of one of the glands of this region. Ordinarily, the affection, though annoying, is trifling in character; the swelling becomes invested with a yellow cap, indicating suppuration, and the purulent contents are evacuated by spontaneous rupture or by incision. Some- times, however, the appearances are similar to those of purulent o])hthalmia, from which it may be differentiated by observing the indurated portion of the lid, the point of suppuration, and the absence of profuse purulent discharge. Styes tend to recur or to come in “ crops.” They are excited by exposure to dust and cold and the strain of uncorrected ametropia, especially hyjiermetrojiic astigmatism. The repeated occurrence of styes always indicates some general derangement — dyspepsia, constipation, and, in girls at the age of jmberty, menstrual disorders. Treatment. — An attempt to abort a stye may be made by the rej)eat<'d application of compresses steeped in hot boric-acid solution, by rubbing the 1178 DISEASES OF THE EYE. 1179 inflamed area with an ointment of yellow or red oxide of mercury, or by paint- ing the surface with collodion. When suppuration occurs the swelling should be incised by cutting through its base parallel to the lid. Constipation, dys- pepsia, and menstrual disorders should be corrected, and in children of suitable age refractive anomalies should be neutralized with appropriate glasses. Sul- phide of calcium has some influence in preventing the recurrence of styes. Exanthematous Eruptions are found upon the eyelids during the various eruptive fevers, and in small-pox a pustule ma}' form, by preference at the com- missure, leaving a disfiguring scar, or it may terminate in an ulcer of stubborn character which is denominated ulcer. Vaccine vesicles on the free border of the lids have been reported by Hirschberg, Berry, and others, after contact with vaccine. The affection receives the name vaccine blepharitis. Blepharitis. — This term describes the various subacute and chronic inflam- mations of the border of the lids, and the aifection usually appears in a non- ulcerated and an ulcerated form. The non-ulcerated varieties manifest themselves as a simple hypenemia of the lid margins, the “red eyes” of common parlance, characterized by swell- ing, redness, and passive congestion of the superficial blood-vessels ; or in an abnormal secretion of the sebaceous glands, characterized by the formation of crusts and scales of hardened sebum (a similar process often affecting the eye- brows at the same time) at the roots of the cilia, and lying upon a slightly inflamed and occasionally abraded surface. Distinct ulcers usually are not present. This form is always bilateral, and is known as seborrhoea of the lid border, blepharitis ciliaris, or squamous blepharitis. The ulcerated varieties manifest themselves as a marginal eczema, which resembles an aggravated form of the simple hyperiemia ; or as a blepharo-adenitis, characterized by the matting of a tuft of cilia in a crust which covers a dis- tinct ulcer, and which often affects a single lid ; or as a fustular inflamma- tion, characterized by the development of thick yellow crusts covering deep ulcers that destroy the nutrition of the eyelashes, which are misshapen and readily fall from their follicles. This type, called blepharitis ulcerosa^ often affects all of the lid margins, and may lead to deformities, owing to the loss of the cilia and the change in the shape of the ciliary border, which becomes thickened, everted, and rounded lippitudo,” or blear-eye). Etiology. — Blepharitis in many of its forms is distinctly a disease of child- hood, and is apt to attack children of blonde complexion and strumous habit. It frequently follows in the wake of the exanthemata, but may arise in other subjects in seemingly perfect condition. Not infrequently, affections of the nares and naso-pharynx are pre.sent (various types of rhinitis, catarrh, and adenoid vegetation), which probably act as causative factors. Eczema around the nares and auricle is often present. Ametropia, especially hypermetropia and astigmatism, as originally pointed out by Roosa, probably causes many cases, and is responsible for the continuance of others. Abnormal shortness of the palpebral fissure may originate blepharitis (Fuchs). Treatment. — This depends upon the type of the disease, but in children of suitable age refractive anomalies should always be corrected. The forms described as hypermmias will often disappear by this means alone ; if not, the lids may be washed frequently with warm water and castile soap, and an eye- ' Eczema of the border of the lids, according to its manifestations, was formerly described under several names — blepharitis ciliaris, blepharitis ulcerosa, psorophthalmia, lippitudo ulce- rosa, tinea tarsi, sycosis tarsi, ophthalmia tarsi, etc. \\m AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. douche may be employed, the water of which, at a temperature of about 60° F., is conducted from a can held above the head through a tube to the end of which a small rose is fitted, which distributes the fluid in fine, shower-like jets upon the closed lids. Stimulating salves are not indicated in this variety. In the seborrhoeas the crusts should be removed with an alkaline solution, bicarbonate of sodium (gr. viij-fij), or biborate of sodium (gr. iv-f^j), and then an ointment of milk of sulphur or of resorcin (2 or 3 per cent.) applied to the lid margins. In the eczemas, after removal of all crusts, the yellow oxide of mercury (gr. j-f.lj) is the most useful application. In any type associated with much ulceration all loose cilia should be removed with epilating forceps and the ulcers touched with a solution of nitrate of silver. In place of the salves which have been mentioned, boracic-acid ointment (10 per cent.), zinc ointment, or aristol ointment (2 per cent.) may be used. The puncta and lachrymo-nasal duct should be patulous, and any diseased condition of the nares and naso- pharynx should be corrected. As constitutional remedies, cod-liver oil, lacto- phosphate of lime, iodide of iron, and syrup of hydriodic acid will usually find suitable indications. Phtheiriasis of the Lids. — The pediculus pubis (crab louse) occasion- ally infests the eyebrows and eyelashes. The parasites cause much irritation, and the affection may be mistaken for ordinary blepharitis. Treatment. — The margins of the lids should be rubbed with balsam of Peru, mercurial ointment, or a solution of corrosive sublimate. Syphilis of the Eyelids. — A hard chancre may develop on any portion of an area included by the lid borders and inner canthus, the tarsal conjunctiva and the cul-de-sacs (De Beck), the inoculation usually taking place by con- tact with the secretion from a syphilitic mouth. The affection begins as a pimple which develops into a characteristic ulcer with indurated base. A small papular syphilide has been noted upon the eyelids of infants the subjects of hereditary syphilis a few weeks after birth, and madarosis (fixll- ing of the lashes), as well as a form of ulcerated blepharitis, has been ascribed to the same cause.^ Tii.mors and Hypertrophies. — Clear, small cysts, warts, and little masses of granulations may occur on the margin of the eyelid, the last arising from the mouth of a Meibomian duct. In addition to these attention is directed to the following growths : N(£vi (angiomas). — These are congenital growths, either small rod spots or cavernous structures analogous to those which occur elsewhere in the body. They should be removed as soon as practicable. If small, excision may be practised ; if large, they may be destroyed l)y galvano-cautery puncture. Chalazion . — This is a small tumor arising in the tarsus, due to inflammation of a Meibomian grland and its surroundinti tissue; hence it is an adenitis or a periadenitis, and not a true cyst. It occurs in children, but is much more com- mon in adolescence. The exact cause is not known, although it is connected with stoppage of the duct of a Meibomian gland, which in its turn may be caused by inflammatory affections of the lij- Distilled water fsj. — M. When the discharge becomes profuse, the lids should be everted and carefully painted with a small cotton mop or camel’s-hair brush dipped in a solution of nitrate of silver (gr. v-fsj). The following collyria have also found favor with many surgeons : Bichloride of mercury (1 ; 10,000) ; alum (gr. iv-f.lj) ; sulphate of zinc (gr. ij-f 5 j); peroxide of hydrogen (diluted one-half or three-quarters); and creolin (1 per cent.). Atropine is generally unnecessary. A saline laxative and tonic doses of quinine are suitable remedial agents in cases which do not present spe- cial therapeutic indications. II. Purulent Conjunctivitis. — This affection, in so far as infants are concerned, is generally described under the name “ Ophthalmia Neonatorum.” Etiology. — The infecting material enters the eye from some portion of the genito-urinary tract during the passage of the head of the infant through the birth-canal, or inoculation may be effected shortly after birth ; in rare instances it takes place in utero when there has been a rupture of the membranes. The gonococci of Neisser are demonstrable in most of the cases and in all severe forms, and bear the same relation to this disease that they do to gonor- rhoea. There is, however, one non-specific variety in which this micro-organ- ism is not present. Therefore a virulent vaginal discharge (gonorrhoeal) is not a sine qua non of this affection, but it may arise from the introduction of any muco-purulent discharge during birth, ivhile careless bathing and the use of soiled towels or sponges after birth are evident sources of infection. It is probable that injudicious intravaginal antisepsis with strong solutions 75 AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. of bichloride of mercury may originate a vaginitis itself capable of inducing one form of ophthalmia neonatorum, and the best obstetricians confine the application of germicidal solutions in uncomplicated laboi’s to the external genitalia. The author is confirmed in this belief by a consultation with Prof. B. C. Hirst. Boys are more apt to be affected than girls, and inoculation is more likely to occur during retarded labors and with face presentations. Symptoms. — Ophthalmia neonatorum usually begins on the third day after birth, but may set in sooner, and when it results from secondary infection — for example, from soiled clothes — it begins at a later date. Almost invariably both eyes are affected. At first there is a slight discharge, which gathers at the corners of the eye, ra]>idly succeeded by intense injection and chemosis of the conjunctiva, great swelling of the lids, and the free secretion of contagious pus. The swollen lids are at first tense, and the serous infiltration of the bulbar conjunctiva almost hides the cornea, sometimes forming a hard rim around it ; the discharge increases and flows out underneath the lids, often being mixed with blood and serum. During the earlier stages the conjunctiva is red and velvety and often covered with flakes of lymph ; later it becomes dark red, rough, and easily bleeds. In from six to eight weeks, if unattended, the disease gradually declines and the relaxed conjunctiva is thick and granular-looking, and slowly regains its normal appearance. The intense chemosis of the conjunctiva strangulates the vessels which sup- ply nutrition to the cornea ; hence the vitality of this membrane is threatened, constituting the chief danger of the disease. Ulcers are likely to form, either at the margin or centre, and their tendency is to spread and perforate; or the entire corneal tissue becomes hazy. The results of perforation are the formation of a partial or complete staphyloma and adherent leucoma, or a pyramidal cataract. Even without perforation the ulcers leave scars which, according to their density, are nebu- lous or leucomatous. In extensive perforation there may l)e an inflammatory involvement of all the coats of the eye, constituting panophthalmitis, which is followed by shrinking and atrophy of the globe. Some non-specific cases of ophthalmia neonatorum do not have so violent a course, and present the appearance of an ordinary muco-purulent conjunctivi- tis. Again, others are analogous to diphtheritic conjunctivitis, and the danger of corneal destruction is even greater than is ordinarily the case. Prognosis. — This is always grave, but under the guidance of competent medical advice, if the eye he seen udrile the cornea is still clear, except in those examples which assume the dij)htheritic type, the case should be brought to a successful termination. The chief fault lies in the indifference of attendants to what seems to them at first a trivial inflammation. Treatment. — The treatment should meet four indications: (a) During the earlier stages, when the iidlammatory swelling of the lids is great, in addition to proper cleanliness the local application of cold is the most useful agent. This should be applied as follows: Upon a block of ice, S(juare compresses of patent lint are laid, which, in turn, are placed upon the swollen lids, and are as fre(|uently changed as may be needful to keep up a uniform cold impression. The length of time occu])ied with these cold ap])lications must vary according to the severity of the case. Sometimes they may l>e almost continuously used, and sometimes frecpieutly for periods of half an hour. (h) The discharge should be constantly removed, and, if possible, by a DISEASES OE THE EYE. 11«7 trained hand. In order to accomplish this, proceed as follows: Gently separate the lids, wipe away the tenacious secretion with bits of moistened lint or absorb- ent cotton, and irrigate the conjunctival sac freely with an antiseptic solution, care being taken that the ])oint of the pipette does not come in contact with the cornea. For this purpose a saturated solution of boracic acid — which, while it is not germicidal, is still feebly antiseptic and slightly astringent — is the most useful. Bichloride of mercury, one grain to the pint, may also be employed. (c) As soon as the discharge becomes free and creamy, which is very early in the disease, nitrate of silver should be employed; and this drug facile princejys of the local remedial agents. It must be applied as follows : Care- fully evert the lids and secure complete exposure of the inflamed tarsal con- junctiva; remove all discharge and flakes of lymph by irrigating the surfaces with the cleansing lotion, wiping away the adherent particles with moistened cotton; carefully touch the area thus prepared with a cotton mop or camel’s- hair brush which has been dipped in a solution of nitrate of silver, ten, or at most twenty grains, to the ounce; neutralize the excess with a solution of com- mon salt — a pinch of salt in a cup of water will suffice — and keep applying the saline solution until a clean, red surface is secured ; finally, return the lids to their proper position and carefully inspect the cornea before leaving the case, and see that this inspection is made at each dressing of the eye; finally, grease the margins of the lids with pure vaseline, some of which should be introduced within the conjunctival cul-de-sac. {d) Should the cornea become hazy or should a small ulcer form, eserine may be employed in a strength varying from a sixth to a half grain to the ounce, but cautiously, lest it produce iritis. Under the latter circumstance, or if the ulcer be central, atropine is the better drug, and may be used in a strength of from two to four grains to the ounce. Very good results usually follow the use of eserine two, three, or four times during the day, according to the severity of the corneal ulceration, and a drop or two of the atropine solution toward night, with due caution lest the constitutional disturbance from these drugs arise in young infants. If there is corneal haze, indicating low vitality of the membrane, the cold compresses may be replaced by hot applications, which should consist of squares of lint wrung out in a slightly carbolized solution of a temperature of 120° F. The author has thus described the treatment which he has employed many times with success. Among the other solutions which have found favor with surgeons are the following: Alum (eight grains to the fluid ounce) carbolic acid (J to 5 per cent, solution); weak solutions of nitrate of silver; alcohol and bichloride-of-mercury solutions; creolin in 1 percent, solution; peroxide- of-hydrogen solution; permanganate of potassium (1:1000), employed in copious irrigations; cyanuret of mercury (1:1500), and aqua chlorinata. Many others might be mentioned, but the evidence is not sufficient to warrant their recommendation or even their trial. While the author does not wish to condemn the use of a proper strength (1 : 8000) of bichloride of mercury in the treatment of this disease, because it has often served him to good purpose, he is convinced that in many instances a sense of false security has arisen simply because the drug has been employed and because of its vaunted germicidal properties. Strong solutions of sub- limate may occasion cloudiness and even ulceration of the cornea. The success of treatment depends largely upon seeing the case early while the cornea * This has recently received fresh endorsement from Mr. Brudenell Carter (London Lancet, December 10, 1892). \im AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. is still bright, upon the faithfulness of the attendants, and upon assiduous attention to the details of the treatment. Prophylaxis. — Inasmuch as ophthalmia neonatorum is one of the most fruitful causes of blindness, prophylactic measures are of the utmost import- ance. All things considered, Credo’s method of treating the eyes of the new- born child is the one which is followed by the best results. This consists in the instillation of two drops of a 2 per cent, solution of nitrate of silver iti the eyes of the new-born child, which, as soon as it is expelled from the maternal passages and before the cord is cut, is placed upon its back in the bed, the eye- lids carefully cleansed, then parted, and the drug introduced. This instilla- tion, when there is reason to suspect gonorrhoeal contagion, should be repeated on the second day. In the mean time, small compresses soaked in a solution of salicylic acid are laid upon the closed lids. Sometimes the instillation of the silver solution causes hypertemia, which disappears in a feAV days. In a few instances smart conjunctival hmmorrhage has followed this treatment. The enormous value, however, of this prophylaxis far outweighs the few accidents which have occurred after its use. Numerous other methods have been employed in the prophylaxis of oph- thalmia neonatorum, and most of the antiseptic fluids have had their advocates, particularly carbolic acid, 1 per cent., bichloride of mercury, 1:5000, Van Swieten’s solution (corrosive sublimate 1 part, alcohol 100 parts, water 900 parts), and aqua chlorinata, the last drug being especially recommended by Schmidt-Rimpler. On the other hand, many obstetricians are content with painstaking cleanliness during birth and also during childbed, believing that this wdll reduce the possibility of the disease to a minimum. While this may be true in private practice and in the absence of any suspicious secretion in the maternal passages, Crede’s method or an analogous one ought certainly to be used in hospital practice always and whenever there is the least suspicion of contagion. There is reason to hope that stringent legislative regulations will be formulated to lessen this appalling cause of blindness, but in their absence it is the evident duty of physicians, nurses, and directors of public charities to disseminate among the poorer classes a knowledge of the dangers of this dis- ease and the necessity for prompt treatment. When the disease has developed and is monolateral, the unaft’ected eye may be protected with a bandage. Attendants should be warned of the danger of contamination. III. Diphtheritic Conjunctivitis. — This is an exceedingly contagious conjunctivitis, which may arise from a similar case or during the course of a purulent ophthalmia. It may appear in connection with eczema of the face or accompany an acute illness, as scarlet fever or measles. The disease is also seen during epidemics of diphtheria, when it is occasioned by direct inocu- lation. A comparatively rare affection in America and England, it is common in certain parts of France and in the north of Germany. It is most frec^uent in children between the ages of two and eight. Symptoms. — The chief symptoms are swelling of the lids, which become exceedingly hard and board-like ; a dull, grayish, false membrane, either dis- crete or confluent, covers the conjunctival surface. The membrane is often deeply incorporate*! with the subjacent tissue. The cornea rarely escapes, and destruction of this membrane may take place in twenty-four hours. Even in the mild cases severe ulceration is common. Treatment. — During the earlier stages cold compresses are proper, to be substituted by hot affusions later on, especially if there be corneal ulceration. The eyes should be frequently cleansed with boric acid or weak solutions of bichloride of mercury, and atropine drops should be instilled if the ulceration DISEASES OF THE EYE, 1189 of the cornea is peripheral ; but in most instances eserine is the better drug. French physicians warmly recommend the application of lemon-juice and citric- acid ointment, and, on the recommendation of Tweedy, solutions of quinine have been much employed. The internal treatment is that suited to a case of diphtheria, and in the experience of the author, with the few cases which he has seen in the Children’s Hospital of this city, the best results were obtained by the administration of bichloride of mercury or calomel, associated with quinine suppositories.^ IV. Spring Conjunctivitis {Fniehjahr s Catarrh). — This curious form of conjunctival disease is generally seen in children between the ages of five and fourteen years. Its exact cause is unknown. One of the characteristics of the disease is its return about April,, and its subsidence in the fall and winter, although sporadic cases are seen in almost every month of the year. Sometimes it accompanies the disease known as hay fever. Symptoms. — The chief symptoms are photophobia, mucous secretion, hypertrophy of the tissues surrounding the limbus of the cornea in the form of grayish nodules, and a pale, dull color of the palpebral conjunctiva, which has been compared to the appearance of a thin layer of milk, together with the formation of large flattened granulations covering the tarsal folds and causing the eyes to droop and give the patient a peculiar, sleepy expression. It must not be confounded with granular lids, from which it is distinguishable by the flat appearance of the granulations and the absence of corneal compli- cations. So far as vision is concerned, the prognosis is good, but the prom- inent tendency of the disease to return Avith the early spring and Avarm Aveather makes it a difficult disorder to manage. Treatment. — The eyes should be protected Avith dark glasses, the con- junctival cul-de-sac freed from the accumulated secretion, Avhich is sometimes quite free, Avith a lotion of boric acid and salt. When the granulations are prominent the lids may be everted and their surfaces touched Avith a 20 per cent, solution of boroglyceride or Avith a strong solution of bichloride of mercury (1:500), this application to be made once a day. In bad cases the actual cautery may be employed to destroy the granulations, or these may he crushed Avith roller forceps, as in the treatment of granular lids. Internally, some form of ai’senic is advisable, preferably FoAvler's solution. V. Follicular Conjunctia'itis. — This, as its name implies, is an inflam- mation inAA'hich numerous pinkish, round elevations appear in the conjunctiva, chiefly in the retrotarsal folds, sometimes associated Avith the symptoms of an ordinary catarrhal conjunctivitis of mild degree. These bodies are tumefied lymphatic follicles, and disappear under treatment Avithout leaving cicatricial changes in the conjunctiva, and the cornea is not involved — points Avhich dis- tinguish the affection from true granular lids. Some authors regard it as an early stage of granular conjunctivitis. The evidence is in favor of a separate classification. It occurs usually in children and young people, and in its aggravated forms arises under the influence of bad hygienic surroundings in overcroAvded schools and asylums. A mild form is common in school-children under good con- ditions. When neglected, it may become a serious and epidemic disorder. Treatment. — This consists of improvement of the surroundings, building up of the general health if this is beloAV par, and, locally, boric-acid solution * There is also a true croupoxia cmjunclivitiH which occasionally attacks children between the first half year of life and the fourth year. It is not contagious, and the cornea generally escapes, and although membrane forms upon the conjunctiva, the lids remain pliant. It is a rare dis- ease, and the distinction betAveen it and true diphtheria of the conjunctiva is not always main- tained by authors. 1190.1J/£’/2/Cl.V TEXT-BOOK OF DISEASEH OE CHILD BEN. or sublimate collyrium. a salve of sulphate of copper (J gr. to 3j), or dusting upon the retrotarsal folds iodoform, aristol, or etpial parts of suhnitrate of bismuth and calomel. Refractive errors should be corrected. If the disease is at all stubborn, the swollen follicles should be destroyed, preferably with Knapp’s roller forceps. VI. Granular Conjunctivitis [Trachoma). — This is a serious form of inflammation in which rounded granulations' (trachoma-bodies) form in the conjunctiva, resulting in cicatricial changes in the lids and vascularization and ulceration of the cornea. The disease may be acute or chronic. It is dis- tinctly contagious. Although not nearly so common in childhood as in adult life, many cases occur among children, especially of the poorer classes. It is most frequent among the Jews, Irish, Italians, Indians, and inhabitants of the East, but, except in rare instances, is unknown among the pure negroes. Inhabitants of low and damp regions are more liable than those who live on high ground, an altitude of one thousand feet conferring comparative immunity. This pre- disposition to granular lids is also encouraged by residence in badly-ventilated homes and asylums, where the disease may become epidemic, and by imperfect nutrition, but there is no known constitutional disorder at the bottom of the disease. The essential characteristics of the aft’ection are the “granulations” (trachoma-bodies), sometimes called “follicles,” which dift’er from those seen in follicular conjunctivitis because they may be regarded as pathological new formations. It is probable that the active agent in the production of trachoma and its dissemination is a special micro-organism, the trachoma-coccus, but its identity is not clearly established. Symptoms. — In acute granular conjunctivitis, in addition to the phe- nomena of a violent conjunctivitis, associated with great dread of light, free lachrymation, and later a muco-purulent discharge, the conjunctival papillae become hypertrophied and there is a liberal growth of roundish granulations in this membrane. This acute type must be distinguished from the exacerba- tions which are common in the chronic variety of the disease. In chronic granular conjunctivitis there may be a stage of acute inflamma- tion, such as has just been descriljcd, but most frecjuently it appears without such preceding condition. The grayish-white, semi-transparent granulations, often in rows and sometimes resembling the spawn of frogs, develop chiefly in the retrotarsal folds. The most important types are (u) pa])illary trachoma, (h) follicular trachoma, and (c) mixed or diffuse trachoma. In the papillary and mixed varieties, in addition to the granulations, there is much hypertrophy of the conjunctival papillm. At first there is little discharge, but as the develop- ment of the follicles increases a softening process takes place and the secretion becomes abundant and is extremely contagious. Gradually the stage of cica- trization is reached, which results in the formation of scar-tissue, the cicatrices often lying in characteristic parallel lines, while the lids become indurated and their borders inverted, resulting in conditions which have already been described. In bad ca.ses there is a ])ractical drying u]>, or xerosis, of the conjunctiva, with obliteration of the sulcus. Sequelae. — The most important secpiels of granular lids have been referred to, with the exce])tion of the vascularization of the cornea, or pannus, which is really a form of vascular keratitis. It always begins under the upper lid by the development of blood-vessels in the superficial htyers of the cornea, ofteii associateil with ulceration and opacification of that membrane. This pannus is * TTiese slioulil not be cont'oiiiuleil with the ^laiiubitioiisi of wounds. DISEASES OF THE EYE. 1191 partly due to the meeliaiiical effect of the granulations, and partly to a special implantation of the disease in the cornea. Treatment. — xVcute granular conjunctivitis must be managed on the principles already laid down in connection with an acute inflammation of the conjunctiva. In chronic granulations the object is to promote absorption of these with the least cicatricial change, and consequently the application should never be so caustic as to create scars, which would be worse than those resulting from the natural subsidence of the disease. It would be impossible in this brief description even to refer to the numerous applications which have been made, and the author will hence recommend those which in his owm practice he has found most efficacious — namely, (a) nitrate of silver, 10 grains to the ounce, during any stage of granular lids when there is much discharge, to be applied in the manner already described ; (d) strong solutions of bichloride of mercury (1 : 300 or 1 : 500), applied to the everted lids with a cotton mop, associated with frequent irrigation of the conjunctival cul-de-sac with a tepid solution of the same drug, 1 grain to the pint ; suitable in practically any stage of granular lids, but especially wdien there is decided development of the follicles ; (c) sul- phate of copper in the form of a smooth crystal, which is rubbed over the everted lids and well across the retrotarsal folds, useful in any stage except that in which there is much discharge, and particularly valuable in the later periods of the disease ; (rZ) boro-glyceride, 20 or 50 per cent., applied in the usual manner to the affected conjunctiva, most valuable after cicatrization has begun. In mild cases an excellent remedy is a solution of tannin and glycerin, 20 or 30 grains of tannic acid to the ounce of glycerin. Generally, pannus will disappear with the subsidence of the granulations. If it does not or if exacerbations are present, it must be treated after the man- ner suited to keratitis. (See page 1197.) Opei’ative interference, except in the acute cases, yields the most satisfac- tory results in the treatment of granular lids. The best method is expression of the granulations by means of forceps, and of those thus far devised, the one advocated by Knapp, which works on the principle of a roller, is the most val- uable. After the lids have been thoroughly rolled the local treatment must be continued, and generally the sulphate-of-copper crystal will then be found use- ful. The roller forceps, however, are not sufficient in cases of diffuse trachoma. Then the operation called grattaye” is much practised. This consists essen- tially in deep scarifications and rubbing out the trachoma-bodies with a stiff brush which has been dipped in a solution of bichloride of mercury. This last- named method is a vigorous means which should be utilized in selected cases, and for a description of wffiich, and of the many other methods, the reader is referred to systematic treatises on diseases of the eye. Ecchymosis of the Con.juxctiva, which consists of an escape of blood into the meshes of the connective tissue, is particularly interesting in childi’en as the common result of a violent paroxysm of whooping cough, although it may arise under any straining effort. It is also seen with girls at the begin- ning of the menstrual epoch. The entire conjunctiva may become blood-red. The blood disappears without treatment, although hot compresses seem to hasten its subsidence. Chemosis of the C0N.JUNCTIVA is common in various types of conjunc- tivitis, but it is also a symptom of deeper diseases of the eye ; for example, inflammatory affections of the uveal tract. Sometimes it occurs without appa- AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. rent cause. The oedema may be very great, and the conjunctiva appear like a huge bleb and protrude between the lids. Usually the oedema subsides under the influence of hot compresses and an astringent lotion ; for example, a weak solution of alum. If it be very severe, the swollen tissues may be incised. Tumors and Cysts of the Con.junctiva. — Several varieties of benign tumors and cysts (dermoids) have been described, and among the malignant tumors in children should be mentioned sarcoma, which develops usually at the limbus, and is generally pigmented. The benign growths and cysts can easily be removed. If a sarcoma appears, it may be necessary to extirpate the entire eyeball. Tubercle of the Conjunctiva, under rare circumstances, occurs as a primary affection in the form of uneven ulcers beset with grayish-red nodules, in which a decisive diagnosis could be made by bacteriological examination. Pemphigus may attack this membrane. There is a curious form of atrophy of the conjunctiva in which the membrane dries up entirely and the borders of the lid become fixed to the ball. This is probably a form of ])emphigus, but it has also been described as essential shrinking of the conjunctiva. Ordinary atrophy of the conjunctiva following granular lids and diphtheritic conjuncti- vitis has been referred to. Injuries of the Conjunctiva. — Burns, especially with lime and acid, are to be feared mostly on account of the symblepharon which they are likely to produce. After a lime-burn the alkali may be neutralized with a weak acid, but usually it is best to speedily flood the eye with a rapid stream of water — for example, from a spigot — and pick off any pieces which the water fails to wash away. Iced compresses may then be apjilied. Atropine drops should be instilled if there is corneal involvement, and the conjunctival cul-de-sac should be frequently cleansed Avith a solution containing boric acid and common salt. An acid burn is treated on the same principles, an alkaline Avash composed of carbonate of sodium being at first employed. It is usually recommended to drop olive oil on the conjunctiva after a burn, and certainly it can do no harm. A good plan is to incorporate Avith liquid vaseline- some atropine (gr. iA'-oj) and freely introduce this substance. Phlyctenular Kerato-conjunctivitis {J^hh/ctenular Ophthalmia. Stru- mous. Pustular, and Vesicular Keratitis and Conjunctiviti.sf. — It is customary to describe phlyctenular conjunctivitis and ))hlyctenular keratitis as tAvo dis- tinct affections, but as both cornea and conjunctiva are associated in the inflam- mation, and as the lesion is the same in both cases, it is better to include them under one name. The disease is characterized by the formation on the bulbar conjunctiva, at the corneal margin, or on the coniea, of small, grayish-Avhite elevations, often called vesicles or pimples, and usually classified under the generic tonn phlycte- nules. associated Avith injection, lachrymation, and dread of light. Etiology. — It usually occurs in children before their tenth year, and most frequently in those of strumous constitution. Eczema of the face is frequently present. The use of umvholesome food (sAveetmeats, j)astry, tea, and coffee), and consc(iuent derangements of the alimentary canal, are ju-edisposing causes : the conjunctival form folloAVS in the Avake of scarlet fever and measles. All varieties are more common and more aggravated in Avarm and moist Aveather. DISEASES OF THE EYE. 1 1 m There is a direct relation between this disease and various lesions in the nasal fossaj and naso-pharynx (rhinitis, congested tui’binals, and adenoid vegeta- tions). It is j)robable that astigmatic eyes are more liable than those with refractive conditions approaching emmetropia. Several varieties of micro- cocci have been described, but no definite causal relation has been established. Symptoms. — In the conjunctival variety the phlyctenules form on the bulbar conjunctiva and especially affect the margin of the cornea. There may be only one or two of them (^single form), or they maybe numerous and scattered everywhere over the membrane {multiple form). At first translucent, they soon become turbid and break down. The conjunctival vessels are freely injected. In the corneal types the phlyctenules, about the size of a millet-seed, appear near the corneo-scleral junction or encircle the margin {marginal kera- titis), or a single one develops near the border and creeps across the face of the cornea, followed by a leash of blood-vessels {fascicular keratitis). There are, in addition, conjunctival hypermmia, free lachrymation, and intense pho- tophobia. Soon the phlyctenules grow yellow, break down, and ulcers {pltlgc- tenular ulcers) are formed, which at first are superficial and may remain so; or, in the more aggravated varieties, they will grow deeper, the surrounding cornea become infiltrated, and perforation may ensue. This is especially apt to occur if a large yellow phlyctenule {imstuJar form) develops just at the margin of the cornea. Relapses are frequent ; new phlyctenules form, fresh ulcers result, and, unless the process, is checked, the epithelium of the cornea becomes roughened, opaque, and vascular, and pjlilgctenular pannus arises. Almost invariably there is an irritating rhinitis, causing an acrid secretion to flow from the nose and excoriate the lip, while frecjuently patches of eczema appear around the nares, on the face, or at the auricle. Treatment. — The extreme photophobia makes it difficult to properly apply local remedies. For this reason the child’s head should be taken between the surgeon’s knees, wdiile an assistant holds the hands and body. The lids are then separated and the cornea can be gradually coaxed into view. A lid-elevator may be employed, and in very bad cases it is sometimes needful to use ether or chloroform before the necessary inspection of the eye is possible. Cocaine will temporarily relieve the photophobia, but it should never be employed as a con- stant application where corneal ulceration exists. If the child is of sufficient age, the eyes may be protected with goggles, and under all circumstances the little patient should be encouraged not to bury its head in the bed-clothes or hide in dark corners of the room. Photophobia may be allayed by douching the eyes with cold water, and search should always be made for a fissure at the external commissure, which is apt to keep up the dread of light ; if this be present it may be touched with a crystal of blue-stone or the fibres of the orbicularis divided at this point with a sharp knife. The best possible hygienic surroundings, with strict regulation of the diet, out-door exercise in good weather, and frequent sponge baths with salt water are advisable. Atropine drops, 4 grains to the ounce, should be used until complete mydriasis is obtained, and this dilatation of the pupil should be kept up as long as there is irritation. If there is much discharge, boric-acid drops, with or without the addition of common salt, may be used. In severe ulcera- tion of the peripheral type, eserine (gr. J or ^ to the fluidounce) is useful, and may be employed during the day, a drop or two of the atropine solution being instilled at night. After the irritation has subsided yellow oxide of mercury, 1 grain to the drachm, should be employed as a local application, or in its place finely-powdered calomel may be dusted into the eye, provided the patient \\\)A AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN. is not taking iodide of potash or any preparation of iodine, under which circumstances such practice will result in a violent inflammation of the con- junctiva. Internally, after the alimentary canal has been prepared by a course of calomel, the most useful drugs are cod-liver oil, iron, quinine, and arsenic. It is essential in all these cases to treat the nasal conditions which have been described, an excellent routine practice being to spray the parts with Dobell’s solution or listerine, and insufflate powdered iodoform, or a mixture composed of camphor, boric acid, and subnitrate of bismuth, or finely-pul- verized chlorate of potassium. If, however, adenoid vegetations or hyper- trophied turbinated bodies are present, these must be treated on the principles known to nasal surgery. In stubborn cases and with ulcers tending to per- forate the measures to be described for treating corneal ulcers will be required. After the subsidence of the disease suitable glasses should be ordered, if the corneal astigmatism is of such character that it can be corrected. Diseases op the Cornea. Ulcers of the Cornea. — When the stage of infiltration which accom- panies 'an inflammation of the cornea, or a keratitis, fails to end in absorption, and the corneal tissue disintegrates, an open lesion or an ulcer results. In children the majority of corneal ulcers which are of primary origin result from the disease which has just been desei’ibed, and are hence known SiB phlyctenular ulcers. Systematic writers have described a number of other types of ulcer, among which the following varieties may be mentioned : («) Simple Ulcer. — This, sometimes called “pimple ulcer’’ Avhen it arises from a phlyctenule, is a small gray infiltration, and may develop from an injury. Frequently it appears right in the centre of the cornea, and as a slightly cone- shaped, gray-Avhite opacity, without much irritation, and is then known as the small central ulcer of childhood. It heals, leaving a small scar directly in the axis of vision. It is seen in poorly-nourished children of the strumous habit, and probably represents one of the results of imperfect nutrition. It may heal quickly or develop into a deep ulcer. { b ) Deep or Purulent Ulcer. — This is practically described in its title, and is a more aggravated form of the type just described, of yellowish appear- ance with infiltrated margins, and a tendency to penetrate the layers of the cornea. It may be the result of injury, or may follow certain conjunctival inflammations, or arise because a simple ulceration has been neglected. It heals with a dense white scar. (c) Indolent Ulcers. — Several varieties of these have been described. One is apt to occur in the centre of the cornea — a small shallow lesion with a slightly turbid base and not much injection of the surrounding tissues {shallow central ulcer). It is often seen accom])anying granular lids. Another variety is called youged-out ulcer, almost without any injection accompanying it, its most common situation being near the corneal margin. These ulcers heal with less dense scars, sometimes only a faint o])a(pie facet remaining { facetted ulcer). They are common in anmmic and scrofulous patients, and evidently dc])end upon failure in the nutrition of the cornea. {d) SloU(JIIIN(J Ulcer. — A sloughing or infecting ulcer is the rej)resenta- tive of purulent keratitis, and is a more serious grade than the deep or purulent ulcer already noted. This is not so common in children as in ehlerly people; but at the same time very violent and serious ulcers, which are serpiginous or creeping \w type, arise in children as the result of injury, because the abrasion DISEASES OF THE EYE. 1195 thus produced has been infected, probably, with a special form of micro-organ- ism. Not only is there extensive purulent infiltration of the cornea, but also the iris is involved and pus forms in the anterior chamber, and hence the disease is called hypopyon keratitis. In like manner, instead of an open ulcer of this character, the pus may be confined within the layers of the cornea, and an abscess results, or its superficial layers may burst and there is an open lesion. This also is due to the fact that the area has been inoculated with pathogenic micro-organisms. Some of the most typical examples of abscess of the cornea and hypopyon keratitis occur not only from injuries and neglected ulcers, but with small-pox, scarlet fever, measles, typhus, and typhoid fever. Treatment. — Everything which tends to improve the surroundings of the patient and to build up his nutrition is indicated. Proper protection of the eyes with goggles is important; whenever possible, out-door exercise is advis- able. The remedies already suggested with phlyctenular keratitis are usually needed, care being taken to inquire into possible etiological conditions, which should be met with suitable measures. Search should always be made for the presence of a foreign body and for irritating, misplaced cilia. The lachrymal passages should be explored to see if they are patent, and the teeth should be examined, and if they are carious the services of a dentist should be secured. The nasal passages and the naso- pharynx should be carefully examined and treated. In mild cases of simple ulcer atropine drops for a few days, to be followed later by a salve of yellow oxide of mercury (gr. j-3j), usually suffice. In severe cases atropine drops may be employed, provided the ulcer is central and if there is any hypermmia of the iris ; if not, eserine in the strength already mentioned may be dropped into the eye three or four times a day, with one or two drops of the atropine lotion at night. The conjunctival cul-de-sac should be fre([uently irrigated with a mild antiseptic lotion, a saturated solu- tion of boric acid, a weak solution of bichloride of mercury (1:10,000), or aqua chlorinata. These drugs are particularly indicated if there is an asso- ciated conjunctivitis with muco-purulent discharge, which should then be treated also on the principles already laid down. If the ulcer is sluggish, it may be stimulated to heal by the introduction of the yellow-oxide salve. In sloughing ulcers, in addition to the measures already indicated it may be necessary to curette the surface, touch it gently with a solution of nitrate of silver, 10 grains to the fiuidounce, or dust upon it finely-powdered iodoform. In many cases the most effectual treatment is the cautery, the point of a galvano- or a thermo-cautery being applied gently but thoroughly to the involved area. In hypopyon keratitis or in abscess of the cornea, paracentesis of the cornea or the section of Saemisch is sometimes neces- sary. In any case in which I’upture is impending, and there is no contraindi- cation — as, for example, associated catarrhal conjunctivitis — much good may be done by a carefully apj)lied compressing bandage. In any type of corneal ulcer- ation hot compresses are often invaluable, as they aid in healing and preserve the nutrition of the cornea. The Results of Corneal Ulceration. — Every ulcer is follow’ed by a scar, which may be a mere haze, or nebula^ a more pronounced spot, or macula, or a dense white scar, or leucorna. If the cornea has ruptured, the anterior cham- ber is evacuated, and the iris falls forward and is entangled in the opening. This, then, is an anterior synechia, and the scar on the cornea is an adherent leucorna. Sometimes an eye of this character becomes quiet ; sometimes, how- ever, it cannot resist the intraocular tension and the area bulges forward, form- ing a staphyloma. If there has been an extensive rupture of the cornea and \m\ AMERICAN TEXT-BOOK OF DISEASES OF CHILDREN complete matting of the prolapsed iris with the inflamed and broken-down corneal tissue, the whole cornea protrudes as an opaque elevation, forming a complete staphyloma. Treatment of Sequels. — Slight corneal scars and nebulas may be influ- enced beneficially by massage of the cornea, aided by the previous introduction of a small particle of Pagenstecher’s ointment (yellow oxide of mercury, 1 gr. to the drachm). The dense white leucomas, however, are not thus influenced. If they are central and clear cornea remains at the side, an optical iridectomy may be performed and the scar tattooed with India ink to improve its appear- ance. After the perforation of an ulcer and prolapse of the iris it is sometimes possible, when recent, to disentangle this with the aid of an instrument and the vigorous use of esei’ine or atropine, according to the situation of the ulcer. If this fails, staphyloma should be prevented by the vigorous use of a compressing bandage. If, in spite of this, staphyloma, either partial or complete, forms, various surgical measures are indicated, according to the extent of the dam- age — namely, iridectomy, the operation for partial staphyloma, or, in hopeless cases, evisceration or enucleation. Infantile Ulceration of the Cornea, with Xerosis of the Con- junctiva [Kerato-malacia). — In certain amemic and badly-nourished children, sometimes after measles, scarlet fever, violent dian’hoea, and other illnesses with great depression of nutrition, the cornea undergoes a rapid destructive ulcer- ation, while the conjunctiva becomes greasy and dry, little flakes of cheesy appearance forming upon its surface. Not only is the destruction of the sight almost inevitable, but most of the infants — for it usually occurs during the first year of life — die, generally of intercurrent pneumonia. The usual treatment of corneal ulceration is indicated, with an attempt to improve the general condition. This disease should not be confounded with a type of conjunctival. disease known as xerophthalmos, in which the same cheesy flakes form and the mem- brane becomes greasy and di’v, and which sometimes occurs as an epidemic with the curious symptom of night-blimhiess, especially in people who have long fasted. Interstitial Keratitis {Syphilitic, Parenchymatous Keratitis). — In this disease, which is an inflammation of the chronic type, a difl'use keratitis, prac- tically always without ulceration, arises, and the cornea gradually becomes thick with haziness until it resembles ground glass, while superficial and deep vascularization accompanies the condition. It is most often seen between the ages of five and fifteen, and is more fre- quent in females than in males. A very large percentage of cases is due to inherited syphilis, but it has also been attributed to rachitis, scrofula, malaria, rheumatism, and depressed nutrition. In the syphilitic cases generally some other mark of syphilis is present, particularly Hutchinson’s teeth, or evidence of this taint can be acquired from the family history. Symptoms. — The disease begins ivitli slight ciliary congestion, a few spots of infiltration in the cornea, which speedily develop into the general haze already described, the infiltration being in the interstitial tissue ; blood-vessels become thickly set in the layers of the cornea, which in its upper part assumes a dull reddish color. In some types this is so pronouncerognosis of rheumatism, 356 of tracheotomy, 294 of whooping-cough, 189 of occurrence of rachitis, 322 of onset of infantile cerebral palsies, 650 Agenesis corticalis, 655 Agoraphobia, 704 Agraphia, 659 Air-passages, hypersemia of, in chicken-pox, 1.57 Alas of nose, dilatation of, in broncho-pneumonia, 906 Albinism, 1135 partial, 1135 Albumin in acute tubal neph- ritis, 1011 in chronic interstitial neph- ritis, 1026 in chronic tubal nephritis, 1019 Albuminoids in milk, 46 Albuminuria after epilepsy, 751 chronic, in etiology of amy- loid kidney, 1024 in diabetes insipidus, 1005 in diabetes mellitus, 1000 ill diphtheria, 256 in erysipelas, 225 in etiology of incontinence of urine, 998 in malaria, 314 in simple atrophy, 506 in splenic anwmia, 369 in stone in bladder, 1009 Albuminuric retinitis in chronic interstitial neph- ritis, 1026 Alcohol. See Stimulants. in bronchitis, 933 in broncho-pneumonia, 911 in cholera, 246 in chronic intestinal indiges- tion, 471 in croupous pneumonia, 918 indications for, 36 in diphtheria, 261 in epidemic cerebro-spinal meningitis, 213 in influenza, 219 in mucous disease, 459 in peritonitis, 567 in rheumatism, 357 in scarlet fever, 146 1205 120G INDEX. Alcohol in variola, 1()9 Alcoliolism in etiology of cir- rhosis of liver, 5.58 of hysteria, 729 Alexia, 659 Algid stage of cholera, 240 state in acute milk infection, 476 Alkalies in diabetes mellitus, 1004 in mucous disease, 461 in rheumatism, 3.57 Allingham’s method in pro- lapse of rectum, 591 Alloxuric bodies iis a cause of lithffimia, 94 excretion of, 95 Almond-flour in diabetes, 1002 Alopecia areata, 1136 diagnosis of, 1136 from ringworm, 1136 etiology of, 1136 prognosis of, 1136 syphilitic, 112 treatment of, 1137 Alternate heart-beat, 988 Altitude in etiology of granular conjunctivitis, 1190 in tuberculosis, .300 Alum in ophthalmia neonato- rum, 1187 Alveolar sarcoma of kidney, 1035 Amaurosis in hydrocephalus, 604 Amblyopia in erysipelas, 227 in hysteria, 734 American gout, 94 Ametropia in etiology of bleph- aritis, 1179 Amimia, 6,59 Ammonia in functional affec- tions of heart, 989 Ammouiaco - magnesian - phos- phate calculus, 1038 Ammonium carbonate in bron- cho-pneumonia. 911 in diphtheria, 261 in malignant measles, 128 chloride in bronchitis, 931 in cirrhosis of liver, 560 in congestion of liver, .551 in jaundice, 548 in measles, 128 salicylate in rheumatism, 356 urate calculus, 1038 Amoeba coli, 490 dyseuterife, 490 dysenterica in pus from liver, 542 Amussat’s operation, .580 Amygdalitis, follicular. See Follicular ami/ydaiitis. Amyl nitrite as a cause of hsematuria, 992 in asthma, 961 in epilepsy, 7.53 Amyloid changes in Pott’s ilisease, 10li7 disease of kidney, 1024 eti(dogy of, 1024 morbid anatomy of, 1024 lu-ognosis of, 1024 treatment of, 1025 Anadonia of stomach, 447 Ana;mia, 360 Anaemia as a cause of inconti- nence of urine, 1027 definition of, 360 following acute nephritis, 1017 rheumatism, 354 in acute endocarditis, 978 in chronic tubal nephritis, 1019 in functional heart affections, treatment of, 989 in heart-disease, treatment of, 984 in hereditary syphilis, 110 lymphatic, 370 diagnosis of, 372 from pseudo-leukaemia, 372 from tubercular adenitis, 372 etiology of, 370 morbid anatomy of, 371 prognosis of, 372 symptoms of, 370 treatment of, .372 progressive pernicious, 364 diagnosis of, 367 etiology of, 365 morbid anatomy of, 366 prognosis of, 367 symptoms of, 365 treatment of, 367 secondary, 360 diagnosis of, 361 from chlorosis, .361 from pernicious anaemia, 361 from splenic anajmia, 361 etiology of, 3(i0 prognosis of, 361 symptoms of, 361 treatment of, 361 splenic, 368 diagnosis of, 369 • from amyloid infiltration of spleen, 369 from enlarged kidney, 370 from leukaemia, 369 etiology of, 368 morbid anatomy of, 368 prognosis of, 370 spleen in, 369 symptoms of, 369 treatment of, 370 Anaunias, primary, 362 Anaunic headache, 723 murmurs in chronic tubal nephritis, 1019 Anaesthesia dolorosa, 802 in acromegaly, 602 in acute spinal leptomenin- gitis, 780 in cerebro-spinal meningitis, 211 in hereditary ataxia, 818 in hysteria, 733 in. Raynaud’s disease, 821 in tumors of spinal cord, 802 Anaesthetics in tracheotomy, 877 j Analgesia in tumors of spinal I ■ cord, 802 j Anastomosis, lateiiil, in con- I genital malformations of intestines, 577 Anastomosis, lateral, in intus- susception, 523 Anatomy of urinary organs in children, 1045 Anderson’s dusting powder, 1095 Angina in rubella, 1.54 in scarlet fever, 136, 139 Angioma of rectum, 593 pigmentosum et atrophicum. See Kaposi’s disease. Animal broths in subacute milk infection, 483 Animals, experimental pro- duction of rachitis, in 324 Ankle, tuberculous disease of, 1079 Ankle-clonus in hereditary ataxia, 817 Ankle-joint disease, 1079 diagnosis of, 1079 operative treatment of, 1080 prognosis of, 1079 symiitoms of, 1079 treatment of, 1079 Ankylosis following tuberculo- sis of joints, treatment of, 108i Anomalies of auriculo-ven- tricular orifices, 970 of valve-segments, 972 Anorexia, hysterical. 735 in chicken-pox, 1,56 in measles, 120 in typhoid fever, 197 in vaccinia, 174 Anterior fontanelle, ossifica- tion of, 13 region of neck, anatomy of, 872 Antifebrin in diabetes insipi- dus, 1006 in diabetes mellitus, 1004 in tuberculosis, 302 Antihygienic conditions in eti- ology of rachitis, 323 Antipyretics, dangers of, 36 in erysipelas, 229 in measles, 129 in tuberculosis, .302 in typhoid fev^er, 206 in variola, 169 Antipyrine, caution in the use of, 36 in acute follicular tonsillitis, 422 in diabetes insipidus, 1006 in diabetes mellitus, 1004 in epilepsy, 753 in migraine, 720 in pyrexia of broncho-pneu- monia, 912 in tuberculosis, 302 in whooping-cough, 192 Antisepsis in treatment of new-born, 75 Antiseptic alkaline solution, 416 Antiseiitics in dysentery, 494 in subacute milk infection, •183 intestinal, in pernicious au- i lemia, 368 Antitoxines of diphtheria, 266 j .Vnuria, 995 intermittent, in hydrone- phrosis, 1030 INDEX. 1207 Amis, diphtheria of, ,W7 diseases of, 584 fissure of, 58fi occlusion of, complete, 578 stricture of, 587 syphilitic attections of, 584 vegetations or warts of, 585 Aorta, stenosis of, 97’^ Aortic obstructive murmur, 982 regurgitant murmur, 983 regurgitation, 983 prognosis of, 964 stenosis, 982 prognosis of, 984 Apex-beat, altered position of, in disease, 15 position of, in infant, 15 Apex pneumonia, 914 Ajihasia, 659 during acute gastric catarrh, 444 etiology of, 660 from hereditary syphilis, 661 in infantile cerebral palsies, 6,51 in typhoid fever, 200 Aphonia due to ascarides, 527 in hysteria, 735 Aphtha, 309 Aphthae, Bednar’s 400 in simple atrophy, 505 Aphthous ulcer, 400 Apucea, physiological, 76 Apomorphine in broncho-pneu- monia, 910 Apoplexy neonatorum, 74 pulmonary, in new-born, 75 Apparatus for hot-air bath, 1014 Appendicitis, ,509 operation for, after conva- lescence, 516 operations for, 514 Appendix, diseases of. See Cxcuni and Appendix. in congenital hernia, 516 Appetite in chronic gastric ca- tarrh, 449 in chronic intestinal indiges- tion, 468 in chronic peritonitis, 5^8 in simple atrophy, 505 in tuberculous meningitis, 611 in typhoid fever, 206 Arrhythmia, 988 Arrow-root, value of, 22 Arsenic bromide in diabetes mellitus, 1004 in childhood, 36 in chorea, 763 in chronic intestinal indiges- tion, 471 in chronic malaria, 318 in conv^alcscence from vari- ola, 170 in diabetes mellitus, 976 in eczema, 1105 in leukiemia, 376 in lymphatic ansemia, 372 in pernicious anaemia, 367 in psoriasis, 1113 in pulmonary emphysema, 954 in purpura haemorrhagica, 383 in secondary anaemia. 362 in splenic anaemia, 370 Arsenic in tuberculosis, .301 Arterial tension, increased, in chronic interstitial neph- ritis, 1026 trunks, transposition of, 972 Artery, external carotid, liga- tion of, 427 Arthritis in scarlet fever, 140 Arthropathies in syringomy- elia, 813 Arthrospores of Hiippe, 233 Artificial feeding, 21 in etiology of chronic in- testinal indigestion, 468 of gastric catarrh, 441 foods, chemistry of, 47 Asafcetida in constipation, ,500 in croupous pneumonia, 918 in whooping-cough, 191 Ascaris lumbricoides, 524 diagnosis of, .528 habitat of, 525 in cystic and common bile- ducts, 527 methodsof infection by, 526 ova of, ,525 symptoms of, ,526 treatment of, 528 Ascites, .571 diagnosis of, ,572 etiology of, .571 in cirrhosis of liver, treat- ment of, .561 pathology of, 572 physical examination in, 572 prognosis of, 573 symi)toms of, 572 treatment of, 573 Asphyxia from delayed labor, 76 local, 821. See, also, Ray- naud's disease. of the new-born, 75 causes of, 76 complications of labor causing, 76 electricity in, 80 oxygen in, 80 prognosis in, 77 prophylaxis of, 77 recovery after, 77 symptoms of, 76 tracheotomy for, 80 treatment of, 77 partial, causes of, 82 Aspiration in hydronephrosis, 1031 in pleural elTusion, 946 Astasia-abasia, 734 Asthenia in tuberculous menin- gitis, 611 Asthma, bronchial, 9.56 diagnosis of, 9.59 from bronchitis and pneumonia, 9,59 from cardiac asthma, 960 from emphysema, 960 from obstructive dysp- ^ no*a, 959 ' from pleuritic efi'usion, 960 I from pulmonary (edema, I 960 from spasm of dia- phragm, 960 from urwmic dyspmea, 9(i0 Asthma, bronchial, etiology of, 956 pathology of, 9,57 physical signs in, 959 prognosis of, 959 symptoms of, 9.58 theories regarding nature of, 957 treatment of, 960 Milarii, rachiticum, thymicum Koppii. See Lar- yngismua stridulus. uriemic, treatment of, 1023 Astigmatism, 1202 in etiology of phlyctenular k e r a t o-conjunctivitis, 1193 Astringents in subacute milk infection, 483 Astrophobia, 704 Ataxia, hereditary, 815 diagnosis of, 819 etiology of, 815 morbid anatomy of, 817 symptoms of, 817 treatment of, 819 with tumors of spinal cord, 803 Atelectasis during bronchitis, 926 in whooping-cough, 187 post-natal, 899 diagnosis of, 901 from acute miliary tu- berculosis, 902 from pleuritic effusion, 902 from pneumonia, 901 etiology of, 899 pathology and morbid anatomy of, 899 physical signs of, 901 prognosis of, 902 symptoms of, 900 treatment of, 902 Athetoid affections in idiots and imbeciles, 694 Athetosis, 694 diagnosis of, 696 from post-hemiplegic cho- rea, 696 etiology of, 695 in infantile cerebral palsies, 654 pathology of, 69.5 prognosis of, 696 symptoms of, 694 treatment of, 695 Atresia ani urethralis, 583 yaginalis, .582 yesicalis, 582 congenital, of auditory me- atus, 1165 of pulmonary orifice and artery, 971 Ati'ophies of skin, 1135 Atropliy in acute s])inal lepto- meningitis, 780 in knee-joint disease, 1077 muscular, in hereditary ataxia, 818 ^of coujunctiya, 1192 simple, .503 batliing in, ,507 diagnosis of, .506 from syphilis, .506 1208 INDEX. Atrojihy, simple, diagnosis of, from tubercular menin- gitis, 50() from tuberculosis, 50fi etiology of, 503 morbid anatomy of, 504 prognosis of, 50f> symptoms of, 505 treatment of, 507 Atropine in atelectasis, 903 in interstitial keratitis, 1197 in night-sweats, 302 in ophthalmia neonatorum, 1187 in phlyctenular kerato-con- juuctivitis, 1193 in simple corneal ulcer, 1195 Attenuauts, dextrinized, 50 in artificial feeding, 25 Attenuation, barley-water in, 50 gelatin in, 50 oatmeal water in, 50 of milk, 50 Attic, tympanic inflammation of, 1169 Attitude in pseudo-hyper- trophic paralysis, 769 Auditory canal, caries of wall of, 1165 direction of, in infancy, 1167 Aura in epilepsy, 749 in hysteria. 730 Auricle, congenital malforma- tions of, 1160 lesions of, from ear-piercing, 1160 minuteness of, 1160 position of, in diagnosis of mastoid involvement, 1170 supernumerary, 1160 Auriculo-ventricular orifices, anomalies of, 970 Auscultation of chest, 15 in emphysema, 15 in pleurisy, 15 in pneumonia, 15 of heart. 16 Auvard’s incubator, 80 Bacilli in meconium, 472 of pseudo-diphtheria, 253 Bacillus in bronchitis, 926 in measles, 118 of cholera. See SpinUuru cholerse Asiaticee. of El)erth, 195 of foot-and-mouth disease of cattle, 399 of Friedliinder in croupous pneumonia, 914 in broncho-pneumonia, 904 of influenza in croupous imeumonia, 914 of Klehs-Lbfiler, 2.52 of Letzcrich, 373 of Lustgarten in .syphilis, 103 of tuberculosis in tuberculous meningitis, 610 of ty])hoid fever, 195 parotidis, 17H scarlatina;, 134 tuberculosis, 271 anatomical changes pro- duced by, 277 Bacillus tuberculosis, biology of, 272 distribution of, 272 in broncho-))neumonia, 904 in fibroid phthisis, 964 in lupus vulgaris, 1139 in pleural elfusiou, 940 in urine, 281 method of staining, 271 tussis eonvulsiv®, 184 Backache in variola, 164 Backward children, 6(>S Bacteria, absence of, in milk, 39 in acute milk infection, 475 in diarrhoea, varieties of, 4,54 in stomatitis gangrsenosa, 405 in stool of healthy infant. 4,54 multiplication of, in milk, 39 jiresence of, in milk, 39 toxicogeuic, in milk infec- tion, 472 Bacterium coli commune, 454 in normal stools, 472 feetidum in bromidrosis, 1093 in iiarotitis, 178 lactis aerogel) es, 454 in normal stools, 472 Ball’s incision, 580 Bandage, abdominal, for in- fants, 34 Barlev-water, preparation of, ‘23 “ Barrel-shaped ” chest, 472 Basham’s mixture in ascites, 573 Bath, ])ermanent, Wiuckel’s, 80 temperature of, in childhood, 33 in infancy, 33 the cold, 33 the cooled, 33 the hot, 33 Bathing, 18 frequency of, 32 hour for, 33 in chronic gastric catarrh, 4.50 in hot weather, 33 in rachitis, 343 in simple atrojihy, 507 Baths in broncho-pneumonia, 912 in croupous pneumonia, 918 in eclamjisia, 745 in insanity, 708 in laryngismus stridulus, 863 in measles, 129 in Raynaud’s disease, 824 in variola, 169 Bath-tub, Winckel’s, 80 Battledore-hands in acromeg- , aly, 691 Bednar’s aphtha;, 400 Bed-sores in acute myelitis, 785 in typhoid fever, 207 with tumors of spinal cord, 803 Bed-wetting. See Urine, incon- tinence of. in gravel, l(io8 Beef-iieptonoids in I’ott’s dis- ease. 1008 Beef-tea. formuhi for, 25 Belladonna, iidniinistration of, in cliil conditions of infection in, 235 definition of, 231 diagnosis of, 242 etiology of, 231 foudroyant attacks of, 241 modes of infection in, 234 non-contagious attacks of, 236 personal hygiene during epidemics of, 249 prognosis of, 243 prophylaxis of, 248 secondary septic fever in, 241 special complications of, 242 special phases of. 241 symptoms of, 236 Cholera Asiatica, .symptoms of, iu algid stage, 240 in period of reaction, 240 f* iu period of serous evac- uations, 237 in prodromal period, 237 treatment of, 243 in algid stage, 248 iu period of reaction, 248 iu prodromal period, 244 in stage of serous diar- rh3 classification of, 463 Diathesis, scrofulous, 276 tuberculous, 276 characteristics of, 15 Diet in acute gastric catarrh, 446 in acute tubal nephritis, 1017 in asthma, 961 in broncho-pneumonia, 910 in chicken-pox, 161 in chronic gastric catarrh, 4.50 in chronic intestinal indiges- tion, 470 in chronic peritonitis, 569 Diet in chronic tubal nephritis, 1022 in cirrhosis of liver, .5,59 in croupous imeumouia, 918 in diabetes mellitus, 1002 in diphtheria, 261 in dysentery, 492 in eczema, 1104 in erysipelas, 229 in etiology of secondary anaemia, 360 of vesical calculus, 1040 in functional att'ectious of heart, 989 ' in gonorrhoea. 10.54 in inttuenza, 219 in jaundice, 547 in laryngismus stridulus, 864 in lithtemia. 99 in lithiasis, 1010 in measles, 127 in peritonitis, 566 in prophylaxis of stone, 1044 in pulmonarv emphvsema, 954 in rachitis. 344 in rheumatism, 3.56 in scarlet fever, 145 in simple atro|)hy, 507 in typhlitis, 513 in whooping-cough, 190 of infant in health, 29 tables of, 29, 30 water in, 30 Diffuse nephritis, chronic. See Nephritis, chronic tubal. trachoma, 1190 Digestion of cow’s milk, 46 Digitalis in acute endocarditis, 980 in acute tubal nephritis, 1017 in croupous pneumonia, 918 in chronic heart disease, 984 in chronic tubal nephritis, 1023 in diphtheria, ‘.^1 in functional heart affections, 989 in malignant measles, 128 in pericarditis, 976 in peritonitis, .567 in pleurisy, 946 in scarlatinal nephritis, 148 in typhoid fever, 207 Dilatation in treatment of ad- herent prepuce, 1058 of heart in scarlatinal neph- ritis, 143 Diphtheria, 2.50 antitoxines of, 266, 269 ascending, of trachea and larynx, 2.58 bacteriology of, 252 complicated by ])arotitis, 178 complicating other disea.ses, 259 definition of, 2,50 diagnosis of, from catarrhal and spasmodic laryngitis, 2.57 from other pseudo-mem- branes, 255 from simi)le follicular amygdalitis, 256 disinfection in, 260 etiology of, 2,50 Diphtheria, general disease the- ory of, 251 incubation of, 253 in etiology of chronic tubal nephritis, 1019 in typhoid fever, 199 intubation in, 267 Klebs-Lofller bacilli in, 266 laryngeal, 266 local pathological changes in, 254 local treatment of, 263 mode of infection and prop- agation of, 253 mortality of, 260 nasal, in .scarlet fever, 144 naso-phai'yngeal, 266 of anus, 588 of bronchi, 259 of conjunctiva, 258 of larynx, 257 of uares, 257 of pharynx and mouth, 257 of tonsils, 256 prognosis of, 259 prophylaxis of, 260 sequelae of, 259 streptococci in, 266 symptoms and diagnosis of, 2.55 synopsis of treatment of, 268 treatment of, 261 of albuminuria of, 266 of anaemia following, 266 unfavorable prognostic signs in, 260 with pertussis, 188 Diphtheritic sore throat, 418 Diplococcus in normal urethra, 1054 pneumonia;. See Pneumococ- cus. in pleurisy, 938 I scarlatina; sanguinis, 134 Diplopia, monocular, in hys- teria, 734 Dipsomania, 703 Discharge in chronic suppura- tion of middle ear, 1171 in ophthalmia neonatorum, 1186 Disease, appearance of the skin in, 5 Buhl's, 92 clinical investigation of, 1 cough in, 6 cry in, 6 decubitus in, 4 exi)ression of the face in, 3 fa'cal eviicuations in, 8 features of, 3 mode of drinking in, 6 temperature in, 12 urine in, 8 Winckcl’s, 92 Disinfection after purpura ha'inorrhagica, 384 against seat- worms, 532 during pertussis, 190 in acute milk infection, 479 in cholera, 248 in intluenza, 219 in malignant measles, 130 in scarlet fever, 149 in variola, 170 of intubation-tiibes, 897 of skin in variola, 169 INDEX. 1215 Disinfection of typhoid dejec- tions, ‘^07 Dislocation of iiij), congenital, 1080 diagnosis of, 1082 etiology of, 1082 prognosis of, 1083 symptoms of, 1082 treatment of, 1083 at birth, treatment of, 85 in utero, causes of, 84 Displacement of viscera in pleurisy, 042 Disseminated sclerosis in he- reditary syphilis, 647 Dissociation symptom of syrin- gomyelia, 812 Distich iasis, treatment of, 1182 Diuretic pill, compound, 985 Diuretics in chronic tubal nephritis, 1023 Diuretin in scarlatinal nephri- tis, 148 Dolichocephalic idiocy, 671 Douche in atrophic rhinitis, 836 Dover’s powder in phthisis, 302 in pleurisy, 946 Drainage, permanent, in asci- tes, .574 Dried-blood test for typhoid fever, 205 Drinking, mode of, in disease, 6 in disease of throat, 6 in pneumonia, 6 in severe bronchitis, 6 in soreness of mouth, 6 Drinking-water in etiology of amoebic dysentery, 490 of dysentery, 486 Drinks in diabetic diet, 1003 Drop-foot in acute poliomyeli- tis, 793 Dropsy. See (Edema. in acute tubal nephritis, 1012 in chronic tubal nephritis, 1019 of the brain, 624. See Hydro- cephalus. Drowsiness in jaundice, 543 in measles, 120 Drugs in etiology of acute tubal nephritis, 1011 Drum-head. See Drum-mem- brane. Drum-membrane, distention of, 1167 in childhood, misapprehen- sions concerning, 1167 incision of, 1168 retraction of, in chronic tym- panic catarrh, 1175 Dry cases of tracheotomy, 882 catarrh, 833 cups in epidemic cerebro- spinal meningitis, 213 pleurisy, 935 Dryness of tissues in diabetes mellitus, 1000 Ductus arteriosus, persistence of, 971 diagnosis of, 972 Duke’s method of artificial respiration, 79 Dulness, area of, in pericardial effusion, 975 movable, in pleui-al effusion, value of, in children, 943 Dulness of liver, superior border of, 16 Duodenum, condition of, in ty- phoid fever, 196 Dysiesthesia in Landry’s paral- ysis, 799 Dysentery, 48.5 amudjic, 490 diagnosis of, 491 lesions of liver in, 490 morbid anatomy of, 490 I)rognosis of, 491 symptoms of, 491 catarrhal, 485 absence of specific germ in, 486 diagnosis of, 489 etiology of, 485 improper feeding in, eti- ology of, 486 microscopic appearances in, 487 prognosis of, 489 symptoms of, 488 diphtheritic, 491 microscopical appearances in, 491 disinfection in, 492 hygiene of. 492 in scarlet fever, 140 morbid anatomy of, 486 prophylaxis of, 492 treatment of, 492 varieties of, 485 Dyslexia, 659 - Dysj)epsia, acute. See Gastric catarrh, acute. Dysphagia in Landry’s paraly- sis, 799 Dysphrasia, 6.59 Dyspnoea, expiratory, 10 causes of, 10 in aortic stenosis, 982 in asthma, 9.58 in bronchitis, 929 in broncho-pneumonia, 906 in chronic heart-disease, 981 in fibroid phthisis, 965 in lenkamia, 374 t in lymphatic ansemia, 371 in marked laryngeal stenosis, 10 in mitral stenosis. 982 in pericarditis, 975 in pleurisy, 941 in ])rogressive pernicious anaemia, 365 in pulmonarv tuberculosis, 296 in secondary anaemia, .361 in spasmodic laryngitis, 840 inspiratory, causes of, 10 in substantive emphysema, 953 Dystochia from hydronephro- sis, 1029 Ear, anatomy of. 1167 diseases of, 1158 importance of, 11.58 embryology of, 11,58 external, affections of, 11,59 internal, affections of, 1175 middle, acute simple iutlam- mation of, 1166 affections of, 1166 chronic catarrh of, 1174 Ear, middle, chronic su])pura- tion of, 1170 treatment of eczema of, 1109 treatment of, method of hold- ing child in, 1159 Earache, a symptom, 1166 Eberth’s bacillus, 195 Ecchymosis in cholera, 239 of conjunctiva, 1191 of eyelids, 1184 treatment of, 1184 Echinococcus cyst of brain, 636 Echolalia, 661 Eclampsia, 741 diagnosis of, 745 etiology of, 742 in chronic constipation, 498 in lithsemia, 98 in prognosis of scarlatina, 144 in rachitis, 341 pathology of, 743 prognosis of, 744 seat of origin of, 741 symptoms of, 744 treatment of, 745 Ectopia cordis, 973 Ectropion, 1183 Eczema, 1100 after vaccination, 175 associated with asthma, 957 diagnosis of, 1 103 from papular urticaria, 1 103 from pediculosis capillitii, 1104 from scabies, 1103 from syi)hilodermata, 1103 etiology of, 1102 in lithsemia, 99 intertrigo, 1102 treatment of, 1110 marginal, of lids, 1179 of ears, treatment of, 1109 of face, treatment of, 1109 of lids, treatment of, 1110 of scalp, treatment of, 1109 prognosis of, 1109 resemblance of, to mucous catarrhs, 1101 rubruin or madidans, 1101 seborrhceal, 1091 squamosum, 1101 treatment of, 1104 of regional forms of, 1109 Eczematous inflammations of auricle, 1160 Education in moral imbecility, 679 Educational treatment of idiocy, 678 Effusion, pleural, diagnosis of, 943 diagnostic nse of hypo- dermic needle in, 943 Eggs in diabetic diet, 1003 in lithfemic diet, 99 Ehrlich’s reaction in acute tu- berculosis, 281 test, in children, 200 EichofTs thymol soap, 1103 Elbow-joint disease, 1080 diagnosis of, 1080 prognosis of, 1080 symptoms of, 1080 treatment of, 1081 12KJ INDEX. Elateriuni in clironic tubal neplnitis, 1023 Electric cataphoresis in tinea tonsurans, 1154 Electrical excitability in tet- any, 765 Electricity in acute poliomy- elitis, 794 in incontinence of urine, 997 in infantile cerebral palsies, 657 in nsevus vascularis, 1138 Electrization of stomach in mucous disease, 461 Electro-cautery in hypertro- phic rhinitis, 833 Electrolysis in treatment of lu])us vulgaris, 1142 of molluscum epitheliale, 1130 of nsevus pigmentosus, 1132 of verruca, 1131 Elongation of uvula, 471 Emaciation in hydrocephalus, 627 in tuberculous meningitis, 611, 618 in typhoid fever, 198 rapid, in diabetes mellitus, 1000 Embolism in acute endocar- ditis, 978 in infantile cei'ebral palsies, 6.56 of brain in rheumatism, 353 Embryocardia, 988 Embryonine, 1002 Emetics in broncho-pneumo- nia, 911 in eclampsia, 745 Emotioirs in etiology of hys- teria, 729 Emphysema, compensatory, 950 etiology of, 950 pathology of, 951 symptoms of, 951 treatmeirt of, 953 in pertussis, 188 interstitial, 9.50 of eyelids, 1184 pulmonary, 9,50 subi)leurai, complicating broircho-pneumonia, 918 substantive, 951 etiirlogy of, 951 pathology of, 951 physical signs of, 9.53 prognosis of, 9.5.3 sym])toms of, 953 treatment of, 9,53 surgical, after tracheotomy, "886 vesicular or alveolar, 9.50 Emprosthotoiros in cerebro- siunal meningitis, 210 Empyema, 935 in etiology of pericarditis, 975 in ])crtussis, 187 in scarlatinal neiihritis, 142 necessitatis, 946 of antrum in etiology of nasal myxomata, 841 perforation of, 945 Enamel-germ. 410 Endemic ci'etinism, 684 Endocardial murmurs iir rheu- matism, 352 Endocarditis, acute, 977 etiology of, 977 physical signs of, 978 prognosis of, 979 symptoms of, 978 treatment of, 980 with old valvular lesions, 979 during scleroderma, 1133 in diphtheria, 256 in rheumatism, 3.52 in scarlatinal nephritis, 143 in typhoid fever, 201 in variola, 167 relation of, to chorea, 978 ulcerative, .353 Enemata against seat-worms, 532 in chronic intestinal indi- gestion, 471 in constipation, 499 in prola])se hilis, 645 in hydrocepiialus, 626 in infantile cerebral palsies, 653 morbid anatomy of, 748 motor symptoms of, 749 pall lology of, 748 ))rognosis of, 7.52 sym])foms of, 749 psychic, 7.50 ,s<'nsory. 749 treatment of, 7.52 varieties of, 751 Epileptic headache, 722 insanity, treatment of, 710 Epileptogenctic centres, 742 Epileptoid period of hysteria, 730 Epiphora in diseases of lachry- mal sac, 1199 Epiphyseal swelling in syphilis, diagnosis of, from rickets, 107 Epiphyseo-diaphyseal separa- tion in hei'editary sjihv- ilis, 107 Epistaxis in chronic heart dis- ease, 981 in hsemophilia, 377 in measles, 124 in typhoid fever, 197, 198 Epithelioid cells, 278 Ejistein’s apparatus for bowel- washing, 460 Ergot in cerebro-spinal men- ingitis, 608 in diabetes insipidus, 1006 in diabetes mellitus, 1004 in e])idemic cerebro-spinal meningitis, 213 in incontinence of urine, 998 in Landry’s i)aralysis, 800 Ergotine in gastro-intestinal ha-morrhage, 87 in ha;morrhage of typhoid fever, 207 in scarlatinal nephritis, 148 Erotomania, 703 Eruption of cerebro-spinal men- ingitis, 211 of chicken-pox. 156 of erysipelas, 226 of rubella, 153 of scarlet fever. 137 of typhoid fever, 199 of variola, 16,5 stage of desiccation of, 16.5 stage of maturation of, 165 upon mucous membranes, l(i5 Eruptions, exanthematous, on eyelids, 1179 in clndera, 242 in diplitheria, 2.59 in measles, 120 in rheumatism, 3.52 in rubella, 153 Erysipelas, 221 after tracbeotomy, .885 after vaccination, 175 Com])lications and sequelffi of, 226 contagiousness of, 223-228 dclinition of, 221 diagnosis of, 227 from acne rosacea, 227 from angcio-neurotic mde- ma, 227 from erythema, 227 from malignant u'deina, 227 from urticaria, 227 ctiidogy of, 221 history of, 221 in eh ieken-pox, 1.59 of auricle. 1100 of new-born, 90, 22.5 INDEX. 1217 Erysipelas, patholosical anat- omy of, 223 prognosis of, 227 I)ulmonary lesions in, 224 symptoms of, 225 therapeutic use of, 229 treatment of, 228 with peritonitis, 564 Erythema annulare, 1098 bullosum, 1098 caloricum, 1096 gyratum, 1098 idiopathic, 1095 infantile, 1097 diagnosis of, from measles, 1098 from rotheln, 1098 from scarlatina, 1098 treatment of, 1098 in rheumatism, 354 intertrigo, 1096 diagnosis of, 1096 treatment of, 1096 in vaccination, 175 iris, 1098 marginatum, 1098 multiforme, 1098 diagnosis of, 1099 etiology of, 1099 prognosis of, 1099 treatment of, 1099 nodosum, 1099 of buttocks in subacute milk infection, 481 of legs in typhoid fever, 199 pernio, 1096 treatment of, 1097 relapsing scarlatiuiform, 1100 diagnosis of, 1100 from scarlatina, 1100 treatment of, 1100 simplex, 1095 symptomatic, 1097 traumaticum, 1096 tuberculatum, 1098 veuenatum, 1096 vesiculosum, 1098 Erythematous syphiloderm, 1143 Eseriue in ophthalmia neona- torum, 1187 in phlyctenular kerato-con- junctivitis, 1193 Essential shrinking of con- junctiva, 1192 Estlander’s operation, 948 Etat mamelonne, 447 Ethmoiditis, necrosing, in eti- ology of nasal myxomata, 841 Ethyl iodide in asthma, 961 Eucalyptol in tuberculosis, 302 Eucalyptus in malaria, 318 Eustachian tube, formation of, 1158 Evacuation of bowels during urination in vesical cal- culus, 1042 Exalgin in chorea, 762 Examination of the mouth and fauces, 17 Exanthemata in etiology of acute tubal nephritis, 1011 of bronchitis, 924 of chronic peritonitis, 568 77 Exanthemata in etiology of middle-car inflammation, 1166 Exanthematous eruption on eyelids, 1179 Excision in treatment of ad- herent prepuce, 1058 Exercise, 35 hours for, 3,57 in chronic gastric catarrh, 451 in chronic heart disease, 984 in convalescence from acute nephritis, 1018 in etiology of paroxysmal hsematuria, 994 in functional atfections of heart, 990 in lithiemia, 100 in pseudo-hypertrophic mus- cular paralysis, 773 in pulmonary emphysema, 953 Expectoration in asthma, 958 in bronchitis, 928 in broncho-pneumonia, 907 in croupous pneumonia, 915 in fibroid phthisis, 965 in gangrene of lung, 922 in measles, 120 Expiratorv dyspnoea, causes of, 10 respiration, character of, 10 significance of. 10 theory of compensatory em- physema, 950 of substantive emphysema, 9.52 Exploratory incision in chronic peritonitis, 570 Exploring needle in appendi- citis, 514 Exposure in etiology of acute gastric catarrh, 442 of rheumatism, 351 External ear, afl'ectious of, 11.59 Extra-cellular pigmented bod- ies in malaria, 306 Exudate in infectious pseudo- membranous tonsillitis, 418 Exudates, pleural, chemical composition of, 937 interchange of fluids in, 937 without microbic elements, 939 Eye, diseases of, 1178 refraction of, in childhood, 1201 Eyelid, furuncle of, treatment of, 1178 Eyelids, abscess of, 1178 diseases of, 1 178 ecchymosis of, 1184 emphysema of, 1184 injuries of, 1184 syphilis of, 1180 tumors and hypertrophies of, 1180 Eves, treatment of, in measles, 128 Eye-strain in migraine, 721 Eye-symptoms of hydroceph- alus. 626 Face, expression of, in health and disease, 3 treatment of eczema of, 1109 Facial hemiatrophy, progres- sive, 775 symptoms of, 776 treatment of, 776 nerve, obstetric paralysis of, 83 paralysis of, 774 diagnosis of, 775 etiology of, 774 in otitis media, 1117 in tuberculous meningitis, 617 symptoms of, 774 treatment of, 775 phenomenon in tetany, 766 Facies in asthma, 958 in bronchitis, 929 in hereditary ataxia, 818 in suppurative hepatitis, 554 in typhoid fever, 197 Fsecal accumulation, diagnosis of, 14 evacuations in catarrhal ul- ceration of the intestines, 8 in diarrhoea of sucklings, 8 in disease, 8 in dysentery, 8 in entero-colitis, 8 in follicular enteritis, 8 in health. 8 in helminthiasis, 8 in indigestion, 8 in intestinal catarrh, 8 in tubercular disease, 8 in tuberculous ulceration of the intestines, 8 in tyidioid lever. 8 Fseces in jaundice, .543 incontinence of, in tubercu- lous meningitis, 618 Failure of heart, sudden, in diphtheria, 256 sources of, in sounding for stone, 1044 Fall fever. See Ti/phoid fever. Fallopian tube, tuberculosis of, 299 Famdism in simide jaundice of infants, 545 Farinaceous food, when per- missible, 22 Fascia, cervical, deep, 872 superficial, 872 Fascicular keratitis, 1193 Fasciotomy in club-foot, 1084 Fat, deficiency of, in food of rachitics, 323 in human milk, 44 in milk, 46 relative size of globules of, 46 percentage of, in modified milk, ,5.5 Fatty calculus, 1038 degeneration, acute, of new- born, 92 Fauces, appearance of, in health, 17 ascarides in, 527 examination of, 17 Favus, 1148. .See Tinea fa- vosa. Features of disease, 3 1218 INDEX. Febrile and post-febrile insan- ity, 70fi Feeble-mindeduess in infantile cerebral palsies, 654 Feeding, 18 after tracheotomy, 884 artificial, 21 asses’ milk in, 25 attenuants in, 23 bicarbonate of sodium in, 23 goat’s milk in 25 lime-water in, 25 method of preparation in, 23 mode of administration of, 30 modified milk in, 55 peptonization in, 25 position of child in, 31 preservation of milk for, 31 quantity of food for, 22 rules for, 21 selection of food for, 21 of milk for, 31 “ strippings ” in, 25 substitutes for milk in, 28 sugar of milk in, 23 table for, 24 vomiting in, 25 by wet-nurse, 20 from maternal breast, 18 duration of, 18 improper, in etiology of acute intestinal indigestion, 46,5 in acute milk infection, 478 in insanity, 708 ill tuberculosis, 301 mixed, 1!) Feet, enlargement of, in acro- megaly, 691 Fehleisen, streptococcus of, 223 Fehling’s solution, composition of, 1000 qualitative test by, 1000 quantitative test by, 1001 Femur, changes in, in rachitis, 337 fracture of, at birth, 85 Fenestrated spring forceps for circumcision, 1059 Fermentation, butyric, 45 reaction of, 45 intestinal, in lithaimia, 97 lactic, 45 bacteria in, 44 test for sugar, 1001 Ferrum dialysatiim in chronic tubal nephritis, 1023 Fetor in atrophic rhinitis, 834 Fever. .See Temperature. ill rbeiimatism, 352 in scurvy, .392 scarlet. See Scarlet fever. tyiihoid. .See Typhoid fever. Fever-blister. See Herpes sim- plex. “ Feverish ” breath, 7 Fibrinous calculus, 1038 exudates in scarlatina, 139 diagnosis of, from diph- theria, 139 jileiirisy, 936 Fibroid limitation of tubercle, 278 phthisis. See Phthisis, fibroid. Fibrous deposits in chronic tympanic catarrh, 1175 nodules in rheumatism, 3.54, 978 Fibula, changes in, in rachitis, 337 Fievre dothienenterie, 194 iufectieuse tuberculeuse sur a'lgue, 280 Filaria sanguinis hominis a cause of chyluria, 995 a cause of lia-matiiria, 993 Fish in diabetic diet, 1003 Fissure of anus, .586 Fistula, fa'cal, 576 after appendicitis, 515 in ano, .585 treatment of, 586 of lachrymal sac, 1200 Fistute, perineal, in congenital malformation of rectum, 581 Flagellate bodies in tertian malaria, 306 “ Flat-chest,” 432 “ Flat-nose,” 842 Flatulency in chronic intesti- nal indigestion, 468 Flesh, loss of, in tuberculous meningitis, 611 Flour-ball, 51 preparation of, 24 Fluid in hydronephrosis, 1030 Fluorescine in diagnosis of cor- neal abrasion, 1197 Focal epilepsy, 747 symptoms in brain abscess, 632 Foetal bead, compression of, 83 rachitis, 322 Foetus, rachitic, description of, 330 Follicular amygdalitis, diph- theritic nature of, 251 trachoma, 1190 ulceration of bowel, 481 Fontanel le, anterior, ossifica- tion of, 13 bruit of, in rachitis, 339 bulging of, 13 deiiressed, in chronic gastric catarrh, 448 in sinqile atrophy, 505 late closure of, in rickets, 331 puncture of, in hydroceph- alus, 628 Food, average (luantity of, for infants, 346 daily average of, for children, 346 daily ()uantity of, 22 in etiology of rachitis, 323 insufficiency of, ,503 in treatment of constipation, 499 Food and drink admissible in diabetes mellitus, 1003 Foods, artificial, chemistry of, 47 comparison of, 52 predigested, 29 to be avoided in diabetic diet, 1003 Fonunen ovale, patency of, 968 cause of, 969 Forceps, obstetric, injuries from, 83 Forceps, obstetric, limitations of, 83 precautions in using, 83 Foreign bodies in auditory canal, 1163 treatment of, 1164 in caecum or appendix, 509 in cornea, 1197 in larynx, trachea, and bronchi, 865 diagnosis of, 866 from acute laryngitis, 866 from laryngeal obstruc- tion by lymphatic en- largement, 867 from ce.dema of glottis, 867 prognosis of, 867 symptoms of, 865 treatment of, 867 in rectum, .595 body, impaction of, in tym- panum, 1165 Forest’s method of artificial respiration, 79 Fractures att birth, prognosis and treatment of, 85 in utero, 85 Frank pneumonia and typhoid fever, difl'erential diag- nosis of, 204 Freckles. See Lentigo. Fremitus, hydatid, in renal cysts, 1028 vocal, in broncho-pneumonia, 908 French measles. See Rubella. Fresh air in rachitis, 343 in tuberculosis, 300 Friction in massage, .57 Friction-sound in pleurisy, 942 in pericarditis, 975 Friedreich's disease, 815. See, also, Ataxia, hereditary. Friedrichshall water in jaun- dice, .547 Fromentine in diabetes, 1002 Fruobjabr’s catarrh, 1189 Fruits in diabetic diet, 1003 in lithaunic diet, 99, 100 Fuebsin, Ziehl’s solution of, 271 Fundus oculi, luemorrbages in, in leukiemia, 374 Fungus of favus, microscopy of, 1149 of tinea tricopbytina, 11.52 Furuncle of auditory canal, 1161 treatment of, 1125-1161 of eyelids, 1178 Furunculosis, 1124 in chicken-pox, 1.59 in tyi)boid fever, 199 ])ost-eczematous, 1101 Furnnculus, 1123 diagnosis of, 1124 from carbuncle, 1124 from s.vidiiloderm, 1124 etiology of, 1124 l)rognosis of, 1124 treatment of, 1124 Gait in hereditary ataxia, 818 in idiocy, <>74 in I’ott’s disea.se, 1066 (Jallie acid in diabetes insi])- idus, 1006 INDEX. 1219 Gallic acid in hajiuorrhage of typhoid fever, ‘iOT Galton whistle in diagno.sis of aural disease, 117(i Galvanism in alopecia areata, 1137 in constipation, 502 in diabetes insipidus, 1006 in Raynaud’s disease, 824 Galvano-cautery in lupus, 1142 in stomatitis mycosa, 407 in ulcer of cornea, 1195 -puncture in enlarged tonsils, 423 Gangrene, diabetic, rarity of, in children, 1000 in parotitis, 180 in vaccinia, 175 of lung, 919 etiology of, 919 following broncho - pneu- monia, 90(1-908 in tuberculosis, 920 pathology, 921 symptoms of, 921 treatment of, 923 with chronic • bronchitis, 920 with septic processes of ear, 920 with ulcerations in month, 920 symmetrical, 822, See, also, Raynaud’s disease. Gangrenous varicella, 160 Gastric catarrh, acute, 441 diagnosis of, 444 from meningitis, 444 from pneumonia, 444 from scarlet fever, 444 from typhoid fever, 444 etiology of, 441 pathology of, 442 prognosis of, 445 symi)toms of, 443 treatment of, 445 chronic, 446 course of, 449 diagnosis of, 449 from typhoid fever, 450 etiology of, 446 in infancy, 448 pathology of, 446 prognosis of, 450 simulating pernicious anae- mia, 449 symptoms of, 447 treatment of, 450 fever. See Typhoid fever. juice, action of, on milk, 21 ulcer, 452 etiology of, 452 prognosis of, 453 symptoms of, 452 treatment of, 453 Gastritis, atrophic, 450 chronic glandular. See Gas- tric catarrh, chronic. mucous, 450 simple, 449 Gastro-adenitis, 441 See, also. Gastric catarrh, acute. Gastro-intestinal catarrh. See Millc infection, subacute. chronic. See Mucous dis- ease. tubei'culosis following, 282 Gastro-intestinal disorderin eti- ology of eclampsia, 542 of laryngismus, 8.59 of urticaria, 1120 haemorrhage, 86 Gastro-malacia, 4.53 Gavage in dysentery, 492 Gelatin, preparation of, 23 Gelseniiuin in chronic bleph- arospasm, 1181 General development, 12 in health, 12 of the new-born child, 12 management of children, 18 Genital organs, involvement of, in parotitis, 180 Genu valgum, treatment of, 1088 Geratubungen, 55 German measles. See Rubella. Germicidal drugs in acute milk infection, 479 Giant-cells in tubercle, 278 Giddiness in brain abscess, 632 in cerebro-spinal meningitis, 209 Girdle sensation in acute mye- litis, 784 in tumors of spinal cord, 802 Glands, anterior mediastinal, tuberculosis of, 284 axillary, swelling of, in vac- cinia, 174 bronchial, enlargement of, in etiology of bronchitis, 925 enlargement of, in measles, 122 tuberculosis of, 284 cardiac, tuberculosis of, 284 disorders of, 1091 enlargement of, in lymphatic aiiiemia, .371 in rubella, 154 inguinal, enlargement of, in milk infection, 481 swelling of, in vaccinia, 174 in measles, 120 intercostal, tuberculosis of, 284 Ivmphatic, enlargement of, 13 in leukaemia, 375 mesenteric, tuberculosis of, 286 posterior mediastinal, tuber- culosis of, 284 sternal, tuberculosis of, 284 tracheal, tuberculosis of, 284 tracheo-bronchial, tubercu- losis of, 284 Glandular enlargements after vaccination, 175 in diphtheria, 2.56 with eczema, 1101 Glioma of orbit, 1201 Gliomata of brain and menin- ges, 635 Globus hystericus, 730 Gluten-flour in diabetes, 1002 Glycerin in diuretic formulfe, 1017 Goat’s milk in artificial feed- ing, 25 Goitre with cretinism, 682 Gold and sodium chloride in chronic interstitial neph- ritis, 1026 Gonococcus, diagnostic value of, 1053 of Neisser, 1185 value of, in diagnosis of vul- vo-vaginitis, 1056 Gonorrhcea, ante-partum treat- ment of, 88 in male children, 1053 treatment of, 1054 of month, in new-born, 88 treatment of, 89 Gonorrhoeal infection of new- born, 88 ophthalmia, 88 Gout, American, 94 concealed, 94 in etiology of psoriasis, 1112 of vesical calculus, 1039 Gouty kidney. See Nephritis, chronic interstitial, 1025 Grand movements, period of, in hysteria, 731 Granulations of wound after tracheotomy, 886 Grattage in trachoma, 1191 Gravel in bladder, symptoms of. 1008 in diabetes insipidus, 1006 Green stools in acute intestinal indigestion, 466 in chronic intestinal indi- gestion, 468 Grippe and typhoid fever, dif- ferential diagnosis of, 204 Grisolle sign in variola, 167 Growing pains, 758 Grunting expiration in bron- chitis. 928 prognostic importance of, 930 Gum-lancing, danger of, 413 Gumma, 1144 of brain, 636 of iris, 1198 Gummata in hereditary syph- ilis, 646 Gummatous iritis, 1198 Gums, bleeding of, in scorbutus, 391 condition of, in typhoid fever, 199 Gymnastics in hysteria, 740 in scoliosis, 1064 Habit chorea, 1181 due to eye-strain, 1202 Habits of life in etiology of chlorosis, 362 Hajmatemesis in tuberculosis of the bowels, 28K Hwmatogenous jaundice, 543 in new-born, 92 Hieuiatoma of sterno-cleido- mastoid muscle, 72 HiPinatomata of auricle, 1160 Hiematuria, 991 diagnosis of, from calculi, 992 from cystitis or pvelitis, 992 from hyperamiia of kidney, 992 from icteric urine, 991 1220 INDEX. II®maturia, diagnosis of, from passive hyperaemia, 992 from tuberculosis of blad- der, 992 in acute tubal nephritis, toil in malarial fever, 314 in scarlatinal nephritis, treatment of, 148 in scorbutus, 391 in tumors of kidney, 1036 in vesical calculus, 1042 paroxysmal, 994 Hsemic murmur in secondary anaemia, 361 Haemoglobin, excess of, at birth, 76 percentage of, in chlorosis, 363 proportion of, in infancy, 359 Haemoglobinuria, acute, of new-horn, 92 in erysipelas, 227 in Raynaud’s disease, 822 Haemophilia. 377 etiology of, 377 hereditary transmission of, 377 morhid anatomy of, 377 prognosis of, 378 in females, 378 treatment of, 378 Hicmoptysis in chronic pulmo- nary tuherculosis, 295 in fibroid phthisis, 965 in gangrene of lung, 922 in tuberculosis, 277 Haemorrhage after tonsillot- omy, 426 cerebral, following asphyxia, 74 following labor, 74 forms of, 74 during tracheotomy, 881 fatal, after gum-lancing, 413 after tonsillotomy, 426 from kidney, 992 from mucous surfaces, blood- count in, 82 from vagina, 82 gastro-intestinal, 86 pathology of, 87 in abscission of the tonsils, 426 in infantile cerebral palsies, 6,56 in new-horn, 73 causes of, 74 diagnosis of, 74 etiology of, 73 parenchymatous, 75 prophylaxis of, 75 intestinal, in scorbutus, 391 in typhoid fever, 199 meningeal, in infantile cere- bral palsies, 655 multijdc, following umbilical infection, 73 .secondary, after tracheotomy, 885 sub])eriosteal, in scorbutus, 480 umbilical, 85 treatment of, 86 Ilicmorrbages from mucous sur- faces, 82 Ha?morrhages in cirrhosis of liver, 5.58 treatment of, 560 in jaundice, 544 from obliteration of bile- ducts, 546 in leuka?mia, 374 in {)ertussis, 118 in whooping-cough, 116 of the skin, 1125 punctiform, in pernicious ansemia, 366 Hsemorrhagic infarcts in ty- phoid fever, 196 pleurisy in morbus Werlhofii, 936 in scurvy, 936 H.-emorrhoids, 592 in cirrhosis of liver, .558 Hair, falling out of, in typhoid fever, 198 Halitosis, causes of, 7 Hall’s method of artificial res- piration, 79 Hands, enlargement of, in acromegaly, 691 Harrison’s groove, 326, 335 Head, fcetal, compression of, 83 retraction of, in cerebral meningitis, 599 Headache, 718 diagnosis and prognosis of, 724 etiological varieties of, 723 in acute gastric catarrh, 443 in acute tubal nephritis, 1011 in brain abscess, 632 in brain tumors, 636 in cerebral meningitis, 599 in cerebro-spinal meningitis, 209 in chicken-pox, 151 in chronic gastric catarrh, 447 in erysipelas, 225 in leukiemia, 374 in measles, 119 in tuberculous meningitis, 611, 612 in typhoid fever, 197 in variola, 164 mechanism of, 718 persistent, in hereditary syphilis, 645 treatment of, 725 vertical, in chlorosis, .363 with tumors of spinal cord, 804 Headaches due to organic dis- ease, 721 from eye-strain, 1202 Head-banging, 713 Head-louse, 11.56 Head-nodding and head-jerk- ing, 713 Hearing, mechanical aids to, 1049 Heart, congenital aU’ections of, 9()8 symptoms of, 973 treatment of, 973 disease in etiology of chronic gastric catarrh, i)91 chronic, t)81 clinical history of, 981 etiology of, il81 ])rognosis of, !»83 Heart disease, chronic, symp- toms of, 981 treatment of, 984 functional afl'ections of, 986 course of, 989 diagnosis of, 989 etiology of, 986 prognosis of, 989 symptoms of, 987 treatment of, 989 in diphtheria, 2.54 in typhoid fever, 200 irregularity of, during sleep, 987 lesions of, in typhoid fever, 197 obstructive lesions of, in etiology of bronchitis, 925 organic diseases of, 974 peculiarities of, in childhood, 974 rapid, 988 relative ■weight of, 974 slow, 988 syphilis of, 106 Heart -action, irregularity of, in children, 987 Heart-consciousness, 988 Heat in interstitial keratitis, 1197 in ophthalmia neonatorum, 1187 Hebetude in adenoid vegeta- tions, 431 Hebrew race, haunophilia in, 377 Height, increase of, in typhoid fever, lt>8 Hemiamesthesia in hysteria, 733 in tumoi'S of erura cerebri, 641 Hemianopsia in acromegaly, (i91 iu brain tumors, 640 in hysteria, 733 in infantile cerebral palsies, 651 in migraine, 719 Hemicrauia. See Migraine. Hemiplegia from obstetric injury, 83 in hereditary syphilis, 646 in typhoid fever, 200 Henoch’s disease, 384 Hepatitis, suppurative, ,535 diagnosis of. ,554 prognosis of, 555 treatment of, .5.55 with dysentery, .5.55 Hepatogenous jaundice, .543 Hereditary ataxic parajilegia, 815. See, also. Ataxia, hercdilarji. syi)hilis. See Si/ptiitis, hered- itary. Heredity iu etiology of cleft ]>alate, 434 of diabetes mellitus, 999 of eczema, 1102 of hysteria, 728 of laryngismus stridulus, 85i) ‘ of leukiemia, ,373 of lithiemia, !I4 of myotonia, 6.88 INDEX. 1221 Heredity in etiology of pemplii- gus, 1115 of i)seudo-hypertrophic paralysis, 771 of i>soriasis, 1112 of rachitis, 323 of Kaynaud’s disease, 823 of rheumatism, 351 of substantive emphy- sema, 951 of tuberculous meningitis, (>10 of vesical calculus, 1039 Hernia, cajcal, .53(1 umbilical, 86 Herpes facialis. See Herpes simplex. febrilis. See Herpes simplex. iris, 1099 labial is in croupous pneu- monia, 915 of auricle, 1160 simplex, 1116 zoster, 1116, 1117 Herpetic eruptions in typhoid fever, 199 High operation in tracheot- omy, 878 High-arched palate, 430 Hip, congenital dislocation of, 1082 Hip-joint disease, 1072 abscess in treatment of, 1076 ankylosis from, 1081 atro])liy in, 1072 Buck’s extension in, 1074 deformity in, 1072, 1073 diagnosis of, 1072 etiology of, 1072 operative treatment of, 1076 pain in, 1072 pathology of, 1072 premouitorv symptoms of, 13 prognosis of, 1074 sea-air in, 64 symidoms of, 1072 Taylor's hip-splint in, 1074, 1075 treatment of, 1074 Hives. See Urticaria. Hoarseness in chicken-pox, 157 in laryngeal disease, 6 “ Holding-breath ” spells, 340 Holt’s rule for changes in formula of modified milk, .55 Home modifications of cow’s milk, 56 Hordeolum, treatment of, 1178 Horse-pox, vaccination with virus of, 173 Hot bath in acute tubal neph- ritis, 1015 1 douche in acute middle-ear infiammation, 1168 i in chronic suppurating middle ear, 1171 in furuncle of auditory canal, 1161 in suppurating middle ear, 1170 Hot-air bath in acute tubal ne- phritis, 1014 in scarlatinal nephritis, 147 Huguier’s operation, ,580 Humanized milk. 26, 48 analysis of, 49 Humerus, changes in, in ra- chitis, 336 fracture of, ac birth, 85 “ Hunger for oxygen,” 76 Hunyadi water in jaundice, .547 Hutchinson’s teeth, 114 Hydatid cysts of kidney, 1028 diagnosis of, 1029 pathologv and symptoms of, 1028 lu’ognosis of, 1029 treatment of, 1029 fluid from liver, 542 fremitus, 556 of liver, 555 tumor of omentum, 570 Hydriemia in etiology of ascites, 571 Hydragogue cathartics in chronic tubal nephritis, 1023 Hydrencephalic cry, descrip- tion of, 6, 612 Hydrocephalic idiocy, 671 Hydrocephalus. (>24 duration of, 628 etiology of, 625 externus, 624 in hereditary syphilis, 646 internus, 624 morbid anatomy of, 628 symptoms of, 626 treatment of. 628 varieties of, 624 with spina bifida, 627 Hydrochloric acid, deficiency of, in acute gastric catarrh, 443 in cholera, 244 with pepsin, in chronic gastric catarrh, 451 Hydrogen peroxide in acute follicular tonsillitis, 419 in angina of variola, 169 in atroi>hic rhinitis, 836 in chronic suppurating middle ear, 1171 in diphtheria, 264 in eczema of auricle, 1161 in gonorrhoea of mouth, 89 in scarlet fever, 146 in whooping-cough, 192 Hydronephrosis, 1029 diagnosis of, from ascites, 1030 from ov'arian cyst, 1030 from ])yonei)hrosisand peri- nephric .abscess, 1030 from renal cysts. 1030 etiology and i>athology of, 1029 prognosis of, 1031 symptoms of, 1030 treatment of, 1031 Hydrophobophobia, 704 Hyoscine in chorea, 763 in epidemic cerebrospinal meningitis, 213 Hypersesthesia, in acute myel- itis, 784 in cerebro-s])inal meningitis, 211 in hysteria, 732 Hyperaesthesia in Kaynaud’s disease, 821 in simple cerebro-spinal men- ingitis, 606 in tumors of s]>inal cord, 802 in typhoid fever, 200 Hyperalgesia in hysteria, 732 Hyjteridrosis, 1093 etiology of, 1093 prognosis of, 1094 treatment of, 1094 Hypermetropia in infancy and childhood, 1202 Hyperpyrexia in croupous pneumonia, 917 in measles, 129 in rheumatism of children, 352 in scarlet fever, 137 Hypertrophies of skin, 1128 Hypertrophy of fingers, 602 of right heart in fibroid phthisis, 966 of tonsils. See Tonsils, hyper- trophy of. Hypodermic administration of mercury in syphilo- derma, 1146 puncture in diagnosis of pleural eifusion, 944 safety of, in pleurisy, 944 Hvpodermoclysis in cholera, 246 Hypophosphites in tuberculo- sis, 301 Hypopyon keratitis, 1195 Hysteria, 727 diagnosis of, 739 from epilepsy, 739 from organic paralysis, 740 etiology of, 728 interparo.xysmal svmi)toms of, 732 paroxysmal sym])tonis of, 729 statistics of, in children, 728 symptoms of, 729 treatment of, 740 Hysterical headache, 724 Hystero-ei)ilepsy, 7,30 ICHTHYOL in chicken-pox, 161 Ichthyosis, 1128 diagnosis of. 1129 etiology of, 1129 hystrix, 1128 jirognosis of, 1129 simplex, 1128 treatment of, 1129 Icterus neonatorum, 87 physiological, of new-born, 87 Idiocy, 648, 667 accidental, 671 classification of, 670 pathological, 676 congenital, 670 develo])mental, 670 diagnosis of, (>76 etiology of, 673 from hydrocephalus, 626 from obstetric injury, 83 legal definitions of, 668 pathology of, 67.5 prognosis of. 677 sym])toms of, 674 treatment of. 677 Idiotic niyxoBdermateuse. 684 1222 INDEX. Idiots savants, (570 Ignipmicturc in enlarged ton- sils, 423 Ileal intussusception, .517 Ileo-cwcal intussusce]>tion, 517 valve in typlioid fever, 19(5 Ileo-colic intussusception, 517 Ileo-colitis. See Dysentery. Ileum, changes in, in typhoid fever, 190 Ill-temper in tuberculous men- ingitis, (ill, 616 Imbecility, 667, 668 Immunity, artificial, in cholera, 234 in tuberculosis, 277 personal, from cholera, 234 Imperative acts or movements, 703 movements, etiology of, 716 diagnosis of, 716 in defective children, 712 prognosis of, 716 treatment of, 717 Impetigo contagiosa, 1117 after vaccination, 175 diagnosis of, 1119 etiology of, 1118 prognosis of, 1119 relation of, to vaccinia, 1119 treatment of, 1119 Improper feeding in etiology of acute gastric catarrh, 441 Incision and drainage in peri- tonitis, 567 in furuncle of auditory canal, 1161 in perinephritic abscess, 1034 in pleural effusion, 947 disadvantage of, 947 in treatment of hydatid of liver, .557 of hydatids of kidney, 1029 of drum-membrane, 1168 in suppurating middle ear, 1170 Incisions in operations for ap- ]>endicitis, 514 Incontinence of urine, 996 in lithsemia, 96 in tuberculous meningitis, 618 spontaneous cure of, at ]>uherty, 996 treatment of, 997 Incubator, Auvard’s, 80 Indigestion, acute intestinal, 465 etiology t)f. 465 jirognosis of, 166 synonyms of, 465 treatment of, 466 chronic intestinal, 467 diagnosis of, 469 etiology of, 467 l)rognosis of, 468 synonyms of, 467 treatment of, 470 of infants, dietetic treatment of, 29 Indigo ealcnlus, 1038 Indolent corneal ulc(n-s, 1194 Infancy, duration of, 1 Infantile cerebral palsies, 649 Infantile osteomalacia and cre- tinism, 682 paralysis, sea-air in, 65 remittent fever, 194 Infants, chronic constipation in, 497 nursing, wasting in, .504 vaccination of, 176 Infants’ food, value of, 22 Infarcts, ha'morrhagic, in ty- phoid fever, 196 Infection by tubercle bacilli in milk, 286 in utero, 73 by tubercle bacilli, 90 by typhoid bacilli, 90 modes of, in cholera, 234 in measles, 117 of tracheotomy wound, 885 of tvphoid fever by water, 195 septic, of new-born, 89 tbrough umbilicus, 89 prophylaxis of, 89 treatment of, 89 tubercular, of new-born, 90 dog’s serum in, 91 typhoid, of new-born, 90 Infections attacking the new- born, 88 of blood in new-born, 92 Infectious diseases in etiology of pleurisy, 938 with parotitis, 179 Inflammation in intussuscep- tion, 521 sympathetic, of eye, 1199 Inflammations of ,skin, 1095 Inflammatory phenomena in, vaccination. 175 Influenza, epidemic, 214 bacteriology of, 214 circulatory symptoms in, 216 clinical history of, 216 complications and sequelie'of, 217 convalescence from, 219 definition of, 214 diagnosis of, 218 from bronchitis, 218 from meningitis, 218 from pneumonia, 218 from simple catarrh, 218 from tyi>hoid fever, 218 disinfection in, 218 etiology of, 214 gastro-intestinal symptoms in, 217 inctibation of, 215 in etiology of bronchitis, 924 in infants, 215 loss of weight in, 216 nervous symptoms in, 217 pathology of, 215 prognosis and mortality of, 218 respiratory symptoms in, 21 () treatment of, 219 with parotitis, 180 Infusoria in gangrene of lung, 921 Injections in gonorrho'a, 10.54 in intussusception, .521 intravascular, in cholera, 247 Injuries, obstetric, medico-legal aspect of, 83 treatment of, 84 Innutrition in etiology of bron- chitis, 925 Insanity, 697 cataleptic, 701 choreic. 700 circular or alternating, 700 diagnosis of, 707 differences of, in child and adult, 697 epileptic, 701 general etiology of, 707 hysterical, 700 in children, 697 in infants, 697 moral, 702 treatment of, 710 primary delusional, 702 prognosis of, 708 treatment of, 708 varieties of, in children, 698 Insistent idea, 703 Inspection of chest, 15 Inspiration of amuiotic liquid, 76 Inspiration-pneumonia, 76, 91 Inspiratory dyspnoea, 10 causes of, 10 theory of compensatoiy em- physema, 950 of substantive emphysema, 9.52 Instillations into auditory canal, 1169 Instinctive perversions, 702 Insufllation, mouth-to-mouth, 79 Internal ear, affections of, 1175 rarity of, in children, 1175 Interruption of stream in vesi- cal calculus, 1042 Interstitial emphysema, 9.50 keratitis. See Keratitis, in- terstitial. pneumonia. See Phthisis, fibroid. Intertrigo in simple atrophy, 505 Intestinal antiseptics in dysen- tery, 492 in nmcous disease, 459 in typhoid fever, 206 catarrh, chronic. .See Indi- yestinn, chronic intestinal. lavage in acute milk infec- tion, 477 lesion in typhoid fever, 196 parasites. See Par((sites, in- testinal. Intestine, largo, abscess of, 583 Intestines, cbronic diffuse tu- berculosis of, 282 congenital malformations of, 575 tuberculosis of, 286 Intravascular injections in cholera, 247 Intubation of lar.vnx, 891 accidents during and after, 895 after treatment of, 896 feeding after, 896 indications for, 891 in spasmodic l.'iryngitis, 856 INDEX. 1223 Intubation of larynx in steno- sis of larynx, 898 instruments for, 892 position of patient for, 894 preparations for, 893 prognosis in, 891 technique of, 894 unfavorable cases for, 898 Intubation-tubes, disinfection of, 897 removal of, 897 Intussusception, 517 chronic, 520 diagnosis of, 520 from appendicitis, 520 from colic, 520 from dysentery, 520 from enteritis, 520 from faecal impaction, 520 from internal strangula- tion, 520 from suppurative peritoni- tis, .520 etiology of, 518 irreducible, 518 locality of, 517 morbid anatomy of, 518 prognosis of, 520 symptoms of, 519 treatment of, 521 Intussusce])tions, double, 517 triple, 517 Intussusceptum, 517 Intussuscipiens, 517 Invagination of bowel. See Intussusception. “Inward spasms” in simple atrophy, 506 Iodide of iron in bronchial catarrh of rachitis, 347 of potassium in hydroceph- alus, 628 in syphilis, 116 in tuberculous meningitis, 623 Iodides in amyloid kidney, 1025 in rheumatic pleurisy, 357 Iodine in acquired labyrinthine deafness, 1176 in chronic peritonitis, 569 in lupus vulgaris, 1140 Iodine-test in amyloid kidnej^, 1024 Iodoform in scrofuloderma, 1143 in tuberculosis, 301 ointment in cbicken-pox, 161 Ipecacuanha in bronchitis, 932 in broncho-pneumonia, 910 in congestion of liver, .551 in constipation, 500 in jaundice, 548 in spasmodic laryngitis, 851 Iris and ciliary body, diseases of, 1197 and ciliary region, injuries of, 1198 Iritis, 1198 in hereditary syphilis, 112 treatment of, 1198 Iron in anaemia after malarial fever, 318 in chicken-pox, 161 in chlorosis, 364 in chronic heart disease, 957 in convalescence of mucous disease, 462 Iron in convalescence of rheu- matism, 357 in lymphatic anaemia, 372 in phthisis, 302 in purpura haemorrhagica, 383 in secondary anaemia, .361 in splenic anaemia, 370 in sypliilis, 116 in variola, 170 iodide, syrup of, in chronic peritonitis, 569 in lymphatism, 433 Irregular remittent fevers, 312. See Remittent fevers, irreg- ular. Irrigation in diphtheritic dys- entery, 495 in naso - pharyngeal diph- theria, 263 intestinal, in dysentery, 493 in subacute milk infection, 483 method of, 494 of bowel in mucous disease, 460 of pleural cavity after resec- tion, 948 of stomach in mucous dis- ease, 460 Irritability in tuberculous men- ingitis, 611 Irritation, sympathetic, of eye, 1199 Ischio-rectal abscess, 588 j Ischuria, hysterical, 735 Italians, frequency of rachitis j among, 320 Itch. See Scabies. Itching about anus with seat- worms, 530 in eczema, 1101 in jaundice, 543 treatment of, 548 Itch-mite, 1158 Jaborandi in acute tubal nephritis, 1014 in erysipelas, 228 in scarlatinal nephritis, 147 Jacksonian epilepsy, 747 .Tacobi on origin of calculi, 95 ] .Jalap in scarlatinal dropsy, 148 Jambul in diabetes mellitus, 1005 Japanese, non-occurrence of rachitis among, 324 Jaundice, 543 diagnosis of, .544 fi'om Addison’s disease, 544 from chlorosis, 544 from malaria, 544 from pernicious anaemia, 544 due to congenital obliteration of bile-ducts, .545 epidemic, .545 etiology of, .543 following acute gastric ca- tarrh, 444 from inflammation of umbil- ical vein, 545 hfematogenic, in new-born, 92 in childhood, .547 in cirrhosis of liver, .558 .Jaundice in croupous pneumo- nia, 917 in hydatid of liver, ,556 in new-born, ,544 in Raynaud’s disease, 823 in VVinckcl’s disease, 546 simple, in infants, .543, 544 Jejunal intussusception, 517 Jellies in diabetic diet, 1003 Joint aflection in rheumatism, 352 disease, chronic, 1071 old, deformities from, 1081 tuberculous, 1072 swelling in haemophilia, 377 Juvenile dementia from hered- itary syphilis, 706 myxoedema, 684 Kaposi’s disease, 1137 Katatonia, 701 Keratitis, interstitial, 1096 in late hereditary syphilis, 115 symptoms of, 1096 treatment of, 1097 punctata, 1098 purulent, 1094 Kerato - conjunctivitis, phlyc- tenular, 1092 etiology of, 1092 symptoms of, 1093 treatment of, 1093 Kidney, amyloid disease of. See Amyloid disease of kidney. complications of, in chicken- pox, 1,59 congenital cystic degenera- tion of, 1027 hydatid cysts of, 1028 in diphtheria, 254 in malarial fever, 309 in rachitis, 327 in scarlet fever, 135 in typhoid fever, 197 large fatty, 1021 large white, 1021 lesions of, in cholera, 239 in diabetes mellitus, 999 tumors of. See Tumors of kidney. Kidneys, chronic diffuse tuber- culosis of, 282 syphilis of, 106 tuberculosis of, 298 “ Kink ” of whooping-cough, 186 Klebs-LofHer bacillus, relations of, to diphtheria, 251, 266 Kleptomania, 703 Knapp’s roller-forceps, 1191 Knee-jerk in hereditarv ataxia, 817 in Pott’s disease, 1066 Knee-joint disease, 1076 ankylosis from, 1081 diagnosis of, 1077 etiology of, 1076 operative treatment of, 1079 pathology of, 1077 prognosis of, 1078 symptoms of, 1077 Thomas’s splint in, 1078, 1079 treatment of, 1078 1224 INDEX. Knock-knee, brace for, 1089 treatment of, 1088 Koplik’s eruption in measles, 120 Roster’s theory of congenital cystic degeneration of kidney, 1027 Kousso against taeniae, 537 Krull’s method in jaundice, 548 Kussmaul’s apparatus for irri- gating stomach, 500 Kyphosis, 334 in syringomyelia, 813 Labor, precipitate, injuries from, 84 Labyrinth, formation of, 1158 Labyrinthine lesion in total deafness, 1176 Lachrymal abscess, 1200 apparatus, disease of, 1199 gland, abscess of, 1199 inflammation of, 1199 sac and duct, diseases of, 1199 sac, fistula of, 1200 Lactalbuiuin, 46 Lactation, commencement of, 18 Lactic acid, decomposition of, 45 in cholera, 244 in etiology of rheumatism, 351 presence of, in acute gas- tric catarrh, 443 Lactic-acid theory of rachitis, 324 Lactophenin in typhoid fever, 206 Lactose, digestion of, 44 in human milk, 44 properties of, 44 Lacunae of hone, 328 Lagophthalmos, 1182 Lamellar cataract. See Cata- ract, congenital. Landry’s paraly.sis, 798 Laparotomy for perforation in typhoid fever, 207 in intussuscei)tion, .522 Lardaceous disease, 1024. See, also. Amyloid disease of kidney. Laryngeal obstruction, 258 symptoms of, 268 in dii)htheria, 258 Laryngismus stridulus, 857 complications of, H(i2 course and duration of, 861 diagnosis of, 862 from bilateral ]>aralysis of glottis-dilators. 862 from spasmodic laryn- gitis, 862 etiology of, 858 in hereditary syphilis, 645 in rachitis, 340 paroxysm of, described, H6l' jiatliology of, 860 ju’ognosis of, 862 relation of, to tetany, 857 symptoms of, 860 synonyms of, 857 treat nient of, 8(i2 Laryngitis, catarrhal, 844 Laryngitis, catarrhal, etiology of, 845 in broncho-pneumonia, 845 in pulmonary phthisis, 845 in typhoid fever, 845 I>athology of, 845 catarrhalis simplex, 846 complications of, 847 diagnosis of, 847 prognosis of, 847 treatment of, 847 diphtheritic, tracheotomy in, 873 in measles, 124 spasmodic, 848 diagnosis of, 850 from laryngismus strid- ulus, 850 from true croup, 850 severe, 852 course of, 853 sym])toms of, 852 treatment of, 854 j)rophylactic, 856 symptoms of, 848 treatment of. 8.50 suffocative, in chicken-pox, 159 Laryngotomy in treatment of foreign bodies in larynx and trachea, 868 Laryngo-tracheotomy in treat- ment of foreign bodies in larynx and trachea, 868 Larynx, ascarides in, 527 Lassar’s paste, 1107 modification of. 1096 Lateral lithotomy, 1049 Lausedat’s drops, 245 Lavage of stomach in cholera, 248 in chronic gastric catarrh, 451 Laxatives in litha'inia, 101 in pleurisy, 94(! in suh.-icute milk infection, 483 Lead, acetate of, in cholera, 246 Leeches in peritonitis, 566 in typhlitis, 513 in uriemic convulsions, 1016 Lentigo, etiology of, 1128 treatment of, 1128 Leptomeningitis, acute spinal, 779 diagnosis of, 780 from hemorrhage, 780 from myelitis, 780 from tetanus, 780 from tetany, 780 etiology of, 77il ])athology of, 779 treatment of, 781 chroni(! cerebral, 600 spinal, 781 simidc. See Meningitis, simple. subacute cerebral, (iOO Letzerieb’s bacillus, 382 Leucocytosis in hereditary syphilis, 110 Leucoderma, 1135 diagnosis of, 1 135 from morpbo’a, 1132 from nerve-leprosy, 1136 from ]iartial albinism, 1135 etiology of, 1 135 ! Leucoderma, prognosis of, 1136 treatment of, 1136 Leucoma, 1195 ; Leukiemia, 373 diagnosis of, 375 from p.seudo-leukiBinia, 375 from scrofulosis, 375 from splenic ansemia, 375 etiology of, 373 morbid anatomy of, 375 prognosis of, 376 ‘ treatment of, 376 , Leyden’s crystals in asthma, j 957 Lichen ])lanus, 1110 diagnosis of, 1111 Iirognosis of, 1111 treatment of, 1111 scrofulosorum, 1142 tropicus, 1094. See Miliaria. urticatus, relation of, to ec- zema, 1120 Lids, eczema of, 1110 phtheiriasis of, 1180 Liebig’s foods, analysis of, 51 preparation of. 41 with milk, analysis of, 52 Ligaments, changes in, in rachitis, 326 Lime, saccharated solution of, formula for, 23 Linimentum exsiccans, 1107 Lii)oma of peritoneum, 570 Liiipitudo, 1179 Lips, condition of, in tvpboid fever, 197, 199 Litjuor potassie in acid lithi- asis, 1009 Litbsemia, 94 alloxuric bodies as a cause of, 94 convulsions in, 97, 98 diet in, 99 eclampsia in, 98 eczema in, 99 etiology of, 94 exercise in, 100 gastric pain in, 96 gastro-enteric symptoms in, 96 in functional heart afl'ec- tions, t)90 inactivit.v as a cause of, !I4 incontinence of urine in, ill! inthumee of heredity in. 94 intestinal fermentation in, 97 mother's milk in, !)!) migraine, in, 98 nausea in, 9(i, 97 nervous symptoms in, 97 l)ainful urination in, 95 jH'lvic disease in, 100 jnecocity in, 97, its reflex factors in, 100 siek headache in, ilS symptoms of, 95 tt iniierature in, 97 treatment of, 99 uric acid as a cause of, 95 urine in, il6, 99 vomiting in, 96, 97 of blood in, 97 Intlnemic eczema, i>9 Lit Ilia in treatment of vesical calculus. 1015 Lithia- water in litlnemia, 101 IXDEX. 1225 Lithiasis, lOOfi, 1007 (liagnosi.s of, 1009 etiology of, 1008 prognosis, 1009 treatment of, 1009 Lithic acid in the blood, 94 Lithiniu benzoate in litlnemia, 101, 102 carbonate in diabetes mel- litus, 1004 citrate in lith®mia, 102 Litholai>axy, 104G advantages of, 1050 conclusions regarding, 1051 in females. 1052 Lithotomy, 1040 lateral, 1049 emasculation after, 1049 median, 1049 suprapubic, 1048 in females, 1052 vaginal, 1052 Lithuria, 94 Littre’s operation, 580 Liver, amyloid disease of, 551 diagnosis of, 552 symptoms of, 552 treatment of, 552 apparent enlargement of, 541 chronic difl’use tuberculosis of, 282 cirrhosis of, 558 diagnosis of, 559 etiology of, 288 treatment of, 559 congestion of, 549 diseases of, 538 compared with adults, 538 diagnosis of, 541 general etiology of, 5.38 general symptomatology of, .539 physical examination in, 540 enlarged, diagnosis of, from tumor of kidney, 542 fatty, 551 treatment of, 551 hydatid of, 555 diagnosis of, .557 from pleural effusion, 557 prognosis of, 557 treatment of, 557 in infancy and childhood, 540 in pernicious ausemia, .367 malaria, .309 in rachitis, 326 in typhoid fever, 203 lesions of, in cholera, 2.39 in diphtheria, 254 in typhoid fever, 196 operative exploration of, 542 palpation of, 541 passive congestion of, 540 percussion of, 541 pus from, 542 syphilitic inflammation of, 106, 5.52 diagnosis of, ,5.53 treatment of, 553 tuberculosis of, 288 Liver-dulness, superior border of, 16 Local applications in erysipe- las, 229 asphyxia, 821 Local asphyxia and symmetri- cal gangrene. See Ray- naud’s disease. syncoi)e, 821 treatment of i)crtussis, 192 Localizing symptoms of brain tumors, 637 Locomotor ataxia in hereditary syphilis, 647 with syringomyelia, 813 Lordosis in double congenital dislocation of hip, 1082 in Pott’s disease, 1066 in pseudo-hypertrophic paral- ysis, 769 in syringomyelia, 813 Lotions in eczema, 1106 Low operation in tracheotomy, 876 Lumbar nephrotomy for pyo- nephrosis, 1032 pain in acute tubal nephritis, 1011 puncture for hvdrocephalus, 628 Lung, abscess of, 923 fibroid induration of. See Phthisis, fibroid. gangrene of, 919 Lungs, cirrhosis of. See Phthi- sis, fibroid. congestion of, in typhoid fever, 197 hypostatic congestion of, in subacute milk infection, 481 lesions of, in diphtheria, 254 in pernicious malaria, 309 syphilis of, 105 tuberculosis of, 292 Lupus hypertrophicus, 1140 seri)igiuosus, 1140 verrucosus, 1140 vulgaris, 1139 diagnosis of, 1140 etiology of, 1140 prognosis of, 1140 treatment of, 1140 Luschka’s tonsil, 428 Lustgarten, bacillus of, in syjdiilis, 103 Lymphadenitis, retropharyn- geal. See Retropharyn- geal abscess. tracheotomy for, 427 Lymphadenoma of kidney, 10.35 Lymphatic a rife mi a. See Anxmia, lymphatic. glands, enlargement of, 13 Lymphatism in chronic follic- ular pharyngitis, 418 in hypertrophy of tonsils, 418 Lymphocytes, 278 Lysis in tyj)hoid fever, 202 Mackenzie’s astringent mixt- ure, 420 Macrocephalic idiocy, 671 Macula of cornea, 1195 Magnesium carbonate in consti- pation, 499 citrate in constipation, 499 Malaria and typhoid fever, dif- ferential diagnosis of, 204 Malaria in etiologv of aiuemia, 360 of leukaunia, 373 of urticaria, 1120 Malarial cachexia, 31.3 morbid anatomy of, 309 fever, 303 ajstivo-autumnal type of, 312 parasites of, 307 conditions favorable to, 303 eourse and prognosis of, 317 diagnosis of, 315 from tuberculosis, 315 etiology and pathology of, 303 examination of blood in, 366 geographical distribution of, 303 morbid anatomy of, 306 pernicious, 314 prophylaxis of, 317 quartan, parasite of, 366 quotidian or double tertian, 311 relation of types of, to types of organism, 304 specific micro-organism of, 304 symjitoms of, 309 synonyms of, 303 tertian intermittent type of, 310 parasite of. 304 peculiarities of. in young children, 311 temperature in, 310 time of jiaroxysm of, 312 treatment of, 317 yisceral aflections asso- ciated with, 314 with typhoid, 315 hffimaturia, 992 hiemoglobinuria, theories of, 992 infection in Raynaud’s dis- ease, 823 Male fern against tieniae, 537 Malformations, congenital, 84 diagnosis of, 85 simulating fracture, 84 of intestines, congenital, 575 causes of, 576 diagnosis of, 576 prognosis of, 576 treatment of, 576 of rectum and anus, congen- ital, .577 pathology of, ,577 Malignant growths in caecum, 516 measles, 128 Maltose, 45 Malt-sugar, 46 Management of children, 18 at sea-shore, 67 bathing in, 32 clothing in, 34 exercise in, 35 feeding in, 18 slee)) in, 34 Mania, 699 after influenza, 218 1226 INDEX. Mania, homicidal, 703 moral, 703 Marasmus. See Atrophy, sim- ple. Marginal abscess, 587 keratitis, 1193 Marie’s disease, (500. See Acro- megal y. Markoe’s wry-neck face, 10(53 Marrow of bone, 328 of long bones in lymphatic anaemia, 372 Massage in constipation, 518 in incontinence of urine, 969 in pseudo-hypertrophic mus- cular paralysis, 773 in scoliosis, 1064 in simjile jaundice of in- fants, 561 of cornea, 1140 Mastitis in new-born, 91 Mastoid tenderness in suppu- ration of the middle ear, 1169 Masturbation from seat-worms, 530 Masturbational insanity, 706 treatment of, 710 Maternal iutluence in hered- itary syphilis, 104 Maxillae, changes in, in rachi- tis, 334 McBurney’s point in typhlitis, 510 Measles, 117-130 black, 123 complications of, 123 decline of, 122 definition of, 117 diagnosis of, 124 from acute catarrh, 124 from eczema, 125 from rubella, 125 from scarlatina, 125 from syphilitic roseola, 125 from variola, 125 eruption of, 120 etiology of, 117 experimental inoculation of, 117 hybrid. See Rubella. incubation of, 118 in etiology of bronchitis, 924 of chronic tubal nephritis, 1019 malignant, 123, 128 modified forms of, 123 morbid anatomy of, 118 mortality of, 126 prognosis of, 125, 12(5, quarantine in, 130 relapses and second attacks of, 126 sequela' of, 124 sym))toms of, 119 treatment of, 126 with pertussis. 208 with whooping-cough, 124 without catarrh, 123 without interruption, 123 Meats in diabi'tic diet, 1003 in litluemic diet, 99 Mechanism of paroxysms of spasmodic laryngitis, 849 Meckel’s diverticulum, .575 in intussusception, 517 Meconium, vomiting of, 576 Median lithotomy, 1049 Melajna in tuberculosis of the bowels, 288 neonatorum, 92 ulcer of duodenum in, 92 Melancholia, 699 agitated, 699 in typhoid fever, 200 treatment of, 709 Meniere symptoms in internal ear disease, 1176 Meninges, involvement of, in chronic suppuration of middle ear, 1173 Meningitis, basilar. See Men- ingitis, tubercular. following operation, 598 cerebral, simple, 596 diagnosis of, 601 from cerebral pneu- monia, (>01 from middle-ear dis- ease, 601 from pyaemia, 602 from tubercular men- ingitis, 601 from typhoid fever, 602 etiology of, 596 morbid anatomy of, 597 prognosis of, 602 symj)toms of, 598 treatment of, 602 cerebro-spinal, simple, 605 diagnosis of, 607 from tetanus, 608 from tubercular, 608 from typhoid fever, 608 distinguished from cere- bro-spinal fever, 605 ] etiology of, (505 prqgnosis of, 608 symptoms of, 605 treatment of, (508 of Pott’s disease, 10(55 pneumonic lesions in, 598 spinal, 777 syphilitic, diagnosis of, from tubercular, 646 tuberculous, (510 and typhoid fever differen- tial diagnosis of, 204 diagnosis of, 619 from pain tumor, 619 from gastro-intestinal disorder, 619 from hysteria, 619 from infantile convul- sions, 619 from pneumonia, 620 from typhoid fever, 619 duration of, 619 etiology of, 610 in Pott’s disease, 1067 morbid anatomy of, (520 prognosis, 618 syjnjitoms, (ill with ])arotitis, 179 Mental changes in brain tumor, 677 in tubercubnis meningitis, 615 syrniitoms of hydroceidialus, (526 Menthol in tuberculosis, 302 Mercurial ointment in peri- tonitis, .56(5 Mercurial stomatitis, resem- blance of, to stomatitis ulcerosa, 402 Mercurials in diphtheria, 262 Mercuric chloride in chronic interstitial nephritis, 1026 in ophthalmia neonato- rum, 1187 Mercuric-chloride baths in syphiloderma, 1146 solution in corneal ulcer, 1195 Mercury iu aerjuired laby- rinthine deafness, 1176 in acute myelitis, 787 in acute spinal leptomenin- gitis, 781 in cerebral meningitis, 603 in chronic peritonitis, 569 in hereditary syphilis, 115 in hydrocephalus, 628 in interstitial keratitis, 1200 in syphiloderma, 1146 Mesenteric glands, chronic dif- fuse tuberculosis of. 282 lesions of, in typhoid fever, 196 swelling of, in typhoid fever, 196 tuberculosis of, 286 Mesenteron, .577 Methylene blue, G a b b e t - Ernst’s solution of, 271 in malaria, 318 Microcephalic idiocy, 673 Micrococci in meconium, 472 Micrococcus of Fehleisen, 90 Micro-organisms in etiology of eczema, 1103 in measles, 118 in spinal lluid in aeute lepto- meningitis, 779 in whooping-cough, 184 Micturition, frequent, in dia- betes mellitus, 999 in gravel, 1008 in hydronephrosis, 1030 in vesical calculus, 1170 painful, causes of, 9 Middle ear, aeute simple in- flammation of. 1166 diagnosis of, 11(58 acute supi)urativo inflam- mation of, 11(59 symiffoms of, 11(59 affections of, 11(5(5 chronic catarrh of, 1174 chronic suppuration of, 1170 stages of inflammation of, 1168 Migraine, 719 diagnosis of, 720 etiology of, 720 in lithaunia, 98 pathology of, 720 treatment of, 720 Miliaria, 1091 crystallina, 1094 diagnosis of, 1095 froTii eczema papulosum, 10!)5 from varicella, 1095 from vesicular eczema, 1091 etiology of, 109,5 INDEX. 1227 Miliaria in rachitis, 339 pajiulosa, 1094 treatment of, 1095 vesiculosa, 1094 Miliary tuberculosis, acute, 279 Milium, 1093, 1183 etiology of, 1093 prognosis of, 1093 treatment of, 1093 Milk, albuminoids in, 46 and cream modifications of, for infant feeding, 58 as a culture medium, 472 as a source of typhoid infec- tion, 195 breast-, 19 casein in, 46 chemistry of, 37 commercial bottled, 38 compared with other foods, 37 composition of, 37 condensed, 49 dilution of, for food, 47 with lime-water, 47 fat in, 46 home modification of, 56 human, albuminoids in, 41, 44 color of, 41 comparison with cow’s, 41 constancv of composition of, 41 ■ reaction of, 41 specific gravity of, 41 table of analyses of, 42, 43, taste of, 41 humanized, 48 in acute tubal nephritis, 1018 in Pott’s disease, 1068 in typhoid fever, 205 infection, 471 acute, 47.5-479 diagnosis of, 477 from cholera, 477 from sunstroke, 477 etiology of, 475 from condensed milk, 475 prognosis of, 477 season of, 475 synonyms of, 475 treatment of, 477 advantages of the term, 465 subacute, 479 complications of, 481 diagnosis of, 482 from chronic intestinal indigestion, 482 from intussusception, 482 dietetic treatment of, 482 etiology of, 479 prognosis of, 482 prophylaxis of, 482 synonyms of, 479 treatment of, 482 inorganic matter in, 46 analysis of, 47 legal standard of, in various States, 40 modified. See Modified mill-. peptonized, characters of, 25 prohibited in acute milk iu- fectiou, 477 Milk, prohibited in subacute milk infection, 482 prophylactic precautions in marketing, 473 sound dairy, analysis of, 40 characteristics of, 40 sterilization of, 26, 39, 47 transportation of, 31 Milkers, accidental inoculation of, with vaccinia, 172 Milk-laboratories, 53 Walker-Gordon, 55 Milk-mixtures, percentage, 53 Milk-secretion, diminished, treatment of, 20 Milk-sugar, 46 percentage of, in modified milk, 55 Milk-teeth, appearance of, 17 Mineral waters in lith®mia, 102 Mitral obstructive murmur, 982 regurgitant murmur, 981 regurgitation, 981 prognosis of, 983 stenosis, 982 prognosis of, 984 Mixed feeding, 19 or fusible phosphate calculus, 1038 treatment in syphilis, 116 Modified milk, 53 feeding with, 55 home preparation of, 56 percentage of constituents for feeding healthy in- fant, 55 preparation of, 54 theoretical basis for feeding with, 55 Molluscum contagiosum of eye- lids, 1183 epitheliale, 1129 diagnosis of, 1130 etiology of, 1129 treatment of, 1130 Monas scarlatinosum, 132 Mongolian idiots, 671 Monomania, suicidal, 703 Monophobia, 704 Monsel’s solution in hiemo- philia, 378 Morbid fears, 704 impulses, 702 movements in infantile cere- bral palsies, 652 propensities, 703 Morbus cseruleus, 5 maculosus. See Purpura hxmorrhagien. Morphine in asthma, 960 in diphtheria, 262 in i>hthisis, 302 Morpluea, 1134 diagnosis of, from keloid, 1134 from leprosy, 1134 from leucoderma, 1134 etiology of, 11.34 prognosis of, 1135 treatment of, 11.35 Mortality of first year, 68 1 Motor symptoms of syringo- myelia, 812 Mouth, changes in, in disease, 17 Mouth, cle.ansing of, at birth, 78 diseases of, 396 general etiology of, .396 examination of, 17 exanthematous eruptions in, 18 inflammation of, changes in, 18 mucous membrane of, in health, 17 of the infant, 396 primary syphilitic lesions of, 408 secondary syphilitic lesions of, 408 Mouth-breathing in adenoid vegetations, 429 in hypertrophic rhinitis, 831 with enlarged tonsils, 423 Mouth-suction of tracheotomy wound, 880 Muco-pus in urine in vesical calculus, 1043 Mucous disease, 454 appetite in, 456 breath in, 4.56 diagnosis of, 457 from ascaris lumbricoi- des, 457 from dysentery, 4.57 from pulmonary tuber- culosis, 457 diet in, 458 etiology of, 4.54 microscopy of stools in, 457 morbid anatomy of, 4.57 mucus in stools of, 456 nervous symptoms of, 456 nervous theory of, 455 pain in, 456 prognosis of, 458 skin in, 4.56 symptoms of, 4,55 synonyms of, 454 temperature in, 456 tongue in, 4.55 treatment of, 478 urine in, 456 membranes, changes in, in rachitis, 326 lesions of erysipelas in, 224 patches, treatment of, 1147 surfaces, hemorrhages from, 82 Mucus, hypersecretion of, in chronic gastric catarrh, 446 Mulberry calculus. See Oxa- late-of-Ume calculus. Mulls, plaster and salve, of Unna, in eczema, 1108 Mumps. See Parotitis. Murmur in acute endocarditis, 979 in aortic regurgitation, 9.83 in aortic stenosis, 982 in mitral regurgitation, 981 in mitral stenosis, 982 in stenosis of pulmonary artery, 971 in tricuspid regurgitation, 983 Murmurs, hsemic, in chlorosis, 363 1228 INDEX. Murmurs, haemic, iu leukfpmia, 374 iu pernicious auaemia, 366 , iu anomalies of auriculo- ventricular orifices, 970 transient, in rapid or irregu- lar liearts, 987 Muscles, lesions of, in typhoid fever, 197 Muscular atrophy iu hereditary ataxia, 818 with tumors of spinal cord, 803 power iu hereditary ataxia, 818 rheumatism. See Rheuma- tixiii, muscular. Musk in diphtheria, 261 Mussey’s modification of Whitehead gag, 436 Mustard-bath in malignant measles, 129 Mydriatics in treatment of concomitant convergent strabismus, 1203 Myelitis, 782 acute, 782 diagnosis of, 786 etiology of, 782 pathology of, 783 treatment of, 785 chronic, 787 w'ith simple cerebro-spinal meningitis, 606 Myocarditis in typhoid feyer, 200 Myopathic atrophy, infantile type of, 771 juyenile type of, 771 Myopia, infrequency of, in childhood, 1202 Myo-sarcoma of kidney, 1035 Myositis, syphilitic. 111 Myotatic excitability iu hered- itary ataxia, 817 Myotonia, 687 diagnosis of, 689 etiology of, 688 pathology of, 688 treatment of, 689 Myotonic reaction, 688 Myotonus with tumors of spi- nal cord, 803 Myso]»hobia, 704 Myxfcdema, .juyenile, 684 Myxcedematous idiocy, 684 Myxomata, nasal, 837 etiolog.y of, 838 morbid anatomy of, 841 treatment of, 841 Myxo-sarcoma of kidney, 1035 NiEyi of eyelids, 1180 Nmvus j)igmentosus, 1131 etiology of, 1131 jirognosis of, 1131 treatment of, 1131 pilosus, 1131 si)ilus, 1131 yascularis, 1137 diagnosis of, 1138 etiology of, 1138 l>rognosis of, 1138 treatment (d', 1138 ycrrncosus, 1131 Nails, condition id', in typhoid feyer, 199 Naphthaline in cholera, 244 in .jaundice, 549 in mucous disease, 460 Naphthol in ichthyosis, 1129 Narrowing of rectum, congen- ital, 578 Nasal catarrh, chronic, after scarlatina, 142 iu etiology of chronic ca- tarrh of middle ear, 1174 douche iu etiology of middle- ear inflammation, 1166 myxomata, 837 stenosis, 830 Naso-pharyngeal adenoid hy- pertrophy, 428 etiology of, 429 histology of, 428 treatment of, 432 Naso-pharyugitis, 415 Naso-phar.ynx, local treatment of, iu yariola, 169 Nausea, 9 and yomiting in brain- tumors, 637 iu chronic gastric catarrh, 447 iu lithiEinia, 96, 97 in rubella, 154 iu typhoid feyer, 197, 198 in yaccinia, 174 Nebula of cornea. 1195 Neck, anterior region of, anat- omy of, 872 arteries of, concerned in tracheotomy, 872 Necrosis of temporal bone in chronic inflammation of middle ear, 1173 osseous in typhoid feyer, 197 Negroes, frequency of rachitis among, 320 rarit.y of trachoma among, 1190 Nelatou’s operation, 522 Neoplasms as a cause of hasma- turia, 992 Neiihpcctomy for hydronephro- sis, 1031 for pyonephrosis, 1032 in children, 1037 in tumors of kidney, 1036 Nephritic colic, 1170 Nephritis, acute tubal, 1011 diagnosis of, 1012 from chronic nephritis, 1012 from cyanotic indura- tion, 1012 etiology of, 1011 morbid anatomy of, 1012 prognosis of, 1013 synonyms of, 1011 treatment of, 1013 chronic interstitial, 1025 etiology of, 1025 morbid anatom.v of, 1026 prognosis of, 102(> rarity of, in childhood, l()2b5 synon.yms of, 1025 treatimml' of, 1026 chronic tul)al. 1018 diagnosis of, 1020 from amvb)id kidney, 1020 Nephritis, chronic tubal, diag- nosis from chronic interstitial nephri- tis, 1020 from cyanotic indura- tion, 1020 etiology of, 1018 morbid anatomy of, 1020 in first stage, 1020 in second stage, 1021 in third stage, 1021 prognosis of, 1021 in first stage, 1021 in second stage, 1022 in third stage, 1022 synon.vms of, 1018 treatment of, 1022 of convalescence from 1022 complicating croupous pneu- monia, 917 iu chicken-pox, 159 in cirrhosis of liver, ,559 in late hereditarv’ syphilis, 115 in parotitis, 180 iu subacute milk infection, 481 in suppuratiye hepatitis, 554 scarlatinal. See Scarlatinal nephritis. with parotitis, 179 Nephrotomy for hydroneph- rosis, 1031 Nerve, superior laryngeal, irri- I tation of, in pertussis, 185 Nerves, iieinpheral, atfections of, in hereditar.v syph- ilis, 647 disorders of, in tetany, 765 Nervous diseases in causation of chronic constipation, 497 synqitoms in bronchitis, 929 in litha“inia, 97 in t.yphoid fever, 200 system, influence of, iu child- hood, 1 obstetric injuries to, 82 Nervousness in lithannia, 97 Nettle-rash See Urticaria. Neuritic headache, 724 Neuritis nudtiple, after paro- titis, 180 complicating ejiidemic cer- ebro-si)inal meningitis, 211 peripheral, after diph- theria, 2.59 New growths of skin, 1137 New-born, hannorrhage in, 73 Night-dress for summer, 34 for winter, 34 Night-terrors due to eye-strain, 1202 Nii)i)les, India-rubber, 30 Nitre in hydatids of kidney, 1029 ‘ Nitre-paper in asthma, 9(il Nitro-glycerin in asthma, 961 in atelectasis, 903 in (lii)htheria, 2(i2 in scarlet fever, 118 Nitro-muriatie, acid in lith- imuia, 102 in oxalate-of-lime lithiasis, 1010 INDEX. 1229 Nocturnal epilepsy, 751 Noma, 405. See, also. Stomatitis ijaiKjrivnosa. Nomenclature of affections of middle ear, 1166 Nose, diseases of, 826 Nose-picking with tieni®, 535 Nursing, importance of regu- larity in, 18 intervals between, 18 proi)er position in, 18 woman, diet of, 44 Nursing-bottle, care of, 30 graduated, 30 improper form of, 503 Nutrolactis, 344 Nuts in diabetic diet, 1003 Nux vomica in chronic gastric catarrh, 451 in chronic intestinal indi- gestion, 451 in functional heart affec- tions, 989 in incontinence of urine, 997 in night-sweats, 302 in simple atrophy, 507 Nymphomania, 703 Nystagmus, 715 in albinos, 1135 in hereditary ataxia, 818 in infantile cerebral palsies, 6.52 Obstetric forceps, injuries from, 83 prognosis of, 84 limitations of, 83 precautions in using, 83 injuries, medico-legal aspect of. 83 treatment of, 84 paralysis, 82 Obstruction, laryngeal symp- toms of, 870 Obturator for cleft palate, 435 Occlusion of anus, complete, .578 Oculo-motor symptoms in syringomyelia, 813 Odor in favus, 1149 in stomatitis gaugr®nosa, 406 of breath in gangrene of lung, 922 Oedema, 13 cardiac variety of, 13 fugitive, 1184 hepatic variety of, 363 in chicken-pox, 159 in chlorosis, 363 in chronic heart disease, 981 in progressive pernicious an»mia, 365 in scarlatinal nephritis, 141 in secondary an»mia, 361 in tumors of kidney, 1036 localized, in scarlatinal neph- ritis, 142 in suppurative hepatitis, 553 of eyelids, 1183 in renal and cardiac dis- ease, 1184 of face in rubella, 1.54 of glottis in pertussis, 188 of lungs in acute tubal neph- ritis, 1012 CEdema of lungs in chronic tu- bal nephritis, 1020 of neck after tracheotomy, 885 renal variety of, 13 Gilsophagismus, 735 (Esophagus, perforation of, 285 Offensive breath, causes of, 7 Oidium albicans, 400 Ointments, application of, 1107 in eczema, 1106 Old deformities of joints, 1081 Oleum phosphoratum in ra- chitis, 349 Omentum, tumors of. See Peritoneum, tumors of. Onychia, syphilitic, 112 Oogonia of Ferrau, 233 Operative treatment of con- comitant convergent strabismus, 1203 Ophthalmia in measles, 124 neonatorum, 88, 1185 prognosis of, 1186 prophylaxis of, 88, 1188 results of, 1186 symptoms of, 1186 treatment of, 1186 phlyctenular. .See Kerato- con j unctivitis, ph tyc.ten ula r. Opisthotonos, cervical, in cere- bral meningitis, 600 in cerebro-spinal meningitis, 210 in tuberculousmeningitis,617 with tumors of spinal cord, 803 Opium in acute endocarditis, 980 in acute intestinal indiges- tion, 467 in bronchitis, 931 in cerebral meningitis, 604 in cerebro-spinal meningitis, 608 in cholera, 246 in chronic heart disea.se, 985 in croupous pneumonia, 918 in diabetes insipidus, 1006 in diabetes mellitus, 1004 in epidemic cerebro-spinal meningiti, 213 in intussusception, ,521 in pericarditis, i)76 in peritonitis, .567 in pertussis, 191 in purpura hamorrhagica, 383 in rheum,atism, 3.57 in therapeutics of childhood, 35 in tuberculous meningitis, 622 in typhlitis, 513 Optic atrophy in hereditary ataxia, 818 in hydrocephalus, 626 disk, appearance of, with tumors of cord, 804 neuritis after erysipelas, 227 in brain abscess, 632 in brain tumors, 637 in cerebral meningitis, .599 in simple cerebro-spinal meningitis, 606 in tuberculous meningitis, 611, 618 Orange-juice in scorbutus, 395 Orbit, bleeding in, 1201 caries of, 1200 cellulitis of, 1200 cysts of, 1201 diseases of, 1200 morbid growths of, 1201 periostitis of, 1200 Orthopmdics, 1062 Osseous system, alterations of, in rachitis, 328 in health, 327 Ossicles of ear, caries of, 1172 stifiening of the ligaments of, 1175 Osteitis in chicken-pox, 1.59 Osteo - chondritis, svphilitic, 106 Osteoplasty, 435 Otic vesicle, 1158 Otitis in influenza, 217 in measles, 124 in searlatin.al nephritis, 143 in typhoid fever, 199 in variola, Ki7 media in chicken-pox, 1,59 in typhoid fever, 199 Ova of pediculus capitis, 11.56 Ovaries, tuberculosis of, 299 Over-feeding in etiology of acute intestinal indiges- tion, 465 of eczema, 1102 Ovoid bodies in sstivo-autum- nal fever, 308 Oxalate-of-lime calculus, 1038 sediments in urine, 1006 Ox-gall in constipation, .500 Oxyuris vermicularis, 529 diagnosis of, 531 liabitat of, 529 method of infection by, 529 ova of, .529 treatment of, 531 Ozfena, 833 Ozone in sea-air, 60 Pachymeninoitis externa, 777 interna, 778 Pagenstecher’s ointment, 1196 Pain in acute myelitis, 784 in acute poliomyelitis, 791 in chronic gastric catarrh, 449 in chronic heart disease, 981 in chronic peritonitis, 568 in croupous pneumonia, 915 in disea.ses of liver, 532 diagnosis of, from pleu- risy, ,540 from pleurodynia, .540 in hip-joint disease, 1072 in intussusception, 519 in knee-joint disease, 1077 in mitral stenosis, 982 in pericarditis, 975 in peritonitis, .565 in I’ott’s disease, 1066, 1067 in Raynaud’s disease, 821 in simple cerebro-spinal men- ingitis, 606 in suppurative he])atitis, .553 in tumors of kidney, 1035 of spinal cord, 802 in typhlitis, 510 in vesical calculus, 1042 1230 TXDEX. Painful micturition, 9 in lith®mia, 95 Paints in eczema, 1109 Palate, soft, appearance of, 17 Pallor in chronic tubal neph- ritis, 1020 Palpation of chest, 10 Palpitation in chlorosis, 363 in chronic heart disease, 981 in mitral stenosis, 982 in pericarditis, 975 of heart, 9.s9 Palsies, cerebral, acquired, 051 infantile cerebral, 049 diagnosis of, dill'erential, 050 etiology of, 650 morbid anatomy of, 654 jirognosis of, 656 statistics of, 650 syin]ttoms of, 651 treatment of, 656 occurring during parturition, 651 of pre-natal origin, 620 Palsy in tuberculous meningi- tis, 611, 017 of brachial jilexus in heredi- tary syjihilis, 647 Pancreas, syphilis of, 106 Pancreatic disease, relation of, to diabetes mellitus, 971 . .juice in new-born, 403 Pancreatin in , jaundice, 548 in simple atroi)hy, 507 Pannus, 1190 phlyctenular, 1193 Panophthalmitis from ophthal- mia neonatorum, 1186 Pantophobia, 704 Papilla of tooth, 410 Pai>illai'y trachoma, 1190 Papular syphiloderm, 1144 Papules in stomatitis syphilit- ica, 409 Paracentesis abdominis in ascites, 574 in ascites of cirrhosis of liver, 561 in chronic peritonitis, 569 of cornea, 1195 of drum-membrane, 1169 pericardii, 977 Paradoxical pulse, 988 Parsesthesia in Landr.v’s paral- ysis, 799 in Ra.vnaud’s disease, 821 in tumors of spinal cord, 802 Paralexia, 659 Paralysis, diiihtheritic, 259 treatment of, 200 facial, 774 hysterical, 734 in acute gastric catarrh, 444 in acute s])inal leptomenin- gitis, 780 in cerebral meningitis, 599 in cercbro-spinal meningitis, 210 infantile, 789 in hydrocciihalus, 626 in measles, 124 in Pott’s disease, 1006 recognition of, 1008 treatment of, 1071 in tuberculous meningitis, 017 Paralysis, Landry's, 798 diagnosis of, 799 from myelitis, 799 etiology of, 798 pathology of, 798 prognosis of, 799 syini>toms of, 798 treatment of, 799 local, in simple cerebro-spiual meningitis, 007 obstetric, 82 rachitic, 342 with tumors of spinal cord, 803 Paralytic deformities, 1086 Paramimia, 059 Paranephric cyst, 1028 Paranoia, 702 Paraphimosis, 1060 Paraplegia in acute spinal lep- tomeningitis, 780 in hereditary syphilis, 647 Parasites, intestinal, 524 Parasitic atl'ections of skin, 1148 Parenchymatous keratitis. See Keratitis, interstitial. nephritis, acute. See Neph- ritis, acute tubal. chronic. See Nephritis, chronic tubal. Paresis with tumors of spinal cord, 803 Paretic dementia, 705 Parker’s soda solution, 882 Parotid gland, enlargement and suppuration of, in ty- phoid fever, 199 Parotitis, 177 bacillus of, 178 bacterium in, 178 com|)lications of, 180 conditions of infection in, 189 definition of, 187 epidemics of, 187 etiolog.v of, 188 incubation of, 189 infectious, etiology of, 188 in intluenza, 217 in t.vphoid fever, 199 involvement of other glands in, 180 micrococci in, 188 pathological anatomy of, 187 period of greatest contagious- ness of, 181 quarantine in, 181 traumatic, 187 etiolog.v of, 188 treatment of, 180 Paroxysmal hannaturia, 994 Parrot’s disease, 048 nodes, 108 Passionate movements, period of, in hysteria, 731 Pastes in eczema, 1107 Pasteurization, 28, 48 Patency of foramen ovale, 908 Patent foods in etiolog.v of scorbutus, 389 Paternal inlluence in hered- itary syphilis, 103 Patho]ihobia, 704 Pavor noctnrnus with i)iu- worms, 530 Pediculosis, 11.50 Pediculosis, etiology of, 1157 treatment of, 1157 Pediculus capitis, 1150 pubis on eyebrows, 1180 Pelletierine against tienise, 536 Pelvic bones, changes in, in rachitis, 330 disease in lithanuia, 100 Pelvimetry, 74 Pemphigus, 1114 diagnosis of, 1115 etiology of, 1115 foliaceus, 1115 of conjunctiva, 1092 prognosis of, 1115 treatment of, 1115 vulgaris, 1114 Pepsin in diphtheria, 264 Pcjisol in t.vphoid fever, 206 Peptogenic milk-powder, 26, 48 method of using, 48 Peptones, formation of, 45 Peptonization in artificial feed- ing, 25 partial, advantages of. 26 Peptonized milk, eharactcrs of, 25 Percentage milk-mixtures, 53 Percussion of chest, 16 method of, in child. 10 resonance in health, 16 Perforation of bowel in ca- tarrhal dysentery, 486 in tyi)hoid fever, 196, 199 of cacum or ai)i)endix, diag- nosis of. 512 Pericarditis, 974 com)>licating croupous pneu- monia, 917 during scleroderma, 1133 etiology of, 975 in rheumatism, 353 in scarlatinal nephritis, 142 in typhoid fever, 201 in variola, 107 physical signs in, 975 prognosis of. 970 treatment of, 977 tuberculous, 298 without lihilitic, 107 Periin-octitis, 588 Peritoneum, tumors of, ,570 prognosis of, 571 treatment of, .571 Peritonitis, acute, 503 diagnosis of, 560 etiology of, .503 morbid anatomy of, 564 prognosis of, ,500 treatment of, .560 ulceration of, j>us from, 505 chronic, .508 diagnosis of, ,509 INDEX. 1231 Peritonitis, chronic, diagnosis of, from tul)crcular pe- ritonitis, 5(>!) etiology of, 568 l>rognosis of, 56i) treatment of, 569 chronic adhesive tuberculous, ^90 diagnosis of, 291 prognosis of, 291 treatment of, 291 in intussusception, 518 in new-horn, 90, 565 in typhoid fever, 196, 199 in utero, 563 tuberculous, 288 ascitic form of, 289 morbid anatomy of, 288 ulcerative form of, 290 Peritonsillar abscess, 421 diagnosis of, 421 etiology of, 421 evacuation of, 422 prognosis of, 421 treatment of, 421 Perityphlitis, 509 Permanent teeth, 17 order of appearance of, 411 Pernicious malarial fever, 314 Peroxide of hydrogen in chick- en-pox, 161 Persistence of ductusarteriosus, 971 Perspiration in rachitis, 325, 338 profuse, in etiology of consti- pation, 497 Pertussis, 190. See Whooping- cough. in etiology of bronchitis, 924 of mucous disease, 454 Petechiffi in cholera, 242 in invasion of variola, 164 significance of, 164 Petechial fever. See Cerebro- spinal meningitis, epidemic. Petit mal, 751 Peyer’s patches in cholera, 236 in typhoid fever, 196 Pharyngitis, acute, 415 diagnosis of, 415 etiology of, 415 pathology and symptoms of, 415 prognosis of, 416 treatment of, 416 chronic, 417 treatment of, 417 folliculous, acute, 415 chronic, 418 treatment of, 418 in scarlet fever, 137 lateralis, 418 Pharynx, appearance of, in health, 17 Phenacetin, caution in the use of, 36 in acute folliculous tonsillitis, 420 in bronchitis, 932 in diabetes mellitus, 1004 in eczema, 1105 in endocarditis, 1108 in epidemic cerebro-spinal meningitis, 213 in measles, 130 in migraine, 720 Phenacetin in parotitis, 180 in pleurisy, 946 in pyrexia of broncho-pneu- monia, 912 in scarlet fever, 145 in vvhoo])ing-cough, 192 Phimosis, 1057 as a cause of enuresis, 998 secondary, 1059 Phlebitis, umbilical, 89 Phlegmon of orbit, 1200 Phlegmonous ulceration in vac- cinia, 175 Phlyctenular kerato-conjunc- tivitis, 1192 pannus, 1193 ulcers, 1193 Phlyctenule, 1192 Phobias, 704 Phosphate of sodium in lith- amiia, 101 Phosphatic sediments in urine, 1006 Phosphorus in laryngismus stridulus, 864 in rachitis, 347 Photophobia in cerebral men- ingitis, 599 in cerebro-spinal meningitis, 210 in simple conjunctivitis, 1185 in spring catarrh, 1189 Photopsia in migraine, 719 Phtheiriasis of lids, 1180 treatment of, 1180 Phthisis, fibroid, 963 diagnosis of, 966 from chronic pleurisy, 966 from pulmonary tubercu- losis, 966 etiology of, 963 morbid anatomy of, 964 prognosis of, 966 symptoms and course of, 965 treatment of, 966 pulmonalis. See Tuberculosis, pulmonary. in etiology of amyloid kidney, 1024 Physical examination, order of examination in, 9 Physiognomy of adenoid vege- tations, 430 Pick’s linimentum exsiccans, 1108 paste, 1096 “ Pigeon - breast ” deformity, 432 Pilocarpine in acquired laby- rinthine deafness, 1176 in acute tubal nephritis, 1014 in asthma, 961 in chronic tubal nephritis, 1022 in erysipelas, 228 in jaundice, 548 in scarlatinal nephritis, 147 in spasmodic laryngitis, 851 Pin-worm. See Qjyuris rer- micularis. Piperadzin in lithiasis, 1010 Pityriasis rosea, 1122 diagnosis of, 1122 Pityriasis rosea, diagnosis of, from circinatc syphi- lidc, 1122 from ringworm, 1122 from seborrhoua, 1122 etiology of, 1122 prognosis of, 1122 treatment of, 1122 Placenta, syi)hilis of, 105 tuberculosis of, 273 Plagiocephalic idiocy, 671 Plasmodium malariie, 304 Plaster-of-Paris bandage in club-foot, 1084 jacket in Pott’s disease, 1069 splint for hip-joint disease, 1075 for knee-joint disease, 1078 Plasters in eczema, 1107 Plethora, definition of, 359 Pleura, thickening of, in fibroid phthisis, 964 tuberculosis of, 298 Pleurisy, 935 complicating croupous pneu- monia, 917 complications of, 945 diagnosis of, 943 etiology of, 937 following broncho-pneumo- nia, 908 frequency of, 935 gangrenous, 921 in erysipelas, 224, 227 in rheumatism, 353 in variola, 167 pathology of, 935 physical signs of, 941 prognosis of, 945 symptoms of, 940 treatment of, 946 tubercular, ])athology of, 936 with etfusions, 9.35 Pleuritis necessitatis, 936 Pleurosthotonos in cerebro- spinal meningitis, 210 Plox scindens, 133 Pneumatic speculum in chronic tympanic catarrh, 1175 Pneumococcus in exudate of sini])le meningitis, 597 of Friinkel in broncho-pneu- monia, 904 in croupous pneumonia, 913 Pneumonia, catarrhal. See Bronchopneumonia. in measles, 123 chronic. See Phthisis, fibroid. following broncho-]ineu- monia, 907 com])licated by parotitis, 178 with iileurisy, incomplete crisis in, 944 crou))ous, 913 complications and sequels of, 917 diagnosis of, 917 from broncho-pneumo- nia, 917 from jileurisy with efl'u- sion, 917 etiology of, 913 in ])ertussis, 188 morbid anatomy of, 914 physical signs of, 916 prognosis of, 918 1232 INDEX. Pneuinouia, croupous, symp- I toms of, ill 4 treatment of, 918 varieties of, 91(5 embolic, in rheumatism, 353 fibrinous. See Pneumonia, croupous. following asjthyxia, 80 in diabetics, 1000 in etiology of fibroid phthi- sis, 9(53 of pericarditis, 975 infective interstitial, in ery- sipelas, 22i in rheumatism, 353 in septic infection. 89 inspiration, 7(5, 91 lobar. See Pneumonia croup- ous. lobular. See ISroncho-pneu- monia. migrans, 916 mode of drinking in, 6 septic, in scarlet fever, 142 staphylococci in, 74 with parotitis, 179 Pneumothorax complicating broncho-pneumonia, 908 Pockmarks in chicken-pox, 157 Pointing of perinephritic ab- scess, 1033 Poliomyelitis, acute anterior, 789 diagnosis of, 793 from cerebral palsy, 793 from diphtheritic pal- sy, 793 etiology of, 789 morbid anatomy of, 789 pathology of, 790 prognosis of, 793 symptoms of, 790 treatment of, 794 subacute and chronic ante- rior, 795 diagnosis of, 796 from neuritis, 796 treatment of, 797 Politzer bag in middle-ear in- flammation, 1168 inflation in chronic tympanic catarrh, 1175 in suppurating middle ear, 1169 Poluboskos in diabetes, 1002 Polyadenitis, diagnosis of, from Hodgkin’s disease, 283 from syjihilis, 283 tuberculous, 283 after infectious disease, 283 Poly myoclonus, post-hemiple- gic, 6.52 Polyp masses in chronic sup- purating middle ear, 1171 umbilical, 86 Polypus of rectum, .592 Polyuria in diabetes insipidus, 1005 in etiology of constipation, 497 Pomegranate against ticniie, 536 Porence|)baly, 649 Post-natal atelectasis, 89i). See ,4 leJectasis, post-natal. Posture in infancy, 12 Posture in perinephritic ab- ’ scess, 1033 Postures in rising in pseudo- hypertrophic paralysis, , 770 I Potassium acetate in ascites, | 573 in rheumatism, 3.57 bromide in chorea, 763 in diabetes insijiidus, 100(5 in eclampsia, 746 in epidemic cerebro-spinal meningitis, 213 in erysipelas, 229 in infancy, 36 in pertussis, 191 in scarlet fever, 146 in variola, 169 carbonate in treatment of stone, 1045 chlorate as a cause of hsema- turia, 992 in acute pharyngitis, 416 in diphtheria, 262 in diseases of the mouth, 397 in mercurial stomatitis, 409 in stomatitis ulcerosa, 404 citrate in measles, 128 iodide in acute myelitis, 787 in asthma, 961 in brain tumors, 644 in broncho-adenitis, 931 in cerebral meningitis, 603 in cerebro-spinal menin- gitis, 213 in chronic interstitial ne- phritis, 1026 in cirrhosis of liver, 5.59 in epilepsy, 752 in fibroid phthisis, 967 in interstitial keratitis, 1197 in imlmonarv emphysema, 954 in syphiloderma, 1146 salts in acute tubal nephritis, 1017 Pott’s disease, 1064 absee.ss in, 1067 treatment of, 1071 ambulatory treatment of, 10(58 amyloid changes in, 1067 cervical, 1066 coni])lications of, 1066 deformity in, 1066, 1068 diagnosis of, 1067 dorsal, 1066 etiology of, 1064 gait in, 10(56 lumbar, 10(5(5 pain in, 10(56, 10(57 l>aralysis in, 10(56 treatment of, 1071 pathology of, 1065 prognosis of, 10(58 psoas spasm in, 10(57 pulmonarv tuberculosis in, 10(57 symptoms of, 10(55 treatment of, 10(58 tuberculous meningitis in, 1067 Poultices forbidden in conjunc- fiviti.s, 1185 in bronchitis, 9553 Poultices in pericarditis, 976 in peritonitis, .5(56 in peritonsillar abscess, 422 Pouting perforation of drum- membrane, significance of, in suppurating mid- dle ear, 1170 Powder-burns of eyelid, 1184 Powders in eczema, 1106 Priecordial distress, 988 jiain, 988 Predigested food in acute in- testinal indigestion, 465 in mucous diseases. 458 Predigestion, chemistry of, 47 Predisposition in etiology of diphtheria, 2.52 Prepuce, adherent, 10,57 treatment of, 10.58 traction u])on, in gravel, 1008 Preputial adhesions, spontane- ous separation of, 1057 Presystolic mitral murmur, comparative frequency of, 982 murmur in mitral stenosis, 982 Priapism in acute myelitis, 784 in adherent pre{)uce, 10.57 Prickly heat, 1094. See Mili- aria Primarv jdeurisy, etiology of, 937, 940 Prince’s s t a p h y 1 o r r a p h y- necdle, 436 Proctitis, .587 acute catarrhal, .588 chronic catarrhal, ,588 Proctodauim, .577 Procursive epilepsy, 751 Profound sleej) in etiology of incontinence of urine, 996 Prolapsus ani in chronic, intes- tinal indigestion, 4(59 of rectum, 590 in pertussis, 188 Proliferation, zone of, in ra- chitic bone, 329 Prophvlaxis of seiitic infection, 89 Prostate gland in children, 1045 Prostration in cholera, 237 in variola, 164 Proteid food, excess of, as a cause of lithaunia, 94 poisons from toxicogenic germs, 474 Proteids, percentage of, in modified milk, ,55 Prurigo, 1123 Pruritus ani, .584 genital, in diabetes mellitus, 1000 in vaccinia, 174 P.seudo-crouii, 848 Pseudo-diphtheria, 418. See 'l'o}isilliti.s, infectious jmriKlo-mcmhranous. in variola, 167 Pseudo-hj'])ertrophic muscular paralysis, 768 diagnosis of, 773 from congenital spas- tic paraplegia, 773 INDEX. 1 233 Pseudo-hyportropliic muscular paralysis, diasuosis of, from progressive chronic neuritis, 773 etiology of, 771 morbid anatomy of, 772 treatment of, 773 Pseudo-membrane of diphthe- ria, 254 of pharynx in variola, 165 Pseudo-membranes, strepto- cocci in, 251 varieties of, 260 Psoas abscess in Pott’s disease, 1067 spasm in Pott’s disease, 1067 Psoriasis, 1111 circinata, 1112 diagnosis of, 1112 from scaling syphilides, 1113 from scaly eczema, 1112 from seborrhoea, 1112 diffusa, 1112 etiology of, 1112 guttata. 1112 gyrata, 1112 nummularis, 1112 prognosis of, 1113 punctata, 1112 treatment of, 1113 varieties of, 1112 “Psychical equivalent” of hysteria, 736 Ptomaines in scarlatinal neph- ritis, 140 in septic infection, 89 Ptosis, 1182 Ptyalin, scarcity of, in infants, 45 Pubic louse in eyebrows or lashes, 1156 Puerile respiration, 16 Pulmonary arterv, stenosis of, 970 ' emphysema, 950 orifice and artery, atresia of, 971 resonance, alterations of, 17 at bases, 17 in infrascapular regions, 17 in iuterscapular space, 17 in scapular region, 17 tuberculosis. See Tubercu- losis, pulmo^Ktry. in Pott’s disease, 1067 Pulsating pleurisy, 945 Pulse, 10 diminished frequency of, 11 in jaundice, 11 in nephritis, 11 importance of, in diagnosis, 11 in acute milk infection, 476 in acute spinal leptomenin- gitis, 780 in acute tubal nephritis, 1011 in asthma, 958 in bronchitis, 928 in broncho-pneumonia, 906 in catarrhal dysentery, 488 in cerebral meningitis, ,599 in cerebro-spinal meningitis, 211 in childbood. character of, 11 in chlorosis, 363 in cholera, 238 T8 Pulse in chronic tubal nephri- tis, 1019 increased frequency of, 11 in croupous pneumonia, 915 in diphtheria, 256 in erysipelas, 225 in gangrene of lung, 922 in influenza, 216 in invasion of variola, 164 in jaundice, 543 in leuksemia, 374 in measles, 120, 121 in pericarditis, 947 in peritonitis, 565 in pernicious aneemia, 366 in pleurisy, 940, 941 in ])Ost-natal atelectasis, 900 in rachitis, 339 in rubella, 154 in scarlet fever, 136 in simple cerebro-spinal meningitis, 607 in stomatitis gaugrsenosa, 406 in subacute purpura hsemor- rhagica, 381 in tuberculous meningitis, 611,612 in typhoid fever, 198, 200 palpation of, in infants, 11 relation of, to fever, 11 Pulsus paradoxus, 987 Pumpkin-seed against tteuise, 537 Puncture, lumbar, for hydro- ce])halus, 628 Pupil, alterations of, with tu- mors of spinal cord, 804 in cerebro-spinal meningitis, 210 in simple cerebro-spinal men- ingitis, 606 in ura?mia, 1011 Pupillary symptoms in heredi- tary ataxia, 818 in syringomyelia, 813 Pupils in cerebral meningitis, 599 in coma of pernicious malaria, 314 in tuberculous meningitis, 617 Purgatives in cerebral meningi- tis, 603 in cerebro-spinal meningitis, 608 in typhlitis and appendicitis, ‘513 Purpura, 1125 after influenza, 218 diagnosis of, 1127 from flea-l)ite. 1127 from scurvy, 1127 etiology of, 1127 hsemorrhagica, 379, 1126 acute, 384 cases complicating preg- nancy, 386 cases with marked sepsis, 285 cases with visceral hem- orrhages, 386 essential. .379 ordinary cases of, 380 secondary, 387 after fright, etc., 388 in non-syphilitic infants, 388 Purpura Inemorrhagica, sec- ondary, in syphilitic in- fants, 388 with aniemia, etc., 388 with cases of .severe jaun- dice, 388 with infectious diseases, 388 with maliguaiit endocar- ditis, 388 with multiple sarcomata, 388 subacute, 380 constitutional symptoms of, 380 ha'morrhagic symptoms of, 380 pathology of, 381 prognosis of, 382 treatment of, 382 neonatorum, 1126 prognosis of, 1127 j rheumatica, 387, 1126 simplex, 387 treatment of, 1127 Purulent corneal ulcer, 1194 iritis, 1198 pleurisy, 935 Pustular syphiloderm, 1144 Pustule of hamorrhagic variola, 163 of variola. 163 Putty stools, 468 Pyone])hrosis, 1031 diagnosis of, 1032 etiology and pathology of, 1031 prognosis of, 1032 treatment of, 1032 tubercular, 298 Pyoimeumothorax, 945 Pyrexia, tyi>es of, 12 Pvrogallic acid in lupus vulga- j ‘ ris, 1141 Pyromania, 703 ' Pyrophobia, 704 Pyuria, 995 in stone in bladder, 1009 Quarantine in measles, 130 in rubella, 155 Quartan malarial fever, charac- teristics of, 312 parasite of, 306 difl'erences of, from tertian, 306 ! Questioning the attendants, definite order in, 2 Quincke’s lumbar puncture in diagnosis of tubercu- lous meningitis, (!20 in hydrocephalus, 629 Quinine and urea, muriate of, in malaria, 317 in acute endocarditis, 980 in acute middle-ear inflam- mation, 1169 in amoehic dysentery, 495 in asthma, 962 in broncho-imeumonia, 911 in croupous luieumonia, 918 in eczema, 1105 in malarial fever, 317 in malignant measles, 128 in measles, 128 in ])ertussis, 191 in Raynaud’s disease, 825 1234 INDEX. Quinine in rheumatism, 357 in scarlet fever, 140 in tuberculosis, 302 in variola, 109, 170 locally in pertussis, 192 Quinsy. See Peritonsillar ab- scess. Quotidian intermittent fever, diagnosis of, 315 temperature in, 311 Race in etiology of vesical cal- culus, 1040 Rachitic bone, analyses of, 330 child, characters of, 331 deformities, 1087 of pelvis, 330 fo?tus, 330 head, description of, 332 paralysis, 342 pseudo-cretinism, 682 rosary, diagnostic value of,322 Rachitis, 319 See, also, Ricfcets. age of occurrence of, 322 among the well-to-do, 320 anatomical characters in stage of deformity of, 330 in stage of proliferation of, 328 in stage of reconstruction of, 338 changes in osseous system in, 327 in soft tissue in 325 of cranial bones in, 331 definition of, 319 diagnosis of, 320 dietetic cau.scs of, 325 due to proprietary foods, 323 etiologv of, 323 foetal, 322 frequency of, 319 amoug Italians and ne- groes, 320 general symptoms of, 338 hygienic treatment of, 342 pathology of, 325 treatment of, 342 Radius, changes in, in rachitis, 336 Rales in asthma, 9.59 in bronchitis, 930 in broncho-pneumonia, 908 in pleurisy, 942 in pneumonia, 916 in ])ulmonarv tuberculosis, 296 Rapid heart, 988 with tumors of spinal cord, 804 Rash. See, also, Ernption. in malignant measles, 123 Rashes. See, also. Eruptions. in chronic gastric catarrh, 448 initial, in variola, 164 Raspberry excrescence, 174 Raynaud’s disease, 820 course, duration, results of, 824 diagnosis of, 824 etiology of, 822 pathology of, 823 relation of intermittent luemoglobinuria to, 823 treatment of, 824 Reaction of degeneration in acute j)oliomyelitis, 791 Reactions, electrical, in acute poliomyelitis, 791 in i)seudo - hypertrophic paralysis, 771 Rectum, absence of, 583 congenital narrowing of, 578 diseases of, 584 foreign bodies in, 595 imperforate, .578 perineal o])cration for, 479 malignant diseases of, 594 nawns of, 593 polypus of, 592 treatment of, 593 prolapsus of, 590 diagnosis of, 591 treatment of, 591 varieties of, 590 with seat-worms, 530 stricture of, 589 syphilis of, 589 ulceration of, 589 wounds of, 594 Recurrence after nephrectomy for tumors of kidney, 10.37 after operations for stone, 1047 in endocarditis, 978 of paroxysms of spasmodic laryngitis, 849 Recurrent attacks in purpura hfemorrhagica, 381 headache, 721 “ Red softening,” 630 Reduplication of second sound at apex in endocarditis, 979 Refiex headache, 723 insanities, 706 irritation of anus in chronic gastric catarrh, 449 of nostrils in chromic gas- tric catarrh, 449 pains in vesical calculus, 1043 symptoms from cerumen im- paction, 1162 Reflexes in acute myelitis, 784 in acute poliomyelitis, 791 in athetosis, (>9,5 in hereditary ataxia, 817 in infantile cerebral palsies, 652 with tumors of spinal cord, 803 Refraction of eve in childhood, 1201 Regurgitation, aortic, 983 mitral, 981 tricus])id, 983 Reinfection in rubella, 1.54 Relapses in rubella, 1.54 in subacute milk infection, •182 in tyi>hoid fever, 198 Remittent fevers, irregular, 312 Renal cirrhosis. See Nephritis, chronic interstitial. cysts, 1027 insuflieioncy in chronic heart disease, treatment of, 98.5 sclerosis. See Nephritis, chronic interstitial. Resection of rib in empyema, 947 Resonance of chest, different degrees of, 16 percussion, in health, 16 pulmonary, alterations of, 17 at bases, 17 in infrascapular regions, 17 in interscapular .space, 17 in scapular region, 17 Resorcin in erysipelas, 229 in mucous disease, 459 in pertussis, 192 Respiration, 10 accelerated, causes of, 10 arrest of, during trache- otomy, 881 artificial, Duke’s method, 79 Forest’s method, 79 Hall’s method, 79 Re 5 'iiolds’s method, 79 Schultze’s method, 78 Sylvester's method, 79 changes in, in tuberculous meningitis, 618 Cheyne-Stokes, 10 diminished frequency of, 10 expiratory, 10 in ascites, 15 in asthma, 958 in bronchitis, 928 in cerebral meningitis, .599 increase in rapidity of, 10 in enteritis, 15 in infancy, 16 in malignant measles, 123 in measles. 122 in peritonitis, 15, ,565 in pleurisy and pneumonia, 15 in post-natal atelectasis, 901 in rachitis, 15 in severe spasmodic laryn- gitis, 852 in tubercular meningitis, 604 in variola, 164 irregularity of, 10 in children, 987 mode of estimating, 10 jmerile, 16 rapid, in hysteria, 735 rates of, during sleep, 10 in children, 10 tyiie of, in children, 10 Rest in chronic tubal nephritis, 1022 in hip-joint di.sease, 1074 in knee-joint disease. 1078 in Pott’s disease, 10(i8 Results of corneal ulceration, treatment of, lli)6 Retention of clots in luema- turia, 991 Retraction of chest-wall in atelectasis, 901 Retractors in tracheotomy, caution in use of, 878 Retro-])haryngeal abscess, 427 treatment of, 128 lymphadenitis, 427 tracheotomy in, 140 Reynolds’s 7uetliod of artificial resi>iration, 7tt Rhahdis genitalis a cause of Inmuaturia, 993 Rhabdo-sareoma of kidney, 1035 INDEX. 1235 Rhagades in hereditary syph- ilis, 160 syphilitic, characteristics of, 408 Rheumatic diathesis in etiology of acute gastric catarrh, 443 Rheumatism, 351 acute, 351 course and duration of, 355 cutaneous eruptions in, 354 definition of, 351 diagnosis of, 354 from cerebro-spiual fever, 355 from pyiemia, 355 from rickets, 355 from scarlatinal rheu- matism, 354 from scurvy, 355 from syphilis, 355 etiology of, 351 prognosis of, 355 treatment of, 356 after influenza, 217 chronic, 358 diagnosis of, from rheu- matoid arthritis, 358 treatment of, 358 in etiology of acute endocar- ditis, 977 of pericarditis, 975 of psoriasis, 1112 of vesical calculus, 1039 local treatment of, 357 morbid anatomy of, 352 muscular, 357 diagnosis of, 358 from neuralgia, 358 prognosis of, 358 treatment of, 358 of the legs in scurvy, 391 with jieritonitis, 564 Rhinitis, acute, 826 treatment of, 827 atrophic, 833 diagnosis of, 835 from hereditary syphilis, 835 treatment of, 836 hypertrophic, 829 diagnosis of, 831 pathology of, 829 treatment of, 832 purulent, 828 treatment of, 829 simple chronic, 828 diagnosis of, 828 Ribs, changes in, in rachitis, 334 Rickets. See Rachitis. acute, 342 in the etiology of eclampsia, 742 in the etiology of laryngis- mus stridulus, 858 of splenic ansemia, 368 predisposing to scorbutus, 389 Rigidity and contractures in infantile cerebral palsies, 652 in acute spinal leptomenin- gitis, 779 in simple cerebro-spinal men- ingitis, 606 Rigors. See Chills. Ringworm. See Tinea tricho- phi/tina. Romanowsky’s method of stain- ing in malaria, 316 Rosauilin hydrochlorate in tinea tonsurans, 1153 Rose spots in tyi>hoid fever, 199 Roseola, epidemic. See Rubella. infantilis, 1097 Rotch, Thomas M., method of modified milk, 53 Rbtheln. See Rubella. Round-worm. See Ascaris lum- bricoides. Rubella, 152 complications and sequelae of, 1.54 definition of, 152 diagnosis of, 151 from measles, 154 from scarlet fever, 1.55 distinction of, from measles, 1.54 incubation of, 152 in etiology of bronchitis, 924 morbilliforme, 153 prognosis of, 1.54 quarantine in. 155 scarlatiniforme, 153 symptoms of, 1.53 synonyms of, 152 treatment of. 155 Rubeola. See Measles. Saccharin in diabetic diet, 1003 Saccharomyces albicans, 401 biology of, 401 Saemisch’s section, 1195 Salads in lithaemic diet, 100 Salicin in rheumatism, 3.57 in scarlatinal arthritis, 146 Salicylate of bismuth in typhoid fever, 206 of sodium in lithaemia. 101 Salicylates in lithaemia, 101 in rheumatic tonsillitis, 3.57 value of, in rheumatism, 3.56 in treatment of warts, 1131 in tuberculosis, 302 Salicylic-creasote plaster-mull in lupus, 1141 Salines in dysentery, 493 in peritonitis, 567 Salivation in stomatitis ulce- rosa, 404 Salol in cholera, 244 in chronic gastric catarrh, 451 in gonorrhoea, 1054 in jaundice, 549 in lithaemia, 101 in mucous disease, 4.59 in parotitis, 180 in vulvo-vaginitis, 1056 Salophen in chorea, 762 Santonin against ascarides, 528 against seat-worms, .531 Sarcoma of eyelids, 1181 of kidney, 1035 of orbit, 1201 of peritoneum, 570 Sarcomata of brain and menin- ges, 635 Satyriasis, 703 Scabies, 1154 Scabies, diagnosis of, from ecze- ma, 11.5.5 etiology of, 11.55 j)rognosis of, 11.55 treatment of, 11.55 Seal]), eczema of, treatment of, ' 1109 Scajiboceiilialic idiocy, 671 Scarification in treating ery- sipelas, 229 Scarlatina. See Scarlet fever. fulmiuans, 137 iutermittens, 139 miliaria, 139 pupulosa, 1.38 pemphigoides sen bullosa, 139 petechialis.seu hmmorrhagica, 139 simplex, 137 sine angina, 137 with pertussis, 188 Scarlatinal nephritis, 140 diagnosis of, from septic, 142 heart-failure in, 148 prognosis of, 144 treatment of, 146 Scarlatiniform erythema fol- lowing chicken-pox, 159 Scarlet fever, 146. See, also. Scarlatina. association of, with vari- cella, 131 bacteriology of, 133 com]ilications of, 139 contagion after disinfection in, 133 by fomites, 133 by milk, 133 contagiousness of, 131 contagium of, 132 danger in light cases of, 144 day of minimum tempera- ture in, 137 definition of, 1.30 diagnosis of, 143 from erythema scarlatini- forme, 143 from measle.s, 144 from rubella, 144 disinfection of bedding after, 151 of room after, 151 endocarditis with, 978 etiology of, 131 examination of urine in, 147 history of, 131 incubation of, 136 in etiology of chronic tu- bal nephritis, 1018 of jiericarditis, 975 microbic origin of, 132 mode of transmission of, 133 mortality of, 145 pathology of, 135 prognosis of, 144 prophylaxis of, 149 failure of drugs in, 149 quarantine in, 149 sequel® of, 142 symptoms of, 1.36 treatment of, 136 value of isolation in, 149 varieties of, 1.39 Schools, physical culture in, 54 123U INDEX. Schultze’s method of artificial respiration, 78 Sclerema neonatorum, 1132 diagnosis of, 1132 from (edema, 1132 etiology of, 1132 prognosis of, 1132 treatment, 1132 Scleroderma, 11,33 diagnosis of, 11,33 from Kaposi’s disease, 1134 from sclerema neonato- rum, 1133 etiology of, 1133 j)roguosis of, 1134 treatment of, 1134 Sclerosis, lateral, with syringo- myelia, 813 of Ammon’s horn in epi- lepsy, 748 of tubercle, 278 Scoliosis, 334, 1063 causes of, 54 diagnosis of, 1063 due to Pott’s disease 1064 etiology of, 1063 in syringomyelia, 813 mechanical support in, 1064 prognosis of, 1064 treatment of, 54 Scorbutus, 389 diagnosis of, 395 etiology of, 389 pathology of, 390 prognosis of, 395 relation to rickets, 392 symptoms of, 391 treatment of, 395 Scrofula, relation of, to tuber- culosis, 277 Scrofuloderma, 1143 diagnosis of, 1143 etiology of, 1142 treatment of, 1143 Scrofulous diathesis, 276 in etiology of acute gastric catarrh, 442 iritis, 1198 kidney, 298 Scurvy, 389, See Scorbutus. as a cause of ha>matnria, 994 Scutulnm of favus, 1148 Sea-air, 60 in asthma, 63 in chorea, 64 in convalescence, 62 from measles, 128 in diseases of the eye, 65 in entero-colitis, 62 in nasal catarrh, 63 in pharyngeal catarrh, 63 in phthisis, 63 in Pott's disease, 64 in rheumatism, 64 in rickets, 64 in whooping-cough, 6,5 odoir of, 60 ozone in, 60 sodium chloride in, 90 Sea-bathing, 65 effects of, 66 freciuency of, 66 hour for, 66 rules for, 66 season for, 66 value of, 65 I Sea-coast, clothing at, 67 ' Sea-coast, death-rate at, 61 exercise at, (>7 food at, 67 rainfall at, 62 temperature at, 61 wind at, 62 Season in etiology of chorea, 756 of erysipelas, 221 of malaria, 304 of measles, 118 of variola, 163 of whooi>ing-cough, 182 Seat-worm. See Oxyuris ver- micularis. Sea-water, comiiosition of, 65 Sebaceous cyst of eyelid, 1183 Seborrhtta, 1091 diagnosis of, 1091 from eczema, 1091 from psoriasis, 1091 etiology of. 1091 of lid-border. See Blephari- tis. jirognosis of, 1092 treatment of, 1092 Second attacks of whooping- cough, 182 Sedentary habits in etiology of constiiKVtion, 497 life in etiology of constipa- tion, 497 Sediment in urine of acute tu- bal nephritis, 1012 Segmentation of malarial or- ganisms, 306 relation of, to paroxysm, 306 Sensory symptoms of syringo- myelia, 812 Septal deflection in adenoid hypertro])hy, 431 Septic diseases in etiology of acute tubal neidiritis, 1011 infection of new-born, 89 prophylaxis of, 89 treatment of, 89 Septicfcmia in etiology of bron- chitis, 925 in scarlet fever, 142 Septico-pyamiia of new-horn, pleurisy in, 938 Serous cystic tumors of ])erito- neum, 570 exudate in peritonitis, 565 irido-cvclitis, 1198 iritis, 1198 Serpiginous corneal ulcer, 1194 Serum-test for typhoid fever, 205 Serum treatment of croupous pneumonia, 918 Sex in etiology of chlorosis, 362 of chorea, 756 of chronic peritonitis, .568 of cirrhosis of the liver, 558 of diabetes mellitus, 999 of intu.ssnseeption, 518 of larvngismus stridulus, 858 of rheumatism, 351 of simple meningitis, .596 of tuberculous meningitis, 610 Sex in etiology of typhlitis, 510 of vesical calculus, 1040 of whooping-cough, 183 in prognosis of pertussis, 189 Sexual organs in idiocy, 675 power in hereditary ataxia, 817 Shell-fish in diabetic diet. 1003 Shingles. See Herpes zoster. Shoe for club-foot, 1085 Shoes for children, 34 Shoulder-joint disease, 1081 prognosis of, 1018 symiitoms of, 1081 treatment of, 1081 Sigue de Dance, 519 Silver nitrate in Jaundice, .548 in ophthalmia neonatorum, 1187 in stomatitis aphthosa, 400 catarrhalis, 398 syphilitica, 409 Simple atrophy. See Atrophy, simple. corneal ulcer, 1194 Sinapisms in Landry's paral- ysis, 799 Sijdionage in empyema, 948 of chest, details of operation, 949 Size, average, of nesv-born child, 12 Skeleton, efl'ect of rachitis upon, 337 Skin, appearance of, in dis- ease, 5 in health, 5 atrophies of, 1135 condition of, in health, 13 in intestinal tuberculosis 13 in marasmus, 13 in mucous disease, 13 in jirotracted diarrluea, 13 diseases of, 1090 ha-morrhages of, 1125 hypertrophies of, 1128 in acute poliomyelitis, 792 in post-natal atelectasis, 900 in scarlet fever, 136 in simjile atrophy, .505 in typhoid fev(;r, 197 new growths of. 1137 parasitic affections of, 1198 symi)toms in tvphoid fever, 199 Skoda's resonance, 296 •Skull, depressions in, 83 Sleep, 34 amount reiiuired, 34 in chronic gastric catarrh, 449 in tyjihoid fever, 198 regularity in, 34 temi>eraturo of room for, 35 ‘‘ Sleeping cool.” 4 “ Slec'i)ing high,” 4 Sloughing corneal ulcer, 1194 Slow fever, See Tyjihoid fever. heart, 988 pulse in acute gastric catarrh, 444 in diphtheria. 256 •Small-pox. See Variola. •Soa]i jilaster, Hardaway's modi- fication of Pick's, 1108 Pick’s, in eczema, 1108 INDEX. 1237 Soda solution, Parker’s, 882 Sodium bicarbonate in chronic fjastric catarrh, 451 in rbenmatism, 357 in stomatitis mycosa, 402 bromide in chronic heart disease, 985 in unemic convulsions, 1010 ethylate for naevus vascu- laris, 1139 hypophosiihite in furuuculus, 1124 phosphate in cirrhosis of liver, 560 in congestion of liver, 551 in constipation, 499 in Jaundice, 548 in litha;mia, 101 salicylate in acute folliculous tonsillitis, 420 in chorea, 762 in diabetes mellitus, 1004 in lithsemia, 1101 in peritonsillar abscess, 421 in rheumatism, 356 Softening of tubercle, 278 Solitary follicles in typhoid i^ever, 196 Solution, Gabbet-Ernst’s, 271 of fuchsin, Ziehl’s, 271 Somatose in typhoid fever diet, 206 Somnambulism, 732 Somnial epilepsy, 751 Sore throat. See Aiif/iiia. in chicken-pox, 157 in typhoid fever, 199 Soups in diabetic diet, 1003 Soya flour in diabetes, 1002 Sparteine in atelectasis, 903 in peritonitis, .567 Spasm in Laryngismus stridu- lus, 861 inward, 744 Spasmodic laryngitis, severe form, 852 Spasmus glottidis. See Laryn- gismus stridulus. Specific fevers in etiology of acute gastric catarrh, 442 Spectacles in treatment of concomitant convergent strabismus, 1203 Speech, aflections of, due to peripheral paralysis, 664 bad habits of, 665 defects and anomalies of, 658 from adenoid growths, 665 treatment of, 665 in cretinism, 681 in hereditary ataxia, 818 in idiocy, 675 Sphincter ani, paralysis of, with tumors of spinal cord, 804 Spigelia against ascarides, .529 against seat-worms, .531 Spina bifida in hydrocephalus, 627 Spinal cord, tumors of, 801 tenderness in acute lepto- meningitis, 779 Spine, lateral curvature of, 1063. See Sclerosis. tuberculosis of, 1064. See Pott's disease. Spirillum cholercse Asiaticse, 2.32 bacteriology of, 232 modes of multiplication of, 232 multiplication of, in cul- ture-media, 233 poison elaborated by, 235 Spleen, chronic diifuse tubercu- losis of, 282 enlargement of, diagnosis of, 14 in malarial cachexia, 314 in rachitis, 326 iu diphtheria, 254 in leuksemia, 374 in pernicious malaria, 309 iu splenic auiemia, .368 iu typhoid fever, 196, 197, 200 superior border of, 17 syphilis of, 105 Splenectomy in leukaemia, 376 Splints for knee-joint disease, 1078 Sporadic cerebro-spinal menin- gitis. See Menbujitis, simple cerebrospinal. cretinism, 684 Spraying in diphtheria, 264 Sprays iu hypertrophic rhinitis, 832 Squamous blepharitis. See Blepharitis. Squills in broncho-pneumonia, 883 in severe spasmodic laryngi- tis, 1^.54 Squint. See Strabismus. Stacke oper,ation in chronic suppurating middle ear, 1172 Stammering, 664 Staphylococci iu croupous pneu- monia, 914 Staphylococcus albus in acute folliculous tonsillitis, 418 in broncho-pneumonia, 904 in peritonitis, 564 pyogenes aureus in acute fol- ■ liculous tonsillitis, 418 Staphyloma of cornea, 1195 treatment of, 1196 Staphylorraphy, 435 conditions for success in, 436 Starch, digestion of, 45 diastase iu, 45 fermentation of, 22 Starvation, partial, in treat- ment of taenia, 536 Statistics in appendicitis, 516 of operations for stone, 1047 of tracheotomy, 873 Status eclampticus, 744 epilepticus, 751 Stenosis, aortic, 973 mitral, 973 of aorta, 963 of conus arterio.sus, 962 of pulmonary artery, 961 causes of. 962 symptoms of, 962 Sterilization, 47 apparatus for, 26 at low temperature, 48 method of, 27 of milk, 26 advantages of, 48 Sterilization of milk, disadvan- tages of, 48 Sterilized milk, character of, 27 Stigmata degeneratiouis, 654 in cirrhosis of liver, 558 of epilepsy, 751 of hysteria, 732 Stimulants. See Alcohol. iu acute milk infection, 478 in cerebral meningitis, 604 in croupous pneumonia, 918 in dysentery, 493 iu erysipelas, 229 iu post-natal atelectasis, 903 “ Stomach cough ” in chronic gastric catarrh, 149 Stomach-washing in acute milk infection, 477 Stomatitis ai)hthosa, 399 etiology of, 399 prognosis of, 400 treatment of^, 400 catarrhal is, 397 erythematous form of, .397 etiology of, 397 iu pertussis and acute ex- anthemata, 398 in teething, 412 prognosis of, 398 treatment of, 398 crouposa, 407 diphtheritica, 407 diagnosis of, 408 primary, in mouth, 408 prognosis of, 408 treatment of, 408 follicular, iu chronic intes- tinal indigestion, 468 gangrienosa, 405 etiology of, 405 pathology of, 405 prognosis of, 407 treatment of, 407 iu subacute milk infection, 481 mycosa, 400 etiology of, 401 in chronic gastric catarrh, 448 pathology of, 401 prognosis of, 407 treatment of, 402 syphilitica, 408 treatment of, 409 ulcerosa, 402 chronic, 404 etiology of, 402 pathology of, 403 prognosis of, 404 treatment of, 404 Stomoda-um, 477 Stone in bladder, symptoms of, 1008 Stools in acute intestinal indi- gestion, 466 in acute milk infection, 476 in amoebic dysentery, 491 in catarrhal dysentery, 488 in cholera, 237 in chronic intestinal indi- gestion, 468 in simple atrophy, ,505 in subacute milk infection, 479 Strabismus, 1102 after acute illness, 1103 concomitant convergent, 1102 1238 INDEX. Strabismus, concomitant con- vergent, causes of, 1103 diagnosis of, from par- alytic, 1103 treatment of, 1103 convergent, 1102 divergent, 1102 in cerebral meningitis, 599 in cerebro-spiual meningitis, 210 in idiocy, 074 in simple cerebro-spinal meningitis, 606 in tuberculous meningitis, 617 in typhoid fever, 200 paralytic convergent, 1102 upward or downward, 1102 Stramonium in asthma, 961 Strangulation, internal, by ap- pendix, 516 Strapping in hydrocephalus, 629 Streptococci associated with bacillus of diphtheria, 252 in diphtheria, 266 in septic infection of new- born, 89 Streptococcus erysipelatis, 223 in acute folliculous tonsillitis, 418 infection by, in pustules of variola, 167 in peritonitis, 564 in pseudo-membrane of vari- ola, 165 invasion of, in variola, 167 lanceolatus in pleurisy, 939 pyogenes aureus in pleurisy, 939 in acute folliculous tonsil- litis, 418 in broncho-pneumonia, 904 in croupous pneumonia, 914 in pleurisy, 939 Stretcher-bed ' for ambulatory treatment of Pott’s dis- ease, 1069 Stricture of anus, 587 of rectum, 589 “ Strippings,” 25 value of, 38 Strontium lactate in chronic interstitial nephritis, 1026 Strophanthus in atelectasis, 903 in chronic tubal nephritis, 1023 in peritonitis, 567 Strophulus albidus. See Mil- inm . in simple atrophy, 505 Strumous keratitis and con- junctivitis. See Kerato- conj imctivitis, phlyctenu- lar. Strychnine in acute poliomye- litis, 795 in asjdiyxia of new-born, 80 in asthma, 962 in broncho-pneumonia, 911 in chronic heart disease, 985 in croupous inieumonia, 918 in diphtheria, 261 in diphtheritic paralysis, 268 Strychnine in incontinence of urine, 997 in pulmonary emphysema, 954 in variola, 170 Stupes in peritonitis, 566 Stupor in invasion of variola, 164 in tuberculous meningitis, 611, 616 Stuttering, 664 Stye. See Hordeolum. Subcutaneous nodes in chorea, 755 Subsultus teudinum in cerebro- spiual meningitis, 210 Succussion sound in pyopneu- mothorax, 945 Sucrose, 46 Suction, act of, significance of its diminution, 6 significance of its re-estab- lishment, 6 Sudamina in typhoid fever, 199 Sugar in urine in simple atro- phy, 506 proportion of, in milk and cream mixtures, .59 tests for. in diabetic urine, 1000 Sugars, digestion of, 45 Suggestion in hysteria, 740 Sulphonal in diabetes mellitus, 1004 in variola, 169 Sulphur in scabies, 1155 in pertussis, 193 Sulphuric acid in cholera, 244 in night-sweats, 302 Sulphur-vapor after diphthe- ria, 261 Summer diarrhoea. See Milk infection, subacute. Superficial cervical fascia. 872 Suppositories in constipation, 499 in prolapse of rectum, 591 Sui)puration, chronic, in etiol- ogy of chronic tubal nephritis, 1018 fever of, in variola, 165 in etiology of amyloid kid- ney, 1024 in hydatid of liver, 556 in typhlitis, 511 Suppurative pleurisy, 935 Supraglottic laryngitis. See Laryngitis catarrhalis sim- plex. Suprapubic lithotomy, 1047 Surf-bathing in etiology of middle ear inflamma- tion, 1166 Surgical treatment in infantile cercljral palsies, 657 of brain tumors, 644 of epilepsy, 753 Sweating in gangrene of lung, 921 in pulmonarv tuberculosis, 296 Sweats in rheumatism, 3.52 Sylvester’s method of artificial respiration, 79 Symblei>haron, 1182 treatment of, 1182 Sympathetic irritation, 1199 ophthalmitis, 1199 Syncope, 988 in secondary an®mia, 361 local, 821 Synechia, anterior, 1195 Synechise, posterior, 1198 Synovitis in chicken-pox, 159 Syphilide, papular, of eyelid, 1180 Syphilis, acquired, 103 after vaccination, 175 as a cause of rickets, 323 hsemorrhagica neonatorum, 110 hereditary, 103 alopecia in, 112 blood in, 110 bone-lesions in, 106 diagnosis of, from rickets, 113 from tubercular, 113 conceptional, 103 coryza in, 109 definition of, 103 diagnosis of, 112 from scrofula, 112 disturbance of nutrition in, 110 glandular enlargements in, 110 in etiology of splenic anse- mia, 368 in infancy, 103 involvement of bones in, 111 lesions of heart in, 106 of kidneys in, 106 of liver in, 106 of lungs in, 105 of mucous membranes in, 105, 109 of pancreas in, 106 of spleen in, 106 of testicles in, 106 maternal influence in, 128 morbid anatomy of, 105 mucous patches in, 110 myositis in, 111 nervous disturbances in, 111 of nose and throat, 842 paternal influence in, 103 placenta in, 105 prognosis of, 103 rashes of, 109 skin symptoms of, 109 symptoms of, 108 teeth in. 111 treatment of, 1 15 visceral lesions of, 105 in etiology of acciuircd laby- rinthine deafness, 1176 of amyloid kidney, 1024 of cirrliosis of liver, 5.58 of leukamiia, 370 of lymphatic ammnia, 370 of jiaroxysmal hamiafuria, !)94 inherited nervous afi'ections due to, 645 late hereditary, 114 bone-affections in, 114 genital organs, in 115 interstitial keratitis in, 115 INDEX. 1239 Sj’philis, late hereditary, ne- phritis in, 115 periostitis in, 114 teeth in, 114 of eyelids, 1180 of rectum, 589 primary lesions of, in mouth, 408 pulmonary, causative of as- phyxia, 77 secondary lesions of, in mouth, 408 skin-lesions of, 105 tarda. See Syphilis, late he- reditary. Syphilitic asthma, 954 headache. 722 lesions of auricle, 1160 Syphilization, double, 104 Syphiloderma, 1143 diagnosis of, 1145 bullous, from pemphigus neonatorum, 1145 erythematous, from inter- trigo, 1145 etiology of, 1145 prognosis of, 1145 treatment of, 1145 Syringing in cerumen impac- tion, 1162 in extracting foreign bodies from auditory canal, 1164 Syringomyelia, 809 diagnosis of, 814 etiology of, 809 morbid anatomy of, 810 pathology of, sio symptoms of, 812 treatment of, 914 Systolic mitral murmur, rela- tive frequency of, 982 mu rmur i n aortic stenosis, 982 in defect of ventricular septum, 969 in mitral regurgitation, 981 Tabes mesenterica, 286 Tache cerebrale as a differ- ential sign in tuberculous meningiti.s, 203 in cerebral meningitis, 599 Tachycardia, 988 Tsenia, 532 cucumerina, 534 mediocanellata, 533 nana, 534 solium, 533 Tseuise, diagnosis of, 535 habitat of, 534 method of infection by, 534 ova of, 534 treatment of, 535 varieties of, 533 Talipes calcaneus, 1083 equinus, 1083 in pseudo - hypertrophic paralysis, 771 equino-varus, 1086 open incision for, 1086 valgus, 1083 varus, 1083 Tannin in gastro-intestinal haemorrhage, 87 Tapeworm. See Txnia. Tapotement, 57 Tar-aud-zinc ointment in ec- zema of scalp, 1109 Tarsitis, 1181 Tarsorraphy for lagophthalmos, 1182 Tarsus, tuberculous disease of, 1079 Tartar emetic in severe spas- modic laryngitis, 854 Tattooing in leucoderma, 1136 Taxis in intussusception, 521 Taylor’s brace for Pott’s dis- ease, 1070 long hip-splint for hip-dis- ease, 1074, 1075 Tears, significance of, in prog- nosis, 7 Teeth, eruption of, in etiology of eczema, 1103 in typhoid fever, 197 milk, appearance of, 17 permanent, 17 order of appearaxice of, 411 premature, 411 time of eruption of, 411 Teething as an etiological fac- tor, 409 order of, 410 symptoms of, 412 treatment of, 413 Temperature, 11 abnormal depression of, 12 during first week of life, 11 estimation of, 11 in acute gastric catarrh, 443 in acute intestinal indiges- tion, 466 in acute milk infection, 476 in acute myelitis, 784 in acute poliomyelitis, 790 in acute spinal meningitis, 780 in acute tubal nephritis, 1071 in brain abscess, 631 in bronchitis, 928 in broncho-pneumonia, 906 in catarrhal dysentery, 488 in cerebral meningitis, 598 in cerebro-spinal meningitis, 211, 607 in chicken-pox, 158 in cholera, 238 in chronic intestinal indiges- tion, 468 in chronic peritonitis, 568 in cirrhosis of liver, 558 in croupous pneumonia, 914 in diphtheria, 256 in disease, 12 in epidemic cerebro-spinal meningitis, 211 in erysipelas, 225 in gangrene of lung, 921 in infectious pseudo-mem- branous tonsillitis, 419 in influenza, 216, 217 in intussusception, 419 in Landry’s paralysis, 799 in lithsemia, 97 in lymphatic anaemia, 387 in malignant measles, 123 in measles, 119, 121 in perinephritic abscess, 1033 in. peritonitis, 565 in peritonsillar abscess, 421 in pleurisy, 940, 941 in post-natal atelectasis, 900 in rachitis, 339 in Raynaud's disease, 822 Temperature in rubella, 1.54 in scarlet fever, i;i7 in scorbutus, 392 in severe spasmodic laryngi- tis, .583 in simple atrophy, 505 in spasmodic laryngitis, 8.50 in stomatitis catarrhalis, 398 in stomatitis gangnenosa, 406 in subacute milk infection, 479 in subacute purpura hsemor- rhagica, 380 in syphilitic inflammation of liver, 552 in tuberculous meningitis, fill, 614 in typhlitis, 511 in typhoid fever, 198, 201 in vaccinia, 174 in variola, 164 after eruption, 165 in whooping-cough, 185 maximum of, 12 minimum of, 12 oscillations of, 11 in disease, 12 post-mortem rise of, in ery- sipelas, 223 post-typhoid elevation of, 221 variations in typical range of, 12 Temporal bone, necrosis of, in ear disease, 1173 Tenderness in intussusception, 519 in peritonitis, 565 in typhlitis, 510 of surface in rachitis, 349 in scorbutus, 451 Tendon-reflexes in pseudo-hy- pertrophic paralysis, 771 Tenesmus, hysterical, 735 in intussusception, 520 Tenotomy in club-foot, 1084 in infantile cerebral palsies, 657 Terebene in pulmonary emphy- sema, 955 in tuberculosis, 302 Terebinthine in tuberculosis, 301 Tertian intermittent fever, 310 chilly stage of, 310 diagnosis of, 315 fever stage of, 310 parasite of, 304 physical signs in, 312 sweating stage of, 311 temperature in, 310 Testicle, syphilis of, 106 tuberculosis of, 99 Tetanus of new-born, 91 treatment of, 91 Tetany, 794 diagnosis of, 766 from hysteria, 766 etiology of, 764 in rachitis, 341 morbid anatomy of, 766 prognosis of, 767 relation of, to laryngismus stridulus, 8,58 symptoms of, 765 treatment of, 767 Theoretical formula for feeding with modified milk, 55 1240 INDEX. Thermo-cautery in stomatitis mycosa, 407 Thirst in acute milk infection, 470 in cholera, 237 in diabetes insipidus, 977 in diabetes mellitus, 971 in measles, 119 in rachitis, 339 in simple cerehro-spinal men- ingitis, 607 in typhoid fever, 205, 206 Thomas’s knee - splint, 1078, 1079 Thompson’s mixture in rachi- tis, 349 Thomsen’s disease. See My- otonia. Thorax, deformity of, in ra- chitis, 334 with adenoid vegetations, 432 rachitic deformity of, 341 Thread-worm. See Oxyuris ver- micularis. Thrill in mitral stenosis, 982 Throat, treatment of, in scarlet fever, 146 Thrombosis in infantile cere- bral palsies, 656 of dural sinuses in dysentery, 486 Thrush in chronic intestinal indigestion, 486 in simple atrophy, 505 Thymol in tuberculosis, 302 Thymus gland, relations of, in tracheotomy, 872 Thyroid extract in cretinism, 685 gland, alteration in, in cretin- ism, 683 connection of cretinism with, 684 desiccated, in cretinism, 686 importance of, in animal economy, 683 transplantation of, in cre- tinism, 685 Tibia, changes in, in rachitis, 337 Tinea circinata, 1151 diagnosis of, 1152 from psoriasis, 1152 from seborrhoea, 1152 from syphilis, 1152 treatment of, 1153 favosa, 1148 diagnosis of, 1149 etiology of, 1149 prognosis of, 1149 treatment of, 1150 tonsurans, 1151 diagnosis of, from alopecia areata, 11.52 from eczema, 11.52 from jisoriasis, 11.52 from scborrhfea, 1152 disseminata, 11.52 treatment of, 11.53 trichoj)hytina, 1151 etiology of, 11.52 prognosis of, 1 1.52 trejitmcnt of, 1153 Tongue, ai>pearance of, in health, 17 Tongue in acute gastric catarrh, 443 in catarrhal dysentery, 488 in fever, 17 in invasion of variola, 164 in malignant measles, 123 in measles, 120, 122 in peritonitis, .565 in post-natal atelectasis, 899 in rheumatism, .352 in rubella, 1.54 in scarlet fever, 137 in simple atrophy, 505 in stomatitis catarrhalis, 398 in stomatitis syphilitica, 409 in typhlitis, 511 in typhoid fever, 197, 199 paralysis of, in tuberculous meningitis, 617 yellowish ulceration of fr®- num of, in pertussis, 188 Tongue-tie, 665 Tonic spasms in cerehro-spinal meningitis, 210 Tonics after parotitis, 180 after pericarditis, 976 in middle-ear inflammation, 1169 Tonsillitis, acute folliculous, 418 infectious nature of, 418 treatment of, 420 croupous. See TonsiUitis, in- fectious pseudo- membran- ous. infectious pseudo-membra- nous, 418 diagnosis of, 419 from diphtheria, 419 etiology of, 418 in rheumatism, 354 lacunaris, 418 parenchymatous, 421 phlegmonous, 421 simple folliculous, 419 suppurative. See PeritonsUlar abscess. Tonsillotome, Mathieu’s, 424 Tonsillotomy, author’s method of. 425 Tonsils, hypertrophy of, 422 etiology and pathology of, 422 hyperplastic form of, 422 symi)toms of, 423 treatment of, 423 Topophobia, 704 Torticollis, 1062 brace for, 1063 diagnosis of, 1062 difl'erentiation from cervical abscess, 1063 from I’ott’s disease, 1062 prognosis of, 1063 treatment of, 1063 with tumors of si)inal cord, 803 Toxalbumin of dii)lithcria, 2.53 Trachea, relations of, in tra- cheotomy, 873 Tracheal dil.ators for trache- otomy', 87.5 forceps for tracheotomy, 875 Tracheitis, 924 Tracheo-bronchial glands, sup- I)uration of. 286 tuberculosis of, 285 Tracheo-bronchial glands, tu- berculosis of, symptoms of, 2b6 Tracheotomy, 870 after-treatment of, 881 age in prognosis of, 874 auffisthetics in, 877 causes of death after, 884 choice of operations for, 876 complications after, 885 during operation of, 881 condition of patients after, 889 feeding after, 884 immediate results of, 881 indications for operation of, 873 in diphtheritic or membran- ous laryngitis, 872 instruments required for, 874 in treatment of foreign bodies in larynx and trachea, 867 in very advanced cases, 871 position of patient for, 877 prognosis of, 873 rapid, 889 removal of membrane in, 880 statistics of, 873 technique of, 878 thermo-cautery' in, 889 time for operation of, 871 without tubes, 888 Tracheotomy'-tube, care of, 883 change of, 683 difficulties in permanent re- moval of, 886 disinfection of, 883 permanent removal of, 883 Tracheotomy-tubes, 875 Trachoma. See Conjunctivitis, (irnnular. Trachoma-coccus, 1190 Traction ujjon iirepucc in stone cases, 779 Tragus-pressure in chronic tympanic catarrh, 1175 Training in trejUment of speech-defects, 666 Transitory frenzy, 699 psychoses, 698 T r a n s p o s it i o n of a r t e r ia 1 trunks, 972 * Traumatic iritis, 1198 Traumatism in etiology of acute peritonitis, .563 of acute tubal nephritis, 1011 of hysteria, 729 of pleurisy, 938 Treatment, general remarks on, 35 Tremor in hereditary ataxia, 818 in liysteria, 735 Trephining in hydrocephalus, 629 Trichiasis, 1182 Trichoccphalus dispar, 537 Trielioiihyton fungus, 11.52 Tricusiiid regurgitant murmur, 983 regurgitation, 9,83 jirognosis of, 984 valve, anomalies of, 970 Trigeminal ]inlsation, 988 Trional in typhoid fever, 206 Trommer’s lest for sugar, 1001 INDEX. 1241 Trophic disturbanco in infan- tile cerebral [lalsies, 652 lesions in syringomyelia, H13 with tumors of spinal cord, 803 Tropical dysentery. See Dijs- eiilery, muasbic. malaria. See JEstivo-antum- nal fevers. Trousseau sign in tetany, 765 Trousseau’s diuretic wine, 1023 Trypsin in diphtheria, 264 Tubercle bacilli. See Bacillus tuberculosis. in air, 274 in dust, 274 in milk, 286 difl'use intiltrated, 278 in etiology of typhlitis, 510 of conjunctiva, 1192 secondary intlammatory pro- cesses with, 279 Tubercular infection of new- born, 90 iritis, 1198 syphiloderm, 1144 tumors of brain and menin- ges, 635 Tuberculin, Hunter’s modifi- cation of, 301 in lupus vulgaris, 1033 in tuberculosis, 301 Tuberculocidiu in treatment of brain tumors, 643 Tuberculosis, 270 acute, Ehrlich’s reaction in, 281 following operation, 277 miliary, 279 diagnosis of, 281 prognosis of, 281 pulmonary type of, 280 typhoid type of, 280 bacillus of, 271 chronic diffuse, 282 diagnosis of, 283 from gastro-intestiual catarrh, 283 from rickets, 283 from syphilis, 283 complicating broncho-pneu- monia, 908 conditions favoring, 276 congenital, 273 experimental, 272 following acute gastro-intes- tinal catarrh, 282 following infectious disor- ders, 276 following measles, 282 following whcopiug-cough, 282 general etiology and morbid anatomy of, 270 generalized forms of, 279 hemoptysis in, 277 hereditary transmission of, theories of, 273 immunity of, 277 incidence of, statistics of, 271 in infancy and childhood, 270 in dairies, 275 in diabetes, 1000 individual predisposition to, 276 Tuberculosis in etiology of fibroid phthisis, 964 ino(mlation of, 274 local epidemics of, 274 localized, 283 modes of transmission of, 272 mortality of, 271 in prison, 274 of abdominal organs, 287 of ankle, 1079. See Ankle- joint disease,. of elbow-joint, 1080. See Elbow-joint di.sease. of Fallopian tubes, 299 of hip-joint, 1072. See Hip- joint disease. of intestines, 287, 288 of joints, 1071 of kidneys, 298 of knee-joint, 1076 of liver, 288 of lungs, 292 of lymim-glands, 283 of ovaries, 299 of pericardium, 298 of pleura, 298 of shoulder-joint, 1081 of spine, 1064. See Pott’s disease. of testis, 299 of wrist-joint, 1080. See Wrist-joint disease. prophylaxis of, 299 pulmonary, 294 course of, 297 diagnosis of, 297 in etiology of bronchitis, 925 morbid anatomy of, 295 physical signs of, 296 prognosis of, 297 symptoms of, 295 relation of broncho-pneu- monia to, 293 relation of scrofula to, 277 spontaneous cure of, 300 transmission of, by food, 275 by inhalation, 274 by meat, 275 by milk, 275 treatment of, .300 uro-genital, 298 Tuberculous diathesis, 276 characteristics of, 15 infiammation of middle-ear, 1171 meningitis, 600, 610. See Meyiintj it is, tnbercnilons. in Pott’s disease, 1067 ulcer, description of, 287 virus in foetus, 273 Tumor in hydatid of liver, .556 in hydronephrosis, 1030 in intussusception, .520 in suppurative hepatitis, 503 Tumors about crura cerebri, 641 at base of brain, 643 in causation of headache, 721 of brain and meninges, 634 comparative frequency of, 634 differential diagnosis of, 643 etiology of, 634 pathology of, 634 Tumors of brain and meninges, I)rognosis of, 643 symptoms of, 636 treatment of, 643 of cerehellum, 643 of conjunctiva, 1136 of cortical and subcortical regions, (>38 of eyelids, 1180 of frontal lobe, 641 of kidney, 10.34 diagnosis of, 1036 from ovarian cysts, 1036 from perityphlitic ab- scess, 1036 etiology and jiathology of, 1034' prognosis of, 1036 symptoms of, 10.35 treatment of. 1036 of medulla oblongata, 643 of motor area, 640 of occipital lobe, 640 of parietal lobe,640 of pons, 642 of quadrigeminal region, 642 of spinal cord, 801 diagnosis of, 806 from fracture of ver- tebra;, 806 from haimorrhage, 806 from hysteria, 806 from neuritis, 806 from pachymeningitis, 806 from spinal caries, 806 from transverse my- elitis, 806 etiology of, 801 favorite sites of, 804 morbid anatomy of, 805 jwognosis of, 807 surgical treatment of, 897 sym]itoms of, 801 type of, in cervical re- gion, 805 in dorsal region, 805 in lumbar region and cauda, 805 of temporo-sphenoidal lobe, 641 of third frontal convolution, 640 Tuning-fork tests in young pa- tients, 1176 Turpentine as a cause of h®- maturia, 9.32 Tympanic attic, infiammation of. 1169 Tympanites in intussusception, 519 in peritonitis, 565 Tyjihlitis, .509 Typho-haciliose, 281 Typhoid condition in purpura hspinorrhagica, 381 fever, 194, 207 bacillus of, 195 in milk, 195 in water, 195 brain symptoms in, 200 Brand’s treatment of, 206 convalescence in, 198 definition of, 194 diagnosis of, 203 from cerebral pneumo- nia, 204 1242 INDEX. Tyjdioid fever, diagnosis of, from cerebro-spinal fever, 204 from frank pneumonia, 204 from general tubercu- losis, 204 from gri])pe, 204 from malaria, 204 from tuberculous menin- gitis, 203 digestive symptoms of, 109 drinking-water as a cause of, 195 duration of fever in, 202 enlargement of spleen in, 200 etiology of, 194 family j)redisposition to, 195 history of, 194 in children, 194 influence of climate upon, 194 of sex on, 194 intestinal lesions in, 196 mesenteric glands in, 196 morbid anatomy of, 196 nervous sym]itoms of, 200 period of incubation of, 196 prognosis of, 205 prophylaxis of, 207 relapse in, 198 symptoms of, 197 respiratory svmptoms in, 198 synonyms of, 194 treatment of, 205 ulcerations of intestine in, 196 urine in, 200 Widal’s blood-serum test, 205 infection of new-born, 90 state in jaundice, 543 symptoms in rheumatism, 352 Typho-tuberculose, 281 Tyrotoxicon, 473 Ulcek of cornea, 1194 treatment of, 1195 post-variolous, of lid, 1179 tuberculous, description of, 287 Ulceration of intestine in ca- tarrhal dysentery, 486 Ulcerations of intestine in ty- |)hoid fever, 196 of laryngeal cartilages in tyjihoid fever, 19’7 of rectum, 589 of trachea after tracheotomy, 886 Ulcerous lesions of scrofulo- derma, 1141 Ulcers of animbic dysentery, 490 idilyctenular, 1193 Ulna, changes in, in rachitis, 336 Umbilical cord. See Cord, umMiical. haemorrhage, 85 hernia, 86 jioly]), 86 Umbilicus, warty tumors of, 575 Unguentum vaselini plumbi- cum, 1107 Uraemia in acute tubal neiihri- tis, 1011 Uraemic convulsions in acute tubal nephritis, 1016 Urea in urine of chronic tubal ne]>hritis, 1019 Urethra, diagnosis of hemor- rhage from, 981 dilatation of, for stone, 1052 in females, 1046 in males, 1045 Uric acid as a cause of incon- tinence of urine, 998 of litha-mia, 95 in the blood, 94 in urine of new-born, 1006 Uric-acid calculus, 1038 Uric-acid sediments iu urine, 1006 Uricacidaemia, 94 Uricaemia, 94 Urinary organs, anatomy of, in children, 1045 Urination, diminished fre- quency of, 9 involuntary, during sleep, 9 painful, in lithaemia, 95 Urine. See, also. Urine in health. examiuatiou of, iu scarlet fever, 147 frequency of passage of, 8 in acute gastric catarrh, 443 in acute tubal nephritis, 1011 iu catarrhal dysentery, 488 in chlorosis, 363 in cholera, 238 in chronic tnbal nephritis, 1019 in cirrliosis of liver, .558 incontinence of. See Incon- tinence of urine. iu variola, 164 in vesical calculus, 1042 with seat-worms, 530 in diabetes mellitus, 1000 iu di])htheria, 256 in disease. 8 in erysipelas, 226 in health, 8 characteristics of, 9 daily amount of, 9 reaction of, 9 specific gravity of. 9 in jaundice, .543 in lcuka“inia, 374 in litha*mia, 96, 99 iu measles, 122 in perineidiritic abscess, 1033 in peritonitis, .565 in ))yonephrosis, 1032 in rachitis, 327 in rheumatism, 3.52 in scarlatinal nejihritis, 141 in siin))le atro])hy, .506 in tumors of kidney, 1036 in tyiihoid fever, 197, 200 in whooping-cough, 187 incontinence of, in lithfemia, 96 in tuberculous meningitis, 618 partial sup])ression of, in chronic tuhal nephritis, 1020 Urine, partial suppression of, in intussuscei)tion, 519 quantity of, in diabetes in- sipidus, 1005 iu diabetes mellitus, 1000 selection of specimen of, for analysis for sugar, 1001 specific gravity of, in acute tubal nephritis, 1011 in diabetes insipidus, 1005 in diabetes mellitus, 1000 Urostealith, 1038 Urticaria, 1120 bullosa, 1120 diagnosis of, 1121 etiology of, 1120 factitia, 1120 hsemorrhagica, 1120 iu simple atrophy, 505 papulosa, 1120 pigmentosa, 1121 prognosis of, 1121 treatment of, 1121 tuberosa, 1120 vesiculosa, 1120 with scarlet fever, 128 Uvula, abscission of, 417 elongation of, 417 Uvulatome, 417 V-SUAPED indenture of jaw, 421 Vaccination, 171 after exposure to variola, 168 age at which to perform, 176 arm-to-arm, 175 by animal virus, 176 complications of. 174 constitutional svmptoms of, 174 history of, 171 methods of, 175 points for, 176 protective ))ower of. 176 exceptions to, 176 recent studies iu, 173 secondary constitutional syni])toms in, 174 secondary fever in, 174 Vaccine-blepharitis, 1 179 Vaccine-lyin])h, animal, 1173 superiority of, to humau- ized, 174 from spontaneous cow-pox, 173 humanized, 173 transmission of syphilis hy, 174 im])urities of. 175 micro-organisms in, 173 selection of, 174 varieties of, 173 Vaccino-i>ock, areola of, 174 cicatrix of, 174 desiccation of. 174 injury to, 175 structure of, 173 Vaccine-syphilis. See Ftyphilis after vneeination. Vaccinia, 171 auto-inoculation of, 174 coccus of, 173 eru)itive, 174 etiology of, 171 INDEX. 1243 V'acciuia, irregularities in course of, 174 Jenuer’s theory of, 172 lymph of, characteristics of, 173 pathological anatomy of, 173 symptoms of, 174 theories of nature of, 172 theory of specific contagium of, 172 traditions of dairy-hands con- cerning, 171 variolation theory of, 172 vesicle of, 174 Vagi, compression of, hy en- larged glands, 276 Vaginal lithotomy, 1052 Vaginismus in hysteria, 735 Valerian in diabetes insipidus, 1006 Valsalva inflation in chronic tympanic catarrh, 1175 Valve - segments, numerical anomalies, 972 Valvular disease of heart. See Heart disease, chronic. drains in empyema, 948 Van Swieten’s liquid, 116 in syphiloderma, 1146 Vapor-baths in ascites, 573 Varicella. See Chicken-pox. gangrienosa, 160 with pertussis, 188 Varicella-prurigo, relation of, to eczema, 1120 Variola and varioloid, 163 complications and sequel® of, 167 confluent, 166 course of, 165 definition of, 163 diagnosis of, 167 from measles, 167 from pneumonia, 167 from scarlatina, 167 from varicella, 167 discrete, 166 eruptive stage of, 164 etiology of, 163 h®morrhagic, 166 incubation of, 164 after inoculation, 164 influence of vaccination, 168 inoculation for, 171 invasion of, duration of, 164 Jenner’s theory of, 172 mortality of, without vac- cination, 176 pathological anatomy of, 163 prognosis of, 168 quarantine of, 170 second attacks of, 163 secondary fever in, 165 stage of invasion of, 164 striking distance of, 163 susceptibility to, 163 symptoms of, 164 transmission of, 163 treatment of, 168 typhoid symptoms in, 165 vaccination after exposure to, 168 varieties of, 166 Variola-lymph, 172 Variolation of cow, 172 Variola-vaccine, 173 Varioloid, definition of, 167 Varioloid, types of, 167 Vascular keratitis, 1196 Vaso-motor disturbance in sy- ringomyelia, 813 involvement with tumors of spinal cord, 804 Vegetables in diabetic diet, 1003 in lithiemic diet, 99 Vegetations in endocarditis, 977 post-tracheotomie, 888 Vein, meningeal, rupture of, 83 superficial anterior jugular, 872 Veins, jugular, fulness of, in rachitis, 339 Venous hum in chlorosis, 363 obstruction in etiology of ascites, 511 Ventilation in typhoid fever, 205 Ventricular septum, defect of, 969 Veruix caseosa, 1091 Verruca, 11.30 diagnosis of, 1130 etiology of, 1130 necrogenica, 98 treatment of, 1131 Vertebr®, changes in, in rachi- tis, 332 Vertigo in acute tubal neph- ritis, 961 in brain tumors, 6.37 in leuk®mia, 374 Vesical calculus, 10.38 irritation in adherent pre- imce, 1057 Vesicles of chicken-pox, 10.57 diagnosis of, from variola, 10.57 Vesicular syphilodenn, 1144 Villous growths in bladder a cause of h»maturia, 982 Virchow’s theory of congenital cystic degeneration of kidney, 1027 of cretinism, 683 Visual fields, narrowing of, in hysteria, 733 Vocal cords, hypersmia of, in chicken-pox, 1.57 resonance in pleural effusion, 942 Voice in cholera, 2.38 in simple catarrhal laryngi- tis, 846 Volatile antiseptics in diphthe- ria, 263 drugs in pertussis, 193 Volvulus due to ascarides, .528 Vomit, lumbricoid worms in, 9 Vomiting, 9 beef-juice in, 29 character of ejecta of, 9 chronic. See Gastric catarrh, chronic. in acute gastric catarrh, 443 in acute milk infection, 476 in acute poliomyelitis, 791 in acute spinal leptomenin- gitis, 779 in broncho-pneumonia, 907 in cerebral meningitis, 599 in cerebro-spinal meningitis, 607 in childhood, 9 Vomiting in cholera, 2.37 in chronic gastric catarrh, 448 in chronic intestinal indiges- tion, 469 in infancy, causes of, 9 in intiissu.sception, 519 in lith®niia, 96, 97 in malarial fever, 314 in measles, 122 in migraine, 719 in onset of croupous pneu- monia, 914 in peritonitis, .564 in pertussis, 188 in scarlet fever, 136 in simple atrophy, ,505 in subacute milk infection, 480 in tuberculous meningitis, 611, 612 in typhlitis, .570 in typhoid fever, 197 in variola, 164 in whooping-cough, 187 of blood in lith®niia, 97 ur®mic, in acute tubal neph- ritis, 1011 Viilvo- vaginitis, 1055 catarrhal, 10.55 treatment of, 1056 from seat-worms, 530 gonorrhoeal, 10,55 diagnosis of, from catarrhal, 10.55 treatment of, 10.56 symptoms of, 10.5.3 treatment of, 1056 W.\lker-Gordon milk labora- tories, 55 Wandering imeiimonia, 916 Warner- Langenbeck method of staphylorrhaphy, 437 Warner’s post-nasal douche, 836 Wart, iiost-mortem, 274 Warts of anus, .585 Washburn siiiiie-brace for Pott’s disease, 1070 “Washerwoman's hands’’ iu cholera, 2.38 Washing prohibited in eczema, 1105 Wasting in artificially-fed chil- dren, ,503 in nursing infants, .504 Water as a source of typhoid fever, 195 drinking of, in lith®mia, 101 in cholera, 246 in diet, 20 in lithiasis, 1010 in scarlatinal nephritis, 147 in treatment of vesical cal- culus, 1045 in typhoid fever, 206 lack of, in etiology of con- stiiiation, 497 Water-bed in acute myelitis, 787 Waxy kidney. See Amyloid disease of kidney. Weaning, date of, 19 early, as a cause of rachitis, 344 gradual, 19 1244 INDEX. Weaning, methods of, 19 premature, indications for, •20 sudden, indications for, 19 Weight, average, of new-born child, 12 daily increase in, 12 Werlhof’s disease. See Pur- pura hxmorrhngica. Wet-nurse, age of, 20 feeding by, ‘20 disadvantages of, 20 for syphilitic infant, 116 health of, ‘20 qualifications of, 20 rules for selection of, 20 Wharton’s grooved director, 874 Whip-worm. See Trichoceph- alus (Uspar. White liquefying germ, prod- ucts obtained from, 473 swelling of knee, 1076. See Knee-joint dUease. Whooping-cough, 182 association of, with measles, 183 auscultation in, 187 catarrhal stage of, 185 complications and sequelse of, 187 conditions of contagion in, 183 diagnosis of, 188 from bronchitis, 189 Whooping-cough, diagnosis of, from broncho-pneumo- nia, 189 from pulmonary tuberculo- sis, 189 from tuberculosis of bron- chial glands, 189 during foetal life, 183 etiology of, 182 followed by tuberculosis, 282 history of, 182 hygienic treatment of, 190 incubation of, 185 local treatment of, 192 mortality of, 189 paroxysmal stage of, 186 pathology of, 183 jirognosis of, 189 prophylaxis of, 190 quarantine in, 190 second attacks of, 182 symptoms of, 185 mechanism of, 184 synonyms of, 182 terminal stage of, 187 theories of nature of, 184 treatment of, 190 Widal’s hlood-serum test for typhoid fever, 205 Winckel’s disease, 92 Wire loop for foreign body in auditory canal, 1165 Wooden resistance in pleural effusion, 942 Wormwood, oil of, in reflex vom- iting of diphtheria, 262 Wounds of cornea, 1197 of eyelids, 1183 of rectum, ,594 Wright’s adaptation of Mac- kenzie tonsillotome, 425 Wrist-joint disease, 1080 diagnosis of, 1080 ]>rognosis of, 1080 symptoms of, 1080 treatment of, 1080 Wry neck, 1062. See Tor- ticollis. Xanthic-oxide calculus, 1038 Xeroderma pigmentosum, 1137. See Kaposi’s dis- ease. Xerophthalmos, 1196 Xerosis of conjunctiva, 1190, 1196 Yawning, significance of, 10 Yellow-oxide-of-mercury oint- ment in eczema of lids, 1110 ZiNc-AND-TAR salve, 1107 Zinc oxide in jaundice, 548 Zona. Sec Herpes zoster. capillitii, 1116 facialis, 1116 frontalis, 1116 nuchse, 1116 ophthalmicus, 1116 Zonular cataract. See Cata- ract, congenital. CATALOGUE OF THE MEDICAL PUBLICATIONS OF W. B. SAUNDERS, No. 925 WALNUT STREET, PHILADELPHIA. Arranged Alphabetically and Classified under Subjects. books advertised in this Catalogue as being sold by subscription are usually to be obtained from traveling solicitors, but they will be sent direct from the office of pub- lication (charges of shipment prepaid) upon receipt of the prices given. AU the other books advertised are commonly for sale by booksellers in all parts of the United States ; but any book will be sent by the publisher to any address, carriage prepaid, on receipt of the published price. Money may be sent at the risk of the publisher in either of the following ways: A post-office money order, an express money order, a bank check, and in a registered, letter. Money sent in any other way is at the risk of the sender. See pages 30, 31, for a List of Contents classified according to subjects. LATEST PUBLICATIONS. American Text-Book of Genito-Urinary and Skin Diseases. Page 4. American Text-Book of Diseases of Children — Rev. Edition. Page 3. American Text-Book of Gynecology — Revised Edition. See page 4. American Year-Book of Medicine and Surgery. See page 6. Anders' Practice of Medicine — Revised Edition. See page 6. Vierordt's Medical Diagnosis — Fourth (Revised) Edition. See page 28. Van Valzah and Nisbet's Diseases of the Stomach. See page 28. Church and Peterson's Nervous and Mental Diseases. See page 9. Da Costa's Surgery — Revised and Enlarged Edition. See page 10. Saunders' Medical Hand-Atlases. See page 2. Saunders' Pocket Formulary — Fifth ( Revised) Edition. See page 24. Keen's Surgical Complications of Typhoid Fever. See page 15. Griffith on The Baby — Revised Edition. See page 12. Butler's Materia Medica and Therapeutics — Revised Edition. Page 8. Stevens' Practice of Medicine— Fifth (Revised) Edition. See page 27. De Schweinitz' Diseases of the Eye — Revised Edition. See page 10. Chapin's Compendium of Insanity. See page 8. Senn's Genito-Urinary Tuberculosis. See page 25. Penrose's Diseases of Women. See page 18. McFarland's Pathogenic Bacteria — Revised Edition. See page 17. Macdonald's Surgical Diagnosis. See page 16. Moore's Orthopedic Surgery. See page 17. Mallory and Wright's Pathological Technique. See page 16. Saunders’ Medical Hand-Atlases. The series of books included under this title are authorized translations into English of the world-famous Lehmann Medicinische Hand=atlanten. For scientific accuracy, pictorial beauty, compactness, and cheapness these books surpass any similar volumes ever published. Each volume contains from 50 to 100 Colored Plates, besides numerous other illustrations in the text. These colored plates have been executed by the most skilful German lithographers, in some cases twenty or more impressions being required to obtain the desired result. There is a full and appropriate description of each plate (printed, for convenience, opposite the plate), together with a condensed outline of the subject to which the book is devoted. The same careful and competent editorial supervision will be secured in the English edition as in the originals. The translations will be directed and edited by the leading American specialists in the different subjects. The great advantage of natural pictorial representation is indisputable. For lasting and practical knowledge, one accurate illustration is better than several pages of dry description. These Atlases offer a ready and satisfactory substitute for clinical observation, avail- able only to the residents of large medical centers ; and with such persons the requisite variety is seen only after long years of routine hospital service. By reason of their projected universal translation and reproduction, affording inter- national distribution, the publishers have been enabled to secure for these Atlases the best artistic and professional talent, to produce them in the most elegant style, and yet to offer them at a price heretofore unapproached in cheapness. The success of the under- taking is demonstrated by the fact that volumes have already appeared in German, English, French, Italian, Russian, Spanish, Danish, Swedish, and Hungarian. 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It is destined to make and hold a place in gynecological literature which wdll be peculiarly its own.” — Medical Record, New York. AN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND TOXI- COLOGY. Edited by Frederick Peterson, M.D., Clinical Professor of Mental Diseases in the Woman’s Medical College, New York ; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York ; and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago. In Preparation. AN AMERICAN TEXT-BOOK OF OBSTETRICS. By 15 Eminent American Obstetricians. Edited by Richard C. Nor- ris, M.D.; Art Editor, Robert L. Dickinson, M.D. One handsome imperial octavo volume of over 1000 pages, with nearly 900 beautiful colored and half-tone illustrations. Cloth, ^7.00 net ; Sheep or Half Morocco, $8.00 net. 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BOISLINIERE’S OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERATIONS. Obstetric Accidents, Emergencies, and Operations. By L. Ch, Boisliniere, M.D., late Emeritus Professor of Obstetrics, St. Louis Medical College. 381 pages, handsomely illustrated. Cloth, $2.00 net. “ It is clearly and concisely written, and is evidently the work of a teacher and practi- tioner of large experience.” — British Aledical Journal. “ A manual s6 useful to the student or the general practitioner has not been brought to our notice in a long time. The field embraced in the title is covered in a terse, interesting way.” — Yale Aledical Journal. BROCKWAY’S MEDICAL PHYSICS. Second Edition, Revised. Essentials of Medical Physics. By Fred J. Brockway, M.D., Assistant Demonstrator of Anatomy in the College of Physicians and Surgeons, New York. Crown octavo, 330 pages; 155 fine illustrations. Cloth, $1.00 net ; interleaved for notes, $1.25 net. 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Burr, M.D., Clinical Professor of Nervous Diseases, Medico-Chirurgical College, Philadelphia ; Pathologist to the Orthopedic Hospital and Infirmary for Nervous Diseases; Visiting Physician to St. Joseph’s Hospital, etc. In Preparation. 8 Medical Publications of W. B. Saunders. BUTLER’S MATERIA MEDICA, THERAPEUTICS, AND PHAR- MACOLOGY. Second Edition, Revised. A Text=Book of Materia Medica, Therapeutics, and Pharma- cology. By George F. Butler, Ph.G., M.D., Professor of Materia Medica and of Clinical Medicine in the College of Physicians and Surgeons, Chicago ; Professor of Materia Medica and Therapeutics, Northwestern University, Woman’s Medical School, etc. Octavo, 860 pages, illustrated. Cloth, $4.00 net; Sheep, $5.00 net. “ Taken as a whole, the book may fairly be considered as one of the most satisfactory of any single-volume works on materia medica in the market,” — Journal of the Ame7'ican Medical Association. “The work is executed in a clear, concise, and practical manner, and should meet with a hearty endorsement from the students of our up-to-date colleges. The book will be found a valuable work of reference for the practitioner.” — American Medico^Surgical Bulletin. CASSELBERRY ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By W. E. Casselberry, Pro- fessor of Laryngology and Rhinology in the Northwestern University Medical School, Chicago. Jn Preparation. CERNA ON THE NEWER REMEDIES. Second Edition, Revised. Notes on the Newer Remedies, their Therapeutic Applications and Modes of Administration. By David Cerna, M.D., Ph.D., formerly Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania; Demonstrator of Physiology in the Medical Department of the University of Te.xas. Rewritten and greatly enlarged. Post-octavo, 253 pages. Cloth, ^1.25. “ The appearance of this new edition of Dr. Cerna’s very valuable work shows that it is properly appreciated. The book ought to be in the possession of every practising physi- cian.” — New York Medical Journal. CHAPIN ON INSANITY. A Compendium of Insanity. By John B. Chapin, M.D. , LL.D., Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi- cian-Superintendent of the Willard State Hospital, New York; Hon- orary Member of the Medico-Psychological Society of Great Britain, of the Society of Mental Medicine of Belgium. 121110, 234 pages, illustrated. Cloth, $1.25 net. The author has given, in a condensed and concise form, a compendium of Diseases of the Mind, for the convenient use and aid of physicians and students. the work will also prove valuable to members of the legal profession and to those who, in their lelations to the insane and to those supposed to lie insane, often desire to acquire some practical knowledge of insanity presented in a form that may be understood by the non-professional reader. CHAPMAN’S MEDICAL JURISPRUDENCE AND TOXICOLOGY. Second Edition, Revised. Medical Jurisprudence and Toxicology. By Henry C. Chapman, M.D., Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Philadelphia. 254 pages, with 55 illustrations and 3 full-page plates in colors. Cloth, ^1.50 net. “The best book of its class for the undergraduate that we know of.” — Nent York Medical Times. Medical Publications of W. B. Saunders. 9 CHURCH AND PETERSON’S NERVOUS AND MENTAL DISEASES. Nervous and Mental Diseases. By Archibald Church, M.D., Professor of Mental Diseases and Medical Jurisprudence in the North- western University Medical School, Chicago; and Frederick Peter- son, M.D., Clinical Professor of Mental Diseases in the Woman’s Medical College, New York; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York. In Preparation. CLARKSON’S HISTOLOGY. A Text=Book of Histology, Descriptive and Practical. By Arthur Clarkson, M.B., C.M. Edin., formerly Demonstrator of Physiology in the Owen’s College, Manchester; late Demonstrator of Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 22 engravings in the text, and 174 beautifully colored original illustra- tions. Cloth, strongly bound, $6.00 net. “The work must be considered a valuable addition to the list of available text books, and is to be highly recommended.” — New York Medical Jourtial. “ This is one of the best works for students we have ever noticed. We predict that the book will attain a well-deserved popularity among our students.” — Chicago Medical Recorder. “The volume is a most valuable addition to the armamentarium of the teacher.” — Brooklyn Medical Journal. CLIMATOLOGY. Transactions of the Eighth Annual Meeting of the American Climatological Association, held in Washington, September 22-25, 1891. Forming a handsome octavo volume of 276 pages, uniform with remainder of series. (A limited quantity only.) Cloth, $1.50. COHEN AND ESHNER’S DIAGNOSIS. Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- fessor of Clinical Medicine and Applied Therapeutics in the Philadel- phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic. Post-octavo, 382 pages; 55 illustrations. Cloth, $1.50 net. [See Saunders' Question- Compends, page 21.] “ We can heartily commend the book to all those who contemplate purchasing a ‘com- pend ’ It is modern and complete, and will give more satisfaction than many other works which are perhaps too prolix as well as behind the times.” — Medical Review, St. Louis. CORWIN’S PHYSICAL DIAGNOSIS. Essentials of Physical Diagnosis of the Thorax. By Arthur M. Corwin, A.M., M.D., Demonstrator of Physical Diagnosis in Rush Medical College, Chicago ; Attending Physician to Central Free Dis- ]>ensary. Department of Rhinology, Laryngology, and Diseases of the Chest, Chicago. 200 pages, illustrated. Cloth, flexible covers, $1.25 net. “ It is excellent. The student who shall use it as his guide to the careful study of physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good working knowledge of the subject.” — Philadelphia Polyclinic. “A most excellent little work. It brightens the memory of the differential diagnostic signs, and it arranges orderly and in sequence the various objective phenomena to logical solution of a careful diagnosis.” — Journal of Nervous and Mental Diseases. 10 Medical Publications of W. B. Saunders. CRAQIN’S QYN/ECOLOQY. Fourth Edition, Revised. Essentials of Gynaecology. By Edwin B. Cragin, M.D., Attend- ing Gynaecologist, Roosevelt Hospital, Out-Patients’ Department, New York, etc. Crown octavo, 200 pages; 62 fine illustrations. Cloth, jgi.oo; interleaved for notes, $1.25. [See Saunders' Questio?i-Compends, page 21.] “ A handy volume, and a distinct improvement on students’ compends in general. No author who was not himself a practical gynecologist could have consulted the student's needs so thoroughly as Dr. Cragin has done.” — Medical Recoz-d, New York. CROOKSHANK’S BACTERIOLOGY. Fourth Edition, Revised. A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B., Professor of Comparative Pathology and Bacteriology, King’s College, London. Octavo volume of 700 pages, with 273 engravings and 22 original colored plates. Cloth, $6.50 net; Half Morocco, $7. 50 net. ” To the student who wishes to obtain a good resume of what has been done in bacteri- ology, or who wishes an accurate account of the various methods of research, the book may be recommended with confidence that he will find there what he requires.” — London Lancet. DaCOSTA’S surgery. Second Ed., Revised and Greatly Enlarged. Modern Surgery, General and Operative. By John Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. Handsome octavo volume of 900 pages, profusely illustrated. Cloth, ^4.00 net; Half Morocco, ^5.00 net. “We know of no small work on surgery in the English language which so well fulfils the requirements of the modern student.” — Medico-Chirurgical Journal, Bristol, England. DE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition, Revised. Diseases of the Eye, A Handbook of Ophthalmic Practice. By G. E. DE ScHWEiNiTZ, M.D., Professor of Ophthalmology in the Jefferson Medical College, Philadelphia, etc. Handsome royal octavo volume of 700 page.s, with 256 fine illustrations and 2 chromo-litho- graphic plates. Cloth, ^4.00 net; Sheep or Half Morocco, 55- net. “ A clearly written, comprehensive manual. One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical science.” — British Medical Journal. “ A work that will meet the reciuirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it.” — William Pepper, M.D., Professor of the Theory and Practice of Medieine and Clinical Medicine, University of Pennsylvania. DORLAND’S OBSTETRICS. A Manual of Obstetrics. By W. A. Newman Dorland, M.D., Assistant Demonstrator of Obstetrics, University of Pennsylvania; Instructor in Gynecology in the Philadelphia Polyclinic. 760 jiages; 163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net. “ By far the best book on this subject that has ever come to our notice.” — American Medical Review. “ It has rarely been our duty to review a book which has given us more )ileasure in its perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, a gold mine of practical, concise thoughts.” — Anierican Medico-Surgical Bulletin. Medical Publications of W. B. Saunders. 11 FROTHINQHAM’S GUIDE FOR THE BACTERIOLOGIST. Laboratory Guide for the Bacteriologist. By Langdon Froth- iNGHAM, M.D.V., Assistant in Bacteriology and Veterinary Science, Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts. “ It is a convenient and useful little work, and will more than repay the outlay neces- sary for its purchase in the saving of time which would otherwise be consumed in looking up the various points of technique so clearly and concisely laid down in its pages.” — Ameri- can Medico- Surgical Bulletin. GARRIGUES’ DISEASES OF WOMEN. Second Edition, Revised. Diseases of Women. By Henry J. Garrigues, A. M., M.D., Pro- fessor of Gynecology in the New York School of Clinical Medicine; Gynecologist to St. Mark’s Hospital and to the German Dispensary, New York City, etc. Handsome octavo volume of 728 pages, illus- trated by 335 engravings and colored plates. Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. “ One of the best text-books for students and practitioners which has been published in the English language ; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished author find expression in this book in a most attractive and instructive form. Young practitioners to whom experienced consultants may not be available will find in this book invaluable counsel and help.” — Thad. A. Reamy, M.D., LL. D., Professor of Clinical Gynecology, Medical College of Ohio. GLEASON’S DISEASES OF THE EAR. Second Edition, Revised. Essentials of Diseases of the Ear. By E. B. Gleason, S.B., M.D., Clinical Professor of Otology, Medico-Chirurgical College, Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- ment of the Northern Dispensary, Philadelphia. 208 pages, with 1 14 illustrations. Cloth, $1.00; interleaved for notes, $1. 25. [See Saimders' Question- Compends, page 21.] “ It is just the book to put into the hands of a student, and cannot fail to give him a useful introduction to ear-affections ; while the style of question and answer which is adopted throughout the book is, we believe, the best method of impressing facts permanently on the mind.” — Liverpool Medico-Chirurgical Journal. GOULD AND PYLE’S CURIOSITIES OF MEDICINE. Anomalies and Curiosities of Medicine. By George M. Gould, M.D., and Walter L. Pyle, M.D. An encyclopedic collection of rare and extraordinary cases and of the most striking instances of abnormality in all branches of Medicine and Surgery, derived from an exhaustive research of medical literature from its origin to the present day, abstracted, classified, annotated, and indexed. Handsome im- perial octavo volume of 968 pages, with 295 engravings in the text, and 12 full-page plates. Cloth, $6.00 net; Half Morocco, $7.00 net. Sold by Subscription. “ One of the most valuable contributions ever made to medical literature. It is, so far as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for the medical profession has this volume value : it will serve as a book of reference for all who are interested in general scientific, sociologic, or medico-legal topics.” — Brooklyn Medical fournal. “This is certainly a most remarkable and interesting volume. It stands alone among medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in medical literature. It is a book full of revelations from its first to its last page, and cannot but interest and sometimes almost horrify its readers.” — American Medico- Surgical Bulletin. 12 Medical Publications of W. B. Saunders. GRIFFIN’S MATERIA MEDICA AND THERAPEUTICS. Manual of Materia Medica and Therapeutics. By Henry A. Griffin, A.B., M.D., Assistant Physician to the Roosevelt Hospital, Out-Patient Department, New York City. In Preparation. GRIFFITH ON THE BABY. Second Edition, Revised. The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini- cal Professor of Diseases of Children, University of Pennsylvania; Physician to the Children’s Hospital, Philadelphia, etc. i2mo, 404 pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50. “ The best book for the use of the young mother with which w'e are acquainted. . . . There are very few general practitioners who could not read the book through with advan- tage.” — Archives of Pediatrics. “The whole book is characterized by rare good sense, and is evidently written by a master hand. It can be read with benefit not only by mothers but by medical students and by any practitioners who have not had large opportunities for observing children.” — Ameri- can Journal of Obstetrics. GRIFFITH’S WEIGHT CHART. Infant’s Weight Chart. Designed by J. P. Crozer Griffith, M. D. , Clinical Professor of Diseases of Children in the University of Penn- sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. A convenient blank for keeping a record of the child's weight during the first two years of life. Printed on each chart is a curve representing the average weight of a healthy infant, so that any deviation from the normal can readily be detected. GROSS, SAMUEL D., AUTOBIOGRAPHY OF. Autobiography of Samuel D. Gross, M.D., Emeritus Professor of Surgery in the Jefferson Medical College, Philadel])hia, with Remi- niscences of His Times and Contemporaries. Edited by his Sons, Samuel W. Gross, M.D., LL.D., late Professor of Principles of Sur- gery and of Clinical Surgery in the Jefferson Medical College, and A. Haller Gross, A.M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In two handsome volumes, each containing over 400 pages, demy octavo, extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price per volume, $2.50 net. “ Dr. Gross was perhaps the most eminent exponent of medical science that America has yet produced. His Autobiography, related as it is with a fulness and completeness seldom to be found in such works, is an interesting and valuable book. He comments on many things, especially, of course, on medical men and medical practice, in a very interest- ing way.”^ — The Spectator, London, England. HAMPTON’S NURSING. Nursing: Its Principles and Practice. By Isabel Adams Hamp- ton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital ; Superintendent of Nurses, and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. i2mo, 484 pages, profusely illustrated. Cloth, $2.00 net. “ Seldom have we perused a book upon the subject that has given us so much pleasure as the one before us. We would strongly urge upon tlic members of our own profession the need of a book like this, for it will enable each of us to become a training school in him- self.” — Ontario Medical Journal. Medical Publications of W. B. Saunders. 13 HARE’S PHYSIOLOGY. Third Edition, Revised. Essentials of Physiology. By H. A. Hare, M.D., Professor of 'rherapeutics and Materia Medica in the Jefferson Medical College of Philadelphia ; Physician to the Jefferson Medical College Hospital. Containing a series of handsome illustrations from the celebrated “leones Nervorum Capitis” of Arnold. Crown octavo, 239 pages. Cloth, $1.00 net; interleaved for notes, $1.25 net. [See Saunders' Question- Co?npends, page 21.] “ The best condensation of physiological knowledge we have yet seen.” — Medical Record, New York. HART’S DIET IN SICKNESS AND IN HEALTH. Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly Student of the Faculty of Medicine of Paris and of the London School of Medicine for Women ; with an Introduction by Sir Henry Thompson, F.R.C.S., M.D., London. 220 pages ; illustrated. Cloth, $1.50. “ We recommend it cordially to the attention of all practitioners ; both to them and to their patients it may be of the greatest service.” — New York Medical Journal. HAYNES’ ANATOMY. A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- ment of the New York University, etc. 680 pages, illustrated with 42 diagrams in the text, and 134 full-page half-tone illustrations from original photographs of the author’s dissections. Cloth, $2.50 net. “ This book is the work of a practical instructor — one who knows by experience the requirements of the average student, and is able to meet these requirements in a very satis- factory way. The book is one that can be commended.” — Medical Record, New York. HEISLER’S EMBRYOLOGY. A Text=Book of Embryology. By John C. Heisler, M.D., Pro- fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. In Preparation. HIRST’S OBSTETRICS. A Text=Book of Obstetrics. By Barton Cooke Hirst, M. D. , Professor of Obstetrics in the L^niversity of Pennsylvania. In Prepa- ration. HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL DISEASES. Syphilis and the Venereal Diseases. By James Nevins Hyde, M.D., Professor of Skin and Venereal Diseases, and Frank H. Mont- gomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, Chicago, 111 . 618 pages, profusely illustrated. Cloth, $2.50 net. “ We can commend this manual to the student as a help to him in his study of venereal diseases.” — Liverpool Medico-Chirurgical Journal. “The best student’s manual which has appeared on the subject.” — St. Louis Medical and Surgical Journal. 14 Medical Publications of W. B. Saunders. JACKSON AND GLEASON’S DISEASES OF THE EYE, NOSE, AND THROAT. Second Edition, Revised. Essentials of Refraction and Diseases of the Eye. By Edward Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- delphia Polyclinic and College for Graduates in Medicine ; and — Essentials of Diseases of the Nose and Throat. By E. Bald- win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia. 'I'wo volumes in one. Crown octavo, 290 pages; 1 24 illustrations. Cloth, $1.00; interleaved for notes, ^1.25. [See Saunders' Question- Compends, page 21.] “ Of great value to the beginner in these branches. The authors are both capable men, and know what a student most needs.” — Medical Record, New York. KEATING’S DICTIONARY. Second Edition, Revised. A New Pronouncing Dictionary of Medicine, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M.D., LL.D., Eellow of the College of Physicians of Phila- delphia; Vice-President of the American Pediatric Society; Editor “Cyclopaedia of the Diseases of Children,’’ etc.; and Henry Hamilton, Author of “A New Translation of Virgil’s Hineid into English Rhyme,” etc.; with the collaboration of J. Chalmers Da- Costa, M.D., and Frederick A. Packard, M.D. With an Appendi.x containing Tables of Bacilli, Micrococci, Leucoma'ines, Ptomaines; Drugs and Materials used in Antiseptic Surgery; Poisons and their Antidotes; Weights and Measures; Thermometric Scales; New Official and Unofficial Drugs, etc. One volume of over 800 ]iages. Prices, with Denison’s Patent Ready-Reference Index: Cloth, $5.00 net; Sheep or Half Morocco, ;^6.oo net; Half Russia, $6.50 net. AVithout Patent Index: Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. “ I am much pleased with Keating’s Dictionary, and shall take pleasure in recommend- ing it to my classes.” — Henry M. Lyman, M.D., Professor of the Principles and Practice of Medicine, Rush Medical College, Chicago, III. “ I am convinced that it will be a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use.” — C. A. Lindsley, M.D., Professor of the Theory and Practice of Medicine, Medical Dept. Yale University. KEATING’S LIFE INSURANCE. How to Examine for Life Insurance. By John M. Keating, M.D., Fellow of the College of Physicians of Philadelphia; Vice- President of the American Paediatric Society; Ex-President of the Association of Life Insurance Medical Directors. Royal octavo, 211 pages; with two large half-tone illustrations, and a plate prepared by Dr. McClellan from special dissections ; also, numerous other illustra- tions. Cloth, $2.00 net. “ This is by far the most useful book which has yet appeared on insurance examination, a subject of growing interest and importance. Not the le.ast valuable portion of the volume is P.art II, which consists of instructions issued to their examining physicians by twenty-lour representative companies of this country. If for these alone, the book should be at the right hand of every physician interested in this special branch of medical science.” — The Medical News. Medical Publications of W. B. Saunders. 15 KEEN ON THE SURGERY OF TYPHOID FEVER. The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; Corresponding Member of the Societe de Chirurgie, Paris ; Honorary Member of the Societe Beige de Chirurgie, etc. Octavo volume of 386 pages, illustrated. Cloth, $3.00 net. This monograph is the only one in any language covering the entire subject of the Surgical Complications and Sequels of Typhoid Fever. It will prove to be of importance and interest not only to the general surgeon and physician, but also to many specialists — laryn- gologists, gynecologists, pathologists, and bacteriologists. KEEN’S OPERATION BLANK. Second Edition, Revised Form. An Operation Blank, with Lists of Instruments, etc. Required in Various Operations. Prepared by W. W. Keen, M.D., LL.D., Professor of the Principles of Surgery in Jefferson Medical College, Philadelphia. Price per pad, containing blanks for fifty operations, 50 cents net. KYLE ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By D. Braden Kyle, M.D., Clinical Professor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia; Consulting Laryngologist, Rhinologist, and Otologist, St. Agnes’ Hospital ; Bacteriologist to the Philadelphia Orthopedic Hospital. In Preparation. LAINE’S TEMPERATURE CHART. Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x 13^^ inches. A conveniently arranged Chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. Price, per pad of 25 charts, 50 cents net. “To the busy practitioner this chart will be found of great value in fever cases, and especially for cases of typhoid.” — Indian Lancet, Calcutta. LOCKWOOD’S PRACTICE OF MEDICINE. A Manual of the Practice of Medicine. By George Roe Lock- wood, M.D., Professor of Practice in the Woman’s Medical College of the New York Infirmary, etc. 935 pages, with 75 illustrations in the text, and 22 full-jDage plates. Cloth, ^2.50 net. “ Gives in a most concise manner the points essential to treatment usually enumerated in the most elaborate works.” — Massachusetts Medical Journal. LONG’S SYLLABUS OF GYNECOLOGY. A Syllabus of Gynecology, arranged in Conformity with “ An American Text=Book of Gynecology.” By J. W. Long, M.D., Professor of Diseases of Women and Children, Medical College of Virginia, etc. Cloth, interleaved, $1.00 net. “ The book is certainly an admirable resume of what every gynecological student and practitioner should know, and will prove of value not only to those who have the ‘ American Text-Book of Gynecology,’ but to others as well.” — Brooklyn Medical Journal. IG Medical Publications of W. B. Saunders. MACDONALD’S SURGICAL DIAGNOSIS AND TREATMENT. Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. Edin., L.R.C.S., Edin., Professor of the Practice of Surgery and of Clinical Surgery in Hainline University ; Visiting Surgeon to St. Barnabas’ Hospital, Minneapolis, etc. Handsome octavo volume of 800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, ^6.00 net. “ A thorough and complete work on surgical diagnosis and treatment, free from pad- ding, full of valuable material, and in accord with the surgical teaching of the day.” — The Medical Ne~ivs, A^ew York. “The work is brimful of just the kind of practical information that is useful alike to students and practitioners. It is a pleasure to commend the book because of its intrinsic value to the medical practitioner.” — Cincinnati Lancet-Clinic. MALLORY AND WRIGHT’S PATHOLOGICAL TECHNIQUE. Pathological Technique. A Practical Manual for Laboratory Work in Pathology, Bacteriology, and Morbid Anatomy, with chapters on Post-Mortem Technique and the Performance of Autopsies. By Frank B. Mallory, A.M., M.D. , Assistant Professor of Pathology, Harvard University Medical School, Boston; and James H. Wright, A.M., M.D., Instructor in Pathology, Harvard University Medical School, Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth, ^2.50 net. “ I have been looking forward to the publication of this book, and I am glad to say that I find it to be a most useful laboratory and post-mortem guide, full of practical information, and well up to date.” — W illiam II. Welch, Professor of Pathology, Johns Hopkins Uni- versity, Baltimore, JIil. MARTIN’S MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. Second Edition, Revised. Essentials of Minor Surgery, Bandaging, and Venereal Diseases. By Edward Martin, A.M., M.D., Clinical Professor of Genito- Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 166 pages, with 78 illustrations. Cloth, $1.00; interleaved for notes, ^1.25. [See Saunders' Question- Compends, page 21.] “ A very practical and systematic study of the subjects, and shows the author’s famil- iarity with the needs of students.” — Therapeutic Gazette. MARTIN’S SURGERY. Sixth Edition, Revised. Essentials of Surgery. Containing also Venereal Diseases, Surgi- cal I.andmarks, Minor and Operative Surgery, and a complete de- scription, with illustrations, of the Handkerchief and Roller Bandages. By Edward Martin, A.M., M.D., Clinical Professor of Genito- urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338 pages, illustrated. With an Appendix containing full directions for the preparation of the materials used in Antiseptic Surgery, etc. Cloth, ^i.oo; interleaved for notes, ^1.25. [See Saunders' Question- Compends, page 21.] “ Contains all necessary essentials of modern surgery in a comparatively .small space. Its style is interesting, and its illustrations are admirable.” — Medical and Surgical Reporter. Medical Publications of W. B. Saunders. 17 IVlcFARLAND’S PATHOGENIC BACTERIA. Second Edition, Re- vised and Greatly Enlarged. Text-Book upon the Pathogenic Bacteria. By Joseph McFar- land, M. U., Professor of Pathology and Bacteriology in the Medico- Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages, finely illustrated. Cloth, $2.50 net. “ Dr. McFarland has treated the subject in a systematic manner, and has succeeded in presenting in a concise and readable form the essentials of bacteriology up to date. Alto- gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the students of Trinity College.” — H. B. Anderson, M.D. , Professor of Pathology and Bac- teriology, Trinity Medical College, Toronto. MEIGS ON FEEDING IN INFANCY. Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound in limp cloth, flush edges, 25 cents net. “This pamphlet is worth many times over its price to the physician. The author’s experiments and conclusions are original, and have been the means of doing much good.” — Medical Bulletin. MOORE’S ORTHOPEDIC SURGERY. A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professor of Orthopedics and Adjunct Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. Octavo volume of 356 pages, handsomely illustrated. Cloth, ^2.50 net. A practical book based upon the author’s experience, in which special stress is laid upon early diagnosis, and treatment such as can be carried out by the general practitioner. The teachings of the author are in accordance with his belief that true conservatism is to be found in the middle course between the surgeon who operates too frequently and the orthopedist who seldom operates. MORRIS’S MATERIA MEDICA AND THERAPEUTICS. Fifth Edition, Revised. Essentials of Materia Medica, Therapeutics, and Prescription- Writing. By Henry Morris, M.D., late Demonstrator of Thera- peutics, Jefferson Medical College, Philadelphia; Fellow of the College of Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 21.] “ This work, already excellent in the old edition, has been largely improved by revi- , sion.” — American Practitioner and News. MORRIS, WOLFF, AND POWELL’S PRACTICE OF MEDICINE. Third Edition, Revised. Essentials of the Practice of Medicine. By Henry Morris, M.D., late Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia ; with an Appendix on the Clinical and Microscopic Examina- tion of Urine, by Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- tial formulae collected and arranged by William M. Powell, M.D. Post-octavo, 488 pages. Cloth, $2.00. [See Saunders' Question- Compends, page 21.J “ The teaching is sound, the presentation graphic ; matter full as can be desired, and style attractive.” — American Practitioner and News. 2 18 Medical Publications of W. B. Saunders. MORTEN’S NURSE’S DICTIONARY. Nurse’s Dictionary of Medical Terms and Nursing Treat- ment. Containing Definitions of the Principal Medical and Nursing Terms and Abbreviations ; of the Instruments, Drugs, Diseases, Acci- dents, Treatments, Operations, Foods, Appliances, etc. encountered in the ward or in the sick-room. By Honnor Morten, author of “How to Become a Nurse,” etc. i6mo, 140 pages. Cloth, $1.00. “ A handy, compact little volume, containing a large amount of general information, all of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference. It is certainly of value to those for whose use it is published.” — Chicago Clinical Review. NANCREDE’S ANATOMY. Fifth Edition. Essentials of Anatomy, including the Anatomy of the Viscera. By Charles B. Nancrede, M.D., Professor of Surgery and of Clini- cal Surgery in the University of Michigan, Ann Arbor. Crown octavo, 388 pages; 180 illustrations. With an Appendix containing over 60 illustrations of the osteology of the human body. Based upon Gray' s Anatotny. Cloth, $i.oo; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 21.] “ For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at school, it would not be easy to speak of it in terms too favorable.” — Americati Practitioner. NANCREDE’S ANATOMY AND DISSECTION. Fourth Edition. Essentials of Anatomy and Manual of Practical Dissection. By Charles B. Nancrede, M.D., Professor of Surgery and of Clinical Surgery, University of Michigan, Ann Arbor. Post-octavo ; 500 pages, with full-page lithographic plates in colors, and nearly 200 illustrations. Extra Cloth (or Oilcloth for the dissection-room), $2.00 net. “ It may in many respects be considered an epitome of Gray’s popular work on general anatomy, at the same time having some distinguishing characteristics of its own to commend it. The plates are of more than ordinary excellence, and are of especial value to .students in their work in the dissecting room.” — Journal of the American Medical Association. NORRIS’S SYLLABUS OF OBSTETRICS. Third Edition, Revised. Syllabus of Obstetrical Lectures in the Medical Department of the University of Pennsylvania. By Richard C. Norris, A.M., M.D., Demonstrator of Obstetrics, University of Pennsylvania. Crown octavo, 222 jiages. Cloth, interleaved for notes, $2.00 net. “ This work is so far superior to others on the same subject that we take pleasure in calling attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and the practitioner.” — Medical Record, New York. PENROSE’S DISEASES OF WOMEN. Second Edition, Revised. A Text-Book of Diseases of Women. By Charles B. Penrose, M.D., Ph.D., Professor of Gynecology in the University of Pennsyl- vania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 529 pages, handsomely illustrated. Cloth, ^3.50 net. “I shall value very highly the copy of Penrose’s ‘Diseases of Women’ received. I have already recommended it to my class as THE BEST book.” — Howard A. Kelly, ProfeSsor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. “ The book is to be commended without reserve, not only to the student but to the general practitioner who wishes to have the latest and best inodes of treatment explained with absolute clearness.” — Therapeutic Gazette. Medical Publications of W. B. Saunders. 19 POWELL’S DISEASES OF CHILDREN. Second Edition. Essentials of Diseases of Children. By William M. Powell, M.D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of Children in the Hospital of the University of Pennsylvania. Crown octavo, 222 pages. Cloth, ^i.oo; interleaved for notes, $1.25. [See Saunders' Question- Conipends, page 21.] “Contains the gist of all the best works in the department to which it relates.” — American Practitioner and News. PRINGLE’S SKIN DISEASES AND SYPHILITIC AFFECTIONS. Pictorial Atlas of Skin Diseases and Syphilitic Affections (American Edition). Translation from the French. Edited by J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex Hospital, London. Photo-lithochromes from the famous models in the Museum of the Saint-Louis Hospital, Paris, with explanatory wood- cuts and text. In 12 Parts. Price per Part, $3.00. Complete in one volume. Half Morocco binding, ^40. 00 net. “ I strongly recommend this Atlas. The plates are exceedingly well executed, and will be of great value to all studying dermatology.” — Stephen Mackenzie, M.D. “The introduction of explanatory wood-cuts in the text is a novel and most important feature which greatly furthers the easier understanding of the excellent plates, than which nothing, we venture to say, has been seen better in point of correctness, beauty, and general merit.” — New York Medical Journal. PYE’S BANDAGING. Elementary Bandaging and Surgical Dressing. With Direc- tions concerning the Immediate Treatment of Cases of Emergency. For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late Surgeon to St. Mary’s Hospital, London. Small i2ino, with over 80 illustrations. Cloth, flexible covers, 75 cents net. “ The directions are clear and the illustrations are good.” — London Lancet. “ The author writes well, the diagrams are clear, and the book itself is small and port- able, although the paper and type are good.” — British Medical Journal. RAYMOND’S PHYSIOLOGY. A Manual of Physiology. By Joseph H. Raymond, A.M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; Director of Physiology in the Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the text, and 4 full-page colored plates. Cloth, $1.25 net. “ Extremely well gotten up, and the illustrations have been selected with care. The text is fully abreast with modern physiology.” — British Medical Journal. RONTGEN RAYS. Archives of the Rontgen Ray (Formerly Archives of Clinical Skiagraphy). Edited by Sydney Rowland, M.A., M.R.C.S., and W. S. Hedley, M.D., M.R.C.S. A series of collotype illustrations, with descriptive text, illustrating the applications of the new photo- graphy to Medicine and Surgery. Price per Part, ;gi.oo. Now ready: Vol. L, Parts I. to IV.; Vol. II., Parts L, II. Saunders' Question COMPENDS Arranged in Question and Answer Form> MOST COMPLETE AND BEST ILLUSTRATED SERIES OF COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature .... with Students and Practitioners in every City of the United States and Canada. ^ OVE R 165,000 COPIES SOLD . ^ THE REASON WHY. They are the advance guard of “Student’s Helps” — that DO hei.p. They are the leaders in their special line, well and authoritatively written by able men, who, as teachers in the large colleges, know exactly what is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional standing. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have become Professors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine jtaper. The entire series, numbering twenty-three volumes, has been kept thoroughly revised and enlarged when necessary, many of the books being in their fifth and sixth editions. TO SUM UP. Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of them approach the “ Blue .Series of Question Compends and the claim is m.ide for the following points of excellence ; 1. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Quality of illustrations, paper, printing, and binding. Any cf these Compends will be mailed on receipt of price (see next page for List). Saunders^ Question-Compend Price, Cloth, $1.00 per copy, except when otherwise noted. “ Where the work of preparing students’ manuals is to end we cannot say, but the Saunders Series, in our opinion, bears off the palm at present.”— VWrr/ York Medical Record. 1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Third edition, revised and enlarged. ($l.oo net.) 2. ESSENTIALS OF SURGERY. By Edward Martin, M.D. Sixth edition, revised, with an Appendix on Antiseptic Surgery. 3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Fifth edition, with an Appendix. 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. By Lawrence Wolff, M.D. Fourth edition, revised, with an Appendix. 5 . ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth edition, revised and enlarged. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. Armand Semple, M.D. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- SCRIPTION=WRITING. By Henry Morris, M.D. Fifth edition, revised. 8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. Third edition, enlarged by some 300 Essential Formulae, selected from eminent authorities, by Wm. M. Powell, M.D. (Double number, $2.00.) 10. ESSENTIALS OF GYN/ECOLOGY. By Edwin B. Cragin, M.D. Fourth edition, revised. 11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, M.D. Third edition, revised and enlarged. (^l. 00 net.) 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. By C. E. Armand Semple, M.D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, M.D. Second edition. 16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, M.D. Colored “ Vogel Scale.” (75 cents.) 17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, M.D. {$i-So net.) 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. Second edition, revised and enlarged. 20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, revised. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. Shaw, M.D. Third edition, revised. 22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D. Second edition, revised. ($1.00 net.) 23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., and Edward S. Lawrance, M.D. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D. Second edition, revised and greatly enlarged. Pamphlet containing specimen pages, etc. sent free upon application, Saunders’ Manuals for Students and Practitioners. 'pHAT there exists a need for thoroughly reliable hand-books on the leading branches of Medicine and Surgery is a fact amply demonstrated by the favor with which the SAUNDERS NEV SERIES OF MANUALS have been received by medical students and practitioners and by the Medical Press. These manuals are not merely condensations from present literature, but are ably written by well-known authors and practitioners, most of them being teachers in representative American colleges. Each volume is concisely and authoritatively written and exhaustive in detail, without being encumbered with the introduction of “cases,” which so largely expand the ordinary text-book. These manuals will therefore form an admirable collection of advanced lectures, useful alike to the medical student and the practitioner: to the latter, too busy to search through page after page of elaborate treatises for what he wants to know, they will prove of inestimable value ? to the former they will afford safe guides to the essential points of study. The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior to any similar books now on the market. No other manuals afford so much infor- mation in such a concise and available form. A liberal expenditure has enabled the publisher to render the mechanical portion of the work worthy of the high literary standard attained by these books. Any of these Manuals will be mailed on receipt of price (see next page for List). Saunders^ New Series of Manuals VOLUMES PUBLISHED. PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital; Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, $1.25 net. SURGERY, General and Operative. By John Chalmers UaCosta, M.U., Clini- cal Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, etc. Second edition, thoroughly revised and greatly enlarged. Octavo, 900 pages, profusely illustrated. Cloth, ^4.00 net ; Half Morocco, #5.00 net. DOSE=BOOK AND MANUAL OF PRESCRIPTION=WRITING. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia. Illustrated. Cloth, ^1.25 net. SURGICAL ASEPSIS. By Car t. Beck, M.D., Surgeon to St. Mark’s Hospital and to the New York German Poliklinik, etc. Illustrated. Cloth, $1.25 net. MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- delphia. Illustrated. Cloth, ^1.50 net. SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D., Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, Chicago. Profusely illustrated. (Double number.) Cloth, $ 2.^0 net. PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of Practice in the Woman’s Medical College of the New York Infirmary; Instructor in Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. (Double number.) Cloth, $ 2.^0 net. MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Department of the New York University, etc. Beautifully illustrated. (Double Number. ) Cloth, ^2. 50 net. MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis- pensary, Pennsylvania Hospital, etc. Profusely illustrated. (Double number.) Cloth, $ 2.^0 net. DISEASES OF WOMEN. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to Middlesex Hospital and Surgeon to Chelsea Hospital, London ; and Arthur E. Giles, M.D. , B..Sc. Lond. , F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. Handsomely illustrated. (Double number.) Cloth, ^2.50 net. VOLUMES IN PREPARATION. NOSE AND THROAT. By D. Braden Kyle, M.D., Clinical Professor of Laryn- gology and Rhinology, Jefferson Medical College, Philadelphia ; Consulting Laryngolo- gist, Rhinologist, and Otologist, .St. Agnes’ Hospital ; Bacteriologist to the Philadel- phia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous Diseases, Medico-Chirurgical College, Philadelphia; Pathologist to the Orthopaedic Hospital and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph Hospital, etc. *»* There will be published in the same series, at short intervals, carefully-prepared works on various subjects by prominent specialists. Pamphlet containing specimen pages, etc. sent free upon application. 24 Medical Publications of W. B. Saunders. SAUNDBY’S RENAL AND URINARY DISEASES. Lectures on Renal and Urinary Diseases. By Robert Saundby, M,U. Edin., Fellow of the Royal College of Physicians, London, and of the Royal Medico-Chirurgical Society ; Physician to the General Hospital ; Consulting Physician to the Eye Hospital and to the Hos- pital for Diseases of Women; Professor of Medicine in Mason College, Birmingham, etc. Octavo volume of 434 pages, with numerous illus- trations and 4 colored plates. Cloth, $2.50 net. “ The volume makes a favorable impression at once. The style is clear and succinct. We cannot find any part of the subject in which the views expressed are not carefully thought out and fortified by evidence drawn from the most recent sources. The book may be cordially recommended.” — British Medical Journal. SAUNDERS’ POCKET MEDICAL FORMULARY. Fifth Edition, Revised. By William M. Powell, M.D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N. J. Containing 1800 formulae selected from the best-known authorities. With an Appen- dix containing Posological Table, Formulae and Doses for Hypo- dermic Medication, Poisons and their Antidotes, Diameters of the Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- somely bound in flexible morocco, with side index, wallet, and flap. ^1.75 net. “ This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and, as the name of the author of each prescription is given, is unusually reliable.” — Medical Record, New York. SAUNDERS’ POCKET MEDICAL LEXICON. Fourth Edition, Revised. A Dictionary of Terms and Words used in Medicine and Surgery. By John M. Keating, M.D., Fellow of the College of Physicians of Philadelphia; Editor of the “Cyclopaedia of Diseases of Children,’’ etc.; Author of the “New Pronouncing Dictionary of Medicine;” and Henry Hamilton, Author of “A New Translation of Virgil’s yEneid into English Verse;” Co-Author of the “New Pronouncing Dictionary of Medicine.” 321110, 280 pages. Cloth, 75 cents; Leather Tucks, ^i.oo. “ Remarkably accurate in terminology, accentuation, and definition.” — Journal of the American Medical Association. SAYRE’S PHARMACY. Second Edition, Revised. Essentials of the Practice of Pharmacy. By Lucius E. Sayre, M.D., Professor of Pharmacy and Materia Medica in the University of Kansas. Crown octavo, 200 pages. Cloth, jgi.oo; interleaved for notes, $1.25. [See Sattnders' Question- Compends, page 21.] “ The topics are treated in a simple, jiractical manner, and the work forms a very useful student’s manual.” — Boston Medical and Surgical Journal. Medical Publications of W. B. Saunders. 25 SEMPLE’S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. Essentials of Legal Medicine, Toxicology, and Hygiene. By C. E. Armand Semple, B. A. , M. B. Cantab., M. R. C. P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 2 1 2 pages ; 130 illustrations. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 21.] “ No general practitioner or student can afford to be without this valuable work. The subjects are dealt with by a masterly hand.” — London Hospital Gazette. SEMPLE’S PATHOLOGY AND MORBID ANATOMY. Essentials of Pathology and Morbid Anatomy. By C. E. Armand Semple, B.A., M.B. Cantab., M.R. C.P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 174 pages; illustrated. Cloth, $1.00; interleaved for notes, $1.25. [See Saunders' Question- Cotnpends, page 21.] “ Should take its place among the standard volumes on the bookshelf of both student and practitioner.” — London Hospital Gazette. SENN’S GENITO=URINARY TUBERCULOSIS. Tuberculosis of the Genito-Urinary Organs, Male and Female. By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net. “ An important book upon an important subject, and written by a man of mature judg- ment and wide experience. The author has given us an instructive book upon one of the most important subjects of the day.” — Clinical Reporter. “ A work which adds another to the many obligations the profession owes the talented author.” — Chicago Medical Recorder. SENN’S SYLLABUS OF SURGERY. A Syllabus of Lectures on the Practice of Surgery, arranged in conformity with “ An American Text=Book of Surgery.” By Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and of Clinical Surgery in Rush Medical College, Chicago. Cloth, $2.00. “ This syllabus will be found of service by the teacher as well as the student, the work being superbly done. There is no praise too high for it. No surgeon should be without it. ” — New York Medical Times. SENN’S TUMORS. Pathology and Surgical Treatment of ,Tumors. By N. Senn, M.D., Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. Joseph’s Hospital, Chicago. Octavo volume of 710 pages, with 515 engravings, including full-page colored plates. Cloth, $6.00 net; Half Morocco, $7.00 net. “ The most exhaustive of any recent book in English on this subject. It is well illus- trated, and will doubtless remain as the principal monograph on the subject in our language for some years. The book is handsomely illustrated and printed, and the author has given a notable and lasting contribution to surgery.” — Journal of the American Medical Association. 26 Medical Publications of W. B. Saunders. SHAW’S NERVOUS DISEASES AND INSANITY. Third Edition, Revised. Essentials of Nervous Diseases and Insanity. By John C. Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous System, Long Island College Hospital Medical School ; Consulting Neurologist to St. Catherine’s Hospital and to the Long Island College Hospital. Crown octavo, i86 pages; 48 original illustrations. Cloth, $1.00 ; interleaved for notes, $1.25. [See Saunders' Question- Compends, page 21.] “ Clearly and intelligently written.” — Boston Medical and Surgical Journal. “There is a mass of valuable material- crowded into this small compass.” — American Medico- Surgical Bulletin. STARR’S DIETS FOR INFANTS AND CHILDREN. Diets for Infants and Children in Health and in Disease. By Louis Starr, M.D., Editor of “An American Text-Book of the Diseases of Children.” 230 blanks (pocket-book size), perforated and neatly bound in flexible morocco. $1.25 net. The first series of blanks are prepared for the first seven months of infant life ; each blank indicates the ingredients, but not the quantities, of the food, the latter directions being left for the physician. After the seventh month, modifications being less necessary, the diet lists are printed in full. Formulae for the preparation of diluents and foods are appended. STELW AGON’S DISEASES OF THE SKIN. Third Edition, Revised. Essentials of Diseases of the Skin. By Henry W. Stelwagon, M.D., Clinical Professor of Dermatology in the Jefferson Medical College, Philadelphia; Dermatologist to the Philadelphia Hospital; Physician to the Skin Department of the Howard Hospital, etc. Crown octavo, 270 pages; 86 illustrations. Cloth, ^i. 00 net; inter- leaved for notes, ^1.25 net. [See Saunders' Question- Compends, page 21.] “ The best student’s manual on skin diseases we have yet seen.” — Times and Register. STENGEL’S PATHOLOGY. A Manual of Pathology. By Alfred Stengel, M.D., Physician to the Philadelphia Hospital; Professor of Clinical Medicine in the Woman’s Medical College ; Physician to the Children’s Hospital ; late Pathologist to the German Hospital, Philadelphia, etc. In Preparation. STEVENS’ MATERIA MEDICA AND THERAPEUTICS. Second Edition, Revised. A Manual of Materia Medica and Therapeutics. By A. A. Stevens, A.M., M.D., Lecturer on Terminology and Instructor in Physical Diagnosis in the University of Pennsylvania; Demonstrator of Pathology in the Woman’s Medical College of Philadelphia. Post- octavo, 445 pages. Cloth, $2.25. “The author has faithfully presented modern therapeutics in a comprehensive work, and, while intended particularly for the use of students, it will be found a reliable guide and sufficiently comprehensive for the physician in practice.” — University Medical Magazine. Medical Publications of W. B. Saunders. 27 STEVENS’ PRACTICE OF MEDICINE. Fifth Edition, Revised. A Manual of the Practice of Medicine. By A. A. Stevens, A.M., M. D. , Lecturer on Terminology and Instructor in Physical Diagnosis in the University of Pennsylvania; Demonstrator of Pathology in the Woman’s Medical College of Philadelphia. Specially intended for students preparing for graduation and hospital examinations. Post- octavo, 511 pages; illustrated. Flexible leather, ^2.50. “ The frequency with which new editions of this manual are demanded bespeaks its popularity. It is an excellent condensation of the essentials of medical practice for the student, and maybe found also an excellent reminder for the busy physician.” — Buffalo Medical Journal. STEWART’S PHYSIOLOGY. A Manual of Physiology, with Practical Exercises. For Students and Practitioners. By G. N. Stewart, M.A., M.D., D.Sc., lately Examiner in Physiology, University of Aberdeen, and of the New Museums, Cambridge University; Professor of Physiology in the Western Reserve University, Cleveland, Ohio. Octavo volume of 800 pages; 278 illustrations in the text, and 5 colored plates. Cloth, $2,. 50 net. “ It will make its way by sheer force of merit, and amply deserves to do so. It is one of the very best English text-books on the subject.” — London Lancet. “Of the many text-books of physiology published, we do not know of one that so nearly comes up to the ideal as does Prof. Stewart’s volume.” — British Medical Journal. STEWART AND LAWRANCE’S MEDICAL ELECTRICITY. Essentials of Medical Electricity. By D. D. Stewart, M.D., Demonstrator of Diseases of the Nervous System and Chief of the Neurological Clinic in the Jefferson Medical College; and E. S. Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- strator of Diseases of the Nervous System in the Jefferson Medical College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, $1.00; interleaved for notes, ^1.25. [See Saunders' Question- Compends, page 21.] “ Throughout the whole brief space at their command the authors show a discriminating knowledge of their subject.” — Aledical News. STONEY’S NURSING. Second Edition, Revised. Practical Points in Nursing. For Nurses in Private Practice. By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass.; late Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated with 73 engravings in the text, and 8 colored and half-tone plates. Cloth, $1.75 net. “ There are few books intended for non-professional readers which can be so cordially endorsed by a medical journal as can this one.” — Therapeutic Gazette. “ This is a well-written, eminently practical volume, which covers the entire range of private nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise, and how to prepare everything ordinarily needed in the illness of her patient.” — Arnerican Jotirnal of Obstetrics and Diseases of IVoruen and Children. “ It is a work that the physician can place in the hands of his private nurses with the assurance of benefit.” — Ohio Medical Journal. 28 Medical Publications of W. B. Saunders. SUTTON AND GILES’ DISEASES OF WOMEN. Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- somely illustrated. Cloth, $2.50 net. “ The book is very well prepared, and is certain to be well received by the medical public.” — British Medical Journal. “The text has been carefully prepared. Nothing essential has been omitted, and its teachings are those recommended by the leading authorities of the day. ’ ’ — Journal of the American Medical Association. THOMAS’S DIET LISTS AND SICK=ROOM DIETARY. Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, M.D., Visiting Physician to the Home for Friendless Women and Children and to the Newsboys’ Home ; Assistant Visiting Physician to the Kings County Hospital. Cloth, $1.50. Send for sample sheet. “ The idea is good, and the lists are copious.” — London Lancet. “Its practical usefulness places it among the requirements of every practitioner.” — - Chicago Medical Recorder. THORNTON’S DOSE=BOOK AND PRESCRIPTION=WRITING. Dose=Book and Manual of Prescription- Writing. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net. “Full of practical suggestions; will take its place in the front rank of works of this sort.” — Medical Record, New York. VAN VALZAH AND NISBET’S DISEASES OF THE STOMACH. Diseases of the Stomach. By William W. Van Valzah, M.D. , Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D., Adjunct Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic. Octavo volume of 674 pages, illustrated. Cloth, $3.50 net. VIERORDT’S MEDICAL DIAGNOSIS. Fourth Edition, Revised. Medical Diagnosis. By Dr. Oswald Vierord r. Professor of Medi- cine at the University of Heidelberg. Translated, with additions, from the fifth enlarged German edition, with the author’s permi.ssion, by Francis H. Stuart, A. M., M. I). Handsome royal octavo volume of 600 pages; 194 fine wood-cuts in text, many of them in colors. Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net; Half Russia, ^5.50 net. “ A treasury of practical information which will be found of daily use to every busy practitioner who will consult it.” — C. A. Lindsley, M.D., Professor of the Theory and Practice of Medicine, Yale University. “ Rarely is a book publi.shed with which a reviewer can find so little fault as with the volume before us. Each particular item in the consideration of an organ or apparatus, which is necessary to determine a diagnosis of any disease of that organ, is mentioned; nothing seems forgotten. The cliapters on diseases of the circulatory and digestive apparatus and nervous system are especially full and valuable. The reviewer would repeat that the book is one of the best — probably the best — which has fallen into his hands.” — University Medical Magazine. Medical Publications of W. B. Saunders. 29 WARREN’S SURGICAL PATHOLOGY AND THERAPEUTICS. Surgical Pathology and Therapeutics. By John Collins Warren, M.D., LL.D., Professor of Surgery, Medical Department Harvard University; Surgeon to the Massachusetts General Hospital, etc. Handsome octavo volume of 832 pages; 136 relief and lithographic illustrations, 33 of which are printed in colors, and all of which were drawn by William J. Kaula from original specimens. Cloth, $6.00 net; Half Morocco, $7.00 net. “There is the work of Dr. Warren, which I think is the most creditable book on Surgical Pathology, and the most beautiful medical illustration of the bookmaker’s art, that has ever been issued from the American press.” — Dr. Roswell Park, in the Harvard Graduate Magazine. “ The handsomest specimen of bookmaking that has ever been issued from the American medical press.” — American Journal of the Medical Sciences. “ A most striking and very excellent feature of this book is its illustrations. Without exception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section.” — Annals of Surgery. WEST’S NURSING. An American Text=Book of Nursing. By American Teachers. Edited by Roberta M. West, late Superintendent of Nurses in the Hospital of the University of Pennsylvania. In Preparation. WOLFF ON EXAMINATION OF URINE. Essentials of Examination of Urine. By Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, etc. Colored (Vogel) urine scale and numerous illustrations. Crown octavo. Cloth, 75 cents. [See Saunders' Question- Compends, page 21.] “ A very good work of its kind — very well suited to its purpose.” — Times and Register. WOLFF’S MEDICAL CHEMISTRY. Fourth Edition, Revised. Essentials of Medical Chemistry, Organic and Inorganic. Containing also Questions on Medical Physics, Chemical Physiology, Analytical Processes, Urinalysis, and Toxicology. By Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, etc. Crown octavo, 218 pages. Cloth, $1.00; inter- leaved for notes, $1.25. [See Saunders' Question- Compends, page 21.] “The scope of this work is certainly equal to that of the best course of lectures on Medical Chemistry.” — Pharmaceutical Era. CLASSIFIED LIST OF THE Medical Publications OF W. B. SAUNDERS, 925 Walnut Street, Philadelphia. ANATOMY, EMBRYOLOGY, HISTOLOGY. Clarkson — A Text-Book of Histology, 9 Haynes — A Manual of Anatomy, ... 13 Heisler — A Text-Book of Embryology, 13 Nancrede — Essentials of Anatomy, . . 18 Nancrede — Essentials of Anatomy and Manual of Practical Dissection, ... 18 Semple — Essentials of Pathology and Morbid Anatomy, 25 BACTERIOLOGY. Ball — Essentials of Bacteriology, ... 6 Crookshank — A Text-Book of Bacteri- ology, 10 Frothingham — Laboratory Guide, . . ii Mallory and Wright — Pathological Technique, 16 McFarland — Pathogenic Bacteria, . . 17 CHARTS, DIET-LISTS, ETC. Griffith — Infant’s Weight Chart, . . 12 Hart — Diet in Sickness and in Health, . 13 Keen — Operation Blank, 15 Laine — Temperature Chart, . . -15 Meigs — Feeding in Early Infancy, . . 17 Starr — Diets for Infants and Children, . 26 Thomas — Diet-Lists and Sick-Room Dietary 28 CHEMISTRY AND PHYSICS. Brockway — Essentials of Medical Phys- ics, 7 Wolff — Essentials of Medical Chemistry, 29 CHILDREN. An American Text-Book of Diseases of Children, . . 3 Griffith — Care of the Baby, 12 Griffith — Infant’s Weight Chart, ... 12 Meigs — Feeding in Early Infancy, . . 17 Powell — Essentials of Dis. of Children, 19 Starr — Diets for Infants and Children, . 26 DIAGNOSIS. Cohen and Eshner — Essentials of Di- agnosis, 9 Corwin — Physical Diagnosis, .... 9 Macdonald — Surgical Diagnosis and Treatment, 16 Vierordt — Medical Diagnosis, .... 28 DICTIONARIES. Keating — Pronouncing Dictionary, . . 14 Morten — Nurse’s Dictionary, .... 18 Saunders’ Pocket Medical Lexicon, . 24 EYE, EAR, NOSE, AND THROAT. An American Text- Book of Diseases of the Eye, Ear, Nose, and Throat, . 3 Casselberry — Dis. of Nose and Throat, 8 De Schweinitz — Diseases of the Eye, . 10 Gleason — -Essentials of Dis. of the Ear, 1 1 Jackson and Gleason — Essentials of Diseases of the Eye, Nose, and Throat, 14 Kyle — Diseases of the Nose and Throat, 15 GENITO=URINARY. An American Text-Book of Genito- urinary and Skin Diseases, 4 Hyde and Montgomery — Syphilis and the Venereal Diseases, 13 Martin — Essentials of Minor Surgery. Bandaging, and Venereal Diseases, . 16 Saundby — Renal and Urinary Diseases, 24 Senn — Genito-Urinary Tuberculosis, . 25 GYNECOLOGY. American Text- Book of Gynecology, 4 Cragin — Essentials of Gynecology, . . 10 Garrigues — Diseases of Women, . . . ii Long — Syllabus of Gynecology, ... 15 Penrose — Diseases of Women, .... 18 Sutton and Giles — Diseases of Women, 28 MATERIA MEDICA, PHARMACOL- OGY, AND THERAPEUTICS. An American Text-Book of Applied Therapeutics, 3 Butler — Text-Book of Materia Medica, Therapeutics and Pharmacology, ... 8 Cerna — Notes on the Newer Remedies, 8 Griffin — Materia Med. and Therapeutics, 12 Morris — Essentials of Materia Medica and Therapeutics, . . 17 Saunders’ Pocket Medical Formulary, 24 Sayre — Essentials of Pharmacy, ... 24 Stevens— Essentials of Materia Medica and Therapeutics 26 Thornton — Dose-Book and Manual of Prescription-Writing, 28 Warren — Surgical Pathology and Ther- apeutics 29 MEDICAL JURISPRUDENCE AND TOXICOLOGY. An American Text-Book of Legal Medicine and Toxicology, 4 Chapman — Medical Jurisjuudence and Toxicology, 8 Semple — Essentials of Legal Medicine, Toxicology, and Hygiene, 25 Medical Publications of W. B. Saunders. 31 NERVOUS AND MENTAL DISEASES, ETC. Burr — Nervous Diseases, 7 Chapin — Compendium of Insanity, . . 8 Church and Peterson — Nervous and Mental Diseases, 9 Shaw — Essentials of Nervous Diseases and Insanity, 26 NURSING. An American Text-Book of Nursing, 29 Griffith — The Care of the Baby, ... 12 Hampton — Nursing, 12 Hart — Diet in Sickness and in Health, 13 Meigs — P'eeding in Early Infancy, . . 17 Morten — Nurse’s Dictionary, .... 18 Stoney — Practical Points in Nursing, . 27 OBSTETRICS. An American T ext- Book of Obstetrics, 4 Ashton — Essentials of Obstetrics, . . 6 Boisliniere— Obstetric Accidents, Emer- gencies, and Operations, 7 Borland — Manual of Obstetrics, . . . lo Hirst — Text-Book of Obstetrics, ... 13 Norris — Syllabus of Obstetrics, .... 18 PATHOLOGY. An American Text-Book of Pathology, 5 Mallory and Wright — Pathological Technique, 16 Semple — Essentials of Pathology and Morbid Anatomy, . . 25 Senn — Pathology and Surgical Treat- ment of Tumors, 25 Stengel — Manual of Pathology, ... 26 Warren — Surgical Pathology and Thera- peutics, 29 PHYSIOLOGY. An American Text-Book of Physi- ology 5 Hare — Essentials of Physiology, ... 13 Raymond — Manual of Physiology, . . 19 Stewart — Manual of Physiology, ... 27 PRACTICE OF MEDICINE. An American Text-Book of the The- ory and Practice of Medicine, .... 5 An American Year-Book of Medicine and Surgery, 6 Anders — Text-Book of the Practice of Medicine, 6 Lockwood — Manual of the Practice of Medicine, 15 Morris — Essentials of the Practice of Medicine, ... 17 Rowland and Hedley — Archives of the Roentgen Ray, 19 Stevens — Manual of the Practice of Medicine, 27 SKIN AND VENEREAL. An American Text- Book of Genito- urinary and Skin Diseases, 3 Hyde and Montgomery — Syphilis and rile Venereal Diseases, 13 Martin — -Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 16 Pringle — Pictorial Atlas of Skin Dis- eases and Syphilitic Affections, ... 19 Stelwagon — Essentiais of Diseases of the Skin, 26 SURGERY. An American Text-Book of Surgery, 5 An American Year-Book of Medicine and Surgery 6 Beck — Manual of Surgical Asepsis, . . 7 DaCosta — Manual of Surgery, .... 10 Keen — Operation Blank, 15 Keen — The Surgical Complications and Sequels of Typhoid Fever 15 Macdonald — Surgical Diagnosis and Treatment, 16 Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 16 Martin — Essentials of Surgery, .... 16 Moore — Orthopedic Surgery, 17 Pye — Elementary Bandaging and Surgi- cal Dressing 19 Rowland and Hedley — Archives of the Roentgen Ray, 19 Senn — Genito-Urinary Tuberculosis, . 25 Senn - Syllabus of Surgery, 25 Senn — Pathology and Surgical Treat- ment of Tumors, 25 Warren — Surgical Pathology and Ther- apeutics, 29 URINE AND URINARY DISEASES. Saundby — Renal and Urinary Diseases, 24 Wolff — Essentials of Examination of Urine, 29 MISCELLANEOUS. Bastin — Laboratory Exercises in Bot- any, 7 Gould and Pyle — Anomalies and Curi- osities of Medicine, 1 1 Keating — How to Examine for Life Insurance, . . . . 14 Keen — Surgical Complications and Se- quels of Typhoid Fever, 15 Rowland and Hedley — Archives of the Roentgen Ray, 19 Saunders’ Medical Hand-Atlases, . . 2 Saunders’ New Series of Manuals, 22, 23 Saunders’ Pocket Medical Formulary, 24 Saunders’ Question-Compends, . . 20, 21 Senn — Pathology and Surgical Treat- ment of Tumors, ... . .25 Stewart and Lawrance — Essentials of Medical Electricity, 27 Thornton — Dose-Book and Manual of Prescription-Writing, ...... 28 Van Valzah and Nisbet — Diseases of the Stomach, 28 In Preparation for Early Publication, AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT, Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Jeffer- son Medical College, Philadelphia; and B. Alexander Randall, M.D., Professor of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia Polyclinic. AN AMERICAN TEXT=BOOK OF PATHOLOGY. Edited by John Guiteras, M.D., Professor of General Pathology and of Morbid Anatomy in the University of Pennsylvania; and David Riesman, M.D. , Demon- strator of Pathological Histology in the University of Pennsylvania. AN AMERICAN TEXT-BOOK OF LEGAL MEDICINE AND TOXICOLOGY. Edited by Frederick Peterson, M.D., Clinical ; Professor of Mental Diseases in the Woman’s Medical College, New York; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York ; and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago, Illinois. STENGEL’S PATHOLOGY. A Manual of Pathology. By Alfred Stengel, 1M. D., Physician to the Philadelphia Hospital ; Professor of Clinical Medicine in the Woman’s Medical College; Physician to the Children’s Hospital; late Pathologist to the German Hospital, Philadelphia, etc. CHURCH AND PETERSON’S NERVOUS AND MENTAL DISEASES. Nervous and Mental Diseases. By Archibald Church, M.D., Professor of Mental Diseases and Medical Jurisprudence in the Northwestern University Medical School, Chicago ; and Frederick Peterson, M.D., Clinical Professor of Mental Diseases in the Woman’s Medical College, New York ; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York. HEISLER’S EMBRYOLOGY. A Text-Book of Embryology. By John C. Heisler, M.D., Professor of Anatomy in the Medico-Chirurgical College, Philadelphia. KYLE ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By D. Braden Kyle, M. D., Clinical Pro- fessor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia; Con- sulting Laryngologist, Rhinologist, and Otologist, St. Agnes’ Hospital ; Bacteriologist to the Philadelphia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. HIRST’S OBSTETRICS. A Text-Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of Obstetrics in the University of Pennsylvania. WEST’S NURSING. An American Text-Book of Nursing. By American Teachers. Fldited by Roberta M. West, Late Superintendent of Nurses in the Hospital of the University of Pennsylvania. ■ r .'V ^ •t ll ' \ , • . ‘ ■■ * -- ily~' '/• \ ■•WvV ,v It ■'■ i ‘•n . ’ S . • . * ’ . V J • *1 UNIVERSITY OF ILLINOIS-UHBANA 3 0112 069418074