:si*.illlliii*t!ifli »i^"izrTl? -'-?,'-*.•--' Nem fork Btatt QfoUcgc of Agriculture At (JorncU llntncrBtty atljaca. N. 1- Sjibtrarg Cornell University Library RJ 45.C48 1919 Diseases of infants and children, 3 1924 003 491 614 Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924003491614 DISEASES OF IMAMS AID CHILDEEN BY HENRY DWIGHT CHAPIN, A.M., M.D. TKOFESSOK OF DISEASES OF CIIILDEEN, NEW YORK POST-GRADUATE MKDICAL SCHOOL AND HOSPITAL; SUPERVISING PHYSICIAN OF THE CHILDREN'S DEPARTMENT, NEW YORK POST-GRADUATE PIOSPITAL ; CONSULTING PHYSICIAN TO THE WILLARD PARKER HOSPITAL ; TO THE RANDALL'S ISLAND HOSPITAL ; TO ST. AGNES HOSPITAL, WHITE PLAIXS ; TO CONVALESCENT HOME FOR CHILDREN, SEA CLIFF, AND TO THE HACKENSACK HOSPITAL ; EX-PRESIDENT OP THE AMERI- j, CAN PEDIATRIC SOCIETY AND ■• ■ ,' , GODFEEY ROGER PISEK, M.D., Sc.D. PROFESSOR OF DISEASES OF CHILDREN AND ATTENDING PHYSICIAN TO TL-JC NEW YORK POST- GRADUATE MEDICAL SCHOOL AND HOSPITAL ; PROFESSOR OF DISEASES OF CH'LDREN, UNIVERSITY OF VERMONT, MEDICAL COLLEGE ; VISITING PHYSICIAN TO THE WILLARD PARKER AND RIVERSIDE PIOSPITALS ; PEDIATRIST TO THE PARK HOSPITAL ; CONSULTING PEDIATRIST TO THE DARRACH HOME FOR CHILDREN AND TO THE ^ DNION HOSPITAL, PORTCHESTER , - i ■ ^ FOURTH REVISED EDITION WITH ONE HUNDRED AND EIGHTY-TWO CUTS AND THIRTEEN COLOirED I'LATES ATEW YOEK WILLIAM WOOD AND COMPANY JIDCCCCXIX CoprniGHT, 1010 Bt WILLIAM WOOD AND COMPANY First Edition, August. I'JOO Reprinted, August, 1910 i^econd l-'dition, September, 1011 Reprinted. August, 1911: lieprintcd, April. 1913 Tliird Edition, August, 1915 Reprinted, August. 1917 J-Ieprinted, Oetober, 1917 Edurtli Ediiidii. August, 1919 HAMILTON rniNTTNn CO ALBANY. N. T TO THE STUDENTS BOTH GRADUATE AND UNDERGRADUATH; IN THE UNITED STATES AND CANADA WHOM IT HAS BEEN OUR PLEASURE TO TEACH THIS BOOK IS DEDICATED. PREFACE TO THE FOURTH EDITION. TliL' miiiierous ailvanccs and progressive changes in tliouglit relative to I'ediatries have Ijeen incorporated in tliis new edition. Many of the cliapters have been recast and additions ]ia\-e hecn made in accordance witlr the progress in tliis specialt}'. Xew articles liave been written on sucli subjects as Acidosis, Food Allergy, Epidemic Encephalitis, Functional Heart Disorders, and the newer conceptions regarding Spasmophilia and its allied conditions have been incorporated. Further dietaries, jjarticularly for older children, have been added, .suitaljle under varying conditions and seasons. The illustrations have been improved and some new ones added where it was believed the text would be made clearer therel)y. Treatment, and particularly ])reventive treatment, has been empha- sized, but only such measures are advocated as liave j)ro\ed wortliy and liave stood the test of clinical experience. It is hojied tliat a -work as compact as is consistent with thoroughness and completeness A\-ill receive the same kind reception accorded it heretofore by the profession. The authors wish again to thank the publishers for their unfailing courtesv and helpful suggestions during tlie progress of the re\ision. H. i). C — G. R. P. June 15, IV 19. PREFACE TO THE FIRST EDITION. This volume lias been written by teachers who feel tliat a large contact with students has made them fairly familiar with their needs. Probably the first requirement at present is to bring each branch of medi- cine into as compact a form as is consistent with a thorough presentation of the subject. Our aim has been to accomplish this with pediatrics. To many, the diagnosis and treatment of diseases of infants and children are most perplexing. These difficulties can only be overcome by first sharply differentiating the anatomical and physiological peculiarities of the infant and child, and then considering their practical bearings. The student must be familiarized with all the more recent tests, as well as the older practical bedside experience, in the study of disease. He will then, by a systematic examination of the patient, lie able to make a scientific diagnosis. He must also be taught to treat rationally and with a distinct purpose in mind. We have aimed to present the subject in this way, and thus to make the work as practical as possible. The physician needs such a description of disease as he will actually encounter at the bed- side. Where pictures can serve as a type, we have used illustrations, most of which are original. Theory and pathology have only been considered in so far as may be necessary to an understanding of the diagnosis, course and treatment of disease. We have ti'ied to take a middle course between the compendium, which is nsualh' unsatisfactory, and a too exhaustive work, which, by dw-elling over much on theory and exceptions, tends to confuse the reader. Our thanks are due to our hospital assistants, Drs. Dennett and Albee, for their help during the progress of the work. While a book of this sort must be indebted to all the workers in pediatrics, whom we have freely consulted, our personal experience at the Infants' and Children's Wards of the ISTew York Post-Graduate Hospital, and in private practice, has formed the essential basis of our description of the diseases and their treatment. Our thanks are due to the publishers for their care and courtesy in the preparation of the book. The Authors. New Yorl; SepfrNiher, 1909. CONTENTS. SECTION I. The XEWLY-r.ORX. CILVrTEi; I. Page The Management A^Trl Cark hi- I'KK^rATrRE Infants 1 CIIArTEU II. lNJURTi;S PlRINf; IllRTIT. Deformity of Head: Caput Siuceilaneuni ; CepliaUieiiiatoma ; Injuries to L'.oue and Muscle; Birtli I'alsies ; Facial Paralysis ; I'pper-arm I'aralysis (Ducbenne's) ; Central I'aralysis: Asphyxia: Con.nenital Atelectasis; Fetal r>eatU 5 CIIArXEIt II. Disi-.a.ses of the Xkw LY-j:0r!X. Acute Infei-tiiius Diseases; Sepsis of tlje Xewly-liorn ; Unil)ilical Ilenior- rliage ; Uubilical Vegetations; Uuil)ilical Hernia; Epidemic Ilemogloliin- uria (Winekel's Disease) ; Fatty Degeneration of tlie Xewly-lioru (Buhl's Disease); Icterus Neonatorum; Tetanus Neonatorum; Conjunctivitis: Ophthalmia Neonatorum: Mastitis; Sclerema Neonatorum; Spontanenns Hemorrhages in the Ne\\i,\-lMirn 12 SECTION II. Hygiexe op Infancy. CHAPTEU IV. Hygiene of Infancy. Clothing; The Nursery: I'.athing: E.xenise and Fresh Air; General Ilaliits . 2'^ CHAI'TEIt V. Weight and Development. Weight; Length; General Shape; Head; Brain; Spine; Glands; Stomach; Intestines and Liver; Bladder; Muscles; Dentition; Delayed Dentition; Disturbances of Dentition; Care of Temporary Teeth; Permanent Teetli ; Ilutcbiiison's Teeth; Growth during Childhood: Jlental and Moral Growth : Adolescence : Table of Height and Weight 20 ix CONTENTS. SECTION 111. The Examination of the Sick Child. ClIAl'TEK VI. The KXAMINATION OF THE SiCK CHILD. Page Ilistcii-y: Iiisiieetidii ; I'aliiatioii ; Aiisiultatii)ii ; I'evL-ussion ; ileiisuration ; Keotal Kxaminatiou 39 CIIAl'TEU VII. .Special Exami.natioxs. j:;xudatf s ; The Sputum ; Tbe Gastric Coutents : The Feces ; Tbe Cerebrospinal Fluid; Tecbnic for Subdural or Luiiiliar ruucture ; Tecbuic for Aspiratiuu of I'leural Cavity; Tbe Urine; Test f(ir Indican ; Transudates and Exudates: Tbe Uoentgeu liavs ; lleniuglobin ; lied and Wbite Bl.iod Counts: Ited Ceil Count in Early Life; Wbite Cell Count; Blood Smears; Nucleated Ued Cells in Infants; Tbe Itelation of I'olynuclear Neutropbiles to Lyuipbocytes duriuju; Cbildbood ; Eosiuupbiliu ; Malaria; Widal Test; Tuberculin Tests; :\Ietbod of Ciillectin.y; tbe Serum for tbe Wassermann Test; Sypbilis and the Wassermann Reaction; Luetin Test; Reasons and Tecbnic for Entering' Tji)in;itndiiial Sinus 4S CHARTER VIII. SlCX.S (IF Il.LXKSS IN IXFANCY. Irritability nf Temjier; Restless Sleep; ('lian;.'i's in Features; State of tbe Discbarges (iO CHARTER IX Gexkkaj, Therapeutics. Drug Adniinistrati((n ; Table of .V\erage Doses; Introductory Remarks; I'sycbotbcrapy ; Aerotheraiiy ; llydrotlierapy ; Special Batbs ; Xaso- pbaryngeal Toilet; Lavage; Ilypndermoclysls ; J'^nteroclysis ; Gavage ; Rectal Feeding; Vaccine Tberaiiy ; Exercises i:,;; cn.vrTER X. Si'i-iOESTiVE Scheme fok Diagnosis. Head; Neck; Face; .Montli : Swallowing: .Minornjalitics in Breatbing; Cliest : Alidoiiieii ; Inguinal Region: Delayed Grnwtb: llemorrbages Extremities . S.") CONTENTS. XI SECTION IV. Infant-Feeding. CHAPTER XI. The Infant feom the Xutkttional Standpoint. Page The Infant; Essential Unity of Foods; FooUs of tbe First Nutritive Period; Breast Secretions; Specialized Foods; ('(in)]iosition and Projierties of Breast Secretions ; Development of the Digestive Tract ; Comparative Mammary Secretions; Cbeniical and Biological Standards 93 CHAPTEU XII. Breast Feeding. Importance of; Preparation for JIaterual Feeiling; Management; Rcgnlarity; Mill< Agrees bnt Flow Scanty; Elimination (if Drugs and Excretory Products in Milk; Milk Plentiful but Disagrees with Infant; Examiiudion of Breast Milk; Nursing not Possible; Contraindications for Nursing; Weaning and Mixed Feeding ; Selection of Wet Nurse 99 CHAPTEU XIII. Principles of, and Materials Used in Substitute Feeding. Dilliculties Encountered; I'rinciples that Apply to All Infants; Cow's Milk; One Cow's Milk ; Influence of Breed on Composition ; Bacteriology of ; I'roduction of Sanitary Milk ; Market Milk ; I'asteurized and Sterilized Milk ; Cream ; Condensed Milk ; Evaporated Jlilk : Mammala : Cereals, General Properties of": Carbohydrates of Cereals; Eggs; Dextri-.AIaltose ; Proprietary Infant Foods; Classification of; Analyses of lOS CHAPTER XIV. Rise and Development of Scientific Infant-Feeding. Historical; Fundamental Errors Made; Classification of Methods of Modifying Milk; Infants tend to a(laj)t tliemselves to their Food; Infants differ in digestion and assimilation efficiency; Assimilation most Efficient in Early Infancy 121 XU CONTENTS. t'lIAr'TKU XV. PRACTIf AL I''i:i:i)I.\G. I'AOE I'.asis of; rercentage of Milk JILvtures ; Top Milk; rercentase Cereal Gruels: Outline of Feeding Directions: Food for Ilealtby Infants; Directions fur Jinking (Jruels; Approximate Home Jlodification of Whole Milk; Adapta tion of Food to Inf.mt ; Food for Infants Previously Badly Fed: Feeding History: Management: Focid for Inf.auts of Feelile Constitution: A "Wet Xurse Unohl.ainaljle; Calalysers; Fond for the Acutely 111; Eiweissniilk : Management of Cases \vh(ai All Attenijits at Adding Fresh Milk Fail: Laboratory Feeding; Caloric Feeding; Finkelsteiu"s Classification; Direc- tions for Mother and Nurse; How to Interpret Results; Feeding in Hot Weather; Feeding when Traveling: Feeding when Aw.ay from Home; Feeding Among the I'diir ; Infant's Food Dispensaries ; L)ried Jliik . . . I'M CHAPTEU XVI. DiKT DCRIXG THE SeCO.M) YEAE. Liietary Twelfth to Eighteenth Months; Eigliteenth to Twenty-foui'th Months; Tv.'O to I'liree Years; Three to Six Years; Diet List for Children's Hus- pitals : Diet Lists for Day Nurseries and Creches; Diet During Later Childhood: Suggestive I)iets for Special Conditions ; Summer Diet; Winter Diet l.-.! SECTION V. DiSEASi« OF THE Digestive System. CHAPTER X\TI. Diseases oe the Mouth. General Considerations; Descpiamative Glossitis; Simple Stomatitis; Aphthous Stouiatitis; Lednar's Aplitlia'; I'erlcclie ; Mycotic Stom.atitis (ThrLislii; Ulcerati\'e Stomatitis; (Jangrenous Stom.atitis (Noma) ; Fhmgated Uvul.a. 171 CHAPTER XVIII. Diseases of the Digestive Tuact. Corrosive Escjphagitis ; Congenital Occlusion of the Esophagus; Acute G.astrie Indigestion (Acute (Jastritis ) ; Gastric ricca-; Chronic (Jastritis; Dilata- tion of the Stomach; Stenosis of the Pyloris and l'yi(n-io Spasm; Iteiairrcnt cr Cyclic \'omitiiig: Acidnsis : Aller.gy ; Inhalation ct I'roteiiis; Infant's Stouis ; (.'nlii-; .Viaite Clastroeideritis ; A(aite lOnterocolitis ; (.'hroiiic (iastriiintestiiial Iniligestiun : ('(ingenital Dil.atalion of the (.'ohm (Ilirsclisprung's Disease): Clinlcra Inf.antum; Constipation: Amebic Dysentery ITS chapti:k XIX. TlIi: .V.M.Nr Al, I'AIt.VSITES. I'ar.asitic Prolozua : Oxyuris Vermicularis ; Ascaris lAunl)ricoides ; Cestodes i]|- Tape-w iirms : Tenia .Medidi-anell.at.i : 'I'oiia Solium: Hynienolc|iis ,\:iiia : I'licinaria .Vmcrir.ina : Trichina Spiralis 'JO'.") CONTENTS. Xiii CHArXER XX. Diseases oe the Lheh. Page The Liver; Kxaiiiiiiatidii ot! tbe Liver; Juundici': Iiitlaiiiiuatioii of the Biliary Duets; Iiiflauimatioii of the I'ortal A'ein : ('on,;;estioii of tlie Liver; Fatty Liver; Amyloid Liver; Cirrhosis of the Liver; Aljseess of the Liver . . 217 SECTION VI. The Infectious Diseases. CilAPTEK XXL The Imeectiuus Disease.s. Measle.s ; German Measles : i^earlet Fever ; Variola ; Vaccination ; Varicella ; Table of Exanthemata; Diphtheria; Fertussis ; Mumps; Typhoid Fever Influenza; Intluenzal Meninj;itis ; Syphilis: Cerebrospinal Jleniiisitis Poliomyelitis; The Epidemic Form in Children; Rheumatic Fever; Malaria (I'aludism) Erysipelas: Disinfection 222 CHAPTER XXII. Tuberculosis. Etiology ; Tuberculosis Adenitis ; Thoracic Tuberculosis in Children ; I'ul- monary Tulierculosis (Acute and Chronic) ; Acute Jliliary Tuberculosis; Tulien ulcus Jleningitis; Tuberculims Peritonitis; Tul)er( ubjsis (jf P>ones and .Joints: Tuberculosis of the A'ertebra'; Tuberculous Disease of the Kip; Tuberculous L>isease of the Knee: Treatment of Tuberculosis in (Jeneru! :312 SECTION VII. Diseases op the Resitratoky Tract. CHAPTER xxrii. Diseases oe the T'pi'kp. Respiratory Tract. Acute Rhinitis; Epistaxis; Foreign Bodies in tbe X^ose : Examination of the Infant's Throat; Pharyngitis and Tonsillitis in Infants; Acute Pharyngi- tis; Acute Follicular Tonsillitis; Ulcero-membranous Tonsillitis (Viii- ceufs Angina); Streptococcus Sore Throat; Chronic Tonsillar Ilyper- troph.v ; Adenoids; Peritonsillar Abscess; Retropharyngeal Abscess; Ac\ite Laryngitis (Spasmodic Croup): Eilema of tbe Glottis; Laryngisnuis Stridulus; Congenital Laryngeal Stridor; X'ew (irowths in Larynx . . . S.tO XIV CONTENTS. cii-vrxKR XXIV. Diseases of the Luncs and Pleura. Page Acute Bronchitis; Chronic P.roneliitis ; I'ulmonary Collapse; Emphysema; P>ronchial Asthma ; Acute P>r(jnchopneun]onia ; Hypostatic PiieuuKniia ; Loliar Pneumonia: I'leui'isy. Dry. Serofibrinous; Emp.yema ; Pneu- Mothorax ; Pulmonary Alisccss; Gangrene ot the Lung; P.ronchiectnsis ; Foreign Bodies in the i;es]iirator.y Tract; Subphrenic Abscess 353 SECTION YIII. Diseases of the CmcufjATORY System. CIIAl'TER XXV. Diseases of the Heakt. The Heart; Congenital Heart Disease (Cyanosis); Eudocarilitis ; Myo- carditis 37.5 CHAPTER XXVI. Chronic Vaiaulak Disease. Mitral Regurgitation; Mitral Obstruction; Aortic Obstruction; Aortic Regur- gitation ; Tri(.'uspid Regurgitation ; Functions of the Heart ; Functional Cardiac Disorders; Heart Block .38.5 CHAPTER XXVII. r>ISEASES OF THE PeIUCARDIUM. Pericarditis; Instruments of Precision in Cardiac Disease ;390 SECTION IX. Diseases op the Blood an'd Ductless Glands. CHAPTER XXVIII. Diseases of the Beoou. Glossary; The Blood; Anemia; Sim|ile or Secondary Anemia; Chlorosis; Pernicious Anemia; Leukemia; Pseudo-leukemia of Infants (von .Taksch's Anemia); Table of .\nemias; Treatment of the Anemias; Purp\ira ; Pni'iiura Simplex ; Purpura Hemorrhagica ; Henoch's Purpura; Schiinleiu's I'urpuia ; Purpura Fulminan's; Hemopb.ilia .'!9:^ CONTENTS. XV CHAPTER XXIX. Diseases of the Ductlios.s (!lanus. Pace The Thymus ; Enlargement of tlie Thymus ; Status Lymphaticus ; Diseases of the Spleen ; Inflammation of the Spleen ; Chronic I'asslve Congestion of the Spleen : Disorders of the Adrenals ; Addison's Disease ; HodgUin's Disease (Lymphadenoma) : Acute Adenitis ; Chronic Adenitis ; Exophthal- mic Goitre ; Achondroplasia ; Infantilism : Cretinism 408 SECTION X. General Diseases of Nutrition. CHAPTER XXX. NLITKrriONAL DiSOKDKKS. Rachitis ; Congenital Rachitis ; Scorbutus ; Marasmus ; Diabetes IMellitus . . 424 SECTION XI. Diseases of the Uropoietic System. CHAPTER XXXI. Disorders of the URI^'E and Kidneys. The Urine in Infancy; Character of the Urine; Formation of the Kidney; Anuria; Polyuria; Diabetes Insipidus; Renal Calculi; Hematuria; Hemo- globinuria; Functional Albuminuria (Cyclic or Physiologic Altiuminuria) ; Indianuria ; Acetonuria and Diacetonuria ; Congestion of the Kidney ; Chronic Congestion (Passive Hyperemia) of Kidney; Nephritis. Acute, Chronic ; Pyelitis ; Tumors of the Kidney ; Hydronephrosis ; Enuresis . . 4.37 SECTION XII. Diseases of the Genital Organs and Bladder. CHAPTER XXXII. Diseases of the Genital Organs. Phimosis and Paraphimosis; Balanitis; Urethritis; Vulvovaginitis; Mastur- bation; Hydrocele; Undescended Testicle; Differential Diagnosis of Swellings in the Inguinal Region 459 XVI CONTENTS. CUAl'I-EIt XXXI 1 1. DiSKASKS in- iiii: Ulauder. Page • 'ystitis; A'fsical t^jiasLi] ; \'i'siral Cnlriiliis "IWJ SECTION xin. Diseases of the Nervous System. CIIAl'TKU XXXIV. (Jknekai, Xekvolis Diseases. General Considerations; I'aralysis in (Jeneral ; Cliaracteristies of tlie Various 'J\\]i('s; Convnlsions : Cliorea ; Hysteria : Kpilepsy ; Ileailaclies (Migraine) ; Iiisiininia ; I'avor Xin'turuus: Spasnjn|iliilia : Tetany : Congenital Jlyotonia (Tlionisen's Disease) : I'arainyoelonus .Multiiile.x : Aiiginneurotie Eilenia ; Tics 4GS CnAI'TElt XXXV. Diseases of the 1'].]:ii'1ikkal Xerves. Multiple Neuritis; Diphtheritii' I'aralysis; l-'aci.-il I'aralysis 489 CIIAl'TKU XXXVI. Diseases of the Si'I.n'ae Cord. Myelitis; Mnlli]ile Scleriisis ; Hereditary .\ta.\ia ( Friedericli's Disease); I'ri- luary Myopathies 4',.).'; CIIAl'TKU XXXVII. Diseases oi- the 1'rain. Meningitis; Eneophalitls ; Ejiideniie lOncephalitis : Abscess of the Brain; Tnniiii's of the Itrain; ('erehral I'alsies; IIy(Ir()ie)ihalns ; Mieroee|ihalns ; I(li(ii->-; I iiiliecility ; I'^eelili'-niindedness ; Mongolian Idiocy; Ani.-iurnlic Family Idiocy; The liinet-Sinion Tests ool CONTENTS. XVU SECTION XIV. Congenital Malformations and Deformities. CIIAPTEU XXXVIIl. C'O.N'GEXITAI. Malkoriiatioxs axd Defoemities. Page Tongue Tie; Hare-lip; Cleft-ijalate ; Braiiebial Cysts; Malt'oniuitioiis of tLe Esophagus ; Molforniatious of the Rectum and Anus ; Hypospadias ; Extropliy of tlie Bladder; Congenital Dislocation of the Hip; Congenital Absence of Bones; Talipes; Wehbed Fingers and Toes; Meningocele and Encephalocele ; Spina Bifida 519 SECTION XV. The Commoner Surgical Diseases. CIIAI'TEU XXXIX. The Commoner Surgical Diseases. Anesthesia; Hernia; Circumcision; Appendicitis; Intussusception (Including Intestinal Olistruction ) ; Peritonitis, Acute, Xe>Yly-ljorn, Early Life, I'neunjococcic ; Ascites; Ischiorectal Abscess; Rectal Polypus; Fissure of the Anus ; Prolapse of the Anus and Rectum ; Malignant Tumors in Childhood 530 SECTION XVI. Diseases of the Ear and Eye. . ., CHAPTER XL. Diseases of the Ear. General Considerations; Otoscopy; Otitis; Mastoiditis; Infective Cerebral Sinus Thrombosis .545 CHAPTER XLI. The Coximoxer Diseases of the Eye. Foreign Bodies; Blepharitis: Conjunctivitis. Dijihtheritic, Chronic, Granular; Chalaziim; Hordeolum; Sti-abisnins ; Keratitis; The Diagnostic Signifi- cance of Ocular Affections; Diagnostic Hints; Refractive Eri'ors . . . 5.50 XVIU CONTENTS. SECTION XVII. Diseases of the Skin. CHAPTEU XLII. Diseases of the Skin. Page Ichthyosis; Nevi ; Dermatitis Exfoliativa Neonatorum (Ritter's Disease); I'emphigus Neonatorum; Impetigo Contagiosa; Seborrhea Capitis; Erythema Multiforme ; Acute Exfoliative Dermatitis ; Eczema, Acute. Subacute, Chronic; Psoriasis; Miliaria; Urticaria; Furunculosis ; Herpes Zoster; Pellagra 5-55 CHAPTER XLIII. Parasitic Skin Diseases. Pediculosis ; Scabies ; Tinea Tonsurans ; Tinea Favosa ; Alopecia Areata ; Ivy ' Poisoning .5^8 | f I Index 573 DISEASES OF CHILDREN SECTION I. THE NEWLY-BORN. CHAPTER I. THE MANAGEMENT AND CARE OF PREMATURE INFANTS. When a premature infant is born it is suddenly deprived of a very important organ, namely, the placenta, which has a selective action for the developing fetus. Three and sometimes four factors mitigate strongly against its extrauterine existence. These factors are in the order of their importance: (1) Undeveloped heat and respiratory centers; (2) increased susceptibility to infection; (3) patent umbilical vessels with a tendency to putrefaction; and (4) sometimes possible congenital disease from its progenitors. The temperature of a premature babe at the time of birth varies from 98.6° to 100° F. It is often suddenly introduced into, and examined in a room temperature of 74° F. ; that is, with a \ariation of 34° or 2(1° F. A subnormal temperature undoubtedly often results, from which the child's undeveloped heat centers fail to assist it. A lowered temperature, then, is the first evil to combat. More than one-half of all deaths imder four weeks are attributable to prematurity. We believe that many preuuiture infants that help to swell the mortality statistics may be saved by timely and appropriate directions from their medical attendants. More viable under-term childi-en are born now than formerly, owing to better metliods at tlie time of birth and to sucli surgical measures as. Cesarean section. The records of those born and reared in a maternity hospital show a high percentage saved ; but these cases had never been exposed to chilling and transportation and had the advantage of woman's milk as a pabulum. Our maternity hospitals have no facilities for caring for outside cases, and these are finally sent after a variable time to an institution which has an incubator. The natural solu- tion would seem to be incubator life, and this apparatus will nuiintain the body heat, if properly managed, at 90° F., but it will also necessitate that the babe respire this superheated air, often vitiated and liable to germ 1 2 DlSJiASES (IF L'UILDKK.W contamination. Constant and eternal \i<.nlan(e is lecjiiiri'il to keep the a]i|iai-atus — e\cn tlie best obtainable — in piopei- working oiilei'. If the temperature rises suddenly a heat stroke results, and if tlie gas pressure falls or the wind changes, a subnormal temperature may follow. The pre- mature infant delivered at liome should therefore be placed in a padded basket or crib (see Fig. 1) and surrounded with bot-water bottles, or kept warm with an eleetrie lieater. The room luust be quiet and a sunn)' one; it should be kept at 78° to S0° F.. preferably heated and ventilated by an open fireplace. The supply of fresh aii- sliould be constant. If unavoidably the infant's temperature has fallen to subnorn)al, a warm bath and gentle friction are indicated before supplying the swaddling blankets made of cotton which are to serve as clothes. The importance of conserving this body heat uuiy be emphasized by tlie statistics of Budin in Fi-anee. Ninety per cent, of tlie jiremature infants died who liad a temperature between 110° and 02° F. Fio. ]. — I'.-Mlilnl liaskct-i-rili suitable tur premature iiifaiits rejilai .111 ini-uliator. It is a sigiiilicanl I'acl that the great majorily of casen brought to us for incubatoi- life at the lios|iital lia\'e a subnormal iem|)era(in-e. The "weight and Iriigtii must ue.xt lie considered in ils relation to viability and lo feeding. If the weight is liclow 2i pounds, the iirematiire ai-c rai-ely saved, "H'bile those with liirHi weights between 3,^ and 5 pounds ai'c to be regarded as congenitally feeble. The length of time in utei'o is, ]io\ve\-er, of gi'cater im)'iortance than the birth weight in establishino- the prognosis. Moore saveil a premature infant hoin at the sixih month of gestation "\\"liieli was nine iiiclics long and \v('ighe(l one ami ime-half pounds THE MANAGEMENT AND CARE OF PEEMATUKE INFANTS. 3 1 ■4 !7i;! € (this babe weighed 19 pounds at the end of fifteen montlis). Therefore, if tlie child is bom alive, it should l)e given every chance to live. The obstetrician should immediately place the babe in a wanned l)hmket or in warm cotton wool and have liot bottles close to its Ijody an to 2 hours. If the prema- ture infant is one born nearly at term, with its powers of suckling well developed, 1/4 per cent, fat is added to the whey. Attention must again Fig. 2.— Breck feeder for prema- ture infants. Fici. .'!. — Iloiue- made feeder. 4 DISEASES 01' OHILUKEN. be called to the great value of even a small quantity of breast milk, to assist in the digestion of the artificial feeding. Later, as the weight increases, skimmed milk mixtures made from the mixed remaining milk, after removing top 4 oz., and diluted 5 times with eold boiled water, to which 4 per cent, of sugar has been added, will usually be found to agree. Peptonization is indicated if the stools show feeble digestion. The weaker infants are fed with a dropper, while tliose capable of making suck- ing efforts are fed with a modified Breck feeder. This can be made from a piece of glass tubing with dropper nipples applied, the one being perforated by three small holes (see Figs. 2 and 3). Gavage is dangerous, for we have found milk in the trachea and bronchi of premature infants at autopsy which reached there via the tube. The medical attendant must not be discouraged to note a falling off in weight for some time. It is sometimes three to four weeks before the birth weight is regained. The nurse must be ever watchful for attacks of cyanosis, which must be combated with two- to five-drop doses of diluted brandy, or canqihor, gr. -}, in sterile olive oil hypoderrnatically. The icterus, which is not uncommon and which is usually associated with constipation, often produces fatal results. It is best treated with one- to two-twentieths of calomel. Daily inunctions of liquid petrolatum (albolin) are given in lieu of baths for cleanliness after the usual diapering. After the first year these premature infants are not necessarily weak and puny, but on the contrary are often indistinguishable from the full-term infant. The prognosis, however, should always be considered as unfavorable, as the undeveloped digestive tract, the possibility of sepsis, and the defects in the heart all mitigate against its existence. The importance, however, of ol>taining breast milk cannot l)e overestimated, for it is almost impossible to raise them without its help. Our experience, which includes over one hundred pre- mature cases, leads us to advocate the open method of treating premature infants to the use of the incubator, and we have tried all kinds. Tf an incubator is used, only the type having connection witli the outside air sliordd be employed, as these infants are exceedingly susceptible to a lack of fresh air. CHAPTEK 11. INJURIES DURING BIRTH. Deformity of Head. A certain pointing toward tlie occiput and elongation of tlie head are noted in Tii08t labors. 'I'his may be extreme in eases where a long or diffi- cult labor has resulted in excessive moulding of the presenting part. For- tunately, little damage is done by this distoi'iion and the head usually takes on its natural shape in a few days. Caput Succedaneum. The swelling on the presenting pait of tlie head ]-esulting froui pres- sure is known as caput succedaneum. It consists of transuded serum and extravasated blood located between the scal]j and pericranium in the loose connective tissue of this part. It has a soft, boggy feeling. Prolonged or difficult labors produce this effusion from pressure on the portion of the head that presents. No special treatment is required, as the absorbents of the connective tissue will cause its disappearance within a day or so. Cephalhematoma. Cephaliiematom.a is aji effusion of blood between the bone and the periosteum covering it. It usually appears within one to three days after birth. Its seat may be any jiortion of the cranial vault. Most commonly it occui's in the parietal region, sometimes over the temporal or occipital bones. The overlying integument presents no discoloration. A bony ring is soon developed around the base from the secretion of the periosteum. The effusion is, in most cases, limited by a suture. The effused blood, as a rule, undergoes absorption within the first tliree months of life. In rare cases suppuration ensues, and even caries of the subjacent bone may occur. The fact that the tumor does not communicate with the brain cavity, which fact can usually be readily made out by palpation, serves to distinguish this affection from encephalocele. To differentiate caput succedaneum and cephalhematoma it may he borne in mind that while the former is non- fluctuating and disappears in a few days, the latter is soft and fluctuating, presenting a marginal ridge, in the center of which tlie slnill is felt, and disappears in a few^ months. Treatment. — In most eases no treatment is called for. Should the tumor grow it may be strapped with adhesive plaster, the head first being 5 b i)i8i:Ash:s uf i.'iui.ijimvN. shaved. Incision, while generall.v condeumed, has been practised with success. It offers the advantage of inmiediatc relief and leaves no per- manent deformity. The effused blood can usually be removed tlirough .1 small opening. A firm compi'ess is worn for several days to ])re\ent refilling. It is needless to say that the strictest asepsis must be observed. If suppura- tion occui'S the usual surgical treatment of abscess must be carried out. Injuries to Bone and Muscle. (a) Bone. — The soft and pai-tially developed condition of infantile bone renilers it liable t(j injury if subjected to much mechanical violence during delivery. The cranial bones ai'e especially liable to indentation anil fracture when the forceps is employed, yet such accidents jnay wcur in spontaneous labor. Fracture of the cranial bones is most frequent in the parietals. When the bi'ain is not injured the fracture is not apt to ivsult seriously. Ifupture of intracranial blood-vessels uuiy lead to fatal hemor- rhage. Simple indentations apparently cause little if any damage to the brain structures. Gentle efforts at reduction nuiy be attempted, and thus the normal shape be I'estored. Fi'actui'c of the inferior maxillarv hone inav result from traction with the lingers in unskillful delivery of the after-com- ing head in breech presentations. Injui-ies may he infiicted upon the vertebra' or the sjiinal cord, with resulting paraplegia, and they are almost invariably fatal. Fracture of the humerus not uncommonly occurs in foi-ci- ble delivei'\ of the aian in lireech births, oi- separation of the epij>h\sis from the shaft of the bonc' may take ])lace. Fi-actiire of the clavicle iisualU' results from violent use of the fingei-s in e.vtracting the after-coming head. The femur iiuiy be fractured from misdirectfd traction with lingers or lillel in breech delivery. (b) ^IiTscr.io. — Hematoma of the sternocleidomastoid muscle ruav result fi'om artiticial interfeveiu-c in breech extractions. A hard tumor about the size nl a ]>igeon"s egg may be seen deve]o]iing in this muscle, usuidly on its anterior hoi'der. It is noticed Ijetween the ages of one and si,\ weeks, and usually disappcai's by ahsorjil itm in a nmntb oi' so. The muscle fihei's ai'e sonu'times toi'ii. Ilcmatoina of the sternocleidonuistoid may lead lo conti'acture of the i]ijurcd uiusclc ninl torticollis. As a rule the blood is s]]ontaneousl\' absorhcd in a few weeks. Birth Palsies. Injuries to the ncr\'cs (hiring hirlli iua\ he ccniral or peripluM'al ^PIV' latter are foi'tunately the most coiiiiikiu, and the usual l\pcs are facial and uppi'V-ariii paralvsis. IXJUUIES UUiaXply in the case of very feeble infants. It consists in making rhythmical traction upon the tongue, eight to ten times to the minute. After the respirations have been started, the infant must be watched to see that they continue. It may be advisable in some cases to administer hypodermatically ten to twenty drops of whiskey combined with 1 minim of the tincture of belladonna or 1/200 grain of strychnin. In most cases it will be necessary after resuscitation to apply heat by a hot-water bag or other means. In asphyxia pallida a rectal injection of water at a temperature of 110° F. is of marked service. Congenital Atelectasis. Closely allied to asphyxia, and often associated with it, is a persistence of the fetal condition of the lungs, either of one or both in whole or in paii. It is due to failure of the infant to completely inflate the lungs, and may persist for a considei'able time. Sometimes it results in death, even after respiration has apparently been fully established. This is more apt to involve the lower lobes than the u];>per ones. It is frequently seen in ])reniature infants with feeble respiration. The cause mav also be injury to the brain from pressure. The symptoms are those of deficient rcspii'atoi'v action, such as pallor, feeble cry, and poor circulation, with very little expansion of the cliest-walls over the affected area. Deep inspiration may be encouraged by artificial respiration, and the vitality ■conserved by the external application of heat and the judicious administra- tion of nourishment and stimulants. Fetal Death. Death may take phiee at or before birth, which nuist sometimes be differ- entiated from :is])hyxia. In the former the heart imls.-itions cannot be felt and respirations and reflexes are .-ibsent. In the latter the hei\rt is pulsating, reflexes are present, and there may be feeble attempts at res]iiration. We should not refrain from efforts at resuscitation because the heart-sounds are .absent or no pulsations can be felt in the precordial region. The distinction lietween a dead- born and a .still-born infant can usually be made by the rapid fall of rectal temperature in the former to ten or fifteen degrees below normal and by the widely dilated condition of the ]iupils in the dcad-hnrn. In the stilbborn, artificial respiration may be enuiloyeil. .-uul the hypodermatic injection of a few drops of whisky and gr. l/2nO of sulphate of strychnin may lie gi\-en. CHAPTEli 111. DISEASES OF THE NEWLY-BORN. Acute Infectious Disease. While the newly-born infant sfenis to beai- a sort of natural immunity to the common infectious diseases of childhood, it is possible for an infant to be infected through the jilacenta l)efore birtli or by the usual methods soon after birth. Wliile the sy]ii])to7ns of measles, pei'tussis. pneumonia, scarlatina, or influenza are hugely the same as when seen later on, the prognosis in the newly-born is bad. Sepsis of the Newly-born. An infection induced by pus-forming organisms such as tlie strepto- coccus pyogenes and the staphylococcus pyogenes aureus and albus may be seen in the newly-i)()in. 'I'iie umbilicus is the most vuhiei-able spot for the entrance of septic poisons during or shortly after- birth. Upon ligation of the cord the blood that reuiains in the umbilical veins forms small thrombi that should gradually harden and in time become calcified, forming a fibrous cord in the same mannei' as in the ductus art<'i'iosus and ductus venosus. In these latter structures the formation of throndji is never accompanied with grave consecpiences. since their internal situation prevents the access of inf(?ctious agents. I'yogcuic organisms, however, can readily gain access to tlie umbilical vein and gixc rise to umbilical phlebitis and septicemia. There is a constant alteration aftci- birth in the blood-piessuri" in the umbilical vein, due to the action of the heart and luugs, bv which a sort of flux and reflux is produced. 'I'his favors infection of the svstem when the contents of this vein become septic. This grave accident is liable to occur when the mother is in a septic condition. The poison may be produced b\ the same agents that have caused the puerperal fever. In these cases of s(>psis thei-e is a ]niriform or yellow softening of the thrombi that fill the umbilical vein. The softened matter consists of ])us-cor|mscles and finely granular uiattei- containing micrococci. This sets up an inflammation not oidy in the v<>ssel itself, but also in the surrounding tissues. Infective emboli may be carried to various parts of the body. .\s the micrococci enter the umbilical \c'in from the umbilical fossa, owing tn thi' ]>ei-viousucss nf this v(>sscl. the slructui'es near at band, cspcciallv the liver, bear the first brunt nT the -^cyitic in llnminat ion, 12 U18KASliS OF THE NEWLY-BOEN. 13 The latter organ is usually i'ound inucli diseased or degenerated. There is jaundice, witli constant elevation of temperature and other s\'niptoms of general septic infection. If tlie infant lives long enough peritonitis vt'ill probably develop, and sometimes empyema, pleuropneumonia or even men- ingitis. In all cases evidence of severe illness and prostration are present. Cutaneous, mucous, or visceral hemorrhages may supervene at any time. The abdomen is generally swollen and tender, and dirty-looking pus may be seen oozing f I'om the navel ; slight pressure about the umbilicus will often cause pus to e.xiule if it is not otherwise apparent. The fecal dis- charges may be of natural appearance, but the urine is usually highly colored. The infant refuses nourishment, and there may be vomiting of greenish matter. Severe nervous symptoms, such as convulsions or coma, supervene before death. While the umbilicus is the most common seat of septic infection, any sore or abrasion elsewhere may afford entrance to germs. Erysipelatous eruptions on the abdomen, chest, or other parts, are the most frequent inanifestati(.ins of such infection. Multiple joint inflammation and suppuration may appear as evidences of a general pyemia, and a few cases of osteomyelitis have been reported. Treatment. — The prophylactic treatment of sepsis consists in the careful antiseptic management of labor and proper attention and cleanli- ness in reference to the navel. Localized sepsis may be combated by the topical use of peroxid of hydrogen, bichlorid of mercury solution, or other strong antiseptic agents. The remedial treatment of systematic infection consists in full stimu- lation and genei'al suppoit and the judicious use of external refrigerant measures. In the latter condition, however, treatment is generally futile. Empyema, pleuropneumonia, erysipelas and any other local effect of infection must be treated symptomatically. Umbilical Hemorrhage. Hemorrhage iiiuy take place from the stump of the cord shortly after birth from insecure ligation, from shrinkage (if the funis, or from slipping of the liga- ture. Xjaceration of the cord l)etween tlie abdomen and the ligature may also be responsible for hemorrhage. Secondary hemorrhage, usually between the fifth and fifteenth days, may occur, even thcmgh the cord has been securely ligated and properly watched. The troulile may be due to changes in tlie walls of the minute Idoo'd-ves.sels, allowing transudation, or to imperfect eoagul.ability of the blood. In the latter case the hypogastric urtery and the umbilical artery and vein have not been tightly occluded by the usual fibrinous plug. The hemorrhage is accounted for by syphilis, .i.aundice. hemophilia, or by depraved health on the part of the parents. Treatment, The great majority of cases are fatal from the impossibility of controlling the hemorrhage. In the milder ones a compress of gauze tightly applied with adhesive strips may be sufficient. 14 DISEASES OF ctiildkj;n. Adremiliu (1/1000) may also be used to moisten tbe eom))ress. lu the most obstiuate i-ases it may be necessary to transtix tbe luiibiiieus by two needles placed at i-i^lit anj;les'\vitb a tif;ure-'of-ei,i,'bt ligature placed ti.Lcbtly around them. Thrcinibo]dostin and coaLculnse njay be used tor their coagulatin.i; properties. Umbilical Vegetations. Fungous granulations at times appear, arising from the floor of the umbilical fossa, shortly after the falling of the cord. They may attain the size of a pea. and they usn.illy exude a bloody serum, which may induce excoriations in the surrounding skin. The granulations may gradually atrojdiy after weeks or nionths of sluggish existence. The constant moisture and discharge is, however, a source of irritation, and it is best to ilestroy the growths. This can be accom- plished by repeated cauterization with the solid stick of nitrate of silver or, better still, by passing a ligatui-e around the base of the mass and amputating the exuberant grainilations with scissors. A dry dressing of boric acid or suligallate of bismuth may then be applied. Umbilical Hernia. There is a tendency, especially on the part of badly-nourished in- fants, for the gut to pi-otrude a little at the umbilicus. It is hence desirable to keep a firm abdominal binder in place for the first two or three months. After this time if a protrusion persists, the hernia may be retained by two o\'erlap])ing strips of adhesive plaster. See Fig. 5. It may be necessar\' to keep u]) this sujiport for sev- eral nionths. The dress- ing may be examined and changed every few -weeks to be sure the pressure stays in the right place. The skin must he kept scrupulouslv cleau aiul fi'e(|uenlly dusted with powder. lu older in- fants, an abdominal truss may occasionally do good service. It is rare Cor tins form of umliilical hernia to last Ihrough chih.lhood. In exci'ptioiuil cases when the ru]itiire increases ra])idly in , l''i(;. .'i. — Adb(^si\-e jilasfer dressing tor um- slzi' Operative interference bilical bei-nin, made \\'\\\\ Iwo pieces over- „,,, i -i , iaj,,ang. ( /"/.vr/,'.. inriho,!.) Miay be Considered. DISEASES OF THE NEWLY-BOBN. 15 Epidemic Hemoglobinuria. ( Wiiickcl's Dinca.w. ) This form of liemoglobiuuriu is very rarely seen in the newly-born and then usually in institutions. It begins a tew days after birth in healthy infants with constitutional symptoms of depression shown by a weak rapid pulse and general asthenia. An icterus soon develops that becomes very marlced and is noted over ilie whole body. The urine is soon lessened in amount, contains traces of albumin aud hemoglobin in large amounts, ("asts are occasionally also f(iuneing due either to congestion or to edema of the hepatic tissue. It seems liighly probable that both these theories may apply in different instances, and doubtless many eases of icterus neonatorum are to be satisfactoi'ily explained only by taking into consideration a morbid condition of both the blood and the liver, thus combining the hematic and hepatic theories. The intense congestion of the skin observed during tlie first few hours of life often produces a yellowish coloration that cannot be considered jaundice. It is of the same nature as the discoloration of the skin follow- ing an ordinary cutaneous bruise. The yellow tint is at first seen only on deep pressure, but as the erythema fades the yellowness increases. The conjunctivas are not coloi-ed, and the urine appears normal. This yellowness is usually first noticed on the second day, and may continue a few days or a week. The term " true icterus " can be applied only to those cases in which the yellow discoloration of the skin is cMV.sed by a staining by tlie bile pig- 16 UlSliASlia 01'' UliiLDltliN. ments. This more often occurs in cases of prolonged or difficult labor, in children born aspliyxiated or before term, and in generally feeble infants. It is very frequently seen in foundling asylums. It may appear as early as a few hours after birth, but usually is not marked until the second or third day. In very mild cases the 3ello\v color may appear only on the face, chest, and back, the conjunctivii.' being but faintly tinted and the urine and feces normal in appearance. In severer forms the urine may be high colored enough to stain the linen, and the jaundiced hue may extend to the arms and abdomen. Some infants present a yellowish discoloration of the whole body, with typical clay-colored stools. In most cases the jaundice has disappeared by the eighth or tenth day. It may persist for several weeks. In rare cases, after having much diminished, it reappears with renewed intensity. No matter how extensive this form of jaundice may be, it causes very little constitutional disturbance. The liver may be slightly enlarged, and occasionally there are symptoms of intestinal indigestion. A few small doses of calomel oi- mercury with chalk will be all the medication required . (b) Gkave Form. — This form is fortunately rare, and may be pro- duced by several different conditions. Defects in the bile-ducts will first be mentioned as among the commonest causes. In some cases all the large bile-ducts have been absent; in others the ductus communis chole- dochus has been narrowed, obliterated, or entirely absent. Sometimes a fibrous cord has been found in place of the gall-duct. The cystic duct has been absent and the gall-bladder in a rudimentary condition. Accompany- ing an obliteration of the gall-ducts cirrhosis is usually found in the liver, which will be more or less marked, according to the length of time the infant survives. The liver is generally enlarged. Jaundice tliat is due to obstruction or obliteration of the biliary passages may appear a few hours after birth and soon acquire a marked intensity. It nl'ten, however, does not apj)ear for one or two weeks after birth. The yellowish discoloration of the skin may vary from day to day, at times being much more intense than others. The conjunctiva;' are yellow. The fecal (hscharges lose color and have an offensive odor, while the urine stains the na]ikin a yellow or greenish-bi'own. The sjileen, as well as the liver, is usually enlarged, which partially accounts for the increase in size of the abdomen. ITmbilical hemoriiiagc is a grave and not infrequent symptom in this form of jaundice. The bleeding is not sudden and profuse, but begins as an oozing shortly after the separation of the navel string. It is apt to commence at night. Death is always hastened by this accident, and exhaustion from loss of blood is added to that induced by indigestion and malassimilation. There may DIWFASES Oi'' THE NEVVLY-UOUN. 17 also be a speeit'S of geiierul purpura, bleeding taking place from the nose, mouth, or stomaeh. Infants nia}' live for several months witli impervious or defective bile-ducts, tliough deatli usually takes place earlier from failure of nutrition. Another form of grave icterus neonatoruiu is observed in connection with certain inflammatory clianges in the liver, usually taking tlie foiiii of an interstitial hepatitis, witli which may be conjoined inflammation of the biliary canals. This lesion is apt to be one of tlie results of congenital syphilis, as is likewise periliepatitis, whicli may cause a complete obliteration of the biliary passages. Tlie latter form of inflammation often involves the connective tissue surrounding the common duct, the portal vein, and the hepatic artei'y on the under surface of tlie liver. These cases, liowevei', may not always be of syphilitic origin. Perhaps the commonest manifestation of the grave form of ictei'us in ihe newly-born is seen in connection with septic poisoning that is generally accompanied witli plilei)itis. This has been noted under the head of sepsis. Later I'esearches seem to prove that the bile itself may carry the infective agent. Tetanus Neonatorum. Altliougli this disease is distriliuted tlirougli ii wide geograr>hieal :irp;i. it is most apt to l)e found in filtliy surroundings. Sonietliing tieside filtli. liowever, is necessary : tliere must lie a sfieeitie cause. Tliis consists in tlie tetanus liacillus, sometimes called Nicolaier's bacillus whiob produces tetanoto.xiii, a most virulent poison. It may exist in straw or dust from hay. which explains the fact that horses are suliject to tetanus and that traniiiatic tetanus is often seen anions laborers who are employed about farms and stables The disease usually begins during the Hrst ten days of life, and the onset is apt to be preceded by great fretfulness. Disinclination to nurse is soon fol- lowed b.v rigidity of the voluntary muscles, usually starting in the masseters. The rigidit.y increases, reaching its maxinumi in from twelve to twenty-four hours. The bead is thrown back, and there is a general flexion of the extremities. One peculiarity of the disease is that while the toes are flexed the great toes are adducted. There may he some relaxation at times, especially during sleep, but there are constant exacerbations, iirovolced liy any peripheral irritation. Respira- tion and circulation may be extremely embarrassed, and opisthotonus may he present during these exacerbations. The temperature is irregular, but usually high. Toward the end the pulse becomes rapid and feeble .and death takes place from exhaustion. Treatment. — While the sjiecific cause of the disease may gain entrance at any point of the body when the necessary lesion exists, the umbilical wound is undoubtedly the seat of infection in the great majority of cases of tetanus neonatorum ; hence tlie utmost cleanliness must be observed in cutting the cord and in dressing it. The seissors. the ligature, and the entire management of the navel, cord, stump, and the umbilical wound nnist be rigidl.y aseptic. The excess of the gelatinnus matter should be strijiped from the ford, and a dry, antiseptie dressing applied. Speedy iiiummifieation of the stump is the best safeguard against infection. Special care must t)e exercised in the umbilical dressings where the dwelling is easy of access to stable-yards containing horse-manure or loose earth. 18 DIWJiASJia OF CIIILDKEN. When the disease is once established it is almost invariably fatal. In cases of supimration at the umbilicus, frequent cleansing with a solution of mercuric bichlorid of suitable strength should be employed. With reference to drugs, the two most valuable are i)otassium broniid, gr. iv every two to four hours, and chloral hydrate, gr. ,i every hour. The extract of calabar bean from 1/10 to 1/12 grain may be given hypodermatically. While these are administered the infant must be given nourislnnent frecinently. and stimulants should be freely emploj-ed. The dirticulty of swallowing, iKjwever, is a source of embarrassment in satisfae- toril.v carrying out these measures. Noui'ishment may be given by the rectum or b.v a nasal tube. A tetanus antito.xin is now [iroduced by several manufacturing cliemists. but so far the experience repcjrted in the serum treatment of tetanus neonatorum has been rather negative. Conjunctivitis. Tlie conjunctival nicmbraiic in the newl3-born is very sensitive, and frequently the seat of inflammation. A mild inflammation is often seen, unattended by swelling of the lids, tlie inner surface being reddened and covered with a slight viscous secretion. The eyes must be kept cleansed by frequent bathing or irrigation with a saturated solution of boric acid. A little sterile vasclin may be applied to the lids tn ]ircvcnt retention of the secretion by adhesion of their edges, and two drops of argyrol, lOOf, should he instilled twice daily. Ophthalmia Neonatorum. This form of purulent conjunctivitis mav be due to infection by the gonococcus in the severer cases or hy various ]>yogenic cocci in tlie milder ones ( Ivoch-Weeks bacillus). If the disease manifests itself by the second or third day, the infection probably took place iluring birth. WHien there is a ilelay of a week or more, however, the virus has probably been conveyed by cai'eless attendants, by soiled fiiigei's oi' other infected ottjects. The inflaiiiination is of an intensely virulent typ(>, involving both the ocular and ])alpebral conjunctiva'. The sac is filled with a grayish mucopurulent scci'etion, and thei'c is intense cheniosis. The subconjunctival connective tissue and skin ai'e much swollen, so that Ihe eye can o]d\' with difficulty be opened. Tliere are ]iliotophnbia, pain in the eye, and i-ise of temperature. T'nless the symptoms cpiickly subside, the eye is iri'ejiai'ablv damaged bv ulceration and partial destruction of Ihe cornea. 'I'lie inflammation begins in one eye, but soon attacks the other unless it is effectively protected. ""I'lie diagnosis of the various foi'uis may be made bv culture oi by direct smeai-; the lattei- alone will disclose the gonococcal form; a smear at least should be made in e\('i'y case. The Prophylactic Treatment consists in eni]iloying antiseptic vaf^inal douches in Ihe paitii rieiit woman whoi thei-e is an^- inucoiiurnlent dischar per cent, or argyrol 10 per cent, solution can be recommended as a substitute for nitrate of silver. It has the advantage of being less painful, and is ecpially efficient. ]f the disease is limited to one side an effort should be inailc to jn'otect the sound eye from infection by applying a compress iiioistcued with an antiseptic. The pupil must be dilated with sulphate of atropin if the cornea is attacked. Mastitis. The iiiiinmiary .ulauds of tlie new-boni infant often secrete a niilU-l.ike sub- stance, which appears between the fourth and tenth days after liirth. During tliis time there may be swelling of the ghinds. wliieh gradually abates with the subsidence of the secretion until, usually by the twentieth day at the latest, both secretion and swelling have disappeared. In some cases, iKJwever, the glaner antiseptic precautions, constitutes the treatment. Sclerema Neonatorum. This rare condition consists of an induration of the skin and subcutaneous fat. The hardening may be present only in patches or involve all of the body. It may occur in the calves of the legs, in the thighs, buttocks or parts of the back. Sometimes the cheeks are principally involved. The skin may be lobulated or raised in ridges over the circumscribed patches. The part affected feels as h.-ird as a board, and when the limbs are involved they liecome stiff and unyielding. In some cases the whole body becomes affected, then having ahiiost the nyipearance and feeling of a cadaver. The skin feels hard and cold and does not pit on pressure as in edema. The capillary circulation is very sluggish which gives a bluish tint to the lips and nails. The coldness of the i)0({\"is caused by a subnormal tempei'ature. The pulse is feeble and the respira- tion slow or irregular. The prognosis is bad where the hardening is at all extensive, the infant dying of exhaustion in a few days. In milder cases, where 20 DltflCASliS OF CiriLDREK. only a few ixitcbes occur, such areas of induration may gradually disappear and recovery tal^e place. The disease is apt to affect premature infants or those who are feeble and \vith lo\v vitality from any cause. The treatment consists m cou- serNiuK animal heat and d.iing everything to promote the general nutrition Ihe catton jacket may he employed and hot water bottles kept in the crib. Stimula- tion by hypodermics of camphor ov caftvcm may be employed where theie is inu. h blueness from a feeble heart or atelectasis. Fii, II. — Srler<'iii:i Xeiiiniti Spontaneous Hemorrhages in the Newly-born. In addition to the accidental lieiiioiiliages during the [iroccss of deliv- ery caused by pressure effects, we may occasionally liave spontaneous hemor- rhages during the first week of life that are independent of liiitli. These hemorrhages may oc<-ur in connection with various forms of sepsis, with congenital syphilis or fioni unknown causes. A general jircdisposino- cause douiitlcss exists in Ihc gi'eat alteration in the cii-culation iiuluccd hv the transition from fetal to e,\ti-auterine life, from the ra])iil chaimcs taking placi' in the lilood at this time, and the fragile stale of llie \vi\\[< of tiie blood-vi'ssels. The lilood may ooze from the mucous iiK^mhrane of tlie nose, mouth, gastrointestinal tract, umliilicus, oi- vagin,-i. The skin may also he affected, especially at the occiput, along the hack and wherever pressure is DISEASES UE THE i\ EWLY-BOUK . 31 .ijit to be exerted. There may likewise be small extravasations in the vari- ■ as viscera, but tliese are not usually recognized during life. The hemor- ihage takes the form of slow, continuous oozing and is not apt to last more than one or two days. While the actual loss of blood may not be great, a large number of the cases die from exhaustion, as losses of blood are not well tolerated at tliis time. The bleeding is apt to start from the intestinal tract, called melena neonatorum, when the infant may be restless oi' soumolont, with bloody stools, and occasionally vomits hemorrhagic masses. The umbil- icus may Icgin to show oozing a few days later and hematuria is sometimes noted, ^\'here tlie hemon-hage is limited to the nose, congenital syphilis is probably the cause. While the etiology of some of these cases is obscure, tlie condition is different fi'om hemophilia, and the hemorrhages usually stojj spontaneously in a few davs. Fic. 7. — Flask for collection of blood serum. Unless immediate treatment is instituted the prognosis is bad, tlie infants succundjing to exhaustion. The treatment consists in ti'ying to keep up the strength by careful feeding and stimulation and by employing adrenalin in connection with the bleeding surfaces wdien they can be reached. The recent work of Dr. John E. Welch, however, has yielded brilliant results. His treatment coirsists in the subcutaneous injection of norriuil human blood serum, 10 c.c. three times a day. and. in severe cases, every two hours, starting at the very beginning of the hemoi'rhage. The technic of collecting the blood is as follows: Tho ii 1-111 at tlie houA of the elbow should be made surgically clean. Iodine for this purpose is not very satisfactory, as it tends to conceal the faint lilue coloring of the yeins, making it difficult or Impossible to find them. A muslin bandage or a piece of rubber tubing is drawn around the arm jnst aboye thi' elbow sufficiently tight to cut off the 22 DISiiASIiW Ol' C'lllLDIiliX. venous circukitiiiu hut should uot eutirelj- obliterate the pulse. The most proujiiient vein in the lorearni or at the l)end of the elbow is chosen and a rather small sized aspirating needle connected to the previously sterilized apparatus quickly pushed into it, the point being opposed to the direction of the current. If the needle is in the lumen of the vessel there is a fairly rapid flow of blood. As soon as a How of blood is established the constricting bandage is removed or loosened. The needle should be connected by means of a rubber tubing to a flask (Ehrlenmeyer flask). A partial vacuum may be obtained by suction through a second tube. The glass connection of the aspirating tube should be lightly plugged with cotton in order to prevent contamination. When the flask is filled with blood to the desired level it is stoppered with cotton and allowed to stand at room temperature for one or two hours ; and then is placed in an ice chest for ten or twelve hours. This allows the blood serum to separati' from the clot. At the end of this time the serum is drawn up into sterile pipettes (the Tnouthpieees of which are stoppered with cotton) and is then run into large test-tubes for preservation. Each test-tube is to contain one dose. Injections of whole blood subcutaneously or transfusion of blood by the syringe eatiula method (particularly homologous blood) are measures which have recently saved many of these infants' lives. The donor selected should be healthy, non-syphilitic, and his blood tested for any hemolyzing action before the transfusion is made. The blood of the mother is more apt to be compatable than tliat of the father, and should be used without further tests in an emergency. Various diseases and affections that are often seen, in the newly-born, but not confined to this period, vrill be discussed in their appropriate sec- tions. Among these may be noted tuberculous infection, congenital syphilis, thrush or sprue, colic and indigestion, edema and pemphigus. SECTION II. HYGIENE OF INFANCY. CHAPTEit IV. HYGIENE OF INFANCY. After birth a careful inspection of tlie infant sliould be made to dis- cover any defects tliat may be present. The body sliould then be thoroughly oiled, and, if the infant is cold or gives evidence of poor vitality, it may be wrapped in cotton batting and put in a warm place for rest. Vigorous children may be bathed in water at 100° ¥. shortly after the oiling and then dressed. The first bath must always be given expeditiously in a warm room. A dry dressing is best for the cord, which, after a thorough powder- ing, may be wrapped in sterile gauze. A daily sponging of the body with castile soap and warm water will take the place of the bath until after the cord separates. A pad of sterile gauze may be applied over the umbilicus for several weeks and kept in position by the abdominal binder. The eyes can be cleansed with a saturated solution of boric acid or a 2 per cent, solution of nitrate of silver where a purulent vaginal discharge has existed in the mother. The mouth may be gently wiped out with boiled water and a teaspoonful of tepid water given to swallow. Clothing. The clothing consists of an iibdoniinal binder of flannel, which, in a few weeks may be changed in vigorous infants to a knitted band with shoulder straps. The binder should not press so tightly as to retard the free expansion of the lungs in breathing. Next will come a shirt with a little extension below to which the diaper may be attached by pinning and then .-i flannel ])etticoat. Finally a dress of some light material will complete the raiment. Care must be taken to have the clothing neither too tight nor too loose. In the former case, the free movements of the chest, abdomeu and legs are interfered with, while in the latter instance the clothing creases or works up and down in a manner to cause much discomfort. Long, warm stockings, with knitted bootees will keep the lower extremities protected in cold weather, .-md in the warm season, short, thin socks may be substituted. In early infancy the clothing is made long enough to well cover the feet, but it is not necessary to have dresses and petticoats unduly long so as to drag on the feet. The Gertrude patterns are excellently adapted to the dressing of infants as the several pieces may be put on at one time, obviating unnecessary handling. Diapers may be made of linen, cotton, stockinet, or canton flannel, according to the season, care being taken to have them snugly applied and warm. Watchfulness of the nurse is required to have them quickly changed after being soiled. 23 24: DISEAy£S or CilJLill;J£\. The Nursery. Tbis should be -a large well-veiitilated ruouj with a sunny eximsuie. The temperature sboukl be Uept ciuistant — from GS° to 70° F. during the (biy and night from 05" to 55' F.. according to tlie age and vitalitj' of the infant. An intake of fresli air witliout a draft niay bo accumiilislied by fitting a board under the lower window sasli. If iiossil)le beat the room with an open fire on account of the ventilation. When furnace heat is employed, a thorough airing twice a day by widely ojicned w indoxNS is desirable. Bathing. After the c(jre placed at regular times on a small commode for this purpose, taking care to support the baby in thi' proper ])osition. At a year, efforts may l)e made to train the bladder liy encouraging the young infant to indicate his desire for urination. After many trials progress will he made in this direction. The greatest regnlai'it\' in feeding must be entailed from the first, hut tlie necessary details will be considered in the chapter on feeding, AYatcr must always be regularly given, even the newly-born getting a few teaspoon- fuls daily. The young infant must always be kept quiet, as the rapidly growing nervous system suffers from romping and too much attention. This must especially be enforced late in the day. CHAPTEi; \'. WEIGHT AND DEVELOPMENT. It is important to have a record of the birth weight in every case. The male infant usually weighs a little iiioi-e than the female. In a series of 200 eases examined by the authors the males weighed from G to 8 pounds and the females from oi to 7 pounds. As nuiny of these were born in institutions the averages of light weight were fairly large. Seven pounds may be considered a good average birth wciglit. As far ais initial weight may he considered a gauge of vitality, 6^ pounds will show a good vitality. Fig. 9. — Normal infant at ?.Vo nmnths, Typicnl attitude (in v^ntruni. 5-| pounds a rather poor, and from 4 to 5 pounds a very poor vitality at the stai't. ])ui'ing the first few (hiys tliei'e is generally a loss of from four to six ounces, after whicli there should be a steady gain. It must be remend)ered, liowcver, tliat babies are apt to gain ii-i'cgidarly at short intervals. One day the infant may show a gain of an ounce and the next day a (|uarter of that amotmt while doing perfectly well. Again, the weight may remain stationary foi' a day or so, and then jump u|i two ounces in twenty-four hours. According to Piotcli, there should he an average daily gain from birth to five months of 20 to 30 gm. (two-thirds of an onunce to an ounce), and from five to twelve months of 10 to 20 gm. (one-third to two-tbirds of an ounce). This would mean an avei-age wecklv gain durino' the (Irsl fi\'e months of about four and a half lumccs lo seven ounces, and from five to twelve months of from about two and a half to four and a half ounces. 20 WEIGHT AND DEVELOPMENT. 37 The infant treble it at tw by the saiuo i)er construeted for During the first montlis, once in Careful records The length in the female. should double its birth weight at H\e or six months, and elve to fifteen months. The weighing should be done son either on grocer's scales or those h'vcr scales specially infants. Daily weighings are deceptive and undesirable, six months, once a week is sufficient, and, in the second six two weeks is often enough in cases that are doing well, should be kept, and charting is convenient for reference, of the new-born baby is slightly greater in the male than In tlie series alreadv noted, the males averaged 50 cm. ■ 1 ;7C 1 1 >i"' "^HB 1 1 1 ■ 1 ^ 1 \ 1 \ h ! W: ,• _it-/-*- -..i£d^ .A ^ -«. ^^_ ^.^ ' HH Fig. 10. — Normal iiifaiit. Tyiiical attitude on dorsum. (19.6 inches) and the females 48.6 cm. (19.1 inches). In private practice, with healthy parents, the length will average about 20 inches. Growth in length is most rapid during the iirst month, a little less so during the second, the rapidity decreasing with each month. The following figures are taken from Eoteh : The average increase for the first month is about 4.5 cm. (If inches) ; for the second month about 3.0 cm. (\\ inches) ; for the third to the fifteenth month about 1 to 1.5 cm. (-|- to J inch) ; for the first year about 20 cm. (8 inches) ; for tlie second year about 9 cm. (3| inches) ; for the third year about 7.4 cm. (3 inches). Just after birth the trunk, arms, legs, and head have peculiar confor- mations. The body is of an elliptical shape, with the widest part at about the center over the liver, in the region of the lower ribs. The two ends of the ellipse, represented by the thorax and pelvis, are small and not well developed. The arms are stronger and better developed than the legs. During intrauterine life the baby is placed in a sort of squatting position with the legs drawn up and curled inward. This explains why the legs of 28 UJSEA8JiS OF CillLDKEN. tlie young infant are not straight, but show a decided bowing of tlie tibia and iibula. The soles of the feet also tend to point inward. The head is larger than the chest at this lime, with a very short neck, and the baby assumes a ])osition of general flexion. While infants al biith may vai'v in size, each inilividaal shonld develop in proper propoi'tioii, tlie ^■arious ]iar(^ of the body bearing a syininetrical ri latiiiir-;lii]) to one anothe)'. 'Hie cii-cniiifci-enee of the bead is gi'eater than V^EIGHT 7 LBS.12 OZ. LENGTH WEIGHT 15.4 LBS. 6 MOS. WEIGHT 1S LBS. 9 02. 12 MOS. Fifi. 11. — Dia.L'raiiiiiiafic talilc ol' i-s formerlv attributed to teething nvf now known to have other causes that have been revealed bv nioi-e aecui'ate diagnosis and ]inthology. This is a ]ieriod of rapid growth and instal)ility, es]ii>cially of the digestive and nerv(uis sys- tems. Manv troubles at (his time are due inori> to fault\' care and feedinac than to any normal physiological activity and growth. Still a e(M-fnin Tiumber of infants do show disturbances at this time that are apparently WEIGHT AND DEVELOPMENT. 33 due to the eruption of leetli, as careful examination fails to show other cause. Tliere iiia\' be evidences of nervous discomfort shown by constant restlessness and fretfulness, disinclintaion to take food, and various grades of indig'cstion. There is drooling with swollen gums, and the infant keeps putting its hands into its mouth. ' A light, irregular temperature may also develop that will be aggravated by indigestion if food is foi'ced in too great amount or strength. In a few cases the infant seems much sicker, with high fever and severe nervous symptoms, such as semi-stupor or convulsions. Rickety babies are prone to the latter. Most cases, how- ever, show the disturbances of dentition rather by an aggravation of any existing trouble that othei'wise might hardly be noticoalile. The treatment consists in careful regulation of the diet, which will usually take the form of temporarily weakening tbr food, ami in gi\iiig a sedative, such as sodium bromid. Incising the gums is not advised. Any diarrhea at this time must I'eeeive prompt and careful attimliuri. Caue of TE-urouAUY Ti:cth. — Tlie teeth must be cleansed twice daily by gently rubbing up and down with a very soft, wet tooth-brush. The" health and jjreservation of the temporary teetli are necessary to favor a good set of permanent teeth. Any pyogenic gei'iiis allowed to lodge in the roots may injure the permanent teeth; ndlk-teetli must accordingly be filled if carious and preserved as long as possible. They also tend to preserve the alveolar shape. Permanent Teeth. — '^I'liere are thiidy-two in the complete set. The first molars are usually the earliest teeth to appear in the second dentition, at the sixth or seventh year. Tbcn flie central and lateral incisors, from the seventh to the ninth year: the bicuspids from the ninth to the tenth \'ear : the canines from the tfl'elftli to tlie fourteenth year; the second molars from the twelfth to the sixteenth year; and the tliird molars, or wisdom teeth, from the seventeenth to the twenty-first year, or even later. The pi'oper developuient of the pernianeTd teeth may be inteidered with by nudnutrition or repeated attacks of stonuititis which may cause a poor formation of dentine and enamel. Tln' emls of tlie incisors and molars may show constrictions and erosions. Carious teeth fre(|uently cause earache, neuralgia, adenitis in the the neck, and poor nutrition from chronic indigestion due to imperfect mastication. Htitciiinson's Teetif. — Congenital syphilis will sometimes induce a change in the upper central incisors of the permanent teeth only, known by the name of their discoverer. They are small and peg-shaped, with seooped-out grinding edges, usnally deflected inward ; occasionally they are deflected outward. 34 UlSEAHliS OF CllILUIiKN. Growth during Childhood. The increase in weiglit and height depends ujjon race and climate as well as on the size and physujiie of tlie parents. It is tlius evident that no absolute rules eau be given for eonipaiison tliat will apply to all children. "We have already given data as regards infancy, when growth is steady and rapid. After the period of infancy, growtli is not relatively so rapid and takes place more in cycles. It depends very largely upon good lieredity, and a liealtliy well-nourished state during the first years of life. Biobjuical researches have shown that fa\orable eml^rvonic condi- 15 M yrs. 9>a yrs. « >a yis. 4a. !) 50.0 inclios 45. L' \h, 59.0 His. 12 a vrs. 55.4 iiH-licw 7G."J His. 62.9 10T.4 1bs. l'"ii:. 1.'!. — lMa,i;r;ni]niatic tal)le "f relative lurasiirciiiriits. tions and gond nuti'ilion during tlie earliest yeai'S liave the gi'catest inlluence in deti'rniining tlie full height and de\ehj|)iiicnt of the indivitlual. If a cliild is fortunate m its ))iidli and -^^'el] nourislied up to its fifth or siNtli year, thei'e will proljably l)e a normal growtli tliereaftci', as, even if tliere arc piini- condilioiis latci' on, nature will ])i'o]iabl\- be able to compensate fill' thcin. faicb iiidividual has a certain normal size to attain which will usually be reached if tlic first years have hern favoral)le. It is difficult to make up, however, for early unfavni'able conditions. 'I'lie two ]ii'ineipa1 ])eiaods of aeei'leration of growtli occur dui'ing the' second dentil ion and at the period of adolescence. This rou'i-hly corre- WEIGHT AND DEVELOPMENT. 35 sponds, first, with the period from six to nine years in boys and girls, and second, from eleven to thirteen in girls and from fourteen to sixteen in boys. This cycle of increase in height should precede and be shortly fol- lowed by an increase in weight. There also tends to be some variation in growth at different seasons. In a series of cases quoted by Tanner, the period of most rapid increase in lieigbt among seventy boys, from seven to fifteen years of age, was found to be from April to August, and tlie least from August to December, while the greatest increase in weight occurred from August to December, and the least from April to August. Whenever there is a rapid increase m height, the child is apt to grow thin and anemic, as the making of bone particularly uses up the red blood-corpuscles. The children then become nervous and irritable, recjuiring extra care at home and school. In order to present a guide of average growth, the following tables have been combined and compiled from the studies of Boas on the rate of growth in height and of Burke on the weight of American children: Table of height and weifflit of American bovs. Years Average height (Boas) Average weight (Burke) 6* 43.!) inches 45.3 pounds n 46.0 inches 49.5 pounds 8-1 48.8 inches 54 . 5 pounds ^ 50.0 inches 59 . 6 pounds m 55.4 inches 76.9 pounds m 62.9 inches 107.4 pounds of 1) eight and weight of American girls. Years Average height (Boas) Average weight (Burlve) H 43.3 inches 43.4 pounds n 45.7 inches 47.7 pounrls H 47.7 inches 52.5 pounds H 49.7 inches 57.4 pounds I2i 56.1 inches 7S . 7 pounds i.H 61.6 inches 106.7 pounds Mental and Moral Gro"wth.— The mental development of the child must ho carefully watched from the beginning. Just as the huuian embrvonal life represents various upward stages of animal development, so the child's mind reproduces in miniature the earlier stages of the growth of the race. It is early necessary to recognize the various tendencies that manifest themselves in a growing child, so that they may be guided aright. It must be remembered that the child exhibits the elemental human forces 36 DISEASES OF CHILDREN. and instincts. Just as tlie emotions are developed in tlie race before the reason, so it is with cluldieu, who can he moved by tlieir sympathies long before they can be iuHucnced by their intellect. Love is a surer guide for them than reason. This is the secret of success of many mothers and of some teachers. The most lasting impressions of childhood come through the feelings. At the end of infanc}', and during early childhood, the imitative faculties are especially dominant. The acts of oliler children, of adults, and even ol animals arc faithfully copied witliout much idea of tlieir signiJicaiice. U]) fo the ago of seven ^cars miidi of tlie training ;ind education of the child must come from imitation. Before this age nearly ail the playing of children is iniilative, shown by the delight in toys representing aificles in I'cal life, but after this, (■spcciallv m bo\s, the games take on a more competitive form involving muscular e.xercise. There exists in some children a toucli of bailiarism that is iiiei-clv an evidence of underdevelopment. Apparent cruelty, shown in a callousness to suffering, is sometimes seen, but this is rather due to a lack of experience as to the meaning nf pain than to del'cctiNe moral sensil)ilities. The con- duct of the child is lai-gely influenced hy the tone and temper of those around him, in the intclleeliial as well as in the moral sphere. A cultivated home will do more for the proper development of the child than the formal education of the finest schools. AdolkscioxcI':. — The beginning of this period is a most interesting and critical tiinc for the child. Up to this time, as alreadv noteil, the child has livi'd the race life, but he now begins to ilcvelop individual cliiir- acteristics. and fninilv traits come out iiiuri' stronglv. There is a ra])id growth of all pai'ts of the body, especially marked in the re]irodnctive organs and the heart and lungs, with increase in blood-pressure and in general glandular activity. The appearance of hair on the pubes is con- sidered cbaraetei'istic of the period. The ])eeiiliaril ies of sex now liegin to manifest 1lieiiisel\'es ; boys and girls eease to mingle in sueh an indiscrim- inate wiiy as ill earlier cbildhood. T"p to t\vel\-e vears there need not be much differentiation of the sexes, but after this tbev must be separatelv considered. \'agne as|iirations and a general r-estlessness show the stirring of new life in ihe child's mind. Roth the emotional natui-e and the imagination become very active. Tf any trait is entiivlv absent at tin's time it is not apt to be seen later in life. As growth and development are so rapid during adolescence, nothing must be allowed to conflict with the physical nature at this time. Over- strain in school must be guarded againsl. Tt has been proven froiu sjBa.C sx ■SJBaiC jj Or-tiHr-iHC) SJBaA: 9x 105 107 10!) Ill ll:l 117 121 ■sjua^c ox OSOOOOrHrH • ■SJU9^ tX eSg§S8|B : : ■sjcai (;X -t t- CI 00 i^l t- ^ ■ • • • t- 1> CO W OS Ci cs • ; ; ; •SJBB^t ST §sfiE:eg ;;;;;;; ■SJBB.t XX CO f- CO tH (M (D ci to ci t- 1- 1- ;;;;;;;; ; 'sjceii OX fesassg ;;;;;:;;;;; •SJH3iC 6 SSggSS ::::::::::::: ■SIL'O.t S ^ggsiss ;;;;;;;;;;;;;;; ■sai;3-t 2, Ct-f "-2I-C10C-I s.TcaX 9 t- Ci C-1 -fH '-J t- CC CO :■" T*H -^ -^ -l^ -T '.''.'.'.'. ■s.i;:a.f Q -*H L-i O .H CO o COCOCO^rfltl '.'.'.'.'.'.'.'.'.'.'.'.'. ■njmS.H OS o iH CI CO -r lO '::^ t- v:. Ci Q w -ri CO -rf k-"^ CD t- « oi o H 01 oj -t o « -r 5 -ti Tt. 4^ -fH -tH -- -f -f S !.-:■ i:^ l:: L'^ iq lO' lo irrio 'X* cd ct ci :c :f GD O N N N N N ^'S o o o o o .s -s ^ e.o E3 Vi « n- U o-; c 3 9 o <^'S £ (B r^ >1 h s c o ctt a ■s ^.^ iHiHrH t^ ^ C O ceo ic X T- ^ :s sg X> < C3.5 SJL'9.f ST sj>;dji 2.x sjcai: 9t sj^sjC cx fijT;ai£ ^x ejtJo-f f:x RJT.'9it 7;X ■SJB9^ XT •sjca^ OX ■sjiio^ ■SJB8^ 8 ■SJ[B3jC i 'SJB8jC 9 ■saB9^ Q ■nnqS.H OOC^Oi :r^OOC:c: t-oit-oi t-Oll- 1-^^H^HOlrlcococo-r■^lOLTtotot^^- ^H:DrH'■-^rHlOcri-t-cccot-1HmQ^50L50l.o c; oi o o iH iH rH o) oi CO CO Tt< TtH tS lO :s 'J t-- 1- r4iH»Hi-Hr-li-fiHr oC"+ai'i*Oi-*c/Dcor-C'icoo"*C5"*03-^o:-t< oo S d> Oi o o i-i 1-+ oi o t CO CO -ti Tt< -ji Ko lo ':c -jD t- t-t-t-QOCOiyjC-CaCiOOrHC-IC^KOCOCO 01iQC0OC0'X>OC0:DCJC0I:-0H~-C to'-DOl;-t-L-Cl000iXa)CSC5OwT- lO LO CD to 'ZD iD t- t- t- «j CO 00 C -t to CZ' O CO O CC' iH -H CO T-i -1^ r- -H LO to iS 'J to to to I- 1- 1- CO CC X CJ tHCOlLOCOOOI-tt-toCOt- lo ID lA lo to 'to to to- 1- 1- 1> -f to t- aj o c) \o I" a .H CO -jd i^ ■^ -h -r^ Tfiffl i.'s ira lo lo :d to '.::> to CO CO -f -*1 -t"t( -t+ IC o b ^ S toX " H c ^ s c WEIGHT AND DEVELOPMENT. 37 examinations of many si-liool cliildifU tliat, as a ruli', tlie lieaviest and tallest, or those with the best pliysique, stand highest in their classes. Hence if a cliild is poorly nourished or undeveloped, the best thing, even for his intellectual growtli, is to focus attention on liis body for a tijne and let his mind be temporai'ily neglected. Apparent stupidity or bad mentality in Bcliool children is often the result of physical causes that may and should be removed. Deafness, defective eyesiglit, enlarged tonsils and adenoids, and poor nutrition from lack of proper food may be especially mentioned in this connection. 'Ihe accompanying tables showing the normal ratio between the height and weight for boys and girls liavc recently Ijccn ananged by the Child Health Organization and are serviceable for school work. Flc. 14. — ( 'iilTccI lllctllod (if llMMSIIl'illi;-. .'111(1 wcijihilli;- :i cliild. SECTION III. THE EXAMINATION OF THE SICK CHILD. CHAl'TEE YI. THE EXAMINATION OF THE SICK CHILD. If the physician unaccustomed to the care of cliildren will first learn what to exjject to find in the normal child, he will better appreciate the variations in disease, lie must first of all learn tliat a proper examination will ta]wborn, .T.T to t."i First to second year. 20 to S."! First to the second month. 24 to ?,C, Second to sixth vear. 20 to 2?, Second to the sixth month, 20 to 32 Sixth to twelfth year, 18 to 20 39 40 msEASKS OF c:HI1-L>I:EN. < Kcu£ a Hi a m :.^i in to V lilis ■arriagi at B. Ued at < .^i^l Z < CQ K O H rt ?: , — I C c3 C ^ S^ ^ c 13 JZ) e2 2U ■^.•S ^•p = H 3 o g o XI H w O - (5 4^ X o 5 5 O - u Bowels Sleeps vious Dis w re C o >, c o; U Crs o O Oh yi ra.2 ra . — :\Ietlloil (if iiallKitiiCi;- li\-cv anil splc the (hroat liciiig left for the lin.ll jirocedure (p. 33S). The hands are now passed i)\cr the neck to lind any ahuoriiialilics in the anlerior gnuip .if tilands. Xc.\t the shoulder-joints and the axilhe are exploi-ed ; a( the same tiiii'c the musculature will be estimated to aid in establishing the degree 111' ph\-sical ilc\-chipiiicnt. The epitrochlrai' glands should not he forgoitcn in the cxaiiiinatimi. The hands of the patiml are ]ialpntcd for (eiiiperatni-e, ii'reguliii'il ics. or cliibhing. The pulse is best counted when the child is asleep, 'i'lie carotid or tciiijioral pulse iiia\' be used it the wrisi is not <'\'])(iscd. , , THE EXA-UINATION OF THE 8ICK CUllLD. :43 In extreniel.v weak infants tlie count is talven of tlio heart beats at "the apex by using a stethoscope. The pulse varies from: 120 to 140-in the new-born. 1111 in the first year. ' ' 1(10 in the second year. ;M) in the fifth to the eiglitli year. ■ ' : " and averaaes - If the ciiild is irritated, crying, or in pain, tlie pulse rate wiU be accelerated, and a note should be made of this circumstance. The force and character of the pulse are of as much importance as its frequency. I'K.. Hi. — .Metliiid (;f eliciting Keniig's sign. " The apex beat on the cliest wall may be located, or a thrill felt in certain valvular diseases, and occasionally tactile frenatus will be an aid in diagnosis. Bony rachitic changes as the rickety rosary or Harrison's groove are identified by the examination with the hands. The right hand on the abdomen feels for the lower border of the liver, while the left may palpate the spleen. If this is ]ialpable in a child, it is said to be enlarged. The liver in infants when in the prone position is normally about one inch below the free border of the ril>s. Tn the erect position in the infant it may touch the crest of the ilium. Tumors in the abdomen and an enlarged kidney as in pyeloncphrosis can be palpated. 44 DISEABEB Oi' CillJLDIiEN. The hip-joints and the lincc-joints are examined for j)iol)ilit3-. Pain, if elicited over the tibia, may assist in establisliing the diagnosis of scurvy. The anlcle and feet are examined for signs of edema and tiat-foot. The lower extremities are approximated, and any abnormalities in outline such, as knock-knee or bow-legs will tlien be readily ap|)ieciated. The child is now induced to walk, and if postural defects warrant it a detailed examination eetion. Infants should be lield in the arms of the mother or nurse, against her left shoulder with the infant's back to the examiner, as illustrated in Fig. 17. A stethoscope with a snuiU bell is quite necessary, as the ear cannot advantageously be placed, for example, in the axilla of an infant. Children are best examined seated upon a table. The stethoscope is Fir,. IS. — risck's reversible stetlioseupe. alternately pa.ssed from side to side in a line parallel to the spine, then the infrascapular region is auscultated, then in the axillary line on either side, beo-inning well up in the axilla, with the ariiTs raised above the head. The front of the chest is gone over in a similar manner. The examiner should recollect that the lungs in an infant on the left side posteriorly reach to the eleventh rib; on the right side posteriorly, to the lower Ijorder of the ninth rib. In front, on the right side to the fourth or fifth rib and on the left side to the ninth or tenth rib. Auscultation of the heart sounds is made at the apex, at the base, and at the second right intercostal space: if any murmurs are present they are traced along the lines of intensity. The examiner must accustom himself to pick out the normal breath sounds while the child is crying. After he becomes expert he will almost 4(j lUSILVSES OF rjIlLDISEX. prefer that the eliilil eries while he is auseiiltating. So-called puerile breathing, tliat is, exaggerated normal vesicular breathing, is to be expected. It must furthei- be recollected that the chest wall is tbin, and the sounds within are therefore more readily transmitted to tlie eai'. Percussion. — This should he accomplisbed with a suilden light tap because of the thin wall and the elasticity of tlie iil)s. Pej'cuss alternately from side to side, pi'efei'ably lirst over the doi'sum of tlie chest, then the antei-ior surface of the lungs, and linallv the area of the heart may be mapped out. Td do this begin your percussion iieai- tlii' clavicle and percuss down- ward until the note changes at the base of the heart. Make vour line here with a flesh pencil. 'Jdie I'ight border of the heart is found by beginning the pei'cussion well to the right of the stei'num and mapping out this boi-der to the apex. The left side is similai'ly found, by begiiniing the ])ei-cussii)n fi'om the axillary side. The apex heat nuiy he located both by palpation and auscultation. The area of absolute heart dullness is relatively small in infants, hut tbe fact tbat tbe lungs do not o\ei-lap the heart as they do in tlic adult sIkuiIiI not lie forgotten in percussing for the I'clative dullness. Tercussiou o\ci- tlie abdomen iiia\' be made, to obtain the lo^'er hoi'dei' of the stouuich, or a distended colon, for fi'ce fluid in the alidomen, a distended ui'inai'y bladder, partial intestinal colla[:ise, or npjicmhcial abscess. Iji cerebral cases in «'hicli fluid is sus]iected in the \-enti-icles Macewen's sign shouhl he soiigbt for; this consists of a tympanitic note beard ONcr the ]iarietal ai'ca wlicn tbe \'i.'ntricles are distended as in hyilrin-ejihalus or in i-crlain cases of meningitis. Mensuration. — The weight should be recoi'ded in infants once or twice a we(d\. in older children, each time the\' are brought to the ]fliysician so tbat he may judge of the progress of their general develo|mient. For infants a weight chart, such as has been devised by T*)'. \V. L. Cai'r, is useful. The standing height sliould be occasionallx' taken and com|)ared to the weighl. (See diagrammatic table, ]iage 2S, for mjriual relations.) The cii'cumference of tbe head and cliest and their I'clations to each other give \'alual)le data as to disease conditions or to defects in pli\sical develop- ment. The- tajic' used should he made of ndnstretchable linen or steel. if in the eyes may demonstrate on sme.-ir the presence of the Koch-Weeks b.icillus or the gonococcus of Neisser. A sindlar test of a vaginal or urethral disch.irge may be necessary to determine the character of the contaginn and to determine upon tlie nei-cssary precautionary measures. The Sputum. — The ex.iininalion of the sputum in infants and very .young children is not satisfactory, owing to the dilliiulty of olitainiug a satisfactory specimen. This may in a measure be overcunje by passing a stom.ach tube into the first ii.irt of the esophagus — the tube as a rule bringing uii some secretion. A more agreeable method is to p.ass a cotton swab on a long sharply Iient probe into the larynx. In order to dn tliis the eiiiglottis must be held forward as is done in iiassing a laryngeal tulie. Snjcars made from sputtim obtained in this way will nccdsioiialhi show tulicnle b.icilli. In lobar pneumonia it is sometimes possible to demonstrate rusty s]iutum in this way. The pneumoccx'cus and influenza bacilli can be found in such a smear. Gangrene at the lungs is characterized by the offensive odor .and by the color and fluidity of the sputum. Such sputum will separate into layers, witli a tliick brownish dejiosit at the bottom, a clear fluid in the middle, and a frothy layer on the to|i. When an empyema rui)tures into the lungs the sputum is composed almost entirely of jius, and is thin and liiiuid. In those cases wliere bronchicctatic cavities have fcjrmed, the sinitum is abundant and tiiin, and on standing sei>.irates into a Layer of jius and one of mucus. If the cavities are large, putrefa<-tion can take place, and large .amounts of thin, foul-smelling gr.iy-green fluid may be cougheil \^^. The Gastric Contents. — The exannnation of the gastric juices in infants and small children has not developed any sjiecial diagnostic features of importance 48 SPECIAL EXAHriNATlONS. 49 Much can lie learned in this way as regards gastric niotilitv. Imt aside from this such examinations have an astonishingly small value. The Feces.— It is certain that the feces are not examined as f requently as they ought to be. Much can he learned regarding the well-being of the infant and the small child by a systematic inspection of the stools. As a rule the whole stool is not necessary, one or two drams being a sutlicient amount. The exam- ination should be made as prianptly after the passage as is possible, as the .stool undergoes putrefactive and fermentative changes if allowed to stand. In exam- ining for ova an old stool may l)e used. The reaction of the stool of course changes rapidly on standing. In a general way it may be said that a sti-ongly all<;iline reaction in feces which have recently been passed, suggests protein imtrefaction. anil that an acid reaction points towards a disturbance in the digestion of the fats. An excess of muscle fiber, ciauiective tissue or vegetable fiber can be deter- mined by placing a small ]iiece of the stool under the microscope. If Lugol's solution is added, the starch granules are stained blue or violet. There should be practically no unchanged starch in the normal stool. An alcoholic solution of Sudan III or scharlack R stains fat globules reil. and the fatty acids a some- what lighter color. The casein is soluble in a n per cent, solution of IIOI or in a little acetic acid, and is hardened by the addition of formalin. Coagula composed of casein, or of mucus plus fat, fatty acids and insoluble soaps are some- times found in the stools of infants. Most of these coagula are of the latter type, though occasionally true ca.^ein curds are present in the stools. The point can. as a rule, be ipiickly deternnned by shaking out a few of the masses in ether — those due to fatty acids, soaps, etc.. are dissolved by the fats going into the solution with the ether. Blood in the feces can be Identified by adding 10 drops of freshly prepared alcoholic solution of resin guaiac and ."0 drops of ozoned (old) turpentine to an ethereal extract of the stool. Another method is to dissolve a few granules of benzidine in 2 c.c. of glacial acetic acid. A small fr.igment of the stool is mixed with 2 c.c. of water and boiled. Ten drops of benzidine-acetic acid solution and 3 c.c. of a '■'• per cent, hydrogen i)eroxide solufl;iii ;ii-e mixed in a test-tube and a few drops of the cooked enuilsion of feces are added. In both these tests a greenish or bluish color shows the presence of blood. The benzldin test is extremel.v delicate, and may be positive if the patient i.s eating meat. Ova. — Any of the cestoda may exist in the Intestinal tract of children. Their identification depends upon finding the ova in the stool — as a rule not a difficult matter with the more counnim forms, though during the earlier stages of the infectl(]n a long and careful search nnist be made. The Cerebrospinal Fluid. — The exaniinatier minute, and the sediment dried on the same cover slip as is the fil)rin. After staining it is ixissibk' to demonstrate in ncai-ly 100 jier cent, of the cases the Bacillus tuliercuhisus. The diagnosis can also be nnide by inoculating a little of the sediment into a guinea-jjig. ]•'](.. lii. — Mctli.)il iif ]icrfiiniiing subilmMl or lumli.ir lanic-fui'c. .\ Wasserman icaclidii may also be made willi spinal tliiid. and it is apparently as de|iendable as when IiIikjcI si-runi is nscd. (See also page ."iS. ) is'oguchi has devised a nietliod wliic-li ni.iy pmve applicable to some of the ill-defined intlanimatory cdnditions (if flic meninges, such as the so-called serous meningitis in which micro-organisms and inflannnatory cells cannot as a rule be demonstrated. The metliod is as follows: To t,nr or two juirts of ciTchrosiiinnl fluid :irc juldi'd fi\-(- imrtw of :i 10 por ci:ut. liilt.vric JK-ifl solution in ;i iili.\ wiolo^^ic suit solution. This is hoilcd for :i brief porlod. <.>nf' pjirt of n norinnl solution of XmOII is tlion (piickly nddi'd. jind tlii' w liolr hoilcd oikc more for m few seconds. Tlic inci-cased amount of protein in the cerebrosjiinal fluid is indicated by the appcar.incc of a granular or flocctilent precipitate. Normal i-ercbrosiiinal Huiil gives a slight uiialcsccncc or Sdinctimes a tnrliidity, but tint a gi'anul.ar precii>itate. unless allowed tii staiul for a nmiiber of bean's. 'I'bis test is positive in syphilitic and iiarasy|iliilitic condilicins. and in all c.-ises of inflammations of the meninges SPECIAL EXAMINATIONS. 51 caused by micro-organisms. It suffices to distiuguisli normal from patliolof»ical cerebrospinal fluid, and especially that form of pathological fluid which is altered through an increase in its protein content. Cerebrospinal fluid often contains a sugar reducing agent, hut this condition is only of confirmatory diagnostic value so far as is known at the present time. Technic for Subdural or Lumbar Puncture. — One of two positions may be selected: the sitting ijosture, or the cliild may be placed on its side with the spinal colunui well flexed. Cleanse the lower lumbar area until the parts are surgically clean. The operator, who has thoroughly cleansed bis hands then takes the sterilized needle in his right band, as one holds a pencil in writing, and inserts the same at right angles to the body through the skin and soft parts between the third and fimrth lumbar vertelaw (see I'l.-ite II). This point is conveniently located by placing the index- and third fingers of the left hand on the highest points of the respective iliac crests, tlie middle finger I)eing placed on the vertebral spine which is on the same level as the crests above deternjined. This is the third lumbar S]>ine, and the point of election is midway between this spine and the one immediately below it. The needle meets with only cartilag- inous resistance if properly inserted, and should be introduced abovit three- ((uarters of an inch. If bony resistance is encountered, withdraw slightly (not entirely) and change somewhat the .angle of insertion. If the spinal canal is entered a free flow of fluid follows; then allow the fluid to esca]ie int(j a sterile tube. At the same time collect two or three drojis in a (ailtnre tube of blood serum. When 1.5 cc. have been collected quickly withdraw the needle and seal the puncture wound with cotton and collodion. Technic for Aspiration of Pleural Cavity. Aspirated fluid from the chest Avhen slightly clouded is microscopically ex- amined for the presence of pus-cells, and ojierative interference is often based on their numerical estimate. Sterilize a needle and clean the chest wall over the site of electinn. in all cases observing strict surgical asepsis. (See fig. in2.) Place the child in a sitting posture with both arms drawn well forward then, holding the needle at a right angle to the liody, puncture In the niidscai)nlar or In the postei-ior axillary line (preferably the former), the ]ioint of ekM-tioii being the interspace just lielow the angle of the scapula. Insert the needle about tbree-qu.-irters of an inch. From the fiuld a culture is n)ade and the remainder is collected in an emjity sterile tube for further examination. Seal the puncture wound with cotton and collodion. The Urine. Only the more Important diagnostic features of nrinai-y analysis will be touched' upon. The subject has a great |n-actical intei'est not only for the diagnosis of kidney lesions, but also for the recognltio)! of changes in other organs. The siiecimen should as far as possible be a part of tlie wliole 24-liour urme, in order to avoid the well-known variations in the specific gravity, the reaction and other proi)ertles of the urine. For microscopical ex.-iminatlon it is impoi-tant to have a fresh specimen as decomposition may change the entire iiictnre within •I few hours Fermentation sometimes results In the entire disai)iH'arance of small aniounts of sugar .and greatly reduces the total percentage where it is present in lar'-er quantities. All such changes may at least be delayed by keep- ing the urine in the ice-box er cent, sohition of potassium ijermanganate. then 1 or 2 c.c. of chloroform, tlien 10 c.c. of concentrated hydrochloric acid ('. I'., and lastly 1(1 c.c. of urine. Invert the test-tube two or three times to thoroughly mix and .allow to stand five minutes. The ethereal suljihates in the urine are broken down by the li.ydrochloric acid and are oxidized by the potassium permanganate to indigo which is dissolved by the chloroform, giving a deep blue color, the intensity of which when compared with the color scalp (I'late III ) determines the extent of the i)utrefactive changes occurring in the intestine. The presence or absence of indican in the urine is im]iortant. as its iiresenee indicates an excessive putrefaction of the protein substances in the intestines. The test can .also lie made by placing an equal amount of urine .and h.vdrochloric acid in a test-tube to which is .added our rjrnp of peroxide of hydrogen. If much indican is present a dark blue or purple color is produced, which nia.v be shaken out with chloroform. The reaction may not .apjiear at first but may come out after standing fm- a tinii'. If more than one drop of hydrogen-peroxide is .added the blue color ma.\- be bleached. In alkidine urine the indican is usually destroyetl. Transudates and Exudates. Rivalta has recently perfected .-i test for accurately distinguishing between transuil.ites .and exud.ites. .\(1(1 2 drops of acid acetic (glacial) to KIP c.c. of water to ni.ake the test solution. Allow the exudate, .-i drop at a time, to nudce its w.ay down througli the dilute .acid medium and it will le.ive a bluish trail in the water like n puff of cigarette smoke, each drop leaving a separate trail. The fluid remains clear and unaltered if the added dro]) be that of a transudate. The Roentgen Rays. The Koentgen rays are, of late, assvniiing a more important role in ]iediatric practice. Foi'eign bodies swallowed or aspir.afed, fra<-tures and dislocations, bone changes and tumors, disjilaced viscera, consolidations and exudations in the thorax an> conditions in which we can obtain valu.able aid. In the stoni.ich .anl intestimil ti-.-ict the use of bisuLutli enables us to obtain exiiosures wiiiili slmu clearly the |iatency or nle above is to be looked u|)on as iiathological and at least requires an explanation. A well-m.arked (polynucIe;ir) leukocytosis, is to be expected in scarlet fever, erysii)Clas. di])litheria. pnevnnonja, acute articular rlieumatisni, tuberculous meningitis, and su|ipurative conditions. There is only a slight leukocytosis iu typhoid, roetheln, mumjis, malaria, and uncomplicated tuberculosis, except when it invades the merjinges or serous surfaces, or when it becomes complicated with SPECIAL EXAMJXATIONS. 55 a septic condition. There is also a higli (lymphatic or myelogenous) leukocytosis in the leulcemias. A moderate (jiolynuclear) leukocytosis is frequently present alter ether or chloroform inhalation, after taking (iiiinine, the salicylates, tuber- culm injections, and following saline infusions. Even more important than the leukocyte count is the making of a differential count. Blood Smears. — An important point in making a good smear is to have a cleian slide. If new slides are used it is usually sufticient to breathe on them and polish them off with a dry towel, lint old slides must first be cleaned with acid. One end of a slide is .just touched to a drop of lilood, and this slide is then gently touched to the surface of another slide at an angle of about :'.0 degrees. The flrst or smearing slide is then gently drawn over the surface of the slide on which the smear is being made, thus dragging the blood out in a broad thin film ^vhlch quickly dries. The size of the dro)) and the speed with which the smear is made determine the thickness of the preparation, and not the pressure, which should always be light. Such a smear is used for studying the morphology of the blood-cells, in the search for malaria Plasmodia, and in some regions for parasites (filaria, bilharzia, etc.). Nucleated Red Cells in Infants.— In infants nji to the eighth month it is possible to find an occasional nucleated red cell, whicli may be either the size of a normal red cell or from two to four times larger. The Relation of Polynuclear-Neutrophiles to Lymphocytes During Child- hood. — The relation of the neutro)ihiles to tlie lymiihocytes during cliildhood is shown in the following table: Age Nursing period . . 8th-] Oth montb . After intli month 2d .vear 6th-8th year . . . l(lth-14tl] yi'ar . . Polynuclpar- Neutrophiles 28% 51-.j9% 2.T/0 50-Bl% Sti% 56% •41% 55% 41 ;% 41% 55% S')% Lymphocytes The increase in neutrophiles occurs chiefly in the second, third, and fourth years, but an increase is noticeable up to the fifteenth year. The disease in which there is or may be an increase of neutro[ilillic (poly- nuclears) leukocytes have already lieen discussed under leukocytosis and, there- fore, it is only necessary at this iioint to indicate those conditions in which the leukocytosis is due to the increase of other cellular elements. The lymphocytes in typhoid are iriiilircl!/ increased, but empliasis should be placed on the fact that the total number of leukocytes are ilecienxcd, so that the white count in this condition will vary from .'i.nOO-t.OOO. The increase in lymphocytes is chiefly important in the leukemias — a rare condition in children and wlien present usually of the chronic lymjihatic variety. The diagnosis of the condition depends upon repeated leukocyte counts of .'lO.OOO (generally lOO.OdO) or more, made up almost entirely of lymphocytes, or myelocytes and lympho<-ytes. Von .Jakseh's anemia or infantile pseudoleukemia resembles both perni<-ious anemia and leukemia. It is characterized by a marked anemia, enlarged spleen and (occa- ■ sionall.v) liver, enlargement of the lymph nodes, and by an increase in the leukocytes to 20,000 or 50,000 (rarely 100,000) per cubic millimeter. There are many nucleated red cells of both the normoblastic and niegablastie type. The leukocytes are chiefiy mononuclear in form, and myelocytes are present in moderate numbers. It is probably a severe form of secondary anemia. Eosinophilia. The eosinophiles average in healtli from 2 to 4 per cent, of the total white cell count. In infancy, according to Wood, the maximum is 7.5 per cent, and the minimum 0.5 per cent The same authority states that durlni? childhood the ma.ximum is 12.5 per cent, and the minimum 0.7 per cent. In bronchial asthma there may be an eosinoiihllla of 10 to 30, or even 50 per cent. Scleroderma has been known to give an increase to 10 per cent. Intestinal 56 DISEASES OF CHILDREN. pnrMsites sometimes Oiiuse an ciisinopliilia as l)if,'b as Tn per cent.. esi)eeiall.y in tUe earl.y stages of the iufeetioii. only to fall liaciv to normal or nearly normal later. In searlet fever a moderate eosinophilia is iiresent, in contrast to measles in wliicli no sucli phenomenon is observed. Malaria. — The diagnosis of malaria can be made by Hnding the [ilasmodia in the blood. These iilasmodia are present in largest numbers just previ(ms to or at the time of the chill, but in the quartan and tertian types a few may be found at any time. In the estivo-automnal form of malaria it is often necessary to .searcli for a long time before the Plasmodia are found. In some cases of malig- nant malaria (black-water fever) the i)lasmodia disappear entirely from the jieriplieral circulation. Even one-half of a gram of quinine is suitieient to nullify a most careful search for the Plasmodia, so that a negative result under these circunistaiices is of little value. The Widal Test for Typhoid. Preparation of Blood. — In making a Widal test either a dried specimen (f the blood may be used or. lietter still, the serum. In obtaining a dried specimen of blond the finger is jirit-ked witli a needle. preferal)ly a Ilagedorn needle, and a very small drop of lilood is i)laced on a clean side and allowed to dry. Several su<-h drops should be made in order to give the pathologist a choice and also t > avoid losing the specimen tlinjugh error or breakage. Blood serum is to be preferreil because it is more ac<-urate for the making of dilutions. The method of collecting the l)l(iod is the same as that described later imder the Wasserman- Xogui-lii test. Dilutions. — The iialliologist should always state the dilution made, and if there is .1 positive result with l -.'20 a dilution of 1:40 and 1 :()0 should be tried. Karely there is a positive result in dilutions of I :2(» in normal lilood. With dilutions of 1 :(J0 for one hour Wood obtained only PI per cent, of positive results during the lirst week, but many of these cases gave good agglutinaticais in one hour in dilutions of 1 :20, In tlie second week the reaction was present in about ,S(» jier cent, of the cases, using a dilution of 1 :(iO for one hour. During the fourth week 8 to It per cent, more of these c.ises gave |iositive results. Taking the whole course of the disease, only 1-2 iier cent, of the c.isi's failed to react when the blood was fi-e(|uently tested, Agglutnatioiis to this degree, c. ii.. 1 :(■(! for one hour, may be present for onl,v a few da.v.s and then become weaker, Libman states that he has never failed to obtain a iiositive reaction some time dui'ing tlie course of the disease, using a dilution of 1 :2P, The Widal reaction appears so late in dilutions wiiich are absolutel.v diag- nostic tli.it it is of little value in the early diagnosis of an active and well-marked typhoid. If. however, the clinician is in :i iiositinn lo inter|iret the test, very suggestive results are often obtained during the first week, ,V Wid.-il h;is a great value in the diagnosis of obscaire and ambulent cases, and in children where tlie symptoms referable to the intestinal lesion .-ire not proniinent Tuberculin Tests, One of three tests may be selected for use in s\is]iected tuberculous children. The skill test w.is superseded by the eye test and inunction test, but to-day it has the greatest nnniber of advocates, since it is the most reliable and at the same time least annoying to the jiatient. The test is of the greatest value in children uiiiler the age of V\\i\ for it then denotes witii a fair degree of cert.iint.v tli.it there lias been or is an active tuberculous process going on, .V positive reaction is proportioii.-ilcly \alnable to tlie age of the iiatient. The younger the child the more valuiible the sign. The rapidit.v of the apiiearance of llie reddened zone is also pro|iortionate to the severity of tlie process. The reactions are usually graded for jiurposes of coniiiarison as mildly imsitivc iiositive, .-iiid strongly positive. Skin or Von Pirquet Test, (I'lalelV.) This is made by cleansing the forearm with other, scarifying three small areas on llie arm, as lor \acciiialioii, and inuculaling (he central one with a drop PLATE IV. The ocular, peroutuneous and cutaneous tests, (a) ocular reaction; (6) inunction or Moro reaction; (c) cutaneous or Von Pirquet reaction. Sl'EC'lAL li-XAAI IXATIOXS. 57 of Koch's old tuberculin (obtniiuilile iu the iiuirketl, ushig the upper anil lower areas as controls. In from twelve to fcjrty-eif^lit hours (occasionally even longer) a reaction will be observed in tnlierculous individuals. At Hrst a reddened blush appears which soon beccaiies intianjed and reseud>les the first stages of a suc- cessful vaccination. ' Tlie controls should show no reaction. In advanced cases the reaction usually fails, due to the presence of numerous antibodies in the blood of the child; it may lie negative in cases of marked anemia, in very acute disease, and in mixed infections complicated by acute diseases. The Calmette or Eye Test. (Plate IV.) In selected cases in which we are positive that the eye is normal, one drop of a 1 per cent, solution of tiiberculin for older children and a 1/2 per cent, for infants, is dropjied cm tiie lower lid of one e.ve and the eyelid held down for a moment before allowing the eye to close; the closure should not be spasmodic, but gentle; it is better to gently massage the eyelids over the eyeball for a moment. A positive reaction is indicated by a feeling of annoyance in the eye which ensues in from six to twenty-four hours, or even after two days. Tlie palpeliral or ocular conjunctiva beciimes injected, later the caruncle is swollen, and, iu intense reactions, an exudate is observed. The patient complains of having a " cold in the eye." The s.vmptoms soon diminish, so that in four to five days the eye is quite normal again. The indiscriminate use of this test has led to reiiorts of corneal ulceration. The severity of the reaction is no criterion for the intensity of the infection. Severe reactions may follow in incipient cases. As in the skin test, active and latent cases will react, but those far advanced may give a negative test. It should be rememliered that no imn(unity to tuberculin is produced by these tests; tlic other eye will react; a skin test or inunction test can be subsei|uently ajade in the same individual. 'I'his test has been quite superseded by tbc Xon I'irc|uet test in this country. The Inunction or Moro Test. (I'late IV.) The Moro reaction is obtained by using a ."0 per cent, tuberculin and lanolin ointment, and vigorously rubbing a piece the size of a split pea for a few moments over the site selected; this may be, for example, the axillary or the interscapular region. A maculopa]iular eruption is iiroduced iu the tuberculous at the anointed area in from twelve to twenty-four hours. It may persist for five days to over a week, and in neurotic children may appear on the oiiiiosite side of' the body. The test is sinijile. easily jii'rfornied and conmien-(aitane(ais than does tlie conjunctival. Cases 'rulMTClllnUS Per cent. 89-88 79-20 85-.'-,9 Number givin.? reaction Suspects Per cent. Non-tuberculous Per cent. Subcutaneous Con.lunctival Cutaneous TONS (i.^O-l (13-34 .n7-so (■.7-48 .-1-30 1 3-73 31-Ci2 Method of Collecting the Serum for the Wassermann Test.— Only about 9 cc of the patient's blood is needed. A convenient method is to punctuie the finder with a TIagedorn needle or a sbai'ppointed scalpel. The blood can be driven toward the extrenntv of the finger by coiling around it tightly a small 58 DISEASES OF CIIILDKEN. rubber tube or band. This luny be repeated several times, nllowiiig the hauaction are lc]irosy and yaws, and very rarel,y one of the infectious diseases. 4. A negative Wassermann does not necess.-irily mean tli.-it the ]iati<'nt is cured or b.is not a syiihilitic infection. It is iirobable that a certain number of syphilitics give a negative reaction ; this is esi)ecially true of those cases which are known as latent syphilis. Active syphilis is nearly always positive. 5. In hei-editary syphilis those children liorn without symptoms may give a negative reaction until .iust previous to the .appearance of symptoms. If l)orn "With symptoms the reaction is at once positive. SPECIAL EXAMINATIONS. 59 6. Under treatment with nier(:ui'.y or iodides the reaction generally becomes weaker and weaker, and finally disappears. The reaction may become positive again it' treatment is stopped for a few days or weelis. In some cases, especially congenital syphilis, it is extremely ditticult to make the reaction disappear under treatment. 7. Children born of sj-philitic parents under treatment may or may not give & positive reaction. It is certain that a few of these children escape infection. 8. Frequently the last child or children which manifest no symptoms, though born of syphilitic parents, are negative to the Wassermann reaction. 9. While the mothers of sypliilitic infants may present no signs of syphilis, yet examination of tlie blood of the mothers gives a positive reaction in half the nundjer of eases examined. The negative reaction in the other half is due to the latency of the disease. Enough has lieen accomplished to throw doubt upon the dictum of Colles, and it can lie said that the mother of a syphilitic child has syphilis. Luetin Test. Luetin Test. — Krown found that in Id untreated children only (! were posi- tive, but the 24 treated all gave a positive reaction. Noguchi sa.vs that in children the reaction as a rule is negative, but as soon jis intensive treatment is started the number of positives becomes ver.y high. He obtained UO per cent, positive reactions under these conditions in children from 2 months to 2 years old. He claims the test is dependent upon the tVjrmaticin of anti-bodies and that it is trul.v specific. A jiositive ri'action should not be loolastedo"s I'ule whicli Avas deduced from tables of weights of noi'mal chikbvn of different ages is as follows: Multiply the adult dose by age + 3 30 In other words, in writing for thirty doses. foi- example, a four ounce mixture with teaspoonful dose, put down as many minims or grains as the age ]3lus three. In writing for fifteen doses {2 oz. mixture) put do\\n half as many minims or grains as the age ]3lus three. In the metric system, for thirty doses, put down the adult dose X (age + '■'>) X 3, ami move the decimal point two places to the left. This seems to be an ad\'autage over Young's and Cowling's rule and furthermore meets with the approval of pharmacologists. Castor oil should be administered ice cold on a wet spoon. The taste 63 64 DISEASES OF (.'HILDKEN. of quinine in solution may be clisguiseil with S}rup of yerba santa, extract of licoriee or syrup of wild elierry, but it is not unusual to lliul cliildren who take hitter medication iietter than adults. Tasteless (|Uiniu m the form of eu(jLnnin, tannate nf ()uiiiin, or sai'ehaiatc(l (piiniu is imw ohtainahle. Sweet chocolate disguises the taste admirably. Opium or its derivatives, with the exception of eodein, are to be largely a\oided. 'J'he cual-lar dei'i\ ati\'es, combined with laft'ein, are used at times to control jiain. They should ije given in small doses, and not as a routine measure f(.)r the control of pyrexia. The drugs or preparations of drugs most f i'e(|uentl)' used internally with the greatest advantage in pe(liati-ic ]iraetice are; Calomel. Castor oil. Fdwler's .sdlutiuri. B.-isbam's mixture. Bismuth subiiitrate. Bromides. Cascara sagrada. Cod-liver oil. Stryelmin .sulphate. Digitalis. Syru]) TS. Aconite Tinct. (10 per cent.) . . gtt. I gtt. i gtt. 1-2 Ammonium Chloride Sr. i gr. i gr. 1-2 Ammonium Carbonate gr. 1 gr. I gr. 1-2 Ammonium Acetate !Sol. (Spirits Mindercrus) gtt. 10 dr. 1 dr. 1-2 Ammonium Aromatic Spts . . . gtt. -i gtt. 5 gtt. 10 (Liq. Anmionii Anisatis).. . . gtt. 1-2 gtt. 3 gtt. 5 -Vnfljiyrin gr. i gr. 1 gr. 2-3 A7ilitoxin. p,i . — ^ Diphtheritic Immunization 500 units 500 to 1,000 units 500 to 1,000 units Pharyngeal Typi- 3,000 units 5,000 uriits 5,000 units Laryngeal Type lO.OOO 10,000 10,000 units units units Arsenic Fowler's Sol. (Liq. Pot. Arsenitis) "I i "l I "l '-'-5 Arsenious ;\cid gr. ,,',„ gr. A., gr. „'h, Dose, Frequency q. 2-4 hrs. q. 2-4 hrs. q. 2-4 hrs. q. 4 hrs. q. 1-4 hrs. q. 1-4 hrs. t.i.d. Repeat or doubU the dose in 12 hrs, if neces- sary. t.i.d. ti.d. Dose, Maximum in 24 hrs. Age 5 yrs. "l2-(i gr. 12-24 gr. 12-24 dr. 3-<) dr. i-U gtt.30-dr.l gr. 5-10 to effect ni 10, or to effect gr. ..,',„ -A GENEKAL THERAPEUTICS. 65 TABLE OF AVERAGE 'DOSACE. —Cmtinu.ed. Drug. Dose, Age tj mos. Asafetida, Milk of, bj' rectum only. Aspidium Oleoresin. . . . Aspirin Atropin Basham's Mixture Belladonna Tinet Beta-naphthol Benzoic Acid Bismuth Subcarbonate Bismuth Subgallate (Dermatol) Bismuth iSubnitrate. . . , Bismuth Salicylate. . . . Brandy (Cognac) Bromide, Ammonium Bromide, Potassium Bromide, Sodium Bromide, Strontium J Brown jNIi.xture (scr' Licoric Comp. Mixt.). Caffein Citrate Calcium Chlorid Calcium Sulphid Calomel Camphor, Pulverized Camphor Spts. 10 per cent.. Cascara Sagrada, Ext Casoara Sagrada, Fluid Ext . Castor Oil Cerium Oxalate Chalk, Pr(^parcV 3' 9 15 5-15 Introductory Remarks. The treatment of diseases in eliildi'eii requires a tiiorougii knowleilge of all measures, besides dmgs, tliat may be used for alleviation or eure. If tlie medieal attendant })laees sutKcient de[)en(lenee upon sueli measures as hydrotherapy, fresh air, and diet he will be inclined to order fewer drugs or only such as are still indiealed. Faniiliarily with the details of tlie gen- eral thei'apeuties of childhood will make him resourceful and ea]5able of adapting his treatment tn the [larticular surroundings and needs ot the child. The phvsician ishould take into consideration the general develop- mental condition of the cbihl, its usual liabits and the intelligence ot those who will carry out his oi'ders. Orders slioidd always be specific, and are preferalih' written out in detail, as a inollier's anxiety for her sick child rnay lead to misunderstandings which may prove serious. While many of the diseases are self-limited, and recoveries are generally speedy because of the recu]>erative powers in early life, still the practitioner should always alleviate distress and hasti'U complete recovery by the pro])ei- use of drugs and other medical measures. Prescriptions should tie siiii])le, cdidaining only one oi' two ingredients, and made as palatable as possible without endangering the child's diges- tion. (Jl\cei-in and sacchai-in will serve this purpose and are to be preferred to the syi'ups or sweet elixirs which so readily cause fermentation. Meili- cation and other measures for j-elief should be so arranged that the child will not be continually disturbed; for rest is an important adjunct in all cases. GENEKAL THEKAPEUTICS. 69 In the practice of pediatrics preventive treatment should be con- sidered firstj last, and all the time, for it is only thus, through the saving of lives and the rearing of healthy children who can later become healthy parents, that infant Jiiortality can really be reduced. Psychotherapy. The influence that can be exerted for good or evil, over the receptive mind of a cliild has been well emphasized in recent years by psychologists and physicians. Often a good part of a physician's success in handling little patients is due to his knowledge and interest in their mental processes. He learns to take advantage of tlieii' susceptii)ility t(i conviction, io sugges- tion, or of their pride, and control is thus easily acquired. Tlie harmful in- fluence of certain members of the family may prevent good results, especially in neurotic diseases, until the child is removed to different surroundings. A stranger often has better control over tlie sick clnld than its own mother. Time spent in studying tlie mental attiibutes of a seemingly incorrigible patient is well spent, for almost without exce|ition tlie maturer mind con- quers by persistence tempered with kind indifference. In obler cliildren hysterical manifestations can he controlb'd by tlie forceful attendant and their repetition prevented by a radical change in environment and daily routine. Sucli conditi(jns as enuresis Ave have often been able to cure by psychic influences depending mainly upon the child's pride. Another factor often lost sight of in this connection is the influence of associates. Tiirough a proper selection of playmates in age and tem- pei-ament, mueli may be done from a psychic standpoint. Aerotherapy. It is a de])lorable fact tliat tliere is any need of empliasizing the use of fresli air in the treatment of disease. The laity, liowever. liave been so imbued for years with the idea that colds are the result of cold air, and that sickness in the house demands warm rooms tliat the ]iractitioner, in fpite of bis better judgment, often ac(|uiesces in these notions. Among the more intelligent of our population the need of an outdoor life is begin- ning to be appreciated, and it only demands that orders for sufficient fresh air be given with a spirit of conviction that the method is a right and just one, to gain the cooperation of the parents. The harmful influence of iinpure air or a paucity of fresh air is no better illustrated than by com- paring the poor results formerly obtained in institutions and hospitals for cliildren, even when skillful nursing was at hand, to the good results obtained with abundance of fresh air. 70 DlSKASJiS OF t'lLlLUHKiS. Aei'otiierapy, or an abundance of pure fresh air, sliould be arranged for in every sick-rouni as well as in the nurseries of healtliy ehildj'eii. In respiratory diseases accompanied with fever the good etfects of cool fresh air are particularly noticeable. In convalescence a change to the country or seaside, where ozone is abundant, will do more than a course of iron tonics or artificial stimulants. The summer diarrlieas are often promptly alleviated by a sojoui'n in a cool and dry atmosphere. Hydrotherapy. The use of water is safer and often more effective than the use of antipyretics in reducing temperature. It also has a tonic effect instead of the depressing effect of antipyretic drugs. A warm bath given to a child conserves the body lieat, is sedative in its action, and iiici'eascs tlic perspir- ation. On the otlier hand, cold baths decrease the body heat and leave a stimulating and eliminati\c action. Sponge Baths. — Cool sponge batlis with or without alcohol are effectual and usually agreeable to childi'en when their tempearture is high. Cold baths or cold packs are rarely necessary and may be productive of con- siderable shock. pj(|ual parts of alcohol and water at !li)° F. are a|i]>lied to the child lying in a woolen blanket ; gentle friction causes air evaporation and reduction of temj)erature. While the bath is in progi-ess ice cold (doths may be placed on the forehead and head of the child. Sheet or Bed Baths. — Rubber sheeting is spread on the l)ed and a soft slicet or blanket is wrung out of water at '.M)° to llMt'' F. The patirnt is wrapjK'd in this and cold ajiplications at (iO° F. ))lace(l to the head. In older children water at a lower temperature, 70° or 80° F., may be s])i'iiikled over the sheet to effect a fuidher reduction of body heat. The patient should remain in such a bath for about twenty minutes and it may be repeated several times during the day if the necessity arises. Ice Cap. — For persistent high temperatui-e with delirium an ice ca]i may be ]«laced at the nape of the neck or on to]i of the occijnit. The thin rubber ice bladders are half filled with small pieces of crat-ked ice and all air is expelled. They should be used only intermittently, and a trained attendant should be present, as all cases do not i'es])ond well to its applica- tion. Ice Poultice. — Small pieces of cracked ice are mixed with an equal portion of bran or sawdust and wrapped in oil silk or rubber sheeting in such a way as to prevent leaking. Tins may be used as the ice cap above, but has the advantage t1iat it may be improvised at home. Compresses. — Compresses wnamg out of water varying from S0° to GENEILVL THEiiAi'EUTICS. 71 100° F. according to indications may be applied to the neclc in tonsilitis, over the abdomen for enteralgia and about tlie cliest in cases of pneumonia. Wlien used on the chest tbey sliould be divided into two portions, one for the left and one for tlie right, so that tliey may be removed with as little dis- turbance as possible to the patient. They may also be applied to the exposed part of the eliest in one piece and tucked around as far as possible without disturbing the child. Warm and hot baths are agreeable, soothing, and sedative. The temperature of the body is i-edueed and tlu> i-ehixatic>u wliicli follows pro- motes sleep and diuresis. A warm bath is given at a temperature of 85° to 98° r., while a hot bath may range to 110° F. The warm bath is suitable for the reduction of teiiipei-ature, and should last from five to fifteen minutes. Cool applications may be placed upon the head if the pyrexia is particularly high. Hot baths should be given to asthenic infants when the temperature is high or subnoriiial. The addition of mustard is useful, especially if there are evidences of shock or collapse. The baths should be short, riot exceeding over five minutes in duration. The ])atient should be "wrapped in wai'iiicd A\'oolcn lilankcts an° F. and covered with another di-y one, iK'ueath which ai'e placed numei'ous hot-water bags. Hot drinks are offci-eil. The pulse should be watched and the child removed when a free pcrsjiiration is induced. A hot-air bath is given by introducing vapor from a croup kettle under the blankets of the bed for about half an hour or until free diaphoresis is obtained. Special Baths. A brine bath is given by adding a lialf-poimd of sea salt to six gallons of water at a tem])erature of 10.5° F. and gradually reducing to 00° F. Gentle friction should be ke]it up throughout the bath, whicli should not last longer Ihan fifteen minutes. It is indicated as a stimulating bath for imdernourished, poorly developed children, especially those with tuberculous tendencies. The addition of bran, starch or bicarbonate of soda in luke-warm water will serve to allav the irritation of certain skin diseases, as urticaria. A quarter of a pound of soda is sufiicient for a six-gallon hath. "When a liran bath is given half a pint of bran in a cheesecloth bag is drawn through the water. For the starcli hath a quarter of a pound, or half a cup, of raw- starch is slowlv dissolved in the water. n DlyEAHES OP t'lllLDHHN. A soothing bath wliiili will proiiioti' slrcji in nervous, initable chil- dren is niadf by the addition of hfteen drojis of pine-needle oil to tlie water af 110° ¥. Xo friction should be made. A mustard bath is prepared by iiniueisin;;- an ounce of mustard in a cheesecloth or muslin liag in the water, usually at a temperature of 105° F. Cold eonijiresses are a])])lie(l to the head, and the body is gently rubbed. Carbonic acid baths (artificial Xaubeim baths) may l)c prepai'ed by the addition o[ ebeniii-als or spi'ciallv jircpai'cd 'I'riton salts to the water, but the i'\dlutioii id' the "'as is somewhat uncertain and irregulai'. The gas *« Viu. 2L'. — Melliud of t'i^ui!,' alciilml siieiige batli. may lie generati.'d by the ;K-tion oC bicai-bomite of soda and hvdroebloric acid in a j)oicelain-lined tidi. 'I'lie acid being diffused through the water after the soda has b<'en dissolved. Another method has recently been placed on tlu; inai-ket which is de])endent upon the use of a specially constrneted mat through which the gas is allowed to flow from a cylinder of the compressed gas. The flow of gas is greater, it is more evenly distrihuled through the bath and it can be regulated. It is certainly prefeiable to th(> older methods fill- hrime use if ilii> baths aic likely to be needed for a haig period of time. J'lie batli is given at !I0° to 9,5° F. for five minutes and is Followed GENERAL THEIiArEUTICS. 73 by gentle friction and rest in bed for sevei-al liours. These baths must be given at least three times a week for several niontlis to produce perinanentlv good effects. The baths are indicated in tlie convalescent stages of myocardial diseases. The Nasopharyngeal Toilet. The nasopharyngeal toilet, as advocated by Caille, is a valuable pro- phylactic measure in diseases affecting or euumating from tlie respiratory tract, and is an effective adjunct in ])i'o:iiotin<,^ a hcaltliy condition of tlie nasopharyngeal niucuous membrane in many febrile diseases. Method. — The method consists in slowly pouring into each nostril, by means of an ordinary teaspoon, a draclim of normal salt solution wliilo the child lies with his head tilted liack over a ])illow ami his mouth open. If gentleness is comliined vi'ith tact when the measure is first attempted, the child soon learns tfiat tlie method is not painful nor disagi-eeable. Tt can be used to aihantage in sucli infectious diseases as diphtheria and scarlatina, and before and after operations upon the nose and throat, as in adenectomy and tonsillotomy and retropharyngeal abscess. Lavage. ( Stomach Wash inij. ) This is a useful practice, but one which is often much abused. It is indicated as an initial procedure for persistent vomiting, esiiecially in sumiiiei' diaij'liea, in cases of chronic gastiointestinal iiKhgestion, acute gastiitis, ])oisoning, in persistent vomiting, and preceding certain operative procedures as intestinal obstruction. ]-iepeated stomach washing is to be deprecated. If the symptoms persist it is usually an indication that the dietary regulation is faulty. The apparatus used is made with a soft-rubber catheter. Xo. 13 American. attache(l by means of a piece of glass tuliing to another length of rubber tubing at the end of which is placed a small funnel. The catheter is introduced into the esophagus without any difficulty and with little dis- comfoi't to the infant. A Avarmed fluid, which may be cither a normal saline solution, or contain bicarbonate of soda (a dram to the pint), oi' boric acid 2 per cent., is used in amounts depending u]ion the age and development of the child (see Chap. T). When the stomach is full this will be noted in the funnel, which is then depressed and the contents siphoned off. This process is repeated until the return flow is clear. The preferable method is to hold the child upright in the nurse's lap, the head I'i UlSEASiiS or (.'IllLOItlvN. being slightly inclined. i'orwaiJ ; if for an\- reason this is eoiitraindicated the infant may he jilaced on its side, but tliis position recjuires more dexteiity than the npriglit. Hypodermoclysis. By this means fluids, drugs and nutidents nniv lie i)itroducrd innh'r the skin for ali^arption. It is partieularly nsetul before and after eertain ()|)crati\c |ir(>ce(lures, following i'Xt(_'nsi\c heiiiori'hage, in severe gastro-enteriti.-, in jiuti'kedly asthenic eases, and m acidosis. Vu). 2:',. — Illnstratiiis tpcliiiif for liypodprninclysis. Xormal saline solution, dextrose, or bicarbonate of soila are selected according lo the indications. Two to four ounces are nsually alloweil to flow in \ciT slowly ]>v gravity, the bottle or container lieing placed two feet aboNc tlir Ijody. Two needles are generally emploved, lessening thei-el>v file ( umefaction. The siti' selected is ordinarily the pectoral or loH-cr abdominal area. (See Fig. 2:!.) GKXKKA L 'I'l LICl!Ari:UTICS. 75 Tor acidosis only a cliemicall}- pure bicarbonate of soda should be used. A 4 per cent solution is made up in sterile water. To this may be added dextrose the strength of -f per cent for nutritions purposes. Enteroclysis. Entcroclysis is a measure which can readily be used in infants and children. Xo special apparatus is required as in venous infusions or hypo- dermoclysis. In the latter, surgical cleanliness must be strictly observed, and it is difficult to carry out the technic, without trajnetl assistants, outside of a hospital. Flushing the colon not only clears out the lower intestinal Fig. '24. 'l"Ii<^ lar.w intostiiip of iiu iiif.-int, sluiwin;,' rnrvc of sigmoid flexure. tract of deleterious jiiati'rial, liut it stiiuulates renal secretion, thus promot- ing the excretion of toxic products. If tliei-e is high temperature this will be reduced and thirst assuaged. The absorption of the fluid increases the blood pressure, and l)y eliminating poisonous products indirectly assists in renewing the condition of the blood itself. Method. — A soft-rubber rectal tube is attached to the end of a foun- tain bag- into which has been poured a saline solution made by dissolving two teaspoonfuls of salt to two quarts of water at 110° F. The bag should be hung about three feet above the patient and the water allowed to flow slowlv into the gut. If the intestine is irritable the pressure may be lowered so that the water will flow very slow-ly after the bowel has been emptied. Fluids will not usually penetrate beyond the ileocecal valve, but tlie entire intestinal tract will be stimulated to greater activity by the process. 76 r)isi:,'vSJ:s ijF ( hilokhx. In a series of I'ailiograpliic studies of llio colon and sigmoid flexure in the infant, CJjapin showed tliei'c Avei'c remarkable \-ariation3 both in form and situation. From these and other studies it has been proven that it is rarely, if ever, possible to pass the tube throiigli the sigmoid flexure. In flushing the bowel it is onl}^ necessary to jiass the tube through the sphincter and a few inclies Jiito the rectuui. The tiiiid will tlien by reversed peristalsis reach the ileo-ci'cal valve, ft is unnccessai'y and e\-en harmful to try and pass the tube too fiii-. In place of the sahne solution Jt is often of ad\antage to use a bland Fig. 2.5. — Eiiteroclysis ; position of the patient for bowel irrigation, rectal njedicatiou or nnti'ient eneninta. soothing preparation, such as starch Avatei-, or, on the contrary, soap suds may be necessaiy if the intestine is inactive. The indications for flushing or inigation of the bowel are the removal of the putrescent mateiial, as in enteritis and cholera infantum, and to assist elimination in the infectious diseases, such as typhoid and scarlet fever. Tt is also of distinct value in septic condilious and nephritic. In conjunction with baths it may also be used to I'cihice high ici'mperatures GEXKKAL XIIEUAI'KUTICS. 77 thus counteracting the harmful effects produced by the loss of fluids in the tissues. Once a day is usually sufficient. The mucous membrane is rendered irritable by too frequent irrigations. Gavage. Gavagc, or forced feeding ])y the stomach-tube, is accomplished with practically the same kind of apparatus as that used for lavage, that is, a Ko. 12 American, soft-rul)]ier catheter, a piece of tubing and an eight- ounce funnel, preferably of glass. The upright or the prone position, with the child lying on its back, may be selected. With infants no mouth-gag is required. In older children a mouth-gag, well protected by pieces of 'i /. / Wiwi : J, Fig. 20. — Positinn and apparatus for savage. rubber to prevent laceration of the gums, will be necessary. Before intro- ducing the food for the first time it is better to do a preliminary stomach washing. The food is allowed to flow slowly into the stomach, and when the desired amount has been introduced the catheter should be quickly with- drawn, the tube first being firmly pinched to prevent regurgitation and the entrance of any of its contents into the larynx. The infant should then be placed in bed and not disturbed, as in highly irritable conditions the food might be regurgitated. 78 DJ.SIiASi;« OF (IlILDKEiV. The indications for gavage are tlie feeding of premature or asthenic infants who are nnable to otherwise take tlieir food, cases of habitual or obstinate vomiting in wliich the infants, as shown bj' Iverley, may vomit the food when swallowed, but retain it when given by the tube. Occasion- ally following intubation or operations on the esophagus, feeding by gavage is necessary. During meningitis or conditions in wliich there is coma, forced feeding may ho indicated; as rectal feeding, except for a day or two, is of little value in early life. The food used may be breast milk, full strength or diluted, modified or peptonized cow's milk, plain or dextrinized gruels. The amounts should be somewhat below the usual requirements and the periods of feeding lengthened. Care should be taken that the food is sufficiently warmed when it enters the stomach, as a luke-warm temperatuiv is apt to induce vomiting. Rectal Feeding — Nutrient Enemata. Eectal feedmg is rarely of service except for temporary use, as very little nutriment is absorljcd. It may be possible to check body waste by this means, but we lia\"e never seen increase in weight when this was the only form of feeding. It is indicated in cases of cyclic or incessant vomiting or where there is an inaljility to swallow, in certain operative cases and when tlie food is not tolerated ))y tlie stomach. Method. — 'I'lie rectum should be cleansed with a bland enema, as saline solution, and an interval of at least a half-hour should lie allowed liefoi-e injecting the food into tlie I'ectura. The child is ))laced on his back or left side with the thighs well elevated. The prepared food is allowed to flow into the rectum from an ordinary fountain bag to the end of which has been attached a small-sized colon tnlie or largo-sized catheter. If the anus and tube are "well anointed with vaseline the tube may be advantageonsly passed well up into the colon. If this is slowly and gently done, peristalsis -will not be excited, and the contents of the bag held just high enough to permit a flow "s\ ill he more apt to be retained. Infants v.'\\l retain al)out two to six ounces, young children four to ten oiin(;es. These enemata may l)e given thr(>e or four times in the tAventy- four liours. Smaller amounts are always better tolerated and retained than larger fjuantitics. AVlien the rectal tube is withdrawn the buttocks should be pi-essed togethei', the child still retaining the recumbent posture. The fluids that may be used ai'e ]icpt(inized oi- ]iancri'nl inized milk, eggs, nlhuniin GENJiJiAL TIIKHAPKUTICS. ViJ and gruels, or a combination of tliese. Occasionally stimulants or other drugs may be added to tlie food. Vaccine Therapy. Tlie pathogenic action of any organism is almost entirely dependent upon the toxins which it produces. The most important feature of the bacterial toxins is its relation to immunity. An animal immunized to the action of a toxin is also protected against tlie pathogenic action of tlie bacterium which produces it. The toxins fall into two main groups: the extracellular soluble toxins (exotoxins) and the intracellular insoluljle toxins (endotoxins). The exotoxins are gi^en olf in a free state when the bactei'ia are grown in a suitaljle medium, and can easily be separated ])y means of a porcelain inter. They are not formed by all pathogenic bacteria. The most impor- tant examjiles of toxins Ijclonging to the exotoxin group are the Bacillus diphtheria and Bacillus tetani ; and it is in tliis group tliat the antitoxins are most easily developed and are most potent. The group of the endotoxins is a much larger one, and it is witli tliis type that a great deal of experimentation with the ^■aecincs has been under- taken. Tlie endotoxins are present in the bodies of bacteria, whether the latter have been killed by heat, by antiseptics, or by drying. This whole subject is further eomjilicated liy the fact that when bactei'ia are injected into a living animal they meet with resistance on (lie jiai't of the host, and under these circumstances may produce pr()tecti\e substances which are toxic. This may in. paii account for the disappointing results which so frequently follow the use of a vaccine. All in(li\-idual,s have a certain amount of natui'al resistance to infection, and the effort with vaccines is to increase this I'csistance. The protective substance which exists in the blood is called oiisoiiiii, and its function is the preparation of bacteria for ingestion by the leukocytes. I)uring an infec- tive process the amount of opsonin is below normal. Dead bacteria from a culture of the infective organism are injected into the infected individual for the purpose of increasing the opsonins to normal or aljove normal, and hv thus rendering the blood rich in ]n'otective substance to hasten immunity. Immediately after injection resistance is on the whole lowered, and this is known as the negative phase, following which the resistance increases. In order to a\-oid giving a second injection during this negative phase Wright devised a method for measuring the opsonic power of t1ie blood. This method is cumbersomo, difficult and at best uneei'tain ; and at the present 80 DISEASES OF L'UILUKEN. (d) m Fig. 27. — IC.xercisi-s lor ilfveloping children ; (:i) uniTow flat chest in a mouth breather; (\>) .sljovving winged seapulie and curvature; (c) and (d) corrective exercises. (ii':XEX(AL THERAPEUTICS. 81 time lias been largely given up. In its place lias been substituted a eaieful study of the clinical symptoms, and this method perhaps gi\es sufficient indications for tlie timing of the dose. In any case it is jirobable that the importance of the so-called cumulative negative phase has been exaggerated. Still it must be confessed that there is very little agreement among those who are using vaccines as regards either the size or the spacing of the dose. Tlie preparation of a vaccine is comparatively simple. The organism to be used is grown in pure culture. The cultui'e is taken up in physio- logical salt solution, which is shaken until evenly distributed, after vi'hich it is standardized so that each c.c. contains a definite number of bacteria. These bacteria are then killed by heating to ()0° C'. for one-half hour, and 0.5 per cent, of carbolic acid is added as a preservative. In children a smaller dose is given than to adults, and as usual this is based on age. The dose varies, however, according to the organism injected. It might be added that larger doses are rarely followed liy dis- turbing symptoms, and there are indications that the present dosage of vaccines is too small. Unfortunately the statistics as regards vaccines are not very reliable. The occasional brilliant result in an isolated case may be due to the part nature plays in affecting a spontaneous cure, while on the other hand where no results are obtained there is nothing to publish. Also it is certain that overzealousness in trying a new remedy has frequently eclipsed the better judgment of the observer. Typhoid Fever. — Available statistics indicate that prophylactic vac- cination against typhoid is an invaluable measure. The duration of the immunity conferred is not as yet determined, but it is probably about three years. The reaction to this vaccination is only occasionally quite severe; there being malaise, fever and soreness at the point of injection. As regards vaccination during the course of the fever itself there is a great difference of opinion, the consensus of opinion l)eing that it is of no value. Septicemia and Septicopyemia. — Its treatment with autogenous vaccines has seemingly been of value in some cases. Certainly a blood culture should be made in all of these cases and the effects of a vaccine tried. Acute Ulcerative Endocarditis. — If a positive blood culture is obtained benefit may be hoped for by the use of an autogenous vaccine. About one-third of the cases will show no iiiipi'ovcmeiit. Out of six cases treated by "Wright two were cured, one improved and three were not affected one way or tlie other. 82 DISi;-\Sl;s OF ( HILDUEX. Adenitis. — The eases of acute adenitis are too (-i:w to allow of any conelusions. In tubei'eiilous adenitis the tuberculin treatment seems to be of some Aalue. This is especial]}' true if treatment is begun before the gland begins to l)reak down. Pyelitis and Cystitis. — The result of treatment with vaccines in both of these conditions is very good, particularly in colon b. types. The im- provement usually begins promptly, the fre(iuent urination, pain, etc., disappearing quickly. It is, however, practically impossible to cause a total disappearance of tlie pus and bacilli. Furunculosis. — The vaccines are of benelit in this condition. Xo other method of tieatment will give such satisfactory results, although it must be borne in mind that for some unknown reason a small percentage of cases will not I'eact. Acne. — ^'accines \vill cure a large percentage of these cases when the acne bacillus can be isolated. In nearly eveiy other case there will be some improvement, Imt here and there a case will be met with in which the vaccine will exert no aj)|)arent influence. Xearly all those who have worked with vaccines disagree as to the dosage. It would lie a distinct ad\"antage if there could be some unil'ormity of dosage, but in examining the literature it is found that one man is treat- ing furunculosis with ](),0IH.(HIO lllilliou ■J."i iiiiUion 1110 iDiUidii ."■ill-.IIIO inillldii 7."ill-L',(IO(l rnilUon lll-no lililliiiii T!ite]'\iil bet^\een iloses Tliree to Hv\cn il;n-s. Diiily. I'h-ery lifth ihiy. In three doses nt ten days interval. Three to t\^elve da.is. Stock vaccines may be used if the diagnosis is establislu'd, until such a time as is necessarv to prepare an autogenous vaccine. It should he boine in mind, ho\\'c\ei-, ihat they are md as satisfactory as those prepared directly from cultures of the inlVctini: organism. GENERAL THEBArEUTICS. 83 Breathing and Resistant Exercises. While special physical training is important and often opportune in the cure of deformities and badly-developed children, a greater proportion of all cliildren need some systematic training in the act of correct breathing and instruction as to correct posture. The schools in some of the larger cities are making some valuable elforts along these lines, through physical directors who have made a study of life during the developmental stage. At this time good habits arc easily inculcated; later, in adult life, they are brought about only with difficulty and the expenditure of valuable time. If breathing as an art is taught the child, it will develop its lung capacity and supply the proper amount of oxygen to the growing tissues. Each breath should be taken in slowly through the nosti'ils in as large a quantity as is comfortable without effort; gradually this amount is in- creased as the natural elasticity of the lungs is increased, and in a short time, M'ith thouglit and practice, diaphragmatic breathing becomes the natural breathing of the child. In the Logi method, the patient lies on the floor upon a sheet, with windows wide open and clothing perfectly free. One nostril is closed and an inhalation taken and held a few seconds before I'xbaling throngli the opposite nostril, and this is repeated several times wjtli frequent pauses for rest and diversion. The next step is the development of intercostal breathing; later the accessory breathing muscles are utilized, and finally the so-called complete Ijreathing is perfected. The best results are obtained when individual instruction is given by a competent teacher. The parents may later act as monitors and encourage the children to go through their exercises daily. As a rule, tlie little ]")atients delight in this, and consider it a pleasure rather than a task. Hy continuing slo\v, resistant exercises with the deep diaphragmatic breathing, placing the p\ipil i>efore a mirror and teaching him to concentrate his mind upon eacli move- ment, the general tone of the body can Ijc markedly raised. Three times a week for fifteen-minute periods usually suffices in the beginning. Tlie aim should Ijc not to pi'oduce great muscular development, but simply to create a natural demand for proper food, improve tlie general circulation, and bring about better health. The indications for these t'xei'cises are many, but the best results are obtained in children who are shallow mouth-breathers as a result of various disorders of the respiratory tract or of nutrition. We have had excellent Si DISEASES OF CHILDREN'. results with this metliod following ink'noid operations, ami in rachitic and anemic children with perverted appetites. Neurotic children also react very favorably. CHAPTEE X. SUGGESTIVE SCHEME FOR DIAGNOSIS. To confirm the suggestions for diagmosis in this table the reader can refer to tlie section tljat treats at length of the disease mentioned. Head. Size. (a) Small — Microcephalus, idiocy. (b) Large — ll3'drocephalus, rickets, hypertrophia cerebri. Shape. ((/) Sc:|uare — ^Rickets. (I'rominent frontal eminences.) (b) Asymmetrical — Eickets, cretinism, idiocy, brain tumors^ atrophy of brain. (c) Bulging Forehead — Hydrocephalus. (d) Prominent Frontal and Parietal Bones — Syphilis. {(') Craniotabes — Syphilis, rickets, chondrodystrophy. (/) Open Sutures — Eickets, hydrocephalus, cretinism, idiocy. Position. (a) lietraction — Meningitis, Pott's disease. (b) Lateral Deviation — Wry neck, rlieuraatic torticollis, Pott's dis- ease, injury to nock muscles at birth, abscess. (Peritonsilar, postpharyngeal or of cervical glands.) Middle ear or mastoid, heniatonia, sternomastoid, curvature, hysteria. Motion. (a) Purposeless Movements — Chorea, ties. ( h ) livthmic — Nodding spasm. (c) Flacciditv — Anterior poliom3felitis, coma, late meningitis. Fontanel. (Normally open till eighteenth month.) (a) Bulging (during cry normal) — Hydroceplialus, meningitis, hemorrhages within, brain tumor, thrombosis of sinus. (&) Depressed — •Atrophic constitutional diseases, severe diarrhea, first stages of meningitis. Tumors. (About the head.) Hematoma, abscess, sarcoma, syphilis, encephalocele, hvdromcningocele, hernia cerebri. 85 86 DISEASKS 01" CHILDKJSN. Neck. Tumors. (About the neck.) ((/) Parotitis. (6)' Lymph node hypertrophy. (c) Thyroid enlargement. (d) Branchial cleft. (e) Congenital cysts (blood cysts, angiomata, hygroma). (/) Hematoma (especially of the sternomastoid). Face. Expression. (a) Pain (intermittent) — Colic, ilentition, dysuria, otitis, bodily discomfort. (b) Pain (continuous) — Pneumonia, pleurisy, peritonitis. (c) Pain (on handling) — Scurvy, fracture, dislocation, rickets, spinal paralysis, meningitis, neuritis, rheumatism. Id) An.xious — Obstructed breathing or dyspnea from any cause; heart disease, (e) Cretinoid — (Thick lips, protruding tongiic, stolid). (/) Sad — (spirituellc) . Tuberculosis and chronic diseases. (g) Disgust — Dyspepsia, gastritis, abdominal disease. (h) Senile — Marasmus, syphilis, internal hydrocephalus, (i) Pinched (abdominal) — Peritonitis, cholera infantum, prolonged or severe diarrhea, collapse. (;') Foolish — Idiocy. (k) Stupid (fish mouth) — Adenoids. Mouth. Open Mouth. Cretinism, rickets, idiocy, cory/ia, inflammation of the throat. Lips. Enlarged. — Cretinism, syphilis, adenoids and hypertrophicd tonsils, infection, neoplasms. Fissures and Ulcerations. Svphilis, stomatitis, after and during acute infectious diseases, injuries. Tongue. Enlarged. — Congenital, cretinism, idiocy, inflammatory processes, trauma, infection. SUGGESTIVE SCHEME EOK DIAGNOSIS. 87 Fissures and Ulcers. — S_vphilis, caries of the teeth, tuberculosis, stom- atitis, ulcer of i'reuuni. Enlarged Papilla'. — Strawberry tongue of scarlet fever, diabetes, lymphatic leukemia, status iymphaticus. Geographical. — Intestinal fermentation, tuberculosis. Gums. Swollen, Bleeding or Spongy. — Gingivitis, acute infectious diseases, scurvy, congenital heart disease, leukemia, stomatitis, difficult dentition, caries of the teetii, neoplasms. Teeth. Syphilis (Hutchinson's teeth), cretinism (small pointed), severe chronic diseases (notches, ridges, rings). Delayed dentition; rick- ets, syphilis (in infancy), t'lironic diseases of infancy — Loosening and shedding in scurvy, mercury, caries. Swallowing. (a) Pseudodysphagia. Nasal obstruction, sore mouth, parotitis, adenoids, pyloric stenosis, anorexia. (6) True Dysphagia. ParalijSTs of soft palate, pharynx or tongue. Spasm of muscles in tetanus, chorea, strychnin poisoning, hysteria, Thomsen's disease. Swellings of tonsils. Peritonsillar abscess. Angina, mediastinal glands, thyroid, thymus. Macroglossia. — Cictinisui. Corrosion. Cicatri.c. Heat, drugs, syphilis, tuberculosis, trauma, ulcer, foreign body. Congenital Defects. — Atresia, stenosis, diverticula. Abnormahties in Breathing. Mouth Breathing in Nasal Obstruction. (Noisy breathing, snoring) narrowing or obliteration, congenital ob- struction, cretinism, syphilis, deformities, chondrodystrophy, ade- noids, polypus, foreign bodies, hematoma, tuberculosis, lupus, abscess, rhinitis acute and chronic, injuries. Inspiratory Dyspnea. (a) Phari/ngeal Stenosis. — Enlarged tonsils, chronic neoplasms, retro- pharyngeal and peritonsilar abscess. Diphtheria, cold abscess. an DISEAHEH OF L'llJJ.DKK.X. tiiln'i'eulous glands^ vertebral caries, luacioglussia, ranula, neo- ])la.siiis oi tougue and jaw. (6) Ldnjiiiival SIriiosis. — ■ Diphtliei'ia, spasmodic laiyugitis (croup), larviigo-sj)asiii Avith crowing inspiration, tetan)', rickets, hydro- cephalus, enlarged bronchial glands, status lynipliaticus, mem- brane in scarlet and measles, tul)erculosis, syphilis, neoplasms, urticai'ia, foreign bodies, drugs, scalding, corrosion, edema glottis, edema from renal and cardiac disease, goiter, paralysis. (f) Tnirlu'fil ami Bronch'uil Sti'imsis. — Diphtheria, enlarged bron- chial glanils. thymic disease, goiter. Expiratory Dyspnea. Emphysema, asfhiiui, s]iasm of inspii-alcu'y muscles, tetanus, tetany, epilepsy, hvstei'ia, convulsions (irritation phienic nerve in pericardial elfusidn ) . Mixed Dyspnea. Bruiuhitis. |ineumonia. pulmonary edema, pleurisy, tuberculosis, heart ilisease, the anemias, toxic and acute infectious diseases, diabetic coma, uremia, gas poisoning, heat stroke, organic lesions of pons anil medulla, tumoi's, abscess and hejnorrhages of brain, anterior poliomyelitis with cerebral symptoms. Chest. Shape. {a) Barrel Shape. — Emphysema, pertussis, asthma, bronchiectasis, cbi'onic 1n-oncliitis, pneumothorax. (h) Cofitractf'd Chest. — Eickets, tuberculosis, stenosis of upper res- ]iiratory tract as adenoids and stenosis of larynx. (c) Ball/nil/ Sfei-tiata (jiigeon bi'east). — Kickets, heart disease, per- tussis, stenosis alone. (d) .\sij]inaetriral . — I'leural effusions, i>iieumothorax, ])leural adhe- sions, scoliosis. {e) Finirul Shajie. — TJickeis, intraabdominal ]iressure. (/) JTarrhon's flronve. — "Rickets. Tumors of Chest Wall. (a) Pointing empvema, caiies of spine, bronchial glands, periostitis. (I) BreasI — (Milk distention, septic mastitis, mun)ps, true tumors.) (r) Bulging precoi-dia. heait disease, pericarditis. ((/) TTernia of lung. SUULJKSTIVE SCHEME EOli DJAU2^0SIS. 89 Abdomen. General Enlargement or Prominent Abdomen. (a) Distenlion with Gas. — Dyspepsia, gastritis, pyloric stenosis, intes- tinal indigestion and dysentery, intestinal obstruction, constijja- tion, tulx'rciilosis and septic peritonitis, pneumonia, typhoid, congenital dilatation of colon, obstructed hernia, intestinal per- foiation. (h) Fluid. (1) I'eritonitis (chronic, serofibrinous, tulterculous, septic (from umbilicus), gonorrheal, pneumonic. (2) Heart disease (uncompensated heart and clironic adliesive pericartlitis). (3) Kidney diseases. (4) Hepatic diseases (cirrhosis, true tumoi's, degeneration). (5) I'ortal obstruction (enlarged glands, adhesions). (G) (ii'ave anemias. (c) Coii.siittitioiiiil l)i.'yelitis, perinephritis, neoplasm, cystic kidnc}', tuberculosis. 90 DISEASES OF CHILDREN. (h) Stomach and Iniextiiu's. — I'vloiic stenosis, intussusception, appen- dicitis, impacted feces, worms, neoplasms, congenital dilatation of colon. (c) MisccUaneuus. — Thickened omentum (tuberculous peritonitis), mesenteric glands, psoas abscess, encysted peritoneal abscess, distended bladder. Tumors of Abdominal Wall. Abscess, hematoma, hernia (muscular). Umbilical Region. (a) Hernia (ot omentum, intestines, bladder). (h) Fungus (granulations), (c) Periumbilical abscess. Inguinal Region. Tumors or Enlargements. («) Hernia, liyih-oci'le of tunica vaginalis and cord. {h) Undescended testicle. (f ) Orcliitis, mumps, syphilis, tuberculosis, influenza, trauma. . {d) Xeoplasnis. (e) ^'aricocele. Delayed Growth. (a) Improper feeding and digestion, starvation, pyloric stenosis, mai'asnius. (&) Cretinism, rachitis, idiocy, infantilism, osteomalacia, micromelia. (c) Tubci'culosis. {d) Syi)liilis. (e) \'al\ular heart disease. (/) Progress! \e paralysis. Hemorrhages. 3. General Causes. (a) Acute Infectious Diseases. — Pyemia, septicemia. (h) Toxic. — lodids, mercury, ergot, belladonna, phosphorus, anti- pyrin, chloral, arseiii'\ food poisoning, snake bites. (c) Constitutional Dinniscs. — Syphilis, scurvy, Bright's disease, tuber- culosis, atlirepsia. {d) Fuypura. — Purpura simplex, fulminans, hemorrhagica rheumat- ica, Henoch's purpura. SUGGESTTVK SClIEJrE FOR DIAGNOSIS. 91 (e) Blood Diseases. — Hcmopliilia, leukemia, pseinloleukemin, splenic anemia, Banti's disease, severe seeondai^ and pernicious anemia. (/) j\[ccltanical. — Injury, pertussis, epileps}'. 2. Special Causes. (a) Of New-horn. — Asphyxia, obstetrical operations, deficient expan- sion of lungs, sepsis, syphilis, hemophilia, congenital disease of liver and bile duets. (6) From Nose. — (1) In new-born as above. (2) Affections of mucous membrane. Traumatism, foreign body, acute and chronic rhinitis, adenoids, polypus, diph- theria, measles, worms. (3) Congestion, prolonged cough. Cardiac and pulmonary affections. Overheating, nephritis, sinus thrombosis. (4) Prodromal, in acute infectious diseases. (5) Vicarious menstruation. (6) Fractured skull. /{c) Of Stomach. — Gastric ulcer, chemical erosions, worms, foreign body. Occlusion of intestines, swallowed blood, general causes as in 1. \d) Recttim. — Cxeneral causes and new-born. Severe enteritis, gas- tric and intestinal ulcer, follicular and membranous enteritis, worms, intussusception and strangulation, hemorrhoids, polypus, anal fissure, condyloma, prolapse rectum, injury with enemata, etc., typhoid, tuberculosis. Extremities. 1. Disturbances of Motion. (a) Paralysis or Pseudoparalysis. — Anterior poliomyelitis, scurvy, syphilis, rickets, postdiphtheria, cerebral palsy, neuritis, birth palsy, meningitis, fracture, epiphyseal suppuration, osteomye- litis, spina bifida, transverse myelitis, progressive muscular atrophy. Landry's paralysis. (6) Inability to Wall or Wall with Limp.— (Any of the above pa- ralyses cited in (a) ). Delayed walking. Tuberculosis of the hip, knee, ankle. Pott's disease, osteomalacia, congenital dislo- cation of the hip, rickets, coxa vara, rheumatism, mental defi- 92 DISEASES 01 CHlLDIfEX. ciency, idioey, hydrocephalus and iiiiiroeephahis, cretinism, weakness after disease or poor uutritiou, progiessive muscular atrophy, fliat-foot, improperly fitted shoes. (c) Spastic E.rtiriiiHies {rigidity). — (Xoriual in early infancy.) Girujiiiata, cerebral heuiori-liages, sclerosis, tumoi's, spastic para- plegia, acute encephalitis. Little's disease, hydrocephalus, men- ingitis, lateral sclerosis, hereditary ataxia, tetany, catalepsy, tetanus. 2. Swellings. (a) Joints. — Chronic and acute polyarthritis. (Rheumatic, purulent, gonorrheie. following scai'let fever and pneumonia). Tubercu- losis of the joints, simple effusion, bui'sitis. (&) Bones. — Eickets (epiphyseal), syphilis, scurvy (subperiosteal). Osteomyelitis, neoplasms. (c) General Enlnrgeiiieul. — Anasarca, angioneurotic edema, sepsis, hydremia, acromegaly, elephantiasis, erysipelas, cretinism. 3. Hands. (a) Dactijlilis. — (Simple, tuberculous, svpliilitic.) (6) CJuhJjed Fingers. — Meart disease, chronic cough, hepatic cirrho- sis. (c) (Haw lliind. — I'lna paralysis, progressive atrophy, lesions spinal cord, ischemic paralysis. (d) f'lirpiiseles.^ In roliintar/i 'Movements. — Chorea (infectious and hereditary, Huntington's). Organic brain lesions (hemiplegia, tumors, abscess brain, sclerosis after meningitis). Friedrich's ataxia, habit spasm, idiocy, hysteria. SECTION IV. INFANT FEEDING. CHAl'TEit XI. THE INFANT FROM THE NUTRITIONAL STANDPOINT.* Introduction. The general practitioner is expected to look after the nutritional wanta of infants. With the average normal baby he can succeed, provided lie is grounded in the principles of nutrition. In tlie succeeding chapters infant feeding will be outlined in such a way as to enable the physician to apply the principles involved in the management of all infants. It is unwise to read or study any one section, without noting its relation to the entire subject. Infant feeding is perhaps the most difficult of the pediatrician's prob- lems, and the general practitioner must realize the need of a careful study of this subject. The Infant. — The problem of nutrition begins when the fertilized ovum starts to divide and form additional cells, and from this time on until death there is an unc-easing demand for food. During a life history the food is supplied in many different forms, and as the organs of nutrition change in the earlier stages of development, the physical properties of the food change also. In the earliest stages the food is supplied from the yolk of the ovum ; as development progresses, the villi of the chorion appear and act as organs of nutrition ; these gradually merge into the ]ilacenta, which derives food from the maternal blood ; at birth the breasts supply food in the form of colostrum for a few days, which is gradually displaced by milk. When the milk supply naturally fails, toward the end of the first year, the child is capable of digesting some forms of semisolid food such as its parents eat, and continues its development on this food. Essential Unity of Foods. — When all forms of food, including mother's milk, are subjected to chemical analysis they are found to be eom- * For greater details in reference to the biolo^ of thi.s subject, see "Theory and Practice of Infant Feeding." by Dr. H. D. Chapln. Third edition. William Wood & Co. 93 94 DitiKASES OF ClllLDJfEN. posed oi' iiigiviliciits wliicli I'aJl into Ine gj'oups: I'l-oteius, ol'teiilimes termed proteids, wliieh I'onu tlie tissues; mineral matter which is necessary for bone iormation, and also in lesser quantities to rejjlaee metabolic waste ; fats and carbohydrates wliicli supply tlie energy; and water. Tlie ijreat difference in fouds at different ages is iwt one of composition, hut of fwm. Foods of the First Nutritive Period. — The mother supphes food to her otl'spi'ing in six dill'erent forms: First, the yolk of the ovum; next the tluid in which the ovum is bathed; then that which is supplied in a form suited for assimilation by the chorion ; and then by blood ^^'hich circulates through the placenta. When birth occurs, the food is supplied through the breasts in two forms, at iirst colostrum and linally as milk. Each of these forms of food is specially adapted to the infant at the time it is furnished, and as soon as tlie infant outgi-ows one form of food another is su]iplied. L'S. — Xoruial buuiaii m (Jcuctt.-) Fig. 20. — Colostrum curimseles (Jeieett.) Breast Secretions: Specialized Foods. — It is [ilain tliat befoie biith the Toi'in of tlie food sujiplied by the mother and the method of fur- nishing it change to suit the state of (le\elopuient of the fetus; and as at birth the digestive organs of the infant are not fully developed, it may be lonchided that in souie way the breast secretions ai'e ])eculiarly ada]ited for that part of tlie fii'st nutritive period in which the digesti\e tract is developing. Composition and Properties of Breast Secretions. — 'i'he first secre- tion of the breasts or mammary glands after the infant or young animal is born is called colostrum. Chemical analvsis shows it to be <'nmposed, like all foods, (if |)rotiuns. mineral inalier, fats, caitiohvdrales, and watei'. THE INFANT FROM THE NDTRJTION STANDPOINT. 95 Upon boiling, colostrum coagulates, owing to a large portion of the protein being in the form of albumin. It is also distinguished by the pres- ence of colostrum corpuscles (Fig. 2!.)). In the course of a few days after birth the character of the breast secretion undergoes a complete and radical change. Tlie later secretion is milk, which is also com])osed of protein, mineral matter, fats, carbohydrates, and water, but it will not coagidate when boiled, showing there has been a change in the character of the pro- tein, and the colostrum corpuscles are absent. From these facts it is evi- dent that chemical analysis throws little light on the properties of cither colostrum or milk, except to show that they are composed of the basic food elements. As the characteristic feature of nutrition during the first nutritive Teeth and salivarysliiiMls. Stouiacli. Intestines. Fig. mo. — Develoimiciit (if luiiuan ;]ierinient with the infant. Recapitulation. — The main points to be kept in mind in infant- fwding are : The mother's breast secretions are specialized forms of food, adapted to the developing digestive organs. Milks of lower animals and table food are as nutritious as mother's milk, but are not adapted lo the undeveloped condition of the infant's digestive tract. The chemical composition of a food shows nothing concerning its suitability for any animal and is not of first importance. The value of foods for individuals cannot be judged by comparing their cliemical composition alone. Foods may be " chemically right but practically wrong."" The food elrnierifs required by all infants are the same, but the form in which they are to be presented must be determined for each infant. CHAPTER XII BREAST-FEEDING. Importance of Breast-feeding. — The breast secretions are furnished during the time the infant's digestive apparatus is developing, and serve a purpose in addition to supplying nourishment. The secretions of the breasts adapt themselves to the increasing strength of the digestive organs, and, instead of these organs finding their work easier as the}' become stronger, they find the digestive woi'k increases as their digestive capacity becomes greater. This is brought about by an alteration in the physical properties of the mother's milk in the stomach by the infant's gastric secretions before true digestion commences. The rennin, pepsin and acid of the stomach, as they successively appear, produce profound changes in the physical condition of the milk. When rennin acts alone, as it does in very early infancy, the milk becomes a fluid jelly; but later on when pepsin and acid appear the milk is changed into a mass having much of the con- sistency of well-chewed food, and which should be looked upon as its proto- tvpe. It is thus that the digestive organs are prepared to digest semisolid food about the twelfth month, when weaning naturally takes place. In addition to this interesting and important i)roperty of the mother's milk, it generally contains the food elements in tlie proportions and forms best suited for proper nutrition of the infant. It is not a difficult matter to bring together the food elements in the same quantities as arc found in any specimen of breast milk, oi- colostrum, but even when derived from milk of lower animals the food does not have the delicate properties of the breast secretions, and it is often contaminated or lias undergone bacterial changes. 'While many infants are successfully fed on substitutes for breast seei'ctions, such feeding should not be attempted until every effort to secure breast-feeding lias failed. The death rate is mucli higher among artificially fed infants than among those breast-fed, and in hot weather when bacterial changes in the food are greatest tlie loss of artificially fed infants is several times greater than during the colder seasons, while the increase in death rate among breast-fed infants is slight. Every consideration sliows the advantage of employing the maternal method of nutrition while the infant's digestive organs are developing, and breast-feeding should always be advocated irnlcss contraindicated (see p. 105). 99 :; 100 DISEASES OF CTIILDREN. Preparation for Maternal Feeding. — I'^or some inontlis before de- livery, the nipples sliould he trertted so as to prepare them and thus prevent tenderness or fissure when the infant nurses. This is done by gently rubbing and applying sueh a lotion as the tineture of benzoin. Depressed or mis- shaped nipples may thus be made usable, and the comfort of th(" mother will also be conserved. Management of Breast-Feeding. — When the mother is enough rested after delivery the infant should be offered each nipple. If it does not seem satisfied and becomes fretful or restless, a teaspoonful or two of boiled water may be given. This will quiet the infant and helps to flush out the digestive tract and kidneys. For the Jirst day of two the infant may be offered the breast every three hours during the day and twice during the night, at four- to six-hour intervals. After this it should be nursed every two hours dui'ing the day and once or twice at night. When the supply of milk is sufficient the infant will suck for fifteen to twenty minutes and then drop oif to sleep. If after having the nipple twenty to thirty minutes the infant seems restlses and unsatisfied it may be suspected that the milk supply is insufficient. A weighing before and after nursing will help to determine whether the amount has been sufficient. After the first few weeks such a test should show an increase in weight of between tu'o and three ounces. If under such management the infant has soft yellow stools with no pronounced signs of indigestion and gains steadily in weight, it may be considered as doing well. Regularity of Feeding Important. — One of the most fruitful causes of indigestion in breast JVd iiil'ants is feeding at irregular, and especially at short intervals. Soiiietiiiies a fresh feeding is taken into the stomach before the previous meal has been digested, which is bad enougli ; hut in addition to this, tlic irregularity in nursing has a jjrofound effect on the composition of the mother's iinlk. If the intervals between nursings are long there will be a large quantity of ratliei' poor milk; but when the milk is draflir at short intervals it has the effect of reducing the (|uantity and greatly increasing the ].)ercentage of fat, till.' other ingredients not being affected to any great e.xtent. An o-xcess of fat in the food is apt lo produce vomiting, and an abnormal gasti'ic secretion may follow, causing the milk to curd or solidify abnormally ; hence it is not difficult to see why frequent nursing causes digestive disturbance. Wlien milk is drawn at regular intervals it has practically the some compo- sition, unless the mother has been subjected to influences that derange her' BltEAST-FEEDING. 101 nervous system. These ma^f profounrHy alter tlie character and composition of her milk and produce great disturlianees in the infant. It is, therefore, of the greatest importance to hn\X' the mother regular in her own liabits anil free from excitement, and that the infant lie fed at regular hours. It will he helpful if the mother is given directions for feeding by tlie clock, as at 0, 0, 12 A. M. ", 3, H, P. M., and once during the night in occasional cases. Milk Agrees, Flow Scanty. — When the mother's milk agrees with the infant, hut is not sufficient in quantity to cause it to gain in weight steadily, attempts should he made to increase the flow, and when these are not successful, mixed feeding, that is, part breast and part artificial feeding, must be employed. If the mother is to secrete sufficient milk she must digest and assimilate a liberal supply of food herself, for unless she does this the milk will be produced fi'om her own tissues and she will lose in weight. The diet of the mother should consist of simple, easily digested food in liberal quantity, milk, eggs, meats, and thoroughly cooked cereals being the mainstay. Tea and coffee should be withheld or used sparingly, cocoa or chocolate being given in their place. Soutliworth, who has devoted much attention to this matter, recom- mends the use of cornmeal gruels to be taken between meals as a means of increasing and conserving a scanty flow of breast milk. "When cornmeal gruel is not relished, oatmeal gruel may be substituted. The gruels are made as follows : Two to four heaping tablespoonfuls of yellow cornmeal or rolled oats are placed in one quart of cold water in a double boiler and the water in the boiler is kept boiling for two or three hours. The gruel is then .strained through a foarse wire strainer and enough boiling water is added to make one quart of gruel. The gruel should be well salted. It is often advantageous to add an equal- quantity of milk. A pint of such gruel is to be taken about ten o'clock in the morning and again at about three in the afternoon. The gruel, when dextrinized, supplies energy food in a form quickly assimilable, and the coarse particles of the gruel undoubtedly promote normal action of the bowels and thus promote the general well-being of the mother and incidentally that of the infant. Whm there is anemia iron should be administered. Elimination of Drugs and Excretory Products in Milk. — It is a well-known fact that some substances pass inio the milk from the mother's system which may unfavorably affect the infant. Constipation of the mother will affect the infant unfavorably, and under certain conditions urea in appreciable quantities finds its way into the milk. When the mother 103 DISEASES OF CIIILDKliiSr. is constipated and tlie use of eoiiinieul gruel does not overcome the condi- tion, cascara sliould be given. Great care must be exercised in giving drugs to nursing women, as they may be excreted in their milk. Morphin, mercury, quinin, iodid of potassium and similar preparations should be given cautiously and their effects watched. Milk Plentiful, but Disagrees with Infant. — As a general rule, the milk of the motlier will agree with her infant. However, there are some women whose milk may at times be excessively rich in all of its elements or may fluctuate widely in the amount of fat present or have properties that make it unacceptable to the infant. If the milk agrees with the infant for a time and then suddenly dis- agrees the probabilities are that the mother has been subjected to excitement of some kind ; it may be worry, fright, anger, grief, or loss of sleep that has made her irritable. Such influences will produce sudden changes in the character of milk and alter its digestive properties. It is well known that the milk of a cow that has been ovei-heated, driven rapidly, or made irritable by flies or dogs, will not react normally to rennin and acid. The changes brought about by these nervous influences are more than variation in percentage composition, and caimot be detected by chemical analysis. The remedy in this class of cases is to remove all causes of anxiety and nervous disturbance, and have the mother sleep in anotlier room so that she shall not be disturbed by the infant's crying. Pleasant surroundings, and mod- erate daily exercise in the fresh air are also indicated. Sometimes the milk of one breast is perfectly satisfactory while that of the other causes disturbance. In such cases the remedy is to secure all of the feedings from the good breast if possible until the other one secretes normal milk. A\'hen the milk disagi'ees from the start and the mother seems liealthy it is possible that the trouble is caused by the milk lieing too rich, the result of overeating on the part of the mother. At any rate it is lielpful in all of these cases where the milk disagrees to make an examination of it, as will be explained below. If it is found that the amount of fat and total solids in the milk is too high the diet of the mother should be restricted, and exercise to the point of fatigue, to divert the food supply from the lireasts, may be advised. It may also be necessary to give saline cathartics. If there is an over-abundant supply of i-ich milk, the infant sliould be allowed to take only the first milk from each breast and thus avoid the extra fat " strippings " oi- the last milk secreted which contains a much higher percentage of fat than the first part BEE.VST-FEEDIXG. 103 of the secretion. If the infant has eurdy stools and colic, a tablespoonful of barley water, limewater, or water containing; one grain sodium citrate may be given just before each nursing. If the methods of management suggested above do not overcome the difficulty, so tliat tlie infant gains from four to six ounces a week, vvitli good digestion and normal stools, it will be necessary to resort to mixed feeding. Give a l)ottlo every other feeding, using a formula suitable for a younger infant at the beginning, as described on page 134. Examination of Breast Milk. — • There are two ways of examining breast milk: (1) by liaving an analysis made showing its percentage com- position expressed in proteins, mineral nuittei', fats, carliohydrates, and water; (2) by roughly determining these ingredients by means of the auioimt of cream that will rise on a given quantity of milk and tlie specific gravity of the milk. The chemical analysis of milk is expensive, and its value is apt to be overestimated. It takes several days to get a report from the laboratory where it is made, and laboratories for this purpose are not always available. The second method of determining facts and specific gravity takes twenty- four hours, but can be utilized anywhere. A specimen of the milk is drawn from the breast, care being taken to get all there is, because the first portion contains little fat, while the last portion or " stripping? " is very rich in fat. The milk is mixed and its specific gravity is taken with an ordinary urin- ometer. Ten cubic centimeters of the milk are then placed in a graduated ten c.c. tube or graduate and allowed to stand twenty-four hours for the cream to rise. Poor milk will have a small layer of creanr and rich milk a much thicker cream layer. The amount of fat in the milk is thus esti- mated. The specific gravity of normal human milk is about l.Ool. If the milk shows a layer of cream not over one c.c, and has this specific gravity, it may be looked upon as normal milk as far as percentage composition is concerned. If the specific gravity should be as low as l.OS.S, with more cream, it would indicate that the milk was rich in fat, as the fat being lighter than the milk serum reduces the specific gravity of the milk. This method is widely used in the dairy industry for calculating the composition of cow's milk, but the fat is accurately determined by the Babcock test, which may also be used with human milk. x\bout half an ounce of milk is required for this test, but if this quantity cannot be obtained, what is available may be diluted with water two or three times after the specific gravity has been obtained and the result multiplied by the number of times the milk was diluted. If the specific gra\ity is al)ove 1.030 and there is little cream, or fat 104 DISEASES OF CHILDREN. shown by the Babc-ock test, the milk is poor in fat and normal in other solids, or all of tile milk was not drawn fi-om the breast and that portion containing the fat was left bi'himl. A second specimen should be drawn and greater care taken to get all there is. 'I'he milk should be drawn at the regular nursing interval or milk extra rich in fat will be obtained, for, as stated before, milk drawn at short intervals is abnormallv rich in fat. Flfi. 31.^ Kr( puiuri. ■ast Fig. .",2. — llnover breast iiuuip- An ostimation f>f thf tntnl solids and solids not f:it inn.v bo obtained from these fipnres, i. r., thv last two li^aires of tbe specific j;ravit,v divided by four and adding one- fifth of the percentaKe of fat which gives thi' solids not fat — then it the fat is added to these solids we obtain the total solids. For example : I Sp. er. 102S — butter fat r,%) 2S -^ by 4 = 7 + J (of '>%) = 7.1 solids not fat + ." or 1 LM - total solids. At one time sreat irnportance was laid vipn7> the reaction of breast milk. It was supjioserl always to be alkaline or ampboteric in reaction. At present com- paratively little importance is attached to tbe reaction of breast milk, for the same specimen of milk may be found to be acid, amphoteric, and alkaline, all dependini,' uiion how the reaction is determined. Litmus-paper was the substance used to di'tennine tlie reaction of mill;, u strip bcin;; dijiped into the millc and its reaction jud^'cd by the change of color of the litnius-pa|)cr. Litnuis and litnuis- paper vary a Kreat deal in sensitiveness, and all kinils of reactions can he obtained with milk by usinfc different lots of litmus-paper, rhenolphtbalein in 1 per cent, alcoholic solution is now used as tbe indicator in testing the reaction of both human and cow's milk, as it is many times more sensitive than litnuis. lame- water is usuall.v employed in neutralizins acidity in milk, and it takes about 10 per cent, tn 20 per cent, to make human milk .alkaline to phenolpbtbalein. With a better undcrstandins of tlie chemistry of milk and tbe yn'ocess of its di.cestion. it is seen tbiit undue im|iortance was plac(^oi'ated milk." 'I'his is eondensed milk M'hich has been canned without tlie addition of sugar. It lias a creamy consistency and when diluted with water is very mucli like sterilized milk. It d and these contain eiiougli of the food elements in suitable foi'ni to nuike all kinds of tissues. Fggs, thei'cfoi'e. are verv nsefid additions to diet during the growing period, and espeei^dly wdien the iniant is Ix'ginning to eat table food and needs easilv diucjled proteins. I'lUNCll'LES AND ilAXIilUALS USED IX SUBSTITUTE I'EEUING. 117 Dextri-Maltose. — This is a preparation nf nialt-siigar consisting of maltose, ol pLT cent.; dextrin, 47 per cent.; sodium clilorid, 2 per cent. Eacli ounce has a food value of 111) calories. It is a readily absorbable sugar containing no cellulose, fats or proteins. It often agrees better than milk or cane sugar, and is especially indicated in infants in wlioin it is desired to get an increase in fl-eight without causing sugar disturbance. Proprietary Infant Foods. General. Properties. — Before the subject of infant-feeding was as well understood as it is at present, many attempts were made to furnish artificial foods which should take the place of mother's milk and of cow's milk. For a time they served a useful purpose and when it was impossible to obtain a supply of good cow's, milk they were of considerable value, as very often they were retained and saved the infants from stai'vation or serious digestive disturbance caused by contaminated milk. On them many infants gained in weight and thrived temporarily, hut frequently these infants developed rickets and scurvy, or were poorly developed and of feeble constitution, and consequently were carried off by the first serious sickness. All of these foods are composed of proteins, mineral matter, fats, and carbo- hydrates. In some the amount of fat is infinitesimal, the protein low in quantity and the carbohydrates very high. None of them are at all like mother's milk in properties. They often contain only enough protein to but little more than make up for metabolic waste, but the carbohydrates are in such a form that they are easily assimilated and converted into fat which causes increase in weight. All of the proprietary infant foods are composed of cereals, sugars, dried milk, and eggs, either singly or in combinations that have undergone special treatments. Chemical analyses shov,^ little or none of their proper- ties except their possible nutritive value. Classification of Proprietary Infant Foods. — A clear idea of what the infant foods on the market are like will be obtained if they are classified according to the materials from which they are made, and according to this plan they will all fall into about three or possibly four distinct groups or classes, as follows : o - u. w' UJ fD H tr tr- p M ■- p ?r ^ o o a p R B CO P C- !Vi» O fo M III Ol OTl o O s O o R O c^ t-( o y ro ?r "5 3 S c o 3 "-J O cr a> M n I'D -+> H cc 05 C3 &- ^ '-^ ^ s O P tv C+- o Si i/J yj a p crq f^ 3 5- r+ c-t- m o ' J ■i O c:- cr B ^ c-t- p-n n t-^ o o z^ ffi B pa ^ CO o) ?r S tOtiS: 1 enburys' enbm-ys' rden's Mi 'adow's ]\ )rlick's M stie's Foo rnrick's S real milk, ctated foe rnrick's I fo o :l o g; tr. ^ So o 1-1 po • igt? po ■ o o : tow tO^CnCOCOCOM^ Crii+^C7. Water hp^h-coi— 'OtOiO ht^(;oco OitOtOOCOCOh^ tsDC^tO !_. 1_. |_l 1—1 1—1 >_i 1—1 H-' 00 O to I-" to CO CO CO CD Protein k+^i— 'COtOCncOGO COOO (N X 6.25) >f- CO 00 Oi a: ^^ 00 00 O CO tOi-'tOtObOCOCO COC04- Mineral cD^tOOtO-^JtO i-'Cr^O matter hJ^cCiOOh4^0l:0 ^cOO h- ' t— ' to O 4^ HJ Cn Oo rf^ Oi CO CO Fat tO^-lOi-'MCoi-' i-'-qo en* to C^ 4* 0'» Oj H-' ^J^ to O OtOOOOOli-^*^ k-CO--l Nitrogen-free extract cClOOOcD':oco^;^ a:CO--l h-' h^ h- ' *.J to -^ CO Oi CO C7I (Carbohydrates) ai ^ toco COCDtOOOOO O^JtO Lactose M0iOC0t0C04^ 011—0) h- '-^lOi*— '1— 'COCO )— 'ht-CO h^ K- h- to H- bO O) en o o Starch CO CO CO to CO o^ c: I-' ^4^ CO O O to to No st No t glu Nost Nost Raw , Cook. Small Disto Trace "> o o ^ ^ --r ta- i^ o SS-s.p-51 g -i^&^ ft 2 S-[L E° ^ p. » : S'oi ?= t3 — m ci- Hi CO c5 • cr cr p R- jn g a. 1 t; Q 1 , O o Tl a 1 L ^ •-1 -T ^ H tr- > fa .71 -D T3 3 ^ T3 y. V> c :? M — f^ ■^g. as^ ?3 CO p t-i s O- o s-c tr ai ^ 3 o B P ""^T" '< TO ^ p ■3^ ■a b cm 3 *fl a. o a -3 a. ?7^ "D hH O ,~ OJ ,__. — ^1 ,__, Oi ". CO y^ 1 ^ ^. y-j 4- ^ ^ C7I lO OJ o a.' y: GC -( C^ 'y-j h4- o O :0 w a: a. GO tc X ►4- '"' ^ r^ O x P d: o tr^ 1 t3- C O o Tf- CfJ P D" C ?r a- o '-I p ^ a ^ ^ ^ 2^ 2 i" "^ t:" ra > OS-? a. crq o £3 ^ O . - 3 3 o crq 3 2 a- )^i sri a-h-, 3 O 3 CO ^ CO ^. d Oi en '73 Ot to 30 O O OJ CO 00 CO CO - ^ ^ O O O Oi to - X :n o :j» 28K ^ ^ ^-^ 1 — ' io Oi-O ,_^ _. Oi oi O ^ 4* CI h+* O CO -O) CO H- O Oi o o o ^ oo ^ ooo o ~j cc X M CO Gc :» -.1 cc M W ^^ CO to o» O -^1 o tO'y:otOh^coo4^x OOOOOOOOO Protein (N X li.2.5) Mineral matter Fat Nitrogen-free extract (Carbohydrates) Lactose ytarch M o o 2; z; ?3 a ?o 2 t^^rCo ^t;3-- ^ 05 a,^wo o-^ o^ 3 ^ - S" „ S- :? S TT a = s- -X 3- cr <: < at m CD c« .t> Is-? O g to « :^ ^ ^' 3" TJ a ^ — 3'H ^ ^ -^ o r/1 b r/i ■-n o :3 ■^ o - u- v/ rr ^ — . 3-3-s ^ P r-t- ^ o 3 9. fa p- n 3 '•< T^ Pft i^ 3 c^ nrq n tr p P OJ r^ ,'-7' — ^ n :>■) J /J ■FT ^ 3 n n. 7q CTJ 3 3" ^ rv- jq B p "<; 3^ P o ^- (» 3 a, 0} 3 3 g; S-CB cu ^ 2 o B <^ :;• s * 120 ))iyi-;Awi-;s of c ii i I-Ui:iii\. Tlie composition of tlii' tood when ii i< in lliu infant"^ bottle will de}H'ii(l aljsohitely on liow iniu-li of tlio in-opnetarv lood is iisoil oj' on the riclinoss and (jiiantity of niill< to wlueli it is addod. Tims it is nianifestl}' impossible to give anal\'ses wliieb will give a correct idea of the nutritive value of these mixtures. There is one ]ioint. howexer, whicli should lieeome fixed in the mind and tbat is that neaidy all of the proprietary foods are composed of carbo- hydrates mostly, anil these carbohydrates ai'c largely if not entirely derived from cereals. Gain in weigbt is often made on tliese foods, but luiless thev are reinforced l>y milk the tissues are not of the hrm muscular character proiluce(l bv foods richer in ]irotcins. Sometimes, as when traveling or when a good ((uality of milk cannot he obtained, tlie fooils tbat ari' to lie used without fresh milk may serve a useful pui'pose. But for general purposes of feeding these foods possess disadvantages over food mixtures for which the ph\"sician can write pre- scripti% tliey are not beins nsed so much. Some still take the protein as RXi%, init this is rather high for the general rnn of milk. 12U PRACTICAL FEEDING. 127 If a feeding mixture contains one-fourtli milk, the quantities of tlie food elements supplied by the milk will be one-fourth of the foregoing- figures or : Fats 4 [4%_ Carbohydrates Proteins 3 . '2% Mineral Matter 0.7% 1% 1.25% 0.80% 0.18% If the proportion of milk m tlie food was one-third, one-half, one-tentli, or any other fraction, the composition of the food would be determined in the same manner. msnoniiiiiiioFmiiioT Slim.tOF4>:MILK.EtCKOI. REMOVED WITH DIPPER Fli;, LAYER OF CREAM> NOT UNIFORM IN COMPOSITION FAT IN DIFFERENT PORTIONS REMOVED FROM THE TOP AND MIXED. ISIOZ. 2NP07. TOP 2 0ZS.MIXED 24J« FAT 22.5/'« " 21.4i< " 19.2!*" 16.8!«" 1B.0;<" 13.3i« " 1I.B!« " ;!i. — I'erceiitages of fat in iliffereiit ]iortii)iis of a iiiiart buttle er cent, of fat even on which the cream had not completeh' risen, as is shown by till' high perei.'ntagi; of fat in the millc under the cream la\'i>i'. At one time it was believed that cream which I'ose of its own accord, and known as gra\ity eream, was uniform and contained but K'l per cent, of f:it ; and as \'i'rv often the ci-eam to bi' added to (he infant's food was takrn dii'cctb; from the mouth nf a quart bottle, instead of Ihr infant getting Ki |ier cent, fat creaiii, one containing 'i~> pei- eenf. nv moi'e nf fat was obtained. A comnmn thing was to see infants suffering from fat indig(>stion caused bv an e.\eess of I'at Ihus nnwiltingly introduced into tlie food. It is e\'idcnt that if all of the fat of a quart of whole milk containing 4 per cf.'nt. di' fat rose to Ibe sui'face, the top or up|)er ]iin(, oi' om^'-half of the (|uai't of milk, would contain twice Ibe percentage of fat in the original milk, oi' X |ici' cent., while (he reiuaining pint would contain ini fat at all. If all of the fill was in (he lop one-(hird nf th" ouirt of milk il would con- lain llii'ee limes 1 per cent, oi' 12 pel' ci'iil. of fat. PEACTICAL FEEDING. 129 As a matter of fact, nearly ail of tlie fat in a quart of niillv is found in the top six to eight ounces after the cream ha,s risen, so by taking all of tliis layer of cream with some of the fat-free milk underneath, milk containing- \\, 2, 3, or any other number of times as great a percentage of fat as the whole milk contained may be had from the ordinary quart bottle of milk. As a small percentage of fat remains in the milk below the cream, a little less than the above theoretical quantities are removed from the top of the bottle. Fig. 40.— Quart bottle of milk, sliDwiiiS layer of cream. Fig. 41.— Chaiiiu cream clipiiei'. These top milks, as they are called, contain about tlie same quantities of protein, mineral matter, and carliohydrates as whole milk, so when using whole milk or top milks for dilution the percentages of all the elements except the fat will be the same no matter which is diluted. Therefore, by using definite quantities of the upper part of a quart, of milk after the cream has risen the amount of fat in the diluted milk can readily be varied, while the percentages of the other elements remain unchanged. For ex- ample, there could be obtained top milks containing Pat 6% S% 12% Carbohydrates •■5% 5% r.% Protein 3.2% 3.2% 3.2% 130 DiSJiASJiS 01" CHlLDliEX. And if each was diluted four times the diluted milk would contain percent- ages equal to one-fourth of these ligures, or Fat CarLioli.vdrates Protein 1 . 5% 1 . 25% . 80% 2.0% 1.25% ..S0%> 3.0% 1 . 25% . 80% The percentages of the elements in any dilution can jeadijy he de- termined in tlie same manner. To obtain these diifeient top milks the dipper' shown in Fig. 41 is used. It ineasures one ounce. Percentage Cereal Gruels. — Until comparatively I'ecently tiie use of cereal gruels has been purely empirical, and little attention has been paid to their composition or nutritive value. But recognition of the benefits to be derived from their intelligent employment is leading to their being used in a scientific manner, and the tendency is to prescribe them in definite quantities and of approximately definite percentage composition. The com- position of cereal gruels depen\ a o :3 =3 (-. m S-; (1) \o jq N ■J-j o ^rl o -t 'ji a, o H d " L- lO C-l O t- lO ^ ^ C^I -o CO -t^ \rj : I- -H ) CO -^ 6/0 S a LO O to O lO o o T-< i-i CI 01 CO CO ^ '' -£ — •a " ^ V H 0- -^ ^ ;^ " 1^ o ■f: o a M;i;'-^ t: o .-3 •a J 3 'M ^ 2 M 5 = a- ^ "a S S " ? '2^ oj a 1-1 s o 2 a i i £ C S ~ a- 5 cL i^ '^ «5 2 ■S Os| CO Tt< lO CD N l>0 1 " 1) Oj dJ GJ C II ;= ^ ^ ^ i; ^ II tsi ■< ^ .y -^ .^ .^ .^ tii'^ o v^ .l(5M'^-i<)-l'M!4-(^ 3 ■^0000 OT^M D CO ID O CC- fl .iil s a 01 CO 132 DISEASES OF (JlilLDUEN. Outline of Feeding Directions. — ^ It is impossible to give explicit directions i'or preparing i'uod IJjr each i^articular infant, as infants diifei' in tlieir digestive eapaeily, in their t'dieieney in assimilating food, and in their condition when the pliysieian is called in. However, all cases naturally fall under aliout four headings: (a) A\'ell infants which cannot obtain breast-milk, and the eonlro] of which the physician has from the start. (b) Infants that are well except that they are suffering from bad methods of feeding. {<■) Infants of feeble constitution whose digestion is easily deranged, (il) infants that are acutely ill. Bi'fore attem[)ling to feed an infant, its feeding histor\' should be carefulh' taken to determine in which class the infant belongs. The methods of feeding these different classes of infants vary con- siderably, and while the same general principles hold, they must be applied differt'ntly. In all metlioils attention must be paid to percentage com- position of the food. This is not a difficult matter, and can be readily learned, but the skill and ability of the infant feeder have a chance for display when it comes to adapting the form of the protein, fats, and carbo- hydrates to the infant; or io modifying the action of the infanfs digestive secretions on its food by various additions to the food as exjilained on page 123. lu the suggestive feeding mixtures given here the ]n-e))aration of the food is sharply divided into two parts: First, adjustment of the quantitative or ))ercentage composition. Second, modifieation of the form of the food, or the action of the digestive secretions on the food. Food for Healthy Infants. The object in pi'cparing Food f(jr healthy infants is to so modifv or adajtt the food that they will be well nourished and have their digestive organs so de\'eloped that the inl'ants will become able to take «diole cow"s milk without digesti\'e disturbance. It is genei'alh' about the ninth to t«'el Fth montli befoi'e this is |)iissible. and if alkalies or antacids ha\'e been added to the food in too great (luantities it may be later, as these substances seem to interfere with the noi-mal develo])inent of the stomach. In reality the whole process amounts to a training of the infant's digestive organs, and it is important to commence in the early months with small quantities of the fat of cow's milk", as this causes the greatest amount of trouble, moderate cpiantities of ])rotein, and a liberal simply of earbo- liydrates, as these cause little digestive disturbance \\dien not given in too great excess. 'I'he fats ai'e ke])t in the neighborhood of 2-:) per cent, during till' whole period of artificial feeding, anil the carbobydi'ates at about (1 pel- cent, or 7 pel' cent., seldom over these figures. But the protein is jiiaiiaged in an eiilirely diU'erent inaniier. At first the protein is given PRACTICAL FEEDING. 133 in as small a qnaptity as 0.4 per cent., or about nnc-eiglitli as much as is found in cow's milk and about one- fourtli as nmch as in breast milk. As soon as a tolerance is establisbed the quantity is increased about 0.40 per cent, at a time until the infant is able to digest wliole milk with its .3.20 per cent, of protein. These advances in strength of food are made about a month apart. Tbere is no fi.xed rule, except to increase as rapidly as the infant can stand it. With some the advance can be quite rapid, while with otliers it must be made slowly. By this process the heat and energy portions of the food arc kept up to the highest point of -efficiency, while the growth-producing elements are at first given in less quantities than is desirable; but gradually they are brought up to a point where proper tissue formation becomes possible. If the protein is given in too great quantities at first, indiges- tion results and a period of greater 01' less duration ensues in which little growth can be made. For this j'eason it is better in tlie long run to slightly underfeed with protein for a short time and avoid digestive dis- turbances. In increasing the quan- tity of protein in the food it is often the case that the more the haste the less the speed. The following table gives an outline of the quantities and compo- sition of food wliich may be taken as a working basis in preparing food for healthy infants by the top milk method. ^ 1^ -^ 1-at •2 ^ oj " tU ^tl ll ■a N ° < s . O S3 Z ■B £ » 11 ■n a a ^^ o ID 3 a s ® CU CUM ^ 8 I a 1 m ■O J3 ■° !;; > " <-. III • „ e^l ol ° a St O o is o • ^— -. 1 1 " 11 1 "J.°I 1 t 1 3 •o s < e z !d . . Ill M ^ X 5 B ^3 « £ 2 3 *^ a a _ o Q. ai r. -Bf 3 S •ail P a 6 ? g •o g-c o 3 1 — .a S B 0) O gj o — OP o fi a t E( a a -0 p. o ^ . 3 ^ a II a o £ fi *■ C 1 ■■3 S o j; a o H c •5 pa o ■a be ^ CO o C>3 O t4 o o N i o —In 1S3 O 0t o CO N O N O o CI o CD o CD o Cl o CD bt 3 CO C3 3 3 f aa "3 3 i§ 0.0. 2? -S ho o 1—1 S] O o rtlfl c .— ( o o r/3 O -Iri ?3S w SI O -Iff CO N o O o o CO N o CD N O Cl ISl O CD 3, s O & o c 'y: ^^^ 'i. O fO O ts] O SJ O CO •— 1 X o o CD CO S] O Tf2 71 c f2 O o o O o CI a o H -a CO c > > oximate per- e composition o o o o o o o o o £' o CO CD C) o £5 o CO o CO CO '1 o I" c ■ o o o Cl ^ ■ o ci o 'X' Cl c Cl CO Mi2 c n 11 J - faO o ^ C.O o II ,71-. Sf o ■J. oi - be ? bO -f 3 Number and size of feed- ings for 24 hours N CO 1 O CO 1 1^ o 1 CO ° CD o T CD tsi o CO o I CSJ O O o CO 1 Cfi S] O O 00 1 >o - 8 O CI CO SI o CI CO O o SJ O 00 S3 o 00 S] O 0^ 7' '/i o o1 s CO G o s CD O -C -t" o a ■a & J3 Q O s x; Cl o c O a O J= Cl PRACTICAJ. I'-HEDING. 135 It will be noticed in the feeding table tliat less sugar is to be added to the food when gruel is used than when water diluent is employed. This is because the gruel contains considerable carbohydrates. A convenient rule to remember is, when gruels made with one ounce of flour to the quart are used, add 3 per cent, of sugar; and when two ounces of flour to the quart are employed, add 3 per cent, of sugar. These additions would be one thirty-third and one-fiftieth of the total quantity of the food, respect- ively. These proportions will always make the percentage of carbohydrates in the food between R and 8 per cent. ^K Tj* in Jp*' ^ > v^P ■ '■, ^ --^^m^ijl^^ll\ wm^"^'- Fig. 43. — Simple utensils for home niodiflcatioii. A rule often employed for adding sugar to food is, add 5 per cent, or one part to twenty parts of food. This will always make the percentage of carbohydrates fall between 5. .5 per cent, and 9.5 per cent, when water diluent is used and much liigher when gruel diluent is employed. One part of sugar to twenty-five parts of food makes the percentage of carbohydrates fall between 5 per cent, and 8 per cent, when water diluent is used. \Vben gruels are used to dilute the milk the percentages of protein in the mi.xtures will be greater than those given in the feeding table which are for milk and water mixtures. The protein added by the gruel not only increases the tissue-building value of the mixtures, but acts as a mechanical diluent or softener of the solid formed from the protein of the cow's milk, and hence makes it more digestible. As the value of gruels when used intelligently has become l)etter appreciated, they have come to be employed more and more, and whenever they are tolerated they should be useil in loG DISBASJiS OF C'HILDHEN. preference to water for diluting? tlie milk. Two kinds of gruels are em- ployed : (a) those made by boiling the cereal in water, which contain starch in an imclianged condition: (&) tlioge to wliich an agent for chang- ing the starch into dextrin and maltose is added. Grnels so made are called, respectively, plain gi-ttch and de.rtnnizciJ //riit'ls. Dextrinized gruels should be used for young infants and when plain gruels are not well borne. Directions for Making Gruels. — Sliv froiu one to four level table- sj)oonfuls of the cereal flour into one rpiart of cold water to avoid the formation of lumps. Place the mixed flour and water into a double boiler (Fio;. 44) and «itli cojistant stirring biing to a boil. This will Fig. 44. — PrmMe tioiler. cause the flour to swell up owing to the gelatinization of the starch. Xow allow the gruel to boil for tifteen minutes. Stirring will not be necessary. If an open kettle is use(l the gruel may bum at the bottom and impart a bad taste to the food. If tlje gi-uel is to be used plain, strain through a fine wire strainer and add enough boiled water to make one quart of gruel. If it is to be dextrinized set the cooker into cold watt'r for two or three minutes and when the gruel is cool enough to taste add a teaspoonful of some preparation of diastase. A decoction of diastase may be juade at home by covering a tablespoonful of crashed malted barley grains by a little cold water and placing the mixture in the refrigerator over night. In the morn- ing tlie water that is strained ofi' will be active in diastase, but will not kee|i long. A glycerite of diastase known as Cereo is now made for this jmrj)ose, and has pi'o\'en to be reliable. Stir and the gruel will become thinner as the staicli gf)es into solution and foiius dextrin and nuiltose. Strain and add enough boiled water to nudnfuls. Su.car. 2 teaspooiifuls. Six sui-li feedings in tbe twcnt,\ -fnur li.iurs. Babv si.\ to nine months olil. Milk, 12 tablespoonfuls. Water or barle.v w.iter, d talilesi nfuls. Sugar, 2 teaspoonfuls. (live five sueli feedings in tbe twent.\-f(iur huild u]i their strength, and when this is done place tliem on a more natural diet. There is more to feeding than coml)ining food elements in certain more or less definite propoi'tinns. A subtle factor in managing these difficult cases is the arousing of the dormant ]iowprs of digestion and assimilation of the infants. This is often accomplished hy a change in the flavor, taste, or physical condition of the food and in the form in which some of the elements are supplied. (See catalysers, p. 143.) So simiile a change as substituting dextrinized gruel for plain gruel of the same strength, in a modified milk mixture, lias sometimes had a good eflfect. The use of cooked foods, meat-broths, oi' other forms of food, such as ess: niixtures or l(>gume i'KAUTICAL FEEDING. 143 gruels, has also bvought about sudden and permanent improvement. Chem- ical analj'sis does not sliow what there is about the food that produces such changes in digestion and assimilation, but that different forms of food do have different effects on different individuals is an vmdeniable fact, well known to animal feeders, wlio find that b}' catering to the idiosyncrasies of individual animals, mucli better assimilation is brought about, and more economical use is made of the food. This comes under the head, or in the same class, as the fact that food served to an adult in an attractive, appetiz- ing manner will l)e digested much better than if it is served in an un- attractive, repulsive condition. Catalysers. That a mere change in the flavor or forui of food oftentimes produces a remarkable improvement in tlie assimilation of nourishment has long been known to investigators in the Held of animal nutrition, as well as to many pihysicians, and the n)Ost sti'iking results in difficult infant-feeding cases have come from tlie application of this principle although tliis fact has not always been recognized. Until recently, however, there has been no satisfactory explanation of this phenomenon, but experiments made to discover simpler processes of manufacturing cei'tain chemical products, which could only be obtained by indirect methods, have brought to light a factor in chemistry whose im- portance hitherto liad not been suspected, and which explains this peculiar effect on assimilation of a change in the form and flavor of foods. An illustration from actual experience will make the matter clear. It has long been Icnown tlmt certain cliemical products can not he produced by merelv bringing together their constituents in proper proportions. A mix- ture having the same chemical composition as the desired product can be obtained but no chemical combination is produced. However, the presence of some extraneous substance may cause the chemical combination to take place, although this substance does not enter into the combination ; remains unchanged, and can be used repeatedly for this purpose. Such substances are known as catalysers and a quantity so small as to be not detectable by chemical analysis is oftentimes all that is needed to cause certain chemical combinations to take place that would not occur in their absence. Now, these catalysers may become poisoned and lose their efficiency, and then either a new supply of the same catalysers must be had or a different one must be employed, for different substances may have the power to cause the same chemical combination to take place. After foods have been digested they must he absorbed and then com- bined chemically to form the tissues. The materials necessary to form the lii DISEASED (JE C'l-IILDUEN. tissues are well kiiovvn, but liovv to make tlieiu coiiibiue is not known. There are imdoui)te(lly eatal\'sers in tlie organism wliicli cause the chemical t-ombinations to take place and iiialiiutritiou is i)robably the result of their absence or of their being poisoned. A change in the character of the food may stimulate their production or present forms of food that they can cause to cond^ine. The remarkable results obtained in industrial chemistry with catalvsers in proilucing substanees which have heretofore l)ccn obtain- alile only by the action of living substances, seems to indicate that catalysts play a great jsart in nutrition. Food for the Acutely 111. Classification of Cases. — I'nder the heading of Acutely 111 it is intended to group only those whose illness is reflected in disturbances of the digestive organs m- by general malnutrition. Infants may be acutely ill with pneumonia or other infections and still not show special derange- ment of the nutritional functions. Again, as in gastroenteritis, there is an infection or intoxication which calls for more than dietetic treatment, so such cases will be treated under their respix'tive titles. Management of Cases. — In all of tliese cases it is of first import- ance to find something that will be retained, and before time is wasted in calculating a theoi-etically indicated mixture which may be rejected, it will be best to try some of the following ndxtures, which if retained, will serve as a starting-point in working np to a suitable food mixture. 1. Dextrinized barley, legume, oat or wheat gruel made with one ounce of flour to the quart, as directed on i^age 13G. If any one of these gruels agrees, the strength may be increased to two ounces of flour to the quart. Such gruels will contain about 0.80 per cent, pi-otein and .5 per cent, carboliydrates, except the legume gruel, which will contain about 1.5 per cent, proteins with about 5 ]X'r cent, carbohydrates. 2. Whey, made as directed on page 141. may be tried, which will contain about tiie same quantities of protein and carboliydrates as the gruels made witli two ounces of flour to the quart. 3. The white of one egg beaten up in eight ounces of water may be retained when notliing else is tolerated. Such a mixture contains about 1.5 per cent, of protein, but no carbohydrates or fat. Its nutritive value ia very small, and other substitutes should lie again tried. 4. White of egg and dextrinized gruel, made by beating up the white of one egg with ciglit ouiu'^'s of dcxtriuizi'd wlieat flour gruel (1 ounce to quart) will somelirues agree. If it is acceptable, one to two even tea- spoonfuls of granidated sugar may be added to the eight-ounee mixture. PRACTICAL FEEDING. 145 which will then have about the following composition : protein 2 per cent, and carbohydrates 6 per cent. 5. Yolk of egg and dextrinized gruel, made by adding the yolk of one fresh egg to eight ounces of dextrinized wheat flour gruel ( 1 ounce to quart), and if tolerated adding one to two level teaspoonfuls of granulated sugar, is highly nutritious and especially rich in blood making substances. If well borne in malnutrition cases legume flour may be used in place of the wheat flour. This will increase the quantity of nucleoproteids in the food materially. 6. Meat broths oftentimes arouse the appetite, and if acceptable may be nii.xed with dextrinized gruels made with two to three ounces of flour to, the quart, in equal parts, or tlicy may be thickened with tbo gruel flours by. stirring in an ounce of flour to the quaii of brotli and boiling. This will make a thick broth. Broths in themselves have, however, very little, nutritive value. To make broths, take one pound of lean mutton, veal, or chicken with some cracked bone and cut into small squares ; add one pint of cold water,; heat gentlv, and allow to simmer for about three hours. Strain and add enough boiled water to make a pint of broth. When cool remove the fat or skim it off while hot. The broth will be gelatinous when cold and should be served warm. 7. Beef tea is often useful as a digestive stimulant and is made by taking a pound of lean beef and cutting it into small pieces and allowing it to stand in a pint of cold water for an hour. It is then heated to not abovg 160° F., and the meat is expressed through cheese cloth. If heated to above this temperature the albumin of the meat will coagulate. If the coagulum i^ allowed to remain in the tea none of the nutritive value will be Inst, but if it is removed the tea will have little but flavor. 8. Beef juice is often a useful addition to other foods in cases of mal- nutrition, and may be made as follows : a. Slightly broil a thick piece of round steak that is perfectly free from taint. Cut into small pieces and press in a clean meat press or lemon squeezer. h. Cut the fresh steak into small pieces and just cover with cold^ slightly salted water, and set on ice for several hours. Then press by squeezing in a piece of cheese-cloth. The quantity of beef juice given should not be over one ounce in twenty- four hours, and "it is given to best advantage when added a teaspoonful at a time to other feedings, as in larger quantities the infant soon tires of it. 9. Eiweissmilch! One quart of whole milk is heated to 190° F. for three minutes and then cooled to body temperature. Add 3 teaspoonfuls of 10 146 DISEASES OF ClIII.DliEX. essence of pepsin to coagulate all of the casein. Break up the curd with a fork or spoon and allow to settle. The precipitated casein is allowed to settle and the liquid part is decanted. Straining the curd through linen or a wire strainer is impossible because the curd is of such consistency that the meshes of the strainer are (juickly obliterated so that no drainage takes place. After all of the liquid has been removed and only the curd remains tliis pre- cipitate may tlien be put into a wire strainer and the remaining portion of the whey allowed to drain off. This dry curd is then pushed through a fine wire strainer l)y means of a spoon, into one pint of buttermilk and one pint of water. After the curd is strained into an empty dish, the particles quickly adhere and you have gained practically nothing by straining. This precipi- tate must be strained into liquid in order to make use of the colloidal action so that these particles will remain separated. The buttermilk, water and curd is then strained again, put into glass Jars or bottles and kept on the ice. (Hvrif.) 10. Buttermilk. A pure culture of lactic acid bacilli is added to skimmed milk in an earthenware dish, and allowed to stand at about 70° F. for twenty-four hours, or until the casein is coagulated. Stir vigorously with a spoon or egg beater until the curd is very small, and then push the contents through a fine wire strainer with a spoon. If the buttermilk is too thick add a small amount of water. When the buttermilk is once made, a small portion (about four ounces ) 7nay be used as the inoculating agent for the next supply to be made. In this way the original culture may be made to last from six to eight weeks. The quality and action of product made will vary but little. Add the four ounces of buttermilk to the fresh milk, incubate and follow the above outline. Sometimes the milk will not coagulate al- though it mav smell sour. Stirring gentlv with a spoon will often produce coagulation in a few minutes. The fat present will rise to the top and when coagulated appears as a brownish yellow scum which may be removed before the curd is broken up. (TTinif.) If any of the mixtures just given agrees, attempts at adding fresh cow's milk, a teaspoonful at a time, may be made. If the milk is tolerated the quantity may be increased cautiously until it forms one-fourth of the mix- ture, when the fats may be increased and the infant can be put on a formula suitable for its age and weight. (See pages 134 and 137.) When all Attempts at Adding Fresh Milk Fail. AA'hen infants fail to tliri\'e nn any of ilie foregoiiig mixtures and all aitciiipts al gi\iiig fi'i'sli milk in aii\' (|uanlil\ fail, tln' fnllDwing mixtures may be iried and often arc Itiglily successful. \\'liciic\-cr the J'noils that are PRACTICAL FEEDING. 147 cooked are used, a teaspoonful or two of beef juice or orange juice should be given daily, as on such foods infants are liable to develop scurvy. Formula No. 1. Wbole milk 12 ounces Wbcat or oat gruel flour 4 level itablespoonfuls. Granulated sugar 2 level tablespoontuls. ''alt 1 pinch. Cold water 22 ounces. Mix cold aiul with eonstant stirring slowly bring U> a boil and boil for three minutes. Strain and add enough boiled water to make thirty-two ounces. Feed quantity appropriate for age. For young infants or very delicate ones the food may be diluted with one i)art of water to two parts of the food. Approximate Composition. — Fat, 1.5 per cent; carbohydrates (starch, milk- sugar, cane-sugar), 7 per cent.; protein, L.^j per cent. By using the top 16 ounces from one quart of milk and taking 12 ounces of this instead of whole milk in the above mixture the percentages will be : Fat, 2.5 per cent. ; carbohydrates, 7 per cent. ; and protein, 1.5 per cent. Formula A'o. 2. Whole milk 12 ounces. Wheat or oat gruel flour 4 level tablespoonfuls. Glycerite of diastase (Cereo) 3 teaspoontuls. Salt 1 pinch. Cold water 22 ounces. Mix cold and with constant stirring bring slowly to a boil, and boil for five minute.s. Strain and add enough boiled water to make 32 ounces. Feed quantity appropriate for age, or dilute two parts of the food with one part of water for very young or delicate infants. Approximate Composition. — Fat, 1.5 per cent.; carbohydrates (soluble starch, dextrin, maltose, milk-sugar), per cent; proteins, 1.8 per cent. If top 16 ounce milk is used instead of whole milk, the percentage of fat will be 2.5 per cent. With both of the formulas above it will be better to begin with whole milk and increase to top si.xteen ounce milk if digestion is good. Keller's malt soup is a mixture similar to the above. The carbohydrates in the mixture are starch, maltose, and milk-sugar. It is prepared as follows : Wheat flour 2 ounces. Whole Milk 11 ounces. Mix and rub through a fine strainer thoroughly. In another vessel add to 20 ounces of water, and ?, ounces of malt extract (Keller uses Liebig's), warm to 120° F. and add 2i drachms of a 11 per cent solution of bicarbonate of potash. Now boil these together. The approximate composition will be: Fat, 1.2 per cent. ; proteins, 2.0 per cent, and carbohydrates, 12.1 per cent. A few eases may be met in which no food previously suggested agrees. In these cases condensed milk, peptonized milk, or buttermilk may solve the problem. Condensed Milk Mixtures. — Fresh condensed milk is to be preferred, but if unobtainable the best brands of sw^eetened condensed milk should be employed. A teaspoonful of condensed milk to four ounces of plain or dextrinized gruel may be used at the start. If this is well borne, the quan- 148 DISKASIB OF t:iIlLDREN. tity of condensed milk should be rapidly increased until two to four tea- spoonfuls to four ounces of diluent are used. Tlien equal parts of top milk and condensed milk should be mixed and used for dilution, which may be reduced until one part of this mixture is used with five parts of diluent. Peptonized Milk. Warm Process. — (1) Empty into a clean quart bottle the contents of one of Fairchild's peptonizing tubes; (2) add four ounces (eight tablespoonfuls) of cold water; shake, and (3) add one pint of cool fresh niilk and again shake; (4) place the bottle in water not too hot to be uncomfortable to the hand for ten minutes. Then either place on ice or boil to prevent further digestive action. This milk is likely to taste bitter. Cold Process. — Prepare the bottle as before, but set on ice without warming. This milk is only partially peptonized so will not have a bitter taste. Buttermilk. — For temporary use buttermilk has a liuiited field. It is best made at home by using a pure lactic acid ferment. Natural buttermilk contains little fat, as tliis has l)een removed as butter. In making buttermilk the cream may be removed and the ferment added to the skimmed milk, OT whole milk may be used (see 10, p. 146). Two types of buttermilk food are employed. First, the raw butter- tnilk, which contains enormous numbers of lactic bacteria; second, butter- milk to which one ounce of flour (four level tablespoonfuls) is ad; bottle, prefer- able type. Fic. ii>. Freeman pasteurizer. may cause disturbance of tlie infant's digestive tract. Old pasteurized milk should never be used. Fresh food should be made every day. Administration of Food. — Reguhirity in feeding should be insisted tipon. The food should be slightly warmed by placing the bottle in warm jQv A A J-j-.^-: -^ Fici. 47. — Ildiiie-iiiiide pasteurizer. (A'h.sxp/?. ) Fto. 4S. — Pasteurizer for bottled mil (Russell.) water for a few minutes. Kight feedings should not be warmed before retiring and kept warm. This is a pernicious practice. The cotton stopper is then removed and a black rubber nipjile should be placed on the bottle. PRACTICAL FEEDING. 153 which should be inverted to see that the hole in the nipple is large enough to allow the food to drop slowly, but not so large as to permit the food to run in a stream. The mother or nurse sliould be cautioned not to put the nipple in her mouth. By allowing the food to drop on the wrist it will be possible to determine whether it is too hot or too cold. The infant should not be over twenty minutes in taking its food, and if satisfied will drop off to sleep. Never use the food that may be left in the bottle, but throw it away. If a considerable portion of the food is left in the bottle the nipple should be examined to see if the hole is too small or lias become clogged. Care of Utensils. — After preparing food the dipper, double boiler, bottles, spoons, and all articles that have been used should be washed, first with cold water, and then with soap or washing compound and hot water, and then scalded. The bottles should be cleaned with a brush (Fig. 49), and after being scalded should be kept inverted until ready to be filled again. The nipples should be thoroughly washed and kept lying in a cup of water in which a good-sized pinch of borax has been dissolved, after they have been sterilized. Examination of Stools. — The mother should be taught to examine the stools and to report to the physi- sian the appearance of anytliing abnormal, as change of color, diarrhea, the appearance of curds or of mucus. The mother should not be taught that these are alarming symptoms, but that they indicate something is wrong and needs attention. Fig. 49.— Bottle brush. How to Interpret Results. Weighing the Infant Important. — Infants should be weighed at regular intervals in about the same clothing, as steady gain in weight is one of the indications that they are thriving on their food. But judging the value of a food by the mere fact that it causes gain in weight is quite wrong, as the gain may be only in fat. The composition of the food, the general development and gain in weight should be taken into consideration, and no infant should be dismissed nntil its food contains considerably over one per cent, of protein and it is gaining in weight on it. The gain in weight is greatest in proportion during the first few months, as fond is assimilated more completely at this period, as has been explained on page 12.5. Just how much an' infant should gain each week 154 DISEASES OF CHILDREN. cannot be stated definitely, as infants vary in tliis respect. Some will gain a pound and others not over two ounces, but tlie latter gain is too small for a healthy infant. Six ounces is a good gain. If the food is agreeing the Cjuantity or strength ]uay be increased cautiously to see if greater gain will result, but this plan must not be pushed to an extreme, for loss instead of gain may result. A record of the weight should be kept. Weight charts have been prepared on which is .shown the ''normal weight curve" deduced from the average gains of a large number of infants. It is better not to use this style of weight chart, as few infants pass their first year without some ups and downs, and the sliglitest variation from the " normal curve " is a «ause of worry and anxiety to the motlier and through her to the physician. Feeding in Hot Weather. — Upon the advent of hot weather special precautions should be taken to forestall attacks of gastroenteritis. The means for keeping the food cool should be looked after, and tested with a self-registering thermometer, or the food should be kept packed in ice to make sure it is kept cool. Pasteurization is a safeguard, particularly if ice is not available. If the infant has a tendency to indigestion or to vomit- ing, the amount of fat in the food should be reduced. One or two feedings of gruel used as the diluent may be put up, and given as night feeclings or as substitutes when milk feedings seem to disagree. If the air is humid and the temperatui-e higli, the infant shotild be given a sponge liath twice a day. The excess of body heat is excreted by the evaporation of perspiration, and this is retarded by high humidity. And unless tlie skin is kept clean and free fi'om the residue from the evapo- ration of ])ei'spiration, this will also retard evaporation. Feeding when Traveling. — Changes in the food are risky at any time, and es]iecially so when traveling. A good plan to follow is to have the regular food pre])ared and packed in ice to insure thorough cooling and then to place it in vacuum bottles. The bottles should be filled right up to the stopper, otherwise the agitation of the food will churn the milk so that the fat will se]3arate as butter. Several of these bottles will be required if the journey is to last several days. If there is a question about the food being kept cool, it should be pasteurized, then cooled or iced if possible, before being put into the vacuum bottle. These bottles will keep food cold for about seventy-two hours. The food foi- the infant can be poured from the vacuum bottle into a clean nursing bottle and warmed as wanted. But the food should be slightly shaken so as to mix the cream which will have risen to the top with the remaining inilk. The food should not be warmed and then ke)it in one of these bottles to save wanning. Milk soon spoils if kept warm. PRACTICAL FEEDING. 155 For a single day's journey the food may be put up as usual in the home and boiled and put in a pail with cracked ice around the bottles. When it is not possible to have the foregoing directions carried out, one of the best brands of sweetened condensed milk diluted with boiled water may be used. The boiled water may be carried if it will not be obtainaljle during tlie journey. Dried milk is also available. (See p. 1.5G.) Feeding when Away from Home. — During the heated term large numbers of families leave the cities and live in the country at boarding houses, hotels, or in their own homes. In many of the more remote dis- tricts the milk-supply problem has not yet been solved, and much disturb- ance may be caused by milk which has been improperly handled through ignorance. In such instances the mother should make an arrangement with some milkman or farmer to supply milk produced under sanitary condilions. The farmer should be instructed to clean the cows as thoroughly as he cleans his horses, to wipe the belly and udder with a damp cloth before milking, to wash his hands before milking, and to reject the tirst two or three jets from each teat. The milk pail should be well washed and scalded after being used, and kept inverted in the sun. As soon as the milking is finished the milk should be mixed, as it is not uniform in composition as it leaves the cow, and then poured into quart milk bottles. These should be set in ice- water, or if this is not obtainable, into cold well water which rises nearly to the tops of the bottles. The milk can he delivered in the morning in time to prepare the food for tlie day, first pasteurizing or scalding it. Such milk will cost more than the ordinary milk, but it is worth all it costs, and will be found cheaper in the end. The motlier should see for herself that the milk is produced under cleanly conditions. She would not tolerate a filthy wet-nurse for her infant and should not allow her infant's food to come from a filthy cow. Feeding Among the Poor. — The preparation of food or even obtain- ing suitable food materials is often a perplexing problem among the poor and in the tenements of large cities. The intelligence of the mother may be limited, and even when the mother is capable of carrying out directions the facilities for preparing food and keeping it cool are wanting. Some families are too poor to buy clean bottled milk at ten cents a quart, and oftentimes such milk is not offered for sale in the poorer sections of a community. Correct dietetic principles must be applied as best they can be. Where good milk can be obtained, but careful modification cannot be expected, the food may be made with whole milk and gruel, using one-fourth, one-third, ]5G DISEASES OF CHILDREN. .-inil one-half milk ami adding one part of granulated sugar to thirty-three ]iarts of food, or two level tahlcspoonfuls to the quart of food. ( See p. 137.) AVhere good milk is iinohtainable, condensed milk may be used with Avater or barley gruel iiuule with one ounee of flour to the quart. The milk sJiould be diluted 8 to 15 times, that is, one part of condensed milk to 7 to 14 parts of water or gruel. No sugar is to be added. Cod-liver oil or olive oil can be given daily, one teaspoonful three times a day, to supply the fats. Infant's Food Dispensaries, — The unsatisfactory results obtained in infant-feeding among the tenement population, owing to improper prepara- tion of food or lack of suitable food, has led to the establishrrient of food dispensaries in the crowded sections of many cities. There are three types of these feeding stations: (1) Tliose at which a few formulas of modified milk may Ije obtained in nursing bottles by anyone who applies for them. (2) Tliose at which modifications of milk are given by trained physicians who examine the applicants and aim to give a formula wliich is likely to agree. (3) Those at which the food is prepared for each infant while it waits, upon the prescription of the attending physician. The feeding stations at which food is dealt out without taking into consideration the condition of the infant are not to be encouraged, for while they do much good, they also do harm. During the heated term feedings of plain and dextrinized gruels made with one to two ounces of barley flour to the quart should be kept on hand to be given when milk feedings disagree ; for infants that are quite sick they may be diluted once with boiled water. Dried Milk. — These milks are of various kinds, depending on the mode of manufacture and as to the amount of milk sugar and fat they contain. Tlie milk is evaporated until it is in the powdered form and needs only tlie addition of hot water. The Honor Brand milk is low in fat, i. e., 13 per cent, in the powdered form, which is rather advantageous in infant feeding. It is sterile and will keep for many montlis. In certain localities where fresh certified or wholesome milk is not obtainal)le it is quite valuable and much less expensive. Fifty calories per pound per day are furnished by giving three leveled tablespoons of the dried milk for every pound of the baby's weight. A well nourished infant needs approximately only 30 to 40 calories per pound. The food is freshly jnade for each feeding. CHAPTET? XVI. DIET DURING THE SECOND YEAR. By the beginning of the second year the infant's digestive organs should be sufficiently developed to warrant giving some soft food. The greatest amount of trouble will be caused by cereals whicli are not properly cooked. Fig. .50 shows a cross- section of an oat grain. It will be observed that the protein and carbohydrates are in- closed in cells. These are composed of cellu- lose which is indigestible, and they must be ruptured by cooking before tlie digestive secretions can get at their contents. Fig. 51 shows what takes place when cereals and vegetables are cooked properly and too much emphasis cannot be laid upon the importance of thoroughly cooking cereals. Oatmeal par- ticularly should be cooked in a double boiler several hours. Flours do not need such long cooking. ' The following schedule has been arranged as a suggestive scheme for the feeding nf older normal childi-en: Fig. 50. — Section of oat grain, c. protein layer ; d, starch and protein. {Good- ale.) Fig. ."il. — Rupture nf starch .srains by eoolviiis. { rAiiif/irortli ii. i Many children are indiscriminately fed, and the physician being unfamiliar with the kind of food suitable and agreeable to the child neglects to supply directions as to the dietary. Changes should be made in the list 157 15S DISEASES OF CHILDREN. if there is illness, habitual constipation, or ditfictilty in digesting certain forms of food. It should be recollected that the child can be trained to like almost every suitable article, and it is a mistake to cater to their likes and dislikes if they are not developing and gaining weight. ITnder their respective sections changes in tlie character of the food have been suggested where they liave any liearing on tlie progress of the disease. Dietary. Twelfth to Eighteenth Month. — Select from the following articles: First inenl — on arising. Juice of a sweet orange, one to two ounces. Pulp of six stewed prunes. Pineapple juice, one ounce. Milk, eight ounces, zwieback, toasted biscuits (as Huntley & Palmer's), stale toasted bread. Second meal — during forenoon. Milk alone or with zwieback. Noon meal. Soup uuide of chicken, beef, or mutton, six ounces; or beef juice three ounces. Stale or toasted bread nuiy be added to the above. Fourth iiinil — afternoon. Milk, or toasted bread and milk. • Eveiiiiuj meal. fTrnel made of oatmeal, farina or barley, taken with whole milk, four ounces of each. Apple sauce or prune jelly. Zwieback. Eighteenth to the Twenty-fourth Month. BrealfasI . .Tuicc of one sweet oiange. Pulp of six stewed prunes. Pineapple juice, one ounce. A cereal, such as cream of wheat, oatuu»al. farina, or hominy preparations with top milk (top Ki o/.). Sweetened or salted. A L^lass of milk. DIET DURING THE SECOND YEAB. 159' Forenoon. A glass of milk with two toasted biscuits or zwieback. Dinner. Broth or soujj made of beef, mutton, or chicken and thickened with peas, farina, sago or rice; or beef juice with stale bread crumbs; clear vegetable soup with ^olk of one egg; or egg, soft boiled, with bread crumbs, or the egg poached, or a baked potato. A glass of milk. Dessert. — Apple sauce, prune pulp, stale lady-fingei's, or graham wafers. Supper. Custard. Cup of milk warm or cold. Stewed fruit. Zwieback. Two to Three Years. Brenkfast. Juice of one sweet orange; pulp of six stewed prunes. Pineapple juice, one ounce, or apple sauce. A cereal, such as oatmeal, farina, cream of wheat, hominy, or rice, slightly sweetened or salted as preferred, with tlie addition of top milk (top 16 oz.) ; or a soft-boiled or poached egg with stale bread or toast. (If there is a tendency to constipation give the fruits before breakfast with water ; if not, they may be given during the forenoon if preferred.) A glass of milk. Dinner. Broth or soup made of chicken, mutton, or beef thickened with arrowroot, split peas, rice, or with the addition of the yolk of an egg or toast squares. Scraped beef, white meat of chicken, l)roiled fish (halibut is free from bones) . Mashed or baked potato, fresh peas, spinach, asparagus tips. A glass of milk with educator crackers. Huntley & Palmer biscuits or graham wafers. Dessert. — Apple sauce, baked apple, rice, junket, or custard. 160i DISEASES 01'' CHILDREN; ,, i.i Supper. ... \. ''. stewed fruit. A cereal or egg (if not taken for l)reakfast) ; bread and milk; or custard ; cup of warm milk or cocoa; crackers or zwieback. Three to Six Years. Brecdfiisf. Fruits. — Oranges, cantaloupe, apples, or stewed prunes. Cereal. — Oatmeal, liominy, rice and wheat preparations, well cooked and salted, as described on jiage IT)?, with thin cream and sugar. Eggs. — Soft boiled, poached. Milk. — Milk or cocoa to drink. Dinner. Soups. — Reef, cliicken, or mutton, or milk soups. Meat. — Chicken, Ix'efsteak or roast beef, lamb chops, fish. Yegetaliles. — Spinach, carrots, string beans, peas, cauliflower tops, mashed or baked potato, asparagus tips. Bread and butter (not fresh bread or rolls). Pessei't. — Custai'd, i-ice or bi'ead pudding, tapioca, ice cream (once a week), prune souttle, or baked apple. Milk. Supper. Milk toast, or a thick soup, as pea, or cream of celerv, or a cereal and thin cream. Egg. Stewed fruit, custai'd or a plain pud- ding, graham crackers and milk. Suggestive Diet List Suitable for Children's Hospitals. Moinfiiii. Breakfast. — O.-itiiical, bread and butter, milk. OimiPr. — r.eef soup, chicken, iiiaslied potatoes, bread and l>utter, porn starch puddiiii;, milk. Supper, — P.read and liuttcr, milk, apple sauce. ... Tiicudiiy. Breakfast. — E,u,ss, bread and butter, milk. Dinner. — Cliicken soup, cbickcn, m.asbcd potatcjcs, bread and butter, rice pudding, milk. Supper. — Bread and butter, jnilk, stewed jirunes. Wrdiir.idii!/. Breakfast. — Hoinin.v, bread and butter, milk. Dinner. — Beef soup, roast beef, mashed potatoes, bread and butter, bread pudding, milk. Supper. — Bread and butter, jam, and milk. DIET DURING THE SEOOXD YEAR. 161 TliKisday. Breakfast. — Eggs, bread and butter, inilk. Dinner. — Beef soup, cbicken, mushed potatcies, bread and butter, ire cream, milk. Supper. — Bread and Iratter, ,iam, and milk. Friildj/. Breakfast. — Oatmeal, bread and liutter, milk. Dinner. — Mutton broth, ro.-ist mutton, mashed potatoes, bread and Imtter, cus- tard pudding, milk. Supper. — Bread and butter, milk, apple sauce. Satiinhiy. Breakfast. — Hominy, bread and butter, milk. Dinner. — Beef simp, roast lieef, mashed potatoes, bread and butter, chocolate pudding, milk. Supper. — Bre;id and butter, milk, stewed prunes. Sniidaii. Breakfast. — Oatmeal, bread and butter, milk. Dinner. — Beef soup, roast beef, mashed potatoes, bread and butter, ice cream, milk. .Supper, — Bread and butter, milk, .ielly. Suggestive Diet Lists for Day Nurseries and Creches. Group 1 (Bottle-weaued babies). Milk (^Yhole milk). \Yarm or cold, S ounces. Farina gruel with milk and sugar, zwieliack. Beef or mutton soup, thickened with toast crumbs. Orange .iuice, 1 ounce. Apple sauce. Prune pulp. Amount needed daily — tlu-ee meals — 24 ounces milk, 10 ounces soup, zwie- back, 2 pieces, fruit, one kind. (jROirp 2 (" Runabouts "). Milk. Zwieb.ack or toast, or stale bread. Soft-boiled egg. Farina, cream of wheat, oatmeal. Soup, beef or mutton thickened with split iieas, rice, or f.irina. Baked iiotato, mashed potato, carrots, beets. Custard, cornstarch, farina pudding, apple sauce, prune .jelly, or apple butter. Amount required daily, three meals. 3(1 ounces of milk, one cereal, one vegetable, one soup, bread, one fruit. Gkoup ?, (Kindergartners — two meals). Bowl of crackers and milk, f.-irina, oatmeal. Beef or mutton stew. Eggs, soft-boiled or scrambled. Mashed potato, peas, carrots, beets, cauliflower. Kice pudding, cornstarch pudding, liaked apple, apple sauce, prunes. Amount required, three cups milk, soup, vegetable, bread and butter, cereal or pudding. 11 162 DJSK.ASES OF CHILDREN. Gkovp 4 (School age). Sou] I, lieef or mutton. Beef or mutton stew. I'otiito (miislied), siiinaeli. carrots, or l)eets. Bread and butter. I'uddin};. t'ariiia, rice, cornstarch. 4 p. M. Milk, cocoa. Bread and butter, jam. Kaw aj)iiles. Diet During Later Childhood. The period of growth from early childliooil to pubei'ty requires careful oversight of the nuti'itioii. The chihl must be regularly trained in all the hygienic details of feeding, including slow eating and the avoidance of strenuous e.xercise just before or after eating. The diet requires a large amount of protein owing to the rapid growth, and this must he supplied principally by the oidinary meats (beef, mutton, and chicken) and such vegetables as peas and beans. All the cereals will also supply some protein with a large amount of starch. The heat- and energy-producing foods (starches, sugars, and fats) may be suii]3lied in the form of potatoes, cereals, fruits, and fats fi-om milk or meat. It is very desirable to train the child to take a varied and properly balanced diet, which includes all the foods in common use. Thus if very much meat is taken to the exclusion of carbohydrates, tlie ])i'otein will be emploved too largelv in oxidation to produce body heat instead of in building tissue, and hence growth may be retarded. A certain amount of the carbohydrates acts as protein sparers, and tlius allows the pi'otein to be used entirely in its propei' function of building tissue. This is an exam]ile of the desirability of a properly bal- anced diet. The green and succulent vegetables and fndts also have an important function in nutrition, as is seen in cases of scoi'liutus where there has been a long deprivation of these articles of diet. Lesser degrees of malnutrition result if they are not taken in ]3roper amount. The two usual cycles of growth, nameh', at the secoud (b'utition and adolescence, require an es])cciallv generous diet. l!a]iid gi'owth alwa\s uses up nutrient material and hence calls for food I'icb in protein, otherwise various grades of anemia arc liable to result. Dietary Suitable for Children After the Sixth Year. Soups. — Beef liroth, chicken broth, mutton broth, oystei' broth, bouillon, milk soups, purees of vegetables, legumenosc sou|)S. Vegetables. — Teas, carrots, spinach, baked potato, mashed ]iotato, stewed potato, celery, string beans, lima beans, beets, beet-tops, i-liubarb, sfpiash, ])umpkin, lettuce, endive, stewed tomatoes. DIET DURING THE SECOND YEAR. 163 Eggs. — Soft-boiled, poadied eggs, scrambled eggs, omolet (plain). Sea Food. — Kaw oysters, steamed oysters, boiled fish, broiled lish. Meats. — Beefsteak, roast beef, roast chicken, minced chicken, boiled chicken, broiled chicken, roast mutton, roast lamb, lamb chop, turkey, squab, sweetbreads. Farinaceous. — White bread, whole wheat bread, gi'aham bread, coi'U cake (not hot), gems, toast, plain crackers, educators, zwieback, farina, cream of wheat, oatmeal, rice, hominy, macai'oni (plain), spaghetti ( plain ) . Fats. — Cream, butter, olive oil, peanut ])utter. Beverages. — ■ Milk, topmilk, buttermilk, cocoa, matzoon. Dessert. — Stewed fruits, baked custard, bread pudding, cornstarch pud- ding, rice pudding, tapioca pudding, junket, plain cake, ice cream. Fruits. — Itaw apples, baked apples, apple sauce, stewed prunes, stewed figs, pears, peaches, grapes, oi'anges, grape-fruit, melons, strawberries, rasp- berries, blue berries, blackberries. Suggestive Diets for Special Conditions. Diet after an Attack of Eecuhkent Vomiting (for i Years ok Over). May hare for ilie first tivo weel'S the following: Oatmeal, Pettijohn, farina, cream of wheat, rice, yellow corn meal, milk t(jast, graham bread (stale). Baked apple, apple sauce, stewed prunes, stewed tigs. Purees of vegetables, as celery, spinach, carrots, peas, baked or mashed potato. White meat of cliicken, sweetbreads. Junket, baked custard, cornstarch pudding, bread ]]udding, blanc mange, home-made ice cream (once a week), milk after removal of top 2 oz., cocoa, buttermilk. May have after two weels the following in addition: Steamed oysters, broiled fish, butter, spinach, peas, lettuce, rice pud- ding, mutton broth, chicken liroth. Eggs. — Soft-boiled, coddled, drojiped. Lamb chop, beefsteak, roast beef, chicken (roasted, mmced, boiled or broiled). Beets, carrots. Stewed apples or stewed pears. 164 diseases of children. Diet to Overcome C'cnstipation : Suitable for a Child 8 Years Old. Brcal'fa^l. Juice ()[ a sweet orange, or six stewed pi'uiies, or balran and flour last. Moistrn the soda with a tablcspoonful of warm watiT. llix all toKi>tber. I3akc In moderate oven. (Do not get too stiff.) Diet .\fter Diarrhea Attack in Older Children. Skimmed milk boiled, baked potato, white meat of chicken, macaroni, farina, liominy, rice, toast, arrowi'oot crackei'S, soft eggs, cold boiled water. DIET DURING THE SECOND YEAR. 165 Wlien stools become formed allow : Lamb chop, rare roast beef, strained apple sauce, carrots creamed, milk (remove top 2 ozs. of tlie cream and pasteurize). Then gradually resume regular diet. Diet List for Obesity. (Prepared for 10-year-old child.) Breal'fast. 1 orange, 3 pieces of toast or 4 pieces of bran bread, 1 butter ball, fish (except salmon or eels), 1 glass of milk (hot or eold). Dinner. One of the following soups: Bouillon, consoiiiiiic, julienne, or any thin soup. 4 tablespoons of white meat of chicken, or 2 ounces of rare roast beef, or 2 ounces of rare mutton (very lean). Liberal helping of sti'ing beans, spinach, celei'y, kale, cauliflower, cab- bage, beans, asparagus, young onions, tomatoes, plain lettuce or with lemon juice, sour grapes (tart), orange. Supper. 1 or 2 soft-boiled or i)oachcd eggs, 3 slices of bran bread, or 6 graham crackers. Drink very little water, cup of cambric tea, cut up oranges. AVater taken preferably between meals if necessary. If very liungry upon retiring, may have a glass of skim milk and 5 graham crackers. To be judiciously increased as excessive weight is lost. Diet PREPOxnERATixG ix Carboity'drates. (Al~o suitable for nephritics.) (Pre])ared for .'i-vear-old cliild.) Brealfrist. Juice of a sweet orange, or six stewed prunes, or baked apple, or 4 ozs. of apple sauce; 4 ozs. of a cereal, as oatmeal, farina, rice, sago, hom- iny, corn meal witli butter; stale bread and butter, wheat bread, graham bread, 2 ])ieces. Dinner. ?, tablespoons of carrots, 1 medium size mashed or baked potato. 3 tablespoons of t)eans, peas, sweet potato, beet greens, cauliflower, 166 DISEASISS OF (JHILDREN. ct'lcry, sijuash, beets, grahaiu bread or graham cracker, 2 pieces; macaroni or spaghetti, 3 tablespoonf uls ; stale bread and butter, 2 slices. Desserts. — ^ Apple sauce, 4 ozs. ; baked apple; plain rice pudding, 4 ozs.; tapioca pudding, 4 ozs.; cornstarch pudding, 4 oz., or arrow- root pudding, 4 ozs. Supper. Stewed fruit, 4 ozs. ; a cereal, 4 ozs., or peas or green vegetables, 3 tablespoons (whole wheat bread or graham bread if constipated). After the two weeks may be added the foHowing: Whole orange, 1 egg, soft, coddled or sliirred. Eacahout. — 1 tablespoon to 6 ozs. of water, once daily. Milk, 1 pint for entire day. Peanut butter, 2 teaspoons every other day. An elastic dietary slip such as the following, prepared by Dr. C. H. Smith, can be readily adjusted by tlie practitioner to suit the needs of the individual child : Diet List. Date Diet for Breal-fad. At Fruit: Orange juice, or cooked apples, or stewed prunes, or stewed dry peaches. Cereal (.... tablespoonf uls ; no sugar): Oatmeal, wheatena, malt breakfast food. Pettijohn's, com meal, cream of wheat, farina, hom- iny, rice. Cook two or three hours, night before, in double boiler. Milk: .... cups (put part on cereal), or weak cocoa. Toast, or zwieback, or bread, and butter. Egg, soft boiled, ])oached, or scrambled (without butter). Dinner. At Soup: P>roth or any cream soup may be given, if not greasy, but there is not Miucli food in soup. Do not make this the main part of the meal. Meat : One of these : P)cef steak (bi'oiled), chopped beef (cooked dry in pan with no grease nor butter). PoaMt beef. DIET DUKING THE SECOND YEAK. 167. Eoast lamb, lamb chop (broiled or cooked in pan with no grease nor butter). Chicken, roast or broiled (no gravy). Fish, boiled cod or halibut. Vegetables : Give .... tablespoonfuls of each, green and white, every day. Green : Spinach, peas, stewed celery or knob celery, oyster plant, car- rots, string beans, lima beans, squash, beets, greens, turnips, aspar- agus tips, stewed tomatoes, cauliflower, parsnips. White: Potatoes (boiled, baked, mashed, creamed), sweet potatoes (boiled or baked), rice, macaroni, hominy. Toast or stale bread. Dessert: .... tablespoonfuls of rice or bread pudding (no raisins), junket, custard, cornstarch, gelatine, ice cream or cooked fruit. Bupjicr. At Cereal, .... tablespoonfuls ; milk, .... cups ; toast or stale bread. Or, bread, .... slices, and milk, .... cups, or uiilk toast. Or, soup and bread, .... slices, and milk, .... cu[)s. Or, egg, ..... and toast and milk. And cooked fruit : Apple sauce, baked apple, stewed prunes or stewed dried ywaehes may be given with any of the above. Give .... table- spoonfuls. You Mcnj Also dive: At : Orange Juice or grape fruit juice. Raw apple, scraped. At : Broth and crackers. At : Graham crackers or At : Milk, .... cup. Water. One glass may l>e taken with each meal ; never any more at meals. Water should be given between meals, but not at bedtime. Boil the water and put on ice to cool. Do Not Give: Tea, coffee, soda water, beer, wine, whiskey, cider. Fried food of any kind (meat, potato, eggs or fish). Pork, veal, kidneys, greasy stews. Gravy made from grease or drippings. Dish gravy (meat juice) is all right. 168 DISEASES or CHILDREN. Cand\'. It is easier to give none at all. "A little " always means too mueli. Sugar, jellv, sweet preserves. Fresh bread, ealie, 2)ie, fried cakes, ricli puddings. Nuts, I'aisins. Bananas, berries, clierries. Give no raw fruit of any kind in very hot weaflier. Eaw apples uiust always be scraped witli spoon or knife. Corn, cabliage, cucuiiibcrs, egg plant. Too iiiucli milk. One quart a day at uiost is enough for any child. Bules for Edtinij: Make cvei'v child 1. Wash hands and face before meals. 2. Eat slowly and chew food Avcll. 3. Eat neatly. No child is too young to learn good manners. 4. Eat what is |)ut before it. Let it go Iningiw if it will not eat proper food. Give no food that is not on the list. 5. Prink little water with uieals. Do not let it wash food down with water or milk. 0. Eest after meals half an hour. 7. Eat only at meal times. Give no food between meals unless ordered li\' doctor. Serve food wai m and well cooked on clean dishes and clean table. Keo]] flies away from food. One fly can give tyjjhoid or summer com- plaint. Good 1(1(1(1 is as cheap as poor food. Do not s]Mii] good food by frving. Do not give a child tea, copf'ee. or beer, and think they are food. Tliey arc not nouiislnr(g at all. and do much harm. Milk is the best food, liut spoils easiest. Buy only bottled milk, and keep on the ice always. S''7io fear of being late and get exliausted bfl'ore ilie end of tlie day. It is desir- able to have hot soup or cocoa at school ; it is then eas\- to supplement this. If, however, he must carry the whole luncheon, it must be a nutritious as well as an appetizing one. Suggestions for a Ijasket luncheon : The most feasible are sandwiches, dessert, fruit, and a bottle of milk. For sandwiches use the mo;oup. with carrots, beans, onions Spinach with poached egg Corn bread and butter Four dates Bake'l potato Bread and butter Stewed apricots Cottage cheese Cornmeal with milk Toast and butter Apple sauce Milk to drink Rice and meat loaf Ki and detailed feed- ing lists su)»plied. Milk and eggs made palatable (see diet lists) should be forced if necessary. An antiscorbutic diet, such as is described under infantile scorbutus is particularly serviceable in these cases. Medicinal treatment is confined to the use of the chlorate of potash in 3- to 3-grain doses, three or four times a day. It is better not to write for more than a three-ounce mixture, as the potash may affect the kidneys if given for too long a period. Gangrenous Stomatitis. (Noma. Concriim oris.) Definition.— A rapidly developing and usually fatal sangrpue, beginnina; in the cheek. Etiology.— No specific organism has as yet been satisfactorily proven as the causative agent. The disease occurs in cliildren only, most often between DISEASES OF THE AKJl'TH. 1^'^ the ages of two and five years and rarely in nurslUiKs. CliiUlren living in bad bygienic circnnistunces that have liad their resistance niueh lowered liy [ireviou.s diseases, especially those that have been confined to hospitals and asylums, are more prone to the affection. It may follow measles, diphtheria, typhnid, ulcer- ative stomatitis, scarlet fever, enteritis, pneumonia, pertussis, tuliereulosis, etc. The greater uumljer of cases occurring in this country have followed severe cases of measles, and in the ei>i(lemic form in institutions, it ma.v there even follow mild cases. Symptomatology. — A putrid odor from the mouth may be the tirst s.vmp- tom to attract attention. Ins])ectiiin ma.v then disclose a stom.-ititis as a fore- runner. In other cases there is tirst observed .a swelling of the cheek, which is hard, shining, and pallid. Pain is nnt caused b.v the examining Hnger. The inner surface of the cheek ma.v show the original site of the iuHltration and at this point an lUceration is observed. The submaxillary gl.-mds, if not as yet affected, soon hypertrophy. The iiitiltr;ited area in the cheek now becomes dark red, and soon is bluish and later black In color. The fetor increases. A line of demarcation now appears about the dark area and spreads upward to the eye and outward toward the ear. A inmched-nut area soon appears, permitting insiiection into the mouth. The gums are C(irres|iondingly affected, being covered with greenisli-gray slough. The periosteum ma.v be se|i;irated. The teeth are loosened or even droj) out. There is seldom an.v bleeding because the process is a gangrenous one. The stench is now almost intoleral)le. As may be supi)osed. the general condition soon suffers from such a destruc- tive process. The pulse and temperature are elevated — lOL'" to lO-t" F. — with a corresjiondingl.v weak pidse. While at first nourishment is taken and little p.-iin complained of, soon the patient succumbs and is b.-ully [irostrated. Signs of exhaustion are apparent. Patches of bronchopneumonia or a diarrhea complicate 'the disease. A comatose condition with septic rises of temperature usher in the fatal ending. In certain cases in female infants the necrosis involves the vulval ring, which may soon completely slough out. Course and Prognosis. — Tlie course is rapid; the disease may end in a week or it may last three weeks from its inception. Only 15 per cent, of the cases recover (Moro). Those that do live are left with severe deformities of the face. Treatment. Strict attention to the nasopharyngeal toilet in the infectious diseases will tend to prevent this affliction. The early and complete extirpation of the diseased area and cauteriz;ition of the edges is the modern treatment adopted b.v the surgeons, and the results achieved warrant its reconnnend.-ition. Wherever i>ossil)le, attempts should be made to save the angle of the mouth to prevent .i disastrous deformity. Loosenetl teeth or neca-otic ahcolar stiaictnre slionid be removeil. Meanwhile, the internist will flush the mouth with a 2 ]ier cent, solution of peroxid of h.vdrogen, or swab with a 5 per cent, solution of nitrate of silver, followed by salt solution. Nourishment sh(mld be forced and stimulation in the f(U-m of brandy and strychnia given. Turpentine spirits, if kept near the patient, will mitigate the nauseating odor. Elongated Uvula. Although rarely observed, this condition has led to nuich impro|ier medication for iiersistent cough. The elongated uvula irritates the pharynx and causes a cough which is esi)ecially marked when the prone position is assumed or when the child is overtired. If tlie chest is negative, this condition should be thcaight of. Treatment is by astringents, applications of silver nitrate, but usually ampu- ' tation is indicated and necessary. CHArTEIJ XVIII. DISEASES OF THE DIGESTIVE TRACT. Corrosive Esophagitis. Etiology. — Tills mndition is onusecl by tbe swallowing of (^nnstic chemicals, such as potash and snliiliuric acid, which produce corrosive burns of the esopha- JTUS. Lye is the most common substance ingested b.y children. The lesions vary. There ma.v be an intense acute intlanuuation. a necrosis of the nnicous membrane, or extensive ulceraticms which produce cicatricial strictures in healing. Symptomatology. — If much caustic has been swallcjwed. death may shortly result; otherwise there is prostration and vomiting of shreds of iiloody mucus, or even jiieces of muccjus membrane ma.v be expelled. The child cannot swallow without pain. An erosive hemorrhage may occur after a day or two. or a deep- seated cellulitis may result with infection. A stricture is very likely to develop in severe cases. Treatment. — .ViM'ropriate antidotes are to be j^iven if tlie jiatient is seen early : such as the acids or the alkalies, de])ending on the character of the poison. The ])rostration nuist be ccjmbated by supportive treatment, h.vpoderniatie injec- tions of camphor or strychnia. For the intense pain, codein subcntaneously will be indicated. Olive oil thrown into the esophagus is a distinct advantage, and if the child <-an swallow, this should be regularl.v administered. The treatment of the stricture is surgical. The string method has given some brilliant results in <-ases coming under our observation. Gastrostomy ma.v be necessary to preserve the life of the child if sudden occlusion of the esojihagus results. Congenital Occlusion of the Esophagus. This condition is rarely observed. Difficulty in swallowing and the regurgi- tation of even the smallest quantities of food should lead to an investigation with the bougie. The atresia or stricture is usually situated at or near the bifurcation of the larynx. Acute Gastric Indigestion. {Acute gastrins, acute di/spepsia, acute gastric catarrh.) Etiology. — 1m-)-oi's in diet are the principal cause, lii infancy tlie qnalit\' and (|iiaiitity of tlic milk, oi' the irrational use of extraneous articles added to the dictaiT act as causes. Improper feeding, habits will bring on occasional attacks. Sweets, unripe fruits, and pastries in older children or even lai'ge (piantities of one kind of food may jiroduce an attack. I'^sually there is more or less involvement of the intestinal tract. Symptomatology. — The symptoms very often l)egin suddenly with fever, headache, abdominal ]iain. and yomiting. The temperature may reach 104° F. with a correspondingly high pulse rate. Tlie vomiting is repeated several times, and the evidences of undigested food, or a certain article of food which has caused the attack, as unripe fruit, are seen therein. The patient is chilly at times and apt to be sleepy. Food is abhorrent, the tongue is coated with a thick fur, and the breath is disagreeable. Oecasion- i;8 DISEASES OF THE DIGESTIVE TRACT. 179 ally convulsions occur, especially in neurotic children. After the vomiting has ceased or a (compensatory) diarrhea has set in, there is relief from the distressing symptoms, although nausea and vomiting may reappear if the child is pressed to eat. Prognosis. — This is usually very favorable, although the onset of convulsion in a weakly infant would warrant a guarded prognosis. Treatment. — In breast-fed infants, examine the mother's milk, and give plain boiled water until vomiting and fever have subsided; a cleansing enema will complete the cure if the milk is not permanentl} abnormal. Bottle-fed infants suffer often from this malady, and the food formula ami its preparation should be inquired into most minutely, for well-intentioned attendants often make grievous errors. Calomel gr. i in divided doses every ten minutes will clear the bowels. If there is a convulsion, clean out the bowels at once with an enema and later wash out the stomach if vomitine lias not been free. In all cases the patient should be put to bed, without a pillow, and a mustard paste applied to the epigastrium in the strength of one to seven of flour. The fever is controlled by sponging with alcohol and water. Dietetic management is very important. Infants may be kept on albumin water, cereal decoctions, or whey, and then gradually returned to their regular feedings. Older children are not allowed to take any food for twelve to twenty-four hours, except sips of cold water. Then beef tea, toast, and crackers are allowed and later milk, milk toast, etc., slowly returning to the regular diet. Gastric Ulcer. "While this disease ir; not of froiiuent occurrence during childhood, it may happen at any period of life, even during infancy. Stowell has collected thirty- five cases from birth up to puberty, the earliest at five days, and six during infancy. Etiology. — The following conditions may act ns causes: Hyperacidity of the stomach with spasm of the pylorus, swallowing sharp substances with resultant local injury, various infectious diseases and septic conditions following birth, extensive burns, thrombosis of the umbilical vein and embolisms in the stomach wall. Pathology, — In young infants there may be melena, usually from st-psis, and blood may be passed in the stools presenting a darl; appearance from iron snlphid produced frou) the henjatin of the henioglol)in. The ulcer may be located in any part of the stomiich. lint is most commonly situated in the lesser curva- ture. In cases that perforate, the site is most often on tlie anterior wall. Symptomatology. — During infancy the princijial symptom may only be a constant gastric irritation and indigestion with occasional hematemesis, or the vomitus may simply he streaked with blond. If there is sufficient blood to pass into the bowel, dark, coffee ground masses may appear in the stool. Vomiting, however, is not such a constant symptom in early life ns in adults. Pain is a fairly uniform symptom : It is aggravated at once by taking food, especially sugary or rich preparations, and relieved by vomiting. Pain can also usually be elicited by pressure over the stomach. The imperfect digestion and disinclina- tion to take food soon result in progressive emaciation. Constipation Is often 12 180 DISEASES OF CHILDEEN. present and profound tinemm may result if beuling does not soon take place. Ir perforation or severe hemorrhage occurs, there will be the usual symptoms of marked collapse. Diagnosis. — This must depend upon constant gastric irritability, blood in vouiitus or stools, pain immediately after food which is relieved by vomiting, and pain on local jiressure. Jacubi has given the following interpretation of the relation between jiain and the ingestion of focjd : Tain half an hour or an hour after food jioints to duodenal ulcer, or peritonitic adhesions of the duodenum ; pain three or four hours after a meal may be referred to the colon; pain most Fi(, ricer on lesser (■ur\;itnre: infant 7 nmnths old. markc'il when the stmiiiicli is ('iiipty and relieved by fund nsuall,\- indie, ites a neui' i>is. Treatment. — Tlie iiatient should l>e given easily digested food in small amounts at frequiMit intervals. Peptonized milk or skinuned milk and gruels, buttermilk, dextrinized gruels, light cereals and egg water may be tried. The acidity of the stomach may be lessened liy the simpler alkalies, such as calcined magnesia, milk of magnesia, cnrbnnnte of lime and similar preparations. The stomach may be partially rested by rectal feeding. Tf pain is severe, bismuth subciirbonnte and small doses of codein may be employed. Tn cases of perfora- tion, surgical frentnient is indic;ited. This, fortunately, is rare. DISEASES OF THE DIGESTIVE TKACT. 181 Chronic Gastritis. Definition. — A clironic disturbance of llie gatitric function, associated usually with a similar involvement of the intestinal tract. Etiology. — Improper feeding at irregular intervals is the main cause, especially when couphnl with bad hygienic living. Rickets, tuberculosis, and chronic affections of the liver predispose to a chronic gastritis. Among pampered children it results from tlie use of sweets, pastries, and rich dressings which the cliihl is allowed to have. Symptomatology. — Frequent vomiting first attracts the attention of the parent. This aftei' a tiuie follows each meal. There are eructations of gas and a feeling of discomfort after eating. The tongue is coateil. The appetite is capricious. The outline of the stomach shows a well-marked dilatation. The abdomen remains quite pei'sistently distended in spite of medication. The child is fj-etful and restless in sleep; the weight falling off gradually in aggravated cases. In infancy the picture of marasmus may be seen. Periods of prostration and collapse may precede a lingering death. Older children show no inclination to play, slowly grow more feeble and flabby; mucus is seen with greater icgularity and in greater quantity in tiie vomitus. Diagnosis. — From a basilar meningitis the disease may be distin- guished by the absence of stupor or coma and lack of reflex changes. In doul)tful cases the A'on Pirquet reaction or a study of the s]nnal fluid coukl be resorted to for verification. Pyloric stenosis should be excluded by careful pliysical examination and the character of the vouiiting. Course and Prognosis. — The disease may last for weeks and the child drag on a miserable existence until it succumbs to a terminal disease, such as bronchoianeumonia or marasmus. Infants rarely withstand the disease, wliile if they survive they are apt to be weak and puny. In older children the prognosis is better and treatment of greater avail, although convalescence is prolonged sometimes through months. Treatment. — If all children were brought at stated intervals to their physician for examination and counsel, whether well or ill, chronic gastritis would be a much rarer disease. " Proper food properly given " is the prophylactic treatment. The treatment is mainly dietetic. A careful history and study of the ]n-evious diet is the first refjuisite. Find the factor that is causing the disturbance; determine whether it is the butter fat. carbohydrates, or protein elements, for example, that is at fault. Tlie periods of feeding, the (|uantity. the quality, and the digestive ability of the stomach itself must be weighed in the balance and corrective measures instituted as described in the cliapter on Infant Feeding. The fact must 182, DISEASES or CHILDItEX. not be lost sight of that some children cannot digest cow's milk in any form. For the eorieeliun ol llie vomiting and to control the failing nutrition it is necessary to suppl)' such food as will meet the lowest nutritional requirements, and in as readily a digestible form as possible. It is well to wash out the stonuich before beginning the treatment. Tlie legume flours, as pointed out by Edsall and Miller, are excellent substitutes for cow's milk if it disagrees, and tlicy furnisli sufficient protein to keep up nutrition. Beef blood, yolk of egg, and gruels are to be tried, and if they agree, that is, cause no vomiting, may be alternated so tluit they will not pall on tlu' appetite. If an increase in weight is obtained, weakened regular milk feedings may then be cautiously tried. Occasionally the stomach-tube must be used in o))stinate cases. Eectal feeding is witliout much merit in tliese cases. Children two to three years old are often beneiiteil bv a change to the seashore. Tlie appetite is thereby stimulated and tlie strict dietetic regime more willingly followed. A special diet list should be prepared by the physician for each case. From this shoidd be excluded all sweets, gravies, and pastries. Milk, gruels, eggs, and the softer vegetables should be the mainstay. Coupled with the dietetic management, the dailv routine of the child should be outlined. A fresh-air life, plenty of sleep, plenty of water to drink, and agreeable baths are necessities. Cases seen late or doing badly require stimulation, and this is best given in the form of the tincture of nux vomica three minims well diluted one-lialf hour before meals. Con- stipation is relieved by milk of magnesia or cascara in children or with a suppository in infants. Dilatation of the Stomach. Etiology. — Tliis <-oii(lition results from causes wliicli teiiil t(i weaken tlie nuiscular walls uf llie stomueli. It is more commonly observed in infants suffer- ins from constitutional diseases, such as rickets, marasmus, s,viitillis. and tuber- culosis. Amoiif; tbe rarer causes are pyloric hypertrophy or stricture. Symptomatology. — Those whieli result in the course of the coiistitution.il diseases will lie liere descrilied. Vomiting occurs usually some time after meals: food is not taken with avidit.v, and later in tlie disease may be abhorrent. Con- stipation is a noticeable sym])toiii. The abdonieu is usually tympanitic, toii,i;ue coated, and in older ehildren headaches may l)e coiiiiiUiined of. Physical Examination. — In emaciated siib,iects the greater curvature of the stomach ma.v be seen on inspection. Tlie alMlomeii is generall.v iirominent, but percussion over the dilated viscus gives a highly resonant tympanitic note. If fluid is present a succussion note can be obtained by tapjiiiig witli the ends of the fingers. If the diagnosis is still imleflnite. water or air may ))e introduced as an aid in determining its size and capacity. Prognosis. — T'nh'ss due to a congenital stenosis, the jirogiiosis is fairly good, but the course is sluw and de|)endent upon the underlying disease. In itself the eoiiditioii may retard the ]irogress of a case of ra<'hltis, for example, or even become tlie f.ictor that may lead 'to a fatal termination. Treatment. — The motor inactivity necessitates in the lieginning a course of gastric lavage coupled with dietary regulations as outlined under the article on Chronic Gastritis. Kresh air, massage, electricity, or vibration will be additional DISEASES OF THE DIGESTIVE TRACT. 183 aids, no matter what the uudei-lyiiig disease. Tiie tiiature of iiu.x: vouiica iu small doses will stimulate the appetite and assist the motor fuiietiasm of the pylorus. Fi(i. ."i.".. — (") Frcjni a cise of congenital hypertrophic pyl(iric stejiosis : infant six weeks old — seen li.v one of us. {Ji] section of tumor in s;inie case. Etiology. — There are no positive etiological factors known. Pathology. — The muscular, and occasionally the connective tissue at the pyloi'us, is hypertropliicd. The stomach is dilated and thick tenacious mucus is found on the mucous membrane. ]S4 DISEASES OF CniLIJKLN. Symptomatology. — The disease is iisua]l\- not recognized when the first Kvinptoin aiipcars. An a]-)paiTntly lieallhy infant at the breast may begin to vomit after nursing. This being i-cpeated at frequent intervals, advice is souglit. Tlic usual corrective measures do not suffice and the Yoniiting is more persistent. Closer observation will show (hat the stools Fig. .'54. — Wave in a i-ase nf p,vli>r'n obstruetiiju. Fid. ."I'l. — I'yliiro-s]i:isiii : little fciml only has liceu e.xlrudcil as i-diniiarcd witli normal stciniarl]. ai'e e.vtreinelv small, ihat tlie uianc, is scanty, ami thai the vomitus is projectile in t\pe. Tlie diagnosis now jieroiiies more a^jparent. I'hys- jcal exainiiiation may sliow a thiek'eniiig about the piyloiais, cspe- cialh' if anesthesia is used, )>ut Ibis is mit always pix'seut. Tlie cases iif simple ]i\'hiric spasm dn iu)t give e\idcnccs ol tumor formation; the vomiting is nol (piile so jici'sisteiil, and Ihe cmaeiatioii mit so ]'a[)id. DISEASES OF THE DIGESTIVE TKACT. UsS The stools are small and like dry putty, sometimes alternating with diar- rhea. Owing to the obstruction, little or no chyme enters the duodenum, and progressive emaciation results. Tlie stomach is dilated, but tlie intestines are collapsed, a valuable sign in this disease. A peristaltic wave may be observed passing from left to right upon slight mechanical stimula- tion. Examination of tlie stomach contents shows a mixture of food and nrueus, but without any bile. Hyperchlorhydria may be present. If measures for relief have not been successful the child dies of starvation. Diagnosis. — The characteristic vomiting without dietetic error, visi- ble peristalsis, and a palpable tumor are of especial diagnostic importance. If to these are added the sunken abdomen and progressive emaciation, the diagnosis should be more certain. Course and Prognosis. — In cases of true stenosis, due to hypertrophy, the course is progressively downward and, unless there is successful inter- vention, ends fatally in six to ten weeks. Oases that have been cured by medical treatment alone are probably those in which there was spasm only present and not a true stenosis. It is certain that the older the infant becomes before symptoms appear, the better its chances for recovery. Notable achievements have lately been made in Roentgenology, especially with the use of bismuth in the alimentary tract. The fact that we may be able to observe the exit of food into the duodenum within a minute or two after its intake rather tends to show that we may have been overvaluing this portion of the alimentary tract. That liquid foods begin normally to be expelled in a very sliort time after they are taken into the stomach is very helpful in our diagnosis of conditions dealing with some form of pyloric obstruction, for, if we can demonstrate, with a degree of exactness, by a series of radiographs, that the milk is retained for a greater length of time than in a normal stomach, as shown by the bismuth shadow, we can determine with a fair degree of certainty with what type of obstruction we arc dealing. If such striking results can be obtained by this means, it would seem manifestly unfair not to early obtain a series of radiographic pictures in every suspected case, so that the infant, suffering from a true tumor with a lumen so small as to practically occlude the passage of food into the duodenum may be early given over into the hands of the surgeon while its physical condition is still good. On the other hand, cases of pyloric spasm, even of marked degree, but without tumor formation, can be differentiated, since the time and the amount of the food passing through the pylorus can be seen and thus the diagnosis, and even the prognosis, can be fairly well fixed. In every suspected case of pyloric obstruction a radiographic study should be made before a plan of treatment is determined upon. 186 D1SKASE8 OF C'HILDKIiN. Treatment. — Cases of true pyloric stenosis should be placed in the liands of the .surgeon just as early as possible for the performance of the rianunstedt operation. This when done dexterously is a short operation causing little or no shock, and giving the infant a splendid chance for recovery. Breast millv dikited one-half may he given in drachm doses eveiy hour the first day Ijv dropper, and this quantity rapidly increased until the infant is taking t"'o to three ounces at tlie breast a few days after the o]ieration. The amount to be given and the rapidity of increase depending upon the infant's previous condition and lack of untoward symptoms, especially vomiting. Pyloro-spasm. if it can he demonstrated to be such, especially if occur- ring in a hypertonic infant, is best treated by anti-spasmodics, stomach washings and feedings containing basic alkalies as sodium citrate, grains two to the ounce. With each feeding one one-tliousandth of a grain of atrojdne is gn'cn as a sunken, and the child was at first restless, then stu]ierous and finallv hi\- in a coma. Often a specimen of urine was olitniiU'd witli a gi'i'at deal of didlculiy e\-en with a catlieter, there apparently lieing a lack of ui-inai'v secretion. Idle tojigiie was a|it to tie coate(l, hut red at the ti|i and along the edge-. Witli some exceptions the fi'\"er was not high, the range averag- ing fi'om 100° to K)]° P., with an occasional excursion to 10-»° oi- 10,",° V., DISEASKS OP 'ViLK DrCIESTIVl-: TI!ACT. 189 and a rather frequent ante-uiorteiii rise to 10i° F. or more. If the patient came to tlie liospital early in the illness, voniitino- was often marked : hut later, as tlie child hccame more and more stuporous, it usuall)' became less, and in the terminal changes ahuost ceased. The nuudjer of stools in the twenty-four hours was subject to great variation. Perhaps the most typical finding was a few foul smelling stools, or a history of many stools Ijoth during and preceding the onset of acidosis. The most constant and perhaps the most nearly pathognomonic symptom of acidosis was alteration in tlie respiration. The costal and abdominal type of respiration took the place of the usual abdominal type. The amplitude of the respiration being greatly increased and accomplished witli a distinct effort. A modified Cbeyne- 8tokes type of respiration was occasionally present, but in general the excur- sion of the thorax and abdomen was nearly the same in each succeeding respiration. Eventually the respiration became feebler, with onh' an occa- sional deep gasp, and finally ceased altogether, as if tlie respiratory center was exhausted by the exertion it had undergone. TJiere was never any evidence of obstruction, and there was no cyanosis. In dialjetes mellitus and cyclic vomiting there is often an iuci-eased amount of acetone, diacetic aciil and beta-oxyjjutyjic acid without marked symptoms of acidosis. The suggestion that the etiologic factor of acidosis is to be found in the decomposition of the proteins is supported in an interesting manner l)y the frequent finding of large amounts of indican in tlie urine. Indican was not invarialjly present, but when found was often in very large amounts. Com- monly it was a very transient finding, being found on one day and absent or nearly so on the next. Determinations of tlie alveolar air almost invariably show a marked reduction from the normal of 3.5-d5 mm. of mercury. In some cases going as low as 15 mm. This test is especially valualde for differential purposes and to determine the prognosis. Treatment. — A very important part of treatment is a thorough clean- ing out of the bowels and es]iecial]y of tlie small intestines. Colon irriga- tions and stomach washing do not accomplish much improvement if our efforts cease at this point. Xearly always such a catliarsis resulted in a very nasty, foul smelling stool. The treatment consists in a1)solute rest to the stomach and giving 1 to 2 oimces of nutrient enemas of a 10 per cent, dextrose solution. Large doses of bicarbonate of soda, 10 to '■'>() grains every two or three liours for an infant, and larger doses to older children DISEASES OF THE DIGESTIVE TRACT. 191 are more apt to follow the injection of serum vaccines than the ingestion of food. The patient is seized with sudden dyspnea, sometimes accompjanied b)' cyanosis. A very acute urticaria may develop in the skin, with much SM'elling of the face or other parts, and sometimes with an edema of the glottis and of the lungs. A serous discharge may pour out of the nose and inouth. If not relieved, this will quickly be followed by collapse and death. ^\hen nntoward symptoms are caused by the ingestion of food, there is probably some lesion of the gastro-intestinal mucus membrane that allows the undigested protein to gain entrance to body tissues that are already sensitized. Diagnosis. — There has recently been worked out a scratch test for anaphalaxis that is aimed at detecting the protein toward which the patient shows an idiosyncracy. A purified protein, prepared from the suspected food to which the patient is allergic, is l^est employed in making the test.* The flexor surface of the fore-arm may Ije utilized, on which, after cleansing, a number of slight abrasions are made, according to the number of pro- teins to be tested. The object is simply to remove tlie superficial epithelium without any flow of blood. A little of the dried protein, covered with a drop of sodium hydroxide solution (0.4%) (N^/10 Xa OH) as a solvent, is rubbed into each abrasion. A control scratch is then made for comparison. A positive reaction shows a slightly raised, irregular, whitish edema with a surrounding red areola. It usually appears 5 to 10 minutes after the scratch and may last from 25 to 45 minutes. The appearance of a marked reaction is shown in the accompanying plate. Another and simpler method of detecting an offending food substance is to gradually eliminate various articles of food to see when the irritating effects cease. Egg protein is one of the commonest sources of disturbance, and a few children are intolerant of cow's milk. Treatment. — When an individual is intolerant of food proteins, there are two plans of managing the case. The simplest way is to eliminate from the diet the food substance that is causing the disturbance; the other method is to try and desensitize the patient to the oifending protein. The latter may be affected by first administering very minute amounts of the food and o-radually increasing the quantity until there is no skin reaction to the • A large number of these purified prciteins is prepared by tbe Arlington Chemical Co., Yonkers, N. Y. 193 DISKASKS OF CiriLDKlCX. protein. iSomctimcs a powdered protein given in eapsules will he the best method of proeedure. In otlier eases desensitization ma}' be eft'eeted by the subcutaneous injection of extremel}' small doses of the food protein. All such efforts can be controlled by repeating the scratch test to learn if tolerance is being established. Children who are intolerant to cow's milk can sometimes take boiled milk or buttermilk with impunity. When de- sensitization has been accomplished, the food must be continually taken, in small amounts as otherwise the sensitiveness will return. In cases of anaphylactic shock, the child can be given Inpodermically adrenalin chloride ^ 5 to '^ 10, or strychnine sulphate Gr. Vxo to %oo or atropine sulphate Gr. ■'Am to Vam. The clothing around the neck should be loosened and if there is a profuse serous discharge from the nose and mouth, the child can lie placed head downward to allow it to run out. ' The Inhalation of Proteins. A^arious disturbances, especially^ of the respiratory tract, may follow the inhalation of vegetable (pollen) or animal proteins. The pollen pro- teins may come from the early summei' grasses, such as tiiuothv and orchard grass, or from late summer and autumnal plants, such as golden-rod, rag- weed and daisy. Animals give oil' keratinoid pi-oteins, found in liorse tlandei', dog and cat hair and sheep wool. The skin trst may be used in this class of cases to detect the olfending substance the sanu"; as with food proteins. Various types of asthma nuiy l)e induced by the inhalations of proteins called karatinoids, from furs or from the hair or feathers of domestic animals. The hair of horses, dogs and cats mo^t frequently causes the ti'ouble. The pollen from plants may produce hay fever and congestions of the nose, throat and up])er air tract and seasonal astlima. In such cases the mucus membrane affected has an almormal peruiialiility in addition to sensi- tization to the inhaled protein. Tlie employment of diagnostic jiroteins by the scratch test, the same as in food proteins, may point out the offending substance. The patient can then be desensitized by minute and graded injections of the particular proteins causing the trouljle. DISEASES OF THE DIGESTIVE TRACT. 193 Talljot points out " that if a carol'ul history ixAeals no particular fooil idiosA-ncrasy as the cause of the symptoms tests should be made with mate- lial representing each of the food groups, as for example: halibut, beef serum, millc, egg, wheat, potato, l)ean, orange, banana, English walnut. Should negative reactions result from these tests with the exception of wheat, the materials for subsequent tests should be chosen especially from ilie foods closely related to wheat, such as barley, rye, oat, corn and rice. Group reactions, however, are not the general rule. '' There is also a biological similarly as well as a difference between products of the same animal. For instance, an individual may react to botli beef serum and mill':, but more often when milk is positive, the serum is negative or vice versa. The same may 1je true of ciiicl^en sei'um, eggs and lien feathers."' Stools. The stools of the breast-fed infant nury lie from one to five in number, and numerically we should not judge tliem as abnormal, provided tlieir color, consistence;, and odor are within the normal limits. Tlieir color should Ije a yellow or orange tint with homogeneous consistency produced by the unchanged bilirubin. Tlieir reaction should be acid and th(.' odor not disagreeable. The amount of residue found in the stools will lie in direct jiroportion to the amount ingested or retained. The latter statement, however, does not hold true for the baliies artificially fed. Stools of Artificially Fed Infants. — Cow's milk normally produces a ^tool lighter in color, liulkicr, and numerically fewer. The feces amount to about 5 per cent, of the food ingested. In the hand-fed infant the protein elements are longer exposed in the intestinal canal to putrefaction. Examination of Stools. — If we examine a freshly passed stool from an infant fed on Imman milk (see PI. B, fig. 3), and with an improvised spatula spread out a central portion, we may find that there are yellow masses or flakes present ; these are often mistaken for curds, but in reality are made up of fats; firm, hard curds are not found in mother's milk — only in cow's milk. Sueli a stool in an infant not steadily gaining would indicate a scanty milk supply, and if the stools were frequent, dark green 194 DISEASES OF CHILDEEN. and mucoid, with very little milk residue, tlie maternal font would surelv lie found to be at a low ebb. The indication would be wet-nursing r,i' alternate feedings and regulation of the diet and life of the nurse. In the bottle-fed baby we are often confronted with the symptoms of constipation or diarrhea. Either of these conditions may arise from ton much })rotein in the food. The constipated stool will be friable, like dry putty, while the loose stool due to this cause can be smoothed out and the masses will be readily soluble in ether, proving them to be fat and not curds, as they are so often designated. True curds are formed in the stomach by the action of lactic acid or an e-xcess of hydrochloric acid and rennet on tlie paracasein. They are hard, smooth, yellowish on the outside and white within, with a cheesy odor when opened, and will not dissolve in ether. The remedy for too much protein is evident. Correct tlie formula, and if true curds are present, examine the character of the milk. The millc may have been sterilized or it needs to be mechanically diluted with gruels, or chemically modified, when the stools will assume the normal type. A loose, greasy, sour-smelling, acid movement, resembling scrambled eggs, will indicate excessive fat in the dietary. E.xamination of the breast milk or a study of tlie formula will show that the fats ingested have been persistently too high. Three per cent, of fat should never be exceeded by an infant to the third or fourth month, and more than four per cent, should never be prescribed. It should be recollected that a certain amount of fat is always present, but should not be visible in distinct masses. Mothers often erroneonslv speak of large quantities of mucus as pres- ent in the baby's stools. The doctor must remember that some mucus is normal ; that it should, however, be found intimately mixed with the feces. Barley water produces a slimy stool often mistaken for mucus, and undi- gested food elements also cause this error. If mucus is seen in any quan- tity with the naked eye by a competent observer, it is pathological and means inflammation, usually located in the large intestine, of a subacute or chronic form. If the disease is in the small intestine, the mucus is mixed with the stool and it is usually found to be bile-stained. The hint for cor- rection is embodied in the following fact — that the greater the amount of nonassimilable substances present, the greater the amount of mucus. The color of the stools when immediately passed should be considered. If the absorptive process has been delayed and putrefactive changes have taken place in the protein element, the bilirubin will be changed to hiliverdin, but it is not known whether the reaction itself, or cbromogenic bacteria, pro- duce the coloration. Nitric acid will prove whether or not we are dealing DISEASES OE THE DIGESTIVE TKACT. V.l'i with bile salts by the familiar play of colors. The green color in conjunc- tion with mucus, and fecal acid reaction, indicate true intestinal disease and call for radical change in the dietary. Acid fermentation will require such temporary food as albumin water for its correction, while alkaline putre- faction will respond to the carbohydrate foods, as dextrinizcd gruels. The brownish movements often seen, if we exclude certain drugs and blood, are due to the ingestion of undextrinized starches alone, or a preponderance of carbohydrates in proprietary infant foods (See PL B, fig. 5). A stool that presents a foamy, bubbling appearance and is acid in reaction will signify the presence of too much sugar in the mixture, as is often the case in canned condensed-milk feedings. We have not hinted at the bacterial examination of the stools, as it lias proven of no clinical value as yet. The reaction of the stool is a help and -should be ascertained, and always taken from the middle of the fresh stool. If a blue color is obtained, we have alkaline protein putrefaction going on, and if the color of the litmus is unchanged, we have acid fermentation due to the breaking down of the fat and carbohydrates. (For further tests see page 49.) Again, the stools may be of considerable aid to us in certain patho- logical conditions, as illustrations of the intensity of the process in the summer diarrheas, and in such pathological states as intussusception, in which we have frequent paroxysmal discharges witli blood and mucus, but no feces. Eectal polypi should be strongly suspected where we have a normal stool, except for a fresh-blood coating: these hemorrhages being intermittent in character and not necessarily connected with a hard or scybalous mass. Fissures may be produced by hard fecal masses and have a blood coating, or in their passage produce bleeding from the rectum. Dark grumou.s blood mixed with the feces is indicative of hemorrhage, higher up in the bowel — probably from intestinal ulcerations. In gastric or acute duodenal ulcer there is vomiting of blood and mucus, but there is no fresh blood in the stools. Colic. (Enteralgia.) The term colic is used to designate the paroxysmal pains which occur in the abdomen. It is a symptom and not a disease, and usually denotes the presence of an abnormal amount .of gas in the intestines, which stimulates undue peristaltic movements. Etiology. — It occurs most frequently in artificially fed babies, as a result of digestive disturbances dependent upon the food ingested. This inC; DISEASES OF CIIILDUEN. food may have bucii miwliok'soiiic, loo great in amount, or one of its con- stituunts may lia\L' been jn exeess. i'\jr eAampIc, the percentage of pi-oteins in a gi\eu mi.xtiii'e ma}' he too liigli, or tlie siigai' ma\" cause fei'mentation if present it) undue amounts (beyond G per cent.), or tliere may he starchy indigestion. Bj'cast-fed inl'ants may ,-uffcr from a poorly hahineed milk or from overfeeding or too ha>tv niii-ing. Colic occurring in the course nf otliei' diseases is dependent upon the resriliing atonic eomlition cF the iiiiestinal \valls. Symptomatology. — The attacks come on suddenly, the infant is restless and uneasy, and crii'S unceasingly. The abdomen is distended and I'igid and the thiglis are drawn uji (i\er the abdomen. Idle extrciuities may be cold. If during the rxa.uiination some flatus is expelled tlie screaming ceases and the evidences nf I'clief ai'c a]>pai'ent. Treatment. — In the attack, heat should be applied to the abdomen, an enema of w.uiii saline 'solution should lie given and sips of hot water given bv mouth. These measures will usually lie effective. If relief is not obtained, massage of llie aljdoiueir with "warm olive oil, followed by a hot colonic irrigation containing two drams of the milk of asafetida fo four ounces (if water can be used. The following jii'escriiition may 1)C of occasional service: !R. riilftrnli liydriitl gr. viii Soiiii liic;irli(in;l tis p:i". x Sndil broniidi ^ss .'\qnn:' moDthir i)ipri-t;i' n^^s .\quffi (]. s. :n] oij Miser ft si^nii. — (live ;i tciisj nliU in ;i littli' Ijdt water vYcry two or tliriT iKiurs. The furtliei- treatment resolves itself into efforts to discover the cause of the colic. The details of the ]H'eparation and administration of the infant's food nia\' disclose a fault worthy of correction. The care of the mother or wet-nurse must nof be forgotten when colic is present in the breast fed. Acute Gastroenteritis. (Slim III cr Diiirrhea. Siuiiincr Cinii jiliiiiil. I iifcifinus Dniii-]icn.) Etiology. — ,\rtiliciallv fed babies in tlie hot, humid summer months are especially ](rone to this infection, sui>erinduced by the ingestion of un\\'hiilesouie uiilk. Tnfaiits and childi'eii nnder two years are mainly attacked. The children in the tenementdiouse districts of our lai'ge cities siiow the greatest niorbidily to infectious diarrhea. Although a lowering of tlu^ bod\' resistance by tlie heat serves to ]iroduce the ilisease, the specilic factoi's are organisms of the bacillus dysenteria:^ ^d^e? g'"is I'iicilli, colon, streptococcus and the pyocyaneus bacillus. The bacillus dysenteriiu (Shiga- DISEASES OF TTTE DIGESTIVE TRACT. 197 Flexner bacillus) can ));■ isolated from many of the stools. The infection is nsualh^ fi'om without, l)nt autoinfeetion is jiossihlc. The lack of rcfrigrr- ation, the feeding of food nnfitied to tlie age, plus tlie devitalization l)y the fiiininer heat, makes infection easy and common. Bahies in crowded hospital wards may hecomc infected by careless handling of the soiled diapers on the part of their attendants. Pathology. — Ko special characteristic may be observed at necropsy, except a congested mucous membrane iu the stomacli and small intestine, with enlarged lymph glands. As a lade tlie Peyer's patches and solitary follicles are prominent with occasional ulceration of these areas. It is rare to find lesions outside of tlie large intestine and the last section of the small. Cloudy swelling of the kidneys is quite constant. Symptomatology. — Mild Form. — The stools first attract attention. Thej are curdy, loose and somewliat foul. Soon mucus and blood-sti'i'aked fecal matter appjear ; tlie chihl is restless, loses its desire for food, ami may fomit if the food is urged. The fever is moderate and tlie child fretful. The character of the stools soon changes to a green ish-yollow, and they liecome more numerous, five to six a day, and the fever lises to ]0-.>° or 103° F. If prompt measures, as indicated below, are taken, recovery is rajiid and ([iiite certain. Severe Form. — Here the onset is cjuite sudden, and the predominat- ing syuiptom is tlie marked diarrhea. The numerous small, green, foul- smelling stools, often with a putrefactive odor, contain much mucus and are blood streaked. Eestlessness and pain distui-h the sleep, and the cliild rapidly becomes emaciated. After a few days, if tlie numerous stools con- tinue, tenesmus and vomiting ensue, tlie jiatient often refusing any food. The abdomen becomes sunken and the rectum is apt to protrude from the fi'ef|uent movements, the fontane-'l in infants becomes sunken, and the jnilse thready, the fever rises to int-°-10o° F. with few i-emissions, the urine becomes diminished, and symptoms of meningeal irritation may supervene. E.xcept for a moderate increase in tlie ])olynuclears, fifteen to twenty thousand, the blood offers nothing characteristic. Toxic Form. — From the onset the symptoms are unusually severe. High fever and intense prostration are added to the incessant vomiting and frequent stools. The color of the stools is constantly green, the odor ex- tremely foul, and blood-streaked mucus appears early, f'ei'eliral sym]itoms soon supervene, delirium and coma usiier in the end, which may come on in a day or two, or even within twenty-four lioui's. In this form the Shiga bacillus can usuallv be demonstrated. IDS DISEASES OF CUILDIIEN. Course and Prognosis. — Tins lias been iinlK-ated uiuler the separate divisions, depending upon the sevei-ity of ihe infection. If seen early, the mild and sevei'ei- forms are amenable to treatment, although a guarded prognosis is always advisable. The toxic type is apt to baffle even the jniist hei'oic iu<>asures. The aliility to command good nursing and later change of climate naturally influence the prognosis. Cases responding to treatment usually clear up within two weeks. The previously enfeebled infants may go on to a condition of chronic gastro-intestinal indiges<:ion. (See page 202.) Signs of meningeal irritation (meningisnius) , pi'olonged high fever, uncontrollable vomiting, or convulsions indicate a grave prognosis. Treatment. Prophylactic. — Breast-feeding whenever possible, es- pecially in the summer months, is desirable. Cleanliness and care in every detail of the child's diet and clothing are necessary. The use of jiasteurized or constantly refrigerated clean milk is indicated. Proper disinfection of stools and tlie nurse's hands must be insisted on. Eegulation of the diet, accni'ding to the heat and the condition of Ihc infant, will hel]) in pre- vention. Weak infants are more susceptilile in the second summer. General Management. — Place the patient in the coolest, cleanest and largest room ])ossible. A cotton slip and diajiers only are to he worn in hot weather. Secure a competent nurse to intelligently follow orders. Pe- diicc the fever by fi'e(|uent cool sponging with a tiftv per cent, alcohol solution, or by iepid sheet packs, or by reducing the temperature of the water used for colon irrigations to '(,5° or even !I0° F. If the temperature is above 10f° F. and the ])ulse ))erniits, use an ice-hag to the head. A satisfactoi-y initial purge with castor oil or calomel is indicated. One, or at most two, bowel irrigations of normal saline solution are to 1)6 given fi'om a fountain hag as indicated under enteroclysis (page T.5). AVhere there is much tenesmus, starch encmata may be given. In con^'al- escenec, or in the sub-acute form, a pint of a two per cent, silver nitrate solution may be allo\\ed to gently tlow into the colon, to be retained as long as j)0ssib]e. For the prostration, water must he olTered freely, and if not retained it should he given li\' the drip mi>tliod bv reeium, or four ounces may be given snbcutaneously. AVhen no food has been retained, much benefit can be derived hv adding two nr thi'ee ])er ci'nt. of dextrose to the solution. This may he given foui- times in thi' t\\'ent\'-foui' houvs. Since no dependence can he placed upon intestinal antisejitics. and since bismuth has been practically discarded, the drugs that are used are the stimulants, and very occasionallv, the sedatives in the form of Dover's powder, after the toxic svmptoms have suhsided. Caffein, particnlarlv in the form of sodium benzoate, is the preferable stimulant. It mav be given to DISEASKS OF THE DIGESTIVE TRACT. 199 an infant in quarter to a lialf grain doses alone, or alternating with strych- nin sulphate 1/240 of a grain, every four hours. Dietetic. — Stop milk in all forms for at least twenty-four hours, place the child on a starvation diet of boiled water alone or on barley water, made with one ounce of flour to the quart. If at the end of a day the frequent stools persist, continue the substitute feeding a day longer until a change for the better is noticed. If barley gruel is not palatable or tolerated, one may try rice water or albumin water. (See section on Dietetics.) In the case of nurslings re- sume the feeding at longer intervals preceded by a dram or two of boiled water. Substitute feedings such as barley water must not ))e continued too long a time as the infant's life may be jeopai'dized ))y too jnolonged starva- tion. Morse has pointed out that the cliaracter of the food offered should depend upon the type of organism producing the diarrhea. Unfortunately it is rarely practicable, except wliere trained lalioiatorians are at liaml to do this. It is demonstrable, however, that cures are more readily effected if carbohydrates are offered when the infecting oi-ganisni is dysentery or colon bacilli, or a streptococcus; while the gas bacillus and its ]irototypes do best on protein, fat-free food. (See buttermilk feeding and Eiweiss milk.) This dietetic test is suggested in outlying districts wliere laboratory aid is not available. When Eiweiss feedings are used tlie nipple must be perforated to permit the flow of the particles of casein. It is sometimes necessary to add a grain of saccharine to a pint of mixture to make it ])alata- ble. The stools clurnge from a tliin watery consistency to a lieavy ]iuItaceous mass, decrease in number, thereby adding to the com fort of the child. Unfortunately we do not meet with success in all cases, by this metiiod. It is woi'thy of a trial, however, when the above mentioned dii'cctions do not succeed. The stools having in any instance assumed a more normal appearance, skimmed milk, diluted if necessary, is fed before returning to the proper modification. In ai'tiiicially fed liabies, resumption to cow's milk feedings must be made only when tJie stools begin to resume the normal type. Begin with a modification lower than the original prescriptions. The diarrheal diseases of infancy and childhood do not permit as 3'et of any definite classification, foi- the etiological factoi's may he the same in a number of the allied affections, and the various patliological changes found are often those of degree or situation onlv. It is to be hoped that in ihe near future these grouped diseases may be more accurately separated and defined. 200 . DISEASES OF CIIILDUEN. Acute Enterocolitis. Definition. — This is an inflaiuiiiation of the mucous membrane of the small and large intestine associated with ulcerations and characterized by tenesmus and blood-stained stools. Etiology. — C'hildien in the summer months, especially those who have had previous attacks of gastroenteritis, or who suffer from chronic indiges- tion, are especially liable to attack. The children of the poor in the large cities because of iiiipi-(jpri' food and uncleanliness ai'c most frequentlv the victims of the disease. Such constitutional conditions as rickets, tubercu- losis, and syphilis are ]u-edisposing elemenls. The Shiga bacillus and its prototypes are found in a great many of the cases Pathology. — In the colon and about the ileocecal valve the charac- teristic lesions arc commonly observed. In some of the lighter forms of the disease we find only evidences of congestion and inflammation with a roughened or somewhat denuded epithelium. The lymphatic sti'uctures are h)'pertropliied oi' shov,- loss of tissue. If tlie affliction has fieen of a severer grade, the follicles are degenerated, producing a slight ulceration and conscrpient uneven frel to the gut. These clianges are commonly seen in the colon and rarely in the ileum or rectum. In the usual typc^ seen after' a severe illness quite dee]5 ulceration may exist, so as to produce a shaven beai'd appeai-ance. The ulcers may later extend down to the muscular layer, and a large area of rrlceration may be found bv tlie coalition of a number of smaller ulcers. Another tvpc occa- sionally seen pi-esents a fibrinous deiiosit over isolated areas of the colon. Quite genernilv there is a swelling of the retroperitoneal and mesenteric glands. I^)i'onehopniuimonic ]iatches ai'c often found at necro]isv. Symptomatology. — in a eliild whose vitality has ali'cady been im- ]wired liv ])i'e\ioiis disease the attention may be directed to the condition of the stools, which ai'c frequent and passed with much straining. These stools ma\' contain blood-sti'caked mucus with undigested food masses. Fe\"er is f|uite constant and varied in degree, in ilie beginning 102° to 10,"i' F. with a correspondingly rapid ])ulse rate. In the severer cases tbei'c is i'a])id prostration and vomiting. The stools are passed with tenesmus, ami abdominal ])ain may be nuirkcd. There is restlessness, and often dcliriuiir, with intense thirst. The eyes are sunken and e.vpressionless. The lips and tongue are dry and coaled. The stools are now fi'cquent — from ten lo twentv a dav — small, ami contain almost no feces. Death will occiii' fi'om exhaustion or a pneumonic complication if the symptoms do Tiot show signs of abatement. Improvement is shown by a rieerease in the number of stools, a lowered temperature with absence of vomiting and DISEASES or THE DIO'ESTIVE TKACT. 201 tenesmus. The lost vitality is regained very slowly. For days or weeks there is a low-grade temperature, and temporarily the tenesmus or green stools may appear. The appetite is capricious for a long time. The abdominal tone which is lost during the height of the disease will now slowly return to the normal, and the child will gain in weight. Diagnosis. — The diagnosis is made from tlie presence of mucus and blood in diarrheal stools passed with straining over a period of several days or weeks in a child of deficient vitality. Intussusception is differentiated by the alisence of fever, the acute onset, the pain, the shock, the presence only of mucus and blood, but no feces, and a tumor palpable through the abdomen or rectum. Course and Prognosis. — Severe types end fatally after a few days, or a week at most, of high fever and prostration. The mortality rate is from 30 to 40 per cent. Tlie subacute types remain ill for a niontli or six weeks with periods of remission and relapses and a slow painful con- valescence. The prognosis is more favorable in this class, especially if they are removed to suitable surroundings, and have proper nursing and attendance. Infants withstand the disease badly. Treatment. — This does not differ from that given on page l!J(i, under gastroenteritis. It should lie recalled that these infections may be com- niimicated to others in a family or ward. An initial cleansing of the bowel with castor oil or calomel is imperative, followed by starvation for twelve to twenty-foiii' hours. Egi; albuuiin. barlev «'ater, oi' beef lu-oth may be given (see p. 144). ]v|ual jiarts (if beef bi-ntli or barley gruel are sometimes more acceptable. Protein milk often produces happy results (see p. 14-5). The tenesmus is relieved by the control of the diet and by the use of codein gr. 4 to -]-, accoixling to the age, or Dover's powder, gr. 4 to 2 grains every two or three hours, until the painful symptoms abate. Sup- positories containing cocain gr. -|- and aristol gr. l-') are soothing in older children. Bismuth snhcarbonate gr. 20 or bismuth subgallate gr. 2, with powdered ipecac gr. 1, may be given advantageously every two or three hours for the control of the mucus and blood in the stools in the later stages. After the acute symptoms have subsided sterilized milk is allowed in small amounts well diluted with barley or wheat-flour gruel. Later pas- teurized milk is permitted with jellied gruels and broths. The prostration may require hypodermatic medication in the form of atropin gr. 1/400 with strychnin sulph. gr. 1/2.50. As a daily routine, one saline irrigation 13 ■v'tia DISEASES OF CHlLDIiEN. at 100° F. serves a double purpose, as a cleansing solution and for absorp- tion of part of the water. Strychnin sulphate gr. 1/300 may be given as a tonic three times a day, and astringent enemas for the control of blood and mucus. Silver nitrate 2 per cent, or a starch paste in less severe cases may serve the latter purpose. They should not lie given more than once daily, and discontinued if the effect is not satisfactory. Too frequent irrigations often cause irritation and aggravation of the symptoms. Re- luoval to the seaside or cool mountain air is a great help in the management, particularly in the convalescent stage. Chronic Gastrointestinal Indigestion. This is a condition resultiiij; from defirient motor and secretory powers in the alimentary tract, or as a result of continued imiu-oper food. Etiology. — Improiier fecdiui;, es])ecially hi poor children in the cities where the surroundings are unhygienic, is the iirincijial cause at this affection. When the food is radically wrong, or unwholesome, an acute condition develops which makes the p;irent seek medical treatment; on the other hand, the chronic con- dition due to incapacity to digest certain ingredients of the food is often over- looked or ascriliecl to anemia, parasites, etc-. ,Vn excess of the fats, carliohy- drates, and sugars or of the proteins may overtax the intestinal digestion, thereliy using uji energy which should h.-ive jiroduced development and growth. In filder children hadly ])reii.ired foods or indulgence in rich foods, jiastries, and condiments lead to this condition. Pathology. — There are no definite organic ch.'iugcs found in this disease. If of long st.'inding, the lymph follicles in the region of the ileocecal valve may be hypei-trophied or a chrcjnic colitis may be found. Symptomatology, — ,\s indicated above, the symiitoms are not appreciable at first, unless the disease directly follows an acute gastritis or enterocolitis. After some time failure to gain weight is noticed : the child sleeps badly, has frequent attacks of colic, and cannot easily be comforted; the stools become diarrheal for several da.vs. then resume a more normal appearance, only to relapse into a condition . f diai'rhea or even constipation. Closer examination of the stools shows that they consist of masses of undigested food, intermingled with a small quantity of mucus, while streaks or splashes of green color are not infrequent. The musculature l>ecomes soft and flabby. If the child has previously sat up or walked, it may now be unable to do so. The abdonunal wall offers little or no resistance on palpation and the normal peristalsis is sluggish. The temperature is rarely elevated except late in the disease; on the other band, a subnormal temperature is not unconunon. Intertrigo in the napkin region is exceedingly common in infants. If corrective measures have not been instituted by this time a marantic condition supervenes which may lead to a fatal issue. In older children the symptoms are not as marked, bnt the stationary weight or loss of weight, anemia, and listlessness should recall the possibility of this condition. The appetite is capricious, and as a consequence the children are iTidulged to a vicious degree by their parents. ,'\ttacks of constipation alternate with diarrhea, the ui'ine is somewhat decreased in amount, it may be cloudy, and contains an excess of indican (see Plate TK The children become irritable and moody, having seemingly lost their former characteristics. They become cold easily, develop headaches, and are easily nauseated. The abdomen becomes prominent from gas distention, the stomach itself, if mapped out, shows enlarge- inent. but there is no pain or tenderness on abdominal palpation. Treatment. — Oood hygiene and proper dietetic treatment are absolutely neces'-iu'x' to effect a cure. In the ease of the poor, removal to a properly con- ducied Iiospital, preferably one near the seashore, will often work wonders. DISEASES OF THE DIGESTIVE TKACT. 203 The diet must be so atlapted that it will correct tlie former faults, but still take into consideration the deficiency of digestive secretion and maldevelopment of the alimentary tract. An analysis of the breast milli or of the last formula given to an infant, studied in connection with its stools, will usually show which ingredient is at fault. A wet-nurse will sometimes quickly produce' an ameliora- tion of the symptoms. Detailed instructions as to the room, air, bathing, and exercise must be given if the patient is to remain at home. The roof or piazza can be effectively utilized, and the gi-eater part of the day should be spent out of doors. Before any dietary changes are made it is well to wash out the stomach, and thoroughly irrigate the bowels with saline solution. In some instances the bowel irrigations may have to be repeated once or twice. An initial dose of castor oil, one to two drams and a minim or two of the tincture of nux vomica, three times a day, will usually constitute all the drug treatment that is necessary. If the infant is artificially fed. the milk can for a time be so modified as to prevent the curdling action of rennet in the stomach by the use of peiitonizatiou or the alkalies or the addition of sodium citrate. A formula weaker than the requirements of a normal child of a corresponding age must be temporarily given. Kapid gain in weight must not lie ex))ected. ( 'onvalescence is slow and pro- tracted. The management in the case of older children is mainly dietetic. From time to time a diet list of certain permissible articles of food should be given. l>egin- ning with such as are easily digested and assimilated, and gradually increasing the number and variety as the improvement warrants (see diet list. p. !(]()). Aerotherapy, stimulating baths, and massage are necessary ad,1uncts to the dietetic treatment. Without constant supervision and attention to the daily routine, meager improvement will be experienced. Pjg ,50;. — Congenital dilatation of the colon. Congenital Dilatation of the Colon. (Hirschspruiuj's Disease.) This is a rare condition which consists of an increase in the length and circumference of the descending colon and the sigmoid flexure. In some cases there is an added hypertrophy of tlie muscle fillers. As a result of this condition the abdomen is greatly distended from meteorism, feces are more or less retained, the constipation is extremely obstinate, and when the fecal masses are passed. ■10^ DiSEAyEs OF cj:ilul;ex. either ii:itiu':!ll.v or l>.v artificial iiieau.s, tbfy are extremely toul, imtresi-eiit, and may be cuvered with mucus and some blood. Treatment. — Daily irrigatimis must be used to produce bowel e\aiuatiuu. JMassage aud doucbiiis of the abdomen with cold water should be persisted in for a long time. Internally the daily administration of a laxative and drop doses of the tincture of iiux yumiea l)et'ore meals are advisable. Since the condition predisj)oses to the ready ](Utrefaction of food elements, owing to the stasis which results fron! meager peristaltic action, it is necessary to carefully supervise the diet, feeding only wholesome millc, well-cooked cereals (at least 3 hours), scraped meats, chiclien, etc.. aud stewed fruits. Foods which may contain large quantities of purin bodies are especiall.y to be avoided. If, in spite of the dietetic and mechanical treatment, the condition is not improved, surgical intervention may be i-onsidercd — some surgeons electing to do piicatiun. An X-ray exam- ination with a liismntii meal will give a good idi\i of the jinigress that is being made by treatment. Mineral oil is especially useful in this condition. Cholera Infantum. Cholera infantiuu is a very acute disease eliaracterized by rapid pros- tration, voiiiitiny. and a profuse .serous diai'rliea. Etiology. — It occurs almost entirely in the hot months of the year, among the poorer classes who li\'e on inferior milk, and very rarely attacks breast-fed infants. It is tlie result of a toxic jjoisoning from an organism or group of organisms still undetermined. Symptomatology. — The symptoms ai'e out of all pi'oportion to the anatomical lesions which are found at necropsy. A child apparently C|uite well or only ill from a digestive disturbance suddenly begins to vomit and has a rise of temperature. A profuse diarrhea follows, ])ossessing the char- acteristics of decomposition with very foul-smelling stools. The stomach and intestinal contents are at first expelled in this manner. The vomiting then consists of a watery fluid with flakes of mucus. The stools also now lose theii' fecal chai'acter, and ai'e watery, greenish-gray in color, with a peculiar old musty odor wliich is quite characteristic. I'lu^se discharges at first co])ious and explosive become smaller in amount 1nit very fi-equeiit; they consist of serum and mucus, and may be as many as twenty or thirty a day. In some cases there is an almost constant oozing from the anal ring. The vomiting and diai'ihea with tlie high temperature causes a quick collapse and an emaciation which is extremely rapid, due to the character of the discharge, which is largely blood serum. The extremities are cold, the pulse fechle, the respirations shallow and sighing, and the infant lies in a semicoma. Thirst is extreme, and water is eagerly taken. Meningitic symptoms supervene, with delirium, twitching, purposeless movements or convulsions. Unless the progress of the disease is arrested the temperature rises to 10.")° or 107° F., with coma and death resultino- from cardiac exhaustion at the end of the second or third day. If the treatment has been successful, the convalescence is extremely slow and demands incessant care. Di«i:aoi;,s of the digestive tract. 20.5 Course and Prognosis. — This shoulu always be given as e-xti-emely bad. 11 prostration eoiues on rapidly, witli high temperature and nervous symptoms, the course is often not longer than twenty-four hours. Treatment. — This must be energetie and lieroic if any good is to be accomplished. Gastric lavage with warm saliire solution sliould be made if the patient is seen early. If prostratioir is apparent, stiimdation is the first indication, and is here best obtained by the use of hypodermoclysis which supplies the tissues witli fluid and likewise stimulates. Inject eight to ten ounces into the subcutaneous tissue of the abdomen — using for this purpose sterile normal saline solution ( i] grs. to the liter) and repeat this every four to six hours. Enemas of normal salt solution may also be employed. For a very rapid effect a hypodernuitic injection of atropin gr. L''.JOU is elhcacious, acting also as a clieck to the serous waste. Tliis may 1je repeated every three hours if neccs>ary. Gainphor in sterile olive oil ((ine grain of camphor to every ten miniurs of oil) may be injected in the intervals, if the cardiac action is feeljle. Immersioir in warm baths at l)lood lieat, or at 1]0° F. if the tempei'ature should suddenly dro]i, is efficacious. They should be continued for a halfdiour, aird I'epeated at three-hour intervals: gentle friction ami the addition of mustard, one tablespoonful to the bath, will assist in keeping the extremities warm. No food is permitted and no medicines should be adnnnistered by mouth until tlie danger of deatli from collapse is past. Slundd the child rally, eautious feedings and nusdication as outlined undi'i' tlie article on Summer I)iai-rhea, is to be followed undei- the supervision of a competent nurse. As soon as possible th.ereafter a cliange to the seaside should be made. Constipation. This should be regarded as a symptom and not a disease, and accord- inglv the underlying cause should 1je souglit for ami corrected. Etiology. Rare Causes. — The condition nray be caused liy congenital anatomical abnormalities, liy new growtlis, oi- liy the disproportionate length of the sigmoid flexure. Adhesive peritonitis (especially the tuberculous variety) also causes constipation. The commoner causes are mainly dietetic. Artificially fed infants are the most frequent sufferers because of badly balanced food mixtures (see Artificial Feeding, p. 140), either too large or too small an amount of one ingredient of the milk, or the boiling of the milk itself acting as causes. Breast-fed infants are constipated from deficiency in the fat or total quan- titv of solids present in t^'c mother's milk. In older children a badly arranged dietary, especially a deficiency in the carbohydrates and fruit 20G D1SI;ASI;s of LlllLUltLN. juices, will eausu this syiii])tuiii. .Next to the diet, the laelc of training of the child is au important cause in producing constipation. Children who suffer from constitutional diseases, such as rickets and infantile atrophy, may be constijjated because of the lack of expulsive power and deficient peristaltic action. Other causes are deficiency of the intestinal and biliary secretions, nervous inhibition of the normal peristalsis in such diseases as meningitis, and intestinal parasites. Tlic fear of causing pain wlien at stool, as from fissures of the anus, may lead to constipation. Symptomatology. In Infancy. — Colicky pains and flatulence precede the passage of tlie fecal mass, which is hartl and dry or putty-like. Ab- sorption of tlu' toxins may cause rise of temperature or possibly convulsions. These infants are inclined to be fretful witli capricious appetites and are poor sleepers. They are likewise inclined to eczema. Rectal examination will reveal tlie fecal masses. In Older Children. — The tongue is coated, the breath is foul, and there is lassitude and depression with headache. There may be a slight rise of temperature, and the complexion becomes sallow or pasty. The appetite is lost. Sleep is disturbed. The stools are passed with an effort, may be mucus-coated and exceptionally large and ball-like. The child may go for several days without a movement. Digital examination will clear up any doubtful case. Treatment. — With persistent and patient effort all cases can be cured. The food taken by the child must be studied and the error which is usually dietetic set right. Medicines should have a minor place; the main 7-eliance should be on diet, correct habits, and massage. Deficiency in the total amount or irregularity of any of the food com- ponents must be properly balanced. If the fats are deficient in the mother attem])t should be maile to improve the milk by dietetic and hygienic measures, and by regulating the amount of slee]i and exercise. If this fails, alternate feedings or supplementary fee(lings of modi- fled milk mav be given. Xursing mothers should be placed on a diet list which would include plenty of clean raw milk, cornmeal gruel, and water between meals. Feeble infants in whom the efforts to expel the mass are unsuccessful, as is evidenced by the finger in the rectum, are helped by gentle massage of the abdomen, the introduction of a gluten suppository or the nipple of a rectal syringe. Artificially fed babies are most often constipated because they are usually on a modified food incorrectly ordered. See to it that there is a sufficiency of fat and protein in the mix- ture and that the curd is mechanically broken up by the addition of a gruel. DISEASES OF THE DIGESTIVE TRACT. 207 Oatmeal gruel may be tried in infants sufEering from constipation. Water between tlie feedings must be offered freely. A tablespoonful or two of orange or pineapple juice is decidedly beneficial in infants after the first six months of life. Beef Juice or chicken broth are laxative and may be judiciously employed. If the mixture has been made up with a pro- prietary infant food, this should be changed. If the constipation has been neglected for some time it may be necessary to use soap enemata, four to eight ounces at a time. Glycerin suppositories at first may be tried in conjunction with a proper diet and hygienic measures, and tlien gradually use milder procedures as improvement takes place. By simpler procedures is meant the injection of a few drams of olive oil or an ounce of warm water with a baby rectal syi-inge. The elixir of cascara sagrada (N. F.) ten to thirty drops may be prescribed, or malt and cascara given in the minimum dosage possible to produce a satisfactory / \ movement (one-half to one teaspoonful). As soon as 'i -1 the supplementary measures can be depended upon, the medicines should be abandoned altogether. A regular stooling habit can be cultivated almost V. from infancy by placing the baby on a small commode / at regular intervals and is a prophylactic measure of ' importance in child life. __ The constipation of older children may be corrected syringe for infants. ^J the addition of cream and butter to the food, or in other instances, a greater amount of vegetables and fruit must be ordered. The giving of food stuffs that leave a large residue in the bowel are of service, such as bran biscuit, shredded wheat biscuit, whole wheat bread, graham crackers, agar-agar (the latter to be mixed in about 1 teaspoonful) with the morning cereal. (See special diets, p. 163.) Tak- ing a glass of water on arising, followed by a cold sponging and abdominal massage will cure many cases if regularly carried out, besides improving the general body tone and blood-supply. Calomel, castor oil or the salts should not be given for this condition. They are cathartic in action and tend to produce constipation. Amebic Dysentery. Etiology. — Sporadic cases of ani9l)lc dysentery in children have come under our observation with greater frequency in the past few years. The diarrhea is characterized liy profu.se. watery stools admixed with blood from which the ameba coli can be isohited. It probably occurs much more frequently than is recognized in our Southern States, and because of our colonial possessions it i3 208 DISEASES OF ClilLDItEN. liiore apt to s^in nii e;itiniice iiilo this coniitry. The exact soarr-es of infection are not known Iml in all ]irobaliility tlie inti'slinal tract is infected by Contami- nated drinlles or frnits. The anjciia is a unici'llular hit cit inutile iirutoplasni having a clear outer zone and an inner graiuilar area witli a nucleus and usually some vacuoles are present. Schaudin descrihes two varieties — Kntamelia coloid, a nunpatliogenic organism, an(t Entamelia hystnlytica. a pathogenic organism. Later cliservers have pointed cut that all forms may hecome pathugenic. The I'nited States government refuses admissiim to the Ilawaii.an Islands of any Filipincj whose stools ciinlain anieha (if any kind. Examination of Stools. — Tlic specimen is cdllectcd on a warm glass slide, from a freshly passed stciil. It ilic stimls are nut free, a saline la.xative may be given. The nnicus ]iresent or a slireil itf mucous uiemhrane usually contain the greatest number cf anieba. I.eischmann's stain may be used. Pathology. — The lesions ccaisist of ulcerations in the large intestines or the lower ji.irt nf the ileum. Necrosis of the mucous mendirane over these ulcers soon takes place leaving a dirty edematous, sulinuicous layer exi)osed. The ulcers are generally undernihu'd witli rounded intiltrated edges. In aggravated cases the muscular or even the serous coat m.ay be e.xpcsed and the ulcers are then found extending throtigh the hepatic tle.xure into the recttnn. Symptomatology. \n irregular diarrhea in a child which does not abate after the usual course of treatment should excite our su.spieions and invite careful examinations of the stools for the presence of the ameba. This is especially true if sudden exacerbations occur after a period of apparent quiescence. The stciols are usually very numenms. watery and contain mucus and blood. The blood varies in quantity and is out of proportion to the amount of mucus. During the exacerbations in which the patient will have abdominal |iain and tenesmus, the ameba are more likely to be found in the fresh stool. The course of the disease is rather jirotracted and convalescence is slow, usually cnmiilicated by a secondary anenjia. We have never observed complicating abscesses of the liver or lungs in any of cur cases, althougli these form must dangerous sequeihe in tro]iica! countries. The ameba are jiersistently found in the stools even after convalescence is \nc11 established and the stools are no longer dysenteric in character. Treatment. Prophylactic. — ( '(mtaminated foud and water convey the dis- ease, the latter in turn, being infected iirohalily through the agency of the coininon fly. For the must [i.-irt it may lie regarded as a water horn disease, boiling the water and even the milk is necessary in suspected localities and tro])ical countries. No raw vegetables should be included in the dietary of children residing in locali- ties where the disease is endemic. The jiatient should be kejit in bed at rest until the stouls assume a formed character. This is necessary to ])revent exacerba- tions and complications. The diet should consist uf w.-irm gruels or paps made from sucli ai'ticles as arrowro(d", cornstarch or farina. It is best to withhold milk until the active symptoms have subsided. Kggs and thickened broths may be cautiously added, and finally whe.v and ndlk. Drug Treatment. — One-half to one ounce of castor oil should be given at tlie oulset. Ihiietine in doses of gr. 1/10 increased to gr, ],'i; is given dail.v hypo- derm.itically. The ididominal pain is relieved by hot ttu']ientine stoops, and the tenes}iuis wilh thin stan-h enemata. Wai-m colonic irrigatiiins ut quinine in solutinn 1 to KitKi are dcstru(;tive to the ameba. The syruji uf the iodide of iron is inilii-ated in cnnvalescence as it counteracts the anemia. Change of climate sliunld be ordered if pnssilile and the altendants instructed to carry out typhoid ]iri'i'antions until the stools are entirely free of the infecting agent. CHAPTER XIX. THE ANIMAL PARASITES. These may be conveniently divided into several groups and sub-groups (see table below). Only those that are found with some frequency in childhood will be described and pictured. Parasitic Protozoa. Animal Parasites Found in Childhood: Nonatodes. — Oxyuris vermicularis (thread worm). Ascaris lumbri- eoidcs (rounil worm). Trichina spiralis. Ankylostoma (hook worm). Strongyloides intestinalis. Cestodes. — Tenia saginata (Ixx'f ta]ie-worin ). Tenia solium (pork tape-worm). Bothriocephalus latus (fish tape-worm). Teiria elliptica. Tenia nana. Although infection is more frequent with intestinal parasites among children than in adults, the cases are mainly found in the offspring of foreigners in this country. These parasites are taken to fie the cause of many of the ailments of children by parents frequenting the dispensaries and many of them have been given the therapeutic test without any clinical evidence of the parasites being present. When they are present in any quantities they may do harm, especially in sickly children, hj^ iiii]ioverishing the albumin' content, bv acting as forci,gn bodies in unusual sites, and by poisoning their host through their metabolic products. The evil effect of intestinal parasites is often exaggerated in the mother's niiud. Oxyuris Vermicularis. {Tlirciiil H'or/z/.s, /'/'/( ^Y^)nll.•<.) These are small white filament-like worms usualh' found in the rectum. Tlie female is larger than the male, and usually is found in tlie cecum, imtil impregnated, when it descends to the rectum. The eggs are oval, asymmetrical, about O.Q^ mm. in size. Their inte- rior is filled with a granular yolk, containing a clear nucleus. The oxyuris differs from some of the other parasites in that it does not require an intermediary host. The worms and the eggs pass out of the rectum alone or with the feces, and may directly inoculate a human body. The child may reinfect itself by handling toys, or food, and may infect its playmates. The ova are carried in drinking water or by flies to vegetables and fruits. 2uy 210 di8i:ases or children. Symptomatology. — The worms by their presence may produce irritation of the anus, or it present in sutficient numbers, even a colitis or proctitis may result. The children sleep poorly and scratch about the anus. They lose their appetites, be- come irritable, and even anemic. In girls, particularly, the parasites may invade the genitals, and result in masturbation or in- continence of urine. Sometimes no symp- toms are to be noted. Diagnosis. — An enema of cold water will disclose any parasites present if they are not found in the stools or at the anus. The eggs are found with difficulty in the stools ; more often they are found under the finger-nails of the infected child. Treatment. Prophylactic. By at- tention to the person of the patient, self- inoculation can and must be prevented. Baths, clean finger-nails, restrictive ap- paratus fur the hands or heavy canvas drawers to prevent scratching are some- times necessary. Examine other suscep- tible members of the fanuly to prevent reinfection. Internal. — A grain of calomel or a tea- spoonful of Rochelle salts in water is given to bring down the females from the cecum. Locally. — Daily enemata of saline solution nuiy be given followed three times a week by injections of the infusion of quassia, this to be retained for a time if possible. Further, a 2 per cent, vellow oxid of mercury ointment is applied about and into the rectum at night. This treatment should be persisted in until the bowel is thoroughly rid of the worms, and renewed if any are seen at a later date. Fio. ."hS. — Ox.vnris vermioula- ris : a. se.xually mature female; h, female with ef^fjs ; r, male. {After Heller.) Ascaris Lumbricoides. (RoiiikJ ll'((r//(.) This parasite is round with a smooth body from four to six inches long and pointed at each end. The mouth has Ihivc suckers and teeth. THE ANIMAL PARASITES. 2U The female is very prolific, producing millions of eggs. Tliese are roundeii or oval in shape (see Fig. -jO). It has been proven by experimentation that no intermediary host is necessary. Al- though they normally inhabit the small intestine, they move from place to place. They have been frequently vomited from the stomacli and have been found in the gall bladder and appendix in children. Through its ova it gains entrance to the human in- testinal canal. Round worms are spread by water and uncooked vege- tables througli deposited ova. Symptomatology. — The parents themselves often make the diagnosis of round worms wlien they have seen them passed. When questioned the majority of the patients do not give any symptoms directly referable to the worms, and many have had no symp- toms whatever. The symptoms usually present are loss of appetite, nausea, or diarrhea, occasionally there are pains referable to the abdomen, which are soon forgotten, only to reappear again. Pruritus ani, pavor nocturnus, eliorei- form movements, and convulsions have been observed. A rather constant eosinophilia is present in patients with round worms, and this should be a stim- ulus to examine the feces for ova. By their local action of migration they may produce obstruction of the intestine or even a fatal issue, as in laryngeal obstruction. Diagnosis. — The microscopic ex- FiG. 59.— Aaearis lumbricoides. amination for the ova is readily made 6, cephalic end enlarged, showing and should not be omitted in ques- A, a female ; B, a male natural size; , . , , , . . , ... 'lips (After Peris.) tionable cases havmg an eosmophilia. 212 DISEASES OF CniLDHEN. Treatment. Prophylactic. — Cleanlinet^s of body, a jDure water-supply, and avoidance of unboiled vegetables for children decrease the possibility of infection. Care in tlie handling of the stools of children will also prevent infection of others. Internal. — (.'aloiiiel and santonin is a dependaljle combination for this parasite. A half-grain of each drug \\itli sugar of milk is usually sufficient. Xever give more than a grain of santonin, as poisoning nuiy 1je produced. It is best gi\un «illi some food and in dixidcd doses, 'i'lie stools should be exammed fur o\a eacli week for tliree \\'eeks, as until then tlierc is no posi- tive certaint}' of their aljsence. Several doses nut}' be necessary. Cestodes, or Tape-worms. General Characteristics. — The tajie-worms commonly met with in this country in children are the Tenia niedioeanellata (or saginata) or beef tape-worm, and the Tenia solium or the pork tajie-worm. They are flat. ribbon-lila', jointed jiarasites, yellowish in color, and vary in length from Fid. CO.— I-Iend of Tciii;! s;ii,'iii;it:i. jiiiii-li iii:i,i,'iiilii'(l. Fk;. (;1. — Head of Tenia siiliiuii, shdwiiig scdlo.x, sncliiTs, liddlv^i, .-uul iiddk. ten to twenty b'et. the segiiimts growing smallei' until tlie liead is reached. It is oiil\ ill llie intestinal 1 1'act of man that ilie fully (lcvclo|)dd ]iafasite is found. Tlid (i\M aiv lak'en into the aliiiieiitavN' (ract (d' an animal and tlieir covdriiig is dissiihrd and lliey tlien pass thi'oiigb iiilo the muscles of llie ani- mal and bcdome encysteil there. Such meal is commonly spoken of as lieing "measly." This inlVcIdd meat wlii'U ealen by man allows the lai'va^ to develop inio Ihe la|)e-\\iirii!. Although oci-nn'ing rai'ely, num may himself act as llie iniei'iiiediarv liost and cyslicerci devel(i|i in his oi'gans. THE AXIMAL I'ARASITlib. 213 Tenia Mediocanellata or Saginata (The Beef Tape-worm). These worms may be distinguislied bv tbe appearance of their heads under the magnifying glass. The head of the beef worm is cuboid, sliglitly darker than tbe rest of the body and it has no hooks as the pork worm has ; instead four suckers /**S '^^^^ §'^\ '^^'^ ^^^^^ "'^ ^^^^ bead. Its eggs are smaller - ' ^"^ ^^W\ H i than that of the Tenia solium, and contain booklets. Tenia Solium (TJie Pork Tape-worm or the Armed Tape-icorm) . Tbe bead of tliis parasite which is about tbe size of a pin-bead, lias l)esides tbe four suckers ■ finmd on tbe beef-worm, a set of booklets. They oftim reath nine feet in length. Tbe eggs are round and contain tbe embryo with its booklets. Symptomatology. — In tbe great ma- jority of cases there are no pathognomonic symptoms referable to tbe tenia'. Often it is only when tlie segments are passed tbladder may l)e palpated. There may be some tenderness on pressure over tlie riglit hypoclionilrium. When the inflamma- tion of tlie ducts is secondary to ((jngestion of tlie liver, tliere is less digestive disturliance and milder .iaundice of shorter duration. The treatment is the same as that of .iaundice. Where the inflammation Is induced liy clianges in tlie parenchyma of tlie liver or by certain Infectious dis- eases, treatment must lie ainieil at the underlying cause. Inflammation of the Portal Vein. Suppur.itive ])yle]ilileliitis m.iy oc<:'ur as a secondary lesion resulting from suppuratiijii in some of the org.ans drained by the portal vein or its radicals. Ulcerations of the gastrointestinal mucous membrane, inflammation or ulceration of the liiliar.v duct and umbilical phleliitis in new-born infants whose mothers are septic may spread to the portal system and set up inflammatiou there. Symptomatology. — Local jiain in that jiart of the portal vein involved will follow the sym]>tonis of the primary m:irbid condition. Enlargement anil tender- ness of the liver may lie due to a general hepatitis or to abscesses. The spleen may likewise become enlarged and tender from occlusion of the splenic vein. As pus forms in the imrtal vein, there will be chills, fever, sweating, and general emaciation. Intestinal indigestion with bilious stools and .iaundice usually are present. Although tliere ma.v be remissions, the disease usually ends fatally in a few «eeks. Treatment, Vll that can be done is to tre.it symptoms as they arise and sustain the strength .as much as iiossil)lc. Organic diseases of tlie liver are rare in earl.v life and do not differ essen- tially from adult life. Congestion of the Liver. This condition may lie active or secondary. The active form occurs during certain infectious diseases, esjiecialiy paludism, and in the earl.v stages of abscess of the liver. The secondary form is seen in affections of the heart and an.v other physii-al i-ondition which causes stagnation in the liver b.v checking the access of blood to the ascending vena cava. The organ is enlarged in both forms, but more so in the cases of passive hyperemia. There is usually tcnilerness on ])ressur( over the region of the liver. The treatment must lie addressed to the disease oi local condition that causes tlie congestion, riiospliate of sodium, citr.ite of niagnesium. and other saline purgatives may ))e given to try and deplete the piirtal circulation. Fatty Liver. This condition ma.v be present in v.ii'ious constitutional iliseases. especially rickets and tuberculosis. It is more often secmidary to the latter disease than to any other. Chronic intestinal disorders and blood dyscrasias ma.v also act as causes. The oi'gaii is generally uniforml.v enl.argeil. In some cases the increase in size is very great, but tenderness is absent. There are usually no symptoms, and treatment of the original disease is all that can be accomplished. If there is little eiilai'gement, the conilition cannot be recognized during life, but it is seen to some extent in a l.irge number <>i the autopsies made on .vouiig cliildren. Amyloid Liver. Waxy liver is seconil.iry to prolonged suppuration in any organ, to chronic .ioint or bone disease, to tuberi'ulosis or s.viiliilis. The liver is .generall.v enlarged, with a hard, rounded border and free from pain on pressure. On section, it gives DISEASES OF THE LIVER. 221 a reddish-brown reaction with iodin. Similar elianges also nsiinlly develop in the spleen and kidneys, and the spleen is thus enlarged. There are no distinctive liver symptoms or jaundice. Albuminuria may be present from the kidney affection, and ascites or edema from pressure, gastrointestinal irritation, shown by vomiting and the passage of foul-smelling stools, is often noted. When waxy liver is recognized, it means some form of chronic disease and a grave prognosis. The treatmeut consists in trying to check the original focus of suppuration, in su]iportiiig the patient, and in handling various symptoms as they arise. Cirrhosis of the Liver. This disease is rare in early life and is oftener accompanied b.v enlargemeut Fig. t;6. — Cirrhosis, hyper- trophic due to alcohol given from the time of weaning. than contraction of the liver. The com- monest priniar.v causes are syphilis, alco- hol, and chronic paludism. Syphilitic cirrhosis is seen in early infancy, and i.s perhaps the connnonest form of organic disease of the liver at this time. When alcohol acts as a cause, it is in older children of from ten to fifteen years of age. In chronic malarial, poisoning, there is great enlargement of the liver when this organ is the seat of cirrhosis. There may be secondary cirrhosis, as in adults, from hepatic hyperemia due to chronic c.Trdiac disease, from prolonged olistruc- tioji of the bile ducts, and possibly from infectious diseases, such as measles and scarlatina. The patholo.gy and symptoms do not differ from cirrhosis seen in later life. It is often difficult to recognize the dis- ease apart from the general condition, such as syphilis, that produces it. There may be no symptoms directly referable to the liver. Icterus may or may not be present, but enlarged spleen and ascites are connnon. The treatment must be directed to the primary disease and various symptoms as Ibev arise. Abscess of the Liver. \bscess may follow suppuration within the abdomen, very rarely from the migration of round worms through the common duct, from infectious diseases, and in the newly-JKirn from sepsis. It is very rare, however, and the symptonis are similar to those seen in the adult. The treatment is surgical. Acute yellow atrophy and gall-stones occur with very great r.-ii-ity in early life, and do not differ iri course and symritoms from the same affections in the adult. SECTION VI. THE INFECTIOUS DISEASES. CHAPTIillf XXI. THE EXANTHEMATA. The exanthemata consist of five diseases : scarlet fever, measles, German measles, small-pox and eliieken-2j(x\. All except small-pox are distinctively diseases of childhood ; although any of them may occur in adults. Each runs a definite self-limited course, subject to variations and complications. As a rule, each renders an individual immime to future attacks of the same disease, but one does not confer immumty from another. Two of them may occur izi the same individual at the same time. Each is divided into four stages: the stage of incubation, proilromal stage, efflorescence, and desquamation. The stage of incubation comprises the interval from the time when the contagium is taken into the system until the first symptoms appear. The prodromal stage is the period included between the appearance of the first symptoms and the appearance of the erujition. The stage of efflorescence extends f i-om the time of the first appearance of the eruption until it fades and the stage of desquamation begins. As the great majority of cases run a typical course, such a form of the disease will first be described, always bearing in mind that the many variations and complications which are later described may alter the general picture. Measles. (Rubeola, MorhiUi.) Definition. — Measles is an acute contagious disease characterized by a period of incul)ation. a piodromal stage with fever, coryza, laerimation, cough, and Koplik's spots, followed by a red, papular eruption and a fine desquamation. Etiology. — Xo specific microorganism has as yet l)ecn discovered. The contagium is contained in the nasal, lacrimal, and bronchial secretions. It has hoen transmitted through direct inoculation of the nasal secretions and blood. It is, therefoie, more contagious in the early stage. The con- tagion may extend through the eruptive and desquamative stages. It has PLATE VI Measles, showing tj'pical eruption. THE EXANTHEMATA. 223 Dot the propert}' of clinging tenaciously to such objects as clothing, and it IS doubtful if it is often carried by a third person; surely not as easily as scarlet fever. Epidemics spread rapidly, owing to its transmission on short exposure and to its highly contagious character before the diagnostic eruption appears. Most people have the disease at some time during life; therefore, adults are not immune unless they have already had it. It is most frequent between the first and sixth years; rare before the fifth month, and only 5 per cent, of the cases occur under one year. We have, however, seen it at birth. One attack usually protects the individual from further attacks, but recurrences are more common than in any of the other exanthemata. It occurs in all countries and at all seasons. Pathology. — The skin shows an infiltration of round cells which sur- rounds the sweat and sebaeious glands as well as the capillary blood-vessels which are found distended with blood. The mucous membranes show in- flammatory changes. Other pathological conditions, such as bronchopneu- monia, are not typical of measles. Incubation. — Eight to twelve da}s ; usually ten days. Prodromal Stage. — Three to five days : generally four days. The onset is not usually as abrupt as in scarlet fever. The child appears to liave a cold in the head, has some cough, and a temperature of 100° F. to 104° F., according to the severity of the disease. There is not apt to be vomiting, nor are convulsions common, although either may occur. The coryza gradually increases, lacrimation and the nasal discharge become more profuse, the child grows sicker, and finally the face assumes the puffy appearance with redness about the nose and eyes commonly seen in a severe coryza. Ycrv often a deceptive fall in temperature, with seeming improve- ment of the child's general condition, takes place on the second day, only to be followed the next day by a further rise of temperature and increased symptoms, which continue to increase until the eruption is at its height. There mav he in some cases a regular remittent fever during tlie three or four days of the invasion. Koplik's spots, which are pathognomonic of measles, and almost invariably present, are found on the mucous membrane of the cheeks and lips all through the prodromal stage if inspected in strong sunlight. The first day there are usually less than six of these rose-red spots scattered over the pink mucous membrane, in the centre of which are bluish-white specks. Some are minute, about one-eighth of an inch in diameter. Soon they may increase in number until they coalesce and lose their characteristic appearance as the exanthem comes to its height. Kop- lik's spots are to be differentiated from the rose-colored papules with super- imposed whitish vesicles seen on the soft and hard palate in German ■.'24 DISICASES or L'lIILDHEN. meask'S, scarkt iv\vi\ and simple angina, as well as in measles. A redness of the fauces and pharynx somewhat corresponding to the characteristic eruption on the skin may be seen. Eruption. — On the third or fourth day the exanthem appears on the face in the form of discrete, raised, red, pin-head-sized papules. They are sometimes arranged in crescents. The eruption spreads to tlie neck, chest, back, and arms, and within Ihirty-six hours the "wliole body, including the palms and soles, is involved. ^\'hile spreading thus, the papules on the face ai'e enlarging peripherically until they become confluent and large areas are covert'd. with only lieie and there small areas of intervening normal skin. This process takes place also on the rest of the body in the order in which the eruption oi'iginally appeared. The whole face is swollen and has a charactei-istic mottled appearance when the eruption is at its height. The lids are red and edematous, and the conjunctiva inflamed, tendiiig to keep the eyes half-closed. Photophobia is pronomiced. This condition is usually reached within thirty-six hours after the first appear- ance of the erujition, and continues together with the maximum tempera- ture, coryza and cough, for one or two davs. During the next two days the eru])tion fades and the tempei'ature falls, so that within seven or eight days from the onset of thr first symptoms the temperature is normal and desqua- mation is taking jilacc. Des(|uamation begins in the order in which the eruption a]>peared, often beginning on the face as the exanthem has reached its lieight on the limbs. Tt consists irf line flakes unlike the large lamellffi of scarlet fever. It is completed in one or two weeks. Variations, Complications and Sequellae. — The incubation may last as hing as twenty-one days. There may he no symptoms of rhinitis or bronchitis whatever, tliroughout its course. Eelapses, i.e., recurrences of temperature and eruption, ai'e very rare, but may occur a few days after the tcniperature has become normal. Fever. — Tbei'e are afebrile cases and eases with hyperpvrexia, but neitliei' are common in uncomplicated measles. T1ic I'emission of tempera- ture on the second ibiy of tlic |ii'odromal stage may not occur, but the majoritv of cases show it. .\ eontiuued tem]ierature aftei' the eruption subsides, or a persistent rise of temperature during the first or second week of con\ali'seenee always leads us to suspect complications, particularly bron- cbojincumoiiia or middle-ear infection. Exanthem. — riccasionally the eruption itself is so atypical that a diagnosis can onl\- be made b\' a genei-al consideration of the oth(>r features of the case. Karch' it nia\' I r\theinatous or even vesicular in character. THK EXANTHEMATA., 285 or the papules may be very large or macular from the first. They may vary from the typical red color to purple or, on the other hand, they may be very faint pink. There may be minute hemorrhagic spots about the papules even in benign cases ; or in the severe toxic and often quickly fatal cases the hemorrhagic areas are extensive and siuiultaneous hematuria and epistaxis occur. In weakly children the eruption is often very limited even in severe cases. It may vary in the order of its appeai-ance, coming simul- taneously upon the face and thorax, or even on the thorax or abdomen first. It may subside entirely in twenty-four hours. Entire absence of the erup- tion is very rare, if it occurs at all. Lungs. — Here we find the most common and the most dreaded com- plications of measles. A mild bronchitis with coarse mucous rales through- out the chest is very common during the early stage, and may pass off with the eruption. But often this outcome is not so fortunate, for it niay con- tinue into a chronic broncliitis; or while the disease is at its height the respirations may become more rapid, localized areas of fine crepitant rales appear, and bronchopneumonia may develop. Its course differs in no way from the ordinary bronchopneumonia, being the cause of death in the great majority of fatal cases. It may occur at any time between the beginning of the prodromal stage and the completion of desquamation. Lobar pneu- monia is seen less frequently. The above-mentioned conditions of the respiratory tract make good soil for the growth of the tubercle bacillus, so that measles is one of the most frequent sources of pulmonary tuberculosis in childhood. Continued involvement of pneumonic areas with persistent cough, temperature and bronchitis should receive prompt attention, and the physician should have this complication constantly in mind. Pertussis is a very serious complication. Pleurisy and empyema are less common complications. Nose, Pharynx, and Larynx. — The inflauimatory conditions here may cause enough obstruction to lead to mucli difirculty in feeding or in breathing. Spasmodic croup, a pseudomembrane of streptococcic origin or a double infection with the diphtheria bacillus may complicate the case. Diphtheritic croup complicating measles is very fatal, owing to the rapid descent of the pseudomembrane into the bronchial tubes. Ulceration of the larTOx may cause great edema with extreme dyspnea or subsequently the scar may cause a serious stenosis of the larynx. Ear. — The external auditory canal may be painfully swollen through extension from the skin. Otitis media is often of a mild grade when due to infection through the blood, but severe cases are due to extension through 226 DISEASES or cjiildhen. the Eustacb.ian tube. Mastoid disease lias its usual relation to the otitis media, and is a fairly common eomplicatiuii in the purulent otitis cases. Eye. — Conjunctivitis is of the usual type in a more oi- less severe form. Keratitis and iritis may result and do permanent damage to the eye. Any previous condition may be rendered more active. Other Oiigaxs. — The intestines nre occasionally involved, and the resulting diarrhea is often severe. Stomatitis may occur from the same source. Ccrcbrtispinal meningitis is occasiiiually seen, particularly in the pncuuionic cases. The heart and kidneys arc larely affected in unconipli- eatcd measles, although the kidneys may show transient abnormalities through the urine. Osteomyelitis and suppuration of the joints have been seen, but are rare. Prognosis. — The mortality from measles itself is not high, hut the pulmonary complications render it one of the most serious of children's diseases. Fatal cases almost invariably show lironchopneumonia or less frequently lobar jmeunionia. The mortality averages S to 10 ])er cent., and is greatest dui'ing the first year. i-]pidcmics in institutions often give a high moi-talitv. Prophylaxis. — ■ ]\Ieasles is by no means a mild disease. Tlii-ough its eomjjiications it is productive of many deaths. All i)ossiblc ]irecautions should be taken against exposure, especially of those under three yeai's of age. Isolation should be carried out just as soon as the disease is suspected and sliould last at least three weeks, ('hildi'cu who have heen exposed should be kept segregated fi'om other children for that period. Treatment. — Hygienic and liydrotherapeutic measures are of greater importance than the medicinal treatment. Select a well-ventilated room that is ns far as jiossihlc from dii'cct communication with the rest of the house. The light should he thoroughly subdued with dark shades or eye screens until all photophobia is ]«ist. If the fever is high and causing ill effects, such as delirium, it can be controlled by sjionging with luke wai-m water and by fi'e(|uent driidxs of cool water. If a sedative scimhs necessai'y, small doses of ]ilienaeitin will liaxc the desired elfect (one gi'ain for a two-year-did (liilil ever\' two hours foi- four doses). The cough in the eai'lv davs of the eMi]ilinn is ofleu ti'oublesome and prevents sle(^]i. Small doses of the bromid of sodium with chloi-al or eoilein uiav he given foi' its conti'ol. (Four grs. Viromid with oni' gi'. chloral everv fmir hours for a child of five vears or codein phos]ihate 1 /'? I of a grain foi- one nr two doses.) AniHionium (hlorid and sweetened cough mixlnri's onlv tend to ])roduce an irritable stomach and conse(|uent anorexia. The eyes should he bathed with 4 per cent, boric acid solution. In some cases there is considerable itching PLATE VII. '* , #■ * '■ Rubella (German Measles). THE EXANTHEMATA. 237 ^Ji thu skin, and this may be relieved by inunctions of 5 per cent, ichthyol and lanolin, or 2 per cent, carbolic ointment. The bowels are kept open preterably witli small doses of calomel or eneinata. The ears should receive careful daily inspection for any redness or bulging, and if present incision and drainage of the ear drum may be indicated. By careful attention to the eyes, ears, and nasopharyngeal toilet, many of the disastrous complications oi measles may be avoided. Bronchopneumonia, as a rule, supervenes more often in those cases that have been treated by sweating and administration of liot drinks, thus further lowering the resistance of the child. The diet should be light until the temperature has been normal for several days. German Measles. {Rothehh, Rubeola.) Definition. — ^ German measles is a mild acute contagious disease, hav- ing a period of incubation, a pi-odromal stage followed by a red macular eruption and desquaiuation. It is attended by little if any systemic dis- turbance. Etiology. — There is no known specific microorganism. The disease spreads with great rapidity, the contagium taking place on slight contact. It is conveyed by direct contact, and is probably not carried by a third person. One attack usually protects, but it has occurred in the same indi- vidual a number of times. Xeitlier scarlet fevpi- noi- measles render im- munity, as it seems to bear no relation to these diseases. Pathology. — There is no specific pathology. Symptomatology. — After an incubation of between two and three weeks, during which there are no symptoms, a sliglit coryza or sore throat develops with a temperature rarely over 101° F. In a great many cases these prodromal symptoms are wlioUy lacking, and in about 50 per cent, there is no temperature at any time. There is rarely more than a slight indisposition and loss of appetite. On the first or second day the eruption appears. Often a premonitory general blushing of tlic skin, fading in a few hours, with small discrete macules, deep pink in coloi-, are seen on the face. These rapidly spread to the thorax, and tlienee within twenty-four hours to the rest of the body, hut thev are much more numerous on the face than elsewhere. The eruption never reaches its height in all parts of the bodv at the same time, as it begins to fade on the face before the extremities are reached. The throat is reddened. If there has been any fever it dis- appears soon after the eruption comes out. In two to four days the eruption has faded, and a slight brownish staining of the skin, with slight desquama- tion, is at times seen. The posterior and occipital lymph nodes are very 228 DisEAaiis or ciiildukn. constantly enlarged, even before the appearance of the eruption, and confirm the diagnosis. Iless showed that in almost all eases of German measles there was a definite increase in the lymphocytes, even preceding the appear- ance of the exanthem. This fact should be utilized in institutions where an epidemic is in progress to separate the infected from the non-infected children. Prognosis. — Ifecovery after a short mild course is to be expected. Treatment. — This is, as a rule, mainly symptomatic. Beyond a liquid diet and sponging witli alcohol very little is required. In severer cases the treatment given under Measles may be appropriately followed. Tlie chil- dren are isolated for a period of two or three weeks, and their surroundings should be such as described under Measles. Scarlet Fever. (Scarlatina.) Definition. — ■ Scarlet fever is an acute infectious, and contagious dis- ease, characterized by a sudden onset, vomiting, and a generalized scarlet rash, accompanied by high fever. Incubation. — Varying periods of incubation are recorded. In our experience two to seven days after exposure the symptoms appear. The German authors give an incubation period from eight to eleven days. Etiology. — The specific causative factor is still unknown. It occurs more often between the ages of one to five. Tlie incubation period is tlie least contagious, while the eruptive stage is the most contagious. The stage of desquamation was formerly considered the period of greatest danger. One attack, as a rule, protects the individual from subsequent attacks. The immediate neighborliood of the patient is probably a contagious zone. The secretions, particularly of the nose and throat, are active in carrying the infection. It is not now believed that the desquamated epithelium is the principal agent in the spread of the disease, as was formerly taught. Pathology. — The lesions found vary greatly with the intensity of the infection, and are due to the action of the scarlatinal toxin (streptococcic) or to a mixed infection. The heart muscle and the kidneys show degenera- tive changes in complicated cases. The cervical glands are found liyper- trophied. Symptomatology (Simple Form). — Vomiting is usually the first symptom. Convulsions may iisher in the disease in younger children. The child has fever and within twenty-four hours the rash appears, first upon the neck and chest. It is bright in color, diffuse, pin-point, with no areas of healthy skin in between ; it rapidly spreads downward to the arms. THE EXANTIIEJIATA. 22^ trunk, and legs. The face is not as much atfeeted as the rest of tlie body. Sometimes hardly any rasli appears there. The rash is accompanied by a variable amount of pi'uritus. The tongue is coated quite heavily and often has the so-called ras})berry appearance, due to the injection of the papillffi. Later the tongue takes on a red beefy appearance, when the coating disap- pears. The fauces and tonsils are congested. The fever ranges from 103° to 104° F., with a rapid pulse. The glands in the cervical region are tender and often become swollen, especially in the later stages of the disease. Tlie urine will show traces of albumin, which is often only temporary. It is apt to be scanty and high colored. The blood shows a leukocytosis, while a differential count may assist in the diagnosis by showing an increase in cosinophiles quite early in the disease. Desquamation. — This begins witli the fading of the rash about the second or thii-d day. The skin appears in fine scales, usually seen first on the face and about the joints, then over the ).)ody. On the hands often large sections of skin are shed. The process lasts many days, sometimes weeks, but can generally bo assisted by the treatment given below. Anginal Form. — The tonsils and retropbarynx arc congested. The tonsils may show exudation in their lacunar spaces, and tlie cervical lymph- glands are much enlarged. In another form, a meudu-ane nuiy be present on ))oth tonsils, spi'eading to the adjacent fauces, and gave rise to the false tei'in of diphtheritic scarlet fever. It is due to a streptococcic infection, and should be regarded as the septic form of this disease, as in these cases there is always more or less general systemic infection. The fever in this form is usually of a remittent character and will be influenced by any complications that may arise. The severe foi-ms cause prostration, stupor, or profound coma. The temperature remaining about 105° F. with rapid pulse. The urine is scanty and high colored. Deglu- tition is extremely difficult. There is marked restlessness. The membrane may invade the nose or larynx, the lips are fissured and excoriated, while the breath is extremely fetid. Koutine examination of the ears will show some degree of involvement in more than a fifth of the cases ; if the patient goes on to recovery the Ivmph-glands are apt to degenerate with the formation of abscesses. Men- ingeal symptoms may precede a fatal issue. The mastoid cells may become diseased after convalescence has set in. Septic thrombosis and cerebral abscess are fortunately rarer complications. The otitis media of scarlet fever may persist, and become the cause of partial or absolute deafness. 2.'!() DISEASES OF CHILDREN. Kidneys. — Modern methods of urine examination will show traces of albumin and a few liyalin easts even in mild attacks. This should not be regardetl as a true nephritis. The septic form of the disease through the agency of its toxins is more likely to be complicated by a true nephritis. Puffiness of tlie eyelids and face, edema about the ankles sjjreading to the rest of the body will be the lirst objective signs. The urine then per- sistently contains albumin and mixed casts, with a high specific gravity. The nephritis usually lasts through a protracted convalescence or may become chronic. Uremic symptoms begin with vomiting or convulsions, sometimes only convulsive movements are observed. Coma with feeble heart action arc symptoms of grave peril. The liASH. — The development of the rasli, usually after twenty-four to forty-eight hours, offers considerable information of value in differen- tiating scarlet fever from the confusing erytliematous eruptions. The ex- aminer sliould place his patient in a good wliitc light. A magnifying glass and a glass slide, such as is used for blood and sputum, will be found to be exceedingly helpful in studying the cxantliem. The rash first makes its appearance on the sides of tlie neck, upper par-t of the chest and face; thence spreads to the arms, upper part of the back, and finally involves the trunk anil lower extremities. Its color is not scarlet, but a dull red, almost a brownisli-i'cd (Fig. :^, I'late TX). Tliis color varies ]iroportionatelv to the fever, being more marked usually in the evening. The general char- acteristics of this rasli about to be described will always he found present in a true case of scarlet fever, even tliough certain modirications or variations are observed. Close inspection of the rash resolves it into two factors, which are constantly present: 1. .\n erythematous background; 2. small, deep red. injected puncta (Fig. 5, Plate IX). Souietimes variations in the rash just described are present which give a diffuse, a mottled, or a speckled appearance. These changes are caused either by the closer merging or by the non-extension of those puncta with their erythematous areola. ,\ normal or pale flesh tint is seen on pressure with a glass slide early in the disease, while later there is a dirty, yellowish-red pigmentation. Itching is quite a constant symptom, but is more marked when many groups of miliarv vesi- cles are pi'csent. .\t the height of the eruption it is often possible to find small pin-point, conical, whitish vesicles, with a serous content, over the chest and lower alidomen (Fig. 1, Plate IX). '\^^len they occur in c-roups about the axilla' or in the groins, they are quite confirmatory from a dia"'- nostic standpoint. Tlie harsh, uneven feel which the rash occasionnllv irives to the hand passed over the skin is dui' In papular or even vesicuhii- eleva- tions occurring at llie sites of tlii' hair follicles. This papulation affords PLATE VIM. Rash of scarlet fever. THE EXANTHEMATA. 231 IS rasli. another valuable aid, as it does not disappear with the erythematous but the roughness of the skin persists after it has faded. Certain regional characteristics are present in this e.xanthem, which, if appreciated, tend to help tlie puzzled physician. The face, for example, shows the true rash only on the temples; tlie cheeks are profuselv red, hut ine nose, chin, and upper lip appear nnduly pale, causing a circiim-oral pallid ring which should he sought for in suspected cases, as it is not ])resent m the counterfeiting rashes. Ihe flexor surfaces of the joints deserve careful scrutiny and special mention. Tliese regions i-arely exhibit the characteristic rash; they are apt to he the site of petechial hemorrhages or else they have a blotchy appearance. If the palms and soles are examined with the magnifying glass, no puncta are seen, only a simple erythematous blush. DES(^rAjrATio.\. — In tlie exfoliation of scarlet fever we expect to find it occurring in tlie order of the appearance of the exanthem. At first there are observed fine discrete scales in the infraclavicular and episternal regions (Fig. (I, Plate I.\). These scales ai'e made up of the epidermal covering of the above-descriijed puncta and vesicles. Wlien des(|uamation Hrst occurs flakes having a perforated centi'r are cast off. This is known as "pin- holing." Later, and continuing fur fi\e to seven weelcs, tlie skin becomes rougher, throwing off irregulai' rings of desi|uamation of varying extent. The large strips of epithelium and casts of the hands and feet, which are sometimes shed or torn away, ai'e more often seen in tliose suljjccts who have a skin of coarse texture. Another diagnostic feature of this stage of desquamation is seen in the finger-nails. If the pulp is pushed back from the nail, there will he seen just beneath its free border a scaling or cracking line which extends up to the fingers. Four to five weeks after the beginning of the disease we may find a transverse linear groove, sometimes with a corresponding ridge, which shows itself on the roof of the nail. The thumb-nail exhibits tliis condition better than the fingers. These nail changes serve as corroborative evidence in the subserpient diagnosis, and this desquamation may be seen on the nails when other evidences are not found elsewhere. On the other hand, it must not be forgotten that the desquamation may be so slight as almost to escape notice. Unfortunately, desquamation alone is often regarded as sufficient evidence of the disease, and a diagnosis is based thereon. In view of the fact that so many of the erythematous eruptions produce skin exfoli- ation, we are not justified in this conclnsion, nnless we have (1) the ^'■V-i DISEASES OF CIIILDIIEN. regional m\"(ihx'inciit. (2) tlic piu-holiiig, and (3) the nail clianges^ plus other pertaining elinieal symptoms. The Toxgte. — The tongue m tlie hrst da^vs is usually thickly coated, and the papilhv are oljseured, but as tlie tongue clears up at the edges and tip, we can observe the enlarged papilhv (Fig. i, Tlate IX), wliich become more and more prominent, and sliow at tlieir best about the fourth day. The lingual mucous membrane now begins to exfoliate; tlie tongue beconres red, dry, and glistening. It is in the jiosteruptive stage tliat this feature is particularly of diagnostic importance. Ti-iE Blood. — Tlie lilood in scarlet fever has been carefully studied, and may l:ie of service in obscure cases, as an additional confirmatory linlc. The red blood-cells are gradually diminislied tbrougliout the course. A leukocytosis is piresent a ilay or tivo l)efore the appearance of the rasli, and the normal is regained only in convalescence. We have found this leulvocy- tosis to be ];irnportionate to the severity of tlie angina. Tlie polynnclears are increased and tlie mononuclears decreased, lioth relatively and absolutely. To the eosinophiles we may look for some rather characteristic variations. In tlie initial stages tliey may disa])pear almost entirely, while in deferves- cence, and later to the si.xth or seventh week, 8 to 12 per cent, may be counted. Differential Diagnosis. — 'Tlw Eriiiliomain. — Erytiiematous eruptions which may simulate the rash of scarlet fever are quite common ; and if a careful examination and study nf the rash is not made, weighing with it all the clinical evidence, mistakes are easily made. The simple form of ery- tlienia results from external iri'itants. while the exanthem of angioneurotic origin results eitlier fi'om systemic disturbance, ingestion of certain drugs, or from specific poisons. These fortunately have certain characteristics which should be borne in mind, for while we are not always able to distin- guish them one from the other, the differentiation from scarlet may be thus made possible. One of the striking features is the tendency to recurrence, and undoubt- edly many of the so-called second and third attacks of scarlatina have been in this class. In a general way these dermatoses are distinguished by the following peculiarities: They may ajipoar in any region of the body — at one time there may be present in the erythema elements of the various exan- themata. Their type may rapidly change so that they may be scarlatini- form one day and rnorliilliform the next. The puncta seen in tlie scarlet fever exanthem are aljsent. Desquamation is coarse and flaky, and recur- rences are fre(|uent. THE EXANTHEMATA. ^'-jJ Erythema Scaelatiniforme. — This is a non-contagious dermatitis, simulating scarlet fever in its cutaneous manifestations. It is liable to occur seconclaril}' to other infectious diseases and to medicinal and food intoxication. As it is important to differentiate the disease from scarlatina, its distinguishing features will therefore be given. This erythema spreads very rapidly, sometimes reaching its height in a few hours. Patches of erythema may alone be present. Under the glass there is no rmiforui redness. The face is rarely involved and the tongue shows no '' raspberry "' ajapearance. The fauces may be red, but are not swollen. Desquamation takes place at an early date after the erythema, sometimes on the second day ; it is a quick process and the scales are large, abundant, and f\irfuraccous. The course is l)rief, and tliere are no compli- cations or sequela?. Such a clinical picture, especially in a child who has given a history of previous similar attacks, should exclude scarlatina. A scarlatinoid erythema may follow the use of such drugs as belladonna, qninin, chloral, chloreton, salicylic acid, antipyrin, digitalis, opium or veronal, especially in those patients having a drug idiosyncrasy. Tliese eruptions almost invariably follow very quickly after the ingestion of the drug. We have seen it occur within an hour after a dose of antipyrin. The close relationship to the drug taking is a diagnostic feature of consider- able value. Belladonna rashes are perhaps most often seen. This eruption is usually confined to the face, neck, and chest, and is only rarely general- ized. It fades quickly and is rarely followed by any desquamation. The absence of fever, the dilated pupils, tlie evanescent rash and the history should cause no confusion. It is well to recollect that drug rashes in general, and in conti-ast to scarlet fever, appear for the most part on the extensor surfaces of the extremities, and if they be present on the face, then the circumoral ring is not observed. Moreover, they are not associated with fever, angina, or adenitis. If any doubt still exists, the repetition of the dose of medication under suspicion should be gi\-en to reproduce the erythema. Acute Exfoliative Dermatitis. — Another disease which may raise a veritable doubt in the stage of efflorescence or in the desquamative period is acute exfoliative dermatitis. It differs in that the constitutional symp- toms are more pronounced than in scarlatinoid erythema, while the eruption appears as a general hyperemia very soon covering the entire body. The exfoliation follows in a day or two, and is general in cliaracter and intensely profuse; large papery strips being cast off (Fig. 8, Plate IX). The nails and hair may drop out before the process is complete. 15 234 DISEASES OF CHILDREN. Another disease which necessitates correct interpretation is tlie acar- latinifunit rariety uf rubella; fortunately, tliis is not a common type (Fig. 7, Plate IX). Close inspection of the rash will disclose morbilliform char- acteristics. The mild constitutional symptoms and tlie enlarged postcervical glands of rubella will define it. Seruui Bashes. — The use of antitoxic serum may be productive of a scarlatinoid rash that is very puzzling. This is especially true when anti- diphtheritic serum has been injected. The angina of the diphtheria is already present and cannot assist us, while fever and malaise supervene. We must then depend upon the following facts : That the rasli frequently spreads from the site of the injection ; that these rashes are often polymor- phous in character and fleeting in duration. They appear on the third or fourth day, the eruption occurs usually in patches and only rarely appears on the face. A well-marked enlargement of the superficial lymph-glands in the inguinal, axillary, and epitrochlear regions will also help to distin- guish this rash from scarlatina. Open wounds and especially burns are liable to direct inoculation. Many of tlie so-called cases of '" surgical scarlet "' of the older writers were probablv scarlatinoid erythemas or what we now recognize as septic rashes. For our guiilance in differentiation the wound is of considerable help; an erstwhile healthy wound may begin to look unhealthy, and an exudate may form upon it. The rash is very likely to first appear at or near the wound. The neai-est hniphatic nodes will be found tender and enlarged. Vomiting may occur, but sore throat is rarely complained of. There are no charac- teristic changes in the des(|namation. The Septic rashes which were i-cf erred to above occur more often in earlv life, and either precede or accomjiany a definite septicopyemia. Occa- sionallv thev may indeed he the first to call attention to the true condition of tlie patient. When tlie rash is small and macular, it may resemhle scarlet fever. Its spotted character and the huge nuicules which are seen on the extensor surfaces of the extremities with absence of i^uncta fix the diagnosis (Fig. 0, Plate TX). A high leulcocvtosis would ho confirmatory. From ervsipelas, scarlatina can be distinguished by the shining, glazed appearance and characteristic spreading. The Fourth or Duke's disease is of interest in this connection because of its confusion with scarlet fever, jn'ovided we accept the dictum that attacks of the Fourth disease do not protect the individual against scarlet fever and uieasles. The disease is described as differing from scarlet fever in its longer incubation period, absence of prodromal symptoms, such as vomiting, high pulse rate, and severe angina. The rash itself shows but PLATE IX. The differential diagnosis of scarlet fever and the Scarlatiniform eruptions. 1. Scarlet fever rash showing sudaminal vesicles. 2. The fading scarlatina erup- tion. 3. Scarlatina eruption, early stage. 4. Typical scarlet fever tongue. 5. The scarlet fever rash, magnified. 6. Scarlet fever desquamation. 7. The scarlatinal form of rubella. 8. Acute exfoliative derrnatitis. 9. Erythema in- Icctiosa. (Pisek's original plate ; courtesy Archives of Diagnosis.) THE EXANTHEMATA. 335 ittle difference except that it usually begins on the face and is not exten- i^'e. The desquamation, ho-vvever, is profuse and out of all proportion to the exantheui. Renal complications do not occur. As the practitioner is often called upon to offer a diagnosis at different stages of the disease, the distinctly helpful phenomena to be observed at "various stages in scarlatina will be given. -rUEEKuPTivE STAGE. — Here the diagnosis is only rarely possible and trien it can be made only in the pi'esence of an epidemic and a history of •contagion. The sudden invasion with an angina, bright red puncta seen in the roof of the mouth, and initial vomiting without satisfactory cause, may be symptoms anteceding the eruption. The polynuck-ir cells are increased, while m rubella the lymphocytes appear in greater numbers. Eruptive Stage. — The diagnosis is at this period rarely obscure. The vomiting, higli pulse rate, characteristic punctate rasli, congested fauces and evidences of tlic " raspberry " tongue are usually conclusive. Pkedesquamative Stage. — The rash has faded or disappeared, and desquamation has not yet begun. Here tlie distinctively glazed, papillated tongue and the injected fauces are seen. The enlarged lymph nodes be- neath the maxilla are tender to the touch. The skin looks dirty yellow under a glass slide, and has a distinctly dry and uneven feel. Sudamina or miliary vesicles may be jjresent in groups. Desquamative Stage. — ^\1ien the disease is seen late, exfoliation beginning on the face may be found on the fourth to the sixth day of the disease, and on the neck and chest about the twelfth to the fourteenth ila\-. On the palms of the hands and soles of the feet it persists sometimes for weeks; this possibly ser\ing to differentiate it from the scarlatiniforin erythemas. " Pin-hole '" scaling on the body and the lines on and lieneath the finger-nails strengthen the diagnosis. It is not uncommon to find still further cori'oborative evidence at this stage in complications of the kidneys, joints, in the ear or in suppurating cervical glands. Prognosis. — In the mild cases tliis is extremely good. The septic cases in the epidemics raise the mortality. In this country the mortality in several epidemics averaged 3 per cent. IvTephritis is the most common complication and often a fatal one through uremia; the chronic form react- ing badlv to treatment anil often ending in death. Otitis and its compli- cations may result in deaf-mutism or have a fatal issue through the involve- ment of the brain or sinuses. The involvement of the serous membranes of the heart or Joints tends to a grave pi-ognosis. The older the patient the better the prognosis. t.':if'> IllSKASES OF Ullll.UliEN. Treatment. Prophylactic. — Tlie loutine examination of school chil- ilrwi whicli is now practised in a number of tlie largest cities ^vill notably tend to diminisli the niindjer of scarlet fever cases and prevent epidemics. Isolation should be insisted upon, and be carefully carried out even in mild or suspected cases. Children or even ailults wlio have been subject to pharyngitis or tonsillitis ai'e more likely to take or spi'ead the infection. Air and sunlight shouhl lie I'cgarded as tlie best disinfectants. Children from whom enlarged tonsils and adenoids have been pi'evi- ously removed are less lial)le to such complications as otitis and sinusitis. Sick-room and Quarantme. — A quiet sunny room that can best be used for puiposes of isolation should be selected. An open fire-place is preferable to any other form of heating. All unnecessai'y furniture should be removed, a gown or sheet and a howl of bicldoi'id of mercury (1/1000) should be placed in readiness in an empty closet outside of the room for tlie use of the doctor. During convalescence toys of little value, tliat can be burned, should be provided so that the period of ijuaj'antine. which is usuallv six weeks, may Jiot be too irksome for the child. Disinfection can lie cari-ied out as described on i)age 300, when the jiatient is ready to be discharged. Routine Measures. — All cases of scarlet fever, whetlicr mild or severe, should be regarded as dangerous, as the com]>licatio7is and scr|uehp may permanently injure the patient. Skilled nursing will do more to promote the comfort, progress, and tlie preventinii oF eompliealions tlian remedial measures. If circumstances will not ]iermit of a trained nurse, some one member of tlie household should be ]iut in charge and given careful instruc- tions as to the quarantine regulations and written orders for the patient. The diet should consist wholly of millc in the first few days of tlie ill- ness, later, for the sake of variety, fruit juices, whey, buttermilk, or matzoon. may be added or substituted. Vriien convalescence is established, gruels, crackers, well-toasted hrcad, and apple sauce may 1ie added to the dietary. Vegetables and eggs are allowed in the fourth or fifth week if there is no fever or other contra- indication. "\^'ater should be offered often and freely tliroughout the illness. The skin should be anointed with a ."i per cent. l)oric acid ointment or with ]i(|uid albolin daily as soon as des(|uaiiiation is cstalilished. Tf the pruritis is troublesome a 1 or 2 per cent, carbolic acid ointment will be effective in its control. The nasopharyngeal toilet should be made dailv Avith a mild allvaline antiseptic oi' a normal saline solution. Hie metliod employed will (hqiend THE EXANTHEMATA. 237 upon the age of the child. Those who are old enough and willing may gargle. A spray or irrigation is necessary for the obstreperous or septic cases. The solution may be instilled with a medicine dropper into the nares of infants. The Urine. — A specimen should be obtained for examination (see Methods, page 437) three times a week. If this is done the complicating nephritis will be detected early and proper measures can be taken at once. Symptomatic Treatment.— The fever, if high, above 104° F., can be controlled by sponging with water 85° to 90° F. every two or three hours. Cool packs are rarely necessary except in those cases in which there is con- siderable restlessness and delirium. The child may then be wrapped in a sheet as described on page 70 and left in this for a few hours if sleep is produced. Heart. — Persistent high fever, especially in the septic cases, may weaken the action of the heart so that the pulse becomes soft and somewhat irregular. The first sound is not distinct and the pulse rate becomes high. Stimulation with strychnia alternating with the tincture of stroplianthus is now indicated. Alcohol in the form of sherry wine (vini xerici) may be substituted profitably in the septic cases. One to two ounces may be given freely diluted in water during the twenty-four hours to a five-year-old child. Normal salt solution, two to three ounces, given by hypodermoclysis may tide over a critical period. The bowels are kept open preferably with the effervescent citrate of magnesia. Constipation, which is so often present on a strictly milk diet, will not be so troublesome if the dietary is varied as outlined above. The milk of magnesia may be added to the bottle in infants. Complications and Sequelae. — The cervical adenitis which so often occurs requires the use of ice-bags or compresses of a saturated solution of magnesium sulphate in the early stages. Ichthyol ointment 20 to 30 per tent, in lanolin is applied daily wlien the acute symptoms liave subsided. The abscess must be incised and drained if fluctuation denoting suppuration is detected. Nephritis will necessitate the continuance of a liquid diet, alkaline diuretics, or such drugs as diuretin or agurin, and in the graver cases high colonic irrigations of saline solution twice a day imtil the normal amount of urine in secreted. Otitis. — The ear drums should be examined every other day as a routine measure, and any redness and bulging should receive prompt treat- ment by incision and drainage as outlined on page 546. If this is done, chronic otitis and mastoid infections with their sequela may be avoided. 2".S DISEASES or CHILDIiEN. Arthritis occasionally occurs as a complication which prolongs the convalescence, and if neglected ma}' cause joint deformities. Artluitis at times occurs as a complication, usually- in the third week. A normal con- valescence may be disturbed b_y a rise of temperature which cannot be accounted for. In about 24 hours the patient may complain of pain in the joints, principally tlie knee, the wrist, or the joints of the fingers being affected. The pain is best elicited by transverse pressure across the joint. We liave occasionally obsei'ved a fine erythematous rash preceding the arthritis. Pi-olonged hot baths and the ap]>lication of a saturated solution of magnesium sulphate give most relief. Small doses of aspirin are soiiietinies needed. The Serum Treatment. — Except in those cases whicli by culture give evidences of an added Klebs-Loelfler infection, serum therapy as thus far elaborated is without value. Diphtheria antito.xin should be administered in those cases in which a true diphtheria is present, clinically or by culture. Small-pox. ( Vnriuln.) Definition. — Small-pox is an acute contagious disease characterized by a j)erioil of incubation, a prodromal stage with intense constitutional symptoms, followed by a progressive eruption of macules, papules, vesicles, pustules, and cicatrices. Etiology. — Specific. — Councilman in 1003 discovered a protozoan in the skin of small-] >ox patients. The relation of tliese parasites to the skin lesions is of such a definite and intiiriate character as to lead to the conclusion tliat they are the cause of the disease. They have a double life cycle, intracellular and intranuclear, wliich they undergo in the epithelial cells. In the flist cycle they are small homogeneous bodies found in vacuoles in the cells of fhe lower layer of epithelium, and ilevelop there into large ameboid multi-chambered organisms, destroying the epithelial cell and by segmentation bi'eaking up to form the protozoa of t1ie second cycle. These in\ade the nuclei of othei' ejiithelial cells and continiu^ tlieir growth until the cell is dostroy<'d. The ]5arasite has not been found free in the vesicle contents, nor anywhere, as yet, except in prepared sections of the skin. Non-specific. — The conlagiuin exists in the secretions and excretions, in tlie skin lesions, and in the dried scales and crusts that come from them. It clings to everything with which it comes in contact, and may therefore be f I'ansiiiifted by a third pei-son ; all ])iiblic places ai'c thus dangerous for an unvaccinated individual during an e]iideuiic. Tt is probably contagious during fhe proilronial stage as well as throughout the course of the eruption PLATE X. Differential diagnosis of variola and varicella, (o) variola; (b) varicella. THE EXAXTHEilATA. 239 and desiccation. A very virulent case of variola may be contracted from the mildest varioloid. A'accination protects for a variable time (six years to a lifetime) in different individuals, and always lessens the danger and sever- ity of an attack. One attack protects for life. Pathology. — The papule is seen to be a focus of coagulation necrosis in the rete mucosa, surrounded by an area of active inflammation. The vesicle is made up of numei'ous recticnlae and spaces which contain serum, leukocytes, and fibrin. AVhen the pustule involves the true skin a per- manent scai' results. Incubation. — Twelve to fifteen days. Prodromal Stage. — Three or foui' days. Symptomatology. Description of Prodromal Stage. — This is ushered in with convulsions, vomiting or a chill, and in older cliildren severe frontal headache and backache are complained of. The temperature quickly rises fi'om 103° F. often to 106° F. Tlie pulse becomes ra]>id and full, and within twenty-four hours there may be delirium and marked rest- lessness. This condition continues with no diagnostic signs on tlie skin usually for four days, wlien the erujition appears. Simultancouslv tliere is a fall of temperature even to normal in the less severe cases, and marked impi'ONeuient in the general symptoms. The Exanthem. — At first the exanthein is in the form of small raised red papules, most commonly developing on the foreliead, particularly at the junction with the hair, and on the wrists. They I'apidly extend to the rest of the face and to the extremities, including the palms and soles, and in less numbers to the ti'unk. They all come out in one ci'op within twenty- four hours. They feel hard and have the so-called " shotty " touch, be- cause they extend deeper into the skin than other jiapules, as, foi- instance, those nf chicken-pox. These same red papules are to be seen on the hard and soft jialate and ]iharyn\, causing an accompanying soi'e tliroat. In two days, sometimes less, the papules on the skin becouie vesicular, with a slight depression in the center of each vesicle, and if ju-ick'od with a needle the\- do not collapse because they are divided into many parts by a reticular construction. They still have an indurated reddened Itasc. On the eighth dav of the disease, four days after their first appearance, the vesicles be- come full and rounded and the serum in them changes to pus. The skin becomes tense and swollen, and the individual lesions enlarge, so that in tVie severe cases (confluent form) they coalesce and the face appears much swollen and changed beyond recognition. This is accompanied hy a second rise of temperature (secondary fever), and a return of the constitutional symptoms with redoubled vicor. The delirium returns, the pulse grows 240 DISEASES OF CHILDREN. weaker, and the patient shows every sign of a severe intoxication. In the fatal eases this may go on for two or three days with increased severity until death results. But in the milder cases, within twenty-four to tliirty-six hours after maturation takes place, the pustules hreak and the pus exudes, and on the tenth or eleventh day the temperature begins to fall by lysis. The pustules rapidly dry with the formation of crusts, and usually during the third week the temperature becomes nornuil and the desiccated pustules alone remain. These may adhere for a week or longer until at last tliey fall off and leave the scar or pit which may, especially in tlie confluent form, be carried throughout life. A leukocytosis occurs in the pustular stage, but at no other time unless tliere is some complication to cause it. Variations, Complications, and Sequelae. — There are really four forms of small-pox, differing chiefly as to their severity; varioloid, discrete, confluent, and hemorrhagic small-pox. Varioloid is a pox modified by a previous vaccination, and does not often occur in children, since a child that has been successfidly vaccinated is generally immune until after puberty. Tlie mild discrete form is also unusual, l)ecause in unvaccinated children small-pox is apt to run a very severe course. These two forms are mild and differ only in degree. The symptoms are all milder than in the other two forms, although the initial temperature may be high. The papules are fewer in number, particularly on the face, and do not coalesce. The disfiguration is less. There is less secondary fever from suppuration (in varioloid often 7nore) and convalescence is therefore much more rapid. In the confluent form the eruption is apt to appear earlier, about the third day, with a lesser fall of temperature upon the advent of the eruption. Thei'e is nmre swelling and distortion of the features during tlie sup]uirating and coalescing stage and more pain. Delirium, ceaseless, restless move- ments, and other nervous manifestations are pi'ominent in children. Diar- rliea is also peculiar in children. The larynx and phai-ynx may be greatly swollen. Edema at times being tlie cause of death through suffocation. The cervical glands are much swollen and may suppurate. Hemorrhagic small-pox may show itself either before the real eruption apjiears or at the time of suppuration and secondary fever: the earlier the hemorrhage, the greater the danger. At first there arc small punctifoi'ui hemorrhages. Tliey rapidly increase in size, and soon liemorrhages appear fiom the mucous memljranes, hematemesis, hemoptysis, cpistaxis, and hematuria develop. Large conjunctival hemorrhages with deeply sunken cornea com- ph'te the picture. The pulse is rapid and the respirations frequent. On the other hand, hemon-hagc into the vesicles themselves, with abortion of THE EXANTHEMATA. 241 the rash and speedy recovery even in cases tliat wei'e previously considered severe, have been noted. Other complications are edema or necrosis of the larynx, wliich may be fatal. Bronchopneumonia is common, wliile heart and kidney complica- tions are rare. Arthritis going on to suppuration, and acute necrosis of the bones liave occurretl. The eye may be permanently injured by inflam- matory changes. Otitis media may complicate. Boils, acne, and ecthyma are apt to be troublesome sequela'. Prognosis. — ^ The matter of previous successful vaccination is the most important item in the course and termination of small-po.\;. In one large epidemic the mortality of the unvaccinated was 54 per cent., while that of the vaccinated was I of 1 per cent. In children it is particularly fatal. Of .■>,164 deaths in the great Montreal epidemic, S.5 per cent, of these were in children under ten years. The younger the child the more serious the course, and tlie more fatal the outcome. The hemorrhagic form is almost invariably fatal. The more numerous the lesions on the face the more grave is the prognosis, as is seen in tlie high mortality of the confluent form. High fevei', delirium, continued convulsions and other nervous symptoms are particularly dangerous. Laryngeal and pulmonary complications are very fatal in children. Prophylaxis. — Vaccination is the measure whicli, if thoroughly car- ried out, would eradicate this disease. The strictest quarantine regulations must be enforced even in suspected cases; all individuals exposed are to be imnu'diatcly vaccinated. The di.'- mand of scliool boards that all children be fre(iuently vaccinated has been followed by the most satisfactory results. Treatment. — If the patient has not l)een vaccinated, and is in the incubation stage, the ravages of the disease uuiy be prevented and only a mild course observed, if he be immediately vaccinated. The high fever is controlled by cold sponging and the use of the ice-bag imder skillei! super- vision. The racking pains are best controlh'il in children by Dover's pow- ders. Water is freelv demanded and sliould be freely given. Convulsions and other nervous phenomena may be prevented and relieved by insisting upon a cool temperature in tlie room ; prefei'atily -at fi5° to T0° F. The diet should be liquid during the febrile period. A 4 per cent, solution ,of boracic acid should be used for the eyes, mouth, and nose. A 2 to -5 per cent, ichthvol ointment will very effectively control the itching in the erup- tive stage. A great deal may be done for the patient during the stage of suppuration. Welch, who has had a large experience, recommends the application of a mi.xture of olive oil and lime-water -} oz. each with carbolic 243 DISEASES OF OIlll.DKKN. acid ten to fifteen drops. Elbow sleeves will effectively prevent the child from scratching and tluis causing pitting and distigurenient. Martin states that he can pievent pitting by treating each pustule hy incision and drain- age. The patient's strength is to be carefully watched and strychnin pre- scribed at the first signs of a weakening heart. In the convalescent stage, forced feeding will serve as the best tonic treatment. Vaccination. Definition. — A'accination is the iniioculation of an individual with the virus taken from tlic vesicle of a cow that has vaccinia or cow-]iox. Etiology. — It is now known that vaccinia is caused by a protozoan which ri'scmbh'S tliat of small-pox, hut which differs from the latter in that it has onl\' one life e\'cle. the intracellular form described under the etiology of Su)all-pox. Value of Vaccination. — In the immense majoritv of cases vaccination renders the individual immune from small-pox for many years. Before it was generally practised terriblv fatal epidemics swe]>t over different parts of the ^\orhl, carrying away cnoruious nuudiers of victims. I?otch stated that in the last fifteen years no deaths fiom small-pox occurred in Boston in children who had heen vaccinated uiiiler five years of age, and at the same time the mortality in the unvaccinated was 75 per cent. Where small- pox is ac(|uired after successful vaccinaiton, even years after, it is the mild form, called varioloid. When to Vaccinate. — Every infant should he vaccinated ]5referably between the fourth and si.xth months of life, before teething has begun and bcfori' the child can disturb the dressing. An acute or a severe chronic disease is a contraiudi( ation exeejit in an emergencv. IJevaccination is advisable at pul)erty, and at any other tiuie when the child has been exposed to small-pox or during a general epidemic. If an unprotected child is vaccinated within two days after exposure to small-pox, it will probablv not contract that disea.se, and if vaccinated within five days thereafter the small-pox will be modified, and it will convert a possibly severe case into a mild one. Method of Vaccination. — Only sealed tubes or ipiills should be used. Boys ai'e vaccinaied on the left arm at the insertion of the deltoid, girls on the thigh or calf. The skin is cai'cfullv cleaned with soap and water and a piece of steiile gauze. Tf is then washed Mdth alcohol and alhiwed to drv. .\ large sewing-needle is sterilized by beating over a lamp. The skin is pulled taut without touching the place to b cases the eruption is ))rofuse on the vulva and nates, with consequent vesical and leetal tenesmus. Occasionally one or two of the vesicles become infected and moi-e or less deep destruction of tissue results. Cases of high fever and pustulation of all the vesicles, lasting a week or longer, have been reported. A depression in the center of each vesicle, tliat is, umbilication, is not typical, but it occurs often enough to be misleading in dift'erentiating an atypical case from small-pox. Albumin in the ui'ine is not uncommon, but true nephritis is rarely seen, except in an unusually severe case. Acute simple inflammatory in- volvement of the joints, lasting only a few days, has been noted. Otitis and pneumonia are rare complications. Prognosis. — ■ Eecovery is to be expected after a short mild illness. Treatment. — To prevent the ti'ansmission of the disease, isolation from other childien should he insisted upon, for although the disease is mild it occasionally produces some serious conse(pienees. ^I'he child should he ke])t from sci'atching the vesicles to present infection by the finger-nails. An initial dose of 1 gr. of calomel, and a liquid diet, are the only measures, as a I'ule, reipiired during the illness. Diphtheria. Diphtheria is an acute infectious disease due to the growth and action of the Klebs-LoefHer bacillus on a vulnerable surface producing a local mem- brane and general toxic symptoms. Etiology. — Tlu^ disease is endemic in large cities. Local epidemics frecpientiv occur in small towns and villages. Statistics show the disease to he more pievnh'iit in the winter and fall than in the summer months. Tn fact, varati'iii ]ieriods show a falling off in all infectious ami contagious diseases. The disease is contracted directly or indirectly from another case of diphthei'ia or from diphtheria carriers. The indirect means are usuallv the handling of infected objects and attendants who do not take pi-ojier precautions. I'lven contaminated food, such as berries and milk, have been PLATE XI. Differential diagnosis of (a) follicular tonsillitis; (6) scarlatinal angina; (cj diphtheria; {d) lacunar tonsillitis. THE IXI'ELTIULS DISJ-ASKS. 917 b^r known to infect tliu euusuniLT. Tliure is nu discrimination as to sex; age, liowever, plays an important part. xXurslings possess considerable ininiu nity. The third to fifth year is tlie period of greatest liability. From the tenth year to puberty, the susceptibility markedly decreases. Children of the so-called "lymphatic diathesis " are particulariy vulnerable, as are those "who have been weakened by previous diseases. Pathology. — The pathology is in the main that of the pseudomem- brane. This is a true c(jagulation necrosis, which may be situated upon the pharynx, nasopliarynx, larynx, trachea, or lironehi. More rarely it is found upon the mucous membrane of the nose, conjunctiva, or vaginal membrane. The bacillus or its toxins circulating in the blood may produce myocardial changes of a fatty or degenerative nature. The cervical lymph nodes show a simple cell hyperplasia. The involvements of the lungs and kidneys must be regarded as complications. Symptomatology. — The symptoms differ as they are the results of a pure or a mixed infection, and as to the anatomical distribution of the pseudomembrane. The mixed type is usually an association of the Klebs- Loeffler bacillus with the streptococcus as in scarlatina. The general symptoms of any of the forms of diphtheria are dependent upon the degree of toxemia. The attack is usually ushered in with vomiting or a chill. There is no characteristic temperature curve. The fever is of a low grade, 101° to 103° F., in uncomplicated cases. The pulse rate is increased in direct proportion to the youthfulness of Che patient. Lassitude or somnolence in various degrees may be observed liefore local lesions are suspected. The quantity of urine is diminished, and traces of albumin are found in a large proportion of the cases. The blood shows a bypei'leuko- cytosis, especially in the polyuuclear elements. The red blood-cells and the hemoglobin are correspomlingly diminished. Diphtheria (Tonsillar and Pharyngeal). — In this type the clinical manifestations \ary from those of an extremely mild variety h) severe toxic cases. The child may not complain of any sore throat and the membrane may be found only on routine examination. On the other hand, there may be low fever, vomiting, and some difficulty in swallowing. Examination of the throat, which should always be done with the l)est possil)le light and with a curved tongue depressor, may show membrane in the form of a grayish-white patch on one or both tonsils. The tonsils may be enlarged and congested. The uvula or adjacent pharynx soon become involved (see Plate XI). A graver or dirtier colored membrance is seen after the third or fourth dav. In severer cases the uvula, posterior pharynx, and fauces show the characteristic membrane. The general symptoms arc now more 24.S DISEASES or CllILDKEN. aggravated, due to the toxemia, while piostratioii is marked. The glands of the neek enlarge and heeome painful. There is dysphagia and difficult}' in enunciation, and there may be delirium. The breath is offensive and quite eharaeteristic, with a pulse rapid and feeble. The temperature is irregular and at limes high. If m this form we have the added complica- tion of a mixed infection, the toxemic s^ymptoms are still further aggravated, becoming those of a true sejjsis. Complications are then apt to supervene early, and the kidneys almost invariably suffer. Differential Diagnosis. — Tonsillar diphtheria must often be distin- guislied from a follicular tonsillitis, especially if the exudation from the crypts has merged, and seeminglv forms a membrane. This is es^Decially necessary in the absence of a bai-terioldgical diagnosis. (Plate XI.) In follicular tonsillitis, both tonsils are usually involved simultaneously. There is an initial high tempeiatui'c of 10 1° to 10,")° F. Usually there is no xomiting. Careful inspection will reveal isolated crypts distended with their cheesy detritus. The pscudomembi'ane can be rt'adily removed. The diphtheritic lueniliranc, on the (ither hand, adheres closely and leaves an excoriated ami l)leeding sui-face if foix-ible attempts are made to remove it. The bactei'iological diagnosis should be made whenevei- feasible, but the returns should not be waited for exeejit in extremelv mild suspicious cases. The bacteriological examination may he made with a smear preparation stained with Loefl1er"s solution and dii'cctly examined, or by inoculating the tube of lilood serum and examining tlie gi'owtb aftei' twentv-four hours of ineul)ation. The ]irecaution should lie observed to tak(> the culture before any antise])ties have been ap))lied, or at least within some hours thereafter. Schick has recently ])erfected a ]iractical test which can be empl()\"e(l to separate the suscejitilile fi'om the non-susceptible cases. A positi\c local reaction is olitained when a minute (|nantity of diphtheria toxin is injected under the skin, if antitoxin is absent, or ]n'esent onlv in minute amounts. The Schick Test. — 'i'his te>t is of practical value in detei'inining the imiounitv to iliplillieria of the jmlilic in geiici-al. hut especially of the child p(i])ulatinii ill sclidiils, h()S|)itals, institutions, and in liouies during an out- Iircak 111 dijilithcria. It «'ill save a considerable aiuount of antitoxin and a\'oid ullnecessal■^■ sensitization of mci'i' than (i.") per cent, of the exposi'd individuals. Tlie test is also of distinct \'alue in the active immmrization of su-ccpt ilile individuals against di|)lilhei-ia, with mixtures of toxin-anti-. toxin, ami in the iliagnosis of clinically doubtful cases oC dijihtheria. I'lie X. Y. I )c|iai'tnicnf ol' Ib'altb advises the following technic ; Technic. — The Schick reaction is a convenient and reliable clinical test, by wliicli w'r can detiu'iniue llie antitoxic iiumunifv of an individual to (hpldlieria. ,\ fr'csli sohilioii of ili|ihlhei'ia toxin is ]n'epai'ed for this purpoM' of sucli >lrcngtli tlial O.',' c.c. rcpresenls l/.'iO (d' the minimuui ■liii: ixFKCTioi's i)i.si:asi:s. 249 lethal dose of toxin for a 2M gi-aiii guinea-pig. This amount is injected with a good syringe, pj-eferahly a 1 c.c. " lleeord "' and a fine steel or platinuni-iridiuni needle, intracidaneoudij on the flexor surfaee of the fore- arm or arm. A properly made injection is recognized hy a distinct wheal- like elevation, "which shows tlie prominent openings of the hair-follicles. 'I'he result of the test sliould he read at the end of 2i, 4.S, 12 and 9G hours. The reaction that appears at the site of injection may he eitlier positive, negative, psoudo, or combined positi\e and jiseudo. The posit He reaction represents the action of an irritant toxin npon tissue cells that ai'e not protected by antitoxin. It indicates, tlierefoix', an absence of immunity to diphtlieria. A trace of redness appears slowly at the site of injection in frour 12 to 24 hours, and usually a distinct reaction in the course of 24 to 4S hours. The reaction reaches its height on the 3rd or 4th day and gradually disappears, lea\'ing a definitely circumsciibed scaling area of brownish pigmentation, wliich persists for 3 to G weeks. At its height the positive reaction consists of a circumscribed area of red- ness and slight infiltration, winch nu'asures from 1 to 2 cm. in diameter. The degree of redness and infiltration varies to a gi-eat extent with the relative susceptibility of the individual. The pjositive reaction is seen in about 1 to 10 per cent, of the new-horn, 30 per cent, during tlie first year of life, 3-") decreasing to 1.") per cent, between 2 and 14 years and 10 per cent, of adults. In the negative reaction the skin at the site of injection remains nornml. The negative reaction definitely indicates an immunity to diph- theria if tlie test-toxin is of full strength, has been freshly diluted, and the injection has been made into th.e proper la\'er of the skin. A negative reaction obtained in a child that has reached the age of 3 years indicates that is has an immunity which is probably permanent. Of 1000 cai'efully observed individuals, no one developed clinical diphtheria, even though they were exposed to the disease, and some were carriers of A'irulent di]ihtheria bacilli. "Jdie jiseudo-rcftctioii represents a local anaphylactic response of the tissue cells to the protein substance of the autolyzed diphtheria bacilli, present in tlie toxic broth used for the preparatioir of the test. Laryngeal Diphtheria. — In this form the inembrane may extencT from the nose or throat, or it may primarily involve the larynx. In the latter case there are symptoms due to congestion of the mucus membrane of the larynx and the vocal cords; that is, a hoarse inspiratory cough, some restlessness and a low grade of temperature. Cultures, if taken at this stage, are usually found to be negative, especially if a laryngeal swalj is not correctly used. As the disease jirogresses symptoms of olistruction are ;5!oO I)l^l■:Asl:,-. of i-ii i ldki:\. apparent, due to the foi'iiiation of the laryngeal membrane which is some- times visible about the epiglottis. Tlie eough is more aggravated and paroxysmal m character; the patient acts as if attempting to dislodge an irritating foreign body. There is partial or complete aphonia with a iiiutlied or suppressed eough and wliisperiiig voice, llie accessory muscles of respiration are brought into requisition. The periods of leuiission from coughing become shorter and shorter in (hiration, aud are easily brought on by disturl)iug the pntieut. If the child falls into a restless sleep, the s\-mp- tonis are less noticeable, but do not in any sense resemble the normal. The pause lietween inspii'ation and expiration is noticeably prolonged. The supraclavicular, e])igasti-ic, and diaphragmatic spaces show marked recession at the height of iiiS])iration. The mucous membranes and nails are cj'anosed. Unless relief is now obtained, extreme restlessness sets in, and the child attempts in every way to get aii-; it is markedly cyanosed, a cold perspiration appears on the forehead, stupor supervenes with spasmodic breathing, apnea, and death. In eertiiiii eases the uiembrane may extend to the trachea, even beyond the bifurcation of llie bronchial tube (see I^'ig. 67 ). The Heart in Diphtheria. — During the coui-sc of di]ihtlieria, as well as throughout eonxalescence, the heart must be mosi eai'efidlv watched. When the local manifestation of the disease is slight and there is no sepsis, the heart may suffer com]iaratively little. Thei'c is a direct ratio between the amount and ehai'acter of the local inflammatory |)rocess and the nature and severity' of the constitutional symptoms, especially as regards the heai't. In mild di))litheria. a moderately rapid or irregular ]nilse, without other eoiistitutii]nal s\'m|)tcuns, does not seem to ]ioi'b'nd the danger that tlu' same action does in severe septic cases. Thus, in mild attacks, an irregnlar ]ndse during convaleseence may sometimes be imju-oved by letting the child get out of bed. An ii'i-egular or interiiiittcnl jiulse, without svuiploms of prosti'ation, cannot have the same signifieance as when the two coexist. The septic type, with inucli glandular swelling in the neelc, is often fatal from a persistent and powerfully de]5ressant action upon the heart, ^'liis organ has here not only to contend with the toxins of (h])htbeiaa, Init with a general septic poisoning as well, sho-wn by extreme ])allor, persistent vomiting and stu]ioi-. Tlie oecui'rence of \(imiting in connection wiih a. weak ]i\ilse is here an exceedingl\' gra\'e onien. The \'Oiiii(ing ma\' lake place befoi'e thei'e are marked e\'idences of heai't failure, hut the latter will soon fullow. If, in cases where Ihe pnisc is acting liadU', x'omiliuL;' heu'ins, the lieart will usually prose iutraelahlc. .\ distim-f and marked Inwcrinix of the ])ulse rate is somelimes noted in grave eases, '^riiis slowing may take 16 Till': liM-'ECTlOUa DISEASES. 251 place before or after a distinct quickening. The prognosis will depend upon the degree of slowness, which, if extreme, is always followed by a fatal ending. In a ease treated by one of us, a boy of five years started with a rapid pulse, which slowed up until it was only 28 for two days before his death. Hypodermic stimuhiiioii by strychnin, camphor, calfein and brandy i-; all that is a\'ailahle in these cases. When the heart is not acting \i-el! in Fig. liT. — C.-ist of the traeliCM and brdiiclii e.xiielled tfum a case of laryngeal diphtheria. diphtheria, the patient must be kept very ipiiet in the recumbent posture until complete recovery takes place, otherwise sudden death may ensue even during convalescence, especially in septic cases. Differential Diagnosis. — AVe have abandoned the term croup as applied to diphtheria, as it only tends to misleading conceptions, and per- haps to serious mistakes in management. Clinically, the dia,a:nosis should be based upon the character of the ci)ugh, the aphonia, tlie muffled cry, the progressive signs of laryngeal obstruction, and the recession of the thoracic spaces. In non-diphtheritic laryngitis the child is taken suddenly ill at night with an attack of suffocation and a bi-assy, barking cough. Ordinary remedial measures, such as steam inhalations and emetics, give speedy relief, with the resumption of noi'mal breathing and apparent health during the next twelve to twenty-four hours, Ai'lien a second milder attack may 2o2 bISKAMICS OL-' CIIILDIM^N. supervL'iU'. Edema of the lungs, especially when it earl}' complicates a Iji'oucliopneiimonia, may snnuhite an attack of laryngeal diphtheria. The physical signs must be depended upon to clear up the diagnosis. Nasal Diphtheria. — Tliis form is usually seen in children of the school age, and unfortunately the cases are not recognized and isolated as early as they should l)e. From a clinical standpoint tlie Schick reaction is particu- larly useful in the diagnosis of doubtful cases of nasal diiihtheria to deter- mine fl-hetlier they are true cases or simply carriers. The negative reac- tion excludes clinical diphtheria. Children with nasal diphtheria are undoubtedly great carriers and disseminators of the infection. The disease should be suspected in cases of intractable or aggravated rhinitis in which there is a mucopui'ulent, blood-tinged discbai'ge, accompanied by evidences of nasal obstruction. The nostrils and up]ier lip are often excoriated. Tlie children are not sick enough to want to go to bed and may have little or no fever. The use of the nasal speculum will often show the membrane in the nares. It is usually in shreddy patches rather than in firm membranous masses. The glands at the angle of the jaw are moderately enlarged. A culture should be made in all suspicious cases. If the posterior nares is involved by extension fiom the ]iharynx, the prognosis is graver, as it tends to lessen the res]iiratoi-v ability and the willinpni'ss of the child to take food. The toxemia is likewise greater, and the cardiac uiuscle soon weakens. Conjunctival Diphtheria. — As in the other foiaus, this may be pri- mary or secondary to the disease of the nose or throat. The course is extremely rapid. There may be a profuse jjurulent discharge with marked edema of the eye-lid ; the conjunctiva is clouded with a thin membrane of a gray color which ailheres closely and bleeds easily if attempts at removal are made. These local symptoms are accom]ianied by an increase in the tempera- ture, pulse rate and bv somnolence due to the toxeuiia. Complications. — The res]uratorv tract, the nervous system and the heart arc the greatest suffei'crs from the toxemia of diphtheria. Pneumonia is a frequent complication, especially in badlv nourished children or in those that ba\-e ht^en intubated. The mixed infections predispose to this couiplicatiou, (■spccialh' in those under two vears of age. Postdiphtheritic paralysis occurs in aliout one-nfth to one-seventh of all cases. The common form is the local paralysis of tlie palatal group of muscles coming on early or late in convalescence. The symptoms are regurgitation of liquids through the nose, dysphagia, and dvsarthria. The uvula is found relaxed and not supported by its irinscles. In the severer forms the ]ih\-siological action of 'j':ir; i \ i'i:r"rii)rs i)isI':a,si;s. 253 the pliarynx and iarj-nx is disturbed. The muscles of the lower extremities and the eye may be involved in the paralysis. The patellar reflexes ai-e lost, and there nury be anesthesia of the lower extremities. Only rarely is there paralysis of the upper extremity as a part of the general paralysis. If the branches of the vagus are involved cardiac irregularity is noticed, and vomit- ing and pains in the abdomen are complained of by older children. There is a tendency to sudden death in these cases. Nephritis occurs as a result of the toxemia and as it often appears insidiously without puffiness or anasarca, the urine should be carefully watched. Prognosis. — This must be formed by a consideration of the patient's age, his resistence, the location of the membrane, whether of tlio pure or of the mixed type, and the time of the serum administration. The following are the mortality statistics from the Boston City Hospital: (Cases treated with antitoxin.) Under five years, 20 per cent, of all cases. Five to fen years. S per cent.. of all cases. Ten to fifteen years. 3 i)er fent. of all cases. Exclusively nasal cases offer the best prognosis. Fncomplicated ton- sillar or pharyngeal cases rank next in a good pi-ognosis. Laryngeal cases are the least favorable, especially when the necessity arises for intul)ation or tracheotomy. In private practice, where the circumstances are tlie most favorable, the mortality has l)een reduced to less than one-third of all cases. Antitoxin has been the means of reducing all the mortality statistics : and if given before the fourth dav of the disease the prognosis is very favorably influenced. Treatment. — The management uuiy be divided into the prophylactic, o-eneral, serum, local, anrl operative treatment. Prophylactic. — Immunization with antitoxin assumes the first place in prophylactic treatment. Tlie immunity lasts from three to four weeks and, as conclusively proven by the statistics from the Xew York Board of Health and elsewhere, has saved luany lives. Thirteen thousand persons received immunizing injections through the New York Department of Health ; of these only three-fourths of 1 per cent, had a subsequent mild grade of diphtheria, and there was only one death. Immunizing doses of 500 to 1,000 units shoidd be given to all the susceptible individuals in a family who have been exposed. In hospitals or institutions patients may be immunized, especially if measles are epidemic. All true cases and sus- pected cases should be carefully isolated, and disinfection practised as is indicated in the special article on this subject (page olO). (See Shick reaction, page 2 t!).) 2.-i4 DISK-\S1':S OF CHILDREN. General Treatment. — The cliikl should be placed in bed in a well- ventilated, sunlit i-oom, capable of separation from the rest of the house. Cool liquid or semisolid foods, such as milk, ice cream, junket, etc., should be offered at short intervals. Cold compresses are useful to mitigate the dvsjilia.yia, while lij^iit iee-Liladders are often agi-eeable and efficacious when applied to the neck, ))articularly in glandular cases. The bowels should be kept open with calomel or salines. The urine should be examined at least bi-weekly. Sti-yelmin sid])hate in doses of from ]/24() to 1/100 of a grain, accoi'ding to tlie age of the child and the necessitv for stiuiulation, may be given evei'y two to three houi's. AMiiskey may lie alternated with the sti-ych- nia in toxemic eases witli irregular heart action or bi-adycardia. Small doses of morphine. 1/1:0 to 1/lG of a grain, arc often efficacious in con- trolling the restlessness, and at the same time acting as a tonic to the heart. Infusions of normal saline solution have been of material assistance in sav- ing des]ierate cases, liromid of sodium, if not contraindicated by the heart's action, is of value as an antispasmodic liefore extubation in laryn- geal cases. Paregoric or Dover's powder in small doses may be given for the same purpose. Serum Treatment. — .\ntitoxin should be given in all cases of diph- theria or those suspected of being diphthei'itic. In its im))roved form there ,..e no contraindications to its use. Five thonsaud units at least should be gi\-('n in mild cases of rmicial or nasal diphtlieria, aiul repeated with a (limlile di)so in t\veutv-J'(iui' hours il' the false mcmbi-auc has not shown siens 111' di>appuariug ; 1, ()()() uuits iiuiy be the iuitial dose in sewrer eases. In laryngeal diphtheria r>,000 units in infants and 10,000 units in older children should be given at ouce. The dose should be repeated in twelve hours in cases of stenosis if tlie respiratory difficulty is not ameliorated. Double doses must be given if the disease is seen in its later stages. Immu- nization is satisfactorily accomplished with injections of .500 to 1.000 rmits, acconling to the age of the child. In very toxic cases of diphtheria the antitoxin should be injected intravenously in large doses. The loose tissues undei' the pectoral region or over the right or left iliac region may be selected for the site of the injection. The skin is made surgically clean, and the antitoxin injected with a large sterile syringe and needle. The wound should be sealed with collodion. The pseudomembrane after the iujection of antitoxin slowly tends to detach itself. In larvno-eal eases, in which the mendirane is not seen, the decreasing svmptonis of ob- struetion give evidences of its good effects. The hypertrophied lymph nodes decrease in size, and the general symptoms are all improved. An eniiition in the form of an erythema or urticaria sometimes follows the TJiK :_\FECTjors ))isi:a.si;s. , ;-.).j injection of antitoxin. Tliis is attributable to tlie liorse serum itself. A scarlatiniform or macular rash is occasionally obseryed. The improved concentrated preparations rarely produce skin manifestations. Local Treatment. — The curative eilect of antitoxin has superseded the use of the strong antiseptics which were formerly locally a|jplied to the membrane. In older children who can gargle, the use of a mild antiseptic solution, such as diluted Dobell's solution, listerine, oi' a common salt solu- tion, will assist in removing the loosened membrane. Younger children are markedly benefited by irrigations of salt solution, especially in nasal diph- theria (half a dram to the pint), used at a temperature between 100° F. and 115° F. An ordinary fountain bag is used, placed about two feet l'"Hi. (iS. — Positiiiii dl' tlic ]i:iti('iit in intul>atii)n. above the patient's head, who lies on his side, prepared as for intubation (see Fig. 68). A small nozzle is then placed in one of the patient's nostrils and the water allowed to flow, with intermissions to allow for expulsion and breathing. If done in this way, the child soon becomes accustomed to the process and is not frightened, and much relief is obtained. In certain cases the nozzle may be inserted behind the back teeth, and the mouth thus irri- gated. If the bag is not placed too high the pressure will not be sufficient to carry infection through the Eustachian tube. An ice-bag applied to the neck in cases of tonsillar diphtheria afEords relief and tends to inhibit the groAvth of the membrane, and to reduce the swollen lymph nodes. 256 nrsKAsi:s of cilildkion. Laryngeal cases are often relie\'ed by swabbing away the collected material at the head of the tube, an ordinary laryngeal applicator being used for this purpose. Diphtheria affecting the conjunctiva must receive as close attention as a case of gonorrheal conjunctivitis besides the injection of large doses of antitoxin. Intubation. — Intubation, or the relief of lar}iigeal stenosis by the insertion of a tube, was perfected by Dr. Joseph O'Dwyer, of ISTew York, in 1883. The brilliant results obtained have brouglit this means of relief into universal favor almost to the exclusion of tracheotomy, which is now rarely practised. Fig. G9.^ O'Dwyer's intubatinn iiistrumonts witli detachable parts, in an aseptic case. The indications for ]jorforming intubation are as follows: Intubation sliould be performed in laryngeal dipbtbei'ia when tliere is marked dvspnea, restlessness, retraction of the epigastric and supraclavicular spaces with evidences of cyanosis. Tlie cliild is prepared by lieing closely wrapped and pinned in a sheet (Fig. n,S). The operation may be performed in a horizontal position on a table or in an upright position with the child's head resting against an assistant's sliouhler. A second assistant is reipiired to liold the head in the median line and to keep the nioutli gag in place, as rajiidity and a certaia TTIE INFECTIOUS DISEASKS 25r amount of dexterity are necessary. Practice uj^on the cadaver, and if pos- sible upon the living subject, should be had under the instruction of an experienced operator. The instruments used are generally those of the O'Dwyer pattern, as they conform most accurately to the anatomy of the region. They are now made of hard rubber, metal lined, in sizes according to the age of the child. The neck of the tube is held within the vocal cords, ivhile its lower end extends almost to the bifurcation of the trachea. 0. — LuU-oducer, witli obturator aud tube iu place. An inti'oducer, an extubator, the tubes, a mouth gag and scale complete the set. The proper tube having been selected, a loop is made by threading a piece of strong silk through the eyelet placed in one side of its head. The child's head is firmly held and its extremities kept from moving by a second assistant when on a table, or by the knees of the assistant who holds the patient in his lap. The left index-finger is inserted and the epiglottis found and firmly held forward. The palmar surface of the finger should be presented to the tube. At first the handle of the introducer is held parallel to the child's body ; it is then raised until the tube passes between the vocal cords, when it will be beyond a right angle to the body of the child. The trigger of the introducer is now used, which allows the body of the tube to pass well beyond the vocal cords, the finger at the head of the tube gently forcing it into place while the obturator is being removed. The 25S iiisi;a.si:,s oi-' ni i i.duiox. cord is still kept in plact, but the luoutli gag should be quiclily removed. A metallic cough and the relief of the Sjniptoius of stenosis will be the proof of success. A series of expulsive efforts, followed by free inspiratory effort, disappearance of cyanosis, and a period of calm and rest for the child, will follow. Failure may result because the operator has not kept closely to the dorsum of the tongue in ])assing his tube, or because he has failed to keep the liandle of his instrument parallel to the child's body in the first n^ove- nient to\\ar(l tlie epiglottis. In rare instances a certain amount of mem- brane is pushed down before the tube, and as a result there is no relief, or there nuiy be an iuci'eas(; in the stenotic symptoms. The child should tlien I'^ic. I n m - Iiitul)atioii tubes, f, (;i':iiml:iti(in or hnilt-n]i tnlii-s: IT, (irdinary tube (lateral view) ; III, ordinary tube (front view). be held in an iiiverted position, when the membrane usually is expelled, and the tube may then be reinserted. Jf any foi'ce is used damage may lie done. The cord luay be removed after some minutes by placing the finger on the head of the tube and withdrawing it, or it may be fastened on the side of ihe face with adhesive plaster. Extubation. — -This should be performed as soon as there aie cviilenees of j)iai'ked impi-ovement in the general condition of the patient as shown by decreased toxic symptoms, and a mai'ked deci'ease in the laryngeal obstruc- tion. This may occur on the third, fifth, or seventh day, depending upon the sevei'ity of the case, upon the early use of the antitoxin, and upon the age of the child. Children under two years of age cannot, as a rule, be o.xtubated as soon as older children. If cyanosis follows the removal of the tube, it niust be quickly replaced, all tlie prcparatifins having been made for this ]i;)ssiliilitv. Special tubes 'I'ILK INFKCriors DfSlCASKS. 259 witli built-up heads and retention swells are used in cases demanding pro- longed intubation (Fig. 72). Tliey act by preventing and causing destruc- tion of tlie granulation tissue. The Feeding of Intubated Cases.— Older children soon manage to take fluids and semifluids without much difficulty. Infants and vounger childivn may be fed in a prone position, or with the head lower 1lian the Fio. Extubatioii. body, being fed, if necessary, by a Iwttle or medicine dropi^er for a few days. Feeding by gavage may occasionally be necessary. Tracheotomy. Indications for Tracheotomy. — Ti-acheotomy should be performed in those cases in which intubation has failed and the membranes are forced further down into the larynx ; in cases in which the membrane forms below Ihe tube and no relief is obtained; and in cases of edema of the glottis in which there is e.xtensive infiltration. 2G0 iii^|':asi:s dI'' cm i i.I):;i-;\. It may here be luentioued that intubation is far preferable to trach- eotomy, and the hitter operation should be performed only as a last resort or in those rare cases in which a proper tube is not retained. The operation should be performed, if possible, under a light general anestiietic. The patient should be prepared as for any aseptic operation if the ciicuuistanees allow, the neck being extended over a sand-bag and kept in the median line. An incision one to one and a half inches long is made tlirough the subcutaneous tissue, and then the facia and sternohyoid muscles are separated. The engorged venus ple.xus is pushed to one side and the trachea exposed. By means of a bistoury an opening is made sufficiently lai-ge to admit the cannida. (An instrument which will at once incise and dilate the tracheal wound is now on the market.) "When free respiration is established, the cannula is fastened in place by tapes about the neck, and the wound dressed with moist gauze. A steam atomizer to moisten the respired air is helpful. The attendant should dili- gently remove the tracheal secretions deposited upon the pledgets of mois- tened gauze. The inner tul)e of the cannula should be removed and thor- oughly cleansed three or four times a day, or whenever it is obstructed. After the tliird or fourth day an attempt may be made to permanently remove the cannula. If the jiatient can get along without the tube, the wound is cleansed, dressed, and allowed to heal. Pertussis. (Wh 00 pi nff-roii fjJi .) Pertussis is an acute infectious disease characterized by a paroxysmal cough that consists of reppat(>d expirations ending in an inspiratory whoop, which, is often followed by vomiting. Owing to its complications it must be classed as one of the dangerous diseases of early life. Etiology. — The Bordet-Gengou bacillus is now generally accepted as the specific oiganism. The secretion is apparently the means of transmission from one individual to another and is very communicable. Clothing and the rooms of the patient do not seem to carry or retain the infective agent. Sporadic cases are constantly seen in large centers, and epidemics frequently occur both in urban and in rural districts. Wiooping-cough is no respecter of age. It has occurred in the newly-born and in well-advanced adult life. The period of incubation is from seven to fourteen days. The primary stage is probably the time of greatest danger to others. TIIIO JNFHCTIOUS DrSKAPES. 261 Pathology. — The lan-nx and traehea show a marked congestion and exudative inflammation of their mucous membi'ane. In fatal cases, areas of emphysematous lung are commonly found. Subconjunctival hemor- rhages occur in severe cases, and cei'ebral hemorrhages have been found. Symptomatology. — For purposes of convenience in description, the disease may be divided into three stages. Xamelv, the primar}' (in which the mucous membranes of the nose, larynx and trachea are inflamed), the spasmodic stage, and the period of recession. These, however, merge into each other and are not sharply defined. Primary Stage. — The ex])osed cliild. after a varying period from two days to two weeks, may have suffused eyes, a rhinitis, and a congestion of the pharynx on examination. The child does not feel sick, hut coughs severely, especially at night. The cough is described as having a croupy character. After a few days it becomes more pronounced at niglit and more frequent in the day time. Physical examination at this lime may give no evidences of bronchitis if tliis is suspected. These negative signs are valuable in leading to tlie true diagnosis. An increase in the mono- nuclear leukocytes is quite frequently found at this time. A tongue depressor irritating the pharynx will sonretimes produce the cliaracteristic whoop, and thus confirm the diagnosis. A rise of one or two degrees of temperature is sometimes observed, especially when there is an accompanying bronchitis. Spasmodic Stage. — This is so named because of the paroxysmal cough or whoop which follows the several expiratory efiiorts. The child realizing the approach of a paroxysm, seeks sujiport from its attendant or clings to some article of furniture. There are three or four violent expiratory efforts, followed by a period of apnea, and then the tremendous inspiratory effort is made which, entering through a partially closed glottis, causes the so-called whoop. During this effort the eves have liecome congested, the face almost cvanosed, mucus streams from the nostrils, and a mass of mucopurulent secretion follows the whoop. Vomiting occurs if there is any food in the stomach, belief now comes to the exhausted patient, and after a brief period of rest, duidng which there is sweating of the forehead and face -the child goes back to its plav. These attacks may occur ten or even a hundred times a dav. Naturally, the nutrition soon suffers : the face may later become edematous or puffy, masking the malnutrition of the body. Severe cases may have subconjunctival hemorrhages or bleeding from the nose or lungs. The urine mav show traces of albumin and hvalin casts. Convulsions'sometimes follow an exceptionally severe paroxysm, especially in infancy. In voung infants the spasmodic stage begins very soon after the beginning of the attack and the " whoop " may be absent. 203 Dl.SEAriluS OK t'lllLDUK-\. Recession of symptoms is showai hy a decrease in the number and severity of the paroxysms, ending in a cough which persists for several weeks. Complications. — Broncliopneumonia frequently complicates pertussis, especially in infancy. This is the result of an infective process made pos- sible by the abnormal condition of the bronchial tubes and the lowered vital resistance. It generally occurs at the end of the paroxysmal stage. Bron- chitis and emphysema are complications more frequently seen in older chil- dren. Tuberculosis not infrequently follows in the wake of pertussis. It may be localized (from latent bronchial lymph nodes) or even a general miliary tuberculosis may result. Sevei'e attacks of vomiting reduce tlie general nutrition and predis])ose to more important complications. Con- vulsions result from congestion of the brain, or from minute capillary hem- orrhages which may occur during the paroxysm. We liave seen hemiplegia follow a severe paroxysm. Hemorrhages into the conjunctiva and hernias in various parts of the body also j'esult from the severe strain iuiposed by the paroxysms. Course and Prognosis. — In some cases the disease lasts only a week or two, but on the other hand, we liave seen it persist beyond three months. If complications occur it is more apt to be prolonged. The mortality of tliis disease and its complications is highei- Wv.xn is gcnei-ally a])preciated. Infants, especially, are prone to fatal attacks of pneumonia, convulsions, and tuberculosis. Among the poor, where undernourished children are most likeh' to be found, the mortality is liigh. 1910 1911 1912 c«£i 2018C Deaths 2941 a^s 3210: Doths 3841 a^^s ?132C bfATHs 2871 DcATHs 420^H The prognosis is based upon the general condition of the child, I be number and cbaracter of tlie daily paroxysms, and its ability to retain food. Treatment. — Although whooping-cough, like the other infectious dis- eases, is self-limited, its severity can be considerably modified and its com- plications often prevented bv appropriate treatment. TilK INl-'KUTIOUS DISKASKS. 263 Serotherapy.— The child should spend the greater part of the day out of doors in pleasant weather. If the circumstances permit removal to the seashore it is of undoubted benefit. The fine saline particles thrown up by the surf give quick relief by being inhaled. The sleeping-quarters should also be well ventilated. Drugs. — For the control of the cough early in the spasmodic stage we have had very satisfactory results with the three following drugs: fluoro- forni, the bromids, and antipyrin. The treatment may be begun by giving two drops of a 2.8 per cent, solution of fluoroforni every two hours during the day to a year-old child. The dose may be increased by two drops for each succeeding year of age. Occasionally this is not effectual enough, or apparently the child becomes accustomed to its sedative action. The bromid of soda in two-grain doses every three hours for a two-year-old child may be Fig. H. — 1'lie Kilmer belt fur pertussis. substituted. Antipyrin is well tolerated, and can safely be prescribed if complications do not contraindicate. It may also be combined witli the bromids as in the prescription given below. A child of si.\ months can be given i grain of antipyrin at three-hour intervals, 2 grains to a two-year-old child. If it is used with the bromids the dosage must be regulated accord- ingly. In exceptional instances in which the paro.x3-sms are particularly severe and are preventing rest, small doses of heroin, as indicated in the prescrip- tion below, M'ill give relief for the night. For a two-year-old cliild : R .Vntip.vrini f.''.-.-'''^*'-'' filvcprini ^^\i Aqua; ■ Q- «• -id- M jrisce et signa. — Oni» tciisiioontul every thrcM- hiiurs lor six doses. V, Sodii hroiiiidi "''■ '''_^' Antip.vrini ^.I . ""''^ Olvcerini ■ '1]{^ Aqua- -q- s- ^^d. 5i.l Misce et .signa. — One teaspoontul every three hours tor a three-year-old child — well diluted. 2(J-± disi:asi;,s oe ciiiLUuiiN. B IlmiiiiL feyilroihluriiii t'f. ?. Aiitipyriiii i^v. xvj ]']lixiris :HlJu\';uitis 3iJ Miscu ut siyiiM. — A teas|)iniiiiu] every tbree linurs to a rhild nt two years fur three ilcses. Vaccine Treatment. — There is imuli dmiht as to tlie Mtlue of vaccines in tlie treatment uf pei'tussis wlien the dise^ase is fully estaljlislied. In a series of experiments cdiidueted Ijv Jh's. \cm Sho'ly, Blum and Suiith of the X. Y. Board of Jlealth, no positi\'e conclusions "were reached as about ihc same resnlts Avere ohtained by the use of a non-s])Ccific influenza vaccine. Many good (ibservers, however, believe that Aaluable results in a prophy- lactic way nuiy be obtained liy pertussis vaccine. Thi'ce subcutaneous in- jections are usually ,u'i\en, oni' evei'v tinrd day. The dose for children is 500 million. 1.000 million and 2.000 million. There is little local or gen- eral reaction. Diet. — Food should be taken in smaller quantities and at lessened intervals than in health. This measure in itself prevents the vomiting which readily occurs when a fidl meal is taken. After vomiting, a cup of milk or meat broth niay be immediately given. Only simple, light and nutritious articles should be permitted in the dietary. Tlie inhalation of antiseptics has given us no satisfactory results. In fact, it tends to encourage poor ventilation in the sleeping apartment. A belt as suggested by Kilmer can be worn if vomiting is frequent. In a cer- tain number of cases this appliance (see Fig. 74) has given relief from tliis distressing symptom. Mumps. ( Ejiidciiiic rardihtia.) Mumps is an acute communicable disease of the salivarv glands, char- acterized liy a swelling of tlie ])ai'otid gland and the neigliboring salivary glands, ami at times ii)\'nl\iiig the testis or o\"arv. Etiology. — Children from tAvo to lifteeii ycar.s of age are most often afTected. E]iideniies ai-e common in schools and institutions. The specific contagium has not b(>en isolated, ('lose contact is necessarv for its dis- semination, but the disease is transmissible before the swelling appears. The portal of entry seems to be the Ijuccal cavity. The ])eriod of incuba- tion i.s an indetei'ininate one: it ranges from one to four weeks. Immunity is generally conferred by the one attack. T?ecurrences, however, do occur. Pathology. — Accoiding to Yiichow, there is an inflammatorv. serous and cellular infiltration of the intraacinous and periacinous connective tissue, which tends to resolution without induration. Symptomatology. — In children the onset is usually mild, with a period of malaise, drowsiness, fever of one or two degrees (onlv rarely 104° F.), (hilliiiess. and sometimes vomiting. A swelling now appears THE TXFKCTIOI'S IIISEASKS. 365 below the lobe of the ear on one side of tbc face and in a few days the opposite gland is generally involved. Tlie child complains of a feeling of fullness, with pain localized in the angle of the jaw. Tlie swellings are elastic on palpation. Mastication is difficult and food may l)e refused for this cause. Tlie fever ranges fi'om 101° to 103° F. Occasionally there is earache or deafness. The swelling may extend over the pai'otid in front, or involve the submaxillary gland and the neighboring lymph nodes, giving the characteristic rounded appearance. The ilisplacement of the auricular lobule with the lobe of the ear in tlie center of the swelling assists in fixing jhe diagnosis. In some instances there is little or no discomfort, and the child is not willing to go to bed. After seven or ten days the swelling subsides and entirely disappears. Kelapses, however, may occur. Oecasionallv the swelling is very large and painful. In exceptional instances only, tlie submaxillary glands may alone be invohcd. Lymphocytosis is quite a constant accouipaniment, especially at puberty (Wile). Complications. — In boys orchitis is occasionally seen, and the same may be said of ovarian pain in girls. The breasts especially in girls may be tender. When tliese complications do occur, the child is generally at or near the age of puberty. The lymph nodes may become secondarily in- volved, and suppuration of the affected glands take place, but only if thei-e has been a mixed infection. Deafness, inflammatory eye diseases and rarely nephritis are complications which may occur, and should be guarded against. Differential Diagnosis. — Mumps should not be confounded with hypertrophied lymph nodes which present an irregular nodular swelling and are not found on the face. An examination of tlie throat or a con- comitant infectious disease may account for such a swelling. Involvement of the submaxillary glands alone, so-called submaxillary mumps, must, however, be considered. If with a history of exposure there is a large soft swelling filling up the space between the angle of the jaw and the mastoid process^ and it lifts forward the lobe of the ear, the diagnosis is quite certain. Prognosis. — In this benign disease, which is rarely complicated, fatal- ities do not occur, and the ])rognosis is most favorable. Deafness some- times results and rarely following an orchitis the testicle ceases to develop. Treatment. As it is a communicable disease, the children should be isolated. If there is fever and discomfort, a laxative is given, and tlie child is put to bed. Local anodyne applications of 3 per cent, ichthyol- :H')C) iiisi:A.si;y of rrni.DUEx. lanolin ointiuent, or •\\rtriu oil of liyoscyaiiius are applied. Ol'ten a hot- water bag is found to be very agreeable. Moutli-^aslies of listerin or boric ai'id solution should be used fi'e(|uently. The bowels sliould be kept freely opened, and a liquid or soft diet ordered, (iuaiaeol ointment (o to 10 per cent.) is soothing if orelutis is present as a couiplieation. The patient may mingle with othei- eliildren after the thiid week. Tlie question often arises, when nuiy a ebild who suffered froui a recent infection return to school or mingle with other children? The following suggestive taljle mav here he of service: ]>ISK.VSE. After an Attack a Pupil May Not Return to Si'lmol T'ntil If Other Children Are at Once Uemoved from House They May Return to School ^Vtter 4 ^^"eel^s from in- ceptiiin of disease, jirovided tliere is no nasal or aur.al dis- cliari^e. 14 days after tlioruuKh disinfection and en- tire chan;;e of clotli- ing. I )i|)lltlicri;l After .". ne,:iative threat cultures taken on different d,-iys. 7 days .after immuniza- tion and .". ne.LC.-itive cultui-es. VIeasli'S ] week after ajipear- .■mce of rash and un- til all .'ictive syniptoms iiave disaiipeareil. 3 weeks after last ex- posure. ( Jmii.-iii Mh:is]cs 1 week after ajipear- ance of rash anlace, tlie " shaven beai-d " appearance is souietimes seen due to pigmentation. The ulceration rarelv penetrates Ijeyond the submucosa. This pathologic picture is in distinct j-elation to the milder character of the symptoms as met with in children. Tlie mesenteric lymph nodes in the ileoccal region are enlarged. Tlie spleen may be enlarged, congested, and soft. Tlie mucous membrane of the bronchi and larynx are often involved in vai'ying grades of inflammation. The kidneys quite regularly show cloudy swelling. The heart muscle shows mild grades of myocardial rlegeneration. Symptomatology. — The prodi'omal symptoms are so irregular and so apt to be influenced by some one prominent symptom or svmptom- complex as to lead the examiner astray. In infants the mode of onset is quite different from that of older children. The infant has an initial high fever which becouies irregular or remittent, and subsequently the symptoms resemble a gastroenteric infection. Convulsions are the exception. Older cbildi-en who are able to describe their symptoms complain of headache and chilliness. Malaise and vomiting are frequently observed, while delirium at night, when the fever is high, is seen after a few days. Epistaxis is the exception. Cerebral symptoms may usher in the disease. A cough is often present quite earlv and serves to obscure the diagnosis. A careful physical examination of ^68 DISEASES OF CHILDltEN. the eliost liv a ]ii'Ocess of uxclusidii inay point tlic way to an early diagnosis. It will be well to take up the symptoms seriatim to give a picture of the varied manifestations of the disease, and these will be described in the order of their early assistance in diagnosis. Roseola. — These spots, which are macules fading on pressure and distinctly disciete, are oliservcd in more than (JO per cent, of the cases. The eruption is seen as early as the fourth or fifth day, and, as a rule, is widely scattered. The abdomen, chest, and back may each show them. AVe liine seen hemorrliagic arens on llie abdomen, toes, and heels in severe or fatal cases. Spleen. — As a rule, the younger the child the less often is the en- largement felt early. It is distinctly palpable in the second week. The splenic enlargement often persists after convalescence has begun. There may be a relapse without an enlargement of the spleen, or the spleen may not be felt throughout the course. Mouth. — The rathei- characteristic tongue seen in adults is rarely observed in children, and it clears up much more rapidly. Sordes on the lips are common. The Stools. — These are not necessarily of the pea-soup variety; in fact, moderate constipation more often persists throughout the disease. The Temperature. — The temperature curve is only rarely typical. During the first week there is a gradual rise in temperature until the max- imum point is reached. The fever now assumes a remittent type, hut it is not unusual to li:ive intermissions. Cases with cerebral symptoms may have a hyperpyrexia for days. The temperature curve uuiv last from two to six weeks: occasionallv in protracted cases there is a gradual daily rise: but we feel that this fever may be solelv due to the astlienia caused bv a low diet. Complications such as broncl'.itis, pneumonia, otitis, or i^ven constipation may influence the course of the ]i\'i-exia causing irregularities in tlic curve, Iiela]ises pro- duce a ]o\v-gr;id ' tciiijierntin-e after ii ])eriod of norinnl or almost normal temperature. Laboratory Tests. — An eaily test and oni> which often gives results .during the first week is the usi; of blood cultui'es made from fi'esblv drawn blood. The Widal reaction (see p. ofi) is present in IK") per cent, of ty])hoid patients, and may be obtained as early as the end of the first week. The urine and I'ei-es contain llic liacilli. and im|)rnvi>d laboi'atory meth- ods show tlieii- |ireseiice in 20 to •"■>() pci- cent, of ihe cases. The Ehrlich- Diazo reaciion i-^ sometimes jircsent hi'Toi-e ihe Wiihil rcactioTi. and when obtained i< con 'irmalory evidence of Hie disease, but not |)athoLruouiic. THJi INFECTIOUS WSEASIOS. 269 The Blood. — 'I'lie red blond-cells and the hemogloliin diininisli as the disease progresses, but the leukocytes are finite uniformly low from the "beginning. With the establishment of convalescence, the diffei'ential count shows an increase in the eosinophiles and mononuclear lymphocytes and a corresponding decrease in the polynuclear neutrophiles. Pulse.— The relatively slow pulse is obtained only in older children, from ten to fifteen years. Infants and young children not uncommonly have a pulse rate as high as 1.50. Irregularity is rpiite frequently noted, -while the dicrotic pulse is rare. Pain. — It is seldom that this symptom is elicited in young subjects. In older children it is present in the ileocecal region in a good number of cases, and usually is accompanied by tympanites and probably is a result of ulcerative processes in the agminate glands or Peyer's patches. Hemorrhages.— It is rare to have hemorrhages in children. Wiien they occur the amount is usually small and more easily controlled. The Heart. — -Depending upon the amount of toxemia we have mvo- {•ardial changes which mav produce systolic murmurs and cardiac irrei'u- larities. Treatment. Prophylactic. — If children live in vicinities having a suspected water supply, or remove to such a locality, precautions should be taken to boil the water and to supply an absolutely clean, uncontaminated milk. The excreta of the attendants should be examined for the possibility of the presence of the bacilli if there has been a history of previous typhoid. Weaning or a wet-nurse is indicated if the motlier herself is infected. Typhoid precautions should be scrupulously observed e\'i>ri in suspected oases, the feces, urine, and clothing being disinfected witli cai-bolic acid or chlorinated lime (as given on page 311). The napkins of infants should be made of cheap material and destroyed by burning. Dishes and other washable articles should be sterilized by boiling. Acquired Immunity. — Further experimentation has established the value of typhoid immunization incorrectly s]ioken of as typhoid vaccination, and children may be thus protected, especially if they are to live or travel in a section having typhoid outbreaks or poor sanitary laws. Dosage for Typhoid Immunity.— For adults .500,000,000 bacilli are advised for the first dose and one billion for the second and third doses. For children the dosage may be gauged according to body weight; thus a child of .50 pounds will require one-half that of the adult. It is best given in the upper arm and the subsequent two doses given at ten-day intervals. 270 disi-:asi:s of ciiildkkx. General Treatment. — Careful, capable nursing far exceeds the value of drugs in this disease. A well-kept chart recording the valuations in tcmporaturo, pulse, and respirations, every tlirec or four liours, with notes upon the character of the pulse and stools, is of great importance to the physician. The room shouhl ))e as large as possible and one that can be well aired, and in which quiet can be maintained. Two beds so as to allow ready change of linen and position are preferable. Scrupulous attention should be paid to the mouth, tongue, and teeth, keeping tliem as free as possible from foreign material by the use of swabs dipped in mild antiseptic solu- tions, such as listerin or boraeic acid. For disinfection of excreta, see Disinfection (p. 310). Feeding. — In mild cases in whicli tlie temperature is not high, and the digestive processes have been little interfered with, milk and lime-water, thin gruels, plain or dextrinized, broths made of mutton or chicken, orangeade, and lemonade, form a list which will not be tiresome and which furthermore will fairly well kee]i up the patient's nutrition until lie is able to take semisolid food in the beginning of convalescence. Severe cases with continued high temperature may require the pepton- ization of the milk or tlie discontinuance of milk entirely, if it causes tympanites. Dextrinized gruels, beef broths, and albumin water may be substituted. In convalescence, in addition to articles already permitted, zweiback dipped in broilis, milk toast, junket, scraped beef, baked custards, and soft-boiled eggs are cautiously added to the diet. Matzoon and kuinvss or home-prepared buttermilk are occasionally relished by the child and varv the monotony of his restricted dietary. In 11 consecutive cases in our hosjn'tal, 7 gained in weight, 3 lost slightly and 1 showed a considerable loss on the regular soft diet. Hydrotherapy. — Tlic fever is in nearly all eases effectively controlled by s]:)onging with alcohol and tepid water. AVe have discontinued the use of tubbing. Any good effects of the reduction of tem|XM'ature obtained are more than counterbalanced by the nervous excitement it produces. Therefore, a wet pack is preferable for high temperatures not controlled by sponging, the sheets being wrung out in water at 00° F. If at this terii]:ierature a satisfaciory reduction is mil obtained, the wrappings may be sprinkled with water at 8.5° or even 80° F. An ice-bag may he applied to the head, es|ieeially if tliere is headache or d(>lii'ium, Iiut it re(|uires eon- 'Ill 10 jKFJCCTiob's ])ish:Asi:s. 2; I staiit vigilancL' on the jjart of the nurse who sliould be instructed to remove it if any e3'anosis develops. Drugs. — W'itli tlie e.\ception of certain symptoms wliieli will rei|uire control Ijy Ihc use of mcdicalion, no driipfs should be pivcn. Intestinal antiseptics and alcohol as routine measures are to be deprecated. The bowels are kept open with saline enemas wliicli may be uivcn cool if the temperature is high. Divided doses of calomel are indicated in the begin- ning of the disease. Tympanites sliould be prevented rather than treated by caieful sujicrvision of otfenaction is obtained much less often in the father than in the mother, this probably being due to the fact that syphilis is in a majority of cases a self-limiting disease, the dangers of transuiissicm after the fourth or fifth vear being greatly diminished. Pathology. — The sjiii'ocbeta is widely distributed in the infanfs body, Accoi'ding to Trinchese, they ai-e found most abundantly in the suprarenals, then in the liver, lungs, ovaries, testes, spleen, the fetal end of the funis, and also with i-elati\'e fi'e(|uency in the blood. The\- are relati\'i^lv rare in the [ilaccnta, liut may he found in the stroiiui and on the surfaci^ of the \illi. The migration of the spinichel ii from the \'cssels of the villi to the sur-facc of Ihc \illi nnd into the intervillious spaces is n^nai'ded bv Trinchese a*: nni-ni;d. THE IXFKCTIOT'S DISKASKS. li i i The spirocheta can, as a rule, be easil,y ilemoiistrated in any of the superficial ulcerating areas b,v the " iiidia-ink method " of Ilech and Wilenko. A small drop ()f serum is pressed out of the tissues and jilaced upon a slide. To this is added a similar sized drop of India ink (Gunther's and Ilisgin's) and thomushly mixed with a iilatinum loo]i. The mixture of serum aiid ink is allowed to dry, after lieing spread out as thinly as ])0ssihle. This smear is then examined under an oil-inimersidu lens. The fetu.s may die at any time during the nterogestation witli resulting miscarriages, or ]iiay live to term and then be still-born. When born alive, the lesions resulting from the disease may be l^roadly divided into those involving the skin and mucous membrane.?, the viscera, and the bones. Thci-c may be erythema, maculo-papulcs, oi- papules on the skin, or a vesicular and pustular eruption may occasionally be seen. Bleljs or bulla:: often appear at birth in a severe type of the disease. Crops of boils, with well-defined, coppery-reil bases, are apt to be symmetrically arranged when many are present, or asymmetrically distributed if only a few are seen. The lesions of the mucous membi'anes may take the form of inflammatory pro- cesses, of mucous patches, or of superfical or deep ulcerations. The junction of skin and mucous memlirane is a favorite scat for the sypliilitic lesion. The viscera are more apt to be involved in hereditary than in acquired syphilis, the lesion taking the form of an interstitial hyperplasia. The growtli of interstitial connective tissue, which, by gradual contraction, partially obliterates the parenchyma of the organ, may involve the lungs, spleen, liver, pancreas, and testicle, Usnally a portion of a Inhe, liut occasionally a whole lobe of the lung, may present a diffuse fil)roid infiltra- tion with a grayish-white color. The liver, which is not infre(|uently affected, is liardened and enlarged fi'om a diffused sclerosis, although oc- casionally the affection may be circumscribed. Gummata, in the form of email, circumscribed nodules, may be found in the lung, livei-, oi- other viscera. Bone lesions are quite common and some that were formerly re- ferred to ricltets or sci'ofula are now recognized as syphilitic. There are two principal ways in which the specific poison affects the bones in early life. In one instant the bi'unt of the disease and morbid change takes place at the junction of the shaft with the epiphysis — osteochondritis ; in the othcT-, the periosteum covering the long bones is jirincijially affected with a resulting periostitis. Both of these varieties involve prin- cipally the long bones. Osteochrondritis develops early in life, usually within the first month. It may, however, occur later, when it is not apt to become multiple, and may be unsymmetrical in distribution. "While epiphy- seal swellings may be due to rickets as well as syphilis, such swellings are pretty surely syphilitic if they occur during the first six months of life and tbev are relieved by mercurial treatment. Again, the epiphyseal swellings ■> ^' w' 1)1si-:a,sI':,s ok niiiJ>i:i:\. of rickets are always syiiinietrical, while those of syphilis may be unilateral. Periostitis occurs later in hereditary syphilis, usually after the child has begun to walk. It attacks by ])refcrence the femur, tibia, and bones of the forearm, occurring usually from the second to the fourth or fifth year. At an early stage of the disease the bones are attacked symmetrically, but later, circumscribed nodes may be placed unilaterally. A dactylitis attacking by preference the proximal phalanges of the metacarpal and metatarsal bones, enlai-ging them to several times their natural size, ma\' occur. There is not much destnu'tion of bone but after a time the skin iiui\' become inflamed and break do\^■n from the formation Fk;. C'r ' -- /.Hi f y T ' Fig. 70. — Sei-ticin of liver frcjiii syphilitic iiif;int, sluiwiiig larse inirabers of spiroclietic. sure, and usually appearing first on the lower portion of the abdomen. These may later tal. In syphilis there is little tendency to suppuration and necrosis; in tubercu- losis the pyogenic tendency is marked. 4. In syjihilis, osteocopic pains, with tendency to nocturnal exacerbation are a pronounced feature ; in tuberculosis the pain is dull and heavy, not aggravated at night. •^. The osseous lesions of syphilis rarely react upon the general system, while those of tuberculosis often determine a maj-ked impairment of the general health. In differentiation of syphilis from rickets, epiphyseal swellings under six montlis are very apt to be syphilitic. In syphilis the epiphyseal swelling 28'Z l)lsiv\si:s oi' en I Li)i;iii\. may be unilateral, but it is always symmetrical in rickets. In doubtful cases the swelling must be subjected to specific treatment. It is well to rememljer, however, that rickets and syiihilis may coexist in the same case. Prognosis. — The eaiiier the symptoms appear after birth, the severer will he the type and the worse the prognosis. Breast-fed infants have a much better chance than those artilicially fed. If the digestion remains, good and the manifestations of the disease are not severe, complete recovery takes place and the infant may grow up healthy and sti'ong. The average prognosis, however, is bad. ]\assowitz states that one-third of all syphilitic children die before birth, and among those who are born 34 per cent, die in the first six months of life. Treatment. — Parents who exhibit any specific symptoms or who have had syphilitic children should be subjected to specific treatment in the hope of avoiding infection of the fetus. Mercury is the specific remedy and may be administered to an infant either externally or internally. Daily inunc- tions of mercurial ointment, mixed with from two to eight times its quantity of vaseline or rose ointiiu'iit, may be employed. A lum]i about the size of a small hickory nut may be rulibed on the inside of the thighs or in the axillaj, the parts having previously been cleansed with soap and warm water. It is more cleauly to apply five drops of a 10 per cent, solution of oleate of mercury three times daily. Internally, mercury with chalk is one of the best preparations in doses of one-fourth to one grain three times a day. Calomel, in doses of 1/20 to !/(> grain, three times dailv, will have a more rapid action when such is desired, or bichlorid of mercury 1/200 to 1/60 grain may be given. If the latter induce intestinal irritation, a menstruum, containing bismuth, will usually allay it. When mercuiy is given for a long time it is well to occasionally change its form, although in syphilis it is a tonic, acting like iron in anemia. The nostrils must be kept clear, using, if necessary, some blaml oil like albolin. Mucous ]iatches and ex- coriations must be kept clean and dusted with calomel and bismuth, eipial parts. It is usually necessary to give mercury for at least a year, with occasional intervals of tonic treatment. In visceral lesions and where the bones are involved and evidence of gumma in any part of the body appears, iodid of potassium, in doses of 1 to 5 grains, will be indicated. The general care and feeding is most inipoi'tant. While the infant should not, if possible, be taken from the uiothei's breast, it must never be given to a wet-nurse. Ehrlich's Preparation. — Recently there has been placed on the market a drug under the tradi' name of neosalvarsan. The drug is an arsenic preparation, and must be given in lai'ge doses in order that it may produce IS TIIK JNFICCnOUS DLSKASHS. ' 283 its effects quickly, as otherwise tlie spiroclieta become " arsenic fast," i. e., are not affected by arsenic. Neosalvarsan is a nuich safer preparation for children than salvarsan. Following the injection there is a rapid improvement of all the symptoms. It is a mistake to suppose, however, that there is a complete cure from one or more injections of the drug. As a rule it is necessary to continue the use of mercury in some foi'm not only before but after tlie treatment with neosalvarsan. When given intramuscularly there is some danger of the formation of a slough. Injection into the deep tissues is always accompanied by pain. The dose is about 0.04 per pound of body weight. As neosalvarsan is a neutral salt its preparation is a simple matter, the drug being mixed with cold distilled water. The injection into a child's vein is not a simple mattei'. Occasionally the vein can be directly entered through the skin, but not infrequently it is necessary to expose tlie vein. At the present time a 5 per cent, solution of the drug can be injected into the blood stream with no ill effects. These injections of neosalvarsan should not be given by the general practitioner, but should be left to those who have perfected their technic by special study. Whenever possible the case should be in a hospital where there are special facilities for sterilization and skilled assistance. It is a method of treatment which should be reserved for syphilitics who need rapid heroic treatment or for those cases not doing well on routine treatment. The course of the disease should be carefully followed by the Wasser- niann reaction, and occasional tests should be made after all symptoms have disappeared. Late Hereditary Syphilis. This form of syphilis comprises those cases in which early evidences of the disease have either not existed or have been in such slight form as to have been overlooked. Late hereditary syphilis may manifest itself either in certain active lesions plainly to be attributed to this condition or by certain developmental defects that may easily be confused with tuberculosis or rickets. The secondary teeth are affected in a way that has been considered pathognomonic. The principal change is noted in the two superior middle incisors, which are small, peg-shaped with scooped-out grinding edges, and placed at such an angle that the cutting borders, if continued, would meet. They may occasionally be deflected outward, and are known as Hutchin- son's teetii (Fig. 77). IJlceration of the palate, usually, beginning in the center, may take place and be followed by caries or necrosis of the bone. There mav be simultaneous or consecutive deep ulceration of the soft palate, 28i I)Isi:asi:s hi' cii i i.diji.v. pharynx, and naso-p]iarynx at any tiiiiu pru\ious to the age of puberty. Lai'ge. inilolt'ut amicous patches may t'xist in the mouth, and tliere may be ulceration about the lips leaving long scars, especially at the commissures. The nasal bones may become necrotic with depression of the bridge from destruction of tlie bony arch. A periostitis, accompanied by a thickening on the surface of the bone, may involve the long bones, especially the tibia, ulna, radius, and humerus. The lesion may be multiple and symmetrical, although occasionally uni- lateral. Gummata. involving the bones and occasionally the soft tissues. Fig. (S. — IlutchiiLsuii's teotli. (Dr. /•'I'tiiiciitltuVx case.) may be seen, and, in tlie latter case, may break down with nlceration and leave large scars. Intei-stitial keratitis, without nmch congestion of the con- junctiva, is not infrequent, and is lialile to he followed by corneal opacities; although primarily attacking one eye, it may imolve the otlier. There may coexist an indolent iritis without the usual severe pain and pliotophobia. A chronic form of otitis may be followed by deafness. I'ainlcss enlargement of one or both testicles may be caused by syphilis, but there will be a]it to be lesions in other parts of the body to aid in the diagnosis when this occurs. In many cases all the evidence of syphilitic taint in cbildhood will be found Tiiii ixFEfrnors di,si;asi:s. 2S5 in arrested and perverted development. As an example, the testicles at puberty may be about the same size seen in very early childhood, and in .tjirls in absence of mammary development, delayed menstruation and a non- appearance of hair on the genital and axillary region may be noted. Veeder and Jeans in their recent report state that the incidence of manifest hereditary lues of the late type is much greater in proportion to the incidence of early syphilis than previous figures would indicate. Lesions of the central nervous system appeared in 43 per cent, of their cases. Acutely developing lesions responded promptly to intravenous injections of neosalvarsan, but permanent results are to be obtained only by prolongerl, intensive mercurial treatment. The Wasserman reaction, even if once negative, returned if the treat- ment was discontinued, and a negative reaction could not be obtained in some cases even after two years' active treatment. In other words it is felt that late hereditary lues cannot ]x eradicated. Treatment. — The treatment of the later forms of syphilis must depend on the activity of the morbid process. Mercury in some form should be exhibited when there is evidence of active syphilitic disease. lodid of potash is also to be given in fair doses, three to five grains. The treatment should also be directed toward improving the nutrition of the child in every way. Good food, iron, cod-liver oil, are all of value in aiding healthy growth and development in these retarded cases. (See treatment with neosalvarsiin, page 2S2.) Acquired Syphilis. The syphilis detected in early life, although usually hereditary, is not necessarily so, but may be acrpiired. A primary sore upon the genital tract of the mother can possibly infect the infant during birth. The nurse or attendant may have a primary lesion upon the 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 meiubranes of an infant or child. A chancre will then appear at the point of contact, followed in due time by the later manifestations of the disease. Karely, in older cbihlren, the disease may be contracted by sexual contact. The symptoms and treat- ment present essentially the same elements as in adult life, and hence will not be considered here. The acquired disease in the infant or voung child tends to he milder than the hereditary form in its symptoms and less apt to affect seriously the general health and development. 386 iiisi:asi-:s uf cii M.niiKX. Epidemic Cerebrospinal Meningitis. (Ccrehrospinid Fercr.) [Spotldl Fvvcr: Ohsolete.) This form of meningitis is an acute infectious disease due to tlie dip- lococcus intracellularis, cliaracterized by motor and sensory cerebral and spinal symptoms. Etiology. — The disease, without question, has its specific germ in the dijilococcus intracellularis meningitidis, fully described by Weichselbaum in 1887. This organism, fortunately of low resistance, gains access to the general system through the lilood or tjirough some local determination in the naso- pharynx, ear, or eye. and in those with depleted \itality and lowered resist- ing force finds suitable soil for its propagation. It usually occurs in epidemic form, although occasional sporadic cases are seen from time to time, especially in the large centers. The spring of the year, after pi'olonged confinement to ill-ventilated and superheated apartments, finds the greatest number of predisposed indi- viduals. It is essentially a disease of the voung. Oui' youngest case was twelve weeks old, although Eotch. of Boston. re])orts a case six days old. The second year claims the greatest number of victims. Pathology. — In making postmortem examinations of those dying with the disease, we find, as a rule, an exudative inflammation of the pia arachnoid of the brain and spinal cord. The amount of infiltration found, however, often docs not correspond to the gravity of the symptoms observed during the life of the patient. The degree of infiltration varies from an intense hyperenria to a fibrinoplastic seropurulent or purulent exudate. This exu- date is most marked at the base of the brain and along the fissure of Rolando and the dorsal portion of the cord. In the ventricles is found a cloudy or oparpie serum and in a few cases pttre pus. The effusion in the subarachnoid space (and it must always be kept in mind that there is more fluid in the subarachnoid space in children than in adults) is increased in normal amount. Frequently there is seen a parenchymatous degeneration of the kidneys, degeneration of the heart muscle and the muscles in general. There will also be found in a number of cases multiple abscesses, septic joints and ecchymoses of the skin as a i-esult of complicating conditions. Symptomatology. — In cerebrospinal meningitis the symptoms vary according to the type of the disease present. The onset is usually sudden and abrupt. The malignant types are seen largely in the epidemics only and are responsible for the large mortality record. In this type headache, vertigo, vomiting, and high fever are soon followed by coma and death. The symptoms in the sporadic cases will vary with the gravity of the THE INFECTIOUS DISEASES. 287- local lesion and the intensity of the toxemia. The historj' of the prodromal period maj' be of material assistance in establishing the diagnosis: there is malaise, headache, chills, loss of appetite, body pains, and some rise of temperature. Later frontal headache is complained of and succeeded bv vomiting, restlessness, and rapid pulse. Herpes on the lips and nose, retraction of the posterior cervical group of muscles, hyperesthesia and opisthotonos are observed. The general nutrition suffers severely and ema- ciation is steady and progressive. Delirium, stupor, or profound coma develop. Convulsions of a severe type (particularly in infants and younger children) are apt to occur at or near the beginning of the disease. The loss of flesh and strength is ]-apid and marked. Photophobia and irregularity of the pupils with loss of pupillary light refle.x and nystagmus are quite regularly present. Neuroretinitis is found on ophthalmoscopic examination of the fundus in some cases. The respirations vary with the stage of the disease; they are increased when the fever is high, sighing and shallow Fig. 79. — Cerebrospinal iiieiihigitis with marked opistbotouos. when stupor begins and are irregular when coma develops. The blood shows a leukocytosis rarely under 25,000 to the cubic millimeter. The tem- perature curve is not characteristic and bears no relation to the prognosis. The excursions are wide and varied. The pulse is rapid and sometimes irregular. Ecchymotic spots and purpuric areas are seen in some of the fulminating cases, but a roseola or an erythema is more apt to occur in the sporadic cases. Tlie reflexes will help to establish the diagnosis, but must be interpreted with caution. The tache cerebrale is always obtained, but is only a minor confirmatory sign. The Babinski reflex, or extension of the great toe on irritating the plantar surface of the foot, is confirmatory, especially in chil- dren over two years of age, although negatively it may be of assistance. Kernig's sign, which is obtained in nearly all the cases at some stage or 2S8 I)isi:asi:s hi-' ririLDiiEN. other, is also present in all fdrius of cerebral irritation. Brudzinski's sign is a rather recent but valuable sign in meningitis. It is elicited by placing the left liand on the thorax and forcibly and rather suddenly depressing the chin to the sternum. If the extremities have been previously relaxed, they will now be (juickly flexed until a croucliing attitude is assumed. Macewen's sign, or the hollow note elicited by percussion over the parietal Ijone, is obtained only in those cases in which fluid has accumu- lated in excessive <|uantity in tlie ventricles. The rigidity of the neck, with dilatation of the pupils when attempts are made to flex the neck, is also a helpful and confirmatory sign of meningitis. The urine in tlu^ course of the disease often contains albumin and hyalin casts, the result of toxic substances in the blood stream. Loefler and Gour- and, of France, have called attention to the fact that in the beginning of the disease large amounts of urine of low specific gi-avity are passed, con- taining a high percentage of urea. An examination of the blood will assist in making a differential diagnosis. Leukocytosis, principally of the poly- morphonuclear cells, is present, while the mononuclear elements predomi- nate in the tuberculous typ<' of meningitis. Lyons classifies tlie order of importance of the clinical signs. First in importance he noted tlie value of lundjar puncture in 95 per cent.; second, rigidity of the neck in 9o per cent of the cases; third, Kernig's sign in 90 per cent, of cases; fourth, Brudzinshi's sign early in 75 per cent., later in 9-i per cent, of cases ; fifth, contralateral sign early in 33 per cent., later in 50 per cent, of cases; sixth, Babinski's sign in 11 per cent. He places no value upon patellar reflexes as a diagnostic aid in his cases. Lumbar Puncture. — Although the diagnosis can often be made from the clinical phenomena alone, confirmation and temporary relief fiom intra- cranial ]iiessui'e symptoms are afforded by lumbar puncture, and it is also an aid in establishing the diagnosis and ju'ognosis. The jn'ocedure is not difficult, and if |)ei'foi'med with aseptic precautions and a due regard for the anatomy, is productive of no harm. The tcchnic is as follows (also see Fig. 19, page 51 ) ; Infants in whom opisthotonos has not yet developed may be placed over a pillow at the end of a table, the s])iue and outlying soft parts being thus put on the stretch. The spine may be entered between the third and fourth lumbar vertebra;. This space is found by an imaginary line dra\\^l across the iliac crests and intersecting the spine. In older patients, or those with opisthotonos, it is necessary to place them on their side and enter to one side of the median line. I'he needle of an ordinary good-sized aspirat- ing syringe cannot be improved upon for the procedure. A snutll ti'ochar Till:; ixi'iccriois nisi-;Asi:s. 2.Sl> and cannula may also be used and 10 to 15 c.c. {i ounce) should be with- drawn, pio\ided the fluid flows freely, as this amount will include fluid from the cranial cavity and lead to more accurate Ijacteriological results. It is not wise to withdraw more than 'M) c.c. or an ounce at a sitting. In infants with an o])en bulging fontanel, an ainounl can be withdrawn which will appreciably depress the fontanel. Dry taps, which occasionally occur, are usually the result of imperfect technic, the operator either not reaching the spinal canal, or the needle liecomes obsti'ucted with blooil. If tlie exudative processes have occluded the connection between the ventricles of the brain and the cerebral and spinal subarachnoid spaces, as sometimes occurs in well-advanced cases, the ojieuing may be partially occluded and the fluid flow very sparingly. In cerebrospinal meningitis the fluid obtained is generally clouded or turbid, sometiiues it is purulent or again vai'ies from time to time. In a small percentage of eases it is (piite clear tbroughout. It contains the diplococcus intracellulails, and in some aspirated fluids in addition, staphylococci and streptococci are found. I'olynuclear leukocytes predominate and contain the specific organisms. Complications. — Those which may be attributed more directly to the disease itself are those of the eye, the ear, tlie brain, and the joints. The drum frequently is infected and may result in deafness and the labyrinth is apt to be likewise involved. Chronic hydrocephalus develops in a number of cases beginning either during the acute stage or in convalescence. These children are usually mentallv deficient or idiotic. I'arely an arthiitis develops in one or more joints. Differential Diagnosis. — As a rule, the symptoms are typical enough to make the diagnosis of meningitis, which is confirmed and further differ- entiated by lumbar puncture. The sudden onset, the headache, fever, vom- iting, or convulsions in the face of an epidemic are especially significant. Meningilic symptoms in typboiil fever ^\-ith I'apid onset are often confusing. The blood examination for leukocytosis and the Widal reaction should be used to assist in the differentiation. Tuberculous meningitis, especially in infancy, is often confused with sjjoradic cases of cei'ebrospinal lueningitis, and indeed the pathological examination of the spinal fluid may in some eases be absolutely necessary to differentiate them. The slow onset in tuberculous meningitis, the low leukocyte count, and the absence of hyper- esthesia are distinctly helpful points. Prognosis. — We can base oui- prognosis on the following facts: Spo- radic cases have a greater natural tendency to recovery, luilial symptoms do not, as a rule, indicate the subsequent course. Mixed infectioTis as found 290 DISEASES OF ('1iii,diii:n. in the spinal fluid indicate a general septic condition and an unfavorable prognosis. Tlie younger the i)atient the more unfavorable the outcome. Do not interpret as a sign of restoration to healtli a temporary remission with return of ronseiousness from coma. Wideh' dilated, rigid pu]ii]s, unvarying coma with slow pulse, sub- normal teni]ierature, persistent opisthotonos, and convulsions are signs teniling to a fatal termination. Treatment. — ^The germ and its toxins must he combated. Detailed study of the portals of entry of the infecting organisms has thus far failed to establish much that is new. Care of tlie nasopharynx as insisted upon by Jaeobi and Caille is a loial uieasui'c producti\-e of much good, especially in tlie crowded eeutei's. Seliool ins]>eclioii and a Idgher standai'd of sani- tary regulalioiis in everv district will do much to )irevent epidemics of this disease. Serum Treatment. — The promising results that have been obtained from the use of Flexnei-'s aid iii]eiiingi(is serum when used by tlie sulidural nietliod warrant its use in cases in wliicli the diplococcus intracellularis has been dc'monsti'ated. It is ineffective in othei' conditions. If the bacterio- logieal test is iiiijii'aetieable m- would l)e umluly d{ tiie X. Y. State Department; oi' llealtli, linds i'rom the study of a large iiuinljer oi' eases in wliieli a single exposure eould lie determined that the incubation period varies from four to fourteen days, with an average of about a iveek. The persons attaeked were found to be sourees of aetive infeetion for a pei'iod of at least eight days after the onset. In a number of eases infection took place ill as short a period as two days before the frank onset of poliomyelitis symptoms. Tliere has been little eviilenco, however, of the disease being contracted from a person who had been ill longer than two weeks, whieli suggests the linut of the necessaiy period of isolation to be required for sus])ected cases of polionnxditis in future outlireaks. The following pjoiiits will fairly re[)reseiit the peculiarities of the epidemic form of paralysis in children : f. The disease is occasionally fatal, especially early in the attack. The eiideiuic form is rarely, if evei', fatal in its ending. 2. Thi'i-e are great variations in the extent of the paralysis in the epiilemic fcnu. i\[an\' eases show \X'r_y extensi\e palsy, inyolving all the extremities and the muscles ot tlie back and neck as well. (Jthcr cases show a very slight h>ss of power, and the disease is doul)tless occasionally over- looked from this cause. 3. Pain seems to occupy a more prominent feature in the epidemic than in the endcmii' fni-ni. This ]iaiu may e\eii last well along in the course of the disease. In tlir ordinary endemic disease, if pain exists it is not apt to last more than a day or so. ■i. A certain proportion of cases in these epidemics seem to undergo a complete reco\eiy. This rarely, if ever, happens in the endemic form. 5. The lesion tends to be more varied and exteiisiye in the epidemic than in tlie endemic form. It may include the following conditions: Polioenee])halitis (if Striimpell; ])oIiomyelitis ; peripheral neuritis, and occasionally meningitis. Rheumatic Fever. [Acute Aiiivuhir IHieuniatisiii.) Rheumatic fever is a febrile disease of the joints characterized by transi- tory inflannnatory attacks wbicli do not tend to suppui'ation. Etiology. — The infectious origin of the disease is accepted ns a fact; although the diri'ct etiological factor is still in dispute. The disease as- THE IXFEC'TIOCS DISEASES. 209 sumes certain cliaraeteristics in cliildliood whicli distinguish it from tlie adult type. The course is milder and shorter, while involvement of the heart is more frequent than in adults. vSingle epidemics and a .snecession of epidemics have been reported from time to time. Several members of tlie same family may be attacked siinul- taneously. The oral cavity and more particularly tire tonsils have been regarded by many as the portal of entry of the infecting organism. Predisposing factors arc exposure and residence in cold damp apartments. Heredity seems to play a distinct part if the predisposing factors are ]irescnt. Tlie disease is not very common before the fifth year, altliough cases have been I'ecorded during tlie nursing period. One attack predisposes to subsequent attacks. Among the 70 cases studied cliuicalh' bv C'hapin the following were the ages : r, iiut^,. 1 11 1 Ill's,. 1 20 IIIOS.. 1 " vrs. 1 4 yrs., 2 n -yrs,, 4 11 vrs.. r> 7 1 , rs.. s vrs., 11 II yi's., n 10 yrs,. ,", 11 yrs,, S lli yrs.. 7 1-1 ': vrs.. \i 14 yis.. -1 1 ."' yrs.. \1 17 ,\TS,, li Symptomatology. — An attack may be preccdeil by languor, loss of appetite, mild tonsillitis, abdominal pains, and indefinite pains in the joints. With the localized jiain there is a febrile reaction of variable intensity, 102-104° F., and occasionally there is vomiting. The knee- and ankle- joints are, as in adults, most frequently involved. In children the hip and cervical vertebra' and joints of the fingers and toes may be the areas attacked. Usually more than one joint is affected, but symmetrical involvement is not the rule. It is exceptional for the attack to persist more than a few days in any one joint. The joints, as a rule, are not exquisitely painful on active or passive motion, while the swelling, if any. is moderate. The fascia covering muscles may be attacked without any involvement of the joints. The sternocleidomastoid muscle is especially liable to such attack. The acid perspiration so commonly oljscrved in adults is rarely present in children. A waxy ajipearance is observed in severe eases with insomnia, anorexia, and insatialile thirst. The blood findings are of no assistance in making the diagnosis. Mild, almost afebrile cases may, however, be followed 1iy serious involvement of the heart. Complications. — These bear a direct relation to tlie toxins of the disease itself. Eheumatism in childhood is characterized by its cardiac complications; it thus must always be considered as a disease of serious import. Nearly half of all the cases leave permanent cardiac effects. The mitral valve is most frequently affected. The involvement is :;(10 DisicASKs of riL]i.uKi:x. aceiiiiipaiiied by iiT(.',uiilar rises uf k'uipuvalure and iiid'cast-'d pulse rate. The sviiiptoms aecoiupanying valvular Jefeets, Ijnweve)'. may be llie iirst indieation for iiiedieal attention and lead to the diseovery of llieir rbeuiuatie- ori,i;in. iV'i-iearditis is piesent in 10 to 20 pei- cent, of all eases in children anil is freipiently associated with endocarditis, and is an important and often fatal com])lica1ion. Serous, or serofibrous pleurisy, is a comjdication seen in severe and long-standing cases. Tneunionia and occasionally ni'phritis are j-arer complications, in all probability due to mixed infection. A pur- puiie lasli oi' an ervtbema may l>e seen as rheumatic manifestations. Chorea must be regarded as a ilistinct rheumatic nianifestation and often may pre- cede the disease. Involvement of the endocardium is not I'arc in cases of chorea. Ebeumatic iritis is rare in childhood, but can be diagnosticated by a competent opthalmologist. Tiheumatic nodules occasionally appear under the skin, developing rapidly. They appear, as a i-ule, near the joints, and follow the course of the tendons. Sometimes thev are painful rm pressure. They may be from one 1o fiftv in number, and mav last for several weeks before absoryition takes place. Prognosis. — Tiheumatic ]iolyarth litis in childien tends to quick recov- ery. Eelapses are common, and it is in these secondary attacks that the endocardium most often suffers. Fatalities may follow severe comjilications. Differential Diagnosis. — Septic ai'thritis as seen in scarlet fever and gonorrheal arthritis should be excluded, as should tlie rarer cases of }ineu- mococcic ai'thritis. The liistoi'\- and the intense localizalion tending toward suppuration in the se])tic tyjies M'ill assist in making the diagnosis. A blood count in sejitic cases will show high leukocytosis. .\n exploratory puncture is often ]ustifial)le in establ isliing a pi'ompt diagnosis. Scai-latinal jiolyai-thritides, as a rule, affect the wrist-joints fii'st, then the shoulders, knees, and feet. Thev a]i]iear in the seconil or third week of llie disease, and last about lianees and s\irgical inter- vention ai-e often neeessar\' to e(U'rect resulting dcfdrmities. Still's f)ist:-\si':. — This is a ]i(il\'arthi'itis oe(ainang in ehildiiood wliicli is as "\'et liltle undei-stoiiil. ('linieally, if seems related to ceidain forms of chronic si']isis. There develo]"is an eidargement and ]iartial anlc\'losis of the joint witi: some tem])i'rature of an iia'cgular t\pe associated with s]ilenic h\"|ierfi'0]ihv, aiid (pi iti' general enlargement nf the li\rr and l\iuphatii- glands. As dist ingiii~heil frnin the nlhrr rheiiinaliiid^. the disease does not tend to dcstructi\'e changes in the joints, and in fact sei>ms to he self-limited. Malaria. {Fill 11,1 is III.) Malaria is an infections disease caused liy the liemacvtozoon of Laveran, and chai-acferized h\- a periodic intermittent nr reinillent fe\ei'. Ktiology. — The parasite i< eari'ieil through the ano|)heh's mosipiiln, which is distinguished from the common inosipiitn ay eulex hv the following [•haracteristics. A-Noerrha.Ks. ( 'or.KX. 1. 'I"w(i lar^'c |i:ilpi 11)1 side (if 1. Siii.-ill |i.-il|ii. [irelioscis. •J. Miiltleil wind's. 2. .\(i spiits iin wilisjs. :!. r.ddy held at an .■iii-le 4.'." :!. Tteily held |iiir.illel. or more. INistei'lor le^^s ofleii itossihI over hack. 4. Tilore orieii I'liund in Ihe 4. More often found in eilies. ciimdrx . THE IXFECTIODS DISEASES. 305 The parasite of Laveraii occurs in three foriiis : tlic tci'tian, i|iiartan, and estivoautuinnai. In the fall of the year the greater number of cases ai'e seen. Regions in which much marsh land is found are favorable places fiir the breeding of the anopheles, and in these localities malaria is naturally more prevalent. Pathology. — The tertian variety develops .in the liunian organism in forty-eight hours. At first there is seen a small ovoid particle within a red blood-cell. Pigmentation appears as development progresses around the periphery of the parasite. Ameboid movements may be noted. The hemo- globin of the red cell appears to be destroyed by the parasite. Segmentation now takes place, creating the spores which are freed in the l>looil stream and are ready to attach new red cells, and then pass througli a similar cycle of development. The (]uartan type completes its development in seventy-two hours, ]ii-o- ducing the characteristic paroxysms on the fourth day, instead of on the third, as in the tertian type. It may be differentiated from the tertian liy tlie lack of movement on the third day, and l)y the peculiar yellowisli-green color of the cell, and by the rosette appearance on the fourth day. The estivoantumnal variety takes twenty-four to forty-eight hours to complete its cycle, and cresentic forms appear after a week of development. The parasite is sparsely pigmented and smaller in size. The ganietocytes or sexually differentiated types develop only in the interuuMliato host. Sporozoiils develop in tlie host or mosfpiito, ai:>d through its salivary o-lands infect the bitten individual, where they develop into parasites and jiass through 'one of the cycles as Just descril^ed. In mild cases of malaria little alteration in the body structures may be found besides an enlarged spleen and changes in the blood. Malaria is rarely fatal in infants and chikh'en. In the pernicious forms both the liver and spleen are enlarged. In chronic malaria the spleen and sometimes the liver become hard and deeply pigmented. Symptomatology. — In infants (in whom it is quite rare) and in younger children the symptoms are irregular in form and the clinical diag- nosis is often obscure. In older children the typical adult type is seen, presenting little or no difficulty in diagnosis. A distinct chill or chilly sensations, and sometimes a convulsion, may usher in an attack. Chills are not observed in infants. The child has been listless for several days or complains of being tired, stretches, and yawns. The extremities are cold, and the child seeks its bed ior warmth. ;iOG DISKASKS OF CIIILUIIEK. ; Tim eoiimiou tvpt' in infants and younger cliildren results fi'oni a double infeetion with the tertian parasite, producing the so-ealled quotidian fever. The temperature is liigli, with a corresponding pidsc rate. •• The estivoautumnal type is not often met with; it produces a very irregular form of fever with or without a definite paroxysm. The fever may be intermittent or even remittent in type; that is, a continuous fever with small excursions and no drop to the normal. In older children, as has been said above, the adult type is simulated. The period of chill is followed by the stage of fever and more or less per- spiration. The tempei'ature reaches 104° or ]0.5° F. and is accompanied by headache, often vomiting and extreme thirst. A normal or subnormal temperature follows after the period of high fever. The succeeding day a robust child may be willing to go about and play as usual. In the cities we see a subacute varietv, usually in children, aljout the fifth year- of age. Thev are brought Ijecause thcv are on different davs list- less, pale, and without ambition. The physical examination often shows an enlarged spleen and cbaractcr'istic blood changes. Tnie chills are not experienced nor does one obtain a histoi'y of fever followed by jierspiration. Malarial cachexia and the pernicious forms of malaria arc rarelv seen among children in the T^nited Stales, at least in the N'ortb. In the cachectic or chronic type the spleen is uniformly large and firm, sometimes extending to the crest of the ilium. In these cases the liver is apt to be enlarged. The child is extremely anemic, has a greenish-yellow tinge, and a poor com- plexion. Loss of appetite and consti]iation are commonly found. The urine is highly colored and may contain casts and blood. Differential Diagnosis. — ]\ralaria must be diffcreutialed fi'om tvphoid. secondary anemia, Banti's disease, and certain forms of nephritis. Repented examinations of a fresh or stained sjiecimen of blood, or both, should be made for evidences of the malarial organism. The therapeutic test with (|uinin may be made in suspected cases in which a blood examination is not feasible. A 20 per cent, increase in the large mononuclear leucocytes usually means a pi'otozoal infection. The uniformly enlarged spleen found in malaria is a diagnostic feature of gi-eat impoi-tanee. The spleen is said to be enlai-gcd in a child when it can 1)0 felt. The Widal test and a dilferenlial blood count will often assist in fixing the diagnosis when a careful physical examination, including the ears, has been made to exclude other conditions. Pyelitis is excluded bv a urinary examination. Treatment. Prophylactic. — The physician should be acquainted with Ihe genus of mosipiilo in his locality. If the anopheles are present he should insist upon the aulborities taking all ]iossihle measures to drain the THE INFECTIOUS DISEASES. 307 ewainpy areas. The children's cribs sliould be closelj' screened. Water bar- rels and similar tanks must be protected by screens to prevent the develop- ment of larvae. The latter may be killed by the use of crude petroleum floated over infested pools. Therapeutic. — ■ An initial purge with calomel is recommended. The early and continued use of quinin until a cure is effected is essential in any of the forms above mentioned. Eelatively larger doses may be given to children than to adults. For infants and younger children, the soluble bisulphate is recommended. Its bitter taste is often less objected to by younger children than by their elders. The syrup of yerba santa best dis- guises its bitter taste if any addition is necessary. Euquinin and tannate of quinin are tasteless preparations which may be given in mild cases, and when given should be prescribed in doses double that of the sulphate. The sulphate of quinin in half-grain doses may be made more palatable by the use of chocolate in tablets or lozenges. The year-old child may be given one grain of the sulphate or bisulphate every three hours. A child of five j-ears, three grains every four hours. Larger doses ma}' be given on well days, and decreased or omitted during the paroxysms. Where the stomach is irritable and the quinin not retained, rectal injections of the bisulphate may be made, preferably in a mucilaginous suspension. Suppositories of quinin are not very satisfactory for continued usage. Tlie hydrochlorate or bimuriate of quinin in cocoa-butter should lie used for this purpose. The hypodermatic administration of quinin in children in this country is unnecessary and uncalled for. The chill is combated with a number of hot-water bottles, a hot ]iack or a hot bath. The oncoming fever is allayed with alcohol sponging and cool drinks in small quantity at frequent intervals. Quinin should be administered for at least a week following the last symptoms of malaria. The elixir of iron, quinin and strychnia will do much to combat the resulting anemia, a half-dram three times a day after meals to a five-year-old child. Fowler's solution or Warburg's tincture are useful in the long-standing cases. Erysipelas. This is a constitutional infectious disease presenting a diffuse, rapidly spreading inflammation of the skin and subcutaneous connective tissue, and occasionally of the mucous membranes. Etiology. — No specific organism has been found in erysipelas, but a streptococcus is thought to be usually the active cause. It may occur in :!U8 DISEASES OF CHILDREN. connection with a septic couditiou of the iiiotlier during or shortly after birth, or from contauiinalion in lying-in hospitals or niidwives. The virus enters the system through an abrasion of the skin or mucous membrane. Symptomatology. — 'i'he disease is more apt to occur during infancy than eiiildhood. and the earlier it appears after birth the more serious will be its effects. In robust infants the inflamed skin will present a deep-red Fig. 8-1.-- Krysipelas. wliieh liegau on the faee and spread (j^ei- Uie li.idy. color, while in feelder bal)ies it will lie lighter, presenting moi'e of a pinkish appearance. The deeper 1 issues may likewise be involved in a phlegmonous inflammation in severe cases, and tliere nuiy also be edema and finally some desquamatiim. In the newdy-hom the disease is apt to be contracted from some septic condition of 1bi' mother. It may then start at the umbilicus, in the genital region, or from some point of abrasion consequent to the delivery. Where the nndiilicus is affected, the disease is apt to extend THE INFECTIOUS DliSEASES. 301J inward, producing a i:>eritonitis. In otlier cases pnen)nonia or empyema may ensue and liasten the fatal ending. In older infants the disease begins on some abrasion of the skin, freijuently around the genital organs, but sometimes on the trunk, arms, or legs. It is not so apt as in adults to attack the face and scalp. The cutaneous ]-edness and subcutaneous infil- tration spread rapidly, but with a sharp line of demarcation between the diseased and healthy skin. The affected part is usually hot to the 'touch. The constitutional symptoms are commonly severe, vrith evidences of prostration. The result of the pricking or burning pain is seen in great restlessness, disturbed sleep, and occasionally convulsions. The fever is irregular and high up to 105° F. where much of tlie skin is involved. The pulse is usually I'apid and feeble. There may be evidence of gasti'oenteric irritation, shown either by vomiting or diarrhea. In fatal cases death usually results from exhaustion oi' from some complicating disease, such as peritonitis or pneumonia. Abscesses and even sloughing of tissues may accompany severe and deep-seated erysipelas. Tlie tendency to spread is shown in some cases by the wliole surface of the body becoming involved. There is frequently in infants a recurrence of the inflammation involving the sauie surfaces as were originally attacked. The disease raa^' last from one to three or four weeks. Prognosis. — The prognosis will vary with the age of the infant and the extent of the inflammation. It is very fatal duiing the first month, and from that period up to the sixth month the outlook will be uncertain. After six months the prognosis is good. Constitutional symptoms are usu- ally less severe when the arms and legs are involved llian when the disease affects the region around the umbilicus or the neck and head. If the inflammation is superfical and spreads slowly, the prognosis is naturally more favorable than where it spreads rapidly and is more deep-seated with the character of a cellulitis. Treatment. — "While the disease cannot l)e aliorted, every effort must be made to sustain the strength of the infant by simple, nourishing diet. If the mother is se]">tic, the l)a1jy must be removed from the breast, but otherwise maternal feeding offers the best cliance for recovery. In bottle babies it may be necessary to weaken the formula or to peptonize when there are evidences of digestive disturbances. We believe that tincture of the chlorid of iron is beneficial, and an infant of a year old may be given three or four dro]is, well diluted, every three hours. As it is an asthenic disease, it is often necessary to stimulate, giving strychnin or whiskey when the pulse is weak. Cooling and antiseptic applications may be applied to the skin and such as the liq. alumini aeetatis N. F. or a 50 per cent, solution "310 DiSliAlSJiH eration of the liyi)ochlorous acid. Herein lies the greatest oiijection to tliis agent, for much of the chemicals sold in the shops is too old to be efficient. CHAl'TKi; XXII. TUBERCULOSIS. TulK'rculosis is an infcctiNX' fe\('i' caustMl by the toxins of tlie tubercle bacillus, and cliaiactciizcd by tlic fdrmatinu of lieteroneoplasms called tubercles. Any organ or part of tlic b(jdy may be attacked. The disease niay be contined to certain organs oi' nuiy be generalized, occurring at the same time in many parts of the body. Etiology. — TJie tubeicle bacillus upon which tuberculosis in any or all of its manifestations dejiends, is a roil-slia]ied, facultative, c()loi'less bacillus, slightly bent and having rounded onls. In size it is about one- fourth to one-half tlie diameter of a led blood-cell. It is especially distin- guisliable for its staining projierties. It strongly resists decolorization after having been stained with acid dyes. There are scve:'al varieties of the bacillus. AVe are mainly concerned here wiili the human and liovine ty]ies. The controversy regarding these types is not yet settled, Init tlie distinction still seems to be a sti'ong one between these foi-ms. The lio\ine type of bacillus diffei's somewhat in form, being more irreg- ular, thicker or oval in shape with lihmted ends. The types may also be dill'crenliated by cultural methods. This method, liowevcr, is suitable only for a laboratory specialist. Aliout ]0 ]ier cent, of all tuberculosis in early- life has been demonstrated to lie caiised by tbi' bovine type. Pulmonary forms are rarely of bovine origin. Glandular forms are mainly bovine. The liacilhis is easily destroyed bv sunlight or heat, either dry or moist, but is not affected by lov,- teni]icratni'cs. Tlie ilisease occurs at all ages — fetal tnlierculosis has liecn recorded (.Tacobi, AVollstein, and others). The invading niicioorganism gains entrance to the body through three main channels, given in the order of their relati\e im])ortance ; through the rcspi)'ator\- tract, ihrough the intestinal traet. and thi'ongh wounds and abrasions of the skin. Infants and children ai'e infected mainly through the respii'atory tract. T-Jercditarv predisposition is still the subject of arguiuent, but the posi- tion held bv Adami appeals to us. lie believes that two ]iossihil ities may result frcin parental tnbercnlosis ; tlie offs|ifing mav become es]ieciallv susceptible if the gei'ininal cells hecoini' weakened by progressive disease, or if the disease is -well resisted the ehibl may acrpiiiv an increased resistance to the disease. 312 TUBEKCULOSIS. 313 Parental diseases, nutritional faults and developmental defects in the parents often leave the offspring with a lowered resistance to tuberculosis. A child with poor muscular development, with a flat and narrow chest and small abdomen is considered to have a disposition to tuberculosis; we can add to this class children who are mouth-breatliers and have defects of the nose and mouth. In cliildliood there is little resistance to tlie disease; the glands, meninges, bones, joints, and lungs are easily invaded and are believed by v. Behiing often to ]-emain latent and develop in later life into the pulmonary form. Again, in childhood the dis- ease is not apt to develop at the site of infection as in adults, but extends to other tissues and forms tubercles there. The entity known as scrofula is still acceptable to Continental Europe ; but in Amer- ica the weight of opinion is that scrofula indicates tuberculosis, and we believe with Baldwin that it can be used to mean an important predisposition to pulmonary tu- berculosis, wbich he says is asso- ciated with it in 2.5 per cent. f)f nil cases. Measles, whooping cough, dijihtheria, pneumonia, in- fluenza and, in a lesser degree, scarlet fever, tonsillitis, and vari- ola are often the jn-ecursors of tuberculosis, because of their ef- fect on the mucous membranes and lymph glands accompanied by the lowered resistance of the convalescent child. T?ickets, too, is a disease favoring tuberculous infection when accom- panied by defective nutrition and thoracic deformities. Finally, gastro- intestinal diseases from their destructive action on the mucous membranes lead sometimes to open infection and probably often to the latent form. Fig. 8.J. — Confnnr.n'.inn and posture commonly seen in tuberculous ehiklren. ;;14 DISEASES or ciiildken. The children of poor parents in unsanitary surroundings, wliether in city or even in tlie country, are prone to tlie infection, which they may receive from the following sources : Human sputum, through food objects or dust, urine or feces on soiled clothing or beds, and milk of tuberculous cattle. Milk as a food, howe\er, may be indirectly contauiinated by dust or infected containers. Infants at the breast have been infected by their riu>tlier's soiled liands or kisses. Cornet reports infection by midwi\'es who lilew into the mouths of the infants to start iip respiration. In ritual circumcision direct infection has occurred. Cliildren ai'e intiiiuitcly connected with tlie fact tluit tuberculosis is a ''family disease'' — 40 to Go per cent, disclosing a history of other eases in tlie houseliold; and this close contact is tlic great infecting method: the nursling infected by clo^e touch with its mother, tlic creeping infant on the contaminated floor carrying all things to its iiioath, the school boy trading toys — all show at a glance the numberless ways in which children may liccome tuberculous. Tuberculous Adenitis. Tills may be confined to certain groujis of lymph-glands, as the cervical or lironcliial. or tlici'c may ])e an involvement of all, or neai'lj* all, the lyuiph nodes of the body. The glands become infected liy access of tuljercle jjacilli through the lymph channels. The ]ioiiit of entrance jnay ha\e been only a slight alirasiou or scune form of dcniiatitis. 'blie glands ma\" also become infected from tuberculous lesions in their vicinity or from infected milk. A cross section of a tuberculous gland shows the parenchyma swollen and hypei'plastie, grayish in color, containing nodules varying in size, some of which are undergoing caseation. If the latter process is advanced, the gland is soft and the tubercles are found at the margins only. The glands most commonly involved are those at the I'oot of the lung. The mesentei'ic lymph nodes are fre(piently infected in children and are the usual accoui- paniment of the miliary and generalized forms. Symptomatology. — Tlie subjects of tuberculous adenitis are, as a rule, anemic children of the blond type. The appetite is capricious or lost, the weight decreases, and at this time the parent may notice an enlargement of a gland or group of glamls. They are not painful to the touch, growing slowly but steadily; sometimes there is a rise of fever, especially in the evening. Physical examination may show tuberculous lesions elsewhere in the body. If the cervical lymph nodes are iiivolvi'd the tumors are at first found in relation with the sternocleido mastoid muscle. At first they are TUBEKCULOSIS. 515 freely movable, but the chain of glands increasing, they soon adliere one to the other, forming sometimes large masses which may even cause me- chanical obstruction. Bilateral involvment is not uncommon. The overly- ing skin now becomes attached to the mass below, and when the glands caaeate the skin is thickened and loses its normal color, often becoming purplish-red. If there is no surgical intervention the glands rupture through the overlying skin or dissect the fascial planes ; the abscess may discharge at some distant point. Often several long-persisting fistulous tracts result. Fig. si;. Tulierfiiliiiis adenitis of tlie eprvienl .iiiil axiliary slands. In the generalized form, the cervical, inguinal, and axillary glands show the greatest and earliest involvement. The children are markedly anemic and often have a \ariable amount of temperature. Wasting slowly takes place and new foci are found developing in other parts of the body. Bimanual rectal examination will show the involvment of the retroperitoneal and uiesentcric lymph nodes. 30 31G iiisi:asi:s "F (■iiiliiui-;n. Wlicii tliL' bmncliial lyiiij)li iiuilcs aw largo, pressure sviiiptoiiis may otx-ur, causing a paroxysuial cough M'itli bi-cathing signs of broneliial astliiua. h\ ailvaiu'cd cases dyspnea is pi'odueed on sliglit exertion. Sonie- tinies dullness is olilained on percussion o\ei- (lie manubrium wbieli extends over a varying area. This is usually aceouipanied liy tubular breatbing on the left side. D'Espine's sign when pi'esent is contirmatory. Diagnosis. — The diagnosis of tuberculous adenitis is based ujion the slow course and the absence of active inflammatory changes, such as heat or ]>ain on palpation. Simple adenitis can usually be traced to some source of infection, as an eczematous area, caries of the teeth, etc. These glands subside wh.en the focus of ii'iitatioii is ren)0\ed. If there are evidences of tuberculosis in other structures, tuberculous adenitis may be suspected. The tuberculin tests (p. 50) may be used to corroborate the diagnosis. Sy]ihilitic glands are distinguished by their location. The e]iitrochlear glands show simultaneous enlargement with other syi)hilitic manifestations in different parts of the body. Lymphosarcoma is sometimes confounded with generalized tuherculous adenitis. This disease usuallv primarily involves the retroperitoneal glands or those within the mediastinum. The growth here is ra]3id. invading neigh- boring structures, and often producing serious symptoms before the true nature of the disease is suspected. Course and Prognosis, — Tt is often dillieult to ]iredict the end-i'esult of a tuberculous adenitis, ^fhe prognosis should always be considered ser- iouslv as a focus which may at anv time spi-ead the ilisease to the lungs or other structures. If the suliject is young and can be placed in favorable surroirndings, restitution to the normal may take ])lace. J''ven degenerated glands with fistidous tracts mav eventually terminate in a cure under pro]ier care. Treatment. — Immediate ste]is should he taken just as soon as the diagnosis is ei'itain to revio\'e the child, if ]iossible, to the seashore, where it should ]i\e in the sundiine and fresh air. The diet should be as nourish- ing as possible, consisting principally of milk, eggs, cereals, and i-are meats. Cod-liver oil, if well borne, should be given twice a day, after the midday and evening meal. If this is not acceptable, good results can be obtained bv increasing the quantity of butter, cream, or top milks. Sometimes olive oil in two-di-am doses twice a day can be substituted if the child prefers it. Surgical removal of the glands nniy be considered when they are super- fi' caused by slight exertion or coughing. Hemopty- sis is exceedingly I'are in children. If death does not supervene, the affection may appear elsewhere, as in tlie bi'ain. intestinal tract, or in the glandular structures. Physical Signs — Tliesc may not differ from the oi'diuary broiiclm- pneumonic t\]>e of tlic disease. Occn- siona]l\' on]\' are there signs (if cavitv foi'iuation, ni- "\^'ell-de\'elo]>ed signs (if br(ji)(hial and jieritraciical ubindiibir hyp('i-ti'0])hy. The latter signs, if oli- tainable, are of distinct diagnostic im- portance. The examination oi the sputum, obtained with a laryngeal swah oi- from the stomach contents, ui'ine, and feces, may reveal the presence of tubercle bacilli. Fiii. ST. — Clu'onie puliiK^nary tuber- culosis iu a five-vear-old boy. Chronic Pulmonary Tuberculosis. This form is rarely seen under live years of age. In the cases that have come under our observation, ihe tulieiculous pi-ocess was extremelv diffuse in character. The physical signs do not mai-kedly dilfei- from those of the adult type. TUiiKUCULOSlS. ;i2i Progressive loss of weight, niglit-sweats, extreme anemia witli high leukocytosis, and frequent attaclcs of gastroenteritis are tiie symptoms which finally precede death. At any age the pleura may become involved in the tuberculous process, and an empyema result. The jms in these cases is thinner and more watery in consistency, and only rarely can the tubercle bacilli be isolated. Tliese cases do not tend to recovery; further lung involvment takes place, and death often results with meningeal symptoms. Course. — The course of the disease in early life varies with, the form. There is a latent form in which the chai'acteristic features are irregular fever, rajDid emaciation, and late pulmonary signs. The affection runs a Fig. 88. — Chilibecl fiuaers in ehronie iiulmoiiary tuliennilosis. speedy course, terminating sometimes in a few days to a fortnight. The cliild with the Ijroncliopnueiiionic oi' tlie moi-e usual vai'iety may live several weeks. In exceptional cases the patient has lived six months. The chronic form, under favorable circumstances, sucli as the modern sanatoi'ium treat- ment, gives a more favorable ])rognosis ; tliat is, tliere i- a tendency toward arrest of tlie pi'ocess especially if heliothei'apy is used. Acute Miliary Tuberculosis. ' This is an acute general infection witli tubercle bacilli, occurring at any period of childhood. As a rule, it is secondary to some primary focus in the bod}', which may have been dormant for some time. Etiology. — Measles, whooping-cough, and tnbercidous lymph nodes are the exciting causes. The disease occurs quite commonly in early life, especially the meningeal form or tuberculous meningitis. McCrae had forty-three cases of generalized miliary tuberculosis in 417 autopsies oa ;!22 DISEASEB OF LlIlLUliEX. tuborenlous indivHlnals ; nmong these were lifty-five children. The meninges were involved in twenty-one, and the thoracic lymph nodes in thirty-three cases. Two forms of tlie disease are recognized — the genci'al and local — . based iip(m the svmjiloins. In the ijviicnd joint the sym]>tom.« in tlie early stages are such as to simulate beginning tyj^hoid. There is irregulai' fever witli no character- istic curve, malaise, loss of appetite, slow emaciation at first, becoming more marked as the disease progresses. The pulse is increased out of proportion to the temperature. Rapid, shallow breathing is later followed by the t'lieyne-iStokes type as the disease ])rogresses, or if meningeal symptoms intervene. Vomiting is often an early s)'mptom. The spleen is eii]argeX'al tem- perature curve, with th(> chai'acteristic eruption, plus the relative iiicrease in the mononuclear elements in tvphoid. must lie depended u]>or to dis- tintruish this form of tuberculosis from typhoid, although this is soTietimes e.xti'emely dilTlcult. In miliary tuberculosis, besides the tulierculin test, an ocular examination mav', especially in the later stages, show tuberck s in the clioi'oid, or fluiil Avithdrawn from the spinal canal mav show tuberck- bacilli. Local Manifpxtnilonx. — Miliary involvment of the lungs usuaPv occurs aftei' measles or whooping-cough, or is secondary to a hron'-hopn'^umonie process. The physical signs offer no help in differentiation. The r'jagnosis in children is extremely difficult until the disease has progressed to some other structure, as the brain, when more characteristic svm|' ims are obtainable. Tuberculous Meningitis. The tubercle bacilli spicad from some focus of ijifeetion through the lymph channels or blood current to the meninges, and usuallv form an eruption of miliary tubercles at the base of the brain, spread! ig up to the vessels in the fissure of Sylvius. An inflammatory exudate s almost in- variably found in the space between tlie optic chasm and i e peduncles. TUBJiliCULOSlS. The exudate is yellowish-green in color, tenacious and adherent to the pia mater. The ventricles are more or less distended with fluid, in some instances forming a distinct internal hydrocephalus. The ependyma, if carefully removed, is found to be rough, edematous, and may be infiltrated with tubercles. The pia mater is injected with a serofibrinous or seropuru- lent infiltrate. Not infrequently the tubercles are seen in the choroid plexus. Occasionally there is only a slight amount of exudate, and the infection is found to be localized in the form of one or more uodules. some the size of hickory-nuts, which are known as solitary tubercles of the brain. Etiology. — Tuberculous lymph nodes whicli have become diseased as a result of the acute infectious diseases, especially pertussis and measles, play the principal role in the causation. A latent tuberculous focus may set free the tubercle bacilli into the blood stream. A tuberculous osteitis or an infection in the uropoietic system may be responsible for tlie menin- geal involvement. A number of cases seem to be traceable to a chronic otitis media. Unsanitary surroundings, especially in a tuberculous environ- ment, predispose to the disease. On the other hand, it occurs among the well-to-do, and may attack a child that has been considered exceptionally healthy. It commonly occurs below the age of five years. Infants of five months have been reported who have died of the disease. (Rilliet.) In Koplik's series of fifty-two cases, eleven were less than one year old, wbile the average age was slightly over four years. Symptomatology. — It is impossible to give a typical description of the symptoms of this disease, so varied are its manifestations. The prodromal symptoms usually come on gradually and insidiously. A previously healthy child becomes irritable, morose, and refuses to play. Lassitude, coated tongue, loss of appetite and occasional vomiting are, as a rule, attributed to digestive disturbances. If the child is old enough, head- ache, dull in character, is complained of. ]''rogressively the symptoms grow more marked until signs of cerebral irritation appear. Occasionally the onset is abrupt with fever, vomiting, and pressure symptoms. The diagnosis may not be suspected until the child refuses to leave the bed. The pulse rate in infants is u.sually increased ; in older children it may he irregular in character. Vomiting occurs irregularly and with no regard to the food ingested. The temperature is not high, rarely over 101° F., and may be normal during the morning hours. The mentality is dulled and the child is aroused with difficulty. The food is taken without protest or interest. Infants may show increased tension by a bulging fontanel. A high-pitched scream, which if once heard is easily recognized and kno\^'n as the hydrocephalic cry, often accompanies the headache which 324 DISKASIJS OF ClIILDUEX. may now be intense. Except in infants, tlie abdomen becomes flat or sunken in the later stages, forming tlie so-called scaphoid abdomen. Constipation is the rule. Eigidity of the muscles of the neck may be noted, but distinct retraction may never occur or only in the Hnal stages. There may now supervene irregular or associated ataxic movements. The respii-ations are slow and irregular, with the inspiration prolonged and sigliing. The pupils may be imevenly contracted and react slowly or not at all to light. Nystag- mus may l>e an early sym|)tom, wlule conjunctivitis, strabismus, and ptosis usually appear in the final stage. Marked apatliy with delirium and coma super\('nc. Occasinnnlly convulsions iiuiy occur. The pupils are now almost constantly dilated. The extremities are rigid or spastic, althoiio-h Flu. SO. — Tulicrciilous iiii'uinu'il i^ : imtipiit coiuatdse. paralyses, monoplogie or hemiplegic in type, may appear before the terminal stage. The I'cspi rations tend now to the C'heync-Stokes t\pe. The final stage is usual l\" k'Dowii by the frequent con\'ulsivc seizures. The emacia- tion is now i-a])i(l, the pulse becomes small and ivj-egular until the agonal stage. Tlie eyes arc sunken. Edema of the lungs may be found on plivsical examination. The rigidity of the neck is su].)phinted by paralvses in vari- ous parts of the body. Examination of Ihe fumlus usuallv shows an optic neuritis. Tlie urine and feces may be involuntarily passed. The tempera- tui'c toward the cud may rise to 10.5° or 10(1° F., or tliere may be a sudden drop (o suhnovmak The reflexes are usually inhibited in this stage. Txernig's sign ami the Babinski reflex are present in about 50 per cent, of flic cases. Mac- ewen's sign, or a tympanitic note on ])iu'cussion over t1ie ventricles, is obtained in lho=e eases in which there is an internal bvdrocepbalus. If TUBEKCLTLOSIS. 325 obtained in children over two years of age, it is of value in establisliing tlie diagnosis. Lumbar puncture is of great importance in making the diagnosis, and sometimes is the onl}' practical method of making the speeilic diagnosis (see p. 51). In this form of meningitis the fluid frequently flows out under increased pressure ; it usually is clear and contains a greater amount of protein than normal. Fehling's solution occasionally is reduced by the fluid. If the proper teclmic is followed, the presence of tubercle bacilli can be demonstrated, although such expert labor should be placed in the hands of a trained pathol- ogist. Inoculation experiments into animals may also be made for con- firmation. Mononuclear cells, sometimes over 90 per cent., are present in the fluid. Course. — The duration is usually from three to four weeks. Occa- sionally there are periods of apparent improvement, which may give rise to a false hope of recovery. On the other hand, cases have remained under our observation for many weeks with slow and progressive emaciation, finally terminating fatally. Diagnosis. — The slow onset, the lack of liyperesthesia, tlie slower pulse and respiration, and the type of temperature curve, with the aid of lumbar puncture, are the only definite means of differentiation from the cerebro- spinal ty]ie. A careful history is usually helpful. Some intracranial diseases may in their incipiency lead to confusion uidess the cliaracteristic symptoms of a meningitis are souglit for. Prognosis. — Although there have been several reported cures in cases in which tul)ei'cle bacilli were found after repeated lumbar punctures, the disease must lie regarded as quite liopeless. Treatment. — Quiet and rest, with bromids for the relief of the ner- vous symptoms, and lumbar puncture for the relief of intracranial pressure, witli frequent repetition of tliis procedure, if followed by amelioration of the symptoms, are indicated. The diet, usually liquid, is taken in a bottle or may be given by gavage. lodid of potash and inunctions of mercury liave proved valueless in our hands as well as otliei' drugs. Tuberculous Peritonitis. Tuberculous peritonitis is a comparatively rare affection, although this variety of peritonitis is more frequently seen in childhood than the non- tuberculous forms, and a diagnosis, first as to the condition itself, and then as to its particular variety, is of importance because of tlie direct bearing on the prognosis and surgical treatment. The peritoneum may become . 32r, DIS1;ASES of CI-IlLDLiEX. iuvolveJ from a tuberculous focus in any part of the body. The disease is nearly always sceondary and the- infection is carried through the lym- phatics or blood stream. Bovaird in 12.5 eases of general tuberculosis found the peritoneum involved in 7 per cent. From an anatomical standpoint four forms are usually recognized — miliary, miliary with ascites, the ulcerative, and the fibrous variety. The JiiLiAKY Fortii is met with in cases of general infection. It is practically im[)()s- sible to jiiaki' antemortem diagnosis of this fdi'iii. Tlie tubercles arc found scattered over the peritoneum and intestines in large oi' small nundjers. Adhesions foi'in. binding the viscera to themselves, to the neighlioring oi'- gans, and the abdominal wall. On opening the al)dominal cavity a serous or sero]5urulent fluid is found. The ])critoneum is clouded and sti'caked -with lymph. In older cases adhesions foi'in. Ttik T'l.ciKnATivK OR C'ase.vting roK.\r. — I'ostiiuji'teiM findings in this variety sliow easeating foci in tlie peritoneum. Lvmph or pus takes tlie ]ilace of ascitic fluid. The in- tcsliiial cdils ai'e matted with fibrinoplastic de|)osits. The abdominal wall mav also be found aillierent to the intestines. Tubercu- lous masses are found scattered over tlie parietal and visceral peritoneum, while in some cases ulcerations occui'. The glands are usually greatly enlarged, and may be found in sacculations filled with purulent fluid. Fistulous ti'acts may occur and perforate at or near the iindjilicus. The FHUtotJS FORjr rarely gives evidences of nn effusion. There is an abundance of Iviupli on a thickened |)eritoneum, studded with niiliai'y tubercles. The peritoneal ca\- ity may be completely (jbliteiated by the dense matting and firm adhesions, liolls of omentum are occasionally seen, covered witb libmus tissue. The intestines themselves adhere to each other. The characteristic of this form is a tendency to the formation of cicatrical tissue. Fii;. !«).— The ascitic form of tuberculous peritouitis. TUBliliClLOSiS. ,127 Symptomatology of the Special Forms.— Ascitic Form.— The symptoms ina}- be very insidious. There is a slow but steady increase in the size of tlie abdomen, and constipation alternates with diarrhea. There may be vomiting, the appetite is capricious or lost. Careful examination may now elicit fluid in the abdominal cavity. The superficial veins over tlie abdomen and lower chest are prominent. There is an evening rise of temijerature, and ])rogressive emaciation is noted. Eectal examination may disclose peritoneal nodules and enlarged mesenteric glands. An acute form is occasionally seen in which the symptoms simu- late an inflamnurtion of the small and large intestines. The fever is quite high, the abdomen rapidly becomes distended with fluid. The prognosis is better in the insidious form. Ulcerative Fokii. — The sjmiptoms are those of various grades of enteritis. There is vomiting, constipation or diarrhea, abdominal pain, loss of appetite, with occasionally bloody stools. The fever is quite higli, irreg- ular in type with occasional sweating, especially on exertion, and consider- able prostration. Percussion shows areas of dullness or flatness, alternating with areas of tympany. Bimanual rectal examination may give strong evidence of tlie matted condition of the intestines. Occasionally the stools contain blood. Pus may be discharged through openings near the umbilicus. Emaciation is extreme, and the end comes through asthenia. FiBEOUs A'aeiett. — The symptoms come on very gi'adually with some colicky pains in the abdomen. The bowels are usually C(mstipated. There is some distention of the abdomen. Nausea and vomiting or symptoms of obstruction may lead to a careful examination of the abdomen, and the masses or rolls of omentum with some intraabdominal fluid may assist in establishing the diagnosis. Diagnosis. — A child between the ages of one and six years, who has lived in an environment of tuberculosis or whose vitality has been lowered "by an infectious disease, and who is languid, peevish, and has an evening rise of temperature with some enlargement of the abdomen, should be care- fully examined for tuberculous peritonitis. The child may present the phthisical habitus or only appear to have lost some flesh. The skin is almost constantly dry and harsh. Passing the hand lightly over the abdomen, subcuticular nodules about the umbilicus are often felt. Fluctuation may be readily made out, or a suspicion of fluid only may be found on palpation and percussion. Bimanual rectal examination in the semirecumbent posi- tion should now be made to confirm the presence of fluid and to further ascertain the condition of the intestines, whether they are free or bound by a fibrinoplastic exudate. One accustomed to the normal conditions as found 328 DISEASKS ()]■■ (;il I l,L)l!EN'. by the OAaniiiiing finger in ebildreii will appi'eeiate tlie elianges produced by a plastic exudate, and may furthermore feel hypertrophied mesenteric lymph nodes and a band of adliesions running transversely across the abdo- men. If the pi'Ocess has so far advanced that rolls of omentum, or agglu- tinated masses of mesentery and intestine have formed, palpation over the abdomen and the finger in the rectum 'will readily reveal the presence of these tumors. The abdomen may then ajipear flat or gas-distended, and Thomayer"s sign of dullness on percussion on the left side of the abdomen, with a tyin])anitic note on the right side, may be obtained: in this latter condition fluid is rarely made out before operation, and only small cjuantities are seen on t)pening the abdomen. Ill the eai'ly stages of the ascitic form we sliould if possible e.vclude circulatory, renal and hepatic disturbances, and abdominal growths. The general nutrition may still be fairly good. The fluid readily gravitates to the dependent section on change of position. Corroborative evidence may be obtained by flndiiig Marfan's symptom, that is, the ])resence of pleuritic friction I'ales at the base of the lungs, sometimes associated with small exudations into the pleura. Pain is rarely obtained on palpation, but indefinite colicky pains are complained of. If, coujiled with the above symptoms, the skin is harsh and dry, and subcuticular nodules are present over the abdomen, the diagnosis, now fairly certain, should be confirmed by laboratory and tuberculin tests. The fj-i'<|uent use of the thermometer showing ])r<>dominating small evening rises and the presence of large num- bers of lymiihocytes always tend in favor of a tuberculous process. In a tuberculous peritonitis the mononuclear leukocytes are generally increased. Cytological stud\' of the tapped ascitic fluid mav also assist in confij'iuing tlie dia,2nosis. The diagnosis in the first form is not always certain wnthout furtlier trsts, and even the last-described vai'iety may cause confusion. If a chronic peritonitis of the tubei'culous variety is suspected, a very tlioi'ough c.vamination of the entire body should be made for possible tuber- culous disease in other organs not only lo confirm the diagnosis, but to determine what shall be the character of tlie treatment and the prognosis. For if the lungs are involved and the s])leen and liver ai'c enlarged, general miliary tuberculosis is in all probability present, and the iiatient is beyond the hope of recovery. Whether or not the peritoneal ]ii'occss is tuberculous may be confirmed either by tlic skin-inoculation test of Yon Pirquet, by the Moro reaction (i.e., a 50 per cent, tuberculin ointment) or by the Calmctte test; hut this is not recommended if there is any possibility of corneal involvement. Tlie catlicterized urine may be eentrifuged for the presence of tubercle bacilli, or inoculation tests can be nuidc with guinea-]iigs. Treatment. — The trend of o|)inion, buoyed up by some successful TUBERtl'LOSIS. 3291 results in recent years, tends toward operation in all eases of tuberculous peritonitis, especially as the opei'ation i'S comparatively simple and not dangerous to life. If more regard had been paid to the general examination and only selected cases operated upon, the statistics would have lieen stead- ily in favor of operation. The ascitic form of localized tuberculous peri- tonitis does well under laparotomy, the plastic form rarely does well; fistulas are apt to form, and the lungs frequently sliow early involvement following the laparotomy. Again, if the diagnosis can be made early in the ascitic ^i "^^ ^H -J ^^BmiC M^ ^ ^^-'^^H 1^ HHI^^^ JBfe |h K fei4,:^fe..v.ji ^^: " 1 •€„ ^ H Fig. 91,— Tnberculniis daftylitis. form non-operative interference uiay be counseled provided the circum- stances are such that all the advantages accruing from life at the seashore, rest and nutritious food are possible. Otherwise the cjiild should be watched, and if the exudate is on the increase operation should be reconi- mended. A life in the fresh air, confinement to bed while an active process is going on, food high in proteids and fats, with the addition of cod-liver oil and the syrup of the iodid of iron, are indicated after laparotomy, and for the inoperable cases. :!() DISEASED Ol' C'lIlLDlili.V. Bone and Joint Tuberculosis. {Caries; of Bunc.) This affection is the result of the uiMisioii of tubercle bacilli in the spongy i)ortion of the bone. Usually beginning as a single focus, it spreads and often involves the whole epiphysis. Tubercles ai'e loriiicd \vhicli later may degenerate, forming many necrotic areas whicli laav nieige to form a caseating area. Granulation tissue is found at the perijihery. In some in- stances a sequestrum forms or an abscess results. The joints are infected through the cartilage, and the disease rapidly spreads to the svnovial membrane, where ulcerations form. When tlie car- tilage becomes detaclied, destruction begins in tlie bare bone. In this way deformities so common in and ai)out the joints are jiroduced. Etiology. — The infectious dis- eases, especially irieasles and scarlet fever, ai'e pi'ol)ablv more often the direct cause of tuberculous joint dis- eases than traumatism. Any devital- izing disease, bowevei', must lie consid- ered as a factor. The affection is ex- tremely rare in infants. After the third year it is distinctly a disi>ase nf childhood. Tuberculosis of the Vertebrje. KiG. 02. — Torticollis, due to cer- vical Pott's disease. {Bruilford mill r.nrrll.) {Pntt'f: Disease : Curies of llie Spine: S jioinJill itis.) This affection is the result of a tubei-culous osteitis in the sjjongy por- tion of the l)odies of the vertebra. It is extremely common in early childhood, and, according to Taylor, more than half the cases occur under six years of age. The dorsal region is most often a£fectee palpated and usually easily seen. LrTMBAR Pott's disease. — Here tlic attitude of lordosis should attract attention, especially if accompanied with deviation to one side, and a care- ful abnormal gait. Hyperextention of the leg in the prone position elicits the sign of psoas contraction. Paralysis. — This may occur at any time in tuberculous spinal disease, although as a rule it occurs as one of the later 'symptoms. The patellar reflexes are increased, ankle clonus may be present, and the pain, if absent before, is now present or increased in severity. A rachitic spine is often mistaken for Pott's disease. The curve, however, is rounded and the spine is supple. If the child is raised with the hands of the examiner in the axilla the curvature tends to disappear. Other bonv changes or the symptoms of rickets may be present. The de- formity in Pott's disease does not disappear when the child is raised or is in the prone position. Treatment.— This is mainly orthopedic and involves the use of appa- ratus to promote spinal rest (Fig. 95) and the correction and prevention 21 Fig. 9:!. — Dorsal Pott's disease. DISEASES OF CHILDKEX. of deformities. The medical treatment encompasses dietetics and h^'gienic management. The Albec bone graft oilers a more rapid cure witli less deformity. Fiti. 04. — Lumbar Pott's disease. Tuberculous Disease of the Hip. (TJip-jolat Disease ; Morbus Co.nr; Co:rnJf/ia.) This affection is due to a tuberculous osteitis of the head of the femur, of the acetabulum, or both. The disease usually begins gradually, the par- TUBERCULOSIS. ents first noticing a limp. Night cries occur, but pain is a very variable symptom. The attitude assumed is one with a little flexion of the knee of the affected side and a slight tilting of the pelvis. In later stages of the dis- ease much can be learned by testing the child for freedom of motion, pick- ing up objects, mensuration, pain and swelling. The classical symptoms upon which a diagnosis can be based with certainty are limit of motion, muscular spasm, pain, swelling, attitude, short- ening and atrophy of mnsele. The A'-rays and the tuberculin tests may be required in difficult cases. Treatment. — Immobilization and protection of the joint by casts, trac- tion, and later, braces ; a life in tlie open air and good food do much to assist the orthopedic measures. Osteotomy and excisions are performed only in desperate cases. Tuberculous Disease of the Knee. (Goniti.<< Tulierculosa; WJtite Sirelling.) The epipliyses are nearly always primarily involved. It is most coui- monly observed in children, and, after the spine and hip involvement, it occurs most frequently. The diagnosis is usually quite readily made, as the knee-joint easily lends itself to examination. Swelling. with lameness which may be intermittent, are the first diagnostic symptoms. Stiffness and pain follow. Muscular spasm on passive motion u:ay be observed. The knee may be held in a position of flexion. Infectious synovitis is distiaguished by the more rapid onset, temperature, and signs of localized inflammation. Chronic synovitis is very slow in its course and is not accompanied by much lameness or pain. Sometimes crepitus may be obtained. Eventu- ally a true tumor albus may result. The X-rays, tuberculin, and inocida- tion tests mar be made if necessary. IP'' ^^^^^^^^^H I '"'V ' }^ ^^^^P-'^-'- mM Fro. 9.0. — Infant with Pott's disease on a Bradford frame. o34 DISEASES UF CUILDEEIs'. Treatment. — The medical treatment does not difier from that of tuberculosis elsewhere. The joint should be encased in a splint which will prevent joint motion of the knee and foot. Treatment of Tuberculosis in General. Prophylactic. — There are but few diseases m which prophylaxis can aecomplisli so much for tlie child as in tulierculosis. Upon the physician and health officer the duty devolves, and it begins even before conception. It is largely a problem of sociology and preventative medicine. Laws which have lately been passed in many States prohibiting the sale of tuberculous milk and meat, tenement-house inspection, health-board notification, and the educational exhiliits will all tend to decrease the spread of this disease. Tuberculous mothers should not nurse their children because of danger in tlie close contact. Milk for infant feeding should be obtained from tuberculin tested cows, or should have the stamp of approval of a medical commission as being "certified." A^liere this is not possible the milk should be pasteurized. The children of tuberculous parents should be brought up, if possible, in the country and early trained to live an outdoor life. Such defects as adenoids or carious teeth should be removed. They should be especially guarded from measles and whooping-cough. School houses should be so arranged that proper ventilation can be obtained in rooms with ample air space and sunlight. Teacliers, who as a class are particularly susceptible to tlie disease, should be frequently exam- ined. Knopf has forunilated the following valuable set of rules for school children : Do not spit except in a spittoon or a piece of cloth or a handkerchief used for that purpose alone. On your return home, have the cloth burned by your mother or the handkerchief put in water until ready for the wash. Never spit on a slate, floor, sidewalk, or ]ilayground. Do not put your fingers into j'onr mouth. Do not pick your nose or wipe it on your hand or sleeve. Do not wet your fingers in your mouth wlieu turning the leaves of books. Do not put pencils into your mouth or wet them with your lips. Do not hold money in your mouth. Do not put pins in your mouth. Do not put anything into your mouth except food and drink. TUBEKCULOSIS. n o r- Do not swap apple cores, candy, chewing-gum, half-eaten food, whistles, bean-blowers, or anything that is put into the mouth. Peel or wash your fruit before eating it. Never cough or sneeze in a person's face. Turn your face to one side and liold a handkerchief before your mouth. General.— Reports from the sanatoria would indicate that tlie child over four rears of age afflicted with tuberculosis in the incipient stage has a better prognosis than the young adult. Graduated heliotherapy is a form of treatment that is particularly suitable to tlie child. This is borne out by our own dispensary cases, wliich have had but indiiferent opportunities, and still have shown gratifying results. The diet for these children should consist principally of milk, eggs, and fats ; such as butter, creaui, olive or cod-liver oil, and meat for older children. The syrup of tlie iodid of iron should be given. If tlie appetite fails a change from inland to seashore or vice versa may be proposed, or if this is not feasible the tincture of nux vomica with the compound tincture of cardamon can be given before meals. Medication directed to the disease itself is useless and often harmful. In hopeless cases the symptoms are alleviated as tliey arise. The tuberculin treatment is again being tried in children's hospitals and with more success. Good results are obtained in localized conditions, and some cases having pulmonary involvement have been benefited. The former unsatisfactory results are attributable to our meager knowledge of its action, and ]irobably to overdosage, which seemed to produce harmful results. Children in whom the disease seems to he arrested, as shown by absence of temperature and increase in weight, are especially suitable for the tuberculin treatment. The injection in these quantities may be given twice a week until a tolerance is reached, when the dosage may be slowly increased by 0.1 mg., depending iipon the effect produced. 1/13.000 to 1/8000 mg. of T. E. tuberculin is given to a child one year old. 1/4000 mg. for a child five years old. 1/3000 mg. for a child ten to twelve years old. Its effect should be watched, and a dose given every two weeks. The weight and general progress of the child must act as guides. SECTION VII. DISEASES OF THE RESPIRATORY TRACT. CHAPTKi; XXIII. DISEASES OF THE UPPER RESPIRATORY TRACT. Acute Rhinitis. This is quite coninionly seen in infants and children, and is due to bacterial infection as a result of a temporary or prolonged lowered resist- ance. This is made possible by keeping- tlie child in superheated apart- ments, sudden elianges of tenipei'atui-e. or exposing it to direct infection from a niendjer of tluj household. Tliere is at first a constant serous and later mucopurulent discharge from (he nares. with irritability, restlessness in sleep, loss of appetite, and a slight temjjerature. Tn infancy the symptoms are of greater import than in childhood, as it may seriously interfere with nursing and thus add to the lowered resist-' ance thi'ough malnutrition. Sleeji is liroken, feeding rules are interfered with and disturbances of tlie gastrointcsf inal tract may result. Older chil- dren complain of fullness in the lu^id and cliilliiiess. fhildren who have frequent attacks of rhinitis are ofttiuies sulferci-s fi'om adenoids. Treatment. — "Wliilc rhinitis is a sidf-limiteil disease, lasting from one to two wcks, it should not be left untreated. The infei-tirm may s])read" to the lower respii'atoi'y tract and I'lid disastrously. If ]iossitile, remove the indirect cause, as, for example, badly heated and unventilated rooms. The child is best confined to one room, esjxx-ially if there are other children. Localh- liquid alholin with camphoi' gr. i to the ounce may be instilled into the nose. A solution of adi'cnalin cldorid t to .5000 in infants and 1 to 1000 in oldei' children gives temporary ndicf before suckling and at bed- time. Morse found it necessary to introduce a small rubber catheter into each nostril in a serious case to enable it to breathe. Small supportive doses of strychnia 1/240 t.i.d. are sometimes necessary to assist the child in ridding itself of the infection. The (>ars should be examined daily, as an. otitis is very likely to supervene by extension. DISEASES OF THE UPPER PESPIUATOPY TKACT. 3?,7 Epistaxis. Bleeding from the nose is not often seen in infants, although not uncommon in children; when it occurs in infants it is usually a i-esult of adenoids, syphilitic rhinitis, or an ulceration of the nasal mucous mem- brane, commonly found on the anterior and inferior portion of tlie septum. Children are liable to nose-bleed because of their tendency to ac(|uire turgidity of the nasal mucous membrane. Traumatism, adenoids, foreign bodies, and purulent rhinitis ai'e among the more common causative factors, while a nose-bleed is also seen in the course of many of the infectious and blood diseases of early life. -A history of frequent epistaxis should lead one to examine for adenoids, ulcers, or cardiac disease. Treatment. — Keep the child in the upright position and apply pres- sure with tlie Angers against tlie septum, meanwhile having an ice applica- tion held over the cervical spine. If bleeding still persists pack the nose with cotton which has been dipped in a 1/2000 adrenalin solution. As soon as feasible, make a careful examination for the imderlying cause. If an ulcer, cleanse and apply a 20 ]3er cent, solution of nitrate of silver. If adenoids are present, they must be removed; this is especially true in infants who have frequent nose-bleed. Warning .should be given the attendant as to the significance of swallowed blood from a nose-bleed, which may occasion unnecessary alarm when vomited. Foreign Bodies in the Nose. In children, itsrrally between two and five years, it is not uncommon to find that they have placed various objects in their noses. Tliese may cause immediate symptoms of annoyance or distress or, becoming lodged, cause a unilateral nasal discharge that is persistent. Closer exanunation shows a partial or total occlusion of that side of the nares, a mucopurulent discharge, occasionally blood-tinged, and, with some objects, an odor of putrefaction. We have removed peas, pearl buttons, shoe-buttons, paper, and a kernel of corn. Treatment. — Place the child in a good light and use a small nasal speculum. The object if in situ for some time mav be covered liy mucous membrane or altered in apiiearance so as to be unrecognizable. If there is still doubt, a probe slightly bent can be inserted and the obstruction recog- nized; wipe out the discharge and with a nasal forceps, snare, or hook remove it. If the object has been recently inserted and is not high up, causing the child to sneeze by tickling the opposite side has succeeded easily in effecting its dislodgement. The rhinitis induced clears up rapidly after the offending material is removed. :i:!8 DISliASES OF CIIILDHEN. Examination of the Throat in Infants. A careful inspection of tlie throat should be made as part of the rou- tine examination of the sick infant. Many attacks of fever and illness in infants are due to inflaninration of the throat, such attacks being not infre- quently attributed to some other cause. The principal reason for such a possible error lies in the difficulty in getting a satis- factory view of the fauces. This is especially true in very yoimg infants. The tongue is liigh and the soft palate and pillars of the fauces low down, so that it is extremely diffi- cult to get a clear view of the parts. Unless a satisfactory view is obtained at the first attempt it becomes incj-easingly difficult, if not impossible, to see clearly at all. The opening is so small that a little mucus pro- duced by the irritation of a second or third examination completely obstructs the view. In addition to this some milk is apt to be regurgitated from the stomach, and then it is absolutely impossible to see the real con- dition of the mucous membrane. Most of the tongue depressors in use are not only too large, but do not have the pi'oper slant for the infant's tongue. As a result, the back of the tongue, not being properly held, arches u]i and obstructs the view of the fauces. The depressor here pre- sented is small enough for the youngest in- fant's mouth, and is intended to curve over the tongue to the base of the epiglottis. It can likewise be used in older subjects. By exercising a little pressure downward and forward the parts will come into clear view. Of course the infant should be properlv held and placed before a good light (Fig. 98). When everything is in readiness the left hand is used to steady the head while the right hand, manipulates the depressor. These details will naturally suggest themselves to the careful physician, but are often overlooked, with the result of unduly fretting the infant and failiua; in the examination. Ftc. nil. — rhapin's tongue depressor (straight). DISEASES OF THE UPPER KESPIRATOKY TRACT. 339 Pharyngitis and Tonsillitis in Infants. — In infants, tonsillitis, as distinct from pharyngitis, is rare. The whole mucous membrane of the pharynx and tonsils is involved in the inflammation. The tonsils may be somewhat enlarged and are covered with very fine pin-head points of a whitish exudation. These points can be recognized only when the fauces are well exposed in a good light. In rare instances the uvula is swollen Fk;. 07. — Chiipiii's tongue depressor (fiirvertl. and infiltrated. The secondary forms of pharyngitis seen in most infec- tive diseases will not be here considered. Tlie primary form is apt to ))e overlooked from the absence of symptoms referable to the throat, and the inability of the infant to call attention to the affected part The swelling of the lymph-glands of the neck, so often noted in diphtheria and scarla- tina, is not usually present in primary pharyngitis. The two most com- mon predisposing causes of primary throat inflammation in infants are: (1) disordered stomach and (2) exposure to cold. The frequent mistakes in the feeding of infants, especially overfeeding, produce an acid fermenta- tion in the stomach. By direct continuity the mucous membrane of the pharynx and mouth may become irritated and inflamed. '\^'hen the latter happens the temperature keeps up instead of subsiding when the stomach is relieved of its contents by vomiting or by their passage into the bowel. Exposure to cold is likewise a common predisposing cause. Many infants, especially among the poor, are too warmly clad, especially about the neck and chest. As a result the skin is constantly moist. Such infants live and sleep in overheated rooms. In these cases an ordinary exposure to cold will induce throat inflammation through bacterial invasion. 340 DISKASKS OF CIIILDliEX. It will be noticed that the causes here given are mentioned as predis- posing. Most, if not all, forms of tonsillar and pharyngeal inflammation are due to the presence of pathogenic organisms. In health and under good hygienic conditions the mucous meudjrane of the throat may not be un- favorably affected by organisms, but under depressing conditions, particu- laily when the digestive tract is in an irritated condition, the throats of infants are vulueiable. It is quite possililo that many impurities may like- wise find their wav to the mouth and tliroat bv means of dirty fingers or Fk;. On. — Mcllind fur c.x.iiiiiii.-iriipii nf the tliroat. objects which are given to infants as toys and wliich ipiicklv find their way to the iiioutli. Treatment. — The treatment consists in removing the cause, whether it be a deranged stomach, defective action of the skin, or faulty hygienic surroundings. The recurrence of attacks of jiharyngitis in infants is the most common cause of postnasal rhinitis in, children. The repeated irrita- tion induced by these attacks canses hypertrophy of the adenoid tissue at the vault of the pharynx, which is the invariable accompaniment of rhinitis in the later years of childhood. The immediate treatment consists in opening the bowels with a mild DISEASES OP THE UPPER RESPIRATORY TRACT. • ' H^ laxative dose of castor oil or calomel, followed bv small and frequent doses of tincture of aconite, one-qnarter to one-half a drop every two hours. If restlessness is a prominent symptom, a grain of phenacetin may be given every three hours for a few doses. As the acute form of the disease is self- limited, it is not well to give drugs verj' freely, especially those that tend to upset the digestion. The importance of recognizing the conrlition con- sists in taking steps to pre\"cnt its recurrence. Acute Pharyngitis. Definition. — An acute inflammation of the pharynx and neighhoring struc- ture.-;. Etiology. — Sudden exposure to inclement weather which Is dust and germ laden ])redisposes to the affection. It is present in the early stages of many of the .acute infectious diseases and may accompany gastric disorders. Exposure to chemical irritants in the form of vapors which produce a pharyngitis. Ohildren with ohstruetions in the respiratory tract, especially adenoid growths, are liable to repeated attacks. Symptomatology. — Locally there is seen a reddened congested pharynx with the uvula and tonsils sharing in the inflammatory process. The larynx and naso- pharynx may also be involved. There may be a rise of pulse and temperature, but this is rarely high. The child complains of sore throat and difliculty in swal- lowing. TTnder ajipropriate treatment there is a rapid subsidence of symptoms. Diagnosis. — With high temperature and vomiting scarlet fever must be kept in mind. Measles will show the presence of Koplik's spots, while a diphtheritic process will show a beginning membrane and give a positive culture. Treatment. — Prophylactic treatment resolves itself into the removal of any ol>structions to proi>er breathing and the maintenance of proper resistance a.gainst infections. Locally. — Cold compresses applied every half-houi-. Mild antiseptic gargles for older children, stieh as the Liq., antisepticus alkalinus N.F. or Doliell's solu- tion, one part to eight of water will suffice if used evcr.v two hours. Constitutional. — An initial laxative, such as the citrate of magnesia or calo- mel, should he prescrilied. If there is high temperature and much discomfort phenacetin with salol. 2 grains of the former to li grains of the latter, for a flve- year-old child, will be efficacious. The diet should consist of cool demulcent preparations, such as oatmeal or barley gruel, junket or ice-cream. Acute Follicular Tonsillitis. (Acute A iiii/gdnJitis.) This is a selfdimited disease of short duration, usually bilateral, with constitutional symptoms and a marked local infective process involving the tonsillar crypts and the entire glandular structure. Etiology. — Children with rheumatic tendency or of a lymphatic type are prone to acute attacks; those with chronically enlarged tonsils being particularly susceptible. In these latter cases, slight exposure to cold often brings on an attack. One infection predisposes to a second, presumably because of the presence of bacteria in the crypts or their accessibility to the tonsil through the mouth and nose. ">-!:-2 DISEASES OF CHILDIfEN. Symptomatology. — The onset of tonsillitis is sudden ; a chill or chilly sensations often being the first evidence. This may be followed by marked prostration, malaise, and vomiting. The temperature is high, fre- quently rising to 104° or 105° F. At first the tonsils and soft palate are reddened and swollen, and in a few hours cream-colored isolated spots appear on the tonsil plugging the mouths of the cr^-pts. These spots are about the size of a pin-head, though at times they coalesce, forming a pseudomem- brane which can be easily wiped off with a swab without producing a de- nuded or bleeding area. The membrane does not spread to the soft palate nor to the pillars of the pharTOx. Frequently the glands at the angle of the jaw are enlarged and tliese, together with the inflamed tonsils, produce considerable discomfort and pain on swallowing. A routine examination of the throat in all cases will often disclose a tonsillitis which has produced no subjective symptoms. Course and Prognosis. — The inflammatory condition is active for at least three or four days even under treatment, but because of the consti- tutional svmjitoms convalescence may be slow; ten days usually elapsing during this stage. The prognosis is good if the patient is well cared for, iliough the danger of endocarditis and the possibility of peritonsillar abscess must not be forgotten. Differential Diagnosis. — At the onset, tonsilitis may be confounded with malaria, pneumonia, scarlet fever, or influenza. A careful history and blood examination will usually eliminate the first; a careful physical exam- ination and absence of disturbed ]nilse-respi ration ratio would differentiate it from pneilmonia, while further observation for twenty-four hours will render the diagnosis more certain on account of the more characteristic ap|)carance of the tonsils. From diphtheria, the absence of Xlebs-Loeffler bacilli, the sudden onset and initial chill, the position and character of the local lesion, the high temperature and the absence of a history of exposure to diphtheria infection point strongly to the diagnosis of follicular tonsil- litis. (See Plate XT.) In ulceromeml)ranous tonsillitis, the constitutional symptoms are iinich milder ; the pain in the throat more severe, and enlargement of lymph- glands more marked. The local lesion is usually one-sided, the aflfected tonsil iH'ing covered with a dirty yellowish exudate eloselv resembling the membiaui/ nf diphtheria. Treatment. — Kest in bed is imperative on account of the great danger of endocarditis. Depletion by calomel gr. 1/10 every half-hour for ten doses will reduce the intoxication. Hot fonunitations or cold compresses to the Ihtnnt will give relief from pain. Alcoliol sponge baths when the tern- DISEASES OF THE UPPER P.ESPIRATOPvY TRACT. ?>4-^ perature is high will add luateiially to the comfort of the patient. During the first twelve to twenty-four hours the following may be given to a child two years old : R Phenacetini gr. * Salol gr. J Oleosacchari anisi, q.y. M. Ft. pulv No. j Mlsce et signa. — One every three houre. For young children who have not learned to gargle, a very efficient local application to be used on a swab every two or three hours is the following : I^ Tinctura; iodini ni i^- ArgjTol sol. riU% gtt. iij Aqua> q.s. ad. 3ss Misce et signa. — Swab on tonsil.s ever.v two to threr bours. Older children may gargle with the Liq. antiseptic, alkalinus (N". F.) or any of the equally efficient mild antiseptic solutions. Ulcero-membranous Tonsillitis. ( Vincen t's Amjlna. ) Clinically, this affection closely resembles a mild diphtheria ; bacterio- logicall}', the findings show the presence of an elongated fusiform bacillus and long wavy spirilli. The general symptoms are mild or absent except for the pain in the throat, which is severe. The lesion is a superficial ulcer on the tonsil the size of a dime, usually unilateral in location, of a dirty yellow color, and exhibiting no great ten- dency to spread. If the ulceration is deep, upon an attempt to pull off the membrane the underlying surface bleeds slightly. The cervical glands are enlarged and the muscles along the side of the neck are stiff and tender. The pulse and temperature are nioderately increased, the latter closely re- sembling the temperature in diplitheria. As a rule, the breath is foul and there is much drooling. Hot anti- septic gargles and mildly astringent applications (see p. 332) locally, combined with hot or cold external applications, are very efficient measures of relief. The disease runs a more prolonged course than a follicular tonsillitis. A smear and culture should be made in all suspicious cases for purposes of differentiation. Streptococcus Sore Throat (Streptococcic Angina). (Former];/ considered as: Menihranoiis Tonsillitis : Croupous Tonsillitis : Pseudo-dipli th eria.) This disease may occur as a secondary condition in various infectious diseases, especially scarlatina, or as a primary inflammation, when it may prove to be a form of milk poisoning. 34 t DISEASES OF CIIII-DUEN'. Etiology.— Tlie inflammation is causeil by streptococci of varying degrees of viralenco. sometimes associated witli staphylococci. Children with lowered vitality from any cause, and especially institutional children, may liarboi- stre]itococci in their throats. The same condition may oeca- siniiallv he found in healthy children, when cold or inclement weather mav cause the ince]ition of the disease. In recent years, several epidemics have been traced to infected milk. It has been found that a combination of mastitis in cows with sore throat in the milkers has been followed by an epidemic in the region supplied bv snch a farm. Converselv, it has been pi'oven liy Capps and others that hemolytic sti-eptococci of human origin may canse mastitis lasting for several weeks in cows, which time roughly corresponds to the relation of milk-borne epidemics. Symptomatology. — Two forms of the disease may be recognized, the mild and severe. Tlie onset is rapid and well marked with vomiting, chilli- ness, headaclie and grippv pains. The temperature is usually high — from 10,?° to ^0.^° F. — which in the milder cases subsides by the third or fourth day. The condition of the throat is variable. At first there is a diflfused redness involving pharvnx and tonsils, resembling a scarlatina throat, but this is soon followed by patches of exudate in the form of a pseudomem- braue. Tliese patches may be limited to the tonsils, but in severe cases they may cover the phar^-nx and extend to the soft palate, the nose and rarelv the laT3Tix. Morphologically the meudirane is like that of diphtheria, but con- tains streptococci and no dipldheria bacilli. In severe cases it assumes a yellowish or dirty-green appearance. The lymph nodes of the neck become swollen and sore, and, in severe cases, may undergo suppuration. Abscesses in tlie peritonsillar region may also occur. There is always prostration, but, in the milder cases, the symptoms usually subside in four or five days and the patient goes on to complete recovery. In the more serioas type there is evidence nf an extensive streptococcus infection. This general sepsis shows itself bv great prostration, irregular and high temperature, and occasionally delirium or stupor. Xephritis usually supervenes, and pleu- risy, bronchopneumonia and even erysipelas may occur and prove to be the terminal condition. Diagnosis and Prognosis. — The only positive method of differentia- tion from diphtheria is by culture. The membranes seen during the early course of scarlatina are usitally caused by streptococci. The prognosis is good in all hut tlie severest t}7>es of the ilisease. In the latter the mortality may run as high as from 10 to ?0 per cent. Treatment. — In young children antitoxin should he given at the start if there is anv doubt as to the nature of the disease. Benefit will be derived DISEASKS OF THE UITEU KESPIRATOKY TRACT. 345 from irrigation of tliu throat, and nose if affeetod, witli hot normal salt solution as in dii^htheria. Ice bags to the neck may be applied when this part is SAvollen or painful. Stimulation by stryclmin, camphor or caffein may be required in the severe cases, and soft nourishment, frequently admin, istered, will serve to keep up tlie strength. When occurring as an epidemic the milk supply of the affected area must be diligently investigated by the health authorities, and any suspected farm quarantined and its milk supply cut i)ff. This was successfully done in tlie epidemics at Boston, Chicago and Baltimore. ■ Chronic Tonsillar Hyoertrophy. A condition of clirrmic enlargement nf the tonsils is seen in raanv children giving a liistniT of repeated attacks of tonsillitis, or a^ a result of the infections diseasi's. Adenoid vegetations and hyi^ertrophicd tonsils are associated in many cases. Symptomatology. — There is impaired ]ihonation and the train of sym]itoms which are associated with adenoids, the distress l)eing especiallv produced at night during sleep. Restlessness and snoring are marked. Anemia and anorexia result. Treatment. — Chronic enljsrgements should be removed, f'ocain as an anesthetic should not be used. If adenoids are present remove the tonsils first. An anesthetic is necessary, and the child should be prepared as for the adenoid operation. The head may be slightly raised and the assistant should gently press the tonsils from the outside, toward the middle line. The results obtained seem to warrant complete excision with special instruments. Complete enu- cleation is desirable, produces less traumatism, and better after-efiFects. Adenoids. (Hyperti-ophtj of ihe Pliarynfieal Tonsil.) This term is applied to a hyjiertrophy of tlie lymphoid tissue normally found in the pharyngeal vault. Etiology. — Adenoids are found at all ages and are far from infre- quent in infants. Children who have lived in a ]ioor hygienic environment or whose parents liave chronic diseases seem to inherit a tendency to ade- noids. They are nsually associated with enlargement of the faucial tonsils. Rickets and the condition known as the lymphatic diathesis predispose to adenoid vegetations. Kerley believes that the pernicious use of the so-called comforter with the constant sucking is directly productive of adenoids. Symptomatology in Infants. — The symptoms differ considerably in 346 DISEASES OF CHILDREN. infants, and tlierefore will be described separately. The babe may be brought because it cannot suckle without freijuently stopping to breathe through its mouth. Sleep is broken and the infant cries and almost chokes when it drops into a deep sleep. A persistent rhinitis is commonly observed, and sniffling may be the most prominent symptom. The expression is not changed as in older children. W^i^^^ ■■ b^^^fl 3 ^HHHw ' ^^^ J^bRb 1 ^^^^^^^^^HnA .^fllV *^ 3 ^P'^-^-Wifci ^ e I''i(.. !)!1. — Tyiiicil iiilennid fur In Children. — In early cases the child is bi-ought for e.xamination because of frequent '■ colds in the head "" associated with troubled sleep and snoring. In moi-e aggravated conditions, mouth-breathing, snoring at night with tossing, restless sleep, and occasional night terrors should lead to a careful nasopl laryngeal examination. In typical eases, the vacant expi-ossion, fish-like face, and open moutli, often with a high arched palate, are readily noted. The face in these mouth-hi'cathers has often been visiblv deformed (Fig. 99). The following characteristics make the diagnosis sim- ple: partly pursed moutli, protruding lower jaw; narrowed long face; A'-sliapcd palate; enlaiged tonsils; narrow abv nasi ; dull eyes; pale muemis membianes; narrowed cliest, sometimes otitis and evidences of general mal- nutrition. 'Iliese children have a nasal twang to the voice and are poor s.liolars. They tire easily, do not eat well, and may suffer from incontinence of urine. There may be partial .leafness from obstruction of the Eustachian tube, if a gi-aniilar pharyngitis with plugs of mvieus hanging from the disi-;asi:,s of tiii; litku HEsriiiAxoiiY tkact. 347 posterior nares is observed, adenoids are usually present. A useful test generall}- indicating nasal obstruction due to adenoids is to request tlie child to repeat the words " Claphaui Common " which lie cannot enunciate without a nasal twang. Examination. — In infants it is a difficult procedure, but niav be occasionally accomplished with care and patience; the little finger must be used for exploration as the space is so small. In older children the finger properly protected should be passed into flie nasopharyngeal space and the amount and character of the adenoid tissue appreciated. Soft pendulous masses or firm growths may be felt and, if the vault is found to be occluded with hypertrophied tissue, operative interference should be resorted to. Fic. 100. — iletbod of palpating for adenoids. Treatment in Infants. — If the symptoms of obstruction are such as to interfere with the infant's nutrition, tlie adenoids . should be carefully and completely removed Jjy an expert. Palliative measures aic ofttimes successful in less aggravated cases, and we have found tlie instillation of a mixture such as tlic following to be of benefit: T^ C'amphora? si", j Monthol <;r. j Resorciai ST. i.i nenzoinol 5j Misco ct sisna. — Fi\o drops evfry tliroo hours into ttic nares with .1 modi- cine dropper. Fl .\drenaUni inlialantis ."ss T.iquidi albolini q. s. ad .^ss Slisce et signa. — A few drops in nares nigtit and morning, 22 348 DISKASES OF Cini,D]!EX. In Older Children. — I'dliative measures liere are useless. The ope- laiiou slioulil be performed luidei' a general aiiesllielie if thei'e are no euiitraindieations, sueli as ljix)neliUis, aeiite ti)usillitis. ete. The adenoids, and if present, the enlarged tonsils are removed at the same time. The aftcr-ii'eatment is to 1)i'eak np the haliit of moiuh-bi'eatliing Ijy careful instruetions in proper In-eathing and eoi'reetive exercises. (See page 83.) Peritonsillar Abscess. (Qiiiiixi/.) A retrniiliaryngeal abscess is more common in int'anry tlian jjeritonsillar aliscesK. Oilier cliiUlren, iKiwevei-. liave abscess furniatioji in tbe iieiatoiisillar tissue, aeiomiianieil by fever, cjiilliness and ililticult swallowin.LC. Tlie nunitli is (ipeiie years. lll-iKaii-islied cbiKlren .are more ]ircaie to it becairse of tbeir lowered vitalil.v, and infection t.ikes pl.ace from tlie organisms connnonl.v found in tbe niontb. Symptomatology. — Tbe infant is nsually lirimgbt for examination because of distinctly beljjful. Dover's powders will alla.v ]iain .and restlessness mitil more heroic measures are taken. Scai'ification is occasionally successful in giving relief wlien performed by a spe- cialist. Tracheotomy is to be preferred to intubation in desperate cases when sufffication is innninent. Laryngismus Stridulus. (See also Spasmophilia, p. 481.) Laryngismus striihdus is a mairotic ilise.ase of infancy, characterized by spas- modic attacks a.ffecting tbe glottis and the neighboring laryn,geal muscles. Etiology. — Rachitic, spasnmphilic infants and those with adenoids are espe- cially iiredisposed. Exposure to irritating gases or vap(u-s, or badly ventilated apartments may bring on an attack. Symptomatology. — This varies witli the severity of tbe disease and with the iiarticnlar siiasm. Tn some cases the spasm is but momentary, ending with an insjiiratory crow: again it may recur every few moments with but slight inconvenience to the patient. In severe attacks the crowing insjiiration is dis- DISEASES OF THE UPPER liESPIRATOKY TRACT. 351 tinctly audible, tbe infant becomes spastic, and tbe efforts to breatbe are marked. Lividity of tbe faee and a gasping expression are observed. Carpopedal spasm and in some instances convulsions follow severe attacks. In tbe intervals the breatbing may be quite free and unobstructed, with no constitutional symp- toms. Fatal eases are rare, but have been reported. Stkioulus. under two years. Lakvn'cis.m is Ill-nourished infants No jiyrexia. No cough or rhinitis. Attacks momentary and recur often. SPASMonic Ckoup. (Acute Larijtiiiitia. ) Commonly from two to five years. Some pyrexia. Brassy cough and eoryza. Attacks usually at night, last longer and have longer periods of remission. Fm. 101. — Croup tent. Treatment. — In the severe cases, emesis with wine of iiiecac in half-dram doses every half-hour until vomiting ensues may be employed, with cold sponging of the face and chest. A cleansing enema in a badly-fed rickety infant is often effectual. Tbe underlying cause nuist be removed or combated in tbe interval. Adenoid.s should be removed, and the infant placed on a properly proportioned diet. This alone is curative in certain babies fed on the proprietary foods. A quiet atmosphere and a well-regulated dietary will cure the majority of eases. ■ i-ii DISEASES OF CHILDREN. Congenital Laryngeal Stridor. {Congenital Infantile iStridor. Tliifinic Asthma.) This congenital condition is rare and is often confused with laryngismus stridulus. Etiology. — There is still confusion as to the causation. One theory is that it is due to a poorly coordinated action of the respiratory muscles involved in the act of breathing. The epiglottis is deformed as a resvilt, and inspiration then jiroduces the peculiar crowing respiration of the affection. (Thomson.) Sometimes a narrowed, infolded and thinned-out epiglottis is found which can be observed by laryngoseopic examination to cause the peculiar sounds. Yariot claims that the condition is found in the lymphatic diathesis and that it is caused I)y an enlarged thymus, his oliservations lieing confirmed )iy A'-ray exam- inations. Others believe it to lie a jiure neurosis dependent upon an underlying nutritional defect. Symptomatology. — From liirth tliere is heard mainly on inspiration a high- pitched rasijing croak ; with expiration this is heard ouly with ditliculty or not at all. Crying or excitement of any kind increases the stridor iind even retrac- tion of the thoracic spaces. On the other hand, it is rarely audible during quiet sleep. The voice is not affected even in crying. There is no cyanosis produced by obstruction. Diagnosis. — This is founded upon the inspiratory stridor ]ireseut since birth in a child otherwise unaffected as to development and who is not made side or uncomfortable by the condition. Laryngoseopic examination or a direct exam- ination of the epiglottis can be quite often made in infants w'ith a correctly- shaped tongue depressor. Laryngismus stridulus (p. 351) is found mainly in rachitic children, is rare before the dentition period, and is often associated with tetany. New growths of the larynx should be ruled out by careful examination. Course and Prognosis. — Up to the end of the first year the condition is at its worst ; then amelioration begins, and at the second year it quite disappears. The physical condition is not affected, but superadded diseases of the respiratory tract are apt to have a fatal issue. Treatment. — The condition does not leml itself to any form of treatment, but the iiituliation tube and instruments for tracheotomy should be on hand if any respiratory disease complicates it. New Growths of the Larynx. I'APiLLOMATA. — Altliongli liy no .means conunon. the.v are not rare. They may be congenital or attril)uted to the sjieciHc fevers. Distinct continued hoarse- ness is the prominent symptom. As the .growth later on causes olistructive symptoms, dyspnea or suffocative attacks follow. The diagnosis may be made oi- confirmed liy the direct method, using either the instruments of Jackson or r!runin,g. The latest method for work in the larynx is that of Killian suspension laryngoscopy. A case may he suspended for one-half or three-ijuarters of an hour. Rectal anesthesia should he used in this type of work. For the examination of the trachea and bronchi we have the .Jackson instrti- ment, a hollow tulje with an electric lamp at the distal extremity, or the Bruning instrtmient, slightly modified by Kahler of Vienna. This last instrument has a universal handle to which various sized tulies can be attached for direct exam- ination of the larynx, tracljea, l>ronchi, esopliag\is, and stomach. The Bruning type of histrunient has its warm advocates, the main advan- tage being successful and continual illinnination at the end of the tube. The small lamp at tlie end of the Jackson tube is too easily covered with blood, mucus or pus. CHAPTEE XXTY. DISEASES OF THE LUNGS AND PLEURA. Acute Bronchitis. This is an acute infiamiiiation nf the iimcnus iiienibrane of tlie large and mediiuu-sized bronclii. It is a frequent disease in early life. Etiology. — Brnncliitis results as an infection followincr lowered resistance from exposure, iiuilnutrition, rickets, enlaro'cd tonsils, adenoids, valvular disturbances, or followinp- the infectious diseases. Irritatinji; gases or dust particles may also cause a form of bi'onchitis. The bacteria found in the secretions are many and varied and of the types commonly found in the bronchial tract. Symptomatology. — The symptoms usually begin with a coryza, or follow an obstinate rhinitis or tracheitis. There is a hard, dry cough which soon becomes loose as more mucus is produced. The pulse and temperature are slightly elevated, rarely owv 101° F. during the day but may be a degree or two higher in the evening, while the resjiirations are always higher than normal. The child, as a rule, does not coni])lain and may be quite willing to be about; infants, however, are often restless and irritable and vomiting may result from an attack of coughing. The stools are rarely normal, either constipation or loose stools being observed. It must lie recollected that the sputum is swallowed by infants and children up to five years of age. The disease tends to recovery in from five days to a week. Severer forms are seen which are due to involvement of the smaller bronchi (formerly termed capillary bronchitis) in which the symptoms are more pronounced and there is some dyspnea. The pulse and respiratory ratio may be somewhat disturbed and a pneumonic process result from infection of the alveoli. Physical Signs. Inspection. — Breathing is quickened, and there may be recession of the softer parts of the chest wall, especially in rickety children. Percussion. — ^ X o changes from the normal. Auscultation. — Exaggerated puerile breathing and rales of varied character, according to the location of the inflammation, are found. Large, coarse rales (ronchi) over the larger tubes and moist rales with finer rales over tlie smaller bronclii may be noted. Tactile fremitus is oftt'u ilistinct in infants when the secretions are viscid. 353 ;!•"!- DISEASES OF CHILDREN. Diagnosis. — Tlie differi'ntial diagnosis is to be made from bronclio- jiiU'iiiiKinia. in wliicli tlie temperature is liigher witli a disturbed pulse and res]iiration i-atio. liy tbe f^runting respiration and dyspnea. The physical e.xamination does not elicit dullness and subcrepitant rales as in pneu- monia. In pulmonary collapse there is dullness on percussion and absence of respiratory murmur and subnormal temperature. Prognosis. — This is usually good except in cases of rickets and after tlie infectious diseases, M'hen pneumonia is likely to follow. Young infants, however, may die from a simple bronchitis when the tubes become obstructed witli mucus, cyanosis and cardiac faihire resulting. Treatment. — Kest for the patient and fresh air are necessary require- ments. .V cliange io a dry climate will often alone effect a cure. The bowels should be opened with a grain of calomel in divided doses or one or two drams of castor oil. Tlie diet is to be restricted and water freely given. If the temperature is unduly high and is causing discomfort, an alcohol rnl> is indicated. The use of hot poultices and jackets are mentioned only to be condemneil. and the same may be said of the so-called svrupv cough mix- tures. If the secretions are persistently dry and the cough harassing, the Lif|. ammonia anisatis in .S to .5 drop doses in water to a child of five years or in the following mixture will prove useful, and will not disturb the digestive apparatus. R Liquor nininonii anisatis 3.i Potnssii iddidi gr. iv rjlyciTini ,^ss .Aqua- q.s. ad- gij Misoc ft si,t.'na. - 3j C'Vory tl'in !■ limirs. The aromatic s])irits of ammonia in five to ten drop doses, diluted, is also effective. I)o not give muriate of ammonia to children. If at night a sedative is necessary to allow the child to sleep, appropriate doses of any of tlie following drugs may be given: Codein, Tincture oiu'i camphorata, Antipyrin, or Sodium bromid. Tlic room is to l)e kept well ventilated and the temperatui-e preferablv not above 70° F. An enforced rest in lied with no further treatment than a free catharsis is often alone curative. If the child has adenoids and enlaiged tonsils, these should be removed at a later date to prevent subsequent attacks. Chronic Bronchitis. Etiology. — This may result from repeatefl attar-ks of the acute form. Chil- dren suffiTinfT from (lisfase of the heart, kidneys, or liver are prone to imlmonary (•(iijf.'('stifiii. and thus acf|nire :i clironic Imiiu-liitis. Kafliitic cliildreii. those with a tendency to lyniphatisni .and adenoids, and those witli a tulicn-iilons diathesis are often afflicted with chronic lironchitis. Symptomatology. — Fever is rarely oiiserved ;ind tiie child is not incapaci- tated from its jjlay. Tlie couf,'h is often mistaken for pertussis, and is worse at DISEASES OF THE LUXGS xVXD PLEUBA. 355 liedtiuie and upon arising. Older eliildren expectorate an abundant frotby mucoid secretion, while younger children may swallow or vomit it. The physical signs are more marked when there is an accuumlation of mucus and almost disappear in the quiescent stage. During the warmer months the cough may entirely disappear. Diagnosis. — From pertussis the differential diagnosis is made Ijy the course and the paroxysmal attacks followed by vomiting. Tuberculosis may be differ- entiated by the tuberculin tests, the absence of fever, and the physical signs. Prognosis. — The prognosis bears a distinct relation to the etiological factor. If this can be remedied, as adenoids for example, much improvement may be expected. If there is glandular enlargement present or a tuberculous tendency, the outcome is not as hopeful. Treatment. — First remove if possible the underlying cause. Climatic treat- ment is often jiroductive of good results. Tonics such as the syrup of the iodid of iron and cod-liver oil are serviceable. Carbonate of guaiacol in 3 to 5 gi'ain doses in sugar of milk is beneficial for the cough. Pulmonary Collapse. Collapse of small areas of the lung occurs frequently and quite easily in infancy. The condition may occur in cases of bronchitis and in obstruction or stenosis of the upper resiJiratory tract or of the bronchi. Children with rickets are particularly predisposed, as the condition is dependent upon the yielding nature of the thoracic walls in early life. Symptomatology. — Superficial areas cannot be detected by physical exam- ination, nor do they produce any noticeable symptoms. Larger areas give rise to very marked and sudden symptoms. The child's condition suddenly changes to one of cyanosis ; his restlessness is dependent upon the inability to get air ; the breathing is extremely shallow and gasping ; the supraclavicular spaces show marked recession with each effort of breathing. A fatal issue may be ])receded by convulsions. Physical Examination. — Dullness, or dullness to flatness, over the collapsed area is noted. On auscultation, the breath sounds are entirely absent. The cry- ing voice is diminished. Areas of comjiensatory emphysema are present, usuall.v in the upper portion of the chest. These signs, with the history of sudden onset, in a child suffering from a previous pulmonary c-ondition, should cause no con- fusion in the diagnosis. Treatment. — A full hot mustard bath followed by artificial respiration may be employed in desperate cases. Holding the infant by the heels may succeed in producing an effort at deep inspiration, and will dislodge any considerable amount of nmcus that may have acted as the cause of the collapse. The production pt emesis by the introduction of the finger in the throat should be tried. If the secretions are still found to be considerable in amount after amelioration of the collapse, a hypodermatic injection of atropin sulphate 1/300 gr. will be etlicaeious. A trained attendant should be placed in charge. Emphysema. Emphysema in some degree occurs very frequently in infants and children suffering from Iironchial affection. Acute emphysema occurs most frequently in bronchitis, bronchopneumonia, pertussis, stenosis of the larynx, and puluKuiary collapse. It is produced by overdistention of the weak elastic tissue of the alveoli when the glottis is closed in violent efforts of coughing. Children suffering from chronic bronchitis frequently have an accompanying emphysematous condition which does not recede until some time after all evi- dences of the bronchitis have disappeared. The condition of chronic emphysema is not often seen in childhood. T!ie diagnosis is based upon the abnormally full and rounded chest, the hyperresonant note on riercussicjn, the diminution of the area of relative cardiac dullness and ^^•"'•i DISEASES OF GIIILDKEX. the soiior(i\is and sitiilant rfili'S licaiwl all i;n()sis and tri'utnieiit are mainly tliose relaUnsr to the underlyiii", conditions. Bronchial Asthma. This is a disease not common to eai'ly life and is due to a s])a.smodii? contraction of tlie bronchial tubes as a result of some foi-iii of ]iatliolog-ical stimulation of the bronchial muscles. Etiology. — Salter records 225 cases, among which 11 began tlie first year of life, and 60 as occurring from tlie first to the tenth year of life. Bi-onchitis is, in the majority of instances, the predisposing disease. N"asal obstructions, esjjecially adenoids, are important etiological factors. They were present in 47 per cent, of La J\^tra's eases. The relation of asthma to various forms of pj'otein poisoning must not be forgotten. Kgg white, e.ij., causes acute asthmatic attacks in some children, usually with evidences of a mild anaphylaxis. Symptomatology. — 'ilie attack may begin with a fairly ])i'onouncccl bronchitis which lasts foi- several days: tlien there may be suddenly super- added dyspnea with its accompanying rapid j-espiration, anxious cx|)i('Ssion, and rarely cyanosis. Inspection of the chest duiing tlie paroxysm shows retraction in the suprasternal and suprachiviculai- spaces, and the activity of the accessory muscles of inspiration. Auscultation. — Siliilant and sonorous rales are heard both during inspiration and expiration all over the chest. Percussion. — A liyperresonant note is elicited during the height of the attack. There is rarely any temperature unless the attack has closely followed an acute bronchitis. Tt rarely rises above 102° F. Blood examinations may be of assistance from the standpoint of dif- ferential diagnosis. Polymorphonuclear eosinophiles are inci'cased in number, while in prolonged subacute cases a relatively lower eosinopliili;i is found. Scarification as for the von Piri|uet test and the introduction of a sir.ail ((iiaiitit\ of eg'i albumin into the site will result in a wheal if the case i- line oC egg anaphylaxis. See pau'e 101. Treatment. — Ail<'noids, enlarged tonsils, ami otiier ohstruelions to proper breathing must be removed. AttadvS of hi'oncliitis are to be Liiinrded against. .V careful pi'ocess of hardening hy hydi-otberapv m- a cliniiLje of envi ronini^nt may hi' necessary to prewnt repeated attacks. Tareful over- sight id the diet must be obsei'ved and indigestion avoiiled. T'he sui;'ars and mi'als are the [)iincipal ofFenders, Tlic indication \'nv Ihe ti'entmenl of the aciile attack" is the relief of DISEASES OF THE LUNGS AND I'LEUJfA. 357 tlie brnni-liial spasm. For this purpose a combinatiim of tlic ioJids and bromids is of distinct service. The bowels shoidd be emptied witli a Foapsnds enema, and if tlierc is an)' history of indiscretion in diet, an emetic dose of tlie wine or the syrnp of ipecac given. Atropin 1/500 of a grain for a two-vear-old child may be necessary for relief in severe cases. The syrnp of the iodid of ii'on is valuable following the attack. Acute Bronchopneumonia. (LobvJar Pnenmonia, Catarrhal Pneumonia. CapiUarij Bronrhilis.) This is perhaps the most common disease of infancy and is vcrj' often a secondary manifestation to an involvement of the bronchial tubes. It is most often met with during tlie first two years of life, and is rarely seen after the sixth year. In a series of 1,000 cases of pneumonia in our wards, only 31 cases of broncho-pneumonia occurred between the ages of four and six years. Bronchitis, the infectious diseases, especially ineasles, l)ertussis, influenza, diphtheria, and scarlet fever, are the ])redisposing causes. Children with rickets, marasmus, sypliilis, neplii-itis, and gastro- enteritis, especially if they live in bad hygienic circumstances, Iiave their resistance lowered, and are thus predisposed. Infants in asylums and insti- tutions are especially prone to the affection. Tlie pneumococcus of Friinkcl, Friedlander's bacillus, strepto- and staphylococci, and the l)actei-ial flora of the nose and mouth are the exciting causes. Pathology.— The pneumonic areas result from extension nf the inflammation through the bronchial walls and from the bronchial walls themselves into the peribronchial tissue. Thus not only the alveoli to which the bi'onchial tubes lead are involved, but also those which surround the tube. The alveoli become invaded by the bacteria and distended with white blood-cells, and contain some fibrin and red blood-cells. The small patches soon coalesce and become the size of a half-dollar or even in excep- tional instances involve the greater part of one lobe. On cut section, the bronchioles are found partly dilated and mucopurulent exudate flows out on pressure. The bronchial glands at the root of the lung may be infiltiated and an increase in the interstitial tissue is found in the older cases. Pleuritis is seen with any considerable area of pneumonia. Accumulations of fluid, small in amount, are not uncommon at autopsy. Symptomatology. — There are few diseases in which the symptoms may be so varied as in bronchopneumonia. The following description will show how varied the symptomatology may be, and wdiat wide differences are found in the physical signs. The disease may be ushered in with vomiting or liigh temperature. On the other hand, fever may be absent or 358 DISKASES OF CUILUliKX. fxtruuR'lv low tliruughout the disease. The temperature in cliaracteristic cases is inarkeilly irregular. There usual!}' is restlessness, rapid breathing, and a cough which may be severe or scarcely noticeable. If the disease follows, as it usually does, an attack of bronchitis, all the sj-mptoms which were present are exaggerated while the breathing liecoiiies labored and the temperature increases. The cry is stifled and an expiratory grunt which is quite characteristic of acute lung involvement is heard. The pulse rate is much increased, rising to 120 or ISO, and is small in character. The respirations are increased to GO or 80, and tlie effort made to get enough oxygen is shown at the peripneumonic groove and by the dilated alse nasi. If a considerable portion of the lung is involved, cyanosis in the lips or iinger-nails is observable. The cliild feels distinctly sick ; it may refuse food, but usually takes water eagerly. The tongue is dry and coated. The dyspnea increases, and the cough may be harassing and suppressed. The pulse becomes weaker, and the hands and feet are cold. Sleep is fitful and constantly disturbed by efforts to cough. If the disease progresses and the temperature remains persistenly high, stupor, delirium, or even coma may ensue. The pulse may become iri-egulai'. The heart action may give indi- cations of myocardial changes and eon\nlsions may precede a fatal termi- nation. Improvement or retrogression of the affection is shown by a decreased number of respii'ations and a moi'c normal pulse-respiration ratio. The eharactei' of the pulse iui]")roves, the infaut takes some interest in his .surroundings, sleeps more, and finally takes nourishment eagerly. Physical Signs. — -The objective symptoms vary as greatly as the sub- jective signs. The examiner must not be astonished if he finds signs not commensurate with the degree of prostration. Palpation. — Little or no satisfactory information is obtained. How- ever, the apex beat of the heart may be located and pain on handling appreciated. Inspection. — Rapid, tailored breathing is noted. The ala? nasi are dilated, and there may be soine degree of cyanosis visible. Ketraction of the peripneumonic groove is observed in advanced cases. Auscultation. — .Vuscultation with inspection are of the greatest value. A pause between inspii-ation and expiration occurs, and can l)e appreciated if the child is quiet oi' sleeping. The bronchitis present will be revealed by coarse, moist rales, often sonorous in character. Suhci-epitant and crepi- tant rales with diminished breathing licard at the end of ins]iiration over a limited area reveal the location of the ]meumonic involvement. These are best heard when the infant is crying or during coughing. The exami- nation should not cease without sufficiently forcible respiratory efforts on the pai't of tlie infant. Prolonged expiration and bronchial breathing are DISEASES OF THE LUNGS AND PLEUKA. 3-"i!> obtained wlien the area of the piieiinionia is recent. A^ocal fremitus may I)e heai'd while the chihl is crying, over hu'ger areas of consolidation. The examiner must not fail to use a stethoscope with a small bell, and must not omit in his search the axillary region, for the first signs are often found there. Percussion. — Light percussion is a desideratum. Dullness may be appreciated if present and points to consolidation. x\reas giving a hyper- resonant note are obtained over portions of the lung in which a compensatory emphysema has occurred. The Important Symptoms in Detail. Temperature. — • As a rule, the temperature is higli in the beginning, 103° to 104° F., althougli periods of remission are not uncommon. The disease ends by lysis and the curve shows the gradual return to the normal. 'No typical temperature curve can be presented because of the intermittent and remittent cliaractcr of the fever. Sudden liigh rises may indicate a complication or an added area of pneumonia. Marasmic infants frequently are seen with little or no fever, or they may even have a sulmormal temperature. Respirations. — The normal ratio of pulse and respirations, 1 to 3, or 1 to 4:, may he so far disturbed as to reach 1 to 2.-5 or 1 to 2. The severity of the dyspnea can be judged by the amount of recession at the sternal space and diaphragmatic attachments. Tlie breatliing may be irreg- ular or simulate the Cheyne-Stokes type. Coughing or crying markedly accelerates the respirations, and if pain is present it is increased. The l' wrilication. Clinical Forms of the Disease. — Disseiiiinati'd bruuehopneuiiiuoia is thij funu ill which thciu are small areas seatteied u\er different parts of the lung. They do not coalesce, and varying physical signs are found in the several patches. The asthenic funu is frequent in marasmic or I'acliitic infants, and it generally accompanies a gastrointestinal infection. There is little or no fever in this type, and the course is protracted and often ends in deatli. Bronchopneumonia Complicating the Infectious Diseases. — With ri:riTrssis. — To the syuiptoiiis of iironcliitis present are added the objective signs of a pneumonia usually of the disseminated type. The temperature rises abruptly and often to 10.")° Y. The dyspnea is marked and cvanosi- appears early. The compdication seriously affects the ])rognosis. Tuber- culosis may follow in its wake if the child recovers. The course is usuall\' long and tedious, remissions being very comiuon. Ituring the course of the pneumonia tlu' spasmodic or paroxysmal diaracter of t1ie cough is not so marked as in uncom]ilicated pertussis. With ]\Ieasi.es. — If, after the eruption of measles when the fever has suljsided, there is an abi'U])t lise of tem|)erature and on physical e-\amina- tion there are found crepitant and suhcrepitant rales over localized areas, lii'onchopneinuonia may be diagnosticated. The cough is increased; it is more fi'equent and dyspnea is moi'e uiarked. ^riie pulse and respirations are increased. The somnolent and apathetic state is again present. A\'iTii DiPTi'rtiEruA. — The pneumonia is more apt to occur in cases having laryngeal in\-olveuieuf. especially those which liave necessitated op:'i';itive interference. It is one of the commonest causes of death after iritulial ion. Bronchiectasis or ]iuluionai'y abscess mav develop in tlu^ more chronic foi'iiis. A\'TTir Otiiior E.\iL\rsTixG Diseasks. — .\s a terminal infection. T)]-onchopneuiuonia may occur in a variety of diseases common to childhood, moiT> esjiecially those that are of bacterial oilgin, such as ty]ihoid and gastroenteritis. "Wh^i-e a g<'neral sepsis is present, it is sometimes only discovered at necropsy. Complications. — As has been stated above, the disease is in itself niainl)' secondary to some other process. Tturing its course there may develop an involvement of the ear, heart, peritoneum, pleura, or meninges. Jfollowing cases of delayed I'csolution, brochiectatic cavities, abscesses, and fibroid changes may de\'<']op. Differential Diagnosis. — From acute bronchitis it ma)' be distin- guished liy the milder symptoms, the lower grade of temperature and pulse. DISIiA.SES OF Tl-IK LUNGS AND I'LKlliA. 3U I and the less disturbed luilse-respii'ation ratio. .\o luealj/ed ai'ea of broncliial breathing, bronehophon\-, or tine crepitant lales will be found. Instead there will onh' be present numerous eoarse and fine bronchial jales. From Lobau Tneumonia.— If occurring in an infant, and thej'e is a histor}- of a primary infectious disease, bronchopneumonia is rather to be suspected. In the lobar type the tejnperature is more constantly high and drops by crisis, while the course is invariably shorter. The pliysical signs may not be distinctive until consolidation has taken place. Leuko- cytosis is higher and pei'sists until the temperature falls at crisis. Fiioi: TuBEKCULosis. — A bronchopneuuionia of long duration is often regarded as a tuberculous process. It is to l.)e differentiated by the tul)er- culous aspect of the child, tlie greater wasting and possibly by the signs of tuberculosis elsewliere. A negative von Pirquet test is of value in diffei'cntiation. Course and Prognosis. — The course varies from two to six weeks, as a rule, and only rarel\- ends by crisis, lysis being the rule. A pneumonia superimposed on gastroenteritis or other debilitating diseases is apt to he prolonged and to leave the child in an e.xtremely emaciated and asthenic condition. This is always a very serious disease. The prognosis is alwavs unfavorably influenced when it complicates poorly nourisheil infants with infectious or constitutional diseases. Tlie younger the child the more un- favorable the prognosis. Artificially fed infants in institutions and tliose witli rickets or whooping cough must be regarded as especially anfavoral)]c. The signs upon whicii the practitioner may base a favorable prognosis are undisturbed heart sounds, absence of marked dyspnea, willingness to take noui'ishment, and undistui-bed gastrointestinal tract. On the contrarw if vomiting and diari-hea, iri'cgular breathing, meteorism, and cerebral svmji- toms develop, the outlook points to a fatal issue. Treatment. — The high mortality of this disease will be reduced if tlie disease is treated rationally. The vital resistance of Ihe infant must be sup]iorted or increased so tliat the self-limited disease may terminate favor- ably. Fresh air. proper diet, hydi'otherapy, and stimulation, when appro- priately used, will conserve the resisting powers. Anti-pneumococcic sera are worthless unless prepared for the particular type of pneumococcus present. Aerotherapy. — The patient should be placed in its crib in a large sunny room, the windows of which are opened to admit an abundance of fresh air. Light and warm clothing should be worn in the colder months, hot-water bags or an electric tliermophor being placed at the child's feet if the extremities are cold. A screen may he used to shield the patient from a direct draught. ■3fi3 DISKASKS OF ClIlLDliliX. Tlie diet ^iliouiil lie a luodifieatiou of tlie previous feedings. With the Ijreast fed, reduce the intervals and ^uive water before nursing. The food of the artilieially fe(l slioukl be reduced witli grueL Older children are allowed milk, gruels, broths, albumin water, and orangeade. The temperature should be controlled bv hydrotherapeutic measures if it is causing unrest, insomnia, or cerebral symptoms. A temperature of 104^ F. in one infant nuiy cause less distress than a temperature of 101° F. in anothei' child. A daily cleansing bed-bath should be given in all cases. The milder measures for the reduction of temperatui'e should l)e first at- tempted, — for example, an alcohol sponge-both (one part to fou7') will irsually reduce the teui]3erature a degree or two, and also has a tonic effect npon the patient. The water may lie luke-warm, but its alcoholic strength may be increased if the desired effect is not obtained. The naked infant is wrapped in a flannel blanket and one portion of the body after anotlier is sponged, and by gentle friction the li(|uid made to evaporate, and thus the cooling effect is obtained. Such a liath should take fi-om ten to twenty ]uinutes and is often followed by I'elaxation and a refreshing sleep. Com- presses wrung out of "\\'ater at 00° F. may be placed about the chest and renewed hourly almost without disturbing the patient. The cool pack will be required in sthenic cases with high temperature and delirium. Ice-bags to the head, wliile effective in reducing temperature, are dangerous unless cautiously employed under tlie direct supervision of a competent nurse. Weak, badly nourished infants or those with a sulmornial temperature are preferably given a hot mustard bath with the water at 105° F. A cheese- cloth bag containing an ounce of mustai'd is drawn through the water and the infant is i-emoved when the skin reddens from the counterirritant. Local Applications. — ilustard pastes are esjiecially effective in the beginning of the disease and should lie applied directly over the affected area in the strength of one part mustard to six or seven of flour. Fiii-ec- tions should be given as to the size and frequency of the application. 'W'lien the skin is well reddened the application should be removed. If the area becomes blanched within four hours a second application may be made. Warm poultices and oiled silk jackets are only mentioned to be deprecated. Medication. — No drug, however harmless, should he prescribed with- out a distinct indication. The symptoms will in greater part he relieved by sponging and locnl applications. If the bowels are constipated an initial calomel purge in di\iih'd doses or an enema may be given. Sedatives for the cough as a routine measure, especially in the form of .syrups, tend onlv to produce fermentation and retai'd progress. A stimulating expectoi-nnt in the form of the nmmonia preparations, as the aronuitic s])irits oi- the Liq. ammonia^ anisati, will ]iromote freer secretion if required and also tend DJSIINSK^ UF TiU; LL'XGS AND I'LEL'KA. 3G3 to sup^oort the heart. A liarassing purposeless coiigli wliich prevents sleep can be profitably controlled with small doses of Dover's powder (1- gr. to one-year-old child, q. 4 h.). Judicious stimulation of the heart is one of the most essential parts of the treatment. The physician must be guided by the action of the heart when the child is quietly sleeping. A rapid feeble pulse rate, weakness of the heart sounds, an I; 20 per cent, were of i:i-oii|> IT. 8 per cent, in fjroup TIT ami o!t per cent, were of group TT. Pathology. — I'lie apices arc in onr expei'ience more frerpiently first affected in cln'ldreii, and then tlie liases. Tlie disease passes tlirongli tlie four stages just as it does in adults; i.e., congestion, red and gray liepatiza- lion, and resolution. Symptomatology. — The onset is sudden, most fre(|uently nitli a cliill or chilly feelings or convulsions, followed cjuickly by higli fever and j'apid breathing. In some cases the nervous symptoms mask the pulmonary con- dition, simulating meningitis. The temperature rises to 103° or 105° ¥., and remissions are only slight and usually take place in the morning. The pulse is relatively high and full. In severe cases the prostration is com- plete, with deliiium and semicoma. The child refuses food, is thirsty, and may complain of pain on coughing, or of abdominal pain. The cough may be slight or even absent for a few days, but toward tlie end is quite marked. In older children rusty sputum is sometimes observed. The disease ends l)\- a crisis, but this is not always sharply defined. It may end also by pseudo-crisis or lysis, especially in those childi-en who have previously been enfeebled. Physical Signs. — Inspection. — Flushed face, dilating alve nasi, and rapid respirations. Auscultation. — Bronchial breathing is noted in the earlv stages and later fine subcrepitant rales; when resolution takes place, bronchovesicular breathing and many moist rales may also be present. Percussion. — 'Pullness over tlie affected area diminishing as the dis- ease pi'ogresses and resolution takes place. Palpation. — Increased fremitus. Complications. — More or less pleurisy of a dry character is present in neai'ly every case. Meningitis or meningismus is often secondarv in the grave or fatal cases. Otitis is not rare, while pericarditis and peritonitis are sometimes seen. Empyema should always be considered if convalcsence is protracted. Diagnosis. — The sudden onset, more constant high fever and physical signs of consolidation difTerentiatc it fi'om a bi'onchopneumonia. A cen- tralized pneumonia is often puzzling and causes a sus]ucion nf typhoid fever or nuilaria. A Idood examination will then assist the diagnosis. In the central pneumonia the process is enclosed in healthy lung tissue, and the physical signs may not a)ipeaT- for several days, but the rational signs plus the fairly characteiistic symptoms will fix the diagnosis. The pain referred to Ihe abdomen has led to a mistaken diagnosis of appendicitis. Examine the lungs particulai'h' for n centralized process. uiska,sj:s of the lungs axi> im.hl'jia. 3G5 Prognosis. — The prognosis is good iii previously liealtliy sHienic children. Treatment. — The general treatment and management lias a]read\- been considered under hronelio-pneumonia but some special eonsideratjoiis j>ertain to this type. Contact infection should always be avoided in hos- pitals and in homes. Non-Specific. — Proper feeding, expert nursing, rest, and fresh air iire of more iuiportance than drugs. A diet restricted to milk only becomes nauseating and often causes distress. Diluted min<, gruels, and milk soups aix' acceptal)le and less likely to produce metabolic faults. Cool, moving fiesh air, is a most valuable means of decreasing rest- lessness and for the joromotion of sleep. Cold packs and ice-cold sponging are contra-indicated as measures too liarsh. Sponging with a solution at fi\"e dcgi'ecs below that of the body temperature will be equally eifecti\x- and more soothing. Abdominal distention must be avoided and iuiproper feeding and sugary medicines are mainly responsible. Enemata are helpfid after removing the cause. In intestinal paresis pituitary extract is a most ])otent aid. It .should be given in O.-'J c.c. doses hypodermatically until relief is obtained. The stimulants must not be abused. Care must be taken not to over- tax a toxic myocardium. Caffein is valuable in the soporific septic type of child, and the drug is contra-indicated in the sleepless or restless patient with signs of meningeal irritation. Digipuratum may be necessary in collapse and may be given intravenously if necessary. Specific Treatment. — If the sputum test proves the case to be of Type I an effective serum is available. Unfortunately except in hospitals, the laboratory diagnosis is usually made too late to be of any value. With the specific type serum in profoundly sick, septic cases the pneumococci disappear from the blood and the bad prognosis is altered. It is well to make an intracutaneous test for a serum reaction and if time permits de- .sensitize with a minimal dose of 0.02 c.c. subcutaneously before giving the specific serum intravenously. Injections of tlie serum (couiputed in doses vf 5 c.c. for evci'v two pounds of body weight) are repeateil eveiy tuelve or twenty-four houi's until a general improvement with fall in temperature results. 366 iJlSKASJiS Oi'^ CIliLDllKN. Pleurisy. Dry I'LEURTSY. — Tliis is an inflaiiiiiiation of a Incalized area of the pleural surface, usually in con.iuiiftlon with a piieuinonie i)r()eess. over infarcts or exten- sion from a tnliercnlous imeunionia. Tliese lesions are seen frecjuently post- mortem : tlie iilenral surface is found to be dull and Insterless with the adhesions firm or fibrinous. Symptomatology. — To these adhesions the pain accompanyin,^ a pneumonic process may lie ascribed (a pleuritic friction rub is heard on auscultation over the consolidated area). The iiain is sharp and lancinating, and usually produced or noticed after coughing. In older children it is evidenced at the end of a deep inspiration. Treatment. — Outlined under Serous I'leurisy. Serofibrinous Pleurisy. This form also results from extension of infection from a tuberculous or pneumonic process. The fluid is usually foujid to be .stejilc on ordinary culture media, but in cases in which perfected methods have been employed the tubercle bacilli may be found. Infants rarely have this form of pleurisy; it is more commonly found after two years of age. The weight of opinion inclines to the belief that previously infected bronchial lymph-glands are the source of infection. Pathology. — On the surface of the pleura is found a filjrinoplastic exudate, sometimes thick, but usually thin and soft. The fluid which exudes is yellow or yellowish-green in color. The lung may be found col- lapsed in whole or in part. Sacculalcsulting from pyogenic bacteria infecting a necrotic portion of the lung. It is a secondary condition following pneumonia, the infectious diseases, broncbiect.asis, tbe aspiratimi of foreign tjodies, or gangrenous stomatitis. Tbe diagnosis is more often made at necropsy than during life. Diagnosis. — Tliis is founded ujion the imtrid ex|iectoratiou of a dirty green- ish colnr. wliicli (in cxamimition is fomid to contain shreds of luilmonary tissue. The child's breath is almost .always offensive. There is progressive em.-iciation, [irostration and an irregular temperatui-e. The cough is somiMvb.-it iiaroxysuial, followed by the expectoration of a good quantity of the characteristic sputum. Dlf^EASICS OF THF, LUXdS AND TLEUIIA. 373 Even young cbildren will expectorate or vomit who are suffering witli pulmonary gangrene. Following tlie evacuation of the pus we may be able to obtain the cavernous signs indicating a cavity. Hemoptysis sometimes folbjws after a severe attack of coughing. Course and Prognosis. — The prognosis is invariably grave. Careful super- vision and acrotheraijy may so far improve the patient's general condition that surgical measures may be .iustiflably at- tempted with the chance iration at the time of coughing ov laugliing when the foreign Imdy is in the mouth. Among the ob.i'ects we have collected are an upbdlstei'cr's tack, the glass e.ve of a doll, tish bones, and a carrib liean. Symptomatology. — A sudden violent fit of coughing or choking follows the aspiration and cyanosis results; extraordinary efforts are made by the child to breathe. (Jccasinnally tlie paroxysm is so slight as to be mistaken for whooping cough or croup. If the ob.ject is sharp, as a fish bone, for examjile, there is some local irritation or later .s.vmptoms of obstruction. The attacks may be followed by periods of comparative quiet and rest. If the object is small and smooth, and is not coughed up at once, it will eventually find its way into a bronchus. It Iiassi's nsii.ill.x', owing to its position, into the right bronchus. Diagnosis. — If a history is obtained and tlie symptoms of the initial suffo- cative attaclc are well described, the dia.gnosis may be m.-ide, witliout the knowl- edge that an object has been aspirated. When the symi)tonis come on gradually, the diagnosis may be entirely obsiaired. However, a bronchiectatie cavit.v, pul- uKaiar.v collapse, or abst-es.ses should lead to a careful investigation with this diagnosis in mind. An A-ray examination may materially aid in clearing up a susjicctcd CISC. Treatment, — The finger or the laryngeal forceps may succeed in removing a recently aspir.ited object. If unsuccessful, tracheotomy may be necessar.y in cases wliich would otherwise suffocate, surgical measures for the removal of the foreign body being later employed. Direct l.ii-yngolironcliioscopy (see p. o.j2j has rendered excellent sca'vlce In the removal uf object.- from the bronchi. The fluoroscope has also successfully dircH'ted the surgeon in locating and extracting the foreign body. Subphrenic Abscess. This consists of an accumul.-ition of pus between the liver and the diaphragm on the riglit side, or between the stomach, spleen, and diaphragm on the left side. Downw.-ird extension of an eiiiiiyenia tlirougb the dia])liragm is the usual cause in children, altlaaigb it ui:[y result fi'oOL intraabdominal disease. It may also com- lilicato conditions such an apiiendicitis and acute i)rieunionia of the septic type. Kmpyema is most often diagnosticated and the real condition discovered at opera- tion. Uarely the .nbscess contains air. and iiyoi)neuniothorax may be suspected. Symptomatology. — Beside the symiitoms of the i>rimary condition there may he addcil chills, rapid pulse, remittent fever, localized iiain and tenderness, nausea and vomiting, with imjieded respirations. In a case seen by one of us there was ■■ilso a aioderate .■iiiionnt of bulging, and the liver was displaced by the lais. Treatment. — Pnanpt surgical intervention with the establishment of dr.ain- age is iiii|>ei'ati\'e. The progaosis should be guarded. SECTION VIII. DISEASES OF THE CIRCULATORY SYSTEM. CHAPTKli XXV. DISEASES OF THE HEART. Two factors in early life contribute to tlie vigor of the circulation : (1) The strengtli of the heart muscle itself and the readiness with which it liypertrophies when compensation is required. (2) The elasticitv of the arteries. It is frequently not appreciated how important a function the Fic. I(i7. — Riuliograph of normal heart. arteries play in the round of the circulation. By their tonicity they aid the heart in propelling the blood in a constant stream to the various parts of the body. If the arteries are healthy and elasti<' great help is thus afforded the heart in the equable distribution of the blood. Even a crippled "76 DISEASES OF CTIILDKEX. heart acts to imieli better advantage wlien the arteries can perform their frill share in the work of the circulation. Thus in earl}' life, when the arteries are nearly always in a sound condition, a lesion of the heart may produce comparatively little discomfort, especially when compensatory hypertrophy is satisfactoiy. as is very apt to be the case. When, however, middle a<;e approaches and a stiffening of tlie arteries ensues from athe- romatous change, Ave will soon encounter dyspnea and other evidences of a failing circulation. Tlic blood pi'essure itself, as registered by the sphygmomanometer, is lower in chihli-en than in adults. The norjiuil limits of systolic pressure at different ages hav(> been given as follows : Infants, 7.5 to 00 mm. Cliildren, 90 to 110 mm. Young adults, 100 to 130 mm. Older adults, 110 to 14.5 mm. In a series of observations made by us at tlie Postgraduate Hospital witli the Stanton spliygniomanometer. the above figures were confirmed, and observations were made in diseased conditions; but while of interest, it was found that blood pressure estimations were not of much practical value in early life. The Heart. The infant has relatively a larger heart than older children and adults, and it assumes a more horizontal position from a greater breadth. The apex beat in early life is in the fifth intercostal space and is sometimes a little external to the mammary line. With increasing age the apex beat deflects a little doAvnward and inward, reaching well within the mammary line. Enlargement of the heart may be noted by the position of the apex beat and by an increased area of dullness on light percussion. The space for such percussion is situated between two parallel lines, one line running through the middle of the sternum and the other through the left nipple. Absolute heart dullness will be noted in a small triangle formed by the left border of the sternum, the lower border of the fourth rib and a line running from the fourth rib just within the mammary line to the third costal carti- lage near the left border of the sternum. The dullness caused by the left ventricle will be marked out by percussing inward from the mammary line over the second, third, fourth, and fifth ribs; that caused by the right ven- tricle will he located by percussing over the fourth interspace beginning outside the right sternal line and percussing toward the sternum, dullness DTSKASKS OF THH HEART. 377 caused by the apex may be noted by percussing from the middle of the Eternum along the fifth interspace to the anterior axillary line. The heart beats with great rapidity in early life and it is often puz- zling to determhie accurately the character of the sounds heard. Tlie pul- monic second sound is accentuated throughout the early years and a certain arythmia is often observed. The pulse is frequently irregular and its rapidity is greatly influenced by any disturbing conditions, sucli as crying; it also varies much dui-ing waking and sleeping hours. The following may l.'e considered as a fair general average : NewbDni, ]2() to 140. i'lrst year, no Second year. 100 Fifth ti) eighth year, 90 Congenital Heart Disease. {Cijanosis : Blue Disease.) Xew-born infants sometimes e.xliibit a persistent bhieness, due to mal- formation of the heart. This defect usually takes the form of deficiency in the interauricular and interventricular septa. The great vessels may like- wise be involved in the malformation, especially the pulmonary artery. Dr. J. L. Smith found in over half of the 162 cases he examined at autopsy tliat the pulmonary artery was absent, i-udimentary, impervious, or ]DartiallT obstructed. He also found tlie following lesions: Right auriculoventricular orifice impervious or contracted : orifice of the pulmonary artery and the right auriculoventricular aperture impervious or contracted ; right ventricle divided into two cavities by a supernumerary septum ; one auricle and one ventricle ; a single auriculoventricular opening, with interauricular and interventricular septa incomplete ; mitral orifice closed or contracted ; aorta absent, rudimentary, impervious, or partially obstructed : aortic orifice and left auriculoventricular orifice impervious or contracted : aorta and pul- monary artery transposed, the vena cava entering the left auricle; pulmo- nary veins opening into the right auricle or into the vena cava or azygos veins ; aorta impervious or contracted above its point of union with the ductus arteriosus : the pulmonary artery wdiolly or in part supplying blood to the descending aorta through the ductus arteriosus. It is obvious that with any of these grave central lesions not only the peripheral circulation, but the nutrition as well must suffer. The blood is deficient in oxygen and has an excess of carbon dioxid. The blueness is most pronounced in the prominent parts of the face, such as the eye-brows, cheek-bones, nose, and lips. The hands and fingers are also prominently 378 DisiiASKs OF ciiii.nnKX. affected. The colnr varies fi-nm a li{?lit to a very deep purple, the diseolor- ation being aggravated by crying or other disturbing influence. AVhile tlie infants at birth may be well developed, there are soon evi- dences of failure of nutrition, and they are very susceptible to intercurrent diseases. The action of the lieart is rapid and tumultuous, and the I'espira- tion is correspondingly disturbed. Various bruits are heard upon auscul- tation of the heart, especially a systolic murmur at the base. The right heai't is usually enlai-ged. The infants suffer from lack of sufficient animal heat, and because of this and pulmonary congestion they easily contract pneumonia. They are apt to be carried off by any intercurrent disease, and whooping-cough is especially badly borne. Tn a Tuajority of cases of congenital heart lesion, the general blueness is noted immediately or very shortly after birth. In a minority of cases, however, the lividitv is not noticeable for an interval of time, varying from a few weeks to a few months after birth. A few cases have been reported where even a few vears have elapsed before the blueness has become marked. The defect occurs more frequently in male than in female infants. Wide this peculiarity has been noted by most observers no explanation can be given of it. Most cases do not survive the first year, but occasionally a case will live through infancy and childhood. It is very rare to find one surviving adolescence. Those that survive infancy present a stunted appearance, although well formed at birth. The chest becomes deformed, with a projecting sternum, and the fingers and toes bulbous from the sluggish circulation. Anasarca may occur toward the end of life, to be noted in the face or ankles, and rarely in other parts of the body. Death may take place from exhaustion, during a paroxysm of dyspnea, from convulsions or from a feeble resisting pow(U- in some intercurrent disease. Diagnosis. — In order to distinguish congenital from acquired heart disease, it may be borne in mind that the latter is rarely seen in infancy, especially early infancy. The congenital type sliows earl\' and there is general blueness, marked dyspnea, defective development with later bulbous fingers and toes. There is likewise no appearance or history of rlieuiuatism or acute endocarditis. The commonest bruit is the loud unirmur at the Ii i,-c u-iiall\" sNstolic and ditluse. I)i,-p1iic('iiiriit or trnns|iosition usually with other abdominal organs jiiav occur. 1 )extri-cardia alone is exceedingly rare. The main jiossihilities to he coiisidri'cd arc: (a) jiersistcucc of fclal conditions (]intent forauien ovale and ihictus ai'ti'riosus) ; (\i) intci'fi'iTnce "\^'il1i uovinal development, defects in the septa, stenosis of orilices, nialforniations of the sireat vessels; (c) fetal cndorarditis, usually riiilit sided and invohing ]mlnionarv valves. DISICASICS OF TJIK HEART. ' 379 The c^yanosis wlnii pi'Lswit is due generally U> a lesimi of the puhiioiiai-y •artery. The diagnosis of the eondition is not difficult, of the exact lesion often extremely ditlicult. Electrocardiographic tracings are of value here as they give us information relative to the heart chambers, and so may decidedly hel|) in fixing the type of lesion. Prognosis. — This depends on the character of the lesion. Cases of defective septa alone are less likely to be serious wliile cases of atresia of the pulmonary vessels or aorta are usually rajiidly fatal. Treatment. — A general hygienic oversight is the most that can be accomplished. Tlie infants must be kept "warm and carefully fed. If the blueness and dyspnea become extreme, oxygen may give temporary relief. Small doses of digitalis may be occasionally given as an aid to the circula- tion. Acute Endocarditis. Endocarditis is an inflammation of the endocardium which especially affects the lining mend)rane of the valves and the parts contiguous to them. Etiology. — The commonest cause is the virus of rheumatic fever, and, in some cases, it may be tlie first and even the only manifestation of tliis disease. Usually, howe\er, it is preceded by sevei'al attacks of the mild foian of rheumatism seen in early life. It is also iu)t infi'e(|uently seen in connection with chorea and repeated attacks of tonsillitis. The latter dis- ease may alone be responsible for endocarditis or it may be associated with rheumatism, the two conditions either ]ireceding or following the heart attack. Clinical experience forces the belief that certain forms of tonsillitis, rheumatism, chorea and endocarditis are frei|uently manifestations of the same underlying pathological eondition. Any infectious disease may attack the endocardium, especially scarlet fever, cerebrospinal fever, diphtheria, and tvphoid fever. In some cases influenza may act as a cause. Any of the septic conditions are also lialile to i)rovokc inflammalinn in the endocardium. Pathology. — In fetal life the rigjit side of the heart is attacked, but this rarely occurs after birth, when 'the left side is almost exclusively affected. The valves are most frequently the seat of the inflammation, the mitral valve being oftenest afi'ected and next the aoi-fic and occasionally the pulmonary valves. The affected valve is thickened from a proliferation of connective-tissue cells and may be covered by small deposits of fibrin, espe- cially around the margins. Small throndji and vegetations nmy also be present, which are liable to sepaiate and be carrieil into the general cii-cu- lation. In this manner secondary infections are liable to take place in \-arious vital organs. Leakage of the valve may he eau-ed liy contractions 380 DisEASKs OF ciin.niiKX. of the cIioi'(I-ulnionie second sound and difliculty in locating ihe a])ex bi'at. In addition to these local signs there will be fainlness, palloi', and general ])i-osti'ation. Treatment. — The heart must be su]iported liy alisolute rest in the I'ecuuibent position. Sudden dilatation and weakness nut)' be condiated by bypodei'inatic injections of small doses of morphin and atro])in. Sul- ]ihale of sti'vdmin is useful in sustaining the heart's action. Trolonged rest and avoidance of exeiiion must be insisted iij)on during convalcs<-enc(\ CHAPTER XXVI. CHRONIC VALVULAR DISEASE. Physicians are often called upon to treat cases with valvular diseases of the heart when it is impossible to find out the beginning of the trouble. The patient may be unable to give a history either of rheumatism or endo- carditis, but seeks advice for dyspnea, swelling of the extremities, or other symptoms of failing circulation. We believe that a large proportion of the cases of valvular disease in the adult started during childhood, the first beginning of the trouble, which is the period for hopeful treatment, not tiaving been recognized. The nature of the rheumatism that attacks chil- dren is often obscure, and several attacks of wandering or so-called " grow- ing pains " may be overlooked. While the heart may be the first structure attacked by rheumatism, this is not the cominnn order of events. Tn most of our histories of valvular disease in children the cardiac affection seemed to come on after several attacks of rheumatism. Great care should be exer- cised in making an early diagiiosis. and vigorous measures lie taken to combat these first manifestations of rheumatism, fearful that, although the heart may escape the first mild attacks, it may suddenly and unexpectedly become affected by an equally light manifestation of the disease. When endocarditis ensues, as previouslv noted, the symptoms are often very obscure. Palpitation, slight pain, and breathlessness, with a dry cough, may not be patticulai'ly noticed b\' parents. In all suspicious cases we would strongly emphasize the importance of a careful examination of the heart on the part of the physician, a stethoscope Ijciug used. Just at this juncture rest is indicated above all things. If this is not ]irocured, the delicate, softened heart muscle quickly undergoes dilatation, followed bv permanent damage to the valve. Dilatation takes place very i-eadily in the young subject. If it is true that endocarditis need not always nor neces- sarily eventuate in permanent valvular disease, and this seems to be gen- erally believed, we may certainly aid such a result bv doing all in our power to avoid dilatation. By recognizing the endocarditis at the beginning and keeping the child as quiet as jjossible, we may thus seek to avoid dilatation and consequent crippling of the valves. Even after the immediate symp- toms of endocarditis have passed, children are too often allowed to take part in all kinds of vigorous exercises as if nothing amiss had happened. Tn many cases children suffering from chronic valvular disease show few symptoms of circulatory disturbance. This is explained by a more or n,s.3 384 Di.sicAsi;s or t'iiij.niti;\. less perfect compensation whicli generally and completely ensues from hyper- trophy, and there may thus be no positive si^n until years later that serious damage has been effected. The peripheral arteries are also healthy and elastic at this time, which fact, as previously noted, greatly facilitates the work of the lieart. As tlir jiatients grow older, and vascular degenerations begin, and the limit of compensatory hypertrophy is reached, marked dyspnea and otliei' symiitoms of a failing circulation will be noted. We have seen cliildren after a severe, neglected case of endocarditis, or after several attacks, suffer in this way, but in a large numljer of cases tlic principal evidence of valvular disease will l)e shown Ijy general un- derdevelopment, malnutrition, and anemia. Tlic extent of tlie heart lesion cannot be estimated by tlie I'elative loudness or softness of the murmur. We must estimate the amount of ci-ip|)ling caused by valvular defect by two factors in our exauiiiiation of tlie heart: first, the position of the apex beat, and second, a nurrked ac- centuation of the pulmonic second sound. Tf there is no hypertrophy of any part of the heart muscle, it is not proJjable that any real valvular defect is present. While in early life the pulmonic second sound is relatively louder than in later years, if it is very markedly accentuated there is evidently an interference to the passage of the blood through the lungs, clue to some valvular lesion. Tn early years the mitral valve alone is most frequently the seat of chi-onic disease; next a combination of nutral and aortic lesions is found, and verv rarely the aortic valve alone is affected. This is explained by the fact that the mitral valve is most often attacked by rheumatism, while atlicroma, gout, and old age are the commonest causes of aortic disease. Loralion of the TV//(t.<. — ^ The mitral valve is situated at a point where the upper border of the left fourth costal cartilage joins the left border of Fic. 10S. — riiniiiic endiiennlitis. cardiac liy]if'i'tr(i|iliy. enlargement nf liver will) ascites. CIIEONIC VALVULAlt DISKASE. 'i^^ the sternum. The aortic valves are placed behind the sternum at the junc- tion of its left margin with the lower edge of the third left costal cartilage. The pulmonary valves are located at the junction of the left border of the sternum and the third left costal cartilage. The tricuspid valves are found behind the middle of the sternum on the level of the line connecting the fourth costosternal cartilages. The valves of the left heart arc situated deeper than, and behind those of the right heart. Organic defects in the valves give rise to adventitious sounds known as organic cardiac murmurs, produced by the passage of the blood over or through the valves affected. These murmurs are not heard with maximum intensity directly over the valve affected, but near it, and are transmitted in the direction of the blood current. The following are the locations of the loudest sounds in the valves when diseased: mitral murmurs loudest at the apex; aortic murmurs loudest at second right intercostal space ; tricuspid murmurs loudest at the ensiform cartilage. Mitral Regurgitation. Any insufficiency or leak in the mitral valves will be followed by regur- gitation of blood during the systole. There will then ensue, first, a dilata- tion and hypertrophy of the left auricle; next, hypertrophy of tlie left ventricle required by the extra work thrown upon it in propelling the blood through the aortic valves, and. finally, an hypertrophy of the right ventricle which has difficulty in forcing the blood through the lungs to be emptied in the left auricle. A physical examination will show general evidence of enlargement. A visible impulse of the heart's action can usually be detected and the apex beat is felt below and to the left, or outside its usual location. On percus- sion, the area of dullness will be increased to the left and below, from en- largement of the left auricle and ventricle. On auscultation a systolic murmur is heard, having a blowing and rarely a musical character. The murmur is transmitted from the apex across tlie axilla to the inferior angle of the left scapula. The murmur is sometimes heard in children at the latter location behind, plainer than at the apex at front. An accentuation of the pulmonic second sound is usually marked. Mitral Obstruction. A presystolic or auriculoventricular sound is produced by some inter- ference with the normal and easy passage of blood through the auriculoven- tricular septum or valve. The murmur is rough and blul)bering in quality, beginning at the end of diastole and ending abruptly with systole. One of ?.st) disi;asi:s of cirii.njiKX. tlie ]iio?t eliavactcristic points about tliis murmur is its abrupt termination. This (|ui(k stop of tlie al)normal liruit is vorv diflforent from tlie gradual ending nf mitral r(_\L;ur-,<^itation. T])r obstruction in tlie valve leads to liypertro]i]iv of tlie left auricle and finally to enlargement of tlie right ven- tricle, Avliicli has more work to do in flushing the blood through the lungs. Tlie left ventricle is not ]iy]iertrophied. and accordingly the apex beat will ap])car in al)out its normal location. Anv enlargement will be noted by an increased area of dullness to tlie riglit of flic stei'nuiii. A puriing thrill ia usually felt bv placing the liand over the lieart. On auscultation a blubber- ing murmur is heai'il only in the region of tlie apex and is not transmitted. It is lil^ewisc somcwliat varialilc and may be hardly audible during reposn, and yet very eviilent when the patient is required to make some exertion. The pulmonic second sound is always accentuated. C'liapin has reported a series of forty cases in which children giving evidence of mitral olistruction were kept under observation for different in- tervals of time from a few weeks to several years. The commonest symptoms noted were varying degrees of pain referred to the region of the lieart and dyspnea on exertion. Thirty-one nf the cases gave evidence of simple mitral obstruction, while in nine cases there were combined murmurs. Most of the cases were preceded by a rheumatic manifestation that was mild even for children, and he concludes that while mitral stenosis is not independent of rlieumatism it is ajit to l)e associated M'itli the less pronounced forms of it. Tn growing children, especially girls, who arc pale, nervous, anemic, and ti'ouliled witli digestive disturliance, an irregular action of tlie lieart mav ]iroduce a i-ougli sound simulating mitral obstruction, which ilisappears umlri' improved conditions. Aortic Obstruction. Tliis lesion is infrei|uent in i-liildliood. It is accompanied by a systolic muniiur fieard at tlie base at tlie second riglit interspace and ti'ansmitted upward, d'lie aortic second sound is somewhat weakened, but there is no accentuation of the ]iuliii(inic second sound. There is hypertrophy of the Ir^ft \"i'nl I'iclc and the apex Ijcaf is accordingly ]uished downward and out- ward. Tlie latter Mill distinguish this sound from functional or henric murmurs with which it is a]it to he 'MHifused. Aortic Regurgitation. This lesion is likewise not very fi'dpicntly seen in earl\' life. The murmur is diastolic, lak'iiig the )dacc of the aovtic second sotiml. Tt is rallici- jiiirsh in characiiT and is fraiismitted downward over the sternum. CUHOXIC VALNLLAJt DISEASE. 387 being heard with greatest intensity at about the fourth cartilage or some- times at the lower extremity of the sternum. There is great hypertrophy of the left ventricle, and aecordingl}- much displacement of tlie apex beat downward and outward, and the heart usuall}' acts with considerable force. The so-called '" water-hammer pulse " is typical, consisting of a full, arterial wave followed by a sudden fall in tlie pressure. Tricuspid Regurgitation. This lesion is very rare and apt to be overlooked. It may be caused by disease of the valve itself or secondary to a dilated light ventricle. There is a very soft systolic murmur heard over the ensiform cartilage. It is distinguished from aortic regurgitation by being systolic instead of diastolic, and also by more marked cyanosis, by pulmonary edema, and jugular pulsation. Prognosis in Valvular Disease. — The immediate prognosis in chil- dren, even when the lesion is fairly severe and extensive, is usually good for reasons already noted. There is nearly always, however, a more or less defective nutrition. There are cases in which slight lesions appear to undergo complete recovery, especially when a healthy general growth can be accomplished. Repeated attacks of rheumatism, with the danger of renewed endocarditis, are a grave menace to the heart by upsetting com- pensation and increasing existing lesions or forming others. The ultimate prognosis is not good in most cases of marked valvular disease with any evidences of decompensation, as it is only a question of time when the compensation will fail in later life. Treatment. — Many cases require no treatment directed to the heart, but the general nutrition and growth require careful oversight. Xourish- ing, digestible food, with the occasional administration of remedies to build up tissues, such as iron and cod-liver oil, are frequently all that are required. These cases should not be restricted too much in exercise and amusement. All the milder games may be allowed, only avoiding the more violent and competitive sports. Any acute infectious disease and the slightest mani- festation of rheumatism must inean extra rest, and anxious care on the part of the physician. Any evidence of failing compensation will likewise require rest and the administration of heart tonics, especially strychnin and digi- talis. Then Nauheim baths and graduated cardiac exercises will be re- quired to establish convalescence. In cases of great dyspnea and restless- ness small doses of eodein by the mouth or minute non-narcotic doses of morphin given hypodermatieally will often afford relief. CHAPTER XXVII. DISEASES OF THE PERICARDIUM. Pericarditis. This is an inflammation of tlie pericardium secondary to some infectious disease. Etiology. — The most frequent cause is rlieumatic fever. It may also occur in connection with the exanthemata, especially scarlet fever, in various septic processes, in tuberculosis and pneumonia. Direct injury is rarely a cause, and it may spread by continuity from pleurisy. The following bac- teria may act as exciting causes — streptococci, staphylococci, the tubercle bacillus, the colon bacillus and the pneumococcus. Pathology. — We may recognize three varieties — the fibrinous, sero- fibrinous and purulent, according to the inflammatory exudate. In the first or adhesive form, the pericardium is covered by an exudation of fibro- plastic matter which may lead to adhesions between the visceral and parietal surfaces. In the serofibrinous form, the pericardial sac contains a serous fluid, together with a fibrinous exudation, which produces adhesions on absorption of the fluid. The serofibrinous exudation may occasionally become purulent, and rarely blood is exuded into the sac. Miliary tubercles 7iiay infiltrate both the visceral and parietal surfaces in the tuberculous form. Permanent adhesions will be produced by the fibrinous exudation Ijeing replaced by new connective tissue. More or less myocarditis is present in connection with pericarditis, the same as in endocarditis. Symptomatology. — The subjective symptoms are of such a negative cli.iraeter that tlie disease is often overlooked. As it is usually a secondary condition, the original disease is apt to mask the symptouis that are pres- ent and occupv all the attention of the physician. Palpitation of the heart, dvs]mea, more or less pain in the epigastric region, rapid, irregular pulse, and increased respirations are usually present. In severe cases cyanosis may be marked. Where pus is pi'esent in tlie effusion, the tem]ierature assumes a more remittent curve. Physical Signs. — As the rational signs are obscure, the physical signs assume gi'eat importanc(.' in uiaking a diagnosis. In the (ilii-ous form, a superficial friction sound, synchronous with the beat of the heart, may be (h'ti'cted. It mav he heard on systole alone, or with both systole ami diastole. It is usually more distinct at the base, but it luay also he heard toward the apex, especially at the onset of the disease, and is not transmitted. DISEASES OF THE TEItlCAliUJ UM. ';!!:il At firsts the sound may have a erepitant quality, but later assumes a coarser, rubbing, or rasping charaeter. A friction fremitus may be felt over the region in which the friction rub is localized by auscultation. In the serous form there may be some bulging at the precordial I'cgion, depending upon the amount of the effusion. From one to two fluidounces must be jiresent in the pericardial sac in order to produce marked signs. The apex beat is not distinct, being puslied upward and to the left. Where there is extensive effusion, the apex beat may be lost. There will be an increased area of precoi'dial dullness over the distended sac. It may extend on the left outside the mammary line from the seventh rib up to the first rib, and from a little to the right of the sternum down to the liver. As in pleural effusions, there will be a sliglit resistance to the finger on percussing. On auscultation the heart sounds are muffled or feebly heard, and the apex is located with difficulty, if at all. As the fluid is absorbed the friction rub will again be noted and the valvular sounds become more distinct. Diagnosis. — This must be made by a careful examination of the heart in reference to the physical signs just noted. In endocarditis the apex can be located and the soft, blowing murmur is transmitted. Acute dilatation of the heart and h)pertrophy will show an enlargement and increased area of dullness, but there will be no friction rub nor signs of effusion, and the previous history will help to throw light on tlic case. A left plcui-al effusion, with or without pericardial effusion, may raise a difficult ]>oint in diagnosis. The flatness from the pleural effusion will not extend over the heart and sternum if there is -no ]iericardial eft'usion, but, if both are pi'esent, tlie extensi\e dullness and feeble or absent heart sounds will afford a probable diagnosis. Prognosis. — The immediate outlook is good except in tlic septic and purulent forms of the disease. The heart ma)-, liowever, be permanently crippled in the case of extensive adhesions. Treatment. — The child must be kept ]ierfectly quiet in the recumbent position as in all other foiins of acute heart trouble, and milk or other bland food given. Tuiiiultunus action uuiy be controlled by an ice-bag over the heart. Small doses of morpliin or eodein may be emjdoyed to (|iiiet and strengthen the heart's action, to control pain, and relieve restlessness. If the heart is weak and unsteady, strychnia, caffein, or alcohol may be em- ployed. Where effusion is extensive enough to seriously end)arrass the action of the heart, aspiration nuiy be considered. AVe have seen a case of sudden death, however, due to a slight puncture of the heart muscle where this operation was emplo\cil. Tilieuniatisiii if iiresent, or the original causative disease, must be ti'e!ite(l in connection with the measures aimed at the pericarditis. CHAPTEU XXV ir. DISEASES OF THE PERICARDIUM. Pericarditis. This is an inflammation of tlie pericardium secondary to some infectious disease. Etiology. — The most frequent cause is rheumatic fever. It may also occur in connection with the exanthemata, especially scarlet fever, in various septic processes, in tuberculosis and pneumonia. Direct injury is rarely a cause, and it may spread by continuity from pleurisy. The following bac- teria may act as exciting causes — streptococci, staphylococci, the tubercle bacillus, tlie colon bacillus and the pneumococcus. Pathology. — We may recognize three varieties — the fibrinous, sero- fibrinous and purulent, according to the inflammatory exudate. In the first or adhesive form, the pericardium is covered by an exudation of fibro- plastic matter which may lead to adhesions between the visceral and parietal surfaces. In the serofibrinous form, the pericardial sac contains a serous fluid, together with a fibrinous exudation, which produces adhesions on absorption of the fluid. The serofibrinous exudation uuiy occasionally become purulent, and rarely blood is exuded into the sac. Miliary tuberch's may infiltrate both the visceral and parietal surfaces in the tuberculous form. Permanent adhesions will be produced by the fibrinous exudation being replaced by new connective tissue. More or less myocarditis is present in connection with pericarditis, the same as in endocarditis. Symptomatology. — The subjective symptoms are of such a negative chai-acter that the disease is often overlooked. As it is usually a secondary condition, the original disease is apt to mask the symptoms tliat are ])res- ent and occupy all the attention of the physician. Palpitation of the heart, dysjmea, more or less pain in the epigastric region, rapid, irregular pulse, and increased respirations are usually present. In severe cases cyanosis may be marked. Where pus is ])resent in the etfusion, the temperature assumes a more remittent curve. Physical Signs. — As the rational signs are obscure, the |)hysical signs assuiiU' gi-eat importance in making a diagnosis. In tlic fihious foriu. a superficial friction sound, synchronous with the beat of tlie heart, may he detectcfl. It may be hear'd on systole alone, or with lioth systole and diastoh'. It is usually luore distinct at the base, but it may also be lieard towuj-d the apex, especially at the onset of the disease, and is not transmitted. DISEASES OF THE I^EKKAKDIUII. WM At first, the sound may have a crepitant quality, but later assumes a coarser, rubbing, or rasping character. A friction fremitus may be felt over the region in which the friction rub is localized by auscultation. In the serous form there may be some bulging at the precordial i-egion, depending upon the amount of the effusion. From one to two fluidounces must be present in the pericardial sac in order to produce marked signs. The apex beat is not distinct, being pushed upward and to the left. Where there is extensive effusion, the apex beat may be lost. There will be an increased area of precordial dullness over the distended sac. It may extend on the left outside the mammary line from the seventh rib up to tlie first rib, and from a little to the right of the sternum down to the liver. As in pleural effusions, there will be a slight resistance to the finger on percussing. On auscultation the heart sounds are muffled or feebly heard, and the apex is located with difficulty, if at all. As the fluid is absorbed the friction rub will again be noted and the valvular sounds become more distinct. Diagnosis. — This must be made by a careful examination of the heart in reference to the physical signs just noted. In endocarditis the apex can be located and the soft, blowing murmur is transmitted. Acute dilatation of the heart and hypertropliy will show an enlargement and increased area of dullness, but there will be no friction rub nor signs of effusion, and the previous history will help to throw light on the case. A left pleural effusion, with or without pericardial effusion, may raise a difficult point in diagnosis. The flatness from the pleural eff'usion will not extend over the heart and sternum if tliere is -no pericardial effusion, but, if both are present, the extensive dullness and feeble or absent heart sounds will afford a probable diagnosis. Prognosis. — The immediate outlook is good except in the septic and purulent forms of the disease. The heart may, however, be permanently crippled in the case of extensive adhesions. Treatment. — The child must be kept perfectly quiet in the recumbent position as in all other forms of acute heart trouble, and milk or other bland food given. Tumultuous action may be controlled by an ice-bag over the heart. Small doses of iiiorphin or eodein may be employed to quiet and strengthen the heart's action, to control pain, and relieve restlessness. If the heart is weak and unsteady, strychnia, caffein, or alcohol may be em- ployed. Where effusion is extensive enough to seriously en^barrass the action of the heart, aspiration may be considered. We have seen a case of sudden death, however, due to a slight puncture of the heart muscle where this operation was employed. Eheumatism if pi-esent, or the original causative disease, must be treated in connection w'tli the measures aimed at the pericarditis. 392' DISEASES OF LIULDKEN. Instruments of Precision as Aids in Diagnosis of Cardiac Conditons. There have heen no startling advances in our methods of physical diagnosis since the days of Skoda and his pupils, and we are only now, through the use of scientific instruments, adding valuahle record findings to tliose of the unaided senses. Tire use of the polygraph and cardiograph have proved of great value in correlating physiologic and clinical data, and give recoi'ds which are true for all time, and only require correct interpretation. These records have stimulated closer study of the heart and the circulation, so that the anatomist, pliysiologist, pathologist and clinician have all ]irotited thereby and developed newer conceptions of the intricate cardiac mechanism. With these instruments it can be shown definitely whether the cardiac rhytlnn is normal ; if normal, whether the arrliythmia is due to respiration or other influences; whether ventricular contraction follows auricular con- traction as it should: whether the excitability of the heart is normal. It is possible to study the functions of the cardiac muscle, namely, tonicity, rhythmicity, contractibility and conductivity. Thus far, the function of conductivity is best understood, and we find it disturbed in the usual forms of pulse ii'regularity. A study of the tracings tells wiiether the irregularity is due to heart block, fibrillation of the auricle, or extrasystole, and, if the latter, which one of the three varieties of extrasystole is present. If the lesion is in the auriculoventrieular bundle, and is so extensive as to cause complete "lilocking" of the stimulus, then ^•entricular con- traction does not follow that of the auricle, as it normally should, resulting in what is known as "heart-block." The dissociation between auricle and ventricle may he absolutely complete (the auricle heating inde]iendently of the ventricle and i-icc rersn) or the ventricle may beat to every second, third or fourth aui-icular contraction. When making a physical examination of a patient with heai't disease, perhaps the least important for the patient is the determination of the pre- cise valve involved. The examiner should endeavor to determine the exact power of the heait io respond, to studv the functionating abilitv of the myocardium and obtain data of the cardiac activity. These facts, in con- junction with the physical findings as to size, possible dilatation, or organic lesion, enable the ph\'sician to form a much more precise o])iuion as to the ))rognosis, while bis treatment, at least, is based on scientific facts and can be controlled h\ further observations. SECTION IX. DISEASES OF THE BLOOD AND DUCTLESS GLANDS. CHAPTER XXVJll. DISEASES OF THE BLOOD. Glossary. Corpuscular Elemekts. Erytlii'ocytes re(l(i Plates l."i(l,(|{|(l to :;(IO.(l(i() The color of liliKid is due to the |iresence of hemogloliin, an m'ganic coni]>ound of iron. When ot normal intensity, this color is given as Kill i)er cent. The color- index of a specimen of blood is obtained by dividing the per cent, of hemoglobin by the tier cent, of red blood-cells. Xormallv. the cdlor-inde.x is ,. , ,'' =1, 100';^, r.b.c. The specific gravity of blood is highest in the new-born ,ind during the tirst week or two falls to its lowest iioint. It remains low during the Hrst two years of life, averaging l.o.-iO to l,(iri5, then gradually increases ;is ])uberty is reached. In adtilts the s|iecit1c gravity is about l.orill. The s|iecitic gravity varies directly with the amount of hemogloliin present. Keb nrooD-CELi.s ( er.vthrocytes ) are most numerous |ipr cubic millimeter in the first twenty-four hours of life, Uayem estimating the number to be r),cit)0,0OO, This mimlier gradually falls during the days in which the infant loses weight. About the seventh day the average number per cubic millimeter is 4..500,()00. This is the average number of cells thr RED CELLS are not normally fcmnd in infants. Tn prematures they may be found for three or four days. There are three varieties of nucleated red cells: (li Xornioblast wliicli resembles .1 normal red cell in all particulars except that it is nucleated; (2) Megaloblast — a large cell 10 micromillimeters to 20 micromillimeters in diameter — seen only in severe anemias; (.3) Microcyte which is smaller than the ordinary red cell ; this form is rare. White hlood-corpuscles (or leukocytes) vary in size from the size of a red cell to two or three times that size. In the fresh state the larger ones present ameboid movements if kept at body temperature. In stained s|)eciniens the fol- lowing forms may be recognized. (1) I'olynucle.ars (or pol.vmorplionuclear neutro- lihilic leukocytes): these constitute about two-thirds of all the white cor[)Uscles in normal adult blood. In infancy, they occur in about 18 to 40 per cent. Stained by Wright's method, the mieleus takes on a deep navy-blue color. The nucleus is very irregular in shape, no two being alike. The protoplasm stains jiiuk. The average size of these leukocytes is IS.-j micromillimeters. (2) Lymi)hocytes. stained by Wright's method, show a small oval nucleus about the size two or three times this .size, and so are named large or small. In the large variety, the nucleus ma.v be placed eccentricall.v or indented, and the i)rotoplasmic rim m.ay be much wider than in the small ones. The average size of large lymphocytes is 1:'. micromillimeters; of small ones 10 micromillimeters. (3) Eosinophiles also have polymorphmis nuclei of much looser structure and larger granules than the polyuuclears. With Wright's method the nucleus stains a light lilue or lilac and the granules a brilli.int pink, the protoplasm stain- ing a pale liluc. The average size of eosinoiihiles is 12 microniillimeters. (4 1 .MasI cells are nliuut twice the size of a red cell. i.e.. 1.5 micromillimeters. The nucleus is usually pnlymorphous. Large granules (staining dark blue or .ilmost l)lack ) lie (iver and around the nucleus and along the margins of the cell. (.5) Myelocytes oci-ur only in pathological c;inditions. These are lione- niarrow cells, and .are the forerunners of the polynuclear cell. It is a arge cell, the average iliameter being iri.7.j micromillimeters: it differs from the large lymphncytes in having granules; it differs fi-om tlie polyuuclears only in the shape of its nucleus which is oval and not broken up and which is in cln.^c contact with the cell wall for a l.irge iHirtimi of its extent, i.e.. if egg-shaiieil it is placed eccentrically. According to Ilayem. the number of leukocytes per cubic millimeter during the first fort.\-iMght hours of life averages 18.000; falls to T.OtlO for the third and fourth days; and aver.ages O.llOO to 11.0(1(1 after the lifth day. The counts of 8chiff. Orunsky and Rieder run considerably higher than this. The following table (by Wile) gives the relative percent.igc of iiolynu.'lear's and lymphocytes in the blood during the Hrst ten years: DISEASES OF THE BLOOD. 395 Age in Polyniicletir years neutropUiles Lyinphocytes 1 'Si°/o 53% 2 38% 51% 3 42% 47% 4 47% 41% 5 52% 39% C 52% 37% 7 53% 35% 8 54% 33% 9 , 55% 31% 10 00% 30% Leukocytosis (or liyperleukocytosis), i.e., an increase in tbe number of white blood-corpuscles ]ier cubic ujilliuieter, i.s present iu the following iiatlio- logical couditions : I'neunionia, diphtheria, pertussis, scarlet fever, erysipelas, rheumatism, acute rickets, septic and cerebrospinal meningitis, and in pus cases, such as appendicitis, peritonitis, empyema, osteomyelitis, and acute abscess. In the above couditions the increase of cells is in the polynuclears and is known as polynucleosis. Leukocytosis is also physiological ; (■.., ■a O •^ ,r o p k.+^ 1. ^^% t 5a 1 Tfl ci' o^ a tf -^ M T/ ^ t-( O a 0) a t>i a iS E: n a a 0; 3 03 a a S S «i %'"'% a K = a a> t*. a ■a c 03 , 0) . •73 03 OJ a 3 ^ o o tH (!■ a 03 a 'A rt M -o 0) a M a -Sii (>■. a =^ .a o 0) Q y s i^ ■Sag Ml a . C3 3 ^ CU " "-iZl K g ei 5^^ ■^ ^r:^ -! '^ :=> ? == p: i ;:^ ^J J ft ft r* I o 9 H O P H o rf ri o Sf i o ^'i ■73 a o S d ® 0^ lO ^ M O rt »-H ^ — • i
  • i — ' -in t>i 1 i- "iJ 13 g a 3 o ^ S t-i a >^ o a- >i il 3 iH 5 '^1 ZS a £ i;- c^ d O +j ^ ^ ::2 OJ t^ oJ ht 3 ■—• O !::) ^ "A ^ a d a « -/;' m rfi ^ O o; i '/ o .- JS i' a -■ gl ft a iC' " 1i^ 1-J S i r-. 'dH a O _|02 ' DISEASES OF LlilLDliES. Treatment of the Anemias. Tlio general manafjement of these cases is of greater importance than the administration of dings. Tlie causes wliich have produced the anemia may or may not be clear, bnt the majority of cases are in all events bene- fited by a regulation of their daily life. If the causative agent, as para- sites, is found, treatment should be directed toward its removal. Sunshine and fresh air coupled with an easily assimilated diet as rich in proteids and organic iron as possible, should be considered as necessities for all the anemias. Aerotheraphy may be limited by the circumstances as in the case of the poor city child, but five hours a day in the open air can always be obtained even in the winter months by using the child's room, the roof, or the parks. The children are more benefited when removed to the country. If the child has been attending school, this should be discontinued and the amount of exercise curtailed. Rest in bed is necessary for the severe cases, but this should not preclude sun baths and fresh-air treatment. If possible the child should be cared for and entertained by one person so as to avoid undue excitement or fatigue. A bottle-fed infant should gain in weight and strength if the formula is suitable to its requirements. If assimilation is at fault a wet-nurse may be required, or such changes and additions should be made to the food as will at least temporarily promote the digestive capacity. (See article on Infant Feeding.) Older children should have an individual diet list prepared for them which will contain especially such articles as fresh raw milk, eggs, green vegetables, rare meats, and fresh fruits. (See Diet Lists, p. 163.) Spin- ach, yolk of egg, and tlie legumes contain organic iron in largest quantities, and it is desirable that the deficiency in iron should be made up from the natural foods rather than iron preparations. Drugs. — In chlorosis the iron preparations are of distinct value, especially when given with a nutritious diet and baths. Many of the anemias are benefited by the scale preparations, especially the citrate of iron and ammonia and the bitter wine of iron. Several trials may be required to find the preparation of iron best suited to the individual case. The various peptonates often do well, as they are easily tolerated by the stomach, but other cases will apparently do better on the old tincture of the chlorid of iron, well diluted and given through a tube. In older chil- dren, Blaud's pill will often do good service. Fowler's solution should be given in addition to the leukemias and in pernicious anemia, beginning with DISHASIW OF TJIK BLOOD. 403 one ilrop tliree times a day well diluted and gi'adually increasing to the physiological result, care being taken not to produce symptoms of arsenical neuritis. Cod-liver oil is a valuable addition if it is well borne and does not produce an aversion to the ordinary diet. X-ray thera])y in massive doses is applicable in selected cases. Xo arsenic should be given during this treatment. Several of our severe secondary aneuiias not due to any recognizeil underlying cause, which Jiave resisted all otlier forms of treatment, have been cured by transfusion of whole blood by the syringe-canula method. The method is not advised in the well-advanced cases, as it only tends to hasten the e.xitus. Purpura. In this condition subcutaneous hemorrhages, petechial or ccchymotic in type, appear spontaneously and form one of the symptoms of a disease. Different names have been applied varying with the location and extent of the hemorrhages. It is known as purpura simplex when the hemorrhages occur into the skin only, and purpura hemorrhagica when bleeding takes place into the mucous membranes or internal organs. Etiology. — Any infectious process at any time during its course may be accompanied with purpura. It especially occurs in cliildren with scarlet fever, variola, measles, cerebrospinal meningitis, and with septic processes in any organ. Pathology. — Hemorrhagic exudates may be found varying with the type of tlie disease either in the skin, mucous membranes, or internal organs, or in all of these situations. The spleen is enlarged in those types occurring with marked infection. The study of the blood has thus far thrown no light on the pathology of the disease. Further study of the adrenal bodies, which sometimes show large hemorrhages, may explain the etiology of the disease and prove whether it is an infectious process, a pathological change in the arteries themselves, or whether it is due to vasomotor changes that allow the hemorrhage to take place. Purpura Simplex. — The purpura may appear suddenly in a child that is apparently well, but as a rule it is preceded by prodromal symptoms resembling those of intestinal disturbance. There may be lassitude, loss of appetite, even nausea or vomiting. The stools may be slimy from improper digestion, and a low grade of fever is present in older children, but little or no variation is noted in infancy. The tibial surfaces are usually first involved, the hemorrhagic areas varvine; s;reatlv in rxtent in different sub- 404 DISICASES OF CIIILDREX. jeets. The color soon L-luiiigt'S from a inirplisli-red to a dark, mottled, bluish-black. There is no pruritus nor j)ain on pressure over these areas. Indefinite muscle or joint pains are c(nuplained of, but localized with dithculty. In cachectic or marasmus infants it is not uncommon to see these hemorrhagic areas appear over the abdomen or extremities. In anv long- standing or exhausting disease in the early months of life, purpura luay appear and must be regarded as of serious import. In older children, howe\er, purpura simplex tends to i-ecovery, although relapses sometimes occur ivlien the outlook seems most bright. Fig. no. — I'uriiurii liemorrlnijirica. Purpura Hemorrhagica. — In contrast to the simple form, this is a much more serious condition w ith a ratlier severe train of symptoms. iVfter a few days of indisposition, uitli iiaus(?a and vomiting, fever appears, rang- ing from 100° to 104° F., with prostration out of ])roportion to the symp- toms. At the same time that the licmorrhages ajipear in the skin, there may be bleeding fi'om the nose or mouth. Hemorrhages in the alimentary ti'act may occur and are noted by finding blood in the vomitus or in the stools. The fact must not l)e forgotten, however, that the blood may be swallowed au(] later appear in tin.' vomitus or stools. Blood in the urine usuallv occurs in the liegimiing, hut <'eascs wlicii the child is put at rest. Local izi.'d areas of edeuui may be present and. as a rule, correspond to. Disi:A,sj:s OF the elood. 405 altliough greater than, the heinorrliagic areas. Pain referred to the gastric region, headaclie, and anorexia are quite common symptoms wliicli persist in spite of treatment. Sleep is broken, and delirium, especiall.v at night, may occur. Coma resembling that of the typhoidal state occurs in tlie severe cases and may persist until a fatal issue takes place. Henoch's Purpura. — This symptom-complex, occurring as a rule in childhood, was first described by Henoch. The symptoms referable to the skin consist of a purpura of varying degree, often accom]ianied by an exudative erythema and urticaria or a localized edema. Besides the above manifestations, there are lesions in one or more joints which resemble rheumatic fever. Colicky pains, with vomiting and diarrhea, are nearly Fio. 111. — rnrpuru lieiyorrlingica, — fulminant t.ype. always present, but as a rule are not of long duration. As in purpura hemorrliagica, there may be hematuria or hematemesis. Albumin is gener- ally found in the urine. liecurrences are frequent and succeeding attacks may show wide variations in the symptoms. Schonleins Purpura. (Purpura Eheumatica.) — This form is char- acterized by a polyarthritis with tlie symptoms of rheumatic fever and purpuric hemorrhages. Circumscribed edema may l)e present. A varial)]e amount of temperature occurs with the arthritis. Albumin is generally found in t)ic urine. Purpura Fulminans. — A very rare but fatal form of purpura is designated as a fuhninant type. The onset is sudden, occurring with high fever, convulsions or chills, vomiting, and marked prostration. The pur- puric eruption rapidly spreads over the whole body. The urine is scant and contains albumin. It most frequently occurs in children under five years of age, and what was formerly kuo-wn as malignant or black scarlet fever 406 disi:asi:s of ciiildiikn'. and measles probably l)elong to this type. Heiiiorrliages into the adrenals have been recorded. Diagnosis. — The diagnosis of purpura is usually easily made from the hemorrhagic nature of the lesions which do not disappear upon pressure. It is to be distinguished from infantile scurvy in which there arc present swollen, spongy, bleeding gums, and articular pain combined with a long history of cooked food. Prognosis. — Tn certain forms, as the simple and rheumatic, the prog- nosis is favoi-a1)le, although it may persist for several weeks. Hemorrhagic purpura and TTcnoeh's purpura have sometimes been attended with fatal results. The fulminant type is always dangerous to life. Treatment. — This must necessarily be directed to the underlying cause when this is kno\Aai. Eest in bed with a carefully regulated diet, including raw fruit juices, is indicated. Five minims of a 1/1000 adre- nalin solution liypodi'i-niatically may be gi\-en if the hciuorrhages are pro- fuse. In convak'si-ence tbe tinctiiri_' of the cldoriil of iron is im))ortant. Transfusion ot blood should be tried in severe cases by serial treatments. Hemophilia. Hemophilia is an hereditary blood disorder characterized by a tendency to inordinate bleeding fi-om the vessels following a trauma, or spontaneously from tlie cn]iillailes into tlie tissues. It is almost invarial)1y transmitted through the mother, who herself may not liavi' lieen a Ijleeder. The male offs]iring (the first born often escaping) is affected in t1ie proportion of eleven to one of the female. The male mav again transmit the disease through his daughter. Xo charactei-istic blood changes or histological pcculiaritv of the vessel^ has been found. Coagulation is always retarded. The hemorrhages occui' most frequently from the nose, mouth, genital organs, and luno-s. Some trauma to these parts may be the first notice of tbe diathesis or the fact that slight, almost ini]ierce]iti))le blows produce subcuticidar hemorrhages. Following a fall tliere may be internal hcmori'hagcs or bleeding into a joint that may ])i-oduce disability or subsequent anchylosis. Death has occuri-ed from mieoiiti'ollable hemoi'i-bage following circumcision or tbe extraction of a tooth. Treatment. — Marriages in the families of bleeders should be con- trolled or at least due warning of consequences given. Subcuticular hemorrhages are sometinu'S controlled by absolute rest, with ice applications and compression. Adrenalin 1/1000, or 1/.500 adrin DISKASKS OF Till; LiLOOK. 407 solution, may be directly applied. Stypticin in doses of gr. -J offers some hope of control. The gelatin solutions for subcutaneous use are to be deprecated, as they may be carriers of tetanus infection. Warm or rather tropical climates are the safest for the hemophiliac. Serial injections of whole blood — 30 c.c. once every week for six injections — has been of decided benefit in bleeders with recurrent frequent hemorrbages from the nose. Acute lyin|ih:!tic Icnkeuiia ; markings show enlnrgemeut 111' liver and spleen. CHAPTER XXIX. DISEASES OF THE DUCTLESS GLANDS. The Thymus. This smiill, ductless gland, of epitbelia) origin, consists of two lobes coming in contact in the median line. It is located during its greatest development partly in the lower jiart of the neck and partly (jn the anterior mediastinum, extending from the lower ed'jre of the thynjid above to the fo\n-th costochondral articulation below. It is tlius in relation with the trachea above and the great vessels and pericardium below. It is largest during the tirst two years of life and then atrophies, but occasionally it persists longer and may last until puberty. In the course of atrophy it disappears from the neck and remains behind tlie manubrium. Various authorities disagree as to its normal weight. From 14 to 20 grams are said to be the average weiglit during infancy, Imt Roviard finds it much smaller than usually stated. From 100 observations made on the normal size of the thymus in early life, he found it averaged not over .3 grams, in weight. The histological structure of the thymus is similar to that of l.vmph-glands, and it prot)ably functionates as a blood-forming organ. Enlargement of the Thymus. Hypertrophy of the thymus may produce .£;rave effects apparently from prcsstire. Two possible explanations may be offered — first, that the en- larf^i'd thymus pushes on the trachea and thus embarrasses breathing; second, that dyspnea may be eau.sed by pressure on the phrenics or pnettmo- gastrics. It is, however, difficult to prove the latter. Larynfjismus stridu- lous and various forms nf dyspnea, sometimes called " thymic asthma," have been referred to the enlarged thymus. The symptoms may eventuate in sudden death. The diagnosis of enlarged thymus by physical signs is rarely made positively dining life. It may occasionally be palpated by deep presstire over tlie tnp of the sternum and there may be dullness on percussion behind the upper part of the manubrium extending down from both lateral borders of the sternum. The area nf dullness on the sides of the sternum may be unsymmetrical. Status Lymphaticus. By this condition is understood a lowered vitality seen in connection wath enlarged thymus and a general liyperplasia of tlic lymphoid tissue of the body. Sudden death from cardiac paralysis and asphyxia may ensue under anesthesia or fi-nm any intercurrent disease or irritation. Enlarge- ment may be noted of the superficial and deep lymph nodes of the neck, of the follicles at the root of the tongue, of the tonsils, of the adenoid tissue at the vault of the pharMix, and, on autnpsv, of the lymphoid structures nf IDS DISEASES OF THE DUCTLESS GLANDS. 40 Fig. 112. — Marked enlnrsement of the thymus ghmd with its relations; fnmi an infant. 7 months old. 410 DISEASES OF ClIILDUEX. the stomacli and bowels. There may be some enlargement of the spleen^ with hypertrophy of the Malpighian bodies. There may likewise be a proliferation of the lymphoid tissue of the bone-marrow. Drs. Musser and UUom report the pathologieal findings to be practically constant in eighteen cases of status lymphaticus collated from the literature of the subject, consisting of an enlarged thymus, spleen, lymph glands, Peyer's patches, tonsils and pharyngeal tissue. While these conditions were not reported Fig. 113. - Radiograph showing enlarged thynuis in a 14 uios. old child. in every case, the enlarged thymus, spleen, and some of the lymph-glands were constantly fonnd. Cloudy swelling of the liver and kidney were also fairly constant lesions. German patlrologists, especially Yirchow, have noted a lack of development of the heart and arteries. Thus the heart may be small and tlie aorta narrow and thin-walled. With this may be asso- ciated a lack of development of the sexual organs, sometimes reaching the condition of infantilism. Varying grades of rickets, with resulting mild DISEASES OF THE DUCTLESS GLANDS. 411 or severe l)ony deformities, are seen in a large number of cases of status lymphaticus. These children may show a fair amount of fatty tissue, but are usually anemic. Chlorosis or hemophilia may also exist. It is very probable that the disastrous results so often seen in status lymphaticus are due to an autointoxication from a sort of lymphotoxemia having its source in the lymphatic tissues of the body. The importance of recognizing the condition is very great not only in respect to anesthesia, but for guarding the prognosis in any intercurrent mild or severe disease, and as an explanation of certain cases of sudden death without any known cause. The diagnosis often cannot positively be made, but children or young adults with bony evidences of rickets, with much enlarged tonsils and adenoids, with generally hypertropliied lymph-glands, with the male genital organs or breasts undeveloped in the older subjects, together with an absence of pubic hair, should be considered as possible subjects of status lymphaticus. In young subjects, attacks of laryngospasm, in conjunction with a number of these stigmata, will greatly strengthen the diagnosis. Congenital underdevelopment of the heart and arteries is usually accompanied by smallncss of the surface arteries and a small pulse. The treatment consists in careful hygienic oversight, especially as regards food, fresh air, and warm clothing. Cod-liver oil and the syrup of the iodid of iron may be given. The hypertrophied tonsils and adenoids must be earlv removed, but without the administration of an anesthetic. Diseases of the Spleen. The spleen is not uncommonly found to be enlarged in infants and children. Its elastic, distensible structure makes it peculiarly susceptible to enlargement, especially from congestion, infectious, blood, or constitu- tional disorders. Its upper border lies on a line with the ninth rib, its lower border reaching to the eleventh ril). It is a safe rule to say the spleen is not enlarged if it cannot be palpated below the ribs. The position for palpa- tion should be that described on page 42 (see Fig. 15). Inflammation of the Spleen. This occurs, as a rule, from a neislihoring process or from trauma. Peri- splenitis may occur in syphilis, tul)erculosis, peritonitis, and injuries. Older children may refer their pain accurately to the splenic region. In some eases a friction rub is distinctly felt. With the stethoscope ;i eoarse frirtion sound, not unlike that in pleurisy, can he heard. 413 DIISICASKS (IF ClllLDHl.X. Chronic Passive Congestion of the Spleen. This is seen in roiineetion \Yith eul;\i\i,'eiiieiit of tlie live)', tuliereulosis, uud in cardiac affections. Other ENLAEtiEMiiNTs OF the Si'leem. — Sarcoma, altbougli rare, has been observed as a iiriiuary condition. Tbe tuberculous and syphilitic euhirgeuients are nodular and irregular. Primary splenomegaly is acconjpanied by enlarge- ment of tbe liver and anemia. Hydatid <'ysts and aliscesses have lieen reiKirted, but are extremely r.are. Disorders of the Adrenals. Reports of sudden deaths from hemorrhages into the adrenals have increased tbe importance of these structures in early life. In infants they are relativel.v larger, and destructicn of tlieir function, whatever it may be. is attended witli serious results. IIemobritaoe into the Adrenal. — The sym]itians conje on suddenly not unlil;e an acute infection. Thei-e may lie vumiting iinil diarrhea with acute abdominal pain and, in some instances, a purpuric rash. The iiulse is weak, the pallor is marlied, and coma or convulsions may usher in the rapidly fat.-il endings. Addison's Disease. This is extremely rare in e.-irly life and is accompanied by the same symp- toms ; that is, slow- progressive cachexia and bronzing that the glands most frequently affected are the cervical, mesenteric, axillary, inguinal, bronchial, and mediastinal. The majority of child rcn with enlarged glands have cervical adenitis. This is accounted for by the delicate epithelium of the skin of the face and neck and the mucous membrane of the mouth and the pharynx. These being lai'gely exjiosed to irritations, to bacteria, and to traumatism, we find the glands easily overpowei-c(l. It is always necessary to seek the cause or focus of the trouble and, if possible, to remove it. Ecmembering that the superficial glands drain the side of the head and neck, face and external eai-, and that the deeper glands drain the mouth, tonsils, palate, pharynx, and larynx, we have a clue to the initial trovdjle. It is not to be forgotten I hat the ])riniary focus may have (deared ii)i or may have been apparently cured and foigotteu, but still the glands remain enlarged. A cai'cfnl history of tlic ciuptive and infectious diseases must be obtained : anv ii-r-itations of the scalp, diseases of the ear, eyes, nose, throat, gums, or teeth must be taken into consideration. The importance of work- ing backward from the effect to the cause in these cases must he kept in mind. Eithci- the su])erficial or deep nodes may be affected. [Tnder two years of age the e\tei-nal glands arc afr'ected in the majority of cases, and they also have a greater tendency to undergo suppuration. When the latter is about to take place the gland becomes painful and tender and the over- lying skin is reddened. Iiestlcssness and some degree of temperature is observed. As a rule, this takes place during the second week or it may be held in check bv cold applications and result later. A spontaneous discharge of pus does not occur irntil the entire gland has been disintegrated. Occa- sionallv there seems to he no apparent cause except anemia and debility for the glandular hypertrophy, but here we have a valuable cl\ie to the tri'atnient. 0(i 414 nisKASES OF ('Hn,Di!i;x. Tlie glands may at lirst sliow no acute inflaniiiiatdrv clianges; tliej^ grow steadil_y and surely, and do not easily break down. Because of the slow growth and ]iainless tumor, and with no local cause observable, we are justified in presuming the glands to hv tuberculous. The tuberculin test (page 56) should be made. Such a condition by no means signifies that the child has pulmonary tuberculosis, althougli liaving once given entrance to tliese germs, the possibility of an extension is present. The cervical glands may infect the thoracic chain and thus infect tlie lungs. Chronic Adenitis. This may occur as a result of fiiMpient attacks of acute adenitis or from persistent local lesions in the neighboring structures. It is also ol)served in children who are the subjects of status lymphaticus. Tlie glands must be differentiated from tuberculous lymph nodes or those seen in Hodgkin's disease. Thoracic adenitis is in greater part of the chronic type and vci'y often the glands are tuberculous. Loomis examined and found the tubercle bacillus in apparently normal glands. AVe may safely say that in a large proportion of tuberculous cases in children it would appear that the primary infection was in these structures, and that, contrary to Parrot's law, clinical experience shows that the glands may be involved without local lesions in the lungs. In a large number of autopsies in children we have found the medi- astinal and bronchial lymph-glands enlarged, sometimes pressing on the great vessels or against the bronchial tulies. In one case perforation of the cheesy bronchial gland into tlie adjacent lung was tlie cause of death. We cannot describe any definite symptoms invariably produced by these patho- logical glands, but occasionally we do get a persistent irritative cough caused by pressure on a bronclnis or on the recurrent laryngeal nerve, or localized feeble breathing with sibilant rales due to compression of a bronchus. Per- cussion is unreliable, for the dullness may be due to the thymus. Pecur- rent attacks of bronchitis may, however, often be traced to hypertrnphied lympli nodes in the thorax. The enlarged mesenteric and retroperitoneal glands of the abdominal cavity may alone give sufficient evidence of the old-fashioned tabes mesen- terica. The point of entranc(> of tlie offending germs in these cases is through the mucous membrane of the intestinal canal. If we find a gen- eral enlargement of the glands all over the body — a comlition which Legrouz called microadenopath\'. mc have a valuable hint in doubtful cases of general tuberculous infection. On the other hand, the aliseiice of hyper- DISEASES OF THE DUCTLESS GLAXDS. -115 « trophied lympli-glands and the enlargement of the liver and spleen is an important negative sign in chronic diffuse tuberculosis, provided we can rule out s_yphilis by the history of skin rashes, fissures, and the therapeutic test ; for here also we may have enlargement of the superficial glands. The glands, therefore, may assist in establishing a correct diagnosis ; they may point out by tlieir anatomical distribution the source of their own infection, or they may themselves be productive of patliological conditions in adjacent viscera. Treatment. (Acute.) — As lias been above pointed out, the removal of the local focus of irritation is most important. If seen early tlie appli- cation of the ice bag or cold compresses of 50 per cent, magnesium sulphate solution ma)^ cause a subsidence of the process. The application of a 5 to 10 per cent, ointment of ichthyol is also effective. If suppuration lias begun the local application of heat will hasten the process. Incision and drainage are then indicated. Dietetic and liygienic measures arc iniportant. (Chronic.) — Any underlying cause, as a chronic eczema, adenoids, and hyixM'tropliied tonsils, or a sinus, must be removed before treatment can be effective. The syrup of tlie iodid of iron must be given for a long period. The -Y-ray treatment has given some good results. Tuberculous nodes should not be removed unless the extirpation can be clean and thorough. Exophthalmic Goiter. (Grave'fi Disease; Bascdoii's Disease.) This condition, which is rare in early life, is due to an increase in the growth and activity of the thyroid gland. Our cases have occurred at or about the time of puberty, especially in girls of the neurotic type. Hyperemic goiters occurring at the time of puberty must be distinguished from true Basedow's disease. Tachycardia is present in both conditions, but the exophthalmos, tremors and jmrposeless movements are not present. This variety often disappears suddenly when menstruation is well established. Symptomatology. — With the gradual enlargement of the lobes of the thyroid there may be noted symptoms resembling chorea. Nausea and vomiting at the sight of "food may be the first symptom to call attention to the true condition. The child is apt to be irritable, easily excited and depressed if left without companionship. Physical examination will show a well-marked tachycardia, usually with a soft systolic murmur at the base. The eye later has a peculiar fixed, staring look, and is covered by the upper lid'with difficulty. Graefe's sign, or the difficulty of raising the upper eyelids when the child is askeil to look upward, is usually observed. I'rofuse diarrhea which is eon- trolled with difficulty is rather frequent in early life. The sleep is disturbed, and several times during the day the face may become flushed and perspiration appears on the body. Course and Prognosis.— Rarely the course is very rapid and ends fatally in a few weeks. In the majority of cases the prognosis is slow, with steady emaciation and periods of remission. The younger the patient the better the prognosis. 416 DISI'IVHKS OF CHILUKHX. Treatment. — Rest in bed. both physical and mental, with a light milk and vegetable diet is re|iropoi-- tion between the head and trunk and extremities. This is due tu an uh- nornial ])rocess of en(h3i'hondral ossi- tication at the junction of the epiphysis and diapliysis. Tlie ]irin- cipal change is a defective formation of rows of cartilage cells in the col- nnmar zone. There often occurs an overgrowth of periosteum in this re- gion, this tissue wedging its way in between the epiphysis and diapliysis fi'oni the pei'iphery toward the axis of the bone. These ])rocesses hotli prevent growth in length of the hone. Achrondroplasia is a congenital condition, ami the featui'cs are evi- dent at birth ; sometinu'S the parenls are undersized or dwaifed. The extremities are mostly af- fected, leaving the head and trunk nearly normal; the length of the arms and the legs is greatly dimin- ished, the hands often reaching only to the trochanters, while normally they should leaeli to the knees. There is a rei]uiidanc\' of tissues around the thighs, making thick folds in the skin. Muscular tone is low and the joints are l.'ix, cnnsei|uentl\ all these children in-e late in Widkiiig. 'i'he head is relali\"ely large, Ihe liridge (d' the nose is usually di.'pressed, Uie tip of the nose is l)ulbous, the eyes ai'c far apart and Fig. 114. — Achondroplasia (Four-year-old child.) DISEASES OF THE DUCTLESS GLAXDS. 417 in the infant the tongue may be thiek, this being due to a real hyperplasia. As a rule, the fontanels are late in closing; teething also is delayed. The bones are short and thick with enlarged epiphyses; curvature in the shaft of the long bones, which often occurs, is not duo to softening, but to periosteal intrusion, which offers resistance to growth in lengtli of the dia- physes. Frc(iuently a marked lumbar lordosis is present, the sacrum being tilted upward and backward. Beading of the ribs, as in rickets, may be present. The hands are small and square, the fingers being short and nearly equal in length and blunted at the ends. The " trident deformity " (diverg- ence of middle and inde.v-fingers from ring and little fingers) is often noted. The mentality in these children is not affected to any marked degree, al- though they are inclined to be backward. Prognosis as to life is good, but such children are always undersized. Organic extracts from the thyroid and pituitary glands are used in the treatment, although the results have not been satisfactory and are not to be compared in any sense to tliose obtained with cretins. For the diiferential diagnosis see the article on Cretinism, p. 408. Infantilism. This is a condition characterized by a retardation of Ijodily developiuent out of all proportion to the chronological age. These children are always small in stature, underweight, undeveloped sex- ually, and retain the falsetto voice of childhood. Their mentality, however, i.s usually fair and they are capable of making good progress when placed in school. Two types have been distinguished. In the Brissaud type the children are somewhat cretinoid in appearance, the face being flat and chubby, the liody plump, the hair sparse and fine on the head, and there is an absence of pubic hair. In this type, ossification and epiphyseal growth may be delayed. The Juvenile state of the body and mind is long retained. The second, or Lorain type, is distinguished by the rather slender body and finer features, although the genitals and voice remain long undeveloped. The mentality is api)arently unimi)aired in this latter tyjie. Ilerter has recently pointed out that in cases of infantilism an intestinal digestive disorder may be the etiological factor. lie believes the Bacillus infantilis to have a direct relation to the disease. The intestinal bacteria are replaced by gram-positive bacilli. The mal- development is attriliuted to the loss of fat in the stools and the intolerance to carbohydrates. The cretinoid type reacts favorably for a short time to the use of thyroid extract. The Lorain type is not affected by this drug, and we are inclined to favor Herter's suggestion to treat the disease as a nutritional disturbance. Gelatin is reconunended as of value. The diagnosis, however, would need to be made very early in order to obtain good results. Cretinism. (Myxedema.) Myxedema is a disorder of metal)olism, resulting from an alteration or absence of the thyroid bnd\- or its functions. 418 disi:ases of ciijldi;i;x. Cretinism. — Two varieties are ri'eogni/ed : The endemic ami sporadic (infantile myxedema). It is with spora carefully given if there is any Fig. 120.— Rndioffrapli i.f Ijaiicl and arm from Fir;. 120, slmw- ing uudeveloped c.iriials. Fid 121. — Cretin, ase 7 years, un- treated. canliac lesion. It should he given in increasing doses to iul'aiLts, lieginning widi one grain tlii'ee linu's a day, and increased slowly to live grains three times a day. Older chiidi-fii may finally take Iwcntv to thirh' gi-ains in a i|;i\ ir neiT>sar\- an'l if no ilc|n'i'ssing rllVi'l is pi'oduccd. ( .\ c-isc under our oliser\'ation had so far iin]iiT)ved as to locale the liox of tahlets hidd(>n in th.e DISEASES OF THE 11UCTLI;S.S GLAXDS. 42 ;i clock. He ate sixty gi'aius in all. He beeaiiie soinewliat e\aHotie. but quickly revived under tlie intiuenee of stimulation.) The treatment must be continued in fairly large doses, until a decided cliange has been readied Fig. 122.— Cretin, before treat- ment. {Dr. TjOiifi'f: ra<:r.) Fig. ]2o. — Same case ;ifter one year of treatment. and further improveuient does not take place. Tlien smaller do. K.'lrhil i-.. lllin r ]■; Willi |]iiw-le,i;s. l-'H.. rJil.- ■ Kcliili-:. sliowi piScoii-elu'st (lernrniit.w is marbled with enlarged veins and in sliajie is squared in front and Hat-, tened on toj). 'Hie fontanels are late in closing, c\-cii the line of Ihe siiliires being ])alpahle. liosses may he felt in the center ot the ]iarie(al bones iiiid near the base of the temporal bones. At this stage there is generalh an e\-ening rise of bMuperature and an acceliTalcd jmlsi' I'aic. 'The hiid\ \\cii;ht may remain stationary or Ibc increase may be ver\ irrcgidar. jleiilition is NCTTKITIOXAL DISOUDK 437 a very irregular proeess. The first teetli are frequently delayed, sometimes eruijfing only during tlie seeond year, and then with much discomfort. They easily decay, sometimes eroding almost to the gum. Nerroits Phenoiiiciia often develop in the rachitic infant. Among these the most characteristic is lai'yngismus stridulus. This glottic spasm may occur several times a day and sometimes results in carpopedal spasms. In others nystagmus, tetany, or inspiratory crowing develops from the nervous instal)ility. C'on\ulsions are not uncommon and recur froui apparently slight causes. Dcfuniiitie.'i occui' later in tlie disease as a result of the softened con- dition of tile bones and the relaxation of the ligaments. Besides tlie de- forniit\' of the head, the thorax shows marked changes. The rachitic rosary becDiiics iiioi-(' iiuirki'd. (luc t(i a sinl t1ie legs are deformed from the ^^■eight put upon tlicm in efforts to stand or walk. P)Ow-legs, knock-knees, and deformities of the foot are thus produced. The ])cculiar sitting posture of these children someliiues induces curvature of the femur. Fig. r_'i . — Kiioi-ic-lciicc-; a rachitic cliild. structures witliiii. ^'Iie lui rl'JS l)ISi;,\SI';S OF CIIILUKEX. The sjjinc. owing to the relaxed condition of tlie ligaments, bony eliMnges, and deficient muscnlar power, loses its normal curves, eventually becoming bowed fi'om the cervical region to tlie pelvis. Lateral curvatures or scoliosis result from postural positions assumed while being carried in its inotlier's arms. Tlie pelvis may sufiFei' with the remainder of the skeleton, becoming flattened or sboi'tened in its anterojiostei'ior diameters. Tlie hloofl shows no characteristic changes. Simple anemia is always present. The hcmogloliin niav be reduced to 40 or ."iO ]-)n- cent. A moderate leukocytosis is occasionally obtained. Diagnosis. — There is no difficulty in making the diagnosis in well- advanced cases. In the caily stages sweating of the head, anemia, marked restlessness at night, irregular dentition, pseudoparalysis, and a distended abdomen in a child exliibiting abnormal nervous symptoms, are often suffi- cient to suggest the diagnosis. Infantile paralysis may be distinguished by tlie electrical reaction or by obtaining mobility in the ]irone position by irritating the plantar surface of the foot. In hydrocephalus (see Fig. 145) there is a true enlargement, in place of an apparent enlargement, of tlie circumference of the head, with a bulg- ing fontanel. Syphilitic affections arc monoarticular, while many joints are simultaneously affected in rickets. In Pott's disease the spinal deformity is angular and rigid, causing pain when attempts at motion or pressure are made. Course and Prognosis. — The disease itself, wdiile chronic, has a tend- ency to arrest or recovery when changes are made in the dietary and sur- roundings of the patient. But even if a cure results, many of the bony deformities remain. Wiile it is seldom a fatal disease, it influences the mortality in early life because of the lowered resistance wdiich it engender.s. These children more readily succumb to respiratory, intestinal, and infec- tious diseases. Under suitable treatment the disease may be arrested after two or three months, and further bony changes prevented. Xervous symji- toms, such as laryngismus stridulus, are very promptly controlled when the proper treatment is instituted. Treatment. Prophylactic. — The education of mothers and of school girls by settlement workers in matters pertaining to the feeding and hygiene of infants will do much to reduce the number of cases. Freipient regula- tion and supervision of artificially-fed babies by their physicians W'ould prevent overfeeding with too strong formuhi^ which so often occurs among the rnorc intelligent classes. Examination of the breast milk in children who arc not sufficiently developing may show a marked deficiency in the NUTRITIOXAL DISORDERS. 439 protuins or fats. Milk of this character may cause tlie development i)f rickets. Mixed feeding and improvement in the secretion should he attempted by proper food. Dietetic Treatment. — Dietetic instruction for the mother, an out- door life, and cleanliness are the necessary requirements for a cure. The food in the case of an infant must contain a sufficient amount of proteins. If the feeding has been on condensed milk and high dilution or the pro- prietary foods, properly modified cow's milk will in a short time produce a marked improvement. The modifications recommended for difficult cases of infant feeding should be studied in this relation, as the change must be so made that it will be compatible with the defective assimilation which is usually present. Older children should have a diet list especially prepared for them, which may contain fresh raw milk, yolk of eggs, butter, leguminous gruels, and vegetables suitable to their age. Hygienic Treatment. — Provision should be made so that the child may live as much as possible in the open air. In bright sunny weatlier at least fi're hours a day should be spent out of doors. A roof or a room with a sunny exposure and with open windows may be utilized .for this purpose. Daily baths to which a pound of sea salt is added are given, unless contra- indicated by muscular tenderness. Mild forms of massage, breathing exer- cises, and gymnastic treatment given in the second year of life are produc- tive of good results. Medication. — With the exception of cod-liver oil or olive oil, which is of value in older children, drug treatment is of little avail. Iron and arsenic may be given for the anemia after progress has been made in proper food assimilation. If phosphorus is administered, the oil or the elixir may be used, although this drug and the lime salts have not proven of any benefit in our experience. Deformities of the long bones may be prevented by not allowing the child to assume wrong positions and not encouraging him to stand or walk until the softness of the bones is overcome. The rachitic spine is corrected by keeping the child in the horizontal position in bed or on a frame. Surgical measures to correct bow-legs and knock-knees are necessary in the advanced cases. Congenital Rachitis. (AntrnnlnJ Raehitix.) Rarely we see infants born with well-marked evidences of rickets. The rachitic fetus develops the affection in its intrauterine existence, probably during the placental period of nutrition in consequence of disease or starvation in the 27 430 disi:asi:s of ciiilduex. jire,i;n;int mother. The infant is bom with changes in the Iiony skeleton which, altlionsh not well-niarlied. i-esemlile those in a lesser degree found later in rachitic infants. C'raniotalies, enlarged ejiipyses. and beaded ribs may be seen and palpated. Scorbutus. (lufiintilc Snii-ry : Barlou:'.^ Disrasc.) Scorljutiis is a cDiistitiitioiial (lisca!^(' due to a ])rolon(Tc(l faulty diet and characterized by pain and swelling in the extremities, and hemorrhages into the skin and mucous membranes. Etiology. — Proprietary infant foods, the continued use of sterilized and incorrectly pasteurized milk, food almost exclusively of one kind, as condensed milk or cereals alone, are the factors whicli produce the necessary predisposition to intestinal putrefaction and toxemia, and which may result in scurvy after some weeks or months. Although it occurs in children under two years of age, the latter half of the first year shows the greatest number of cases. Malnutrition from food not adequate to maintain devel- opment is also a causative factor of importance. The chemical changes brought about in the food by boiling or evaporation in dry heat for the purposes of preservation are essentially the underlying cause of the disease. The cases occur more frequently among the well-to-do than among the dis- pensary cases, as the latter cannot afford proprietary foods, and much sooner give a mixed diet. Pathology. — Subperiosteal hemorrhages occur in the long bones, espe- cially in the tibia and femur. The epiphyses show similar changes, usually in proportion tn tlie involvement of the periosteum of the shaft. In some cases the periosteum itself, close to the bone, is infiltrated and thickened. The ribs in marked cases show these changes, especially on their margins. The spleen ma>' be found enlarged and licmorrhages occur in the pericar- diu7u, pleura, liver, and into the muscles. Symptomatology. Mild Cases. — Attention is usually first attracted to the infant because it cries when handled. The tenderness is especially marked about the lower extremities. The child is extremely fretful, and usually anemic. It is not uncommon to obtain a history of some fancied injury which may be misleading. The infant will hold the limbs motion- less, usually in a position of flexion, and cries or screams when any attempt to disturb them is made. In some cases only one extremity may at first be tender. No fever and no swelling may be ]U'esent at this stage in the early or mild types. Such a train of symptoms, when present in conjunction with a histoiy nf prolonged feeding with artificial foods which lack the essential quality of freshness, should be suggestive and the therapeutic test applied. X'JTRITIOXAL DISORDERS. -131 If swellings are noted over the epiphyses in one or both extreiuities, with swelling and engorgement of the gums, the diagnosis is quite cei'tain. Aggravated Cases. — In these uni'ccognized or neglected cases, hema- turia may he the first symptom for wliich the child is brought to the physi- cian, or it may have been treated for rheumatism because of the swelling and pain at the ankles. Careful examination will show spongy gums, bluish in color, which may bleed on pressure. If teeth are present the gums override them, and ulcerations may be seen. Anemia is a constant symp- tom. The appetite is lost, the child cries constantly when handled, and blood may appear in the stools. In exceptional cases blood is effused into the joints and the epiphyses may separate. Ecchymotic areas appear under the skin, especially over the swellings on the lower extremities, but may also appear over the ribs. Concomitant rachitic changes may also he noted due to the nutritional faults. About the orbit, conjunctival hemorrhages may be seen or even protrusion of the eye-ball. The face is usually swollen, or even edematous. Albumin and casts are sometimes found in the urine. A collective investigation by the American Pediatric Society gave the following symptoms in their order of frequency: Pain and tenderness of the extremities, sponginess or puffiness of the gums, disability, anemia, cuta- neous hemorrhages, hemorrhage from the rectum and hematuria. Diagnosis. — Infantile scurvy is rarely mistaken by tliose who are accustomed to obtain a good history and who make a sj'stematic examina- tion. Traumatism, acute infectious arthritis, and osteomyelitis are differ- entiated by the swelling, which is mainly over the shaft of the bone, the absence of temperature, swollen gums, ecehymoses in the skin, pseudo- paralysis, and blood in the urine and stools. A radiograph will in ques- tionable cases complete the diagnosis. Course and Prognosis. — The prognosis is very good when the disease is recognized in its early stages and prompt treatment instituted. The development of rickets or extreme malnutrition may delay the cure in aggravated cases. The great majority, even the neglected cases, recover under anti- scorbutic treatment. Beneficial results are noted after a few days, the mild types showing remarkable changes within a fortnight. Treatment. Prophylactic. — The disease can be prevented by the use of some orange juice and untreated cow's milk in the dietary. Over- anxious mothers should be warned against repasteurization of their infant's milk supply. Since so much of our milk is now pasteurized, some orange juice should be given in conjunction with the formula, at least at the sixth 433 DISEASES OF C'lIlEDKEX. month. Milk treated by the holding method of pasteurization is not likely to cause scurvy. Dietetic Treatment. — Tlie food should be abruptly changed ; fresh raw milk, properly modified, is allowed. Orange juice, one ounce daily in divided doses, and expressed beef juice about one ounce during the day, in addition, are readily taken. Older children should be given mashed pota- toes and minced vegetables, such as carrots or spinach. The limbs are encased in cotton wool and supported on a jiillow until the tenderness dis- appears. Unnecessary handling should he avoided. Removal to the outer air should be made with the infant in its crib or on a pillow. The anemia needs no drug treatment, as it disappears under the dietetic management outlined above. Marasmus. {Infantile Atroph;/ ; Athrepsia.) Marasmus is a very common functional disorder in infancy, character- ized by extreme emaciation resulting from inability to assimilate food. Etiology. — This is still obscure. Tt is usually seen in the first year of life. The greatest number of cases appear in institutions and in dis- pensary practice. Undoubtedly^ food poor in quality and given in great quantities, coupled with unsanitary surroundings, have a distinct otiologic bearing on the development of marasmus. If the digestive secretions have not been sufficiently developed by proper food, or if they have been over- produced for some time in efforts to digest abnormal food constituents, then the disorder may insidiously appear with symptoms of acid intoxication. It is rarely seen among breast-fed infants unless there is a marked perversion of the supply. Pathology. — The gross lesions found in even a well-marked case of marasmus are surprisingly few. Microscopically, nothing characteristic can be described. The body is devoid of adipose tissue. The muscles are soft, pale, and thin. The overlying skin is dry and wrii"ikled. Hemor- rhagic areas are frequently seen beneath the skin and sometimes in the mucosa of the gut. The lungs are frequently involved, showing either bypostatic pneumonia, bronchopneujnonia, or atelectatic areas. We have found these often in combination. The liver is somewhat enlarged and fatty. The spleen may be soft, but is not enlarged. The kidneys show dec;enerative changes or at least a cloudy swelling. The heart is small, with pale muscle fibers. The mucous membrane of the intestinal tract is extremely thin and pale. The stomach is usually dilated, and its lining is covered with ropy mucus. The agminate and solitary follicles stand out NUTRITIONAL DlSOEDEIfS. 433 heard, most noticeable at the apex and traiisniitted toward the axillary more prominentl}' and give the " shaven beard " appearance. The villi are not easilv found, or in some cases are entirely absent. The lympli nodes are enlai'ged. In some cases connective-tissue changes take place in the intes- tinal mucosa in isolated patches. Symptomatology. — The ti'ain of symptoms begins insidiously. The mother usually brings the infant because she has noted emaciation in spite of the fact that the food has been the same or even increaseil in auiount. The loss of weight, if recorded, is found to be steady but constant. The jnuscles be- come soft and flabby. The skin is loose and wrinkled. The facial appearance changes, due to the loss of fat, with a wrinkled fore- head and sunken cheeks. The fat pads over the buccinators in young infants remain, however, almost to the end. The .abdomen and thighs show the emaciation quite early. The skin feels harsli and dry. and has lost its elasticity. The muscle tone, especially over the abdomen, is lacking. The emaciation progressing further, gives an " old man " expression to the face. This outward wast- ing that takes place corresponds with changes in the heart muscle. The pulse becomes weak, and an- emia of a simple kind is present. A striking featui-e is the in- satiable appetite. The infants will take an enormous quantity of food and still cry as if unsatisfied. The stomach dilates and vomiting may occur. The abdomen is distended with gas, and the liver may be palpated well down in the abdomen. The stools vary considerably. As a I'ule, they are mixed in color, with a greenish- yellow cast pi'cdominaling. Thoy contain much unchanged food, and the l)ulk is decidedlv increased. The odor is musty and foul and almost charac- Vw. 12S. — Marasuuis. 434 DISKASES OF CHILDREN. teristic. Diarrliea may follow after several days of constipated movements. Erythemata in the napkin region develop and persist. The temperature is rarely much above normal, although subnormal readings are not uncommon. The thirst in some cases is extreme; the infants have a red, dry, and glazed tongue. A finger or the hand is sucked continually, which the mother attributes to hunger. The cry is a low moan or whine, and is not repressed when attempts at comforting the baby are made. In fact, it often cries more when disturbed. As the disease progresses the emaciation becomes extreme: the child resembling a living skeleton. The fontanel and eye- balls are sunken. Excoriations and bed-sores develop easily. Stomatitis is not infrequent. Otitis may develop. The breathing becomes shallow and feeble. Pneumonia, usually of the hypostatic variet_y, or convulsions, frequently liring on the fatal termination. If the disease is arrested, the improvement is noted first in the station- ary weight and improved condition of the stools. Later slight gains are maathology of diabetes mellitus are as obscure and uncertain in the child as in the adult. Symptomatology. — Among the earliest symptoms noted is an e.Kcessive thirst. A child who has been previously well-nourished, besides drinking great quantities of water, is seen to be listless or irritable, easily tired and with a large and capricious apjietite. Failure of nutrition and strength soon follow, and in a short time, jiossibly within a few weeks, the wasting becomes very appreciable. The urine is passed fre treatment of nephritis. The |)rincipal treatment must naturally be aimed at tbe original con- dition iliat residis in keeping up the congestion. disoi;i)i:jis of tre uuine and kjdxeys. 445 Nephritis. In attempting to classify the various forms of nephritis fj'oiii the stand- point of morbid anatomy, the student at tlie bedside will be mueli con- fused. It is often impossible to diagnosticate the anatomical varieties of nephritis l)y either a study of the clinical symptoms or of the urine. The physician frequently cannot tell whethei- he is dealing with acute conges- tion, acute degeneration, or acute glomerulonephritis of a mild type. From the standpoint of treatment, it is not very important to attempt to sharply differentiate these various distui'bances. Xephritis will he liere considered only as acute or chronic, althougli the synonyms will show the lesions that may pi-eponderate in each condition as far as the epithelial, interstitial or vasculai' tissues of the kidnev are concerned. Acute Nephritis. {Acute Pnrpnchjjmriioiix Ncpliritifi: Acute E.rudatice NcjilirHix : Acute Desf/vamative Nephriti. point of inflammation in striving to eliminate noxious products. Thus the colon bacillus may be the irritating agent. Cases that are considered primary are doubtless usually due to some infec- tion that is obscure as to its point of entrance. The kidney lesions mav he started by the toxins generated by infectious bacteria or may he caused by the direct action of the organisms themselves, in which case the disease assumes a severe type. Exposure to cold and wet may cause nephritis, possibly bv checking the action of the skin and thereby throwing extra work upon the kidneys, or possibly by lowering the vitality so tliat various bacteria will grow sufficiently to infect the body, as in tonsillitis. Thi^ continued ingestion of drugs irritating to the kidney, especially chlorate of potash or the carbolic acid series, may induce nephritis. Pathology. — The kidneys are usually congested, soft and somewhat enlarged, the cortex being swollen and presenting the appearance of cloudy swelling. The pvramids generally appear congested. In other cases the 28 446 D.SHASES OF CIliLDJtEN. kidney shows little apparent change to the naked eye. Under the micro- scope, changes may be noted in the epitlielial, interstitial or vascular tissues. The various names have been given .to tlie nephritis according to the tissue that is preponderatingly aiiected by tlie inflammation. AVhen the glomeru- lar lesions are most marked, it may be called glomerulonephritis; if the glandular, epithelial cells in the tubules are mostly affected, we have parenchymatous nephritis: if the stroma is principallv affected, it is named interstitial nephritis. Wlien all the anatomical structures of tlie kidney are markedly involved, it is called diff'use nephritis. The renal cells of the tuljules. as seen under the microscope, show cloud}' swellings degeneration and sometimes des- quamation. Tlie tubules may be filled witli casts. In the glome- rular type, the cells covering the capillary tufts undergo swelling and proliferation. The cells mak- ing u]) the capsules of the Mal- pigliian bodies may likewise un- dergo proliferation. There may be an infdtration of the stroma, with leiikocytes and ]ilasma cells and a production of new connective- tissue cells. The blood-vessels of the affected part are engorged, and there may be a proliferation of llie cells of tlie capillaries. Symptomatology. — In early life, nephritis most frecjuently oc- curs as a secondary condition in tlie infectious diseases, especialh^ in scai'let fever. It may come duiing the lieiglit of the ]n'imary disease or wlien the latt(H- is subsiding. In scarlet fever it is more apt to ensue during the period of des(|uama- tion in 1he tlijrd and fourth week. The urine becomes scanty Avith a reddish-l)i'own, smoky discoloration fi'om the presence of red hlood-cella or hemogloliin. Albinninui'ia is present, usually in marked degree; it may he so extreme as to change the ui'ine into a solid on lioiling. The urea is only partly exci'cted by the crippled kithieys, and hence accu- Fio. lol. — Puffiiiess of the face and edema of tlie extremities iu a case of acute nephritis. DISOKDEHS OF THE UKINE AND KIIJXEYS. 447 mulates in tlie l)loo(l. Tlie amount of uixa ilaily found in tlie urine is thus below normal. Tlie specific gravity may be diminished, but when the urine is loaded with albumin it usually is as high or higlier than in normal urine. Epithelial, granular and hyalin easts ai'e usually found in abundance. Renal epithelial cells, red blood-corpuseles and leukocytes are also present. The temperature in nephritis is not ajit to be very high, perhaps averaging from 101° to 108° F. ; if it goes much higher — ■ such as 104° to 105° F. — it sliows a severe type of the disease. The nei'vous symptoms vary with tlie severity of the attack. In mild cases there may be only apatliy or restlessness and slight headache : in severer cases there is worse headache, dimness of sight, stu]3or, coma, or convulsions. A higli tension pulse usually precedes the sym])toms of uremia. The graver ner- vous symptoms usually come in connection with scanty or suppressed urine and they disappear as the secretion liecomes more abundant, with a lessening of the amount of blood, al))umin and casts, and a freer elimination of urea. The cereliral symptouis may be caused by a general edeuia of the brain or bv a compression of tlmt oi'gan by an effusion of seniiu \\ itliin the ventricles. The principal gastroenteric symptom is vouiiting, witliout much or any nausea, and occasionally diarrliea is seen in the uremic state. More or less dropsv, due to a transudation of serum caused by the altered condition of the blood, is one of the commonest symptoms of the disease. It usually begins as a slight anasarca of the feet and ankles from whence it may extend np the legs to the scrotum and finally to the trunk. An effusion of serum in and around the internal organs with grave residts may take place in the following usual order of fref|uency — edema of the lungs, effusion into the pleural and iieritoneal cavities, into the pericardia] sac. into the brain, and finally into the loose connective tissue of the larynx producing that alarm- ing and fatal condition, edema of the glottis. The anasarca is apt to pre- cede these internal effusions but this is not invariably the case. It is evident that dropsy as a symptom may induce little or no discomfort to the patient or seriously threaten his life according to the part of tlie bodv affected. The tvpcs of nephritis seen in different infectious diseases show some difference as far as the symptom dropsy is concerned. Thus in scarlet fever there is early seen a puffiness under the eyes and a swelling of the limbs, while in diphtheria it is rare to see any anasarca, even with a severe nephritis. The nephritis rarely seen in infants and young children, independently of the acute exanthemata, is sometimes called the primary form. This means only that the exact source of the agent that infects the kidneys is unloiown. It may come from the tonsils or gastroenteric tract. Doubtless the colon bacillus is frequentlv responsible. The few cases reported in 448 DISEASES OF CHILDREN". iufaiicy liave usually shown an abrupt onset, liigli fever, vomiting, and some- times diarrliea and a liigli mortality. In older cliildren, the onset and course are less severe and the prognosis better. Dropsy is reported as uncommon in both varieties in so-called primary nephritis. The average duration of acute nephritis is from one to thi'ee weeks. The improvement in symptoms, and clearing up of the urine is gradual. ?^epliritis is usually accom]ianied and followed by marked pallor and anemia. While there is always diminution in the amount of urine, complete sup- pression is compai'atively rare. The latter may exist for many consecutive hours and yet be followed by recovery. An examination of the bladder must always be made to he sure that retention is not interpreted to mean suppression. Complications. — The most frequent complications are referable to the heart and lungs — in the former, endocarditis and pericarditis; in the latter, pneumonia and pleurisy. Tn rare instances meningitis may supervene. Diagnosis. — The recognition of the disease must rest princi]ially on careful examinations of the urine. Tt may be suspected when moderate fever and pallor exist without apparent cause. Prognosis. — The younger the child, the worse the prognosis. After three or four years of age the prospect of recovery is good, especially if a fair amount of urine is passed and there are no marked evidences of uremia. If, however, there is a large number of casts present with a tendency to suppression, the outlook is graver. The mere amount of albumin passed is not of so much prognostic value. While a majoritv of the cases undergo complete recovery, there is always the possibility of chronic nephritis super- vening. This must be borne in mind in giving the ultimate ]irognosis and the urine should be examined at intervals for a long time so that such a condition mav be earh' recognized. Children nui\' have a subacute or chronic nephritis with very few symptoms, and hence the condition may b(^ overlooked during a long period of apparent health, or until an acute exacerbation brings on a serious or fatal result. Treatment. — Children suffering from infectious diseases, especially scarlet fever, should he handled carefully as far as the organs of elimina- tion are concerned — particularly the bowels and the skin. In this way the kidneys will be saved some of the irritation induced by the effort to eliminate the toxins produced by the original disease. Best in bed, keeping the skin warm, and the use of mild saline laxatives, witli milk and farina- ceous foods will usually be sufficient for this pur]iose. When nephritis supervenes, in spite of such care, more active measures must be employed. DISOUDEIiS OF TIIK UltlXE AND KJDN'KYS. 'll-' These resohe tliciuselves inlc a freer use oi' eathartie.s, (iiiifetics and diapliorcties, with a fluid, unstimulating diet. The action ol eathariies is usually more certain than other agencies. Caloiuel in doses of one or two grains is a good cathartic and diuretic as well. Citrate of magnesia, a few ounces at a dose, and compound jalap powder, ten grains to a child of five years, given every few hours, will |)rove helpful in relieving the kidneys through the bowels. Unstimulating diuretics, such as the citrate and acetate of potash, from two to five grains every two or three hours, are valuable remedies. A teaspoonful of cream of tartar to a glass of water, drunk freely from time to time, is a pleasant diuretic. Plain water, given freely, is one of the most constant and valualile diuretics we possess. It should always be frequently given in cases of illness of all kinds in children to insure a free action of the kidneys. Tlie alkaline effervescing waters, such as viehy, will sometimes be taken in preference to plain water. Most of the diuretic remedies have diaphoretic effect when the skin is kept warm, while if the surface is cool the latter is lost and the result will be exclusively diuretic. In urgent eases, the muriate of pilocarpin will often liave a most beneficial effect in producing free sweating and hence in relieving the engorged kidneys. To a child of three years, gr. l/fiO or even 1/50 of a grain may be given every five or six hours until results are obtained. It may be given hypodermatically if a r|uick effect is desired, but, as it is depressing, stimulants must be given at the same time. The infusion of digitalis has a diuretic as well as stimulating effect, but it sometimes tends to upset the stomach. The hot pack affords one of the most convenient and efficient methods of acting on the skin. A blanket is soaked in hot water (110° to llo° F.) wrung out and packed around the patient's body. Hot water bottles are put in position and the whole is surrounded by a dry blanket. The skin is soon bathed in a profuse perspiration, and this may be repeated several times in the day if necessary. Hot saline injections (10.")° F.) given with a fountain syringe and soft eathcter, or a double current tube, have a very heneficial effect in favoring kidney action. One or two quarts may l)e thus employed several times a day. During convalescence, some preparation of iron, preferably Basham's mixture, should be given for the anemia that always ensues. The diet all through the disease must consist principally of milk given freelv. Some of the variations of milk often do better than whole milk. Thus skim milk, buttermilk, milk and vichy, kumyss, junket, , a purely local irritation involves only one side. The inflammation involves the mucous meml)rane of the pelvis and is of an acute inflammatory nature with congestion and infiltration of the cells and occasionally punctate hemorihages. Pus is formed and passes out with the urine. Tt may quickly collect in such an amount as to distend the pelvis and calicos of the kidney, thus leading to pyonephrosis. A pyelitis that persists is accompanied by more or less nephritis. The colon bacillus is found best in a catheterized specimen. Symptomatology. — These are somewhat irregular in character. Pain nui\- lie a prominent symptom, especially noted during urination. In other cases thei-e is no evidence of local discomfort and not much besides pyuria to indicate the disease. A moderate, continuous fever may be present or, perhaps more often, the temperature assumes an intermittent character and nuiy be accompanied by chills and sweating. In all cases of unexplained fe\'er in early life with cachexia, this disease may be suspected and the urine cai'cfully examined. The urine is turbiil. with an acid reaction, and contains hlood- and pus-cells and epithelial cells desquamated fi-orii the pelvis of the kidney. Albumin is present, sometiiues from the pus and at other times as an evidence of accompanving nephritis, when epithelial, granular,, or hyalin casts are also found. The urine is usually swai'ining with bacteria. If the pyelitis is of tuberculous origin, tubercle bacilli will be present in the urine. Occasionally large quantities of pus will be dischai-ged into the urine from an abscess rupturing into the ])ilvis of till' kidney. If the disease becomes chronic, jniria nuiy be the only constant symptom to be noted. There are also apt to be evidences of MSOUDEUS OF THE UBINE AND KIDNEYS. 45,") failure of liealtli and emaciation in tliese cases. An e-xaniination of tlio blood in pyelitis usually reveals a leukocx'tosis. Diagnosis. — 'J'liis rests finally on an examination of tlie urine^ which when acid and containing pus and pelvic epitlielium, will make tlie diag- nosis positive. Cystitis is rare in children, but examination for urethritis in tlio male and vulvovaginitis in the female must be made when pus is found in the urine. The acid reaction, however, indicates pyelitis. Pain in the region of the kidneys, irregular fever with chills and scanty urine point to pyelitis, but pj'uria is the only constant and positive symptom. Prognosis. — The prognosis is good wlien the kidney piopcr has not become much much involved in tlie inflammation. Where there is extensive nephritis fi'om calculi or pyonephrosis ensues, the prognosis is bad. Treatment. — A free administration of water to wliich citrate or acetate of potash has been added will serve to flush out tlie kidney and clieck the acidity of the urine. Two to five grains of these alkalies may lie given every three hours. Hexamethylenamin in doses of three to ten grains, three times a day, to a three-year-old child, is an efficient urinary antiseptic. The alkalies and the urinary antiseptic should not be given at the same time, as the latter acts only in an acid medium. It should be given in small doses for a few days and then in large doses if well tolerated. See page 83 for vaccine treatment. Tumors of the Kidney. Very rarely tliere may l)e tuberculous growths iu tlie kiiluey, usually in con- nection with a tuberculous infiltration of other portions of the jrenitonrinnry tract. The vast majority of cases in which a malisnant growth attacks the kidney in the child are of a sarcomatous nature. The sarcomata are pri'ijury growths in these cases and may be followed by secondary growths in other organs, such as the lungs or liver. The growth may start in the ])Glvis of the kidney nv in the adrenals or cortex. The increase in size is rapid and may pro- duce jiressnre effects on the various abdominal viscera, with ascites and rarely general peritonitis. Generally only one kidney is involved. Symptomatology. — The tumor is usually the first symptom to be noted. It steadily grows until a very great size is reached. The growth may usually be first noted in the side of the abdomen, l>ut soon pushes forward to the middle, and in a few months may fill the whole cavity. Hematuria is sometimes present, and there is a rajtid failure of strength afid vitality. There will be pressure symiitoms according to the size and direction of the growth. The patients rarely live beyond a year, and frequently not so long unless an 0]ieration is successful. Diagnosis. The diagnosis is made by the rapid growth of a solid abdominal tumor in an infant or a young child. Practically all tumors of this nature at this time and in this position are sarcomata. Treatment. The tumor must be retnoved as soon as recognized. While the mortality is high, a certain number of recovei'ies have been reported. See page 'o-i-i 454 DISEASES OF OICILDKEN. Hydronephrosis. Ilyilroiiepbriisis is :i dilatation of tlie jiolvis and calices of the kidney, often associated with necrosis of the kidney iiarenehyuia, due to some ol)struction to tlie outtliiw cf tlic urine. It is seen uioro frc(|uently in early than late childhood and about half the cases are found to l)e con.wnital. The obstruction may be situated anywhere in the genitourinary tract from the external meatus to the calyx of the kidney. The followinjj causes luuy be l:;--'.— Bilateral congenital hydronephrosis, caused by valve-like strictures in the ureters. From an infant 20 days old. noted: Iniiierforatc |ire|iure or me.itus ; congenital stricture of the \irethra • cmi- genital hyperti'o|)liy of the bladder wall inducing stenosis of the ureters •'mis- placejiient of the ureters; valve-like strictures in the course of the ureter'or of the ostium pelvicuni, showing a reduplication of the mucosa and cjf the nui.scul.iris from iriMammatory change or nlmormalities of development: urin.-iry calculi occurring after birth and, by their growth, occluding the urinarv tract :' pressure by abnoi-ni.al growths in neighboring organs or mechanical pressure from a float- DISOUUEliS OF THE UEINE AND KIDNEYa. 455 ing kidney ; deformities of tlie skeleton or auy foreign body in connection with the genitourinary triict. Hydronephrosis niuy lie unilateral or bilateral, in the latter case the obstruc- tion usually exists in the bladder or urethra. The congenital form may be either unilateral or bilateral, but is usually unilateral. There will be extensive dilatatiou if the obstruction in the urinary tract occurs before the fourth month of in- trauterine lite, as the secretion of urine begins about this time. AYhen the hydronephrosis is unilateral, the other kidney will functionate vicariously. In some cases the obstructi(Ui may he only temporary or i)artial. when the affected kidney will retain part of its function. Cases of hydronephrosis of both kidneys are fatal during infancy, and the condition is usuall.v overlooked, the babies dying of some intercurrent affection. In older children, with the unilateral form, the disease may be suspected or recognized when the dilatation is suthcient to produce a tumor in the lumbar region. Nephrectomy may then afford a radical cure if the other kidney is .sound. Where hydronephi'osis is due to an im])acted calculus in a ureter, the condition is apt to eventuate in pyelonephritis. Enuresis. (Incontinence of Uiine.) The syinptoiii-complex of incon- tinence of urine can best be studied by considering-, first, the plienomena wliich accompany the voiding- of itrine under the action of tlie bladder reflexes, and, second, tlie anatomical and physiologi- cal peculiai-ities accompanying this function in early life. The bladder, the spinal centers in- nervating it, and the brain holding an inhibition over the spinal centers, all have a part in this action. The follow- ing diagram, modified from (lowers, will give a suggestive idea of these parts : In the bladder we have the sphinc- ter (S), guarding the outlet by its tonic contraction, and the detrusor (D), or muscle of the bladder, usually dis- tended, but which, by its contraction, empties the organ. Both sphincter and detrusor are innervated l)y the segments in the spinal cord correspond- ing to the third, fourth, and fifth sacral nerves. The motor tonic centers for the sphincter (MS) keep this muscle in contraction, while the centers for the detrusor (MD) hold it in a state of dilatation corresponding to a positive and negative, or plus and minus action, of the motor nerves MNS Fio. I."^ 4.")6 mSKASliS OF CIIJLDREN. and MND. As the bladder Iteeomes distended witl) urine, sensory impulses are transmitted by sensory nerves (SX) to tlic sensory centers of the cord (SC) wliich are connected with tlie motor reflex centeis (MS and MD) by association libers. When the motor centers are sufficiently irritated they reverse their action, as a negative im))ulse { — ) is sent down l)y tlie motor nerves MX8 to the sphincter, which ililates, and a positive ( + ) action is tiansniitted l)y tlie motor nerves MX!) to tlie detrusor which pronipjtly contracts. The action of a ])hysiologica], automatic reflex is tlius shown. This action, howevei-, is held in check hy the inhibition of tlie Ijrain (B) that holds a restraining influence on the spinal )-eflexes by nerve fibers connect- ing with them (MT and ST). It is usually necessary to relax the inliibi- tiou of the brain liefnrr tlie autom.itic reflex can talxes of the spinal centers in )u-ojier e(|uilibrium. There are two foi'iiis of incontinence — active and ]iassive: (a) Active incontinence is produced when sufficient urine is present in the bladder to cause enough irritation of the sensory nerves to induce a contraclion of the delriisoj- and dihdi(m of the s]>hinctei' througli tlie s|5inal centers. There is no paralysis, but either a lack of proper brain conirol or o^el■a(■tion in the cord. In this form the nrine usually passes rapidly and in full stream. DISOKDEHS OF TlIJi URINE AND KIDNEYS. 457 (b) Passive incontinence is caused b\' weakness or paralysis of tlie sphincter, and the urine usually dribbles away without ability of control. With tlie constant undeiiying jjredisposition to incontinence in early life^ there are certain specific causes that may be mentioned in order to throw light on treatment: (1) Excessive acidity of the urine. Uric acid is I'cadily formed in early life; in new-born infants crystals are often seen in the calices of the kidney. The urine may thus become so irritable as to be passed drop by drop, or with a reddLsli tinge that simulates the appear- ance of blood on the diaper. Otlier acids, such as the acid phosphate of sodium and lactic and hippuric acids, may be present in excess in the urine. A'ery small quantities of overacid urine often provoke incontinence by irritating the Ijladder, and thus stimulating the nerve refle-\es to act. (2) E.rcessire IrritabiJity of the muscular coat of the bladder even ivhen ttie unne is mildly acid or neuiral. As the detrusor has an exaggerated con- tractile power in tliese cases, the urine is passed in a full and rapid stream. Even ordinary stimulation often causes strong contraction in the unstriped muscular fibers. This explains why atropin or belladonna acts ahnost as a specific when the muscle is thus at fault. (3) Wenl-ness of tlie sphincter. This form occurs in feeble children who are in poor condition from severe illness or underfeeding, or where the innervation of tlie sphincter has been weakened by disease of the spine or spinal nerves. The urine is not passed rapidly nor in full stream, but is more apt to dribble away. (4) Reflex irritation from disturbances outside the bladder. The genitals, anal ring or rectum may present conditions producing sufficient irritation to cause frequent contractions of the bladder under reflex action. Phimosis, adhe- sions of prepuce to glans M-itli retained smegma, stricture of tlie urethra, balanitis, vulvitis, ascarides, fissure of the anus and hard scybala in the rectum may be noted in this connection. (5) Neurotic causes. Cliildren with unstable nervous equilibrium from chorea, epilepsy, and similar condi- tions are prone to incontinence of urine. TTnder psychical influence, especially in dreams, the child inmgines a convenient place for iirination and the reflexes act. (6) Vesical calculus may be a rare cause of incon- tinence, and, when acting, will be both diurnal and nocturnal, with urine turbid from mueopus and frequent jjainful micturition. (7) Malformation of tlie bladder. Congenital deformities, such as extroversion of the bladder, rectovesical and vesicovaginal fistuhp, and a few eases reported wdiere ureters have emptied directly into tlie urethra, will lie accompanied by constant dribbling of the urine. Treatment. — It is evident from an enumeration of the different causes that one kind of treatment will not be adapted to all cases, and hence the 458 DISKASKS OF CIIILDEEX. ])liysifian must linil, if possible, the iniiieipal reason for incontiiieiice by an examination of the urine, together witli a general and local physical examination of the ])atient. More than one cause will often be found present. Highly acid, scanty urine may be relieved by a free administration of water together witli an alkali, such as the acetate or bicarbonate of potash, five grains of either thrice daily. ^Vhere overirritability of the detmsor is the principal cause, belladonna in full physiological dose, by its action on unstripcd muscular filler, will usually diminish functional activity and thus correct the condition. For a child of five years, grain l/iOO atropin sulphate or the tinctui-e of belladonna, ^\ v, may be gi\en late in the da\, and the (hise increased until there is dryness of the throat and flushing of the skin. If the incontinence is not relieved when the drug is pushed to its full effect, it will not be necessary to continue it very long. Where there is evidence of weakness of the sphincter, nux vomica or strychnin and ergot will act in strengthening its tcnicity and stimulating the nerve centers. From -5 to 10 minims of fluid exti'act of ergot and -"i minims of the tincture of nux vomica may be gi\en thrice daily, well diluted in water, to a child of five years. Unlike belladonna, these remedies may have to be continued for several weeks before the full benefit is obtained. Occasionally good results will be obtained by a few hypodermatic injections of ten drops of the fluid extract of ergot directly into the ischiorectal fossa. Supjjositories. containing half a grain of ergotin, may also do good in this class of cases. Incontinence of feces may have the same nervous causes and mechanism as incontinence of urine and may require the same treatment. The general hygienic treatment is always important. A simple, unstimulating diet, with a liglit, di-y supper is desirable. Iiestiiction in the amount of fluids, especially late in the day, may be tried. Postural treatment at night, with the buttocks elevated to save the neck of the bladder, has been advised, hut is impracticable. General tonic treatment, such as tlie use of large doses of the syrup of the iodid of iron, will relieve certain cases. Cold bathing, and plenty of fresh aii- will act as adjuvants. The children should be taken up late at night and early in the morning, and placed upon a commode to prevent the blailder from getting too full. Punishing these children is unavailing and usually makes the matter worse by upsetting the nervous system. The trouble is apt to he more frequent and intractable in boys than in gii-ls, and in rare cases may last for vears. An intelligent study of the child's condition and a recognition of the ]irin- cipal cause in each case and an adaptation of the treatment to such specifii' cause will, however, usually bring relief. SECTION XII. DISEASES OF THE GENITAL ORGANS AND BLADDER. CHAPTEE XXXII. DISEASES OF THE GENITAL ORGANS. Phimosis and Paraphimosis. Phimosis exists ^\lien the prepuce is so narrowed or contracted that the foreskin cannot be freely drawn back over the glans. Hofniokl notes four causes of phimosis : (1) A prepuce congenitally too long and too narrow (hypertrophic form), (2) congenital nai'rowness restricted to tlie external opening of the prepuce, (3) long persistence of extensive epithelial agglutination between glans and prepuce, (4) congenital and abnormal shortness of the frenulum and its location too far toward tlie front. Symptomatology. — Urination is frequent and painful. Wlien about to urinate the child is very restless, and while voiding will often cr^- out with pain. Older children attempt to restrain the act as long as possible. In some cases the pre]nice balloons out with ui'ine as it passes or it may escape drop by drop. If the foreskin is very tight, drops of urine remain, and decomposition of this retained urine often produces an eczema at the meatus or even on the thighs and over the entire genital region. Such inflammatory processes may cause balanitis. Tlie halnt of masturbating may be induced by the irritation. Following such a course, an infection may occur which may ascend througli the urethra, sometimes, although rarely, causing urethritis and cystitis. Dilatation of the bladder and hydrone]ihrosis may also result in neglected cases. Syncope and epilepti- form convulsions were formerly erroneously attriliuted to phimosis. If the foreskin be forcibly retracted over the glans, the pressure of the preputial ring in the coronai-y sulcus may cause strangulation. Such a condition is known as paraphimosis and soon causes violent pain. If this obstruction to the circulation is not relieved, edema and inflammation will occur, which later can produce ulceration and necrosis of the parts. Treatment. — The treatment of pliiniosis with adhesions consists in gentlv separating the agglutinated surfaces with a blunt probe and then Am 460 DISEASES OF fllJLDllEX. retracting carefiiUv the foreskin ovei- t1ie plans. If this is not easily accom- plisheil the foreskin may he stretched by slowly separating the blades of a forceps until it is possible. Any smegma which is pi-esent is wiped away. If urine is retained in the foreskin, causing decomposition, circumcision is- indicated rather than stretching. To lelieve a paraphimosis, j-eplace the glans within the prepuce by using the fii'st and second fingers of both hands from Ix'low and witli the thumbs above, forcing the glans tlirough tlie con- striction. If this cannot be accomplished by manipulation, the strangulat- ing I'ing must be incised and cold compresses applied to reduce the swelling and inflammation. As a rule, circumcision is performed at a later date. Balanitis. Tliis conditioii is usually due to an acfuimilation of smegma and retained urine, the deeompesition of wliicli causes an inflammation of tbe jirejiuee. Such accumulations occur most frei|nently where there is phimosis. Other causes of balanitis are mastnrhaticjn. in.iury. and infection of the uuicous memlu-ane of these parts. There is redness and swelling of the free margin of the iireimee, the opening of which is often covered hy small crusts. Several drops of seropus may appear if the opening of the preiaice is separated; it is usually impossihle to retract the pre])Uce entirely. Treatment. — Distend the iirejiuce l)y injecting an antiseiitic solution, such as bichlorid of mercury, 1 to ."j.dOO. or a weak permanganate of potash solution, three or four times ;i day. "When this cannot lie accomplished, ajiply the antiseptic dressing ice-cold. .\ solution of bichlorid of mercury 1 to lO.OtK) or liquor alumini acetatis N. F., one to four parts, is suitable. The wet dressings are ajiplied until the swelling is reduced. Slitting up Ihe ju'epuce to jiermit of thorough cleansing is sometimes necessary and then gives the quickest relief. ,\11 adhesions should be removed when this is done. Circumcision at this time should not be performed. Urethritis. Urethritis may be simple or specific. In the former, lack of cleanliness, ininr.v or the passage of uric acid crystals are the usual causes. There is pain on urination and a slight discharge of jius. The inflanunation is usually confined to the anterior portions of the urethra. There are no se(juel;e as in the specific form. Infection causing specific urethritis takes jilace by direct contact and can be diagnostic:ited only by a bacteriological examination, (touocci are generally found in great numbers in the discharge. E.xcciit for the constitntion.-il synqitoms. which are mild or entirely absent, specific urethritis gives the same clinical jiicture as in adults ; that is, a thick purulent discharge and burning pain on urination. Complications are rare; those likely to arise are stricture, posterior urethritis, epididymitis, arthritis, and gonorrheal conjunctivitis. Treatment. — llexaniethelamin in .^-grain doses three times a day with rest in bed is usually sutticient. but in some obstinate cases it is necessary to irrigate the urethra with argyrol in a .'i ]ier cent, solution or potassium permanganate in -J per cent, solution twice daily. The iielvis should be covered to avoid carrying the infection to the e^.'es .-ind the attendants warned of such danger. Vulvovaginitis, ( Prof/cinhil Blciiiiiii-vlnd.) This condition is a frc(|ueut cause of dysiiiia in girls, and may occur under tlie influence of general malnutrition, as in marked anemic conditions. DISEASES OF IMTE GEXITAL ORGANS. 4f)l, uncleanliness, masturbation, when parasites are pi'csent, or following an infectious disease. The usual cause, however, is an infection b\- Neisser's gonococcus. In this speciiic form infection takes place by either direct sexual con- tact or by handling, contact with the infected bed linen of parents, and less frequently from towels or discarded dressings. Epidemics of vaginitis frequently occur in hospitals and especially in institutions for cliildren. Differentiation of the simple and gonorrheal types is based on the bacterio- logical examination of the pus. A'ulvovaginitis begins with redness and swelling of the parts and a discharge of ])us, which is usually yellowish or white in the simple form and greenish in the gonorrheal. The pus is abundant, and on drying forms crusts, causing the labia to adhere. Micturition is frequent and painful, due to contact of the urine with excoriations of the mucous mem- branes of the urethra and the labia. There is also pain on locomotion, due to the excoriated thighs. In severe cases pus may be seen oozing from the cervix. The vaginal mucous membrane bleeds easily, due to the excoria- tions present. Constitutional symptoms are infrequent, but buboes occa- sionally occur and may even suppurate. In the gonorrheal form the usual adult complications may occur, such as arthritis of the large joints, con- junctivitis, and cystitis. Salpingitis and general peritonitis have occurred in our service. On the other hand, the symptoms may be so mild as to cause no disturbance, and are only diagnosticated as specific in the labora- tory. This type is more apt to be seen in institutions than in private practice. Treatment.— Treatment of all vaginitis cases requires isolation of the case and scrupulous cleanliness as regards the patient, the linen, and the dressings as well as the attendant's hands. In severe cases the patient should be in bed. In the simple form, after removing the cause, irrigate the parts two or three times daily with warm normal salt or boric acid solu- tions, bicblorid of mercury 1 in 10,000, or formalin solution 1 in -5.000. Cover the thighs and vulva with unguentum zinci oxidi or stearatis. A sterile pad is applied over the parts. In gonorrheal cases this treatment may be supplemented by the use of vaginal suppositories of arg^Tol 10 per cent, in oleum theobromatis ; insert one after each irrigation. In all cases general tonics are indicated. In simple cases under treatment the course of the disease is about two or three weeks. The gonorrheal form lasts much longer, often for months, and relapses are frequent. Some seem to assume for a time a latent form, 29 463 DISEASES OF CHILDREN. tvliich is apt to become active when tlie resistance is lowered from inter- current disease. Vaccine Treatment. — Tlie vaecine treatment may be tried in intract- able cases or for a series of eases in an institution. A dose too large or too small gives little or no response, live million dead bacteria Iteing tlie pre- ferred initial dose. Under tbis treatment clinical evidences of gonoi-rliea disappear in ten to twenty-one days, and no gonococei may be found in tbe smears for some time. In some cases a polyvalent vaccine seems more efficient than a univa- lent one. The best results are obtained when the vaccine used is obtained from the patient's own organisms, except where the case is of long duration or has been treated by antiseptics, as these lower the virulency of the organ- ism : it is then better to make vaccine from a strain of known high virulence. Experiments have proved this step to be most efficient in spite of Torrey's conclusion that " the family gonococcus is heterogeneous." If an eye should become infected, the injections should be given at once, using temporarily a stock vaccine (see p. 79). As a rule, the discharge increases for the first two or three days after the injection, and then diminishes quite rapidly. However, the vaccine treatment is many times unsuccessful, and a case should not be considered cured until a long period of quiescence has elapsed without recovery of the organisms. Masturbation. In infants and very young children the presence of some organic source of irritation in or about the genitalia is assumed as the cause of masturba- tion. Of such irritations itching, vulvar eczemas, and pin worms which have escaped from the rectum and found their way into the vagina are the most frequent causes in girls. Attempts to relieve this irritation by scratch- ing or rubbing the thighs together results in the persistence of the habit because of the sensations it produces. In boys, an elongated prepuce, fric- tion from a phimosis, excoriations at the meatus from a highly acid urine, may be the original cause. In girls, adliesions about the clitoris from smegma and unclcanliness are common causes. In older children the beginning of such a habit is more probably due to acquaintance with others with whom the practice is in vogue ; in some cases, accidental discovery that genital irritation produces voluptous sensa- tions occurs in certain sports, such as bicycle-riding or tree-climbing. It is an error to assume that this practice produces nervous, irritable children, with pallor, headache, and sickly appearance and dark rings under the eyes unless masturbation be indulged in to excess. In children of the DISEASES OF THE GEXJTAL OTIGAXS. 46:'] neurotic type such symptoms are, lioweYer, greatly aggravated by tlic violent sexual excitement so produced. Treatment. — It is essential to remove the cause. By the use of suit- able night gowns and bandages children can be prevented from masturba- tion at night. During the day constant supervision is desirable, Imt the early evening and early morning are critical times. Dietetic changes and psychic treatment after suitable explanation are potent factors in eradicat- ing the habit. Effort should be made to keep the child occupied all the time, and frequent diversion of the mind towai'd active and healtliy normal chan- nels will prove most efficient measures. Cold affusions to the spine may- be employed in intractable cases. Hydrocele. AAHien the peritoneal sac surrounding the testicle and epididymis is distended with iluid, the condition is known as hydrocele. It is not ■uncommon, and is usually congenital in origin. The following varieties may be differentiated : Hydrocele of the Tunica Vaginalis (with the funicular process oblit- erated). — This is one of the most common forms found in children. The tumor formed is oval and is firm and tense. It may occur on one or both sides. The tumor cannot be reduced. Fluctuation can usually be obtained, and the site of the testicle can be seen by illumination of the scrotum. The cord is felt above the rounded upper portion of the swelling, and the testis is generall.v situated posteriorly, projecting into the cavity, and is therefore not readily detected by manipulation. Congenital hydrocele exists when the funicular process is patent. The signs above stated exist except that upon manipulation the fluid can be returned to the abdominal cavity. Infantile hydrocele occurs when the funicular process is closed at its upper extremity only. The fluid extends along the cord, and the timior is therefore elongated : the other signs are the same as given above. Encysted hydrocele of the cord is one in whirh there is an additional point of oliliteration nf the intraabdominal ]iortions of the funicular process al)0ve the internal abdominal ring: fluid distending this portion of the canal forms a tumor resembling a cyst in addition to the tumors in the scrotum. Treatment. — As a rule, no treatment is required. After several weeks the condition spontaneously disappears. If phimosis is present this should be corrected at once. In more resistant cases puncturing the sac and allowing the fluid to thoroughly drain off usually produces a cure. If relapses occur, instillating one or two drops of the tincture of iodin in ten drops of water will set up adhesions sufficient to obliterate the sac. In some of the congenital forms, a truss may be applied in order to obliterate the funicular process, and then if a cure is not affected aspiration is per- formed. If the hydrocele is associated with a hernia a suitable truss must be worn after the evacuation of the fluid. 464: DISEASES OF CIIILDKEN. Undescended Testicle. {Cri/ptorchiili.siii. i When not in the sfrotum, the testis may lie fciund (1) in tlie abdominal cavity attached to the alidoniinal wall or (2) just inside the internal abdominal ring or (3), as is most conunon. in the inguinal canal or (4) just beyond it. The causes of sucb a malformation may be a short or abnormally attached subernaculum. a contracted e.xterual ring, or an alinormally large epididymis. The diagnosis is made when the scrotum is found empty on the affected side, and a small movable tumor the size of a hazelnut is found in the inguinal region which gives the unpleasant testicular sensation on jiressure. If no sym]itoms arise the best treatment is neglect ; if. however, there is much pain or tenderness, which sometimes occurs when the testicle is in the canal, surgical intervention is required. The surgeon may succeed in drawing the testicle down into the scrotum or he may be obliged to replace it in the abdomen. If the testicle lies within the abdomen an4, — \'olIaiiairs iseheiiiic iiaralysis, following fracture of the radius. Pseudoparalysis. — - True paralysis may be simulated by muscle weak- ness, as in i-acliitis or chorea; or from the lesions themselves in syphilis and scur\'v. Close observation and the electrical reaction easily distinguish the condition. Convulsions. {Eclampsia Infantum.) This symptom or symptom-complex results from a cerebral irritation producing a temjiorai'v unconsci(nisness, attended by ii'regular muscular contractions. The syiii])tom in the infant and young child often corresimnds to the ehdl of the adult. It is quite commonly observed because of the relatively greater excitability of the brain and the undeveloped power of inliibitory control. We may divide the causative factors into two groups — the reflex 01' fumtional and the organic. CiENEUAL NEKVOl'S DISEASES. 471 Etiology.— The peripheral disturbances whicli may cause a convulsive seizure are many and various. The susceptible age is in the first two years of life. An apparently trivial cause, such as psychic or sensory impressions resulting from unusual excitement in a child with an inherited unstable equilibrium, may produce a typical seizure. Foreign bodies in the nose or ears, traumatism, intestinal parasites, preputial abnormalities, improper or indigestible articles of food, poisons, and the toxemias resulting from or preceding certain diseases, as rachitis, malaria, or tetany, are among the causes producing convulsions. Rachitis deserves special mention as an underlying predisposing cause because of the nervous instability it produces. The organic causes are meningeal hemorrhages at the time of birth, tumors of the brain, cerebral abscess, hydrocephalus, and the various forms of inflammation of the brain or its coverings. It sliould be recollected that regional as distinguished from general convulsions are indicative of organic lesions, and also that rejjeafed seizures over prolonged periods are character- istic of cortical disease. Description of the Symptom-complex. — The attack begins witliout warning. It may be preceded by slight twitching of the face and rolling of the eyes. There is then unconsciousness, the eyes are fixed and staring, tonic rigidity of the head, back, and extremities is shortly followed by clonic contractions of the facial muscles. These usually begin at the mouth, caus- ing grimaces and distortions of expression and some frothing. The teeth are firmly set. The color is dusky. In a general convulsion all the extrem- ities show clonic contractions and purposeless activity. The pupils are usirally dilated and do not react to stimuli. The respirations are labored, affecting the pulse and causing irregidarity of the heart action and increas- ing the cyanosis. There may be involuntary passage of urine and feces. After a variable time the muscular twitchings cease and the child passes from a coma into a deep sleep. The attacks may be and usually are shortly repeated unless influenced by treatment. After a period of sleep the child arouses and takes a normal interest in its surroundings ; it may then be considered free from the danger of another immediate attack. Prognosis. — This is usually good, but should be guarded until a defi- nite cause is established. It is always serious if the attacks occur in the new-born, in advanced childhood, or if they are unduly iirolonged and recur often. If convulsions usher in a disease they are not of as great prognostic importance as when they occur in the course of the disease. An exception to this statement must be made in cerebrospinal meningitis, in which initial convulsions are of bad omen. Differential Diagnosis. — The essential characteristics are temporary imconsciousness and irregular nniscular contractions. 4" 2 DISKASKS OF CHILDREN. In convulsions from orj^'anic causes, the regional involvement, often neuritis, and the resulting paralysis, luay be distinguishing features. Epi- leptic seizures occur usually after the second year of life, they are apt to I'ecur after longer periods and without an immediate causative factor. The history of predisposition may be obtained. Treatment. — First overcome the attack or symptom. Some one in the family will in all probability have given a mustard batli before the ar- rival of the doctor. If the attack persists inhalations of a few drops of chloroform may be given, an liours (2 uap.si. One to three years. 12 hours (;ni(l one n.-ip). Three to six years, 10-12 hours. Six to ten years, 8-10 hours. When the infant is unable to approximate the normal amount of .sleep a careful examination of its mode of life should he made followed by a systematic physical examination. Among tlie more frequent causes of sleeplessness are digestive disturbances, undue excitement, bad hygienic conditions, and localized pain. Physical examination may show that the child is suffering from an otitis, skin lesions, enlarged tonsils, adenoids, rachitis, extreme anemia, or the disease may be organic, such as meningitis or incipient disease of the brain or spinal cord. Treatment. — When the cause is found efforts should be made to remove or correct it hefore any other measures are undertaken. A careful regulation must he made of the child's daily life, not omitting what may seem to he minor influences bearing npon its sleeplessness. A well-venti- lated, cool, darkened room should be provided, which the infant or child should occupy alone; the bed clothing should he light and not too warm. The evening meal must be simple, not containing too much li(|uid. Read- ing of exciting stories to children sliouhl be prohibited. These changes with an outdoor life arc often sufficient to correct insomnia. Tf a high temperature is the cause of the insomnia, baths or sponging with alcohol will often promote sleep. Tf temporarily any of the hypnotics ai'e necessary, the bi'oiiiids, in doses of one and a half grains for each year of age, 01- one grain of veronal for a two-year-old child, will produce the desired cnVct. The bromids combined with chloral hydrate are effective in older neurotic children, especially if they also lia\e night tei'rors. GENERAL NERVOUS DISEASES. 481 Pavor Nocturnus. [Night Terrors.) This condition occurs in cliiitlren who liave in some manner unduly excited their nervous system. They may or may not be the children of neurotic parents. Children from tlie third to the eighth .year are more connnonly suli.iect to night terrors. In our experience the condition appears with the greatest freiiuency at the beginning of scliool life when unaccustomed resiionsiliilities must suddenly be assumed. The reading of unnatural stories so often practised by nurses or unusual and grotesque sights, as in the circus, may induce an attack. A heavy meal .just before retiring may also be a cause. The children awalve suddenly, usually before the midnight hour, and cry out, exhibiting signs of fright or terror. They are soothed with difficulty and can give no explanation of tlieir sudden awalcening or dream. If questioned in the morning they remember nothing of the occurrence. The terrors may repeat themselves sever.-il times in a weeli. but they seldom occur twice in the same night. When the cause is removed the recurrences become more infrequent and finally disappear altogether. Treatment. — Every effort should lie made to decrease the nervous excitabil ity of the child by prohibiting school worli at all for a time or ilecreasing the number of school hours. At home no supplementary teaching should be allowed and association with older minds not encouraged. A healthy amount of physical tire, rather than mental strain, sliould be the ilcsiileratittii. The evening meal particularly should consist of light and easily digestible articles, and should be eaten at least an hour before retiring. If these measures are carried out it will rarely be necessary to give bromlds or hypnotics. Spasmophilia. Spasmophilia is a symptom complex of early cluldhood that exhibits a marked tendency to spasms both tonic and clonic, and accompanied by great irritability of the peripheral nerves. Etiology. — A hereditary tendency toward tliis condition is to be noted, especially in families with a neurotic history. It is manifested more fre- quently in the winter and spring- months, in this respect resembling ricl^ets. The age of most frequent incidence is from 6 to 18 months. Tlie under- lying cause seems to be some kind of faulty metabolism. This may be due partly to a defective diet and jJai'tly to bad hygienic surroundings such a,s overcrowding, lack of sunlight and fresh air, and accompanied by poor digestion and assimilation. Spasmophilia is commonly seen in bottle Labies; breast fed infants are neai'ly always exempt. Some autlioritics con- sider that a faulty metabolism of the mineral salts is tlie cause of tlic dis- turbance. This may have relation to calcium or the various alkaline salts, specially potassium. Some believe that a disturbance of tlie parathyroids, ■either functional or pathological, may account for a faulty calcium metabol- ism. This, however, may be an effect rather than a cause of some underly- ing condition. Finally, spasmophilia may follow any acute infection in susceptible cases, as well as increasing the severity of sucli infections in tlio latest forms of tliis symptom complex. 48:^ i)isi:-\si:s OF ciiiJ.DitEN. Symptomatology. — 'I'Ir' coinlilion is slow and inogular in its course. Its Diauifustations Jiiay In: at-tixe (.lui'ing tlic cold months and Jaj-gely absent in sunmicr. TliuiX' are tliree outstanding clinical types in which marked and distinct symptoms may be noted: Laryngismus stridulus (see page ;!o()). Tetany, described Ijelow, and Spasmophilic convulsions. Spasmophilic Convulsions. — There is usually no tonic spasm but clonic t'iN'itcbing of a local or general natui'e, accompanied by unconscious- ness. There is great variety in the extent of muscular involvement and the attack is usually shoi't-li\ed. There may be only one attack, or repeated convulsions at iri'egular inter\als wliicli nuiy simulate epilepsy. The imme- diate cause of attack ma\' he acute stomach indigestion, distension of the bowel from flatulence or any reflex irritation. The onset of the exam- FiG, 1:1.". — Tetany, ^^■itll i-liarui'tcristic jiositioiis of liaiids and fent tliemata and \-ai-inus ijther infections is apt to lie ushered in by a con\ulsion in a spasiii(i])liilic subject. Diagnosis. — The hyperexcitahility of the ]ieripheral nerves so constant in this condition may he I'ccognized 113^ the gal\"anic current. A cathodal o|ieniiig contraction with less than (h'c milliam]iers will give the diagnosis. ('h\"ostek's and "Ti'ousseairs signs, ali'cady desci'ibed, will also aid in the liiagnosis. E\idences of rickets are nearlv ah\'avs present in these cases, and manifestations (tf laryngosjiasms or tetany ai'e likewise often seen. Treatment. — A\'ben ))ossihle, human milk should alwavs he given as it is not oidy pi'e\entive but curative in its action. Tt is difticult to ada]it co\v's milk" to tlii'se cases, although it is nnciu'tain what ingredient is respon- sible for tbe malassimilalion. Dilution of the milk nuiy he nmde with grui'N, jilain oi- de\i I'iiiized, oi- (ine of the maltose pre])arations may be suh- stituted for the lactose. As soon as the infant is old enoutrh, a diet of UENJCIiAL NJiUVOTTS DISKASK.S. 483 rereals, meat broths and green vegetables, with a iiiinimum quantity of cow's mill';, will give the best results. The medicinal treatment consists in the administration of cod liver oil and one of the calcium salts. Lactate of calcium, from 3 to 5 grains at a dose, has been recommended. Sedgwick reports better results from massive doses of the chloride of calcium. He gives from 50 to 75 grains a day, mixed in with the feedings, and claims that this acts almost as a specific in spasmophilia. The general hygienic management is very important and must especially include plenty of sun- light and fresh air. Kk;. ^■^i'l. — 'I'liP f.-K-e in tetiiny. Tetany. ( Te tanilla: A rtli rogrijpasis. ) Tetany is a neurotic disorder characterized liy intermittent or constant tonic spasms of the muscles of the upper and lower extremities. Etiology. — The disorder is dependent upon the absorption of toxic products wdiich readily affect the highly sensitive nervous system of early life. It occurs most frequently from the sixth month to the end of the second year. We would give rachitis the first place in the role of etiologic factors, and the conditions which may produce this disease may also pro- duce tetany. This is further borne out by the fact that convulsions and 484 DTSKASKS OF rTIlLIiIlFX. laiyngisjiuis stridulus frequentl}' occiu- in lliosu subject to tetany. It also results from intestinal or peripheral irritation and may follow exhausting- diseases or secondary pneumonias. Defective parathyroid nurtabolism is believed to be an underlying cause of this and similar spasmophilic conditions. With this MaeCallunr asso- ciated defective calcium metabolism and treatment has been leased on this delieieney. It also follows exhausting cases of measles, pertussis and tvphoid fever. Peripheral ner\"e excitability is always present. An Frii. ].")7. — Pseudo tetany, cbaraeterized li.v trismus, and marked spasm of muscles; uniuvolveuient of upper e-xtremity ; mentalit.v' unimpaired. ennervateil muscle group responds to Ijotli catliodal and anodal closing contractions A\'licn less than five milliamperes of euri'cnt are used. Symptomatology. — The condition begins ^vit1lout any \yarning in infancy, ahbough oliler children sometimes eom])lain cu' give e\idi'nee of an itching or tingling sensation. Attention is gimerally called to the con- dition ))y tlie muscular contractions of tlie hands and feet. A close exami- nation will sliow tliat file arnrs are held i|uite <'losely to the cliest, tlie fore- arms being partly flexed on the arms and the hand flexed at the wrist, while the fingers may either he tightly closed o\-er the inverted thumli on the palm, simulating the driving position, oi' they may h(>, hvpen^xti'iided and ]i(dil closely together like the obstetric hand. In tlu> lower exti'eniilies the UK^■J■:KAL NEIU'OL'S DISEASES. 485 thiglis may be drawn up onto the abdomen and the legs Hexed on the thighs ; some degree of adduction of tlie thighs is generally" present. Tlie foot itself is extended or hj'perextended, and the toes are flexed. The position of talipes equinovarus being often assumed. AVe have also noted Spasticity of the erector-spina? group of muscles, so that the child could be raised by the head retaining an erect posture. The child's expression is one of dis- comfort. Pain is elicited if attempts are nuide to replace the extremities in their natural positions. There is rarely any temperature which can be attributed to the condition itself and the mentality is not affected. After a variable time, sometimes a few days or it may be weeks, the contractures intermit and the so-called latent period may be entered into, in which there is weakness and some slight spasticity of the affected muscle groups, or the symptoms may never return. In this disease certain phenomena may be elicited which are distinctly helpful in making or confirming a diagnosis. Trous-ieau's symptohis can be produced in the latent period by pressing iipon the main nerves and arteries of the extremities. In this way a char- acteristic paroxysm can be produced which ceases when the pressure is removed. Ei-Jj's sijinptoiii is def)endent upon the increased electrical excitability in the peripheral nerves, muscular contractions Ijeiug produced even by weak currents. Clirosteh's syinptom is a facial phenomenon which is of value if obtained in conjunction with the others and is elicited Ijy pressing the finger or any other blunt object over the facial nerve or tapping smartly over the exit of the nerve when contractions immediately occur of the enervated muscles. Differential Diagnosis. — From tetanus it may be distinguished by the absence of trismus, which is an early symptom, by the lack of fever, l)y the intermittent attacks, and the ability to elicit Trousseau's, Erb's and Chvostek's signs. Cerebrospinal meningitis is distinguished by the presence of high irregular temperature, cei'eljral signs, and by lumbar puncture. Prognosis. — The prog-nosis is mainly dependent upon the underlying cause. In itself it rarely endangers life except by predisposing to con- vulsive seizures. Eelapses are not uncommon, especially in those cases due to nutritional disturbances. Treatment. — The underlying condition must be carefully sought for and treatment immediately directed toward its removal. It is a safe rule to thoroughly empty the bowels by the use of a large dose of castor oil or calomel. An enema may be given for immediate relief. The stools should be kept for the physician's examination, as he may therein find the source -itSli UhSEASliS OF CHILDliEN. of the pL'riplieral irritaliun, sucli as badly digested food or intestinal para- sites. Batlis at a temperature of 110° F. may be given two or tliree times during tlie day for their relaxing eft'eet. In severe eases a mixture of ehioral Iiydrate and the broniid of soda eau be injected into the rectum. In the latent period dietetic measures should be coupled with most favorable hygienic conditions. The food ordered must be sucli as to overcome the rachitic manifestations if present (see p. 425), or to produce an increase in weight if tiie neurosis has resulted from an exhausting disease. Calcium lactate 2-5 grains three times a da}', may be given to supply calcium deficiency. Myotonia Congenita. (ThoiiLscii's Dlseai/c.) Myotonia congenita is ;i rare disease, mainly hereditary, characterized by a sudden rigidity of certain uuiseie groups wlieu a voluntary movement is at- tempted. Etiology. — The disease may occur early in childhood, hut the greatest num- ber of eases are seen between the fifteenth and twenty-fifth year. Thomsen believes it to be a hereditary disease; five generations in his own family having been so alflicted. Inclement, cold weather and emotional states may bring on the attacks. Symptomatology. — The muscular contractions develop when the patient attenjpts some voluntary act, as rising from bed or from a chair. The muscular spasm prevents the completion of this effort, and repeated attempts are necessary before it is accomplished. These inhibited efforts in a child otherwise well developed are strilving enough to fix the diagnosis. If a sharp blow is given over a nuisele. a tonic contraction occurs which persists foi- some time. Erl) has shown that the nuiscles reaet peculiarly to eleetrical stimuli. This " myotonic reaction," as he calls it, is a valuable confirmatory sign. Faradic currents stim- ulate the muscles, producing wavy, rliythmical long-contiiuied contractions. The same effect may be produced by the galvanic current. Diagnosis. — The disease is distinguished from tetany by the contractions produced by mechanical stinuilatiou and by the peculiar electrical reaction (Erb's my(itiinic reaction). Furthennore. there is no increase in mechanical e.xcitability b.v ]iressure over the nerve or vessel trunks as in tetany. Congenital paramyotoni.i (Eulenberg's modification) m.iy be differentiated b.v the absence of the myotonic electric reaction and also of any inca'ease in the mechanical excitability. Treatment. — Thomsen noted that the symptoms a]ipeared less often the greater the uius(ular activity of the patient; lie therefore advised a life which would necessitate a constant use of tlie muscles. Paramyoclonus Mutliplex. This disease, altliough very rare in early life, is mentioned here mainly for the i)urposes of differential diagn(]sis. It is cli.ir.icterized by the production of rejieateil momeiil.ary clonic s|)asnis affecting a certain nuiscle or groups of nmscles which are usu.illy symmetric.illy involved. The nuiscles of the face are r.-irely involved. A sliglit tremor of the muscles may be observed between the attacks wliicli usually follow some strong emotional excitement or jiliysical effort. The myotonic reaction is rarely increased and no change in electrical excilability is noticed. Treatment. — We are almost v'owerless to effect a cure in tliis disease, al- though amelioration of the symptoms is possililc liy the use oC sedative baths, mild gymnastic exercises, and a life free from excitement. UEXEltAL XEJiVOUS DlSi;A,SJ::.S. . 487 Angioneurotic Edema. (Acute Circumscribed Edema.) TLis is a vasomotor disturbance, ti-opbic in origin, cliaracterized by attacks of circumscribed edematous areas on tbe body. Gastrointestinal intoxication is tbe most freijuent cause in children, altbougli it sometimes appears without any discoverable reason. The edema may be well- marked a few hours after its inception and may just as suddenly disappear, only to reappear in some other portion of the body. There are no marked constitu- tional symptoms, the chiidreu simply complaining of the itching or the discomfort caused by the edema when it affects, for example, the face. In a case seen by one of us there were un(inestioauble signs of edema of the lungs, which appeared suddenly, and cleared up within forty-eight hours. Tbe area affected is raised, pale in the center, with an irregular bluish-red margin, differing from the other edemas in tliat it does not pit on pressure. Fatal cases have been reported in which the iaryn.x and pharyn.x were affected. Treatment. — Special treatment during tlie attack is hardly necessary. Com- presses wrung out of warm boric acid solution are soothing to the patient. A saline purge should be given and future attacks inhibited by scrupulous attention to the dietary. Tics. A tic is tlie unconscious activity ol' a group of \olimtary muscles resemljliug a purposcl'iil niovcuient, its fre(|uent i-epetition cla.-sing it as a liabit. Tliey occur most frequently in cliildren from tlie fiftli to tlie four- teentli year of life. An underlying neurotic element can usually be found in the patient or lie has been trained under attendants who by their man- agement have not developed his self-control. These neurasthenic children may easily develop a tic from some primary source of irritation, as foreign objects or growths in the air passages or eyes, skin diseases, phimosis, or even chorea. They may arise from emotional disturbances or as a result of imitation, as pointed out by Scripture, in children of unstable and willful disposition. The most common tic is the one involving the muscles about the eye in which the child rapidly winks the eye-lid several times in suc- cession. This occurs at short intervals during the day. Xot unlike these in motor characteristics are the tics affecting the face, scalp, ears, tongue, neck, and extremities. When tics are accompanied by mental disturbances, a child otherwise rational may repeat words or phrases of an obscene char- acter witliout provocation or regard to the time and place. This is known as coprolalia. Differential Diagnosis. — Tics may be distinguished from chorea by the purposive, systematic nature of the movements which occur at intervals. The spasms of paramyoclonus multiplex affect only a C(utain muscle and are not controlled by fixing the attention. Habit spasms resemble normal movements, hut differ from them in that they are rmnecessary. They are unlike tics in that they are not convulsive in type. 48S . DISEASES OF CIIILUFlEX. Stuttering and Stammering (Iljpeiphonia.) — In this connection another clat-s uf tics foniiing a large part of the speech defects of childhood may be considered. Scripture delines liyperphonia as a psychomotor neuro- sis or a mental tic or lialiit over whicli the i)atient has no control and winch is the result ol a compulsive idea connected with speaking. A neurotic child may ac(juire the liabit by imitating others or he may have some defect connected with liis respiratory apparatus. The symptoms have Ijeen divided into spasms and hypertonicity, affect- ing the respiratory, laryngeal, and articulatory muscles; to these are sometimes added facial and bodily ties. Treatment. — A careful physical e-\amination, including the special organs, and an inijuiry into the details of the child's life should he made in every case. An underlying and neglected cause may be found in refractive errors, abnormalities in the nose, ears, or teeth. Peripheral irri- tation from any soui'ce must )je removed. AVhile this is not curative, it is conduci\e to a more rapid recovery and prevents recurrences. The physical condition of the child should 1)e improved by nutiitious food, tonic baths, a!ii]de amount of sleep, and a routine life under judicious discipline. A cliange of environment Avill often make the special treatment much more ettecti\e. Fowder's solution may often be given with benefit. In a num- ber of our cases the method advocated by Scripture was remarkably effective. It depends upon the voluntary injitation of his own act by which the child is trained to a conscious performance of the tic. In this way he is encour- aged and enabled finally to inhibit the act. The child looks into a mirror and is directed to imitate five times in succession his own tic when it appears. At llrst the imitation is a poor one, but improves with practice, until finally complete control is obtained. Scri])ture's method for stuttering and stammering consists in intro- ducing melody into the nronotone voice of the stutterer. The child is directed to repeatedly sing a line of some familiar song; he is then taught to speak a sentence in the same sing-song fashion. In this way the mono- tone voice is finally abandoned and cadences and inflections are introduced. The " melody cure "" is founded upon the fact that a stutterer never stutters when he sings. This simple treatment is elaborated by encouraging the child in for]ns of elocution and graceful mannerisms. Finally, in some cases it is also necessary to distract the mind wdien the patient starts to speak; this is done by teaching him to beat time in a quick, vigorous manner as he starts to speak or to set himself off by repeating one, two, and starting off' to speak on three. These lessons are given at first three times a week for half-houi- pi-riods, the time and interval being lessened as progi'e^s i< made. CHAPTER XXXV. DISEASES OF THE PERIPHERAL NERVES. Multiple Neuritis. Definition. — An inflaiiiination of the ])eripheral norvi'f:, in some of which there is a tendency to acute de.<,'-enerative chan,s;es. It may affect several nerves, usually symmetrically, or it mav l)e genei'al. Etiology.— Bacteria or at least bacterial toxins in all probability cause the disease. T1k> infectious diseases, especially measles, malaria, influenza, typhoid, and tuljerculosis, may be followed by a polyneuritis, but it is a rare complication, wit]i the exception of diphtheria. Sometimes exposure or cohl and rarely alcohol, arsenic, or lead cause tlie disease. Alcoliol must !)(' considered as a factor in treating tlie children of our foreign population. Pathology.— Tliere is an inflammation of the affected nerve, inter- stitial or pareiuhvmatous in character, followed by more or less complete det^eneration of tlie fibers. Tlie apix-arance of tlie nerve at first is that of an acute inflammatory nature, with SAvellin.t,'', hyperemia, and minute hemorrhages in the nerve sheaths. Later degenerative changes in the nerve fibers only are seen. The muscles undergo parenchymatous or even interstitial changes. Symptomatology. — Tlie onset may be sudden, with a chill or a con- vulsion and fever; as a rule, however, it is gradual. The mother may notice that the child is unable to properly support itself on its feet: if forced attempts to walk are made the child stumbles or sinks to the floor. After a few days or sometimes within a few hours there is intense pain on handling. The child cries when approached, fearing the pain of motion. Occasionally the sensitiveness along the course of the nerve may be elicited. Paralysis now follows the muscular weakness and it progresses symmetri- cally. The child may continually moan or cry out with the pain, but does not refuse its food. Foot-drop and wrist-drop develop, and the muscular contractions may cause deformities. Tendon reflexes are abolished alto- gether, or at least diminished, and the reaction to the galvanic current is slow. Muscular atrophy develops, but is not marked. Diagnosis. — The history of an antecedent disease or a distinct causal factor, as alcohol, may be suggestive when pain and paralysis ensue. The association of motor and sensory symptoms or paralysis along anatomical lines and the changed electrical reaction should cause no confusion. Wlieji 4S0 -I'JO DISEASES OF CllU.UltliX. there is lordosis present I'roiii invohenient of the muscles of the back, it may be mistaken foi- I'ott's disease, but the tk^fomiity is not angular and tlie position assumed will differentiate it. Course and Prognosis. — Cases with sudden onset in which the elec- trical reaction is ra[)idly changed and in which atrophy occurs early are not favorable for recovery. The average case begins to improve after the first month, recovery generally being complete in three months. The sensory symptoms clear up first, then the reflexes are obtained. In some cases the para lysis -ma-y be permanent. Involvement of certain nerves, as tlie vagus, or intercurrent diseases may bring on a fatal issue. Treatment. — If tlie disease is due to a drug or alcohol poisoning this must be stopped at once and eliminatives given. An initial dose of calomel is always in order. The eliild should be placed in a comfortable attitude, the limbs encased in cotton wool and lying on a down jiillow. The pain should be controlled hy analgesics, sueli as the bromids, plienacetin, or even codein if necessary fur one or two doses, licst and hot applications during the onset, and later massage and vibratory treatment as it is given in infantile spinal jiaralysis is etfecti\-e. If the extremities are kept in a proper position while the disease is in progress, defoi-mities are not likely to result and ortho|)edie appliances will not be necessary. Diphtheritic Paralysis. — This is a form of multiiile neuritis worthy of special note. It is the most common cause in early life and affects for the most part only one region, that is the ]ialate. We do not meet with the condition as fre(|uently since antitoxin has come into general use. It is less likely to follow if the diphtheria lias been recognized early and the chilli injected with the serum at once. AVe have, however, seen a fatal issue in cases that were considered extremely benign and in which the ]irognosis was excellent. Children under two years of age are rarely affected. Malig- nant laryngeal cases are more susce|)tihle of involvement. It sometimes occurs during tlie active process, but usually it ap]iears in the third or fourth week of convalescence. Symptomatology. — Inability to swallow well with regurgitation of fluiils through the nose or a peculiar nasal twang in the voice may lirst atti'act attention. The eyes may next show the paral\sis, and if this is luore extensive the lowei' extremities are affected, followed by similar elianges in the arms and the mustles (if the trunk. Examination of the throat will easily disclose a paresis of the ])liarvnx and soft iialate; it is relaxed, flahbv. and does not take i"iart in the acts of speaking oi- swallowing. Closer examination of Ihe e\"es shows weakness of the eiliar\" muscles, the {iu|iil i-eaeting sluggishl\ and omsing ilefeclix-e \ision. A\'hen the external iieular niiisdes are parnhzed. strahisnins results. DISEASES OF THE rEKIPHEKAL KERVES. 4!.)1 Following the laryngeal eases the loss of voiee is particulai-ly marked and persistent, and if the paralysis oecnrs during tlie intuhatiou pei'iod difficulty may be experienced in keeping the tube in place. Recovery is the general rule; fatal cases resulting from the involvement of the vagus, or from aspiration pneumonia when the epiglottis is involved. The course depends upon the extent of the paralysis and the regional involvement. The average case requires two months for recovery. The muscles of tlie eyes and the palate recover much more quickly than the muscles of the extremi- ties. AVeakness of the back and inability to properly suppoit the head, with the loss of the reflexes, may persist for months. Treatment. — Eest in bed and close observation should be insisted upon wdien the first symptoms of paralysis appear. The management will depend upon the extent of the regional involvement. Certain cases in which there is only aphonia or partial paralysis of the palate will require no special treatment, but the heart in all cases should be carefully watched and stimu- lation given if necessary. Strychnin nitrate has served us tlie Ijest for tliis purpose. Where deglutition is interfered with gavage may be necessary, although careful feeding from the spoon in small quantities can usually be successfully practiced. The food should be as nourishing as possible, and the appetite and general liealth are improved by placing the patient as much as possible in the open air. Facial Paralysis. {Bell's T'nlsii.) Paralysis of the seventh nerve is not an infi'e(|uent affection in infants and children. Etiology. — Dui'ing infancy it may occur as a result of inx'ssui-e upon the nerve with tlie forceps or in contracted pelves from impaction upon the head. Caries of the petrous portion of the temporal bone accompanied with inflammatory exudates may cause paralysis by pressure on the nerve. In childi-en over three years of age sudden exposure to cold, which in all probability induces an infection, is the commonest cause. Tt may also accompany or be produced by traumatism within the skull, basilar forms of meningitis, polioencephalitis, and tumors of tlie brain. We fre- quently see this paralysis following the radical mastoid operation in which the nerve mav be temporarily injured or destroyed. Symptomatology. — Inspection of the child's face will show a dioop at tlie mouth on the affected side and the natural folds in this region almost or quite disappear, while the angle of the mouth is drawn down. The cliild cannot close its eye, and if attempts are made to do so llie cye-Iiall moves upward. It can onlv blow nut the cheek on the unaffected side. The pro- 403 dis1':ask,s of chii.dken. truded tongue dfviatcs to 1lie nnattected side and food ])articles )nay lodge between the cheek and ginus. Speecli may be affected, while attempts at Avhistling or laiigliing accentuate tlie paralysis. Prognosis. — This is good for iliose cases due to sudden eliilling. Pressure palsies at birtli may reco\-er in \\'liole or in part. If due to destructi\'e disease in llie jietrous jiortion of Ihe temporal heme or to intra- cranial diseases, tlie jirognosis is ))ad. Following operative procedures the Fk;. 1:!S.— Facial r,iral\- prognosis depends up(]ii ilie amount of traumatism ihe nt'rve lias sustained, and many of these cases slowly recover even after complete section. Treatment. — In the mild cases recovery -will tal-;e ])lace witliout any treatment. The gahanic curi-ent is used in the severer cases and in those whidi follow operative procedures in conjunction with massage and mild viljiatory treatments. As the power returns tlie child may be encouraged to exercise tlie muscles by imitating grimaces or blowing u|ion musical instruments. IF a neglected otitis media is the cause, surgical procedures are indicated. CHAPTER XXXVI. DISEASES OF THE SPINAL CORD. Myelitis. Myelitis or inflammation of the spinal cord may be divided accordino- to tlie course into an acute, a subacute, and a chronic form. Etiology. — It may result from severe injuries or even considered mild in character. It may follow the acute infectious fevers and septic processes anywhere in the body. It may extend or result from a meningitic process. It may also be caused by new growths in tlie spinal canal. Syphilis and Tott's disease, however, are the two causes which are most common in children. Pathology. — The coi'd on section, in the affected areas, shows a congestion of its juen- inges, while tlie cord itself has 'been changed to a soft pulpy mass. The white matter is with difficulty distinguished from the gray. Minute capillary hemor- rhages are found throughout the gray matter and the cells in the anterior horn show mai'ked de- generative changes. Tlie blood- vessels of the cord are dilated witb proliferation of leukocytes, ania- lacious bodies, and degenerated axis-cylinders. In the subacute or chronic forms some evidences of sclerosis may be found. Symptomatology. — In acute myelitis there is a sudden onset with a temperature which may rise to 104° F. as a result of the infective process. Painful areas may lie elicited on pressure along the spine or the tenderness niav be sulijective. 4ri3 Fiu. ly.t. — Lumbar myelitis, showing traetures and deformities. 41)4 DI.Sl:.'.Si:.S OF CIIILDI.'KN. Clinical evidence will soon appear of functional disturbance of the cord and will vai-}- with the intensity and localization of the process. The myelitis will ait'eet motion and sensation and derange the functions of the bladder and rectum. Paraplegia results, and anesthesia will be present in the parts of the bod}' supplied by the nerves which originate below the involved area. Thus there is loss of such sensory impulses as pain, touch, thermal and muscular sense. A hyperesthetic zone, due to the irritation of the nerve fibers may be present above the anesthetic area. The reflexes are disturbed depending upon the area involved. Fig. 140. — P.pd-sores in myelitis. Cervical lesions cause a paralysis in all four extremities. In the arms it will be flaccid in type, while in the lower extremities the palsy will be spastic in character. The whole body is anesthetic below the neck. In the dorsal region which is most commonly affected in children the upper extreniitii'S are not involved, while the lower become spastic. The patellar and plantar reflexes are increased and ankle clonus is present. Lumbar lesions produce a flaccid paralysis in the lower extremities wliieli is later accompanied by some degree of atrophy. The urine dribbles away and the rcftuui is incontinent. The reflexes are lost and sensation is absent to a point above the lesion. Bed-sores, the result of trophic disturbances, cvstitis. and inflations of the urinary tract easily occur, and in fact may 31 DISEASES OF THE SPINAL CORD. 4!),") bring the case to a fatal issue. Contractures and deformities may result in the extremities unless measures are taken for their prevention. Diagnosis. — The etiological factor, the sudden onset, the paralysis of a flaccid type above and spastic below, accompanied with anesthesia and derangements of the bladder and rectum should make tlie diagnosis easy. Prognosis.— Lesions in the cervical region are the most dangerous to life. Myelitis in tlie dorsal and lumbar region maj^ cause death from infective processes arising in the bladder, rectum, or from bed-sores. The younger the cliild, the more imfavorable the prognosis. Syphilitic cases, if the diagnosis is made early, give favorable results under specific treatment. Treatment. — Acute Stage. — Absolute rest in bed on an air mattress is essential. Ice bladders may be placed over the spine while the fever is active and for the relief of pain. The bowels are emptied by a brisk cathartic, and the bladder relieved by an attendant accustomed to surgical cleanliness. In syphilitic cases the mercurials with the iodids are given. If there is intolerance to these, tlie mercury may be given by inunction. If a specific infectious process can be demonstrated, such as streptococci, and isolated from the patient's own blood, treatment by vaccines may be tried. Bed-sores must be guarded against by scrupulous cleanliness, fre- quent change of position, and the daily application of alcohol or astringents. If they do develop they should Ix- thoroughly cleansed and treated with stimulating antiseptics, such as silver nitrate. After tlie subsidence of the acute symptoms, skilled massage may be employed in conjunction with warm tonic baths. Arrangements should be made so that the child can be taken out of doors on a roller bed or chair so that its nutrition may be preserved and its desire for food stimulated. Multiple Sclerosis. (Dixnciiiiiiated ficlerosiii.) The disease may have its inception in, or it may he associated with any of the acute infectious diseases. Pathology. Throu.ghout the central nervous system patches of sclerosis are found. They may he more frequent in one area than in another, invading the brain the pons, the medulla, the lateral and the posterior columns of the spinal cord or even the spinal roots may lie affected. Closer examination shows that the myelin sheaths of the nerve flhers are destroyed, althoush the axis-cylinders in the sr-lerotic areas do not suffer. Symptomatology.— At first there may he weal^ness of tlie upper and lower extremities accompanied witli some trembling of the hands and the development of a spastic gait. This is followed by an intention tremor which is quite char- acteristic of this disease, and which is accentuated by voluntary action on the part of the patient. It disappears when the extremity is at rest. Later in the disease the tremor mav be so intense as to prevent the ordinary activities, as dressing or eating, etc. ' A speech defect now appears; it is slow, deliberate, care- ful with a tremulous character. It is spoken of as scanning speech. Xystagnuw or oscillation of the eve-ball appears at this time and is especially marked when 496 DISKASICS OF CIIII.DtlEX. lateral movements are attempted. The pupils usually are contracted and reaction of accommodation to light is sluggish. The mental faculties heeome impaired, memory particularly is poor, and sudden emotional changes occur on the least provocation. The expression of the face becomes dull and stupid. A spastic form of paralysis, not very apparent at first, later becomes well-marked, producing a spastic gait. As the disease advances the tremor becomes so intense that walking is impossible, and finally the patient is bed-ridden. After a long and tedious course the disease finally ends fatally, the patient dying ot some intercurrent disease. Treatment.— All that can be done for this incurable disease is to regulate the life of the patient so that an unusual amount of rest is secured and the nmscles kept in good condition by baths, massage, vil>ra- tory treatment, and the galvanic current. Drugs do not influence the disease, and if given at all they should be prescribed for symptoms as they arise. Hereditary Ataxia. {Frlcdrcidi'x Ata.riri.) This is a disease occurring in the meml)ers of the same family and characterized by an ataxia with a slow but progressive course. Etiology. — The disease is hered- itary in character, passing often through several generations. The males or the females of a family in- herit tlie dise.ise. The si)inal s.vmp- toms in some cases predominate, and in others the cerebellar are more in evidence. The spinal form occurs in the ages of four to seven, while the cerebellar foi-m is rarely .seen before the twentieth year. Pathology. — The changes found are in the posterior roots. There is sclerosis of the posterior columns. Tlie spinal cord as a whole is smaller than nornnil. In some cases the lateral tracts and the columns of riai'k are atrophic, especially in the tyi)e known as the cerebellar, in which tliere is a marked diminution in the size of tlie cerebelhnn and de- generation of its nerve tracts. Symptomatology. — Tlie gait is the first symptom to .ittract atten- tion. Tlie walk is swaying in cliaracter, with the legs held apart (sailor fash- ion) ; i-ven while sitting and standing the patient cannot control his position accurately. Atbetoid inovements or tremors ai'e present, especially in the ex- tremities, riyiierextension of the great toe m.iy be an early svinptom and later deformities, as pes equinus, may develop. Romberg's symptom' is obtained in the Fig. lit.— Hereditary ataxia (Fried- rich's ilisciiKc). (Saclis.) DISEASES OP THE SPINAL f'OED. 497 Spinal cases, but is more strouf^ly iiiarlied in tlie cerebellar type. The patellar reflex is variable and inconstant, and cannot be depended upon for much diaji- nostic aid. The cutaneous reflexes also remain quite normal. Atrophy of muscle after a time occvu-s and produces such deformities as scoliosis and thus destro.ys the normal spinal curves. Nystagmus is a quite constant symptom. The pujiils are normal, but other ocular disturbances, as ptosis and strabismus, occur. 0])tic atrophy is not rarely found in the later stages. Dysarthria is commonly present. Sensation is uninqiaired. Tlie spliincters do not suffer. As the disease pro- gresses signs of failing intellect are observed; these may be preceded by dizziness or hysterical phenomena. Differential Diagnosis. — Tabes dorsalis may be differentiated by the alisence of lightning i)ains and spliincteric changes, and again the .ataxic gait is rarel.v seen in infantile tabes, v^iiile the pupillary changes are freiiueut. New growths of the cerebellum might sinnilate a l>eginning ataxia, but the course is more rapid and there is headache and vomiting. Course and Prognosis. — The disease is extremely slow in its progress. Eventually, after years, the jiatient is lied-ridden after the musculature is in- vaded. Death occurs from some intercurrent njaladv. The prognosis is invariably bad. Treatment. — A nutritious diet, massage, hydrotherajw, and the best )iossible hygienic surroundings are our only recourse. Medicinal treatment is symptomatic only. Iron is necessary for the anemia. Primary Myopathy. [ILusruhir Diistriiiiluj : Irliniialliir j]htsnil(ir Alroplii/.) Eor tlie purposes of clearness and to prevent tlie confusion wliicli must arise in the mind of tlie reader attemptinfj to pain information on tliis topic, we will embrace all the various described types under this one general title of the myopathies. Clinically, these ty]ies have lieon separated on a basis of ase, as the juvenile (Erb type) and the infantile type; on an anatomical basis, for example, the facio-scapulo-lmmeral type (Landouzy-Dejernie) ; and still another type is based on the distal involvement, i.e., those in which the proximal parts of the body remain intact for many years and only the distal parts are affected ; finally on an objective basis, in wliich there is enlargement or apparent hypertrophy of portions of the body (pseudo- hypertrophic muscular paralysis of Duchenne), Pathological classification offiTs no relief at present fi-oin the aii]iarent confusion, as the study of muscle components and muscle embryology Jias not as yet advanced sufficiently to warrant such a classification. Etiology. — Gowers suggests that the myopathies are duo to an inherent defective vital endurance. Collins says they are an expression of prenatal inadequate endowment. Maternal heredity seems to have a distinct place, ■while paternal heredity because of the early impotency of the diseased father is to be disregarded. Several members of one family may be attacked. The affection tisually begins about the sixth to the eleventh years of life, although cases have been reported occnring at birth, and as late as the thirties. Boys are more frequently seen with the disease than girls. A 49S DISEASES OF CIIIl.DRKN. liistiii y (if trauma is often given as a cause by tlic parents, but may be dis- regartliMl in a disease of tliis eausation. The acute exanthemata, especially scarlet fever, may so lower the resistance that the disease is more readily usliered in. Pathology. — A'arious anatomical changes have been found, but the reports are various and confusing. Tlie nervous system does not seem to be involved in sn far as modern teclmic can discover in the normal case. Gowers rejects the theory that the disease may be a tropho- neurosis. Tlie cells in the dorsal ganglia have been found shrunken liy Brooks and others. Tlie muscles themselves show the true pathological changes. Atrophy and hypertrophy of muscle fibers may be seen in the same specimen. Fatty deposits and con- nective-tissue increase are likewise found. In some cases (the pseudoliypertropliic type) tlie adipose tissue is in excess, while in others (the so-called sclerotic type) the connective- tissue elements pi'edominate. In the latter form the muscles liecome firnr and thin and later simply degenerate into fibrous bands. The lipomatous type is never hard, but soft and flabby. Symptomatology. — The first symptom noticed mav be a weakness in walking or clumsiness in going up or down stairs ; later the child stumbles or falls on slight provoca- tion. These symptoms come on very gradu- allv, so that they are often considered negli- gible in tlie dispensary ]iatients, especially as they seem to be physically in verv good con- ilition. The calves may seem to the laitv to be unusually well developed. When the dis- eas(> is more advanced the gait becomes waddling, tlie legs are not lifted mucli from the ground. If a test is now made a very eharaeteristic attitude will be assumed, namely that of "climbing up on himself;" especially if the patient attempts to pick an object fiom tlie floor. If placed on his back on llie floor, the ]iatient is obliged slowly to turn face downward, get on his knees with the aid of bis arms, then raising liis knees he forms an arch and now by grasping his Fir;. 142. — Pseuclo-musculav li.v|)ertro|iliy : unto size of calves as coiiipared to up- Iier pxtreinit.v. DISEASi:S OF THE SPINAL COED. 499 knees he works liis hands liiglier and liiglier up the thighs nntil he can assume tlie erect jjosture. In advanced cases even this is impossible and the child is finall}- hed-ridden. The knee and ankle I'eflex are diminished, and in terminal stages entirely absent. The posture is also quite characteristic. Lordosis is sometimes seen quite earlv, and at this time it disappears if the child is asked to sit down. As the disease advances, the lordosis is more marked, the head aud pelvis is lield well back and no change is observed in the sitting position. The Fig. 14.1. — I'usitioii taken by tlie m.vuijatliic when rising from the tlcior. ( Collins.) face loses its original C-xpivssion, becoming dull and mask-like. When the disease is well advanced even closure of the eye-lids is accomplished with difficulty and articulation is imperfect. All tliese changes are due to atrophy of the facial muscles in some degree. The lower extremities, while mainly involved, are not alone afEected. After several years the shoulder group muscles begin to lose their power, the patient is unahle to raise his 500 DISEASES OF CTITLDIiEN. arms and flex his elbows, but tlie\- still are able to perform the finer move- ments of the liand. The supraspinatus muscle Gowei'S describes as being almost tlie last to become affected. The atropine muscles allow the shoulder blades to recede from the thorax, forming the winged scapula' so often observed in the myopathies. Electrical E.raiiiinaiion. — TJeaction of degeneration is not obtained. There is, however, lessened excitability to both currents. Complications. — Fractures, contractures, and deformities may occur in these cases. The fractures are due to the stumbling or awkwardness of tlie patient. "\'arious theories have been advanced by neurologists for the contractures, but suffice it to say, that thev are of all possible varieties that are reducible and subject to relapse. Collins and Climenko give the following order in which the muscles are in\'olved : Drnse. Tliirl-ened ^[uscJes. — Calves, sartorius, glutei, triceps, deltoids, infrasjiinati. Afrophj/. — Pectoralis major, trapezius, serratus magnus (anterior portion), latissimus dorsi, biceps, ([uadriceps femoris, abductors. Differential Diagnosis. — The characteristic features are the disin'o- portionately enlarged calves, the peculiar facies, the gait, the lordosis and the peculiar attitude assumed when arising from the prone positioTL, Atypical cases are often puzzling and must be diffei'cntiated from antei'ior poliomyelitis in which there is a regular corresponding distribution of the affected muscles to the portion of cord involved, while in dystrophy this is not so. In chronic progressive anterior poliomyelitis, there is, besides the regular muscle grouping, the reaction of degeneration and the absence of pseudohypertrophy. In syringomyelia the early involvement of the finger muscles serves as a guide, for in the dystrophies these often remain unaf- fected to the last. Progressive muscular atrophy may he confusing, but Ihe age. the origin in the digital muscles and the fibrillarv twitchiugs which are present will distinguish the disease. Treatment. — These cases, unfortunately, are not amenalile to cure. Much can l)e done, however, by obtaining complete control of the patient's daily life. Directions should be given to supply a liberal nutritious diet. "Rxeicises should lie cai'efully carried out, especially valuable being those of the resistant form, the |)hysieian or a trained assistant shouhl by example teach the child tlie various movements. "Rlectricity will assist the g>'m- nastic movements if the faradic current is userL Massage will keep up to some extent the muscle nutrition. The orthopedist must be consulted and defoi'milies corrected in their incipiency. CITAPTEK XXXVII. DISEASES OF THE BRAIN. Meningitis. Pachymeningitis, an inflammation involving the dura mater, is rare in early life. It may occur in connection with injuries of the skull or ear disease, and, in acute cases, usually affects only the external portion of the dura. A more chronic form is seen in connection with hemorrhages on the vertex, when the pia as well as the internal surface of the dura are involved in the inflammation. Such hemorrhages are liable to occur in feeble infants sufl^ering from some exhausting disease. This low grade of meningitis is more apt to be discovered at autopsy than during life. Acute leptomeningitis, or inflammation of the pia, has already been described in its two most common forms — acute cerebrospinal meningitis and tuberculous meningitis. There is, in addition, a form that may be different in its causative factors from these two varieties, although there is a certain similarity in symptoms. Etiology. — Instead of the diplococcus intracellularis or the tubercle bacillus acting as a cause, we may have a number of organisms, seen in connection with injuries of the skull, ear disease, or various infectious dis- eases, producing inflammation of the pia. In these cases it is more dis- tinctly a secondary disease. Any traumatism of the skull from falls or blows, suppuration after cranial operations, disease of the middle or internal ear or mastoids, can afford access to the various forms of streptococci or staphylococci that may attack the pia. It may also be affected by the pneu- moeoccus, the typhoid bacillus, the influenza bacillus and rarely by the Klebs-Loeffler bacillus and the gonococcus. A meningitis may thus be seen in connection with pneumonia, typhoid fever, influenza, scarlet fever, diphtheria, and as a terminal infection in almost any chronic infectious disease. Symptomatology. — The symptoms of all varieties of meningitis are generally alike, although differing somewhat in the course, rapidity and sequence of the various manifestations. As a secondary condition the symptoms are apt to be masked at first by the course of the original disease. The occurrence of projectile vomiting, convulsions, irregular respiration and pulse, stupor, or coma, will call for a diagnosis of meningitis during the original infection. The symptoms will vary according to the part of the brain involved, "\^^^ere the inflammation involves principally the convexity, as may be seen in pneumonia or malignant endocarditis, there inay be no symiptoms besides the stupor to distinguish it from the original infection. g02 ■ DISKASRfS OF flllLDnEN. Where the inflainiiiation is at tlie base of the brain, the cranial nerves are apt to become involved and there will be various paralyses and some retrac- tion of the head. Wliere the inflammation extends from the middle ear or mastoid, meningitis at the iDeginning will be unilatei'al and may continue so during the course of the disease, and facial paralysis may ensue on the affected side in addition to tlie other symptoms. The meninges over the first and second temporal convolutions are apt to be es])ecially involved in the ear cases. In all varieties, when the meningitis is well under way there will be hyperesthesia of the skin, and there may be local or genei'al convul- sions, ])lioto]iliobia, stupor oi' conur, and irregularities of tlie ]mlse and respiration. The temperature is irregular and is influenced by the primary disease. The duration of secondary meningitis is usually short, from a few days to a week, and the prognosis is bad. We have, however, seen a few cases recover where the original disease was controlled and the ]neningitis apparently not extensive. Diagnosis. — Lumbar puncture nniy aid in differentiating the various forms of meningitis by a discovery of the causative organism in the fluid withdrawn. On the clinical side the secondary nature of the meningitis vill be shown by its onset during the course of some general infectious diseases or when there is a recognized lesion in the ear that is prohably being treated. Acute cerebrospimd meningitis is sudden in its onset, without anv previous disease, and as the lesion is apt to involve all the surface of the hrain as well as the cord, the symptoms are general and severe from the first. Tuber- culous meningitis is verv slow and irregular in its onset, sometimes taking as long as several weeks to attain its maximum intensity, and the brunt of the lesion is usually at the base of the brain. Treatment. — Tlie pi'incipal effort must be directed toward a free drainage of any localized suppuration in the ear or skull that may be caus- ing the infection. We have seen eases of sinus thrombosis inducing menin- gitis, lioth relieved liy surgical measures. The general management is the same as in other forms of meningitis. The bowels must be freely opened and bromids given to relieve pain. An ice-bag may he intermittently ap- pli(Hl to the head, and, if there is much evidence of intracranial pressure, lumbar puncture may bo employed. Small doses of iodid of potash may also be tried. The nourishment must consist of milk, meat hrotlis, or similar easih' assimilable foods. Acute Encephalitis. This is ail inflamniatinii of the lirain tissue usually oceurrins in conneetion with iiK'niii,t;itis froii) an extension inward of the inflannniitor^' process. The symiitoins arc largely the same as those caused liy inflammation of the pia. They will vary, hnwevei-, as to whether the convexity or hnse of the hrain is the prin- cipal seat of the disease. In the former ease there will be convulsions, paralyses, DISEASl'S OF THE BCAIX. 503 anil coma, and iu the latter cranial nerve paralyses will f(jrm the dorulnant symp- toms. Strtimpell describes a hemorrliagic encepbalitis occurring in connection with influenza or other infectious disease. It may then be seen without a coex- isting meningitis. There is severe pain in the head, followed by stupor and eventually by coma. In other cases there will be great restlessness, alternating with drowsiness. There is apt to be rigidity of the neck ; in some cases there may be loss of power in an arm or leg, and in others hemiplegia may ensue. Fever is present and the pulse and respiration are irregular. In nuld cases, recovery may occur after one or two remissions, but, in the severer types death usually takes place in coma after an interval of from one to three weeks. The treatment is the same as in meningitis. Epidemic Encephalitis. (Eiiccplialitix Irtliarriica : Hl(C]>hi(i Sickness.) Recently much notice has been attracted to ttiis disease following the great pandenuc of influenza. At different times following epidemics uf influenza iu various (.-ountries oliservers have noted encephalitis of a peculiar type in v.-Uich lethargy or unusual somnolence prevailed. The disease has clinical manifestations with deSuite features and it is un- doubtedl.v a generalized infection due probably to a virus. Tilney separ.ites it into ten forms in which the title gives a clue to the prevailing manifestations : 1. Lethargic. 2. Cataleptic. 3. Paralysis agitans type. 4. Polio-encephalitic type. 5. Anterior poliomyelitic t.vpe. 0. Posterior myelitic type. 7. Choreo-athetoid type. 8. Acute psychotic. 9. Manic and epileptic. 10. Newborn. Symptomatology. — Certain only of these forms need concern us in pediatric practice. Marlced letbarg.v or sonmolence, following a history of influenza, with involvement of the cranial nerves, plus an asthenia out of all proportion espe- cially if there are present an.v of the symptoms enumerated under encephalitis must lead to a consideration of this disease. The spinal fluid shows little or no change and differs in this respect from poliomyelitis in which there obtains an increase in glol>ulin and cell count. The course is slowly progressive. A guarded prognosis should be given especially when the cranial nerves are affected. Abscess of the Brain. Cerebral abscess, single or nailtiple, may occur in early life. The wliite matter is more apt to undergo suiipuration than the graj- matter, and hence abscesses form more frequently within than on the surface of the brain. The temporosphenoidal lobes, the frontal lolies, and the cerebellum are most frequently attaclced. Etiology. — Boys are more often affected than girls, and the most frequent cause is ear disease, especially if there is a secondary inv(dvemeut of the petrous portion of the temporal bone, when the abscess is usually located in the tem- porosphenoidal lobes or occasionally in the cerebellum. Injuries of the skull due to trauma and sinus thrombosis occurring in connection with such injuries or with ear disease may caues abscess. Infective processes within the nose may spread to the brain and induce an abscess, and rarely septic emboli from pus formations in distant parts of the body may be carried to the brain and produce a similar effect. Symptomatology. — As the abscesses do not commonly form in tlic motor area of the brain, the objective symjitoms are often very oliscure. If. Iinwever, the abscess does form or spread into a motor area we will have localized symptoms, ^)04 lUSIOASlCS OF CUILDKEN. tlie same as seen in the pressure effects from tumors or hemorrhage. The early symi)tonis are much the same as those of meuiiigitis. There is vomiting, ijuin in the head, fever, and occasionally localized or unilateral convulsions. The fever is irregular in type and may be accompanied b.v chills. If these symptoms ensue in connection with acute or chronic disease of the ear, traumatism of the cranial bones, or more distant foci of suppuration that ma.v give off septic emboli, we may suspect cerebral abscess. In case the abscess becomes encapsulated, there may be no symjitoms at all, in this respect differing from the disturbing effects of solid tumors. Optic neuritis is occasionally present. Where the abscess is located at the base of the brain, the different crauial nerves may become affected. If the speech centers are involved in the abscess, asphasia may be noted. In some <'ases the pus may rupture into the ventricles, thereby producing serious and iirgent symptoms. Diagnosis. — It is often impossible to differentiate abscess from meningitis, encephalitis, or tumors of the brain. If, in connection with the symptoms of brain disturbance seen in common with the latter conditions, there is a high irregular fever with chills, and if ear disease or trauma of the sIvuU exists, we may strongl.v suspect the formation of an abscess. A differential blood count and lumliar puncture may aid in establishing the diagnosis. Prognosis. — The prognosis is bad, but if the abscess can be located and treated surgically, recovery occasionall.v tal^es place. Treatment. — Any suppurating area involving the ear or bones of the skull must be carefully watched and thorough drainage maintained. If the symptoms ]ioiut to internal abscess the surgeon must trephine and endeavor to open and drain the abscess. The first and second temporal convolutions are most often the seat of abscess following ear disease. The deeper-seated abscesses may be located by inserting a needle into the part of the brain suspected. Brain Tumors. Tuberculous tumors predominate, consisting usually of a caseous tumor of the cerebellum. Gliomata, sarcomata, and cysts occur usuall.v in the cerebellum and pons. Males are more ju'one than females. Infants under six months very rarelj- Lave brain tumors. Tuberculous and sarcomatous growths are secondary to growths elsewhere in the body. Symptomatology. — Tlie symptoms are produced by iJressure. Irritation, exu- dation, or interference with the blood supply and vary also with the location involved. Headache. — This is persistent and I)oring in cliaracter, causing restlessness, insomnia, rolling of the head, cephalic cry, and pliotophobia. Occasionally the liain is well localized at the site of the tumor. Waiisea and Voiiiithnj. — This is iiersistent and without causal relation to food. It is projectile in character. Vertigo or dizziness are common symptoms, elicited by change of position. The gait may be reeling. Ocular siiniptoms are particularly helpful — optic neuritis in one or both eyes is usually present, and especially so when the cerebellum is aft'ected. Optic atroiihy may follow and is seen early if the chiasm is involved. Convulsions occur when the cortex and motor areas are involved. They are general or local in character. Tumors which have not as yet invaded tlie cortex produce iiaralysis and later convulsions. Loeulizution. — Special symptoms will he caused by involvement of areas with Icnown functions, and are not different from those manifested in adults. They will not be enumerated here. Diagnosis. — From abscess of the brain, tumors may sometimes be distin- guished Ijy the absence of local causes, lack of temperature, and the slower course. Septic symptoms, if present, are indicative of abscess, and are confirmed by blood examination. Macewen's sign may be of help if otlier confirmatory signs ere obtained. Tuberculous tumors occur geiu'rally in tlic cerelM-llum, and there may be IJISEASICS (IF TJIE BliAlX. 505 evijeuces of tuberculous infections elsewhere in the body. Lumbar puncture should always be iierformed if any doubt remains, as a cell count and chemical analysis may give considerable assistance. Treatment. — Oiierative jirocedures are carried out with great risk in early life even when the conditions for removal of the growth are favorable, but often this is the only hope for relief or cure. The operation of decompression can at least be done to i-elieve intracranial jn-essure. Medical treatment should be dires may be required to prevent this, but they must be applied with care, as extreme Fig. 144. — Spastic paraplegia : cross-legged progression. 5 OS DISEASES OF ''IIIJ^DEEX. pressure from this source nui\' likewise pru\o]\e a lieiuorj'liage. Li'landular extracts as pituitrin, and tlie narcotic drugs (twiligiit sleep) should tie given cautiously to prevent injurious action on the unborn. After labor, if there is any evidence of cerebral injury, extra care must be taken to keep the infant very quiet. If it cannot suckle, the mother's milk may be carefullj- given by a medicine dropper. Where there ai-e twitchings or convulsions, small doses of bromid of sodium (3 to 3 grains) may be given every few" hours. A lumbar puncture may give direct evidence of the hemorrhage, ia which ease operative relief should be consi fluid within the cranium, which may be as nuicli as Ti/lOO c.c, does not alloAv normal ossification to take place; hence 2. Acquired bydrocepUalus UrSHASES OF THE BRAIN". 50!) llie tremendous enlargement of the vault; the sutures are wi. Have 4 pieces of colored paper, red, blue, yellow and green. I'oint to each, asking, " What is this enJorV " (No error allowed.) MOKONS. Mental Ace ^ Years. 'II. (:\) " I>o ymi know what paper is? " " Tut you know what cardboard is? " "Are they alike? " ■■ In what "way are they not alike? " ll)) "Have you ever seen a fly?" "Have you ever seen a butterfly?" "Are they alike? " ■• In what way are they not alike? " (e) "Do you know wood when you see it?" "Ho y<.u know glass when von see it? " "Are they alike? " " In what way arc they not alike? " (Two satisfactory answers required ) ?.2. " I want you to count backward from 20 to 0. Like this — ^ ij(>-l'.)-l,s." (This must be accomplished in 20 seconds; one error alloweei'formed as early as possible. The sur;:eon who is to operate must decide upon the preferred age. which depends u))on the character of the opei'atiaii and the nutrition of the cliifh Some sn}',i;eons operate at the end of the second Year, while others pu'cfer to wait until the arches are well develo]ied. Congenital Branchial Cysts. f'ertaiii tumors of tlie Tieck in infants and younj; ebildren have tlieir ciritciii hi .in incciniiilete closure of nne iif the liranchial clefts. Earl.y in the fetal life of the vertehrata fliere ;i])iie;irs under thp pro.ieetins frontal ])rocess a series of four iilati's, lionndin.r the cavity of the phar.vnx on the side. These plates unite to fiiriii fiair jiarallel iirches separated by transverse clefts. The branchial clefts luiile, anil by a ]iri»-ess nf ni(ir]iliiiloj.'icaI chanj;e form v.irious structures of the, neck. If this i-etcnlar process of develiiiiment is interfered with from any cause, various abnornialities may result, as a condition intended to be merely tem- jiorar.v remains more or less iiermanent. Hence, .iciordiiif; to the various ijrades of arrested develoianent. we may have marked defnrmities, branchial cysts, or the rem.ains of fetal eiiitbelial tissue destined to pi-oliferate at a latei' day and form a cyst. There likewise may it'sult flstulous tracts from non-union of the brnnchi.il clefts, particularly from the lowest one. These have been divided into: (.11 coniiilete branchial fistula-, open the whole length of the trai-t; (b) fistula' havinj: only an external nrifice and endiiis; in a cnl-de-sac. which is the <-oninionpst form: (c) fistula' with only an internal orifice. More frequently the Iiranchial tract is close<] at both the pharyngeal and cutaneous ends, and n cyst is formed between, Senn has made the following classification according to the cystic contents : 1. ]\Iucous branchial cysts, due to imperfect closnre of the u|iper iiurtion of the branchial tract with retention of i1;s jihysiologicai secretinn. 2. .Vtheromatous branchial cysts, usually located in the second iind tliird br.'inchi.-ii tracts in the region of the hyoid bone, :'.. Serous hi'anchial cysts, having a Ihin-waHed capsule lined with pavement eiiithelium, and following the defective obliteration of any of the branchial clefts. 4. liemato-cysts of branchial clefts, in which the serous lluid f tlie radius Talipes. {rhih-f„ot.) Congenital talipes resnils fidiii iiialforniation or lack of development of tlie bones about tlie ankle. .V small uterus with deficient liquor amnii ma)' produce a talipes by abnormally coniiiressiriij; tlie ))artp. the nonual position of tlie feet in iilcro beinfr a tali]ies varus. All acquired talipes are due to patbolocjical conditions', for example, follo^vinf: anterior poliomyelitis or contractions of tissues after extensive CONGENITAL IMALFOKilATIONS AND DKFOltMITIEa. 335 burns or diffiuse suppurations, and as tin? result of the overaction of certain muscle groups when the nerve trunk supplying their e <-M ^K - iP^ f; Br * ^ A '^m r" -"^v , W' ;^S ^^ '^ ■ ^„,,jp *^ im W^^: ,-J-Sb ^m ^ ^^^^^H Fig. 158.- — Webbed fingers. Fio. 1~>9. — Snpernumerar.y thumb. In meningocele and encejilialoeelc the prognosis is hetter, especially if the tumor be small. Treatment.— Treatment in these cases is of little avail, although the withdrawal of fluid and even stimulating injections have heen tried. 33 528 DISEASES OF fltlLllliliN. Spina Bifida. Owing to congenital failure in the development of the vertebral arch, one or more of the lamina^ may l)e absent, with resulting protrusion of the spinal meninges. Tlie lumbar region of the spinal column is tlio part usually affected. Occasionally, however, we liave meningocele or enecplial- ocele. Tlie tumor is round, fluctuating, and liy compression the cerebro- spinal fluid can be forced back into the spinal canal. Too severe jiressure, however, mav ]u-odnce eclampsia or other grave cerebral s\iiiptoms. The Fig. IfiO. — Menhiijocele. base of the tumor depends upon the size of the opening, being pedunculated if it is small, but ]uore sessile if large. The tumor is usually covered with skin, whicli, however, may be absent, exposing the dura mater. If tliere is not much tissue covering the tumor, transudation may occur through the walls or rupture of the sac may take place if growth is raj)id. Some portion of tlie lower segment of the cord or the cauda cipiina is a])t to be imprisoned in the sac. The extent of the involvement of nerve-tissue can be measured by the paraplegia or other evidences of lesion in the spinal cord and nerves. COXGKXrrAL ilAU-OEMATlONS AND DEFOKMITIES. oJiyt Gradual absorption of the fluid iiia}' occur, and tlie cliild iiia\ grow up witli little incon\enience from tlie slirivelled tumor. Tliis, ot course, takes place onlj- wlien tiie nerves are not involved. In juost cases there is a gradual increase in the size of the tuuior, with final ulceration or rupture, followed by convulsions or coma and deatli. The fatal ending mav also come witli a gradual emaciation accompanying paraplegia. Treatment. — Tlie treatment of small tumors consists in tlie apiilica- tion of a soft compress to a\oid friction and to support the parts. When the tuuior is growing, howe\er, more energetic measures ma\- be tried. The simplest procedure is to withdraw the fluid by aspiration, and follow this Fh;. nil. — .S|iina liitid.i. witli gentle but constant pressui-e. The fluid must be slowly ami cautiously removed, for fear of active nervous disturbance and even eclampsia. Injec- tions with iodin of various strengths have been tried, but without much .success. In some cases tlie tumor can be surgically removed by completely excising the sac. This may be successfully accomplished in the peduncu- lated variety where the opening in the lamina is small. It should never be attempted if there is evidence that the cord or cauda equina may be involved in the tumor. Radiographic e.xaniination should be made in all cases in which it is proposed to do surgical work, as in this way the operative cases often can be separated from the non-operative variety. SECTION XV. THE COMMONER SURGICAL DISEASES. CHAPTEli XXXIX. THE COMMONER SURGICAL DISEASES. Anesthesia. Tlie adniinisti'ation of an anestlietie io a cliild i< oftei: i-ifjlitly viewed ■ivitli apprehent^ion liy tlie practitioner, and (piestions arise as to tlie ))est jiietliod and safest anestlietic to employ. Tlie same ]ilienomena are obser\'ed in earh- life as in adults, but tlie mai'gin of safetv is less, and tlms the nse of any anesthetic slimdd be re- garded as a factor by itself and piven the consideration it deserves in rela- tion to the ape, the jiliysical condition of the ]ialieiit, ami the chai'acter of the operation which is to lie undertaken. It should be I'ecollccted that anv anesthetic given lieyond lis ]n'0|"ier limits is a canliac depressant. Choice of Anesthetic. — >"tlier is jireferahle if the anesthetist is not tlioroupiih ex)ierienced : if the pei'iod of insensibilitx' is to lie a lonp- one: in cardiac diseases and in opei'ations for the relief of olistrncted resi^i ration, as Ludwip's anpina, ]ia]iillomata of the lar\iix or deep cervical adenitis. It is also to Ije jireferrcd if the jiatient must be ke]it in an erect or semi-erect posture. Chloroform in the hands of an exjicrt in anesthesia is sometimes prefer- ahh' to ether. C'liildi'cn are rapidlv liiTiupht under its influence, as thev usually ci'y and thus insjiii'c rapidly, b'lentv of aii', constant vip-ilance, and the utilization of the dro]i-hv-dro)i method, dejiendinp on each minim admin- istrri'd to add io the rff'ect. is tlic ]iro]ier ]irocedure. Tn minor snrpical affections in which onl\' a )ii'imai'\' anesthesia is ]-e(pn'i-ed, chloroform is of advantage, as the ]"iatient ra]iidly comes out of its influence without the nausea and voniitinp which are so often seen with ether. Chloroform is ]ireferable if ne]ihritic conditions are present, or a ])ossibilitv, as in sup])urative adenitis follo\\inc' scai'lalina. T.ividit\- of the lips, wilh an ashen-pale face and weak, slow judse. are iudica.lions that shoidd be met li\- immediately sto]i)iinp the anesthetic, indncinp free respirations and by liy|iodcrniatic stimulation. THE COiUrONEl! SCHGICAL DISKA8KS. r/M Gas-ether anesthesia, in tlie bands of professional ancstlietistn, is the method to be selected for older children, but in infancy and the first years of life the nitrous o.\id gas is poorly borne and liable to cause suffocative cyanosis. Anesthesia, according to the method of Schleich, or the spray method with ethyl chlorid, is satisfactory in the hands of those accustomed to them, but cannot be commended for general use. Preparation for Anesthesia. — Feeble children should not be denied food foi- a longei' period than three or four hours before administering the anesthetic. Often a small amount of a hot liquid, such as thin giiK'l, will be effective in preventing collapse of the infant. Tlie bowels slimild be moved liy a soap-suds enema, and in older children a dram or two of licorice ])0wdei' sliould be given the niglit before. As the bodily lieat is easily dis- sipated, especially in infants, they should not be unduly uncovered, and artificial heat may be applied dui'ing the operation with favorable effect. A jircliininary stomach washing in cases of intestinal obstruction with incessant vomiting should precede the operation. Hypodermocylsis and a nutrient enema may also be indicated in certain feeble or anemic infants in whom collapse is feared. Hernia in Early Life. Hei'nia occuts in young children as a result nf ari-est or defi'ctix'i' devel- opment of the fetus, which allows the pi'otrusion of some ol' the abdominal contents through a natural openinf;;. Etiology. — Hernia in early life uia\- be in the order ol' tlicii' fi-e(|ucncy, inguinal, umbilical, ventral, and femoral. Inguinal hernia occurs moi-e commonly in boys than in girN. and we are inclined to agree with Russell that this form is I'ssentiallv due to a pre- formed sac or an obliterated portion of the vaginal process. Such a sac results when a part of the peritoneum coming down in fiont of the testicle as it ]iasses into the scrotum in fetal life fails to lie obliterated and sepa- rated from the remainder of the peritoneal cavity. Thus oljlicpie or indi- rect hernia is congenitally formed. Coley suggests that the terms "con- genital "' and ''acf|uired" be abandoned and that we adopt instead the classification of total or partial funicular sacs. Direct and femoral hei-nias are in the majoiity of cases acquired, as they rarely result from congenital sacs. The most common predisposing causes other than the anatomic are constipation, pertussis, tympanites, crying, straining, and coughing. Symptomatology. — The sig-ns do not differ very materially from those found in the adult. A tumor may appear and reappear several times 532' i)isi;Asi:y of ciriLDitEX. before attention is diieeted to it. The tumor gives an impulse to the finger on erving or laughing; it may disappear spontaneously (m lying down; it may cause discomfort or even pain at this time of life, and if the intestine has protruded a sensation of gurgling is felt when the tumor contents slip into the abdominal cavity. Strangulation is not common, and when it occurs results from constriction at the external abdominal I'ing, from tough and inelastic fibrous bands or i-ings which may be found witliin the sac (De Garmo), or from focal impaction. The symptoms of this complication are. besides the tumor itself, nausea and vomiting, constipation with abdom- inal distention, ]iains of a colicky character which are increased on urination, increased pulse rate, a variable amount of temperature, restlessness, and if relief is not obtained at this point vomiting becomes stercoraceous with suijnorinal fviii])eratui-e. and a fatal issue will result. Diagnosis. — The differential diagnosis is given on page 464. Treatment. — The gi'eat majority of children under thi'ce years of age can lie cui'cd Ijy mechanical means. This imjilies the jiroper application of a suitaljle ti'uss. This should be made of hard rubber with a slightly con- vex pad of the same material, or consist of a water pad covei'ed with imper- vious, watei'-proof material. These are recommended because thev can be readily adjusted and kept clean. Leather trusses soon become soiled or soaked with rrrine and produce excoriation. The physician himself should select and fit the truss: the spring should be just strong enough to pi-o|i(u-ly retain the hernia even when the child cries or strains. It should be ap])lieit only in the pi'one position and worn continually day and night. Pai'ents should be warned not to unnecessarilv I'cmove it unless the child is hing down and the hernia meanwhile diaitallv retained. A cure is a'enerallv affected within a year, although it is advisable to retain the support for a year and a half. Tf after this time the tumor still protrudes on exertion, recourse must lie had to operation. Children over six years of age are rarely, if ever, crrred by the ap]ili- cation of a truss. The treatment of uiribilical hernia has been discussed and illustrated on page 14. 0))eration is indicated immediately in all cases of strangulateil hernia. Tt is necessary in hernia complicated with irreducible hydrocele, in femoral bornias, and in childi-en over four years of age who have not been cured by the application of a |>roperlv fitted truss worn over the prescribed period. TTie Eassini operation, which is founded upon the etiological factors involved in the production of hernia, almost invarinbl\' gives iriost satisfac- tory results in competeni bauds. THE COM.MOXKi; SFIJOICAL DISEASES. 533 Circumcision. Many male infants need circumcision. The operation promotes clean- liness and inhibits the formation of the habit of masturbation. In cases in which the adhesions about the glans penis have been sepa- rated and the prepuce still does not sufficiently retract, circumcision is indi- cated. It is certainly necessary in all cases in which the prepuce is tight enough to hold drops of urine or when it balloons out on urination. The prepuce should be so trimmed that the corona is covered and only enough should be cut away so that the prepuce can move freely over the glans. In this way its physiological purpose will be preserved. This operation should be performed in the early months of life. It should be unnecessary to say that surgical cleanliness is to be observed. With a pair of hemostatic forceps stretch the prepuce, and insert a director between it and the glans. Then incise along the dorsum in the middle line to a point just proximal to the corona. Separate all adhesions until the coronal sulcus is defined and remove all smegma. Cut away the redundant tissue, including both skin and mucous membrane from both sides down the frenum. After all the edges have been carefully trimmed put in three or four fine plain catgut sutures to prevent any exposure of raw surface. Bleeding is .slight and probably no ligatures will be required. Fse ]ilain gauze strips covered with sterile vaselin for a dressing. If the suture mate- rial used is non-absoibable, remove the .sutures on the fifth day and powder the wound with aristol. Appendicitis. Etiology. — Appendicitis is comparatively rare in early life. In in- fancy it is extremely uncommon. Invasion of the lymphoid structure of the appendix by bacteria is made possible by traumatism from within or with- out, bv intestinal parasites, mucous inclusion, or constrictions iiarboring fecal masses. From a pathological standpoiirt the disease in children does not mate- rially differ from that found in the adult. It shorrld be recollected, liow- ever, that the appendix in children is normally not larger in diameter than a goose-quill ; that it is more apt to be found in diverse situations, and that it normally lies higher in the abdomen. Suppuration takes place more readily and localized abscess formations are not unusrral. In quite a number of our cases, children with appendicitis were willing to walk about or sit up even when ulcerative conditions were subsequently found at laparotomy. Symptomatology. — In the acutp inflammatnri/ form the child may complain of indefinite colicky pains, which are often attributed by the par- 53-1 DISKAaES OF CIIILDKEN. ents to some indiscretion in diet, especially when vomiting occurs early. The fever is not liigli, rarely I'ising above 102° F. If the patient is walking about, he usually stoops, and his movements are made cautiously. After being placed in bed he may prefer to lie on his back, drawing np the knees to relax the abdomen. Although if asked to do so he may not hesitate to turn to either side or extend the thighs. The area of pain may not be definitely located by the patient in the right iliac fossa ; in fact, he very often refers it to tlie umbilical i-egion. Dysuria is often a prominent symp- tom in suppurative cases. Examination. — On inspection the contour of the ab->. again occurs, the abdomen is distended with gas, obscuring the liver dull- ness. When the peritonitis is localized about the caput coli the inflamed appendix may l)e walled off from the general cavity. This is indicated by a diminution of the general symptoms. An abscess may form within this area from perforation, gangrene or rupture of the appendix. Fluctuation may be obtained, but even before this a sudden drop in the temperature curve points to a focus of pus. A differ- ential leukocyte count will also act as corroborative evidence when the percentage of polymorphonuclear leukocytes is greater than eighty. Diagnosis. — Cases presenting the classical symptoms of pain in the right iliac fossa, with rigidity of the right rectus muscle, tumefaction, fever, and vomiting, should occasion little or no difficulty in diagnosis. Exam- ination under a general anesthetic may sometimes be necessary in doubtful cases, especially if a skilled surgeon is not at hand. Intestinal obstruction is to be differentiated by the absence of initial fever, the presence of a palpable sausage-shaped mass, tenesmus, and discharges of blood and mucus. Not infrequently a pneumonic process involving the base of the right lung causes pain which is referred to the ileocecal region, and the unwary may mistake this for appendicitis. Prognosis. — The tendency toward suppuration and the development of general peritonitis make this disease a grave one in early life. The mortality, however, will be distinctly lessened when early diagnoses are made^ followed b}^ prompt surgical intervention. Treatment. — The medical treatment of appendicitis should consist in immediately placing the patient in bed, allowing him to assume a position of comfort. A light ice bladder is placed over the point of greatest tender- ness. The bowels should be moved with a soap-suds enema. A liquid diet, consisting of milk, ice cream, and thin gruels, is given if the vomiting per- mits. The question of operation should be left to the judgment of a com- petent surgeon. Children bear the operation well, and, unless the circumstances contra- indicate it, immediate operation is to be preferred to the chances of perfora- tion or general peritonitis. Intussusception. {Invagination.) This very frequent form of intestinal obstruction in children is caused by a prolapse of a portion of intestine into the lumen of the adjoining bowel. "RTiile other causes, such as volvulus, Meckel's diverticulum, bands, and foreign bodies, may produce intestinal obstruction, they occur so rarely that they need not be considered here. 53C DISEASES OF CHJLDHEX. Etiology. — Wr are incliiK'd to IjL'licvc tliat the condition can be ac- -counted for by irregular peristaltic action taking place in a gut, tlie walls of which are thin and undeveloped and only loosely held by mesentery. Tlie exciting cause may be undiscoveral)le. We have s;'en it in breast- fed infants who appeared healthy in every way. Overloading of the intes- tine, producing fi'rnicntation, colic and an irritative form of diarrhea, may induce it. Constipation, tenesmus, polyjii in tlie intestinal wall, appen- dicitis, and catliai'tic drugs have been lield res])onsilile for its onset. Tt occurs more frequently in males and tlie nurjority of cases occur in poorly nourished children in tlie first year of life, the fourth to the sixth month being the time of greatest incidence. Symptomatology. — Tlie onset is sudden and acute in the majority of cases. Only in such situations as the rectum or low down in the colon may the symptoms come on at all gradually. .Vn infant apparently healthy may .siiddeulv begin to crv violentlv with pain whi<-h is usually regarded as colicky in nature, and the extremities may be kept incessantly moving. Vomiting soon occurs, and the child's appearance changes. The face is pale, showing nuirked evidences of distress and prostration. Tlie first move- ment of tlie bowels after the intussusception may contain a slight amount of fecal matter: thereafter the movements consist only of blood and mucus, which are passed with some tenesmus. The vomiting, which is almost pro- jectile, occurs at very frequent intervals, .\fter the stomach contents have been emptied, bile-stained mucus or even fecal matter may he vomited in the final stages. Tliei'e is little or no fever, hot tlie pulse is extremelv ra]ud and thready. On examination of the abdomen a sausage-shaiied tumor mav be felt, which, if firmly palpated, may feel harder. This tumor mav be found in different situations, but generally is found in Ihe loft iliac fossa along the line of the colon. Bi-manual rectal examination may confirm its pres- ence. Tn some instances it may protrude from the rectum and mav be mis- taken for a prolapse. Tt must not be forgotten that intussusception can occur witliout the presence of a ]ialpable tumor. i~^omelinies a dei^'Tssion or flattening in the opposite iliac fossa is observed. Fnless relief is ob- tained the prostration becomes more intense, while subnormal temperature and death mav ensue from exhaustion. Tases of spontaneous reduction and relief by gangrenous sloughing of the intussuseeptum have been reported, but are so rare as to merit recognition only as curiosities. Diagnosis. — This may be founded upon the following symptoms: The sudden onset, paroxysmal colicky pain, vomiting, prostration, with discharges of blood and mucus without fecal matter. Tn our experience dysentery is most often confounded with intussus- ception. The presence of some fecal matter in the stools, the constant fever. • THE COMMONEK SURGICAL DISEASES. 537 and the moderate vomiting, with prostration only proportionate to the severity of the disease, should distinguish the conditions. It should not be forgotten that there may be periods of comparative comfort in the early stages of the obstruction, which may disarm suspicion. Prognosis. — Unless the condition is promptly recognized and imme- diate treatment instituted, a fatal issue may be expected. The mortality statistics vary from 60 to ^0 per cent. The younger the infant the graver the prognosis. Treatment. — An attemjit and only one should be made to reduce the intussusception if the diagnosis is quite certain within a few hours after the onset of the acute symptoms. It may then be successful, especially if the invagination is in the colon. The child is placed on its back, the buttocks elevated, and a warm saline solution from a two-quart fountain bag, held four feet above the patient, is allowed to distend the gut. The fluid sliould be retained by holding the buttocks firmly together. A long, large catlieter is preferable to the ordinary hard-rubber tip. Wliilc the child is in this position gentle manipulations to assist t1ie I'eduction may be made. If the result is suc- cessful the tumor disappears with a gurgling intestinal sound. Undue efforts in tills dii-ection should not be made. If reduction is unsuccessful or the case of longer standing immediate operative interference is demanded. A preliminary stomach washing and stimulation hypodcrmatically in the form of strychnin or brandy, will better prepare the patient to withstand operative interference. Acute Peritonitis. In the New-born. — The diagnosis of the acute forms in infancy are too often made only at necropsy. This is so because of the uncommonness of the affection, the meager historv obtainable, if anv. the lack of distinctive physical signs, and the inability of the patient to relate subjective svmptonis. Fortunatelv, acute ])critonitis is not a frequent occurrence among children, although in the new-lwrn it is not as rare as is commonly sup- posed. Through the umbilicus, or skin, pathogenic bacteria may gain entrance and cause peritoneal infection. The streptococcus, and the bacterium coli communis can be held responsible for the majority of the cases occurring in the new-born, ^^^len a general sepsis results the diagnosis is not as difficult as when the infection is localized in the peritoneum. Symptomatology.— In the new-born, the disease must be considered when there is a localized umbilical infection followed by a sudden abrupt change in the infant's condition. The extremely rapid gasping breathing may first attract the attention of the attendant. The infant cannot or 538 DISEASES OE CHTLDKEN. will not nurse, the teniper.ituve is persistently liigli, 104° to 105° F. witli a rapid weak pulse. Tlie position assumed by tlie infant is one of tension. Its legs are drawn up and pain is sluii'ply elJeited by attempts to even gently move the legs. The hrcatliing if closely observed is seen to be mainly costal in type and extremely shallow. The distress caused makes abdominal palpa- tion almost impossible. The constant rigidity encorrntered is quite char- acteristic. The urine is almost entirely suppressed. Pallor soon becomes marked, and death usually results in two or three days. In Early Life. — A similai- train of symptoms occurs in the early years of life in peritonitis resulting from disease processes in other parts of the body as appendicitis, intussusception, perforation, trai'.matism, strangulated hernias, lung involvement, or following the acute infectious diseases. Besides the streptococcus, we have the pneumococcus. gonococ- cus, colon bacilluF, or the lu-dinary pus organisms as etiological factors. Pneumococcic and gonorrheal peritonitis are almost distinctively diseases of childhood. The diagnosis is likely to be obscured by the underlying affection. The medical attendant is likely to center his attention on the primary disease and is not attracted by the insidious train of symptoms in the abdomen. Invasion of the peritoneum is evidenced by sudden high increase of temperature, or by a subnormal temperatui-e with signs of collapse, extreme pallor, feeble rapid pulse, 120 to 180, and cold extremities. The eyes are fixed and sunken, nausea and finally bile-tinged vomiting may follow. An^- attempt to give medication or food by mouth is apt to be followed bv vomiting. Constipation is the rule. The postui-al picture is the same as that just described foi' the new-horn, excejit that a tympanitic condition is more apt to occur and the young child uuiy feebly attempt to ward off an\- attempts at palpation of the abdomen. The ]iain may be referred to the navel or localized in the iliac fossa. The leukocytes are moderately iiu-reased. Peritonitis of gonorrheal origin should l)e sus]iected where such a train of sym]itoms iu a fenuile child are accompanied liv a specific vulvovaginitis. Pneumococcic peritonitis uiay result from any pulmonarv disease, and especially fi'oni an enipyemic jirocess. It occurs here probablv bv direct infection through the lym]ihatics of the diaphragm. T-Teiuatogeuous iufec- tiou seems to be the usual mode, since imeuniococcie meningitis and abscess formations are not unlcnown. Since the exudation of juis is in this varietv considei-able in amount, the diagnosis is moi'c readily made bv the finding of accumulated fluid in the lower segment of the abdomeu. If i-ecognized earlv and proper measures of rest and iiostur'e are instituted, (>nca])sulation is apt to occur, and the prognosis is eorresjiondingly impi-oved. Paroxvsmal THE COJIMONER SOIKIICAL DIWEASES. 530 pains, chills, vomiting, severe diarrliea, anil abdominal distention are noted in the early days of the disease. On palpation, there may be fluctuation, corroborated by dullness on percussion. I'neumococcic infection of tlie peritoneum, though a dangerous disease, is not necessarily fatal, as the pus may discharge through the umbilicus. If, however, surgical measures are not instituted at the beginning, rapid emaciation and prostration usually take place. Diiluse suppurative peritonitis may then result, and a serious prognosis is inevitable. The diagnosis as to the exact form can only be made by examination of the pus which will show the presence of the diplococcus pneumoniae. Diagnosis. — The diagnosis in older children with a well-marked train of symptoms is not so difficult. In infancy it is often extremely puzzling and can often be made only by a process of exclusion. The symptom of pain cannot always be depended upon, as it is often relatively less than in adult life. From intestinal obstruction it is not always easy to differentiate peri- tonitis, but the lesser amount of abdominal tenderness, absence of fecal vomiting, and the passage of some gas or feces may be of assistance. It should not be forgotten that these conditions may be combined. Diaphragmatic pleurisy, or even pneumonia, when the pain is referred to the abdomen may occasion a mistake, if a conrplete physical examination is not made. Prognosis.- — In infancy it is invariably bad. In children peritonitis must always be regarded as a grave affection, although the encapsulated forms offer some little hope. If a perforation has taken place or if the process is general a fatal issue is to be expected. The gonorrheal variety, €specia]ly in older children, has a better prognosis. Treatment. — An early diagnosis will be of value to the patient if prompt measures are taken to insure bodily ami intestinal rest. If the case is seen very early, calomel or a saline may be given, Ijefore the appli- cation of an ice-coil. Paregoric for young children and codein hypodermati- cally foi- older cases will he required to alleviate the pain and to inliibit peristalsis. Xo attempt should be made to feed the patient. Pieces of ice or sips of ice-water to which brandy has been added are grateful and often allav vomiting. ITypodermoclysis and stimulants may he roi|uired for the pulse. The surgeon should l)e consulted as early as possible and decide as to the feasibility of operative interference. Ascites. By ascites is meant the condition prodnrert )iy an efTusion of sprniii into the neritonenl cavity. It may occur as a secondary condition in peritonitis in nny of its varieties, In cbronic nephritis and in certain blood diseases. Olistrnctions 540 UISEABJiS 01' CHlLDiiEN. to tlx' iKirtal riix-ulatiun, anil rlirouic diseases (if the lieart aiul lungs maj- also Xirudnee aseites. Diagnosis. — Tlie iiby.sieal signs differ in nowise from those obtained in the adult, and tlierefore may lie onutted here. Chylous Ascites. — The diagnosis of this rare form is made only after aspira- tion. Several eases have lately been reported. Its causation is unknown, but is attributed to some obstruction or disease of the thoracic duet. The ascitic fluid is milky white in color and usually contains fat globules in a fine emulsion. Leukocytes and a few red blood-cells may be found. Treatment. — Withdrawal of the fluid for the relief of pressure symptoms may be necessary in advanced cases, otherwise the treatment resolves itself into measures directed to the primar.v condition. Ischiorectal Abscess. These aliscesses are more connnonly observed in children of poor nutrition who have been reai'ed under unhygienic circumstances. Through the lymphatic channels of the rectum, the perirectal lymph nodes lieconie infected and form an abscess. The diagnosis is made on inspection and pali)ation or by rectal examination. Treatment. — Free incision, cleansing with antiseiitic solutions, such ;is the peroxid of hy- drogen .and stinuilation with a 2 per cent, silver nitrate solution, or ])ackings saturated with b.alsam of ])eru and castor oil, one to ten, will effect a cure. In tuberculous children these aliscesses may be exceedingly intractalile and do not tend to heal initil the general nutrition is imjiroved. Rectal Polypus. The growths are eommonl.v found low down in the rectum and attached by a pedicle. Rarely are they nuiltiple and sessile. On examination they ai-e found to be adenomatous or flbromatous in structure. They v.ar.v in size, but rarel,v are larger than a hazel nut. Symptomatology. — The case is usually brought to the attention of the physician because of intermittent hemorrliages which may or may not be accomjianied with tenesnuis. Sometimes onl.v the fecal masses are blood-streaked. If the straining is iiersistent prolapse of the rec- tum may result. Rectal examination is indi- cated with the above train of symjitoms and the source of bleeding will then be found. Treatment. — The removal of the pedunculated tumors is easily accomplished Viy twisting the ])edicle or jiassing a ligature about it before cutting it. If it cannot be withdrawn the use of an anesthetic and a speculum will be required so that bleeding from the stump may be arrested. Fissure of the Anus. This may occur following the passage of :\ hard constipated movement. It is also seen in children suffering from marasmus, syjihilis. and eczema. Occa- sionally a fissure is produced by undue dilatation of the siihincter by in.iections. sujipositories or rectal exandnations. Pain, some bleeding, and tenrsnius are the signs wliich should lead to a carefiil inspection of the anal region. Treatment. — The buttocks should be separated as widely as iiossible and tlie fissures touched daily with a solution of silver nitrate, dram one to the ounce. If coiisti]iation is jiresent l.ax.itives or enemas with careful ov(>rsight of the diet will pT'omote healing. In iTitractable cases the rectum should be gently dilated, a feat which is easily accomplished in children by the successive introduction of well-greased fingers begiiniing with the smallest. This iirocedure should cause little or no pain, and generally effects a cure. i'lG. 162. — Characteristic shape of belly in ascites. (C'ahot.) THE COilJIONKIi SUliGICAL DISEASES. 541 Prolapse of the Anus and Rectum. Prolapse of the rectum is juoru eouiiiioni)- observed in children of the second and third years of life. The protrusion may be partial, being only a simple eversion of tbe mucous membrane, or complete, in wliich all the layers of tlic- rectal wall protrude outside of the sphincter, sometimes for one or two inches. Etiology. — The causes provokina; this condition are tliose accom- panied by much tenesmus, such as colitis, sti'aining in chi-onic constipation ■or diarrhea, or with calculi. Tfectal polypi will often lead to a prolapse. A neglected cause is the use of stooling chambers too large to give proper Kill. K;.'!, — .Adhesive iilaster (.Iressiiii;; for prol.-iijse of Uh' rei'tiini. support to the liuttocks. Anemic and l)adly nourished childi-cn are par- ticularly ])rone to this affection, as in them tlie pelvic musculature, is incompetent. Symptomatology. — Tlie protrusion of a daik red cone-sliaped mass covered by transverse folds of mucous membrane, and with a rounded open- ing at the apex of tlie tumor is diagnostic. In some cases blood-sti-eaked mucus soils the clothes. The mass can usually be readily rephiced, but the protrusion will be apt to recur after straining or coughing or with the next defecation unless preventive measures are taken. Diagnosis. — Althougli the diagnosis is generally easily made, one of us has seen a mistake made in a case of intussusception in an infant in whom the invaginated gut protruded fi-om the rectum. Treatment. — This consists in replacing the tumor and retaining it. A piece of gauze covei-ed with vaseline is placed over the tumor, and by gentle pressure exerted over the entire mass the prolapsed tissues will slip back into place. If the reduction has been delayed too long it mav be necessary to apply ice or ice-cold cloths for a sliort period and then to repeat the above manipulation. r,43 ])]SKASKS OF CIIlLDrtEN. 1111(1 ilie as ( iiial Two wiile baiiils o[ a(lliesi\e jilastcr applied ovur the buttocks, above beb)w the anus, so as to exeii tinii pressure and give added support to pelvic attaehiuents. will retain tlie prolapse. Local conditions, such •onsfipatioii, colitis, and ]iolypi, should be remedied and conditions of nuti'ilioii enri'ccled liefoi'o a linjie of ]ieriiianent cure can bo entertained. Tlie cliild must lie (111 a lie(l|iaii (luring (hdVcation and the movement slioiild be induced liv a mild enema (if (lil or glycei'in. TTe should be taught to avoid excessive abdominal ]ii'essurc. Local a]iplieations of as- tringents, such as the fluid extract of kraineria oi' tannic acid ointment, arc licl]ifnl. The diet should he so regulated during the cure that the moNcments ]")assed will he soft and uiifdi'mcd. ^Tihl laxatives as cascara fiv the milk' (if magnesia may he iicccssarv. In excc])tionally severe or neg- h'cted eases, the jirolapsing mucous iiu'mbranc must lie linearly cauter- ized bv the tlieruiocanter\' to jiro- duce cicaii'ix. or a radical o]ieratioil may he nccessar\'. Malignant Tumors in Children. While alnidst any form of lie- iiign oi- malignant groM'th mav occur in early life, it may be said that cai-cinoiua is (piite rare, while sar- coma is much more frc(piciit. AVlicii this foi'iii occiii's in chihlren it is much more malignant than in adults. Three types arc known, the round cell, spindle cell and yiant c(^ll \arictics, the first being the most malignant. Nevi soMutiines become sarcomatous, but the liones, kidnev, testes, and epidermal tissues are more fre(|uently involved. The ends of the lono- b("ines showing a special predilection. Sarcoma of the face often causes confusion of diagnosis. Sarcoma of the kidney ^\hicb is often congenital may attain an immense size. Their growth is exceedingly rapid and they are never bilateral. (See p. 451.1 Fic. Mfi — Sarcoma cf tlie lower abdouieu. THE COMMONKl; SL'l;(JlCAL DISEASES. 54. -J Diagnosis. — The shape and size of the tumor is determined by its site and the tissues involved. The tumors are at first freely movable if located in soft tissues; they are seldom hard and firm; on the contrary, they may Fiu. 105. — Osteo-sarcoma of the temporal Ijoiie l''i(i. KU;. — Sarcoma of llie face. even feel fluctuant. Particulailv suggestive are the superficial veins, usu- ally dilated, which are found over lliese tumors. The skin covering them may be somewhat dusky or bluish in color. 34 544 Ill.SKASES Ui' tJULL)IM:X. Metastases oceur by way of the blood stream, eonsecjuently adjacent lymphatic glands are not involved. Treatment. — Sarcoma is of relatively rajjid growth and extension and this fact makes an early diagnosis essential, as complete removal is the only treatment. Coley's fluid which contains the toxins of stix-ptococeus, erysipelatosus and, bacillus prodigiosus can be tried in inoperable cases with the hope of Fig. hit. — Sarcoma nf kidney. arresting the growth. It is aduiinistered hypodermatically the injection being made into the periphery of the growth. Begin with injections of one minim, and as tolerance is produced the dose may l)e increased to five minims twice a day. In certain situations, as on the face, considerable pain is experienced nnless fairly powerful analgesics are given. SECTION XVI. DISEASES OF THE EAR AND EYE. CHAPTER XL. DISEASES OF THE EAR. General Considerations. Familiarity with tlie anatomy of the organs and structures of liearing-, at least in a general way, is incumbent upon those wliose practic'e is among infants and children. At birth the external bony canal has not developed and there is present only a cartilaginous canal. The walls of the soft meatus may in infants he found almost in contact so that the tympanic membrane is examined with difficulty unless these are separated. In structure the walls of the meatus are thicker than in the adult. The vault of the tympanum is dis- proportionately large and may have an incomplete tegmen. The Eustachian tube is shorter, horizontal, and relatively wider, the pharyngeal outlet being on a line below the hard palate. The mastoid process is entirely undeveloped at birth, and it is not until pnberty that it assumes the adult characteristics. The antrum, however, is developed, surrounded by thin bony walls. The close relationship of the sutiircs and the lateral sinuses to these structures accounts, in greater part, for the frequency of intracranial complications in early life. Otoscopy. For this purpose a good light and a properly shaped speculum (see Fig. 168) is necessary. The child's arms should be fastened to its side by wrapping in a large sheet or towel ; the attendant holds the child with one arm thrown about the chest and with the other on top of the head keeps the ear in the right direction. By drawing the auricle downward and hackward a better view can be obtained. Accumulations of wax or exfolia- tions of the drum membrane must first be removed by the use nf a fine cotton-tipped applicator before a good view of the drum can be had (McKernon). Tf the ears of normal children are first examined the method and a working knowledge of the normal appearance will soon be obtained and otoscopv will then be more frequently made a part of the routine examina- 545 54 (J DISEASES OF CIIILDDEN. tion, and imral eoinplications will go luirecognizccl I'css frequentl}-, and iiioiv .serious foiiiplieations, such as jiiastoid involvement ami ileaf-mutism, ]irevente(l. ' The desevjptions in this seetion are for diagnostic purposes and the reader is referred to books on tins special subject for details of treatment. Otitis. Tliis is very common in early life, occurring almost always secondarily to ibe acute exanthemata, gastroenteritis, influenza, adenoid vegetations, and chronic rhinitis. Less commonly it may follow such diseases as tvphoid iniection, diphtheria, acute follicular tonsdlitis. and ccrclirospinal luenin- gitis. . It may also he induced by improper methods of nasal irrigation or *~-'-Wf^ "'"^-SSi, ^ Fic. 1f;S. — Properly sh.'iped p.ir-siipcnhini. by violently hlo\\ing tlie nose, tlie bacteria in the nasojiharynx lieing fm'ced into the Eustachian tube. According to Liebman. the streptococcus is most frecpientlv found (52 per cent.), streptococcns mncosus next in frequency (8 ]ier cent.), then the ]ineumococeus (Cifio per cent.). Symptomatology. — Tlifortnnately, in many instances otitis occurs during the conise of an illness, as, for example, in measles, and imless daily otosco]iic examinations are made, the first intimation of the process is a discharge from the external ear. If after the acute symptoms of the ]v\- mary disease have sulisided a sudden and i-ather constant elevation of tem])erature, with or without earache, occurs, otitis should be suspected. DISEASES OF THE EAR. " 547 In some eases rupture takes place even without elevation of temperature. When in infants there is restless sleep with sudden unexplainable outcries, pulling at the ear, with pyrexia higher at niglit, inflammation within the ear should certainly be thought of. Older children who are able to localize and speak of their pain describe it as " stinging " in character. The pain comes on at intervals and is worse toward evening and during the night. Otoscopie examination in these cases will disclose a much reddened, swollen, or bulging membrane. If the process has not advanced to tlie point of actual suppuration there may only be found a crescontic area above Shrap- nell's membrane with absence of the normal shining appearance of the lower half. If the perforation has occurred, the opening is visually seen in the posterior and lower quadrant. The discljarge may be serous, seropurulent, or purulent in character. Chronic otitis media, sinus thrombosis, and men- ingitis sometimes follow. In most of the cases, however, following spon- taneous rupture or incision of the membrane the discharge after a time ceases, healing takes place and restitution to normal occurs, often with little or no disturbance to the hearing. Treatment. Prophylactic. — Daily examination of the tympanum in the course of the acute infectious diseases, the removal of adenoid growths and hypertrophied tonsils, and the inculcation of habits of cloaTiliness, such as the nasopharyngeal toilet (see p. 73), will do mucli to prevent the involvement of the ear. General. — Earlv incision of the drum membrane should be practiced in the acute cases if the condition of the membrane warrants. Hot irri- gations of saline solution at 110° Y. with a fountain bag lield two feet above the ear, give considerable relief, and in the milder cases the symp- toms may entirly subside under this form of treatment. Chronic condi- tions require copious irrigations with a warm solution of (1/10,000) bichlorid of mercury several times a day. It is best to refer these cases to the specialist for more radical treatment if they do not show improvement after a few weeks. Mastoiditis. This most frequently results as a complication of acute or chronic middle-ear suppuration and the same etiological factors as given under the article on Otitis concern us here. The anatomical structures as outlined in the general consideration and the greater tendency toward necrosis of bone in early life favor the involvement of the mastoid process. 5-i8 - DISEASES OF CHILDREN. Symptomatology. — Tlie symptoms api^ear after a variable time dur- ing the eonvaleseenee following an artificial or spontaneous rupture of the drum. A sudden or gradual pyrexia may be the initial symptom. This, as a rule, is not high, but continues several days, reacliing its highest point in the evening. Otoscopy, if thei-e has been a previous perforation, may show a decrease in the amount of discharge, but the pus may show that some retention in the deeper structures has taken place by appearing in drops after cleaning the canal. Sometimes there is seen prolapse and bulging of tlie superior and posterior portion of the canal wall. Eestless- ness with frequent periods of crying, especially at night, is present in most of the cases. Occasionally the temperature reaches 104° or 10.5° F. in the evening, and the lymph-glands in the neighborhood are swollen. The tissues over the nuistoid may become edematous and the auricle is pushed out from the scalp. In unrecognized cases a perimastoid collection of pus takes place, especially in infants, and pressure over this tumefaction causes a discharge of the pus which has collected in the external canal. Meningeal symptoms may appear or in neglected cases the cerebral symptoms may predominate and obscure the diagnosis. Treatment. — i\n early diagnosis is imperative in mastoiditis, for it is only by the radical operation whjcli drains the middle ear that the mortal- ity in this serious disease may be lowered or more serious complications, as infection of the jugular bulb, avoided. Infective Cerebral Sinus Thrombosis. {Jugular Bulh TnfecUnn.) The most freqiient cause of local infection of the cerebral sinuses is suppuration in the middle ear and mastoid cells. A general septicemia as a result of aural complications may also produce sinus thromhosis through the general circulation. Streptococci are most frequently found to he the direct cause of the infection. Symptomatology. — The disease should be considered if there is a sudden rise of temperature in a patient who has a discharge from middle- ear disease. This fever is extremely irregular, septic in character, rising oftcT^. to lO.'i" or 107° F., with remissions to the normal or subnormal. The pulse rate is correspondingly high, the infant is at first highly irritable and restless and soon becomes apathetic and finally stuporous. There may DISEASES OE THE EAi;. 54IJ Le evidences of meningeal involvement with vomiting and convulsions, and pain in the cervical region. If the disease has resulted from tlie mastoid there may be edema in this region, and jDerhaps, a clot in the jugular vein. The percentage of polynuclear elements is high, ranging from 80 to 90 per cent. Prognosis. — This is extremely unfavorable. A fatal issue usually results in a few days unless operative interference is successful. Treatment. — Early diagnosis followed by prompt operative procedare is the only recourse. Recent reports show encouraging results. Fig. 100.— a servi(ea))le electric nurcsccjic imrtieulMrly adapted fcv children. CHAPTER XLT. THE COMMONER DISEASES OF THE EYE. Foreign Bodies. — Foreign bodies are frequently caug'lit under the eye-lids of ehildren, and if not washed away by their own tears, which are usually copious, tliey should be (|uickly removed to ])revent inflammatory changes. The upper lid can be everted easily if the child is prone and correctly lield to prevent interference. The foreign substance can usually be easily removed by a fine prol)e, tlic end of whicli has been wrapped with a few strands of absorbent cotton. Metallic substances may require local anestliesia, which is accomplished with two drops of a 2 per cent, solution of cocain. If the particle is not readily removed, the patient should be referred to a ])ro])erlv equipped ophthalmologist. Blepharitis. — This is often obseiwed in tuberculous, anemic, or poorly nourished childi'en. especiallv when they have a der'iuatitis elsewhere on the body. The secretion as it dries produces further e.xeoriations and aggra- vates the trouble. Treatment sliould be directed to the general condition, improving the nutrition by pi'ojiei' diet, cod-liver oil and iron tonics for the anemia. General cleansing baths daily with bicarbonate of soda will prevent reinfection. Locally, the eye-lids are bathed with a 2 per cent, boric acid solution until all the crusts are removed and applicatims of an ointment of yellow nxid of mercury (1/100) are then made morning and night until a comjilete cure is produced. Conjunctivitis — Acittc — Injuries and the infectious diseases pro- duce acute inflammations quite readily in children and the mucoid secre- tions are apt to be more profuse than in adults. The eye-lids should be gently separated and the secretions flushed out. Microscopical examina- tion of a ]iiii'ulent secretion i^hould b(^ made to determine the possihilitv of infection by the Klebs-Loeffler bacillus or the gonoccoccus of Xeisser. A careful search should 1)0 made for foreign bodies. If there is no secretion, applications of a 2 per cent, warm boric acid solution every fifteen minutes may suffiic for a cure. If the secretion is purulent, argvrol in 12 per cent, solution (freshly prepared) may be ordered or silver nitrate (1/100) may be applied by the physician and quickly flushed out Avith sterile salt solu- tion. Ice-cold applications ai'e often necessary and should be freshly applied every ten minutes until the inflammation subsides. X drop of atropin sulphate (1/200) Tiiay lie necessary two or three times a dav to ]irocnre rest for the eye. r>r>(i THE t'OALMO.XEl! DISEASES UF THE EYK. 551 Diiihtheritic. — The jiieiubiane is tenacious, with an absence of secre- tion and much exudation and edeuia in the eye-lids. Tlie extreme rapidity of tlie involvement and the presence of a possible nasal diplitheria should excite suspicion. The treatment is that of diphtlieria elsewhere. An injection of 10,000 units of antitoxin should be given, and locally the eye should be flushed with boric acid solution and kept cold with ice com- presses. Protecting the sound eye from infection may be accomplished hv the use of a shield or the instillation of a 25 per cent, solution of argyrol every two hours. Chrome. — A careful examination for ocular defects should always be made in these cases and the child's habits as to study, etc., inquired into. Xot infrequently the condition is improved by appropriate general treat- ment or a change from urban to rural life. Locally, astringent applications of zinc sulphate (1/250) or silver nitrate (1/500) may be made by the physician several times a week and one of the organic silver salts sup- plied for home use, as argyrol in ten per cent, solution one or two drops, twice a day. Internally the syrup of the iodic! of iron is often of assistance. Trfichoiiia (tjranuhir coniiinciivith) . — Routine examination of the school children in New York City has brought to light many cases of chronic conjunctivitis which are termed trachonuUous. The condition occurs in several children of a family and certainly appears to be of a microbic nature. Ordinarily the type seen is mild in character and is often classed as granular conjunctivitis. The heaped-up granulations and deposits are plainly seen when the lids are pulled down. The upper lid should also be everted and examined. Marginal ulcerations may occur if the disease is allow'ed to run its course untreated. Treatment should be proportionate to the severity of the condition. Prophylactic measures to protect other children in the family and school should be insisted upon, such as individual towels and wash cloths. Con- stant supervision and treatment will finally eradicate the condition and lessen the host of cases now in our schools. Locally, a solution of zinc sulphate (1/S50) or the cupric stick may be used by the physician several times a week on the granulations. A solution of bichlorid of mercury (1/5000) or argyrol 10 to 30 per cent, may be ordered for home use, one drop being instillerl twice a day in each eye. Severe cases will require the expression operation with forceps under a general anesthetic. Chalazion.— A chalazion is n cyst which results from retention products of the Meihoniinn fflnnds. There is rarely any pain, although diseonifort is com- plained of by older children. They are generally exeised if they tend to recur. Hordeolum or stye is found on tlie margin of the eye-lid ,ind nets like a furuncle on any other part of the liody. The evacuation is hastened by hot applications and early incision. o:,-^ m;ii:ASj;s of ciiildiiex. Strabismus. — Straliisinus (?(|iii)ii) iiiav l.)o eitlicr paralytic or non- paralytic. I'aialylic S(|uint is iliic tn jiartial or complete paralysis of one or iiioi'e of the iimsclcs of the eye. It may he con,i,'enital, or it may be ae(|uii'eil fioiii trauma or from an acute iiift'ctions disease, such as diph- tlieria or cerebrospinal mcnin.iiitis. It may also result from photo]")hol)ia, jilihctcuulai- keratitis, ajid inici'stiiial keratitis. Xon-paral\'tic squint in cliildren is inore common, and it is usmilly convergent. Contrary to a eomnum liidief, ehildrcn seldom " groM' out" of it. If neglected, the S(piinting eye usually l)ecoim:"S andjlyopic. Xcg- lected "cross eyes" ai'e responsible for many blind eyes in adults. If prescribed sutticiently earl\'. correi-t glasses accomfilish cures in many of these cases. Even young childi'en can wear glasses without danger. Keratitis. — This is usually IotukI in tul)preulous and ractiitic children, sec- ondiny tcj otlii'r dcular and dermal conditions, nlthoush syphilis itself causes the interstitial or |iareneliyinatous v.iriety. The condition lie,i;iiis with congestion and in\'(ilvenient tiipholiia. orliii-uhir sjiasiu. ]iain, and an al)Uoi-nial flow of tears. Later a haziness is observed and vision is inuiaired. The sniiertieial lesion, if untreated, soon invades the corni'a, and ulceration or even supjiuration results. Tlie iddyetenular variety is most fr<'(|ueut in early life. P.e.^'iuninl; with, small vesicles on the jiaipehi-al eon.iuuetiva. it srireads to the ocular con.iunctiva and hi're foims characteristi<- idcerations which luay leave permanent opacities of tlie cornea. Treatment should he directed to the underlyins constitutional conditi(a). The interstitial form senerally reacts to antisy]ihilitic treatment, diildi-en poorly nourished or badly hous<'d nmst he removed to hygienic quarters to effect a cure. Good food, fi-esh air. and liaths add sreatly to the possibilities of lc]<-al treatment. Any tissui-es in the angles should lie treated with silver nitrate solution (dr.am oue to the ounce), followed by a flushins with novmal saline. riacing a shade over the eyes is preferalile to a darkened room for the child. Bathinc with hot boric acid solution three or four times a da.y is soothin,? and liel)d'ul. An ointment of yellow oxid of mercury (1/1001 may be supplied for use on the eyelids at night in phlyctenular keratitis, and au ointment of biehlorid of mercury (l/.'iOOO) ajiplied for the other varieties. A solution of atropiu sul- phate (4 per cent.) may be necessary in some cases to give rest until the child responds to the general treatment. The Diagnostic Significance of Ocular Affections. The eve mav so often he n\' assistance in establishing a diagnosis that a short ai'ticle will ])<• devoted to the interpretation of certain ocular lesions or manifestations. Every physician sboubl l>e ]"ire]iaied to make certain simple tests in his nlfice to disco\er ocular defects, and the eyes should he examined in the routine examination, even when the iiatient is not presented for defective eye-sight. Tn this way he nniy find the cause for backwardness in school studies, headache, and dizziness. Of still greater importance is the fact THE COMMON EK DISEASES OF THE EYE. 553 that recognizing iinpiispccted delieieneies in visual acuiiy lie will refer the child to an ocnlist for more rigid and detailed test? and correction of refractive errors while the eye is still in the formative period. All that is required for these tests is a Snellen's test card, a graduated picture card for children unable to read, a candle placed at twenty feet and the multiple rod of Maddox for testing the functional balance of the ocular muscles. Talk has shown that the Americans as a nation are found to be far- sighted with astigmatism. There is no doubt that many of the children of this generation suffer from overuse of their eyes because of the compe- tition of school life and the multiplicity and cheapness of all forms of reading matter to which they have unrestrained access. Parents must be warned of these conditions and prophylactic measures advised to ]irotect tlie vision of their children so that artificial aid may not be rerpiired. The study room should be well-lighted and ventilated, with the desk or table so ]daecd that the light will come over the left shoulder. The use of vertical writing is to be commended. Eeading in the recumbent position oi' during convalescence should be prohibited. Badly printed hooks should not he tolerated in these days of modern printing. Diagnostic Hints. Ptosis as seen in children is usually a congenital defect as lesions of the ocidomotor ner\"e are exceedinglv uncommon in eliiblhond. Photophobia is not uncommon and usuall}' indicates some inflamma- tory affection of the structures of the eye. for examjile, corneal ulceration. It does not usually occur wit1i conjunctival diseases. Exophthalmos, or prominence of the eye-ball, is sometimes seen in older children who have the symptoms of goiter. Diplopia indicates paralysis of any of the straight ocular nmscles. and it may result from any cause which will ]irevent both eyes being fixed on the same point. The form varies with the muscle affected. It is sometimes a symptom in hereditary ataxia. Strabismus appearing suddenly, convergent in character and accom- panied with diplopia, is one of the signs of tuberculous or basilar meningitis. It ma.y also be seen in hysteria. l)ut here is functional only in character. Nystagmus, or I'apid oscillation of the eye-balls, may be lateral, ver- tical, or rotary movements. Tt usually is Inlateral. It occurs rarely eon- genitallv, and is then without serious significance. Tt is observed in many 554 disi:asi:s oi- cii i i.iii;i:n'. cerebral disuascs, fspt'cially tliose assoeiak'd. with congenital defects, in dis- seminated sclerosis, and in Friedreich's ataxia. Tumors of the cerebellum or pons may produce this ocular symptom. It is sometimes seen in the later stages of hydrocephalus. Optic Neuritis (Choked Disk), Papallitis. — This condition may be found on optlialmoscopic examination and indicates some form of intra- cranial lesion or affection of the orbit, rapillitis is seen in meningiti?, particularly of the tuberculous variety; sometimes it occurs with tumor and ahscess of the brain. Refractive Errors in Childhood. As a result of nearly five thousand ci>iui)lete aud careful refractions perf(irmed at the Health Department's Clinic, Tenner demands that every child t)efore begin- ning school life should have its refraction estimated. If correcting glasses are required, the.v should be worn. The following conclusions are presented : 1. In accordance with the observations of previous investigators, myopia or short sight is a condition rarel.v present at the beginning of school life, gradually increases with the age of the child, so that at the age of sixteen years, almost one-half of our cases had more or less myopia. 2. Children with hypermetropic conditions became myopic, the percentage of emmetro]iia or normal eyes remaining about the same. 3. That the correction of the hypermetropia and astigmatism with the con- stant wearing of the correcting glasses will prevent the development of m.vopia in many instances, is the belief of most ophthalmologists. Myopia in its high degrees becomes more than a mere handieaji in life's race, producing degenerative changes, detachment of the retina with ultimate total loss of sight ; therefore, apart from the relief and Improvement in vision afforded b.v the wearing of glasses in cases of hypermetropia and astigmatism, the early refraction of chil- dren to prevent the development of myopia is most important. If a child has a high degree of hypermetropic astigmatism, mixed astigmatism, or myopia of uiedium or high degree, with vision after correction, of only 20/50 or less, it should be placed in special classes with a curriculum that minimizes the amount of near work. There should be close co-operation between school authori- ties, school nurses, school ductor on the one hand, and ophthalmologists on the other. Education boards should employ some one interested in the conservatiou of vision of children, preferabl.v an ophthalmologist, in an advisory capacity. Such an officer could work to improve many existing defects, such as improper desk ad.jnstnientf^ and poor lighting. The I'cgnlation of t.vpe and paper in school books is another matter to come luider such an officer's control. SECTION XVII. DISEASES OF THE SKIN. CHAPTER XLII. DISEASES OF THE SKIN. Introduction. Diseases of tlie slvin form a very important part of the affeetions of early life. In infants this is particularly true, owing to the hypersensitive- ness of the skin, which is suddenly bereft of its covering- of vernix caseosa at birth and exposed to irritants of varying degree either from witliout or from within. It must also be recollected that faulty metabolism will ac- count for many of these skin lesions. Young protoplasm is very irritable, and hence comparatively slight causes may produce severe lesions of the skin. The causative factor should be carefully sought after in each case, and treatment should be directed not alone to the local lesion, but to the systemic condition as well. When prescribing local treatment the tenderness and sensitiveness of the infantile epidermis should not be forgotten. Better and more permanent results are obtained if soothing and unirritating drugs are employed and if the skin is protected from further injury by prevention of scratching or further infection. The latter condition often masks the nature of the original disease, hence the most recent lesion must always be sought for diagnostic purposes. A certain number of skin diseases are congenital or are seen mainly in infancy. These will be mentioned first and then the commoner diseases met with in the early years of life, and finally those seen for the most part in the school age. Ichthyosis. (Xerodermia.) Ichthyosis, or fish-scale disease, is regarded as a congenital skin affec- tion, mainly transmitted by heredity. It is characterized by a dry scaling condition of the skin, whose outer layers are hard, dry, and thickened and without any inflammatory phenomena. Several members of a family may he affected. Symptomatology. — The whole body, as a rule, may he covered with ;i scaling, wrinkled, papery skin, especially on the outer surfaces of the arms 555 .'i.'itj DISEASES VF CHILDREN. and legs. In the floxiii-es of tiie joints lissuvcs are somctiiiios formed. The general hcaltli remains uiiatfeeted. Irritants easily cause pi'iiritis and local inflammatory reaction. Diagnosis. — Tlie disease is rarely mistaken on account of its distinct characteristics. The history and its non-inflammatory character distinguish It from trophoneuroses or pityriasis. Prognosis. — It is an intraetahle disease requiring long ami patient treatment to atfeet auv amelioration. It is never reallv cured. I'le. 170. — I'igmented iir\ii>. Treatment. — ^If the treatment is hegun in early infancy much more can be aceoni]ilished than when seen later. l>aths of green soap, followed bv inujietions of lanolin or vaselin and pi'oteetion of this greased surface with gntta percha tissue, later a ■") to 10 ]>er cent, sulphur ointment, can be applied. Life in the ti'opical countries is fa\orable to comfort and possible cure. Sun-baths and life at tlie sea-shore arc helpful. Nevi. These congenilal growths may he vascular or ])ignu'nti'd (moles). The latter may also he hairy or rough and wai'ty. Tlie color \ai'ics fi-oiu a light In-own to lilack. \'asiailai- ne\i ai'e due to local e-\cessi\-c ]U'olil'eration ol;' lil(iod-\-esse|s at or soon after hii'lii. These disligurements ai'c found f(n' the gi'eater |iiirt in the eoi'ium, and \ai'y from the familial- ]ioi-t-wine stain to DISEASES OF THE SKIN. 5.' pulsating angioinata. Tliev are apt' to increase in size soon after birth and do not grow beyond certain limits. Prognosis. — A'ascular nevi of the cavernous type may be dangerous to life because of the danger of bleeding or from their effect on neigliboring structures. Pigmentary nevi have shown metamorpliic changes into 'later growtlis of a malignant character. Treatment. — This is accomplished by electrolysis or cauterization act- ing upon the coriuni only. Eadiotlierapy occasionally is successful. Ex- cision offers the best results ; occasionally skin grafting is necessary follow- ing excision of a large nevus. A needle may be heated to a cherry-red color and plunged into the margin at three or four points. This may be repeated at subsequent sittings until the nevus has been entirely eradicated. A white scar remains over the site. Ice made from liquid carbon dioxid is often suitable for the removal of port-wine stains or superficial nevi. Dermatitis Exfoliativa Neonatorum. (Riiter'.'i Di.iease.) Badl.v nourislietl infants, usuall.y nurslings, are aff'^oted by this diseast^. It is quite rare. It l)eKins. as a rule, on the lower half of the face as a reddened area with exfoliation, Tliis er.vthema soon spreads over the entire l)od.v, and the resulting sealing is jirofuse. Fissures .-ippear at the mouth and anus. Con- stitutional s.vmptoms are those of nialassiniilation or, in severe eases, those of sepsis. Even when restitution to the normal takes i)laee after patient and dili- gent treatment, relapses are not uncommon. Ritter gives the cause as a general sepsis. Course and Prognosis. — The two cases coming under our observation in hospital practice were markedly toxic, and both died. The mortality is r>() per cent. Occurring as the.v do among the poorer classes, medical attention is not drawn to them until the vitality has suffered beyond repair. Treatment. Maintain the liody heat by the use of lanoli i and sucli manage- ment as is re<-onunen(led for the premature (see p. 2). Carefully examine the hreast milk, and if abnormal a wet-nurse is indicated. Str.vchnin in doses of gr. 1/300 every two or three hours is given if the vitality is low. Pemphigus Neonatorum. This is a contagious skin disease cliaraeterized by the formation of bulla! containing a puralent fluid. Xo specific microorganism has as yet been isolated. The large vesicles or bullse may sudlenly make their appear- ance on any part of the body, causing little or no systemic disturbance. The blebs vary from transparent to grayish forms. Tlie distended vesicles mav rupture, leaving a crust and a reddened base, but no scar formation results. The exudate may infect new areas or even tliose in contact. The disease usually runs a favorable course, tending to complete recovery m a few weeks. They should be differentiated from the bullous syphiloderm, sometimes called syphilitic pemphigus, which occurs mainly on the soles of 558 DISEASES OF CTllLllIiEX. the feet and palms of tlie hands, \\itli usually an uleerated liase, and is accompanied with other manifestations of infantih' svpliilis. Treatment. — Evacuate each bleb carefully by prickin.i: Avith a sterile needle, and apply zinc stearate for desiccation. A daily liath in a solution of hiehlorid of mercury (1/10,000) is indicated if self-inoculation is e\ ideiulv going on. Impetigo Contagiosa. This skin disease usually attacks the face at tlie eoi'nci-s of the mouth and nostrils, altliougli any poi'tion of tlie l)ody may exliibit the lesions. These consist of grayisli-yellow sticky crusts Avliich have a honey-like discharge. They ai-e seated upon a I'ed base. The cliild eagerly jhcks at tliese crusts and infects other areas. Treatment.-- The general health, if dehcient, will require proper fee Erythema Multiforme. This is iiu acute iiiflaiiiiiiatory disease, in ^YllicLl are variously produced areas of erytliema, macules, papules, or vesicles. Some eonstitutioual disturbance may usher in the attack. This is usually mild in cliaracter ; there may be fever and malaise with or without rheumatic pains. The lesions, as a rule, appear on the extensor surfaces of the hands, arms, feet, and legs. The face and tipper chest are often involved, althou^'h any part of the body may exhibit the eruption. The color varies from a light red at first to a deep red in older lesions. Only occasionally are hemorrhagic areas seen. Pruritus is not a marked symptom. Accompanying the erythema in children there are usually observed symptoms of intestinal derangement, autointoxication, ptomain poisoning, etc.. which have undoubtedly produced this external manifestation. The disease is liable to recur- rence, lasting, as a rule, for a few weeks before subsiding. Treatment. — This should be mainly directed to the underlying viceral derangement. An initial purge is indicated in the form of calomel or castor oil. A careful history of the child's diet will nearly always disclose some radical fault which needs correction. A specially arranged dietary should be provided. The emunctories should be kept active. Locally, if there is pruritus, an ointment containing resorcin or acid carbolic may be applied. Acute Exfoliative Dermatitis. This condition is of interest because of the confusion whicli it may cause in 'children from its resemblance to scarlatinal infection. Intestinal toxemia will commonly be found to be tlie underlying cause. Following an erythema of the scarlatiniform type, in a few days or sometimes hours, there occurs a profuse exfoliation. Constitutional symptoms are more pronounced than in scarlatinal erythema. The exfoliated scales of large and papery strips are cast off (see Fig. 8, Plate IX). The hair and nails may drop out before the process is complete. Furnuncles and pustules are sometimes engi-afted on the dermatitis with involvement of the neighlioring lymphatic glands. Diagnosis. — The differential diagnosis in the erythematous stage and in tli.-it of e.xfoli.-ition is given under the article on Scarlet Fever (see page 221). Treatment. — Correct the toxemia by unloading the intestine and prescriliing a diet that will not cause fermentation. Repeated examinations of the urine fcir iudican will assist in jiroperly meeting this indication. Fowler's solution with iron is of value after the dietetic error has Ijeen corrected. A 2 to .5 per cent, ichthyol ointment is soothing to the skin. The cure is slow and recurrences are I frequent. The exfoliation may occur two or three times a year. Eczema. (Tetter; SaJt-rheum.) This is a protean disease of unknown oi'igin assuming an acute, sutj- aeute, or chronic course, characterized by an erythematous eruption of vary- ing intensity, which goes on to scaling or crusting and is associated invariably with marked pruritus. It is the most common of all the skin diseases observed in earlv life. Etiological Factors. — Irritants either of external or internal origin, or both, are responsible for the affection. Children who have the spasmo- philic tendency, nutritional or blood disorders, are particularly susceptible. Tlie usual pyogenic bacteria found on the skin are no doubt responsible indirectly for many cases. Their growth is facilitated or increasi'd by 35 ."i(iO DISEASES OF CHILDltEN. nieclianical or chemical irritants witli wliich the child comes into contact. The so-called " predisposition " to the disease is often accounted for by careful investig-atiou for the cause along the lines above enumerated. Para- sitic skin diseases, discharges from various parts of the body, badly prepared soaps and powders, and irritating underclothing are among the more com- mon external causes. Excessive feeding, in general or in kind, but par- ticularly the sugars, and constipation, are the prominent internal causes. Varieties. — Depending upon the degree of the exudative inflammation in the epithe- lium, there is produced an enjtiieiiiatous. papular, i-esiciilar, or pustular eczema. These forms either remain distinct or merge one into the other, somewhat masking the original type. The erythematous va- riety is characterized by redness and swelling over certain areas, especially the face. The papular type is known by the formation of small red papules which tend to group and coalesce. In the vesicular phase the upper layers of the epidermis are raised by the exudative process, forming vesicles or blebs which tend to coalesce and exude a viscid serum. These, however, are evanescent and are rarelv seen because they are rapidly dis- solved off, leaving a. wet surface. If the lat- ter form becomes infected by pyogenic skin bacteria or overloaded with leukocytes the pustular form develops. SuB-VARiETiKs. — ^^Ticn the discharge in the vesicular form dries readily it forms crusts (E. crustosum). If the exudation is profuse and the rete is uncovereil, the weep- ing or moist form I'esults (E. madinans vel rnbrum). A squamous variety is superimposed or develops from the crusty, papular, or vesicular form when considerable epidermal infiltration and scaling appears. Chronic Varieties.— These result from repeated recurrences, or ex- acerbations, or neglect of the etiological factors. The chief characteristic is the inFdtration into tlie upper layer of the skiu. Symptomatology and Diagnosis.— All the varieties described above Iiave certain common features, namely, redness, itching, and burnino-, accom- panied by the formation of papules, vesicles, or pustules, the skin beino- Fki. 172. — Cliruuic eczema. DlWEASJiS or THE SKIN. r^iii either dry, moist, infiltrated, or scaling. In infants the scalp, face, and napkin region are most fre(|uently attacked. The diagnosis is, as a rule, not difficult if the above description and classification is kept in mind. Erysipelas is distinguished by the rapidly spreading margin and higli fever. Scabies is often confounded with eczema or the two are combined. Tlie distribution and the itching, wliicli is woi'se at night, tlie history of the other children or members of the family similarly affected, or the burrows and tlieir contents themselves, can he dejicnded u|ion to eslal)lislt tlie diag- nosis. Psoriasis is rare in early life; it is never moist; it is commonly I '«fc «l ^^^R^ ji M !B- ^l^^ii W: Jlff^ ,, .^ . '«>-. mmjg Wma Ml%" HHp^ M EISh 'MrJkl Hi ^^^^HB^, 1 1 K HI 1 H Fig. it:"!. — Child with eczema fitted with metallic glove to prevent scratching:. found upon the elbows and knees, and lias silvery scales. Syphilides occa- sionally are difficult to distinguisli. Tlie infiltration is deeper and greater; they do not burn or itch and are usually accompanied by other manifesta- tions. In difficult cases the Wassermann test may he em]iloyed. Impetigo contagiosa has discrete vesicles upon a slightly reddened skin, with alirupt margins. They are contagious and tlic child easily inoculates itself in different parts of the body. Prognosis. — This is vaiiahle. depending uiion the underlying cause and the time of instituting treatment. Acute cases are favorable, but the 5C.3 DISKASES OF CHILDREN. chronic varieties are often intractable and persist with exacerbations and recurrences for years. Acute Eczema. — Treatment. General. — Tlie nnderlving cause should be carefully sou.i^'lit for and removed. If tliis is accomplished the cure will be well under way. Especially important is the proper regulation of the diet. If there is present such a condition as rickets, marasmus, or anemia the diet rinist Ije so ai'i-anged as to overeonu:' the nutritional disorder, r'dd-liver oil is often lieljiful. If, on the othei' hand, tliere has hpcn over- feeding or indulgence in s]jecial articles, as the sugars or potatoes, sue]) indisci'c- tion must be sto])])ed. Tlie constipation should l>e relieved h\' correcting tlu^ diet or adding tbci'eto sucli articles as fruits, tlie di'iulciug of ]ilentv oF water and a])]iropriate massage and exercise. 3n infants tlie milk of magnesia may be added to tlie mil]; for its laxative effect. Local. — Xever allow soa]i nr water to be used on an\' eczematous sni'faee. Cleansing can he satisfactoi'ily accom- |)lislied with olive or linseed oil. The irritated skin must he ti'eate(l by bland, soothing ointments or powders and sei'ateh- ing absolutely ])reventeil. I'est Toi- the inllamed area is iiiipei'ative. Scratching is ]ireveuted by the use of masks, band- ages, oi' sleeves, as sliOAvn in tlie illustra- tion (Fig. ITI). The mild eases of the erythema- tous, ]iapular or moist ty]ies ma\' be dusted with stearate of zinc, cai'bouate of magnesia, oxid (it zinc, or boric acid. Tn the inflammatoi'y stages lotions of 2 ]ier cent, boric acid, calamin, or a 1 ]ieT- cent, solution of aluiiiinum acetate, are applied as moist dressings. These soothe and lediiee the inflammation. Occasionallv small areas of weeping eczema may lie rapidly iiiqiroved by the ]irimary ai3)ilication of i per cent, solution of the nitrate of silver. Among the ointments, Lassar's paste (X. F. ) lias given us the best results. Tt is aiiplied thickly over the inflamed area and a retaining bandage or mask is applied. If tliick crusts Fig. 174. — Eczema mask with stiff sleeves to iireveut scrateliiug DISEASES OE THE SKIX. 503 are present tliese must first be removed with applications of olive oil or Ijoric acid ointment. The diessings are removed daily, the ointment carefally removed with absorbent cotton dipped in oil and the ointment reapplied. Subacute Eczema. — If for any reason treatment has been delayed or has been unsuccessful in the acute stage more stimulating applications are necessary. The amount of oxid of zinc in the pasta Lassar (X. F.) may be increased, and small amounts of tar in the form of tincture picis liquidse may be added, or the following may be used: R Picis liquid:© 5ss Sulphuris prfecipitati 5j Unsuenti zinci "xidi ^IJ Wit:ce ot sipna. — .\pply iijorning niKl evening. The same precautions must be observed to prevent scratcliing oi- ii'rita- tion of the area, and the diet and bowels regulated. Chronic Eczema. — I'erseverance and careful watchfulness as to the action of the drugs used in tliis form will be necessary to effect a cure. The thick crusts must first Ije I'emoved by applications of oil, boric or bis- muth ointment. Stimulating ointments are then to be used. The majority of chihlren bear the ointments well, but occasionally they are not well tol- erated and stimulating lotions must be sirbstituted. Tar is added in greater proportion to the ointments which have been recommended above. The tincture picis liqiridte or the liquor carbonis detergens act advantageously by producing stimulation and at the same time preventing itcliing. Tf large areas are affected, it is well to apply the tar ointment to limited portions of the skin first and observe its effect. After it has produced an acute reaction the milder pastes are applied. Psoriasis. Psoriasis among the skin affections is quite commonly observed in apparently healthy children. It begins as a papular affection with silvery scales on their summits. Their growth causes the commonly observed ir- regular patches with w^ell-defined edges, of a bluish-red color, somewhat raised above the surrounding skin. Invariably silvery scales are found in these plaques, which can he readily removed, leaving a reddish glazed base. The extensor surfaces of the extremities are the favorite seats, next the trunk and scalp. The affection is a chronic one, with a great tendencv to return in spite of well-directed treatment. Spontaneous cure in the summer months is not imconiinon. Treatment. — Bulkley emphasizes the dietetic treatment, and as the youthful patient is apt to be indiscreet, this should be the first consideration. A vegetarian diet may be appropriate for the child with a rheumatic history, although obviously unfitted for an anemic child below weight. Outdoor 5()-l: DlSEASi:S OF CHILDREN. life at the seashore, with sea-batliing, is productive of mucli good. As soon as tlie lesion appears an application of green soap and a full bath are ordered to remove the superficial scales. A crysai'obin ointment is applied to a small area in the strength of 5 to 10 grains to the ounce (except to the face) twice a day until the skin is clean. Latterly X-ray treatment has produced rapid results. Wai'ning should always be given as to its liability to return and the importance of renewing the treatment early. Miliaria. {Prkl-lii Heat; Strophulus.) Miliai-Ja is an affection developing at the sudariporous glands, usually during the summer months. It consists of nund^erless minute reddish papules and vesicles which appear with or after an unusual amount of per- spiration. It is accompanied by itching and burning. After a few days to a week it subsides, althougli fresh outbreaks are likely if weather con- ditions are favorable. Evidences of scratching are often seen in children in (onnection with miliaria. Treatment. — A 4 per cent, solution of boric acid is soothing, or with infants bran baths may be used. Frequent bathing and light clothing are prophylactic measures with children in the summer months. Tfemoval to the seashore and sea-batliing produce ra]ud amelioration and cure. Urticaria. (NrHlr-nisli : flireg.) ITrtieaiia consists of large wheals made Tip of a localizcil area of edema in the ]iapillary layer of the skin. Their centers are pale, wliile the uurrgins are reddened. These wheals are distinctly felt by the hand and cause in- tense itcliing, especially at night. In the majority of cases urticaria results reflexly from intestinal causes. External irritants, such as the stinging nettle (lience one of its names), insect bites, etc., may bring on a typical attack. C'ei'tain fruits, as strawberries, produce urticaria in the pi'edis- posed. A small pa])ular urticaria, consisting of minute papules, the tops of which are soon sei-atcbed off, causing a drop of serum or lilood to exude, may often be seen in early life. This form may persist for months and, if neglected, will eventually result in a form of papulai' eczenui. This varietv is iv all cases the result of a prolonged faulty diet. Strophulus is a name som(>timcs given to this condition. Treatment. — Discover the offending cause, whether external or die- tary. Locally, baths containing bicarbonate of soda, salines for the bowels, and local applications of ointments containing menthol, cam]ihor, or carbolic DISEASES OP THE SKIN. 51)5 acid. Small doses of salicylate of sodium or aspirin will relieve the intes- tinal fermentation that is often the underljdng cause of urticaria. Furunculosis. This is a condition in wliicli boils occur over any part of the body, but especially about the head. They are due to an infection of the skin with pyogenic organisms. The staphylococcus pyogenes aureus is the predomi- nating direct cause. They differ in their virulency and occasionally cause marked systemic infection. Lowered vitality from malnutrition, improper feeding, previous debilitating diseases, and skin diseases predispose to the formation of furuncles. They are usually small in size, multiple, and tend to rapid formation of pus. If uncared for, they rupture and the pus may inoculate otlier abraded surfaces. The areas are painful to the touch, reddish or bluish-reil, and discharge a yellowish, creamy pus. Children with furuncles are rest- less, sleep badly, may have a low-grade temperature, cry inordinately, and lose flesh and strength. Treatment. Local. — A general bath in bichlorid of mercury (1/5000) is first ordered; the furuncles in whicli suppuration has occurred are then surrounded with lanolin, incised and drained completely, exercising care not to infect neighboring regions with the pus. Remove local causes, if any, as scabies. General. — Improve by diet and fresh air the general tone, prescribing strychnia, nux vomica, or "the bitter wine of iron in the anemic. Tlie re- sistance may be raised by the injection of vaccines in cases in which reciir- rences are common or in which tlie systemic infection is marked. Herpes Zoster. [The Shmfjles; Zoster.) Herpes zoster is a painful acute inflammatory affection cliaractcrized by the production of a vesicular eruption appearing over tlie course of dis- tribution of the cutaneous nerves. It is accompanied by an inflammation of the peripheral nerves or of tlie sensory ganglia of the posteiior nerve roots. Following a day or two of localized pain, there will appear on one side of the bodv a crop of vesicles having a reddened inflamed base, which are seen to follow the distribution of an affected nerve. The vesicles, as a rule, dry up without pustulation, unless infected by unclean children. Adults suffer more intensely with this affection than do children. It is recognized by its unilateral distribution over a nerve tract emphasized bv tlie svmptom of pain. ">(ii; DISEASES or OHILDKEN. Treatment. — Locally, stearate of zinc as a dusting powder and a pro- tective di'essintr are i-e(iuired. Small doses of plienacetin or codeiu ma}' be required for the relief of pain. The incandescent lamp has given relief in some cases, as liave the A'-rays. Fk;. Ii5.— llci-i>es Zoster. (Walker.) Pellagra. Since the investigations by the Pellagra Commission cases of this disease have been found among the children, especially in our Southern States. The disease manifests itself in disorders of the digestive .system, localized erythenuita of tlie skin, and varied nervous symptoms. Its etiology is still obscure. It occurs cliiefly among those living in unhygienic quarters, and who arc; likely to su1)sist upon damaged corn. Symptoms. — The acute manifestations ap]iear as undefined attacks of gastro-enteritis, accompanied liy extiHMiie lassitude and wealaiess. After a variable time skin lesions appear, for the nmst part upon the extensor sur- DISEASES or THE SKIN. ofi" faces of the arm and hand, and on the back of the face, neck and feet. The skin is mottled red, witli a formation of blebs, whicli tend to become indu- rated and desiccated. These lesions are symmetrical. Except for restless- ness and insomnia, further neurotic symptoms are not apt to manifest themselves in children. Treatment. — Eemoval to a northern climate, improvement of hygienic conditions, plain nourishing food, with arsenic and iron, are indicated. CHAPTEE XLIII. PARASITIC SKIN DISEASES. Children are more liable to tins group oi diseases because of their vulnerable, tender skin, and because even clean children are apt to mingle with their uncared-for schoolmates. Pediculosis. These are insects readily seen under a low-power glass. The head louse is from 1 to 3 mm. in length, has a head, tliora.x and abdomen, and a sharp proboscis bv which it attaches itself. Tliev are extremely prolific, the female laying about fifty eggs, and the young being ready to multiply their kind after three weeks of life. The ova are enveloped in a capsule and are attached to the hair. Tliese are commonly known as nits. The parasite feeds by im- bedding its proboscis in the scalp and sucking. Thus the intense ilcliing is caused. Scratching causes further iriitation and patches of eczema may appear. The post-cervical glands arc enlarged in neglected cases, and a re(] line at the base of the hair Ixdiind is often visible to confirm tlie diagnosis, are distinguisliable from FTfi. ITC). — Pedicu- lu-s capitis. Micro- The nits Nits Vhotogv^ph (After rlandruff scales bv their position on ot pe.licnlus .-apitis, the hair, their tenacitv to it, and the ^'^^ ' -l""^'*''"-^ ability to move them up and down the hair. Treatment. — Cut the hair as closely as possible in long-standing cases if no great objection is made. Apply a cap made of a ligbt towel soaked in coal-oil (kerosene) or pour alcohol over the scalp, beginning at tlie base witli the head held over a basin; the parasites will then move on before it and are washed away. In the daytime a 10 per cent, boi'ic ointment is rubbed into the scalp in aggravated cases to allay the irritation. T1ie nits are removed only after patient treatment with a fine comb. Scabies. {Thr. Tfrh.) Scabies is a disease of the skin produced by the Sareoptes seabiei or itch-mite, which by its entranc(> into tlic skin produces burrows and an PAKASITIC SKIX DISEASES. F)(')H eruption of yesiek'S, pustules, and nodules. To these are added tlie sciatcli- marks produced by the patient's finger-nails. Infants and young children are greatly annoyed by the irritation and the evidences of scratcliing are observed early. The intei'digital spaces, the wrists and flexor sui'faces of the foreaiius, tlie toes and inner surfaces of tlie thighs are especially affected. The wliole body may be invaded in unrecognized or neglected eases. The prominent symptom, itching, is worse when the patient is in a warm bed. If the child is predisposed to eczema this is almost sure to supervene, and, in fact, sometimes masks the original cause. The disease is commonly seen in dispensary children, who are apt to sleep witli others and receive meager bodily attention. The itch-mite can with care be seen by tlie naked eye. The female is larger than the male. They are ovoid in shape, covered with hairs and g~ have a pair of mandibles by which they attach ,„ themselves to the skin in burrowing. The female deposits its eggs and perishes, while the colony work their way to the outer skin and start burrows of their own. r- mi T • Ti 11 Fig. its. — The itch-mite. Treatment. — The rlisease is readily amenable {'Neumann.) to cure if certain rules are followed faithfully. Remove all the clothing and bedclothes and sterilize them by Ijoiling or baking in an oven. Follow a vigorous soap and hot-water bath with the application of suljihur ointment drachm one to the ounce. If i-czema is present, use mild detergents, especially in the case of infants. Powdered sulphur may be used in children or a solution of styrax in the strength of half an ounce to the ounce of lanolin. The ointment selected should be applied to the whole body twice a day and two weekly baths taken. If there is a superadded eczema, treat the latter along the lines outlined for that disease. Tinea Tonsurans. (Ringicunn of the Scalp.) This is a contagious disease produced by a vegetable parasite, Iieginning as a mass of minute vesicles which soon affect the hair. The lesion consists of a rounded patch showing broken-olf hairs (shaven beard appearance) or a partly bald area, with extension taking place into the periphery. The central area is more or less reddened with a dirty scaly margin. OiU DISEASES OF CHILDEEX. The disease is almost entirelj- confined to cliildren, rarel)- appearing after puberty- : children infect each other directly or through articles of clothing or toys or through their pets. The patches are rarely seen by the physician while vesicles are present. The diagnosis must be made on tlie presence of the giiawed-oif looking hairs in a rounded, reddened, scaly field in which the fungus can be foumi on the hairs. Examination for the Fungus. — A loosened diseased hair mav Ije placed on a slide and soaked in a 10 to 20 per cent, potasli solution, and examined for the parasite under tlie microscope with at least a ,t-ineh lena. Fig. 179. — Favus of tlie scalp. (WaJL-ci:) Treatment. — Eingworm does not respond quickly to treatment. If dcpilation is first performed, a better response to antiparasitic remedies is obtained. The scalp should ])e cleansed for several days witli green soap and water. Tlie surrounding hair is best kept short or, if possible, shaven about the lesion. A solution of potash applied on a piece of gauze and rubbed in will remove any debris tliat remains after the washings. An antiparasitic ointment is now daily u]i])lied and a protective dressing or cap used. We have tried to our satisfaction apjilications of oil of cade and castor oil, equal parts, or betanaphthol one-half to one drachm to the ounce. Ten per cent, aristol in flexible colloiliou has commended itself in cliildren who are in asylums and apt to infect others. The A'-rays are highlv spoken of by dermatologists as a rapid and permanent means of cui'e. PARASITIC SKIN DISEASES. 571 Tinea Favosa. Favus is a feebly contagious parasitic disease, caused by the Achorion Schouleiiiii. The lesion consists of sulpbur-yellow areas on the scalp through which the hair.s appear. The liair shaft is Ijroken (iff, lieing diseased by the fungus. Closely examined, it is found that each hair is surrounded by a cup- shaped area ; these cnalescing proug cbildren who are susceptible. City cfiildren, because of their unfamiliarity with tlie plant, are more apt to exjiose themselves to its venomous activity. When barefooted they are particularly liable to come in contact with it. and they readily spread the jinison to their face, neck and genitals. The erythematous eruption appears within a few hours, and is followed by numerous vesicles which soon rupture and wet the surface with their serous exudation. Signs of inflanunatlon. jiain. heat and swelling are still further aggravated by intense itching. Aliout the face the edema may produce great distigurement ; after reaching its heiglit the erythema subsides in a few days, especially if restitution to the normal is assisted liy apjiropriate treatment. Children and their parents should be taught to recognize these plants and know their characteristics. 6i-i DISEASKS OF CIIILDHEN. Treatment. — TIk' c-liild sboulil bo restruiiuxl I'rouj infecting otbiT parts of tbo body and from soratobing tbe acutely inflamed area. If tbe erujition is seen soon after its aiipearaiice tbe parts sboiild be copionsly liatbed witb an alkaline solution, sueb as a .r> per cent, solution of bicarbonate of soda. Tben apply gauze wet with a 2 per cent, solution of iiermangauate of potasb. Tbe pbysician, if suscei)tible bimself, sbould wear rubber gloves wben doing tbe dressing. Tbe dressing sbould be apiilied in such a way as to prevent tbe ruptured vesicles from coming in contact witb tlie bealtby skin. After tbe acute stage is passed, sootbing ointments such as Lassar's paste produce good results. I'rdiibyl.-ictii- injections (if tbe sjiocitic plant serum .-ire now availalilc an(i offer great relief to tlie ]ireilispnseil. INDEX Abdomen, as aid to diagnosis, 80 enlarged. 89 prominent, 89 tumors of, localized, 80 Abdominal wall, tiinuirs of, 90 Abnormalities in lireatbing, as aid to diagnosis, 87 Abscess, cerebral, 503 ischiorectal, 540 of brain, 503 of liver, 221 of lung, 372 peritonsillar, 348 pulmonary, 372 retrojiliaryngeal, 348 subphrenic, 374 Absence of bones, congenital, 522, 524 Acetonuria, 444 Achondropasia. 41(1 diagnosticated from cretinism, 420 Acidosis, 1S8 Acne, vaccine therapy in, 82 Addison's disease, 412 Adenie. 412 Adenitis, acute, 413 chronic, 414 tuberculous. 314 vaccine theraji.v in, 82 Adenoids, 345 etiology, .•'.45 exaniin.'ition, 347 symptomatology, 345, 340 treatment, 347, 348 Administration of drugs, 03 of food for infants, 1.52 Adolescence. 30 Adrenals, disordci's of. 4]2 hemorrhage into. 412 Aerother.-ipy. 09, 70 Air, fresh, <'i9 Albuminuria, cyclic, 443 functional, 443 physiologic, 443 Alcohol sponge bath, 72 Allergy, 100 Alopecia areata, 571 Amaurotic fandly idiocy, 515 Amebic dysentery 207 Amygdalitis, acute, 341 Amyloid liver, 220 Anamnesis of sick child, 39 Anaph.vlaxis, 190 Anemia, 305 pernicious. 397, 40<5 secondary, 395 simple. 395 splen;.\ 400 von .Tacksch's. 308 Anemias, table of, 400 treatment of, 402 Anesthesia, 530 chloroform, 530 gas-ether, 531 preparation for, 531 Anesthetic, choice of. 530 Angina, streptococcic, 343 Vincent's, 343 .Vngioneuriitie edema, 487 Animal parasites, 209 found in childhood, 209 .Vnk.vlostoma Americana, 214 Ank.vlostoinum duodcn.ile. 214 Ano|iheIes mosquito. 304 Anterior poliomyelitis. 201 .Vntitoxin, diphtlierin, 2.55. 250 Anuri.i. 441 Anus, fissure of. 540 imperforate, 521 malformations of. 521 prolapse of, 541 stenosis of, 521 Aortic obstruction, .380 regurgitation, 380 Apht:i:r, 173 Eednar's 173 Apoplex.v. meningeal, during birth, 8 Appendicitis, 533 abscess formation, 535 diagnosis, 535 etiolog.v, 533 e.-s:aniination. 5-34 pathology. .533 prognosis. 535 suppurative form, 534 symiitomatology, 533 treatment, 535 Appendix, of infant, 31 Artliritides, infections, 303 Arthritis, diagnosed from rheumatism, .■;(I0 tnbercailous, 304 Arthritis deformans, .303 5?; 574 Ai'tlu'dsryposis, 4S.'"'., and see Tetany Artificial respiration, 30 Articular rlieuniatisni, acute, 2'JS Ascaris luuibricoides, 210 Ascites. 530 chylous, 540 Asphyxia, during Iiirtli, 0, 11 artificial resjiiration in, 10 direct insuttlation in, lu preventive treatment of. 10 Aspiration of pleural cavitv. teclmic of, 51 Assimilation, infants differ in jiower of. 125 most elficient in early infancy, 125 Astbni.a. bronchial, 350 hay, 102 thymic, .''52 Ataxia, Friedreich's, 400 hereditary, 400 Atelectasis, congenital. 11 Atbrejisia, 432, and see Marasmus Atrophic paral.vsis, acute, 201 Atrophy, 150 idiopathic nuiscul.ar, 407 infantile. 440. and see ."Marasmus Attitude. tv]iical. of normal infant. 20, 27 Auroscope, electric, 540 Auscultation of infants and children, 44, 45 P.ABi^-sKi's refiex, 45, 2,S7 Balanitis, 400 Baldness, 571 B.arlow's disease, 430 Basedow's disease, 415 Basket crib for premature infant, 2 luncheon, 100 Bastedo's rule fur dosage, 03 B.athing, in infancy. 2.'1. 24 Baths, alcohol sponge, 72 artificial Nanheim, 72 bed, 70 brine, 71 cai-linnic acid, 72 hot, 71 hot .air, 71 nnist.'ird, 72 sheet, 70 .soothing, 72 sjiecial, 71 sponge, 70 \Aarm, 71 l-.ed baths, 70 I'.ednar's nphthfe, 173 B>eef .juice, to make, 145 Beef tea, t(j make. 145 B(41's i'alsy. 401 P.iliar.v ducts, intlannji.ition of, 210 Binet-Simon tests for mental deficiency, 510 Birth, in.iuries durin.g, 5 palsies, Bladder, calculus in, 407 diseases of, 4(iO ectopia of. .522 extrufihy of. 522 iiOlaJnm.ition of, 4ij6 of inf.'int, 31 spasm of, 400 Blennorrhea, urogenital, 400 Blepharitis, 550 Blood, 303 cells red, 303 nucleated. .'^.04 nuuiber of, 303 corpuscles, white, .394 corpuscular element of, 393 counts, 53, 54 diseases of. :;o;! examination of, .53 in feces. 49 in urine. 443 plates. 305 pressure. 370 smears, method of mailing, 54 lilue disease, 377 Boiler, double, 330 Boils, 5(i5 Bone, c.iries of. 330 congenital absence of. 522, 524 fractures of, durin.s; birth, injuries to, during'birth, swollen, 02 tuberculosis of. 3.")0 Bowels, irrigation of, 74, 75 regularity of, in infancy, 25 Boys, height and weight of, 35, 37 Brain, abscess of, 503 diseases of, i!i01 tnnairs of. 504 Bran(4ii.al c.\sts. congenital, 520 fistuliP, .520 Breasts, preparation of, for lactation, 300 type of. i)referable for wet nurs- ing, 100, 107 Breast feeding. 99. and see Nursing in)|)ortance of, 00 intcrv.als of, 100 jnanagement of. lOO i not jiossible, 105 ]ircp.iratlon for. 100 regularity of. 100 scanty su|)ply of milk, 101 Breast milk, examination of. 103 for premature infants. 3, 4 reaction of. 104 sjieclHc gravity of. 103 INDEX. 575 Breast pumps, 104 secretions, 94 composition of, 94 properties of, 94 Breutliing, abnormalities in, as aid to diagnosis, ST exercises in, ,S.T montli, in nasal obstrnctinn. S7 Breek feeder for ]irematnre infants. 3 Brjghfs disease, acute, 445 Brine batb, 71 Broncbial astbma, "r)G stenosis, 88 Bronchiectasis, 373 Broncbitis, acute, 353 diagnosis, 354 etiology, 353 physical signs, 333 prognosis, 354 syniptoniatoi igy , 353 treatment. 354 capillary, 357 chronic, 354 Bronchopneumonia, acute, 357 aerotherapy in, 301 clinical forms of. 3(10 complicating the infectious dis- eases, 3r;o complications of, 3(J0 course of. 301 diet in. 302 differential diagnosis of, 300 hydrotherapy in, 302 local applications in, 302 medication in, 302 pathology of, 357 physical signs of. 358 prognosis of, 301 symptouiatulogy of, 357, 359 treatment of, 301 tuberculous, 317 Broths, to make, 145 Brudzinski's sign, 45, 288 Buhl's disease. 15 Buttermilk, 140, 148 Calculi, renal, 442 vesical. 4(J7 Calmette test for tuberculosis, 57 Caloric value of foods. 149 Calorie feeding, 14S Calx chlorata, as a disinfectant, 311 Canci'cim oris, 170 Cap, ice, 70 Capillary bronchitis, .357 Caput succedaneum, 5 Carbohydrates, diet preponderating in. 105 of cereals, 110 Carbolic acid, as a disinfectant, 311 Carbonic acid baths. 72 Cardiac disorders, functional, 388 instruments in diagnosis of, 392 Cardiograjib, 392 Cariole, 24 Caries of bone. 330 of spine. 330 Catalysers, 113 Catarrlial fever, acute, 271 Central jiaralysis, during birth, 8 Cephalbematoma, 5 Cereal gruels, jjcrcentage, 130 Cereals, 115 carbohydrates of, 110 prepar.-ition of, 130 properties of, 115 Cerebral abs<'ess, 503 palsies, infantile, 5(i5 paralysis, 409 tumors, 504 Cerebrospinal fever, 280 Huid. examination df, 49 meningitis, epidemic, 280 Cereo, 130 Cestodes. 2n9, :.M2 Chalazion. 551 Changes in features, as a sign of ill- ness, (il CLajiiii's cream dipper, 129, 130 infant urinal. 437 tongue depressor, 3:^.8. 339 Chest, abnormal sli.-ijie of. 88 as aid to diagnosis, 88 Chest wall, tinnors of, 88 Chickenpox, 244 return to school after, 206 Child, height of, 35, 37 mental growth of, 35 moral growth of, 35 relative measurements of, 29, 34 weight of, 35, 37 Childhood, diet during later, 102 growth during. 34 pulse in, 43 relation of neutrophiles to l.ym- pbocytes in. 55 respiration in, 39 Children, auscultation of, 44, 45 mensuration of. 40 palpation of, 42 perciission of. 40 rectal exannnation of. 47 Children's hospitals, diet lists for, 100 Chlorid of lime, as a disinfectant, 311 Chloroform anesthesia, 530 Chlorosis. 390. 400 Choked disk. 554 Cholera infantum. 204 Chondrod.vstrophy. fetal, 410 Chorea, 472 57G l^JDEX. Chore;!, coniplicutions, 47-t course, 47."> diagnosis, 473 etiology, 472 forms of, 47.5 patlioldgy. 472 prognosis, 47'! syuiiitouis, 473 treatment, 474 liereditary, 47.5 Huntington's, 474 insaniens, 47-j major, 475 minor, 472 Sydenham's, 472 C'lioreiform affections, 47."i Cliyostelv's symiitoms in tetany, 4S3 Cliylous ascites, •"40 Circulatory system, diseases of, :'.7.j Circumcision, 5.'li! Cirrliosis of liver, 221 Claw-hand, 9? Cleft-pal.ate, .")2(J Clotliing, in inf.ancy, 23 Clubbed fingers, 02 Club-foot, .j24 Colds, return to school .after, 2i!<"> Colic, 105 Collapse, pulmonary, .".55 CoUes' hnv, 2TU Colon, dilatation of, congenital, 203 flushing the, 74, 75, 7(j irrigation ol the, 74, 75, 7i; Colostrum, 04 CuU]presses, 70 Condensed milk, 114 mixtures, 147 Congenital absence of bones, 522, -524 atelectasis, 1 1 branchial cysts, 52u deformit.y of hand, 522 dilatation ol colon, 2o3 dislocation of hi|i, 522 heart disease, .".77 hydroceplialus, 50S, 51(i infantile stridor, 352 huyngeal stridor, 352 malformations and deformities, 519 rachitis, 420 Congestion of liver, 220 Conjunctivitis, acute, 5.50 chronic, 551 diiihtheritic, 551 granular, .551 of the newl.y born, IS return to school after, 2(l•".. 04 elimination of. in milk. 101 freciuently used in pediatric prac- tice, 04 Duchenne's par,-\lysis, during liirtli. 7 pseudohypertrophic nuiscnl.ir p.i- rai.vsis. 497 ty]ie of primary myopath.v. 497 Ductless glands, diseases of. 4ns Duke's dise.ase. diagnosed from scarlet fever. 2.34 Dysenter.v, amebic, 207 Dyspejisia, 150 acute. 178 Dysphagia, false, 87 true. 87 D.vspiiea. expiratory, 88 inspiratory, 87 mixeil, 88 D.vstroph.v, muscular, 497 Ear, .545 ' ■ ■ : ' diseases of. .545 ' ' speculum, .545, .540, 549 Eating, rules for. 108 Eclampsia inf.mtum. 470, and see Con- vulsions Ectopia of bladder. 522 Eczema, 559 . acute, treatment, .502 general, 502 local .502 chronic, .500 .; ; treatment, 503 :' ■ crnstosum, 500 i ; , di.ignosis, 500 5:8 IjXDex. Ec-zenia, etiolofik-al factors, 559 erytlieiiiatims, 500 madidaiis, 5U0 iiiasU. 5lj2 pajHilar. 5(i0 ]iro)j;ii(isis. 5(51 liUKtiilar, 5ri0 rulinim, 5(J0 subacute, treatnieut, 503 subvarieties, 5(10 sj'iii]itiiniatolog,v, 5(;0 varieties. 5i;0 vesicular, 5(iO Edema, acute circuuiscrilied. 487 aiiRimieurotie, 4ST of glottis, -.'.M Kkss. 11 (J Khrlicli's jireparation for syiihilis, 2S2 Eiweissniilcb. to make, 145 Emiib.v.sema. .■:!55 acute, 355 Emp.vema. 307 exploratory puncture. 300 syi]iptoiiiatolog.v, .3(JS treatment. •".70 Euoepbalitis, acute, 492 epidemic, 503 letb.argica, 503 Enoepbalocele, .520 Endocarditis, aiaite, 379 diagnosis, 380 etiology, 379 patbology. 379 prognosis, 381 symptomatology, 380 treatment, 381 maliguaut, 380 septic, 380 ulcer.ative, .380 vaccine therapy in, SI Endotoxins, 78 Eiiemata. nutrient, 77, 78 Enlargement, general, 92 Enteralgia, 195 Enteroclysis, 75, 70 Enterocolitis, acute, 200 f;nuresis, 455 psycbotbera|i.v in, 09 treatment, 457 Eosinopbiles, 304 Eosinopbilia, ,55, 393, 395 Epidemic cerebrospinal meningitis, 280, 207 encc|ibalitis, .503 heuKJglobijiuria, 15 paralysis in cbildren, 297 parotitis, 204 Epilepsy. 477 diagniisis. 478 etiology. 477 Epilepsy, grand mal, 477 fietit mal, 477 prognosis, 478 symj)t(iinatology, 477 treatment, 478 Epileptic voice sign, 478 Ejiistaxis, 337 Erb's nj.volonic reaction. 480 Iiaralysis during bii'tb. 7 symjitom. in tetany. 4S5 type of jirimary myopathy, 497 Erysipelas. 307 etiolog.v, 307 prognosis, 309 s.vmiitomatology, 308 treatment, 309 Erythema multiforme, 559 sea rlat in i forme, diagnosticated from scarlet fever, 233 Er.vtbemat.i. diagnosed from scarlet fever, 2.32 Erythrocytes, 393, 394 Esophagitis, corrosive, 178 Esophagus, congentit.il occlusion of, 178 inflannnation of. see Eso)ihagitis malformations of. 521 Essential paralysis of children, 291 Evap(u-ated cream, 114 milk. 114 Examination of sick child, 39 blank for, 40 Examinations, special, 48 Exanthemata, 222 return to school after, 200 table of, 245 Exercise and fresh air in infancy, 24 Exercises, breathing, S3 for develoi)ing children with de- formities, 80 for increasing resjiiratorv capac- ity, 83 resistant, 83 Exo)ihth.-ilmic goiter, 415 I'jXdphthalmos, 553 Exotoxins, 78 Exiiloratory puncture in empyema, .369 Expi-pssion of face. 80 Exiiemities. as aid to diagnosis, 91 enlargement of, 92 rigidity of, 92 spastic. 92 Extrojiby of bladder. .522 Extubation. 2.58 Exudates and transudates differenti- ated. .52 examination of. 48 Eye, affections of. diagnostic hints re- garding. 553 diagnostic signifiiance of. .5.52 INDEX. 679 Eye, diagnostic bints regarding af- fection of, 553 diseases of, 550 foreign bodies in, 550 test for tuberculosis, 57 Face, as aid to diagnosis, 86 expression of, 80 Facial paralysis, 491 during birth, 7 Fat in milk, percentages of, in differ- ent portions of mill;. 127 Fattv degeneration of tbe ne\ylv born, 15 liver, 220 Favus, 570 Features, changes in, as a sign of ill- ness, 01 Feces, and see Stools blood in, 49 examination of, 49 OYn, in, 49 Feeblemindedness, 511, and see Idiocy I'^eeders for premature infants. :; Feeding, and see Infant Feeding, Nutri- tion calorie, 148 directions, outline of, 1"2, 151 forced, 76 in hot weather, 154 in typhoid fever. 270 infant, chemical and biological standards in, 97 laboratory, 148 mixed, 105 of intubated cases, 259 of premature infants, o, 4 practical, 126 rectal, 78 substitute, see Substitute Feeding table, suggestive, 134 top milk method, 1.34 utensils, care of, 153 when away from home, 155 when traveling, 154 Fetal chondrodystrophy, 416 death, 11 Fever, acute catarrhal, 271 cerebrospinal, 286 hay, 192 rheumatic, 298 sjiotted, 286 Fingers, clubbed, 92 webbed. 526, 527 Finkelstein"s classification of nutri- tional disorders, 150 Fissure of anus, 540 of mouth, 86 of tongue, 87 Fistul.'P, branchial, 520 Fontanels, abnormal, 85 Food, adaptation of, to infants, 138 administration of, 152 caloric value of, 149 care of, in infant feeding, 151 dispensaries, 15G essential unit.v of, 93 for acutely ill infants, 144 for healthy infants. 132 for infants, administration of, 152 for infants of feeble constitution, 142 for infants previously badly fed, 140 for infants who fail to thrive on fresh milk, 146 idiosyncrasy, 190 improper, cause of scorlmtus, 4.30 of first nutritive period, 04 spe<-ialized, 94 values, caloric, 149 Foot, club, 524 Foot drop, in poliomyelitis, 293 J'orced feeding, 76 Foreign bodies in eye, 550 in nose, 337 in respiratory tract, 374 Fourth disease, diagnosticated from scarlet fever, 2.34 Fractures during birth, G Freeman's pasteurizer, 1.52 Fresh air, in infancy, 24 in treatment of disease, 69 Friedreich's ataxia, 406 Functional cardiac disorders, 388 Furunculosis, 565 vaccine therapy in, 8- (jArr, observation of, 468 (jangrene of lung, 372 Gas-ether anesthesia, 531 Gastric catarrh, acute, 178 contents, examination of, 48 indigestion, acute, 178 ulcer, 179 Gastritis, acute, 178 clironic, 181 Gastroenteritis, acute, 196 Gastrointestinal indigestion, chronic, 202 Gavage, 77 danger of, in premature infants, 4 Genital organs, diseases of, 460 Geographic tongue, 171 German measles. 227 return to school after, 266 Girls, height and weight of, 35, 37 Glands of infant. 31 (Jlomerulonepbritis, acute, 445 Glossitis, desquamative, 171 •5,80 INDEX. Glottis, eaeiiia of. .3."0 Gl.vcosuria. -i'AU Goiter. exo[ilitliaIuiic. 41." Gonitis tuliei'oulosa. 3o.'^. Grand nial, 477 Graves' disease. 41.5 Growtla, delayed, as aid to diagnosis, ilO during cliildliood, ."4 mental, of eliild, ."-"i moral, of cbild. .l-'i of infant, 27 Gruels, cereal, pereent.ige, l.'JO, 135, !•"(> de.xtrinized, to make. 144 directions for nialcin,!;. 13(; Gums, bleeding, S7 spong.v, 87 swollen, ST Habits, general, of infants. 2."i Hand, abnorni.il, 9- claw, !12 congenit.il deforniily of, .')L'2 intra-uterine aniput.itinn of, ."(23 Harelip, 52!) Hay astlnna, 102 fever, 1!>2 Head, as aid to diagnosis, .S5 deforniit.v of, fontanels, abnormal, 85 injury to, during birtb, 5 motion of, almornial, 85 of infant, 28, 20 position of, abnorni.il, 85 sbape of, abnormal. 8." size of, abudrmal. 85 tumors about, 85 Headacbes, 478 Hearing, estimation of, 4li0 Heart, 374 Hodgklns' disease, 412 Hook worm, 214 lloiiver Iireast pump, 104 Hordeolum, 551 Hot air bath, 71 Hot liaths, 71 Hot ]iack, 71 Hot weather, infant feeding in, 1.54 Huntington's chorea, 475 Hut(4iinson's teeth, .'13. 283 llydrencepbalocele. 520 Hydrocele. 403 congenital. 403 encysted, of the cord, 403 infantile, 4G3 of tunica vaginalis, 403 Hydrocephalus, 508 ac(|uired, .508 cl.assification of, 508 congenital, ,508-510 diagnosis. .500 . , IXDHX. 581 Hydrocephalus, etiology, 508 prognosis, 510 syniptouiutology, 508 treatment, 510 IIytlronei)lirosis, 454 Hydrotherapy, 70 Hygiene of infancy, 23 Hynienoleiiis Nana, 214 Hyperleukocytosis, 303, 305 Hyperplionia, 480 Hypertrophy of pylorus, congenital, 183 of tonsil, 345 Ilypodermoelysis, 74 Hypospadias, 522 Hypostatic pneumonia, 303 Hysteria, 475 etiology, 475 prognosis, 470 psychotherapy in, 09 symptomatology, 475 treatment, 470 Ice cap, 70 poultice, 70 Icterus in premature infants, 4 neonatorum, 15 Ichthyosis, 555 Idiocy, 511 etiology, 511 prognosis, 513 symptomatology, 512 treatment, 513 Idiocy, amaurotic family, 515 Mongolian, 513 Idiots, tests for, 517 Imbecility, 511, and see Idiocy Imbeciles, tests for, 517 Idiopathic muscular atrophy, 497 Idiosyncrasy, food, 190 Ijnjietigo ccjutagiosa, 55S Inability to walk, 91 Incontinence of urine, 455 Incubator, for premature infants, 1, 2 Indican, test for, 52 Indieauuria, 444 Indigestion, gastric, acute, 178 gastro-intestinal. chronic, 202 Infancy, assimilation in, 125 bathing in, 23, 24 clotliing in, 23 exei'cise and fresh air in, 24 general habits in. 25 habits of sleep in, 25 hygiene of. 23 pulse in, 43 regularity of bowels in, 25 respirations in, 39 signs of illness in, 60 urine in, 437 Infant, and see Newly born Infant a.utely ill, food for, 144 ada])tation of food to, 138 ajiiiendix of, 31 attitude of normal, 20, 27 auscultation of, 44, 45 Iiladder of, 31 dead born, 11 dentition of, 31 development of. 20. 2S difference of. in digestive and as- similative efficiency, 125 glands of. 31 gro\\th of, 27 head of, 28, 29 healtliy, food for, 132 intestines of, 31 lacrimal glands of, 31 length of, 27 liver of, 31 loss of weight during first few days, 20 mensuration of, 40 muscles of. 31 nucleated red cells in, 55 nutrition of, 93, 97 of feeble constitution, foods for, 142 pancreas of, 31 percussion of, 40 premature, see Premature infants previously badl.v fed. fond f(.ir, 140 rectal examination of. 47 relative measurements of, 29 salivarv glands of, 31 sebaceous glands of, 31 shajie of, 28 skull of, 30 SI line of, 30 stillborn, 11 stomach of, 31 teeth of, 31, 32, 33 tendency of, to adapt themselves to their food, 124 testicles of. 31 thyiims of, 31 viscera of, 31 weighing of, 20. 15.3 importance of, 153 weight and development of. 20 chart, 1.54 who fail to thrive on fresh milk, foods for, 140 Infant feeding, 93 among the poor, 155 care of food, 151 of utensils, 1.53 chemical and biological standards in, 97 directions for, 1.32, 151 education of mother necessary, 151 583 INDEX. Infant fccdini;, fnndaniental errors in, 121 how to intur|iri't results, iri:; in liot weatlier. iri4 methods of uiodifyins; mill< for, 12:^ percentage niill< mixtxires in, TJc. practical, 12(j basis of, 12«J scientific, rise and development of, 121 when away from home, l"i when traveling;, l."i4 Infant foods, administration of, l.j2 dispensaries. I.Ki proprietary, 117 classiHi-ation of, 117 composition of. 117 Infantile atrophy, 4.32, and see Maras- mus cerelir.il ji.alsies, ."lO.j paralysis. 2'.)1 scurvy. 4.'!0 stridor, congenital, 352 Infantilism, 417 Brissaud type. 417 diagnosed from cretinism. 420 Lorain type. 417 Infarction, uric acid. 442 Infectious arthritides, .30-5 diarrhea, 19i! diseases, 222 bronchopneumonia complicating, 3(j(i disinfection in, 310 of the newly born, 12 sick room in, 310 Inflammation ot biliary ducts. 2ly of portal vein, 220 Influenza, 271 deliiiition. 271 diagnosis. 274 etiology. 271 incul)ation, 271 patliology. 271 symptomatology. 272 treatnient, 274 Inguinal region, as aid to diagnosis. 0() enl.argement of. !Mi swellings in. differential diagnosis of, 404 tumors (it. Oil Inhalation of iiniteins, 102 Injuries during birth, 3 to bone. G to lic;iil. 5 to mus(4e, G Insomnia, 4.S0 Ins])ectioii of sicic child. 39 Insuiriation. direct, in aspliyxia. 10 Intestines, of inf.-uils. .",1. 7." Intestines, tumors of, 90 Intoxic.ition. l.'iO Intnli.ition. 2."G Intussusception. ."iSS di.-ignosis. .530 etiolog.v. 1530 prognosis. 537 s.vmptomatology. 53G treatment. 537 Inunction.s for premature infants, 4 Inunction test for tuberculosis, 57 Invagination, intestinal. 535 Irrig.ation of bowel. 74. 75 Irritaliility of temper, as a sign of ill- ness. 00 Ischemic jiaralysis. Yolkman's, 470 Ischiorectal abscess, .540 Itch, the. 508 Itch mite. 509 Iv.v poisoning, 571 .T.\r.\uKi;. 218. and see Icterus .loints. swollen. 92 tuberculosis of. 330 .Jugular bulb infection, .548 Kku.xtitis. .552 Kerni.g's sign, 287 method of eliciting, 43, 44 Kidney, amyloid. 450 congestion of. 444 clironic. 444 disorders ot. 437 formation of. 441 large white. 4.50 passive hyperemia of. 444 tumors of. 80. 453 waxy, 4.10 Kilmer belt for pertussis. 203 Knee, tulierc ulous disease ot. 3.33 Koplik's spots. 223 Laiio[!at(i1!v fi'eding. 148 Laborde's metliod of artificial respira- tion, 11 Lacrim.-il glands of infant. .31 I>a (Jriiipe, 271 Lanilouzy-Dejerine type of iirini.iry niyo]iathy. 497 Laryngeal diiilitheria. 249 stenosis, 88 stridor, congenital. 3.52 Lar.Migisinus stridulus. 3.50 Laryngitis, acute. .348 diagnosticated from laryngismus stridulus. 351 dilihtheritic, dia,gnosticated from acute layngiti.s, 349 s|iasinodi<', .348 suliiiiucous. 3.5(1 INDEX. 583 I^aryux, new growths of, 352 IJapiUoimi of, .352 Lavage, 73 Length of infant, 27 premature infant. 2 Leptomeningitis, acute, 501 Leulvemia, 397 I.vmiiliatie. 308, 400, 407 splenoiu.velogenous, 307, 40O Leut:ocytes, 303, 304 number of, 393 Leulcocytosis, 303, 395 Leulvopenia, 393, 305 Limp, wallving with, 91 Lip, bare-, 510 Lips, enlarged, SO Liver, 217 abscess of, 221 amyloid, 220 cirrhosis of, 221 congestion of, 220 diseases of, 217 enlarged, 80 examiuatiou of. 217 fatty, 220 Liver of infant, 31 Lobar pneumonia, 303 complications, 304 diagnosis, 304 etiology, 3G3 pathology, 304 physical signs, 304 prognosis, 305 symptomatology, 304 treatment, 305 Lobular pneumonia, 357 Logi's method of breathing. 83 Longitundinal sinus entering. 59 Luetin test for syphilis, 50 Luml)ar puncture in cerebrospinal men- ingitis. 288, 291 technic of. 50, 51 Luncheon, baslcet, 109 Lungs, abscess of, 372 diseases of. 353 gangrene of, 372 Lymphadenoma, 412 Lympliatic leukemia. 308, 400, 407 Lymphocytes. 394. 395 in childhood. 55 Lymphocytosis, 303, 305 MacEwen's sign, 288 Macroglossia, 80 Malaria, 304 diagnosis of. 50 differential diagnosis, 300 - etiology, 304 pathology, 305 prophylaxis, 300 Malaria, s.vmptomatolog.v, 305 treatment, 300 * Malformations, congenital, 519 of anus, 521 of esophagus. 521 of rectum, 521 Malignant tumors in children. 542 JIammala, 115 Mammar.y secretions comparative, 90, and see Milk Marasmus, 432 course, 434 diet in, 434 etiology, 432 medication, 435 patholog.v, 432 prognosis, 434 symptomatology, 433 treatment, 434 Mask, eczema, 502 Mast cells. 394 Mastitis of the newly born, 19 Mastoiditis, 547 Masturbation, 402 Measles, 222 complications, 224 definition, 222 eruption, 224 etiology, 222 exanthem, 224 fevei; 224 German, 227 incubation, 223 Koplik's spots, 223 liathology, 223 prodromal stage, 223 prognosis, 220 phophylaxis. 220 return to school after, 200 seciuehv. 224 treatment. 220 variations, 224 Measurements, physical. 34. 37, relative, of infant, 20 of child, 20, 30 Meat liroths, to make. 145 Megaloblast, 303. .304 Melena neonatorum. 21 Meningeal a|ioplexy. during birtli, 8 Meningitis, 501 diagnosis, 502 etiology, 501 leptomeningitis, 501 pachymeningitis, 501 symptomatology, 501 treatment, 502 epidemic cerebrospinal, 280 complications, 289 differential diagnosis, 289 etiology, 280 5!S4 IXDKX. poo Mcnin^'itis, epidemic eerelirosiiiuul, lum- bar ininetiire in, 2NS, 2'.)1 jiatholo.ii.v. 2SG Iirognosis, 289 serum treatment, 200 i5.vn)])tomatolo,gy, 2SG treatment, 200 intlnenzal, :'~~ tiilierrulons Afeningdcele, 'ri2(;. ."28 Slensuratiiin of infants and cliildren, 4ri Jlcntal deficiency, tests for. ."1(! Mental growth of a cbild, y.j Jlierolilast, li'M 5Iicroce|ilialiis, 511 Microc.A'te, 394 Migraine, 470 Miliaria, .j(J4 Wiliar.v tuberculosis, acute, 321 of lungs, ;jl8 Milk, and see Mamm.iry serretions and water iiereentages, l.'Il bacteriology of, 110 bottled, in cert i lied. 111 couimissions. 111 condensed, 114 mixtures, 147 cows', 109 crust, 558 dried, loG elimination of drugs in, 101 ev.'Uior.ited, 1 14 grocery, 1 1 1 Liuiiian, ni>rmal, 04 insiiected. 111 ■ market. 111 microscopical appearance of, 113 mixtures, percentage, in infant feeding, 12(j modification of, approximate, 137, 138 modified. 123 elassitication of nietliods em- ployed, 123 mother's disagrees with infant, 102 drugs eliminated in, 101 iusutlicient, 101 one cow's, 109 pasteurized, 112 peptonized, 14,8 ]iercentages of f.it, in different por- tions of, 127 sanitary. 111 production of, 110 sterilized, 112 top, 127 Mitral olistructioii, 385 i-cgiii'gitation. 385 M of infants, 31 paralysis of, 470 Muscular atrophy, idiopatliic, 407 dystrophy, 407 paralysis, pseud(jhypertro]ihic, of Duchenne, 407 Mustard bath, 72 Myelitis, 403 diagnosis, 405 etiology, 40.'! Ijathology, 493 jirognosis, 405 symiitomatlogy, 493 treatment, 405 Myelocytes, 304 Myocarditis, 382 Myopathy, primary, 407 comiilications. .500 diff(>rential diagnosis, 5(X1 eti(jlogy, 407 pathology, 408 .symptomatology, 498 treatment, .500 INDEX. 585 Myopathy, i^riiuary, types of, 497 Myotonia congenita, 4.S(; Myotonic reaction, of Krb. 4S6 Myxedema, 417, and see Cretinism Nasal obstruction, moutli lireathing in, 87 Nasopharyngeal toilet, tLie, 7o in scarlet fever, 23G Naubeim batbs, artificial, 72 Necli, as aid to diagnosis, S(> tumors about, 80 Nematodes, 209 Neosalvarsan, 282 Nepbritis, 445 acute, 443 complications, 448 definition, 445 diagnosis, 448 etiology, 445 patbology, 445 prognosis, 448 symptomatology, 446 synonyms, 445 treatment, 448 des(iuaniat)ve, 445 diet in, 105 diffuse, 445 exudative, 445 glomerulo-, 445 parencbymatous, 445 tubular, 445 cbronic, 450 complications, 451 definition, 450 diagnosis, 451 etiology, 450 patbology, 450 prognosis, 451 symptomatulogy, 450 synonyms, 450 treatment, 451 • diffuse, 450 interstitial, 450 parencbymatous, 450 Nerve paralysis, 470 Nerves, peripberal, diseases of, 489 Nervous diseases, general, 408 system, diseases of, 408 Nettle rasb, 504 Neuritis, multiple, 489 course, 490 definition, 489 diagnosis, 489 etiology, 489 patbology, 489 prognosis, 490 symptomatology, 489 treatment, 490 optic, 554 Xeutro|ibiies in cbildbood, 55 Xevi, 557 New growths of larynx, 352 Newly-born, and see Infant acute infectious diseases of the, 12 conjunctivitis of the, 18 dimensions of, 20 diseases of the, 12 epidemic hemoglobinuria in, 15 fatty degeneration of the, 15 hemorrhages of, 91 icterus of, 15 mastitis of, 19 ophthalmia of, 18 sclerema of, 19 sepsis of the, 12 spontaneous hemorrhages in the, 20 tetanus of, 17 umbilical hemorrhage of, 13 Night terrcjrs, 481 Nipple shield, 105 Noguchi's metliod of examining cerebro- spinal fluid, 50 test for syphilis, 58 Noma, 170 Normoblast, 39-'!, 394 Nose, bleeding from, 91, 337 foreign bodies in. .337 Nucleated red cells in infants, .55 Nursery, the, 24 Nursing, and see Breast feeding bottle, 1.52 contraindications for, 105 not possible, 105 Nutrition, and see Feeding difference of infants in capacity for, 125 diseases of, 424 of infant, 93 of pi-eiii.iture infants, 3 Nutritional disorders, 424 Finl;lest(>in"s classification of, 150 Nystagmus, 553 OcESiTY, diet in, 105 Occlusion of esophagus, congenital, 178 Ophthalmia neonatorum, 18 Opsonins. 79 Oi)tic neuritis, 5.58 Otitis, .540 Otoscop.v, .545 Ova in feces. 49 Oxyuris vermicularis, 209 Pachymeningitis. 501 racks, hot. 71 Palate, cleft, .520 Palpation of sick child, 42 586 INDEX. I'alliitntion of lioart, ."188 Palsies, birth, (i clnssiticatidn ol. 50o INDEX. 587 rieurisy. dry, otJG serofibrinous. HC>C) pathology, 8(JG pliysieal signs, 366 prognosis, ?>07 symptomatology, 366 treatment, .".(JT Pneumonia, catarrhal, 357 croupous, 363, and see Lobar pneu- monia hypostatic, 363 lobar, 363, and see Lobar iineu- monia lobular, 357 Pneumothorax, 372 Poilcilocytosis, 303 Poliomyelitis, 291 definition, 291 diagnosis, 294 epidemic form of, 297 etiology, 291 pathology, 292 prognosis, 295 spinal fluid in, 295 symptomatology, 292 treatment, 296 Pollen, 192 Polygraph, 392 Polynuclears, 394 in childhood, 55 Polynucleosis, 393 Polypus, rectal, 540 Polyuria, 441, 442 I'ortal vein, infianmiation of. 220 I'ostdiphtheritic paralysis, 252 I'osture, in ])rimary myopathy, 497 L'ott's disease, 330 cervical, 331 dorsal, 331 lumbar. 331 Poultice, ice, 70 I'ractical feeding, 126 basis of, 126 I'remature infants, breast millv for. 3. 4 care of. 1 cyanosis in, 4 danger of gavage in, 4 death rate of, 1 factors i)rejudicial to life of, 1 feeders for, 3 feeding of, 3, 4 icterus in, 4 incubators for, 1, 2, 4 inunctions for, 4 length of, 2 management and care of, 1 modified milk for, 4 nutrition of, 3 peptonized milk for. 4 subnormal temperature of. 1. 2 Premature infants, temperature of. 1. 2 viabilit.v of. 1 weight of, 2 Prescriptions, OS Prickly heat, 564 I'rimary myopathy, 497 Profeta's law, 276 Prolapse of anus, 541 of rectum, 541 Proprietary infant foods, 117 classification of, 117 composition of, 117 Proteins, inhalation of, 192 Protozoa, parasitic, 2(19 Pseudod.vsphagia. 87 Pseudohvpertropliic nmscular paralysis, 497 Pseudoleukemia, 412 of infants, 39s. 4(1(1 Pseudoparalysis. 91, 470 Pseudotetany, 4S4 Psoriasis, 563 Psychotherapy, (J9 Ptosis, 553 Pulmonary abscess. •372 collapse. 355 gangrene. 372 tuberculosis, 319 Pulse, in infancy and childhood, 43 Puncture, lumbar, 50, 51 subdural, 50. 51 Purpura, 403 fuiminans, 405 hemorrhagica, 4(_i4 Henoch's, 405 rheumatica, 405 tScbonleiu's, 405 simplex, 403 I'utrid sore mouth, 175 Pyelitis, 452 definition, 4.52 diagnosis, 453 etiolog.v. 452 pathology. 4-52 prognosis, 4.53 symptomatology, 452 treatment. 453 vaccine, tlierapy in. s:j Pyleiililebitis, suppurative. 255 Pyloric sjiasm. 183 I'ylorns. hypertrophy of, congenital, 183 stenosis of, lS-"> Quixsv, .".48 Rachitic spine, 331 Rachitis, 424 antenatal, 429 bones in, 424, 42(). 427 588 INDEX. liacliitis, eoiisenital, 420 course, 4l'S (Icfoniiities ill, 427 di:i.,^ii(isecl from syjibilis, 281 (liatriKisis. 428 deformities in, 427, 420 dietetic treatment of, 420 eiiipliyseal enlargements, 427 etiolo^'.v, 424 Harrison's .groove, 427 liy.sienic treatment of. 420 medication in, 420 nervous iilienomena in, 427 patliology of, 424 jiroKUOsis of, 42S jiropliylaxis, 428 spine in, 428 spleen in, 425 symptomatology of, 42.1 thorax in, 427 treatment of, 428 Radius, congenital aliseme of, 524 Rectal examination of infants and cbil dren, 47 feeding, 78 polypus, 540 syringe for infants, 2(I7 Rectum, Iiemorrliages frdiii, 01 mnlfonnations of, 52] olistructions of, 521 jirolapse of, .541 Refractive errors in cliildren, .554 Reiiiil cal(/uli, 442 Resist.ant exercises, K) Respiration, artificial, methods of, 10 in infancy and cliildhood, :!0 Respiratory capacity, exercises for in- creasing, 8o tract, foreign bodies in, .'174 upi>er. diseases of tlie, :joU estless sleep, as a sign of illness, in tro])bai'yngeal abscess, .j48 ('\'i'rsilile stetboscoi)C, 45 lieumatic fever, 208 Iieumatisiii, acute articular, 208 com]ilications, 200 differential diagnosis, .'JOG drugs for, oUl etiology, 208 jirogiKisis, ;!00 jirojibylaxis, 301 sym|]tomatolog.y, 209 treatment, .">01 lieumatoids, ','>()?> hinitis, acute, .">:1G bus iioisoniiig, 571 ickets, 424, and see Rachitis (li.igiKJsed from cretinism, 420 igid extremitii-s, 02 ingworm of scalji, 5r,o Ringworm (jf tongue, 171 Ritter's disease, 557 Rocl;iiig of infants, undesirable, 25 Roenlgen rays, 52 Rotbeln, 227 Round \yorm, 210 Rubella, scarlatiniform, diagnosticated from scarlet fever, 234 Rubeidn, 222, 227, and see Measles .SALiVAiiY glands of infant, 31 Salt-rheum, 550, and see Eczema Sarcoma, .542 Scabies, 508 Scalp, ringNvorm of, 509 Scarlatina, 228, and see Scarlet fever Scarlet fever, 228 anginal form, 229 complications of, 23,7 detinition, 228 des(|uainatioii, 220, 2.'!1 desquamative stage, 235 diet in, 230 differential diagnosis, 232 eruptive stage, 2.j5 etiology, 228 inculiation, 228 pathology, 228 predes(iuamative st.-ige, 2.".5 pre-eruptive stage of, 2.';5 jirogiKisis, 235 lH'ophylaxis, 23(; rash. 2:;0 return to school after, 2(>(i siMiuela' of, 237 serum treatment of, 238 sick room, 23,0 simple form, 228 symptomatic treatment, 237 symptomatolog.v, 228 treatment, 2:'i(; Scbonlein's ]]urpura, 4(I5 School luncheons, IdS, liiO Schultze's method of artifici.al respira- tion, 10 Sclerema neonatorum. 10 Sclerosis, disseminated, 405 multiple, 495 Scorbutus, 430 aggravated cases, 4.".1 course, 43,1 dietetic treatment of, 432 di.ignosis of, 431 etiology of, 430 mild cases, 43,0 liathology of, 4.30 jirognosis of, 4.31 liro]di,\ l.axis id', 431 syn'i]tom,atology of, 430 Ireatment of, -131 IXDEX. 589 Scurvy infantile, 4r',0 Sebueeous glands of infant, 31 Seborrhea capitis, 558 Secretions, breast, 94 Sepsis of tlie newly born, 12 Septic rashes diagnosed from scarlet fever, 2:!-t Septicemia, vaccine therapy in, 81 Septicoj)yeniia, vaccine therapy in, 81 Serum, method of collecting for tests. 57 rashes, diagnosed from scarlet fever, 2;U Schick test, 248 Sheet baths, 70 Shingles, 5U9 Sick child, examination of, 39 blank for, 40 histor.v of, 39 blank for, 40 inspection of, 39 palpation of, 42 to take temperature of, 41 Sick room, in infectious diseases, 310 Signs of illness in infanc.v, 00 ■Sinus thrombosis, infective cereliral. 548 Skin, diseases of, 555 parasitic, 559 Skin test for tuberculosis, 50 Skull of infant, 30 .Sleep, amount re(|uired, 480 habits of. in infancy, 25 loss of, 480, and see Insonniia restless, as a sign of illness, 01 Sleeping sickness, 503 Smallpox, 2.38 complications, 240 definition, 238 etiology, 2.'!8 exauthem, 239 incubation, 239 prodromal stage, 2.39 pathology, 239 prognosis, 241 proph.vlaxis, 241 sequehe, 240 symptomatology, 239 treatment, 241 variations, 240 Soor, 174 Soothing bath, 72 Sore mouth, putrid, 175 throat, streptococcic, 343 Spasm, pyloric, 183 vesical, 460 Sttasmodic croup, 348 Spasmophilia, 481 Spasmophilic convulsions, 482 Silastic diplegia, 505 extremities, 92 Spastic hemiplegia, 505 parariiegia, 505 Special examinations, 48 Specialized foods. 94 Speculum, ear, 550, 559 Spina bifida, 528 Spinal cord, diseases of, 493 inflannnation of, see INlyelitis Spinal paralysis, 409 Spine, caries of, .3.30 of infants, 30 rachitic, 331 Spleen, chronic jiassive congestion of, 412 diseases of, 411 enlarged, 89 enlargement of, 412 inflammation of, 411 Spondylitis, 330 Sponge baths, 70, 72 Spontaneous hemorrhages in the newly- born, 20 Spotted fe\er, 280 Sprue, 174 Sputum, examination of, 4.8 Squint, .552 Stannnering, 488 Status lymphaticus, 408 Stenosis, lironchiai, 88 laryngeal, 88 of pylorus, 183 lihar.vngeal, 87 tracheal, 88 Sterilized milk, 112 Sternocleidomastoid, hematoma of, tj Stethoscope, I'isek's reversilile, 45 Stillborn infant, 11 Still's disease, 304 Stomacace, 175 Stonuich, dilatation of, 1S2 hemorrlinges from, 91 inflammation of, see Gastritis of infant, 31 tumors of, 90 ulcer of, 179 washing, 73 Stomatitis, .aphthous, 173 cat.irrh.il, 172 follicular, 173 g.-ingrenous, 170 herpetic, 173 maculofibrinous, 173 mycotic. 174 parasitic. 174 simple, 172 ulcerative, 175 vesicular, 173 Stools, 193, and see Feces character of. as a sign of illness. 02 examination of. 1.53. 19:i jCO INDEX. f?tools of avfificinlly fe^l infants, ]93 StMliisuius, 552, 553 Streptococcic sore throat, 343 Stridor, con.yenital infantile, 352 laryngeal. 352 Sti'ijipings, 103 8troi>linlnK, 504 Stutterins. 488 St. Vitns' dance. 472, and see Chorea Stye. 551 Subdnral piinctnre. technie of, 5ii, 51 Subphrenic abscess, 374 Substitute feeding, 108 ditlicailties of. 108 material used in. 108 jirincijiles of. 108 Suggestion, in treatment of disease, 00 Summer complaint. 106 diarrhea, 100 diet for children, 109 Supernumerary thumb, 527 Surgical diseases, 530 Sutures of skull. 2;i Swallowing, as aid to diagnosis. 87 Swellings in inguinal region, differen- tial diagnosis of, 404 of extremities, 02 Sydenham's chorea, 472 Syndactylism, 520 Syphilis, 275 acquired, 287 congenital, 275, and see Syphilis, hereditary , dehnition, 275 diagnosed from tuberculosis. 2M Ehrlicli's preiiaration for. 2s2 hereditary, 275 Codes' law, 270 definition, 275 diagnosis. 281 method of transmission, 270 pathology, 270 l'r(jfeta's law, 270 prcjgnosis, 282 s.ym])t(jmatiilog.v, 278 treatment, 282 late hereditary, 283 Hutchinson's teeth, 283, 2,S4 treatment, 285 luetin test foi', 50 Wassernjann test for, 57, 58, 270 Syiihilitic dactylitis, 278, 281 Syringe, aspii'ating, 309 rectal, for infants, 207 'lALU'ES, 524 acquired, 524 calcanens. 5"25 congenital, 524 Talipes, equinus, 525 treatment, 525 valgus, 525 vai-us, 525 I'ape worms. 212 armed, 213 beef. 213 dwarf. 214 jiork. 213 Teeth, abnormalities, 87 llutiliinson's, 33, 283 of infant, 31 teniiiorary, care of, .33 permanent, 33 Tenqier, irritability of, as a sign of illness, 00 Tenqierature of premature infant, 1 to take, 41 Tenia mediocanellata, 212, 213 saginata, 212. 213 solium. 212, 213 Terrors, night, 481 Testicle, undescended, 404 1'esticles of infant, 31 Tetanilla, 483, and see Tetany Tetanus neonatorum, 17 Tetany, 483 differential diagnosis, 485 etiolog.y, 483 ])rognosis. 485 s.vmptomatolog.y, 484 ,/^. ti'eatment. 485 Tetter. 559, and see Eczema Therapeutics, general, 63 Therapy, vaccine, 79 Tliomsen's disease, 486 Thoracentesis. 309 'J'hiiraric tuberculosis. 317 Thread worms, 2(19 Throat examination of, in infants, 338, 340 Thrombosis, sinus, infective cerebral, 548 Thrush, 174 Thund). supernunierar.v, 527 Th.vndc asthma, :'>52 Thymus, 408 enlargement of, 408 of infant. 31 Tics. 487 differential diagnosis, 487 treatment. 488 Tinea favosa. 570 tonsurans, 509 Toes, weblied. 520 Tongue depressors. Chapin's, 338. 339 enlarged. 80 lissnres of. 87 geograpliic, 171 inflamnmlion of, see (ilossitis INDEX. 591 Tongue, ringworm of, 171 ulcers of, 87 Tongue-tie, 519 Tonsil, iibaryngeal, hypertrophy of, 34.5 Tonsillar hypertrophy, chronic, 31.J Tonsillitis, acute follicular, .341 diagnosed from diphtheria, 248 in infants, 339 treatment, .340 ulceromembranous, 343 Top milk, 127 method, 1.34 Toxins, 78 Tracheal stenosis, 88 Trachoma, 5.j1 Transudates, examination of, 52 Traveling, infant feeding when, 154 Tracheotomy, 259 Trichina .spiralis, 215 Tricuspid regurgitation, 387 Trousseau's .symptom, in tetany, 485 Tuberculin tests, 50, 57 Tuberculosis, 312 acute miliary, 321 differential diagnosis, 322 etiology, 321 bone, 3.30 diagnosed from syjibilis, 281 etiology, 312 incipient, diagnosis of, 318 joint, 330 miliar.y. of lungs, 318 of vertetir.-T', 330 diagnosis, 330 treatment, 331 projibylaxis, 3-34 imlmouary, 319 acute form, 319 etiology, 319 physical signs, .320 chronic, 320 course, 321 subacute form, 319 etiology, 310 physical signs, .320 tests for, 5erit(jnitis, 325 ascitic form, 320, 327 caseating form, 320 diagnosis, 327 fibrous form, 320 miliary form, 320 .symptomatology, 327 treatment, 328 ulceralive form, 320 Tumors ab:iut head, 85 about neck, 80 malignant, in children. 542 diagnosis, 543 treatment, .544 of abdomen, localized, 89 of alidominal wall, 90 of brain, .504 of (best wall, SS of inguinal region, 90 of intestines, 90 of kidney, 89. 441 of stomach, 90 Typhoid fever, 207 drugs in, 271 etiology, 209 feeding in, 270 bydrotlier.-ipy in, 270 imnmnit.v in. 200 laboratory tests for, 208 pathology, 207 I)rophylaxis, 209 s.vmptomatology, 2(57 temperature curve in, 208 treatment, 209, 270 vaccine therapy in, SI, 209 Widal test for, 00 Flcer. gastric, 179 Ulcerations of mouth, SO of tongue, 80 Umbilical hemorrhages, 13 hernia, 14 I'isek's dressing for, 14 5!)--; IXUJ5X. Umbilical region, almornialities of. 00 vogetatioiis, 14 Uiiciiiaria. 214 Uiuloseeiided te.stitlr. 4(14 Upper arm iiaral.vsis dnrin,;; liirtli, 7 Uretliritis, 4i;0 TTrinal, for infants. 4:17 Urine, absence of, 441 acetone in. 444 albumin in. 443, and see Albunii- luiria blood in. 443 character of, 4.".8 as a sii,'n of illness, V,2 diacetic acid in, 444 disorders of. 4:'.7 examin.-ition of, 51 excess of. 441, 442 liemo.elobin in, 44.3 incontinence of, 4."i.j indican in. 52, 444 in infanc.v, 437 quantit.v of, 51 suppression of. 441. and see Anuria to collect, 437 T'rosenital blennorrhea, 400 Uropdietic s.vstem. diseases of, 437 Urticaria, .5(14 brine bath iu, 71 Uvula. elon.i;ated, 175 VACCIN.iTIOX, 242 descri]ition of normal course. method of. 242 value of. 242 variations and complications. when to vaccinate, 242 Vaccine therapy, 70 dosage in. 82 Vaccinia, 243 ^'alves of heart, location of, ;'.S4 ■S'alvular disease of heart, chronii aortic, 38G mitral, .385 prognosis, 387 treatment, 387 lri(ais|iid, 387 Vai-iceila, 244 ^'al■icJla, 238, and see ^m.-illjiox A ariidoid, 240 A'egetations, umbilical, 14 243 24,-, A'crtebra', tuberculosis of, 330 A'esical calculus, 4(>7 spasm, 40(! A'incent's angina, 34,3 \'iscera of infant. 31 "N'oice sign, ejiileptic. 478 ■N'olkman's ischemic paralysis, 470 A'oniiting. as a sign of illness. Gl cyclic. 18(j periodic. 18(j I'ccairrent. 180 A'on .J.ikscirs anemia, .308. 400 A'on riniuet test for tuberculosis, 50 Vulvo-vaginitis, 400 treatment, 401 vaccine treatment, 402 Walk, inaliility to. 01 with limp. 01 Warm baths. 71 Wasserni.-;;;;! test for syjiliilis. 57, .58 Wasting paralysis, acute. 201 Water, in treatment of disease. 7(.> Weaning and mixed feeiling. 100 Webbed fingers, 520 toes. 520 Weighing infant. 20. 15.". imjxirtance of. 1.53. Weight, disturbances of. 150 of child, 35, 37 of infant, 20 of prem.ature infant, 2 Wet nurse, selection of, 1