• MODERN DIAGNOSIS AND TREATMENT OF Diseases of Children A TREATISE ON THE MEDICAL AND SURGICAL DISEASES OF INFANCY AND CHILDHOOD, WITH ESPECIAL EMPHASIS UPON CLINICAL DIAGNOSIS AND MODERN THERAPEUTICS. FOR Practitioners and Students of Medicine HERMAN B. SHEFFIELD, M.D. Instructor in Diseases of Children at the New York Post-Graduate Medical School and Hospital; Visiting Physician (Diseases of Children) to the Philanthropin Hospital, Northwestern Dispensary and the German Poliklinik; Asso- ciate, Babies' Hospital Dispensary; Fellow of the New York Academy of Medicine; Associate Editor of the Centralblatt f. Kinderheilkunde, etc. THIRD EDITION With Two Hundred and Seven Illustrations, Most of Them Original Halftone Photoengravings, Some in Colors. PHILADELPHIA A. DAVIS COMPANY, Publishers ENGLISH DEPOT : STANLEY PHILLIPS, LONDON. 1916 COPYRIGHT, 1911 COPYRIGHT, June, 191- 1 COPYRIGHT, 1916 BY F. A. DAVIS COMPANY Copyright, Great in. All Rights Reserved Philadelphia, Pa., U. S. A. J re?s of F. A. Davis Company 1914-16 Cherry Street MAR 23 1916 )CI.A427388 PREFACE TO THIRD EDITION. It affords me great pleasure to present to the pro- fession a third edition of this clinical treatise on Pediat- rics. I sincerely hope that with the numerous additional practical suggestions in the Diagnosis and Treatment, and the complete revision of the chapter on Infant Feeding, this handbook will further merit the approba- tion and good will of the busy practitioner. H. B. S. New York City, 127 West 87th St. (v) CONTENTS. CHAPTER I. page. Examination of the Patient 1 Past and present history of patient 1 Physical examination of the Head and its contents 4 Neck and throat 16 Thorax and its contents 17 Abdomen and its contents 36 Urogenital system 44 Vertebral column 50 Extremities 51 Weight and length of the child 57 CHAPTER II. Prevention and Control of Disease : 59 Nutrition 61 Hygiene and sanitation 82 Immunization and biologic diagnosis and therapeutics 91 Materia medica and physical therapeutics 102 CHAPTER III. Congenital Malformations of Head and its contents 123 Neck and throat 134 Thorax and its contents 135 Abdomen and its contents 136 Urogenital system 148 Vertebral column 154 Extremities 157 CHAPTER IV. Birth Injuries 159 Superficial structures 159 Deep structures 160 CHAPTER V. Diseases of the Newly Born 165 Feeble vitality of the newly born 165 Sepsis neonatorum 172 Functional disorders 183 CHAPTER VI. DlSI VSES OF THE ALIMENTARY TRACT 185 Diseases of the mouth 185 Diseases of the esophagus 191 I liseases of the stomach and intestines 193 Intestinal parasites 222 (Vii) viii CONTENTS. CHAPTER VII. page. Diseases of the Liver 230 CHAPTER VIII. Diseases of the Respiratory System 235 Diseases of the nose, throat and ear 236 Diseases of the lungs and pleura 259 CHAPTER IN. Communicable Diseases 287 Exanthemata , 287 Tuberculosis 351 Diseases of the bones and joints 374 Syphilis 398 Malaria 410 Rheumatism and allied affections 415 CHAPTER X. Diseases of the Heart 428 Congenital 428 Acquired '. 433 CHAPTER XI. Diseases of the Kidneys, Bladder, etc 447 Diseases of the kidneys 447 Diseases of the bladder 458 Diseases of the genitalia 463 CHAPTER XII. Diseases of the Blood and Ductless Glands 470 Diseases of the blood 470 Diseases of the spleen 481 Diseases of the thymus gland 482 Diseases of the thyroid gland 485 CHAPTER XIII. Disturbances of Metabolism 493 CHAPTER XIV. Diseases of the Nerve System 512 Diseases of the brain 512 Diseases of the cord 527 Diseases of the peripheral nerves 541 Muscular atrophies and dystrophies 545 General spasmodic affections 549 CHAPTER XV Mental Diseases 570 CHAPTER XVI. Skin Diseases , 591 Index 607 LIST OF ILLUSTRATIONS. FIG. PAGE. 1. Top View of the Foetal Skull (Grandvn, Jarman and Marx) 3 2. Posterior View of the Foetal Skull (Grandin, Jarman and Marx). 4 3. Diagram of the Visual Tract 9 4. First (Milk) Set of Teeth (Starr) ... 13 5. The Thoracic and Abdominal Regions 18 6. The Regions of the Back 19 7. Diagnostic Lines of the Thorax 22 8. Anterior Boundaries of the Lungs 23 9. Posterior Boundaries of the Lungs 24 10. Skiagram of Normal Heart 29 11. Topography of the Heart 30 12. 13, 14. The Relative and Absolute Heart Dullness at Different Ages 31 15. Location of Heart-apex at Different Ages 32 16. Topography of Cardiac Valves 34 17. The Thoracic and Abdominal Regions 37 18. Topography of the Liver and Spleen 38 19. Topography of Kidneys, Spleen and Liver 39 20. Severe Acute Nephritis (Lenharts) 4/ 21. Weight Chart 58 22. Microscopical Appearances of Woman's Milk (After Fleisch- niaii) 61 23. Breast Pump 63 24. Holt's Milk Set 64 25. Chapin's Dipper for Removal of "Top-milk"' 69 26. Arnold Steam Sterilizer 70 27. Stages in Widal Reaction (After Robin) 102 28. Stomach Tube 107 29. Microcephalus — brain disease 123 30. Microcephalus — miniature brain 124 31. Congenital Hydrocephalus 125 32. Hare-lip . . . .' 129 33. Bilateral Anophthalmia 131 34. Megacolon Congenitum 140 35. Congenital Absence of Scrotum and its Contents, Anus and Rectum 141 36. Stomach and Intestines of Case Fig. 35 142 37. Diastasis Recti Abdominis 143 38. Umbilical Hernia 144 39. Thoracoabdominopagus, with Ectopia Viscerum 145 40. Skiagram of Thoracoabdominopagus 146 41. Congenital Hydrocele, Communicans 152 42. Myelocystocele 155 43. Congenital Talipes Varus 158 (ix) LIST OF ILLUSTRATIONS. FIG. PAGE. 44. Obstetric Facial Palsy 161 45, 46. Bilateral Obstetric Brachial Paralysis 162, 163 47. Obstetric Brachial Paralysis 164 48. Incubator for Premature Infants 169 49. Incubator Boom for Newly Born Babies with Feeble Vitality 170 50. Gonococcus. (Gonorrhceal Pus.) (colored) (Lenhartz and Brooks) 175 51. Bacillus Tetani (After Frankel and Pfeiffer ) 179 52. Ulcerative Stomatitis 186 53. Gastroenterocolitis Chronica 201 54. Prolapsus Recti 211 55. Oxyuria Vermicularis ( After Leuckart) 223 56. Taenia Saginata (Partly after Leuckart ) ( Lenhartz) 223 57. Taenia Solium ( After Leuckart ) 225 58. Bothriocephalus Latus ( After Leuckart) 225 59. Taenia Nana (After Leuckart ) 226 60. Taenia Echinococcus of the Dog (After Leuckart ) 227 61. Ankylostomum Duodenale (After Leuckart ) 228 62. 63, 64. Primary Family Splenohepatomegaly 232, 233 65. Tonsillotome 243 66, 67, 68. Adenoids 244, 245, 246 69. Adenoid Curette 247 70. Retropharyngeal Abscess 249 71. Diplococcus Pneumoniae (Pneumococcus) (colored) (Lenhartz and Brooks) 266 72. Fever Curve of Typical Lobar Pneumonia 267 73. Fever Curve of Fatal Apex Pneumoniae 268 74. Pneumothorax 284 75. 76. Pneumi thypoderma 285, 286 77. Influenza Bacilli (colored) (Lenhartz and Brooks) 287 78. Fever Curve of Atypical Influenza 288 79. Paralysis of the X. Abducens 289 80. Diphtheria or Klebs-Loffler Bacilli (colored) (Lenhartz and Brooks) 297 81. Introducer with Tube and Detached Obturator 306 82. Extubator 307 83. Mild Discrete Small-pox (Schamberg) 324 84. Fatal Small-pox (Schamberg ) 325 85. Fever Curve of Typhoid Fever 329 86. Fever Curve of Tuberculous Meningitis 337 87. Lumbar Puncture 339 88. Bilateral Epidemic Mumps 345 89. Tubercle Bacilli and Micrococcus Tetragenus (sputum) (colored) (Lenhartz and Brooks) 352 90 to 94. Breathing Exercises 353 95. Acute Pulmonary Miliary Tuberculosis (Langerhans) 356 96. Miliary Tuberculosis (skiagram) 357 97. Tuberculosis (Zicglcr) 359 98. Phthisis Pulmonum 362 99. Tuberculosis of the Brain 366 LIST OF ILLUSTRATIONS. xi FIG. PAGE. 100. Tuberculous Peritonitis 357 101. Tubercular Infiltration (Leedliam-Green) 371 102. Tubercular Ulcer {Lecdham-Green) 371 103. Bladder Tuberculosis of Left Kidney (Wyatt) 371 104. Tuberculous Axillary Lymphadenitis 373 105. Tuberculous Disease of the Elbow-joint 375 106. Pott's Disease (Ldiigerhans) 376 107. 108. Cervical Spondylitis 377, 378 109, 110. Dorsal Spondylitis 379, 380 111, 112. Lateral Spinal Curvature 382, 383 113. Rachitic scoliotic skeleton (Grandin, Jarman and Marx) 384 1 14. Paralytic Scoliosis 385 115. 116. Lateral Spinal Curvature 386, 387 117, 118. Hip-joint Disease 388, 389 119. Sarcoma of the Femur 390 120. Tuberculous Disease of the Knee-joint 391 121. Spina Ventosa 393 122. Osteomyelitis of Tibia (Senn) 395 123. Osteomyelitis of the Radius (Senn) 397 124. 125, 126. Congenital Syphilis 398, 399, 400 127. Pemphigus Syphiliticus 401 128. Syphilitic "Hutchinson Teeth" 405 129. Syphilitic Osteoperiostitis of the Tibiae 406 130. Malaria Plasmodia; Tertian Type (colored) (Lciiliartz and Brooks) 410 131. Temperature Chart of Quotidian and Tertian Malarial Fever 411 132. Rheumatic Polyarthritis 416 133. 134. Rheumatic Torticollis 418, 419 135. Multiple Exostoses 426 136. Vitium Cordis. "Morbus Cceruleus" 429 137. Dextrocardia 432 138. Fever Curve of Malignant Endocarditis 438 139. Acute Hemorrhagic Nephritis (Lenhartz and Brooks) 448 140. 141. Acute Nephritis with General Anasarca 449, 450 142. Sarcoma of the Kidney 457 143. Precocity 469 144. 145. Pseudoleukemia Infantum Splenica 473, 474 146. Acute Leukemia (Leu harts and Brooks) 475 147. Progressive Pernicious Anemia (Lenlmrtz and Brooks) 476 148. Large Thymus (skiagram) 483 149. Goiter 486 15(1. Cystic Goiter 487 151. ( Congenital Cretinism 488 152, 153, 154. Sporadic Cretinism 489, 490, 491 155. Marasmus 494 156. Rachitic Frons Quadrata and Curvature of Spine 497 157. Rachitic Heading of Ribs, "Pot-belly" and Bowlegs 498 158. Rachitic Kyphosis 499 159. Rachitic Bowlegs, "Tug"-shaped Abdomen, and Separation' of Epiphyses 500 LIST OF ILLUSTRATIONS. FIG. PAGE. 160. Rachitic Knock-knees 501 161. Achondroplasia 505 162. Moeller-Barlow's Disease 506 163. 164. Adipositas 510. 511 165. Acquired Hydrocephalus, Following Acute Gastroenterocolitis 517 166. Polioencephalitis 520 167. Encephalitis, with Left Hemiplegia 523 168. Anterior Poliomyelitis, Involving Right Arm 529 169. Poliomyelitis, Involving Right Leg 530 170. Poliomyelitis. Involving the Neck 531 171. Anterior Poliomyelitis, Affecting Right Leg 532 172. Paralytic Equinovarus in Poliomyelitis 533 173. Anterior Poliomyelitis, Involving Extremities, Face and Abdom- inal Muscles 534 174. Little's Disease 539 175. Peripheral Facial Paralysis — Bell's Palsy 541 176. 177, 178. Pseudohypertrophic Paralysis 546, 547 179, 180. 181, 182, 183. Tetanism 556, 557, 558, 559 184. Tetany 561 185. Hydrocephalic Idiot 575 186. 187. Microcephalic Idiot. Amaurotic Idiot 576 188. Mongolian Idiocy. (Calmuck type) 577 189.' Mongolian Idiocy. (Malay type) 578 190. Cretinic Idiot 579 191. Paralytic Idiot 580 192. 193. Infantilism 581 194. Skiagram of Wrist of Normal Child 582 195. Skiagram of Wrist of Idiot 582 196. Amaurotic Family Idiocy 583 197. The Normal Fundus of the Right Eye (Hcnle) 583 198. Macular Change (cherry-red color) in Amaurotic Family Idiocy (Tay) 584 199. Seborrheic Eczema of Head and Face 592 200. Psoriasis 596 201. Psoriasis of the Legs (Shoemaker) 597 202. Herpes Zoster 598 203. Phthirius Pubis (Crab-louse) (After Landois) 601 204. Sarcoptes Scabiei (After Gudden) 602 205. Trichophyton Tonsurans (After Bizzozci'o) 603 206. Tinea Tonsurans (Shoemaker) 604 207. Achorion Schonleinii (After Bissosero) 605 CHAPTER I. Examination of the Patient. Systematic and thorough examination of the patient is the keynote to successful diagnosis and treatment. In infants particularly the physical examination calls for a great deal of patience, care, and scrutiny, and while gentleness in handling the patient is certainly to be preferred, ofttimes firmness will succeed, where kindness utterly fails. Before, or while, pro- ceeding with the physical examination of the patient, an effort should be made to be informed on the following points of interest : — Family history — Longevity of the parents, brothers and sisters ; the dis- eases they suffered from, especially as to tuberculosis, rheu- matism, heart, kidney or liver disease, alcoholism, epilepsy, insanity, etc. Miscarriages in the mother. Past personal history of the patient — Degree of maturity at birth, and mode of delivery (instrumental or otherwise) ; condition soon after birth, par- ticularly as to signs of traumatism, convulsions, asphyxia, deformity, hemorrhages, skin eruptions, nasal catarrh ("snuffles'') ; the diseases the patient suffered from at a later period, e.g., gastro-intestinal, exanthematous, pulmonary; otitis, rheumatism, bone affections, etc. Mode of feeding (breast or bottle) ; gain or loss of weight; 1 time of eruption of temporary or permanent teeth ; the time when the patient began to sit up, stand, creep, and walk. Pecul- iarities of temper, etc. See page 57. (1) 2 EXAMINATION OF THE PATIENT. Present history of the patient — Age of patient. Mode of onset of the disease (gradual or sudden). Fever (continuous, remittent or irregular). Convulsions 2 (apparent cause ; time of occurrence ; dura- tion). Vomiting 3 (during, after, or between meals ; appearance of vomit). Skin eruption (location, duration; desquamation). Diarrhea 4 (duration ; frequency and appearance of the stools). Constipation 5 (acute or habitual; appearance of the stools). Pain (situation, duration; degree of severity). Cough (duration; paroxysmal or croupy ; appearance of sputum ). Dyspnea 7 (worse after fatigue or at night; sudden). Cyanosis 8 (duration; mode of onset. — with convulsions). Urinary disturbance 9 (enuresis, dysuria ; suppression; ap- pearance of urine). Disturbance of sleep (pavor; snoring; twitching). Behavior and mental capacity (recent change; truancy). Condition of special senses 10 (defective vision, hearing, etc.). Intelligent response to the aforementioned questions on the part of those in charge of the patient, will materially aid in the diagnosis. It will be found of advantage to keep a brief but comprehen- sive record of the history and condition of the patient at the time of examination, and of the further course of the disease. The different so-called card systems in vogue generally answer this purpose admirably, especially in private practice. 2 See page 52. " See page 24. 3 See page 41. 8 See page 7. 4 See page 42. 9 See page 44. 5 See page 42. 10 See pages 8, 9 and 10. See page 27. PHYSICAL EXAMINATION. PHYSICAL EXAMINATION. The history-taking completed, we next turn to the physi- cal examination of the patient. This should be systematic, preferably with the child entirely undressed, and if deemed Fig. 1. — Top View of the Foetal Skull (showing the Ante- rior Fontanelle and the Frontal, Coronal, and Sagittal Sutures). {Grandin, Jarman and Marx.) necessary, sbould include inspection, palpation, auscultation, percussion, mensuration and weighing. We usually begin with the examination of the head, noting it.^ ^ize and shape, the condition >>[ the bones of the 4 EXAMINATION OF THE PATIENT skull, its fontanelles and sutures, its attitude; facial expression and hue ; the condition of the nose, eyes, ears, mouth, lips, tongue, teeth and pharynx. THE HEAD. The head is rarely normal in shape immediately after birth. The seal]) is swollen, the bones are often displaced, and here Fig. 2. — Posterior View of the Foetal Skull (showing the Posterior Fontanelle and the Lambdoidal and Sagittal Sutures). (Grandin, Jarman and Marx.) and there are bruises and ecchymoses, the results of a long and painful journey. Within about a week, the swelling subsides, the bones adjust themselves, the head becomes round or oval and smooth except for the markings of the fontanelles and sutures. The cranial circumference (fronto-occipito diameter) soon after birth measures about thirteen inches. The skull enlarges THE SKULL. 5 rapidly up to six months old — seventeen inches ; then more slowly about one inch every year up to five years — twenty-one inches ; it then remains stationary in growth up to adult life, when it measures from twenty-two to twenty-three inches. The posterior fontancUc closes by the end of the second month, the anterior when the infant is about eighteen months old, at the latest. A healthy baby is able to hold the head erect when about four months old. The skull is — Asymmetrical, with depressions and protrusions, in caput succedaneum ; meningo- and encephalo-cele ; syphilis; neoplasms; abscesses, etc. Large, in hydrocephalus ; hypertrophy of the brain ; rachitis. Small, in microcephalus ; porencephalia. The fontanelles are — Closed late, in hydrocephalus ; rachitis ; cretinism ; idiocy ; osteogenesis imperfecta. Closed prematurely, in microcephalus ; atrophy of the brain. Distended, in active and passive congestions of the brain, e.g., diverse forms of meningitis ; meningismus ; hydro- cephaloid ; intracranial tumors ; cerebral hyperemia. Sunken, in wasting diseases ; after great loss of body fluids ; after lumbar puncture. The cranial bones are — Soft and thin, in chronic hydrocephalus ; craniotabes. Hard and thick, in syphilis ; exostosis. The sutures are — Widely separated, in hydrocephalus; intracranial tumors. Prematurely closed, in microcephalus. Attitude. The Head is — Retracted, in general debility; macrocephalus ; hydro- cephalus; amaurotic family idiocy. Spasmodically retracted (opisthotonos), in meningitis; meningismus; encephalitis; apical pneumonia. Turned laterally, in torticollis; hematoma of the sterno- cleidomastoid muscle; retropharyngeal abscess; cer- vical spondylitis; cervical adenitis; mastoiditis. Moving irregularly, in hyperpyrexia; spasmus nutans; chorea ; habit spasm. 6 EXAMINATION OF THE PATIENT. THE FACE. Fades dolorosa — Continuous pain (eyes open, face wrinkled, mouth half closed and drawn to one side, moaning and whining), in diverse acute inflammatory diseases, e.g., pneumonia, pleurisy, rheumatism, appendicitis. Intermittent pain (face distorted, red, perspiring; loud cry- ing, tossing, kicking), in colic, dysuria, etc.; vertebral caries ("starting pain"). Facies luctuosa — Face of sorrow (forehead and face wrinkled, face pale, emaciated, indifferent, apathetic, eyes half closed) in chronic wasting diseases, especially tuberculosis, and last stage of heart disease. Facies anxiosa — Face of anxiety (eyes glistening, congested, red or livid, and perspiring; alae nasi active) in orthopnea from various causes, e.g., laryngeal stenosis, extensive pneu- monia, pulmonary edema ; in hysteria. Facies Hippocratica — Face of grave abdominal distress, or extreme exhaustion (face pale, contracted, corneae dull, eyeballs and temples deeply sunken, nose pinched, lips dry, cyanotic, and covered with sordes), in moribund state, collapse, cholera nostras, peritonitis, etc. Facies meningitidis — Face of internal convulsions (staring look into distance, glassy corneae, rapidly changing complexion of the face), in meningitis; severe eclampsia. Facies senilis — Face of extreme old age (shriveled facial muscles and skin, pointed nose, lusterless eyes), in marasmus; syphilis; chronic hydrocephalus. Facies idiotes — Face of the mentally defective (senile features, open mouth, protruding tongue) in all forms of idiocy and imbe- cility ; less marked in adenoids. Facies sardonica— Face of facial muscular spasm (peculiar "grin," proboscis- form mouth, sometimes foamy) in tetanus and similar prolonged convulsive conditions. THE EYES. 7 See also "Facial Paralysis," "Facial Hemiatrophy," "Per- tussis." Facial hue — Livid, in congenital and acquired heart disease ; in pro- nounced respiratory difficulty, e.g., laryngeal stenosis, pulmonary edema, asthma, etc. ; in cerebral hyperemia ; sinus thrombosis ; in "holding the breath." Pale, in anemia; in acute and chronic wasting diseases; sudden pallor, in collapse, e.g., from exhausting hemor- rhage. Waxy, in chronic malaria ; suppurative processes ; chronic nephritis; malignant disease. Yellow, in icterus neonatorum or catarrhalis ; congenital obliteration of the bile duct; in Buhl's or Winckel's dis- ease ; in liver affections, especially due to syphilis. Purplish, in phthisis pulmonalis ("hectic flush"), hyper- pyrexia; pneumonia; compensating heart disease. Greenish, in chlorosis. Copper-color {e.g., on forehead), in syphilis. Bronze color, in Addison's disease. See also "Exanthemata" and "Skin Diseases." THE EYES. The eyelids are — Edematous, without local inflammation, in anemias; heart and kidney diseases; pertussis. Crusty, red and swollen, in acute and chronic inflammation of the eyelids; in pediculosis of the eyelashes; in con- genital syphilis (in conjunction with rhagades at the canthi, and purulent nasal discharge) ; in scrofulosis (with keratitis, excoriation of the upper lip, and adenitis) ; red and watery, in nasal catarrh, hay fever, and measles. Retracted, inability to lower upper lid, from loss of power in the palpebral muscles, in facial paralysis. Drooping (ptosis) of upper lid, from inability to raise it, in congenital defects of the palpebral levators or their nerve supply; in local trauma; in oculomotor paralysis. Spasmodically contracting, in local inflammatory processes of the lids ; in spasmodic affections, such as chorea and tic; in divers forms of meningeal irritation. 8 EXAMINATION OF THE PATIENT. The eyeballs are — Congested, in inflammatory processes of the eye, e.g., kera- titis ; in meningitis ; asphyxia. Protruding, in exophthalmic goiter; in neoplasms (gum- ma) ; in chloroma (frog-like appearance). Immobile, partially or completely, in ophthalmoplegia. Turned laterally (strabismus, squint ) ; in errors of refrac- tion ; in paralysis of the abducens (convergent strabis- mus) ; in paralysis of the oculomotor (divergent stra- bismus — with ptosis, mydriasis, and diplopia). Oscillating (nystagmus), in hereditary ataxia; lesions of the corpora quadrigemina ; multiple sclerosis ; menin- gitis ; sinus thrombosis; hydrocephalus. The pupils are — Contracted, unilaterally, in paralysis of cervical sympa- thetic, e.g., migraine, cervical rib ; in pressure by central tumor. Bilaterally, in affections of the cervical cord, both sides; early stage of meningitis; from the effects of opium and its derivatives, chloral, pilocarpin, physo- stigmin, etc. Dilated, unilaterally, in irritation of the cervical sympa- thetic, e.g., migraine; in oculomotor paralysis. Bilat- erally, in marked dyspnea ; collapse ; from the effects of atropine, belladonna, hyoscyamus, cocaine, etc. Unequal, in unilateral contraction or dilatation, as afore- mentioned ; in unilateral pontine lesion, and in apo- plexy. Immobile, in adhesions of the iris to the lens; in eclampsia; in lesions of the corpora quadrigemina ; in tabes dor- salis (immobility to light, but responding to accommo- dation — Argyll-Robertson pupil) . Vision is — Diminished, in errors of refraction ; miosis ; mydriasis ; hys- teria ; acute eye affections, e.g., iritis, retinitis, etc. ; in corneal opacities, etc.; congenital eye defects, e.g., albinism, irideremia ; in toxic amblyopia, e.g., overdoses of quinine, tobacco; congenital amblyopia (usually unilateral) ; optic neuritis. Lost, temporarily or permanently, in uremic, diabetic, or other forms of toxemia ; in severe convulsions of cen- tral origin ; congenital cataract ; amaurotic family THE EARS. 9 idiocy (gradual onset) ; in embolism of the central retinal artery (unilateral) ; local injuries; optic atrophy. Double (diplopia), in peripheral palsies of the eye muscles, e.g., after diphtheria, influenza, herpes zoster ophthal- micus (unilateral) ; in strabismus. In orbital palsies, through outside pressure, e.g., neoplasms. In central palsies (affecting' the eye on the opposite side). In nuclear palsies, e.g., of the abducens (involving the eye on the same side). Half, i.e., blindness of one-half of the visual field (hemia- nopia) : lateral or homonymous, in lesions of the optic tract between chiasm and cortex; temporal, in dis- ease of the optic chiasm affecting the anterior or pos- terior angles ; nasal, in disease of the chiasm affecting the outer angles. (See Fig. 3.) Fig. 3. — Diagram of the Visual Tract. N. Lesions producing nasal hemianopia. L. Lesions producing lateral hemianopia. T. Lesions producing temporal hemianopia. (Sheffield.) THE EARS. Abnormalities of the ear and adjacent structures — Asymmetry of the ears, in congenitally, mentally defectives. Tumefactions, at and about the ear : In the external meatus, in furuncles, abscesses, and local traumatism. In front of the ear, in epidemic parotiditis (often bilat- eral, though not simultaneously) ; in secondary paro- titis (complicating diseases of the mouth; local infec- tion in the vicinity; acute infectious diseases, e.g., typhoid); in new growths. Behind and downward, pushing the auricle forward, in mastoiditis; in per- forating abscess of the external auditory canal ; in pre- 10 EXAMINATION OF THE PATIENT. auricular lymphadenitis ; and much less marked in glandular fever. Hearing is — Diminished, at a distance, but not by bone conduction, in external and middle ear disease ; in occlusion of the auditory canal by foreign bodies, e.g., cerumen, fu- runcles ; or outside tumors, e.g., parotitis ; in naso- pharyngeal disease, e.g., adenoids. Lost, temporarily or permanently, both at a distance and by bone conduction, in congenital defects of auditory apparatus ; in compression (by intracranial tumors) or atrophy of the auditory nerve ; in disease of the pons or cerebellum which has spread to the fourth ventricle; in amaurotic family idiocy (late). Disturbed by noises (tinnitus aurium), in foreign bodies in the auditory canal, e.g., cerumen, mycosis, myringitis ; in catarrh of the Eustachian tube; in otitis media; neuroses; epilepsy, and mental affections. THE NOSE. Abnormalities of the nose in structure and function — Saddle-shaped, sunken, in hereditary syphilis ; in trauma- tism. Compressed and pointed, in nasal obstruction, chiefly adenoids. I'inched and pale, in collapse; sudden fright; phthisis pul- monum. Purplish in color, in circulatory and respiratory difficulties, e.g., pneumonia, heart disease. Hyperactivity of the alse nasi, in grave dyspnea. Nasal voice or cry, in nasal obstruction, e.g., in adenoids, rhinitis, retropharyngeal abscess ; in diphtheritic paral- ysis ; in ulceration of the nasal bones, especially in syphilis. Nasal discharge — Serous, transparent, later mucous, in acute simple rhinitis ("cold") ; measles ; hay fever. Serosanguinolent, later purulent, in diphtheritic, scarlatinal, and syphilitic rhinitis; in the presence of foreign bodies in the nose ; in scrofulosis. THE MOUTH. 11 Mucopurulent or purulent, in severe acute rhinitis; in putrid infection. Hemorrhagic (epistaxis), in nasal trauma; inflammation of the nasal mucosa; nasal polypus; adenoids; hemo- philia; vicarious menstruation; passive congestion of the brain ; increased vascular tension, e.g., hyper- pyrexia (especially if sudden, as it is apt to be at the onset of exanthematous diseases), heart and lung dis- eases, pertussis; in diseases of the blood, e.g., sepsis; leukemia, etc. The lips are- THE LIPS - Excoriated (upper lip) from acrid nasal discharge, in acute and chronic affections of the nose, e.g., rhinitis, ade- noids ; in scrofulosis ; syphilis. Covered by herpes, a vesicular eruption (usually upper lip at angle of mouth), in ordinary "colds" ; in pneumonia ; in meningitis cerebrospinalis. Cracked and scarified, especially at the angles of the mouth, in syphilis hereditaria; but also in burns (usually unilaterally). Covered by sordes, in septic infections ; in typhoid fever. Rosy in color, in good health. Deep red, in compensating heart disease. Purple, in marked dyspnea, from respiratory and circula- tory disturbance. Pale, in divers forms of anemia. Livid, in heart failure. Dirty, soot-like, in sepsis; typhoid fever; ulcerative stoma- titis. The mouth is- THE MOUTH. Drawn to one side, droops, in facial paralysis, especially when the facial muscles are brought in action ; in pro- gressive facial hemiatrophy; in bemiplegia. Drawn outward and downward, with the lips pointed for- ward, proboscis-like, in trismus neonatorum, tetanus and tetany. Broad, grinning, in cretinism; idiocy. Large from birth, in macrostoma. Small and contracted, in microstoma; in congenital syph- ilis ; fri im the effed - < »f burns. 12 EXAMINATION OF THE PATIENT. Open habitually ("mouth-breathing-"), in nasal obstruc- tion ; adenoids ; idiocy ; in retropharyngeal abscess. Twitching spasmodically, chorea; habit spasm. Foetor ex ore — Stale insipid, in catarrh of the nasopharynx ; dental caries ; in febrile diseases ; chronic dyspepsia. Putrefactive, at short range, in diverse forms of simple stomatitis; acute indigestion. At a distance, in noma; malignant diphtheria or scarlatinal angina. Sulphuretted hydrogen odor, in fetid bronchitis ; pulmonary gangrene. Aceton odor, in diabetes ; cyclic vomiting. Ammoniacal odor, in uremia. Chloroform, ether, alcohol, etc., odors, from the effects of these drugs. THE ORAL CAVITY. In irritable children it is preferable to postpone the exam- ination of the mouth-cavity until the other portions of the body have been thoroughly examined, since the undue excite- ment usually created by the inspection and palpation of the mouth and throat of the patient greatly interferes with erudi- tion of the other physical phenomena. Through daily prac- tice, the physician soon learns almost at a glance to distinguish the abnormal from the normal ; until he has acquired this skill, however, he should examine the contents of the oral cavity slowly and systematically. The gums, teeth, floor and roof of the mouth; the tongue, buccal mucous membrane, the uvula, fauces, tonsils and pos- terior pharynx — all should receive careful attention. The gums are — Whitish, thin, and hard, normally in early infancy. Reddened, slightly swollen and painful to touch, before eruption of teeth. Spongy, swollen, and prone to bleed, in divers forms of stomatitis; in scurvy; purpura; in other grave consti- tutional diseases, such as leukemia. Purulent, receding from the teeth, in pyorrhea alveolaris (Riga's disease) ; alveolar abscess. Bleeding, without inflammatory symptoms, in hemophilia. THE TEETH. Colored blue, forming a blue line along the margin of the gum, in lead poisoning. The temporary teeth are twenty in number, and under normal conditions generally appear in groups, at variable in- tervals, as follows : — Two lower central incisors at the age of from 6 to 8 months. Four upper incisors (2 central, 2 lateral), from 8 to 10 months. Two lower lateral incisors, from 11 to 12 months. 1 J Lower Incisors— fifth to ninth month. 2 | | Upper Incisors — eighth to twelfth month. 3 |£Stv> ; '1 Lateral Incisors and First Molars — twelfth to eighteenth month. 4 [IIIIIIH Stomach and Eye Teeth— eighteenth to twenty-fourth month. 5 y/////^ Second Molars — twenty-fourth to thirtieth month. Fig. 4.— First (Milk) Set of Teeth. (Starr.) Four anterior molars (2 upper, 2 lower), from 14 to 16 months. Four canines (2 upper, 2 lower), from 18 to 20 months. Four posterior molars (2 upper, 2 lower), from 22 to 30 months. Abnormal teething — Dentitio tarda, i.e., considerable retardation (absence of a tooth at the age of a year or later), in rickets; general debility; congenital syphilis; cretinism; idiocy, etc. Dentitio precox is of no special significance. Occasionally 14 EXAMINATION OF THE PATIENT. occurs in congenital syphilis (a tooth may appear soon after birth) ; in hydrocephalus. Irregular implantation, the same as in "dentitio tarda" (q.r.). The permanent teeth appear normally in the following order : Four first molars (2 upper, 2 lower) at about 6 years. Four central incisors (2 upper, 2 lower) at about 7 years. Four lateral incisors (2 upper, 2 lower) at about 8 years. Four anterior bicuspids (2 upper, 2 lower) at about 9 years. Four posterior bicuspids (2 upper, 2 lower) at about 10 years. Four canines (2 upper, 2 lower) at about 11 years. Four second molars (2 upper, 2 lower) at about 12 to 15 years. Four third molars (2 upper, 2 lower) at about 17 to 25 years. Abnormalities of the permanent teeth — - Increased vulnerability and brittleness, in divers grave con- stitutional affections, e.g., rickets, profound anemia; in neglect and injury of the teeth, especially by eschar- otic drugs for cleansing of the teeth or medicinal pur- poses {e.g., the tincture chlorid of iron, acids). Asymmetry, in hare-lip ; cretinism and other forms of de- fective mentality; nasal obstruction, "mouth-breath- ing" ; thumb sucking. Looseness, in gingivitis; ulcerative stomatitis; mercurial- ism ; scurvy ; pyorrhea alveolaris. Hutchinson teeth, i.e., peg-shaped, dwarfed upper central incisors, notched in their cutting edge, in inherited syphilis. The floor of the mouth may present — Adhesio lingua?, a frequent cause of difficult suckling: and later of difficult speech. Sublingual ulcer, in protracted coughing, especially pertus- sis. Xew growths, e.g., ranula, fibroma sublinguals; salivary calculi ; inflammatory swelling. The palate is — Highly arched and asymmetrical, in divers forms of mental degeneracy ; adenoids. Defective, or perforated, in congenital clefts of the palate ; THE TONGUE. 15 in syphilitic or gangrenous processes {e.g., diphtheria, scarlatina). Red, velvety, in scarlatina. Punctiform or stellate, in measles or rotheln. Vesicular with red areola, in chicken-pox. Papular, in small-pox. Whitish-yellow eroded dots, in Bednar's aphthae. Minute, yellowish-white milia, in "epithelial pearls." White specks or scattered patches, in different forms of stomatitis. Hemorrhagic and punctiform, in hemorrhagic diathesis; tuberculous and cerebrospinal meningitis ; pernicious blood affections. The buccal mucous membrane presents, in addition to the dis- colorations occurring upon the palate, also the follow- ing:— Brownish, greenish or grayish ulcer, in incipient noma. Red spots with central, rounded, slightly elevated, bluish efflorescence (Koplik-Filatov spots), in measles. The tongue is — Large, in congenital macroglossia ; in cretinism ; idiocy ; glossitis. Furred, in all acute and protracted forms of gastroenter- itis ; febrile diseases ; nasopharyngeal catarrh. Red, in scarlatina (strawberry tongue) ; stomatitis ; glossi- tis; gastritis (hyperacidity). Yellow, in biliousness; liver disease. Pale, in anemia. Gray, brown and somewhat black, with red border and tip, in typhoid fever; in sepsis. Black, in profound sepsis; in collapse impending death. Livid, in general cyanosis ; congenital heart disease. Spotted, desquamating, in geographical tongue ; hyper- pyrexia ; stomatitis. Fissured, in glossitis desiccans ; hyperpyrexia ; burns. Ulcerated, in severe forms of stomatitis ; in syphilis ; tuber- culosis ; traumatism (biting of the tongue during an epileptic fit; irritation by carious teeth). Dry, in mouth-breathing; excessive thirst (e.g., hyper- pyrexia, diabetes) ; in sqi^. Protruding, in macroglossia (e.g., idiocy, cretinism). Hi EXAMINATION OF THE PATIENT. Drawn to one side, in paralysis of the hypoglossal nerve (towards the diseased side) ; in peripheral facial palsy (towards the healthy side). Tremulous, in hyperpyrexia ; debility ; chorea ; dissemi- nated lateral sclerosis ; bulbar paralysis. The saliva is — Increased in quantity, in mercurialism ; stomatitis; teeth- ing- ; idiotic conditions, and adenoids. Diminished in quantity, in fever; from the effects of atro- pine, etc. ; parotitis ; glossitis. The uvula — May be elongated ; the seat of a deposit which may extend from the tonsils or from the buccal mucous membrane (e.g., stomatitis). The tonsils are — Enlarged, in divers form of amygdalitis; diphtheria; scarla- tina; pharyngitis; influenza; rheumatism; abscess; traumatism; glandular fever; foreign bodies (e.g., calculi ) ; new growths (e.g., fibrous polypus, hydatid cyst). The seat of a deposit, in follicular tonsillitis (small isolated white pellicles which coalesce); in parenchymatous tonsillitis (at first white, later yellowish green, resem- bling ''point of abscess") ; in tonsillitis herpetiformis (vesicular deposit, ending into ulcer) ; in necrotic ton- sillitis (yellowish-green patch); in influenza and pharyngitis (superficial exudation) ; in scarlatina and diphtheria (large pseudomembrane) ; in stomatitis mycotica (flour-like deposit). In doubtful cases it is imperative to examine a smear of the tonsillar deposit microscopically or bacteriologically. THE NECK. The lymphatic glands are — Enlarged, in all forms of angina, especially that due to diphtheria or scarlet fever ; in affections of the mouth (e.g., stomatitis, gingivitis); in parotitis; mastoiditis; glandular fever ; pseudoleukemia ; scrofulosis (tuber- culosis ) ; eczema capitis ; local infections. The thyroid gland is — Enlarged, in goiter; exophthalmic goiter; endemic goitrous THE THORAX AND ITS CONTENTS. 17 cretinism ; thyroiditis ; temporarily before menstrua- tion. Atrophied or absent, in sporadic cretinism. Tumefactions (other than those of the glands of the neck) — Hematoma of the sternocleidomastoid, in the center or at sternal insertion of the sternomastoid muscle. Hygroma cysticum, between lower jaw and clavicle, attains enormous size. Fistula coli congenita, at sternoclavicular articulation. Pulsation of the — Arteries, in aortic regurgitation ; hyperpyrexia, etc. Veins, in tricuspid insufficiency. Stiffness of neck — See "Attitude of Head," page 5. THE THORAX AND ITS CONTENTS. AUSCULTATION AND PERCUSSION. Auscultation is best performed by means of a small bi-aural speculum, as with this instrument every inch of the infantile thorax can be thoroughly examined and small circumscribed lesions readily detected. Normally the respiratory sound is puerile (rough vesicular) in infancy or early childhood; and vesicular in older children. In auscultating the infantile lungs we should remember the following peculiarities: 1. During quiet respiration the in- spiratory sound is fairly audible, while the expiratory sound is but slightly so, — hence to obtain more distinct physical signs it is of advantage to disturb the infant, or to make it cry. 2. Owing to the larger diameter of the right bronchus, the respiratory sounds are louder on the right side than on the left. 3. Pure bronchial breathing is often normally heard over the interscapular regions, especially to the right of the spinal column. 4. Adventitious sounds originating in the naso- pharynx and larynx are frequently transmitted to the chest and may be misinterpreted as signs of pulmonary disease. The normal pulmonary percussion note is clear, loud, and somewhat tympanitic. It is somewhat metallic, when the child cries; cracked-pot-like, over the right subclavicular region ; somewhat dull over the areas overlapping the liver, heart and spleen. 2 is EXAMINATION OF THE PATIEXT. Percussion of the infantile lungs should be practised while the patient is held in a sitting posture, perfectly still and as erect as possible. It should be performed gently, preferably during the height of inspiration and expiration. Every portion of the lung should be carefully gone over, paying especial attention to the sub- and supra-clavicular spaces, which are not Fig. 5. — The Thoracic and Abdominal Regions. 1. Hypo- chondriac. 2. Lumbar. 3. Inguinal. (Sheffield.) rarely the seat of consolidation, and the area corresponding to the tracheal bifurcation, which is often the seat of tuberculiza- tion of the bronchial glands. The physical signs obtained on percussion are not always conclusive, if percussion is per- formed too forcibly (may give rise to covibration of the more distant parts) ; if the child cries (during the act of crying com- pression of the lung by ascension of the diaphragm produces artificial dulness ) ; if the position of the child is faulty (e.g., lying on the abdomen pushes the diaphragm upward and com- presses the lungs) ; or if the thorax is bent sharply forward. AUSCULTATION AND PERCUSSION. 19 In auscultating the heart we should bear in mind the fol- lowing: 1. Accentuation of the first sound is heard equally as well at the arterial and venous orifices. 2. Accentuation of the second sound is ordinarily not heard until about the age of puberty. 3. Both heart sounds are louder in children than in adults and are more widely transmitted. 4. Reduplication of the heart sounds is not uncommon, and generally the result of 8 \\\ , 6 mSmme j e 1 %. $ ft i » 5* 1 -- : * 1 ■ 1 T F H Fig. 6. — The Regions of the Back. A. Suprascapular or supraspinatus. B. Scapular. C. Interscapular. D. Infrascap- ular or lower dorsal. E. Lumbar. F. Sacral. (Sheffield.) excitement. 5. In infants hemic murmurs are rare. 6. The heart-beat, as to frequency and rhythm, is apt to undergo great variations on slightest provocation. Percussion of the child's heart should be performed very gently while the patient sits quietly and bent slightly forward. The data obtained on percussion while the child cries, holds its breath, etc., are not win illy to be depended upon, since dur- 20 EXAMINATION OF THE PATIENT ing bodily unrest the heart is very apt to change its relation to the chest wall. The same holds true in the event of the heart being overlapped by emphysematous lungs; if the heart is left bare by atrophy of the adjacent lung portions or by retraction of the heart or lungs by pleuritic or pericardial adhesions. THE THORAX. The normal infantile thorax is round and somewhat cylin- drical, its sagittal and transverse diameters being nearly equal. As the child grows older, the chest assumes a more conical shape, until at puberty it resembles that of the adult. The chest walls of the child are thin, elastic and yielding, owing to incomplete development of the muscular and bony structures. The ribs of the infant are nearly horizontal. The measurements of the thorax are — In the newly-born infant, about 14 inches. At one year, 17 inches. At three years, 20 inches. At six years, 23 inches. At twelve years, 26 inches. At the end of the fifteenth year, the measurement of the circumference of the chest is about half of that of the body length. Up to about eighteen months the circumference of the chest nearly equals that of the head. If from the end of the second year on the circumference of the head exceeds that of the chest, there is a strong suspicion of hydrocephalus, marked rachitis, contraction of the chest through pulmonary disease or imperfect development (adenoids). On the other hand, if the chest measurement in earl}- childhood greatly exceeds that of the head, it is indicative either of an abnormality of the chest, e.g., distension by fluids, or of congenital maldevelopment of the head, e.g., microcephalus, infantilism. Abnormal shape of chest — Barrel-shape (deep, short and broad), in emphysema, and the lung affections that precede it, e.g., asthma, per- tussis ; protracted laryngeal stenosis. Flask-shape (flat, narrow and long), in phthisis pulmonum ; nasopharyngeal stenosis, especially adenoids. Funnel-shape (depression of lower portion of sternum), in rachitis; Barlow's disease: also congenital. THE LUNGS. 21 Pigeon-breast-shape (protrusion of median portion of ster- num), in rachitis; congenital heart disease. Unilateral bulging, in pneumothorax; pleurisy or pericar- ditis with effusion; tumor; scoliosis (opposite side). Unilateral flattening, in pleuritis retrahens (after absorp- tion of fluid) ; pulmonary contraction, e.g., tuberculosis ; after pyothorax operation; scoliosis. Tumefactions — Costal, nodular, in rachitis (rachitic rosary) ; tuberculous and syphilitic processes; multiple exostoses. Intercostal, doughy, in suppuration of the bronchial glands ; empyema necessitatis ; lung hernia. Mammary-, in mastitis ; cold abscess ; as a partial manifes- tation of parotitis ; new growths. Abnormal shape of scapulae — Prominent, uni- or bi-laterally, "angel wing" deformity, in congenital malformation; in emaciation. Unilaterally, in scoliosis; paralysis of the scapular muscles, e.g., after local trauma ; poliomyelitis ; progressive atrophy. Sunken, in scoliosis; after empyema operation. Activity of the thorax in breathing is — Increased, bilaterally, in asthma ; laryngeal obstruction. Unilaterally, on the sound side, in pleurisy with effusion; pneumothorax; fixed deformities. Diminished, bilaterally, in emphysema ; hydrothorax ; diffuse tuberculization ; paralytic conditions of the chest wall ; sclerema ; collapse. Unilaterally, in pleu- risy with effusion ; pneumothorax ; pleurodynia ; pleu- ropneumonia with "stitch" pain. Pain on pressure — Superficial, in rheumatism of the chest muscles; intercostal neuralgia ; affections of the ribs (caries, periostitis, fracture, etc.) ; localized abscesses (empyema necessi- tatis) ; and tumefactions {e.g., mastitis). Deep, in pleurisy; pneumonia; phthisis pulmonalis. THE LUNGS.i The lungs are normally fully distended with air within the firsl Few hours of life. \n the premature or delicate infant full See "Auscultation and Percussion," pa^'e 17. ■22 EXAMINATION OF THE PATIENT. lung inflation may not occur until several weeks after birth. The lower lobes particularly may remain in a state of atelec- tasis. The normal boundaries of the lungs differ somewhat with the age of the child. On both sides they project with their summits into the supraclavicular fossae. From here they descend in the following- manner : — The right lung lies — In the sternal line at a point corresponding to the fifth (upper border) rib. TERNAL LINE PARASTERNAL LINE MAMMARY LINE Fig. 7. — Diagnostic Lines of the Thorax. (Sheffield.) In the parasternal line at a point corresponding to the fifth (lower border) rib. In the mammary line at a point corresponding to the sixth rib. In the axillary line at a point corresponding to the seventh rib. In the scapular line at a point corresponding to the tenth rib. The left lung lies — In the sternal line at a point corresponding to the fourth rib. THE LUNGS. 23 In the parasternal line at a point corresponding to the fourth rib. In the mammary line at a point corresponding to the sixth rib. In the axillary line at a point corresponding to the seventh or eighth rib. In the scapular line at a point corresponding to the tenth rib. Posteriorly the base of the left lung is slightly lower than that of the right lung. Number of respirations per minute — In the newly born infant from 35 to 40. At the end of first year, 30. Fig. 8. — Anterior Boundaries of the Lungs. (Sheffield.) At the end of second year, 25. At six years, 22. At twelve years, 20. Character of respiration — Abdominal, in children under four years of age. Costo-abdominal, in children (male and female) up to ten years; in the male, in older ones. Thoracic, in girls over ten years old. Regularity of respiratory rhythm is usually not fully estab- lished before the age of two years. Abnormalities of respiration — Increased frequency, in respiratory and circulatory diseases (see "dyspnea") ; pyrexia ; emotional excitement ; com- pression of the lungs by an accumulation of gas, fluids, or solid masses. EXAMINATION OF THE PATIENT. Diminished frequency, in grave central disease; extreme weakness; poisoning from belladonna, opium, etc. Costal breathing in boys over ten years old, and increased costal breathing in girls, in inflammatory diseases of the abdominal and pleural cavities (by interference with the action of the diaphragm) e.g., peritonitis, pleuritis; in abdominal distension by gases, fluids, or solid masses ; in paralysis of the diaphragm, e.g., bulbar paralysis, polioencephalitis, neuritis (postdiphtheritic) of the phrenic nerve; in drug poisoning; in hysteria. Fig. 9. — Posterior Boundaries of Lungs. (Sheffield.) Purely abdominal breathing, especially in girls over ten years old, in emphysema ; scleroderma ; paralysis of respiratory muscles, e.g., bulbar paralysis. Irregular breathing, in conditions associated with ''difficult breathing" ; in cerebrospinal affections ; in atelectasis ; painful diseases of the respiratory muscles ; in hysteria. Stertorous breathing, in nasopharyngeal obstruction, e.g., retropharyngeal abscess, adenoids; in uremic or apo- plectic coma. Cheyne-Stokes' breathing, occasionally in infants during sleep ; in heart failure from divers causes ; in menin- gitis, especially the tuberculous variety; in meningeal hemorrhage, tumors or abscess exerting pressure upon the brain; in drug poisoning, e.g., opium; in death- agfony. THE LUNGS. 25 Difficult or labored breathing (dyspnea), in laryngeal, tracheal or bronchial obstruction from divers causes, e.g., croup, diphtheria, large thymus, asthma, etc. ; in affections associated with diminution of the usual pul- monary breathing area, such as active or passive con- gestion, compression or displacement by neoplasms, e.g., pneumonia, pleurisy or pericarditis with effusion, deformities of the thorax, advanced pulmonary tuber- culosis ; in grave circulatory disturbance inducing deficient oxygenation of the blood or obstruction to pulmonary circulation, e.g., blood, or heart diseases ("cardiac asthma") ; in conditions giving rise to "irreg- ular breathing" (q.v.) "stertorous breathing" (q.v.), and "Cheyne-Stokes' breathing" ; in neuroses, e.g., hys- teria, neurasthenia — asthma hystericum. Respiratory sounds — Vesicular, exaggerated, in bronchial inflammation ; atelec- tasis. Weak, in thickened pleura ; moderate pleuritic effusion; emphysema. Absent, in extensive pleuritic effusions. Bronchial, over the seat of the lesion, in pneumonia ; tuber- culization. Above the seat of lesion, in compression of the lung by tumors in the chest cavity or by pleuritic exudates. Amphoric, in smooth-walled cavities; open pneumothorax. Secretory sounds — Dry, sibilant and sonorous rhonchi, in bronchitis ; asthma (wheezing and whistling). Dry, crackling, in incipient phthisis (apex) ; beginning of second stage of pneumonia. .Moist, large and medium-sized rales, in bronchitis (larger bronchial tubes) with abundant secretion; in cavities. Moist, small rales, in capillary bronchitis. Moist, crepitant (fine ) rales, in croupous pneumonia (crepi- tatio indux or redux) ; catarrhal pneumonia; capillary bronchitis (in conjunction with coarse rales) ; tuber- culization ; pulmonary edema (in conjunction with larger moist rales). 26 EXAMINATION OF THE PATIENT. Metallic tinkling, in pneumothorax. Metallic splashing or gurgling, in sero- or pyopneumo- thorax. Friction sound, in pleuritis sicca; pleuropneumonia; mil- iary tuberculosis. It is not altered by coughing, as is the case with rales. Vocal resonance 1 — Diminished, in bronchitis with free secretion ; pleurisy with effusion ; obstruction of bronchial tube ; emphysema ; pneumothorax. Increased, in tuberculization; pneumonia (over-consolida- tion). Bronchophony (concentration of voice near the ear), in tuberculization ; pneumonic consolidation ; compressed lung above pleuritic effusion ; bronchial dilatation. Exaggerated bronchial whisper; the same as for broncho- phony (q.v.). Pectoriloquy (complete transmission of sound), the same as for bronchophony (q.v.). Amphoric voice ("the echo"), in large cavity; pneumo- thorax. Egophony, bleating (goat-like resonance of voice), in pleurisy with effusion (near upper boundary of dul- ness) ; pleuropneumonia; hydrothorax. Abnormal percussion-resonance — Dull or diminished resonance, in pneumonia; tubercle; neo- plasms; pulmonary gangrene; pulmonary abscess with thick masses; pleuritic thickening; atelectasis. Flat or absence of resonance, in pleurisy with effusion ; hydrothorax; hemothorax. Resonance may alter with change of patient's position. Also in last stage of pneumonia with extensive consolidation. Tympanitic, or drum-like, resonance, in tuberculosis (cavi- ties) ; open pneumothorax; lung atrophy; above peri- cardial or pleuritic exudations or near neoplasms — the result of increased air pressure; pulmonary edema; moderate emphysema. 1 Vocal resonance elicited on auscultation corresponds to vocal fremitus as obtained by palpation. Fremitus is increased in consoli- dation and diminished in effusions. COUGH. 27 Amphoric, metallic, or concentrated tympanitic sound, in large tuberculous cavity with solid and tense walls lying close to the chest wall; occasionally heard in healthy child during crying. Cracked-pot-resonance, in pulmonary cavity communicating with the bronchial tubes — usually in tuberculosis; may be elicited also in healthy child during talking or singing. Band-box-note (abnormally loud and deep), in pronounced emphysema ; pneumothorax with strong tension of the chest wall. COUGH. It is essentially a reflex act arising from direct or indirect irritation of the respiratory center. In a measure it can be voluntarily produced or suppressed. The ability to cough is lost in paralysis of the crico-arytenoid or the respiratory mus- cles, hence cessation of coughing — with plenty of mucus in the bronchial tubes — particularly in pulmonary disease, is con- sidered a bad omen. The nature of the cough may often be decided upon from its character. The cough is usually — Short and somewhat hoarse, in nasopharyngeal catarrh, adenoids. Loud and barking, in laryngitis and spasmodic croup. Dull, barking and somewhat moist, in ulceration of larynx (diphtheria, syphilis, etc.). Dry, tight and whistling, in early bronchitis. Soft, deep, and loose, in advanced bronchitis. Paroxysmal and whooping, in pertussis and other spas- modic affections. Hemming, in incipient phthisis and in nervousness. Short, sharp and painful, in pneumonia, pleurisy, and car- diac disease. Deep and distressing, in chronic phthisis, asthma, emphy- sema, etc. Too much reliance should not be placed upon the character of the cough, as it is very apt to vary with the duration of the cough, medication and complications. By far more reliable information may be obtained from a careful examination of the expectoration. 28 EXAMINATION OF THE PATIENT. SPUTUM, EXPECTORATION. In cases where the children cannot or will not expectorate, the sputum may be obtained by introducing into the throat a sterile cotton swab or fenestrated stomach-tube — both of which usually receive enough of sputum during the act of coughing as to suffice for ordinary examination. The expectoration is — .Mucous, frothy, grayish-white, in acute catarrh of the air passages. Mucopurulent, tenacious, yellowish-gray, in chronic tra- cheobronchial catarrh; in pertussis (voluminous, often mixed with vomitus) ; in asthma (Curschmann's spirals, Charcot crystals): in bronchiectasis (periodic '"mouthful expectoration," separable into a purulent and mucoserous layer). Purulent, fetid, dirty grayish-green, in fetid or putrid bron- chitis (separable in three layers, suspended in the lowest, purulent, layer are Dittriclr s plugs i ; in pul- monary abscess (separable in two distinct layers, con- taining a great number of micrococci, elastic libers, fat- crystals, etc.) ; in pulmonary gangrene (same as putrid bronchitis, plus tissue-fragments). Serous, prune-juice-like, and profuse, in pulmonary edema. Bloody, in nasopharyngeal catarrh with violent paroxysms of coughing (occasional streaks of blood) ; in foreign bodies in the air-passages (bright red mixed with frothy mucus) ; in pneumonia (uniformly stained, "rusty" sputum to dark "prune-juice" color with pneu- mococci) ; in heart disease, with edema (the same as in pulmonary edema from other causes; besides "heart- cells") ; in tuberculous lesions of the air-passages (either large hemorrhage, "hemoptysis," or blood stained "nummular" and heavy sputum, containing tubercle-bacilli) ; in neoplasms ("red-currant"-like spu- tum, with characteristic histologic structures) ; in vicarious menstruation ; hemorrhagic diathesis, and hysteria. See "Hematemesis" and "Epistaxis." The expectoration contains numerous micro-organisms and occasionally bile (in icterus), hydatid hooklets. distomum pul- monale, and cercomonas. THE HEART. 29 THE HEART.i The heart is comparatively larger in infancy than in later life. It is relatively largest at birth, and smallest at about the age of seven years. At birth the walls of both ventricles are nearly of equal thickness, but as the infant grows older the left ventricle rapidly gains in thickness, so that by the end of the second year it is almost twice as thick as the right ventricle. Fig. 10. — Skiagram of Normal Heart of a Child 8 Years Old. Corresponding to the relatively larger size and more trans- verse position of the heart of the young child, its boundaries are greatly at variance with those of the heart of the adult. The boundaries of the normal heart — The apex-beat is situated — To the left of the mammary line, in the fourth inter- costal space up to the fourth year of age. At the mammary line, at or slightly below the fifth rib up to the eighth year. 1 See "Auscultati Percussion," page 17. 30 EXAMINATION OF THE PATIENT. Slightly to the right of the mammary line, in the fifth intercostal space up to the twelfth year. Between the mammary and parasternal lines, i.e., the same as in the adult, in children over twelve years. The relative "heart-dullness" in infants is bounded as fol- lows : — Above, by a line corresponding to the lower border of the second rib. Fig. 11.— Topography of the Heart. (Sheffield.) On the left side, by a line parallel and slightly to the left of the left mammary line. On the right side, by the right parasternal line. Below, by a somewhat semicircular line along the fifth rib. As the child grows older and the heart assumes a more oblique and lower position, the boundaries of the relative heart dullness gradually fall in line with those of the adult. THE HEART. 61 The absolute "heart-dullness" in infants is bounded as fol- lows : — Above, by the upper border of the fourth rib. On the left side, by the left mammary line (slightly to the right of it). On the right side, by the left sternal line. Below, by a line corresponding to the upper border of the fifth rib. These boundaries, like those of the relative heart dullness, change gradually with the advance of the child's age, so that in children over twelve years old the upper boundary is formed by the fourth rib, the lower by a line drawn parallel to and be- tween the fifth and sixth ribs, on the right side by the sternal line, and on the left by a line midway between the parasternal and mammary lines. Fig. 12. — Up to 4 years. Fig. 13. — Up to 8 years. ig. 14. — Up to 12 years. The Relative and Absolute Heart Dullness at Different Ages. (Sheffield.) :; L > EXAMINATION OF THE PATIENT. The normal pulse-rate (most reliable when patient is asleep), is — In the newly-born infant from 120 to 150 per minute. At one year old 100 to 120 per minute. At four years 90 to 100 per minute. At eight years 80 to 90 per minute. At twelve years 75 to 80 per minute. Normal pulse-respiration ratio is approximately 1 : 4. A ratio of 1:3 or less is a certain indication of pulmonary disease, especially pneumonia. Fig. 15. — Location of Heart-apex at Different Ages. (Sheffield.) Apex-beat — Displaced — Outward, to the left, in hypertrophy of the right ventricle; dilatation of the right ventricle; right-sided pleurisy with effusion; right-sided pneumothorax; ab- dominal distention, pushing the diaphragm upward and the heart to the left. Outward and downward, in hypertrophy of the left ventricle; dilatation of the left ventricle; pericardial effusion ; congenital or acquired (by pressure from above, e.g., tumor or abscess) dislocation of the heart. Inward, to the right, in left-sided pleuritic effusion ; pronounced left-sided deformity of the thorax ; persist- THE HEART. 33 ence of the embryonic position or situs inversus (up to dextrocardia). Effaced {i.e., apex-beat is invisible and barely palpable), in obesity; pericardial effusion; heart-failure; emphy- sema; edema cutis; tumors. Diffuse, and weak in irregularity of the heart associated with grave heart disease. Diffuse and strong, in cardiac hypertrophy; hyperpyrexia; overstimulation; excitement. The cardiac impulse may only appear strong when the chest wall is very thin. Heart-sounds — Accentuation of — Systolic mitral, in excitement; fatigue; fever; hyper- trophy of left ventricle. Diastolic pulmonic, in hypertrophy of right ventricle. Diastolic aortic, in hypertrophy of left ventricle. AVeakening of — Systolic mitral, in dilatation of the left ventricle ; loss of compensation. Diastolic pulmonic, in dilatation of the right ventricle (e.g., relative tricuspid insufficiency) ; stenosis of pulmonary artery. Diastolic aortic, in aortic stenosis. Division (double ) of diastolic at apex, in mitral stenosis ; adhesive pericarditis. Gallop rhythm, in heart-failure {e.g., incipient diphtheritic paralysis). Metallic ringing, in pneumopericardium; pneumothorax; large pulmonary cavity; intense meteorism. Murmurs — Systolic, loudest at apex and transmitted to axilla and angle of left scapula, in mitral regurgitation. Systolic, loudest at base (midsternum) and trans- mitted to the arteries upward and sometimes over the whole sternum, in aortic obstruction. Systolic, at base, but not transmitted upward, in pul- monic obstruction. Systolic, loudest at ensiform cartilage, in tricuspid regTirsritation. 34 EXAMIXATIOX OF THE PATIENT. Diastolic, loudest at base, and transmitted to apex and ensiform cartilage, in aortic regurgitation. Diastolic or presystolic, loudest at apex, in mitral obstruction. To-and-fro friction, superficial, limited to precordium, not influenced by respiration (as in pleuritis sicca), in fibrinous pericarditis. Fig. 16. — Topography of Cardiac Valves. Points of Transmission of Heart-murmurs. A. O., Aortic Obstruction. P. 0. and R., Pulmonic Obstruction and Regurgitation. A. R., Aortic Regurgitation. T. 0. and R., Tricuspid Obstruction and Regurgitation. M. 0., Mitral Obstruction. M. R., Mitral Re- gurgitation. (Sheffield.) Areas of heart-dullness — Enlarged — To the left, in hypertrophy or dilatation of the left ventricle. To the right, in hypertrophy or dilatation of the right ventricle. THE PULSE. 85 Bilaterally, in pericardial effusion. The area of dull- ness is larger in sitting than in recumbent posture; it is often triangular, wider below than above. Reduced — In pulmonary emphysema; pneumopericardium. Displaced — In congenital malpositions, e.g., dextrocardia, meso- cardia, diaphragmatic hernia. In acquired affections, such as pneumothorax ; pleurisy with effusion ; neoplasms ; pleuritic retraction ; atro- phy of the lungs. The pulse — Frequent, in fright; excitement; fear; febrile diseases (ex- cept uncomplicated typhoid or meningitis) ; valvular heart diseases (except aortic stenosis) ; anemias, espe- cially on slight exertion ; tachycardia ; exophthalmic goiter ; convalescence from acute affections ; paralysis of the heart (central or peripheral paralysis of pneu- mogastric nerve) ; heart-failure {e.g., collapse in febrile diseases). Slow, in uncomplicated typhoid fever or meningitis ; after crises {e.g., pneumonia) ; acute nephritis ; catarrhal jaundice; intracranial pressure {e.g., hydrocephalus, hemorrhage, tumors) ; heart disease, such as aortic stenosis, myocarditis ; bradycardia ; profuse hemor- rhage; marked inanition {e.g., a pyloric stenosis); opium poisoning. Irregular, in last stages of valvular heart disease ; myo- carditis; profound anemia (on exertion); nervous palpitation; indigestion (flatulent colic). In the irregular pulse we distinguish the : — 1. Intermittent pulse — Pulsus alternans (every second beat weak). Pulsus bigeminus (every third beat weak). Pulsus trigeminus (every fourth beat weak). 2. Intercidens pulse (several regular beats suddenly followed by a small beat and pause), in heart weakness. 3. Paradoxic pulse (the pulse grows smaller or ceases entirely on deep inspiration), in adhesive peri- carditis; constriction of the air-passage; mediastinal tumors. 36 EXAMINATION OF THE PATIENT. 4. Dicrotic or double pulse (in part explained by a loss in the muscular tone in the arteries, so that the arterial impulse is separated from that of the ven- tricles by a perceptible interval), in typhoid fever and less marked in other acute febrile diseases; in chronic wasting diseases, especially tuberculosis; in anemias ; after great loss of blood. Asymmetric (radial pulse), in congenital anatomical varia- tions of the artery on one side ; acquired narrowing, compression, or cicatricial contraction of the radial, brachial, axillary, subclavian or innominate artery ; aneurism of the aforementioned arteries or of the aorta ; in pneumothorax compressing the subclavian artery. THE ABDOMEN AND ITS CONTENTS. In order to save time, inspection and palpation of the abdomen may at once be supplemented by percussion, succus- sion, etc. To judge matters correctly we should bear in mind the normal relations of the abdominal parietes to the under- lying structures. The abdominal wall is moderately arched; readily com- pressible without undue resistance or pain; moves slightly upward and downward quite evenly and regularly with inspira- tion and expiration ; and on percussion yields a loud, tym- panitic sound over all portions of the abdomen engaged by the intestines. The stomach at birth is nearly cylindrical and lies obliquely in the abdominal cavity. Gradually the fundus increases in size and the stomach assumes a transverse position in such a manner that five-sixths of its volume occupies the left half of the abdomen and one-sixth the right. The capacity of the stomach varies, of course, with the age and size of the child, as fully given when discussing "infant feeding" (page 77). The infantile intestines, especially the small intestine, are relatively lunger than those of the adult. At birth the small intestine is about nine feet long, the large intestine about eighteen inches, the sigmoid flexure forming about half of the colon. The capacity of the infantile intestines is relatively greater than in the adult, but their musculature is thinner and weaker, hence the tendency to constipation and colic. THE LIVER. :r, The liver of the newly born is relatively very large in size, much larger than in the adult, constituting in the former about one-eighteenth and in the latter about one thirty-sixth of the entire body weight. As the child grows older the size of the liver is greatly reduced, but owing to the sloping course of the lower ribs the liver appears considerably larger than it actually is. Fis 17. — The Thoracic and Abdominal Regions. 1. Hypo- chondriac. 2. Lumbar. 3. Inguinal. (Sheffield.) Normal boundaries of the liver (as determined by percussion) : Upper border, midsternal line, base of ensiform cartilage. Mammary line, sixth rib. Midaxillary line, eighth rib. Scapular line, tenth rib. Lower border, parasternal line, seventh rib. Mammary line, about half an inch below free border of ribs. 38 EXAMINATION OF THE PATIENT. Midaxillary line, tenth rib. Scapular line, eleventh rib. Left border, joins lower absolute heart-dullness. Right border, joins the right kidney. Its position varies greatly with the ascent and descent of the diaphragm — rises with expiration and descends with deep Fig. 18.- ipography of the Liver and Spleen. (Sheffield.) inspiration. In the same manner it rises with intestinal meteorism, and descends with overdistention of the lungs through disease, e.g., emphysema or pneumothorax. The spleen lies in close contact with the diaphragm, and extends from the left midaxillary line to a point near the left border of the spinal column. Its upper border follows the ninth rib, its lower border the eleventh rib, for the most part bounding the left kidney. Normally the spleen cannot be out- lined by percussion, but during deep inspiration it can some- THE KIDNEYS. 39 times be palpated at the free borders of the tenth and eleventh ribs. The kidneys are situated upon the right and left sides of the spinal column, and extend from the levels of the twelfth dorsal to the second lumbar vertebrae. The uppermost end of the right kidney (the suprarenal capsule) is slightly overlapped by the liver and that of the left kidney by the spleen. Normal Fig. 19. — Topography of Kidneys, Spleen, and Liver. S. Spleen. L. Liver. K. Kidneys. (Sheffield.) kidneys are occasionally palpable, but can never be outlined by percussion. The urinary bladder is situated underneath the symphysis pubis, but when fully distended rises above it, eliciting dull percussion resonance. Abnormal size and shape of abdomen — Large and uniform, in flatulence; acute and chronic gas- tro-enteritis ; acute peritonitis from various causes ; intestinal atony or paralysis; extensive ascites. 40 EXAMINATION OF THE PATIENT. Large and irregular, in gastrointestinal disease (congenital megacolon, pyloric stenosis, intussusception, appen- dical tumor or abscess, fecal impaction, strangulation, helminthiasis, tuberculosis); in peritoneal or omental affections (chronic peritonitis, tuberculosis, sacculated abscess, sarcoma, cysts) ; in Ik'er disease (congestion, abscess, syphilis, rachitis, fatty or amyloid degenera- tion, leukemia, pseudoleukemia, hypertrophic cirrhosis, neoplasms); in spleen affections (leukemia, pseudo- leukemia infantum, rickets, syphilis, typhoid, malaria, sepsis, neoplasms) ; in kidney disease (floating kidney, perinephritic abscess, neoplasms, hydronephrosis) ; also overdistention of the urinary bladder; large ovarian cysts; local injuries of the abdominal wall. Retracted, in collapse especially from gastro-intestinal dis- ease ; in inanition (pyloric or esophageal stenosis) ; in meningitis ("scaphoid abdomen") ; general cachexia and loss of fat and muscle. Increased abdominal resistance — Local, in localized affections of the different abdominal organs (tumors, abscesses, foreign bodies, e.g., fecal impaction ; helminthiasis). General, in hyperesthesia; rheumatism of abdominal mus- cles ; colic ; peritonitis from different causes ; appendi- citis; sclerema; scleredema; extensive dropsical effu- sion. Abdominal pain — In all conditions enumerated under "abdominal resistance," except sclerema, scleredema, and dropsy. In pneu- monia, pleurisy — reflex ; in cholelithiasis ; gastralgia ; ulcer; nephrolithiasis; cystitis; vesical calculi; intes- tinal adhesions; ren mobilis ; uterine and ovarian dis- ease (in older girls) ; in hysteria. Visible intestinal peristalsis — Normal, in very thin and lax abdominal parietes, e.g.. con- genital diastasis recti abdominis (see Fig. 37) ; infan- tile athrepsia; atrophy due to paralysis. Abnormal (increased or reversed), in pylorus stenosis; intestinal obstruction or constriction from various causes; congenital dilatation of the colon. VOMITING. 41 Palpable or visible hernias — In the linea alba (ventral; diastasis recti abdominis). At the umbilicus (congenital hernia of the cord — ectopia viscerum; simple umbilical hernia). In the lumbar triangles (lumbar hernia; lateral ventral hernia). In the inguinal regions (direct and oblique inguinal hernias). At the femoral fossa (femoral or crural hernia). Vomiting — Gastro-enteric (associated with nausea and effort ; followed by relief) ; in simple gastroenteric disturbances and intoxication ; pyloric stenosis or spasm ; intestinal obstruction from various causes ; appendicitis ; peri- tonitis ; the effect of emetics or poisonous drugs (taken by mouth). Cerebral (explosive; watery, recurrent without relief). Direct, in acute and chronic affections of the cerebro- spinal system; shock; psychic emotion. Reflex, in extracranial irritation of the cranial nerves, e.g., of the optic or oculomotor nerves in visual defects; of the auditory nerve, in otitides; pneumo- gastric, in pulmonary and cardiac diseases. Also in toxemia, by bacterial or chemical products (e.g., sepsis, uremia, etc.). To the latter group belong also the so-called "cyclic" vomiting and the vomit- ing accompanying migraine. Vomitus — Mucous, in chronic catarrh of the stomach; after swallow- ing large quantities of expectoration, in nasopharyn- geal and laryngeal inflammation or pertussis. Bilious (yellowish-green or green), in gastro-enteric dis- turbances after repeated vomiting; in peritonitis; intes- tinal obstruction; liver affections. Bloody (hematemesis), in hemophilia and melena neona- torum; congenital obliteration of the bile-ducts; cir- rhosis of the liver; ulceration of the lining of alimen- tary tract, especially of the upper part (from corrosive poisons; syphilis, etc); in vicarious menstruation. Purulent, in rupture into the stomach of large abscesses in the adjacent organs (e.g., empyema). 42 EXAMINATION OF THE PATIEXT. Fecal, in severe intestinal obstruction with reversed peris- talsis (e.g., intussusception). Parasitic, in helminthiasis; ankylostomum duodenale; trichinae ; echinococci. Diarrhea 1 — One to two movements in twenty-four hours are looked upon as normal. But even double the number of evacuations is not necessarily a manifestation of a path- ologic condition unless the consistency, color and odor of the stools are materially altered. As on the first visit a specimen of the stool is not always obtainable, and if obtained not invariably of the same consistence as the pre- ceding movements, it is important to gather all the infor- mation possible as to the abnormality in question — number, time of occurrence, quantity and quality. 1. Acute diarrhea occurs after the administration of cathar- tics or corrosives ; in indigestion ; stomatitis ; gastro- enterocolitis ; proctitis and dysentery (blood, mucus and often pus) ; acute peritonitis; during the course of divers infectious diseases, especially cholera, typhoid, scarlatina, measles, influenza, sepsis, etc. 2. Chronic diarrhea is observed in dyspepsia; chronic gastroenterocolitis ; chronic proctitis and dysentery (amebic) ; intestinal tuberculosis and other chronic wasting diseases (especially syphilis, leukemia, amy- loidosis) ; helminthiasis (especially in trichocephalus and ankylostomum — often mucosanguinolent stools) ; malaria (periodic) ; intestinal lithiasis (mucus, blood and sand), and in partial intestinal stenosis (band-like, flat, mixed with mucus). Constipation 2 — In determining the clinical significance of con- stipation, inquiry should be made as regards the duration of the constipation, mode of feeding of the child, presence or absence of vomiting and tenesmus, and the color and consistency of the stools. 1. Habitual constipation occurs in consequence of insuffi- cient (pyloric stenosis) or improper feeding (lack of fat, water, etc., excess of starches, etc.) ; intestinal atony (from a great number of causes, e.g., congenital or acquired muscular insufficiency — megacolon, or 1 See "Infants' Stools," pas?e 43. 2 Ibid. INFANTS' STOOLS. 43 artificial distention), general debility, cretinism, etc.; partial intestinal obstruction {e.g., hernia, neoplasms) and abstinence owing to painful lesions in the rectum {e.g., hemorrhoids, fissures). 2. Acute constipation, with persistent vomiting, pain, meteorism, etc. — in all forms of congenital intestinal atresia and acquired acute intestinal obstruction (intussusception, strangulation, fecal' impaction, peri- tonitis, appendicitis, and volvulus). INFANTS' STOOLS. The character (consistency, color, reaction, odor, etc.) of infants' stools greatly depends upon the kind and quantity of food consumed. Normal stools are — Soft and pasty, golden yellow, slightly acid and almost odorless, in breast-milk feeding. Soft — putty-like — whitish-yellow, slightly alkaline and slightly offensive in odor, in cows' milk feeding. Soft — salve-like — yellowish-brown or brown, slightly alka- line or neutral, and malt-like in odor, in feeding with malted or farinaceous foods. Abnormal Stools — (a) Consistency — Thick and formed, in deficiency of fat supply ; excess of starches; habitual constipation. Soft, smeary, like moistened shavings of soap, in fat indigestion. Soft or hard and mixed with tough white curds, in casein indigestion. Thin, watery, in catarrhal gastroenteritis; typhoid fever ; from the effects of hydragogue cathartics ; rectal stricture {e.g., syphilitic). Serous, in severe gastroenterocolitis; cholera. Mucous, in obstinate constipation with tenesmus ; in disease of the large intestine (large quantity) ; in disease of small intestine (mixed with feces). Bloody, in rectal affections {e.g., proctitis, hemorrhoids, fissure, polypus, prolapsus); dysentery; intussus- ception; hemorrhagic disease {e.g., melena, pur- pura, hemophilia, etc.) ; foreign body in rectum. 44 EXAMINATION OF THE PATIENT. (b) Color— Yellowish-green, in gastrointestinal indigestion (espe- cially of casein ). Green, in gastroenteritis; from the effects of calomel. Clay-color, in obstruction to the flow of bile. Black, in meconium; from the effects of iron, man- ganese and bismuth; also blood (coming from upper portion of the bowels). Red, from admixture of blood (from lower portion of bowels, especially rectum). (c) Reaction — Decidedly alkaline, in proteid indigestion. Moderately acid, in fat indigestion (from fatty acids) ; carbohydrate indigestion (acetic or lactic acid). (d) Odor- Foul, in proteid indigestion; fermentation. Rancid, in fat indigestion. Sour or pungent, in carbohydrate indigestion. The stools should be examined also for parasites (see "Intestinal Worms" page 222) and calculi. PRINCIPAL ABNORMALITIES OF URINE. In male infants the urine may be collected by placing the penis in a test-tube or the neck of small bottle fastened by means of strips of adhesive plaster; in female infants, by placing absorbent cotton in front of the vulva. Where these measures fail, catheterization should be resorted to. Traces of albumin and sugar; occasionally hyaline and granular casts ; a moderate amount of mucus, uric acid crystals and urea, are found in the urine of healthy infants a few weeks' old. The quantity of urine passed in twenty-four hours is larger in infants than in older children, but varies with the amount of liquid consumed. It is smaller in breast-fed than in bottle- fed babies. Polyuria (increased amount of urine) — Diabetes mellitus. Diabetes insipidus. Contracted kidney. Granular atrophy of the kidney. ABNORMALITIES OF URINE. 45 Amyloid kidney. Convalescence after acute diseases (epicritic polyuria). Disease of the nervous system, functional and organic, as hysteria, neurasthenia, migraine, chorea, epilepsy, tabes, cerebrospinal meningitis. Medicinal (acetates, salicylates, digitalis, calomel, etc.). Oliguria (decreased secretion of urine) — Febrile conditions. Profuse diarrhea. Circulatory disturbances. Acute nephritis. Some forms of chronic nephritis. Anuria (suppression of urine) — Uremia. Acute anemia. Catarrh of the stomach or intestines. Cholera. D} r sentery. Nervous manifestations. Lead colic. Poisoning with arsenic, corrosive sublimate, morphine, atropine, oxalic acid, etc. Glycosuria — Constant in diabetes mellitus. Transient glycosuria — Cholera. Typhoid fever. Intermittent fever, particularly during convalescence. Syphilis. Scarlatina. Measles. Diphtheria. Influenza. Gout. Disease of the lungs and liver. Disease of the brain, especially if involving the fourth ventricle. Cerebri ispinal meningitis. Tetanus. Lesions affecting the central and peripheral nervous system. 46 EXAMINATION OF THE PATIENT. Poisoning" with morphine, atropine, strychnine, oxalic acid, carbon monoxide, lead, chromates, chloroform, ether, etc. Transient alimentary glycosuria — Disorder of the stomach. Overingestion of starchy and saccharine foods. Cirrhosis of the liver. Morbus Basedowii. Disease of the heart. Phosphorus poisoning. Atrophy of the liver. Traumatic neuroses. Fatty degeneration of the liver. Psoriasis. Aceton — Diabetes mellitus, especially in advanced cases ; diabetic coma. Fever. Carcinoma. Auto-intoxication. Psychoses. After chloroform narcosis. Diacetic acid — Diabetes mellitus, advanced cases. Auto-intoxication (diaceturia). Albuminuria — (a) Renal (nephritis, pyelitis, pyelonephritis, nephrolithiasis) and vesical (calculi, colicystitis). (b) Changes in the constitution of the blood : Ischemia. Anemia. Struma. General weakness. Effect of certain poisons, as cantharides, mustard, oil of turpentine, carbolic acid, alcohol, lead, etc. Infectious fevers — micro-organisms in the blood. Febrile conditions. (c ) Disturbance in the circulation : Acceleration of the arterial current. Slowing of the venous current. Prolonged muscular exercise. ABNORMALITIES OF URINE. 47 After cold baths. After epileptic fits. Compression of the thorax. Derangement of the cerebrospinal system. (d) Functional. Orthotic. (e) Digestive. Ingestion of excessive quantities of albumin (e.g., eggs, cheese, raw beef). Fig. 20. — Severe Acute (at first decidedly hemorrhagic) Nephritis, which Ended Fatally in Four Weeks. X 350. h, Hyaline cast, g, Granular cast, w, Waxy cast, e, Epithelial cast, ep, Free renal epithelia. Also two finely granular, uniformly fatty renal epithelia. (Lenhartz.) Casts — Hyaline (narrow and broad) : Acute and chronic nephritis. Granular (coarse and fine granules) : Chronic pathologic conditions of the kidney. Epithelial : Inflammation in the anatomical structure. Bloody : Hematuria. Acute diffuse nephritis. Acute renal congestion. Hemorrhagic infarction of the kidney. 48 EXAMINATION OF THE PATIENT. Fatty : Fatty changes in the kidney, large white kidney. Waxy: Amyloid kidney and many forms of nephritis. Bacterial : Interstitial suppurative nephritis, ascending pyelo- nephritis. Purulent : Abscess of the kidney. Uric acid (pathologic when deposit occurs shortly after urine is voided) — Acute fevers. Inflammation. Increased tissue metabolism. Defective physiologic action of the liver. Sedentary habits of life. Early stages of interstitial nephritis. Convalescence from scarlatina. Hematuria (blood) — ((7) Renal: Cystic disease of the kidney. I '.right's disease. Abscess. Amyloid disease. Renal embolism. Malignant growths. Hydatids. Tuberculosis. Acute febrile processes. Renal calculi. Purpura hemorrhagica. Traumatism involving the kidney. Medicinal, as turpentine, cantharides, arsenic, etc. i b ) Vesical : Cystitis. Stone in the bladder. Neoplasms of the bladder. ( (• ) Urethral : Neoplasms. Acute gonorrhea. Traumatism. Pyuria (pus) — ( (g) Lime-water (// Lactic acid bacillus J r /c of milk and cream I r /c of total mixture i 1. To inhibit the saprophites oi i fermentation I. To facilitate digestion of the proteins Heat at ° F. Number of feedings Amount at each feeding Ordered for Date M.D. EXPLANATORY. (a) It requires 0.75 per cent, starch to make the precipitated casein finer. (b) One hour completely dex- trinizes the starch. (c) In case physicians do not wish to subdivide the proteins, the words "Whey" and "Casein" may be erased. (d) Twenty minutes render the mixture decidedly bitter. (c) It requires 0.29 per cent, of the milk and cream used in modify- ing to facilitate the digestion of tin- proteins ; i.e., the formation of a soft curd. 0.40 per cent, to pre- vent the action of rennet; i.e., the formation of tough curds. (/) it requires 0.68 per cent, of the milk and cream used in modify- ing to favor the digestion of the proteins. 1.70 per cent, of the amount of milk and cream used suspends all action on the proteids in the stomach. 0.17 per cent, of the total mixture gives a mild alka- line food. (g ) It requires 20 per cent, of the milk and cream used in modify- ing to favor the digestion of the proteins. 50 per cent, of the amount of milk and cream used suspends all action on the proteins in the stomach. 5 per cent, of the total mixture gives a mild alkaline food. (h ) Percentage figures repre- sent the per cent, of lactic acid at- tained when the food is removed from the thermostat. When the lactic acid bacillus is used to facili- tate the digestion of the proteins, this is the final acidity, as the proc- ess is stopped by heat at this point. When the bacillus is used to inhibit the growth of saprophites the acid- ity may subsequently increase to a variable degree, as the bacilli are left alive. 0.25 per cent, lactic acid just curdles milk. 0.50 per cent, gives thick curdled milk. 0.75 per cent, separates into curds and whey. formula. NUTRITION. 73 When "laboratory milk" is not obtainable, and "home modi- Home fication" has to be resorted to, we may greatly facilitate the of cows' process and obviate the difficult task of memorizing complicated standard er formulas by selecting a "standard" milk formula of simplest com- position (1:1, i.e., 1 ounce or its multiple of milk to 1 ounce or its multiple of a diluent) and preparing the other milk mixtures by modifying this "standard" formula. Directions. — 1. Bear in mind the standard formula (1:1), which is intended for an infant 3 months old. 2. For infants under 3 months increase about every month downward the diluent by one ounce or its multiple, using "top milk" (upper 18 ounces) as a base and plain water as the diluent. 3. For infants over 3 months of age, increase every two months upward the milk by one ounce or its multiple, using "whole milk" as a base and cereal water as a diluent. 4. Add to each ounce of the diluent from % to Y 2 teaspoon- ful of sugar and 1 teaspoonful of lime-water. 1:5 2:1 one week five months 1:4 3:1 two weeks seven months Standard Formula 1:1 three months. 1:3 4:1 one month nine months 1:2 5:1 two months eleven months Milk modified in accord with these suggestions yields milk mixtures of the following composition : — For an infant 1 week old — (1 : 5). Top milk 2% ounces Proteins . . . 0.50 Lime-water 3 drams Sugar 6.00 Water 13 ounces Fat 1.00 Milk-sugar 4% drams Divide in 8 bottles ; give a feeding every three hours during the day and night, if baby is awake. For an infant 2 weeks old — (1 : 4). Top milk 4 ' ounces Proteins .... 0.6 Lime-water r / 2 ounce Sugar 6.00 Water \Sy 2 ounces Fat 1.20 Milk-sugar % ounce Divide in 8 bottles ; give a feeding every three hours during the day and night, if baby is awake. For an infant 1 month old — (1:3). Top milk 6 l / 2 ounces Proteins . . . 0.75 Lime-water 3^ ounce Sugar 6.00 Water 17j/j ounces Fat 1.50 Milk-sugar -)4 ounce Divide in 7 bottles; give a feeding every three hours during the day, and once during the night, if baby is awake. 74 PREVENTION AND CONTROL OF DISEASE. For an infant 2 months old — (1:2). Top milk 10 ounces Proteins .... 1.00 Lime-water 1J4 ounces Sugar 6.00 Water 19 ounces Fat 2.00 Milk-sugar 7/% ounce Divide in 7 bottles; give a feeding every three hours during the day, and once during the night, if baby is awake. For an infant 3 months old — (1 : 1 ). Whole milk 18 ounces Proteins 1.50 Lime-water 2 l /+ ounces Sugar 6.00 Barley-water 16 ounces Fat 2.00 Milk-sugar % ounce Divide in 7 bottles; give a feeding every three hours during the day, and once during the night, if baby is awake. For an infant 5 months old — (2:1). Whole milk 26 ounces Proteins 2.00 Lime-water 314 ounces Sugar 6.00 Barley-water 10 ounces Fat 2.60 Milk-sugar i/> ounce Divide in 6 bottles; give a feeding every three hours. For an infant 7 months old — (3: 1). Whole milk 32 ounces Proteins .... 2.25 Lime-water 4 ounces Sugar 6.00 Barley-water 7 ounces Fat 3.00 Milk-sugar l / 2 ounce Divide in 6 bottles; give a feeding every three hours. For an infant 9 months old — (4: 1). Whole milk 34 ounces Proteins .... 2.45 Lime-water 4 l /> ounces Sugar 6.00 Barley-water (concentrated) ... 4 ounces Fat 3.25 Milk-sugar V; ounce Divide in 5 bottles: give a feeding every four hours. For an infant 11 months old — (5:1). Whole milk 3714 ounces Proteids .... 2.50 Lime-water 4^ ounces Sugar 6.00 Barley-water (concentrated ) . . . 3 ounces Fat 3.50 Milk-sugar l /± ounce Divide in 5 bottles; give a feeding every four hours. For infants over a year, give undiluted whole milk (see also page SO i . Advantages The method of home modification of milk here described, method! while not very exact, is based upon clinical experience, and has the further advantage over many other methods in vogue in that NUTRITION. 75 it does not require the knowledge of higher mathematics for its Feedino . b calculation. Infant feeding by calories, while very ingenious, is calories. hardly applicable in the feeding of infants under 3 or even 6 months of age, since it provides amounts of fat or protein often entirely beyond the infantile digestive capacity. According to Heubner 1 an infant requires a daily ration of about 45 calories for every pound of its weight during the first quarter of a year, 40 calories during the second quarter, 35 during the third, and 30 during the fourth quarter. Fifteen grains (1 gram) of protein or carbohydrates furnish 4.1 calories and 15 grains of fat 9.3 calories ; or 1 ounce of whole milk 20 calories. Taking for ex- ample an infant one month old, ordinarily weighing 8 pounds, it would require in 24 hours 8x45 = 360 calories, i.e., either 18 ounces of whole milk, which would be entirely too rich in casein for an infant of that age, or A l / 2 ounces of gravity cream greatly diluted, which would be too rich in fat and too poor in protein and sugar. The same fault is to be found in Budin's 1 method of giving daily an amount of milk equal to 10 per cent, of the body weight of the baby. The keynote of successful artificial feeding is individuality, the selection of a food in proper proportions as to fat, sugar, and protein suitable for each individual baby's power of digestion and Quantit assimilation, and in sufficient quantities. The amount of food of f° od " ' ^ _ vanes with needed by the healthy infant is best judged by the capacity of size of the stomach 2 subiect, of course, to variations as to size, activity, capacity of . . stomach. etc. The question of the proportion of the food elements must be decided from time to time in each individual case, after con- sidering the gain or loss in weight under the respective food, and watching the consistency, etc., of the bowel movements. All disturbances of digestion, be they due to an excess of , . , , , , . ,, Disturbances protein, sugar, or fat, have several symptoms in common, thus: f digestion. Restlessness, flatulence, colic, loss in weight, frequent defecations and vomiting; in acute indigestion also moderate or high fever. To determine whether the digestion of fat, sugar, or protein is at fault, we have to examine the vomitus and faeces. In fat indigestion, the stools are either soft (containing soft Fat curds ) and oily in appearance or of creamy consistence, or, espe- llldl g estI0n - 1 Both Heubner's and Budin's suggestions work well in breast-feeding. - The following fairly represents the average capacity of the infantile stomach: At the end of the first week, 1 ounce; the second week, 2 ounces; first month, 3 ounces; second month, 4 ounces; fourth month, 5 ounces; sixth month. 6 ounces; eighth month, 7 ounces; tenth month, 8 ounces; twelfth month, 9 ounces; fourteenth month, 10 ounces. Proteid indigestion. 76 PREVENTION AXD CONTROL OF DISEASE. daily in cases of long duration, gray or grayish yellow, hard and dry. forming the so-called "soap-stools." Sometimes the stools are watery, strongly acid, causing severe irritation of the buttocks. The vornitus also is strongly acid. The lips are often cherry-red in color. In sugar indigestion vomiting is less common than in fat indi- indigestion r gestion. but if it does occur, the vornitus. like the faeces, is acid in reaction and often presents the characteristic odors of lactic, acetic or succinic acid. The stools are usually thin, often mixed with mucus, light or dark green, and very irritating to the but- tocks. In severe cases there may be high fever, with other symp- toms of acute intoxication. Starch indigestion may give rise to loose, brown stools, mixed starch w ith mucus, changing into blue color on addition of iodine. In- mdigest'.on. ' . fants fed exclusively on starch food slowly develop athrepsia. An excess of casein usually gives rise to large, often tough, curds in the vornitus and stools, neutral or slightly acid in reaction and free from any characteristic odor. In some cases the stools are loose, mucous, brown in color, and musty in odor. The management of the aforementioned digestive disturb- ances, in a way, is self-evident : we have to temporarily reduce the offending food element in the infant's diet, which must either be reduced in quantity or eliminated entirely. Skimmed milk and cereals should be given in fat indigestion : diluted skimmed milk or Eiweissmilch in carbohydrate indigestion ; or condensed milk. Management. W ell-diluted boiled milk, or weak mixtures of Eiweissmilch with the addition of malt-dextrin in digestive disturbances due to an excess of protein. Of course, with disappearance of the symptoms the required fat, carbohydrate- and protein-proportions of the food are gradually to be resumed. COWS' MILK SUBSTITUTES. Malt-soup. — Two ounces of wheat-flour are slowly and thoroughly mixed with one pint of milk, and strained through gauze. In a second vessel three ounces of thick malt are dis- solved in a quart of warm water to which bad been added fifteen grains of carbonate of potassium. Now both solutions Dyspepsia are m i X ed together and heated very slowlv up to a boil. As and ° j i the children improve the water may gradually be reduced to a pint. Malt-soup is often particularly beneficial in underfed, dyspeptic and rachitic babies. If well tolerated it may be con- tinued for several months. marasmus. NUTRITION. 77 It is advisable, however, gradually to replace the malt-soup by ordinary milk mixtures, and other foods (see p. 80). Condensed Milk. — Where the principal difficulty consists in incapacity to digest cows' milk casein, condensed milk 1 will be found to act kindly, since the consistency of the coagu- lum of condensed-milk casein formed in the infantile stomach greatly resembles that of human milk. It has also the advan- tages of being inexpensive and not as readily subject to contamination as ordinary cows' milk. However, containing as it does about 51 per cent, of sugar, and requiring eight to ten times dilution to approximate the sugar content of human milk, the simultaneous reduction (by dilution) of the fat and proteid contents to about 1 per cent, and 1^4 per cent, respect- ively renders condensed milk too poor in quality to serve as an ideal infant food. Indeed, it is usually found that infants . As a over three months fed on diluted condensed milk soon contract temporary rachitis. Nevertheless, as a temporary food, especially during the summer months or a long journey, it is invaluable. As already suggested, condensed milk should be administered in quantities appropriate for the infant's age, in dilution with from eight to ten or even twelve parts of plain or cereal water. The deficiency of fat may be supplemented by the addition of cream. Whey. — Where the digestive capacity of casein is greatly at fault, we may temporarily resort to whey feeding. Whey is obtained by adding to a pint of fresh warm (100° F.) milk two teaspoonfuls of essence of pepsin. After it stiffens beat up the curd with a fork and strain through a few layers of gauze so as to withhold the coagulated casein. The decanted liquid contains approximately : — Proteids. Sugar. Fat. Lactalbumin 0.9% 4.5% 0.5% Casein 0.3% By adding a little sugar to overcome its deficiency and em- ploying a cereal diluent instead of plain water, the whey mixture is amply nutritions to sustain an infant's vitality for several weeks. 1 Approximate Composition of Condensed Milk: — Proteids. Sugar. Fat. Salts. Water. 8.00 51.0(1 7 1.5(1 32.00 Fresh condensed milk contains only in per cent, of sugar. 78 PREVENTION AND CONTROL OF DISEASE. Buttermilk. — This is prepared by thoroughly mixing, in a suitable agate vessel, one quart of fresh, rich milk, with a pint or less of water, a pinch of salt, and the pure lactic acid culture (any one of the pure mercantile lactic bacilli tablets answers the purpose). The vessel is covered with a thin cloth and allowed to stand in the room (70° to 80° F.) for from eighteen to twenty-four hours. It is now placed on ice until needed. For infant feeding we add to every quart of butter- milk a flat tablespoonful of wheat-flour and two tablespoonfuls of cane-sugar and allow the mixture to boil over a low fire, for two to three minutes, with constant stirring. The food is now poured, in quantities varying with the age of the patient, in sterilized bottles, properly corked, and placed on ice until in fat use( '- The mixture is indicated especially in cases requiring indigestion. a high percentage of protein and a low percentage of fat, e.g., gastroenteritis and fat indigestion. Eiweissmilch (Albumin-, Protein-, or Casein- milk). — This food, originally recommended by II. Finkelstein and L. Meyer, is gradually being accepted by the profession as an ideal food in the management of fermentative dyspepsia and nutritional disturb- ances from intolerance of milk. It consists of 2.50 per cent, of fat, 1.5 per cent, of sugar, 3 per cent, of protein, and 0.50 per cent, of salts, and is prepared as follows : One liter of warm milk is treated with 15 grams of essence of pepsin, and allowed to stand in a water bath at 107.6° F., until a curd is formed. This mass is poured into a linen bag and allowed to filter for about half an hour, and while gradually adding half a liter of water the curd is pressed through a fine sieve 2 or 3 times by means of a wooden spoon. To this milk-like mixture we next add half a liter of buttermilk. Drs. Finkelstein and Meyer were prompted to sug- gest the Eiweissmilch after establishing the facts that non-toxic 1,1 fermen- fermentative dyspepsia is due principally to abnormal fermenta- tative . i i ii. .... dyspepsia, tion of the carbohvdrates (not the casein!) of the infant food, colitis and J carbohydrate and that fat forms a disturbing element only when preceded bv indigestion. . .'.,,,,,'. . . . sugar fermentation. Albumin-milk should be given in quantities of about V/z to 2 ounces every three or four hours. In very young infants it may at first be diluted with an equal quantity of water. As the patient improves, it is advisable to increase the amount of the Eiweissmilch and to strengthen it also by the ad- dition of 1 per cent, of maltose, or malt-dextrin. After full recovery from the disease. Eiweissmilch feeding is gradually dis- continued. As may be noted from the above directions, the great stumbling-block to the more general use of Eiweissmilch is the difficulty of its preparation. But this hindrance has recently been NUTRITION. 79 overcome by W. Stoelzner, who, appreciating the fact that the essential therapeutic value of Eiweissmilch consists in its low percentage of sugar and 'high albumin and calcium content, has after many experiments succeeded in devising means to perfect a finely granular and readily soluble casein-calcium (Larosan), which, when combined with diluted 1 milk, furnishes a milk mix- ture practically identical in. its composition with that of Eiweiss- milch and more acceptable in taste and form. It has been demonstrated that, as in the case of Eiweissmilch, the action of casein-calcium is manifested by the formation of soap stools. Stoelzner's casein-calcium, obviously, acts by virtue of the casein content favoring intestinal digestion and thereby opposing acid fermentation, while the calcium, in conjunction with the fat, serves to increase the lime-soap formation in the intestines. Proprietary Milk Modifiers and Milk Foods. — We distin- guish two kinds of proprietary foods — milk modifiers and so- called milk foods. Neither of them contains a sufficient amount of nutrient elements to supply the needs of the baby for life and growth for any length of time ; they are useful, however, in digestive disturbances and "milk idiosyncrasy," and to bridge over an acute siege of sickness. The mercantile milk idiosyncrasy. modifiers furnish soluble carbohydrates, free starch, or pre- digested proteids in small quantities, and thus save the trouble of home-preparation of suitable diluents. Contrary to what is generally expected, the so-called milk foods occasionally prove very beneficial in cases of pedatrophy. On the other hand, it should be remembered that their prolonged use is frequently followed by scurvy and rickets. Peptonized Milk. — The use of peptonized milk is nowadays limited chiefly to feeding of children of very low vitality, in pocJ ery whom the powers of digestion are in abeyance, e.g., high fever, coma (administered in the form of nutrient enemata, or by gavage ) , pyloric stenosis, etc. Mode of Preparation. — Mix in a quart bottle one pint of fresh milk with 4 ounces of cold water containing 5 grains of pancreatic extract and 15 grains of sodium bicarbonate, or the contents of one of Fairchild's peptonizing tubes. Place the bottle in a pot of hot water and maintain its temperature digestion. 1 Mix % ounce of Larosan with 8 ounces of cold milk and pour it into a saucepan containing 8 ounces of boiling-hot milk. Boil the entire mixture for live minutes, with constant stirring, and. after straining through a few layers of cheese-cloth, dilute it with 1(> ounces of boiled water or gruel. Giv< l 1 -.- t<> 3 ounces every four hours. Time foi weaning. 80 PREVENTION AND CONTROL OF DISEASE. at about 115° F., either for about twenty minutes ("partial" peptonization) or two hours ("complete" peptonization). Shake the bottle from time to time. When the mixture is ready, give it. either pure or diluted, in quantities suitable for the age of the child. Keep it on ice until used. WEANING OF THE BABY AND ITS FEEDING THEREAFTER. Ordinarily it is not advisable to nurse an infant beyond ten or eleven months old. As exceptions to this rule, we may mention the very hot summer months, acute diseases, difficult teething, etc., when a complete change in feeding is prone to prove hazardous to the child's health. It is preferable to wean a baby gradually, by substituting bottle- for breast- feedings, and to continue to partially nurse it, until the infant has learned to submit to the inevitable, and thrives well on the new food. Feeding of Infants Over Ten Months Old. — When the normal infant reaches the age of ten months or thereabouts, nature announces the urgencv of a change in the dietary — from liquid to solid — by hastening the eruption of the lower and upper incisors, which for months had threatened to escape, from Gradual their seat of birth and captivity. At this age also salivary transition . . , " ., from milk digestion is fully established, so that an allowance, once or articles of twice a day, of a crust of stale or toasted bread, or zwieback, certainly can do no harm. As at this period of life the tend- ency to rickets is very pronounced, the dietary should be grad- ually improved upon by the addition of cereals, a teaspoonful or more of fresh, soft-boiled egg, oatmeal or Graham crackers ; strained chicken, mutton, or beef soup, with fresh vegetables (e.g., carrots, potatoes, etc.), orange- or pineapple- juice, and later baked apple, baked potato with some sweet cream or butter, bread and butter, milk custards, cocoa, and occasionally finely scraped beef or chicken. Of course, the transition from an exclusive milk diet to a more or less mixed diet must be very slow and gradual. The effect of the change should lie watched from day to day and week to week, always bearing in mind that milk is the ideal food for the infant and indispensable to the child up to the period of second dentition. This fact should be strongly impressed upon those in charge of the child, as only too often, with the allowance of a semi- NUTRITION. 81 solid diet milk is crowded out entirely by an oversupply of thin soups, indigestible, proprietary "breakfast foods/' and all sorts of sweets and fruit of poor quality, which sooner or later upset the child's digestive powers and arrest its growth and development — doing just the opposite of what the change of diet was intended for. With the change in the diet also it is frequently observed Miikto that the infants refuse to drink milk. Inquiry into the cause principal e usually reveals the fact that upon the advice of some artistic- ally inclined neighbor — who thinks that the bottle effaces the child's "beauty lines" — and more generally upon the recom- mendation of the family physician, the child is forced to part with its bottle and nipple — its dear and faithful companions for the many months past. Why milk-bottles are to be looked upon as an abomination for children over a year or so and as a salvation for those under this age, is to me a mystery. The mere facets that if given in a bottle, large quantities of milk are Advantages enjoyed by children up to four or five years of age: that if milk , , " ' 1 1 .„ , ill 1 through taken through a nipple, milk enters the stomach slowly, and, a bottle. hence, is more easily digested, and, finally, that during sickness milk (as well as water) is best administered through a bottle, are ample justifications for the encouragement rather than the prohibition of the use of the bottle — provided, of course, that the bottles, as well as the nipples, are kept scrupulously clean ; are sterilized, if you please. The additional articles of food should be given at definite intervals, preferably together with the milk feeding. Thus, for example, with the ten o'clock bottle the child should receive the soft-boiled or poached egg and crackers ; at two o'clock the meat broth and potato; at six o'clock, some cereal and bread and butter. Orange- or pineapple-juice may also be given between meals. The child should be taught to appreciate that to get other food-stuffs it must drink its allowance of milk. Feeding of Children of from Two to Four Years Old.— With completion of primary dentition, which usually occurs between the twenty-fourth and thirtieth months, the dietary of , the child can be considerably enlarged. The breakfast in addi- Breakfast. tion to the milk should consist of well-cooked cereal gruel, toasted bread and butter, scraped or baked apple. The dinner Dinner. may embrace meat broths, broiled rare steak, mutton chop or white meat of chicken — all cu1 up finely; scraped raw beef. diet. 82 PREVEXTIOX AND CONTROL OF DISEASE. boiled fish; small quantities of vegetables, such as potato, fresh string beans or peas, spinach or asparagus tops, stewed supper. f ru j t or a little custard or pudding. The supper should include a soft-boiled or poached egg, bread and butter, stewed fruit, and milk or cocoa. The child should receive a cup of milk between breakfast and dinner and between dinner and supper. Fresh, pure water should be given between meals, the first thing in the morning and the last thing at night. Feeding of Children from Four to Six Years Old.— The dietary of children over four years old is practically identical with that just mentioned, except that the quantity of the food i^rai" should be more liberal, the fruit may be given raw, and that the between-meals milk allowance should be dispensed with. Occasionally the child may receive home-made cake, a little ice cream and other condiments of good quality. All these food-stuffs, however, should be given with regular meals. II. HYGIENE AND SANITATION. Next to suitable nutrition hygiene and sanitation play the most important role in the preservation of good health. It is within the province of the physician's duties to formulate, to those intrusted with the care of the child, rules and regulations as to its cleanliness and comfort, mode of clothing, time for sleeping, airing, bathing, rest and exercise, both during health and disease. Without the advice and supervision of the physi- cian, the nurse or mother is only too apt to either overdo or underdo, i.e., in both events do irreparable damage to the health and welfare of the child. The period of blind credulity, stupid mysticism and absurd fatalism still reigns supreme, the great strides in science and adventure notwithstanding. GENERAL CARE OF THE NEWLY BORN AND OLDER CHILDREN. The Newly Born Baby. — Immediately after birth the infant instinctively, by its shrill cry, announces its demand for protec- tion against the sharp change of atmosphere and surroundings, iter dressing its navel (see page 173). washing its eyes and mouth with a saturated boric acid solution, 1 the baby should be wrapped in a warm woolen blanket and placed and eyes. 1 Where gonorrhea in the mother is suspected, we should instill into each eye one drop of a 2 per cent, solution of nitrate of silver. HYGIENE AND SANITATION. 83 in a warm, darkened, but airy, quiet room, and left to rest for Rest - a few hours. It should then be sponged off with warm soap water, dressed, given a little clean water, and, the condition of the mother permitting, put to the breast (see page 62). Nursing. Wherever possible, the child's crib should be kept in a room apart from that of the mother, so that the latter is not dis- turbed by the possible uneasiness experienced by the baby. As lactation is usually not fully established before the third or fourth day after labor, the infant should, in the mean time, several times daily receive a few teaspoonfuls of plain or slightly sweetened warm water or of a mild carminative, such as fennel-seed tea, to satisfy its thirst and hunger. Sleep. — The normal newly born baby sleeps practically all the time except the brief periods occupied with nursing, diaper- ing, and dressing. If the baby is well developed and strong, it should be left to sleep until it wakes up of its own accord from hunger; if delicate it should be aroused every two hours Hours & ' J of sleep. during the day, and once at night, made to cry a little to help expanding its lungs and put to the breast for from ten to twenty minutes. At six weeks the infant needs twenty hours of sleep; at three months eighteen; at one year sixteen and from two to four years fourteen hours of sleep. All children should get accustomed to sleep uninterruptedly (except for one nursing in the middle of the night in early infancy), from seven in the evening until seven o'clock in the morning, and one hour each sometime between seven and twelve o'clock in the fore- noon and two and seven in the afternoon. Sleeplessness in the infant is ordinarily due to intestinal colic or other pain, discomfort from soiled diapers or faulty dressing (overheating by superabundance of clothes, etc.), noise in the room, lack of ventilation, bad habits, such as rock- ing, or keeping an empty nipple in the mouth, etc. Repeated waking is frequently due to over- or under-feeding. Bathing.— In view of possible local or systemic infection (see page 172) through the umbilical rest, and the advis- ability of keeping the latter perfectly dry, the full tub-bath should be withheld until the navel has completely healed. The f a D e' ng same applies for circumcision wounds. In the mean time the P° st P° ned - infant should receive at least one sponge bath a day, to be given as gently as possible, since the infantile skin is very 84 PREVENTION AND CONTROL OF DISEASE. delicate, very apt to be abraded on rough handling, and readily becomes subject to divers skin affections. In the absence of the aforementioned or other contraindica- tions, every child, in addition to local cleansing as frequently as necessity arises, should receive a tub-bath once a day, prefer- clean a bi v a t bedtime. The water used should be free from visible bath-water. impurities, and obtained from sources inaccessible to pollution. The temperature of the water should range between 95° F. and 98° F., the latter for infants under six months, and cooler water for older ones. Fat babies tolerate much lower temperatures, but I see no special benefit to be derived from the use of bath- water under 95° F. unless it be in the open sea or ocean (which Temperature is permissible in children over three vears of aere), where the of the . . . " . water, saline ingredients and forceful current exert a stimulating, refreshing effect upon the system and thus counteract the depression produced by the sudden lowering of the body tem- perature. If cool bathing is desirable it is better to place the child in warm water and either to gradually cool off the water while the child is in the tub or use a cold shower. The bath should be followed by thorough drying of the body and gentle friction. Care should be exercised in the selection of pure, non-irritating bathing soap, lest its irritating ingredients may of iTrffation P rove a source of annoying skin eruptions. For the same of the skin. reason an( \ t furthermore, owing to the fact that they are apt to harbor dirt and disease, the use of sponges is to be deprecated. Clothing. — Infants should be clothed warmly and simply, free from fancy frocks and frills, strings and bows, that embar- rass free motion, breathing, sleeping and eating. The under- sukor wear should be made of silk or thin flannel. The abdomen underwear' should be protected against being chilled by a flannel band. The consistency of the outer clothing should vary with the changes of the weather and season of the year. The feet of infants should at all times be kept warm, if necessary, by means of a hot-water bag. The night clothes should be loose and warm, and consist, in addition to a small silk or flannel shirt. Canton flannel or stockinet diaper and the belly-band, of ^blg 1 a nightshirt in the form of a "bag" that buttons around the neck and can be closed at the feet by means of drawstrings. In this manner the unnecessary piling up of blankets, to keep the baby from uncovering, can advantageously be dispensed with. Shoes to fit the feet. HYGIENE AND SANITATION. 85 Older children should gradually get accustomed to light clothes — linen or silk undergarment, linen or woolen suit or dress, and for the winter a warm top coat and cap — but no collars or neck mufflers. A woolen union suit with feet for the night. Especial attention should be paid to the selection of shoes. They should comfortably fit the feet and allow spread- ing of the toes. The stockings should be fastened to the drawers, as garters are apt to interfere with the blood circula- tion of the lower extremities. The corset should be prohibited in girls under fourteen. Airing. — .Fresh, pure air is the panacea for good health, the cure of all bodily ills. Thus far it is non-assessable, non-tax- able, and hence should be inhaled ad libitum — while this free- Fresh air dom lasts. Weather permitting it should be inhaled out of outdoor^fr' doors, otherwise indoors — in properly ventilated rooms. The leather 611 ' newly born baby should be taken out of doors in the summer peri1 when it is two weeks old, in the spring and fall at one month and in the winter at two months of age or later. It should be suitably dressed and protected from undue exposure to the sun and wind and severe cold. It is foolhardy to expose an infant to marked atmospheric changes without proper shelter, merely for the purpose of "hardening" it. Its first airing should last from fifteen to thirty minutes, and as it grows older the airing time should be lengthened so that, weather permitting, the child may live out of doors the greater part of the day from sunrise until sunset. Slight rain or snow forms no hindrance to taking the baby out of doors, although in such weather delicate babies do better if aired indoors, in front of open windows and dressed as for outdoors. Exercise. — A healthy infant, if not immobilized by burden- some clothes, begins to take physical exercise soon after birth. It kicks, moves its arms and head and exercises its thoracic muscles while crying lustily, especially when feeding time approaches. It should be picked up in the arms at every nurs- ing to insure change of position. At about four months of age the baby is able to hold its head erect; it may then be Holdillg gradually trained to sit upright upon the arm of the nurse with head erect the hand of the other side supporting its back and head. As it readies the age of seven or eight months, the infant may be Sitting seated alone in a baby-chair supported with pillows at the creeping, back and sides. When it shows an effort to creep, it may be Frequent change of position. 86 PREVEXTIOX AXD CONTROL OF DISEASE. placed upon the floor, which should be well covered by thick carpet or a blanket, preferably within a small portable "creep- ing- pen/' and allowed to roam about for half an hour at a time once or twice a day. Less freedom should be granted an Stand anl m f an t in its first attempts to stand or walk. These practices walking. s h ou id no t be encouraged in babies under one year of age, nor in older children who show a tendency to bony curvatures and rickets. In the beginning they should not be allowed to stand or walk, especially if unsupported, for more than a few minutes at a time. But, as they grow older and stronger they are gradually permitted to enjoy shorter or longer outdoor walks and to romp merrily, giving vent to that characteristic boundless joyousness of early childhood which is blessedly ignorant of the pangs and pains of later life. Older children, like infants, should spend the greater por- tion of the day outdoors in parks and play-grounds and engage in amusing games and light calisthenics which will keep them from harm and mischief. It is opportune on this occasion to Danger of emphasize the danger of overindulgence in the practice of indulgence gymnastics, especially in children of school age — a period of life which is coincident with prevalence of communicable dis- eases and their grave sequelae, particularly cardiac involvement. Carried away by the enthusiasm over the daring feats of the author and exponent of "strenuous life," the young and old alike have recently rushed for rough athleticism with a ven- geance, that is daily reflected by multitudes of crippled, so- called athletic, hearts, and apt to become a menace to the health and welfare of our country. It is the duty of the physician to impress upon those under value of his care that while moderate exercise, especially walking, exercise, skating and horse-back riding; the daily use, for about fifteen minutes at a time, of light wooden dumb-bells, light clubs or wands; the practice of breathing (see page 353), of swing- ing of the body from a swinging bar or rings and straps, will do much for the development of delicate and narrow chests and to prevent and straighten curvatures of the spine, stooping of the shoulders, and the like (and should be encouraged), violent sports, like racing, rough baseball- and football-playing, leap- ing, prolonged swimming and similar severe exercises indulged in to excess, will sooner or later lead to cardiac hypertrophy with its consequences. HYGIENE AND. SANITATION. 87 Nursery. — As infants and older children spend about two- thirds or more of their time of life in the nursery, provisions must be made that the room is spacious and airy, dry and sunny, that its air is fresh and pure, free from obnoxious odors, gases, dust and smoke. To thrive well an infant requires Air space, about 1000 cubic feet of air space. The room should not be crowded with dust gatherers, i.e., overabundance of furniture, toys, heavy hangings, carpets, rugs, pictures, etc. The tem- perature of the room should be about 70° F. during the day and Temperature, about 65° F. during the night. Whenever possible it should be heated from an open fire-place or a hot-air furnace. Steam heat or gas greatly vitiates the air. To insure proper ventila- ventilation, tion, it is advisable to keep the windows more or less open from top and bottom most of the time unless the outdoor temperature is below 35° F. The windows and doors should be widely opened while the child is out of doors, otherwise ventilation should be accomplished with the doors closed to avoid draughts. For the latter purpose one of the many ventilating devices on the market will prove very serviceable. Financial circumstances permitting, every child should have a separate room, if possible, situated one floor above the ground. Of course, this is rarely attainable in the dingy apart- ments of overcrowded cities. Physicians should insist, how- ever, on every child having a separate bed in order to minimize the danger of transmitting communicable diseases from the sick to the healthy child. The Sick-room. — The hygienic suggestions just made in reference to the nursery apply with greater force to the sick- room. If possible, the latter should be situated on a different floor from the living apartments. From a sanitary as well as economic point of view it is essential to have the sick-room gatherers, cleared of curtains, tapestries, superfluous furniture, carpets, etc., so as to facilitate keeping the room perfectly clean, and to prevent pathogenic germs (e.g., with the skin-peeling of scar- latina), becoming firmly imbedded in those articles. The floor and furniture of the sick-room should be wiped off with a damp cloth instead of dusted or swept. An ante-room is a useful addition to .a sick-room, especially Ante-room, when the patient is suffering from a communicable affection, as it enables the nurse to disinfect the dishes, soiled bed-clothes, linen, etc., and to prepare some of the patient's food. 88 PREVENTION AXD CONTROL OF DISEASE. When the isolation-period of the patient is over, the sick- room, ante-room and their contents must undergo very thorough cleaning and disinfection. Quarantine and Disinfection. — In order to prevent spread- ing of communicable diseases from one individual to another, we have to resort principally to the following prophylactic measures : — 1. Isolation of the patient. 2. Disinfection of the patient's excretions, fomites, etc., coming in contact with the pathogenic micro-organisms. 3. Exclusion and destruction of other germ-carriers, e.g., mosquitoes, flies and fleas. 1. Isolation of the Patient. — This is the most essential and efficient mode of prevention of transmission of disease. The isolation to be effective must begin early and be complete. Early and In hospitals and asylums every child should be isolated in an iso™uon e observation ward for at least three days before being permitted to mingle with the other inmates; in private families isolation should be enforced with the earliest appearance of tangible symptoms of the specific affection. As those coming in close contact with the patient are apt to carry the disease from the sick to the well, it is imperative to isolate the nurse together with the patient and to forbid any member of the family to stay around the sick-room or make herself generally useful unless on entering the sick-room she dons a clean gown and cap, and before leaving it washes her hands and forearms with soap and water and removes the gown and cap. These latter rules should be complied with also by the physician. In a private dwelling, and especially in houses where a room is reserved for the sick, perfect isolation can readily be insured. In crowded tenement rooms, however, with people in poor circumstances, all attempts at isolation almost invari- ably fail, and where the spreading of a grave, epidemic affec- tion is concerned {e.g., small-pox, cerebrospinal meningitis), should not at all be attempted. In such cases it is best to to hospital' remove the patient to a hospital for contagious diseases. The period of isolation varies, of course, with different dis- eases and the degree of severity. The following suggestions will meet the ordinary requirements as to the period of isola- tion and the principal mode of prophylaxis: — HYGIENE AND SANITATION. 89 In typhoid fever, while the disease lasts. (Disinfection of periods of ,. , n- \ isolation excreta; protection against nies.) indifferent In typhus fever, while the disease lasts. (Free ventila- diseases! 1 tion.) In miliary tuberculosis, while the disease lasts. (Disinfec- tion of excreta.) In epidemic cerebrospinal meningitis, while the disease lasts. (Disinfection of discharges.) In yellow fever, while the disease lasts. (Destruction of mosquitoes.) In relapsing fever, while the disease lasts. (Destruction of insects.) In influenza, pneumonia and pulmonary tuberculosis, while the diseases last. (Disinfection of discharges.) In bubonic plague, about one week after termination of the disease. (Destruction of vermin, especially rats; disinfection of excreta.) In cholera Asiatica and epidemic dysentery, one week after termination of the disease. (Disinfection of excreta; avoid- ance of pollution of water, milk, etc.) In small-pox, six weeks. (Vaccination, disinfection of discharges.) In chicken-pox, three weeks. (Disinfection of discharges and skin.) In measles, two weeks. (Disinfection of discharges and skin.) In German measles, two weeks. (Disinfection of dis- charges and skin.) In diphtheria, as long as diphtheria bacilli abound in the throat. (Disinfection of discharges.) In scarlet fever, while the desquamation lasts. (Disinfec- tion of discharges and skin.) In whooping-cough, while whoop or vomiting lasts. (Dis- infection of expectoration.) In mumps, three weeks. (Disinfection of sputum.) In erysipelas, two weeks. (Disinfection of the skin; anti- septic dressing. ) In gonorrheal ophthalmia or urethritis, while gonococci are found in the discharges. Before leaving the isolation-room, trie patient should receive a cleansing, hot, soap-water bath (including thorough scrub- DO PREVENTION AXD CONTROL OF DISEASE. bing- of the scalp, ears, finger- and toe-nails), and dressed anew with freshly disinfected clothing. 2. Disinfection of Excreta, of Fomites, etc. — In order to be on the safe side, the nurse should be instructed to disinfect the stools, urine, vomitus, sputum, and nasal, aural, conjunctival and vaginal discharges of the patient, regardless of whether or not they carry contagious matter. For Excreta. — Chloride of lime in powder or in solution. Four ounces of lime to one gallon of soft water. A sufficient quantity of this solution should be thoroughly mixed with the feces, urine, sputum, etc., and allowed to stand for about three hours before emptying. Sputum is best collected in paper cups or small cloths and immediately destroyed by fire. Bichloride of mercury in solution 1 : 500 — a 7^-grain tablet solutions, in a pint of water. Copper sulphate in solution (5 per cent.). Zinc sulphate in solution (io per cent.). Cresol or creolin in solution (5 per cent.). For Clothing, Bedding, Linen, etc. — Destruction by fire — the safest measure. Exposure to dry heat at a temperature of about 300° F., or moist heat at 212° F., for two hours. Boiling for at least half an hour. Immersion in a bichlorid solution ( 1 : 2000) for about three hours. Fumigation by formaldehyd (see below). For the Hands, General Body, Dishes, etc. — Labarraque solu- tion (chlorinated soda, 10 per cent.). Bichlorid of mercury in solution ( 1 : 1000). Permanganate of potash in solution (5j to a quart of water). Formaldehyd in solution (1:200). For Rooms, Furniture, Mattresses, etc. — Fumigation by For- maldehyd Gas. — It may be employed in concentrated powdered form or in pastels. For small rooms the ordinary Shering Fumigation, lamp, which is constructed for vaporizing formaldehyd pastels, will suffice. For large hospital wards, however, the "fortnal- dehyd-potassium-permanganate method" is best. It is of advan- tage to use a container consisting of a large open vessel protected from losing its heat by some non-conducting material such as asbestos. But one can get along almost equally as well by using a large milk-pail set in a wooden bucket. The infected room should be made as air-tight as possible by snugly closing the windows and doors (key-holes, ventilators, IMMUNIZATION. 91 fire-places, etc.) by means of cotton or cloths. All articles intended for disinfection are freely exposed (mattresses, pillows, boxes and drawers should be opened). The fumigating apparatus is placed in the center of the room ; 6?4 ounces of potassium permanganate (for each 1000 cubic feet ' + r . r . 1 , Formaldehyd of room space) are put in the container; and lo ounces of 40 per potassium perman- cent. formaldehyd solution (for each 1000 ^cubic feet of room ganate. space) are poured on the top of the permanganate. The operator now quickly leaves the room, and closes the door or window. The room should remain tightly closed for about ten hours. After disinfection the disagreeable odor of the formaldehyd may be removed by sprinkling the room with ammonia water, and thorough ventilation. Fumigation with Sulphur. — The procedures are the same as sulphur, with formaldehyd. The sulphur, about three pounds for a room 10 feet square, is placed in an iron pan, supported by bricks and set in a tin vessel with water. The sulphur is ignited by live coals or a tablespoonful of alcohol lighted by a match. Sulphur fumigation should not wholly be depended upon after grave epidemic affections. Finally, it is well to bear in mind that sunlight is a disin- Sunlight, fectant of great efficiency, and that prolonged exposure to its rays will materially aid in rendering rooms and fomites free from infectious matter. III. IMMUNIZATION— ACQUIRED IMMUNITY. BIO- LOGIC DIAGNOSIS AND THERAPEUTICS. Medicine is rapidly reaching the goal of its highest ambition, the prevention and control of communicable diseases by "Nature's method," i.e., immunization (see page 60). Stupid skepticism and boundless enthusiasm are gradually yielding to deliberate experimentation and experience, and it does not require a very „ 1 ... . . * Common great stretch of imagination to predict that in the near future sens< r sooa .... . t0 reign every communicable affection will be successfully resisted and supreme. combated by an antagonist evolved by the causal micro- organism. In order to obviate unnecessary repetition we will briefly describe the biologic products at present in use for diagnostic, protective and therapeutic purposes and the results thus far achieved. 92 PREVEXTIOX AND CONTROL OF DISEASE. VARIOLA VACCINE. With the enforcement of vaccination by all civilized nations small-pox, the most loathsome pestilence, has practically been eradicated from every well-regulated community. The principle of vaccination is the introduction into the human body of a vaccinia, weakened and harmless form of vaccinia, cow-pox, which renders the system immune (i.e., creates enough of antibodies to resist the disease) to variola. The vaccine is obtained from the vesicles that form on healthy young heifers as a result of inoculation with the virus of cow-pox. VACCINATION. In the absence of contraindications (see page 94) every child of from 6 to 12 months old should be vaccinated, and revac- cinated about seven years later. It is preferable to vaccinate at a time when neither excessive heat nor cold prevails, i.e., in May or October. The right arm at the insertion of the deltoid is usually chosen for the first vaccination, and the left for revac- cination. In girls the leg may be preferred to avoid the possibility of an exposed disfiguring scar. The parts to be inoculated should be freely bared and cleansed with soap- precautfons water and thoroughly dried. When one inoculation is to be made the epidermis should be abraded for about an eighth of an inch in diameter (until a serous exudate or a trace of blood occurs) by means of a sterile needle ; when several inocula- tions are to be made, they should be fully one and a half inches apart. About a drop of vaccine is then gently rubbed into the denuded surface and allowed to dry. In successful vaccina- tion the inoculated area begins to redden and swell on the signs of third or fourth day; on the fifth day a vesicle appears which vaccination, gradually changes into an umbilicated pustule surrounded by a red areola. The pustule persists up to the eleventh or thirteenth day and then becomes covered by a seal). The latter remains stationary about ten days longer, then falls oft". leaving behind a red scar which gradually becomes white and glistening in appearance. The scar usually remains visible throughout life. Vaccination is associated with more or less marked constitutional symptoms. With appearance of the vesicle there is a slight rise of temperature ; the child is restless, sleeps badly, loses its appetite, and shows other signs of indisposition. IMMUNIZATION. 93 Some children react more strongly than others, but if the vaccine is pure, the vaccinator clean and careful and the inoculated area kept free from irritation and infection, all the constitutional symptoms disappear by the twelfth day. Under adverse circum- sepsis. stances (e.g., old, impure lymph, defective asepsis, constitutional diseases) vaccination may be accompanied by very grave symp- toms. The pustules may become very large ; the redness in the vicinity very marked and extensive ; the axillary glands very much swollen and painful ; the whole arm very strongly infil- trated ; the fever very high, up to 104° F. ; and convulsions and respiratory and gastrointestinal symptoms develop. Suppuration of the glands, phlegmonous processes, and even erysipelas may set in. Finally, vaccination may be accompanied by transient or genuine nephritis, and cases of scrofula, tuberculosis and syphilis of W iatent mg are on record — undoubtedly pre-existent, latent, but awakened by or syphilis! ' the acute inflammatory process. Occasionally the inoculation wound fails to cicatrize, continues to suppurate or ulcerates. Children with a tendency to skin diseases may develop divers skin eruptions, such as erythema, eczema, lichen, impetigo, psoriasis, a purpura-like eruption (purpura vaccinatoria), general furun- culosis, or, by transference (autoinoculation) of the vaccine virus to some diseased parts of the skin, produce general vaccinia, vaccinia. (The latter may develop — usually about the seventh or eighth day — spontaneously, from within, independently of any external influences. The lesions, which may be discrete or confluent (grave), bear a certain resemblance to the regular vaccinal pox.) In the same manner the vaccine may be carried to the eyes (vaccine ophthalmia), and cause serious trouble. In fact, inoculation pustules have been observed on different portions of the bodv, and even on the tongue. Furthermore, vaccinia 1 • Aut0 - may also be transmitted to other persons by means of infected inoculation. articles in use, fingers, bed-sheets, bath-water, sponges, etc. Hence the importance of a protective dressing over the vac- cination mark (clean sterilized linen, sewn to the sleeve, changed every day) from the time the vaccine has dried up to the falling off of the scab, and of keeping the child's nails very short and its hands very clean. Bathing should be inter- rupted from the fifth to fifteenth day. Moist boric acid dress- ings are useful to reduce the severe, local inflammatory process, and where the latter is grave, and the itching intense, a con- tinuous, moist dressing with nitrate of silver ( T 4 per cent.) of silver. 94 PREVENTION AND CONTROL OF DISEASE. will prove especially beneficial. In delayed healing the wound should be cauterized with a 5 per cent, to 10 per cent, solution of nitrate of silver, and dressed like any other wound. Other complications arising should be treated according to indica- tions. Revaccination. — As already suggested revaccination should be performed about seven years after the first vaccination, a period of time after which the immunity against small-pox to guard usually ceases. In case of epidemics revaccination should be epidemics, resorted to more frequently. Revaccination is also indicated to modify an attack of small-pox. In successful revaccination the local and systemic manifestations are essentially the same as after the first vaccination except that they are much milder in form. Contraindications to Vaccination. — It is not advisable to vaccinate infants under three months, and children of all ages who are suffering from severe acute and recurrent skin affections, local or general syphilitic or tuberculous (scrofular) lesions and great debility. ANTIDIPHTHERITIC SERUM. Diphtheria antitoxin is the purified blood-serum of a horse that has been rendered immune to diphtheria by a long course of treatment with diphtheria toxin. It is specific in its effects, having mortality, lowered the high (40 to 60 per cent.) mortality from diphtheria to about 5 per cent. — if administered early and in ample quan- tity. Furthermore, those exposed to diphtheria almost invariably escape infection by timely administration of the serum. It is practically harmless if free from admixture of virulent bacteria, and with introduction of the concentrated, high-grade prepara- tions and the application of greater care in handling and adminis- tration, the numerous disagreeable accompaniments (fever, multifarious eruptions, articular swellings, etc.) have ceased to be as common and as severe as in former years. The dose of antitoxin for ordinary cases of diphtheria should Dosage, be 1000 units for every year of the child's age up to six years, to be repeated once or twice at intervals of from six to twelve hours. Malignant, especially laryngeal, cases require double doses. For protective purposes a third of the ordinary dose usually suffices. The protection usually lasts from four to six weeks. IMMUNIZATION. 95 The antitoxin is administered by a sterile hypodermic syringe (or the mercantile serum-containing syringes) by deep injection into the anterior surface of the abdomen or thorax or outer sur- precautions. face of the thigh, which are rendered aseptic by soap-water, ether and alcohol. The point of injection is subsequently sealed by sterile adhesive plaster. ANTITETANIC SERUM. Like diphtheria antitoxin, anti tetanic serum is obtained from the blood of horses previously immunized to the toxin of the tetanus bacillus. Its efficacy as a curative remedy is as yet await- ing indisputable demonstration, but its value as a preventive of tetanus is authoritatively established. Whenever there is reason to fear tetanus infection {e.g., contused or lacerated wounds — toy-pistol wounds — soiled with earth or other foreign matter) especially when an unusually large number of tetanus cases prevail, it is imperative promptly to administer tetanus antitoxin as a prophylactic measure. Tetanus antitoxin is usually administered subcutaneously in Dosage. doses of 1000 to 1500 units; the dose is repeated as a preventive measure after ten days, as a curative (3000 to 15,000 units) several times a day. In urgent cases the antitoxin may be given by intravenous, intracerebral or subarachnoid injection. ANTIMENINGITIS SERUM (FLEXNER). This serum acts specifically in cerebrospinal meningitis due to the diplococcus intracellularis (Weichselbaum) only. If used by the subdural method of injection in suitable doses, promptly and at proper intervals, it is capable of greatly diminishing the fatality generally due to the disease; of reducing the period of illness, and, in a large measure, of preventing the chronic lesions and types of the affection. After reducing the intracerebrospinal pressure by with- drawal, by lumbar puncture (see page 339), of about 30 to 60 cubic centimeters of cerebrospinal fluid, we inject 30 cubic Dosage, centimeters of the serum into the spinal canal by means of an antitoxin syringe or by gravity through a funnel and rubber tube attached to the puncture needle. The injection is repeated daily for three or four days or longer until the diplococci dis- appear. In fulminating cases a second dose may be given after the lapse of twelve hours. If after a period of apparent 96 PREVEXTIOX AXD CONTROL OF DISEASE. recovery the symptoms recur and the diplococci reappear, the injection should be repeated. The serum is practically useless in cerebrospinal meningitis after the condition of hydro- cephalus has supervened. Several other sera {e.g., antipneumococcic, antidysenteric) are now on the market. Their curative merits, however, are still unestablished. BACTERIAL VACCINES. Following upon the great researches of our contemporary pathologists, bacteriologists and clinicians, A. E. Wright, of London, has demonstrated the remarkable fact that emulsions of dead bacteria — bacterial vaccines so called — if injected subcu- taneously increase chemotaxis and, therefore, phagocytosis. The molecular group produced by the presence of the killed bacteria in the blood that renders the living bacteria of the same species a o sonic reacr y P re y to tne phagocytes he designated "opsonin/' correspond- index. ni g- to the Greek verb "opsono" — I cater for, I prepare victuals for. He also devised a method to determine the "opsonic index," or sensitizing power of the blood, so that in a given case of infection one can, as it were, measure the opsonin content of the blood and increase it, if found below par. Bacterial vaccine therapy is as yet limited to local infections, e.g., furunculosis, phlegmons, carbuncles, where the offending micro-organisms can readily be determined by microscopic exami- nation of the discharges, and accordingly the vaccine chosen to meet the indications. Of the numerous vaccines thus far recommended the staphy- J lococcus and streptococcus vaccines have actually stood the test Strepto- and r J staphyio- an d proved of great utilitv. Thev are deserving of more general coccus . ' vaccines, application. Favorable results are also on record from the use of vac- cines prepared from the bacillus coli (in colicystitis) ; from gonococci (in gonorrheal affections, especially vulvovagini- tis') ; from typhoid bacilli (in typhoid, especially as a preventive measure). The inoculations are given by means of a sterile hypodermic syringe, in the same manner as antitoxin. In children particularly Dosage, it is advisable to begin with small doses, let us say, 50 million staphylococci, or 2 million streptococci, and to increase the dose at each succeeding injection, which should occur every three to seven days. IMMUNIZATION. 97 In order to obtain prompt results it is essential to know not only the specific infecting micro-organism but also its variety, for instance, whether the offending staphylococcus is an aureus, albus, or citreus, as the employment of a different variety of vaccine is apt to prove useless. Bacterial vaccines are often prepared directly from cul- tures obtained from the individual to be treated. TUBERCULINS. These bacterial products are invaluable in the early diagnosis of tuberculosis in children. By means of tuberculin we are enabled to detect from 90 to 95 per cent, of cases of tuberculosis, often at a time when no other clinical manifestations or bacterio- logic examinations indicate its presence. It has furthermore specific the great advantage that its use calls for no complicated pro- tests, cedures, methods, calculations or instruments. The specific test is based upon the fact that on meeting with the antibodies evolved by the organism the tuberculin sets up a reaction, which is mani- fested either by a local inflammation or systemic disturbance. The tuberculin reaction may be elicited in the following manner : — 1. The Cutaneous Method (von Pirquet). — After cleansing the anterior surface of the forearm with soap-water and ether, two small abrasions (as for vaccination) or punctures of the skin are made at an interspace of about two inches. On one of the two abraded spots a drop of a 50 to 100 per cent, solution pap U i e . of Tb is applied and allowed to dry. If tuberculosis is present, a red pea- to bean-sized papule appears after from twenty- four to forty-eight hours at the point of contact of the injured skin and tuberculin, while the other non-tuberculized spot remains free from the inflammatory reaction. 2. Conjunctival Method (Calmette). — A drop of Yi to 1 per cent, (trying the weaker solution first) of old Tb solution is instilled into the conjunctival sac of one eye. In the presence of tuberculosis a positive reaction is manifested within twenty- congestion four hours by reddening of the caruncles and semilunar fold of the conjunctiva and injection of the corneal conjunctiva. The other eye remains normal. 3. Nasal Method (Wolff-Eisner and Calmette).— A cotton tampon saturated with a 1 per cent, solution is applied against the nasal septum and allowed to remain there for about ten Papules. 98 PREVENTION AND CONTROL OF DISEASE. minutes. In from eighteen to forty-eight hours a peculiar exuda- crust. tion appears which dries and forms a yellow crust upon a con- gested mucosa. From this clumps of extravasated red cells pro- ject here and there as minute reddish points. The crust generally falls off from the fourth to the sixth day. 4. Percutaneous Method (Moro). — This method is less reliable than the aforementioned procedures. A 50 per cent. tuberculin ointment is rubbed over about a square inch of epidermis until absorbed. If the reaction is positive, papules appear within from twenty-four to forty-eight hours. 5. Subcutaneous Method. — Almost never employed in young children. Tuberculin-therapy. — A very enthusiastic revival has recently taken place in the employment of tuberculin in the treatment of tuberculosis, especially of bones, joints, glands and the skin. As during the period of the tuberculin treat- ment the patients are receiving also the benefits of outdoor air, good food, tonics, etc., it is still questionable whether the results warrant the unbounded enthusiasm. However, the administration of tuberculin in minute, gradually increasing doses (%o m g-> %o m g-, /4o g m -> 1 m g-> etc., every three days, up to 1 eg. or more 1 — subcutaneously into the cellular tissues of the thorax) being harmless, there is no objection to its use in selected cases. SERUM DIAGNOSIS OF SYPHILIS (WASSERMANN).^ The substances employed in this reaction are as follows 3 : — 1. Fresh Serum of the Guinea-pig. — The animal is bled from the carotid or the femoral artery. The blood thus obtained preparation, is either rapidly centrifuged or allowed to stand for some time after first removing the upper layer of the clot which adheres to the walls of the receptacle. The separated serum floating over the clot is drawn off by means of a pipette with a rubber tube and glass mouthpiece attachments. The serum should be kept Mode of 1 Centralbl. f. Kinderheilkunde, May, 1910. - In view of its comparative simplicity, the technique perfected by Dr. J. Bauer, of Dusseldorf (La tribune med.), is here described. 3 Noguchi employs for Wassermann's reaction small squares of paper representing measured amounts of the antigen, amboceptor, and the complement, thus greatly simplifying the method and enabling the physician to perform the test in his office, provided he can procure active Noguchi test-papers. IMMUNIZATION. 99 on ice ready for use, and before using diluted with ten parts of salt solution. 2. Washed Sheep's Blood-corpuscles. — This is a 5 per cent, suspension. The blood is collected from the jugular vein of a sheep in a sterile bottle containing iron filings, to avoid coagula- tion, and is shaken for ten minutes. It is then strained through a sieve to remove the fibrin and centrifuged and washed with salt solution. This is repeated several times until the solution over the sediment remains quite clear. The liquid is then poured off and an equal (the same as it was after the first straining) quan- tity of normal salt solution is added instead, so that the propor- tion of the blood-corpuscles remains the same. From this sus- pension we prepare a 5 per cent, solution (by adding to one part of the blood mixture twenty parts of physiologic salt solution) and place it on ice ready for use. 3. Normal Human Serum. — This is obtained preferably from the blood of a placenta. The serum should be heated over a water bath up to about 130° F. to render it inactive. 4. The Syphilitic Extract. — This is prepared by triturating in a mortar 100 cubic centimeters of alcohol (96 per cent.) and 10 grammes of the liver of a syphilitic infant, allowing it to stand (well covered) over night, centrifuging, decanting the clear liquid and placing it on ice. With the mother solution of the organic extract ready, we now proceed with an experimental test as follows : Into a series of test-tubes we pour, respectively, 0.25, 0.15, 0.10, 0.05, 0.025 t E e * t perimeiltal and 0.015 cubic centimeter of the mother solution of liver extract, and to each of the tubes we add enough of physiologic salt solution to make its total content equal 1 cubic centimeter. In addition another test-tube (control tube) is filled with 1 cubic centimeter of salt solution without any organic extract. In each of the six tubes containing the extract we next pour 1 cubic centimeter of the fresh 10 per cent, solution of guinea-pig's serum, then 0.2 cubic centimeter of normal human serum heated up to about 130° F. The series of tubes is next placed in an incubator at 99° F. for thirty minutes, then each tube charged with 1 cubic centimeter of a 5 per cent, of sheep's blood-cells, and again put into the incubator for two hours. If now the con- tents of all the tubes (except, of course, the control-tube, in which the liquid should always be clear) are found dissolved, the first tube can be used, otherwise any of the remaining Actual KM) PREVENTION AND CONTROL OF DISEASE. tubes in which the solution is complete. As each tube con- tains 1 cubic centimeter of fluid and indicates the amount of organic extract therein, we can readily tell how much of the latter is required for the diagnosis. Suppose, for example, that in the experiment the fourth tube be selected as perfectly dissolved, we at once know that the quantity of organic extract needed for the test is 1 in 20. The correctness of the conclusion should be verified by repeating the test with differ- ent dilutions of the extract (1 : 10, 1 : 20, 1 : 30, etc) and several specimens of blood of healthy and positively syphilitic persons. 5. The Serum of the Patient. — The serum is obtained by puncturing a subcutaneous vein or finger with a large needle and collecting it in a test-tube. Allow it to clot; remove the separated serum; centrifuge to clearness; pipette off into another test-tube, and render it inactive by an half-hour's exposure to 130° F. Now that everything is ready for the actual test, we fill four t est - test-tubes as follow si- Tube 1. The patient's serum 0.2 c.c. The organic extract (tested) 1.0 c.c. The guinea-pig's serum (1 :10) 1.0 c.c. Tube 2. The patient's serum 0.2 c.c. Physiologic salt solution 1.0 c.c. Guinea-pig's serum (1 :10) 1.0 c.c. Tube 3. Normal hlood-serum 0.2 c.c. The organic extract (tested) 1.0 c.c. Guinea-pig's serum (1: 10) 1.0 c.c. Tube 4. Normal blood-serum 0.2 c.c. Physiologic salt solution 1.0 c.c. Guinea-pig's serum (1 : 10) 1.0 c.c. The last three ttibes serve merely for comparison to make sure that there are no accidental errors which render the test unreliable. The four tubes are shaken and placed for thirty minutes in the incubator at 99° F. To each then is added 1 cubic centimeter of the 5 per cent, suspension of sheep's blood- cells and the reaction is then watched in the incubator. Usually in tubes 2 and 4 the contents become clear in from fifteen to thirty minutes. Hemolysis then appears in tube 3. When the blood-corpuscles in tube 1 dissolve almost simultane- IMMUNIZATION. 101 ously with those in tube 3, the patient is free from syphilis. On the other hand, if the contents of tube 1 do not dissolve, the sus- pected patient has syphilis. The test is of no value unless the contents of tube 2 completely dissolve. If the contents of tube 1 dissolve imperfectly about half an hour or so after hemolysis in tubes 2 and 3, the existence of syphilis is possible, and therefore we must start the test again with tubes 1 and 2, but with smaller quantities of the patient's serum, e.g., 0.15 cubic centimeter. If this is not successful, we repeat the test with 0.1 cubic centimeter and again with 0.05 cubic centimeter of the patient's serum, endeavoring to find that combination which will allow the con- tents of tube 1 to remain intact while those of tube 2 to dissolve completely. If this is obtained the diagnosis of syphilis is still fairly certain. If the contents of tube 2 do not dissolve completely, we should add to tubes 1 and 2 from 0.1 to 0.2 cubic centimeter of human normal serum from fifteen to thirty minutes after (to make sure that the contents of tube 2 do not dissolve) the addi- tion of the 5 per cent, solution of the sheep's blood suspension. The idea is to find for tube 2 the amount of normal human serum that will exactly dissolve its contents, and then to use the same amount for tube 1. Judging by the conclusions arrived at by different clinicians, the serum reaction for syphilis is specific and found positive in from 90 to 95 per cent, of all cases with syphilitic manifestations. It is invaluable, especially in the detection of latent forms of the disease. SERUM DIAGNOSIS OF TYPHOID. (Gruber-Widal.) The blood of persons suffering from typhoid, when added to a broth culture of typhoid bacilli, arrests the characteristic move- ments of these germs and produces their agglutination and sedi- mentation. This phenomenon may be observed macroscopically in a suspension of bacteria in test tubes ; or, microscopically, when the bacteria are mixed with the blood and mounted in a hanging drop preparation. The test is generally positive in typhoid patients after the fifth day of the disease and several weeks thereafter. The blood (or serum from a blister) is obtained from the skin covering the ear lobe. After cleaning this part, the lobe is pricked with a sterile needle, and two drops of blood are placed Positive after fifth day. 102 PREVENTION AXD CONTROL OF DISEASE. on a glass slide, one near either end and allowed to dry in the air. The examination can then he undertaken any time there- after by diluting one drop of the blood in ten or twenty parts of the typhoid culture. Fii -Sta.i n Widal Reaction. (After Robin.) IV. MATERIA MEDICA AND THERAPEUTICS. (Including Hydrotherapy, Electricity, Massage, Climato- therapy and Organotherapy.) No one method of treatment suits all cases. Some diseases subside spontaneously, if left alone ; others go from bad to worse if not treated promptly and energetically. Some affec- tions yield readily to biologic remedies, others to crude drugs or synthetic pharmaceutical preparations, and again others respond to change of climate, mode of living and eating, and to remedial measures other than pharmaceutical, such as hydrotherapy, massage, electricity and the like. Our duty being to alleviate suffering, we owe it to our patients to keep pace with the advances of the time and to employ every useful method of treatment regardless of its source or charac- ter. "The period of exclusiveness is past." While a certain conservatism degree of conservatism is alwavs wise and safe, skepticism to versus Q # J r nihilism, well-tried remedies is worse than follv. HYDROTHERAPY. of water as a therapeutic agent varies with The virtue the idiosyncrasy of the patient, the temperature of the water employed, and the method of its application. Heat applied to the surface of the body produces a relaxation Dilatation of MATERIA MEDICA AND THERAPEUTICS. 103 of the vasomotor system. The cutaneous vessels dilate and become more active, diaphoresis ensues, and effete matter is eliminated. The volume of blood in the deeper structures is cutaneous biood- diminished ; hence, congestion relieved. The temperature of vessels. the body is first increased, but after free diaphoresis consider- ably lowered. Cold contracts the terminal blood-vessels and stimulates the internal circulation. It reduces the temperature of the body not . . . Contraction only by conduction but also by inhibition of heat production, of terminal Soon after discontinuance of the cold a reaction takes place, vessels. respiration becomes deep and full, more carbon dioxid is excreted and the supply of oxygen is increased. The pulse, which is at first feeble, soon becomes full and strong ; the chilliness and rigor disappear, and a sensation of warmth pervades the body surface. The blood-current in the capillaries becomes gradually acceler- ated and the internal circulation relieved of its tension. The External Use of Water. — Neither extreme heat nor extreme cold should be employed in the treatment of diseases of children. Heat should be avoided on account of the severe depression, and cold because of the shock it is apt to produce. Cold Sponging. — In the employment of cold water in the treatment of diseases of children, sponging advantageously sup- plants the cold bath. The temperature of the water should vary between 70° and 90° F. Three basins of water, one each of 70° F., 80° F. and 90° F., respectively, are placed at the bedside. The child is stripped and laid upon a blanket, and by means of cloths the surface of the body is sponged for from two to three minutes, in the following order of succession : face, neck, chest, back, abdomen, buttocks, upper and lower extremities. The warmest water (90° F.) is used first and the coldest (70° F.) last. Each part of the body should be thoroughly dried imme- diately after it has been sponged. The indications for the use of the sponge bath are hyperpyrexia and nervous irritability ; con- Antipyretic. stitutional disorders, such as anemia chlorosis, scrofula, etc., and in cases in which a general tonic effect is desired. In the latter conditions sponging should be followed by active friction. Cold Wet Pack. — The child is stripped and blankets are placed over and under it. A small sheet is dipped in water at a tem- perature of 70° to 90° F.j thoroughly wrung out and wrapped loosely around the patient. The child's body is then envel- oped in the blankets. To reduce high temperatures, for ex- 104 PREVENTION AND CONTROL OF DISEASE. ample, in typhoid or pneumonia, ice may be rubbed over the chest. The next pack is applied after an interval of ten minutes and may be repeated from ten to twelve times in twenty-four hours. The feet should be kept warm by artificial heat. Vapor Pack. — If the cool wet pack is allowed to remain in position for from one to two hours and loss of body heat pre- vented by thoroughly covering the child with woolen blankets, the cold pack is converted into a warm pack which produces effects similar to those obtained from a vapor bath ; namely, free diaphoresis, lowered activity of the nervous system, calm and repose, and equalization of the internal circulation. The vapor in nephritis, pack is, therefore, invaluable in acute catarrhal conditions of the air passages, in nephritis, dropsical effusions, muscular rheumatism, eclampsia, hyperesthesias, etc. Wet Local Compresses (Priessnitz) — Cold Compresses. — These are applied in all forms of local inflammation, to relieve pain, swelling, heat and redness. In order to obtain good results, the temperature of the water should vary between 50° and 60° F., and the compress left in place and kept cold either by frequently in local sprinkling cold water over it or by the application of an ice-bag. tions. Indications : Meningitis, angina, acute pharyngitis and laryngitis, hemoptysis, appendicitis, intestinal hemorrhage, etc. Warm Compresses. — While cold compresses delay the flow of blood and cell-activity, warm compresses accelerate the blood- current and promote cell-activity. They are applied by means of cloths immersed in water at a temperature of about 100° F., thoroughly wrung out, and then covered with flannel and rubber tissue or oiled silk to prevent rapid evaporation and cooling. The compresses should be changed as soon as they become dry. Indications : Neuralgia of the head ; throat affections after subsidence of the acute inflammatory stage, to promote absorp- in local tion of diseased products ; in exudative pleuritis ; in bronchitis. Pd spasm. to allay severe cough and to promote expectoration ; in all spasmodic conditions of the intestines ; to hasten suppuration and relieve stasis. Baths. — Tepid Bath. — This is a very useful bath in children. The temperature of the tepid bath varies between 85° F. and 92° F. It is employed in diseased conditions requiring sooth- ° Severs 6 ing, for example, in eruptive skin diseases and as an antipy- retic in infectious diseases. MATERIA MEDICA AND THERAPEUTICS. 105 Warm Bath. — In a general sense, this is the most valuable bath in the treatment of diseases of children. It tranquilizes the nervous system, equalizes the circulation, produces diaphoresis and reduces temperature. Indications : All spasmodic conditions ; affections of the lungs and kidneys; exanthematous diseases, and nervous affections, sedative, such as hysteria, etc. The temperature of the bath should vary between 92° F. and 98° F. The patient should remain in the bath for from two to five minutes. The warm bath is sometimes employed as a permanent bath, in extensive burns and wounds, and in skin diseases associated with intense itching. The patient is suspended in the bath on a sheet. The water is kept at an equal temperature by proper arrangement of inflow and outflow. Hot Bath. — The temperature of the hot bath may be carried as high as 108° F., and the patient should remain in the bath for from one to three minutes. It is very useful in collapse, con- . . x In collapse: vulsions and chronic rheumatic conditions. It is occasionally convulsions. administered to break up a "cold," and to produce rapid dia- phoresis. While in the bath the patient's head should be kept cool by an ice-bag. Shower Bath. — Cold shower baths are generally given for their stimulating effect. Hence, they are of great value in nervous affections, such as neurasthesia; in enuresis, and as a general tonic. For these purposes one shower (shock) at a time is sufficient. The shower bath should be followed by active friction. Aspersion Bath. — The value of cold water dashed suddenly over the frame or directed in a steady, broad stream upon some particular part, is very great. The cases in which such a mode of treatment is beneficial are numerous. The following are a few of the more important : Where the muscular power of a leg or arm is impaired from long inaction, as in cases of frac- ture, dislocation, bandaging, sprains and partial paralysis. The patient sits in a bath-tub or on the floor and the operator, stand- ing on a table, directs the stream of cold water upon the affected part from a watering-can from which the sprinkler has been removed. This mode of treatment is rendered particularly serviceable if the circulation is quickly restored by vigorous dry friction for several minutes. It is also efficacious in systemic poisoning from drugs, suffocation from noxious gases, etc. Nerve stimulant. Local stimulant. 106 PREVENTION AND CONTROL OF DISEASE. Medicated Baths. — Aside from the natural mineral baths obtained in the celebrated spas, which will be discussed later, a number of artificial baths are commonly used in the treatment of diseases of infancy and childhood. The efficacy of these baths is, in the majority of instances, due probably to the effects of heat or cold and friction employed with the non-medicated bath. . Iromatic Bath. — About six ounces each of chamomile flowers, calamus roots and peppermint leaves are tied up in a muslin bag stimulant, and thrown into a warm bath. Aromatic baths are recommended in marasmus, infantile spinal and other forms of paralysis, in sclerema, etc. Bran Bath. — Two or three pounds of wheat bran are boiled for about an hour in about three quarts of water. The decanted In skin diseases, liquid is added to the bath. It is useful in intertrigo, eczema, pemphigus, lichen, strophulus, etc. Malt Bath. — A few ounces of malt extract are added to the bath. Malt baths are recommended in rachitis, spasm of the glottis, and in general debility. Mercurial Bath. — This form of bath is employed as an adju- in syphilis, vant in the treatment of syphilis. It is usually prepared by the addition of 20 to 30 grains of calomel, or 0.5 to 1.0 gramme (gr. viiss to xv ) of bichlorid of mercury. Mustard Bath. — Two or three ounces of mustard are dis- solved in a few pints of tepid water and added to the bath. The temperature of the bath may vary between 100° F. to 106° F. It may be administered in the form of a sitz bath or full bath. To break J up "cold." The patient should remain in the bath for from three to ten minutes. Mustard baths are indicated in collapse, shock or heart- failure from any cause, in sudden congestion of the lungs or brain, etc. Sea-salt Bath.- — About two pounds of sea salt are dissolved stimulant, in the bath of four or five gallons of water. It is stimulating in its effects, and useful in rachitis, various forms of paralysis, etc. Soap Bath. — This form of bath is employed in the treatment diseases! ot " prurigo, lichen, strophulus, scabies, etc. It is prepared by the addition of from three to six ounces of soft green soap to five gallons of water. Sulphur Bath. — A half to one ounce of potassium sulphuret should be added to each bath. In some cases the addition of about three ounces of animal gelatin is of advantage. Sulphur MATERIA MEDICA AND THERAPEUTICS. U)- t baths are deserving of recommendation in rheumatism, eczema, prurigo, urticaria, lead poisoning, etc. The Internal Use of Water. — The benefits derived from the internal use of water are manifold, but unfortunately greatly underestimated. Water taken by the mouth in moderate quan- tities — large amounts weaken digestion — cleanses the alimentary canal, stimulates peristalsis and produces diuresis and diaphoresis. To a certain extent it acts also as a food. In acute diseases asso- ciated with anorexia the free use of water will often sustain life for weeks. In febrile dis- eases water not only quenches thirst, but aids also in the re- duction of temperature. Water stimulates expectoration, and in the form of cracked ice checks vomiting. For the latter purpose small sips of hot water are sometimes resorted to. Lavage. — Stomach washing in children is performed in the same manner as in adults. Its field of usefulness, however, is much wider. It is invaluable in cases of acute simple and toxic gastritis, cholera infan- tum, chronic indigestion and difficult feeding. A funnel with a few feet of rubber tubing, to which a small soft-rubber catheter (No. 12 or 14) is joined by means of a glass cannula, is the best apparatus for stomach washing. About ten inches of the catheter should be passed beyond the lips. The temperature of the irrigating solution should be about 100° F., or higher, if special indications arise. The quantity of solution to be instilled varies with the capacity of the child's stomach. Generally, pure boiled water answers all medicinal purposes, except in poisoning, in which instance antidotes may be em- ployed. In hyperacidity of the stomach bicarbonate of soda or lime-water may be added. Lavage is contraindicated in heart disease and hemorrhagric diathesis. In skin diseases. Fig. 28. — Stomach Tube (ca- theter, rubber tube, glass con- nection, and funnel). Contra- Indical inns. 108 PREVENTION AND CONTROL OF DISEASE. Irrigations. — The action of irrigations is chiefly mechanical. To cleanse They are indispensable in the treatment of divers affections of cavities, the lining membranes of internal cavities. In chronic cystitis, for example, washing of the bladder by means of sterile or medi- cated (boric acid, silver nitrate) water will often rapidly effect a cure. Irrigations of the vagina are frequently employed in vulvo- vaginitis. A slow current of water should be employed, per- mitting the fluid to return without injury to the adjacent parts. A fountain syringe with a small, sterile, soft-rubber catheter attached, generally suffices for ordinary purposes. The water- bag should be suspended about two feet above the child's body. Irrigations with warm, sterile water are very beneficial in car affections, such as impacted cerumen, foreign bodies in the ex- ternal auditory meatus and external otitis. In febrile diseases, adenoids, chronic pharyngitis, etc., instilla- tions of weak salt water or ichthyol solutions prevent and cure affections of the nasopharynx and ear ; it often also relieves reflex cough and embarrassed respiration. Instillation may be performed by means of a teaspoon or dropper, and should be repeated at least twice a day. Copious irrigations of the mouth with sterile or medicated (silver nitrate, hydrogen peroxid) water are invaluable in the treatment of grave forms of stomatitis. Entcroclysis. — The indications for low enemas are too well known to need further discussion. It may be mentioned, how- ever, that in habitual constipation only small quantities of water should be injected into the bowel. Large quantities are apt to produce atony of the colon by overdistention and thus aggravate the disease. High enemas are given by means of a flexible (colon) tube and a fountain syringe. High enemas not only remove effete material from the intestines, but by using water at a temperature cleanser of 80° to 90° F. also reduce temperature. Hence, they combine stimulant, two therapeutic measures, which are of signal benefit in all gastrointestinal disorders, peritonitis, typhoid, etc. Soap-suds, turpentine, starch and salt, among other adjuvants, may be added according to indications. Saline injections stimulate the kidneys and promote elimina- tion of putrid material. They stimulate the circulation and supply the deficiency of body fluids in conditions associated with an MATERIA MEDICA AND THERAPEUTICS. 109 excessive drain of fluids. Saline injections are, therefore, a 1 • • • r General sovereign remedy in uremia, typhoid fever, scarlet fever, small- stimulant. pox, measles, diphtheria, eclampsia, anemia, hemorrhages, and in shock after surgical operations, etc. A physiological (0.9 per cent.) salt-water solution at a tem- perature of from 100° to 110° F. is generally used. It should be injected slowly through a colon tube, and continued for from fifteen to twenty minutes. Saline injections are contraindicated in chronic kidney disease. Hypodermoclysis. — Subcutaneous injection of salt water (110° F.) is performed by means of an ordinary fountain syringe with an antitoxin syringe-needle attached. The needle and skin should be rendered aseptic. The injection should be made in places where there is an abundance of subcutaneous cellular tissue, for example, the anterior surface of the abdomen and thorax. The current should be very slow, and the quantity of the saline solution to be injected should vary between from two to six ounces, according to age and indications. Hypodermo- , . . , . . , , , . . ., , . In collapse, clysis is of inestimable value in cases of collapse resulting from especially , . . . . f from loss hemorrhage ; in pneumonia ; uremia ; acute gastroenteritis with of blood, great loss of body fluids ; and in leukemia. It should be pre- ferred to intravenous infusion. ELECTRICITY. Electricity as a remedial agent in the treatment of diseases of children is employed in the following forms, in the order in which they are named : Galvanic, Faradic and Static. The Galvanic Current. — The effect of the galvanic or direct current on the muscle is to produce contraction. The contraction takes place at the moment the current is closed or opened (make or break). The galvanic current, if applied by means of two electrodes along the course of a motor nerve, produces a uniform contraction of the entire muscle supplied by that nerve. The reaction produced by the constant current upon the sensory nerve varies according as the application is made with the positive or negative electrode, the anode being sedative in its effects, the cathode stimulating. A constant current of suitable strength — 10 to IS milliamperes — passed through living tissues causes, at the point of contact of the anode, an accumulation of oxygen, chlorin and acid; coagulation and shrinking of the exposed Nerve and muscle stimulant. HO PREVENTION AND CONTROL OF DISEASE. tissue — positive electrolysis. On the other hand, if the cathode is brought in contact with living anmial tissue, hydrogen and the alkalies are set free, and liquefaction of the parts adjacent to the electrode takes place — negative electrolysis. The Faradic Current. — The faradic or induced current Nerve and causes contraction of muscles and nerves and is very effective in muscle . . , T • 1 • stimulant, producing muscular massage. It stimulates nerve action and nutrition, excites secretion, and arouses latent physiological function. The Static Current. — The static current produces vivid and Tonic and P ers istent contraction of a large group of muscles with a mini- sedative. mum f p a i n . The second prominent characteristic of this cur- rent is its power of relieving pain. The following rules should be borne in mind : — 1. Always administer the weakest possible current that will cause muscular contraction. 2. Never employ electricity in the inflammatory stage of organic disease. 3. In applying electricity to muscles always endeavor to separately reach the electromotor points. In deep-seated muscles the current should be applied along the course of the nerves supplying them. 4. Each electric treatment should last no longer than twenty minutes, and no one muscle should be subjected to the currents for more than three minutes. The indications for electricity in the treatment of diseases of children are practically the same as in adults. The discussion of the subject will, therefore, be limited to diseases in which electricity is of undoubted value. Chronic Constipation. — The galvanic or faradic current may be used. One electrode is passed successively over different por- tions of the abdominal wall, and the other electrode is placed upon any other part of the body. The electric treatment should be continued for a long period. Diphtheritic Paralysis. — In this condition, faradization of the respiratory muscles, particularly the diaphragm, is of some service. It should be used in attacks of respiratory failure and continued while they last. Enuresis. — The broad anode is placed over the lumbar region of the spine and the small cathode over the region of the bladder or upon the perineum, allowing quite a strong galvanic current to MATERIA MEDICA AND THERAPEUTICS. HI act for from two to four minutes. Sometimes faradization value of proves effective. The wire end of a conducting cord, connected different 7 m with the negative pole, should be introduced into the urethral dlseases - orifice for from one to two centimeters and quite a strong faradic current allowed to act for from one to two minutes. Facial Paralysis. — This form of paralysis is greatly benefited by a weak stabile galvanic current. It should be employed four to six times a week, for from two to three minutes at a time. The anode should be placed in the auricular fossa and the cathode upon the muscles of the affected side ; or the anode may be placed behind the ear while the different nerve branches and the muscles are slowly stroked with the cathode. In later stages faradization also is of service. Hysteria. — The vague disconnected symptoms of hysteria call for general electric treatment, and no form of electricity so advantageously combines tonic and sedative effects as the static current. A mild current should be employed. Two or three treatments a week will generally suffice. Galvanism and fara- dism also are of service, especially in hysterical contractures. Multiple Neuritis. — The application of electricity to the affected muscles is important in order to maintain their nutri- tion. It should be begun after the acute stage has passed, that is, at the end of from three to four weeks. A moderate faradic current may be used if the muscles respond to it; otherwise a voltaic. The electricity should be applied daily by means of large electrodes, so that the current may reach as much muscular tissue as possible. The current should be strong enough to produce visible contraction of the muscles. Poliomyelitis.— The galvanic current gives the best results. It should not be employed earlier than the third or fourth week. A large, flat electrode, well moistened in salt water, is placed 'upon the spine over the affected region and the muscles repeat- edly stroked by means of a small electrode. The current should be of such strength as will produce visible contraction of the muscles, without, however, causing severe pain to distress the child. Rheumatism. — The sequelae of rheumatism, atrophy and con- tractures, often call for electric treatment. The galvanic, faradic or static current may be employed. It is sometimes advantageous to use the galvanic and faradic currents at one sitting. The treatment should be repeated at least every alternate day and 112 PREVENTION AND CONTROL OF DISEASE. continued for several months. In muscular contracture the anode should he placed over the portion of the spine governing the contracted muscles and the cathode over the muscles themselves. For the relief of pain the positive pole should be applied to the most painful spot. Tetany. — Electric treatment has been followed by improve- ment in a number of cases. The stabile galvanic current should be employed ; the negative pole to the spine and the positive to the irritable nerve trunks. Torticollis. — A weak galvanic current is frequently very serviceable. The positive pole should be placed just below the occiput and the negative pole allowed to act upon the contracted muscles for from five to ten minutes. The indications for electrolysis are identical with those in adults. MASSAGE. Massage is a mechanical form of treatment consisting of intelligent manipulations of the superficial parts of the body. It is intended to produce changes in the local and general nutrition, action and other functions of the body. Indications. — Massage is indicated in hysterical, paralytic, stimulant, rheumatic and traumatic contractures of joints ; in fractures, to hasten absorption of callous masses ; in chronic glandular enlarge- ments ; in swellings associated with rheumatism, sprains, con- tusion, etc.; in torticollis, to relax muscular contraction; in con- stipation, atonic dyspepsia and gastric dilatation ; in all forms of to remove muscular atrophy or dystrophy ; as a general stimulant in cases ° C factions" of prolonged muscular inactivity, whether from indolence, dis- ease, feebleness (rachitis), or prolonged use of splints or braces. or other cause ; in various forms of paralysis, to improve the nutrition and function of the affected muscles. Contraindications. — Massage is contraindicated in children suffering from gonorrheal rheumatism or peliosis rheumatica ; in tuberculous, typhoid or syphilitic ulcerations of the intestines; in acute peritonitis, appendicitis, gastroenteritis, gastric ulcer ; in tubercular glandular enlargements. Massage is generally divided into the following principal manipulations : — Effleurage or Stroking. — In making the strokes both hands are employed. The limb is grasped with one hand just above the other, in such a manner that pressure is exerted to some extent MATERIA MEDICA AND THERAPEUTICS. 113 by the whole palm, but especially the ball of the thumb and the inner surface of the last two phalanges of the fingers. The 1 • r ,- • , , Methods of strokes are delivered in the form of an ascending spiral, the two application, hands being moved simultaneously in opposite directions, the lower following closely upon the upper. The strokes must be made with great regularity. Light stroking has a soothing influence ; heavy stroking stimulates the superficial structures increasing the arterial, venous and lymphatic circulation. Friction. — This manipulation is performed with the finger- tips and consists of firm circular, semicircular, or to and fro movements. It is usually combined with effleurage and is intended to promote absorption by the veins and lymphatics. Petrissage or Kneading and Pinching. — In kneading the en- deavor of the operator is to pick up the individual mMscle or muscle-groups between the fingers of the two hands, or in some cases between the thumb and finger of one hand, and then to roll and squeeze the muscle with a double movement. These ma- nipulations cause circulatory, nutritive and alterative changes in the muscles, tendons and organs within reach. Tapotement, Percussion or Tapping. — Percussion is made either with the points of the fingers brought into a line with one another or with the side of the hand and fingers. The movement should be very rapid and elastic. These manipulations are usually employed on muscular parts, such as the back of legs and gluteal regions. The effect of tapotement is similar to that obtained by petrissage. This manipulation may be enforced also by vibra- tions, that is, by rhythmic, tremulous movements under pressure. Generally, all the movements are practised at one sitting, thus, effleurage, friction, petrissage, tapotement and vibration. The treatment is concluded by effleurage. While in local affections local massage is generally sufficient to effect the desired results, it is always advantageous to supplement the local treatment by general massage. The duration of each seance varies from a few minutes to a quarter of an hour. At first the treatment „ , ^ . Gentle should not last more than five minutes. No force should be manipulation, used, and the delicate skin of the child should be spared unneces- sary injury. It is, therefore, advisable to anoint the skin with boric acid vaselin, cocoanut oil or any other emollient. In young infants massage should lie limited to general friction of the body. In cases of malnutrition it is a good rule to give a fat-inunction daily after the morning bath. 114 PREVEXTIOX AND CONTROL OF DISEASE. CLIMATOTHERAPY. Change of climate has from time immemorial been recognized as a therapeutic measure par excellence, and, fortunately, our great country abounds with vast mountain, seashore and inland resorts, which rival, if not surpass, the most celebrated spas of Europe. In selecting a suitable health resort, we should bear in mind importance not only the state of health and the peculiarities of the individual of individ- . . . uaiization. patient, but also the local conditions of the particular resort, such as the drainage, water supply, prevalence of epidemic or endemic diseases, etc. The air of mountainous regions is rarefied, dry, cool, bracing and free from organic and inorganic impurities. It improves the Mountains, action of the skin ; favors deeper expansion of the lungs, and correspondingly accelerates the heart's action, improves sleep and stimulates the appetite and the powers of assimilation. Moun- tain air. therefore, is particularly beneficial in chronic disorders of the alimentary tract and liver ; in anemia ; in divers respiratory affections ; in malaria ; in rheumatism, and compensating heart disease. The climate of the seashore is pure and very strong. The air seashore. j s loaded with moisture, and comparatively free from dust par- ticles, hence very beneficial to convalescents from pneumonia, pleurisy and empyema; also typhoid and surgical operations. It often acts almost specifically in acute gastroenteritis. The surf-baths are invaluable in cases of nervousness, rachitis and local tuberculosis. Dry, sheltered inland resorts are to be preferred for patients Inland „ . . ,. , resorts, suffering from non-compensating heart disease; severe bron- chitis; chronic kidney disease, and all such affections as are apt to be badly influenced by sudden variations of temperature. It is often of advantage to spend part of the summer months at the seashore and part time in the mountains or inland resorts. Young children suffering from tuberculosis will, during the winter months, derive the greatest benefit from a sojourn in New Mexico and Arizona. Children over ten years old often do well in colder climates, such as the Adirondacks. MATERIA MEDICA. As already suggested, quite frequently we have to resort to drugs for the relief and cure of the patient. It is very unfor- MATERIA MEDICA AND THERAPEUTICS. 115 tunate that medical students are nowadays given so little oppor- tunity to familiarize themselves with the intrinsic value of a great number of old and new pharmaceutical products. I am firmly knowledge „-., ,. . ,.... .,. responsible convinced that so-called lvledicinal Nihilism, to a great extent, for 111-1 11 r 1 • i • • r medicinal is due to lack of knowledge of the physiologic action of the skepticism. numerous standard drugs and inexperience as to their indications and mode of administration. Palatable Medication. Palatable medication is, to say the least, highly appreciated by sick adults, and practically indispensable in the management of sick children. The physician who believes in the usefulness of the medicines he prescribes owes it to his patients that they are able to swallow and retain them. As a rule, adults manage, by means of condiments and pleasant beverages, to render drugs disgusting in taste at least acceptable. On the other hand, chil- dren are compelled to take the medicine as given to them, and what is still worse, the more they resist the more they are sub- jected to anguish and distress, nay, even to corporal punishment Force a which not infrequently borders on actual injury. Indeed, it is dangerous. not at all rare to find children suffering from acute pneumonia in a state nigh to suffocation from the effects of prolonged and firm compression of the nostrils ; and many a child bleeds from gums and lips, and loses a tooth or two through the attempts of the overzealous mother to force down into the unfortunate's throat a teaspoonful of a miserable mixture — which was, perhaps, in- tended only as a placebo. As most drugs are now obtainable as solid or powdered extracts, whenever possible, older children should receive their medication in the form of freshly prepared pills or capsules, capites Whenever the necessity arises to administer offensive fluid ex- tracts or tinctures, essential oils and the like, it is best to order them in what I may venture to call "home-made liquid capsules." The liquid medicine and the empty gelatin capsules are prescribed separately, and the patient is directed by means of a dropper to prepare each dose of medicine just before taking it. These "home-made liquid capsules" are quite a boon to patients who are averse to taking nauseous mixtures. By means of these capsules you can readily administer also the tincture of iron chloride, which in solution exerts a very destructive effect upon for older 116 PREVENTION AND CONTROL OF DISEASE. the teeth ; or the different hygroscopic medicinal agents, such as the iodides, bromides, chloral, etc. Unfortunately this convenient way of dispensing non-palat- able drugs to older children cannot be taken advantage of in selection prescribing for small children. Hence, an attempt will here be palatable made to devise other means, based chiefly upon the selection of the fittest and most useful preparations, which will enable the physician to render the giving and taking of medicine an act of benevolence rather than an act of cruelty. For the sake of convenience and in order to avoid repetition the usual classification of drugs in accordance with their thera- peutic effects will here be followed. Digestants. — Most of the so-called appetizers and digest- ants, such as the pepsin and pancreatin preparations, can be made pleasant in taste by the addition of sugar or in solution with sweet wine or simple elixir. Bitter Tonics. — The simple bitters fully deserve their cog- nomen, since they are certainly very bitter, and simple, insignifi- of nttie cant, in their therapeutical effect. The tinctures of gentian, 1111 value, quassia, and calumba owe their medicinal value chiefly to the alcohol they contain. Their use should, therefore, be discouraged, and. if alcohol be indicated, pleasant wines preferred. Of the so- called peculiar bitters, the cinchona preparations are the chief representatives. As their disgusting taste can almost never be disguised, they should never be prescribed for small children, unless intended as an antimalarial. In malarial conditions qui- nine can best be given by rectum in the manner suggested by me about nine years ago. A half to one dram of quinine sulphate or bisulphate and a few grains of salt are mixed with the white of an egg, and by means of a large glass syringe and wide but short rectal tube injected into the bowels. The white of egg prevents irritation of the intestine, and together with the salt aids in the absorption of the quinine. Older children should be coaxed to take quinine in freshly prepared capsules. The newer "tasteless" quinine preparations are also deserving of trial, and children not averse to bitter medicines can frequently be induced to take quinine in solution with the syrup of verba santa. or licorice, or in powder form in sweetened chocolate. The different liquid iron preparations, such as the official wine and the tincture of the chloride, may be rendered palatable MATERIA MEDICA AND THERAPEUTICS. 117 by the addition of glycerin, syrup of orange, and water. Pow- dered iron goes well with sugar and chocolate. Mineral Acids. — Insufficient attention is being paid to the medicinal properties of mineral acids in the treatment of diseases of infancy and childhood. These acids advantageously replace instead bitter tonics and act specifically upon the alimentary canal and tonics. 61 " osseous system. Children like the taste of most of them if well diluted in sweetened water or in combination with raspberry or orange syrup and water. Alteratives. — Arsenic, iodine, and mercury are the leading remedies of this group. Arsenic is best exhibited as Fowler's solution in plain water. Syrup of iron iodide with simple syrup forms a palatable and very useful hematinic and alterative for children. Sodium and potassium iodide may be prescribed in peppermint or orange-flower water with a little simple syrup, or in compound syrup of sarsaparilla, or elixir of taraxacum. The same holds good for corrosive sublimate. Calomel, the prac- titioner's panacea, is readily taken by children in powder form with a pinch of sugar. Cod-liver oil, the almost indispensable tissue builder in all wasting diseases of children, is the stumbling block of the phar- maceutical reformer. Do what you please, cod-liver oil always tastes like cod-liver oil as long as there is any in the mixture. In infants cod-liver oil may be tried by inunction. The majority of children can be ''bought" to like the following emulsion : — B- Cod-liver oil 4 ounces | 120. Extract of malt, Syrup of calcium hypophosphite aa 1 ounce I 30. Glycerin, Powdered acacia aa. y 2 ounce | 15. Cinnamon water q. s. ad 8 ounces | 240. Antipyretics and Antirheumatics. — The best antipyretic for children is water, externally and internally. If coal-tar products the'best and the salicylates are indicated they may be administered in antipyretlc - powder form triturated with a little sugar to which a minute quantity of essence of peppermint may be added to impart its taste. In prescribing sodium salicylate in solution its nauseating sweet taste may be disguised by a drop or two of the tincture of mix vomica. Hypnotics and Anodynes. — The selection of pleasant hyp- notics and anodynes is rather difficult, and perhaps fortunately so, in view of the very deleterious effect they exert upon the 118 PREVENTION AXD CONTROL OF DISEASE. delicate infantile organism. However, sometimes they are indis- poses! pensable, and in minute doses can readily be made palatable. This is particularly the case with the deodorated tincture and the wine of opium, which can be rendered more or less pleasant in taste in a mixture of glycerin and orange-water. The camphor- ated tincture of opium is a safer preparation for infants and may be prescribed in althea syrup and water. In dispensing the dif- ferent morphine derivatives, it is advantageous to add a little syrup or powder of acacia to the mixture in order to avoid the formation of a sediment. In excessive irritability of the stomach, the opiates, the bromides, chloral and the newer hypnotics should P an(fhv U o- ^ e administered by rectum, and on rare occasions morphine may dermaticaiiy. a i so b e gi ve n hypodermatically. Antispasmodics. — Belladonna is the principal drug of this group ordinarily employed in diseases of children. The fluid extract tastes fairly well in combination with licorice and water. Spirit of camphor can be made quite palatable in syrup of wild cherry or simple elixir, and the powdered camphor loses part of its miserable taste in chocolate. The emulsion of chloroform and the compound spirit of ether are useful antispasmodics, and fairly palatable in syrup of orange, or almond, and water. Stimulants. — Nux vomica, strychnine, ammonia, alcohol, strophanthus, caffeine, digitalis, and sparteine, all call for skill- Extr a C nd ^ compounding to make them at least acceptable. The extracts alkaloids. an( j alkaloids should at all times be preferred to tinctures, infu- sions, or decoctions. Thank heaven ! the times have passed when the greatness of the physician stood in direct ratio to the great quantity of medicine he prescribed ! As quick circulatory and respiratory stimulants the ammonia preparations, such as aro- matic spirit and the anisated solution, are very agreeable and effi- cient. It is truly sinful to prescribe ammonium chloride instead. Heart Sedatives. — There are but few occasions when these drugs are of actual benefit to children. Aconite, the standby of the homeopath, may be given in homeopathic doses well diluted Dangerous m sweetened water. Aconite, like digitalis, is a dangerous drug remedies. j n t h e i ian( j s f the ignorant. The indication for aconite is sthenic fever, and there are not many children too vigorous while sick. Bitter-almond water in small quantities and well diluted is a use- ful addition to a palatable cough mixture. The same may be said of compound syrup of squill. MATERIA MEDICA AND THERAPEUTICS. 119 Emetics. — Although intended to disgust the patient, most emetics are not disgusting in taste. The wine of ipecac, requiring but small doses to produce the desired results, should be pre- ferred to the syrup or infusion. Whenever a quick emetic is indicated, apomorphine may be used hypodermatically, but very cautiously. No special effort need be made to make emetics for emesis. palatable. It is to be regretted that emetics are dropping into disuse, since many cases of acute gastritis can be arrested in their incipiency by the timely administration of an emetic. Laxatives, Cathartics, and Purgatives. — Very few of the many members of these groups are being employed in the chil- dren's practice. Calomel and aromatic syrup or tincture of rhubarb answer the purpose in most cases. If castor oil is par- ticularly wanted, an emulsion may be made of the following ingredients : — IJ Castor oil 1 ounce | 30. Oil of peppermint 5 drops Sugar 1 dram 4. Mucilage of acacia and water q. s. ad 2 ounces 60. Rochelle salts with a little aromatic spirit of ammonia, glyc- erin, and water form a pleasant mixture. Podophyllin and aloin are best prescribed in suppositories of cacao butter. Finally, enema" S it is well worth remembering that an enema of soapsuds often dispenses with drugging. Anthelmintics. — Santonine and calomel, the most efficient vermifuges, are readily taken by children either pure or with a little sugar or chocolate. Their effect is greatly enhanced by enemas of soapsuds and turpentine, or a decoction of quassia wood. All teniafuges are very disagreeable in taste and irritating to the stomach. Male fern, the most active teniafuge, may be exhibited as follows : — B Ethereal extract of male fern 3 drams I 12. Emulsion of chloroform 4 drams j 15. Emulsion of almond q. s. ad 2 ounces | 60. Failure to expel the worm is often due to the fact that an Fresh oleoresin is used which is prepared from old male fern. drug - Diuretics and Diaphoretics. — Water is the most palatable and, in many diseased conditions, perhaps, most useful diuretic. Tt should always be thought of before resorting to offensive ^afuretic. medicinal combinations. The alkaline diuretics, such as ammo- nium, potassium, and sodium acetate, as well as potassium 120 PREVENTION AXD CONTROL OF DISEASE. citrate, the lithium preparations and sodium benzoate, may be rendered palatable in any medicated water with a little syrup. I believe that sodium benzoate is not receiving due recognition as benzoate. a therapeutic agent. Being an active diuretic, diaphoretic, expec- torant, and antirheumatic, it forms, as fully demonstrated by me ten years ago, an ideal remedy for the grip and similar acute affections. The mode of rendering the "hydragogue" diuretics and "special" diaphoretics more or less pleasant in taste has been suggested when speaking of the "heart stimulants and sedatives." I may also add that high intestinal irrigation often advantageously supplants the internal administration of drugs. Expectorants. — Anisated solution of ammonia, compound syrup of squill, and wine of ipecac, which have already been referred to, are quite palatable and efficient expectorants. To these may be added syrup of senega, tincture of cubeb, com- pound mixture of glycyrrhiza, syrup of wild cherry, syrup of Tolu, and syrup of althea ; the last-named syrups serve also as creosote excellent adjuvants. Creosote, the most valuable remedy in pro- eS reme(fy. tracted coughs due to pharyngeal, laryngeal, and bronchial catarrh, is fairly palatable in a mixture of glycerin and sherry wine or elixir aurantii. Astringents. — It will usually be found that bismuth and chalk mixture will do well in most cases where astringents are indicated. The following is a pleasant combination : — R Bismuth subnitrate or subcarbonate 4 drams | 15 Chalk mixture 4 drams | 15 Glycerin 3 drams | 12 Syrup of acacia 2 drams ] 8, Peppermint water q. s. ad 2 ounces | 60 Krameria and tannic acid are best administered in enemas of starch and water. The different newer tannin preparations may be given by mouth with aromatic powder or peppermint sugar. Gastric Sedatives. — Last in line but primary in importance are the gastric sedatives, since a highly irritated stomach will often reject even the most palatable medicine. Cracked ice, cold or hot water, calomel and sodium bicarbonate, lime, peppermint, or bitter-almond water, small doses of bismuth and cerium oxalate, minute quantities of tincture of iodine well diluted in plain or medicated water — are all useful and more or less pleas- Lavage ant gastric sedatives. In continued vomiting of infants lavage advantageously supplants drugging. MATERIA MEDICA AND THERAPEUTICS. 121 In administering medicines to infants it is often very helpful to divide the regular dose into several smaller doses, giving it, Drop by if need be, drop by drop until the whole dose is consumed. In doses. this manner the most irritable stomach will frequently retain the medication where it would otherwise reject it. Before prescrib- ing any nauseous medicine the physician should always bear in mind the grand dictum of Hillel, "What is hateful to thee, do not unto thy fellow-man." Finally, let us remember that a great many drugs can now- adays be administered hypodermatically, a method of medication which is especially advantageous in the treatment of very sick children. ORGANOTHERAPY. Organotherapeutics, though still in the experimental stage, is rapidly assuming an enviable position in the field of specific medication. This is true especially of the thyroids, and less so of the suprarenals, pituitary and thymus glands. Their modus operandi upon the human economy — whether by Regulates regulation of metabolism, or neutralization of specific poisons — is and •11 1 11- t • r • 1 11-111 neutralizes still shrouded in mystery. It is definitely established, however, poisons, that they are all of fundamental importance to the health and growth of the human organism. Furthermore, evidence is grad- ually accumulating which goes to prove that : — 1. Absence, atrophy or degeneration of the thyroid gland is • • , • r -1- Cretinism. followed by cretinism and infantilism; 2. Absence or disease of the parathyroids gives rise to a state of tetany and disturbance of calcium metabolism 1 ; 3. The suprarenals exert a powerful influence over the dorso- lumbar sympathetic nerve system and upon the circulation (Addison's disease is generally associated with involvement of the suprarenals) ; 4. Hypertrophy, and particularly tumors of the hypophysis Gigantism are productive of gigantism or acromegaly, and, finally, 5. Hypertrophy of the thymus gland is usually associated with ^fp^ atlcus "status lymphaticus." From a therapeutic point of view the thyroid gland only has thus far met all expectations. It acts specifically in cretinism and Myxedema, myxedema, and is very serviceable also in obesity and pachyderma- 1 Tetany and calcium deficiency forming conspicuous phenomena also of rickets, there is probably an etiologic relation between this disease and the functional incapacity of the parathyroids. 122 PREVEXTIOX AND CONTROL OF DISEASE. toses. The gland may be administered fresh (in soup) or dry. The dry preparations are usually given in from l / 2 - to 3-grain doses twice daily, until the desired results have been obtained and in smaller quantities thereafter. Engrafting of the sheep's thyroid in the human body has met with some success. The para- thyroids are generally employed (gr. y i0 to %) as adjuvant or substitute of the thyroid. The suprarenal solutions are used principally locally as hemo- Hemorrhages. static and astringent, e.g., epistaxis, rhinorrhea of divers origin. Internally, usually hypodermatically (5 min. of a 1 : 1000 solu- tion) ; its action resembles that of digitalis. The pituitary gland is highly recommended (gr. /4) in infan- infantiiism. tilisrn, in hay-fever and asthma (topically as well is internally). The therapeutic application for the thymus gland is thus far limited to pronounced anemias and marasmus. The results are encourasfino'. CHAPTER III. Congenital Malformations. Congenital malformations depend upon the following causal factors : — ■ 1. Hereditary disposition {e.g., supernumerary fingers and toes). 2. Antenatal constitutional diseases, especially syphilis and tuberculosis {e.g., hydrocephalus and spina bifida). 3. Traumatism during pregnancy {e.g., multiple fractures and dislocations). 4. Extra- or intra-abdominal pressure through pelvic deformities, tumors, etc. {e.g., talipes). 5. Constriction by amniotic bands {e.g., amputations). CONGENITAL MALFORMATIONS OF THE HEAD. MICROCEPHALUS. We distinguish two varieties of microcephalus : One, which appears as a genuine brain dis- ease and is the result of antenatal structural disease of the brain (inflammation, sclerosis, cystic degeneration) ; the other, which presents itself in the form of a miniature brain (abnormally small, but not necessarily dis- eased), is due to congenital arrest of development and leads to premature synostosis of the bone sutures of the skull. Microcephalus as a brain dis- ease presents typical symptoms of "cerebral paralysis" at birth or soon after. The child suffers from convulsions, rigidity of the entire body, anomalies of sensi- bility, involvement of the cranial J ' , , .. , , lMg. 29.— Microcephalus— brain nerves and later disturbances of disease. (Sheffield.) (123) Symptoms of cerebral paralysis. 124 CONGENITAL MALFORMATIONS. locomotion and signs of mental degeneracy, the latter symp- Mentai toms gradually getting worse. The head is small compared with backward- ° " , , ., , , . ,, _. , ness. that ot a normal chila, but not exceptionally so. On the other hand, in miniature brain, the mental deficiency predominates while the physical signs are comparatively slight and are apt to improve as the child grows older (see page 570). Treatment by means of massage, electricity and baths may improve the paralytic symptoms. Fig. 30. — Microcephalus — miniature brain. (Sheffield.) Large CONGENITAL HYDROCEPHALUS.! Hydrocephalus is recognized chiefly by the increased size of the head. The enlargement is not always symmetrical on the head, two sides. All are more or less plagiocephalic, but some are rounded and brachycephalic and others dolichocephalic or scaphocephalic. Hence, the measurements of the head must embrace not only the transverse diameter from one mastoid process across the vertex to the other, and the longitudinal See ''Acquired Hydrocephalus," page 516. CONGENITAL MALFORMATIONS OF HEAD. 125 diameter from the glabellum across the vertex to the occipital tuberosity, but particularly the circumference — with the glabellum and occipital tuberosity as centers — the measure- ment of which greatly exceeds that of the normal child (see page 4). Due allowance, however, should be made for the increased measurement observed in rickety projection of the Congenital Hydrocephalus. (Sheffield.) parietal bones. In the typical hydrocephalic the fontanelles are widely open, the sutu pressure with the finger, usually to a muc than in rachitis. The head sometime size, so that the child is often unable to noia i up — to and fro and From side to side'— and contrasts strangely with the delicate, emaciated face. The skin of the head is very thin eparated and the bones yield to °Pf n fon ^ a - J nelles and attains an enormous like . , consistence hold it Up — it shakes of cranial bones. 126 COXGEXITAL MALFORMATIONS. and tense and traversed by dilated veins. The orbital plates are pushed downward and the eyeballs forward, so that the lids remain partially retracted, leaving- a ring- of the sclerotic exposed. Hence the peculiarly staring expression, which is greatly exaggerated by the not infrequent accompaniment of strabismus, nystagmus, and optic atrophy — the result of pressure. The brain symptoms of true hydrocephalus depend upon the amount of cerebrospinal fluid and relative size of the skull cavity and the resultant pressure atrophy of the brain. Where the brain remains unimpaired, the child may grow up apparently healthy in mind and body. This may occur, though less fre- quently, also with cases in which the disease comes to a standstill. In the majority of instances, however, the symptomatology of hydrocephalus is very definite and progressive in character. Defective Vision and hearing are frequently defective; intelligence is vision, fe 1 - 'to hearing and impaired and ranges between simple dullness up to total idiocv. intelligence. r ° t t r ... Not rarely hydrocephalus is associated with paraplegia, epilepti- form attacks, disturbance of the motor functions and spastic symptoms; contractures of the upper extremities, spasmus glottidis, and similar spasmodic manifestations. In congenital cases the course of the disease is rapid and death usually occurs in the first few Marasmus, months of life in consequence of marasmus (notwithstanding good appetite and perfect digestion), intercurrent diseases, convulsions and coma. The prognosis is most favorable in syphilitic hydrocephalus, especially if specific treatment is begun early. Antisyphilitic medication should be tried in all cases spinal and irrespective of cause, and where the exudation is marked this puncture, should be supplemented by lumbar puncture (once a week), or possibly puncture of the lateral ventricles followed by firm but strapping, even strapping of the skull. Cases of hydrocephalus with idiocy, spina bifida, etc., are best left alone. CEPHALOCELE (HERNIA OF THE BRAIN). Meningocele, Encephalocele, Encephalocystocele or Hy- drencephalocele. — Congenital defects in the cranial bones permit the protrusion of a portion of the contents of the skull. The hernia may consist of : — CONGENITAL MALFORMATIONS OF HEAD. 127 (a) Meninges (which form the hernial sack) with or with- ^ e f r r e n ^ ia " out cerebral fluid — Meningocele. 1 talse . u meningocele. (b) Meninges and brain substance — enceplialocele. (c) Meninges and brain substance, which enclose a cavity which is filled with fluid and communicates with a cerebral ven- tricle — hydr enceplialocele or encephalocystocele. In accordance with their location we distinguish the following forms of cephalocele : — (a) Cephalocele occipitalis superior — situated above the ex- ternal occipital protuberance. (b) Cephalocele occipitalis inferior — situated below the pro- tuberance. (c) Cephalocele nasofrontalis — emerges from above the nasal bones. (d) Cephalocele nasoethmoidalis — situated below one of the nasal bones. (e) Cephalocele naso-orbitalis — appears at the inner angle of the eye. The presenting tumor varies in size from a small nut to a fetal head. It may be flat, sessile, hemispherical, pear-shaped or pedunculated. Small tumors are soft and elastic, larger ones pulsate and are often translucent. They enlarge during crying, and may be reduced in size by compression, — a procedure which is usually attended by meningeal disturbances. By bearing in mind the characteristic signs, there ought to be no difficulty in differentiating cephaloceles from extracranial cysts, hematomas, abscesses, etc. The diagnosis may be facilitated by an X-ray examination, showing the edges of the opening in the bone. Cephaloceles may remain small and give rise to but very little disturbance. As a rule, however, they grow rapidly and produce death from meningitis, convulsions, or rupture, or proceed a slower course manifested by more or less pronounced backward- ness in physical and mental development and other evidences of organic brain disease. Small cephaloceles require no surgical interference, but merely protection against external injuries by suitable caps, etc., Reducible on pressure. 1 Congenital meningocele is not to be confounded with acquired so-called pseudomeningocele or meningocele spuria s. traumatica, which is either a result of trauma during delivery or a carious process, especially syphilis. Here the tumor is usually situated at one of the parietal bones, increases in size with the development of the brain or enlarge- ment of the cleft in the bone. 128 COXGEXITAL MALFORMATIOXS. Reposition or g en tl e compression after reposition of the protrusion. Inoper- .mpression. a ^\ Q cases are those complicated by pronounced flattening or diminution in size of the skull, by hydrocephalus or other serious malformations, or where the cleft in the skull reaches down to the foramen magnum. In all other cases removal of the growth is the only proper treatment, followed, if necessary, by osteoplas- tic closure of the defect in the skull. The operation is not rarely successful, if performed by a skillful surgeon, and, in view of the extremely grave prognosis Earl r in large tumors if left alone, there is sufficient justification for operation, early ( I) surgical interference. CONGENITAL MALFORMATIONS OF THE FACE. Including those of the Palate, Mouth, Eyes, Nose, and Ears. CLEFTS OF THE FACE AND LIPS. 1. Median, the result of non-union of both globular processes of the central nasal process. This cleft is rarely extensive. 2. Lateral (Labium Leporinum, Harelip, Cheiloschisis), pro- duced by failure of union of one or both globular processes with the superior maxillary processes. Clefts of the upper lip may accordingly be unilateral or bilateral, may exist as a mere notch into the skin margin of the lip, or more fre- quently extend for some distance upward, involving the whole lip, nostril and upper jaw. It is occasionally asso- ciated with cleft palate. 3. Oblique (Meloschisis), arises from defective closure of the groove between the lateral nasal process and the superior maxillary process. The cleft runs as high as the lower lid. 4. Transverse ( Macrostoma ), as a result of patency of the groove between the superior maxillary process and the first branchial arch (mandibula). Occasionally fistules and fissures are observed in the bridge of the nose and lower lip. treatment! For details of treatment the reader is referred to text-books on Surgery. CLEFT PALATE (PALATUM FISSUM, PALATOSCHISIS). It is due to defective union of the processes of the superior maxillary and palate bones which during intra-uterine life nor- mally grow inward to meet the vomer in the middle line and the intramaxillary bone in front to form the hard and soft palate. CONGENITAL MALFORMATIONS OF FACE. 129 1. Complete (Uranoschisma). — The fissure extends in the mid- dle line through the uvula and the soft and hard palate, and thence through the alveolar process in the line of suture either on one or both sides of the intramaxillary bone. It is generally combined with double or single harelip, and is wolfs then designated "Wolf's Jaw." jaw- Hare-lip. (Sheffield.) 2. Partial ( LTanocoloboma). — It may involve the uvula only, or part of the soft and hard palate as well. Sometimes it is limited to mere notching of the alveolar process on one or both sides and forms the continuation of uni- or bi-lateral harelip. The consequences of cleft palate, if extensive in degree, are by far more serious than those of cleft lip. Suction and deglu- tition are greatly interfered with. In older children the voice, articulation, sense of taste, smell, and hearing may all be impaired. The management of cleft palate is principally surgical. The Difficult feeding. 130 COXGEX1TAL MALFORMATIONS. earlier the operation is undertaken the more perfect are the operatioif resu ^ s - The mode of feeding frequently presents great diffi- culty. Infants born with marked cleft palate who are unable to nurse have to be fed artificially either with the spoon or through a tube passed through the nose into the stomach. A rubber plate covering the defect in the palate often acts admirably DEFECTS OF THE MOUTH AND TONGUE. Atresia Oris (Microstoma). — The lips may be grown together partially or completely. In the latter event an immediate plastic operation is inevitable. Congenital microstoma should not be confounded with the acquired contractures of the oral orifice resulting from syphilis, gangrene, burns, etc. Adhaesio Linguae (Ankyloglossia, Tongue-tie). — It is pro- duced by a large and anteriorly displaced frenulum, and varies greatly in degree, the insertion of the frenulum sometimes extend- ing so far forward as to interfere with suckling and, later, with speech. The anomaly may be removed by nicking the frenulum with a scissors, and further "loosening of the tongue-string" with the finger, thus avoiding injury to the ranine artery (dangerous in hemorrhage, hemophilia). The rare adhesion between the epithelial surfaces of the tongue and floor of the mouth can be liberated in a similar manner. Macroglossia (Large Tongue). — Enlargement of the tongue may be due to a true lymphangiomatous tumor (cavernous macroglossia), or to a fibrous hypertrophy (fibrous macroglos- sia). Both forms may coexist. The tongue may be so markedly enlarged as to find no room in the mouth, and by protruding from it become bruised, chapped and cracked, assume such dimensions as to render suckling very difficult or impossible, and possibly lead to a fatal issue from inanition. Congenital macroglossia tions e from from the aforementioned causes is not to be mistaken for pro- trusion of the tongue associated with cretinism. Mild degrees of macroglossia usually improve spontaneously, with the growth of the oral cavity; severe forms call for removal of a wedge- shaped piece of the protruding tongue. MALFORMATIONS OF THE EYES. Anophthalmus (Absence of One or Both Eyes). — This is a rare malformation. In a great many cases careful anatomic f-retini CONGENITAL MALFORMATIONS OF FACE. 181 examination reveals the presence of rudimentary eyes. If only one eye is absent the existing eye may be perfectly normal or defective in various ways. Microphthalmus. — An adbnormally small eye causes more phthalmia. (Sheffield.) or less severe disturbance of vision which may in some instances Eyeglasses be relieved by suitable glasses. It is sometimes associated with adhesion of the edges of the eyelids (ankyloblepharon, cryptoph- thalmus), and other abnormalities of the bulb, which may require S-eltmenl surgical treatment. L32 CONGENITAL MALFORMATIONS. Atresia Pupillae Congenita. — Occasionally the pupillary mem- brane persists after birth and varying with its extent leads to more or less grave defective vision. The fine, gray membrane Differentia- mav be mistaken for an exudation or capsular cataract. Spon- tion from .atarait. taneous improvement is the rule. Cataracta Congenita. — It is usually partial, rarely complete. It may exist in the form of limited opacities and not be recognized until school age. In the complete variety the condition may present a white pupil. Coloboma Iridis (Iridoschisma, Fissure of the Iris). — It is usually bilateral and sometimes associated with coloboma of the choroid, fissure of the upper eyelids without involvement of the external skin, microphthalmus, and cataract. If uncomplicated, it disturbs vision but slightly. Irideremia (Aniridia). — Partial or complete absence of the iris usually occurs on both sides and is associated with abnormal- ity of the cornea and poor vision. The pupils are iridescent like cats' eyes, and owing to too strong perception of light, the affected children convulsively open and close the eyelids. The same Albinism, phenomenon is often observed in albinism — a condition in which there is a congenital deficiency of pigment in the iris and choroid. Albinos have a blue iris and very fair complexion. E of 1 iight! Exclusion of superabundance of light by means of dark glasses or artificial diaphragm. MALFORMATIONS OF THE NOSE. Adhesions between the turbinated bones, particularly the inferior, and the septum. The adhesions may be membranous or bony, and not rarely associated with deflection of the septum. The treatment is the same as in the acquired conditions. Atresia of the Posterior Nares. — The closure may be mem- branous or bony ; in the latter condition there is bony union between the palate and the sphenoid. If the closure is only moderately firm, it can be perforated by a stout probe or Difficult galvanocautery. Firm bony union giving rise to difficult suck- suckiing. ling calls for the employment of chisel and mallet or trephine, using tlie finger in the nasopharynx as a guide to prevent the instrument from penetrating too deeply. MALFORMATIONS OF LARYNX AND TRACHEA. 133 MALFORMATIONS OF THE EAR. Fissures and Fistulas of the Ear. — Fissures (beneath the tail of the helix) and fistula (in front and above the tragus) are occasionally observed, especially in connection with other con- genital malformations. Deep fistula; sometimes secrete a serous fluid, not rarely causing intractable eczema and requir- ing operative interference. Auricular appendages in the form of scattered round or oblong, smooth or warty pieces of cartilage are not rarely found in front of the ear. They can readily be removed by knife or cautery. Ear prominence is a malformation which can often be remedied in the newly born by keeping the ear properly bandaged for several weeks. Sometimes it calls for a slight operation. Atresia auris, absence of the auditory meatus, is most fre- quently complete, involving the cartilaginous as well as the bony often portion of the canal. Moreover there is usually also an abnormal tympanic cavity. Hence very little benefit can be expected from operative interference. All sorts of ear deformities are encountered in connection with idiocy and the allied mental deficiencies (q. v.). MALFORMATIONS OF THE LARYNX AND TRACHEA. Congenital Diaphragm of the Larynx. — The glottis is more or less occluded by a membrane running transversely across the vocal cords. The symptoms stand in direct relation to the size of the remaining opening. In marked cases the membrane should be excised after pre- liminary tracheotomy. Laryngocele and Tracheocele (Aerocele). — The tumor is situated laterally or in the median line. It increases in size on abnormal tympanun Enlarges on coughing or crying and diminishes on pressure. crying or The treatment consists of excision of the cyst and closure of the communication with the respiratory tube. Stridor Congenitus (Child-crowing). — This congenital anomaly is not to be confounded with laryngospasmus (spasmus glottidis. see page 562), which is an acquired affec- tion and forms a symptom of spasmophilia (q. v.). The etiology is still indefinite, though in a number of cases the 1:11 CONGENITAL MALFORMATIONS. stridor could be traced to malformation of the epiglottis and hypertrophy of the thymus gland. Stridor congenitus is manifested by a loud, crowing inspira- tion, accompanied by retraction of the jugulum and epigastrium, from It is free from cyanosis or any systemic disturbance, and usually subsides spontaneously in the course of a year or so. MALFORMATIONS OF THE NECK. Fistula Colli Congenita. — It is a rare anomaly, the result of defective closure of the second and third branchial arches. The fistula is situated either laterally immediately above the sternoclavicular articulation or medially at a varying level be- tween the hyoid bone and the jugulum. The fistula becomes apparent by its fine, pinhead-sized opening with an irregular, moist surface. By passing a fine probe the fistula is found to end either blindly or in the pharynx or esophagus. As long as its track is free, the fistula gives rise to no serious symptoms. Its occlusion, however, is associated with danger of retention of the mucoid secretion and cyst formation. Hence the indication for complete extirpation of the fistulous canal. Branchial Appendages. — They occur in the shape of warts, nipples or mushrooms, along the margin of the sternomastoid, between the sternoclavicular region and the hyoid bone, consist of skin alone or of skin and cartilage, and are frequently asso- ciated with auricular attachments (q.v.). They cause no annoy- ance except from a cosmetic point of view. They are readliy removable and non-recurrent. Branchiogenetic Cysts. — The seat of these variously sized (from a small nut to a hen's egg), elastic, serous, seromucous, sebaceous, sometimes dermoid cysts is the anterior region of the neck (in the middle line or at the side). The cyst contents may infection, become purulent through infection or sanguinolent through involvement of a blood-vessel. Aspiration is a useful aid in the diagnosis, and extirpation of the cyst the only rational mode of treatment. Hygroma Cysticum Colli Congenitum (Lymphangioma Cysticum). — This tumor consists of a number of small or large communicating or non-communicating cysts. It varies in size from a slight swelling under the lower jaw or over the clavicle to an enormous tumor embracing the whole neck, and extending Differentia- tion from exostosis or spondylitis. MALFORMATIONS OF THORAX. 135 downward to the chest and upward to the face. It may even involve the mouth, throat, base of the cranium and mediastinum. In the latter event the prognosis is extremely grave. As the removal of large tumors is attended by great difficulties, it is often justifiable first to try aspiration with subsequent injection of iodine or incision and antiseptic packing. Small hygromas should unhesitatingly be extirpated. Cervical Rib. — The supernumerary rib is a hard, bony clasp which begins at the seventh cervical vertebra and either ends there as a small protuberance or continues farther to join the first thoracic rib, or even the sternum. The symptoms depend upon the degree of pressure exerted by the cervical rib upon the Pressure neighboring structures, especially the subclavian artery and some branches of the brachial plexus. Cervical rib may be confounded with exostosis of the first rib, tumor (also tuberculous glands) in the supraclavicular fossa, or cervical spondylitis. Exostosis and spondylitis are best diagnosed by means of a careful X-ray examination. A tumor is softer and movable. In the event of marked disturbances the supernumerary rib should be resected, care being taken not to injure the pleura. MALFORMATIONS OF THE THORAX. Defects of Sternum. — Partial or complete absence or smaller congenital clefts of the sternum are of rare occurrence. They give rise to hernial protrusions of the lung which if small in size are apt to be mistaken for soft tumors or abscesses. Lung fg™*™^ 11 hernia is reducible on pressure, changes in size and shape on pressure, with respiration and is frequently associated with paroxysms of coughing. Among the divers deformities of the sternum, congenital, non-rachitic "funnel chest" is deserving of special mention. It differs from congenital or acquired rachitic funnel-shaped chest by the absence of other rachitic deformities. Anomalies of the Ribs. — One or more ribs may be absent or rudimentarily developed. The intervening space is filled with membrane. There may also be accessory ribs (see Cervical l\ib), or several ribs may be united. Defects of the Thoracic Muscles. — Congenital, partial or total absence of one or several of the thoracic muscles is apt to 136 CONGENITAL MALFORMATIONS. Resembles be mistaken for progressive muscular dystrophy. The former, muscular i o j i j dystrophy, however, is unilateral, while the latter is bilateral. Secondary scoliosis is apt to follow the congenital muscular defects. All the aforementioned malformations of the thorax require some mechanical contrivance, to prevent either injury to the internal structures or secondary deformities. MALFORMATIONS OF THE ALIMENTARY TRACT. Atresia CEsophagi. — Congenital esophageal strictures are very rare. They give rise to difficulty of swallowing and Regurgitation . J . . ' of food, immediate regurgitation of the food through the mouth and nose. The treatment is the same as in acquired esophageal strict- ures. Owing to the absence of true scar tissue in the congenital form, the prospects of recovery are brighter. STENOSIS PYLORI CONGENITA. Stenosis of the pylorus may be complete or partial. Complete atresia is extremely rare and invariably fatal within a few days after birth — before the diagnosis can be established. Partial stenosis of the pylorus, on the other hand, is a com- paratively frequent affection which not rarely terminates in re- covery, either spontaneously or through medical and surgical treatment. It is distinguishable in two forms : True and False. 1. True or hypertrophic pyloric stenosis is invariably due to narrowing. a congenital narrowing of the lumen of the pylorus and is asso- ciated with more or less primary hypertrophy of the pyloric ring. 2. False or spastic pyloric stenosis (pylorospasm i is the result of congenital faulty innervation of the stomach, or of acquired digestive and nervous disturbances. It is free from primary spasmodic hypertrophy of the pyloric ring. Sooner or later secondary hypertrophy of the muscular and mucous coats of the stomach occurs in consequence of the increased force required by the stomach to propel the ingesta. At a later stage of the disease the stomach walls lose their tonicity and dilatation is a frequent complication. The diagnosis of true pyloric stenosis usually presents no difficulty, and it can readily be distinguished from atresia of the esophagus or duodenum by bearing in mind the typical clinical picture of the disease. The apparently fully developed infant at MALFORMATIONS OF ALIMENTARY TRACT. . 137 birth, after a period of well-being of from a half to three weeks, begins to vomit sometime after each feeding. The vomiting rapidly becomes very violent in character, and the contents of the stomach, which appear greater (ischochymia — retention of ^mltfng^ digested food) than the child could have taken in one feeding remnants o ' o of previous and consists of a hyperacid 1 mixture of mucus, digested and un- feedings. digested food, free from bile, is explosively ejected. As an im- mediate result of the vomiting, the intestinal tract remains empty ; hence, pseudoconstipation or only occasional evacuation of a small quantity of brown, foul-smelling fluid. The urine is scanty Absenceof and concentrated. The infant acts very hungry, voraciously J^Jv^entg swallows a few mouthfuls of food, but, being seized by sudden spasmodic pain, drops bottle or breast, only to grasp it again after some relief prevails. The abdomen is sunken in, while the epigastrium is distended, and here and there are visible peristaltic peristalsis, movements {hyper kinesis') of the stomach, from right to left. In some cases a tumor — the hypertrophied pylorus — is palpable a little to the right of the stomach and in cases of long standing there is usually more or less marked gastric dilatation. In pylorospasm the symptoms are much less pronounced, but otherwise cannot be distinguished from true pyloric stenosis. The course of the affection varies with the degree of the con- tracture. In the majority of instances the true form of the dis- ease, if not operated upon early, terminates fatally in from four weeks to four months, with symptoms of inanition and collapse, baa^wnh Occasionally, however, a change for the better occurs and slow operation, recovery follows. This is particularly apt to take place in spastic pyloric stenosis, especially if early and properly treated. With these facts in view, it is extremely difficult to decide when, and whether, surgical intervention is indicated. The profession is greatly divided on this question. The statistics adduced for and against an operation seem to favor both contentions. The surgi- cal "cures" do not always assure us of their permanency. 2 On the other hand, who can vouch for the permanency (remissions are not rare!) of the medicinal "cures," and for the correctness of the diagnosis in such cases ! Appreciating, then, the gravity of the prognosis of true pyloric stenosis even under the best medical management, and the recent grand achievment in stomach 1 In one case under our observation there was total achylia gastrica. 2 A little patient of mine, nine weeks old, recently operated upon, did well for six days, hut died two days later from the effects of a minute gastrointestinal fistula. 138 COXGEXITAL MALFORMATIONS. surgery, it is justifiable after two weeks' faithful but unsuccessful trial of dietetic and medicinal measures to recommend an opera- tion, namely : — 1. In bottle-fed infants presenting the usual symptoms of pyloric stenosis, plus pylorus-tumor. 2. In breast-ted infants presenting the usual symptoms of pyloric stenosis, even minus palpable pylorus-tumor. An operation, if indicated, should not be delayed until the operation child is at death's door. The choice between divulsion (Loreta's), in true v J ' stenosis, pyloroplasty and gastroenterostomy depends upon the patho- logical condition of each individual case. The now-surgical treatment of congenital pyloric stenosis must be carried out systematically and faithfully. Whenever possible, the infant should be fed on woman's milk, preferably with a spoon or tube, in order to gauge the amount of food con- sumed and possibly retained by the infant. The amount of feelings' eacn ±eecnn g should not exceed one ounce, but may be given every hour, so as to sustain the child's vitality. Modified or pre- digested milk may be administered instead of woman's milk if the latter is not readily obtainable. In view of the fact that almost two-thirds of the cases of pyloric stenosis thus far re- ported were breast-fed babies, one is tempted to recommend cows' milk feeding as a therapeutic or, at least, prophylactic measure against pyloric stenosis. Indeed, following the tempta- tion in one of my own cases I was — perhaps accidentally — re- warded by happy results. May I venture to suggest that the large curd of cows' milk tends mechanically to dilate the contracted pyloric orifice? Reduction in the frequency of the attacks of vomiting and in the amount ejected forms the first and best indication of im- provement in the condition. Next to careful feeding, systematic washing of the child's stomach serves as the sheet-anchor in the Lavage, therapeusis of congenital pyloric stenosis. It should be prac- ticed at least twice a day with plain, cool (6o° to jo° F.) water, occasionally adding a small amount of bicarbonate of soda to neutralize the hyperacidity of the stomach. The washing should be continued until the water returns clear. The effects of the lavage are the removal of decomposing substances from the stomach, arrest of fermentation and allayment of pain and spasm. For the latter purposes prolonged warm baths and hot poultices! compresses to the epigastric region are also very useful. To MALFORMATIONS OF ALIMENTARY TRACT. 139 counteract the excessive loss of fluids, a daily enteroclysis or hypodermoclysis is of advantage. Internal medication is of little value except anodynes for the relief of pain and spasm. Anod y nes - For this purpose minute doses of codeine with or without bella- donna may be administered in the form of suppositories. Skillful nursing privately or in hospital should be insisted upon. CONGENITAL STENOSES AND ATRESIA OF THE INTESTINES. Any portion of the intestines may be congenitally malformed or completely obliterated. Partial stenosis is most frequently observed in the small intestine, while complete atresia in the rectum and anus. As in acquired intestinal obstruction, the lumen of the intestine above the occlusion is widely dilated, while that below it is more or less collapsed. The symptoms vary with the seat of the lesion. The higher the stenosis, the earlier and more pronounced the vomiting, the larger the quantity of the meconium, and the more marked the dyspnea and eventually the cyanosis as a result of compression of the thoracic organs by the highly distended stomach. On the other hand, the lower the stenosis, the more fecal the Fecai vomiting, the greater the meteorism, and the more marked the meteorism illiuriM. disturbances of the bladder and kidney (partial or total anuria as a result of compression of the ureters by the highly distended intestines). In stenosis of the duodenum the vomitus contains bile substances. Associated with the local symptoms of intestinal stenosis are : dry tongue, subnormal temperature, rapid emaciation, complete pinched features of the face, and collapse. Death usually takes iatai° Sls place within a week. Where the stenosis is only partial and slight, the child may linger for months and ultimately recover. In mild cases the treatment should be symptomatic, princi- pally to relieve constipation and to mitigate the pain and agony. Surgical intervention as a last resort. CONGENITAL HYPERTROPHY AND DILATATION OF THE COLON. (Megacolon Congenitum, Hirschsprung's Disease). This congenital affection should not be mistaken for acquired dilatation of the large bowel associated with intestinal atony from various causes. Operation. 140 C< >NGENITAL MALFORMATIONS. Greatly distended abdomen. Constipation alternating with diarrhea. The congenital dilatation is manifested soon after birth by retention of the meconium, although the child is otherwise ap- parently healthy and free from congenital stenosis of the anus or rectum. Intestinal irri- gation brings forth but a small quantity of feces. The infant is restless and constipated, and its abdo- men gradually becomes greatly distended. Some time later the constipation is followed by more or less copious diarrhea due to irritation from retained feces. After expulsion of the stool and gases the abdomen is reduced in size, but after a short time it again becomes distended, giving rise to the afore- mentioned symptoms. Most infants succumb early to the disease, from inter- ference with the thoracic organs or autointoxication by the decomposing intes- tinal contents ; others may live longer and in rare in- stances even entirely re- cover. Post-mortem examina- tion reveals either of the following conditions : — 1. Simple dilatation and often lengthening of the colon ; 2, ectasis of a section of the colon with or with- out compensating dilata- tion or hypertrophy of the adjoining portions; 3, general enlargement of the intestinal lumen and hypertrophy of its walls. The hypertrophy usually involves the longitudinal and circular muscular fibers. Fig. 34. — Megacolon Congenitum (3 Pathologic years old). The size of the abdo- findings. men j s considerably reduced after high enema. (She field. ) MALFORMATIONS OF ALIMENTARY TRACT. 141 The treatment is chiefly symptomatic (see Constipation). t r y e ™ t p ^° e ™ t ati o r eventually operation. In severe cases surgical intervention. ATRESIA OF THE RECTUM AND ANUS. (a) Atresia Ani Proper (Imperforate Anus). — The rectum is normal and ends blindly into the completely closed anus. Fig. 35. — Congenital Absence of Scrotum and its Contents, Anus and Rectum. (Sheffield.) There may not be the slightest indication of an anus, or the latter is indicated by a few comb-like prominences, a small fossa, or a round induration. (b) Atresia Recti. — The anus is normally developed, but the rectum ends blindly somewhere higher up in the canal. (c) Atresia Ani et Intestini Recti. — In this condition the anal orifice is absent and the rectum is arrested in its develop- ment higher up, usually in the region of the sacroiliac symphysis. 14-2 C( INGENITAL MALF( >RMATIONS. (d) Atresia Ani Complicata. — There is atresia of the anus, and the rectum terminates either (1) in the bladder (atresia recti vesicalis) ; (2) in the vagina (atresia recti vaginalis), or some- where in the urethra (atresia recti urethralis). (e) Atresia Recti cum Fistula. — The anus proper is occluded ; the rectum ends blindly, hut is connected with the Blind pouch Fig. 36.— Stomach and Intestines of case Fig. 35, showing ending of colon in a blind pouch tilled with meconium. (Sheffield.) outer skin by a fistulous tract. The anal orifice is thus located in an abnormal position in the perineum, vulva, scrotum, etc. The diagnosis of imperforate anus or rectum usually presents no difficulty. Imperforate anus can readily be made out by Absence of inspection. Absence of meconium in the presence of a normal meconium. anus indicates that the defect is somewhere higher up. Digital or instrumental examination rarely fails to locate the seat of MALFORMATIONS OF ALIMENTARY TRACT. 143 obstruction. Atresia ani complicata may be detected by the presence of meconium in the urine or by continuous escape of Meconium feces from the abnormal communications. The latter symptom Sine! is indicative also. of the last form (e) of atresia, which can readily be seen. Imperforate anus and imperforate rectum are the only two conditions giving rise to immediate more or less grave symp- toms. The child passes no meconium, appears restless, strains, cries, its abdomen is distended, it suffers from dyspnea, and of „ Tr ,. , . .... obstruction. vomits occasionally. If not relieved it succumbs within a week from rupture of the intestines and peritonitis. Prompt Fig. 37. — Diastasis Recti Abdominis Patient suffering also from amaurotic family idiocy. (Sheffield.) operative interference is therefore imperative. If the obstruc- tion is in the anus, or in the lower part of the rectum, puncture or incision with consecutive dilatation will often suffice to effect a cure. Whenever the point of the atresia cannot be discerned, operative 1 _ treatment. an artificial anus should be made for quick relief, postponing the curative measures for later. An operation should be post- poned also in all other forms of atresia ani or recti, where the escape of meconium is not entirely interfered with. DEFECTS OF THE ABDOMINAL PARIETES. Diastasis Recti Abdominis. — Lozenge-shaped separation of the abdominal wall extending from the xiphoid to the umbilicus is congenital in nature and due to defective closure of the deep layers of the abdominal coverings. It is sometimes associated with umbilical hernia. 144 CONGENITAL MALFORMATIONS. The symptoms make their appearance when the child is able SU c d o < ii e c n to run a ' JOUt an( ^ jump, and consist of sudden attacks of colic (not to be mistaken For enteralgia!), uneasiness in the epigastric region, pallor, etc.. which subside when the child is perfectly at rest. These paroxysms are due to partial incarceration of the Fig. 38.— Umbilical Hernia. (Sheffield.) stomach in the abdominal slit, and should be remedied by bring- Abdominai [ n g anc } keeping the separated recti muscles together by means of plaster straps or suitable bandage. CONGENITAL UMBILICAL HERNIA. (Hernia Funiculi Umbilicalis, Exomphalos, Omphalocele Congenita, Ectopia Viscerum, Amnion Navel). As a result of faulty development of the abdominal cover- ings, instead of an umbilicus, a variously sized, saclike dilata- MALFORMATIONS OF ALIMENTARY TRACT. 145 tion is occasionally observed which may contain intestinal loops, the stomach, liver, spleen, etc. The hernial sac is composed of the amnion and parietal peritoneum. At birth the contents of the sac can usually be recognized through the thin, transparent protrusions J . . may be membranes, but small protrusions into the cord are apt to be overlooked Fig. 39. — Thoracoabdominopagus, with Ectopia Viscerum. (Sheffield.) overlooked, and carelessly tied off with the umbilical rest. If there is considerable eventration, the infants die early from rupture of tbe sac and peritonitis. The first indication there- 1 1 . Reposition fore is to replace the prolapsed structures into the abdominal of prolapsed . portion, and cavity and to keep them there by means of a suitable bandage, strapping. 14(1 CONGENITAL MALFORMATIONS. Radical In this manner small hernias not rarely subside spontaneously. operation. Large h ern i as should he treated by a radical operation. PERSISTENCE OF THE DUCTUS OMPHALO- MESENTERIC^. (Vitellointestinal Duct). Physiologically, the omphaloentericus duct, the embryonic tubular communication between the intestinal canal and the Fig. 40. — Skiagram of Thoracoabdominopagus (same as Fig. 39), with Ectopia Viscerum. (Sheffield.) germinal vesicle, disappears at about the eighth week of fetal life. Occasionally the duct is not obliterated, and leads to the following principal abnormalities: — 1. A tine fistula at the umbilical ring, forming a communica- MALFORMATIONS OF ALIMENTARY TRACT. 147 tion between the bowels and the exterior, and secreting a cloudy fluid containing a trace of fecal matter. 2. A hernial protrusion through the umbilicus in the form of a red finger-shaped tumor which is usually composed of the prolapsed walls of the fistula, but sometimes is composed of intestinal loops. 3. Open Meckel's diverticulum. It is a blind appendage of the lower part of the ileum, and may be free or united with the umbilicus by a solid cord. Under certain conditions it may enter Danger of a hernial sac and here become strangulated. It may produce strangulation. "ileus" by incarcerating some loops of the intestines, and give rise to local intestinal inflammation closely resembling that of appendicitis. Persistent omphaloenteric duct may be mistaken for : — „ . . . Differentia- 1. Persistent urachus. On examination with the catheter tion from persistent it can be reached through the bladder; the secretion is urachus, & ' and composed chiefly of urine. sarcomphaios. 2. Sarcomphaios — has no fistular opening. Fine fistulae frequently close after repeated cauterization with the caustic stick. Wherever the prolapse is very marked or in cases associated with open diverticula a radical operation is imperative, since their presence is always a menace to life. URACHUS FISTULA. (Fissura Vesicae Umbilicalis). Persistent urachus — the duct through which the urinary blad- der communicates with the allantois — gives rise to a fistulous tract which ends at the umbilicus. On pressure a small hernial tumor arches forward and secretes a clear or turbid fluid, com- Escape of posed of urine alone, or urine, mucus and pus. If the fistula is trough large, the flow may be continuous. It may give rise to cystitis and umblllcus - even pyelonephritis compelling early operative procedures. The first attempt at a cure should be directed to making the natural outlet quite free (e.g., cure of phimosis). Small fistulae often yield to cauterization and continued pressure with ;i bandage. If this fails, tile walls of the sinus should be freshened and then sutured. Its differentiation from persistent ductus omphalomesenteri- cus has been emphasized above. 1 JS ( :< tXGEXITAL MALFORMATIONS. MALFORMATIONS OF THE GENITO-URINARY ORGANS. CONGENITAL ABNORMALITIES OF THE KIDNEYS. The kidneys, like all other parts of the body, are subject to Deformity, defective embryonic development. They may be abnormal in size, shape (horseshoe) and number. This is of clinical impor- tance, since malformed kidneys are more easily affected by dis- ease, especially tuberculosis, than normal organs. Congenital Absence, absence of one kidney has been observed once in about 4000 autopsies. Furthermore, it is usually found that, whenever one kidney is absent, the other one is in a more or less diseased con- Dispiacement. dition, chiefly greatly hypertrophied. Congenital displacement of the kidney (both kidneys on one side; in front of the verte- bral column; low down in the pelvis) is very apt to cause many diagnostic errors. MALFORMATIONS OF THE URETERS. Abnormal ureteral openings, as to size and position, are of great clinical significance. In the male the ureter may termi- nate into the sphincter of the bladder, the prostatic portion of the urethra, or in the seminal vesicle, and by interference with the secondary flow of urine give rise to dilatation of the ureter and renal of kidneys, pelvis and atrophy of the renal parenchyma. In the female the ureter may end in the sphincter of the bladder, in the urethra, or in the vagina. More serious than misplacement is absence or atresia of the ureter. Either one of these latter conditions in- variably produces hydronephrosis, compelling extirpation of the affected kidney. Double ureter, if free from any other anomaly, is not attended by any pathologic phenomena. MALFORMATIONS OF THE BLADDER. Ectopia Vesicae Congenita, Cleft Bladder, Fissure of the Bladder, Exstrophy Vesicae. — Cleft bladder arises from arrest of development of the anterior walls of the bladder and abdomen, and often also of the symphysis. It may be partial Round, or complete. In the complete variety the posterior vesical red m°ass wa ^ protrudes as a round, moist, bright-red tumor, through a Kustrulm" § a P m tne abdominal wall, situated in the median line between the umbilicus and the urethra. The mass is marked by two small tubercles on both sides — the orifices of the urethra — MALFORMATIONS OF GENITO-URINARY ORGANS. 149 from which the urine dribbles continuously. In the male this is associated with epispadias of the rudimentary penis; in the female the clitoris is clefted, the labia are widely separated, and the urethra and vagina more or less defective. Eversion prognosis of the bladder is often complicated also by other malformations of the body, and in majority of instances leads' to early death. Partial ectopia vesicae offers a more favorable prognosis, par- ticularly if a plastic operation is resorted to early. Temporary relief may be obtained from a suitable urinal held in place by means of a truss. MALFORMATIONS OF THE URETHRA, PREPUCE, TESTICLES, AND VAGINA. Atresia Urethrae. — Total atresia urethra? is a rare malforma- tion. When it does occur, it is usually epithelial in nature or at most membranous. In the former instance the atresia promptly yields to pressure with the tip of a sound, in the Dlvulsion - latter to a small incision and dilatation by means of a small, blunt silver probe. Complete absence of the urethra is extraordinarily rare. Congenital stenoses are not rarely found along the urethra, and if presenting no distinct hindrance to urination are fre- quently overlooked. In cases of marked urethral stenosis, the still patent urachus often permits the escape of urine through its fistulous tract running from the bladder to the umbilicus. Misplacement of the Urethral Opening (Epispadias, Hypo- spadias). — The urethral opening may be situated on the upper part of the penis (epispadias) or at its inferior aspect (hypospa- dias). The latter abnormality is more frequent than the former. Both conditions are productive of more, or less disturbance of incontinence; urination (incontinence in epispadias; dysuria in hypospadias), " secondary intertrigo, erosion and ulceration of the genitalia from the effects of the irritating urine, and later in life interference with virility. Pronounced hypospadias (perineoscrotal) closely resembles hermaphroditism, and when it is associated with retention of the testicles it may be impossible to determine the sex of the infant. Except in the very mildest cases early operative interference 0perative is indispensable. treatment. Dysui i:,l) COXGEXITAL MALFORMATIONS. CONGENITAL PHIMOSIS. A moderate degree of adherence of the prepuce to the glans penis is physiologic in the newborn. Ordinarily the adhesions disappear spontaneously in the course of time. In some cases, however, the prepuce remains adherent and stenosed at its orifice so that the glans cannot pass through. In consequence there is more or less retention of urine between glans and prepuce (par- ticularly if the latter is elongated or hypertrophied), infection and decomposition of the sebaceous secretion (smegma), and secondary inflammation of the penis and adjacent structures. In the presence of inflammation urination is difficult and very painful; the infant cries, presses and strains (in predis- Retention posed children often the cause of hydrocele, hernias and prolap- of urine. x J l l sus recti), or fearing pain retains the urine for many hours, a habit which is apt to give rise to cystitis, pyelitis, and even uremic convulsions. Phimosis frequently forms also the cause of enuresis, pria- pism, masturbation, and a number of more or less reflex nervous phenomena. In mild cases of phimosis the prepuce should frequently be pushed back and forth and the retained smegma removed. Where the adhesions are very firm they may be broken up with the aid of a dull probe and kept loose by daily pulling back the foreskin and applying an antiseptic cooling lotion such as lead- water or a 2 per cent, solution of aluminium acetico-tartrate. In this manner good results are obtained within a few days. Where the preputial stenosis is the predominating trouble, incisions slight nicking of the preputial ring with a scissors (laterally, loosening above, and below), followed as before by loosening of the adhe- of prepuce. s j onSj daily preputial retraction and local antiphlogosis, is all that will be necessary to effect a permanent cure. This pro- cedure is at all times preferable to circumcision, except in cases of phimosis associated with elongated or greatly hypertrophied foreskin and severe inflammation. Circumcision, when indicated, should be performed under very careful aseptic precautions, preferably under general anes- thesia. The surgeon grasps the prepuce between the thumb and index finger, exerting sufficient traction to draw it from the glans penis, puts over it a shield or forceps just in front of the glans, and with scissors or knife removes the distal, superfluous MALFORMATIONS OF GENITOURINARY ORGANS. 151 portion of the prepuce. He next seizes the inner layer of the prepuce, which still covers the glans, with a thumb forceps and with the aid of a scissors cuts it so far backward as to enable him fully to expose the glans and bring the edges of both pre- putial layers in apposition by a fine continuous suture. The Danger of dressing should consist of sterile gauze (not medicated! danger and'nenior-' of intoxication). Numerous accidents have been reported as the result of circumcision, but all, except uncontrollable hemorrhage in the hemophilic, are preventable. In such hemorrhage the actual cautery should be resorted to without delay. Milder hemorrhages will often yield to firm compression of the penis with a hard catheter in the urethral canal. CRYPTORCHIDISM. (Undescended Testicles). Normally the testicles descend into the scrotum by the end of fetal life. In the event of a constriction of the inguinal ring, and malformation of the testis, epididymis, or the vas deferens, etc., one (mon orchidism) or both (cryptorchidism) testicles are not infrequently retained in the abdominal cavity, at the inguinal ring, or at the upper portion of the scrotum. More rarely the testicles become displaced, and through a false passage emerge either at the crural arch (crural testicle) ; under the fold of skin between the thigh and scrotum ( scrotof emoral testicle) ; or behind the scrotum (perineal testicle). In the majority of instances an undescended testicle is free from any serious consequences, and reaches its normal position spontaneously within the first few years of life. Occasionally, Spontaneous . . . . . descent. however, it may become impacted at the inguinal canal, giving rise to excruciating pain and inflammatory symptoms; if asso- ciated with a hernia, strangulation may take place in both struc- stranguia- tures at the same time ; it may cause atrophy of the genitalia ; it may be the seat of malignant degeneration, and, finally, it may be productive of a number of reflex phenomena (epilepsy?). Cryptorchidism should not be confounded with anorchidism or absence from the body of both testicles (is usually associated with rudimentary penis and, later, absence of spermatic secre- tion), or with ascent of the testicles from contraction of the scrotum (they descend with relaxation of scrotum). Expectant plan of treatment up to puberty in the absence of complications. Capsular truss in cases of misplacement. Gentle Reflex symptoms. 152 CONGENITAL MALFORMATIONS. massage is useful. Orchidopexy and other surgical procedures as indications arise. Speedy operation in case of strangulation. HYDROCELE. It is a common affection of early infancy and most frequently congenital in nature. Varying with the seat of the accumulation Fig. 41. — Congenital Hydrocele, Communicans. (Sheffield.) of the abnormal quantity of serous fluid, we distinguish the fol- lowing kinds : — 1. Hydrocele Tunics Vaginalis. It is a unilateral, oval,. at^iowef smo °th> translucent, more or less tense, fluctuating swelling, scrotum* wn i cn appears first at the lower part of the scrotum, and grad- ually rises up to the abdominal ring. Posteriorly to the hydrocele usually lies the testicle. MALFORMATIONS OF GENITO-URINARY ORGANS. 153 2. Hydrocele Funiculi Spermatid {hydrocele of the cord}, resembles the former, except that the testicle usually lies at the separated bottom of the scrotum and is distinctly separated from the testicle hydrocele by a constriction. It is sometimes made up of several constriction, small cysts simulating a string of beads. 3. Hydrocele Vaginalis Communicans ("Congenital Hydro- cele"). This form occurs when the tunica vaginalis preserves its communication with the abdominal cavity and becomes filled with serum, forming a cylindrical tumor, extending to and through the abdominal ring. It is often associated with hernia with hernia. (hydrocele hernialis). As the contents of both are reducible on pressure the differential diagnosis between congenital hernia and hydrocele vaginalis communicans is sometimes difficult. In hydrocele, however, the return of fluid to the peritoneal cavity occurs without intestinal gurgling — the reverse being the case in congenital hernia. Hydrocele often disappears spontaneously, especially after removal of reflex irritation, e.g., phimosis. If it persists, we employ local counterirritation (painting with tincture of iodin or mercury ointment), or aspiration, if the hydrocele enlarges. The latter procedure may be followed by the injection of a few drops of equal parts of tincture of iodin or carbolic acid and alcohol. Absorption of the fluid is hastened by a few large doses of potassium iodid. In hydrocele communicans a truss should be worn to prevent hernia. The pressure exerted will often oblit- erate the inguinal portion of the vaginal process, and also cure the hernia, if present. If the aforementioned palliative and curative measures fail — which is rarely the case — a radical operation becomes necessary. Atresia Vulvae. — It consists chiefly of a cellular adhesion of the labia minora, and may be partial or complete. In total atresia vulva? there is anuria, with its secondary symptoms, necessitating immediate attention, i.e., forcible separation of .the labia with the fingers or with the aid of a dull sound or scalpel. In partial atresia separation of the labia occurs spontaneously. Atresia Vaginas Hymenalis (Imperforate Hymen). — Tin's congenital malformation usually escapes observation until pu- berty, when partial or total retention of the menstrual flow gives rise to local and general disturbances. Incision and packing with iodoform gauze readily remedies the trouble. Counter- irritation. Radical operation. 154 CONGENITAL MALFORMATIONS. - Atresia Vaginae. — Like the aforementioned malformation, narrowing or complete closure of the vagina is not detected until after puberty. Total atresia vaginae is usually associated with absence of the uterus. This should always be borne in mind before resorting to operative procedures for the relief of the atresia. CONGENITAL MALFORMATIONS OF THE VERTEBRAL COLUMN (Including those of the Sacrum and Coccyx). SPINA BIFIDA (HERNIA OF THE CORD). Meningocele Spinalis, Myelocystocele, Myelomeningocele. — Analogous to hernia of the brain (see "Cephalocele"), that of the cord also is divisible in three principal groups: Menin- gocele spinalis, myelocystocele, and myelomeningocele. (a) Meningocele spinalis is a protrusion of the pia mater _.„ , .„, without participation of the spinal cord. It is filled with cere- Filled with l l ' (e s et inTi t>rospinal fluid, translucent, often pedunculated and may reach fluid - the size of a child's head. It is covered by normal skin. Paral- ysis is rare. Pressure on the tumor produces bulging of the fontanelles and spasms. (b) Myelocystocele is situated on a broad base and is readily replaceable on pressure. The covering skin is greatly distended solid ^ut norma l m color. Palpation reveals that the tumor consists an™ fluid* ot " s °hM masses in addition to fluid. It is frequently associated with hydrocephalus and accompanied by motor and sensory disturbances. (c) Myelomeningocele is a pear-shaped or spherical, fluctuat- ing, tense, broad or pedunculated tumor the size of a walnut to that of a child's head. Its covering skin is bluish, very thin and Cord traversed by numerous blood-vessels. It is composed of cord SUb an cut's substance and its membranes and forms a true hernial protrusion """' hn ""' s ' through a cleft in the vertebral column. The cleft and to some extent also the hernial orifice can often be felt at the base of the tumor. Myelomeningocele is the most frequent variety of spina bifida and gives rise to marked motor and sensory paralyses. Almost all forms of spina bifida are associated with hyper- trichosis of the surrounding skin. This is especially pronounced, and indeed, often forming the only outward sign of deformity, in spina bifida occulta (a meningocele usually of the sacrolumbar region hidden under masses of fat). The hair is usually so MALFORMATIONS OF VERTEBRAL COLUMN. 155 arranged as to form a crown over the center of the defect. When well developed it may resemble a tail. Apart from the malformation the condition of most children at first is perfectly normal. As the tumor enlarges the results of the pressure on the cord or the cauda equina gradually ap- pear. The symptoms vary with the degree of involvement of the spinal cord ; they are, therefore, most pronounced in myelo- meningocele sacrolumbalis. Here we have motor and sensory paralyses of the legs, of the rectum, bladder, and the perineal muscles, convulsions and trophic disturbances. In less severe cases, the paralysis may be limited to the legs only. Pressure symptoms. Fig. 42. — Myelocystocele. Note funnel-shaped eversion of rectum owing to paralysis of the levator and sphincter ani. {Sheffield.) Bearing in mind the characteristic symptomatology of spina bifida, i.e., a more or less translucent, compressible, barely mov- able, thinly covered tumor, in the majority of instances associated with paralyses, there ought to be no difficulty in differentiating it from sacrolumbar neoplasms. In cases of doubt the diagnosis may often be cleared up by exploratory puncture and radiographic examination | the latter showing a vertebral cleft ). Spina bifida may sometimes escape notice when it is sur- rounded by a solid tumor. The majority of children with marked ^)ina bifida die when very young, often during birth, owing to rupture of the tumor and shock following rapid escape of the cerebrospinal fluid. Most of those who survive succumb later from rupture of the Differentia- tion from neoplasms. 156 CONGENITAL MALFORMATIONS. sac and subsequent infection and purulent meningitis ; from gangrene and ulceration of the skin with subsequent sepsis ; and finally, from intercurrent diseases and marasmus. Simple r °against meningocele gives the best prognosis if recognized early and injury. p rotecu .,i f rom external insults by a suitable pad or apparatus. This palliative method of treatment should always be tried in cases of spina bifida that project very slightly and are covered by normal, well-nourished skin. Aspiration of the hernial sac is useful to relieve the symptoms of compression and to lessen the danger of spontaneous rupture. Aspiration may be followed by injection of iodin or preferably iodin-gelatin. In selected cases it may prove of permanent benefit. Radical operation is the ideal procedure in suitable cases. Radical However, extensive paralyses, severe irreparable malformations operation. 111 ~ elsewhere, hydrocephalus, and grave systemic arrections are con- traindications to operation. In such cases palliative and symp- tomatic methods of treatment are indicated. CONGENITAL SACRAL TUMORS. Closely related to and frequently associated with spina bifida (q.v.) are congenital sacral tumors. They may be classified as follows : — 1. Double Formations — (a) Complete — two fully formed individuals grown together at the buttocks. (b) Incomplete or parasitic formations — one or several rudimentary portions of the body attached to the buttocks of a fully formed individual. 2. Sacral Hygromas. — Single or multiple cysts, attached by a broad base to the dorsal surface of the sacrum. They are sometimes associated with spinal hernia. 3. Tumores Coccygei. — Neoplasms attached to the anterior surface of the sacrum and coccyx. The tumors are composed of fibrous or granular masses, generally of sarcomatous nature ; sometimes of fat, cartilage, or bone. Occasionally they involve the spinal canal, or surround a spinal, dural protrusion (spina bifida). They never extend above the lower border of the Spread gluteus, but spread toward the pelvis and between mward ' the legs of the child. MALFORMATIONS OF EXTREMITIES. 157 4. Caudal Formations — (a) Complete tails, manifested by an actual increase in the number of coccygeal vertebra. (b) Imperfect tails, enlargement of vertebral column by rudimentary tissue. But few children born with coccygeal tumors live beyond the age of one year. As the tumors enlarge, the infants succumb to progressive cachexia and exhaustion. As a rule, sacral tumors do not interfere with the life of the Protection child if suitable protection is employed against vulnerability of injury and the tumor and secondary infection. In some selected (see Spina Bifida) cases perfect results are obtained by skillful surgical interference. MALFORMATIONS OF THE EXTREMITIES AND HIP. Of the numerous malformations of the extremities (e.g., complete absence ; spontaneous partial amputations ; fractures ; supernumerary fingers and toes, etc.) but few are of interest to general practitioners, namely, congenital dislocation of the hip and club-foot. As these abnormalities are apt to be confounded with similar acquired affections, they will receive special con- sideration. LUXATIO COX^ CONGENITA (Congenital Dislocation of the Hip). The dislocation may be unilateral or bilateral. The acetab- ulum is rudimentary in form, and the head of the femur rests either above it, above and to the outer side, or above and behind it upon the ilium, sometimes immediately at the side of the great sciatic notch. If one leg is displaced it is shorter than the other, giving rise to distinct limping. If both sides are affected the w t ? t b . blins gait is wobbling — "duck gait." As a result of this anomaly the b U °t cks g buttocks project prominently backward while the spine is either thrown forward (lordosis, in bilateral) or tilted sideways (scoliosis, in unilateral dislocation). The differential diagnosis between this condition and rachitis and coxa vara is best estab- lished with the aid of the X-rays which shows the abnormal posi- tion of the head of the femur. If the malformation is detected early, it may be corrected either by opening the joint, replacement and fixation of the head of the femur in the artificially deepened ^pg^'on acetabulum or by bloodless forcible reduction of the deformity 1 58 CONGENITAL MALFORM \Tlo.\S. 1 liffen iiiki tion from rachitic and para- lytic club- foot. and fixation of the bead of the femur in the acetabulum by pro- longed use of plaster-of-Paris bandages. For details of treat- ment the reader is referred to text-books on "Orthopedic Sur- gery." TALIPES (Club-foot). 1. Talipes varus, inversion of the foot, so that its sole faces the other foot. This is the most common of the congenital forms. 2. Talipes valgus, flat- foot, effacement of the arch. 3. Talipes equinus, lowering of anterior part of the foot, the child steps on his toes. 4. Talipes calcaneus, elevation of anterior part of the foot, heel alone touching the ground. Compound forms may be produced by combina- tion of the different varie- ties. The diagnosis of the type of club-foot can readily be made by in- spection ; it is sometimes difficult, however, to dif- ferentiate the congenital from the acquired forms, e.g., rachitic or paralytic club-foot. In rickets the distortion of the feet is generally associated with other pathognomonic symptoms of rickets and is gradual in development. In paralytic club-foot {e.g., poliomyelitis) the limb is wasted, flabby and cold and there is a history of post-natal, gradual appearance often in association with other paralytic deformities. Congenital club-foot is being attributed to various causes, but is probably due to some mechanical interference with the normal development of the joints, ligaments or tendon insertions. 43. — Congenital Talipes Varus. (Sheffield.) CHAPTER IV. Birth Injuries. Nature in its infinite wisdom provides a more or less large quantity of liquor amnii to protect the fetus in utero against undue pressure and possible injury. If, perchance, the amniotic fluid escapes prematurely either spontaneously or artificially, the fetus in its descent through the parturient canal, subjected to of pressure. powerful pressure by the maternal structures or mechanical manipulations, sustains a number of injuries which vary in severity from simple external bruising to grave compound frac- tures and internal, sometimes fatal, injuries. I. SUPERFICIAL STRUCTURES. CAPUT SUCCEDANEUM. . Vertex presentation being the most common form of delivery, the head consequently stands the brunt of the injuries. The so- circumscribed x J . J edema. called caput succedaneum is a circumscribed edema of the scalp. It is observed immediately after birth as a doughy, evenly distrib- uted, variously sized tumor which disappears spontaneously by absorption, unless infected through external abrasions. In the latter event it requires surgical treatment, such as antiseptic drain- age, incision and drainage. CEPHALHEMATOMA. More serious than the aforementioned condition is hemor- rhage occurring between the pericranium and cranial bones in the form of a circumscribed, elastic, distinctly fluctuating, pain- ^ 1 I m t r iating less tumor, situated upon the right or left side of the head (some- times both sides are affected). The cephalhematoma develops gradually within the first few days of extra-uterine life, and owing to the firm attachment of the periosteum to tbe edges of the cranial bones along the sutures, it never extends beyond the latter, or over the fontanelles. All around the tumor a hard. bony ridge is soon (after about two weeks) detected, which ridge. (159) 160 BIRTH INJURIES. with the depressed center gives a sensation somewhat like that of a depressed fracture. Cephalhematoma may he mistaken for caput succedaneum, which appears immediately post partum and disappears after a 'tiorffroni day or two ; for subaponeurotic or subcutaneous hemorrhages, cedaneum" which occur sometimes also from intrapartum pressure, but hemorrhage extend beyond the sutures ; for congenital encephalocele, which an g d eni°tai lies between but not over the bones, pulsates, enlarges on crying or coughing, and can be partially reduced, and, finally, for vascular tumors, which are compressible and free from a bony ridge. The tumor usually disappears spontaneously, sometimes re- quiring weeks and months to do it. If suppuration occurs, it calls for surgical interference. HEMATOMA STERNOCLEIDOMASTOIDEI. Pathologically akin to cephalhematoma is the intrapartum Hemorrhage hemorrhage which takes place within the sheath of the sterno- withm the fe _ ^ sheath cleidomastoid muscle, as a result of rupture of several muscle of the L muscle, fibers and consecutive myositis. The tumor in the neck is generally observed a few weeks after birth, more rarely earlier. It varies in size from that of a hickory nut to a walnut. It is at first soft, later hard, cartilag- inous in consistency. Severe hemorrhages may give rise to torticollis. This condition demands perfect rest to the head, cold com- presses for the relief of pain, and later gentle massage to pro- mote absorption of the tumor. R Ung. kalii iod. (U.S. P.), Adipis lante aa 3ij. | 8. M. ft. ung. Sig. : To be applied with gentle massage once a day. II. DEEP STRUCTURES. Birth traumatism is not always limited to the skin and muscles. Now and then the viscera (the lungs, liver, perito- neum, etc.), the bones, the peripheral nerves, the meninges and brain are involved. Fractures and dislocations are not rarely observed, especially in the long tubular bones and the clavicle, while the cranial bones are often badly displaced (the occipital and frontal are pushed under the parietals), fissured (see DEEP STRUCTURES. 161 Meningocele), compressed and fractured, giving rise to grave, frequently fatal, intracranial hemorrhages. CENTRAL BIRTH PARALYSIS. Cerebral Hemorrhage. Apoplexia Neonatorum. Usually the seat of the hemorrhage is the subarachnoid space; seat of often the delicate pia mater ; sometimes between the dura and hemorrhage. Fig. 44.- — Obstetric Facial Palsy (15 months old). Failed to yield to treatment. (Sheffield.) arachnoid ; more rarely between the meninges of the cerebellum ; the lateral ventricles, and exceptionally the brain substance. The symptoms differ with the extent and seat of the hemor- rhage. Most infants are born asphyxiated. The majority of those born alive succumb within a few days under symptoms of y ™rebr a S i of asphyxia and atelectasis, slow irregular pulse, bulging of the P aral y sis - fontanelles, convulsions, rigidity and paralysis. Those few who survive, at an early age present the symptom-complex of cerebral paralysis (see page 587), with or without idiocy. The diagnosis of this condition in the absence of focal symp- toms may present considerable difficulty. Nowadays it is greatly facilitated by lumbar puncture, the cerebrospinal fluid containing disintegrated blood-cells and products of decomposition. 11 1 (•>■_> BIRTH INJURIES. The treatment is the same as for traumatic cerebral hemor- Eariy rhage in the adult — principally surgical. Recent results warrant opera ion. ear jy sur gj ca ] intervention. Fig. 45.— E Obstetric Brachial Paralysis, so-called "Duchenne- Erb's Paralysis." (Sheffield.) PERIPHERAL BIRTH PARALYSES. Facial Paralysis. Facial paralysis in the newly born is usually of traumatic origin, as a result of pressure exerted upon the facial nerve by the obstetrical forceps or deformed pelvis. It may be unilateral Rarely or bilateral. It resembles facial paralvsis of older children (see permanent. . . page 541) except that it runs a milder course. Very rarely the paralysis is permanent. The so-called congenital, non-traumatic 0C syp 1 humc y facial paralysis is probably syphilitic in nature. DEEP STRUCTURES. 163 Brachial Paralysis. Obstetrical Paralysis. Duchenne-Erb Paralysis. In mild form it is of quite frequent occurrence. In typical cases the paralysis is usually limited (80 per cent.) to the muscles supplied by the brachial plexus composed of the lower four cervical nerves and the first dorsal, and their branches Fig. 46. — Bilateral Obstetric Brachial Paralysis (same as Fig. 45), six weeks later. Considerably improved. (Sheffield.) i.e., the deltoid, biceps, brachialis anticus, infraspinatus, supinator longus and the supinator brevis. The arm (rarely both sides [see Fig. 45] are affected — from reckless instrumental manipulations) hangs motionless, the usually ; , , ' . , , , unilateral. upper arm is rotated inward, the forearm is pronated, and the palm of the hand is turned backward and outward. The wrist- and finger-joints are usually only slightly affected; sensibility is intact and electrical reaction diminished or lost. n;i BIRTH INJURIES. Trophic changes. Recovery is the rule in mild cases. Those lasting over three months show trophic changes in the affected muscles, especially the deltoid. The prognosis in cases of brachial paralysis present- ing reaction of degeneration is doubtful. After keeping the affected arm perfectly at rest for two Fig. 47. — Obstetric Brachial Paralysis. Erb's "upper arm type.' Failed to respond to treatment. (Slieffield.) Electricity and massage. weeks the faradic or galvanic current should then be applied daily, for about five minutes at a time, until muscular power has been restored. Gentle massage and passive motion are very useful as a prophylactic against atrophy and contractures. In complete rupture of one or more cords of the brachial plexus, nerve end to end anastomosis and tendon transplantation are the only curative means at our command. CHAPTER V. Diseases of the Newly Born. FEEBLE VITALITY OF THE NEWLY BORN. The physician is often confronted by a group of clinical phenomena in the newly born which may briefly be designated "feeble vitality." It is a clinical entity which, though greatly at variance as to cause and ultimate course, at birth presents a uni- form symptom-complex and demands a more or less uniform mode of treatment. It is characterized by pronounced respiratory and circulatory disturbances, subnormal temperature, somnolence, general debility and emaciation, and is usually associated with one or several presently to be described diseased conditions. 1. ASPHYXIA NEONATORUM (Suspended Animation). The asphyxia may be momentary, or last several minutes up to an hour or longer. Mild forms of asphyxia are manifested r J Asphyxia by slight lividity (asphyxia livida) of the face, feeble superficial Hvida. breathing, and slow and weak heart-beat. If the asphyxia is allowed to continue, the face becomes deeply cyanosed and con- gested, the eyes bulge, the muscular tonus and cutaneous sensi- bility are retarded, the umbilical cord is collapsed, and respira- tion is barely perceptible. Finally, the infant becomes deathly pale (asphyxia pallida), the muscular tonus and reflexes are lost, A | 1 ^| 1 d y a xla the heart-beat is scarcely audible and respiration ceases. Post-mortem examination reveals overdistention of the right ventricle ; cerebral, pulmonary and hepatic congestion ; increased fluidity of the blood ; serosanguinolent exudation in the serous cavities ; accumulation of liquor amnii, blood and mucus in the air passages, and pulmonary atelectasis. Prompt and prolonged resuscitating efforts (Sylvester's, Artificial Schultze's and Laborde's) are usually attended by favorable respiration- results. However, intracranial hemorrhage with consecutive mental and physical defects are not infrequent sequelae of severe forms of asphyxia. (165) 166 DISEASES OF THE NEWLY BORN. 2. ATELECTASIS NEONATORUM (Congenital Collapse of the Lungs). Inflation of the lungs of the normal newly born infant begins with its first cry uttered announcing its arrival into the domain inflation of the living. Succeeding respiratory acts gradually unfold the lungs 6 originally collapsed alveoli and bronchioles, and full expansion of the lungs is ordinarily completed within the first forty-eight hours. The posterior portions of the lower lobes, particularly the right, are last to expand. Failure of the lungs fully to unfold gives rise to the condition under discussion, i.e., atelectasis pulmonum. The alveoli and bronchioles are collapsed. The lung is brownish red in color, feels tough and resistant to the touch Pathologic . . ... findings. — like liver — does not crepitate, and sinks in water. Usually both lungs, particularly the posterior parts of the lower lobes, are affected. In cases succumbing to the disease after weeks or months there is also congestion of the heart, spleen and liver. The causes of atelectasis are essentially the same as those of asphyxia ; the former is sometimes a sequel of the latter, espe- ,, daily if inadequately treated. Inflation of the lung's is occa- Occasionally ... . . caused by sionally interfered with by congenital hyperplasia of the thyroid compression J J ° J r r J of trachea. Q r thymus glands compressing the trachea. In marked atelectasis the infant makes but faint efforts to respire. It is pale, sometimes cyanotic; its temperature is sub- normal, and its pulse slow and weak. It is unable to suckle properly and to cry aloud. It sleeps most of the time and but respiration; lazily responds to external influences. Auscultation discloses cyanosis. J L . . . weak and vesicular breathing (never bronchial) and occasional crepitation. Slight dullness on percussion. The great majority of otherwise healthy children recover under prompt and energetic treatment. Delicate infants either die a few hours, days or several weeks after birth from prostra- tion following repeated attacks of cyanosis, or survive and remain debile for life, often suffering from organic defects, such as incomplete closure of the foramen ovale or ductus arteri- osus, and the like. The treatment of atelectasis consists in stimulating the Artificial respiratory and circulatory functions by keeping the infant wide stimulation! awake ; frequent change of position; artificial respiration; alter- FEEBLE VITALITY. 167 nating warm and cold baths or showers followed by brisk fric- tion; oxygen inhalation and gentle faradization. Lustily crying babies do well. 3. VITIA CORDIS. (See page 428.) 4. SYPHILIS EMBRYONALIS S. FCETALIS. The few babies who survive the syphilitic onslaught during intra-uterine life and are born at full term present a ghastly sight. They are shriveled and shrunken, emaciated and disfigured, with shriveled barely a spark of life in them. They are often asphyxiated and shrunken, usually die soon after birth. Post-mortem examination reveals pronounced pathologic changes in the lungs (fatty degeneration of the pulmonary alveoli — -"pneumonia alba") ; in the liver (in- Post- terstitial hepatitis) ; in the spleen and pancreas (induration and findings. gummatous deposit) ; in the kidneys and suprarenal glands (peri- vascular infiltration and anemic necrosis) ; in the thymus gland (cystic degeneration and abscess formation) ; and in the osseous system (epiphyseal osteochondritis after multiple fractures). The skin affection consists chiefly of "pemphigus syphiliticus," Pemphigus a bullous eruption on a dusky red, slightly elevated base, with a sanguinopurulent content. It is usually localized on the palms of the hands and soles of the feet. Owing to extreme tenderness of the body (syphilitic myositis?) the infant is very restless, and cries pitifully when handled. (See Syphilis Congenita.) 5. PREMATURE BIRTH. Children born before full term — between the twenty-eighth and thirty-eighth weeks of intra-uterine life — are designated "premature." Thanks to the earlier and better recognition of syphilis, the more thorough appreciation of the methods of its prevention and 0ften cure, as well as the tendency of the syphilitic virus spontaneously gyp^;? 7 to lose its virulence through attenuation, premature births, being due chiefly to parental syphilis, are no longer as frequent in occurrence as in former years. The physical condition of premature infants rests largely upon the period of prematurity, inherent vigor of the newly born, and the presence or absence of serious organic defects. Ordinarily premature infants are considerably punier than full term infants. They weigh and measure approximately : — Extremely low vitality. 168 DISEASES OF THE NEWLY BORN. Age at Birth. Weight. Size. At 29 weeks 1600 Gm.— 3% lb. 40 Cm.— 15 inches. " 31 " 1900 " 4 " 43 " 16'4 '• 33 " 2100 " 4^4 " 44 " I6'y 2 " 35 " 2600 " Sy 4 " 47 " \7V A " " 37 " 2800 " 5V 4 " 48 " 18' " 40 " (full term) ..3100 " 6/4 " 52 " 19^ The body is limp ; the movements of the extremities are help- less and tardy. The face is usually sunken and senile. The skin is soft and delicate, vulnerable to an extreme, hence readily sus- ceptible to infectious processes. Respiration is irregular, super- ficial and sometimes of Cheyne-Stokes type. Atelectasis and cyanosis are not rare accompaniments. The heart beat and pulse are weak, often irregular, and the blood lacks in coagulating power. The bones are soft, more or less yielding to light manip- ulation. The temperature is subnormal. Premature infants, as a rule, are unable to suckle or swallow properly, and owing to incapacity of the digestive organs and atony of the intestinal musculature, to fully assimilate the food consumed. Severe colic and uric acid infarcts, which latter often lead to anuria and other uremic manifestation, add misery to their painful existence. Encumbered with so numerous deficiencies, the span of life of the delicate premature infant must obviously measure but a j^i'fy 11 few hours or days. The mortality of premature infants under 1600 grammes in weight, especially if they are inadequately cared for, is estimated to be about 80 per cent. ; of those weighing over 2000 grammes, 40 per cent. ; while of those weighing over 2500 grammes only 20 per cent. — almost as low as with full-term babies. Such as survive, however, often remain very feeble for many years, manifest a greater tendency to disease, and lack power of resistance to overcome it. Occasionally, after many ups and Recovery downs, premature infants marvelously extricate themselves from suitable tne pangs of death and grow up full of vivacity and vigor. It is therefore incumbent upon the physician to look upon every premature infant that respires at birth as one whose life can be preserved by suitable care and treatment. Management of "Feeble Vitality of the Newly Born" with Especial Reference to the Premature Baby. Three special indications are to be met in the management of newly born, delicate infants. We must (1) endeavor to maintain the best features of antenatal life; (2) supply nutriment suitable mortality. FEEBLE VITALITY. 169 for the infant's growth and development and (3) awaken and strengthen the dormant or inefficient functions of its organs. The first prerequisite should be met by an artificial environ- ment which should as nearly as possible resemble that of the Artificial heat. it l 'ii"ML,n»ij..:»;..i | .;"ii«' lilldBUOTHlMiMMIll" iKlMtulHMMMMH )lri!!;j;]:u r .ut»!iiiJ[C«tt Fig. 48. — Incubator for Premature Infants. interior of the uterus. The numerous modern incubators on the market in many instances answer the purpose. The infant is clothed in a woolen shirt and napkin and placed in the incubator, upon a cotton bed. 170 DISEASES OF THE NEWLY BORX. The temperature of the incubator is maintained steadily at about 96° F., and fresh air supplied by the automatic ventilating contrivance and by oft and on leaving the door open. Infants showing a fair amount of vitality usually get along very well without incubators, the latter being supplanted by ordinary bassenets and warm-water bags. Delicate incubator babies should be disturbed as little as possible, and removed only for feeding and cleansing (by means of lukewarm oil), or for such thera- peutic purposes (e.g., artificial respiration) as necessity arises. Fig. 49.— Incubator Room for Newly Horn Babies with Feeble Vitality. Prof. Th. Escherich. (Sheffield.) Avoidance of Bathing is contraindicated, and any undue handling of the skin or handling, mucous membranes must be carefully avoided, since most trifling injuries are very apt to be followed by fatal sepsis. Every effort should be made to feed the premature infant on woman's milk, for at least the first few weeks of extra-uterine life. When too weak to suckle from the breast, the milk may be given in diluted form (1:2) by means of a dropper or little spoon, care being taken that the milk flows down into the throat very slowly, lest it enter the trachea and lead to aspiration pneu- monia. In the absence of breast milk, light mixtures of cows' feeding 1 m ^ ( V 2 P er cent - °* ^ at > V 2 P er cent - P r oteids and 5 per cent, of milk-sugar) should be administered every hour or two, in quan- tities of 1 to 4 teaspoonfuls. FEEBLE VITALITY. 171 The third indication applies principally to infants who, though born at full term, possess very little vitality, and whose organs, especially the heart and lungs, fail to functionate. This vitality stimulation, is best aroused by artificial respiration — by alternate flexion and extension of the infant's body while it lies on the operator's palms. An occasional dash of cold water upon its face, to induce the child to cry aloud and take deep breaths, and stimulation by means of oxygen and strychnine, serve as useful adjuvants. SCLEREMA NEONATORUM (Sclerema Adiposum). This very rare affection may be primary, without any appar- ent cause, or secondary in nature, as a result of great loss of . body fluids (internal hemorrhages, gastrointestinal disease), or extensive exudations into internal cavities (thorax). It occurs principally in the premature, very feeble and badly nourished infants in the first few days of life (but also very much later, up to six months of age). It begins in the lower extremities, particularly the calves. Begins _, . . . ... ......... . with lower brom here it spreads symmetrically over the thighs, loms, trunk, extremities. neck, upper extremities and head, leaving penis, scrotum, planta pedis and palma manus uninvolved. The skin is dirty yellow, very tense, cold, hard, immovable over the underlying struc- tures, and does not pit on pressure. From day to day the skin becomes more indurated, marble- Marbieized. ized, and the patient lies stiff with rigid, mask-like face and firmly closed mouth as though in a state of tetanus. Suckling is interference often impossible. There is gradual sinking of all vital func- suckling, tions. The temperature falls (to 85° F. or lower), the heart action becomes weak, the pulse is slow and barely perceptible, subnormal respiration shallow and irregular, the voice feeble and whining, emperc the intestines and kidneys are inactive, the child wastes rapidly, and death ensues in about a week from exhaustion or some complication, the commonest being pneumonia and sepsis. Milder cases, especially older infants, not infrequently recover. Early hypodermo- and entero-clysis with hot (104° to 106° Acth F.) normal saline solution (from 2 to 3 ounces t. i. d.) ; gentle massage with oil; stimulation; maintenance of body heat; careful feeding, etc., as outlined under "Feeble Vitality of the Newly Born." (See page 168.) stimulation. 172 DISEASES OF THE NEWLY BORN. SCLEREDEMA NEONATORUM (Sclerema Serosum). This form of edema affects especially premature, weak (twins), atelectatic, and syphilitic infants. It usually begins a few days post partum (it is rarely congenital) with puffiness and swelling of the feet and legs. The edema soon extends upward (involving also the mons veneris, scrotum and penis) over the usually entire body, except the chest, and rarely the eyelids and face. free, -p^ ^^ j g tensej shiny^ wa xy white, or cyanotic, and pits on pressure. When the edema increases it greatly resembles true sclerema, but may be differentiated from the latter by bearing in mind the following characteristic symptoms : — Sclerema. Scleredema. Differentia- Color of skin Dirty yellow. Shiny or mottled. tion from Parts exempt Genitals, palms of the Chest. sclerema " hands and soles of the feet. Pitting on pressure Absent. Marked. The general symptoms, such as low temperature, great de- pression, etc., are not quite as pronounced as in sclerema adiposum. The prognosis is not as grave as in true sclerema. The treatment consists chiefly of stimulation (camphor, stinuiiatmn; c ijgjt_alis) , hot baths, massage and passive motion, active diuresis and proper feeding. See also "Feeble Vitality of the Newly Born." SEPSIS NEONATORUM. With the usual aseptic precautions that are now being taken in the management of labor and the puerperium, the number of cases of sepsis neonatorum has been reduced to a minimum. This is true especially of systemic sepsis. The extreme impor- tance, however, of the subject in question, demands its careful consideration. LOCAL SEPSIS. Omphalitis (Inflammation of the Navel). Simple omphalitis is manifested by delayed closure of the umbilical wound after separation of the umbilical cord, wetness, innammauon 1 sn g nt suppuration, and incrustation. There is no inflammatory reaction in the surrounding parts. The general health is undisturbed. SEPSIS NEONATORUM. 173 Phlegmonous omphalitis usually begins the second week after birth. The navel forms an ulcerated conical projection. The conical surrounding tissue is firm, infiltrated, glossy and painful to the pro:iec ! touch. Sometimes the inflammation extends rapidly over the abdominal wall or into the deeper structures, giving rise to peri- tonitis. The constitutional symptoms vary with the degree of constitutional r rr ■ symptoms. seventy ot the affection, but are sufficiently pronounced as to make the child quite ill and to render the prognosis doubtful. Milder cases often terminate in suppuration and with careful treatment (see page 174) in recovery. Erysipelatoid omphalitis is a very grave affection, often ter- minating fatally either within a few days from exhaustion or a week to ten days later from septic peritonitis, icterus, and local septic symptoms. suppuration. The symptoms and treatment are the same as in ordinary erysipelas. Diphtheritic omphalitis (ulcus umbilici) is characterized by a fibrinous umbilical exudation which when cast off leaves behind Kiebs- Loffler a superficial or deep ulcer. Occasionally it is due to Klebs- bacilli. Loffler bacillus. Gangrenous omphalitis ends fatally in the majority of cases. At first a small, discolored, ulcerated spot, if not immediately sioughing. arrested, it rapidly develops into a large, gangrenous, fetid mass. It sometimes extends into the deeper structures, giving rise to peritonitis, urinary and fecal fistulse, profuse hemorrhage and pronounced constitutional symptoms. As the umbilical wound forms the principal and most fre- quent portal of entry for septic infection, the importance of caring for the umbilicus with the minutest detail is quite obvious. Strictest cleanliness should be enforced and unnecessary hand- Aseptic ling prohibited. Clean scissors, clean ligature, preferably com- posed of several strands of cotton or silk thread, and, above all, clean hands should be used in cutting, ligating, and dressing the cord. The dressing should consist of a few layers of sterile Dry linen cloths and a dusting powder (1 part of salicylic acid and ofnavei. 6 parts of starch) and be changed every alternate day, preceded by cleansing the wound with a little pure alcohol to hasten desic- cation of the umbilical rest. As moisture favors the growth and absorption of the bacteria which accumulate at the navel wound, the child should daily receive a sponge-bath instead of a tub- bath, until the navel has completely cicatrized. To prevent hernia as well as access of dirt, the umbilical precautions. 174 DISEASES OF THE NEWLY BORX. hand should be continued for some time after complete healing of the navel. If inflammation of the navel, no matter how slight in degree, energetic occurs notwithstanding all the precautions, it should receive immediate and energetic treatment. Procrastination is danger- ous, nay, often fatal. Cauterization of the affected parts with a 2 per cent, to 5 per cent, solution of nitrate of silver, once a day or less often, 'stiver, is very useful in all forms of omphalitis. The wound should be kept scrupulously clean, and protected by a moist (boric acid solution 4 per cent.) gauze dressing, covered by rubber tissue. If the septic process does not yield to this treatment early, a surgeon should be consulted. A bacteriologic examination may Diphtheria . . . . . . . , , . antitoxin, prove helpful in giving a correct clue as to the treatment, as for example, in diphtheritic omphalitis, where diphtheria antitoxin is of undoubted benefit. (See also "Biologic Therapeutics," page 94.) Omphalorrhagia (Bleeding from the Navel. Idiopathic Umbilical Hemorrhage). Umbilical hemorrhage may occur as a result of tearing of the cord during delivery, defective ligation, or imperfect estab- lishment of respiration (delaying the closure of the umbilical vessels). The hemorrhage may be slight or severe, but is readily controllable. In contradistinction to these forms of navel bleed- ing which take place soon after birth, there is another variety of bleeding from the navel, the so-called "Idiopathic or Spon- taneous Umbilical Hemorrhage" which occurs at about the time the umbilical rest separates (between the fourth and ninth days). The bleeding takes the form of a steady oozing of blood as se sis of though coming from a compressed wet sponge. It is probably u ™biood- ( ^ ue to se P s ^ s OI the umbilical blood-vessels. Some authors are vessels. i nc li ne(: i to attribute it to congenital syphilis or transitory hemo- hiiis P mna ( see P a & e 477). In a great many instances the hemor- Hemophiiia. r hage cannot be arrested, death taking place either from exsan- guination or from gradual exhaustion and complications (sepsis). For details of treatment see "Hemorrhea Neonatorum" (page 181). Umbilical Granuloma (Excrescence, Fungus, Sarcomphalos). strawberry- It is a strawberry-like, small tumor, attached to a broad like tumor, base or pedicle at the umbilical stump. It bleeds readily and SEPSIS NEONATORUM. 175 usually discharges thin pus. Like exuberant granulations in other localities, it is promptly cured by a few applications of nitrate' of silver (the stick or 10 per cent, solution). It should o/snver. not be confounded with ''Persistent Omphalomesentericus." (See page 146.) Ophthalmoblennorrhea Neonatorum (Gonorrheal or Purulent Ophthalmia). Gonorrheal ophthalmia is caused by infection of the con- junctiva of one or both eyes by the gonococcus (Neisser). The Fig. 50. — Gonococcus. (Gonorrheal Pus.) Stained one- half minute with methylene-blue. a, Free in groups. b, Enclosed in pus cells. Leitz ocular I. Oil immersion 1 /±2- (Lenharts and Brooks.) inoculation usually occurs during the passage of the head through the parturient canal containing a gonorrheal discharge. It may ^°g° t 7 ^ eal also be conveyed to the eyes of the infant post partum by means of the fingers of the attendant or articles in use which have been soiled by the purulent discharge. The disease begins two or three days after the gonorrheal inoculation with intense tumefaction of the lids, redness, swell- ing and thickening of the conjunctivae, lacrimation, and mucous and mucopurulent secretion. From day to day the discharge Thick, "becomes thicker and more purulent ; the conjunctiva assumes a discharge, velvet-like appearance (chemosis), and papillary deposits or longitudinal folds appear upon the conjunctiva bulbi. If not immediately arrested, especially if the purulent secretion is 176 DISEASES OF THE NEWLY BORN. allowed to accumulate between the edematous, pasted lids, the disease spreads rapidly to the cornea, causing haziness, macera- invoivement tion and partial or total perforation. As a result of the latter and depending upon its location total or partial staphyloma, panophthalmitis with phthisis bulbi, capsular cataract, and anterior synechias may supervene. Occasionally, particularly in delicate infants, gonorrheal con- junctivitis gives rise to numerous complications, such as articular affections, gonorrheal rhinitis, stomatitis, etc. The duration of the disease varies from four to eight weeks. Until the introduction of Crede's method of prophylaxis, gonorrheal ophthalmia was supposed to have contributed 60 per cent, of the cases of blindness of one or both eyes. At present riie percentage has been reduced to one-third and with early and careful treatment the prognosis is still more favorable. Gonorrheal ophthalmia is not to be confounded with the simple conjunctivitis not infrequently met in the newly born in connection with local sepsis. The latter variety is readily recognized by the absence of gonococci in the discharge and by its much milder course. Where there is the least suspicion of gonorrhea in the mother, her parturient canal and external geni- talia should be carefully disinfected by a bichlorid solution (1 to 5000) before, during and after delivery. In addition to this the method* f°U° wm g directions given by Crede in the way of prophylaxis should promptly be resorted to: Wash off each eye with a boric acid wipe ; into each eye instill two drops of a 2 per cent, solution of silver nitrate ; in about thirty seconds wash out the excess with saline solution. This should be done as early after birth as possible. During the puerperal state the child should be kept away from the mother. In absence of gonorrhea, the infant's eyes should be washed with a saturated solution of boric acid. If only one eye be infected the fellow-eye should be securely of'heaithy covered by a watch-glass or a small pad of lint, oiled silk and eye - roller bandage. This protected eye should be inspected and cleansed twice daily. As soon as the child is seen by the physician he should pencil Nitrate tne affected eye with a 2 per cent, silver solution. If this occurs of silver. ear i v> the ophthalmia may sometimes be arrested in its incipiency or at least rendered milder in its course. The affected eye must be handled by the nurse from behind the patient's head. Small, round layers of lint are transferred Gentle cleansing. SEPSIS NEONATORUM. 177 every three to five minutes from a large square of ice to the affected eye, continuously for one hour. An intermission of one hour is then given and the cold applications are resumed. This should be continued day and night until there is positive evidence of abatement of the inflammation and excretion. This usually occurs within two weeks. The eyes should be carefully but very gently cleansed every half an hour with warm saturated solution of boric acid (4 per cent.). If the lids are so swollen as not to permit thorough cleansing, canthotomy may be resorted to. Silver being the most proficient antigonococcus, a 2 to 3 per cent, solution should be applied to the conjunctiva daily as long as the excretion is profuse and less often when it becomes more scanty and less purulent. In involvement of the cornea the ice- cloths should be discontinued, but not the silver applications. A i per cent, solution of atropine should be used as necessity arises. Examination of the discharge for gonococci should be made at least once a week, and the case should not be regarded non- contagious and out of danger until the discharge from the eye Repeated . examination remains free from gonococci for at least two weeks. The treat- of discharge for gono- ment of gonorrheal ophthalmia should not be intrusted to cocci, unskillful hands. The better trained the nurse is in handling serious eye cases, the more rapid and perfect the recovery. Pemphigus Neonatorum. Simple, non-syphilitic (see page 400) pemphigus makes its appearance between the fifth and twentieth day of the child's life. It is quite communicable, sometimes epidemic, and is Communi- n r cable. probably due to the staphylococcus pyogenes aureus. Its seats of predilection are the abdomen and inguinal region, but the lesion may be found on any part of the body. It but very £ alms o£ d rarely affects the palms of the hands and soles of the feet herein markedly differing from syphilitic pemphigus. The erup- £ree tion consists of tense bullae, varying in size from a lentil to a quarter of a dollar piece and contains a serous, rarely seropuru- lent fluid. The blebs are situated upon a reddened base, and on bursting leave moist red spots which very soon are covered over by skin. Occasionally ulceration of the skin supervenes, and is accompanied by high fever and other constitutional symptoms 1- i • \ om ■ £ r .i i- • Malignant (malignant pemphigus). I Ins severe form or the disease is pemphigus. 12 soles of feet usually 178 DISEASES OF THE NEWLY BORX. observed particularly in cachectic and bottle-fed infants, exposed to unsanitary surroundings, and often leads to fatal issue. In otherwise healthy, well-nourished and well-kept infants, recovery may be expected within from two to three weeks. Simple pemphigus is preventable by strict attention to general hygiene and proper feeding. Those in charge of the child should isolation, be cautioned as to the communicability of the disease. If large surfaces are involved warm baths are very useful, preferably with oak bark (quercus corticis), bran or clay. They may be administered two or three times a day and followed by dusting over the moist surface R. Bismuthi subgall., Acidi salicyl aa gr. x | 0.6 Zinci stearat Sj | 30. and enveloping the body in cotton. Occasionally, application of a 2 per cent, solution of nitrate of silver. Dermatitis Exfoliativa Neonatorum. Slight dermatitis, or erythema, with or without desquamation, is more or less physiologic in the newly born. There is, however, an obscure (sepsis?) form of exfoliative dermatitis which is peculiar to early infancy (usually in the second, rarely after the fifth week of life), and is closely related to pemphigus. It begins Rhagades. with inflammation of the oral mucous membrane, rhagades at the angles of the mouth and diffuse redness of the entire body, Large followed by active desquamation of the skin in large lamellae. It is sometimes preceded by detachment of skin and bursting of vesicles filled with clear fluid. Not infrequently the erosions extend to the oral mucous membrane. The disease runs its (afebrile) course in a few weeks, and in Bad prog- ro b us t children ends favorably. In delicate children it may be nosis in J J children 6 f°ll° we d by general furunculosis or even gangrene, gastroin- testinal disturbance and pneumonia and prove fatal. Like non-syphilitic pemphigus, dermatitis exfoliativa is pre- ventable by scrupulous cleanliness, and avoidance of local irrita- tion. The local treatment consists of inunctions of 1 per cent, salicylic or carbolic acid oil. GENERAL SEPSIS. In speaking of primarily local septic affections attention has been directed to the frequency with which grave constitutional SEPSIS NEONATORUM. 179 symptoms are observed during their protracted course. In these cases the systemic manifestations are secondary to the local ones, and if the latter are detected and treated early, the former may be prevented or arrested in their incipiency. We are now about to describe a group of septic diseases in the newly born which either present no visible local lesions at all, or so slight as to escape attention in their early stages. Tetanus (Trismus) Neonatorum. Tetanus in the newly born, like the corresponding disease in the adult, is due to the tetanus bacillus (Nicolaier, Kitasato). i ^ Prophylaxis. Fig. 51.— Bacillus Tetani. X 1000. (After Frankel and Pfeiffer.) Infection usually occurs through the umbilical stump or circum- cision wound. The bacillus multiplies by spore-formation and generates toxins which enter the system, and are absorbed prin- cipally by the endings of the motor nerves. From here the toxins are ultimately carried to the anterior horns of the spinal cord and the nuclei of the medulla oblongata — hence the tetanic contractions. The symptoms begin within the first week after birth, rarely later (after ritual circumcision), with restlessness, dropping of Lo( ' kjnw the nipple of the breast or bottle with a cry, and tension of the masseters. The spasm rapidly involves the orbicularis oris and palpebrarum muscles, the lower jaw becomes rigid, the mouth Infection through open wound. 180 DISEASES OF THE NEWLY BORN. proboscidiform, the forehead and cheeks are wrinkled, and the eyelids are half closed (risus sardonicus). The hands are spasmodic clenched, the legs flexed and abducted and, varying with the oflxtremi 1 - degree of severity of the attack, there is more or less marked Opisthotonos! opisthotonos. At first the paroxysms occur only during the act of nursing, gradually, however, more frequently and more per- sistently. In severe cases there are also spasmus of the glottis, of the esophagus, and diaphragm, and in consequence attacks of asphyxia which may end fatally. On the other hand, the affec- tion may run a protracted course, sometimes for weeks, and end occasionally in recovery. The more violent the attacks and the higher the tempera- ture, the less favorable the prognosis; 70 per cent, of the cases succumb within a few days, either from spasm of the diaphragm or, more rarely, from exhaustion. Asepsis. Careful protection against wound infection and prompt atten- tion to existing traumatism. Considering the very grave prog- nosis under the ordinary methods of treatment and the occa- sional success obtained by means of hypodermic or subdural Tetanus administration of tetanus antitoxin, the latter should be resorted antitoxin. to at the earliest possible time, either as a prophylactic imme- diately after the injury (1500 units) or as a curative measure (3000 units p. r. n.), in addition to the symptomatic treatment generally in vogue. This consists of perfect rest, lukewarm baths, chloral hydrate and the bromides per rectum, feeding (mother's or diluted cows' milk) with a tube through the nose, and avoidance of any irritation of the skin. Arteritis and Phlebitis Umbilicalis. This condition is usually observed secondarily to omphalitis, usually but may occur as a primary disease. In the latter event no local to ompha- alterations are discernible at the navel and the grave affection frequently escapes notice until pronounced symptoms of general sepsis make their appearance. * These consist of restlessness, fever, prostration and death within a few days, or gradual exhaustion from numerous complications. In umbilical phlebitis intense intense icterus — from extension of the inflammation to the liver icterus. . . . — forms a characteristic symptom. In some cases of arteritis and phlebitis umbilicalis a fistulous tract is observed at the navel which on pressure discharges blood and pus containing patho- genic micro-organisms. redness. SEPSIS NEONATORUM. 181 For prophylactic and local treatment see "Omphalitis" (page 172). The constitutional symptoms call for symptomatic treat- ment. Thus, careful feeding, preferably breast milk; active stimulation by means of enteroclysis, hypodermoclysis, sterile Antistrepto- camphorated oil, etc. Antistreptococcic serum is deserving of serum, trial. Erysipelas Neonatorum. This affection begins suddenly, with high fever, convulsions, and often other symptoms of general sepsis. The glossy redness Rapidly rapidly extends over large areas, often over the entire body. The |¥ossy ms disease proves fatal in a few days and the cases that survive the acute attack usually succumb to cutaneous necrosis (particularly of the scrotum, extremities), copious diarrhea, septic peritonitis, pneumonia and exhaustion. The treatment is principally prophylactic. The inflamed areas should once a day be painted with pure ichthyol. HEMORRHEA NEONATORUM ACQUISITA. Melena Vera. Epidemic Hemoglobinuria with Icterus (Winckel's Disease). Acute Fatty Degeneration (Buhl's Disease). Latest investigations tend to establish the fact that the afore- mentioned symptom-complexes in all probability are part-mani- festations of general sepsis of the newly born. Mention, how- ever, may be made that congenital heart disease, syphilis, and "feeble vitality" serve as predisposing causes. 1. Melena Neonatorum. Melena vera should not be mistaken for melena spuria, in which condition the blood originates from erosions in the mouth True and or nasopharynx, or from swallowing of blood from fissured nipples, etc. Melena vera usually begins in the first few days of the child's life with bleeding from the bowels, and often with hematemesis. As a rule, the blood is mixed with stool, and is dark brown or black in color. In some cases the loss of blood is slight, recurs at canal long intervals and terminates spontaneously without serious con- sequences except tedious convalescence. In the majority of cases of genuine melena, however, the bloody discharge is pro- fuse and leads to rapidly increasing anemia and collapse. Symptoms of general sepsis. Blood from mentary 182 DISEASES OF THE NEWLY BORN. 2. Epidemic Hemoglobinuria with Icterus in the Newborn (Cyanosis Icterica cum Hemoglobinuria, Winckel's Disease). This extremely grave (90 per cent, mortality) epidemic affec- tion makes its appearance about the fourth day post partum, in apparently healthy-born and well-developed children. The infant becomes restless, refuses nourishment, shows signs of respiratory disturbance and slight rise of temperature. The skin turns greenish-yellow, and soon deeply jaundiced and cyano- tic. Collapse, somnolence and convulsions, rarely preceded also Hemoglobin, by vomiting and diarrhea (no blood), are rapidly followed by b }ooA- death. The urine is pale brown, contains hemoglobin, renal cells in r ° urine, epithelium, granular and blood casts, and masses of detritus, but no free blood-corpuscles. The autopsy reveals congestion and fatty degeneration of the Pathologic Eternal organs, with punctiform hemorrhages, especially in the findings. m ucous and serous membranes ; masses of granular hemoglobin in the kidneys and spleen, thickening of the blood, and slightly increased leucocytosis. 3. Acute Fatty Degeneration of the Newborn (Buhl's Disease). The essential anatomical features of this rare but very F f.tty malignant affection are fatty degeneration of the internal organs, degeneration ° 7 . of internal notably the heart, liver and kidneys, and hemorrhages in any organs. J J ° J of the viscera, and into the serous cavities. The disease attacks full-term infants who for some inexpli- cable reason are born asphyxiated. Those few who survive, As h xia res P^ re badly, are cyanotic, or rather icteric, and present hemor- Hemorrnages. r hages in the skin and mucous membranes, from the alimentary canal, and the umbilicus. They almost invariably succumb before the end of the second week from progressive anemia, anasarca, and collapse. Treatment. — The indications for the treatment of any of the manifestations grouped under "Hemorrhea Neonatorum Acquisita" are: 1, to arrest the hemorrhage; 2, to improve or, at least, maintain the vitality of the newly born infant. The first indication may be met by the administration of sterile ( !) Gelatin warm gelatin subcutaneously (10 per cent, solution, in doses of a quarter to half an ounce three times a day), per rectum (one to two ounces) and by mouth (2 per cent, to 5 per cent, solution, a teaspoon ful t. i. d.), in addition to local hemostasis by means FUNCTIONAL DISORDERS. 183 of adrenal solutions, perchloric! of iron, packing, compression, and cauterization (by nitric acid, Paquelin cautery). Very recently good results have been reported from hypodermatic in- Fresh jection (once or twice) of 5 cubic centimeters of fresh rabbit- serum" serum. To meet the second indication, the reader is referred to the instructions given under the "Management of Feeble Vitality of the Newborn" (see page 168). FUNCTIONAL DISORDERS OF THE NEWBORN. URIC ACID INFARCT, ICTERUS, MASTITIS. Uric Acid Infarct. The urine of the newly born is clear immediately after birth, but turns turbid soon after and remains so for the first four or five days. It contains bladder and kidney epithelia, hyaline and epithelial casts, and a large quantity of urates. In consequence of the sudden alteration in the blood circulation there is an exces- sive excretion of nitrogenous metabolic products, and, as the newly born consumes but very little water during the first few days of life, uric acid crystals and ammonium urate instead of being washed away are retained in the renal tubules. The symptoms accruing from this functional insufficiency depend greatly upon the degree of obstruction of the urinary tubules. Ordinarily gradual elimination of the uric acid and ammonium urate crystals occurs within a few days without any abnormal manifestations, except restlessness and crying just before and during the act of urination, and passage of small quantities of highly colored urine showing brick-red stains and a fine granular deposit on the diaper. Occasionally, however, Anuria there are complete retention of urine, fever, and, owing to irri- tation of the renal pelvis, nephritis with its concomitant symp- toms (albuminuria neonatorum). Treatment. — Large quantities of fluids, hot baths, mild diuretics. $ Kalii acetatis 3ss [ 2 Aq. fceniculi Siij | 90 M. Sig. : 3j every hour if necessary. Icterus Neonatorum Catarrhalis. The theories promulgated to explain the causation of icterus in the newborn are so numerous, pedantic and contradicting, that. Uric acid crystals. Complica- tions. Hyperactivity of liver. Gastro- enteric irritation. 184 DISEASES OF THE NEWLY BORN. for the sake of clearness, are best left alone. It is perfectly safe and sane to look upon this common (in about 80 per cent, of all newly born infants) and harmless phenomenon as an expression of the active physiological changes in the liver to which all the other organs are subjected in the first few days of life. It would seem, however, plausible to assume that analogous to catarrhal jaundice in older children, icterus of the newly born is also a manifestation of gastrointestinal irritation, produced by the sudden demand upon the digestive system to exercise functions hitherto not accustomed to. The yellowish discoloration of the skin usually appears on the second or third day, first on the face and chest and gradually extends to the abdomen and extremities and, rarely, also to the course, scleras. The icterus runs an afebrile, uncomplicated course of about two weeks' duration. Cases proceeding a more protracted course and presenting more or less severe general symptoms should always be looked upon as a partial manifestation of sepsis neonatorum (q.v.). Mastitis Neonatorum. Moderate swelling of the mammary glands of the newborn and discharge of a milklike secretion ("witches' milk") is phys- iological in infants of both sexes. It begins between the first and third weeks of life and may persist for weeks without giving rise to ill effects. Occasionally, however, as a result of traumatism or infection it may terminate in acute inflammation or even sup- puration. In this event the breasts are red, swollen and painful, and may present fluctuation at one or more points, and constitu- tional symptoms, such as restlessness, vomiting and fever. If the mammary glands are from the beginning not sub- jected to meddlesome interference, in short, are left entirely alone, there is usually spontaneous, gradual restitutio ad integ- rum. Should inflammation ensue, the breasts should be wrapped in oiled cloths or absorbent cotton lightly painted with tincture of iodin, or covered with emplastrum belladonnas smeared on soft thin leather. In the event of suppuration, if not relieved by spontaneous evacuation of the pus, a radiate incision under asep- tic precautions is indispensable. Phlegmonous inflammation and gangrene are rare complica- tions, while atrophy of the mammary glands and more or less loss of function may prove very serious to girls. Spontaneous. Traumatism or infection. Evacuation of pus. CHAPTER VI. Diseases of the Alimentary Tract. DISEASES OF THE MOUTH. STOMATITIS. This inflammation of the mucous membrane of the oral cavity is a more or less contagious affection peculiar to infancy and contagious, early childhood. It varies in intensity from simple temporary catarrh to fatal gangrene. It is invariably of parasitic origin. The degree of severity of the disease depends upon the patho- genicity of the parasite, the power of resistance of the patient, and the promptness and accuracy of the treatment. Stomatitis occurs, therefore, principally at a time when the child's health is undermined, as, for example, during dentition, or synchronously with acute infectious diseases. Even normally the . ...... Lack of mouth forms a favorable nidus for cocci, bacilli, spirilla, cleanliness, leptothrix, and like vegetations, and their growth is surely enhanced by allowing the child to enjoy its acrid nasal dis- charge ; to suck on dirty nipples, toys, and eatables ; by keeping its mouth and teeth filthy; by denuding the oral mucous mem- trauma. brane of its epithelium by brisk rubbing in the act of cleansing, and by permitting every friend or kin to infect the child's mouth by overindulgence in the art of osculation. Finally, dental caries, Dental J ..... canes. hemorrhagic affections, intoxication from the use of mercury, bismuth, etc., among many other diseased conditions frequently form contributing causes of stomatitis. In accordance with the seat and appearance of the lesion it is customary to distinguish the following varieties of the disease : — 1. Stomatitis Catarrhalis (Erythematosa). — Redness and slight tumefaction of several portions of the mucous f^ ness membrane of the mouth, coated tongue with prominent dwelling papillae and red tip and edges. Often marked salivation. 2. Stomatitis Mycotica (Soor, Thrush, Sprue). — Probably due to a hyphomycete, the .1/ on ilia Candida. Usually begins with a fine, white, flour- or casein-like deposit upon deposit' 1 '' ( 1 85 I L86 DISEASES OF ALIMENTARY TRACT. Extension to pharynx, etc. the slightly reddened tongue and buccal mucous mem- brane. If not arrested the dots and maculae coalesce and often extend to the pharynx, esophagus, stomach and intestines. This is apt to occur especially in atrophic children. 3. Stomatitis Maculofibrinosa (Aphthosa, Follicularis, Herpetiformis). — The causal micro-organism is still Fig. 52.— Ulcerative Stomatitis. (Sheffield.) Yellowish- gray or white specks. undetermined. Often begins with small vesicles. The inflamed mucous membrane is here and there (usually anterior part of mouth) covered by small, grain- to lentil-sized, variously shaped, yellow, grayish-yellow, or grayish-white foci surrounded by a dark-red areola. By coalescence of several follicles large raised plaques are sometimes observed. Foetor ex ore. Stomatitis Ulcerosa (Stomacace). — It is attributed to the Bacillus fusiformis and the Spirochete denticola. The lesion consists of numerous, grayish, irregular ulcers with Grayish ulcers upon red DISEASES OF THE MOUTH. 187 a bleeding base and angry-looking areola, situated at first on the red, spongy and painful gums, and, if not arrested, spreading to the tongue, cheeks or lips. Septic odor ex base " ore. This form of stomatitis differs from the yellowish to greenish, superficial, easily bleeding ulcers, known as Bednar's Aphtha (ulcera pterygoidea), by the fact that the latter appear symmetrically on each side of the tionTrom a median raphe near the junction of the hard and soft aphthae s palates. "epithelial It may occasionally also be mistaken for the excep- peai tionally ulcerating, so-called "epithelial pearls." These innocent milia-like dots, however, are usually found only in the newly born, and situated along both sides of the raphe of the palate. 5. Stomatitis Gangrenosa (Noma Faciei, Cancrum Oris). — It occurs principally in cachectic children, chiefly between two and five years old. May follow ulcerative stomatitis or acute exanthematous diseases (measles!). Begins with a small, rapidly spreading, brownish, greenish ulcer upon a hard, elevated base, on the inner surface of the cheek, near the angle of the mouth or on the lips. Very soon a black spot appears on the outside of the cheek, Black spot r rl ' outside surrounded by marked tumefaction of that side of the of cheek, face and of the submaxillary glands. The cheek becomes perforated, the edges of the wound turn black, and the Perforation sloughing process spreads rapidly so that the whole thick- ness of the cheek has the appearance of a dirty, greasy scab, and within a few days may be completely destroyed. Sepsis. Rapid exhaustion. Mild or even moderately severe cases of stomatitis rarely give rise to systemic disturbance, and unless the local lesion is situated on the lips, tongue, or gums and interferes with sucking or chew- ing, several days may pass before the disease is detected. Some- hence often _ & ' . . . overlooked. times the patient is feverish and restless, cries and refuses food in the earliest stage of stomatitis, but the constitutional symptoms do not stand in direct ratio to the extent and gravity of the local manifestations. Indeed, the reverse is often the case. However, with persistence of the local symptoms, sooner or later the general health participates in the pathologic process. Starch digestion is greatly impaired by the excessive loss of saliva, which General sepsis. Mild at onset, 188 DISEASES OF ALIMENTARY TRACT. almost incessantly dribbles from tbe swollen, reddened, half- closed mouth, and vomiting and severe diarrhea are frequent involvement results of swallowing of the putrid saliva and the decomposing, tary tract, more or less ichorous and membranous oral contents. These lat- ter symptoms, in addition to the emaciation from refusal of food and absorption of septic material, greatly delay convalescence and may lead to gradual or rapid exhaustion and fatal issue. In the absence of such grave symptoms and with early and careful treat- ment the prognosis is good in all forms of stomatitis, except noma (85 per cent, mortality). Above all, cleanliness should be enforced and the sooner it is begun with the surer we are of rendering the disease free from untoward consequences. Strictest cleanliness of the food, feed- ing-bottles and nipples, cups, spoons and everything else coming in contact with the child's mouth should be observed. The child's Gentle cleansing mouth should be regularlv washed after each feeding, bv gently of mouth. s - s ' J y J imping it with absorbent cotton dipped in a 2 per cent, watery solution of boric acid or bicarbonate of soda. As to general cleanliness see "Hygiene" (page 82). In mild cases it is usually sufficient to paint the affected parts once a day with a 2 per cent, solution of nitrate of silver and to employ the following mouth-wash every two to four hours :— H Boric acid, Borate of soda aa 3j | 4 Hydrogen dioxid, Glycerin aa 3j | 30 Alcohol Siv I 15 Rose-water q. s. 5iv j 120 M. Sig. : To be diluted with an equal quantity of water, as a mouth-wash. Should the stomatitis fail to yield to the treatment after twenty-four or forty-eight hours, more energetic measures should then be adopted to stay its destructive tendencies. The strength Nit siiver! °^ tne s ^ ver solution should be doubled, and the mouth irrigated every two hours with 1 per cent, permanganate of potash ; 5 per cent. Labarraque's solution, etc. It is often advantageous to suspend milk feeding for a few days and nourish the child on broths, light cocoa, cereals, toast and tea, pineapple juice, etc. Protracted illness demands active stimulation, stimulation by means of good wines (diluted), strychnine, and stomachics, compound tincture of cinchona. This may be combined with the rhubarb and soda mixture, to remedy gastrointestinal disturbance Diphtheria antitoxin. DISEASES OF THE MOUTH. 189 which is ever present in cases of long standing. In the majority of instances even severe cases of stomatitis promptly respond to this mode of treatment. An exception to this rule is made, how- ever, by noma,— that rapidly advancing form of necrosis, which of noma, knows no barrier to its destructive, death-dealing trail, and often even the knife cannot stay its ravages. At the earliest possible moment the gangrenous portion should be destroyed with the caustic stick, nitric acid or preferably the actual cautery. Fre- quent cleansing of the parts should be continued day and night, and strengthening food and stimulants administered at short intervals. As Loffler's bacilli were found in a few cases of noma faciei and vulvae, diphtheria antitoxin (5 to 10,000 units) should be resorted to early in the course of the disease. Very often everything fails; fatal issue occurs either after two or three weeks (sometimes when the patient is apparently saved) or, more rarely, suddenly as a result of entrance of air into the veins. Radical operation has recently received enthusiastic advocacy. DENTITIO DIFFICILIS (Difficult Teething). As a rule, normal children get their teeth without any diffi- culty. They may show a slight indisposition in the form of fret- indisposition, fulness, disturbed sleep and slight loss of appetite. If care is being taken not to overfeed the baby during this teething period and the mouth is kept free from outside infection, there is rarely any need for special therapeutic measures. On the other hand, infants of low vitality and more especially those who had been suffering from gastroenteric disturbances or rachitis previous to the eruption of a tooth, teething, particularly when several teeth come at once, is very apt greatly to aggravate the diseased con- ditions. But, even in these children, neglect in the general care of their health to a great extent is responsible for the serious con- sequences. Most people are so strongly imbued with the idea cause of that teething is the sole cause of gastroenteritis, bronchitis, otitis and what not, and must be so as a matter of course, that they complacently wait and watch for the teeth to protrude and seek no medical aid to stay the ravages of the incidental ailments. It is usually in these cases that hyperpyrexia and convulsions are encountered, and that remedial measures have to be resorted to, as it were, to facilitate teething. Of course there are infants (see "Spasmophilia") who will feeding. 190 DISEASES OF ALIMENTARY TRACT. get convulsions, high fever, etc., on the most trifling provocation, teething also contributing its share in this direction, but all these extraordinary manifestations are surely exceptional. The main thing, therefore, is to reduce the food, avoid careful "soothing syrups," which almost invariably contain opium and upset digestion, and to keep the child outdoors. Where the gum is very much swollen and the tooth is visible under the mucous membrane, lancing of the gum can do no harm and may hasten eruption of the tooth. DISEASES OF THE SALIVARY GLANDS. SALIVATION. Increased salivary secretion is almost physiological during first dentition, and is the result of increased blood-supply to the oral mucous membrane. Pathologically it is observed in stoma- titis, cretinism, helminthiasis and mercurial intoxication. Occa- sionally it is met in apparently healthy children long after first dentition, and in the absence of any discernible cause it is attrib- uted to a neurosis. In view of the harmlessness of the condi- tion per sc no special treatment is indicated except protection of the chin and chest against the irritating effect of the constantly dribbling saliva, and removal of the causes wherever found. RANULA. Retention cysts, congenital or acquired, are not rarely observed in children, and are the result of obstruction of the sa ducts! salivary ducts. Most frequently a globular, usually unilateral, tense, cystic swelling is found on the floor of the oral cavity, sometimes close to the frenulum. This tumor, which is designated ranula, varies in size from a pea to a pigeon's egg and contains a thin or viscid fluid. If large in size, the tumor interferes with suckling, swallowing and breathing, and calls for its incision and cauterization, or complete excision. Ranula is not to be confounded with the peculiar sublingual growth (Riga's or Fede's disease) quite frequently observed in Italy 1 among nurslings. This neoplasm is usually situated at the insertion of the frenum linguae, attains the size of about a five- cent piece and shows a tendency to return unless completely extirpated. Obstructed Sublingual growth. Only a few such cases have thus far been observed in this country. DISEASES OF THE ESOPHAGUS. 191 SECONDARY PAROTITIS. This form of inflammation of the parotid gland may occur in connection with acute infectious diseases. It differs from epi- demic mumps (q. v.) inasmuch as it is, as a rule, unilateral, heals spontaneously within a few days, or ends in suppura- Tendency to r J J r r suppuration. tion, in the latter event requiring operative interference. DISEASES OF THE TONGUE. GLOSSITIS. Aside from the divers pathologic conditions of the tongue ordinarily met in connection with stomatitis, tonsillitis, pharyn- gitis, exanthematous affections, etc., the tongue is subject to the following peculiar diseases : — 1. Glossitis Marginalis Erythematosa. The inflammation is usually limited to the edges of the tongue which are red and partially denuded of epithelium. It is observed in artificially fed infants and probably the result of mechanical irritation in the act of sucking. The treatment is the same as for mild stomatitis. 2. Glossitis Areata Exfoliativa (Annulus Migrans, Lingua Geographica). As a rule, it begins with a brownish thickening at the margin of the tongue and by gradual spreading forms irregular, circum- scribed lines, resembling, as the name indicates, a geographical map. Now and then part of the thickened epithelium is thrust off, but new places are soon involved, and in this manner the affection may go on for years, without, however, giving rise to ulceration of the tongue or any constitutional symptoms. It is syphilitic not, as was frequently supposed, a sign of syphilis. The treatment consists of cleanliness and occasional painting with a strong solution of chromic acid. (See also Stomatitis.) DISEASES OF THE ESOPHAGUS. ESOPHAGITIS. Primary inflammation of the esophagus is comparatively rare in children, since the principal cause of the disease in the adult, i.e., corroding of the esophagus by caustic poisons taken with Denudation of epithe- lium. Not 192 DISEASES OF ALIMENTARY TRACT. suicidal intent, is of exceptional occurrence. However, it is occa- Accidentai sionally met in connection with accidental injuries, such as impac- injunes. ^ Qn q £ f ore jg n Doc ii eS) unintentional swallowing of caustics, etc., or scalding by hot fluids. The accompanying symptoms vary with the extent of the injury. They consist chiefly of dysphagia, tendency to vomit, and expectoration of bloody, membranous masses. In severe cases, if the patient at all survives (frequently fatal collapse) from the immediate effects of the injury, the esophagitis runs a very protracted course and produces secondary stricture, esophageal strictures (q. v.). Secondary esophagitis occurs as an extension of inflammatory, especially diphtheritic, processes of the mucous membrane of the mouth and pharynx. Antidotes. Antidotes in cases due to corrosives, morphine hypodermat- ically for the relief of pain and shock, ice collar to the neck and ice by mouth to subdue the inflammation, and stimulants when- Anodynes. ever indicated. STENOSIS OESOPHAGI. Esophageal strictures may be congenital (q.v.) or acquired, the latter being the result of esophagitis (q. v.). Depending upon the severity of the injury the stricture may advance up to total atresia. In children the stenosis is most frequently situated in Upper third of the upper third of the esophagus, and may occasionally be de- tected by esophagoscopy. Otherwise the diagnosis is established by introduction into the esophagus of an elastic catheter or whale- bone provided with small, olive-shaped steel tip. For this pur- pose the patient is placed in a sitting posture with the head extended slightly backward. The oiled instrument is guided with the first two fingers over the dorsum linguae and the epiglottis into the esophagus. In acquired stenosis the symptoms usually appear about two Dysphagia; we eks after the injury, and consist chiefly of difficult deglutition weight, and gradual loss of weight. In cases of stenosis due to compres- sion of the esophagus by diseased neighboring organs or tumors the symptoms are, of course, more gradual in their development, and more intricate in nature, agreeing with the primary cause. Partial stenoses often yield to dilatation by means of bougies, provided it is continued two or three times a week for at least six b^botf'i'e" months. The bougie is left in place for from five to thirty minutes. Occasional introduction of the bougie after apparent DISEASES OF STOMACH AND INTESTINES. 193 cure will prevent recurrences. Great care and patience are re- quired to prevent perforation. Gavage and nutrient enemata, if necessary. In severe and recurrent strictures operative interfer- operation. ence (esophagotomy or gastrotomy). Good results are claimed from the use of thiosinamin. Five drops of a 20 per cent, solu- Thiosinamin. tion may be injected hypodermatically twice a week, in addition to the dilatation previously spoken of. DISEASES OF THE STOMACH AND INTESTINES. General Remarks. The stomach is the most abused organ of the infantile body, Intended to serve as a recipient of only a sufficient quantity of infantile food to supply the needs of the human organism for its repair, maintenance and growth ; destined by means of its juice and ferments to subdivide, assort and predigest the food consumed, — in short to prepare it for easy assimilation ; and finally, created to macerate, filter and propel its contents into the channels best suited to complete wholesome metabolism ; this very same stom- ach, regardless of its inherent powers, capacity, state of health, and actual size, only too often is filled to overflowing, forced to "churn" almost incessantly, and to propel the food into the duodenum, frequently long before it is ready for reception. Dumping Nay, this very same stomach is rendered a dumping place, indigestible during meals, for everything on and off the table, and between meals, for "just a taste" of over- or under-ripe fruit, anilin- dyed sweets and cakes, in addition to the bottle- or breast-feed- ings given merely as a "drink" to quench the child's thirst. What wonder then that gastroenteric disease is fiercely rampant, that the death-rate from intestinal affections exceeds that of all other infantile diseases combined, and that those unfortunate, foully-fed children who survive remain dyspeptic, rachitic and decrepit, forming an easy prey to acute contagious and infec- tious diseases that usually befall the faint and the frail ! Verily, considering the baleful acts of omission and commission in infant feeding, one is amazed by the ever-swelling hordes of youthful humanity that have apparently escaped the clutches of ignorance ■ — and death. Merciful Nature! With the recent advances in bacteriology and physiological chemistry and corresponding improvements in sanitation and infant-feeding, cows' milk no longer holds the record of 13 l'.M DISEASES OF ALIMENTARY TRACT. "YVuerg-Engel" (destroying angel) of the poor innocent babes. Indeed, seldom a case of gastroenteritis is met which is not pri- ciean milk marily traceable to some gross error of diet entirely independent DOt sIbie"for of the cows' milk feeding. The sooner the physician will appre- ciate that fresh, unpolluted, properly modified (as to quality and quantity), well kept, and regularly administered cows' milk is not inimical (excepted are of course the comparatively rare cases of so-called "cows' milk idiosyncrasy" from birth) to good health and perfect development of the child, the better will he be pre- pared to reveal the etiologic factors of the gastrointestinal dis- turbance and combat them ! On the other hand, cows' milk, especially in the hot season of the year, whether contaminated at the dairy or at the filthy shop of the remorseless vendor, like water, may form an excellent vehicle for dissemination of pathogenic bacteria, and for the transference of infectious gastroenteric affections. Whatever the vehicle of transmission, — be it decomposed Danger in milk, f ruit, vegetables, or meats ; infected water, feeding-bottles infected ' & .... milk and or nipples, cups or spoons, toys or fingers ; infectious discharges articles from the mouth or nasopharynx, etc. — careful investigation has of food. . established the fact that most, if not all, acute gastrointestinal diseases are primarily or secondarily due to microbic invasion of the alimentary canal, the severity of the affection more or less corresponding to the pathogenicity of the invading micro- organisms. The bacteria responsible for the production of gastrointes- tinal diseases are very numerous. Streptococci, the bacillus coli communis; the dysentery bacilli of Shiga, Kruse and Flexner; staphylococci, influenza bacilli, the bacillus pyocyaneus, and pro- teus, among many others, contribute their share as etiologic factors. The determination of the specific germ of each type of gastrointestinal diseases, however, is still a matter of experi- mental research and subject to great diversity of opinion. Gastroenteric disorders in breast-fed babies may occur, in Er dtet{n addition to errors of diet and exposure to infection — less fre- br infants! ( l uent causes than in hand-fed babies — as a result of disturbance of the quality of the breast milk by disease, fright, grief, priva- tion, pregnancy, and like influences on part of the mother, or wet nurse. Finally, even in most carefully fed infants, gastrointestinal disorders are accasionally encountered where the alimentary incapacity. Misleading classification. DISEASES OF STOMACH A^D INTESTINES. 195 canal is functionally or anatomically defective from birth or where the infant is suffering from diseases of the other organs congenital of the body, or is indisposed from the effects of functional or organic alterations associated with normal bodily development (e.g., dentitio difficilis!). GASTROENTEROCOLITIS (Dyspepsia, Cholera Infantum, Summer Complaint). The more critically one analyzes the etiologic factors and pathologic data of the common gastroenteric diseases of early childhood, the more threadbare and misleading appear the exist- ing "text-book" classifications of these affections. It is to be regretted that modern authors still tenaciously cling to and elo- quently dilate upon the subdivisions of "gastritis," ''enteritis," "colitis," "gastroenteritis," "enterocolitis," and what not, claiming separate and independent existence for each and every one of them, whereas, in reality, neither the clinical signs of a typical case nor the post-mortem findings warrant such an assumption. On the contrary, one is often amazed by the poignant incongruity between" y that prevails between the scarcity and mildness of the post-mortem and P ost- a findings and the extreme gravity of the intra-vitam manifestations findings, of gastroenteric disease in early childhood, and vice versa. We are inclined to look upon the aforementioned group of gastrointestinal disorders as mere stages of one and the same pathologic condition, and will endeavor to discuss the subject in question from this point of view. 1. Acute Gastroenterocolitis. Occasional vomiting and diarrhea, occurring as a result of unusual overloading of the stomach, too hasty feeding, partaking of indigestible articles of food (peels and parings) or foreign bodies, exposure to sudden atmospheric changes and undue excitement, etc., are not rarely observed in otherwise apparently healthy, well-nourished children, and if of brief duration, are of no special clinical significance. These attacks may even be accom- panied by fever, mild cerebral irritation, colic, etc., and yet remain outside the domain of pathology, or represent an affec- tion which is generally spoken of as simple indigestion or the first stage of gastroenterocolitis. By avoiding further trans- n', 1 .^'^'^, 1 .'.',!"^ gressions of the ordinary dietary and hygienic rules, and by 196 DISEASES OF ALIMENTARY TRACT. removing the causal obnoxious influences recovery is usually prompt and permanent. If, however, the vomiting and diarrhea persist or recur at frequent intervals; if the child loses its appetite and some of its weight; if its tongue becomes heavily coated, its abdomen greatly distended and its general health more or less seriously impaired ; if the infant suffers from severe abdominal pain after each feed- ing and vomits part of the food consumed and some mucus and bile; finally, if the stools rapidly increase in number and consist of masses of undigested food, of bad color and offensive odor, second a symptom-complex develops which represents the second stage of gastroenterocolitis and is generally described as gastrointes- tinal catarrh or dyspepsia. Ordinarily these manifestations set in insidiously and if not promptly arrested grow w r orse gradually, arousing little if any anxiety on the part of those in charge of the baby, or are lost sight of, sometimes because of coincident "teething" (with the Gastroentero- laity the presumptive cause of all ills), until there is a sudden third stage, aggravation of the condition — supervention of the third stage of the disease. In this stage gastroenterocolitis assumes a very acute course. It is manifested by violent vomiting, excessive thirst; frequent, thin, watery, brownish, greenish, and later colorless or blood- stained stools. The vomitus is acid in reaction, bile-stained, and offensive in odor. The bowel movements vary between ten to fifteen in twenty-four hours, are preceded and followed by grip- ing pain and tenesmus. The child is very restless, feverish, sleep- less, and, with the symptoms persisting a few days, rapidly loses in weight, and sinks into a state of collapse, followed by con- vulsions, coma and death. More favorable cases may improve under energetic treatment, or linger for weeks or months, fre- quently suffer from intense exacerbations of the attack, and, finally, either recover after tedious convalescence or die from inanition or complications. Closely allied to the gastroenterocolitis just described (though possibly differing as to the exciting micro-organism), and prob- Fulm form! a ^- v representing only a severer, "fulminating" form of the same disease, is the so-called infantile "summer-complaint" or cholera nostras s. infantum. It usually rages in epidemic form during epidemic! tne not summ er months, especially among bottle-fed infants and those exposed to bad hygienic conditions, but occurs sporadically DISEASES OF STOMACH AND INTESTINES. 197 also at other seasons of the year. As with other contagious and infectious diseases previous ill health serves as an active and favorable predisposing cause also in this destructive affection, the acute and grave symptoms ordinarily supervening upon a latent period of indisposition of variable duration.. The attack ushers in suddenly with vomiting, diarrhea and collapse, prostration. The vomiting is more or less projectile in character and occurs especially immediately after drinking. The evacua- tions range between fifteen to thirty or more in twenty-four hours, are at first fecal in consistency and odor, but soon turn very watery, serous, light yellow or greenish in color, and occa- watery, sionally mixed with blood-streaked mucus. The abdomen is often and biood- trough-shaped and but slightly sensitive to pressure. The thirst stools, is intense ; the tongue dry, brown or black and cracked, irre- spective of the degree of temperature, which is rarely very high. Owing to the excessive loss of fluids the urine is very scanty and often contains a moderate amount of albumin. As the disease progresses the child perceptibly loses in weight, from hour to hour ; its face is pinched ; its f ontanelles, temples and eyes are deeply sunken; its extremities are cool and blue; the heart-beat and respiration barely audible — in short it is in a state • Intense of profound collapse. Apathy, somnolence, convulsions and emaciation, death then follow in rapid succession; the younger the child, the earlier, as a rule, the fatal termination. The latter is sometimes preceded by a state of hydrocephaloid — a condition variously ascribed to cerebral anemia or hyperemia, edema of the meninges cepnaioid. and uremia, and presenting the following symptom-complex : First stage, fever, restlessness, jactitations, and insomnia, flushed face, strong and bounding pulse ; second stage, subnormal tem- perature, cold extremities, feeble, irregular pulse and respiration, apathy, sopor and coma. The disease having reached this grave stage it offers a very bad prognosis ; but few children manage to survive so violent an R . h attack. Some of the few who do are apt to succumb later to mortality, complicating nephritis, pneumonia, cerebral sinus thrombosis, peritonitis and the like. Convalescence is very tedious even in the absence of compli- cations, and a great many children remain decrepit for life, chronic otitis media, xerosis of the cornea and panophthalmia often adding their share of misery. With such sad prospects in view after the gastrointestinal 198 DISEASES OF ALIMENTARY TRACT. affection is fully established, the urgency of early and energetic prophylaxis and treatment can readily be appreciated. To prevent the graver forms of gastroenterocolitis we must promptly remove the causes and effects of the mildest symptoms Preventive of the disease. Attention to every detail of rational feeding and personal hygiene and strictest cleanliness of the child's living rooms, feeding utensils, wearing apparel, and of all other things coming in direct contact with the patient are the surest means of prevention. As in the majority of instances the pathogenic bac- teria enter the infantile alimentary tract with infected milk or water, these should, especially in the summer months, be steril- of milk, ized or even boiled, regardless of the temporary arrest of gain in weight that is concomitant with such feeding — a puny baby on the lap rather than a fat one in the grave ! Weaning of the baby and other innovations during the hot summer months should be avoided. Lengthy voyages exacting prolonged disturbance of rest, sleep, and proper feeding should be interdicted. On the other hand, a sojourn in the country (inland, mountains, or sea- Change of air. shore) should be encouraged. Last but not least in importance as a prophylactic measure is the practice of whole or partial Breast breast feeding of infants under one year of age, unless counter- feeding. f r . . . J b manded by definite contraindications. The active treatment should begin, as already suggested, with the earliest inception of the gastrointestinal disorder. Regula- tion of diet is our most efficient therapeutic measure, and is almost invariably attended by improvement in the child's condi- tion if it is begun with a few hours' starvation of the patient and prompt cleansing of the alimentary tract of its obnoxious con- Discon- tents. Feeding:, breast or bottle, should at once be suspended tinuance of ° r milk. un til such time as exigencies for resumption of feeding will demand. In the mean time, especially in the absence of strong contraindications, such as violent vomiting, the infant should receive small quantities of hot or cold pure water or a light infusion of black tea. Recurrent vomiting calls for prompt atten- tion especially because of its fearfully exhausting effects, but also because it greatly hinders in the administration of suitable medi- cation. Ordinarily vomiting can be controlled by "ice-sand,*' minute doses of calomel with or without bicarbonate of soda or bismuth ; bismuth and cerium oxalate ; tincture of iodine (in y 30 of a drop doses, to be repeated every hour or two) ; silver nitrate (gr. DISEASES OF STOMACH AND INTESTINES. 199 fail, lavage. In hospital practice the order of these therapeutic suggestions is usually reversed, i.e., lavage is usually resorted to Lavage first, and as a rule with immediate relief to the patient. In enterociysis. private practice, however, one often meets with objections on the part of parents, and hence is obliged to primarily "medicate." Lavage should be supplemented by enterociysis and, with the vomiting checked, also by a small dose of castor-oil. This mode of treatment generally suffices to arrest gastroin- testinal affections of moderate severity. Where the diarrhea persists we are often called upon to administer an astringent Astringents, mixture like the following: — IJ. Bismuthi subcarbonatis, Mist, cretse comp., Syr. rhei aromat., Glycerin., Aq. menthae pip aa 3ij | 8 Aq. destil q. s. ad f 5ij j 60 M. Sig. : One teaspoonful every two hours for a child one year old. The camphorated tincture of opium may be added for the relief of pain. After complete cessation of vomiting, we may resume feeding, first with small quantities of toast- or barley- Cereals. water and, several hours later, diluted, sterilized cows' milk or breast milk. In fulminating attacks of gastroenterocolitis where the bac- terial toxins so violently overwhelm the infantile organism, pro- ducing intense shock, the treatment must be very prompt and more heroic. In the initial, febrile stage, after a single but thorough irrigation of the stomach and bowels the little patient is given one-fiftieth of a grain of morphine and one five-hundredth and ° ... atropine. of atropine hypodermically, is wrapped in warm blankets and sent outdoors — wherever a good breath of air is obtainable — preferably to the seashore. After responding favorably the treat- ment is followed up in the manner previously outlined for less severe cases. In the algid stage, where the child is at death's door — wasted, cold, blue, rigid and lifeless, in short in profound collapse — powerful stimulation is in order. Thus, a hot bath with brisk Heat - rubbing of the body; a hot, high enema (injected slowly so as to stimulation be retained), hot water by mouth, hypodermatic administration of sterile camphorated oil (8 drops of a 15 per cent, solution), strychnine (gr. % Q to %o)> caffein sodium benzoate (gr. j), or whiskey (gtt. x), and hypodermoclysis (1 to 6 ounces of a 200 DISEASES OF ALIMENTARY TRACT. 0.6 per cent, hot sterile salt solution). As the patient improves a milder course of treatment is, of course, resorted to. The physician should not be deceived, however, by those apparent improvements, as they not rarely precede fatal termination. 2. Subacute and Chronic Gastroenterocolitis. Exhausted by the paralyzing action of the virulent bacterial toxins ; wasted and weakened from the excessive loss of body fluids and the strict starvation diet enforced during the acute course of the disease, the little patient rarely, if ever, emerges in a state of health capable to exercise its digestive organs to their Delayed normal capacity. On the contrary, convalescence usually pro- ceeds at a very slow pace, and is frequently interrupted by milder exhibitions of gastrointestinal indigestion which, if not Recurrences, promptly yielding to energetic treatment, eventually lead to chronic involvement of the alimentary tract. The mucosa of the stomach and bowels, especially of the ileum and colon, undergoes gradual thickening, ecchymosis and ulceration. The mesenteric glands are more or less enlarged, Pathologic , . , 7 , , ,, • , i findings, and on cross-section partly red and partly yellowish gray in color and sometimes caseated. In very protracted cases the mucosa and its follicles are atrophied, and the lungs, liver and heart in a state of inflammation and degeneration. The bowel movements continue to be frequent (four or five times in twenty-four hours). The stools are thinner than normally, are mixed with particles of undigested food, mucus, Diarrhea. an d blood. The abdomen is flat, sometimes deeply sunken, and through its thin and wasted wall one can readily palpate the greatly enlarged, "ropy," mesenteric glands. The child's appe- Persistent ^ te * s ca P r i c i° us > often rather very good, and contrasts strongly wef S ht n w * tn tne P ers ' s tent loss of weight. The tongue is coated and flabby, its edges are red and indented by the teeth or gums, and here and there covered by an aphthous deposit. Slight indiscre- tions in the dietary are promptly followed by vomiting and diarrhea. Chemical examination of the contents of the stomach discloses marked diminution of hydrochloric acid. The course of chronic gastroenterocolitis varies in individual cases. Some infants, especially those in whom the chronic affec- tion followed upon the acute form, who remained free from grave complications and retained some vitality, often unex- DISEASES OF STOMACH AND INTESTINES. 201 pectedly show marked improvement with the setting in of cooler weather, and regain their health fully within but a few weeks. In another group of cases recovery is less rapid. Improve- variable ment alternates with aggravation of the condition, but, finally, prognosii the infant extricates itself barely alive, with a load of sequelae Fig. 53. — Gastroenterocolitis Chronica in a child 10 weeks old. Suffering also from Tetanism. (Sheffield.) (e.g., rachitis) which keep it in a state of decrepitude for many years after, and not rarely for life. In still another group of cases all therapeutic efforts utterly fail to effect a cure. The child's face has a pallid, earthy tint, and senile expression; the skin is dry and hangs in folds; the fontanelles and temples are depressed, and after a period of several weeks or months the infant finally succumbs either slowly 202 DISEASES OF ALIMENTARY TRACT. with symptoms of cerebral anemia and heart-failure or suddenly during an attack of eclampsia. The fatal termination is fre- omphca- C j Uent i v enhanced by complicating pulmonary (passive- or bron- cho-pneumonia ) and renal ( colicystitis, pyelitis, etc.) affections; skin (ecthyma, furunculosis), ear and mouth infections, or inter- current acute communicable diseases (exanthemata). At best the prognosis is very grave (30 per cent, mortality), especially so in infants reared under bad hygienic conditions, in want and misery, and in those born with lowered vitality and congenital defects. However, no effort should be spared to save an infant that is apparently hopelessly lost, for iust in chronic gastroenterocolitis Unexpected f l J 1 , J . ' J & , recovery, the unexpected sometimes happens — recovery takes place at a time when relief by death is prayed for. The patient should be removed from unsanitary surround- ings and intrusted to the care of someone who would obey orders and not use her own judgment and that of the many "good and experienced" neighbors. Be it remembered that only change of too often change of nurse (with her gross negligence and stub- born interference) has saved many a hapless baby ! Regulation Regulation of diet is most essential. No hard and fast rule, however, can be of diet. laid down in this direction. We must feel our way in every individual case. It is always a good plan in bottle-fed babies to begin treatment with discontinuance of the milk for a day or two and thorough cleansing of the alimentary tract by lavage and enteroclysis. In. the mean time the patient should be fed on thin barley-water, a light infusion of black tea, albumin-water, and, perhaps, a small quantity of freshly boiled, fat-free chicken soup. As soon as the stools diminish in frequency and improve in consistency, we resume milk-feeding in very high dilution, cereals For a cm 'd ' et us sav s i x months old we prescribe one teaspoonful later mii t k °f m ^ c to seven teaspoonfuls of barley- or rice-water, to be given every three hours, and direct daily to increase the quantity of milk until the percentage of one to three has been reached, and then gradually to augment the total quantity at the last ratio (i.e., i to 3), until six ounces are obtained for each feeding. Should the milk mixture disagree, a weaker milk mixture is resorted to, or milk is again discontinued, falling back upon cereals, albumin-water and tea. Some infants do well, at least for a time, on condensed milk and barley-water ; others, especially those suffering from the so-called "fat-diarrhea," improve rapidly DISEASES OF STOMACH AND INTESTINES. 203 on skimmed milk or whey, and still others (older ones), who can- J^fyin ■" v J fat diarrhea. not tolerate milk in any form, get along on toast and tea, cocoa in water, mashed potato with beef juice or chicken soup, soft-boiled egg, custards and similar semisolid articles of food. In a great many instances "malt-soup," prepared in accord with the direc- M ait-soup. tions of Keller, acts admirably, both as a tissue builder and to check the protracted diarrhea. Last in line, but foremost in importance, is the fact that a complete cure of chronic gastro- . enterocolitis in bottle-fed infants is almost invariably effected by a prompt change from bottle- to breast-feeding. The medicinal treatment of chronic gastroenterocolitis is chiefly symptomatic. Where vomiting persists, lavage (with warm boric acid solutions) should be practised daily or every alternate day, and continued for a few weeks. Digestion may be aided by means of pancreatin and diastase, and the appetite improved by small doses of tincture nux vomica and cinchona. Enterociysis. The patient should be given daily a high intestinal irrigation, either with one quart of plain hot (105 F.) water, 2 per cent, of bicarbonate of soda, or, where the lesion is localized principally in the lower bowel — as indicated by predominance of blood and mucus in the evacuations — with y 10 per cent, solution of nitrate of silver. Where the diarrhea persists notwithstanding progres- sive improvement in the general condition of the patient, the F . & , „ . \ ' Tannates. newer tannin preparations (e.g., tannalbin, tannigen) are very serviceable. The tannates may be combined with some bis- ... Bismuth. muth preparation (e.g., subgallate of bismuth gr. ij to iv), to enhance the astringent effects. Change of air (seashore), strict cleanliness of the body, change of position and frequent picking up of the patient from its bed, and active stimulation (strychnine, cinchona, Tokay wine and champagne) are active preventives of serious complications. PROCTITIS. Inflammation of the rectum is usually secondary in character, and not rarely associated with gastroenterocolitis, dysentery, Secondary oxyurides, and prolapsus recti, and less frequently with gonorrhea (vulvovaginitis, q. v.) and diphtheria. Occasionally it is the result of trauma (e.g., foreign body), and the effect of drastic cathartics. The principal symptoms of this affection consist of tenesmus (sometimes also strangury), frequent discharge of blood, mucus. 204 DISEASES OF ALIMENTARY TRACT. and pus, with little fecal matter, and more or less severe colic. Depending upon the primary cause of the disease, the discharges may contain different kinds of bacteria (e.g., ameba, gonococcus, Differentia- diphtheria bacillus, worms, etc.), a fact which should always hemorrhoid™ be borne in mind before arriving at a diagnosis and resorting to purpura treatment. Proctitis should not be confounded with rectal fistula susce'ptMon" or hemorrhoids, purpura hemorrhagica and intussusception. The treatment depends upon the underlying cause ; in the main resem- bling that of dysentery (q. v.). COLICA INFANTUM, GASTRALGIA, ENTERALGIA, NEURALGIA ENTERICA. Infantile colic is usually associated with a number of con- genital (gastrointestinal stenoses, etc.) and acquired (gastro- intestinal inflammations, etc.) diseases of the alimentary tract. Less frequently it is apparently free from organic underlying causes. This so-called "idiopathic" form of colic is a spasmodic affection of the intestinal musculature, the result of pathologic Digestive ... ... disturbance, irritations which act by way of the peripheral cutaneous nerves or the sensory intestinal nerves. To avoid unnecessary repeti- tion, it may briefly be stated that anything capable of producing gastrointestinal disturbance may form the cause also of the said pathologic irritations. This occurs especially in premature incapacity, infants and in those whose digestive organs are not quite fully developed. Some babies, breast- or bottle-fed, begin to suffer from colic soon after birth, and do what you will, maintain their "record" for several months, — until, with gradual growth, the digestive organs attain their normal functions. Such "colic-babies," if reared without immediate strict supervision of a capable nurse or physician are apt very soon to contract a severe gastrointes- tinal disorder from the effect of the experimental efforts, in feeding and medication, on the part of all who sympathize with Habitual. t ] le "j nnocen t babe." This habitual colic, which is manifested by continued fretfulness, sleeplessness, and pseudobuMvmz. (instinct- ive, eager desire for warm drinks which temporarily relieve the pain), is to be distinguished from acute intestinal colic (colica Flatulent, flatulenta), which is sudden in development and rapid in disap- pearance, the latter depending upon the time required to get rid of the gas or stool. During a severe attack of acute colic the child's face is spasmodically drawn and bathed in perspiration. DISEASES OF STOMACH AND INTESTINES. 205 The patient refuses food, cries pitifully, and draws its legs upon the abdomen. The spasm sometimes extends to the other muscles spasms. of the body, leading to general convulsions, and exceptionally even to coma and fatal issue. Of course, in the great majority of instances, the termination is favorable, especially under prompt and appropriate treatment. In breast-fed infants attention to the health of the mother or wet-nurse — avoidance of excitement, regulation of the bowels, indulgence in outdoor exercise — and, in both breast- and arti- ficially fed, prevention of constipation and overfeeding of the of constipa- infant are very efficient anticolic measures. Where repeated examination of the breast milk proves it to be too rich in fat or proteids, the infant should be given a few teaspoonfuls of water or of some other diluent immediately before each nursing, and the length of time for each nursing proportionately reduced. As long as the infant thrives, notwithstanding the colic, no very material changes in the feeding should be attempted, as too much experimenting often makes matters worse. In habitual as well as flatulent colic, heat, either in the form of fomentations (a few drops of turpentine in a quart of warm water), gentle massage of the abdomen with warm oil, or warm Hea t drinks such as chamomile-, fennelseed- or peppermint-tea, will be and r L1 internally. found to act well. In cases of acute colic this must be preceded by a warm-water enema to aid in the expulsion of the gas or stool. Of drugs the following preparations are worth trying: — Charcoal and magnesia, of each 1 or 2 grains one hour after Soda mint. feeding; mistura sodae et menthse, N. F., 5 to 10 drops every ten minutes until relieved ; compound spirits of ether, sweet spirits of nitre, or camphorated tincture of opium in doses of from 2 to 5 drops, to be repeated two or three times. In purely nervous colic asafetida often acts magically. The lac asafetida (§ss to p^recufm Oj of warm water) should be gently administered by rectum. The ammoniated tincture of valaria (gtt. v) and sodium bromide (gr. ij) are often equally efficient. As to the treatment of con- vulsions see page 554. Proper food, regular bowel movements, and fresh air are efficient prophylactic measures. Infantile colic should not be confounded with intestinal intus- Differential susception, appendicitis, and biliary, renal (uric acid infarct!) dia s nosis - or vesical calculi. 206 DISEASES OF ALIMENTARY TRACT. CHRONIC CONSTIPATION. Judging by the construction of the infantile intestines — their great length, the thinness and feebleness of their musculature, etc. — nature seems to have intended that infants as well as older children should be more or less constipated. Indeed, the popular belief that healthy children are usually constipated is often corroborated by actual observation. Not infrequently, however, obstinate constipation gives rise to a number of disagreeable conltipation f symptoms (flatulence, anorexia, headache, restlessness, sometimes convulsions, proctitis, anal fissure, prolapse of the rectum, hemor- rhoids, etc.) requiring active treatment, a task often difficult to cope with in view of the uncertainty of the etiological factor of the underlying disease. The causes of habitual constipation are very numerous. Aside from the cases resulting from gross abnormal anatomical relations or diseases, such as the different varieties of atresia Congenital . . . . . .,..,. . maiforma- mtestini, recti, or am ; tumors ; congenital dilatation with hyper- trophy of the colon ; hypertrophy of the valvulse conniventes ; hypertrophy of the so-called rectal valve ; inflammatory adhe- sions ; congenital displacements, etc. — which will not be discussed here — constipation is ordinarily caused by faulty diet, atony of the bowels, and constitutional disturbances. Faulty diet is responsible for a great many cases of constipa- tion. This etiological factor is frequently potent also in infants, when the woman's milk contains too much or too little of one or more of the constituents of milk, or is insufficient in quantity. In artificially fed infants the cause of the constipation will prob- La £k ably be found in the insufficiency of fat consumed. In some chil- dren constipation is due, on the one hand, to too early and persist- ent feeding with amylacea, and, on the other, to the consumption of food that does not stimulate peristalsis, such as an exclusive diet of milk, meat, eggs, etc., and no potatoes, bread, fresh vege- tables, etc. Atony of the intestines may be primary, congenital in nature, or secondary or acquired. The former variety can frequently be traced as an hereditary taint through several generations. Some- insufflc!ency r tnTies there is, in addition to the muscular insufficiency, also con- genital weakness of the innervation of the intestines. The latter condition embraces also the form of atony usually associated with congenital diseases of the brain and spinal cord. Secondary or DISEASES OF STOMACH AND INTESTINES. 207 acquired intestinal atony is generally the result of repeated at- tacks of temporary constipation, gastrointestinal indigestion with fermentation, enterospasm, arrest of peristalsis due to reflex Enterospasm. irritation of the inhibitory nerves of the intestines, acute inflam- matory processes of the intestinal canal with consecutive atrophy of the intestinal coats, constriction of the lumen of the bowels by temporary displacements (enteroptosis, hernia, etc.), habitual Hernia. suppression of defecation or attention to it at irregular hours, enemas with large quantities of fluids, etc. All these etiological factors produce intestinal atony by directly or indirectly distend- ing the lumen of the bowels and depriving the intestinal muscula- ture of its resilience and tonicity. The latter condition is also apt to follow the abuse of antispasmodics, while drastic cathartics may lead to atony by mechanically thinning the intestinal coats. In different chronic diseases associated with general debility {e.g., rachitis) and loss of flesh; in diseases of the nervous sys- organic tern, such as locomotor ataxia, myelitis, meningitis, etc., the sluggishness of the bowels forms merely a symptom of the prin- cipal disease. Habitual constipation is often met in diseases of the heart, profound anemia, etc., as a result of venous stasis of the abdominal organs ; to the same cause is attributable also the constipation occurring in children who through deformity or otherwise are incapacitated to enjoy a sufficient amount of bodily exercise. The treatment of obstinate constipation in infancy and child- hood resolves itself, firstly, in arresting the causes instrumental in the production of the disease ; secondly, in the removal of the damage done during the continuance of the constipation — not quite as easy a task as some authors wish us to believe. Indeed, a good number of cases of chronic constipation are never cured, no matter what therapeutic means are being employed. Prevent- ive measures are, therefore, to be recommended early and car- ried out with precision. It is of primary importance to train the child to have a move- ment regularly every day. Proper habits are often easily formed ? e j^i lar if the child is put upon the chamber or chair invariably at the same hour. The first few days it may require local stimulation to defecation {e.g., introduction into the rectum of a small oiled syringe-tip). Similar means should be employed also with older children and particularly school-children, who are very apt to suppress nature's impulse to empty the bowels. 208 DISEASES OF ALIMENTARY TRACT. Two main factors are instrumental in the expulsion of the rectal contents : Contraction of the abdominal muscles and the diaphragm, and separation or relaxation of the gluteal group of suitable muscles. If the seat of the commode is too high and the aper- ommode. ture -^ t j ie seat too w j ( j e no SU pp or t \ s given to the tubera ischii, the gluteal masses are crowded together instead of separated and the descent of the floor of the perineum is much hindered. This impediment to defecation may be obviated by substituting a low seat on a nursery chair or closet or small vessel for the high one previously used. The child is thus enabled to accomplish this act in a squatting posture which is most favorable to thorough "emptying of the rectum. Correction of diet is, of course, very valuable for the preven- proper tion of habitual constipation, but does not always remedy the trouble. This is particularly true of cases of very long stand- ing, since here we are dealing with secondary atony following prolonged distention and enfeeblement of the intestines. With the introduction of the recent methods of percentage feeding and the employment of "top milk" as a base, and barley- or oatmeal- water as a diluent, the number of cases of obstinate constipation among bottle-fed infants, due solely to faulty feeding, has per- in fat. ceptibly diminished. Hence, the indication of these methods of feeding also as a corrective of constipation. In breast-fed infants attention should be directed to the improvement of the general nutrition of the mother or wet-nurse. Frequently, however, it is almost impossible to regulate the quantity of fat in breast-milk. In this event the deficiency in fat may be supplied by administer- ing to the infant, just before nursing, a teaspoonful or two of sweet cream. The addition of cream, malt preparations, butter- milk, honey, an extra supply of cooked or raw fruit and vege- M ^d tables to the regular "mixed-diet" is invaluable as a corrective of constipation also in older children. A glass of cold water on an empty stomach and at night before retiring is often very useful. Faithful compliance with the suggestions just made very often yields favorable results. In a certain percentage of cases, however, more active measures have to be resorted to and it then devolves upon the physician to select such therapeutic means as will not affect the general well-being of the patient. This indi- cation can most appropriately be met by the simultaneous employ- ment of a combination of the so-called physicochemical pro- cedures, consisting of massage, oil enemas and hydrotherapy, and diet. DISEASES OF STOMACH AND INTESTINES. 209 occasionally, also, electricity. This treatment is more advan- tageously carried out in the evening, before the patient goes to sleep. The child is placed on a hard couch or mattress with head and thorax raised and legs sharply flexed at the knee-joint Massage. and somewhat rotated outward. The attendant stands on the left side of the patient. The manipulations are begun at the fossa iliaca sinistra, where the sigmoid flexure is situated and is frequently found to be a halting place for hardened feces. With the tips of the fingers of one hand (in older children both hands may be used, one hand being placed upon the other) the attend- ant makes gentle circular movements along this portion of the colon and at the same time exerts upon it considerable pressure downward toward the rectum. Without changing these move- ments the attendant slowly ascends as far as the splenic flexure. From here he gradually returns to the sigmoid. He now begins a new tour going as far as the hepatic flexure, and after gradually returning to the starting point he makes his final trip reaching the cecum and, in the manner just outlined, returns again to the fossa iliaca sinistra. These manipulations should be followed by rhythmical vibratory strokes over the entire abdomen, inter- rupted by a few pressure movements against the spinal column in the epigastric region. The treatment should last from six to twelve minutes. Instead of trying the massage, oil enemas, and hydrotherapy separately, it is certainly preferable to employ these three pro- cedures — the anticostive triad — simultaneously, as they do not Anticostiye interfere with one another, but, on the contrary, are destined to triad — J ' massage, supplement one another in their beneficial effect. Thus, after on enemas 1 L and hydro- COmpleting the massage the little patient is turned upon his left therapy. side, and by means of a piston syringe half an ounce or more of oil is gently injected into the rectum and allowed to remain there. This is followed by the application around the abdomen of a Priessnitz compress, which should be left in place until the next morning. It will almost invariably be found that the patient's bowels will act either during or soon after the treatment or, at any rate, not later than the following morning. A three or four weeks' course of treatment will usually suffice to establish regular- Perslstence ity of the bowels provided the preventive measures suggested be- | 1 " e ' ] r t eat " fore are strictly adhered to. In some, very protracted, cases of constipation these procedures may lie supplemented by llie appli- cation of the galvanic or faradic current. ( )ne electrode is passed 14 210 DISEASES OF ALIMENTARY TRACT. successively over different portions of the abdominal wall, and the other electrode is placed upon any other part of the body. Proctologists frequently advocate divulsion of the sphincter Divuision ani as a sure cure of habitual constipation. I am not inclined to involvement, be quite as enthusiastic over it, except in cases of constipa- tion due to rectal disease, as, for example, fissura ani, recto- spasmus, etc. Finally, there is a class of cases of chronic constipation which resists all forms of treatment as regards a permanent cure, but may be considerably improved by alternately resorting to the therapeutic measures already enumerated as well as to drugs. In the selection of an evacuant the physician must be guided by Laxatives, the etiological factors and the individual peculiarities of the case in question. The indiscriminate use of antispasmodics as well as the ever-ready, "soothing" laxatives is to be strongly deprecated. Effective and comparatively harmless are the following remedies : Soap and glycerin suppositories, medicated cocoa butter supposi- suppositories. tories (with aloin and belladonna in spastic, or aloin and mix vomica in atonic, constipation), enemas with small quantities of glycerin or larger quantities of soap-water; internally magnesia usta, magnesia and rhubarb, compound licorice powder, castor- oil, extract of cascara sagrada, calomel followed by a mild saline aperient, and, in older children, the standard mineral salts or waters. Whatever the method of treatment employed, the establish- ment of a habit to move the bowels regularly at a certain time of the dav should at all times be our chief aim. PROLAPSUS ANI, PROLAPSUS RECTI. If the prolapse is limited to the mucous membrane of the anus, the condition is spoken of as prolapsus ani ; if the lower portion of the rectum protrudes through the anal orifice, it is known as re the application of an ice-bag or light turpentine stupes to the abdomen and discontinuance of any nourishment until vomiting has completely ceased. Vomiting is best arrested by lavage or minute doses of iodin. After arrest of vomiting feeding may very cautiously be resumed. Breast-fed babies may again be put to the breast and bottle-fed should receive small quantities of milk, gruel, beef-juice, Tokay wine, champagne, and, if improvement continues, light mixed Rectal diet. For excessive tympanites the long rectal tube may be tried, allowing it to remain in situ for hours at a time. Cases run- ning a protracted course often do well on daily local inunction of ung. hydrargyri { l / 2 a dram), and the iodids internally. Localized abscesses should be incised and drained. In slow con- valescence, a sojourn at the seashore will prove beneficial. (For Tuberculous Peritonitis, see page 366.) INTESTINAL WORMS. Worms gain entrance into the human system chiefly through the ova — consumed with food or water, or carried to the mouth by means of the fingers. We distinguish the following varieties of worms : — Oxyuris Vermicularis (Seat-, Thread-, or Pin-worm). — Small, white, thread-like, freely movable worm, one- fourth to one-half inch in length. Its chief seat is the INTESTINAL PARASITES. 228 Fig. 55. — Oxyuris Vermicularis. • Female and Male. (After Leuckart.) Fig. 56. — Taenia Saginata. a, Natural size of the worm at different sections, b, Head (with pigment canaliculi). c, Pro- glottides. (Partly after Leuckart.) (Lenhartz.) 2 24 DISEASES OE ALIMENTARY TRACT. I II Y.'I'liS appendix. Skin, heart, brain, and eyes. Severe anemia. Stubborn diarrhea. In liver id lungs. rectum, where it causes intense itching. It may also infest the colon, cecum, appendix and vagina (vulvo- vaginitis ). Ascaris Lumbricoides (Roundworm). — Cylindrical, reddish gray in color, from four to ten inches in length. It resembles the earthworm in form. Its chief seat is the small intestine, but it may migrate to the stomach, gall- bladder (icterus), throat, etc., in the latter event occa- sionally producing attacks of suffocation. Taeniae (Tapeworms). — They are segmented worms of variable size. They inhabit the intestine and develop by budding. ( a ) Taenia Mediocanellata s. Saginata, or the beef tape- worm. It is several yards long. The head presents at its middle a pit-like excavation and four anterior suckers. (b) Taenia Solium, or pork tapeworm. It is shorter than the former. It is provided with four suckers, one pro- boscis, and a wreath of hooklets. After invading the human stomach the liberated embryos may wander to various portions of the body (skin, heart, brain, and eyes) and there develop into small vesicles (cysticercus) and lead to serious disturbances. (f) Bothriocephalus Latus, or fish tapeworm. Several yards long, possesses about 3000 segments, a flattened head with two shallow suction grooves. May be the cause of severe anemia. (d) Taenia Nana. About one inch long, possesses a head with four suckers and a wreath of hooklets. May cause stubborn diarrhea. (c) Taenia Cucumerina s. Elliptica. From five to fifteen inches long ; develops from swallowing dog-ticks that infest the hair of dogs and cats. (/) Taenia Echinococcus. It inhabits the intestine of the dog. The latter transmits the ova to the human gastro- intestinal tract through the mouth by licking, etc. The embryos develop chiefly in the liver and lungs, forming cysts. Symptomatology. — In times bygone the laity looked upon intestinal worms as the source of all evil, and even the physician was frequentlv inclined to hold the same view. As a matter of fact, worms, with hut few exceptions, rarely produce very serious INTESTINAL PARASITES. 225 - " :x >^ b \ Fig. 57. — Tsenia Solium. (After Leuckart.) Fig. 58. — Bothriocephalus Latus. a, Worm, in sections ; natural size. b, Head; lateral and front views. (After Leuckart. ) 15 226 DISEASES OF ALIMENTARY TRACT. Examina- tion of stools and sputum. disturbances. Indeed, numerous round- and tape-worms may infest the human intestines often without any indication of their pres- ence until accidentally discovered in the stools. Among the signs which are otherwise said to indicate their presence are the fol- lowing : A pale complexion, black rings under the eyes, footer ex ore, capricious appetite, picking at the nose, recurrent urticaria, colic, headache, vertigo, apathy, mydriasis, pavor noc- turnus, grinding of the teeth, and dry cough. Some authors claim to have observed divers neuroses, convulsions, chorea, trismus, epilepsy, amblyopia, strabismus, and the like. The majority of the reported cases of this sort, how- ever, do not bear close scrutiny and are readily traceable to other causes. The actual harm done by some of the worms has been mentioned under each heading. Diagnosis. — The diagnosis can read- ily be made by macro- and micro-scopic examinations of the stools and sputum (echinococcus hooklets) for worms or their ova. The finding of intestinal parasites may be facilitated by the administration of anthelmintics. Treatment. — Santonin and calomel act very efficiently in thread- and round-worms. R Santonini, Hydrargyri chloridi mite aa gr. vj | 0.4 M. et div. in pulv. no. vj. Sig. : One powder to be given every morning, on an empty stomach, for a child 3 years old. To expel tseniee the following is a very useful combination : — B Ext. fil. mar. seth 3jij | 12 Emulsi chloroformi 3iv 15 Emulsi amygdalarnm q. s. ad 3ij 1 60 M. Sig. : Two teaspoonfuls as a dose for a child 3 years old, to be administered as follows : The day before the diet should be restricted to fluids. In the evening the patient is given a few pieces of salt herring, fol- Fig. 59. — Taenia Nana. a, The whole worm (X 9). b. Head (X 50). c, Hooklet (X 300). d, Segment (X 50). e, Egg (X 125). (After Leuck- art.) INTESTINAL PARASITES. 227 lowed an hour later by a purgative (castor-oil or calomel). The next morning the male fern should be administered on an empty stomach followed within half an hour by a dose of castor-oil or calomel. If only part of the tapeworm escapes, and the other part remains inside, the torn end should by means of adhesive plaster be fixed to the buttocks, and another dose of the anthel- mintic administered until the rest of the worm has been expelled. The effect of anthelmintics by mouth is greatly enhanced by enemas of soapsuds and turpentine (oss to Oj) or a decoction of quassia wood. Quassia is very useful in pinworms, especially if followed by local application of gray ointment. In older chil- dren the fluidextract of male fern may preferably be given in Mode of administra- tion of male fern. Fig. 60. — Taenia Echinococcus of the Dog. a, Taenia, b, Hooklets. c, Membrane fragment. (After Leuckart.) capsule form. The rare attacks of asphyxia from roundworms are best relieved by turpentine administered by mouth or by rectum. ANKYLOSTOMIASIS. UNCINARIASIS (Hookworm Disease). Although prevailing in this country for many years past, this affection has only very recently, principally through the efforts of Dr. Charles W. Stiles, received due recognition as the "American murderer." It is practically endemic throughout the South, but is met sporadically also in other States of the Union. The disease is caused by the hookworm which infests the human body either through the mouth (by swallowing of infected water or food), and through the skin, especially the skin of the feet (the larvae of the worm gradually entering the circulation), and ultimately settles in the upper portions of the small intestines. The hookworm comprises two species: Ankylostomum duo- denale (old-world species), which is endemic, especially in Italy and Egypt, and Uncinaria Americana or Necator Americanus (the Endemic in the South. Ankylosto- mum. 228 DISEASES OF ALIMENTARY TRACT. new-world species). Both species measure from about % to 2 :{ inch in length (the females somewhat larger than the males), but while ankylostomum carries on its head four hook-like teeth on the ventral side and two smaller vertical teeth on the dorsal side, the uncinaria has a dorsal pair of prominent semilunar plates or lips, and a ventral pair of smaller plates of similar nature. By means of its armed mouth the worm fixes itself to the intestinal mucosa, producing minute erosions and hemorrhagic Fig. 61. — Ankylostomum Duodenale. a, Male, b, Female, c, Head. (/, Natural size. (After Leuckart.) spots, and sooner or later a more or less severe catarrhal process in the alimentary tract. It is still a matter of diversity of opinion, whether the uncinaria feeds on the epithelial cells of the mucosa C 'the 8 biood or u P on blood. However this may be, the blood certainly under- goes marked changes, in severe cases, resembling the blood findings of primary pernicious anemia. Very soon other organs of the body are affected, especially the liver and spleen. Post-mortem examination usually reveals fatty degeneration of the liver; softening of the spleen and paucity in lymphoid resembling pernicious anemia. Stunted growth. INTESTINAL PARASITES. 229 elements ; nephritic changes in the kidneys ; pallor of the lungs ; ^ _ flabbiness of the heart, and anemia of the brain and effusion into findings the ventricles. Hookworm disease is most destructive in the young. Chil- dren remain stunted in physical and mental development ; they look old, tired, apathetic, and with puffiness of the face not rarely resemble cretins. The skin is sallow and the scleras white or bluish-white. They suffer from palpitation of the heart, dyspnea, headache, dizziness, tinnitus, nausea, occasionally vomiting and abdominal pain. The appetite is either poor or voracious, often accompanied by a desire for unnatural food, leading to eating of earth, dirt, rags, etc. With increasing anemia there is frequently dropsy in the subcutaneous tissues and serous cavities — the edema often masking the emaciation and flabbiness of the body musculature. Occasionally the disease runs quite a rapid course, within a few weeks ending fatally from exhaustion. The diagnosis of hookworm disease is based upon a mac- roscopic and microscopic examination of the stools for the worm and its ova. Thymol acts specifically in this affection. It may be admin- istered in an emulsion with acacia or, in older children, in the form of capsules, the thymol crystals being first triturated with sugar of milk. The following mode of administration is recom- mended : Late in the afternoon the patient receives 2 grains of calomel (no castor-oil!), and the next morning 1 dram of Epsom salts. After the bowels have thoroughly acted 5 or 10 grains of the thymol are given on an empty stomach, and, if indicated, the dose repeated after an hour. The patient is kept in bed, without food, until late in the afternoon. The feces should again be examined for uncinaria after the lapse of from two to four weeks. CHAPTER VII. Diseases of the Liver. ICTERUS CATARRHALIS (Catarrhal Jaundice). Catarrhal icterus (catarrh of the ductus choledochus) occurs as frequently in children over four years of age as in adults. It is comparatively rare in infants. As a rule, it is caused Gastro- ^y anc ^ assoc i ate d with gastroduodenal catarrh, and begins with catarrh' coate( l tongue, anorexia, nausea, vomiting, and slight rise of temperature. Sometimes (epidemic icterus) the onset is sudden with high fever, apathy, delirium, headache and vomiting, so that before the appearance of the icterus cerebral disease is first thought of. In a day or two it is usually found that the urine is brownish yellow (bile-stained), the feces are gray and clayey, and the conjunctivae, sclerse and skin yellow in color. This path- ognomonic group of symptoms increases in intensity up to about a week, and then begins to diminish, first with clearing of the urine. The pulse is usually retarded, about seventy beats to the minute when the child is at rest. Palpation and percussion reveal tenderness over the stomach and liver, and occasionally some enlargement of the latter. This is particularly the case in catarrhal jaundice running a protracted course. The prognosis is favorable and under suitable treatment the symptoms ordinarily subside within from ten to fourteen days. The treatment consists of restriction of diet to thin soups, eS of a diet! albumin-water, skimmed milk, tea and toast, boiled fish or xo fats, chicken, and similar, easily digestible food, free from fat (no cream, eggs or pastries!). Gradual return to a heavier diet. Medicinally, a few small doses of calomel and bicarbonate of soda, and daily intestinal irrigation (with 2 quarts of water, at 90 F.) will usually suffice to arrest the disease. Pancreatin, rhubarb and soda mixture, and sodium salicylate are useful reme- dies, and prolonged warm alkaline baths (one-half pound of bicarbonate of soda to the bath) hasten recovery in chronic cases. R. Acidi nitromuriat. dil 3ss I 2 Elixir taraxaci (X. F.) q. s. ad 3ij \60 M. Sig. : 3j in water, three times a day ; in convalescent stage. (230) CIRRHOSIS OF THE LIVER. 2,31 DISEASES OF THE PARENCHYMA OF THE LIVER. Primary disease of the parenchyma of the liver is extremely rare in children under twelve years of age, since its principal cause — alcoholism — is practically unknown in; young children. On the other hand, secondary involvement of -the '-liver is not infrequently met in connection with syphilis, tuberculosis, chronic In connec- . J . . . . tl0n Wltl1 suppurative processes, malaria, rachitis, valvular heart disease, chronic rsr L diseases. protracted gastrointestinal disease, and infectious fevers. In these conditions the symptomatology is the same as in adults. CIRRHOSIS OF THE LIVER. 1. Atrophic Cirrhosis. — After a prodromic stage of several weeks, consisting chiefly of gastrointestinal disturbances, emacia- tion, tympanites, ascites, slight enlargement of the spleen, and dilatation of the abdominal veins gradually complete the clinical picture of the disease. The atrophy of the liver usually sets in insidiously, as a result of gradual hardening and contraction of the connective tissue. The course of the disease is shorter in children than in adults. Hemorrhages from the stomach and nose and into the skin not rarely occur toward the end of the disease, Hemorrhages. J Ascites. and progressive ascites hastens fatal termination. 2. Hypertrophic Cirrhosis. — This disease is characterized by considerable enlargement of the liver, pronounced icterus, very marked enlargement of the spleen, and protracted course, icterus. Ascites is absent until very late. The children usually remain stunted in growth. The liver is of very hard consistence. 3. Congestive Cirrhosis (Cardiac Cirrhosis, Cardiotubercu- lous Cirrhosis). — Pathologically it is characterized by hyper- trophy of the liver and spleen, obliteration of the pericardium, and tuberculous pleuritis and peritonitis. Intense ascites forms the principal clinical symptom. 4. Sugar-cake or Sugar-coated Liver (Pericarditic Pseudo- cirrhosis of the Liver — Pick's Disease). — This form of liver disease is closely allied to the former variety. It is a progressive, incurable affection of unknown etiology. Treatment. — As small quantities of spirituous liquors have proved to be the cause of quite a few cases of hypertrophic cir- rhosis of the liver in children, it is essential to interdict its use in Noaico- holic stimu- children, unless intended for temporary therapeutic purposes. hml> - The iodids and mercury should be given a fair trial in all Pronounced ascites. 232 DISEASES OF THE LIVER. form- of cirrhosis irrespective of cause. The ascites may be relieved by tapping, if diuretics, cathartics and heart stimulants fail to do so. Bland diet. Sojourn at the seashore. Absence of ascites. TUMORS OF THE LIVER. Benign as well as malignant tumors of the liver are occasion- ally observed in young children and even in the newly born. Cystic degeneration is most com- mon, and cases of carcinoma and adenocarcinoma, and more rarely sarcoma are on record. These growths should not be confounded with gumma of the liver — the effect of specific treatment being most decisive in the diagnosis. AMYLOID LIVER. It is often associated with amyloid degeneration of the spleen and kidneys, and secon- dary to some wasting disease, especially chronic suppurative processes in the bones and joints. The hepatic and splenic dullness is enlarged, but pain on pressure, jaundice, or ascites are absent, unless the portal circulation is interfered with by enlargement of the glands in the portal fissure. Attention to the cause and dietetic and hygienic measures may prove effective to arrest the degenerative process. Fig. 62. — Primary Family Splenohepatomegaly. Same as Fig. 63, when 4 years younger. (Sheffield.) Probably congenital. PRIMARY FAMILY SPLENOHEPATOMEGALY. This peculiar, apparently congenital, enlargement of the spleen and liver is occasionally encountered in two or more members of the same family. Although accurately described by Gaucher thirty years ago, and carefully studied since then in the living and post-mortem, its etiology is still shrouded in mystery. PRIMARY SPLENOHEPATOMEGALY. 288 It is generally overlooked in early infancy, or the splenic and Large liver, ... . .. . . . spleen, and hepatic enlargement is attributed to rachitis, splenic anemia or lymph-nodes, syphilis. As the child gets older it is found that notwithstanding good hygienic care and treatment the affected organs assume Fig. 63 Fig. 64 Figs. 63 and 64. — Primary Family Splenohepatomegaly in brother and sister. (Sheffield.) greater dimensions, often occupying the entire abdominal cavity. In addition to this symptom the patient usually suffers from anemia and its accompanying manifestations; occasional hemor- rhage fnnn the nose and mouth; pigmentation of the skin, and enlargement of lymph-nodes. The disease usually proceeds a chronic course and is sometimes marked by remissions or even Chronic course; usually fatal. 234 DISEASES OF THE LIVER. spontaneous arrest of further enlargement. In the majority of instances, however, death supervenes in from three to ten years as a result of passive congestion of the different adjacent organs which are displaced and pressed upon by the ever-growing spleen and liver. A correct diagnosis can usually be made by excluding syphilis ( Wassermann reaction positive), tuberculosis (tuberculin Differentiation test positive!), splenic anemia (liver usually free!), von Jacksch's tuberculosis! anemia (distinct blood changes; liver usually normal !) and Band's ' pseudoieuke- disease (spleen but moderately enlarged; usually ascites; not con- Banti's disease- genital). Early splenectomy is the only procedure that offers any prospect of recovery. Cases in which the splenohepatic enlarge- ment progresses very slowly are best left alone. Complica- tion of suppurative processes. Septic symptoms. ABSCESS OF THE LIVER. This condition is occasionally observed in children, most fre- quently as a result of extension of septic processes from neigh- boring structures, e.g., suppurative appendicitis, phlebitis umbili- calis, typhoid or dysenteric intestinal ulceration. It may follow traumatism, invasion by roundworms, suppuration of echinococ- cus cysts, or of the mesenteric glands. The abscess may per- forate into the thorax, intestines, or externally. Symptomatology. — Chills, hectic fever, tenderness over the liver, marked gastrointestinal disturbance, slight icterus, enlarge- ment of the liver, sometimes fluctuation and pus on aspiration. Treatment. — Free incision and evacuation of the pus as soon as the diagnosis has been established. Differential Diagnosis. Liver Ab- scess Hydatid Cyst of the Liver Pleurisy with Effusion Solid Tumor of the Liver Chills Marked Hectic Marked Slight, early Moderate Highest in mid- axillary line Pus Absent Absent Absent Absent Late Pronounced "hy- datid vibration" Highest in mid- axillary line Non-albuminous fluid with "hook- lets" Absent Slight Moderate Absent Tenderness Moderate Fluctuation Absent, diffuse flat Absent area, uninflu- enced by inspira- tion Aspiration reveals Lung symptoms... axillary line Albuminous fluid which coagulates on boiling. Pus in pyothorax Present Blood Absent CHAPTER VIII. Diseases of the Respiratory System, GENERAL REMARKS. The inherent frailty of the infantile respiratory tract is very conducive toward its morbidity. The nasopharyngeal passages inherent being very narrow and winding — intended to halt air impurities acquired and to moisten and warm the inspired air before its entrance to S naso- lon into the larynx — functionate to their own detriment in localities catan-hf ea where the air is dust-, smoke- and dirt-laden, and where atmos- pheric changes are many and marked. Thus, the child being unable to clear its nose, the detained foreign bodies irritate the delicate, highly vascular mucous membrane, before long forming a nidus for bacterial invasion. As we will see later "a cold in the head" is quite common in infants, and, while per se harmless in its immediate effect, is often serious in its remote results. The local congestion by its repeated recurrence produces a locus minoris resist entice not alone of the mucous membrane of the nose, but, by extension and persistence of the inflammatory changes (hypertrophy), of the pharynx and adenoid tissue as well. With ensuing nasopharyngeal obstruction breathing now proceeds principally through the mouth ; the air no longer undergoes the preparatory process of filtration, moistening and warming, but reaches the larynx in its impure, irritating state, sooner or later giving rise to a catarrhal inflammation of the larynx and neighboring structures. This condition is soon aggra- vated by the continuous affluxion of foul nasopharyngeal secre- Extension tion, and by the inability of the little patient to clear its throat £^|^™~ by forceful expectoration. Furthermore, the thorax being short bronchi and J l ° pulmonary and narrow, its musculature thin and feeble, and the heart and aiveoii. thymus gland comparatively large, the more or less compressed lung is greatly hampered in free aeration and in ridding its distantly located portions of the obnoxious inflammatory prod- ucts. Hence the pertinacity of apparently insignificant pul- monary lesions, the frequency of unresolved pneumonia ami pyothorax, and the insidious development of asthma, atelectasis (235) 236 DISEASES OF RESPIRATORY SYSTEM. and emphysema. As the child grows older, the nasopharyngeal tract larger, the thoracic cavity more spacious and, synchronously, the respiratory function more forceful, there is a corresponding reduction in frequency and persistency of respiratory disease notwithstanding, or, perhaps, because of the increased exposure of the child to atmospheric changes and infection. DISEASES OF THE NOSE, THROAT AND EAR. RHINITIS ACUTA (Coryza). Acute coryza is a frequent affection of childhood. It may occur primarily as a result of bacterial infection following ex- Primary posure to thermic, mechanic or chemic irritation, or secondarily and l secondary. m association with measles, influenza, scarlatina and diphtheria. Primary coryza (with sneezing, slight rise of temperature, anorexia, etc.). while quite harmless in older children, is often very serious in infants. Here it usually begins with vomiting, fever, and sometimes convulsions and occlusion of the upper air passages by a mucous or mucopurulent secretion. Owing to tion. thickening of the nasal mucous membrane there is partial or total obstruction to nasal breathing, giving rise to interference with suckling, dyspnea, and even acute attacks of asphyxia. The latter are prone to occur especially in the newly born who are not accustomed to breathe through the mouth and "swallow'* the tongue. Every case of acute rhinitis associated with severe local (membranous deposit) and systemic (vomiting, rapid loss of diphtheria, strength) symptoms should arouse the suspicion of being diph- theritic or scarlatinal in character. Acute rhinitis is not rarely complicated by otitis, laryngitis and bronchitis. The prognosis is generally good, although in young infants convalescence is slow. Treatment. — Avoidance of exposure to all atmospheric changes. Cleansing of the nostrils by repeated instillation of a few drops of a 2 per cent, solution of bicarbonate of soda, alter- nated with lukewarm mentholated olive oil or albolene. Careful feeding, if necessary, by the spoon. As measures of temporary relief, we may recommend local applications of atropine (% per cent.), cocaine (1 per cent.), or suprarenal solutions (%o per cent.) and camphor and the salicylates and quinine internally. Sneezing Hypersecre Xasal obstruction. Examina- tion for DISEASES OF NOSE, THROAT AND EAR. 237 More or less strict isolation of the patient. Attention to con- stitutional symptoms. Serum therapy whenever it is indicated (diphtheria.) R Natrii salicyl gr. xij | 0.8 Pulv. camphors gr. iij | 0.2 Chocolate q. s. M. ft. pulv. no. vj. Sig. : One powder every two hours for a child 3 years old. RHINITIS CHRONICA (Nasal Catarrh, Ozena). It is characterized by marked congestion and thickening of the nasal mucous membrane and hypersecretion — hypertrophic Hypertrophic rhinitis, or by atrophy of the various layers of the mucous mem- brane and foul-smelling incrustation — atrophic rhinitis, ozena. Atrophic. The latter form is rarely observed in children under ten years of age. Chronic rhinitis is usually the result of repeated attacks of acute coryza or other affections of the nasopharynx associated with nasal hypersecretion and obstruction to free nasal breath- ing (adenoids). In the presence of foreign bodies in the nose syphilitic, it is usually unilateral. In the nursling it is often due to hereditary syphilis (syphilitic rhinitis). Treatment. — As all forms of chronic rhinitis by respiratory interference and secondary glandular infection give rise to more or less impairment of the constitution, the treatment of this condition should embrace local as well as general therapeutic measures. The nose and nasopharynx should be kept clean by cleanliness, antiseptic and oily sprays and the congestion allayed by painting the mucous membrane twice a week with silver nitrate (1 per cent.), tannin-glycerin (5 per cent, to 10 per cent.), etc. Exces- ' ° J ■ L l . . Cauteriza- sive hypertrophy should be reduced by trichloracetic acid and tion. similar caustics and, if these fail, by means of the galvanocautery or nasal scissors. n Thymolis gr. ij | 0.15 Olei eucalypti gtt. v | Albolene q. s. ad Bi j 1 60. M. Sig. : Nose-spray, to be used morning and evening. EPISTAXIS (Hemorrhage from the Nose, Nosebleed). Bleeding from the nose may be due, primarily, to trauma- tism, external irritation of the mucous membrane Erom various Numerous causes. 238 DISEASES OF RESPIRATORY SYSTEM. causes, foreign bodies, etc. ; or may occur as a result of vascular excitement during the course of febrile, circulatory (especially after exertion) and pulmonary diseases; hemorrhagic affections, etc. Treatment. — The treatment of epistaxis varies, of course, with the cause. In slight hemorrhage simple compression of the ala? nasi against the septum acts efficiently. In cases of moderate bleeding, sitting posture, head erect, with hands folded over the head, and ice application to the nose and nape of neck, or instillation of cold water (with some vinegar, alum or potassium permanganate) into the nose will usually suffice. If this fails, the nares should be packed as far back as possible with pledgets of cotton or gauze, dipped in a strong solution of alum, in peroxid of hydrogen, or suprarenal gland solution. In secondary epistaxis due to vascular congestion a small dose of morphine hypodermically in conjunction with the aforementioned measures will often act very promptly. As the last resort we turn to the post-nasal tampon which, as a rule, checks the hemorrhage unless hemophilia is the underlying con- dition of the bleeding, when the treatment must be directed chiefly against this affection (q.v.). Detection of the local cause is very essential. Every visible bleeding bleeding spot should be cauterized with chromic or nitric acid or with the galvanocautery. Constitutional symptoms, if present, should receive prompt attention. TUMORS AND FOREIGN BODIES IN THE NOSE. Mouth-breathing, snoring, and nasal speech are not due solely to adenoid vegetations or large tonsils. Not infrequently obstruc- tion to breathing is the result of the presence of mucous polypi (soft, jelly-like), fibrosarcomas (hard and pedunculated) or 'bodi'e" f° re ig n bodies. The latter are usually beans, pebbles, cherry- stones, and so-called rhinoliths. Sooner or later they give rise to (unilateral) foul, bloody discharges and implicate the lacrimal duct and Eustachian canal, and form a reflex cause of persistent, irritable cough, and asthmatic conditions. The diagnosis can readily be made by inspection. Treatment. — Tumors should be removed with the cold snare, galvanocautery, or by torsion with a slender forceps. Bleeding may be arrested in the manner outlined under Epistaxis. Cauteriza- tion of Polypi Air inflation. Primary and secondary. DISEASES OF NOSE, THROAT AND EAR. 239 Foreign bodies if anteriorly situated can readily be removed by air inflation through the free side, or by means of a pointed forceps. If impacted farther back, it is preferable to dislodge the foreign body with a slender hook or forceps under cocaine and either extract it anteriorly or force it posteriorly into the nasopharynx. PHARYNGITIS ACUTA. Acute pharyngitis is rarely primary (streptococcic infection) but quite frequently secondary in nature as a complication of acute, rhinitis, tonsillitis, acute exanthematous affections, etc. Primary pharyngitis is ordinarily of short duration and mani- fested by dryness in the pharynx, pain in swallowing, and moderate rise of temperature. The pharynx is reddened, some- what swollen,- and often granular. Secondary pharyngitis will be considered in connection with the diseases it complicates. Treatment. — Attention to the bowels, rest in bed, Priessnitz symptomatic compresses to the neck and antiseptic sprays to the throat. Liquid non-irritating diet. PHARYNGITIS CHRONICA. It may develop after repeated attacks of acute pharyngitis or as a result of extension of an inflammation from the adjacent structures. The posterior pharyngeal wall not rarely presents a deeply congested granular appearance, and here and there covered by a tenacious mucous deposit. The affection is associated with more or less dryness in the throat, hawking and coughing. On examination the fauces ap- pear swollen and relaxed, the tonsils hypertrophied, and the anauonsiis esophageal opening covered by a thick, grayish-white deposit. Treatment. — Avoidance and removal of causes. Locally the parts must be kept clean by mild antiseptic sprays (Dobell's solution), and the swelling reduced by nitrate of silver (2 per ^7^ ° f cent.'), or tannin-glycerin (5 per cent.) solutions. Change of air, iodid of iron, cod-liver oil, etc., are very helpful to effect a cure. treatment. Hypertrophy of fauces R Suprarenal solution (1:2000), Dobell's solution aa oj | 30 M. Sig. : Throat-spray in acute or chronic pharyngitis. 240 DISEASES OF RESPIRATORY SYSTEM. Bacterial origin. Chills, fever, pain and swelling. White dots. Abscess "point." ANGINA (Sore Throat). Tonsillitis Acuta, Amygdalitis, Quinsy. Children under two years of age seem to present a decided immunity against tonsillitis. On the other hand, all forms of angina are extremely common in children over two years old. Those with a "catarrhal habit" are especially prone to contract tlu- disease. Streptococci, staphylococci and pneumococci, among other micro-organisms, form the most frequent primary cause, and are productive of the usual symptom-complex which is characteristic of similar contagious and infectious diseases of childhood. Thus, the attack is ushered in suddenly with a chill, rise of temperature (with evening exacerbations), vomiting (in younger children) and sometimes convulsions. The younger the child the less conspicuous the dysphagia. Hence the impor- tance of a routine examination of the throat in all febrile affec- tions. To avoid unnecessary repetition it is advantageous to classify tonsillitis in accordance with the tonsillar deposit as follows: — Angina Catarrhalis. — Redness and swelling of one or both faucial tonsils and adjacent tissues. Thin mucous exudation. Angina Follicularis. — The deposit begins as one or more white, small pellicles upon the middle or anterior por- tion of the tonsil. The white dots, at first distinctly isolated, soon coalesce to form yellowish- or greenish- white elevated patches. These are removable without profuse bleeding, and reform slowly. Angina Parenchymatosa (Quinsy, Peritonsillar Abscess). — The tonsil (usually one) and peritonsillar tissue are greatly enlarged, often displacing the uvula. It is bluish in color and doughy in consistency. The deposit, at first white, gradually turns yellowish-green, resembling the "point" of an abscess. Pus on puncture. Angina Herpetiformis. — The deposit begins with minute vesicles, which tend to burst and leave behind superficial ulcers. This form of amygdalitis usually involves both tonsils and is at times complicated by stomatitis. Angina Gangraenosa (Necrotica). — The tonsils are mod- erately enlarged and almost completely covered by a DISEASES OF NOSE, THROAT AND EAR. 241 greenish-yellow, continuous, deposit surrounded by a red zone. The exudation if removed leaves behind a deeply seated ulcer. The deposit often spreads from one tonsil deposit. to the other by way of the anterior pillars, palatine arch and uvula. Angina Ulcerosa (Vincentii). — It greatly resembles the latter but is usually limited to one tonsil, and occasionally presents a pseudomembrane. Vincent's bacillus in pure Vincent's culture is almost always found in the exudation. The course of the different varieties of tonsillitis varies but slightly. After subsidence of the acute initial symptoms pre- viously spoken of, the disease assumes a much milder aspect, except as to prostration, pain in swallowing and evening exacer- bations of the fever. The latter ranges between 102° and 105° F. and is especially high in follicular tonsillitis. More or less marked lymphadenitis is present in all forms of angina, and in accord with the tonsillar involvement it is either unilateral or Torticollis, bilateral. Parenchymatous angina is not infrequently associated with /wMcfo-torticollis, and pain on moving the jaws is present also in the other forms of the affection. In uncomplicated cases recovery is the rule in from three to ten days but quite a number of deviations from the usual course are observed. Tonsillitis is not rarely the forerunner of true diphtheria or rheumatic affections with their respective complica- Rheumatism, tions, and cases are on record where it proved to be the source of general septic or pyemic infection. Differential Diagnosis. — Angina may be confounded with influenza, glandular fever, diphtheria and scarlatina. In influ- Di(ferentia . ensa the exudation is slight and not strictly limited to the tonsils ; ^°° i™, m o J ' influenza, adenitis is comparatively rare. Furthermore, influenza is charac- fgver^nd terized by the simultaneous presence of respiratory, digestive, diphtheria, and often nervous phenomena, while in tonsillitis throat symp- toms predominate. Glandular fever differs from tonsillitis by the comparative absence of tonsillar manifestations and prepon- derance of glandular swelling (also of the bronchial, esophageal and retroperitoneal glands). The distinction between severe cases of tonsillitis and moderately severe forms of diphtheria without a bacteriological examination is often very difficult in the first twenty-four hours of the disease. In pharyngeal diphtheria the pseudomembrane appears as a small uneven, grayish white, slightly elevated patch upon the inner tonsillar <>r 16 ■242 DISEASES OF RESPIRATORY SYSTEM. faucial surfaces of the throat. The deposit augments by rapid spreading, within a few hours reaching the posterior wall of the pharynx and adjacent structures. The surrounding, uncovered areas are grayish in color, due to overcrowding of leucocyte- nuclei and mucus beneath. The tonsils are moderately large in size, but the submaxillary glands are large and hard, assuming the shape of a large walnut and bulge conspicuously forward. The deposit, if removed, leaves a raw, bleeding surface and rapidly reaccumulates. This clinical picture differs materially from that of tonsillitis and often proves useful in arriving at a Differentia- correct diagnosis. Tonsillitis with and even without erythema scarlatina, may be mistaken for scarlatina and a differential diagnosis is sometimes impossible until a few days after beginning of the attack. Treatment. — -In view of the possible serious complications tonsillitis should be arrested at its inception. The following mixture should be used every two hours as a local application — - undiluted, by means of a cotton swab in young children, or Antiseptic . gargle, diluted 1 to 20 oi water, as a gargle, in older ones : — ty Acidi carbolici 3ss j 2. Pulveris camphors gr. x | 0.6 Alcoholis 3ij j 8. Glycerini q. s. ad Si j | 60. M. Sig. : One teaspoonful in twenty of water as a gargle every two hours, etc. For the relief of pain cold Priessnitz's compresses or an ice Salicylates, collar to the neck and salicylates internally. The latter is in- tended also to guard against rheumatic affections. In angina parenchymatosa if suppuration is inevitable it should be hastened Evacuation \ . .. . , , , T • r of pus. by hot applications and the abscess opened early, irrigation of the throat. Rest in bed, liquid diet, plenty of water. Avoidance of transmission of the disease. (See also "Diphtheria," page 296.) HYPERTROPHY OF THE TONSILS. Chronic enlargement of the tonsils often develops after re- peated attacks of angina or pharyngitis, not rarely follows scar- Secondary. ] aT jna or diphtheria and is frequently associated with adenoids. When the tonsils become so large as to obstruct respiration, the same symptom-complex makes its gradual appearance as is path- ognomonic of adenoids. As in the latter anomaly, removal of the hypertrophied tissue is the only actual cure, and unless con- DISEASES OF NOSE, THROAT AND EAR. 243 traindicated by hemorrhagic diathesis, should be undertaken j^^rha-e with the aid of a tonsillotome — the earlier the better, since the presence of more or less degenerated tumors acts not only as a cause of a number of reflex phenomena {e.g., enuresis), but as a harboring place for divers pathogenic bacteria, including the tubercle bacillus. Tonsillotomy is usually performed in the following manner : — The patient is placed on a table (if an anesthetic is to be Tonsillotomy, used) or seated on the lap of an assistant or nurse. The arms are immovably fixed by means of a wide towel or sheet. The ton- sillotome is introduced into the mouth like a tongue depressor and turned sideways and pressed against the base of the hyper- trophied tonsil so that its summit protrudes through the circular -Tonsillotome. opening of the tonsillotome. With the tonsillotome thus fixed and the thumb of the operator in the handle of the blade the latter is firmly driven through the gland. The same procedures are repeated for the other tonsil. Slight bleeding calls for no treatment. Profuse hemorrhage A rrestof should be promptly checked by local use of ice-water, peroxid nemorrha s e - of hydrogen, adrenalin (1 : 1000), local pressure, or other thera- peutic measures generally employed in local hemorrhage. ADENOID VEGETATIONS (Hypertrophy of the Nasopharyngeal or Luschka's Tonsil). The mucous membrane of the rhinopharynx is normally rich in lymphoid or adenoid tissue which bears the name of naso- pharyngeal or Luschka's tonsil. Like the faucial tonsils the latter is subject to frequent attacks of inflammation with second- ary hypertrophy. Whenever the hypertrophied adenoid tissue assumes such proportions as to more or less lill the nasopharyn- geal space and obstruct nasal breathing, a pathognomonic clinical 244 DISEASES OF RESPIRATORY SYSTEM. syndrome develops which, though apparently insignificant in its lesion, is often very serious in its immediate and remote consequences. The clinical picture unfolds gradually, almost insidiously, growing more pronounced from time to time as the patient "catches cold." The child is unable to clear the nasopharynx, and the retained irritating nasal discharge helps to swell the adenoid tissue and to obstruct the rhinopharynx. The child is open thus forced to breathe through the mouth. As immediate results we hud that it keeps the mouth open, sleeps restlessly with the Fig. 66. — Adenoids. Note typical idiotic face. (Sheffield.) Snoring. Apathy. mouth open and as a rule snores heavily. He is frequently awakened by extreme dryness of the throat, and a croupy, harassing cough. In the morning he is tired, complains of head- ache, is drowsy and apathetic. His speech is dull, nasal (m and n sound like b and d) and hesitating, and sometimes stuttering. 1 Were it possible to bring these little sufferers under proper treatment at this stage of the disease, quick and uneventful re- covery would be the rule. Unfortunately, however, the laity, nay, the physicians as well, rarely think these symptoms of sufficient gravity to necessitate medical and particularly surgical intervention. The deplorable condition is therefore allowed to 1 It should be remembered, however, that the presence of adenoids does not necessarily produce the typical symptoms of the disease. It all depends upon the proportionate size of the tumor to that of the rhino- pharynx. DISEASES OF NOSE, THROAT AND EAR. 245 proceed and the tumor to spread and sprout. The sequelae ap- pear .in rapid succession. The labored breathing sooner or later breathing, produces deformity of the thorax (pigeon breast) and often curvature- of the spine. Owing to non-participation of the nose in respiration there is gradual atrophy of the levators alas ° f e t£oraxf nasi et labii superiores, the depressors alae nasi, and the septum Fig. 67. — Adenoids. Note funnel-shaped chest. (Sheffield.) mobile. The nose becomes pinched and pointed, the external angle of the eye deeper than the internal, the lower lip droops, Idiotic the lower jaw sinks down, and the face assumes that dull, fixed appearance, and irresolute expression which is so characteristic of adenoids. In addition to this, hearing is impaired as a result of secondary catarrhal inflammation of the Eustachian tube, etc. The child Mental is absent-minded and dull of perception, does poorly at school, n|g^ ward " and becomes the target for abuse and corporal punishment by 246 DISEASES OF RESPIRATORY SYSTEM. teachers and parents — all for no fault of his. When brought to the physician — often chiefly on account of impaired hearing- — the diagnosis can readily he made by mere inspection. Such a super- ficial examination, however, should not be relied on, as similar symptoms are produced by nasal obstruction from other causes (deformities, growths, foreign bodies, etc.). Inspection of the Fig. 68. — Adenoids. Note spinal curvature. (Sheffield.) mouth reveals the bony palate high and narrow, leaving insuffi- the teeth and causing their displacement. The faucial tonsils are greatly enlarged (in about 25 per cent, of the cases), the posterior pharyngeal wall is granular, and, with the velum palati raised, often shows the distal ends of the adenoid vegetations. Rhinoscopy confirms the presence in the naso- pharyngeal space of a pale-red, smooth, soft tumor which some- times resembles a mass of earthworms. It bleeds readily. The D ot'Safftl y cient space for Mass in rhiuo- pharynx. DISEASES OF NOSE, THROAT AND EAR. 247 diagnosis is further corroborated by palpating with the finger the soft masses blocking the rhinopharynx, or by nipping off a small portion of the adenoid vegetations by means of an adenoid forceps introduced behind the velum palati. The diagnosis once established the treatment should be prompt and energetic. Mild cases in their early stages may be arrested at their inception by scrupulous cleanliness of the nasopharynx, cleanliness, local applications of Lugol's solution or 2 per cent, of nitrate of silver, change of air, outdoor exercise, cold shower baths, and hematinics and alteratives internally. These procedures should also be followed in cases with hemorrhagic diathesis where an operation is contraindicated for fear of uncontrollable bleeding, and in those associated with other grave affections. In all other cases removal of the adenoids is the only actual cure, and should Danger of hemorrhage. Adenoid Curette. be undertaken as early as possible. The mode of procedure varies with each individual case. In young children under three years of age the operation may be performed without an anesthetic, in sitting posture ; in older ones or in those who are hypersensitive to pain and shock preferably under primary anesthesia with ether (drop by drop method), ethyl ether or nitrous oxid gas, in recumbent posture. The child's arms are fastened to the sides of the thorax by a wide towel, and his jaws are separated by a mouth-gag placed between the left upper and lower teeth. The operator stands on the right side of the patient and introduces the adenoid curette sideways into the latter's mouth and passes it beneath the soft palate and up along the anterior wall until he reaches the vault of the rhinopharynx. The physician then implants the cutting edge of the instrument into the adenoid mass and makes a firm semicircular movement, directed backward, downward and forward. One such movement usually suffices to remove the tumor. It may be followed up, however, by a few lighter, similar strokes, to smoother! the rough edges. The patient is then turned on the side to allow the blood to drain into a basin. Tliis may be facilitated by the injection of ice-cold water through the nostrils. After arresting the more or less profuse hemor- Careful anesthesia. Bandage over mouth. 248 DISEASES OF RESPIRATORY SYSTEM. rhage, which always accompanies the operation, the child is put to bed for a few hours until he has regained full consciousness and kept indoors for a day or two on a non-irritating, cool, liquid diet. After-treatment. — To prevent the recurrence of the adenoids, which is prone to take place in children with a tendency toward glandular hyperplasia, it is advantageous to instill into each nostril a few drops of Lugol's solution, once every other day for a period Local of about four weeks, and to use an oily antiseptic spray for several weeks thereafter. This procedure will prevent also adhesions between the cut surfaces and the soft palate. Delicate children should be put on syrup of the iodid of iron, cod-liver oil, etc. To regulate nasal breathing it is often necessary by means of a bandage to keep the mouth closed, especially at night, and to take prolonged breathing exercises with closed mouth. Impaired speech sometimes calls for instruction in speaking or, in the event of a paretic condition of the velum palati arising from inactivity, for treatment by electricity or tonics. In the majority of in- stances, however, the operation is followed by immediate restitutio ad integrum. All reflex symptoms and to a great extent even the deformities of the thorax subside rapidly. DANGERS AND ACCIDENTS ATTENDING ADENOID OPERATION. Simple and harmless as the operation is under ordinary condi- tions, it is not always free from danger. As in more serious operations the possibility of fatality from the effect of the anes- thetic or infection is gravely to be borne in mind and the fre- sepsis. q U ency of primary or secondary — occasionally fatal — hemorrhage Hemorrhage, should engage the constant attention of the operator. To obviate untoward complications all such preparations should be made as are customary with capital operative work. Ethyl chlorid and ether (drop by drop method) should be the anesthetic of choice, and primary in preference to deep anes- thesia. The instruments to be used should be carefully sterilized, and the field of operation and everything coming in contact with it rendered as aseptic as possible. Before beginning the operation the surgeon should test the efficiency and entirety of his instru- ments, and see to it that he is amply supplied with all such drugs (peroxid of hydrogen, suprarenal gland in solution 1 :1000, the tincture of chlorid of iron, etc.) and implements (post-nasal Anesthetic. DISEASES OF NOSE, THROAT AND EAR. 249 tampon, artery forceps, sponge holder and stypic gauze — which styptics. can be used to exert direct pressure upon the bleeding spot; actual cautery, etc.), as will enable him to promptly check profuse hemorrhage. RETROPHARYNGEAL ABSCESS (Retropharyngeal Lymphadenitis). Retropharyngeal abscess is a disease of early infancy when the retropharyngeal lymph-nodes are in a state of highest develop- Fig. 70. — Retropharyngeal Abscess. Note characteristic attitude of head — "Pseudotorticollis." (Sheffield.) ment. It usually begins as retropharyngeal lymphadenitis, most frequently the result of infection by offensive nasopharyngeal discharges. More rarely it is due to spondylitis of the cervical vertebne or occurs as a metastatic abscess or in consequence of trauma. Not all cases of lymphadenitis undergo suppuration ; on the contrary, quite many retrogress and escape attention. Hence the apparent rarity of retropharyngeal disease. Some cases undergo suppuration and break spontaneously, and others run a rather latent course, and when seen by the physician present fully developed abscesses. Digital examination of the throat usually Lymph- adenitis Tuberculosis. Dysphagia. 250 DISEASES OF RESPIRATORY SYSTEM. reveals a round or oval fluctuating mass the size of a pigeon's in U phai?nx S ^gg, m the median line of the pharynx, and more rarely laterally on a line with the velum palati or somewhat below it. In the advanced stage the abscess may be recognized as a bluish-red tumor on ordinary inspection of the pharynx. The symptoms vary with the size of the tumor. In marked cases they consist of dysphagia, snoring respiration, especially snoring, during sleep, muffled voice and, with progressive growth of the swelling, dyspnea and attacks of asphyxia. Where deglutition is u coiiis" very painful there is also sympathetic pseudo-torticollis. Occa- sionally the submaxillary, parotid and other neighboring glands are involved, and in spontaneous rupture of the abscess metas- tatic abscesses are apt to develop in the supraclavicular fossa, mediastinum, and lungs. Treatment. — Early opening of the abscess is therefore imperative. This is best accomplished by gently perforating it Evacuation , r . , , . , . , . of pus. by means of a pointed artery clamp and widening the puncture by opening the clamp. As soon as the perforation is made the child's head should be promptly bent forward to prevent the pus from entering the larynx (danger of asphyxia, aspiration pneumonia, etc.) and the nose and throat cleared of blood, pus and mucus. In multiple communicating abscesses with palpable involve- ment of the adjacent glands, the operation is preferably per- formed (with a knife) from the outside so as to afford thorough drainage. Relief from the symptoms is very prompt after evacuation of the pus. Rapid recovery, however, occurs only in primary streptococcic or staphylococcic abscesses ; in metastatic and tuber- culous abscesses the disease proceeds a protracted course, the prognosis depending upon the original disease and the age and vitality of the patient. OTITIS MEDIA. The gravest feature of nasopharyngeal affections, be they primary or secondary, is their great tendency to ear complica- Se to nd naso^ tions. The nasopharynx and ear being in direct communication pharyngitis. th roU gh the Eustachian tube, infectious material can readily travel from the nose and throat to the middle ear and transfer the disease from one locality to the other. Hence the frequency of ear disease in rhinitis, adenoids, divers exanthematous affec- tions, influenza, etc. Only a small percentage of cases of otitis DISEASES OF NOSE, THROAT AND EAR. 251 media are contracted through traumatism or extension of an Traumatism. inflammation from the external auditory meatus, and, in infants, middle-ear disease with masked symptoms is occasionally observed ,, in connection with wasting diseases {e.g., tuberculosis, marasmus, catarrh. syphilis). The infection may remain limited to the Eustachian tube (catarrh of the Eustachian canal), and give rise to very few and mild symptoms. The child may complain of earache for a day Earache, or two, perhaps, wake up at night with a crying spell, but get immediate and usually permanent relief after application of heat or some "ear drops." Sometimes the pain may return and get much more intense, and examination of the drum would show Injection of injection of the drum or, perhaps, a slight mucopurulent dis- drum, charge indicating spontaneous rupture of the membrane. The discharge may continue for a few days or weeks and disappear without further ado. In another group of cases, due to greater virulence of the infective material or possibly neglect, the inflam- matory process pursues a more violent course (otitis media puru- lento). The temperature rises, the earache is very intense, the charge, child is very restless, cries almost incessantly, rubs or strikes the ear with its hands, and as the symptoms persist there may be vomiting and cerebral irritation up to convulsions. If the pus is not evacuated, we soon find that it eats its way into the deeper structures, leading either to an acute or chronic involvement of the bone (mastoiditis). In severe infections this stage of the Mastoiditis, disease is often reached within a few days. The aforementioned constitutional symptoms are greatly exaggerated. The local signs, in addition to intense earache, deafness, headache and marked congestion of the drum, also are augmented by tenderness • i , , r , • • Marked over the mastoid process and by swelling of the tissues covering swelling, the bone, extending downward along the entire side of the neck •11 i-i • Constitution and forward to the retromaxillary fossa, pushing the auricle for- symptoms. ward. The upper and posterior walls of the meatus are more or less swollen and the drum is highly inflamed, bulging and irregular in contour. The further course of the affection depends greatly upon the mode of treatment. If the inflammatory process is allowed to continue the pus may find its way either externally, somewhere along the side of the neck, into the throat (retro- pharyngeal abscess) or, in malignant cases, into the lateral sinus 1 J ° . . Involvement (phlebitis, thrombosis), or the middle fossa of the skull (menin- of sinus; gitis, purulent encephalitis). The same grave condition is some- 252 DISEASES OF RESPIRATORY SYSTEM. times observed in otitis pursuing a very slow course — months or years. In these cases it is usually found that the patient is suffer- Cerebrai m g from recurrent attacks of earache with or without profuse abscess. p Uru ] ent discharge, more or less severe headache, dizziness, occasional rise of temperature, tenderness over the mastoid proc- ess, and, toward the end, loss of weight, anorexia, persistent headache and repeated vomiting. The disease having reached this deplorable stage one is very rarely apt to err in the diagnosis. A question may arise as to Differentia- whether the meningeal symptoms are secondary to otitis or to "central" some other affection (e.g., pneumonia, sepsis), or primary in character. A history of ear disease and the presence of local ear symptoms (discharge; inflammation of the drum, etc.) at once point to its true nature. Neither is there any difficulty in diag- nosing otitis media purulenta with acute symptoms. The diag- nosis, however, is not so easy in cases with an insidious course. It is especially difficult when the ear symptoms are masked by manifestations of the primary affection (e.g., influenza), but an otoscopic examination almost invariably clears up the diagnosis, and should always be resorted to whenever inexplicable pain or temperature prevails. Only very recently I had occasion to find double otitis in a boy 14 months old who, for three weeks, was treated by a prominent clinician for "central pneumonia." Mild cases of middle ear disease may be mistaken for otitis externa. In this affection, however, the local signs are limited to the external auditorv canal (redness and narrowing of the meatus I Mt'ft rentia- tion from without involvement of the drum). Similarly middle ear disease ear may be confounded with furunculosis or foreign bodies in the auditory meatus, but these can readily be eliminated by an otoscopic examination showing the seat of the lesion. Occasion- ally an abscess in the external canal burrowing itself through the cartilaginous portion of the canal in back of the ear may be mistaken for mastoid abscess ; in such cases constitutional symp- toms and inflammation of the drum are absent and the abscess is superficial and communicating with the swelling in the external canal. Bearing in mind the great tendency of nasopharyngeal affec- tions to lead to ear disease, and the latter to become a source of everlasting misery and death, it is self-evident that all precautions should be taken to prevent the causes and their dreadful results. During the course of acute febrile, especially exanthematous dis- Attention to nasopharynx. Removal of adenoids. DISEASES OF NOSE, THROAT AND EAR. 253 eases, the nasopharynx should receive especial attention in the way of careful, gentle cleansing. Warm salt water or albolene should be instilled into the nose twice daily, preferably with a spoon or dropper, lest forcible syringing may drive the discharge from the nasopharynx into the Eustachian tube. Hypertrophied tonsils and adenoids should be removed and chronic nasopharyn- geal catarrh treated with appropriate remedies. The instillations should also be continued after the appearance of ear symptoms, and as long as the membrane is intact syringing of the ear with warm boracic acid solution will prove beneficial. If the otitis continues and the drum does not rupture spontaneously, free paracentesis should be performed without delay, to allow the paracentesis, pus to escape. The mode of after-treatment is still subject to controversy, several prominent otologists preferring the "dry" ^ent. treat " method (drying of the external auditory canal several times a day and loosely packing with absorbent gauze) to repeated syringing. Where the discharge continues instillation of a few drops of a 2 per cent, solution of nitrate of silver, or in very chronic cases cauterization of the tympanum with trichloracetic acid will be found to act splendidly. If sensitiveness over the mastoid is detected and the constitutional symptoms show that disease is rapidly growing worse, an attempt should be made to arrest its progress by a new paracentesis, icebags and leeches and, if improvement does not set in early, there is nothing else left but immediately to proceed with opening of the mastoid process with a chisel to prevent the pus invading the sinus, meninges or brain substance. In the majority of instances a radical mastoid operation is a life-saving procedure. Unfortunately this opera- tion is not rarely undertaken either too late or on a patient in a state of very low vitality from the baleful effects of the primary disease, so that the results are not always very gratifying. It is questionable whether operative interference is to be advised after the disease has spread to the meninges or brain. The recoveries in these cases are certainly very few and far between. LARYNGITIS ACUTA. Catarrhal Laryngitis ; Spasmodic or False Croup ; Laryngitis Stridula ; Membranous, Non-diphtheritic Croup. Acute primary, idiopathic laryngitis is comparatively rare in children, except as the result of the traumatic action of strong gases, vapors, fluids or excessive heat. On the other hand, larvn- Icebag. Radical operation. 254 DISEASES OF RESPIRATORY SYSTEM. gitis quite frequently occurs in conjunction with divers acute exanthematous diseases, especially measles and influenza, often follows attacks of rhinitis, pharyngitis, tonsillitis and esophagi- tis, and may develop in connection with intra- and extra-laryngeal growths. This so-called secondary laryngitis affects children principally of from two to ten years of age. The severity of the symptoms is often by far out of propor- tion to that of the underlying anatomic lesion. Thus, simple hyperemia of only a small portion of the laryngeal mucous mem- brane not rarely gives rise to marked symptoms of suffocation. Several forms of laryngitis are noted in practice : — 1. Catarrhal Laryngitis. — The child complains of sore throat and sensitiveness of the larynx to pressure. The cough is cough, dry, short, and barking; the voice husky or only slightly muffled. Respiration is normal ; fever is absent or slight. Expectoration is at first slight and of a mucous nature, later more profuse and mucopurulent. The attack lasts about a week. Occasionally, especially in neglected cases or in those suffering from affections of the nasopharynx, the laryngitis may pursue a chronic course with a tendency to permanent alteration of the voice. In this event laryngoscopy examination usually reveals a moderate hyperemia of the laryngeal mucous membrane, and in some cases slight erosions. 2. Spasmodic Laryngitis (Laryngitis Stridula, False Croup). — It develops, either very suddenly or after a few days' illness, with catarrhal laryngitis or nasopharyngitis. Sudden attacks usually occur in children under eight years of age, more frequently boys than girls. After retiring apparently healthy and sleeping fairly well until about midnight (this may also happen during the clay after prolonged sleep, when the naso- pharyngeal or laryngeal secretion desiccates and gives rise to irritation of the larynx, and possibly edema of the subchordal tissue) the child wakes up with a harsh, croupy cough, inter- rupted by deep inspiratory stridor. The child looks frightened and anxiously gasps for air, its face is flushed and bathed in perspiration, its eyes stare and its lips are cyanosed, and the whole clinical picture is very alarming. The dyspnea usually passes off in a few minutes but may last hours with slight remis- sions and gradual improvement. Ordinarily the child is well again in the morning except for a simple mild laryngitis which may subside in two to ten days or give rise to renewals of the Sudden attacks of croup. Intense dyspnea. DISEASES OF NOSE, THROAT AND EAR. 255 attack for a few successive nights. Sometimes the paroxysm may be so severe as to require intubation or tracheotomy for immediate relief. Spasmodic croup occasionally forms the beginning of pertussis, measles, influenza or membranous, non- diphtheritic croup. 3. Membranous, Non-diphtheritic Laryngitis. — In the begin- ning the symptoms are those of simple laryngitis. Very soon, however, the catarrh is increased in intensity. The cough becomes harsher and more croupy, the voice hoarse (sometimes aphonia), inspiration prolonged and expiration noisy. It may begin also with bronchial catarrh and become suddenly compli- cated by fibrinous tracheolaryngitis — ascending croup — reach a very high degree of intensity, become more severe from hour to hour, and threaten suffocation, if not immediately relieved by intubation or tracheotomy. The aspect is still worse when the croupous inflammation descends into the bronchi — bronchial Descending. croup. In this condition the patient may cough up white reticu- lated shreds (which float in water) or complete cylinders with dichotomic ramifications or multiple dendritic branchings. The prognosis in such cases is very grave. The pulse fails, the dyspnea and cyanosis increase, the patients fall into a state of sopor and die from collapse. Not infrequently fatal brain symp- toms occur as a result of passive venous congestion in the brain D and transudation in the ventricles. The course and termination cyanosis eventually of the disease, however, is not always so bad, and quite a number asphyxia, of uncomplicated (sometimes complicated by bronchopneumonia) cases recover without much ado. This non-diphtheritic form of laryngitis is often mistaken for diphtheritic membranous laryngitis, but a diagnosis can in the majority of cases be made with the aid of the following differ- dia^no^is 31 ential points : — Membranous Diphtheritic Membranous Non-diphtheritic Laryngitis. Laryngitis. Diphtheria bacilli present. Absent. Distinctly contagious, giving also Not contagious. a history of contagion. Early enlargement of the submax- Submaxillary glands, as a rule, illary glands. not involved. Diphtheritic patches are found, as The fauces may be covered with a rule, on the fauces and poste- a mucous exudation, which can rior pharyngeal wall. easily be wiped off. Albuminuria usually present. Absent. Treatment. — Mild cases do nicely on very simple thera- peutic measures such as rest in bed, hot baths, hot drinks (tea, 256 DISEASES OF RESPIRATORY SYSTEM. lemonade, milk and seltzer), Priessnitz's compresses or turpen- tine and camphorated oil to the neck and a few doses of sodium salicylate internally to relieve the sore throat and to stimulate diaphoresis. Should there he any tendency for desiccation of the laryngeal secretion, softening of the same should be endeavored by means inhalations, of expectorants, steam inhalations and emetics. In the majority of instances this mode of treatment prevents the occurrence of attacks of spasmodic laryngitis. R Vini ipecacuanha? 3ss. | 2.00 Syr. scillse comp 3j. j 4.00 Sedatives. Syr. senega? 3ij. | 8.00 Codeinae sulph gr. ss. | 0.03 Mist, glycyrrhiza? comp q. s. ad f3ij. |60.00 M. Sig. : One teaspoonful every two to four hours for a child 3 years old. R Eucalyptol 3j. | 4.00 Tinct. benzoini comp 3ij.|60.00 M. Sig.: One teaspoonful in a pint of hot water for inhalation. Sudden paroxysms of false croup are best remedied by Emetics, prompt emesis, a hot mustard bath (see page 106), a hypoder- matic injection of morphine and atropine, counterirritation by a strong sinapism and, if the cyanosis increases notwithstanding, intubation or tracheotomy. The management of membranous non-diphtheritic croup is frequently quite a difficult proposition. Hence, the importance of its prevention by early attention to catarrhal laryngitis. Steam inhalation (see above) and emesis are useful remedies, and inhalation of amyl nitrite or chloroform is often effective Antispas- to relieve threatening dyspnea. Severe cases call for early intubation! intubation or tracheotomy. Recurrent laryngeal spasm some- times yields to spraying of the larynx with 2 per cent. sol. Antitoxin, of cocaine. As diphtheria antitoxin carefully administered is a safe remedy, it is always advisable to resort to it, although bac- teriologic examination of the pseudomembrane fails to reveal the diphtheria bacillus. Prophylaxis. — Removal of local causes, such as adenoids and large tonsils; change of air; tonics, especially cod-liver oil. LARYNGITIS CHRONICA. Chronic laryngitis may follow repeated attacks of acute catarrhal or diphtheritic laryngitis or develop slowly by extension DISEASES OF NOSE, THROAT AND EAR. 257 of inflammation from the neighboring structures. Overexertion of the voice and excessive smoking in boys are occasionally causes. Laryngoscopic examination shows hyperemia and swelling of inflammatory the mucous membrane of the larynx which vary in extent with symp or the duration of the affection. The mucous membrane is some- times covered with granulations and in severe cases shows more or less superficial ulceration. There is a moderate secretion of mucus and pus which has a tendency to desiccate, and gives the Resembles sensation of a foreign body in the throat. The cough is usually tuberculous insignificant, occasionally, however, troublesome, harsh and bark- ing, especially at night. Diagnosis. — Although syphilis and tuberculosis of the throat are comparatively rare in children, their presence should always be suspected and looked for in obstinate laryngitis. The following differential points are helpful in the diagnosis : — Simple Laryn- gitis Secondary Tertiary Lesion Hyperemia, slight Mottled hypere- Deep, angry Anemia, grayish thickening, ero- mia, superficial ulcers, color, solid thick- sion of mucous ulceration cicatrices, ening, worm- membrane, rare- stenosis eaten ulcers ly slight ulcera- Expectoration. Freefrom tubercle bacilli Spirochetes The same Bacilli present Deglutition ... Usually painless Normal Difficult Very painful Cough Dry or moist, pain- less Slight hacking Infrequent Severe, as a rule Respiration . . . Normal Unaltered Embarrassed with stenosis Early acceleration Voice Variable Hoarse, nasal Raucous, husky Partial or complete aphonia Complications. Nasopharynx; gen- Syphilitic lesions The same Involvement of eral health unaf- elsewhere lungs, emacia- fected tion Treatment. — Attention to existing causes, especially ade- noids and enlarged tonsils if present; local application, three times a week, of nitrate of silver (1 per cent, to 2 per cent.), glycerate of tannin (10 per cent.), or chloric! of zinc (2 per cent. to 4 per cent. ) ; steam inhalations (see page 256) ; cleansing of the nose and throat, three times a day, with Dobell's solution, and the like, will very promptly effect a cure, provided the laryngeal affection is not based on some grave constitutional affection, or benign (papilloma) or malignant growths. Rest to the voice is of material benefit. Tn very protracted cases change of air and 1 T Nitrate of silver. Removal of growths. 258 DISEASES OF RESPIRATORY SYSTEM. constitutional treatment. Faradization of the larynx is often very serviceable to relieve aphonia. R. Codeinae sulph gr. ss | 0.03 Creosoti carbon 3ss j 2. Syr. acacise q. s. ad f 5ij j 60. M. Sig. : One teaspoonful every three honrs for a child 6 years old. CEDEMA GLOTTIDIS. Edema of the larynx occurs in two forms: Active (inflamma- tory, phlegmonous), and passive (serous). Inflammatory edema may be primary, usually traumatic (e.g., scalds or burns), or secondary, as a result of extension of inflammation from neigh- boring structures. Passive edema is usually observed in connec- tion with grave kidney and heart diseases — often long before secondary, dropsy is manifested in any other part of the body — and second- arily to pressure on the larynx by swellings or growths. Anatomically edema of the larynx consists of a yellowish- white or reddish tumefaction — a serous, seropurulent or san- guinolent transudation into the submucosa — involving the upper findings, portions of the larynx, the epiglottis, the aryepiglottic folds, the false (rarely the true) vocal cords, and the mucous membrane of the arytenoid cartilages. These local changes can readily be detected by inspection of the larynx, often without the mirror, by simply depressing the tongue and pulling it forward, and by digital examination. The result of such swelling of the laryngeal tissues is quite obvious, namely, interference with normal respiration. The Dyspnea. c i VS p nea [ s a t first paroxysmal, and, if the edema is not very marked, only moderately severe. The poor little patient hacks and coughs, in vain trying to clear the throat. If the edema advances, the dyspnea becomes extreme ; symptoms of asphyxia set in which, if not promptly relieved, lead to a fatal issue. CEdema glottidis should not be mistaken for spasmodic croup ! Treatment. — Partial edema may be reduced by icebags to the neck, swallowing of ice, local application of suprarenal extract solution (1 :1000) and morphine and pilocarpine hypo- dermatically. In severe cases tracheotomy should be resorted to in addition to the mode of treatment just outlined. Recur- rence of an attack should be prevented by prompt attention to the etiologic factors. Passive or Pathologic Tracheotomy. tion from adenoids, retropharyn- croup. DISEASES OF LUNGS AND PLEURA. 259 LARYNGEAL TUMORS. Neoplasms of the larynx are very rarely seen in children. This is especially true of malignant growths. Papillomata are Papiiiomata. not quite so rare, and are sometimes congenital. Their usual seat is at the true vocal cords, and if of considerable size they give rise to obstinate, severe cough, hoarseness, dyspnea and at- tacks of asphyxia. These symptoms develop however, gradually, and sometimes disappear spontaneously owing to retrograde metamorphosis of the tumor. Recurrences are frequent. Laryn- D ifferentia- geal neoplasms may be confounded with adenoids, retropharyngeal abscess and croup, but the diagnosis can readily be made by T s fH laryngoscopic examination. Operative treatment should be instituted only in cases presenting troublesome symptoms. Endolaryngeal removal of the growth is the procedure of choice. Tracheotomy, in threatening asphyxia. FOREIGN BODIES IN THE LARYNX. Various articles of food, little playthings, buttons, needles, ascarides, etc., may find their way into the larynx. Small foreign bodies are usually expelled by the attacks of forcible coughing. Larger non-impacted articles may be removed by an extubator or similar forceps after cocainizing the upper part of the larynx. Foreign bodies firmly impacted in the larynx should be removed under anesthesia through the tracheotomy incision. In threaten- ing asphyxia tracheotomy should be performed immediately threaten 3 - 7 irrespective of subsequent procedures. To reduce hyperemia, ice externally and internally. Local antiphlogosis (Lugol's solu- tion, 1 per cent, nitrate of silver) after removal of the foreign body. Anodynes for the relief of pain and irritability. (For removal of ascarides see page 226.) ing asphyxia. DISEASES OF THE LUNGS AND PLEURA. BRONCHITIS AND BRONCHOPNEUMONIA. Tracheobronchitis; Capillary Bronchitis; Lobular Pneumonia. Bronchopneumonia in children is usually secondary in nature (forming a complication of divers acute and chronic diseases) and is generally preceded by or associated with a catarrhal inflam- mation of the mucous membrane of the trachea and bronchi. As the tracheobronchitis advances the inflammation spreads to the 260 DISEASES OF RESPIRATORY SYSTEM. fine bronchioles— capillary bronchitis — and, finally, to the pul- irreguiar nionary alveoli — lobular- or broncho-pneumonia. In the latter dl of n !esion! affection the consolidation is irregularly distributed, sometimes over the entire lung, in variously sized patches. On section the affected lobules present quite a smooth surface of bluish-red color, and contain a mucosanguinolent fluid. When placed in water they sink to the bottom. In cases of long standing atelec- tasis, emphysema and caseation are common complications. °cou g h. In tracheitis the cough is short, dry and harsh, becoming longer and softer as the inflammation extends to the bronchi. Respira- tion is but little embarrassed, the temperature is normal or slightly elevated and the general health corresponds with the underlying condition. The onset of bronchitis, on the other hand, is signal- ized by a rise of temperature of from two to three degrees, some- times vomiting and marked restlessness. The cough is frequent and painful, breathing is accelerated and somewhat difficult, and auscultation reveals a great number of large, harsh and moist Large rales. „ , ., ., , , . , . , . . , rales and sibilant rhonchi which are transmitted over the entire wheezing, chest wall and give rise to the characteristic wheezing and whis- tling which are readily heard at some distance from the patient and felt by the palpating hand. This "rattling of the chest" usually diminishes in intensity or disappears temporarily after forcible coughing. Under suitable treatment the tendency of primary tracheo- bronchitis is toward gradual evanescence. After a few days the disease assumes a milder course ; the cough becomes looser and less frequent ; the breathing slower and less noisy ; the general condition rapidly improves, and recovery is often complete within from seven to fourteen days. Not infrequently, especially in secondary bronchitis, where often *' ie P rmiar V etiologic factors remain active, or in neglected cases, course ^ ie catarrn pursues a protracted course (chronic tracheobronchi- tis) ; aggravation of the condition alternates with amelioration; the child continues to hack or cough for weeks or months, presents large and moist rales over different portions of the chest, but may otherwise remain free from any constitutional symptoms. In a small number of cases chronic bronchitis forms tuberculosis" a P recursor °f tuberculosis of the bronchial glands or lungs. In young and delicate children tracheobronchitis is always fraught with the danger of terminating into capillary bronchitis or bronchopneumonia. Indeed transition of the inflammation DISEASES OF LUNGS AND PLEURA. 261 from the large bronchi to the fine bronchioles (bronchiolitis, Transition capillary bronchitis) and the lung tissue (bronchopneumonia or ^ronchTt'is^or lobular pneumonia) not rarely proceeds insidiously, and may monia! opneu ~ exist for some time, especially in the lower lobes, before being detected. As a rule, extension of the pulmonary inflammatory process is associated with sudden rise of temperature (up to 105° F.) temperature. with its concomitant symptoms, and increased frequency of respi- ration. The cough becomes dry, short and very painful. The nostrils dilate and contract. The eyes are dull. The face is pale, cyanotic, and often covered with perspiration. No mathe- breathing. matical distinguishing line can be drawn between the symptoms and physical signs of capillary bronchitis and catarrhal pneu- monia, except, perhaps, that in capillary bronchitis the pulmonary lesions are more diffuse (the whole bronchial tree may suddenly . . ■ i i a Confluence become involved) while in lobular pneumonia more local. As of lesions, the disease advances the local pneumonic foci gradually multiply, become larger and more confluent, and coalesce in extensive masses. Then, and often not until then, can dullness be demon- Dullness. strated on percussion. Where the patch is small the percussion note may be normal or even tympanitic. Inspection discloses retraction of the lower ribs during breathing. Auscultation „ . . , ° ° _ Bronchial elicits accentuation of the expiratory sound, bronchial breathing, breathing. bronchophony over the dull portions and fine crepitation, in addi- tion to large, soft and sonorous rales, distributed over different parts of the lungs, especially over both sides of the spine, and along the axillary lines. Lobular pneumonia being usually a secondary affection (pri- mary pneumococcic bronchopneumonia may, like lobar pneumonia, end by crisis) runs a very protracted course, from two to six weeks or longer. This is often due to repeated extension of the inflammatory process, sometimes with disappearance of the original focus. This accounts also for the apparent improvement and relapse. Under the circumstances the wear and tear upon the child's constitution is very great, especially since with per- sistent anorexia tissue repair is at complete abeyance. The heart's action grows weaker; the power to cough dimin- D ishes, notwithstanding exaggeration of the physical signs ; breath- ing becomes more difficult, and the pulmonary circulation more Hea . rt ° l - weakness. and more obstructed. The child finally succumbs to autoinfection and cardiac exhaustion (the overdistended right heart being 262 DISEASES OF RESPIRATORY SYSTEM. unable to propel its content), not rarely preceded by attacks of suffocation, coma, and convulsions. The prognosis is not always so grave. In some cases, espe- Grave cially in children whose constitution has not previously been prognosis. un{ ]ermined by wasting diseases, defervescence occurs after a week or so, the dullness diminishes, the cough loosens, sleep becomes more restful, respiration less painful, the appetite returns, and if not interrupted by complications, gradual recovery ensues within a few weeks. On the other hand, fatal termination after a few days' sickness is not at all rare. This is more apt to occur in primary, pneumo- coccic bronchopneumonia from an overwhelming toxic effect upon the heart muscle and the cerebrum (meningitis, enceph- alitis). Pyothorax, miliary tuberculosis, gastroenteritis, stomatitis, more rarely otitis, pleuritis, and gangrene of the lungs, form the compiica- principal complications. Empyema, tuberculosis and pulmonary gangrene are usually found only in cases of bronchopneumonia with delayed resolution, as a result of caseation and liquefaction of the unabsorbed inflammatory products. Treatment. — The management of bronchopneumonia in young children depends upon the underlying condition of the disease. Primary, pneumococcic, lobular involvement, like lobar pneumonia, usually proceeds a self-limited course and is little influenced by therapeutic measures. On the other hand, second- spreads by J r continuity, ary catarrhal pneumonia spreads by continuity and may often be arrested in its inception by early and energetic treatment. This is true particularly of bronchopneumonia supervening tracheo- bronchitis — as already alluded to, in the beginning, a simple local catarrh, readily amenable to prompt attention. As the initial symptoms of bronchitis and bronchopneumonia Energetic are not a ^ wa y s easily distinguishable, and as the success of our treatment, treatment invariably depends upon its promptitude, it is good practice to err in the direction of judicious overtreatment rather than in that of irresolute undertreatment, and to at once proceed with active therapeutic measures in tracheobronchitis and bron- chopneumonia alike. The treatment consists of induction of free perspiration, enhancement of expectoration, allaying nerve irritability and pain, and maintenance of the patient's strength. Seeing the patient in the early stage of the disease we direct the administra- DISEASES OF LUNGS AND PLEURA. 263 tion of a hot mustard bath of about three minutes' duration and Hot mustard bath. the application of a poultice consisting of the following ingre- dients : Five parts each of flaxseed-meal and camphorated oil, one to two parts of mustard, and a sufficient quantity of boiling water to make a thick paste by thorough stirring. This mass is Local heat spread on thin gauze or paper (two layers) and applied snugly to the chest and back. The child is then wrapped in an oiled- silk jacket, lined with absorbent cotton, and in a blanket, which, with the hyperpyrexia of the body, maintains the heat of the poultices, so that renewal is required but three or four times in twenty-four hours. This poultice has special advantages over any other in use. As just mentioned, it requires but occasional changing, thus saving time and labor and avoiding unnecessary exposure of and annoyance to the patient. The mustard and camphor act as mild counterirritants, and after some time bring the blood to the surface, thus relieving the pulmonary engorge- ment. Furthermore, the skin over the chest and back does not become "soggy and sodden," or "water-logged" from the use of this poultice as is apt to occur from prolonged application of ordinary flaxseed poultices. In conjunction with the external treatment the patient receives also a few doses of sweet spirits of niter and liquor ammonium Diuresis and , • , i • 11 1 , i-i • i-i diaphoresis. acetate which act very kindly both as diaphoretics and stimulants. The beneficial results derived from this mode of treatment are manifest within a few hours. The suffering infant who but a short time before had been on the verge of collapse — moaning, tossing and twitching from pain and distress, gasping and panting for a free breath of air — now lies peacefully enjoying calm Effects of J J J ° treatment. repose and healthful sleep, ready and apparently able to battle for a new lease of life. The system having been greatly relieved of its toxemia by means of the free perspiration, the disease now usually assumes a much milder course. Indeed, it is not at all uncommon to see a severe attack of tracheobronchitis to end then and there, and that of bronchopneumonia to resolve itself into simple bronchitis. The enthusiasm just expressed applies, of course, only to such cases as are ordinarily met as a result of a "cold." This treatment is surely no panacea for respiratory embarrassment complicating grave affections of other bodily organs, e.g., heart or kidney. Here symptomatic medication is in order — at best an unthankful task. 264 DISEASES OF RESPIRATORY SYSTEM. To enhance free expectoration we resort to the following expectorant mixture: — R Ammonii carbon gr. xvj | 1 Vini ipecacuanhas 3ss Syr. scillas comp 3j Syr. senegas 3j Syr. Tolutani 3iv | 15 Aquae destil q. s. ad Sij | 60 M. Sig. : One teaspoon ful every two or four hours for a child two years old. To this we may add a small quantity of the camphorated Anodynes, tincture of opium (gtt 2 to 5) or codeine sulphate (gr. % ) for the relief of pain and to allay nerve irritation. For the latter pur- pose an ice-bag to the head or sodium bromid internally often does well. We cannot pass this question without expressing our disap- proval of the absurd criticism often heard as to the use of torants" expectorants. When a little infant is tormented almost to death by an incessant, dry, hacking cough and the painful phenomena associated with it, it is no empiricism to administer an expecto- rant mixture which helps nature to rid the lungs of effete material (which more or less obstructs respiration and causes autoinfection by systemic absorption) and permits the patient to refresh upon a brief period of rest and sleep. The maintenance of the child's strength is most essential to the successful management of bronchopneumonia. The heart should be looked after from the very inception of the disease, stimulants. For be it remembered that death in pneumonia is due to heart failure and not to pulmonary insufficiency. In the early stages of the disease we rely principally upon strychnin (gr. %. 00 to Yso), but as the circulatory and respiratory difficulties increase we do not hesitate to administer camphor (gtt. x of a 15 per Camphor. _ _ ? ... cent, sterilized camphorated oil) hypodermatically and digitalis and strophanthus by mouth, as indications demand. Every effort should be made to replenish the vital body fluids consumed during the active febrile process by suitable nourish- ment such as water, milk, beef-tea, broths, fruit-juice, etc. (See also "Pneumonia.") When called upon to treat a case of bronchopneumonia of several days' or weeks' duration that has failed to respond to active treatment, our efforts should be directed toward the pre- vention of pyothorax or tuberculous infiltration of the lungs. DISEASES OF LUNGS AND PLEURA. 265 A great deal can be accomplished by an ample supply of fresh Fresh a ir. air, the iodids, creosote and essential oils by mouth and inhala- tion. (See also "Chronic Pneumonia.") Whenever possible, the child should be removed to the country (seashore or mountains), and, weather permitting, kept outdoors most of the time. The iodids will be found very useful to hasten resolution (preferably in the form of sodium iodid gr. y 2 , t. i. d. for a child one year old). We usually recommend its administration from the sixth day of the disease until resolution has been established, and then continue with the syrup of the iodid of iron and the syrup hypophosphite compound, which act both as an efficient alterative and tonic. Creosote is indicated in all stages of the disease. It should Creosote, be prescribed in small doses several times a day. The tent made of bed-sheets hung around the bed and moistened with creosote, oil of eucalyptus and the like is of service, especially in tracheo- bronchitis. LOBAR PNEUMONIA. Croupous or Fibrinous Pneumonia, Pneumonitis. Acute lobar pneumonia is an acute, specific, inflammatory affection of the lung tissue arising as a result of invasion by the encapsulated diplococcus of Fraenkel-Weichselbaum. It may occur as an independent process or in connection with other dis- eases, e.g., influenza, measles, diphtheria, scarlet or typhoid fever, etc. It is communicable and occurs occasionally in epidemic form. Genuine pneumonia in children, as in adults, is characterized Three by three pathologic stages : Engorgement, red hepatization or stages- consolidation, and gray hepatization, followed by resolution or purulent infiltration. The pleura is almost invariably implicated. Sudden Primary lobar pneumonia usually ushers in suddenly, often onset - after exposure to cold or wet, with a chill, vomiting, high tempera- CM1L ture, and more or less marked dyspnea. The initial symptoms are frequently misleading. They may consist of vomiting, diarrhea, pain in the abdomen, nosebleed, and prostration, sug- gesting the beginning of typhoid, or convulsions and vomiting may predominate justifying the diagnosis of meningitis. Where ^ b u S gh C j e n of the pneumonic lesion is located centrally (central pneumonia), pneumonia the physical signs, nay, even the cough, may be absent or slight, 266 DISEASES OF RESPIRATORY SYSTEM. so that remittent fever is often thought of or even intermittent fever, if the temperature pursues an irregular course. Further- more, there are also numerous abortive cases of pneumonia which terminate in a few days — often before the diagnosis has been established. Of course, the majority of cases of pneumonia present typical physical signs and can be readily disclosed on careful examina- tion. Auscultation reveals during the first and third stages fine crepitation, crepitation at the edge of the consolidation, and during the Fig. 71. — Diplococcus Pneumonia; (Pneumococcus) : (a) single diplococci : (&) the same in chains (Wolf's double stain). Leitz ocular I, oil immersion Ho- (Lcnhartz and Brooks.) „, ,_ , second stage, distinct tubular breathing and bronchophony over Tubular & te 1 J breathing, the affected portion of the lung. In the first day or two of the disease the percussion sound is usually tympanitic, but as the Dullness, pneumonia advances, first dullness and later flatness can readily be elicited, the experienced hand perceiving also a distinct increase of sense of resistance on percussion. Pectoral fremitus is ordi- narily not sufficiently distinct in young children except when they cry aloud, which act should always be encouraged to facilitate the detection of the physical signs. sif-iimited Croupous pneumonia runs a self-limited course, between five and thirteen days, or longer, most frequently terminating by crisis, at a time when the disease is at its height. Until then, in the absence of unexpected complications, there is little change DISEASES OF LUNGS AND PLEURA. ■2iu in the clinical picture of the affection. The fever remains high continued (104° to 105° F.), with slight morning remissions; the pulse- and pyrexia. respiration-ratio is greatly disturbed, from 1 to 3.5 to 1 to 2; the urine scanty, high colored, rich in salts (with diminution in chlorides) and occasionally in pepton and aceton; the cough is short, dry and painful; older children (rarely those under three years of age) expectorate rusty sputum; the face is flushed, the tip of the nose and lips are cyanotic; the tongue is coated, pasty, DATE M* ? n (% r *i ii'T-1 ■p" "^ a ffl T T-1 A^l T^i -3-^q •05 ,, I '. '1 i"l N /\ 104 A \ / \ r f 101 \ 1 | / \ / I, 103 V- ida \ \ 10. ;02 101 101 IOC ;co 39 39 38 98 - - — L P £5 -fb 1 i i to fl>f ?* in a ■5 i 2 a 4 1 § *U l £ $ t- |* P R 5? $ j d« yj tk < q Sfc ^ -2 i 5 c. - 3 r : i ifj R Fig. 73. — Fever Curve of Fatal Apex Pneumoniae, with marked Cerebral Symptoms in a child 2 years old. (Sheffield.) Wandering pneumonia. Complica- tions. and after a few days' persistence finally subsides by lysis. In some instances pneumonia runs a very protracted course ; the inflammatory process "creeps" from lobe to lobe, and finally terminates in unresolved, chronic or the so-called caseous pneu- monia. Quite frequently the pleura is markedly implicated, (pleuropneumonia), without or with an effusion into the pleura, in the latter event frequently resulting in pyothorax. Termina- tion of pneumonia in pulmonary gangrene is rare. Primary pneumonia under suitable management offers quite a favorable prognosis. More serious are the cases in which the lung involvement is very extensive (e.g., double pneumonia) or located at the apex. Still less favorable is the pneumonia super- vening other infectious and contagious diseases, especially if it DISEASES OF LUNGS AND PLEURA. 269 is preceded by a prolonged exhausting siege of the underlying affection. Complications substantially mar the prognosis as regards immediate and ultimate recovery, meningitis and peri- carditis especially proving fatal. Acute nephritis usually ends in sequelae, recovery. Gangrene, pyothorax, peritonitis and suppurative inflammation (pneumococcic metastases) of the bones and joints not rarely yield to early operative interference. Exceptionally fulminating attacks of pneumonia, with extremely high tempera- ture, marked dyspnea, and very rapid and feeble pulse are met which prove fatal within two or three days. The relation between high leucocytosis and a favorable prognosis is still an open question. Diagnosis. — In the initial stage lobar pneumonia may be confounded with lobular pneumonia, pleurisy, meningitis and intermittent fever. In the second stage, with pleurisy with effusion, and in the Diff ti absence of cough (which often occurs when the bronchi are free), g°£ n ^ m: and the presence of abdominal pain and tympanites (the pleural pneumonia r r j r \ r and pleurisy; pain is frequently erroneously referred to the abdomen ; the tympanites is a result of intestinal fermentation, and swallowing of sputum and air) with peritonitis or appendicitis. Errors in Appendicitis; diagnosis are prone to be made, especially in "central pneumonia" with masked physical signs. In the third stage of the disease, with miliary tuberculosis Mmar and typhoid fever. tuberculosis J l _ and typhoid Accidental supervention of angina and erythema (the latter fever; often as a result of heat or rubefacients) may lead to the suspi- cion Of Scarlatina. Scarlatina. Bearing in mind the characteristic symptoms of the diseases for which pneumonia is apt to be mistaken, there ought to be no difficulty in eliminating most of them. The greatest difficulty is usually experienced in the differential diagnosis between acute lobar pneumonia and catarrhal pneumonia and acute miliary tuberculosis : — Acute Lobar Pneumonia. Catarrhal Pneumonia. Generally a primary disease. Secondary. Onset sudden. Gradual. High regular fever. Moderate and irregular. Inflammatory process localized. More diffuse. Physical signs distinct. Indistinct. Termination by crisis the rule. By lysis. 270 DISEASES OF RESPIRATORY SYSTEM. A( ite Lobar Pneumonia. Miliary Tuberculosis. Onset sudden and marked. More gradual and masked. Fever high and regular. Very irregular. Tuberculin test negative. Positive. Sputum contains pneumococci. Tubercle bacilli. Duration from one to two weeks From three to six weeks, ending with tendency to recovery. fatally. See also Pleurisy, page 278. Coi fcabie Pneumonia being a communicable affection it calls for all such hygienic precautions as are ordinarily employed for the prevention of other contagious and infectious diseases. As the contagium is carried by means of the sputum, the latter should be collected in separate receptacles, preferably small pieces of gauze, and destroyed. The active treatment of pneumonia is essentially symptomatic — intended principally to make the patient comfortable and to maintain his power of resistance. Fresh air. Fresh air is the sine qua non! It purifies the respiratory tract, eases respiration, facilitates pulmonary circulation \ hence, relieves and regulates the heart's action, reduces temperature, cheers the patient in those endless, wakeful hours, winch are characteristic of pneumonia, and, last but not least, disinfects the sick-room, and thus prevents transmission of the disease to others and autoinfection of the patient. Pure water. Plenty of pure drinking water is the next most important requisite. This heavenly beverage should be given to the little patients ad libitum, unless temporarily contraindicated by uncon- trollable vomiting, when only small quantities should be admin- istered. Pure water cleanses the mouth and alimentary canal, which in children with pneumonia is usually infected by the large quantities of putrid sputum swallowed; it quenches the ever- present, agonizing thirst; stimulates expectoration and aids in the reduction of temperature. Moreover, at a time when anorexia is complete, little children, like fish, seem to subsist solely on water, and when the body fluids, desiccated by the burning heat, are at a very low ebb, nature seems to find in water a grateful auxiliary, to "turn the tide." It is very advantageous to have a standing order to employ daily a high intestinal irrigation to cleanse the bowels and to relieve the painful flatulence. Enteroclysis may be repeated a few times a day for the purpose of stimulating the action of the heart and kidneys. Entero- clysis. DISEASES OF LUNGS AND PLEURA. 271 Water should serve as the only antipyretic, when reduction of fever is indicated. As long as the temperature is below 103° F., Hydro- no antipyresis is necessary. In higher temperatures, sponging, therapy - warm baths, cold packs, and, in older children, cold baths followed by brisk friction in accordance with the directions given under "Hydrotherapy," should be resorted to. Occasionally we are called upon to relieve pain, allay the dry cough, subdue the nervous irritation and to support the heart's action. Pain in pneumonia is best relieved by local heat, either in the form of a flaxseed and mustard poultice (see page 263) or cloths counter- immersed in warm mustard water and wrung out, and covered with oiled silk. These may be left in place for from ten to twenty minutes, and repeated twice or thrice a day or more often if the pain persists. The same local remedies are also efficient to lessen the har- assing cough. Excessive nerve irritability is either the result of toxemia or hyperpyrexia, or both. If due to high fever the treatment is self- evident. As warm baths combine antipyretic and soothing quali- ties to the nerve system, they are admirably adapted for the purpose. In cerebral irritation caused by the bacterial toxins an effort should be made to eliminate the latter by colon irrigation, diuresis and hot baths. In the majority of instances, however, we have to have recourse to the bromids, chloral and similar reme- dies, especially when convulsions supervene and not rarely threaten tbe life of the patient. Cardiac debility setting in early is a very grave proposition. Cam hor Camphor and strychnine in gradually increasing doses are best an r d . suited for the purpose. Whenever possible, stimulation should be employed hypodermatically, to obviate gastric disturbances. In severe cases nitroglycerin and digitalis are indicated. We should not exhaust all stimulants at once, but always keep one stimulant in reserve to have something to fall back on when an urgent necessity arises. Protracted and unresolved pneumonias respond favorably to the iodids, which may in small doses be begun with about the Iodids - fifth day of the disease. Iodism can readily be prevented by minute quantities of belladonna. The problem of feeding pneumonia patients is a very difficult one. It is well to bear in mind that a filled stomach by upward 272 DISEASES OF RESPIRATORY SYSTEM. pressure greatly interferes with respiration and cardiac action. The nourishment should he very light and easily digestible, and Feeding. gj ven j n ver y sma li quantities. It is remarkable how often appar- ently delicate infants withstand a very tedious and trying course of pneumonia with barely any food. Breast-fed babies when suf- fering from dyspnea should receive mother's milk from a spoon, since by overlapping the child's mouth and nose the breasts are very apt to cut off the little pure air supply the child is able to obtain. The mouth and nasopharynx should be cleansed twice a day. CHRONIC PNEUMONIA. Unresolved Pneumonia, Fibroid Pneumonia. The mode of development of chronic or unresolved pneumonia has already been referred to when speaking of lobar and lobular pneumonia (q.v.). The lymph in the lungs degenerates into Pathology, fibrous tissue and caseous matter, and the pulmonary interstitial connective tissue undergoes hypertrophy, leading to induration and contraction of the parenchyma, and bronchiectasis. After apparent termination of the pneumonia, the child con- tinues to cough, fails to regain its strength, suffers from embar- rassed respiration, and now and then exhibits rise of tempera- ture. Examination of the chest reveals circumscribed areas (most frequently over the upper lobes) of dullness, bronchial breathing, bronchophony and large crepitant rales. In children „ a with an undermined constitution or an hereditarv tuberculous dis- Tendency to _ _ / tuberculosis, position this condition often gives rise to phthisis and early death. Stronger children, especially if the lesion is small, may after an indefinite period of suffering finally recover. Treatment. — Earl)- attention to the pneumonia, in its acute and chronic states, is of primary importance. Removal of the patient from stuffy unsanitary rooms, and allowing a free influx of pure air will do much to prevent the destructive tendencies of the infected foci. With the same object in view we must avoid administering drugs which suppress cough — nature's method of change of clearing the lungs of impurities. Early sojourn in the mountains and mild seashore resorts ; nutritious food ; breathing exercises ; the internal administration of small doses of creosote and guaiacol and large doses of the syrup of the iodid of iron with cod-liver oil and malt will help to enhance a cure. air. PLEURIT1S. 273 B Guaiacol carbon 3ss | 2 Chocolate 3j 1 4 M. Ft. pulv. no. xv. Sig. : One powder every four hours for a child 4 years old. PLEURITIS (Pleurisy). The pleura, like other serous membranes, may be affected, primarily as a result of trauma, or invasion of pathogenic bac- primary. teria, such as the pneumococcus, streptococcus, the microbe of rheumatism, etc., or secondarily by extension of an inflammation from neighboring structures. Primary pleurisy is comparatively rare in young children. The secondary variety, however, is secondary, quite common in connection with pneumonia, tuberculosis, acute heart disease, and affections of the abdominal organs. Pathologically pleuritis is characterized by congestion and Pathology, roughness of either the parietal or visceral layer of the pleura or of both ; a fibrinous exudation upon the pleura ; in severe cases a more or less large collection of (serous, serosanguinolent, or purulent) fluid between the surfaces of the pleura, or between the gaps and in the meshes of the fibrinous exudation. In accord with the extent and location of the pleural effusion, there is more or less severe displacement of the contiguous structures. I. DRY PLEURISY. It is quite probable that many cases of dry pleurisy in young children escape detection. This is apt to occur especially in secondary pleurisy, where the symptoms of the original disease obscure those of the complication. Moreover little patients often refer the pathognomonic "stitch pain" to the abdomen instead of stitch pain - the side. Apart from the pain the subjective symptoms are few and mild. The child instinctively abstains from coughing and deep Cou s b - breathing, and, like an adult, lies on the affected side. As a rule, the diagnosis can readily be made on hearing the pleuritic fric- ^j^ 011 tion sound — a dry, crackling sound on inspiration. The termina- tion of dry pleurisy is either in rapid and uneventful recovery (sometimes leaving behind slight pleural thickening and adhe- sions) or in the graver form of the malady — i.e., in pleurisy with effusion. 274 DISEASES OF RESPIRATORY SYSTEM. II. PLEURISY WITH EFFUSION. A perceptible pleural effusion, be it composed of serum, blood and serum, pus or chyle may generally be recognized by tbe following distinctive features : — Inspection. — Dyspnea with impairment of movement of the affected side. Bulging. In large effusions bulging of the affected area of the thoracic wall, and not rarely prominence of tbe hypochondrium of tbe corresponding side. Occasionally enlargement of tbe sub- cutaneous veins, and superficial edema. In cases of long standing in which tbe effusion undergoes partial or complete absorption, scoliosis, there is a lateral curvature of the spine with compensatory enlargement of the unaffected side of tbe chest. Palpation. — As compared with the healthy side, there is dis- tention of the intercostal spaces on inspiration, and diminution Diminished ... T „ . vocal of vocal fremitus. In large serous effusion fluctuation may be fremitus. ..... Z. . ..... perceived by placing one finger of one hand in the intercostal space, and with the finger of the other hand imparting quick but gentle impulses to the fluid, in the direction of the other finger. Auscultation. — Varying with the amount of pleuritic effu- . sion or thickening, the respiratory sounds may be diminished or respiratory absent over the affected side and exaggerated over the healthy sounds. , . . portions of the lung. Where the effusion is small and tbe larger bronchi remain open for the respiratory current of air, we may bear distant bronchial breathing. In rare cases, especially in tuberculous pleuritic effusion, tbe respiratory murmur may simu- late cavernous breathing and lead to errors in diagnosis, especially if the bronchophony over tbe compressed lung is transmitted along pleuritic adhesions or the chest wall. Dul up e to Percussion. — Dullness or flatness, corresponding to tbe amount flatness. Q f pleuritic thickening or effusion, over the affected portion of tbe lung, and often tympanitic resonance over the retracted lung tissue. Percussion must be performed lightly, for in the presence of only a thin layer of fluid forced percussion may elicit the normal resonance of the underlying lung. Tbe sense of resistance to the finger is greatly increased. Displacement of tbe neigh- boring organs. Grocco's sign (paravertebral triangle of dullness) is rarely elicited in young children. PLEURITIS. 275 With the establishment of the presence of a pleuritic effusion by means of the aforementioned physical signs, the nature of the pleural fluid content still remains to be determined. In the majority of instances this can readily be accomplished by means of exploratory puncture. Except where the exudate is buried behind a thick pleural membrane or, more rarely, behind tumors of the chest wall (so that the needle does not reach the fluid), or where the pleural content is too thick to pass through the needle, exploratory punc- ture of a pleural effusion usually reveals any of the following Different fluids: Serum, serum with blood, serum with pus, pure pus, or chyle. In accordance with this finding it is customary to dis- tinguish : Serous or serofibrinous pleurisy ; hemorrhagic pleurisy ; purulent pleurisy (empyema, pyothorax), and chylothorax. SEROUS OR SEROFIBRINOUS PLEURISY. The onset may be sudden with vomiting, chills, rise of tem- perature and pain in the side, or, more frequently, insidious, — either as a primary disease with general malaise, short cough, increasing dyspnea and pallor, or as a secondary affection, with accentuation of the symptoms of the primary disease. In acute pleurisies the fever may be moderately high and persist for from two to three weeks, and then gradually subside, even though the effusion remains. Bilateral pleurisy is almost always tuberculous. Pleurisy associated with pericardial or peritoneal symptoms points to its tubercular character. In young children with a yielding thorax, absorption of large effusions is always associated with contraction of the affected half of the chest. The ribs become pressed together, the intercostal spaces narrow, the Tuberculous. shoulder-blade is drawn nearer the vertebral column, and the Def01111it .v ' of thorax. latter twisted (scoliosis). With complete recovery from the disease, the deformity may in some cases gradually disappear. In the majority of instances, dullness and suppressed respiratory murmur continue as a result of pleuritic thickening. The prognosis of this form of pleurisy except that due to tuberculosis is generally favorable. Occasionally acute pleurisy terminates fatally either as a result of a sudden excessive effusion or of pulmonary edema, embolism of the pulmonalis or of a cerebral vessel. 276 DISEASES OF RESPIRATORY SYSTEM. HEMORRHAGIC AND TUBERCULOUS PLEURISIES. Protracted cases of pleurisy should always be looked upon with suspicion. In very many instances they are of tuberculous nature. This is particularly true of bilateral pleurisy and of that temperature, with prolonged irregular temperature and a sero-hemorrhagic exudation. It is well to remember, however, that a hemorrhagic rhagic effusion is sometimes observed in scorbutic children, and that puncture of a blood-vessel or injury to the diaphragm or liver may bring forth blood in the aspirating syringe. In tuberculous pleurisy, before long, other symptoms of tuberculosis make their bacillus, appearance. The presence of the tubercle bacillus in the exudate, or, if the lungs are involved, in the sputum, and positive tuber- culin test settle the diagnosis. PURULENT PLEURISY (EMPYEMA, PYOTHORAX). Owing to the frequency of pneumonias (the principal cause of pleuritic effusions ) in children, empyema is of very common occurrence. In the majority of instances the exudation is puru- lent from the beginning, more rarely it is serous at first, and, after a protracted course, undergoes suppurative transformation, as a result of an endogenous infection by the pneumococcus, streptococcus, staphylococcus, or the tubercle bacillus. Pyo- Locaiizatiou. thorax is usually unilateral, and localized on the left side more frequently than on the right. Occasionally it is bilateral, e.g., in sepsis, pyemia, etc. Still more rarely it is multilocular, en- cysted, or interlobular. The amount of pus varies, from a few teaspoonfuls to a quart. The exudate may on the first puncture prove to be seropurulent. but as the disease advances the puru- lent character increases, becomes greenish-yellow in color, and sometimes fetid in odor. It may be feculent, indicating some connection with the abdominal contents. Pyothorax may develop primarily as a result of trauma. As P s r econdar° r a rule, however, it is met secondarily to inflammatory, especially suppurative, processes of the thoracic and abdominal organs, of joints, of ribs and vertebra?, or in association with general sepsis. As a sequel or complication of thoracic or abdominal diseases empyema usually sets in very insidiously, and may remain latent for some time until either the effusion is so large as to cause bulging of the affected side of the chest, or be discovered acci- dentally during a routine examination for some other ailment. PLEURITIS. 277 The onset is more acute in cases due to trauma, necrosis of neighboring bony structures, exanthematous diseases, or in sudden rupture into the pleural cavity of abscesses of neighbor- ing organs {e.g., hepatic, perinephritis etc.). In such cases the symptoms resemble those of acute serofibrinous pleurisy, except septic fever. that the temperature is higher and more irregular and emaciation and exhaustion are more pronounced. With early operative treatment empyema in children usually Evacuation terminates in recovery. If let alone, the abscess may rupture spontaneously either in the lungs or externally through the chest spontaneous ,, . . rr^-i r i • rupture of wall — empyema necessitatis. I he point of external rupture is abscess. usually found in the vicinity of the sternum, where the chest wall offers least resistance. If the rupture is in the lungs, a very large expectoration of pus occurs suddenly. In these cases there is always danger of pyopneumothorax. In another group of cases the pus may by inspissation lead to caseous residues and fatal issue from gradual exhaustion or from complications, such as tuberculosis, amyloid degeneration, etc. CHYLOUS PLEURITIS (CHYLOTHORAX). Genuine chylous effusion in the thorax is an exceedingly rare condition. More frequently we meet with other milky effusions, — chyliform, latescent (non-chylous). True chylous effusion is cnyiiform. the result of injury or obstruction of the thoracic duct, allowing the escape of chyle either directly through an opening in the wall of the duct or indirectly by transudation. The differential diagnosis between the different varieties of pleurisy can readily be made by means of exploratory puncture, and chemic, bacteriologic, and microscopic examination of the fluid obtained. Bilateral (usually tuberculous) pleurisy may tion e from a ~ be confounded with hydrothorax. The latter condition, how- H y drothorax: ever, is associated with anasarca, consecutive to heart or kidney disease, and generally runs an afebrile course. Left-sided pleurisy may be differentiated from pericarditis by the absence of wftn^ef^sion- heart-symptoms (triangular heart-dullness) in the former, and of lung-symptoms in the latter. The synchronous occurrence of both of these diseases, however, should be borne in mind. Right- sided, purulent pleurisy may be mistaken for an abscess or hydatid cyst of the liver. Careful examination will elicit the fol- abscess- lowing differential points : In liver affections the midaxillary line forms the highest point of dullness, there is fluctuation, local 278 DISEASES OF RESPIRATORY SYSTEM. tenderness and icterus ; in pleurisy with effusion the last-named signs are absent and the midaxillary line forms the lowest point of dullness. Furthermore in pleurisy aspiration brings forth Hy cyst, serum, blood or pus ; in hydatid cyst of the liver, a non-albumin- ous fluid with "booklets. " The differentiation between lobar pneumonia and pleurisy is and not always easy, since both diseases often coexist. In the latter event, however, exploratory puncture will readily clear up the diagnosis. Pneumonia. Pleurisy. Dullness (late). Flatness (early). Temperature high. Low. Pulse-respiration ratio greatly dis- Not so. turbed. Bronchial breathing, bronchophony. Suppressed breathing. Vocal fremitus and resonance in- Diminished. creased. Treatment. — During the acute stage, keep the patient in bed. Limit the supply of fluids (in older children a semisolid Dry diet, diet, consisting principally of cereals, concentrated soups, beef- juice, soft-boiled eggs, etc.). Relieve pain by salicylates, per- Anodynes. haps, with some opiate internally; by strapping of the chest; flaxseed poultices, or the following ointment : — R Tinct. iodini, Olei gaultheriae, Olei terebinthinae, Guaiacolis, Ichthyolis aa 3ss I 2 Liq. vaselini q. s. 3j j 30 Sig. : Paint the affected parts twice a day, cover with absorbent cotton and bandage. Should the exudation increase to such an extent as to greatly Aspiration, interfere with breathing, aspirate and follow it up with the local application and strapping, and the administration of sodium iodid and infusion digitalis — the iodid to promote absorption of the fluid, the digitalis to counteract the interference with the heart's action by the exudate, as well as to stimulate diuresis. These latter procedures (except aspiration) are indicated also in cases running a protracted course, even without a large effusion. Aspiration should be practised in tuberculous pleurisy only to relieve the respiratory difficulty, and in chylothorax, both as a palliative as well as a curative measure. As soon as pyothorax is detected, an immediate operation for removal of the pus is imperative. To wait for eventual spon- ASTHMA. 279 taneous evacuation of the pus through the lungs or externally is Dangers of r ° ° J spontaneous hazardous, principally because of the supervening, often fatal, evacuation exhaustion, and of the danger of complicating pyopneumothorax, an incurable fistula, or caseous degeneration. In tuberculous empyema, surgical interference is indicated only in threatening suffocation, or grave cardiac embarrassment. Empyema of brief duration with readily flowing pus usually does well with a free £^ment incision into one of the intercostal spaces and good drainage. On the other hand, cases of long standing or those with inspissated pus should be treated by resection of a rib, in order to permit free escape of the pus. The disfigurement after such operation in children is comparatively slight, and many cases of regenera- tion of even several ribs are on record. If the empyema is bilateral, it is advisable to operate at separate sittings. Patients recovering from pleurisy, with or without effusion, should have plenty of outdoor air, preferably in the country, Fresn air seashore or mountains. Older children will derive great benefit from horseback riding. For expansion of the retracted lung after a protracted attack of pleurisy with effusion, systematic breath- ing exercises and cold sponging of the chest or cold affusions are very useful. The importance of wholesome feeding should not be under- estimated. Iron, the hypophosphites, cod-liver oil, and extract of malt are helpful to effect the cure. Prompt attention to suppurative foci {e.g., necrosis of ribs or vertebra) and early treatment of pneumonia by fresh air will frequently prevent empyema. ASTHMA. The pathogenesis of asthma in children is essentially the same .... . . . . , . . Stenosis of as that in adults, — stenosis of the lumen of the bronchial tubes, bronchial Breathing exercises. The stenosis may be brought about either by a spasmodic con- traction of the muscle-fibers of the bronchioles, or by vasomotor turgescence and swelling of the bronchial mucosa. Children suffering from asthma usually present an hereditary tendency toward the disease, a susceptibility to protracted irritations of the nasopharyngeal, laryngeal, and bronchial mucous membranes, or a history of pertussis, bronchopneumonia or chronic bron- chitis. In many instances local causes, such as adenoids, deformi- ties of the nasopharynx, persistent thymus, etc., are met, and tubes. 280 DISEASES OF RESPIRATORY SYSTEM. some cases are traceable to reflex causes, e.g., indigestion. Symp- Hay fever, tomatic asthma is occasionally based upon hay fever — resulting from the action of pollen of certain grasses upon the mucous membrane of the nasopharynx — and, finally, an asthmatic attack is sometimes a manifestation of hysteria. With these etiologic factors in view, the subdivision of asthma into true and false is quite justified. Clinically the two varieties differ in that genuine asthma is invariably associated with chronic bronchial catarrh, hence, is based upon a path- ological entity, and is of longer duration than false asthma. There is nothing characteristic about the catarrh. The paroxysm usually comes on at night. The child coughs, is a little wheezy, and in a few hours the typical attack is in full sway. The latter paroxysms, consists of extreme dyspnea, anxious expression of the face, congested eyes, cyanosis or pallor, cold extremities, restlessness and prostration. The patient is usually relieved by sitting up in bed. Auscultation of the chest reveals sonorous and sibilant rales, wheezing, squeaking, and whistling respiration. These sounds are often audible at a distance. As the attack subsides the breathing becomes less and less noisy, less labored, and less rapid. There may be complete apyrexia, or a rise of temperature of labored from two to three degrees. The respiratorv rate may be anv- breathing. ° r _ - J . where from 40 to 80 and the pulse 150 or over. During Eosinophiiia. the height of the paroxysm there is marked eosinophilia. and where expectoration is abundant Curschman's spirals and Char- cot-Leyden's crystals are found in the more or less glairy mucus. Toward the end of an attack the thorax may appear barrel- shaped; but unless the asthma is chronic in nature and charac- terized by prolonged attacks, the emphysematous deformity of the chest is usually only temporary. The attack may last minutes, hours, or days with temporary remissions, but after abatement Recurrence. f fa e paroxysm the child is apparently in good health except for Differentia ^ ie bronchial catarrh. In genuine asthma exacerbations usually tion true W and occur m tne ^ a ^ an( l spring, when the sudden atmospheric asthma. 6 cnan g es contribute to catarrh of the mucous membrane of the respiratory tract. On the other hand, paroxysms of false, spasmodic asthma may occur at any time when the exciting cause, e.g., indigestion, sudden fright, etc., presents itself. As a rule, asthma is not fatal per se. Delicate infants, how- ever, may succumb during a severe attack, as a result of suffo- ASTHMA. 281 cation, or after frequently repeated attacks, as a result of emphysema, cardiac dilatation, or even cerebral hemorrhage. The importance of curing the disease at its very inception or, at least, preventing or mitigating the paroxysm is obvious. A cure can be effected, if the cause can be found and corrected. Attention to Attention to abnormalities of the nose and throat is especially of "naso- fruitful in this direction. Children having an asthmatic or arthritic history should be given particular care in the way of preventing colds and coughs, overfeeding, exposure to unhealthy surroundings, miasmatic affections, undue excitement, etc. An attack may, so to say, be aborted by early administration, pref- erably hypodermatically, of atropine %ooo an d morphine % °f a grain or occasionally by apomorphine gr. y 50 to %oo> repeated, if necessary, after a half an hour. The latter drug is especially efficient in "dyspeptic" or "hysterical" asthma. A few drops of a suprarenal gland solution instilled several times a day into the nose sometimes act admirably. If the paroxysm continues we may resort to the following combination : — Morphine and atropine. I£ Natrii iodidi 3ss Tr. hyosciami 3j (Tr. quebracho 3j ) Ext. grindelise rub 3ss Syr. pruni Virginianae q. s. ad Sij M. Sig. : 3j every three hours for a child 5 years old. A course of syrup of the iodid of iron with cod-liver oil is very useful in all cases, and change of climate, to the seashore or inland, is sometimes effective in enhancing a permanent cure. In treating asthma we should always bear in mind that asthma- like attacks are observed as a manifestation of a large thymus, malaria, or heart and kidney disease, calling for specific therapeu- tic measures to remedy the underlying affections. Asthma. Rare in infants. Mostly of reflex origin. Cough first dry, later loose. Expectoration clumpy. Difficult inspiration and expiration, whistling. Spasmus Glottidis. Peculiar to infancy. Associated with rick- ets. Croupy. Not characteristic. Inspiration, stridulous. Duration, days. hours and Minutes. Pulmonary Edema. Moderately frequent. Secondary to cardiac debility. Short and harassing. Frothy, bloody. Inspiration and expira- tion. Subcrepitant, bubbling rales. Minutes. Change of climate. Differential diagnosis. 18a 282 DISEASES OF RESPIRATORY SYSTEM. EMPHYSEMA PULMONUM. Abnormal distention of the lungs with air occurs as a result of forced inspiration, e.g. } in stenosis of the larynx (croup) or bronchioles (asthma), whooping-cough, in bronchitis or broncho- pneumonia with violent coughing, etc., or expiration, e.g., cornet playing. ( )wing to the great elasticity of the puerile lung and its tendency to rapid adjustment, emphysema is rarely observed in children. If it does occur, it is most frequently limited to the apices and the anterior borders of the lungs. Exceptionally the emphysema is disseminated throughout the entire lung. In this Exaggerated event the symptoms are practically the same as those in the resonance. * r adult, to wit: Exaggerated resonance on percussion, dyspnea, shaded barrel-shaped chest, and prolonged, incomplete expiration. In chest, cases of long standing there is consecutive involvement of the heart — usually dilatation of the right heart, with or without hypertrophy. The treatment consists, in addition to removal of the cause, chiedy of change of air (mountains), light breathing exercises. BRONCHIECTASIS. Bronchial dilatation is not very uncommon in children, but as it usually forms a sequel of respiratory diseases (unresolved pneumonia) with violent coughing, or aspiration of foreign bodies into a bronchus, its presence is frequently obscured by the symp- tomatology of the preceding affection. The dilatation of the bronchus may be cylindrical or saccu- lated, and is almost always associated with peribronchial sclerosis (pulmonary contraction), and occasionally with emphysema. There are no pathognomonic signs of this affection except, ex C e°tora- P erna P s > tl 1e copious morning expectoration of greenish-yellow, '° n i°a f ers° °^ ten fetid, purulent mucus, which on standing separates into an upper layer of serum and a lower of pus. Auscultation of the affected part of the chest reveals abundant moist rales, and if the bronchiectatic cavities lie near the chest wall, cavernous signs, Free from wn ich greatly resemble those of tuberculous cavities. In bron- 'baciiii 6 chiectasis. however, the sputum is free from tubercle bacilli and the course is usually afebrile and often remittent — the child often doing well for weeks. Relative recoveries from this affection are on record. The majority of cases are incurable, and after a shorter or longer Cylindrical or sac- culated. PNEUMOTHORAX. 283 (years) course the patients succumb to intercurrent diseases, such as pneumonia, miliary tuberculosis, or pulmonary gangrene. The treatment, therefore, is principally hygienic and prophy- lactic : Wholesome food, tonics, breathing exercises, inhalation of warm vapors with eucalyptus, creosote or turpentine ; residence in creosote. a high, dry region. To facilitate emptying the dilated bronchi of their mucopuru- inversion of lent content, gentle inversion of the little patient a few times a day proves useful. PULMONARY GANGRENE. Gangrene of the lungs is not rarely a sequel of pneumonia, phthisis, grave exanthematous diseases, gangrenous processes of the mucous membrane or skin, foreign bodies in the air-passages (entrance of bits of food), etc. The symptomatology of this affection is ill defined. In older children, as in adults, the macro- expectoration of three and micro-scopic appearances of the expectoration (upper layer, layers. mucopurulent ; middle, serous ; lower, almost wholly of pus ; remains of lung tissue and plugs containing needles of fat acids and detritus) are very helpful in the diagnosis. On the other hand, in infants chief reliance must be placed upon the general cachectic condition of the patient; the coexistence of gangrene of the mouth, throat or vulva ; the frequent occurrence of hemoptysis (absence of tubercle bacilli), fetid diarrhea, and foul breath. The cough is usually spasmodic. The course of the disease is comparatively rapid, fatal ter- Rapid mination usually occurring within a few weeks, either from course - gradual loss of strength or from complications, such as hemopty- sis, pneumothorax, thrombosis, or cerebral abscess. The treatment is symptomatic — tonics, inhalation of antisep- tics, and if the gangrenous process is accessible, surgical inter- vention. PNEUMOTHORAX, HEMOPNEUMOTHORAX, PYOPNEUMOTHORAX. These conditions occur principally as a result of traumatism Traumatic (fracture of a rib or clavicle), laceration of the lungs from on % m - violent coughing or by foreign bodies, perforation of the lungs through empyema, gangrene and similar destructive processes. The symptomatology is the same as in adults, thus: Sudden 284 DISEASES OF RESPIRATORY SYSTEM. Fig. 74. — Pneumothorax. Note compression of lungs. (Sheffield.) PNEUMOTHORAX. 2Xo severe dyspnea, bulging of the affected side, tympanitic percus- sion sounds. When effusion occurs, there is hyperresonance over the upper portion of the affected part of the chest and dullness or succussion flatness below the line of effusion. Succussion sfives rise to Fig. 75. — Pneumohypoderma 1 (five years old). The patient developed these symptoms suddenly during an attack of measles, with pneumonia. {Sheffield.) splashing sounds. The diagnosis can readily be corroborated by thoracentesis. The treatment consists in the administration of opiates for Aspiration. the pain and aspiration (of air or fluid) to relieve the intense dyspnea. 1 See page 286. 286 DISEASES OF RESPIRATORY SYSTEM. Result of violent coughing. Crackling perceived on palpation. PNEUMOHYPODERMAi (Emphysema Cutis). Entrance of air into the subcutaneous areolar tissue ordi- narily results from rupture or laceration of pulmonary alveoli or bronchi during violent coughing or dyspnea {e.g., in pertussis, measles, phthi- sis pulmonum), or second- arily to suppurative or case- ous processes in the lungs. It is occasionally observed in connection with trauma- tic pneumothorax, and after tracheotomy and intubation. The air-inflation may remain limited to the neck or face or spread over the entire upper half of the body (see Fig. 75 ) , and exceptionally also to the lower half. Pneumohypoderma can be detected by the distinct crackling sensation imparted to the examining finger, and can readily be differentiated from anasarca by the ab- sence of pitting on pressure. If the immediate cause can be promptly arrested, e.g., violent cough by means of morphine, reabsorption of the air usually occurs within a few weeks. Rapidly fatal cases, however, are on record. 1 The new term is suggested because it indicates the exact seat of the trouble; it also helps to distinguish this condition from "surgical emphy- sema," which is produced by gasogenic bacteria. CHAPTER IX. Communicable Diseases. INFLUENZA (The Grip). Influenza is an acute, communicable, epidemic and sporadic disease due to the influenza bacillus of Pfeiffer and Canon. It is ratory. Fig. 77. — Influenza Bacilli. Sputum smear, stained with dilute Ziehl's solution. Bacilli chiefly intracellular, most of them show thickened ends. X 800. (Lenharts and Brooks.) characterized by a variable group of respiratory, gastric or r J^p nervous symptoms, marked prostration and great tendency to furiTnees" complications and sequelae. No age is exempt from this affection, and one attack neither predisposes nor immunizes against another one. The incubation period varies from two to five days ; the onset, as a rule, is sudden, or may be preceded by a few mild prodromata common to all contagious and infectious diseases. Tbe attempt to classify the grip into three distinct types, to wit: catarrhal gastric and nervous, is based upon an erroneous ( 287 ) 288 Cl IMMUN1CABLE DISEASES. conception of the pathology and clinical data of this disease. On Multiplicity the contrary, it is the multiplicity of the lesions and symptoms of lesions, ^j^ j s characteristic of influenza. Thus, the child sneezes, cough, coughs, has no appetite, vomits, complains of pain in the entire body, especially in the throat, head, and the lower extremities, is restless or lies exhausted in a semistupor for hours or days. The cough is dry, loud, harsh, and painful (especially over the region of the sternum). The throat is deep red in color, and Sore throat. Prostration. •>» TE (kI+ "f t /(. n // ia u 2. > i-t 2/i iy xr i-c ±7 -if 0ATE mIememememememememem »»e|— a-, — 3 — — hWBi 102 *■ — - -4 ; -4-1 — 1 \4 — emememememememememe = ===== :=|l========« _ZI._ | 03 \ 1 a 1 1 ' FH . . . J_ : l 2_ i ' IfffrH 99 1 — -*i 1I|:*llHIIIi- _.E : ./. :: :: — | —98 .. . . . **Sr R "^n nn^^Siii nil ^ " "i a > » s| * a p s| * a a a a .s_a |_. a Fig. 7S, -Fever Curve of Atypical Influenza in a child 14 months old. (Sheffield.) Gastro- enteritis. the tonsils and fauces are often covered with glairy mucus and occasionally with a yellowish-white, irregular deposit. In severe cases and especially in young children, large, soft or dry, sibilant rales are heard over a greater portion of the thorax, and, with the dyspnea and sometimes cyanosis, may readily be mistaken for bronchopneumonia. In infants particularly there are observed simultaneously more or less pronounced manifestations of gastroenteric involve- ment. The infant vomits, refuses breast or bottle, cries from pain of a colicky nature, and has an increased number of evacua- tions consisting of variously colored, undigested food. In older children the gastroenteric disturbance is much less marked — being INFLUENZA. 289 limited to anorexia, nausea, vague abdominal pain, and some- times constipation. The nerve symptoms range from simple paresthesia, restless- ness, dizziness and headache, to severe convulsions and profound stupor. In infants somnolence is more frequent than insomnia, and with the baby in a opisthotonos-like position (as a result of pain in the neck, trunk and extremities) one is fre- quently tempted to diagnos- ticate meningitis. Influenza begins with abrupt rise of temperature of from 3° to 5° F., which runs an irregular course and ends by lysis or crisis, often accompanied by free per- spiration, and intense pros- tration. Occasionally the tem- perature with its concomit- ant symptoms may, without apparent cause, continue for weeks (see chart, page 78) and likewise suddenly cease. This type of the disease is often spoken of as chronic influenza, and is very apt to be mistaken for typhoid or malaria. Fortunately it is not commonly met in chil- dren. The majority of cases terminate within from three to eight days. Convalescence is usually rapid in uncomplicated grip, especially in strong children and those free from hereditary or acquired encumbrances. In delicate and previously diseased children recovery may greatly be delayed by prolific complications and sequeke. Pneumonias and otitides are especially common ; and, frequently secondarily to these affections, and more rarely pri- marily, inlluenza may be complicated or followed by encephalitis, Fig. 79.— Paralysis of the N. Ab- ducens, with convergent strabismus and slight facial paralysis, complicat- ing an acute attack of influenza. (Sheffield. ) Delayed convales- cence. 10 290 COMMUNICABLE DISEASES. CompHca- meningitis, paralysis, neuralgias, neuritis, nephritis and cardiac tlons ' neuroses {e.g., bradycardia). The grip has a speciaUpredilection for hemorrhagic processes, such as hemorrhagic encephalitis, pleuritis or otitis, hemorrhages He ™rocesses! from the bowels, nose, skin, etc. — and occasionally gives rise to suppurative adenitis (especially of the submaxillary and parotid glands), rhinitis, conjunctivitis, periostitis, and more minor affections. Every form of cutaneous eruptions may be met in this dis- ease, and lead to erroneous diagnoses. In the presence of simple erythema, for instance, influenza may greatly resemble scarla- tina and baffle the skill of even the keenest observer. In doubtful cases of grip, especially in the absence of an epidemic, a correct diagnosis can be arrived at only by systematic scientific elimination of the suspected diseases and careful search- influenza ing for the influenza bacillus in the expectoration or discharges bacillus. & l b from the nose, throat or ear. Influenza is a treacherous disease and hence, however mild, the attack should not be neglected. Appreciating its high com- municability and its tendency to many and grave complications, every effort should be made to arrest further spreading of the isolation disease bv strict isolation of the patient. Attention should be of patient. J paid to the prevention of complications, principally pneumonia and otitis, — the first by avoiding exposure of the patient to bad atmospheric changes, the second by early treatment of the naso- pharynx — which in the majority of instances serve as the causal factors of grip meningitis, and less serious complications and sequela?. Daily examination of the urine is a highly commendable phrms° cna g nos tic and prophylactic procedure, especially in the so-called chronic grip which is prone to be followed by nephritis. Rest in bed should be enjoined as a means of prevention of cardiac disturbances. benz diU te U ^ ne act ' ve treatment is chiefly symptomatic. The following combinations are quite efficient: — R Xatrii benzoatis 3j 4 Antipyrinje 3ss 2 (Codeinre gr. ss) 0.03 ■ Syr. altheae 3iv | 15 Aquae q. s. ad 3i j | 60 M. Sig. : 3j every three hours for a child 4 years old. Tend MEASLES. 291 R Natrii benzoatis 3ss | 2 Aspirini gr. xv | 1 Olei sacch. menth. pip q. s. M. ft. pulv. no. viij. Sig. : One powder every three hours for a child 6 years old. R Antipyrinse salicylatis 3ss | 2 Ft. pulv. no. viij. Sig. : One powder every three hours for a child 6 years old. For the acute cough ordinary mild expectorants will suffice. Protracted coughs usually yield promptly to creosote internally, Cre0 sote. and the tincture benzoin compound (oj to Oj of boiling water) by inhalation. Complications should be atended to at their earliest inception. Marked prostration calls for prompt stimula- Tonics . tion by means of wholesome diet, small doses of strychnine, and digitalis. A sojourn in the country will materially aid in the prevention of dangerous sequels {e.g., tuberculosis). MEASLES (Morbilli, Rubeola). Measles is probably the most frequent and most readily com- municable eruptive fever of childhood. Children of from two to six years old are most susceptible to it, but it is not rarely met in older and younger ones. In the majority of instances one attack immunizes the patient against another one ; numerous exceptions, however, are on record. The cases of recurrent measles often prove to be rubeola on one occasion, and rubella, or a similar skin eruption, on another. The disease is com- municable in all its stages by means of the contagium — which dwells in the lacrimal, nasal, and bronchial secretions, and prob- ably also in the papules and squamse — either by direct contact or, more rarely, through intermediate persons, the air or fomites. Nine to eleven days — the period of incubation — pass after inva- sion of the system by the materia morbi without any characteris- tic manifestation of ill health, except slight anorexia, restlessness, ephemeral rise of temperature, etc., which toward the end lead to a more acute aggravation of the condition and mark the begin- ning of the prodromic stage. This stage usually lasts three days, rarely longer (up to a week in debilitated children). The little patient complains of chilliness, headache, and fatigue, hangs its head or sleeps most of the time, coughs and occasionally £j£|*J. h sneezes, and presents a rise of temperature of from 2° to 4° F. Not rarely the fever drops the next day, but the catarrhal symp- 292 COMMUNICABLE DISEASES. Red spots on buccal mucous membrane. Eruption. Conjuncti- vitis. Fine des- quamation. toms continue in severer form. Examination of the mouth and throat in the majority of cases reveals upon the mucous mem- brane of the soft and hard palate diffuse redness or punctiform or stellate spots, and on the buccal mucous membrane from six to twenty, rarely more, red spots, with a central, rounded, slightly elevated, bluish efflorescence. These spots never cause pain or ulcerate. They are called Filatow or Koplik spots — the latter deserving the credit of having proven the pathognomonic sig- nificance of the spots as an early sign of measles. Another twenty-four hours and the eruptive stage is reached. Bright red, pinhead- to lentil-sized dots appear over the forehead, about the ears and over the face (chin and around the nose and mouth — circumoral ring), and rapidly enlarge to irregularly serrated, pea- and bean-sized, sharply circumscribed, rounded or crescentic, slightly elevated red spots, which disappear on pres- sure. From these points the eruption rapidly spreads, often in crops, over the body and limbs, taking about twenty-four hours to complete the process. At this time the catarrhal symptoms also are at their height. The face is flushed; the eyes are red and watering and dreading light ; the nasal catarrh is intense ; the cough frequent, harsh and often barking ; the voice hoarse ; the temperature high (104° F., or higher); the urine scanty, high colored (diazo-reaction positive); the child is drowsy; at times delirious, often vomits and occasionally suffers from diarrhea (sometimes bloody). The peripheral and lymphatic glands are not rarely swollen and painful, and the spleen is somewhat enlarged. The eruptive stage lasts from five to six days. Toward the end of this stage the eruption begins to fade, especially on the face, and bran-like scales take the place of the exanthema. With the fading of the eruption there is often a critical decline of the temperature and concomitant symptoms, except the bronchial catarrh. The desquamative stage lasts about one week, so that the patient is usually entirely well by the end of the fourth week from the time of infection. Sometimes traces of the exanthema in the form of bluish-red spots remain over some portions of or the whole body which do not disappear on pressure with the finger. They are of no special significance. Deviations from the typical course of the disease are not rare. Thus, the exanthema may be absent or so scanty as to escape observation — morbilli sine exanthema — notwithstanding the pro- Resembles influenza. MEASLES. 293 nounced character of the catarrhal and febrile symptoms. In such cases the diagnosis from the grip is almost next to impos- sible, and can at best only be surmised in the presence of an epidemic or another case of measles in the immediate sur- roundings. The eruption may appear in the form of small papules, at times penetrated by a hair — morbilli papulosi; or be covered by minute vesicles — morbilli miliares. The appearance of the exanthema may be delayed for a day or two and then be localized principally upon the body and limbs Scarlatini- or become confluent so as to resemble the rash of scarlatina — form. morbilli scarlatinosi. Occasionally small hemorrhages occur between the spots — morbilli hemorrhagica. This form of measles . . . .... VUao-k is not to be mistaken for morbilli hemorrhagici maligni, "black measles," which is rather very rare and observed only in delicate, cachectic children. In this condition instead of the eruption there are numerous petechias and ecchymoses, in addition to hemor- rhages from the nose, ears, genitalia, kidneys or bowels. Malig- nant measles is usually associated with early depression, very high temperature, rapid and frequent pulse ; dry, brown and thickly coated tongue ; sopor, convulsions and coma, and often ends fatally within three days. Occasionally the temperature is protracted or after a fall suddenly rises, indicating the occurrence or near advent of com- plications or sequelae. Ordinarily complications set in toward the end of the eruptive stage, but may appear as early as the pro- dromic stage. At this period also we are apt to find angina tonsillaris, epistaxis, severe vomiting and diarrhea, catarrhal laryngitis, pneumonia, etc. In the eruptive stage pneumonia forms the chief complication. Violent coughing is prone to give rise to laceration of the lungs and consecutive "pneumohypoderma" (see page 286). Quite fre- quently we meet also with pseudocroup and more rarely with diphtheria. The diphtheria of the throat sometimes develops secondarily to that of the conjunctiva ; more frequently, however, the former occurs primarily, and the diphtheritic conjunctivitis remains limited to the original focus. It was my privilege to see two cases in point. One boy, six years old, succumbed to laryn- geal diphtheria, while his brother, three years old, was saved from blindness and, perhaps, death, by early administration of antitoxin. The affected eye presented a clinical picture resem- Croup. 294 COMMUNICABLE DISEASES. bling that of gonorrheal ophthalmia. The diphtheritic conjuncti- vitis cleared up entirely within ten days, but was followed by typical diphtheritic paralysis of the throat. Severe stomatitis is Noma ' not uncommon, and numerous cases of noma (q. v.) complicating or following measles are on record. The same observation holds good for divers forms of ear affections. Measles is not infre- quently associated with typhoid, erysipelas, varicella, scarlatina and acute pemphigus. The latter eruption may become gan- grenous and prove fatal. The tendency to gangrene of apparently mild lesions of the mucous membranes and skin should always be borne in mind, as it is not at all rare to find general sepsis super- vening just such lesions. Measles acts as a great predisposing cause to pertussis, which latter may prove fatal from rapid col- lapse or early supervention of bronchopneumonia. Sudden heart paralysis is rare. Among the sequelae the following affections deserve special otitis, emphasis : Chronic conjunctivitis, keratitis, otitis, deafness, deaf- mutism, osteomyelitis, purulent pleurisy, or pericarditis, nephritis, Tuberculosis, tuberculosis, psychoses, meningitides and other nerve affections. Fortunately, most of the aforementioned complications and sequelae are rare. Ordinarily measles runs a benign course. Still, measles should always be looked upon as a very serious disease, especially if it attacks very young and delicate children and those with a tainted hereditary disposition. The custom still prevailing with some ignorant people to con- „ gregate the children free from measles with those affected by it Isolation of ° fe _ J patient. so that "they should all have it at once" is condemnable. Isola- tion of the patient should be insisted upon, and all other precau- tions available (see page 88) strictly adhered to. The special measures in the treatment of measles consist Dia horetics P rmc ip a Hy of active diaphoresis by hot drinks, hot baths and diaphoretics (decoction of crocus, 5j to Oss), and minute doses of Anodynes. an opiate and expectorants to relieve and loosen the cough. Attention to complications is all important, whether grave or mild. A light diet should be enforced as long as the temperature is above normal. The fear of free ventilation of the sick-room is unfounded. On the contrary, a liberal supply of fresh air should be allowed as a therapeutic measure. Where photophobia exists, the room should be darkened by shades. The mouth and eyes should be kept clean with warm boric ROTHELN. 295 acid solutions, and the nasopharynx by instillations of a few drops of albolene. Other symptoms arising should be treated according to indi- cations. R Liq. amnion, anisat 3ss | 2 Spts. aetheris nitrosi, Syr. scillse comp., Tinct. opii camphorae aa 3j 4 Syr. rhei 3iv 15 Aq. anisi q. s. ad 3ij 60 M. Sig. : 3j every three hours for a child 4 years old. (Useful expectorant, etc.) For differential diagnosis see page 327. ROTHELN (German Measles, Rubella, Epidemic Roseola). On superficial examination rotheln closely resembles measles, but on careful observation it is found to differ from it in so many respects as to justify its classification into a distinct disease. It is highly communicable and often occurs in epidemics. One attack is supposed to confer immunity for life; the exceptions to this rule, however, are by far more numerous in this disease than slight -' prodromata. in measles. The incubation period lasts from ten to twenty-one days, and is generally free from any manifestations. There are none or very slight prodromata of from twenty-four to forty- eight hours' duration, consisting of languor, anorexia, and slight catarrhal symptoms. The eruption usually appears suddenly first on the face, and within from twelve to twenty-four hours over the entire body. Often it has disappeared from the face by the time the extremities are involved. The rash appears in two ra°h bllhform forms. One resembles that of measles — pale red papules, up to the size of a lentil, usually discrete, rarely confluent, and momen- tarily disappearing on pressure. The other form is finely punc- tuate and coalesces into diffuse rose-red patches — resembling the ^rni^rash. rash of scarlatina. The eruptive stage lasts from three to four days, and is usually free from severe general symptoms. During the height of the exanthema, there may be a rise of temperature of two or three degrees, but it is only of short duration. As in measles, the mucous membrane of the throat is the seat of diffuse or dotted redness; the buccal mucous membrane, however, shows no typical Koplik spots. Most patients complain of sore throat An ina during the acme of the disease, but not nearly as much as in Largo spleen. Free per- spiration gnomonic. 296 COMMUNICABLE DISEASES. scarlatina. The superficial glands, particularly those in the Adenitis, region of the angle of the jaw and less frequently those of the axilla, groin, etc., and the spleen are enlarged and tender. The differential diagnosis between rubella and rubeola will be outlined on page 327. Attention will here be directed, how- ever, to the frequent, nay, almost constant, occurrence of free perspiration in rotheln, a symptom almost never met in genuine monic. measles. Where the rash is scarlatiniform, it may in the begin- ning be confounded with scarlet fever, but in the latter affection there are marked initial symptoms (vomiting!), high fever and pulse, and more severe throat manifestations. Numerous so-called heat and stomach rashes greatly resemble German measles and it is not always very easy to tell them apart, particularly in the absence of an epidemic of rotheln. Under the circumstances it is safe to reserve the diagnosis for about twenty- four hours, and watch the results of a "cooling lotion'' and a laxative. For its differentiation from Duke's disease see page 327. Rubella is considered the mildest of all acute exanthematous infectious diseases, and, as a rule, terminates favorably within one week from the onset of the symptoms. But in view of the occa- sional occurrence of serious complications (severe angina, bron- chopneumonia, suppurative adenitis, and even meningitis), it should always receive proper attention, especially in the way of rest in bed, light diet, cleansing of the nasopharynx, and good hygiene. See also the treatment of measles, page 294. DIPHTHERIA. Diphtheria is caused by a bacillus discovered by Klebs and Loffier in 1883. The bacilli are found in the secretions and excretions of the structures involved, and are transmitted usually through direct personal communication (kissing, etc.), but prob- ably also through the agency of dishes, clothing, etc., and through a third person. The bacillus is very tenacious to life, so much so bacillus, that rooms previously occupied by diphtheria patients and left vacant for weeks frequently harbor infective diphtheria bacilli, having resisted disinfection and prolonged ventilation. The diphtheria bacilli have a predilection for the lining of the nasopharynx and larynx, especially of children of from two to eight years of age. By far more seldom they attack other parts Complica tions Diphtheria DIPHTHERIA. 297 of the body, e.g., intestines, by extension of the primary inflamma- tion. After imbedding themselves into the primarily affected structures the bacilli multiply and secrete their toxins, which enter the tissues and lymphatics and thence produce general infection. The incubation period varies from five to ten days. As a rule, the onset is sudden with vomiting, headache, chills, fever, sore throat, and difficulty in swallowing. Not rarely however it is preceded by indefinite signs of ill health of a few days' duration, consisting of anorexia, lassitude, slight fever, irritation of the Primarily local. Fig. 80. — Diphtheria or Klebs-Loffler bacilli ; smear prepara- tion from tonsillar deposit. Ldffler's stain. X 800. (Lenharts and Brooks.) respiratory tract, etc. In such cases the active stage of the dis- ease may insidiously follow upon the prodromic stage without any pronounced variation in the clinical manifestations, the throat symptoms often remaining latent until discovered by a routine examination of the throat or unmasked by grave correlative symp- toms. The importance of a routine examination of the throat of children in all kinds of complaints, therefore, is obvious. The initial symptoms of the disease are not very characteristic, ■especially if the attack is mild. The uvula and tonsils are inflamed and somewhat enlarged. Careful inspection of the throat usually reveals upon the inner tonsillar or faucial surfaces in , ner ton - •' ... sillar and a small, uneven, grayish-white, slightly elevated patch, or a few fauci ai gray streaks or hemorrhagic specks. Within a few hours the deposit is found to have spread to the palatine arches and the 19a Deposit on surfaces. 298 COMMUNICABLE DISEASES. posterior pharyngeal wall, giving the appearance of a greenish- Raw, bleed- white, sharply defined, firmly adherent membrane, which if for- mg surface, ^jy detached leaves behind a raw, bleeding surface, and re-forms very soon after. As the deposit assumes greater dimensions, the cervical and submaxillary glands, which at first are but slightly involved, become large and hard, assume the shape of large walnuts, and are very painful to the touch. Deglutition is difficult but not very painful — due to partial degeneration of the pharvngeal muscles and their nerves. The aforementioned con- stitutional symptoms continue. The symptomatology thus far represents the first stage of a moderately severe attack of pharyngeal diphtheria. From now on three eventualities are possible: 1. The clinical picture may remain stationary. 2. The disease may spread to the nose. 3. involve- The diphtheritic process may extend downward to the larynx. larynx. Since the introduction of the antitoxin treatment of diphtheria the number of cases falling into the first category has enormously increased. With early treatment the disease is rapidly arrested, the membranes are cast off spontaneously, and the patient makes an uneventful recovery within from four to eight days. Less frequently the second or third possibility occurs. Either as a result of extreme virulence of the infection or of negligence or improper treatment, the nose or larynx or both become invaded. Nasal sero- I n nasal diphtheria (rhinitis fibriuosa et membranaced), in addi- purulent discharge, tion to the previously mentioned symptoms, nasal breathing is obstructed and accelerated. The child keeps the mouth widely open, snores, is very restless, speaks through the nose, is almost unable to swallow, has fcetor ex ore, and coryza with a sero- purulent discharge. In laryngeal involvement {diphtheritic croup ), symptoms of laryngeal stenosis predominate. The child's voice becomes husky, then hoarse, aphonic, and its breathing noisy, rough and wheezing, and as the disease advances it is True croup, attacked by a barking, croupy cough, dyspnea, retraction of the lower portion of the sternum and the ribs with each inspiration, and cyanosis. The dyspnea often occurs in paroxysms, which greatly resemble those of spasmodic croup (q. v.), and grow worse from time to time. Unless the air passages are promptly freed from the obstruction by intubation or tracheotomy, the patient passes into a state of stupor and finally succumbs to the effects of increase of carbonic acid and deficiency of oxygen in the lungs. DIPHTHERIA. 299 Both laryngeal and nasal diphtheria may develop primarily, and later become associated with pharyngeal diphtheria. The course of the disease varies greatly with the location of the lesion, severity of the attack, and the period at which treat- ment is begun. Pharyngeal diphtheria usually pursues the most Prognosis favorable course. Mild cases, as mentioned, may end in complete g^ recovery in from four to eight days. In severer cases the symp- favorable? toms may increase in intensity up to the fifth or sixth day, and then begin to abate, and after a rapid or protracted course finally subside. The same holds true of nasal or laryngeal diphtheria, provided treatment is instituted early and no complications super- vene. Unfortunately in the latter form of the disease complica- tions are of quite frequent occurrence. Exhausted from the prostrating effects of the paroxysmal attacks of laryngeal stenosis, the child is unable to withstand the onslaught of the diphtheritic poison (sometimes also mixed diphtheritic and streptococcic infection). The deposit, originally limited to the upper portions of the larynx, rapidly extends downward, involving the trachea and bronchi — leading to croupous bronchitis and pneumonia, and, as a rule, to a fatal issue — and upward, exerting its destructive action upon the pharyngeal, oral and nasal structures, often Malignant resulting in perforation of the palate, gangrenous sloughing of the uvula, etc. These cases of so-called diphtheria gravissima s. maligna sometimes develop very slowly and insidiously (diph- jE^£ nt theria larvata) with symptoms of slight indisposition, slight rise of temperature, bronchial or gastrointestinal catarrh, and after a period of from a week to ten days are abruptly announced by true croup and the accompanying grave manifestations. Occa- symptoms sionally this form of the disease pursues a septic course right from the start, — irrespective of the location and extent of the deposit. It is characterized by vomiting, prostration, puffiness and earthy pallor of the face ; small, often irregular pulse ; epistaxis ; bleeding from the mouth, pharynx or into the skin. The urine is scanty, loaded with albumin ; the temperature may be slightly raised or below normal. Within from three to five days the child dies, in a state of low muttering delirium, from gradual exhaus- tion, or earlier from cardiac paralysis. On post-mortem examina- post-mortem tion, in addition to the diphtheritic lesions pathognomonic of all forms of the disease, the spleen is found enlarged; the kidneys, liver and heart in a state of cloudy swelling — a group of patho- logic findings ordinarily met in severe infectious diseases — and, 800 COMMUNICABLE DISEASES. varying with the intensity and number of complications, divers lesions in other organs of the body {e.g., lungs, brain and alimen- tary canal). There is nothing definite about the number and severity of the complications in any given case. As already stated, mild cases may become severe and exhibit all sorts of complications and sequelae and, vice versa, cases with severe onset may under proper treatment remain free from either and end favorably in a comparatively short space of time. Kidney, heart, lungs and nerve diseases form the most frequent complications and sequelae. albuminuria. Transient albuminuria is often observed even in mild cases. It usually begins the third or fourth day of the disease, sometimes earlier or later, and disappears with abatement of the other diph- theritic symptoms. Occasionally we find true nephritis diph- Nephritis. tlieritiea, with large quantities of albumin and casts and more rarely also blood. The nephritis may also set in as a late sequel, during apparent convalescence, and remain more or less perma- nent. As a rule, however, the nephritis is of short duration, and rarely gives rise to local or general dropsy. By far more serious is the accompanving heart affection — so-called "heart Heart- . / J fa . paralysis, paralysis from involvement of the pneumogastnc nerve. It is often manifested by sudden heart-failure, and may set in either during the acme of the disease or any other time between then and as late as from four to six weeks after. It is apt to arise on the slightest exertion. The heart paralysis is not invariably sudden and fatal, however. Quite often it is preceded by heart- weakness with symptoms of dilatation — interstitial myocardial degeneration — such as extreme pallor ; feeble, rapid, and irregular pulse ; attacks of syncope, albuminuria, exhausting diarrhea, some- times apathy, somnolence, sopor and death ; or, less frequently, very slow convalescence, and gradual recovery, usually with p ■ df remaining heart disease. Occasionally diphtheria is complicated Endocarditis, by pericarditis or endocarditis. Bronchitis and pneumonia are especially prone to occur in laryngeal diphtheria, as a result of direct extension of the diphtheritic process to the trachea, bronchi, etc. (in intubated cases through entrance of foreign bodies. Aspiration P ai 'ticles of food, etc., into the air-passages — "aspiration pneu- pneumonia. nionia"), but also in other forms of the disease. The occurrence of pneumonia greatly mars the prognosis. The most frequent sequel — occasionally also complication — of diphtheria is multiple neuritis, "diphtheritic paralysis." It is due DIPHTHERIA. 301 to an intense degeneration of the peripheral nerves up to their ^^jf roots. It follows in about one-tenth of all cases, probably mild and severe alike. It generally develops about the third or fourth week after the onset of the diphtheria, sometimes earlier or later, and affects the muscles of the soft palate by preference, causing a nasal tone of voice, and regurgitation of fluids through the tion of nose. In combined esophageal and laryngeal paralysis there is through also great difficulty in deglutition, not rarely giving rise to "aspira- tion pneumonia," as a result of entrance of part of the food into the air passages. These disturbances usually disappear spon- taneously or on suitable treatment, within from four to six weeks. The paralysis may extend to the eye-muscles and cause strabismus, oculomotor paralysis, disturbance of accommodation strabismus, and even total ophthalmoplegia. Less frequently the muscles of the trunk and extremities are implicated. The symptoms result- ing are more or less identical with those observed in cases of multiple neuritis from other causes, and vary in intensity from simple motor weakness and ataxic gait up to hemiplegia. In Ataxia - severe cases the tendon reflexes and faradic irritability are entirely lost, and the muscles undergo atrophy. Nevertheless, recovery is the rule in the majority of instances, except when complicated by paralysis of the respiratory muscles (diaphragm) and the aforementioned baleful sudden heart-failure. As regards the hemiplegia, it is still uncertain, whether it is a genuine diph- Hemiplegia. theritic paralysis or caused by underlying alteration in the brain, such as cerebral hemorrhage, or cardiac thrombosis with embolism of the arteria fossae Sylvii, since the hemiplegia not rarely begins with convulsions, loss of consciousness, and is often associated with aphasia and facial paralysis. If the patient sur- vives the attack the hemiplegic symptoms usually subside within a few weeks, but weakness and contractures of the extremities may remain permanent. Less common complications and sequelae are arthritides, Inyo ivement otitides, pleuritis, peritonitis, suppurative adenitis, diphtheritic °ract imentary affections of the stomach, various rashes, etc. From the foregoing discussion it can readily be appreciated that a positive prognosis is almost impossible. It should always be guarded, no matter how mild the case. The gravity of the epidemic, the severity of the attack, the strength and age of the patient, the quality of the heart, the period at which antitoxin has been administered — all have an important bearing upon the out- 302 COMMUNICABLE DISEASES. come of the case. However, no case should be despaired of, no matter how grave. Antitoxin treatment often performs miracles, even in apparently hopeless cases. With the advent of the serum treatment, diphtheria has ceased to be the dread of the community. The mortality of diphtheria which previously ranged between 50 and 75 per cent., has now dropped to about 5 per cent, in pharyngeal and to 20 per cent, in laryngeal diphtheria — the earlier the serum treatment is begun with the lower the mortality. Indeed by administering diphtheria antitoxin at the very inception of the disease we are often enabled to limit the latter to its local manifestation — almost free from constitutional symptoms. Furthermore, those coming in close immuniza- contact with the diphtheria patient may by means of from 500 to 1000 units of antitoxin be immunized against this affection for a period of from four to six weeks. This procedure and isolation of the patient are the most isolation, potent prophylactic measures of diphtheria. As the nasopharynx forms the principal nidus for the development and spread of the diphtheria bacilli and their toxins, cleansing of the nasopharynx by means of mild antiseptics (instillation of DobelFs solution three or more times a day) will often aid in the prevention of infection. This prophylactic measure should be employed in con- Contra- junction with immunization by antitoxin, or without the latter — indications J to antitoxin, wherever there are contraindications to its use (e.g., status lymphaticus, hemophilia) or objections on part of the family. Heart disturbances being the most dangerous complication of diphtheria, the heart should receive very careful attention, even in the mildest form of the affection. It should be examined daily, especially as regards acute dilatation of the heart. The patient should be kept under observation for at least four weeks after abatement of the acute course of the disease, and in the event of any untoward symptoms arising, immediately be put to bed and treated in accordance with the directions presently to be outlined. Even with an apparently normal heart it is imperative to keep the Perfect rest, child perfectly at rest in bed for at least ten days after disappear- ance of the local symptoms. As to the prevention of "aspira- tion pneumonia," the reader is referred to the chapter on "Intubation." The active treatment of diphtheria can be summarized in a few words: Counteract the diphtheria toxin; arrest the local lesion, and increase the power of resistance of the patient. When DIPHTHERIA. 303 called upon to see a case of sore throat or laryngitis that is strongly suspicious of being diphtheritic in nature, we should immediately administer diphtheria antitoxin and lose no time in waiting for the results of a bacteriologic examination. The serum Mode of should be administered by deep hypodermic injections, a syringe tioru 1118 somewhat larger than the ordinary hypodermic syringe being pref- erably employed for this purpose. The anterior surface of the abdomen or thorax or the outer surface of the thigh, where there is an abundance of subcutaneous cellular tissue, is generally chosen for the injections. Previous to the administration of the antitoxin the skin should be carefully washed with alcohol or some disinfecting solution and the syringe carefully sterilized. Nowadays the serum is obtainable in clean, hermetically sealed syringes, rendering their sterilization unnecessary. Children Dose of under two years of age should receive from 2 to 3000 units of antitoxin, and those over this age from 4 to 5000 units. Equal or smaller doses may be given after about eight hours, if no improvement is observed. In malignant cases, 1 or in those seen late, double doses should be administered at once and if neces- sary repeated. The effect of the serum is very beneficial, nay, sometimes magical. After a temporary rise, the fever often falls by crisis, the pulse improves, the membranes loosen and disap- pear, and the whole aspect of the case sometimes changes com- pletely, for the better, within from eighteen to twenty-four hours. However, notwithstanding all that was said in favor of the anti- diphtheritic serum, it is not always advisable to depend upon the serum alone. As diphtheria is originally a local affection and the secretion Local and absorption of the metabolic products (toxins) occur from the local lesion, the urgency of the immediate destruction of the bacilli at their point of entrance is self-evident. This is best accomplished by the different germicides and solvents, such as peroxid of hydrogen, strong solutions of carbolic or salicylic acid, 20 per cent, to 50 per cent, solutions of resorcin in alcohol, papain Resorem- or pepsin, or the carbol-camphor solution referred to on page 242. Milder solutions of the same preparations should be used also for cleansing the nose — even in the absence of any lesion there. The local treatment should be repeated every two to four hours and continued until total disappearance of the acute symptoms of the diphtheria. tment. 1 In desperate cases the antitoxin may he administered intravenously. ;;04 . COMMUNICABLE DISEASES. IJ Glycerit. papain 3iv j IS Acid, carbolic. | Pulv. camphor aa gr. viij | 0.5 Alcoholis q. s. ad solv. Glycerini q. s. ad £3ij i 60 This is applied to the throat by means of a cotton swab every two hours — changing the swab each time — diminishing the fre- quency of applications with the abatement of the severity of the symptoms. The third indication, to increase the power of resistance of the patient, should be met by an abundance of nutritious, easily Feeding, digestible food, stimulants and hematinics. Feeding of the little patient is as difficult as it is important. As a rule, total anorexia prevails, and it requires a great deal of patience and tact to induce the child to swallow a few mouth fuls of milk, broth, beef- juice, ice-cream, fruit-juices, etc. Still, much may be gained by administering the nourishment in small, frequently repeated quan- tities, and in small children, if need be, by rectal alimentation (peptonized milk). As a food and stimulant good wines and stimulant^ co g nac are °f inestimable value in diphtheria, especially in the septic variety. In malignant cases it should be given well diluted in large, frequently repeated doses (oj to 5ij every two hours) preferably by mouth, and in urgent cases in smaller doses also hypodermatically. It is advisable to employ mild stimulation from the earliest inception of the disease, and to continue it for weeks after in order to obviate — at least to a certain extent — sudden heart-failure. A useful combination which acts both as stimulant and hematinic, is the followim ip--- Strychnine. IJ Strychnine sulph gr. U I 0.01 Liquor, ferri et ammon. acetatis Bij | 60 M. Sig. : One teaspoonful every six hours, diluted in sweetened water. Whenever the local as well as systemic effect of iron is desirable, the iron and myrrh mixture referred to on page 319 answers the purpose admirably. Any untoward symptoms aris- ing should be combated according to indications. In heart Digitalis, weakness strychnine and digitalis should be pushed to full tolerance. In laryngeal diphtheria without nasopharyngeal lesions the local treatment outlined for the pharyngeal involvement may be dispensed with. Occasional cleansing of the nose and throat with Dobell's solution, however, is useful as a preventive measure. DIPHTHERIA. 305 It is of advantage also to have the patient inhale medicated vapors, such as the following: — R Thymolis gr. x Acidi carbolici 3ss Olei eucalypti 3j Alcoholis q. s. ad Sij M. Sig. : 3j in a pint of hot water. 0.6 2 4 60 With early administration of antidiphtheritic serum the laryngeal stenosis rarely attains such severity as to demand relief by intubation or tracheotomy. Mild paroxysmal attacks of dyspnea often yield to emesis (oss of wine of ipecacuanha, or Emetics - gr. y 2 o of apomorphine hydrochlorate), and a small dose of morphine (gr. % ) and atropine (gr. % o)- But if these remedies fail, intubation or tracheotomy should be resorted to. modfc P s as " It is always preferable to intubate (or tracheotomize) early than late. Whenever the dyspnea is steadily increasing in intensity and the temperature rises, this life-saving measure is indispen- sable, and procrastination is apt to prove fatal. INTUBATION.l For intubation as now performed the world is indebted to the late Joseph O'Dwyer, of New York. Intubation is employed o'Dwyer's in acute laryngostenosis whether of diphtheritic or other nature mventlon - (see page 256). It consists in the introduction of a tube into the larynx, the size of the tube varying with the age of the child. A set of intubation instruments (O'Dwyer's) suitable for children up to the age of puberty consists of six tubes, an intro- ducer, an extractor, a mouth-gag, and a scale of sizes. O'Dwyer's latest tubes are made of hard rubber and lined with gold-plated metal. Each tube is supplied with an obturator, one end of which screws on the introducer. The tube is selected according to the age of the patient, — the smallest size for the first year, the second for the second year, the third for from two to four years, and the others, successively, for children two years older. It should be remembered that the tube must fit the larynx and the latter not be made to fit the tube. Mode of Operating. — A tube of proper size for the child's age is selected, and, through the eyelet intended for the purpose, threaded with strong silk- or linen-thread, — long enough to reach the stomach and still protrude through the mouth. The Partly after Graetzer and Sheffield's ''Practical Pediatrics. 20 306 COMMUNICABLE DISEASES. thread is used as a precaution to prevent the tube from slipping into the stomach, in case it is wrongly placed into the esophagus instead of the larynx. The obturator is then screwed tightly to the introducer and passed into the tube, and by repeatedly pushing the latter off from and replacing it upon the introducer we determine that the instru- ment is in working order. Preparation The patient is now placed upon a strong table and the body, from shoulder down, is wrapped snugly in a small sheet or blanket retained in position by several safety pins. An assistant standing at the head of the table inserts the gag in the left angle of the child's mouth, well back between the of patient. Fig. 81. — Introducer with Tube and Detached Obturator. teeth, and opens the gag as widely as possible without using too much force. The same assistant steadies the patient's head and holds the gag in situ. The operator standing to the right and in front of the patient introduction holds the introducer lightly between the thumb and fingers of the of tube. . . . right hand, with the thumb resting just behind the button that serves to detach the tube, and the index finger in front of the trigger underneath. The index finger of the left hand is now quickly passed into the pharynx down to the beginning of the esophagus and, by bringing the finger forward in the median line and raising and fixing the epiglottis, the tube is gently introduced, along the left index finger, into the larynx. When the tube is inserted, it is slipped off by pressing forward the button on the upper surface of the handle with the thumb, while counterpressure is made with the index finger under- neath. In removing the obturator the tube must be held down DIPHTHERIA. 807 by placing the finger either on the side or posterior portion of the shoulder of the tube, lest the tube will be pulled along. After placing the tube in position the gag is removed, but the string is allowed to remain for about ten minutes, or until it is ascertained that the dyspnea is relieved and that no loose membrane is crowded down in the lower portion of the trachea. In removing the thread the finger is reinserted to hold the tube in place. If any difficulty is experienced in locating the epiglottis, it is better to seek the cavity of the larynx, a cul-de-sac into which the tip of the finger readily enters, and which cannot be mistaken for anything else. Once in this cavity, the epiglottis must be in front of the finger, and the latter is then raised and carried to the Removal of obturator. Removal of thread. Localization of epiglottis. Fig. 82. — Extubator. patient's right in order to leave room for the tube to pass beside it. In the beginning of the operation the handle of the introducer is held close to the patient's chest, and then rapidly raised as the lower end of the tube passes behind the epiglottis ; otherwise it slips over the epiglottis into the esophagus. After-treatment. — The patient should be kept in a recum- bent or upright position, but not allowed to lie upon the face or upon the nurse's shoulder, face downward. After about two hours feeding (in very small quantities) may be resumed, — nursing infants at the breast or bottle, and older children with semisolid substances, such as custards, matzoon, wine jelly, scrambled eggs, ice-cream, etc. It is of advantage to feed while the patient's head is lower than the body. The presence of the tube in the larynx does not contraindicate the use of emetics, which are sometimes needed when the bronchi arc loaded with secretions. Feeding. 308 COMMUNICABLE DISEASES. Accidents and Dangers of Intubation. — With the experi- enced operator the principal danger that may attend intubation membrane 6 is asphyxia from existence of loose membrane below the tube, that is, in the lower portion of the trachea. If this occurs the tube should immediately be withdrawn and, after clearing the trachea of the membrane by induction of expulsive coughing or emesis, reinserted. There is rarely any danger from repeated failure to intubate, provided the operation is performed without passage 6 such forcible manipulation as to produce a false passage, and the finger is not retained in the pharynx longer than ten seconds at a time, and the child is given a chance to get its breath between the attempts. Removal of the Tube. — The condition of the child being favorable, the tube is ordinarily removed after from five to seven davs. This is accomplished with the patient in the same position of extractor, as tor insertion, ihe extractor is guided along beside the finger, which is first brought in contact with the head of the tube (be sure that the tube is still there!) and then carried to the right in order to uncover the aperture by lifting the epiglottis and to leave room for the instrument to enter beside it. Occasionally one succeeds in removing the tube by "stripping" the larynx from below upward with one hand and grasping the head of the tube between the index and middle fingers of the other hand. Retained Intubation Tube (Prolonged Intubation). — Occa- sionally cases are met in which removal of the tube is imme- diately followed by asphyxia, though otherwise the patient seems in good condition. This is sometimes remedied by the use of sedatives, sedatives internally and a spray of cocaine locally to relieve the spasmodic laryngeal stenosis, if present; or by gradual intro- duction of larger and larger intubation tubes anointed with some antiphlogistic drug (5 per cent, ichthyol). The Advantages of Intubation over Tracheotomy. — 1. With an experienced operator, it is a bloodless operation. 2. No fresh wound is made which may prove a new avenue of infection. 3. No anesthetic is required, hence no shock or exhaustion from operation. 4. No skilled after-treatment is needed; no granula- tion wounds to treat. fo^'tTache- Tracheotomy is indicated whenever the larynx is obstructed otomy. ky foreign bodies, edema of the glottis, tumors {e.g., multiple laryngeal papillomas, or compression tumors from neighboring structures) and cicatricial construction of the larynx. (See page 259.) DIPHTHERIA. 309 DIFFERENTIAL DIAGNOSIS. 1. Pharyngeal Diphtheria. — (a) Pseudomembrane : In phar- yngeal diphtheria the pseudomembrane appears as a small, uneven, grayish-white, slightly elevated patch upon the inner tonsillar or faucial surfaces of the throat. The deposit — which contains diphtheria bacilli — augments by quick spreading, reaching within a few hours the posterior wall of the pharynx, and, in severe cases, the Eustachian tube, nares, and, more Extensive rarely, the conjunctiva. Anteriorly the pseudomembrane attacks the palatal arch and uvula. It may spread downward into the larynx or alimentary canal. The surrounding un- covered areas are grayish in color, due to overcrowding of leucocytes, nuclei, and mucus beneath. The tonsils, as a rule, are but slightly enlarged. The deposit, if removed, leaves a raw, bleeding surface and re-forms rapidly. In follicular amygdalitis the deposit begins as one or more white, small pellicles upon the middle or anterior portion of the small, iso- tonsil. The pellicles, at first distinctly isolated, gradually coalesce, gradually' r • 1 ^, i- -1 coalescing. forming elevated patches. Ihey are limited to the tonsils, may easily be removed, and reform slowly. The tonsil, usually one, is moderately enlarged, sometimes previous to the appearance of the deposit. In parenchymatous amygdalitis the tonsil is greatly enlarged, often displacing the uvula. It is bluish in color and doughy in consistence. The deposit, at first white, soon becomes yellowish, resembling the "point" of an abscess. In herpetic amygdalitis the deposit begins with minute vesicles, which have a tendency to burst and leave superficial ulcers. This vesici form of amygdalitis is at times accompanied by stomatitis. Otherwise it resembles follicular amygdalitis. In necrotic amygdalitis the tonsils are moderately enlarged and the deposit lies deeply imbedded within the structure of the mucous membrane. The deposit, if removed, leaves behind a deep ulcer — sometimes gangrenous — surrounded by a distinct red zone ; it spreads, as a rule, from one tonsil to the other by way of the anterior pillars and palatal arch, frequently attacking also the uvula. (b) Submaxillary Glands: The submaxillary glands in diph- theria are greatly involved. They are large and hard, assuming the shape of a large walnut, and can easily be seen protruding from the angle of the jaw. They are very painful to the touch. Minute Spreading ulcer. Large and hard. 310 COMMUNICABLE DISEASES. In follicular and herpetic amygdalitis the glands are moder- Moderate. ately enlarged, softer in consistence and less painful to the touch than in diphtheria. In parenchymatous amygdalitis the glands are moderately Diffuse, enlarged and diffuse, the swelling often extending as high as the car. In necrotic amygdalitis the glands differ but slightly from unilateral those of diphtheria and cannot be relied on as a differential point at first. e ,. of diagnosis. (c) Early Constitutional Symptoms: Except the presence of albumin in diphtheritic urine, none of the early constitutional symptoms are characteristic of diphtheria. Indeed, they are fre- quently less pronounced in diphtheria than in the other throat affections, unless the former is complicated by streptococcic Moderate infection. The temperature in diphtheria, as a rule, is moderate, in diphtheria, about 101° to 103° F., and continuous. The pulse is feeble and quick and soon gives signs of exhaustion. The face, as a rule, is pale. Swallowing is difficult, but not very painful, due to partial degeneration of the muscles of deglutition and their nerve supply. Albuminuria is invariably present from the earliest beginning of the disease and is of great significance in the differ- ential diagnosis. In the various forms of amygdalitis the temperature is quite high, especially toward evening, often reaching 105° F. The Hyper- f ace j s flushed. Deglutition is painful and difficult as a direct pyrexia in . . tonsillitis, result of soreness and sensitiveness of the tonsils. Albuminuria is usually absent. The diagnosis of scarlatinal angina is at best very difficult. It may be taken for granted that the primary amygdalitis is scarlatinal in nature, and that the sore throat setting in several days after is diphtheritic. It should be left, however, to the bacteriologic test to clear up the diagnosis. 2. Laryngeal Diphtheria. — Laryngeal diphtheria can only be mistaken for non-diphtheritic membranous laryngitis, also known as croup, which, on the other hand, is entirely distinct from spasmodic laryngitis (a mild catarrhal inflammation of the mucous membrane of the pharynx or larynx without the formation of a pseudomembrane). In speaking of non-diph- theritic membranous laryngitis I am fully conscious of the Differentia- , ..." tion from manifold denials made by advanced clinicians as to the exist- non-diph- ,.,,..,,,. , . T theritic. ence of such a 'non-diphtheritic disease; here, again, I am SCARLET FEVER. 311 merely guided by the observations made in my own practice without attempting either to confirm or refute the views of others, and, while the exact distinction is associated with extraordinary difficulty, I believe to have been successful in making a correct diagnosis with the aid of the differential points referred to on page 255. I may also mention that pharyngeal or laryngeal syphilis in childhood, if accompanied by an acute attack of amygdalitis, is Differentia- apt to be mistaken for diphtheria. Early in the disease the his- syphilis™ tory of the case, the usual presence of syphilitic manifestations on other portions of the body and the absence of diphtheria bacilli are reliable differential signs. SCARLET FEVER (Scarlatina, Febris Rubra). The more frequently one has occasion to observe and to treat scarlet fever, the more he appreciates the treacherous nature of Treacherous this affection. Grave danger lurks often in the most benignly appearing attack, and dreadful surprises are not rarely encoun- tered at a time when the patient is apparently at the threshold of recovery. It may be so mild in one child as to entirely escape observation, and yet may give rise to a most virulent type of the disease in another child. It is highly contagious and infectious in all its stages, the contagium (which is still unknown) being transmitted from person to person, through a third person, arti- cles in use, toys, food and the air. Children of from 2 to 7 years are especially prone to contract the disease, but it has been observed even in newly born infants of mothers suffering from scarlatina just before delivery. As in other contagious and infectious diseases, some individuals possess an inherent or acquired permanent or temporary immunity against the disease. On the other hand, some children are highly susceptible to scar- latina and may have several attacks, sometimes even in the form of a relapse within from two to six weeks after the first attack (scarlatina rccurrcns) . The incubation period of scarlet fever is ordinarily shorter than that of any of the other exanthematous febrile diseases. As a rule, it lasts only a few days (varies from one clay to one or two weeks), and rarely gives rise to distinct symptoms of the Vomiting, approaching disease. On the contrary, often in the midst of apparently good health, the patient vomits (usually repeatedly), 312 COMMUNICABLE DISEASES. complains of fatigue, slight sore throat, and chilliness, and young and nervous children are occasionally attacked by convulsions. The temperature rises up to 103° or 104° F., or higher; the pulse sore throat, is greatly accelerated; the throat is deeply injected; the tonsils are somewhat enlarged and covered with a slight mucopurulent or hemorrhagic deposit. Sometimes a transient, prodromal Transient erythema is observed on different portions of the body. The ery ema. a f oremen j-j onec i symptoms continue for about twenty-four hours. By this time, or a few hours later, a bright-red rash becomes visible on the neck, chest and back and the flexor surfaces. On close examination the eruption is found to consist of very fine, searie/rash. rose-red to deep-red dots separated by minute, pale areas of healthy skin. The scarlet points are not elevated above the surface. The rash disappears on pressure, and when the finger- nail or a pencil is drawn across the reddened surface, a white line (taches scarlatinale) develops which remains in situ for a few seconds. This is due to increased contractility of the super- ficial arterioles. Gradually the eruption spreads over the entire Circumorai bodv. It is least marked upon the face, and the circumoral ring ring, free. — a space extending from the alae nasi to the chin — is nearly always free from the exanthema. The affected skin is often edematous. With advent of the eruption the temperature rises, the submaxillary glands swell up, are hard and painful to the touch. Inspection of the throat in the majority of instances reveals a follicular deposit upon the tonsils which shows a tend- ency to coalesce and to form necrotic patches. The tongue is coated, very gray, and its edges and tip are bright red. The papillae fungiformes soon project through the coating as red papules — "strawberry tongue." In accord with the height of the temperature, the patient is more or less thirsty, restless, delirious, refuses food, sometimes vomits ; his urine is scanty, high colored, and usually contains a trace of albumin. The symptoms thus far related represent the clinical picture of typical scarlatina during the first two or three days of the eruptive stage. As the disease "Straw- advances the gray deposit on the tongue is cast off, the entire tongue' ton g ue is more or less swollen, red, and covered with thickened papillae. The deposit in the throat loses its tenacity, and often falls off en masse, leaving behind raw, sometimes bleeding sur- faces. The pulse and temperature continue quite high (103° to 105° F.). Cases of considerable severity present in addition marked debility ; febrile, cardiac, systolic murmurs ; slight SCARLET FEVER. 313 enlargement of the liver and spleen; at times somnolence, delirium, with or without high temperature. On the other hand, mild cases by this time may be on the road to recovery, free from fever and rash, ready to be around and about. The stadium desquamativum usually sets in four or five days after the appearance of the eruption, and depends somewhat upon Desquama- the intensity of the exanthema, beginning earlier when the rash is pronounced. The peeling may vary from fine branny scales to large patches of epidermis, the coarser scales being usually limited to the hands and feet. Occasionally the nails shed with the epidermis. The peeling may last from two weeks to as many months, or even longer. In uncomplicated cases desquamation is followed by decline of the symptoms and convalescence. Complications are quite frequent, and their appearance is usually manifested by recrudescence of the temperature after defervescence. Scarlatinal angina — a necrotic inflammation of Angina. the throat — heads the list. It is caused by streptococcic infection and differs clinically from true diphtheria in that it almost never spreads to the larynx nor causes paralysis. Occasionally it is associated with true diphtheria. The throat involvement may be grave right from the begin- ning of the scarlatina, but more frequently it develops between the third and fourth days, usually in the form of an aggravation Adenitis. of the previous condition. The glands at the angles of the jaws swell enormously, are very hard and tender. Inspection of the throat reveals a large yellow or gray exudate on the greatly enlarged tonsils, and often also on the posterior pharyngeal wall. Scarlatinal angina often extends also to the nose, giving rise to a fetid, brownish-yellow discharge, and occasionally to deeper de- structive processes and even to necrosis of the nasal bones. Scar- latinal angina is a very malignant affection, and frequently leads to a fatal termination as a result of gangrene of the throat, Gangrene . fe f= > of throat. involvement of the neighboring large blood-vessels, purulent inflammation of the serous membranes (pleura, pericardium and meninges) extreme prostration, and general pyemia. In some epidemics one is able to distinguish two additional types of angina: 1. The "pestilential form," characterized by muco- purulent, foul masses in the throat and nose, spreading of the gangrenous process to the mouth and the mucous membrane of the lips and cheeks with consecutive hemorrhage, septicopyemic symptoms, increasing collapse, and fatal termination within about ;J14 COMMUNICABLE DISEASES. one week. 2. "Lentescent scarlatinal diphtheroid," which sets in about the sixth day of the disease with sudden rise of tempera- ture, grave constitutional symptoms and intense swelling of the submaxillary glands. The local symptoms (which, by the way, are sometimes hidden ! ) in the nose and throat resemble those of true diphtheria, except that in scarlet fever there is a greater of paute 3 tendency to necrosis of the affected portions, and to perforation of the palate (as in syphilis). After stubborn persistence it quite frequently leads to fatal issue with symptoms of pyemia and asthenia. True diphtheria may be associated with any of the aforementioned forms of scarlatinal angina. An examination of the deposit for Klebs-Loffler bacillus, therefore, is always oppor- otitis. tune. Purulent otitis frequently arises as an immediate sequel of the nasopharyngeal involvement by extension of the inflamma- tion through the Eustachian tube and tympanic cavity. It is manifested by the usual symptoms of otitis media: earache, rest- lessness, rise of temperature, congestion and bulging of the drum membrane, and, as a rule, rapid perforation of the drum by the pus. In a great many cases the otitis leaves no serious conse- quences behind ; in some of them, however, especially in those in which the escape of pus is delayed, scarlatinal otitis may lead to very grave consequences, such as deafness (in very young chil- dren deaf-mutism) mastoiditis, meningitis, etc. Another serious sequel of the throat affection is Angina Angina Ludovici: an inflammation of the submaxillary lymph-glands and the surrounding cellular tissue of the neck, extending from the submental region up to the mastoid process of the temporal bone. The inflammatory infiltration sometimes extends to the larynx and produces oedema glottidis, and, by gravitation, the pus may enter the mediastinum and neighboring structures (purulent pleurisy or pericarditis). It not rarely ends fatally with symp- toms of septicemia, embolism or thrombosis. Among the earlier complications of scarlatina we may mention also pneumonia, rheumatism (myositis, synovitis) and endocardi- tis. All of these complications are probably of septic origin, neumoma. ^he pneumonia presents nothing characteristic, may be lobular or lobar in type. It usually runs a shorter course than primary pneumonia. Scarlatinal rheumatism occurs in two forms: Myositis. gj m pi e myositis, i.e., a localized muscular infiltration, with sensi- tiveness on pressure, and vague "wandering" pain; and scarlatinal synovitis or arthritis which is manifested by pain, swelling and SCARLET FEVER. 315 redness of the joints, especially those of the fingers and toes; rise of temperature, and other constitutional symptoms. Sometimes several joints are affected by leaps. As a rule, scarlatinal rheuma- tism is benign in nature; occasionally, however, the joints may suppurative undergo suppuration, leading to general pyemia with fatal termination. In association with scarlatinal rheumatism, but often also without this, endocarditis forms a relatively frequent complication Endocarditis. and sequel of scarlatina. Indeed the majority of cases of valvular heart disease in children, except, of course, those complicating primary rheumatic fever, are traceable to scarlatina. The endo- carditis may at first be latent and escape detection, and again usher in with very grave symptoms, run the course of ulcerative endocarditis, giving rise to emboli and metastases in the liver, spleen, and kidneys, and end in sudden death or permanent val- vular heart disease. The treacherous nature of scarlatina is most poignantly illus- trated by the occurrence of nephritis as a complication. In the Nephritis. midst of apparently perfect health, at a time when the eruption has entirely subsided, either with or without any tangible cause (often after a slight error in the diet), the child is suddenly at- tacked by headache, dizziness, sometimes vomiting, and convul- sions and examination of the urine reveals an interstitial inflam- mation of the kidneys. As the disease advances the symptoms enumerated under "nephritis" (q.v.) are rapidly and fully estab- lished. This complication usually occurs between the end of the second and third weeks. Hence the importance of daily examina- tion of the urine in all cases of scarlatina, irrespective of the type or degree of severity of the disease. The duration of the nephritis varies greatly according to its severity, and the prompt- ness with which it is discovered and treated. Ordinarily it lasts from two to four weeks and ends favorably, but relapses are not rare, and the nephritis may go on to chronic renal disease. In Chronic fact, scarlet fever, as a rule, forms the principal cause of chronic ^^ e s nephritis in children. Protracted scarlatinal nephritis often gives rise to hypertrophy of the left ventricle and occasionally also to dilatation of the heart with consecutive symptoms of ruptured compensation (recurrent anasarca, dyspnea, etc.). Genuine scarlatinal nephritis should not lie confounded with the transient albuminuria not rarely observed during the first week of scarla- tina, which most probably is due to the hyperpyrexia. As regards 316 COMMUNICABLE DISEASES. uremia, and its grave accompaniments, the reader is referred to "Acute Nephritis." More rare complications are the following : Stomatitis Noma, ulcerosa and aphthosa, noma, gangrene and diphtheria of the genitalia, orchitis, vaginitis, gangrene of the skin and of the tapering extremities; various nerve disorders, such as meningitis, hemiplegia, aphasia, tetany and psychoses; conjunctivitis, iritis, keratitis, choroiditis, neuroretinitis, retinitis albuminuria and sudden amaurosis. Aside from the sequelae previously spoken of, scarlatina may be productive also of chronic purpura, chronic cutaneous affec- tions (furunculosis), chorea, paralyses, marasmus and tuber- culosis, etc. For the differential diagnosis see table, page 327. The discussion of the subject in question thus far relates principally to cases of scarlatina of ordinary severity. In these cases the diagnosis is usually quite easy, and the prognosis, except in the presence of serious complications, relatively favorable — provided, of course, energetic treatment is instituted early. We will now emphasize some of the numerous atypical forms. Occasionally scarlatina is associated with an atypical erup- tion. Instead of the fine scarlet rash there may be variously eruption 1 size & papules or wheals upon a reddened base ; minute vesicles {scarlatina miliares) ; or pemphigus-like blebs. The exanthema sometimes evolves gradually, requiring several days instead of hours as is the case in typical scarlatina. The rash may appear localized with intervening larger portions of normal skin (scar- latina variegata). Finally, there may be genuine scarlatina, with typical angina, nephritis, and even slight desquamation, without any exanthema (scarlatina sine exanthema). The diagnosis in all ^nthema! sucn cases is extremely difficult, and sometimes impossible, unless at the same time typical scarlatina prevails in the imme- diate surroundings, and the other symptoms point strongly toward this disease. The course of the attack also may present great variations. It may be so very mild and brief as to escape observation, or run a mild but protracted course, and remain free from complica- tions. In the latter group of cases the temperature may be low, or remittent, with evening remissions and morning exacerbations (typus inversus). Fever may be entirely absent even in severe cases. Sometimes the temperature is very high (hyper pyretic SCARLET FEVER. 317 scarlatina) from the beginning, giving rise to delirium, convul- Nerve- sions, etc., but subsides again after a few days, leaving the symptoms - patient apparently unharmed. At other times very high tempera- ture is characteristic of malignant scarlet fever. Scarlatina maligna, gravissima s. fulminans, fortunately is not Malignant of very frequent occurrence. In the majority of instances the grave manifestations are in full bloom within the first twenty- four hours of the onset of the attack. The child is suddenly seized with vomiting, rigors, delirium or convulsions ; the tempera- Profound ture rises to 106° F. or even higher. The pulse is weak, rapid and irregular. Sudden collapse, coma, eclampsia and death follow in rapid succession (often within twenty-four hours). In another group of cases the course is more protracted, and typhoid in character. The temperature is not as high as in the aforementioned class, but is marked by evening exacerbations ; the tongue is dry, the lips and teeth are covered with sordes, the abdomen is very tympanitic, and the stools are watery. The sub- maxillary glands are enormously enlarged. There are also signs of blood-dissolution, extensive hemorrhages from the nose, gums, and stomach, which greatly enhance the (fatal) exhaustion. The rash is usually of a violet color and hemorrhagic spots are scat- tered over the surface of the body. This form of scarlet fever is often spoken of as "septic, hemorrhagic scarlatina." Appreciating the unreliability of the initial manifestations, the uncertainty in the further symptomatology, the diversity of the course of scarlatina and its great tendency toward grave complications and sequelae, it is prudent always to be very guarded in expressing an opinion as to the outcome of the disease, no matter how mild (or serious) the attack. The mortality varies in different epidemics, and depends partly upon the age (it is high in children under four and over ten years old) of the patient and principally upon the number and severity of the complica- tions and sequelae. In view of the high mortality it is essential to institute prompt prophylactic measures from the very incep- tion of an attack of scarlatina. Rest in bed is indispensable even bed* in the mildest cases, and should be enforced for at least two weeks (much longer in severe cases) from the beginning of illness. For about the same length of time should the diet be ^st restricted, avoiding all such articles of food as are apt to upset the alimentary canal and to irritate the kidneys. In the active stage of the disease the diet should consist of milk only, and, as 318 COMMUNICABLE DISEASES. the symptoms abate, light eereals and thin broths may be added; in older children also small quantities of toasted bread and butter. fish (boiled), chicken, soft-boiled eggs, and similar light food — all free from salt and spices. Easily digestible food should be continued for several weeks after subsidence of all traces of the disease. These procedures form the most potent means of pre- vention of renal and cardiac disease. In view of the frequency of ear complications every effort nasopharynx, should be made, firstly, by cleanliness of the nose and throat, to prevent infection of the Eustachian tubes, and secondly, infec- tion arising, promptly to make a free outlet to the accumulated discharge (see Otitis), isolation of As regards isolation, room ventilation, and disinfection, see patient. 00 page 88. It is quite difficult to formulate rules for the active treatment of the disease. Every case is a law to itself. We have no specific to combat the affection. Overdosing — but also underdosing — with medicines is to be deprecated. Very mild cases do best if left alone, except as regards prophylaxis. The average case being usually of medium severity, an attempt will here be made to outline a mode of treatment which is best suited to meet ordinary indications. The patient should be put to bed in a well- ventilated room (about 68° F.), the diet restricted to moderate quantities of water and a little milk — in the absence of vomiting. As at the onset of the attack vomiting is usually very marked, no medication per mouth should be prescribed, except, perhaps, a few minute doses of calomel and bicarbonate of soda. To relieve high temperature and nervous irritation, we warm baths. 01 - ( Jer a warm bath every three hours. The baths have also a very salutary effect upon the kidneys by enhancing the elimina- tion of the scarlatinal poison through the skin. Warm packs may be given instead of the baths. As soon as the vomiting has ceased, we increase the quantity of nourishment and direct our chief attention to the throat. The latter is swabbed every two hours with from 5 to 30 per cent, resorcin-alcohol solution or with the following: — Local treatment. R AH(H carbol j d 3ss | 2 Pulv. camphone gr. v 0.3 Alcoholis 3ij I 8 Glycerini q. s. ad Si j j 60 M. Sig. : Apply to the diseased parts by means of a cotton swab every two hours. SCARLET FEVER. 319 The nose should be cleansed with Dobell's solution or similar antiseptic. If dysphagia and tonsillar swelling are marked, we prescribe moderate doses of sodium salicylate, or one of the newer salicylate preparations, and the following mixture : — R Tinct. ferri chloridi, Tinct. myrrhas aa 3ss | 2 (Kalii chloratis 3ss) | 2 Glycerini q. s. ad 3ij j 60 M. Sig. : 3j every three hours for a child 4 years old. With the aforementioned therapeutic measures we are ordi- narily successful to favorably proceed with the case up to the sixth day, — the time when "scarlatinal diphtheria" is prone to Diphtheria .... . ... .. rr . antitoxin. appear. As it is almost next to impossible to differentiate scar- latinal from diphtheritic angina, it is sound and safe practice to administer diphtheria antitoxin in all cases of severe angina, especially if an exacerbation of the symptoms occurs by the end of the first week of the disease. We usually inject 5000 units of antitoxin at once and repeat the dose as indications arise. The local and internal medicines should be continued, however, except bathing, which should be discontinued as soon as the temperature comes down to 100° F. The heart's action should be carefully watched, and any irregularity or debility detected, promptly treated by means of moderate doses of strychnine, digitalis or strychnine J . . and digitalis. strophanthus. The latter two preparations are particularly useful in secondary involvement of the heart muscle. With the dietary and hygienic precautions taken, one is seldom confronted by grave scarlatinal nephritis. Ordinarily the symptoms are limited to slight albuminuria with occasional casts and blood-cells, which readily disappear upon the administration of a few doses of calomel and alkaline diuretics and diaphoretics, high flushing of Enterocl y sis - the bowels and a few hot baths. But, as already suggested, occa- sionally the manifestations are extremely violent (delirium, con- vulsions, coma, etc.), resisting all sorts of medication, and growing worse from hour to hour. In these uremic conditions two therapeutic measures have proved to us of particular benefit : Morphine 1. Morphine and atropine hypodermatically. 2. Lumbar punc- and atr °P ilie - ture. For a child four years old we may administer gr. % of p"^ture morphine and % 00 of atropine, to be repeated once or twice within twenty-four hours. In very bad cases both of these measures may be employed simultaneously. Their effect is often magical. 820 COMMUNICABLE DISEASES. Where the uremic symptoms are slight, bromids with or with- Bromids out chloral per mouth or preferably per rectum suffice to relieve and chloral. ^ nervous symptoms. As to the management of protracted cases of nephritis, see "Nephritis." Simple transient scarlatinal myositis calls for no specific medication. On the other hand, arthritis demands prompt atten- tion, since in the majority of instances it is a manifestation of sepsis and if left alone is apt to lead to general pyemia. The salicylates, salicylates internally and ichthyol externally seem to influence it very favorably, and where these measures fail and pus forms we should resort to a free incision and drainage — but not too hastily. The same holds true for cervical adenitis which, though assuming very large dimensions, does not always suppurate. For suggestions as to the treatment of the remaining, less common complications of scarlatina, the reader is referred to the discussion of the respective diseases. An extremely difficult problem confronts the- attending physi- cian when called upon to treat a case of malignant scarlet fever. Do what you will, the treatment is seldom of any avail. Early Antistrepto- . . J . ' . . .,.,,.. J coccic and administration or antistreptococcic and antidiphthentic serums antidiph- tneritic sometimes saves life, and should always be employed, regardless of bacteriologic findings in the nasopharyngeal discharges. The same holds good for lumbar puncture, if meningeal symptoms predominate. High temperatures failing to yield to hot baths should be reduced by cold (68° to 70° F.) packs or baths. The heart should be kept actively stimulated by strychnine, strophan- tus, digitalis, and suprarenal extract, the latter especially in hemorrhagic complications. During convalescence particular attention should be paid to the alimentary tract and skin. The bowels should be looked after, and stuffing the child with sweets, heavy meats, and alcoholic alcohols " ton ' cs " strictly forbidden. The patient should be warmly clad and wear flannel or silk next to the skin. Exposure to sudden atmospheric changes should be avoided. To facilitate desquamation, the child should be given a hot soap bath every two or three days followed by oil inunction to prevent free distribution of the scales. The following combina- uchin Ve t ' on ^ s c l 1 - ute serviceable, and may be employed also in the erup- tive stage of the disease to relieve itching and burning of the skin : — Duration of contagion. VARICELLA. 321 H Thymolis gr. x | 0.6 Acidi carbolici gtt. x 0.6 Alcoholis 3ij 2 Liq. vaselini Sij 60 M. Sig. : For external use, p. r. n. When desquamation is completed and there is otherwise no contraindication, the patient may be allowed out of doors. Cod- liver oil with the syrup of the iodid of iron and a sojourn at the seaside prove very helpful to rapid recovery. The patient is "contagious" for at least six weeks from the onset of the disease, hence, should not be permitted to mix with other children for that length of time or longer, if desquamation continues, or discharges from the nose, throat, vagina, etc., are present. THE FOURTH DISEASEi (Duke's Disease). The existence of this affection is still awaiting authoritative confirmation. Some authorities maintain that it is merely a mild form of measles or scarlet fever. It begins after an incubation period of from 6 to 14 days with very mild febrile symptoms and an efflorescence on the face, including the circumoral ring. The next day the rash spreads, grouped in a sort of lacework arrangement, to the extremities and trunk. The course of the affection is conspicuous by absence of any severe symptoms and usually terminates favorably in from 5 to 8 days, without any specific medication. VARICELLA (Chicken-pox). The identity of the causal micro-organism of varicella is still unknown. It is absolutely proven, however, that it has nothing in common with the infectious agent of small-pox ; hence an common with . . . small-pox. attack of chicken-pox confers no immunity against the former affection. The disease is communicable from person to person, through an intermediate person, through fomites, and the air. Children of from two to ten years of age are especially prone to contract the disease, but it is not rarely observed also in very young infants, and in children over ten, and even adults are not entirely exempt from it. Slight efflorescence. Nothing in 1 Termed so, being additional to the three known diseases : Scarlatina, Rubella and Rubeola. 322 COMMUNICABLE DISEASES. The incubation period lasts about two weeks, the last few days showing slight prodromata. Occasionally the symptoms of invasion arc moderately severe. There may be vomiting, angina, conjunctivitis, transient ecthyma, considerable rise of temperature preceded by chill, and in small children convulsions. The erup- tion, which appears usually in small or large crops without any characteristic grouping simultaneously upon several portions of the entire body (also the mucous membrane of the mouth and throat), is fully established within twenty-four hours. At first vesicular the eruption appears in the form of slightly elevated rose-red spots, which disappear on stretching the skin. Within a few hours the center of the spot turns vesicular, filled with a clear fluid. The spots attain the size of a lentil or pea, but they may lie larger, pemphigoid, and more rarely umbilicated. On the third day the vesicles usually collapse and desiccate, and become covered by brownish-black crusts. The latter usually fall off on the fifth or sixth day. leaving slight red spots which soon dis- severai appear. Repeated recurrences of new crops of the eruption in different stages of development (papules, vesicles and crusts), sometimes as late as ten to twelve days after the onset, are not rare and often serve of signal value in the differentiation of varicella from variola, in which latter disease the eruption remains uniform and stationary until the final stage of the disease. Occasionally the vesicular content is turbid or purulent (usually as a result of infection by scratching), and when the pustules heal leave behind scars resembling "small-pox pits." Some- times the vesicles burst early and give rise to erosions and ulcerations which if occurring in the larynx may be productive of attacks of dyspnea and even fatal laryngospasm. The latter condition is of very rare occurrence. More frequently we meet, usually as a result of infection, with multiple ulcerative and Gangrene gangrenous processes of the skin — varicella c/aiicirccnosa — in which of skin, » » i J J the vesicles terminate in deep, foul-smelling ulcers, and extensive gangrene of the skin. This form of chicken-pox is most common in delicate, ill-nourished children and is apt to prove fatal. Com- Com tions" Plications and sequela? in the form of nephritis — nephritis vari- cellosa — pneumonia, pleuritis pemphigus — varicella bullosa — multiple abscesses, pyemic processes (due to staphylococcic or streptococcic infection), icterus catarrhalis, dysentery, polioen- cephalitic manifestations, marasmus and even tuberculosis are on record, but they are rather of unusual occurrence. VARIOLA. 323 As a rule, varicella pursues a benign and brief course, free from high temperature and any other constitutional symptoms, and rarely calls for any therapeutic measures. Rest in bed, careful diet, and local cooling lotions (2 per cent, thymol) or ointments (zinc oxid with 1 per cent, of salicylic acid and thymol) to relieve itching usually suffice in ordinary cases. Cleanliness of the mouth and throat. Attention to the urine. Finally, varicella is occasionally associated with other exan- thema {e.g., measles, scarlet fever). For additional differential points see table, page 327. VARIOLA VERA. VARIOLOID (Small-pox). The history of small-pox is that of death and destruction. It is estimated that, before Jenner's discovery of prophylactic vac- cination, one-tenth of all the children died of small-pox. On the other hand, with vaccination and revaccination rendered obligatory in most of the civilized countries, the occurrence of variola in a child is almost unheard of. If it ever does occur in successfully vaccinated children, the disease is usually mild, modi- fied in form — varioloid. Small-pox is an acute, highly contagious and infectious, endemic and epidemic disease, characterized principally by an Endemic and eruption that passes through the stages of papule, vesicle, pustule epi and scab, — the development of the pustule being accompanied by a secondary fever. The nature of the small-pox producing poison is still unknown. It is undoubtedly a mirco-organism that exists in the eruption and probably also in the blood. The disease is most communicable during the pustular and desquamative stages — at which time mere entering the sick-room is said to infect one not protected by vac- cination. After an incubation period of from nine to fifteen days, which, as a rule, is free from any significant signs of illness, the patient is suddenly seized by a violent chill, fever, severe pain in the back, convulsions, delirium, prostration, and sometimes collapse and death — long before the appearance of the eruption. This mode g of onset and termination is quite common in variola vera, affecting: violent' 1 & symptoms. children under three years of age. Some cases survive until the appearance of a papular exanthema upon the buccal and pharyngeal mucous membranes, and then usually die from 324 COMMIWICAP.LE DISEASES. Fig. 83. — Mild Discrete Small-pox in an Unvaccinated Girl. Note absence of lesions upon the trunk. (Kindness of Dr. J. F. Schamberg.) VARIOLA. 825 exhaustion; others again — usually older than three years — suc- cumb to the attack in the suppurative stage, or, rather rarely, recover after a painful and tedious convalescence. It is customary to distinguish three types of variola vera : Discrete, confluent, and malignant (hemorrhagic). Discrete Form. — After the violent onset, the eruption, con- sisting of red, coarse spots, appears during the third day, first on the forehead and lips. The constitutional symptoms then abate, and the patient feels quite comfortable. On the fifth day of the disease the spots develop into papules ; on the sixth day into Fig. 84. — Fatal Small-pox in an Unvaccinated Four-week-old Infant. Seventh day of eruption. (Kindness of Dr. J. F. Schamberg.) vesicles which soon become umbilicated. On the eighth day the Vesicles - vesicles are transformed into pustules which emit a characteristic odor and on the ninth day they become entirely purulent and Pustules surrounded by a broad red band, the halo or areola, the face becoming swollen and the features distorted. On the eleventh day it is usually found that pus oozes from the pustules which on drying forms the scab or crust. The latter falls off some time between the seventeenth to twenty-first day, leaving a red, glisten- ing depression or pit which soon changes into a white cicatrix. With maturity of the pustules (eighth or ninth day) the symp- toms observed at the onset return — secondary fever. This fever of suppuration is the most critical period of the disease. In favorable cases the secondary fever abates after a few days and convalescence follows. The stage of suppuration is very prone to be complicated by severe inflammation of the larynx, bronchi. Secondary fever. 326 COMMUNICABLE DISEASES. lungs, and serous membranes. As further complications or sequelae we may mention stomatitis, noma, involvement of the eyes (phthisis bulbi), otitis media, dysentery and nephritis, violent Confluent Form. — It is characterized by extreme violence '""uonai of the constitutional symptoms and by the confluence of the eruption at certain portions of the body, such as the thigh and lower portion of the abdomen {.Simon's triangle) and the neck. Malignant or Hemorrhagic Form. — This type of small-pox is characterized by malignancy and irregularity "of the symp- toms, and coexistence of hemorrhages and petechia?. In this form smaii-'p'ox' are included the so-called black small-pox (variola hemorrhagica pustulosa ) which usually leads to fatal issue in the suppurative stage, and the fulminant type of small-pox (purpura variolosa) which ends fatally within from three to four days. In contrast to variola vera with its dreadful consequences varioloid, stands variola modificata or varioloid. The latter form of small- pox is usually ohserved in children rendered partially immune by previous vaccination or an attack of small-pox. Its course is Mild. snori shorter and milder than that of the other forms, the eruption is slight and devoid of suppuration, — hence its freedom from secondary fever and severe complications and sequelae. The mor- tality in varioloid varies between 8 per cent, and 10 per cent, in infants and about 5 per cent, in older children. Small-pox may be confounded, in the initial stage, with menin- gitis and, in the eruptive stage, with varicella and morbilli (espe- cially morbilli hemorrhagici ). Meningitis can readily be elimi- Differentiai nated after a day or two. The differential signs between small- diagnosis. J . ° pox and the other exanthemata are outlined on next page. (See table.) If the patient with small-pox is seen early, vaccination should Vaccination. De performed at once ; it may modify the attack. As a prophylac- tic measure it is also advisable to vaccinate all those who come and are apt to come in contact with the patient. Isolation, disin- Quarantine. fection and preparation of the sick-chamber (the room should be kept dark by a deep-red shade) should be carefully carried out, in the manner described on page 88. The child should be con- lined to bed, and kept on a light but nutritious diet, and liberal stimulation, supply of stimulants (wine, cognac). Especial attention should be paid to disinfection of the mouth and nasopharynx (mild solu- tions of potassium permanganate, or chlorate, peroxid of hydro- gen). Tn high temperature and severe nervous phenomena pro- TYPHUS ABDOMINALIS. 327 Variola U-3 Headache, back- ache, chills, con- vulsions. 3d day; coarse pap- ules on forehead and lips, spread- ing downward, changing into umbilicated vesi- cles, pustules and scabs. Disappearance of fever on 3d day; reappearance of "secondary fever" on 9th day. cd" cd a .22 o -a S >> CD o a - a ftj2 CD m a! 3 > S Sa 1st day; crops of thin papules, soon changing into vesicles which dry on 3d day. Pharyngeal and tracheal catarrh. a o a a m 5* o o m |S 0) CD* CD o o ft ra 1st day; efflores- cence on face; next day on ex- tremities and trunk. CD 3 CD' 3 o a 02 O Vomdting, sore throat, hyperpy- rexia; very rapid pulse. 2d day; bright red, pinpoint sized rash on neck, chest and face. Hyperpyrexia, se- vere angina, strawberry ton- gue, desquama- tion. Diphtheria; otitis; myositis; renal disease. Rubella 6 CD m go . a ft cu ..Si Ortp, 13 ^ ° O 2d day; pale red macula? on face and irregularly distributed over body. .2.2 > m jj w CD S cS a _5 o .n 3 Catarrh of nose and eyes; Fila- tov-Koplik spots. 10 w a si «° -a to Mo a §■ "3 ? "d $ .3 •a - -" cu ft a fl h 10 CD 3 o si g.3 ■o 2 Pulmonary and ear disease. [ncubation Period (number of days). h II Time of appearance and character of eruption. "■a 3 o s » III a ° o o •" ° U Principal complica- tions. 328 COMMUNICABLE DISEASES. warm baths, longed warm baths or cool packs act favorably. To prevent itch- ing and extensive pitting we may apply 5 per cent, to 10 per cent. ichthyoi. f jchthyol in equal parts of zinc and sulphur ointments, covered by some unctuous material to exclude the air. It is sometimes necessary to tie the patient's hands to prevent scratching; and Anod nes to administer hypnotics and anodynes for the relief of restlessness and pain. The child should be quarantined for about six weeks. R Antipyringe salicylates gr. xxiv | 1.6 Tr. cinchonas comp 3iij | 12. Syr. aurantii 3j j 30. \i| aurantii q. s. ad f§iv | 120. M. Sig. : Sss every six hours for a child 4 years old. (Antipyretic and anodyne.) R Mentholis gr. v | 0.3 Bismuthi subgallatis gr. x | 0.6 Zinci stearatis 3ij | 60. M. Sig. : Dusting powder to enhance desiccation of eruption and to relieve itching. TYPHUS ABDOMINALIS (Typhoid, Enteric Fever). Typhoid fever is an endemic, epidemic, and sporadic infec- tious disease due to the bacillus typhosus of Eberth. It is char- acterized by a continuous, typical fever, gastrointestinal catarrh, in children, and a roseolar eruption. It occurs probably as frequently in children (even fetal typhoid is on record!) as in adults, but owing to the mildness of the clinical picture it is frequently overlooked. The younger the child the greater the deviation of the fever from course, the usual course. Thus, the onset is either more protracted (with symptoms of subacute gastroenteritis) than in the adult or very sudden with chills and high fever. In older children the initial stage (pyrogenetic stage, first week) resembles that of adults and Pyrogenetic . fe \™, * . . & r ; . . , stage, is marked by epistaxis, frontal headache, anorexia, furred tongue (later dry and brown), restless sleep, and gradual rise of tem- perature. The action of the bowels is not characteristic, and constipation may alternate with diarrhea (sometimes bloody). The fever reaches its height with the approach of the second Fastigium. week (fastigium), and varies in mild cases between 101° and 103° F. and in severe cases between 104° and 106° F., with morning remissions and evening exacerbations ("step curve"). Occasionally the typus inversus is observed, and not rarely the temperature is remarkably low throughout the entire course of the disease. The pulse is sometimes very frequent (160 to 180) TYPHUS ABDOMINALIS. 329 but rarely dicrotic. The urine responds to the diazo-reaction, and f^°{ on contains traces of albumin. During this stage, the second week, the spleen is palpable, but not as distinctly as in adults. The Lar s e s P leeu - roseolar eruption which usually appears about the eighth day on the abdomen, chest, back and limbs, is rather scanty and not rarely entirely absent. The typical eruption consists of small, elevated, rose-colored spots which momentarily disappear on pressure. They evolve in successive crops, each crop lasting Rose-colored spots, in crops. i zi i-i j.x ■*■£ -2-7 EMEMEMEME n i m 1 Fig. 85. — Fever Curve of Typhoid Fever in a child 4 years old. (Sheffield.) about three days, and subside entirely after about ten days. Cor- responding to the comparative mildness of the intestinal lesions, tympanites, iliac tenderness and gurgling are rarely marked. Apathy. During the acme of the fever there are more or less marked nervous phenomena. Some patients are drowsy and apathetic ; some are restless, shriek, and rave ; some suffer from defective hearing, hyperesthesia, insomnia, or semi-stupor, and, finally, others may be dull during the height of the fever but otherwise be playful during the entire course of the disease. Children almost never present the status typhosus. As a rule, the blood gives a positive Widal reaction. (See page 102.) widai test. With the beginning of the third week (de fervescent stage) Deferves- there is a decided improvement in the general symptoms. The 330 COMMUNICABLE DISEASES. tongue begins to clear at the edges, the appetite (often voracious) returns, the temperature declines, as a rule, by lysis, and the grave nervous symptoms gradually abate. The temperature sometimes drops suddenly and remains normal or even sub- normal. In severe cases, however, the fever may continue 'luge 8 (ambiguous stage) and with it all the other symptoms. Indeed, in older children the intestinal manifestations may become more pronounced, and hemorrhage from the bowels, perforation and peritonitis supervene. The usual bronchial catarrh may extend to the bronchioles and pulmonary tissue and lead to diffuse broncho- pneumonia. Furthermore, improvement and recovery may be Relapse, greatly delayed or entirely arrested by relapses, which are not uncommon between the third and fifth weeks, or by the following complications and sequelae : Inflammation of the mucous mem- branes of the mouth (occasionally noma!), nasopharynx and larynx ; parotitis, otitis, cutaneous abscesses, periostitis, peri- spondylitis (typhoid spine) ; pericarditis, endocarditis, purulent tions and arthritis, pyemia, thrombosis and embolism; paralyses (usually neuritis), chorea, aphasia (lasts about a week), dementia, mania- cal and melancholy states. The mental sequelae usually consists merely of temporary irritability, hypersensitiveness, disposition to cry, capriciousness and surliness. On the other hand, cases of permanent mental aberration are on record. Typhoid fever is sometimes associated with pertussis, morbilli, scarlatina and diph- theria and in cases with a predisposition it is apt to be followed by pulmonary tuberculosis. Occasionally typhoid is followed by a post-typhoidal desquamation of the skin, and during and after an attack there is frequently a marked longitudinal growth of the bones, especially of the tubular bones of the lower extremi- ties. As a result of it, the skin over these bones is transversely torn, the tears being indicated at first by red lines, and later by white scars. The aforementioned grave complications and sequelae are very rarely observed in children. As a rule, the prognosis is favorable (less so in infants), and, even after severe attacks, convalescence comparatively rapid and uneventful. In young children the course of the disease is usually very brief, between twelve and fifteen days ; in older ones it is nearly the same as in adults. The morbid anatomical condition in the intestines is much ^nai leskms" m ^^ er than m adults; ulcers are rare, and, if present, are small, superficial and isolated ; hence they heal without leaving behind TYPHUS ABDOMINALIS. 331 any cicatrices in the intestines or any tendency to cicatricial contraction. In view of these marked deviations of the clinical picture, the diagnosis of sporadic cases of typhoid often presents great diffi- Differentia- culties. It is apt to be mistaken for simple gastroenteritis — Gastro° m ' febrile stage of shorter duration; spleen, in uncomplicated cases, enteritis ' not enlarged ; diazo-reaction and Widal's blood test negative ; influenza with pronounced intestinal symptoms — febrile "step" influenza, curve absent, nervous phenomena less pronounced, catarrhal symptoms more marked, Widal's test negative, the influenza bacillus in the expectoration ; pneumonia — more sudden onset, pneumonia, more positive pulmonary physical signs, Widal's reaction nega- tive, diplococcus pneumoniae in the expectoration, neutrophilic cuiosIX leucocytosis ; acute miliary tuberculosis — irregular temperature with sweats, hectic flush, often tuberculous sputum, more pro- tracted course, Widal's reaction negative; tuberculous meningitis meningitis, s — lower temperature ; slow, irregular pulse and respiration ; trough-shaped abdomen ; malaria — usually intermittent or recur- Malaria, and rent fever, malarial plasmodium in the blood, influenced by quinine ; septic endocarditis — pronounced heart symptoms, chills with septic temperature, absence of Widal's reaction. Occasion- ally typhoid begins with pain in the occiput, neck and back, opisthotonos, and other grave nervous phenomena, presenting the clinical picture of acute meningitis. The diagnosis in such cases spinal is often almost impossible in the first few days of the disease. In doubtful cases the bacteriologic examination of the cerebrospinal fluid for the diplococcus intracellularis, and of the stools and urine for the bacillus typhosus often proves decisive. As the contagium of typhoid fever resides principally in the . , ... . ....... Disinfection gastrointestinal contents, it is imperative to thoroughly disinfect of discharges, the stools and vomitus, as well as the linen and other articles in use that have been soiled by the discharges. Furthermore, by taking the precaution of boiling the drinking water or milk, ex- cluding mosquitoes and flies from the sick-room, and by avoiding dissemination of the source of infection through soiled bath-tubs, hands, etc., the disease may be limited to a single patient not- withstanding the intercommunication between patient and other members of the family. Strict isolation, therefore, is not essential. Typhoid fever is a self-limited disease and not controllable by any specific measures. The treatment, therefore, should be Opium in hemorrhage. 332 COMMUNICABLE DISEASES. symptomatic, principally hygienic and dietetic. Cleanliness of the mouth and nasopharynx, cool sponging of the body, with water and alcohol or vinegar, or if the temperature is high, cool therapy! P ac ^ s or full baths, at a temperature of from 80° to 90° F., and an ice-bag to the head, usually suffice to make the patient fairly comfortable. During the first few days we may administer small doses of calomel and bismuth, and later dilute hydrochloric acid. pineapple juice and some good wine or cognac. Hexamethyl- enamine is useful during the entire course of the disease. In intestinal hemorrhage, an ice coil to the abdomen and opium suppository (gr. y i0 for every year of the child's age) will be found very efficient. Rest in bed should be enjoined for at least two weeks after defervescence. The diet should be fluid (milk with tea or a little cognac, soups, light gruel, chicken broth) during the acute course of the disease, and semisolid thereafter, diet, care being taken not to overfeed. Transition to a more solid diet should be very gradual. Relapses call for the same mode of treatment as the original attack. During convalescence the dif- ferent bitter tonics and iron are very desirable, and a sojourn at the seashore often works wonders. Complications should be carefully guarded against and imme- diately treated according to indications. Frequent change of position of the patient is usually effective to prevent serious of decubitus, pulmonary complications as well as decubitus. The skin should be hardened by alcohol, alum-water, etc., and as much as possible protected by air-cushions. The slightest abrasion of the skin should at once be treated by antiseptic dressings (2 per cent, solu- tion of aluminum aceticotartrate). Insomnia and excessive restlessness sometimes require hypnotics. R Olei terebinthinae gtt. xvj | 1 Olei menthae pip gtt. iv | Mist, acacice q. s. ad Sij | 60 Ft. emulsum. Sig. : 3j every four hours for a child 4 years old. (For tympanites.) B Tr. nucis vomicae gtt. xvj 1 Acidi hydrochlor. dil 3ss j 2 Aq. aurantii flor q. s. ad Bij j 60 M. Sig. : 3j, in water, three times a day for a child 4 years old. (Useful as a general tonic during the entire course of illness. ) ILEOCOLITIS EPIDEMICA. 333 ILEOCOLITIS EPIDEMICA (Dysentery). This form of dysentery is entirely distinct from hemorrhagic enteritis or proctitis spoken of in connection with gastroenteritis on page 203. It is an infectious, epidemic and sometimes spo- radic disease caused by the dysentery bacilli described by Shiga, Cruse and Flexner. The lesion is localized principally in the Lesion. colon and less frequently in the ileum and rectum, and varies from a simple inflammation of the mucosa to a croupous, diph- / theritic inflammation, with a membranous deposit, necrosis and ulcer formation. In the majority of instances dysentery begins with simple diarrhea, without any constitutional symptoms and after from twenty-four to forty-eight hours is followed by the characteristic symptoms later to be spoken of. In some cases the onset is sudden with high fever and, in small children, with convulsions. Once the affection is established the symptomatology is quite pathognomonic : Colic, tenesmus, and bloody stools. The colic colic, r ° _ _ J diarrhea, precedes and accompanies defecation and is followed by severe te " d es b r ! lus d and prolonged tenesmus. The bowel movements vary between stools, ten and thirty or more in twenty-four hours, and the dejecta con- sist either of pure blood or of blood and dirty, ragged shreds of tissue and fecal masses. The abdomen is most frequently sunken, permitting palpation of the contracted colon. The tongue is dry and heavily coated, the lips are cracked and covered with sordes, the appetite is lost, and the child suffers from intense thirst, and occasionally nausea and vomiting. As a rule, the tem- perature is raised (intermittent), but it may be normal or sub- normal. After a few days the patient becomes greatly emaciated and prostrated, very anemic, and the expression of the face Prostration - denotes great suffering. Quite a number of children succumb during this stage of the disease ; others again continue to battle for life and after a course of from seven to ten days begin to improve, the stools becoming less bloody and more feculent in character, the anorexia less marked, and the general condition much better. Relapses are not rare, and, when they occur, there Relapse. is a great tendency toward the transition of the acute into a chronic process, with a very tedious convalescence, or death chronic from exhaustion. torm ' An attack of dysentery may be complicated bv peritonitis. 334 COMMUNICABLE DISEASES. noma, parotitis suppurativa, abscess of the liver, fissura or pro- compiica- lapsus ani. pulmonary affections, etc.. and may be followed by tions. j ntest j na ] cicatrices and stenosis, paralysis of the sphincters, paresis of the extremities, and marasmus. The very protracted cases of dysentery are usually found to be due to the amoeba coli (entamoeba dysenteriae). The dif- dysentery° ferentiation between this form of dysentery, that due to Shiga's bacillus, and catarrhal enteritis is important from the therapeutic point of view and can readily be made by a bacteriologic examination of the dejecta. Furthermore, it is well to remember that foreign bodies in the lower bowel may give rise to a group of symptoms similar to that of dysentery and that an inflamed Differentia- ' . . , , , , tion from prolapsed rectum, intussusception, an ulcerated rectal growth or with rectal hemorrhoids with coincident enteritis are very apt to mislead in involvement. ... -, . . . . . '. , . . . the diagnosis. Careful examination (inspection and palpation) of the rectum disposes of these difficulties. The patient suffering from dysentery, like one with typhoid, Disinfection need not be strictly isolated. The dejecta and everything coming in contact with them, however, should be thoroughly disinfected. During an epidemic the drinking water, fruit and vegetables should be boiled, all modes of exposure to infection (mosquitoes, flies!) avoided. Acute dysentery calls for perfect rest in bed, an opiate (pref- erably hypodermically or per rectum ) for the relief of pain, and light astringent diet (tea and toast, rice- and barley-soup or Opium, water). In the beginning the bowels should be cleansed with one moderate dose of castor-oil or syrupus rhei by mouth and one sterile cool water irrigation. The patient is then put on the fol- lowing mixture :— B Bismuthi subcarbonatis 3iv | 15 Vini ipecacuanha; 3j | 4 Tinct. cinchonas comp 3i '30 Mist, acaciae q. s. ad fSiij i 90 M. Sig. : One teaspoon tul every two hours for a child 2 years old. irrigations ] n severe cases the intestines should be irrigated twice a dav with ° nitrate of with 1 : 1000 of nitrate of silver, and once a dav with 1 : 1000 silver; ... quinine, quinine sulphate solution. The irrigation should be executed very gently by means of a soft-rubber catheter attached to an ordinary irrigator. Hydropathic applications to the abdomen (plain Priessnitz compress, or warm turpentine stupes) are useful. MENINGITIS ACUTA. o"35 Collapse should be combated by local heat, cognac, red wine with a hot infusion of cinnamon, camphor, strychnine, etc. During convalescence care in dieting is still demanded, and the persistent anemia calls for iron, analeptics in the form of strength- ening food (fresh eggs, milk with cereals, broths, etc.) and plenty of fresh air, and, whenever possible, a sojourn in the country, preferably at the seashore. Complications and sequelse require special treatment. In chronic dysentery the tannates in conjunction with the quinine and silver irrigations do better than the bismuth prepara- tions. Otherwise the management is the same as in acute dysen- tery. The more protracted the course, the greater the exhaustion and loss of blood ; and the younger the child, the worse the prog- nosis. The mortality in different epidemics varied between 5 per cent, and 30 per cent. Early attention is a very great factor in reducing the mortality and the tendency toward chronicity. Stimulation. Tannates in chronic forms. MENINGITIS ACUTA (Meningitis Cerebrospinalis). 1 MENINGOCOCCI^ PNEUMOCOCCIC, TUBERCULOUS, STREPTOCOCCIC, ETC., MENINGITIS. Meningitis may be primary or secondary in nature. Primary primary, meningitis may be the result of traumatism (may involve both 1 Our venturesque attempt to disrupt the time-worn, confusing mode of grouping of the different varieties of meningitis is based upon the fol- lowing considerations : 1. The symptom-complex of fully established men- ingeal inflammation is practically identical in all forms of the disease, and differs only in the degree of mildness or severity of the attack, which depends upon the extent of the lesion, the susceptibility and the power of resistance of the patient to the microbic toxin and its baleful effects. 2. The same lack of distinction is observed in the pathological anatomy of the diverse forms of meningitis, except that in tuberculous meningitis we find local or general dissemination of tubercles in addition to the usual inflammatory process, which, however, are not manifested by special clin- ical symptoms. 3. Even the formerly accepted view as to the characteristic distribution of the inflammation in certain varieties of the affection, e.g., the so-called ''vertical" or "basilar" meningitis, etc., is no longer scien- tifically tenable in a strict sense of the word, since meningitis of the con- vexity of to-day may, by extension, be that of the base the day following and vice versa. With these considerations in view, and appreciating also the fact that a positive differential diagnosis of the variety of meningitis can be made only by the findings of the etiologic factors in the cerebro- spinal fluid obtained by lumbar puncture, we feel fully justified to discard the time-worn subdivision of meningitis into "serous," "purulent," "epi- demic," "posterior basic," etc., and to classify the disease from an etiologic point of view. As we do of "tuberculous meningitis," we speak also of meningococcic, pneumococcic, streptococcic, influenzal meningitis, etc. — a classification which is not alone scientifically correct, but at once offers a clue as to the etiology, mode of treatment and prognosis. 336 COMMUNICABLE DISEASES. the dura mater — pachymeningitis hemorrhagica — and pia mater, but usually the former) or be due to direct infection of the mening m'dis! meninges by the diplococcus intracellularis meningitidis (Weich- selbaum) and other pathogenic bacteria, e.g., streptococci or staphylococci. Secondary meningitis is due to extension of the infection from neighboring or more remote parts. This form secondary, includes the tuberculous, or pneumococcus meningitis and the meningitides which are met with in divers acute infectious dis- eases, such as influenza, typhoid fever, erysipelas, otitis, diph- theria and the like. The infection spreads either by continuity (throat, nose or ear), by the lymphatics, or by the blood-vessels. Meningitis is a disease peculiar to early childhood, the majority of cases occurring in the first three years of life. It Epidemic, prevails principally, often in epidemic form (cerebrospinal menin- gitis), during the late winter and spring months, at a time when, with rapid changes in the weather and crowding of the children in stuffy rooms, "colds" and their sequelae are fiercely rampant. It sporadic. j s observed also sporadically during all seasons of the year. Delicate children are more prone to be attacked than robust ones, this being the case especially with tuberculous meningitis, which is frequently the culmination of latent tuberculosis of other organs of the body. The mode of onset of the disease varies greatly. It is usually abrupt in primary meningitis, rarely preceded by a few indefinite signs of ill health, such as anorexia, restlessness and headache. In secondary meningitis the attack, as a rule, develops more insidiously and is often obscured by the symptomatology of the preceding affection. Meningitis supervening latent tuberculosis with few exceptions is particularly prone to be gradual in its siow onset development. In these cases the child may for weeks manifest in cu"osis" apathy, anorexia, vomiting, wasting, occasional rise of tempera- ture, and other symptoms corresponding to the seat of the original lesion (e.g., caseation of the bronchial, mesenteric, or intestinal glands; bone or joint disease, etc.). Acute meningitis, be it primary or secondary, gives rise to dizziness, headache, nausea, projectile and usually persistent Headache, vomiting, rise of temperature, jactitations up to convulsions, projectile & . . . vomiting and alternating with drowsiness, stiffness and pain in the neck. This convulsions. ° * group of symptoms while per se not at all characteristic is never- theless strongly suspicious of the disease. Finding a patient in this condition we should at once carefully examine him for MENINGITIS ACUTA. 337 the following more or less pathognomonic physical signs and symptoms of meningitis : — Rigidity of the Neck. — This symptom is elicited by placing the hand under the patient's occiput and flexing the head upon the Neck chest. In meningitis the neck will be found stiff and painful. symptom - Forcible flexion of the head upon the chest usually produces synchronous flexion of the legs upon the abdomen. 1 The child instinctively assumes a lateral position, as the dorsal position OATE > n<>~f 1 id " /i /> j f J glands, (sooner or later) extends to the contiguous structures, exerts pressure upon the adjacent blood-vessels, nerves, and bronchi, and, after forming adhesions, may displace, erode and perforate these parts. In this manner not only may tuberculous infection be rapidly carried throughout the lungs and more distant organs (producing an acute or chronic tuberculous pneumonia), but per- foration of a blood-vessel or bronchus or entrance of caseous masses into the trachea may unexpectedly produce sudden and often fatal hemorrhage or suffocation. The symptoms vary with the primary seat of the lesion and the subsequent pathologic changes. A small tuberculous focus r be it in the lung or bronchial glands, rarely gives rise to any definite clinical phenomena. As a rule, in the beginning the dis- ease pursues a latent course. This is especially true in infants. The child is pale, loses in weight, often notwithstanding good Emaciation, appetite; gets tired on slightest exertion, "hems" and coughs a little, and the temperature rises somewhat in the evening. Sooner or later the symptoms become more distinct. Emaciation, cough, and gastrointestinal disturbances increase in severity, the child suffers from dyspnea, and, if the bronchial glands are involved, iroX cough 1 from paroxysmal attacks of cough, greatly resembling per- tussis. This cough is the result of pressure exerted by the enlarged bronchial glands upon the pneumogastric and recurrens nerves. Physical signs, however, are often still wanting. Occa- sionally percussion over the mediastinum may reveal increased dullness, but in infants this symptom is not pathognomonic in view of the physiologically large thymus. Indeed, the disease is- often not detected until grave, not rarely fatal, symptoms (e.g. r Diagnosis hemoptysis, hectic fever) announce the seriousness of the condi- entire tion. The diagnosis of pulmonary phthisis in infants, therefore, picture, must be based upon the entire clinical picture, rather than the local symptoms. If, for example, bronchial catarrh is associated with progressive emaciation, multiple glandular swellings, pro- tracted diarrhea and possibly also some bone or joint disease, the diagnosis of tuberculosis is justifiable even though careful examination of the thorax fails to disclose pulmonary consolida- tion or cavity. For corroborative evidence we should carefully Tuberculous examine the child's sputum (obtained by means of a catheter sputum. ' J introduced to the base of the tongue) for tubercle bacilli, and employ the tuberculin test. TUBERCULOSIS. 361 In older children the symptomatology of pulmonary tuber- culosis is essentially the same as in adults. Its onset is usually insidious, and quite frequently follows delayed convalescence from some acute disease, such as pertussis, morbilli, broncho- or lobar pneumonia and the like. The child fails fully to recuperate, is pale, thin, and feeble ; suffers from slight shortness of breath, dry cough, chilliness and fever. At first these symptoms are more or less masked, but as the lung destruction advances the symptoms and physical signs rapidly grow worse. The cough becomes persistent, often distressing, especially at night, and attended by expectoration and pain. The fever is intermittent or remittent fever. (hectic) in character. It is usually normal or slightly above nor- mal in the morning, and from two to three degrees higher in the evening. It is often preceded by chilliness and followed by pro- fuse sweating. During the height of the fever the cheeks are usually brightly flushed and contrast strongly with the remaining portions of the face, which are deathly pale. Night-sweats are sweats, often observed early in the course of the disease. With further progress of the disease, the expectoration becomes mucopurulent or purulent, mummular, and streaked with blood; the fever more irregular, and attended by great exhaustion, and the emaciation profound. The agony may further be aggravated by the concurrence of a number of painful complications. The disease may extend to the pleura (pleuritis sicca or with serous or hemorrhagic effu- sion) ; to the trachea and larynx (dysphagia, frequent hemor- rhages, and aphonia) ; to the alimentary tract (colliquative diarrhea) ; and where the bronchial glands or pleura are involved, Hemoptysis to the pericardium (pericarditis). By this time and sometimes at an earlier period the child presents a characteristic, ghastly appearance. The cheeks are hollow, the eyes and temples sunken, the bones of the face and the ears prominent, the nose is pointed and drawn, and the hair thinned, lusterless and brittle. The face is either deathly pale or marked by florid redness along the zygomatic regions. The neck is wasted, the supra- and sub- clavicular spaces are depressed, the shoulders stoop, and the shoulder blades project wing-like far beyond the shrunken, im- movable spine. The thorax is narrow and contracted, and the contracted 1 thorax. ribs overlap each other, effacing the intercostal spaces. The abdomen is flat or deeply sunken below the strikingly prominent pelvic bones. The extremities are mere skin and bone and their Pleurisy. Dysphagia. Character- istic facies. 362 COMMUNICABLE DISEASES. Pulmonary consolidation. epiphyseal ends seem greatly enlarged as they protrude through the wasted, arid integument. The physical signs vary with the stage, location and extent of the lesions. As already mentioned tuberculosis of the bronchial glands may by physical examination entirely escape observation. The same holds true of cases where the tubercles are scattered throughout the lungs and do not coalesce. On the other hand, where pulmonary consolidation (tubercu- lous pneumonia) occurs early and progresses rapidly, the physical signs resemble those of ordi- nary pneumonia, i.e., dull- ness on percussion, pro- longed expiration, in- creased vocal fremitus ; hue, coarse and crepitant r ales, and b r o n c h i a 1 breathing. To these may be added the physical signs of dry or serohemor- rhagic pleurisy (see page 275), which frequently ac- companies phthisis pul- monalis. Where cavities cavernous are formed, the physical signs consist of cavernous respiration, breathing, bronchophony or pectoriloquy. The percussion resonance is amphoric, if the walls around the cavity are thin and tense; cracked-pot cracked-pot sound, if the walls are thin and relaxed; and dull, sound, jf tne wa u s are thick. If pneumothorax is present, the percussion sound is tympanitic, and the respiratory murmur is lost; while hydropneumothorax gives rise to tympanitic resonance above water line, dullness below, and metallic tinkling on auscultation. The poignancy of the clinical picture just depicted notwith- Differentiai stan(nn K' errors of diagnosis are quite possible. Pulmonary diagnosis, phthisis may readily be confounded with bronchial dilatation, localized empyema, fetid bronchitis, pulmonary gangrene and Fig. 98. — Phthisis Pulmonum (child 2U months old). (Sheffield.) TUBERCULOSIS. 363 syphilis. In view of the prognostic importance of an early diagnosis of tuberculosis, it is imperative to employ every means of diagnosis (especially repeated examination of the sputum, and the tuberculin reaction) to clear up all doubt. The course and duration of phthisis pulmonum ranges within very wide limits. Not only is it true that tuberculosis may pro- ceed a latent course for months or years and suddenly break out — often after some trivial cause, such as vaccination, measles, etc. — and rapidly end fatally under symptoms of lobular or lobar pneumonia and the like, but post-mortem examinations have repeatedlv established the fact that after existing for some time, Exceptionally .... r . spontaneous with or without indications of their presence, tuberculous lesions healing, may heal spontaneously never to return. As a rule, however, pulmonary phthisis in young children runs quite an acute course. Unless the disease is arrested in its incipiency, infants usually succumb to it within from four to eight weeks, either from the immediate effects of the pulmonary lesions or as a result of generalized tuberculosis not rarely of the miliary variety. In older children the disease pursues a less violent course, and, as in adults, shows a tendency to remain localized at its originally in- fected focus until a very late stage of the disease. If the tuber- culous process is allowed to continue, death invariably occurs in from two to three years or earlier — either from asthenia (with symptoms of gradual exhaustion, profound anemia, dropsy, etc.) or from apnea (suffocation by sudden hemorrhage, rupture of large cavity, pulmonary edema, etc.). On the other hand, if the tuberculous process is detected in its incipiency — which is quite possible with the existing modern diagnostic methods — and im- mediately and energetically treated, the chances for arrest and eventual cure of consumption of the lungs are very good indeed. The treatment comprises outdoor life, good food, personal hygiene, and symptomatic medication. Whenever possible, tuber- 0utdoor culous children should be sent to country regions where the climate is dry and of equable temperature, so as to allow the patients to enjoy outdoor air the greater part of the day. The climates of New Mexico, Arizona, and Egypt are best suited for the purpose, although a great many patients will be found to do well in Colorado, in the Adirondacks and Sullivan County of New York, in Montana, Wyoming and North Carolina. Those financially incapacitated to take advantage of these climates should be removed to climatically less favorable mountain regions life 364 COMMUNICABLE DISEASES. or even to ordinary city suburbs, but at all events should not be left to perish in overcrowded, unsanitary tenement districts. It is often of great advantage to place the child in an up-to-date treatment 1 sanitarium — if possible in a private room — as the principles of the treatment are more accurately enforced (and with less resist- ance on the part of the patient) under the supervision of a reliable physician and nurse of a properly conducted sanitarium, than at the patient's residence among his timid and sympathetic immediate relatives. The diet should vary with the age of the patient, but should be nutritious highly nutritious and liberal. Milk, meat, eggs, fresh fish, oat- meal, peas, beans and lentils, carrots, spinach, asparagus, potatoes, etc., in addition to an ample supply of bread and butter, should form the principal components of the regular meals. Between meals the child should receive plenty of fresh fruit or fruit juices, and, to satisfy its craving for condiments, a small portion of milk chocolate or calf's foot jelly. The room occupied by the patient should be large and airy. Airy room, and its windows open day and night, irrespective of season or weather. The child should sleep alone. In addition to a warm cleansing soap bath once a week it should receive a cool sponge bath twice a day followed by brisk rubbing of the entire body. The underwear should be of thin silk or wool, and the outer garments should vary with the season of the year — always suffi- cient to keep the patient comfortably warm. In the absence of fever or circulatory disturbance light exercise that does not fatigue acts very beneficially. Horseback riding is highly to be recommended. The value of drugs as auxiliaries in the successful manage- ment of pulmonary tuberculosis should not be underestimated. creosote. j t j s not ver y \ ng ago that creosote was almost universally hailed as the specific against consumption. And, while its curative claims had been Cas is always being done witli new methods of treatment) grossly exaggerated, its efficiency to relieve distressing symptoms (useless cough), and to aid in arresting the further spread of the tuberculous lesion cannot wholly be denied. Creo- sote should be given in small gradually enlarged doses, well diluted in milk, malt extract or red wine. Another drug-mixture deserving of trial is the compound syrup of hypophosphites. It is cod-liver a useful tonic, and may advantageously be combined with malt oil - and cod-liver oil, as follows: — Arrest of hemorrhage. TUBERCULOSIS. 365 n Olei morrhuae 3iv | 120 Extracti malti, Syrupi hypophosph. comp aa %] 30 Glycerini 3iv 15 Pulveris acacise 3iv 15 Aquae cinnamomi q. s. ad Sviij 240 M. Sig. : One teaspoonful three times a day. The bowels should be kept open, and the appetite improved by means of bitter tonics, especially nux vomica and the tincture of cinchona compound. In incipient phthisis it is very rarely necessary to resort to opiates or its derivatives to check the cough, but when the latter is distressing, especially at night, those remedies should be cau- tiously administered as often as indicated. The management of advanced cases of tuberculosis of the lungs is essentially the same as in incipient cases, except that one is often called upon to arrest hemoptysis (ice-bag to the chest, morphine hypodermatically), to check hyperidrosis (sponging of the body with a strong alum solution, atropine by mouth or hypodermatically), and to strengthen the heart's action (digitalis and strychnine). In the presence of the aforementioned compli- cations, however, very few children survive — do what you will. Like the flickering flame of the candle end, after many ups and downs, slowly but surely, life is extinguished — often at a time when the patient seems on the mend. TUBERCULOSIS OF THE BRAIN. Brain tuberculosis in children occurs (1) as partial manifes- tation of general tuberculosis, (2) as tuberculous meningitis, and (3) as brain tumors. The brain lesions are essentially the same in the three clinical types of the disease. They consist in the deposit of tubercles in the brain substance which vary in size from a millet seed to that of a hen's egg. In tuberculous menin- gitis we find in addition inflammation of the pia mater of the brain and sometimes also of the cord and transudation into the ventricles (chronic hydrocephalus). The tubercles are usually Hydro- located in the gray matter — in the large ganglia, in the pons and in cep the cerebellum — and occasionally also in the white substance. During life, however, it is extremely difficult to determine the seat of the lesion, except when the latter is large enough to exert pressure upon vital structures which in their turn give rise to focal symptoms — as, for example, paralysis of the cranial nerves Variously sized tubercles. :;<•><; COMMUNICABLE DISEASES. Headache, convulsions and paral- ysis. in disease of the pons. In absence of such symptoms tuber- culosis of the brain may exist for months without being detected. This is true especially of brain tuberculosis associated with tuber- culosis of other organs. As the disease progresses, the symptom- atology becomes clearer. The child suffers from intense headache, convulsions, paresis or paralysis of some of the cranial nerves or extremities, but even then it is often a matter of conjecture whether these pressure symptoms are due to tubercle or to other tumors (see Tumors of the Brain, page 524). The diagnosis is least difficult when tuberculosis of the brain is manifested by meningitis (see page 342). Here lumbar puncture often helps to clear up the diagnosis. Recourse should be had also to the Eig. 99. — Tuberculosis of the Brain (4 years old). During the protracted course of the disease a marked hypertrichosis developed over the entire body, especially the legs. (Sheffield.) Post-mortem findings. tuberculin test, examination of the sputum for tubercle bacilli, and ophthalmoscopic inspection of the eyes for choroidal tubercles. TUBERCULOUS PERITONITIS. This condition is the result of dissemination of tubercles over the peritoneum, omentum, and adjacent structures. The inflam- mation excited by their presence gives rise to a serofibrinous or hemorrhagic exudation with gradual agglutination of the inflamed portions, caseation and ulceration. Post-mortem examination of cases of long standing usually reveals involvement of the mesen- teric and retroperitoneal glands, fatty degeneration of the liver, tuberculosis of the lungs, and parenchymatous nephritis. Tuberculous peritonitis is comparatively rare in children under three years of age, but quite frequent in those over this TUBERCULOSIS. 367 age. The classical variety of tuberculous peritonitis is the chronic form. Occasionally, however, it may pursue a subacute, or even an acute course with chills, nausea, vomiting, acute abdominal pain, and high fever. In the majority of instances the disease sets in insidiously, with symptoms of dyspepsia, anemia, evening rise of temperature, accelerated respiration and Chronic course. Fig. 100. — Tuberculous Peritonitis (15 months old). Recovered after Laparotomy. (Sheffield.) pulse, frequent attacks of colic, and more or less pronounced diarrhea. Very soon the characteristic symptoms of the disease Distended are in full bloom. The abdomen is distended and its wall often abdomen, glistening and traversed by blue lines, the epigastric veins. The umbilicus is either effaced or protuberant. The extremities are emaciated and contrast strongly with the gradually enlarging Emaciation abdomen. Palpation of the latter reveals that its consistence is 368 COMMUNICABLE DISEASES. not everywhere uniform. Some portions of the abdomen are fiat, aMo U m d inai on percussion eliciting the presence of fluid or nodular masses; y ' other portions again are tympanitic, denoting that that part of the abdominal enlargement is due to intestinal gases. Palpation sometimes confirms the findings on percussion. masses 6 Occasionally hard, cord-like, painful masses and thickened omentum or adherent intestinal loops are found, and more rarely large tumors or encapsulated abscesses are detected. The latter if situated near the navel (periumbilical tuberculous abscess) may open and discharge through the navel. The abdominal enlargement may persist, or after disappearance of the fluid content and formation of fibrous adhesions the abdomen may retract, become tray-shaped, and remain so until exitus. If not arrested by therapeutic measures the disease usually runs a very protracted course — months or even years. Remis- sions are not rare, but sooner or later the symptoms return, sometimes in acute form : the patient wastes away, is troubled by Hectic fever, ,.,.. , .. , sweats and hectic fever, sweats, diarrhea, hiccough, vomiting, dysuria, diarrhea. . ' , ' t . . & J . anuria, and edema of the lower extremities or anasarca, until death finally relieves him of his agony. Fatal issue may occur also from intercurrent diseases, such as intestinal perforation, tuberculosis of the meninges or lungs. On the other hand, the prognosis is not as grave if treatment is instituted early, provided, of course, that the disease is limited to the peritoneum. Unfortunatelv in the early stage of the disease the symptoms Latent . - b ... . until late. a r e not infrequently masked, and a positive diagnosis cannot be arrived at until the pathognomonic signs of the disease have made their appearance, i.e., abdominal distention, circumscribed dul- ness, emaciation, diarrhea (diarrhea, emaciation and glandular swelling are often absent), hectic fever and swelling of the inguinal glands. Even then the peritonitis may be confounded Differentia w '^ 1 asc ' tes accompanying cirrhosis of the liver or valvular heart tion from disease. In such cases the diagnosis may sometimes be settled bv hepatic ° ... . cirrhosis, the tuberculin tests, by a bacteriologic examination of aspirated adbominal fluid or by inoculation experiment. As spontaneous cure is extremely rare and radical cures by Laparotomy laparotomy are quite frequent, the latter mode of treatment should be resorted to as soon as practicable. Some authors attrib- ute the curative effect of laparotomy to the admission of atmos- pheric air to the abdominal cavity, others to hyperemia of the Usually secondary. TUBERCULOSIS. 369 peritoneum produced by the operation in a manner similar to that employed by Bier in the cure of tuberculosis of the extremi- ties. Except abundance of sunshine, sojourn at the seashore or Tonics, mountains and plenty of wholesome food — which measures should be employed also in conjunction with an operation — all other medical procedures are only of temporary benefit. TUBERCULOSIS OF THE ABDOMINAL ORGANS. Aside from the intestinal tract and peritoneum, the spleen, liver, pancreas, diaphragm, omentum, suprarenals, and the uro- genital system may also be the seat of tuberculous disease. Except in the rare instances of invasion of the abdominal organs by tubercle bacilli through the general circulation, the abdominal organs usually become involved secondarily to intestinal or peri- toneal tuberculosis. As a rule, these latter structures become infected primarily by swallowing of food, sputum or necrotic tissue from the nasopharynx contaminated by tubercle bacilli. INTESTINAL TUBERCULOSIS (Tabes Mesenterica). The tuberculous lesions are usually found in the lowest por- tion of the ileum, ileocecal region and colon. It is manifested by a tuberculous infiltration of the solitary follicles and mucosa of the intestine, which gradually undergo softening and caseation and Caseation, ° . - . ulceration finally break down, leaving behind annular ulcers. Tuberculous and intestinal J . . obstruction. inflammation of the large intestine may produce so much swelling as to occlude the intestinal lumen. Sooner or later the inflamma- tion extends to the mesenteric glands and peritoneum. Occasion- ally the lungs and other organs also become involved. All these manifestations, however, are observed only at the autopsy. During life the symptoms are very obscure. Palpation may reveal enlarged mesenteric glands deep down in the abdomen, ^j^^ic but more frequently owing to meteorism they escape observation, glands, and even if palpable are not invariably tuberculous in nature. If, however, this symptom is associated with enlargement of other stubborn glands of the body, stubborn diarrhea (greenish-gray in color, diarrhea, mixed with mucus, pus, and often blood), emaciation and cachexia, sweats and hectic fever, the diagnosis of intestinal tuberculosis is fairly certain. The diagnosis is rendered positive Tubor( , le by the demonstration of tubercle bacilli in the stools. The tuber- j^jj" in culin test and examination of the sputa often prove decisive in 24 370 COMMUNICABLE DISEASES. doubtful cases, and complications, such as perforation of the intes- tines with consecutive peritonitis, settle the diagnosis beyond doubt. Indeed, in the majority of instances the diagnosis cannot be made until these complications arise, a period at which thera- peutic measures almost invariably fail. At all events the prog- nosis is extremely grave. Cases of local tuberculosis detected early and treated energet- ically (chiefly surgically) may recover. TUBERCULOSIS OF THE GENITOURINARY TRACT. Urogenital tuberculosis, especially tuberculosis of the kidneys, is quite common in children. It occurs either as a manifestation of general tuberculosis or as an independent disease. In the latter event it almost invariably begins in one kidney, and from here it spreads to the bladder and the other kidney. In the beginning the affection is very apt to be overlooked, but, as the tuberculous process advances, the symptoms (pain in the region of the kidney and ureter, thickening of the ureter — as evinced by palpation with the finger in the rectum or vagina — irritability of the bladder, albuminuria, pyuria, and often hematuria) become hematuria sufficiently characteristic as to demand careful, repeated, bacteri- and bacmi C in °l°gi c examination of the urine for tubercle bacilli, and cysto- urine. SCO pj c inspection of the bladder for tuberculous lesions. Even in the early stage systematic cystoscopic examination of the bladder will rarely fail to detect tuberculous nodules and ulcera- tion about the opening of one ureter (see Fig. 103). In cases of long standing the lesions are often found scattered through- out the bladder. As in tuberculosis of other organs the tuberculin test should always be employed to corroborate the diagnosis. Early recognition of the condition and prompt surgical treat- ment are not rarely followed by permanent recovery. SCROFULOSIS (Tuberculosis of the Skin, Mucous Membranes and Glands). The tuberculous nature of the symptom-complex embraced by the term "scrofula" is no longer a matter of dispute. The disease attacks children with undermined constitution who are poorly fed and cared for, are forced to live in damp, dark and filthy dwellings, and are exposed to tuberculous infection. Portals of ^ ar i° us s hin eruptions, or injuries, exanthemata, decayed teeth, entry. an( ] diseased tonsils and adenoids, among others, serve as the TUBERCULOSIS. 371 portals of entry to the tubercle bacilli. The immediate result of the tubercular infection is hyperplasia, and the more remote Hyperplasia effect, caseous degeneration of the parts primarily involved, and degeneration, frequently secondary infection of the neighboring structures. Fig. 101. — A characteristic early tu- Fig. 102. — A large tubercular ulcer bercular infiltration, as seen through below the orifice of the right ureter, the cystoscope. (Leedham-Greeii.) (Leedham-Green.) Fig. 103. — Cystoscopic view of the base of the bladder in a case of tuberculosis of the left kidney (Wyatt). The opening of the right ureter is normal ; the opening of the left ureter is seen to be gaping, the lips edematous and thickened, showing the presence of small miliary tubercles. Clinically scrofulosis is characterized by simultaneous or suc- cessive involvement of the skin, mucous membranes and lymphatic glands; chronicity of its course, and a tendency toward slow Cnr °' lic ° J J course. spontaneous recovery, or transition into general tuberculosis. Suppuration. 372 COMMUNICABLE DISEASES. The skin is the seat of a pustular eruption which resists ordi- nary local treatment, generally involves the subcutaneous tissue, and breaks down, forming slowly discharging abscesses or indo- uiceration. lent ulcers. It is most frequently situated upon the back and nates, but is found also upon the scalp and face — probably carried from one part to the other by scratching by means of infected ringers. Scrofulosis of the mucous membranes is manifested chiefly by nasopharyngitis. From the nasopharynx the inflammatory process may spread to the ears, eyes, larynx and oral cavity. The nasal mucous membrane is red and swollen and dis- pharyngitis. charges a seropurulent secretion which forms yellowish-green crusts within and around the nares, producing snuffling respira- tion, and excoriation of the upper lip. A similar acrid discharge otorrhea, is usually observed from the ears (bilateral otorrhea). Both the nasal and aural discharges may become purulent and fetid, in the first instance, by extension of the inflammation from the Chondritis and nasal mucous membrane to the cartilage, periosteum and even nasal bones (sometimes marked nasal deformity) ; in the second instance, by implication of the middle ear and eventually the ossicles, or petrous portions of the temporal bones. Scrofulosis of the eyes, the so-called strumous ophthalmia, usually begins with redness and swelling of the palpebral mucous membrane, and in the majority of cases is soon followed by Phlyctenular involvement of the cornea, in the form of phlyctenular keratitis, keratitis. . ' - . with strong lacrimation, pain, and photophobia. The phlyc- tenular are very slow in healing, and show a great tendency to leave behind corneal opacities. Blepharoadenitis, madarosis and permanent thickening of the edges of the lids are quite common accompaniments. The lymphatic glands are affected early or late — secondarily to the inflammation of the skin and mucous membranes. Except their wide distribution the glandular swellings present nothing characteristic in the beginning, but as the disease progresses they show a marked tendency to undergo caseation and suppuration. Fistuiae. Furthermore, after evacuation of the pus which usually contains tubercle bacilli they rarely cicatrize, but, on the contrary, continue as pus-discharging fistulas or indolent ulcers. The course of the disease depends greatly upon the vitality of the patient and the mode of treatment. It is always chronic. Children removed from the obnoxious surroundings frequently SPONDYLITIS. recover completely. In those not properly cared for the tuber- culous process is very prone to spread to the osseous system and to the internal organs. Spina ventosa, osteomyelitis and spondy- litis form frequent sequelae (for details of these affections the reader is referred to the chapter on "Tuberculosis of the Bones," page 374). The internal organs, especially the liver, spleen and lungs, may be implicated singly or collectively, in which event the prognosis, of course, is extremely bad. Spina ventosa. 104. — Tuberculous Axillary Lymphadenitis. (Sheffield.) Characteristic as the symptom-complex of scrofulosis seems to be, errors of diagnosis are nevertheless very apt to be made. The perplexity is often great in the differentiation between scrofula and inherited syphilis, both of which diseases have many symptoms in common. In all such doubtful cases it is wise, on the one hand, to employ the tuberculin reaction, and examine the aural and nasal secretions as well as the pus from scrofulous abscesses for tubercle bacilli, and. on the other, to administer mercury and look for the spirochete pallida. One should not be too hasty in pronouncing a case as scrofulosis because of the so-called "torpid habitus" of the patient (pale, flabby, puffed face; thick n< ise, swollen and excoriated upper lip, redness and chick- Resemble syphilis. Tubercle bacilli in scrofulosis; spirochaetes in syphilis. Prompt and :174 COMMUNICABLE DISEASES. ening of the lids), or the presence of adenoids or glandular swelling. These symptoms can and often do exist independently of tuberculosis. Scrofula, like other forms of tuberculosis, demands early and treatment energetic treatment. The patient should be removed from the obnoxious influences, well nourished and kept outdoors the greater part of the day (see page 352). Internally we should administer, for several months in succession, moderately large doses of the syrup of the iodid of iron and the syrup of hypo- Tonics, phosphites, as well as cod-liver oil or similar alterative tonics. The local treatment, which is of very great importance, essentially cleanliness, consists of thorough bodily cleanliness (daily bath with sea salt; antiseptic dressings to open wounds, etc.) ; removal of diseased foci (e.g., tonsils and adenoids, decayed teeth, caseated glands, etc.), and evacuation of pus wherever found. Individual com- plications should be vigorously combated according to indica- tions. (See bone tuberculosis, below; otitis, page 250; eczema, page 591, etc.) As the external lesions are probably the result of carrying infectious material from place to place by means of the fingers, open wounds (vaccination wounds!) should be thor- Protection ° I _.,,.,, of open oughly protected and the patient's finger-nails clipped and kept scrupulously clean to prevent scratching the diseased parts of the body and direct infection of its healthy portions. R Syr. ferri iodidi 3iij | 12 Syr. hypophosph. co q. s. ad Sij 1 60 M. Sig. : 3j three times a day for a child 3 years old. TUBERCULOSIS OF BONES AND JOINTS (Tubercular Osteomyelitis and Arthritis). The grouping together of tuberculous bone and joint diseases is intended to emphasize their correlation. The favorite seat of bone tuberculosis is usually in the epiphyses, the joint becoming involved secondarily by extension of the inflammatory process to the synovial structures. Occasionally the joint is affected primarily. The immediate cause of the disease is the tubercle bacillus which invades the medullary tissue, the bone proper, or the primary or ar tj c ular structures, either from within — from a florid or latent secondary. tuberculous focus elsewhere — or from without — as a result of traumatism. An inherited predisposition and impaired nutrition from various causes favor the development of tuberculous disease. TUBERCULOSIS. 375 Osseous as well as articular tuberculosis is essentially a chronic inflammatory process, free from the violent symptoms chronic which are characteristic of acute, non-tuberculous osteomyelitis. proc Extensive lesions may exist for weeks and months with appar- Fig. 105. — Tuberculous Disease of the Elbow-joint in Boy 18 Months Old. (Sheffield.) ent perfect health. Fever is usually absent in the beginning and only slight — in the evening — at a later stage of the disease. As the tuberculous process advances progressive anemia and emacia- tion make their appearance but are not pathognomonic of the affection. The local symptoms also are very vague at first. Hence the reason why local tuberculous disease is frequently Emaciation. 376 COMMUNICABLE DISEASES. Frequently overlooked until, as will presently be shown, deformity and loss overlooked. Q f function have occurred, which vary greatly in extent and severity with the seat of the lesions and the mode of treatment. 1. TUBERCULOSIS OF THE VERTEBRAL COLUMN (Spondylitis; Pott's Disease). The tuberculous process usually begins in or near the verte- bral body, and if not arrested, gradually extends to the contiguous structures, including the spinal cord. Fig. 106.— Pott's Disease (Langerhans) . Kyphosis of dorsal vertebrae, the result of caseous tuberculous periostitis and osteo- myelitis. Destruction of three thoracic vertebrae. Two-thirds natural size. It is manifested by an ulcerative and often suppurative destruction of the bone, with metastatic — gravitation — abscesses in distant locations, e.g., retropharyngeal abscess, in cervical softening spondylitis ; psoas abscess, in lower dorsal and lumbar disease. and crurn- ' J ' l biing of Furthermore, vertebral with softening and crumbling of the vertebral bodies, bodies, the spinal column, as it were, topples over, usually back- Kyphosis waI "d> producing a deformity known as kyphosis, gibbus or Pott's hump. The condition is gradually further aggravated by com- Lordosis. pensatory spinal deformities (especially lordosis) and a group SPONDYLITIS. 377 of other distressing pressure symptoms soon to be related which if not arrested throw the unfortunate creature in an abyss of everlasting misery. This process, fortunately, is very slow in development, afford- ing ample time — from three to ten years — to arrest and mend its Slow onset and course. Fig. 107. — Cervical Spondylitis. Note broadness and tilting of neck. (Sheffield.) ravages and ample warnings to the patient to seek relief. We may frequently differentiate four stages in the progress of the affection: 1. The stage of onset, where the symptoms are very vague and inconstant. The child shows a disinclination to play, refuses to walk or tires easily when it does walk. Tt complains of pain in different parts of the body, following the distribution at nigrht. that it wakes the child from its si eep with a sudden Four stages. Pain, espeoi night. 378 C'OMMl'XkABLE DISEASES. start — "starting pain." 2. The stage of fixation of the spinal starting column; 3, the stage of characteristic deformity; and 4, the stage pain ' of suppuration and pressure paralysis. The disease does not always progress to the last stages. In some instances, after two or three years' course, either through treatment or spontaneously, Pressure paralysis. Fig. 108. — Cervical Spondylitis. Same case as Fig. 107, in brace. (Sheffield. ) solidification of the diseased vertebrae and relative cure occur. Relapses, however, are not infrequent. Pressure paralysis (see Myelitis ) is especially common in disease of the lower cervical and upper dorsal, and rare in that below this region. The focal symptoms vary with the seat and extent of the lesion. In cervical spondylitis the patient, if old enough, com- spondyutis 1 P^ anis of neuralgic pain in the head and upper portion of the neck. Very young children indicate the presence of pain by suffering SPONDYLITIS. 379 and anxious expression of the face, by refusal of food and crying on handling. The head is stiff, tipped backward, or laterally (torticollis-like), and when the child moves it is often seen to support its head with the hands. At a later stage of the disease, there are often disturbances of deglutition and voice — not rarely due to retropharyngeal abscess. If the uppermost cervical verte- Fig. 109. — Dorsal Spondylitis, Gibbus (12 years old). (Sheffield.) brae are diseased, there is danger of anterior displacement of the head between the atlas and axis, more rarely between the occiput and atlas, and death from pressure upon the cord. The permanent deformity in cervical spondylitis usually consists of thickening and broadening of the neck, and sinking of the head upon the shoulders. In dorsal spondylitis the distribution of the pain differs some- Dorsal what with the particular part of the spine involved. If the s P° nd y litis - upper dorsal vertebrae are affected, the pain resembles that of 380 COMMUNICABLE DISEASES. intercostal neuralgia, and increases on coughing, sneezing, laugh- ing, etc., while in spondylitis of the lower dorsal vertebrae, the most frequent seat of the disease, the pain radiates to the lower extremities. In disease of this region, furthermore, the upper part of the body deviates to the side, one shoulder is elevated and the trunk bent to the opposite side — a state of scoliosis ; at Fig. 110.— Dorsal Spondylitis. Same case as Fig. 109, front view. {Sheffield.) the same time the vertebral column is kept rigid, every move- ment carefully avoided, and in walking short rigid steps are ■ t^ hE ttftude taken, tne P at i ent timidly balancing the superincumbent weight in walking f the body by firmly supporting the spine with the hands. If and stooping. JJ J ^ ° 1 urged to pick up something from the floor, the child stoops by strongly flexing the knee- and hip-joints, while holding the verte- bral column perfectly rigid, and raises himself by resting the hands upon the thighs, and then, with alternating supporting SPONDYLITIS. 381 movements along the thighs and trunk, elevates the body and lastly extends the legs. If bending of the spinal column is Attitude in attempted, motion occurs only in the healthy sections, the diseased en ins ' portions remaining firmly fixed. The ultimate spinal deformity consists of kyphosis, kyphoscoliosis and lordosis. scoliosis. In lumbar disease the patient complains of pain in sitting, and refers it also to the lowest portion of the abdomen and the legs. The physical signs are essentially the same as in spondylitis of the lower dorsals, except that the deformity occurs at a later period and is not as pronounced. On the other hand, there is a greater tendency toward the formation of psoas abscess — a abscess, tumor deep in the iliac fossa or at the anterior surface of the thigh, lameness and flexion of one thigh. Careful attention to the aforementioned physical signs rarely fails to disclose the presence of vertebral caries, even at an early r , . ,. ^ . , 11-- 1 -i i- Differentia- Stage of the disease. Cervical spondylitis may be mistaken for tion from torticollis (sudden onset, pain and unilateral contracture more cervical rib, .... retropharyn- pronounced ; early response to anodynes and antirheumatics, geai abscess \ r • i -i / 1,1-^ \ i i and rachitic etc. ) ; for cervical rib (revealed by X-rays) ; non-tuberculous kyphosis, retropharyngeal abscess (immediate relief on puncture). Dorsal and lumbar spondylitis may be confounded with rachitic curva- ture (rounded in rickets; angular in spondylitis; rachitic kyphosis is reducible by placing the child upon the abdomen and over- extending the thighs ; absence of characteristic gait and mode of Differentia- ... ... tion of right stooping). Right iliac psoas abscess often resembles appendicitis psoas abscess r ° ° 1 L r from appen- ( onset sudden or recurrent, rigidity of the abdominal muscles, dicitis, . . coxitis and absence of spinal disease). Psoas abscess differs from hip-joint inguinal 1 N r J hernia. disease by the hip-joint being fixed in the latter affection; and from hernia by being reducible in recumbent posture. In view of the comparatively slow course of the disease in the majority of cases, the prognosis as to life is good, and as to permanent deformity fair, provided the treatment is begun early and persisted in. The prognosis is bad in cases presenting abscesses, fistulse, and pressure paralysis. Even here surprisingly good results are often obtained under suitable treatment. The treatment is principally orthopedic and surgical — fixation Fixation, of the spine by a plaster of Paris or (in milder cases) celluloid jacket, rest in bed to unburden the spinal column, and evacuation ^p C ^ s ation of large collections of pus {e.g., retropharyngeal or psoas abscesses). Good hygiene, outdoor air. plenty of nutritious food, and iron, hvpophosphites, and cod-liver oil will facilitate a cure. 382 COMMUNICABLE DISEASES. SCOLIOSIS' (Lateral Curvature of the Spine). In contrast to the aforementioned spinal deformities, this form of scoliosis is not tuberculous. As a rule, it is habitual in nature, the result of unequal ( one-side ) compression of the Fig. 111.— Lateral S] (Sheffield.) intervertebral cartilages, favored by atony of the muscles and ligaments and weakness of the bones. It is most frequently Unequal compression vertebral observed in school children, especially girls, and is generally cartilages. ascribed to faulty posture while sitting at the school desk, etc., and to the habitual carrying of heavy books with one arm. I firmly believe that a great many cases of the so-called habitual 1 This spinal, non-tuberculous deformity is discussed here ii to emphasize its differences from spondylitis. irder SCOLIOSIS. asa lateral spinal curvatures originate during early infancy in con- nection with rachitis (q. v.), are generally overlooked while Rachitic, the deformity is slight and are detected later, at a time when the deformity does and would gradually get worse, whether or not the child goes to school. Of course, this view does not Fig. 112. — Lateral Spinal Curvature. Same case as Fig. 111. Side view. (Sheffield.) preclude the fact that faulty posture and encumbrance of one- half of the body hasten to aggravate the curvature. Less fre- quent causes are obliquity of the pelvis (e.g., shortening of one lower extremity from birth or postnatal disease) ; uni- lateral paralysis (e.g., poliomyelitis, progressive muscular atrophy) ; unilateral immobility of the thorax (e.g., protracted extensive pleuritic exudation or adhesions) ; and unilateral sinking of the thorax from traumatism or operations (e.g., 384 COMMUNICABLE DISEASES. multiple fractures of ribs, resection of ribs in pyothorax). Very Congenital, rarely scoliosis is congenital in nature, when, as a rule, it is associated with other congenital malformations. Scoliosis is manifested first by elevation of one shoulder. High and later by prominence of one hip and scapula on the same side and gradually increasing convexity of the spinal column Fig. 113. — Rachitic scoliotic skeleton. (Grandin, Jarman and Marx.) S-shaped curvature. and side. With further progress of the deformity, the spinal column presents two curves, in the shape of the letter S (see Figs. 115 and 116) — the primary curve, which is usually in the dorsal region, and the secondary or compensatory curve, usually in the lumbar region. Bad cases are occasionally complicated also by lordosis, deformity of the thorax and displacement of the heart and lungs, but are otherwise free from constitutional symptoms. Fortunately, nowadays, with the greater attention being paid to the general health of children, these dreadful deformi- SCOLIOSIS. 3S5 ties are very rarely encountered. Many cases come under the care of the physician in the first stage of the disease which ordinarily yields to massage, calisthenics, fresh air, ample calisthenics, nutrition, general medicinal tonics, and, above all, removal of etiologic factors. Severer forms of scoliosis are often cor- rected by a plaster-of-Paris or celluloid corset — worn con- jacket. Fig. 114. — Paralytic Scoliosis. Same case as Fig. 173, posterior view. {Sheffield.) tinuously for several months, and followed by massage and exercise to strengthen the weak muscles. Fixed scoliosis can at best only be impeded in its further progress, but the damage done is frequently irreparable. Hence, the importance of early and energetic treatment, and particularly of prophylactic Prophylaxis. measures, which are especially effective in habitual scoliosis. Here the school physician is offered many opportunities to merit the gratitude of the community. :;s,; COMMUNICABLE DISEASES. 2. MORBUS COXARIUS (Hip-joint Disease, Coxitis Tuberculosa, Articular Osteitis of the Hip). The pathologic process of this tuberculous affection is usually osteitis, described as consisting of three stages: 1, the stage of osteitis, 115. — Lateral Spinal Curvature (S-shaped scoliosis; see page 384). (Sheffield.) Suppuration. as a rule, involving the femoral head, less frequently the acetab- ulum ; 2, the stage of arthritis or suppuration, in which all the joint structures are implicated; and 3, the stage of disintegra- tion and absorption of the head and sometimes the neck of the femur and the upper and back part of the acetabulum, with '"wandering" of the head of the femur upward and backward upon the dorsum ilii. Simultaneously with the onset of the first stage of the patho- COXITIS TUBERCULOSA. 387 logic process, or sometimes at a later period, the child begins to limp and to complain of pain in the knee- or hip-joint or both. Limp. As a rule, the limp at first is intermittent in character, more p a m in marked either in the morning or in the evening, but as the inflam- mation progresses it becomes constant and quite pronounced, the Fig. 116. — Lateral Spinal Curvature (S-shaped scoliosis). Same as case Fig. 115. Side view. {Sheffield.) leg at the same time being held very rigid. With the occurrence Rigidity of articular exudation, the leg assumes a pathognomonic position Falge _ of flexion, abduction and eversion, and the patient in order to tion o£ leg - bring the foot to the ground depresses the pelvis on the affected side, thus giving rise to slight — apparent— lengthening of the ^|tnenLg limb. With destruction of the joint and the articular bony struc- tures, the hip-joint becomes further flexed, inverted and adducted. To overcome tbe uselessness of the limb in this position the 388 COMMUNICABLE DISEASES. Compen- satory scoliosis and lordosis. patient elevates the pelvis on the affected side, and to counteract Apparent the — apparent — shortening he steps on the ball of the foot, lortenmg. L ater rea i s h or tening ensues, owing to the wandering of the femoral head upward and backward, and firm contrac- tion and atrophy of the muscles. In upright posture, in con- sequence of the pelvic obli- quity, the patient assumes a position of compensatory sco- liosis and lordosis. In re- cumbent posture, with the limbs brought down parallel to each other, there is always compensatory lordosis of the lumbar region. This lordosis disappears on flexing the af- fected limb at the hip to an angle at which it is held flexed by the contracted muscles. The intensity of the pain varies. It is usually worse after manipulation and fatigue, and at night. It may awaken the child from its sound sleep with a cry ("start- ing pain"). The pain not rarely is referred to the knee, or to other parts supplied by the obturator nerve, e.g., the inner side of the thigh. Hence the importance of always examining the hip-joint in such cases. In addition to the pain, the limp and false position, we may find at a late stage of the disease involvement of the inguinal glands, with or without suppuration and perforation ; enlarge- ment — "white swelling" — of the hip ; flattening of the gluteal region and effacement of one gluteal fold ; multiple abscesses and fistulse at various points of the hip or thigh, especially at the Starting pain. 117. — Hip-joint Disease. {Sheffield.) Tumefaction. COXITIS TUBERCULOSA. yxy tensor fasciae late; irregular temperature, especially during the stage of suppuration. Cases presenting . the aforementioned typical symptoms are recognizable at a glance. Indeed, at this late stage of the disease, it is almost immaterial whether a correct diagnosis is made or not, since a fatal issue from exhaustion, amyloid degeneration and general tuberculosis is all that can be expected, particularly in children with a tuberculous diathesis. The center of the physi- cian's interest therefore should rest upon the diagnosis of incip- ient coxitis which, if properly treated, offers good prospect of recovery. A history of slight trauma ; occasional dragging of the Irregular temperature. Fig. 118. — Hip-joint Disease. Note compensatory lordosis on full extension of affected limb. (Sheffield.) leg or limping; pain in the hip- or knee-joint; disinclination to play and undue fatigue after slight exertion; restless sleep and "starting pain," all point to coxitis and demand very careful and repeated examinations of the hip-joint. The diagnosis is greatly facilitated and in the majority of instances rendered positive by the presence of pain on pressure against the tro- chanter, or against the acetabulum (by digital rectal examination), and von Pirquet's tuberculin test. Advanced coxitis can readily be diagnosed by the aforementioned faulty attitude of the patient, in recumbency, standing, or walking. In doubtful cases, an X-ray examination (by an experienced radiographer) is decisive. The latter procedure is especially useful in differenti- ating coxitis from: Injury to the hip (disability follows imme- diately after the accident; local signs of injury, e.g., ecchymosis, etc.) ; coxa vara (X-ray shows downward inflexion of the neck of the femur; adduction and extension of the limb are usually X-ray in differentia- tion from trauma of hip and coxa vara. 390 COMMUNICABLE DISEASES. iteomyelitis with separation of the epiphyses (very Differentiation possible ) ; congenital dislocation of the hip (history of lameness congenital trom birth : absence of inflammatory signs or limitation of diSl o C f a hip! motion i myelitis] violent course); rheumatism (yields to the salicylates; no bone rheumatism: i cs j on -, . spondylitis of the limihar region (distinct symptoms of Sp °hSeria; spondylitis ; hip-joint free); hysteria (absence of joint trouble, best proven under anesthesia, and by means of X-rays) ; perios- Fig. 119. — Sarcoma of the Femur in (Sheffield. ) and sarcoma teal sarcoma of the trochanter (see Fig. 119) (swelling rapidly part of increases in size; marked dilatation of the superficial veins). femur. _ r ' The treatment consists of : reduction of existing deformity, either gradually (by weight and pulley, while the patient is in bed) or forcibly (under anesthesia); disencumbrance of the hip-joint of the body weight, at first by rest in bed (bed extension apparatus, so as to enable the patient to enjoy fresh air) and later by means of an extension-walking apparatus; and, finally, fixation of the hip-joint by a plaster-of-Paris spica or a fixation apparatus. Fixation of the joint as well as extension should be continued for some time after apparent recovery. Constitutional Reduction of deformity, fixation and rest. KNEE-JOINT DISEASE. 391 treatment. Massage to prevent atrophy of the muscles and Massage, stiffness of the healthy joints. 3. KNEE-JOINT DISEASE (Tuberculosis of the Knee-joint. White Swelling). The pathologic process of tuberculosis of the knee-joint resembles that of the hip. It may begin in the synovial mem- Fig. 120. — Tuberculous Disease of the Knee-joint in a CI 13 Months Old. Patient succumbed to tuberculous pyothorax. (Sheffield.) brane or in the articular ends of the osseous structures. The clinical symptoms are practically the same, whether the synovialis Fusiform has been affected primarily or secondarily. They consist of fusi- swelling, form swelling, local tenderness, atrophy of the thigh and calf Constitu tional synip ier's passive 392 COMMUNICABLE DISEASES. muscles, flexion and slight outward rotation of the knee, and later ahscess formation (extra- or intra-articular). During the sup- purative stage, less frequently in the absence of suppuration, there are more or less constitutional symptoms, such as anorexia, anemia, emaciation and irregular fever. The latter is quite high in the presence of secondary infection. The tuberculous process pursues a rather slow course. Xot Remissions, rarely it is interrupted by prolonged remissions. Exacerbations are often induced by local trauma or intercurrent acute diseases, sometimes after an "apparent" cure had been established. The prognosis as a whole, however, is favorable, if treatment is begun early and properly. The very rarely occurring spontaneous recovery should not be depended upon. Within recent years the treatment of tuberculosis of the knee- joint, as well as that of the other smaller joints, has been entirely revolutionized. Instead of resorting to immobilization, resection and permanent fixation, Bier's method of passive hyperemia has a ' become the treatment of choice, since it not only aids nature in the healing of the tuberculous process, but tends also to restore the normal functions of the affected joint. The mode of procedure is very simple. A soft-rubber bandage about 2 inches in width is applied gently and evenly around the extremity, at some distance above the lesion, e.g., at the middle or upper third of the femur in tuberculosis of the knee-joint, and left in place for an hour or two. once or twice a day. If the bandage is properly applied it gives rise to no pain, nor interruption of the pulse. The ex- tremity below the bandage soon swells slightly, and assumes a bluish-red color, but remains warm. The favorable results obtained from this mode of treatment of tuberculous joints are rather slow in coming (from three to nine months), but in uncom- plicated cases well worth waiting for. Complications arising should be treated symptomatically. Thus cold abscesses call for free incisions and evacuation (may be enhanced by cupping- glass) of the necrosed tissue; large exudations should be treated by aspiration and injection of iodoform emulsion, and the general health should be improved by outdoor fresh air, nutritious food, tonics (iron and cod-liver oil), massage and hydrotherapy. For differential diagnosis, see "Arthritis," page 419. Surgical treatment. SPINA VENTOSA. :m 4. SPINA VENTOSA (Tuberculosis of the Metacarpals and Phalanges. Tuberculous Dactylitis). This disease most frequently affects the first phalanx of the usually index finger, but may occasionally be found simultaneously in several phalanges or metacarpals of the same hand. The osseous tissue is gradually destroyed, and, while this is going on, here and there new bone tissue is gradually formed under the periosteum. Fig. 121.— Spina Ventosa. (Sheffield.) In consequence of the latter process, the finger becomes fusiform, as if the bone had been "blown up" (see Fig. 121). As the inflam- matory process is very slow and painless, it, as a rule, takes sev- eral months before the characteristic appearance is developed. At a later stage of the disease, there is circumscribed redness, fluc- tuation, impairment of function of the tendons and spontaneous rupture of the suppurating focus with very tedious discharge of the contents. Tuberculous dactylitis may be mistaken for a congenital or acquired syphilitic lesion. The history of syphilis, the presence of other syphilitic symptoms, the greater tendency of syphilitic dactylitis to he multiple and symmetrical, and the ready response Fusiform swelling. Differentia- tion from syphilis. surgery. 394 COMMUNICABLE DISEASES. to antisyphilitic treatment usually suffice to clear up the diag- nosis. A positive von Pirquet tuberculin test and the coincidence of tuberculous lesions elsewhere point strongly to tuberculosis. Early constitutional treatment and passive hyperemia (see conservative page 392) are very efficient curative measures. Conservative surgery (evacuation of pus and sequestra) is indicated in neg- lected cases. In these recovery is slow, usually with permanent deformity. NON-TUBERCULOUS OSTEOMYELITIS (Osteitis; Periostitis). The term osteomyelitis refers chiefly to inflammation of the marrow of the hone, hut includes also the morbidity of the bony matrix and periosteum, which at one period or another partici- pate in the destructive processes. Osteomyelitis is exceedingly common in children below the age of puberty — before completion of ossification of the epiphyses and diaphyses — since the anatomic peculiarities of the circulation in growing bones particularly favor its development on slight provocation. The affection is observed in two forms: Non- tuberculous and tuberculous (see page 374). Non-tuberculous osteomyelitis most frequently affects the long bones of the lower Affects extremity ( femur and tibia), less often the other long bones, and exceptionally the short bones of the body. In most instances it Microbic is the result of infection of the medullary tissue by pus microbes. infection. .... . . , , . , , especially the staphylococcus and streptococcus, which enter the blood from suppurating wounds of the skin (pustular eruption!) or pathologic foci in the respiratory or alimentary tract. As predisposing and contributory causes we may mention the various contagious and infectious diseases, such as typhoid, scarlatina, measles, pneumonia, sepsis neonatorum, etc., all of which being instrumental in lowering the vitality and resistance of the patient. Infection of the medullary tissue once established, the patho- vioient logic process is very acute and violent. If left alone the inflam- course. ° l matory process rapidly goes on to suppuration, leading to loosen- ing of the periosteum and bone necrosis and separation of the Diaphyso- diaphvsis from its epiphysis. If the patient survives and the epiphyseal ' - . . separation, inflammatory process subsides, there is a separation of the dead bone ( sequestrum) from the living. Unless removed the seques- trum may remain an everlasting source of irritation and sup- puration. long bones NON-TUBERCULOUS OSTEOMYELITIS. :19.- The osteomyelitic process is ushered in by a chill, rapid rise of temperature and pulse and other symptoms which usually symptoms accompany acute suppurative affections. Before the appearance tion UPPUra ~ of the local symptoms the disease is very apt to be mistaken for a pyemic or typhoidal condition, and in infants unable to indicate the presence of local pain osteomyelitis may end fatally before a correct diagnosis has been arrived at. Hence the importance of a careful examination of the bony system in all febrile affec- tions with indefinite source. Fig. 122. — Osteomyelitis of Tibia (2 weeks old). Compli- cated by Extension of Phlegmonous Inflammation to the Prepa- tellar Bursa. (Senn. ) Excruciat- ing pain. The local symptoms of osteomyelitis are : Pain, tenderness, swelling, redness, synovitis, epiphyseolysis, and loss of function. The pain is excruciating, boring or throbbing, worse at night, and increases in intensity as the exudation becomes more abun- dant. Young children are rarely capable of locating the exact seat of the pain, but usually refer to the entire affected limb. As a rule, the pain disappears suddenly with the escape of the inflam- matory products from the interior to the exterior of the bone. Tenderness on pressure can be detected early, and is most Tenderness 1 J on pressure. severe where the inflammation has approached nearest the surface of the bone. Where the disease is located deeply in the medulla, tenderness can readily lie elicited by percussion. !96 COMMUNICABLE DISEASES. Epiphyse- olysis. Leuroevtosis. Swelling and redness are not discernible until the inflamma- tion has readied the periosteum. Thrombophlebitis and edema, however, are often early symptoms. Synovitis is the rule where the disease affects the epiphysis as well as the end of the diaphysis. The intraarticular effusion is at first serous, the result of vascular disturbance, but as the suppurative process in the hone advances, the effusion becomes purulent by direct extension of the infection. The character of the effusion can readily be determined by exploratory puncture. Epiphyseolysis, or separation of an epiphysis from the diaphy- sis, is a late symptom, or rather a complication. It may be recog- nized by soft crepitation between the separated parts, false point of mobility and displacement — signs of fracture. Loss of function of the limb is invariably present, and as the disease advances there are marked contractures. The patient instinctively assumes such postures as will best relax the muscles and ligaments connected with the affected area, and thus prevent painful tension. These symptoms if closely kept in view will generally avoid errors in the diagnosis. Typhoid fever can readily be excluded even before the development of local symptoms by the presence of marked leucocytosis in osteomyelitis. For differential points between osteomyelitis and arthritides, see page 420. As previously indicated the course of the disease varies with the degree of infection and the aggressiveness of the treatment. Early operative interference is usually followed by recovery in the great majority of cases. In some cases the infection is extremely violent and death occurs within the first thirty-six hours, before (or in spite of that ) a diagnosis had been made and the appropriate therapeutic measures employed. The great dan- ger in osteomyelitis is the tendency to venous and arterial throm- bosis with secondary embolism and abscesses in different parts of the body, especially the lungs, heart and kidneys. With subsidence of the acute symptoms, the osteomyelitic process is not always at an end. Transition into chronic osteo- myelitis is not uncommon (for details see treatise on surgery). Suppurating sinuses leading flown to the infected sequestra may indefinitely persist, and, with occasional improvement, continue to undermine the vitality of the patient. Amyloid disease of various viscera (liver, q. i\) may form a sequel of prolonged sup- puration. NON-TUBERCULOUS OSTEOMYELITIS. 397 Fig. 123. bon< -Osteomyelitis of the Radius. Enlargement of the ent and three well-defined abscess-cavities. (Semi.) 398 C( 1MMUXICABLE DISEASES. SYPHILIS HEREDITARIA S. CONGENITA (Syphilis Embryonalis or Fcetalis, Syphilis Neonatorum, Syphilis Hereditaria Tarda). Congenital syphilis is due to a specific micro-organism, the Spir pamda e spirochete pallida, which is transmitted to the embryo or fetus Fig. 124. — Congenital Syphilis (3 weeks old). Note peculiar deformity of feet, excoriation of upper lip, tumefaction on fore- head. (Sheffield.) either through the syphilitic semen (ex patre), ovule (ex matre), or maternal blood (at any time during pregnancy). The great majority of syphilitic embryos or fetuses are Few aborted. The few that survive may pass through the syphilitic survive. - ' ° J l process in utero (syphilis embryonalis or foetalis) and emerge into the world either dead or in a shriveled, shrunken, emaciated or disfigured (hydrocephalus, spina bifida, etc.) condition, and, as a rule, succumb soon after birth ; or the fetus may maintain a SYPHILIS. 399 good state of health during intra-uterine life, be born in appar- ently perfect health, and develop the syphilitic manifestations soon after birth (syphilis neonatorum), or not until several years after (syphilis hereditaria tarda.) Having fully discussed "syphilis- embryonalis" in connection with "feeble vitality of the newly born" (q.v.), we will limit our present remarks to syphilis of the newly born and to late syphilis. SYPHILIS NEONATORUM. As previously alluded to, the infant may at birth appear per- fectly healthy. It may continue to thrive, especially if fed on Fig. 125. — Congenital Syphilis (8 weeks old). Note multiform eruption, rhagades, and exfoliation. (Sheffield.) breast milk. Before long, however, — usually after from about one week to three months — the clinical aspect changes materially. The baby begins to breathe noisily, especially while it nurses, "sniffles," becomes hoarse, or loses its voice entirely. The nurse or the weather is blamed for the baby's "cold in the head," until examination reveals that the syphilitic coryza is associated with swelling of the nasal mucous membrane and occlusion of the anterior nares by a seromucous or serosanguinolent discharge and incrustation. Inspection of the mouth and throat often dis- closes grayish-white patches (plaques muqueuses) upon the mucous membrane of the month and pharynx, more rarely papil- lomatous vegetations, and occasionally edema glottidis, which latter may lead to fatal termination. Not rarely the inflamma- tion of the nasal mucous membrane extends to the nasal Noisy- breathing; ozena. Mucous patches. 400 L'OMMIWICABLE DISEASES. Skin lesions. periosteum and perichondrium, arresting the development of the nasal bones, and giving rise to the peculiar sinking of the bridge of the nose which is generally designated "saddle nose." The syphilitic manifestations augment from day to day. The skin assumes a peculiar light- or dark-yellow (copper) color, is dry and hard to the touch, and soon becomes covered by an eruption which is typical for its multiplicity and variability. Almost every kind of skin disease is represented. Papules, vesicles, pustules, smooth and scaly patches, tubercles, wheals, macules, hemorrhagic spots, simple redness, scabs, ulcers, etc., Fig. 126. — Congenital Syphilis (11 weeks old). Note keel- shaped deformity and bossing of the skull. (Sheffield.) Rhagades. v * e w ' tn one anotner m their supremacy, and rhagades surround the different external orifices of the body (angles of the eyelids and lips, at the alse nasi, anus, labile vaginse, etc.). The hairy portions of the body also participate in the syphilitic process. L °hair f The hai 1 ' OI the scalp, eyebrows and eyelashes rapidly fall out and are very slow in returning. The nails undergo certain alterations, such as thickening, claw-like deformities, suppura- onychitis. t j ve i n fl am mation (onychitis) and exfoliation (paronychia), the process not rarely extending also to the phalanges (syphilitic phalangitis, q.v.). In the majority of cases we find a bullous eruption which is pathognomonic of grave syphilitic infection, Pemphigus. % > e -> pemphigus syphiliticus. It usually sets in within the first week after birth as flaccid, yellow or brownish vesicles, surrounded by an areola of dry epidermis or excoriation. The bulla; vary in size from a pinhead to a cherry, burst readily and SYPHILIS. 401 tion from simple pemphigus. discharge a seropurulent or serosanguinolent content. They are distributed all over the body, but particularly over the palms of Differentia the hands and soles of the feet — herein differing from non-syphi litic pemphigus which but rarely affects these parts. In conse quence of the inflammatory state of the skin the superficial lymphatic glands are more or less implicated, the swelling often persisting long after disappearance of the primary cause.. En- ^trochlear largement of the epi trochlear glands — just above the internal glands - Fig. 127. -Pemphigus Syphiliticus Involving Especially the Soles of the Feet. (Sheffield.) condyle of the humerus is especially common and of diagnostic importance. Special mention deserve also the syphilitic condylo- Condylomata, mata, especially at the anus and female genitals. They usually begin as simple papules and from the effect of irritating dis- charges undergo transformation into luxurant growths. With the aforementioned clinical findings in view, it requires no sage to solve the problem of diagnosis. Now, if the physician bases his judgment upon the symptoms presented, does not allow himself to be led astray by spurious histories (omnis syphiliticus mendax ! ). but goes right ahead and employs suitable antisyphilitic measures (see page 408), the chances of rapid improvement and ultimate recovery are very good indeed. ( )therwise, the syphilitic 402 COMMUNICABLE DISEASES. process often violently runs its destructive course, attacks one structure after another, one organ after the other, crippling the hapless infant for life, if it unfortunately survives. The osseous system hardly ever escapes involvement. As in fetal syphilis (q. v.), the syphilitic hone affection consists prin- chondHUs" cipally of an osteochondritis and sometimes caries and necrosis. There is an overgrowth of the cartilage between the epiphyses and diaphyses of the long bones, often giving rise to painful circular swelling in the epiphyseal region and separation of the affected limb (spontaneous fracture), with consecutive loss of power paralysis" (Parrot's pseudoparalysis). This process is usually (but not invariably) unilateral — herein differing from rachitis in which the epiphysitis is almost always bilateral. The skull presents P no r des S enlargements (Parrot's nodes) of the parietal eminences and a buffer-like bossing of the frontal bone which is generally designated as "hot-cross-bun" tumors. Occasionally the frontal bone appears either unduly convex and prominent (front forehead. Olympian) or keel-shaped, with a central ridge and lateral flat- tening. These syphilitic manifestations are often associated with craniotabes, delayed (or premature) closure of the fontanelles and great brittleness of the milk-teeth. The liver is often the seat of cellular infiltration (interstitial Hepatitis, hepatitis) or variously sized gummata, rarely large enough to be visible to the naked eye. The liver is enlarged, hard and uneven to touch, but palpable through the abdominal wall only in advanced cases. Marked syphilitic changes in the liver fre- quently give rise to icterus, acholic stools, and bile-colored urine. On the other hand, mild forms of the disease are usually entirely free from symptoms. Next to the liver the spleen is most prone to suffer in syphilis. Perisplenitis. It is enlarged and readily palpable through the abdominal wall. Splenomegaly being of so common occurrence in early childhood, it is difficult to determine how much of this phenomenon is due to the syphilitic process and how much to other causes, especially rachitis. The younger the infant (under six months), the greater the probability of the perisplenitis being syphilitic in nature, especially if the splenomegaly be associated with other syphilitic symptoms, such as "Parrot's nodes," condylomata, and ozena. Syphilis of the pancreas is not demonstrable during life, but it has repeatedly been proven, by post mortem, that the pancreas is affected in a way very similar to that of the spleen. SYPHILIS. 403 The intestines are but rarely affected. Intestinal syphilis is manifested chiefly by ring-shaped indurations of the muscles and mucous membrane, leading to gradual constriction of the intes- patches* 1 tinal lumen. The pathologic process resembles that of "Peyer's patches." Clinically intestinal syphilis gives rise to protracted diarrhea, often with fatal termination. Syphilitic changes (perivascular cellular infiltration; gum- matous deposit) are occasionally met also in the kidneys and suprarenals (paroxysmal hemoglobinuria; nephritis), in the heart urogenital (symptoms of myocarditis), in the lungs (pneumonia with slow lungs™' course; spirochete in the sputum), in the thyroid gland thymus, (struma), in the thymus (cyst, or abscess), in the testicles (often greatiy enlarged; hydrocele; arrested development), and in the ovaries (demonstrable post mortem; sometimes by rectal, biman- ual examination during life). Arteritis and periarteritis, gummatous deposits and sclerosis occasionally occur in the brain and spinal cord as in the other organs of the body, and the concomitant symptoms vary with the seat of the lesions. Chronic meningitis and hydrocephalus are chronic . . . . meningitis. not rarely of syphilitic origin, and epilepsy, idiocy, local paralysis of the extremities and of the eye muscles, blindness, disseminated sclerosis and tabes dorsalis have occasionally been traced to con- genital syphilis. Also cases of syphilitic encephalitis are on Encephalitis, record. The resemblance between syphilis of the nerve system and tuberculosis should not be lost sight of. As already suggested the diagnosis of syphilis is very easy when the aforementioned symptom-complex is in full bloom. Cases, however, are not rarely encountered which are apt to test Diagnosis in the skill of even the best diagnostician. I am referring espe- ^^ daily to those which either run a very latent course from the beginning, or do so after a few weeks' antisyphilitic treatment. Every bit of information as to the past personal ("snuffles," erup- tion, etc.) and family history (miscarriages; persistent sore throat in the mother or father!) should be utilized to arrive at a correct conclusion. Old cracks and scars at the anus, mouth, nares, etc.; dark, mottled skin; old marks of healed ulcers in the mouth and throat; persistent ozena; intractable intertrigo, etc.; excessive brittleness of the milk-teeth — should all be carefully looked into, and where doubt still exists the patient be given the benefit of the doubt and actively treated for syphilis — the rapidity 404 COMMUNICABLE DISEASES. of response to treatment at the same time serving as a differential Therapeutic point of diagnosis (therapentie test ). Wherever possible laboratory tots should supplement ordi- nary clinical examination. Of these Wassermann's serum diag- Wassermann ])( ,sis of syphilis is deserving of special consideration (see page ' ,0Q ' 98). With establishment of the diagnosis of syphilis, the remedies to be employed to eradicate the disease fortunately leave no room for speculation. The treatment which will be fully outlined in the subsequent pages (see page 408) should be carried out ener- getically and systematically and continued until apparently even- vestige of the disease has been completely removed. Inadequate treatment not only greatly mars the prognosis of syphilis as to life and recurrences, but only too often is respon- sible for the development of the symptom-complex which is syphon! generally described as "parasyphilis." This group of syphilitic manifestations (syphilitic cachexia) consists of extreme debility, marasmus (especially in artificially fed), profound anemia (pseudoleukemia), obstinate gastrointestinal and bronchial catarrh, otitis (deafness), disposition to rachitis, cretinism and idiocy, and lowered power of resistance to divers acute infectious High diseases. While the mortality of the carefully treated syphilitics is comparatively small, those who are carelessly managed often succumb to intercurrent diseases, even of the most trifling char- acter, not rarely die suddenly without apparent cause, and if they survive, remain decrepit for life, and a source of horrible misery to future generations. SYPHILIS HEREDITARIA TARDA S. LATA. Late hereditary syphilis attacks the offspring of syphilitic parents at any period between early childhood and adolescence. The children thus affected may or may not have shown manifes- tations of congenital syphilis during intra-uterine life or soon after birth. The symptoms; however, are more pronounced in those who had been treated inadequately or not at all. Late hereditary Corresponds syphilis essentially corresponds to the tertiary stage of acquired to acquired - ' - ' '. tertiary syphilis. Like the latter it shows a predilection for the osseous stage. • ' r system ; but no structure or organ of the body is exempt from its destructive effects. As we will presently demonstrate, the lesions of late hereditary syphilis may be numerous and grave, but not always mortality SYPHILIS. 405 strictly pathognomonic of this disease. There is, however, one group of syphilitic manifestations, which, if present, invariably betrays the presence of a syphilitic taint. This symptom-complex is generally described as the "triad of Triad of syphilis" and consists of the following phenomena : — 1. The so-called Hutchinson teeth. The characteristic teeth of syphilis are the two upper central incisors of the permanent set. The teeth are chalky, ill-developed, small, and irregularly placed. They taper from the free border to the base — hence the term "screwdriver teeth" — and present a broad, semilunar notch in the center of the edge. They should not be confounded with Hutchinson . ... . . teeth the brittle and decayed milk-teeth observed in infantile syphilis or rickets, and the irregularly implanted teeth associated with deformed palate or dental arches. Fig. 128. — Syphilitic, ''Hutchinson Teeth." Note semilunar notches in central incisors. (Sheffield.) 2. Interstitial keratitis. The almost invariably symmetrical Keratitis. affection begins with corneal haziness which rapidly increases until the entire cornea is in a condition of partial opacity resem- bling "ground-glass." It is associated with congestion of the ciliary region and slight inflammation of the conjunctiva, and in severe forms of the disease, with iritis, retinitis and choroiditis. In addition to the corneal gray-colored patches, abruptly margined, crescentic patches of salmon tint are often present on the corneal surface, this sign of vascularity not rarely spreading over the whole cornea and giving rise to a deep plum tint of purple redness. Excessive lacrimation and photophobia prevail from the start, in marked cases reducing the patient to a state of practical blindness. The disease runs a very slow course, from about three months to a year or longer, and when it sub- sides leaves behind more or less marked corneal opacity and visual impairment. 3. Deafness. This condition is not accompanied by any Dea fness inflammatory symptoms. It is caused by syphilitic involvement of the labyrinth (Often of both ears). The deafness very rarely 406 COMMUNICABLE DISEASES. clears up spontaneously and entirely. On the contrary, even Permanent under active treatment permanent defective hearing is the rule. " This peculiar form of deafness often precedes or follows the attack of keratitis and is gradual in its development. Fig. 129. — Syphilitic Osteoperiostitis of the Tibiae. "Saber-shaped Deformity." Xote also deformed bridge of nose. {Sheffield.) eriostttis ^ ne ' )one lesions of syphilis consist of an osteoperiostitis, or soft gummatous periostitis, especially of the tubular and cranial bones. The most frequent seat of the disease is the tibia; then follow the ulna and radius, the humerus, femur, clavicle, the bones of the skull, the phalanges and sternum. Syphilis of the shaft of the tibia usually skives rise to a characteristic "saber- SYPHILIS. 407 shaped" deformity of the tibia, the so-called "tibia en lame de s t her ' d sabre." It differs from the rachitic deformity of the tibia by its deformity, crest being rounded (in rickets it is sharpened) and its internal and external surfaces convex (in rickets they are flat or concave). The cranial bones are affected in a manner similar to that of syphilis neonatorum (see page 402). Ulceration of the soft palate and perforation of the hard palate and nasal bones with secondary "saddle-shaped" deformity of the nose are of common occurrence, shaped" Syphilis of the phalanges (syphilitic dactylitis) is character- ized by a puffy, fusiform, or spindle-shaped swelling. It affects Dactylitis, the fingers more often than the toes. The inflammation may begin either in the connective tissue and ligaments or in the periosteum and bone. If left alone the disease progresses rapidly and leads to protracted osteomyelitis with ankylosis, shortening and permanent deformity of the affected parts. Syphilitic dactylitis differs from the tuberculous variety, which it greatly tio/from 1 " resembles, by its being less common, often symmetrical and accompanied by other syphilitic lesions. Occasionally the joints participate in the syphilitic process, but the affection is rarely of serious nature. It essentially con- sists of a recurrent synovitis with thickening and ankylosis, and Synovitis, may readily be mistaken for articular rheumatism. The absence of fever and redness and the history of syphilis usually clear up the diagnosis (see page 419). The skin sometimes presents subcutaneous gummata which Subcutaneous x ° gummata. when neglected have a great tendency to break down and to form large phagedenic ulcers. They are most frequently met on the face and upper part of the thighs or legs. They promptly yield to energetic antisyphilitic treatment — a feature to be borne in mind in the differential diagnosis between syphilitic and tuberculous ulcers. Similar ulcerating gummata are not rarely found in the mouth, nose and throat. If not promptly arrested they are rapidly destructive and may occasion extensive disfigurement. The lymphatic system and the viscera, especially the liver and spleen, rarely fail to show late syphilitic manifestations. The latter are essentially identical with those described in connection with congenital syphilis neonatorum (see page 402). Finally, mention may be made of the tendency of late syphilis to arrest the development of the child's body and mind. Dwarfism and infantilism are not rarely traceable to this baleful Infan ti'ism. Patho- gnomonic symptoms. JOS COMMUNICABLE DISEASES. cause. Indeed, appreciating the gravity, multiplicity and com- plicacy of the syphilitic lesions, it is rather surprising that the aforementioned bodily and mental deteriorations are not more rampant. Notwithstanding the apparent explicitness of the symptoma- tology, the diagnosis of late hereditary syphilis is by no means a simple proposition. It is especially difficult in cases complicated by intercurrent diseases, e.g., tuberculosis or rickets. The specific history; the simultaneous occurrence of lesions in various parts of the body; the tendency of the bone lesions to be symmetrical; the appearance of the manifestations very fre- quently in the midst of apparently perfect health, and, finally, the quick response to antisyphilitic treatment — are more or less decisive in the diagnosis. Of course, all doubt is removed by positive microscopic or bacteriologic findings, especially serum diagnosis. ACQUIRED SYPHILIS. Newly born infants may acquire syphilis either intrapartum, by coming in contact with a chancre in the parturient canal, or while nursing of the breast of a woman (mother or wet-nurse) in the contagious state of syphilis. The disease may further be acquired by infants and older children practically in the same manner as by adults. It is well to remember that newly born Conta | 1 s ° s U of infants with secondary symptoms of syphilis may transmit the syphilis disease to healthv people through fondling, the use of articles neonatorum. . ... coming in contact with syphilitic lesions, etc. I have now in mind two older, previously healthy brothers who have in this manner acquired syphilis from a newly born syphilitic child. The course of acquired syphilis in children is identical with that observed in adults, except that it is prone to be more rapid and violent. Treatment of Syphilis. — The treatment of syphilis is alike in both tonus of the disease — inherited (early and late) and acquired. It should be begun with as soon as the diagnosis has been established. Temporizing is often fatal. Mercury in some Mercury. f° nri is the only remedy that is certain in its results, and should be administered continuously until every vestige of the disease has apparently disappeared, and then given at intervals of from two to six weeks for a total period of from two to three years. Calomel is the preparation par excellence. One-tenth to one-fourth of a "rain twice (to an infant ) or thrice (to an older SYPHILIS. 409 child) will usually suffice. Now and then we may also employ sodium iodid (half a grain for every year of the child's age) The iodids. three times a day, or the syrup tof the iodid of iron (three drops for an infant under one year, five drops for two years, and ten drops for over five). To hasten saturation of the system with the mercury, we may, in addition, resort to mercury inunctions. From 10 to 30 grains of mercurial ointment may be rubbed in once a day alternately into the axilla, groin, abdominal wall, calf- muscles, and loins. To prevent excessive salivation the oral Salivation, cavity should twice daily be washed with a 2 to 5 per cent, solu- tion of chlorate of potash or tincture of myrrh. Syphilitic ulcers ulcers. should be cauterized with nitrate of silver solution (3 per cent, to 10 per cent.). Keratitis calls for local use of atropin sufficient Keratitis. to keep the pupils widely dilated, hot poultices (by means of moist hot cloths), occasional dusting of calomel over the corneal ulcers, protection from bright light (dark room or smoked eye-glasses), and, of course, internal administration of mercury and the iodids. The great majority of cases of osteitis yield promptly to consti- osteitis. tutional treatment, but where necrosis is pronounced the manage- ment must follow ordinary surgical lines. Persistent condylomata Condylomata, will rapidly disappear after a few applications of a 5 per cent, salicylic-resorcin-collodion solution, or occasional painting with caustics. Onychia and paronychia should be treated by local onychia, bichlorid baths (1:2000), once or twice daily, and dusting with calomel 1 part, gum arabic 1 part, and stearate of zinc 20 parts. Indurated lymph glands usually yield to potassium iodid oint- Adenitis, ment, while suppurating glands require surgical interference. The general health of the patient should not be lost sight of. Other conditions being favorable, a syphilitic mother should nurse ^frshig' 1 her syphilitic child. This being impossible, the infant should be put on properly modified cows' milk, or on the breast of a wet- nurse who emerged from an attack of syphilis without serious consequences. In older children also particular attention should be paid to good nutrition. The tendency of rickets complicating syphilis should be borne in mind. Hydrotherapy, plenty of fresh, pure air, and general tonics are essential to success. Within the last few months marvelous cures have been re- ported from the hypodermatic use of dioxydiaminoarsenobenzol (the mysterious "606" of Ehrlich and Hata). The remedy is 606 . dissolved in commercial soda lye by rubbing in a mortar; glacial acetic acid, drop by drop, is then added, obtaining a fine yellow precipitate. This is suspended in distilled water and the reaction 410 COMMUNICABLE DISEASES. of the liquid is made exactly neutral to litmus paper. The sus- pension (containing from 2 to 5 grains of the remedy ) is slowly injected below the shoulder blade or in the gluteal region. One injection is claimed to arrest the disease. 1 MALARIA (Febris Intermittens. Febris Remittens, iEstivo-autumnal). Malaria is endemic in the greater portion of the inhabited world, and is most prevalent in moist tropical regions. No age Fig. 130. — Malaria Plasmodia ; Tertian Type. Plehn-Chenzinsky's Stain. X 1000. (Lenhartz and Brooks.) is exempt from this disease. The exciting cause of malaria is the hematozoon of Laveran conveyed to the human body principally sionThrough by the bite of the Anopheles mosquito which has previously moS bUes° sucked the blood of a malarial patient and has acted as an inter- mediate host for the malarial parasite. The hematozoon enters the blood-corpuscles and, after undergoing the different stages of development, the blood-current — at this time giving rise to the characteristic chill or paroxysm. Depending upon the period of maturity and species of the Plasmodium, the febrile attack may Quotidian, occur every day (quotidian) ; every two days, going on the third quartan (tertian) ; every three days, going on the fourth (quartan) day; types ' or may be more or less continuous with daily remissions (remit- tent or estivo-autumnal fever). 1 Syphilitic newly born infants who are nursed by their mothers (or syphilitic wet-nurses) will derive the full benefit of the remedy by ad- ministering it to the mother. In fact, this method of treatment is greatly to be preferred to direct treatment of the baby. MALARIA. 411 INTERMITTENT FEVER. This form of malaria is characterized by the occurrence, at regular intervals, of paroxysms divided into four stages — pre- monitory, chill, fever, and the sweat. During the premonitory stage the patient complains of headache, lassitude, and nausea ; he vomits, yawns, is irritable and drowsy. Suddenly he is seized with a feeling of cold — the chill. The features become pinched, the lips blue, the skin cool and rough (cutis anserina) ; he shivers and shakes, and his teeth chatter while the thermometer in the axilla or rectum shows a decided rise of temperature. These phenomena may continue for from a few minutes to an hour or 105 103 ic: ■ 3E \ % -_ 98 Fig. 131. — Temperature Chart of Quotidian and Tertian Ma- larial Fever in a Child 22 Months Old. The fever changed from quotidian to tertian on administration of a few large doses of quinine. (Sheffield.) longer and are then gradually replaced by those of the hot stage, i.e. j hyperpyrexia, flushed face, headache, full pulse, intense thirst, scanty urine, sometimes nausea, vomiting and severe nervous manifestations. The hot stage lasts from three to six hours or longer, and subsides gradually, being succeeded by more or less marked sweating, rapid defervescence and abatement of the other symptoms. The duration of the entire paroxysm is from six to twelve hours, after which time the patient is appar- ently well — until the return of a new attack, which, as already mentioned, may occur every day, every two days or three days. Tliis description corresponds with the symptomatology of typical intermittent fever, uninfluenced by medication, as it occurs in children over ten years of age. It is thus identical with that in adults. In younger children the course of the paroxysms pre- 412 COMMUNICABLE DISEASES. Deviations sents numerous deviations. The prodromic and cold stages may nfants. ^ a k sent or f ver y ] J1 - le f duration. The chill may he replaced by grave nervous manifestations, such as convulsions, or be indicated cyanosis, only by cyanosis of the lips and the tips of the fingers and toes. Sweating is slight or absent, or may be well marked and continue until the subsequent paroxysm of fever. Young children are rarely entirely free from discomfort during the intermittent stage. As a rule, they are exhausted, restless, have no appetite, etc. "pieln. With repeated attacks of the fever there is marked swelling of the spleen and great diminution in the number of red blood-cells. In view of the aforementioned deviations from the typical course of the paroxysms, the diagnosis of intermittent fever in young children often presents great difficulties. It is apt to be mistaken for tuberculous (meningitis, lymphangitis, peritonitis, Differentia- . . . ,..,., ... tion from etc.) and pvemic (empyema, pyelitis, ulcerative endocarditis, tuberculosis, ... . , . . _. ,. pyemia, otitides, etc.) processes, typhoid and influenza. A correct diag- influenza. nosis, however, can usually be arrived at by exclusion, always bearing in mind the facts that in malaria the plasmodium malariae or secondary pigmentation of the blood-cells is invariably present in the blood and that the course of the disease is greatly modified by full doses of quinine. The finding of an enlarged spleen (also liver) without a history of syphilis or rickets points to malaria of more or less prolonged standing, and a history of malaria is, of course, corroborative in the diagnosis. REMITTENT (ffiSTIVO-AUTUMNAL) FEVER. This type of malarial fever is usually observed in temperate zones, principally in the autumn. In institutions where large numbers of children are congregated it may occur in epidemic Occasionally b ° J \ epidemic, torni and lead to grave diagnostic errors. It usually sets in sud- denly with malaise and chilliness, followed by fever with exacer- bations and remissions, the temperature during the latter, how- ever, remaining constantly above normal. The other symptoms are very indefinite. As in all febrile diseases, anorexia, nausea, sometimes vomiting, headache, drowsiness and lassitude pre- dominate. In some cases gastrointestinal symptoms prevail, in fever U with otners respiratory. But the cardinal manifestations of the affec- irreguiar t j on are t i ie continued fever of from one to three weeks' duration remissions. with irregular remissions, palpable spleen, and the plasmodium malaria? in the blood. Bearing these clinical symptoms in mind and those of the diseases suspected, there ought to be no difficulty MALARIA. 413 in differentiating remittent fever from typhoid fever or protracted influenza — with both of which diseases it is most apt to be con- founded. The quinine test is not reliable in the remittent form of malaria. The prognosis of remittent fever is favorable, except for the tendency to recurrence at shorter or longer intervals and of ultimately becoming chronic. CHRONIC MALARIAL CACHEXIA. The diagnosis of this condition is often very difficult, since its principal symptoms — anemia, debility, enlarged spleen and liver — are also pathognomonic of severe rachitis, pseudoleukemia, and similar wasting diseases. Corroborative data may be obtained from a history of previous attacks of either intermittent or re- Periodic mittent fever or the occurrence of periodical headache, neuralgia, hematuria dysentery or hematuria. One should be very cautious, however, etc - in making a hasty diagnosis of "malaria," unless there be ample reason for exclusion of the other affections and the therapeutic quinine test prove positive. Chronic malarial cachexia per se is not dangerous to life, but is apt to prove so from its concomitant symptoms, such as pro- found anemia and amyloid degeneration of the viscera. Treatment. — As malarial fever is ordinarily contracted through the bites of mosquitoes, to prevent malarial disease, we Destruct ion must either destroy the mosquitoes or avoid their bites. An of mosquitoes- effort should be made also to isolate, by mosquito-netting, all cases of acute malarial disease, in order to deprive the mosquitoes of the infective material. Another very important measure is to prevent the breeding of the mosquitoes. Mosquitoes lay their eggs in water-barrels, pans, tin cans, pots, kettles, wells, springs, rainpools, cesspools, drainage traps, ponds — in short wherever stagnant water is found. We have to see to it that all water receptacles are closely covered with thin, wire gauze, and that where drainage cannot be carried out, the surface of ponds, etc., Kerosene is covered with a film of kerosene oil. One ounce of oil to fifteen square feet of water will usually suffice. The oil must be re- newed about once a week during the mosquito season. A solution containing one pound of sulphate of copper and one pound of unslaked lime in ten gallons of water will kill the mosquito larva? when added in the proportion of one of the solution to fiftv of the infected water. 414 COMMUNICABLE DISEASES. White people settling in malarial tropical regions should not plant their houses near native settlements. Where the aforementioned prophylactic measures cannot prop- erly be enforced, resort should be had to the routine administra- tion of quinine during the mosquito season. Whether as a prophylactic or curative measure, quinine is specific! the specific destructive agent of the malarial parasites. To obtain prompt results it should be given in full doses. Children tolerate relatively much larger quantities of quinine than adults. An ny mouth, infant of two years requires about 15 or 20 grains a day until the attack is controlled and smaller doses after. For children unable to take quinine in capsules I prefer the newer "tasteless" quinine preparations, such as quinine ethyl carbonate, diquinine carbonic ester, etc., or administer ( see page 116) the ordinary bitter quinine Per rectum, per rectum (quinine subsulph. gr. v in ^ij of water by means of colon tube). In cases of marked gastric irritability or in those very grave in nature or protracted in course, quinine may be maticaiiy. employed in 5 gr. doses hypodermically. For this purpose bimuriate of quinine and urea, the hydrochlorosulphate, the hydrobromate, or the bisulphate may be used. Ugly sloughing which is apt to follow at the site of the injection may be pre- vented by cleanliness of the needle and skin and by throwing the solution deeply into the subcutaneous tissues and sealing the point of puncture with adhesive plaster. In protracted cases iron and arsenic (Fowler's solution) will rsenic. ] )e found useful additions to the quinine, and when there is a great tendency to recurrences, permanent residence in dry moun- tainous regions will sometimes remain the only curative measure at our command. R Quinine ethyl carbonate, or diquinine carbonic ester... 3ss | 2 Syr. simplicis q. s. ad Sij j 60 M. Sig. : 5j every two to four hours for a child 3 years old. R Quininse mur gr. xv 1 Acetanilidi gr. vj 0.4 Podophyllini gr. Y 8 0.008 Ext. nucis v< imicae gr. ^4 0.016 M. ft. caps, no xij. Sig.: Two capsules every three hours for a child 10 years old. n Acidi arseniosi gr. }io I 0.006 Quininae mur 3ss |2 Fer-ri sulph. ex gr. x [ 0.666 Pulv. rhei gr. v | 0.333 M. ft. caps. no. xx. Sig. : Two capsules every six hours for a child 10 years old. (Chronic malaria.) Iron RHEUMATISMUS ACUTUS. 415 R Elixir ferri pyrophosphatis, quiniriEe et strychninse (N. F.) §iss J 45 Syr. aurantii q. s. ad 5ii j | 90 M. Sig. : 3j three times a day for a child 4 years old. (In convales- cence.) RHEUMATISMUS ACUTUS (Rheumatic Fever, Polyarthritis Acuta). Acute inflammatory rheumatism is an infectious disease with a specific predilection for the fibrous tissues and serous mem- branes. The muscular and neural structures, however, are not exempt from it. The discovery of the rheumatism-producing micro-organism is a matter probably of the very near future. origin. 10 Like other infectious diseases rheumatic fever is most prev- alent in certain climates and seasons of the year. It presents a prodromic stage of variable duration, which is characterized by chilliness, languor, etc. Like the eruptive fevers it is manifested by general febrile disturbances with local lesions. To a certain extent it is self-limited, since with exhaustion of the fertile soil in one place, the inflammation "jumps" to another place. It ordi- narily yields promptly to specific medication — in this respect, also resembling infectious fevers, e.g., malarial fever. After a brief prodromic stage, the symptoms of acute rheu- matism usually set in suddenly, with chills, rise of temperature, vomiting, and vague pain in several parts of the body. In very young children the onset is not rarely associated with cerebral symptoms, especially convulsions. Older children often complain throat, of sore throat, and in some cases articular swelling forms the first and principal manifestation of the affection. The disease once established differs in its symptomatology and course but little from that observed in rheumatism in adults, except, as will be seen later, that in children there is a great tendency toward cardiac complications, while the articular involvement is usually less pronounced. The joints of the knee, ankle, elbow and wrist are most com- monly affected, occasionally also those of the phalanges and hip. The articular involvement is accompanied by stiffness, slight red- redness S ' ness, swelling and excruciating pain, the latter especially on pain Iin ^ and moving or handling the parts affected. The inflammation may abruptly cease at one or more joints and, as suddenly, attack others. During the acute stage the temperature ranges between 102° and 104° F\, and as the inflammation "jumps" from joint Jumping from join to joint 416 COMMUNICABLE DISEASES. 6 to joint there is usually a sharp rise of temperature. Correspond- ioint ingly the temperature falls with abatement of the local manifes- tations. The urine is usually scanty and high-colored, filled with Fig. 132. — Rheumatic Polyarthritis (2 years old). Note swelling of knees; tumefactions at right ankle and foot, effacing the normal bony prominences and the arch. (Sheffield.) Rarely sour sweat. urates, and occasionally contains traces of albumin. The charac- teristic sour ( lactic acid ) sweats observed in adults are much less pronounced in children. There is no definite limitation to the duration and course of the affection. Mild cases, after pursuing a few days, may either RHEUMATISMUS ACUTUS. 417 recover entirely or enter into a subacute, afebrile stage, and for weeks and months be manifested by vague articular and muscular pain, and ultimately end either in complete recovery, or leave behind some form of subacute or chronic heart disease. Indeed, it is usually in such cases that the heart affection is overlooked, Heart dis- and accidentally discovered some time (years!) later, without overlooked, being able to disclose a rheumatic history. Severe cases may run a febrile course of from three to five, weeks, and if left untreated, sometimes, as many months. It is well to remember that the gravity of an attack is not always commensurate with the severity of the articular involvement. In quite a number of cases endo- carditis or pericarditis, or both, may predominate while the other symptoms are barely noticeable. Hence the importance of a routine and careful examination of the heart of children suffer- ing from rheumatic and "growing" pain, or chorea. The latter Rheumatism ,• 11 ■ 1 1 n- 1 1 , and chorea. disease, by the way, is closely allied to, and may precede, accom- pany or follow rheumatism in its various forms. (See "Chorea.") The earliest symptoms of rheumatic endocarditis are increase Endocarditis, of frequency and intensity of the heart-beat and precordial pain. This is soon followed by the usual physical signs of endocarditis — those of mitral regurgitation predominating. Endocarditis forms the most frequent (in about 60 per cent.) complication of inflammatory rheumatism and usually sets in within the first ten days from the onset. Pericarditis is observed only in about 10 per cent, of the Pericarditis, cases, and somewhat later than endocarditis. It is manifested by a serous exudation which may rapidly, and unnoticeably, dis- appear, or persist and lead to pericardial adhesions and their accompanying more or less grave sequelae. Less frequent complications are pleuritis and pneumonitis. p leU ritis and Both of these affections are ordinarily limited to the left side. P neumonia - The pleuritic effusion may be serous or serofibrinous and is most frequently associated with pericarditis. Of still less frequent occurrence are peritonitis and nephritis. The abdominal pain, peritonitis however, not infrequently complained of by children during an nephritis. attack of rheumatism is usually due to muscular hyperesthesia and not to peritoneal involvement. As in adults, rheumatism of children may also affect the Muscular muscles. Rheumatic torticollis is especially common, and in r eumatism - .severe cases is apt to be mistaken for cervical spondylitis. Torticollis. Muscular rheumatism affecting the muscles of the lumbar region 418 COMMUNICABLE DISEASES. Resemblance to spondy- litis and Differentia- tion from osteomye- litis. Patho gnomonic j symptoms, may resemble lumbar spondylitis ; and that of the leg may give rise to symptoms (pain on motion, lameness, stiffness, etc.) simulating coxitis. As previously mentioned rheumatism of the abdominal muscles may simulate peritonitis, while rheumatism of the intercostal muscles may be mistaken for dry pleurisy. In all these cases a diagnosis can usually be arrived at by bearing in mind the pathognomonic symptoms of the affections the mus- cular rheumatism resem- bles, and the facts that the latter promptly yields to the salicylates, and that there, as a rule, is a his- tory of involvement of other groups of muscles. Rheumatism may also affect the periosteum and give rise to thickening of the underlying bone, which condition, with the accompanying pain and fever, may simulate incip- ient osteomyelitis. From what has been said, it can readily be seen that the diagnosis of rheumatism in its various phases is far from being easy. Moreover, articular rheumatism may also be mistaken for: Syphilitic, gonorrheal, tuberculous, and the so-called septic arthritides, scurvy, and its allied affections and osteomyelitis. In our endeavor to differentiate rheumatism from the divers forms of articular and periarticular inflammations we must bear mind that rheumatism is a primary febrile affection, as a rule, sudden in development ; that its inflammatory process is transient, and its localization multifarious and rapidly shifting, and, finally, 133. — Rheumatic Toi in a Child 6 Years Old, greatly resembled Cervical dylitis. (Sheffield.) which Spon- RHEUM ATI SMUS ACUTUS. 419 that its course is promptly and often permanently influenced by the Salicylates. Differential Epiphysitis Syphilitica. — Develops slowly, in the first few months of life — rather exceptional for rheumatism — in associa- tion with other symptoms of congenital syphilis. It runs an afebrile afebrile course and yields promptly to anti syphilitic medication. Arthritis Heredosyphilitica (Tarda). — Develops gradually, Fig. 134. — Same case as Fig. 133. Three weeks later. (Sheffield.) and affects principally one or both knees. It is usually associated with other syphilitic symptoms, especially parenchymatous keratitis. As a rule, the subjective disturbances are incongruous j£ c tfve U symp- with the severity and extent of tbe local signs, and the arthritis toms " is but rarely accompanied by inflammatory symptoms. It yields promptly to antisyphilitic medication. Puncture of the swelling spirochsete. reveals serofibrinous fluid and not rarely tbe spirochsete. Arthritis Gonorrhoeica. — It occurs as a complication of gonorrheal ophthalmia, urethritis or vulvovaginitis. It is most Gonorrheal ° . . ° history. frequently limited to one knee, more rarely to both knees, or the maxillary or sternal articulations, and is accompanied by pro- nounced inflammatory local and general svmntonis. The articular Atrophy. 420 COMMUNICABLE DISEASES. involvement is more lasting than that of acute rheumatism, and resists antirheumatic measures. Arthritis Tuberculosa. — It develops gradually, usually remains limited to one joint, and resists antirheumatic treatment. Atrophy of the affected limb sets in early, and an X-ray examina- Tubercuiin tion often shows involvement of the bone. Tuberculin reaction test positive. ^^ positiye _ Arthritis Septica. — Septic or infective arthritis arises secondarily to sepsis (e.g., purulent arthritis, in sepsis neona- secondary. torum) or acute infectious diseases, such as typhoid fever, influenza, pneumonia, diphtheria, scarlatina, etc. The history is the most reliable clue in the diagnosis, and the finding of the streptococcus, pneumococcus, etc. in the seropurulent fluid obtained by exploratory puncture of the swelling is decisive. Scorbutus (Barlow's Disease), Purpura Hemorrhagica and Hemophilia (with sanguineous effusion into the joints) also may be mistaken for acute articular rheumatism. In the hemor- rhages, rhagic diseases, however, there are hemorrhages from and into other parts of the body. The articular swelling is not as evanes- cent. Fever is usually absent or slight. Furthermore, Barlow's disease is observed in very young infants, who are rarely attacked by rheumatism. Antirheumatic treatment is futile. Osteomyelitis. — The swelling does not appear until a few davs after the onset of the disease, and has its center, not opposite Different " . . . . , . ' , ' K1 . localization the loint, as in articular rheumatism, but above or below, opposite of swelling. J . il one or other of the epiphyses of the bones entering into the forma- tion of the joint. In advanced cases the swelling extends along the shaft to a variable distance. In contrast to osteomyelitis rheumatism is rarely limited to a single joint, and its swelling Marked never suppurates. Leucocytosis is absent in rheumatism, and, as leueocytosis. * 1 _ J a rule, marked in osteomyelitis. A skiagraph is helpful in the differential diagnosis. Rheumatic fever per sc is very rarely fatal, but only very few patients emerge uninjured from a severe attack of rheumatism. Prognosis. j n probably two-thirds of the cases some form of heart-disease is acquired which sooner or later manifests evidence of its destructive character. This obtains particularly in recurrent rheumatism as well as in cases improperly cared for as regards b . . . . rest and specific medication. Rest in bed. _ ' Rest in bed is the most important therapeutic measure in the prevention of grave complications and sequelae, and should be RHEUMATISMUS ACUTUS. 421 enjoined at least during the febrile course of the disease. Medi- cinally the salicylates act specifically in all acute rheumatic con- Sallcy ates - ditions and their administration should be continued until every vestige of the disease has disappeared. In' the beginning the salicylates should be pushed to their full tolerance — say one grain of the sodium salicylate for every year of the child's age, every two hours, until the acute symptoms have been arrested, then every four or six hours according to indications. With the appearance of cardiac complications the iodids, in small doses, iodids. should be added, and if necessary also digitalis. For the relief of articular pain and swelling the joint should be enveloped in absorbent cotton wrung out of a warm saturated solution of bicarbonate of soda. The compress should be covered with oiled compresses, silk and flannel bandage and changed every two to four hours. When the pain is very acute I found the following very service- able : — 3 Olei gaultheriae, Guaiacolis, Ichthyolis aa 3ss I 2 Adipis lanae 3j | 30 Sig. : Apply gently twice a day, and cover with flannel bandage. Acute rheumatism being an infectious disease, I have no faith in "mathematical dietetics" as a cure of the disease, hence do not employ any specific dietary, but limit the diet to a so-called "fever Feve r diet. diet" during the febrile stage of the disease and to easily digestible food of all sorts later. This has the advantage of maintaining the nutrition of the patient who at best is weak and anemic. The prolonged use of the iodid of iron and cod-liver oil is always in n. ' order in the convalescent stage, and a sojourn in a dry and high inland resort will prevent recurrence and chronicity. B Natrii salicyl 3ij | 8 Mist, rhei et sodse 3iij | 12 Aq. destil q. s. ad Siij j 90 M. Sig. : 3j every two to four hours for a child 4 years old. R Antipyrinae 3ss | 2 Natrii salicyl 3iss | 6 Caffeine natrii benzoatis gr. xvj | 1 Syr. simplicis 3iv | 16 Aq. destil q. s. ad f5ij | 60 M. Sig. : 3j every six to twelve hours for a child 4 years old, for quick relief of pain. B Olei gaultheriae 3j | 4 Ft. caps. no. xij. Sig. : One capsule every four to six hours for a child 6 years old. (For subacute rheumatism.) 422 COMMUNICABLE DISEASES. RHEUMATISMUS CHRONICUS. Chronic rheumatism in children is very rare. As in adults it may supervene after recurrent attacks of acute or subacute rheumatism, or, very exceptionally, it may develop primarily. In either case the local manifestations are clinically alike, and consist of gradual enlargement of the affected joints, painful and hindered motility, ankylosis, and deformity of the bones at the articulations. The course of this form of rheumatism, though very protracted, and extending over a period of years, is usually not as slow as in adults. It eventually leads to crippling of the patients, and fatal termination either from exhaustion or second- ary tuberculosis. Chronic articular rheumatism may be confounded principally with syphilitic and tuberculous affections of the joints. Syphi- litic arthritis is usually accompanied by other syphilitic symptoms, Differentia- especially keratitis, and ordinarily yields to antisyphilitic treat- tion from ^ . " " . . , • - syphilitic meiit. The differentiation between simple chronic arthritis and and tuber- culous tuberculous joints is quite difficult, since, as previously mentioned, the latter may follow upon the former. However, the absence of temperature and failure to obtain a positive tuberculin reaction speak in favor of chronic non-tuberculous arthritis. The finding of a tuberculous exudation in the affected joint, of course, is decisive in the diagnosis. As the prognosis in protracted cases is very bad, active treat- ment should be begun with early and not too rapidly discontinued in disgust because of more or less persistent failure to effect a cure. The salicylates with small doses of sodium iodid internally and pure ichthyol externally should be given a thorough trial. Where stiffness and swelling of the joints prevail, daily gentle massage preceded by a hot local bath and followed by hot, moist compresses often works wonders. Passive motion should be practised early and where the contractures are very pronounced one should not hesitate to reduce the same under anesthesia and proceed with the treatment just outlined. Concomitant acute symptoms should be treated in the same manner as in acute rheumatism, and when there is reason to believe that the diseased condition is the result of faulty metabolism (intestinal intoxica- tion or uric acid diathesis?) the dietary should be regulated accordingly (exclusion of meats, acids, liquors, etc.). Persistence in treat- ment. RHEUMATISMUS NODOSUS INFANTILIS. 423 Natrii iodidi gr. xv | 1.0 Ext. hyosciami fl gtt. vj | 0.4 Natrii salicyl 3j | 4.0 Syr. sarsaparillae. comp §j | 30.0 Aq. destil q. s. ad fgiij [ 90.0 . Sig. : 3ij every four hours for a child 6 years old. STILL'S DISEASE. This affection generally sets in during the first three or four years of life, and attacks girls more frequently than boys. It is characterized by gradually developing stiffness and enlargement Gradual of several joints, beginning with the knee, wrists and cervical lniar|lmtnt vertebrae, and gradually extending to the fingers and toes. It ° J0m differs pathologically from rheumatoid arthritis or tuberculosis in that it is free from destructive or proliferating processes of the bony structures. The enlargement of the joints is due purely to thickening of the soft tissues. Aside from the articular in- volvement Still's disease is characterized by a more or less marked enlargement of the lymphatic glands (axillary, cervical and adenitis, mesenteric) and of the spleen. It is occasionally associated with a slight rise of temperature, and shows a tendency to pericardial and pleural adhesions. It is a very chronic, incurable affection of unknown etiology. Its progress may be partially arrested by the therapeutic measures outlined under "chronic rheumatism" (q. v.). RHEUMATISMUS NODOSUS INFANTILIS. ERYTHEMA NODOSUM. PELIOSIS RHEUMATICA (PURPURA RHEUMATICA). These three distinct diseased conditions are grouped together to facilitate their identification. They have several symptoms in common, and bear a close resemblance to rheumatism. Their i a tfon to" 6 true nature, however, is a matter of conjecture, and with our present ignorance as to the identity of the specific rheumatic germ there are no means of corroboration or of contradiction of any of the numerous assumptions advanced by different authorities. 1. RHEUMATISMUS NODOSUS INFANTILIS. It is peculiar of early childhood and occasionally follows a protracted or recurrent attack of rheumatism, especially in asso- Nodules near joints. 4-24 COMMUNICABLE DISEASES. ciation with grave cardiac manifestations. It is characterized by the (often symmetrical) appearance, chiefly about the joints and the tendon insertions, of several nodules (noduli or osteomata rheumatici) which grow to a perceptible size, and then either undergo regressive, fatty metamorphosis and absorption, or persist, become calcified and acquire a bony consistence. The nodules (exostoses) vary in size from a small pea to a plum, and in number from one to a hundred. They are at first soft, flat and painful or tender to the touch, and later they become harder and rounder, resembling the fibromatous and osteomatous growths observed in "myositis ossificans" and in "multiple exostoses" (q.v.). Treatment, antirheumatic. 2. ERYTHEMA NODOSUM. Until recently this affection has been looked upon as a skin disease pure and simple. The sudden appearance, tbe rise of temperature, the self-limited course, and its association with more or less marked constitutional symptoms and occasionally grave complications (principally rheumatic pain, bleeding from mucous membranes and heart trouble) stamp it, however, as an acute infectious disease of obscure etiology. Locally it is char- acterized by the appearance, chiefly on the anterior portion of noduies in the lower legs and forearms, of from a pea- to a walnut-sized, front of ° l lower legs pale-red painful nodules which at first resemble contusions and fore- r I ... arms, (erythema contusiforme). They gradually disappear, changing in color to bluish, green and yellow within from two to three weeks, as a rule, without any specific medication. Complications of the heart and joints demand antirheumatic treatment. 3. PELIOSIS (PURPURA) RHEUMATICA (Schoenlein's Disease). The local manifestations of this affection consist of variously Hemor- _ - about knees slzec ^ bright- to bluish-red hemorrhagic spots which are unin- and ankles. fluenced by pressure with the finger. Here and there they present a central papular hardness. The eruption is usually limited to the lower extremities, especially about the knees and ankles, but the upper extremities may be affected as well. The appearance of the eruption is preceded and accompanied by articular pain and swelling, occasionally soreness of the soles of the feet, and difficulty in walking. Fever and constitutional symptoms are ordinarily slight. POLYMYOSITIS. 425 The prognosis is usually favorable, but the disease manifests Tendency a tendency to recurrences, and to cardiac complications. Treat- disease", ment, symptomatic (salicylates; hemostatics, such as iron, gela- tin, turpentine; rest). MYOSITIS (Inflammation of the Muscles). The causes of myositis are very numerous. We had occasion to refer to scarlatinal and rheumatic myositis. It may also be traumatic, gonorrheal, syphilitic and tuberculous in nature, and In connec . is occasionally observed in connection with other infectious dis- * ion J ith ■J divers ease, e.g., typhoid. Myositis is characterized by pain, swelling ^g™^ and loss of function of the affected muscles, and in protracted cases by contractures. Where pain predominates and the swell- ing is slight, myositis may readily lead to diagnostic errors — as emphasized in the discussion of "muscular rheumatism" (see page 417). Traumatic, syphilitic and tuberculous myositides are prone to lead to suppuration, while simple . so-called rheumatic Tendency 11 i •• 1 " • 1 1 1 • t0 su PP ura - myositis eventually subsides either spontaneously or under anti- tion. rheumatic treatment. POLYMYOSITIS. This form of general myositis is of much graver nature than the aforementioned varieties. It occurs either primarily, without any apparent cause, or secondarily as a result of parasitic infec- . , . , . , . . . . Due to tion, such as trichinae, echmococci, cysticerci, etc. trichinosis, t->i,i 1 r i- •■ i 1 • •• echinococci, Preceded by prodromata of a few days duration, consisting cysticerci, of headache, muscular pain, anorexia and slight fever, the condi- tion rapidly grows worse ; the temperature rises, and edema of the eyelids and face appears which soon spreads over the entire surface of the body. Beginning also with the face, the entire musculature of the body (least marked in the hands and feet) J v J Stiffness rapidly becomes stiff, board-like, and very painful, so much so interfering . . with different that the different functions of the body (mastication, deglutition, functions of J v ' & 'the body. respiration, etc. ) are interfered with and the condition greatly resembles that of cerebral rigidity. In some cases cutaneous edema predominates (dermatomyosi- tis), in others a hemorrhagic condition of the skin and mucous membrane (polymyositis hemorrhagica). Some cases develop very slowly and lead to overgrowth of the connective tissue {myositis fibrosa). In trichinosis the polymyositis is usually 426 COMMUNICABLE DISEASES. Trichinosis preceded by gastrointestinal disturbances, and the stools and the wifh S gastro- muscles reveal trichinae spiralis. disturbance! I" children the course of the disease is usually milder than in adults and, as a rule, ends in recovery. Treatment, symptomatic ; thorough cleansing of the alimentary tract; relief of pain by antispasmodics. Fig. 135. — Multiple Exostoses. The tumors, varying in size from a pea to a walnut, were especially numerous at the costosternal articulations, the wrist-, knee- and ankle-joints. (Sheffield.) MYOSITIS OSSIFICANS. Myositis ossificans multiplex progressiva is a disease of child- hood, the majority of the cases on record having been observed in children under ten years of age. Anatomically it is charac- MYOSITIS OSSIFICANS. 427 terized by progressive interstitial connective-tissue proliferation, with consecutive ossification. The affection begins with the muscles of the neck and back, then spreads to those of the thlfneck 1 extremities, and, finally, involves the masseter and temporal muscles. The etiology of the disease is unknown. It is possibly due to a congenital anomaly of the connective-tissue structure. The onset is sudden with fever, and a soft, painful swelling Fever; • • localized of a section of a muscle, over which the skm appears reddened swelling, gradually and edematous. becoming of bony con- The febrile symptoms soon abate, but the swelling in the sistence. muscle persists, and gradually — it sometimes takes years — assumes a bony consistence. Several muscles may thus become affected, leading to disturbances of motion, rigidity and deformi- ties, and ossification of a large portion of the body so that the patient becomes bedridden for life. The prognosis, therefore, is grave, and life is endangered early if the muscles of mastica- tion and respiration are involved. Treatment. — Avoidance of traumatism; the iodids internally and externally ; gentle massage and hot baths. MULTIPLE EXOSTOSES. Bone tumors in children may be congenital or acquired. The congenital latter variety has been spoken of in connection with rheumatism (see page 422). Congenital exostoses may escape observation for several years and then erroneously be attributed to acquired causes. The etiology of congenital exostoses is obscure. Some cases are traceable to syphilis hereditaria. Bone tumors local- ized in the immediate neighborhood of joints and interfering with motility should be extirpated. POLIOMYELITIS ACUTA. (See page 529.) and acquired. CHOREA ACUTA. (See page 563.) CHAPTER X. Diseases of the Heart. CONGENITAL HEART DISEASE (Vitium Cordis). Delicate ^ s a ru ^ e ' m f ants born with heart disease are very delicate. Most of them are horn asphyxiated and if resuscitated remain cyanotic, cyanotic, 1 or very anemic, atelectatic, cry feebly, breathe super- ficially, are barely able to suckle, present a very weak pulse and subnormal temperature. 2 Not rarely they are born prematurely and with congenital defects of other parts of the body. Some children present a club-shaped appearance of the fingers and toes at an early age. some of them later. If they survive for any length of time their growth and development are very much delayed. They are helpless, begin to hold up the head or sit up at a much later age than the normal baby. When they start to rapidly 6 walk they tire very rapidly. They rarely creep and when on the floor they are often unable to lift themselves. They are very susceptible to colds, and once taken sick they are very slow to recuperate- Bottle-fed babies frequently succumb to gastrointes- tinal diseases, even of comparatively simple nature. If they live up to school-age, and are more frequently exposed to acute con- tagious and infectious diseases their weakened constitution forms a favorable nidus for the contraction of these affections, and is rarely able to withstand them. Even under the best of care, children with congenital heart lived, disease usually live but a few years. Death sometimes occurs suddenly, or incidentally in the course of other diseases which in normal children are not dangerous to life, especially respiratory affections. Unless the heart defect is very mild in nature, chil- dren with vitium cordis very rarely survive the age of puberty. 1 From time immemorial cyanosis (morbus coeruleus or "blue-sick- ness") has been looked upon as a cardinal symptom of congenital heart disease. It is usually associated with clubbing of the fingers and toes (see Fig. 136). Its diagnostic importance has been greatly exaggerated, since it is not rarely absent in the severest forms of congenital vitium cordis. 2 See "Feeble Vitalitv of the Newly Born." (428) CONGENITAL HEART DISEASE. 429 The course of congenital heart disease varies, of course, with the severity of the defect, but practically resembles that of acquired es acquired vitium cordis, which is fully described in other parts of this treatise. The following are the most common congenital heart affections : — Fig. 136. — Vitium Cordis. "Morbus Coeruleus." Note "club- shaped" fingers and cyanosis (represented by dark patches on face and lips), in a child 8 years old. (Sheffield.) PERSISTENCE OF THE FORAMEN OVALE. This condition is the result either of faulty construction of the foramen or its valves, or defects in other portions of the heart (e.g., stenosis of the pulmonary artery) which by indirect blood-pressure prevent complete obliteration of the foramen. It is the most frequent kind of congenital heart disease, but is not always recognizable during life. In the presence of clinical symptoms the diagnosis may be based upon predominance of Most common. 430 DISEASES OF THE HEART, systolic cyanosis, a systolic blowing sound at the base of the heart or over Hypertrophy of right ventricle. murmur, the third or fourth costal cartilage. PERSISTENCE OF THE DUCTUS ARTERIOSUS BOTALLI. ( a nnplete obliteration of this duct is supposed to occur by the end of the third month. This may be retarded or may entirely fail — usually in cases where the left ventricle is not properly idled with each heart-cycle (e.g., in atelectasis, fetal pneumonia, stenosis of the pulmonary artery) — in which event the blood from the pulmonary artery continues to flow through the ductus arteriosus to the insufficiently filled aorta. As a result of this anomaly there develops sooner or later hypertrophy of the right ventricle, usually with dilatation of the pulmonary artery. The symptomatology is very variable. In cases of only partial patency the symptoms may be so slight as to escape observation. Complete patency of the duct very gradually gives rise to the following group of symptoms : Thriii; Disposition to respiratory affections, cyanosis, or waxy pallor; murmur S over dyspnea, cool extremities, palpitation, a thrill over the anterior chest wall, increased cardiac dullness to the right, accentuation of the second pulmonic sound, loud ■ systolic murmur over the precordium, often epistaxis or hemorrhage from other mucous membranes ; finally, sometimes not until after several years of existence, marked symptoms of failure of compensation with rapid fatal termination. DEFECTS IN THE SEPTUM VENTRICULORUM (Communication of the Ventricles). It is a very common condition, most frequently the result of fetal myocardial diseased processes, and not rarely coexisting with congenital stenosis of the pulmonary artery. The defect is situated either in the anterior or posterior portion of the septum. Very rarely the whole wall between the ventricles and auricles is absent so that all four heart cavities communicate. ., , . Accentuation of the second pulmonic sound; overfilling of the Marked I _ ° cyanosis veins ; marked cyanosis developing soon after birth or, more soon after f ' ° birth, gradually, some time after, and hypertrophy and dilatation of the right ventricle — all point to a defect of the ventricular septum. A positive diagnosis, however, is almost impossible during life of the patient. The prognosis is very bad. CONGENITAL HEART DISEASE. 431 CONGENITAL STENOSIS OF THE PULMONARY ARTERY. The stenosis may involve the orifice alone, the entire trunk, or the branches of the pulmonary artery. Accordingly the symp- tomatology varies with extent and location of the lesion. As a rule, there is marked cyanosis from birth. Some children are Bom with cyanosis. born asphyxiated, and if resuscitated continue to suffer from attacks of suffocation and convulsions, to which they usually succumb within the first few days of life. Stronger children may survive these attacks, gain some strength, lose part of the cyanosis and live several years. Physical examination reveals arching of the anterior left chest wall; enlargement of the cardiac area, chiefly to the right; Basic diffuse systolic murmur, heard loudest over the left second and murmur, third costal cartilages, and often a purring thrill on palpation. CONGENITAL STENOSIS OF THE TRICUSPID VALVE. It is usually the result of an anomalous or excessive develop- ment of muscle substance instead of the valve, or of fetal endo- carditis, and is often associated with other congenital heart defects. The symptomatology resembles that of stenosis of the pul- Murmur monary artery, except that the murmur is heard loudest over the fourth and fifth costal cartilages, and hypertrophy of the right side is either absent or very slight. The prognosis is unfavorable. CONGENITAL STENOSIS OF THE OSTIUM ATRIO- VENTRICULARE SINISTRUM (Stenosis of the Aorta). The stenosis may be situated at the point of origin of the aorta ; at any place throughout the entire aortic system ; or at the ductus Botalli. As a result of either one of the aforementioned conditions „ , . Hypertrophy there is hypertrophy of the left heart. Varying with the seat of ^ar" the atresia, the blood-vessels given off above the lesion may be abnormally filled with blood, while those emerging below the lesion suffer from a deficiency of it. Between the two groups of vessels a collateral circulation is usually established, which may frequently be recognized by numerous, visible, actively pulsating, Pulsation subcutaneous blood-vessels over the thorax. A systolic murmur °'J )1 1 00<1 " is often heard over the dilated arteries. The heart is usuallv over tricuspid valve. !:;: DISEASES OF THE HEART. free from any auscultatory signs, unless the orifice of the aorta be involved, when a loud systolic murmur may be heard at mid- sternum. The patient may live for several years — until compensation ruptures. Death sometimes ensues very suddenly from rupture of a group of vessels above the stenosis. Treatment. — The treatment of congenital heart diseases is ia in a Girl 6 Years Old (skiagram view). (Sheffield.) essentially the same as that of acquired, and is fully outlined ° m rest e on page 443. Complete rest in the strictest sense of the word will help to prolong life — possibly to an advanced age. DEXTROCARDIA. Among the few congenital malpositions of the heart (meso- cardia — the heart occupies a central position of the chest-wall ; ectopia cordis — the heart may be situated either between a fissure in the sternum immediately beneath the skin, in the neck, or in the abdomen below the diaphragm) dextrocardia, or transposi- tion of the heart to the right side, is of special interest inasmuch as it very rarely interferes with the life or welfare of the patient. ACQUIRED HEART DISEASE. 433 Dextrocardia is often associated with a general transposition of 0ften tra ns- the viscera. The aorta and its branches usually remain in their vfscera? ° f normal situation. Dextrocardia should not be confounded with displacement of the heart by large effusions or growths in the thoracic cavity. ACQUIRED HEART DISEASE. MYOCARDITIS. Inflammation of the muscular tissue of the heart is occa- sionally congenital, a sequel of infection during fetal life, but most frequently acquired, occurring either secondarily to acute acquired, infectious diseases, or as a result of extension of an inflamma- tion from the inner or outer lining of the heart. The inflammation may be diffuse or circumscribed, and as in adults either plastic or interstitial, or degenerative or parenchy- matous. The interstitial variety of myocarditis usually leads to sup- puration and abscess formation of the musculature. In parenchy- matous myocarditis the transverse striae of the fibrillse appear lost, the muscle consisting chiefly of fatty and granular matter. The course of the disease varies greatly with the underlying cause and the rapidity of the inflammatory process. In the majority of instances interstitial myocarditis is com- interstitial, plicated by endocarditis and pericarditis, and in consequence of preponderance of the signs of the latter affections it is very seldom possible early to diagnose the existence of the myocardi- tis. In cases where the inflammation is circumscribed, myocarditis J Sudden may be surmised by the sudden precordial pam, dyspnea, high precordial fever, restlessness and delirium. The apex-beat and pulse are weak, arhythmic and rapid. Death is the usual termination ; not Arnythmia. rarely occurring suddenly (sometimes from rupture of the abscess in the heart cavities) with symptoms of sudden collapse. Parenchymatous myocarditis ordinarily runs a slow and latent Parenchyma- course. Occasionally, however, the degenerative process develops quite rapidly. Extreme pallor, breathlessness, and weak and galloping pulse point to the involvement of the myocardium, but Galloping in the early stages the diagnosis can rarely be made with any degree of certainty. As the disease advances and symptoms of cardiac dilatation and passive pulmonary congestion set in. the diagnosis is fairly certain. The treatment is the same as in endocarditis (q.z\). 434 DISEASES OF THE HEART. PERICARDITIS. Like pleuritis, inflammation of the pericardium may occur in dry form or with an effusion. The exudation may be sero- fibrinous, hemorrhagic, or purulent. Dry as well as exudative " adh'eslonZ pericarditis usually gives rise to inflammatory adhesions between the pericardium and heart, and occasionally to the anterior and posterior chest-walls and vertebral column. Chronic pericarditis is productive of grave disturbances of the circulation, cardiac hypertrophy and dilatation. The gravity of this affection should, therefore, not be under- estimated. The prognosis is serious, especially in the secondary variety occurring in connection with tuberculosis, septic pro- cesses, pleuropneumonia, caries of ribs or vertebrae, severe exanthematous diseases {e.g., scarlatina), purpura hemorrhagica, chronic nephritis, etc. It is less dangerous in primary, usually rheumatic form, particularly if the patient is over three years of age, or when caused by syphilis and is detected and treated early. Bearing in mind the etiologic factors just enumerated, we can readily appreciate that pericarditis in children must be quite common. Indeed, there is ample reason for the belief that in children over three years of age pericarditis is more frequent than endocarditis — with which affection, by the way, it is not rarely associated. The onset of primary pericarditis is usually very sudden, but Fever- sometimes, like in the secondary variety, it may be insidious. oppression^ Ordinarily it is ushered in with high temperature, vomiting, cough. car( ij ac oppression, dyspnea, and accelerated pulse. Cough is an early symptom and, in the presence of an effusion, quite pro- nounced. This symptom is probably due to cardiac pressure against the lungs. The pulse, which in dry pericarditis is strong, in marked exudative pericarditis it is often very feeble, barely perceptible, and irregular. Pain is frequently intense, especially if associated with polyarthritis. The patient is restless, sleepless; his expression of the face is anxious, denoting great suffering. Of course, the symptomatology is greatly modified by that of the underlying affection, if existing. The physical signs vary with the stage of the disease. Before the development of the effusion auscultation elicits superficial, To-and-fro exocardial, to-and-fro friction and creaking sounds, limited over friction. ' . . the cardiac region, often changeable with position of the patient hypertrophy. ACQUIRED HEART DISEASE. 435 and audible independently of the heart sounds. Endocardial murmurs may coexist. When serous effusion occurs, the friction sound is found diminished or absent, the heart impulse very feeble impulse, (whereas the pulse may be felt quite strong), the area of heart- dullness greatly increased and wider at the apex than at the base, apical and when the effusion is large we notice also diminution of the respiratory movements of the left side. With absorption of the fluid in the pericardium there is gradual return of the symptoms of the first stage and in favorable cases restitutio ad integrum, or, quite frequently, supervention of pericardial adhesions with consecutive systolic retraction of the chest-wall over the entire precordium. The percussion symptoms are not absolutely reliable, since increase of the area of cardiac dullness is also observed in dilatation or hypertrophy. There are, however, . . . . Differentia several other distinctive features which render the differentiation tion from of pericardial effusion from enlarged heart possible. Thus, in dilatation or hypertrophy of the left ventricle the apex-beat is felt at the extreme left limit of the dullness and at its lowest level, while in effusion the apex-beat or rather the heart-impulse is at a spot inside and above the boundaries of the cardiac dullness, somewhere between the fourth or third interspace. In pericardi- tis the dullness develops much more acutely than in an enlarged heart, which latter occurs usually secondarily to more or less chronic valvular disease. However, we should bear in mind that pericarditis, acute or chronic endocarditis, and hypertrophy and dilatation may coexist and give rise to a symptom-complex beyond the possibility of individualization. For the differentiation between pericarditis and endocarditis the reader is referred to the discussion of the latter affection (see page 439). The nature of the effusion can readily be ascertained by exploratory puncture, but even without it we may surmise the presence of pus if the pericarditis develops secondarily to septic processes ; blood, after severe trauma, and scrum, in primary, usually rheumatic, pericarditis. The determination of the character of the effusion is impor- tant especially as regards the further course and treatment of the disease. Rheumatic pericarditis, if free from complications, usually lasts for from two to three weeks or longer. After about ten days there is gradual evanescence of the symptoms. Not infrequently, however, the "apparent" recovery is only tempo- Nature of effusion. 436 DISEASES OF THE HEART. rary, inasmuch as there may he a return of the effusion, or development of valvular deposits, which sooner or later give rise to marked valvular disease. These manifestations are partic- Rheumatic. ularly prone to occur in pericarditis with polyarthritis. Peri- carditis, like endocarditis, not rarely precedes the joint symptoms, may run a latent course and disappear again without being detected — possibly not until repeated recurrences and appearance of complications. More rarely, pericarditis ends in death either rapidly as result of cardiac muscular insufficiency and pulmonary edema, or slowly from early complications, such as pleurisy, pneumonia, severe adhesions, endocarditis, etc. Purulent. Purulent pericarditis pursues a much more violent course. Extreme fatigue, severe attacks of syncope and pyemic fever predominate, while the local symptoms are comparatively insig- nificant. Even the exudation is often slight. When it occurs in Tuberculous, conjunction with tuberculosis, it is very malignant in character. It is then manifested by enormous hypertrophy of the peri- cardium, extensive adhesions, large quantity of pus between the heart and pericardium, and numerous tubercles in the latter. It is invariably fatal. The same holds true for pyemic pericarditis, in which streptococci, pneumococci, staphylococci and less fre- quently gonococci act as the principal exciting cause. A disease presenting so many phases as pericarditis can at best ieeba St - ^ e treatet l on 'y symptomatically. Absolute rest in bed, an icebag, salicylates. or a flaxseed-meal poultice, to the precordium, and sodium salicy- late (1 grain for every year of the child's age every two hours) and codein (%oo °f a grain every six hours) internally will often do well in rheumatic cases. In large pericardial serous effusions with threatening syncope we may try free diuresis, with or with- Aspiration. out aspiration (in the fifth intercostal space a little to the left of the border of the sternum). The latter procedure frequently proves useful in small non-tuberculous purulent effusions, while in large purulent effusions incision and drainage are preferable to aspiration. In quite a number of cases sodium iodid seems to exert a iodids. S p ec ifi c effect, and bearing in mind also the possibility of under- lying latent syphilis we should always administer this remedy irrespective of the variety of the pericarditis and the mode of treatment simultaneously employed. Digitalis or strophanthus may be given to strengthen the heart. ACQUIRED HEART DISEASE. 437 ENDOCARDITIS ACUTA. The etiologic factors of acute endocarditis are essentially the same as in pericarditis (q.v.), except that the former is more frequently associated with rheumatic affections, such as arthritis, chorea, tonsillitis, erythema nodosum, etc., and not rarely com- plicates pericarditis. Invasion of the endocardium by the strep- tococcus, staphylococcus, pneumococcus, the bacillus pyocyaneus, coccic, etc. tubercle bacillus and gonococcus usually occurs through the cir- culating blood, giving rise to a pathologic condition very similar to that observed in adults. The inflammation which is usually limited to the left side of . Pathologic the heart first attacks the vascular layer of the endocardium findings, between the muscular and fibrous coats, resulting in an exudation of lymph and serum principally beneath and on the free surface of the membrane covering the valves and chordae tendinese. As the disease progresses large or small papillary nodules, vegeta- tions, are formed on the endocardium — endocarditis verrucosa, or ulcerations occur as a result of destruction of the superficially necrosed tissue — endocarditis ulcerosa. The latter condition is usually found in the malignant, usually septic, form of endocar- ditis. During the course of endocarditis many organs of the body, e.g., the kidneys, spleen, brain, etc., may become implicated through emboli composed of masses of fibrin or necrosed tissue which become detached by the circulating blood principally from the irregular valvular deposits. In septic cases these emboli give rise to abscesses. It is well to remember, however, that moder- ately severe cases of endocarditis may go on to complete recovery, and leave no trace of the original inflammation on the endo- cardium ; furthermore, that slight valvular vegetations are not infrequently found post mortem without any apparent clinical signs of heart disease during life. This latter observation can readily be explained by the fact that mild endocarditis is not rarely masked by the course of another disease, and unless presenting marked disturbance of the circulation is very apt to be overlooked. More often, of course, endocarditis sets in with severe unmistakable symptoms. The chilis fever, \ r precordial patient vomits, suffers from chills, more or less high fever (102° distress and 1 t & \ cough. to 105° ), precordial distress, short cough, dyspnea, and acceler- ated and sometimes irregular pulse. These symptoms, however, arc not sufficiently characteristic of endocarditis and may still 438 DISEASES OF THE HEART. Usually mitral murmur. leave the nature of the disease obscure until the subsequent appearance of local signs, especially of a systolic heart murmur, audible chiefly at the apex ( the mitral valve being most fre- quently involved) or also over the whole cardiac region. As will be seen later (see "Endocarditis Chronica," page 439) murmurs may subsequently develop at the various orifices of the heart, and at a later stage of the disease additional physical signs (dila- tation or hypertrophy ) may be obtained by percussion. Occasionally (in children less frequently than in adults) acute ■p- ^^ -pim _«jj» -(if** -a. j» Jitt. -a_U*. -M* -aX -li. &. - a* a= as be ^ j^ s= m '05 — *N h ^,3 ^xi y^i tja. H tr, H i i la "■ v.i — ' f— 105 103 — IBl J J 1 ! |_, M Will 101 — 100 — ?9 — T • 1 1 1 f^ — 1 — 1 — ■ ,00 99 97 — * $ =3 33 Jxi 41 _HX1 "^ T7 11 11 __ *_ « 4 -* -» > f>>,^^-S-?,54~>!??*S , >f> il25MlL3l^IfiC£S ■ Fig. 138. — Fever Curve of Malignant Endocarditis in a Child 3 Years Old. {Sheffield.) Malignant form. Septic symptoms. endocarditis pursues a very septic and often violent course — endocarditis maligna (ulcerosa). It may be preceded by pneu- monia, exanthematous diseases, septic processes in some other parts of the body, etc., or occur without any apparent cause and exhibit a symptom-complex resembling either a low typhoid state or cardiac insufficiency with acute dilatation (cyanosis), and loud murmurs at the various orifices. The duration of malignant endocarditis varies. Ordinarily it runs a protracted course with irregular temperature, chills, rigors and sweats. Sooner or later emboli develop in different organs of the body and the capillaries of the skin the superadded symptoms varying, of course, with the organ affected. If the brain is involved, we find palsies with disorder of consciousness; if the spleen, enlargement of this CONGENITAL HEART DISEASE. 439 organ and tenderness; if the kidneys, albuminuria, hematuria and Compiica- anasarca; if the skin, petechias and a pustular eruption. It is not rarely complicated also by purulent pericarditis. When malignant endocarditis runs so very violent a course it, as a rule, terminates fatally within a few days. On the other hand, simple, benign endocarditis in children is usually not dangerous to life. If free from complications the symptoms begin to subside after about a week or ten days, eventually leading to recovery in about four weeks. In quite a number of cases, however, it is followed by permanent valvular disease, with or without cardiac hyper- trophy (see "Endocarditis Chronica"). Death is usually due to cardiac paralysis. Benign endocarditis may be mistaken for dry pericarditis, especially if the former is associated with articular rheumatism. The following table contrasts the most important distinguishing features. Both diseases, however, may coexist. Differential Simple Endocarditis. Dry Pericarditis. diagnosis om Blowing or musical sound. "To and fro" friction or creaking pericarditis, sound. malaria Sound is associated with systole or Not necessarily. May be heard at miliary' diastole. any period of cycle. tuberculosis Sound is distant. Near to the ear. Sound is uninfluenced by pressure Increased. with the stethoscope. Sound is conducted upward, to the Not so. axilla, and to the back. Sound usually loudest at apex. Anywhere over precordium. The diagnosis of ulcerative endocarditis is very difficult, especially in the incipient stage, before the appearance of a heart murmur. Whenever several orifices are the seat of the murmur, paroxysms of cyanosis and dyspnea and irregular temperature predominate, and cardiac dullness is increased, the diagnosis of malignant endocarditis is justified. The elimination of typhoid, irregular malarial fever, miliary tuberculosis, and pyemia, the four affections with which malignant endocarditis is most apt to be confounded, will greatly facilitate the diagnosis. The treatment of endocarditis is essentially the same as in pericarditis — purely symptomatic. (See "Pericarditis,'' page 436.) ENDOCARDITIS CHRONICA (Valvular Heart Disease). Chronic endocarditis is most frequently a sequel of acute inflammation of the endocardium, especially of the valves, and pathologically consists of proliferation and thickening of the pycini 440 DISEASES OF THE HEART. valvular connective tissue with a great tendency to contraction and adhesions, and very rarely to calcification. The chronic iett'heart inflammatory process is usually limited to the left side of the heart except in cases developing during fetal life, when the reverse is the case. Coincident with the inflammatory process in the endocardium, the cardiac musculature undergoes gradual enlargement. This hypertrophy, unless assuming exceptionally large dimensions ( e.g., cor boviniim), is strictly speaking not a disease per se, but, trophy, on the contrary, an effort on the part of nature to overcome or undo the evil effects of the disease. As the disease advances and the heart muscles lose their power, get exhausted, the hyper- Diiatation. trophy is replaced by dilatation, indicating that compensation has "ruptured," and that disease is beyond control. Until failure of compensation has occurred children may for years remain apparently free from any marked disturbances of health, except, perhaps, rapid fatigue, palpitation of the heart Anemia, on exertion, progressive anemia and malnutrition notwithstanding good appetite and digestion. Indeed, it is often chiefly for dis- turbance of the latter that the patients are brought to the physi- cian. Shortness of breath, which increases on exertion, usually forms an early manifestation of failing compensation. It is the result of stasis in the pulmonary circulation with con- secutive impairment of aeration. ■ This sooner or later leads to passive congestion of the pulmonary alveoli, giving rise to bron- chitis, with an irritable cough, and, as the heart-failure increases, to paroxysmal attacks of dyspnea especially at night ("cardiac Pulmonary asthma"), pulmonary edema, cyanosis, and occasionally to hemorrhagic infarcts in the lung with consecutive hsemoptce. Simultaneously with the aforementioned manifestations, pathologic changes go on also in other internal organs — the liver, compiica- spleen, and kidneys. The liver and spleen are enlarged, and by pressure upon neighboring thoracic organs increase the dyspnea. As a sequel of the passive congestion of the liver and stasis in the blood-vessels of the stomach and intestines, numerous gastro- intestinal disturbances — e.g., anorexia, vomiting, constipation — develop, which add misery to the patient's painful existence. The changes in the kidneys are manifested by diminution in the quantity of urine, often albuminuria (slight), hyaline and cylindrical casts, and occasionally white and red blood-corpuscles — signs of passive congestion. Dropsy. Heart- failure ACQUIRED HEART DISEASE. 441 With increasing venous stasis there is coincident transudation of the fluid of the blood from the capillaries into the meshes of the tissues, leading to edema. At first the dropsy is limited usually to the ankles and eyelids, but as the disturbance of circula- tion advances it grows worse and involves the entire integument and the internal cavities, especially the abdominal and pleural cavities. Notwithstanding the extreme gravity of the condition, the end is not always as near as would be expected. The inherent Remissions, power of the infantile heart is still capable of temporary repara- tion. The arhythmia, dyspnea, and dropsy may disappear; the appetite and nutrition may improve ; the tottering patient may again be up and around ; in fact, may appear at his best. Exacer- bations and improvements of the disease may come on several times. The improvement is but short-lived. Very soon the symptoms return, and, as a rule, with greater severity. Finally, after a more or less prolonged period of illness the patient succumbs to heart-failure. Occasionally death occurs suddenly after severe exertion. Quite a number of children are carried away by intercurrent infectious diseases, pericarditis or recurrent endocarditis. The physician should therefore always be very guarded in the prognosis. The relative gravity of valvular lesions is as follows : Tricuspid regurgitation ; mitral regurgita- tion; mitral stenosis; aortic regurgitation; pulmonic stenosis; aortic stenosis. Differential Diagnosis. 1 — As the physical signs of valvular R r avu ve of heart disease in children differ but little from those in adults, we lesions - will review only the most essential differential points of diagnosis. MITRAL REGURGITATION. Insufficiency of the mitral valve is characterized by a systolic blowing murmur which is loudest at the apex and transmitted to the axilla and near the lower angle of left scapula. Accent- uation of the second pulmonic sound. Hypertrophy of the left ventricle, and later left auricle, and sequential hypertrophy of the right ventricle. The pulse may be normal or accelerated, and with disturbed compensation — which may not occur for many years — irregular and unequal. MITRAL OBSTRUCTION. It is frequently associated with insufficiency. The murmur is Presystolic 11 i- ii-i-ii,i or diastolic usually presystolic or also diastolic, best heard at the apex; may murmur at apex. Systolic. murmur at apex. See Fig. 16. Diastolic 442 DISEASES OF THE HEART. be conveyed to the fourth interspace, but never to the angle of the scapula. The pulmonic second sound is accentuated and sometimes double. It frequently leads to hypertrophy of the left auricle and right ventricle. AORTIC REGURGITATION. Aortic insufficiency is rare in children. It is accompanied by hypertrophy of the left ventricle, and often pulsation of the murmur at arteries of the neck. The murmur is diastolic, loudest at the right base. insertion of the right second costal cartilage and over the upper portion of the sternum. At first the murmur is quite noisy, but with ensuing disturbance of compensation it loses its intensity. It is usually combined with aortic stenosis, becoming the gravest form of valvular disease of childhood. It sometimes causes sudden death, and but few children survive the age of puberty. Aortic regurgitation may often be recognized by its peculiarly collapsing pulse — the water-hammer or Corrigan's pulse. AORTIC OBSTRUCTION. This affection is usually observed in older children in connec- Systolie ..... murmur tion with aortic insufficiency. The murmur is harsh, systolic, at right . J . . J base, heard loudest over the aortic orifice, transmitted to the right, and sometimes over whole length of sternum, and the arteries of the neck. Hypertrophy of the left ventricle. TRICUSPID REGURGITATION. Except as a congenital defect it most frequently occurs secondarily to affections of the left heart. Auscultation reveals a systolic, blowing murmur heard loudest over the lower part of the sternum (xiphoid) and at the juncture of the fourth costal cartilage. Second sound is weak. Jugular pulsation. Hyper- trophy and dilatation of the right heart. In severe cases cyanosis, and pulsation of the liver. TRICUSPID OBSTRUCTION. This condition is extremely rare; hence, calls for no detailed discussion. No particular change in size of the heart is known. (See "Congenital Heart Disease.") PULMONIC REGURGITATION. Insufficiency of the pulmonic valve is chiefly congenital, rarely acquired. The murmur is diastolic and limited to the site of the Systolic murmur at xiphoid. ACQUIRED HEART DISEASE. 443 valve — at the junction of the left second costal cartilage and Diastolic the sternum. Unlike that of aortic insufficiency it is not trans- ™ft"bas r e. at mitted to the arteries of the neck. Hypertrophy of the right heart. PULMONIC OBSTRUCTION. Principally a congenital malady. The murmur is basic, sys- tolic, heard loudest at the left second costosternal junction. It is murmur at associated with hypertrophy of the right ventricle, and some- times cyanosis. (See "Congenital Heart Disease.") Functional or inorganic murmurs — those arising during the course of acute febrile diseases or in association with anemic conditions — may be mistaken for organic murmurs of valvular heart disease. The chief points of distinction between them are as follows : Functional murmurs are inconstant, heard prin- Differentia- cipallv at the base with systole, not transmitted away from the organic 11 • • murmurs. heart, and usually disappear with defervescence, or improvement of the anemia. Functional murmurs are very rare in children up to seven years of age. The management of chronic valvular heart disease in chil- dren is the same as in adults. It differs with the stages of the disease — when compensation is intact, and when it "ruptures." STAGE OF COMPENSATION. The well-being and longevity of the patient stand in direct ratio to the capacity of the heart to compensate its insufficiency by secondary hypertrophy of the musculature of one or more of its chambers. Hence, the aim in the treatment of chronic val- Maintenance vular heart disease should be directed chiefly to the maintenance pg^™" of compensatory hypertrophy. Bearing in mind the facts that hypertrophy. with increasing circulatory disturbance there is on the part of the heart a spontaneous muscular development to overcome its difficulties as long as its supply of nourishment is sufficient, and its hypertrophic process is not interfered with by unequal demands upon its reserve force — as it is apt to occur, e.g., in overexertion, intercurrent diseases and the like — we can readily formulate a plan of treatment which will, at least for a time, amply meet with the aforementioned indication. Parents should be given to understand that the treatment of compensating heart disease is principally prophylactic and hygienic, and that its success is commensurate witli the degree of co-operation on the Care during ivales- cence. 444 DISEASES OF THE HEART. part of the patient as well as those guiding his destiny when the heart is at its best. Convalescence from acute or recurrent heart disease calls for convaie"- very careful attention. Too early attempts at walking or standing are apt to prove disastrous, not rarely leading to sudden dilata- tion of the heart, perhaps, with fatal issue. Beginning with gradual raising of the head and shoulders, and watching its effect upon the patient's heart-action — strength and rhythm — we may gradually allow greater liberties, provided slight exertion is unattended by detrimental influences. In severe cases of valvular heart disease it is usually not safe to permit the patient to be out and around in less than three months. A sojourn in a quiet inland resort is very helpful to recovery. A heart with crippled valves demands an adequate supply of nutrition, healthy blood in the coronary arteries. This is best secured by suitable nutrition and a rational mode of living. The diet must be appropriate to the age of the patient, at all ages milk forming the principal food-ingredient. A vegetable diet with small quan- tities of light meats is suitable in most cases. Liquors and Non-alco- . ° . .... hoiic tonics, stimulants of all kinds should be avoided, administering instead nutrient tonics such as malt and cod-liver oil, with or without small quantities of iron and arsenic, etc. Especial attention should be paid to the action of the bowels, outdoor Sidneys, and skin. Daily cool sponging followed by gentle air - massage is very invigorating. Warm clothing is essential, but unnecessary coddling of the patient should be interdicted. Weather permitting, the child should be kept outdoors from nine in the morning until about five o'clock (later in the summer) in the evening, allowing him to participate in all such amusements as will not call for undue exertion. Racing, jumping, football, Avoidance an< ^ baseball playing and swimming should be forbidden. Light and P nientai athletic exercise is useful if it gives rise to no undue fatigue, or disturbance of compensation. Passive exercise, in the form of massage, is highly to be recommended. The question of how much brainwork a patient with poorly compensating heart disease is to be permitted to do cannot be decided offhand to apply to all cases. Its effect upon the general health of the patient must be watched, and changes in the curriculum promptly made if head- ache, insomnia, anemia, debility, excessive nervous irritability, and the like make their appearance. It is of very vital importance to obviate intercurrent diseases, and mental overexertion Prevention of communi cable di ACQUIRED HEART DISEASE. 445 especially infectious diseases, such as scarlatina, articular rheu- matism, etc., which are apt to reinfect the endocardium, and aggravate the patient's condition. If such diseases prevail it is imperative, whenever practicable, to isolate the child, or remove him to a place where he will be least exposed to infection. For fear of contracting contagious diseases, patients in good financial circumstances should be kept from visiting public or private schools and preferably be instructed at home. Particular attention should be paid to incipient symptoms of tonsillitis, "growing pains," etc. — forerunners of rheumatism. In these conditions the salicylates should be resorted to early to prevent graver rheumatic manifestations. With every appearance of indisposition the patient should be put to bed, and kept there until every vestige of the malady has abated. In intercurrent febrile diseases the heart demands very careful watching, and in the presence of any disturbance immediate treatment. STAGE OF FAILING COMPENSATION. Varying with the inherent strength of the patient, the severity of the lesion and the precautionary measures employed, compen- sation may be maintained for a shorter or longer time — weeks, months or years. However, it is only a question of time when compensation ruptures. As previously mentioned, the break- down may be only temporary — readily yielding to a few weeks of rest, careful feeding, possibly requiring also a few doses of digitalis — and recur on several occasions. But sooner or later the . . Signs of heart muscle gives way — the pulse becomes feeble and irregular, heart- the breathing deep and difficult, the urine diminished in quantity and the general condition of the patient greatly impaired. Here rest in bed is indispensable, but this alone is not sufficient to restore compensation. We have to resort to cardiac stimulants to strengthen the heart muscle and to regulate its beat, and to vaso- dilators, with each ventricular contraction, to allow the blood to flow in the arteries without resistance. Various drugs are being recommended for this purpose, but none meet the indications with the same degree of certainty as digitalis, and the iodids. In incipient failure of compensation we usually begin, for every two years of the child's age, with half a grain of the sodium iodid and a quarter of a dram of the infusion of digitalis, to be failure. Digitalis and the iodids. thus; caffeine. 446 DISEASES OF THE HEART. repeated every six hours, and as the disease advances increase the doses proportionately up to one grain of the iodid and one dram of the digitalis. The cumulative action of the digitalis should be borne in mind, and its administration discontinued if untoward strophan- symptoms arise. In this event, or where digitalis is not well tolerated by the stomach, we may substitute strophanthus, caffeine sodium benzoate or spartein sulphate instead. The latter two remedies have the advantage that they may be safely given hypodermatically if irritability of the stomach precludes their administration by mouth. In the early attacks of failure of compensation the effects obtained from the simple mode of treatment just outlined are often entirely beyond expectation. Sometimes within but a very few days the urine greatly increases in quantity, the edema dis- appears, the dyspnea ceases, the distressing cough abates — in short restoration of compensation is apparently complete. In the later stages of compensatory failure, however, the treatment by means of rest, good food, the iodids and digitalis fails to assert its magic influence. We have to resort to symptomatic medica- symptomatic tion, especially with the view of relieving suffering. In this respect the treatment is the same as that employed in adults, morphine with atropine being the most potent remedy at our command. R Strychnina- sulph gr. V 8 | 0.008 Xatrii iodidi gr. xvj 1 Inf. digitalis fol l\ I 30 Syr. althea? q. s. ad 3i j j 60 M. Sig. : 3j t. i. d. for a child 4 years old. (Alterative heart-tonic.) R Syr. ferri iodidi 3iij | 12 Syr. aurantii q. s. ad Sij | 60 M. Sig.: 3j every four hours for a child 4 years old. (Between "heart attacks.") R Liq. ferri et ammonii acetatis. Inf. digitalis fol aa 3j | 30 M. Sig. : 3j every four hours for a child 4 years old. (When dropsy is present.) R Tr. digitalis, Tr. strophanthi aa 3ij | 8 M. Sig. : Gtt. v every four hours for a child 4 years old. (In marked heart-dilatation with irregularity.) R Strychnine sulph gr. V 5 | 0.003 Caffeinae natrii benzoatis gr. xij | 0.8 Aq. destil 3ij | 8 M. Sig. : Gtt. x, hypodermatically, p. r. n. for a child 4 years old. (Quick stimulant.) treatment. CHAPTER XL Diseases of the Kidneys, Bladder, etc. NEPHRITIS ACUTA. Acute nephritis is most frequently met in association with common in acute infectious and contagious diseases, especially scarlatina, cable diphtheria, and pneumonia. Less frequently it occurs as a result of exposure to wet and cold; of structural alterations of the skin, e.g., extensive burns ; of ingestion of certain irritants to the kidneys, e.g., cantharides, potassium chlorate, aspidium, etc., and, finally, not rarely it is observed in infants suffering from gastroenteric affections. The aforementioned causes usually operate upon both kidneys, so that both kidneys are equally affected. The lesion may, however, remain limited to one kidney where the disease is caused by direct, unilateral trauma. The seat of the kidney lesions varies somewhat with the cause. For example, the glomeruli (glomerular nephritis) are most severely involved in scarlatina, while in diphtheria we most commonly find degenerative changes in the renal tubules (degenerative or Parenchy- ° ° . matous. parenchymatous nephritis). But no particular form of acute nephritis is peculiar to a given cause. In severe cases the kidneys are greatly increased in volume and weight. The surface is smooth and the capsule readily removable. The renal cortex is either uniformly reddened or pale and mottled with red. The tubuli uriniferi are partly or completely obstructed by large granular epithelial cells, blood-corpuscles and fibrin. In the early stage of the disease the interstitial tissue shows no altera- tion; in protracted cases, however, this tissue may suffer very severely. In this event the process is often spoken of as pro- Interstltial - ductive or interstitial nephritis. Consonant with the etiological factors we distinguish a primary and secondary form of acute nephritis, but, except for some slight difference in the onset (it being more sudden in primary nephritis), the symptomatology is practically the same in both varieties. The child complains of backache, headache, nausea and chilliness, occasionally vomits, and. in severe forms, shows (117) 44S DISEASES OF KIDNEYS, BLADDER, ETC. other symptoms of grave constitutional disturbance. Not infre- quently attention to the illness is not attracted until the appear- Edema. ance Q £ p U ffi ness f the eyelids, or, especially in infants, the occurrence of partial or total suppression of urine with or with- out uremic symptoms. Examination of the urine discloses more or less marked alteration in its constituents. Chemically the urine almost invariably reveals the presence of a variable amount AI and Ui casts a °^ albumin, and, microscopically, casts of all sorts, especially hyaline, red and white corpuscles, epithelium, detritus, etc. The urine is usually acid, and its specific gravity high, the latter being, Hematuria. Fig. 139. — Acute Hemorrhagic Nephritis. X 350. Small and large squamous epithelium, hyaline casts (at the margin), g, Finely granular cast, bl, Red blood-corpuscle cast, e, Tubular epithelium (arranged in cast form). Here and there are blood- corpuscle rings ("shadows" [ghosts]). {Lenhartz and Brooks.) of course, most marked when the quantity is very small. The secretion of urea is diminished. In severe inflammation of the kidneys the urine contains a large quantity of blood (hemorrhagic nephritis), and is dark-red or smoky in color. As already alluded to, the onset of nephritis often escapes detection. This is especially true in the secondary form. Hence the importance of systematic examination of the urine during the course of acute communicable diseases. It is well to remember, however, that not every albuminuria is of nephritic origin. A small quantity of albumin and a few casts are not rarely found in acute febrile diseases (e.g., in the beginning of scarlatina) without kidnev lesions and are onlv transitory in nature. NEPHRITIS ACUTA. 449 Cases running a favorable course begin markedly to improve after about two weeks. The albumin diminishes ; the urine in- creases in quantity, becomes light and clear, and the microscopic abnormal constituents subside. Edema, if present, is slight, and usually limited to the eyelids and rapidly disappears with the improvement of the other symptoms. Fig. 140. — Acute Nephritis with General Anasarca in a Child 4 Months Old. (Sheffield.) Less favorable cases are of longer duration. From day to day the edema assumes wider dimensions, involving the dorsi of Malignant the feet, the legs, the genitalia, and, if not checked, the serous effusion may rapidly fill the abdominal and thoracic cavities. In the majority of instances, however, gradual recovery from the immediate attack occurs, although in these cases a relapse must always be apprehended. 20 450 DISEASES OF KIDNEYS, BLADDER, ETC. Oliguria up to anuria. Uremia. Another group of cases is characterized by great diminution of urine (oliguria) or total suppression and consecutive uremia. The latter is manifested by intense headache, dizziness, vomiting, dimness of vision up to total blindness, disturbance of hearing, slight twitching up to repeated attacks of severe convulsions, slow, irregular pulse, dyspnea, somnolence, sopor and possibly coma and death. Fig. 141. — Same case as Fig. 140. Three weeks later. (Sheffield. 1 The incipient symptoms of nephritis offer no reliable indica- tions as to the further course of the disease. Scarlatinal neph- ritis, for example, ushers in with vomiting, intense headache, con- vulsions, local or general dropsy, and yet clears up completely within two or three weeks; and, conversely, nephritis may set in insidiously, apparently entirely free from any alarming symptoms, and. nevertheless, proceed a very protracted course and possibly lead to permanent degeneration of the kidney structures. Furthermore, relapses may complicate matters often when recovery is imminent. NEPHRITIS ACUTA. 451 The prognosis, therefore, should always be guarded, even though the general condition of the patient is good. Even in mild cases untoward complications are apt to supervene. Serous effusions in internal cavities are not rare. This is true especially Ascites. of ascites, less frequently of pleural or pericardial effusions. The heart rarely escapes involvement. Hypertrophy of the heart is hypertrophy. quite common, and if the nephritis runs a protracted course dilatation of the heart may prove a very dangerous complica- tion, particularly in view of the secondary pulmonary edema, edema. nar ' which is very prone to occur in such cases, and often prove fatal. Extensive anasarca with scanty urine, especially if ascites is associated with hydrothorax, greatly mars the prognosis. As further complications we may mention uremia, pneumonia, tions. edema of the glottis, severe intestinal catarrh, more rarely peri- tonitis, pericarditis and endocarditis (more frequent in scarlatinal nephritis). Notwithstanding, however, the great array of com- plications, immediate death from acute nephritis, especially from the primary variety, is not common. The death rate ranges between five and twenty per cent. — the variation depending upon the primary cause, mode of treatment and severity of the compli- cations. A great many patients who survive the acute stage remain invalided for life. As we shall see later, gradual transi- ... Chronic tion from acute into chronic nephritis is not of uncommon occur- course. rence. Convalescence is often prolonged for weeks and months, and even without permanent injury to the kidneys albumin may recur in the urine from time to time for a period of a year or two or longer and continue to undermine the child's constitution. Every case of nephritis, be it ever so mild, should be taken seriously, and kept under strict observation not only during the active stage of the affection but for many months after. During the acute stage perfect rest in bed should be enjoined and the diet Rest limited to bland articles of food free from salt, preferably milk in moderate quantity with strained oatmeal or barley, zwieback Restricted with sweet butter, stale bread with a little apple sauce, and occa- sionally a little chicken soup. The partaking of water should be restricted to a few tumblerfuls of Vichy or lithia water per day. As the condition improves the dietary may be augmented by the addition of freshly boiled — without salt — vegetables, such as carrots, spinach, cauliflower, fresh green peas, etc., stewed fruit, and freshly boiled whitefish. The bowels should be kept open Laxatives bv an occasional dost' of calomel followed by citrate of magnesia 452 DISEASES OF KIDNEYS, BLADDER, ETC. and by daily high intestinal irrigation. Where the excretion of urine is greatly reduced and the dropsy marked, energetic measures to relieve the kidney should be instituted without delay. This should be attempted, not, as is frequently advised, by means of active diuretics — which only help to increase the renal con- gestion — but by stimulating the activity of the skin and allaying Hot baths; the irritation of the kidney. For this purpose we resort to hot flushing, packs (105° F.), hot baths (103° F.), and hot colon flushing (110° F.). These may be repeated every six hours. Perspira- tion may be stimulated by small quantities of hot water, or hot lemonade. In hemorrhagic nephritis small doses of ergot act beneficially. Camphor will be found valuable to counteract camphor, collapse, and should be administered hypodermatically in the form of sterilized camphorated oil. Excessive irritability of the nerve system should be combated by means of the bromids and chloral. By carefully following the aforementioned directions, uremia Arrest of j s f rare occurrence. Uremic convulsions should be controlled uremia. by chloroform inhalation, hypodermatic injection of morphine and atropine (for a child two years old gr. % 2 °f morphine, and gr. y 5() Q of atropine, if necessary to be repeated once after two hours), and, where these therapeutic measures fail, by lumbar puncture. Children recovering from nephritis should not be exposed to After-treat- the ill effects of overfeeding, overexertion, and exposure to ment. . . marked atmospheric changes. They should wear light woolen underwear, and, financial means permitting, should spend the winter following an acute attack of nephritis in a warm climate. To overcome the remaining anemia, iron and cod-liver oil will be found of service. NEPHRITIS CHRONICA. In the majority of instances chronic nephritis develops as a sequel of the acute affection of the kidneys. The parenchyma or interstitial tissue or both remain permanently impaired. On the one hand, we may find the kidneys greatly enlarged, the cortical portion increased in volume, its surface white or pale- yellow — large white kidney or parenchymatous nephritis. On the other hand, the whole organ is reduced in size, the capsule firmly adherent, and the surface irregular and nodular — the kidney! granular or cirrhotic kidney, or interstitial nephritis. Amyloid Large, white kidney. NEPHRITIS CHRONICA. 453 degeneration is another form of chronic nephritis in childhood. It is usually associated with amyloid degeneration of the liver and spleen, and ordinarily occurs secondarily to suppurative processes of the bones or joints. Occasionally chronic nephritis is encountered in connection with congenital malformations of the kidneys, or as result of hereditary syphilis, tuberculosis, and heart disease. In the early stages of chronic nephritis the diagnosis rests principally upon the chemic and microscopic findings in the Findings in .... .... urine. urme. In parenchymatous nephritis the quantity of urine is normal or diminished, the specific gravity normal or increased, the albumin content high, and the color cloudy, brownish yellow or bloody. In interstitial nephritis the quantity of urine is increased, the specific gravity low, the albumin content low (occa- sionally no albumin), and the color clear, and pale. In amyloid degeneration the urine is rich in serum-albumin and globulin. Its quantity is often increased. Casts in the urine are present in all varieties. With further advance of the disease, the appearance of pro- found anemia, digestive and respiratory disturbances, local and Anemia, general dropsy, and cardiac debility readily discloses the under- lying condition. Toward the end of life the symptoms resemble Hear i ms greatly those of non-compensating heart disease. Parenchymatous nephritis offers the worst prognosis, death usually setting in within a year from the appearance of the secondary symptoms. The course of interstitial and amyloid nephritis is much more protracted and cases of amyloid kidney are on record which markedly improved on removal of the suppurative bone affection, but complete recovery is practically out of question. Under suitable treatment (except in the parenchymatous variety) life may be prolonged for many years. As in acute |f e ' t t " free nephritis, the diet should be free from salt, but otherwise more liberal. Older children may live on a mixed diet ; the following food-stuffs, however, are to be exempt from the list : Liver, ham, brains, kidneys, beef-juice and beef-extract, coffee, liquors and ^e^vo^ed spices. All meats, eggs and fish should be taken sparingly. Whenever possible, the child should live in a warm climate. Out- door life and very light exercise are desirable. Daily warm baths with gentle massage act beneficially. With appearance of dropsy, dyspnea, or other grave symptoms, the patient should be put to Hematinies. 454 DISEASES OF KIDXEYS, BLADDER, ETC. bed and treated in the manner outlined tinder "acute neph- ritis" ( q. v.). Hematinies, in small doses, and other tonics in the form of cod-liver oil, mix vomica and digestants are in order as necessity arises. Excessive dropsical effusions should be relieved by active catharsis, alkaline diuretics, and heart stimulants, in addition to the therapeutic measures recommended in dropsy accompanying acute nephritis. NEPHROLITHIASIS (Stones in the Kidney; Renal Calculi). sudden Renal calculi in children give rise to symptoms identical with attacks. t j lose k servec i j n adults. Thus, sudden attacks of pain in the lumbar region, radiating downward along the course of the ureters, groins, and, in the male, to the testicles. The attacks are usually associated with nausea, vomiting and convulsions and often collapse. The urine is passed frequently, in small quan- pyuria! tities, and contains blood- and pus-cells. The urine, however, may appear normal if it is excreted from the healthy kidney only, or there may be complete anuria if both ureters are simultaneously obstructed. Where the stones remain impacted in the ureter, the condition is apt to become very grave in consequence of nephrosis, supervening hydronephrosis, pyonephrosis or pyelonephritis. In this event we are often obliged to resort to surgical interference. ( )therwise symptomatic treatment usually suffices to effect marked improvement or even a cure. Alkalies should be administered in Specific . . . . .... medication, uric acid coucrements, sodium phosphate in oxalic acid, and citric acid and acetic acid in phosphatic concrements. The diet should be bland (avoidance of meat), and metabolism enhanced by digestives, mild laxatives, moderate exercise, hydrotherapy Anodynes, and massage. To relieve an attack we resort to anodynes (morphine and atropine hypodermatically), hot baths and hot poultices. An X-ray examination is often decisive in the diagnosis between nephrolithiasis and appendicitis, with which affection the former may lie confounded. PYELITIS, PYELONEPHRITIS, PYELONEPHROSIS. Inflammation of the pelvis of the kidney and contiguous RenaJ structures with consecutive suppuration may occur as a result of stones. di rec t injury of the lining mucous membrane, e.g., renal stones; HEMOGLOBINURIA. 455 as a sequel of infectious diseases, such as scarlatina, diphtheria, variola, or pyemia, or by extension of a suppurative process from the neighboring tissues or organs, e.g., perinephritic abscess, cystitis, colicystitis, purulent vulvovaginitis. It is also met in coiicystms. connection with congenital malformations of the kidneys or ureters, renal tuberculosis and tumors. The pyelitis may be unilateral (when due to a local cause) or bilateral. The symptomatology of pyelitis varies greatly with the cause and the course it pursues. In acute cases there are rigors, high fever"' and fluctuating temperature, frequent and scanty urination, pain in the lumbar region, and, above all, pyuria. The morphological constituents of the urine vary with the degree of involvement of the kidneys, ureters and bladder. Cases proceeding a chronic course are ordinarily free from febrile excursions. Pyonephrosis Tumefaction, often gives rise to a palpable tumor. There are a number of other symptoms which vary with the primary or secondary disease. Where the cause is removable, and prompt treatment is insti- tuted, the pyelitis may entirely disappear and leave the kidney uninjured. Otherwise the prognosis, as to complete recovery, is bad. The prognosis as to life depends entirely upon the exciting cause and complications, nephritis and exhaustion forming the principal sources of danger. The aim of treatment, therefore, should be to avoid the latter „ Prevention by earlv elimination of the fundamental disease, and prevention of recur- J - 1 rence. of recurrence of attacks. The details of such treatment are fully outlined when speaking of the diseases in question. Otherwise the treatment is symptomatic. The urine should be rendered alkaline, and as aseptic as possible. This is best accomplished operation, by a liberal supply of water, alkaline diuretics and hexamethyl- enamin. Pyonephrosis calls for surgical interference. HEMOGLOBINURIA. Hemoglobin or methemoglobin in the urine is occasionally observed in infants and older children, either as a result of J oxic drugs. poisoning by phosphorus, potassium chlorate, carbolic acid, etc., or in connection with severe burns, acute and chronic infectious dis- eases, such as exanthemata, malaria, and hereditary syphilis. The urine is mahogany-brown or black in color, greatly resembling ^ m °g y blood\- urine. Microscopically, however, it shows the presence 456 DISEASES OF KIDNEYS, BLADDER, ETC. No blood, of blood coloring substance only, but no blood-corpuscles. The spectroscope discloses bands of hemoglobin. The attacks of the hemoglobinuria are of brief duration (sometimes last but a few hours), and are manifested by debility, chilliness, cyanosis, and sometimes high fever. These symptoms disappear as the urine clears up. Occasionally the hemoglobinuria appears in paroxysms Paroxysmal, (paroxysmal hemoglobinuria) without any discernible cause or after exposure to cold or undue fatigue. By rest in bed, liberal supply of liquids, and attention to the exciting causes, the hemoglobinuria subsides without any serious consequences. (See also "Epidemic Hemoglobinuria," page 182. ) ORTHOTIC, CYCLIC OR FUNCTIONAL ALBUMINURIA. As the term (orthotic = standing up) indicates, the disease is absen^wheS characterized by the presence of albuminuria after the patient pa at ei rest s ^ as been U P an d around, and by its absence while he is perfectly at rest. It is observed especially in delicate children of from five to fifteen years old, and seems to have nothing in common with organic kidney disease. A family predisposition has been traced in some cases, and a history of scarlatina and diphtheria in others. The urine is free from abnormal morphological con- stituents — the opposite being the case in true renal disease. Under suitable treatment, which is essentially the same as in the early stage of chronic nephritis, the albuminuria often dis- appears for a time, but may return after a shorter or longer interval (intermittent form). Notwithstanding the continuance of the albuminuria for many years, the system is very little affected by it, and the prognosis as to life is good. Transition of cyclic albuminuria into nephritis, however, is on record. TUMORS OF THE KIDNEY. Aside from tuberculosis and syphilis, which have been dis- Benign. cussed elsewhere, the kidneys are occasionally the seat also of benign and malignant neoplasms. The benign tumors (adenoma, fibroma, lipoma, cysts, etc.), owing to their very slow growth, generally escape observation, and are often found post mortem in children who, during life, never manifested signs of kidney Malignant, growths. To a great extent this is true also of malignant tumors (sarcoma, carcinoma, myosarcoma and adenosarcoma) in their TUMORS OF THE KIDNEY. 457 early stages of development, since the tumor is barely palpable and the two additional characteristic symptoms of malignant kid- ney growths (i.e., hematuria and cachexia) are present in only Hematuria, a small percentage of such cases and is encountered also in a number of other wasting diseases. In the beginning the tumor may be felt only in the loin ; within a few months, however, it is found to have spread in all direc- Fig. 142. — Sarcoma of the Kidney (child 27 months). The tumor occupied almost the entire abdomen. (Sheffield.) tions, displacing the liver, spleen, lungs and intestines, and to palpable occupy the entire abdominal cavity (see Fig. 142). Not rarely umor ' it forms secondary metastases in the other kidney, in the liver, Metastas spleen, intestines and retroperitoneal glands, and, by pressure upon the ureter, may give rise to hydronephrosis. Unless operated upon early — which treatment should invari- Early ably be recommended — the children usually succumb to progres- sive emaciation and exhaustion within about a year from the time the tumor makes itself felt. As the majority of growth is of antenatal origin nothing can be done in the way of prophylaxis. operation. Colicystitis. 458 DISEASES OE KIDNEYS, BLADDER, ETC. CYSTITIS. Inflammation of the bladder may occur as a primary or secondary disease. Primary cystitis is extremely rare in children, more especially in infants, since the principal cause — direct mechanical injury of the mucous membrane by surgical instru- ments or other foreign bodies — is but very rarely operative in young children. On the other hand, secondary cystitis is of com- paratively frequent occurrence, and may arise from a great many causes, the most important of which being infectious dis- eases (diphtheria, scarlatina, etc.), kidney and bladder diseases (calculi, pyelitis, tuberculosis, tumors, etc.). cerebrospinal affec- tions (atony and overdistention of the bladder with consecutive inflammation by decomposed urine), intestinal diseases (invasion of the bladder by colon bacillus — colicystitis), and diseases of the vagina and urethra, especially of gonorrheal origin (by exten- sion of the inflammation). Cystitis may follow chemical irrita- tion (overdoses of cantharides, balsams, liquors, etc.), exposure to cold (sitting on cold stones, etc.) and direct external violence. The lesions in the bladder may range from simple localized redness to extensive ulceration of the mucous membrane and Extension pseudomembranous deposit. In cases of long standing the inflam- mation is prone to spread to the ureters and kidneys. In chronic cystitis the mucosa assumes a gray, pigmented color, becomes greatly hypertrophied, and covered by mucopurulent masses. In accord with the severity and extent of the lesion cystitis may be manifested by mild or grave symptoms. The latter are most pronounced in primary cases, in those associated with infec- tious diseases (e.g., diphtheria), and in infection by the colon bacillus. In mild cases the symptomatology consists of painful strangury. anc i frequent micturition, sensitiveness over the region of the bladder, sometimes rectal tenesmus and excoriation of the urethral orifice and of the contiguous structures. The urine is voided in small quantities, sometimes only a few drops at a time, and contains mucous shreds, bladder epithelium, pus- isiood. corpuscles, blood-corpuscles, and numerous bacteria. The urine is neutral or alkaline, cloudy and dark red, and may contain Acid urine Pi eces °f membrane if the cystitis is of diphtheritic origin. In in coil- colicystitis the urine is usually acid in reaction, and in addition cystitis. - to the aforementioned constituents presents traces of albumin. The constitutional symptoms are slight. Severe forms of cystitis, especially colicystitis, give rise to marked constitutional disturb- diet. Hyoscyamus. CYSTITIS. 459 ances, such as vomiting, chills, irregular fever, and sometimes ^^"j convulsions (particularly if anuria exists). The local symptoms symptoms vjr J J tr especially in also are much more pronounced. If left to run its course, the coiicystitis. condition is not rarely aggravated by the concurrence of nephritis, which may lead to a fatal termination. As it is not always possible in the beginning to foresee the eventual course of the disease, and as the tendency even of mild cases towards chronicity is great, it is essential not to trifle with the affection, but promptly to employ all such therapeutic measures as will insure its early arrest and ultimate cure. The Restricted patient should be put to bed and on a mild diet (milk and Vichy water, milk-gruel, chicken soup, eggs, cereals and bread). All spices, alcoholic beverages, coffee and tea should be prohibited. To relieve pain, hyoscyamus is the remedy par excellence. It may be combined with acetate of potash and small doses of hexa- methylenamin. Warm Priessnitz compresses are also of value. Where the pain persists, a suppository of codeine and extract of belladonna will be found to act well. With subsidence of the acute symptoms — usually after a week or two — it is advisable to begin to irrigate the bladder (under the most careful aseptic precautions) with a warm solution (% oo or /4ooo) °f nitrate of silver or potassium permanganate. From half a pint to one quart of the solution may be used for each treatment, and the irrigation may be repeated once a day or every other day. Under this method of treatment the majority of cases of cystitis will recover in from four to eight weeks — provided, of course, the primary cause can be detected and removed. Transition of acute cystitis into chronic is by far less common Tendency to in children than in adults. The possibility of the disease being chronicity. tubercular should always be borne in mind (see page 370). R Kalii acetatis 3j 4 Ext. hyosciami fl gtt. xvj 1 In f . uvse ursi V] 30 Aq. anisi q. s. ad §ij 60 M. Sig. : 3j, in water, every three to six hours for a child 3 j^ears old. R Hexamethylenaminse gr. xvj | 1 Natrii benzoatis 3ss 2 Ext. belladonnas fl gtt. iv 0.3 Mucilaginis ulmi 3iv 15 Aq. fceniculi q. s. ad foij 60 M. Sig. : 3j, in water, every four hours for a child 3 years old. (In coiicystitis.) Sec also "Biologic Therapeutics." page 96. Irrigations. 460 DISEASES OF KIDNEYS, BLADDER, ETC. VESICAL CALCULI (Stones in the Bladder). Bladder stones sooner or later give rise to the following characteristic symptom-complex : Vesical and often rectal tenes- strangury. mus, strangury, partial or complete retention or incontinence of interrupted urine, difference in the force of the stream of the urine with urine, change in posture of the patient, and, after a protracted course, the usual symptoms of cystitis (q.v.). The urine may reveal the presence of either phosphate stones (phosphate and carbonate of lime, magnesia), oxalate stones (oxalate of lime) or urate stones (uric acid). Small concrements may escape with the urine; impacted large ones, however, are apt to become impacted in the urinary canal and cause intense pain and grave nervous symptoms, e.g.. convulsions. The diagnosis is based upon the aforementioned manifesta- tions, upon feeling the stone in the bladder by rectal digital examination or by a sound introduced into the bladder, and upon x-ray. an X-ray examination. The development of stones may frequently be prevented by a bland diet (no meats), ample supply of water, and attention to Anodynes, the bowels. In cases of long standing operative interference is indispensable. Painful symptoms are relieved by means of hyoscyamus. SPASMUS VESICA, DYSURIA, ISCHURIA (ANURIA). These conditions are etiologically correlated. In the majority calculi, of instances they are the result of vesical calculi, blood-clots obstructing the urinary flow, phimosis, paraphimosis, vulvitis and vaginitis, cystitis, uric acid infarcts (in the newly born), sudden chilling of and injury to the lower portion of the abdomen, nerve affections (functional or organic), and priapism (in the male). The treatment varies with the original cause. An attack is usually relieved by a hot bath, a suppository of codeine and extract of belladonna, and the administration of diuretics, such as sweet spirits of niter and triticum repens. R Kalii citratis 3j ! 4 Ext. hyosciami fl., Ext. triticum repens fl aa oss 2 Syr. simplicis 3iv 15 Aq. destil q. s. ad f3ij 60 M. Sig. : 3j, in water, every three to six hours for a child 3 years old. Uric acid infarct. ENURESIS. 461 ENURESIS. Atony. Spasm It is customary to distinguish two varieties of enuresis in children : Enuresis diurna and enuresis nocturna. The first Diurna and variety is but rarely met in children, capable of differentiating nocturna. right from wrong, excepting in those who willfully "wet" them- selves, or in congenital deficiencies. The second variety, on the other hand, occurs in a very great number of children, regardless of age, sex, intelligence or social conditions. The child may wet itself one or more times every night, or at intervals of days or weeks ; in the last event, it is usually due to willfulness, excessive drinking, or faulty diet. An inherited tendency and neurotic disposition seem to play an important part in the causation of enuresis, although the latter may exist independently of either of these causes in children apparently perfectly healthy. The causes of enuresis may conveniently be arranged in two classes : — 1. FUNCTIONAL. The cases due to functional causes are purely neurotic in character. The urine is voided involuntarily either owing to atony of the sphincter vesicse, or to a spasmodic condition of the detrusors vesicse. In both cases there is a functional disturbance in the nervous apparatus of the urinary system. It is usually found that enuresis due to atony is associated with general debility, and often follows a protracted course of an exhausting disease. On the other hand, enuresis due to "spasm" is usually found in children who are irritable, who present an increased patellar reflex, are easily frightened, are subject to pavor noc- turnus and similar nervous conditions. 2. ORGANIC. The greater number of cases arise from organic troubles. The child may suffer from : — Organic disease of the spinal cord ; cystitis ; phimosis or para- phimosis (in the male) ; hypertrophy of the clitoris or adhesion of the prepuce (in the female); masturbation; undescended testicle ; hernia ; worms ; vesical and renal calculi ; tumors in the bladder; excessive quantity of lithiates or phosphates; con- stipation and accumulation of feces ; epi- or hypo-spadia ; fissure ani ; vulvovaginitis ; diabetes, gonorrhea, simple or gonorrheal proctitis. Local and systemic affections. 462 DISEASES OF KIDNEYS, BLADDER, ETC. In the treatment of enuresis it is of greatest moment to systematically examine the patients for the organic diseases just enumerated and to endeavor to eliminate every symptom suspicious of organic disease. In absence of organic causes there is evidently a neurotic case to be dealt with and the treatment must be adopted accordingly. Patient if old enough should be instructed not to abstain from micturition when called upon habit by nature to do so. and small children should be trained to void urine about every three hours, and not be permitted to withhold the urine for a longer period. This is very important, for it is often overdistention of and decomposition of the urine in the bladder that prove the primary cause of the subsequent secondary etiological factors (atony or hyperesthesia of the bladder, pres- ence of concretions, cystitis, etc). It is also advisable to en- courage drinking of water in cases of enuresis due to concretions, cystitis, or gonorrhea, but to forbid it in other cases. The patient is not to be permitted to sleep on his back, and it is often of advantage to raise the foot of the bed in such a manner that the child's trunk and head lie deeper than the pelvis. In enuresis due to atony a general constructive treatment is indicated. Plenty of good nourishment, change of air, cold spinal douches, medicinal tonics and electricity are usually effective in bringing about a cure. A moderate galvanic current is usually best; one pole is applied to the symphysis or rectum, the other to the perineum. The following mixture is often very serviceable : R Ext. ergotae £3ilj | 12 Ext. rhus tox f3j | 4 M. Sig. : Five to 10 drops every four to six hours to a child 6 years old. In incontinence of urine associated with hyperesthesia of the Antispas- collum vesica? or spasm of the detrusors, an antispasmodic treatment is indicated, consisting of hot sitz-baths, avoidance of irritating food or drinks and the administration of either ext. belladonna or hyoscyamus. I usually prescribe the following: — B Ext. hyoscyami 3ss | 2 Natrii bromidi 3j | 4 Aquae anisi 3j I 30 Syrupi simplicis q. s. ad 3ij j 60 M. Sig.: One teaspoonful every four to six hours to a child 6 years old. Counterirritation by means of sinapisms over the lumbo- sacral regions often does well, and if everything fails this class VULVOVAGINITIS. 463 of cases is occasionally cured by gradual dilatation of the posterior urethral canal. As to the treatment of enuresis from organic causes, nothing more will be said here than that each case must be treated as an individual disease in accordance with its etiology. Remonstrance, severity and moral suasion will often cure Moral cases of enuresis of nervous origin or those which continue from mere habit long after removal of the original cause. VULVOVAGINITIS. Notwithstanding recent advances in bacteriology and micros- copy, the profession is not as yet in accord as to the exact nature of vulvovaginitis in children. Some physicians still doubt the fact that most cases are due to the gonococcus of Neisser and are highly contagious, but tenaciously cling to the "scrofulous" theory of the disease and recommend tonics to combat it. As a result, innumerable cases run at random, leaving sources of contagion in public schools and baths, homes, and hospitals, with apparently no one in authority to check the further spread of the affection. Clinically vulvovaginitis may be classified as follows : — 1. Catarrhal vulvovaginitis, which is generally due to (a) lack of cleanliness or (&) chemical irritation. 2. Traumatic vulvovaginitis, which is caused by (a) mastur- bation (?), (b) mechanical injury, or (c) indecent violence. 3. Parasitic vulvovaginitis, which is clue to (a) oxyurides, (b) saprophytes, or (c) pathogenic bacteria, especially the gono- coccus. The first variety of vulvovaginitis is usually met in poorly Catarr nourished children of overcrowded tenement districts, who receive a thorough cleansing on very special occasions only. As a rule, these cases begin with vulvitis, the vagina becoming gradually involved by extension of the inflammation. Catarrhal vulvovagi- nitis is not always limited to the very poor, and the physician need not hesitate to suspect dirt even under the most elaborate Dirt apparel. This varietv of vulvovaginitis is also frequently observed in P 11 ?" 1 ^ children whose genitalia arc exposed to excessive wetting by irritating, decomposing secretions, and excretions — sweat, diar- rheal stools, hyperacid urine — and to undue pressure and friction. Mastur- Foreign 464 DISEASES OF KIDNEYS, BLADDER, ETC. In former years, when bicycle riding was a national fad, vulvo- vaginitis was not rarely met in assiduous bicycle riders, undoubt- edly as a result of the aforesaid causes. The consideration of the second, traumatic, variety of vulvo- vaginitis does not, strictly speaking, belong to the domain of medicine, except as regards the treatment. We are dealing here with faulty habits and criminal traits which deserve serious atten- tion on the part of teachers, the clergy, and jurists. However, as it is the physician who is usually consulted first, a few points of information will prove useful to him, particularly as a warning not to be too hasty in expressing a positive opinion. I believe that entirely too much stress is being laid by some bation. authors upon masturbation as an etiological factor of vulvo- vaginitis. It is much more probable that masturbation is a result rather than a cause of it, the undoubtedly existing irritated state of the erectile tissue inducing that bad habit. The presence of foreign bodies in the vagina is not infre- quently found to be the cause of vulvovaginitis. While some girls will introduce foreign bodies in the vagina with lascivious bodies, intent, the great majority of foreign bodies, e.g., safety pins, will find their way in the vaginal canal accidentally, and should always be looked for, particularly in cases of long standing. Occasionally cases of vulvovaginitis are encountered which are the result of indecent violence. The purulent discharge is either non-gonorrheal or gonorrheal, the latter only if the criminal who attempted rape had at the time been suffering from gonor- rhea. It is well to remember that not every case of vulvo- vaginitis reported to be due to rape is really such, and unless the vaginitis is associated with actual penetration of the hymen and concomitant signs of inflammation due to violence, the physician should be very cautious in venturing a positive opinion. Saprophytic micro-organisms are responsible for a great number of cases of vaginitis. To them is attributable the vagini- tis not infrequently met after acute exanthematous diseases (with or without desquamation) and in conjunction with divers forms of cutaneous eruptions. The same cause accounts also for the vaginitis observed in strumous and debilitated children suffering from purulent discharges from the nose, ears, etc. Indeed, the number of cases of saprophytic vulvovaginitis would by far exceed all those arising from all other sources collectively were it not for the antagonistic action of the bacillus of Doederlein Rape. VULVOVAGINITIS. 465 which normally inhabits the vagina. This vagina bacillus, which is anaerobic and may be cultivated on ordinary media, produces lactic acid during its growth, a quality to which is due the presence of lactic acid in the healthy vagina. In its presence saprophytes, as well as numerous other bacteria, such as the saprophytic, staphylococcus and streptococcus, are unable to develop, and within a short time perish. Gonococci, however, do not yield as promptly to the destructive effect of the vagina bacillus ; hence the frequency with which gonorrheal vulvovaginitis is met, not- withstanding the resistance offered to the entrance of gonococci into the vagina by the stratified squamous epithelium lining it. As stated before, contamination of the vagina by criminal assault is comparatively very rare. Much more frequently infection takes place by voluntary sexual act or accidentally. Little girls sleeping with their parents, elder brothers, sisters, or nurses suffering from gonorrhea, may contract the disease by coming in contact with soiled bed-clothes, cotton pads, or other articles used for cleansing purposes. Gonorrheal vulvovaginitis runs a more or less virulent course, Gonorrheal. and in hospitals and asylums where many children are con- gregated in comparatively close quarters, and frequently make common use of infected bathtubs, toilets, etc., the disease is very apt to become epidemic as well as endemic. In one epidemic under my care, in an orphan asylum, comprising over one hundred cases, it required many months of very active treatment to eradicate the affection. Arrest of further spread of the gonorrhea was not effected until every patient was isolated and kept in bed for several weeks. A biweekly examination of every female inmate of the institution (including the nurses in charge) for vaginal discharge was continued for several weeks after dis- appearance of the last case of vaginitis. Such procedures form the main prophylactic measures against the disease. Of course, the patients must be restricted from the Prevention common use of chambers, bedding, bathtubs, etc. In hospitals and asylums, admitting physicians should be particularly careful to exclude all children having a purulent vaginal discharge, unless provisions be made for the isolation and treatment of such cases. This point is well worthy of consideration, as it would greatly aid in checking further transportation of the disease. As the majority of cases of vulvovaginitis is observed among school- children, a suggestion to the health authorities is, perhaps, in 30 Prophylaxis. of epidemics. 466 DISEASES OF KIDNEYS, BLADDER, ETC. order, viz., to instruct the school inspectors to pay more attention isolation, to the detection and isolation of the cases of gonorrhea in chil- dren than they do now. As gonorrhea in adults, that of children presents a marked tendency toward grave complications. Among 148 cases under compiica- my care, the following serious complications were observed : ; ' Purulent ophthalmia, 7; local peritonitis, 4; proctitis, 3; arthritis, 4; adenitis, 12. Several cases of pyosalpinx, endocarditis, and pleuritis are on record. However, the more familiar one becomes in eradicating it, the less numerous will become the complications and sequelae in his new cases. After extensive experimenting I found that gonorrheal Prevention ophthalmia can best be prevented by frequent cleansing of the rneai genitalia and hands of the patients, and by the employment of a large, tightly fitting vulvar pad. The latter should be changed for a clean one at least every three hours. The child should wear one-piece night-drawers during the night as well as day. The ophthalmia may sometimes be arrested in its incipiency — I suc- ceeded in two cases — by instillation of silver solutions after Crede's method. In view of the unusually rapid progress of the ophthalmia, unfortunately, it is not often that the physician has the opportunity to resort to the prophylactic measures, and nothing else remains but to treat the disease actively and skillfully, and, if not already involved, to endeavor to save the other eye from the dreadful infection. Involvement of the uterus and adnexa secondarily to gonor- rheal vulvovaginitis in most instances results from injudicious Danger of use of douches by forcing the vaginal discharge upward into the douching, uterus, Fallopian tubes, etc. The treatment therefore should not be intrusted to the inexperienced. I believe that I am entitled to the credit of having been the first to call attention (American Medico-Surgical Bulletin, May Gonorrheal 30, 1896) to the occurrence of gonorrheal proctitis as a compli- cation of vulvovaginitis. The rarity with which this complica- tion is observed, notwithstanding the constant exposure of the anus to the gonorrheal vaginal discharge, would seem to prove the comparative immunity of the skin and mucous membrane of the anus and rectum to gonorrheal infection. Moreover, proctitis usually does not develop until late in the course of the vaginitis, i.e., until the skin of the anus and the adjacent struc- tures has become abraded and denuded by the continued irrita- VULVOVAGINITIS." 467 tion of the vaginal discharge, or by scratching for the relief of the ' not infrequently accompanying intense itching. The diagnosis of gonorrheal proctitis is rendered positive by the presence of the gonococcus in the mucopurulent stools. Like the former complication, arthritis, the so-called gonor- Arthritis. rheal rheumatism, also develops late in the course of vulvo- vaginitis. In the majority of cases the inflammation is limited to one joint, usually that of the knee, and occasionally ends in sup- puration and ankylosis. Inguinal adenitis is quite a frequent complication. The glandular enlargement may increase up to a well-marked bubo. It sometimes suppurates as a result of an additional infection by pus microbes. The differential diagnosis between the different varieties of Differential vulvovaginitis can readily be made by bearing in mind the previously mentioned classification. No examination should be considered complete without a very careful microscopic scrutiny of the vaginal discharge. In doubtful cases a culture will settle the diagnosis. Furthermore, it is well to remember that several etiological factors may be operative in the production of the vaginitis in one and the same patient. Hence, the finding of pin- worms, for example, in the vagina should not lead us to conclude the absence of gonococci. The treatment of vulvovaginitis varies greatly with the cause. Non-gonorrheal cases usually yield promptly to removal of the etiologic factors {e.g., foreign bodies) and to cleansing of the cleanliness, genitalia with salt, boric acid, or sulphocarbolate of zinc solu- tions. Gonorrheal vulvovaginitis should be treated by instillation into the vagina (through a soft-rubber catheter) once a day or every other day of half an ounce of a 2 per cent, to 5 per cent, solution of nitrate of silver, followed by neutralization with salt Nitrate of . silver. water. After subsidence of the active symptoms douches with mild antiseptics will suffice. It is well to remember that recurrence of the affection after Tendency to recurrence. a period of latency is frequent even under the most careful method of treatment. No case of gonorrheal vulvovaginitis, therefore, should be considered cured unless three or more thorough microscopic examinations of the vaginal discharge prove the absence of gonococci and pus. 468 DISEASES OF KIDNEYS, BLADDER, ETC. MASTURBATION (Onanism, Thigh-friction). Production of venereal orgasm by hand, or other unnatural means, is a very common vice among school-children, who usually acquire the vicious habit from older playmates, or erotic governesses, etc. Occasionally masturbation is observed in younger children Thigh and even in infants. The latter may be seen to rub their thighs friction. a g a j nst eacr] th er or against the bosom of the nurse, or to exert peculiar rocking motions and fall back in a more or less marked state of exhaustion. The effects of masturbation vary with the frequency and duration of the habit and the psychical condition of the child. In Effects the majority of cases masturbation produces physical and mental "bation" debility, especially depression of spirits, headache, palpitation of suspicious the heart and emaciation. In boys we may suspect masturbation by excessive elongation of the penis, in girls by the presence of vulvitis, and often stretching of the hymen. Boys are apt to suffer from nocturnal seminal emission and later also impotence. Removal of In remedying this evil, it is essential to remove all local sources of irritation, such as phimosis, hypertrophy of the clitoris, pin- worms, etc. Infants should be restrained from practising the bad habit by mechanical devices (separation of the thighs, tying of the hands). Older children should be placed under proper Surveillance, surveillance and in suitable spiritual surroundings (change of school; nurses!). The general health should be improved by out- door exercise, cold shower baths, and by a nutritious but bland Tonics, diet (no liquors). Bromids are indicated to subdue sexual excitement. Dime novels should be eliminated from the child's reading room. GANGRENE OF THE GENITALIA. Diphtheria Vulvae, Noma Vulvae. Gangrene of the genitalia (vulva, penis, scrotum, etc.) usually develops secondarily to grave local inflammatory processes in the vicinity. More rarely it is primary in nature (after too liberal Drugs; use of strong antiseptic dressings in open wounds, e.g., carbolic diphiuleria! acid gangrene in circumcision; the result of direct violence, e.g , stuprum) or occurs in connection with diphtheria, dysentery, typhoid, and similar affections. MENSTRUATIO PR.ECOX. 469 Whatever the cause, the prognosis is always very serious, fatal termination usually taking place within about ten days from the onset, unless we succeed in checking the spread of the Caute ri- gangrene by early cauterization or excision of the affected part. zation - Diphtheria antitoxin is deserving of trial. fnmoxfn!* Fig. 143. — Precocity (child 8 years old). (Sheffield.) MENSTRUATIO PRECOX. Genuine precocious menstruation in early childhood is of very rare occurrence. If it does occur, it is usually associated with development, general bodily and mental overdevelopment. The diagnosis of menstruatio precox should not be made until vaginal bleeding Mistakes in r & o diagnosis. from local injury, from papillomatous growths, prolapse of the urethral mucous membrane, and hemophilia, has been excluded. Precocious menstruation, being free from serious consequences to the general health, calls for no therapeutic measures, except perfect rest during menstruation. CHAPTER XII. Diseases of the Blood and Ductless Glands. The grouping together of the affections of the hlood and ductless glands is intended to emphasize their correlation. They are of very common occurrence in children, especially in infancy and in those approaching puberty. At these periods of life, owing to the rapid bodily development, the blood-forming organs are taxed to their greatest capacity, and, hence, are very apt to suffer on slight provocation. The anemias of children are usually secondary, secondary in nature, only exceptionally primary. With the present inadequate state of our knowledge, however, no sharp line of demarcation can be drawn between the various types of blood disease. Only too often do we find the clinical and histo- logic aspects of simple secondary anemia merging into that of splenic anemia, and that of the latter disease into the one of leukemia. The same is true of lymphatic leukemia, chloroma, and lymphosarcoma. For the reasons just stated, therefore, no attempt will here be made to offer an -ironclad classification of the diseases in question. In studying blood disease it is well to bear in mind that the constituents of the normal blood vary within more or less wide limits, and that slight ailments are prone to produce marked disproportion between the number of red and white blood- corpuscles. At birth the number of red cells is about 6,000,000, and of white cells, between 20,000 to 30,000 per cubic millimeter. The hemoglobin is very high (about 110 per cent.) and the specific gravity 1066. After the second week the red cells fall to 5,000,000, and the white cells to about 15,000, the hemoglobin to 100 per cent., and the specific gravity to 1050. The red cells are fewer in number in the female than in the male. The percentage of the different leucocytes in infants presents the following variations: Polymorphonuclear neutrophiles, 28 to 50; poly- morphonuclear eosinophiles, J / 2 to 10; lymphocytes, 50 to 70, and large mononuclears, 6 to 14. The adult proportion is usually (170) Xormal blood. CHLOROSIS. 471 reached by the time the child is six years old. Then the number of leucocytes falls to about 10,000, presenting the following percentage : Neutrophiles, 65 to 75 ; eosinophiles, y 2 to 4 ; lympho- cytes, 20 to 30, and mononuclears, 1 to 4. Normally coagulation of the blood usually occurs within from two to five minutes. ANEMIA SIMPLEX, CHLOROSIS (Green Sickness). Both of these conditions present identical pathologic changes in the blood — reduction in the number of red cells, decrease of Reduction of r6 its outcome. The etiology of this affection is obscure. As a Fig. 144. — Pseudoleukemia Infantum Splenica. Note position of enlarged spleen. {Sheffield.) rule, it is observed in connection with pronounced forms of mal- nutrition, especially rachitis. The chief alterations in the blood are reduction of red cells and hemoglobin, the presence of many nucleated red corpuscles, and an increase in the number of leucocytes, mostly of the mono- nuclear type. This blood picture essentially corresponds to that of ordinary secondary anemia. In pseudoleukemia infantum, .".Oa Increased leucocytosis. 474 DISEASES OF BLOOD AND DUCTLESS GLANDS. Enlarged however, there is marked enlargement of the spleen and occasion- spleen. ° ally also of the liver and lymphatic glands. The general symptoms differ but little from those observed in severe anemia. The same applies to the treatment. The syrup of the iodid of iron with the syrup of the hypophosphites seem to exert a specific action in the majority of cases. Fig. 145. — Same case as Fig. 144 after three months' tonic treat- ment. Note reduction in size of spleen. (Sheffield.) LEUKEMIA (Leucocythemia). As the term indicates, leukemia is characterized principally High leuco- cytosis with Dy an abnormal increase in the number of leucocvtes (sometimes unusual J types of reaching as high as a million), and by the presence of unusual blood-cells. fc> & j ■ r types of these cells, i.e., Markzellen (myelocytes), JVlastzellen (nutritive cells), and giant basophiles. From a pathologic point PERNICIOUS ANEMIA. 475 of view it is customary to distinguish two forms of leukemia : 1. Lymphatic leukemia, in which the lymphatic glands are chiefly involved (hyperplasia), and 2. Splenomedullary or myelogenic form, in which the spleen (greatly increased in size) and the bone marrow (hyperplasia) are the principal seats of the lesion. Mixed forms also are encountered. The principal difference between the two forms of leukemia are the preponderance of lymphocytes in lymphatic and myelocytes in splenic leukemia. The red cells and hemoglobin are reduced in both varieties. The clinical manifestations are essentially identical with those of pernicious anemia, plus enlargement of the lymphatic glands, Lymphatic. Fig. 146. — Acute Leukemia. This picture is made from two different, rapidly fatal, clinically similar cases. The upper portion is stained with Ehrlich's stain with eosin-hematoxylin ; the lower portion is stained with the Plehn-Chenzinsky's stain. (Lenharts- and Brooks.) or spleen and liver. The disease may run a very acute course (acute leukemia), and end fatally within a week or two, or proceed a slower course (chronic leukemia), and lead to a fatal issue after a few months. As the nature of leukemia is entirely obscure, little else can be done but treat it symptomatically. Grave prognosis. PERNICIOUS ANEMIA. This form of anemia is characterized by great diminution in G the number of red cells (2,000,000 to 1,000,000 per centimeter) ; £f d r u e c d ti ° e tl lls reduction in the total quantity of hemoglobin with a comparative 476 DISEASES OF BLOOD AND DUCTLESS GLANDS. increase of the hemoglobin in the red cells ; increase in the size Megaiobiasts. of the red cells with predominance of megaloblasts ; loss of cohesive quality of the red cells (their failure to form rouleaux) , and, finally, absence of distinct change (or slight reduction) in the Normal number of the leucocytes. This blood affection is very rarely met in children. As in adults, it may occur secondarily to protracted simple anemia or in intestinal consequence of abstraction of blood by intestinal parasites, c.y. r bothriocephalus latus; uncinaria (q.v.). Fig. 147. — Progressive Pernicious Anemia. The case ended fatally in six weeks ; cause unknown ; possibly in connection with typhoid fever. Ehrlich's triacid stain. Zeiss ocular 1, oil immer- sion y&. a, normal erythrocytes; b. megalocytes; c, microcytes ; d, marked poikilocytosis ; e, megaloblast ; /, polynuclear neutro- philic leucocyte. (Lcnharta and Brooks.) In the beginning the symptoms resemble those of severe simple anemia (q. v.), but at a later stage of the disease the con- Hemor- dition is greatly aggravated by supervening hemorrhages from the mucous membranes, cutaneous ecchymoses and general dropsy. In such cases death invariably occurs within a few months. Post-mortem examination usually reveals fatty degeneration of the internal organs. The treatment is the same as in severe anemia (see page 472). Besides, removal of intestinal parasites, if present. H^MORRHCEA CONGENITA. 477 H.EMORRHCEA CONGENITA (Hemophilia). Hemophilia is an inherited, congenital tendency to post- traumatic or spontaneous, profuse, often uncontrollable hemor- rhage. It affects boys much more frequently than girls and shows a predilection for those of the Hebrew race. The disease becomes less marked with advancing age. The nature of the disease is still obscure. It is reasonable to suppose, however, that some toxic hemolytic agent transmitted through the spermatozoa or the maternal blood exerts its dele- terious influence upon the embryo in its very earliest develop- ment, leading to permeability and friability of the blood-vessel walls and lessened coagulability of the blood — these being the only Lessened characteristic changes met with in hemophilia with a certain of a fhe lablht5 degree of regularity. blood - While, as previously alluded to, the hemorrhage may start spontaneously, in the great majority of cases it follows some trivial injury. A scratch or the prick of a pin or slight abrasion spontaneous of the body surface, vaccination, snipping of the frenum, cir- or™fter iase cumcision, extraction of a tooth, opening of abscesses, etc., are injury, followed by severe often uncontrollable hemorrhage. Any undue exertion of a muscle or a group of muscles {e.g., jumping off a chair, sudden twisting of an arm), a bump or a blow, etc., often gives rise to a profuse extravasation of blood into the skin or joints. Forcible blowing of the nose may be followed by an exsanguinating nosebleed, and in a case under our observation sneezing produced an enormous hemorrhage from the nose and ear (rupture of the drum!) which nearly ended fatally. In girls hemorrhages may occur from the vagina (often mistaken for menstruatio prsecox) long before the age of puberty; and with establishment of menstrual function, the bleeding may be so pro- fuse as to leave the patient monthly in a state of collapse. Hema- temesis, hemorrhage from the bowels and hematuria are less common, and bleeding into the serous cavities (peritoneal, pleural and pericardial) and the brain are still less frequent. Hemophilia in the newly born may be manifested during or immediately after birth by severe hemorrhages occurring from abrasions and con- tusions sustained during delivery, or after cutting the umbilical cord. These hemorrhages are not to be mistaken for hremorrhcea mistaken 6 neonatorum complicating sepsis (see page 181) or the so-called neonXrum. transitory hemophilia which is manifested by idiopathic umbilical 178 DISEASES OF BLOOD AXD DUCTLESS GLANDS. hemorrhage (see page 174) or fearful, sometimes fatal bleeding following ritual circumcision. In this form of hemophilia the heniorr S hage y tendency to hemorrhage is greatest between the seventh and fourteenth days of life, gradually lessening in intensity until the infant reaches the age of two or three months, when it dis- appears entirely. The differential points of diagnosis between haemorrhoea congenita and haemorrhoea acquisita will be spoken of in the discussion of the latter affection (see page 480). Little can be expected from treatment, except in mild forms bleeders, of hemophilia ("partial bleeders"). Sterilized, liquid gelatin, (10 per cent.), administered twice daily, for months at a time, per mouth, rectum or hypodermatically has proved very serviceable, especially in partial bleeders. Calcium chloride, in from 2-grain to 5-grain doses, twice daily is useful. Thyroid gland substance, in small doses, continued for weeks at a time, is deserving of trial. To arrest the hemorrhage we may resort to the actual cautery, compression, suprarenal extract, perchlorid of iron, etc. Recently fresh rabbit-serum and horse-serum have been highly recom- mended. We should guard against injuries and operative interference (gelatin feeding before operation is helpful) of all kinds. Bleeders, especially females, should not marry. Prophylaxis. h5;morrh(ea acquisita (Purpura Simplex. Purpura Hemorrhagica s. Morbus Maculosus, Purpura Fulminans). Purpura is an acquired affection of the blood or its vessels characterized by hemorrhages into the skin, mucous membranes and other tissues and more or less marked constitutional dis- turbance. Pr °m!crob?c ^ ne etiology of the disease is still obscure, but is probably a origin, specific micro-organism which invades the blood. Purpura is most frequently observed in children (male and female) over five years of age, and more rarely in younger ones. It occurs either as a primary affection or in connection with acute infectious diseases, such as scarlatina, measles, typhoid, etc., and shows a predilection for poorly nourished, anemic and rachitic children living in dark, damp dwellings, with bad hygienic surroundings. Consonant with the degree of severity of the affection, it is customary to distinguish the following forms of purpura: — Free from hemorrhagic tendency at birth or soon thereafter. membranes. H^EMORRHCEA ACQUISITA. 479 1. Purpura Simplex. — The hemorrhage is confined to the skin only, and appears as pinhead- to lentil-sized spots at first upon the lower extremities, but later also on the other portions of the body. Aside from occasional prodromata consisting of hemorrhage, gastroenteric disturbance of brief duration, it is free from con- stitutional manifestations. The majority of these cases pursue a favorable course. The petechias either subside entirely within from one week to one month, or return at shorter or longer intervals, in which latter event transition into a severer type of the disease is not uncommon. 2. Purpura s. Peliosis Rheumatica. (See page 424.) 3. Purpura Hemorrhagica (Morbus Maculosus Werlhofii). Hemorrhage — This form of purpura is manifested by hemorrhages in the and mucous skin as well as in the mucous membranes. Its onset is either sudden or preceded by slight prodromata or purpura simplex. The skin petechia? may vary in size from a lentil to the palm of a hand, and do not disappear on pressure. They usually spread rapidly over the entire body. The hemorrhages into the mucous membranes are rarely very profuse. As a rule, there are only ecchymoses upon the mucous membranes of the nose, gums, and pharynx, but in severe cases the hemorrhagic tendency may extend to almost every structure and organ of the body, so that the patient bleeds from the nose, mouth, ears, retina and choroid, throat, lungs, stomach, bowels, kidneys, genitalia, etc., and some- times even into the brain and cord. Under these conditions there are well-marked constitutional symptoms (prostration, headache and articular pain, cerebral symptoms as a result of the anemia or meningeal hemorrhage, colic and tenesmus, etc.), but in mild cases the patient may appear perfectly well. The course of the disease, therefore, varies with the seat and amount of the bleed- ing. An attack of purpura hsemorrhagica of medium severity usually lasts from ten to fourteen days. After about a week the cutaneous ecchymoses begin to change from the original red to bluish, yellow, greenish and brown, and disappear entirely within another week. The hemorrhages from the mucous membranes and viscera also gradually cease, the general condition of the patient improves, and recovery ensues, apparently without any serious consequences. On the other hand, in a great many cases, not only may the course of the first attack be protracted for weeks and months by frequent recurrences of the bleeding, and lead to profound anemia and death, but a tendency to relapses is Recurrences. Violent course. 480 DISEASES OF BLOOD AND DUCTLESS GLANDS. not rarely established, which may manifest itself on slight provocation. 4. Purpura Fulminans (Henoch). — This type of purpura is essentially identical with the former variety, except that its course is extremely rapid and violent, with severe constitutional symp- toms, such as chills, vomiting, hyperpyrexia, cerebral symptoms, and collapse. It is invariably fatal, death taking place with symp- toms of cardiac paralysis, within from one to four days. Post- mortem examination is negative. Purpura may occasionally be complicated by gangrene of the skin, subcutaneous tissue or mucous membranes, rendering the prognosis very much worse. In the early stage of the disease hsemorrhcea acquisita may be D d?agnos ! is! mistaken for hasmorrhcea congenita, infantile scurvy, and exan- themata (scarlatina, morbilli diphtheria, variola, typhoid, etc.) with hemorrhagic symptoms. Hemophilia presents a history of an hereditary tendency, most frequently follows some local injury, and if it occurs spon- taneously almost never involves several portions of the body simultaneously. Infantile scurvy is an affection principally of early infancy and associated with malnutrition. The hemorrhage is also deep- seated ( subperiosteal ) . Exanthemata have pathognomonic symptoms of their own which are wanting in purpura. The concurrence of the former with the latter, however, should not be lost sight of. Purpura associated with sepsis can readily be recognized by the septic symptoms. The treatment of purpura is very unsatisfactory. Mild cases usually recover spontaneously, and grave ones may go from bad to worse even under the best mode of treatment. Absolute rest in bed, nutritious diet, plenty of fresh air, iron and arsenic, and the administration of fresh fruit-juice will enhance the arrest of milder forms of the disease. The hemorrhagic tendency may in some cases be checked by means of suprarenal gland extract, aromatic sulphuric acid, calcium chloride, and spirits of turpentine. Local hemorrhage should be treated in accordance with the rules laid down for the management of bleeding from other causes (compression, ice- bags, styptics, etc). After cessation of the bleeding tonics are useful. Stimulants, in collapse. Caseation DISEASES OF THE SPLEEN. 481 MORBUS ADDISONII (Bronzed Skin). The pathogenesis of this affection is as yet awaiting correct interpretation. While in the majority of cases post-mortem examination reveals disease of the suprarenals (caseation or and caicm- calcification), cases of Addison's disease are also on record which suprarenals. failed to show distinct pathologic changes in these glands. The disease usually attacks children over ten years of age and excep- tionally younger ones. It is manifested by progressive emacia- tion, dyspepsia, uncontrollable diarrhea, anemia, and bronze-like discoloration of the skin. The discoloration begins at the breast nipples, axillary regions, hands and face, and gradually affects the entire body. The patients succumb within from a few months or years to exhaustion and paralysis of the heart. Hematinics, roborants, and, possibly, suprarenal, parathyroid and pituitary extracts are deserving of trial. DISEASES OF THE SPLEEN. Spleen affections are manifested principally by enlargement of the organ — demonstrable by palpation and percussion. MOVABLE SPLEEN (Wandering Spleen, Lien Mobilis). This condition is important chiefly from a diagnostic point of view, as it is apt to be mistaken for splenic enlargement. It differs from the latter by the absence of constitutional symptoms and by the softer consistence of the spleen. It is usually asso- ciated with general atony of the entire musculature, especially of muscular the abdominal wall, and in older children not rarely with sinking of the intestines, floating liver and kidneys. Subjective symp- toms may be absent. Older children may complain of a feeling of weight or pain in the left side, colic, and nausea. Mild cases frequently obtain permanent relief from the use of an abdominal binder and general tonic treatment (massage, cod-liver oil, arsenic). In very pronounced cases splenectomy is indicated. ACUTE SPLENITIS (Splenic Congestion). An acute splenic enlargement may be caused by malaria, typhoid, recurrent fever and miliary tuberculosis; more rarely by atony. 182 DISEASES OF BLOOD AND DUCTLESS GLANDS. influenza, rdtheln, scarlet fever, tuberculous meningitis, mumps, usually erysipelas and angina. Very rapid and intense enlargement of aIJ ' the spleen may occasionally be followed by rupture of the spleen, hemorrhage in the abdominal cavity and death. In the majority of instances the splenitis subsides sponta- neously with the underlying cause. If the disease is due to direct infection by pyogenic micro-organisms, trauma (with open wound) or metastasis, it may end in suppuration (splenic abscess). Occasionally the inflammation extends to the sur- rounding tissues, especially to the capsule of the organ, peri- splenitis, and gives rise to inflammatory adhesions to neighboring structures (diaphragm, colon or fundus ventriculi). CHRONIC INFLAMMATION OF THE SPLEEN (Chronic Hypertrophy, Splenomegaly). Occasionally chronic enlargement of the spleen is the result of acute splenitis. Most frequently, however, it develops insid- iously in connection with chronic malaria, syphilis, tuberculosis, rachitis, leukemia, pseudoleukemia and amyloid degeneration. The symptoms vary with the original cause and the degree of pressure exerted by the spleen upon the neighboring structures. No attempt will therefore be made to go into a detailed descrip- tion of the symptomatology. Mention may here be made of the idiopathic fact that in the so-called "idiopathic" splenomegaly the patient forn1, may appear entirely free from constitutional manifestations. The treatment is symptomatic. If the spleen alone is involved and gives rise to grave pressure symptoms, splenectomy may be resorted to. BANTI'S DISEASE. This disease is not infrequently observed in children. It is spieno- characterized by splenomegaly, anemia, ascites, cirrhosis of the Ascites! liver, and hemorrhages. Early splenectomy is said to cure the affection. The diagnosis can be made only by exclusion of similar spleen and liver diseases. DISEASES OF THE THYMUS GLAND. The thymus gland consists of two lateral lobes coming in close contact along the middle line. It is situated in the anterior por- tion of the neck and superior mediastinum, extending from the Pressure symptoms. DISEASES OF THE THYMUS GLAND. 483 lower border of the thyroid gland to the upper border of the fourth rib. The thymus varies greatly in size and weight. It is about 2J^ inches in length, 1 J/> inches in width (at its lower portion), and a quarter of an inch in thickness. It attains its greatest development (weighing y± ounce) between the first and second years, and undergoes rapid degeneration soon after puberty, so that, at the age of twenty, it is a mere vestige of lymphoid tissue and fat. In children under six years of age, light percussion over the superior mediastinum reveals a triangular Normal anatomy. 148. — Large Thymus (skiagram). field of dullness, its base being- on a line with the sternoclavicular Triangular articulations, and its apex the second rib. It is well to remember, ^miess. however, that similar dullness is obtained in enlarged bronchial glands. Like other glands of the body the thymus gland is subject to TD y mit j S . acute and chronic inflammation (thymitis) with consecutive hyperplasia, or premature atrophy; tuberculosis; syphilis, and neoplasms. Acute thymitis occurs usually secondarily to systemic pyemic processes or by extension of the inflammation from the adjacent structures. The inflammation is very prone to lead to suppuration of the gland. Hvpertrophv of the thymus is sometimes inflammatory in Hypertrophy. 484 DISEASES OF BLOOD AND DUCTLESS GLANDS. nature and sometimes of obscure origin. When the enlargement of the gland is pronounced, the diagnosis can frequently be made Dullness; by an increased area of thymus-dullness over the sternum, by an >lllns ' arched elastic swelling above the incisura sterni, and by its asso- ciation with enlargement of the lymph glands in the lateral lower region of the neck. The X-rays are often very helpful in the diagnosis. In the majority of instances thymus hypertrophy gives rise to disturbances of the circulatory and respiratory ("asthma thymicum," "inspiratory stridor of sucklings") organs, Pressure as a result of pressure upon neighboring blood-vessels, nerves, symptoms. . . , ... and trachea. Tuberculosis. Tuberculosis of the thymus gland, as a rule, is not discovered until post mortem, and hence is of no clinical importance. To a great extent the same is true of syphilis of the thymus, which, by the way, is of very rare occurrence. Both of these pathologic processes usually lead to atrophy, sarcoma. Sarcoma is the most common new growth of the thymus gland. The symptoms and diagnosis are essentially identical with those of hyperplasia, already referred to. As the affections of the thymus at best escape detection until a late stage, little can be accomplished in the way of treatment. Where syphilis is suspected the iodids will prove efficient and in cases of neoplasm an attempt may be made to extirpate it. Acute inflammatory symptoms should be relieved by antiphlogistic measures (ice. cupping, and the like). STATUS LYMPHATICUS (Thymus Death). sudden In a certain number of apparently healthy children sudden a e fter death occurs after some trivial cause, such as shock following cause, slight trauma, or operation, injection of serum, etc., inhalation of a minute quantity of an anesthetic and the like. Post-mortem examination reveals no definite lesion in any organ to account for the sudden death, except general enlargement of the lymphoid tissue of the body (adenoids and tonsils, the follicles of the intes- tinal walls, the peripheral glands, etc.) and especially of the thymus gland. This pathologic condition is being generally described as "status lymphaticus." The pathogenesis of this anomaly is still shrouded in mystery. The view previously held that such deaths were the immediate result of compression of the neighboring vital structures by an enlarged thymus ("thymus operating. DISEASES OF THE THYROID GLAND. 485 death") has been found devoid of indisputable pathologic or clinical foundation. Whatever the etiologic basis, however, the mere fact that sud- den death may follow any of the aforementioned seemingly harm- caution in less therapeutic measures should serve as a warning against their employment in children in whom status lymphaticus is suspected. Children suffering from scrofula, rachitis, spasmus glottidis, and the like, belong to this category. DISEASES OF THE THYROID GLAND. The normal thyroid gland is somewhat larger in children, Normal especially girls, than in adults. It consists of three lobes, one thyroid- middle small lobe (inconstant) and two larger lateral lobes. The latter are connected by an isthmus. The lateral lobes are situated on each side of the trachea along the second and third tracheal rings ; the middle lobe lies in front of the thyroid cartilage and ascends upward in the direction of the middle of the hyoid bone. As the gland is thin and often lies deeply imbedded into the neck, it is very rarely possible to determine the size of a normal thyroid by palpation. THYROIDITIS (Strumitis). Primary inflammation of the thyroid gland is usually of traumatic origin (direct violence, or injury during delivery). It is of very rare occurrence. More frequently we meet with secondary thyroiditis, as a rule, in connection with acute exan- thematous diseases and occasionally with parotitis, malaria, and articular rheumatism. The symptomatology consists of swelling of the gland, pain swelling, on pressure as well as on moving the neck, and in some cases red- ] ness, fluctuation and suppuration, and more or less marked pres- sure symptoms. The inflammation usually disappears under local application of cold. Should an abscess form, it demands immediate evacua- tion of the pus and drainage. Severe protracted thyroiditis not rarely leads to atrophy of the eland. pressure symptoms. 186 DISEASES OF BLOOD AND DUCTLESS GLANDS. Hyperplasia. Cystic degeneration. GOITER (Struma). As in adults, the thyroid gland of children is subject to hyper- plasia and cystic degeneration. In countries where goiter is endemic it is not rarely observed in very young infants, and is probably of antenatal origin. On the other hand sporadic goiter, as a rule, develops at the period of puberty, particularly in girls. Small goiters may remain free from any manifestations, except the loeal swelling in the anterior portion of the neck, while symptoms 6 goiters large enough to exert pressure upon the adjacent struc- tures may prove a menace to life by compression of the trachea, and the large blood-vessels and nerves which abound in the neck. The pressure symptoms ordinarily consist of headache, dizziness, aphonia, dyspnea and paroxysmal cough. This grave symptom- complex, however, is of unusual occurrence. On the whole, the prognosis is favorable. The great majority of cases of goiter yield promptly to internal administration of DISEASES OF THE THYROID GLAND. 487 small doses of iodin, with or without thyroid or parathyroid gland substance, and external use of iodin ointment. Large goiters causing marked pressure symptoms call for their extirpation. In countries where goiter is endemic its development to a great extent may be prevented by change of residence, by boiling Distilled the drinking water, and by drinking large quantities of distilled prophylactic. water. In infants goiter may be mistaken for a large hygroma Fig. 150. — Cystic Goiter. Within the last two years patient (13 years old) has been gradually becoming feeble-minded. (Sheffield.) Differentia- tion from cysts in the neck. cysticum coli congenitum or other cysts of the neck, and in older children for exophthalmic goiter. Cysts of the neck are characterized by marked fluctuation and rapid development ; and usually arise from the submaxillary region. Exophthalmic Goiter (Basedow's or Graves's Disease) is characterized, in addition to the goiter, by tachycardia, muscular tremor, exophthalmos, general ill health, vasomotor disturbances ^ e m ^ ai Tachycard'a (flushes of the skin alternating with pallor), the skin. (1 pigmentation of th£ 188 DISEASES OF BLOOD AXD DUCTLESS GLANDS. CRETINISM (Endemic or Goitrous Cretinism, Sporadic Cretinism or Myxidiocy). Arrest of Cretinism is due to partial or total arrest of the secretion of secretion, the thyroid gland, in consequence of congenital or acquired Fig. 151. — Congenital Cretinism. Child 6 months old; showed typical symptoms soon after birth. {Sheffield.') (extirpation) absence, atrophy (from strumitis, syphilis, tuber- culosis, or neoplasms), or goitrous degeneration of the gland. Endemic cretinism occurs in children living in countries where Endemic. g j ter j s enf j em ic, or in descendants of people coming from these regions, and is very frequently associated with goiter. On the other hand, sporadic cretinism is observed in children coming Sporadic. ' ° from other parts of the world. The term "myxidiocy" is usually DISEASES OF THE THYROID GLAND. 489 reserved for the pronounced forms of cretinism which are asso- ciated with marked pseudolipomatosis. The great majority of cases of cretinism in children are of antenatal origin, although the pathognomonic manifestations with few exceptions (see Fig. 151) do not appear until the child is over one year of age. At about this time it is usually noticed Usually- congenital. Fig. 152. — Sporadic Cretinism in a Girl 8 Years Old. She measured 33 inches in height. (Sheffield.) that the infant's bodily development is arrested, and its intelli- gence, instead of rapidly progressing, grows perceptibly backward. Arrest of The fontanelles remain open; the head is large, flat and plump physical and and set upon a thick and short neck. The forehead is low and development, the root of the nose is broad. The face is weak and senile ; the eyelids, lips and tongue are thick and the latter slightly or markedly protrudes from the half-open mouth. The teeth are slow in coming and rapid in decaying. The abdomen is greatly 190 DISEASES OF BLOOD AND DUCTLESS GLANDS. distended, often presenting an umbilical hernia. The extremities arc mure or less deformed and the articulations thickened. The hands and feet are short, broad and thick. Cretins slowly learn to walk, but their gait is dragging and awkward, with a tendency to fall forward. If left untreated typical cretins rarely attain Feeble- 3 feet in height. Ordinarily cretins of ten or twelve years of mmdedness ^ a pp ear ] JUt two vears i c ] j n stature, and still younger in their idfocy 1 mental development. The intelligence of the cretin is invariably • ri Fig. 153.— Same case as Fig. 152 at the age of one year. Apparently perfectly normal. (Sheffield.) Half-cretin. below par ; it varies, however, greatly with the functionating capacity of the thyroid gland, and the period at which the morbid process makes itself felt. Thus, some cretins ("half-cretins") possess a fair measure of intelligence, appreciate their surround- ings and are able to acquire a vocabulary ample to make their wants understood or even to hold an intelligent conversation; others are totally idiotic and grow more stupid with advance in years. The special senses suffer greatly. Taste and smell are obtuse ; hearing is defective and not rarely associated with mutism. The voice is husky. Tn early infancy, before the degree of intelligence is determinable, the diagnosis of cretinism can fre- DISEASES OF THE THYROID GLAND. 491 quently be made by the dryness and waxy color of the skin; the profound anemia; the sparseness and brittleness of the hair; the subnormal temperature and the presence of so-called "fatty tumors" in the clavicular regions. As the child grows older it is noticed also that the genitalia Pseudo- lipomatosis. Fig. 154. — Sporadic Cretinism. Same case as Fig. 152, after two months' treatment with thyroid. Note complete transforma- tion of features, etc. She gained 2 inches in height. (Sheffield.) and their functions remain in a primitive state. Typical cretins, fortunately, have no power of perpetuating their monstrous kind. Up to the discovery of the underlying pathologic basis of the disease, cretins used to go on from bad to worse until finally relieved of their miserable existence by death, at an age of from Hopeless without thyroid. 492 DISEASES OF BLOOD AND DUCTLESS GLANDS. thirty to forty or earlier in consequence of intercurrent diseases, specific Nowadays, however, a great deal can be done to ameliorate their thyroid condition by the administration of thyroid gland. Partial cretins particularly can now be improved sufficiently as to enable them to pursue some occupation and to provide for their maintenance. The results obtained from thyroid medication are often miracu- lous. After exhibition of thyroid but for a short time — some- times only a few weeks (see Fig. 154) — the cretin is frequently transformed from an uncouth, apathetic and clumsy little creature into a lusty, gracile and growing human being. The blurred facial features gain youthful expression, the lusterless and withered hair takes on new life, the stunted stature approaches normal proportions and the brutal stupidity slowly gives way to human intelligence. The sooner the treatment is begun and the longer it is persisted in the more certain are the favorable results. At best, however, a cretin always remains childish for life — mentally as well as physically. The thyroid gland may be administered in the form of extract Mode of . 1 . '.,,.,,, . 1 \ 1 r i adminis- ( 1 grain for every year of the child's age, twice a clay), the fresh tration. , . , ... thyroid gland, or any of the numerous thyroid preparations on the market. The effect of thyroid is often enhanced by combin- ing it with parathyroid. (See page 121.) Endemic cretinism may frequently be prevented by treating Prophylaxis, the pregnant mother with thyroid-gland extract. For the differential diagnosis between cretinism and other Differential , . . ,. , ? diagnosis, forms of idiocy, the reader is referred to the chapter on "Idiocy and the Allied Mental Deficiencies," page 570. Mention will here be made of the fact that in doubtful cases the diagnosis can often be decided by the experimental administration of thyroid gland. The advisability (and success) of transplanting the thyroid gland from a sheep is still subject to controversy. CHAPTER XIII. Disturbances of Metabolism. MARASMUS; ATHREPSIA; INFANTILE ATROPHY (PEDATROPHY). The nature of this appalling infantile wasting is still shrouded in mystery. It is apparently only a functional disorder, a form of intestinal autointoxication, arising from non-assimilation of automtoxica- . . tion. the food consumed, since the post-mortem lesions (atrophic patches in some portions of the intestinal tract) are not uniform and rapidly disappear when the atrophic infant is put on.a suit- able diet, which may vary from an ideal breast milk to some proprietary artificial food ( !). In this group, of course, are not included the cases of marasmus accompanying tuberculosis, syphilis and the like. Whatever the pathology and cause, the symptomatology is ' very pathognomonic. The apparently normally born infant, after P? r t ^ al at thriving fairly well on the milk-mixture it has been receiving, begins to show signs of ill health and rapidly loses in weight. The food disagrees ; it is vomited or regurgitated. The stools are green and frequent, scanty in quantity, and contain undigested particles of food. The child suffers from colic, especially soon after feeding; is very restless, cries and whines pitifully, sleeps poorly, and, do what you will, the emaciation continues at a rapid pace. Before long the fontanelles, the eyes and cheeks are sunken ; the nose and chin pointed ; the abdomen is at first prominent but later retracted ; the skin wrinkled, often hanging in 1 ' . . Senile face; folds, and adding to this the earthy pallor and senile expression shrunken of the face, the poor creature is a sight dreadful to behold. Though dried up to mere skin and bone, with respiration shallow and pulse bad, it keeps on fighting for life for weeks and months — not rarely successfully. Unless wrecked by intercurrent diseases, those showing tenacity to life, and coming under observation not entirely in a hopeless state, stand some chance to recuperate their vitality and to recover completely. The prognosis depends also upon the (4i)3) 494 DISTURBANCES OF METABOLISM. duration of the marasmus, the age of the patient — it is more favorable in infants over four or five months than in younger ones — and the care it can receive from those in attendance. The om ?ions" concurrence of complications or sequela?, such as atelectasis, rolicystitis, pyelonephritis, ostitis, general ike, greatly mar the chances of recoverv. edema, pneumonia, furunculosis and the Fig. 155. — Marasmus in a child ten months old. "senile face." {Sheffield. ) Note Breast milk the best remedy. As athrepsia almost invariably occurs in artificially fed infants, the line of treatment which at once suggests itself is to supplant the artificial food by human milk. Indeed, through such a change miraculous improvement in the infant's condition may often be observed within a very few days, requiring no further treatment to complete prompt and uneventful recovery. Wet-nursing, therefore, should be the treatment of choice, even if it be only for a month or two, after which period cows' milk feeding may MARASMUS. 495 frequently, successfully be resumed. Occasionally breast milk does not quite agree at first; but after persistent effort by allow- ing the baby to nurse only from five to ten minutes at a time, and giving it a little plain-, lime-, or barley-water before each feeding, the difficulty will readily be surmounted. Lavage and colon flushing often act very beneficially. When the services of a wet- nurse are not obtainable (for financial or other reasons), an attempt should be made to feed the baby on "laboratory" milk, m 1ik. ra ° r always beginning with small quantities of weak milk-mixtures, and gradually increasing in quantity and quality according to indications. Not infrequently whey-mixtures act kindly. With poor people unable to carry out any of the aforementioned sug- gestions, we may try — for want of or as a stepping-stone to some- thing better — condensed milk in mild dilution with plain- or barley-water (5ss condensed milk to gij barley-water). Indeed, condensed milk is often invaluable during the summer months, and, if found to agree with the child, should unhesitatingly be con- tinued until cold weather will allow a change for cows' milk. I cannot pass the subject without emphasizing the fact that on a few occasions fearfully marasmic babies were rescued from im- Artificial minent destruction by means of proprietary infant foods. As this signal success was attained after many other methods of feeding had utterly failed, I am looking upon it as more than a mere coin- cidence. In some cases "malt-soup" (q. v.) acts exceedingly well. Lavage and colon irrigation are useful in all cases. The latter should be employed daily ; the former every alternate day, or more often if the return-water contains large quantities of mucus, and the vomiting persists. In the latter event it is often of advantage to add a little boric acid or bicarbonate of soda to the sterile water used for stomach washing. Of medicinal agents, in addition to an occasional dose of calomel, pancreatin is the only remedy I place some reliance upon. One or 2 grains each of pancreatin and bicarbonate of soda may be administered after feeding. The mouth of the infant should be kept scrupulously clean, and the buttocks dry and clean — to prevent stomatitis and inter- f^g™ 1 trigo, both of which form common complications. The child should not be left too long in recumbent posture, lest decubitus or passive pulmonary congestion supervene. For details of treatment of atelectasis, edema, and other complications the reader is referred to the respective chapters. foods. Lavage. of posture. 496 DISTURBANCES OF METABOLISM. ° ut< iife r Outdoor life and plenty of fresh air while the patient is indoors are essential to successful management of the cases in question. Whenever possible the child should summer in the country. Above all, however, hreast milk is the specific for marasmus, in the way of prophylaxis as well as cure. See also "Tuberculosis/ 5 and "Syphilis." RACHITIS (Rickets, The English Disease). Rickets is one of the most common affections of early child- hood. It prevails to a greater or less extent in almost all parts of the world, but shows a predilection for poorly born, poorly nourished (also among the well to do) and poorly housed children of temperate zones. The immediate cause of rickets is an as yet undiscovered micro-organism or toxic product (parathyroid dis- ease?) circulating in the blood. As its direct and most con- Deficiency spicuous result we have great diminution of the inorganic elements salts, of bones, exaggerated production of epiphyseal cartilage, exces- sive cell proliferation beneath the periosteum, and incomplete ossification of the new osseous tissue. As the disease advances chronic inflammatory changes occur also in the different soft structures (muscles, arteries, etc.) and organs (spleen, liver, etc.) of the body, leading to a complex pathologic entity sui generis— entirely distinct from any other diseased process. This pathogenic process is very insidious in its onset and its course ; hence in the beginning rickets is very apt to be overlooked, especially if following upon some other illness. As a rule, the initial symptoms are very vague, and consist of recurrent indigestion, restlessness and debility — a non-pathogno- monic group of symptoms rarely arousing the anxiety of those in charge of the patient as to seek medical advice. When seen by the physician, therefore, the disease is usually in full bloom. skull; 'open The skull is relatively large, the forehead broad and prominent and > b t aidness.' m profile (frons quadrata). The parietal eminences project strongly, and the fontanelles, especially the anterior one, and the sutures fail to close in due time. The occiput is thinly covered by hair or entirely bald, and here and there yields to pressure with the finger (craniotabes). The local baldness is the result of undue pressure and friction of the occiput against the pillow, and the effect of profuse RACHITIS. 497 perspiration which is most marked at the posterior portion of the head. The sweating and rubbing of the head, both very early symptoms of rickets, in a way are correlated, and probably due to cranial hyperemia. The lower jaw instead of being rounded becomes flattened, Deformed and its alveolar edge turned inward. The upper jaw also is more Jaw ' or less deformed, and the teeth, which are late and irregular in 156, -Rachitic Frons Quadrata and Curvature of Spine. {Sheffield.) coming, are asymmetrically set, conforming with the altered shape Faulty of the jaws. Owing to the deficiency in enamel the teeth soon teething turn yellow, brownish or black, are streaked and brittle and sub- ject to rapid decay. The rachitic thorax is very typical in appearance. The clavicles are more sharply curved than in the normal, and occasionally infracted; the costochondral junctions are thickened, bead-like in shape (most marked from the fourth to the eighth rib), assuming in their sloping course from above downward a rosary-like appearance (rachitic rosary) ; the sides of the thorax are flattened and the sternum projects, as in birds, — hence Deformed thorax. 4'. is DISTURBANCES OF METABOLISM. pigeon- or the so-called chicken pigeon-" or "chicken-" breast (pectus cannatum), and. finally, the lower lateral diameter is widened. The vertebral column, though rarely affected in mild forms of rachitis, invariably suffers in severe and protracted cases. The deformities most frequently met with are kyphosis and scoliosis. Figr. 157. -Rachitic Beading- of Ribs, "Pot-belly" and Bowlegs. (Sheffield.) Kyphosis. The kyphosis or backward curvature usually extends from the middorsal to the sacral region. It differs from tuberculous kyphosis by being rounded, and in the early stages reducible when the child is placed upon the abdomen and the thighs are over- Differentia- l ' ° . . sondvutT extended (see "Spondylitis," page 381). Rachitic lateral curvature or scoliosis is produced by the relatively heavy weight of the head upon the yielding (muscular and ligamentous insuffi- The condition is further aggravated ciency) vertebral column. RACHITIS. 499 by allowing the patient to sit up or walk at too early an age and for too long periods and by the habitual unequal distribution of the encumbrance. As regards the latter it will be noted that right-handed persons usually carry their children on the left arm, so as to have the right hand free, and, in consequence, the right pelvis of the child is lifted upward, the right shoulder tilted downward and the middle spine shoved laterally — lateral Fig. -Rachitic Kyphosis in a Boy 20 Months Old. superabundance of fat. (Sheffield.) Note scoliosis with the spinal convexity to the left. While rachitic scoliosis is most frequently observed in early childhood, rickets undoubtedly forms also the principal cause of the so-called postural scoliosis of school-children, the curvature being merely an exaggeration of the former condition. Rachitic scoliosis is to be differentiated from congenital scoliosis (very rare; as a rule associated with other congenital deformities) ; cicatricial scoliosis (following operation for purulent pleurisy) ; paralytic scoliosis — in association with poliomyelitis, etc. (sec Fig. 114) ; spondylitic scoliosis — usually kyphoscoliosis ( sec "Spondylitis," page 381) ; Differentia- tion from other varieties of scoliosis. 51 )i ) DISTURBANCES OF METABOLISM. Epiphys. al enlaru. Curvatures of lower extremities. static scoliosis i in congenital or acquired shortening of one lower extremity I. Although, as previously alluded to, rachitic scoliosis is reducible in it- early stage, if left alone for a long period the deformity is apt to remain permanent, notwithstanding the dis- appearance of the other symptoms of rachitis. The extremities very rarely escape involvement. In the upper extremities we usually find marked enlargement of the epiphy es at the wrists, and less frequently at the elbow. In creeping infants the radius and ulna are often curved and some- times infracted, and in severe cases the hand is separated as it were by a furrow — "double jointed.'' Occasionally there is also an enlargement of the ends of the metacarpal bones or the phalanges. By far more marked are the deformities of the lower ex- tremities. The soft tibia and fibula are ill prepared to balance the weight of the body. The flimsy fundament thus tumbles under its encumbrance. The hapless patient learns to walk late and with difficulty, or, as it were, "forgets" or unlearns how to walk. If he continues to walk, the tibia and fibula bend either outward (bowlegs — genu varum; O-shape), inward (knock-knees — genu valgum; X-shape), forward (saber-blade shape), or in severe cases simultaneously in different directions. As in the upper extremities there is also an enlargement of the epiphyseal ends of the bones, and occasionally infraction of the diaphyses. Children sitting crossed-legged may present also more or less pronounced curvatures of the femur and pelvis. Rachitic flat- fi H >t is rare. The course of these deformities varies. In the majority of mild and moderately severe cases spontaneous recovery occurs with improvement of general condition. On the other hand, in Fig. 159.— Rachitic legs, "Jug"-shaped Abdo- men, and Separation of Epi- physes — "Double-jointed." (Sheffield.) RACHITIS. 501 extreme cases, where, as a rule, growth is greatly retarded, the curvatures persist and require forcible corrective measures. The muscles generally participate in the rachitic process. They are thin and flabby and partly responsible for the difficulty in sitting and walking ("pseudoparalysis"), abdominal distention pfraiysu ("pot-belly"), and for the constipation and prolapsus recti. The pot-beiij Fig. 160. — Rachitic Knock-knees. Note also infraction of left femur. (Sheffield.) muscular insufficiency may be associated with overfatness (see Fig. 158) and mask the local rachitic manifestations. The ligaments are more or less lax allowing undue mobility at the larger joints, and giving rise to the abnormality known as "double- joints." Coincidentlv with and in a measure because of the gross alterations in the body framework manifold changes occur also in the functions and structures of other components of the body. Double- jointed. 502 DISTURBANCES OF METABOLISM. The respiratory system suffers early. The contracted chest Respiratory compresses its contents and disturbs the equilibrium of the s ' thoracic and abdominal organs. The area of breathing space is reduced, hence, respiration more or less interfered with, and the tendency to respiratory disease greatly increased. The latter is favored also by the timidity of the parents to expose their delicate babies to outdoor air, keeping them huddled up in poorly ventilated rooms and thus reduce their power of resistance to infection. In consequence of it slight catarrhs of the naso- pharynx or larynx instead of, as in the normal, yielding promptly to suitable treatment, persist indefinitely and lead to capillary bronchitis or bronchopneumonia, not rarely with fatal issue or greatly protracted convalescence with a predisposition to tuber- culous infection. As an immediate result we have also profound Anemia, secondary anemia — reduction of hemoglobin and red blood-cells and moderate leucocytosis. The child is pale, sometimes waxy in color; its digestion is poor; diarrhea alternates with constipation, the latter, however, preponderating. The liver and spleen are more or less enlarged and help to distend the abdomen. Rachitic children are very irritable, sleep restlessly, and show a great Spasmodic . . J r J ' . & affections, disposition toward different spasmodic conditions. Spasmus glottidis, eclampsia and tetany are frequent complications of severe and protracted cases of rickets, especially in very young- infants. Cases of rickets presenting the local and general symptoms here depicted usually offer no diagnostic difficulties. Less typical cases, however, may be confounded with cretinism, achondro- plasia, congenital syphilis, incipient hydrocephalus, and osteo- genesis imperfecta — a group of diseases which not only have _,._ .. , several symptoms in common and are to a certain extent etio- Differential J l diagnosis, logically correlated, but may also be associated with rickets. In cretinism there is marked mental deficiency; the tongue is thick and protruding from the mouth; as the child grows older there is very pronounced disparity between its age and body length. Achondroplasia is characterized by a striking disproportion between the length of the trunk and extremities ; the curvature of the shafts of the bones is due, not as in rickets, to softness of the bones, but to embryonic defective development; the fingers do not lie parallel as in the normal, but are spread out like ribs of an open fan. RACHITIS. 503 The epiphyseal thickening at the ribs and the long bones of syphilis hereditaria, as a rule, is observed soon after birth in association with other symptoms of syphilis which yield promptly to specific treatment. Incipient hydrocephalus has several symptoms in common with rickets (separation of the fontanelles, softening of the cranial bones, irritability of the nerve system). In hydroceph- alus, however, the cranial distention is rapidly progressive in character, leaving the long bones of the body, which suffer most in rickets, almost unmolested. Osteogenesis imperfecta differs from rickets in that in the former the bones are so soft that they can be cut and bent, splintered and fractured in several places. The importance of an early diagnosis cannot too strongly be emphasized, as upon it depends the prognosis, the success of treatment. While it is generally admitted that rachitis per se is not dangerous to life, and that in a number of cases sponta- neous recovery is possible, the indifference of the laity as well as the physician regarding early and persistent treatment is strongly to be deprecated. Spontaneous recovery is rarely complete. On the contrary, without suitable treatment the majority of children „ J J J ' . J J Retarded are left stunted in growth, distorted in shape and features, and bodily . . . . development. depressed in spirit — in short poorly qualified to struggle for an existence and to compete with their fellowmen favored by good fortune with sound mind and body. Rickets is preventable by abundance of sunlight and fresh Preventive 1 _ -' o measures. air and by a mixed, nutritious diet. In the absence of contra- indications, children over three months of age should receive in addition to milk small quantities of carbohydrates ; those over six months also thin soups and orange-juice; those over nine months Diet - half of a soft-boiled egg, some beef-juice, and a little toasted bread with sweet butter, and those over a year one egg daily, some fresh vegetable soup, oatmeal gruel, light cocoa, etc., and occasionally a small quantity of finely scraped fresh beef (see page 81). Season permitting, raw milk should be given in preference to boiled, sterilized or pasteurized. Rachitic deformities may be prevented by avoiding super- encumbrance of the spine and extremities. Infants with incipient Rcg( . rickets should, as much as possible, be kept off their feet, and advantageously held in recumbent posture, allowing them to remain in upright position only for short periods at a time. Nitrogenous diet. Organo- therapy. 504 DISTURBANCES OF METABOLISM. The suggestions just made apply as well to the management of further advanced cases of rickets. Here, too, sunshine and nitrogenous diet in abundance and removal of the superincumbent weight of the body are the remedies par excellence. To these we should add hydrotherapy (sea-salt baths), massage and pas- sive motion, and corrective, light braces where the deformities persist. Operative corrective procedures should be reserved for deformities of over three years' standing, as slight curvatures usually respond to non-operative antirachitic measures. As auxiliaries, especially with the view of overcoming the anemia and the deficiency of mineral elements, the syrupus hypo- phosphites" phosphitum compositus (U. S. P.) and cod-liver oil are of undoubted therapeutic value. Syrupus ferri iodidi with syrupus calcii et sodii hypophosphitum (N. F.) also is of service. In intractable cases organotherapy, especially the extracts of thyroid, thymus and pituitary glands and red bone marrow should be given fair trial. A sojourn at the seashore is highly to be recommended. ACHONDROPLASIA! (Chondrodystrophia Foetalis; Fetal Rickets; Micromelia). These terms are used to designate a peculiar type of con- Congemtai. o en j ta i dwarfism arising from early fetal arrest of growth of the bones that are formed in cartilage, leaving the bones that are laid down in membrane unaffected. Thus, we have shorten- ing of the extremities, and of the bones of the base of the skull, while the bones of the vault of the cranium and the trunk are normal. This peculiar chondral dystrophy produces the fol- lowing characteristic statural disparities :— Shortness of the extremities as compared with the normal abdom°en g (relatively long) abdomen; bowing of the extremities, especially lower, and thickening of the terminal epiphyses ; limited power of extension of upper extremities; peculiar fan-like divergence of ^b'and 1 the thick, uniformly sized fingers, the so-called "trident hand"; marked narrowing of the pelvis ; lordosis ; protuberant abdomen ; narrowing of the base of the skull ("pug-nose," broadening of the jaws), as compared with the normal (relatively large) upper part of the skull. The skin and nails are normal ; the hair is soft and abundant in growth. Intellect is usually normal. The Short extremities; 1 Though not an acquired disease, this subject is treated here in order to emphasize its many differences from rickets. SCORBUTUS INFANTUM. 505 great majority of cases of achondroplasia die in utero or soon after birth. Those who survive may attain old age. They very rarely exceed four feet in height. Fig. 161. — Achondroplasia (10 months old). Note length of trunk and shortness of extremities. (Sheffield.) SCORBUTUS INFANTUM (Moeller-Barlow's Disease, Acute Rickets). Infantile scurvy is an acute specific hemorrhagic affection of Toxemia, as yet unknown origin. It is probably due to direct microbic infection or toxemia resulting from intestinal putrefaction. As Malnutrition the disease occurs principally in infants from six to eighteen months old, the period when nutritional disturbances are most rampant, there is every reason to believe that malnutrition is the 506 DISTURBANCES OF METABOLISM. Usually sudden ouset. most active predisposing cause. This explains also the frequency with which infantile scurvy is observed in infants fed on boiled, sterilized or pasteurized milk (milk deprived of some of its nutritious qualities) or poor breast milk. The onset of the disease is usually sudden or, less frequently, preceded by malaise or digestive disturbance of a few days' dura- Fig. 162. — Moeller-Barlow's Disease (girl 15 months old). Xote hemorrhage from the gums and in the skin and swelling of lower extremities. (Sheffield.) Pseudo- paralysis. Tuiwfaction. tion. The child is restless, cries when it tries to move itself or when it is being handled. This symptom is the result of pain and tenderness especially in the lower extremities. For fear of pain the patient instinctively ceases to move its limbs (pseudo- paralysis). Examination of the extremities soon reveals at the diaphyses of one or both femurs, more rarely of the tibia and fibula, or upper limbs, spindle-shaped, colorless, smooth, non- fluctuating swellings surrounding the bones. The tumefactions Spongy gums. SCORBUTUS INFANTUM. 507 for the most part are due to subperiosteal hemorrhage. Ex- ceptionally there is bleeding also from beneath the periosteum of H emor- the ribs and the bones of the head (protrusion of the eyeball, in rhages - subperiosteal hemorrhage of the frontal bone) and face, and occasionally spontaneous separation of the epiphysis from the shaft of the bone, leading to bone infraction, impaction or frac- ture. The next important symptom of infantile scurvy is spongi- ness and discoloration (minute transient ecchymoses) of the gums, with a tendency to bleed. In quite a number of cases the hemorrhagic tendency extends also to the skin, subcutaneous tissue (typical "black eye" after a fit of crying or laughing, also discoloration and proptosis of an eye resembling that of chloroma), mucous membranes and the viscera (dysentery!), so that as a result of loss of blood profound anemia, edema and albuminuria supervene. On the other hand, some cases pursue a very mild course (formes frustes), especially if recognized early and treated energetically. Except occasional permanent hyperostosis of the affected shafts the prognosis as a whole is favorable, recovery usually taking place within from a few weeks to as many months. Neglected cases, however, may end fatally from the aforemen- tioned complications, or pneumonia. Antiscorbutic diet and fresh air form the treatment par Fresh, 77 -r-i • , • 1 ii nourishing excellence. .Prompt improvement and rapid recovery usually food, follow the administration of fresh cows' milk, fresh fruit-juice Fruit-juice, (lemon, orange, or pineapple), beef-juice, and in older children fresh eggs and vegetables (potato puree, carrots, spinach, etc.). Where convalescence is protracted we may prescribe the syrup hypophosphites compound (U. S. P.), with extract of malt and on. cod-liver oil. Infantile scurvy may be mistaken for : Rheumatism, peliosis ^.^ . ... . . . Differential rheumatica, purpura hemorrhagica, syphilitic epiphysitis, osteo- diagnosis, myelitis, rickets and occasionally (when the orbit is involved) for chloroma. In rheumatism the swelling is usually localized at the articula- tions and "jumps" from one place to another. It is accompanied by fever and responds to the salicylates. Hemorrhages are absent. Peliosis rheumatica is characterized by deep red or bluish spots as a rule limited to the extremities. Purpura hemorrhagica is free from diaphyseal hematomas and pain. 508 DISTURBANCES OF METABOLISM. Syphilitic epiphysitis is free from the hemorrhagic tendency, and often presents other syphilitic lesions. Osteomyelitis is associated with high fever and local abscess. Rickets is free from acute pain and hemorrhagic symptoms. I [as other pathognomonic symptoms. It responds very slowly to treatment. Chloroma or green turner usually shows a predilection for the skull (temporal fossa? and orbits), giving the child a characteristic frog-like appearance. It is a grave blood disease — profound anemia with relative and absolute increase in lymphocytes. DIABETES MELLITUS (Glycosuria). Within recent years, with increased interest in accurate Frequent J in children, diagnosis, the number of cases of diabetes in children recorded has greatly increased. In former years undoubtedly many of the rapidly fatal cases escaped observ ation . T^ ? "r_??ort?nce o f careful examination of the urine of older children and infants suffering from polyuria or enuresis, therefore, cannot too strongly be emphasized. We distinguish two forms of glycosuria : Glycosuria spuria diabetes, (temporary or dietetic), and glycosuria vera (diabetes mellitus). The first variety is comparatively of little clinical importance. It is the result of consumption of sugar greater in quantity than can be assimilated, and usually disappears after arrest of the causal factor. Diabetes Qu f-j-jg other hand, diabetes mellitus is an extremely fatal mellitus. ... . affection, death taking place, in violent cases, sometimes after a few days, weeks or months, and in less acute cases often within a year or two at the latest. S onslt 1 ^ ne onset °f diabetes mellitus is sudden. The child begins rapidly to lose in weight, notwithstanding good appetite, suffers from excessive thirst, passes a large quantity of urine (often Polyuria. enuresis nocturna as well as diurnal), of high specific gravity Glycosuria (1030), containing a large proportion of sugar, and loses in vitality from day to day. In addition to these symptoms there arc also digestive disturbances, skin affections (furunculosis, onychitis), cataract, nerve disorders (e.g., often Friedreich's ataxia), obstinate acetone odor, dryness of the skin, etc. The course of the disease varies. As a rule, it is more rapid than in DIABETES INSIPIDUS. 509 adults; the younger the patient the more violent the course. Death usually occurs as a result of general exhaustion or inter- ComSi current diseases, such as pneumonia, tuberculosis, and the like, and is frequently preceded by coma diabeticum or uremia. Recoveries, however, are also on record. Every effort should be made to trace the cause of the disease and to combat it energetically. As congenital or acquired syphilis has frequently been found to play an essential part in the causation of diabetes, it is prudent to subject the patient to a course of antisyphilitic treatment. We have no means at our command to influence the other supposed etiologic factors of diabetes, such as traumatism to the head, shock, various infectious diseases, etc. ; the time is not distant, however, when the true nature of the affection will be disclosed, and the remedies found which will greatly aid us t/eTtme^t 1C in the prevention and arrest of the disease at its very inception. Until this blissful moment we will have to continue groping in the dark, empirically treat symptoms, and depend chiefly upon a restricted diet, which at best never strikes the root of the evil, and from sugar is hardly practicable in diabetes of early childhood. Wherever possible (especially in older children), the diet should consist of fresh meat-soups and broths ; bread and biscuits of gluten flour, with cream and butter ; eggs ; moderate quantities of meats of all kinds, with spinach, asparagus, mushrooms, string beans, cab- bage, radishes and turnips ; fresh sour fruit, such as grapefruit, lemon, cranberries and raspberries. Saccharin instead of sugar. In infants milk and amylacea are indispensable, but should as much as possible be restricted. Oatmeal gruel seems to work well in some cases. Mild hydrotherapeutic procedures and light exercise are useful. Methylatropine bromid (gr. %oo) twice a day, hypodermatically ; opium in some form, and arsenic, in addition to cod-liver oil and iron, are the only drugs of thera- peutic value. Complications should be treated according to indications. DIABETES INSIPIDUS (Polyuria). Polyuria, like glycosuria, may be transient or persistent. Transient or Transient polyuria is quite common in children and usually of P ersistent - nervous origin. On the other hand, persistent polyuria — diabetes insipidus — is comparatively rare. It is manifested by Polyuria excessive thirst, polyuria (pale, sugar-free urine of low specific ^,ga£ ut gravity), dry skin, disturbances of the digestive and nerve sys- 510 DISTURBANCES OF METABOLISM. Tonic treatment. tems. The course is very protracted, but the prognosis quoad vitam favorable. Permanent recovery is rare. As the etiology is obscure (essentially the same as for diabetes mellitus), little can be expected from treatment, except in cases due to syphilis, which frequently yield to antisyphilitic medication. Change of air, hydrotherapy, and a nitrogenous diet act beneficially. 163. — Adipositas (8 months old). Weighs 36 pounds. (Sheffield.) ADIPOSITAS (Lipomatosis Universalis. Obesity). Contrary to what is observed in older children or adults, very rarely gives rise to constitutional ^recovery overfatness in infants infants 6 disturbances. As a rule, the fatness subsides when the child In- ins to walk about. In older children obesity is often associated with marked anemia, shortness of breath and fatty degeneration of the ADIPOSITAS. 511 heart. If such symptoms appear, it is essential to eliminate Diet. fats and carbohydrates from the dietary and to recommend systematic exercise, active massage and hydropathic pro- cedures. Carlsbad salts and thyroid gland substance are medication. Fig. 164. — Adipositas. Same case as Fig. 163, back view. (Sheffield.) often useful ; some cases, however, resist all sorts of treatment, and readily succumb to intercurrent diseases. Adipositas should not be mistaken for cretinism (q. v.). CHAPTER XIV. Diseases of the Nerve System. nerves. GENERAL REMARKS ON CEREBRAL OR CENTRAL PARALYSIS AND BRAIN LOCALIZATION. A S o™brain "Cerebral Paralysis," so called, is not an independent brain disease. ( ii sease , but merely a symptom occurring in connection with a number of congenital and acquired brain affections. Depending upon the extent of the lesion the paralysis may appear either in the form of hemiplegia, double hemiplegia, or monoplegia. unilateral Hemiplegia is the result of a lesion (disease or trauma) in lesion. one cereDra i hemisphere. The paralysis is situated on the side opposite that of the lesion. Motile power may be completely abolished or only partially so (paresis). Sensation may remain intact, but is lost if the brain lesion is in the internal capsule and extends to the sensory fibers. The paralysis is associated with rfgidity! s P ast ic rigidity of the affected muscles ; exaggeration of the deep reflexes ; implication of some of the cranial nerves, such as the In o°f U cran e iai facial (paresis), hypoglossal (deviation of the tip of the tongue to healthy side), and ocular nerves (nystagmus, hemianopsia, and optic atrophy), and occasionally — in left-sided lesion — also with motor aphasia. As the paralysis becomes chronic the paretic musculature shows a tendency to arrest of development, tremor Athetosis. am \ athetosis ; epilepsy and mental impairment up to total idiocy Mental , , • , , symptoms, make their gradual appearance. Double hemiplegia (diplegia) may be the result of two separate atacks of hemiplegia. More frequently it develops with one attack as a sequel of an extensive brain lesion in both cere- bral hemispheres or in the pons and medulla (affecting both lateral halves). If only one side of the pons is involved we have crossed paralysis of extremities on one side and of the facial nerve on the other side. In double hemiplegia, in addition to the symptoms enumerated under hemiplegia, functions may suffer which escape ordinary hemiplegia, e.g., that of swallowing and, perhaps, that of mic- turition. Occasionally it is accompanied also by paralysis of the (512) Bilateral lesion. Crossed paralysis. Improvement CENTRAL PARALYSIS. 513 tongue, . giving rise to symptoms which closely resemble those fbe^ngue * associated with bulbar paralysis. However, there is no wasting of the tongue, nor change in the electric reaction; hence, is spoken of as "pseudobulbar paralysis." Monoplegia as a primary manifestation of a cerebral ^ spinal™ 1 paralysis is rare. More frequently it is met in the regressive stage of the aforementioned two types of paralysis or in connec- tion with lesions of the spinal cord or peripheral nerves. Cere- bral monoplegia usually arises from a limited lesion in or near the cortex, less frequently from small capsular lesions involving individual nerve-bundles for the face, arm, leg, etc. (See also "Brain Localization," page 514. The course of cerebral paralysis differs with the gravity and extent of the lesion. In cases of sudden onset which survive the immediate attack there is usually an early and appreciable improvement in the motor paralysis. The spasmodic rigidity paralysis. may considerably improve or grow worse. The choreic and . athetoid movements usually persist. The same is true of the mental impairment and of the posthemiplegic epilepsy, except that under suitable treatment there is some fair prospect to lengthen the intervals between the epileptic attack. Cerebral paralysis may sometimes be confounded with infan- tile spinal paralysis affecting one arm and one leg. The diagnosis diagnosfs. al can readily be cleared up, however, by bearing in mind the follow- ing differential points : — Cerebral Paralysis. ' Poliomyelitis. Paralyzed limb rigid. Flaccid. Tendon reaction exaggerated. Diminished or lost. Electric reaction normal. Diminished or lost. Involvement of cranial nerves com- Exceptional. mon. Atrophy of affected muscles slight. Marked. Athetosis common. Absent. Mentality affected. As a rule not. Monoplegia of cerebral origin differs from spinal in the same manner as hemiplegia. Besides, there is usually a history of pre- ceding unilateral or bilateral paralysis with gradual improvement. The treatment of cerebral paralysis is practically the same as in spinal paralysis : restoration of the sensory and motor power, 2nd prevention of permanent deformities. Where the paralysis is due to local pressure (trauma, tumor, etc.), operative inter- ference is indicated. A thorough course of antisyphilitic medica- 514 DISEASES OF THE NERVE SYSTEM. Anti . tion will not rarely be found a thankful experiment — regardless men't of discernible cause. Except in syphilitic cases, however, the prospects of a cure are very poor. The prognosis quoad vitam is fair, but depends upon the cause and treatment. Brain Localization. Seat of Lesion. Usual Manifestations and Their Seat. Central convolutions : 1. Upper third. Paralysis of leg, opposite side; con- vulsions. 2. Middle third. Paralysis of arm, opposite side; convulsions. 3. Lower third. (a) Upper part. Paralysis of the muscles of one- half of the face. ' b i Lower part. Paralysis of the muscles of the lips and tongue. Frontal convolutions. Disturbance of speech. Parietal convolutions. Disturbance of cutaneous and mus- cular sensibility. Occipital convolutions (especially Hemiopia; loss of visual memory. cuneus). Temporal convolutions. Disturbance of hearing, opposite side, and sense of smell. Centrum ovale. Monoplegia, hemiplegia, hemiopia, word-deafness and aphasia ; con- vulsions. Central ganglia (caudate and len- Hemiplegia and hemianesthesia. ticular nuclei I. Optic thalamus. Disturbance of vision up to blind- ness. Internal capsule. Hemiplegia and hemianesthesia, and sometimes loss of special senses. Corpora quadrigemina (anterior Oculomotor paralysis, reeling gait, pair). possibly total blindness and deaf- ness. Crura cerebri. Hemiplegia with crossed paralysis of oculomotor nerve. Pons and medulla (one-half). Hemiplegia with crossed paralysis of facial nerve ; hemianesthesia : also involvement of other cranial nerves, e.g., hypoglossal, abducens, varying with the height of the lesion. Cerebellum. Ataxia, vertigo, and vomiting. PORENCEPHALIA. Absence of brain substance may be congenital or acquired, occurring either as a result of embryonic arrest of development or of ante- or post-natal brain disease. The clinical symptoms arising therefrom depend upon the seat and extent of the defect, but generally correspond to those of pronounced microcephalus idiocy; or hydrocephalus, i.e., idiocy, hemiplegia, diplegia, defective speech, etc. Congenital or acquired'. Stage of excitation; of pros- HYPEREMIA OF THE BRAIN. 515 ANEMIA OF THE BRAIN (Hydrocephaloid). This condition is usually the result of excessive loss of body fluids (repeated hemorrhages), general grave anemia, exhaus- tion from acute (rarely chronic) gastrointestinal diseases, inter- ference with the blood-supply of the brain (pressure on the part of tumors), etc. If the anemia is moderate, it is manifested principally by syncope. Anemia of the brain occurring in violent gastroenteric affec- tions (with profuse vomiting and diarrhea) is generally spoken of as "hydrocephaloid," so designated by Marshall Hall, who first described the symptom-complex. Hydrocephaloid is char- acterized by a stage of excitation : flushed face, fever, restless- ness, jactitations; and one of prostration: pallor, sunken face, tration. irregular pulse and respiration, cold extremities, subnormal tem- perature, sunken fontanelles, stupor with half-closed eyes, hazy cornese, coma, convulsions, and, as a rule, death. Occasionally hydrocephaloid yields to energetic treatment, which consists of external heat stimulation by entero- and hypodermo-clysis, sterile camphorated oil and strychnin hypodermatically, champagne, and small quantities of food by mouth. Fresh air. The brain of infants dying from cerebral anemia is pale, watery and softer than normal. R; Caffeinse natrii benzoatis gr. xij I 0.8 Aq. destil 3ij | 8.0 M. Sig. : Gtt. x, hypodermatically, for a child 1 to 2 years old. HYPEREMIA OF THE BRAIN. The hyperemia may be active, or arterial ; or passive, or venous. Active hyperemia may occur as a result of sunstroke, trauma- ActiV e. tism, mental or physical overexertion, overstimulation by exhil- arating beverages or drugs, hysteria, onset of acute infectious diseases, etc. It is manifested by deep redness of the face, congestion of the congestion; conjunctivae, contraction of the pupils, hot skin, high temperature, convuisfons. accelerated pulse, strong pulsation of the carotids and temporals, ringing in the ears, intense headache, excessive thirst, and in severe cases convulsions, delirium, distention of the fontanelles, and other symptoms of meningeal irritation. 516 DISEASES OF THE NERVE SYSTEM. Passive. Passive hyperemia of the brain is caused by passive conges- tion of the cerebral veins owing to cardiac debility, grave pul- monary affections (edema, pertussis, etc.), compression of the veins in the neck, etc. Exhaustion. The symptoms of passive hyperemia are those of exhaustion, apathy, somnolence, cyanosis of the face and dyspnea. The treatment depends upon the original condition. It is stimulants more or ' ess symptomatic — sedatives in active, stimulants in passive variety of hyperemia. Upon the underlying cause also depends the final outcome. Protracted hyperemia sooner or later leads to meningitis, rupture of the blood-vessels, and dropsical effusion in the cranial cavities. ACQUIRED HYDROCEPHALUS 1 (Dropsy of the Brain). By hydrocephalus is understood the accumulation of fluid within the cranium. The fluid may collect in the subdural space External, (external hydrocephalus) and be general or local ("sacculated"), internal. or j n t the ventricles (internal hydrocephalus I. Clinically hydrocephalus may be divided into false and true. False. F a l se hydrocephalus embraces all forms of dropsy of the brain accompanying active or passive inflammatory processes the intra- cranial pressure of which being insufficient to produce destruction of the contiguous brain tissues. It includes all cases of acquired hydrocephalus with a comparatively slight exudation, such as arise in connection with inflammation of the brain and meninges (tuberculous and non-tuberculous), acute infectious diseases with cerebral symptoms, severe gastrointestinal intoxication (acute True - and chronic ), traumatism during or after birth, etc. True hydro- cephalus is characterized by a primary deficiency (congenital!) or secondary (acquired!) destruction of brain tissue as a result of excessive pressure by a large exudation. The symptomatology of false hydrocephalus resembles that of an acute or chronic inflammatory process of the meninges, or brain, or both, and depends not only upon the seat and amount of the effusion but also upon the course of the original affection. The principal symptoms are those of cerebral irritation, which may vary from simple irritability to marked convulsions, paresis, loss of vision, and coma. The symptom-complex is not a con- See "Congenital Hydrocephalus," page 124. ACQUIRED HYDROCEPHALUS. 517 stant one, as is characteristic of true hydrocephalus. It may vary In false from day to day and may subside entirely with abatement of the cephaius original cause. The shape of the skull is but little changed. In infants the fontanelles are enlarged and bulging and the sutures are slightly separated. In older children with closed fontanelles no perceptible enlargement is discernible, except in progressive symptoms inconstant. Fig. 165. — Acquired Hydrocephalus, following Acute Gastro- enterocolitis. Patient also suffering from rachitis. See Fig. 156. (Sheffield. ) cases of long standing — in which event true hydrocephalus is then dealt with. The course of false hydrocephalus differs with the etiologic factors. If the exudation is moderate and due to curable dis- eases, e.g., gastroenteritis, traumatism, rickets, syphilis, etc., the further progress may be arrested and recovery occur. Some cases, of course, end fatally — with the underlying cause; others J/phaiu^' " again, as previously mentioned, are transformed into true hydro- [he e con- eS cephaius, which is practically identical with "congenital hydro- y|"iety. cephaius" ( q. v.). 518 DISEASES OF THE NERVE SYSTEM. INTRACRANIAL HEMORRHAGE (Meningeal Hemorrhage, Hemorrhage in the Brain). We had occasion (see page 161) to direct attention to hemorrhages resulting from obstetrical injuries. This space will be devoted to the discussion of intracranial hemorrhages occur- ring during infancy and childhood. The usual sites for intra- fesion. cranial hemorrhages are as follows : Neighborhood of the large central ganglia, pons, meninges, convolutions, cerebellum, crura cerebri or medulla. Trauma. They may occur as a result of trauma, such as a blow or fall upon the head, in association with meningitis, infectious diseases, purpura, pertussis (as a result of severe venous congestion), sinus-thrombosis, syphilis (syphilitic arteritis), richly vascular increased tumors, nephritis and hypertrophy of the heart (owing to in- pressure. creased blood-pressure), etc. In the majority of instances the symptomatology is at first indefinite and inseparable from that of the fundamental disease. Where the hemorrhage is extensive, the symptom-complex Loss of resembles in its entirety that observed in intracranial hemorrhage conscious- , ' _,, TT . . . . . in adults, thus: Unconsciousness, convulsions ; slow, irregular breathing; slow and full pulse, coma and death, or partial recovery with persistent focal signs, especially paralysis. (See "Cerebral Paralysis," page 512.) The treatment consists of an icecap to the head, counter- irritation, perfect rest, light nutritious diet, and, later, ergot and the iodids. (See also "Central Paralysis," page 513.) EMBOLISM OF THE BRAIN ARTERIES. Cerebral embolism, like hemorrhage, is rarely observed in valvular children. It is occasionally met in connection with severe val- dis'ease 1 vular heart disease, and acute infectious and pyemic processes, and most frequently affects the arteria fossae Sylvii. Differentia- The symptomatology of embolism is practically the same as in "cerebral cerebral hemorrhage (' n g. fever, stupor and convulsions. Older children complain of dizziness and headache, This condition may last one or two days or as many weeks. Then either the coma increases and is fol- lowed by death or the symptoms abate, and the patient is appar- ently on the mad t<> recover)', except that in the majority of ENCEPHALITIS. 523 instances monoplegia, or hemiplegia with or without involvement of some cranial nerves is left behind. The subsequent course of the disease depends upon the nature of the brain lesion. Simple encephalitis or suppurative encephalitis of very limited extent, with its cause removed, may clear up without appreciable after- effects. On the other hand, where an encapsulated abscess has formed, the violent symptoms may abate and the acute pass into a chronic stage. This state reached, the encephalitis is apt to run a very protracted course, with recurrent violent exacerbations and deceptive remissions, on the one hand giving rise to symptoms of acute meningitis ; on the other, especially if the abscess is large and pressing upon the motor areas and cranial nerves, to those of tumor of the brain. In either case the diagnosis is often extremely difficult. Ordi- narily meningitis differs from abscess in that it pursues a more acute course, and the brain symptoms are indicative of a more diffuse lesion. The diagnosis between brain tumor and abscess is still more diffi- cult. In abscess there is usually an irregular tempera- ture with rigors, motor aphasia and paraphasia, while in tumor fever is rare and there is a greater tendency toward dis- turbances in the area of distribution of the cranial nerves at the base of the brain, and toward choked disk. (See "Brain Tumor," page 524.) A history of ear disease or direct violence points strongly toward abscess. Slowly developing focal brain symptoms are characteristic of brain tumor. These differential .points, however, at best, are not very reliable. Paralysis. Fig. 167. — Encephalitis, with Left Hemiplegia. Note droop- ing of left shoulder and drag- ging of left leg in the act of walking. (Sheffield.) Differentia- tion from meningitis and brain tumor. Surgical treatment. Attention to ear disease. ■"-•J I DISEASES OF THE NERVE SYSTEM. As previously mentioned the remissions occurring during the course of chronic 1 train abscess are very deceptive. In the first course! place, the "latent period'* is rarely entirely free from signs of ill health. As a rule, the patient surfers from occasional head- ache, vomiting, rise of temperature, mild paresis, etc. Secondly, there is no way of telling when in the midst of apparent good rupture of health the abscess may suddenly rupture in the brain ventricles or meninges and rapidly end fatally. The prognosis of brain abscess, therefore, is always very grave, unless surgical interference is resorted to early. The operative results are especially favorable in abscesses due to otitis or trauma — provided they can be localized. Hemorrhagic encephalitis, or purulent encephalitis before operation, should be treated by perfect rest, icebags to the head, lumbar puncture, etc. — the same as acute meningitis. Treated in this manner primary, simple encephalitis not rarely terminates in recovery. Early prophylactic measures, particularly energetic treatment of ear trouble, scrupulous attention to suppurative conditions of the eyes, nose and throat are all powerful in the prevention of the dreadful complications and sequelae. TUMORS OF THE BRAIN. Of the total number of cases of brain tumors on record about one-half occurred in children. Brain tubercle is especially com- mon, and relatively frequent also are divers forms of sarcoma (gliosarcoma). Hidden as intracranial neoplasms are from sight and touch, their nature must necessarily be a matter of conjecture only, except, perhaps, in cases of bony growths, which may be diagnosed by means of the X-ray, and tubercle and syphilis, which may be surmised by the presence of other tuber- culous or syphilitic lesions in other parts of the body or detected by the tuberculin or Wassermanms tests. The diagnosis of brain tumor is based upon the general and local nerve disturbances they produce. As a rule, the general symptoms precede the local, and consist of: Headache, vomiting, vertigo, optic neuritis, and convulsions. The headache is usually persistent, but may also be periodical, suggesting a malarial origin. The headache may be frontal, vertical or occipital, or equally distributed over all parts of the cranium. The locality of the pain occasionally bears a direct Gliosarcoma. Gumma. TUMORS OF THE BRAIN. 525 relation to the seat of the tumor, thus : when the growth is in the white substance the pain is usually frontal; when beneath the tentorium, occipital, etc. The same rule often applies to the pain elicited on tapping the skull over the seat of the disease. Intense headache in infants is indicated by rolling of the head from side to side, by throwing the hands up to the head, contrac- tion of the eyebrows, and intolerance to light. The headache is frequently followed but may also be preceded by vomiting. vomiting. The vomiting is projectile in character, and comes on sud- denly. It differs from gastric vomiting by the absence of other signs of stomach trouble, and from vomiting accompanying migraine by the fact that the headache does not always terminate with it. Vomiting is especially characteristic of tumor in the medulla oblongata and in the middle lobe of the cerebellum, but it may occur in tumors affecting any part of the brain. The vertigo may be constant or paroxysmal and is most vertigo. marked in affections of the pons or cerebellum. Vertigo in infants frequently escapes notice. It is manifested by sudden drooping of the head, pallor of the face and occasionally also vomiting. Optic neuritis sometimes forms one of the earliest symptoms optic r . ■ r neurltis - of brain tumors. It does not always correspond to the size of the tumor. The neuritis is usually bilateral. It may develop slowly or rapidly, and in either case proceeds to complete optic atrophy. The child's nerve system being highly susceptible to irritation, J • • 1 j • r Convulsions, increased intracranial pressure is quite early productive of con- general or . , . , 1 local. vulsions of varying severity. The convulsions may be general or local. General convulsions with loss of consciousness may occur in tumors of any part of the brain, but are more common in tumors of the posterior fossa than in those of the anterior or middle fossa. Local convulsive seizures are met with chiefly when the neoplasm occupies certain situations. For example, convulsions beginning in the foot, as a rule, are indicative of the lesion being in the upper region of the motor area ; those of the arm. the middle region, and those of the face, the lower region. It should be remembered, however, that the effects of a tumor may extend far beyond its actual site, and, furthermore, as the case proceeds, convulsions which from the outset have been local may become general. The convulsive attacks may recur fre- quently and last from several seconds to as many hours. The 526 DISEASES OF THE NERVE SYSTEM. convulsions are not rarely followed by paresis or paralysis of the affected limbs. At first the muscular weakness may be transient, but as the disease advances it becomes permanent. The focal symptoms of brain tumors are manifested by uni- or bi-lateral hemiplegia, monoplegia, affections of speech, and Paralysis, paralysis of cranial nerves. The local symptoms pointing to the seat of a tumor attain their greatest precision when the swell- ing — be it a new growth or an inflammatory mass — is seated in the motor area of the cortex. They do not always correspond, however, to the size of the tumor. Furthermore, as the brain usually accommodates itself to the gradually increasing pressure and functional interference produced by the new growths, the appearance of the focal symptoms is frequently delayed until a very late stage of the disease. Once established, local symptoms arc of great help in arriving at a correct diagnosis, except, per- haps, in cases where the tumor is multiple and distributed through various parts of the brain {e.g.. tuberculosis). See "Brain Localization." page 514. With the determination of the seat of the tumor, the diag- nosis is greatly facilitated but rarely entirely settled. Brain Differentia- tumors have several symptoms in common with tuberculous tuberculous and syphilitic meningitis, brain abscess, epilepsy and hysteria ; sypb.iimc the differentiation between tuberculous and syphilitic tumors and mD brain chronic tuberculous and syphilitic meningitis is extremely difh- S epnepsy. cult and often impossible, especially when the tumors are multiple. In tubercle and gumma the symptoms are more gradual in development, the optic atrophy more pronounced and the focal symptoms more marked and localized, while the course of tuber- culous or syphilitic meningitis is more rapid. In brain abscess optic neuritis is less common, there is usually a history of ear disease, and after a period of "latency" it is usually accompanied by severe cerebral symptoms, fever and rigors (see "Encephalitis" page ?22). Jacksonian epilepsy may resemble brain tumor in its early stage, but as the disease advances the diagnosis can readily be cleared up by the absence of optic neuritis and other focal symptoms. There are cases on record of hysterical hemiplegia with convulsions, and contractures which were mistaken for brain tumor. Careful investigation, however, will usually reveal the absence of optic neuritis, and the fact that in hysteria the symp- toms are inconstant and multifarious, rather sudden in develop- ment and rarely progressive in character. SYRINGOMYELIA. 527 The nature of the tumor can sometimes be established by its nl^" 011 of seat. Thus, if the tumor is located in the cerebellum or pons, it of tumor - is probably tubercle or glioma ; if in the cortex, it is apt to be syphilitic. Cysticerci are most commonly met in the meninges or cortex. Abscesses are usually situated in the cerebral or cere- bellar "hemispheres," and but rarely in the central ganglia, the pons, medulla, or the middle lobe of the cerebellum. In view of the possibility of the tumor being syphilitic, it is always advisable to put the patient on an active antisyphilitic course of treatment (iodids and mercury, page 606). In syphi- Anti _ litic disease prompt treatment will soon be followed by ameliora- treatment tion of the symptoms, and, if faithfully persisted in, often by a cure. This therapeutic measure is occasionally attended by favor- able results also in growths other than syphilitic, and should, therefore, be resorted to as a routine procedure in all obscure brain lesions. Should antisyphilitic treatment prove negative, and tonics in the form of fresh air, generous diet, cod-liver oil, iron and Tomcs - the hypophosphites fail to benefit the patient — tonics often do well in tubercle, and if employed early may in exceptional cases arrest its growth — the question of surgical interference should be taken under advisement. An operation is indicated where the tumor is single, and situated superficially in a part of the brain (motor area of the cortex) which can be reached and from which the tumor can be removed without immediate danger to life. Under favorable conditions, an operation should be performed early, before the general health has greatly suffered and per- manent injury has resulted to organs and limbs from persistent brain pressure. Recently successful attempts have been made to remove growths from deeply seated structures ; the results as to life and eventual cure, however, are still too few and too far between to warrant precipitate action. In hopeless cases morphine and its derivatives will help to relieve agony. SYRINGOMYELIA. Cavities in the cord may occur primarily as a congenital arrest Congeil itai of development or secondarily as a result of a gliomatous process *j?q Uired- in the gray (cervical enlargement) and white matter. In pro- nounced non-congenital cases it is manifested by gradual loss of Paralysis power in the upper limbs, trophic disturbances in the skin, sul>- Operation. 528 DISEASES OF THE NERVE SYSTEM. changes 5 cutaneous tissue, and bones (glossy skin, ulceration and necrosis of the phalanges), disturbance of sensibility (partial or complete loss of pain- and temperature-sense, while the muscular and tactile senses are preserved ). Later, signs of muscular atrophy — Atrophy. De g mn j n g w jth a small muscle of the hand and gradually extend- ing up to the shoulder— and paralysis, first of the upper then of the lower extremities, set in. The course of the disease is slow and occasionally interrupted by stationary periods. SPINAL HEMORRHAGE. The hemorrhage may be outside the dura, in the membranes, or umatiZ in the substance of the cord. It is usually of traumatic origin — instrumental delivery, a fall or blow, severe convulsions. The history of the case, therefore, is valuable in the diagnosis. Slight hemorrhage may give rise to no definite symptoms. The diag- nosis of severe hemorrhage is based on the sudden appearance of intense pain in the back, rigidity of the spine, sometimes convul- Pressure sions and, if the pressure upon the cord is marked, paralytic symptoms (see "Myelitis"). The latter are especially pronounced in hemorrhage into the substance of the cord. \Yhere the hemor- rhage is moderate and the patient survives the immediate attack, the tendency of the affection is toward recovery. This may be enhanced by absolute rest on the face or side in a somewhat prone position. Local abstraction of blood, ice to the seat of the injury. Later, attention to the palsy. traumatic symptoms. Paralysis. SPINAL MENINGITIS. hi the majority of cases inflammation of the meninges of the spinal cord is associated with that of the brain (see "Cerebro- spinal Meningitis." page 335 ). Occasionally, however, the inflam- mation is limited to the spinal membranes, like spinal hemorrhage, being produced by traumatism. The symptoms of spinal meningitis are practically the same as rie 'arai sis* ' n s P nia ^ hemorrhage, except that the former affection is marked by a sharp rise in temperature at the onset, and by a more progressive character of the symptoms. Recover}' is exceptional. The treatment is symptomatic. Pain, fever. SPINAL PARALYSIS. 52\) SPINAL PARALYSIS (Poliomyelitis Anterior, Infantile Paralysis). As the name indicates the pathologic anatomy of this affection consists of multiple inflammatory foci (hyperemia, edema, infil- tration of the small cells, swelling and cloudiness of the ganglion cells, destruction of the nerve elements, etc.), principally in the gray substance of the anterior horns of the spinal cord. Occa- sionally the inflammation extends to the anterolateral tracts and Lesions principally in anterior horns. Fig. 168. — Anterior Poliomyelitis, Involving Right Arm. Note atrophy. (Sheffield.) posterior horns, and while, as a rule, the lesion is limited to the cervical or lumbar enlargement or both, it may be found also in other regions of the cord and even in the medulla and pons — hence the diversity of the symptomatology. After abatement of the acute inflammatory process, some of the affected portions of the cord usually (there are but few exceptions) remain more or less permanently injured (atro- phied), and it is upon the extent of this permanent — and not upon the initial — lesion that the further course of the disease depends. It is now generally agreed that the disease, whether it occurs sporadically or in epidemic form, is the result of invasion of the 34 Spontaneous recession of inflam- mation. ,;;n DISEASES OF THE NERVE SYSTEM. spinal cord by a micro-organism or its toxin. The onset is Microbic usually sudden. The local symptoms are preceded by systemic origin " manifestations, such as rise of temperature, headache, muscular pain, drowsiness, sometimes convulsions and other grave cerebral symptoms. This initial stage may last from a few hours to sev- eral days and as the general symptoms disappear they are being Fig. 169.— Pol myelitis, Involving Right Leg. Note 'Toot-drop. (Sheffield.) Sudden, complete, flaccid paralysis. Reflexes lost. replaced by the typical phenomenon of the disease — flaccid paral- ysis. The paralysis usually affects either both legs and one arm, one leg and one arm on opposite sides or very rarely on the same side, or both legs and both arms. Occasionally one extremity is affected, or only the muscles of the neck or abdomen. The paral- ysis is usually complete. The reflexes, both superficial and deep, are almost invariably lost. The faradic reaction is lost early, while the galvanic persists for some time. The paralyzed limbs are limp, flaccid, cool, and at times also cyanotic. The sphincters are almost always intact. In uncomplicated cases sensation is SPINAL PARALYSIS. 531 undisturbed, and there is no tendency to the formation of bed- sores. The paralysis does not remain long in its original inten- spontaneous sity. Consonant with the abatement of the inflammatory process plrfiysis. ° in the spinal cord, which usually occurs within a week, the paral- ysis begins to recede in one or more of the affected limbs, and at the end of a few weeks it is often limited to one or part of one extremity, to a group of muscles, or, in exceptional cases, to one 170, -Poliomyelitis, Involving the Neck. Note forward "head-drop." (Sheffield.) or two muscles. If the paralysis does not disappear within the first few weeks or months, it usually persists for life. The per- manently paralyzed structures soon begin to waste and undergo Atrophy. fatty degeneration. The muscles are flabby and thin and the articular bands so lax that the limb appears elongated and is prone to slip out of joint. Frequently there is also atrophy of the bones. As an immediate result of the atrophy of the diseased parts and the unopposed action (contraction) of the non-paralyzed Contractures antagonistic muscles, the affected extremities become contracted 532 DISEASES OF THE NERVE SYSTEM. and deformed — ordinarily for life, unless prevented and remedied by orthopedic and operative procedures. The deformities in the legs usually occur in the following order of frequency : Talipes equinus, equinovarus, equinovalgus, calcaneus or calcaneovalgus, and talipes varus. Manifold deformities arise also in the arms, neck and vertebral column from paralysis of the respective muscles I see Fig. 114). This is the typical course of the disease. r;is.'H. Fig. 171. — Anterior Poliomyelitis, Affecting Right Leg. Note atrophy and flaccidity of knee-joint. (Sheffield.) Atypical Deviations from the typical course of the disease are not rare, and every epidemic is prone to present certain peculiarities. Thus, the onset may be either very mild or exceptionally severe. Where the onset is mild, the child may be found hopelessly maimed abruptly in the midst of perfect health. On the other hand, not rarely the initial stage is ushered in with vomiting, con- vulsions, stupor and similar meningeal symptoms, and continue for a week or so before revealing the exact nature of the affec- tion. Furthermore the paralysis may develop in stages — at irreg- ular intervals. In some cases paresthesia prevails; in others anesthesia — showing implication of the gray substance of the posterior horns. Occasionally the muscles of deglutition and SPINAL PARALYSIS. 533 respiration are affected, and where the lesion is situated in the medulla oblongata and pons the clinical picture of cephalitis" (facial palsy, etc.) develops. Finally, some epidemics cephalitis polioen- hilarity to Fig. 172. — Paralytic Equinovarus in Poliomyelitis o Standing. (Sheffield. )' Two Years' are distinguished by prompt and complete recession of the appar- ently genuine paralysis. Typical, fully developed spinal paralysis is strongly character- istic and presents no diagnostic difficulties. The initial febrile stage, the sudden appearance and spontaneous partial recession of 534 ►ISEASES OF THE NERVE SYSTEM. Patho- t j ie paralysis, the almost constant integrity of the sphincters and gnomonic l ■ . symptoms. t ] K . sensor) sphere, the abolition of the reflexes and the electric i faradic) reaction and. finally, the appearance of muscular atro- Fig. 173. — Anterior Poliomyelitis, [nvolving Extremities, Face and Abdominal Muscles. (Sheffield.) phy furnish a clear clinical picture. I [owever, in the absence of an epidemic and where the case runs an atypical course, polio- myelitis, especially in its early stage, may be confounded with: Cerebral paralysis, polioencephalitis, myelitis, diphtheritic paral- SPINAL PARALYSIS. 535 ysis, and other affections associated with muscular and neural hyperesthesia and consecutive immobility of the affected limbs. The difference between cerebral and spinal paralysis has already been spoken of (see "Cerebral Paralysis," page 512). Severe poliomyelitis and mild polioencephalitis have many symp- toms in common, and their differentiation is based principally Differentia- upon the facts that in polioencephalitis the tendon reflexes are poiioen- exaggerated and the muscles never exhibit the reaction of degen- myentis! s ' eration. Furthermore, spasticity and choreic and athetoid move- pa P isy, en ments which are characteristic of the latter affection are absent scurvy^ in poliomyelitis. In myelitis the sphincters and the sensory paralysis sphere are almost invariably affected, and decubitus is quite com- progressive mon. Diphtheritic paralysis is preceded by diphtheria, is dis- atrophy, tributed symmetrically, and does not recede en masse, as is typical of poliomyelitis. During an epidemic, when our judgment is apt to yield to the anxiety not to miss the mark, rheumatic affec- tions and scurvy may occasionally be mistaken for spinal paral- ysis. The presence of other rheumatic symptoms (tumefaction of the affected muscles or at the joints) in rheumatism and hemorrhages from the gums, etc., in scurvy, and, particularly, the absence of genuine paralysis in both diseased conditions are decisive. Chronic poliomyelitis may occasionally be confounded with Landry's paralysis (peculiar progress of the paralysis — no reces- sion — normal electric reaction) and progressive muscular dys- trophy (apparent hypertrophy in some muscles and atrophy in others, characteristic waddling gait, family proclivity to the disease. (See also page 545.) With an early diagnosis we are frequently in position to limit the lesion to the primary focus and in part prevent all such deformities as arise from too early and strenuous use of the Rest in affected limbs. During the initial stage — i.e., if the nature of bed - the affection can at all be surmised — all such measures should be adopted as will insure perfect rest to the mind and body of the patient. Die diet should be bland, the bowels kept open, the kidneys and skin active (principally by warm baths) and the ^ a ^f patient preferably isolated, both to avoid transmission of the disease to others and to facilitate the enforcement of absolute restf ulness of the patient. Medicinally, in addition to the warm baths. I place a great deal of reliance upon the abortive and SaIirylates curative value of the salicylates. It should be given in moderately Orthop< flic appliani es. 536 DISEASES OF THE XERVE SYSTEM. large doses all through the initial stage, and be followed by small doses of sodium iodid for a period of about six weeks. Me- dicinal nerve-tonics are in order later. As soon as the febrile symptoms have disappeared it is advisable to institute a course of local treatment consisting of gently stimulating baths, gentle Massage, massage, passive motion — to bring the paralyzed muscles into action — and the galvanic current (two or three times a week with the negative pole on the spine and the positive over the affected structures). This treatment should be continued for months. To prevent severe deformities of the lower extremities it is best to keep the patient off his feet for several months— until the paralyzed muscles have at least in part recovered their strength through the aforementioned mode of treatment. Above all. the child should not be allowed to run about without some sort of orthopedic apparatus to counteract the contraction of the antagonistic muscles. Old deformities demand surgical inter- ference (tenotomy and tendon-transplantation) followed by the roborant mode of treatment just outlined. Persistence in the treatment is the keynote to success. H Natrii salicyl 3iss I 6 Strychninae sulph gr. J4 | 0.016 Elixir simplicis 3j I 30 Aq. destil q. s. ad fSij | 60 M. Sig. : 3j every three hours for a child 4 years old. MYELITIS. This affection is occasionally observed in children principally as a result of traumatism, syphilis and compression of the cord by tuberculous masses and exudates between the dura and vertebrae secondarily to spondylitis. The pathologic process in the cord Psrtboiogic var i es vvith the etiologic factors. Ordinarily the diseased portion at first is red and soft, and later yellow, fatty degenerated, atro- phied and sclerosed. The lesion may be situated in any part of the cord and accordingly the symptoms differ with the localiza- Cervicai. tion. Thus, in disease of the cervical region there is first involvement (motor paralysis and sensory disturbances) of the upper extremities, then of the lower, and, if the lesion is very high Dorsal U P' tne diaphragm also is affected and respiration is interfered with. Tn disease of the dorsal portion there is paraplegia (with muscular rigidity), with exaggeration of the reflexes, anesthesia of the extremities, paralysis of the bladder and rectum and ATAXIA HEREDITARIA. 537 decubitus. In myelitis of the lumbosacral region the paralysis, ^.™^°" etc., is the same as in the former lesion ; but the muscles are at first flaccid, then show degenerative changes to electric tests, then waste, and the skin and tendon reflexes are alike abolished. The feet fall into an extended position, so that the instep is on a line with the tibia. In partial myelitis the symptoms are less pronounced, extending only to such structures as are innervated by the diseased segment of the cord. In unilateral lesions the symptoms, of course, are limited to the side affected. The onset may be sudden or slow, according to cause. Acute cases set in with chills, moderate fever, nausea, sometimes vomiting and convulsions, radiating pain in the back and legs, rapidly followed by the aforementioned typical signs. Cases with gradual onset, e.g., secondarily to spondylitis or compression by extraspinal growths, are manifested by gradually progressing debility of the muscles supplied by the spinal nerves below the compressed area, neuralgic pain, and disturbance of the bladder. If the primary affection (e.g., syphilis) can be reached and remedied before destruction of the cord has advanced too far, the progress of the disease can readily be arrested. Otherwise the f r y e ™tment atlc symptoms continue to grow worse and at best can only be im- proved by massage, passive motion and faradization, procedures which are generally employed in all forms of chronic paralysis. Attention should be paid to the bladder (catheterization) and bowels, and particularly to the skin, as the tendency to the development of bed-sores is very great. ATAXIA HEREDITARIA (FRIEDREICH) ; HEREDO- ATAXIE CEREBELLEUSE (MARIE). Often parental syphilis. This family affection which is traceable through several gen- erations is of obscure origin. Syphilis in the parents is the most probable cause. The anatomical lesion — degeneration — is sit- uated principally in the cord (the column of Goll, and partly also of Burdach and Clarke) and in some cases also in the cerebellum. The cord as a whole is very thin and small, i.e., arrested in development. The disease attacks the patient insidiously, between the sixth and fifteenth years of life, with symptoms of simple progressive inco-ordination of the lower limbs, trunk, and arms — irregular |" c n °" ordina " swaying resembling that of chorea. Gradually the tabetic-cerc- Progressive ,38 DISEASES OF THE NERVE SYSTEM. c, rebellar gait. General paralysis. Mental irment. bellar gait develops, so that the child is ultimately unable to walk or stand. As the disease progresses, speech becomes peculiar, slightly scanning, heavy and awkward, vision disturbed by nystagmus, and occasionally optic atrophy (Argyll-Robertson symptom is absent, while Romberg's is occasionally present), the face expressionless, the general musculature paralyzed, atrophied, the spinal column curved, the feet humpy-looking with the toes turned up (Friedreich's foot), and, finally, intelligence impaired. Unprovoked and uncontrollable laughter is said to be character- istic of the disease. As a rule, sensation and the cutaneous reflexes remain undisturbed; the sphincters intact until very late, while the tendon reflexes are abolished. The course of the dis- ease is very chronic. The patient is usually bedridden after a period of from five to ten years, but he may continue to live in this -tate another ten vears. Loss of memory; scanning speech ; spastic- paraplegia. DISSEMINATED SCLEROSIS (Multiple Sclerosis). The etiology of diffuse and disseminated sclerosis is not definitely known. It is either congenital, and traceable to alcoholism or syphilis in the parents, or it is met in young, appar- ently healthy and normally developed children some time after traumatism or an attack of an infectious disease. Its onset is usually insidious with disturbance of motion, loss of memory, and dullness of intellect, soon to be followed by defective speech (at first slow and later scanning), hearing, and vision (nystagmus, amaurosis, and strabismus), spastic paraplegia (weakness and rigidity first of the upper extremities, then of the lower; exaggerated tendon reaction and ankle clonus) and inten- tion tremor. In the later stages of the disease the patient loses control of the bowels and bladder, suffers from difficult deglu- tition, and attacks of vertigo, loss of consciousness and convul- sions, and finally enters into a state of mental and physical exhaustion, paralysis and idiocy. Death occurs after several years. The symptoms just enumerated do not all prevail in every case. They differ with the location of the sclerosed patches. As a rule, the latter are found not only in the brain but in the medulla and spinal cord as well — chiefly in the white substance. The disease is very rarely influenced by treatment. Antisyphilitic medication, however, is worth trying. CONGENITAL RIGIDITY OF LIMBS. 539 CONGENITAL RIGIDITY OF THE LIMBS (Little's Disease). The nature of spastic spinal paralysis is still obscure. Degen- erative changes have frequently been found in the pyramidal Fig. 174. — Little's Disease. "Scissors-gait" or cross-legged progression. (Sheffield.) Lesions tracts or their correlative structures of the encephalon. But whether these are the results of early antenatal arrested develop- g*™™'" 1 * 1 ment (porencephalia), intra-uterine disease, traumatism during labor (embolism or hemorrhage), or simple prematurity are questions awaiting correct solution. Some cases are certainly acquired. The symptomatology of this affection is sometimes manifested 540 DISEASES OF THE XERVE SYSTEM. soon after birth and sometimes not until the child hegins to walk. Rigidity. One of the earliest symptoms is rigidity of the limbs. The child usually lies motionless (does not kick) with the legs pressed against each other or one upon the other. He begins to walk late and with difficulty or may not walk at all. If he is able to walk, he takes short rigid steps with the feet in tiptoe position. Scissors- and the knees pressed closely together or crossing one another, sometimes half running so that at every step a fall seems immi- nent. The rigidity gradually grows worse, leads to fixed defor- mities and extends to the upper extremities and even the trunk. z-shaped A Z-shaped deformity is often observed in the hand when the patient attempts to use it. Early in the disease the deformities disappear during sound sleep or deep anesthesia. The knee-jerk is exaggerated, ankle clonus is generally present, atrophy is slight and develops late and the sphincters are normal. The majority of cases present symptoms of defective psychical development (up to idiocy), stammering nystagmus, strabismus, athetosis and epileptic convulsions. Where the latter symptoms prevail, the prognosis is very bad, otherwise it is not absolutely unfavorable. Under suitable treatment — stimulating baths, pas- symptomatic sive motion, massage and galvanization and later immobilization treatment. .. ° . ....... in the corrected position for a period of months, and, if this fails, tenotomy, tenectomy and tendon transplantation followed by the aforementioned therapeutic measures — the progress of the disease may be arrested and a partial cure obtained. Antisyphilitic medication is sometimes beneficial. The differential diagnosis between this disease and polio- ^foTf'rom ence P na litis is based principally upon the absence (in Little's dis- poiioen- ease) of true paralysis and the presence of the characteristic, cephalitis. l ' jerk}', half-running, spastic scissors-gait. TUMORS OF THE CORD AND MEMBRANES. Neoplasms of the cord are very rare and, hence, principally of pathologic and diagnostic interest. They may be primary (some- times congenital) or secondary. Tubercle is the most frequent variety observed ; next in frequency are gliomas, syphilomas, 1 1 1 >< imas and sarcomas. The symptomatology depends upon the seat of the growth, essentially resembling that of myelitis, except that it is of gradual development. In benign unilateral tumors the symptoms (motor PERIPHERAL FACIAL PARALYSIS. 541 and sensory paralysis) are limited to the side affected. Anti- syphilitic treatment deserves full trial, and, if this fails, operative interference should be resorted to. PERIPHERAL FACIAL PARALYSIS (Bell's Palsy). Facial paralysis may be due to trauma, pressure and irrita- tion (swelling or disease) from contiguous structures, or ex- posure to cold or draughts. Fig. 175.— Peripheral Facial Paralysis— Bell's Palsy. Note inability to close right eye and drooping of right lower lip. (Sheffield.) The symptomatology is essentially alike in all cases irrespec- tive of cause. The paralysis is usually unilateral and affects the muscles of the forehead, the orbicularis oculi and some of the lower facial muscles. As a result of it the paralyzed side of the face is lax and expressionless, the nasolabial fold more or less effaced, the eye remains widely open and the angle of the mouth droops. The paralysis becomes especially pronounced, when the muscles are thrown into action, e.g., on laughing or crying. In severe cases there is also paresis of the soft palate, and impair- ment of speech and mastication, ami occasionally dullness of taste and diminished secretion of saliva. In otic facial palsy there may be disturbance of hearing ( hyperacuteness ). In the so- lvability to close affected eye. Distorted tVat ur.'S. 542 DISEASES OE THE XERVE SYSTEM. Rheumatic, called rheumatic variety (due to exposure), the onset is usually sudden and accompanied hy neuralgic pain. The electric reaction remains normal in mild cases, but is diminished or lost in grave cast--. The prognosis and treatment depend upon the etiologic fac- Traumatic. tors Traumatic, especially obstetric facial palsy (q.v.), where the trauma is slight, usually ends favorably within a few weeks — without any therapeutic measures. Facial palsy arising from involvement of the facial nerve by aural suppurative processes (middle ear disease ; caries of the petrous portion), usually runs a more protracted course, often long after removal of the cause. Early attention to the ear affection is of vital importance. Cases resulting from dental carles! cai "i es can readily be remedied by treatment, possibly extraction of the diseased tooth. Rheumatic, grippal, etc., facial palsy ordinarily responds to local heat, the salicylates, quinine and arsenic. Pressure neuritis usually abates with disappearance of the tumor exerting the pressure upon the nerve. Facial palsy occurring in connection paralyses 6 w ^ n parotitis calls for no special treatment. Where the pressure is due to a new growth, enucleation of the latter should promptly be undertaken. Recovery is not as rapid in the latter form as in the other varieties. After abatement of the hyperacute symptoms a weak galvanic current should be applied four to six times a week, for from two to three minutes at a time. The anode should be held behind the ear. while the different facial nerve branches and muscles are stroked with the cathode. It has been observed that recovery is assured — after a shorter 1 assured or longer period of time — in all cases of facial paralysis in which "r'ciurn'of the electric reaction remains normal from the start or returns to reaction normal after a lapse of from one to two weeks. On the other hand, cases which present complete reaction of degeneration of nerve and muscles after that period of time usually offer a doubt- ful prognosis. Protracted cases may lead to degeneration and shortening of the affected muscles, so that the face appears drawn to the paralyzed side. Differentia- Peripheral facial paralysis should not be mistaken for central cerebral or nuclear facial palsy. In cerebral palsy the muscles of the nuclear forehead and eyes, for the most part, escape (i.e.. the patient is paralysis. able to frown and to close the eve on the affected side) ; the elec- POLYNEURITIS. 543 trie reaction is retained ; furthermore, the palsy is frequently asso- ciated with hemiplegia of the same side. In nuclear or basilar paralysis the palsy is usually limited to the lower half of the face (from the mouth down) and is complicated by other symp- toms indicating a lesion in the pons, such as crossed paralysis and disturbed action of other cranial nerves. POLYNEURITIS (Multiple Neuritis). Polyneuritis is an inflammatory, degenerative affection of the peripheral nerves. In severe cases the lesion ascends to the nerve trunks or even the roots. Its distribution is almost always Bilateral and sym- bilateral and symmetrical. Polyneuritis is very rarely observed metrical. in children, since the principal causes of the affection — alcohol-, lead- and arsenic-poisoning — are of exceptional occurrence in young children. The most frequent form of polyneuritis en- countered is that described as "Diphtheritic Paresis." (See "Diphtheria.") The onset of multiple neuritis is usually fairly rapid with numbness, pricking, pain and chilliness of the parts to be affected. ^ T . > r a> r r- Numbness, This is followed by the appearance of motor inco-ordination P ain and J rir motor mco- ( ataxia) up to paralysis of symmetrical groups of muscles {e.g., ordination, of the hands and feet) or of entire extremities. The lower extremities are ordinarily affected first and the upper later. Genuine foot- and wrist-drop are rare exceptions. The same is true of involvement of the muscles of the trunk, and the sphinc- ters. The motor symptoms are usually associated with sensory disturbances — pain, especially on pressure, along the nerve trunks, hyperesthesia and more rarely anesthesia. The electric and tendon reactions are diminished, and reaction of degeneration is quite common in severe cases. With early treatment — elimina- tion of the poison (sodium iodic!, magnesium sulphate, in lead poisoning), mitigation of pain (salicylates, warm baths), tonics (strychnine, iron, etc.), and galvanic electricity and massage — the prognosis is usually favorable, except when the respiratory muscles are affected. Occasionally atrophy, with consecutive Atrophy contractures and deformities, may persist for a long time, and contracture; even for life. 544 DISEASES OF THE XERVE SYSTEM. Differential Diagnosis. Polyneuritis. Poliomyelitis Landry's Disease. Onset Usually slow. Slight fe- ver, if any. Quite acute ; often vomiting. Moder- Slight prodromata (pain); no fever. ate fever. Distribution of par- alysis Symmetrical. Partial. Lower than upper ex- Irregular. Complete; often only onelimb, At first asymmetrical. Ascending. Com- tremities. Exception- or a group of mus- plete. Legs, trunk, ally other parts of cles, e. g., neck. arms, and muscles body. innervated from the medulla. Hyperesthesia Persistent. Transient. Variable. Anesthesia Present (partial). Absent. Absent. Atrophy and de- formities Late. Early. Very late, if at all. Termination As a rule, gradual recov- Partial, spontaneous, Usually fatal within ery. recovery. two weeks. Excep- tionally, recovery. The history of the case is very helpful in the diagnosis. Thus, in multiple neuritis, we are often able to elicit a history of some form of toxemia (infectious disease; lead-, arsenic-, or alcohol- poisoning) ; in poliomyelitis its prevalence in epidemic form may be decisive. Differentia- Polyneuritis may occasionally be mistaken for hereditary tion from . J ,-,, • , r • , hereditary ataxia — very slow in development, involvement of cranial nerves; ataxia and myelitis, mental debility ; and myelitis — sphincters invariably involved. HEMIATROPHIA FACIEI (Progressive Facial Hemiatrophy). The nature of this rare affection is still obscure. The path- ologic findings point to an interstitial inflammatory process of the trigeminus. It occurs in girls more frequently than in boys, on the left side more than on the right, and exceptionally affects both sides of the face. Beg 'fossa ^ begins with a small part of the face (usually over the fossa canina canina) turning white, thin, wrinkled, etc. From here the Atrophy of * muscles atrophy rapidly spreads to the muscles and bones of the entire and hones. tr J tr J r half of the face, including the hair. At times the atrophy spreads to the chest and other parts of the body, but finally reaches a permanently quiescent stage. Sometimes there are also anomalies of pigment. It is occasionally associated with scleroderma and exi >phthalmic goiter. Sensation remains intact and the electric reactions are normal. The cause of the atrophy being unknown, the treatment must, necessarily, be symptomatic. Paraffin injections have proved very useful to correct the remaining facial deformity. MUSCULAR ATROPHIES. 545 HEREDITARY PROGRESSIVE MUSCULAR ATROPHIES (1. Spinal. 2. Neural. 3. Myogenic). This classification is intended solely to emphasize the prin- Family cipal locations of the underlying lesions. The disease is trans- dlsease - mitted from generation to generation and often affects several members of the same family. 1. SPINAL PROGRESSIVE MUSCULAR ATROPHY. It is observed in early infancy. It begins with weakness of the muscles of the legs, back, neck, throat, shoulders, arms, hands, fhTielsT'^ fingers and toes. As the disease advances the muscles are com- over^body! pletely atrophied (rarely pseudohypertrophied) so that the child is entirely helpless. The reflexes are abolished and the electric reactions greatly disturbed. The disease ends fatally within about four years from involvement of the respiratory muscles and consecutive pneumonia. The lesion consists of atrophy of the cells of the anterior cornu of the entire spinal cord and degenera- tion of the motor nerve fibers. There is no central involvement ; hence, no cerebral symptoms. The sphincters are intact. Fibril- lar twitching is infrequent. 2. NEURAL PROGRESSIVE MUSCULAR ATROPHY (Peroneal Type). It is characterized by atrophy beginning with the muscles of the legs, especially the peroneal group, and by predominance of pe^^ 1 ^ sensory disturbances, hyperesthesia or anesthesia. In walking |[°g C p le ° f the child lifts the feet high and touches the floor with the tips. ^ C n a ds 0nally If the muscles of the hands are affected the hand becomes claw- shaped. Occasionally other muscles are implicated. The patel- lar- and Achilles'-tendon reflexes are at first diminished and later abolished. The electric reaction of the atrophied muscles varies — is normal in some cases, disturbed in others — irrespective of the state of the atrophy. Fibrillar twitchings are common. The {BtSSngfc course of the disease is very slow and interrupted by remissions of variable length, and judging by the underlying pathologic anatomy of the affection (degeneration of the respective per- ipheral nerves, with slight implication of the spinal cord ) it is per se probably not fatal. Massage, baths and electricity are of benefit. 35 ,4i; DISEASES OF THE XERVE SYSTEM. MUSCULAR ATROPHIES. 547 3. MYOGENIC PROGRESSIVE MUSCULAR ATROPHY (Dystrophia Muscularis; Pseudohypertrophic Paralysis). Under this heading are grouped the following four morbid conditions which were formerly looked upon as distinct path- ologic entities : — Fig-. 178. Figs. 176, 177 and 178. — Pseudohypertrophic Paralysis. Dem- onstration of mode of rising from the floor by "climbing upon him- self." (Sheffield.) (a) Simple Hereditary Muscular Atrophy. — Tt usually attacks children between eight and ten years of age, and is mani- ^l^oph fested by weakness and atrophy of the muscles of the back (with- muscles. 1 out pseudohypertrophy ). lordosis and paresis. 548 DISEASES OF THE NERVE SYSTEM. ( /' I Infantile Muscular Atrophy — Facioscapulohumeral in early Type (Landouzy-Dejerine). — As the name indicates it begins T ' in early infancy with atrophy of the face, especially the orbicu- laris oculorum and oris and the lips. The patient is unable to face, close the eyes, to point the month, and his face becomes expres- sionless, like a mask. Pseudohypertrophy of the facial muscles sets in later, so also the atrophy of the muscles of the scapulo- humeral regions. (c) Juvenile Muscular Atrophy (Erb). — The atrophy is Muscles manifested, at a later age than in the former variety, in the and back, following order: The pectorals, the anterior serrati, the latissi- mus dorsi. the rhomboidei, and the trapezius muscles, and then the triceps, biceps, brachioradial and brachial muscles. The del- toid is usually strongly hypertrophied. ( r ri 1 t °^ ns promptly removed, and all such therapeutic measures instituted as will help to counteract and eradicate the inherent tendency to spasmodic affections. Fig. 180. — Tetanism. During partial relaxation of spasm. Same case as Fig. 179. (Sheffield.) fy Natrii bromidi 3j Antipyrime 3ss Tr. ammonii valerianatis 3ij 8 Syr. lactucarii 3iv 15 Aq. aurantii flor q. s. ad fjjij 60 M. Sig. : 3j every three to six hours for a child two years old. (Gen- eral nerve sedative.) More or less continuous. DISEASES OF THE NERVE SYSTEM. 2. TETANISM. i This term is intended to denote a peculiar form of more or less continuous muscular hypertonicity occasionally observed in infants under three months of age. The affection is most probably due to Fig. 181. — Tetanism. During Fig. 182.— Tetanism. Same case acme of spasm. Note characteris- as Fig. 181. During partial re- tic position of extremities. (Shcf- laxation of spasm. (Sheffield.) field.) gastrointestinal intoxication, since the infants suffering from it almost invariably are bottle fed, greatly reduced in vitality (often premature or syphilitic), subject to gastrointestinal derangement 1 A similar or the same affection has been described by Hochsinger as "myotonia of the newly born and nursling." This designation is very misleading in view of its resemblance to "myotonia congenita" (Thom- sen), which is an entirely different disease. FUNCTIONAL SPASMODIC AFFECTIONS. 559 — in short present the clinical picture of profound marasmus. The onset of the spasmodic condition is fairly rapid. When fully estab- lished, the posture (see Figs. 179, 181) assumed by the infant is very pathognomonic. The head is retracted, the facial muscles are contracted, the jaws are firmly pressed together, the forearms Flexion of are flexed upon the arms, while the hands are clinched so as to upon form closed fists. The rigidity of the lower extremities is less Fig. 183. — Same case as Fig. 181 iter. (Sheffield.) pronounced. As a rule, the legs are bent angularly, and the feet either overlap each other or are strongly arched. Now and then a partial relaxation of the spasm is observed (see Figs. 180, 182), and the spasm ceases entirely during sound sleep. The hyper- tonicity increases on handling the baby, but the "triad of tetany" is absent. The child is able to nurse without difficulty, in these respects differing from genuine tetanus and eclampsia. With improvement in the general condition the spasticity gradually (within a week or a month or longer) subsides. Few babies survive, however, the persistent gastroenteritis and increas- ing exhaustion. The treatment is the same as in tetany, except Differentia- tion from tetany, tetanus and eclampsia. 560 DISEASES OF THE NERVE SYSTEM. that there is seldom an indication for the employment of hypnotics. 3. TETANY. contract! ^' 1 ' s disease ^ s characterized by intermittent somewhat pain- ful contraction of certain groups of muscles, especially of the extremities, with exaggeration of the mechanical and electric and B sudden! irritability. The spasm is bilateral and usually sets in abruptly without loss of consciousness. The hands assume a very peculiar shape greatly resembling that of holding a pen or of an obstet- rician dilating a tense cervix uteri (main d' accoucheur). Thus, T hand l ' ie ,m & ers are flexed upon the palms, the phalanges are extended, the thumbs are turned inward so as to he covered by the other fingers, and the wrists are flexed in pronation. When the lower extremities are affected the legs are adducted and the plantar surfaces of the feet are strongly arched, with a tendency to an equinovarus position. Occasionally the tetanic spasm extends to the neck and back, and exceptionally also to the laryngeal and ^iorm. other muscles of the body. On the other hand, cases of tetany are encountered in which the spasms are entirely wanting or barely indicated. These "latent" or passive forms of tetany may frequently be brought into activity by energetic pressure upon the . main trunks of the nerves or vessels. This peculiar mechanical Trousseau s l sign, manifestation is spoken of as "Trousseau's phenomenon," and forms one of the three positive signs of tetany — the so-called chvostek's "triad of tetany." The other two signs of tetany are those of phenomenon. Chvostek and Erb. "Chvostek's phenomenon" is based upon exaggeration of the mechanical irritability of the motor nerves, especially of the face (facialis phenomenon), and consists of lightning-like contractions of the face superinduced by percussion (with the finger or hammer) over a branch of the facial nerve Erb's sign. wn ji e r h e f ace j s m a state of perfect rest. "Erb's phenomenon" is based upon electric excitability of the motor nerves, so that a very slight electric current produces KaSz 1 or even KaSTe, if the current is but slightly increased. Sometimes AnOeTe and KaOeTe are obtained. The duration of the tetanic attack varies from a few minutes to several hours or longer, and may recur once or several times daily or but once in several days. In the great majority of cases the disease usually subsides within a few days or a month or 1 Ka stands for cathode; An, for anode; S, for closing; Oe, for open- ing; z, for weak contracture; Te, for tetanic contraction. FUNCTIONAL SPASMODIC AFFECTIONS. 561 two, without any permanent sequelae, provided suitable treatment is instituted early. The treatment, especially with the view of prophylaxis, is essentially the same as employed in rachitis — cor- responding to the apparent relationship that exists between the pathogenesis of rickets and that of tetany. Like rickets, tetany Related to rickets. Fig. 184. — Tetany (child 11 months). Note characteristic attitude of hands. Slight contracture of feet. (Sheffield.) occurs in infants chiefly of a half to two years of age. Like rickets, tetany shows a predilection for poorly fed and poorly housed children, and finally, as in rickets, the immediate cause of tetany seems to be some form of intoxication, intestinal or .otherwise. Whether or not the immediate cause rests upon functional or Anti- rachitic treatment. Differentia- tetanus, tetany and tetanism. 562 DISEASES OF THE NERVE SYSTEM. organic disturbance of the thyroid gland or parathyroids is still subject to great differences of opinion. The diet should be regulated, as to quality and quantity. Young infants should, if possible, receive breast milk. The intes- tinal tract should be cleansed with calomel by mouth, lavage and high enemas. For the relief of severe contractions prolonged warm baths, bromids and chloral, will usually prove efficient. (See also "Rachitis," page 503.) 4. PSEUDOTETANUS (ESCHERICH). tTon e from This affection differs from tetanus principally by its predilec- tion for the muscles of the trunk, and by its afebrile course ; from tetany by its spasticity being continuous, and from tetanism by the fact that it attacks children of from four to fourteen years of age (instead of infants) who are apparently enjoying perfect health. The pathogenesis of the disease is still unknown. The patients (usually boys) suddenly complain of stiffness in the legs and inability to walk about. The rigidity rapidly extends Arms and to the back and head, so that the patient lies motionless like a log, hands free. exce p t f or n j s ability to make free use of his arms and hands. The affected muscles are maximally contracted, prominent, and as hard as marble. The facial muscles except those of the eyes also are in a state of tonic spasm, so that the facial expression is that of trismus, the teeth are firmly set together and barely sep- arable with force. Nevertheless, there is but little difficulty in feeding the patient. The rigidity is in partial abeyance during sleep as well as perfect rest, but greatly increased — up to painful opisthotonos, spasm of the diaphragm, etc. — by all sorts of bodily or mental irritations. During the height of the disease such spas- modic paroxysms may occur also spontaneously several times a day and are usually followed by profuse sweating. The spasmodic condition persists without apparent variation for from three to six weeks, whereupon the contractures gradually (within from two to four weeks) abate never to return. The treatment is symptomatic (see "Tetany," page 558). Gavage, if necessary. 5. SPASMUS GLOTTIDIS (Laryngospasmus). Spasm of the glottis is a disease of infants of from six to twenty-four months old — the age in which rickets is most apt to Persists for weeks. CHOREA VERA. 563 prevail. It is closely related to and a frequent partial phenomenon of tetany, and seems also to rest upon the identical pathogenesis of the latter disorder. The spasmodic attack is manifested by sudden deep inspira- tion, dyspnea, apnea, pallor and later cyanosis of the face, fixation Attacks of or rolling of the eyes, and more or less marked rigidity of the apne ' body. At the end of a few seconds breathing is resumed after a noisy expiration. In severe cases the spasm not rarely extends expiration, to the diaphragm and to the entire musculature of the body. The attacks usually recur at shorter or longer intervals (sev- eral times a day!) and, if not terminating fatally — which may occasionally take place very suddenly even during a simple attack as a result of asphyxia — gradually subside after a few weeks or months. In mild cases recovery is the rule. The physician should be guarded, however, in the prognosis. Spasmus glottidis can readily be distinguished from other forms of laryngeal stenosis by its intermittency and noiselessness. tion from It should not be confounded with the momentary apnea ("hold- stenosis'. ing the breath"), frequently observed in children during a fit of crying. (See also "Congenital Stridor," and "Thymus Hyper- trophy.") As the physician rarely has the opportunity to witness an attack of laryngospasm, his efforts must be directed chiefly towards its prevention. This is best accomplished by antirachitic rachitic . . ... treatment. treatment (q. v.), careful atention to the alimentary tract, and calming of the nerve irritability by means of small doses of sodium bromid (see "Eclampsia," page 555). Severe attacks call for stronger hypnotics. A severe attack may be aborted by dashing cold water in the child's face, exciting choking motions by pressure upon the root of the tongue, and exciting sneezing by irritating the nasal mucous \membrane. Timely intubation and artificial respiration have saved some babies from immediate death. CHOREA VERA (St. Vitus's Dance). Genuine chorea is an acute, infectious, sporadic and epidemic affection characterized by spontaneous, irregular movements of j^° bic the voluntary musculature, and by a special tendency toward cardiac complications. 564 DISEASES OF THE NERVE SYSTEM. The specific causal micro-organism of this disease is still Related to unknown, but is probably closely related to that of rheumatic affections, with which chorea is occasionally associated. Other infectious diseases (such as exanthemata), fright and mental overwork serve as predisposing causes. The onset of chorea is preceded by prodromata varying in duration from a few hours to a few days. They consist of fret- fulness, fatigue, restless sleep and occasional twitching. After the prodromic stage the actual attack may be precipitated abruptly and witli full force, or come on gradually and run a mild course. Grotesque, The cardinal svmptoms of the disease are irregular, awkward, iuvoluntary . , . , , , , muscular involuntary, muscular movements — hasty and beyond control — which which cease only during sound sleep. The movements inter- auring mittently involve various sets of muscles, never letting up a moment while the patient is awake. The movements are intensi- fied when the patient is conscious of being observed, and tries to control them, or attempts to perform some voluntary action. The shoulders, one or both, jerk upward or downward ; the arms rotate from side to side, or are forcibly thrown backward or forward ; the hands are engaged in incomplete extension, flexion, pronation or supination, while the fingers are bent, extended or shoved one over the other so that the patient is unable to hold an object firmly, to write, to button a garment, etc. The head sways from side to side, often describing a semicircle, or is dropped downward so that the chin touches the chest wall. The facial muscles twitch, and produce grotesque distortions of the face and mouth. The forehead is wrinkled, the eyes open and close, the patient seeming to cry or laugh. In one case under our observation the iris ( !) was involved so that the pupils contracted and dilated almost incessantly. The tongue participates in the movements, causing difficulty in eating and drinking, and defective speech up to aphakia. The movements of the lower extremities vary with the intensity of the attack, in severe cases being of such nature that the patient is unable to stand, sit or lie still, and frequently falls, stumbles, or is thrown out of bed and injured. During the acme of the attack it is not uncommon to find irregular respiration and InV o'f V he 1 a e r I t t ar hy tnrma °f tne pulse— both from implication of the respiratory muscles and the heart {chorea cordis). Notwithstanding, how- ever, the intensity of the movements the patients rarely complain of being fatigued, in fact a great many children are otherwise in perfect health. The temperature is normal, the digestion good, CHOREA VERA. 565 sensory disturbances are usually rare and slight (hyperesthesia along the course of the nerve trunks), the patellar reflex is some- what exaggerated, but the cutaneous sensibility and reflexes are unaltered. If left untreated the active stage of the disease lasts from four to six weeks, then the symptoms gradually diminish and may Self - hmited - disappear entirely a few weeks later. Some cases run a mild course from beginning to end, at no time presenting the afore- mentioned grotesque muscular excursions. This is especially prone to occur if treatment is begun early, and persisted in. The intensity of the atttack stands in no relation to its dura- tion; on the contrary, cases of slow development and moderate severity may run a chronic course and suffer relapses, while violent cases often respond to a few weeks' treatment. This incongruity is often observed also as regards complications, mild cases being tu>ns Pllca ~ not rarely associated with inflammation of the joints, pleura, peri- cardium or endocardium, whereas severe chorea may run its course without any untoward result. In reference to heart com- plications it is well to remember that not every blowing heart sound heard in chorea is indicative of a valvular lesion — the majority of these adventitious sounds disappear, perhaps, never to return. On the other hand, heart lesions have been found at the autopsy without any indications of their presence during life, a fact which strongly emphasizes the necessity of prophylactic measures being taken against heart disease (perfect rest) during the active stage of the disease. Sometimes the muscular disturbance is limited to one-half of the body (hemichorea), showing that the lesion is localized in one hemisphere of the brain. This form of chorea is more serious than bilateral chorea. It is often associated with paresis of the • it \ Paralysis. extremities, one or both {chorea paralytica; chorea mollis), and changes in the psychical condition, e.g., melancholy, hallucina- tions. Notwithstanding the grave nature of the affection the prog- nosis of chorea, on the whole, is favorable. A fatal termination is exceptional. It may occur either as a result of complicating heart disease, or from some, as yet unknown, effect upon the central nerve-system. To the latter class belong the cases asso- ciated with delirium and prostration. On the other hand, the prognosis as to permanent recovery is not quite promising. Recurrences are frequent, and as previously mentioned the tend- Recurrence, ency to permanent heart disease great. 566 DISEASES OF THE NERVE SYSTEM. With these facts in view, the urgency of instituting preventive measures against chorea is obvious. This is strongly empha- Epidemicity. s j zec i ] )v {] lc observation that chorea may appear in epidemic form (it is quite common to find several members of one family to be pseudo- attacked simultaneously or within a brief period of time). I am chorea. not re f err j n itdii Crusta lactoa. DISEASES OF THE SKIN. Chronic coursi . of a pustular eruption as a result of scratching and secondary infection. The course of eczema is very tedious. It may last weeks, months, or years. Improvement often alternates with aggrava- tion of the condition. This is true especially of eczema accom- panying constitutional derangement, e.g., gastrointestinal intoxica- Fig. 199. — Seborrheic Eczema of Head and Face. (Sheffield.) Secondary infection. Avoid trritatioD tion. The duration of the disease is often greatly prolonged by infection of the diseased as well as healthy areas with divers para- sites during the act of scratching. The success in the management of eczema depends greatly upon the ease with which the underlying causes can be prevented or removed. The infantile skin being very delicate and vul- nerable, it is essential to avoid its undue exposure to mechanical (scratching; woolen, rough underwear, etc.), thermal (excessive heat or cold, also direct action of the sun, etc.) and chemical (rubefacients, irritating soaps, urine, acrid discharges, etc.) ECZEMA. 593 Correct faulty irritation. The diet should be bland (not too rich in fat), and regulated as to the time of feeding and its quantity. Constipa- diet - tion should be promptly remedied. Cleanliness of the skin and everything coming in contact with it should be insured. The active treatment of eczema should be regulated in accord with the stage of the disease. While the skin is highly inflamed, all sorts of irritation should be interdicted. Tub-bathing of the Avoid & excessive entire body should be discontinued for a time, firstly, because of moisture, the tendency of water to irritate the denuded skin, and, secondly, in view of the possibility — particularly in eczema due to external parasitic infection — of conveying the disease from one portion of the skin to the other. The healthy parts of the body, however, should be kept scrupulously clean by frequent sponging, followed by careful drying. The following soothing and protective ointment, employed Protective with great success at the New York Post-graduate Hospital, will ointments - be found invaluable in the great majority of acute or subacute cases : — R Zinci oxidi, Pulveris cretae aa 3iv | 16 Mix, and add with constant stirring : Olei lini (hot), Liq. plumbi subacet. dil aa 3ij | 8 The ointment is applied once or twice a clay thickly over the affected areas and covered by sterile gauze held in place by means of a bandage. Scratching of the skin should be prevented by f c r r e a ^j ng mechanical means, such as celluloid armlets, and the like. Ex- coriated surfaces often heal promptly after painting with a 2 per cent, solution of nitrate of silver. After the inflammation subsides and scales and crusts firmly adhere to the skin, the soothing ointments are gradually replaced by those of a stimulating nature. The crusts are softened with oju^nts 115 carbolized oil (1 to 100), and gently removed. The hairy por- tions of the body are carefully shaved and cleansed with car- bolized oil. After giving the affected skin a few hours' rest we apply one of the following preparations : — B Acidi salicylici, Bismuthi subgal aa gr. xx | 1.3 Thymolis gr. v | 0.3 Pulveris amyli oiij | 12 Ung. hydrargyri ammoniati 3ij I 8 Ung. zinci oxidi q. s. ad .?i j | 60 38 594 DISEASES OF THE SKIX. B Resorcini gr. xx Acidi carbolici gr. x Olei cadini ihxx Sulphuris precipitatis 3ij Ung. pctrolati q. s. ad Si j 1.3 0.65 1.3 8 60 irrigation. Transient multiform intestinal High intestinal irrigation once a day with a quart or two of plain water or with the addition of 2 per cent, of bicarbonate of soda is useful in all cases. In gastric hyperacidity carbonate of magnesium (gr. xxx, once a day) acts well. Obese children suffering from obstinate eczema with dryness of the skin often do well on minute doses of thyroid extract. Finally, it is worth remembering that protracted eczema is occasionally a manifesta- tion of hereditary syphilis, and responds promptly to the exhibi- tion of mercury and the iodids. URTICARIA (Hives, Nettle Rash). Urticaria is characterized by a multiform eruption of whitish, eruption, pinkish or reddish color upon different portions' of the body, which is sudden in appearance and disappearance, and shows a tendency to repeated recurrences. The eruption may consist of "Wheals." circular or spiral elevations ("wheals"), papules, vesicles, or hemorrhagic spots, and is generally associated with intense itch- ing and stinging. It is frequently preceded and accompanied by gastric and nervous disturbances and rise of temperature. Recurrent urticaria is prone to leave behind marked pigmenta- Tend pruHgo° ti° n °f tne s k' n or to terminate into prurigo, a very chronic skin affection manifested by dryness, hypertrophy and pigmentation of the skin and inflammation of the neighboring glands. As in the majority of instances, urticaria in children is the tl&aAni resu 't of faulty feeding, especially of eating candies and cakes of poor quality, fish, fresh berries and the like, it is essential promptly to regulate the diet, and to clear the gastrointestinal tract of the obnoxious material. The latter is best accomplished by small doses of calomel, magnesium carbonate and sodium bicarbonate and a high enema. To relieve itching we may resort to warm baths with bicarbonate of soda ( J / 2 to 1 pound) ; sponging of the body with vinegar followed by glycerin, or to the following preparations : — R Thymolis gr. v to x | 0.3 to 0.65 Ung. aquas rosse 3j | 30 Sig. : P. r. n. PSORIASIS. 595 fy Aquae ammonias 3ss | 2 Aquae hamamelidis Biij | 90 Sig.: P. r. n. Not to be used over abraded portions of the skin. INTERTRIGO (Chafing). This affection occurs with predilection in localities where opposed body surfaces rub against each other, and in the "napkin region.'' It is the result of irritation of the skin by acrid secre- tions or excretions (sweat, diarrheal stools, acid urine, purulent discharges, etc.), excessive heat or moisture. Intertrigo usually begins with simple erythema. At this stage it readily yields, in addition to removal of the etiologic factors, to the application of a. dusting powder of : — 3 Zinci stearatis 3iv | 15 Bismuthi subnitratis • gr. xv j 1 Amyli Sj j 30 and the separation of the apposed surfaces by thin layers of absorbent cotton. As the disease advances, the skin becomes _; Glossy, glossy, moist, sticky, and denuded of epidermis, and the seat of m ° ist ° J ' J ' _ .... . redness. papules, abscesses and ulcerations. In this condition intertrigo is very refractory to treatment, often demanding a complete change in the regime of the baby — beginning with its diet and ^ n |® of ending up with its nurse. The customary daily tub-bath should nurse, be replaced by a sponge bath, taking special care to keep the affected parts of the skin perfectly dry. The denuded skin should once daily be painted with a 1 or 2 per cent, solution of nitrate £[{*^ te of of silver, and the entire diseased surface covered with the fol- lowing ointment : — I£ Acidi carbolici, Balsami Peruviani aa m v | 0.3 Olei lini, Adipis lanae, Ung. zinci oxidi aa 3iv | 15 Sig. : To be applied several times a day after carefully cleansing (with oil) and drying the affected parts. PSORIASIS. The disease is very exceptionally met in children under five years of age, but is not uncommon in older ones, it begins with minute white spots usually upon the extensor surfaces of the siiyery. 1 J l white elbows and knees and upon the scab), and gradually assumes the S( ' ales . shape of disks with tawny-red base and silvery-white scales, not base - 596 DISEASES OE THE SKIN. rarely giving the skin the appearance of having been splashed Probably with mortar. The cause of psoriasis being obscure (apparently c ' of parasitic origin, though it seem to run in families), the treat- Fig. 200.— Psoriasis in a Girl Seven Years Old. (Sheffield.) ment is necessarily symptomatic, and very unsatisfactory as to ultimate cure. Internally we may try small doses of arsenic, to Arsenic. De continued for several months-, or thyroid extract. Externally we resort to alkaline baths, and, after removal of the scales, to an ointment composed of chrysarobin or salicylic acid and ichthyol. I?. Acidi salicylici, Resorcini, Ichthyoli aa 3ss I 2 Ung. sulphuris 3ij | 60 Sig. : To be applied twice a day. R Chrysaroliini, Ichthyoli aa 3j | 4 Ung. petrolati 3ij j 60 Sig. : To be applied once or twice a day. HERPES ZOSTER. :,<.)- Fig. 201. — Psoriasis of the Legs. {Shoemaker.) HERPES ZOSTER (Shingles). Contrary to what is observed in adults, herpes zoster in children is rarely accompanied by severe neuralgic pain. The eruption usually appears suddenly in the form of groups of vesicles along the tracts of either the intercostal or pudendal nerves, or the brachial plexus. The vesicles remain either isolated or coalesce and form large patches covered by yellowish- brown crusts. Different patches often exhibit different stages of development or decline. As a rule, the eruption is unilateral. The course of the disease is usually completed within two weeks, except in cases leading to deep ulceration and sloughing (herpes gangrenosus), a very rare condition, usually the resull o\ secondary infection. The treatment consists of local application Vesicles along nerve tracts. Danger o£ sloughing. 598 DISEASES OF THE SKIN. of a dusting powder or ointment composed of stearate of zinc with or without 2 per cent, of bismuth subnitrate or subgallate. Occasionally the nerve pain calls for some anodyne, e.g., sodium salicylates, salicylate. Fig. 202.— Herpes Zoster. (Sheffield.) MILIARIA LICHEN STROPHULUS (Prickly Heat). This very common affection in infants, especially during first dentition, appears suddenly upon the face, trunk and extremities Har ™not e fther as discrete papules or vesicles from a pinhead to half a infected. p ea j n s j ze or j n g roU p S upon a slightly reddened infiltrated base. It is produced by all sorts of external or internal irritations (heat, rough flannel underwear, overfeeding, etc.), and readily yields to Flat IMPETIGO CONTAGIOSA. 599 attention to these causes, and the administration of mild laxatives. The slight itching may be relieved by alkaline or bran baths, and sponging of the body with Dobell's solution. ECTHYMA (Pseudofurunculosis). It consists of pea- to bean-sized, flat pustules surrounded by a red zone. The lesions are situated chiefly upon the thighs, legs, pustules J \ _ ° . ' ° surrounded shoulders and back and are frequently associated with eczema — °y red . . zone. probably produced by infection of the eczematous lesions during the act of scratching. Occasionally the pustules enlarge gradually and burst, leaving behind deep ulcers which heal very slowly with scar formation, ulcerations. These are prone to occur in ill-fed, scrofulous or otherwise seriously diseased children, and may sometimes end fatally as a Gangrene result of gangrene of the skin. Simple ecthyma usually responds to hot baths, antiseptic ointments, or sponging of the affected parts of the body with the following : — U Etheris, Tr. saponis viridis aa 5j | 30 Large pustules should be treated by incision and antiseptic dressings. (See "Scrofulosis," page 370.) IMPETIGO CONTAGIOSA. The favorite seat of impetigo is the face, hands and scalp, but the other portions of the body are not exempt from inoculation. The eruption begins as small groups of minute vesicopapules which soon burst and dry up into yellowish crusts. When a crust has lasted for some time its surface becomes slightly lamel- lated and its edge detached, the crust then presenting the appear- ance as if "stuck on" to the healthy skin. The surface beneath appearance, the crust is raw and suppurating. If further autoinoculation of the disease is prevented, impetigo usually heals spontaneously in about ten days. Otherwise, by the development of new lesions, it may persist for several weeks. In view of the highly contagious nature of the disease and its Conta s ious - tendency to run in epidemic form through schools or asylums, it is imperative to isolate all those children who are suffering from Differentia- tion from simple impetigo. 600 DISEASES OF THE SKIX. this disease and to employ active therapeutic measures to eradi- cate it. This is readily accomplished by means of local antisepsis. After softening the crusts with warm carbolized sweet oil (1 per cent. i. and removing them, and thoroughly washing the diseased surface with soft green soap, the spots are touched up with a 2 to 5 per cent, solution of nitrate of silver, and covered over with sterile gauze and adhesive plaster. This treatment is repeated for a few days and followed up with a 2 per cent, ichthyol in a 10 per cent, sulphur ointment. Simple impetigo differs from the contagious variety by its lesions being pustular from the beginning and by showing no tendency rapidly to coalesce in large patches and to spread to other portions of the body. There is no history of contagion. PEDICULOSIS CAPITIS (Head-lice). The favorite seat of the head-louse is the occipital portion of the seal}). In cases where the hair is thick and the parasites are few in number and hence not easily seen, their presence can readily be surmised by the existence of ova (nits), which are firmly attached to the shafts of the hair. The lesions produced R °eczema S ^y pediculi resemble those of eczema of the head — intense itch- ing, pustules, scabs, matting of the hair, and marked enlargement of the glands of the neck, isolation Children affected by pediculosis should be isolated for a few days until the disease is cured. The hair should be clipped, the scalp thoroughly cleansed with the tincture of green soap, and then dressed with a cloth dipped in petroleum or the tincture of larkspur (delphinium). A few such dressings usually suffice to effect a cure. After removal of the pediculi the scalp should be cleared of its remaining eruption by an antiseptic ointment. PEDICULOSIS CORPORIS (Body-lice). itching. Eody-lice are seldom seen in young children. They give rise to red dots, itching, and scratch marks. The diagnosis is settled by finding the parasite in the clothing or on the body of the child. The treatment consists in destroying or baking the infested garments, scrubbing the child's body with green soap, and the SCABIES. 601 application of a zinc and sulphur ointment until the eruption has entirely disappeared. PEDICULOSIS PUBIS (Crab-lice). This skin affection is of diagnostic interest principally because of the power of the crab-louse to infest (in addition to the hair of the pubis, abdomen, chest and axilla) also the eyebrows infection of and eyelashes, in the latter case giving rise to a clinical picture eyeiashes an resembling blepharitis. Fig. 203. — Phthirius Pubis [Crab-louse]. (After Landois.) The insect succumbs ointment. rapidly to the effects of mercury R Ung. hydrarg. nitratis 3j | 4 Ung. petrolati 3iij j 12 M. Sig. : Externally once a day. SCABIES (The "Itch"). The eruption of scabies is localized chiefly in places where the skin is thinnest, i.e., the hands, the folds between the fingers, the flexor surfaces of the wrists, the anterior fold of the axilla, also the back and lower extremities. The characteristic skin lesion of scabies is an irregularly shaped, brownish-black ridge (cuniculus or furrow), the result of the burrowing process of the Acarus or Sarcoptes scabiei. The latter is the cause of scabies and can readily be demonstrated microscopically in the scrapings of the cuniculus. As the disease advances, it fre- quently spreads over the entire body and gives rise to a multi- form eruption, consisting of papules, vesicles, pustules and hemorrhagic spots (scratch marks). It is accompanied by violent itching, which is worse at night, when the patient is warm in bed. As the disease is highly contagious (conveyed through close Localized chiefly where skin is thinnest. Itching worse at night. .in: DISEASES OF THE SKIN. Disinfection of clothes. bodily contact, clothes, underwear and bedding), it is advisable to restrict the patient from too closely mingling with other mem- bers of the family or outsiders. The patient's clothes, bed-sheets, towels, etc., should be boiled, and the other unwashable articles thoroughly disinfected. Furthermore, all inmates of the house should be examined and, if necessary, treated for scabies, lest the disease will recur through renewed infection. The treatment of scabies varies with the stage of the disease. Green Incipient scabies responds promptly to a few hot baths, thorough ba S t°h a s P scrubbing of the affected skin with soft green soap and the /n\\\///nv\\ Fig. 204. — Sarcoptes Scabiei. Female seen from Above and Below. (After Gudden.) sulphur, inunction of sulphur ointment with 1 per cent, carbolic acid. The management of advanced scabies with the same therapeutic measures is not quite as satisfactory. A number of remedies (strong ointments of carbolic acid, naphthol, creolin, etc.) have been suggested for such cases, but owing to their irritating qualities (upon the skin and kidneys) should be used with caution. The following combination will probably be found to do well in the majority of cases : — R Mentholis, Pulv. camphorae aa gr. x j 0.65 Olei cadini, Balsami Peruviani aa 3j | 4 Ung. sulphuris q. s. ad 5ij j 60 M. Sig. : To be applied in the evening after a hot soap bath. R Acetanilidi 3ss J 2 Ung. zinci oxidi 3j j 30 M. Sig. : To relieve irritation. TINEA TRICHOPHYTINA CAPITIS. 603 TINEA TRICHOPHYTINA CAPITIS (Ringworm of the Scalp, Herpes Tonsurans). Ringworm of the scalp is due to the trichophyton fungus. It is highly contagious and often spreads with great rapidity and Highly pertinacity in schools and children's homes where great numbers C0ntagl0US - of inmates are crowded in comparatively small rooms. The eruption consists of ring-shaped, slightly elevated, scaly, reddish, grayish, or greenish-yellow patches. The hair over the affected areas becomes brittle and loose and falls out, leaving Brittieness behind bald and shiny spots. Fig. 205. — Trichophyton Tonsurans — Threads and Chains of Spores. X 400. (After Bissosero.) At times the eruption is accompanied by severe local inflamma- 1 1 • r 1, • 1 • • •< , • • Tinea tion and exudation of a yellowish, viscid or gelatinous secretion — kerion. a condition generally described as tinea kerion. In the treatment of ringworm of the scalp it is essential not only to prevent spreading of the disease from one child to the other, but also autoinoculation from one part of the scalp to the Prevention other. This is best accomplished by sterilization (before and of epidemics, after using) of the hair clippers, scissors, combs, etc, and thorough scrubbing of the scalp with the tincture of green soap twice daily, and immediately after a haircut. In an epidemic at an orphan asylum comprising nearly 400 cases of ringworm of the scalp, I found the following method of treatment exceedingly serviceable : — R Acidi carbolici, Olei petrolei aa 5ij | 65 Tinct. iodini, Olei ricini aa 3iiiss I HO Olei nisei (German ) q. s. ad 5xvj | 500 604 MSFASFS OF THE SKIX. After clipping the hair close to the scalp this mixture is applied over the entire scalp — more thickly over the affected spots specific — by means of a painter's brush, once a day for five successive of treatment, days. On the sixth day it is wiped off with a rag dipped in plain olive-oil; now the hair is clipped again and the scalp washed thoroughly but gently with green soap and a soft nailbrush, care being taken that all the scales and loose hair covering the scalp Fig. 206. — Tinea Tonsurans. (Shoemaker.) are removed. As a ride, no epilation is necessary. On the seventh day the mixture is reapplied as thickly as before and the whole process repeated regularly for three or four successive weeks — the length of time depending upon the severity of the case. New hair will now be found to appear, and no trichophy- ton fungi will be discovered in the hair epilated for microscopic examination. These procedures are followed by a few days' application of a 10-per-cent. sulphur ointment, and then by the use of the follow- ing preparation for about two weeks : — TINEA TRICHOPHYTINA CORPORIS. 605 B Resorcini, Acidi salicyl aa 3iv Alcoholis Biv Olei ricini q. s. ad 3xvj 16 120 SOU This mixture considerably hastens the growth of the hair on the bald spots. In cases where isolation is impracticable or impos- sible, as often happens in private families, this resorcin mixture serves as an excellent substitute to prevent spreading of the affection. _ Differentia- Tinea tonsurans is not to be confounded with tinea favosa, a tion from tinea hair affection caused by the Achorion Schonleinii, and character- favosa. Fig. 207.— Achorion Schonleinii. X 400. (After Biszosero.) ized by sulphur-yellow, cup-shaped crusts or scutula, penetrated by a hair or two. TINEA TRICHOPHYTINA CORPORIS (Ringworm of the Body, Herpes Circinatus). Ringworm of the body begins as a small, scaly, circular spot which rapidly spreads peripherally and clears in the center, resembling a "ring" in shape. The rings frequently coalesce, forming serpiginous lesions. It is a trivial eruption and promptly yields to a few local applications of the tincture of iodin, white precipitate ointment, Jf" 1 ^ 1 ™ or glacial acetic acid (applied once every other day). 606 DISEASES OF THE SKIN. MOLLUSCUM CONTAGIOSUM. Contagious molluscum is not rarely met in epidemic form in large institutions for children. The etiologic factor of the dis- ease is as yet unknown, wart-iike The eruption appears principally upon the face, eyelids, neck principally and arms, and consists of discrete, semiglobular, waxy-white, umbilicated, small (up to a split pea) wart-like elevations, with sebaceous contents. It is a benign affection and readily curable by ablation of the nodule or expression of its contents, and cauterization with tinc- ture of iodin or 5 per cent, salicylic acid in collodion. on face. INDEX. Abdomen, retracted in meningitis, 343; size and shape of, 39. Abdominal, organs, anatomy of, 36; pain, 40; regions, 19, 37; resist- ance, 40; tuberculosis, 369; wall, normal, 36; wall, congenital mal- formations of, 143. Abducens nerve, paralysis of, 289. Abscess, in appendicitis, 218; cere- bral, 252, 522; ear, 251; in coxitis, 386 ; hepatic, 233 ; in spondylitis, 376; retropharyngeal, 249. Acarus or sarcoptes scabiei, 601. Aceton in urine, 46. Achondroplasia, 504; differentiated from rachitis, 502. Achorion Schonleinii, 605. Addison's disease, 481. Adenie, 472. Adenitis, scrofulous, 370; in skin dis- eases, 591 ; tuberculous, 373. Adenoids, 243; curette, 247; differen- tiated from laryngeal tumors, 259; operation, 247. Adhesio, linguae, 130; preputii, 150. Adipositas, 510. Aerocele, 133. yEstivoautumnal fever, 410. Airing, 85. Albinism, 132. Albuminuria, 46; cyclical or func- tional, 456 ; in nephritis, 448 ; transient, 315. Alimentary tract, diseases of, 185 ; malformations of, 136. Alteratives, 117. Amaurosis, uremic, 316, 450. Amaurotic family idiocy, 574, 579, 583. Amebic dysentery, 334. Amnion navel, 144. Amygdalitis. 240. Amyloid, disease, 396; liver and spleen, 232, 233. Anemia, cerebral, 515; pernicious, 475; pscudolcukcmic, 473; simple, 471 ; splenic, 473. Angina, 240; Ludovici, 314. Aniridia, 132. Ankle-clonus, 56. Ankyloblepharon, 131. Ankyloglossia, 130. Ankylostomiasis, 227, 228. Ankylostomum duodenale, 227, 228. Annulus migrans, 191. Anodynes, 117. Anophthalmus, 130, 131. Anthelmintics, 119. Anticostive triad, 209. Antidiphtheritic serum, 94; in diph- theria, 303 ; in noma, 189 ; in scar- latinal angina, 319. Antimeningococcic serum, 95 ; in meningitis, 344. Antipyretics, 117. Antirheumatics, 117. Antispasmodics, 118. Antistreptococcic serum, in scarla- tina, 320. Antitetanic serum, 95 ; in tetanus neonatorum, 179. Anuria, 45, 460. Anus, absence of, 142; imperforate, 141. Aortic, obstruction, 442; regurgita- tion, 442; stenosis, congenital, 431. Aphtha?, Bednar's, 187. Aphthous stomatitis, 186. Apoplexia neonatorum, 161. Appendicitis, 214, 269; acute differen- tiated from intussusception, 213 ; from psoas abscess, 381. Argyl-Robertson pupil, 8. Arnold sterilizer, 71. Aromatic bath, 106. Arteritis and phlebitis umbilicalis, 180. Arthritis, gonorrheal, 419, 467; he- reditosyphilitic, 419; rheumatic, 415; septic, 420; tuberculous, 420. Articular osteitis, of hip, 386; in rheu- matism, 415. Artificial, feeding, 67; respiration, 165. Ascaris lumbricoides, 224. Aspersion hath, 105. Asphyxia neonatorum, 165. Aspidium (male fern). 119. Asthma, 279; thymicum, 484. Astringents, 120. Ataxia, diphtheritic, 301; hereditary, 537. Atelectasis neonatorum, 166. Athetosis, 521. (607) 608 INDEX. Athletics. 86. Athrepsia, 493. Atresia, ani, 141 ; auris, 133; hyme- nalis, 153; oris, 130; oesophagi, L36; posterior nares, 132; pupillae, 132; recti, 141: urethras, 149; \ aginae, 154 ; vulvae, 153. Atrophy, infantile, 493. Attitude of head, 5. Auditory meatus, absence of, 133. Auricular appendages, 133. Auscultation, of lungs, 17: of heart. 19. Babinski's sign. 57: in meningitis, 338. Bacterial vaccines, 96. Bacteriuria, 49. Band's disease, 482. Barley water, 69. Barlow's disease, 506 ; differentiated from rheumatic arthritis, 420. Basedow's disease, 487. Bathing, 83. Baths, 104. Bednar's aphtha?, 187. Bed-wetting, 461. Bell's palsy, 541. Bier's passive hyperemia. 392. Biologic diagnosis and therapeutics, 91. Birth, injuries, 159; paralysis, 161. Bismuth mixture, 120. Bitter tonics, 116. Black, measles, 293 ; small-pox, 326. Bladder, congenital malformations, 148; stones, 460; tuberculosis of, 370. Bleeding - from navel, 174. Blood, diseases, 470; normal, 470. Blue sickness, 428. Bone diseases, non-tuberculous, 394; tuberculous, 374. Bothriocephalus latus, 224, 225. Boundaries, anterior, of lungs, 23; posterior, 24; of heart, 29. Bow-legs, 500. Brachial paralysis, 163, 164. Bradycardia, in influenza, 290. Brain, abscess, 522; abscess differen- tiated from tumor, 526; anemia. 515; dropsy. 510; hyperemia, 515 localization, 514; syphilis, 403 tuberculosis, 365 ; tumor, 524 tumor differentiated from ab scess, 523; from meningitis, 343. Bran bath, 106. Branchial appendages, 134. Branchiogenetic cysts, 134. Breast, inflammation in newly born, 184; nipples, attention to, 62; pump, 63. Breast milk, 60; analysis of, 64; too rich in fat, 65. Breathing exercises, 353. Bronchial glands, tuberculosis of, 358. Bronchiectasis, 282. Bronchitis, 259. Bronchopneumonia. 259; differen- tiated from lobar pneumonia, 269. Bronzed skin, 481. Brudzinski's sign in meningitis, 337. Buhl's disease, 182. Buttermilk, 79. Calculi, renal, 454; vesical, 460. Calmette's tuberculin reaction. 97. Calmuck type of idiocy, 577. Cancrum oris, 187. Capacity of infantile stomach, 77. Capillary bronchitis, 259. Caput succedaneum, 159 ; differen- tiated from cephalhematoma, 160. Cardiac cirrhosis of liver, 231. Care of, the eyes, 176; teeth, 354; umbilicus, 173. Care of the newly born, 82. Caries of vertebral column, 376. Carpal bones, deficiency in idiots, 580, 582. Castor-oil mixture, 119. Casts in urine, 47. Cataract, 132. Cathartics, 119. Caudal formations, 157. Central, birth-palsv, 161 ; pneumonia, 265. Cephalhematoma, 159. Cephalocele, 126; differentiated from cephalhematoma, 160. Cerebral, abscess, 252, 522; convul- sions differentiated from eclamp- sia, 555 ; facial paralysis differen- tiated from peripheral facial palsy, 542: hemorrhage, 161, 518; hemor- rhage differentiated from embol- ism, 518; paralysis, 512; paralysis differentiated from hysterical par- alysis, 587. Cerebrospinal, fluid, 340, 341 ; menin- gitis, 335 ; meningitis differen- tiated from typhoid, 331. Cervical rib, 135, 381. Chafing of the skin (intertrigo), 595. Chapin's milk dipper, 70. Cheiloschisis, 128. Chest, abnormal shape, 20. Chicken-breast, 498. Chicken-pox, 321. INDEX. 6UU Child-crowing, 133. Chloroma differentiated from scor- butus, 508. Chlorosis, 471. Choked disc (optic neuritis), 525. Cholera infantum, 195. Chondrodystrophia fcetalis, 504. Chorea, 563 ; magna, 588 ; rhythmica. 588; electrica, 567. Choroidal tubercles, 366. Chvostek's phenomenon, 560. Circular insanity, 586. Circumcision, 150. Circumference, of chest, 20; head, 4. Cirrhosis of liver, 231 ; differentiated from tuberculous peritonitis, 368. Cleft, bladder, 148; face, 128; palate, 128; vertebral column, 51. Climatotherapy, 114. Clothing, 84. Clubfoot, 158. Club-shaped fingers, in heart disease, 429. Coccygeal tumors, 156. Cold, effects of, 103; packs, 103; sponging, 103. Cod-liver oil mixture, 117. Colic, intestinal, 204. Colicystitis, 455, 458. Colitis, 195. Coloboma iridis, 132. Collapse of lungs, congenital, 166. Colon, congenital dilatation and hypertrophy, 139. Colostrum, 63. Communicable diseases, 287. Compresses, Priessnitz's, 104. Condensed milk, 78. Condyloma, syphilitic, 400. Conjunctiva, tuberculin test of (Cal- mette), 97. Constipation, 42, 206; electricity in, 110. Consumption, hasty, 356. Contractures of extremities, 52. Convulsions, 554. Cor bovinum, 440. Cord, umbilical, care of, 173. Corvza, 236. Cough, character of, 27. Cows' milk, approximate composition of, 68; care of, 71; feeding, 68; substitutes, 77. Coxa vara, its differentiation from coxitis, 389. Coxitis tuberculosa, 386; differen- tiated from rheumatism, 418. Crab-louse, 601. Cranial, bones, 5; circumference, 4; sutures, 5. Cream in top-milk, 69. Crede's method, 176, 466. Creeping, 86; pen, 86. Creosote in tuberculosis, 364. Cretinism, 488 ; differentiated from rachitis, 502; idiocy, 574, 577, 578, 579; endemic and sporadic, 488. Croup, 253; diphtheritic, 298; differ- entiated from laryngeal tumors, 259; false, 254; spasmodic, 254. Crusta lactea, 591. Cryptophthalmus, 131. Cryptorchidism, 151. Curvatures of, extremities, 51 ; spine, 50. • Cutaneous tuberculin test, 97. Cyanosis, congenital, 428. Cyclic albuminuria, 456. Cysticerci in the brain, 527. Cvstitis, 458. Cytodiagnosis of cerebrospinal fluid, 341. Dactylitis, syphilitic, 407 ; tubercu- lous, 393. Deaf-mutism, 573. Deafness, syphilitic, 405. Death, thymus, 484. Dementia, acute, 586; paralytic, 586. Dentitio difficilis, 189. Dermatitis exfoliativa neonatorum, 178. Dextrocardia, 432. Diabetes, insipidus, 509 ; mellitus, 508. Diagnostic lines of the thorax, 22. Diaphoretics, 119. Diarrhea, 42; and vomiting, 195. Diastasis recti abdominis, 143. Diazo-reaction in typhoid, 329. Dietary, after weaning, 80. Difficult teething, 189. Dierestants, 116. Diluents, 68. Diphtheria, 241, 296; antitoxin, 94, 189, 303, 319; bacilli, 297; differen- tiated from tonsillitis, 242; in scarlatina, 314; laryngeal, 310; pharyngeal, 309 ; vulvae, 468 ; diph- theritic paralysis, 300; paralysis differentiated from poliomyelitis, . S35 : Diplegia, 512. Diplopia, 9. Discharges, rectal, 50; vulvovaginal. 49. Disinfection, 88, 90; solutions, 90. Dislocation of hip, congenital, 157; differentiated from coxitis, 390. Disseminated sclerosis, 538. Diuretics, 119. Diverticulum, Meckel's. 147. 39 (310 IXDKX. Double-jointed, 501. Dry middle-ear disease, 251. Duchenne-Erb paralysis, 163, 164. Duck gait, 157. Ductless glands, diseases of, 470. Ductus, arteriosus Botalli, persistence of, 430; ompbalomesentericus, 196. Duke's disease, 321. Dysentery, 333. Dyspepsia, 195. I )ystrophia muscularis, 547. Dysuria, 460. Ear, affections, 251 ; appendages, 133. Eclampsia, infantile, 554; differen- tiated from meningitis, 342. Ecthyma, 599. Ectopia, cordis. 432; vesicae, 148; viscerum, 144. Eczema, 591. Edema, of eyelids, 7; glottidis, 258; scleredema, 172. Effleurage, 112. Ehrlich and Hata preparation in syphilis, 409. Electricity, 109. Embolism of cerebral arteries, 518. Emetics, 119. Emphysema, cutus (see Pneumohypo- derma), 286; pulmonum, 282; sur- gical, 286. Empyema, 276 ; necessitatis, 277. Encephalitis, 522. Encephalocele, 127. Endocarditis, acute, 436 ; chronic, 439 ; malignant, 438 ; in rheuma- tism, 417; in scarlatina, 315. English disease (see Rachitis), 496. Enteralgia, 204. Enteric fever, 328. Enteritis, 195. Enteroclysis, 108. Enterocolitis, 195. Enuresis, 461; electricity in, 110. Eosinophilia in asthma, 280. Epilepsy, 549; nutans, 551; procur- siva, 552; differentiated from eclampsia, 555 ; from hystero- epilepsy, 589. Epiphvseolvsis, in osteomyelitis, 396; rachitic, 500. Epiphysitis, syphilitic, 419. Epispadias, 149. Epistaxis, 11, 237. Epithelial pearls, 187; differentiated from ulcerative stomatitis, 187. Epitrochlear glands, enlarged in syph- ilis, 401. Erb's, paralysis, 163; sign of tetany, 560. Eruptive fevers, differential table, 327. Erysipelas neonatorum, 181. Erythema nodosum, 423. Escherich's incubator room, 170. Esophagitis, 191. Esophagus, atresia of, 136; diseases of, 191. Eustachian tube, catarrh of, 251. Examination of patient, 1. Exanthemata, differential table, 327. Exercise, 85 ; danger in overindul- gence of, 86. Exomphalos, 144. Exostoses, multiple, 426. Expectorants, 120. Expectoration, character of, 28, 29. Exstrophy of bladder, 148. Extremities, examination of, 51 ; shortness of, 51: tumefactions of, 51. Eye, normal fundus of, 583 ; in the newly born, care of, 176. Eyeballs, semeiology of, 8. Eyelids, semeiology of, 7. Face, semeiology of, 6. Facial, appearance of, in diagnosis 6; hemiatrophy, progressive, 544 hue, 7 ; paralysis, 162, 534, 541 paralysis, electricity in, 111. Family, "history, 1 ; idiocy, 583. Faradic current, 110. Fat, breast milk, 65 ; diarrhea, 202 ; percentage in top-milk, 69. Fatty, degeneration in the new-born, acute, 182; liver, 232. Febris rubra, 311. Fede's disease, 190. Feeble vitality of the newly born, 165 ; management, 168. Feeding, of__ infants, 60, 80, 81, 82; scheme, 76. Fever charts, of endocarditis maligna, 438; influenza, 288; intermittent malarial, 411; pneumonia, 267, 268; tuberculous meningitis, 337; typhoid, 329. Fever, glandular, 241 ; malarial, 410 ; rheumatic, 415; scarlatinal, 311; tvphoid, 328. Filatov-Koplik spots, 292. Fissure, of bladder, 148; and fistulas of ear, 133; vesica? umbilicalis, 147. Fistula, coli congenita, 134; ani dif- ferentiated from proctitis, 204. Fits, epileptic, 549. Flaccid paralysis, 52. Flatulence, colic, 204. Flaxseed poultice, 263. INDEX. 611 Flexner's serum in meningitis, 95. 344. Floating kidney, 148. Floor of mouth, abnormalities of, 14. Fetal skull, 3. Foetor ex ore, 12. Fontanelles, 5. Foods, infants', 79. Foot-drop, 530. Foramen ovale, persistence of, 429. Foreign bodies, in ear, 252; differen- tiated from otitis media, 252; in larynx, 259; in nose, 238. Formaldehyd-potassium permangan- ate fumigation, 91. Fourth disease, 321. Friction in massage, 113. Friedreich's ataxia, 538. Fumigation, 90. Functional, diseases in the newly born, 183; heart murmurs, 443. Funnel-shaped chest, in adenoids, 245 ; congenital, 135. Furunculosis of the ear differen- tiated from otitis media, 252. Gait, semeiology of, 56. Galvanic current, 109. Gangrene, of genitalia, 468; lungs, 283 ; mouth, 187 ; skin in vari- cella, 322. Gastralgia, 204. Gastric sedatives, 120. Gastritis, 195. Gastroenterocolitis, acute, 195 : chronic, 200; differentiated from typhoid, 331. Gavage, 344. Genitalia, 49; congenital malforma- tions, 148 ; diseases, 463 ; tuber- culosis, 370. Genu, valgum, 500 ; varum, 500. Geographic tongue, 191. German measles, 295. Gibbus (see Kyphosis), 379. Glands, bronchial, tuberculosis of, 358. Glandular fever differentiated from tonsillitis, 241. Glossitis, 191. Glottis, edema of, 258; spasm, 281, 562. Glycosuria, 45, 508. Goiter, 486; cystic, 487; exophthal- mic, 487. Gonorrheal, arthritis, 419, 467; differ- entiated from rheumatic arthritis, 419; ophthalmia, 175. 466; proc- titis, 466; vulvovaginitis, 463. Granuloma of umbilicus, 174. Green, sickness, 471 : tumor, 508. Grip, 241. Grocco's sign in pleurisy, 274. Growing pain, 417, 445. Gumma, subcutaneous, 407. Gums, semeiologv of, 12; bleeding from, 480, 505. Growth, sublingual, 190. Habit spasm, 567. Hsemorrhea, acquisita, 181, 478; con- genita (see Hemophilia), 477. Half-cretin, 490. Hand-trident in achondroplasia, 504. Hardening, 85. Hare-lip, 128. Head, attitude of, 5; circumference, 4; drop, 531; lice, 600; nodding, 567; semeiology, 4. Headache, 568; in brain tumor, 524. Health resorts, 114. Hearing, defects of, 10. Heart, apex, 32 ; beat, 32 ; boundaries, 29 ; dilatation, 440 ; diseases, ac- quired, 433 ; diseases, congenital, 428; dullness, 30, 31, 34; mur- murs, 33 ; normal, 29 ; hyper- trophy, 440; paralysis in diph- theria, 300; percussion, 19; seda- tives, 118; skiagram, 29; sounds, 33 ; topography, 30 ; transposition, 432 ; valves, 34. Heat, effects of, 103. Hebephrenia, 585. Hectic fever, 361. Height, 58. Hematoma of sternomastoid, 160. Hematuria, semeiology of, 48. Hemianopsia, semeiology of, 9. Hemiatrophia faciei, 544. Hemichorea, 565. Hemicrania, 568. Hemiplegia, 512; in diphtheria, 301; double, 512; spastica infantilis, 520. Hemoglobinuria, 455 ; with icterus, 182. Hemophilia (see Hsemorrhea), 477. 480; differentiated from purpura, 480; transitory, 478. 1 [emothorax, 283. 1 [emoptvsis, 361. Hemorrhage, cerebral, 161, 518; cutaneous, 480; intestinal, 333; intracranial, 518; meningeal, 518; nasal, 137: pulmonary, 361; rectal. 203; renal. 448; spinal, 528; um- bilical, 174. Hemorrhoids differentiated from proctitis, 2(14. Henoch's purpura. 480. Hepatitis in svohilis. 402. 612 IXDEX. Heredoataxie cerebelleuse, 5.37. Herniae, 41; cerebral, 126; inguinal, dfferentiated from psoas abscess, 381; spinal, 154; umbilical, 144. Herpes, circinatus, 605 : tonsurans, 603 ; zoster. 597. Hip, congenital dislocation of, 157; joint disease, 386. Hives, 594. Hirschsprung's disease, 139. History of patient, 1. Hodgkin's disease, 472. Holt's milk set, 64. Home-made liquid capsules, 115. Home modification of cows' milk, 73. Hookworm disease, 227. Horseshoe kidney, 148. Hot baths. 105. Hutchinson's, teeth, 405 ; triad in syphilis, 405. Hydatid cyst of liver, 234. Hydrocele, 152. Hydrocephalic, cry in meningitis, " 343; idocy, 574, "575, 578. Hvdrocephalocele, 127. Hydrocephaloid, 197, 515. Hydrocephalus, acquired, 516; chron- ic, 365; congenital, 124; false, 516; differentiated from rachitis, 503. Hydronephrosis. 148. Hydrotherapy, 102. Hydrothorax, 277; differentiated from pleurisy, 277. Hygiene and sanitation, 82. Hygroma, cysticum, 134; differen- tiated from goiter, 487; sacral, 156. Hvmen, imperforate, 153. Hyperemia, cerebral, 515; passive. Bier's method of treatment, 392. Hyperidrosis in rachitis, 496. Hypertrophic, cirrhosis of liver, 231 ; pyloric stenosis, 136. Hypertrophy, of heart, 440; differen- tiated from pericarditis with effusion, 435; pseudo, muscular, 547 ; of tonsils, 242. Hypnotics, 117. Hypodermoclysis, 109. Hypospadias, 149. Hysteria, 587; electricity in, 111. Hysterical contracture differentiated from coxitis, 390. Hysterocpilepsy, 589. Icterus, catarrhal, 230; epidemic, 230; with hemoglobinuria, 182; neona- torum, catarrhal, 183. Idiocy. amaurotic, 583: different varieties, and allied mental defi- ciencies, 570. Idiotic face in adenoids, 244. Ileocolitis, epidemic, 333. Imbecility, 581, 585. Immunity, 91. Immunization, 91 ; in diphtheria, 302. Imperforate, anus, 141 ; hymen, 153. Impetigo contagiosa, 599. Incubators, 169, 170. Infantile, paralysis, 529; muscular atrophy, 548. Infantilism, 575, 577, 581; syphilitic. 407. Infants' stools, semeiology of, 43. Infant, feeding, 60, 80; foods, 79. Infarct, uric acid, in the newborn, 183. Influenza, 287: differentiated from tonsillitis, 241 ; from typhoid, 331. Inherent strength, 59. Inland resorts, 114. Inorganic murmurs of heart, 443. Insanity, circular, 586. Intermittent fever, 410. Intestines, 36; catarrh (see Gastro- enterocolitis), 195; diseases of, 195 ; invagination or intussuscep- tion, 212; stenosis, 139; differen- tiated from strangulation, 213 ; syphilis, 403; tuberculosis, 369; worms, 222. Intubation, 305 ; accidents during, 308. Intussusception, 212; differentiated from proctitis, 204; from prolap- sus recti, 210. Invagination, intestinal, 212. Iridoschisma, 132. Tridoschisme, 132. Irrigations, 108. Ischuria, 460. Isolation, 88. Itch, 601. Jacksonian or cortical epilepsy, 550. Jaundice, catarrhal, 230 ; with hemo- globinuria, 182 ; neonatorum, 183. Joints, tuberculosis of, 374. Juvenile muscular atrophy, 548. Katatonia, 585. Keratitis, syphilitic, 405. Kernig's sign, 57, 338. Kidney, diseases. 447; malformations, 148; normal, 39; stones, 454: topography of, 39; tuberculosis, 370; tumors, 457. Knee-jerk, 56. Knee-joint disease, 391. Knock-knees, rachitic, 500. INDEX. 613 Koch's tubercle bacillus, 352. Koplik-Filatov spots, 15 ; in measles, 292. Kyphosis, 381, 498. Labium leporinum, 128. Laboratory milk, 72. Landry's paralysis differentiated from poliomyelitis, 535 ; from polyneu- ritis, 544. Laryngeal, diphtheria, 255, 298 ; syph- ilis, 257; tuberculosis, 257;' tu- mors, 259. Laryngismus stridulus, 254. Laryngitis, acute, 253 ; catarrhal, 254 ; chronic, 256; diphtheritic, mem- branous, 255, 298; membranous, non-diphtheritic, 255 ; spasmodic, 254; stridula, 254. Laryngocele, 133. Laryngospasmus, 562. Larynx, foreign bodies in, 259; mal- formations of, 133. Lateral curvatures of spine, 382. Lavage, 107 ; contraindications to, 107. . Laxatives, 119. Leichtenstern's sign in meningitis, 338. Length of child. 57. Leucocythemia, 474. Leukemia, 474 ; lymphatic, 475 ; splenic, 475. Lice, body and head, 600. Lichen strophulus, 598. Lien mobilis, 481. Lingua geograohica, 191. Lipomatosis, 510. Lins, semeiology, 11. Little's disease, 539. Liver, abscess, 233 ; abscess differen- tiated from pleurisy, 277 ; amy- loid, 232; atrophy, 232; cirrhosis, 231; diseases of, 230; normal, 37; sugar-coated, 231; topography, 38, 39 ; tumors, 234. Lobar pneumonia, 265. Lobular pneumonia (see Broncho- pneumonia), 259. Lordosis, 384 ; compensatory, 389. Lumbar puncture, 339; in meningitis, 339; in scarlatinal uremia, 319. Lungs, auscultation of, 17; diseases <«f, 259; normal, 21: percussion of, IS: topography, 21. Luschka's tonsil, 243." Luxatio coxae congenita, 157. Lymphadenitis, tuberculous, 37.1. Lymphadennma, 472. Lymphangioma cysticum, 134. Lympbatic glands, semeiology, 16. McEwen sign in meningitis, 339. Macroglossia, 130. Macrostoma, 128. Malaria, 410; chronic, 413; differen- tiated from miliary tuberculosis, 357; from typhoid, 331. Male fern (aspidium), 119. Malt bath, 106. Malt soup, 77 ; in marasmus, 495. Mammary glands, inflammation of, in the newborn, 184. Mania, 586. Marasmus, 493 ; differentiated from miliary tuberculosis, 358. Massage, 112; contraindications to, 112; indications of, 112. Mastitis, complicating mumps, 346 ; neonatorum, 184. Mastoiditis, 251. Masturbation, 468. Materia medica, 102. Maternal nursing, 62; contraindica- tions to, 66. Measles, 291. Meckel's diverticulum, 147. Meconium, absence of, 142. Medicated baths, 106. Medicines, mode of administration, 121. Megacolon congenitum, 139. Melancholia, 586. Melena neonatorum, 181. Meloschisis, 128. Meningeal hemorrhage, 518. Meningitic idiocy, 574, 577. Meningitis, acute, 335 ; acute, differ- entiated from encephalitis, 523 ; antitoxin, 95 ; spinal, 528 ; tuber- culous, differentiated from other forms, 342. Meningocele, 127; spinalis, 154. Menstruatio praecox, 469. Mental, diseases, 570 ; stigmata of degeneration, 572. Mercurial bath, 106. Mesocardia, 432. Metabolism, disturbance of, 493. Microcephalic idiocy, 574, 575, 579. Microcephalia, 123. Micromelia, 504. Microphthalmia, 131. Microscopy of human milk. (>1. Microstoma, 130. Migraine, 568. Miliaria, 598. Miliary tuberculosis, 356; differen- tiated from lobar pneumonia, 270: from typhoid, 331 ; skiagram of lungs, 357. 614 XDEX. Milk, cows'. 68; formula'. 74; human. 60; modified, 72; peptonized, 79; top, 69. Mineral acids, 117. Miniature brain, 123. Mitral heart disease, 441. Moeller-Barlow's disease, 505. Molluscum contagiosum, 606. Mongolian idiocy, 574, 576, 579. Monoplegia, 513. Monorchidism, 151. Morhilli, 291. Morbus, cceruleus, 428; coxarius, 386. Moro's tuberculin test, 98. Mosquitoes as malaria carriers, 413. Mountain resorts, 114. Mouth, semeiology, 11; wash, 188. Mumps, epidemic, 345. Muscular, atrophies, hereditary, 545 ; contractures, 52; rheumatism, 417; weakness, 52. Mustard, bath, 106; water compresses in pneumonia, 271. Myelitis. 5,36; differentiated from poliomyelitis, 535. Myelocystocele spinalis, 154. Myelomeningocele spinalis, 154. Myocarditis, 433. Myositis, 425; ossificans, 427; scar- latinal, 314. Myotonia congenita, 549. Myxidiocy, 488. Nares, posterior, atresia of, 132. Nasal, discharge, 10; hemorrhage, 237; tuberculin test, 97. Navel, diseases of (see Umbilicus), 172. Neck, malformations of, 134; in meningitis, 337; semeiology, 16. Nephritis, acute, 447; chronic, 452, diphtheritic, 300; parotitic, 450; scarlatinal, 346; varicellosa, 322. Nephrolithiasis, 454. Neuralgia, enteric (see Colic), 204. Nerve diseases, 512. Nettle rash, 594. Neuritis, multiple, 543; multiple, diphtheritic, 301. Newly born, care of, 82; diseases of, 165. Night, sweats, 361 ; terrors, 569. Noguchi-Wassermann test in syph- ilis, 98. Noma faciei, 187; in measles, 294; in typhoid, 330; in scarlatina, 316; noma vulvae, 468. Nose, bleeding from, 237; malforma- tions, 132; semeiology of, 10; sad- dle-shaped. 400, 407; throat and ear diseases, 236. Nuclear, facial paralysis, differen- tiated from peripheral, 543. Nursery, ( X7. Nursing, time for, 63. Nutrition, 60. Aystagmus, semeiology, 8. Oatmeal water, 69. Obesity, 510. Obstetric, brachial paralysis, 162, 163 ; facial paralysis, 161. O'Dwyer's intubation set, 305. Oliguria, semeiology, 45. Omphalitis, 172. Omphalocele, 144. Omphalorrhagia, 174. Onanism, 468. Onychitis, 409. Ophthalmoblennorrhea neonatorum, 175. Ophthalmia, gonorrheal, 466; puru- lent, 175 ; strumous, 372. Ooisthotonos in meningitis, 337. Opsonin, 96 ; opsonic index, 96. Optic neuritis, 525 ; in amaurotic idiocy, 584 ; in meningitis, 338. Oral cavity, examination of, 12. Organotherapy, 121. Orchitis in mumps, 346. Orthotic albuminuria, 456. Osteochondritis, syphilitic, 402. Osteogenesis imperfecta differen- tiated from rachitis, 503. Osteitis, 394. Osteomyelitis, 420; differentiated from coxitis, 390; from rheuma- tism, 418; from scorbutus, 508; non-tuberculous, 394; of radius, 397; tibia, 395. Osteoperiostitis, 406. Otitis, double, differentiated from meningitis, 342; externa, 252; media, 250 : in mumps, 346 ; in scarlatina, 318. Otorrhea, bilateral, in scrofulosis, 372. Oxvuris vermicularis, 222. Ozena, 237; syphilitic, 399. Pain in chest on pressure, semei- ology, 21. Pack, cold, 103. Palatable medication, 115. Palate, semeiology of, 14. Palatoschisis, 128. Palatum fissum, 128. Pancreas disease in syphilis, 402. Papilloma, laryngeal. 259. Paralysis, brachial, 163 : cerebral, 512; crossed, 512; diphtheritic, 300 ; extremities, 53 ; facial, 162, 541 ; muscular, 54 ; pseudobulbar, 513; spastic, 520; spinal, 529. INDEX. 615 Paralytic, dementia, 586; idiocy, 580; scoliosis, 385. Paramyoclonus, 567. Paraplegia, in myelitis, 536; in dis- seminated sclerosis, 538. Parasites, intestinal, 222. Parasituria, semeiology, 49. Parasyphilis, 404. Parathyroid gland substance, 121. Parotitis, epidemic, 345; secondary, 191. Parrot's nodes in syphilis, 402. Passive hyperemia, Bier's treatment, 392. Pasteurization of cows' milk, 72. Pavor nocturnus, 569. Pectus carinatum, rachitic, 498. Pearls, epithelial, 187. Pedatrophy, 493. Pediculosis, capitis, 600; corporis, 600 ; pubis, 601. Peliosis rheumatica, 423, 479; differ- entiated from scorbutus, 507. Pemphigus, neonatorum, 177; syph- iliticus, 167, 401 ; differentiated from simple pemphigus, 177. Peptonized milk, 79. Peptonuria, semeiologv, 49. Percussion, of heart, 19; of lungs, 18; resonance, 26. Percutaneous tuberculin test, 98. Pericarditis, 434; differentiated from endocarditis, 439; from pleurisy, 277. Periosteal reflex, semeiology, 57. Periostitis, 394. Peripheral, birth paralysis, 162 ; facial paralysis, 541. Perisplenitis in syphilis, 402. Peristalsis, intestinal, visible, 40. Peritonitis, acuta, 221 ; differentiated from intussusception, 213 ; tuber- culous, 366. Peritonsillar abscess, 240. Perityphlitis, 214. Pernicious anemia, 475. Perspiration excessive in rubella, 296. Pertussis, 347. Petrissage, 113. Pharyngitis, acute, 239; chronic, 239. Phimosis, 150. Phthisis pulmonum, 358; differen- tiated from bronchiectasis, 282. Physical, examination, 3 ; stigmata of degeneration, 575. Pick's disease, 231. Pigeon-breast, in adenoids, 245 ; in rachitis, 498. Pinworms, 222. Pituitary gland, extract, 121. Plaques muqueuses, 399. Plasmodium malariae, 410. Pleurisy, 273 ; chylous, 277 ; dry, 273 ; differentiated from liver abscess, 234; from pneumonia, 269; with effusion, 274; hemorrhagic, 276; serous, 275; tuberculous, 275, 276. Pleuritis, 273. Pleuropneumonia, 268. Pneumococci, 266. Pneumohypoderma (emphysema cu- tis), 286; in measles, 293. Pneumonia, 265 ; alba, 167 ; aspiration pneumonia, 300; broncho, 259; central, 267; chronic, 272; differ- entiated from meningitis, 342 ; from miliary tuberculosis, 357; from otitis media, 252; from pleu- risy, 278; from typhoid, 331; fibroid, 272 ; lobar, 265 ; unre- solved, 268, 272; wandering, 265. Pneumonitis, 265. Pneumothorax, 283. Polioencephalitis, acute, 520; differ- entiated from poliomyelitis, 535. Poliomyelitis, 529; differentiated from cerebral paralysis, 513; from polioencephalitis, 521 ; from poly- neuritis, 544; electricity in, 111. Polyarthritis, 415. Polymyositis, 425. Polyneuritis, 543. Polyuria, semeiology, 44; in diabetes, 509. Porencephalia, 514. Pot-belly, in rachitis, 501. Pott's disease, 376. Poultice of flaxseed meal, 263. Precocity, 469. Premature birth, 167. Prepuce, malformations of, 149. Pressure paralysis in spondylitis, 378. Prevention and control of disease, 59. Prickly heat, 598. Priessnitz's compresses, 104. Proctitis, 203; gonorrheal, 466. Progressive muscular atrophy and dystrophy, 547 ; differentiated from poliomyelitis, 535. Prolapsus ani et recti, 210. Proprietary infant foods, 79. Prurigo, 594. Pseudofurunculosis, 599. Pseudohypertrophic paralysis, 547. Pseudohypertrophy, 548. Pseudoleukemia infantum, splenica, 437 ; lymphatica, 472. Pseudomeningocele, 127. 616 INDEX. Pseudoparalysis, rachitic. 501 : syph- ilitic. 402. Pseudotetanus, 562. Psoas abscess, 381. Psoriasis, 595. Pulmonary edema, differentiated from asthma. 281. Pulmonary valve, affections of, 431, 442. 443. Pulsation of arteries and veins of neck, semeiology, 17. Pulse, semeiology, 35; rate, 32; res- piration ratio, 32. Pupils, semeiology, 8. Purgatiyes, 119. Purpura, fulminans, 480; hemor- rhagica. 420, 470; differentiated from scorbutus. 507; rheumatica, 423; simplex, 479; vaccinatoria, 93. Purulent ophthalmia, 175. Pyelitis, 454. Pyelonephritis, 454. Pyelonephrosis, 454. Pyloric stenosis, 136. Pylorospasm, 137. Pyopneumothorax, 283. Pyothorax, 276. Pyemia, differentiated from inter- mittent fever, 412. Pyuria, semeiology, 48. Quantity of food for infant feeding, 75. Quarantine, 88. Quinine, specific in malaria, 414; in pertussis, 350. Quinsy, 240. Rachitis, 496 : acute, 505 : differen- tiated from scorbutus, 508 ; fetal, 504; kyphosis, differentiated from spondylitis, 381; rosary, 497; scoliosis, 384. Ranula, 190. Rectal, discharges, semeiology, 50; malformations, 141; polypus, dif- ferentiated from prolapsus recti. 210; prolapse, 210. Reflexes of tendons, semeiology, 56. Regions, abdominal and thoracic, 37; of spine, 19. Remittent, sestivo-autumnal fever, 412; differentiated from menin- gitis, 342. Ren morbilis, 14S. Renal, calculi, 454: hemorrhage, 448. Resorcin-alcohol, in scarlatinal an- gina, 318. Respiration, semeiology, 23. Respiratory, diseases, 235; sounds, 25. Retained intubation tube, 308. Retropharyngeal abscess. 249, 259, 381. Revaccination, 94. Rheumatism, acute, 415 ; chronic, 422 ; differentiated from coxitis, 390; from poliomyelitis, 535 : from scorbutus. 507: electricity in, 111; muscular, 417: nodosus, 423; scar- latinal, 314. Rhinitis, acute, 236; chronic, 237; diphtheritic, 298; syphilitic, 399. Ribs, malformations of, 135; cervical, 135, 381. Rice-water, 69. Rickets, 496. Riga's disease, 190. Rigidity of the limbs, congenital, 539. Ringworm, of body, 605; of scalp, 603. Risus sardonicus, 180. Roseola, epidemic, 295. Rotheln, 295. Roundworms, 224. Rubella, 295. Rubeola, 291. Saber-shaped deformity of tibia, ra- chitic, 500; in syphilis, 406. Sacral tumors, congenital, 156. Saddle, back, 548; nose, in syphilis, 400, 407. Saint Vitus's dance, 563. Salaamkrampf, 551. Salicylates, specific, in rheumatism. 421. Saline injections, 108. Saliva, semeiology, 16. Salivary glands, diseases of, 190. Salivation, 190. Sarcoma, of femur, 390: differen- tiated from coxitis, 390; of kid- ney, 457; of thymus gland. 484. Sarcomphalos, 147, 174. Sarcoptes scabiei, 602. Scabies, 601. Scapula, abnormal position of, 21. Scarlatina, 311 : angina, 313: differen- tiated from diphtheria, 310; from tonsillitis, 242; from incipient pneumonia with erythema, 269; malignant, 317 : nephritis in, 315 ; otitis in, 318; rheumatism in, 314. Scheme for infant feeding, 76. Schoenlein's disease, 424. Scissors gait, 539. Scleredema neonatorum, 172. Sclerema, adiposum, 171 ; serosum, 172; differentiated from sclere- dema, 172. INDEX. 617 Sclerosis, multiple, disseminated, 538. Scoliosis, 382, 384, 498. Scorbutus, 505 ; differentiated from poliomyelitis, 535 ; from purpura hsemorrhagica, 480; from rheu- matic arthritis, 420. Scrofulosis (see Tuberculosis), 370. Scrotum, absence of, 141 ; tumefac- tions of, 49. Scurvy (see Scorbutus), 505. Sea-salt baths, 106. Seashore resorts, 114. Seborrhcea capitis, 591. Selection of wet-nurse, 66. Sepsis neonatorum, 172. Septic, arthritis differentiated from rheumatic, 420; endocarditis from typhoid, 331. Septum ventriculosum, defects in, 430. Serum diagnosis, of syphilis, 98; of typhoid, 102, 329. Serum, antidiphtheritic, 94, 303 ; anti- meningitic, 95, 344; of rabbit, in hemorrhea, 183. Shape of head, semeiology, 4. Shiga's bacillus, 194; in dysentery, 333. Shingles (see Herpes Zoster), 597. Shortness of extremities, semeiologv, 51. Shower bath, 105. Sick-room, 87. Sinus-thrombosis, 519. Skin, diseases of, 591 ; tuberculosis of, 370. Skull, semeiology, 5. Sleep, 83. Small-pox. 323 ; black, 326 ; confluent, 326; malignant, 326. Snuffles, 1, 399. Soap bath, 106. Sodium, benzoate, 120; in influenza, 290; citrate, in cows' milk modifi- cation, 70. Soor, 185. Sore throat, 240. Spasmodic, affections, functional, 554 ; movements, 52. Spasmophilia, 554. Spasmus, glottidis, 562; differentiated from asthma, 281 ; nutans, 567 ; rotatorius, 567; vesica?, 460. Spastic, paralysis, semeiology, 52 ; hemiplegia, 520; paraplegia, 536, 538. Spina bifida, 154, 155. Spina ventosa, 373, 393. Spinal curvatures, lateral, 382: in adenoids, 245. Spinal, hemorrhage, 528; meningitis, 528; paralysis, 529; paralysis dif- ferentiated from hysterical paral- ysis, 587 ; progressive muscular atrophy, 545. Spinal cord, tumors of, 540. Spleen, diseases of, 481 ; movable, 481 ; normal, 38, 39. Splenic, anemia, 473 ; leukemia, 475. Splenitis, acute, 481 ; chronic, 482. Splenomegaly, 482. Spondylitis, 376; cervical, 377; cer- vical differentiated from cervical rib, 381 ; dorsolumbar differen- tiated from coxitis,- 390; from rheumatism, 418. Spotted fever, 338. Sprue, 185. Sputum, semeiology, 27. Staphylococcus vaccine, 96. Starting pain, 378, 388, 389. Static current, 110. Status, lymphaticus, 484; idioticus, 576. Stenosis, and atresia of intestines, 139; of esophagus, 192; of ostium atrioventriculi sinistrum, 431 ; of pylorus, 136 ; of pulmonary artery, 431 ; of tricuspid valve, 431. Sterilization, 72. Sternocleidomastoid, hematoma of, 160. Sternum, defects of, 135. Stiffness, of neck, semeiology, 17; of vertebral column, 51. Stigmata of degeneration, 572, 575. Still's disease, 423. Stimulants, 118. Stomacace, 186. Stomach, semeiology, 36; capacity, 77 : diseases of, 193 ; tube, 107 ; washing of, 107. Stomatitis, 185, 186. Stools, abnormal, 43 ; normal, 43. Stones, in bladder, 460; in kidneys, 454. Strabismus, semeiology of, 8. Strangulation, intestinal, 213. Strawberry tongue in scarlatina, 312. Streptococcus vaccine, 96. Stridor congenitus, 133; differen- tiated from spasmus glottidis, 563. Struma, 486. Strumitis, 485. Strumous ophthalmia, 372. Sublingual growth, 190. Sugar-cake liver, 231. Sulphur, baths, 106; fumigation, 91. Summer complaint (see Gastroen- terocolitis), 195. Suprarenal extract, 121. 618 INDEX. Suspended animation, 165. Sutures, cranial, semeiology, 5. Sweating in German measles, 296. Syphilis, acquired, 408; congenital, hereditary, 398; embryonalis s. foetalis, 167, 398; hereditaria lata, 404; neonatorum, 399; differen- tiated from rachitis, 503 ; from scrofulosis, 373 ; Wassermann re- action in, 98. Syphilitic, arthritis differentiated from rheumatic, 419: dactylitis differ- entiated from spina ventosa, 393 ; epiphysitis differentiated from rheumatic arthritis, 419; from scorbutus, 508; idiocy, 576; laryn- gitis differentiated from diph- theritic. 311; from simple laryn- gitis, 257. Syringomyelia, 527. Tabes mesenterica, 369. Taches, cerebrale, 338; scarlatinale, 312. Taeniae, 223. Talipes, 158, 532; paralytic differen- tiated from congenital, 158. Tapeworms, 224. Tapotement, 113. Teeth, semeiology of, 13 ; Hutchin- son's, 405. Teething, difficult, 189; normal, 13. Tendon reflexes, semeiology, 56. Tepid bath, 104. Testicles, congenital malformations, 149: undescended, 151. Tetanism, 558; differentiated from pseudotetanus, 562. Tetanus, antitoxin, 95 ; bacillus, 179. Tetanus neonatorum, 179; differen- tiated from pseudotetanus, 562. Tetany, 560; differentiated from pseudotetanus, 562; electricity in, 112; produced by disease of para- thyroids, 121. Therapeutics, 102. Thigh friction (see Masturbation), 4< iN. Thomson's disease, 549. Thoracic muscles, malformation of, 135 ; regions, 18. Thoracoabdominopagus, 145, 146. Thorax, activity of, semeiology, 21 ; congenital malformations, 135; measurements, 20; its contents, 17. Threadworms, 222. Throat, diseases of, 239. Thrombosis, sinus, 519. Thrush, 185. Thymitis, 483. Thymol, specific in uncinariasis, 229. Thymus, death, 484; diseases of, 482; hypertrophy, 483 ; gland substance, 121. Thyroid gland, diseases of, 485 ; sub- stance, 121. Thyroiditis, 485. Tinea, favosa, 605 ; trichophvtina, 605. Tongue, semeiologv, 15; diseases of, 191. Tonics, 116. Tonsillitis, 240; differentiated from diphtheria, 309. Tonsillotomy, 243. Tonsils, hypertrophy of, 242; removal of, 243. Top-milk, 69. Torticollis, 250, 381, 418; electricity in, 112. Trachea, congenital malformations, 133. Tracheobronchitis, 259. Tracheocele, 133. Tracheotomy, 308. Triad, anticostive, 209; of syphilis, 405 ; of tetany, 560. Trichinosis, 425. Tricuspid valve, diseases of, 442. Trident hand, 504. Trismus neonatorum, 179. Trousseau's sign, in meningitis, 338; in tetany, 560. Tuberculin, tests, 97: therapy, 98. Tuberculosis, 351 : abdominal organs, 369: bones and joints, 374; brain, 365; elbow-joint, 375: genito- urinary tract. 370; knee-joint, 391; intestines, 369: lungs and bron- chial glands, 358; lymphatics, 373; metacarpals and phalanges, 393 ; miliary, 356; prevention of, 352; skin and glands, 370; vertebral column, 376. Tuberculous, arthritis differentiated from rheumatic. 420 ; dactylitis from syphilitic, 407; disease from intermittent fever, 412 ; laryn- gitis from simple laryngitis, 257 ; meningitis from brain tumor, 526; from non-tuberculous meningitis, 342; from typhoid, 331; from os- teomyelitis, 374; from peritonitis, 366 ; sputum, 360. Tumefactions, of extremities, 51 ; of neck, 17; scrotum, 49; of thorax, 21. Tumors of, brain, 524; cord, 540; kidneys, 456; larynx, 259; liver, 234; nose, 238; sacrum, 156; vertebral column, 51. INDEX. 619 Turbinated bones, adhesions of, 132. Tussis convulsiva, 347. Typhlitis, 214. Typhus abdominalis, 328. Typhoid fever, 328 ; differentiated from meningitis, 342; from inter- mittent fever, 412 ; from malig- nant endocarditis, 439; from miliary tuberculosis, 357. Typhoid reaction (Grueber-Widal), 329; diazo, 329. Typhoid spine, 330. Ulcerative stomatitis, 186. Umbilical, arteritis and phlebitis, 180; granuloma, 174 ; hemorrhage, idio- pathic, 174; hernia, 144. Umbilicus, diseases of, 172; care of, in the newborn, 173. Uncinaria, Americana, 227. Undescended testicle, 151. Urachus, fistula, 147; persistence of, 147. Uranocoloboma, 129. Uranoschisma, 129. Uremia, in nephritis, 450; in scarla- tina, 316; differentiated from eclampsia, 555 ; from meningitis, 342. Ureters, congenital malformations, 148. Urethra, congenital malformations, 149. Uric acid, semeiology, 48; infarct, 183. Urine, semeiology, 44; acetone in, 47; casts in, 47. Urticaria, 594. Uvula, semeiology, 16. Vaccination, 92; contraindications to, 94. Vaccine ophthalmia, 93. Vaccinia, 92, 93. Vagina, congenital malformations of, 149. Vaginal discharge, semeiology, 49. Valvular heart disease, 439. Vapor pack, 104. Varicella, 321 ; gangrenosa, 322. Variola, 323 ; vaccine, 92 ; hajmor- rhagica, 326. Varioloid, 323, 326. Ventilation, 87. Ventricles, communication of, 430. Vertebral column, congenital mal- formations, 154; deformities, semeiology, 50; normal, 50; tume- factions, 51. Vertigo, 525. Vesical calculi, 460. Vincent's angina, 241. Vision, disturbance of, semeiology, 8. Visual tract, 9. Vitellointestinal duct, 146. Vitium cordis (see Heart Disease), 167, 428. Vocal resonance, 26. Vomiting, semeiology of, 41. Vomitus, semeiology of, 41. Von Jaksch anemia, 473. Von Pirquet tuberculin test, 97. Vulva, atresia of, 153. Vulvovaginal discharge, semeiologv, 49. Vulvovaginitis, 463 ; gonorrheal, 463. Walking, 86. Wandering pneumonia, 268; spleen, 481. Warm baths, 105. Wassermann's reaction, 98; in svph- ilis, 404. Water internally, 107. Weakness of extremities, semeiologv, 52. Weaning of baby, 80. Weight, chart, 58; of child, 57. Werlhof's disease, 479. Wet compresses (Priessnitz's), 104. Wet, nurse, selection of, 66; nursing, 66. Whey, 78. White swellings, 391. Whooping-cough, 347. Widal reaction, 102; in typhoid, 329. Winkel's disease (see Hemoglobin- uria), 182. Wolff-Eisner tuberculin test, 97. Woman's milk, 60, 68. Worms, intestinal, 222. Yellow atrophy of liver, acute, 232. •-■$$■ :j LIBRARY OF CONGRESS 022 216 455 2