4J | r^ 4+J- W Li •**>*" DISEASES OF CHILDREN A TEXT-BOOK FOR THE USE OF STUDENTS AND PRACTITIONERS OF MEDICINE BY C. SIGMUND RAUE, M. E>., CLINICAL PROFESSOR OF PEDIATRICS, HAHNEMANN MEDICAL COLLEGE, OF PHILADELPHIA VISITING PHYSICIAN TO THE CHILDREN'S WARDS AND CHIEF OF THE CHILDREN'S CLINIC, HAHNEMANN HOSPITAL, PHILADELPHIA; PODIATRIST TO THE WEST PHILADELPHIA HOMOEOPATHIC HOSPITAL; MEMBER OF THE AMERICAN INSTITUTE OF HOMOEOPATHY, ETC. SECOND EDITION REVISED, ENLARGED AND ILLUSTRATED PHILADELPHIA : BOERICKH & TAFKL. 1906. LIBRARY of CONGRESS Two CoDies Received FEB 10 1906 Q Copyright Entry . GLASS (As XXc No. I3J* > 3 t COPY B. COPYRIGHTED BY BOERICKE & TAFEL. 1906. J. NICHOLAS MITCHELL, M. D., FORMERLY PROFESSOR OF OBSTETRICS IN HAHNEMANN MEDICAL COLLEGE, PHILADELPHIA ; IN APPRECIATION OF THE INSPIRATION OF HIS TEACHING, HIS DEEP INTEREST IN PEDIATRICS, AND HIS MANY ACTS OF FRIENDSHIP TO THE AUTHOR PREFACE TO THE FIRST EDITION In presenting this work to the profession the author has aimed to make it a purely clinical one. In the sections on treatment he has endeavored to give his own experience as much as possible, and has sought to ex- clude all doubtful symptoms and theoretical indications. The section on Skin Diseases is from the pen of Dr. Leon T. Ashcraft, Lecturer on Venereal Diseases at the Hahnemann College. In the section on Nervous Diseases, valuable suggestions have been made by Dr. Weston D. Bayley, Lecturer on Men- tal Diseases and Clinical Instructor in Nervous Diseases at the Hahnemann College. C. SlGMUND RAUE. Philadelphia, 1899. PREFACE TO THE SECOND EDITION Since the appearance of the first edition of this work seven years ago, a number of important discoveries have been made in the field of Paediatrics, and some significant changes have occurred in the views held at that time regarding the etiology and treatment of not a few T of the commonest affections in childhood. Furthermore, it is but fair to say that the writer himself has felt the need for revising some of his views ex- pressed in the former edition, for with riper years and larger experience he has learned the value of conservative methods, and has endeavored to replace the mere possibilities of thera- peutics with clinical certainties. The text has been entirely rewritten, and new matter has been added wherever it was found desirable to amplify any subject. The chapter upon Infant Feeding is practically new, and the aim has been to present in a concise and clear form the most acceptable and modern views upon this sub- ject, which has of late years been made unnecessarily compli- cated. A chapter upon Diseases of the Ear, Nose and Throat has been added, and illustrations have been inserted wherever a picture or a diagram could be advantageously employed to elucidate the text. I am again indebted to a number of my colleagues for valu- able suggestions and friendly cooperation, which, to my mind, is necessary in any work covering so broad a field as that of Psedriatics. Dr. Chas. M. Thomas has kindlv read the sec- Vlll PREFACE. tions dealing with the diseases affecting the eyes, the ears, the nose and the throat, and has made a few additions to the manuscript. To Dr. Wm. B. Van Lennep I am indebted for assistance in revising the articles upon Appendicitis and In- tussusception, and also for suggestions concerning the treat- ment of other conditions, wherever this has presented a surgi- cal aspect. Dr. W. D. Bayley has kindly offered some sug- gestions relative to Mental and Nervous Diseases. For the excellent index I am indebted to Dr. Ernest A. Farrington, whose painstaking arrangement of the various subjects mentioned and discussed must of necessity add to the practical value of the book. 1 have also to thank the pub- lishers for their liberality in preparing the many illustrations, and for numerous other courtesies. I cannot refrain from expressing my appreciation of the kind reception which the first edition received at the hands of the profession and of the students of our colleges, and while my aim has been not to overstep the bounds of a Text- Book, I trust that the busy practitioner will find within these pages all the practical information which he may need. C. S. Raue. 1626 Walnut St., Philadelphia, Pa. February, /po6. TABLE OF CONTENTS CHAPTER I. Hygiene and Nursing. Page. The new-born — Bathing — Clothing — The month and teeth — Sleep — The bowels — Airing — Exercise— Premature and delicate infants — Incu- bators — Therapeutic measures — Cold — Heat — Baths — Packs — Nasal syringing — Throat spraying — Inhalation — Lavage — Gavage— Irriga- tion of the colon — Enemata — Inunctions — Massage 9 CHAPTER II. Mkthods of Clinical Examination. Periods of infancy and childhood — Diseases of infancy and childhood — Morbidity — Mortality — Growth and development — Diathesis — Temperament — Methods of taking history and keeping records — Physical diagnosis — Inspection — Palpation — Percussion — Ausculta- tion — Pulse — Temperature — Respiration — Urine 30 CHAPTER III. Therapeutics. Stimulants— Prescribing — Dosage •. 69 CHAPTER IV. Enfant Feeding. Human milk studied in comparison with other milks and feeding mix- tures — Milk analysis — Cow's milk — Causes influencing composi- tion of breast milk — Modification of cow's milk — Other foods than milk — Weaning— Indications for varying percentages of proximate principles of infant's food — Intervals for feeding and quantity re- quired at different ages — Sterilization of food —Pasteurizing — Prep- aration and indication for other foods and adjuvants to child's dietary — Artificial foods 77 CHAPTER V. Diseases of the New-born. Asphyxia — Cephalematoma — Hematoma of sterno-mastoid muscle — In- tracranial Inctnorrhages — Septic and other infections — Acute fatty CONTENTS. Page. degeneration or Buhl's disease — Acute hemoglobinuria or Win- kel'* disease — Ophthalmia neonatorum — Mastitis — Icterus neona- torum— Oedema — Gastro-intestinal haemorrhage or melena — Gonor- rhoea — Sudden death in infants 112 CHAPTER VI. Diseases of the Mouth. Dentition — Abnormalities of the teeth — Stomatitis — Catarrhal stoma- titis — Pityriasis linguae — Aphthous stomatitis — Bednar's aphthae — Aphthae epizooticae — Ulcerative stomatitis — Parasitic stomatitis — Gangrenous stomatitis 124 CHAPTER VII. Diseases of the Stomach. Acute gastric indigestion — Dyspepsia — Chronic gastric indigestion — Nervous dyspepsia — Acute gastritis — Chronic gastritis— Chronic gastric catarrh — Cyclic or periodic vomiting — Gastralgia — Malform- ations and malpositions — Contraction of the stomach— Dilatation of the stomach — Hypertrophic pyloric obstruction — Ulcer of the stomach —Cancer of the stomach 137 CHAPTER VIII. Diseases of the Liver. Jaundice — Icterus — Cholelithiasis — Acute yellow atrophy — Cirrhosis of the liver 177 CHAPTER IX. Diseases of the Intestines. vSimple diarrhoea— Acute intestinal indigestion — Acute infectious diar- rhoea — Cholera infantum — Acute gastro-enteric intoxication — Acute ileo-colitis— Acute intestinal catarrh — Dysentery — Amoebic dysentery— Chronic diarrhoea — Chronic gastro-intestinal catarrh or mucous disease — Intestinal tuberculosis — Constipation — Acute in- testinal obstruction — Intussusception — Appendicitis — Intestinal parasites 183 CHAPTER X. Diseases of the periton^eim. Acute peritonitis— Chronic peritonitis— Tuberculous peritonitis . . . 248 CONTEXTS. XI Page. CHAPTER XL Diseases of the Respiratory Tract. Spasm of the glottis — Acute catarrhal laryngitis — Spasmodic croup — Acute bronchitis — Chronic bronchitis— Asthma — Acute broncho- pneumonia — Croupous pneumonia — Pleuro-pneumonia — Pulmon- ary tuberculosis — Pleurisy — Empyema 254 CHAPTER XII. Diseases of the Heart and Its Membranes. Congenital diseases and deformities — Pericarditis — Endocarditis — Myo- carditis — Chronic valvular disease — Mitral stenosis — Aortic steno- sis — Aortic regurgitation — Functional disorders 332 CHAPTER XIII. Diseases of the Kidneys and Urinary Tract. Albuminuria — Cyclic albuminuria — CEdema without kidney lesion — Hsematuria — Hemoglobinuria — Acute nephritis — Chronic ne- phritis — Bright' s disease — Chronic parenchymatous nephritis — Chronic interstitial nephritis — -Diabetes insipidus — Diabetes niel- li tus — Renal calculi — Cystitis — Enuresis — Vulvo- vaginitis — Gonor- rluea 3b4 CHAPTER XIV. Diseases of the Skin. Inflammations — Eczema — Tetter — Erythema — Furunculosis, boils — Impetigo — Impetigo contagiosa — Urticaria, hives — Vegetable parasites — Tinea — Tinea tonsurans — Tinea circinata — Ringworm — Animal parasites — Pediculosis, lice — Scabies, itch 393 CHAPTER XV. Diseases of the Blood. Anaemia — Chlorosis — Progressive pernicious anaemia — Leukaemia — Pseudo-leukaemia— Splenic anaemia — Hodgkin's disease — Haemo- philia— -Purpura 418 CHAPTER XVI. Diseases of the Nervous System. Insanity — Idiocy — Imbecility — Diseases of the brain and its mem- branes — Acute leptomeningitis— Tuberculous meningitis — Basilar meningitis — Lumbar puncture— Hydrocephalus — Convulsive affec- tions—Epilepsy — Tetany — Affections with motor disturbance- Xll CONTENTS. Page. Chorea — Spasmus nutans — Head-nodding with nystagmus — Hys- teria — Paralytic affections — Cerebral palsies — Acute anterior polio- myelitis — Infantile spinal paralysis — Family ataxia — Hereditary spastic paraplegia — Syringomyelia — Multiple cerebro-spinal sclero- sis — Multiple neuritis —Symptomatic affections — Neuralgia — Head- ache 438 CHAPTER XVII. Diseases of the Ear, Nose and Throat. Otitis — Acute catarrhal otitis media — Acute purulent otitis media — Acute tonsillitis — Acute folliculous tonsillitis — Ulcero-membran- ous tonsillitis — Acute parenchymatous tonsillitis— Peritonsillar ab- scess—Hypertrophy of the tonsils — Retro-pharyngeal abscess — Acute rhinitis — Pseudo-membranous rhinitis — Simple chronic rhi- nitis — Purulent rhinitis — Hypertrophic rhinitis— Atrophic rhinitis — Adenoid vegetations of the naso-pharynx 530 CHAPTER XVIII. Constitutional Diseases. Ivithsemia — Uric acid diathesis — Rickets — Infantile scurvy — Barlow's disease — Status lymphaticus — L,ymphatism — Scrofula — Tubercu- lous adenitis — Tuberculosis — Rheumatism— Acute articular rheu- matism or rheumatic fever — Hereditary syphilis — Marasmus or athrepsia — Malnutrition 567 CHAPTER XIX. Acute Infectious Diseases. Exanthemata — Measles— Rubeola — Scarlet fever— Rubella — Variola — Varioloid — Vaccinia — Varicella — Pertussis — Parotitis — Influenza — Epidemic cerebro-spinal fever — Spotted fever — Malaria — Malarial fever — Typhoid fever — Diphtheria — Membranous croup — Intuba- tion — Glandular fever 535 LIST OF ILLUSTRATIONS Figure. Page. 1. Apparatus for feeding premature infants, 15 2. Infant incubator, . . 16 3. Method of syringing the nose 20 4. Steam atomizer, 21 5. Apparatus for performing lavage, 22 6. Method of performing lavage, 25 7. Weight, length, chest and head measurements under twelve months, $2> 8. Weight, length, chest and head measurements over twelve months, 34 9. Weight chart for first month of infancy, 35 10. Weight chart, after Holt, .... 37 11. Card for recording history of case, 42 12. Method of determining the character of a spinal deformity, .... 46 13. Method of obtaining knee-jerk, 49 14. Method of palpating the lower border of the liver 52 15. Method of palpating the spleen, . . 53 16. Diagram showing lower border of lungs and liver, 56 17. Diagram showing superficial and deep cardiac dulness, 57 18. Method of holding infant during auscultation, 59 19. Monaural stethoscope, 60 20. Binaural stethoscope with large and small chest-pieces, 61 21. Child of six years; lines showing percussion border of lungs, ... 63 22. Anterior view, showing apex resonance, deep cardiac dulness, etc., 64 23. Holt's apparatus for examining woman's milk, 81 24. Diagram showing percentage of fat in whole milk and set milk, . . 90 25. Diagram showing fat percentage of different layers of set milk, 91 26. Freeman pasteurizer, . . . • 102 27. Arnold steam sterilizer, 103 28. Diagram showing time of eruption of the milk teeth, 124 29. Hutchinson teeth, 127 30. Author's acidometer for estimating acidity of gastric contents, . . . 144 31. Oxyurisvermicularis, 243 32. Ascaris lumbricoides 244 33. Taenia saginata, 245 34. Head of taenia solium, 246 33. Spasmodic asthma, 268 36. Temperature chart in lobar pneumonia, -bowing pseudo-crisis, . . 286 37. Temperature chart in remitting pneumonia, 287 38. Lobar pneumonia in child of four years 292 39. Advanced case of fibro-caseous pulmonary tuberculosis, . . 306 XIV LIST OF ILLUSTRATIONS. Figurk. Page. 40. Temperature chart in empyema, developing after pneumonia, . . . 322 41. Skiagraph of child's chest, three years old, posterior aspect, .... 333 42. Cardiac dulness at one year, six years and twelve years, 334 43. Acute rheumatic endocarditis with dilatation, 349 44. Acute nephritis with anasarca and ascites, 371 45. Chronic parenchymatous nephritis, 375 46. Method of eliciting Kernig's sign, 440 47. Method of performing lumbar puncture, ... 461 48. Hydrocephalus; early period, ... 471 49. Cerebral diplegia, showing spastic rigidity, .... 514 50. Climbing up the thighs in pseudo-hypertrophic paralysis, 518 51. Diagram showing line of incision through the tympanum, . . . . 536 52. Tonsillotome, 545 53. Method of holding child for palpating pharyngeal vault, 563 54. Curette for removal of adenoid vegetations, 566 55. Child with rickets, showing large head, narrow chest, etc. , . . . . 579 56. Infant of one year with marasmus, 628 57. Temperature chart in measles, ... 639 58. Temperature chart in scarlet fever, 647 59. Temperature chart in typhoid fever, 705 60. O'Dwyer's set of intubation instruments, 741 61. Diagram showing proper position of child in? intubation, 742 Diseases of Children CHAPTER I. HYGIENE AND NURSING. The New-Born. — Although the care of the new-born be- longs, strictly speaking, to the domain of obstetrics, still a few practical remarks cannot well be omitted in the introduc- tion to the subject of nursing and hygiene of children. As soon as the head is born the mouth and eyes should be cleansed, the latter being washed out thoroughly with a warm boric-acid solution, and this is to be followed by the instilla- tion of a drop of a 2 per cent, solution of nitrate of silver, according to the method of Crede, if the mother be affected with a purulent or specific vaginitis. After the cord has been dusted with powdered boric acid and dressed in sterilized cotton or gauze the child should be wiped dry, the body anointed with sweet oil, especially when there is an abundance of vernix caseosa, and wrapped in a warm blanket and laid aside until it is convenient to resort to the cleansing bath, Bathing. — The full bath should not be given until the cord has come off, which is usually about the fifth or sixth day ; stripping the cord hastens its separation. The child should be bathed always in a warm room, preferably before an open fireplace. The first bath must be a warm one, ap- proximating the normal body temperature ; in hardy children it can gradually be reduced, so that a temperature of 95 ° F. may be reached, by the end of the sixth month. It should be of short duration and the body dried by light rub- 10 DISEASES OF CHILDREN. bing with a soft towel. The bath is best given in the morn- ing about one hour after feeding. In children who do not react well the full bath must be either prohibited entirely or it should be followed by a rapid sponging with alcohol and warm water, about one to two dilution. The free use of soap is a great mistake, as there is no necessity for the daily use of the same, and the irritation of the skin induced thereby often excites cutaneous eruptions. Clothing. — The material should be of wool ; very light weight in summer and heavier for the winter. Grosvenor {Present Status of Pediatrics, 1895) speaks highly of the princess-cut Gertrude suit, in which the child's organs have perfectly free play, no constricting bands being present. He also lays stress on the proper construction of the diaper, show- ing how the unnecessarily large, old-fashioned muslin can be the cause of much harm by overheating the buttocks and kidneys and retaining the excreta too closely. A snug fitting flannel band about the abdomen is a necessary support during infancy, as well as a safeguard against exposure and a pre- cautionary measure in children who are prone to diarrhoea. In such children it may be worn to the end of the first denti- tion period, while in hardy infants it may be discarded after the first year. The Mouth and Teeth. — Instead of washing the infant's mouth after each feeding it is safer to carry out the method advocated by Epstein and wash the mother's nipple with a solution of boric acid before nursing. There is more danger of carrying infection into the mouth in washing the same than by leaving it alone, and there is often much harm done to the delicate mucous membrane by rough treatment on the part of the nurse. Should thrush develop, a mild antiseptic, preferably a 2 per cent, solution of boric acid, must be used as a mouth-wash. The care of the teeth has an important bearing on the child's health. Indigestion, enlarged tonsils, cervical ade- nitis, and catarrhal affections of the throat and mouth can HYGIENE AND NURSING. 11 often be traced directly to dental caries. Beside these, there are many other conditions which show little or no signs of improvement until the dentist has been consulted, and all source of irritation from carious teeth, dental periostitis, overcrowding of the jaw, and the like, has been removed. Much trouble can be avoided and the state of the teeth pre- served in a sound, healthy condition by the daily use of the tooth-brush and early attention to the teeth showing signs of caries. There are, however, children in whom the teeth be- come brittle or decay in spite of all prophylaxis ; such cases require constitutional treatment. Sleep. — The healthy babe enjoys a peaceful, undisturbed sleep, assuming usually a graceful attitude, indicative of complete relaxation. It arouses only to take food, and is seldom awake more than one-half to one hour at a time in early infancy. After the sixth month the child gradually becomes more wide-awake during the day, requiring usually two or three naps, and about twelve hours of sleep at night, up to the age of two years. From this time on until the fourth year it should have at least one nap during the day. Children should be carefully trained in regular habits of sleep, for if once allowed to develop, the insomnia of infants is most stubborn to overcome. The most common causes for this disorder are indigestion from over-feeding and the habit of nursing during the night, although in children of a nervous temperament it may be the result of nervous excitement in- duced by playing just before bedtime. Local causes, such as seat worms, must also be borne in mind. As regards feeding, the first nourishment should be given at 5 A. M. and the last at n P. M. ; rarely is it advisable to feed during the night, at least not after the fifth month, and at the age of two years the child may go without food for twelve hours during the night. To the observant physician a sleeping infant is an interest- ing study, particularly so in case of illness. There are many valuable signs of disease, frequently absent during the wak- 12 DISEASES OF CHILDREN. ing state, that become prominent during sleep. As pointed out in the chapters on Diagnosis and Treatment, sleep is an important element in the recognition of diseases and in prescribing. The Bowels. — The early training of the child to regular habits of stool is of the utmost importance, both from the practical and hygienic standpoint. Already in the early months of infancy the child can be taught to form the habit of emptying the bowels regularly by holding it over a small chamber, which can be held between the nurse's knees, and, if necessary, irritating the anus by means of a conical piece of soap in order to suggest the desire for stool. This should be done mornings and evenings and soon the child realizes the object of the procedure and the habit becomes established without great difficulty, perseverance and regularity on the part of the nurse being the key-note to success in obtaining such a result. Airing. — The nursery should be sunny and well-ventilated, no draughts, however, being permissible. If the child is al- lowed to crawl on the floor, there must be a carpet in the winter, and in the summer matting can be substituted. A rug should always be at the door to prevent the draught com- ing through the sill and coursing along the floor, which in- variably happens when the temperature of the room is higher than that of the hallway. For a similar reason it is advis- able to have double windows, or at least curtains, in winter, as a current of cold air constantly flows down along the window-panes, which will surely strike the child if it be al- lowed to play or sleep in their vicinity. Airing the nursery in winter is best accomplished by hav- ing the windows open in the adjoining room until the air has been perfectly purified, when the windows should be closed and the communicating door opened to allow a diffusion of the atmosphere from one room to the other. When the child can be removed from the nursery it ma}- be aired like any other room. HYGIENE AND NURSING 13 In summer, the room should be kept darkened during the heat of the day ; and at sunset, when the outside air has cooled off, the windows should be opened, while the child may be taken out for an airing. Ordinarily, in the spring and fall an infant may be taken out into the fresh air at one month and even earlier during the summer. During cold weather, however, an infant under three months should not be taken out of the house, and after that age only during the sunny hours of the day. The precautions necessary to be ob- served in taking a child out in its coach are that it be kept out of the wind, that it be sufficiently covered and that the sun does not shine directly into its eyes, but there is no valid objection to allowing a child to sleep in the open air in clement weather providing the above precautions be taken. Statistics show that infants require a greater amount of air- space, proportionately, than adults, and that overcrowding is a prolific source of ill-health among children. This is es- pecially the case in institutions and hospitals for children. Infants require 1,000 cubic feet of air-space in order to thrive ; but as they grow older they develop greater resisting power to external influences, and may do well under circumstances where no more than the above, or even less, breathing-spree is available for each child. Exercise. — The infant gets its exercise to promote metabol- ism in crying and in the non-volitional movements it per- forms. It should, however, also have its daily sun-bath and airing and it is a good plan, once a day, to allow the infant the full and free use of its limbs by removing all tight gar- ments and letting it lie upon a bed in this condition for a quarter of an hour. Older children require exercise of a more definite kind, such as walks in the open air, games, etc. A cold sponging every morning aids greatly in the physical development of the child. Fatigue and over-exer- tion in all forms of sport and exercise are to be strenuously guarded against, for the tissues and delicate organs of the growing child are far more liable to receive permanent injury 14 DISEASES OF CHILDREN. from their abuse than later in life, when they have become accustomed to accommodate themselves to the extra strains not infrequently brought upon them. Premature and Delicate Infants ; Incubators. — The period of viability in a premature babe cannot be exactly stated, as the condition of the infant plays a more important role than its age. The state of nutrition at birth ; the weight and, length ; the condition of the mother during pregnancy and above all, the fact as to whether the respiratory function is active should rather decide the question of viability than a mere arbitrary age limit. The period of viability has been usually fixed at twenty-eight weeks, but a number of premature infants of twenty-four weeks have been successfully raised. Ktheridge {American Text-Book of Obstetrics) suggests that any child that breathes at birth should be considered viable. Tarnier gives the following statistics based on five years' ex- perience with the incubator : Infants of 6 months, 16 per cent, saved ; 6% mos., 36 per cent, saved; 7 mos., 50 per cent, saved; 7^ mos., ^ per cent, saved; 8 mos., 89 per cent, saved; S}4 mos., 96 per cent, saved. This is fully a saving of 10 per cent, of lives, as compared with the death rate among premature infants not placed in incubators. The percentages given by Ktheridge are not quite so high, but on the whole quite encouraging. An infant weighing less than four pounds and measuring less than nineteen inches should be looked upon as pre- mature, or at least under-developed, aside from its great feebleness and impossibility of maintaining normal body heat. These infants possess a digestive tract and respiratory organs that are imperfectly developed. The same usually holds good with the circulatory organs. Owing to the poorly developed state of the muscles, they do not have sufficient strength to suckle and deglutition is difficult. The success- ful rearing of these infants, therefore, resolves itself into two problems : First, the maintenance of the normal body tem- perature ; second, the proper mode of nourishment. Owing HYGIENE AND NURSING. 15 to the rapid loss of heat, strength and weight incident to the early days of infancy these children must be cared for from the very beginning if we expect to save them. Infants weighing three and one-half pounds or over can usually be raised outside of an incubator. The body should be wrapped in a thick layer of cotton batting instead of attempting to dress it. In order to prevent soiling, a soft diaper is to be adjusted before wrapp- ing up the body. The entire body is then wrapped in a blanket and hot water bags applied to the feet and sides of the body. It is well to rub the child with olive oil daily, but it should only be washed as often as is absolutely necessary. The diet must be that suitable to the new-born or even more diluted (see chap- ter on Infant Feeding). If breast-milk can be obtained, this is, of course, an advantage. The milk should be taken from the breast with a pump and collected in a sterile receptacle. It is then best administered to the child with a medi- cine-dropper, the milk being dropped well back into the pharynx, with the child in the recumbent position. Two to four drachms of nourishment should be given hourly. If the infant cannot be made to take sufficient nourishment in this manner, gavage must be employed, although this procedure is less frequentlv indicated in these cases than in the incubator babes. I have found that partial peptonization of the food is often an advan- tage in premature and feeble infants owing to the under- developed state of their digestive organs. Fairchild's Pepto- genic Powder answers best for this purpose; it supplies milk- sugar to the food besides a small amount, of pancreative and bicarbonate of soda. FIG. I. — APPARATUS FOR FEEDINCx PRR- MATrRK INI' A NTS. (KOPUK. ) 16 DISEASES OF CHILDREN. ItMUUiHUUIBIlk. jIUBJt'iaiiKU'jiuisiMnHii The incubator is a necessary apparatus for maintaining the bodily temperature in premature babes. There are a number of patterns, each possess- ing good points and all differing only in minor details. The require- ments of a good incuba- tor are that it should maintain a regular de- gree of heat, supply the infant with a sufficient amount of fresh air and be readily accessible for purposes of changing the soiled cotton and for gavage. The improvements and special features found in some of the more com- plicated incubators are advantages, but not ab- solute necessities. Personally, I have had good results with an im- provised incubator made out of a box with a false bottom into which hot water bottles may be placed and changed as they cool off. A ther- mometer must be kept in the box and the tem- perature watched ; it should be kept at about 90 F. A light blanket or shawl may serve as a cover, leav- ing the child sufficiently exposed to allow of a free inter- change of air. FIG. 2. — INFANT INCUBATOR. THERAPEUTIC MEASURES. 17 At the Hahnemann Maternity Hospital Dr. Korndoerfer has observed haemorrhage into the spinal cord in two incubator babes at autopsy ; the cause of this was probably excessive heat. Gavage is imperative when the babe cannot take a suffi- cient amount by means of the medicine dropper. One to tw r o drachms of breast milk or of a 10 per cent, top-milk diluted five to six times with a six per cent, solution of milk sugar may be administered every hour. If the babe cannot digest plain milk, it must be peptonized. Exhaustion is averted by handling the child as little as possible. Pads of absorbent cotton are more readily adjusted and removed than diapers, for which reason they should be used, and in place of a full bath a daily rub-down with w T arm olive oil is to be given. From two to four drops of brandy in twenty drops of sweetened water may be administered as a stimulant when necessary. THERAPEUTIC MEASURES. Cold. — In cold we have one of the best and safest anti- pyretics known, beside its well-known analgesic and astrin- gent properties. To get the latter effects cold is best applied in the form of an ice-bag, a rubber coil through which ice- water is allowed to circulate, or cloths wrung out of ice- water (cold compresses). Cold is a valuable application in most inflammations, but particularly in ophthalmia, meningi- tis and synovitis ; as a rule, heat is preferable in inflamma- tory affections of the chest and abdomen. Cold compresses are useful in croup ; it is contraindicated in diphtheria (GooDNO)and in inflammations of the larynx, trachea and bronchi (Hoi/r). Heat. — Heat is perhaps the most useful of all non-medi- cinal therapeutic measures, and has a wide field of appli- cability. In painful inflammatory affections it acts promptly by relieving tension and hastening resorption. The old- fashioned poultice is rapidly being superseded by hot anti- 18 DISEASES OF CHILDREN. septic fomentations in suppurative processes, which do in- finitely less mischief than the former. Fomentations pre- pared by wringing a piece of spongiopiline or flannel out of hot water, best immersed into the same by means of a towel and wrung out by winding up both ends of the towel (the water should be slightly hotter than the hand can bear), are most serviceable when quick results are necessary, as in peritonitis, colic, etc. Dry heat is most conveniently applied by means of hot-water bags or baked flannel. It must be remembered that the child's skin is more sensitive and more readily scalded than an adult's, for which reason proper precautions must always be taken. Baths. — By means of the bath we are able to apply heat or cold most rapidly to the entire body. Hot baths are often useful in collapse and asphyxia neonatorum ; by adding a tablespoonful of powdered mustard to the warm bath we have an excellent means of relieving serious congestion of internal organs, through its derivative effect, and a harmless method of bringing out the rash, especially in cases of measles slow in developing. The bran bath is most useful in cases of eczema or other excoriated conditions of the skin. In cases of collapse the child may be placed in a bath of ioo° F., which is gradually raised to no°, until reaction sets in. The action of the cold bath is to reduce the temperature and restore the lost tone to the cutaneous vessels, thus in- creasing the resistance to the blcod current and improving cardiac action ; besides, it gives a powerful stimulating shock to the nervous system. For this reason it is of decided value in typhoid fever. It is best given in the following manner : The child being stripped and wrapped in a light blanket, a bath tub filled with water at 92 ° F. is brought beside the bed and the child immersed by means of the blanket. The temperature of the water is then reduced by the addition of cold water to 8o°. THERAPEUTIC MEASURES. 19 While in the bath, friction must be applied to the child's body to prevent collapse. The duration is ten minutes, and it should be repeated every three hours, reducing the tem- perature each time until 75 ° or 70° are reached, continuing at this temperature as long as the rectal temperature registers above 103 F. (Baruch). The cold bath is contraindicated in diphtheria and scarlet fever, and in all cases it must be remembered that the child's temperature falls more rapidly and more persistently than in the case of adults. After the bath it should be dried well and rolled up in a blanket if there is chilliness, which is sel- dom the case in typhoid fever, but pneumonia patients do not stand the cold so well and in these cases a gradual reduction in the temperature is always necessary as well as thorough dry- ing after the bath. Packs. — Packs are highly efficient antipyretics and dia- phoretics ; especially is it for the latter effect that they are employed. The cold pack is applied by wrapping the child in a sheet wrung out of cold water, the sheet being sur- rounded by a dry blanket. When used to reduce fever it can be reapplied hourly, or more frequently, as necessary. In pneumonia the pack is often restricted to the chest. The hot pack is most useful in nephritis and uraemia, or suppression of urine from whatever cause. A light blanket is wrung out of hot water and applied as above, with the dry blanket on the outside. The hot mustard pack is prepared by adding a little ground mustard to the hot water ; it is in many instances preferable to the hot mustard bath, and is especially useful in convul- sions, congestion of the lungs and of the brain ; also to bring out tardy eruptions. While in the pack, the head should be sponged with cold water or water and alcohol. Nasal Syringing. — This is most important in obstruction of the nasal chambers from diphtheric deposits, although cases of simple rhinitis frequently require douching to effect a prompt cure. The child is placed in the nurse's lap, its 20 DISEASES OF CHILDREN. legs held between her knees, and the arms and chest con- trolled by a towel ; the head is inclined somewhat forward, and the blunt nozzle of a douche-bag inserted into one of the nostrils. On raising the bag, the irrigating solution flows into one nostril and out of the other, being caught in a basin held under the child's chin. The nose can also be douched with the child lying on its side (Fig. 3). Throat Spraying. — The safest and most satisfactory method of bringing an antiseptic or oily solution in contact with the FIG 3. — METHOD OF SYRINGING THE NOSE. (KOPUK. mucous membrane of the pharynx and tonsils is by means of the atomizer. Children are late in learning to gargle, and even this procedure is not always to be commended, as it is at times positively harmful. In case of emergency, however, should the child be unruly, cry and not permit the use of the atomizer, it can be laid on its back across the nurse's knees, with the head thrown back, and the fluid poured into its mouth, when it will involuntarily gargle. But in employing THERAPEUTIC MEASURES. 21 such a method only fluids which can be swallowed with im- punity are permissible. Inhalation. — The inhalation of steam is very beneficial in most respirator}' ailments, but especially so in croup, and after tracheotomy it is absolutely necessary. In the absence of the specially-constructed u croup-kettle,' ' an ordinary tea-kettle in which water is boiling may be used, the steam being directed under a sheet overhanging the child in the fashion of a tent. The steam atomizer shown in the i^ustration is a satisfactory instrument (Fig. 4). Lavage. — The apparatus for carrying out lavage in chil- dren consists of a soft- rubber catheter, attached to a piece of rubber tub- ing two to three feet long by means of a piece of glass tubing, and a medi- um-sized glass funnel which is attached to the other extremity of the rubber tube (Fig. 5). The identical apparatus is also used for gavage. For an infant three months old I use a No. 10, English ; six to nine months old, No. 11, E., and for an older infant, No. 12, E. In the new-born the catheter reaches the fundus, when introduced to the length of eight inches ; in an infant of three months it must be inserted nine inches and in older infants from ten to twelve inches. I am in the habit of enlarging the eye of the catheter to facilitate the passage of mucus and curds through the same. Stomach washing, as an adjuvant in the treatment of gas- tric disorders, is a procedure that has long been practiced, but its introduction into pediatric practice is due to the efforts of FIG. 4. — STEAM ATOMIZER. 22 DISEASES OF CHILDREN. Epstein, who, in 1883, published a report of 286 cases in which lavage was used in gastric disorders in infants with great benefit and without a single unfavorable result. Since then it has been extensively employed by pediatrists every- where. Holt speaks of it as one of the most valuable thera- peutic measures we possess, and he states that it has been used thousands of times under his directions without any ac- cident whatever. While I have never seen an evil result that could be traced directly to stomach washing, still I feel that it has its contra-indication as well as advantages, and must always be carried out with care and caution. It is hardly necessary to argue in favor of so practical and simple a pro- cedure, and to plead for the ac- ceptance of a mode of practice whose efforts are self-evident and whose application is based purely on the principles of com- mon sense. We have always recognized that in toxic cases the first rule is to apply the stomach-pump. Since we have learned that most cases of acute indigestion and all cases of cholera infantum are toxic in origin, it becomes our duty to immediately empty the stomach under these conditions unless nature has helped herself and free emesis has set in. The passage of a tube into the infant's stomach is, as a rule, accompanied by no depression and only slight discomfort, which is not to be compared to that resulting from severe nausea or artificially-induced vomiting. By this method we not only empty the stomach, but we are also able to wash FIG. 5. — APPARATUS FOR PER- FORMING LAVAGE. THERAPEUTIC MEASURES. 23 it out thoroughly and remove every vestige of harmful matter and abnormal secretions, in consequence of which, recovery from an attack of acute gastritis is more prompt than under ordinary circumstances. Besides, remedies are better able to act when taken into a clean stomach than in one containing decomposing food and mucus. It is not, however, only in acute conditions in which lavage is of benefit ; in subacute and chronic gastritis, fermentative dyspepsia and dilatation of the stomach, it has proven very useful. Daily lavage for the purpose of removing tenacious mucus that interferes with the digestive process, or for draw- ing off undigested food and gases where they have accumu- lated, is a most valuable adjuvant in the treatment of chronic gastritis and dilatation. These conditions are by no means rare, as anyone having extensive practice among children knows. Lavage is highly recommended to allay gastric irritability and control distressing vomiting associated with obstruction of the bowels. In acute gastritis with uncontrollable vomit- ing there is no method of treatment so efficacious as lavage. I wish to refer to another use to which the stomach tube may be put with great advantage, namely, for the purpose of putting food into the stomach. It may seem uncalled for to administer food in this manner, but the clinical experience upon which it is based fully justifies it. The most rebellious stomach retains several ounces of food poured in through a tube when a teaspoonful taken by the mouth will be im- mediately vomited. Kerley has brought this fact out prominently, and he explains it on the grounds that the pas- sage of the tube causes less irritation of the pharynx than the food in being swallowed. Formerly, lavage was only used in the rearing of premature infants, as suggested by Tarnier, and in grave acute diseases when the child refused or was unable to take food or drink, — a condition commonly encountered in gastro-intestinal inflammation. The results of lavage in the conditions above enumerated are positive. For the last few years I have tested it practically 24 DISEASES OF CHILDREN. both in my hospital work and private practice and my ex- perience has led me to look upon it as indispensable in the treatment of these maladies. I have seen many cases of gastro -enteric catarrh, and some of gastric dilatation, diag- nosed as marasmus (which, by the way, is a symptom, and not a disease), promptly display a tolerance for the proper food and assimilate it after the institution of systematic lavage. That it was a life saver in many of these cases I am bold to claim. The infant, being held upright, seated on the nurse's lap, should be covered with a towel, to prevent soiling the cloth- ing, and the catheter then inserted in the pharynx with the right hand, its tip following the index ringer of the left hand, which presses down the base of the tongue (Fig. 6). Wetting the catheter with plain water is sufficient, as a rule, on account of the free secretion of mucus in the pharynx, which acts as a lubricant ; but if there be abnormal dryness of the mucous membrane, there is no objection to the use of a little diluted glycerine. The child may make efforts at deglutition as soon as the catheter reaches the pharynx, in which case it glides down into the oesophagus easily. More frequently, however, it gags, interfering with the operation. If we now wait for a few seconds, until the child draws a long breath, a gentle push will readily force it into the oesophagus. All that is then required is to pass the catheter along with the fingers, which can be done without changing the position of the hand, until it reaches the stomach. This usually takes place when about ten inches have passed ; and, if the stomach be full, some of its contents will escape through the apparatus when its end is lowered. In fact, the catheter can be felt to strike the fundus of the stomach, and after a little experience one can readily tell just where the tip of the catheter is located. It is well to first raise the funnel to allow the escape of gas, which is often present. It is then lowered over a basin, and held there until the stomach contents are drained off. Frequently nothing will come from the stomach until water is poured in THERAPEUTIC MEASURES. 2o through the funnel and a siphon established. Again, the gastric contents may be so thick or tenacious as not to flow through the tube until diluted and broken up. With the funnel held a distance of two feet above the level of the epi- gastrium, two to four ounces of plain boiled water at ioo° F. are poured in, and before the last part of the water has flowed FIG. 6. — METHOD OF PERFORMING LAVAGE. in, the tube is pinched, in order to maintain a continuous column throughout the tube. The funnel is then lowered into the basin and the stomach contents siphoned out. This procedure is repeated until the fluid comes out clear. It is often advantageous to leave a few ounces of water in the stomach ; in case of vomiting, pour the feeding in before removing the tube. In acute gastritis hot water at no° F. is 26 DISEASES OF CHILDREN. more advantageous, and when fermentation of food is a promi- nent symptom a i per cent, solution of boric acid may be used instead of plain water. I am also in the habit of using bicarbonate of soda when the gastric contents contain lactic or butyric acid. In carrying out gavage the same steps are taken, with the exception that the child is kept in the prone position throughout. The removal of the tube must be quickly done, at the same time pinching it to prevent the fluid from run- ning into the pharynx and larynx, thus setting up gagging or a coughing paroxysm. The contra-indications for lavage are pulmonary or cardiac diseases, with cyanosis or embarrassment of respiration, ex- treme debility, and ulceration of the stomach. Exceptionally, we encounter forms of gastritis in which the passage of the tube causes slight bleeding from the stomach, leading one to suspect ulceration, — post-mortem examinations, however, showing the mucous membrane intact. In such a case it is, of course, imperative to desist. Occasionally, also, we en- counter an infant in which attempts at passing the tube cause much distress, embarrassed respiration, and prostration. With great care it is often possible to carry out the introduc- tion of the tube ; but it should not be long retained, and if after-effects are to be noted it is not wise to persist. The great majority of cases, however, do not mind the tube in the least, and some hardly seem to realize its presence, giving one ample opportunity to wash the stomach. Caution is, never- theless, always necessary ; and the child must be carefully watched while passing the tube, while it is in position, and after the operation. Gavage, or forced feeding, is often necessary during the course of an acute illness and in certain forms of indigestion, when the child refuses to take nourishment, or is unable to do so or is unconscious. In these cases the food is introduced while the child is in the recumbent position, care being taken to keep it quiet after the operation. In cases of persistent vomiting, food introduced by means of the tube is often THERAPEUTIC MEASURES. 27 retained. Premature infants are in many instances raised by gavage, when they would otherwise have succumbed without its employment. Irrigation of the Colon and Enemata. — For simply empty- ing the rectum the enema is all that is required, but where it is deemed advisable to flush out the entire tract of large in- testine it is necessary to resort to irrigation of the colon. The enema is administered by laying the child upon its back with the thighs flexed upon the abdomen and inserting the nozzle of a hard-rubber syringe, well lubricated, into the anus. Where soap and water have been decided upon for the injec- tion, it is better to use a small fountain syringe, elevated three feet above the child's hips. The hard-rubber syringe is preferable where such substances as sweet oil or glycerin are employed. The glycerin should always be diluted with three parts water ; of this, one ounce may be used. For irrigating the colon the child is placed on its left side upon a rubber sheet covered with muslin or linen, the hips being slightly elevated. A soft-rubber catheter, No. n or 12, English, is attached to the nozzle of a fountain syringe, lubricated, and carefully inserted into the rectum. The water is then allowed to flow in slowly, stopping the stream as the child makes efforts at expulsion. The catheter must be passed through the sigmoid flexure as the water begins to flow and distend the rectum. The fluid will usually reach the colon without difficulty, but cannot pass into the ileum, although it is claimed that if the colon is not distended, and the water allowed to flow in slowly, a closure of the ileo- cecal valve does not take effect, and so the fluid may even reach into the small intestines. However, if the larger bowels are thoroughly cleansed we have accomplished our end. After a half to one pint of fluid has run in, the amount being gauged according to the age of the child, it should be allowed to escape by removing the nozzle from the catheter, and the process repeated until the fluid comes out clear. Tepid water, 80 ° to 90 ° F., answers best for ordinary irriga- tion ; boric acid may be added (2 per cent.), if desired. 28 DISEASES OF CHILDREN. Irrigation of the colon is useful in diarrhoeas, especially if the stools are offensive or contain an abundance of mucus or undigested, irritating particles. The same technique is em- ployed when distention of the bowels with water is used as a means of relieving intussusception. Hot injections have been used in collapse and cold in hyperpyrexia, but the latter pro- cedure is entirely uncalled for. Enteroclysis is a safe and effici- ent means of averting circulatory failure in acute infectious conditions. When a hot normal saline solution is employed it stimulates the abdominal sympathetic nerves and also supplies the tissues with water. The blood pressure is promptly raised and elimination of toxines through the kid- neys hastened. When the blood pressure is high and the heart chambers are over-filled it is not wise to resort to this procedure. Enteroclysis is properly carried out by inserting a Kemp's flexible double current catheter high up into the rectum and allowing water at 105 to no° to flow through for ten to fifteen minutes. In hyperpyrexia the water should be used at 85 ° to 90 ° to bring down the temperature. It is well to leave as much water in the bowel as will remain when removing the catheter. Inunctions and Massage. — The nutritive value of oil inunc- tions renders this form of treatment of great usefulness in all cases of malnutrition and wasting diseases. Beside the direct nutrition resulting from the absorption of the oil or fat, there is also a decided stimulus imparted to the entire nutritive process by the friction and kneading of the surface. For this reason it really encroaches upon the field of massage, from which it borrows a most useful therapeutic measure. Inunc- tions of an animal fat, such as benzoinated lard, not only relieve itching, but also act antipyretically in scarlet fever. They are valuable in any form of fever with dry, hot skin. Massage is perhaps more limited in its field of usefulness in diseases of children when compared with its applicability in adults, but, nevertheless, there are many conditions in which it must always remain indispensable. THERAPEUTIC MEASURES. 29 After the bath it is well to apply general massage to the child, especially if it be of a delicate constitution and slow to react. During the cold or graduated bath it is necessary to employ it to keep up peripheral circulation. Effleurage and Petrissage (stroking and kneading), together with passive motion of the joints, especially the smaller ones, are the procedures employed in the above conditions. General massage is often of great value in cases of malnu- trition, anaemia, most constitutional diseases, and especially in nervous diseases. " It becomes almost a necessary adju- vant in the functional nervous conditions in which over-feed- ing, combined with rest, forms the principal therapeutic means, and in organic nervous diseases generally, to promote local and general nutrition." (Bartlett.) Massage of the abdomen is a valuable adjuvant in the treat- ment of chronic constipation. The warmed hand is placed upon the abdomen in the region of the umbilicus, and under gentle pressure rotary movements are executed for a few minutes. The hand is then passed from the right iliac region upwards, following the direction of the colon, across the abdomen, and down on the left side, repeating the pro- cedure several times. In this way friction is directly applied to the walls of the intestine, and a displacement of their con- tents in the normal direction is effected. CHAPTER II. THE METHODS OF CLINICAL EXAMINATION. The Periods of Infancy and Childhood ; Morbidity and Mortality. — Infancy may be divided into three distinct periods, namely, the new-born, the period of early infancy and the dentition period. No sharp boundary lines can be drawn to separate these periods into distinct stages, as this classification is purely arbitrary and exists only for the sake of conveniently studying and grouping certain physiological and pathological peculiarities belonging to them. Infancy may be said to terminate with the completion of weaning, and, although the entire teething period (twenty- four to thirty months) is sometimes spoken of as u infancy," still the majority of pediatrists consider this terminated at the end of a year, when the child should be able to take a certain amount of solid food and plain cow's milk. Childhood begins from this time on and extends up to the period of puberty (twelfth to fourteenth year in females ; fourteenth to sixteenth year in males). Childhood, again, is divided into early child- hood, or the milk-tooth period, occupying the first to sixth year and later childhood, the sixth to twelfth year, during which time most of the permanent teeth erupt and physical and physiological processes more closely attain to the adult type. The Diseases of Infancy and Childhood. — While in many instances it is correct and permissible to speak of diseases of children, still a large number of diseases encountered in child- hood are but the ordinary ailments that affect all mankind in general. Their course, however, is so modified by the imma- ture or exaggerated anatomical structure and physiological activity of the child's economy that they differ in many respects from the type of the disease as seen in adults. Croup- THE METHODS OF CLINICAL EXAMINATION. 31 ous pneumonia, typhoid fever, enteritis, etc., belong to this group. Capillary bronchitis, spasmodic croup, the exan- themata and a number of other contagious diseases belong almost exclusively to the period of childhood, while rickets and hereditary syphilis are distinctly diseases of children. The new-born is particularly susceptible to septic infection on account of the open state of the umbilicus and the delicate nature of the epidermis. Besides, there are distinct patho- logical conditions belonging to this period. They are spoken of as the diseases and malformations of the new-born {Neona- torum). The young infant is particularly susceptible to mycotic disease of the mouth {thrush) owing to the absence of normal buccal secretion. It may also develop capillary bronchitis or contract whooping cough or succumb as a result of con- genital debility, hereditary syphilis or early tuberculous in- fection. The teething period predisposes to gastro-intestinal de- rangements, although in this period of infancy a large num- ber of infants succumb to broncho-pneumonia. Disturbances of nutrition belong to this period — marasmus, rickets, scurvy. Childhood proper gives us the largest number of acute in- fectious diseases. The intermingling of children on the street and at school explains the prevalence of contagious dis- ease at this period of life. Mortality. — Nearly 10 per cent, of all infants die during the first month of life (Eross). From a study of the death reports of New York City, Holt found that about one-fourth of all deaths occur during the first year of life and nearly one- third during the first two years. The causes for this high mortality are mainly congenital debility, improper feeding and the infections. The largest number of deaths occurs from gastro-intestinal diseases, which are most fatal in the hot summer months. They furnish about 35 per cent, of deaths. Next conic the- 32 DISEASES OF CHILDREN. acute diseases of the respiratory tract, 21 per cent. Other prominent fatal diseases are whooping cough, 12 per cent. ; congenital syphilis, 10 per cent. ; measles, 9 per cent. (Ash- by and Wright.) Growth and Development. — The rate of increase in the in- fant's weight is a safe criterion for judging of its progress, while continued loss in weight possesses distinct diagnostic significance. Absence of the regular weekly gain in weight implies improper feeding providing there are no signs of disease present. When not directly traceable to insufficient nourishment or indigestion we should suspect the advent of marasmus, or the beginning of a tuberculous meningitis, or general infantile tuberculosis. Progressive increase in weight cannot, however, be looked upon as an invariably favorable sign. It is well known that syphilitic infants often look fat and well nourished, but may, nevertheless, die very unexpectedly. Budin (Annates dn Med. et de Chir., June, 1900) has observed that infants suffering from various acute disorders may gain in weight suddenly and then die iu the course of a few days. In some of these cases there is localized oedema and deficient urinary excre- tion. In febrile disturbances he has also noted increase in weight at times. Hand in hand with increase in weight there should also be a regular increase in length in the normally developing in- fant. According to Schmid-Monnard there is an increase in length of three-quarters of an inch per month during the first year. The male new-born measures 50 cm. in length ; the female, 49 cm. During the first two months of life there is a gain of from 3 to 4 cm. ; in the following three months, 2 cm. ; and in the last months of the first year, 1.5 cm. At the end of the first year the total gain is 19 to 23 cm. ; at the end of the second, 10 cm., and during the third year, 7 to 8 cm. The male slightly exceeds the female in length (Monti). The head has a greater circumference than the chest at THE METHODS OF CLINICAL EXAMINATION. 33 birth ; at the middle of the first year the measurements begin to approximate each other and at the end of the year the chest grows larger than the head. A comparison of the cir- cumference of the head with that of the chest, therefore, offers important clinical data. In rickets the head is some- LENQTH 20.7 WEIGHT 7LBS.12 0Z, NEWBORN LENGTH 26.2 WEIGHT 15.4 LBS. 6 MOS. FIG. 7. LENGTH 27.7 WEIGHT 18 LBS. 9QZ. 12 MOS. what larger than normal while the chest is abnormally small. In hydrocephalus the head is unusually large and the chest normal, while in microcephalia the head is proportionately much smaller than normal. The diagrams shown in the illustrations (Figs. 7 and 8) have been constructed from the results of measurements of 200 34 DISEASES OF CHILDREN. healthy infants by Hedlicka and Pisek (Chapin's Theory and Practice of Infant Feeding, pp. 306 and 307). The initial weight, roughly stated, may be said to double length 29.8 LENGTH WEIGHT 22 LBS. 2 OZ. 32.0 18M0S. WEIGHT 24 LBS. 24 MOS. FIG. 8. itself in five months and treble itself at the end of the first year. During the first four months the babe gains half a pound per week ; this gradually falls off until there is from THE METHODS OF CLINICAL EXAMINATION. 3o one-half to one-third of that amount of weekly gain. The average infant weighs seven and one-half pounds at birth, losing half a pound during the first week. Xot until the HAHNEMANN HOSPITAL— Maternity Department WEIGHT CHART Nimt Color Stx Date of Birth 190 DAY V»EL« . -V -: : 7 ■ c ;:• [] 12 13 14 15,1s 17|l8|l9 ;.: 21 22 23 o • " ... ..: ..■ ■! WEEK . DAY MOUTH CAY 1 day '.'.;-.:•-; 4010 1 ■" : :>- 57&33 ■~^: : 55565 5443 1 S5Z *• <* y s r- *» / ' / V / / t / / / / i / / / \ / ™ I 3 MONTHS 6 MONTHS • MONTHS FIG. lo.— WKICHT CHART, AFTER HOLT. 38 DISEASES OF CHILDREN. the eighteenth month. If so, malnutrition or rickets should be suspected. Talking begins coincidently with walking. As a rule, girls begin earlier than boys. At the age of two years a child should be able to put words together intelligently. Aside from tongue-tie — a rare condition — the causes delaying the development of speech are either constitutional enfeeblement or some mental defect (see chapter on Nervous and Mental Diseases). The physiological and anatomical peculiarities distinctive of the period of childhood will be discussed in the introduc- tory remarks to the chapters dealing with the various organs and systems. Diathesis ; Temperament. — Much stress was formerly laid on the value of the diathesis as an important element in diag- nosis, and teachers of pediatrics attempted to classify the various constitutions into definite types, each of which showed pronounced predisposition to certain diseases. It was held that the scrofulous diathesis, for example, was a distinct form of constitution in which there was a tendency to suppurating affections of the lymphatics certain skin diseases, predis- position to catarrhal affections, croup and meningitis, and a number of other constitutional disturbances, among which enlarged tonsils and adenoid vegetations stood prominently. The condition was not clearly understood until it was discov- ered that scrofula, so-called, was in reality tuberculosis of the lymphatics. A tuberculous diathesis was also spoken of, in which there was a strong predisposition to pulmonary tuber- culosis and other acute forms of the disease. We know now that tuberculosis may affect any child that has been exposed thereto, as many authenticated cases demonstrate ; and, while there is no doubt that certain individuals are more susceptible to the tubercle bacillus than others, still the so-called tuber- culous diathesis is nothing more than a frailty of constitution, and has no other significance. It is improper to speak of a syphilitic diathesis, as is some- THE METHODS OF CLINICAL EXAMINATION. 39 times done, because a person either has syphilis or has it not, there being no proof that such a thing as natural predisposi- tion, any more marked than the universal predisposition of all mankind, exists. On the other hand, if syphilis be inherited, the patient is immune to acquired syphilis. The rheumatic diathesis has been described, but there is still confusion in the minds of the profession as to what is really meant by this term. To the writer's mind, this dia- thesis occupies at present the position formerly occupied by the scrofulous diathesis, which we now fully understand. Speaking of the hereditability of rheumatism, Bartlett says : " The hereditability of rheumatism is universally conceded. And yet the present popular view that it is an infectious dis- ease will probably do much to modify this opinion. The difficulties can be reconciled by assuming that there is a special diathesis favoring the incidence of rheumatism, and that this is transmitted from parent to child. It is also sug- gested that the poison upon which rheumatism depends is the special agency which is transmitted. Still others assert that it is some particular anatomical or structural peculiarity which is responsible." (A Text-Book of Clinical Medicine.) It will therefore be seen that it is unsafe, in the present state of our knowledge of diathetic conditions, to place too much importance on this feature of a case, or to go beyond the teachings of Bouchard, who divides constitutions into the arthritic, or a predisposition to certain diseases in which the process of nutrition is retarded (rheumatism, gout, diabetes, cholelithiasis, etc.), and scrofula, in which there is a predisposition to tuberculosis. The writer has faithfully en- deavored to demonstrate to his entire satisfaction that the study and recognition of the diathesis is an important clin- ical datum, but he has not been convinced that this is always the case. (Hahn. Monthly, Feb., 1903.) The following description of the various diatheses is given for the sake of acquainting the student with the characteris- tics held to be sui generis of these types of constitution. 40 DISEASES OF CHILDREN. The scrofulous child is stout and flabby, and is subject to glandular enlargements and catarrhal conditions of the mu- cous membranes and skin; the features are usually coarse, the temperament phlegmatic, and the cerebral faculties dull. The tuberculous or phthisical child is of an active tempera- ment, bright and precocious ; the frame is sparely developed, the skin delicately transparent, the hair generally soft and silken. The syphilitic infant is recognized by the hoarse cry, the snuffles, ulcerated nasal septum, the characteristic eruptions, especially in the groins and about the anus, and the old, withered look, due to malnutrition. Later in life we notice the broad, flat root of the nose, the linear scars about the angles of the mouth, Hutchinson's teeth, interstitial keratitis, and many other possibilities. Of course, it is unreasonable to expect to find all of these signs in every case of hereditary syphilis, but careful examination will usually detect sufficient of them to clinch the diagnosis. The rachitic child is typical in appearance. When well developed there is the characteristic square head, the epi- physeal enlargements, the beading of the ribs, bowing of the long bones, pot-belly, enlarged spleen, profuse sweat about the head, anaemia and constipation. In abdominal tubercu- losis we also have the large belly ; but here the small chest, the wasted thighs and the absence of typical rachitic mani- festations will easily differentiate the two. Rheumatism is more extensive in its areas of distribution in children than in adults. The joints are not, as a rule, so severely affected as the endocardium and nervous system. Tonsillitis, with fever and aching in the limbs, is often the only outward manifestation of an acute attack of genuine rheumatism, during the course of which the heart is often involved, or chorea follows as a sequel. The rheumatic dia- thesis, therefore, often presents itself by nothing more than the common joint-pains, often called growing pains; urinary disturbances, pointing to incomplete oxidation and elimina- TAKING A HISTORY AND KEEPING RECORDS. 41 tion of excreta; a general retardation of the nutritive pro- cesses, from which gravel and biliary calculi may result; anaemia ; subcutaneous fibrous nodules ; chorea and endocar- ditis, and certain forms of cutaneous eruptions. METHODS OF TAKING A HISTORY AND KEEPING RECORDS. The importance of intelligent, systematic case-taking and the keeping of accurate records cannot be overestimated. By using the card system the physician can keep a single set of records, including both his office and outside work, for it is a simple matter to carry a few cards in one's visiting list, and thus take notes at the bedside of the patient. The first part of the history comprises the data obtained by interrogating the child or the attendant upon the child. After this has been recorded the results of the physical ex- amination and such remarks as the physician finds of direct bearing on the case (prognosis, diagnosis, treatment) are added thereto. The schema shown in Fig. 1 1 is a reproduction of the card used in the children's department of the Hahnemann Hos- pital Dispensary. The significance of the data sought and the means by which they are best obtained are as follows : The family history is inquired into for the purpose of de- termining whether there is an hereditary disease or hereditary predisposition. Sometimes, as in the case of tuberculosis, it is difficult to say whether heredity or exposure to a tuberculous relative plays the most prominent part in the case. Inquiry should be made regarding tuberculosis in parents or their im- mediate relatives. A history of syphilis can at times be ob- tained by a frank admission of the parents, but often they will not only deny the same but even evade skillfully applied interrogations aimed at establishing such a history. Rheu- matism should also be inquired into, as there is no doubt that certain diseases are based upon a special diathesis favoring the incidence of rheumatism (see ante). Atavism, the ten 4 42 DISEASES OF CHILDREN. dency of certain diseases, notably tuberculosis, to reappear after having skipped a generation, must also be taken into consideration. Mental and nervous diseases in the parents or immediate relatives should be noted. Temperamental pecul- iarities and neurotic tendencies may be augmented in the child through the intermarriage of near relatives. The health of the other children and their number may throw much light upon the family history. Marasmus com- monly appears when the mother has had a large number of No CHILDREN'S DEPARTMENT HAHNEMANN HOSPITAL DISPENSARY. Name Date Address Nativity Age Occupation Diagnosis HISTORY: Health of father " " mother " " other children Mode of birth Dentition Food Previous illnesses Present environment Present illness Fig. ii. children in close succession. A history of miscarriages, to- gether with stillborn children or the death of preceding children in the early months of infancy from "inanition," point strongly to maternal syphilis. The mode of birth may account for the presence of birth palsies (protracted labor, especially breech cases). It is of prime importance to learn whether the child was TAKING A HISTORY AND KEEPING RECORDS. 4-3 breast fed or artificially fed. Improper artificial feeding is the cause of the various nutritional diseases, such as rickets, marasmus, scurvy and gastro-intestinal catarrh. It may also be the origin of tuberculosis. Unsuitable breast-milk and prolonged lactation, however, not infrequently bring on rickets. Note what the present food is. Xote the time at which the teeth made their appearance and whether dentition progressed steadily or with interrup- tions; also the time of walking and talking. Dentition, walking and the state of the fontanels are indices of the physical development of the child, while talking is an im- portant index of mental development. Previous illnesses. Has the child had the various infec- tious diseases? Name them to the mother individually. As most of them occur only once in a lifetime, a doubt in the diagnosis is at once removed if the child has already had the disease we may be suspecting. Vaccination must not be for- gotten. Aside from the question of immunity we must also consider that certain diseases have sequelae or predispose to other diseases. Thus, measles and w T hooping cough pre- dispose to tuberculosis ; scarlet fever may leave nephritis or chronic suppurative otitis, and the latter may be the cause of some obscure intracranial condition (cerebral abscess, throm- bosis). Convulsions in infancy may terminate in epilepsy in later childhood. Diphtheria may be followed by paralyses of various kinds. EnmronmenL Aside from offering a source of infection, environment may affect the child's constitution to a marked degree. The squalid, sunless tenement houses furnish ample cause for anaemia and rickets, even tuberculosis. Children raised in the country rarely develop rickets. Overwork at school or an exacting teacher may be the etiologic factor in chorea. Again, many vicious habits are directly attributable to environment. The present illness is now recorded. Inquire into the child's health before the first signs of the ailment showed 44 DISEASES OF CHILDREN. themselves. Determine whether there were prodromata and whether the disease developed slowly or abruptly. Exactly how many days has the child been ill? If there is fever, since when, and has the fever been continuously high, remit- ting, or intermitting? What other important symptoms are present — vomiting, diarrhoea, constipation, cough, pain? If there is pain, where does the child refer the pain to, and is it aggravated by motion? Has the child complained of sore throat? In describing the stools, inquire into their size and fre- quency, color, odor. Is mucus, blood or undigested food- matter present? Is there pain before, during or after the stool ? Having completed the interrogation of the case, the find- ings of the physical examination according to the methods detailed below are then added in clear and concise terms, to- gether with the findings in the urine, sputum and blood when called for. For facilitating the recording of physical signs rubber stamps giving the outlines of the front and posterior aspect of the trunk are very convenient. The diagram is simply stamped upon the record card, and by means of lines and arbitrary signs to indicate the outlines of organs and path- ological findings a graphic representation of the case is obtained for future reference. These stamps can be obtained at most surgical instrument houses. PHYSICAL DIAGNOSIS. Inspection is the first step in the examination of a sick child. What has been discussed in the previous section should be put to practical application in beginning the study of a case, and so the diathesis, temperament, state of develop- ment and nutrition, and individual peculiarities of the patient are first to be noted. If the child be of the tuberculous dia- thesis, presenting the constitution and temperament peculiar to the same, we naturally suspect the possibility of pulmonary PHYSICAL DIAGNOSIS. 45 mischief ; or, if such a child complains of a pain in the knee, we immediately turn our attention to the hip-joint rather than consider the pain to be of rheumatic origin, in which case we would expect to find other prominent evidences of rheumatism. To inspect the child satisfactorily it must be stripped and viewed from front and back, both standing and reclining. The diathesis having been noted, the development of the framework should next demand our attention. Is the child emaciated ? If so. in what particular locality is this most marked ? The prominent belly, small chest and wasted thighs have been referred to. The color of the skin is important to note. Normally, in the infant it is pink, and anaemia is not difficult to recognize. Eruptions must be looked for, eczema and syphilis being the most common conditions encountered at this period of life. In cardiac and pulmonary 7 disease, and especially in mem- branous croup, cyanosis is to be observed. Jaundice also is a condition often seen in the new-born and is not foreign to childhood. Miliaria and sudamina are common in rachitic children, especially in summer. By drawing the finger-nail across the skin a red streak will be left, indicating an insta- bility in the vaso-motor nerves. It is very pronounced in dis- ease of the central nervous system, for which reason Trousseau attempted to establish this symptom pathognomonic of meningitis. The phenomenon is known as tache cerebrate. If there be deformity of the spine, we must determine whether it is due to Pott's disease, rickets, a unilateral pleural effusion, old pleuritic adhesions, or lack of muscular develop- ment. The child should be laid flat upon its stomach and the body then partly lifted from the table by making traction on the feet. If rachitic, the deformity is at once reduced by the traction, but the kyphosis of Pott's disease is irreducible under all methods of manipulation (Fig. 12). Retraction of the chest from pleuritic adhesions produces scoliosis, and in these cases we can get the history of a former empyema as well as confirmatory physical signs in the thorax. 46 DISEASES OF CHILDREN. The head presents many peculiar features of prominent diagnostic value. In rickets it is large and square ; in hy- drocephalus large but rounded, the fontanelles are widely open, and the eyeballs displaced downwards. In rickets there are often parchment-like areas representing a thinning out of the bony elements, known as craniuiabes. The osseous nodes of syphilis are very characteristic. FIG. 12. — METHOD OF DETERMINING THE CHARACTER OF A SPINAL DEFORMITY. The. facial expression often points to the seat of trouble ; for instance, the knitting of the brows in headache, which when associated with squinting, is a strong presumptive sign of meningitis ; the fan-like motion of the alse nasi in respiratory troubles, and the pinched expression of the face in abdominal disease. Roughly speaking, it can be said that the upper part of the face represents cerebral, the mid-portion respira- PHYSICAL DIAGNOSIS. 47 tory, and the lower portion abdominal disturbances. Often one cheek will present a circumscribed redness, which is said to correspond to the side affected in pneumonia. Personally I have seen it change from side to side. In severe pulmon- ary infiltration or congestion and in some forms of heart dis- ease the obstruction to the circulation will become manifest by networks of enlarged capillary vessels seen on the cheeks (also on the chest, and sometimes on the palms of the hands). The chest may present deformities, peculiarities of the ribs, deviations from the normal respiratory movements, abnormal movements, and various skin eruptions. In the early stages of pleurisy the painful side becomes fixed and may produce a certain degree of scoliosis. As the effusion is poured out the side bulges. In chronic pleurisy with adhesions the side be- comes permanently retracted. The intercostal phonation phe- nomenon of Stiller {Wiener Med. Wochenschr., No. 15, 1902) is a bulging or elevation of the lower intercostal spaces seen when the patient is made to enunciate sharply words of short syllable. It is due to a wave of air propagated down the bronchial tree as the air is being forced through the narrowed glottis. This wave is transmitted to fluid effusions in the pleural sack, but the sign is absent when pulmonary consoli- dation is present. In rickets the sternum is prominent from lateral compres- sion of the costal cartilages {pectus carinatuni), and the path- ognomonic beading of the ribs, the "rickety rosary," is often present. In phthisis that portion of the chest over the consolidated lobe is flattened and does not move in the same degree as the unaffected side ; the clavicle stands out promi- nently, and there is often marked retraction of the ribs (flat- tening) in that region. In emphysema the chest assumes a rounded fullness, slight motion only being perceptible during respiration. After peri- carditis with adhesions the intercostal space is often seen to retract distinctly during the heart's diastole, but more im- portant than this is Broadbenf s sign, i. e., systolic retraction of the lower ribs posteriorly on the left side. 48 DISEASES OF CHILDREN. The spine has been referred to. Spina bifida must not be overlooked. The limbs and joints must be examined for evidences of arthritis or tuberculous joint troubles ; the fibrous subcuta- neous nodules pathognomonic of rheumatism ; the deformi- ties of rickets, rheumatism, and poliomyelitis anterior ; the bone affections of syphilis and tuberculosis. The limbs will also give evidence of the various forms of paralysis likely to occur in childhood, and of rachitic pseudo-paralysis. The reflexes. Among the superficial reflexes the plantar is of especial importance. Under normal conditions a flexor response is obtained, but in lesions of the pyramidal system hyperextension of the great toe occurs. This is spoken of as Babinski's sign. In infants up to the age of learning to walk the response is somewhat similar to the Babinski phenome- non. The great toe is drawn back ; the toes are extended and spread out and the foot is everted. The Babinski sign is more deliberate, however, and there is but a small amount of movement at the ankle. The knee-jerk is exaggerated in lesions affecting the upper neurons or irritating the lower neurons. Diminished or abolished knee-jerk indicates lesions in the lower neurons. In children it is best obtained in the dorsal position with the foot resting on the palm of the left hand, striking the tendon with a percussion hammer held in the right hand (Fig. 13). Ankle clonus indicates disease in the spinal cord, from the first to third sacral segments. The position assumed by the child during sleep and waking is important to note. We see the child burying its head in the pillow in cerebral inflammations ; lying on the back with limbs drawn up in abdominal inflammations ; on the affected side in acute pleurisy ; the head drawn back and the spine arched during opisthotonos ; unable to lie in the prone posi- tion in the dyspnoea of capillary bronchitis; impossibility of extending the leg upon the thigh when in the sitting pos- ture owing to contraction of the flexor muscles, which disap- PHYSICAL DIAGNOSIS. 49 pears when the dorsal decubitus is assumed {Keriiig^s sign in meningitis) ; sleeping or comatose ; crying out in sleep and gritting the teeth. During natural sleep the child assumes an easy, graceful position, indicating complete relaxation ; the respiration is of the abdominal type. The character of the cry is often a hint in diagnosis. The shrill, piercing cry of meningitis is pathognomonic. The hoarse cry heard in the absence of croup points to syphilis. In otitis the cry is often continuous, in spite of all that is FIG. II. — METHOD OF OBTAINING KNEE-JERK. done to humor the child. The recognition of the cry of hun- ger, pain and temper is more readily attained by observation than from reading. The natural cry is a loud, strong vocal effort accompanied by reddening of the face and does not last more than a few minutes. Abnormal cries are as a rule weaker in character and more persistent. The cry of pain may be strong, but it is accompanied by evidences of suffering and distress, such as facial contortions, drawing up of the legs, bringing the hand to the affected part, etc., and it is more or 50 DISEASES OF CHILDREN. less persistent. The cry of hunger is a continuous fretful cry, ceasing when food is offered. The cry of temper is loud and is accompanied by all the signs of anger, such as kicking and striking about. During serious illness the cry becomes feeble and partakes more of the nature of fretting. The inspection of the throat is left until the last on account of the struggles and resistance of the child usually induced thereby. It should be done quickly and thoroughly, and all preparations relative to the examination must be made before- hand. Taking the child into a good light, or in some cases a head mirror may be used, it is seated upon the nurse's lap or held in her arms, the head slightly thrown back, and the handle of a spoon pressed down firmly on the base of the tongue. This is very often followed by gagging or a violent expulsive effort, but if we are quick we have seen enough. The gagging brings to view every part of the fauces, it being desirable to gain access to the lateral regions. In contagious diseases we should be prepared for the sudden cough which is likely to occur and spurt mucus or pieces of membrane into our face. Often nothing more will be necessary 7 than to allow the child to cry, during which act a satisfactory view of the mouth and throat is obtainable. We must cultivate the habit of taking in the whole picture at a glance and retaining the impression long enough to analyze it, otherwise much val- uable time will be spent in bungling efforts. Palpation. — The sense of touch, when properly trained, will give more information in the study of sick children than is generally supposed. The first thing that strikes our atten- tion as we touch the child's body is the temperature, and with a little practice this method of judging of the degree of fever becomes accurate enough for man}- cases. We should observe whether the heat is uniform, or whether one part of the body is hotter than another, for the head may be considerably hotter than other portions of the body ; in the later stages of entero-colitis the abdomen will be hot, while the extremities may be decidedly cold. PHYSICAL DIAGNOSIS. 51 In palpating the head we determine the state of the fon- tanels, whether they be delayed in closing or prematurely closed, whether bulging or depressed. We also look for craniotabes, exostoses, and any evidence of sensitiveness of the scalp or ears, this often hinting at middle-ear disease when other prominent signs are wanting. If this sensitive- ness to touch be general, it marks the advent of rickets (Jenner). From the head we can descend to the chest, taking in the neck on our way down, where we often find scrofulous en- largement of the cervical glands. Often, however, no definite sequence can be followed out, and we must avail ourselves of an opportunity presented by the child either crying, ceasing to cry, or finding it in a sound sleep, to proceed at once to palpate the abdomen, which can only be done satisfactorily during complete relaxation. In an examination of the chest palpation is usually the first step, and if the child will accommodate us by crying we can judge of the vocal fremitus. The child should be held by the mother in such a manner that it rests on one of her shoul- ders and presents its back to the physician. The hand is placed on the back in order to determine vocal fremitus, and the rattling of mucus in the bronchi is distinctly transmitted to the hands, in bronchitis. The hands can then be placed on the sides of the chest and the respiratory movements of both sides compared. The left hand will now seek the car- diac area, by which means hypertrophy or a thrill can often be detected. Auscultation should follow next in chest examinations, for the disturbance induced by percussion may be so great as to hinder any further progress in the case. The abdomeii is most satisfactorily palpated while the child is asleep, the warmed hand being gently introduced under the bed-covering. Distension or retraction of the abdominal wall was noted while inspecting. The trained palpating hand will recognize enlargement of the liver and spleen (Figs. 14 52 DISEASES OF CHILDREN. and 15); the presence of enlarged mesenteric glands; friction between the abdominal wall and the organs; impacted fecas, etc. Tenderness in certain regions and rigidity of the recti mus- cles is of diagnostic significance. Thus, tenderness over McBurney's point and rigidity of the right rectus is pathog- nomonic of appendicitis. Gurgling in the right iliac fossa together with tenderness is strong presumptive evidence of typhoid fever, but not a pathognomonic sign. ■m FIG. 14. — METHOD OF PALPATING THE LOWER BORDER OF THE LIVER. IN THIS CASE THE LIVER WAS SLIGHTLY ENLARGED. The bladder may be felt in the hypogastrium when dis- tended, and in rachitic children with flabby abdomen it is often possible to palpate the kidneys. A rectal examination should be made as a supplement to the abdominal examina- tion in all doubtful cases. The thighs offer a valuable indication of the state of nutri- tion. If the adductor muscles are wasted, soft and flaccid to the touch, and the skin capable of being pinched up into folds, slow to disappear, we have a marked picture of wasting. The skin furnishes valuable diagnostic signs. The tern- PHYSICAL DIAGNOSIS. o3 perature has been noted. The state of dryness or moisture is determined by palpation ; often an eruption can be better felt than seen, and the shotty feel of the skin in the early stages of small-pox is very characteristic. The tache cerebrate has been referred to. It is a hyperae- mic streak obtained by irritating the skin in cases of menin- gitis — a patch of angio-paralytic area. Percussion. — The usual order of examination in adults can- not be observed in children, as has been already pointed out. On account of the disturbance it is likely to produce in the FIG. 15. — METHOD OF PALPATING THE SPLKKX. child's tranquility, percussion is best left to the last in chest affections, just as inspection of the throat is put off until all other data have been obtained, when the disease points to that locality. Percussion of the head is of little value excepting for the purpose of eliciting tenderness, especially over the mastoid region, when ear disease is suspected. Macewetfs sign is a hollow note elicited by percussing over the anterior part of the skull and is indicative of distention of the lateral ventri- cles with fluid. It is found in meningitis and is sometimes a valuable early sign. 54 DISEASES OF CHILDREN. In percussing the chest of the child we must bear in mind that owing to the lesser dimensions of the thorax and the greater elasticity of its walls it becomes more difficult to out- line the organs and to demonstrate the differences in the in- tensity and pitch of the percussion note at various points. The explanation of this phenomenon lies in the fact that the percussion impulse is transferred over a greater area than in the adult on account of the resilience of the thorax. It is, therefore, necessary to percuss more lightly, not only for fear of eliciting deep dulness from adjacent organs not directly under investigation, but also because it is impossible to outline the superficial dulness by strong percussion. This applies especially to the heart and thymus gland, although the same holds good in percussing the abdomen with the ob- ject of outlining the lower border of the liver or an enlarged spleen, etc. Again, it is .easier to judge between the presence or absence of resonance in a certain locality than to estimate differences in pitch and intensity. Light percussion alone makes this possible. In percussing out a superficial organ (thymus) or a super- ficial area of dulness of an organ situated like the heart (the "absolute dulness") the best results are obtained by pressing the middle finger of the left hand lightly against the chest wall and striking quick, gentle taps with the middle finger of the right hand. When striving to elicit deep dulness in order to outline a deep-seated organ like the spleen or de- termine the deep ("relative") dulness of the heart or liver, the finger must be pressed more firmly against the chest and the percussion strokes dealt more strongly, avoiding, loud per- cussion, however, which drowns out the finer shades of dis- tinction between the notes and practically abolishes all border lines. In percussing, the examiner's finger also experiences varying degrees of resistance, which is a great aid in locating the boundaries sought for and in recognizing the physical na- ture of pathological processes capable of impairing resonance. PHYSICAL DIAGNOSIS. 55 The elicitation of deep dulness is handicapped by certain sources of error, and the results are often misleading. In the first place, there is greater likelihood of our percussion strokes not being of uniform force, and it is difficult to determine just how energetic they should be in order to outline the extent of space through which an organ can diminish the normal reso- nance of the thorax. Secondly, the area obtained may exceed in size the actual size of the organ under examination. This is especially so with the heart, as Sahli has demonstrated {Die Topograph! sche Percussion im Kindesalter, Bern, 1882). The factors influencing the percussion note over the lungs, independent of the adjacent organs, are, according to Sahli : (a.) The thickness of the thoracic wall. It is an estab- lished fact that the percussion note obtained over the lungs under equally strong percussion is the more intense the thinner the wall is that covers the area percussed. (b.) The configuration of the thorax plays an important role in the difference in the intensity of the resonance in dif- ferent localities Convexity of the thoracic wall tends to diminish the intensity of the percussion note, as a greater part of the percussion impulse is required to depress the con- vex wall sufficiently against the underlying structures to set them into vibration than is the case with a plane or concave thoracic wall. For this reason the flattened areas of a rachitic thorax give an apparent hyper-resonance when compared with areas of normal configuration. This modifying factor must also be borne in mind when percussing chests deformed by scoliosis and kyphosis. (c.) The close appositi6n of the ribs in a certain region will give rise to dulness at that point. This is often seen in cases of pleurisy before exudation has set in, and may give rise to a diagnostic error. The explanation of the displacement of the normal relationship between the ribs is a voluntary scoliosis from fixation excited by the pain in the affected side (Werner). (a 7 .) The percussion note obtained in an intercostal space is 56 DISEASES OF CHILDREN. of greater intensity than that obtained over a rib. This is of practical importance in outlining the heart, as apparent dul- ness beginning at the second rib may be due to the rib and not to the underlying upper border of the heart, as percussion in the second intercostal space will prove. FIG. l6. — DIAGRAM SHOWING LOWER BORDER OF THE EUNGS AND EIVER. (SAHEI.) Normally, the percussion note gradually increases in inten- sity both anteriorly and posteriorly as we descend, and then gradually diminishes as the lower border of the thorax is reached. The increase in intensity in percussing downwards results from greater thinness of the thoracic w r all — the pectoral muscles and the scapula and its muscles padding the upper part of the thorax considerably — and the flatter configuration of the chest at its mid-portion. As we descend we impinge PHYSICAL DIAGNOSIS. 57 upon the deep dulness of the liver and spleen posteriorly and the liver and heart anteriorly. The lower boi'der of the lungs in the dorsal position is iden- tical in children and adults, and not higher as Weil claimed ^Sahli). The following points reach the extreme lower border of the lungs : Right mammary line, upper border of sixth rib ; left mid-axillary line, upper border of ninth rib ; FIG. 17. — DIAGRAM SHOWING SUPERFICIAL AND DEEP CARDIAC DULNESS. (SAHLI.) posteriorly, on either side of the spine, eleventh dorsal spine, (Fig. 16). The percussion note over the sternum is more intense than in the adult owing to the elasticity of the thorax, for which reason the percussion stroke is carried to a greater part of the lungs than merely the underlying portion. A slight shade of 5 58 DISEASES OF CHILDREN. difference naturally exists and is apparent when percussing from an adjacent region of the thorax toward the sternum and over it, but it is no more pronounced in degree than the dif- ference existing in the note over a rib and in an intercostal space. Percussion of the sternum in children, therefore, gives more positive results than in the adult. In percussing from above downwards the upper boundary of the deep cardiac dulness may be traced, providing we do not use too strong a stroke (Fig. 17). The presence of the thymus gland may also be demonstrated in the upper sternal region in young children. In the lower sternal region cardiac dulness is demonstrable. Jacobi recommends percussion of the sternum from below, the child being supported face downward, when any difficulty is experienced in outlining the thymus. Normally the child's thorax is hyper-resonant in compari- son with that of the adult, and owing to the pliability of the chest walls a cracked-pot sound can often be elicited, espe- cially when the child is crying. The possibility of emphy- sema and cavity existing must, however, not be forgotten. The posture during percussion is important. If the child does not sit perfectly erect and the spine is curved so as to bring the ribs closer together on one side than on the other, we will obtain dulness over this area. Likewise when percussing the back, dulness may be elicited where it should in reality not exist if the mother holds the child tightly against her chest in presenting the child's back to us for percussion. Again^ dulness due to a pleural effusion changes its level with a change in the position of the child. Crying also causes dul- ness in the bases posteriorly, owing to the prolonged expira- tory effort. In abdominal disease percussion is of great value. The abdomen may be distended either from gas, fluid, or solid growths, and percussion, together with the signs of fluctua- tion, when obtainable, will make a differential diagnosis possible. The boundaries of the liver and spleen can be percussed out satisfactorily with sufficient practice. PHYSICAL DIAGNOSIS. 59 Auscultation. — In auscultating the chest of a young child it is most advantageous that it be held by the mother as shown in Fig. 18 with its back exposed to the examiner. This is the position in which the back and lateral regions also can be most satisfactorily percussed. When we wish to auscultate anteriorly the child is put into the crib on its back. 4^Wr f| ; A 1 ■ FIG. [8. —METHOD OF HOLDING IX! ANT DURING i SCUI/TATION. The proper time to auscultate is when the child happens to be in a tranquil mood, and as a rule- it is wise to begin the examination with auscultation. Should it then begin to cry, we make use of the crying sounds to determine the vocal resonance and the presence or absence of bronchophony. 60 DISEASES OF CHILDREN. Older children may be engaged in conversation when we wish to study the voice sounds. There are two methods of auscultation, namely, the imme- diate and the mediate. In immediate auscultation the ear is placed directly upon the chest — it being preferable always to interpose a towel between the physician's ear and the patient's body — while in mediate auscultation the stethoscope is used to convey the sounds from the bare chest to the examiner's ear. The beginner should first master immediate auscultation and after he has learned to recognize the various sounds and interpret them he may avail himself of the comforts and advantages of the stethoscope. Even the skilled examiner finds it advantageous first to listen with the naked ear and then more accurately localize certain sounds and verify his findings by means of the stethoscope. Deep-seated lesions in the chest may be overlooked when the stethoscope alone is used, for the naked ear is able to perceive sounds originating at some depth below normal lung tissue which the stethoscope fails to transmit. The main scientific purpose of the stethoscope is to ascertain and isolate the sounds from small, circumscribed areas, as the chestpiece of the stethoscope does not conduct sounds from so wide an area as does the ear. There is no doubt that the monaural instrument (Fig. 19) is the more desirable one for this purpose, but from the stand- point of practicability the binaural surpasses it, especially when working with children. With this instrument it makes no difference whether the child be restless or quiet or whether it be too sick to be taken up and held properly — it is always possible to get at the chest without putting oneself into an uncomfortable position. FIG. 19. — MONAURAI, STETHOSCOPE. PHYSICAL DIAGNOSIS. 61 The disadvantages of the binaural stethoscope are that it produces extraneous noises, and while it magnifies low pitched sounds it does not convey certain feeble, high pitched sounds as clearly as the naked ear or the monaural instrument. With constant practice, however, and by checking one's findings by immediate auscultation when- ever possible, these disadvantages can be overcome entirely. Instruments for magnifying sounds, such as thephonendoscope and the Bolles' stethoscope, while at times convenient, are on the whole objectionable. True, one can listen through the clothes with them and examine a patient without even turning him, but such practice is not to be encour- aged. As Sahli says (Klinische Untersuchungs-Methoden) the dif- ficulty encountered in ausculta- tion lies not in hearing the sounds in the chest but in interpreting their meaning. The stethoscope shown in Fig. 20 has two sizes of chest-pieces which is a feature at times most desirable. The thumb-piece gives one a good hold on the instru- ment without danger of touching the tubing and producing ex- traneous sounds. The ear-pieces must be adjusted to each individual. The heart can be auscultated posteriorly almost as well as anteriorly in infants and the murmurs of congenital heart disease are often better heard between the scapulae than ovei PIG. 20. — BINAURAL STETHO- SCOPE WITH LARGE AM) small CHEST-PIECE. 62 DISEASES OF CHILDREN. the cardiac area in front. The heart should always be auscul- tated as a routine practice. This should be the first step, as crying makes it impossible to discover anything abnormal. Normally the first sound at the apex is the loudest sound of the heart. Next in intensity is the pulmonary second, and lastly the aortic second sound. The rhythm is trochaic (Hoch singer). The pulmonary second may be equal to or even louder than the aortic up to the time of puberty (tenth to twelfth year). The explanation of this difference between the sounds of the child's heart and that of the adult lies in the fact that the arterial tension is much lower — the ratio between the volume of the left ventricle and the aorta being less than in adults — while the pressure in the pulmonary circuit is higher. Auscultation is seldom of use in abdominal conditions in children, excepting to determine the absence of intestinal movements as occurs in diffuse peritonitis. In auscultating the lungs, crying does not interfere unless associated with a harsh laryngeal note. In other ways it is an aid in giving us a deep inspiration and an audible expira- tion. The respiration of the child is of the puerile type, character- ized by a harsh, sonorous inspiration somewhat bronchial in character. This type of breathing is encountered in the adult when the vesicular breathing becomes exaggerated or increased in intensity by extraneous causes compelling the lung or a part of it to assume increased activity. In this change both the inspiratory and expiratory factors are pro- portionately increased in loudness and in length, inspiration however being more accentuated than expiration (Tyson). In the infant, owing to the slight movements of the chest wall and the purely abdominal mode of breathing, the re- spiratory sounds are feeble. As the right bronchus is of larger calibre than the left, the respiratory note is more intense on the right side. Bronchial breathing may be heard to the right of the spine in the scap- PHYSICAL DIAGNOSIS. 63 ular region, or to be more exact, broncho-vesicular breathing (Fig. 21). If the diaphragm be forced up by gaseous disten- tion of the abdomen the vesicular murmur will be suppressed at the bases of the lungs. Occasionally during deep inspiration, especially during cry- ing, sub-crepitant rales may be heard at the apices (supra- clavicular region) and at the bases posteriorly. In pneumonic FIG. 21. — CHILD SIX YEARS OLD; LINKS SHOWING EXTREME PERCUSSION BORDER OF LUNGS AND TXTKRLOBULA R FISSURES. BRONCHIAL BREATHING HEARD AT (O). conditions we must be on our guard not to confound the harsh, rasping sub-crcpitaut rales, characteristic in children, with pleuritic friction sounds and diagnose pleurisy where it does not exist. Pulse, Temperature, Respiration. — As in adults, the pulse is best felt at the wrist in children, although it can at times be estimated with advantage through the anterior fontanelle. 64 DISEASES OF CHILDREN. The pulse is very rapid in infants, gradually decreasing in frequency during childhood, attaining the average rate of 76 in males and 80 in females by the time of puberty. In young children the rhythm is variable and irregular, owing to the in- complete development of the physiological inhibitory centres. The pulse-rate is often affected by physiological influences to such an extent that it cannot be taken as a safe criterion of FIG. 22. — ANTERIOR VIEW OF CHILD SHOWN IN FIG. 21. APEX RESONANCE, DEEP CARDIAC DULNESS AND LOWER BORDER OF LUNGS OUTLINED. fever, which can only be surely determined by palpation and thermometry. During the first weeks of life the pulse-rate varies between 125 and 150 beats per minute ; more rapid in female infants, as a rule, and not influenced by posture. From the sixth to the twelfth month it is usually 105 to 115, and more susceptible to bodily exercise. PHYSICAL DIAGNOSIS. 65 From the second to the sixth year it may be said to vary within 90 to 105 beats ; seventh to tenth year 80 to 90 beats, after which it gradually attains the average adult standard. The strength of the pulse is our guide in judging of the heart's condition, and must be carefully observed during the course of the acute infectious fevers and in pulmonary in- flammations. One of the most satisfactory results to be obtained in study- ing the pulse is when we compare it with the temperature and respiratory ratio. Thus in the beginning of typhoid fever the temperature may have risen several degrees above normal while the pulse-rate is still unaffected. Later it may rise entirely out of proportion to the temperature. The pulse does not, therefore, rise in a uniform ratio with the rise of temperature in all cases, although as a rule one degree of fever-heat is usually accompanied by an increase of eight pulse-beats. " A pulse-rate rather slow in proportion to the temperature is favorable, indicating a tranquil nervous system. A low pulse with high temperature invites us to look for spinal cause, as pressure on the brain or depressing action of drugs. A low temperature and frequent pulse points to local com- plications in the thorax or pelvis (Wunderlich). " A slowness in the pulse has often a great significance in the diagnosis of cerebral affections, and especially meningitis " (Finlayson). Irregularity in the pulse is also found in meningitis, com- bined with slowness. When the pulse is more rapid, the fever prominent and the breathing embarrassed, we should suspect peri- or endocarditis. " The number of respirations per minute does not corre- spond so closely to the temperature as the frequency of the pulse. In collapse there is often (not always) a frequency of respiration, and in slight fever of childhood also ; in moder- ate fever the respirations amount to 20 or so per minute ; in children to 40 or 50. In considerable or extreme degrees of 66 DISEASES OF CHILDREN. fever they are higher yet, 60 in many cases ; movement also increases their frequency." In pneumonia and congestion of the lungs the rate of respiration is entirely out of proportion to the fever and pulse, and greatly quickened respirations should at once lead us to examine the chest. The temperature is best taken by inserting a clinical ther- mometer, lubricated with vaselin, into the rectum. It is usually a trifle higher than in the mouth, but it is much more satisfactorily taken here, and far more accurately than in the axilla or groin. The diurnal variation in the temperature is more pronounced than in adults, varying within a range of from two to three degrees. The lowest temperature is at- tained shortly after midnight, when it may be as low as 97 ° F. in the rectum, rising to a height of ioo° F. in the after- noon, in some instances. The Urine. — The difficulty of obtaining a specimen of urine for chemical examination, and of estimating the total quantity in twenty -four hours, leaves the clinical study of urine in in- fancy and childhood a much-neglected branch. Fortunately the necessity for studying the urine does not arise as frequently in children as in adults, but when presenting itself it is of the highest importance that we should know how to proceed. For ordinary purposes a clean sponge can be placed over the gen- itals and held in place by the diaper, which should have a layer of oiled silk or other impervious material on its inner surface. When the child has micturated, the urine is squeezed from the sponge into a clean vessel. By measuring the quan- tity thus obtained and noting the number of urinations in twenty-four hours we can quite accurately estimate the total quantity. Often the variations in the frequency of urination are a safe enough guide in estimating the functions of the kidneys. Should the quantity obtained by the method de- tailed above not be sufficient for a chemical examination, the process can be repeated until enough is obtained. Instances may arise where resort to the catheter will become necessary, in which case a sterilized No. 5 to 6 soft-rubber catheter is to PHYSICAL DIAGNOSIS. 67 be employed. The urine can sometimes be forced from the bladder by gentle stroking in the suprapubic region, it being received into a beaker glass held under the penis. Simply irritating the prepuce will often excite urination. The daily quantity of urine gradually increases from an ounce at birth to six to ten ounces by the end of the second week. The amount is relatively large during early infancy, increasing from six to twelve ounces at the first month to six- teen ounces at the sixth month. By the second year it may reach twenty ounces, and by the eighth year two pints and over. The specific gravity is relatively low r during infancy, the percentage of solids being far below that of adolescence, but the amount of urine passed is greater in comparison w T ith the body-weight than in adults. The frequency of urination gradually decreases as the child develops and gains more con- trol over the sphincter vesicae ; the act is involuntary until after the second year. The variability of the character of the urine in childhood is w r ell known. At times it will be high-colored, staining the napkin, and causing the child to cry while urinating, on ac- count of the presence of urates and uric acid ; again, it may be turbid from mucus or phosphates, especially the latter in intestinal indigestion. The odor is in many cases quite pro- nounced, from the presence of aromatic compounds. Albumin should immediately be suspected when the urine imparts a slight amount of stiffness to the diaper on drying; in fact, it may be so abundant as to stiffen the cloth like starch. It is normally found in the urine of the newborn. Blood is most likely to originate in the kidneys in childhood, especially in scarlatinal nephritis, and give the urine a smoky appearance. Haematuria in infancy is most frequently a sign of scurvy. Sugar is often present in the urine of infants with- out any special reason to account for it; it is probably derived from the lactose in the milk, especially when there is a greater consumption than can be assimilated. The presence of urates and uric acid lias 'been referred to. 68 DISEASES OF CHILDREN. It is usually indicative of a gouty diathesis, especially when the parents present such a history. Indican is often found in the urine of children, probably as a result of intestinal putrefaction (small intestine). Its fre- quent association with epilepsy is its most important feature. The majority of specimens of urine from artificially-fed in- fants that I have examined contained this substance in excess. Correctly speaking, it is an indoxyl-potassium-sulphate. CHAPTER III. THERAPEUTICS. In the treatment of the sick a drug should never be given, unless specific indications for its use exist. Even under these conditions medicines should not be prescribed until every detail of hygiene and diet has been attended to. Moreover, if it is possible to obtain a therapeutic result by means of such simple non-medicinal measures as hydrotherapy, massage and exercise, it is not only superfluous but irrational to subject the system to drug effects. The physician who prescribes small doses cannot shield himself from this criticism by retort- ing that the drug will not injure the patient and, therefore, it will make no difference. Rational therapeutics presupposes accuracy in diagnosis. Our drug pathogenesy, i. e., the reliable symptoms of our Materia Medica, is based on the pathological conditions and physiological disturbances induced in the healthy human or- ganism by the administration of the drug in sufficient quan- tity to induce these phenomena. Our method of prescribing is based on the rule that a drug capable of producing certain pathological effects, with the consequent appearance of cer- tain symptoms arising therefrom, is capable of controlling and removing identical symptoms when encountered in a sick individual. Our dosage is based on the observation that while large doses aggravate these symptoms, smaller ones act curatively. This mode of practice, however, like every other therapeutic system, has its limitations. Circumstances arise, as Hahnemann himself points out {Organon of Medicine, % 67), "where dan- ger to life and imminent death allow no time for the action of a homoeopathic remedy." It is largely a matter of opinion as to just what constitute the indications for physiological 70 DISEASES OF CHILDREN. interference. Errors are made on both sides. The early re- sort to powerful stimulants in all fevers and the free use of the depressing "antipyretics" has undoubtedly done more harm than the absolute neglect of taking the state of the heart and the height of the fever into consideration and rely- ing exclusively upon the "indicated remedy." "In order to obtain indications for treatment, make a diag- nosis. The art is becoming both more accessible and, through honest and hard work, more easy with the aid of modern methods (Jacobi)." By "diagnosis" is not meant the mere tagging of a name to a disease — anaemia, jaundice, dropsy, even more exact nomenclature, such as lobar pneumonia and typhoid fever, is not a diagnosis. Recognize the patient's vital resistance, the state of his heart muscle. Will it see him through unaided? Is your remedy sustaining it or will you have to resort to more energetic means? Is it possible to keep up nutrition by the ordinary means? Can we foretell and prevent complications? This is diagnosis in the modern sense of the term, and when Gerhardt says "without diagnosis no intelligent therapy," he does not refer to the mere detection of physical signs of disease. Stimulants. — In a previous chapter (page 18) it has been pointed out that cold water is a powerful stimulant under cer- tain conditions. This method of stimulation is, however, not always available or applicable. Alcohol is well borne by young children and is one of the most generally used stimulants we possess. Aside from its sustaining action upon the heart it is a food in the sense that it is oxidized in the body and thus spares tissue waste. Alco- hol does not materially affect the blood pressure and is, there- fore, not to be relied upon in a rapidly failing heart or in col- lapse. Its use is rather to ward off such an emergency than to meet it. The antidotal action of alcohol in the various toxaemias is one of its most valuable attributes ; this applies especially to septic conditions and low typhoid states. In diseases of short duration, however, with high fever, it is sel- THERAPEUTICS. 71 dom indicated ; in fact, it is useful only when such cases become adynamic. In gastro-intestinal affections and even in nephritis it is not contra-indicated providing it be cautiously administered and well diluted. The indications for the use of alcohol in a continued fever are a soft, rapid pulse and a failing of the muscular element in the first sound of the heart. The appearance of restless- ness and delirium, dry tongue, distended abdomen and pul- monary congestion calls for an increase in the dose. In diph- theria, alcohol may safelv be used from the very beodnnino- in moderate dosage, and increased as the necessity arises. In a young infant, ten to twenty drops of brandy well diluted, may be given every two to three hours when urgently required. An infant one year old may take half a drachm every two hours; this can be increased to one drachm, if necessary. A child from three to five years old may take as high as two drachms every two hours in low typhoid condi- tions. When the odor of alcohol can be detected on the breath we may know that the patient is fully under its influence and repetition of the dose becomes unnecessary. Camphor. — As a quick, diffusible stimulant there is nothing better than Camphor when urgent symptoms are to be met. The picture calling for Camphor is one of collapse. Drop doses of the tincture should be used, or what is better, cam- phorated oil injected subcutaneously. Personally, I prefer the neutral solution of Camphor. This is of the same strength as the oil, namely, 12^ per cent. In a young infant two to three minims suffice. A year-old babe may receive five minims, while a child from three to five years can safelv be given ten to fifteen minims. If no result is seen within fifteen minutes, the injection may be repeated in a somewhat smaller dose. Digitalin, Strychnia. — Cook (. Itnerican Jour. Med. Scii net s, April, 1903) has demonstrated by means of observations with the sphygmomanometer of Riva-Rocci that Digital in will raise the blood pressure in cases of failing circulation within 72 DISEASES OF CHILDREN. fifteen minutes, and maintain it at a safe point for several hours. It is, therefore, to be preferred to Strychnia when prompt results are demanded. Strychnia, on the other hand, maintains the pressure longer and better than Digitalin and should be used to reinforce the latter when heart failure is to be averted. Cook's experiments have also demonstrated that the blood pressure is a most valuable guide in showing us when stimu- lation is actually necessary. Some cases that appeared to require it were found to have almost normal pressure and consequently the stimulant was stopped, while others that did not betray their critical condition by the ordinary signs were found dangerously near the point at which life ceases. The dosage of these drugs is one four-hundredth grain hypo- derm ically in a young infant, and one two-hundredth grain in a child. Prescribing. — The method of prescribing for children re- sembles the method of diagnosing their ailments in that we are dependent entirely upon objective signs for reliable indica- tions for a remedy. Far from being a disadvantage, this really gives us a better opportunity for practicing scientific thera- peutics because the source of error resulting from the unreli- ability of "subjective sensations" is removed. Moreover, the data upon which we prescribe are based on pathological states which we interpret as "objective symptoms," and. therefore, more demonstrable and tangible than the other class of indi- cations. Prescribing is practically diagnosing the remedy, and we should go about it in much the same manner. The family history, the constitution and temperament, previous history, mode of onset, etc., all offer clues to the proper remedy. While the diathesis and temperament cannot be accepted as genuine indications for a remedy, still we know that certain individuals are especially susceptible to certain drugs, that the state of their nutrition calls for certain remedial agents, and that distinct moods and peculiar states of the mind and nervous system come within the sphere of drug action. THERAPEUTICS. 73 Each diathesis has a group of remedies wonderfully adapted to its needs ; the temperaments are well defined in our Materia Medica, and the constitution likewise, whenever it presents special susceptibility to a drug. This has been noted under the clinical indications of our symptomatology. The previous history often points to a constitutional rem- edy ; thus, late appearance of the teeth and a late closure of the fontanel will suggest the need for Calc. phos.; the oppo- site condition will rather point to Calc. carb. Former skin eruptions, especially when combined with snuffles and sore mouth, will probably indicate one of the Mercuries\ or if the child comes to us with a history of having been salivated, Hepar, Nitric acid and the Iodide of potash will suggest themselves. Certain remedies we know to be especially useful in removing the remote effects of various ailments ; thus, Sulphur after pneumonia ; Arnica when there has been a trauma ; Silicea sometimes after vaccination and Ignatia after fright. Again, disturbances resulting from the abuse of such drugs as Iron and Quinine often require Pulsatilla ; after anodynes, purgatives, cough mixtures and the like Nux vomica will prove useful. We should observe the position assumed by the child dur- ing sleep and waking. This often offers valuable suggestions for a remedy. For example, lying quietly upon the affected side is a characteristic indication for Bryonia. The condition of the skin, whether dry or moist, hot or cold, red or cyanotic ; also, if eruptions be present, their char- acteristic features — all are important to the prescriber. The physiognomy may offer suggestions ; the knitting of the brow r pointing to headache, the fanlike motion of the alse nasi, indicating dyspnoea. The character of the cry may indicate Apts, when there is effusion into the brain ; it may point to Be//., Aeon, or Puis, if otitis is diagnosed, or Mercury and Ka/i bichromicum when syphilis is suspected from the hoarse, feeble tone. Sudden hoarseness should, however, lead us to suspect the advent of 6 74 DISEASES OF CHILDREN. croup, when we naturally choose between Aconite, Spongia and Hepar. In examining the chest we aim to define the character of the rales present, and are thereby able to differentiate reme- dies. Thus, Ant. tart, and Ipecac, are differentiated by the predominance of and finer character of the rales in the latter ; in Ant. tart, there are coarse rales, in the larger bronchial tubes from the accumulation of mucus which the patient is unable to cough up. The discovery of consolidation, effusion and friction sounds will also aid us in prescribing. Objective signs in cardiac disease are valuable aids in pre- scribing, only to mention Aeon, and Rhus tox in hypertrophy ; Spigelia and Bryonia in endocarditis; Glonoin for the high arterial tension and Cactus in valvular affections. In prescribing for diseases of the nervous system we must carefully differentiate the various conditions occurring here. Thus, in differentiating cerebral anaemia and hyperemia from inflammatory processes our prescribing will necessarily be more accurate and successful. After we have decided that the meninges are involved, a number of well-known remedies will immediately present them- selves. To differentiate between them we must take into consideration the degree of fever and cerebral congestion ; the presence or absence of convulsions, photophobia and stra- bismus ; the psychical state, manifested by the disposition, character of sleep and state of consciousness; delirium or coma. This, together with a general survey of the patient, gives the data for finding the similimum. And so the special senses, the alimentary tract and the genito-urinary tract are all to be carefully studied in the man- ner above detailed, in order to gain the requisite knowledge for making a prescription. The results of such prescribing bring their due reward ; it is time well spent in fruitful labor. Dosage. — The dose, while an important question, is not the principle upon which Homoeopathy is based. Our unfair critics would have it believed that Homoeopathy and micro- THERAPEUTICS. 75 therapy are one and the same thing. The fundamental principle of Homoeopathy, however, is the sound deduction formulated by Hahnemann as the general therapeutic rule of practice, similia similibiis curentur, and the dose recommended was the smallest one that would act curatively without aggravat- ing the condition for which it was prescribed. Theie is no necessity, therefore, for invading the realm of the infinitesimal in order to practice Homoeopathy. In fact this method of dosage was adopted by Hahnemann himself only in his later years. To the beginner, and especially to those not in sympathy with the theory of attenuation, small doses of the tincture and the lower dilutions are to be recommended. When employing insoluble substances, the lower triturations may be used. Let the dose just fall short of producing medicinal aggravation, and if the remedy be homceopathically indi- cated, a curative result will follow. Accordingly, the liquid remedies, excepting the very poisonous ones, may be adminis- tered in doses of one to two drops of the first or second decimal dilution, repeated every one to two hours in acute conditions, without fear of doing any harm. In young infants the second and third decimal dilutions are usually preferable. The same may be said of triturations ; but it is reasonable to suppose that insoluble and apparently inert substances like Silica and the Carbonate of Lime are more active when their molecules are mechanically separated than in the crude state. The inter- esting and convincing experiments conducted by Dr. Percy Wilde, published in the Journal of the British Homoeopathic Medical Society, January, 1902 ("Energy in its Relation to Drug Action "), prove conclusively that the process of trituration induces decided changes in the physical properties of the substance thus treated. There seems to be no doubt that this process converts apparently inert substances into a state in which they can enter into chemical combination with certain cells of the human economy for which they possess a selective affinity. If, therefore, we desire to obtain the thera- 76 DISEASES OF CHILDREN. peutic action of one of these remedies, we must give it in a finely subdivided state, such as the third to sixth decimal triturations represent. On the other hand, when we desire to obtain simply the nutritive or chemical effect, as in using Iron in anaemia, a much larger dose becomes necessary. The action of Ferrum phosphoricum in the third decimal tritura- tion in acute bronchitis is essentially different from the action of Ferrum reductum crude or in the first decimal trituration in anaemia ; in the former the action is medicinal, while in the latter it is chemical. Triturations are usually dispensed in tablet form, each tablet representing one grain of the triturate. In acute conditions, a tablet may be administered every one to two hours ; in chronic affections, two tablets four times daily is the usual dose. Naturally, such poisonous substances as Bichloride of Mercury, Cyanide of Mercury and Arsenious acid must be given with caution when used in the third decimal trituration. CHAPTER IV. INFANT FEEDING. A comparison of the results obtained by artificial feeding and breast feeding indicates conclusively that, as ordinarily practiced, the artificial method fails to supplant successfully nature's method. The question naturally arises, can a child be weaned with any degree of safety before the usual time, and can those who are deprived of breast milk from the very beginning of their existence be spared the gastro-intestinal derangements and the later constitutional manifestations of faulty nutrition which are almost universally the lot of hand-fed children? A close study of the subject of infant feeding reveals the fact that nature can be imitated so closely by carefully and intelligently conducted methods that but very slight, if any, difference in results should occur. In the first place, we must study the chemical composition of human milk, and furnish the child with a substitute having a similar composi- tion. Secondly, the food must be served perfectly sterile and of the temperature of breast milk, as the latter is entirely free from pathogenic and fermentative micro-organisms when secreted from a healthy breast, beside being of the body temperature. Thirdly, the proper quantity must be admin- istered, and at regular and suitable intervals. If these con- ditions are carried out, artificial feeding is robbed of its ter- rors, and becomes a boon to infants and to sickly and delicate mothers who are not able to stand the drain of nursing. HUMAN MILK STUDIED IN COMPARISON WITH OTHER MILKS AND FEEDING MIXTURES. Human milk is an alkaline fluid, bluish-white in color, of watery consistency and sweetish taste. It contains a slightly 78 DISEASES OF CHILDREN. lower percentage of total solids than cow's milk, and consid- erably less proteids, but a higher percentage of lactose (sugar of milk). This accounts for the difference in appearance and taste. The amount of fat is about equal in both, unless we take into consideration the milk of special breeds of cows, such as the Jersey, in which the fat may be as high as 5 per cent., more than 1 per cent, above average human milk. The distinctive feature of human milk is its apparent low percentage of proteid, as compared with other milks. The amount of this nitrogenous element ranges between 1 and 2 per cent., the average obtained by Cautley from a large number of analyses being 1.93 per cent. Cow's milk con- tains almost uniformly 4 per cent, of proteid. In good dairy milk, where we obtain a mixed product from many cows, it seldom varies from this standard, and it can be kept so by the proper feeding and management of the herd. Mother's milk presents a much greater fluctuation, owing to the highly susceptible nervous system of the human subject. There is, however, a difference in the proteid, aside from percentage, for the proteid of human as well as of cow's milk is not a single body, but can be resolved into caseinogen and lact-albumin, two bodies of totally different character and composition. In cow's milk the proportion of caseinogen to lact-albumin is four to one ; in human milk, two to one. — (Kcenig.) The caseinogen of cow's milk is precipitated by acetic acid or by a saturated solution of magnesium sulphate. The lact- albumin is not affected by these reagents, but precipitates with tannic acid and by boiling. It is the chief constituent of the scum which forms on boiled milk. To estimate the percentage of lact-albumin in a given specimen of milk it is first necessary to precipitate the caseinogen with acetic acid, filter, and in the filtrate the lact-albumin can be estimated by tannic acid. The caseinogen found in human milk forms a much finer curd than that of cow's milk when coagulated with the rennin HUMAN MILK. 79 of the gastric juice. Again, the greater proportion of caseinogen to lact-albumin in cow's milk is another factor making it less digestible and less suitable for the infant. Ass's milk more closely resembles human milk in the amount of proteids present, containing according to an analysis by Dujardin-Beaumetz, 1.23 per cent, proteids, 6.93 per cent, lactose, and 3.01 per cent. fat. The objection to its use is the difficulty of obtaining it and the low proportion of fat present. The fat-globules of human milk are smaller than those of cow's milk, but aside from this there is no material difference in the cream of the two. The reaction of human milk is alkaline, while cow's milk is usually acid by the time it reaches the consumer. This acidity is often a source of considerable disturbance in the child's digestion, but the difficulty is controllable, as it is a simple matter to recognize this condition of the milk and correct it. The following table presents a comparison of human and cow's milk, constructed from the average of a large number of analyses by competent chemists. Standard Comparative Table of Human and Coze s Milk (Cautley, "The Feeding of Infants.") Cow's Milk. Human Milk. Water. 87. 87.46 Solid- 13. 12.54 Proteids, 4.06 1.95 Fat, . . 3.70 3.62 Lactose, . 4-4S 6.75 Salts, 0.76 o.2t> Reaction . . . Acid. Alkaline. A great variation is found in the results obtained by differ- ent observers in analyses of human milk, the fluctuations in the percentages of proteids and fat being very marked at times, even in the same subject. Rotch cites a case in which the proteids rose from 2.53 to 4.61 per cent, in a wet-nurse, from being fed on a richer diet than she had been accustomed 80 DISEASES OF CHILDREN. to. Again, one observer will report having found 2 per cent, of proteids, while another finds 1 per cent. In a series of analyses made by A. V. Meigs the proteids varied from .73 1.27 per cent.; fat from 2.4 per cent, to 9 per cent. In a series of careful analyses recently reported by Hofmann, of L/eipzig, the percentages stand as follows: Proteids, 1.03 per cent; fat, 4.07 per cent; lactose, 7.03 per cent.; salts, 0.21 per cent. This only demonstrates the fact that the human subject is a very sensitive organism, easily influenced by emotional fac- tors, character of diet, amount of exercise, and certain physi- ological states, such as the recurrence of the catamenia or pregnancy. MILK ANALYSIS. When an infant fails to digest breast-milk, or does not thrive on it, before condemning the child's digestive func- tions, we should examine the milk. Under all conditions, when the food disagrees it becomes imperative to institute a chemical analysis and microscopical examination of the milk. The information sought need be no more than an estimation of the fat and proteid percentages, while the microscope reveals the number and condition of the fat globules, whether perfectly or imperfectly emulsified, showing also abnormal elements when present, i. e., colostrum corpuscles in excess? pus corpuscles, micro-organisms. The physician is to be encouraged in making these examinations, and I can only repeat here what I have elsewhere pointed out {The Dietetics of Childhood in Health and Disease, Trans. Amer. Institute of Horn., 1901, p. 398), that a milk analysis is by no means so complicated a procedure as is generally supposed, being in no wise more troublesome than an ordinary examination of urine. First, we must obtain a sufficient quantity to judge of the appearance of the milk. If the quantity secreted by the breasts be insufficient for the infant's needs, the case is hope- MILK ANALYSIS. 81 less from the beginning, unless we can increase it with gal- actogogues. The specific gravity ranges from 1025 to io 35> the average being 1030. The reaction should be alkaline. The method of obtaining these data is identical with that employed in urinalysis, excepting that a smaller instrument for obtaining the specific gravity is preferable — a lactometer — (Fig. 23) FIG. 23.* — HOLT'S APPARATUS FOR EXAMINING WOMAN'S MILK CONSISTING* OF A LACTOMETER AND CRKAM GAUGES. owing to the smaller quantity of specimen one is obliged to work with. The specimen is best obtained with a breast- piunp, the middle portion of the milking being taken as an average sample. The percentage of fat is the most vital point in question in passing judgment upon a sample of milk. The cremometer- or cream-gauge — (Fig. 23) an instrument in which the milk Made by Kimer .X: Amend. New York City. 82 DISEASES OF CHILDREN. is allowed to stand until the cream rises to the top, when the percentage can be read off — offers a simple but not very accurate method of obtaining the fat per cent. Five per cent, of cream is equivalent to 3 per cent, fat by this method (Holt). The separation of the cream, however, does not depend alone upon the amount of fat present, but is influenced by such physical states as the temperature, size of fat globules, and specific gravity of the milk (Conrad), making it uncertain and unreliable. The lactobutyrometer of Marehand gives more accurate results. The milk-tubes, supplied with the centrifuge, are constructed on a principle similar to that of Marchand's instrument, and offer a rapid and convenient method for obtaining the fat percentage. The lactobutyrometer is a graduated tube into which five c.cm. of milk are poured, together with a few drops of liquor sodcs, after which five c.cm. of sulphuric ether are added, and the fluids thoroughly intermixed by gentle agitation. Alcohol (90 per cent.) is then added in the same quantity — marks upon the tube indicating the proper amount of each element used — the tube is stop- pered, again shaken, and placed in warm water for half an hour. The fat separates into a distinct oily layer that floats to the top, where the percentage can be read off by the scale on the tube. The estimation of the amount of proteids is of less import- ance, and the data furnished by the character of the child's stools are usually sufficient. An approximate estimate of the percentage of proteids is obtained by comparing the specific gravity of the milk with the fat percentage. The specific gravity is elevated by proteids and lowered by fat. If, there- fore, fat be deficient and the specific gravity low, we must infer that the amount of proteids must also be deficient. A high specific gravity with normal fat would, on the other hand, indicate an excess of proteids. A microscopical examination should reveal a preponderance of small, uniformly-sized fat globules, indicating thorough MILK ANALYSIS. 83 emulsification ; they should be present numerously in the microscopic field. After die third week the milk must be free from all cell-elements, of which the colostrum corpuscle is an example, being the remnant of protoplasmic bodies originating from the cells of the mammary gland acini. Cow's Milk. — A few simple facts applicable to cow's milk are worthy of mention, as it often becomes necessary to decide whether a given sample of milk is a suitable food for the infant. In the first place, a quart of milk standing for six hours after milking in an ordinary milk bottle should show a layer of cream in the neck of the bottle six inches deep. This cream contains on an average 12 per cent, of fat, but it varies in richness in the different layers ; the top ounce may contain 25 per cent., and the sixth ounce only 5 per cent, fat (Fig. 25). (Chapin.) In any quart bottle of milk en which cream has risen the top nine ounces will contain about three times as much fat as the whole milk contained, and the top fourteen or fifteen ounces about twice as much (Chapin). This fact is taken advantage of in the top-milk method of home-modification of milk, known as "Chapin's method," and to my mind, the most practical as well as accurate method at our command. Impurities. — Pathogenic bacteria gain entrance into the milk either with dirt acquired during milking, i. e. y stable filth, or direct from the milker, or through the use of impure water in washing out the containers. The germs that cause the milk to turn sour come mostly from the first few jets from the cow's teats. If these first jets are rejected, perfect cleanli- ness observed, and the milk cooled below 6o° F. immediately after milking, it is practically sterile, will keep satisfactorily and can be fed without sterilizing excepting in hot weather. Preservatives. — The presence of a preservative, e. g., form- aldehyde, should be suspected in a milk which does not curdle within twenty-four hours when placed in a stoppered bottle and kept in a warm place. Reaction. — The quantity of lactic acid that has Formed in 84 DISEASES OF CHILDREN. the milk by the time it reaches the consumer is a good index of the amount of care that has been exercised in handling it. The sense of smell and taste is hardly accurate enough to afford a reliable test in determining the quality of the milk^ and the simplest and most practical means of deciding the fit- ness of a specimen of milk is offered by the "Ideal Milk Testers." One of these tablets is dissolved in an ounce of water, and the resulting pink solution is added, a teaspoonful at a time, to a teaspoonful of milk until the mixture becomes permanently decolorized. By following the scale accompany- ing these testers we can draw our conclusions. The reaction depends upon the neutralization of the lactic acid in the milk with Sodium bicarbonate, the indicator being phenol- phthalein. CAUSES INFLUENCING THE COMPOSITION OF BREAST MILK. The milk obtained at the beginning of a milking is known as the fore-milk; it is watery and poor in fat. Next comes the middle-milk, and lastly the strippings. The middle-milk should be used for an analysis when the contents of the entire udder or breast cannot be obtained. The strippings are espe- cially rich in fat, and also contain a higher percentage of pro- teid than the fore-milk. The intervals at which the breast is emptied markedly influ- ences the composition of the milk. The longer the interval, the more watery the milk, and the more frequently the breast is used, the more concentrated the milk becomes. When the bad habit of putting the child to the breast every one or one and a half hours is persisted in, a veritable "condensed milk" will eventually be secreted, which, it is needless to state, cannot be digested by the infant. It may be laid down as a maxim that the more frequently the child is nursed, the more indigestible the milk becomes. The over-stimulation of the mammary gland leads to an increased secretion of proteids, while the percentage of fat is also augmented, the milk re- sembling the strippings in this respect. THE COMPOSITION OF BREAST MILK. 85 Food and exercise exert a marked influence upon the composition of milk. The richness of the milk, that is the amount of fat, is increased by a nitrogenous diet, and is de- creased by an excess of fatty foods, owing to the diminished metabolic activity induced by such a diet. The proteids are increased, together with the fat, on a lib- eral proteid diet ; also from increased frequency of nursing, as has been pointed out, and especially w T hen a liberal diet is enjoyed, together with insufficient exercise. This is fre- quently a source of much trouble with wet-nurses, who, en- tering upon their new duties with privileges not formerly enjoyed, a diet and sedentary occupation to which they are not accustomed, soon secrete a milk hardly to be distin- guished from rich cow's milk in its chemical composition and indigestible character. To correct this condition the nitrog- enous food must be considerably cut down and sufficient ex- ercise taken until the percentages become normal. The effect of alcohol moderately used is not injurious to the milk, and in some instances is highly beneficial to the mother. Some of the malt liquors certainly act as galacto- gogues, and the amount of fat is slightly increased by the use of alcohol. When used in excess, serious gastro-intestinal disturbances in the infant may arise. Menstruation sometimes induces changes in the milk which cause it to disagree. Rotch reports a case in w 7 hich the proteids rose to 2.12 per cent., while the fat fell to 2.02 per cent, rendering the milk difficult of digestion and inter- fering with the regular rate of progress in the child's weight. On the other hand, Schlichter, who made analyses in thirty- three cases of menstruating women, concludes that diarrhoea and colic should rather be looked upon as coincidences, for he found no decided alterations in the milk. Should the mother become pregnant it is not advisable to continue breast feeding, as the drain upon her system is usu- ally too great to be borne by the average woman, and, besides, there is danger of inducing miscarriage. Moreover, the child 86 DISEASES OF CHILDREN. usually ceases its progressive gain in weight, and evinces signs of not being satisfied with its nourishment. If it is necessary, however, to temporize on account of the delicate state of the child and the time of year, it may be suckled to the sixth month, and then partial weaning instituted. This will rarely be necessary, for with our present knowledge of infant feeding, and the accurate and safe methods at our dis- posal, the dangers of w 7 eaning, formerly so much feared, can be reduced to a minimum. The wet nurse is not ordinarily a desirable substitute for the mother's breast, nor is it always possible to obtain one that will conform to the requirements necessary in fulfilling such a charge. In the first place, a careful medical inspec- tion must be instituted in order to be certain that no evi- dences of constitutional or contagious disease are present. Secondly, there must be a sufficient quantity of milk secreted and the breast and nipples must be in a normal condition. It is also important that the stage of lactation shall correspond closely to the age of the infant to be nursed ; especially disadvantageous is it for an older infant to suckle from a nurse in the early period of her lactation, the converse condi- tion being less unfavorable. (Baginsky, Lehrbuch der Kinder- krankheiten.) The prominent influence of diet and exercise upon the composition and digestibility of the milk has been referred to above and the strictest regulations must be en- forced in this direction. Highly seasoned food is also to be avoided, as well as all acid fruits and salads, indigestible vegetables, and the free use of alcoholics. THE MODIFICATION OF COW'S MILK. It has been pointed out that cow's milk in its raw state is not a suitable infant food for two reasons, namely, on account of the excessive amount of proteids and their indigestible character as compared with those found in mother's milk, and the contamination by micro-organisms so universally present. To overcome the first objection, we must put the THE MODIFICATION OF COW'S MILK. 87 milk through a process of modification, in which the per- centages of its proximate principles are made to conform to the standard composition of human milk. Sometimes, how- ever, it will be found necessary either to reduce or increase the percentage of these elements, the necessity and indication for which will be discussed, later. By referring to the table shown below an idea of the dif- ference between human and cow's milk may be obtained. Re- garding the percentage of proteids in human milk, no fast rule can be laid down, and it has been shown how analyses by different chemists vary, and how strongly diet, exercise and constitutional disturbances influence the composition of the mammary secretion. The following table represents a fair working basis for this problem : Human. Cow. Percent. Percent. Proteids, 1-2 4 Fat, .... 4 4 Sugar, 7 4-5 Water, 87 86 Reaction, Alkaline. Acid. Gaertner (Therapeutische Wocheuschrift, May, 1895), has devised a practical method of modifying cow's milk to approximate human milk in composition by the use of the centrifuge. Equal parts of distilled water and milk are put into the centrifuge and separated into two portions, one containing all the cream, beside 2 per cent, of casein. A tablespoonful of sugar of milk is added to each half litre of this " Fettmilch," which renders it very similar in compo- sition to human milk and a very useful food for most infants. Fischer (Medical Record, Dec. 11, 1897) has recently reported a series of cases, among them entero-colitis, gastroenteric catarrh and athrepsia, which improved rapidly under a change of diet to this formula. A preparation very similar to this can be made at home simply by allowing the milk to sepa- 88 DISEASES OF CHILDREN. rate by standing, this method having long been in use, and already warmly recommended by Guernsey {Obstetrics, p. 622; Phila., 1867). It is, however, often not only desirable, but absolutely necessary to vary the percentages of the proximate princi- ples, or to imitate closely a given formula, in which case we must have a definite mode of procedure, which is at the same time simple and practical in its application. A method of modifying cow's milk to conform with the indications of each case, which I have used with signal success both in private practice and in my hospital work, has been reported on a former occasion, under the title The Artificial Feeding of Infants with Synthetical Milk {Hahnemannian Monthly, Feb. 1898). It is, however, too complicated for use in private practice, and the methods of obtaining varying percentages of fat and proteids detailed below will answer for all ordinary purposes. A word as to the use of milk sugar and cane sugar. It is held that lactose, being the natural sugar found in milk, and being more assimilable and less liable to undergo fermenta- tion than cane sugar, should always be used in artificial foods. The objections to cane sugar are, how T ever, rather theoretical than practical, and we know from the condensed- milk baby that cane sugar has great fattening properties. Besides, it does not readily undergo fermentation, its use as a preservative demonstrating this fact. Again, lactose, on ac- count of its property of being converted into lactic acid, which again may be converted into butyric acid, is often ob- jectionable. It may also act as a laxative. Jacobi {Archives of Pediatrics, Oct., 1901) opposes the use of milk sugar on these grounds and also because it is difficult to obtain a pure article. He doubts the identity of the sugar of milk from the cow with that of human milk and calls attention to the danger resulting from the presence of lactic acid in the alimentary tract. This acid throws out of solution the casein of the milk and causes diarrhoea. It also increases the elimination of THE MODIFICATION OF COW'S MILK. 89 lime-salts from the tissues by the kidneys and lays the founda- tion for the development of rickets and malnutrition. In many of the larger cities milk laboratories have been established, where the physician may have made up and served a formula of any proportion of fat, proteids and sugar that he wishes to prescribe. These laboratories are a great convenience, and they are conducted on the lines laid down by Rotch, who was the first to advocate mathematically ac- curate percentage feeding. But the results of prolonged feed- ing with laboratory milk are as a rule unsatisfactory. Pro- teid digestion is defective and the fat does not seem to be assimilated. Evidences of mal-assimilation and malnutrition are commonly observed and I have seen rickets develop under these circumstances. Starr {Diseases of the Digestive Organs in Children) speaks with disapproval of the use of laboratory milk. He has observed the development of gastro-intestinal catarrh in many instances and even of scurvy. In his opinion it is the complete separation of the fat and proteids in the preparation of the milk formulae that interferes with the emulsification and digestibility of the fat. Holt, on the contrary, does not believe that this is of any practical im- portance and speaks favorably of laboratory milk. The theory upon which this mode of feeding is based is correct, but personally I prefer the home modification of milk. There is no doubt that the results obtained from feeding a properly diluted top-milk — whose fat percentage can be easily gauged — are far superior to those obtained from the use of a modified milk consisting of a readmixture of the milk elements after mechanical separation, that have again sepa- rated because the food must be prepared in the laboratory anywhere from twelve to twenty-four hours before the last bottle is fed to the child, and that must be rigorously steril- ized, or be sour and unfit for use by the time the child is ready to take it. It is very likely that the success of laboratory milk has depended more upon the purity of the article than upon the strict adjustment of percentages. 7 90 DISEASES OF CHILDREN. The following rule for diluting cow's milk expresses the underlying principle of the home modification of milk : For an infant under two weeks it should be diluted five times ; from two weeks to six weeks, four times ; from six weeks to three months, three times ; from three months to four months, twice ; and from four months to nine months, once. If, however, we were to use ordinary milk, the result would be a deficiency of fat and lactose in the food, for which reason a milk containing 10 per cent, fat (a 10 per cent. " top-milk ") must be employed up to the third or fourth FIG. 24. — DIAGRAM SHOWING THE PERCENTAGE OF FAT IN WHOLE MILK AND IN THE UPPER LAYERS OF SET MILK USED IN- MODIFYING MILK. (AFTER HOLT.) month and a 7 per cent, top-milk from the fourth to the ninth month. After that, ordinary milk, slightly diluted, may be administered (Fig. 24). The water used as a diluent must contain milk-sugar in the proportion of one ounce to every twenty ounces of food and about the same proportion of lime-water to neutralize the acidity of the milk. In the later period of infancy granu- lated sugar may be used instead of milk sugar. About one- third less than the amount of milk sugar specified should be added. It is always best to boil the water for ten minutes THE MODIFICATION OF COW'S MILK. 91 and dissolve the sugar therein while still hot. Lime-water, however, is decomposed by high temperature. Ten per cent, milk is obtained by dipping off the upper ten ounces from a quart bottle of milk that has stood on ice for from four to six hours (until all the fat has risen to the top) F0R16 0Z. TOP MILK REMOVE THIS QUANTITY AND MIX FOR 9 OZ, TOP MILK ?- REMOVE THIS QUANTITY AND MIX FOR REMOVING TOP MILK 1ST OZ. MUST BE REMOVED WITH A TEASPOON FIG. 25. — DIAGRAM SHOWING FAT PERCENTAGE OF DIFFERENT LAYERS OF SET MILK AND CHAPIN'S MILK DIPPER. (CHAPIX, THEORY AND PRACTICE OF INFANT FEEDING.) with a Chapin milk dipper. (Fig. 25.) Carefully pouring off this upper layer into a glass graduate will answer when the dipper cannot be obtained but the results are by no means as accurate. The formula of this upper third is approxi- mately: fat, 10 per cent.; proteids, 3 J/ per cent.; the ratio 92 DISEASES OF CHILDREN. of fat to proteids being three to one. When not obtainable in this manner the nurse may be instructed to take equal parts of plain (whole) milk and ordinary cream, which con- tains 1 6 per cent. fat. The resulting mixture is a 10 per cent. milk. Seven per cent, top-milk is obtained by dipping off the upper half (16 oz.) from a quart bottle of set milk. Its equiva- lent in cream and milk mixtures is three parts whole milk and one part ordinary cream. The formula of this mixture is 7 per cent, fat and 3 y 2 per cent, proteids, the ratio of fat to proteid being 2:1. The composition of the individual layers of "creamed" or "set-milk" are shown in Fig. 25. It is advisable to make up the twenty-four hours' quantity in the morning, pasteurize it, and then keep the bottles on ice (they must be kept below 40 F.). When, however, fresh milk can be obtained twice daily there may be an advantage in making up half the daily amount at a time. This is especi- ally the case when raw milk of undoubted purity is being fed. When the child experiences difficulty in digesting the casein of the milk we should use barley-water as a diluent. As the young infant has but feeble starch-digesting power it is advisable to predigest the barley solution with one of the commercial diastatic ferments, such as Cereo, Forbes' Diastase or Maltine. A teaspoonful of diastase is added to a quart of barley water (two heaping tablespoonfuls barley flour, one quart water ; boil fifteen minutes and strain) when the same has cooled sufficiently to be tasted. Personally I prefer the top-milk method to the use of milk and cream mixtures, as it is cleaner and simpler. The table given below indicates the times of dilution for the different ages, together with the kind of top-milk to be used, the time for feeding and the amounts to be fed. By times of dilution is meant how many times as much zvater as milk is to be used. Thus, 5X dilution means one part top-milk and five parts water. When a milk and cream mixture is used the sum of the constituents of the food is equal to the amount of top- THE MODIFICATION OF COW S MILK. 93 milk used for a similar formula. Thus, in making up a formula to contain four ounces 10 per cent, top-milk and six- teen ounces water, if milk and cream were to be used it w r ould require two ounces of each. The composition of a given formula is readily calculated by simple division. For example, if we dilute 10 per cent, top-milk (containing 10 per cent, fat and 3H per cent, pro- teids) two times, the top-milk will represent one-third of the mixture. The mixture therefore contains 3 1-3 per cent, fat and 1 per cent, proteids, approximately. In the early months of infancy the proper ratio of fat to proteids under normal conditions is 3 : 1. In later infancy the babe can digest more proteids and the ratio is changed to 2 : 1 with advantage. ,? O u M = ■ X ~ - On 10 £ ■ n M C n. V = a P ^ J3 e - Age. p ntity for e Feed. c ET. 09 _ - n -J 2 - 7: Day Feeding. 1-2 weeks, 10 ^C fat 5* 10 2 hrs. 1-2 oz. 10-20 oz. 2 First Feeding, 1*4 months, TO fat 4x 10 2 hrs. 2-3 oz. 20-30 oz. 2 7 A. M. 2 months, IO % fat 3* 82^ hrs. 3-4 oz. 24-32 oz. I 3-4 months, 10 9t fat 2X 7 3 hrs. 4-6 oz. 28-42 oz. I Last Feeding, 5 months, 7 % fat IX 6 3 hrs. 7 oz. 42 oz. IO P. M. 6-9 months, 7 9i fat IX 6 3 hrs. 1 8 oz. 48 oz. O 3d to 14th 2d to 6th day. week. No. 1. No. 2. Milk, Cream, Lime-water, Water \ i$y 2 Milk-sugar, .... 2)4 (Even tablespoonfuls.) (20 oz. ) 3 3 22^ (300/..) 6th to 1 2th week. No. 3. 4 4 22y 2 4 (32 oz.) 3 to 5 months. No. 4. 12 5 2 23 (42 oz. ) 5 to 10 months. No. 5. 18 6 2 22 (48 oz.) . Remarks. — These quantities and percentages are only approximate, bul they offer a standard by which the physician can be safely guided. It' the child vomits shortly after finishing its bottle, it is either getting its food too rapidly or in too large quantities. Regurgitation of food between 94 DISEASES OF CHILDREN. In the table giving the amount of milk, cream and other ingredients it will be observed that the amount of milk and cream together represent the amount of top-milk that would be required to make up these formulae. Thus, substituting top-milk for milk and cream, formula No. i calls for three ounces 10 per cent, top-milk ; No. 2, six ounces 10 per cent, top-milk ; No. 3, eight ounces 10 per cent, top-milk ; No. 4, seventeen ounces 7 per cent, top-milk ; No. 5, twenty-four ounces 7 per cent, top-milk. In these formulae the ratio of fat to proteids is retained as three to one up to the fourth month, the first containing 1.5 per cent, fat, 0.5 per cent, proteids, and 5.5 per cent, lactose. The second contains 2 per cent, fat, 0.7 per cent, proteids, 5.5 per cent, lactose. No. 3 contains 2.5 per cent, fat, 0.8 per cent, proteids, 6 per cent, lactose. In Nos. 4 and 5 the ratio between fat and proteids stands two to one. No. 4 contains about 3 per cent, fat, 1.5 per cent, proteids and 7 per cent, sugar. No. 5 represents 3.5 per cent, fat, 1.75 per cent, proteids and 7 per cent, sugar (Holt). OTHER FOODS THAN MILK; WEANING. During the first year a child may take farinaceous food in the form of thick, strained gruels prepared from barley, rice or oat-meal, and added in quantities of one to three teaspoon- fuls to a bottle of milk. During the first half of infancy all farinaceous foods should be dextrinized, as the salivary glands and pancreas are not sufficiently active at this period of life to dispose of the starch. A thin gruel, such as barley-water, pos- sesses, besides its nutritive value, the physical property of ren- dering casein more digestible, as has been already pointed out. feedings, usually of sour milk, indicates excess of cream. Constipation, as a rule, indicates deficient cream or deficient quantity of food. Curds in the stool indicate excess of proteids or deficient proteid digestion, and calls for further dilution of the milk. Colic is a result either of proteid indiges- tion or too rapid nursing. A large, robust child naturally requires more food than a delicate, undersized child, and vice versa. Constant crying be- tween feedings, when not due to pain, signifies hunger; this, together with insufficient weekly gain in iveight, suggests an increased quantity or less dilution of the food. OTHER FOODS THAN MILK; WEANING. 95 Beef-juice is a valuable food for infants who are anaemic or who do not thrive well on milk alone ; also in scurvy. A teaspoonful may be given three times daily in the latter part of the first year ; earlier, half that amount, excepting in cases of scurvy, where more is necessary. Orange-juice possesses decided antiscorbutic properties and should be administered regularly, a half to one teaspoonful three times daily, one hour before feeding, to infants taking sterilized milk or a proprietary food, or in cases of constipa- tion. Fresh grape-juice is likewise beneficial. During the first half of the second year five meals a day may be continued at intervals of four hours, the fifth meal being a bottle of milk at 10 p. m. Milk may be given in the bottle until the child is sixteen months old, when it should be taught to drink from a cup. Ten ounces of milk with a cereal (eight ounces of milk, two ounces of thick oatmeal or barley-water) will furnish the main food; this can be given four times daily. At the noon meal a poached Qgg or some chopped broiled meat (rare) on alternate days should be added to the dietary. Stale bread and zweibach softened with milk are allowable, also fiuit-juices, the soft portion of a baked apple and of stewed prunes. By the end of the second year, when all the teeth have made their appearance, a child will be able to take table-food of a light and digestible nature. Meat should only be allowed sparingly, however, and tea or coffee prohibited. The child should be encouraged to drink water freely. Weaning should be begun at the end of the ninth month, providing the mother's condition does not demand that the infant be taken from the breast earlier. During the summer months it is often advisable to carry the child along a little longer to forego the dangers of summer-complaint. When, however, gradually done and the food carefully prepared there is no great danger in weaning. For the first few daws a bottle can be substituted for a nursing; as the child be- comes accustomed to the bottle another can be added until 96 DISEASES OF CHILDREN. the breast is eventually dispensed with entirely. As a rule, it can be said that a babe just weaned from the breast will not be able to digest a mixture of cow's milk which a babe of the same age that was fed by hand from birth can digest. We must, therefore, begin on a somewhat weaker mixture than one recommended for the average case. By the six- teenth month the child should be weaned from the bottle and taught to drink from a cup, excepting the 10 p. m. feeding, which can be given it from a bottle in bed. The following dietary is appended as a resume of feeding in later infancy : Diet from nine to twelve months : whole milk, six ounces ; barley-water, three ounces ; granulated sugar, one drachm ; a bottle every four hours (five feedings in twenty -four hours). Orange juice and meat juice also to be given as directed above. Diet from twelve to sixteen months : whole milk, eight ounces; thick barley or oatmeal-w T ater (gruel), two ounces; sugar, one and one-half drachms ; every four hours (five feed- ings in twenty-four hours). At this period oue semi-solid meal (a soft-boiled tgg } cereal, milk pudding, zweibach soaked in milk) may be given once daily as a substitute for a bottle of milk ; also a bottle of broth. Diet from sixteen to twenty four months: 7 A. M., one-half ounce orange juice; 7:30 A. m., a cereal, soft-boiled egg occasionally, eight ounces plain milk, bread and butter; n A. m., cup of broth with rice or barley, strained (if broth is to be given for dinner, this meal should be a glass of milk) 5 2 P. m., finely-cut meat every other day, cup of broth or glass of milk, baked potato, or boiled rice, or a well-cooked fresh vegetable, bread and butter, dessert (milk puddings, junket, custard, gelatin, stewed fruit); 6 p. M., cereal or bread and milk, stewed fruit. During the third year the same schedule is observed but the variety and quantity of food is gradually increased, as all the teeth are present at this time the food can be of a more solid character and more meat allowed. infant's food. 97 THE INDICATIONS FOR VARYING THE PERCENTAGES OF THE PROXIMATE PRINCIPLES OF THE INFANT'S FOOD. The character of the stool and the rate of progress in the child's weight are the data by which we mnst be guided in regulating the composition of the diet. Exceptionally breast milk disagrees with the child, the commonest source of dis- turbance being the increase in the proteids, as shown in Rotch's case, cited above. The symptoms pointing to this condition are vomiting of large curds, colic, constipation, or greenish stools containing tough curds. If the child per- sistently indulges in a food too rich in proteids, uric acid disturbances may develop. On the other hand, a deficiency of nitrogenous food leads to anaemia, a general laxity of the muscular system and checked physical development. When fats are in excess, vomiting and diarrhoea may like- wise be induced and the stools w 7 ill contain fat in considerable quantity. But when normal amounts of fat are not disposed of we should suspect hepatic and duodenal disturbances or deficient pancreatic secretion excepting in the case of tran- sient attacks of simple indigestion. A deficiency cf fat is very pernicious in its result, laying the foundation for the development of rickets and tuberculosis. The chemical instability of the carbohydrates, of which group lactose, cane sugar and starch constitute the most im- portant members, renders them especially liable to induce trouble, particularly when micro-organisms contaminate the diet. Through their fermentation lactic acid' in the one case and alcohol, acetic, and butyric acid in another are formed in the alimentary tract, and the troublesome summer diar- rhoeas are largely traceable to this source. Children fed over a long period on foods rich in carbohydrates and poor in fat and proteids become large, flabby, and usually rachitic. They are anaemic and resist acute illnesses poorly — in fact, their plump bodies melt down to mere bony framework, almost as 98 DISEASES OF CHILDREN. a dropsy might rapidly disappear and leave an emaciated form behind. The percentages of proteids and fat can often be modified in breast milk by regulating the mother's diet and habits. Still more readily they can be changed under artificial feed- ing, when the condition requiring such a change presents itself. The amount of lactose cannot be controlled in human milk. Whenever a breast-fed child shows signs of disordered digestion and impaired nutrition it becomes necessary to examine the milk, in order that the proper correction of the condition can intelligently be made. THE INTERVALS FOR FEEDING AND THE QUANTITY REQUIRED BY THE CHILD AT DIFFERENT AGES. The new-born infant is put to the breast as soon as the condition of the mother permits. Milk is not secreted before the third day, but Colostrum, which is a fluid rich in cells from the acini of the glands undergoing fatty metamor- phosis, is present in sufficient quantity to appease the child's craving, and by its gentle laxative property empty the intes- tinal tract of the meconium. The child may be put to the breast every two hours during the first month, and if it be weakly, or show signs of not gaining progressively in weight, it may be nursed once during the night. Beginning at 5 A. m., and ending at 11 p. m., the child will have received ten nursings in all. During the second month the interval should be extended to two and one-half hours, and again one at night, if necessary. This will make eight nursings from 5 A. m. to 11 p. M. From the third month to the time of weaning, which should only under rare conditions be ex- tended beyond the ninth month, the intervals will be every three hours, thus making seven nursings during the regular time. These rules should be deviated from under no circum- stances so long as the child is not seriously ill, and it is better to let it cry than give the breast before the prescribed time, THE INTERVALS FOR FEEDING. 99 and awaken it when the time for nursing is due, until the child forms the habit of nursing regularly. Some authorities recommend even longer intervals than those given above, but it will generally be found that the baby does satisfactorily under this regime, and where an indi- vidual case is found in which a more frequent or a more ex- tended period seems necessary, it certainly will prove the wisest plan to make a change. The regularity of the feeding is the most important element. The advantages of this method over irregular feeding, or the little and often method, are too manifest to merit discussion. When the infant is to be raised by hand from the begin- ning, it is well to commence with a 5 per cent, solution of milk sugar, sterilized, one ounce every two hours for the first day, until the bowels have been completely emptied and the child is taking the liquid well. It can then be put on a mix- ture containing about 0.8 per cent, proteids, 2 per cent, fat and 6 per cent, lactose ; this is gradually increased as the child's digestion becomes stronger, until it is taking a formula cor- responding to mother's milk. In regard to the quantity to be given at a feed no fast rule can be laid down, for stomachs vary in size in children of the same age and weight, and a child of five months may have the feeding capacity of another at seven months. It has been estimated that the stomach capacity is equal to one-hundreth of the child's weight ; Frowlowsky giving the following measurements : One week, 1 ounce ; four weeks, 2 l / 2 ounces ; eight weeks, 3 1-5 ounces ; twelve weeks, 3 1-3 ounces ; sixteen weeks, 3 4-7 ounces ; twenty weeks, 3 3-5 ounces. The capacity of a hand-fed babe is, however, usually greater than the above, and the increase after the first month is more rapid than this table would indicate. The average quantity of food required by the infant at the different periods from birth to the time of Weaning is given in the table on p. 93. 100 DISEASES OF CHILDREN. THE STERILIZATION OF THE FOOD. The first milk secreted from the human breast may con- tain a few varieties of staphylococci, as demonstrated by Cohn and Neumann, these micro-organisms having gained access to the milk-ducts through the nipple. After the breast has been thoroughly drained, the micro-organisms are flushed out of the ducts, and the milk is then usually quite sterile. Where, however, the breast is diseased, tjiere may be an abundance of bacteria constantly present in the milk. This is the case in mastitis, especially in the parenchymatous variety, and in tuberculosis affecting the mammary gland. Under such con- ditions it is absolutely imperative to institute weaning. Cow's milk is practically never sterile ; indeed, not only diarrhceal diseases are brought on by the use of contaminated milk, but epidemics of cholera, scarlet fever, typhoid fever and diphtheria, beside infection with tuberculosis and foot and mouth diseases, have been traced directly to the milk supply. Of this group of infectious diseases cholera infantum and gastro-enteritis, respectively designated acute and subacute milk infection by Vaughn, and tuberculosis, are mainly to be feared, as they are constantly traceable to the method of feeding. Regarding the last-named disease, it was formerly taught that tuberculous cows yield milk containing tubercle bacilli, whether or not the udder was affected ; but the recent re- searches of Lewis Woodhead and Sidney Martin demonstrate that only milk from a cow with tuberculous udders is in- fectious. Woodhead proved also that the temperature usually rec- ognized as capable of destroying the tubercle bacillus, namely, 75 C , for a period of ten minutes, was not sufficient to render this micro-organism innocuous ; and even when ex- posed twice that length of time, tuberculous milk produced in pigs a modified form of tuberculosis, manifesting itself as THE STERILIZATION OF THE FOOD. 101 chronic tuberculous glandular and joint affections, analogous to scrofulosis. It is, therefore, highly important that all micro-organisms should be destroyed. Thoroughly boiling the milk for ten minutes renders it sterile from the clinical standpoint, or by subjecting it to a heat of 21 2° F. for an hour and a half in a steam sterilizer it will keep for several days in hot weather if carefully sealed. This process, however, affects the milk in its taste, physical properties and nutritive value. It tastes like boiled milk and is less digestible, the casein being ren- dered less coagulable by rennet and less soluble to the action of pepsin and pancreatin. Besides, it is believed that the prolonged use of sterilized milk invites the development of rickets and scurvy. According to Rundlett the albuminates of iron, phosphorus and fluorin are chemically changed by heating ; the globulin or proteid molecule splitting away from the inorganic molecule, thus rendering these salts un- assimilable (Fischer). For this reason many podiatrists use raw milk — such known as "certified," or "guaianteed milk"* in feeding their babies, excepting in hot weather, when it is safer to assume the risk of scurvy developing than cholera infantum or entero-colitis. Pasteurizing is preferable to steri- lizing, but even this destroys the germicidal action of raw milk which, according to Freudenthal. is one of its natural properties. Personally I prefer the use of raw pure milk in the colder months of the year. *The Milk Commission of the New York County Med. Soc. decided upon a standard to which the milk supplied to that city should conform, which is the following: Acidity must not exceed 2-10 of 1 per cent.; there must be no more than 30,000 bacteria to the c. c. , and butter fat must be present to the amount of at least 3^ per cent. To the dealers attaining this standard a certificate is to be issued and their milk known as "certified milk." {Med. Record, Vol. 60, No. 15. 1 The Milk Commission of the Philadelphia Pediatric Society makes tin- following requirements: The specific gravity shall range from 1.029 to 1.034; reaction neutral or faintly acid; proteids 3.5 to 4.5 per cent.: sugar, 4 to 5 per cent.; fat, 3.5 to 4.5 per cent. It must be free from all contaminated matter and from the addition of chemical substances and coloring matter. It must be free from pus and injurious germs and have no more than 10,000 germs of any kind to the cu. c. {Archives of Pediatrics , March, 1902.) 102 DISEASES OF CHILDREN. Pasteurizing is practiced by immersing the bottle contain- ing the milk into a receptacle holding water to the level of the milk in the bottle. The water in the receptacle is brought to the boiling-point ; the bottle, stoppered with sterilized ab- sorbent cotton, becomes highly heated in the boiling water, and the source of heat having been removed, the bottle is allowed to remain in the hot water forty-five minutes when it FIG. 26. — FREEMAN PASTEURIZER.* is rapidly cooled under a jet of water and placed on ice. By this process the milk has been brought to a temperature of 75 C, or 167 F., and maintained at that heat for an average of half an hour, which is sufficient for all practical purposes. The Freeman Pasteurizer (Fig. 26) is an inexpensive appara- tus and by its use much better results are obtained than by the makeshift method described. The Arnold Steam Sterilizer ^Instructions for using Dr. Freeman's Apparatus for Low Temperature Sterilization of Milk by Pasteurization. 1. Fill the pail to the level of the groove with water, cover it and put it on the stove to boil, the receptacle for the bottles having been left out. 2. Fill the body of each bottle with milk or some modification of milk THE STERILIZATION OF THE FOOD. 103 (Fig. 27) is another good apparatus very convenient for home use, when sterilizing is to be carried out. Pasteurizing milk does not render it sterile in the bacterio- logical sense; it however destroys the various saprophytic germs that are responsible for many cases of diarrhoeas ; the bacillus of tuberculosis, cholera, typhoid fever, and diph- theria, and the organism of scarlet fever. Spores are not destroyed, but as it requires several days' time for their devel- opment any that may be present will not prove a menace to the child, if the food is freshly prepared daily. H. Lahmann (" Allgem. Med. Cen- tral Zeitg." Ixv., 1896) believes that scurvy and rickets developing in in- fants fed on sterilized milk is due to the exclusive milk diet, and not to the process of sterilization. Milk contains too small a percentage of iron, soda, and lime, and to remedy this defect he adds fruit juices to the dietary. The juice of oranges, cherries, strawberries, and other fruits is recommended, and after the third month this can be given with impunity. The evil results from the use of sterilized milk are not seen in a day — they are the outcome of feeding over a prolonged time. There is therefore no objection to the use of sterilized milk during hot spells, while traveling, or when an excellent quality of milk cannot be obtained. One should, however, always en- deavor to give the child raw milk whenever this is feasible. in proper proportion for feeding; stopper with a wad of cotton batting and put in a refrigerator. If all the bottles which the receptacle holds are not needed, fill the remaining cylinders with cold water. Each space in the receptacle must be filled. 3. When the water in the pail on the stove boils thoroughly, take the bottles of milk from the refrigerator and put them in the spaces for them iu the receptacle. FIG. 27. — ARNOLD STKAM STERILIZER. 104 DISEASES OF CHILDREN. If a good milk can be obtained twice daily it is rarely neces- sary to sterilize or pasteurize, excepting as before stated dur- ing hot spells, and also, when there is a tendency to diar- rhoea. Even the continued use of pasteurized milk may bring with it the appearance of signs of rickets and even scurvy. Sill (JV. Y. Med. Record, Dec. 27, 1902) claims that in 97 per cent, of a long series of infants under his observation that were fed on pasteurized milk there were unmistakable signs of rickets or scurvy, or a combination of these diseases. On the other hand we occasionally see perfectly healthy infants that have been on pasteurized milk since birth. 4. Pour cold water into each of these spaces so as to surround the body of the bottle. 5. Take the pail of boiling water from the stove and put it on a table or mat. Do not put it on metal or stone. Be sure that the pail is still filled exactly to the level of the groove and that the water is boiling vigorously. 6. Set the receptacle containing the bottles of milk into the pail of boil- ing water, so that the wire (a) will rest on the support (c), cover the pail quickly and let it stand forty-five minutes. During this period the pail must not be on the stove and the cover must not be removed. 7. Now uncover the pail and lift the receptacle and turn it so that the wire (b) will rest on the support (c), thus elevating the top of the receptacle above that of the pail. Put the pail containing the receptacle elevated in this manner in a basin under a faucet to which a rubber pipe ma)* be at- tached connecting it with the pail (Fig. 2). The water will overflow from the pail into the basin. Or the pail may be stood under a pump, fresh cold water being pumped into it every few minutes. The above described method of cooling is the best. When, however, it is not possible to cool the milk in this way, the cooling may be accomplished by placing the receptacle containing the bottles of milk in iced water, or by simply standing the bottles on wood in a refrigerator. 8. To warm the milk for use, put the bottle containing it in a vessel of cold water on the stove, and leave it until it is warm. Use a fresh bottle for each feeding. 9. Wash the bottles thoroughly after using, and once a day put all the empty bottles in a kettle of cold water on the stove aud let this water boil for an hour. The bottles should then be taken out and stood bottom up until used. Milk sterilized by this apparatus may be used for food during the follow- ing twenty-four hours. The Freeman Pasteurizer is manufactured by James T. Dougherty, 409 and 411 West 59th Street, New York City. ARTIFICIAL FOODS. 105 THE PREPARATION AND INDICATION FOR OTHER FOODS AND ADJUVANTS TO THE CHILD'S DIETARY. ARTIFICIAL FOODS. Barley -Water. — This is a most useful adjuvant in the treatment of many conditions peculiar to infants. According to a series of experiments by Cautley, a weak barley-water will render the curds of milk, when precipitated by acetic acid, much finer than is the case with any other diluent. It is a bland, demulcent liquid, possessing some nutritive prop- erties, mainly from the presence of starch. It should there- fore be used cautiously until the amylotic functions of the saliva and pancreatic juice have been developed. Being de- mulcent, and containing a carbohydrate element which is not so favorable a medium for the development of micro-organisms as a proteid it is especially serviceable in the acute summer diarrhoeas of infants, either as an attenuant of the milk or when given pure. It is best made as follows : " Take two ounces of pearl barley and wash well with cold water, reject- ing the washings. Afterwards boil with a pint and a half of water for twenty minutes in a covered vessel, and strain." — (Pavy.) A quicker method is to make it from barley flour, a tablespoonful to the quart, boiled fifteen minutes. Rice-Water. — This is a very nutritious, soothing drink in acute intestinal troubles. " Thoroughly wash one ounce of rice with cold water. Then macerate for three hours in a quart of water kept at a tepid heat, and afterwards boil slowly for an hour, and strain." — (Pavy.) Rice-Paste.— Dr. George B. Fowler (" N. Y. Med. Record," No. 12, 1890) highly recommends a paste, made by adding four tablespoonfuls of rice to three pints of water, boiling half an hour and then setting aside to simmer, water being occasionally added to maintain the three pints. This is strained through a colander and cooled, when a paste is formed. Three tablespoonfuls of the paste are added to half a pint of sterilized milk. Dr. Alonzo Barnes of this city has 8 106 DISEASES OF CHILDREN. had excellent results from this preparation in summer-com- plaint. Rice is perhaps the most readily assimilated starchy food. Oatmeal- Water. — This is contraindicated in diarrhceal af- fections, but is useful as a diluent in constipation. A table- spoonful of oatmeal is added to a pint of water and brought to the boiling-point under constant stirring. It is then set aside, allowed to cool, and strained. Albumen- Water. — This is a highly nutritious, easily di- gested drink, and is often retained where the stomach rebels against more substantial forms of food. " Take the white of a fresh egg and cut it in various directions with a clean pair of scissors. Shake it up in a flask with a pinch of salt and six ounces of pure cold water. Strain through muslin." Beef Tea. — It is needless to mention here that beef tea con- tains no virtue beyond its stomachic and stimulating effects. It is useful in low, febrile conditions and where there is lack of reaction. In order to render it nutritious, beef pulp or a cereal must be added. Chicken- and Mutton-Broth. — These broths are less stimu- lating than beef tea, but are better tolerated where there is much fever. Chicken broth contains some gelatin. Beef Juice. — When properly prepared, this is a highly nutritious albuminous form of food. It is an excellent food in anaemia and where the digestive powers are weak, but lithaemic symptoms must be watched for when used over an extended period. To obtain the juice, a piece of sirloin steak, or any good piece of beef from which the fat and connective tissue have been removed, is quickly broiled in a hot pan, placed in a strong lemon squeezer, or, better still, the beef press, especially made for this purpose, and the juice squeezed out. It may be served warm with seasoning or on bread ; also diluted with ice-water. Boiling coagulates the myosin and serum albumin, and renders the product less digestible. Junket is often useful to vary the monotony of a milk ARTIFICIAL FOODS. 107 diet. It can be prepared with rennet or Fairchild's essence of pepsin. Peptonized Milk. — This is a most satisfactory food in low typhoid states and sometimes in dyspeptic cases, used until the digestion has regained its normal condition. For rectal feeding it is extremely valuable. The milk used for this pur- pose must not be rich in cream. — (Gilman Thompson.) The quickest and most satisfactory method of preparing it is to dissolve the contents of a Fairchild's peptonizing tube in four ounces of cool water, adding a pint of milk. The bottle containing the mixture is placed in hot water of a tempera- ture that can be borne by the hand for a minute without dis- comfort (Starr), and allowed to remain thirty minutes. If this renders it too bitter, it should be removed earlier. Peptogenic Milk-Powder. — This is a powder containing the pancreatic ferment and milk sugar. By adding it to a mixture of cream, milk and water, we obtain a modified milk, resembling human milk in composition and one in which the casein is at the same time partially predigested. It is well adapted to infants with weak or poorly developed digestive organs ; I have seen it do good in premature and under-developed infants. A mixture of one-half pint milk, one-half pint water, four tablespoonfuls of cream and four measures of peptogenic milk powders makes a close imitation of human milk in composition. The process of peptonizing is essentially the same as in the case of the peptonizing tube above referred to. It can, therefore, be checked by bringing the milk to a boil or continued by keeping it warm (at 115 F.). As the child's digestion improves the peptonizing pro- cess should be shortened until the milk is tolerated in its natural state. Malt Diastase — Liebig's Food. — Ground malt possesses marked diastatic properties, and when added to a starchy food, converts the latter into maltose. Malt extracts have the same power, but to a less degree. In amylaceous dys- pepsia the child's farinaceous food, such as oatmeal, rice, 108 DISEASES OF CHILDREN. cracker-paps and flour soup, should be sweetened with a malt extract instead of cane sugar. It can also be given alone be- fore meals. L,iebig's food contains gluten — the proteid of wheat and barley — dextrin and maltose. It is prepared as fol- lows : u Mix a half-ounce each of ground malt and wheat flour, seven and one-fourth grains of potassium bicarbonate, with one ounce of water and five ounces of sweet cow's milk. Warm slowly and stir until thick. Remove from fire, stirring for five minutes ; replace over fire and remove when quite thick." — (Gilman Thompson.) This mixture becomes thin and sweet as the diastatic process becomes completed, when it is again boiled and strained. Fothergill is a great advo- cate of ground malt. He recommends it in addition wdth baked flour and hot milk. Maltine is a very stable article, and, beside being a digestive agent, is rich in phosphorus and other food elements. When a mild stimulant is indi- cated, a liquid preparation, such as Hoff^s, is very useful. Baked Flour. — Through the process of baking the starch- granules are burst, and some of the starch is converted into dextrin, making it, on the whole, more digestible. A water- cracker is a good example of baked flour, but it contains some lard, which is necessary in the process of manufacture. As most infant foods are deficient in fat, it is rather an ad- vantage than otherwise ; and if these crackers are rolled to a fine powder, stirred to a paste with cold water, and boiled with sufficient milk to make a thin pap, we have here a highly-nutritious food, easily digested by most babies after the sixth month. It can be sweeted with a malt preparation, which will prevent constipation. Comparing this food with the artificial foods flooding the market, we can see readily that the only advantage they have over simple home methods of preparing foods is the rapidity with which they are made and the saving of a little trouble. They are expensive, usually insufficiently nutritious, not always conforming to the formula advertised by the manufacturer, and, although they will save the mother a little trouble for the time being, ARTIFICIAL FOODS. 109 she will be fortunate, indeed, if the expense and worriment attached to the development of tuberculosis, scurvy and rickets be spared her at a later date. Fruit Juices. — In a previous chapter the necessity of using fruit juices where there is a tendency to scurvy and rickets was pointed out. Where fresh fruit cannot be obtained, the sweetened juice of dried plums, apples, apri- cots and the like can be used. In constipation they are often called for. Fat — Cod-Liver Oil. — It may be that fat has been insuf- ficiently supplied in the child's dietary, or that the child can- not properly digest and assimilate it. In the latter case cod-liver oil often comes to the rescue. It is best given as recommended by Fothergill, i. e., taken about an hour after eating, when the food passes out of the stomach into the duodenum. In this way it does not needlessly provoke the stomach, and the disagreeable eructations are avoided. Sometimes an emulsion acts better than the pure oil. The marrow from a shin-bone spread on bread while hot, and a little salt added, is an excellent food for anaemic chil- dren. Fat is the necessary food in struma and rickets. Butter-taffy is a pleasant way of supplying fat when cod- liver oil is refused, and is highly praised by Fothergill. Stimulants. — Brandy, well diluted, is the best alcoholic stimulant. Beginning with half an ounce, the quantity can be increased to one ounce in twenty-four hours for a child one year old. I have often substituted alcohol sponge-baths (one part of alcohol to three parts water), and a compress of dilute alcohol applied to the abdomen, for the internal administra- tion of alcohol, with entire satisfaction. Eggnog is an excel- lent stimulant and food in convalescence from acute illm it is also valuable in the debility of phthisis. Malt extracts have been referred to. Artificial Foods. — Any one who has taken the trouble to acquaint himself with the method of modifying cow's milk to resemble human milk in composition, and has observed the 110 DISEASES OF CHILDREN. results obtained from this method of feeding, and also has studied the simple method of preparing suitable articles of diet for the child in health and in disease, as detailed above, must fail to see any special necessity for the numerous pro- prietary foods so extensively used and advertised. And yet there is a field for them ; there are times when it is extremely convenient to have an article at command requiring simply the addition of hot water or milk for its preparation, and at the same time know that we can rely on it and get results. The mistake is to use a prepared food over a prolonged period of time, for then the mischief is done, but if we em- ploy these foods with judgment, they are very useful. For ex- ample, Horlicfcs Malted Milk is often retained when other food is vomited ; it requires simply the addition of boiling water in its preparation, and will sustain life for a long period of time. It is, therefore, an excellent food to be used in travelling and in some acute conditions. A cup of hot malted milk at bedtime is conducive to restful sleep, this action being usually very marked and to be relied upon, more so than from the use of plain milk, no doubt owing to its greater digestibility. Condensed Milk contains too much sugar and too little fat to be a suitable infant's food, being only permissible in case of emergency. Evaporated milk, without the addition of sugar, prepared from a milk rich in fat, is a much better sub- stitute for fresh milk. Mellin's Food is a Liebig Food and can be used when it is not convenient to prepare the Liebig food at home. It is useful in constipation, and is very fattening. When made according to directions it closely resembles mother's milk, but it must be remembered that the cow's milk which is added to this food is the main factor in the formula. The Allenbury's Foods are excellent artificial foods made in a series of three formulae, the composition of each aiming to correspond to the needs of the different periods of infancy. The milk food, No. i, is to be used during the first three ARTIFICIAL FOODS. Ill months of infancy. It contains casein, fat and sugar in the correct proportion required for the digestive powers at this age. Food No. 2 is similar to the No. I, but contains in ad- dition a certain amount of maltose, dextrose, soluble phos- phates and albuminoids. It is intended for the third to sixth month. The food No. 3 is essentially a farinaceous food, re- quiring the addition of cow's milk in its preparation. It is intended for children of six months and upward. The manu- facturers of these foods, willing to admit that scurvy and rickets are likely to occur in children fed exclusively upon artificial foods over an extended period of time (to say nothing of malnutrition), wisely suggest the daily use of a dessert- spoonful of grape or orange juice to be given two or three times a week after the third month, and later on also raw meat juice. Artificial foods, therefore, have their place ; they are never absolutely necessary, only being convenient contrivances of our progressive age, and they can never supplant mother's milk or cow's milk modified by strictly scientific methods. CHAPTER V. DISEASES OF THE NEW-BORN. A variety of pathological conditions is to be observed in the new-born, resulting either from mechanical injury or from infection. Certain physiological changes taking place in the organism may also give rise to disturbances peculiar to this period of life ; these are notably asphyxia, cyanosis, and icterus. ASPHYXIA. Asphyxia of the new-born may be either of intra- or extra- uterine origin. Intra-iiterine asphyxia results from the in- terruption of the placental circulation through compression of the cord or premature separation of the placenta. Respi- ratory efforts are excited in ; the child through the resulting carbonization of the blood and the lungs consequently become rilled with amniotic fluid. Extra-uterine asphyxia presents itself immediately on or a short time after birth. The degree of asphyxia may be of several grades, varying from a simple interference with the respiratory function from the collection of mucus or other foreign substances in the pharynx and trachea to complete cessation of respiration. In the latter case the child may be robust when born and present all the signs of active asphyxia, the body surface being cyanotic and the face bloated (sthenic asphyxia) ; or it may be pallid and limp and apparently life- less (asthenic asphyxia). A frequent cause of the asthenic form is pial hemorrhage, the irritability of the respiratory centres being abolished through the intra-cranial pressure. In the absence of haemorrhage, malformations of the respiratory or circulatory organs, pulmonary atlectasis, pulmonary syph- ilis, pneumonia or premature birth may be mentioned as causes. HEMATOMA OF STERNO-MASTOID MUSCLE. 113 • The results of asphyxia are stagnation of dark, fluid blood in the veins and filling of the right ventricle, hyperaemia of the various organs, and petechial haemorrhages. The reflexes are not abolished in the sthenic variety and the pulse is slow but perceptible. It presents a better prog- nosis than the asthenic variety, in which there is pallor of the body surface, abolition of reflexes, and imperceptible pulse. The treatment consists in the removal of all obstruction such as mucus and amniotic fluid from the air-passages, sup- plemented by measures calculated to set up respiratory efforts through peripheral irritation. The alternate warm and cold bath is very efficacious. In the asthenic variety the warm bath alone should be employed, together with artificial res- piration, but when the asphyxia is only a symptom of one of the serious conditions above enumerated, the prognosis is utterly hopeless. CEPHALHEMATOMA. A cephalematoma is a tumefaction situated upon one of the cranial bones, usually the parietal, caused by haemorrhage beneath the periosteum. It results from injury sustained dur- ing parturition, and is frequently encountered in children born through a narrow pelvis. Being entirely external no symptoms are induced thereby, the clot becoming organized and absorbed in the course of several weeks. Usually it does not become manifest until a few days after birth and may be confounded with hernia cerebri, but the latter is most fre- quently situated either at the root of the nose or the nape of the neck, and presents a distinct bony edge, indicating the opening from which the sac protrudes. No treatment is re- quired. HEMATOMA OF STERNO-MASTOID MUSCLE This usually affects the belly of the right stenlo-mastoid muscle, most commonly appearing after breach Labors, being 114 DISEASES OF CHILDREN. the result of twisting of the head during parturition. A firm elastic, egg-shaped swelling appears in the middle of the mus- cle about two weeks after birth and is accompanied by torti- collis. It disappears in the course of a few weeks and re- quires no treatment, excepting such measures as will hasten absorption, namely, hot fomentations and Arnica internally. INTRACRANIAL HEMORRHAGES. Apoplexy of the new-born is encountered as a venous or capillary haemorrhage of the meninges of the brain, less fre- quently taking place into the cortex. It results from direct injury sustained during birth. This condition is fully dis- cussed under cerebral palsies. Other forms of injury to the nervous system encountered at this period are facial and brachial paralyses, resulting from pressure or traction upon the nerve trunks supplying these parts. SEPTIC AND OTHER INFECTIONS IN THE NEW-BORN. Septic infection in the majority of instances takes place through the umbilicus. There may, however, be an intra- uterine infection through the placenta or by the aspiration of amniotic fluid containing pathogenic micro-organisms. Again, an abrasion of the skin or of the mucous membranes may give entrance into the system of germs. When the port of entrance cannot be discovered the infection is spoken of as " cryptogenic." The pathological findings depend upon the mode of infec- tion. Often it is impossible to find the site at which infec- tion took place and the evidences of septicemia alone exist. There is fever ; rapid and shallow respiration, vomiting, diar- rhoea and wasting. Collapse with a fatal termination is the usual outcome. Symptomatic icterus and internal haemor- rhages are associated conditions. i. In the cases in which infection takes place through the respiratory tract, the evidences of septic pneumonia, fre- quently with bloody extravasations into the pericardium and pleura, are found. SEPTIC. AND OTHER INFECTIONS IN THE NEW-BORN. 115 2. Infection through the umbilicus gives rise to either a local or general sepsis. Under the heading of the former are included umbilical arteritis, phlebitis and omphalitis. In omphalitis there is an involvement of the surrounding cellu- lar tissues and suppuration results. It occurs most frequently during the second and third weeks. The prognosis is good under prompt surgical treatment, but extension to the perito- neum with general sepsis may occur. General sepsis originating in infection through the um- bilicus is almost invariably associated with peritonitis. Be- sides this localization there may also occur septic pleuro- pneumonia ; pericarditis ; meningitis ; gastro-enteritis ; osteo- myelitis and arthritis. The most frequent of these conditions is peritonitis ; the next in frequency being pneumonia, then pleurisy ; meningitis ; meningeal haemorrhage ; entero-colitis ; pericarditis and meningeal haemorrhage, in the order as named (Bednar). 3. There are also a number of infectious conditions not originating in the umbilicus. They are as follows : Erysipelas. — The distinct type of cellulitis resulting from infection with the streptococcus pyogenes is occasionally en- countered in the new-born. An abrasion of the skin or mucous membrane is the usual site of infection, although it may originate in the umbilicus. In the latter instance a fatal termination is the rule. The remedies most useful are Belladonna, Apis, Rhus tox., and Graphites. Locally a 10 per cent, aqueous solution of Ichthyol proves a valuable adjuvant. Painting the border of the affected area with Collodion to check its spread has not proven of much value in my hands. In the severe cases com- plicated with omphalitis or phlegmon the stronger antiseptics must be applied locally. Tetanus. — The bacillus of tetanus may be inoculated at the site of an abrasion of the skin or of a mucous membrane, or it may gain entrance through the cord. Infection at the umbilicus usually occurs at the time of the separation of the stump of the cord. 116 DISEASES OF CHILDREN. The symptoms are identical with those observed in the adult, the earliest manifestation being rigidity of the jaws, oc- curring as stated above, shortly after the separation of the cord-stump. This trismus is followed by tonic spasms of the muscles of the neck and extremities, occurring paroxysmally. As a rule, it terminates fatally within a few days, although it may pursue a protracted course and result in recovery. The disease is by no means as frequently encountered now as it was in the pre-antiseptic days, when no precautions were taken in the dressing of the cord and when the granu- lating surface left after the separation of the stump was not protected against the invasion of germs. The treatment is both local and internal. The site of in- fection should be dressed with gauze wrung from a one in two thousand solution of the bichloride of mercury in order to check the further progress of infection, and if there be a focus of suppuration, free drainage must be instituted. Hypericum may be administered with the hope of influenc- ing the course of the disease. Other remedies that have been recommended are Belladoitna, Cicnta, Hydrocyanic acid, Lachesis, Nux vomica, Physostigma and Stramonium, Tetanus Antitoxin, although a tiue antitoxin, has not as yet displayed a perceptible advantage over other methods of treatment, nevertheless its use should not be omitted. As the poison of tetanus is an intracellular toxin, only the very early use of the serum offers any hope of cure. In order to relieve suffering, if our remedies fail to act favorably, Chloral hydrate in one-half grain doses should be administered. Fifteen grains daily may be used. When given per rectum twice that amount is necessary. Hot bottles should also be tried, as they enhance the action of the drug and give much relief. The narcotics are of less value. ACUTE FATTY DEGENERATION, OR BUHL'S DISEASE. This disease was first described by Buhl in i860, and pre- sents parenchymatous inflammation, fatty degeneration and OPHTHALMIA NEONATORUM, 117 haemorrhages in the heart, liver and lungs. It is probably of infections origin. It is rare, and is only seen in lying-in hospitals. The children are usually born asphyxiated, and they do not entirely recover from this state. Cyanosis super- venes, and they either die at this time, or the course of the disease is protracted, and bloody diarrhoea, haemorrhage from the navel, mouth, nose and conjunctiva, and icterus, set in. Later, oedema of the skin occurs, and death from collapse fol- lows at about the end of the second week. The diagnosis can only be positively made by a microscopic examination of the organs. The course is always fatal. ACUTE HEMOGLOBINURIA, OR WINKEL'S DISEASE. In 1879 Winkel encountered a series of twenty -three cases of hsemoglobinuria occurring in the new-born, associated with cyanosis, icterus, and haemorrhages in the various organs, with a fatal termination within thirty-two hours in the average of cases. The cause is unknown, but it is undoubt- edly an infection. Other cases have been reported, but not in such an extensive epidemic as the above. — (Winkel, Lehrbuch der Geburtshiilfe^ Ham ill and Nicholson in a series of care- fully studied infections in the new-born {Archives of Pediatrics, Sept., 1903) have found that a variety of micro-organisms is to be encountered, showing that careless nursing is most likely at the bottom of these infections. They would include Winkel's disease, Buhl's disease and melena among the acute infections of the new-born, although haemorrhagic conditions at this time of life may also be the result of syphilis, asphyxia, trauma and malformations. OPHTHALMIA NEONATORUM. The violent conjunctivitis of the new-born, which at times results in destruction of the entire eye is due to infection with the gonococcus of Neisser. When the infant is infected during parturition, the symptoms make their appearance on the third or fourth day ; in some instances the eyes are 118 DISEASES OF CHILDREN. probably infected later and symptoms do not arise until a week or more. The first indication of the trouble is redness and swelling of the palpebral and ocular conjunctiva, pufhness of the eye- lids and catarrhal secretion. The secretion rapidly becomes purulent and the eye-lids infiltrated and leathery. In viru- lent cases chemosis is pronounced and the cornea is deprived of its nutrition through compression of the blood vessels at the sclero-corneal margin. The cornea becomes opaque, its epithelium is desquamated and perforation may result. A benign, non-gonorrhceal form is also encountered. This is recognized by its mild course and by the microscopic ap- pearance of the secretion which contains the ordinary pyo- genic organisms. The prognosis must always be guarded ; it is especially un- favorable in cases that have progressed before treatment is instituted. It is claimed that from 25 to 30 per cent, of blindness can be accredited to ophthalmia neonatorum. Treatment. — On the first indication of ophthalmia the eyes should be irrigated hourly with a 2 per cent, solution of Boric acid and covered with compresses wrung from ice water or laid on a cake of ice and kept constantly applied and changed when they become soiled and warm. As soon as the discharge becomes thick and creamy, a few drops of a solu- tion of Nitrate of Silver, three to four grains to the ounce should be instilled into the eyes two to three times daily. At the same time, as the discharge increases, it is better to resort to frequent irrigation of the eyes with warm Boric acid solu- tion every twenty minutes if necessary, and discontinue the compresses. A bad case will engage the entire attention of two nurses, one for the day and the other for the night. With the subsidence in the inflammation and when the eye- lids loose their infiltrated character, a few drops of a 4 per cent, solution of Nitrate of Silver should be dropped upon their everted surface, taking care not to allow it to run into the eye. This may be followed by irrigating with normal salt solution. ICTERUS NEONATORUM. 119 In order to satisfactorily inspect the cornea from day to day and to properly flush out the conjunctival sacs, it is well to make use of retractors. Should Nitrate of silver appear too irritating, Protargol in a i or 2 per cent, solution may be substituted. When the cornea becomes involved a drop of a 1 per cent, solution of Atropine sulph. must be instilled twice daily. In threatening perforation, Eserine may be tried. Internally, Aconite in the early stages; Arg. nit. later. The responsi- bility of these cases is so great that an oculist should always be taken in consultation. MASTITIS. Inflammation of the mammae with abscess formation is a common result of squeezing out the breasts in a rough man- ner. In the new-born there is frequently present a cholos- trum-like secretion and any form of mechanical irritation of such a breast is likely to result in inflammation and suppura- tion. Under the use of hot fomentations and the administra- tion of Belladonna or Bryonia according as the symptoms of either of these predominate, followed by Hepar, resolution promptly results. ICTERUS NEONATORUM. Icterus may occur symtomatically as a hematogenous jaun- dice in septicaemia, Buhl's disease and Winkel's disease, or it may be due to congenital or syphilitic stricture of the hepatic duct. A physiological icterus occurring several days after birth, disappearing spontaneously in the course of a week, is ob- served in from 79 to 84 per cent, of all infants (PORAK, Cruse). It most frequently occurs when birth lias been pre- mature, or if litigation of the cord has been delayed. Accord- ing to Birch-Hirschfeld, swelling of the capsule of Glisson takes place from interruption of the circulation in the umbil- ical vein, with resulting pressure upon the biliary ducts 120 DISEASES OF CHILDREN. and hepatogenous jaundice. Hofmeier is of the opinion that the icterus is haematogenous in origin, depending upon an extensive destruction of red blood corpuscles, a process which takes place in the liver most actively at this period of life. Stadelmann positively denies the existence of hsemato- genous icterus and he claims that the pigment found in the urine in pernicious anaemia, malaria and acute yellow atrophy of the liver is urobilin and not bilirubin. The concensus of opinion however seems to be favorable to the view that in icterus neonatorum there are two factors active, namely, fall of blood pressure in the hepatic circulation so that the press- ure in the bile ducts becomes greater than in the hepatic veins, and excessive destruction of red corpuscles, making it impossible for the liver to transform all the pigment into bilirubin. CEDEMA. In delicate, feeble infants during early life, a general oedema, affecting at first the eyelids and the dorsum of the hands and feet, and if it progresses, involving the entire cutaneous surface, may develop as a result of a feeble heart muscle. The kidneys are normal in these cases. Ascites seldom occurs. It has been suggested that some toxic agent, probably of gastro-intestinal origin may affect the lymphatics and thus set up the oedema. Kali carb. seems the best indicated remedy. GASTRO-INTESTINAL HEMORRHAGE, OR MELENA. Haemorrhage from the stomach and bowels may take place shortly after birth, and terminate fatally within a few days. These haemorrhages may result from congestion and slight erosion of the mucous membrane of the lower bowel (as a result of thrombosis of the umbilical blood vessels or as- phyxia), follicular ulceration of the stomach and intestines, or from a round, perforating ulcer, and also from any of the infections above mentioned, beside constitutional diseases. GONORRHOEA. 121 The possibility of follicular ulceration of the stomach and bowels existing in infants who have died suddenly without having displayed any of the symptoms of melena, either in the vomiting of blood or the passing of bloody stools, has been impressed upon me on several occasions by post-mortem findings. The pathology of this condition is more fully de- scribed under the diseases of the stomach. Etiologically these haemorrhages undoubtedly belong to the infections of the new-born. The distinctive symptoms, bloody vomitus and bloody stools would indicate such remedies as Hama- melis (abdomen sore to touch, haemorrhage profuse, dark, or clots mixed with mucus) Merc. cor. (tenesmus; bright blood) Argentum nitr. (ulceration of stomach) Arsenicum (great prostration ; septic cases). Other remedies may be suggested by the child's general condition. Supra-renal extract in one- half grain doses is the most satisfactory hemostatic in gastric haemorrhage. GONORRHOEA. The most common form of infection is of the eyes. Bag- insky has recently reported the case of a male new-born in which genital gonorrhoea developed. Of late years frequent attention has been called to the prevalence of gonorrhceal arthritis in infants. There is no doubt that the majority of cases of acute arthritis in infants is gonorrhceal. General septic infection with polyarthritis and constitutional symp- toms occur. I have recently had such a case in which Dr. Sappington was able to demonstrate the gonococcus in the pus from the joints. The course was protracted and the in- fant died from exhaustion. The arthritis was preceded by gonorrhoeal ophthalmia. Kimball (A 7 . Y. Record, Nov. 14, 1903) has reported eight cases of gonorrhoeal pyaemia in infants. In none of his cases was a local infection demon- strable. These cases proved fatal. The temperature is ir- regular and usually runs high. Many joints may be affected, even the fingers and toes, and the fusiform swelling of a finger 9 122 DISEASES OF CHILDREN. may lead us to suspect tuberculosis or syphilitic dactylitis if we are not on our guard. The polyarthritis however elimi- nates these conditions. Other foci of pus are found scattered throughout the body. SUDDEN DEATH IN INFANTS. Sudden death in the new-born is most frequently due to visceral haemorrhages resulting from compression of the head during birth or from haemorrhage into the internal organs. The latter is more frequent in breach cases, no doubt as a result of improperly made traction. Malformations of the viscera, either demonstrable or unsus- pected, are common causes of sudden death in young infants. Here may be discussed thymic death, a subject in which re- newed interest has been shown only in recent years. While Paltauf denies that pressure from the thymus plays a role in the sudden death of these infants, attributing it to the clini- cal entity he has termed status lymphaticus, or lymphatism (see Constitutional Diseases), still the theory that thymic death can occur has many adherents, notably in Jacobi. The latter writes : "It [the thymus gland] is largest, normally, from the third to the twentieth month ; about the ninth month it was found, in usual instances, from 1.5 to 2 centimetres in thick- ness. As the distance between the manubrium sterni and the vertebral column is but two centimetres about the eighth month of life, the slightest increase of an enlarged thymus through distended circulation, by crying or otherwise, may prove suddenly fatal ; for besides the thymus, the oesophagus, the trachea, the blood vessels, and the sympathetic and pneu- mogastric nerves are located in that narrow space. Bending the head backward during tracheotomy proved fatal. Swell- ing of the thymus in a cold bath may be dangerous" (Thera- peutics of Infancy and Childhood). In discussing a case re- cently reported by Caille (Archives of Pediatrics, March, 1903) Jacobi called attention to the fact that but a few of the in- stances are on record since Kopp reported his first case of SUDDEN DEATHS IN INFANTS. 123 thymic asthma nearly a hundred years ago. He related a case operated upon by Konig in which the gland was partly excised with life-saving results. For detailed report on this subject the reader is referred to Jacobi's monograph (Trans. Ass. of American Phys., Vol. III.) and to Fried Jung's article (Archive fur KinderheUk.^ Vol. 29). Atelectasis. — This is either congenital or acquired. Com- plete atelectasis is seen in asphyxia neonatorum. In feeble infants atelectasis may develop after the lungs have been func- tionating, and if progressive it results in death. It is simply a manifestation of a general lack of resistance in the infant to its environment. During the course of bronchitis or broncho-pneumonia areas of atelectasis develop from the oc- clusion of the finer bronchial tubes. In some cases of ma- rasmus nothing is found post-mortem excepting pulmonary atelectasis. Asphyxia from the aspiration of food into the larynx is at times found to be the cause of sudden death in feeble infants. Sudden death may arise from laryngismus stridulus or in gen- eral convulsions, the determining cause being asphyxia. A retro-pharyngeal abscess or the pressure of tuberculosis bron- chial glands upon the pneumogastric nerves or trachea may likewise cause sudden death. Sudden death after a few hours of illness with high tem- perature is as a rule due to congestive pneumonia (Holt). An infant several days old dying suddenly with high temperature and rapid respirations, at the Hahnemann Maternity during Dr. Korndoerfer's service, showed at autopsy a large haemor- rhage from the right middle meningeal artery following for- ceps delivery. The chief interest in the case rested in the utter absence of cerebral manifestations. Sudden death may occur in the first twenty-four hours of a malignant scarlet fever before the eruption has made its ap- pearance. CHAPTER VI. DISEASES OF THE MOUTH. DENTITION. The period of dentition represents the time during which the milk teeth make their appearance, and extends normally from the seventh month to the second year. The period of second dentition begins with the sixth year and is usually com- pleted before puberty, with the exception of the wisdom teeth, which may appear as late as the twenty-first year. The term "teething" applies to the first dentition period, and em- braces the various disturbances occurring at this time, when they can be directly traced to the teething process. FIG. 28. — DIAGRAM SHOWING TIME OF ERUPTION OF THE MIIy Bcenning- hausen, are of exceptional service when given successively, although it will be found usually that one begins in its path- ogenesy where the other leaves off, and it is therefore wisest to continue the single use of each of these remedies as long as it seems indicated. Aeon. — High fever, dry skin, great restlessness, nervous temperaments; after exposure to cold winds or draughts') checked perspiration. Acetic acid is a valuable remedy in croup, especially when there is an accumulation of mucus in the larynx. A few drops of the acid added to the water feeding the steam spray makes a useful adjuvant. The indications under which it DISEASES OF THE RESPIRATORY TRACT. 259 does most good are the following: "Croup, especially when the face is bright red. (Diluted in water, ten drops in a tum- bler of water with some sugar, a teaspoonful every hour or two.)" {Hering^s Condensed Mat. Med.) Bell. — Barking cough; pre-paroxysmal symptoms of at- tacks; child wakes suddenly: great vascular excitement; rawness and pain in larynx, with hoarseness. Spongia. — "Its most remarkable therapeutic virtue is to cure croup. Among other symptoms, it is indicated in this disease by difficulty in breathing, as though a plug had lodged in the throat, and as though the larynx were so constricted that breath cannot pass through it." — (Hahnemann.) "The sawing respiration of this remedy is also characteristic. The aggravation is in the evening; Hepar in the morning." — (Hering.) Hepar. — Deep, rough, barking cough ; rattling of mucus in larynx and trachea ; laryngeal symptoms remaining after the paroxysm. Permanganate of Potash, in the experience of Dr. B. H. Sleght {Horn. Eye, Ear and Nose Journal, June, 1901), is a specific for the croup paroxysm given in teaspoonful doses of a cherry-red aqueous solution. Phosphorus. — This remedy is recommended highly by sev- eral observers, often acting curatively when the above rem- edies have failed to give decided relief. It is especially useful for the hoarseness and bronchitis remaining after the attack. Ipecac and Lobelia are extensively used by many physicians in this affection, and undoubtedly yield excellent results, pro- vided they happen to suit the case. ACUTE BRONCHITIS. Acute catarrhal bronchitis is one of the common ailments of childhood, seen especially in the rachitic or those in whom malnutrition and anaemia are a prominent feature. Children who are closely confined, either in the poorer crowded quar- ters or in nurseries insufficiently aired and sunned, are partial- 260 DISEASES OF CHILDREN. larly susceptible to bronchitis, for which reason most cases prevail during the winter months and early spring. Secondarily, bronchitis accompanies measles, whooping- cough, influenza, typhoid fever and several others of the in- fectious fevers almost unfailingly; its pathology and symp- tomatology are the same in these cases as in the primary variety. Several varieties of acute bronchitis are to be recognized. The mildest form is simply an acute catarrhal condition, afebrile in its course and unaccompanied by constitutional disturbances. Baginsky prefers to call it bronchial catarrh in contradistinction to actual bronchitis. It is very prevalent among infants during the colder months of the year, and seems to be dependent upon atmospheric changes and consti- tutional predisposition. Acute febrile bronchitis is infectious in origin, is accom- panied by constitutional symptoms, and tends to spread to the finer ramifications of the bronchial tree, setting up suffo- cative symptoms — capillary bronchitis. When the process in- vades the pulmonary parenchyma, which takes place both by continuity of structure and by the formation of independent foci of solidification through the agency of micro-organism, we are confronted by a broncho-pneumonia. Pseudo-membranous bronchitis, or fibrinous bronchitis, is in the majority of cases due to the diphtheria bacillus and may follow this disease. I have seen it in conjunction with pneu- monia. The pus organisms may also induce fibrinous exuda- tion upon the bronchial mucosa. A chionic form of obscure origin is to be encountered. Pathology. — As in the case of spasmodic croup, a catarrhal inflammation of the bronchial tubes during infancy is of more serious import and accompanied by more suffocative symptoms than a similar condition in adult life. The greater vascularity and looseness of the mucous membrane, and the relatively smaller size of the air-vesicles and smaller amount of breath- ing-surface in the infantile respiratory tract, are the reasons DISEASES OF THE RESPIRATORY TRACT. 261 for these attacks assuming so dangerous a course. Outside of its tendency to spread to and involve the finer ramifications of the bronchial tree, acute catarrhal bronchitis presents noth- ing apart from the same process in adults. In fatal cases the mucous membrane appears swollen, injected, ecchymosed, and covered with mucus and purulent secretion. In the larger tubes the lining membrane alone is affected, while the smaller and finest ones are involved throughout their entire thickness in the inflammatory process. The lungs are usually emphy- sematous, from dilatation of the air-vesicles and choking up of the capillary tubes with secretion. Areas of atelectasis are also encountered. Every grade, from simple hyperemia of the mucosa with desquamation of epithelial cells up to the highest type of inflammatory reaction with infiltration of the sub-mucous tissue ; necrosis of the epithelium and croupous exudation upon the surface of the membrane will present itself accord- ing to the severity and nature of the infection. The mucous membrane is covered with a tenacious secretion rich in pus corpuscles. Dilatation of the bronchi is a common result of severe bronchitis in children. Symptomatology. — Bronchitis may run a mild or a danger- ous course. In the first instance there will be a slight fever, cough, which at first is dry and irritating in character, later becoming loose and accompanied by rattling of mucus in the larger tubes. Some soreness in the region of the bifurcation of the trachea may be present, but the child evinces no great degree of pain or discomfort, and within a week or less the attack is over. When the smaller tubes, however, become involved, the case presents an entirely different aspect. There is marked dyspnoea, imperfect aeration of the blood and enfeebled circu- lation, higher fever (103 to 104 F. or over), and the chest abounds in subcrepitant and sibilant rales, besides coarse rales of mucus in the larger tubes. The child is exhausted from incessant cough and carbonic acid poisoning, and the 262 DISEASES OF CHILDREN. cough is too feeble to expel the mucopurulent secretion blocking the air-vesicles and bronchioles. It becomes dull and apathetic, even comatose, the pulse rapid and thready or imperceptible, and death, sometimes preceded by convulsions, terminates the scene. This severe type, described as capilliary bronchitis, is, strictly speaking, a broncho-pneumonic process, and it is im- possible to draw a sharp line of distinction between an acute spreading bronchitis and a pneumonia. As stated above, the pulmonary parenchyma soon shares in the inflammatory pro- cess both through continuity and contiguity of structure and therefore these cases present bronchitis, peribronchitis and lobular inflammation. Diagnosis. — In bronchitis the percussion-note never be- comes altered unless emphysema, atelectasis or other com- plications develop during its course. In mild cases there are at first dry rales, followed by large moist rales, with here and there a sibilant and small moist rale, all best heard pos- teriorly. In the second variety subcrepitant and sibilant rales, general in distribution, with large moist and dry rales in the large tubes and trachea, and areas of dullness, with dimin- ished respiratory murmur, indicating collapse of air-cells, may be elicited. Hyper-resonance, resulting from vicarious em- physema, is difficult to identify in children, as the normal percussion-note is in itself highly resonant. Sufficient dilatation of some of the bronchi (bronchiectasis) to produce physical signs may result. In such cases bronchial breathing may be heard over the dilated bronchus and a tympanitic note can be elicited by percussion. The sputum is purulent and separates into a purulent sediment superim- posed by a fluid and frothy layer. Treatment. — In mild cases of bronchitis it is often ad- visable to keep the child out in the fresh air as much as pos- sible, instead of rigid confinement to the bed or nursery. The predisposition to bronchitis must be overcome by cold spong- ing, plenty of out-of-door exposure, and the correction of the DISEASES OF THE RESPIRATORY TRACT. 263 underlying diathetic condition with appropriate remedies and diet, fat being especially beneficial. Severe cases of bronchitis should receive all the care and attention accorded a case of pneumonia. Remedies are numerous, the most useful, however, judging from the frequency of their successful employment, being Aeon., Bell., Bry., Ipecac, Merc., Puis., Rhus tox., Tartar emetic and Sulphur. Beside these the Calcareas, Cham., Ferritin phos., Hepar, Hyos., Lycop. and Phos. are often indicated in individual cases. In the early stages Aeon., Bell., Bry., Cham., Ferrum phos. and Mercurius must be differentiated. Aconite has high fever, dry skin, no chilly feelings as in Mercurius, nor disposition to moisture of the skin, as in Bel- ladonna, which has a dry, distressing, paroxysmal cough, usually worse towards evening. Belladonna is looked upon by some as a specific. The old school resort to its use largely. Its usefulness cannot be disputed, but I see no reason for pushing the drug to its full physiological action. The greatest usefulness for Bryonia seems to be to loosen the cough when the same shows no disposition to become so, remaining deep and hollow, apparently coming from the epigastric region, aggravated by motion and often accom- panied bypain. Scilla is also strongly indicated by painful cough ; it is, however, a more severe type than Bryonia, there being cyanosis and failing circulation, owing to extension of the process into the finer tubes. Cham, suits mild cases of tracheo-bronchitis in the early stages ; the cough is excited by attempting to use the voice, and the child is fretful and cross. Ferrum phos. — Often preferable to Aconite in cases charac- terized by marked dyspnoea right from the beginning, with rapid progress, soon assuming the capillary variety. The cough is short and dry, often paroxysmal, and when expec- toration appears it is streaked with bright blood. Well suited to rachitic subjects. 264 DISEASES OF CHILDREN. Mercurus. — " Mercurius corresponds with the whole course of a severe attack of bronchitis, even better than Belladonna. There is a violent fever, the temperature is very high, there is a great disposition to sweat without obtaining any relief from it ; in contradistinction to Belladonna there is a constant alternation of chills and heat, with a remarkable sensitiveness to the most trifling changes of temperature (B^Ehr, Science of Therapeutics)" Tongue thickly coated yellow ; diarrhoea ; cough dry, worse evening until midnight ; dyspnoea ; expec- toration tenacious. Lobelia inflata. — "Think of lobelia in asthenic bronchitis of children with profuse secretions, and difficulty in removing the accumulations; also if there is a sense of oppression and feeling of dulness." ^Medical Advance" July, 1898, T. G. Roberts.) As the cough becomes loose, Ipecac, Pulsatilla aud Tartar emet. or one of the Calcareas will be required. For the therapy of the severe types and complications the reader is referred to the article upon Broncho-pneumonia. In a case of pseudo-mt mbranous bronchitis I obtained ex- cellent results from Phos. CHRONIC BRONCHITIS. Chronic bronchitis may result from repeated attacks of acute bronchitis, or, more commonly, follow upon an at- tack of whooping-cough, measles, or other acute illness, in w T hich there is offered predisposition to the development of bronchitis. In infants, rickets or simple malnutrition lay the foundation for chronic bronchitis, while in older children the scrofulous diathesis is found. As a secondary disease, it accompanies tuberculosis, organic heart disease and Bright's disease. The important pathological conditions are thickening of the mucous membrane, with areas of superficial ulceration, weak- ening and irregular dilatation of the bronchial tubes, and more or less extensive vesicular emphysema. DISEASES OF THE RESPIRATORY TRACT. 265 The important symptoms are cough and expectoration, the characteristic condition being, that notwithstanding the long continuance of these symptoms, the general health rarely suf- fers to a marked degree. Naturally, these children are not up to the normal standard of health, as the etiology of the affection indicates; at the same time there is no pronounced wasting or suffering induced by the disease. The cough is loose, usually paroxysmal, and may become dry and teasing at times. It is generally worse in the morn- ing, and the expectoration of large quantities of offensive muco-pus on rising, associated with localized gurgling rales, is strongly indicative of bronchiectasis. The course is a slow one at the best, and cases may be apparently cured in the summer only to have a relapse during the winter. Nevertheless, the prognosis is good, the condi- tion being much more amenable to treatment than in adults for the reasons that the tissues are more regenerative and the disease less frequently dependent upon an incurable associated condition. Treatment. — An equable, moderately warm and dry climate is desirable; the mountainous pine regions are especially beneficial. Tonic treatment must be instituted in all cases — baths, fresh air, exercise and a highly-nutritious diet being the essentials. Of the greatest importance in these cases it is to search for and correct any abnormality in the nose and throat. Septal deflections, spurs and polypi are frequent sources of irritation but more commonly adenoids and enlarged tonsils will be found Enlargement of the lingual tonsil is often responsible for persistent winter coughs and should be looked for. Hepar sulph. I have found of especial benefit for the par- oxysmal cough coming on at night. A powder of the second or third decimal trituration will usually relieve these attacks with astonishing promptness. Pulsatilla, of course, is indispensable for the loose cough with profuse easy expectoration of yellowish or yellowish- 18 266 DISEASES OF CHILDREN. green muco-pus, having a tendency to become tighter and more troublesome at night. This remedy acts very satisfac- torily with Hepar, and I frequently employ it during the day, giving a dose of Hepar at night. Lycopodium is particularly useful for the recurrent type of bronchitis, in which the patient is seldom free from a trouble- some cough, "catching cold" on the slightest provocation. "Cough dry, day and night, in feeble, emaciated boys." — (C. WESSELHOEET.) Lyithsemic subjects; acid dyspepsia; cough ending with a loud belch. Sulphur. — Rarely will a case be found in which Sulphur is not at one time or another indicated. Especially in the scrofulous or rheumatic type of constitution will it be found useful. It has not proven of much use where emphysema was present; but where there is a large amount of tenacious mucus, mixed with lumps of pus, of foul taste and odor, it seems particularly applicable. There may also be attacks of oppression of breathing, in which the patient gasps for air. Tart, emetic. — Useful in recent cases, with loud rales in the larger tubes, and dyspnoea with the cough. The Calcareas are especially called for upon their diathetic indications. Calc. carb., beside its characteristic sweat, large belly and glandular enlargements, will be indicated by loose cough, with expectoration of yellowish, sw ? eetish mucus, or dry, teasing cough, with dyspnoea and palpitation of the heart from slightest exertion. Calc. phos. is more suited to the purely rachitic with diarrhota, or cases of simple malnutri- tion. Silicea. — Emaciated children, tuberculous diathesis; night- sweats ; profuse purulent expectoration ; skin dry and scurf}' ; hectic fever ; bronchiectasis ; lack of normal body-heat, with constant chilliness. The cough is aggravated from cold drinks, and is deep and distressing. Beside these it may be necessary to resort to one of the fol- lowing remedies for special conditions and symptoms : DISEASES OF THE RESPIRATORY TRACT. 267 Ars. — Emphysema ; dyspnoea. Carbo veg. — Hoarseness ; chronic spasmodic cough remain- ing after whooping-cough. General loss of vascular tone of the entire mucous membrane of the respiratory tract. Iodinm. — Especially indicated in dark-complexioned, ema- ciated children. Ravenous appetite without a correspond- ing gain in weight ; enlarged bronchial glands. The Iodides are particularly useful in the bronchitis accompanying phthisis. Kali bichromicum. — Tough, stringy expectoration ; cough excited by eating. Bronchitis after measles. Kali hydriod. — Syphilitic cases. Stannum. — Bronchial dilation, with excessive purulent ex- pectoration ; weak feeling in chest. Stibium iodid is also an excellent remedy for bronchiectasis. ASTHMA. The majority of cases of asthma occurring during child- hood are of the catarrhal type, the asthmatic paroxysm ac- companying a bronchitis or broncho-pneumonia. The typical spasmodic type as seen in adults is rare, seldom occurring be- fore the sixth year, although mild asthmatic phenomena such as bronchial spasm, occurring with dentition ; asthma dys- pepticum (Henoch), due to indigestion, and hysterical asthma [pharyngeal spasm and hysterical tachypnea), are frequently met with prior to this time. Idiopathic spasmodic asthma is most probably a vasomotor neurosis intimately associated with the lithsemic diathesis, although the bronchial-spasm theory has still many adher- ents. Local irritation induced by pathological conditions of the nose and pharynx plays an important role as a reflex ex- citing cause. Personally I cannot accept any other explana- tion for the suffocative symptoms than that of turgescence and swelling of the mucosa. Asthma is, so to speak, a "hay- fever" of the bronchia. During attacks of asthma it has been possible to see the mucosa of the trachea and study its 268 DISEASES OF CHILDREN. condition. Freeman has seen it so swollen in cases of influ- enza accompanied by great dyspnoea that the lumen of the trachea was almost occluded. Symptomatology. — The attacks occur suddenly, usually at night, the chief symptom being dyspnoea, accompanied by a dry cough and characteristic respiration. The inspiration is difficult, accompanied by recession of the soft parts of the thorax, and expiration is prolonged. The respiratory mur- ine;. 35.— SPASMODIC ASTHMA, ILLUSTRATING THE ACTION OF THE ACCESSORY RESPIRATORY MUSCLES AND THE DISTENTION OF THE LUNGS. inur is diminished, and the chest abounds in sibilant and sonorous rales ; wheezing may be heard at quite a distance from the patient. Cyanosis becomes pronounced if the attack is a prolonged one. The attacks may last from a few min- utes to an hour or more, and generally cease suddenly with a free secretion from the bronchial tubes ; they recur at in- tervals of days or weeks. DISEASES OF THE RESPIRATORY TRACT. 269 The catarrhal form is only the engrafting of the asthmatic element upon a pre-existing bronchitis or broncho-pneumonia, in individuals thus predisposed. At times these children are subject to pseudo-croup, the asthma seemingly taking the place of the former. During its entire course they are always more or less " wheezy." The diagnosis depends upon a recognition of the nervous element in the case — the spasmodic and paroxysmal nature of these attacks, together with the characteristic physical signs of the diseases, namely, dyspnoea, cyanosis, diminished respiratory murmur, loud sibilant and sonorous rales, vesiculo- tympanitic percussion-note. When bronchitis or broncho- pneumonia coexist, their signs must be discounted. Treatment. — The same hygienic measures recommended for bronchitis are applicable to overcome the tendency to recurr- ing attacks of asthma. All foci of local irritation in the naso-pharynx or elsewhere should receive prompt attention. Of equal importance, and in some cases the sine qua non for a cure, is the strict, systematic supervision of the diet of the patient. Exercise, personal hygiene and thorough ven- tilation of the sleeping apartment must be insisted upon. The remedies most useful to mitigate the attacks are Aeon., Ars., Ipecac and Nux vom.; beside these there are several others which are often prominently indicated. The interval requires constitutional treatment. The inhalation of a spray containing a few drops of the tincture of Ipecac acts as a palliative during attacks. In some cases it is necessary to burn Stramonium leaves in order to make the suffering endurable. Aeon, is recognized by its well-known mental condition, feverishness, etc.; neurotic cases. Apis. — When the attacks seemingly follow the recession of an urticaria, or alternate with the same. The chest feels bruised, and the attack ends with the expectoration of a large amount of frothy mucus and serum. It is a valuable remedy for the asthma of children. 270 DISEASES OF CHILDREN. Ars. — Paroxysms between midnight and daybreak ; must get out of bed ; great anguish and prostration ; broncho- pneumonia. Ars. jod. — Between the attacks. — (Bellvilxe.) Ipecac. — Wheezing ; constant cough, with subcrepitant rales all over chest ; no phlegm yields, although the chest seems full. Gagging and vomiting ; the child stiffens dur- ing the choking attacks ; cyanosis and coldness of extremi- ties. Lobelia. — In connection with disordered stomach ; weak- ness in pit of stomach ; attack preceded by prickling sensa- tion in extremities ; distressing tightness across upper portion of chest. Nux vom. — Asthma dyspepticum ; attacks in morning; irritability and constipation. Pulsatilla. — Cough, becoming dry toward night, with dyspnoea ; inability to lie down ; chilliness ; mild, tearful dis- position. Tart. emet. — Rattling of mucus in larger bronchial tubes, with wheezing, great dyspnoea, and threatened collapse. This is a most valuable remedy for the catarrhal form of asthma, when there is a large secretion of mucus, together with pronounced dyspnoea. ACUTE BRONCHO-PNEUMONIA. Broncho-pneumonia, also described as catarrhal and lobular pneumonia, is one of the most common diseases of childhood, presenting a mortality rate only exceeded by diarrhceal dis- eases, and being particularly prevalent before the fourth year of life. As the name indicates, it is a pneumonic process as- sociated with inflammation of the bronchial tubes, in reality an extension of the latter condition into the walls of the terminal bronchi and surrounding end alveoli. Etiology. — A primary and a secondary broncho-pneumonia are to be distinguished. Primarily broncho-pneumonia occurs with especial predilection in those debilitated by previous ill- DISEASES OF THE RESPIRATORY TRACT. 271 nesses, or in the rachitic and syphilitic. Atmospheric changes are the chief exciting cause, as the greater prevalence of this disease during the winter months and early spring clearly indicates. Primary broncho-pneumonia is rarely seen after the fourth year, being practically a disease of early childhood. Secondary broncho-pneumonia accompanies and compli- cates the acute infectious fevers, prominently the exanthe- mata, diphtheria, whooping-cough and influenza, a class of diseases in which bronchitis is a frequent accompaniment. The latest bacteriological researches indicate that primary broncho-pneumonia is nearly always due to the pneumococcus, while secondary broncho-pneumonia results from a mixed in- fection, in which the streptococci of suppuration play the most important role When complicating diphtheria the Klebs- Lbffler bacillus is the excitant of the pathological process. Pearce (Jour. Boston Soc. Med. Sciences, June, 1897) found in sixty-two cases of this class the Klebs-Loffler bacillus fifty- two times, the streptococcus pyogenes twenty-seven times, the staphylococcus pyogenes aureus eleven times, staphylo- coccus pyogenes albus once, pneumococcus once. In seven- teen cases the Klebs-Lofner bacillus occurred alone ; in seven the streptococcus pyogenes. In the other cases there was almost always a combination of these varieties, with, however, a pre- ponderance of the cocci. In summing up, he remarks that where a local or general infection existed the pneumonia was due to the same micro-organism, but where the condition was a chronic or non-infectious process it was generally due to the pneumococcus. The investigations of Prudden and North- rup (Amer. Jour. Med. Sciences, June, 1889), and those of Neuman (Jahrbuch fiir Kinderheilk., vol. xxx., 1889), and others practically lead to the same conclusions. In pure pneumococcus cases the temperature is generally uniformly high, while in those due to the streptococcus wide fluctua- tions in the fever are more likely to occur. The etiological relationship of influenza to broncho-pneu- 272 DISEASES OF CHILDREN. monia has been carefully studied by Prudden (Influenza and its Complicating Pneumonia, New York Med. Record, 1890) and Weichselbaum {Wiener Klin. Wochenschr., 1890). Pathology. — In the larger bronchi we encounter a super- ficial inflammation, while in the smaller tubes the entire wall shares in the pathological process, and we find here both bronchitis and peribronchitis The characteristic lesions are in the air vesicles, which in typical cases are distended with cellular exudation. The cells are mainly swollen, des- quamated epithelia with small nuclei. Red blood corpuscles and leucocytes are also found in variable number. Fibrin as a rule is scant ; often entirely absent. The fibrin in these cases is difficult to demonstrate, as the threads are rendered indistinct through the presence of a large number of leu- cocytes. (Zeigler.) In the alveolar septa and peribronchial connective tissue the blood vessels are distended with red blood corpuscles and these structures are infiltrated with large mononuclear leu- cocytes. Taking into consideration the above histological changes in the pulmonary tissue it is clear why resolution is slow and why often it is delayed, leading to permanent tissue changes. On account of the coexisting bronchitis in the finer tubes, it is clear also why in the presence of much mucous secretion suffocative symptoms may arise (capillary bronchitis). It may happen — and this is not uncommon during the sec- ond and third year of life — that a mixed form of pneumonia develops, in which one portion of the lung is the seat of typi- cal catarrhal and interstitial inflammation while another por- tion is consolidated by purely croupous exudation without involvement of the alveolar walls and peribronchial tissue. These cases pursue more closely the clinical course of broncho- pneumonia than lobar pneumonia, but it requires microscopic examination to recognize the true character of the lesions. Frequently small broncho-pneumonic areas representing consolidated alveoli may spread and become confluent, thus DISEASES OF THE RESPIRATORY TRACT. 273 invading an entire lobule and giving rise to a lobular pneu- monic process. These lobular areas are in the majority of cases separated by streaks of uninvaded lung tissue, /'. e. y lobules still pervious to air. An entire lobe may, however, become invaded, in which case we are confronted with a broncho-pneumonia of lobar distribution. (Zeigler.) The exudate in some instances is haemorrhagic in charac- ter. When resolution is delayed it frequently becomes puru- lent owing to the presence of a large number of leucocytes that have undergone degeneration. Although the inflammatory process may become general, as is the case in bronchitis, still pneumonia tends to localize itself, in this way differing from the former condition. A localized lesion, therefore, is either pneumonia or tubercu- losis, and rarely, if ever, bronchitis. Again, the temperature is higher and more persistent in pneumonia than in bron- chitis. As Holt points out, the term broncho-pneumonia is a gen- eric one. It is therefore impossible to describe the entire group by a single case, even though such a case present the leading features common to this group of pulmonary inflam- mation. Broncho-pneumonia on the one hand may abort in the early stage before consolidation can be detected and thus run the course of a severe bronchitis, while on the other it may assume the characteristics of a lobar pneumonia. Again, instead of undergoing resolution the inflammatory process may continue and interstitial pneumonia be the re- sult. The pathological findings are by no means uniform and as Delafield has pointed out the consolidated lobules may bear no definite relationship to the bronchus leading to them. The inflammation is diffuse in character, and lobule after lobule may become consolidated without its communicating bronchus being simultaneously involved. The inflammation therefore travels through contiguity of structure as well as by continuitv thereof. 274 DISEASES OF CHILDREN. In the early stage (red pneumonia) the lung is engorged and of an intense red color. On section, a bloody, frothy fluid exudes from the air cells. The bases are heavier and darker in color owing to hypostatic congestion. Consolida- tion has not yet taken place, but microscopic examination reveals cell-proliferation in the peri-bronchial connective tissue and septa and catarrhal and hsemorrhagic exudate in the alveoli. The process may abort here, prove fatal, or go over into the stage of mottled or red and gray pneumonia, representing the fully developed process. By this time the consolidated areas may be felt as small nodules in the pul- monary parenchyma. Both the surface and the sections pre- sent a mottled appearance due to the admixture of consoli- dated (gray) and congested (red) areas. The process may involve an entire lobe or appear only in patches dispersed through the otherwise normal lung tissue. Wherever a bronchus has become occluded areas of atelectasis are seen. Such areas correspond always to a bronchus, but consolidated lobules, as has been pointed out above, do not. If resolution be delayed or arrested^ the so-called gray pneu- monia is the result. In these cases the lung is somewhat en- larged, gray in color and extensively consolidated. Pleural thickening and adhesions are common. On section a muco- purulent exudate covers the cut surface. The bronchial walls and the interstitial tissue are hyperplastic and areas of atelectasis and compensatory and interstitial emphysema lie interspersed between the consolidated structure. In the cases that recover the termination is resolution through expectoration and resorption of the exudate ; in un- favorable cases suppuration ; interstitial induration ; gangrene. Resolution may begin before consolidation can be detected. Ordinarily it is completed in from two to three weeks. When delayed, there is a strong tendency to incompleteness of the process. In recurring attacks, permanent interstitial changes are produced as a rule. Tuberculosis may be engrafted upon a pneumonia secondarily. DISEASES OF THE RESPIRATORY TRACT. 275 The pleura shares in the inflammatory process when the lesions are superficial. Fibrinous and fibro-purulent exudate is poured out upon the surface of the visceral pleura with the consequent development of adhesions and thickening. In some instances the pleuritic process is of equal moment with the pulmonary ; these cases are described under a separate heading (see Pleuro-pneumonia). Symptomatology. — Primary broncho-pneumonia begins as a bronchitis in the majority of cases ; exceptionally the pulmonary changes develop at the same time or prior to, or even independently of, the former. Instead of advancing favorably as an uncomplicated bronchitis, there are added progressively increasing dyspnoea and rapid breathing, in- crease in fever and pulse-rate, and prostration. Some cases begin abruptly with high fever, rapid breathing and pronounced nervous disturbances (toxaemia). They may prove fatal before any signs of pulmonary inflammation have had time to develop ; even cough may be absent. At the autopsy the lungs are found intensely congested and more or less cedematous. In young infants broncho-pneumonia may come on insidi- ously, fever being slight during the entire course. The main symptoms are cough and progressively increasing cyanosis and rapid respirations. As a rule, gastro-intestinal symptoms accompany the pneumonia. The prognosis is grave. During the progress of the disease the child emaciates markedly and caibonization of the blood becomes apparent. The pulse is rapid and weak, and the heart may eventually fail in its work if the pulmonary obstruction be extensive. Cough is a prominent symptom, at first being dry and later becoming loose, although this by no means indicates that the child is gaining relief, for the secretion may be beyond its control, acting as a mechanical obstruction to the air-cells. The respiratory rhythm is changed in a characteristic man- ner, the recognition of which has always been to me a strong indication for pneumonia. Normally, inspiration and expira- 276 DISEASES OF CHILDREN. tion follow each other without interruption, after which comes a pause. In broncho-pneumonia inspiration is sepa- rated from the expiratory act by a well-marked pause, with no pause, however, between the expiration and inspiration. The reason for this change in rhythm is undoubtedly to bring the inspired air in contact with the pulmonary tissue as long as possible in order to overcome the carbonization of the blood ; therefore the child rests rather before expiration than after it, no time being lost, thereby, to draw in a fresh supply of oxygen. Respiration is often accompanied by fan-like movements of the alse nasi and recession of the soft parts of the thorax, notably its lower portion, producing the peri-pneumonic groove of Harrison. When broncho-pneumonia develops during the course of one of the infectious fevers as a complication, it is to be sus- pected from an increase in the fever; increased rapidity of breathing and pulse-rate ; cough and dyspnoea, especially the latter. Broncho-pneumonia tends to localize itself in certain areas of the lungs, in this way differing from simple bronchitis in which the process is general. General bronchitis, however, may accompany pneumonia. In the absence of definite signs of consolidation, the height and duration of the fever may be taken into consideration. The statement Cabot makes about broncho-pneumonia in the adnlt, namely, that the patient is too sick to have simply bronchitis, applies with equal force to children. Broncho-pneumonia is progressive in its development, be- ing slower both in its onset and in the formation and resolu- tion of its pathologic products than lobar pneumonia. Its course sometimes extends over several weeks, and the ten- dency to chronicity is strong, especially in the scrofulous and tuberculous. Meningeal symptoms are of common occurrence in the dis- ease, sometimes being toxaemic in origin, at other times result- DISEASES OF THE RESPIRATORY TRACT. 277 ing from an active congestion of the meninges with serous effusion into the arachnoidal spaces. Here there is always hyperpyrexia and a very rapid course, and rachitic subjects seem most prone to develop this complication. Actual men- ingitis from infection of the brain with pneumococci is by no means rare. I have found it more frequently after broncho- pneumonia than after the lobar form. Death results from respiratory or cardiac failure ; some- times from hyperpyrexia. Collapse is the commonest ter- mination, although convulsions may appear to close the sceue. The fulminating cases undoubtedly die from toxaemia. The prognosis must always be guarded, as can be seen from the high mortality rate ; it is especially grave when the child is very young and debilitated, or when the disease is secondary to a condition in itself dangerous. The pulse and respiration are the main indications of the child's condition, 3nd although a high temperature is a bad omen, still it is not necessarily so unless it is continuous and proves itself beyond control. Rickets seems especially likely to invite hyperpyrexia. The soft condition of the chest-wall in rickets makes breathing very difficult in pneumonia and rachitic children stand the disease badly. A grunting expiration is said to indicate atelectasis, but it is not necessarily a bad symptom, unless very pronounced and persistent. The cough is also a guide to prognosis ; if it be- comes weak and inefficient we must expect gradual suffoca- tion, unless the exudation can be absorbed. Children in whom the tuberculous diathesis is well marked are liable to the most serious consequences from an attack of broncho-pneumonia. An ordinary broncho-pneumonia will become tedious ; the temperature remits, leading us to suspect a possible malarial condition, but the case conti- nues, in spite of our best-directed efforts, toward a fatal termination. Primary tuberculous broncho-pneumonia is of slower onset and the temperature seems out of proportion to the physical signs that can be elicited. Besides, the tubercle 278 DISEASES OF CHILDREN. bacillus can be demonstrated in these cases. As infection generally spreads from the bronchial glands, the presence of subcrepitant rales localized in the region of the nipple on either side indicate the presence of lesions of this nature and offer strong presumptive evidence of tuberculosis. (Holt.) Diagnosis. — The physical signs are those of both bron- chitis of the larger and smaller tubes, together with consoli- dation of scattered areas of pulmonary tissue of varying size and extent. They are best studied posteriorly, the child be. ing held over the nurse's shoulder. Large and small moist rales ; subcrepitant rales ; tubular breathing and dullness over the consolidated areas large enough to convey these signs ; diminished breathing over areas of atelectasis, and ex- aggerated breathing in the vicariously emphysematous lung are to be elicited. However, the irregular fever, dyspnoea, alteration in the respiratory rhythm and cough, and the de- tection of subcrepitant rales and areas of tubular breathing are usually quite sufficient, and often the only available signs upon which the diagnosis can be made. From croupous pneumoiiia it is distinguished by its gradual onset, tedious course, bilateral distribution, and its occurrence in the very young and in the feeble, croupous pneumonia at- tacking those in apparently good health and of maturer age. The differentiation from tuberculosis has been given above. In capillary bronchitis there are fine moist rales generally dis- tributed throughout the chest. There is, however, no sharp line of demarcation between the pathology of the two affec- tions. Treatment. — The child should be put to bed, and its posi- tion changed regularly to avoid adding hypostatic congestion to the already seriously crippled condition of the lungs. In- fants can be taken up by the nurse during coughing parox- ysms and held face downwards or on the side to facilitate the expulsion of the phlegm. The room must be faithfully ven- tilated, and a temperature of about yo° F., or slightly lower, is to be maintained. Beside this, it is essential to keep the DISEASES OF THE RESPIRATORY TRACT. 279 air moist in the immediate vicinity of the child, which is best accomplished by means of the croup-kettle or steam spiay and a tent improvised over the bed. Ordinarily, the fever is within the control of remedies and sponge-baths ; indeed, an alcohol sponge-bath (one part alco- hol to three parts of water) has a most decided effect upon the temperature, rapidly bringing it down to within a safe limit, at which point it is maintained for an hour or more. In fulminating cases, or such as do not respond to the above treatment, the graduated cold, full bath will be required. This is often a life-saver, not only reducing high temperature but also relieving pulmonary congestion and acting in a de- cidedly stimulating manner upon the heart and respiratory centres. When carbonization of the blood becomes manifest and the bronchial tubes become clogged with secretion, the alternate application of hot and cold packs to the chest should be resorted to. This is a most powerful respiratory stimulant besides acting as a derivative and relieving pul- monary engorgement. Oxygen inhalations should never be neglected in serious cases. The mistake is to look upon oxygen merely as a dernier ressort ; given in time, however, it is a powerful agent to save life. I give from one to two gallons (bagfuls) every hour, administered by holding a glass funnel attached to the tube from the water-bottle of the apparatus over the child's mouth and nose. I prefer this to a mask or inserting a glass tube into the nostril. Plain woolen underwear, the weight conforming to the time of year, is all that is necessary to protect the chest, which, witli the rest of the body, should be regularly sponged. Stimulants can rarely be dispensed with, and they will be called for during certain periods in all bad cases. Above all, every effort must be made to keep up the nutrition of these little patients. The remedies most frequently indicated in the early stages are Aeon., Hell., Bry, t Ferrum pJws., Ipecac and Scilla; for 280 DISEASES OF CHILDREN. the later manifestations, especially the unfavorable symptoms likely to arise, Tartar emetic, Phos., Arsen., Car bo veg. and Veratrum alb. are called for. Aconite should always be studied in comparison with Ver- atrum viride and Ferrum phos. All three are indicated early in the disease, when there is high fever and a teasing cough, with little or no expectoration — the stage of congestion. Aconite is distinguished by its great anxiety and restlessness, thirst, and aversion to being touched or moved, which in- duces suffering ; Veratrum viride by its high arterial tension, bloodshot eyes and cerebral irritation ; Ferrum phos. by the absence of either nervous erethism or high arterial tension and by its characteristic frothy, blood-streaked expectoration. It is particularly applicable to the rachitic diathesis. Arsenicum is indicated by extreme prostration and rest- lessness ; dyspnoea from the slightest exertion ; thirst for small quantities of water, the mouth being dry and the tongue and lips cracked ; diarrhoea ; cold surface. Belladonna is particularly valuable when nervous disturb- ances are pronounced. Its excellent effect in capillary bron- chitis makes us think of it in pneumonia when the bronchial symptoms predominate. In oedema of the lungs Atropia is the sheet anchor. Belladonna is exquisitely homoeopathic to the vascular engorgement and high temperature so prominent in many cases. Bryonia is of the greatest service to loosen the cough, con- trol pain, and check the extension of the process into the smaller tubes and promote the absorption of the exudation. It must be differentiated fiom Scilla, which is similar in many respects, but more suitable to grave cases marked by progressively-increasing prostration and dyspnoea ; rapid, weak pulse; short, painful cough, causing the child to cry faintly after each paroxysm ; in fact, it cannot be moved without giving it pain. In my experience, the younger the child, the more efficacious has been this remedy. Hale {Prac- tice of Medicine) considers Scilla the remedy above all others DISEASES OF THE RESPIRATORY TRACT. 281 after Aconite and Belladonna, being in every respect homoeo- pathic to broncho-pneumonia. Chelidoninm is recommended where the right side is chiefly affected, with associated hepatic disturbances. It has the fan- like motion of the alse nasi so strongly indicative of Lycopo- dinm. Personally I have no experience with it. Dr. Bigler considered Chelidoninm very useful in capillary bronchitis. It was recommended by Teste as a specific. Gelsemium. — Broncho-pneumonia complicating influenza ; after sudden checking of perspiration; pain under scapulae; drowsiness; soft, rapid pulse. Ipecac, is the remedy where the bronchial element predom- inates and the chest seems literally filled with mucous secre- tion, subcrepitant rales being heard everywhere in abundance. The cough is troublesome and gagging, giving little relief. The secretion gradually collects to such an extent in the finer bronchi that suffocation becomes imminent. Here it differs from Tartar emetic, which represents a state of carbonic acid poisoning, in which mucus, collecting in the larger tubes, pro- duces the characteristic rattling, or in which there is active pulmonary oedema. Lycopodium is useful in broncho-pneumonia, its particular sphere being, so to speak, a u choked-up ,, condition of the entire respiratory tract. The nose is obstructed ; the alse nasi expand with each inspiration, which is often a purely sympathetic condition, not dependent upon marked dyspnoea. The cough is dry day and night, a few moist rales and some wheezing being heard over the sternum ; swelling of the mucous membrane of the bronchi seems to predominate over secretion. Likewise the lungs may be much involved, with- out, however, much cough or secretion. The child is peevish and irritable, especially on awaking from sleep; the urine is scanty and deep red. and when passed often induces crying; all symptoms are worse in the afternoon and early evening. Phosphorus. — Where consolidation predominates over the bronchial symptoms, together with active congestion, produc- 19 282 DISEASES OF CHILDREN. ing a tight, distressing cough; rapid, shallow respirations; tightness across the upper portion of the chest; blood-tinged expectoration ; failing right heart. We are inclined to think of Phosphorus only in lobar pneumonia, but it is of equal value in the lobular variety when we have to deal with con- gestion, consolidation and toxaemia; in fact, the old school has for a long time prescribed Phosphorus as a nerve tonic in the adynamia of pneumonia. Sulphur is similar to Phosphorus in respect to the consoli- dation, but it has a greater power of removing the same, Phosphorus mainly controls the vascular disturbance (unless pushed to produce fatty degeneration of the inflammatory products, which is not without danger). It is indicated in the later stages of broncho-pneumonia. Tuberculin (Koch) has been highly recommended for bron- cho-pneumonia. Dr. Mersch {Jour. Beige cPHom., 1894 and 1895) reports several cases in which relief was rapidly ob- tained from the sixth dilution. Dr. Arnulphy {Clinique, Feb., 1896) makes strong claims for the efficacy of Tuberculin in broncho-pneumonia, placing it above such remedies as Ipecac. , Iodine, Tartar emetic and Phosphorus, Bacillinum (Burnett) is recommended by Cartier {Traits. Internal. Horn. Cougr., 1896) in respiratory affections characterized by oppression and muco-purulent expectoration; the dyspnoea results from pul- monary obstruction, caused by excessive secretion in the bronchi In his opinion, these cases are non-tuberculous. He recommends the thirtieth potency, one dose every two to three days. Aviare, or Avian tuberculin, he has found use- ful in broncho-pneumonia following influenza and measles, accompanied by an incessant tickling cough, with closely localized pulmonary symptoms and emaciation — suspicious bronchitis — which causes apprehension of tuberculosis. Per- sonally I have no experience with these products. It has seemed to me unnecessary to call upon such uncertain agents in the face of the all-sufficient array of well proven and veri- ified remedies at our disposal. It is true, in tuberculosis a DISEASES OF THE RESPIRATORY TRACT. 283 serum may yet be prepared that will give positive results, but so far there is nothing absolutely certain with which I am ac- quainted. CROUPOUS PNEUMONIA. Croupous, or lobar pneumonia, is a primary acute infectious disease in which one or more of the pulmonary lobes are con- solidated by a croupous exudation. Bronchitis may be asso- ciated, but it is not an essential condition as in broncho-pneu- monia ; besides the infection arises, so far as can be deter- mined, primarily within the alveoli, being due to a specific micro-organism. Etiology. — Croupous pneumonia is most frequently seen after the third year, and usually attacks those of previously good health, unlike broncho-pneumonia, which attacks with predilection those already debilitated or develops in conjunc- tion with the acute infectious diseases. Exhaustion and ex- posure to cold act prominently as predisposing causes, for which reason genuine pneumonia is often seen to follow upon active play in cold weather when boys are likely to become overheated or become chilled from neglecting to dress prop- erly. While the dry, cold months, particularly the early spring, furnish the largest number of victims, still pneumonia may be seen at any time of the year, like all other infectious diseases. Boys are more often attacked than girls, no doubt because they expose themselves more than the latter. The sputum of pneumonia patients was long known to contain micro-organisms in abundance, but it was not until Fraenkel, in 1886, demonstrated the lance-shaped diplococ- cus named after him that the specific cause of the infection became established. Since then, however, it has been proven that other micro-organisms also may set up croupous inflam- mation in a pulmonary lobe or portion thereof. They are notably the pneumobacillus of Friedlander, the influenza bacillus, the typhoid bacillus and the staphylococcus and streptococcus. I have encountered the typhoid bacillus prac- 284 DISEASES OF CHILDREN. tically in pure culture in a case of pneumonia complicating typhoid fever. The influenza bacillus may associate itself with the pneumococcus and render the course of the disease more virulent and irregular. Jousset {Revue Horn. Francaise, June, 1 901) has contributed most interesting observations to the literature of this subject. The pneumococcus is found in great abundance in the alveolar exudate and may enter the general blood current, setting up a septico-pyema or localized complications, notably pleural, meningeal and peritoneal inflammation. Pathology. — In typical cases of croupous pneumonia one lobe is affected throughout its entirety. The most frequently consolidated lobe is the left lower; next in frequency come the right lower and the right upper lobes. The right mid- dle and the left upper are least often attacked. More or less plastic pleurisy is always associated, as is also bronchitis of the larger tubes. Membranous bronchitis seems at times to be due to the pneumococcus ; I have seen it asso- ciated with pneumonia in one instance. When the left lower lobe is affected and the pleura is involved the process may spread to the pericardium. The pleural inflammation may become so prominent as to influence notably the clinical course of the disease. At the onset of pneumonia, the stage of engorgement, the affected lobe is bright red, greatly congested and somewhat cedematous. The lung appears enlarged, as if inflated, and when the inflammatory exudate tills the alveoli and solidifies* the consolidated lobe is actually larger than normal, for which reason the area of d illness elicited by percussion may be of greater extent than the lobe normally occupies. On microscopic examination the alveoli appear engorged, the bloodvessels encroaching upon the lumen of the same. A small amount of serum and leucocytes is now poured out, the exudation becoming more and more rich in cells and fibrin and more hemorrhagic in character. It is at this time that the crepitant rale is most clearly heard. The alveoli eventu- DISEASES OF THE RESPIRATORY TRACT. 285 ally are distended to their utmost with red and white blood corpuscles and micrococci embedded in a stroma of fibrin. The fibrin also fills the lymphatics in the interstitial connect- ive tissue, and it can be seen communicating by thin bands through the pores of the alveoli. This period represents the stage of red hepatization. The color of the lung gradually passes from red over into gray, owing to the compression of the bloodvessels of the al- veoli by the exudate and to the degeneration of the cellular elements. This represents the stage of gray hepatization. The exudate is now gradually removed by the lymphatics, some being expectorated after having undergone softening, and resolution is in progress. In normal cases resolution is complete and the lung is restored to its former condition. During consolidation the lung is quite friable and cuts like liver. On the surface of the section small plugs of hardened fibrin filling the alveoli and independent therefrom are seen, giving it a granular appearance. In children this does not show as typically as in adults, owing to the lesser develop- ment of the air cells. At times, owing to a gradual spread of the process, all stages, that is, red and gray hepatization and beginning resolution, may be encountered in a cut of a single lobe. When resolution is delayed it may terminate in suppura- tion with abscess formation, gangrene, caseation. Complete recovery is, however, the rule, excepting in cases complicated with pleural inflammation, in which it is quite common for an empyema to develop secondarily. Symptomatology. — The onset of croupous pneumonia is rapid, and the course of the disease is characterized by its acuteness throughout; sudden onset, high temperature, with but slight remissions and terminating within from six to eight days by crisis, are the features of a typical case (Fig. 36). The initial symptom is characteristically a chill, which may be replaced by a convulsion in young children ; sometimes vomiting is the sole symptom. The temperature rises rapidly, 286 DISEASES OF CHILDREN. soon reaching a height of 104 or over ; the pulse is rapid and full, and the respirations are notably increased, exceeding the normal ratio between pulse and respiration. Thus, with a pulse of 130 there will be 60 or more respirations, while the normal ratio is one respiration to four heartbeats. The temperature ranges between 102. 5 and 104 F. or over. Remissions are more pronounced than in adults. Associated with the fever there is restlessness; dry, hot skin ; headache and some delirium toward night, and a dry, DayqfDia / FIG. 36. — TEMPERATURE CURVE IN A TYPICAL CASE OF EOBAR-PNEUMONIA, SHOWING PSEUDO-CRISIS. painful cough. Especially when there is considerable in- volvement of the pleura does this painful cough become con- spicuous, it being very sharp and located at the seat of the in- flammation. At times the pain is referred to the epigastrium, in which case it is due to irritation of the intercostal nerves, or it may indicate a complicating pleurisy or pericarditis. Pain in the right iliac region may also be complained of in pneumonia of the right base. When a child complains of DISEASES OF THE RESPIRATORY TRACT. 287 abdominal pain during the course of a febrile attack we should never neglect to thoroughly examine the chest. Within from two to four days the process of consolidation is generally complete, as can be demonstrated by the dulness and bronchial breathing observed over the affected area. With the crisis, which may appear on any day from the fifth to the ninth, oftenest, however, on the seventh day, there is a marked amelioration of all symptoms. A profuse sweat ac- companies this sudden fall in temperature, and at times, in- FIG. 37.— TEMPERATURE CHART OF A CASE OF REMITTING PNEUMONIA. deed, there occur quite alarming symptoms of collapse, calling for immediate action. After the crisis the process of resolu- tion becomes established, being completed in from five days to a week in the average case. I have seen every evidence of dulness and bronchial breathing disappear within three days after the crisis. A rise of temperature during this time— in other words, a post-critical rise — indicates the development of some complication, such as pleurisy, empyema, meningitis, pericarditis or the extension of the pneumonic process to 288 DISEASES OF CHILDREN. other portions of the lungs. A pseudo-crisis is common in children. It may occur as early as the second day, more commonly one or two days before the actual crisis. Termi- nation by lysis is more common in children than in adults. Marked remissions in the temperature are also more common in children than in adults. When pronounced these cases are described as remittent pneumonia (Fig. 37). The blood changes are important. While there is but a slight anaemia, leucocytosis develops to a marked degree. A pronounced leucocytosis indicates a severe infection in an or- ganism capable of good reaction (Da Costa). Leucocytosis offers a strong sign of differential diagnosis between pneu- monia and such conditions as acute typhoid septicaemia, case- ous pulmonary tuberculosis and serous pleurisy, it being ab- sent in these conditions. It is of no value, however, in the differentiation of croupous pneumonia from broncho-pneu- monia, empyema and meningitis (Da Costa). Many severe cases of pneumonia present so different a clin- ical picture from the group of symptoms above enumerated that they merit separate description, being classified into the following varieties : Cerebral pneumonia. — This form is characterized by rapid onset with high fever, convulsions or vomiting, and a pre- dominance of cerebral symptoms during the entire course of the disease. In other words, it is essentially a manifestation of pronounced toxaemia. In children over two years convul- sions are not so common, these cases assuming more of a typhoid state, there being stupor, delirium, dry, brown tongue, involuntary stools. Symptoms simulating meningitis, such as sopor, strabismus, opisthotonos, slow, irregular pulse, re- tracted abdomen, dilated pupils, convulsions, are a frequent accompaniment of pneumonia, and there seems to be a close clinical relationship between pneumonia of the upper lobes and cerebral symptoms, notwithstanding that this is disputed by some competent observers. The pneumonic process is slow to develop in many cases, and often the consolidation DISEASES OF THE RESPIRATORY TRACT. 289 cannot be detected until four or five days after the onset, having begun centrally ; for this reason it may be confounded with meningitis. The writer recalls a case of croupous pneu- monia occurring in a child five years old which was diagnosed as meningitis by a most expert clinician until the detection of dullness and bronchial breathing in the right upper lobe on the fifth day, together with a disappearance of all serious symptoms by crisis on the seventh day, made it possible to recognize the true nature of the case. That these symptoms are toxic in nature there is little reason to doubt, but the possibility of a true purulent meningitis developing must never be lost sight of. This seldom, however, develops dur- ing the height of the pneumonia, a return of the fever with cerebral disturbance after the crisis being more likely to prove of serious import than the earlier manifestations. Another form of pneumonia worthy of mention is the so- called wandering pneumonia, in which the pneumonic pro- cess spreads from its original seat to other portions of the lung, resolution going on at one point while a fresh invasion attacks another. Central pneumonia is of especial interest from the diag- nostic standpoint, as in these cases the process begins in the centre of a lobe, gradually spreading to the periphery. It is a patent fact that they cannot be recognized until there is sufficient consolidation to produce physical signs, and are fre- quently overlooked for this reason. Grave symptoms may exist with but a slight amount of consolidation, the toxaemia being entirely out of proportion to the existing lesion. Pneumonia with Gastro-intestinal Symptoms. — Gaillard has shown that the enteric symptoms of pneumonia are due to the pneumococcus. Toxaemia, however, contributes its share in the production of pronounced gastro-intestinal de- rangements. I have on several occasions wrongly suspected intestinal auto-intoxication when the subsequent appearance of pulmonary signs and a crisis with amelioration of symp- toms cleared up the case. 290 DISEASES OF CHILDREN. Influenzal pneumonia may be either due to the PfeifTer bacillus or result from secondary infection with the pneumo- coccus. These cases begin as an influenzal bronchitis, during the course of which one or more pulmonary lobes become con- solidated. The course is graver and more protracted than simple pneumonia. It is also liable to be followed by tuber- culosis. Abortive pneumonia is rare in children. Cases are en- countered which terminate in from four to five days ; they might be called mild cases. Again, the process may not go beyond the first stage, and although congestion of a single lobe and pneumococci in the sputum can be demonstrated, consolidation fails to take place, the process actually abort- ing, as other acute infections sometimes do. It is needless to say that the diagnosis is beset with great difficulty. There are also fulminating cases, terminating fatally in the first days. Typhoid-pneumonia. — This misleading term refers to those forms of pneumonia in which the patient sinks into a typhoid state as the result of toxaemia. Instead of active brain symp- toms being present as in cerebral pneumonia there is apathy and prostration ; dry, coated tongue ; tympanites with either obstinate constipation or diarrhoea ; involuntary stools ; mut- tering delirium ; subsultus tendinum. Rose-spots, enlarged spleen and Widal reaction are negative. Typhoid fever, how- ever, may begin as a pneumonia ; in these cases a diagnosis can only be made when the last mentioned signs put in an appearance. In doubtful cases blood cultures should be made. Pleuro-pneumonia is a form sufficiently distinct to merit separate discussion. Complications. — A certain degree of pleurisy belongs to pneumonia. Pletu-al effusions, both serous and purulent, are, more strictly speaking, sequelae ; they are much more com- mon in children than in adults. Otitis is common ; it always produces an increase in and prolongation of the fever ; not DISEASES OF THE RESPIRATORY TRACT. 291 necessarily pain. Meningitis is more likely to occur after the critical period ; cerebral symptoms at the height of pneu- monia are usually toxic and do not persist. Pericarditis is a grave complication ; I have several times encountered it at the autopsy. It is seldom recognized in vitam. Other com- plications that may develop are endocarditis, peritonitis, gas- troenteritis, arthritis, septico-pyaemia. Physical Signs. — The physical signs in lobar pneumonia vary with the different stages of the pathological process. The duration, clinical course and complications also modify these signs as well as the age of the child (anatomical pecu- liarities). In Xhe. first stage inspection reveals a flushed countenance ; rapid, shallow respiration and more or less pronounced dysp- noea. When the pleura is much involved the child turns over on the affected side. Dyspnoea may even progress to cyanosis ; retraction of the supra-clavicular and supra-sternal regions ; recession of Harrison's groove ; fan-like motion of the alse nasi. On palpation the skin will be found hot and dry. The pulse is full and rapid. Vocal fremitus is not increased but coarse bronchial rales may be detected. Percussion reveals dull tympany. This can be nicely dem- onstrated in children by gentle percussion as the chest- wall is still resilient. We are dependent upon auscultation for a pathognomonic sign. This is the snbcrepitant rale — a fine, crackling sound, produced at the end of inspiration by the separation of the walls of the air cells which at this stage contain a sticky exudate. As these rales may remain confined to a limited area and disappear after several hours, they are readily over- looked. Friction rales, pleural in origin, are frequently heard. An interesting observation has been made by Shaw {Archives of Pediatrics, Aug., 1903), who found that the crepitant rale and friction sounds can be distinctly heard over the abdomen when the lower lobes are affected. 292 DISEASES OF CHILDREN. Second Stage. — With the completion of consolidation vocal fremitus is increased over the affected lobe and percussion dullness becomes pronounced. The area of dulness apparently covers a larger area than the anatomical boundaries of the lobe allow for. This is explained by the fact that the croup- ous process distends and enlarges the lobe. When pleural effusion takes place the lower portion of the dull area be- FIG. 38. — LOBAR-PNEUMONIA IN A CHILD FOUR YEARS OLD. THE DULL AREA IS OUTLINED AND CORRESPONDS TO THE LEFT LOWER LOBE. AT (x) FRICTION SOUNDS ARE HEARD; AT (O) BRONCHIAL BREATHING AND BRONCOPHONV. comes flat. It is not uncommon to hear friction sounds in the lower part of the chest, posteriorly and laterally, in pneu- monia in this region. The adjoining normal lung, through compensatory emphysema, may give the vesiculotympanitic note. Auscultation reveals bronchial breathing and bronchophony. DISEASES OF THE RESPIRATORY TRACT. 293 The respiratory murmur in trie unaffected lung is harsh and loud, often greatly interfering with a proper study of the con- solidated area. It is undoubtedly more difficult to outline an area giving bronchial breathing in the child than in the adult. Third Stage. — As resolution sets in and the exudation be- gins to soften, crepitation reappears {crepitatio redux). Moist rales are usually added and considerable of the exudate is coughed up. Bronchial breathing persists longer than actual consolidation ; so also dulness. This is no doubt due to the congested state of the pulmonary tissue. For this reason it is possible to demonstrate abnormal physical signs for a week or longer after the crisis. We must, however, regard with suspicion the persistence of pronounced dulness and dimin- ished or absent respiratory murmur after pneumonia. Such a condition on closer investigation will be found to indicate most likely a sacculated empyema. The physical signs of pleitro-pneumonia are described under that affection. Prognosis. — In infants the prognosis is unfavorable. Ro- bust children from three to ten years old recover as a rule. In fact, the mortality rate at this period of life is surprisingly low. The season of the year and the nature of the epidemic affect the prognosis. The association of influenza is unfav- orable. Of primary importance in gauging the prognosis is the de- gree of toxaemia. This seems more important than the ex- tent of the pulmonary involvement or the height of the fever. Naturally, the spread of the disease to adjacent portions of the lung is unfavorable. The heart holds out better than in the adult because the child's circulatory apparatus can adapt itself to increased circulatory obstruction better than the adult's. The association of bronchitis, however, adds materi- ally to the danger of the attack. Pronounced cerebral symp- toms are also grave. The majority of deaths occur at the height of the disease. 294 DISEASES OF CHILDREN. When death occurs later it is the result of one of the above mentioned complications. Diagnosis. — Whenever we are confronted with an acute condition of sudden onset with high fever preceded either by a chill, vomiting or a convulsion, we should first examine the throat. Finding nothing specific here it behooves us to examine the chest most thoroughly. It may be that at this early stage we may discover sub- crepitant rales in one of the bases or in the right upper lobe and possibly a friction sound. The following day, together with a continuance of the high temperature and in older chil- dren the complaint of intense headache and pain in the side or epigastrium, we will find the evidences of beginning pul- monary consolidation. Even should we not be able to dem- onstrate the physical signs, as in central pneumonia (rare), still, the sudden disappearance of all symptoms at the end of a week or less justifies us in diagnosing pneumonia. The conditions from which genuine pneumonia is to be differentiated are broncho-pneumonia, pleurisy, meningitis and caseous tuberculosis. I will not again go over the symptoms deciding the diagnosis. Suffice it to say, broncho-pneumonia is essentially bronchial in origin, both etiologically and patho- logically, and that its course is long and protracted, independ- ent of complications. In pleurisy the physical signs are essentially different and the onset gradual. The fever is not so high and terminates by lysis. Besides, primary pleurisy with effusion is rare in children, but pleuritic inflammation and the exudation secondary to pneumonia is common. In meningitis symptoms are continuous and protracted. Death is practically always the termination excepting in the epidemic cerebro-spinal variety. Meningitis complicating pneumonia occurs in the later stages of the disease ; cerebral symptoms occurring at the height of pneumonia are toxic and disappear by crisis or even before the crisis. Besides, they never attain the character of a true progressing menin- gitis. DISEASES OF THE RESPIRATORY TRACT. 295 Typhoid fever beginning abruptly may cause confusion. The absence of leucocytosis and the later appearance of rose spots, the Widal reaction and enlarged spleen positively identi- fies it. Acute caseous pulmonary tuberculosis may set in with a chill and uniformly consolidate an entire pulmonary lobe within a remarkably short time. The temperature will run high and the entire clinical picture be identical with that of croupous pneumonia. Crisis does not occur, however, and eventually softening and break down of pulmonary tissue sets in. Elastic fibres and tubercle bacilli are to be detected in the sputum at this time, confirming the diagnosis. The most experienced are deceived, however, in the early stage of such a case. PLEUROPNEUMONIA. In a certain number of cases of pneumonia (6.8 per cent, in Holt's series of 398) pleurisy exists at the same time with the pneumonic process and to such an extent as to give the condition distinct clinical features. The pleural inflamma- tion is chiefly plastic in nature and the amount of serum poured out is relatively slight ; never to the extent seen in a primary pleurisy. At the autopsy we will find the pleural surfaces matted together and covered with a thick, yellow, plast'c exudate that can be readily scraped off and from the interstices of which turbid serum exudes. The surface of the entire lung on one side may be covered with this exudate even though only one lobe be consolidated. The changes in the lung are not necessarily lobar ; indeed, the broncho-pneumonic type of lesions is more frequently associated than purely croupous inflammation. If the disease has a chance to progress it terminates in em- pyema and as a rule, owing to the adhesions that develop, sacculated empyema results. The majority of cases prove fatal at the height of the dis- ease. In the first stage there is every evidence of an on-com- 296 DISEASES OF CHILDREN. ing pneumonia, together with severe pain in the side and the physical signs of pleurisy. Friction sounds are plainly heard and in the course of a few days distinct dulness, bronchial breathing and broncophony can be detected. These latter signs are somewhat obscured by the thick fibrinous layer, but never to the extent that an effusion would produce. Aspira- tion is negative, as a rule. An exact diagnosis is at times impossible, but the symptoms are too severe for a simple pleurisy and too indistinct for a pure pneumonia. When effusion develops, in left sided cases, the heart becomes dis- placed. Extension of the line of dulness beyond the mid- sternal line is also strong evidence of pleural effusion. The prognosis is unfavorable as the pathological findings would naturally indicate. The younger the child, the worse the prognosis. Pericarditis is a common complication. Cases that survive must go through the course of an empyema with possibly severe crippling of the lung. When the pro- cess remains localized and abates in time, perfect recovery, barring some adhesions, is possible. Treatment. — The treatment of croupous pneumonia is es- sentially the same as that recommended for broncho-pneu- monia. Nevertheless there are certain remedies which are especially related to croupous exudations, in contradistinction to those of a purely catarrhal type, and they will, therefore, be called for here. Thus, Ipecac and Tartar emetic are less frequently indicated than Bryonia and Sulphur. In the early stages Aconite is by far the most useful drug. Iodine is recommended by Kafka {Homoeopatische Therapie) as being truly homoeopathic to the croupous exudation, as well as to most of the symptoms. The Iodide of Potash he considers more valuable in apex pneumonia, especially when there is a tuberculous tendency. The high fever and cerebral symptoms will call for Bella- donna or Veratrum viride. Tartar emetic and Bryonia hold the first place in pleuro- pneumonia. DISEASES OF THE RESPIRATORY TRACT. 297 Although Phosphorus is more useful in broncho-pneumonia than in croupous pneumonia, still it is of the greatest service where there is marked congestion indicated by dyspnoea ; tightness across the upper portion of the chest; bloody ex- pectoration ; failing right heart and profound toxaemia. Sulphur is one of the most useful absorbents in the Materia Medica, being especially useful in the third stage of pneu- monia. It is recommended by Bidherr when exudation sets in, indicated by the appearance of the crepitant rale. Arsenicum is well suited to those atypical cases of severe grade, in which the poison of influenza is added to that of pneumonia. In the presence of abundant bronchial secretion with dyspnoea and cardiac weakness, the Iodide of Arsenic is preferable. Special symptoms are to be dealt with precisely as directed under Broncho-pneumonia. PULMONARY TUBERCULOSIS. Tuberculosis of the lungs during childhood manifests itself in a variety of forms, each depending upon the nature of the pathological findings for its clinical characteristics. Further- more, it may be a primary or a secondary condition, and as- sume either an acute or a chronic course. The different varie- ties are: i. Miliary Tuberculosis; 2. Caseous Pulmonary Tuberculosis ; 3. Fibro-Caseous, or Chronic Pulmonary Tuber- culosis. A fourth variety frequently encountered in adults namely, fibroid tuberculosis of the lungs, is so rare during childhood that it need not be considered specially. Tubercu- losis is separately discussed in the chapter on "Diathetic Diseases," to which the reader is referred for details regard- ing the factors concerned in the etiology of the disease as well as the bacteriology and pathology of the tuberculous in- fections. I. Miliary Tuberculosis. — Diffuse miliary tuberculosis of the lungs may occur primarily, in which case it runs the course of general tuberculosis described as the "pulmonary 20 298 DISEASES OF CHILDREN. type" (see article upon "Tuberculosis"). In these cases the bacillus gains entrance into the lungs either through the bronchial glands or by means of the general circulation. In the latter instance the infection arises from a local focus in some other portion of the body, e. g., a tuberculous joint af- fection. It may also be the terminal event of a chronic pul- monary tuberculosis, as a result of the discharge of the con- tents of a brokendown caseous mass into a bloodvessel, usu- ally a branch of the pulmonary vein (Weigert). The form arising from bronchial gland infection is the type encountered during infancy. It is hardly probable that pulmonary infec- tion through the lymphatic system from a primary tubercu- lous lesion in the intestines ever takes place. II. Caseous Pulmonary Tuberculosis, also described as acute and subacute pneumonic phthisis ("galloping consump- tion "), is the form of pulmonary tuberculosis belonging to the period of childhood, in contradistinction to the infantile form described above. It is much moie common than the chronic form, which, indeed, is rare in young children. Fre- quently it is engrafted upon a broncho-pneumonia, or occurs as a sequel to measles, whooping-cough or influenza. As a predisposing factor the tuberculous diathesis plays a most im- portant role, no doubt more so than during infancy, when ex- posure to infection, either atmospheric or through the food, is liable to result in the development of the disease even in a healthy babe. Any illness capable of undermining the health and lowering the child's resisting power will also predispose to tuberculosis, even in the absence of a tuberculous family history. The pathological changes in the lungs are either a diffuse pneumonic process which represents the lobar type and is rare, or a disseminated process representing the broncho- pneumonic type. This is the one usually encountered. We find isolated areas of consolidation, generally in the apical region, but not so strictlv confined here as in adults. Usually both lungs are affected throughout, the bases sharing in the DISEASES OF THE RESPIRATORY TRACT. 299 pathological process. The consolidation is the result of the epithelial infiltration of the alveoli {desquamative pneumonia), and spreads from a terminal bronchus into the adjoining pul- monary parenchyma by contiguity of structure. Bronchitis and peri-bronchitis are associated with this process. The solid areas undergo caseation, which terminates in cavity for- mation if the case continue a sufficient length of time. Soft- ening and excavation are the result of secondarv infection with the streptococcus or staphylococcus (Prudden). The fever accompanying this process is one of' septic intoxication. Symptomatology. — Tuberculous pneumonia begins with high fever, as an ordinary broncho-pneumonia, together with the development of signs of infiltration of the lung structure. Physical examination demonstrates areas of consolidation, usually the apices and bases. The percussion note loses its resonance and assumes a tympanitic quality over these areas, while auscultation reveals loud, moist and sonorous rales, ac- companied by bronchial breathing. The temperature range is high and remitting in character. As softening of the pneumonic deposits sets in and the vital powers fail, the temperature may fall to subnormal in the early morning hours, lising above 102 in the evening. Pro- fuse sweating usually accompanies the fall in the temperature, and during the fever the skin is hot and dry and the cheeks flushed {hectic fever). The pulse is weak and rapid, varying from 140 to 160 beats. Breathing becomes rapid and labored, often rising to 60 respi- rations per minute during the acme of the fever. Cough remains troublesome throughout, at times being un- controllable. Emaciation and anaemia develop rapidly, the child becoming pale and haggard, its countenance wearing an expression of great distress. Expectoration is usually scanty in the beginning, but toward the end it may become profuse, changing from mucus to muco-pus. Hsemoptysis may occur. The expectoration contains Koch's bacillus, and frequentlv also fibres of connective tissue, beside pus corpuscles and epi- thelial debris. 300 DISEASES OF CHILDREN. The course is rapid and fatal. Intermissions may occur, during which the disease remains quiescent for a short time, but it seldom fails to relight and terminate in a fatal issue. Instead of signs of resolution appearing at the end of a week or two, as in an ordinary broncho-pneumonia, or a crisis at the end of a week, as in a lobar pneumonia, the disease steadily progresses and the vital forces gradually fail. Death may occur within a period of two or three weeks from the be- ginning of the attack, or, owing to periods of temporary ces- sation of symptoms, be protracted beyond that time. A com- plete arrest of the process may take place, but it is seldom permanent, and, after several such remissions, the child suc- cumbs in a few months. In general it may be said, however, that the course is slower throughout than that of an ordinary broncho-pneumonia. Gastro-intestinal disturbances are present and hasten the decline. Diarrhoea is the most prominent of these. The circulation gradually fails, and respiratory embarrass- ment advances. The extremities are cold, and enlarged ca- pillaries may show prominently on the chest, even on the cheeks and hands, indicating pulmonary obstruction. A gen- eral oedema may set in toward the last, which usually disap- pears just prior to death. Infection of the abdominal viscera may occur as a compli- cation, especially if the case becomes protracted ; a tubercu- lous meningitis may arise in like manner. The prognosis is most unfavorable. It cannot be denied that occasionally, but very rarely, we encounter cases pre- senting every evidence of pneumonia of tuberculous origin that recover, or at least in which the disease is temporarily arrested. Even when evidence of a complicating meningitis is present this may occur. Such a case is reported by Baginsky {Berlin. Klin. IVoc/iensc/ir., 1881, No. 20), and I have personally seen cases that apparently presented this complication get well ; but the prognosis must always be guarded. Fowler (Fowler and Goodlee ''Diseases of the DISEASES OF THE RESPIRATORY TRACT. 301 Lungs,") expresses himself on this topic as follows: u The prognosis is in all cases unfavorable, but not so grave in the broncho-pneumonic as in the lobar form. In the less acute cases it may fairly be hoped that the disease pass into a sub- acute or chronic form." Diagnosis. — A broncho-pneumonia in a child running a protracted course, giving no evidences of resolution, but rather those of destruction of lung-tissue, with hectic fever, should always arouse suspicion of tuberculosis. Likewise a lobar pneumonia running on without a crisis, but going into the above state, providing empyema be excluded, is of grave significance. This form, however, is rare, although I believe extensive consolidations are more commonly encountered in children than in adults. A clear family history of tubercu- losis and the tuberculous diathesis, or a history of prolonged exposure to a tuberculous source of infection, offer strong presumptive evidence. Positive evidence is offered by finding the bacillus of Koch in the sputum, with possibly fibres of elastic tissue. This di- agnostic sign is, however, not always available, owing to the difficulty of obtaining sputum. An ingenious and most satis- factory method of obtaining the sputum for microscopic ex- amination is carried out at Prof. L. Kmmett Holt's clinics. A catheter or small stomach tube is inserted several inches into the oesophagus after a coughing spell, by means of which sufficient sputum can be obtained, as children in- variably swallow their expectoration. This is a simple and perfectly reliable procedure and one that should never be neglected in suspicious cases. I am in the habit of attach- ing a glass syringe to the free end of the catheter for the pur- pose of aspirating enough expectoration for a satisfactory examination. The character of the fever is in itself a strong evidence of the nature of the disease, and when taken in conjunction with the rapid emaciation and prostration, anaemia, diarrhoea, and sweats, the case becomes quite clear. 302 DISEASES OF CHILDREN. From this it will be seen that an ordinary broncho-pneu- monia should not be confused with caseous pulmonary tuber- culosis. A. diffuse broncho-pneumonia attended by acute dila- tation of the bronchi, however, may give rise to physical signs indistinguishable, for a time, from disseminated caseous tuber- culosis, and we should therefore be cautious in giving a posi- tive opinion (FowxER). The physical signs are those of either a disseminated bron- cho-pneumonia or of a lobar pneumonia. In the former, scat- tered areas of dulness, the note assuming a tympanitic quality, can be demonstrated, especially at the apices and the bases of the lungs, bilaterally distributed. The signs of bronchitis will be added, i. e., large and small moist rales. The rales are at first bubbling in character, later assuming a crackling sound. Over the consolidated areas bronchial breathing may be elicited, rarely typical tubular breathing. Signs are not well marked, as a rule, on account of the large amount of secretion which clogs up the bronchi. In the early stages of pulmonary tuberculosis, physical signs may be characteristi- cally scant and the fever be entirely disproportionate to the lesions demonstrable. Often the first signs are subcrepitant rales heard anteriorly in the mammary region, indicating in- vasion of the pulmonary parenchyma from the root of the lungs. (Holt). In the lobar form all the evidences of consolidation of an extensive area of lung-tissue will be found. The treatment is that of pneumonia. When the fever runs high, cold sponge-baths every two to three hours are of de- cided benefit. Food should be given at regular intervals, and in the form of liquids or semi-solids of the highest nutritive value. Milk, eggnog, broths into which a raw egg has been stirred, or strained vegetable broth and raw-meat juice are most suitable. Alcoholic stimulation cannot be dispensed with ; the average quantity will be about two drachms every 3 hours during periods of adynamia. It not only sustains the strength of the patient, but possesses some food value, and assists in controlling the cough. DISEASES OF THE RESPIRATORY TRACT. 303 A warm, moist atmosphere is to be maintained, together with the most thorough ventilation. The spraying of hydro- gen dioxid about the room is advantageous. When the cough becomes tight and suffocative in character, a cold pack about the chest is of great benefit. Remedies may be divided into two classes, namely, those calculated to affect the tuberculous process directly and those useful for special symptoms, such as cough, pyrexia, etc. To the first class belong notably the Iodides, especially the Iodide of Arsenic, and Iodoform, Calc. carb. and phos., Sulphur, Tuberciilinum. Kreosote is much used for its antiseptic ac- tion, but may do harm by upsetting the stomach. Remedies of the second class are Chininum arsenicosum and Baptisia for the pyrexia ; Silicea and Hyoscyamus for the profuse sweats ; Apomorphia, Tartar emetic, Hyoscyamus, Phosphorus and Lycopodium for the respiratory symptoms. Some of these remedies combine, so to speak, both offices — for example, the Iodide of Arsenic. It is not only a constitu- tional remedy, but at the same time exerts a potent influence over the pyrexia and the catarrhal symptoms. Likewise, one of the Calcareas may fulfill every requirement if decided con- stitutional indications are present, the Carbonate suiting the fat, pot-bellied, scrofulous child best; while a poorly-devel- oped, backward child, with flabby abdomen, lax joints and weak limbs, adenoid vegetations and enlarged tonsils, is more benefited by the Phosphate. Avian tuberculin is recommended by Cartier for broncho- pneumonia following one of the infectious fevers and assum- ing a "suspicious" type. The cough is incessant and tickling in character, the pulmonary symptoms become localized, ema- ciation sets in, and tuberculosis may be anticipated. II T. Fibro-Caseous or Chronic Pulmonary Tuberculosis. — The chronic form of pulmonary tuberculosis, in which fibrosis is added to the caseous process, is seldom encountered before the sixth year, not becoming a common disease until the time of puberty. Xo doubt most children showing a decided pre- 304 DISEASES OF CHILDREN. disposition to tuberculosis succumb to either the acute pul- monary form or to general tuberculosis before this period. Its course is identical with that of cases of consumption in young adults, in children above six years. Under this age it may be less typical, the regular hectic fever so characteristic in adults and the classical night-sweats being absent. Indeed, extensive destruction of pulmonary tissue may take place in association with a moderately high temperature without marked remissions or sweating. A variety of lesions is found, the characteristic and most constant changes being caseation and fibrosis in conjunction with cavity formation. Owing to the tendency to destruction and excavation of pulmonary tissue, the term "ulcerative phthisis " is often applied to this disease. The coexistence of miliary granulations and areas of caseation and fibrosis indi- cates that the course has been marked by remissions, as well as periods during which the pathological process has been active. Such a period of activity often occurs immediately before the death of the patient, and during its continuance miliary tuber- cles in great number may form in parts of the lungs hitherto unaffected (Fowler). The seat of the primary lesion is one of the apices, and in the majority of cases the right. The process does not begin at the extreme apex of the lung, but about an inch below that point, and nearer the posterior and external than the anterior border, spreading thence backwards. The upper and posterior part of the lower lobe is involved often long before extensive infiltration or destruction of the upper lobe has taken place, and, as a rule, before the apex of the opposite lung is attacked. Infiltration of the lung at this site, together with infiltration of the apex, is almost positive proof of the existence of tuber- culous disease of the lungs (Fowler). Associated lesions usually found are bronchitis, peri- bron- chitis and bronchiectasis; emphysema (compensatory); pul- monary collapse, the result of bronchial obstruction ; cedema and congestion at the bases; pleurisy, usually chronic fibrous, DISEASES OF THE RESPIRATORY TRACT. 305 although acute pleurisy with exudation is by no means an infrequent complication of phthisis. Lesions in other organs that may be encountered are tuberculous ulceration of the in- testines, amyloid disease of the internal organs, tuberculous adenitis, meningitis and tuberculous arthritis. Females seem more prone to consumption than males. The ages between twenty and thirty furnish the highest percen- tage of cases, the number gradually increasing from the fifth year to that time. Certain previous diseases invite it. An attack of acute pleurisy often precedes the outbreak of pulmonary tubercu- losis, or a lung impaired by a former pleurisy may become susceptible. Bronchitis may pave the way, but, according to Fowler, its importance is over-estimated. The same holds good for pneumonia. Valvular disease of the heart bears an important relation to pulmonary tuberculosis. Congenital stenosis of the pul- monary orifice offers a strong predisposition. Mitral stenosis is not uncommonly found associated with consumption, an observation to which I can add my testimony. The antago- nism between mitral disease, particularly regurgitation, and consumption, taught by Louis, is not absolute. Fowler has observed a number of cases in which the diseases co-existed, and others also have collected a sufficient number to disprove the theory. Syphilis may predispose to tuberculosis by lowering the resisting power of the organism. It is even claimed, by Hochsinger, that both the virus of syphilis and tuberculosis may be transmitted to the offspring by the parent at the same time. Symptomatology. — The only evidence of the disease to attract attention in the beginning may be emaciation, with gradually failing health. Cough is usually slight, and of a dry, hacking character, or there may be an associated bron- chitis, with free expectoration. In some cases, recurring at- tacks of acute bronchitis precede the pulmonary involvement; 306 DISEASES OF CHILDREN. in others, infiltration of the lungs advances steadily in the absence of all catarrhal manifestations. Hemoptysis may be the first symptom to arouse suspicion. Even in young children it is frequently observed (Baginsky), usually auguring a rapid course. Haemoptysis does not, how- ever, always indicate destruction of pulmonary tissue ; to the contrary, it is usually an early symptom, resulting from ob- fig. 39. — advanced case of fibro-caseous pulmonary tuberculosis in a boy ten years old. note emaciation; paralytic chest; flatten- ing of infra-clavicular spaces; also adenoid facies. struction of some of the smaller blood-vessels by the tubercu- lous infiltration with resulting engorgement and rupture of the collateral vessels. Chest pains are due to either localized persistent. Physical examination reveals an emaciated frame ; long, flat chest, and superficial, feeble respiratory movement in DISEASES OF THE RESPIRATORY TRACT. 307 typical cases. The absence of the true paralytic thorax does not, however, exclude the possibility of pulmonary disease. When the process is active, the skin is dry and feverish. Commonly, enlarged superficial lymphatic glands can be felt in various regions of the body. The clavicle stands out prominently, as do also the angles of the scapulae, and the infra-scapular region is flattened. Palpation reveals in- creased vocal fremitus in either one or both infra-clavicular regions ; the percussion note is dull in the supra-clavicular region, and the area of dullness often extends down as far as the third rib anteriorly, occupying the interscapular space on one or both sides of the spinal column posteriorly. The dulness may be associated with a suggestion of tympan- itic quality. Auscultation reveals, in the early stages, harsh breathing in the affected apex, associated with fine, crackling rales. Broncho-vesicular breathing soon develops. As infil- tration advances, bronchial breathing can be elicited in the infra-clavicular space. The first place this can usually be demonstrated posteriorly is at a point opposite the fifth dorsal spine, midway between the border of the scapula and the spinous processes of the vertebrae (Fowler). As softening and excavation occur, the signs of cavity are added. Fever is an indication of the activity of the process. When not exceeding 100.4 F. it may be considered purely of tuber- culous origin; when higher, it is due to secondary infection, and usually betrays its septic character by marked remissions (Koch). While this is true in adults, it does not hold good in young children in whom the fever always tends to run high. Periods of latency may occur, during which there is no pyrexia, although the pulse, as a rule, is weak and rapid throughout the entire course of the disease. As characteristic of the tuberculous pulse, it is claimed that the number of beats per minute is not influenced by reclining or standing, as occurs normally. The morning temperature is frequently subnormal, even during periods of quiescence. With infiltration and begin- 308 DISEASES OF CHILDREN. ning softening, the evening temperature rises to ioo° to 100.5 F. Secondary infection and rapid disintegration of lung-tissue are accompanied by a higher evening rise, the fever assuming the hectic type. At times, extreme fluctua- tions in temperature occur without causing much distress to the patient. Fowler is of the opinion that high fever may be present without septic infection, simply indicating a rapid progress of the disease in an organism still capable of reac- tion. This, however, is at variance with the teaching of Koch and Prudden. Paroxysms of high fever, followed by sweating, invariably indicate an admixture of septic intoxi- cation. Night-sweats are a common and most distressing symptom ; ordinarily they simply indicate exhaustion, occur- ring as the temperature falls to normal or subnormal. The alimentary tract becomes deranged, and anorexia and diarrhoea are common complications. The latter symptom, occurring at the termination of the disease, indicates intes- tinal ulceration. Vomiting may be a troublesome symptom, resulting either from severe coughing paroxysms or gastritis. Albuminuria is more common in children than in adults (Baginsky). In rapidly progressing cases a distressing cough, with free expectoration of yellowish, lumpy muco-pus containing the bacillus in large numbers, will be found. Haemoptysis is generally associated with such cases. Chronic fibroid phthisis may be encountered in children, but it is rarer than the above variety. In these cases there is usually a dry, harassing cough and less pyrexia, while, patho- logically, fibrosis is in excess of the infiltrative process. The course is slower than that of fibro-caseous tuberculosis, but in the majority of cases an acute tuberculous complication brings on a fatal termination (Baginsky). The prognosis is unfavorable, especially when the disease develops at the period of puberty — a time when the organism requires every spark of vitality for its growth and develop- ment, and at which there is the strain of school life to be DISEASES OF THE RESPIRATORY TRACT. 309 considered, In girls, the tendency to chlorosis is also an un- favorable event. In younger children, if the course be not an acute one, the prognosis is more favorable, but still grave. Cases have no doubt been checked, but it is impossible to foretell a relapse or a later complication, such as meningitis, setting in. If arrest in the stage of infiltration can be accom- plished, the prognosis is favorable. The constitution and family history must also be taken into consideration in form- ing an opinion as to prognosis. As Duckworth puts it, we do not cure our tuberculous patients ; all that we can do is to place them under conditions favoring an arrest of the process. A positive diagnosis is based upon a demonstration of the physical signs of infiltration and destruction of lung-tissue described above, the character of the fever, and the finding of the bacillus of Koch. A combination of any two of these data affords the strongest presumptive evidence of the exist- ence of phthisis. Early in the disease, however, at which time it is most important that the malady be recognized, it is not always possible to find unmistakable evidence of tubercu- losis ; and especially in children are we at a great disadvan- tage, owing to the difficulty of obtaining sputum for micro- scopical examination. If the child cannot be made to expec- torate into a cup, the stomach-tube should be passed as directed above (p. 301). Cough and emaciation in a child with a tuberculous family history, or with the history of hav- ing been exposed to such infection, together with slight evening pyrexia, are sufficient data to warrant a most thor- ough examination of the chest. The finding of a few local- ized subcrepitant rales at the apex of the lung, together with a prolonged expiratory sound in such a case, will enable us to make a diagnosis of beginning pulmonary tuberculosis. Later, as the classical symptoms of the disease develop, the diagnosis is comparatively easy. Chronic piimlent bronchitis is, perhaps, the most frequent condition we are called upon to differentiate ; but here the absence of the bacillus and the negative condition of the lungs will exclude tuberculosis. 310 DISEASES OF CHILDREN. Treatment. — In the treatment, prophylaxis is of first im- portance. Children presenting a tuberculous family history are liable to succumb to pulmonary tuberculosis on account of an inherited constitutional weakness. This predisposition is not, however, confined to such alone, as any constitutional enfeeblement in which the resistance of the organism is sub- normal, especially when the chest is underdeveloped, offers a predisposing factor. Such children should be brought up in a locality where fresh air in abundance can be enjoyed, and they should be encouraged to lead an out-of-door life rather than be urged on in their studies. Particular stress should be laid on the physical development of the chest by suitable and methodically carried out breathing-exercises and calis- thenics ; and for overcoming the cold-catching tendency, a cold sponge-bath, followed by brisk rubbing with a coarse towel, is most efficacious. A careful inspection of the nose and throat should be insti- tuted early to determine the presence of local pathological conditions that may interfere with the proper performance of the function of respiration. The importance of early recog- nizing adenoid vegetations or enlarged tonsils, and promptly removing them by appropriate means, cannot be overesti- mated. And, lastly, it must be accepted as a fact beyond dis- pute that the most important prophylactic factor is the avoid- ance of giving entrance to the bacillus of Koch into the sys- tem. The infant's food should, therefore, be sterilized, unless it is positively known to be free from contamination. Nor must it be brought up in an environment menaced by the presence of a consumptive. The same holds good with older children. Until more rigorous sanitary measures are enforced and the consumptive is educated to dispose of his expectora- tion in a safe manner and avoid too intimate relations with those about him, the disease will not decrease very materially. When the disease becomes established it behooves us to decide whether the patient is to be cared for at home or sent to a more suitable climate. It is worse than useless to send DISEASES OF THE RESPIRATORY TRACT. 311 away a patient whose condition is an acute one, or in whose lungs advanced destructive changes have already occurred, and pronounced emaciation, fever and night-sweats exist. On the other hand, a timely change of climate has saved many a life, especially if the patient can pursue an outdoor life. The requirements of a suitable climate are pure, uncontaminated air, equable temperature, and a maximum amount of sunshine. High altitude is by no means necessary ; it best suits cases in which the disease is limited and there are no cavities. It may prove disadvantageous to some cases by bringing on dilatation of the air- vesicles on account of the ratified state of the air, thus making it impossible for the patient to return to a low region. Haemoptysis also contra-indicates a high altitude, and neurotic temperaments are aggravated thereby. A mod- erate altitude is preferable in most cases. The most suitable locations offering this natural advantage are the Adirondacks, the Southern pine regions, and the great plains bordering the Rocky Mountains. A location at sea-level seems better for chronic cases with emphysema, especially when there is nerv- ous irritability, insomnia and loss of appetite. It is also beneficial in septic pyrexias. Many consumptives do not mind cold weather; in fact, it benefits them. For such, Mt. Pocono, the Adirondacks and Denver, Col., are good locations. Others, again, especially those in whom there is considerable bronchitis, are required to . seek a warm, moist climate, especially in winter. Florida, the coast region of Southern California, and the Bermudas offer these advantages. The main feature of climatic treatment, however, is the outdoor life invited thereby. No other form of treatment has yet given the promising results obtained in the sanatoria in which open-air treatment is systemically carried out, com- bined with forced feeding, hydro-therapy and judicious exercise. When it is impossible to send the patient away from home, he should receive all the benefits of the open-air treatment. When he is able to be out, he should enjoy every hour of sun- 312 DISEASES OF CHILDREN. shine available. If he is too weak to walk, or if there is fever, he should sit in the sun, well protected with sufficient cloth- ing and screened from draughts. In winter, as well as in summer, the windows of the sick-room should be kept open. During the night the sleeping-chamber must be kept thor- oughly ventilated, there being less harm in night air than in a stuffy atmosphere. The diet is very important. So long as the appetite re- mains good and diarrhoea is absent, the case should not be despaired of. A change of climate often brings about a restoration of appetite when that has been on the wane, and may in this way alone confer great benefit. It is important to feed the patient as much as he can take ; in fact, overfeed- ing has even proven beneficial in some instances. Osier has seen good results following Debove's method of introducing a mixture of milk, egg and finely-powdered meat into the stom- ach through a stomach-tube, three times daily, in cases in which gastric symptoms were distressing. Raw eggs are es- pecially adapted as a food for the tuberculous. Cod-liver oil is usually well borne by children, and is useful so long as it does not disturb the digestion. Even in the presence of py- rexia not above 100.4 F. we should not refrain from liberal feeding. Alcoholics are useful here, particularly when they tend to increase the appetite. Eggnog is a desirable form in which whisky can be administered. Raw meat is supposed to possess antitoxic properties, and can be administered as balls of chopped meat rolled in pulverized sugar, in which form children will usually take it readily. Personally, I con- sider it one of the most valuable foods for the tuberculous. Special Symptoms. — When there is continuous pyrexia, or high evening temperature, rest in bed is imperative. Spong- ing with tepid water to which alcohol has been added exerts a refreshing and tonic influence, besides being a safe means of reducing temperature. The so-called "antipyretics" are posi- tively harmful. Such remedies as China, Chininum arseni- cum, Baptisia and Ferrum phos. present special indications DISEASES OF THE RESPIRATORY TRACT. 313 for their selection in the pyrexia of tuberculosis, and exert a most favorable influence over the same. Full indications will be given later on. Cough. — A cough which occurs in the morning and is ac- companied by expectoration is useful, and should not be checked. Expectoration is materially aided by giving the patient a cup of hot milk, to which a teaspoonful of rum has been added, in the morning on awaking. On the other hand, a cough that continues during the night, causing loss of sleep v must be controlled (Fowler). The old school employ Codein for this purpose; but we have among our remedies most efficient means for controlling the cough, with which we do not run the risk of drying up secretions or overcoming reflex irritability to a dangerous degree. I would especially mention Hepar sulph., 3X trit., as a most valuable remedy for the teasing night-cough of phthisis. Drosera is highly recommended by Hughes {Man- ual of Therapeutics) for cough depending upon increased re- flex excitability. Beside these, Hyoscyamus, Lachesis, Ipecac and Corallium rubrum should be studied. When profuse ex- pectoration is present Stibium iodide 2x (Goodno), Arseni- cum jod., Lycopodium, Stannum met. and Calc. carb. are the remedies most likely to prove useful. They must be care- fully differentiated in order to yield the best results. Hczmoptysis, when slight and associated with tightness across the chest and hoarseness, calls for Phosphorus. Hughes places Phosphorus foremost when the air-passages are much implicated in the morbid process. Geranium maculatum, tincture, has proven of great benefit in profuse bloody expec- toration. The inhalation of Kreosote, a few drops in a mixture of al- cohol and chloroform, is often efficient in allaying an irritat- ing cough and in improving the character of the expectora- tion when it becomes offensive. Night-sweats are often uncontrollable, and try the physi- cian's skill to the utmost. I cannot see the feasibility of 21 314 DISEASES OF CHILDREN. using extreme measures to check the same, as the sweating is only a sign of exhaustion when it occurs during sleep, or the natural termination of the febrile movement when it occurs at the decline of the fever. Our aim should be to build up the patient, and, if necessary, we may administer a stimulant at bedtime. When due to fever, a tepid or cold sponge-bath at bedtime is beneficial. China tincture is a good remedy in these cases owing to its tonic properties. Silicea, 6x trit., acts most satisfactorily when there is pulmonary disintegration. I have seen an Iron tonic gradually relieve the condition where the usual routine treatment had been used without suc- cess. Hughes recommends Iodine for nocturnal sweats. Phosphoric acid 3X will do a great deal for the debility result- ing from sweats, diarrhoea and bronchorrhoea. Jaborandi is homoeopathic to profuse sweating, and has given good results. Goodno recommends Agaricin ix, one grain at bedtime. A tropin is the standby of the old school. Diarrhoea, when due to catarrh of the bowels, can be con- trolled by restricting the diet to semi-solids and selecting the proper remedy. Phosphoric acid is the most important one. When there is tuberculous ulceration of the bowel, slight hope for improvement is offered. This is the form encountered as a terminal stage of the disease. Arsenic may benefit this condition and should be tried. Gastric disorders may result from overfeeding. The best evidence of this is the presence of undigested food-particles in the stools (Fowler). When there is purely a gastric in- competency, Nux vomica proves of great value. A catarrhal condition calls for such remedies as Pulsatilla, Hydrastis and Ipecac. Kreosote is indicated when there is vomiting of glairy mucus, usually in the morning. It is a favorite rem- edy of the old school to improve the digestive function, in- creasing the appetite and checking flatulency. Laryngeal symptoms supervening during the course of phthisis are mostly catarrhal in nature. Spongia is the chief remedy (Hughes). Tuberculous laryngitis (ulcerative) re- quires the attention of a specialist. DISEASES OF THE RESPIRATORY TRACT. 315 The following list of remedies, with their clinical indica- tions, may be studied for a fuller knowledge of the therapeu- tics of phthisis : Aconite. — Pleuritic stitches, and blood-spitting after taking cold. Ferrum phos. is similar, but under this remedy there is less circulatory excitement, and anaemia and vasomotor dis- turbances are pronounced. Arsen. alb. — Dyspnoea from exertion; cough between i A. M. and 3 A. m. Fever-heat and chilliness intermixed. Restlessness and thirst for small quantities of water. There is prostration and emaciation ; anaemia and oedema of ankles ; terminal diarrhoea. Mostly indicated in the pneumonic type. Arsen. j'od., 3xtrit, freshly prepared is well suited to the Jibro- caseous form of the disease when there is profuse purulent ex- pectoration ; emaciation ; hectic fever and prostration. Stibium iodide, 2x trit, is highly recommended by Goodno in cases presenting profuse muco-purulent expectoration. Stannum iodide has profuse purulent expectoration easily raised, and of sweetish taste. It is more useful in chronic bronchitis. Baptisia. — Chill in forenoon or afternoon, followed by heat and perspiration ; general weakness and languor. Baptisia is one of the best remedies for the pyrexia of phthisis, and has been extensively used since it was first recommended by Dr. J. S. Mitchell. It is usually employed in the tincture and lower dilutions. Bryonia. — Cutting pleuritic pain when taking a deep breath or coughing. Dry, deep cough, the irritation starting from the epigastric region. Calc. carb. — " Pre-tubercular stage " in strumous subjects, the characteristic features being a form of indigestion asso- ciated with acid eructations and difficulty in assimilating fats (Hughes). Pale, rapidly-growing youths (Phos. acid) or scrofulous children are especially benefited by this remedy. In the later stages it is indicated by tendency to perspire on slightest exertion ; damp, cold feet ; shortness of breath on ascending stairs ; expectoration consisting of mucus with an 316 DISEASES OF CHILDREN. admixture of pus which sinks in water, leaving the frothy mucus floating above. Carbo veg. — Flatulent dyspepsia and chronic hoarseness. China. — Septic fever, consisting of a chill, followed by high fever and sweat, usually occurring at regular intervals. Anorexia ; chronic diarrhoea. (Tincture and lower dilutions.) The Arseniate of quinine, 3X trit, is better indicated when the pyrexia is more irregular, especially if arsenic symptoms are present. Ferrum phos. — Fever in the early stages, before septic in- fection has set in. Haemoptysis in the early stages not de- pendent upon excavation of lung-structure. Hepar sulph., 3X trit., two grains every hour at night until cough is relieved. The cough is due to a persistent irritation in larynx, not relieved by free expectoration. It is excited by uncovering any part of the body, or by contact of body with cool bedclothes on first retiring. There is usually slight hoarseness, with rattling of mucus in larynx, but, as before stated, expectoration does not relieve the symptoms. ■ Drosera has a deep, spasmodic cough presenting this element of hyper- esthesia, but there is not the free secretion present in Hepar. Hyoscyamus has symptoms of cough worse on lying down at night ; dry, spasmodic and titillating in character. Iodine. — This remedy also presents characteristic cough symptoms. " Constant tickling in the windpipe and under the sternum, with expectoration of a transparent mticus, sometimes streaked with blood. Morbid hunger, even soon after a meal, and yet loss of flesh. Dark hair and eyes " (C. G. R.). Kali carb. — Sharp stitches in chest; cough worse 3 A. M.; puffiness of upper eyelids and swelling of ankles. Lachesis. — Cough during sleep without awaking the pa- tient ; chilliness, followed by fever, with great talkativeness ; sensation of suffocation ; fluttering of heart ; offensive stools. Lycop. — Expectoration of large quantities of pus after neg- lected pneumonia (C. G. R.). Cough day and night, the ex- DISEASES OF THE RESPIRATORY TRACT. 317 pectoration tasting salty. Hectic fever, with circumscribed redness of cheeks, usually late in afternoon (four p. M. to eight P. M., aggravation of symptoms). During the fever we often observe automatic fan-like movements of the alse nasi, not due to dyspnoea, but sympathetic with the pulmonary disturbance. u It suits cases of a chronic and passive char- acter, and is, I think, especially useful when phthisis occurs in young men." (Hughes.) Nux vom. — Digestive derangements and aggravation of cough symptoms from overeating. Kreosotttm 2x is one of the best remedies for persistent vomiting in phthisis. Phosphorus. — Tormenting cough, often with hoarseness ; worse toward midnight ; tight and painful. There is tight- ness across upper portion of chest; inability to lie on left side. "Cough in the earlier stages of phthisis, with unusual implication of the air-passages in the morbid process." (Hughes). Phosphoric acid, acts restoratively w T hen the system has been drained by long-continued diarrhoea or persistent night- sweats. Sulphur. — Delayed resolution after pneumonia; chronic catarrhal deposits at apices, with a few moist rales. Neuras- thenic individuals. Weak, gene feeling at n A. M., with craving for food or a stimulant. Vasomotor disturbances. Iodoform, 3X trit. — Two one-grain tablets four times daily. It has given me most promising results in incipient cases of nbro-caseous pulmonary tuberculosis, and I use it in prefer- ence to the other iodides in the stage of infiltration. Tuberculin (Koch) has been successfully employed in bron- cho-pneumonia, and is considered by Arnulphy capable of stopping the progress of incipient cases of tuberculosis of the lungs in a large proportion of cases (Clinique, June, 1897). Avian tuberculin is recommended by Cartier for suspicious broncho-pneumonia. These nosodes have usually been given in the higher dilutions, either the 30th or 100th, although Mersch obtained his results from the 6th. 318 DISEASES OF CHILDREN. EMPHYSEMA. Overdistension of the air-vesicles of areas of pulmonary tissue occurs as a complication of almost any of the acute affections of the respiratory tract, resulting from either an interference with the function of a considerable portion of the lungs (vicarious or inspiratory emphysema), or from an obstruction higher up in the tract, leading to dilatation and even rupture of air-vesicles during expiration, especially when this is performed in a forcible manner. The latter variety, or expiratory emphysema, is by far the most pro- nounced form in which this condition is met with acutely, occurring as a common complication of whooping-cough, croup, asthma and measles, especially in rachitic children or those of lax fibre. It has also resulted from forcible expir- atory efforts performed voluntarily, and from the inflation of the lungs of the new-born in cases of asphyxia. Chronic em- physema is occasionally seen in children as a result of chronic bronchitis and organic heart disease. Anatomically, emphysema is classified as vesicular or alveo- lar, and interstitial. In the latter form there is an escape of air into the connective- tissue stroma of the lungs, sometimes burrowing beneath the pleura and along the mediastinum into the subcutaneous tissue of the supra-clavicular spaces. Only then can it be distinguished clinically from the vesicu- lar form when it makes its appearance externally, in the above manner. The chronic form, or substantive emphysema, is defined by Delafield as a chronic interstitial inflammation of the lungs, in which the dilatation of the air-spaces is a secondary phe- nomenon. Accordingly, it is a condition whose etiology and pathology are analogous to that of chronic endocarditis, endarteritis and nephritis. In acute emphysema the upper lobes are principally af- fected, and most markedly in their anterior borders. In the chronic form both lungs are more or less affected in their en- tirety, but seldom to the great extent observed in adults. DISEASES OF THE RESPIRATORY TRACT. 319 The symptoms of a compensatory emphysema are always obscured by the original disease. Hyper-resonance, bulging of the supra-clavicular space during the expulsive efforts of coughing, exaggerated vesicular murmur and dyspnoea are all suggestive. Chronic emphysema presents the typical barrel-chest ; fee- ble respiratory murmur with prolonged expiration ; dimin- ished area of cardiac dullness ; cyanosis, dyspnoea, cough and expectoration ; vesiculo-tympanitic percussion-note. It must be remembered, however, that none of these signs are as pro- nounced as in adults, and the younger the child, the less the aberration from the normal. In both instances treatment is to be directed to the primary disease. Such remedies as Arsenicum, Arsenicum iodide, Aurum mur., Ipecac, Lobelia and Grindelia will be required for the symptoms of the disease per se. Coca and Quebracho are lauded by Hale as the only remedies giving continuous relief. Constitutional remedies are valuable in rachitic children, notably the Calcareas, Silicea, Ferrum phos., Baryta carb. and iodide, Fluoric acid and Sulphur. PLEURISY AND EMPYEMA. Inflammation of the pleura is rarely seen as a primary dis- ease during childhood, but it is quite a common accompani- ment of pneumonia, especially of severe forms of broncho- pneumonia. Pleurisy without exudation may accompany pulmonary disturbances of all kinds, and the frequency with which adhesions and thickening of the pleural membranes are encountered in the general run of autopsies upon children points to the great prevalence of this condition. The exudative variety of pleurisy in children is almost in- variably an empyema, and occurs most frequently as a com- plication of pneumonia, or develops simultaneously with the pneumonic process, which is the case in the pleuro-pneumonia described by some authors as a separate clinical condition. (See page 294). 320 • DISEASES OE CHILDREN. The acute infectious fevers are responsible for the develop- ment of some cases of pleurisy, and in older children a purely serous effusion may occur as a result of tuberculosis or the rheumatic (?) diathesis. The micro-organisms playing the most prominent role in the etiology of purulent pleurisy are the pneumococcus, the pyogenic micrococci and the bacillus tuberculosis. Pneumococ- cus pleurisy is the most frequent form. It may occur simul- taneously with a pneumonia, or, what is more frequently the case, secondarily to the pulmonary affection, sometimes ap- pearing several weeks later (Strauss). The exudate may be either sero-fibrinous or purulent. In the latter case the effu- sion is thick, creamy or greenish, and not clotted. The prog- nosis is better than in the other forms; the course is also milder. Streptococcus pleurisy is more common in adults. The prognosis is not so favorable as in the pneumococcus variety. The course is more prolonged and the fluid re-accumulates after expiration. Tuberculous pleurisy may occur primarily, that is, in the absence of pulmonary tuberculosis ; but in these cases tuber- culosis of the bronchial glands is generally present. The effusion is sero-fibrinous at first and gradually becomes puru- lent. The course is slow and unfavorable. Pathology. — In the early stages of a pleurisy the membrane appears injected and lustreless ; later, it becomes roughened and coated with a layer of fibrinous exudate. The extent of this process depends upon the severity of the attack, and it will vary from a delicate film of fibrin, coating only that por- tion of the pleura .directly covering the affected portion of lung in a pneumonia, to a general involvement of the entire pleural cavity, with a thick layer of inflammatory products plus an abundance of sero-pus. In these pronounced cases the pleura appears coated with a yellowish-green deposit of varying thickness ; the opposing surfaces may become adher- ent, forming pockets in which an abundance of pus is found. DISEASES OF THE RESPIRATORY TRACT. 321 If serum is poured out freely during the first stage, adhesions do not occur, at least not to a very great extent. This fluid sodu becomes purulent from the free admixture of leucocytes. Symptomatology. — An attack of pleurisy may be ushered in with repeated chills, as in adults, or with convulsions, which are especially common in infants. A dry, hacking cough and sharp, sticking pains in the side are the natural accompaniments of the inflammatory process. When free exudation takes place the pain disappears, but with this a new series of symptoms develop. The pain is expressed by severe crying after each coughing paroxysm or when the child is moved ; there is also a ten- dency to lie upon the affected side, together with increased ab- dominal breathing. If the child be old enough to express its suffering, it may mislead us by referring the pain to the epi- gastric region. With the appearance of fluid, which is mostly of a purulent nature, dyspnoea develops, its severity depending upon the amount of fluid present. The cough may become more and more severe, owing to a complicating bronchitis. The fever is remitting in character, seldom very high, rarely running above 103 ° F. As the acute symptoms subside a slight afternoon rise may remain to indicate that the condi- tion has become chronic, as it is very rare for an empyema to recover spontaneously. Obscure cases of sacculated empyema running a high fever for several weeks are occasionally en- countered, and may prove very puzzling. Such a case, fluc- tuating between 98 and 106. 2° F., has been recently reported by Holt {Archives of Pediatrics, Jan., 1902). Cases of pleurisy, fully recovering within a short period of time, and without surgical treatment, have been either a dry pleurisy, a pleuro-pneumonia with scanty exudate, or a serous effusion into which no micro-organisms have gained en- trance. An empyema resulting from infection with the pneu- mococcus may recover spontaneously in the course of two or three weeks, but those of streptococcus or tuberculous origin 322 DISEASES OF CHILDREN. seldom recover without surgical interference. The last men- tioned is, indeed, rarely benefited by any form of treatment. When pleurisy develops secondarily to another disease, its course is not essentially different from the above ; thus, in a pneumonia there will be a post-critical rise in the temperature with all the attending symptoms of pleurisy and effusion, (Fig. 40). Sometimes, however, it is impossible to say just when the pleurisy has developed, the increasing dyspnoea, pain and cough indicating the addition of this serious com- Day*Du \ ? | ? | /Q | // | /Jj | /J | /? | /f\ /{, | /^ j // | /f\ >Qpj FIG. 40.— TEMPERATURE CHART FROM A CASE OF EMPYEMA DEVELOPING AFTER PNEUMONIA OF THE LEFT LOWER LOBE. A DRAINAGE TUBE WAS INSERTED AT iX) WITH RESULTING DECLINE IN THE FEVER. plication. This frequently occurs in broncho-pneumonia, and as both conditions are then practically inseparable, the term pleuro-pneumonia has been rightly applied here. The physical signs by which pleurisy is recognized in chil- dren are mainly those indicating the presence of fluid in the thoracic cavity, as the early signs, namely, the friction-sound and local tenderness, are not so readily elicited here as in adults. By observing the posture of the child, however, and DISEASES OF THE RESPIRATORY TRACT. 323 the fact that coughing produces severe pain, we often suspect a case in its early stages and are enabled to verify the diag- nosis when the effusion appears. Conditions in which sutr crepitant rales are present are a frequent source of error, they being easily mistaken for friction-sounds during infancy. For this reason the diagnosis of pleurisy depends upon a correct interpretation of painful inspiration, painful cough, the char- acteristic onset and fever, and, still later, the demonstration of a pleuritic exudate. In the early stages of pleurisy fixation of the thorax from the pain is often observed in children, producing a voluntary scoliosis, as pointed out by Ziemssen. As a result of this ab- normal position, the ribs are brought closely together on the affected side and the percussion note becomes dull. Under these circumstances, therefore, dulness may be observed before exudation has actually set in. After exudation occurs the symptoms are more character- istic. If the amount of fluid be considerable, there will be a noticeable bulging of the chest on the affected side, together with diminished motion. When the fluid occupies the left pleural cavity the heart is displaced to the right ; when oc- cupying the right pleural cavity there is a downward dis- placement of the liver. The pleural fold is also displaced beyond the midsternal line. Vocal fremitus is absent over the site of the fluid, while the percussion-note is flat and there is increased resistance. These two signs are among the most important data in the diagnosis of effusion. Percussing with the flat hand directly over the site of the fluid gives a very good demonstration of the resistance present. Above the level of the fluid tympan- itic resonance is obtained when the lungs are not entirely de- prived of air. The line of flatness will change its direction with a change in the position of the patient, providing the fluid is not inclosed by inflammatory adhesions. In fresh cases bronchial breathing is very frequently heard above the line of dulness, which only gradually gives place 324 DISEASES OF CHILDREN. to the entire disappearance of the respiratory murmur with the increase in the exudate, (Henoch, " Vorlesung uber Ktnderkrankh.") Rosenbach (NothnagePs Encyclopedia, 1902) has not met with this peculiar type of breathing and he calls attention to the lack of specific signs in the pleurisies of children. The fact is, there are no constant signs. As large effusions are rare, the symptoms are less uniform than in adults. All authorities agree on the importance of the free use of the exploring needle. Even in moderately large effusions it is common to hear bronchial breathing and bron- cophony over the entire back on the affected side. Moist rales may also be present to cause confusion. In children under three years the fluid is usually purulent, and even until puberty this tendency prevails According to Baccelli a purulent exudate is less likely to transmit the whispered voice, but this is not always the case. Subcuta- neous oedema of the thorax on the affected side is not so com- monly present in children as in adolescents and adults to indicate the purulent nature of the exudate. A positive diagnosis cannot, however, be made without the use of the aspirating needle, which is perfectly safe when used under proper aseptic precautions. In old cases, where the pus is too thick to be drawn into the needle, even this method will lead to error unless the negative result is properly interpreted. In a serous exudate, the presence of chain cocci, staphylo- cocci, or the diplococcus pneumoniae, indicates that it will become purulent. — Koplik. Tuberculous pleurisy is recog- nized by finding the tubercle bacillus in the effusion and ac- cording to Dieulafoy by the exclusive presence of lymphocytes and red blood corpuscles. In the other forms of infectious pleurisy polynuclear and large mononuclear leucocytes pre- dominate. Diagnosis. — The early diagnosis of fluid in the chest is of the utmost importance, particularly as the recovery of the patient depends much upon the time when proper treatment has been instituted. Many difficulties may be encountered DISEASES OF THE RESPIRATORY TRACT. 325 in deciding upon this point, especially as the effusion is not generally a large one and because it is usually secondary to pneumonia — metapneumonic pleurisy. The history is there- fore not as clear as in primary pleurisy. Again, owing to the strong tendency for the fluid to become encapsulated, it does not produce the characteristic physical signs expected of free fluid in the chest. The determination of the character of the fluid has been fully discussed above. The chief indications upon which the diagnosis can be made are absence of vocal fremitus; flat quality of the per- cussion-note and resistance ; bronchial breathing and bronco- phony over the entire affected side posteriorly and displace- ment of viscera. Koplik lays special stress upon displace- ment of the pleural fold. Normally these folds meet in the midsternal line and when there is considerable fluid in either side of the chest cavity dulness will be found to extend be- yond the median line over toward the well side. In smaller effusions auscultatory signs are not characteristic and may be misleading on account of the good conduction of sound in the child's chest. Empyema should always be suspected when the tempera- ture remains high for a period beyond two weeks in cases of pneumonia, especially when bronchial breathing can be heard over an entire side. Encapsulated fluid in unusual sites, such as the upper por- tion of the chest, is very difficult to differentiate from per- sistent broncho-pneumonia and abscess of the lung. In the latter condition percussion and auscultation give practically the same signs, but the presence of loud, coarse pleuritic fric- tion sounds are of importance as favoring the diagnosis of abscess (Holt, Archives of Pediatrics, Jan., 1904). Pericardial effusion must also be borne in mind as a pos- sible condition likely to be confused with sacculated empyema. Prognosis. — Serous effusions are usually absorbed readily, seldom persisting over three weeks. If however pus produc- ing micro-organisms gain entrance into the pleural cavity 326 DISEASES OF CHILDREN. the prognosis is immediately altered. As stated above, an empyema due to the pneumococcus presents the most favor- able prognosis, although it may run a prolonged and tedious course, the usual period being from some weeks to two months (Strauss). This is the variety that may recover spontaneously, or after one or two aspirations. When the streptococcus is present the fluid tends to re-accumulate un- less open drainage be instituted. The tuberculous variety is the least favorable. Spontaneous evacuation through the chest wall (usually in the region of the fourth or fifth rib) or through the bronchial tubes, by perforation into the lung parenchyma, is a not infrequent termination of the pneumo- coccus variety. The other varieties, however, rarely evacuate themselves and do not tend to reabsorb. At times perfora- tion into the peritoneal cavity takes place with a fatal issue. The usual cause of death in an untreated empyema is the gradual exhaustion or amyloid degeneration accompanying prolonged suppuration. Tuberculosis is also liable to super- vene. When the fluid is removed early there is a fair chance for the compressed lung being restored to complete function ; on the other hand, if the condition has been one of long standing, dense bands of adhesions have generally been formed to such an extent as to allow of but a partial inflation of the lungs, resulting in permanent deformity of the chest and spine. Treatment. — Local treatment is of little avail in children, with the exception of the judicious use of hot applications and a flannel binder in the early and painful stage. Fluid which is present in considerable amount should be promptly evacuated if absorption is not progressing rapidly ; under no circumstances should accumulations of fluid be allowed to re- main in the chest for a period exceeding two weeks, unless decided improvement is noted daily. As the accumulations are almost invariably purulent in character, they are difficult to absorb. DISEASES OF THE RESPIRATORY TRACT. 327 Sometimes a partial removal of the fluid by aspiration pro- duces sufficient relief of the intrapleural tension to excite the activity of the absorbents and lead to a complete recovery. By this method undoubted cases of empyema have been cured without open drainage. — (Goodno.) In cases of long standing, however, and in serous pleurisies of large effusion, displaying a tendency to rapid recurrence after aspiration and producing alarming pressure symptoms, open drainage is to be instituted. Simple incision, when practiced under the strictest antiseptic precautions, yields such prompt and lasting results that it has to a great extent superseded the operation for the resection of a rib. One of the advantages which this operation offers is the foregoing of the use of a general anaesthetic, the local use of Ethyl chlo- ride or Cocaine being all-sufficient. Parace?itesis of the thorax is accomplished with either an aspirator, such as the Dieulafoy or Potain aspirator, or by means of a small trocar. Before inserting the trocar an ex- ploratory puncture with a large size hypodermic needle should be made to locate the fluid. Negative results with the hypo- dermic needle do not, however, exclude the presence of fluid, as the puncture may not have been sufficiently deep, the pus may be too thick to flow, or the needle may become clogged with fibrin, preventing the entrance of the fluid. The usual site of puncture is the sixth or seventh intercostal space in the mid-axillary line or the seventh or eighth interspace posteriorly. The needle should not be inserted too close to the spine, and should be directed toward the upper border of the rib rather than to its lower, on account of the intercostal arteries. Koplik insists on puncturing at the site indicating fluid, as elicited by flatness and absence of vocal fremitus; when the empyema is localized this rule is absolutely essen- tial to follow. Having decided upon the best site for the puncture, the area is thoroughly cleansed and the trocar, previously steril- ized, is forced through the thoracic wall with a slight rotary 328 DISEASES OF CHILDREN. movement. The thumb is firmly held at a distance of about one inch from the point and the trocar inserted to this depth if abundant fluid is present; the stylet is then with- drawn from the canula and the fluid allowed to flow into a pus basin. Care must be taken not to allow the fluid to run out too rapidly, as syncope may result therefrom. Coughing is excited by the operation, but this facilitates the expulsion of the fluid. As the child inspires it is well to place the fin- ger over the opening of the canula to prevent air entering the pleural cavity. Should this take place it will, how r ever, do no harm. Technique of Incision. — The child is laid on its well side and the arm of the affected side held up by an assistant, there- by exposing the lateral region of the chest to its full extent. Beginning first behind the mid-axillary line, an incision is made in the sixth or seventh intercostal space and carried for- ward for a distance of one and one-half inches. The skin should previously have been scrubbed with soap and water and subjected to the action of a wet 1-2,000 Bichloride dress- ing for one hour. Ethyl chloride is the only anaesthetic re- quired. After dividing the skin and intercostal muscles an artery forceps is plunged through the pleura and an opening made sufficiently large to receive a drainage tube. The drainage tube is introduced with a tissue forceps for a distance of about two inches and its free end transfixed with a sterilized safety- pin. After all of the pus has been evacuated a dressing of sterilized gauze covered with absorbent cotton is applied, which will have to be changed once or twice daily, according to the amount of exudation forming. The tube should be re- moved every one to two days and thoroughly cleansed ; as the case improves a smaller tube may be used until it is proper ta allow the wound to heal. Irrigation of the pleural cavity is seldom necessary and is associated with a certain amount of danger. When a good-sized drainage tube cannot be intro- duced equally good results may be obtained from two smaller ones placed side by side. DISEASES OF THE RESPIRATORY TRACT. 329 Relapses may, however, occur on the removal of the drain- age tubes, if there be a virulent streptococcus infection, neces- sitating the resection of a rib ; and if the lung has become markedly crippled, leaving an open cavity in spite of com- plete recession of the affected side of the thorax, the operation of Estlander is to be considered. In the tuberculous variety the ordinary operation for em- pyema seldom accomplishes anything, owing to the rigidity of the chest-walls and the complete collapse of the lung. Re- accumuiation of fluid always occurs after aspiration, although more slowly than in a streptococcus infection. It may be said that, as a rule, non-interference is the best plan, unless the necessity be urgent (Fowler). Remedies. — Aconite, Arnica, Belladonna, Bryonia, Kali card., Rhus tox., Scilla and Tartar emetic will be found use- ful for the early symptoms, they having a special relation to the inflammatory stage. When exudation is abundant, Apis, Arsenicum, Cantharis, Kali hydrojod. and Sulphur are most frequently indicated. In purulent collections one of the constitutional remedies, prescribed upon the temperamental and diathetic peculiarities of the patient, will yield most gratifying results and greatly hasten the progress of the case. Ars., Ars. iod., Calc. card. and phos., Hepar, Iodium, Mercurius, Silicea and Sulphur stand prominently among these. Aeon. — Sharp, stitching pain in side ; high fever, restless- ness and chills ; after exposure to cold, dry winds or checked perspiration. Apis. — Pleuritic effusion ; scanty urine. Arnica. — Traumatic cases ; haemorrhagic effusion. Arsenicum. — Profuse serous effusion ; dyspnoea ; cachexia ; prostration ; empyema. The Iodide of Arsenic is well suited to tuberculous cases, as is also Iodoform. Asclcpiis tuberosa. — Sharp, stitching pains in the side; dry, hacking cough. Complicating pneumonia and tubercu- losis. 22 330 DISEASES OF CHILDREN. Bellad. — Cerebral symptoms ; complicating the infectious fevers or exanthemata. Bryonia. — Early stage of all pleurisies, and in dry pleurisy frequently to the end. Sulphur is needed in the latter cases to complete the cure. Sharp, stitching pains, aggravated by motion and deep breathing ; friction sounds and local tender- ness. Calc. c. — To absorb the pleuritic exudate. Scrofulous and rachitic diathesis. Canth. — Profuse serous exudation ; frequent cough ; dysp- noea ; palpitation ; profuse sweats ; great weakness ; tendency to syncope; scanty and albuminous urine. — (K. Faivre.) Colchicum. — Rheumatic diathesis; sour-smelling sweats; scanty, red, turbid urine, with abundant uric acid and some albumin. Hepar. — Purulent accumulations ; also dry, croupous ex- udate ; abscess of lungs ; hectic fever. " Hepar will often help to clear up the confirmed cases of purulent pleurisy where galloping consumption is apparently threatening." — (Fischer.) Kali carb. — Violent stitching pains, especially on left side, worse in early morning (after fresh adhesions have formed during sleep), accompanied by dry cough and palpitation of the heart. When Bryonia fails to give relief. Kali hydr. — Serous exudations. Mercurius. — Syphilitic or rheumatic diathesis; pains per- sisting after the fever subsides ; constant chilliness, with ten- dency to sweat ; gastro-intestinal catarrh ; perihepatitis. Merc. corr. is useful in pleuritic effusions accompanying parenchymatous nephritis. Phosphorus. — Complicating broncho-pneumonia. Pain in mid-sternal region and on both sides, especially when cough- ing. Also in empyema with Bright's disease ; hypertrophy of right heart ; amyloid changes. Hard, dry, distressing cough with hoarseness. Rhus fox. — Acute rheumatic cases, after exposure to wet t DISEASES OF THE RESPIRATORY TRACT. 331 or after physical overexertion. General aching and prostra- tion ; typhoid state. Scilla. — Sharp stitching pains in side with broncho-pneu- monia ; prostration ; cardiac weakness. Cannot lie on left side. Sulphur. — Later stages of dry pleurisy and after the effu- sion makes its appearance in the exudative variety. Sulphur is a most valuable absorbent, and we are always obliged to come back to this remedy when others fail to improve the condition, or when clear indications for others are not present. CHAPTER XII. DISEASES OF THE HEART AND ITS MEMBRANES. The heart affections of childhood are both congenital and acquired. Congenital affections may be either the result of fcetal endocarditis or developmental defects and abnormali- ties. Acquired heart disease presents the same pathological phenomena observed in adult life, with, however, such clini- cal deviations from the adult type of a given disease as must necessarily result from the physiological peculiarities of the circulatory apparatus distinctive of child-life. Functional disorders are also encountered, but with greater rarity than in adult life, as the common causes for this train of symp- toms, viz., abuse of coffee, tea, tobacco and alcoholics, also neurasthenia and hysteria, are infrequently active at this age. Reflex irritation, however, is a frequent source of cardiac symptoms in the child, notably, gastro-intestinal irritation, helminthiasis and teething. The heart is relatively larger in infancy than in later life, but it does not increase in size proportionally with the growth of the child, developing only slightly during the first five years of childhood (Barthez and Rilliet). It occupies a higher and more horizontal position than in the adult, and for this reason cardiac dulness extends relatively further both to the right and to the left of the sternum. (Fig. 41.) Up to the sixth year dulness may extend beyond the right border of the sternum, and the apex is generally found outside of the left nipple- line up to the fourth year. Again, the apex may be in the fourth intercostal space until the sixth or seventh year. After the seventh year, however, it should be located well within the left nipple-line and in the fifth intercostal space, to indi- cate a perfectly normal condition. It is important to remem- ber that the nipple is not invariably a fixed point, as it may DISEASES OF THE HEART AND ITS MEMBRANES. 333 be found in the third or fourth intercostal space or over the fourth rib. Most frequently it is situated over the fourth rib, somewhat nearer the median than to the mid-axillary line. Deep cardiac dulness extends beyond the left mammary line up to the second intercostal space, and on the right it FIG. 41— SKIAGRAPH OF CHILD'S CHKST, THRKK YKARS OIvD, POSTERIOR ASPECT, THK SHADED PORTIONS INDI- CATING THE HEART AND THE UVKR. may reach to or even beyond the parasternal line in young children. (Sahli, Topographische Percussion im Kinde Salter.) The same author has found this puerile type of heart as late as the twelfth year, although by the sixth year the rela- 334 DISEASES OF CHILDREN. FIG. 42. — CARDIAC DULNESS AT ONE YEAR, SIX YEARS AND TWELVE YEARS. tions as found in the adult are usually established. He further states that the area covered by the deep dulness differs in size and shape from the heart itself, owing to the projection of the borders of the heart upon a chest wall more convex than in the adult, and the admixture of a certain amount of "lateral dulness," resulting from the great resiliency of the chest wall. The heart is therefore not as large es the boundary obtained by deep percussion would indicate (Fig'. 42). Owing to the yielding character of the sternum and the costal cartilages, enlarge- ment of the heart may cause a decided bulging of the front of the thorax up to the third year. This is usually seen in congenital heart disease. The third piece of the sternum may be displaced at even a later period, as Rotch points out, owing to the fact that it is ossified later than the upper portions. Pericardial effusion will cause bulging over the heart at any period of child- hood. The distance of the apex from the mid-sternal line I DISEASES OF THE HEART AND ITS MEMBRANES. 335 have found to be from 4.5 cm. to 5 cm. in the new-born. By the tenth year it is 7 cm. in the average case. In a male child from one to two years old it is from 5.5 to 6 cm., usually a trifle less in females. From the fourth to the sixth year it averages 6 to 6.5 cm. and may reach 7 cm. by the seventh year. The yearly gain in the distance of the apex from the median line seems trifling and does not appear to correspond with the increase in size of the heart, but it must be remem- bered that the heart is relatively large in early childhood and also that it assumes a more vertical position with the fuller development of the child. The pulse is soft and dicrotic in character during child- hood. It is rapid and arythmic in infants. Its rate is about 130 at birth ; 120 at end of first year, and usually remains about 100 up the fifth year. The chilcPs heart exhibits a greater resistance to organic disease than the adult's. The explanation of this is, accord- ing to Soltman (" Der Kinderarzt," ix., No. 2, 1898), the ab- normal elasticity of the great vessels, the relatively greater muscular development of the heart, and the relation of the ventricles to one another. Intra-ventricular pressure has long been held to exert a pronounced influence in the development of endocarditis and its deformities, as shown by the over- whelming frequency with which it is found in the left heart after birth, and in the right during intra-uterine life. The blood pressure in the arteries is considerably lower in the child than in the adult, owing to the relatively greater de- velopment of the aorta and the low arterial tension. The nor- mal blood pressure in children up to the third year is about 90 to 109 mm. of mercury with the Riva Rocci sphygmomano- meter while in adults it ranges from 125 to 135 mm. The volume of the heart compared with that of the aorta is al- most three times as great at puberty as it is in infancy. Normally the first sound heard at the apex is the loudest ; next comes the pulmonary second best heard in the second interspace at the margin of the sternum. The aortic second 336 DISEASES OF CHILDREN. is heard best at the right border of the sternum, a little higher up. At puberty it is usually a trifle louder than the pulmo- nary second, although they may be of about the same in- tensity. It is wrong to speak of the pulmonary second sound being accentuated simply because it is louder than the aortic. As Cabot says, it must be distinctly louder than under normal circumstances in order to be of pathological significance. The characteristics of cardiac murmurs (excluding those due to congenital defects) are summarized by Soltman as fol- lows : AncBmic murmurs are rare in the first four years, and even up to the eighth year, but they are comparatively common at puberty, at which time anaemia and chlorosis are prevalent. The low blood-pressure in the ventricles and large source of origin of the great blood-vessels in early childhood explains their infrequency, their reverse condition obtaining at puberty. They are heard loudest at the pulmonary valve, and are sys- tolic. There must be no heaving impulse, accentuated second sound, or extension of the apex-beat beyond the mammillary line. The pulmonary area is so frequently the seat of mur- murs that Balfour has referred to it as the area of auscultatory romance. It is well always to bear this in mind before ventur- ing an opinion as to the existence of heart disease on so slender a basis. Cardio-pulmonary murmurs (Hochsinger) are produced by the transmission of the contractions of the heart and its move- ments to the lungs. These murmurs are also systolic, and are differentiated from anaemic murmurs by their definite re- lation to the respiratory function, being increased during forced and suspended by a cessation of respiration. They are common in children with deformed chests, due to rickets or Pott's disease, and are best heard over the praecordial region. Endocarditic systolic murmurs are heard in mitral insuffi- ciency ; and for a long time this sign, together with a heav- ing impulse, may be the only symptoms of endocarditis, cardiac enlargement, accentuated second sound and increased tension in the pulmonary artery being absent. DISEASES OF THE HEART AND ITS MEMBRANES. 337 Other murmurs which may be heard in chronic valvular disease are the presystolic^ which may likewise be felt as a thrill running up into the cardiac systole. Occasionally a presystolic murmur may be heard where at the autopsy no mitral stenosis has existed, the valves simply being distorted or one of the chordae ruptured. Again, mitral stenosis is not always accompanied by the presystolic murmur, but in such cases the murmur can often be brought out by causing the patient to exert himself. On the whole, the presystolic is the most fugitive murmur encountered. The Flint murmur — a presystolic apical murmur heard in aortic insufficiency — is so rarely encountered in children that it need scarcely be considered. A diastolic mitral murmur may occur in old mitral cases where there is much dilatation with- out being indicative of aortic regurgitation. It is accom- panied by a loud, banging, pulmonary second sound, and is explained by Steell as resulting from high pressure in the pulmonary artery. As the aortic diastolic murmur is somer times heard at the apex, considerable confusion in diagnosis may arise, especially if we only take the murmur into consid- eration. The murmur Steell refers to should not be confused with the diastolic shock and reduplication heard in adher- ent pericardium. On account of the rapidity of the heart's action it is practically impossible to distinguish between a presystolic and a diastolic murmur. CONGENITAL DISEASES AND DEFORMITIES. As has been said above, congenital heart affections result from either foetal endocarditis or interrupted or abnormal de- velopment. Frequently, however, both of these processes act together — a mechanical obstruction in the circulation, as a re- sult of endocarditis, leading to non-closure of the auricular and ventricular septa or of the ductus arteriosus. For this rea- son it is more common to find a combination of defects rather than an uncomplicated lesion. Thus, Holt found, from an analysis of 242 cases, that the most frequent lesions were a 338 DISEASES OF CHILDREN. combination of pulmonic stenosis with defective ventricular septum, pulmonic stenosis with defective auricular septum, the three lesions associated, or the first two with a patent ductus arteriosus. Foetal Endocarditis. — Inflammation of the endocardium in the foetus is of the chronic or sclerotic variety, verrucose en- docarditis being very rare (OSLER, Keating *s Cyclopes did). Small, nodular bodies, the remains of foetal structure (Ber- nays), and small, rounded, bead-like bodies of a deep purple color, which are the remains of a hsemorrhage (Osler), have frequently been mistaken as evidences of endocarditis, leading to a misconception as to the prevalence of this affection. The characteristics of foetal endocarditis are thickening of the segments of the valves, their edges becoming rounded and shrunken. The semilunar valves become obliterated, leaving a stiff, contracted ridge at the orifice of the great vessels. The right heart is most liable to endocarditis, as well as to errors of development. Congenital Anomalies. — Mentioned in the order of their frequency, according to Holt, congenital anomalies of the heart may be classified as follows : i. Defect in the Ventricular Septum. 2. Defect in the Auricular Septum, or Patent Foramen Ovale. 3. Pulmonic Stenosis, or Atresia. 4. Patent Ductus Arteriosus. 5. Abnormalities in the Origin of the Great Vessels. 6. Pulmonic Insufficiency. 7. Tricuspid Insufficiency. 8. Tricuspid Stenosis, or Atresia. 9. Mitral Insufficiency. 10. Mitral Stenosis, or Atresia. 11. Aortic Insufficiency. 12. Aortic Stenosis, or Atresia. 13. Transposition of the Heart. 14. Ectocardia. DISEASES OF THE HEART AND ITS MEMBRANES. 339 Defect of the ventricular septum is most frequently associ- ated with pulmonic stenosis or defect of the auricular septum. The defect is most frequently found in the anterior muscular portion of the septum (RokiTANsky). If compensatory hy- pertrophy of the right ventricle supervenes, no apparent symptoms may be present. Cyanosis results from an ob- structed venous circulation, with embarrassed respiration, cy- anosis and oedema. This, and not the mixing of arterial with venous blood, is the cause of the cyanosis (Baginsky). Patency of the foramen ovale may exist without any evi- dence of cardiac disease. When, however, other anomalies increasing the pressure in the right auricle co-exist, a mixing of venous and arterial blood takes place, with resulting cya- nosis. Under these circumstances the child is liable to an early death. Stenosis of the pitlmonary artery is one of the commonest of congenital heart affections, as a rule being responsible for the existence of the above-mentioned anomalies. The usual cause for the stenosis is endocarditis, although there may be a developmental defect of the pulmonary artery (ostium) or of the conus arteriosus. The symptoms depend upon the amount of constriction at the pulmonary orifice. The infant may die shortly after birth with intense cyanosis and as- phyxia, or it may grow up to adult life, with, however, signs of deficient aeration of the blood, cyanosis from undue phy- sical exertion, coldness of the extremities, clubbing of the finger-nails, and mental and physical apathy. Simple pul- monary stenosis is found only before the thirteenth month according to Rokitansky. The obstruction to the circulation in the great majority of cases that do not die in early infancy leads to the defects mentioned above. Patent ductus arteriosus does not necessarily produce symp- toms. Hirst finds a certain degree of patency of the duct quite common in children during the first year of life, but in these cases there is no appreciable deviation from the normal circulation. The symptoms produced are hypertrophy and 340 DISEASES OF CHILDREN. dilatation of the right ventricle ; dilatation of the pulmonary artery ; dyspnoea and cyanosis; bronchitis. The physical signs are pronounced. Abnormalities in the origin of the great vessels are rare, and lead to early death or make extra-uterine life impossible, un- less there is an open foramen ovale or a communication be- tween the pulmonary veins and the right side of the heart. Tricuspid insufficiency and stenosis are grave defects, result- ing from endocarditis. There may be complete atresia of the orifice, in which case a degree of circulation is maintained through an incomplete ventricular septum. The right heart becomes dilated and hypertrophied ; there is cyanosis and tendency to venous haemorrhages. Affections of the left heart are rarer than those of the right, and result likewise from endocarditis. The symptoms and physical signs are the same as observed later in life. The symptoms of congenital heart affections may be summed up as the indications of deficient aeration of the blood or a mixing of venous with arterial blood, and interference in the systemic circulation. Cyanosis is the most persistent symp- tom, and is, in fact, pathognomonic of congenital heart dis- ease in the absence of other causes capable of exciting this phenomenon. Among these may be mentioned pneumonia, asphyxia, bronchitis, atelectasis, congenital pleurisy, partial occlusion of the trachea, degeneration of the blood, interfer- ence with the nerves of respiration. — (Hirst.) Dyspnoea is another prominent symptom. Among the later manifestations of congenital heart disease are clubbing of the finger-nails, cold extremities, mental and physical apathy, deformity of the chest from hypertrophy, and dilata- tion of the heart. Hypertrophy will produce deformity of the sternum up to the third year. The first symptoms are usually noticeable at birth, the child being a so-called " blue-baby." At other times they are very mild, and are only noticed when the child becomes ex- cited or attempts physical exertion. Again, the defect may DISEASES OF THE HEART AND ITS MEMBRANES. 341 not be suspected until an acute affection of the respiratory tract precipitates the symptoms, or it may not become appa- rent until the child grows up. The diagnosis rests upon a recognition of the above-men- tioned symptoms, together with the physical signs. Accord- ing to Sansom, a patent foramen ovale is to be recognized by cyanosis without a heart murmur (in which case we must necessarily exclude all other causes for cyanosis), or by cya- nosis with systolic and presystolic murmurs over the carti- lages of the third and fourth ribs. The same observer also claims that defective ventricular septum is to be recognized by a loud systolic murmur over the praecordium and between the shoulders, not transmitted to the vessels. In tricuspid stenosis and insufficiency there is hypertrophy and dilatation of the right heart, labored heart's action, pre- cordial thrill, loud systolic and diastolic murmurs at the apex. Stenosis of the pulmonary artery presents a hypertrophied right heart ; loud systolic murmur over the second and third costal cartilages to the left of the sternum, not transmitted into the carotids, and precordial thrill. The pulmonary sec- ond sound is weakened. When these signs are present in a child over thirteen months old it can be taken for granted that there is an open foramen ovale. When the murmur is also transmitted into the carotids it points to associated sep- tum defect. When there is a loud, buzzing murmur trans- mitted into the carotids and subclavians, together with accen- tuated pulmonary second sound and hypertrophy of both ven- tricles, there is probably associated an open ductus arteriosus (HochsingER, Auscultation des Kindlichen Herzens). Patency of the ductus arteriosus leads to rapid hypertrophy of the right ventricle and dilatation of the pulmonary artery, increased area of cardiac dulness, long-continued systolic mur- mur with thrill and cold surface. The presence of a thrill and a distinctly-defined area of dulness in the second intercostal space to the left of the sternum, above the heart, is of great diagnostic import (Koplik, Diseases of Infancy and Child- hood). 342 DISEASES OF CHILDREN. The treatment must aim at a betterment of the condition of the circulation through compensatory changes in the heart, and protection against external influences and physical over- exertion. Acute affections of the respiratory tract are espe- cially to be feared. Attacks of cyanosis or threatened cardiac failure and dyspnoea will call for stimulation with either aro- matic spirits of ammonia or brandy. On general lines Aconite, Arsenicum, Camphor, Cuprum, Digitalis, Glonoin, Lachesis, Rhus tox. and Veratrum viride are to be considered, their symptomatology covering the con- ditions met with in these cases, namely, hypertrophy, dysp- noea, excessive heart-action, cyanosis, etc. When symptoms are urgent spirits of ammonia will prove helpful. PERICARDITIS. Pericarditis in infancy is almost invariably seen as a com- plication of pneumonia, especially those severe pneumonias in which the pleura is notably involved (pleuro-pneumonia). Later on it will be seen secondary to rheumatism, pleurisy, scarlet fever and tuberculosis. Of all the causes capable of exciting pericarditis, rheumatism is the most important, and a certain amount of pericardial involvement is always to be suspected in severe cases of rheumatic endocarditis, although under these circumstances effusion seldom takes place. Traumatism and caries of the ribs or vertebrae are local causes which may excite a pericarditis. The effusion shows a strong tendency to become purulent, as do all effusions into serous membranes during childhood. The cases I have seen at autopsy, complicating pneumonia, were serous. Abundant fibrinous exudate is, as a rule, thrown out and a gluing together of the layers with complete oblitera- tion of the pericardial sac is the usual unfortunate result. The pathological changes noted elsewere in inflammations of serous membranes are to be seen in pericarditis. The tendency to the pouring out of effusion, containing cellular elements in abundance, is pronounced. The dry stage is of DISEASES OF THE HEART AND ITS MEMBRANES. 343 short duration. When the amount of fibrin, which covers the serous surfaces, is considerable and the effusion not sufficient to separate the layers, the heart presents a shaggy, irregular surface. The opposing surfaces may become adherent with a net-work of villous bands. As these bands of fibrinous exu- date are absorbed tHey are replaced by granulation tissue rich in fibrinoblasts and permanent connective tissue formation results. More or less mediastinitis, as a rule, accompanies pericarditis in children. Adhesions form to a greater or less degree in all cases which recover from the acute symptoms. This leads to a hyper- trophy of the heart, or dilatation from interference with the nutrition of the myocardium. When absorption of the effu- sion is delayed, myocarditis develops, usually, leading to dilatation. Symptomatology. — The early symptoms of pericarditis are rarely recognized in an infant owing to their obscurity and overweighing symptoms of the disease to which it is sec- ondary. If the child is old enough to complain of pain in the region of the heart, which may also be referred to as radiating to the left shoulder or epigastrium, or as occurring alone. in these locations, a careful physical examination will reveal local tenderness and possibly cardiac friction-sounds, beside direct- ing our attention to the fixation of the left side of the thorax. If friction-sounds are elicited, they will be heard as a rubbing or crackling sound synchronous with the heart's action and in- dependent of respiration. They are most distinct under the fourth rib to the left of the sternum, and may simulate a mitral regurgitation murmur. However, cardiac friction- sounds do not only accompany the heart-sounds, but they are prolonged beyond them, being interposed and at times oc- cupying the whole duration of the cardiac action (Skoda). In several cases I have heard the friction-sound most dis- tinctly toward the base of the heart. Here it will persist even when moderate effusion has occurred, because this gravitates to the bottom of the pericardial sac. 344 DISEASES OF CHILDREN. With the appearance of the effusion the pulse, which was at first full and irritated, becomes feeble and irregular. Op- pression, dyspnoea and cyanosis develop with the outpouring of sufficient fluid to embarrass the heart's action ; and event- ually convulsions, and in older children delirium and coma, close the scene in fatal cases. A rapid outpouring of serum into the pericardium may produce sudden death. We some- times see this occur during an attack of rheumatic fever and in pneumonia. The pulse is of the greatest importance in recognizing acute inflammatory affections of the heart, being strongly suggestive of such a complication when irregularity and en- feeblement suddenly develop during an acute illness. The pulsus paradoxus may be present, but is not pathognomonic, as it may occur under other conditions in childhood (Stef- FEn). Bulging of the prsecordial region, increased area of cardiac dulness, and muffling of the heart-sounds and im- pulse are only to be elicited in severe cases. The two last signs are notably difficult to determine on account of the natural resiliency of the child's thorax and the greater ac- commodation possible under reverse conditions. The area of dulness is not triangular as in adults, and the heart, with its distended sack, retains its normal position, simply enlarging. Enlargement is more pronounced to the left. Unless dulness reaches up to the second interspace on the right side, it is more likely due to dilatation of the right ventricle than to fluid (Koplik). The percussion note is flat and resistent. Adhesions are to be suspected when there is a displacement of the apex not due to marked hypertrophy, or cardiac dila- tation and retraction of the intercostal space during systole. The mere retraction of the apex region during systole is by no means diagnostic of pericardial adhesions. When, how- ever, associated with retraction of a considerable area of the thorax during systole, which rapidly returns to normal dur- ing diastole, we have strong evidence of the same (Gerhardt, Lehrbuch der Auskultation u. Percussion). Perhaps the most DISEASES OF THE HEART AND ITS MEMBRANES. 345 conclusive sign is that pointed out by Broadbent, namely, re- traction of the lower intercostal spaces posteriorly, due to tugging on the adherent diaphragm. The sudden rebound after systole produces a diastolic shock which is also pathog- nomonic taken in conjunction with the above signs. This is followed by a sudden collapse of the veins of the neck (Friedreich). When thickening and contraction of the mediastinal structures, especially in the area surrounding the upper portion of the pericardium, is associated, there may be lessening of the calibre of the radial pulses and swelling of the neck veins during inspiration (Kussmaul). In many cases the diagnosis can be made as nearly as any physical signs permit by the following brief observations insisted on by Paul {Diseases of the Heart) — cardiac hypertrophy ; violent impulse of the heart, as a whole, but a feeble impulse of the apex. To this should be added, diastolic shock. The prognosis of pericarditis is always grave, particularly when complicating pneumonia and scarlet fever. The like- lihood of adherent pericardium resulting, which eventually produces myocarditis and dilatation, must be borne in mind. Treatment. — The child should be kept as quiet as possible during the active symptoms, and in case of recovery any phy- sical exertion must be forbidden until every danger from cardiac dilatation is past. The ice-bag applied to the prae- cordium is of decided advantage in older children. Purulent collections in the pericardium which fail to become absorbed rapidly are less favorably treated surgically than pleural effu- sions, for which reason every effort should be made to over- come this condition remedially before resorting to aspiration. Aeon. — Chilliness; hard, bounding pulse; sharp pain in region of heart ; great restlessness and sighing ; dyspnoea and syncope. Useful in the earliest stages to control the vascular excitement. Arsen. — Great anguish and oppression ; constantly chang- ing position ; cyanosis ; thirst ; in consequence of repelled exanthems, or in connection with pneumonia ; stage of effusion. 23 .346 DISEASES OF CHILDREN. Bryonia. — This remedy follows well after Aconite, and is most applicable during the stage of effusion, although it seldom absorbs the exudate completely. Sulphur is a most valuable remedy for this purpose, especially when the case be- comes protracted. Cactus grand. — Sensation of constriction about the heart, as if a strong hand were grasping it. There may also be a sense of deep-seated soreness in the prsecordium, with dysp- noea ; attacks of suffocation ; fainting ; small, irregular pulse. Digitalis. — Copious serous effusion ; small, intermitting pulse ; diarrhoea and vomiting ; syncope. Ioolium. — Complicating croupous pneumonia. Violent palpitation and oppression from slightest motion ; must lie perfectly quiet on back. Spigelia. — After Aconite, when the friction-sound becomes audible. Sharp, stitching pains in chest. Spigelia is a most efficient remedy for the painful stage. Besides these are to be considered Asclepias tuberosa, Bell., Cannab., Canth., Kali carb., Lack., Merc, cor., Veratr. vir. ENDOCARDITIS. Endocarditis is more liable to develop during the course of a rheumatic fever in children than in adults, but as the rheu- matic condition is not as typical in children as in adults, this relationship is often overlooked. Likewise endocarditis is frequently associated with chorea and erythema nodosum, and recurring crops of subcutaneous fibrous nodules about the joints are taken as an indication of a progressive cardiac affection. Packard (Amer. Jour. Med. Sci., Jan., 1900) notes five cases of acute tonsillitis and pharyngitis having no con- nection with rheumatism or any of its manifestations, in which endocarditis developed. While in these cases toxins absorbed from the throat might have set up structural changes in the endocardium by coagulation-necrosis or other chemico-vital action, still he inclines to the belief that the endocardium is directly infected with micro-organisms, DISEASES OF THE HEART AND ITS MEMBRANES. 347 they gaining entrance by way of the tonsils. In support of this view is Charrius' case in which the staphylococcus aureus was found, both in the tonsils and in the endocardial vegetations. Endocarditis is, therefore, in all probability, of infectious origin, being the result of infection with pyogenic cocci or with the pneumococcus of Frankel. The tubercle bacillus may also set up acute endocarditis (Von Ruck). In simple endocarditis Sanger and Frankel have been able to demon- strate bacteria, and, according to Eichhorst {Specie lie Pathol- ogie n. Therapie), no distinction can be made between the group of micro-organisms capable of exciting the ulcerative variety in one case and simple endocarditis in another. The frequency with which the endocardium is attacked during the course of a rheumatic fever is readily interpreted by accepting in acute rheumatism an infectious disease, the result of spe- cific bacteria, which attack with preference the serous mem- branes. Meyer {Zeitschr. f. Klin. Medicin., Band Ixvi., p. 311) found verrucose endocarditis present in twenty-one of one hundred animals injected with his diplostreptococcus. This micro-organism is probably identical with the one Poyn- ton and Payne claim to be the cause of rheumatic fever. Outside of rheumatism, endocarditis is seen with scarlatina, pneumonia, diphtheria, nephritis and septicaemia, in which case it is usually of a severe type. The ulcerative variety is also frequently associated with wound infection, and always partakes of the nature of a septic condition. In simple or verrucose endocarditis the valves become cov- ered with inflammatory excrescences — endocardial vegetations. ( )wing to destructive changes in the endothelial cells and com sequent roughing of the surface of the valves these fibrinous formations are deposited fiom the circulating blood. At the same time the valves become thickened and distorted from interstitial cellular proliferation and vascular engorgement. Portions of the fibrinous vegetations may become detached and be swept into the general circulation, producing an em- 348 DISEASES OF CHILDREN. bolus at some distant point. The mitral valve is the most frequent seat of the endocarditic process, next in frequency being the aortic valves. Right-sided endocarditis has been discussed under Fcetal Endocarditis. In malignant, or ulcerative endocarditis the inflammatory state is more pronounced, being coupled with ulcerative and even suppurative processes in the endocardium. Symptoms. — The onset of an endocarditis is always insid- ious, and especially when complicating another acute affec- tion is its presence likely to be overlooked. Again, children rarely complain of pain or distress in the region of the heart, and a primary case may run its entire course unrecognized, being mistaken for some infectious disease, such as influenza or rheumatism. When associated with tonsillitis it is fre- quently overlooked. Subacute cases may run a long time with slight afternoon rise of temperature, progressive anaemia and loss of weight. Such cases are easily confused with tuberculosis and malaria. A routine examination of the heart in all febrile conditions is, therefore, imperative. Endocarditis should be suspected if, during an acute infec- tious disease, there is an abrupt rise in the temperature with increased and weak pulse, precordial distress and dyspnoea. In children of the rheumatic diathesis, a fever rapidly attain- ing a height of 104 ° to 105 , together with tonsillitis, is fre- quently accompanied by a severe endocarditis in the absence of all articular symptoms. The pulse, which at first is strong and possibly slow in comparison to the temperature range, soon becomes rapid and feeble, even dicrotic. A certain amount of myocarditis always accompanies endocarditis, and when cardiac weakness becomes extreme it should be sus- pected as a co-existing condition. Praecordial distress and dyspnoea may be present, which, together with flushed face and the peculiarity of the pulse above referred to, are strong indications of this disease. The distress sometimes amounts to actual pain, which in young children may be referred to the epigastrium. DISEASES OF THE HEART AND ITS MEMBRANES. 349 The pathognomonic symptom of endocarditis is the charac- teristic bruit, also described as the bellows murmur from its soft, blowing character. The murmur is systolic and is heard best at the apex. Endocarditis may, however, exist without this murmur being perceptible, as the subsequent course of the disease will show ; and, again, during the infectious fevers a murmur is frequently heard, but it disappears during con- valescence, leaving no trace of valvular defect behind, an BIG. 43- ACUTE RHEUMATIC ENDOCARDITIS WITH DILATATION*; CYANOSIS AND DYSPNOEA MARKED. autopsy entirely failing in these cases to demonstrate an in- flammatory condition. If we study the murmur from day to day, we find that it gradually increases in loudness and dis- tinctness, the first indication of its advent being a prolonga- tion and blurring of the first sound of the heart. According to Dr. O. Sturges (Ashby and IVright), a faint murmur heard at the top of the ensiform cartilage, indicating 350 DISEASES OF CHILDREN. . regurgitation at the tricuspid orifice, due to back pressure through the lungs, can in some cases be heard to precede the mitral bruit. With malignant or ulcerative endocarditis the symptoms of septicaemia become prominent; the temperature is intermit- tent, and there is enlargement of the spleen and albuminuria, beside a strong tendency to embolus formation in the brain or in other important organs. Such cases are fatal, as a rule, while in a well-managed case of simple endocarditis the prog- nosis as to life is always favorable, but the ultimate outcome as regards permanent valvular defects is a question. There is no doubt that in some cases, under proper treatment, the murmur will entirely disappear and there will be no evidence of valvular leakage or obstruction later on. On the other hand, endocarditis may produce such general damage to the endocardium as to blight the child's existence permanently and lead to early death. A comparatively slight lesion, also, by producing mitral stenosis, will do much more harm than one simply causing a leak at this valve. Another important point to be remembered is the strong tendency to recurrence in endocarditis, especially in rheumatic subjects. Every new attack adds to the existing damage. Treatment.— An essential element in the successful treat- ment of endocarditis is absolute rest, as any physical exertion capable of exciting the heart to increased action will neces- sarily exert a baneful influence upon the inflammatory pro- cess. The body surface must be carefully protected against chilling influences, and long-continued rest, even during con- valescence, is at times imperative, particularly when myocar- ditis is suspected. The ice-bag applied for fifteen minutes to half an hour, every two hours, is a valuable adjuvant during the acute stage. Prophylaxis is of importance. Children subject to rheu- matism should be kept under constant vigilance, and their diet and dress carefully regulated. Enlarged tonsils and ade- noids should be removed. DISEASES OF THE HEART AND ITS MEMBRANES. 351 Aconite, Belladonna and Veratrum viride in the early stages, and later Spigelia, Spongia, Cactus, Bryonia and Col- chicum, are the most important remedies. After the acute symptoms have subsided much of the damage to the heart naturally to be expected can be prevented and overcome by the judicious choice of a remedy capable of absorbing the in- flammatory products and correcting the resulting disturbances. It is not difficult to obtain sufficient data for such a prescrip- tion, and here Aurum, Iodium, Spongia, Sulphur, Calc. card., Lachesis, Arsenicum and Arsenicum tod. are the most fre- quently indicated drugs. Kali mur. exerts a specific, action upon the heart-muscle, and is recommended to avert dilatation (Arnulphy). Aeon. — Chilliness; hard, wiry pulse with high fever, rest- lessness and dyspnoea. Veratrum viride has less of the rest- lessness ; the arterial tension is extreme and cerebral symp- toms may supervene, and, although it controls excessive car- diac action promptly, its influence upon the inflammatory process and the fever is inferior to that of Aconite. Belladonna. — Full, bounding pulse, flushed face, skin hot and moist, delirium. Bryonia. — Purely rheumatic cases; pericarditis and endo- carditis; sharp pains at heart, relieved by lying upon the affected side ; tongue dry and coated ; great thirst ; no desire to move. Cactus. — Sense of constriction in region of heart ; oppres- sion of breathing. (See Pericarditis.) Colchicum. — Rheumatic endocarditis ; tearing pain in region of heart; small, thready pulse (JousSET). Iodium. — Purring sensation in region of heart on palpation ; violent palpitation and dyspnoea, even to fainting, on slight- est exertion, with pneumonia ; if Spigelia does not give relief within a reasonable period of time (Kafka). Kali carb. — Blowing systolic murmur with accentuated pulmonary sound ; pulmonary engorgement; weakness of the heart-muscle, with anasarca of feet and ankles; associated myocarditis ; after Bryonia. 352 DISEASES OF CHILDREN. Spigelia. — Considered by some the most important remedy in endocarditis. It may be given as soon as the condition be- comes recognizable, in the absence of strong indications for another remedy. Personally I prefer Bryonia, as I consider it more closely related to the pathologic process. There is no doubt, however, that Spigelia is a most valuable remedy in many cases of acute heart pain. Spongia. — Paroxysms of oppression and pain in the heart ; inability to lie with the head low, or even complete inability to lie down on account of the choking paroxysms induced thereby. MYOCARDITIS. Acute degenerative and inflammatory changes in the heart- muscle are of frequent occurrence in the acute infections of childhood. The toxins of diphtheria, scarlet fever and ty- phoid fever are especially concerned in the production of my- ocardial degeneration (Romberg). True inflammatory changes — myocarditis — are most frequently associated with endo- and pericarditis, and are due to the invasion of the heart-wall with pyogenic organisms, chiefly the streptococcus pyogenes, staphylococci and the pneumococcus (Ziegler). Myocardial changes have also been observed in whooping- cough by Koplik and Osier. Pyrexia is a contributing cause, but does not seem able to produce myocarditis by itself. The varieties of degeneration encountered are granular, hyaline and vacuolar. All of them may have more or less fatty changes associated. The process may be purely degen- erative throughout, but, as a rule, exudation and cell prolifer- ation in the connective tissue stroma is associated therewith. In infectious and pysemic cases areas of round cell infiltration play a prominent role, which may break down, resulting in small intramural abscesses. At autopsy the heart is found of a pale, yellowish-brown, turbid color and the muscle is easily torn. It is the soft-heart of the older writers. The process is mostly diffuse, although DISEASES OF THE HEART AND ITS MEMBRANES. 353 in true myocarditis the changes may be more pronounced in different areas. The symptoms are essentially those of a weak heart. When myocarditis develops during the course of typhoid fever or pneumonia we realize that the pulse is too thin and rapid, the disproportion in the respiratory ratio too pronounced, and the first sound too weak to be accounted for merely by the fever. In the absence of demonstrable peri- and endocarditis we feel that here we have to deal with a degenerated myocar- dium. In the course of diphtheria the child is suddenly seized with epigastric pain, vomiting, syncope; rapid, irregu- lar pulse. A much worse prognosis than such a condition cannot well be named. The softening of the heart-muscle invites dilatation ; there is, therefore, usually some dilatation, especially of the right ventricle. A faint apical systolic murmur may be present. The heart is usually rapid and embryocardiac in rhythm. Bradycardia may develop, especially after diphtheria. On the other hand, there may be no symptoms, or only a short time before death w r ill there be sufficient indications to make us suspect myocarditis. Chronic myocarditis presents the symptoms described under Chronic Heart Disease as "failing compensation." The diagnosis of myocarditis cannot always be made during life, but there are certain symptoms that strongly point to its existence. The subject is well summarized by Koplik {Med. News, March, 1900) as follows: Attacks of faintness, pallor, vomiting; disturbed and irregular heart's action ; persistent distortion of the respiration and pulse-ratio as in adherent pericardium. When these attacks show a tendency to recur they are certainly significant. Physical examination reveals a weak apex-beat, weakness of the first sound or loss of its muscular quality, greater intensity of the second sound at the apex and accentuation of the pulmonary second sound. In pertussis there is in addition slight systolic blow at the apex, oedema of the face and extremities, pallor, cyanosis and drow- siness. 354 DISEASES OF CHILDREN. The prognosis is grave. Under long-continued rest the heart may regenerate sufficiently to resume its function as before, providing the changes have not been too extensive. The symptoms described as indicative of myocarditis are in reality due to dilatation (OSLER). The abrupt death in the course of an acute infectious disease results from cardiac paralysis. The treatment calls for the most complete rest. As long as symptoms show the slightest tendency to recur the child should not be permitted to feed itself or make the slightest physical exertion. The remedy most homoeopathic to the degenerative changes is Phosphorus^ and it is no doubt of value. I have certainly seen it benefit cases of this class. Alcohol should at the same time be given in moderate amounts. As an emergency remedy, Holt speaks highly of Morphia. CHRONIC VALVULAR DISEASE. Chronic acquired valvular disease is the sequel to inflam- matory affections of this organ, notably acute endocarditis. The lesions which may be encountered are : (a) Thickening and distortion of the valves; (b) Fibrinous or calcareous de- posits upon the valve-leaflets; (c) Hypertrophy of the walls; (d) Dilatation of the chambers; (e) Adherent pericardium. These changes are usually seen in various stages of develop- ment, and in pronounced cases they may all be demonstrated in different portions of the organ. The mitral valve is by far the most frequently affected seat of lesion, the aortic valve being rarely affected in children, and, when so, more often in association with mitral disease than alone. The changes in the valves above referred to lead either to regurgitation or obstruction at the orifices. Both conditions may exist at one orifice, so that it is not uncommon to find mitral stenosis and regurgitation in the same patient. Symptoms. — The history of an organic heart affection can be described in three stages, constituting the classical course DISEASES OF THE HEART AND ITS MEMBRANES. 355 pursued by this disease. T\\ejirst stage marks the onset, be- ing- the acute inflammatory stage, which leads either to im- mediate damage to the valves or to chronic endocarditis. The rheumatic diathesis underlies the vast majority of all cases of recurring or chronic endocarditis, and it is usually possible to obtain a previous history of rheumatic symptoms, such as recurring acute tonsillitis with joint pains, arthritis, erythema, fibrous nodul-es, chorea, etc., or to note the later development of one of these conditions in a case of valvular heart disease. The second stage is that of compensation, during which the heart adapts itself to the extra strain brought upon its mus- cular walls incident to the leakage or obstruction at its ori- fices. This is accomplished through hypertrophy of the ven- tricular walls, and a compensating heart is. therefore, usually an enlarged or hypertrophied organ. When compensation is perfect there are naturally no symptoms ; but as this is not always the case, the patient suffering more or less from short- ness of breath on exertion, palpitation, attacks of epistaxis, bronchitis, indigestion. TJiird stage. — The stage of failing compensation is the period at which the heart becomes incompetent to maintain the circulation, in consequence of which the arteries are but imperfectly filled with blood and the veins become engorged. Although the patient may be abruptly thrown into this stage by undue physical exertion or a fresh attack of endocarditis, pneumonia, typhoid fever or scarlet fever, still the usual course is that of progressively-increasing cardiac weakness, hastened by impairment of the general nutrition, anaemia, in- tercurrent diseases, etc. The symptoms of cardiac incompetency, when of gradual onset, will show themselves in dropsy of the lower extremi- ties; difficult breathing from the slightest physical exertion and when lying with the head low ; cough, with frothy, blood- streaked expectoration; flatulent indigestion; scanty, albu- minous urine of high specific origin. When of sudden onset 356 DISEASES OF CHILDREN. there is marked dyspnoea and cyanosis ; the lnngs are the seat of venous engorgement, which frequently leads to pulmonary oedema and death. The imperfect circulation resulting from valvular disease interferes with the general nutrition and sets up important visceral changes. To the former belong clubbing of the fin- gers and stunted growth, and to the latter, chronic bronchitis, chronic congestion of the spleen, liver and kidneys. The prognosis of organic heart disease is never favorable, as complete recovery is impossible, and the possibility of re- newed attacks of endocarditis and other factors capable of rupturing compensation must be a constant menace to the child's condition. The course is usually a progressive one, and puberty seems to exert an unfavorable influence upon the disease. Nevertheless, well-managed cases may attain adult life with safety, and by the maintenance of a good general nutrition develop no serious symptoms. MITRAL REGURGITATION. Mitral regurgitation is the commonest valvular defect of childhood, resulting from distortion, and consequent imper- fect closure, of the mitral valve. Owing to the regurgitation of the blood into the left auricle, the same becomes hypertro- phied, and later dilated; the pulmonary circulation becomes embarrassed and an extra amount of work is thrown upon the right ventricle, which also hypertrophies in order to meet the extra strain upon its walls. The damming back of the blood in the pulmonary artery causes the accentuated second sound over the pulmonary valve, so characteristic of mitral regur- gitation. The left ventricle eventually hypertrophies, in con- sequence of the increased pressure in the pulmonary artery, against which it must work in order to sustain the circula- tion. Urgent symptoms are the result of failing right heart, the right ventricle often dilating to a great degree, even to the production of incompetency of the tricuspid valve. The physical signs of mitral regurgitation are a systolic DISEASES OF THE HEART AND ITS MEMBRANES. 357 murmur heard with the greatest intensity at the apex and transmitted into the left axilla ; accentuated second sound over the pulmonary artery ; increased area of dulness to the right, indicating hypertrophy and dilatation of the right ven- tricle ; displacement downward and outward of the apex. MITRAL STENOSIS. Mitral stenosis is frequently associated with regurgitation, owing to a shrinkage of the valves and the auriculo-ventricular orifice, or obstruction resulting from fibrinous or calcareous deposits. In quite a number of instances, however, it exists alone, and in such cases it is generally associated with sub- acute rheumatism and insidious endocarditis. There are cases in which we can get absolutely no history of rheuma- tism or any other preceding infectious disease. A typical case of mitral stenosis is marked by dyspnoea ; small, feeble pulse ; dilatation of the left auricle, and hyper- trophy, with later dilatation of the right ventricle, the left ventricle not participating in the process unless regurgitation is associated. The physical signs are a presystolic murmur, which may assume a purring character, perceptible to the touch ; sharp, snappy first sound at the apex ; accentuated second sound over the pulmonary valve ; area of dulness in- creased upward and to the right. The presystolic thrill is the most characteristic of all signs in valvular heart disease, and upon this symptom alone — if we can exclude adherent pericardium — the diagnosis is readily made. It is best felt by placing the flat hand over the cardiac area, the thrill being plainest in the fourth interspace to the left of the sternum. Mitral stenosis is more frequently found in phthisical sub- jects than the other forms of valvular disease. Indeed, mitral regurgitation is looked upon as unfavorable to the develop- ment of phthisis. 358 DISEASES OF CHILDREN. AORTIC STENOSIS. Stenosis of the aortic orifice results from pronounced at- tacks of endocarditis, for which reason it is one of the rarer organic affections and seldom seen alone, usually being asso- ciated with mitral regurgitation. From the nature of the lesions at the aortic orifice, regurgitation is also frequently added to the obstruction. Unless there is marked stenosis, symptoms are not prominent, as the hypertrophied left ven- tricle perfectly compensates for the defect. Complete recov- ery is possible. The physical signs are a systolic murmur heard over the aortic orifice and transmitted into the carotids; displacement of the apex downward and outward from hypertrophy of the left ventricle; slowing of the pulse. AORTIC REGURGITATION. Regurgitation of the aortic orifice, like stenosis, is rare in children, and is never observed as a single condition. The commonest causes for aortic regurgitation, namely, sclerosis of the valves due to syphilis, gout and alcoholism, are practi- cally never present in children, and for this reason it is only found with severe cases of endocarditis, especially the variety- complicating the infectious fevers, from which stenosis and mitral disease also result. In a case which came under my notice the valve was found unaffected by inflammatory de- posits at the autopsy. There was, however, mitral disease and dilatation. The insufficiency at the aorta was, therefore, most likely relative, i. DISEASES OF THE NERVOUS SYSTEM. 507 and nothing short of a careful examination under an anaes- thetic will serve to differentiate a pronounced case from true hip-joint disease. This holds good for other joint affections in which fixation and pain without any objective signs are present. In order to expel all doubt it may become neces- sary in an obscure case to resort to the tuberculin test. Tremors and rhythmical spasms, the latter simulating chorea, are other motor accidents deserving mention. Sensory Accidents. — A pseudo-meningitis is occasionally encountered, and is distinguished from true meningitis by the history of the case, the absence of slowing or irregularity of the pulse and active pupils. In other respects it bears a close similarity to meningitis, presenting intense headache ; vom- iting ; fever; vasomotor streaks (laches cerebrates), and rigid- ity of the neck and extremities. Recovery, however, takes place, and a careful study of the patient reveals other evi- dences of hysteria. Spinal tenderness may be confined to the region of a few vertebrae and closely simulate Pott's disease ; but if the patient's attention can be detracted momentarily quite a con- siderable amount of pressure will be borne without causing pain. Visceral Accidents. — Disturbances in the respiratory tract show themselves as aphonia, usually developing suddenly after a fright, the voice being lost, but cough persisting ; dyspnoea, due to laryngeal or diaphragmatic spasm ; tachyp- ncea, sudden attacks of extremely rapid breathing, presenting alarming symptoms, without the evidence of physical signs to account for the same, and pulmonary congestion. The lat- ter is rare. It may produce cough with bloody expectoration, and simulate phthisis. In the digestive tract, vomiting, globus hystericus, oesopha- geal spasm, anorexia and obstinate constipation are to be ob- served. Frequent urination of large quantities of pale, limpid urine or complete anuria, sometimes retention of urine, are the dis- turbances encountered in the urinary tract. 508 DISEASES OF CHILDREN. Vasornotor and Trophic Accidents. — Cutaneous hemorrhages and ga?igrene of the skin are among the rare hystero-neu roses, while erythema and vesicular eruptions are commonly met with. Der7natographism is occasionally observed. Muscular atrophy and fibro-tendinous contractures are rarely well marked, although they may develop to a sufficient de- gree to require tenotomy in cases of long standing. The muscles do not give the reaction of degeneration, although they may be partially atrophied and show a quanti- tative loss in electrical excitability. The prognosis of hysteria is especially favorable in chil- dren, as they are readily influenced by suggestion, and, if the proper surroundings and intelligent treatment can be pro- vided, recovery is generally comparatively rapid. The acci- dental disturbances, as a rule, disappear spontaneously after a variable period of months or years, or they may be purely transient. The mental state can, however, seldom be im- proved beyond a certain limit, and the hysterical tempera- ment will persist throughout life in the majority of cases, even reflecting itself upon the offspring. Sensory accidents are stubborn in their course, bringing considerable suffering to the patient and much anxiety to the friends and attendants. The spasmodic manifestations can usually be cured promptly if the patient can be taken from their parents and kept under intelligent care. In the diagnosis much importance is to be attached to a recognition of the stigmata of hysteria ; in other words, the hysterical temperament, in conjunction with the emotional origin of the ailment and the polymorphous and changeable character of the manifestations. Beside this, the differential features serving to separate hysterical from organic diseases, as pointed out in the symptomatology, should serve in leading to their recognition. This applies particularly to paralytic affections, which are of especial interest to the podiatrists. In coxalgia an anaesthetic may be required to remove any doubt in establishing the condition under consideration. DISEASES OF THE NERVOUS SYSTEM. 509 Hystero-epilepsy is rare in children, and its differentiation from epilepsy has been discussed in the article upon that subject. Treatment. — The general management of hysteria resolves itself into removing all exciting causes, isolation being the most effectual method for this purpose ; attending to the re- moving of all sources of reflex irritations, such as phimosis and errors of refraction, and building up the constitution by means of regular calisthenic exercises, a highly-nutritious diet and a liberal amount of sleep. Suggestion presents itself as a most potent agent in restor- ing the patient's confidence and overcoming the various dis- turbances which have an imaginary origin. In managing cases of paralysis our main effort must be in the direction of promising the patient that the line of treatment employed will bring positive results. To emphasize this suggestion such adjuvants as massage and electricity are employed with benefit. This does not, however, apply to ill-managed cases of long standing, in which the surgeon's aid must be sought. The beneficial results following upon even the most trivial surgical measures resorted to in hysterical subjects is a note- worthy clinical fact, which often can be taken advantage of as a justifiable means of treatment. Medicinal treatment serves a twofold purpose, namely, by augmenting the force of the suggestions and also by improv- ing the patient's general condition and correcting the various disturbances in the nervous system and other localities. It is needless to mention the close relationship existing between neurasthenia and hysteria in children, and, therefore, remedies which will improve the nutrition of the nervous system can- not fail to influence the hysteria. Such remedies as Picric acid, Calcarca ear/?., Silicea and Phosphorus exert a potent influence in this direction. Remedies possessing notably hysterical symptoms are Ig- natia, Hyoscyamus, Aconite, Asafoetida, Moschus and Valerian. The efficacy of drugs in such conditions as hysterical palsy 510 DISEASES OF CHILDREN. and hystero-epilepsy is doubted by many. Arndt {Practice of Medicine) expresses the opinion that " they are often helpful, es- pecially in times of great emotional excitement." If that were the case, a remedy should be useful as well at any other time when its symptoms are present, even if the disease be hysteria. An unfortunate error often made in managing hysterical subjects is to look upon them as simply imagining their troubles and, therefore, requiring no treatment. Nowhere more than in hysteria does it require firm yet gentle supervi- sion and persistent and encouraging suggestion to lift the patient out of his imaginary fears and afflictions. With a hysterical child we have a campaign of education before us which must be carried out up to the time of adolescence. The parents are often these children's worst enemies, and iso- lation is, therefore, one of the first steps in the treatmeut of a confirmed case. PARALYTIC AFFECTIONS: CEREBRAL PALSIES. The cerebral palsies of childhood comprise a group of con- ditions which may be either of intra-uterine onset, or which are acquired during parturition or at a still later period. Cases of intra-uterine origin are usually developmental in character, and to this group belong porencephalia, agenesis corticalis and other defects, although evidences of haemor- rhage and sclerotic changes, as a result of traumatism, foetal meningoencephalitis and syphilis, have been observed in rare instances. In birth-palsies, haemorrhage is the primary lesion. It occurs frequently in protracted labors, and although forceps- pressure may directly induce a haemorrhage, still it does not play as important a role as long-continued compression of the head in the pelvic straits or within the uterus. It has also been supposed that undue pressure upon the trunk during the extraction of a breech presentation maybe the direct cause for the rupture of a bloodvessel in the brain. The bleeding takes place from the capillaries and veinules of the pia mater or DISEASES OF THE NERVOUS SYSTEM. 511 choroid plexus in most cases, more rarely from the longitu- dinal sinus and veins, and almost never from an artery. Venous congestion attending compression of the cord and asphyxia may give rise to a pial haemorrhage, but the weight of evidence is in favor of attributing the majority of cases of asphyxia neonatorum to haemorrhage. A new-born infant therefore, with pallid asphyxia should be looked upon as most likely an apoplectic one unless good reasons for some other cause are at hand. Where the amount of blood-extravasation is not sufficient to cause death, it ultimately is absorbed or becomes organized with consequent sclerosis of adjacent areas of brain-substance and developmental retardation. The symptoms attending such a condition .will naturally depend on the locality affected. The cerebral palsies encountered later in child-life are the result of either haemorrhage, embolism or thrombosis. A cerebral abscess or tumor may likewise cause definite para- lytic manifestations, but in their etiology and clinical course they differ distinctly from the foregoing conditions. Haemor- rhage at this period of life is more frequently meningeal than cerebral. It may result from traumatism, arteritis, or from a sudden and severe venous congestion of the brain occurring during a convulsion or during a paroxysm of whooping-cough. I have seen two cases resulting directly from whooping-cough. The convulsion is probably the result of the haemorrhage, and not vice versa. Birth-palsies are usually bilateral, that is, diplegic or para- plegic, while the later palsies are most frequently hemiplegia Sometimes hemiplegia attacks an infant in apparently perfect health, the symptoms coming on with fever, followed by con- vulsions and hemiparalysis. Struinpell advanced the theory that these cases were infectious, and that an acute inflamma- tory process in the cortical gray matter of the motor area was the primary lesion. Pathologically and etiologically it was supposedly similar to poliomyelitis, for which reason he named it "Acute Polioencephalitis of Infants ." Osier and Sachs 512 DISEASES OF CHILDREN. from a study of a number of these cases, question the correctness of this view, claiming that the lesions are probably always haemorrhagic. In spite of the opinion of the high authorities just quoted, I believe with Mills, Holt and others that we do encounter cases whose mode of onset and clinical course cer- tainly appear to bear out Strumpell's theory of an inflammatory lesion of infectious origin. Again, I believe that in some cases the symptoms are purely toxic, and we know that in adults apoplectiform attacks without haemorrhage frequently occur as a phase of uraemia. In such cases we are surprised to find no gross lesion at the autopsy. Recently a colored child, two years old, previously perfectly healthy, was brought to my clinic for convulsions occurring daily and confined to the left side of the body. There was hemiplegia, although considerable improvement was manifest. The condition de- veloped suddenly six weeks previous, the child being seized with these one-sided convulsions and temporary loss of con- sciousness, followed by hemiplegia. There was also fever continuing for several days. Why haemorrhage should occur in such a case is hard to explain, but an encephalitis is quite conceivable. Abscess is most frequently secondary to suppurating otitis media. Sinus thrombosis results from extreme anaemia in conjunc- tion with feeble heart's action occurring during exhausting illness, or from infection from the middle ear. In such cases thrombosis of one of the lateral sinuses, with its characteristic symptoms, results. Embolism is most frequently associated with endocarditis, only in rare instances originating from clots which have formed in the left auricle or elsewhere. Symptomatology. — The lesions just enumerated may. be productive of a variety of manifestations, for which reason we may encounter either hemiplegia, diplegia, paraplegia or mon- oplegia in these cases. The last two are rare, especially mon- oplegia, and paraplegia is frequently only apparent — a careful examination also revealing evidences of paralysis in the arms, together with mental deficiency. DISEASES OF THE NERVOUS SYSTEM. 513 The mental condition is impaired and the head is usually small or irregular of form. Epilepsy develops in about one- half of these cases, assuming the true degenerate type of the disease. Diplegic cases are congenital, or result from injuries sus- tained during parturition. As above stated, the lower ex- tremities are most markedly affected, and athetosis is a promi- nent symptom. The case shown in the illustration, which is a very typical one, did not have athetoid movements. The child was men- tally deficient, but there had been no convulsions. Lack of mental development can be traced back to the earliest period of infancy and on account of the spasticity of the legs they do not learn to walk until very late. The rigidity in both arms and legs varies in degree ; when pronounced it reminds one of the resistance encountered in bending, a piece of lead > for which reason it has been described as " lead-pipe rigidity." Together with this there is a crossing of the lower extremi- ties due to adductor spasm and a tendency to equino-varus. The gait is, therefore, extremely difficult or impossible, and the hands are usually not well under control, being entirely helpless when athetosis is marked. A type of congenital diplegia resulting from defective development of the pyra- midal tracts in the brain and cord, seen in underdeveloped or premature children, has been described by Little, of London {Little's Disease). They are not deficient in mind, and the spastic condition usually improves with the development of the nervous system. Sachs (New York Medical Jour., May, 1896) has reported a series of cases of congenital cerebral agenesis occurring as a family disease, in which amaurosis, progressive debility and a fatal termination are the clinical features. More or less diplegia, with spasticity, is usually present. A number of these cases is reported in the literature under the name of u - luiaurotic Family Idiocy." The prognosis is unfavorable in all cases, but especially in 514 DISEASES OF CHILDREN. the diplegic forms, in which little can be done aside from im- proving the child's general condition by means of massage and faradism, or by surgical measures when necessary. The proper training of such cases is, however, of the greatest im- portance, through which means both the mind and body may be most wonderfully improved. In recent cases of hemiplegia the child must be dealt with purely symptomatically, and remedies are of decided use FIG. 49. — A CASE OF CEREBRAL DIPLEGIA IN A CHILD TWO AND ONE-HALF YEARS OLD, SHOWING SPASTIC RIGIDITY OF ARMS AND LEGS. here. Massage and faradization of the extensor muscles, and mechanical contrivances to overcome contractures, are gener- ally useful later on. Arnica, Kali hydrojod and Sulphur are aids in absorbing the i hemorrhagic extravasations, while Causticurn, Cocculus and Cuprum frequently exert a beneficial influence upon the paralytic symptoms. DISEASES OF THE NERVOUS SYSTEM. 515 ACUTE ANTERIOR POLIOMYELITIS J INFANTILE SPINAL PARALYSIS. Poliomyelitis is perhaps the commonest form of paralysis encountered in childhood and, as the name implies, is an in- flammatory infection of the spinal cord, the lesion being a focal one and practically confined to the gray matter consti- tuting the anterior horns. The acute form is almost exclu- sively a disease of childhood, being most frequently encoun- tered in the later period of infancy. Poliomyelitis is occa- sionally encountered in adults, and then usually assumes a subacute type. Regarding the etiology nothing definite is known, but, judging from the clinical course of the disease, namely, rapid onset, with fever and other constitutional disturbances, its great predilection for the age of childhood, and the frequency of endemic and epidemic outbreaks — we are justified, in the present state of our knowledge, in classing it among the in- fectious diseases. Pathology. — The site of predilection is the cervical or lumbar enlargement of the cord and the inflammatory process extends into the anterior horns by way of the median branches of the ventral spinal artery. The toxine responsible for the lesions excites either a focal haemorrhagic myelitis, or the initial lesion may be embolism or thrombosis of one of these arteries (Marie). The multipolar cells of the anterior horn undergo atrophy and the inevitable result is paralysis and atrophy of the muscular fibres supplied by these nerve cells. In old cases the horn appears shrunken in size and inflamma- tory tissue occupies the place of the multipolar cells. Symptomatology. — The onset is rapid, with fevei of a moderate degree and some constitutional disturbances, even delirium and convulsions having been observed, or the symp- toms are so slight as to escape notice, and the child develops an extensive paralysis, without any apparent cause for the same being ascertainable. The stage of invasion, therefore, 516 DISEASES OF CHILDREN. varies from a few hours to several days, and is of little diag- nostic value.. The paralysis is usually of extensive distribution in the beginning ; but as improvement sets in the paralysis becomes limited to those regions which have been most seriously af- fected, in which muscular atrophy also develops. With the onset of paralysis local tenderness in the limbs may be noted. The paralysis rapidly increases, remains stationary for a period of a week or two, after which it rapidly improves in certain regions, while in others prominent disability remains and wasting of the muscles sets in. The reflexes are lessened or abolished, according to the ex- tent of the paralysis, but control over the sphincters is rarely lost, such an occurrence indicating a grave outlook. The alteration in the electrical reaction of the muscles manifests itself as the reaction of degeneration. The growth of bones may be greatly retarded through involvement of their trophic centres in the cord. The distribution of the permanent paralysis varies greatly in individual cases. It may involve one or more extremities or remain confined to a few muscles of an extremity. The lower extremities are most frequently affected, but seldom equally. In the leg the most common deformity encoun- tered is talipes equinus with flexed leg, resulting from wast- ing of the extensor muscles. In the upper extremities the deltoid, the extensors of the wrists and the inter osseii are most frequently affected. The prognosis is unfavorable in so far as recovery of function in the paralyzed and atrophied parts is concerned, although there is seldom danger to life. Reaction to faradic stimulation is always a favorable sign, even when the muscles have failed to respond to this test earlier in the disease. Early loss of the same, however, indicates a permanent paralysis in most instances. Diagnosis. — The diagnosis of both the early as well as the late manifestations of poliomyelitis anterior may be beset DISEASES OF THE NERVOUS SYSTEM. 517 with difficulty. Until paralysis is well developed, the disease cannot be positively recognized, and then it may be con- founded with rachitic pseudo-paralysis, multiple neuritis and cerebral palsy. The latter is of abrupt onset, is ushered in by convulsion, and the paralysis is one-sided and uniform. Besides, the reflexes are increased in a central lesion while in poliomyelitis they are abolished. In neuritis the onset is more gradual as a rule and there is pain, together with per- sisting tenderness, along the nerve trunks. There is never the atrophy seen in poliomyelitis. Epidemics have been ob- served in which there were cases of peripheral as well as spinal paralysis. The pronounced muscular atrophy of polio- myelitis, therefore, together with the reaction of degeneration and the history, are the features of poliomyelitis by which it can be differentiated from other forms of paralysis. The Idiopathic Muscular Dystrophies bear a close outward resemblance to the late manifestations of anterior poliomye- litis. They have been divided into a variety of clinical types, but are all closely related both etiologically and pathologi- cally. The main point' of distinction between these myopa- thies and poliomyelitis is their slow and progressive develop- ment, the symmetrical distribution of the atrophic changes, and the strong hereditary element and developmental factor in their etiology. The pathological changes observed in progressive muscular atrophy take place primarily in the muscles themselves, and the various clinical types of the disease really come under one and the same heading from the pathological standpoint (Erb). The muscle-fibres at first become hypertrophied, undergoing subsequent atrophy. The connective tissue is slightly in- creased. In isolated cases degenerative changes have been observed in the cells of the anterior horn (chronic poliomye- litis). The following types have been described : The Juvenile Type of Erb. — In this form the muscles of the arms and shoulders are mainly affected. 518 DISEASES OF CHILDREN. The Facio-scapulo-humeral Type of Landousy-Dejerine (In- fantile Form of Duchenne\ in which the face, together with the arms and shoulders, are affected. The Peroneal Type of Charcot and Marie, in which the peroneal muscles become atrophied. This may be followed by atrophic changes invad- ing the legs, trunk and upper extremities, and there is evi- dence of cord-lesions asso- ciated with the atrophy, showing itself as fibrillary twitching and reaction of degeneration. Pseudohypertrophic Para- lysis is a disease of early childhood, most frequently seen in boys, characterized by enlargement of the calves and buttocks, associated with atrophic changes. The mus- cles finally shrink, present- ing the same condition as the other forms of atrophy. The characteristic symptoms produced are a waddling gait; difficulty of climbing up stairs and great awkward- ness ; enlargement of the legs and buttocks ; lordosis ; inability to arise from the ground without the aid of the hands. In order to attain the erect position the child supports the hands on the anterior surface of the thighs and gradually pushes himself upright (Fig. 50). Treatment. — The child should be disturbed as little as possible, not interfering with ill-judged applications of fara- FIG. 50.— CLIMBING UP THE THIGHS IN PSEUDOHYPERTROPHIC PARA- LYSIS (GOWERS). FROM BARTEETT'S DIAGNOSIS. DISEASES OF THE NERVOUS SYSTEM. 519 dism to the affected limbs during the acute stage, but wrapping them in cotton and enjoining absolute rest. — (BartlETT.) Later in the disease electricity proves of decided benefit. If the muscles do not respond to the faradic current the gal- vanic should be employed. The object is to produce muscu- lar contractions in order to improve the nutrition of the muscle and restore function as far as that is possible. Passive movements and massage should be added to the treatment in order to overcome deformities. When once established, these will require surgical measures to correct them. The disa- bility in a joint resulting from atrophy of one of the muscles either flexing or extending the same is often satisfactorily corrected by a properly adjusted brace, which not only sup- ports the joint but also prevents deformity. The remedies indicated in the early stages are such as will control the inflammatory condition, with the hope of lessen- ing the secondary destructive changes. Aeon., Bell., Bry., Gels., and Rhus tox. should be studied and carefully differen- tiated if there is a sufficiency of symptoms to prescribe upon. Otherwise, Bell, should be given the preference. Mercurius may be given with a view of absorbing exudation as promptly as possible. Plumbum is indicated at a later period. "The symptoms of chronic lead-poisoning correspond very closely with the symptoms of poliomyelitis." — (C. G. R.) It has seemed to me that the administration of Cdusticum has in some cases at least improved the tone of the muscles after the condition had come to the point of standstill. FAMILY ATAXIA. Family ataxia, also known as Friedreich } s disease, occurs as a family disease, several or all of the children of a family being attacked by a degenerative process of the posterior and lateral columns of the spinal cord as a result of teratological defects in its structure (neurogliar sclerosis). The first symp- toms usually make their appearance shortly before puberty, a period at which the processes of growth and nutrition are 520 DISEASES OF CHILDREN. taxed to their utmost. When there are successive in a family they usually develop at a progressively increasing earlier period of life. An acute infectious fever may also hasten the development of symptoms, leading to its occurrence in early childhood. Hereditary cerebellar ataxia of Marie is characterized by a similar defective condition involving the cerebellum ; but it develops after puberty, and is accompanied by pronounced choreiform movements, increased deep reflexes, and optic- nerve atrophy, symptoms not belonging to spinal ataxia. Symptomatology. — One of the earliest symptoms noticed is an awkwardness in the legs, marking the beginning of the ataxia. Later the arms become involved. There is first un- steadiness in walking and standing, the child sways from side to side in attempting to maintain its equilibrum. As the muscular sense is not lost, the condition depending entirely upon incoordination, no increased difficulty in standing is noticed when the eyes are closed. The ataxia is associated with gradually increasing loss of power. The knee-jerk is lost early in the disease. This distinguishes it from the cerebellar variety, in which there is also at times an ankle clonus. Disturbances of speech develop as incoordination becomes general. The speech is irregular and jerky, and lacks modu- lation and rhythm. Nystagmus may develop later in the disease, being espe- cially noticed with lateral rotation of the eyes. The expres- sion is one of apathy and indifference, although the intelli- gence is not impaired early, but it becomes more or less retarded with the progress of the case, as does also the phys- ical development. Shortening of the foot, with exaggerated plantar arch and retraction of the great toe {club-foot and /iammer-toe), is a common deformity of family ataxia. An- other deformity is dorso-lumbar scoliosis. These deformities may develop before ataxia becomes pronounced, and consti- tute an early sign of the disease. DISEASES OF THE NERVOUS SYSTEM. 521 The course is that of a progressively-increasing and hope- less malady, but remissions or aggravations may take place. There is nothing in the disease itself to cause death, for which reason the person so afflicted may live to adult life. Isolated cases are to be differentiated from cerebellar ataxia, chorea and multiple {insular) sclerosis. In the latter there is characteristically scanning speech, spastic gait and intention tremor. HEREDITARY SPASTIC PARAPLEGIA. This is a rare disease, first described by Striimpell, which develops in early childhood and pursues a progressive course. The pathologic findings are degeneration of the lower part of the pyramidal tracts. There is no cerebral involvement, con- sequently no history of birth injury or convulsions during in- fancy followed by paralysis, and the patients do not show evidence of mental deficiency nor do they become epileptic, as in the cerebral diplegias and paraplegias resulting from haemorrhage. Although the symptoms may not develop until adult life, still there seems to be no doubt that it is a terato- logical defect in the upper motor neuron. The symptoms are marked by spasticity and hypertonus of the muscles of the lower extremities, without sensory disturbances or involve- ment of the sphincters. The reflexes are increased. Bayley {four. Xerv. and Ment. Diseases, Nov., 1897) reported a series of cases in which the disease was traced back through five generations. The pathological findings are those of a de- generative process in the pyramidal tracts, the direct cerebel- lar tract and the columns of Goll. The course is slow and progressive. SYRINGOMYELIA. Syringomyelia is a disease of the spinal cord in which the spinal canal becomes pathologically enlarged as a re- sult of gliomatous infiltration, which subsequently breaks down. By the same process new canals of considerable length 34 522 DISEASES OF CHILDREN. may be formed within the gray matter of the cord. Although a rare disease in childhood, still it has occasionally been en- countered in young subjects. As to its etiology nothing definite is known, excepting that embryonal neurogliar tissue degenerates or becomes the seat of haemorrhage. The symptoms resulting from a central myelitis or from a haemorrhage into the cord — the latter, at times, occurring dur- ing parturition — cannot be distinguished from those belong- ing to glioma. Symptomatology. — The disturbances of syringomelia may be divided into several groups. Involvement of the sensory pathway in the gray commissure and posterior horns and columns gives rise to loss of pain and heat perception, with- out, however, loss of the tactile sense. This anaesthesia may be so complete and extensive as to render the patient in- sensible to almost any kind of pain and expose him to many dangers. Motor disturbances develop later than the sensory, and pre- sent paralysis of groups of muscles of a limb, usually becom- ing bilateral and accompanied by trophic changes. The reac- tion of degeneration is present. These symptoms indicate involvement of the anterior horns and pyramidal tracts. Vasomotor disturbances, cyanosis, coldness, cutaneous erup- tions and dermatographia may accompany the above process. Trophic changes, with resulting atrophy, fragility of bones, enlagement of the hands, and tendency to the development of whitlow and abscesses, are also to be noted. The course is progressive, and results fatally when bulbar crises set in. In the diagnosis, the idiopathic muscular dys- trophies, hysteria and multiple neuritis are to be excluded. The distinct features of syringomyelia are its gradual de- velopment and insidious onset, and the dissociation of touch and pain in conjunction with motor, trophic and vasomotor disturbances. DISEASES OF THE NERVOUS SYSTEM. 523 MULTIPLE CEREBRO-SPINAL SCLEROSIS. Multiple or disseminated sclerosis, as the name implies, is a degenerative process affecting the brain and cord as an ir- regularly seattered sclerotic process. The islets of sclerosis are found principally in the centrum ovale, cms, pons and medulla in the biain, and in the cord they are irregularly scattered, as a rule attacking the white matter more promi- nently than the gray. It is most common between the ages of twenty and thirty, but it may occur in children or even be congenital. The cause of multiple sclerosis is probably to be found in an infection, but, judging from the numerous and often mixed infections noted, it seems unlikely that we have to deal with a specific organism. — (Church.) Symptomatology. — Owing to the widely-distributed lesions of multiple sclerosis a variety of disturbances are encountered in the nervous system. The characteristic and most promi- nent features of the disease are : {a). Motor. — A coarse, jerky incoordination, especially in the arms, observed on attempts at voluntary movements. This intention tremor is associated with progressively increas- ing loss of power. The gait is spastic and is associated with deranged equilibrium (cerebello-spasmodic gait). (b.) Sensory disturbances are practically confined to the eye. Nystagmus is a frequent symptom, and optic neuritis and atrophy may develop. (c.) Cerebral Disturbances. — The speech defect, known as u scanning speech, " in which there is an undue separation and accentuation of the syllables of words, and a state of in- difference, loss of memory and dejection, are the prominent cerebral features of the disease. A predisposition to hysteria seems to exist, and it is not uncommon to find livsterical manifestations complicating multiple sclerosis. (d.) The deep reflexes are exaggerated, as a rule, but there may be a loss of knee-jerk, and paralysis of cranial nerves in some cases. 524 DISEASES OF CHILDREN. The course of multiple sclerosis is quite irregular. It may begin gradually and increase in a progressive manner, or it may begin abruptly as an apoplectiform attack, or with vertigo or visual disturbances. Remissions are not infrequent, and may lead to a belief that the disease has been checked ; but complete recovery must be very rare, although Church con- siders it possible. Diagnosis. — Multiple sclerosis is to be differentiated from infantile cerebral palsy, hysteria and family ataxia. In in- fantile cerebral palsy the history of traumatism during birth and the early appearance of diplegia, followed by mental re- tardation, rigidity and athetosis, will serve as a distinguish- ing feature. In hysteria the mental stigmata, the absence of nystagmus, and the presence of sensory disturbances and muscular rigidity, are of great significance, although both diseases may be associated in the same patient. In family ataxia there is inco-ordination and spasmodic muscular action ; the knee-jerks are abolished, the muscles are flaccid, and the eyes are seldom affected, except by a slight degree of nystagmus, with lateral rotation of the eyes. The treatment of these cases is very unsatisfactory. Ac- cording to Arndt, Arsenicum is of especial value. Tarantula has also been recommended. Bartlett refers to the salts of gold, lead and mercury. MULTIPLE NEURITIS. Inflammation of several nerves occurring at the same time or in quick succession occurs mainly from diphtheria during childhood. Malaria, typhoid fever, scarlet fever, measles, in- fluenza and acute rheumatism are responsible for some cases, but to a much less degree than the first mentioned infection. In marantic conditions and as a result of the cachexia of tuberculosis it may be encountered. Toxic cases, notably those seen in adults resulting from alcohol, arsenic and mer- cury are rare in childhood. There is a class of idiopathic cases that is quite puzzling. To this belong the rheumatic DISEASES OF THE NERVOUS SYSTEM. 525 cases following exposure to cold or resulting from over-ex- ertion and those coming on suddenly with febrile symptoms, in the midst of apparently perfect health. Clinically they resemble acute poliomyelitis closely, especially when occur- ring in epidemics. The lesions are a degenerative process in the axis-cylin- ders, not, however, affecting the nerve trunk uniformly and completely. This is associated with hyperaemia of the peri- and endoneurium. In some of the severer cases of diphter- itic paralysis degenerative lesions have been demonstrated in the cord and even in the brain in association with the neu- ritis. Symptomatology. — The clinical course of diphtheritic paralysis has been described under Diphtheria. In non-diph- theritic cases there is first noticed a general weakness of the muscles, together with pain and tenderness along the affected nerves. Tingling and formication are also frequently com- plained of. The paralysis which results is usually of wide distribution, producing foot-drop and wrist-drop, inability to walk, and spinal curvature. Partial anaesthesia likewise de- velops, and considerable atrophy of the paralyzed muscles takes place. The knee-jerk is abolished, and if power of locomotion is not entirely lost the child shows marked ataxia in walking and standing. In the course of a few weeks im- provement sets in, and after a time complete recovery is the rule, although permanent loss of function may persist. Permanent disability is rare in children and the prognosis is good, as the etiologic factors responsible for the unfavorable outcome in adults — such as alcohol — do not enter here. A fatal termina- tion may take place in diphtheritic paralysis, or in other cases of rapid onset and wide distribution, in which the res- piratory and cardiac innervation becomes involved. Diagnosis. — The gradual onset, usually developing during the period of convalescence from an infectious disease or af- ter exposure to damp and cold (rheumatic cases), the sym- metrical distribution, and the accompanying sensory disturb- 526 DISEASES OF CHILDREN. ances, will serve to differentiate multiple neuritis from polio- myelitis anterior, as well as from the various ataxias. Its tendency to progressive improvement and recovery is another feature of diagnostic importance. The presence of pain is an important symptom, especially tenderness along the nerve trunks. In children it is often difficult to estimate the de- gree of pain, but, as Koplik says, the children resent being handled, and they cry most of the time and are restless at night, consequently it is safe to infer that they have pain. It is true, there may be pain in the early stages of acute poliomyelitis, but the general paralysis clears up more quickly and atrophy in a single limb or rarely in a portion of two limbs rapidly sets in. The electrical reactions are more typ- ical and constant than in neuritis. Treatment. — The child should be kept in bed and put on a plain, highly nutritious diet. Mild galvanization of the affected nerves and, as atrophy sets in, massage of the mus- cles are of great benefit. To overcome deformity in the ex- tremities it may be necessary to resort to mechanical devices. Aconite. — Recent cases following exposure. Tingling and formication in the affected parts is its chief indication. This and Rhus tox. are the chief remedies in idiopathic neuritis. Arse?t. — Malarial or cachetic cases; burning pains; gen- eral prostration. Marantic origin ; cachexia. Arge?itum nitr. — Ataxic symptoms. Causticum is a most useful remedy for localized paralyses due to neuritis, or for the later changes of multiple neuritis. Gelse??iiu?n is useful in the early period of infectious cases, notably in diphtheritic paralysis. Rhus tox. is of great value in rheumatic cases. Traumatic cases call for Arnica and Hypericum, especially the latter. SYMPTOMATIC AFFECTIONS: NEURALGIA. Neuralgic pains may be observed in malnutrition and anaemia, particularly in chlorosis, or they may indicate a malarial infection. Hysteria is another prominent factor in DISEASES OF THE NERVOUS SYSTEM. 527 the etiology of various painful affections of childhood in which structural changes cannot be demonstrated, but on the whole neuralgia is uncommon before the period of pu- berty. Gastralgia is a form of neuralgia which is usually the re- sult of indigestion. It is discussed under the diseases of the stomach. Local irritations, especially carious teeth, are com- mon causes for neuralgia. Referred pains have their special significance, e. g., pain in the knee in hip-joint disease ; ab- dominal pain in pleurisy ; the various forms of headache re- sulting from eye-strain, nose and ear disease, etc. Before a diagnosis of neuralgia can be positively made, it is essential to exclude all inflammatory conditions or sources of local irritation which might possibly cause the pains com- plained of. This is especially necessary in children, as seri- ous organic disease may be overlooked by neglect of this pre- caution. The treatment is mainly constitutional. A sufficiency of out-of-door exercise should be combined with a diet consist- ing especially of fats, milk, and vegetables. If anaemia is a pronounced feature, this should be corrected (see " An&mia") The most useful remedies in neuralgia are Aconite, Arseni- cum, Belladonna, Chamomilla, China, Colocynthis, Gelsemi- num, Rhus tox. and Spigelia. The characteristics of these remedies must be taken into consideration in prescribing for a neuralgic affection, noting the locality, the character of the pain and the aggravation and amelioration. In chronic cases, constitutional treatment gives the best results. HEADACHE. A variety of conditions — notably anaemia, lithaemia, eye- strain, neurasthenia, hysteria and gastric derangements — give rise to headache as a symptom meriting special atten- tion. In inflammatory and organic brain affections it is a prominent symptom, and in the infectious fevers and in uraemia it is quite constantly present. 528 DISEASES OF CHILDREN. Migraine is an essential headache, coming paroxysmally and resulting from nervous discharges in the cortical sensory centres. The exciting causes may be any of the disturbances capable of producing headache, such as mental or physical fatigue, eye-strain, acute indigestion, etc. The condition itself is usually hereditary, and is one of the manifestations of a neuropathic constitution, being, so to speak, a sensory epilepsy. The symptoms of migraine in childhood are the same as those observed in adults, with the exception that they are not quite so severe and usually of less frequent occurrence. Scin- tillating scotomata are often observed, being described as fiery flashes or figures before the eyes. The pain may be confined to one side of the head, and is accompanied by nau- sea and vomiting, the latter giving relief, as a rule, although indigestion has nothing to do with these attacks excepting that it may act as an exciting cause. Other disturbances — e. g., amblyopia; hemianopsia; aphasia; numbness and ting- ling in various parts of the body, followed by anaesthesia, and possibly paralysis — may be observed during an attack. The diagnosis of migraine is based upon the paroxysmal nature of the attacks, the presence of nausea and vomiting without gastric derangement, and the accompanying sensory disturbances. Symptomatic headaches are recognized by their transitory nature and the presence of one of the causes enu- merated above as causing the same. It is important both from the standpoint of prognosis and treatment to exclude intracranial disease in these cases by carefully searching for evidences of the same, and observing the patient over a sufficient length of time to determine the true nature of the case. Treatment. — Children subject to migraine should be care- fully dieted, especially avoiding sugar and starch, as these pa- tients are usually lithaemic. Errors of refraction must receive prompt attention. One of the following remedies will usu- ally be indicated during the paroxysm DISEASES OF THE NERVOUS SYSTEM. 529 Arg. nitr. — Deep-seated pains in the temples of a boring or pressing character, relieved by pressure. Dimness of vision with vertigo, tendency to fall to the side. At its height there are trembling of the whole body and intense nausea. Attack preceded by chilliness, indisposition and loss of appetite. Bell. — Congestive headache ; throbbing of the carotids ; throbbing pains in the temples ; face flushed. Often right- sided. The pain is worse lying down, and is temporarily re- lieved from sitting up. Cham. — Beginning with flickering and fiery zigzags before the eyes. Great irritability of temper. Glon. — Violent pulsations in brain from below upward ; there is high arterial tension ; vertigo ; ringing in the ears and palpitation of the heart, each beat seeming to increase the pain in the head. Brought on by exposure to the sun. Ig?iatia. — Hysterical headache ; clavus hystericus ; from emotional excitement or over-pressure at school. Highly nervous temperaments. Iris. — The attack begins with dimness of vision and termi- nates with the vomiting of a yellowish, bitter, sour-smelling fluid. Usually right-sided. Pulsatilla. — Left-sided attacks, with anorexia, belching and vomiting. Anaemia in mild, yielding subjects. Sanguinaria. -Pain beginning in occiput and spreading over the top of the head, settling over the right eye. Great sensitiveness to light ; flushes of heat and alternate chilliness. The attack ends in vomiting. Spigelia. — Neuralgic pains over the left eye Chlorosis. CHAPTER XVII. DISEASES OF THE EAR, NOSE AND THROAT. OTITIS. Inflammation of the middle ear is of common occurrence during infancy and childhood, although it is a condition that is frequently not suspected unless an ear discharge appears. Being often followed by most serious sequelae, which may either result in the death of the patient or leave him perma- nently deaf for the remainder of his life, it is of the greatest importance that its advent should be anticipated ; that it be recognized early and the proper treatment instituted during the course of the attack. Every case of otitis, however, does not present so serious a prognosis. As will be seen from the de- scription of the course of the different varieties, there is a mild, catarrhal form complicating rhino-pharyngitis or appar- ently occurring primarily and also a serious suppurative vari- ety occurring as a complication of one of the infectious fevers, notably scarlatina. The external auditory canal is directed more forward in the infant than in the adult, for which reason it is at times neces- sary to draw the lobe of the ear downward and forward in order to insert the speculum instead of drawing the aurical upward and backward, as in adults. Often the speculum is best inserted when traction is made directly backward on the aurical, and I cannot say that, as a rule, I find the direction of the canal forward, as mentioned in most text-books. The Eustachian tube is wider, shorter and more horizon- tally placed than in the adult, and this anatomical feature, in conjunction with the prone position so constantly assumed by the child, offers the explanation why extension of an infec- tion of the nose and throat travels so readily through the tym- DISEASES OF THE EAR, NOSE AND THROAT. 531 panum. The tympanic orifice is larger than the pharyngeal. Inflation of the middle ear is more easily accomplished than in adults. The membrana tympani, or drum head, is almost horizon- tally placed, at first gradually assuming the perpendicular as the ear develops. It is thicker than in the adult and does not rupture so readily spontaneously. The tympanic cavity is bounded superiorly by a thin plate of bone upon which the middle lobe of the brain rests. In the infant a suture, the petroso-squamosal, is found, allowing a vascular communication between the middle ear and the dura mater. For this reason meningeal irritation is so com- monly observed in conjunction with otitis media. The close proximity of the inferior wall to the jugular fossa accounts for the liability of phlebitis and thrombosis of the jugular vein to occur as complications. The upper portion of the tympanic cavity containing the malleus and part of the incus is known as the attic. It com- municates with the mastoid antrum, and for this reason an ac- cumulation of pus in the tympanum reaching to or confined to this point is usually followed by infection of the mastoid process. On account of the undeveloped state of the mastoid, however, involvement of the petrous bone and of the brain is more common than mastoiditis. The mucous membrane lining the tympanum is quite thin and vascular, presenting a reddish and swollen appearance in young infants. The mastoid process is but a small, undeveloped tuberosity at birth and contains, as a rule, only one cell, the antrum. It gradually develops by extending downwards and at the age of five years reaches the adult type. The upper wall of the antrum is in close proximity to the dura mater, being sepa- rated therefrom by only a thin lamina of bone. The facial nerve passes along the upper portion of the tympanic cavity and downward through the mastoid cells. For this reason it frequently becomes affected in middle ear and mastoid disease. 532 DISEASES OF CHILDREN. Earache is the most prominent symptom of otitis, but it is possible for an inflammation of the middle ear to exist with- out any definite pain. This sometimes occurs in marantic infants, in whom an ear discharge may be the first sign of the trouble. Again, the pain may be vague and not definitely localized or be masked by cerebral irritation, but in these cases pressure at the tragus will usually elicit tenderness. Tenderness and redness (inflammatory blush) over the mastoid indicates involvement of the mastoid cells and is an unfavorable symptom. Discharge. — In the acute forms of otitis media that lead to perforation of the membrana tympani the discharge at first is serous as a rule, becoming muco-purulent later on. In the severe form, namely, that complicating scarlet fever, it is usually purulent from the beginning ; the ordinary catarrhal variety, however, may assume a purulent character if its course becomes protracted. Tuberculosis. — In the tuberculous variety of otitis the mucous membrane of the tympanic cavity is pale and the discharge is watery or a thin pus, in which the tubercle bacillus may be demonstrated. Influenza. — A large number of cases of otitis are due to infection with the influenza bacillus. In these cases the dis- charge at first is sero-sanguinolent, later becoming stick}-. There is always more or less blood, on account of the great congestion of the mucous membrane of the tympanum and of the drum head. ACUTE CATARRHAL AND ACUTE PURULENT OTITIS MEDIA. The two varieties will be considered under the same head- ing, as it is impossible to draw a sharp line of distinction be- tween them. Frequently what in the beginning seems to be a catarrhal otitis eventually becomes a purulent one and again, the early symptoms of both varieties are almost identi- cal. This much, however, may be said, the catarrhal variety is by far the commoner in infants, while in older children the DISEASES OF THE EAR, NOSE AND THROAT. 533 purulent variety predominates. The eNplanation of this lies in the fact that catarrhal otitis usually develops second- arily to an acute naso-pharyngitis, while the purulent variety develops in the course of one of the infectious diseases, nota- bly, scarlet fever and measles, and less frequently in typhoid fever, pneumonia and diphtheria. Influenza is a common cause of the more severe catarrhal cases. The micro-organ- isms most commonly found in the discharge are the pneumo- coccus and the streptococcus ; the latter is responsible for the damage done to the middle ear and adjacent structures in scarlatinal otitis and the other grave symptoms of suppurative otitis. As a predisposing cause adenoid vegetations stand most prominently. Symptomatology. — In infants otitis is usually preceded by a naso-pharyngitis ; as the ear becomes involved there is an increase of fever and earache sets in. Although the child fre- quently gives evidence of the seat of the pain by putting the hand to the side of the head and by crying when the affected ear is touched, still there are a great many cases in which ear- ache is not suspected until the membrana tympani has rup- tured and a discharge makes its appearance. This is espe- cially the case when otitis complicates an acute illness, such as pneumonia for example. In these cases there will be a rise of temperature that cannot be accounted for and the child will cry incessantly for no known reason. In the course of a day or two the appearance of the ear discharge clears up the mystery. Sudden exacerbation of fever in any acute illness not accounted for by other complications should always lead to an examination of the ears. The crying of earache is characteristic. When we are con- fronted with an infant that is crying continuously in spite of ever) effort that may be made to make it comfortable, and, if other causes can be excluded, there is every reason to suspect earache. In older children the disease is ushered in with excruciat- ing pain and high elevation of temperature. Pain begins in 534 DISEASES OF CHILDREN. the ear, but radiates practically over the entire side of the head. As a rule, it is promptly relieved when perforation takes place. Often the symptoms closely resemble meningitis, the dis- ease is ushered in by convulsions and vomiting, and marked cerebral irritation is present on account of the close connec- tion between the middle ear and the dura mater. These symptoms, however, disappear as soon as the middle ear is evacuated. Many subjective symptoms are complained of, but the most important ones of the disease are those above referred to. Early in the disease the drum head in the region of Shrap- nell's membrane is congested. There is also hyperaemia ex- tending along the posterior border of the handle of the mal- leus ; the drum-head loses its lustre and assumes a deep pink color varying with the intensity of the inflammation. The external auditory canal also becomes deeply congested. At first the drum head is somewhat depressed, but as the exudate fills the tympanic cavity it bulges, especially in its posterior half. When perforation occurs it most frequently takes place in the lower anterior or posterior quadrant of the membrane. Spontaneous perforation is less apt to drain the tympanum as thoroughly as an artificial puncture, nor does it heal as well. When the pain continues after perforation, we should suspect involvement of the periosteal layer, or of the mastoid cells. The complications .of otitis media are mastoiditis ; facial paralysis; meningitis; cerebral abscess ; septicaemia; throm- bosis of the lateral or other sinuses ; caries of the sinuses ; facial erysipelas and eczema aurium. As has been stated above, affections of the petrous bone and of the brain are commoner complications than mastoid disease in children. When the hearing is lost as a consequence of otitis, in the very young, deaf-mutism supervenes. Prognosis. — There are two factors influencing the prog- nosis of otitis in children. In the first place the constitution DISEASES OF THE EAR, NOSE AND THROAT. 535 and the state of health at the time the disease is contracted are important factors. Secondly, the nature of the causative infection is important ; those complicating a simple rhino- pharyngitis or influenza are not as grave as those complicat- ing scarlet fever (streptococcic) or those due to the pneumo- coccus or to the diphtheria bacillus. Again, the develop- ment of a complication augurs an unfavorable prognosis, and practically makes it a surgical condition. The prognosis is always more favorable when early incision of the drum-head has been made and free drainage established. Diagnosis. — Earache should always be suspected when an infant cries continuously or when the fever suddenly rises during the course of an acute illness without assignable cause. The throat must be examined for evidences of pharyngitis and when enlarged tonsils and adenoids are found the possi- bility of earache should never be lost sight of. Inspection of the ear drum will give positive evidence of the disease. Treatment. — Absolute rest in bed should be enforced and much relief of suffering may be obtained by instilling hot water into the external auditory meatus, or, better, by the in- stillation of a 10 per cent, solution of Carbolic acid crystals in glycerin in the hope of aborting the attack by osmotic action through the membrana tympani. Fill the external canal every two to three hours with a 10 per cent, solution of crystals of acid Carbol. in glycerin. This is not only useful in relieving the pain, but will at times abort the attack by osmotic action through the membrana tympani, and in any case it will ren- der the canal aseptic in anticipation of perforation, natural or artificial (C. M. Thomas). The most important remedies are Aconite, Belladonna and Pulsatilla. Even the old-school places great confidence in these remedies. Thus, Bacon {Manual of Otology) says: "Aconite in drop doses is a most valuable remedy when there is fever and especially in cases due to cold. Tincture of Pulsatilla, likewise given in drop doses, is indicated also in cases in which there is a profuse discharge from the nares or 536 DISEASES OF CHILDREN. nasopharynx, and may be administered alternately with Aconite." The nose and throat should also teceive attention. When these measures fail to give relief, and if the fever and concomitant symptoms persist, the next indication for treatment is to freely incise the drum-head. Thomas (Hahne- mannian Monthly, Oct., 1901) lays down the following rule : the acuter the attack and the more severe the suffering and prostration, the earlier should this operation be done. A successful paracentesis is a free incision of the membrane and not merely a puncture. The technique is as follows : the patient having been anaesthetized and the external audi- tory canal thoroughly cleansed with a hot 1-5000 bichloride of mercury solution, the drum-head is inspected with the aid of a speculum and head-mirror in order to determine the site of bulging if this be demonstrable. The incision is made with a narrow bistoury or tenotome. Ordinarily the line of incision extends from just behind the stapes to the lower fig. 51.— line of incision border of the drum-head, closely THROUGH DRUM-HEAD , - , £ , „ N hugging the bony structure of the (after bacon). fet > o J canal (Fig. 51). In grave cases, with bulging of the drum-head in its posterior and upper quadrant, together with indications of mastoiditis, the incision should be carried well up the posterior fold and into the attic. At the same time the knife should be brought out along the upper posterior wall of the external auditory canal to relieve all tension. The canal is then lightly packed with sterile gauze and after the acute symptoms have subsided irrigation with 1-5000 bichloride solution may be practiced several times daily. If the discharge persists Thomas recommends the in- stillation of a saturated solution of Boric acid in alcohol, fol- lowed by: Zinc, sulph., Acid carbol., aa, grs. 5; aqua distil.; alcohol, aa oz. y 2 ; eight to ten drops instilled after cleansing, three times daily. Inflation, cautiously employed, when the perforation is large, helps to remove the secretion from the tympanum. DISEASES OF THE EAR, NOSE AND THROAT. 537 Remedies. — In the acute stage, Aconite and Pulsatilla are most commonly indicated (see above). Bellado7tna is the remedy when cerebral symptoms are prominent. Capsicum comes highly recommended for the early stages of mastoid involvement. During the period of discharge, Pulsatilla and Calcarea iodid. are most useful. Hydrastis is particularly indicated in influenzal cases, where the discharge is sticky and tenacious. When the discharge excoriates we should think of Mercurius and in involvement of the bone Silica is the most useful remedy. As the discharge decreases the instillations should be made less frequently and finally daily dusting of the canal with Boric acid should be substituted. After cessation of the dis- charge and closure of the perforation the restoration of hear- ing will be greatly hastened by cautious inflation with the Politzer bag or catheter, every one to'two days (Thomas). ACUTE TONSILLITIS. Acute inflammation of the tonsil may be either superficial, or catarrhal ; folliculous, or cyptic ; and parenchymatous. Anatomically the tonsils consist of an aggregation of lym- phoid tissue embedded in connective tissue and covered by a mucous membrane from whose surface numerous mucous glands dip into its parenchyma. These glands form the so- called crypts, or follicles, and they play an important role in the diseases of the tonsil. Clinically the tonsil is most important as the port of en- trance of the infective agent of many of the infectious dis- eases. Diphtheria and scarlet fever notably attack the tonsils, and rheumatic fever is now looked upon as fre- quently beginning as a tonsillar infection. Indeed, a special variety of tonsillitis designated " rheumatic tonsillitis " is described by some writers, but such a condition should be, strictly speaking, looked upon as an attack of rheumatic in- fection in which tonsillar symptoms predominate, for in these 35 538 DISEASES OF CHILDREN. cases, especially in children, a carefnl examination of the case often reveals the presence of endocarditis and tenderness in the joints. Acute Superficial Tonsillitis. — As the name implies, acute superficial tonsillitis involves only the mucous membrane covering the tonsil, but as a rule deeper structures are more or less involved. The process may also spread to contiguous structures, and it either undergoes prompt resolution or in the case of secondary infection is followed by superficial necrosis of the epithelium, or suppuration of the connective tissue takes place, resulting in peritonsillar abscess. It is a common accompaniment of many of the infectious diseases, notably measles and scarlet fever. In primary cases the usual etiological factor is " taking cold," and by many it is believed that the " rheumatic diathesis " offers especial predisposition to these attacks. Symptomatology. — In primary cases there is malaise and slight chilliness, together with dryness of the throat and more or less pain on swallowing. The tonsils appear bright red, swollen, and their surface presents a somewhat cedematous appearance. It is seldom that the process ends here, however, the crypts usually becoming occluded and filled with fibrin, leucocytes and epithelial debris, which constitutes acute fol- liculous tonsillitis. Associated symptoms are fever ; headache and malaise ; stiffness of the neck, even torticollis and earache. ACUTE FOLLICULOUS TONSILLITIS. Acute folliculous, or cryptic tonsillitis, is an acute infection of the tonsils. The geims usually found are the strepto- coccus, staphylococcus, and pneumococcus. In many cases there is associated superficial necrosis of the mucous mem- brane covering the tonsils, together with an exudation of fibrin and the formation of irregular patches of pseudo-mem- brane. This condition is a frequent complication of scarlet fever, although it may occur independently. It is known as u pseudo-diphtheria." DISEASES OF THE EAR, NOSE AND THROAT. 539 Symptomatology. — The attack begins with malaise and creepy sensations, usually along the spine, followed by fever and aching throughout the body. There is dryness of the throat and some pain on swallowing, but frequently the child does not refer to its throat until the tonsils are greatly swollen, and one is often led to look upon the condition as influenza or beginning typhoid fever unless the routine examination of the throat is practiced. Fever persists for about three days, together with an incre- ment in the severity of the symptoms, ranging between ico° F. to 105° F. By this time the inflammation of the tonsils has reached its climax and they present a characteristic ap- pearance. They are deeply congested, uniformly swollen and their surface is studded with yellowish-white, punctate spots appearing at the mouths of the crypts. When the exudation is abundant it spreads Over the surface of the tonsils and may give rise to the appearance of a membrane. This is, how- ever, readily wiped off. Again, necrosis of the epithelium around the mouths of the crypts frequently takes place, the spots assuming an irregular outline, like a diphtheritic mem- brane, and these spots may coalesce ; but the deposit is only superficial and is readily wiped off, distinguishing it from diphtheria. The lymphatic glands of the neck may become enlarged and tender, but never to the extent found in diphtheria. Associated symptoms are painful deglutition — in fact pain at the height of the disease is one of its most characteristic symptoms ; lancinating pains extending into the ears ; head- ache and prostration. The tongue is coated and slimy ; the breath is offensive, but nothing like in diphtheria, and there is anorexia and con- stipation. The fever subsides on about the third day ; the tonsillar swelling abates at the same time, and convalescence is estab- lished in the course of a few days. Diagnosis. — The most important condition from which 540 DISEASES OF CHILDREN. folliculous tonsillitis is to be distinguished is diphtheria. In a typical case this is comparatively easy, but in the class of cases described as pseudo-diphtheria many difficulties are encoun- tered. High fever, occurring suddenly in older children, is perhaps most frequently due to tonsillitis. The characteristic points to be remembered in the diag- nosis of folliculous tonsillitis are : The punctate spots of soft, unorganized exudation confined to the tonsillar crypts ; the uniform inflammation and swelling of the tonsils ; the high fever and pain and the absence of profound toxaemia ; and, lastly, the absence of marked enlargement of the lymphatics of the neck. In all doubtful cases, however, a bacteriological examination of the exudate should be made, for in rare in- stances the diphtheria bacillus sets up a tonsillitis identical in appearance with the ordinary folliculous variety. Treatment. — If there be fever the child should be put to bed and isolation of the patient enforced. When there is much pain and swelling of the tonsils an ice collar will give decided relief. The throat may be sprayed several times daily with a mild antiseptic, such as Asepticon (Boericke & Tafel) diluted with warm water, and when there is considerable ex- udate and offensive breath the Permanganate of Potash, i to 1,000 solution, is preferable. The most important remedies are : Belladonna, Mercurius iod. rubr., Apis and Ignatia. Belladoiina is indicated in the early stage when there is dryness and redness of the throat with pain on swallowing; throbbing headache ; photophobia ; high fever and flushed face. It is more frequently indicated in tonsillitis in children than in adults. Apis is indicated when ©edematous swelling of the mucous membrane is the leading feature in the case. There are sharp, sticking pains on swallowing. Ignatia is a valuable remedy in folliculous tonsillitis when there are sharp, lancinating pains extending into the ears. Mercurius iod. rubr. is the most useful remedy in the fully developed stage, especially when exudation is abundant. DISEASES OF THE EAR, NOSE AND THROAT. 541 ULCEROMEMBRANOUS TONSILLITIS. This is a condition presenting a marked outward resem- blance to diphtheria, but on close study it will be seen that the resemblance is merely superficial. In ulcero-membranous tonsillitis the tonsil becomes covered with a dirty-yellowish exudate ; this is often confined to a single tonsil. When the exudate is wiped away, especially when done roughly, a bleed- ing surface may remain. The lymphatics at the angle of the jaw on the affected side are swollen. Thus far there is a strong resemblance to diphtheria, even to offensive breath, but constitutional symptoms are slight or wanting and a bac- teriological examination reveals instead of the Klebs-Loeffler bacillus the fusiform bacillus discovered by Vincent and sup- posed to be the etiological factor. Pseudo-diphtheria is also to be differentiated (see Diphtheria;. Ulcero-membranous tonsillitis is at times associated with ulcerative stomatitis and is looked upon as being an analogous condition. The treatment is the same as for other forms of tonsillitis. Locally, Hydrogen dioxid, preferably as a spray, is the most useful disinfectant. The red Iodide of Merairy is well indi- cated as an internal remedy. For fuller symptomatology see "Tonsillitis." Merc. iod. rnbr. — This is the most useful remedy in cases resembling diphtheria where there is superficial ulceration of the tonsils ; fibrinous exudation and enlargement of the cerv- ical lymphatics. ACUTE PARENCHYMATOUS TONSILLITIS ; PERITONSILLAR ABSCESS. Acute parenchymatous tonsillitis, commonly called u quinsy," results from an infection of the tonsil from with- out, either following superficial ulceration or associated with a membranous or inflammatory process of the tonsil and surrounding structure ; it may also be secondary to some 542 DISEASES OF CHILDREN. other form of tonsillitis and to the infectious diseases ; and it may be associated with systemic septic processes (Kyle). Suppuration as a rule sets in, taking place in the periton- sillar connective tissue and terminating in the formation of an abscess which may rupture into the pharynx either an- teriorly or posteriorly, following the line of least resistance. It is a disease common in later childhood and in adolescents. Symptomatology. — The onset is similar to that of other forms of tonsillitis, with the exception that the inflammation is one-sided and attended with more pain and swelling. The pain at first is lancinating ; later it becomes throbbing in character. There is a constant desire to swallow, which adds greatly to the discomfort of the patient. Fever and malaise are usually not so marked as in folliculous tonsillitis. On inspection, the throat presents a swollen, cedematous appearance and a tumefaction arising from the tonsillar re- gion is seen projecting toward the median line. The tonsils and pharynx are covered with a grayish, viscid mucus which gives the appearance of a thin pseudo-membrane being pres- ent, but by spraying the throat it can be completely removed. The tonsil itself is not the seat of the chief swelling, but it is simply carried into the median line by the surrounding tume- fied structures. The opposite side may become affected later on, but the disease is rarely bilateral. Inspection is difficult on account of the stiffness of the jaw that is associated. Fluc- tuation may be elicited, but it is not always easy to deter- mine on account of the boggy, cedematous condition of the tissues. The duration is from a few days to a week or longer. Resolution may set in, or spontaneous evacuation take place after four or five days with prompt relief of the symptoms. Treatment. — If suppuration cannot be aborted by the use of the ice-bag and the indicated remedy, the abscess should be evacuated as soon as pus is suspected and an antiseptic gargle freely used. The incision is made with a sharp pointed bistoury whose cutting edge has been wrapped in DISEASES OF THE EAR, NOSE AND THROAT. 543 cotton, exposing only the point for a distance of about a quarter of an inch. The point is inserted to its full length into the substance of the half arch just above the tonsil and a quarter of an inch from its free border, and the tissue cut through and across, toward the median line. Peritonsilar abscess can often be most satisfactorily evacuated by passing a bent probe outward and upward posteriorly to the anterior half and into the supra tonsillar fossa (Thomas). The pa- tient should then gargle with a warm 2 per cent. Boric acid solution, or preferably diluted Hydrogen dioxid so long as pus is present. Remedies. — Belladonna in the early stage; later, as soon as pus begins to form, Mercurius vivus ; and Hepar sulph. to hasten resolution, are the remedies that will be needed in the majority of cases. Apis may become indicated from a predominance of oedema. In fact, oedema of the glottis may supervene, and for this con- dition Apis is looked upon as invaluable. Capsicum. — Serous infiltration of the faucial tisssues ; boggy not ©edematous, in appearance ; left side worse ; pain burning, stinging. When tongue is heavily coated white, uvula cedematous, especially with a dusky infiltration of the left pillars and some swelling of the lymphatic glands, Caps., in the 3X or 6x, will usually relieve inside of twenty-four hours (Ivins). Guaiacum. — Recurring attacks due to rheumatic diathesis. Phytolacca. — Chills and fever alternate ; prostration ; pain running to ears on deglutition ; affected parts dark-purple, almost blue ; rheumatic subjects ; uvula enlarged and cedema- tous. Silicea. — Protracted cases. Suppuration continues after evacuation of pus has taken place (Calc. snlph.). HYPERTROPHY OF THE TONSILS. There are two varieties of hypertrophy of the tonsils ; in the one the increase in structure is mainly glandular, while 544 DISEASES OF CHILDREN. in the other it is interstitial. The first variety is known as the soft, glandular type ; the other as the hard, fibroid, or lobulated tonsil. An enlarged tonsil is not necessarily an hypertrophied one, as enlargement may result from vascular en- gorgement and does not necessarily indicate cell proliferation. Again, in children the tonsils are normally large, and because they extend beyond the pillars of the fauces, it does not necessarily follow that they are hypertrophied (Kyle). The cause of the various enlargements is both constitutional and acquired. The so-called strumous diathesis, or what is understood by the more modern term lymphatism, is the un- derlying constitution looked upon as responsible for the abnor- mal tendency to hyperplasia of these lymphoid structures. Recurring attacks of acute tonsillitis, and diphtheria and scarlet fever may be looked upon as the chief exciting causes. The condition belongs practically to the period of childhood. Symptomatology. — Subjective symptoms depend largely upon the size of the tonsils. They may be so large as to cause considerable interference with normal respiration by filling up the pharyngeal space, and under these circumstances the voice is also affected, acquiring a nasal twang. Many of the symptoms resulting from adenoid vegetations are also caused by enlarged tonsils. In the soft variety the tonsil is uniformly enlarged, while in the fibrous variety it is lobulated ; the crypts are abnor- mally large, and its consistency is hard and unyielding. The irregular, nodular surface of the enlarged tonsil ; its open crypts and eroded surface ; and its perverted function, render it a source of danger as an avenue for infection, beside its other evil effects upon the child's health. Treatment. — Unless the tonsils are sufficiently enlarged to interfere with the child's health, or to affect the voice, they will require no further treatment than mild local measures and a remedy prescribed upon a constitutional basis. When local symptoms are marked the remedy should be chosen on such indications. It is the simple, hypertrophic variety of DISEASES OF THE EAR, NOSE AND THROAT 545 enlarged tonsil without connective tissue proliferation that so promptly improves under appropriate treatment and under- goes physiological atrophy in later life. The fibroid variety, however, is rarely improved by treat- ment of any kind, and if it be large enough to cause symptoms it should be excised. Excision can be accomplished in older children under local anaesthesia (a 4 per cent, solution of Cocaine), but in the young this should not be attempted. The same preparations as for the operation for adenoids are made, and under good illumination the tonsils are cut off with the tonsil- lotome close to the pillars of the palate. When adhesions between the tonsils and palatine folds exist they should be broken up with a blunt instrument, such as the A His dry dissector, before removing the tonsil. Bleeding is rarely alarming, and it can be controlled by pressure with a mop dipped in a saturated solution of Tannic acid. Under anomalous cir- cumstances a haemorrhage may ensue ; this will require long continued pres- sure (with the finger or an especially constructed tonsillar haemostat), or it may become necessary to place a liga- ture around the stump of the tonsil. The after treatment is the same as for adenoids. Remedies. — Of the many remedies recommended for en- larged tonsils there are only a few that have given me posi- tive results. They are Calc. phos. and Ignatia. Baryta carb. in;. 52. Toxsir.LoTOMK. 546 DISEASES OF CHILDREN. and jod. are usually prescribed for the class of enlargement that is beyond the pale of medicinal action ; consequently the results I have seen from them are not gratifying. Ignatia is of undoubted value in the early stages of simple glandular hypertrophy, and it especially suits those cases in which there is a constant recurrence of acute tonsillitis. Calc. phos. is the constitutional remedy best suited to the condition that predisposes to the overgrowth of the lymphoid structures and its efficacy in tonsillar hypertrophy is not to be questioned. If taken in time most cases will no doubt escape operation, but one should not be too sanguine of results in those of long standing. RETROPHARYNGEAL ABSCESS. The commonest variety of retro-pharyngeal abscess is the result of an acute infection of the lymphatic glands and ves- sels of the pharyngeal space ; in other words, an acute lym- phangitis and adenitis that has broken down in suppura- tion. A septic variety, occurring as a complication of scarlet fever and measles, is sometimes encountered, but it is much rarer than the idiopathic form. Chronic retro-pharyngeal ab- scess is due to cervical Pott's disease. This occurs in child- hood, while the above condition occurs almost exclusively during infancy. As the lymph-nodes of the retro-pharyngeal space are inti- mately connected with the lymphatics of the tonsils and uvula, any acute inflammatory condition of these structures is likely to result in involvement of the pharyngeal lym- phatics. This is especially the case during the period of in- fancy, when these glands are in a state of high physiological activity. Later in childhood, however, they atrophy, for which reason retro-pharyngeal suppuration is rare after the third year. The tumefaction may be situated in the median line, but more frequently it is more to the side and may even appear to arise from behind one of the half-arches. The glands at DISEASES OF THE EAR, NOSE AND THROAT. 547 the angle of the jaw may also be implicated, in which case the swelling is found at or beneath the angle of the jaw and in front of the sternocleido-mastoid muscle. In such cases a spontaneous evacuation of the abscess externally may take place, although the majority break into the pharynx. Septic retro-pharyngeal abscess complicating scarlet fever and measles shows a tendency to burrow into the mediastinum or ulcerate into the carotid arteries and other important structures. Symptomatology. — The onset is insidious and usually it is not suspected until marked symptoms have developed, as there is present always a primary inflammatory condition of the nose or throat upon wmich it depends. In the course of five or six days, by which time the primary condition should have entirely subsided, there is still a trace of febrile move- ment and inspection of the throat reveals a swollen and cedem- atous state of the pharyngeal mucous membrane. Two or three days after this, evidence of suppuration becomes ap- parent and the swelling has attained such size as to call forth the symptoms characteristic of the disease. There will be difficulty of breathing, especially on inspiration ; crowing respiration, due to incoordination of the vocal cords; retrac- tion of the head in order to give the larynx as much free space as possible and distinctly nasal cry. The child breathes with the mouth open and holds the head so rigid that cervi- cal Pott's disease or torticollis may be erroneously thought to exist. Inspection of the throat will, however, immediately clear away any doubt as to the true nature of the case. The abscess is readily made out by carefully introducing the index finger into the pharynx. This must always be done with caution to avoid rupturing the abscess or throwing the in- fant into collapse by rude manipulation of the fauces. If allowed to rupture spontaneously the pus may be as- pirated into the lungs, causing instant death or setting up a fatal broncho-pneumonia ; it may also find its way into the Eustachean tubes and set up an acute otitis. In many in- 548 DISEASES OF CHILDREN. stances, however, the pus is swallowed or evacuated through the mouth without causing any trouble. Nevertheless, prompt surgical interference offers the best prognosis and should be instituted in all cases as soon as they give indications for the evacuation of pus. Treatment. — The abscess is easily incised when it points to the median line or not far therefrom. Cases in which the swelling is well to the side require great care, as there is danger of wounding the carotid artery. Those pointing ex- ternally must be opened with great care, as deep incision must be made in order to thoroughly drain the abscess. Tubercu- lous abscesses should be opened externally whenever possible. The child is held firmly in the upright position and the throat illuminated by the head-mirror. A mouth-gag is un- necessary ; all that is required to expose the abscess and keep the mouth open is a reliable tongue depressor. The incision is made toward the median line with a bistoury whose cutting edge has been protected by wrapping it with cotton up to within half an inch from the point. After making the in- cision it is often necessary to break up septa of connective tissue within the abscess cavity with the tip of the index finger. The remedies indicated are Belladonna in the early stage and Hepar sulph. when pus begins to form. ACUTE RHINITIS ; PSEUDO-MEMBRANOUS RHINITIS. Acute rhinitis is an acute inflammation of the mucous membrane of the nasal cavities occurring either as a primary condition or secondary to one of the infectious diseases, not- ably measles, influenza and diphtheria ; the cause of the acute suppurative symptoms of rhinitis lies in infection by pyo- genic germs which are usually found present in the nose in great number. They do not, however, become active until the vascular engorgement of the nasal mucosa resulting from exposure to cold or draughts offers a favorable soil for their propagation, and invites them to activity. DISEASES OF THE EAR, NOSE AND THROAT. 549 Pseudo-membranous rhinitis associated with faucial diph- theria is due to the Klebs-Laffler bacillus in its most virulent form, while those cases in which a diphtheritic membrane develops primarily in the nose, running a mild course, the bacillus is present in attenuated form. Such cases, however, may give rise to a severe faucial diphtheria, and for this rea- son every case of pseudo-membranous rhinitis should be iso- lated. This attenuated diphtheria bacillus is known as Von Hoffman's bacillus. According to Park (Bacteriology in Medicine and Surgery) only in a few cases have other bac- teria been found to cause the croupous exudate ; they were mainly the pyogenic cocci. Kyle (Diseases of the Nose and Throat) is of the opinion, however, that most cases of croupous rhinitis are simply the result of local irritation from micro- organisms, the streptococcus pyogenes being the most frequent one present in the croupous exudate. All of the cases that have come under my notice were diphtheritic. At times it seems due to some constitutional condition in which the individual cell resistance is below normal. It may also result from traumatism. There is no doubt that a certain amount of contagiousness exists in acute rhinitis. A natural predisposition is found in many cases ; this is particularly the case in anaemic children that have been reared like hot-house plants and in those of the so-called scrofulous diathesis. Symptomatology. — Following upon exposure, or "catch- ing cold " or in the course of an infectious disease a sense of fulness in the nostrils with dryness of the mucous membrane develops, succeeded by an acrid, watery discharge consisting of serum with a small amount of mucus. At this stage the mucous membrane appears red and swollen, and the entire nasal cavity may be occluded by the swollen turbinated bodies. In primary cases a slight febrile reaction sets in and there is headache, and lassitude. Mild cases may be aborted at this stage and resolution occur without any further develop- 550 DISEASES OF CHILDREN. ments. In infants these attacks are spoken of as snuffles, and unless they are due to syphilis or are benign, profuse muco- purulent secretion makes its appearance, flowing freely from the nose and covering over the entire mucous membrane of the naso-pharynx. The process may extend to the frontal sinuses, the Eustachian tubes and middle-ear, and to the pharynx. If the infection has been of a virulent nature ulceration of the mucosa and suppuration of the middle-ear are liable to supervene. Pseudo-membranous rhinitis is almost invariably diphther- itic in origin, as has been stated above. From the fact that constitutional symptoms are usually slight in primary diphtheritic, or fibrinous rhinitis, it frequently remains un- suspected until the membrane is accidentally discovered. The membrane may persist for weeks, coming away in large pieces. If during its course it be removed, it usually recurs. The nose is more or less obstructed, and a thin blood-streaked discharge runs from the anterior nares. Such a secretion should always arouse suspicion of diphtheria. On inspection, the membrane is seen as a firm, grayish exudate upon the interior of the nose. The disease is far more benign than faucial diphtheria with or without extension of the membrane to the nose, but it may assume a most unfavorable course by spreading to the pharynx, under which circumstance severe constitutional symptoms will aiise. Treatment. — In the early stages the obstruction may be much relieved by spraying or douching the nose with a warm mild alkaline antiseptic solution, such as Dobell's solution, or a normal saline solution, followed by spraying with a bland oil containing camphor or menthol in the proportion of one grain to the ounce. Later as the discharge becomes profuse, frequent cleansing of the nasal passages is imperative. In infants or young children who struggle against the use of the atomizer, a small glass syringe may be employed, inject- ing into one nostril and allowing the fluid to flow out of the other, the child lying on its side during the operation. DISEASES OF THE EAR, NOSE AND THROAT. 551 In pseudo-membranous rhinitis a i to 1000 solution of per- manganate of potash should be used freely in the form of an irrigation, allowing about a pint to run through the nares at intervals of a few hours (see Nasal Syringing, Chapter I). In the early stages Aconite and Gelsemium are the most important remedies. In the snuffles of infants Dulcamara has given good results, and when associated with great em- barrassment of respiration, causing the child to start just as it is falling asleep on account of the extreme nasal stoppage, even in the presence of free secretion, Ammonium carb. is a most valuable remedy. Hughes {Manual of Therapeutics) considers Camphor a specific in the early stage, promptly abort- ing most cases and especially relieving the chilly feeling. Aconite. — Sneezing ; fever with restlessness and full pulse ; burning of the eyes. Gelsemium differs from Aconite in the absence of the rest- lessness and high arterial tension and in the predominance of malaise ; chilliness, especially creeps up and down the spine but not a well defined chill ; headache with drowsiness and heaviness of the eyelids ; aching in the muscles. Gelsemium colds are such as are contracted during warm moist weather or occurring in debilitated subjects ; the Aconite cold typi- cally occurs in active, plethoric individuals after exposure to cold winds. Nux vomica is indicated in the early stages of many cases ; there is dryness and obstruction of the nose ; fulness at the root of the nose and frontal headache ; cold hands and feet with a hot head ; anorexia and constipation ; irritability of temper and feverishness. Subjects who are overly sensitive to draughts. In this respect Arsenicum is similar. " Persons who are rarely without a cold " (IviNS). Sneezing ; profuse, watery, excoriating dis- charge ; tendency of cold to travel down upon chest. Belladonna has always been a most satisfactory remedy in my hands for the vascular engorgement of the turbinated bodies. The mucous membrane appears dry and bright red and the nose is much obstructed. 552 DISEASES OF CHILDREN. Cepa. — Profuse, acrid watery discharge with lachrymation. Euphrasia has a profuse nasal discharge which is bland, but an excoriating lachrymal discharge, the opposite condi- tion of Cepa. Ferrum phos. is a valuable remedy in the early stages of coryza, being similar to Aconite, but without the feverish rest- lessness of that remedy. Given over an extended period of time it will do much to eradicate the cold-catching tendency. Sanginnaria Canadensis or Sanguinaria nitr. y 3X trit., is useful when there is a sensation of great dryness and burning in the nose and pharynx, with headache and loss of smell and taste. In the second stage, when the discharge becomes profuse and muco-purulent in character, no remedy is more useful in the majority of cases than Pulsatilla. When there is much soreness of the nose and evidence of ulceration Mercurius is the better indicated remedy. Hydrastis should be thought of, but it seems more useful in chronic cases. Pseudo-membranous rhinitis requires the remedies useful where croupous exudation is found. Hepar, 3X trit., and Kali bichromicum, 2x trit., will most frequently be of service. Local treatment as directed above is not to be neglected. A culture should be made and if it verifies the presence of the Klebs- Loefner bacillus, antitoxin should be used. SIMPLE CHRONIC RHINITIS AND PURULENT RHINITIS. Chronic rhinitis without pronounced hypertrophic or atrophic changes in the nasal mucous membrane is a com- mon affection of childhood. Abundant muco-purulent secre- tion is usually associated with the catarrhal process and makes the disease a particularly unpleasant one. In the etiology recurrent attacks play an important role. The period of childhood itself invites catarrhal inflammations with epithelial cell proliferation, the rapid desquamation of which constitutes the main pathological process in purulent rhinitis. It is not confined to those of the syphilitic or DISEASES OF THE EAR, NOSE AND THROAT. 553 scrofulous diathesis, apparently healthy constitutions falling victims of the disease as well as others. As a predisposing cause, adenoids undoubtedly play the most important role. Unhygienic surroundings, and want of attention during acute attacks or failure to guard against the recurrence of such attacks are the chief exciting causes. No specific micro- organism is present, but there is no doubt that an infection of a mixed character causes the purulent inflammation. Irrita- tion by foreign bodies or other sources of irritation may induce similar pathological changes. Symptomatology. — The chief symptom is a profuse muco- purulent discharge. Xasal obstruction is not pronounced. The nose may become reddened about the orifices and excor- iated and crusts form in the anterior nares, usually at night, in this way inducing mouth breathing during sleep. Sus- ceptibility to acute attacks seems lessened on account of re- duced sensibility of the mucosa from less of epithelial cilia (IVIXS). Atrophic changes will occur in the course of years if the progress be not arrested. It may also pass into the hyper- trophic variety if rhinorrhcea has not been a prominent feat- ure of the case. In scrofulous children infection of the cerv- ical lymphatics is a frequent complication. In the majority of cases the prognosis is good, especial ly under proper treat- ment. Ozaena is the most unfortunate outcome that may be anticipated. HYPERTROPHIC RHINITIS; ATROPHIC RHINITIS. Hypertrophic rhinitis is a chronic catarrhal inflammation of the nasal mucosa and sub-mucosa, characterized by hyper- trophy of the turbinated bodies with resulting nasal obstruc- tion. It is not as frequently encountered in children as in adults, nor is it as common a disease as atrophic rhinitis. The pathological changes are- such as require a long time for their development, being a hyperplasia of the cellular ele- ments and overgrowth of the connective tissue and blood- vessels that form the turbinated bodies. 36 554 DISEASES OF CHILDREN. A variety of hypertrophic rhinitis in which there is simply engorgement and dilatation of the blood-vessels is not uncom- mon. In this class of cases a complete temporary retraction of the mucous membrane may be induced by the local appli- cation of cocaine, or it may occur spontaneously or as the re- sult of appropriate treatment. Atrophic rhinitis, or Ozcena, is characterized by atrophy of the nrncous membrane, of the cavernous structures, and the underlying bone. There is also atrophy of the mucous glands with consequent impaired function and the formation of offen- sive crusts. The crusts represent inspissated muco-purulent secretion which accumulates in the nasal chambers and un- dergoes decomposition. They are the cause of the fetor ema- nating from these patients. Etiology. — Adenoid vegetations play an important role in the etiology of hypertrophic rhinitis, by interfering with the drainage of the nasal chambers, thus inviting the accumula- tion of irritating material which keeps up a constant conges- tion of the mucous membrane. Again, the constitutional peculiarity which invites adenoids and hypertrophy of the tonsils predisposes to chronic catarrh and hypertrophy of the intra-nasal structures. Clinically there is an intimate asso- ciation of these conditions. Another cause will be found in recurrent acute attacks which may lead up to permanent structural changes. Atrophic rhinitis may develop as an independent affection or as a sequel to hypertrophic rhinitis. Casselberry dissents from the latter view, believing the transition of an hyper- trophic rhinitis an exceedingly rare, and in all events slow process ; and he looks upon atrophic rhinitis, particularly in children, as a distinct affection. A pronounced hereditary predisposition, moreover, has often been observed. Bosworth believes suppurative rhinitis of children to be the cause of atrophic rhinitis, the suppurative process destroying the mu- cosa layer by layer in the course of time, until eventually the deepest structures become involved. DISEASES OF THE EAR, NOSE AND THROAT. 555 Symptomatology. — The chief symptom of hypertrophic rhinitis is nasal obstruction. This may be more or less com- plete and involve both sides simultaneously or alternately. Remissions occur, and frequently the nose will be clear un- der ordinary circumstances, only clogging up when irritated by the inhalation of dust ; walking in the wind ; entering a warm room, etc. This peculiar behavior readily explains itself when we remember that the obstruction depends upon the degree of vascular engorgement present at the time. As a result of the reflex irritation in the nose and the inter- ference with respiration, a train of symptoms indicating a disturbance in the general health of the child arises. Ner- vous irritability ; disturbed sleep and mouth breathing ; intel- lectual torpor ; haemicrania ; spasm of glottis ; asthma and enuresis, all may have their origin in the nasal stenosis. It is hardly possible to differentiate between the disturbances in- duced by hypertrophic rhinitis and those induced by adenoid vegetations ; the latter, however, are likely to induce even graver troubles than the former, and they are more frequently encountered as an independent condition. On inspecting the anterior nares we will find the turbinated bodies swollen and of a deep red color, the inferior turbinated being most readily seen and darker in color than the middle or superior. If there be much engorgement it will be impos- sible to see more than the inferior body and at the most the anterior half of the middle body without making an applica- tion of Cocaine to shrink the mucous membrane. Polypi are likely to be confounded with an hypertrophied turbinated body, but they are paler in color, are movable, and occupy a position between the turbinated bodies. Atrophic rhinitis is characterized by the formation of crusts and fetor. Obstruction of the nares only occurs if the crusts are allowed to accumulate in large masses. They may occur simply as scales, or form in large horny masses, completely occluding the nasal chamber. These masses eventually soften by decomposition or cause necrosis of the underlying mucous 556 DISEASES OF CHILDREN. membrane, coming away in large masses and leaving an ulcer- ated surface behind. Trie fetor may be so intense as to render the patient's proximity unbearable. In the beginning the child may be annoyed by the odor, but eventually the sense of smell becomes so obtunded that it is not aware of the fetoi. There may be a sense of distressing fulness in the nose when crusts accumulate, and the habit of constantly picking the nose is soon acquired. Epistaxis is soon a frequent accom- paniment. The general health is naturally affected ; hearing becomes impaired, and the sense of smell may be entirely lost. Inspection reveals a spacious nasal cavity lined with a thin, smooth mucous membrane, covered with crusts. Its surface is studded with superficial ulcers. Hereditary syphilis is to be differentiated from atrophic rhinitis; in the former there is not a uniform distribution of the atrophic process, and there is deep ulceration and cicatrization. Perforation of the septum with sinking in of the nose is pathognomonic of syphilis. The prognosis is not unfavorable. Under persistent treat- ment most cases in children recover, some in the course of a few months, others not yielding to treatment in less than a year or two. Syphilitic cases, if seen early before destructive changes have set in, respond promptly to appropriate local measures in conjunction with anti-syphilitic remedies. TREATMENT OF CHRONIC RHINITIS. In undertaking the treatment of a case of hypertrophic rhinitis we must first of all determine whether it is an inde- pendent affection or due to adenoid vegetations. Should the latter prove the case we must proceed to remove the adenoids as directed under the article on Adenoid Vegetations. If the condition has not advanced beyond the stage of vascular en^ gorgement a cure usually ensues upon the removal of the adenoids. When permanent hypertrophy of the turbinated bodies has set in there is but one sure and permanent method of treatment that fulfills all the requirements of a safe and DISEASES OF THE EAR, NOSE AND THROAT. OO/ radical operation, namely, burning away the redundant tissue with the galvano-cautery. The inferior turbinated body is the obstructing body in the majority of cases, and by burning a linear eschar along its entire length, applying the platinum knife at the posterior border and drawing it forward slowly, burning down to the bone, sufficient retraction is obtained to overcome the stenosis. The operation can be performed en- tirely painlessly with the use of a 4 per cent, solution of Cocaine. In the course of a week or two the opposite side should be operated upon in the same manner. A mild anti- septic alkaline solution, such as Dobell's solution, or a solu- tion of Seller's antiseptic nasal tablets, should be used to cleanse the nose both before and after the operation. During the healing process it may be used either in a douche or in an atomizer, several times daily, to be followed by an oily spray, such as the Thuya Oil Spray made by Boericke & Tafel. Should haemorrhage occur after the cauterization or in the course of a day or two, when the scab comes away, it can readily be controlled by spraying with a 5 per cent, solution of the 1-1000 solution of Adrenalin, or by spraying with 10 per cent, solution of Tannic acid. Packing is seldom required. Milder cases, not requiring surgical interference, should re- ceive local applications of Iodine and Glycerine (5 per cent.), made by means of absorbent cotton on a probe, about twice weekly, followed by spraying with thuya oil. Besides, the nose should be cleansed daily with the alkaline antiseptic, preferably by douching with the Birmingham nasal douche or any other similarly constructed appliance. It is always safer to follow the cleansing process with the oil spray to prevent catching cold. In treating atropine rhinitis the most rigorous steps for maintaining absolute nasal cleanliness must be taken. The free use of the douche bag is here to be instituted, and a pint of DobelPs solution should be allowed to flow through the nares at a time. This should be done twice daily. For the method of giving the nasal douche see page 19. 558 DISEASES OF CHILDREN. If hard crusts have formed that cannot be dislodged by means of the douche, Hydrogen dioxid, diluted twice with warm water, should be slowly injected into the nares with a blunt syringe ; this so loosens them that they can be readily blown out. After the nose has been cleared a few drops of refined carbon oil with iodine (one grain to the ounce) should be dropped into each nostril with a medicine dropper (Kyle). When eroded surfaces remain after the removal of the crusts a stimulating powder, such as aristol, should be in- sufflated. Syphilitic ulcerations are best controlled by the local application of a ten per cent, solution of Nitrate of Silver. Remedies. — When well marked constitutional indications are present such remedies as Calc. phos., Calc. carb., the Iodides, Hepar and Silicea will give better results than rem- edies selected purely on local indications. Pulsatilla and Hydrastis are especially useful in simple, chronic and purulent rhinitis. In atrophic rhinitis the Chloride of Gold, Kali bichromicunh Mercurius corr. and Silicea are the most important remedies, Aurum heading the list. Syphilitic affections require Mercury, preferably the yellow iodide when the ulceration is confined to the mucous mem- brane. When the bones become affected Aurum metallicum is indicated. Ulceration of the septum calls for Kali bichromi- cum. Gummatous infiltration of the soft structures will re- quire the Iodide of Potash in material doses, five grains, three times daily, being the usual dose necessary to effect a cure. Alumina. — Thick, greenish-yellow nasal discharge ; anos- mia ; mind sluggish ; snapping in the ears when swallowing. Arsenicum iod. — Delicate, tuberculous constitution ; acrid discharge with burning in nose. Chronic purulent rhinitis. Aurum. — Offensive discharge ; soreness of bones of nose. Ozsena and syphilis. The metal seems best indicated in syphilis, while in ozoena the chloride is preferable. Calc. carb. — Glistening redness of nasal mucosa; extreme DISEASES OF THE EAR, NOSE AND THROAT. 559 sensitiveness of nose ; purulent discharge. Chronic purulent rhinitis in scrofulous individuals. Calc. phos. — Chronic hypertrophic rhinitis in anaemic chil- dren or in association with enlarged tonsils and adenoids. Graphites. — Chronic catarrh, extending to the Eustachian tubes. Tendency to atrophy. Hepar. — Chronic purulent rhinitis with enlarged cervical glands. Hypersensitive to draughts. Uncovering the body brings on attacks of sneezing. Hydrastis. — Simple chronic rhinitis and purulent rhinitis. Abundant muco-purulent secretion with superficial ulceration of the mucous membrane. The discharge may also be stringy and tenacious. Post nasal dropoing. {Spigelia). Kali bichromicum. — Tenacious, yellow secretion ; ulceration of the septum. Natrum mur. — Simple chronic rhinitis. iw In all absence of clear indications for other drugs this is one of the best remedies where persons draw mucus from the posterior nares in the morning." — (Ivixs. ) Pulsatilla. — Chronic purulent rhinitis. Profuse discharge which is a bland, thick, yellow muco-pus, streaked at times with green. There is loss of taste and smell, and in order to act well there must be, according to Ivins, the typical Pulsa- tilla temperament. Silicea. — Ozai-na. Painful dryness of the nose ; ulceration with acrid, corroding discharge {Merc. sol.). Thick, fetid, post nasal discharge. Periostitis. The Silicea patient is pale and delicate ; predisposed to affections of the glands and bones that undergo rapid destruction ; in other words, it pre- sents the tuberculous type. There is also nervous hyperes- thesia and tendency to neurotic affections. ADENOID VEGETATIONS OF THE NASO-PHARYNX. The muco-lymphoid glands found in the vault of the pharynx and aggregated into a tonsil-like organ known as the tonsil of LushkOy or the pharyngeal tonsil, are in their nor- 560 DISEASES OF CHILDREN. mal state of insufficient size to be readily detected, or to cause the least interference with free nasal respiration. Under cer- tain conditions, however, they become much enlarged ; in some instances a hypertrophy of such extent takes place that they fill up the entire naso-pharyngeal space, thus effectually preventing nasal respiration and giving rise to the pernicious habit of mouth breathing. No definite cause can be blamed for the development of this hypertrophic condition, as it is encountered in children of all descriptions, although the so-called scrofulous diathe- sis, or the more pronounced glandular diathesis, lympliatism, are the most frequent constitutional peculiarities found associ- ated with hypertrophied adenoids. L/ymphatism is in fact interpreted as a species of constitution in which there is a tendency to hypertrophy of the lymphoid structures through- out the body, in particular the tonsils and the lymphoid structure of the naso-pharynx and also hypertrophy of the thymus glands. For this reason the two conditions often go together. Hereditary influence also offers a predisposing factor, notably tuberculosis and syphilis in the parent. The period of childhood proper furnishes the majority of cases, but infants are not exempt. Chronic nasal catarrh ; deflections of the septum ; the ex- anthemata, and a damp, changeable climate furnish the causes which excite the hypertrophy of these glands in children pre- disposed thereto. The pathological changes encountered in the mucous mem- brane of the pharynx are an overgrowth of the muco-lym- phoid follicles and of the connective tissue in which they are embedded, together with increased vascularity and thickening of the mucosa. This hypertrophy leads to the formation of a large glandular mass which may attain sufficient size to en- tirely block up the naso-pharynx. According to the amount of connective tissue present and the mode of proliferation of the glandular elements, there will be either a soft, papilloma- tous growth, or a hard smooth mass, known as the individual DISEASES OF THE EAR, NOSE AND THROAT. 561 variety, in contradistinction to the papillomatous, which is a multiple, pear-shaped mass. The individual variety is smooth and firm, while the papillomatous is soft and irregular in con- tour, conveying the impression of a bunch of earth worms to the examining finger. Adenoid vegetation belongs practically to the period of childhood, and after full maturity a physiological atrophy as a rule sets in, the pharyngeal vault being usually smooth at thirty-five, although it may be rough at as late a period of life as seventy (IviNS). Symptomatology. — Chronic nasal and pharyngeal catarrh is usually associated with adenoid vegetations, especially when the}- have existed for a long time. While a catarrhal affection of the nose and pharynx no doubt often acts as the exciting cause of adenoid tissue proliferation, still adenoids in themselves will set up catarrh through their mechanical interference with the circulation and normal breathing. The obstruction of the nasopharynx leads to lack of development of the frontal, sphenoidal, maxillary and ethmoidal sinuses with consequent narrowing of the face and upper jaw, which, together with the increased atmospheric pressure exerted upon the buccal surface of the palate due to lessened intra- nasal air-pressure and mouth breathing, leads to a gradual forcing up of the arch of the palate. This deformity re- sults in turn in deflection of the nasal septum, on account of the upward crowding of the base of the septum. In this manner the nasal obstruction is still further augmented and hypertrophic rhinitis is invited. Deafness from direct pressure upon the ostia of the Eus- tachian tubes or through an extension of the catarrhal process into the tubes is a frequent symptom accompanying adenoids. The physiognomy is characteristic and practically pathog- nomonic, and taken in conjunction with the alteration in voice and deafness a positive diagnosis can be made without even instituting an examination of the posterior nares. The upper lip becomes shortened from lack of development as 562 DISEASES OF CHILDREN. a result of always having the mouth open ; the expression of the face is vacant and stupid ; the nose is pinched and un- developed and owing to the contraction of the superior max- illa the permanent teeth become irregular in distribution. When the condition has arrived at this stage there results as a natural consequence of the interference with the proper aeration of the blood and with the general nutrition headache and mental hebetude with a certain delicacy of constitution inviting the development of neurasthenia or even serious pul- monary disease. In children who are rachitic, pronounced deformity of the chest occurs on account of the associated bronchitis and the softness of the ribs. Even in the absence of actual deformity, the " flat-chest" is frequently encountered as a result of insufficient air supply to the lungs. In several instances I have encountered cases of pulmonary tuberculosis occurring in young adults which I feel might have been pre- vented had the chest been properly developed. This lack of development dated back to post-nasal obstruction by ad- enoid vegetations which caused in turn mouth breathing ; bronchitis ; chest deformity, and ultimately phthisis. (See Fig. 39-) Through reflex action, when in a state of irritation, ad- enoids in many instances bring on attacks of coughing, spasm of the glottis, and asthma. Bronchitis, due to vaso-motor paresis and irritation of the respiratory tract from mouth breathing, is one of the commoner complications of adenoids. Enuresis is a neurosis often depending upon adenoid irrita- tion. Diagnosis. — The presumptive evidence of adenoid vegeta- tions is found in the fancies and the nasal, non-resonant voice together with the associated symptoms of mouth breathing ; naso-pharyngeal catarrh ; partial or total deafness and re- tarded nutrition. Naturally these symptoms are only to be encountered in well-advanced cases; in incipient cases the age of the child and the development of the nasal obstruc- tions, not springing from an abnormal condition of the nose DISEASES OF THE EAR, NOSE AND THROAT. 563 proper, should always arouse a suspicion of adenoid vegeta- tions. The positive evidence of adenoids is obtained through palpation and posterior rhinoscopy. The latter procedure is quite difficult, practically impossible with some children. In others, however, a very satisf acton- view of the vault of the pharynx may be obtained, which is practically all that is necessary for a diagnosis, and much easier than obtaining a full view of the posterior nares. fig- 53- ■MKTHOD. OF HOLD IXC, CHILD FOR PALPATING THE PHARYNGEAL VAULT. Digital examination is a simple procedure and should never be neglected. Especially when deciding to operate is it necessary to gain a thorough knowledge of the size and char- acter of the growth as well as its location in order that it may be thoroughly and intelligently removed. The mode of procedure is the following: Tress the child's right cheek against your side, encircling the head with the left arm and pressing the flesh of its left cheek in between 564 DISEASES OF CHILDREN. the teeth in order to prevent it from biting down upon the examining finger. Now introduce the index finger of the right hand into the month and insert it into the pharynx be- hind the right fancial pillar, from which position it is then brought to the median line and to the vault of the pharynx. The procedure rarely induces dyspnoea, although the child usually struggles and gags with the finger in place. The papillomatous variety convey the impression of a bunch of soft, irregular growths. The classical description found in the text-books likens it to a bunch of earthworms. In the mirror it appears as a pale, reddish-gray pendant mass, usu- ally covered with a layer of greenish-yellow mucus. The hard variety imparts the feeling of a smooth, rounded mass, and appears in the mirror as a pale swelling with a smooth but more or less irregular surface. Treatment. — The importance of dealing with adenoid veg- etations promptly on the first intimation of their presence must appeal to every practitioner who has had opportunity to see the disastrous results of the presence of these, in them- selves benign growths. The condition is not to be met in a half-hearted manner, but a radical mode of procedure should be instituted from the beginning of taking the case. Remedies have yielded most satisfactory results in many instances, but in my experience the majority of cases are amenable only to operative measures aiming at a complete removal of the growths. Especially is this so in cases of long standing, where as a rule remedies accomplish very little. It is true that at the time of puberty a physiological atrophy sets in, but the harm that has been done in childhood — the period of growth and development — is of an irreparable nature. When a case is encounteied in its iucipiency remedies may be tried over a period of three months, unless urgent symp- toms are present, and if improvement follows and continues satisfactorily the operation may be put off or, possibly, en- tirely dispensed with. If, on the other hand, improvement is DISEASES OF THE EAR, NOSE AND THROAT. 565 only slight or absent, the sooner the operation is performed the better for the child. Local treatment is difficult to carry out and its results are not satisfactory. Remedies. — The remedy which has given the best results in the majority of cases is Calc. phos. It is generally given in the 3d decimal trituration, a grain four times daily. If in- dications for one of the other lime salts are present, notably, the carbonate or iodide, they should be given in preference to the phosphate. Arsenicum alb. is useful for the catarrhal symptoms, espe- cially when associated with hypertrophic rhinitis and ear symptoms. Sanguinaria nitrate, 3X trit., has given excellent results. The indications are mainly clinical. " I have excellent results with this remedy and with Calc phos., the former locally and internally in the 3X trit., and the latter in the 30th or 200th, thus often avoiding operations." — (Ivixs. ) Personally I give Calc. phos., 3X trit., the preference over other remedies. The old school administers the Iodide of Iron with confidence and no doubt obtains good results ; the combination of Iron and Iodine is well indicated in man)- in- stances. The operation is most satisfactorily performed under a gen- eral anaesthetic, for with local anaesthesia it cannot be thor- oughly done, even in children who are willing to co-operate with the physician. Ether is the safer anaesthetic, but in young children Chloroform, unless contraindicated, is preferable, on account of its quicker action and because it does not cause increased mucous secretion in the throat like ether. Profound anaesthesia is, as a rule, unnecessary. The child being placed on the table upon its back and the shoulders elevated to let the head hang down, a mouth gag is inserted between the molar teeth on the left side. The oper- ator now stands on the right side of the patient and intro- duces the index finger of the left hand into the pharynx be- 566 DISEASES OF CHILDREN. hind the soft palate in order to locate the growths. Having pro- ceeded so far he now inserts a Casselberry post-nasal forceps, guided by the left index finger, into the vault of the pharynx and seizes a portion of the growth, which is then torn away. Piece by piece, in rapid succession, the growth is removed, after which it is advisable to introduce a Gottstein or similar curette (Fig. 54) and scrape away the remnants which may have been left. Profuse bleeding follows, which is soon controlled by press- ure with cotton mops dipped in a saturated solution of Tannic acid and held against the bleeding surface by means of a long curved forceps. The blood also runs freely from the nose. It should be wiped away to permit nasal respiration to set in, which usually takes place immediately after the operation. Both before and after the operation the nose and pharynx should be sprayed with a mild antiseptic solution (Dobell's solution ; Seller's Antiseptic Nasal Tablets), and Aconite administered to lessen the in- fig. 54.— curette for the re- flammatory reaction. Acute MOVAL OF ADENOID .... • -i • otitis mav set in as a comph- VEGETATIONS. J . r cation, and if antiseptic precau- tions are not taken during the operation it may terminate in suppuration. The results of the operation are most grati- fying. Nasal respiration promptly ensues (unless the case has been of long standing), the blood becomes more thoroughly aereated, with resulting improvement in the color, and the appetite and general health, and reflex disturbances are re- moved. Naturally cases are encountered in which an opera- tion fails to benefit the child. Here, however, we must look for other lesions, notably, hypertrophic rhinitis and deflected nasal septum, as the cause of obstruction, either in part or in toto. Where, however, these can be excluded the results are uniformly gratifying. CHAPTER XVIII. CONSTITUTIONAL DISEASES. LITH^EMIA ; URIC ACID DIATHESIS. By the term " lithsemia " is represented a group of symp- toms resulting from the presence in the blood of certain products of faulty proteid metabolism. Most prominent among these substances is uric acid, and hence the condition is frequently spoken of as the uric acid diathesis. Closely re- lated to uric acid are the alloxuric bases, xanthin, hypoxanthin, guanin and adenin, and as the symptoms of lithsemia depend upon the retention of an excess of these substances in the body, the condition may be regarded as a form of auto-intoxi- cation, to which Rachford {American Text-book of Diseases of Children) applies the name of leucomain poisoning. Regarding the formation of uric acid in the body, Dr. Chas. Piatt (private communication) writes : " There are two theories current in explanation of the origin of uric acid in the mammalian body. i. That it is derived from the nucleinic bases, e. g., xanthin, hypoxanthin, guanin and adenin ; from those formed within the body and from those ingested with the food. 2. That it is derived from the amido-bodies, e. g^ glycocoll, leucin, tyrosin, etc.; that these are normally con- verted in the liver into urea ; that an interruption of this normal metabolism, ureids, e. g., hydantoin, allanturic acids, etc., are formed, and that these, in the kidney, are changed into uric acid. My own belief is that normally in mammals uric acid has a common origin with the nucleinic bases, viz., in the katabolism of the nucleoproteids ; that it is probably not de- rived from the nucleinic bases, neither from those of the bodv nor from those of the food ; that a certain percentage in health, and a larger percentage in disease, in conditions of 568 DISEASES OF CHILDREN. disturbed metabolism within the liver, arises from the gly- cocoll, leucin, tyrositi, aspartic acid, glutamic acid, etc., which reach the liver, after absorption from the intestinal tract, via the portal vein. A circle which may easily become vicious is established by the fact that the glycocoll itself takes origin in the decomposition of the glycocholic acid of the bile. As regards the normal formation of urea, this is, for the mammal, the end-oxidation product of proteid metabolism, intermedi- ate steps in its formation being the ureids, alloxan, alloxanic acid, dialuric acid, parabanic acid, hydantoin, etc. A certain percentage results from the metabolism of the amido-acids in the liver, and a certain minute percentage from the uric acid carried to the liver by the portal circulation. The term ' uric acid diathesis ' is indefinite, sometimes convenient, often mis- leading, has no significance from a chemical standpoint, and yet may not be abandoned until our knowledge becomes more definite/ ' It seems probable that many of the manifestations of the lithsemic diathesis are due to the xanthin bases rather than to uric acid. It is a well established fact, however, that in cer- tain phases of the condition, known clinically as irregular gout, an insoluble urate is deposited in the tissues, causing characteristic symptoms. It may be shown, on the other hand, that many conditions, loosely designated as lithsemia, are, in reality, evidences of ptomain auto-intoxication or simply of hepatic insufficiency. Sedentary habits and over- eating will of themselves cause hepatic torpor, but it is rea- sonable to suppose that the descendants of gout}' ancestors migfht be cursed with a liver that was bad from birth. During childhood heredity plays the most important role in the etiology of lithsemia, as the other causes which may give rise to it in later life, viz., excessive proteid food, seden- tary habits, alcoholism, etc., are not operative during earlier years. Prolonged illnesses frequently lead to the establish- ment of this condition. Symptomatology. — Infants are frequently born with uratic in CONSTITUTIONAL DISEASES. 569 farcts in the tubules of the renal pyramids ; these are washed out of the kidneys, and may be passed through the urethra or remain in the bladder, forming nuclei for vesical calculi. Older children may also have symptoms of uric acid precipi- tation — lumbar pains, renal colic, painful urination, haema- turia, and, very prominently, enuresis. Examination of the urine will usually reveal the crystalline deposits. The general symptoms of lithaemia are notably those refer- able to the gastro-intestinal tract, to the nervous system, and to the skin. Nausea and vomiting in recurring attacks, accompanied by fever, acute and chronic intestinal catarrh, and stubborn dyspeptic symptoms, belong to the gastro-intestinal disturb- ances. Convulsions, migraine, asthma and cyclic vomiting constitute some of the most prominent nervous manifesta- tions, while eczema is the well known cutaneous lesion of lithaemia. Disorders of vision are said to be of lithaemic origin at times. These conditions, strictly speaking, are in reality more the evidence of auto-intoxications than of gout. Lithaemic children are as a rule delicate, dyspeptic, nerv- ous, and excitable. They incline to be precocious and possess a strong tendencv to nervous and catarrhal affections. Im- perfect nutrition is the keynote to an interpretation of this constitution, which belongs to that group of morbid states known as arthritism (Bouchard), in which are included the principal constitutional diseases. The urine in lithsemia is usually scanty, high-colored, strongly acid, and deposits a large amount of uric acid and urates. Glycosuria and slight albuminuria are at times found. Lithaemic subjects frequently suffer from nephrolithiasis, and oxaluria may also be present. Before an attack the urine is often passed in large quantities, being almost colorless and of low specific gravity, indicating irritation of the kidneys with insufficient elimination of solids. While on the one hand lithaemia is frequently oxer- looked and the proper treatment consequently withheld, 37 570 DISEASES OF CHILDREN. still there is danger, on the other hand, of making a snapshot diagnosis of " uric acid diathesis " in an obscure chronic ailment. Hysteria and neurasthenia and their congeners, while they may be secondary to faulty metabolism, are in the majority of instances dependent upon hereditary defects of the nervous system, faulty education, bad home environment, or emotional causes (BarTXETT, The Clinical Relations and Diagnosis of the Uric Acid Diathesis, Medical Era, June, 1901). Other ailments which may be due either to uric acid or to terminal nerve irritations, such as post-nasal adenoids, phimosis and adherent clitoris, are asthma and enuresis. Auto-intoxication, or more cor- rectly speaking, exogenic intoxication from the intestinal canal, may produce cyclic vomiting, migraine or epilepti- form convulsions, but this is not lithaemia in the strict sense of the term. The xanthin bases, however, which are pro- duced directly within the blood-stream by katabolic changes in the cell nuclein of the leucocytes, are powerful poisons and may produce important disturbances. A careful examination of the patient must therefore always be made and all other conditions excluded before lithsemia can be diagnosed posi- tively. Treatment. — The diet is of the highest importance in lithsemia, for there are many kinds of food which contain al- loxuric bodies, either in the form of waste-prod nets or as nucleoproteids, and the introduction of these into the system only adds to the burden of the already overloaded tissues. For this reason all internal organs, such as sweetbreads, kidney and liver ; all meat-extracts or broths ; and raw 7 or cured meats should be absolutely forbidden. Indigestible articles, shell-fish, sweet wines and malted liquors should be withheld. Cooked meats may be allowed in moderation, but it is a fallacy to suppose that young meat is preferable to old. As a matter of fact, the contrary is true, for the flesh of young and growing animals contains more nuclein than does that of fullgrown ones. Hence beef and mutton are, theoretically, to be pre- CONSTITUTIONAL DISEASES. 571 ferred to veal and lamb, but from the standpoint of di- gestibility the younger meats are more desirable. Poultry and fish are less likely to produce ill-effects than other kinds of meat. There is little difference between rare and well- cooked meats excepting one of digestibility. Sugar and very starchy foods should be given sparingly, because an excess of carbohydrates is apt to overtax the liver, which is usually impaired. The chief articles of diet should be milk, eggs, poultry, fish, oils and butter, fresh vegetables, fruit and the less starchy forms of cereal food. The patient should be encouraged to drink freely of water, preferably before or be- tween meals, to take plenty of out-of-door exercise, and to observe regular hours for sleep. The remedies that have proved of the greatest value in the lithaemic state in general are Berberis, China, Lycopodium, Natrum mur., Pulsatilla, Nux vomica, Sepia, Sulphur, Nitric acid and Benzoic acid. The symptoms on which these rem- edies are to be prescribed are their well-known gastric, urinary and temperamental indications. (See Treatment of Renal Calculi, p. 383.) The remedies which may be called for in the special manifestations of this dyscrasia are numerous, and the reader is referred to the chapters covering these cases in their therapy. A. C. Croftan, following a suggestion of von Noorden's, ad- vocates the use of Calcium in this condition. He prescribes it in the form of the carbonate, giving ten to fifteen grain doses two or three times a day, together with a full glass of water. This mode of treatment is based on the fact that Calcium, on account of its affinity for phosphoric acid, com- bines with this substance in the blood stream, forming a phosphate which is eliminated almost entirely by way of the intestinal canal. The phosphoric acid of the blood and of the urine is thus reduced, and the sodium relatively increased ; hence less mono-sodium phosphate and more di-sodium phos- phate is produced, and as the latter is the normal solvent of uric acid, this substance, instead of being deposited in the tissues, remains in solution and is eliminated. 572 DISEASES OF CHILDREN. RICKETS ; RACHITIS. Rickets is a disease belonging exclusively to childhood, representing a pathological standstill in the normal process of ossification, with resulting softening and deformity of the entire osseous system. Associated with the lesions in the bones there is always more or less disturbance in the general health and malnutrition. The etiology is obscure and the course is essentially a chronic one. While some authorities, notably Kassowitz, claim that many infants show unmistak- able signs of rickets at birth, still the more recent workers in this direction doubt its occurrence much before the second or third month. Personally I have encountered a few cases that presented many of the clinical manifestations of rickets ap- parently from birth where the mother had been in miser- able health during the entire pregnancy. Foetal rickets has been described but it must be exceedingly rare. Stoeltzner {Pathologie u. Therapie der Rachitis, 1904) states that no such condition exists, although abnormal soft- ness of the diaphyses and swelling of the epiphyses may be observed in osteogenesis imperfecta and in chondrodystrophia fcetulis, The majority of cases develop during the teething period. After the second year it is rare, although it may be encoun- tered as late as from six to eight years (Schmorl). By far the most important etiologic factor is improper diet. The disease rarely develops in breast-fed infants unless lacta- tion be prolonged beyond the normal period. In my clinic I have repeatedly demonstrated rachitic manifestations in in- fants from one year to fifteen months old that were still on the breast. The reason for this is the deterioration of the milk which takes place under these circumstances. Arti- ficial feeding, however, is responsible for most cases. While a deficiency of lime salts in the food no doubt plays a promi- nent role in the production of rickets, as Bland Sutton dem- onstrated in his experiments with the lion cubs in the L,on- CONSTITUTIONAL DISEASES. 573 don Zoo, still there are many other factors also to be taken into consideration. Clinical experience has taught us that deficiency in proteids and especially in fat, and a relatively high percentage of starch or sugar, is the usual diatetic error under which 'rachitis develops. Again, the improvement that takes place as soon as these percentages are properly ad- justed is corroborative evidence of the close relationship of diet to the disease. The persistent use of sterilized food, notably the proprietary foods, which, at the same time, are deficient in fat and high in carbohydrates, is an etiologic factor often to be encountered. The geographical distribution of rickets is more or less sharply defined. It is practically a disease of the temperate zone and its frequency rapidly decreases with a rise above sea-level, being quite rare in high altitudes. In large cities it is most prevalent, especially in localities with changeable and damp climate. In the cold and tropical climates it is practically unknown, and in the country districts it is rarer than in the cities. The claim is made that in some of the European cities from 80 to 90 per cent, of all children show evidence of rickets. Unhygienic surroundings; lack of fresh air and sunshine ; closely crowded quarters — these may be looked upon as con- tributing factors. ZweifePs theory that rickets is primarily a form of malnu- trition due to a deficient supply of lime and magnesium phos- phate in the food is controverted by the lack of improvement in these cases resulting from the addition of such salts to the food. Again, that rickets is not entirely due to deficient absorption of lime salts has been proved by Ruedel, who demonstrated through urinary analyses that rachitic infants absorb and eliminate lime as well as healthy infants. Again, the theory that certain acids, most probably lactic acid (generated in the intestinal tract), by lowering the nor- mal alkalinity of the blood to such an extent as to interfere with the precipitation of lime salts in the cartilages, does not 574 DISEASES OF CHILDREN. seem to hold, as the alkalinity of the blood is not altered in rickets (StcELTzner, loco cit.\ Although changes in the bones, similar to rickets, have been induced by the feeding and subcutaneous injection of lactic acid (HeiTzmann, Baginsky), still in the cases experimented upon a diet poor in lime salts was at the same time administered. The role of heredity and of hereditary syphilis in the pro- duction of rickets can practically be ruled out, neither of them being essential to the development of the disease. The infectious theory is advanced by Morpurgo, who cul- tivated a diplococcus from cases of osteomalacia in rats and by inoculating young rats with the same obtained changes in the bones bearing a strong resemblance to rickets. According to Hagenbach rickets is due to some unknown micro-organism, his reasons for its infectious nature being ( 610 DISEASES OF CHILDREN. erythema, fibrous tendinous nodules and chorea are likewise frequent manifestations of the rheumatic diathesis. Acute articular rheumatism is usually of gradual onset, a moderate fever accompanied by tenderness and slight swell- ing of several joints indicating the nature of the complaint. Neither are the joints as highly inflamed and swollen as is the case in adults, nor is the fever so high and abrupt in its onset. The joints most frequently involved are the ankles, knees and wrists, but there is not that wide distribution of arthritis found later in life. The hip may be affected to- gether with the knee, thus closely simulating the symptoms of tuberculous hip-joint disease. I have seen such cases also mistaken for appendicitis and psoas abscess, owing to the fix- ation of the limb, pain, and fever; here, however, the .discov- ery of other sensitive joints and endocarditis, and a careful local examination, will readily indicate the correct diagnosis. It is no wonder that a serious endocarditis so often gains full sway before it is suspected, when we consider how great the liability to error and how slight the indications of the true nature of the case are in so many instances. For this reason it is well to investigate carefully the ordinary colds, fevers and growing pains of children in order to determine their true nature, particularly when they occur in rheumatic fami- lies. An attack of articular rheumatism runs a course of from two to three weeks under proper treatment and in the absence of complications. In a general way, it may be said that rheu- matism shows a tendency to attack more extensively the tis- sues of the growing child, and to manifest itself over a longer period of time than in adults. Endocarditis may exist alone as a symptom of rheumatism, or accompany the articular forms, whether severe or mild. If it is discovered as a primary condition, arthritis or chorea, particularly the latter, frequently follows in its wake. Note- worthy to mention is the strong relationship supposed to ex- ist between the development of fibrous tendinous nodules and CONSTITUTIONAL DISEASES. 611 a progressive endocarditis. They were first described by Barlow and Warner. These nodules are mainly found about the joints, most commonly at the styloid process of the ulna, above the olecranon, and along the tibia and malleoli. In structure they are found to consist of fibrous tissue with an admixture of fibro-cartilage (Mayer). Notwithstanding a careful search for these nodules in every case of rheumatism and endocarditis in children coming under my observation, they have been but rarelv found, and consequently were of little service in diagnosis. Pericarditis is rarer than endocarditis, more commonly of the dry form, and more difficult to recognize than endocar- ditis. There is, however, more pain than in the latter, and, in the advent of effusion, more dyspnoea. Tonsillitis represents one of the types of rheumatic inflam- mation, and it is a common affection of rheumatic children. The inflammation is severe ; the attacks show a strong ten- dency to recur, and the accompanying fever depends upon the local condition. Involvement of the endocardium is possible. These are the features of all rheumatic inflamma- tions, and beside tonsillitis the children of this diathesis are subject to rhinitis, pharyngitis and sibilant bronchitis, any of which may develop from apparently the slightest provocation. When endocarditis follows upon an attack of acute follicular tonsillitis it is hardly fair to refer to this as a proof of the identity of follicular tonsillitis and rheumatic infection, for in such a case the endocarditis is more probably septic or toxic than rheumatic (see p. 346). Muscular rheumatism is only common in the form of tor- ticollis, other groups of muscles being rarely affected in child- hood. The cutaneous symptoms indicating rheumatism are the various forms of erythema, urticaria and purpura rheumatica. They may occur alone or appear in connection with other local manifestations of the disease. Some chronic forms of skin disease are also dependent upon the rheumatic diathesis, 612 DISEASES OF CHILDREN. and by directing attention to diet and selecting a rheumatic remedy many intractable cases of infantile eczema are speed- ily relieved. Ancemia is a direct result of rheumatism, and children who have been repeated sufferers from any of the above manifesta- tions, usually exhibit a high degree of anaemia. Anaemia is especially noticeable in rheumatic fever. Chorea, hemicrania and gastralgia are among the prominent nervous disturbances resulting from the action of the rheu- matic poison upon the nervous system. Especially in chorea has the intimate relationship of the two conditions been so clearly demonstrated that little doubt remains as to the eti- ology of the majority of cases of chorea. Quite often other strong indications of rheumatism are present in these cases, among which endocarditis stands most prominently. Chronic Rheumatism. — Many of the foregoing conditions are chronic in their course or lead to pathological changes of a chronic nature, yet by chronic rheumatism proper is under- stood the chronic articular form. It is a rare disease of child- hood, resulting from an injury to a joint in the presence of a strongly-developed rheumatic diathesis, or through incom- plete resolution or the products of an acute inflammatory attack. Disability from muscular contractures is also liable to occur in rheumatics, particularly after strains or other in- juries to a joint. Chronic rheumatic arthritis is prone to be- come tuberculous. (Wright.) Stengel (Amer. Jour. Med. Sciences, March, 1903) has found chronic rheumatism more frequently in children than in adults. It is essentially a sequel of the acute form. The joints of the fingers are com- monly affected, but the lesions are not symmetrical, neither are there trophic changes in the skin covering the affected parts. Still's disease is a variety of arthritis deformans, encoun- tered in children. Together with the general enlargement of the joints there is swelling of the lymph nodes and of the spleen. The onset may be febrile. General thickening of CONSTITUTIONAL DISEASES. 613 the soft parts is more pronounced than enlargement of the articular ends of the bones and there is no grating as in the adult form. Anaemia and wasting of the muscles is marked but there is no endocarditis. In some of the reported cases marked improvement in the condition of the joints was noted even after the disease had progressed in the usual manner for a year or two. Treatment.— For those of a rheumatic inheritance much can be accomplished in the way of prophylaxis. Careful at- tention to the matter of clothing the child, having it wear flannel undergarments, and especially avoiding wetting of the feet and exposure in damp weather, is of the highest im- portance. The great danger which threatens these children is cardiac involvement. Constitutional remedies will do a great deal toward erasing the tendency to rheumatic attacks and mitigating their severity. Benzoic acid, Calc. carl?., Lycopodium, Causticum, Kali liydrojodicum, Mercurius, Sulphur and Rhus tox. are remedies of this type ; they are frequently indicated upon purely constitutional symptoms, and will accomplish much in this direction. The diet is of importance. Starchy and saccharine foods must be used sparingly, and fresh vegetables, voting meats and fowl, milk and fat (cod-liver oil ; olive oil ; cream, etc.) are to constitute the main dietary. Remembering the strong tendency to anaemia, a highly-nourishing diet becomes im- perative. During acute attacks absolute rest in bed must be enforced, to save the heart and hasten the subsidence of joint-inflamma- tion. Meat should not be permitted at this time. When considerably affected, the joints may be bathed with diluted tincture of HamameHs or rubbed with chloroform liniment and wrapped in raw cotton. Hinsdale {Medical Century, Feb., 1902) has used an ointment consisting of one part salicylic acid in two parts lanolin with much benefit. The following are the most frequently indicated and most useful remedies for the various manifestations of rheuma- tism : 614 , DISEASES OF CHILDREN. Aeon. — Fresh attacks. The early restlessness, fever and involvement of the joints is much benefited by Aconite, es- pecially when the cause can be directly attributed to chilling of the body. Apis. — Stinging and burning pains ; cedematous swelling of affected parts and synovitis. Arnica. — Intense soreness of the body; the bed feels too hard ; great dread of being touched ; scanty, red urine chilly when •moving in bed; great internal heat and sour sweats. Arsenicum. — Protracted cases. Pale swelling of affected parts ; profuse sweats ; great anaemia and prostration. Endo- carditis and pericarditis (advanced cases ; effusion, valvular insufficiency, oedema ; cardiac dyspnoea, etc.). Belladonna is frequently indicated for the febrile condi- tion ; general aching ; sore throat ; torticollis. Phytolacca is, however, more frequently indicated in rheumatic sore throat than Belladonna, and for the torticollis, Lachnanthes has proven useful in many cases. Be7izoic acid. — "Rheumatic diathesis in syphilitic or gon- orrhoeal patients. Urine high-colored ; ammoniacal, very offensive in many diseases." (Hering.) Tearing pains as if in the bones. Bryonia is one of the most useful remedies in articular and muscular rheumatism, as well as in the inflammations of the serous membranes complicating the same. In both of the latter conditions it is indicated early in the dry stage, as well as after effusion has taken place. Rhus tox. is frequently given when Bryonia is indicated, the mere symptom of restlessness leading to the choice of the former remedy. If we remem- ber that the Bryonia patient may become very restless from intense pain — motion, however, giving no relief, and the rest- lessness being worse before midnight — we will not make the mistake of confusing these remedies. Calc. curb. — Frequently indicated upon constitutional grounds. CONSTITUTIONAL DISEASES. 615 Cimicifnga rac. — " Pronounced cardiac lesions, fibrous nodules, and muscular contractures due to inflammation of the tendons and muscle-sheaths." (Cobb.) Chamomilla. — Great irritability of temper ; excruciating- pains, worse at night ; the child tosses about and cannot be pacified. China. — Often indicated as a tonic. Dulcamara. — Chronic rheumatism ; marked susceptibility to changes of temperature. Also rheumatic cutaneous erup- tions. Ferrum phos. — Ferrum phos. and Colchicin are most effect- ive remedies in controlling the intense pains of acute rheuma- tism. Colchicin I have found more applicable to pains distinctly located along the course of important nerve-trunks, especially the sciatic, while Ferritin phos. corresponds more distinctly to joint-pains, either localized or shifting about. Ferrum phos. is, so to speak, a cross between Aconite and Bryonia in rheumatism, its action being as prompt and certain as either of these. It must also be thought of for the anccniia which is liable to develop. Guaiacum. — Rheumatic pharyngitis (Phytolacca affects the tonsils) ; rheumatic contractures. A useful remedy in chronic rheumatism. Hamamelis. — Great soreness of affected parts, especially of the muscles. The aqueous extract, or the fluid extract diluted, has won great popular favor as a local application, superseding such lotions as potassium nitrate and laudanum, lead-water and laudanum, etc. Kalmia I a ti folia is an important remedy when there is cardiac involvement. u Pains flitting from joint to joint with now and then a warning twang at the ' heart-string ' ' (Hinsdale). Mercurius. — Tearing pain, not relieved by sweat ; wor.se at night and from the warmth of the bed ; joints usually swollen, with pale, puff)' appearance of the same. General gastric de- rangement; coated tongue, showing imprints of teeth; foul 616 DISEASES OF CHILDREN. breath ; collection of saliva in mouth with bad taste ; diar- rhoea. Extension to heart, lungs, pleura and meninges. Pulsatilla. — Shifting pains, flying from one joint to another. The joints are highly sensitive, but usually no visible signs of inflammation are present. The child is fretful and dis- posed to cry, frequently changing its position in bed, which gives temporary relief. The symptoms are usually worse at night and aggravated by warmth. Gastric derangements, such as coated tongue, absence of thirst, anorexia, loss of taste or bitter taste, alternate heat and chilliness, and catarrhal affections, are usually present. Rhus tox. — The pathogenesy of Rhus toxicodendron clear ly indicates that it has a wider range of usefulness in rheuma- tism than any other remedy. Its selective affinity not only for the joints and fibrous tissues, but its decided action upon the respiratory tract, the nervous system, the circulator}- sys- tem and the skin, stamp it as the remedy par excellence for any affection to which we may see fit to prefix the term " rheumatic," in the absence of strong, specific indications for other remedies. It is true, the symptoms of Rhus tox. are not so markedly localized as those of Bryonia, Phytolacca or Spigelia, being most suitable to that class of rheumatic dis- turbances designated "diffuse, non-circumscribed rheuma- tism," but nevertheless it may prove of use in any form, pro- viding its leading indications are present. They are : "Draw- ing, tearing pains in fibrous tissues, joints, and sheaths of nerves, attended with a sense of lameness and formication in the affected parts; with or without swelling and redness; caused by exposure to wet, damp weather, to rain, by bathing or a strain ; WORSE during rest and when commencing to move ; BETTER from continued motion and dry, warm, ex- ternal applications ; great restlessness." (C. G. R.) Sulphur. — Frequently of use as a constitutional or inter- current remedy. Sodium salicylate will certainly relieve the excruciating pains of rheumatism, but whether it materially shortens the CONSTITUTIONAL DISEASES. 617 course of the disease or is of any value in the prevention of complications is still a matter of dispute with many leading old-school authorities. Cactus, Cimicifnga rac, Colchicum, Digitalis and Spigelia are indicated in cardiac involvement. (For the indications for these remedies see Treatment of Endocarditis, p. 351.) HEREDITARY SYPHILIS. In children syphilis is almost invariably an inherited dis- ease, although it may be acquired during parturition from a primary lesion of the vulva or subsequent exposure to infec- tion. This is usually the case when the mother acquires syphilis late in her pregnancy, for if the disease is acquired after the eighth month the child escapes direct placental in- fection. The term hereditary syphilis, strictly speaking, ap- plies to those cases in which the ovum itself is syphilitic, either from the existence of maternal syphilis or from infection by the semen of the father — germinal syphilis. In such, syphilis exists from the time of conception. The foetus may acquire syphilis later through placental infection, in which case it is known as congenital syphilis, but the distinction is of no clinical importance. Acquired syphilis differs from the above forms both in the manner in which the disease gains access into the .system and in the presence of the primary sore, or chancre, which is never found in inherited syphilis. A syphilitic child may be born of an apparently healthy mother through paternal transmission of the disease, and although such a child is a menace to the community from the great degree of contagiousness of the disease, still the mother may escape infection from her own infant (Colles* Lazv). There are, however, exceptions to this rule, and mothers have been known to become infected from their own infants, showing that they were perfectly healthy while car- rying a child with germinal syphilis. In the cases where the mother does not become- infected from her offspring it still remains an open question whether she acquires an immunity 40 618 DISEASES OF CHILDREN. through the foetus or whether she is really a subject of latent syphilis. Again, a child may be born of syphilitic parents, having escaped infection, and remain immune to the acquired form of the disease throughout life {Prof eta's Law). Until the true etiological factor in the disease shall be positively known and its biological characteristics fully understood, the subject of hereditary syphilis will be beset with more or less confusion of opinions. Barly or precocious hereditary syphilis may manifest itself in utero, leading to a miscarriage. Children showing active signs of syphilis at birth are seldom born alive. They may appear macerated, or the body be covered with an extensive bullous eruption. The majority of cases do not show exter- nal evidence of syphilis until several weeks after birth, but this almost invariably appears before the third month. The variety of hereditary syphilis described as syphilis hereditaria tarda by Fournier, in which the appearance of specific lesions is supposed to be delayed until after the third year of life, is not recognized by many syphilographers, they being of the opinion that the early manifestations in these cases were overlooked. Again, hereditary symptoms occurring in later childhood may be the result of an innocent infection {syphilis insontium). The pathological lesions of hereditary syphilis are well de- veloped in most of the internal organs. The lungs show an increase in the inter-alveolar connective tissue and prolifera- tion of the alveolar epithelium {pneumonia alba). The liver may be enlarged as a result of round-cell infiltration of the interacinous spaces and pericellular cirrhosis; there may be gummata (rare) or simple interstitial connective tissue pro- liferation. These changes begin in the periportal region and spread into the acini, invading them with new connective tissue and blood-vessels. In the bones, epiphysitis is a characteristic change already observed in the foetus. Other conditions will be referred to under the clinical manifestations of the disease. CONSTITUTIONAL DISEASES. 619 Symptomatology. — One of the first symptoms observed in the syphilitic infant is the syphilitic rhinitis or "snuffles." This is a dry catarrh due to infiltration of the mucous mem- brane and it may lead to ulceration of the septum with the production of the "saddle nose." In severe cases the infants are emaciated and present bullous lesions on the palms of the hands and soles of the feet. This is soon followed by the development of diffuse infiltration of the skin with a tendency to scale ; pustules ; ulcerating lesions of the mucous mem- branes. In less virulent cases there appear at the end of a few weeks macular syphilides on the lower portion of the ab- domen and on the buttocks ; papules and pustules may co- exist. The pustules are especially common upon the face and buttocks. They have a tendency to ulcerate deeply, forming dark-colored crusts. The skin appears shrivelled, poorly nourished, and presents a brownish discoloration. Other symptoms are hoarse, plaintive cry ; mucous patches in the mouth, rhagades at the angles of the mouth, anal con- dylomata and gastro-enteric catarrh, inducing foul-smelling diarrhoea. The syphilitic child is under-developed and anaemic ; the face wears a characteristic old and anxious ex- pression. The internal organs, as mentioned above, are the seat of diffuse interstitial hyperplasia of the connective tissue, through which destructive changes are wrought in the paren- chyma of the liver, lungs, and digestive glandular system. These lesions are responsible for the malnutrition and event- ual death of the syphilitic infant, although it may die with symptoms of basilar meningitis. The later manifestations of syphilis, occurring in cases not so malignant from the beginning, and consequently surviv- ing, are those referable to the bones, teeth, organs of special sense and nervous system. It is readily seen how, in mild cases, slight early manifestations may be overlooked or for- gotten, and how, upon the development of symptoms after the third year — even as late as puberty — the nature of the case is not promptly recognized or suspected. 620 DISEASES OF CHILDREN. In the osseous system epiphyseal osteochondritis and dactyl- itis may occur early in the disease. Osteochondritis develops at the epiphyses of the long bones and by interfering with the growth of the bone may lead to deformity. The symptoms of epiphysitis are acute and simulate arthritis. The child holds the limb as if paralyzed on account of the pain. The lower end of the humerus is most frequently involved. Dacty- litis presents a characteristic fusiform swelling of the fingers, also attacking the metacarpal and metatarsal bones. Ulcer- ation often results with the destruction of the bone and in- tegument. Hyperostosis of the tibia, resulting in rounding out of the tibial crest and curving of the shaft — the sabre- blade deformity — is very characteristic of hereditary syphilis. In rickets the sharp crest of the tibia remains unchanged, while deformities of the bone are most marked at its lower end. Cranial exostoses upon the frontal and parietal bones are also found in well-developed cases. The milk teeth are delayed and decay early ; the perma- nent teeth present pathognomonic signs first described by Jonathan Hutchinson, for which reason they are known as Hutchinson? s teeth. The upper central incisors are dwarfed and present a notch upon their cutting surface, while other teeth show the influence of stomatitis upon their growth (see Ab- normalities of the Teeth^ p. 127). Two other conditions to which Hutchinson has given much prominence are interstitial keratitis and otorrkcea. Otorrhoea or sudden deafness should always arouse a suspicion of syphilis. Interstitial keratitis is a frequent symptom of syphilis, developing at the time of puberty. Nasal deformity is a characteristic sign of hereditary syph- ilis as well as radiating linear scars at the angles of the mouth. The latter result from ulcerating mucous patches, while the former is due to diffuse gummatous rhinitis, with accompany- ing ozsena. Gummatous infiltration of the brain and cord may lead to a variety of disturbances in the nervous system. Meningitis; CONSTITUTIONAL DISEASES. 621 epilepsy ; dementia paralytica ; tabes dorsalis and hydro- cephalus are among the most important nervous affections that can at times be traced to a syphilitic origin. As the syphilitic infant presents a characteristic old, with- ered look, so the older subject of hereditary syphilis may ex- hibit a diametrically opposite condition, namely, that of kl in- fantilism" (Fournier). The individual appears younger, both mentally and physically, than his age would indicate. The diagnosis of syphilis is not difficult in the presence of a clear family history and clean-cut consecutive manifesta- tions of the disease, but it frequently presents the greatest difficulty when isolated symptoms are encountered. In the first place, a history of miscarriages in the mother followed by the birth of a still-born infant or one that died of kt inani- tion" in early infancy is strong presumptive evidence of syph- ilis. Secondly, the presence of snuffles at birth is an import- ant symptom. An underdeveloped, wakeful, old- and un- happy-looking infant (in contradistinction to the bright appearance of the purely marantic infant) should always sug- gest syphilis and lead to a careful watch for such symptoms as hoarse cry. offensive diarrhoea, cutaneous eruptions, etc. The later manifestations of syphilis are all characteristic, and in the presence of such symptoms as Hutchinson's teeth ; radiating linear scars ; flattened nose-bridge ; dactylitis and interstitial keratitis, other symptoms are readily accounted for. The prognosis of syphilis becomes the more favorable the later and the more benign the earliest manifestations of the disease have made their appearance. Death from syphilis is quite common in infants, but after the sixth month there is a good chance for the infant to survive if its nutrition can be maintained at a good standard. Probably one-half of all syphilitic-bora children succumb before the sixth month. The longer life is sustained after that period, with the insti- tution of proper treatment, the greater are the chances for ultimate recoverv. 622 DISEASES OF CHILDREN. Treatment. — The syphilitic infant is a menace to its sur- roundings, for, with the exception of its mother, it is capable of infecting anyone with the disease. The lesions in the mouth and the discharges from the nose or from ulcerating papules or pustules anywhere upon the body are the sources from which infection takes place. If a syphilitic history is obtainable, even before signs of the disease make their appearance, it is advisable to institute treatment at once. As to remedies, there are a number beside Mercury which are not only frequently indicated, but which are indis- pensable in the treatment of hereditary syphilis. Usually, however, Mercury is the best remedy with which to begin the treatment of fresh cases, as it corresponds to the majority of the symptoms of secondary syphilis, the stage in which hereditary syphilis first manifests itself. When rhinitis and laryngitis are the most prominent early symptoms, inducing the so-called " snuffles " and hoarse cry, Kali bicliromicum is indicated. So, likewise, numerous other remedies may be called for from the beginning on special indications. When using Mercury I have obtained the best results from the protoiodide, administering one to two grains of the second deci- mal trituration three to four times daily according to circum- stances. As Bartlett well advises, the administration of Mer- cury should be stopped very shortly after the disappearance of symptoms, for there seems to be no necessity for mercurial- izing the infant. In the late manifestations of hereditary syphilis the Iodide of Potash must frequently be employed in material doses. The smallest dose which will improve the case is the proper one to employ, and I know of authentic cases in which this remedy in potency has yielded prompt, curative results. u It can frequently be well followed or re- placed by the Iodide of Ca/carea or the Iodide of Arsenicum in lesions of the glands ; by Si/icea or Zincum or Sulphur in those of the nervous system ; and by Hepar sulpiiuris or Autum or Nitric acid in those of the osseous system." (Cobb). CONSTITUTIONAL DISEASES. 623 Aurunt. — Tertiary manifestations ; exostoses on skull, tibia and bones of forearm ; dactylitis with ulceration ; caries of nasal bones; defective development of genital organs; infan- tilism ; mental depression. Baryta card. — Glandular enlargements; squamous syphi- lides. Hepar calc. sulpJi. — Hepar has always been considered a valuable antidote to the evil effects of Mercury, but aside from this it is a most efficient remedy for many of the purely constitutional manifestations of syphilis. Its well-known influence over suppurative processes renders it useful in pustular skin affections and in the early stages of bone ne- crosis. The symptoms, u soreness of the nose on pressure with red, inflamed eyes," hint at beginning caries of the nasal bones, and a similar condition is obtained in the bones of the skull and extremities as well. The sharp, sticking pains in the throat are similar to Nitric acid, but when this remedy is indicated there are other symptoms present by which a differ- entiation is not difficult. Kali bichromicum. — Snuffles ; harsh voice and hoarse cry ; deep ulcers on the edge of the tongue ; ulcers on the velum palati, eating through ; ulceration of nasal septum (cartilagin- ous portion) ; ulcers in general, with characteristic punched- out appearance. Kali hydroj. — Tertiary syphilis ; diffuse and circumscribed gummatous infiltrations ; mercurialization ; interstitial kera- titis ; otorrhcea ; swelling and ulcerative destruction of uvula. Kreosotum. — Foul-smelling diarrhoea ; the teeth turn black and crumble. Mercurtus. — As to the homoeopathicitv of Mercury to cer- tain stages of syphilis, this is a fact so firmly established that it requires no further discussion. An analysis cf the cases successfully treated with Mercury indicates that its most marked effects are the healing of ulcers and improvement in the general health, both of which belong to the truly homoeo- pathic action of the drug (Hughes, Pharmacodynamics). Its 624 DISEASES OF CHILDREN. " tonic " action is owing to its haematic power, while its con- trol over diffuse inflammation and swelling of the mucous membranes, accompanied by ulceration and inflammations of serous membranes, periosteum and skin, depends upon its specific action upon these structures. This primary, specific action covers almost completely the early manifestations of hereditary syphilis, and the manifestations of mercurial abuse cover many of the destructive manifestations of the disease. Impetigo and rupia, rapid ulceration of the mucous mem- branes, skin and bones, etc., strongly call for Mercury, espe- cially in combination with Iodine, as recommended above, or in larger doses when symptoms become urgent (inunctions). Mezereum. — Pustular eruptions, forming thick, brownish crusts, with oozing of pus, painful at night; swelling of shafts of bones ; syphilitic neuralgia. Nitric acid. — Deep, irregular ulcers on border of tongue, upon tonsils and soft palate ; sticking pains in ulcers; rhagades at angles of mouth ; pustular and squamous syphilides ; mer- curial stomatitis and cachexia ; urine strong, ammoniacal ; condylomata. Sulphur. — Syphilitic children often require an occasional dose of Sulphur to arouse their reactive powers or to control special symptoms. The symptomatology of this remedy is too extensive to be considered here, its sphere of action em- bracing both general and special indications. Psorinum may likewise be called for occasionally. Thuja. — Flat, condylomatous lesions about the anus and ulcerating papules on the scrotum. MARASMUS, OR ATHREPSIA ; MALNUTRITION. The extreme form of malnutrition in infancy leading to actual starvation is more often seen in hospitals and dispen- saries than in private practice. Aside, however, from this ap- palling athrepsia, or marasmus, there is a large class of 'in- fants in whom the nutrition is simply below par, but whose CONSTITUTIONAL DISEASES. 625 condition tends to become progressively worse unless active measures are taken to restore the balance of the physiological process of normal growth. The pathogeny of infantile athrepsia is as obscure to-day as it was in 1877 when Parrot described the conditions as an independent disease following in the wake of gastro-intestinal disturbances and due to certain changes in the blood through which a reversal of the process of nutrition is effected and such pathologic processes as aphthae, cutaneous eruptions, fatty infiltration of the liver and uric acid infarcts of the kid- neys are produced. The histological findings in the gut are by no means uni- form. Baginsky insists that the mucosa is thinner than nor- mal and that there is distinct evidence of atrophy of the in- testinal tubules and villi. Heubner, on the other hand, claims that pathological changes are not constantly found and when so, that they are only the evidence of a preceding enteritis. On the other hand, the long-continued distention of the gut with gas as a result of fermentation accompanied by the wast- ing of its muscular coat produces the appearance of a glandu- lar atrophy. The careful investigations of Holt substantiate the view that there is no definite gross pathological lesion in the intestinal mucous membrane to account for the clinical manifestations. The theory of a chronic acid intoxication of intestinal ori- gin was advanced by Keller, who found the urine highly acid and containing an excess of ammonia. The origin of these acids lies in a deficient oxidation of the carbohydrates and particularly the fats of the ingested food. The fact, however, remains that this excessive elimination of ammonia has been found wanting in a number of cases of gastro-intestinal atrophy and has been repeatedh found in the absence of any distinct signs of wasting. In a number of my own cases the urine has been excessive in quantity and of very low specific gravity. The only abnormal chemical change noted was an increase in indican. 626 diseasp:s of children. Arguing from the established fact that the intestinal mu- cosa of a marantic infant assimilates the proteids and fats of an artificial food much less satisfactorily than breast milk and consequently expends a much greater amount of glandular energy in this attempt, Heubner explains the failing nutri- tion on the grounds of a disturbed balance of energy, in other words, waste of energy on the part of the organism. My personal investigation of the gastric contents of cases of marasmus (Hahnemannian Monthly, May, 1903) has shown that in a well developed case there is a total absence of free HC1. and that the amount of free hydrochloric acid in less pronounced cases bears a definite relationship to the progno- sis. Indeed, where the emaciation is the result of some other disease, such as tuberculosis, I found more or less free acid, while in genuine marasmus it was absent. I recall a case of marked wasting as a result of ileocolitis seen with Prof. Bart- lett. We found the HC1. but slightly reduced and a good prognosis was given. The child promptly recovered under careful dieting. The etiology of marasmus is not always clear. In some infants there is undoubtedly a congenital feebleness of con- stitution which renders them incapable of conquering in the struggle for existence. Here heredity is an important factor, and we may find evidence of constitutional disease in the parents; on the other hand, they may be perfectly healthy. Extreme youth of the mother, and frequent pregnancy at short intervals is often noted on the maternal side of the his- tory. The surroundings play an important role. Crowded quarters and lack of fresh air and sunshine are strong con- tributing factors. The ordinary hospital ward is a most un- desirable quarter for infants convalescing from an acute ill- ness and unless promptly removed therefrom they soon show signs of failing nutrition. Some believe that infection of one infant from another, possibly through contaminated food, may take place, although there is no proof that specific bac- teria play a part in the etiology. CONSTITUTIONAL DISEASES. 627 Symptomatology. — The infant may be delicate at birth, have difficulty in digesting its food even when breast-fed, and its progress follow a weight curve that is marked by progress- ive loss of weight interrupted by periods of temporary gain or standstill. More frequently the infant appears normal at birth and gets on perhaps as well as the average case up to from the third to sixth month, when as the result of some acute illness or what is more common, a change in the food, the nutrition gradually goes wrong. It is by no means nec- essary that the infant should have been on breast milk and that a change to artificial feeding be instituted in order to bring about this condition. A sudden change during artificial feeding to an ill-selected diet or the more gradual ill- effects from a diet that is unsuitable or insufficiently nourishing will accomplish the same results, especially when the environment is such as to favor marasmus. The emaciation progresses until the infant is reduced literally to skin and bones. The face has an old, wrinkled appear- ance, the eyes being sunken and the small triangular chin showing in marked contrast to the large head ; the chest is small and the ribs are plainly visible while the abdomen is large and distended. Through the thin abdominal wall the stomach and coils of dilated intestines can often be seen. The skin is pale and transparent. There is more or less intertrigo about the genitals and buttox and a few scattered boils are not uncommon. Anaemia is marked. The child presents the picture of distress and restless anxiety. On account of the adynamia these infants are inclined to develop (Edematous swelling of the face and extremities, which comes and goes. A temporary gain in weight may result from this oedema. The urine is normal under these circumstances. The temperature runs a subnormal course. An occasional rise to 99 or ioo° in the rectum occurs when acute indigestion intervenes, but this is only transitory. I have seen it running between 96 and 97 F. in the- morning (rectal) tor weeks with ultimate recoverv. 628 DISEASES OF CHILDREN. The stools vary in character. To all appearances they may be normal, excepting for an increased acidity. They tend to vary from day today in number, color and consistency. Usu- ally they are large and contain light colored curds with green- ish mucus. Alternate constipation and diarrhoea is frequently seen. The appetite is variable. Sometimes for a considerable period it is voracious and the child does not seem to get satis- fied. Then, again, it may be lost and there may be difficulty FIG. 56. — INFANT ONE YEAR OI v D WITH MARASMUS. in inducing the infant to take sufficient nourishment. In some instances acute inanition results from the refusal on the part of the infant to take its bottle. On account of the weak digestion and fermentation, colic is frequent and considerably complicates matters. The duration is difficult to foretell. The child may die suddenly from an intercurrent diarrhoea or broncho-pneu- monia ; gradual and persistent improvement may follow proper treatment or the case may drag on with exacerbations and ameliorations far into the second year. CONSTITUTIONAL DISEASES. 629 The. prognosis is always grave, but it depends much upon the care the child can receive. Thousands of cases that die annually could be saved if they could be removed to more favorable surroundings and receive more skillful and consci- entious nursing. It is marvelous what persistent watching and self-sacrifice on the part of the mother or nurse will accom- plish in some cases with apparently the least hopeful outlook. Diagnosis. — The differentiation between marasmus and tu- berculosis is not always easy. It is said that the tuberculous infant is bright in appearance and. not so prostrated and apa- thetic as the marantic infant, but this is not a reliable sign. In tuberculosis we have continued fever as a more or less con- stant symptom ; at any rate, there will be distinct febrile movements at some time or another during the course of this disease. Besides, repeated careful examinations of the chest will ultimately reveal evidence of tuberculosis and we may also be able to detect enlarged mesenteric glands by palpa- tion of the abdomen. Persistent diarrhoea with pns in the stools and at times blood speaks strongly for tuberculosis. Malnutrition is a much commoner condition than maras- mus. It may be the result of premature or inherited feeble- ness of constitution, or follow after some acute illness, notably a gastro-intestinal affection. Again, malnutrition is a promi- nent symptom in tuberculosis, syphilis and severe rickets. Its most usual cause is improper feeding and unhygienic surroundings. As to the last named factors, they are just as likely to be encountered in well-to-do families as among the poorer classes, for here proprietary foods and close, over- heated nurseries come into play. In older children anaemia and malnutrition often date back to an attack of one of the infectious diseases or result from improper eating and school- hygiene. The diagnosis of simple malnutriton rests upon the exclusion of an organic disease or infection of which it might be only symptomatic. Treatment. — The regular weekly weighing of the infant is an absolute necessity and the only accurate guide by which 630 DISEASES OF CHILDREN. we can judge of the progress of the case. The evening and morning temperature should be taken regularly, as this will indicate to us whether or not we must resort to artificial heat or extra clothing ; also whether the infant must be kept in bed or taken out in the fresh air. With a persistently sub- normal rectal temperature I have found it best to keep the child in bed, well clothed and a hot water bag at the feet. Such children should not be bathed but gently washed and then rubbed with warm olive oil. Very young infants who are too much exhausted by dressing and undressing can be wrapped in raw cotton. Of the highest importance is the diet. If the infant be breast fed we must determine by examination of the milk whether it be sufficient in amount and of proper chemical composition. If the milk be at fault and appropriate treat- ment applied to the mother does not improve the same, we must try a wet nurse. If the milk is simply deficient in quantity, mixed feeding should be instituted. As it is not always possible to obtain a wet nurse, we should bear in mind that in modifying the milk for a delicate or marantic infant it must be of a strength that would be suit- able for a much younger infant than the one in question. It is generally held that the proteids are the elements of the food that cause all the trouble in feeble digestion and there has been a tendency to cut them down to almost noth- ing while the fats are administered liberally. This is the mode of practice that my clinical experience has taught me to be erroneous. Some years ago I learned that infants who could not take milk, even when highly diluted, could often take it in fairly strong proportions if all the fat were removed. This is not true in every case, but there is a large class of in- fants who digest fat less satisfactorily than proteids and vtca versa. Some time ago a colleague consulted me concerning a case under his care, an apparently healthy infant of eight months, that would not gain weight, although the milk seemed to be properly modified. There were some signs of CONSTITUTIONAL DISEASES. 631 gastric indigestion and I advised him to take the cream out of the food entirely. A month later he told me that the child began to gain immediately, but every time he tried to go back to the cream, the gain ceased. Holt has recently reported several cases in which serious toxic symptoms resulted from giving too much cream — the usual reason for giving so much fat being to overcome constipation. Edsall reported similar but less acute disturbances in older children, and here he demonstrated the presence of the lower fatty acids in the urine. The element of the food that is most easily assimilated and that is most required in these cases to maintain the body heat and keep the machinery going is the sugar, or carbohydrate. That is why condensed milk, which contains a low fat and proteid percentage and a high carbohydrate percentage often agrees after the physician has racked his brain in the at- tempt to find a suitable milk-formula. It is eminently bet- ter, however, to apply this principle in modifying the milk than to have the infant put on such an inferior article. Milk sugar is preferable to cane sugar in these cases for sev- eral reasons. In the first place, it is more easily assimilated, and can be given in larger quantities. Secondly, it does not so read- ily undergo fermentation in the intestinal tract, but when there is a tendency to diarrhoea it may aggravate this condition. Cane sugar and even starch should not be depended upon as a food in early infancy. Cane sugar may produce untoward effects in certain infants, such as gastric irritability, vomiting and colic. I have seen cases in which every attempt to sub- stitute granulated sugar for lactose was followed by vomiting. The chief function of starch in early infancy is to render the casein of the milk more easy of digestion. This is purely a mechanical effect. For this purpose we dilute the milk with barley-water. When milk is not borne well it is a good plan to interpolate several bottles of mutton broth made with rice or barley in the feeding schedule. I have not had happy results from the predigestion of starch 632 DISEASES OF CHILDREN. solutions with malt diastase. On the other hand, dextrinized starch is well born in many instances. Baked flour, or a water-cracker rolled into a powder and then boiled with suf- ficient water to make a thin pap and a little milk and sugar added is well borne by infants of a year or older. For the class of infants who do not digest the proteids of milk well, Edsall has suggested bean flour, on account of its high proteid percentage. He used it in a number of marantic cases in a solution that was subsequently dextrinized, and re- ports good results. Dr. S. W. Sappington experimented with this food at the Children's Homoeopathic Hospital, but his re- sults were not encouraging. The use of peptonized milk does not give the results expected of it. It is not so much faulty digestion as faulty assimilation that really lies at the bottom of the trouble. The good results obtained from Peptogenic Milk Powder are, to my mind, due more to the milk sugar and bicarbonate of soda it contains than to the pancreatic extract. Stimulation is at times called for. A few drops of brandy, well diluted, given during periods of great depression, has seemed helpful. Panopetone may also be tried. On account of the anaemia, freshly prepared beef juice (diluted) should be given in small quantities daily (^ss to gj). Diarrhoea would temporarily contraindicate its use. We know that even human milk contains insufficient iron to sup- ply the requirements of the organism after a certain period, as has been pointed out by Bunge, and that the infant actu- ally draws from the store of iron present in its tissues at birth to sustain the haemoglobin percentage of the blood. Conse- quently anaemia develops if milk is continued as the sole food beyond a certain time, and more markedly in subnormal than in normal infants. Instead of giving the usual quantity of food, it may be necessary to use a smaller amount at shorter intervals before the digestive tract will tolerate even a weak milk mixture. This, like every other question with the cases, must be ascer- tained by trial and experimentation. CONSTITUTIONAL DISEASES. 633 The question of the use of alkalies in the food often arises. When there is vomiting of curds or the passage of curds in the stools, sodium carbonate should be added to the milk in small quantities (2 to 3 grs. to the bottle). This will prevent the formation of the tough curds of paracasein chlorid and allow the more delicate curds of casein to enter the intestinal tract where they will be digested by the pancreatic juice. If there are loose, acid stools and much gas, lime water is pre- ferable. I have occasionally seen beneficial results from the administration of a few drops of dilute hydrochloric acid in water, half an hour after nursing, where there was a deficiency of the gastric secretion. The bicarbonate of soda, aside from its action upon the casein, also appears to exert some influence over the acid intoxication that plays so important a role in many of these cases. Orange juice, on account of its beneficial effects in rickets and scurvy, may be used with advantage, especially when there is constipation and when the infant has been taking sterilized milk for some time. When the stools become highly acid and irritating the carbohydrates must be cut down and proteids (egg albumin, meat broth) increased, while in offen- sive and alkaline stools the carbohydrates must be increased and proteids cut down. . In looking over the list of remedies recommended in de- praved states of nutrition, the deep acting constitutional ones stand in the foreground. Much benefit is derived, however, from paying attention to the acute symptoms as they arise and prescribing such remedies as Nnx vomica, Podophyllum, China, etc., intercurrently. The calcareas seem indicated in the majority of cases, es- pecially Calc. phos. Iodine is strongly related to emaciation and glandular atrophy, and the iodides are often indicated, especially the Iodide of Arse?iic, when there is great prostra- tion, nervous irritability and restlessness ; tendency to diar- rhoea ; dropsical swelling of the face and extremities. Sulphur has many of the symptoms of marasmus, and it 4i 634 DISEASES OF CHILDREN. suits especially the cases with cutaneous eruptions ; intertrigo ; irritating stools and urine. Mevcurius naturally suggests itself where there is a suspicion of syphilis. Lycopodium and Natrum muriaticum are important in mal- nutrition and emaciation, and will suggest themselves by their characteristic symptoms. CHAPTER XIX. ACUTE INFECTIOUS DISEASES. EXANTHEMATA. The exanthemata constitute a group of acute infectious fevers belonging to the period of childhood, occurring epi- demically, and characterized by the eruption of an exanthem upon the surface of the body. To this class belong measles, rubella and scarlet fever. Although a specific causative micro-organism has not yet been demonstrated in any one of these diseases, still there is no doubt as to their infectious- ness, and it is quite likely, as Welch {American Text- Book of Practice) states, that they depend upon another form of micro-organism, not a bacterium, for the demonstration and study of which we are at present not fully equipped. In the light of the most recent investigations it appears that a num- ber of the infectious diseases of unknown origin are due to a protozoon and not to a bacterium. MEASLES, RUBEOLA. Measles is one of the commonest of all acute diseases of childhood and there appears to be a universal susceptibility to the disease as few people go through life without having had it either in childhood or in later life. A child that has been exposed to measles rarely escapes contracting the same. It occurs preferably in epidemics during those months favoring catarrhal affections; spring epidemics are usually the severest. One attack affords immunity against another. The period of incubation is from ten days to two weeks in the average of cases. Contagiousness is present from the time of invasion, being most pronounced at the height of the catarrhal manifestations and fever. It rapidly van- 636 DISEASES OF CHILDREN. ishes with the disappearance of the eruption, and at the end of the third week there remains little or no danger of contagion. The contagion is usually spread by close contact, and is seldom conveyed by means of intermediate objects or a third person, it also being readily destroyed by thorough airing and fumigation. Measles, however, is more readily disseminated than scarlet fever or diphtheria and an epidemic is more likely to attain wide-spread proportions than in the latter diseases. Symptomatology. — The course of a typical case of measles is in three stages. These are characteristic to the exanthe- mata in general, but most clearly defined in measles. They are: the stadium prodromorum, or prodromal stage; the stadium eruptionis, or stage of eruption, and the stadium florescenticE, or stage of desquamation. The first stage is characterized by fever and catarrhal symptoms of gradual onset, showing themselves as a cold in the head, with bloodshot eyes and lachrymation, accompanied by chilliness and headache. The catarrhal process extends to the larynx and trachea, resulting in the characteristic hoarse cough. On the third day single, lentil-sized red spots are seen upon the roof of the mouth and soft palate, frequently being observed twenty-four hours before the eruption upon the skin makes its appearance. Koplik's sign appears even earlier and is more truly pathognomonic of measles in the period of invasion. He describes this buccal enanthem as follows : "If we look into the mouth at this period we see in a strong light the usual redness of the fauces, perhaps not in all cases a few red spots on the soft palate. On the mu- cous membrane lining the cheeks and lips (buccal mucous membrane) we see a distinct and pathognomonic eruption. This consists of small irregular spots of a bright-red color ; in the centre of each spot is the interesting sign to which I wish to call attention. In strong daylight we see a most minute bluish-white speck. These minute bluish-white specks in the centre of a reddish spot are absolutely pathog- ACUTE INFECTIOUS DISEASES. 637 nomonic of beginning- measles"* (N. Y. Med. Record, April 9, 1898). This sign is present in all cases twenty-four hours before the skin eruption, and often three days preceding it. (KOPLIK.) The second stage begins on the fourth or fifth day. The eruption makes its appearance first on the face in the majority of cases, accompanied by increased fever. Thence it spreads over the entire body surface, the eruption being completed in two to three days. Its spread, however, may be irregular and interrupted, and desquamation may occur on one portion of the body while the eruption is appearing on another. The exanthem is the product of a superficial dermatitis, with pap- ule formation through round-cell infiltration about the papillae, the cutaneous glands and small blood-vessels. There may be also oedema of the skin accompanying the inflammatory process ; this is most prominently seen upon the face. The eruption proper consists of numerous, roundish, lentil-sized red spots, slightly raised above the level of the surrounding skin, or containing in their centre a little papule. Where they are very numerous they coalesce, forming crescentic plaques, or they may fuse entirely into large, spotted areas {morbilli confluentes). Cases in which the hyperaemia is so great as to cause cutaneous haemorrhages are described as morbilli petechialis or black measles; in these cases the erup- tion assumes a dark color from petechial haemorrhages. Pe- techial measles is by no means always a more serious condi- tion than the ordinary form ; in fact, I have encountered a number of cases running a rather mild course, in which the eruption assumed this haemorrhagic type. A distinctive difference between the eruption of measles and that of scarlet fever is its behavior to point-pressure : "The spots disappear by finger-pressure, but the redness soon reappears from the centre toward the periphery " (Hartmann, Die Kinderkraiikh., Leipzig, 1852) in measles, while in scar- * The first article upon this subject appeared in . trchives of Pediatrics December, icSc^b. 638 DISEASES OF CHILDREN. let fever the redness reappears from the periphery toward the centre. Dr. Hartmann, however, offered no explanation for this phenomenon, which I think is easily understood from a close study of the eruption. In measles we have papules sur- rounded by areas of erythema, and by applying firm pressure to a patch of eruption with the finger-point we force the blood from the erythematous area surrounding the papule, but do not completely deplete the hypersemic papillae forming the papule, which recovers itself quickly through its great vas- cularity, for which reason the redness seems to reappear or even persist in the centre of the compressed skin area. In scarlet fever, on the other hand we have either a diffuse hy- peraemia or a fine, closely-aggregated miliary eruption, which behaves like the erythema surrounding the measle papule; in other words, the area of skin pressed upon is completely depleted, there being no central papule, and the redness reap- pears from the periphery toward the centre, as the greatest amount of pressure has been brought to bear upon the centre of the area, and consequently the greatest amount of depletion. In young children convulsions sometimes occur at the time the eruption makes its appearance. The catarrhal symptoms reach their acme, and broncho-pneumonia and troublesome diarrhoea are to be feared during this period. Catarrhal in- flammation of the conjunctiva, nose, pharynx, larynx, trachea and bronchi are so closely associated with the course of an attack of measles that they are really to be looked upon as characteristic lesions of the disease. The strong tendency for the process to extend from the bronchi into the bronchi- oles and air-vesicles is one of the most dangerous features of measles, and almost every fatal case is directly due to pneu- monia or exhibits signs of the disease. The inflammation of the pharynx and larynx may become croupous, and suppurative otitis media may appear as a* com- plication at this stage, although neither of these conditions are as common to measles as to scarlet fever. In the alimentary tract a similar catarrhal condition may ACUTE INFECTIOUS DISEASES. 639 become established, showing itself as anorexia, vomiting, heavily-coated tongue with enlarged marginal papillae, and diarrhoea. The latter, when once established, is liable to continue throughout convalescence. At the end of about four days the eruption begins to fade, disappearing first in those localities where it was primarily seen. In mild cases it has already become much paler at the end of twenty-four hours, and it may disappear entirely from one part while another part is being invaded. With the fad- ing of the rash desquamation takes place in the nature of fine, branny scales, first noticed upon the face and neck. It is com- pleted in a week in the average case, seldom continuing for a much longer period. The eruptive period is pro- longed in those cases in which it becomes haemorrhagic. Here it assumes a deep-red color, gradually becoming darker (ecchymotic) and slowly fading out as the blood-pigment is absorbed. Again, the eruption may suddenly disappear, indi- cating great adynamia and heart failure. The character- istic " measly odor " is most prominent at this time, although it begins to develop during the height of the fever and catarrhal manifestations. The temperature is not high in mild cases, being highest during the eruptive period, when it may reach 104 F. for a short time. In the average case there is an abrupt rise at the point of invasion — about 102. 5 F. (initial fever). It soon falls to a lower period, not rising again until the fourth or fifth day, when the eruption makes its appearance.- At this stage it may reach 104 F. and higher. In a day or two 104° 1 — — t It 1 A \f- ; 1 n ' 1 \ ■\ . ' — i : 1 ' \~ V \ \ i\ 1 : — ■ 1 — | DayqfDis / z J ¥ S 6 7 r FIG. 57.- FROM -TEMPERATURE CHART A CASE OF MEASLES. 640 DISEASES OF CHILDREN. it drops by crisis, unless it is sustained by a complicating broncho-pneumonia, etc. Among the many complications liable to arise during the course of measles or appear as sequelae, the following are the most important and most frequent in occurrence : Broncho- pneumonia (children under three years) ; lobar pneumonia, pleuro-pneumonia and empyema, (three years and over); mem- branous croup ; putrid sore throat ; noma ; entero-colitis ; conjunctivitis and keratitis ; otitis media. The frequency with which tuberculosis develops after measles is noteworthy. In some instances latent scrofulous lesions are stirred up by the attack, while in others it appears that primary infection occurs directly upon the subacute pneumonic process lingering after convalescence. The con- gestion of the bronchial glands which accompanies measles renders them more liable to infection with the tubercle ba- cillus. According to Osier, tuberculosis is the most important sequela — either an involvement of the bronchial glands, a miliary tuberculosis, or a tuberculous broncho-pneumonia. Homoeopathic authorities are, however, not inclined to take such a grave view in cases of measles under homoeopathic treatment. The blood in measles shows a trifling degree of anaemia and instead of leucocytosis there is an actual leucopenia in uncomplicated cases (Combe). The urine may give the diazo- reaction, but albuminuria is rare. Treatment. — The child should be put to bed in a well- ventilated, moderately-darkened room as soon as the disease is suspected, maintaining a temperature of 65 ° F. when possible. It is unnecessary to render the room dark and cheerless, an effectual shielding of the eyes from direct bright light being all-sufficient. The child should be kept in bed until every trace of the rash has disappeared, which usually takes place about five or six days after its first appearance. The removal of the branny scales of epidermis is greatly fa- cilitated by rubbing the child with olive oil, followed by a ACUTE INFECTIOUS DISEASES. 641 sponging with tepid water and Castile soap. This measure should be employed for several evenings in succession after the febrile symptoms have abated. During the febrile period there is no objection to the cleansing sponge-bath of tepid water. If conjunctivitis be present the eyes should be flushed several times daily with a 2 per cent. Boric-acid solution. In cases in which the rash is tardy in coming out, or in which there is a recession of the same, a warm bath or pack is of great service. With recession of the rash the condition often becomes grave. When due to cardiac failure stimula- tion is indicated, and a hot-mustard bath is a valuable ad- juvant when serious congestion of internal organs (broncho- pneumonia, meningitis, etc.) exists as a complication. In dieting cases of measles we must bear in mind the ten- dency to diarrhoeal conditions, just as in scarlet fever we must anticipate nephritis. During convalescence the diet should be highly nutritious, consisting largely of milk, eggs, fresh vegetables, lamb-chops etc. If a tendency to tuberculosis exists, cod-liver oil may be added with advantage. A week should elapse before the child is permitted to leave the house, and by the end of the third week from the commencement of the disease he may be allowed to commingle with other children, as the infectious period has passed over by that time. The following remedies will be found to cover the usual cases : Aconite corresponds to all of the early symptoms of the average cases of measles, and when given in time will so con- trol the disease that it frequently becomes unnecessary to give any other remedy during its entire course. It is hardly necessary here to give its indications. In infants, however, when the fever is high and nervous symptoms are prominent, I more frequently find Belladonna useful. Apis. — Confluent eruption, with pronounced oedema cf the skin ; oedematous swelling of the throat ; cerebral complica- tions. 642 DISEASES OF CHILDREN. Arsenicum is indicated in those adynamic cases in which there is pronounced prostration ; scanty rash ; anxiety and restlessness ; pneumonia. Bryonia. — Cases calling for Bryonia are characterized by a predominance of catarrhal symptoms from the very begin- ning with tendency to extend to the finer bronchial tubes and involve the pulmonary parenchyma. The rash is slow in coming out, but, when once established, it is usually abun- dant and characteristic. The accompanying symptoms are dry, painful cough ; great lassitude and irritability ; anorexia, with thirst for large quantities of water ; constipation, etc. Bryonia is looked upon somewhat as a specific to bring out the rash, but any well-selected remedy will accomplish the same result, notably Pulsatilla and Gelsemiinn. Camphora. — u In those dangerous cases where the face grows pale and the skin cold, assuming a bluish, purple color, with utter prostration and spasmodic stiffness of the body." (C. G. R.) Coffea is a valuable remedy for the short, dry, teasing cough of measles, frequently becoming a most distressing complaint in nervous, delicate children. Euphrasia. — Profuse corroding discharge from the eyes, with profuse, bland, nasal discharge {Allium cepa has the op- posite condition). Gelsemium. — "After Aconite, great deal of coryza ; drowsy, with fever heat ; no thirst. When the eruption turns livid, with cerebral symptoms" (C. G. R.). Kali bichromicum is indicated in measles when there is a deep, loud cough, with expectoration of stringy, yellowish mucus ; intense conjunctivitis, sometimes going on to keratitis and ulceration; stitches in the ears, extending into the head and neck ; watery diarrhoea, with tenesmus ; ulcerated sore throat. Even when the symptoms are not so severe or characteristic as above stated, this remedy is frequently of great value, especially when Bryonia does not control the bronchitis as promptly as it should. It is followed well by Pulsatilla. ACUTE INFECTIOUS DISEASES. 64-3 Lachesis. — Livid eruption, countenance almost black, tongue coated dark brown, sordes on the teeth, inability to protrude tongue (J. F. Miller). Mercurius is indicated where gastro-intestinal symptoms predominate. The tongue is heavily coated, showing the imprints of the teeth ; breath very offensive ; diarrhoea of slimy stools, with tenesmus. Also bronchitis, with loose, barking cough and no expectoration ; offensive sweats ; diph- theritic angina. Pulsatilla may be indicated early, although its sphere of usefulness lies mostly in the clearing up of the cough and catarrhal symptoms lingering after measles. It is followed well by Hepar. Veratrum viride. — u During febrile stage, especially if pul- monary congestion is impending; red streak down centre of tongue; convulsions before eruption" (C. G. R.). Other remedies which may be called for upon special indi- cations are : Belladonna. — May be indicated early, but less frequently than Aconite in mild cases. Nervous symptoms predominate^ and convulsions occur at the eruptive stage. Carbo veg. — Persistent hoarseness remaining after measles. Drosera. — Cough occurring in paroxysms in the afternoon, spasmodic and attended with bloody or purulent expectoration. Hepar and Spongia may be required when the cough be- comes croupy. Phosphorus and Antimon. tart , in those cases in which broncho-pneumonia predominates. Sulphur. — Either during the first stage, when the eruption is tardy, or for the sequelae, such as chronic coughs, originat- ing in the remnants of partial pneumonia; chronic diarrhoea; hardness of hearing and chronic ear discharges (C. G. R.). SCARLET FEVER. Scarlet fever is a highly contagious, infectious disease of childhood, characterized by fever, angina and a diffuse scarlet 644 DISEASES OF CHILDREN. eruption, followed by desquamation. It is endemic in all large cities, often breaking out in epidemics. The greatest degree of susceptibility exists between the ages of two and six; infants usually escape, especially those nursing at the breast, while in children nearing puberty the susceptibility gradually decreases. One attack gives immunity to a second, as a rule. Epidemics are most prevalent during the fall and winter months. While scarlet fever is not as infectious as measles, its spread being slower and less extensive than that of measles in com- munities or non-isolated quarters harboring cases, still its con- tagiosum vivum possesses much greater tenacity to life, and is much more readily carried from one location to another by means of a third person or by contaminated objects. It re- tains its vitality for months, and requires active germicidal measures for the successful disinfection of infected localities and articles of dress, bedding, etc. The period of contagiousness lasts about six weeks, begin- ning with the invasion of the disease, reaching its height during the febrile period and persisting until desquamation is com- plete. The source of infection lies in the catarrhal discharges, the scales of epidermis, and probably also in the excreta. The contagion may persist in the expectoration or nasal secretion even after the stage of desquamation. The exact nature of the causative agent of scarlet fever still remains obscure. Streptococci are found in the blood in a certain percentage of cases, but they are rather to be looked upon in the light of a secondary infection than as the primary cause of the disease. Hektoen {Jour. Amer. Med. Ass., March, 1904) isolated streptococci from twelve out of a hundred cases. They occur with relatively greater frequency in the more severe and protracted cases, but they may be absent in some of the fatal cases. Mallory {Jour, of Med. Research, Jan., 1904) claims to have demonstrated certain bodies in the skin of fout cases of scarlet fever, which he looks upon to be one of the stages in the development of a protozoon. The period ACUTE INFECTIOUS DISEASES. 645 of incubation is short, usually less than a week, and in many cases only one to two days. Symptomatology. — The course of a typical case of scarlet fever may be divided into the -stage of invasion, stage of erup- tion and stage qf desquamation. Prodromata are rare, the in- vasion being abrupt, with repeated chills, followed by high fever, headache, prostration and vomiting, together with sore throat. Such a combination of symptoms occurring in a child should always lead one to suspect scarlet fever. The temper- ature may rise very rapidly to a high point, reaching 104 F. and over ; in mild cases, however, it may rise but inconsider- ably. The pulse likewise is affected in a characteristic manner, attaining a rapidity of one hundred and twenty to one hun- dred and forty beats per minute quite early in the attack. The throat is highly inflamed, a diffuse erythematous blush covering the tonsils, pharynx and soft palate. Later on, diphtheritic patches are liable to appear. Within from twelve to thirty-six hours from the beginning of the fever the eruption makes its appearance, first showing about the neck and chest, whence it rapidly spreads over the entire body, this being accomplished within twenty-four to thirty-six hours, or in even a shorter period of time. The eruption appears most intense on the neck, over the extensor muscles, about the joints, and on the dorsum of the hands and feet. A peculiar pallor about the mouth is frequently seen, producing a striking contrast with the flushed cheeks, and giving rise to the characteristic "white line'' of the disease. The eruption is due to intense hyperaemia of the skin, accom- panied by exudation of round cells into the rete Malpighii and serous exudation, the process ending in death of the epi- dermis, with desquamation of variously-sized scales and flakes. The predominating feature in the pathology of the cutaneous manifestations is vascular paralysis. When typical, the rash consists of numerous, closely-aggregated red points, the size of a pin-head, evenly distributed over the entire body, giving it a bright, scarlet color. The eruptive points may be but 646 DISEASES OF CHILDREN. slightly red in the beginning, later assuming the bright, scar- let hue. The rash is more frequently a dull red than scarlet* and the general effect is produced by the erythema associated with puncta, fine vesicles and more or less goose-flesh. The punctate spots are the result of inflammation around the hair follicles, and they may become large enough to impart to the skin a distinctly rough feel. The points may be flat or ele- vated, round or lentil-shaped, and with increasing hypersemia they become confluent, the skin becoming turgescent and tense. The swelling is most marked about the face and eyes in these cases {scarlatina Icevigata). This is the variety for which Hahnemann recommended Belladonna as both prophy- lactic and curative, while for scarlatina miliaris, a variety in which there are minute papules interspersed with fine vesicles filled with a turbid serum, he recommended Aconite (HarT- mann, Kinder krankheiteri), considering it a special variety of scarlet fever. Another deviation from the usual eruption is the appearance of roseola-spots of various sizes and shapes, separated by pale areas of skin {scarlatina variegatd). In some cases the rash does not become general, often being ab- sent from the face in mild cases. It may be extremely faint in color, or assume a deep purplish hue, or become hemor- rhagic. At the height of the eruption the skin is burning hot to the touch, and the patient complains of burning, stinging and itching ; at this time, also, all other symptoms are most intense. Pressure with the finger causes momentary disappearance of the rash, which reappears from the periphery toward the center, differing in this respect from the rash of measles. In cases marked by prostration the peripheral circulation is so poor that the rash only slowly reappears after having been obliterated by pressure. This is a valuable prognostic sign. The temperature curve of scarlet fever is one of abrupt onset, the fever running high with very little remission during the first three or four days and then gradually subsiding by ACUTE INFECTIOUS DISEASES. 64-7 lysis so that at the end of a week the temperature is again normal. The tongue is thickly coated white ; the edges, however, remaining red. In the course of a few days the coating is shed, leaving the red and swollen papillae exposed, with the resulting characteristic appearance described as " strawberry- tongue." Enlargement of the papillae of the tongue is such a constant symptom of scarlet fever that it becomes a most valuable diagnostic sign. Indeed, McCollom, of Boston, looks upon this symptom when occurring in association with fever and sore throat as pathogno- monic of scarlet fever, irre- spective of the presence of a rash. In mild cases, how- ever, the enlargement of the papillae may fail to develop. Should the throat become seriously affected at this time, patches of membrane will be seen upon the tonsils which may spread to the soft palate and adjacent parts. This complication is usually due to streptococci, true diphtheria being rare during the course of scarlet fever, and, when associated with the same, occurring as a sequela rather than as a com- plication. Otitis is a frequent complication occurring at the height of the disease, the result of an extension of infection from the angina. It usually terminates in suppuration, and is one of the commonest causes of deafness in children. When occur- ring during convalescence its advent is more readily antici- pated, as there is recurrence of fever, with distinct earache and impairment of hearing. 1 ■ i ; !04° . d A v _\ ij ~ r X ^_ c 98° DayofDis / X i ¥ f t 1 i ' 9 FIG. 58.— TEMPERATURE CHART FROM A CASE OF SCARLET FEVER. 648 DISEASES OF CHILDREN. Parotitis and cellulitis of the neck sometimes accompany the septic process in the throat. The termination of such a process is usually in suppuration. Likewise the tonsils and lymphatic glands of the neck may share in the suppurating process, rendering the prognosis most unfavorable. Synovitis of the larger joints is prevalent during some epi- demics. It develops between the first and second weeks. The duration is short, never ending in suppuration. Beside this condition, an attack of acute articular rheumatism is fre- quently invited in individuals of the rheumatic diathesis, oc- curring as a complication of the scarlet fever either during the eruptive stage or during convalescence. The blood shows a well-marked leucocytosis, the poly- nuclears predominating. The more intense the infection the higher the leucocytosis. In asthenic cases, however, there may be a failure on the part of the organism to react and in such cases a low leucocyte count offers a grave prognosis. In such cases the eosinophiles may be decreased or absent (Da Costa). The lymphatic glands, both the subcutaneous as well as the lymphatic structures of the viscera are involved. There is more or less general adenopathy, the cervical, inguinal and axillary glands being especially affected. Postscarlatinal nephritis is one of the most constant and most important complications of scarlet fever, occurring typically during the third week. Pathologically, it is an acute, diffuse, productive nephritis. It is a more serious con- dition than the simple acute degeneration or acute exudative nephritis which may. occur early in the course of the fever, just as in any other acute infectious disease. There is scanty urine and general dropsy, and suppression of urine and acute urcemia may supervene. Although the kidney is much dam- aged at the time, still a marvellous degree of regeneration may set in and the child shows a fair chance of ' : growing out " of the disease, so to speak, under careful treatment. Desquamation begins shortly after the rash has faded — about ACUTE INFECTIOUS DISEASES. 649 the end of the first week. It begins in the localities in which the rash first appeared, showing itself as scales of varying size about the neck and chest. Gradually the entire trunk is involved in the process, desquamation being completed here long before the fingers and toes have shed their dead epi- dermis. In these parts, especially where the skin is thick, the peeling process is slow, and large pieces of skin, sometimes complete casts of the fingers, are detached in the u moult- ing" process. In cases where desquamation is slight, it may be found characteristically by about the tenth day at the tips of the fingers. A separation of the epidermis at the edge of the nail-bed, producing the line of " subungual cleavage," is a characteristic phenomenon. The prognosis depends to a great extent upon the character of the epidemic ; the general health of the child before the attack ; the height of the fever, and the severity of the at- tending complications. As a rule, the disease is more liable to prove fatal if the child is very young, especially when seri- ous throat implication, nasal diphtheria, diarrhoea or otitis are associated. The degree of toxaemia and the state of the peripheral circulation are important prognostic indications. A livid, sluggish rash or recession of the rash, indicating fail- ing circulation, are unfavorable signs. Cases marked by sud- den onset with excessively high fever offer a grave prognosis on account of the high degree of toxaemia they present. Some cases prove fatal within the first twenty-four hours before the rash appears — "malignant scarlet-fever." Among the later dangers are especially to be feared ne- phritis, which displays a tendency to develop particularly in cases in which cutaneous manifestations are mild, probably because the scarlatinal toxines are more actively excreted through the kidneys than through the skin in these cases. Should ursemic convulsions supervene, either death or cerebral haemorrhage with resulting hemiplegia, etc., may result. Otitis always brings with it danger of cerebral abscess. The patient is also liable to develop true diphtheria at this time. 42 650 DISEASES OF CHILDREN. Convalescence is usually protracted owing to anaemia, chronic otorrhcea and nasal catarrh, hypertrophied tonsils, post-scarlatinal nephritis. Diagnosis. — Scarlet fever differs from measles in the abrupt- ness of its onset, the absence of Koplik's sign and prominent catarrhal symptoms, and the characteristic appearance and behavior of the eruption alluded to in the symptomatology of both affections. The scaling in scarlatina is also different from that observed in measles. From rubella it is dis- tinguished by the sudden onset and high fever with pro- nounced sore throat, by the characteristic appearance of the tongue, and by the occurrence of desquamation. Symptomatic rashes can usually be traced to the partaking of certain arti- cles of food or the administration of certain medicines, or to septic- or auto-intoxication. The rash is of short duration, sore throat is absent, and in the absence of gastric derangement the temperature is normal. Many of the infectious fevers are at times accompanied by an erythematous rash, causing con- siderable confusion as to the true nature of the case. All doubtful cases, however, followed by the typical desquamation and associated with albuminuria, are to be looked upon as scarlatina. The history of exposure to infection is an important datum in atypical and incomplete cases, as is also the appearance of the tongue and the presence of general adenopathy. The presence alone of scaling is not a proof that the case is one of scarlet fever, and scaling may be more pronounced in certain cases of desquamative scarlatiniform erythema than in ordi- nary scarlet fever. The time of onset, mode of progress and its persistence are of more importance than the mere presence of scaling (Schamberg). On the other hand, in a case of scarlet fever with well-developed rash and subsequent marked desquamation, the associated conditions, namely, fever, pros- tration, sore throat and adenopathy, are more pronounced than in the scarlatiniform erythemata. Treatment. — With the occurrence of suspicious symptoms ACUTE INFECTIOUS DISEASES. 651 the patient should be isolated immediately. From this time on until desquamation is completed, and, if practicable, until all catarrhal discharges have been controlled, the child should be kept away from others to whom or through whom it may convey the contagion. Six weeks from the beginning of the attack is usually a sufficiently long period of quarantine ; but, just as with the classical ten days of the lying-in period, there is liability to variation in either direction. The bedroom should be freely ventilated, and all unneces- sary articles of furniture and hangings should be removed, but not after they have been exposed to the contagion, unless they can be immediately disinfected. A sheet wrung out of a 2 per cent, solution of Carbolic acid and hung in front of the door adds to the completeness of the isolation. All kitchen utensils, etc., used by the patient should be immersed in a 4 per cent, solution of Carbolic acid or Formaldehyde for an hour before being removed from the room. The)' should then be scalded, or, still better, boiled for a quarter of an hour. The nurse and the attending physician should protect their outer clothing by donning a long, linen coat on entering the sick room, and disinfect their hands before leaving the room. All sheets, rags, articles of clothing and furniture that can be dispensed with are best burned. For disinfection of the room after its vacation by the patient there is nothing equal to Formaldehyde gas generated in the Schering lamp from pas- tilles. If Sulphur be used, one pound must be burned for each hundred cubic feet of room space; at the same time steam should be generated, the room of course being hermet- ically sealed during the operation. It is always wise to pre- cede the fumigation by a thorough mopping cf the floors with a i to 2,000 bichloride solution, allowing it to dry in situ. If the walls are papered, they should be scraped down and re- papered. During the occupation of the room by the patient the spray- ing of hydrogen dioxid with an atomizer greatly aids in keep- ing the air pure. If the patient suffers much from angina or 652 DISEASES OF CHILDREN. laryngitis it will prove advantageous to generate steam, at the same time placing dishes of slaked lime about the room. u The terrible burning and itching of the skin is best re- lieved by rubbing the body all over with bacon, olive oil or cocoa-butter, once or twice a day ; always if the skin is dry,, glands swollen, and there is a scrofulous diathesis." (C. G. R.) I would object to the use of carbolized oil or other powerful antiseptic applications to the skin at this time, its action being necessarily injurious and its efficacy in destroying con- tagion questionable. The inunction of fats not only relieves the itching and burning of the skin, but it also acts as a sedative and at times reduces the fever. In case of high fever a sponge-bath of tepid water and alcohol (one part of alcohol to three of water) is of great service. In the advent of anasarca or suppression of urine a warm pack should be used. (See Treatment of Acute Nephritis, p. 371.) For the angina, a spray of alcohol one part, glycerin one part and water four parts, may be used sev- eral times daily. Likewise, the nose should be kept scrupu- lously clean by means of douches of a norma] saline solution or Dobell's solution. These simple measures may prevent ulceration and suppuration in the throat, and also suppurating otitis media. Pseudo-diphtheria developing, it should be treated with Permanganate of Potash, as recommended under Diphtheria. " As a preventive I would still recommend the potentized Belladonna, one dose every nigjit, until symptoms appear. If it cannot prevent the attack, it has seemed at least to mitigate its violence." (C. G. R.) The diet should be restricted to a non-nitrogenous one as far as possible, in order to relieve the kidney of any extra strain in its excretory work. Solid food, especially meat, should be prohibited until after the third week, and in case of nephritis developing, a milk diet must be adhered to for a still longer period. The remedies of first importance in scarlet fever are the following : ACUTE INFECTIOUS DISEASES. 653 Aconite. — Aconite was recommended by Hahnemann in scarlatina miliaris. High fever ; great restlessness and anx- iety ; whining and moaning ; delirium, with irrational talk- ing ; anorexia ; mouth and throat dry ; pharynx and tQiisils deep-red color ; skin hot and dry. The eruption in these cases does not correspond to the diffuse, smooth redness character- istic of Belladonna, and, with full development of constitu- tional symptoms, the condition usually goes over into a typi- cal Rhus state. Personally I do not believe that the charac- ter of the rash is of much importance in prescribing and I pay more attention to the other manifestations, namely, the degree of fever, prostration, nervous irritability, angina, etc. For this reason Belladonna is a much better remedy in the early stages of the vast majority of cases than Aconite. Arsenicum. — Eruption tardy, scanty, or becoming petechial. Adynamic cases, with putrid sore throat ; nephritis ; dropsy ; typhoid state. The usual characteristics of the remedy are present. Belladonna. — " Belladonna is only indicated in the smooth form of eruption with vascular and nervous excitement ; it does no good in adynamic cases. The miliary form of erup- tion is much more adapted to Amm. carb., Lack, or Rhus tox." (C. G. R.) There is congestion of the brain, with active delirium ; sudden starting in sleep ; bright, glistening eyes ; throbbing of the carotids ; cerebral congestion ; tongue coated white, with red edges, the papillae showing through the coating ; bright redness of throat, with swelling and dysphagia ; pungent heat of skin, with moisture on covered parts. Indicated in the majority of cases in the beginning of the disease and if the case be a mild one, no change of remedy will be required. Otherwise it is usually followed by Rhus tox. (pronounced toxaemia); Apis (anasarca); Mercurius iod, rubr. (pseudo diphtheria), etc. Bryonia. — Delayed appearance of eruption; face crimson red ; mouth and lips dry ; tongue dry and brown ; great thirst ; the child wishes to lie perfectly quiet and undis- 654 DISEASES OF CHILDREN. turbed. Bryonia is frequently indicated when rheumatism, synovitis or involvement of the pleura and meninges compli- cate the case. Carbolic acid is highly recommended by Goodno. Cuprum. — Sudden recession of the eruption, with occur- rence of cerebral symptoms. The Acetate of Copper is gen- erally preferred. The Arseniate of Copper should always be thought of when the condition is one of uraemia. Gelsemium. — In the early stages, when there is the charac- teristic dullness and drowsiness; aching and prostration; soft, compressible pulse ; aching in the eyes and back of head. The throat is red and feels swollen ; the eyes are suffused, and the patient feels chilly, especially along the spine. Lachesis. — Scarlatina miliaris. Eruption becoming purple and livid; desquamation delayed; hsematuria (Terebinthind) - oppression when lying down ; diphtheritic complication ; di- arrhoea, with foul-smelling stools. Rhus tox. may be indicated from the beginning when the rash is not of the smooth, diffuse variety, and, instead of vascular and nervous excitement, there is prostration, with great restlessness ; high temperature, with drowsiness ; tongue red and smooth ; epistaxis ; cedematous swelling of the skin in various parts, the eruption becoming dusky with the de- velopment of miliary vesicles ; swelling of the cervical glands and cellular tissue about the neck; ulceration of the throat. Sulphur. — Intense redness of entire body, like a boiled lob- ster; skin hot and dry, with great burning. Veratrum vir. — In the beginning, when there is great vas- cular excitement, wiry pulse, dilated pupils, convulsions. The pulse is hard and wiry, arterial tension being greater than in Aconite, while anxiety and restlessness are less marked. Zincum is indicated where the eruption is scanty, of a pale bluish-red color or entirely absent, while cerebral symptoms are pronounced. " Especially in the anaemic; brain exhausted; not able to develop exanthemata" (Hering). Meningitis in ACUTE INFECTIOUS DISEASES. 655 the stage of paralysis. Convulsions followed by stupor; the feet are in constant motion, or the child lies perfectly motion- less, with eyes open, pupils dilated, cornea insensitive. When these symptoms are present there is little to be hoped from any remedy: but if we can anticipate them, and give Zincum on its early indications, a fatal termination may be averted. Remedies less frequently indicated, but of great importance in special cases, are: Ailanthus. — Miliary rash; small, rapid pulse; the eruption becomes dark and livid ; intense angina, with acrid discharge ; muttering delirium followed by stupor. Arum triph. — Tongue red and swollen, acrid discharge from nose; diphtheria, swelling of submaxillary glands; the corners of the mouth and the lips are cracked, and the child picks at the lips and finger-nails until they bleed. Amnion, carb., Apis, Lycop., Muriatic acid, Opium, Phos., Phos. ac, Phytolacca and Stramonium also bear a strong rela- tionship to special symptoms. Complications and Sequelae. — Throat complications call for Phytolacca, the various salts of Mercury, Kali bicJirom. y Per- mangaiiate of Potash, Lachesis and others. (See Diphtheria.) Cellulitis and Parotitis. — The most important remedy for this complication is Rhus tox. Suppuration calls for Hepar, Mercurius, Silica. Otitis. — Bell., Puis., Rhus tox., Pan tag o. Cerebral compli- cations, Apis, Bell., Helleb., Hyos., Stram., Sulph. and Zinc. Entero-colitis. — Mercurius usually controls the diarrhoea, but China, Rhus tox., Veratr. alb. may also be indicated. Nephritis. — Cantharis is a most valuable remedy in post- scarlatinal nephritis when there is not much blood in the urine and only moderate dropsy. When the latter is pro- nounced Apis and Arsenicum are of greater service. The characteristic "smoky" appearance of the urine frequently seen after scarlet fever, from the free admixture of blood, is a strong indication for Terebiuthina. Persistent albuminuria after scarlet fever calls for Mercurius corr. 656 DISEASES OF CHILDREN. RUBELLA. Rubella, R'dtheln, or German Measles, is characterized by moderate fever, sore throat, and an exanthem which in some instances resembles that of measles (rubella morbilliforme), and in others that of scarlet fever (rubella scarlatintforme). Complications or sequelae are scarcely ever observed. It usu- ally occurs epidemically, and one attack gives immunity against another, but in nowise protects against measles or scarlet fever. Nothing definite is known of its etiology. It is contagious, but less so than measles or scarlet fever; nevertheless it may be spread by articles of clothing, etc. Infants under six months are immune. The incubation period averages two weeks, but it may show considerable variation in this respect. Symptomatology. — The period of invasion is short, pro- dromata usually being absent. Drowsiness, slight fever and sore throat precede the eruption by a day or more in some cases; in others the rash appears before the child has shown evidence of any illness. It is first seen upon the face, from which it spreads over the entire body in the course of twenty- four hours. Although the face is the most constant site of the eruption, even when the rash is developed but partially, still the chest and back may show the first signs of eruption in exceptional cases. The duration is about three days. Often it has completely faded from the face by the time the lower extremities are involved. In rubella morbilliforme there is seen a discrete, maculo- papular rash of pale red color, the eruptive points being slightly elevated and about the size of a pin's head or larger. These lesions have a tendency to become confluent upon the face, particularly so when they are numerous. In rubella scarlatintforme the rash is of a diffuse, uniform, scarlet color, never as intense, however, as in scarlet fever, and with unmistakable evidence of the maculo-papular erup- tive points in various localities (on the forehead, fingers and toes, and about the wrists). ACUTE INFECTIOUS DISEASES. 657 Desquamation occurs to a slight degree after deflorescence of the rash, but in mild cases it may be entirely wanting. Catarrhal symptoms are not a necessary accompaniment of rubella, and throat symptoms may be so slight as to remain unnoticed. The slight cough present is due to an infection of the mucous membrane and tonsils, as in la grippe (Kop- LiK). In a number of my cases there was decided follicular pharyngitis, and in some a slight exudate was present upon the mucous membrane. The superficial lymphatic glands of the posterior cervical and posterior auricular region are tran- siently swollen, this being one of the characteristic symptoms of the disease. Usually there is also involvement of the axil- lary and inguinal glands. The duration is short, seldom over five days. The prog- nosis is good; complications are rather to be considered accidental than otherwise. In many instances the diagnosis can only be made after the mild course of the disease has been noted, in conjunction with the absence of complications and sequelae, especially if an epidemic is not known to be on at the time. When, how- ever, we are aware of such an epidemic, and especially if the child has previously had one of the other exanthemata, the diagnosis presents little or no difficulty. From measles it is chiefly to be differentiated by the absence of catarrhal symptoms, absence of Koplik's spots and the slight fever. From scarlatina the absence of the strawberry-tongue, the rash first appearing upon the exposed portions of the body, the low temperature and absence of desquamation and ne- phritis readily differentiate it. The treatment is simple in a frank case of rubella, but until we are aware of the true nature of the case the child should be cared for identically as in a case of measles or scar- let fever, in order to be on the safe side. Cases resembling measles will require remedies suited to mild cases of the same (Aconite, Bryonia or Pulsatilla), and those resembling scar- latina will usually require nothing more than a few doses of Belladonna. 658 DISEASES OF CHILDREN. VARIOLA; VARIOLOID. Variola, or small-pox, is an acute infectious, highly conta- gious disease, characterized by fever of a typical course, vom- iting, intense lumbar pains, and an eruption of papules passing through the stages of vesicles, pustules and crust formation, the vesicles being umbilicated. The nature of the contagion has not been determined. It is contained in the secretions, excretions and exhalations of the body, being especially disseminated by means of the dried scales and contents of the pustule. Pfeifer and others have constantly found small, homogeneous bodies in the epithelial cells surrounding the lesions. One or two are usually found in the cell substance. They probably belong to the class of protozoa (Park). It attacks all ages, from the foetus in utero to the aged. A case came under my notice in which the eruption appeared in a new-born infant on the fifth day. During the last three weeks of her pregnancy, the mother had had an attack of vari- oloid, which was overlooked at the time on account of its mild nature. The infant died on the twelfth day. Among children it proves especially fatal. One attack protects against another, at least for a long period of time. The period of incubation is from nine days to two weeks. The pock first consists of an area of round-cell infiltration into the rete mucosum, in which a central area of coagulation- necrosis takes place. Inflammatory reaction occurs around this area, which represents the central depression of the ves- icle, with the formation of a reticulated vesicle containing serum, leucocytes and fibrin filaments. Pustule-formation supervenes, the leucocytes and cells of the rete mucosum be- coming necrotic. Symptomatology. — The invasion is marked by a severe chill or repeated chills, in children, often convulsions, with rapidly rising temperature. In children, convulsions are common at this period. Vomiting and intense backache ACUTE INFECTIOUS DISEASES. 659 are accompanying symptoms. " In some epidemics the initial stage is marked by an erythematous eruption, either diffuse or measly, or by a hsemorrhagic exanthem which consists of extremely small punctate, often pin-head sized haemorrhages into the epidermis, at times so closely crowded together that the impression of a diffuse redness is produced." The tem- perature rises on the first day to 103 to 104 F., continuing with slight morning remissions until the evening of the third day, when it reaches its highest point. On the fourth day it falls several degrees, this remission lasting until the seventh or eighth day, when there is a secondary rise — the suppurative fever. The stage of eruption commences on the evening of the third day. %i There appear little red spots first in the face. If very numerous they coalesce, like measle-spots, with which they might be confounded if it were not for the granulated feel which they present to the sense of touch (like shot)." (C G. R.) The eruption rapidly spreads to other portions of the body, and on the third day of eruption the papule is converted into a clear vesicle presenting an umbilication at its summit. The vesicle is also loculated. In the course of a few T days (eighth day of the disease) the vesicle is transformed into a pustule, which dries up after a few days or breaks down, with the formation of a soft, yellow crust, later becom- ing browmish and dropping off, leaving a somewhat elevated spot which in time entirely disappears. This occurs where the lesions are discrete and where the process has not ex- tended into the deeper layers of the skin. Here they adhere for a long time, leaving an uneven scar, which at first looks pink, but by degrees grows conspicuously white, to remain so throughout life Simultaneously with the appearance of the eruption upon the skin, identical lesions develop upon the mucous mem- branes exposed to the external air. Here it may result in great destruction of tissue. 660 DISEASES OF CHILDREN. Small-pox may run its course as a discrete, confluent, haemorrhagic, gangrenous or malignant variety. The mod- ified variety occurring in those partially protected by vaccina- tion, and running a mild course without secondary fever, is described as varioloid. In every other respect it is identical with true small-pox. The prognosis, excepting in varioloid, is always grave. As complications may be mentioned broncho-pneumonia, pleurisy, septicaemia, ulcerating keratitis, suppurating otitis, arthritis. The diagnosis is often rendered difficult by the primary erythematous eruption. The true eruption may be con- founded with measles in its early stages, but the sensation of balls of shot under the skin imparted to the finger by the papules of small-pox is a pathognomonic distinction, beside the severe initial symptoms of the attack. Again, in measles the temperature rises to its acme with the appearance of the rash, while in small-pox there is a temporary drop in the fever as the rash comes out. From varicella it is distinguished by the intensity of its symp- toms. Moreover, the eruption appears later than in varicella, does not come out in crops, is distinctly umbilicated, and pre- sents a well defined inflammatory areola. The eruption of small-pox is also decidedly harder and more palpable than that of varicella. Treatment. — As small-pox is one of the most serious and most dreaded of all contagious diseases, every precaution to prevent a spread of the same must at once be instituted when we are confronted by a suspicious case. The most rigid iso- lation and disinfection, as described under Scarlet Fei'cr, must be carried out to the letter. Besides this, even- person in the house not recently successfully vaccinated (within four years) should immediately undergo the opera- tion. The patient must have as much fresh air as possible. If the fever is very high sponge-baths are indicated. Osier (Practice of Medicine) has come to the conclusion that the ACUTE INFECTIOUS DISEASES. 661 prevention of pitting is really not within the hands of the phy- sician. Protecting the ripening papules from light and keep- ing the hands atid face covered with lint soaked in cold water or mild antiseptic lotions is, however, to be recommended. The red-light treatment exerts no influence over pustulation (Schamberg). Later on, we should aim to prevent the crusts from becoming hard and dry by the free application of vase- line. The addition of a little Carbolic acid or Boric acid to the vaseline is a distinct advantage. In the early stages, Aconite, Bell., Bry., Gelsemium and RJuts tox. are to be recommended. Jahr [Therapeutische Leitfaderi) began all cases with I ariolinum as soon as the diag- nosis could be established; and if, in spite of this remedy, the course became a grave one, he followed with Sulphur. He preferred these two remedies above all others. Vaccininum is spoken of favorably by Goodno and others. From a limited personal experience with small-pox I have come to look upon Bryonia followed by Ah us tox. as the treatment mcst likely to exert a favorable influence over the disease. In the stage of suppuration when toxaemia sets in Cinchona tincture and whisky should be freely used. When collapse threatens it may become necessary to resort to Strychnia. VACCINIA. Vaccinia, or Cow-pox, is an eruptive disease of the cow, in- oculable into man, and producing a lesion at the site of the inoculation resembling the pock of variola, together with constitutional disturbances. No specific germ for vaccinia is known, nor is the true nature of the disease understood, some considering it a primary disease of the cow, while others be- lieve it to be small-pox modified by its passage through ani- mals. It has been experimentally demonstrated that children vaccinated with cow-pox were not susceptible to inoculation with small-pox virus, the reverse condition also holding true. PfeifTer and others have found small homogeneous bodies in 662 DISEASES OF CHILDREN. the epithelial cells surrounding the lesions of both small-pox and vaccinia, and as small-pox virus has produced in cattle a disease indistinguishable from cow-pox, there is hardly any doubt that the two are due to the same micro-organism, modi- fied by its transmission through the cow (Park). A successful inoculation with vaccinia affords protection against small-pox in the majority of cases, at least for a num- ber of years. Small-pox occurring in those who have been vaccinated usually assumes a mild course, i. e., varioloid. As to the modifying influence of vaccinia upon small-pox already in progress there is a difference of opinion. According to Marson, if a person exposed to small-pox be vaccinated within four days, small-pox will be prevented; if later, but early enough to allow the vesicles to reach the stage of areola, the attack of small-pox will be modified ; but later than this it is useless. Curschmann opposes this view as erroneous. It is interesting to know the views expressed by Hahnemann on this subject, which are no doubt borne out by the most trust- worthy clinical testimony — "It is well known that when var- iola is added to cow-pox, the former, by virtue of its superior intensity as well as its great similitude, will at once extin- guish the latter homceopathically and arrest its development. Cow-pox, on the other hand, having nearly attained its period of perfection, will, by its similitude, lessen to a great degree the virulence and danger of a subsequent eruption of small- pox, for which we have the testimony of Miihry and many others" {Organon). The operation of vaccination consists of the introduction of the lymph from the vaccine vesicle of heifers into the circula- tion by bringing it in contact with a scarified surface for a sufficient length of time to permit of its absorption. Having cleansed the site of inoculation (the usual seat is the left arm, just below the insertion of the deltoid muscle) with soap and water, followed by scrubbing with alcohol or ether, a few parallel scratches about half an inch in length are made with a sterilized needle, just deep enough to break the ACUTE INFECTIOUS DISEASES. 663 epidermis and expose the rete mucosum. A drop of glycerin- ated vaccine lymph, this being the most reliable and aseptic form in which the virus can be obtained, is placed upon the scarified surface and rubbed in gently with the needle. Guest (Pediatrics, Vol. IX, No. 5) has arrived at the conclusion that the entire contents of a tube is too large a quantity of lymph for the average child, judging fiom the results obtained in four hundred cases vaccinated by this method, in which there was more pronounced inflammatory reaction and more gland- ular swelling, besides the formation of a larger scab than in his former cases inoculated with points. I have, however, found that the old-fashioned ivory point usually causes a more severe lesion than the lymph, although in order to avoid an aggravated form of vaccination we must not scarify too freely or rub in too much lymph. After permitting the seat of in- oculation to dry, the scarification is covered with a piece of sterilized gauze, over which a shield or bandage is applied. By the adoption of this careful method, complications and sequelae rarely, if ever, follow. Symptomatology. — During the first three days after the operation, nothing excepting a slight local irritation, soon subsiding, will be noticed. On the third day, however, a papule appears at the site of inoculation, surrounded by an areola; this papule is converted into an umbilicated vesicle on the fifth or sixth day. The vesicle attains its maximum development by the eighth day, after which it becomes pus- tular. The areola gradually increases in size and depth of color until this time, but dissapears as the acute symptoms subside. The pustule then dries up, forming a scab. On the twenty-first day the scab comes off, leaving the characteristic deep, circular, pitted scar. The constitutional symptoms accompanying vaccinia are fever, malaise, anorexia, etc., which begin with the eruption, and attain their height at the period of pustulation, after which they rapidly disappear. Swelling of the axillary glands is usually present. 664 DISEASES OF CHILDREN. Variations from the above-described course frequently occur. The vesicle may be late in developing, may be pre- mature and not fully developed ; a generalized pustular erup- tion may accompany the primary lesion, which may persist in recurring attacks after healing of the same ; or complica- tions, notably erysipelas, ulceration and sloughing, glandular abscesses and septicaemia, may develop as the result of faulty technique. Vaccinia may also occur as a general eruption of papules, which turn into vesicles and pustules. They appear on the face and extremities about the fifth day. I have also encountered a general papular rash occurring on the tenth day, looking like measles or the early stage of small-pox. Deaths have occurred, but they were almost invariably from avoidable causes, as Voigt shows in his statistics. There is always a risk, however, in vaccinating a delicate, sickly child, and the operation should never be performed when an acute disturbance is present, or if there is a case of contagious dis- ease in the family to which the child has been exposed. I have observed some anti-vaccinationists vaccinate, and their careless method has convinced me that they had good cause to be dissatisfied with this practice. Besides, the in vaccination of syphilis (when humanized virus was used) has occurred, and claims have been made that tuberculosis was likewise transmitted. This, however, has not been proved, although vaccination may have been, in some instances, the exciting cause in stirring up a latent tuberculous lesion in strumous and tuberculous children into an acute condition. The age at which children are vaccinated is usually the third month, in the absence of any acute or constitutional ill- ness. In the absence of an epidemic of small-pox I do not see the necessity for so prompt a procedure. It is quite early enough to vaccinate the child after it is out of its teething difficulties, and some physicians, believing in the efficacy of vaccination to control whooping-cough, keep it in reserve to be employed as the opportunity manifests itself. The child ACUTE INFECTIOUS DISEASES, 665 should, however, be vaccinated before it is sent to kindergar- ten or school, and revaccinated at the period of puberty, or on the occurrence of an epidemic of small-pox. Treatment. — After vaccination I give Aconite, following the same with Belladonna if fever, headache, diffuse redness and swelling about the site of eruption and glandular swell- ing develop. Apis or Rhus may be indicated by erysipelatous manifestations. After the acute symptoms have subsided it is well to give a few closes of Sulphur, or if the scab separates with suppuration and an unhealed ulcer remains, Silica. I firmly believe that when vaccination is carried out on strictly aseptic lines, and the child is watched throughout as in the case of any other illness — being put to bed if necessary, and carefully prescribed for — none of the many complications and so-called constitutional after-effects, attributed to vaccination, will follow. The complications and sequelae of improper vac- cination and the constitutional disturbances caused by the same will require symptomatic treatment. The remedies most frequently recommended are Thuja. Silica, Malandri- num and Sulphur. VARICELLA. Varicella, or chicken-pox, is an acute infectious disease char- acterized by the eruption of discrete vesicles, which appear in crops, and disappear, in the course of a few days, by desicca- tion. The specific virus has not been isolated, but it is known to exist in the vesicles, and can be transmitted by inoculation. The usual manner of contracting the disease is through con- tact with a case, although a third person may carry the infec- tion. One attack protects against another. It may occur sporadically or epidemically. The period of incubation is usually two weeks. The symptoms are slight in the majority of cases, but they may assume such a grave nature in delicate children, espe- cially in the tuberculous, that the diagnosis may present some 43 666 DISEASES OF CHILDREN. difficulty. However, the subsequent course of the disease will remove all confusion in the matter. The onset is abrupt, as a rule, the first signs of the disease being the appearance of papules and vesicles upon the trunk and extremities, accom- panied by slight fever, anorexia, coated tongue and languor. Constitutional symptoms may be so slight as to attract no at- tention. Each day a new crop of vesicles makes its appear- ance ; this usually continues for three or four days. The eruption appears first as a small red papule, soon be- coming vesicular. The vesicles are unilocular, although at times multilocular vesicles are seen. They are surrounded by a faint areola, and do not become pustular unless infected by scratching, etc. In the course of a few days they dry up, the crusts soon falling off without leaving a scar, although in some cases a circular, pale area is left, which persists for some time, or, if ulceration has taken place, quite a conspicuous scar may remain. Varicella gangrenosa is a type of varicella which is at- tended by gangrenous stomatitis, as a result of infection in poorly-nourished or tuberculous children. If the process be- comes extensive, it may prove fatal. As complications — which, however, are fortunately rare — may be mentioned erysipelas, adenitis, cellulitis, gangrenous dermatitis and ne- phritis. It is not uncommon to have varicella and one of the other infectious fevers occur simultaneously, although the error must not be made of considering those cases of varicella beginning with an erythematous or measle-like rash as cases of varicella plus scarlet fever or measles. Diagnosis. — Varicella is to be differentiated from small-pox by the slight constitutional disturbances accompanying the rash, which appears abruptly, coming out in crops, and soon disappearing by dessication, without pustulation or scar-for- mation. The eruption of small-pox does not always come out at once, and frequently new papules and vesicles will con- tinue to appear for several days after the first lesions were seen. They do not, however, erupt in distinct crops, nor do ACUTE INFECTIOUS DISEASES. 667 we find lesions in the various stages of development, that is, fresh papules and vesicles interspersed among pustules, as is to be observed in varicella. Again, the papules of varicella lack the shot-like feel characteristic of the small-pox lesion, and the vesicles are more delicate and present a characteristic pearl-like appearance. If the vesicle has not dried up by the fourth da}', it is more likely small-pox than varicella. Treatment. — In the presence of fever, rest in bed, a light diet, and, when there is much itching, the use of rye-flour as a dusting-powder, or olive oil and Boric acid, is about all that is required in mild cases. Aconite may be called for in the beginning, to be followed by Rhus tox. The gangrenous or pustular variety will call for Arsenicum, Merairius, Rhus tox., etc. PERTUSSIS. Pertussis, or whooping-cough, is an acute infectious disease in which there is present a catarrhal process of the respirator}- tract and a characteristic paroxysmal cough. It occurs both epidemically and sporadically, infection taking place through close proximity to a case ; seldom through the agency of a third person. Close proximity, however, is necessary, as the air does not seem to convey the contagion to any great distance, about the patient. Epidemics are said to occur every eighteen months or two years in large cities, as in measles. Several micro-organisms have been credited with being the exciting cause. Afanassjeff isolated a short bacillus, the bacillus tussis convulsive?, but failed to demonstrate satisfac- torily the reproduction of whooping-cough by inoculations with pure cultures of this bacillus. The investigations of Czaplewski point to another bacterium as the contagium vivum ; this bacterium is two or three times as long as broad, rounded and somewhat thickened at its ends, is divided in the middle, and surrounded by a capsule in its natural state-. The secretions of the normal mucous membrane of the nose contain very few bacteria, while in whooping-cough we find 668 DISEASES OF CHILDREN. a large mass of this particular kind, in fact, a natural pure culture (Wagner, N. Y. Med. Jour., Oct. 8, 1898). The most recent studies of the secretion expelled after a coughing paroxysm have shown a short, ovoid bacillus, similar in ap- pearance to, and of the same group as, the influenza bacillus. The bacillus grows best upon blood-agar and agglutinates with the blood of pertussis patients in as high as 1-200 dilu- tion (Martha Wollstein). The contagion exists mainly in the sputum, and the pa- tient should be considered capable of spreading infection as long as the cough retains its characteristic paroxysmal na- ture. The period of incubation is from one to two weeks. The pathological processes accompanying whooping-cough are catarrhal inflammation of the larynx, particularly in the region of the inter arytenoid cartilages; tracheitis and more or less bronchitis ; swelling of the bronchial glands ; rhinitis. In fatal cases broncho-pneumonia with emphysema and areas of atelectasis are the most common lesions found ; there may also be entero- colitis and cerebral congestion, with effusion and cortical haemorrhages. The toxin of whooping-cough in 'some cases appears to affect the smaller blood-vessels and favor haemorrhagic extravasations, either spontaneous or as a Result of the congestion which is associated with the cough- paroxysm. Moebius believes that the nervous system may also be acted upon by this toxin in a manner somewhat similar to the action of the diphtheria toxin. Symptomatology. — The course of whooping-cough is in three stages : the premonitory, or catarrhal ; the spasmodic, and the stage of decline. The first stage usually lasts ten days to two weeks ; the second stage may persist for a month or more ; while the stage of decline is a gradual transition into an ordinary bronchial cough, which varies with the state of the child's health and with the season of the year. The average duration of an ordinary case is, therefore, about six weeks, but the course is greatly influenced by treatment and also by the advent of complications. ACUTE INFECTIOUS DISEASES. 669 The attack begins as an ordinary cold, indistinguishable in the beginning from a simple bronchitis, with, however, this difference, that instead of yielding to treatment in the course of a few days, or abating of its own accord, the cough gradually increases in frequency and severity, soon assuming the paroxysmal and spasmodic type characteristic of the dis- ease. An early symptom that should always arouse suspicion is the nocturnal aggravation of the cough from the very be- ginning. Examination of the chest at this time reveals nothing be- yond a slight bronchitis. In the very beginning there is usually indisposition, running of the nose, a short, dry cough, and slight fever. These symptoms soon abate, but the cough increases in severity. The cough is characterized by a sudden, loud expulsive effort, followed in rapid succes- sion by similar efforts of gradually decreasing force ; through these continued explosions the chest is almost completely emptied of air, so that the child is obliged to draw in a deep breath at the end of the paroxysm. As the glottis is nar- rowed during this long-drawn inspiration, a loud, piping sound is produced, constituting the whoop, from which the disease is named. As soon as the lungs have been refilled the cough begins anew, consisting, as before, of rapidly fol- lowing expulsive efforts, ending with the whoop. This con- tinues (two to six coughing fits) until the paroxysm is ter- minated either by the dislodgement of a plug of mucus from the trachea, or by the vomiting of the ingesta or of a quan- tity of tenacious mucus. During such an attack the face becomes red, even livid ; the eyes are injected and bulging, and the child clings to the nearest object for support, or stands with the feet wide apart and the hands resting upon the knees. Bleeding from the nose frequently occurs during the paroxysm, and cortical haemorrhages from the meningeal vessels are to be feared in violent cases. When such a haemorrhage is extensive, hemi- plegia and convulsions will follow. This haemorrhagic ten- 670 DISEASES OF CHILDREN. dency is one of the most serious aspects of whooping-cough. Sub-con junctival haemorrhage is quite common. No doubt the action of the pertussis toxin upon the blood-vessels is re- sponsible for the condition. The number of paroxysms in a day will vary from only a few to as many as fifty. They are usually more frequent during the night. In very young children the cough is not as characteristic as in older ones, the whoop being especially faint or indistinct, but the same paroxysmal nature of the cough is present, and, indeed, they may suffocate during a severe spell. There are signs upon which we can base a fairly positive opinion as to the existence of whooping-cough in most cases, even without having heard the cough. But it is rarely neces- sary to exclude this pathognomonic symptom, for should the child evince no desire to cough during our examination it is but necessary to press the finger into the jugular fossa, or irritate the pharynx with a tongue depressor, in order to bring on a paroxysm. The face appears bloated from the re- curring vascular enlargement, and the eyes are deeply in- jected ; slight haemorrhages may be seen under the conjunc- tiva. The eyes are unnaturally moist. Under the tongue a characteristic sign is frequently seen, namely, ulceration of the fraenum. This is induced by the repeated propulsion of the tongue over the lower incisor teeth in coughing. In my experience it has only been present when there was at the same time catarrhal stomatitis in association with the whoop- ing-cough, rendering the mucous membrane particularly vul- nerable. With the decline of the disease the paroxysms become less frequent and less severe, soon losing the spasmodic char- acter of the cough, and the expectoration becomes muco- purulent, as in an ordinary bronchitis. With a fresh cold the whoop may reappear ; this, however, is to be considered rather as an intensification of the cough in a subject in whom the spasmodic habit has been formed than as a true recur- rence of the disease. ACUTE INFECTIOUS DISEASES. 671 The commonest complications of whooping-cough are broncho-pneumonia (in the winter months) and entero-colitis (summer months). The advent of broncho-pnenmonia is recognized by the appearance of fever, together with rapid respirations and dyspnoea, and subcrepitant rales throughout the chest. The cough may change during the height of such a complication, assuming more the incessant, dry or rattling- character belonging to broncho-pneumonia. In a case seen in consultation a five year old child was suddenly seized dur- ing the fourth week of whooping-cough, with a high fever and cerebral symptoms so pronounced as to suggest menin- gitis. Examination of the chest revealed croupous pneumonia of the right upper lobe. Diarrhea is liable to become a troublesome symptom in delicate children, often leading to marasmus. Convulsions due to extreme general nervous irritability are frequent among infants. They may, however, be due to asphyxia, meningeal haemorrhage (see p. 511), or pneumonia, giving the case an entirely different aspect. Meningitis rarely, if ever, results from whooping-cough, although marked meningeal symptoms due to hyperaemia of the brain and oedema of the pia mater may be observed. Dilatation of the heart, due both to the strain on the heart as well as to the action of the toxin upon the myocardium, may be observed (Koplik). As a sequela, tuberculosis is most to be dreaded. Whoop- ing-cough, as is well known, is one of the most potent pre- disposing causes of tubercle, ranking second to measles in this respect. This is due to the fact that in both of these diseases inflammation of the bronchial glands occurs promi- nently. The prognosis depends to a great extent upon the age and previous health of the child. Normal children above five years of age seldom suffer great inconvenience or serious after- complaints under proper treatment. The prognosis becomes grave when broncho-pneumonia is added, or where the hsem- 672 DISEASES OF CHILDREN. orrhagic tendency is marked ; and in infants (notably the rachitic and tuberculous) the prognosis should be guarded. Diagnosis. —During the prevalence of an epidemic the diag- nosis should present no difficulties. Isolated cases, however, may become puzzling, especially when atypical. The char- acter of the cough, together with the accompanying signs described under the symptomatology, should bear one out in differentiating whooping-cough from an ordinary bronchitis. The pertinacity and intensity of the cough, with the absence of all other signs indicating a thoracic condition commensur- ate with such a cough, is characteristic. Prof. Filatow, of Moscow, confirms the researches of Hip- pius and Blumenthal, who noticed that pertussis patients have a pale urine of high specific gravity. Hyperplasia of the bronchial glands frequently provokes a paroxysmal cough, but the course is a chronic one, and there is associated bronchitis, and usually tuberculous foci else- where in the chest. Other possibilities of error are found in the so-called "spasmodic broitchitis" of infants, and catarrhal laryngitis (false croup). Treatment. — Isolation is difficult to carry out, as the dis- ease is already contagious during the stage at which it cannot always be recognized. Nevertheless, every effort should be made to protect delicate children and infants against exposure by excluding from their presence, during an epidemic, all children with suspicious colds or hacking coughs. The patient should receive as much air as possible, and in pleasant weather may be permitted to be out-of-doors. Pro- tracted cases do well from a change of climate, the seashore being particularly beneficial. If the cough is very troublesome at night, and especially in the case of infants in whom asphyxia is to be feared, the vap- orizing of Cresoline, Creasote or Oil of Eucalyptus va the sick- room is often attended with the happiest results. Holt pre- fers Creasote, vaporized in a croup-kettle; a weak Formalde- hyde vapor is also of service at times in mitigating the parox- ysms. ACUTE INFECTIOUS DISEASES. 673 The remedies recommended for whooping-cough are legion, and space forbids enumeration of so long a list. While there are, perhaps, a dozen which are used a hundred times when the others are used but once, still it is impossible to tell just which remedy will be of the greatest benefit in a given case before the symptoms have been carefully considered. The popular feeling as to the clinical value of our remedies in this affection is well presented by the following statistical report by Dr. Geo. B. Peck (Trans. American Institute of Homoeop- athy, 1898): "Out of every thousand prescriptions by mem- bers of this Society for the amelioration of that group of mor- bid phenomena popularly designated whooping-cough, at least 175 are for Drosera, 153 for Belladonna, 123 for Ipecacuanha, 76 for Cuprum (metallicum and aceticuni), 54 for Coralliuni rubrum, 44 for Antimon. et pot. tartaricum, 24 for Mephitis, 20 each for Aconitum napellus and for Hyoscyamus, 18 for Naphthalin, 15 for Coccus cacti, 13 for Kali bicJiromicum, n for Bryonia, 9 for Magnesia phosphorica, 8 for Chelidonium majus," etc. In the early stages Aconite, Bell., Ipecac, or Tartar emet. may be indicated. As soon as the true nature of the case be- comes apparent a remedy should be given capable of control- ling the course of the disease. Opinions differ as to the most potent remedy to accomplish this result. No doubt the rem- edy will vary with the epidemic, and while Drosera, Bella- donna, Naphthalin, etc., are useful in many instances, they are not invariably so. As soon as the cough is accompanied by the raising of secretion I am in the habit of prescribing Tartar emetic, 2x trit., unless indications point strongly to another remedy, such as Ipecac. If, in spite of the administration of one of the above-men- tioned remedies, the case continues steadily to advance or be- come of a more serious type, ( 'ufirum, Mephitis, C or allium rubruni, Coccus cacti and Hyoscyamus should be thought of. Protracted cases will often yield to ( arbo veg. with remark- able promptness. 674 DISEASES OF CHILDREN. Ambra ginsea. — Hollow, paroxysmal cough, with expecto- ration of tough, grayish or yellowish mucus, especially after awaking in the morning ; belching after cough. Anacard. — Ill-natured children, with uncontrollable tem- per ; cough brought on by fits of vexation {Ant. crud. — Great irritability ; disagreeable toward these of whom it was formerly very fond, even striking at them.) Arnica. — Painful paroxysms (Bryonia); tendency to haemor- rhages ; meningeal haemorrhage. Bell. — Intense redness of face during paroxysm ; nervous erethism ; convulsions ; eyes bloodshot ; cough deep and hollow ; sneezing after cough. The most important remedy in the early stage. Car bo veg. — Protracted cases. Follows well after Drosera. Hoarseness ; anaemia ; sluggish circulation ; flatulent indi- gestion. Coccus cacti. — Cough, especially worse in the early morn- ing, followed by the expectoration of yellowish or bloody, tough mucus (Ambra grisea). I have had excellent results with this remedy during the paroxysmal stage, when there was abundant stringy, yellowish expectoration. Cuprum,. — Convulsions ; the paroxysms are severe and long- continued, the child becoming blue in the face ; cerebral com- plications (follows well after Ipecac). Drosera. — Paroxysmal stage. Worse after midnight ; gag- ging and vomiting predominate ; the expectoration is fre- quently blood-streaked ; tuberculous diathesis. Personally, I have been disappointed in the results seen from this remedy. Hyos. — Incessant cough when lying down, relieved by sitting up. Ipecac. — Spasm of the glottis before paroxysm ; the child stiffens out during the cough and becomes blue in the face (a strong indication for Ipecac in my experience). Broncho- pneumonia, with abundant fine rales ; vomiting after cough. The expectoration is often blood-streaked. Hughes recom- mends beginning all cases with Aconite and Ipecac in alternation. ACUTE INFECTIOUS DISEASES. 675 Mephitis. — During the spell the child passes both urine and faeces ; diarrhoea and flatus very offensive ; the child must be taken up during the cough, turns blue in the face and seems asphyxiated. In a number of grave cases in in- fants, in whom suffocation seemed imminent, Mephitis in the second decimal dilution has given me excellent results. Naphthalin. — Goodno recommends this remedy to be used as soon as the case is recognized. He employs the first deci- mal trituration. Tartar emetic. — Broncho-pneumonia. Rattling of mucus in larger tubes ; gasping for air ; deficient oxygenation of blood. I have in late years obtained the best results from this remedy as a routine prescription when another remedy was not strongly indicated. Sulphur may be required in the third stage, if the patient relapses into his former condition on the slightest provoca- tion {Car bo veg.). PJienacetine and Antipyrine are much used by the old school. Hale recommends Phenacetine in the ix trituration, two to ten grains ever}- three to four hours. PAROTITIS. Epidemic parotitis, or mumps, is an acute infectious disease in which the parotid glands are attacked by an intense catar- rhal inflammation. The specific contagion is not known, but it no doubt gains access into the gland through the duct of Steno, setting up an intense hyperemia, followed by a profuse serous exudation (soft swelling). The process begins in the ducts and acini of the gland, rarely extending to the inter- stitial connective tissue, and only terminating in suppuration when there is an accidental infection with pyogenic micro- organisms accompanying the primary infection. For this reason resolution is perfect in the vast majority of cases, as the tumefaction is the result simply of hyperaemia and oedema and not of structural changes in the gland. 676 DISEASES OF CHILDREN. Secondary parotitis is an infection of the parotid gland (usually one-sided), with pyogenic micro-organisms, occurring during the course of one of the infectious fevers. It may com- plicate typhoid fever, diphtheria, scarlet fever, small-pox and measles, rendering the prognosis most grave. In these cases the submaxillary gland is rarely spared. Unlike as in mumps, it terminates in suppuration, the entire parenchyma of the gland being more or less involved in the destructive process. Mumps appears epidemically, although never to the extent attained by epidemics of the other prominent contagious dis- eases of childhood. Close contact seems necessary for infec- tion. It is most prevalent during the damp seasons and among those living in damp dwellings. The period of incu- bation is from two to three weeks. One attack gives immu- nity against another. Symptomatology. — For a day or two there may be a slight fever with lassitude, restless sleep, nervous irritability, loss of appetite, etc., preceding the appearance of the characteristic lesion. The inflammation of the gland induces first a pain- ful stiffness of the jaw and tenderness in the region of the parotid. Swelling rapidly sets in, and in the course of a few days the gland will be swollen to its utmost extent. The fever may increase and the sleep become disturbed by restless dreams or delirium ; convulsions have been known to occur in young children. The left parotid is the one most fre- quently attacked first. In the majority of cases the opposite side begins to swell in a day or two after the appearance of the first lesion. Sometimes the opposite parotid is not in- volved until the first begins to subside, or it may escape en- tirely. At the height of the disease the face presents a ludicrous appearance. The entire parotid region stands out promi- nently from the presence of a tense, shining swelling which spreads anteriorly to the zygoma and posteriorly to the sterno- cleido-mastoid. The tumor feels firm over its centre while ACUTE INFECTIOUS DISEASES. 677 the edges pit on pressure. The enlargement is uniform and regular, not nodular as in lymphadenitis. It is also perfectly immovable, for the parotid gland is so firmly held clown by the deep fascia as to render its displacement impossible. The fever now gradually subsides, usually not lasting more than from three to four days, but the patient is extremely uncomfortable, every effort at opening the mouth being at- tended with pain, and any article of food not bland in char- acter frequently exciting intense suffering. In fact, the ex- cruciating pain produced by taking anything acid into the mouth is looked upon as pathognomonic and a symptom of diagnostic value. The swelling attains its height within three or four days, subsiding by the end of a week. This, as has been above stated, is accomplished rapidly and perfectly, and persisting permanent structural changes should lead to a suspicion of a mixed infection istapJiylococci or tubercle bacilli). Metastases to the testicle in the male and to the ovary or breast in the female are not uncommon in older children at this time, /. £., during the stage of decline, but in young chil- dren this does not occur. Aside from the possibility of such a complication the pi-ognosis is good. Secondary parotitis occurs during the course of one of the acute infectious diseases, and begins as a hard, painful swell- ing, more circumscribed than in mumps, with an inflamma- tory blush soon showing itself over the surface. This grad- ually deepens in color; the swelling becomes more tense, and points of fluctuation can be elicited. In the cases which I have seen the sub-maxillary gland was also involved. One case, complicating typhoid fever, proved fatal. If allowed to open spontaneously there is a free discharge of thin, sanious pus. The prognosis is always grave, although it is said to be less so w T hen occurring later in the course of the disease which it complicates. Diagnosis. — It seems unnecessary to call attention to the question of diagnosis in a simple case of mumps, yet errors 678 DISEASES OF CHILDREN. are sometimes made. One of the most frequent is the mis- taking of acutely enlarged cervical lymphatic glands for mumps ; here the slower onset, the multilocular feel of the tumefaction and its movability will readily distinguish this condition from mumps. Diphtheria, with pronounced swell- ing of the cellular tissue of the neck, has likewise been mis- taken for mumps, as I have personally witnessed. The possi- bility of such an error occurring can only impress us most forcibly with the importance of a routine inspection of the throat in every acute febrile disease of childhood. Treatment. — The most important remedy is, no doubt, Belladonna. It corresponds to the vascular engorgement, the fever, and the nervous irritability so common in mumps. Mercurius may be indicated early when there is but slight fever, pale swelling of the parotid region and gastric derange- ment. It is useful in the later stages of all cases to hasten resorption of the exudate. For metastasis to the testicles Pulsatilla and Clematis are the chief remedies. If induration with tendency to atrophy follows, Aurum should be considered. Metastasis to the ovaries calls for Apis, Colocynthis, Pulsa- tilla, Hamamelis. Secondary parotitis finds in Rhus tox. its most appropriate remedy. As the process advances, Hepar or Arsenic usually becomes indicated. Calc. sulph. is the main remedy to promote healing after pus has been discharged either through fistulous openings or by means of an incision. As soon as the gland becomes swollen, hot fomentations wrung out of a i to 4,000 solution of the Bichloride of Mercury should be applied continuously. This offers a hope of abort- ing, or, at least, limiting the process. INFLUENZA. Influenza, or la grippe, is an infectious disease occurring pandemically and attacking all ages alike. It is character- ized by fever of sudden onset and short duration, accompanied ACUTE INFECTIOUS DISEASES. 679 by marked prostration and complicated with either catarrhal inflammation of the respiratory or alimentary tract, or by cer- tain nervous phenomena. This is the true influenza, and it is to be distinguished from those endemic cases of so-called grippe, catarrhal fever or epidemic bronchitis which occur in children with great regularity every year, especially during the fall and winter months. The bacillus of Pfeiffer is the exciting cause, being found in almost pure culture in the sputum of freshly infected cases. It is a short, thin rod with rounded ends; it does not stain by Gram's method and is best demonstrated with dilute fuchsin. It is difficult to cultivate ; besides, it usually disap- pears from the sputum early and for this reason its presence is often missed. The period of incubation is short, seldom exceeding a few days. One attack does not afford immunity against another, as is the case in many of the epidemic infectious diseases ; on the contrary, it may even lead to an increased susceptibility to a fresh attack, or, at least, to acute catarrhal affections. While influenza, as a rule, pursues a short and acute course, nevertheless it shows a tendency to become protracted in many instances, sometimes becoming latent for a while and then suddenly flaring up with acute manifestations. Again, bronchitis may persist for weeks, the secretion showing in- fluenza bacilli in pure culture (OrTNER, Modern Clinical Medicine, 1905) and pneumonia of a protracted course may likewise be due to the influenza bacillus, these cases present- ing particular difficulty in their differentiation from pulmon- ary tuberculosis (Wassermann). Again, certain cases of protracted catarrh of the respiratory tract running their course under the type of remitting and intermitting fever were first recognized by Filatow as a chronic form of influenzal infec- tion {Vorlesungen it. Infections-Krankk* in/ A'iudesal/cr, 1897). Symptomatology. — The disease begins abruptly with fever, severe headache, general aching and prostration. The fever remains at its height for a period of from three to five days, 680 DISEASES OF CHILDREN. in the absence of complications, during trie entire course of which prostration is marked, and headache and muscular aching are usually very distressing. A symptom present at this time and upon which Fiirbringer, of Berlin, lays great stress, is marked redness of the face. This shows itself as a diffuse flush and differs from scarlet fever in the absence of the white line about the mouth and pallor of the forehead. As Fiir- bringer also points out, there is often present a slight icteric discoloration of the skin, although there is not much evi- dence of bile in the urine. I have in a few instances observed actual jaundice develop during influenza. Several clinical types are to be encountered, depending upon the predomi- nance of catarrhal or nervous symptoms and the locality chiefly attacked. Thus, there is the cerebral form, characterized by a pre- dominance of headache, together with delirium, and even un- consciousness, some of these cases simulating meningitis ; the abdominal form, characterized by vomiting, anorexia, gastral- gia, diarrhoea, some with predominance of gastric symptoms, others simulating typhoid fever ; the neuralgic form, in which there are neuralgic pains in the peripheral nerves and other regions ; the thoracic form, complicated by broncho-pneu- monia, and the catarrhal form, the commonest variety, in which catarrh of the upper respiratory tract is the most prominent symptom. Extreme prostration, however, is com- mon to all forms, this being the chief feature of the disease. The toxin exerts a most potent influence upon the nervous system, which manifests itself as prostration, cardiac weakness and neuralgic pains, and during convalescence in the persisting prostration and the strong tendency to the development of neurasthenia, perineuritis, insomnia, persistent headache, and even insanity. Fortunately these complications are not as common in children as in adults, and, taken altogether, 'the prognosis is better, although a complicating broncho-pneu- monia may change the entire aspect of the case. As in the case of measles and whooping-cough, a predisposition to in- fection with the tubercle bacillus is created. ACUTE INFECTIOUS DISEASES. 681 Nephritis may occur in influenza ; sometimes this is of the haemorrhagic type. Rhinitis and otitis (see p. 532) are frequent troublesome complications. The pneumonia complicating influenza is a most serious af- fection, as a rule leading to diffuse and catarrhal inflammation of the finest tubes with pronounced dyspnoea and toxaemia, while consolidation is inconsiderable. Lobar pneumonia, however, appears to occur with striking frequency during grippe epidemics and the two diseases may occur simul- taneously (see p. 284, 290). Pleurisy, with " clay-water effusion " (Furbringer), and abscess of the lung may com- plicate such a pneumonia. The prognosis depends upon the age of the patient, the previous health and the presence of complications. Filatow lavs stress upon the fact that in childhood it is mainly during the first to third year that the grave cases are encountered. The diagnosis seldom presents difficulties during the preva- lence of an epidemic, but isolated cases may be mistaken for a variety of other affections, particularly in the beginning. The catarrhal symptoms, hard cough and drowsiness may lead to a suspicion of beginning measles, but the subsequent course soon corrects this error. From pneumonia it is to be distin- guished by the absence of physical signs indicating lung in- volvement, absence of extreme prostration and comparatively short course. The majority of cases simulate pneumonia more closely than any other disease, and a careful, daily physical examination of the chest is necessary in order to differentiate the two affections. Bacteriological examination of the spu- tum and nasal secretion may or may not throw a positive light upon the subject. Cerebral cases may simulate menin- gitis or cerebrospinal meningitis. The mild cases of grippe above alluded to present none of the profound toxic manifes- tations of influenza, being nothing more than an infectious rhinitis or bronchitis. In protracted cases the condition is often very puzzling. Such cases especially simulate tubercu- 44 682 DISEASES OF CHILDREN. losis. Here the absence of physical signs of tuberculosis and the bacteriological examination of the mucous secretions are the most conclusive diagnostic data. In cases of influenza in which pulmonary consolidation oc- curs as a complication the differentiation from primary croupous pneumonia rests upon the following data, according to Filatow (loco cit.): (a) Mode of onset, whether with catar- rhal symptoms or with a chill, (b) The presence of an epi- demic or occurrence of other cases of influenza in the same house, (c) The time of occurrence of the physical signs of consolidation, i. reports twenty-two cases of haemorrhages in a series of seven hundred and sixty-two cases, ten of which resulted fatally. Diagnosis. — Aside from the pathognomonic symptoms of typhoid fever, viz., continued fever of a definite type, rose- colored spots, tympanitis with gurgling and tenderness in the right iliac fossa, enlarged spleen and pea-soup stools, there is at our command the blood test of Widal and the urinary test (diazo-reaction) of Ehrlich. Unfortunately for the general practitioner, the former is difficult to carry out, requiring spe- cial laboratory facilities and expert technique in bacteriology. In every large city : however, there are pathological laboratories where this test can be made so that it is rarely necessary for the physician to be especially equipped. Ficker has devised a ACUTE INFECTIOUS DISEASES. 713 substitute for the Widal method in the form of a glycerine emulsion of typhoid bacilli. This has been placed on the market as Ficker's Diagnosticum and should prove of great practical value to the practitioner. Widal's test consists of the introduction of a few drops of blood from a patient suffering with typhoid fever into a pure culture of typhoid bacilli. A microscopical examination reveals a prompt formation of clumps consisting of the agglutinated bacilli, which have also lost their motility. The reaction is one of infection and of immunity, indicating that a toxic substance has been formed in the blood serum, which is capable of destroying the motil- ity of the germs causing the disease, and also inducing their agglutination. Johnson (Amer. Public Health Assoc, 1896) advocated the use of dried-blood specimens as more expedient, and this method is now largely employed. By simply redis- solving the dried blood, which has been collected upon a piece of unglazed paper, with a little water and adding this solution ( 1 to 40 or 50 dilution) to an equal quantity of a young bouillon culture of typhoid fever bacilli, the reaction is ob- tained just as satisfactorily as with the fresh blood. The reaction may be observed on the fourth day of the disease, but it is usually delayed to the end of the first week. It con- tinues throughout the fever and may persist for some time after the recovery. The frequently-recorded negative results should not weigh heavily against this most valuable diag- nostic adjuvant, as faulty technique is probably more to be blamed than the test itself. The proportion of cases in which a definite reaction occurs and the time of its appearance, based on an extended Health Department Laboratory ex- perience, is given by Park (Bacteriology), as follows: 20 per cent, gave positive results the first week, 60 per cent, in the second week, 80 per cent, in the third week, 90 per cent, in the fourth week. In 88 per cent, of the cases in which repeated examinations were made (hospital cases) the reaction was found at some time during the fever. Withington {Boston Med. and Surg. Jour., May, 1901) reports two 46 714 DISEASES OF CHILDREN. hundred and fifty-three cases, with but 4 per cent, failures. Its late appearance, usually not before the eighth day, renders it less valuable as an early sign. The diazo-reaction is a valuable corroborative test, but it is also obtained in acute miliary tuberculosis and in rapidly progressing pulmonary tuberculosis. In fact, a large num- ber of infectious conditions will give this reaction, notably measles. I also obtained it in a case of suppurative adenitis. For this reason it is not so conclusive as was first supposed. It is said to be absent in diphtheria. The reaction is a rose-red color imparted to the urine by the addition of ammonia after the urine has been treated with Sulphanilic acid and Sodium nitrite. It is present from the middle of the first week until the end of the fever period ; the presence of nephritis interferes with this action. I have been impressed with the large number of cases one encounters in which the clinical picture presents nothing more than a con- tinued fever of remitting type, anorexia, a heavily-coated- tongue and constipation. Gurgling in the ileo-csecal region and tenderness are usually so ill-defined that they are easily overlooked. Rose spots and enlarged spleen may be absent. And yet, no other diagnosis than typhoid infection is to be thought of, which is eventually corroborated by the Widal reaction in the majority of these cases. Another aid in the diagnosis of typhoid fever in children is the presence of an epidemic. Cases occurring sporadically may present difficulties. In all cases of simple continued fever occurring during an epidemic the Widal test should be made. Sahli, of Bern, during an epidemic, obtained it in a number of cases that were sick for only a few days. Cases without intestinal localization will present difficulties in diagnosis. In such, only a bacteriological examination of the blood will solve the problem. Many of the acute typhoid septicaemias are of this character. They present the picture of a profound toxaemia with high fever and early delirium. Death may occur before it is possible to reach a diagnosis, and the post- ACUTE INFECTIOUS DISEASES. 715 mortem findings may be entirely negative (OslER, New York Med. Jour., Nov., 1899). In such cases I think we are justi- fied in diagnosing typhoid fever, if we are unable to demon- strate a lobar pneumonia, or if meningitis can be excluded. From malarial fever it is to be differentiated by means of a blood examination to ascertain the presence or absence of the malarial parasite, and by the temperature curve. Meningitis. — A strong point of difference between men- ingitis and typhoid fever is the behavior of the pulse. In typhoid fever it is relatively slow in the beginning, becoming rapid toward the end of the disease ; in meningitis the pulse rises proportionately with the fever in the beginning, but be- comes slow and irregular towards the close of the case. Fur- thermore, in meningitis the abdomen is retracted, the bowels are constipated throughout, and paralyses of the cranial nerves are to be observed. The reflexes are exaggerated, and Kernig's sign may be elicited. None of these symptoms are present in typhoid fever. Meningeal irritation is common, but true meningitis is very uncommon. In typhoid fever of the cerebro-spinal type, it may be necessary to resort to lum- bar puncture before a positive diagnosis can be made. Acute miliary tuberculosis may present difficulties in differential diagnosis. Aside from the absence of the Widal reaction in tuberculosis there is a more rapid pulse and greater irregularity in the course of the fever. Often the " inverted type " of fever is noted. Aside from this there is rapid breathing and dyspnoea when the lungs are in- volved, together with pronounced catarrh of the- finer tubes. An old tuberculous lesion may be demonstrable. True meningitis is commonly associated. The most difficult cases to differentiate are those in which abdominal symptoms arc the predominating feature. Early pronounced localization of theinfection in souk- other system than the intestinal tract may lead to confusion. As Osier (he. cil.) emphasizes, the brunt of a very acute infec- tion may fall upon the cerebro-spinal, the pulmonary, or the 716 DISEASES OF CHILDREN. renal system. Such eases would be more appropriately designated " typhoid infection " than " typhoid fever." Treatment. — The patient shpuld be put to bed at once in a room that can be freely ventilated, and from which all un- necessary furniture and draperies have been removed, not es- pecially on account of any degree of contagiousness on the part of the fever, but in order to give as much air-space as possible and make it less difficult to keep the room clean. Provision must be made for the disinfection of the stools and urine, which can be accomplished by the use of an active germicide. A strong solution of chloride of lime, Piatt's chlorides, or carbolic acid (5 per cent, solution) is to be poured over the stools as soon as they are passed, and allowed to act upon them for several hours before they are emptied into the water-closet. All towels, napkins and sheets soiled by the patient should be boiled in order to render them sterile. The diet is of the greatest importance. Owing to the in- testinal lesions, solid food must be withheld until at least a week after disappearance of the fever, diarrhota and abdo- minal tenderness. Where abdominal symptoms have been pronounced during the fever, it is better to wait even longer before resuming solid food. In the milder class of cases we may return to semi-solid food on the fifth day after the temper- ature has ceased to rise above ioo° F., gradually returning to solid food. Such articles of diet as thoroughly cooked cereals • poached eggs ; milk toast ; the soft portion of a baked apple ; baked potato, etc., should be selected at this time. Although milk is looked upon as an ideal liquid food, still it does not act as such in many cases, and, when given un- modified, may pass through the bowels in firm curds. The stool should, therefore, alw T ays be inspected when administer- ing milk, as such curds may induce most unfavorable symp- toms. A notable ill-effect of milk observed in some patients is tympanitis; this promptly disappears when the milk is dis- continued. In young children it is always best to dilute the milk with barley-water, or administer it predigested. ACUTE INFECTIOUS DISEASES. 717 Strained vegetable soup, made with mutton and a variety of fresh vegetables, is a most valuable food, and an agreeable change to the patient. Likewise grape juice, when diarrhoea is not prominent ; and any of the reliable proprietary foods such as Horlick's Malted Milk, Eskay's food, and Mellm's food (the latter when there is constipation), are all of value. The mistake, however, is to feed the patient without any de- gree of regularity or restriction as to quantity, changing from one article to another promiscuously. The best results are obtained by selecting the food best adapted to the case, and administering three to four ounces every three hours. Some variation in the character of the diet is most agreeable to the patient and a great aid in keeping up the nutrition. The carbohydrates are especially valuable in preventing the marked emaciation so prone to occur in typhoid fever. The patient should also receive water f reel v. The child must be sponged daily with cold or tepid water and alcohol (one part to four of water), and when the fever runs high, remaining above 103 degrees F. during the greater period of the twenty-four-hour range, these baths may be re- peated every three hours. Should this fail to control the fever, a cold cheese-cloth pack may be tried, or, what I prefer, sprinkling the body with water at 70 to 80 degrees F., and at the same time applying friction to the extremities. In order to carry out this procedure, the child is stripped and laid on an oil cloth sheet over which a linen sheet is spread, while the head of the bed is elevated so that the water may run off into a bucket. The water may be poured from a watering-can cr it may be freely squeezed from a large sponge. Sometimes rubbing the body briskly with pieces of ice wrapped in a towel will have a most grateful and beneficial action in cases of hyperpyrexia. I have found these methods a good substi- tute for the full bath (see p. 18). Should the patient read poorly after any form of cold water treatment it is better to desist and use milder measures (luke-wann Sponging). The Indications for the Differt nt Hydrotherapeutic Measures 718 DISEASES OF CHILDREN. in Typhoid Fever. — It is a mistake to attempt to treat all cases of typhoid fever on the same plan, and by "hydro- therapy" to understand simply the cold bath treatment. While the majority of cases are eminently suited to this mode of treatment in one of its forms, i. e., the full bath, the cold sponge bath, or the cold shower bath, still there are those in which the baths fail either to improve the case or actually aggravate the condition. In such the ice-bag may do good, or intestinal irrigation with luke-warm water (enteroclysis) may be the therapeutic measure indicated. The explanation for this apparent disparity is as follows : Where the brunt of the infection falls upon the vasomotor centres and the pulse is weak, rapid and dicrotic and the peripheral circulation poor (vasomotor -paresis), the intermitting cutaneous shock produced by the cold bath is the form of treatment indicated ; where the localization is primarily intestinal and there is in- tense inflammatory reaction and tendency to haemorrhage and perforation the ice-bag is useful while the bath may do harm, and where toxaemia predominates and the cerebro-spinal ner- vous system and the kidneys are chiefly attacked, enterocly- sis, by favoring elimination and lowering temperature, is the form of treatment that will do the most good. Some patients present such a pronounced idiosyncrasy against cold water or are in such a condition in which reaction is impossible, that it becomes positively harmful to persist in giving them cold baths or cold sponging. Here luke-warm water, espe- cially if it be allowed to evaporate from the body and in that manner abstract heat, is beneficial and should be resorted to* In hyperpyrexia in children who do not stand cold water, sponging with hot water, especially along the spine, has often proved beneficial. Stimulation may become necessary in the later stages of the fever. The first and most prominent indication is car- diac weakness. Daily auscultation of the heart should be practiced and when the first sound loses its muscular ele- ment and resembles the second sound (embryocardia) alco- ACUTE INFECTIOUS DISEASES. 719 holic stimulation should be resorted to. Other indications are continuous delirkim of the low muttering variety ; dry, trembling tongue ; tympanitis and pronounced adynamia, and I may add lack of reaction to remedies. Many of our remedies act prominently in a stimulating way, but we meet cases in which the system fails to respond to them until re- action has been brought about by physiological means. A teaspoonful of whiskey diluted with water may be given every two to three hours to be decreased or increased accord- ing to circumstances. Collapse will call for strychnia. Haemorrhage, if slight, requires nothing more than tem- porary withdrawal of food followed by greater caution in feeding, absolute quiet of the patient and possibly a change of remedy. When severe, it proves a grave complication. A cold application to the abdomen in the form of Leiter's tubes or an ice bag will prove of great benefit. Absolute rest must be enjoined, even the bed pan may be put aside and clothes used to collect the excreta. If collapse threatens, stimulants must be used. They should, however, be used cautiously, as overstimulation of the heart may favor increased haemorrhage. Strychnia nitrate, hypodermically, is perhaps the best stimulant to employ. Geranium tincture, per rectum, as recommended by Dr. Woodward {Eclectic Med. Jonr., June, 1901) using two ounces of tincture in a pint of milk and water, seems a most valuable adjuvant. Infusion of a normal saline solution where loss of blood was great has saved life. Perforation and peritonitis are extremely fatal com plica, tions, although early laparotomy in perforation before peri- tonitis has set in offers better hope for the patient than con- servatism according to the observations of Finney and Keen. Wescott collected eighty-three well authenticated cases of perforation that were operated, of which number sixteen re- covered, making a mortality of 80.6 per cent. Comparing this with Murchison's figures of 90 per cent, to 95 per cent, mortality among unoperated cases, operative interference 720 DISEASES OF CHILDREN. seems to offer much for the future. Five of these cases were in children under fifteen years, of which two recovered. The most favorable time to operate has been the second twelve hours after perforation, but under certain circumstances it may be more prudent to operate earlier. Operation should, however, always be deferred until the primary shock has worn off. (KEEN, Surgical Complications and Sequels of Typhoid Fever.) The leading typhoid fever remedies are Baptisia, Bryonia, Gelsemium and Rhus tox., and in certain epidemics one of these remedies may be indicated in almost every case. The selected remedy should be continued throughout the entire course of the disease unless positive indications for a change of remedy present themselves ; even in such an event it is wise to return to the first remedy when the intercurrent has corrected the symptoms for which it was chosen. Thus, in many epidemics Bryonia will be found the chief remedy, and although indications for Hyoscyamus, Phosphoric acid, or some other remedy of a similar sphere of action may arise during the progress of the case, a return to Bryonia may, as a rule, be made with advantage as soon as these symptoms have been controlled. It is not at all rare to find cases running a short and uncom- plicated course receiving but a single remedy during the entire period, providing the remedy has been carefully selected from the beginning. In a disease like typhoid fever, which we may expect to assume a most grave aspect at any moment, we must prescribe with caution and precision from the begin- ning and only change the remedy after mature deliberation. As to repetition of the dose, it has been my experience, in common with that of many others, that the best results are obtained from a frequent administration of the remedy when symptoms are urgent, lengthening the intervals as soon as. improvement is noted. The following indications embrace the most important symptoms of the leading remedies at our command : ACUTE INFECTIOUS DISEASES. 721 Agaricus. — In typhoid fever where the nervous symptoms predominate. Low fever, tremulous tongue, and general tremor of the entire body. Among adults it is recommended for drunkards in whom the heart is giving out. Alcoholic stimulants must, of course, not be withheld from such cases. We often encounter boys who smoke cigarettes excessively and whose nervous system is about as wretched as the adult drunkard's. Here Agaricus is well indicated. Apis. — Remitting type of fever. Chilliness in afternoon with oppression of breathing; heat without thirst; later, un- consciousness with involuntary stools ; dry tongue, which is cracked and covered with aphthae, difficult to protrude; diffi- cult deglutition ; scanty urine ; muttering delirium. Arnica. — General stupefaction of the senses ; general sore- ness, bed feels too hard ; the sleep is disturbed by anxious dreams ; the tongue is red and dry, with a brown streak down the centre ; putrid taste in mouth ; fetor ex ore ; involuntary discharge of faeces and urine ; the extremities become cold while the head remains hot ; haemorrhages and bedsores de- velop. Arsenicum. — Low types of typhoid, usually the later stages in unfavorable cases. Farrington cautions against the early use of Arsenic in typhoid fever, and considers it a remedy capable of doing harm unless clearly indicated. It is most useful in the young or aged, or in those debilitated by pre- vious ailments. The general symptoms are so characteristic of Arsenic, such as great restlessness, prostration ; thirst for small quantities of water ; hot, dry skin ; general aggrava- tion of all symptoms soon after midnight or noon ; cadaverous smell of the discharges as well as of the patient, are all prominent indications for its use. " Its true place is there, where rotten, putrid and cadaverous stools and dry, wooden tongue indicates a degree of disintegration of the vital fluids which Rhus no longer can check." (Jahk.) Baptisia. — The well-known mental symptom, the halluci- nation that the body is dismembered, that certain parts of 722 DISEASES OF CHILDREN. the body are double, or that there is a second self in the bed with the patient, is a strong indication for Baptisia, although its absence by no means deprives this drug of its usefulness in typhoid fever. Phosphorus and Petroleum both have simi- lar symptoms. The condition calling for Baptisia is charac- terized by great weariness and a bruised feeling of all the limbs, together with a low type of fever and physical prostra- tion ; offensive diarrhoea ; breath, sweat and urine are alike offensive ; there is dull, stupefying headache ; the patient is delirious, sleeps heavily and is aroused with difficulty. The tongue is dry and brown, the conjunctivae are injected; the face is flushed and presents a besotted expression ; exhaustion is marked. Baptisia may be indicated early in the disease when the symptoms are intense from the beginning, thus ex- cluding such remedies as Bryonia and Gelsemium. Bryonia. — Bryonia may be indicated at any stage, although its most frequent application will occur during the first stage. The symptoms calling for its selection are very characteristic and prominent — irritability, lassitude, desire to remain quiet and sleep ; headache, worse from opening the eyes or moving the head ; dryness of the lips, mouth and throat, with thirst for large quantities of water ; aching of the limbs, worse from motion ; frequent brown, putrid stools ; delirium at night and restless sleep, disturbed by dreams of daily affairs ; wants to go home ; visions when closing the eyes. Carbo veg. — Carbo vegetabilis is indicated in extreme cases. It has well been said: "The Carbo vegetabilis patient is dying," nevertheless, reaction may take place even in such a serious state as it pictures. Many writers speak very highly of this remedy, but personally I am not able to say what Carbo vegetabilis will do, as in such a condition I never fail to resort to stimulation. The picture is a familiar one — pro- gressive stupor ; lustreless eyes ; with sluggish pupils ; Hip- pocratic countenance ; parched tongue ; distended abdomen ; involuntary diarrhoea ; haemorrhages from the nose, mouth or intestinal tract ; cold extremities, the coldness gradually ACUTE INFECTIOUS DISEASES. 723 extending from the feet up to the knees; small, frequent pulse, at times imperceptible ; decubitus. The Carbo vege- tabilis patient is passive, the Arsenicum patient restless. Gelsemium. — In the early stages Gelsemium is frequently indicated on the symptoms of lassitude, drowsiness, dull headache, with heaviness of the eyelids and photophobia ; slow, intermitting pulse, accelerated from slight exertion ; blueness of the lips ; chilliness up and down the spine ; epis- taxis ; catarrhal condition of the eyes and respiratory tract ; diarrhoea. Hamamelis. — Haemorrhages of dark, fluid blood from the bowels, with great soreness of the abdomen. Hyoscyamus. — The delirium indicating Hyoscyamus is characterized by loquacity, obscene actions, or even attempts at violence. The patient picks at the bed-clothes and grasps at flocks in the air, with continual muttering. Stramoniu))t is similar, but the loquacity is confined to one subject and the patient is more noisy, often crying out in terror from sup- posed visions of horrible animals, bugs, and the like, which he sees coming out of the floor, crawling along the ceiling, etc. The automatic movements of the extremities occurring during the delirium are also characteristic in both drugs, but in Hyoscyamus they are more jerky and spasmodic. Hyoscya- mus also has total loss of consciousness, with dry tongue, involuntary stools, subsultus tendinum, dribbling of urine. Lachesis. — The Lachesis patient, similar to the condition noted under Hyoscyamus, is also loquacious, but he jumps from one subject to another in an incoherent manner ; there is stupor, dropping of the lower jaw; dry, red, or blackish tongue which is red at the tip and bleeding, and trembles on being protruded; the stools are horribly offensive, the abdomen sensitive to touch, and all symptoms are more intense after sleep. Mercurius. — The characteristic nocturnal aggravation, the greenish-yellow stools, broad, flabby tongue and drowsiness may indicate Mercurius, especially when there is hepatic dis- turbance in connection with the case. 724 DISEASES OF CHILDREN. Muriatic acid. — Low types of typhoid fever, in which the patient is stupid, sliding down to the foot of the bed; the tongue is parched and dry, difficult to protrude ; stools invol- untary while passing urine ; loud moaning during sleep, and when awake not fully conscious of his surroundings. Opium. — Hither complete loss of consciousness with loud, stertorous breathing, contracted pupils, face dark red and bloated or pale with death-like expression, dropping of the lower jaw, hot sweat, or delirium with sleeplessness due to hypersesthesia of the special senses, so that slight noises keep him awake. Phosphoric acid. — Low typhoid state, in which the patient becomes totally indifferent to his surroundings. He can be aroused, but with difficulty, and soon relapses into his apa- thetic condition. There is great debility, rattling of mucus in the chest, rumbling in the abdomen, tympanitis, grayish watery stools, bleeding from the nose, red streak through the centre of the tongue, milky urine, clammy skin. Rhus tox. — After Bryonia and Gelsemium, Rhus toxicode?i- dron and Daptisia frequently follow. The provings of Rhus tox. present a typical typhoid state, and the anatomical changes in the intestines closely correspond to the lesions of typhoid fever. The symptoms are sharp and well-defined, as is the case with Bryonia. The mind becomes beclouded and the mental operations are performed with difficulty. The patient is restless from a distressing aching in every limb, and constantly changes his position to gain relief (not as in Arnica, where there is soreness produced by lying in one par- ticular attitude, which makes him seek a new position). The sleep is restless, disturbed by dreams of great physical exer- tion. The lips are brown and dry, and the teeth are covered with sordes ; the tongue is likewise brown and dry, present- ing a triangular red tip. The diarrhoea is worse during the night, often involuntary during sleep. Beside this, there may be bronchitis, hypostatic pneumonia with bloody expectora- tion, and bleeding from the nose. Active irritative symptoms ACUTE INFECTIOUS DISEASES. 725 referable to the cerebrospinal system indicating profound ty- phoid toxaemia often yield better to Rhus to.v. than to such remedies as Hyoscyamus, Helleborus and Stramonium. It is not always possible to get clear-cut indications upon which to differentiate these drugs, and under such circumstances Rlius should be given the preference if it is a clear case of typhoid fever in the second or third week. Stramonium. — The Stramonium stool is blackish and hor- ribly offensive; the noisy delirium, has been alluded to under Hyoscyamus. Suppression of urine during typhoid fever is a prominent symptom. Sulphuric acid. — Protracted cases, especially in children with aphthous stomatitis ; stools like chopped eggs and very foetid; haemorrhages, with rapid sinking of the vital forces; desire for stimulants. (AiXEN.) Similar to Phosphoric acid, but more intense. Veratrum viride. — Veratrum viride is indicated when there is furious delirium ; full, tense pulse, later becoming soft and irregular ; red streak down the centre of the tongue ; pneumonic complications. Tartar emetic ma}- likewise be called for in dyspnoea, cyanosis, rattling of mucus in the bronchial tubes, subcrepitant rales, and oedema of the lungs. DIPHTHERIA. Diphtheria is an acute infectious, highly-contagious disease due to a specific micro-organism. While diphtheritic inflam- mations of mucous membranes may result from other micro- organisms — notably from the streptococcus pyogenes — still the term "diphtheria" should be restricted to those cases of pseudo-membranous pharyngitis and laryngitis due to the specific diphtheria germ. The other condition, described as pseudo-diphtheria, or diphtheroid, embraces those anginas complicating scarlet fever, measles, and occasionally others to the infectious diseases, or occurring primarily as "diphtheritic sore throat," being due to infection with the streptococcus or some other organism (staphylococcus, pneumococcus). 726 DISEASES OF CHILDREN. The appearance of the membrane and the accompanying symptoms should differ greatly in these two conditions, so that a differential diagnosis might be made upon a clinical examination alone ; but it must be remembered that mixed infection is quite a common occurrence, and that in such cases confusion may arise. Again, true diphtheria may present an entirely atypical exudate and the concomitant symptoms be of a mild type, while, on the other hand, a streptococcus angina may be accompanied by high fever and considerable adenopathy. For this reason it is unwise to attempt to make a diagnosis of diphtheria upon the appearance of the throat and the associated symptoms alone, never neglecting a bacteriological examination in any case presenting mem- branous exudate upon the tonsils. Membranous croup is that form of diphtheria in which primary infection takes place in the larynx with the develop- ment of a diphtheritic membrane, which may either remain confined to the larynx or spread upward or downward, involv- ing the pharynx and trachea secondarily. Faucial diphtheria frequently invades the larynx second- arily, the resulting laryngeal symptoms being identical with those of a fully-developed case of croup ; but the clinical picture presented by a case of primary croup differs so mark- edly from the manifestations of faucial diphtheria that its description, like that of pseudo-diphtheria, must be con- sidered separately. The Klebs-Loeffler bacillus is a micro-organism varying greatly in size, being broad, straight or slightly curved, and presenting a club-like extremity. It contains highly refrac- tile, oval bodies, which take the stain more deeply than the bacillus itself, the best stain for bringing out these bodies be- ing an acidulated solution of methylene blue, a counter-stain of aqueous Bismark brown being used to stain the body of the bacillus. This is known as Neisser's Stain and the best results are obtained in young cultures (from 6 to 12 hrs.). As the bacillus will grow readily upon Loefner's blood-serum ACUTE INFECTIOUS DISEASES. 727 at a temperature of 8o° F. to ioo° F., it is a simple matter to carry out this most important procedure, even in private practice. The examination of smears from the throat is neither accurate nor satisfactory. A bacillus may be found, irregular in shape and taking the stain (Loeffler's methylene blue) irreg- ularly, but in order to be absolutely certain we must make a culture and observe its mods of growth (delicate grayish colonies) and study the early-appearing growth for the above mentioned peculiarities. The bacillus is spread by the discharges from the mouth, throat and nose, and may persist for a long time in the throat of a patient after recovery. Infection may take place either directly from the patient, or indirectly through the medium of articles of bedding, clothing, toys. etc. It may also be spread through the agency of a third person. We should, however, remember that a child with a perfectly healthy throat is less liable to contract the disease than one with a catarrhal angina, slight superficial erosions of the mucous membrane, enlarged tonsils, naso-pharyngeal catarrh and catarrhal laryngitis. Pathology. — Pathologically, a diphtheritic inflammation presents a pseudo-membrane, which is inseparably attached to the deeper layers of the mucous membrane upon which it develops, the entire mucosa having undergone a process of coagulation necrosis, accompanied by the exudation of fibrin. Such a condition is rarely met with, however, in Klebs-Loefner diphtheria of the fauces and larynx, a croupous exudation of varying thickness, separating without leaving a lacerated surface, being the pathological process usually en- countered. The true diphtheritic process, resulting in ulcera- tion and sloughing, is more likely to take place in scarlatinal pseudo-diphtheria (septic angina), or in eases of septic diph- theria where mixed infection exists. The membrane consists of a dense network of fibrin, con- taining in its meshes pus-cells, dead epithelial cells and numerous micro-organisms. The Klebs-Loeffler bacillus can 728 DISEASES OF CHILDREN. be demonstrated in the upper and outer layers of the mem- brane. The mucous membrane underlying and adjacent to the pseudo-membrane is found in inflammatory reaction, though rarely oedematously swollen unless pyogenic micro- organisms are plentifully admixed with the bacillus. The lymphatic glands of the neck are markedly swollen, but do not tend to break down*. The surrounding structure may present a puffy appearance. The glandular enlargement is most marked in cases complicated by invasion of the pos- terior nares. When the process is confined to the larynx they may not be involved at all. Parenchymatous degeneration of the heart, kidneys and liver are the changes observed in the internal organs. A secondary broncho-pneumonia (inhalation pneumonia) is rarely absent in severe and fatal cases. Here the Klebs-Loefner bacillus is usually found in the lungs. In sixty-two cases of broncho-pneumonia, associated with diphtheria, reported by Pearce, {Jour. Bost. Soc. Med. Sciences, June, 1897) the bacillus was present in fifty-two instances, being the only organism present in seventeen cases. The streptococcus pyo- genes was also prominently present. The changes occurring in the nervous system, which become manifest at a somewhat later period than those observed in the other tissues, are parenchymatous degeneration of the myelin sheath of the nerves, affecting both motor and sensory fibres alike (Bat- ten, British Med. Jour., Nov., 1898), and at times degen- erative changes in the gray matter of the cord, cerebellum and brain. Symptomatology. — A typical case of pure diphtheritic infec- tion presents the following characteristics : The child will usually complain of sore throat for a day or two, which may not attract special attention until fever, offensive breath, prostration and swelling of the glands at the angle of the jaw become apparent. An examination of the throat at this stage of the disease reveals a deposit of false membrane, usually upon one of the tonsils, associated with slight swelling of the ACUTE INFECTIOUS DISEASES. 729 same and redness of the mucous membrane. This may, how- ever, be slight, in consideration of the serious nature of the condition, and in fact the mucous membrane in some instances will appear pale rather than congested. Likewise the pain on swallowing may be so inconsiderable as to attract little or no attention. I have had children brought to my clinic in whom both tonsils were covered with membrane, and yet these children had not complained of their throats sufficiently to lead the parents to suspect the true nature of the case. The membrane is of a grayish or yellowish-gray color, and firmly adherent to the subjacent mucous membrane ; in fact, it requires more or less force to remove it, which usually re- sults in some traumatism to the mucosa. This is a patho- gnomonic sign of diphtheria, and taken in conjunction with the swollen lymphatics, the offensive breath and the moderate degree of fever, a diagnosis of true diphtheria can usually be made without hesitation, which a bacterio- logical examination will subsequently verify. Instead of beginning as a single patch, there may be seen isolated dead-white spots of varying size upon one of the tonsils, which may remain discrete throughout the entire course, if the disease does not assume a severe type. Usually, however, they unite into one large, irregular patch, and the opposite tonsil, from being brought into contact with the affected one during deglutition, soon develops a similar mem- brane. In severe cases the membrane spreads rapidly from its peri- phery, travelling along the margin of the soft palate, cover- ing the uvula, which becomes elongated and swollen, and finally invading the opposite half arch and coalescing with the membranous deposit of the other tonsil. It also spreads pos- teriorly to the pharynx, whence it may invade the posterior nares or the larynx. When membrane develops at this rapid rate it sometimes appears simply to run over the mucosa as a delicate fibrinous exudate, the epithelium beneath it remain- ing intact for some time. 47 730 DISEASES OF CHILDREN. In a steadily progressing case the above distribution of the membrane will have been completed in about three to four days from the time of onset. At this time the membrane can be studied in various stages of development. At the site of origin it will be found to have attained considerable thick- ness, being of a brownish or dirty grayish color, with a well- defined outline and areola, and a thick, partly detached border, while in another direction it fades ont into a thin, grayish film, which is invading new territory. This film likewise thickens and assumes the same color as the other portion of the membrane, which now shows a tendency to become loose. By the fifth or sixth day the process has reached its acme, and in the course of three or four days the membrane sepa- rates spontaneously, providing the patient has not succumbed to the disease or has not had antitoxin. (In the cases receiv- ing antitoxin early, the conrse is materially shortened.) A red areola of reactionary inflammation is seen about its border, and it gradually loosens and comes away in pieces, leaving behind a reddened, slightly swollen and readily bleeding mu- cous membrane. Coincident with these changes the consti- tutional symptoms rapidly improve, and the patient is on the road to convalescence. The symptoms accompanying the diphtheritic process are those of a most grave toxaemia. As pronounced symptoms may be delayed until the disease is far advanced, they are seldom of diagnostic valne. The child complains of lassitude, anorexia and sore throat ; repeated chilly sensations and headache may also be present. Fever is usually not high in the beginning, and may remain at a comparatively low point throughout the entire course, fluctuating between icu° to 103 F. An abrupt onset, however, with high fever, headache, severe pain in the throat and considerable swelling of the tonsils, may take place. In such cases the early symptoms may be due to an admixture of the streptococcus. This, however, is not necessarily the case, for diphtheria is most irregular in its clinical manifestations. There are cases in which even in the presence of considerable ACUTE INFECTIOUS DISEASES. 731 membrane constitutional symptoms are entirely wanting. Again, the most serious symptoms, even sloughing of the soft tissues and suppuration of the lymphatic glands may result from the diphtheria bacillus alone without the intervention of a secondary infection. The lymphatic glands at the angle of the jaw are involved early in a typical case, but the adenopathy may be so slight, as to escape notice. Absence of adenopathy is by no means evidence against the presence of diphtheria. The pulse becomes rapid and weak during the later stages, the heart being affected to a marked degree by the toxins of diphtheria. Sudden death may take place from cardiac pa- ralysis during the height of the disease, or it may not occur until the child is convalescing, following upon some incau- tious physical exertion. The myocardium, as well as the in- nervation of the heart, is affected by the toxin. In some cases the pulse becomes slow and irregular ; this is prob- ably a sign of myocarditis. The tongue is coated from the beginning and the breath characteristically offensive. The bowels are generally con- stipated. Albuminuria is found in many cases ; it usually clears up promptly, simply indicating acute degeneration of the kidneys as a result of the elimination of toxins. Diphtheritic paralysis occurs more frequently in adults than in young children, being seen seldom under two years. The severity of the case does not necessarily indicate the amount of paralysis which is to be expected, for cases with but a small amount of membrane may be followed by considerable paraly- sis, and vice versa. The clinical picture is that of a multiple neuritis, the pathological changes in the nerves having been described above. Symptoms may occur while the membrane is still present, but this is unusual. In the majority of cases they do not occur until two or three weeks after recovery. Paralysis of the soft palate is the first symptom noticed, man- ifesting itself by nasal voice, regurgitation of food through the nares, and difficulty in swallowing. 732 DISEASES OF CHILDREN. The eye-muscles are frequently affected early, and loss of accommodation, strabismus and ptosis are the disturbances encountered here. When the extremities take part in the paralysis the patient will complain of muscular weakness, with tingling and numbness, gradually increasing in severity until he is perhaps unable to walk or use his arms, although complete paralysis is rare. When the extremities become in- volved the paralysis is symmetrical. Sensation is markedly impaired and the knee-jerk lost, even at times without the existence of paralysis. The prognosis as to ultimate recovery is good, although the course is variable, some cases continu- ing for several months before improvement sets in. Death may result from paralysis of the respiratory muscles. Extension of the membrane to the nose is indicated by nasal obstruction with an acrid, offensive, muco-purulent discharge and increased swelling of the lymphatic glands at the angle of the jaw, together with involvement of the submaxillary glands. Epistaxis occurring during diphtheria is always a suspicious symptom. Owing to the large absorbing surface brought in contact with the toxins, constitutional symptoms are markedly aggravated, and prostration becomes extreme. Primary nasal diphtheria is, as a rule, not nearly as grave a condition as the secondary form, although such a case may infect another child with a faucial diphtheria of the usual severity. (For a full discussion of nasal diphtheria see Pseudo-membranous Rhinitis, pages 549 and 550.) Extension into the larynx is indicated by progressively in- creasing dyspnoea, cyanosis, and a croupy cough. The pro- cess may result in complete stenosis of the larynx, with death from suffocation. Septic diphtheria is characterized by the addition of sepsis to the diphtheritic condition. It was formerly supposed that this form of diphtheria is invariably due to mixed infection with the streptococcus, but it is now known that even the most virulent cases with all the outward signs of a septic in- fection may be due to the Klebs-Loefner bacillus alone. The ACUTE INFECTIOUS DISEASES. < 33 throat assumes a dirty grayish color, or even blackish where blood extravasation into the false membrane has taken place, and a cadaverous stench emanates from the mouth. A tena- cious brownish mucus covers the tongue and lips, and an acrid discharge runs from the nostrils. The lips are dry, swollen and cracked, and ma}- be covered with patches of false membrane. Swelling of the lymphatics at the angle of the jaw is pronounced, and is accompanied by infiltration of the cellular tissue of the neck. The pulse is rapid and feeble, the extremities become cold, and prostration is profound. The temperature fluctuates greatly, and in a given case may range from subnormal to a hyperpyrexia. Septic cases are usually rapidly fatal, succumbing to the toxaemia more often than to laryngeal involvement. Laryngeal Diphtheria or Membranous Croup is a primary infection of the larynx characterized by the formation of a false membrane (croupous exudate) upon the laryngeal mu- cous membrane. The false membrane may remain confined to the larynx, or extend down into the trachea and up into the pharynx. Often it is accompanied by a scanty tonsillar exudation. Laryngeal diphtheria presents few of the char- acteristic symptoms of faucial diphtheria for a number of rea- sons. In the first place, the bacillus causing croup is usually less virulent than that found in faucial diphtheria. Again, owing to the feeble absorptive power of the mucous mem- brane lining the larynx, glandular enlargement does not take place, and as constitutional symptoms are delayed for the same reason, they are not frequently observed, owing either to the rapidly fatal course of the disease or to a checking of the process before symptoms have had time to develop. Goodno states that the fatal cases of primary pseudo-mem- branous laryngitis observed by him which were subjected to tracheotomy, and lived long enough to develop constitutional symptoms, died as diphtheria patients die. The onset is insidious, witli moderate fever, eronpv cough, and hoarseness. During the first few days symptoms are 734 DISEASES OF CHILDREN. slight and only point to a catarrhal laryngitis, nocturnal ag- gravations frequently occurring from spasm of the vocal cords. When, however, an exudate is seen upon the tonsils, or down in the pharynx, we are justified in suspecting the diphtheritic nature of the case. At the end of from three to four days laryngeal obstruction has become the chief feature in the case. The voice is hoarse or entirely lost ; during in- spiration a harsh, tubular sound (stridulous respiration) is heard, and the act is accompanied by retraction of the supra- clavicular and intercostal spaces and the lower border of the thorax. Recession of the epigastric region during inspiration is a sign by which we can most satisfactorily guage the de- gree of laryngeal obstruction in young children. The child usually sits erect, and every effort at inspiration is laboriously performed, all of the accessory respiratory muscles being thrown into action. With progressing stenosis the body sur- face becomes cold and cyanotic, and the child becomes drowsy and later comatose, dying from asphyxia. Death may result in a few days from the time of onset, although the course is usually somewhat longer. With the intervention of surgical measures (intubation and tracheotomy) the case presents a less unfavorable prognosis. Pseudo-Diphtheria, or Diphtheroid, differs from true bacil- lary diphtheria both etiologically and symptomatically. Such a diphtheritic process may develop independently or compli- cate scarlatina, measles, etc. As a complication of scarlatina it appears, however, more frequently and more virulently than in any other form. In this disease an angina of almost any grade of severity seems possible, the virus of scarlatina exert- ing direct and specific influence upon the throat, and permit- ting of the development of the gravest forms of diphtheritic inflammations. The streptococcus pyogenes is the germ most frequently found in pseudo-diphtheria, as was first demonstrated by Prudden. Although other micrococci, notably the staphy- lococcus aureus and albus y are sometimes found alone in these ACUTE INFECTIOUS DISEASES. 735 cases, or in association with the streptococcus, still they play a less important role than the latter, which is capable of pro- ducing the most destructive manifestations. The work of Filatow {Vorlesungen ii. Infections-Krankheiten im Kind- esalter, 1897) fully confirms these observations, and he is led to the belief that all '" scarlatinal-diphtherias " are strep- tococcus anginas ; furthermore, pseudo-diphtheritic strep- tococcus angina may be encountered as an independent disease, occurring without scarlet fever. Holt states that from 25 to 35 per cent, of cases formerly sent to hospitals with a clinical diagnosis of diphtheria were really cases of pseudo-diphtheria. Vierordt {Berliner Klin. IVochenschr., 1897) found in a series of diphtheroid anginas both streptococci and staphy- lococci, and in one case a diplococcus. The Klebs-Loeffler bacillus was present in none or these cases. The membrane did not extend to the nose or pharynx, but in the greater number it passed beyond the tonsils in the direction of the soft palate. Boulloche (Les Aug ines a Fausses Membranes) divides the various pseudo-diphtheritic anginas into the fol- lowing classes : streptococcus angina, staphylococcus angina and pneumococens angina. He considers them non-contagious and usually mild in their course. I have encountered the pneumococens in a few of my cases. Although these bacteria are found as contaminations in most cases of diphtheria, still they do not modify the course of the disease unless present in large numbers, aud even then it is only the streptococcus which materially alters the nature of the case, the bacillus-streptococcus combination being the most unfavorable form of infection, producing a septic diph- theria. The clinical course of pseudo-diphtheria is quite different from that of bacillary diphtheria. In cases of mixed infec- tion a clinical differentiation becomes difficult or impossible. In pseudo-diphtheria there is pronounced inflammation ^i the pharynx and tonsils, with redness, swelling and pain. It be- 736 DISEASES OF CHILDREN. gins abruptly, with high fever, lassitude and headache. Soon small, white or yellowish patches are seen to develop upon the tonsils ; they become darker in color and may coalesce, but seldom spread beyond the tonsils. The membrane is more friable than that of true diphtheria, and can usually be detached without much difficulty. Swelling of the lymphatics seldom takes place. Such cases run a comparatively short course — from four to five days — and although constitutional symptoms are severe during the height of the disease, the throat symptoms being particularly distressing, still they are never dangerous in character, and sequelae are rare. Of course, albuminuria and even an endocarditis may complicate such a condition (see Acute Tonsillitis, p. 537). Paralysis never follows pseudo-diphtheria, nor is extension to the larynx to be feared, although in the severer cases which complicate scarlatina extension to the nose and Eustachian tubes frequently takes place. Scarlatinal pseudo-diphtheria may become a very serious condition. Beside the extension of the membrane just al- luded to, sloughing and ulceration may occur, with general septic infection, and cellulitis of the neck and suppuration of the lymphatics. Such cases present a high mortality rate, being equalled in virulence by septic diphtheria only, from which they cannot be separated except by a bacteriological examination. The membrane develops during the height of the fever in the majority of cases, but it may be seen before the eruption appears. A diphtheritic sore throat developing after the fever has abated, or during convalescence, is more likely of bacillary origin than one developed at the height of the disease. Prognosis. — In estimating the prognosis in a given case of diphtheria several factors must be taken into consideration. In the first place, we must exclude pseudo-diphtheria, which in its primary form offers a good prognosis ; in its secondary form (scarlatinal) the prognosis is less favorable and it as- sumes more the type of a septic infection. ACUTE INFECTIOUS DISEASES. 737 The age is of importance, as diphtheria is uniformly more fatal in infants than in older children. Adults present the best chances, but they are more subject to paralytic sequelae. The character of the epidemic is of importance, as is also a knowledge of the source of infection. Hut this is not always reliable, for a most virulent diphtheria may originate from an apparently mild diphtheritic sore throat, and vice versa. The appearance and distribution of the membrane offer valuable suggestions for the prognosis, but here again errors are liable to occur. Extensive membranous deposit may ex- ist with but slight constitutional disturbances, and scanty membrane may be accompanied by grave toxaemia. Neither can we foretell if laryngeal involvement, with rapidly de- veloping stenosis, will occur. The time at which treatment was begun and the patient's general condition, therefore, offer the safest guides in deter- mining his chances for recovery. So long as the pulse remains good and prostration is not pronounced the case should not be despaired of. Nasal and laryngeal diphtheria are about equally grave, although the nasal type is somewhat slower in its course. Septic cases are practically hopeless. Other unfavorable symptoms are epistaxis and haemorrhages into the subcutaneous tissues ; nephritis ; marked prostration and cardiac weakness ; cervical cellulitis. In croup the prognosis is more favorable than in secondary laryngeal diphtheria, owing to the absence of septic symp- toms. During convalescence there is danger of paralysis of the heart. This may appear as a progressively increasing heart weakness, or occur suddenly upon some physical exertion. The child is seized with epigastric pain and nausea ; there is dyspnoea ; cyanosis; small, irregular pulse and collapse. If the first attack does not prove fatal there is usually a recur- rence with a fatal issue. Broncho-pneumonia occurring with diphtheria is very un- favorable ; when complicating croup the case is practically 738 DISEASES OF CHILDRExX. hopeless, as intubation or tracheotomy is of no avail in such cases. Diagnosis. — There is only one safe means of escaping the error of allowing a case of diphtheria to gain headway un- recognized until so far advanced as to be self-apparent, and that is to examine the throat of every child presented for treatment in an acute condition, as a matter of routine. The importance of such practice is realized only when we recall how trivial the throat symptoms may be in the beginning of diphtheria, particularly in a child not able to express itself or comprehend its sufferings properly. The differential diagnosis rests mainly between pseudo- diphtheria and folliculous tonsillitis. Psettdo- diphtheria is ab- rupt in onset ; lymphatic swelling is absent in primary cases ; fever is high, and the throat is markedly reddened and swollen, and there is considerable pain on swallowing ; the exudate is purely fibrinous, rarely croupous, and it does not tend to spread beyond the tonsils. Secondary cases occur during the febrile period of scarlet fever. Paralysis never follows, and although septic symptoms may be present the specific toxic symptoms of diphtheria are absent. The mem- brane is thinner, can be removed without bleeding, and is usually of a yellowish color, later becoming dirty. In folliculous tonsillitis both tonsils are uniformly swollen and covered with small, round, white spots, which are not ad- herent to the mucous membrane, but consist of plugs of exudation filling up the lacunae of the tonsils, from which they can be readily expressed and wiped off. Membranous croup is to be differentiated from acute catar- rhal laryngitis. (See p. 257.) Lastly, it may be said that no diagnosis is complete with- out a bacteriological examination, for a case which may ap- pear clinically of minor importance may harbor germs of a most virulent nature. The differentiation of pseudo-diphtheria from true diphtheria becomes also of the greatest importance in the matter of isolation, particularly in avoiding the deten- ACUTE INFECTIOUS DISEASES. '39 tion of patients suffering from the former disease in isolating wards harboring true diphtheria. Treatment. — Isolation and siek-room hygiene are to be car- ried out on the same plan as recommended under Scarlatina, page 650. Children who have been exposed to diphtheria should have their throats examined several times daily, and be instructed to use a gargle of Permanganate of Potash (1 to 1,000) three or four times daily. Royer {Therapeutic Gazette, April, 1905) insists that the general practitioner does not re- sort with sufficient frequency to immunizing doses of anti- toxin. He commonly sees at the Philadelphia Municipal Hospital a patient admitted seriously ill with diphtheria, and in the course of a few days a second or third patient from the same house. For a child that has come in direct contact with a diphtheria case he recommends one thousand units. In my own practice I carry out this principle when- ever possible. The diet must be of a most concentrated and nutritious form, and stimulation is of the greatest importance as soon as the toxic influence of the diphtheria virus upon the heart and nervous system becomes apparent. A teaspoonful of whisky well diluted with water or milk, and administered every two to three hours, suffices for the average case ; but where there is much prostration and failing heart the quantity must be increased accordingly. Absolute rest is to be enjoined during convalescence as well as during the disease in all cases show. ing cardiac weakness, in order to avert a possible sudden death. As to local treatment, it can be positively stated that all measures in any way giving the patient pain or discomfort and requiring physical restraint, or resulting in injury to the mucous membrane of the throat, will do nothing ex- cepting harm. In infant- a spray of Permanganate of Potash (1 to 1,000) given, by means of an atomizer, every two or three hours, and in older children a gargle similarly em- ployed, has yielded the best results in my hands. Should the 740 DISEASES OF CHILDREN. child be too weak to gargle, a teaspoonful of the solution may be given internally every two hours. Alcohol diluted with four or five parts of water is also an excellent gargle, but not as active as the Permanganate. In nasal diphtheria our aim should be to keep the nasal chambers as open and free from secretion as possible. A douche of Permanganate, i to 2,000, or a warm normal saline solution should be given about three times daily, as directed on page 19, but the child should be held in the recumbent position with its head turned to one side, lying on a Kelly pad. In laryngeal diphtheria an emetic will give temporary re- lief when suffocation becomes imminent, but intubation or tracheotomy should not be put off to so late a period. Al- though still a matter of dispute, intubation is the preferable procedure in the majority of cases. It should always be at- tempted first, and, in the event of not offering the most desir- able results, tracheotomy may be resorted to as a dernier ressort. Intubation consists in the introduction of a hard rubber tube into the trachea by means of an especially constructed in- strument invented by O'Dwyer. In construction it is practically nothing more than a handle, to the end of which, at a right angle, the intubation tube is temporarily fastened by being slipped over an obturator. From this it is released at the proper moment by means of a hook-like arrangement that is pressed down over the collar of the tube and thus pushes it loose from the obturator (Fig. 60). Extubation is performed by means of a long, curved, forcep-like in- strument with a small beak, as shown in the illustration. The beak is inserted into the opening of the tube, the blades are separated until the tube clings to the same, and the tube is then withdrawn from the larynx. The child may be intubated in the erect or in the recumbent posture. Personally, I find the recumbent posture preferable, and it is employed in the majority of the hospitals that I have ACUTE INFECTIOUS DISEASES. 74-1 visited. The child is easier to control in this position, and, furthermore, the palate tends to fall upward and away from the pharynx, thus facilitating the introduction of an instru- ment into the larynx. The child is prepared by being wrapped in a sheet with the arms pinned down to the sides, and the nurse is in- structed to hold the legs and trunk, while an assistant should be at hand to control the head and keep the FIG. 60. — O'DWYKR'S SET OF INSTRUMENTS FOR INTUBATING THE LARYNX. mouth-gag in place. A table covered with several thick- nesses of blankets and a sheet should be used, and not a couch or bed. The mouth-gag is then inserted into the left side of the mouth, well back between the molar teeth. The proper tube having been selected, according to the age of the child, and threaded with a loop of heavy linen thread, it is n<>\\ slipped firmly over the obturator of the introducer. The latter is lightly held in the right hand, with the thumb upon the knob 742 DISEASES OF CHILDREN. of the sliding arrangement which releases the tube. The left index-finger is passed quickly into the child's pharynx, keep- ing to the right side of the mouth, as shown in Fig. 61, and the epiglottis is hooked up and held out of the way so that the tube may be guided along the middle line, over the base of the tongue, and then directly downward and slightly forward into the chink of the glottis. In order to give the proper direction to the tube the handle of the instrument must be FIG. 6l. — CHILD IN PROPER POSITION FOR INTUBATION. INDEX FINGER OF LEFT HAND IN MOUTH, FEELING FOR THE EPIGLOTTIS. RIGHT HAND HOLDING INTRODUCER WITH TUBE READY FOR INTRODUCTION. well elevated as soon as the tip of the tube reaches the glottis. When the tube has entered the glottis it should be released (by means of the slide on the introducer, which is pushed forward with thumb), and then buried to its full length into the larynx by a gentle push with the left index finger upon the collar of the tube. No force is necessary, and undue pressure or rough manipulation of the larynx is strictly to be avoided. Should the first attempt fail to enter the tube promptly ACUTE INFECTIOUS DISEASES. 74-3 within the glottis, the finger should be removed from the pharynx and the child allowed to get its breath before mak- ing another attempt. The commonest mistake is to pass the tube into the oesoph- agus instead of into the larynx. This results from not elevat- ing the handle of the introducer sufficiently and failing to direct the tube sufficiently forward ; also from getting away from the middle line and not keeping closely to the base of the tongue. The most reliable landmark by which to find the larynx is the arytenoid cartilage. Even when the mucous membrane is swollen and false membrane is present this knob-like projection can readily be distinguished by the index finger. From this we may pass a little inward and for- ward in order to find the epiglottis, which must be lifted up before the tube can enter the larynx. If we have been successful in our attempt, a remarkable change soon passes over the child. There will first occur a coughing paroxysm, more or less severe, accompanied by a characteristic whistling sound which tells us that the tube is in the larynx. The cough results from the mechanical irritation of the larynx, but this is beneficial, as it usually effects the removal of a large amount of tenacious mucus. The normal color is restored to the features, and the breath- ing, which was rapid and labored, becomes slow and tranquil. Usually the child soon goes off into a refreshing sleep. As soon as we are convinced that the tube is in place and the dyspnoea is relieved, we should cut the string that has been attached to the tube (mainly for the purpose of pull- ing it out of the oesophagus in an unsuccessful attempt) and draw it out of the eyelet in the collar of the tube with the left index finger in position upon the collar in order to avoid an accidental extubation. At the end of the fifth day the tube should be removed. The child is held exactly as for intubation and, with the left index finger upon the collar of the tube, the beak of the in- tubating instrument is guided into the opening of the tube, 744 DISEASES OF CHILDREN. its jaws are opened until they will not slip from the opening, and thus gripping the tube it is lifted from the larynx. It can then be easily removed from the pharynx with a quick sweep of the index finger. We must always be ready to re-intubate promptly, however, as there may still be sufficient stenosis to render the wearing of the tube necessary, or a spasm of the laryngeal muscles may follow the removal of the tube, calling for prompt action. In rare cases the intrinsic muscles of the larynx become paretic from the pressure of the tube, or a cicatricial atresia of the larynx may follow upon pressure-ulceration. Fortu- nately, the beneficial results from skilfully performed intuba- tion so far outshadow its evil results that it has attained to a position of universal praise as a life-saver. One of the disadvantages of intubation in private practice is the possibility that the child may cough up the tube and suffocate before the physician can return to the case. It is well to remain with every case, or at least close by, for several hours after intubating, and if the child shows a tendency to cough up the tube it should be removed, whenever possible, to a hospital where skilled residents are in charge. Death may result under somewhat similar circumstances, even after tracheotomy; the child may pull the tube out or it may become clogged with membrane. The eminent psediatrist, Prof. Caille once remarked, we can do no more than perform our duty under these circumstances,' and if we have done the best we know how, results may come as they will. The membrane may extend down too low to enable the in- tubation tube to relieve the dyspnoea, or we may push the membrane down ahead of the tube and thus cause suffocation. In the latter instance a violent coughing fit will sometimes expel both the tube and the membrane. These difficulties are mainly encountered in the cases we see late, and I have been forced to do tracheotomy several times under such cir- cumstances. But we should not wait until the child is suffo- cating before intubating. As soon as the breathing becomes ACUTE INFECTIOUS DISEASES. 7-L5 laborious and the epigastric region is plainly drawn in during inspiration it is our duty to spare the child not only from the suffering, but also from the exhaustion that comes with these undue respiratory efforts. Nasal intubation as recommended by Xorthrup (New York) merits serious consideration. It is indicated in com- plete obstruction of the nose by membrane, in young children and infants, when this obstruction materially interfers with the child's respiration. An old-fashioned English (stiff) catheter of the proper calibre is carefully worked through the naris until the pharynx is reached ; it is then cut off, allowing about an inch to protrude. Tubing one side may give suffi- cient relief in the case. Dr. H. M. Gay has reported a case which I saw with him and treated in this manner, the infant making a good recovery (Tran. Horn. Med. Soc, Penna., 1904 ). In all forms of diphtheria, but especially in croup, it is es- sential to keep the air of the room moist and at a temperature of about 70 F., if this be practicable. The air must, at the same time, be kept as rich in oxygen as possible. The spraying about the sick-room of hydrogen dioxid, or the slaking of lime, is an excellent means of purifying the air. It is by no means easy to say just which are our most im- portant remedies in diphtheria, as no attempts at differentiation have been made in the past between pseudo- and true diph- theria, and the errors which so frequently beset the diagnosis of membranous croup render it difficult to estimate the exact value of the treatment employed. The Mercuries, especially the Cyanide, the Bichloride and Red iodide; the Bichromate and Permanganate of Potash, the Chloride of Lime, Lachesis, Arsenic and Arum triphyllum are most closely related to the bacillary variety. Merc. cyan, and Kali bich., especially when there is extension to the larynx; Arum triph. in the nasal variety, and Arsenic, Lach., Rhus tox. and the Chloride of Lime in septic casts. The high-grade inflammatory symptoms of pseudo-diph- theria call for remedies like Apis, Belladonna, . Ulan thus, Phytolacca and Rhus tox. 48 746 DISEASES OF CHILDREN. Mild diphtheritic anginas yield promptly to the Mercuries \ Bell, and Apis. The Red iodide is supposed to be indicated when the left tonsil is affected, and the Yellow iodide when the right side is involved. Personally, I do not pay any at- tention to the side affected, and always give the Red iodide the preference over the Yellow. In Belladonna there is con- siderable fever and headache, the throat is dry and glistening red, and there is pain in swallowing and a sense of constric- tion. When these symptoms are present with considerable exudate I alternate Belladonna with the Red Iodide of Mer- cury. Apis presents more of an oedematous condition, the swelling being paler in color and the pains of a stinging char- acter, worse on swallowing. The most efficient remedies in croup are Bromine, Iodium y Kali bichromicum. Liquor calcis chlorinata and Hepar. The symptoms of Spongia are more purely catarrhal and spas- modic than croupous. Bromine has given me good results in a few cases, but since the introduction of antitoxin the mortality of croup has been so much reduced that we have no right to rely exclusively upon a remedy. Dunham's experience {The Science of Therapeutics) with Bcenninghau- sen's method of prescribing Aconite, Hepar and Spongia in rotation seems to have been of the happiest kind. Neidhard obtained good results from his Liq. calcis chlorinata in croup as well as in faucial diphtheria, but he frequently alternated with Potassium bichromate in the former condition. The routine treatment advised by Heysinger (fourn. of Ophthal., Otol. and LaryngoL, January, 1892) is of great value in all cases of pseudo-diphtheria and in diphtheria with sep- tic symptoms. He administers a teaspoonful of a solution of Permanganate of potash, one grain dissolved in two and one- half to three ounces of water every one to two hours, accord- ing to circumstances, in alternation with a teaspoonful of Belladonna, five minims of the tincture in three ounces of water. The Belladonna relieves the fever and hyperaemia ; but with toxaemia it is of no value, and a reined v must be ACUTE INFECTIOUS DISEASES. 74-7 chosen symptomatically {Merc. cyanat., Arsenic, Lachesis, Rhus toxicodendron and others). The symptoms upon which the remedies applicable to diphtheria and croup have been prescribed most frequently are the following : Acetic acid. — Croup, attended by bright redness of the face. From five to ten drops of acetic acid in a half tumblerful of water with some sugar ; a teaspoonful every two to three hours (C. G. R.). Ailanthus. — Scarlatinal diphtheria (diphtheroid) with livid and swollen throat. Deep ulcers on tonsils ; the patient gradually sinks into a stupor. Amnion, carb. — Nasal obstruction and carbonization of the blood ; extreme prostration. Apis mel. — (Edematous swelling of the fauces, cellular tis- sue of neck and of the glottis. Burning and stinging pains in throat ; albuminuria. Arse?i. — In the later stages, especially in toxic cases with marked cardiac weakness ; albuminuria ; irregular fever ; ex- treme restlessness. Aram triph. — Acrid discharge from the nose excoriating the upper lip ; an acrid fluid oozes from the mouth which causes the lips to become sore and swollen. The child con- stantly picks at the lips and nose, keeping them in a bleed- ing condition. There is burning pain in the throat, and the breath is very offensive. The membrane spreads up into the nares. Bell. — Early, especially in cases beginning abruptly with pronounced throat symptoms and fever. Bromiam. — Croup. Best suited to fair, chubby children, and in cases with little or no fever. lodium is recommended in brunettes and in the presence of fever. Calc. chlor. — The liquor calcis chlorinata was first recom- mended by Dr. Neidhard [Diphtheria, Its Nature and Home- opathic Treatment, 1867) in diphtheria and croup, and it is still a favorite remedy with many practitioners. He em- 748 DISEASES OF CHILDREN. ployed five to fifteen drops of the Liquor in half a tumbler of water, giving a teaspoonful every fifteen minutes in urgent cases, or only at intervals of several hours in more favorable ones. His success was apparently most gratifying. Hepar. — Croup. The cough is hard and metallic, with a loose edge ; although the child may expectorate, the obstruc- tion is not relieved. Croup developing after exposure to cold wind. Kali bichr. — Croup. Tough, stringy discharge from throat, with hoarseness and croupy cough. Also nasal diphtheria with a similar discharge from nose ; extension up into the Eustachian tube. The best remedy to control the excessive secretion in croup cases even after antitoxin has been ad- ministered. Lachesis. — The symptoms are intense, although the throat lesion may be apparently slight (toxic cases). The membrane is grayish or becomes black, (hsemorrhagic) and is surrounded by a purplish areola ; the throat is purple, not bright red as in Apis (Allen) ; the cellular tissue of the neck is infiltrated and the skin presents a livid hue. Hyperesthesia about the throat is a most characteristic symptom, and the patient must have all garments as loose as possible in this region. According to Allen, in all cases requiring Lachesis there is usually sharp pain shooting from the throat up into the ears. Cardiac symptoms may also be prominent, the patient being unable to get his breath unless propped up in bed, etc. Merc, cyanatus. — Adynamic cases with abundant mem- brane displaying a tendency to travel down into the larynx. " Adynamic fever and collapse already in the commence- ment." (Von Villers.) According to Allen it is also of service in nasal cases with profuse debilitating sweat from the slightest exertion. The Cyanide of Mercury is undoubt- edly a truly homoeopathic remedy to toxic diphtheria, pro- ducing the extreme adynamia observed in these cases as well as gangrene of the velum palati and fauces (Beck). Of late the old school has been making use of it, a series of eighty-one ACUTE INFECTIOUS DISEASES. 74-9 cases of diphtheria with but one death being reported by Luddeckens-Leignitz {Aerztliche Rundschau, 1896, No. vi). He also uses it in scarlet fever, whether complicated by mem- branous angina or not. His usual dose was a teaspoonful of a 1 to 10,000 solution every hour (fourth decimal dilution). Merc. jod. ruber. — Membrane begins on the tonsils ; pain- ful swelling of lymphatics ; the tonsils are swollen and the palate elongated ; the patches are irregular in outline and of a dirty yellowish color ; tongue heavily coated and flabby ; offensive breath. The Yellow iodxide, it is claimed, affects the right side and partakes more of the general characteristics of Mercury, while the Red iodide displays more of the action of Iodine. I do not believe, however, that there is sufficient clinical experience to give the proper authority to this distinction. Phytolacca. — Much pain and swelling in the throat. The mucous membrane is of a bluish-red color and is covered with grayish ulcers. Rhus tox. — The throat appears as if varnished (glistening), and of a dusky red color. Swelling of the lymphatics and cellular tissue of the neck is marked. There is great rest- lessness and prostration, with aching in every joint. vSeptic cases. Post-diphtheritic Paralysis. — The most useful remedies are Gelsemium, Causticuni, Phosphorus, Cocculus and Nux vomica. Strychnine is extensively used by the old school, but many of its best authorities are in doubt as to any specific influence exerted by it over the condition, relying more on a general tonic treatment and galvanism. Stiegele [Allg. Horn. Zeitung, Dec, 1901) reports a case in which Phosphorus, 5th dilution, was prescribed with rapid improvement, un- doubtedly due to the drug's action, on the following symptoms : Cardiac weakness with spells of palpitation ; marked debility of the extremities ; uncertain gait, and formication in the hands and feet. Causticum is most useful in laryngeal and ocular paralysis. Cardiac weakness with blueness of the lips and ptosis call for Gelsemium. 750 DISEASES OF CHILDREN. Serum Therapy. — The antidotal treatment of diphtheria, by means of the hypodermatic injection of the blood-serum of horses, previously immunized to the toxins of diphtheria by being subjected to progressively increasing doses of the same, has furnished us with the most valuable means at our command for the cure of this much dreaded disease. Not only is the serum, popularly known as diphtheria antitoxin serum^ capable of antidoting the systemic disturbances belonging to diphtheria, but it also exerts a specific in- fluence upon the local manifestations. Furthermore, it has been conclusively demonstrated that an artificial im- munity against the disease can be obtained from a com- paratively small dose. This, however, is of a transient nature, only lasting for a period of a few weeks, but it nevertheless indicates the strong antagonism which ex- ists between the serum and the toxin. The overwhelming evidence in favor of this form of treatment in diphtheria, based on statistics coming from both Europe and America, and from private practice as well as from large hospitals for contagious diseases, should expel all doubt as to its efficacy. When we consider that the clinical manifestations of diph- theria are purely of toxic origin, requiring antidotal treat- ment as well as any other case of poisoning, be it a snake bite, arsenic- or opium-poisoning, we should gladly take advan- tage of such a potent remedy, and by using it in conjunction with judicious local measures and remedies chosen on indica- tions requiring special consideration, we may hope to still further lower the death-rate so materially changed within the last decade. The sphere and scope of antitoxin must not be superficially considered, for it has both its limitations and characteristic in- dications, as well as any other remedial agent of positive value. Again, the limit of its action is to antidote the toxins circu- lating in the blood and check the local process ; it has no curative effect beyond this, which is simply the creation of an artificial immunity. Upon the parenchymatous changes ACUTE INFECTIOUS DISEASES. 751 in the heart, kidneys and other internal organs, and the speci- fic changes in the nervous system, it has not the slightest influ- ence. Consequently its efficacy becomes less and less positive as the disease is allowed to progress without efforts to check it, and the occurrence of diphtheritic paralysis cannot be averted in a system which has already been saturated with the toxins, even if antitoxin be used late in such a case with otherwise favorable results. In pseudo-diphtheria and in septic cases it is useless. The use of antitoxin in such cases has given it many a black eye, if I may use such a term. If a serum is at all to be used here, it must be one capable of neutralizing streptococcus toxins. A slight admixture of streptococci cannot be said to contraindicate the employment of antitoxin, as the bacillus produces the most important disturbances in these cases ; but if there be considerable angina and adenitis, fever, headache and other symptoms of a similar nature, the best results are obtained by using the Belladonna and Per- manganate of potash combination in conjunction with the antitoxin. A perfect case for antitoxin is one in which the bacillus is found in practically pure culture in the throat and the symp- toms correspond to the description of a typical case of uncom- plicated diphtheria as depicted above. Membranous croup of purely bacillary origin is also most positively benefitted by it. As pseudo-membranons laryngitis only exceptionally re- sults from other than diphtheritic infection, the exceptions being those rare cases accompanying malignant scarlatina, it possesses in antitoxin a remedy for which we should indeed be thankful. According to the report of the collective investigation of the American Pediatric Society {New York Medical Record \ May 15, 1897), the mortality among cases of laryngeal diph- theria operated upon was reduced to 27.24 per cent., early statistics of intubation in pre-antitoxin days showing only 27 per cent, recovery. The number of cases requiring operation was also greatly reduced, being 39 per cent, with the use of 752 DISEASES OF CHILDREN. antitoxin, and about 90 per cent, without it. In a former re- port it was shown that the average mortality from faucial diphtheria in private practice was about 12 per cent., but among the cases which received antitoxin within the first three days it was only 7.3 per cent. Prof. Goodno, who was one of the first in our school to champion the serum therapy of diphtheria, reported two hundred and seventeen cases of diphtheria seen in private practice (mostly in consultation) with nine deaths, a mortality of about 4 per cent. (Hahne- mannian Monthly, June, 1901). Baginsky treated eighty-two consecutive cases with antitoxin at the Friedrich's Hospital in Berlin, with a mortality of 12.2 per cent. Immediately following this series, one hundred and three cases were treated without antitoxin, and the mortality rose to 53.4 per cent. After this, antitoxin was resumed, and out of one hundred and twenty-four cases only 11.3 per cent. died. Clubbe {Brit- ish Medical Journal, Oct., 1897) reported a parallel series of three hundred cases of diphtheria, treated with and without antitoxin, at the Sydney Children's Hospital. The diagnosis was confirmed bacteriologically in all cases. Of those treated without the serum, 52.7 per cent, died; one hundred and ninety-nine required tracheotomy, with a mortality of 67.8 per cent. The mortality was reduced to 20 per cent, by the employment of serum injections, and among this series only one hundred and twenty-nine required tracheotomy, with a mortality of 37.9 per cent. Since antitoxin has been used more heroically even better results are obtained. Thus, in Boston, McCollom (City Hospital, South Dept.) gradually brought his mortality rate down to about 11.5 per cent, in 1903, from 14.5 per cent, in i895~'96, — the early period of serum therapy. In intubation cases it fell from 64.5 per cent, in 1896 to 26.6 per cent, in 1903. Statistics could be cited ad infinitum, but as they all practically indicate the same beneficial results from the antitoxic treatment the foregoing will suffice. Accurate rules for dosage cannot be laid down for all cases > ACUTE INFECTIOUS DISEASES. 753 nevertheless there are certain rules of procedure that apply to the average case. In the last few years the views concerning the dosage of antitoxin have changed con- siderably, especially since McCollom, has so clearly demon- strated the harmlessness of large doses and their advantage over the smaller dose. The following doses are in use at the Municipal Hospital (Philadelphia). Purely tonsillar exudate (single), 2,500 units ; the same, double, 5,000 units. Tonsillar exudate with in- volvement of pillars and uvula and larynx, 7,500 to io,oco units; nasal and any other part involved, 7,50c to 10,000 units ; laryngeal, 7,500 to 10,000 units. Repeat the dose in each case in from twelve to twenty-four hours, depending upon severity of case and signs of improve- ment (Rover, loc. ctt.). I doubt the necessity for such doses in private practice, es- pecially when we see the case early. In mild cases, seen early, 2,000 units usually suffice. In the severe cases we should begin with 4,000 units and repeat the injection at the end of twelve hours if the progress of the disease has not been arrested. If the patient is worse I recommend double the initial dose (8,000 units) to be given at this time. If improvement sets in, but the membrane does not promptly come away, the injection should be repeated at the end of twenty-four to forty-eight hours. In laryngeal cases it is best to give 4,000 units at once on suspicion. If, in the meantime, we have been able to estab- lish the diagnosis of laryngeal diphtheria we should repeat the dose at the end of twelve hours if the case is no worse, and twice this dosage if stenosis is progressing. A third injection is, as a rule, unnecessary and it may not even become neces- sary to intubate. This I have seen repeatedly. In children under two years of age the- dose- should not ex- ceed 3,000 units in the severer cases. In mild cases, which are seen early, 1,500 units is the max i mum dose usually re- quired. In order to obtain the best results, therefore, anti- 754 DISEASES OF CHILDREN. toxin must be used early and insufficient potency to neutralize the toxins in the blood, repeating the dose if the action of the first one does not yield the desired results after a reasonable length of time. The method of injection is simple. A site at which the skin is loose and not highly sensitive (preferably the axillary region or that of the shoulder-blade) is cleansed preparatory to the injection and the child is laid on its side. The injection is then made in the usual manner, and in order to avoid fright- ing the child unduly, we should keep the syringe out of sight and not make elaborate preparations before the unfortunate patient. Again, by injecting slowly, much unnecessary pain is avoided and loss of serum is likely to be less than by too hurried a procedure. Since the improvements in the pre- paration of serum have given us the same in a highly con- centrated form, the necessity for employing an especially large syringe is done away with. Again, the sera on the market are put up in convenient packages, combining a con- tainer and aseptic syringe. However, it is well to have a special hypodermic syringe (one of 5 c.c. capacity) for this purpose, in order to insure of its being in readiness at all times. The needle should be boiled before inserting it under the skin, and the barrel of the syringe cleansed with an anti- septic solution before and after using. By carrying out a per- fectly aseptic technique and employing a concentrated form of serum the local and general disturbances attributed to antitoxin will seldom be seen. The beneficial effect of the serum upon the local and con- stitutional manifestations of the disease is noteworthy. First of all, there is a drop in the temperature. Repeated examin- ations of the throat will indicate that the membrane has ceased to spread, it becomes paler and cleaner in appearance, and at the end of twenty-four hours begins to loosen and shrivel. Within forty-eight hours an extensive membrane may have almost entirely disappeared, leaving behind only small fragments of the more firmly attached portions. Laryn- ACUTE INFECTIOUS DISEASES. 755 geal stenosis is sometimes relieved sufficiently within a few- hours to render intubation unnecessary. Nasal obstruction is relieved in a similar manner. As regards the constitu- tional symptoms, there is a rapid change from a condition of a most serious illness to a comparatively benign one. How r ever, as said before, antitoxin does not prevent sequelae, nor does it undo the mischief which has resulted from the action of the toxins upon the organs and tissues of the body. For this rea- son it is always wise to combine constitutional treatment with the antidotal treatment, with the object of counteracting these pathological processes and preventing sequelae. GLANDULAR FEVER. This disease w2 of gastric content-, 142 in cyclic vomiting. 165 in marasmus, 62b of milk, cow's, 83 human. 80 of stools, 188 of urine, 66 Angina pectoris, 3^2 Ankle clonus, 48 Anomalies of heart (v. heart anom- alies). 338 Antitoxin, diphtheria, 750 dosage, 752 statistics, 732 technique of injection, 734 tetanus, 116 Aortic regurgitation stenosis, 358 Aphthae, Bednar's, 130 epizooticae, 130 758 INDEX. Aphthous stomatitis (v. stomatitis) 129 Apoplexy in newborn, 114 Appendicitis, 236 diagnosis, 238 symptomatology, 237 therapeutics, 239 treatment, 238 varieties, 237 Arteritis, umbilical, 115 Arthritis deformans, 612 Arthritism, 569 Artificial foods, 109 Asphyxia, extra-uterine, 112 intra-uterine, 112 neonatorum, 112 treatment, 113 sudden death from, 123 Asses' milk (v. milk), 79 Astasia abasia, 506 Asthma, 267 diagnosis, 269 of Millar, 254 symptomatology, 268 therapeutics, 269 thymic, 254 treatment, 269 varieties, 267 Atavism, 41 Ataxia, family, 519 diagnosis, 521 prognosis, 521 symptomatology, 520 hereditary cerebellar, 520 Atelectasis in newborn, 123 Athrepsia (v. marasmus), 160, 624 Atresia of stomach, 169 Atrophy of liver, acute yellow, 179 Aura, epileptic, 480 Auscultation, general methods, 59 in diseases of stomach, 140 Babinski's sign, 48, 439 Bacteria in milk, 100 of intestinal tract, 193 Baked flour, 108 Barley water in modified milk, 94, 105 Barlow's disease (v. scurvy), 584 Bathing, 9 Baths, alcohol, 109 bran, 18 cold, 18 hot, 18 Bednar's aphthae, 130 Beef juice, 95, 106 tea, 106 Black measles, 637 Blood corpuscles, morphology, 418 diseases of, 418 erythrocytes, 418 determination, 421 examination, 421 in amoebic dysentery, 223 in anaemia, 424 in chlorosis, 425 in leukaemia, 431 in malaria, 694 in meningitis, cerebro-spinal, 690 in pernicious anaemia, 427 in pneumonia, 288 in rheumatism, 607, 612 in rickets, 580 in rubeola, 640 in typhoid fever, 708 leucocytes, 419 determination, 422 differential count, 422 pressure in childhood, 335 specific gravity, 418 determination, 422 Boils (v. furunculosis), 405 Bowels, regulation, 12 Brain, diseases of, 450 Brandy, use of, 109 Bright's disease (v. nephritis, chron- ic), 373 Broadbent's sign, 47 Bronchiectasis, 262, 265 Bronchitis, acute, 259 diagnosis, 262 pathology, 260 symptomatology, 261 INDEX. 759 Bronchitis, therapeutics, 263 treatment, 262 varieties, 260 capillary, 262 chronic, 264 pathology, 264 symptomatology, 265 therapeutics, 265 treatment, 265 Broncho-pneumonia, acute, 270 diagnosis, 278 etiology, 270 pathology, 272 prognosis, 277 symptomatology, 275 therapeutics, 279 treatment, 278 Broths, 106 Buhl's disease, 116 Calculi, biliary, 179 renal, 382 symptomatology, 382 therapeutics, 383 treatment, 383 vesical (v. cystitis), 384 Camphor, uses of, 71 Cancer of stomach, 176 Cane-sugar in modifying milk, 88, 90 Carpo-pedal spasm, 490 Case, methods of taking, 41 Catarrh, gastric, acute, 152 gastric, chronic, 158 gastro-intestinal, chronic, 223 intestinal, acute, 209 Cephalalgia (v. headache), 527 Cephalhematoma, 113 Cerebral palsy (v. palsy) , 510 Cerebro-spinal fever, epidemic, 684 fluid, analysis of, 462 meningitis, epidemic, 684 Chapin dipper, 91 Chapin's method of modifying cow's milk, 83, 91 Charcot-Leyden crystals, 191 Chicken broth, 106 Chicken-pox (v. varicella), 665 Childhood, periods of, 30 Chlorosis, 424 blood in, 425 etiology, 424 prognosis, 425 symptomatology, 424 therapeutics, 428 treatment, 427 Cholelithiasis, 179 Cholera infantum, 204 diagnosis, 207 etiology, 204 pathology, 205 symptomatology, 205 therapeutics, 218 treatment, 214 Chondrodystrophia foetalis, 572 Chorea, 492 cardiac, 498 diagnosis, 498 diet, 499 etiology, 492 in rheumatism, 612 laryngeal, 495 paralytic, 496 pathology, 494 post-hemiplegic, 495 prognosis, 498 symptomatology, 495 therapeutics, 499 treatment, 499 Chvostek's symptom, 490 Cirrhosis of liver, 180 Clinical examination, methods, 30 Clothing, 10 Club-foot, 520 Codliver oil, 109 Cold, therapeutics of, 17 Colic, 138 renal, 382 Colitis, follicular, 212 ileo-, acute, 209 membranous, 210, 213 diagnosis, 213 Colli-,' law, 617 Colostrum, So, 98 Condensed milk, 1 10 760 INDEX. Constipation, 231 symptomatology, 231 therapeutics, 233 treatment, 232 Constitutional diseases, 567 remedies, 75 Consumption (v. tuberculosis) , 297 galloping, 298 Contraction of stomach, 170 Convulsions (v. eclampsia), 473 epileptic (v. epilepsy), 478 Convulsive affections, 473 Costiveness, 231 Cowpox (v. vaccinia), 661 Cow's milk (v. milk, cow's), 83 Coxalgia, 506 Craniotabes, 46 Cremometer, 81 Cretinism, 448 sporadic, 449 Croup, membranous, 726, 733 spasmodic (v. laryngitis, acute ca- tarrhal), 256 Cyclic albuminuria (v. albuminu- ria), 365 vomiting, 164 Cystitis, 384 symptomatology, 385 therapeutics, 386 treatment, 386 varieties, 385 Dactilitis, 620 Deaf-mutism, 448 Deformities of heart, 337 Dementia, 444 Dentition, 124 therapeutics, 126 treatment, 126 Development, in infancy, 32 muscular, in infants, 36 Diabetes insipidus, 378 diagnosis, 378 etiology, 378 pathology, 378 prognosis, 378 symptomatology, 378 Diabetes, therapeutics, 379 treatment, 379 mellitus, 379 diagnosis, 380 diet, 380 pathology, 380 symptomatology, 380 therapeutics, 381 treatment, 380 Diacetic acid in gastric contents, 142, 165 Diacetonuria, 165 Diarrhoea, acute infectious, 201 etiology, 202 diet, 203 chronic, 223 diagnosis, 225 pathology, 224 prognosis, 225 symptomatology, 224 therapeutics, 226 treatment, 226 fermental, 201, 207 simple (v. indigestion, acute in- testinal), 196 therapeutics, 218 Diastase, 107 Diathesis, types of, 38 Diazo-reaction, 714 Diet (v. feeding), 77 at various periods, 96 in albuminuria, 366 in anaemia, 427 in cholera infantum, 216 in chorea, 499 in constipation, 232 in cystitis, 386 in diabetes mellitus, 380 in diarrhoea, acute, 216 chronic, 226 in epilepsy, 482 in gastralgia, 168 in gastritis, acute, 155 chronic, 161 in hepatic diseases, 181 in ileo-colitis, 216 INDEX. 761 Diet, in indigestion, gastric, 147 intestinal, 198 in lithaemia, 570 in marasmus, 630 in nephritis, acute, 372 chronic, 377 in renal calculi, 383 in rheumatism, 613 in rickets, 582 in scarlatina, 652 in scrofula, 592 in scurvy, 586 in tuberculosis, intestinal, 230 pulmonary, 312 in typhoid fever, 716 in vomiting, cyclic, 166 Digestion in infancy, 183 Digitalin, use of, 71 Dilatation of stomach, 170 Diphtheria, 725 antitoxin, 750 diagnosis, 738 diet, 739 etiology, 725 intubation in, 740 laryngeal, 733 treatment, 740 nasal, 732 treatment, 740 paralysis after, 749 pathology, 727 prognosis, 736 pseudo-, 725, 734 clinical course, 735 scarlatinal, 736 symptomatology, 628 therapeutics, 745 tracheotomy in, 740, 744 treatment, 739 Diphtheroid, 725, 734 Diplegia, 513 Diseases, acute infectious, 635 of blood, 418 brain, 450 ear, 530 heart, 332 intestines, 183 49 Diseases of kidneys, 364 liver, 177 meninges, 450 mouth, 124 nervous system, 438 new-born, 31, 112 nose, 530 peritonaeum, 248 respiratory tract, 254 skin, 393 stomach, 137 throat, 530 urinary organs, 364 Dosage of remedies, 74 Dysentery, 209 amoebic, 222 pathology, 209 symptomatology, 211 therapeutics, 222 treatment, 214 Dyspepsia (v. gastric indigestion, acute), 146 nervous (v. gastric indigestion, chronic), 149 Dystrophy, idiopathic muscular, 517 facio-scapulo-humeral, 518 infantile, 518 juvenile, 517 pathology, 517 peroneal, 518 therapeutics, 519 treatment, 518 Ear diseases, 530 Eclampsia, 473 diagnosis, 475 prognosis, 475 symptomatology, 474 therapeutics, 476 treatment, 47b Ectocardia, 338 Eczema, 394 definition, 394 diagnosis, 397 erythematosnm, 394 etiology, 395 intertrigo, 394 762 INDEX. 394 319 348 Eczema, papillosum, 394 pathology, 397 prognosis, 399 pustulosum, 394 squamosum, 395 symptomatology , therapeutics, 400 treatment, 399 vesiculosum, 394 Efneurage, 29 Eggnog, 109 Eggs, 95 Emphysema, 318 symptomatology therapeutics, 319 treatment, 319 Empyema (v. pleurisy Endocarditis, 346 foetal, 338 in rheumatism, 610 malignant, 350 symptomatology therapeutics, 351 treatment, 350 - a ulcerative, 350 Enemata, 27 Enteroclysis, 28 Enteroptosis, 170 Enuresis, 387 prognosis, 388 symptomatology therapeutics, 389 treatment, 388 Epilepsy, 478 diagnosis, 481 etiology, 478 hystero-, 504 Jacksonian, 474 prognosis, 481 symptomatology , therapeutics, 483 treatment, 482 Epiphysitis, 618 Erysipelas, new-born, Erythema, 403 caloricum, 404 efinition, 403 319 387 479 ii5 Erythema, intertrigo, 404 medicamentosum, 405 scarlatinoides, 404 simplex, 403 therapeutics, 405 toxic, 403 traumaticum, 404 treatment, 405 venenatum, 404 Exanthemata, 635 Exercise, 13 Faeces (v. stools) , 184 Family ataxia (v. ataxia), 519 Farinaceous food, 94 Fats as food, 109 Fatty degeneration, acute, 116 Feeding (v. diet), 77 adjuvant foods, 105 artificial foods, 105 forced (v. gavage) , 26 infant, 77 intervals, 98 quantity of food, 98 time, 11 variation in foods, 97 Fever, cerebro-spinal, 684 glandular (v. glandular fever) , 755 malarial (v. malaria) , 694 spotted, 684 typhoid (v. typhoid fever), 700 Flour, baked, 108 Fcetal endocarditis, 338 Fontanels, closure of, 36 Formulae for modifying cow's milk, 93 Friedreich's disease (v. ataxia), 519 Fruit juices, 109 Functional heart diseases (v. heart diseases) , 362 Furunculosis, 405 diagnosis, 406 symptomatology, 406 therapeutics, 407 treatment, 407 Gallstones, 179 INDEX. 763 Gastralgia, 167, 527 diagnosis, 167 etiology, 167 in rheumatism, 612 symptomatology, 167 therapeutics, 168 treatment, 168 Gastric contents, analysis of, 142 spasm, congenital, 173 ulcer, 175 Gastritis, acute, 151 afebrile, 153 catarrhal, 152 corrosive, 152 diagnosis, 155 etiology, 151 febrile, 153 follicular, 153 membranous, 153 pathology, 152 prognosis, 155 symptomatology, 153 therapeutics, 156 treatment, 155 chronic, 158 atrophic, 160 diagnosis, 161 etiology, 158 mucous, 160 pathology, 159 prognosis, 161 simple, 160 symptomatology, 159 therapeutics, 162 treatment, 161 Gastro-enteric intoxication, acute, 207 diagnosis, 208 prognosis, 208 therapeutics, 218 treatment, 214 Gastro-intestinal catarrh, chronic, 223 Gavage, 15, 17, 26 German measles (v. rubella) , 656 Glandular fever, 755 diagnosis, 756 Glandular fever, etiology, 755 prognosis, 756 symptomatology, 755 therapeutics, 756 treatment, 756 Globus hystericus, 504 Glottis, spasm of, 254 therapeutics, 255 Glycosuria, 380 Gonorrhoea (v. vulvovaginitis) , 390 Gonorrhoea, newborn, 121 Grand mal, 478 Grape juice, 95 Grippe (v. influenza), 678 Growth in infancy, 32 Haeniatoma of sterno-mastoid mus- cle, 113 Haematuria, 367 in scurvy, 585 Haemoglobin, determination, 421 Hemoglobinuria, 367 acute, in newborn, 117 Haemophilia, 433 pathology, 434 prognosis, 434 therapeutics, 435 treatment, 435 Haemoptysis, 306 Haemorrhage, gastro-intestinal, new born, 120 intracranial, newborn, 114 Haemorrhagic diathesis (v. haemo- philia), 433 Hammer-toe, 520 Headache, 527 diagnosis, 528 etiology, 528 symptomatology, 528 therapeutics, 529 treatment, 528 Head-nodding 1 \. spasmus nutans . 5oi Heart anomalies, congenital, 338 diagnosis, 341 symptomatology, 340 therapeutics, 342 treatment, 342 764 INDEX. Heart, defect of septum, 339 Hysteria, accidents, 504 congenital, 337 diagnosis, 508 deformities, 337 prognosis, 508 diseases of, 332 stigmata, 503 disease, chronic valvular, 354 symptomatology, 503 functional, 362 therapeutics, 509 murmurs, 336 treatment, 509 patent ductus arteriosus, 339 Hystero-epilepsy, 504 patent foramen ovale, 339 stenosis of pulmonary artery, 339 Icterus, catarrhal, 178 symptomatology, 362 neonatorum, 119 therapeutics, 363 physiological, 119 treatment, 363 Idiocy, 445 valvular defects, 340 by deprivation, 448 Heat, therapeutics of, 17 cretinoid, 449 Hemicrania, in rheumatism, 612 eclampsic, 446 Henoch's purpura, 436 epileptic, 447 Hepatitis, 182 genetous, 445 Hernia, incarcerated, 235 hydrocephalic, 446 strangulated, 235 inflammatory, 447 History, family, 41 microcephalic, 446 of case, taking of, 41 paralytic, 447 Hives (v. urticaria), 409 sclerotic, 447 Hodgkin's disease (v. leukaemia), syphilitic, 447 432 therapeutics, 450 Human milk (v. milk), 77 traumatic, 448 Hutchinson's teeth, 620 treatment, 449 Hydrocephaloid, 206 Ileo-colitis, acute (v. dysentery) therapeutics, 222 209 Hydrocephalus, 468 catarrhal, 211 acute (v. meningitis, tubercular), Imbecility, 445 453, 468 Impetigo contagiosa, 408 chronic, 468 definition, 408 diagnosis, 470 diagnosis, 409 external, 468 etiology, 409 ex vacuo, 468 prognosis, 409 internal, 468 symptomatology, 408 symptomatology, 469 therapeutics, 409 therapeutics, 472 treatment, 409 treatment, 471 simplex, 407 Hydrotherapy, in typhoid, 717 definition, 407 Hygiene, 9 diagnosis, 408 Hyperchlorhydria, 151 etiology, 408 Hyperostosis tibialis, 620 prognosis, 408 Hypertrophy, tonsils (v. tonsils, symptomatology, 407 hypertrophy), 543 treatment, 408 Hysteria, 502 Impurities in milk, 83 INDEX. 765 Inanition, acute, 628 Incubators, 14, 16 Indicanuria, 483 Indigestion, acute gastric, 146 etiology, 146 symptomatology, 147 therapeutics, 149 treatment, 147 acute intestinal, 196 diagnosis, 198 etiology, 196 symptomatology, 197 therapeutics, 199 treatment, 198 chronic gastric, 149 symptomatology, 150 infantile, 151 Infancy, development in, 32 growth in, 32 periods of, 30 Infantile convulsions (v. eclampsia) 473 paralysis (v. poliomyelitis), 515 Infantilism, 447 Infant feeding (v. feeding), 77 morbidity, 30 mortality, 31 Infants, delicate, 14 premature, 14 Infectious diseases, acute, 635 Influenza, 678 abdominal, 680 catarrhal, 680 cerebral, 680 diagnosis, 681 etiology, 679 neuralgic, 680 prognosis, 681 symptomatology, 679 therapeutics, 682 thoracic, 680 treatment, 682 Inhalation of steam, 2 1 Injection, rectal, 27 Insanity, 441 circular, 443 delusional, 443 Insanity, epileptic, 442 hysterical, 443 masturbation, 444 morbid fears, 444 moral, 442 periodic, 443 progressive systematized, 443 Inspection, general methods, 44 in diseases of stomach, 139 Interstitial nephritis (v. nephritis) , 376 Intertrigo, 404 Intestinal catarrh, acute (v. dysen- tery), 209 obstruction, 234 parasites, 241 tuberculosis, 227 Intestines, diseases of, 183 Intubation, 740 diphtheria, 740 nasal, 744 Intussusception, 233 Inunctions, 28 nutritive, 28 Irrigation of colon, 27 Ischaemia, 423 Itch (v. scabies), 416 Jaundice, catarrhal, 178 new-born (v. icterus 1, 119 Junket, 106 Kernig's sign, 49, 439, 688 Kidneys, acute degeneration, diseases of, 364 Knee-jerk, 48, 439 Koplik'^ sign, 636 Kyphosis, 57S Lactic acid in gastric contents, 144 test for, 144 Lactobutyrometer, 82 Lactometer , (Si Lactose in modified milk, 88, 90 La grippe (v. influenza), "7 s Laryngismus stridulus, 234 Laryngitis, acute catarrhal, 156 766 INDEX. Laryngitis, diagnosis, 257 etiology, 256 symptomatology, 256 therapeutics, 258 treatment, 258 Lavage, 21, 148 contra-indications, 26 in chronic gastritis, 162 method of performing, 24 Leptomeningitis (v. meningitis), 45o Leucocytosis with anaemia, 424 Leukaemia, 431 pseudo-, 432 symptomatology, 431 therapeutics, 433 treatment, 433 Lice (v. pediculosis), 415 Liebig's food, 107 Lithaemia. 567 etiology, 567 symptomatology, 568 therapeutics, 571 treatment, 570 Lithuria, 569 Liver, cirrhosis, 180 diseases of, 177 therapeutics, 181 treatment, 181 examination of, 177 yellow atrophy, 179 Lumbar puncture, 458 diagnostic value, 462 in meningitis epidemic, 692 operative technique, 460 Lymphatism, 122, 586 Macewen's sign, 53 Malaria, 694 blood in, 694 diagnosis, 698 etiology, 694 irregular, 697 masked, 697 pathology, 695 prognosis, 697 symptomatology, 695 Malaria, therapeutics, 698 treatment, 698 Malarial cachexia, 697 fever, 694 Malformations of stomach,' 169 Malnutrition, 624, 629 diagnosis, 629 Malpositions of stomach, 169 Malt diastase, 107 Malted milk, Horlick's, no Malt extract, 108 Maltine, 108 Mania, 442 Marasmus, 624 analysis of gastric contents in, 626 diagnosis, 629 diet, 630 etiology, 626 prognosis, 629 symptomatology, 627 therapeutics, 633 treatment, 629 Massage, 28 Mastitis in newborn, 119 Masturbation insanity, 444 Measles (v. rubeola) , 635 German (v. rubeola) , 656 Melancholia, 443 Melena, 120 Mellin's food, no Membranous croup, 726, 733 Meninges, diseases of, 450 Meningitis, 450 basilar (v. meningitis, tubercu- lous) , 453 cerebro-spinal, epidemic, 450, 684 abortive, 687 complications, 690 diagnosis, 690 etiology, 684 fulminating, 686 pathology, 685 prognosis, 690 protracted, 687 sequelae, 690 symptomatology, 686 temperature in, 689 INDEX. 767 Meningitis, therapeutics, 692 treatment, 691 varieties, 686 leptomeningitis, acute, 450 diagnosis, 453 pathology, 451 prognosis, 452 symptomatology, 451 therapeutics, 465 treatment, 464 posterior basic, 454, 691 pseudo-, 507 tuberculous, 453 diagnosis, 458 pathology, 454 prognosis, 457 symptomatology, 455 therapeutics, 467 treatment, 464 Methods of clinical examination, 30 of prescribing, 72 Microscopical examination of human milk, 82 of stools, 190 Migraine, 528 Milk and cream mixtures, 92 asses' milk compared with human, 79 cows', analysis of, 83 bacteria in, 83 compared with human, 78 condensed, no digestion of, 183 "Ideal" testers, 84 impurities in, 83 malted, no modification of, 86 barley water in, 94, 105 cane-sugar in, 88, 90 diluents in, 90, 94, 105 formulae, 93 lactose in, 88, 90 milk and cream mixtures, 92 top milk method, 90 peptonized, 107 preservatives in, 83 top milk, 83, 90 Milk, human, analysis of, 80 bacteria in, 100 compared with cows', 78 composition, 77 microscopical examination, 82 strippings, 84 variations in, 84 infection, acute (v. cholora infan- tum), 204 sugar in milk modification, 88, 90 Mitral regurgitation, 356 stenosis, 357 Modification of milk, 86 Morbidity, infant, 30 Morbilli (v. rubeola), 635 Morbus maculosus Werlhofii, 436 Mortality, infant, 31 Motor affections, 492 Mouth, care of, 10 diseases of, 124 putrid sore, 131 Mucous disease (v. diarrhoea), 223 Multiple neuritis (v. neuritis), 524 sclerosis (v. sclerosis), 523 Mumps (v. parotitis), 675 Muscular development in infant>, 36 dystrophy (v. dystrophy), 517 Mutton broth, 106 Mycotic disease (v. thrush), 31, 132 Myocarditis, 352 diagnosis, 353 prognosis, 354 symptomatology, 353 therapeutics, 354 treatment, 354 Nephritis, acute, 368 diet, 372 etiology, 369 pathology, 369 prognosis 371 symptomatology , 370 therapeutics, 372 treatment, 371 varieties, 368 chronic, 373 interstitial, 376 768 INDEX. Nephritis, pathology, 376 prognosis, 376 therapeutics, 377 treatment, 377 parenchymatous, 374 pathology, 374 prognosis, 375 symptomatology, 374 therapeutics, 377 treatment, 377 Nervous system, diseases of, 438 Neuralgia, 526 diagnosis, 527 therapeutics, 527 treatment, 527 Neuritis, multiple, 524 diagnosis, 525 symptomatology, 525 therapeutics, 526 treatment, 526 Newborn, apoplexy in, 114 asphyxia, 112 sudden death from, 123 atelectasis, 123 care of, 9 diseases of, 31, 112 erysipelas, 115 therapeutics, 115 treatment, 115 fatty degeneration, acute, 116 gastro-intestinal haemorrhage, 120 therapeutics, 121 gonorrhoea, 121 haemoglobin uria, 117 icterus, 119 intracranial haemorrhage, 114 mastitis, 119 therapeutics, 119 treatment, 119 oedema, 120 omphalitis, 115 ophthalmia (v. ophthalmia), 117 peritonitis, 115 sepsis in, 114 pathology, 114 sudden death, 122 tetanus, 115 Newborn, umbilical arteritis, 115 phlebitis, 115 Night terrors, 444 Noma (v. stomatitis), 134 Nose, diseases of, 530 syringing, 19 Nurse, wet, 86 Nursing, 9 Nystagmus, 501 Oatmeal water, 106 Objective symptoms, 72 Obstruction, intestinal, acute, 234 diagnosis, 236 OSdema, newborn, 120 without kidney lesion, 367 Oligochromaemia, 432 Oligocythaemia, 432 Omphalitis, newborn, 115 Ophthalmia neonatorum. 117 prognosis, 118 treatment, 118 Orange juice, 95 Organic heart disease, 354 Orthostatic albuminuria, 365 Osteochondritis, 620 Osteogenesis imperfecta, 572 Otitis, 530 influenzal, 532 in scarlatina, 647 media, acute catarrhal, 532 diagnosis, 535 prognosis, 534 purulent, 532 symptomatology, 533 therapeutics, 535, 537 treatment, 535 tubercular, 532 Oxaluria, 385 Ozaena, 554 Pack, cold, 19 hot, 19 mustard, 19 Palpation, general methods, 50 in diseases of stomach, 141 Palsy, cerebral, 510 INDEX. 769 Palsy, prognosis, 513 symptomatology, 512 Paracentesis, 327 Paralysis, post-diphtheritic, 749 pseudohypertrophic, 518 spinal, 515 Paralytic affections, 510 Paranoia, 443 Paraplegia, hereditary spastic, 521 pathology, 521 symptomatology, 521 Parasites in stools, 192 Parasites, intestinal, 241 morphology, 243 therapeutics, 245 treatment, 244 varieties, 241 Parasitic diseases, animal, 415 vegetable, 412 Parenchymatous nephritis 1 v. ne- phritis), 374 Parotitis, 675 diagnosis, 677 epidemic, 675 prognosis, 677 secondary, 676 symptomatology, 676 therapeutics, 678 treatment, 678 Pasteurization, 102 Pasteurizer, Freeman's, 102 Pectus carinatum, 47, 578 Pediculosis capitis, 415 definition, 415 diagnosis, 415 symptomatology, 415 treatment, 415 Peliosis rheumatica 1 v. purpura), 436 Pemphigus, 409 Pepsin, test for, 145 Peptogenic milk powder, 107 Peptonized food in prematurity, 15 milk, 107 Percentage of food constituents, 97 Percussion, abdomen, 58 chest, 54 Percussion, factors influencing general methods, 53 head, 53 in stomach diseases, 140 Pericarditis, 342 in rheumatism, 611 pathology, 342 prognosis, 345 symptomatology, 343 therapeutics, 345 treatment, 345 Periodic vomiting, 164 Periods, of childhood, 30 of infancy, 30 Peritonaeum, diseases of, 248 Peritonitis, acute, 248 pathology, 248 symptomatology, 249 therapeutics, 249 treatment, 249 chronic (v. tuberculous periton- itis), 251 new-born, 115 tuberculous, 251 diagnosis, 252 prognosis, 252 symptomatology , 251 therapeutics, 253 treatment, 253 Peritonsillar abscess, 541 Pertussis, 667 complications, 671 diagnosis, 672 etiology, 667 pathology, 668 prognosis, 671 sequelae, 671 symptomatology, 6hS therapeutics, 673 treatment, 672 Petit mal, 478 Petrissage, 29 Phimosis, 387 Phlebitis, umbilical, 1 15 Phthisic, chronic fibroid, 306 pneumonic, 298 Physical diagnosis, 44 770 INDEX. Pial haemorrhage, 112 Pityriasis linguae, 129 Pleurisy, 319 diagnosis, 324 pathology, 320 physical signs, 322 prognosis, 325 symptomatology, 321 therapeutics, 329 treatment, 326 operative, 328 Pleuro-pneumonia (v. pneumonia) 295 Plica polonica, 415 Pneumonia, abortive, 290 broncho-, acute, 270 catarrhal, 270 central, 289 cerebral, 288 croupous (v. lobar) , 283 influenzal, 290 lobar, 283 complications, 290 diagnosis, 294 etiology, 283 pathology, 284 physical signs, 291 prognosis, 293 symptomatology, 285 therapeutics, 296 treatment, 296 varieties, 288 lobular, 270 pleuro-, 295 therapeutics, 296 treatment, 296 typhoid, 290 wandering, 289 Polioencephalitis, acute 511 Poliomyelitis, acute, anterior, 515 diagnosis, 516 pathology, 515 prognosis, 516 symptomatology, 515 Polyuria, 376, 378, 380, 507 Prematurity, 14 diet in, 15 Prescribing, methods of, 72 Preservatives in cow's milk, 83 Prof eta's law, 618 Pseudo-diphtheria, 725, 734 Pseudo-hype rtrophic paralysis, 518 Pseudo-leukaemia, 423, 432 Pseudo-meningitis, 507 Ptyalin, test for, 145 Pulmonary tuberculosis (v. tubercu- losis), 297 Pulse in childhood, 63, 335 Pump, stomach, 22 Purpura, 435 fulminans, 437 haemorrhagica, 436 Henoch's, 436 rheumatica, 436 simplex, 435 therapeutics, 437 treatment, 437 Pyuria, 385 Quantity of food in infancy, 98 Quinsy (v. tonsillitis, parenchyma- tous) , 541 Rachitic rosary, 577 Rachitis, 572 acute, 581 diagnosis, 581 etiology, 572 fcetal, 572 Pasteurized milk in, 104 pathology, 574 prognosis, 581 symptomatology, 576 teeth in, 128 therapeutics, 582 treatment, 582 Rales, 63 Record keeping, 41 Reflexes, 48 Regurgitation, aortic, 358 mitral, 356 Remedies, constitutional, 73 Renal calculi (v. calculi), 382 Renal colic, 382 INDEX. 771 Respiration in childhood, 63 puerile type, 62 Respiratory tract, diseases of, 254 Retropharyngeal abscess (v. abscess), 546 Rheumatic fever, 606 Rheumatism, 606 anaemia in, 612 articular, 606, 610 chorea in, 612 chronic, 612 diet, 613 endocarditis in, 610 etiology, 607 gastralgia in, 612 hemicrania in, 612 muscular, 611 pericarditis in, 611 symptomatology, 609 therapeutics, 613 tonsillitis in, 537, 611 treatment, 613 Rhinitis, acute, 548 symptomatology, 549 therapeutics, 551 treatment, 550 atrophic, 554 etiology, 554 prognosis, 556 symptomatology, 555 therapeutics, 558 treatment, 557 chronic, simple, 552 symptomatology, 553 therapeutics, 558 treatment, 556 hypertrophic, 553 etiology, 554 prognosis, 556 symptomatology, 555 therapeutics, 558 treatment, 556 pseudo-membranous, 550 therapeutics, 552 treatment, 551 purulent (v. chronic), 552 Rice water, 105 paste, 105 Rickets (v. rachitis) , 572 Ringworm (v. tinea circinata) , 413 Rotheln (v. rubella), 656 Rubella, 656 diagnosis, 657 etiology, 656 morbilliforme, 656 prognosis, 657 scarlatiniforme, 656 symptomatology, 656 therapeutics, 657 treatment, 657 varieties, 656 Rubeola, 635 blood in, 640 complications, 640 desquamation, 639 etiology, 635 symptomatology, 636 temperature in, 639 therapeutics, 641 treatment, 640 Rupture (v. hernia) , 235 Sabre-blade deformity, 620 Saint Vitus' dance (v. chorea), 492 Scabies, 416 definition, 416 diagnosis, 416 etiology, 416 pathology, 416 prognosis, 416 therapeutics, 417 treatment, 416 Scarlatina, 643 complications, 055 desquamation, (>44.s 772 INDEX. Scarlatina, temperature in, 646 therapeutics, 652 treatment, 650 variagata, 646 Scarlet fever (v. scarlatina), 643 Sclerosis, disseminated, 523 multiple, 523 diagnosis, 524 symptomatology, 523 therapeutics, 524 treatment, 524 Scorbutus (v. scurvy), 584 Scrofula, 587 diagnosis, 590 erethetic, 589 etiology, 588 phlegmatic, 589 prognosis, 590 symptomatology, 589 therapeutics, 592 treatment, 592 Scurvy, 584 diagnosis, 585 etiology, 584 infantile, 584 Pasteurized milk in, 104 symptomatology, 585 therapeutics, 586 treatment, 586 Seat-worms, 243 Secondary anaemia, 423 Sepsis in new-born, 114 Serum therapy, 750 Shiga's bacillus, 195, 202 Simple anaemia, 423 Skin, diseases of, 393 Sleep, 11 Small-pox (v. variola) , 658 Snuffles, 619 Sore mouth, putrid, 131 Spasm, congenital gastric, 173 glottis, 254 prognosis, 254 symptomatology, 254 treatment, 255 Spasmus nutans, 501 Spasmus nutans, prognosis, 502 treatment, 502 Spastic paraplegia, 521 Splenic anaemia (v. leukaemia), 431 Sponging, cold, 13 Spotted fever, 450, 684 Spraying, throat, 20 Status choreicus, 498 lymphaticus, 122, 586 Stenosis, aortic, 358 mitral, 357 pyloric, 170 stomach, 169 Sterilization of food, 101 Sterilizer, Arnold steam, 102 Stethoscope, binaural, 60 monaural, 60 Stiller's phenomenon, 47 Still's disease, 612 Stimulants, use of, 70, 109 Stomach, atresia, 169 cancer, 176 contraction of, 170 dilatation, 170 diagnosis, 173 etiology, 171 symptomatology, 173 treatment, 174 diseases of, 137 absorption of food in, 145 auscultation in, 140 etiology, 137 inspection in, 139 mensuration in, 140 motility of, 145 palpation in, 141 percussion in, 140 vomiting in, 141 malformations, 169 malpositions, 169 stenosis, 169 pyloric, 170 tube, 21 ulcer, 175 follicular, 175 round perforating, 175 symptomatology, 176 INDEX. 773 Stomach, ulcer, therapeutics, 176 treatment, 176 tuberculous, 175 washing out (v. lavage :, 21 Stomatitis, aphthous, 129 etiology, 129 pathology, 130 symptomatology, 130 therapeutics. 135 treatment, 134 catarrhal, 128 etiology, 128 symptomatology, 128 therapeutics, 135 treatment, 134 gangrenous, 134 etiology, 134 pathology, 134 prognosis, 134 symptomatology, 134 therapeutics, 135 treatment, 134 parasitic, 132 diagnosis, 133 etiology, 132 pathology, 132 prognosis, 133 symptomatology, 133 therapeutics, 135 treatment, 134 ulcerative, 131 etiology, 131 pathology, 131 symptomatology, 132 therapeutics, 135 treatment, 134 Stone (v. calculi), 382 B Stools, bloody, 187, 192 analysis of, 188 color, 185, 188 decrease in number, 187 frequent, 186 in cholera infantum, 20b in constipation, 231 in fermental diarrhoea, 208 in dysentery, 211 in ga-tro-intestinal catarrh, 224 Stools, in indigestion, acute, 197 in intestinal tuberculosis, 229 in marasmus, 628 large, 185 liquid, 186 microscopical examination, 190 mucous, 187 normal infantile, 184 parasites in, 192 pus in, 192 Stridor, congenital, 254 Strippings, 84 Strychnia, use of, 71 Subjective symptoms, 72 Sudden death in infants, 122 Symptomatic nervous affections, 52b Symptoms, objective. 72 subjective, 72 Syphilis, 617 acquired, 617 congenital, 617 germinal, 617 hereditary, 617 diagnosis, 621 pathology, 618 prognosis, 621 symptomatology, 619 therapeutics, 622 treatment, 622 Syringing, nasal, 19 Syringomyelia, 521 diagnosis, 522 prognosis, 522 symptomatology, 522 Tabes mesenterica. 228 Tache" cerebrale, 45, 53, 45b, 507 Talipes equinus, 516 Tape-wornis, 242 Teeth, abnormalities, 127 care of, 10 Hutchinson, 127 in rachitis, 12S Temperament, 38 Temperature in rubeola, 639 in scarlatina, b46 normal, 66 774 INDEX. Test-meal, 143 Tetanus, 115 antitoxin, 116 therapeutics, 116 treatment, 116 Tetany, 489 diagnosis, 491 etiology, 489 prognosis, 491 symptomatology, 490 therapeutics, 491 treatment, 491 Tetter (v. eczema) , 394 Therapeutics, general methods, 69 Throat, diseases of, 530 spraying, 20 Thrush, 31, 132 Thymic death, 122 Tinea, 411 circinata, 413 diagnosis, 414 etiology, 414 prognosis, 414 symptomatology, 414 therapeutics, 414 treatment, 414 tonsurans, 412 definition, 412 diagnosis, 412 etiology, 412 pathology, 412 prognosis, 412 symptomatology, 412 therapeutics, 413 treatment, 413 Tonsillitis, acute, 537 cryptic (v. folliculous) , 538 folliculous, acute, 538 diagnosis, 539 symptomatology, 539 therapeutics, 540 treatment, 540 parenchymatous, acute, 541 prognosis, 542 symptomatology, 542 therapeutics, 543 treatment, 542 Tonsillitis, rheumatic, 537, 611 superficial, acute, 538 symptomatology, 538 ulcero-membranous, 541 therapeutics, 541 treatment, 541 Tonsillotomy, operative technique, 545 Tonsils, hypertrophy, 543 etiology, 544 symptomatology, 544 therapeutics, 545 tonsillotomy in, 545 treatment, 544 Top milk, 83, 90 Torticollis, 611 Tracheotomy, in diphtheria, 740, 744 Trousseau's symptom, 490 Tuberculin, 303 Tuberculosis, 595 chronic, 602 congenital, 597 diagnosis, 604 diet in, 605 etiology, 595 intestinal, 227 pathology, 228 prognosis, 229 symptomatology, 229 therapeutics, 230 treatment, 230 latent, 597 miliary, 297 acute, 601 pathology, 598 protracted, 602 pulmonary, caseous, 298 . diagnosis, 301 pathology, 298 prognosis, 300 symptomatology, 299 therapeutics, 302 treatment, 303 chronic, 303 diagnosis, 309 diet, 312 prognosis, 308 INDEX. 775 Tuberculosis, symptomatology, 305 therapeutics, 312 treatment, 310 fibro-caseous, 303 symptomatology, 600 therapeutics, 604 treatment, 604 Tuberculous adenitis (v. adenitis), 587, 59i diathesis, 595 meningitis (v. meningitis), 453 peritonitis (v. peritonitis), 251 Typhoid fever, 700 abortive, 709 blood in, 708 complications, 709, 712 diagnosis, 712 diet, 716 eruption, 707 etiology, 700 hydrotherapy, 717 lesions, 700 pathology, 703 pneumonia, 290 prognosis, 711 pulse, 708 relapses, 709 septicaemic, 704 symptomatology, 704 temperature, 704, 706, 711 therapeutics, 720 treatment, 716 urine in, 708 Uffelman's test, 144 Ulcer of stomach, 175 Uraemia, 375 Uric acid diathesis ( v. lithasmia) , 567 Urinary tract, diseases of, 364 Urine, blood in, 367 in cholera infantum, 206 in cyclic vomiting, 165 in cystitis, 385 in diabetes insipidus, 378 mellitus, 579 in diagnosis, 66 in epilepsy, 483 Urine, in hysteria, 507 in kidney disease, 364 in lithaemia, 569 in nephritis, acute, 370 chronic interstitial, 376 parenchymatous, 374 in scurvy, 585 in tuberculosis, pulmonary, 308 in typhoid fever, 708 in yellow atrophy of liver, 179 Urticaria, 409 diagnosis, 410 etiology , 410 papulosa, 410 pigmentosa, 410 prognosis, 411 symptomatology, 410 therapeutics, 411 treatment, 411 Vaccination, 662 operative technique, 662 Vaccine lymph, 663 Vaccinia, 661 prognosis, 664 symptomatology, 663 therapeutics, 665 treatment, 665 Vaginitis (v. vulvovaginitis) , 390 Valvular heart disease, chronic, 354 prognosis, 356 stages, 355 symptomatology, 354 therapeutics, 360 treatment, 359 Varicella, 665 diagnosis, 666 etiology, 665 gangrenosa, 666 symptomatology, 665 therapeutics, '167 treatment, 667 Variola, 658 diagnosis, 6bo etiology . pathology, '>.s< s prognosis, 660 776 INDEX. Variola, symptomatology, 658 therapeutics, 661 treatment, 660 Varioloid, 660. Ventilation, 12 Vernix caseosa, 9 Vesical calculi (v. cystitis), 384 Volvulus, 235 Vomiting, cyclic, 142, 164 prognosis, 166 symptomatology, 165 therapeutics, 166 treatment, 166 in stomach diseases, 141 periodic, 164 Vulvo-vaginitis, 390 .non-specific, 390 specific, 391 therapeutics, 392 treatment, 392 Weaning, 95 Weight chart, 36 curve, 36 Wet nurse, 86 Whooping cough (v. pertussis), 667 Widal's test, 713 Winkel's disease (v. hemoglobi- nuria), 117 Worms (v. parasites), 241 FES 10 1906 >• mt W, .^J* *S *»»*V v ' >y 9 ,C\tV *.- r"