HH^HMHW LIBRARY OF CONGRESS, \?<^ Chap.,./r..:. Copyright No. T* ShellJitl. UNITED STATES OF AMERICA. THERAPEUTICS OF INFANCY AND CHILDHOOD a: JACOBI, M.D. CLINICAL PROFESSOR OF THK DISEASES OP CHILDREN IN THK COLLEGE OF PHYSICIANS AM' SUHGBONS (COLUMBIA UNI VEKSITY), NEW YORK; LATE PRESIDENT OF THE ASSOCIA- TION OF AMERICAN PHYSICIANS; OF THE NEW YORK ACADEMY OF MEDICINE. OF THE MEDICAL SOCIETIES OF THE COUNTY AND OF THE STAT1 01 NEW YORK, ETC. J FOREIGN MEMBER OP THE MEDICAL SOCIETY OF wurzbukg; OF THE OBSTETRICAL SOCIETY OF BERLIN, OF THE ASSOCIATION FOR INTERNAL MEDICINE OF BERLIN; OF THE ROYAL MEDICAL SOCIETY OF BUDA-PESTH, ETC. SECOND EDITION PHILADELPHIA J. B. LIPPINCOTT COMPANY 1808 TWO COPIES HECE1VED #0 2935 Copyright, 1895, by J. B. Lippincott Company. Copyright, 1898, by J, B. Ltppincott Company. THIS BOOK is INSCRIBED TO THE CHIEF OF MY CLINIC, DR. FRANCIS HUBER, IN DUE APPRECIATION OF THE VALUABLE AND UNREMITTING SERVICES RENDERED BY HIM THESE SEVENTEEN YEARS TO ME AND TO THE COLLEGE OF PHYSICIANS AND SURGEONS OF NEW YORK, AND TO OUR STUDENTS. "Die Frucht der Heilung wachst am Baume der Erkenntniss. Ohne Diagnostik keine verniinftige Therapie. Erst untersuchen, dann urtheilen, dann helfen." — C. Gerhardt. PREFACE TO FIRST EDITION Much of what is contained in this work may be claimed as common property. Much of it I have taught before. Indeed, very few books can ever be written that will be entirely new. Paediatrics is not new to-day; nor was it so when, in 1860, I established the first systematic course, in our country, of clini- cal instruction in the diseases of children. Having since that time appeared before the medical public with essays and mono- graphs only, I was repeatedly reminded by friends of my ob- ligation to submit to the profession which lias afforded me so many facilities and advantages a compact picture of the thera- peutics of infancy and childhood as I have it in my mind. A large part of this work is devoted to diet and hygiene, a .good deal also to the consideration of the action of medicines. For, indeed, I believe in medicines. Advancing years and ex- perience during a period of increasing exactness in medical methods have rather strengthened my belief than otherwise. What the knife is to the surgeon, drugs are to the physician. The knife does not make the surgeon, nor do medicines make the physician; both, however, are indispensable. To employ them with benefit takes skill and experience, both individual and collective, as also judgment and honesty. Indications for the administration of medicines are fur- nished by etiology and symptomatology. Both of these oc- cupy a prominent place in this book. "Without a diagnosis of the morbid process and of its evolution, and without the ap- preciation of its influence on the patient, no rational therapy can be thought of. Consequently I have taken particular pains to offer clear, though brief, statements of differential diag- noses. VI PREFACE. I have tried to write a book for those who are sufficiently prepared by previous studies to build their therapeutical meas- ures on the foundation of an exact recognition of the condi- tions they have to deal with. It is intended for those to whom neither the principles of diagnosis nor the facts of materia medica are mysteries. Therefore, I have abstained from orna- menting my pages with numerous recipes. While aiming at accuracy in dosing, I have trusted, as regards the actual writing of prescriptions, to the knowledge and intelligence of the reader. On account of our present period of transition to the metric system, I beg to be pardoned for alternating the old methods with the new. In view of what I have included within the frame of this volume, it might almost claim the name of text-book. I prefer, however, to call it therapeutics only, intending to emphasize the fundamental truth that everything in medical science, in order to be both scientific and humanitarian, should be con- ducive to the prevention or to the cure of disease. The preparation of this book has extended over a long period. The first essays embodied in it were published in the Archives of Pediatrics of 1888. As a consequence the reader may discover occasional incongruities, which, however, he will find to be more those of style than of matter. A. Jacobi. 110 West Thirty-Fourth Street, New York, October, 1895. PREFACE TO SECOND EDITION The revision of this book was begun immediately after its publication. The criticisms of reviewers and of correspondents have been carefully considered and taken advantage of. The final composition of the work as I now offer it represents the labor of a few months. In this way the drawbacks, resulting from the fact that the book which was commenced in 1888 was not published until 1896, were avoided. Some of the chapters are entirely rewritten; a few new ones are added; there is hardly one that has not been somewhat enlarged or otherwise changed. Indeed, every page has been scrutinized. In order to adapt the book more to the wants of the practitioner I have, while still adhering to the general views expressed in my former preface, been more explicit in the discussion of doses of drugs, and have added to the text a num- ber of prescriptions. Altogether I have tried to avoid ver- bosity, to condense my teaching in as few words as possible, and thus, while conveying knowledge to the beginner in a most concise shape, to offer the well-informed medical man a reper- tory of the science and art of modern paediatrics, with the addition of my own views and experience. The remark made by critics, that the book is a personal one, I wish to deserve. A. Jacobi. December 16, 1897. CONTENTS. I. Feeding of Sick Children 9 Dietetics, no universal rules, 9 ; inanition, 10 ; oral secretion, oral glands, pancreas, digestion of starch, 11 ; stomach digestion, 12; in abnormal conditions, 13; water in food, 14; its effects, 15; sugar, 16, 31 ; chloride of sodium, 17 ; fat, 18; fa?ces, substitutes for breast-milk, 21 ; cereals, 22, 29 ; boiling of milk, 23 ; intesti- nal infection, 24; infected breast-milk, 24; sterilization, 25; its drawbacks, 26 ; casein of different milks, 27 ; dilution of food, 30 ; milk modifications, 32 ; meat preparations, 40 ; peptones, 41 ; egg, 42 ; artificial foods, 43 ; alcohol, 44 ; dyspepsia, 45 ; vomit- ing, 46 ; gastritis, 47 ; chronic gastric catarrh, 48 ; ulceration of stomach, 48 ; enteritis, 50 ; constipation, 51 ; rhachitis, 52 ; fever, 54 ; typhoid fever, 55 ; hereditary syphilis, cerebral diseases, respiratory diseases, 56 ; acute renal diseases, acute rheumatism, rectal alimentation, 57 ; forcible feeding, 59. n. General Therapeutics 60 Diagnosis, expectant treatment, 60; preventive treatment, hy- giene, 62 ; bathing, hydrotherapy, 63 ; administration of medi- cines, 66 ; effects of medicines, 67 ; doses, 68 ; continuous medica- tion, 69 ; mode and locality of administration, 69 ; organotherapy, 70; rectal administration, 71; suppositories, 74 ; subcutaneous injections, 74; serumtherapy, 77; anaesthesia by infiltration, in- halation, 78; gargles, skin, 84; sinapisms, vesicatories, 84; ice, 86 ; fomentations, 86 ; depletion, 87. Ill Treatment of the Newly-Born 88 1. Asphyxia 88 2. Postnatal Asphyxia and Atelectasis 94 3. Kephalhaematoma 97 4. Hematoma of the Sterno-Cleido-Mastoid Muscle 98 5. Sclerema 99 1 ix X CONTENTS. PAGE 6. Bathing 100 7. Mamma, Mastitis, Perimastitis, Angioma 103 8. Treatment of the Cord 106 9. Omphalitis 109 10. Umbilical Gangrene 109 11. Arteritis and Phlebitis 109 12. Puerperal Sepsis, Acute Patty Degeneration, Epidemic Hemoglobinuria Ill 13. Umbilical Hemorrhage 112 14. Icterus 113 15. Melaena Neonatorum 114 16. Trismus and Tetanus 115 17. Blennorrhea 117 13. Umbilical Fungus (Granuloma), Adenoma 118 19. Hernia 119 20. Congenital Constipation 121 IV. Diseases of the Blood and Constitution 123 1. Anaemia 123 Pood, 125 ; insufficient innervation, iron, 128 ; oxygen, arsenic, 128 ; spermin, 131 ; pernicious anaemia, 132 ; leu- cocythaemia, 133 ; pseudoleukaemia, splenic anaemia, 134. 2. Ehachitis 134 Digestive disorders, 136 ; craniotabes, 140 ; laryngismus stridulus, 143 ; respiratory organs, 144 ; constipation, 146. 3. Scrofulosis 147 Preventive and curative treatment, 147 ; lymph-bodies, 151. 4. Lymphatism 153 5. Diseases of the Ductless Glands 155 Thyroid gland, goitre, 155; cretinism, 156; exophthal- mic goitre, 158 ; thymus, 160 ; akromegaly, Addison's disease, 161. 6. Hemorrhagic Diathesis 163 "Werlhof's disease, scurvy, peliosis rheumatica, haemo- philia, 163 ; infantile scurvy, 165. 7. Diabetes 166 Diabetes mellitus, 166 ; insipidus, 168. V. Infectious Diseases 169 1. Tuberculosis 169 Acute miliary tuberculosis, 170; tubercular phthisis, CONTENTS. XI PAGE 170; causes, 172; inhalation of bacilli, 173; arsenic, 179; digitalis, 180; creosote, guaiacol, 182; ichthyol, 183; tuberculin, 184; operative procedures, larynx, 185; tongue and pharynx, 186; fistula in ano, 187; hemor- rhages, 188; night-sweats, 189. 2. Syphilis 189 Diet, 189 ; prevention, 191 ; treatment, 192. 3. Intermittent Fever 197 4. Typhoid Fever 200 Preventive treatment, abortion, 201 ; general treatment, 202 ; feeding, bronchitis, high temperatures, 203 ; tym- panites and meteorismus, 205 ; diarrhoea, 206 ; constipa- tion, perforations, hemorrhages, 207 ; heart-failure, 208 ; brain symptoms, 209; convalescence, consecutive dis- eases, 212; typho-malaria, 213. 5. Typhus Relapsing Fever, "Weil's Disease 213 6. Epidemic Cerebro-Spinal Meningitis 213 7. Glandular Fever 215 8. Catarrhal Fever 217 9. Asiatic Cholera 217 10. Dysentery 219 11. Scarlatina 226 Prevention, 227 ; rules of the New York Health Depart- ment, 230; methods of disinfection, 232; disinfection and disinfectants, 234 ; medicinal treatment, 235 ; rheu- matism, the heart, joints, 238 ; respiratory organs, hemor- rhages, pemphigus, 239 ; complications, 240. 12. Measles 241 Hemorrhagic measles, respiratory organs, 243 ; kidneys, brain, 244. 13. Rotheln (Rubella) 245 14. Mumps 245 15. Variola, Variolois 246 16. Varicella (Chicken-Pox) 247 17. Vaccinia 247 18. Erysipelas . 2-19 19. Diphtheria 252 Prevention, 254 ; relation to mucous membranes, 259 ; potassic chlorate, 260 ; heart-failure, 261 ; local treatment, 264 ; nose, 267 ; treatment, 269 ; adenitis, 271 ; internal treatment, 272 ; nephritis, 276 ; paralysis, antitoxin, 277. 20. Rheumatism 285 Xll CONTENTS. PAGE Acute articular rheumatism, 288 ; endocarditis, 292 ; gon- orrhoeal rheumatism, 294; rheumatismus nodosus, peli- osis rheumatica, 295; erythema, 296; chronic articular rheumatism, 297 ; muscular rheumatism, 298. 21. Influenza 299 22. Pertussis 300 VI. Diseases of the Nervous System 311 1. General Indications 311 Polyneuritis, hemicrania, muscular atrophy, progressive juvenile muscular dystrophy, pseudohypertrophy, con- genital myotony, 315. 2. Operations 316 Microcephalus, idiocy, 316 ; brain tumors, 317. 3. Inflammatory and Exudative Processes, Arrests of Develop- ment 318 Cerebral meningitis, 318 ; hyperaemia, 319 ; thromboses, embolism, 320 ; tubercular meningitis, 321 ; lumbar puncture, 223 ; general paralysis, chronic hydrocephalus, 324 ; disseminated sclerosis, infantile spastic hemiplegia, bulbar paralysis, meningocele, encephalocele, meningo- cele spuria, 328. 4. Psychical Diseases 329 Dementia, mania, melancholia, moral insanity, monoma- nia, epileptic and circular dementia, paresis, delirium tre- mens, 329 ; idiocy, cretinism, 330 ; Pavor nocturnus, 333. 5. Spinal Inflammations, Genuine and Infectious, and Arrests of Development 333 Pachymeningitis, leptomeningitis, transverse myelitis, sclerosis, paramyoclonus, tabes, Landry's paralysis, polio- myelitis, 337 ; club-foot, 339 ; hydrorrhachis, 334, 340 ; tetanus, 341. 6. Neuroses of Central or Local Origin 342 Eclampsia, 342 ; chorea minor, 343 ; tetany, 345 ; cata-* lepsy, 346 ; chorea magna, 347 ; athetosis, 348 ; epilepsy, 348 ; salaam spasm, 354 ; stammering, 355. VII. Diseases of the Digestive Organs 356 A. The Mouth 356 1. Hare-Lip and Fissure of the Palate 356 2. Tumors in the Oral Cavity 356 3. Kanula 357 CONTENTS. Xlll PAGE 4. Milia, Epithelial Pearls 357 5. Stomatitis 358 6. Bednar's " Aphthae" 359 7. Thrush 360 8. Infectious Stomatitis 361 9. Noma 361 10. Sublingual Adenitis 361 11. Parotitis 362 12. Difficult Dentition 362 13. Dental Ulceration, Riga's Disease 363 B. The Tongue 363 1. Congenital Anomalies 363 2. Glossitis 364 C. The Throat 365 1. Pharyngitis, including Amygdalitis ("Tonsillitis") 365 2. Retro- and Latero- Pharyngeal Abscess 367 3. Adenoid Vegetations 369 4. Fistula Colli Congenita 370 D. The (Esophagus 371 E. The Stomach 237 1. General Nosology, Dyspepsia t 372 2. Acute Gastric Catarrh 378 3. Gastritis 379 4. Chronic Gastric Catarrh 380 6. Dilatation of the Stomach 381 6. Nervous Dyspepsia 383 7. Gastric Ulceration 383 F. Intestinal Diseases 387 1. Constipation 387 Actual constipation, apparent constipation, me- chanical obstruction, 389; membranous enteritis, incomplete peristalsis, 389 ; colic, 392. 2. Diarrhoea 383 Bacteric, 395 ; acid, 397 ; acute intestinal catarrh, 399; " summer" diarrhoea, 400. 3. Tumefaction of the Mesenteric Lymph-Bodies . . . 401 4. Appendicitis 403 5. Paratyphlitis 406 6. Intussusception 407 7. Helminthes 409 8. Umbilical Hernia 412 9. Inguinal Hernia 413 XIV CONTENTS. PAGE 10. Catarrh of the Kectum 414 11. Prolapse of the Anus and Kectum 414 12. Fissure of the Anus 417 13. Polypus of the Eectum 418 G. The Liver . 419 Enlargement, 419 ; hepatoptosis, fatty infiltration, 420; cirrhosis, 421; congestion, inflammation and suppuration, acute yellow atrophy, jaundice, 422 ; echinococcus, 423. H. The Spleen 424 Enlargement, embolism, abscesses, 424 ; perisplenitis, 424. I. Peritonitis 425 VIII. Diseases of the G-enito-TJrinary Organs 430 1. The Kidneys 430 Preventive treatment, uric acid infarction, 430 ; mal- formations, pseudoplasms, primary tuberculosis, 431 ; echinococcus, hydronephrosis, floating kidney, haema- turia, hemoglobinuria, 432 ; nephritis, causes, 433 ; acute, 435 ; subacute, 436 ; chronic, 437 ; renal calculi, 439. 2. The Bladder 441 Cystitis, 441 ; spasm, retention, incontinence, 442, 444; dysuria, irritable bladder, 443 ; retention, 443 ; muscu- lar debility, 444 ; reflex contraction, irritability of the neck, 446. 3. Other Organs : Anomalies and Diseases 447 Development, 447; epithelial obstruction, membranous obstruction ; imperforation of the glans, strictures, hy- pospadias, 448 ; prepuce, 449 ; phimosis, 451 ; diph- theria of the prepuce, aphthous vulvitis, 454 ; noma of the vulva, paraphimosis, 455 ; balanitis, balanopos- thitis, vulvar and vaginal catarrh, 456 ; atresia, imper- forate hymen, vaginal hemorrhage, masturbation, 458 ; cryptorchis, 459; orchitis, tuberculosis, syphilis, hy- drocele, 460 ; neoplasms, 460, 461. IX. Diseases of the Respiratory Organs 463 1. Nares 463 Acute nasal catarrh, 463 ; chronic, 465 ; polypus, 467 ; foreign bodies, 468 ; epistaxis, 469 ; ulceration, 470. CONTENTS. XV PAGE 2. Chronic Laryngeal Catarrh 472 Diphtheritic laryngitis, pseudo-membranous croup, 473 ; neurotic affections, spasm of the glottis, 477 ; paralysis of the glottis, neoplasms, 478. 3. Bronchi 479 Bronchial catarrh, bronchitis, 479 ; chronic, fibrinous, 481 ; asthma, 482 ; periodic night-cough, 483. 4. Lungs 483 Pneumonia, 483 ; interstitial, emphysema, 495 ; pul- monary oedema, pulmonary hemorrhage, infarction, 496; gangrene, pseudoplasms, echinococcus, actinomycosis, hernia of the lungs, funnel chest, 497. 5. Intrathoracic lymph-bodies 498 6. Pleura 499 Pleurisy, 499 ; hydrothorax, pneumothorax, pyopneu- mothorax, 510. X. Organs of Circulation 511 1. Heart 511 Acute and chronic diseases, 511 ; myocarditis, 323 ; endo- carditis, 524 ; pericarditis, 527 ; congenital anomalies, congenital undersize, 529. 2. Blood-vessels 530 Hypoplastic state, aneurism, 530; thrombosis, 531; naevus, angioma, 532. 3. Lymph- Vessels 534 Lymphangioma, elephantiasis, chyluria, cystic lymphan- gioma, 634. XI. Diseases of the Skin 535 Burns, 535 ; frost-bites, 536 ; erythema, 537 ; erythema nodo- sum, intertrigo, 539 ; acne, lichen, prurigo, 540 ; lichen scrofu- losorum, 541 ; furunculosis, 542 ; eczema, impetigo, ecthyma, rupia, 543 ; eczema seborrhoicum, pemphigus, 546; dermatitis exfoliativa, pemphigus foliaceus, 547 ; pemphigus exfoliativus, neuropathic affections, papilloma, pemphigus neuroticus chroni- cus, oedema, cyanosis, 548 ; symmetrical hemorrhage, erythro- melalgia, gangrene, scleroderma, scabies, 549 ; impetigo conta- giosa, favus, 550; herpes tonsurans, molluscum contagiosum, lupus, 551 ; lupus erythematosus, tuberculosis of the skin, scrofuloderma, 552 ; psoriasis, congenital diseases, 553 ; ich- thyosis, neoplasms of the neck, naevus pigmentosus, verrucosus, lipomatodes, 555. XVI CONTENTS. PAGE XII. Diseases of the Muscles 557 Myositis, 557 ; paralysis, 558 ; myasthenia, torticollis, 559. XIII. Diseases of the Bones and Joints 562 Congenital anomalies, 562; exostosis, 563; congenital luxa- tions, 564 ; bones, fractures, 566 ; chondritis, 567 ; peritonitis, ostitis, 567 ; spondylitis, 569 ; arthritis deformans, 571 ; joints, 572; coxitis, 579; gonitis, 580; ankle- and tarsal-joints, elbow, genu valgum, 581 ; pes varus, 582 ; equinus, cal- caneus, 583 ; valgus, 584 ; scoliosis, 585 ; kyphosis, 586. XIV. Diseases of the Ear 587 Malformations, foreign bodies, 587 ; otitis externa, 588 ; my- ringitis, 589 ; polypus, 590 ; otitis media, 591 ; mastoid process, 594 ; deaf-mutism, 595. XV. Diseases of the Eye 596 Malformations, neoplasms, 596 ; foreign bodies, 597 ; injuries, blepharitis, 598; conjunctiva, 599; conjunctivitis, 600; diphtheritic, 601 ; trachoma, 602 ; keratitis, 603 ; keratoconus, iritis, 605 ; cyclitis, vitreous body, choroid, cataract, 606 ; retina, optic nerve, orbit, glaucoma, strabismus, 607. THERAPEUTICS OF INFANCY AND CHILDHOOD. FEEDING OF SICK CHILDREN. Dietetics must be considered a part of therapeutics. The two must always go hand in hand. Sydenham knew the fact that many diseases are removed by a correct mode of living, and nutrition; and the men who established therapeutical schools on certain positive principles or on preconceived ideas arranged their dietetical and their medicinal and surgical rules on the same basis. Thus, Broussais, among others, while he purged and bled, crowned his work with starvation to such an extent that Graves, in 1843, had to come forward with the declaration that the systematic starvation of the disease ended in the destruction of the patient. It was Chossat, finally, who proved that inanition had many of the symptoms of fever, and that a starvation diet was liable to increase its dangers. Still, there are no universal rules for feeding, as there are none for medication. There are, however, certain indications which can always be fulfilled in the treatment of individual cases. As intellect and knowledge are required for finding those indications, so there is need of tact and experience to apply and fulfil them. Some of them are plain enough. It is clear that in conditions of great debility there must be no 9 10 THERAPEUTICS OF INFANCY AND CHILDHOOD. further reduction of strength; an irritated cerebrum should not be excited; hemorrhages, peritonitis, dysentery, perityphlitis require absolute rest; a hypersesthetic stomach must not be overfed; a gastro-enteritis resulting from the presence of fer- ments should do without milk; convalescence should be shielded and acute inflammatory fevers guarded. Still, there are chronic fevers with fair digestion which permit of generous feeding. All these indications and rules are equally valid for both the adult and the young. Still, the latter have some pecu- liarities which alter the application of general rules to a con- siderable extent, for several reasons. Of these I shall mention but a few at this time. Habits, which play an all-important part in the nosology of adults, such as alcohol, narcotics, sexual abuses, are not observed — unless very exceptionally — in the child. Cardiac debility, which is the constant danger of the senile period, and a frequent one in the adult, is in the begin- ning of a morbid process not so frequent in the very young, partly because the heart, compared with the rest of the body, is larger and more powerful, and partly because it has not had so much time and opportunity to become diseased. On the other hand, general metamorphosis is very rapid in the young, be- cause both of the rapidity of the vital processes, and of the constant necessity of adding to the tissues of the body, besides keeping up the equilibrium. Therefore inanition is not toler- ated for a long time. Thus the child cannot long remain with- out being fed, and, therefore, its digestive organs require per- manent attention. Their physiology must be carefully studied both in the healthy and morbid conditions. What the child eats is important, but of little consequence compared with what it digests. Nor are its subjective sensations the proper guides for the selection of foods or for the times of feeding. It is not always true that where there is no appetite there is no diges- tion. Nor are the pangs of hunger or the temptations of whimsical cravings safe counsellors. Nor does the condition of the tongue, to which we are apt to turn as one of our advisers FEEDING OF SICK CHILDREN. 11 in many of the ailments of the adult, deserve the same con- fidence in the young, for the frequent local processes inside the oral cavity are very apt to mislead us. From the very first month of life a distinct diastatic effect is produced by the oral secretion; it increases with every month. Even infusions of the parotids, prepared at different times after death, produce the same effect. Infusions, however, of the pancreas taken from the bodies of infants who have lived three weeks produce no such changes. The diastatic power of the pancreas begins with the fourth week only, and remains feeble up to the end of the first year. Kriiger (1891) found in the foetus of seven months a sugar-forming ferment which increases towards the normal end of intrauterine life, is still small in quantity at birth, but grows so rapidly that it is as active about the eleventh month of life as it is in the adult. Zweifel experimented with infusions of different glands. That of the submaxillary glands of an infant did not trans- form starch into sugar, even after the lapse of a whole hour. The effect of an infusion of the parotid of a baby seven days old was distinct after four minutes; however, that of the parotid of a baby which had died at the age of eighteen days, of gastro-enteritis, did not act until the lapse of three-quarters of an hour. ~Not was a diastatic result obtained by a similar infusion made of the parotids of a baby prematurely born, and one who died of diarrhoea and debility. It is a remarkable fact that different varieties of starch are not changed by saliva into grape-sugar in the same length of time. In reference to the time required, however, there is no uniformity of opinion. Solera found that the transformation of the starch of the potato was the most rapid. . Xext came that of Indian corn, next wheat, and the transformation of the starch of rice was the slowest. According to Malay, raw starch changes slowly, boiled starch quickly. According to him, that of the potato required from two to four hours; that of wheat from one-half to one hour; of barley from ten to 12 THERAPEUTICS OF INFANCY AND CHILDHOOD. fifteen minutes; of oats from five to seven minutes; of rye from three to six minutes.* It is important to know that the effect produced by saliva persists in the stomach for a period of from one-half to two hours. But it ceases altogether, and starch will no longer be changed into grape-sugar, inside the stomach, as soon as the secretion of hydrochloric acid has begun in the digestive pro- cess. This is a very important fact, because it shows that the farinaceous food of the infant or child, though it be not masti- cated, and pass the mouth very rapidly, is in the stomach still under the influence of the saliva. Hydrochloric acid is not secreted at once. The first acids in the stomach while digestion is going on are organic, mostly lactic. This is found to be contained in that organ when gas- tric juice is removed from it in the first period of digestion. Thus in a gastrostomized boy Uffelmann found under normal circumstances, and in the absence of fever, during the first half -hour, lactic acid only; afterwards hydrochloric acid.f The * When saliva is found insufficient at any age, medicinal aids are welcome. Taka-diastase has been recommended for the purpose of digesting starch. Friedenwald (N. T. Med. Journal, May 29, 1897) is very enthusiastic in its praise. "It is employed in hyperacidity. It converts one hundred times its weight of starch in ten minutes, and thereby replaces saliva. It continues its action in the stomach, stimu- lates gastric secretion, and promotes the motor function of the stomach, and thereby promotes the digestion of the proteids." t This agrees with what Ewald and Boas published as the result of their experiments also. But they claim to have found hydrochloric acid only when a decoction of starch alone was introduced into the stomach. Still later Th. Rosenheim (Centralbl. f. d. Med. Wiss., No- vember 12, 1887) reports as follows, after the ingestion of fifty grammes of bunn and one hundred and fifty of water: Free hydrochloric acid makes its appearance in the healthy stomach very early, 0.3 p. m. after fifteen minutes, 1.0 p. m. after thirty minutes. This quantity or more is found until the elimination of chyme has been completed. From beginning to end there is lactic acid to a uniform amount, — viz., 0.3 p. m. In carcinoma there was but 0.1 p. m. of hydrochloric, acid, in FEEDING OF SICK CHILDREN. 13 latter is not met with during fevers of any kind, provided the temperature is high, nor during a severe gastric catarrh (and also in dilatation of the stomach resulting from congenital or other constriction of the pylorus). In these conditions fari- nacea (amylacea) are taken to advantage, principally because the diastatic effect of saliva is not disturbed. Some of the main points to be remembered from the fore- going are these: There is diminution or absence of saliva from the parotid in the very young while suffering from diarrhoea and debility. It never is copious. Thus the very young when well ought to have but little starchy food, and when sick none at all, par- ticularly as the pancreas cannot be relied on for diastatic action in the first weeks. Whatever saliva, however, has been secreted and is swal- lowed, continues its action in the stomach as long as there is no hydrochloric acid in it. This in the healthy is secreted only after half an hour or later; in the feverish and catarrhal stomach very much later or not at all. Thus what saliva is present displays its diastatic action continually. Therefore the food craved for and digested by children, also by infants to a great extent, is, besides milk, farinaceous. Animal food which requires hydrochloric acid is not wanted, nor is it readily digested in the stomach. In anaemia, convalescence, particularly in fevers, the func- tions of the stomach are impaired. In them both pepsin and hyperacidity 1.0 p. m. In every case and in every period of digestion there was lactic acid. There was less hydrochloric acid (but 0.2 p. m. after an hour) and a fair amount of lactic acid when carbohydrates only were taken, no matter whether saliva was admitted to or excluded from the stomach. These data are here added for the purpose of showing that the diffi- culties of arriving at absolute facts are exceedingly great. Still, the results of the three observers do not differ too much from the accepted doctrine. 14 THERAPEUTICS OF INFANCY AND CHILDHOOD. hydrochloric acid are wanting. To increase their secretion large quantities of watee are required. Infants' food ought to be mixed with large quantities of water, not for the sick only, but under ordinary circumstances. In diseased conditions of the stomach the free dilution of chil- dren's nourishment with water is demanded upon the following additional facts. Only to a certain limit, if at all, will pepsin be furnished for digestive purposes. Probably a portion of this is not entirely utilized, because a great quantity of water is necessary to assist in pepsin digestion. In artificial digestion albumin often remains unchanged until large quantities of acidulated water are supplied. Without doubt many disturb- ances of digestion are to be explained by a deficiency of water, certainly many more than are due to an excess of it, for the latter is speedily relieved by rapid absorption. For the reasons given, I advocate under all conditions a plentiful addition of water to children's food. As a general observation, I would lay stress upon the fact that, as a rule, small children receive water only as they get it in their milk or milk food. Alike in summer and in winter, it is probable that the fact seldom occurs to a mother or nurse that a child may be thirsty without being hungry at the same time. Certainly many a discomfort and even sickness in a child is conditioned upon the fact that it has been compelled to eat in order to get its thirst satisfied, and often has to suffer thirst because the over-stimulated and injured stomach will take no more nour- ishment at irregular and too short intervals. There are even normal products of digestion that are capable of disturbing the digestive process, chief among which is peptone itself, which is not absorbed unless it be greatly diluted. That is why I, when preparing the rules for the feeding of children, which the New York Health Department has annually pub- lished and distributed, these several decades, insisted upon giving infants, who cannot ask in so many words for it, an occasional drink of water, at least during the hot weather. FEEDING OF SICK CHILDEEN. 15 When there is the least ground for the supposition that the drinking-water is contaminated with germs of disease, or where it is unusually hard, it should be boiled before its admixture with children's food, whether the diet be milk or a mixed one. In general it will give greater satisfaction to give very young infants boiled water as a matter of course, even though there be no apparent urgency for it. There are many other indications for the administration of water in the diseases of the young. In many morbid condi- tions it is wanting. Perspiration, diarrhoea, general inanition, feverish diseases, diminish its quantity in the tissues and blood- vessels. Thus an inspissation of the blood takes place, throm- boses form in the small veins of distant parts or the viscera, in the brain they lead to convulsions and defective innerva- tion (hydrencephaloid), in the limbs to oedema or gangrene. The remedy is water in sufficient quantities. Where the stomach rebels, the hungry lymph-ducts of the rectum will greedily absorb an ounce or much more, injected every hour or two. In many a case life is saved in this manner. In ex- treme cases the subcutaneous infusion of a sterilized salt-water solution (6 : 1000) is required. From two to six hundred cubic centimetres (six to twenty ounces) will readily be absorbed in the subcutaneous tissue. Where general metamorphosis is slow, water in abundance increases the elimination of urea and carbonic acid. Where the urine is scanty and of an undue specific gravity, water protects the kidneys from undue irritation. It acts on the mucous membranes as it does on the external integuments. In laryngitis and bronchitis it liquefies viscid expectoration, in many forms of constipation it acts beneficially by increasing the secretion of the muciparous glands of the intestines. Ice and ice-water, or iced carbonated water, in small quantities, but frequent doses, relieve hyperesthesia of the stomach and stop vomiting. Warm water acts as an emetic, hot water injected into the rectum combats collapse. In connection with this sub- 16 THERAPEUTICS OF INFANCY AND CHILDHOOD. ject, however, I may allude to what good may be done by absti- nence from water. In some forms of acute gastro-enteritis, where vomiting and diarrhoea are excessive, the only salvation is in total abstinence for from four to eight or ten hours. Not infrequently the turning-point in the course of the threatened danger dates from the commencement of what appears to be cruel starvation. A regular addition to the milk food of infants and children is that of sugar. Its percentage in the milk of the woman, ass, and mare is larger than that of the cow. Immediately after the milking of the cow the milk-sugar begins, to be changed into lactic acid. This process, after rennet has exerted its coagulating effect, together with the gradual conversion of fat into acid, is the final cause of curdling. The large amount of sugar in woman's milk, together with its smaller percentage of casein (about one per cent.) and butter, gives it the peculiar bluish color and furnishes the colostrum of the first days after birth, which contains plenty of salts besides, its tendency to loosen the bowels. This property becomes manifest, some- times, under abnormal circumstances. Thus in the milk of anaemic women sugar is occasionally found to an unusual de- gree. In their cases the other solid matters may also be di- minished, still, this is not uniformly so. The infants, however, suffer often from obstinate diarrhoea. The conversion of milk-sugar into lactic acid takes place very rapidly. Under its influence cow's milk turns sour at once. Not infrequently is it acid from the first; it has been found to be so in the udder; in most cases it is "amphoteric," neutral. Thus the question arises what kind of sugar is to be used as the addition to the food of children both well and sick. Cane-sugar is not so easily transformed. Indeed, it is util- ized for the purpose of counteracting the rapid conversion of milk-sugar, and for the preservation of articles of food in general. Trade is not so slow in availing itself of the results of organic chemistry as the profession. Condensed milk re- FEEDING OF SICK CHILDREN. 17 mains unchanged a long time, on account of the plentiful addi- tion of cane-sugar, in spite of the original presence of milk- sugar in it. Therefore it is not at all an indifferent matter whether milk-sugar or cane-sugar be added to the food of in- fants and children. I have always insisted upon the selection of the latter for that purpose. Biedert employs cane-sugar in his cream mixture. In the sick the absorption of sugar is slower than in the healthy. Besides, during most diseases, particularly those of the alimentary canal, there is more abnormal ferment in the mouth and stomach. Thus but little sugar ought to be given, and never in a concentrated form. Grape-sugar, and dextrin are absorbed equally. Cane-sugar, according to Pavy, is partly inverted into grape-sugar and partly absorbed. All appear to be changed, when given in moderate quantities, into carbonic acid and water, even during moderate fevers. In that form of constipation of small infants which depends on a relative absence of sugar and superabundance of casein in the breast-milk, the addition of sugar acts very favorably. A piece of loaf-sugar (a teaspoonful or less) dissolved in tepid water (or oatmeal water) should be given before each nursing, and will often prove the only remedy required to regulate the bowels. The physiological effect of chloride of sodium is very im- portant, no matter whether it is directly introduced through the mother's milk, or added as a condiment to cow's milk, or to vegetable diet. Both of the latter contain more potassium than sodium, and neither ought ever to be given, to the well or sick, without the addition of table-salt. A portion of that which is introduced may be absorbed in solution; another part is, however, broken up into another sodium salt, and hydro- chloric acid. Thus it serves directly as an excitant to the secre- tion of the glands, and facilitates digestion. Therefore during diseases in which the secretion of gastric juice is interfered with, or in the beginning of convalescence, when both the 2 18 THERAPEUTICS OF INFANCY AND CHILDHOOD. secreting faculties and the muscular power of the stomach are wanting, and the necessity of resorting to nitrogenous food is apparent, an ample supply of salt ought to be furnished. The excess of acid which may get into the intestinal canal unites with the sodium of the bile in the duodenum, and assists in producing a second combination of chloride of sodium, which again is dissolved in the intestines and absorbed. Its action in the circulation is well understood: it enhances the vital processes, mainly by accelerating tissue-changes through the elimination of more urea and carbonic acid. A very important fact is also this: that the addition of chloride of sodium prevents the too solid coagulation of milk by either rennet or gastric juice. Thus cow's milk ought never to be given without table-salt, and the latter ought to be added to woman's milk when it behaves like cow's milk in regard to solid curdling and consequent indigestibility. Habitual constipation of children is also influenced bene- ficially, for two reasons: not only is the food made more digest- ible, but the secretions of the alimentary canal, both serous and glandular, are made more effective by the presence of sodium chloride. A certain amount of fat is digested even in fevers of mod- erate severity, thus also in typhoid fever. But it is a good rule to rather reduce its quantity, because when infants were fed on cow's milk during capillary bronchitis, the fat in the fasces amounted to forty per cent, of the solid constituents. A few additional remarks will render the subject clearer, and show that it is very easy to give too much fat. Infant faeces are comparatively copious, although the baby receive absolutely nothing but mother's milk. What has been called detritus in the faeces is not exclusively undigested casein, but principally fat and large masses of intestinal epithelium. This so-called detritus is not soluble in water, acids, or alkalies, but quite soluble in alcohol and ether. Casein is present only when it has been taken in too large a quantity, or when there is FEEDING OF SICK CHILDREN. 19 too much free acid in the stomach. In those cases there are large quantities of it in the fasces. An important practical application of this fact is the follow- ing: As it is true that fat is not completely absorbed, even under the most normal circumstances; as free fat acids are so easily formed and accumulated; as they are found in moderate quantities, even in healthy babies; as a surplus is very apt to derange digestion and assimilation, and to prevent the normal secretion of either of the digestive fluids; as there is a super- abundance of fat in the normal food of the nursling, the con- clusion is justified that we should be very careful in preparing foods for the healthy or sick. It is very easy to give too much fat. It is hardly probable that there is too little. V. and I. S. Adriance have succeeded in proving, by exact chemical and clinical researches, some facts which were known, but perhaps not sufficiently appreciated. Both excessive fats and proteids in the milk of the mother may cause gastro- intestinal symptoms in the nursing infant; the former may be reduced by diminishing the nitrogenous elements in the mother's diet; the latter by the proper amount of exercise. Excessive proteids are especially apt to cause gastro-intestinal symptoms during the colostrum period, and particularly during that of premature confinement, when their percentage is higher. Premature infants are, therefore, in particularly great danger, and their food ought to be greatly modified and watered. Under the head of "Pat Diarrhoea" German journals and a few text-books speak of a diarrhoea, the chief characteristic of which is the presence of a large quantity of fat in the stools. The normal faeces of the newly-born contain ten or twelve per cent., sometimes more, of fat. In abnormal cases, even when the food does not contain it, the faeces may contain from forty to seventy per cent, of fat. The microscope reveals in serious cases fat, almost to the exclusion of everything else, sometimes pure, and other times 20 THERAPEUTICS OF INFANCY AND CHILDHOOD. in more or less regular needles. The anatomical condition in fat diarrhoea may vary, but in the majority of cases we have to deal with a simple catarrh of the intestinal tract. There are changes in, and exfoliation of, the epithelium of the small intestine, swelling of the mucous membrane of the duodenum, with obstruction to the flow of the secretions of both liver and pancreas, and such hyperplasia of the mesenteric lymph bodies as to impede the absorption and circulation of chyle. Finally, in a very few instances, anatomical changes were found in the pancreas resembling those which in the adult interfere with the emulsion of fat. No improvement is possible unless the quantity of fat con- tained in the food be largely diminished. The administration of cream and the routine treatment with cod-liver oil are equally injurious in these cases; for even normal digestion disposes only of a limited quantity of fat (cream, butter, cod- liver oil); twenty-live per cent, of it in the food, as lately recom- mended (Berliner Minische Wochensclirift, June 14, 1897), is excessive. One of the preparatory stages of its assimilation is the formation of oleic acid; lipanin, which has been recom- mended in place of cod-liver oil, contains six per cent, of that acid, the physiological preparation of which the body is spared by its administration. There may be very few conditions in which the digestion is so low as not to insure the required transformation, but in chronic dyspepsia of different sorts fat is badly digested and absorbed, and lipanin may take its place. What is it that a sick infant, or child, ought to eat? That question is so grave because the young when quite well are easily disturbed in their health by mistakes in their diet; in- deed, the large majority of the diseases of infancy are those of the alimentary canal; and an error in diet during the course of a disease is liable to prove fatal. Advanced childhood is not so endangered; that is why my first remarks are due to infancy. If the literature dedicated to its physiological and FEEDING OF SICK CHILDREN. 21 pathological conditions were as profitable as it is copious, the gain would be immense by this time. For, indeed, both the hygiene and the pathology and therapeutics of early age do not lack contributions. Particularly the former, being the main prop and staff of infant (as of all) therapeutics, has roused the zeal and industry of many workers; among them some of the very best of modern times. In feeding the sick no new principles must be sought for. The sick child is still the child, and the physiological laws hold their own under changed circumstances. No new articles of food can be discovered or invented, only the preparation or mixture of those in ordinary use may change temporarily, or a restriction in their number or amount may take place. Thus, I cannot undertake to give in full the methods of feeding in- fants and children. In several previous publications I have done so, and must refer to them. I will only repeat a few rules, leaving the reasons for them to the thoughtfulness or the recollection of the reader. The principal substitutes for breast-milk are those of the cow and the goat. The mixed milk of a dairy is preferable to that of one cow. Cow's milk must be boiled before being used. Condensed milk is not a uniform article, and its use precarious for that and other reasons. Goat's milk contains too much casein and fat, besides being otherwise incongruous. Skimmed milk obtained in the usual way, by allowing the cream to rise in the course of time, is objectionable, because such milk is always acidulated. The caseins of cow's and woman's milk differ both chemically and physiologically. The former is less digestible. There ought to be no more than one per cent, of casein in every infant food. Dilution with water alone may appear to be harmless in many instances, for some children thrive on it. More, however, appear only to do so; for increasing weight and obesity are not synonymous with health and strength. A better way to dilute cow's milk, and at the same time to render its casein less liable to coagulate 22 THERAPEUTICS OF INFANCY AND CHILDHOOD. in large lumps, is the addition of decoctions of cereals. It has been stated before, that a small amount of starch is digested at the very earliest age. But cereals containing a small per- centage of it are to be preferred. Barley and oatmeal have an almost equal chemical composition; but the latter has a greater tendency to loosen the bowels. Thus, where there is a ten- dency to diarrhoea, barley ought to be preferred; in cases of constipation, oatmeal. The whole barley-corn, ground for the purpose, should be used for small children, because* of the pro- tein being mostly contained just inside and near the very husk. The newly-born ought to have its boiled milk (sugared and salted) mixed with four or five times its quantity of barley- water, the baby of six months equal parts. Gum arabic and gelatin may also be utilized to advantage in a similar manner. They are not only diluents, but also, under the influence of hydrochloric acid, nutrients. Thus, in acute and debilitating diseases which furnish no, or little, hydrochloric acid in the gastric secretion, a small quantity of the latter, well diluted, must be provided for. This, my method of infant feeding, which is suited for the stomachs and purses of the rich and poor alike, is, however, not the only one proposed and found satisfactory. No single method, indeed, is the only one, nor does it suit every case. It is only an occasional chemist who expects the organic stomach to behave like a chemical reagent; clinicians, however, admit exceptions to the working of their rules and regulations, though their conception were ever so correct and physiological. Still the endeavors to improve the diet of the young, and thereby to remove the dangers of in- testinal disorders and the sources of excessive mortality and invalidism are going on. Nothing has been more successful in that direction than the wide-spread practice of sterilization and pasteurization of cow's milk. Both are the logical de- velopment of the plan of treating milk by boiling which I have persistently advised these forty years at least, and detailed in my "Infant Diet," in Gerhardt's "Handbuch," in Buck's FEEDING OF SICK CHILDREN. 23 "Hygiene/' in "Intestinal Diseases of Infancy and Child- hood,"* and in my clinical lectures delivered during more than one-third of a century. There can hardly be a doubt that if raw milk could always be had unadulterated, fresh, and untainted, and as often as it was wanted, it would require no boiling. It would even contraindicate it, for high tempera- tures destroy not only some of the dangerous, but also those bacteria whose action is desirable for normal digestion. Be- sides, there are those who strongly believe that boiling causes chemical changes. But such ideal milk cannot be had so long as cows are tuberculous, scarlet fever and diphtheria are met with in the houses and about the clothing and on the hands of dairy men and women, and typhoid stools are mixed with the water which is used for washing utensils. Now, what is it that boiling can and will do? Besides ex- pelling air, it destroys the germs of typhoid fever, Asiatic cholera, diphtheria, and tuberculosis, also the oidium lactis, which is the cause of the change of milk-sugar into lactic acid and of the rapid acidulation of milk with its bad effects on the secretion of the intestinal tract. Some varieties of pro- teus and most of bacterium coli are also rendered innocuous by boiling. Thus it prevents many cases of infant diarrhoea and vomiting, but not all of them, for the most dangerous bacteria are influenced neither by plain boiling nor by the common methods of sterilization. Besides, "diarrhoea" is but a symptom of many causes, and "cholera infantum" is a name for a condition occasioned by many. Ebstein emphasizes the * P. 18. "After boiling, milk destined for the use of a baby during the day should be kept in clean bottles containing from three to six ounces, filled up to the cork, and the bottles then turned upsidedown in a cold place ; such will keep longer than milk preserved in the usual way. Before being used it should be heated in a water-bath; and by repeating this heating of the whole amount of the day's milk several times during the twenty-four hours, fermentation will be retarded and digestibility improved." 24 THERAPEUTICS OF INFANCY AND CHILDHOOD. fact that babies at the breast are subject to cholera infantum, particularly in southern climates, also in public institutions. The influence of external temperature is a very important factor; its sudden changes produce intestinal disorders. Babies taken from a hot railroad car to the deck of a lake steamer, from a warm bed to a draughty room, may develop a catarrhal enteritis which disposes to worse forms of disease, for the mor- bid condition of the epithelium caused by such sudden changes is a proximate cause of disease because it opens the way to all sorts of infecting substances. Poisons in the food of cows, in- digestible baby foods, — either indigestible per se or through a morbid condition of the digestive organs, — produce diarrhoea of many varieties. It need not even depend on ingested food, for, according to W. Schild's recent investigations (Zeitsch. f. Hyg. u. Infect., xix.), germs of diseases may be found in the intestine of the newly-born in from ten to seventeen hours after birth (minimum four, maximum twenty). The meco- nium of the newly-born, being free of germs, is supplied through the mouth with the bacterium coli, and through the anus with the bacillus fluorescens, subtilis, and proteus. Even adults are infected through the same inlet. Linen, the bath, the air, the blood are sources of local invasion. In such cases what is the sterilization of artificial food to accomplish? They are not reached by it. Not even the natural food, breast-milk, is free of germs pos- sibly attended by dangers. M. Cohn and H. Neumann found germs in the healthy breast-milk, even after the mamma and nipples had been washed with alcohol and with solutions of cor- rosive sublimate. A. Palleske met with the staphylococcus pyogenes albus in one half of all healthy women, F. Honig- mann {Zeitsch. f. Hyg. u. Infect., xiv.) in most of them, and H. Knochenstein (Inaug. Diss., 1893) in the mammae of eight puerperal and nursing women. He thinks they had immi- grated from outside; they proved innocuous. But who can doubt that if the epithelium of the milk-ducts had been mor- FEUDING OF SICK CHILDREN. 25 bid, there would have been a chance for mastitis, or if the staphylococcic milk had come in contact with a sore stomach or intestine, there would have been an opportunity for gastritis or enteritis? Many more observers have come to the same con- clusions. Several species of cocci, particularly staphylococcus pyogenes albus, are found in most (perhaps in all?) specimens of the milk of healthy women. In that of sick women many more bacteria may be met with, for instance, streptococcus albus, streptococcus pyogenes aureus (in mastitis by Cohn and Neumann), coccus pneumoniae (in pneumonia of the mother by Foa and others). Puerperal women with fever had several bacteria in their milk (Escherich). Whether such milks are safe cannot yet be either asserted or denied. Nor is boiling, or sterilization, a safe protection under all circumstances. Aerobic bacteria, the so-called hay or potato bacilli, have very resistant spores, which develop in time. They are found in cow-dung and in the dust of stables, of the soil and streets, and of hay; they render the milk alkaline and bitter; they peptonize casein and liquefy it and make the milk still more bitter. They are very poisonous; their pure culture gives young dogs a fatal diarrhoea. It takes hours of steriliza- tion to kill them; in some instances it required five or six hours. Even the bacillus butyricus takes an hour and a half. But such a protracted sterilization, besides being far from cer- tain in its effect, is a clumsy procedure and one not calculated to benefit the milk. Thus, hay feeding is an absolute necessity, for the bacilli are destroyed by a six weeks' drying. Besides, it is important to keep the stables scrupulously clean, to avoid dirt and dust, to employ peat instead of straw for bedding, to wash the udder and tie the tails before milking, to throw away the first milk, and to remove foreign material from the milk by centrifuging. But no absolute security can be guaranteed. Therefore Fliigge adds to his expositions a warning against some wholesale manufacturers who, always anxious about some- body's — their own — welfare, were (are?) known to conceal the 26 THERAPEUTICS OF INFANCY AND CHILDHOOD. changed condition of the milk and the separation of butter particles by coloring the glass of their bottles. Whatever I have here brought forward is certainly not to disparage the boiling of the milk; it is meant to prove the danger of relying on a single preventive when the causes of intestinal disorders are so many. It is true, however, that the large majority of the latter depend on causes which may be met by sterilization, but not by sterilization only; also by pasteurization, — that is, heating the milk to 70° C. = 158° F., and keeping it at that temperature for thirty minutes, — a pro- cedure which destroys the same germs that are killed by a more elevated temperature without much change in the flavor and taste of the milk. One of the questions connected with the employment of sterilized or pasteurized milk is this, whether the milk to be used for a child ought to be prepared at home, or whether the supply may be procured from an establishment where large quantities of milk believed to become immutable for an indefi- nite period by sterilization are kept for sale. In regard to this problem, Flugge plaintively expresses his regrets that "we have allowed ourselves to be guided by people who are neither hy- gienists nor physicians, but chemists, farmers, or apothecaries, and whose actions have been based on three false beliefs. Of these the first is that boiling for three-quarters of an hour destroys germs, the second that whatever bacteria remain un- destroyed are innocuous, and the third that proliferating bac- teria can always be recognized by symptoms of decomposition." Nothing is more erroneous. Soxhlet himself, the German originator of sterilization, knew at an early period that the fer- menting process is now and then but partially interrupted by boiling, that butyric acid may be found in place of lactic acid, that a strong evolution of gas may be caused after such boiling, and that such milk may give rise to flatulency. Aye, milk which happens to contain the resistant spores of bacteria be- comes a better breeding-ground for them by the very elimina- FEEDING OF SICK CHILDREN. 27 tion of lactic acid, and the longer such sterilized milk is pre- served and offered for sale the worse is its condition. It may be true that these conditions are not met with very frequently, but an occasional single death in a family caused by poisonous milk will be more than enough. Therefore, the daily home sterilization is by far preferable to the risky purchase from wholesome manufacturers who cannot guarantee because in the nature of things they cannot know the condition of their wares. Another alteration of a less dangerous character, but far from being desirable, is the separation of cream from sterilized milk which is preserved for sale. Renk (Arch. f. Hyg., xvii.) found that it took place to a slight extent during the first weeks, but later to such a degree that 43.5 per cent, of all the cream contained in the milk was eliminated. Sterilization has been claimed to be no unmixed boon be- cause of its changing the chemical constitution of milk. Still, opinions on that subject vary to a great extent, the occur- rence of changes being both asserted and denied by apparently competent judges. But what I have said a hundred times is still true and borne out by facts, — viz., that no matter how beneficial boiling, or sterilization, or pasteurization may be, it cannot transform cow's milk into woman's milk, and that it is a mistake to believe that the former, by mere sterilization, is a full substitute for the latter. It is true that when we cannot have woman's milk we cannot do without cow's milk. There is no alleged substitute that can be had with equal facility or in sufficient quantity. But after all it is not woman's milk. Babies may not succumb by using it, and may but seldom appear to suffer from it; indeed, they will mostly appear to thrive on it; but it is a makeshift after all and requires modi- fications. Hammarsten was the first to prove the chemical difference between the casein of cow's and woman's milk. "Whatever was known on this subject at that time I collated in Gerhardt's "Handb. d. Kind.," vol. i., 1875 (2d ed., 1882). 28 THERAPEUTICS OF INFANCY AND CHILDHOOD. The casein of woman's milk is not so easily thrown out by acids or salts as that 'of cow's milk, and is more readily dissolved in an excess of acid. But lately Wroblewski demonstrated the difference in solubility of the two milks. Woman's casein re- tains, during pepsin digestion, its nuclein (proteid rich in phos- phorus) in solution: it is fully digested; in cow's casein the nuclein is not fully digested: a "paranuclein" is deposited un- dissolved and undigested. Besides, woman's casein contains an additional albuminoid which is not identical with either the known casein or albumen. (H. Koplik in N. Y. Med. Journal, April 13, 1895.) Of the albuminoids in woman's milk sixty- three per cent, are casein, thirty-seven per cent, lacto-albumen (Schlossmann), which being directly absorbable constitutes an essential difference from cow's milk; all of the latter has to be transformed during the digestive process before it can be as- similated. Besides, there is (Wroblewski) in the human milk another proteid rich in sulphur, poor in hydrocarbon, and, ac- cording to several authors, albumoses and peptones. K. Wittmaack and M. Siegfried published lately (Zeitsch. f. phys. Chem., xxii.) their essays on the nucleon (the phosphoric acid of muscle) in the milks of cow, woman, and goat, and on phosphorus in the milks of the cow and the woman. Their conclusions are accepted by E. Salkowski as correct, which, I should say, proves them to be so. Cow's milk contains 0.057, goat's milk 0.110, and woman's milk 0.124 per cent, nucleon. In cow's milk the phosphorus of the nucleon amounts to six per cent, of the total amount of phosphorus contained in the milk; in woman's milk 41.5 per cent. That means that in cow's milk not one-half of its phosphorus is in the organic combinations of casein and nucleon; in woman's milk almost all of it. In cow's milk the phosphorus not utilized for or- ganic combinations is contained in the inferior phosphates. E. Salkowski adds the following remarks; "These conditions are evidently of the greatest moment in the nutrition of the nursling. As the development of bones is more readily ac- FEEDING OF SICK CHILDREN. 29 complished in nurslings fed on woman's milk than in those fed on cow's milk, the probable conclusion is this: that nu- cleon has an important part in the absorption and assimilation of phosphorus. The same should be said of calcium, which also combines with nucleon. Though woman's milk contains less calcium than cow's milk, more calcium is utilized out of the former, and the nucleon is evidently an important factor in its absorption also." Ergo, cow's milk is not woman's milk. It is not identical with it. Sterilization does not change its character; it merely obviates such dangers as result from the presence of most pathogenic germs and from premature acidulation. The sub- stitution of cow's milk or of sterilized cow's milk for woman's milk as the exclusive infant food is a mistake. Experience teaches that digestive disorders, such as constipation or diar- rhoea, and constitutional derangements, such as rhachitis, are frequently produced by its persistent use, and it appears to be more than an occasional (at least co-operative) cause of scurvy. Since the advisability of finely dividing and suspending the casein of cow's milk and of adding to the nutritiousness of the latter caused me always to teach the admixture of cereals to it, even in the very first days of infancy, the subject of infant feeding has never been lost sight of by medical men, scientists, and tradesmen. No subject has been treated more extensively, more eagerly, sometimes even more spitefully, than that of infant feeding. The philosopher's stone has not been so anxiously sought for nor so often found in medical journals, books, and societies as the correct infant food and the appro- priate treatment of cow's milk. After the finally faultless thing had been discovered very many times, it was not a sur- prise but a source of gratification to me to meet, in the Berl. Min. Woch., No. 10, 1895, an article of Heubner's, who, after having contributed for years as much as any writer (if not more) to the literature of the subject, recommends the "utili- 30 THERAPEUTICS OF INFANCY AND CHILDHOOD. zation of flour in the intestines of young nurslings." Basing his remarks, first, on the researches of Schiffer, Korowin, and Zweifel (quoted in my early writings on that topic more than twenty years ago), who, by experimentally proving the digesti- bility of a certain amount of starch in the saliva (and pan- creatic juice) of young infants,* justified my empirical findings of many previous years, and, secondly, on what he is pleased to call "Jacobi's practical experience," the Berlin physician rec- ommends in intestinal diseases of the very young the simplest flours, mainly of rice and oats (which have a finer microscopical structure than wheat). He pointedly adds, "Very young in- fants do better on a dilution of milk with a thin rice decoction than with mere milk-sugar solution. Practical experience sur- passes theoretical conclusions."! There is but one point in which the famous teacher does not yet agree with me, for in his expositions we meet with the remark that he "cannot approve of the colossal dilution recommended by the authority of Jacobi." The "colossal dilution" alluded to is that of milk in four or five parts of oatmeal- or barley-water for the use of the newly-born. In regard to this dilution also I trust I shall yet see my illustrious colleague siding with me. The demands of pepsin digestion and of rapid growth and the necessity of restitution of losses experienced by eliminations and excre- tions are just so many reasons for extra allowances of water in the diet of very young infants, who have to rely on the * Bias dies hard. While it took Heubner more than twenty years to avail himself of very accessible physiological experience, a celebrity of equal rank (Philip Biedert, Handbuch der KinderlcranJcheiten, 11th ed., 1894, p. 39) still appears to approve of the opinion that a nursling must have "no amylacea" because of their indigestibility, before the pro- trusion of teeth. Still, he advises cereals for the dilution of his cream mixture. Before long it will be a generally accepted axiom that cereals must be given to make teeth and tissues generally when milk food alone does not suffice for their development. t "Probiren geht iiber Studiren." FEEDING OF SICK CHILDREN. 31 services of others. Older children know how to find it and how to serve themselves. In addition, it is certainly true that a large amount of water passing through the kidneys removes the inconveniences and dangers of the peculiar physiological process which takes place during the first three weeks of every life, — viz., uric acid infarction, — the results of which are gravel, renal calculus (by no means rare), and nephritis. In- deed, since the rather frequent adoption of my plan of supply- ing the very young with quantities of water, I hear less of renal complaints in them than I did dozens of years ago. Perhaps the tide is already beginning to turn in my direc- tion. Norbert Auerbach, whose researches on the difficulty of destroying the hay bacillus and the bacillus butyricus are very meritorious, recommends larger percentages of water in infant feeding than the customary ones. His mixtures for the first and second months of life are three parts of water and one of milk; for the third and fourth, two and one; for the fifth and sixth, one and one; for the seventh and eighth, one and two. His figures are, therefore, not exactly like mine, but even they may appear heretic to my critic. In connection with this subject I am also pleased to state that Auerbach agrees with me on another subject. The sugar he adds to the milk food of infants is not milk-sugar, but cane-sugar, of which he gives twenty grammes daily, and — also according to my old teaching — more during constipation. He undoubtedly prefers cane- sugar for the reasons which guided me in my recommendations, though it is true that milk-sugar is being stripped of its dan- gers in the same degree as boiling, sterilization, or pasteuriza- tion is carefully practised. Virtually, sterilization has been practised by me these more than forty years, and has been taught by me for thirty-five years, both in lectures and in books and essays. My method has been referred to. I always urged that safety increased with the number of boilings. Still, certain New York gen- tlemen have been pleased to say, even lately, and one of them 32 THERAPEUTICS OF INFANCY AND CHILDHOOD. has printed, though he was told of his mistake before printing, that Jaeobi was an opponent of sterilization. Actual sterilization, according to Soxhlet, was introduced in New York by A. Caille. Then manufacturing firms took it up as a matter of course. One of them was prevailed upon by me to execute a device of Dr. A. Seibert, who advised the determination of the amount of sterilized food and the grad- uation of the feeding-bottles according to the weight of the infant. In most cases this plan is good, for the condition of the child can mostly be measured by the increase of its weight. Only fat, clumsy, rhachitical children are exceptions; in them the rapid increase of weight is rather a morbid condition than a symptom of healthy development. Besides, he improved his food by adding, in conformity with my practice, and steril- izing at the same time with the milk, either barley- or oatmeal- water. A recommendation of his sterilizer is its cheapness, which makes it more accessible to the poor. Before being sterilized (pasteurized) milk ought to be filtered. Most cooks employ napkins for that purpose. Absorbent cotton answers as well. The writings and practical instruction of Dr. Eowland Godfrey Freeman have been a great advantage to New York, particularly to its poor population. He insists upon pasteur- ization as a sufficient method of safety. The apparatus devised by him is thoroughly appropriate. As the adviser of Mr. Nathan Strauss in his successful endeavors to supply thousands with a safe article of food, he has benefited the city and aided in setting an example which should and will be imitated. Pasteurization is also employed by Eotch. In a paper read before the American Pediatric Society at Boston, May 4, 1892,* * "The Value of Milk Laboratories for the Advancement of our Knowledge of Artificial Feeding," by T. M. Rotch, Archives of Pedi- atrics, February, 1893. Also "Pediatrics: The Hygienic and Medical Treatment of Children," Philadelphia, 1896, pp. 153-287. FEEDING OF SICK CHILDREN. 33 he presented, among others, the following statements, which I gladly repeat, as I know his teachings to have done a great deal of good. Indeed, I was so much impressed by them that I encouraged the gentleman who had conducted a milk labora- tory on Dr. Rotch's plan in Boston to establish a similar insti- tution in New York. Northrup, Holt, and many others are ad- mirers of his teachings. Some of Dr. Botch's statements are as follows: "What the profession needs is the knowledge that they may have milk laboratories where the materials are clean, sterile, and exact in their percentages. Slight changes in the three elements of milk of which we have the most accurate knowl- edge — namely, fat, sugar, and albuminoids — are of real prac- tical value in managing the digestion and nutrition of the infant (normal percentage of fat, 2.02-4.37; of milk-sugar, 5.70-7.10; of albuminoids, 1.08-3.07; of mineral matter, 0.12-0.20). The digestive capabilities of infants differ just as do those of adults, and nature therefore provides a variety of good breast-milks adapted to the individual idiosyncrasy of the special infant. With this fact impressed upon us, we can well see that in artificial feeding no routine mixture will in all cases prove successful." All this proves also that nature allows a great deal of lati- tude, for the milk of a woman is changing, sometimes quite rapidly, and still the baby continues to thrive. It also proves that an attempt at regulating the percentages of milk according to invariable rules, while circumstances of surroundings and individual health — perceptibly changed or not — may differ, is liable to be very deceptive. Altogether, no iron-clad rule holds good for a living body in which organic assimilation is not regulated by the fixed laws of crystallization. This is, indeed, proved by nothing better than by the variability of the con- stituents of good milk. According to the very figures pre- sented by Dr. Rotch himself, fat may vary from 2.2 to 4.37, 3 34 THERAPEUTICS OF INFANCY AND CHILDHOOD. albuminoids from 1.08 to 3.27, and still the milks exhibiting these wide differences are "normal."* In regard to the percentages of fat in cow's and in woman's milk, the results of chemical analysis have lately changed in favor of the latter. But the general principles in regard to fat feeding — its effect on digestion, and the normal occurrence of fat in the healthy fasces of an infant fed on normal nourish- ment (breast-milk) — are not thereby altered. Neither mathematics nor chemistry alone directs the organic economy. If that were so, the chemist Soxhlet, otherwise so deserving and justly famous, would be justified in the advice he coolly gives the physician to add milk-sugar when there is no fat in the food, and thereby to obtain the necessary amount of carbon hydrates. Fortunately, organic chemistry is not identical with physiology. The methods of Biedert and Arthur Meigs are based upon these modern analyses of milk. The former prepares a cream mixture which contains one per cent, of casein, two of fat, and four of sugar. It is to be mixed with milk in different propor- tions. One of the reasons urged by him for the addition of cream is the necessity of greater dilution (accomplished by my cereal decoctions) of the cow casein, the difficult digestion of which he takes for granted. In his "Kinderemahrung," 2d ed., pp. 152, 170, Biedert rec- ommends to feed a baby during the first few months as follows: Every kilogramme (two pounds) of the baby's weight is fur- nished two hundred grammes (six and a half ounces) of food which contains fifty of milk, one hundred of oatmeal-water, * "So high an estimate of the casein as this must always be due to error, the consequence of failure to separate the casein and sugar. There is reason to believe that the copper test for milk-sugar is not reliable when applied to milk analysis. This test is the one employed by most analysts to estimate the sugar, and there is good reason to believe it to be entirely unreliable for the analysis of milk." Arthur V. Meigs, "Feeding in Early Infancy," 1896, p. 6. FEEDING OF SICK CHILDREN. 35 and eight of sugar. Heubner ("Sauglingsernahrung und Saug- lingsspitaler," 1897, p. 13) mixes one part of milk with one of a flour decoction (one teaspoonful to one-half pint) which con- tains 12.3 per cent, of milk-sugar. Of this mixture he gives six hundred grammes daily up to the fourth week, seven hun- dred and fifty to the seventh, nine hundred after the eighth, in from eight to six meals. The mixture of Dr. Meigs is well thought of by many physi- cians. In his own words, "There must be obtained a quart of good fresh milk, not too rich, and not poor; average milk is best; this is placed in a high pitcher or other vessel and is allowed to stand in a cool place for three hours. The upper half or pint is then poured off, care being taken not to shake the vessel, and this upper pint of weak cream is to be kept for the use of the infant. "There must also be made a solution of milk-sugar of the proportion of eighteen drachms to the pint of water. It ought to be kept in a fairly cool place; if it be sour it must not be used. "Three tablespoonfuls of each, the weak cream and the sugar-water, are then mixed with two tablespoonfuls of lime- water. They are then warmed for use in the feeding-bottle. "In the great majority of instances where it has been fairly tried, this food has proved very successful" (A. V. Meigs's "Feeding in Early Infancy," 1896, p. 7). This food of Meigs's seems to be too easily influenced by ir- regularities, and by accidents happening to what he calls cream while it is obtained, and to the milk-sugar solution, to be proof against frequent mistakes and failures and to become popular among the masses. Dr. N". B. Coit, who believes that coVs milk when properly prepared furnishes the sufficient diet of an infant and supplies all its needs for robust health, gives the following rules for modified milk for infant feeding, made with one quart of bot- tled cow's milk: "First six months, the top milk, cream one-half 36 THERAPEUTICS OF INFANCY AND CHILDHOOD. pint, boiled water one pint, milk-sugar seven hundred grains; from six to nine months, the top milk, cream one pint, boiled water one pint, milk-sugar nine hundred grains; from nine months to one year, the top milk, cream one and one-half pints, boiled water one-half pint, white sugar three teaspoonfuls." Dr. Rotch continues, "We are in need of a means by which we can prescribe exactly according to the idiosyncrasy of the digestion we are dealing with. "A separator with many thousands of revolutions in a min- ute separates from the milk foreign material and divides it up into a cream of a stable percentage and separated milk. The milk-sugar and the albuminoids, also the mineral matter of this milk, are fairly well known, and thus the laboratory worker is enabled to put up any prescription, which, for a healthy baby of four months, would read: fat, 4 parts; milk- sugar, 7 parts; albuminoids, 1.50 parts. Put up eight tubes, each four ounces, with lime-water ten per cent. Pasteurize (75° C. = 167° F.) for twenty minutes. In this mixture the lime-water is just sufficient to slightly alkalinize the cow's milk.* In this way the food of the child can be modified ac- cording to age and to changed conditions of health." * Cow's milk is either alkaline, or neutral, or acid. The constant rec- ommendation of five per cent, of lime-water for the purpose of alkaliniza- tion is, therefore, far from exact and strictly scientific. Besides, how much alkalinization is effected by one and a half drachms of lime-water? They contain exactly, or are presumed to contain, one-eighth of a grain of lime. Lime-water (liquor calcis) is a saturated aqueous solution of calcium hydrate whose percentage varies with its temperature. At 59° F. it contains somewhat over 0.17 per cent., in rising temperature less, at the boiling-point one part of lime in thirteen hundred of water. It re- dissolves as the liquid cools. If the food containing lime-water be given at a temperature of eighty or ninety degrees, part of the lime is thrown out. Lime-water warmed loses most of its alkaline reaction; it is markedly alkaline when cold, only faintly so when boiled. An experi- ment made with good milk from the household supply gave the follow- ing results: Keaction acid, also on boiling. One- twentieth part of lime- FEEDING OF SICK CHILDREN. 37 In a case of duodenal jaundice in a girl of six years, the doc- tor prescribed fat, 0.5 part; milk-sugar, 6 parts; albuminoids, 4 parts. Give four ounces every two hours. Send twelve tubes, each four ounces, lime-water ten per cent. In a case of sum- mer diarrhoea in a girl of four months, fat, 2 parts; milk-sugar, 5 parts; albuminoids, 1 part. Send twenty tubes, each one ounce and one drachm. At time of each feeding add lime- water, three drachms. Sterilize at 212° F. One of the beliefs guiding the author of this method is as follows: "The constituents of the nutriment which nature has provided for the offspring of all animals and human beings that suckle their young are essentially animal, and not vege- table. Human beings in the first twelve months of life are carnivora. An animal food entirely and always free from any vegetable constituents has been proved to be the nutriment on which the greatest number of human beings live and the least number die." Those who have followed my teachings at any time during the last third of a century know that I take some exception to this broad statement. Saliva and pancreatic juice are good for something better than idle elimination, and "nature" pre- pared the animal young from the first moment for more than mere pepsin digestion. The proof Dr. Eotch refers to is his experience only. Mine has taught me somewhat differently from the axiomatic positiveness of his assertion. But be it far from me not to present Dr. Botch's case in full. His stand- ing and merits are such as to give him a hearing wherever and water added to it changed the reaction but slightly: it remained acid. The mixture being boiled, reaction remained the same. When again cooled and shaken up it was still acid, but slightly less so than before the dilution of the milk with lime-water. The addition of bicarbonate of sodium to milk which is to be kept from souring, a procedure which is (besides lime-water) recommended by Holt also, may become a grave mistake. The very bacilli which, with their spores, resist boiling to an unusual degree, thrive best in a milk that is made thoroughly alkaline. 38 THERAPEUTICS OF INFANCY AND CHILDHOOD. whatever he discusses. His rules, which, moreover, may be modified by my method at any time, are thoroughly good; they are scientific., exact, and well thought out. Moreover, they have been proved to be practicable. No matter whether it is the careful handling of a cautiously prepared milk, the methodical composition according to percentages, or the faith- ful pasteurization, or all of them, the results are good. I know of a number of babies who in health and disease have done well on the protracted use of the laboratory milk. Only one obser- vation struck me in many cases. The formation of the muscles, and particularly of the bones, appeared to be slow; the teeth came a number of weeks or even months too late; the cranial bones turned slightly soft in not a few instances. In many such cases I had to add animal broths or juice before the usual time; in two, when I tried phosphorus (elixir phosphori), it was re- jected; in all others it was well borne and useful. But, taken all in all, the method appears to be sound and successful, so far as it can be with cow's milk and the casein of cow's milk. It is to be deplored that for the present it is a method only ac- cessible to the rich; it required a special benevolent fund to supply one hundred and twenty-five Boston poor children with the same food; mine has the advantage of being one for the people, both rich and poor. If, or as long as, the circulars of the laboratory keep free of pretentious exaggerations, — there was a time when they took that turn, — the profession will do well to rely on it, or its like, as one of the means of furnishing the baby a food deprived of dangers and in most cases suffi- cient. When it is found insufficient as regards tissue-building, cereals may always be furnished in the same mixture. The empirical knowledge of their beneficial effects with which we have been furnished for more than a generation has lately again been tested experimentally by Springer, of Paris, who improves the development of bone by a decoction of mixed cereals boiled for hours in succession. This long duration of the boiling process is, however, not demanded. FEEDING OF SICK CHILDREN. 39 Like Professor Kotch, Professor G. Gaertner,* of Vienna, employs the centrifuge f for the purpose of obtaining a milk resembling that of woman. The latter was found by Escherich to contain casein 1.82, fat 3.10, and sugar 6.23 per cent. The average of many examinations of cow's milk resulted in casein 3.76, fat 1.81, and sugar 2.1 per cent. That of "fat milk"' con- tained casein 1.76, fat 3, and sugar 2.1 per cent. This "fat milk" is obtained by so arranging the tube which expels the cream from the centrifuge separator that just one-half of the milk contained therein is expelled and collected. In this way, as casein, sugar, and minerals are not affected by the process of centrifuging, their percentages are not changed, while that of the fat is doubled. The difference between Gaertner's and Botch's methods is this: that the former is applicable to the large majority (but that only) of infants who require cow's milk appropriately prepared; and that the latter permits of all sorts of changes and percentages, and of all adaptations to the requirements of both the well and the sick, according to the opinions and intentions of the physician in every individual case. Gaertner's milk is to be given in the same unchanged percentages during all the months of feeding; only the quanti- ties are gradually increased and the number of meals is dimin- ished. He does not consider the fact that woman's milk (not to speak of colostrum) contains more albumin and salts and less fat in the first few months, but less albumin and salts and more fat later. What little experience I had with it, however, during a few short months seems to be favorable. But what I said of many cases fed on Botch's modified milk will, I fear, occur here. There will be lack of tissue building, and close watching *Ueber die Herstellunor der Fettmilch, VVien. 1S94. Professor Esch- erich, Die Gaertner'sche Fettmilch. eine nene Methode der Siiuglingser- nahrung. Both in Wiener Med. YToch.. 1S94. t Recommended for the preparation of children's milk in my Cf Intes- tinal Diseases," 1SS7, p. 23. 40 THERAPEUTICS OF INFANCY AND CHILDHOOD. and additional feeding and medication may be required in many instances. Another difference between the two is almost self-under- stood, and explained by the tone and the usages of the medical profession in some parts of Europe. The Gaertner milk is patented by the inventor and sent to the market with semi- scientific, partly unintelligible, and rather boastful circulars. (Per contra, Biedert, whose cream mixture is also in the market, has no personal patent and derives no pecuniary advantage from his procedure.) Practitioners and authors who convince themselves of the ill success often attending the use of milk, or watered milk, com- menced at an early period to mix it with MEAT-soups, meat-tea, or egg. Bretonneau reported, as early as 1818, that "tabes mesenterica" disappeared, in the hospital of Tours, from among the children fed on beef-soup and milk. This mixture Vauquelin declared to come nearest to mother's milk of all preparations. The administration of some beef-soup, well made, a cupful every day (mutton-broth when there is a ten- dency to diarrhoea), is advisable towards the end of the first year. Long before this period, indeed at any time during in- fancy, it is indicated in cases of early rhachitis, though there be but few symptoms such as rhachitical constipation, undue adi- posity, or retarded teething. Beef -tea, well made, in a bottle swimming in the water-bath, is still believed by some to be the model food. That it is not so rich in soluble albuminoids as was believed, ought to be generally understood by this time. What, however, it does contain in large quantities is salts. Thus it is a dangerous article in summer diarrhoea, and must never be administered by itself. When given at all, it ought to be in combination with farinacea, raw albumin (which in this mixture requires very little salt, if any). Beef -broth, as far as albuminoids are concerned, is about as nutritious as whey, and no more. But on account of the ex- FEEDING OF SICK CHILDREN. 41 tractive substances of beef, kreatin and kreatinin, it is more stimulating. The temperature of the body is not raised by it. In gastric irritation, gastritis, and acute dysentery it ought not to be given. Veal-broth is liable to increase diarrhoea, mutton- broth constipation, and the latter is therefore preferable in cases of diarrhoea. A broth of beef, which contains from 1.5 to 2 per cent, of albumin, is made by mixing one part of beef and six of water with a little chloride of sodium and allowing it to stand from ten to twelve hours. Then it is slowly boiled and the whole mass pressed out. Still better is a modification of Liebig's beef-tea, which is obtained by adding one half-pint of water, with six or seven drops of dilute muriatic acid, to a quarter or one-half of a pound of finely-cut lean beef, stirring it occasionally during two hours, and boiling a few minutes. Beef-juice obtained by pressing out beef after slightly broiling it, contains from six to seven per cent, of albumin. It is slightly acid, and spoils quickly. The peptonized beef preparations are available both inter- nally and for rectal alimentation. They may be mixed with hot water or hot broth; a few teaspoonfuls and upwaid are valuable additions to the daily food. Those who object to some of them, because of their strong aromatic taste and color, will still relish them when quite cold. Still, the administration of peptones should be controlled by a careful consideration of the condition of the digestive organs. The last product of gastric digestion is albumose; the formation of peptone is not com- pleted until the diastatic action of the pancreas, and perhaps also of some intestinal bacteria, has reached the chyme. It was taken for granted that neither albumose nor peptone could be formed without the presence of hydrochloric acid. In part this is a mistake, for dogs deprived of their stomachs, and men with no such secretion, are known to prepare them. Still pep- tones have been given for the purpose of supplying what the stomach could not, or was supposed not to be able to, furnish. It has a bitter taste, is not always well borne, even in the rec- 42 THERAPEUTICS OF INFANCY AND CHILDHOOD. turn, and may cause vomiting or purging. A teaspoonful of most of the peptone preparations holds from three to four grammes of albumin, a fair addition to the nutriment of a patient whose condition requires much, and much digestible food. Still, sight should not be lost of the condition of the. digestive mucous membrane. In conditions of fever, conges- tion, catarrh, etc., absorption is very slow; mainly peptone is not absorbed, dyspeptones are formed, and a severe form of autoinfection may be the result. Scraped beef, raw, has been highly recommended in the chronic stage of, and convalescence from, exhausting gastro- enteric catarrh these forty years. It is very digestible, and but for the danger of causing taenia mediocanellata, a valuable addition to our means of restoring health. White meats con- tain less fat, haemoglobin, and extractive material than beef. Sweetbread (thymus), 22 per cent, of albumin, 6 gelatin, but 0.4 fat, 1.6 salts, and 70 water. Meat thoroughly dried in the water-bath, and finely pow- dered, also hard egg albumin in the same condition, are easily taken in milk; they are excellent additions to a patient's diet, at a somewhat advanced age (at and after three or four years). Egg has been utilized as an admixture to milk, or as its sub- stitute, in a great many ways. Both the yelk and the albumin have been so employed. The white of an egg, with a little salt and six ounces of water, well beaten and shaken, is a good mix- ture, which can take the place of infant food only temporarily, but is an invaluable make-shift in severe intestinal catarrh, or a permanent nutriment in the same, when added to other food. Falkland skims milk, and transforms it by means of pepsin. The process does not recommend itself to general use on ac- count of its circumstantiality. Eoberts heats milk to nearly a boiling-point, and treats it with liquor pancreatis and bicar- bonate of sodium. Fairchild's method of peptonizing milk is generally understood all over the country and is widely appre- ciated. J. Kudisch's method of improving cow's milk for the FEEDING OF SICK CHILDREN. 43 use of children and adults, sick and well, particularly those who suffer from gastric catarrh and do not digest milk in its usual composition, consists in mixing twenty-five minims (half a teaspoonful) of dilute hydrochloric acid with a pint of water. Then a quart of milk is added. When this mixture is boiled but a few moments it keeps well, and is quite palatable and highly digestible. Somatose is one of the artificial preparations which deserves some credit, first, because of the absence of such nucleins as irritate the kidneys; second, because it is a genuine albu- mose, a teaspoonful of which contains as much albumin as is held in half an egg or three tablespoonfuls of milk. Thus, a number of teaspoonfuls, well diluted in water or in broth, or now and then in milk, may be given daily in cases of anae- mia, or slow convalescence, or in sickness. To recommend it as a regular food is "trade;" to add it to cow's milk so as to make it "resemble human milk" (Rieth) is sheer nonsense. G. Klemperer, who discussed the artificial nutriments of the trade lately (Berliner Tclin. Woch., 1897, No. 26), takes excep- tion to every one because of their uselessness in "almost" every case. He correctly states that the products of the trade are ex- pensive, are mostly inferior to their promises and claims, and under ordinary circumstances should not be substituted for the direct products of nature. That is exactly the position I have always taken in regard to artificial foods; but the practitioner, who deals both with commonplace and with exceptional cases, is glad now and then to fall back on some preparation which, while not requiring the normal process of digestion, may save life in a given case. There is no food which suits every stomach or every case in the well or in the sick, and the greater the facility of a wholesome change the better. That is why, now and then, the artificial farinaceous foods, in which amy- lum is more or less transformed into dextrin, are filling a gap in the rare cases in which milk, though ever so well prepared, or the cereals, like oatmeal or barley, are not tolerated. Of the 44 THERAPEUTICS OF INFANCY AND CHILDHOOD. artificial foods extract of malt, which, with its albuminoids, fifty-three per cent, of sugar and fifteen of dextrin, is so nutri- tious that a tablespoonful is the equivalent of an egg, may be very serviceable. The percentage of sugar it contains is very nutritious; in the same way the effect of sugar (cane- and milk-), also of honey, ought to be utilized oftener than it seems to be usual. The hydrocarbons, generally, are the main food for the feeble and the feverish. Even the well will get along, for a time, with less albumin than was claimed by Liebig and by Voit, provided they are supplied with non-nitrogenous food. Under these conditions Hirschfeld limits the quantity of albu- min demanded by an adult to thirty or forty grammes (one to one and a half ounces). Alcohol has conquered its place among the medicinal foods in the diseases of infancy and childhood. Very little, if any, is required in catarrhal, or the first stages of inflammatory, diseases. It is contraindicated in meningitis, acute cardiac ailments, gastro-enteritis, peritonitis, and acute dysentery. It finds its application in depressed strength and vitality; thus, in the rules for the management of infants during the hottest (the very hot only) days of summer, distributed by the Health Department of the city of New York, I recommended the ad- ministration of a teaspoonful of whiskey daily. It is also re- quired in chronic diseases and slow convalescence. Its action is stimulant, nutritive, antipyretic, and antiseptic. It is decomposed into carbonic acid and water, and thus saves the waste of material parts of the body. When its odor is per- ceptible in the breath of the patient, it ought to be stopped or diminished. That is very liable to occur, for instance, in pneu- monia, in the first stage of which alcohol is but rarely indicated, or tolerated. When given in sufficient quantities, it reduces the temperature; the amount required for that purpose is, accord- ing to Binz, forty grammes, corresponding with about three ounces of brandy or whiskey. Its most beneficial action is exhibited in sepsis of all forms, mainly also in the septic varie- FEEDING OF SICK CHILDREN. 45 ties of erysipelas, no matter whether there are brain symptoms or not, and of diphtheria. Here it is almost impossible to give too much. The doses must be watched so as to be sufficiently large. Whoever is not afraid of giving, in diphtheria, six ounces of whiskey daily to a child when one or two fail, or ten or twelve when six fail, will soon convince himself of its power for good. It must never be given in concentration; the gastric mucous membrane tolerates no pure brandy or whiskey for any length of time; they must be diluted with either water or milk properly prepared. Wines, brandies, and whiskeys are not equivalent. In our country the latter is obtained pure with greater facility, and at less expense, and besides has, for many, a less disagreeable taste than either of the others, which are often adulterated. The ether contained in wines militates against any antifebrile effect which may be expected from it; the fusel oil, also the furfurol (or pyromucic aldehyde), and the salicylic aldehyde, which is used in the manufacture of bitters, and the artificial bouquets, with which brandies are too fre- quently adulterated, act rather as paralyzing than as stimu- lating agents. Dyspepsia is one of the functional disorders of the stomach, and depends sometimes upon slight changes in the gastric mu- cous membrane. It consists in partial or complete loss of ap- petite, with more or less impaired digestion. In regard to this, however, in every individual case, it is good not to rely too. implicitly upon the reports of mothers or nurses. Older chil- dren will complain of prascordial heaviness. They will suffer, as do infants also, from eructations, which, when they result from swallowing air, are absolutely odorless, but when they consist of actual gastric gases, have a very faint odor. A sen- sation of oppression and frontal pain is complained of by older children; the younger ones are apt to vomit. The causes of dyspepsia must be sought for either in ana- tomical changes in the organ, which can rarely be proved; or (more frequently) in quantitative or qualitative changes in the 46 THERAPEUTICS OF INFANCY AND CHILDHOOD. secretion; or in a changed nervous influence, as, for instance, in fever; or in an abnormal condition of the food, which is the most frequent cause. The treatment of this disorder consists chiefly in abstinence or in the use of the greatest care in the preparation of meals. Milk requires boiling, peptonizing, or treating with muriatic acid according to the method I have detailed before. In every case the admixture of farinaceous decoctions and a little salt improves the digestibility of milk though prepared as de- scribed. In many the latter alone, with or without a meat soup, will be the only food which is tolerated. The gastric secretion of infants who have been fed artificially, is liable to be hyperacid. Alkalies should be given at once. The addi- tion of a few grains of bicarbonate of sodium (baking-powder) to the food may suffice. A few grains of an alkali (magnesia, sodium, calcium, according to the indications explained else- where), given a few minutes before every meal, act more surely. Vomiting has been mentioned among the symptoms which accompany dyspepsia. In the infant, however, it is almost a normal occurrence. The infantile stomach is vertical and more or less cylindrical, and the fundus but little developed. Thus, whenever there is a tendency to empty the stomach the antiperistaltic motions do not press against the fundus, but directly upward. There is, therefore, less genuine vomiting than a mere overflow of the contents, which mostly takes place so easily that the babies are not disturbed by it. The treatment of such cases, if treatment be required at all, would consist in the application of some dietetic rules. The infant should have less food, and at longer intervals; should not be carried about immediately after meals; ought not to be shaken or jolted; nor carried face downward. This overflow takes place, as a rule, immediately after the baby has been nursed; at that time the milk is still fluid. If vomiting occur a little later, the milk will be coagulated; if, then, the milk be not coagulated, the stomach is not in a nor- FEEDING OF SICK CHILDREN. 47 mal condition. In these cases, and particularly when the baby lives on artificial food, there is uneasiness and pain associated with the vomiting. An acid mucus is expelled, together with the contents of the stomach; these are the cases in which anti- fermentatives, such as nitrate of silver, bismuth, resorcin, are indicated. Sometimes antacids alone will suffice, as detailed before. Gastkitis (Acute Gastric Catarrh). — The feeble, the anaemic, the convalescent, and the feverish are predisposed to this affection. But it may occur in the previously healthy as well. In all such children the production of normal gastric acid is diminished. Besides, in all of them, the muscular power of the stomach is reduced. Cold or hot ingesta, too large quantities of food, acids, spices, irritant medicines, alcoholic drinks, fat meat, cake, decom- posed food with its ferment, each may be the cause of acute gastric catarrh, and must be carefully avoided; dentition, as such, is not a cause. Exposure to changes or temperature is apt to produce gastritis, but the usual cause is improper food. A single small meal, consisting of, in that case, indigestible food, increases pain, vomiting, and fever. Abstinence and cold water to the head act well when there is a tendency to convul- sions. Cold applications to the heart will also reduce the tem- perature of the whole body. A warm bath will frequently do good; but bathing and handling the child should proceed with great caution and very gently while a convulsion is lasting. When thirst is very great, small quantities of ice-water should be given often, or seltzer-water, or Vichy, or Apollinaris; also water to which dilute muriatic acid has been added in the pro- portion of one to three or ten thousand. Solid food must not be taken. When there is a great deal of mucus, milk should be given, if at all, very much diluted, or prepared after Budisch's method. When the tendency to vomit is great, food and drink must be given in teaspoonful doses, and, when the sensitiveness of 48 THERAPEUTICS OF INFANCY AND CHILDHOOD. the stomach is very marked, mucilaginous and farinaceous foods only will answer, together with small doses of bismuth repeated every one or two hours. Where acid is predominant, calcined magnesium will answer best, if given in small doses frequently repeated; also bicar- bonate of sodium, and very small doses of opium, one-sixtieth to one hundred and fiftieth of a grain, every hour or two hours. Chronic Gastric Catarrh is either the termination of an acute catarrh, or of the persistent continuation of injurious in- fluences. Large and frequent meals, too cold or too hot food, and fast eating are frequent causes. The stomach may be either in a hyperaemic or in an anaemic condition; it may be hypersesthetic or atonic. Its secretion may be faulty or defi- cient. All of these changes may take place in the stomach without any complication on the part of neighboring organs, or these may be the only, or partial, causes of the gastric dis- order; thus pre-eminently cardiac or pulmonary ailments, which result in impaired circulation of the distant organs. In- deed, many a chronic catarrh of the stomach, both in the young and adult, requires among its first indications a proper atten- tion to the original cause. At all events, the number of meals and amount of food must be adapted to the digestive powers. Medication can do good service in most cases, either such as is directed to the mucous membrane itself (alkalies, bismuth), or to its faulty secretion (pepsin with muriatic acid, resorcin), or to the debilitated condition of its muscular power (strychnia). At all events, the children must be taught to eat slowly. Their food must be tepid, and not too much diluted, inasmuch as ab- sorption in many cases is slow. Sugar, fat, and starch must be allowed in small quantities only. Ulcerations of the stomach (and duodenum) demand that the organs should be kept as alkaline as possible. Abnormal acids (acetic, butyric, caprylic, or lactic in excess) must be neutralized before food is given. An occasional antacid is not sufficient to obtain that end; it must be given regularly, every FEEDING OF SICK CHILDEEX. 49 two or three hours, also a few minutes before a meal. Sodium and magnesium salts, which contain carbonic acid, must not be given regularly. That gas produces peristalsis. Calcined magnesia answers best in doses of one or two grains, adminis- tered every hour, or every two or three hours, in water which must not be too cold. Hot water is even better. More than that quantity is seldom tolerated because of its purgative effect (which, however, is very welcome, to a certain extent, in pa- tients with a tendency to constipation). When a larger quantity of antacids is required, carbonate or phosphate of calcium may be added to the magnesium, with or without the subnitrate or subcarbonate of bismuth. In such a condition the effect of lime-water is in part imaginary. If given for the purpose of neutralizing strong acids, it is a failure. That medicinal treat- ment must be continued through weeks or months. Without it I see no gastric or duodenal ulceration getting well, in spite of the most careful dietetic regulations. The very function of the diseased organ is a great danger. Both stomach and duodenum must be kept as idle as possible, and their labors made easy. ~No indigestible food must be given, no solid food permitted. Most cases in older children bear boiled milk (in some mixed with a little bicarbonate of sodium), strained oatmeal or barley gruel, rice or arrow-root water, and stale wheat-bread; a few, also, raw beef, scraped. Some tolerate nothing but boiled milk, or buttermilk. There are those who prefer koumiss, matzoon, peptonized milk, or that prepared with muriatic acid. Whatever they take must be swallowed slowly. Milk, when drank hastily, is liable to coagulate in big, hard lumps, and proves indigestible and in- jurious. The same milk, when taken by the mouthfuls, or from a spoon, will prove beneficial. The milk should be boiled in the morning, and heated over again several times during the day, or it should be sterilized. It must not be cold when taken, and may be mixed with a little table-salt. Many prefer, and tolerate best, the mixture of milk and cereal decoctions. 4 50 THERAPEUTICS OF INFANCY AND CHILDHOOD. Such must be the food for weeks and sometimes for months; the meals must be small and more numerous. Thus the pa- tients will get well, and thus only. Acute and Chronic Enteritis, Intestinal Catarrh, with diarrhoea as a prominent symptom, compare with acute and chronic gastritis in their mutual relation. Acute catarrh of some duration extends mostly over the whole intestine; its worst cases are also complicated with the same condition of the stomach. The most serious forms are those of "acute gastro- enteritis." In them the diet must be a very strict one. No raw milk, no boiled milk, no milk at all in any mixture, in bad cases. In the very worst cases total abstinence for from one to six hours, or much longer; afterwards, teaspoon doses of a mu- cilaginous or farinaceous decoction from time to time. A good preparation is the following: Five ounces of barley-water, one or two drachms of brandy or whiskey, the white of one egg, salt, and cane-sugar; a teaspoonful every five or fifteen min- utes, according to age or case. Later on, a tablespoonful of boiled milk may be added. The same may be mixed with mut- ton-broth, which, with the white of egg, is better than beef- soup or beef-tea in convalescence. In vomiting, abstinence is mostly superior to ice; the latter may sometimes quiet the stomach, and feel pleasant momentarily, but it stimulates peristalsis. Beef-tea, in its customary preparation, ought to be avoided. In convalescence, when given at all, it ought to be mixed with barley- or rice-water. Towards the end of the dis- ease, or when the discharges are numerous and copious, the blood becomes inspissated, the circulation slow, and throm- boses (hydroencephaloid) form in the smallest veins of distant organs. Then it becomes necessary to introduce liquid into the circulation by administering water through the mouth or, if it tolerates it, the rectum; in desperate cases the infusion of a sterile salt-water solution (6 : 1000) into the subcutaneous tis- sue, once or repeatedly, may save life. Never is the common sense and tact of the intelligent practitioner more thoroughly FEEDING OF SICK CHILDREN. 51 taxed. In regard to that there can be no law. No printed rule ever supplies or substitutes brains. In chronic cases boiled milk must form but a small part of the food. The white of eggs in water, or in barley- or rice- water, is superior. Still, there are exceptional cases in which even they are not tolerated. Then the cereal and farinaceous preparations, with or without mutton-broth, are preferable. In rare cases one of the better artificial foods is quite successful. Acorn coffee, acorn cocoa, answer well when given once or twice daily. The meals must be small, and may be more nu- merous, but a fair regularity must be kept up. Constipation may have many causes. The intestinal mu- cus may be deficient or too viscid. Such is the case in febrile conditions, now and then in chronic intestinal hyperemia, and also when there is too much perspiration and secretion of urine. Or the food may be inappropriate, as when it contains a super- abundance of casein, particularly in cow's milk, or of starch, or too few salts, or of sugar. Peristalsis may be incomplete through rhachitie debility of the muscular layer, or the muscular weakness dependent upon sedentary habits, chronic peritonitis, intestinal atrophy, and hydrocephalus. There is, also, besides mechanical obstruction by cystic tumors, intussusceptions, volvulus, and imperforations, an ap- parent constipation which ought not to be mistaken for any of the above varieties. Now and then a child will appear to be constipated, have a movement every two or three days, and at the same time the amount of fseces discharged is very small. This apparent constipation is seen in very young infants rather than in those of more advanced age. Such children are ema- ciated, sometimes atrophic. They appear to be constipated be- cause of lack of food, and not infrequently this apparent con- stipation is soon relieved by a sufficient amount of nutriment. Constipation resulting from a superabundance of starch in the food is easily cured by the withdrawal of the injurious sub- stance. 52 THERAPEUTICS OF INFANCY AND CHILDHOOD. Constipation produced by too much casein in the food will be relieved by diminishing its quantity. The proportion of casein in the food of infants should never be more than one per cent. Besides, this amount of casein ought to be copiously mixed with a glutinous decoction (oatmeal). Infants that have been fed on starchy food, or even such cereals as barley, should have oatmeal substituted for it. Constipation depending on lack of sugar is very often speedily relieved by increasing the quantity of sugar in the food. This is the case not only in artificial feeding, but also when the children are fed normally on breast-milk. Such mother's milk as is white and dense, and contains a large amount of casein, is made more digestible, and will produce better evacuations, when a piece of loaf-sugar dissolved in tepid water, or in oatmeal-water, is given previously to every nursing. Older children will take honey to advantage, as long as it does not add to the abnormal gastric acids. Eegular doses of cod- liver oil, given twice or three times daily, will obviate or relieve constipation, besides fulfilling other indications. But it is self- understood that it must be pure, and not adulterated by the fashionable admixture of phosphate of calcium. Children of more advanced age, and with good gastric digestion, will be benefited by breads containing husk. Children of any age will be benefited by drinking large quantities of water. Ehachitis is sometimes the result of protracted intestinal disorders. Therefore proper feeding is an absolute necessity. Animal food must predominate, but meat ought to be lean. The so-called erethic rhachitis of thin, nervous children re- quires less meat, but more of the better class of farinaceous foods, — viz., barley, and oatmeal, with boiled milk, and salt. The same indications are valid for all the conditions subsumed under the head of scrofula. Coarse bread, acidulated food, fruit not absolutely ripe should be avoided. The introduction of phosphates, in whatever shape, is a mistake, for the following reasons: FEEDING OF SICK CHILDREN. 53 In the careful experiments of Foster, who fed infants on milk, it was found that the mineral constituents were absorbed least (still less than fat). Of the ashes of milk in general, there were in the faeces 36.5 per cent.; of the calcium in particular, seventy-five per cent. In spite of that the baby throve, and in- creased in weight in one week one hundred and seventy grammes. Thus there appears to be but very little need of salts on the part of the growing baby. The infant of two and a half years receives in one day 1.25 grammes of calcium, of which there is an elimination of 0.92 gramme in the faeces and 0.03 in the urine. There is then a balance of 0.3 gramme in a day, of 2.1 in a week, of a kilogramme, or two pounds of cal- cium, in a year. This is all that is utilized. Almost the entire quantity of calcium in the body is depos- ited in the bones, which contain eleven per cent, of calcium in the adult, and in the infant and child somewhat less. There are some very important practical points connected with the results of these observations. As long as the food contains plenty of calcium and phos- phoric acid there is certainly no indication for the introduction of the same in the form of medicine, or as an addition to food, for the purpose of improving nutrition. Thus the combination of cod-liver oil with phosphate of lime, which has become so fashionable, is based upon an illusion concerning its alleged efficiency. Besides, the empirical observation has been made also, at a very early time, that immediately after the adminis- tration of preparations of calcium there was increased elimina- tion through both the fasces and the urine. Thus, as there is no actual absence of calcium phosphate in the food, the organism should be spared useless labor. In occasional cases, where the effect appears to be favorable, this very effect is different from what was intended. When rha- chitical or anaemic infants are supplied with phosphate of lime, and iron, bismuth, etc., they are generally patients who are suf- fering from primary or secondary catarrh of the stomach, with 54 THERAPEUTICS OF INFANCY AND CHILDHOOD. superabundance of acid in its secretion. In these very cases the calcium phosphate acts as an antacid, inasmuch as phos- phoric acid becomes free and the lime neutralizes the acids of the digestive organs. Fever consumes nitrogen (elimination of urea), carbon, water, and also salts. These losses must be repaired, but with great care. For fever diminishes at the same time the secre- tion of saliva, and of gastric juice, probably also that of the pancreatic secretion. Besides, it renders the stomach hyper- Eesthetic (nausea, vomiting), and impairs the absorbing power of all the mucous membranes. In the capillary bronchitis of the nursling, cow's milk is not digested satisfactorily. Still, nurslings will digest fairly sometimes, and lose less flesh in many of their febrile ailments than older children. A small amount of peptones is absorbed both in the stomach and rec- tum. In moderate fevers some sugar is absorbed, also albumin; fat in but small quantities, because of its tendency to become acid; starch finds its saliva more or less diminished; thus its amount must be carefully estimated. Food, when given in an undue quantity, may act injuriously by acting as a mechanical irritation, and by giving rise to fer- mentation. Can it thus increase the fever? Undoubtedly. We see frequently children sick with pain and fever who re- cover rapidly through the effect of a purgative, which brings away large masses of faeces. Others have what appears to be a second relapse of typhoid fever, and often is but the result of intestinal autoinfection, with a renewal of splenic tumefaction. All the symptoms vanish speedily, in many instances when the bowels are thoroughly emptied of large offensive stools. In ordinary fevers the food must be liquid, and rather cool, in vomiting cold, in respiratory diseases warm, in collapse hot. The best feeding-time is the remission; in intermittent fevers nothing must be given during the attack except water, or acid- ulated water, now and then with an alcoholic stimulant; in septic fevers nothing during a chill, except either cold or hot FEEDING OF SICK CHILDREN. 55 water, according to the wishes of the patient, with an alcoholic stimulant. Common ephemeral catarrhal fevers may do with- out food (except water) for a reasonable time. Sleep must not be disturbed, except in conditions of sepsis and depressed brain action. In both there is no sound sleep, but sopor, which should be interrupted. In sepsis (diphtheria and other) this rousing from sopor is an absolute necessity. Unless they are roused frequently to be fed sufficiently, and stimulated freely, the patients will die. Besides, in most of the cases, the tem- peratures are not high, and there is no contraindication to feed- ing on that account. Chronic inflammatory fevers bear and require feeding as generous as it must be careful. Altogether, however, it re- quires the good judgment of a well-informed physician to take into account the possible influences of individual habits, and energies, of ages and sexes, of constitutions, and of climate and season. Typhoid fever is of long duration, its temperature is some- times quite high in children, when of more advanced age. The small intestines are affected principally. Thus, not only is, after the first few days, a fair amount of food required, but it must be so chosen as to be digestible in the stomach; its proper selection is the more important the more the latter organ is impaired by high temperatures. Besides plenty of water, or acidulated water (hydrochloric, no organic, acid), albuminoids are indicated. Milk and cereals (in decoctions, which must be strained) are the proper foods. The administration of stimu- lants, both as to quantity and to time, depends on the charac- ter of the individual case, and the power of resistance on the part of the patient, besides on the condition of the heart. Where the latter becomes feeble at an early period, besides heart-stimulants (digitalis, sparteine, caffeine, camphor), alco- holic stimulants are required. Diarrhoea demands (besides opium, naphthalin) albumin, rice-water, arrow-root, mutton- broth. Hemorrhage, which fortunately is very rare in children, 56 THERAPEUTICS OF INFANCY AND CHILDHOOD. forbids food in any shape for a time, the duration of which depends on the general condition of the patient. At no time during the disease, and during the first ten days of fully estab- lished convalescence, should the food ever be solid. No veg- etables must be allowed until three weeks have elapsed since the beginning of apyrexia. When milk and cereal food be- come distasteful, a change in their preparation, as described above, are indicated. During most of the time broths of mut- ton, beef, or chicken, may also be given, or beef-juice or pep- tones diluted in water or in broths. The large majority of relapses are due to a dereliction in the strict rules of feeding. The diet in other chronic or acute diseases is regulated by the general rules which have been laid down before. Thus, a few words may suffice. Hereditary syphilis contraindicates the employment of a wet-nurse. The infant's own mother may nurse it if she can. Cerebral diseases contraindicate alcohol, coffee, hot soups, and solid foods. Cerebro-spinal meningitis results in speedy loss of weight and strength, particularly through severe and protracted vomiting, and the greatly-impaired appetite. In these cases feeding must be insisted upon. The feeding-cup, Soltmann's biberon pompe, and feeding through the nose (usually no tube into the oesophagus when there is much vomit- ing) must be resorted to. Eespiratory diseases require liquid food. Jurgensen's recommendation of roast, and bread with butter, is objection- able in every acute inflammatory case. Food and drink must not be too cold. Sugar, and sweets in general, are permissible in small quantities only. Farinaceous foods are the most re- liable ones. In the beginning no alcoholic stimulants. They will be required when debility and collapse set in at an early time, or in protracted cases. Capillary bronchitis is often com- plicated with gastro-enteritis, and then no milk can be allowed; sometimes not even breast-milk is digested. FEEDING OF SICK CHILDREN. 57 Acute renal diseases contraindicate alcohol in any shape, particularly beer; also spices, coffee, and tea. Chronic benal diseases require generous feeding, because of the copious loss of albumin. But — contrary to Oertel and Loewenmayer — no eggs or meats ought to be given in any quantity, or at an early period. Milk and farinacea must take their places. Alcohol, as a stimulant, is permissible in urgent cases only. Salt must be avoided except when the secretion of urine is to be fostered. It ought not to be forgotten that appetite and digestion may be suffering from the fact that the tissue of the stomach is cedematous, like all the rest of the organs. This is another reason why eggs and meats ought to be avoided. If re- quired, in the later stages, peptones may take their place, but in small quantities only. Albumoses, such as somatose, are a good addition to the food, easily borne and readily absorbed. Milk in any shape and preparation is the main article of diet. It has no such nuclein as favors the formation of uric acid, and no extractive matters which contraindicate the use of meat in diseases of the kidneys. Acute rheumatism requires milk (also farinaceous) diet and vegetable acids (lemonade), the latter as long and at such times as they do not interfere with the milk food. RECTAL ALIMENTATION. The rectum absorbs, but it does not digest. Whatever, therefore, is to enter the circulation through the lower end of the alimentary canal must be dissolved before being injected. Suspension alone does not usually suffice. Water can be intro- duced in quantities of from twenty-five to one hundred grammes (one to three ounces) every one, two, or three hours, and may thus save life by adding to the contents of the thirsty lymph-ducts and empty blood-vessels. Salts in a mild solution, with cane-sugar, which is transformed into grape-sugar, and emulsionized fat, will thus be absorbed. Food must be more or less peptonized before being injected. Albumoses (for in- 58 THERAPEUTICS OF INFANCY AND CHILDHOOD. stance, "somatose") are readily absorbed in the rectum, so are also the peptones mentioned above when fairly diluted. When too thick they are not absorbed, become putrid, and a source of irritation. Milk ought to be peptonized. The white of one egg becomes absorbable through the addition of one gramme of chloride of sodium. Kussmaul beats two or three eggs with water, keeps the mixture through twelve hours, and injects it with some starch decoction. The latter is partly changed into dextrin. Fat, when mixed with alcohol, becomes apt to be partly absorbed. Andrew H. Smith recommends the injection of blood. Its soluble albumin, salts, and water are readily ab- sorbed; more we ought not to expect. Still, he has observed that the evacuations of the next day contained none of the in- jected blood. Whatever we do, however, and be the rectum ever so tolerant, not more than one-fourth part of the nutri- ment required for sustaining life can be obtained by rectal in- jections, and inanition will follow, though it be greatly delayed. Finally, children are not so favorably situated in regard to nutritious enemata as adults. In these the lengthening of the nozzle of the syringe by means of an elastic catheter permits of the introduction of a large quantity of liquid; indeed, a pint can be injected, and will be retained. But the great normal length of the sigmoid flexure in the infant and child, which results in its being bent upon itself, prevents the introduction of an instrument to a considerable height. It will bend upon itself; besides, a large amount will not be retained by the feeble or resisting young patient. The amount can be some- what increased by raising the baby by his feet, while the chest and abdomen are supported by a soft pillow, and by injecting quite slowly, or, rather, allowing the liquid to flow in from above downward. While the procedure is going on, the ab- domen should be gently manipulated. When a solid instru- ment is used, it is apt to be felt high up in the abdomen. This is the result of a large portion of the intestine being pushed upward with the tube. FEEDING OF SICK CHILDREN. 59 The ingenuity of the practitioner will sometimes be severely taxed in regard to the choice of the mixture to be injected. Boas recommends for an adult two hundred and fifty cubic centimetres (eight ounces) of milk, the yelks of two eggs, a gramme of table-salt, a tablespoonful of claret, and a table- spoonful of diastased farinaceous food; Dujardin-Beaumetz, one glass of milk, the yelk of one egg, two or three table- spoonfuls of liquid peptone, five drops of laudanum, and one gramme of bicarbonate of sodium. The injections ought not to be too watery, and of the temperature of the body. When the rectum is very sensitive, the addition of a mild opiate is advisable at all events; sugar, alcohol, and whatever is apt to irritate the rectum, should not be given in large quantities. Straining, abdominal pressure generally, may be overcome by supporting the perineum and compressing the sphincter. (See also p. 71.) FORCIBLE FEEDING. When children or infants refuse, or are unable, to take food, forcible feeding should be resorted to. A proper amount of liquid food, from one-half of a pint to a pint or more, according to age, or to circumstances, should be introduced into the stomach by means of a sound of proper size several times a day. The procedure need not last longer than a few minutes, and the tube drawn out quickly so as not to irritate the pharynx. Nasal feeding is best accomplished through a small funnel which, to avoid pain, terminates in a short piece of India-rub- ber tubing. This is introduced into the larger nostril, the patient is held firmly on his back, and just enough food is poured in to allow the child to swallow. A small syringe, from which the piston has been withdrawn, may take the place of the funnel. II. GENERAL THERAPEUTICS. Thekapeutics of infants and children has enjoyed, or suf- fered from, its fate like "books" and that of adults. It has had its stages between the era of dull and ignorant prescribing and that of impotent and conceited nihilism, and of churlish pes- simism. But neither a deluge nor an absence of drugs make a physician, nor do they contribute, when alone by themselves, to the welfare of a single individual or of the community. Much has been said of the difficulty of a diagnosis in the diseases of infancy and childhood, and the consequent diffi- culty experienced in treating them. I do not believe that the diagnosis in the case of an adult is much easier. The latter will often mislead you intentionally, or because he is carried away by prejudices and preconceived notions; the former may conceal by not being able to talk, but will certainly not tell an untruth. Besides, the ailments of children are but rarely com- plicated, and a single diagnosis tells the whole story. If it be not made, it is perhaps best for the practitioner not to attempt much doctoring, and for the patient to be left alone. For, happily, most diseases have a tendency to get well, either com- pletely or partially, and many will run a more favorable course when not meddled with. This does not mean to say, however, that I discourage treat- ment even in such ailments as run a typical course extending over a number of days or weeks. On the contrary, I am op- posed to the practice — much too common — of those who do not, for instance, wish to interfere with a whooping-cough because it finds its natural termination after several months. This is true, but many of the children find their natural ter- mination also during these months. Every day of whooping- 60 GENERAL THERAPEUTICS. 61 cough is a positive danger. A lobular pneumonia which occurs in the second or third month of the disease, and proves fatal or terminates in phthisis, would have been prevented if the origi- nal affection had been removed or relieved by treatment. A physician advising no treatment in such cases as terminate un- favorably in this manner, ought to be made punishable in the state of the future. Nor do I approve of the practice of "meet- ing symptoms when they turn up." My responsibility is not lessened by my busying myself with subcutaneous injections of brandy when a collapse has set in which I ought to have fore- seen and prevented, or with giving digitalis when on the fifth or sixth days of a pneumonia the pulse is flying up to 160 or 200. Anybody can perform that sort of perfunctory expectant treatment extending from the first call to the writing of a death certificate. What I expect of a physician is to know beforehand whether that individual heart will carry its owner through an inflammatory or infectious disease without requiring stimula- tion or not. Many a case might be saved by a few grains of digitalis, or another cardiac tonic, or a few efficient doses of camphor or musk, if administered in time. Altogether, it has always appeared to me most satisfactory to treat children, and particularly infants. They are truthful, unsophisticated; they are what they appear, and they appear what they are. In their pathology and therapeutics there is no mysticism, no faith-cure, no spiritism, nor any other diabolism. Their diseases are seldom influenced by mental impressions and emotions, and for that reason "suggestion," hypnotism, or any other confidence game has no power over them. Their nature and that of their ailments are simple enough, but you must know how to understand them. Unfortunately, however, for incompetent diagnosticians, children are no mere miniature editions of adults, and their ills and whims and their peculiari- ties must be known, patiently studied, and, together with the ignorance and the prejudice and caprices of the parents, en- dured. 62 THERAPEUTICS OF IJSTFANCY AND CHILDHOOD. There is one all-important principle in treating infants and children which cannot be repeated too often. They are very liable to become ansemic, to submit to general inanition, and suffer from failure of the heart in spite of its anatomical and physiological vigor. These facts render it urgent that the physician never lose sight of the general condition of the pa- tient while attending to a local disorder. The best treatment is preventive. Proper feeding and nursing of the infant prevent the numerous gastric and in- testinal diseases of the earliest period, which either destroy life at once or lay the foundation of continued ill health. For that reason a rather large part of my literary labors has been dedicated to the questions of diet and hygiene. These and medication belong together. That is why the first chapter could not help containing some remarks on medicines, and this one, dedicated to therapeutics, cannot abstain from referring to diet. Those who still object to medication on the "principle" of ignorance, or worse, are requested to determine the boun- dary-line between medicinal and hygienic agents or products. Attention to respiration and circulation and to the functions of the skin are of similar moment. Their requirements will be discussed in special chapters. The subjects of climate, massage, electricity, orthopaedics, and gymnastics will find their places' With the diseases of the lungs, muscles, nerves, joints, etc. Bathing, cold washing, exercise, sufficiently long interruptions of school hours to avoid exhaustion, are subjects of vital im- portance. The best exercise of the child is play in open air. Compulsory gymnastics in badly-ventilated localities cannot take its place successfully, and may add to exhaustion and ill health. It is an unfortunate fact that when the claims of physical development were urged upon school authorities, gym- nastics were added to the overcrowded curriculum as a matter of business necessity, or of conviction, not always willingly or intelligently. The summer vacations of school-children ought to be four weeks longer than they are. The public schools ought GENERAL THERAPEUTICS. 63 to be closed about the middle of June and reopened in the be- ginning of October. Some years ago the Harlem Medical Asso- ciation and the Medical Society of the County of New York requested the Board of Education of the city to open the public schools on the third, in place of the first, Monday in September. The soundness of the principle was appreciated, and the neces- sity for such a change was acknowledged by the authorities, and therefore (!) the second Monday of September was selected for the beginning of the school season, so as to afford the children an extra week's boiling in the city sun and an opportunity to lose, as they did formerly, the benefit derived from the summer vacation. The sanitary reason for this loss of a beneficent op- portunity was said to be the virtuous anachronism of an eighteenth century school superintendent, who preferred the influence of the school-room to that of the New York streets for the New York boy. The good effects of the excursions of the St. John's Guild, and the air funds, and of the Sanitaria of the Guild, and the Children's Aid Society are steps in the right direction. The subject of bathing, or rather of hydr other apeutics in general, deserves some preliminary remarks in connection with a future discussion on "bathing." There is hardly a topic which deservedly has attracted the attention of the profession (and of the public) in the last decade or two, to a greater degree, than that of water and of its uses as a remedy. As! I am writing no historjr, I mention but two names which merit most credit in outlining both the indications and the methods of its uses, Winternitz, in Europe, and S. Baruch, in America. As its principal claim, was long considered that of serving as an antipyretic. The indication to reduce the tem- perature of the body arises when an excessive frequency of the pulse, degeneration of the tissues of the heart and other mus- cles, of the kidneys and of the brain, dryness of the mucous membranes, and impairment of absorption appear to result from it. Cerebral symptoms, such as delirium and convulsions, are 64 THERAPEUTICS OF INFANCY AND CHILDHOOD. then not uncommon at all. Particularly is that so in the onset of a disease, while the same temperature may be readily endured at a later stage. That is why the elevation of temperature alone, without dangers present or feared, should yield no indi- cation for treatment; indeed, many a child bears easily a tem- perature which carries danger to another; and there are high temperatures in some diseases, such as many forms of typhoid fever or of intestinal autoinf ection, which do not seem to inter- fere much, for a while at least, with the ease and comfort of the patient. Unfortunately, however, the thermometer, ranging 103° F. or more, is too often permitted to establish indications, and the reduction of temperatures appears to become the only acknowledged duty of many practitioners. To reduce temperatures we have drugs and water. Of the former, quinine should not be relied on except in malaria, also in some septic fevers, when it may Fe used by itself or in com- binations. The coal-tar preparations, antipyrin, acetanilide ("antifebrin"), phenacetin, etc., will all reduce temperatures, and have their occasional indications, but are known to depress, one more the other less, the action of the nervous system, and the functions of the heart, and even to destroy blood-corpus- cles. Their administration requires the utmost care, and fre- quently the combination with stimulants to guard against detrimental effects. Water, when properly employed, lowers the temperature, but has none of the depressing effects of the coal-tar antipyretics. On the contrary, it stimulates the nerves of the skin and by reflex those of the whole system, particularly of the heart; it increases heart and arterial pressure, thereby aids oxidation of tissues, and diuresis, and appears even to increase the amount of haemoglobin and of red cells. In this respect there can be no longer a difference of opinion; but in regard to the use of cold washing, with or without friction or effusion, of packing, of ice applications, of hot, warm, or cold baths, of the duration of an application or of a bath, and of the degree of GENERAL THERAPEUTICS. 65 temperature requiring or permitting their employment in an individual case, no iron-clad rule will ever hold good. A cold bath (60° to 75° F.) is seldom, if ever, appropriate for a baby of less than eight months or a year, and never in con- genital heart-disease. It ought to be interrupted when the child begins to shiver, or the lips become bluish; it cannot be expected to have a good effect unless the feet share immediately in the reaction which should take place after the bath. A cold bath should be accompanied with friction of the surface, mainly of the extremities. A warm bath (85° to 98° F.) dif- fers so much from the temperature of a feverish child that a reduction will also be readily accomplished by it. Besides, the patient submits to it more readily. If necessary, the tempera- ture of the bath decreases from minute to minute, or may be lowered by adding cold water. Packs of cold water, iced or not, need not, in most cases ought not to, cover the whole body of the child; feet and legs should be left out. A single thick- ness of a common towel or napkin is wrapped around the body exclusive of the arms, either the chest alone, or the chest and abdomen, or both, and the thighs, according to the more local or more general effect which is to be attained; and a flannel sheet or blanket should cover the pack. More minute instruc- tion on this point will be found in Chapter III. Cold applications, well wrung out, and covered with flannel and oil silk, to small or large surfaces, and alldwed to remain from twenty to fifty minutes until the skin is hot, are efficient stimulants. Hot baths (96° to 105° F.) act as stimulants, but should be given sparingly, as too exciting or exhausting for most patients. Short hot baths, with or without mustard, and with or without cold applications to the head, dilate the super- ficial blood-vessels, and will be found useful in an occasional case of pneumonia, in collapse, or to favor the cutaneous erup- tions of scarlatina and of measles. Because of its grave necessity I repeat here that milk and drinking-water are safest when boiled. It is to be hoped that 5 66 THERAPEUTICS OF INFANCY AND CHILDHOOD. the practiqe of sterilizing milk devised by Soxhlet, of Munich, and introduced in New York by Caille, and systematically em- ployed by Botch, of Boston, and his followers will prove suc- cessful. Mental and physical labor ought to be easy and pleasant. Factory work for children is an abomination, and not only a cruelty committed against the individual child, who is helpless, but a danger to the future of the republic, which can- not be expected to thrive while the physical and intellectual development of the future citizen is crippled by the greed of the manufacturer and the recklessness or the partiality of legis- latures. In the administration of medicines excitement on the part of the patient must be avoided; the nervous system of infants and children loses its equilibrium very easily. Fear, pain, screaming, and self-defence lead to disturbances of circulation and waste of strength. Preparations for local treatment or the administration of a drug must be made out of sight, and the latter ought not to have an unnecessarily offensive taste. Naphthalin, iodoform, betanaphthol, rhubarb, and such like should be shunned. The absence of proper attention to this requirement has been one of the principal commendations of "homoeopathy," whatever that may have been the last twenty- five years. Still, the final termination of the case and the welfare of the patient are the main objects in view, and the choice between a badly-tasting medicine and a fine-looking funeral ought not to be difficult. In every case the digestive organs must be treated with proper respect; inanition is easily produced, and vomiting and diarrhoea must be avoided, unless there be a strict and urgent indication for either an emetic or a purgative. The most correct indications and most appro- priate medicines fail when they disturb digestion; it is useless to lose the patient while his disease is being cured. The administration of a medicament is not always easily accomplished. Indeed, it is a difficult task sometimes, but one in which the tact or clumsiness of the attendants have ample GENERAL THERAPEUTICS. 67 opportunities to become manifest. For "when two do the same thing, it is by no means the same thing." Always teach a nurse that a child cannot swallow as long as the spoon is between the teeth; that it is advisable to depress the tongue a brief mo- ment, and withdraw the spoon at once, and that now and then a momentary compression of the nose is a good adjuvant. That it is necessary to improve the taste as much as possible need not be repeated. Syrups turn sour in warm weather, glyc- erin and saccharin keep; the taste of quinine is corrected by coffee (infusion or syrup), chocolate, and "elixir simplex," a teaspoonful of which, when mixed each time before use, suf- fices to disguise one decigramme = one and a half grains of sulphate of quinine. Powders must be thoroughly moistened; unless they be so, their adherence to the fauces is apt to pro- duce vomiting. Capsules and wafers are out of the question, because of their sizes; pills, when gelatin-coated or otherwise pleasant and small, are taken by many. The rectum and the nose may be utilized for the purpose of administering medicines in cases of trismus, cicatricial contraction, or obstreperousness. Both of these accesses it may become necessary to resort to for weeks in succession. The effect of a medicine depends on its dose and the readi- ness with which absorption and elimination take place. Both are very active in infancy and childhood; but they vary. Cu- rare, for instance, is eliminated speedily, and must be repeated quite frequently; iodide of potassium soon after its adminis- tration, but there are traces in the urine after some days; phos- phate of lime appears in the urine and feces directly; chlorate of potassium is excreted through the kidneys within a few hours, silver and mercury may take a long time, in exceptional cases. Absorption takes place the more readily the more the solution in which the medicinal substance is held is diluted; but it depends greatly on the condition of the surface or tissue which is selected for the introduction of the drug. A horny skin absorbs but little; inunctions require a clean surface, and 68 THERAPEUTICS OF INFANCY AND CHILDHOOD. are best made where the epidermis is thin and the net of lymph-ducts very extensive, on the inner aspect of the forearm and the thigh. A congested stomach, a catarrhal or ulcerated rectum, are more or less indolent, and disappoint our expecta- tions quite frequently. That the doses must be adapted to the ages of the patients is self-understood; but to establish fixed rules is more than merely difficult. To give as many twen- tieths of the dose of an adult as the child has years is a fair average; but this rule suffers from very numerous exceptions. Like foods which are tolerated by the adult, but are not toler- ated by the young, though their amounts be diminished in pro- portion to their years, so there are medicines which are not borne by the infant. Nor are the doses the same for every adult. As healthy persons thrive on different quantities of food, so there is a variableness in the amount of medicines re- quired for full effect. Besides, there are idiosyncrasies which in some forbid the use of a medicine apparently indicated and borne with success by others. There are those who respond quickly, and sometimes too quickly, to very small doses of opium; others in whom a minute trifle of mercury produces salivation. It is this class of cases which gives rise to much disappointment, and requires all the tact and foresight of a good physician. In some the system gets used to a drug after a short time. Babies, after having taken opiates for some time, demand larger, and sometimes quite large, doses to yield a sufficient effect. Some drugs are required in proportionately large doses. Febrifuges and cardiac tonics, such as quinine, antipyrin, digitalis, strophanthus, sparteine, convallaria, are tolerated and demanded by infants and children in larger doses than the ages of the patients would appear to justify. Iodide of potassium may be given in doses of one or two drachms daily in meningeal affections, while in the same one of the heart tonics, caffeine, must be shunned because of its — under these circumstances — exciting and irritating effects. Mercurials af- fect the gums very much less in the young than in advanced GENEBAL THERAPEUTICS. 69 age. Corrosive sublimate, in solutions of one to six or ten thousand, may be given to a baby of two years with mem- branous croup in doses of a fiftieth of a grain every hour or two hours, for five or six days in succession, with rarely as much as the most trifling irritation of the gums or of the stomach and intestines. In urgent cases of hereditary syphilis it can and should be administered on a similar plan for weeks, and, some- what modified, for many months, to be resumed afterwards. If it be the object of medication to accomplish an end and to fulfil an indication with the least expense to the organic economy, and within the briefest possible time, we do not score a success in very many instances. Indeed, not every aim is reached directly, and not all indications can be fulfilled at a moment's notice. As the object of eating and drinking is the reproduction and the growth of the body, as many a meal is required to produce a lasting and visible effect, and as every one of the meals is necessary for the sum total of the final result, so the administration of numerous small doses of medi- cines extending over weeks, months, and even years may be demanded for a certain purpose. Particularly is this so when chronic ailments of the blood, tissue anomalies, or of the ner- vous system are concerned. To affect rhachitis, phosphorus re- quires weeks. The faulty sanguinification of chlorosis is mended by iron after weeks or months. Pernicious anaemia, sarcomatosis, even chorea require the persistent and protracted use of gradually increasing doses of arsenic. Syphilis and chronic conditions of hyperplasia require mercury, or the iodides, or both, to accomplish the desired end through months and even years. Even the effect of digitalis, as a heart stimu- lant and, by its effect on the smallest blood-vessels of the heart muscle, a nutrient, is obtained solely through the persevering administration of small doses in many cases. The dose of a medicine depends no less on the mode and locality of its administration. Modern therapeutics favor as much as possible local medication, like modern pathology, 70 THERAPEUTICS OF INFANCY AND CHILDHOOD. which requires local diagnoses. Subcutaneous administration dictates smaller doses, the rectum mostly a slight increase. This is a subject, however, to which we shall return. The manner of application results also in different effects. The in- unction of the officinal ointment of iodide of potassium is well- nigh inert; its effect is almost exclusively that of massage, for iodine makes its appearance in the urine after days only. Iodide of potassium in glycerin, rubbed into the skin a number of times, may eliminate iodine after a day, in lanolin after a very few hours. At this place it is well to remember the great additions to our therapeutical possibilities, though in a few words only. Of serumtherapy I shall speak below; organotherapy may be mentioned here. It was introduced to meet the dangers of the absence of "internal secretion." This is a term extensively employed, at first in regard to the adrenals {Brit. Med Journ., August 10, 1895), by Schaefer and Oliver, and generally ad- mitted to be descriptive and telling. It is applied to some of the processes, partly physiological and partly chemical, of the formation and disintegration of matter in different parts of the organism. Saliva, gastric and pancreatic juice, and bile are external secretions, and carried off by efferent ducts. In- ternal secretion, however, requires no efferent ducts, indeed, no glandular stricture, for it occurs also in muscle and in brain substance. Internal secretion is carried off into the lymph and blood directly. Liver and pancreas appear to have both external and internal secretions; but thyreoid, thymus, spleen, and adrenals appear to have internal secretion only. Their ab- sence or removal or destruction by disease causes death with the symptoms of a chronic infection. This may result from one of two sources, or from both. Either those organs have the function of forming certain materials required in the organic economy, or that of destroying poisonous effete results of meta- morphosis. Thus the absence or destruction or extirpation of the thyreoid causes cachexia, that of the pancreas diabetes, that GENERAL THERAPEUTICS. 71 of the adrenals Addison's disease. In regard to the thyreoid, we are now certain that myxcedema and some forms of cretinism are favorably influenced, or even cured, by the administration of the thyreoid gland of animals. More particulars will be found under the headings of myxoedema, cretinism, exoph- thalmic goitre, and others. At best, organotherapy requires patience and time. Some of its effects cannot be obtained except by administering the substitute for the absent or defective organ persistently. Myx- cedema and semi-cretinism are liable to relapse when medi- cation ceases, or is unduly interrupted. This will not be corrected, it is to be feared, until a normal organ is implanted into the suffering organism and made to perform its physio- logical functions. Thus far surgery has not succeeded in yield- ing the coveted results. The rectum of the infant and child has been rising in the estimation of the practitioner since the times of thermometry; for it is certainly the safest and easiest place where to take the temperature. For therapeutical measures it is also invaluable. Its importance for the purposes of alimentation has been de- tailed in a former chapter. (See p. 58.) The rectum of the young is straight, the sacrum but little concave, the sphincter ani feeble, and self-control gets de- veloped but gradually. Thus a rectal injection is easily either allowed to flow out or vehemently expelled. Therefore one which is expected to be retained must not irritate. The blandest and mildest is a solution of six or seven parts of chlo- ride of sodium in a thousand parts of water. This may be made to serve as a vehicle of medicine, unless incompatible with the latter, which it will be but rarely. An enema which is to be retained must be tepid and small in quantity, half an ounce or little more or less, and carried up well into the rectum, for the immediate contact with the sphincter may produce its expulsion. Care must be taken to exclude air from the syringe, which, for small quantities, must be a well-fitting piston 72 THERAPEUTICS OF INFANCY AND CHILDHOOD. syringe, of hard rubber, with a long nozzle. This must be well oiled, and introduced, not straight, but with a gentle turn, so as to avoid folds in the anal mucous membrane (in the same way a thermometer ought to be introduced). The nozzle must not be too thin, as it is liable to be caught; the smallest nozzles of fountain syringes are therefore in most cases improper; the larger size is more appropriate for any age. The injection must be made while the patient is lying on his side, not on his belly over the lap of the nurse, for in this position the space inside the narrow infantile pelvis is reduced to almost nothing. When medicines are to be injected, the rectum ought to be empty, as in infants it mostly is. When it is not, an evacu- ating injection ought to precede the medicinal one by half an hour. It ought to be of the mildest possible nature, for any irritation of the rectum, from the local effect of an enema to a catarrhal or dysenteric process, reduces its faculty of absorp- tion. The medicinal solution must not be saturated; indeed, very soluble medicaments only are to be selected for medicinal enemata. Nor must they be acid or contain anything irritating. Alcoholic tinctures require relatively large quantities of water; quinine salts must not be selected unless very soluble, such as the muriate, the bromide, the carbamide, or the bisulphate. The addition of a small amount of antipyrin renders quinine very soluble. No acids must be used for the purpose of keeping it in solution. Salicylate of sodium, also antipyrin, exhibit their full power through the rectum, and permit of full doses. As a rule, however, the rectal doses are a little larger than those given by the mouth. Larger enemata are not retained, and are therefore utilized for the purpose of emptying the bowels. This effect is easily obtained in infants and children, for their faeces are soft and movable, with the exception of those cases in which improper medicines (large and continued doses of lime and bismuth, or astringents), or badly selected food (casein and starch in undue quantities), or an excess of the normal great length of the colon ' GENERAL THERAPEUTICS. 73 descendens and sigmoid flexure, have given rise to large ac- cumulations of hardened faeces. Small quantities are seldom sufficient for the purpose of relieving the bowels, unless they act as irritants; in this manner glycerin, pure or with equal parts of water, may produce an evacuation readily. An evac- uant injection may weigh from a fluidounce to a quart in some. It ought to be given while the child is lying down; the liquid must not enter the bowels quickly or vehemently, the fountain syringe not hang more than ten or twelve inches above the anus. If that precaution be observed, occasional pain, or faint- ness, or vomiting can be avoided. If water, or water with two- thirds of one per cent, of salt, be insufficient, more salt or soap may be added for the purpose of enforcing the evacuation. Half a tablespoonful of oil of turpentine, with a pint of soap and water, acts often charmingly; so does the addition of a few drachms of tincture of assafoetida, in conditions of constipa- tion, flatulency, and nervous excitability, also in convulsions; or glycerin in obstinate constipation. Large injections will have other indications besides that of evacuation of the bowels. In many cases of intense intestinal catarrh large and hot (101° to 108° F.) enemata will relieve the irritability of the bowels and contribute to recovery. They should be repeated several times daily. "When such evacuations contain a great deal of sticky viscid mucus, the addition of one per cent, of carbonate of sodium will liquefy the tough secre- tion. When there are many stools, and these complicated with tenesmus, an injection, tepid or hot, must or may be made after every defecation, and will speedily relieve the tenesmus. In such cases flaxseed tea or thin mucilage may be substituted for water. When the bowels are in a state of chronic catarrh or ulcer- ation, the injections ought to be particularly large and contain astringent or alterant medicines. Though they be expelled im- mediately, enough of the dissolved or suspended remedy will remain upon the mucous membrane. Sulphate of zinc, alum, 74 THEBAPEUTICS OF INFANCY AND CHILDHOOD. acetate of lead, tannic acid, nitrate of silver, salicylic acid, carbolic acid, and creosote have been used in such medicated injections. One per cent, solutions will suffice. Salicylic and carbolic acid may prove uncomfortable or dangerous because of their effect on the kidneys, and ought to be dispensed with. Mtrate of silver requires some precaution. From a grain to five grains or more in an ounce of distilled water may be safely injected; but this enema must be preceded by an evacuant consisting of water only, and followed by one containing some chloride of sodium for the purpose of neutralizing the nitrate and protecting the anus and external parts from local irrita- tion. It will also be found advantageous to wash the anus and perineum with salt water before injecting the silver solution. In many cases where one of the above-mentioned agents ap- peared to be tolerated badly, or proved inefficient, subnitrate (or subcarbonate) of bismuth mixed with water, or with gum- acacia water, in different proportions, proved very acceptable and healthful. Suppositories are useful both for evacuating and medicinal purposes. Soap is utilized for the former purpose by the public at large, and the same material differently mixed, with or with- out medicinal additions, such as atropia, by the irregular trade. Local medicinal applications to the rectum are best made by means of injections, but a general effect is also obtained through a suppository. Opiates, and narcotics generally, exhibit their full power when the suppository is retained. Extract of hyos- cyamus, from half a grain to a grain in a suppository, to be repeated from two to five times daily, shows its effect in re- lieving vesical spasm nearly as well as when taken internally. Quinine is gradually dissolved and absorbed. Extract of nux, both in ointments and in suppositories, acts well in prolapse of the rectum and debility of the sphincter. Subcutaneous injections of remedial agents ought to be made more frequently than appears to be customary. The extremi- ties, particularly their lower halves, ought to be avoided, for GENERAL THERAPEUTICS. 75 their constant motion and the relative absence of fat in their subcutaneous tissues are liable to give rise to local irritation, swelling, or suppuration. The abdominal wall is preferable. A sharp and aseptic needle and gentle friction of the injected part are all that is required. The solutions used must be clear and without any solid ingredients. When they have been pre- served for some time they ought to be filtered before being used, particularly when fungous growths have begun to make their appearance in the liquid. The latter may be preserved best by adding a small quantity of alcohol, salicylic acid, or hydrocyanic acid. The doses must be small, and the medicine diluted more than in the case of adults. This is mainly re- quired where a caustic effect is to be feared. While, for in- stance, Lewin advised for adults a solution of four grains of bichloride of hydrargyrum in an ounce of water, one or one and a half grains give a more appropriate solution for infants. One or two daily doses of eight or ten drops continued for weeks will prove very useful in those urgent cases of hereditary syphilis which are characterized by pemphigus on the soles of the feet and the palms of the hands in the first days after birth. Brandy and ether may be used undiluted as in adults, but the greatest care must be taken as to the locality injected. The subcutaneous tissue must be reached and the cutis penetrated. Chloral hydrate dissolves readily in two parts of water, but a solution of one in four or six is better tolerated. For the ready symptomatic treatment of convulsions it renders good service. Antipyrin is well borne in solutions of one in six or eight parts of water, camphor in from four to six parts of sweet almond oil. Digitalin, in solution, and the fluid extracts of digitalis and ergot, are very apt to give rise to indurations and, per- haps, abscesses. As a rule, the most convenient medicaments for hypodermic administration are the very soluble alkaloids. One or three drops of Magendie's solution of morphine or the corresponding solution of muriate of morphine are vastly pref- erable to the internal use of narcotics for bad pain in pleuritis 76 THERAPEUTICS OF INFANCY AND CHILDHOOD. or pleuropneumonia, or in peritonitis of advanced childhood. It may be mixed with atropise sulphas for the reasons regu- lating its use in the adult. The latter by itself has been found quite effective in the case of an epileptic boy, who had taken the same drug internally without any success. If possible, it ought to be injected during the aura; if not, twice a day. Apo- morphise murias is a ready emetic in doses of a thirtieth or a fifteenth of a grain. Pilocarpise murias can be injected in doses of one-twentieth to one-eighth of a grain. Its reckless use, both hypodermically and internally, has led to occasional mishaps, but the drug is a powerful agent for good when care- fully applied, and has saved for me several cases of meningeal hyperemia and cerebral oedema, mostly of nephritic origin. Sulphate of strychnine, while in the same affections it has mostly proved inefficient when taken internally, has rendered efficient services in enuresis depending on paralysis or weak- ness of the sphincter of the bladder, and in prolapse of the rectum, and fascal incontinence resulting from paralysis of the anus, which depended either on disease or congenital incompe- tency. In these cases a daily dose of a fortieth or a twenty- fifth of a grain — according to the age of the patient or the severity of the case — is sufficient. More frequent doses, how- ever, are required in the diphtheritic paralysis of the respira- tory muscles, which is dangerous and apt to become fatal unless speedily relieved. A daily dose will also yield fair results, when long continued, in the later stages of spinal or cerebral paral- ysis, where its internal administration is entirely, or wellnigh, useless. Quinia salts must be neutral when injected; I prefer the bromide, the muriate, or the carbamide. They, particularly the last, are among the most soluble. The carbamide dissolves readily in from four to six parts of warm water; the latter tem- perature ought to be preferred in every case of subcutaneous injections. Quite saturated solutions ought to be avoided, because it has happened to me that the water of the solution was speedily absorbed, and the quinia remained as a foreign GENERAL THERAPEUTICS. 77 body in the subcutaneous tissue. Caffeine, in its combination with sodium and salicylic or benzoic acid, is an excellent heart stimulant, and has rendered splendid service in urgent cases of heart-failure or pulmonary oedema depending on cardiac disease. Both the salicylate and the benzoate of sodium and caffeine are soluble in two parts of water, and are readily ab- sorbed. Both must be avoided in those cases which are com- plicated with cerebral irritation or sleeplessness. Fowler's solution, carefully filtered and diluted with at least twice its quantity of distilled water, may be injected into healthy or mor- bid tissues without often risking irritation and abscess. Still, I have seen a splenic abscess after such an injection in a case of sarcoma of the spleen. Undoubtedly, the continued use of arsenic renders very efficient services in sarcoma; but as it has to be used a very long time, it is almost impossible, except in hospital practice, to resort to hypodermic medication. There is no harm in this, however; for a very gradual increase of the drug is tolerated by the stomach to such an extent that, after awhile, very large doses (amounting to half a drachm = two cubic centimetres) of Fowler's solution daily, well diluted, may finally be administered after meals. Subcutaneous injections have reached an extensive field of usefulness in serumtherapy. After it was proved that animals could be immunized against certain virulent bacteria, it was found that the blood-serums of previously immunized animals* could be utilized as powerful remedies in infectious diseases of man. In the chapter on diphtheria more will be said of the effect of its antitoxin, the preparation and knowledge of which is due to Aronsoii, Eoux, and Behring. Tetanus and diph- theria are certainly influenced by their proper antitoxins to a remarkable degree. Asiatic cholera is likely to be the next great scourge of mankind to be stripped by its antitoxin (Haff- *Not to be mistaken for the congenital protection afforded by the presence in the blood-serum of the newly-born of "alexins." 78 THERAPEUTICS OF INFANCY AND CHILDHOOD. kin) of part of its fury. Neither Marmoreck nor others, how- ever, have thus far succeeded in producing an antitoxin which is as effective as those of tetanus and of diphtheria in such infectious diseases as appear to be connected with, or depend- ent on, streptococci (puerperal diseases, erysipelas, scarlatina, and some forms of abscesses, of angina, and of diphtheria). Nor are the claims of Coley, who, with antitoxin procured from the coccus of erysipelas and from bacillus prodigiosus, ■exhibits interesting results in sarcomatosis (not in carcinosis), generally accepted by all. In many more diseases antitoxins have been recommended; prematurely it appears, for neither croupous pneumonia, nor typhoid fever, nor syphilis has been benefited thus far. Nor have the attempts at obtaining an antitoxin to take the place of calf vaccinia in the immuni- zation against variola been successful. Not infrequently the lymph usually employed is mixed with bacteria and other im- purities. Thus far, however, a sterile blood-serum of the vac- cinated calf could not be obtained in sufficient condensation and efficacy. In organotherapeutics the hypodermic method is no longer employed extensively, since the internal administration of the different tissues, or its extracts, or other modes of preparations, are both efficient and (mostly) palatable. The subcutaneous injections of cocaine, according to Schleich's method of "anaesthesia by infiltration," will prove a great gain to the practitioner, inasmuch as, with or without the previous use of ethyl-chloride, it will facilitate many opera- tions. Maybe its principal advantage will lie in this, that many abscesses and furuncles will be dealt with before they are per- mitted to get larger. Their antineuralgic action will not be re- quired frequently, because of the relative scarcity of neuralgias in childhood. In almost every case the solution is to consist of cocaine muriate 0.1, morphia sulphate 0.02, chloride of sodium 0.2, distilled water 100.0 (5 : 1 : 10 : 5000). Inhalation is resorted to in two different ways. Either the GENERAL THERAPEUTICS. 79 air of the room or a tent is impregnated with the substances to be introduced into the air-passages, or these substances are introduced through sprays or atomizers of different shapes and patterns. Some of the latter have always appeared to me very faulty, and not to the purpose at all. Tubes introduced into the mouth, through which substances are to be carried down, will land them in the mouth; it takes all the self-control and intelligence of an adult patient to allow the object in view to be accomplished. The oral cavity of the infant or child is small, the tongue gets coiled up, and the faucial muscles will not relax. Nose and mouth must co-operate to allow inhalations to enter the larynx, or the former alone must be relied on. A spray cal- culated to reach the larynx of infants or children is always best introduced into and through the nose. In this way, at all events, the posterior part of the pharynx and the respiratory tract are reached to best advantage. The manner in which the spray is employed in diseases of the nose and pharynx is quite often too perfunctory, with no other result but to make the patients wakeful and restive. Eeal inhalation, however, means filling the lungs with a gas or vapor. Warm steam will do good service in bronchitis and pneumonia, when the bronchial secretion is viscid and expec- toration difficult, and in diphtheria, for the purpose of soften- ing membranes and increasing the secretion of a thin and normal mucus. Cases of fibrinous bronchitis I have seen get- ting well in bath-rooms, the hot water being turned on for days in succession and the air thick with steam. An excel- lent inhalation in the inflammatory conditions of the respira- tory organs is that of muriate of ammonium. Every hour, or in longer intervals, a scruple or more of the salt — the quan- tity depending in part on the size of the room — is burned on the stove, or over a live coal or an alcohol-lamp. The heavy white cloud fills the room, is easily borne by both sick and well, and improves expectoration. Oil of turpentine can be utilized in a similar way. Its action is both expectorant and 80 THERAPEUTICS OF INFANCY AND CHILDHOOD. disinfectant. In the latter stages of pneumonia, when the bronchial secretion is thick, viscid, or deficient, and expectora- tion and cough are wanting, the room may be filled with tur- pentine vapor. This can be accomplished in different ways. A large soft sponge may be soaked with turpentine, with or without the addition of some oil of sassafras, and suspended at the bedside. Or a kettle may be kept boiling day and night with water, on the fireplace or over an alcohol-lamp (this is preferable to a gas-stove, which consumes too much oxygen), and a tablespoonful of turpentine, more or less, poured on the boiling water every hour or two hours. The same may be done to advantage in diphtheria, with or without a teaspoonful of carbolic acid in addition to the turpentine, and in gangrene of the lungs. The inhalation of benzine, cresolin, and similar substances, and of the coal-gas of the gas-factories, has been amply recommended in whooping-cough. In its worst forms, particularly when it is complicated with convulsions, the fre- quent inhalation of chloroform is sometimes life-saving. A baby of six months, with hourly attacks of convulsions, I kept alive by putting him under the influence of chloroform at the beginning of every attack, and continuing that treatment for fully four days. Asthmatic attacks will do well sometimes with inhalations of chloroform, ether, and spirits of turpen- tine in different proportions, mostly 1:2:4. Mtrite of amyl also will influence them favorably; as a preventive of epileptic attacks I have experienced but little success with its admin- istration. But in collapse, with paralysis of peripherous blood- vessels, it certainly renders good service. With the inhalation of oxygen for the purpose of bridging over the most dangerous period of a suffocating pneumonia, and of improving tissue- change in general ansemia and ill-nutrition, the profession is well acquainted. With the inhalation of ether as an antidote to poisoning with santonine I have no personal experience. Ozone inhalations have been highly recommended in ansemia, whooping-cough, and septic fevers. We shall have to learn GENERAL THERAPEUTICS. 81 more of its effects, and particularly in regard to a ready and reliable method of its preparation.* In pulmonary tuberculosis the inhalation of disinfectant vapors is employed less than the necessity of the cases appears to indicate. Carbolic acid, turpentine, eucalyptol have been utilized for that purpose. The object is to supply the lungs with those substances in thin dilutions, but constantly. Prud- den has proved that carbolic acid in twelve hundred parts of" water stops the emigration of leucocytes in inflammatory dis- orders. Thus high dilutions, though they be hardly percep- tible to the senses, and certainly not to a disagreeable extent, may be amply sufficient. It is for this reason that Feldbausch invented small apparatuses filled with a disinfectant substance to be worn in a nostril, constantly. The inhalation of chloroform, which is preferable to ether for the purpose of producing anaesthesia in the cases of infants and children, is rather unsatisfactory at the earliest age be- cause of the superficial character of respiration. So is that of ether, which, moreover, may become contraindicated in every period of life because of its detrimental effect on kidneys and * After the above was written a letter was received from Dr. A. Cattle, dated August 9, 1897, in which he says: "That the oxyheemo- globin will increase markedly and rapidly under the use of ozone in- halations is a fact which can be demonstrated in any case of chlorosis or secondary anaemia. I can also show you a middle-aged woman who four years ago had a bad pulmonary tuberculosis, and is absolutely cured after three years of ozone inhalations. No trace of the former extensive lung infiltration can be detected. As regards pertussis, the duration and severity of the attacks are unquestionably shortened. What is wanted is a cheap home machine made up of dry cells or spark coil and ozone tubes. The apparatus in the market costs seventy-five dollars. A large apparatus to use with the street current I can show you in the Babies' Wards of the Post-Graduate School and Hospital. If a glass tube with rubber tube attached is placed between the poles of a static machine, therapeutic quantities of ozone can be conveyed to the patient." 6 82 THERAPEUTICS OF INFANCY AND CHILDHOOD. on the respiratory organs. It frequently begets nephritis, bron- chitis, and pneumonia. The effect of the anesthetic is very temporary, and the administration must be repeated and closely watched during a convulsion or an operation. The difficulty in obtaining a complete narcosis is particularly great in the newly-born. The stage of excitement is but brief, the pulse becomes frequent, and the pupils contract. After a short time the pulse, however, becomes slow, and the pupils dilate. The after-effects are not so inconvenient as they often prove in the adult; children vomit less frequently and less profusely, and certainly with greater facility and ease than adults. They are liable to remain under the influence of the anaesthetic a long time after an operation has been completed. After trache- otomies, which I never performed without chloroform unless the children were asphyxiated by carbonic acid poisoning, the patients are apt to sleep long and undisturbed. Thus they require a ceaseless watching until the effect has surely passed away. Through the opened trachea the children will get under the influence of chloroform very easily. Five or six drops on a sponge or on some absorbent cotton, held in the mouth of the tube by means of a pair of pincers, have an almost instantaneous effect, and came near destroying, when I under- took to change the tracheal tube on the third day, a successful case of mine nearly thirty years ago, before I had the experience detailed in the previous remark. Further care is also required in regard to patients in ill health. Chronic pulmonary and heart-diseases do not tolerate chloroform very well, but the diagnosis of these conditions is more readily and quickly made in children than in the adult. Adipose children are liable to faint. The usual operations in the mouth, such as resection of tonsils, incision of abscesses, it is best to perform without an anaesthetic, for the amount required to overcome the re- sistance of the masseter and buccinator is so large, generally, as to possibly endanger the life of the patients, besides the im- possibility of obviating successfully the entrance of blood into GENERAL THERAPEUTICS. 83 the digestive organs, where it is inconvenient, or into the res- piratory organs, where it is a positive danger. Gargles of any description require a certain degree of train- ing and self-control, and are therefore rarely available for chil- dren of less than seven or eight years. The liquids thus em- ployed do not reach any farther than to the uvula, the pillars of the soft palate, and the anterior part of the tonsils. What- ever succeeds in passing them is swallowed. Thus the alleged efficacy of gargles is greatly over-estimated. Astringents only have a certain influence reaching beyond the area of contact, but through their secondary effect on contiguous tissue only. When a thorough effect is aimed at, it is better to rely on sprays, which may affect the whole pharyngeal cavity, or on insuffla- tions of powders. As, however, in most cases where a local effect on the pharynx is desirable, the local affection spreads over the posterior nares as well, spraying, or injecting, or irri- gating the nose is preferable. The liquids thus employed reach the pharynx, and are either swallowed — which is often an indifferent matter — or expelled through the mouth. When these methods are undesirable, for instance, when the liquids injected enter the Eustachian tube, they may be poured into the nasal cavities from a teaspoon or a pipette. A common medicine-dropper will often suffice. There is many a case of diphtheria in which the very gentlest method of cleansing and disinfecting the surface of the naso-pharyngeal cavity ought to be selected. More on this subject will be said in another part of this book. When no liquids are tolerated, fluid ointments may be in- troduced into the nostrils by means of a eamePs-hair brush, or poured in. Ointments prepared with vaseline, glycerin, or cold cream are good vehicles for that purpose. Sponges and brushes ought to be avoided whenever the young patient ob- jects to these strenuously. No violence must be used, for several reasons. The child's strength must not be exhausted by his attempts at self-defence, and most local affections of the 84 THERAPEUTICS OF INFANCY AND CHILDHOOD. throat get worse by any injury done to the epithelia. Even galvano-cauterization can and must be applied without much violence. Persuasion, patience, and cocaine will render its employment possible in many instances. The skin in infancy and childhood participates in the ana- tomical structure of all the tissues at that early period, inas- much as it contains more water than in advanced age. Be- sides, it is thinner, and its lymphatics are more numerous, larger, and more superficial. This explains some peculiarities in regard to the effects of many medicaments. Electricity in all its forms is more efficient, and a relatively mild current suffices. This fact is of particular importance, as, moreover, the bones also are thinner and more succulent. To act upon the brain, very mild currents only must be used. The spinal cord is less accessible, and appears to require rather large doses. The galvano-caustic effect resembles very much that obtained in the adult. In most cases it should be closely watched while being employed; thus, for instance, in the operation on angi- omata, or diseases of the tonsils or nose, it readily destroys more than was intended. Sinapisms, when not mixed with flour, must not be per- mitted to remain more than a few minutes. As soon as the skin begins to be discolored they should be removed. When that is done, they may be repeated every few hours, and they are active derivants in many cases of deep-seated congestive processes. The same remark is due in reference to the use of mustard-baths. A hot mustard-bath renders good services in suppressed or insufficient cutaneous eruptions of an acute character, internal hemorrhages, meningitis, and pneumonia. But it must not be continued beyond reddening the skin. Vesicatories have lost much of the esteem in which they were held in former times. I remember the time when many a case of pleurisy, articular inflammation, herpes zoster, was not permitted to get well without a Spanish-fly blister. Nor am I of the opinion to-day that it will do no good in some such GENERA T. THERAPEUTICS. 85 cases, provided it be not used during the feverish stages. But their drawbacks are many. A plaster will not stick to an emaciated and uneven surface, and is even apt to give rise to gangrene when the surface circulation is very defective. In these cases the wound will heal badly. The skin of the infant being very vulnerable, eczema and impetigo will easily arise on ever so slight a provocation. The local pain of the application produces irritation*, nervousness, and sleeplessness. This is particularly so if the application be made on the extremities or on the posterior surface of the body. The kidneys are fre- quently affected by cantharides, dysuria being the result in many cases, which then require energetic camphor treatment for the relief of the torturing symptoms. There are some absolute contraindications to the external use of cantharides: the presence of diphtheria in any shape or manner, and such diseases as are liable, during the prevalence of an epidemic, to become complicated with diphtheria. Therefore no vesicatory must be used during nasal, pharyn- geal, or laryngeal diphtheria (croup), or in the different forms of pharyngitis, or in laryngeal catarrh, or in erysipelas. "When a plaster cannot be expected to remain on the surface and to have its full effect, cantharidal collodion may take its place. The application will prove more effective when the surface is first washed with vinegar, or irritated by a sinapism, which, however, is allowed to remain a few minutes only. Then a flaxseed-poultice or warm-water applications may be applied over the vesicatory to diminish the pain and accelerate the effect. Very young infants ought not to carry a vesica- tory more than an hour, at least not on the same spot. That is why to them the cantharidal collodion is less adapted. The plaster may be shifted from place to place. After the epidermis has been raised, the serum must be al- lowed to escape through small punctures, but not so as to moisten the adjoining parts, for the cantharidin contained in the serum may exert a disagreeable local effect. The epider- 86 THERAPEUTICS OF INFANCY AND CHILDHOOD. mis ought not to be removed, and no irritating ointment used to keep up a secretion. To cover the sore surface, vaseline or cold cream are preferable to common fats, which may be, or be- come, rancid. The best final dressing is borated cotton and a bandage. Vaseline ointments with opium, lead, or zinc, and powders of zinc, subnitrate of bismuth, iodoform and amylum, in equal parts, or salicylic acid one part, with twenty-five of starch, will find their occasional indications. In many affections of the skin powders, solutions, liniments, ointments, and baths are employed. The skin is thin and irritable. Erythema will follow the contact with water quite often; thus many forms of dermatitis contraindicate its fre- quent use. Acute and chronic eczema get on better without than with it. Therefore astringent solutions are less advisable than astringent ointments. For superficial effect these must be prepared with vaseline or cold cream, either of which may be readily combined with lead, tannin, zinc, bismuth, salicylic acid, or iodoform. In not a few cases, on a very sore sur- face, denuded of its epithelium and oozing, the powders alone, or combined with starch in different proportions, will prove very effective. Oleates ought to be avoided, — they irritate the skin and produce eruptions. As the skin is thin and succulent, and the lymph-ducts of the young quite superficial, large, and numerous, substances will penetrate the skin quite readily. Ointments with that ob- ject in view must be prepared with animal fats, particularly with adeps lanae hydrosus of the TJ. S. Pharmacopoeia (lanolin), to the latter of which, when rather dry, ten per cent, of water may be added. Still, much friction may by itself irritate the surface and give rise to suffering. In the very young, ice and ice-water applications are not tolerated a long time. Ice to the cranium, the bones of which are but thin, is liable to produce collapse; about the neck and occiput it is better borne and often beneficial. Warm fomen- tations and hot poultices are very beneficial in many morbid conditions of the trunk and extremities, but dangerous when GENERAL THERAPEUTICS. 87 applied to the head and not carefully watched. General baths are frequently required, local baths but seldom; foot-baths may be given while the patient is lying down, but hot fomentations are more readily made, and do not require the same amount of watching, nor are they equally objectionable to the young patient. Depletions were frequently resorted to scores of years ago. Modern practice has learned how to do without them, though we may be willing to assume that they were more frequently indicated than many of us believe at present. At all events, it ought to be taken into consideration that there is but a single pound of blood in a baby of twenty pounds, and that a patient rapidly reduced by sickness is least able to stand a loss of blood ever so small. Thus a venesection will hardly ever be thought of; at all events, I hope never to repeat the opening of a ju- gular vein, practised by me in a case of convulsion depending on, and increasing, cerebral congestion, a third of a century ago. Local depletions were once more frequent, though the liability of the skin to inflammation and furuncle was well understood, and the excitement of the little patient was such, now and then, as to lead to an increase of the symptoms, and even to convulsions. Among the occasional drawbacks was also the possible loss of blood after the leeches had fallen off. In such a case the local use of tannic acid, alum, perchloride or subsulphate of iron, digital pressure, or in bad cases the ligature underneath a harelip needle, which was inserted through the wound, were resorted to. A solution of from twenty to fifty per cent, of antipyrin in water, to which tannic acid may be added or not, is a powerful styptic. The indica- tions of depletion were bad and painful cases of pleurisy and peritonitis, and cerebral inflammatory diseases. In the latter, the mastoid process and the septum narium are the points on which the leech or leeches ought to be applied. It is the latter spot which I prefer, when I have the choice, in those rare cases of brain-diseases of infants and children in which I still feel justified to recommend a depletion. III. TREATMENT OF THE NEWLY-BORN. 1. Asphyxia. The prognosis of asphyxia and of its treatment is a very doubtful one in many cases. It depends not only on the knowledge and skill of the physician, but on the causes of the abnormal condition. A moderate or serious compression of the head, compression or prolapse of the cord, intrauterine respiration and aspiration of foreign bodies (amniotic liquor, meconium), apoplexy, anaemia of the foetus, accumulation of carbonic acid in the blood, poisoning by morphia, or chloral, taken by the mother, or by her excessive temperature, con- genital diseases, and malformations, each of them, or several combined, influence both the prognosis of the individual case and the result of therapeutic procedures. When the long duration of labor, the prolapse of the cord, the protracted compression of the head, the early loss of amni- otic liquor, or a high temperature of the mother endangers the life of the foetus, the best preventive of asphyxia is the artificial termination of parturition. The respiratory organs of the foetus passing out of the vagina should be protected from con- tact with copious discharges of liquor amnii and other foreign material accumulated in the bed, and the face be raised so that aspiration, mostly through the nose, cannot take place. The mouth of the newly-born, unless it cries lustily, must be cleansed immediately, but very gently, by a moistened piece of cloth wrapped round the finger, the tongue drawn forward, and the baby placed on its side before attention is paid to any- thing else. Beating the nates, tickling of the fauces by means of the feather of a hen or a goose, and the momentary inhala- TREATMENT OF THE NEWLY-BOEN. 89 tion of ammonia can be resorted to before the baby is separated from the placenta. Most practitioners, indeed, will prefer to prolong the connection with the maternal organ until the pul- sation of the cord begins to flag, under the usual circumstances. The separation of the baby must take place immediately when there is no pulsation in the cord, or when asphyxia is well pro- nounced. When the baby is strong and cyanosis marked, Grenser recommended to allow the cord to bleed before the application of the ligature. When bleeding was but scanty, he increased it by placing the baby in a warm bath. This pro- cedure I have imitated several times with advantage. When the ligature has been applied and the baby removed, the mouth of the asphyctic infant ought to be cleansed again as above, quickly but gently. For amniotic liquor, meconium, and vaginal secretion, when aspirated, will, though the as- phyctic condition may be relieved, give rise to bronchitis and pneumonia after two or four days. Many babies die in this way. Insufflation into the lungs for the purpose of establishing respiration has been practised by Smellie as early as 1762. It is done from mouth to mouth, from mouth to nose, or by the catheterization of the larynx. The first method is not reliable, for the tongue is liable to close both pharynx and larynx; the second is often successful, but may inflate the stomach as well as the lungs. By inflating the former the chances for a normal action of the lungs become less. After every insufflation which fills the lungs, the chest ought to be compressed by two hands over the lower latero-anterior region of the chest-walls. The direct insufflation of the lungs may become detrimental for several reasons. H. Reich relates the case of a consump- tive midwife who was reported to have infected twelve infants with acute tuberculosis in thirteen months. In the practice of another midwife, who was healthy, in the same town, no such case occurred. During nine previous years there were 90 THERAPEUTICS OF INFANCY AND CHILDHOOD. but two cases of tubercular meningitis, and but one in the year following the death of the consumptive woman. Moreover, the act of insufflation may prove dangerous by the impossibility of limiting the force of the entering volume of gas. Eupture of pulmonary tissue and emphysema and pneumothorax have been observed. The same accident may occur when a catheter is used for the same purpose. It has, however, the advantage of permitting the sucking out of the aspirated material before air is blown into the lungs. Ribemont's and others' metal catheters cannot be carried much below the vocal cords. An elastic catheter, guided by a wire which allows any degree of bending and may be withdrawn when the vocal cords have been passed, is better adapted both for aspiration and inflation. The asphyctic baby ought to be plunged into a warm bath (100° F.) immediately, and gently rubbed. The other methods may be continued during that time, — beating, tickling, elec- tricity. When it is thin, pale, and collapsed, a hot injection into the bowels (104°-108°) will render good service. The quick and repeated alternation between the warm bath of a minute and a cold one of one or two seconds, or the pouring of cold water on chest, or neck, while the body is in the warm bath, restores many. But great care must be taken lest the latter be too hot. It may produce convulsions, and has been known to give rise to tetanus. Before, and after the bath, in- deed at any time, the vigorous swinging of the baby on the arms of the medical man is a good adjuvant. Among all the mechanical methods of artificial respiration (Marshall Hall, Silvester, Howard, B. Sehultze, Pacini, Woih- ler, Bani, S chillier, Dew, and others) those of Silvester and Sehultze render the best services in the asphyxia of the newly- born. Both are very simple, and either of them is effective. A. Brothers prefers the former ("Infantile Mortality during Childbirth and its Prevention," Philadelphia, 1896). Silvester places the patient on his back, a small pillow (piece of clothing, towel, sheet) between the shoulders, the tongue TREATMENT OF THE NEWLY-BOBN. 91 drawn forward. The two arms are caught above the elbow and while being everted are slowly carried upward. Thus the chest is expanded. Then they are carried downward and pressed against the sides of the chest, a little anteriorly to the axillary line. Thus the lungs are compressed. This com- bined action may be repeated fifteen or twenty times in a minute, and a hot bath given afterwards. Then the pro- cedure is renewed. B. Schultze places his index-fingers into the axillas, the three other fingers gently against the sides of the chest, the thumbs covering the shoulder from behind. The infant is then swung forward. The lower extremities bend on the abdomen, the abdomen presses against the diaphragm, and the lungs are compressed, — expiration. The parts then return slowly down- ward and swing back, thus expanding the chest, — inspiration. This action may also be repeated fifteen or twenty times in a minute. After each minute's swinging the baby is placed in a warm bath. There, is but one (occasional) contraindication to the employment of this method, — viz., the insufficient de- velopment of the foetal bones. When the newly-born is too premature, and the ribs too soft and flexible, it is useless. It is also contraindicated in the plethoric, congestive variety of asphyxia. That proper caution should be exercised is self- understood. In a case published in the London Lancet of May 8, 1897, the infraspinatus and teres minor muscles were injured so as to cause rotation and adduction of one arm. During all this time, whenever feasible, the surface of the infant must be kept warm artificially by hot blankets, stones, bottles, and a few drops of brandy, whiskey, camphor-water, or tincture of musk, or a drop of tincture of belladonna, may be given in some hot water if deglutition is possible, or a larger quantity (some ounces) of hot water (104 o -110° F.) injected into the rectum. When the main difficulty appears to be, after a while, in the excessive debility of the heart, it is possible that a five-hundredth part of a grain of nitroglycerin, repeated 92 THERAPEUTICS OF INFANCY AND CHILDHOOD. after fifteen and thirty minutes, will render good and speedy service through its ready absorbability on every mucous mem- brane. I have no experience with it in the asphyxia of the newly-born, but its rapid action in failing heart and collapse and shock from other causes encourages me to recommend it for a fair trial of its powers. Laborde was very successful by drawing the tongue of the asphyctic baby forward in rhythmical alternations. That pro- cedure is to be repeated ten or fifteen times a minute. It does not seem to be promising unless the reflex irritability of the medulla oblongata is rather intact. Electricity was recommended in cases of asphyxia as early as 1793 by Huf eland. But the first case, in which the rhyth- mical faradization of the phrenic nerve and its associates was resorted to (Ziemssen) for the purpose of producing artificial respiration, was that of an asphyctic girl poisoned by carbon oxydul. The phrenic nerve acts on the diaphragm. Its aids are the cervical plexus, which controls the trapezius, levator scapulae, and middle scalenus muscles, and the brachial plexus. The ramifications of the latter are the anterior thoracic nerve for the pectoralis major and minor; the posterior thoracic for the middle scalenus, posterior superior serratus, and the rhom- boid muscles; and the lateral thoracic for the serratus anticus major. In many cases since, such as poisoning by chloroform, coal- gas, opium, diphtheria, sulphide of hydrogen, and pernicious intermittent fever, also in those of apoplexy, drowning, and hanging, electricity has been employed to advantage. Its effect is often rapid and powerful. In asphyxia of the newly-born, the systematic faradization of the phrenic nerve has been first employed by Lauth and Pernice. The point of application selected by most authors is near the sterno-cleido-mastoid muscle, over the phrenic nerve. The other pole is applied either to the neck or to the diaphrag- TREATMENT OF THE NEWLY-BOKN. 93 matic region or any other part of the surface. The localiza- tion of the effect to the phrenic nerve alone, which was insisted upon by many, is certainly an illusion. The current will surely strike the pneumogastric, phrenic, sympathetic, and many sen- sitive and motory nerves at the same time. As this cannot be avoided, as indeed it is better that it should be exactly so, it is best to use large sponge electrodes and moisten them thor- oughly with salt water. The head, arms, and shoulders should be slightly raised, and a small pillow placed between the, shoul- ders for the asphyctic baby to rest on. One of the electrodes must be kept stationary; the other brought into contact with the surface but a single moment. A deep inspiration will then take place, the lungs will expand, and lateral pressure on the lower part of the chest should be resorted to for the purpose of emptying the lungs afterwards. Another application is then made with the same result, and must be followed with the same manipulation. This has to be continued for some time until the baby cries, and it appears safe to discontinue the applica- tion. Whenever a cough or a coughing movement is noticed, it should be omitted temporarily. The favorable result, how- ever, is not always permanent. The causes of the asphyctic conditions are still active, and the infant will require resuscita- tion again, and perhaps many times. Thus close attention must be paid, sometimes for hours. Great care should be taken in regard to the duration of the application. Continued or too frequent irritation by the cur- rent causes over-irritation and paralysis. ISTot infrequently is the immediate effect a favorable one, inspiration becoming deep and the heart active, but after a short time the former grows more superficial, the pulse feeble, and the C3^anotic hue returns to the lips and finger-nails. Then it is time to stop for a while, and resort temporarily to other means of resuscita- tion. Thus the practice of Lauth's, who applied the current persistently for two or three minutes, is decidedly improper and dangerous. 94 THERAPEUTICS OE INFANCY AND CHILDHOOD. In some cases, where the interrupted current is inefficient, the galvanic (continuous) current, with occasional reversions, has been known to yield better results. In my own cases I have never had an opportunity or been under the necessity of employing it. The application of large sponge electrodes may not always be convenient. In those cases no harm is done by using the metal poles instead. Though the irritability of the brain (and nerves) is but low in the newly-born, the pain produced by the interrupted current thus applied is very intense, and the effect on the contraction of the diaphragm quite marked. Thus it is not necessary to lose time for preparing, if it be not on hand, the more complicated apparatus. Still, exhaustion is more readily obtained through resuscitating by pain and muscular action combined than by muscular contraction alone. In most cases, however, I was satisfied with not losing even a fraction of a minute, particularly in those early times, where the most convenient apparatus was the old-fashioned rotating machine. How long is the asphyctic baby to be watched and the at- tempts at resuscitation to be renewed? At all events they must not be given up as long as the heart-beats are audible, though ever so feebly. Nor is a single scream sufficient to per- mit watchfulness to be relaxed. The deep recession, during in- spiration, of the diaphragmatic region (the "peripulmonary groove" of Trousseau) should have ceased, the cry be vigorous, the eyes wide awake, and the extremities in lively motion. Be- fore this is accomplished there is danger of a relapse, partly from impaired innervation and the continuation of some of the causes of asphyxia, and partly from obstruction through mucus, which may be coming up constantly and gather in the pharynx and posterior nares. 2. Postnatal Asphyxia and Atelectasis. Atelectasis may be congenital or acquired. The lungs may never have expanded to their normal degree, or after expan- TREATMENT OF THE NEWLY-BORN. 95 sion had taken place, they may have collapsed, or contracted again. The causes of this condition may also be either con- genital or acquired. There may be malformations and intra- uterine diseases of the organs of respiration or circulation, such as defective development of the lungs, hernia of the diaphragm, hypertrophy of the thyreoid gland, pleural effusions, syphiloma of the lungs, acquired bronchial catarrh, bronchitis, and pneu- monia. Or anomalies of the nervous system may exist, such as hemorrhage or some other injury of the respiratory centre, and cerebral pressure from effusion, besides intrauterine mal- formations. Or, finally, the baby may be premature, with feeble muscles and soft bones. The treatment resembles much, or is identical with, that of genuine asphyxia. Respiration must be insisted upon. Warm and cold baths, cold affusions in the warm bath, swinging, beat- ing, and electricity come each in for their share in the treat- ment. The baby must be made to cry, or it will perish. This indication is particularly urgent in the acquired cases of ate- lectasis which result from bronchitis. There the small bronchial tubes are filled with a viscid sticky mucus, which must be removed. This is a condition not peculiar to the quite young only; it is as well met with in older babies suffering from bronchitis, particularly when in a condition of ill-nutrition and general debility. In them, the closing of the nose and mouth for from four to eight seconds will so saturate the respiratory centre with carbonic acid as to elicit deep and forcible inspira- tion immediately. It is an effective method, and not cruel because it is successful. The babies should be fed conscientiously. (See Chapter I.) As many are suffering from inanition, this requires close at- tention. They should have plenty of water, warm or hot, with from one to four drachms of brandy through the twenty-four hours, aqua camphorae, a few drachms; perhaps, as suggested above, nitroglycerin. Hot injections into the rectum will stimulate the nerves and fill the blood-vessels. The infant 96 THERAPEUTICS OF INFANCY AND CHILDHOOD. must be carried about, its position in bed changed from time to time, and its skin be kept warm according to the methods detailed before.* Even the most desperate-looking cases, with shallow respiration, and cyanosis of the skin and mucous mem- branes, may recover when the attendants are as persistent as the morbid condition is dangerous. D'Outrepont saved a newly-born of thirteen inches in length and one and a half pounds in weight, Kopp one of eleven inches and two pounds, Eedman one of thirteen inches and a pound and three and a half ounces, Ahlfeld one that was born in the twenty-ninth week of utero-gestation, measured fifteen inches (thirty-nine and a half centimetres), and learned how to suck after a few weeks; and another one that had the same size of fifteen inches and a weight of forty-eight ounces (fourteen hundred and fifty grammes) when five weeks old. It also took the breast afterwards. Several infants of less than three pounds at birth I have saved myself, nor are similar cases quite rare in the literature of the subject. J. H. Moore published in the Philadelphia Reporter of April 17, 1880, the case of a foetus born before the end of the sixth month of utero-gestation — length nine inches, weight one and a half pounds — that cried after thirty minutes, but did not move. Fifteen months afterwards the same foetus is said to * It is this condition, in which Crede's, WinckePs, and Tarnier's ap- paratuses {couveuse) have triumphed over great difficulties, and mainly in premature babies. Holt's apparatus is simple, practical, and inex- pensive. A large metal incubator, devised by Mr. John P. Putnam and Dr. Rotch, of Boston, in which the baby lies upon a water-bath and is heated by graduation from all sides, was described by Dr. H. D. Chapin in Archives of Pediatrics, May, 1897. Still, any box or bed, with hot bottles and stones, or a box with double walls filled in with hot sand, or a bed with hot flannel, or cotton, or the hot register, or anything the good-will and ingenuity of the practitioner will supply, will answer the purpose. At the same time the air admitted to the lungs must be cool and pure. TREATMENT OF THE NEWLY-BOEN. 97 have commenced to walk, and to have weighed nineteen pounds. 3. Kephalhcematoma. The hemorrhage between (mostly) the parietal bone and its pericranium is usually the result of pressure by the lower seg- ment of the uterus, not always during protracted labor, or by the forceps. Occasionally, however, kephalhsematoma is ob- served after breech presentation also. Predisposition is caused by the deficient development of the external layer of the cranial bones and the shallowness of the indentations in which the blood-vessels are running, the thinness of the vessels, and the mobility of the integument. It is circumscribed, does not spread beyond a suture, fluctuates, and begins, after a few days, to be surrounded by an osseous ring, the result of the formation of new bone from the raised periosteum. It grows in size for some days, then remains stationary, and is gradually absorbed within from six to twenty weeks. After this time the bone is thickened, but absorption of the newly-formed osseous tissue will take place in most cases. In exceptional cases only a per- manent thickening will be noticed in later life. In some cases there is an internal kephalhgematoma as well. It consists in a hemorrhage between dura mater and cranium, and may lead to all the consequences of intracranial hemor- rhage (apoplexy of the new-born), — viz., convulsions, paralysis, death, or meningitis, cystic degeneration, etc. There may be no contiguity between the external and the internal hematoma. Still, many cases of the external form will extend directly into the cranial cavity through a congenital fissure in the bone. The treatment is forestalled by what has been said of the spontaneous absorption of the extravasation. No treatment is required. The swelling must be left alone. The bony thick- ening will also get well in the course of time. It is impor- tant to insist upon this expectant treatment, because the at- tendants will often not appreciate the absolutely benign nature of the large tumor. 7 98 THERAPEUTICS OF INFANCY AND CHILDHOOD. Meddlesome practitioners have tried compression. If there be any communication with the cranial cavity, this procedure may become dangerous by blood being forced into the interior. Ointments have been recommended "to make believe/' for the purpose of quieting the anxiety of the family. Puncture has been resorted to. If made at an early period, it will facilitate new bleeding; in many a case it has been known to produce suppuration, though the operation was believed to have been aseptic. Incision is still more reprehensible. It is not per- missible except in those cases which have terminated in suppu- ration through previous maltreatment. Then a large incision and thorough disinfection are indicated, and will be followed by a relief to pain, redness, and fever. Puncture, aspiration, or incision may perhaps be necessary, even without suppura- tion, in one of two conditions: firstly, the tumor may be so large as not to undergo absorption for many weeks, and to en- danger the bone, which may become necrotic; still, I have not seen such a case these twenty years; secondly, in a case of complication with apoplexy, aspiration may be capable of al- lowing some of the internal extravasation to escape. Other indications for the treatment of this internal kephal- hsematoma are suggested by asphyxia or other symptoms which depend on disturbed innervation. The antiphlogistic treat- ment will be confined to cold or cool applications only. The consecutive paralysis demands an appropriate treatment, the results of which will be mostly questionable, and depend upon the amount of extravasated blood, of tissue destroyed or com- pressed, and consecutive changes in the nerve-centre. Surgi- cal interference, particularly when there is depression of bone, was recommended by Jenkins, who reported a successful case. 4. Hcematoma of the Sterno-Cleido-Mastoid Muscle. The fragility of the foetal blood-vessels and some injury experienced by the muscle during parturition give rise to a hemorrhage about or above, seldom below, the middle part of TREATMENT OF THE NEWLY- BOKN. 99 the long muscle. When observed the tumor has the size of a hazel-nut or more; it is spherical, circumscribed, and rather hard. The latter condition is due to the secondary inflamma- tion of the torn muscular fibres. This occurrence is not at all very uncommon. Even in older children, mainly in kite-flying boys, who suddenly strain either of their sterno-cleido-mastoid muscles, the same hematoma and myositis are observed. When observed at an early period the local application of ice may reduce the bleeding. For a week, after ceasing the employment of ice, small pieces of cloth moistened with cold water will check the secondary inflammation to a certain ex- tent. Very gentle massage should be employed. During all this time the head must be kept immovable, — best perhaps by carrying the baby on a hair pillow large enough to support the whole body, head included When the tumor has time to become hard, it may last for years; when it is large, it may give rise to torticollis. Then gentle stretching and massage, the application of a mild galvanic current, and the inunction of an absorbable ointment of iodide of potassium may be tried to advantage (iodid. potass., aq., aa 1; adip. suill., 2; adip. lanse hydros., 6-8). 5. Sclerema. The induration of the connective tissue of the newly-born known by that name consists of a serous infiltration of, and under, the skin, begins generally in the lower extremities, and spreads over the whole body with the exception of the chest. The surface is apt to be slightly hypergemic in the beginning, and then turns yellowish and quite pale. Eespiration is shal- low, nursing feeble, secretion of meconium and urine scanty, sensibility diminished, the pulse slow (60-75), accelerated only towards the fatal end, and temperature reduced much below the normal, even to 90° F. and less. Recovery takes place but very rarely. Even those who suffer from a slight attack only are liable to perish of pneumonia after two or three weeks. Many of the infants are prematurely born, exhibit defective 100 THERAPEUTICS OF INFANCY AND CHILDHOOD. innervation, possibly resulting from foetal brain-disease, or suffer from some cardiac affection. The patient must be fed from a spoon or dropper and by the rectum. Food should be warm, rectal injections hot. Al- coholic stimulants may be given in the shape of brandy or whiskey, four to six drops every half -hour; also a drop of tinc- ture of digitalis every hour or two hours, and aqua camphorse, ten drops every hour. Massage with oil or lanolin, com- mencing at the periphery, gentle but persistent with the thor- oughly warmed hand, or through a warmed cloth, will improve circulation, and probably absorption, to a certain extent. Maybe, also, passive movements, practised gently but per- sistently, and extensive (general) galvanization of the surface will serve the same purpose. The infant must be kept warm near a stove or furnace register, provided the head can be kept away from it and the air-supply for the lungs be kept up at a moderate temperature. Otherwise hot stones, hot sand, hot bottles, must be distributed, well covered, through the bed at a safe distance. Frequent bathing in salt-water of at least 100° F., with constant friction and massage in the bath, will prove as beneficial as the bad or very doubtful prognosis will permit. 6. Bathing. The first bath of the newly-born, and bathing of infants in general, demand great caution. For the temperature of the young has its peculiarities. Immediately after birth it is apt to lose- a degree (F.) or more, in consequence of defective cir- culation and respiration and of the great difference in the baby's surroundings before and after birth. A feeble new- born requires more time before its temperature rises again to a normal standard. That is particularly so in regard to the skin. Thus it is that the thermometric measurements when made in the axilla are as deceptive in the feeble young as they are apt to be in adipose adults, with their insufficient super- ficial circulation. TREATMENT OF THE NEWLY- BOKN. 101 To a certain degree the cool air of the room has the tendency of reducing the surface temperature of the newly-born. When moderate, the sudden change acts favorably by inciting reflex action, but a considerable and continued reduction of tempera- ture must have a dangerous influence at a time when the func- tions of the body are not yet regulated. In Lassar's experiments, when an animal after recovering from albuminuria got exposed to a cold temperature, the same condition returned. Eabbits thus exposed, without or after depilation, suffered from interstitial inflammations of liver, lungs, heart, and neuroglia. The blood-vessels of liver and lungs became enormously dilated, the arteries filled with thrombotic masses, and leucocyte emigration was marked round the smallest veins. When the animal was pregnant, even the liver and other organs of the foetus were found to be inflamed. This is exactly what clinical experience has taught every ob- server of every generation, in spite of modern contradiction. Thus I have observed a sudden return of the morbid symptoms in three persistent and protracted cases of hemoglobinuria after every exposure to cold, and particularly to cold and moist air. Therefore the newly-born babe should not remain uncovered for any length of time. The nurses who spend — with more pedantry, emphasis, and self-consciousness than intelligence — much unnecessary time in oiling and soaping and washing and bathing, turning this and that way, drying the surface, wrap- ping the navel, applying the bandage, and dressing the newly- born in fineries, in which it finally returns to its mother's bed or to its crib shivering with a cold nose and blue feet, are not infrequently the causes of ill health or death. In a case recently seen, the pneumonia of the newly-born was un- doubtedly due to the fact that the baby was neglected while both physician and nurse were engaged about the fainting mother. Craig must have seen many such cases, for with him "no baby is ever washed, dressed, fed, tied up, the cord is not 102 THERAPEUTICS OE INFANCY AND CHILDHOOD. wrapped up, but the infant is anointed with fat and wrapped in flannel the first twenty-four or thirty-six hours." Similar advice has been given repeatedly. The bath of the newly-born must not be hot. A single mid- wife in Elbing lost ninety-nine babies out of three hundred and eighty, of trismus. Through all her life she had estimated the temperature of the bath by trying it with her uncovered arm. She lost her temperature sense after a while, as was found by a judicial investigation, and the babies their lives. Still, the bath ought not to be less than 90° F., nor ought it to be much cooler through a number of months, in spite of a French author's opinion, who says that the epidermis becomes macerated by warm baths; that babies who are getting bathed grow "pale, soft, and flabby and eczematous," and proves the correctness of his position by his zoological discovery that "no other mammalia take a warm bath regularly." * The proportion of the surface to the cubic mass of the human body is larger in an infant than in an adult, and the number of peripherous nerve-ends and capillaries relatively larger. Thus there is a greater liability to reflex symptoms depending on exposure in spite of the low degree of nervous irritability in the newly-born during the first few weeks. , That is why a protracted cold bath is not well tolerated even by older infants; but, also, why tepid or cold bathing or packing ex- hibit a very much more rapid effect in the young than in the old. For both the reduction of temperature and the reflex * To the general rule implied in the above remarks on the necessity of bathing in warm water only, according to which the body of the newly-born infant is to be kept warm, the head forms an exception. Artificial heat and feather pillows ought to be avoided. A soft hair pillow is preferable, or a quilt lined with a layer of cotton. When- ever it is necessary to employ a soft head-rest, a feather pillow may be covered by a bed-sheet folded up to the size of the pillow and fastened to its corners by safety-pins. Air-cushions ought to be in more common use than they are. TREATMENT OF THE NEWLY-BORN. 103 effect do not depend on the weight of the body, but on the extent of the conducting and radiating surface. When the baby is six months old, particularly during the summer months, the warm bath is to be succeeded by washing and friction with tepid and, later on, with cold water. When washing is substituted for bathing, water may be selected of a lower temperature, inasmuch as but a part of the surface is exposed to its influence at one time. When the bath, in the course of time, is gradually made cooler, friction of the skin during bathing stimulates its action. In pathological condi- tions, when cool or cold bathing is resorted to for the purpose of reducing an abnormal temperature, this aim is always and easily reached as far as the surface is concerned. But to ac- complish the same end for the whole body, it is necessary that the skin should retain its vitality and lively circulation. Unless that be so, the internal temperature may remain un- changed, or even rise while the surface is cool. In such a case, which must be ascertained by taking the rectal temperature, the cold bath ought to be followed immediately by a hot one for the purpose of restoring the surface circulation. In this way the reduction of temperature aimed at by the administra- tion of a cold bath may finally be accomplished by hot water. In less urgent cases the warming of the extremities and of the general surface by dry heat may suffice to restore the warmth of the surface. At all events, a cool or cold bath after which the feet do not become warm at once is dangerous. 7. Mamma. Mastitis. Perimastitis. Angioma. Since the time of Menard, Scanzoni, and Guillot, the secre- tion of the mammary gland of the newly-born has been the subject of frequent investigations by clinicians, chemists, and physiologists.* It is mostly found towards the end of the first * Jacobi, in Gerhardt's Handb. d. Kinderkrankh., 1st vol., 2d part, p. 39, of the 2d ed. 1882. 104 THERAPEUTICS OF INFANCY AND CHILDHOOD. week, and resembles very much the milk of the mature woman, in the mammae both of the male and female infant. The superficial milk-ducts are obstructed with epithelium; the interior ones are dilated in many places and filled with a cu- boid epithelium and a liquid which resembles colostrum. This secretion may be absent, but it is frequently found in prema- ture or still-births, though the mammas be but rudimentary. The dilatations will increase in size for weeks, and begin a retrograde development as late as the middle of the first year of life. The tendency to epithelial elimination, which is a peculiar feature in the newly-born, and which is so commonly observed in its skin, mucous membranes, sebaceous follicles, and kid- neys, appears to be very marked in the mamma of the newly- born. This discovery of Epstein's renders the subject of our discussion very much clearer from an etiological point of view. The swelling and secretion of the gland may last a week or two when undisturbed. After it has been squeezed out ever so gently, a new secretion will be invited and continue five or six weeks. Thus pressure of any kind should be avoided. It is barely possible that it may not be injurious, and that a gentle inunction of warm oil, which is so commonly used, may do no harm. But as a rule every sort of pressure occasions an attack of inflammation and, maybe, suppuration. Though an abscess be ever so small it is sufficient to destroy forever all or a part of the mamma, — a serious misfortune in a female. A swelled mamma must be left alone. Applications of cool or warm water, the cloth being well pressed out and covered with oil- silk and cotton, or flannel, or of a mild lead-wash, will answer well. Also applications of iodide of potassium dissolved in glycerin, one part of the former in two or five of the latter, which are repeated every few hours. Extract of belladonna may be added to advantage. When suppuration could not be avoided, the incision must not be delayed. It ought to be made at the greatest possible distance from the nipple, directed TREATMENT OF THE NEWLY-BORN. 105 towards the nipple, so as not to cut the main milk-ducts, and treated antiseptically. Indurations remaining behind require frequent and gentle inunctions of an iodoform ointment (iodo- form, 1.0; ol. bergamot, 2 drops; adip. suill., 6.0-8.0), or iodo- form collodium, to be applied with a brush twice every day (iodof., 1; collod., 10-20) in such a manner that only those scales of the application which are peeling off from the skin are removed before a new layer is applied over the dried-up pre- vious application. No collodion should be employed as long as there is the slightest secretion from the surface, or from a wound. In place of the iodoform iodide of potassium may be used. A very mild galvanic current of from two to six ele- ments, conducted through the induration by means of soft sponge electrodes moistened with salt-water, has rendered me good service in many cases. Perimastitis, the inflammation of the surrounding connective tissue, may occur primarily, but is mostly the final result of traumatic mastitis. It is liable to grow dangerous, unless in- cisions are made early and treated antiseptically, with great care. I have met with not a few cases in which the suppura- tion of the connective tissue was very extensive, spread over a large surface, undermined the skin of the chest, axilla, and back, resulted in gangrene, erysipelas, or sepsis, and terminated fatally. Antiseptic solutions (applications, injections, irriga- tions) must be used frequently, but ought to be mild. Carbolic acid should be avoided, for infants are easily poisoned by it. The mamma ought to be examined for angiomata in every baby, whether there be mastitis or not. Nsevi are by no means rare in this neighborhood, and ought to be destroyed at once, either by the application of fuming nitric acid when superficial or by the actual cautery (red-hot iron, galvano- cautery, or thermo-cautery) when deep-seated or genuine vas- cular tumors, for they are liable to grow rapidly, and prove dangerous to the female. 106 THERAPEUTICS OF INFANCY AND CHILDHOOD. 8. Treatment of the Cord. The indications for the application of the ligature, and thereby the complete interruption of f cetal circulation, appear to vary in the practice and teachings of the obstetricians. When the baby has cried a few times, the majority apply the ligature and cut the cord. Others insist upon waiting for the collapse of the cord produced by that of the vein, while the arteries are still pulsating, and some will wait for the disap- pearance of the arterial pulse. A few facts may be remem- bered for the purpose of guiding the practitioner in individual cases, for the amount of blood entering, or retained in, the body of the infant is by no means an indifferent matter. If the ligature be applied after the cessation of the umbili- cal pulsation, there are still six ounces of blood (one hundred and ninety-two grammes, according to Zweif el) in the placenta. If the latter be compressed by Crede's procedure that amount is reduced to three ounces (ninety-two grammes). Thus the difference between the two procedures means a difference of three ounces of blood in the circulation of the newly-born, which is an enormous addition to the usual quantity of blood, which in the infant slightly older is but little more than five per cent, of the total weight of its body. After all, it appears that the deferred separation of the baby, when poorly devel- oped and pale, and the admission of more blood to its system, is deserving of recommendation; while, on the other hand, there may be an occasional indication for bleeding the infant.* The admission of a large quantity of blood, however, is no unmitigated blessing. The blood-vessels of the newly-born are so thin and fragile that spontaneous hemorrhages on serous membranes and into the nerve-centres, etc., are by no means uncommon under normal circumstances. It is true that the destruction of superfluous blood-corpuscles is very rapid, as * Archives of Pediatrics, March, 1888, p. 130. TREATMENT OF THE NEWLY- BOBN. 107 rapid, indeed, as it is known to be after transfusion in the adult, but some time is required to accomplish that end, and during that time hemorrhages may take place, and have been reported by Neumann and Illing, and observed by me. This danger is sufficiently great to counterbalance the alleged ob- servation of Hofmeier, according to whom babies, after de- ferred separation from the mother, lost less weight and com- menced to increase sooner than those removed more speedily. However, Violet states that the former lost twenty ounces (six hundred and nineteen grammes), the latter but nineteen (five hundred and eighty-five grammes). Nor does Porak's observation, according to which congested babies exhibit a more intense degree of jaundice, lack con- firmation. If the ligature be thin, it is liable to cut through the walls of the blood-vessels prematurely; if too thick, it may not suf- fice to compress them satisfactorily. It ought to be applied at a distance of from one and a half to two and a half inches from the abdominal wall (three to five centimetres); not nearer, in order to avoid the effect of the immense muscular power of the umbilical arteries inside the abdominal cavity. A second ligature is placed about an inch from the first, and the cord cut between them. It is a good rule, which must surely be adhered to in every case of thick cord, to apply an additional ligature between the first and the abdominal wall, to avoid hemorrhage which may take place after the cord has com- menced to shrink, from the insufficiently compressed arteries. The abdominal end of the cord is then wrapped up in a dry and soft piece of linen, lint, or borated cotton, placed on the left side of the abdomen, and fastened, by means of a soft flannel bandage, which is wide enough to cover the larger part of the chest and all of the abdomen, so as not to slip. In wrapping up the end of the cord no oil or fat should be used. "Warmth and dryness favor mummification; moisture and exclusion of air, gangrene. This holds good also for the cord 108 THERAPEUTICS OF INFANCY AND CHILDHOOD. when it is separated from the living baby by an additional liga- ture, and in the dead. Thus, the former forensic axiom, which prevailed for decades after Meckel had demonstrated its fallacy as early as 1853, that a dry cord proved that the baby had lived, is absolutely worthless. Fatty substances, and moisture of any kind, must be avoided. Powdered subnitrate of bismuth, or oxide of zinc, or iodoform, or salicylic acid, one part with forty or twenty parts of starch, may be dusted round the inser- tion of the cord and over the stump daily. The latter appli- cation is not necessarily useless (from the point of view of anti- sepsis), for the separation of the cord is a gradual one, and not uniform through the whole thickness of the amnion and the three blood-vessels. The size of the sore stump and the rapidity or slowness of cicatrization depend upon the thickness of the cord, the inten- sity of the line of demarcation, and the reactive inflammation. The latter are most marked in vigorous infants. As a rule, the surface is dry a few days after the falling of the cord, and cicatrization complete within twelve or fifteen days after birth. This normal process is, however, disturbed by careless hand- ling, local irritation, and infectious influences. In these un- favorable cases there is a serous or purulent secretion, and cicatrization may be deferred for many weeks. Under these circumstances local treatment is required. Carbolic acid ought to be avoided, for the newly-born and infant are easily influenced by its poisonous properties. Solutions of lead, zinc, or alum answer quite as well as any solutions do. As I said, however, it is best to avoid water. I recommend the powders of zinc oxide, bismuth subnitrate, alum with starch, salicylic acid with starch, or iodoform. Such measures will always prove helpful; to omit them in times of prevailing ery- sipelas or diphtheria is unpardonable. Perchloride of iron, or subsulphate of iron, must not be used. Under the hard coagulation formed by their application over the whole wound secretions will accumulate, cannot escape, are absorbed, and TREATMENT OF THE NEWLY-BORN. 109 produce sepsis. I have seen babies die from applications of iron to the umbilical stump, as I know of women dying for the same reason when the hemorrhages from their uteri or from the lacerated vaginae were maltreated in the same manner. 9. Omphalitis. Inflammatory infiltration of the abdominal integuments which surround the stump, with swelling, pain, purplish dis- coloration, gangrene, or abscesses, and consecutive peritonitis, occurs within a few weeks after birth, and is the result of trau- matic or septic influences. The dermatitis requires applica- tions of lead-wash; tendency to suppuration, moist antiseptic (or aromatic) applications, such as Thiersch's solution (sali- cyclic acid one part, boric acid six parts, water one hundred and twenty-eight parts); the presence of pus, a large incision, with antiseptic after-treatment. Cold applications are not toler- ated. Bathing is painful. Any of the antiseptics mentioned previously will render good service. Carbolic acid must be avoided. Generous feeding by a wet-nurse, alcoholic stimu- lants (from one to two teaspoonfuls of whiskey daily), plenty of water, and evacuation of the bowels by injections, are the additional aids in treatment. The main reliance is on the local treatment, — viz., large incisions and antisepsis. 10. Umbilical Gangrene. This is the result of an inflammatory process, mostly in a prematurely born baby, or one that fell sick with diarrhoea. It may extend inward to the intestine and terminate in perfora- tion. The prognosis is very bad except in the few cases in which there is a well-marked line of demarcation. The treat- ment consists in antisepsis and stimulation. 11. Arteritis and Phlebitis. The former is very much more frequent than the latter. Arteritis is often connected with general sepsis, pneumonia, 110 THERAPEUTICS OF INFANCY AND CHILDHOOD. pleurisy, peritonitis, arthritis, and subcutaneous abscesses. The infection reaches the arteries from outside through the lymph circulation, begins in the connective tissue surrounding the vessels, and attacks the adventitia first. To discover the source of infection is sometimes very difficult; in his experi- ments Budin succeeded in forcing septic material through the cord from beyond the umbilical ligature. Pus can seldom be squeezed out of the arteries, and the diagnosis is sometimes made at the autopsy only. The disease begins often before the complete separation of the cord, absorption taking place through the cord, which dries and shrinks irregularly, and admits poison through the newly-formed cuts or fissures. The treatment is indicated by the causes, which are self-in- fection from a putrefying surface, infection by soiled fingers, cloths, baths, applications of any kind, the contact with a septic mother, or the contact with anything septic, — for instance, the pus of ophthalmo-blennorrhoea, or the decomposing lochial discharges of a healthy woman. Thus the treatment is mostly preventive. The scissors, cloths, and sponges used for the newly-born must be aseptic. The baby must not be in the mother's bed, and must be attended before the mother on the days following her confinement. The hands touching the baby's body must be carefully cleaned and disinfected many times a day, the cord and umbilical wound treated as detailed before. They should be kept tied up conscientiously. There should be no possible contact between them and the faecal dis- charges, be these ever so normal; if there be diarrhoea the greatest caution is required, for the danger of infection is im- minent. If the mother suffer from puerperal sepsis the baby may be permitted to nurse, but should be kept in another room constantly and carried into the presence of the mother for the purpose of nursing only, and contact avoided. The internal treatment is identical with that advised in omphalitis and gangrene. The symptoms of phlebitis differ sometimes from those of TREATMENT OF THE NEWLY-BORN. Ill arteritis in this, — that there is more peritonitis of the hepatic region from the beginning, more epigastric meteorismus, more icterus. Now and then pus may be obtained by gently squeez- ing along the course of the vein. The infection is either di- rect, through the vein, in which an ulcerous process is some- times found half an inch or an inch above the navel, or also through the lymph-current in the surrounding connective tissue and the adventitia of the vessel. The treatment cannot differ from that of arteritis. Eecovery is possible when the absorption of the poison has not been very copious, or elimina- tion progresses with absorption at an equal rate. A female baby of less than three pounds, in my experience, exhibited no other source of septic infection but a slight erosion or ulcera- tion of the umbilical stump, with hardly any secretion. She recovered, though the process extended to the end of the second week, with temperature reaching sometimes 103° F. 12. Puerperal Sepsis. Acute Fatty Degeneration. Epidemic Ho3moglobinuria. The treatment outlined in the last chapters is to a great extent also that of the puerperal sepsis of the newly-born con- tracted before birth, or immediately after, from the mother (umbilical changes, fever or collapse, peritonitis, pleuritis, pneumonia, meningitis, jaundice, diarrhoea, — in fact all the possible symptoms of septico-pyoemia). It takes more than "an ounce of prevention;" but, after all, prevention is all that can be done. Eecovery is a bare possibility only. Acute fatty degeneration of the liver, heart, and kidneys, also of the lungs and the intestinal villi, with multiple hemorrhages, jaundice, cyanosis, vomiting, and diarrhoea, does not seem to get well. Almost the same may be said of epidemic hemo- globinuria (Winckel), which exhibits the same symptoms, to which is added the presence of haemoglobin in the urine. It is of a brownish-red color and contains no blood, but renal and vesical epithelia, casts, and cocci. 112 THERAPEUTICS OF INFANCY AND CHILDHOOD. 13. Umbilical Hemorrhage. This may take place from the arteries, either before or after the separation of the cord. Its treatment is either mostly preventive, or the indications become so clear in every indi- vidual case that it becomes easy to fulfil them. Though the pulmonary aspiration and the great contractility of the mus- cular layers of the arteries render a hemorrhage difficult, even when no ligatures were applied, an insufficient develop- ment of those muscular fibres, or the presence of asphyxia or atelectasis, or a pneumonia, may produce a disposition to bleed. That is why the ligature, or ligatures, should be tied accurately. In such cases of bleeding it may become necessary to apply an additional ligature. The arterial power being greatest in the abdominal cavity and near the umbilical ring, the cord must not be cut near the body. Two ligatures, as described above, are a fair preventive. Tight abdominal bandages im- pede circulation, and should be avoided. When the cord is cut too short, or torn off, it may be impossible to secure the vessels; in such cases two long harelip needles should be run through the abdominal wall, near the vessels, crosswise, and a strong ligature tied underneath them. The same procedure may be resorted to when the hemorrhage takes place after the separation of the cord, either from the blood-vessels or from the slowly-healing surface, in consequence mostly of incon- siderate handling. When the hemorrhage ceases, a moderate compression of the wound, which is covered with iodoform or the salicylic acid and starch-powder, and borated cotton, by means of a bandage, will answer well. In obstinate cases anti- pyrin in a twenty or fifty per cent, solution should be applied. No iron. When the surface is granulating, the proliferations may be touched with the solid stick of nitrate of silver. All of such cases yield a better prognosis than those result- ing from haemophilia, congenital syphilis, general sepsis, or acute fatty degeneration. In these conditions the blood co- TREATMENT OF THE NEWLY-BOEN. 113 agulates with even greater difficulty than that of the healthy new-born, and not infrequently all attempts at stopping the bleeding are liable to prove futile. The ligation of the whole mass is often unsuccessful because the stitch-channels will also bleed; chemical styptics are too often useless; plaster of Paris has sometimes proved successful, and the actual cautery has proved advantageous in a few cases. But the majority of such cases terminate fatally. If the case be one of syphilis, subcutaneous injections of corrosive sublimate should be tried (see pp. 75, 114). A sugges- tion of Bienwald's, who applied fresh coagulable blood of a healthy person to the bleeding wound of a hsemophilic patient, with the result of causing coagulation and insuring recovery, is here reported for what it may be worth or not. A. E. "Wright claims a styptic effect of a solution of fibrin ferment and chloride of calcium. 11. Icterus. A certain degree of yellowish discoloration of the skin is the result of the normal changes of hasmatin deposited in the skin during the rapid transition from foetal to postnatal cir- culation. When by retarded separation of the newly-born from the mother, and compression of the placenta, the amount of blood in the circulation of the infant is unduly increased, this form of hsematogene jaundice is rather more developed. The simplest form of hepatogene icterus is produced by the sudden diminution of the blood circulating in the vessels of the liver, which encourages the exosmotic transition of bile from the bile-ducts into the adjoining blood-vessels. All of these forms of jaundice require no treatment. Duodenal catarrh will produce, in rather rare cases, icterus in the newly-born, as it does in advanced age. That is why the feeding and the diges- tion of the baby must be carefully watched, and the air pure. The routine administration of syrup of rhubarb is a mistake on the part of the female busybodies which should be discouraged. Maybe some of them can be taught that acid cow's milk and 8 114 THERAPEUTICS OF INFANCY AND CHILDHOOD. indiscriminate feeding in general, and exposure, tight band- aging, and cold feet, can do still more harm than their medi- cines. Icterus resulting from congenital obliteration of the large biliary ducts, or from congenital cirrhosis, or from acute fatty degeneration, or from epidemic hemoglobinuria is in- curable. Icterus during septic infection is a bad symptom, and rarely terminates otherwise than in death. Icterus de- pending on congenital syphilis of the liver is grave, but I have met with several cases that recovered. A thorough and en- ergetic antisyphilitic treatment is the only safe-guard in such cases. It may prove unsuccessful, however, because the syph- ilitic process of the connective tissue is not confined to the liver, but extends to the rest of the organs. Mercury must be administered for a long time, a twentieth or a twelfth of a grain of calomel three times a day; careful inunction of a scruple of blue ointment daily; or one-thirtieth of a grain of corrosive sublimate in a one-fifth of a per cent, solution of dis- tilled water for subcutaneous injection daily. In the begin- ning of the treatment two of these medications may be com- bined, or one of these together with the internal administration of from three to five grains of iodide of potassium daily, in three doses, which are given after meals. The internal ad- ministration of the bichloride of mercury is also well tolerated; one one-hundredth of a grain may be given in a teaspoonful of water, or food, every two or four hours, and continued many weeks. 15. Melcena Neonatorum. Hemorrhage from the bowels (more frequent than from the stomach) occurs on the second or third day of life; also later within the first week. Syphilis, acute fatty degeneration, epi- demic hemoglobinuria, and sepsis of other varieties, — also asphyxia, — cause a predisposition; also pulmonary obstructions, cardiac disease, and a widely open ductus Botalli with consecu- tive intense congestion. A thrombus emanating from the latter, or one coming from the ductus venosus Arantii (Landau) TREATMENT OF THE NEWLY- BORX. 115 may cause an embolic ulceration of the stomach or duodenum. The blood is fluid or coagulated, rather black, like that of haematemesis in advanced age. It is, however, mixed with the food and rather reddish when it was swallowed while nursing. A mistake in diagnosis may happen when blood is swallowed, during an operation on the lip or cheek, or during an epistaxis resulting from an injury. A single observation of the latter kind was published lately, and generalized as the cause of melsena. The quantity of blood evacuated from the bowels is some- times enormous, particularly in view of the fact that the weight of the blood in the body of the newly-born amounts to little more than five per cent, of the weight of the baby. The cases complicated with vomiting are the worst. These result mostly from the presence of ulcerations in the stomach and duodenum. Competent respiration and an aseptic um- bilical wound are the best preventives. Babies should cry from time to time to stimulate and strengthen both circula- tion and respiration. The treatment consists in applications of ice to the epigastrium, while the limbs are kept thoroughly warm by artificial means. Tincture of chloride of iron may be given in drop doses. Food is to be given at a low tempera- ture. Rectal alimentation is mostly useless because of the fre- quency of discharges. In a desperate case of anaemia and collapse the subcutaneous injection of a sterilized salt-water solution may prove helpful. I could not convince myself of the usefulness of subcutaneous injections of ergot. 16. Trismus and Tetanus. Its prognosis is not quite so bad as it was believed to be, formerly. Now and then recoveries have been reported, and I have seen them myself, though the number of cases observed by me have not been very numerous. The prognosis is better when trismus appears at a later period after the separation of the cord than usual, and when its course is protracted. Cases 116 THERAPEUTICS OF INFANCY AND CHILDHOOD. lasting more than five or six days are rather promising. Such as set in early and exhibit a high temperature (106° and more, up to 111° F.), with disturbances of respiration and great in- anition, are bad. As a preventive, it has been proposed to re- move women, for the time of their confinement and recovery, from districts where trismus is endemic. At all events, the greatest care should be taken of the umbilical wound, through which the invasion of the specific bacillus takes place. Some of the cases are mild, — that is, not fatal. Maybe they are those only which are due to excesses of temperature, high or low, — there are those of "rheumatic" origin, — or to lesions of the brain or medulla oblongata. Food must be introduced through the rectum or the nose, and as much water as possible. For days after no food could be swallowed when introduced into the mouth, the patients were sometimes able to swallow what- ever was thrown into their pharynx. By means of a medicine- dropper or a small teaspoon fluids may be poured down. Medi- cines must be administered subcutaneously, atropiae sulphas in doses of one one-thousandth or one six-hundredth of a grain a number of times daily; curare, one-fiftieth or one-thirtieth; extract of calabar, one-half of a grain. A few of my cases got well with chloral, mostly per rectum, in doses of from one to five grains from six to ten times a day, and occasional inhala- tions of chloroform. High temperatures may be influenced by antipyrin or antifebrin, combined with whiskey or brandy. Bathing is contraindicated because the baby bears no handling. Even applications of cold water for the purpose of reducing high temperatures should be local only, and made without turning or tossing the patient. All this medication is not rendered superfluous by the sub- cutaneous administration of the antitoxin, first introduced by Tizzoni and Cattani. They should be combined. One case out of four of Escherich's recovered* under the use of three * It is an aseptic serum in a desiccated state. ". . . According to Merck it is to be dissolved in distilled water in the proportion of ten parts by TREATMENT OF THE NEWLY-BORN. 117 doses of three decigrammes (five grains) each injected in the course of two days. The chemical poison evolved out of the invading bacilli is not absorbed at once; the invasion is more or less persistent and should be stopped in the admitting wound (mostly the umbilicus) by the actual cautery, or by applications of tincture of iodine, or of a one- or two-per-cent. solution of iodine trichlorid, or a one-half of a per-cent. solution of potas- sium hydrate, or one-twentieth-per-cent. dilution of hydro- chloric acid, or a one-per-cent. dilution of kresol (Sahli D. Med. Zeit., No. 11, 1896). Similar rules are given by the Health Department of New York. Of the antitoxin, twenty cubic centimetres are a dose for an adult; accordingly, one cubic centimetre seems to be appropriate for the newly-born. (Archives of Pediatrics, July 1, 1897.) 17. Blennorrhcea. Blennorrhceic conjunctivitis may be prevented by repeated disinfectant injections into the vagina of the woman in labor. For that purpose a solution of three parts of carbolic acid in one hundred of water, or one of bichloride of mercury in one or two thousand of water, are sufficient. After the newly-born has been bathed, a few drops of a two-per-cent. solution of ni- trate of silver, or a one-twentieth of a per-cent. solution of bi- chloride of mercury, are applied to the cornea. When the disease is established, both eyes are affected in most cases. When but one, the healthy eye should be covered with a disin- fecting lotion and borated cotton, and its infection by sponges, towels, water, and fingers guarded against with the greatest care. The diseased eye must be kept scrupulously clean by weight to one of the desiccated serum. ... It is imported in small bottles, and it is recommended to inject the contents of half a bottle for a first dose" (for an adult), "while the remainder is divided into four equal quantities and injected at intervals depending on the result of the first dose and the symptoms of the disease." (James Stewart, in Loomis and Thompson, "A System of Practical Medicine," vol. i. p. 943.) 118 THERAPEUTICS OF INFANCY AND CHILDHOOD. pouring tepid water over the cornea, or (and) removing the pus by means of small pellets of borated cotton. To succeed in this the upper and lower eyelids must be turned out. This is not always easy, and is never satisfactory unless the cornea becomes perfectly visible during the manipulation. Once a day the application of a mitigated stick of nitrate of silver (nit. arg., 1; nit. sod., 2) is useful. It may be substituted by a two- per-cent. solution of nitrate of silver in water. In both cases the diseased surface should be washed with a mild solution of table-salt afterwards, and ice-cloths, small and as dry as pos- sible, applied every ten minutes or oftener. When the cornea is ulcerated, a few drops of a solution of sulphate of atropia (1 to 200) may be instilled several times daily. But lately G. Schallern experimented on the eyes of nine hundred and seventeen new-born, in the obstetrical clinic of Gottingen. Two babies only became affected, and on the eighth day only; all were saved. The slight irritation following (in some cases) the application of the two-per-cent. solution of nitrate of silver passed by without any injury. When that irri- tation is observed, no new application should be made- in the next twenty-four or thirty-six hours. (Archiv f. Gynak., 1897, p. 86.) 18. Umbilical Fungus {Granuloma). Adenoma. The umbilical stump requires frequent inspection. Unless it cicatrizes speedily, granulations will spring up from its sur- face and form into small tumors. They are either sessile or pedunculated, and are apt to grow very fast. They are not sen- sitive, but apt to bleed. In some cases they are discovered on very close examination only, and may remain many years, even to advanced age. Exceptionally such a fungus is not, or but partly, the result of granulation, but consists mainly of the remnants of the omphalo-mesenteric duct (with unstriped muscular fibres, tubulated glands, and cylindrical cells) or of the allantois. Once it was found by Yirchow to be a sarcoma. Waldeyer met with some that were adeno-sarcomata. TREATMENT OF THE NEWLY-BORN. 119 Usually it requires no excision, but only cauterization or as- tringent and antiseptic applications. Nitrate of silver may be used, but must be neutralized by chloride of sodium imme- diately. Other applications are, a drop of liquor subsulphatis ferri once or twice daily; the powdered subnitrate of bismuth; iodoform; one part of salicylic acid with five parts of starch. If the granuloma is large, or when it returns, it should be removed with the scissors, and the stump scraped off. Dry antiseptic treatment is to follow (subnitrate of bismuth, dermatol, aristol, nosophen). The persistence of the omphalo-mesenteric duct which presents itself as a small tumor after the cord has fallen off, should not be taken for a granuloma. It would be a grave error to treat it like one lightly, and cause a peritonitis or a persistent intestinal fistula. To close it a careful aseptic oper- ation is required. 19. Hernia. Congenital umbilical hernia (exomphalus) is called a fissure of the median line of the abdominal wall, which is the result of an arrest of development. When the fissure is but small and the sac contains intestine only, the condition was con- sidered incurable. There is no reason why an operation on these cases, in which the abdominal defect is small, should not be at least as successful as those on more pronounced ones, for when the sac is large, containing at least a portion of the liver, together with intestine, the contents may be reduced and the cases cured. Twenty-four such cases have been collected by Kocher.* C. Brenz reports the case of a girl weighing two thousand seven hundred grammes at birth. "When the hernial contents had been reduced, which was accomplished with diffi- culty, he caught the edges of the sac by means of a pair of pin- cers, removed it with scissors, applied three percutaneous liga- tures, removed the clamp, applied the actual cautery to the *A. Jacobi, "The Intestinal Diseases of Infancy and Childhood," p. 267. 120 THERAPEUTICS OF INFANCY AND CHILDHOOD. stump, and covered it with antiseptic dressings. Both these and the ligatures were removed on the eighth day. The case proved successful, though there was peritonitis as early as twenty-four hours after birth. D'Arcy Power reports an un- successful case ("Surg. Dis. Child.," 1895). Acquired umbilical hernia, which contains small intestine and peritoneum, and is produced by a large size of the cord, by leanness and insufficient development of the baby, and by screaming, coughing, and the straining consequent upon diar- rhoea, constipation, phimosis, or anal fissure, demands the treat- ment indicated by these causes, and reduction, which is almost always quite easy, and retention, which is by no means so easy, within the abdominal cavity. The usual shape of trusses is unavailing, or even injurious. Whatever appliance is used should be larger than the aperture, and not be too hard. Linen or lint compresses, plates of cork, covered with linen or lint, may be held in position by means of a bandage, to which they can be fastened by stitches or pins. Knitted bandages are more useful than those of linen, cotton, or flannel cloth. Adhesive plasters are used frequently, but are generally too irritating on the sensitive surface of the infant. Incarceration and strangulation of an umbilical hernia are very rare, but there is on record a fair number of cases in which herniotomy was performed successfully on infants of a slightly advanced age. Inguinal hernia is a curable disease. When the short and straight inguinal canal of the newly-born becomes more ob- lique and the adjacent fat increases in the course of a few years, the rupture will disappear, provided a proper truss has been retained for a long time. During that period the intes- tines must not be allowed to protrude at all. The truss must be worn day and night, with the exception of such times when the infant is sleeping quietly. A good fit does not mean undue pressure. The testicle must be closely watched. It is found high up in the scrotum, behind the hernia. Sometimes it has TREATMENT OF THE NEWLY-BOKN. 121 not descended into the scrotum, and is then mostly discovered in the inguinal canal. By gently pressing it downward and ap- plying the truss above, we not only protect it but facilitate a complete descensus. Mr. William Coates's (1848) appliance "consists simply of a skein of lamb's wool; for infants Berlin wool is preferable. This encircles the pelvis, one end being passed through the other at a point corresponding with the inguinal ring; the free end is carried between the thighs, and is fastened behind to that portion which forms the cincture. This simple and cheap contrivance can be worn during the morning and evening ablutions, and then changed for a dry one. No attention is required on the part of the nurse, except at the moment of changing." (D'Arcy Power, "The Surgical Diseases of Children," Philadelphia, 1895, p. 414.) For such cases as prove too obstinate, a radical operation becomes advisable, in some it is inevitable. (D'Arcy Power, and the special works on surgery. See also Digestive Organs.) 20. Congenital Constipation. Malformations of the intestinal tract, such as strictures or complete interruptions, will either terminate fatally (when inaccessible) or require surgical treatment. The latter class includes imperforate anus and rectum. In these cases, the ob- struction being complete, we cannot speak of constipation. This latter condition may, however, be found to depend on an anatomical peculiarity which is quite frequent, and may give rise to mistakes in diagnosis and treatment. The colon descen- dens of the newly-born is quite long. The sigmoid flexure, which I have found to measure as many as thirty centimetres (twelve inches), is bent upon itself several times in the narrow pelvis. Thus the convolutions of the intestine will press upon and compress each other* to such an extent as to result in ob- * A. Jacobi, "The Intestinal Diseases of Infancy and Childhood," Detroit, 1887, p. 184. 122 THERAPEUTICS OF INFANCY AND CHILDHOOD. stinate constipation. In some extreme cases the babies died without or with colotomy, which was performed on the strength of a mistaken diagnosis. The treatment of that congenital form of constipation must be adapted to the anatomical con- dition which gives rise to it. Rectal injections alone are rational. They must be made daily, at least once a day, and continued up to the completion of the fifth or sixth or even seventh year. At that period the normal relations of the several parts of the intestine are established, the pelvis be- comes larger, and evacuation of the bowels easier. No purga- tive medicines must be resorted to, inasmuch as the obstacle is mechanical only. There is, however, a single indication for their administration, — viz., those symptoms depending upon constipation, which point to the absorption of intestinal toxins above the obstruction. Septic fever, high temperatures, and serious reflex symptoms — such as convulsions — may require the speedy evacuation of the bowels. Though such occurrences be rare, they should be looked for. (See "Non Nocere" in Trans. 11th Internat. Med. Congress, or N. Y. Med. Record, May 19, 1894.) IV. DISEASES OF THE BLOOD AND CONSTITUTION. 1. Ancemia. Anemia is often the result of a hereditary predisposition, or it is congenital from some accidental cause. Mothers who suf- fered much during their pregnancies, or were delicate them- selves, are liable to give birth to anaemic and puny infants. Pre- mature infants, or those afflicted with congenital diseases, such as "cyanosis" or neoplasms, or smallness of heart and arteries, are anaemic, and apt to remain so. Another cause of idiopathic or primary anaemia is found in actual loss of substance by copious suppuration, excessive exudations in pneumonia and pleurisy, or by actual hemorrhages, the results of which are in some cases perceptible through a whole lifetime. They are quite frequent in the newly-born or young, in true melaena, haemophilia, umbilical bleeding, and sometimes even in kephal- haematoma; from harelip operations or ritual circumcision; from the prolonged losses by rectal polypi; in older children from epistaxis occasioned by coryza, heart-disease, or ab- dominal stagnation; from ulcerations in diphtheria; from trauma. Acute anaemia thus caused requires external and in- ternal styptics, the closure of wounds, the application of ice, and mainly when parenchymatous bleeding is obstinate, the external use of a twenty- or even fifty-per-cent. solution of antipyrin. The subcutaneous injection of fluid extract of ergot, the internal use of acetate of lead (hourly doses of two or five centigrammes (gr. ^-f ) may be given ten or twelve times without fear) or of liquor perchloridi ferri (five to ten drops amply diluted), stimulants internally, externally, and 123 124 THERAPEUTICS OF INFANCY AND CHILDHOOD. subcutaneously, ligature around the extremities so as to com- press the veins, warming of the surface, transfusion of defibrin- ated blood, or of a sterilized salt solution (6 : 1000) are apt to meet the most urgent necessities. As far as chronic anaemia is concerned, I cannot do more than simply allude to its direct and indirect causes for the pur- pose of obtaining the indications for treatment. Among the former is prominent an insufficient amount or an improper composition of food and insufficient supply of oxygen. Poverty with its wants, its squalid and airless dwellings, and overwork in overcrowded school-rooms, are all powerful sources of wide- spread anaemia; they become social problems, more than merely medical questions. Among the indirect causes I count every disease of more than a temporary character; all those ailments which so change the alimentary digestive organs as to inter- fere with digestion; intestinal worms, which are sometimes borne without symptoms, sometimes irritate and annoy (oxy- uris, ascaris), sometimes, however, interfere with assimilation to such an extent as to cause the gravest forms of anaemia" (ascaris, taenia, bothriocephalus); diseases of the organs of respiration, circulation, and elimination (kidneys); all feverish diseases, and particularly the infectious fevers (scarlatina, ma- laria, least of all typhoid fevers, unless they result in chronic intestinal ulcerations) ; diseases of the lymph system (including what is meant by "lymphatic condition" in the writings of a few modern authors), the larger part of which are accessible to successful treatment. It is true that pseudoleukaemia, leucocy- thaemia, pernicious and kindred anaemias offer the same diffi- culties which we meet in the adult; but the many glandular swellings — "scrofulous" or not — permit of successful treat- ment, both preventive and curative. All of these affections, the number and names of which I do not care to multiply, are the more dangerous, and require the more dietetic and medicinal attention, the greater their detrimental influence during infancy and childhood, — that is, DISEASES OF THE BLOOD AND CONSTITUTION. 125 during the period of growth, in which the organism has not only to sustain itself, but to increase steadily. The latter con- sideration is a very important one. It includes the necessity to which I have alluded in a previous chapter, not to permit a morbid condition, either acute or chronic, to run its full course without interference. A disease shortened a day, a sleepless night less, a dozen of diarrhoeal movements prevented, a rack- ing cough soothed, a convulsion interrupted, an excessive tem- perature relieved, are just as many prophylactic points gained, and as many causes of persistent anaemia mitigated in their dangerous influences. These considerations are the more weighty the younger the patient. For in regard to anaemia the young are in a very precarious condition indeed. The infant (and child) has less blood in proportion to its entire weight than the adult; this blood has less fibrin, less salts, less haemoglobin (except in the newly-born), less soluble albumin, less specific gravity, par- ticularly between the second and twelfth month of life, and more white blood-corpuscles. It has a specific gravity of but 1045 or 1049 compared with that of 1055 in the adult. The total amount of the blood in the young is relatively small. Its weight, compared with that of the body in the newly-born, is 1 : 19.5. The relative figures in the adult are 1 : 13. Hence it follows, from a practical point of view, that it is important not to permit the proportionately small amount of blood in an infant or child to be unduly diminished or diluted. That is why the subject of feeding and digestion is of such paramount weight in paediatrics. While it is a good rule to be careful in regard to the amount of food to be given in the beginning of a feverish disease, a fair quantity should be allowed after a while, provided it is fluid and well selected. Unless there be a contraindication in the condition of the stomach, a fair amount of albuminous nutriment (milk) should be administered. During protracted diseases the danger of inanition becomes imminent, still more 126 THERAPEUTICS OF INFANCY AND CHILDHOOD. in the young than in the adult. Convalescence requires gener- ous feeding and stimulation also, with this restriction, that the meals should be small and frequent, and the stomach sustained all the time. In this way many a case of secondary anaemia may be avoided. (Chapter I.) Babies become anaemic when their mothers or nurses have too little milk, or when the supply is ample but of an improper quality. Nursing during a subsequent pregnancy ought to be forbidden. It must not be continued too long, certainly not beyond the protrusion of the first group or groups of incisors. Nor must it be continued beyond the tenth month if at that- time no tooth has made its appearance. Many a case of anaemia or rhachitis will be cured by a change of such faulty diet. It is better for the baby to develop teeth, bone, and muscle on barley or oatmeal and cow's milk and beef-broth than to be- come rotund with cedematous fat, and anaemic on its mother's powerful sympathy and powerless breast-milk. Maternal love does not improve the breast-milk of a person with a history of consumption, rickets, syphilis, nervous disorders, or intense anaemia. Sometimes even a healthy woman has a milk which is not adapted to that particular baby; then another woman or artificial food must be preferred. The addition of barley or oatmeal and beef -soup or beef -tea is always advisable when a nursling becomes anaemic without having been afflicted with a tangible disease. A small piece of beef, half an egg daily, a crust of bread, may be added about the end of the first year. The diet ought to remain simple, and mostly fluid or semi- solid until the child is two years old. Prevent bad habits, such as fast eating, and enforce regular defecation (not by medica- tion), plenty of exercise out of doors, and undisturbed and long sleep in a cool room. Avoid crowded school-rooms and pro- tracted lessons. "We have laws to protect children from being sent to work in factories, or to be employed on the stage, but none to protect them from the equally destructive, incessant schooling in close rooms, without air or exercise. There are DISEASES OF THE BLOOD AND CONSTITUTION. 127 too many books bought for Christmas, and too few skates." (Arch, of Med., February, 1881.) The subject of nursing and artificial feeding, and of digestive organs, has been treated of elsewhere;* thus I abstain from dis- cussing the matter here beyond the above fragmentary remarks. What cannot, however, be emphasized too much or too often is the necessity of resorting to animal food — soups, teas, peptones — in cases of infantile ansemia. The medicinal treatment of anaemia must fulfil the causal indications first. That which depends upon chronic gastric catarrh requires, according to circumstances, alkalies or hydro- chloric acid, pepsin, bismuth. Besides the well-known subcar- bonate and subnitrate, the salicylate has made many friends of late. Pepsin and dilute hydrochloric acid are best when com- bined; a baby of a year may take six or eight drops of the latter in six or eight ounces of water daily, or the acid may be mixed with milk according to the formula given in a previous chapter. Disease of the kidneys has its own indications. The regulation of the heart's action — which, when abnormal, is the most fre- quent cause of habitual epistaxis, and of gastric catarrh and hepatic congestion — is the first indication in secondary anaemia. Many a gastric catarrh will not get well without digitalis or some other cardiac tonic, and persistent nose-bleeding is apt to improve immediately after the administration of digitalis, with or without iron. Thus, in a great many cases, anaemia is "cured by digitalis." In a similar manner digitalis can be utilized for the purpose of more competent oxygenization of the blood. When the heart is weak, and the lungs, by virtue of old pneu- monic infiltrations, offer too great a resistance to an easy circu- lation in the pulmonary vessels, it is again digitalis (or its equivalents) which facilitates the extensive contact of the oxy- gen of the atmosphere with a larger number of blood-cells. * A. Jacobi, "The Intestinal Diseases of Infancy and Childhood, Detroit, 1887. 128 THERAPEUTICS OF INFANCY AND CHILDHOOD. The insufficient innervation of the muscular tissue of the heart, stomach, and the rest, which is one of the most serious results of anaemia, is corrected very happily by strychnine or other preparations of nux. An infant a year old tolerates and requires one-fortieth of a grain of strychnine, or one-fifth of a minim of the fluid extract of nux, daily, for a long time in suc- cession. These preparations may easily be combined with any other medicinal administrations. Iron is looked upon as the sheet-anchor in anaemia. It is mostly indicated in cases of primary uncomplicated anaemia. A catarrhal stomach does not bear it well; when the stomach, however, is abnormal in consequence of the general anaemia, iron improves both the general condition and the stomach. In many of these cases the addition of bitter tonics is advisa- ble; strychnine is perhaps preferable. Anaemia after malaria, dropsy from anaemia and chronic nephritis, anaemia with neu- ralgia, anaemia with (and from) valvular diseases which do not result in local congestion, — mainly incompetency of the aortic valve, — are greatly benefited by iron. Anaemia after chronic diarrhoea requires great care in its use; in most cases it may, or ought to be, avoided. While it is very beneficial in the pre- disposition to hemorrhage, it should be avoided in haemoptysis. It is contraindicated in inflammatory fevers, for it increases pulse, arterial pressure, and temperature. But in infectious fevers, such as erysipelas and diphtheria, it is very efficient. It requires good digestive powers, which may be stimulated by aromatic tincture of rhubarb, tincture of cinchona, or by strychnine, and, to combat anaemia only, no large doses. The total amount of iron introduced into the system in the daily food does not exceed much a single decigramme (one and one- half grains), and that contained in the blood of the adult has a total weight of three grammes (two scruples) only. Still, it is quite possible that the iron introduced into the stomach fulfils more indications than that of supplying red blood-cells and (to DISEASES OF THE BLOOD AND CONSTITUTION. 129 a lesser degree) haemoglobin. Indeed, it sometimes acts as a stomachic. Of the preparations mostly in use, either officinal or other- wise, I have mostly employed dialyzed iron, a few minims several times daily, the tincture of the malate (pomate), twelve to thirty minims daily, and the same, or somewhat smaller doses, of the tincture of the chloride of iron. The dry prepara- tions are the phosphate, one-half to two grains three times a day, and the same doses of the carbonate (saccharated). The latter is aptly combined with proper doses of bismuth. The p)Tophosphate demands smaller doses. The lactate is a mild and digestible preparation which seems not to be appreciated at its full value. The citrate of iron and strychnine, and that of iron and quinine are valuable preparations when the effects of the combinations are sought for. Coming with the recom- mendations of Schmiedeberg, ferratin in several daily doses of one or two decigrammes (grs. 1J-3) each, has been awarded a fair trial; so have some other preparations, the peptonate, the albuminate, the peptomanganate. The obtrusive methods of advertising them do not prove their superiority over the drugs and preparations of the Pharmacopoeia and of the National Formulary. The syrup of the iodide of iron is well tolerated by the youngest infants; as many drops as the baby has months may be given three times a day up to eight or ten drops a dose. It is well tolerated by the stomach, in which the iodine is freed from the iron and acts as an antifermentative. Besides, ex- perience appears to confirm the theoretical inference that it proves its power as an absorbent in cases of anaemia complicated with glandular enlargements. The syrup of the hypophos- phites cum ferro of the Pharmacopoeia may be given in larger doses; this is the preparation which I frequently select when I mean to add the fluid extract of nux vomica. It is self-under- stood that I prefer the legitimate preparations of the Pharma- copoeia to the wares of the agents and advertisers, "physicians' samples" or no. 9 130 THERAPEUTICS OF INFANCY AND CHILDHOOD. Other (animal, like ferratin) preparations of iron are Ro- bert's haemol and hsemogallol. It has been suggested, not proved, that their animal origin renders them more homo- geneous. For subcutaneous administration the pyrophosphate of iron with citrate of sodium, also the albuminated iron have been recommended; also, by Rummo, a ten-per-cent. watery solution of the ammoniated citrate of iron, and by Lepine, one of a two-and-a-half-per-cent. solution. As anaemia is a chronic con- dition which requires "chronic" treatment, and the injections cause pain, it is not very probable that this mode of employing the remedy is very available. The administration of iron appears to have an indirect effect also, which is apt to do much good. As a rule, the inhalation of oxygen gas, continued for five or ten minutes, at intervals of from an hour to two hours, seems to improve sanguinifica- tion and metamorphosis considerably. This wholesome action, it always seemed to me, was most perceptible while iron was administered. To admit oxygen red blood-corpuscles are re- quired; it appears that the influence of iron on their organiza- tion and numbers renders the introduction of oxygen into the blood easier and more beneficial. Oxygen was often credited with being a general tonic, and its inhalation was considered at one time almost a panacea. As long as the organs of respira- tion and circulation are normal, the atmospheric air contains more than they require. Still, whenever they are disordered, in the orthopncea of pneumonia, in asthma and emphysema, in pulmonary tuberculosis, in cardiac diseases (as also in poi- soning with carbon oxide, or when there is methaemoglobin in the circulation), and in anaemia depending on these condi- tions, the inhalation of oxygen is of undoubted service. It has the advantage of being readily prepared pure; that is more than we can say of ozone. (See p. 81.) Some of the worst forms of anaemia are greatly benefited by arsenic. They are those which result from long-continued in- DISEASES OF THE BLOOD AND CONSTITUTION. 131 anition and slow convalescence, in which the stomach does not suffer primarily; from primary catarrh; from chronic malaria; from chronic tuberculosis of the lungs; from chronic glandular swellings of a malignant type, either lymphoma or sarcoma or adenoma. In all of these forms it is highly useful. The doses need not be large, but may be increased slowly. One one-hun- dredth of a grain of arsenous acid, or one drop, or one and a half, of Fowler's solution, three times a day, after meals, the latter amply diluted, are well borne for weeks, even months, without interruption, by a child of four or five years. In malaria, the remedy may be given with quinine (and iron), in other forms with strychnine (and iron); in pulmonary tubercu- losis, with digitalis. The gradual increase of the doses of arsenic may be effected in the following manner: A drachm of Fowler's solution is diluted with sixty drachms of water; three doses of this mix- ture are given daily. If the initial dose is to be one drop, give a teaspoonful; the next dose is a teaspoonful + one drop, the third dose a teaspoonful + two drops, and so on, until the sixty-first dose consists of a teaspoonful and sixty drops. Thus the original dose is gently and slowly doubled in twenty days. Children bear arsenic better than adults, and very much better than senile patients. Still, even they must not take it when they are affected with gastric disorders; nor continue it when in the course of treatment conjunctivitis, oedema of the eyelids and face, or diarrhoea make their appearance. Among the sjTnptoms, or consequences, of anaemia there are two of great prominence; first, insufficient tissue-forma- tion, and, second, incompetent innervation. To what extent spermin, which is not only claimed as a constituent of sperma, but of most or all tissues, deserves its exorbitant praise as a tonic remains to be seen. It is said to stimulate oxidation in the organic cells and to produce leucocytosis. The dose is, for an adult, a cubic centimetre of a two-per-cent. solution. This dietetic and medicinal treatment, mostly so effective in 132 THERAPEUTICS OF INFANCY AND CHILDHOOD. simple anaemias, is also indicated in chlorosis when it develops in children. In them the anatomical cause giving rise to life- long chlorosis — viz., persistence of the foetal smallness of the aorta (Yirchow) with smallness of the general arterial system — cannot be wholly overcome. It is here that bitter tonics should be added from time to time to the preparations of iron and digitalis to stimulate arterial and cardiac action. Both of these require the continued use of cold water, — viz., daily wash- ing or bathing with vigorous rubbing, and systematic exercise. The diminution of haemoglobin, while the number of red blood- cells is more or less normal, requires ample and cautious feed- ing; it is here that peptones to such an extent as can be ab- sorbed are indicated. It should never be forgotten, however, that all the symptoms of chlorosis in a child (as in the grown woman) may be caused by undiscovered malignant tumors or by gastric ulcerations (not so very uncommon). Pernicious (essential) ancemia is characterized by a decrease of red blood-cells (from four or five millions in a cubic centi- metre to one or even one-half of a million), which, moreover, exhibit irregular sizes and shapes (poikilo-, micro-, and megalo- cytes), while haemoglobin is not reduced at the same rate. When it is caused by atrophy of the peptic glands (Kinnicutt), or prolonged icterus, or syphilis, or entozoa (ascaris, taenia, bothriocephalus), the indications are clear. Many such cases get well when treated for known causes. That is why every addition to etiology is so welcome. Ewald has found atrophy of the small intestines in many cases of pernicious anaemia. Knud Faber published a case (Berl. Tclin. Woch., July 26, 1897) which seems to prove its connection with a stricture of the small intestine. If a diagnosis could have been made in his case it is possible that an operation would have prevented anaemia. As other such strictures (tubercular, syphilitic), quoted by him, are also known to have been connected with intense anaemia, the suspicion is justified that an intestinal toxin caused or occasioned by them (as also by apepsy and hel- DISEASES OF THE BLOOD AND CONSTITUTION. 133 minthes) is the source of the rapid destruction of blood-cells and the cause of pernicious anaemia. If that be so, intestinal antisepsis, if it ever will be accomplished to a sufficient degree, will cure many a case. Of the remedies mentioned above, arsenic in rising doses is quite effective; iron and small doses of quinine act as adjuvants; bone-marrow (when raw or boiled, it nauseates quickly) or its preparations (Armour's, "carno- gen"), the daily doses of which may vary from one-half of one to two teaspoonfuls, has been credited with good effect. I have seen improvement, but no cure. Weir Mitchell's rest and feed- ing cure, with general massage, benefited some. The capricious appetite prefers mostly a vegetable diet, the failing digestion requires stimulants (strychnine), besides pepsin with hydro- chloric acid; the absence of blood-cells and the consequent inability to bind oxygen and to produce heat demand warm clothing and warm rooms; diarrhoea, its symptomatic treat- ment; and utter debility and collapse, infusion of salt water. The prognosis of leucocythcemia (leukcemia) is still worse than that of pernicious anaemia. From the latter it is diagnosticated by the increase of leucocytes (1 : 50-2, instead of 1 : 250-350) and the increase of eosinophile cells. It is known to follow, in instances, malaria, influenza, syphilis, glandular, and bone-dis- eases; and prevention is therefore a possibility. Albuminoids in blood and tissues are rapidly destroyed; therefore albu- minoids in every possible shape, peptones, albumoses, etc., should be given in absorbable quantities. Rest, massage, cold and heat, transfusions, infusions, oxygen inhalations, arsenic and iron, quinine, bone-marrow, injections of ergotin into the subcutaneous tissue, of arsenic into the spleen, electricity and galvanism, extirpation of the spleen (all fatal), treatment of the accompanying hemorrhage, of perspiration, of pleuritis, and of ascites, — all are in vain. I know of no authentic case, either acute or chronic, that recovered. Pseudoleukemia (Hodgkin's disease), though there are so many transformations of this form of anaemia into leucocy- 134 THERAPEUTICS OF INFANCY AND CHILDHOOD. thaemia as to make a common origin (infection ?) and nature very probable, has in most cases its own symptomatology (swelled lymph bodies all over the body, swelled liver and spleen, no leukaemic blood, merely leucocytosis). The diagnosis from general sarcomatosis, which causes inflammatory adhe- sions between the lymph bodies (isolated in pseudoleukemia), is not always easy. Arsenic is again the sheet anchor. Piperin, five to fifty centigrammes or more daily (grs. 1-10), has been recommended. Berberin sulphate seems to deserve credit; it certainly stops the troublesome constipation, but should not be given in such doses as to cause diarrhoea. It seems to improve the appetite and to reduce the size of the glands and of the large viscera. Splenic ancemia, with its large spleen and somewhat swelled liver, no leucocytosis, but poikilocytosis, and some diminution of haemoglobin, and some nucleated blood-cells, does not de- serve a place of its own in our nomenclature. It shares the therapeutical indications of its sister anemias. 2. Rhachitis. Many cases of rhachitis which depend on hereditary influ- ences might have been prevented or modified by attending to the parents before conception, or to the mother during preg- nancy. I have known women to bear healthy or rhachitical children according to the condition of health or ill health dur- ing the year preceding parturition. A number of their constitu- tional ailments, such as anaemia, tuberculosis, and syphilis, make their appearance in the offspring with the symptoms of rhachitis. If that precaution have been neglected, the injury inflicted upon the infant cannot be completely annulled; in many cases, however, it can be greatly moderated. Thus there are a great many cases of early rhachitis which are due to the influence of mitigated syphilis in the parents. Indeed, some of the microscopical bone-lesions of the two diseases, as they are met with in the newly-born, are difficult, some impossible, to DISEASES OF THE BLOOD AND CONSTITUTION. 135 distinguish from each other. Such cases can be greatly bene- fited by an antisyphilitic (mercurial) treatment, which should be continued through a period of many months. Attention should be paid to general hygiene. More can be accomplished by furnishing good air than by any other means. The air of the winter is no contraindication to keeping win- dows open and to taking the young baby out as long as there is ample clothing and covering. Sea-air is preferable as long as there is no contraindication, for instance, in the condition of the respiratory organs. Sojourning in the country is beneficial only when the rhachitical infant is not locked up in the house. Sea-air, to- gether with sea-bathing, warm, cool, or cold, according to age, condition, and training, is an excellent preventive and curative measure. England commenced that practice on a large scale in 1750; Italy, France, Germany, America, these last twenty years only. The sea-hospitals have done an im- mense amount of good. To eradicate rhachitis, however, the children must be kept on the shore for years. In America we are always too much in a hurry and expect the benefits of heaven and earth in a particle of a season. When no sea-shore is accessible the bathing in salt water with friction, massage, occasionally with electricity, may be done at home. When eczema is caused by it, the salt-water treatment should be dis- continued. Plenty of air by day and by night, coupled with poor food, is still safer than the best possible food with bad air. Comby's saying that rhachitis gets access through the stomach, not through the skin or lungs, requires a good deal of modification. Still, the nature of the food is highly important. Lactation must not be continued be3^ond the appearance of two or four teeth. A wet-nurse should not be too young nor too old. But, after all, even an apparently proper age or condition of mother or wet-nurse does not always exclude the possibility of a breast- fed baby becoming rhachitic. In such a case a well-selected 136 THERAPEUTICS OF INFANCY AND CHILDHOOD. artificial food is preferable to breast-milk. Pure cow's milk, when given as exclusive food, no matter whether raw or boiled, is harmful. Artificial foods must be well selected and watched. The absence of pathogenic germs from them is not the only safe-guard. Even Botch's modified milk and Gaertner's fat milk do not protect against rhachitis, though they be fairly proof against microbes. The addition at an early date of cereal de- coctions, barley, oatmeal, and of animal broths, renders all the known milk preparations safer and more wholesome. Too large a percentage of fat in the foods of young infants should be avoided. The addition of fat is not always a protection against rhachitis, and may easily be overdone. Diarrhoea, dys- pepsia, from whatever cause, and constipation should be cor- rected, and the warning often expressed by me and urged by Comby should not be forgotten, that over-alimentation is at least as dangerous as under-alimentation. That the skin re- quires intelligent attention was suggested above. Whether a bath should be given immediately after birth and continued regularly during the first weeks ought to depend on the nature of the individual case. As a general rule, which is valid for every child, bathing — first tepid, later on cooler, in salt-water when there appears to be an indication for more surface stimu- lation, with appropriate friction — improves both the cutaneous and the general circulation. Ehachitis due to, or connected with, digestive disorders de- mands the correction of the latter. Gastric catarrh is not fre- quently primary; more commonly it is the consequence of faulty diet; but in both cases it is the cause of anagmia, and either of insufficient or of abnormal secretion of both the mu- cous membranes and the glands. The gastric catarrh of rhachitis is pre-eminently acid, thus neutralization of the stomach is often required before every meal and between meals. Prepared chalk, calcined magnesia, bicarbonate of sodium, the several preparations of bismuth, find their proper indications in this condition. The salicylate of bismuth, ani- DISEASES OF THE BLOOD AND CONSTITUTION. 137 mal carbon, resorcin find their places, besides aromatic teas, in complications with fermentative processes in the intestine and with excessive flatulency. When the secretions of the stomach are merely insufficient, the addition of chloride of sodium in proper quantities will facilitate the formation of hydrochloric acid. When that plan does not suffice, pepsin and muriatic acid, the latter largely diluted, will take the place of the physiological gastric juice; and bitter tonics and alcoholic stimulants, also di- luted, will stimulate a normal secretion. Still, the selection of a proper food forms the main part of the indications. The principles of infant feeding, both in health and disease, I have laid down in the first part of this book; to that I refer; also to my suggestions, in the same place, on the selection of animal foods so urgently required in rhachitis. Cod-liver oil, when tolerated, influences rhachitis favorably. As a rule, however, it is not so universally well borne in rhachitis as it is in "scrofula." I do not advise the use of its compounds, emulsions, and so on, except when it is disliked or the latter have some other indications, for instance, diarrhoea; this is sometimes produced by the oil, mainly in the hot season. In that case the remedy may have to be discontinued, or may require the temporary addition of bismuth or phosphate of calcium. The action of cod-liver oil is considered by some hy- gienic only, by others remedial. The former attribute its effects to the fat, and believe the substitution of any assimilable fat an equivalent. As I said before, I do not believe its agency to be thus restricted, for three teaspoonfuls of cod-liver oil will never be replaced by three teaspoonfuls of cream or other fat. Universal experience teaches its wholesome influence in many morbid tissue-changes. Possibly the mystery of its action is best explained by attributing to it a percentage, though ever so slight, of some organic tissue juice of a nature and efficacy to be compared with that of the thyreoid gland. Tempted by that point of view, Heubner tried the action of thyreoid gland in rhachitis, but without any tangible effect. He believes, 138 THERAPEUTICS OF INFANCY AND CHILDHOOD. however, that the general condition of the infants appeared to be improved by it. Malt and "maltine" preparations have found favor both with the profession and the public. Unfortunately the market has been swamped with all sorts of combinations and mixtures to such an extent as to shake confidence in their honest composition in the same degree as the mere object of making money by it becomes pre-eminently clear. Though rhachitis be a general disease, and not merely one of the osseous system, the anomalies exhibited by the hones are apt to attract most attention. The changes exhibited in the shape of the chest, which result from the pressure of the atmosphere on the soft rhachitical ribs, are not liable to disap- pear entirely. The "pigeon-breast" — that is, the prominence of the sternum and (or) the costo-cartilaginous junctures — re- mains for life to a greater or smaller degree, according to the severity of the affection or to the restoring power of the ex- panding lungs. It requires early medical and surgical inter- ference and protracted gymnastic exercise. Even crying is welcome, and in children of two or three years trumpet-blow- ing, soap-bubbling, etc. The curvatures of the diaphyses of the long bones are apt to be less marked in the adult because of the extension which takes place during growth. If ever splints are to do any good they should be applied before the bones have become hard again; the eburnation following the softness of the bones after recovery resists every degree of permissible pressure. The tendency to flat-foot, acquired through the flab- biness of the ligamentous apparatus during the attempts of the child at locomotion, requires massage and sustaining by a shoe made strong enough to support the ankle and a steel spring just sufficiently strong to restore the arch of the foot; scoliosis, a Sayre's plaster-of-Paris or a felt jacket; the rhachitical groove round and above the insertion of the diaphragm, well- directed gymnastics of the chest; inflexible and ugly curva- tures of the long bones, either osteoclasy (fracturing of the DISEASES OF THE BLOOD AND CONSTITUTION. 139 curved bone while leaving the periosteum intact, and resetting) or- osteotomy (straightening the bone after it has undergone a cutting operation). Of these two, osteoclasy was the only oper- ation resorted to formerly. The fracture of the bones was either manual or instrumental, mostly successful in the middle of the femur or tibia, mostly unsuccessful for genu valgum or varum inasmuch as it often tore off the epiphysis or fractured in an undesirable place, and was sometimes followed by septi- caemia. Osteoclasy has been mostly replaced by osteotomy. It is a simple and open operation. It is seldom required on the upper extremity, mostly on the lower, not so often on the thigh as for genu valgum and varum, or for the curvatures of diaphyses. The genu valgum of children results from the curvature both of the femur — usually the only one at fault in adolescents — and of the tibia. It requires the supracondyloid operation of Mac- ewen, and often a supplementary operation on the tibia. The curvature of the tibia has mostly its concavity interiorly and posteriorly, and is usually found at its lower half. The opera- tion may be either simply linear, transverse or oblique, or cuneiform (wedge-shaped). In bad cases the latter is preferred, and not seldom a single operation is insufficient. An interval of a few weeks is ample between the several operations that may become necessary. The results of osteotomy are almost alwa} T s absolutely good. Suppurations there are a few only, and controllable. During the acute rhachitical process the bones will not only bend, but are liable to be changed in their continuity. It is true that genuine fractures are not quite frequent because of the very softness of the bones and the succulence of the peri- osteum. But infractions (green-stick fractures) are quite com- mon about the extremities and clavicles. The periosteum never participates in the injury; the bone is more or less bent upon itself; the ends are not entirely separated and are easily re- adjusted, but require splinting until the rhachitical process 140 THERAPEUTICS OE INFANCY AND CHILDHOOD. has terminated in general recovery. Immobilization of the entire body is sometimes required when the tendency to infrac- tion is quite extensive. Many of the serious results of softness of the bones could be avoided or mitigated by precautionary measures. Babies in general, and those with incipient rhachitis in particular, must not be made to sit up before their vertebral columns and their dorsal muscles are able to support them. They must not be carried about in an erect posture, nor on the same arm always; that practice is an invariable cause of scoliosis, and frequently of genu valgum of one side, and of genu varum of the other. They must be kept and carried about in a reclining posture; better on a hair pillow than on the arm until they feel strong enough to do without it. Thus scoliosis can be pre- vented. They must be discouraged to walk before their limbs are sufficiently strengthened; no walking baskets should be em- ployed, no fond and proud grandparents allowed about; thus the curvatures of the diaphyses of the lower extremities, which in part result from the vertical weight of the body on the feeble limbs and the secondary deformities of the pelvis, are reduced to a minimum. Craniotabes, the rhachitical softening of the cranial bones, is one of the earliest symptoms of the disease. The bones which commenced their postnatal ossification in a normal man- ner begin to soften to such an extent that the parietal and occipital bones exhibit a number of spots in which the osseous tissue has nearly entirely disappeared. The hair falls out in that neighborhood, the scalp is perspiring copiously, the veins get dilated, the bones and meninges become hypera3mic, and meningeal effusions are quite frequent. The softness of the bones results in asymmetry of the cranium, which is flattened by the very pressure of a soft pillow. This asymmetry is liable to disappear after recovery, except in grave cases. The local hyperemia and excessive occipital heat forbid the use of warm bonnets and feather pillows. A soft hair pillow DISEASES OF THE BLOOD AND CONSTITUTION. lil must be so arranged that the head, together with the body, can be comfortably carried without any pressure. Elsaesser (1843) recommended a pillow with a central depression or perforation; a small air-cushion filled to one-third of its capacity is very acceptable. Consecutive brain symptoms require appropriate treatment. Great convulsibility demands bromides, chloral, and mild opiates, which are well tolerated in this condition. The perspiration requires cooling with water, or water and vinegar, or powdering with one part of salicylic acid mixed with ten parts of oxide of zinc and twenty-five of starch. The general treatment of rhachitis improves this local cranial symp- tom, which is quite serious. In former years I was in the habit of giving a good prognosis provided the next six or eight weeks would pass without fatal symptoms (convulsions, etc.). That period was generally sufficient to so change both the general nutrition and the local condition as to restore a fair average of health both in the cranium and its contents. The experience of late years has shortened this period. What I suggested in a brief paper on the use of phosphorus in the treatment of chronic and subacute diseases of the bones in the "Transactions of the Medical Society of the State of New York," of 1880, and in a paper on ansemia in infancy and childhood read before the Medical Society of the County of New York in 1880 (Arch, of Med., February, 1881), has proved a great success in other hands. For it is to Kassowitz that the credit of the introduc- tion of phosphorus as the principal remedy in rhachitis is mainly due. When, twenty years ago, C. Wegner fractured the bones of rabbits and fed the animals on minute doses of phos- phorus, he found that these bones would heal in a much shorter time than those which were not so supplied. This observation induced me to employ the drug in all cases of (mostly tubercu- lous) subacute and chronic ostitis, Pott's disease, and caries of the tarsus; and a great many cases led me to conclude that re- covery was more readily accomplished under this treatment. Phosphorus is, by virtue of its irritating effect, when given in 142 THERAPEUTICS OF INFANCY AND CHILDHOOD. small doses, a tissue-builder (Kassowitz claims that it impedes the formation of blood-vessels), when in large doses, a tissue- destroyer. In the former it would in part act through the rapid development of connective tissue, similarly to what Lanne- longue expects to attain by the local injections of chloride of zinc solutions. Thus I became convinced of its tissue-building properties in other parts also. I may mention here, before I shall have an opportunity to return to the subject in extenso, that I have availed myself of this quality of phosphorus for other purposes also. It has served me well in many ominous cases of purpura and similar processes, in which a congenital or acquired ill nutrition of the blood-vessel walls results in habitual hemorrhages. Kassowitz's results with the use of phosphorus in rhachitis are generally good. The cases in which it has rendered me its best services are exactly those alluded to, of craniotabes. A very few weeks suffice to change the condition of the cranial bones considerably, the softened parts become smaller and harder, and the consecutive symptoms milder. It is of equal value in acute rhachitis, with its extensive acute epiphysitis, rapid pulse, diarrhoea, general feebleness, and (frequently) symptoms of scurvy. The dose of phosphorus in these cases is from one-third to one-half of a milligramme three times or twice a day. The oleum phosphoratum of the U. S. Pharmacopoeia contains one part of phosphorus in ten parts of ether and ninety of oil. Its daily dose is from two to three minims. Concentrated oil solu- tions are liable to get decomposed. "Thomson's solution" keeps fairly well, but the best preparation is the elixir of phosphorus of the TJ. S. Pharmacopoeia, composed of 210 parts of the spirit of phosphorus, 2 parts of oil of anise, 550 parts of glyc- erin, and a sufficient quantity of aromatic elixir to make 1000 parts. Of this elixir a teaspoonful contains one milligramme of phosphorus, and a dose, to be repeated three times a day, is from six to fifteen minims. No temptation ought to be strong DISEASES OF THE BLOOD AND CONSTITUTION. 143 enough to employ phosphates, which will invariably reappear both in the urine and in the faeces. It seems probable, more- over, that the phosphates contained in nutriment are more digestible and more assimilable. Phosphates are much inferior in effect to the hypophosphites of the Pharmacopoeia with or without iron. Phosphorus given simultaneously with cod-liver oil is a good combination, but it is a doubtful practice as long as the latter is not a uniform compound to dissolve phosphorus in the oil. Where anaemia is intense, the preparations of iron are required. Besides the above, the syrup of the iodide of iron may be given, as many drops three times a day as the baby is months old, or from ten to twenty-five drops three times a day to children of from one to two or three years. "When the spleen and also the lymph-bodies are very large, three daily doses of one-half to one drop of Fowler's solution is bene- ficial. In scorbutic cases or complications, fruit-juices are re- quired. Heubner's experience with phosphorus in bad hospital cases is negative. The famous teacher knows, however, that bad rhachitis never does well in hospitals. If it requires any- thing, it is air, air, and again air! To his discomfiture, how- ever, we owe some observations which, though they be negative, are valuable. Guided by what he takes to be a fact, that all irritations and inflammations from known causes are local, and by Lanz, who finds certain relations between the thyreoid and bone development, and suggests a trial of thyreoid in rhachitis, he gave from one-half to one decigramme of Merck's thyreoidin every other day, or every day, with negative result as far as improvement of rhachitis was concerned; with a favora- ble effect, however, he believed, on the general condition of the child. Laryngismus stridulus, the crowing inspiration of infants, is almost always connected with craniotabes, and caused by its meningeal and encephalic results. It consists of two stages, the first of which is that of paralytic apncea, the second of a long-drawn and loud inspiration through the spastically con- 144 THERAPEUTICS OF INFANCY AND CHILDHOOD. tracted glottis. The causal treatment is that of rhachitis in general, of cranial rhachitis in particular. Before, however, it can accomplish a permanent effect the single attacks of, and the general tendency to, laryngismus require attention. For any attack may prove fatal, though the assertion of Vogel, who expresses the opinion that most cases of laryngismus are fatal, is grossly exaggerated in my opinion, which has not changed in this respect since my utterances in 1871.* Besides phosphorus, syrup of the iodide of iron, and other treatment, constipation requires more than the usual attention, for the nerve-equilibrium is easily disturbed by a slight irregularity in any of the organic functions. To soothe its general vul- nerability the regular administration of the bromides (twelve or fifteen grains daily of a mixture of the potassium, sodium, and ammonium salts) or a few grains daily of the valerianate of zinc are indicated. Many cases bear one-sixth of a grain of codeine in the twenty-four hours. These cases of ex- cessive irritability are quite precarious. In them the ears re- quire particular attention, for the slightest (external or) in- ternal otitis is liable to produce convulsions. In them even the lancing of gums, where there is but a suspicion of local pruritus, may become pardonable. The attack can be cut short by shaking the infant, or slapping the face with a cloth dipped in water, or using the spark of a Leyden flask (for there is no time for the administration of the interrupted current). Gen- eral convulsions, which are not uncommon at all after an at- tack, require the inhalation of chloroform or the rectal injec- tion of from four to eight grains of chloral hydrate. The rhachitical disorders of the respiratory organs owe their origin to several causes. In rhachitis the heart is of average size, but the arteries are abnormally large. Great width of arteries lowers the blood-pressure. That is why the muscles and bones suffer from insufficient nutrition; and why the circu- * American Journal of Obstetrics. DISEASES OF THE BLOOD AND CONSTITUTION. 145 lation in the respiratory organs is slow and sluggish, with a ten- dency to produce congestion and catarrh. Other causes of the chronic bronchial catarrh of the rhachitic infant, which is so apt to become bronchitis and terminate in broncho-pneumonia, depend upon the smallness, particularly of the lower half, of the contracted chest, which compresses the lungs; and the tumefaction of tracheal, bronchial, and mediastinal gla?ids, which are in close lymph communication with the bronchial mucous membranes. There are but few thoroughly developed cases of rhachitis, when complicated with bronchitis, without them. Not infrequently can some of them be felt in the supra- clavicular spaces; more commonly can they be percussed behind the manubrium sterni, the dulness of which is in many cases but partly thymic. Sometimes they can be discovered by per- cussion of the infraclavicular region of the (right or more fre- quently the) left side and often on the left side of the intra- scapular region. These glandular swellings, which point to and explain the frequent relations of rhachitis, scrofula, and tuberculosis with each other, are no uncommon appearances in the autopsies of rhachitical babies who finally died of the last developments of their chronic catarrh. This tendency to glandular swellings requires early attend- ance. It is here where cod-liver oil and the syrup of the iodide of iron are mainly serviceable. In many cases the addi- tion of half a minim of Fowler's solution, administered three times a day, acts favorably. This is the condition of things in which the use of cold sponging, salt-water bathing, salt air, are particularly beneficial. Out-door life must be insisted upon, and there are but few reasons — mostly of a local character — which forbid such babies to enjoy fresh air at all hours of the day and night. Subacute or acute inflammations of the respiratory organs, when they have made their appearance during the chronic rhachitic catarrh, require, besides the usual rational treat- ment, some additional measures. More care, than in an average 10 146 THERAPEUTICS OF INFANCY AND CHILDHOOD. case of the otherwise healthy, must be taken lest the faltering strength be exhausted before the acute disease has had time to run its course. The sluggish circulation, depending on general debility and the large size of the arteries, demands the ad- ministration of heart tonics, — digitalis, strophanthus, spar- teine, caffeine, or coffee, from the very beginning, and besides small doses of alcoholic stimulants at an early stage, or the use of stimulant expectorants, such as carbonate of ammonium or camphor. There is a positive contraindication to antimonials and squills; even ipecac must be avoided because of its possibly depressing effect. Rhachitic constipation is mostly due to the incompetency of the muscular layers of the intestine and of the abdominal wall. Thus purgatives must be avoided in its treatment, with the ex- ception of those cases in which the accumulation of faeces in the bowels happens to be attended with serious consequences. In these an occasional dose of calomel will act both as a lax- ative and a disinfectant. When an acid gastric catarrh accom- panies the intestinal weakness, calcined magnesia in doses of a grain, given on an empty stomach, or before meals (never after), repeated several times daily, will neutralize the ab- normal acidity of the stomach while opening the bowels. A daily enema of tepid water continued for years will mostly suffice to alleviate the troublesome symptom. Cod-liver oil, while being administered on account of the general indications, has also a beneficial local effect. Pure cow's milk is more con- traindicated in this condition than in almost any other. Arti- ficial food should contain a copious addition of salt and sugar, and oatmeal rather than barley. Gentle massage of the ab- domen, and strychnine, one two-hundredth of a grain, three times a day, improves the muscular strength. The syrup of the iodide of iron, in three daily doses of a few drops, and the regular administration of beef preparations," will improve con- stipation with the other symptoms; particularly when this treatment is commenced at an early period. For it is at an DISEASES OF THE BLOOD AND CONSTITUTION. 147 early period, generally in the second or third month, that this rhachitic constipation will make its first appearance. It is one of the first symptoms of protracted rhachitis, and is diagnosticated from what I have described as congenital constipation — which depends on an abnormal length of the sig- moid flexure — by the fact that the latter begins at birth. 3. Scrofuhsis, — Scrofula. The discrimination between scrofula and tuberculosis is at- tended with no difficulty for those who claim the bacillus of Koch as the pathognomonic essence of the latter. For all others, and so it was before the period of the bacillus, the dis- tinction may not be quite so easy; at all events, the boundary- lines between scrofula and tuberculosis are not always quite marked. But it is certain that the bacillus need not be present in the former as long as it remains uncomplicated. We speak of scrofula in persons who exhibit a great ten- dency, with no apparent, or upon the slightest, provocation, to subacute or chronic inflammation of most tissues, mainly the cutis and mucous membranes, sensory organs, glands, bones, and joints. These inflammations are persistent and liable to return; they run their course both with rapid formation and disintegration of the cells, equally in the erethic and torpid forms. Of these, the former is recognized by a frail and thin stature, delicate features, great intellect, blue sclerotic, and large pupils; the latter, by coarse and expressionless face, cedematous lips and nose, congested eyes, large abdomen, swollen glands, and frequent cutaneous eruptions. It is the commendation of modern therapeutics to be mostly preventive. So is the treatment of scrofula. Many cases of the disorder would not appear if our modes of thinking and feeling, our habits and laws, were not the immediate results of individual egotism. As long as the welfare of the common- wealth, both present and future, does not supersede, in the convictions of the many, the dictates of selfishness, there will 148 THERAPEUTICS OF INFANCY AND CHILDHOOD. be no restriction on the marriages of the scrofulous, syphilitic, and tuberculous, and the propagation and proliferation of their dangerous ailments. If the mankind of the future means to be healthy and happy, there must be found some mode of prevent- ing hereditary influences from having full sway. We are no Spartans, who kill the unhealthy newly-born, but we are to develop into men who pity those laden by their very parents with the eternal curse of illness, and citizens who feel respon- sible for the physical and intellectual welfare of the com- munity. In the United States, scrofula has been on the in- crease at a rapid pace since the immigration of the most abject parts of the most abject peoples of the Old World has been allowed to swell our numbers by the hundreds of thousands for each of the last dozen years. An important preventive measure is the suppression of the attacks of acute diseases in children, mainly the eruptive fevers. Upon a former occasion I have emphasized the necessity of medical (hygienic and pharmaceutical) treatment of most cases of sickness. It is particularly measles and scarlatina which are liable to interfere with the subsequent normal development, — the former through its influence on the respiratory, the latter through its effect on the digestive and lymphatic systems, and also on the bones. The modification of a severe form into a milder form, and the early restitution of the physical functions to a normal standard, is a gain for life. Scrofula being frequently the direct result of digestive dis- orders, resulting either from improper food or nutriment im- properly given or insufficiently digested, the greatest care is to be bestowed on both food and the digestive organs. This is of more than the average importance in regard to the offspring of tuberculous parents. No tuberculous mother must nurse her own infant. The selection of the wet-nurse must be the most painstaking, and the period and mode of weaning must be supervised with the utmost care. Afterwards amylaceous food, particularly potatoes, should be avoided, or given in small quan- DISEASES OF THE BLOOD AND CONSTITUTION. 149 tities only. Good milk (boiled), cereals, and meat, with the ad- dition of fruit, ought to be the principal food of children up to their tenth or twelfth year. Stimulants must not be given except on proper and exceptional indications; thus tea, coffee, alcohol, beverages of any kind, are forbidden articles of diet. Cocoa must take the place of chocolate. The best beverage is water. It supplies every want, and when taken in sufficient quantities is the best stimulant of tissue metamorphosis. In the very rare cases in which a sensitive stomach does not bear it well a carbonated or (and) slightly alkaline water will take its place. Among the foods, cod-liver oil ranks high. Most children take it readily after a short time, and are anxious to have it. Thus there was no necessity of peptonizing, emulsionizing, or "hydroleinizing" from the point of view of the children, or of practice. Of the reprehensibility of filling the child's diges- tive organs with unlimited lime I have spoken in another place. The oil can be taken through successive 3 r ears. Its adminis- tration ought to be interrupted during warm days and during the summer. Still, there are those who bear it well all the time. Fat children do better without it. In disorders of the stomach, and while the appetite is bad, also during a feverish disease of any kind, also during a diarrhoea, it must not be given. (See pp. 53, 137.) Preparations of malt may be administered to advantage in small quantities several times daily. It is self-understood that the multitude of preparations containing medicines will be left by the intelligent practitioner on the shelves of the corner pharmacy. Tea of walnut-leaves was a universal remedy in scrofulous affections when tastes were simpler, medicines less in num- ber, and when less money was invested in expensive articles. Among the poor, and in country districts, it will prove an ad- mirable adjuvant. Among medicinal preparations it is those* of iron and iodine 150 THERAPEUTICS OF INFANCY AND CHILDHOOD. which have met with most praise. The indications for the administration of the former are those of anaemia. Where this is marked, iron ought to be given, and continued for a long period, according to the principles and methods laid down in a previous chapter. Iodide of potassium, of sodium, and the tincture of iodine have been used. In the erethic form of scrofula they may do harm, and ought to be avoided. The same warning holds good in reference to those children who suffer from frequent attacks of bronchitis, which may already be the precursor or accompaniment of pulmonary tuberculosis. A sensitive stomach will not bear it. It may be made more digestible by the addition of a bitter tonic, and particularly by a few drops of tincture of nux vomica, diluted, with each dose. When the iodide results in bringing on the disagreeable or dan- gerous symptoms of iodism, the addition of chlorate of potas- sium to the iodide, in doses of from fifteen to thirty grains daily, according to age, will prove beneficial. The potassium (or sodium) iodide may be taken in five- or six-grain doses, daily, by a child of two years, fifteen grains at ten years, for a long period. The sodium is better tolerated, as a rule. The tincture must not be administered in more than one-drop doses, three times a day. The syrup of hydriodic acid is often toler- ated better than the previous preparations (two to four cubic centimetres = J-l drachm daily). The syrup of the iodide of iron is a valuable preparation, to be given three times a day in doses varying from three to twenty drops. So is the saccha- rated iodide of iron, in three daily doses of from two to five cen- tigrammes (gr. -J-f). The indications for the use of iodine in general are also valid for that of the mineral springs containing that element, such as St. Catherine or Kreuznach. Fat children, and those with cedematous swellings, glandular infiltrations, or the exu- dations resulting from scrofulous inflammations, are mostly benefited by them. Of phosphorus, as a tissue-builder in subacute and chronic DISEASES OF THE BLOOD AND CONSTITUTION. 151 inflammations of the bones, I have spoken in another connec- tion. (See p. 141.) Its property as a stimulant of growth in general I have often verified in many morbid conditions. Scrofulous tissues, with their rapid decay and new formation, exhibit indeed the type of subacute inflammation, with the peculiar characteristic of rapid cell-proliferation, which per- ishes speedily because it is not sustained by a healthy connec- tive tissue. The latter is formed by the internal administration of minute doses of phosphorus, such as I recommended for the above indications. Thus I refer to the remarks (made pre- viously on the subject) on the doses in which the drug is to be given, the period during which it is to be continued, and the impossibility of substituting for it any of its salts. Those who do not pin their faith in the treatment of any disease on any single remedy, but combine remedial measures with the proper regard to hygiene, will not be mistaken in their expectations of the effects of phosphorus in the treatment of scrofulous dis- order. I have used arsenic for the same purposes, and on the strength of the same indications, but it has appeared to me to offer less advantages in these conditions. A very active treatment can and should be applied to the lymph-bodies. Their tumefaction may be prevented in most cases. They swell under the influence of an irritation in the neighborhood. An intestinal catarrh will congest the neigh- boring mesenteric lymph-bodies; within a few days they are enlarged and hyperaemic. When the local catarrh continues the hyperemia will result in hyperplasia, and no long period is required to so change the tissue as to render the induration unabsorbable. If the diarrhoea "of the second summer/' or of "teething," had not been permitted to go unchecked, these "scrofulous" glands would never have existed, and never inter- fered with lymph circulation and nutrition. Or the caries of a tooth, or a nasal catarrh, or a facial eczema, or one of the scalp, is allowed to continue and develop into a chronic condition, and the secondary swelling of the glands round the throat and 152 THERAPEUTICS OF INFANCY AND CHILDHOOD. neck is the irrepressible result. Principiis obsta. The greatest and gravest consequences might easily be prevented by attend- ing to their trifling causes. When the lymph-bodies have had time to undergo indura- tion, an attempt should be made at reducing them, though they be ever so hard or large. The frequent inunction of iodide of potassium ointment made with lanolin will often carry the point; so will that of green soap. Which preparations ought to be used, and to what extent the remedy, to what the massage of the parts alone is effective, is left to the decision of the practi- tioner. At the same time the syrup of the iodide of iron may be administered internally. When these measures have proved inefficient after a reason- able time, the indurated lymph-bodies should be removed. The operation is not always easy, but recovery is almost certain, and the protection afforded by it pays more than fully for every exertion on the part of the medical man, and the tem- porary annoyance on that of the patient. When an abscess forms in the centre of a gland, this should be enucleated. If it rupture, all the remaining parts of the lymph-body should be scraped out, disinfected, and made to heal. Diseased bones should be treated on similar principles. Un- less a scrofulous ostitis be superficial and within easy reach, the diseased parts ought to be removed with the least possible delay. The number of cases recovering, though after a long time, and sometimes with shattered general health, without an operation, affords no excuse for those which have been per- mitted to develop into caries, or necrosis, or pyaemia, or leuco- eythasmia, or tuberculosis. Scrofulous conjunctivitis, keratitis, otitis, eczema, and ar- thritis should be treated internally, and to combat the morbid disposition, besides the procedures and appliances taught in subsequent chapters. That the scrofulous condition requires good air and ventila- tion may be mentioned, though it hardly appears necessary DISEASES OF THE BLOOD AND CONSTITUTION. 153 to do so. The children ought to be kept in the open air con- stantly. For that purpose the winters should be passed, if circumstances permit, in warmer climates. From that point of view the summer sea-sanitaria of our large cities, and the similar institutions of the civilized countries of Europe, have rendered valuable services. The skin of a scrofulous child must be kept scrupulously clean. But water must do more than merely that: the child must get used to cold water, and thereby accustomed to changes of temperatures. The principles laid down in connection with the bathing of the very young hold good here, and I refer to my remarks on the subject. Salt-water is preferable to plain water, and sea-bathing to either. Only in the cases of those who suffer greatly from eczema and other scrofulous eruptions, water must be avoided as long as the surface is not relieved. Indeed, no irritation of the surface is tolerated. Thus a scrofulous skin ought to be spared adhesive plasters or vesi- catories, though the indications for their use be ever so tempting. Incidental diseases of scrofulous children require more than the usual care. The perishable character of all their tissues renders an average febrile or inflammatory disease uncommonly dangerous. Unexpected deaths are frequently met with in such cases. In them the avoidance of strong purgatives, or depletions, is the first commandment; in them early feeding and sufficient general stimulation are among the principal indications; in them cardiac tonics, given timely and plenti- fully, will save many a life that would otherwise succumb. 4. Lympliatism. A number of infants and children exhibit a peculiar pallor, coupled with adiposity and rhachitical symptoms. I have alluded to this form of rhachitis repeatedly during many years. These patients, always pale and flabby, show a singular general debility. The laryngismus found in such children, with or 154 THERAPEUTICS OF INFANCY AND CHILDHOOD. without sudden death, like the other symptoms, glandular swellings, etc., I mostly attributed to this form of rhachitis; probably correctly, at least in many or most instances. Maybe others should be explained differently. "Lymphatic state" has been called a condition of pallor, adiposity, hyperemia, but otherwise normal structure of most organs, rather large (sometimes very large) spleen, thymus, and also thyreoid, rhachitical epiphysitis, swelling (in different de- grees) of the lymph-bodies of the neck, axillae, mesentery, of the tonsils and the follicles of the naso-pharynx, and of the tongue. This condition is also complicated with hypoplasia of the heart and arteries (Virchow, different from actual rhachi- tis, in which the arteries are rather large), which explains many a case of chlorosis, and also of haemophilia, sometimes with infantilism of the sexual organs, hairless pubes, and lympho- cytosis. Sudden deaths seem frequently to be due to this condi- tion, or rather to the excessive weakness of the heart connected with it (Paltauf, Escherich, J. Ewing). Escherich tried the effect of calf-thymus feeding in this complex ailment, with negative result. Besides general antirhachitic treatment I should feel like relying mainly on phosphorus. In some cases of general lipomatosis of children of both sexes, I was struck with the smallness of their radial and carotid arteries and their feeble heart-beats. The percussion of the heart yields very questionable results, on account of the large diameter of the chest walls. Still, this was never so thick as to prevent the percussion of the thymus behind the manu- brium sterni. In several instances it was found to be large, in patients of ten and twelve years. In every one of its varieties lipomatosis, being general, is a serious danger in any intervening disease. All the organs, mainly the heart, being liable to be incompetent, stimulants and roborants should be given through the whole course of feverish diseases, intervening in excessively adipose children. Intertrigo is very common and obstinate. DISEASES OF THE BLOOD AND CONSTITUTION. 155 The diet should be principally albuminous, with a fair amount of fat, and very little vegetable hydrocarbons, and little water. General massage, exercise, a dose of sodium sulphate every morning, and iodide of iron are helpful. Thyreoid may safely be given, with some caution and combined with a car- diac stimulant (strychnine), to advantage. In hydremic anaemia also, with or without a slight enlargement of the thyreoid, and in marked simple anaemias, with or without enlarged spleen, be- sides lipomatosis, thyreoid is recommended by N. Koplik (Arch, of Ped., July, 1897). 5. Diseases of the Ductless Glands. Their "internal secretion" is required in the organic economy either as an additional element, or for the purpose of destroy- ing the toxic results of metabolism. Diseases of the thyreoid gland are not often observed in in- fancy and childhood; still, even carcinoma and tuberculosis have been noticed. Syphilitic gummata have been found, and would, if diagnosticated, demand specific treatment. A der- moid tumor was removed from an infant two hours old, who recovered (London Lancet, May 22, 1897). Atrophy with myxoe- dema has been reported in a girl of twelve years; its treatment consists in the administration of thyreoid gland. Inflammation has been known to follow trauma and infectious or common catarrh of the nose and naso-pharynx. The treatment should consist of local applications of ice, hydrotherapeutic measures in general, saline purgatives, irrigations (both cleansing and antiseptic) of the nares and pharynx, and perhaps iodine both internally and externally during slow absorption. Goitre — struma — is mostly met with in the lateral lobes, and therefore is not liable to annoy respiration until it becomes very large; should it do so, it compresses, particularly when behind the sternum, the trachea, vessels, and nerves. The usual forms found in the adult (lymphatic, cystic, even colloid and fibrous) are observed. When congenital, it is apt to be absorbed; the 156 THERAPEUTICS OF INFANCY AND CHILDHOOD. age of puberty also predisposes to spontaneous decrease. Most eases presented were in children from seven to ten years old. An occasional pulsation is not, of itself, pathognomonic of Graves's disease. An epidemic — infectious and contagious — form of goitre has been observed in schools, but was only a temporary ailment. Tincture of iodine, strong or modified, may be applied once every few days, or iodide of potassium in glycerin (1 : 2-8), or a potassium iodide ointment with lanolin (1 : 4-10) may be rubbed in several times daily. Potassium iodide may be given in doses of from five to fifteen grains daily. AVith iodide of potassium injections into the tissue of the en- larged gland I have had no experience. The cystic form re- quires puncture with injection of Lugol's solution; if the secondary swelling be too large and annoying, ice should be ap- plied. Or the cyst, or cysts, may be incised and tamponed with aseptic gauze. If extirpation be preferred, it must not be total, because of the consecutive occurrence of cachexia strumipriva, tetany, and myxcedema. Extirpation has the same effect which is observed in cases of absence or of degeneration of the thyreoid gland. This degen- eration may lead to atrophy or to an apparent hypertrophy; that is why thickness of the thyreoid should not be taken for the presence of normal tissue. Myxoedema (mainly characterized by that condition of the thyreoid, by the peculiar myxomatous structure of the skin and subcutaneous tissue, and by mental failure) is seen in the young as well as in the adult. In the young it is mostly complicated with cretinism or semi-cretinism; in many cases the absence or degeneration of the thyreoid may be its only cause, in many others it exhibits at the same time changes in the skeleton, prominent among which is the shortening of the cranial base produced by the premature ossi- fication of the occipito-sphenoidal synchondrosis. Thus, with the exception of the latter, the cretinism of the foetus and in- fant and the myxoedema of the young and of the adult are the results of the same anomaly. DISEASES OF THE BLOOD AND CONSTITUTION. 157 This cretinism is by no means so rare among us as it has been reputed to be even among the best observers. The patients with their thick, short neck, clumsy-looking head, retracted root of nose, wide-apart eyeballs, thick lips and tongue out- side the teeth, large abdomen and dwarfed stature, and their indolence seldom turn up in practice. They are occasionally found in the retreats of the tenement houses, where the general practitioner may happen to see them, though he be not con- sulted about them; only of late they turn up in the dispensaries. In the therapeutics of cretinism in most of its forms the thy- reoid gland, in its various preparations, has worked a beneficial revolution, as it also has in that of myxcedema. This addition to our facilities for overcoming a formerly incurable ailment, at least to a certain extent (for no perfect recovery is known as yet), is, as Meltzer has so well shown (New York Med. Monats- schrift, May, 1895), eminently due to biological experiment and to it only. There are but few cases that resist its efficacy. The doses, however, must be small, particularly in the beginning; from one-third of a grain to one grain of Parke, Davis & Co.'s powdered thyreoid three times a day, the small doses first, the larger one afterwards, are all that ought to be given an infant or child, according to age. The treatment must be continued a long time. It cannot be expected to act so well as in the myxce- dema of the adult, because the cretinism or semi-cretinism of the child is the result of an arrest of development at a very early period of intrauterine life. It follows that the treatment ought to begin as early as the diagnosis can be made. Besides the pow- der of Parke, Davis & Co., I know only Armour's preparation and the tablets of Burroughs and "Wellcome. They are not of equal strength, and in every case ought to be commenced with in small doses; for sometimes even apparently small doses pro- duce general and cardiac irritation, palpitation, tremor, de- bility, and diarrhoea. Other effects of the thyreoid medication are obtainable in the child as in the adult. Myxcedema, the near relative of cretinism, shows its main symptoms in the sud- 158 THERAPEUTICS OF INFANCY AND CHILDHOOD. cutaneous tissue, in the skin, and in the nervous system. I have seen good results of the thyreoid treatment in cases of excessive adiposity, — one boy of eleven years, weighing one hundred and fifty pounds, was reduced to one hundred and twenty in four months under the use of small doses, — in scleroderma, and in a case of psoriasis. Fortunately, all such cases are rare. The attempts at isolating the active principle, either organic or probably chemical, have not yet proved successful. Neither the iodothyrin of Baumann nor the thyreoantitoxin of Fraenkel have given uniform satisfaction. The latter is recommended in doses (to an adult) of one centigramme (gr. J), five or six of which may be given daily. Not infrequently have I combined arsenic, or phosphorus, with the thyreoid, some of the cases of cretinism showing char- acteristic symptoms of rickets. Indeed, the condition of the base of the skull appears to be one of the manifestations of localized rhachitis which has completed its entire course before birth. The rapid effect of thyreoid administration is rather jeopar- dized by the necessity of persisting in the treatment, in order to escape relapses. Horsley's attempts at transplanting glandular substance will have to be repeated until they will be successful, and place the effect of the miraculous therapy beyond any risk. Such risks there are now. The effect, some- times of small doses, may be distressing, — prurigo, perspiration, tachycardia, delirium, even tonic spasms, and undesirable loss of weight. In all these symptoms the effects of the treatment resemble very much those of exophthalmic goitre (Graves's or Basedow's disease) in which the thyreoid is enlarged, and, in all probability, the seat of abnormal functions. I treat of it in this connection, instead of giving it, as I did in the first edition of this book, a place among the vascular neuroses. Exophthalmic goitre is not a frequent disease in childhood. Of twelve cases reported in literature until 1879, four were mine (New York Medical Record, July 5, 1879); they occurred DISEASES OF THE BLOOD AND CONSTITUTION. 159 in children of from nine to thirteen years. Nor are the symp- toms so grave as they are liable to be in the adult; in many, not all of the three alterations (exophthalmos, goitre, and tachycardia) are found at the same time. In the treatment proper regard must be paid to diet and hygiene. Xo excite- ment, fear, work, stimulants. Prolonged or but partial rest in bed at home or in a hospital. Baths of moderate temperature. Ice to the heart and (or) to the goitre for days, or hours, in succession. Application once or twice daily of a mild galvanic current (negative pole, from one to three milliamperes) from five to ten minutes over the sympathetic nerve, between the horn of the hyoid bone and the sterno-cleido-mastoid mus- cle. Digitalis acts badly, and is apt to increase tachycardia; strophanthus and iodide of potassium act more favorably. Gowers recommends belladonna in rising doses. My most suc- cessful medicinal treatment has been with arsenous acid, from two to six milligrammes (one-twentieth to one-tenth grain), atropine from one-third of a milligramme to one milligramme (one one-hundred-and-eightieth to one-sixtieth grain), and ex- tract of ergot a gramme (grs. 15) daily. I lately had a child's case under observation for some time, and was favorably im- pressed with the effect of thyreoid in that case. Possibly it acts better in children in whom the course of the disease is mostly milder; for, as far as adults are concerned, experience does not seem to be favorable. It is quite possible that Graves's disease will be much more influenced by the administration of thymus gland. Eeinbach found fresh thymus to act in cases of goitre, in which thyreoid treatment had proved ineffective. The direct dependence of Graves's disease on the condition of the thyreoid glands appears to be proven by the result of operations (partial removal), which, according to Oppenheimer, cured eighteen and improved twenty-six out of sixty-six cases. Nine died within a day. Of late the results of operations are greatly better; Kummell, for instance, operated on fourteen severe cases of exophthalmic goitre with partial removal of the thyreoid gland; 160 THERAPEUTICS OF INFANCY AND CHILDHOOD. twelve were permanently cured. The report was made from two to seven years after the operation. The remaining part of the gland showed a tendency to shrink, in one case only it grew a little larger. The other two cases were cured, with the excep- tion of the exophthalmos, which persisted at first, but gradually diminished in size (Berl. Klinik, June, 1897). Doyen reported two equally successful cases (Sem. Med., 1897, p. 280). Further favorable results of the thyreoid treatment may be mentioned here. It is said to have improved dwarf growth, akromegaly, hyperplastic otitis interna in young obese persons, and psoriasis (besides prurigo); the absence of thyreoid func- tion certainly injures the growth of bones, while it seems to leave intact the large abdominal viscera. It has sometimes improved tetany and certainly has a very favorable effect in simple hyperplastic goitre, in which the normal structure of the gland has been destroyed. Diseases of the thymus gland are not yet amenable to treat- ment. Inflammations, abscesses, syphilis, tuberculosis, sar- coma, lymphadenoma, and carcinoma have been observed. Its physiological dignity in the fcetus and young infant is cer- tainly great. Nearly forty years ago Friedleben proved that it is indispensable in the foetal and infant economy. It is largest (normally) from the third to the twentieth month; about the ninth month it was found, in abnormally large cases, 1.5-2 centimetres in thickness. As the distance between the manu- brium sterni and the vertebral column is but two centimetres about the eighth month of life, the slightest increase of an en- larged thymus through disturbed circulation, by crying or otherwise, may prove suddenly fatal. Another danger is the irritation of the recurrent nerve by the constant up-and-down movement of the thymus gland. Koenig extirpated a part of the thymus of an infant of nine weeks that suffered from intense dyspnoea. The remaining part he attached to the manubrium sterni and the tendons of the sterno-cleido-mastoid muscles; recovery was complete in DISEASES OF THE BLOOD AND CONSTITUTION. 161 four weeks. Thus, local pressure or irritation by the greatly enlarged gland may prove fatal, though most cases of sudden death in laryngismus stridulus must be explained otherwise. A recent case of death from large thymus occurred nine hours after birth (Schleif). Like the thyreoid, the thymus was found enlarged in many, according to Erb in all, cases of akromegaly. Acromegaly, enlargement of all the tissues — except skin — of hands and feet, of both maxillae, with alveolar processes, of ears, tongue, and thorax, was attributed by Marie to hyperfunction of the hypophysis (pituitary gland), which is in part a secreting organ without a duct, so that the lymph-vessels carry off the secretion. Marie, therefore, looks upon akromegaly (and many cases of gigantic growth, — several professional giants were found to be akromegalic) as a nutritive disorder connected with an anomalous hypophysis, as myxcedema is with the thy- reoid gland. Possibly, as the thymus appears to be affected, akromegaly is the result of the complex anomalies of several organs. The treatment with hypophysis gave no conclusive re- sults; nor that with thymus. The latter was also employed by Macalister in pseudohypertrophy, and Mikulicz in goitre and Graves's disease; in the latter it has also been used by Owen, Cunningham, Edes, and Solis-Cohen. X. Mackenzie reported twenty cases treated with thymus (Amer. Joum. of Med. Sc, February, 1897). One died, six showed no improvement, thir- teen showed some improvement, which, however, was not con- sidered marked or conclusive. Addison's Disease. — The "suprarenal melasma" depends on anomalies (tuberculosis, carcinoma, induration, hemorrhage) of the adrenals. In some cases the semilunar ganglia have been charged with being its cause. Great muscular weakness, de- bility of the heart, frequent and small pulse, irritability, later apathy, cephalalgia, exhaustion (together with the character- istic discoloration of the skin) are the symptoms common to a number of constitutional ailments leading to a slow death. The 11 162 THERAPEUTICS OF INFANCY AND CHILDHOOD. treatment is therefore, to a great extent, that of the anaemias, and requires iron, arsenic, strychnine, and measures directed against incidental symptoms, such as diarrhoea. Adrenals have been given in powder or in glycerin extract, or cooked.* The equivalent of two glands was administered by Osier, with vary- ing results; he has a case (adult) that gained fifteen pounds in six weeks and felt stronger ("Princ. and Pract. of Med.," 2d ed., 1895, p. 749). Most valuable general information on organotherapy we owe to Hun, and lately (Amer. Journ. of Med. 8c, July, 1897) to Kinnicutt, who gives the results of vast experience and large numbers. According to him, in accordance with other observations, the myxoedema of cretinism is readily re- moved by thyreoid treatment. The earlier it is commenced in the young the greater is its influence on growth and mental development. In the idiot, with rather more a lymphatic than a myxoedematous condition, improvement is also obtained. Hyperplastic goitre (not the cystic) is greatly improved if not cured. Exophthalmic goitre was not improved; on the con- trary, many patients felt worse. Obesity is influenced rapidly, losses of from two to eleven pounds having been observed; these losses will continue for some time only. Psoriasis is in- fluenced to a certain extent only; the thyreoid treatment seems to have no better effects than others. Other skin-diseases were not particularly benefited. Of forty-eight cases of Addison's disease treated by suprarenal extract, six were cured, twenty- two improved, eighteen not improved, and two aggravated. Thymus extract appears to be useless in exophthalmic, benefi- cial in hypoplastic goitre. Of thirty there was improvement in twenty, a cure in two. Pituitary preparations were used in thirteen cases of acromegaly. Varying degrees of improvement were noticed in seven, none in five, and one became worse. In one the affected extremities decreased, in two the pain in the head and the limbs diminished. * Literature in E. Merck's Annual Report on the Year 1896. DISEASES OF THE BLOOD AND CONSTITUTION. 1G3 6. Hemorrhagic Diathesis. Under this head I propose to treat of purpura, the hemor- rhagic disease of Werlhof, scurvy, poliosis rheumalica, and hemophilia, because of their similarity of symptoms and their — to a certain extent — uniform anatomical cause. Among them all, the first, with its wide-spread petechia? and subcutane- ous and cutaneous hemorrhages, is most frequently mentioned. It results from all causes interfering with general nutrition, and particularly with that of the blood-vessels. Among them are poverty, uninhabitable dwellings, chronic gastro-intestinal catarrh, dysentery, typhoid fever, diabetes, miliary tuberculosis, pneumonia, diphtheria, scarlatina, and measles. Relapses are very common. The complications with hemorrhages from the mucous membranes of the nose, stomach, and intestines, from the kidneys, into the brain and retina, and often with fever, are denominated Werlhof s disease. The diagnosis of "scurvy" requires bleeding from the gums, "peliosis" complications with "rheumatic" pain and swelling of the joints, but without an affection of the heart, and haemophilia the hereditary tendency to bleeding of (mainly) the male transmitted through the female, on the bases (Virchow) of narrowness of the arteries and insufficient development of the thin blood-vessel walls. The alleged defective condition of the blood does not explain the hemorrhagic tendency. No blood, though ever so thin, penetrates a healthy blood-vessel wall. Hydremia by itself does not produce bleeding without an impaired condition of the tissue of the blood-vessel; thus it is that the same degree of anaemia in women may result in metrorrhagia in one, in amenorrhcea in the other. Infants are peculiarly liable to bleed, because in them the blood-vessel tissue is still unde- veloped; the embryonic condition extends into early infant life, and gives rise to frequent hemorrhages into the brain, meninges, and other serous membranes. "When morbid influ- ences are added to this physiological predisposition, the result is easily comprehended. 164 THERAPEUTICS OF INFANCY AND CHILDHOOD. These influences are unknown. Bacteriological explanations are not yet quite satisfactory; still it is possible that all these varieties of hemorrhagic diathesis, which have been subsumed by Wm. Koch under the common heading of "scurvy," are more or less acute infectious diseases. That suspicion appears particularly justified in regard to the purpura fulminans, a few cases of which have been observed in the very young (Henoch). The treatment is to a great extent preventive. The social condition of a large part of the population is a main cause and ought to be improved. Thus the successful treatment depends largely on the prosperity of all, and is another proof of what ought to be considered a fact, that medical and social questions and aims are frequently identical. Zymotic disorders and erup- tive fevers should be treated with a view of sustaining the strength of the system and the vigor of circulation. The heart's action ought to be watched constantly, and cardiac tonics given before heart-failure sets in. The dietetic treat- ment of these diseases is at least as important as their medi- cinal management. In this way hemorrhagic diathesis is kept off, as well as exhaustion. Medicines can accomplish a great deal, but ergot less than it is often credited with. In these conditions I have often met with its untoward influence on digestion, and but rarely with a favorable influence on the hemorrhagic deposits or processes. Perhaps hydrastis does better. Iron also does not appear to yield desirable results; among its preparations the tincture of the chloride is perhaps the best; the tincture of the malate and the liquor of the albuminate are well tolerated. Digitalis has a favorable effect on the heart's action; an infant of a year may take the equivalent of from one to four grains daily for some days, two grains daily afterwards. "With it may be combined strychnia; the same baby may take a fiftieth of a grain daily. As relapses are quite frequent, the invigoration of the blood- vessels is the main object in view. From one to three drops of DISEASES OF THE BLOOD AND CONSTITUTION. 165 Fowler's solution, largely diluted, may be given every day for a long time. Better still is phosphorus, the method of whose administration, and the doses of which, have been detailed in a former chapter. Lead and tannin have not satisfied me at all. Local hemorrhages, when accessible, will require the applica- tion of ice, or compression of the bleeding vessel. The solution of antipyrin (5-20-50 per cent.), with or without tannic acid, is a good styptic. The success of the preventive treatment of haemophilia will be rather doubtful as long as individuals are not controlled by the community in regard to the demands of public health. The daughters of hasmophilic families ought to be prevented from, and protected against, contracting mar- riages and having children. Phosphorus, administered in small doses and continued a long time, seem to diminish the tendency to bleeding. Infantile scurvy ("Barlow's disease") has become very amen- able to treatment, both in its early and in its advanced stages. Its main and characteristic symptoms are pain and immobility of the (mostly lower) extremities, swelling (mainly) of the diaphyses depending on subperiosteal hemorrhages, petechias, and ecchymoses over any part of the skin, particularly of the eyelids, spongy condition and purple color of the gums, no mat- ter whether teeth have appeared or not, and sometimes separa- tion of an epiphysis. These symptoms are frequently compli- cated with the tumefied epiphyses and other marks of rhachitis. The prognosis is good. The principal remedy is fruit-juice, that of from one-half to two oranges a day, or of a pineapple; it is the specific. Complications with rhachitis require, besides, the elixir of phosphorus. Sterilized milk, if the only nutriment, as in many instances it will be found to have been, should be banished. If no reliable sweet milk be accessible, it should be pasteurized and combined with cereal (barley, oatmeal) decoc- tions, and meat broths, or some meat-juice should be adminis- tered as a regular food. 166 THERAPEUTICS OF INFANCY AND CHILDHOOD. 7. Diabetes. Diabetes mellitus is by no means a common disease among infants and children, but it is not so rare as some will have it, nor so frequent as those assert who have found glycose in the urine of infants whose food was supplied with an unusual quantity of sugar. Indeed, traces of sugar are often met with in the urine of nurslings. But this is not "diabetes." In the ten years before 1860 there were thirty-one deaths from actual diabetes in Great Britain in children under fifteen years, annually. Since that time the occurrence of the disease in every period of life appears to have increased considerably. Hereditary and family influences, such as neuropathies, epi- lepsy, insanity, syphilis, exert a great influence. Caron reports the cases of three children of the same mother, at the ages of three and a half, and one and a half years, and of three months. Hydrocephalus, injuries to the head, colds, atrophy of the pancreas, dysentery, morbus maculosus, measles, and scarlatina are referred to as causes. In most of the cases which have come under my own observation I could not elicit a cause. The highest percentage of sugar I have noticed in a child (boy of four years) was six and one-half. Heubner observed eight and one-half, with a daily quantity of five thousand grammes, or five quarts, Leroux ten and a half. The prognosis is not so good as Eedon and a few others appear to believe. Twenty years ago Kulz reported six recoveries in one hundred and eleven, Wegeli, thirty-nine in one hundred and eight cases. I am afraid the diagnosis was obscured by the facility with which copper is reduced by creatinin, creatin, and other con- stituents of the urine. Therefore, several (different) tests should be employed, when dry skin, emaciation in spite of ravenous appetite, polyuria with high specific gravity (up to 1044), also furunculosis, are noticed. The disease runs a more rapid course in infants and children than in adults, and termi- nates more readily in coma and death. I never saw a recovery in more than fifteen cases. Therefore the treatment must be DISEASES OF THE BLOOD AND CONSTITUTION. 167 circumspect and energetic. Strict antidiabetic diet should be enforced. Fortunately, the young, with very rare exceptions, are apt to live mostly on milk, which may be given copiously in any shape. Thus less difficulties are encountered in them than in adults. For these also milk, skimmed or not, forms a principal and beneficial part of their nutriment. Saccharin or glycerin may be used instead of sugar. "Gluten bread" contains too much starch, the "aleuronat" of the Germans about half as much as common bread. The medicinal treat- ment of the young requires some modifications. The facility with which cerebral symptoms ("coma") are developed, ren- ders the persistent use of alkalies advisable (mineral waters), mainly the sulphate of sodium. Opium is tolerated in increas- ing doses. Iodoform, which I have seen to render fair service in adults, in daily doses of from ten to twenty grains internally, is seldom tolerated by the young, even in proportionately small doses. Arsenic may be given in increasing doses a long time, the bromide as well as other preparations; one drop and more of Fowler's solution, largely diluted, after meals, three times daily, the dose to be increased gradually until doses of from two to four drops are taken. As in every disease which resists treat- ment to an unusual degree, a large number of other medicines have been recommended. As this book is not a library, but written for practical purposes only, I abstain from enumerating drugs which I believe to be useless. There is one, however, which, in connection with everything destined to improve di- gestion and assimilation, appears to have a very favorable influ- ence on the diabetic process. Salicylate of sodium, with an alkaline beverage (Selters, Yichy), has a decidedly favorable effect. A child of five years may take from five to eight grains, three times a day, and continue its use for many weeks, to ad- vantage. Lactic acid (cantani) may be tried with equal parts of bicarbonate of sodium in water, one or two grammes a day (srs. 15-30), lactate of calcium in the same or larger doses. Ex- tract of jambul has been powerless in my hands, benzozol in 168 THERAPEUTICS OF INFANCY AND CHILDHOOD. daily doses of half a gramme or more (gr. 10) nearly so. Anti- pyrin appeared to be a little more efficient, the feeding with pancreas not at all. The prognosis was always bad when oxy- butyric acid or renal casts made their appearance. Tubercu- losis is not so frequent as in the adult. Diabetes insipidus is a rare disease, but more common than diabetes mellitus. A large amount of urine of a low specific gravity (1000 \ to 1005) is secreted daily. The increased mic- turition, great thirst, and emaciation are among the prominent symptoms. In some cases there appeared to be a hereditary influence. Syphilitic and other brain lesions, and injuries, have been found to explain its occurrence. In one case of mine, that of a girl of five years, it ceased, together with a copious and constant salivation, after the removal of a taenia medio- canellata. Inveterate masturbation and consecutive "neuras- thenia" appeared to be the cause of the excessive flow of urine in several children of from four to eight years. It ceased gradu- ally with the restoration of correct habits and better general health. Of the remedies which have been recommended, I men- tion valerian, valerianate of zinc, bromides, salicylate of sodium, and galvanization of the head. All of these proved unsatisfac- tory in my hands. But I have seen good results, and sometimes speedy improvement, from the administration of ergot and atropia. In other cases they were absolutely useless. A child of five years may take daily, of the former two cubic centime- tres (half a drachm) or more (extr. fluid, or the corresponding amount of ext. ergot., or ergotin), of the latter one-hundredth of a grain or less (one-half of a milligramme). More reliable than either has been strychnia, in three daily doses of one-hun- dredth of a grain each, or more (one-half of a milligramme). Valerianate of zinc may be tried in daily doses of half a gramme to one gramme (grs. 7-15). Opiates are highly recommended by Bouchut; pilocarpine, antipyrin, and acetate of lead by others. Fortunately, the prognosis is much more favorable than that of diabetes mellitus, particularly in hereditary cases. V. INFECTIOUS DISEASES.* 1. Tuberculosis. In ten hundred and forty-five autopsies made in the New York Foundling Hospital (Northrup) and the Babies Hospital, all of which were reported by L. Emmett Holt, tuberculosis was found in fourteen per cent.; altogether one hundred and nine- teen cases. These and similar statistics demonstrate the fre- quency of tuberculosis in infancy. In the first year of life, in the second, and in the period from the second to the fifth year, it is the same. In the above one hundred and nineteen cases the lungs were affected one hundred and seventeen times, the pleura sixty-nine, the bronchial lymph-nodes one hundred and eight, the brain forty, the liver seventy-seven, the spleen eighty-eight, the kidneys forty-six, the stomach five, the intes- tines forty, the mesentery thirty-eight, the peritoneum ten, the pericardium seven, the endocardium one, the thymus three, the adrenals three, and the pancreas three times. In the young, as in the old, tuberculosis is spread either by mechanical transmission through cough, deglutition, and aspi- ration, or in the contiguity of tissues after having been devel- oped in a given locality, or through lymph-ducts and blood- vessels. The latter, after having absorbed bacilli from the primarily invaded part, are liable to distribute them in a distant locality or all over the system in the shape of acute miliary tu- * With the exception of a very few (intermittent fever, rheumatism) all the diseases enumerated under this head are also directly or in- directly contagious. As it is not my intention to systematize closely, they all appear in this chapter indiscriminately. 169 170 THERAPEUTICS OF INFANCY AND CHILDHOOD. berculosis. Most frequently the primary seats of the affection in the young are the bones, joints, and lymph-bodies ("glands"). Among the latter, those of the mesentery are by no means so frequently affected as they are still reputed to be; those of the neck and mediastinum are more subject to early infection. Bacilli may be swept into the circulation through healthy epithelia, but the majority of infections are the results of a morbid condition of the integuments, either epidermoid or mucous. Wounds facilitate the admission of bacilli (circum- cision, eczema, not vaccination). The nose, the pharynx when sore or ulcerated, may be equally dangerous. The most common forms in which tuberculosis makes its ap- pearance in the young are acute miliary tuberculosis, acute or subacute caseous pneumonia, and genuine chronic tubercular phthisis with cavities. Caseation, however, does not always mean tuberculosis; for it is also met with as the final trans- formation of pus, of carcinoma, and of typhoid infiltrations. Tubercular abscesses of the lungs are not at all frequent, but we see them at every age. While I have met with but very few cases before the end of the first year, they are not quite rare after the sixth or eighth. Pulmonary tuberculosis is often ac- companied or preceded by pleurisy; indeed, it appears probable that this pleurisy, with its frequent relapses, is the primary seat of tuberculosis in many. The most common form of pulmonary tuberculosis in the young is that which is developed out of caseous pneumonia. It is a frequent result of bronchitis and catarrhal pneumonia attending measles and whooping-cough, and is quite generally accompanied with considerable changes in the neighboring lymph-bodies. It is often seen in the lower lobes; indeed, what is frequently suspected to be pulmonary tuberculosis of the upper lobes is apt to be induration, resulting from intersti- tial inflammations, which retract the corresponding part of the chest, exhibit diminished respiratory murmur, prolonged ex- piration, and dulness on percussion, and may last a long life- INFECTIOUS DISEASES. 171 time without endangering life or health to any considerable extent. What I said about the mode of development of these fre- quent forms points at once to preventive treatment as the principal indication. If bronchitis, catarrhal pneumonia, measles, whooping-cough, and glandular diseases are frequent causes of tuberculosis, those primary affections must be effectu- ally treated. There is no bronchitis which cannot be made milder, many a case of catarrhal pneumonia may be shortened or rendered less dangerous, and most, perhaps all, cases of whooping-cough modified and shortened. In a former, chapter I insisted upon the necessity of watching and treating all the self-limited diseases. The sin of omission is as grave as that of commission. And in my remarks on scrofula, to which I here refer, I pointed out the facility of eradicating the coming evil by removing the unabsorbable tumefaction of lymph-bodies. Unfortunately, the success of treatment in cases of acute miliary tuberculosis is so small, and of chronic tuberculosis so unsatisfactory, that the indications for preventive treatment are the more urgent. The facts of uni- versal tuberculosis arising from a local source cannot be denied, having been proven by thousands of experimental and clinical observations. Now and then a case is quite demonstrable. A few years ago I had a little girl in my division in Belle vue Hospital who suffered from the most exquisite and extensive tuberculosis of the skin I have ever seen. She finally died with empyema and general tuberculosis. Coming from a fairly healthy family, she developed a glandular swelling in her right axilla, which was neglected, and permitted to break spontane- ously and result in sinuses. From that place the lymphatics transported the accidental bacillary infection, and produced extensive ulcerations over the chest; metastases took place in other parts of the body, and the child died of universal tubercu- losis. It is of no account to investigate whether the original affection was tubercular already, or whether the tubercular 172 THERAPEUTICS OF INFANCY AND CHILDHOOD. character was developed afterwards. This much is certain, that the child need not have died if the gland which was primarily affected had been extirpated. It is unnecessary to add that tuberculosis of the bones and joints, so frequent in infancy and childhood, requires prompt attention, and in some cases operative procedures. Among the causes of tuberculous consumption which makes its appearance in otherwise healthy persons, both young and old, the following also are given prominence by all observers of note: Insufficient supply or change of air, absence of exercise, overwork without rest or vacation, monotonous food, and in larger children persistent mental emotions. Most of these sources of disease act as well on the young as on the old, and may lead to infiltration, before there is any cough, but anaemia, muscular debility, and loss of appetite only. Therefore tuber- cular infiltrations are frequently found among the inmates of prisons, particularly those who have been isolated a long time, workmen in factories, soldiers in barracks, students in semi- naries, children in orphan asylums and large boarding-schools, those attending crowded public schools and overworked in their private studies, besides being crippled by unwise discipline, which requires absolute immobility, and by loss of time or op- portunity for exercising. It is not very probable that the occa- sional stately promenades of the young by couples — though not handcuffed, though on a Madison Avenue sidewalk, though attended by the good-will, moral character, and Argus eyes of two elderly ladies — are equivalents for the free and unham- pered play and development of the growing organs. If it be a fact that there is so much less tubercular disease among hun- ters, farmers, gardeners, and sailors than among factory men and women of all trades, school-masters, and tailors, it is cer- tain that rowing, skating, gymnastics, and tennis, even the so- called calisthenics, if practised in the open air, would expand many a child's chest, aerate his blood, keep his organs vigorous, and eliminate invading poisons. INFECTIOUS DISEASES. 173 There are many other causes or influences creating or in- creasing the possibility of tubercular invasion. A considerable predisposition is created by the vulnerability and fragility and cedematous infiltration of scrofula; by the catarrh produced by sedentary life and foul inhalations. Koch has proved that active bacilli pass the stomach unmolested and may infect the intestine under unfavorable circumstances, thus rendering even a primary intestinal tuberculosis possible. While direct heredity is rare, hereditary predisposition to tuberculosis is quite frequent, and is transmitted even by such parents as appear to be in fair health. Constitutional parental disorders resulting from the influence of scrofula, rhachitis, and even syphilis, may finally become manifest in the children in the shape of tuberculosis. In such children every catarrh must be carefully watched. The premature ossification of the costal cartilages, most frequently found about the superior part of the chest, and the consecutive shortening of the sterno-vertebral diameter give rise to contraction of the thorax and insufficient expansibility of the (upper lobes of the) lungs. In such cases the aeration of the blood suffers at a very early date, catarrhal and inflammatory thoracic diseases are liable to become dan- gerous, and gymnastic exercises are required in early child- hood. Direct transmission from the diseased parents to the children is probably more frequent than is commonly believed, and therefore the child should not share the room and bed of the consumptive. Kissing must be omitted under these circum- stances; it may often be the cause of contagion, though, per- haps, not so frequently as, for example, diphtheria is trans- mitted in that manner. The origin of pulmonary consumption is uniformly, in almost all instances, attributed to the inhalation of bacilli. As they are deposited on bedding, clothing, and on the floors and walls of rooms, in handkerchiefs and towels, where they get dry and disintegrated mechanically, nothing appears to be easier than 174 THERAPEUTICS OF INFANCY AND CHILDHOOD. that the long-lived microbes should be admixed to the dust of the room, and thus be inhaled. In this way the contagion of acute exanthems is certainly disseminated. Tubercle bacilli, like everything solid, when floating in motionless air, is certain to sink gradually, and the inference is that children are more liable to inhale them. This mode of propagation has been taken to be the principal one in pulmonary tuberculosis. To such an extent has this belief controlled the teachings of medical men that the rules and regulations of health departments concerned themselves with this mode of transmission only. Experiments, however, appear to prove that the air currents usually found in a room are not sufficient to detach dry bacilli fastened with their surrounding sputum to the walls or floors. It is only strong currents, such as are caused by sweeping, beating, brush- ing, perhaps even by violent slamming of doors, that will float them. Under these latter circumstances it is certainly possible that dry bacilli may be detached in this way and infect those present. But experiments on animals have not yet proven that they could be infected by inhalations thus conducted; and it is quite possible that boards of health will have to alter or rescind, or rather extend, both their opinions and the practical rules built on that foundation. For but lately Fliigge (Zeitsch. f. Hyg. u. Inf. Krarikfi., vol. xxv., 1897) published a long series of experiments and observa- tions which appear to be able to stand accurate tests. Crying, sneezing, coughing, even talking, detach sputum in more or less invisible quantities. Everybody's experience yields such in- stances, palpable ones, in the sick and well. Such moist par- ticles, mostly infinitely small, were proven to remain in the air of a room five hours. Indeed, an air current of from one to four millimetres in a second (= twelve to fifty feet an hour) sufficed to float them for that length of time. In this manner the con- tagiousness of pulmonary tuberculosis is even more pronounced than by assuming the dry sputum to be the only means of con- veying the disease, and the direct transmission from husband to INFECTIOUS DISEASES. 175 wife or children, from the woman in childbed to her newly- born, or between patients in a hospital ward or sanitarium becomes almost a matter of course; and the medical and hu- manitarian devices planned on hitherto imperfect knowledge require a far-reaching revision. It is evident, for instance, that the newly-born cannot be safe with its consumptive mother; and just as probable that a "sanitarium," a ward, a hospital filled with tuberculous pa- tients, is a hotbed of mutual infection. A consumptive mother must not nurse her infant because of the danger of immediate contact. Her milk may be, though it rarely is, infected like the milk of tubercular cows, even though their udders may not be diseased. Two cows, at least, out of a hundred are tubercular. Thus the least that can be done is to boil the milk intended for the nourishment of the infant. By thus obeying the rule I have enjoined these forty years, the milk can be made more innocuous than is possible even for butter* or cheese obtained from such cows. These rules ought to be strictly obeyed, though there be exceptions to the uni- versal experience. An instance of such exceptions is mentioned by Biedert, than whom there is no more reliable observer. He reports the cases of children who were fed a long time on the milk of tubercular cows without being attacked themselves. The meat of tubercular cattle is not infected (for bacilli are not found in muscles) and therefore not so dangerous as possibly its milk. But, after all, the presence of tubercular cattle in a community is more than simply objectionable. Its dangers exist, though they may have been exaggerated. That is why Koch's tuberculin, which failed as a cure, has proved a preven- * Butter does not seem to be very dangerous. For neither Schuchardt nor Rabinowitsch (Koch's Institute) found tubercle bacilli in eighty samples of butter taken from different stores and markets. Twenty- three of them caused, in guinea-pigs, alterations resembling, but not exactly like, tuberculosis (Deutsch. med. Wocli., August 5, 1897). 176 THERAPEUTICS OF INFANCY AND CHILDHOOD. tive, inasmuch as it reveals the presence of tuberculosis by the elevation of temperature following its subcutaneous injection. Among the causes of consumption monotony of food has been enumerated by many. It is evident that it cannot account for much in the cases of infants or children, whose habits are plainer and digestive functions more adapted to simpler and more uniform articles of diet. Most of these, while in health, are satisfied with milk, cereals, and but little meat. Sweet cream may be added to the milk, but more than a few ounces are not digested through the course of a day. Cod-liver oil acts not only through its fat. During the afebrile condition and chronic emaciation, over-alimentation, introduced by Debove, may be tried to advantage, while the insufficiency of gastric digestion may be stimulated by the administration of artificial gastric juice (pepsin with muriatic acid) and mild stomachics (gentian, nux, diluted alcoholic beverages). Where exercise cannot be procured to a sufficient extent, or is contraindicated by the necessity of enforcing temporary, but absolute, rest, mas- sage, according to S. Weir Mitchell's plan, will take its place. During fever, over-alimentation is to be stopped; it deranges digestion and increases bodily heat. Alcoholic stimulants will at that time often take its place to advantage. While they do not act well in certain over-irritable natures, with over-sensitive hearts, and in haemoptysis, they are good stimuli for the general system, diminish perspiration, and act favorably in diarrhoea. In the treatment of tuberculosis no single factor is beneficial by itself. The quality of the air alone will not cure the sick any more than a certain mixture of salts and water in a mineral spring, or some known chemical relation of albuminoids and carbohydrates in an article of food. Insufficient clothing and bedding, unheated rooms, draughty halls, indigestible food, strong coffees and teas, hot cakes and cold drinks, late hours, lively hops, brass instruments and pianos disturbing midnight rest, kill as many, in proportion, in Colorado, Florida, Southern France, and Italy, as in New York. Unfortunately, we know INFECTIOUS DISEASES. 177 too well that our patients believe they have done enough for their physician (or themselves?) when they have followed his advice to change climate. In this respect, too, it is true that those who speed over the sea are changing their sky, but not their spirit.* It should never be forgotten that the change of climate is mostly a negative remedy, and cannot be expected to offer more than the possibility of favorable external circum- stances. Moist air is a better conductor of warmth than dry air. Thus loss of temperature is more rapid in moist air than in dry air. Dry air, therefore, may be very much cooler, and is still better tolerated in spite of its lower temperature, and affords more protection. Haemoptysis appears to be a frequent occurrence at the times and seasons of increasing atmospheric moisture (spring). According to Rohden's researches a rapid increase of the percentage of water in the blood is frequently sufficient to produce a hemorrhage. Thus the drinking of large quan- tities of water ought to be avoided, and no residence be selected for a patient subject to haemoptysis where the atmosphere is very moist. Dry altitudes such as those of New Mexico have given me good results in pulmonary hemorrhage. At all events, no place should be selected where the percentages of moisture in the air are liable to change rapidly. The uni- formity of an insular climate is, therefore, not so dangerous to those who have bled from their lungs. Still, dry air and a higher scale of the barometer are preferable. The diversity of opinions in reference to the climato-thera- peutics of phthisis resulted from the circumstance that the in- dications were not distinctly understood. Neither cold nor warm, neither dry nor moist, air by itself is a remedy. Warm air does not cure, but it enables the patient to remain out of doors. The temperature should be uniform, sudden currents of air avoided, and the atmosphere free of microphytes. At an * "Coelum non animam mutant qui trans mare currant." 12 178 THERAPEUTICS OF INFANCY AND CHILDHOOD. altitude of sixteen hundred feet their number is greatly re- duced (Miquel), there are but few at a height of two thousand six hundred feet (Freudenreich), very few at six thousand, absolutely none at twelve thousand feet, provided the parts are not, or but little, inhabited. Over-population of elevated villages and cities diminishes or destroys their immunity. In the factories of the Jura Mountains, with a great working population, at an altitude of three thousand five hundred feet, tuberculosis is frequent. Protection against sudden gushes of wind and rapid changes of temperature is an absolute necessity. The elevated valleys or rather recesses of mountains (Colorado) deserve their repu- tation in pulmonary diseases. Davos is dusty, windy, and ex- posed to frequent changes of temperature during the summer, and must not be advised for that season. Woods are warmer in winter, cooler in the summer; so is the ocean. Both, there- fore, deserve their reputation in the chronic ailments of the respiratory organs. Not the thinness of the atmosphere, but its purity, is the requisite, and a high percentage of ozone. The latter is de- veloped under the influence of intense light, the presence of luxuriant vegetable growth, particularly of evergreen trees (Terebinthinacege), and the evaporation of large sheets of water. Thus ozone is found on moderate or high altitudes, in needle-wood forests, and near or on the ocean. In the general hygienic treatment of tuberculosis the skin requires particular attention. Sudden changes of temperature, which strike the surface suddenly and work their effects on internal organs by reflex, — "colds," — in spite of the modern superciliousness of some who deny any pathological change unless by the exclusive work of bacteria, will always hold their places in nosology. The skin must be both protected and hardened. Wool, or wool and cotton, must be worn near the skin, the feet particularly kept warm, no wet or moist feet per^ mitted, undergarments changed according to season and the INFECTIOUS DISEASES. 1<"9 alternating temperatures of 'days or weeks, and every night and morning. It is of the greatest importance to impress upon the minds of the very poorest that they must not wear during the day what they have slept in. Still, while protection is to be procured anxiously, vigor and strength is to be obtained by accustoming the surface to cold water. The daily morning wash may be warm in the beginning, and become gradually cooler; alcohol may be added to the water in the beginning (alcohol alone is unpleasant by its withdrawing water from the tissues), or salt. The temperature of the water being gradually diminished, the same treatment can be continued during the winter, with a pleasant sensation of vigor. The subsequent friction with coarse bathing towels sends a glow over the sur- face and through the whole body; it is desirable that, as much as possible, the patient perform it himself. The easiest way to start the habit is by washing, a short sponge- or shower-bath will take its place soon, and a cold plunge will be borne, even by the weak, afterwards. It has become fashionable with many to feign a contempt for internal medicines in the treatment of tuberculosis, pul- monary and otherwise. I am glad I cannot share their opinions. Thus, for instance, I look upon arsenic as a power- ful remedy in phthisis. It was eulogized as early as 1867 by Isnard, in a monograph, for its effect both in malaria and con- sumption, in both of which he explained its usefulness through its operation upon the nervous system. He claimed that sup- puration, debility, emaciation, vomiting, diarrhoea, and consti- pation would improve or disappear under its administration. The doses of arsenous acid used by him in the cases of adults amounted to from one to five centigrammes (one-sixth to five- sixths of a grain) daily. Arsenic is certainly a powerful remedy. It is known to act as a poison and a strong caustic. It prevents putrefaction, though as an antiseptic it ranks even below salicylic acid. It acts favorably in malaria, chronic skin-diseases, and maladies of 180 THERAPEUTICS OF INFANCY AND CHILDHOOD. the nervous system, and has considerable, and sometimes un- expected, effects in the treatment of lymphosarcoma and sar- coma. It is also said to improve sexual desire and power, and in animals physical courage. Thus there is a variety of effects the intrinsic nature of which may be found, uniformly, in the action of the drug on the function and structure of the cells, which, though varying in different organs, have the same nutritive processes. Arsenic has a stimulating effect on cell- growth. In small and frequent doses it stimulates the devel- opment of connective tissue in the stomach, in the bone and periosteum, everywhere; in large doses, by over-irritation, it leads to granular degeneration. Like phosphorus, arsenic builds in small doses, destroys in large ones. By fortifying the cellular and all tissues, both fibres and cells, it enables them to resist the attack of invasions, both chemical and parasitic, or to encyst or eliminate such enemies as have penetrated them already. Thus it finds its principal indication in the peculiar fragility of the blood-vessel walls resulting in pulmonary hemorrhage. The doses should be small. A child a few years old may take two drops of Fowler's solution daily, or a fiftieth or fortieth of a grain of arsenous acid for weeks or months in suc- cession. This amount may be divided in three doses, and ad- ministered after meals; the solution should be largely diluted. There is no objection to combining it, according to necessity, with stimulants, roborants, or narcotics, and to giving it for an indefinite period, unless the well-known symptoms of an overdose — gastric and intestinal irritation and local oedema — make their appearance. But they seldom will, particularly when small doses of opiates are judiciously added to them. In almost every case, perhaps in every one, it is desirable to ad- minister it in conjunction with digitalis. In the vertebrate animal, digitalis increases the energy of the heart-muscle and its contraction; thereby it increases arterial pressure and diminishes the frequency of the pulse. INFECTIOUS DISEASES. 181 By increasing arterial pressure it favors the secretion of the kidneys, improves the pulmonary circulation, empties the veins, thereby accelerates the flow of lymph and of the tissue fluids, and exerts a powerful influence on the metamorphosis of organic material, — that is, general nutrition. Besides, what it does for the general circulation and nutrition it also accomplishes for the heart-muscle itself. The blood-vessels and lymph circula- tion of the latter are benefited equally with the rest. Thus digitalis, while being called a cardiac stimulant, contributes largely to the permanent nutrition and development of the heart. This effect is not only of vital importance for the economy of the system on general principles, but an urgent necessity in view of the fact that there appears to be a relative undersize of the heart, either congenital or acquired, in cases of pulmonary tuberculosis; and there is certainly such a pre- dominance of the size of the pulmonary artery in the young, particularly over the aorta, that the normal succulence of the lung becomes pathological quite readily when the insufficiency of the heart-muscle tends to lower arterial pressure within the distributions of the pulmonary artery. The selection of the preparation to be administered is not always an indifferent matter. The infusion and the tincture are not always well tolerated by the stomach; digitalin, not being a soluble alkaloid but a glucoside, is not always reliable in its effects, and not of equal consistency and strength; a good fluid extract, or the ex- tract, are borne well and may be taken a long time. A child a few years old may take about two minims of the former daily, more or less, for weeks and months, or its equivalent in the shape of the extract (two-thirds of a grain daily); the latter can easily be given in pills, to be taken in bread, or jelly, and combined with any medicines indicated for special purposes, such as narcotics, or nux, or arsenic, or iron; the latter to be excluded in all feverish cases, or in all cases while there is fever. As long as there is no urgent necessity for a speedy effect, digitalis will suffice by itself; as a rule, it does not 182 THERAPEUTICS OF INFANCY AND CHILDHOOD. operate immediately in those small doses. The addition of strophanthus, or sparteine, or caffeine, all of which are speedily absorbed and eliminated, and exhibit their effects rapidly and without the danger or inconvenience of accumulation, will prove advantageous in many cases. Creosote was introduced into practice, both for inhalation and internal administration, since 1877. No direct influence on bacilli should be looked for. What it can do is to better the condition of the patient. It will often improve appetite, com- bat putrefaction, thereby facilitate assimilation, and (some- times) relieve diarrhoea. The doses vary. Almost incredible doses have been given (ten to fifteen cubic centimetres = two to four drachms daily and more to adults). Probably from two to ten drops daily is a dose for children, which, according to their ages, may be administered for a long time. The car- bonate of creosote, almost tasteless, and easily borne, is a proper substitute in as many grains. Neither ought to be persisted in when the appetite does not improve within a reasonable time, nor during a pulmonary hemorrhage, nor when the urine which requires frequent examination, contains, or is beginning to con- tain, albumin. These last seven years I replaced creosote by guaiacol, recommended by Schtiller, Sahli, and others, which forms nearly sixty per cent, of the very best creosote in the market. A child will readily take from six to fifteen drops daily (accord- ing to age) in from three to four doses. It is best taken after meals, in sugar-water, in milk, or in cod-liver oil. There are but few who object to it. Those who do may take one of its salts, the benzoate (benzosol), salicylate, cinnamylate, or car- bonate. Of these I have mostly employed the last, also the first. They are (almost) tasteless and readily taken, in doses of as many (or more) grains as the fluid guaiacol in drops. In guaiacol I have been less disappointed than in any other in- ternal remedy administered in pulmonary tuberculosis, cod- liver oil not excepted. It is a good stomachic, appetite and INFECTIOUS DISEASES. 183 digestion improve under its use, the cough gradually becomes looser, less purulent, the rales more mucous, and the body- weight is apt to increase. While creosote is not well tolerated in the stage of cavities and hectic fever, guaiacol is not only borne, but appears to exert its beneficial influence even in that condition. There are but few patients who do not derive some benefit from its internal use. Externally it has been recom- mended to subdue hectic fevers, for that purpose the chest and abdomen are painted with the pure guaiacol several times daily. It has the advantage over creosote of not being contraindicated either in hemorrhage or in renal complications.* I do not fear lest it be replaced by ichthyol (sulpho-ichthyolate of ammonium), which has been eulogized by Cohn, Scarpa, Le Tanneur, II. Fraenkel, and others. Adults (children in propor- tion) are expected to take 0.25 = four grains in a capsule before every meal, or twenty to forty drops four times a day of a solu- tion in equal parts of distilled water. In spite of the admix- ture of aromatic oil it has a bad taste and will be administered with difficulty only. After the failure of Koch's tuberculin several antitoxins and serums made their appearance. The tuberculocidin of Klebs and the serum of ITaragliano (which is said to contain no anti- toxin) have not conquered the universal good opinion of the profession any more than the cantharidin recommended by Liebreich. Koch's new tuberculin is introduced as containing the insoluble parts of the bacilli in finest mechanical disin- tegration, while the old claimed to be a glycerin extract of the bacilli. What it will do remains to be seen. A patient (adult) in Bellevue to whom I gave increasing doses, beginning with the minute doses recommended (one-fifth of a milligramme of the fluid) and rising to three minims, showed no reaction what- soever, though the autopsy proved the presence of extensive * See my paper in International Medical Magazine. November, 1S92, and Transactions of the Climatological Association, 1892. 184 THERAPEUTICS OF INFANCY AND CHILDHOOD. tuberculosis. Nor are the exaggerated promises held out for the old tuberculin repeated in the new. This is said by Koch to exert its influence in the very beginning of the morbid pro- cess in the lungs, when there is no complication at all with streptococci or septicaemia, and when the temperature of the body does not exceed 38° C. (100.4° F.). It is readily seen that under such circumstances there will be but few cases of pul- monary tuberculosis in children in which, because of the ex- treme difficulty of the diagnosis at that age, and in that stage, the remedy should be administered with any show of justifica- tion. What the tuberculin promised* by Behring will do for us remains to be seen. Other remedies have been used in great numbers. Specifics have been recommended, and symptomatic treatment was re- sorted to. The success of the latter depends on the judgment of the individual practitioner. No text-book or essay can teach more than general principles and their adaptation to the average case, and the measures to be taken in a number of exceptional occurrences. The indications for the use of nar- cotics, stimulants, expectorants, and febrifuges will change ac- cording to the cases and their various phases. In every case the necessity may arise for antipyrin, antifebrin, phenacetin, salicylate of sodium, or quinine. It may be necessary to decide the question whether the administration is to be made through the mouth, rectum, or subcutaneous tissue, or how their effects are to be corrected or combined. I have often found that a hectic fever would not be influenced by quinine, or by anti- pyrin, or salicylate of sodium. But the combination of the first with one of the latter would frequently have a happy effect. The change in our pathological views, or rather the addition of a new factor to our etiological knowledge, has directed our attention to the antisepsis of the respiratory organs. To de- * Fifteenth International Medical Congress, Berlin, session of June 10, 1897. INFECTIOUS DISEASES. 185 stroy bacteria is not necessary in order to make them relatively harmless. It is impossible to kill the bacillus without killing the normal cell, but very mild antiseptics suffice to stop the efficiency and proliferation of the parasite. Thus we can hope that the future will teach us how to reach the destructive pro- cess in the lungs. For the present, however, neither the inhala- tion of hot air or of hydrochloric acid, nor the rectal injections of sulphide of hydrogen have done any good. Turpentine in- halations are frequently beneficial by loosening, in some cases diminishing, expectoration from suppurating surfaces; as they haye the effect, mixed or not with eucalyptol or other disinfec- tants, of relieving the fcetor of pulmonary gangrene. The in- halations of compressed air will prove advantageous in chronic processes where the object is to expand the contracted lung tissue. Inhalations of ozone may render better services in future than A. Caille acknowledged in 1892 (Arch, of Ped., August, 1892). Late personal communications exj^ress them- selves very hopefully. (See p. 81.) Operative procedures are less indicated in pulmonary tuber- culosis of children than in that of advanced age. The opening of a superficial large and copiously secreting abscess is a rare indication, for the latter seldom occurs except in the semi- adolescent; and if it does, the prognosis is anyway absolutely fatal. Besides, the dissemination of the tubercular process is so general in the lungs of the young that not more than a slight temporary improvement can be expected of an operation. Among the localizations of tuberculosis in children that in the larynx is not frequent, but it is met with. According to Heinze, laryngeal tuberculosis is not produced by contact, but through the medium of the blood. But the expectorated masses are undoubtedly a frequent cause of the local infection. Besides nodulated inflammatory swellings in the mucous mem- brane, submucous tissue and glands, sometimes even between the muscles, there are small granulations and ulcerations on the cords, with universal catarrh, oedema, and phlegmonous 186 THERAPEUTICS OF INFANCY AND CHILDHOOD. destruction. The symptoms are those of catarrh and ulcera- tion, and depend on the locality and severity of the lesion. In some cases the diagnosis of pulmonary tuberculosis could not be made in" the beginning, and that of the local affection was based on the duration of the ailment, the persistence of the fever, and steady emaciation. At first the laryngoscopic exam- ination revealed catarrh only, and only later ulceration and infiltration. The local treatment is that of the catarrh, — inhalation of warm vapors, steam, turpentine, carbolic acid, muriate of ammonia; poultices around the neck; opiates at bedtime. The spray with lactic acid and the application of iodoform have served me less well than a daily spray of a solu- tion of one part of nitrate of silver in two to five hundred parts of distilled water. Stronger solutions are rather harmful. The pain produced by ulcerations located on the epiglottis and arytenoid cartilages is somewhat relieved by the application (brush or spray) of bromide of potassium, morphine, or cocaine, or of an appropriate mixture of two or three of them. The air around patients suffering from laryngeal phthisis may be moist; but it is a mistake to believe that it must be warm. Cold air is warmed before it enters the larynx and lungs, provided it enters the respiratory tract through the nares. Only when it is admitted through the mouth it remains somewhat cool when reaching the larynx. Thus the nares must be kept as normal as possible, and competent, no matter with what difficulties; nor will open windows interfere with the comfort of the patient, provided that draught is avoided. That can be easily accomplished by screens or otherwise. Ulcerations of the tongue and pharynx are painful sometimes to such an extent as to require frequent attention. A well- directed spray, as mentioned before, of one part of nitrate of silver in two hundred of distilled water (glass to be of neutral, blue, or black color), administered once a day, will be found serviceable in average cases. Some are so bad as to interfere seriously with deglutition. I have been obliged to use a co- INFECTIOUS DISEASES. 187 caine spray before every meal, or a drop of Magendie's solution on the tongue. For the purposes both of cure and of preven- tion the nose and nasopharynx should be irrigated, copiously and frequently, with a warm salt solution (6 : 1000). Tubercular ulcerations of the intestines may descend to the rectum; in that case the local symptoms, and mainly the te- nesmus, may be alleviated by warm injections containing gum acacia or bismuth, with or without opiates. Food and drink must be warm; bismuth may be given in doses of from two to ten grains every hour or two, so as to form a protection to the sore intestine. Tannin I have not seen to do much good. Naphthalin sweeps the whole length of the tract and acts favorably as a disinfectant. I have seen almost immediate im- provement after its use. From four to ten grains may be given daily (2-6 decigrammes). Now and then the stomach rebels against it; in that case, resorcin, in doses of from one-fourth to one grain (15-60 milligrammes), in a powder or in a solu- tion, may be given for the purpose of disinfection from three to eight times daily. Though it be very soluble, it certainly is effective to a certain extent. All of them may be combined with bismuth, or lead, or opium. Hydrargyrum bichloride can- not be relied upon for any effect in the lowest parts of the in- testinal tract because of its great solubility, the necessity of great dilution, and its ready absorbabilit} 7 . Salol in several daily doses of from one to five decigrammes (grs. l-J-8) is pala- table and effective. Fistula in ano is a rare occurrence in children under all cir- cumstances. I remember but two cases in tuberculous girls of about ten years. No matter whether it is an accidental com- plication, or the bacilli are conveyed to the parts through the circulation, or the fistula, is the result of the presence, in the fasces, of bacilli and of their action on defective epithelium, practice has changed entirely during the last decade. The axiom that fistula in a consumptive patient must not be inter- fered with has given way to a more rational theory and sounder 188 THERAPEUTICS OF INFANCY AND CHILDHOOD. practice. The sooner they are operated upon and treated the better. Pulmonary hemorrhages are not of so frequent an occurrence as in adults, but I have observed them in children of from three to eight years. A single instance of hemoptysis in a girl of eleven years proved fatal by suffocation. The applica- tion of a lump of ice or an ice-bag over the locality of the hemorrhage acts favorably, either through the direct influence of the cold temperature or the reflex contraction of the bleed- ing vessels. The subcutaneous injections of the fluid extract of ergot, or ergotin in glycerin and water, are very apt to give rise to induration or abscesses; thus it will be left to the practi- tioner to decide in an individual case whether that risk may be taken. Sclerotinic acid has been recommended for the same purpose. A syringeful has been injected hourly of a solution of one part in five of water. It is claimed that no local injury is done by it, but it is painful, and has been corrected by the ad- dition of morphine. The latter may be given internally also for the purpose of relieving the patient's symptoms, both objective and subjective. If it cannot be swallowed well, the proper quantity of Magendie's solution, not diluted in water, is readily absorbed through the mucous membrane of the mouth or throat. The internal administration of ergot may be supported by that of mineral acids and digitalis. Of the latter, a single dose of from two to five grains (1-3 decigrammes), or its equiv- alent, acts well. The dilute sulphuric acid is both efficient and palatable; ten or fifteen drops in a tumbler of (sweetened) water will be readily taken to advantage. Acetate of lead, in doses of one-sixth to one-half of a grain, every hour or two., according to age and the severity of the case, is preferable to tannin; it can be given with morphine or digitalis, or both. The patient requires absolute rest and encouragement, and must be induced to make long, forcible inhalations, and told to sup- press the cough as much as possible. To relieve it opiates may be required. For the purpose of stopping hemorrhages the in- INFECTIOUS DISEASES. 189 halation of the sesquichloride of iron (1-100) has been recom- mended. As it was not expected to enter the bronchial tubes, its effect was presumed to be by reflex action. I have tried it a number of times, like many others, but cannot recommend it. Ligature of the extremities tight enough to constrict the veins, but not the arteries, is quite effective sometimes, but should not be continued longer than half an hour at a time. Night-sweats are not uncommon in the tubercular phthisis of children of from five to twelve years of age. They are favorably influenced by the same remedies which are apt to relieve the adult; such are the sponging with vinegar and water, or alum in vinegar and water. A powder of salicylic acid three parts, oxide of zinc ten, and amylum ninety, or sali- cylic acid three, amylum ten to twenty, and talcum eighty to ninety, dusted over the suffering surface, is quite beneficial and soothing. For internal administration the dilute sulphuric acid, ten or fifteen drops in a tumblerful of water, is found en- joyable by a great many. A single dose of atropias sulphas one-half or one-quarter of a milligramme (one one-hundred-and- twentieth to one two-hundred-and-fiftieth grain) at bedtime, or agaric acid (4-10 milligrammes), duboisine (-J or 1 milli- gramme), or camphoric acid in doses of from five to ten centi- grammes will bring relief. Where there is an indication for opium, it may be combined with any of them. When the diges- tion is good, a fair dose of quinine (three to six grains), with or without extr. ergot, (the same dose), or extr. ergot, fluid, (one scruple to half a drachm), deserves a trial when for some reason or other the above remedies are discarded. 2. Syphilis. The nutrition of an infant suffering from hereditary syphilis is attended with great difficulties. Many of the mothers who contracted syphilis either before conception or during gesta- tion are anaemic in addition to their constitutional ailment; thus their milk is certain to be incompetent. The former class 190 THERAPEUTICS OF INFANCY AND CHILDHOOD. is very numerous, although women syphilitic before conception are apt to miscarry and have no living children. The latter class (those who contracted syphilis during their pregnancy) is not quite so large, fortunately; but still the question will come up now and then whether the baby of a woman who ac- quired syphilis in the course of her pregnancy should be nursed by her or not. The theoretical answer to this question has been this, that the baby may be permitted to nurse if it have been infected already, but must not be put to the breast if still healthy. That answer is no answer; for in most cases of such acquired syphilis, and even in the majority of hereditary syphi- lis (derived from a father syphilitic before conception), the first symptoms of the disease in the infant are visible after some, or many, weeks only. Thus, nobody knows whether the newly-born is infected or not. If such a baby be puny, feeble, and in poor general health, nobody would have the courage to deprive it of its mother's milk. Artificial feed- ing, as frequently carried on, would be a death-warrant. Thus, such a baby ought to be nursed by its mother, and, if excep- tions be permissible in favor of the puny, and the puny be ex- pected to thrive on its mother's milk, the vigorous baby's chance will be the better. Therefore I certainly advocate the baby's nursing at the breast of the mother who acquired syphi- lis during pregnancy, no matter whether the symptoms of the disease be visible in the baby or not. Meanwhile, both mother and baby must be subjected to a thorough and prolonged anti- syphilitic treatment. The same baby must not be put to the breast of a healthy wet-nurse, no matter whether symptoms have made their ap- pearance in the baby or not; or whether the baby has been subjected to an antisyphilitic treatment or not. For the nurse must not be exposed under any circumstances, without at least having been made fully aware of the risk she is running. The mother of a baby infected with hereditary syphilis is herself either syphilitic or not. If the latter, she is immune as INFECTIOUS DISEASES. 191 regards her infant, — that is, she will not be infected by her nursing syphilitic infant. In both cases she must and may nurse. For if syphilitic herself, she will not render the case of her infant more serious; if not, she cannot transmit a disease she has not herself. In neither case can she be infected by the diseased infant. In either case, both mother and child must be treated. In no case must a baby, either hereditarily syphilitic or sus- pected of hereditary syphilis, be put to the breast of a healthy wet-nurse. Syphilis contracted through the infection of the nipple is liable to be as destructive as that which attacks physi- cians through their fingers. Such a wet-nurse must be forbid- den to nurse altogether, or permitted only with a full knowl- edge of the circumstances, and directed, if she accept a place after all, to nurse through an artificial nipple. Meanwhile, the syphilitic or suspected baby must undergo an antisyphilitic treatment. If only suspected, but for good reasons, the treat- ment should not be postponed until positive symptoms may have made their appearance. For mercurial treatment is a less grave interference in the young than in the old, and nothing can be more reprehensible than the opportunity given to con- stitutional syphilis to obtain full sway. From what has been said of the many contraindications to the infant being brought up at the breast, it follows that arti- ficial feeding must often be resorted to. This circumstance impairs the prognosis considerably, and claims the best knowl- edge and soundest judgment of the well-informed practitioner. Improved methods of artificial feeding, however, improve the prognosis. The prevention of hereditary syphilis is based in part on that of syphilis in general. Public hygiene is not benefited, as they try to do in New York, under the guidance of a combination of ignorance and hypocrisy, by disseminating venereal diseases throughout the whole city; but by wise superintendence and control of the "social evil." A syphilitic person must not 192 THERAPEUTICS OF INFANCY AND CHILDHOOD. marry. When a man has contracted syphilis he ought to be treated methodically two years, and before he marries three years ought to elapse after the last symptoms of syphilis were noticed. During pregnancy in suspected wedlock, both man and woman ought to be treated. Preventive treatment is required both on the paternal and maternal side. Syphilitic endometritis leads mostly to mis- carriage; when the embryo and foetus survives, the newly-born exhibits syphilis at once. Women infected during pregnancy may, or may not, infect the offspring, according to the time of their own primary and secondary symptoms. It is impossible to be sure. In all of these cases a thorough and protracted antisyphilitic treatment is required. For practical reasons, for women with habitual abortion, where the diagnosis cannot be positively made, I advise and practise mercurial treatment. Most cases of hereditary syphilis, however, are derived from the father. It is he who has to undergo a strict and effective treat- ment for the purpose of extinguishing the calamitous malady. The medicinal treatment of hereditary syphilis requires the several preparations of mercury, in many cases iodides also. Mercurial preparations are well borne by infants and children. Stomatitis and gingivitis are very exceptional occurrences. The indications, modes of administration, and doses of the remedies depend, to a great extent, on the locality or organ affected, whether skin, mucous membrane, subcutaneous tissue, lymphatic glands, muscles, bones, the viscera of the thoracic or abdominal cavities, the nervous system, or the sensory organs; and on the time at which the first symptoms become percep- tible. In the majority of cases this takes place between the fifth and eighth weeks of life. Then the nose, lips, and anus ex- hibit rhagades; these fissures are apt to be quite painful; the skin is getting covered with roseola, the palm of the hand and sole of the foot with efflorescences; the complexion becomes sallow without being uniformly so at all times, for indeed changes and a certain degree of intermission are observed. INFECTIOUS DISEASES. 193 After a while maculous, squamous, and papulous eruptions make their appearance, pustules and vesicles spring up and terminate in ulcerations, gummata appear in the skin. This form permits of a fair prognosis, particularly in the cases of infants reared at the breast. The treatment can be carried out slowly and systematically. It consists in the internal administration of calomel; doses of from one-twentieth to one-sixth of a grain can safely be given three times a day, for months in succession. If in any case diarrhoea were to set in, and no fault be found in the food administered, or in the condition of the digestive organs which may have been impaired by other causes, from a twentieth to a twelfth of a grain (3-5 milligrammes) of Dover's powder may be added to each dose. Other preparations which have been recommended, are the bichloride and the cyanide in doses of from a one-thousandth to a three-hundredth of a grain several times daily. The green iodide of hydrargyrum is not so well tolerated as calomel, and the oxidulated tannate of mercury, recommended by Lust- garten, does not seem to offer any advantages. As these pages> however, are being written for practical guidance, and not for the elaboration of the history of therapeutics of infant syphi- lis, I can but advise the use of calomel as effective and suffi- cient. The use of the blue ointment has been eulogized under the impression that the internal administration of the drug might lead to digestive disorders. As inunctions made in the usual way were found to irritate the skin (oleates are objec- tionable for that reason alone), it was recommended to apply it to a sheet of soft leather surrounding the knee, and to secure its slow absorption by the spontaneous movements of the baby's extremities. Thus the treatment is left to a great extent to the patient, and the actual dose cannot, to say the least, be determined upon or even estimated. TYiderhofer modifies in- unctions by applying a mercurial plaster of the size of the hand, which he changes once a week, to the intrascapular re- 13 194 THERAPEUTICS OF INFANCY AND CHILDHOOD. gion, and praises his results. When the skin is badly affected, from one to two grammes (grs. 15-30) of the bichloride of mercury may be added to the daily bath of the infant. This external treatment also may be continued for weeks. A similar treatment is required in those cases in which an infant or child (in the latter in larger doses) has acquired syphi- lis in one of the many ways in which the disease can be con- tracted. The ritualistic sucking out of the circumcised prepuce has given rise to syphilis as it has produced tuberculosis; syphi- litic nipples of a mother or nurse, vaccination, kissing, the brushing of the throat with infected instruments, in older chil- dren sexual contact, are much too frequently causes of syphilis. This acquired syphilis of infancy and childhood is apt to run a swifter and more deleterious course than the same disease in most adults. Therefore it may become necessary to add to the above treatment such methods as have proven most effective and speedy in the most urgent cases of hereditary syphilis also. These urgent cases run a different course from those briefly sketched above. In many of them the diagnosis of hereditary syphilis can be made immediately after birth. General pem- phigus of the surface of the newly-born is not a symptom of syphilis, but localized pemphigus of the palms of the hands and the soles of the feet is. It is but seldom the only symptom, though it requires often a close observation not to overlook the affections of internal viscera and the bones. The latter are often the seat of syphilitic disintegration; in the costo-carti- laginous junctures Wegner studied the changes worked by syphilis, which resemble very much those of early rhachitis. Liver, spleen, pancreas, and lungs exhibit two different changes, either gummata or intestinal proliferations of the con- nective tissue. In the liver these are mainly met with along the blood-vessels and bile-ducts, and capable of producing jaun- dice, and even total and permanent obstruction of the ducts in the foetus or the newly-born. An early tumefaction of the spleen was the first prominent symptom in one of my cases. INFECTIOUS DISEASES. 195 Twice I have seen both testicles the seat of syphilitic tumors in the newly-born. The blood-vessels suffer at an early period. The syphilitic arteritis, first described by Heubner, gives rise to congestions and hemorrhages (petechia? and purpura) on skin and serous membranes, in the intestines and kidneys, in the cranium, and in the thymus gland. And many early brain symptoms and sudden deaths of the newly-born are due to intracranial hemorrhages, oedema, and softening from the same causes. Nor have the sensory organs of the newly-born any immunity. C. S. Bull has met with iritis and choroiditis. These are the cases in which the systematic calomel treat- ment is insufficient. In them it is of the utmost importance to get the system immediately under the influence of mercury. With or without the internal treatment subcutaneous injec- tions of mercury must be made at once. The subcutaneous in- jections of calomel, which I, like many others, have tried in the adult, have given me, contrary to many assertions of its spon- sors, so much trouble in the shape of abscesses or indurations, that I cannot bring myself to recommend them in the newly- born, with its spare connective tissue. But a solution of from one to two grains of bichloride of hydrargyrum in an ounce of distilled water (1 :'240) is quite innocuous. It can be safely injected once or twice daily, in doses of from one-hundredth to one-fiftieth of a grain (1-2 milligrammes). That treatment I have followed in many an urgent case more than two dozen years, and can safely recommend it. No reliance should be placed on mercury given to the mother or nurse, for its elimi- nation through breast-milk is an uncertain process and an un- known quantity. When the bones and glands suffer at an early period, the mercurial treatment ought to be combined with the adminis- tration of the iodides. Potassium iodide may be given to the infant in doses of from five to twenty grains (3-6 decigrammes) daily. Under all circumstances, the treatment has to be per- sisted in many months after the disappearance of the very last 196 THERAPEUTICS OF INFANCY AND CHILDHOOD. symptoms. In spite of that the constitutional disorder may break out again, either in its original form, or as an osteitis only, leading either to caries or to sclerosis; or as a cerebral or spinal affection. That is why, when the symptoms have dis- appeared, recovery should not be taken for granted. After it seems to have been accomplished, the patient may be left alone for a month or two. Then the treatment ought to be resumed similarly to what we ought to do in the case of an adult who should not be considered safe until years have elapsed without a symptom. Syphilitic arteritis, meningeal exudation, or gum- matous tumor may lead to ptosis, nystagmus, facial paralysis, hemiplegia, hemichorea, or idiotism; to myelosclerosis or trans- verse myelitis. A syphilitic inflammation of the labyrinth with Meniere's symptoms has been observed in a girl of five years by Knapp, and interstitial keratitis, also retinitis, appears to result from syphilis quite often. A painless otitis media was noticed by Fournier. In all such cases the energetic treatment with mercury and iodides combined has to be resumed, and continued for an indefinite period. But it has often appeared to me that syphilis will do more than produce those unmistaka- ble symptoms. There are many cases of "scrofula," chronic lymphadenitis, and rhachitis which — with no other causes to account for them — appear to point to previous syphilis not completely extinguished. In a number of my own cases I have personal knowledge of such a history. Such cases do not only explain the fact that many old authors recommended mercury in "scrofula" and "rhachitis," but also that there are some in which that treatment is indispensable. But lately I had to deal with chronic cervical adenitis, mainly of the left side, and pul- monary infiltration of the left upper lobe, in a baby of two' years. They resisted the usual treatment for more than a year before the suspicion of its syphilitic nature was roused and the history of the disease elicited. Six weeks of a mercurial and iodide treatment have worked a miraculous change in the local and general condition. INFECTIOUS DISEASES. 197 3. Intermittent Fever. In older children it has the same type as in adults. We have acute and chronic forms, the quotidian, tertian, and quartan types. There are the same results and anatomical lesions. There is the general anaemia, in infants and children most rapid and detrimental, the splenic tumor, the hemor- rhages, the amyloid degeneration. It is only in the newly-born infants and very young children that the diagnosis becomes difficult. In them the type is mostly quotidian. Besides, the attack may come at irregular times. Not infrequently is it seen in connection with catarrhal dis- eases, which appear to create a susceptibility to the poison. The chills are not easily diagnosticated. Perspiration is very frequently not profuse. The tumor of the spleen can be recog- nized by palpation at a late period only, but the temperature is apt to be very high. Sometimes the attack is not recognized, because of the first symptom being a convulsion. Masked cases are not uncommon; intermittent pneumonia, neuralgia, even paralysis have been observed. Holt observed intermittent tor- ticollis and bronchial asthma. Attacks of vomiting, also diar- rhoea have been noticed. For all these reasons the diagnosis is often not made. On the other hand, the diagnosis of malaria is made improperly in too many instances. In every doubtful case the blood should be examined for plasmodia. The subse- quent severe anaemia, as blood-cells are rapidly destroyed, is liable to be very obstinate. Among the sequelae glomerulo- nephritis is not uncommon. Quinine ought to be given, if the attacks come at regular intervals, in a single dose, three or four hours before the attack. That is the time when the plasmodia are small and movable. If they occur at irregular periods, it is better to divide up the total amount of quinine in three or four doses, to be given through the day. In the first case a dose of five grains (3 decigrammes) will suffice for a child of three years; in the 198 THERAPEUTICS OF INFANCY AND CHILDHOOD. second case eight or ten grains (5 decigrammes) will be re- quired. It is not always easy to give quinine because of the taste. A solution ought not to be tried for the same reason. Ona part of the sulphate of quinine may be given with forty parts of elixir simplex, but in every case the dose must be mixed just before given. The neutral tannate of quinine is tasteless, and may be given as a powder, but for one part of the sulphate two and a half of the neutral tannate should be administered. The sulphate may be given mixed in chocolate — older children will take it greedily — or in coffee or syrup of coffee. When it can- not be given internally, rectal injections may take the place of the internal administration. No acid must be added to the solution; therefore very soluble preparations only must be used, for instance, the bromide, the muriate, the bisulphate, the carbamide; or suppositories can be given, but with less positive effect than that of other modes of administration. In- unction of quinine has been recommended a great many times. The ointments made as usual with animal fats have but very little effect. Where it would be impossible to use any other method, quinine might be dissolved and mixed with fat and a larger quantity of lanolin; but even in this case the dose which really penetrates the skin and enters the circulation cannot be determined. A subcutaneous administration of quinine be- comes necessary when no other can be resorted to, or when an immediate effect is required. The best preparation for the pur- pose is the carbamide, which will dissolve in from four to six parts of warm water, and give rise to less induration than we are liable to meet with when using the other salts. When re- covery appears to be established, it is advisable to give a weekly dose of the drug for some time. In the chronic form arsenic is the principal remedy, as in the cases of adults. A child of three years may commence with one drop of liquor potassii arsenitis (Fowler) three times a day, to be administered as detailed in a former chapter. The liquor INFECTIOUS DISEASES. 199 sodii arsenatis of the Pharmacopoeia may take its place in those cases in which the stomach is very irritable; also the prepara- tion of the same name as introduced by Pearson, which is ten times milder than the officinal preparation, and must be given in proportionate doses. If the solutions of arsenic be not well tolerated, the arsenous acid may be given instead. It may be administered in the shape of pills in doses of one one-hundred- and-hftieth to one-hundredth of a grain, three times a day, or more, to children of three years, or it may be administered as a powder in combination with other medicines. It may be safely mixed with bismuth, for the disagreeable odor emanating from persons taking bismuth, which has been attributed to arsenic contained in the bismuth, really belongs to a minute dose of tellurium inseparable from some specimens of bismuth in the market. All these preparations of arsenic may and should be given for many weeks or months. Constitutional symptoms belonging to an overdose I have seen more frequently when using Fowler's solution than any of the other preparations, but, after all, they are rare. Tincture of eucalyptus has been given in acute, and particu- larly in chronic, cases. It renders good service now and then in doses of from ten to twenty-five drops, three or more times a day. Methylene blue is unreliable. As there are very obstinate cases in the adult, so there are in children. In them, too, the spleen may remain large and the attacks return indefinitely. These are the cases which try the endurance of the patient and the patience of the physician. In them I have seen excellent results from the use of ergot these forty years. Ergot may be given as fluid extract, and then a child of three years may take from a scruple to a drachm (4 cubic centimetres) every day for weeks in succession, or a corresponding quantity of the extract of ergot. — that is, from three to ten grains (2-6 decigrammes) every day, either in mixtures or, for older children, in pills. I have noticed in a good many cases, in which the fluid extract was not tolerated 200 THERAPEUTICS OF INFANCY AND CHILDHOOD. at all, that the extract of ergot, when given in the latter shape, was easily tolerated. Subsequent anaemia demands the syrup of iodide of iron and other medicinal and hygienic treatment. 4. Typhoid Fever. Though occurring in the first few weeks of life, it is rare in the first years. Most cases are met with between the sixth and the twelfth year. Its danger may come from many causes; from previous ill health and anaemia, which may depend on a feeble constitution, hereditary syphilis, chronic ailments of the organs of digestion, of respiration, and of circulation; from the intensity of the invasion, which sometimes is manifested by a high initiating temperature, and early septic symptoms; from an unusually high temperature; from insufficient power or actual failure of the heart; from diarrhoea, intestinal hemorrhages, perforations, and local or general peritonitis; from complications such as meningitis and nephritis; and, finally, from consecutive dis- eases. The uncertain symptoms of the first days render the diag- nosis difficult. Sometimes it is made by exclusion only. If a characteristic curve of the typhoid fever, the tongue of infec- tious fevers, diarrhoea, tympanites, large spleen, roseola (appear- ing between the sixth and the eleventh day), and a positive diazo test are present, it is not doubtful. It may be difficult to detect a pneumonia even after days, but after a while local symptoms will permit a differentiation. Miliary tuberculosis may be mis- taken for a severe case of typhoid fever, but when it is localized in the cerebral meninges, the slow and irregular pulse, vomit- ing, constipation, and diminished action of the kidneys secure the diagnosis of tubercular meningitis. There are, however, cases in which the general symptoms do not seem to agree with the elevation of the temperature and other symptoms. I know of no other serious and protracted disease in which the patients INFECTIOUS DISEASES. 201 will quite often declare themselves to be so well in spite of marked objective symptoms to the contrary. Widal's test, though not positive and mostly available in the second week only, is suggestive of the presence of typhoid fever. The dem- onstration of the bacillus, if well distinguished from bacterium coli commune, is proof positive. Preventive treatment has led to very good results. Many houses and towns which were the seats of endemic typhoid fever have been rendered immune by improving the sewerage and the condition of the neighborhood. For typhoid fever and dysentery can be traced positively to exhalations of privies and sewers, while with regard to other diseases we can only say that animal exhalations from the same sources may create a predis- position by impairing the general health, but are not able to produce specific diseases independently of other influences.* Where the drinking-water is suspected, it ought to be boiled. No raw milk should be given. The faeces of the patient must be disinfected, though there be no diarrhoea, by crude muriatic acid, or a five-per-cent. solution of carbolic acid, or by copperas. The sick should be isolated when they suffer from typhoid diar- rhoea, and the practice still prevalent in hospitals to place many typhoid patients in general wards should be abolished. Can typhoid fever be aborted? or, in other words, can its first stage be interrupted? An affirmative answer to this ques- tion has often been given, but it is difficult to prove the correct- ness of the diagnosis in an alleged case of typhoid fever that lasted a few days only. While with our present knowledge we cannot believe that the proliferation of the toxin floating in the blood may be interrupted by antifermentative treatment, it is certainly either justifiable or advisable to try the effect of other- wise not injurious anti ferment atives, such, perhaps, as creosote or hydrochloric acid, if it were only for their effect on the intes- * A. Jacobi, "The Production of Diseases by Sewer Air," Transactions of the Congress of American Physicians and Surgeons, 1894, and N. Y. Med. Journ., 1894. 202 THERAPEUTICS OF INFANCY AND CHILDHOOD. tinal tract. As regards the early administration of a large dose of calomel, its effect is notoriously good, no matter whether it acts as a disinfectant directly on the toxin, or whether it simply relieves the intestinal tract of the toxin introduced and in progress of proliferation. A child of three years may take a dose of three or four grains (two or three decigrammes); a child of eight years one of seven or eight grains. While the purgative effect of the calomel can be obtained by simply in- troducing the powder into the mouth, there to be absorbed, it is better in this case to let it be swallowed. It can be safely given during all of the first week of the disease. When, as fre- quently, there is constipation during the course of the disease, calomel is no less beneficial, but then it should be given in smaller doses, which may be repeated. During the diarrhoea of the second or third week it should not be given. With regard to the general treatment of the typhoid fever of children, we are equally liable to injure either by overactivity or by neglect. The so-called expectant treatment has its great dangers in the hands of those who make it their invariable rule; it is safe in the hands of those only who have learned to treat the sick rather than the sickness. The air in the sick- room should be cool, the windows open. Draughts, it is true, should be avoided, but screens around the bed will permit the opening of both windows and doors. The bed-sheets must be smooth; four or eight safety-pins will fasten them to the cor- ners and sides of the mattress. At an early period the whole surface ought to be washed oftentimes either with water or with alcohol and water. The hair, when long, ought to be cut. The children should be allowed plenty of water. Those who are liable to have dry lips and tongue must be made to drink a small quantity of either water or dilute muriatic acid in water, ten minims to the tumblerful, every ten or twenty minutes. Fissures around the lips or in the tongue ought to be washed with a saturated solution of boracic acid, or, when bleeding, should be painted once a day with a mild solution of nitrate of INFECTIOUS DISEASES. 203 silver (not more than one per cent.), the lips also with an oint- ment consisting of boracic acid and lanolin. Very much depends on the mode of feeding. Xo solid food must be given. Boiled milk, milk on the Eudisch plan, broths, farinaceous decoctions, strained. For older children, one or two soft-boiled eggs diluted in broth, either the whole of them or the white only; meat-juice, albumoses. As a general thing, more albuminoids than carbohydrates ought to be given. The food should be so arranged as to be digested in the stomach and small intestines, and not encumber the colon. If necessary, a small quantity of pepsin and muriatic acid may be given with it. Peptones may be given, but they must not form anything like the exclusive diet. I allow no solid food before ten days have elapsed after apyrexia set in. The tendency to complications with bronchitis requires fre- quent changes in the position of the patients. They ought to be turned from their backs to their sides every few hours, and back after a while; otherwise they ought not to be moved too much. Particular care ought to be taken not to raise them too often. Physical and mental rest is an absolute necessity. Def- ecation must take place in the recumbent posture. They must not be permitted to strain. Some warm tepid antifermentative injections should be made daily into the bowels (thymol 1 : 2000). The danger arising from high temperatures varies in different patients. Their injurious influences depend, from a clinical point of view, on many causes, foremost among which are both individual susceptibility and the length of time during which the child is exposed to its internal heat. A high temperature lasting but a certain time, and alternating with either an inter- mission or a remission (as, for instance, intermittent or relaps- ing fevers), may not prove dangerous at all, and may not re- quire any treatment. But the frequent repetition of elevated temperatures, or their long duration, demand interference. Therefore they ought to be measured at least four times a day, 204 THERAPEUTICS OF INFANCY AND CHILDHOOD. particularly as typhoid fever is apt to yield two daily exacerba- tions and remissions. Continued high temperatures in the course of typhoid fever, or intense fever at the very beginning of the disease, require treatment. In them the frequency and quality of the pulse, and the functions of the nervous system, are seriously disturbed at an early time. Under the influence of a cold bath both tem- perature and heart-beats diminish, arterial pressure increases, and the intellect becomes clear; it has a peculiarly favorable influence on the infant and child. In them the surface is rela- tively larger than in adults, and the cooling is more rapid and intense. The circulation is easily disturbed, the surface tem- perature not readily restored afterwards. It may happen that the internal temperature rises while the external blood-vessels are contracted by cold, and the internal organs become en- gorged. In those cases a hot bath is more liable to restore radi- ation from the skin and reduce internal heat. Whenever no immediate reaction takes place, — mainly about the extremities, — after the child has been taken from the bath, this must not be repeated, and the feet kept thoroughly warm. In such cases a warm bath is infinitely milder and more useful; or where the temperature is high and threatening, a cold pack — as detailed in a former chapter — around the trunk is preferable. At the same time the feet must be kept warm and a stimulant given. Cold applications to the heart are frequently sufficient to re- duce the temperature. In such cases as develop sopor at an early period, together with high temperatures, the pouring of tepid or cool water over the head, or head and shoulders, is very beneficial. The contraindications to the use of the cold bath are general debility, weakness of the heart, cold extremities, a cold surface, complicated with high internal temperature, and intestinal hemorrhage. The medicinal agents used to reduce temperatures in typhoid fever are salicylate of sodium, antipyrin, antifebrin, phenacetin, and quinine. Kairin and thallin deserve no recommendation, INFECTIOUS DISEASES. 205 for the reason that, while their effect is no better, their efficacy is soon exhausted, and the drug has to be repeated after very short intervals. All of the medicines mentioned above must be given carefully. To avoid a possible debilitating effect on the heart, a general or cardiac stimulant should be given at the same time. All of them may be given in small doses, and frequently repeated, when the remission is not marked; but as a rule an occasional larger dose is preferable. Antipyrin can be administered internally, through the rectum or, if urgently de- manded, subcutaneously. A child of three years may take from eight to twenty-five grains (one-half or one and a half grammes) a day, in from two to four doses, two of which have often to be given in close proximity (the second after an hour or two hours). The dose of antifebrin is but one-third or one- quarter of that of the former. It is, because of its more diffi- cult solubility, not available subcutaneously, and less so than antipyrin, in the rectum. Phenacetin may be given in doses of from one to five grains (five to thirty centigrammes), twice or three times a day, to a child of the same age. The adminis- tration of quinine follows, as a rule, the method detailed above, but in typhoid fever it is liable to disorder the stomach and intestine and produce diarrhoea or tenesmus. Its time is the remission, its single dose from five to seven grains (half a gramme or less), once a day or every other day. and its best in- dication the persistence of the splenic enlargement in the course of the third week of the disease. The combination of quinine with one of the other antifebriles yields good results quite often when one of them does not appear to be sufficient, in the same way that the effect of a tepid bath combined with an antifebrile is, now and then, quite astonishing. The intestinal tract is the seat of many dangers. Tympanites and meteorismus depend on the paralytic condition resulting from enteritis only, or from enteritis and peritonitis. The lat- ter is either local, and corresponds with the local ulcerations, or general. Cold applications are serviceable. Enemata of ice- 206 THERAPEUTICS OF INFANCY AND CHILDHOOD. water will sometimes do good; or of an aromatic infusion (chamomile, anise, fennel, catnip); sometimes of turpentine, half a teaspoonful or a tablespoonful mixed with the fluid (water, or soap and water). The introduction of a large catheter, with one or more additional eyes, may relieve the lowest part of the intestine of gas. Puncture of the inflated intestine by means of a small syringe ("hypodermic") is not dangerous in such cases where it is not required. Where it would be of service, however, — that is, in the very worst forms of intestinal paral- ysis, with intense and dangerous inflation, — it is injurious. For in these cases the elasticity of the intestinal wall is gone, and the small punctures in the intestinal wall remain open. I have seen faeces entering the abdominal cavity through them, and fatal peritonitis, of my own making. Diarrhoea, when moderate, need not be interfered with in any period of the disease. It is probable that the initial dose of calomel prevents it in a great many cases. When it is copious, such remedies as pass through the whole length of the intestine will render good service either by their soothing or disinfectant effect. Subnitrate or subcarbonate of bismuth, from a scruple to a drachm daily (one to four grammes), are valuable. Salicylate of bismuth does not always act kindly in the stomach. Naphthalin, half a grain to a grain (three to six centigrammes) every two hours, when tolerated by the stomach, — in most cases it is, — improves the odor of the evacuations and diminishes their number. In many cases I have given it, for its disinfectant action, from the very beginning of the fever. Salol, in doses of from one to three grains every two hours, has a similar effect. Mild doses of opium may be added, from half a minim to a minim of the tincture, every two or four hours. Eesorcin is better tolerated than either, but it does not pass the whole tract. Cold applications, covered with rubber cloth and (or) flannel must be changed every twenty or thirty minutes. Warm applications may take their places when the little patients are quite feeble and anaemic. Among INFECTIOUS DISEASES. 207 the astringents, when required, I prefer acetate of lead in small doses of five or more milligrammes each. Both tannin (gallic acid is milder) and alum are liable to annoy the stomach. Constipation is much more frequent in our cases of typhoid fever in both the young and old than in the descriptions of the books, both European and copied. When not too persistent it is not objectionable; for most children have not suffered from constipation before the disease began, and accumulation of faeces is not a very prominent feature in them. When there is peritonitis it must not be disturbed, at any rate. In no case must strong purgatives be given. Castor oil in small doses may become necessary; half a teaspoonful or a teaspoonful, every few hours, may then be given, or small and repeated doses of calomel, from a quarter to one-half of a grain. Eectal injec- tions of tepid water, with, or mostly without, turpentine or thymol, will be all that is required in most cases. Perforations require the treatment best adapted to eutha- nasia, — viz., opium and stimulants; (mostly) cool applications to the abdomen, and hot ones to the feet. Maybe an occasional case will be saved by surgical interference. Hemorrhages are not so frequent, as in the typhoid fevers of adults, in those of the very young, because of the superficial character of the ulcerations. But in older children the intes- tinal lesions are apt to be as grave as in more advanced periods of life. No food should be given for some time, drink in small quantities only, but repeatedly. Applications of iced cloths, an ice-bag, or a lump of ice — to lose no time — to the right hypo- chondrium. They may be moderately heavy, for compression may have a local influence. Hot injections into the rectum have no styptic effect, iced ones may act through reflex. In- ternally, alum or lead, one-quarter or one-half grain (fifteen to thirty milligrammes) or more, every hour or two hours, with opium and digitalis. Ergotin, or fluid extract of ergot, and other preparations of the drug which were claimed to be in- nocuous, I have seen to give rise, frequently, to indurations or 208 THERAPEUTICS OF INFANCY AND CHILDHOOD. abscesses after their subcutaneous administration. Their effect is mostly questionable. I have seen gangrene over a large sur- face after their use, and pyaemia several times. In the case of a little girl, I had to incise about sixty metastases in the course of two months before she was saved from a pyaemia which resulted from a single hypodermic injection. The in- ternal administration of ergot may be tried when the condi- tion of the stomach permits it. Subcutaneous injections of sclerotinic acid (one to five) have been recommended; they are painful. To counteract the imminent fatal termination I have been compelled to perform transfusion of blood in the case of an adult; she recovered, but died on the fiftieth day of a relapse. Injections into the subcutaneous tissue of large quan- tities of sterilized salt water (6 : 1000) yield most surprising and life-saving effects in urgent cases of utter exhaustion. The condition of the heart cannot but influence the course of the disease, its complications and consecutive disorders. It cannot help being enfeebled by a serious and protracted disease such as typhoid fever; still, how far this feebleness will extend cannot be predicted. Besides, it depends to a great extent on causes not exactly connected with the infection itself. Among these accessory causes are original — congenital — debility and chronic heart-diseases previously contracted. Besides, the in- fection itself with its accompanying fever is apt to give rise to an acute myocarditis, or to granular degeneration of the heart- muscle. Among the symptoms of debility of the heart, which may easily lead to complete heart-failure, are pallor of the skin and of the mucous membranes, purplish and cyanotic hue, par- ticularly of the lips, ears, and finger-ends, mottled appearance of the surface depending on venous stagnation in the small blood-vessels, cold extremities and nose, slow or, more com- monly, frequent pulse, which, moreover, is arhythmic, and a heart-beat the sounds of which are either split or embryocar- diac, — that is, exhibiting equal intervals between the first and second sounds. In other cases the danger is indicated by the INFECTIOUS DISEASES. 209 close proximity of the second sound to the first to such a degree that the former is scarcely audible. The brain symptoms belonging to heart-failure are those of anaemia. When beginning to treat them, we should not forget the possibility of an error in the diagnosis of the condition, which may be quite serious, because the signs of anaemia and hyperaemia are in many respects the same. However, the gen- eral indications for the treatment of heart-failure may be laid down in a few rules, the first of which refers to prevention. As heart feebleness must be expected in every protracted dis- ease, and failure feared in many, we ought to act, as a matter of prevention, exactly as the surgeon does in his operations. Before the times of antisepsis and asepsis there were performed a great many operations that would not lead to sepsis or erysip- elas. Indeed, these mishaps were the minority, perhaps a small one at that. But they did occur, and that is why no surgeon would at present perform any operation, either serious or trifling, without measures to secure asepsis. If he neglected them, he would justly be held responsible for any mishap in the shape of erysipelas or pyaemia. Now, the certainty of cardiac debility and the danger of heart-failure are much more threatening in an infectious fever than those complications of convalescence after an operation. Therefore in no case of typhoid fever ought the heart to be left alone to fight its own battle unaided, with the chances of being overexerted (with possible hyper- trophy from that cause), fatigued, or exhausted. The doses of cardiac stimulants cannot be stated categorically, but the prin- ciple must be established that it is a good rule to give moderate amounts of digitalis, strophanthus, convallaria, sparteine, caf- feine, or an alcohol beverage. The particulars have either "Been stated in a former chapter or must be left to the judgment of the practitioner. Digitalis and strophanthus may derange the stomach after a while; digitalis may not act quickly enough under certain circumstances; in such a case sulphate of spar- teine, which is readily dissolved, absorbed, and eliminated, in 14 210 THERAPEUTICS OF INFANCY AND CHILDHOOD. doses of one-tenth to one-half of a grain (six to thirty milli- grammes) every one, two, or three hours will render good ser- vice. Caffeine must not be given when there is hyperemia of the brain. The sodio-benzoate and sodio-salicylate of caffeine dissolve readily in two parts of water, and are reliable aids in sudden attacks of heart-failure, in hypodermic administration. (Dose: five to twenty centigrammes.) Camphor internally, in doses and according to methods described before, will answer well in either the presence or absence of pulmonary complica- tions. In cases of emergency its subcutaneous administration works admirably in sweet almond oil, in a twenty-per-cent. solution. Carbonate of ammonium disorders the stomach more fre- quently than camphor is apt to do. Muriate of ammonium has no stimulant effect at all. Brandy and whiskey, when of good quality and well diluted (at least one in four or five parts of water or milk), hold the first rank. That they should, while sufficient doses must be insisted upon, not be given at all unless indicated, and omitted as soon as no longer wanted, is self- understood. Still, I know that they are often continued too long, and the occurrence of cirrhosis of the liver in children who exhibited no other cause of the disease except the pro- tracted use of alcohol for alleged medical reasons, are by no means unheard of. Champagne will often take the place of brandy and whiskey when speedy stimulation is required, or Tokay, Madeira, Sherry, or a California wine, when the former are objected to because of their taste. When there is diarrhoea, opium given in small doses, perhaps half a minim of the tinc- ture every hour or every two hours, to a child of three years, will act both as a cardiac stimulant and astringent. Of Sibe- rian musk as a powerful stimulant I have seen the best possible results. Nitroglycerin in doses of a two-hundredth or one- hundredth of a grain, repeated frequently until four or six doses have been taken, will be found a vigorous remedy when, while the heart is still acting, the arterial pulse is flagging. INFECTIOUS DISEASES. 211 Whatever medicines may be found desirable, the child should be kept absolutely quiet. In a recumbent posture it has to remain, as a rule; thus the food has to be given, thus it has to be carried to the window, or into the open air, if circumstances permit. Many a case that looked like being near extinction within the four walls will exhibit a wonderful improvement on the lawn or under shade-trees. Besides, the surface has to be kept warm. It is principally the extremities which require external heat. A hot bath, with- out or with an aromatic addition, and hot injections into the bowels will do a world of good in many a desperate case of col- lapse, always provided that the manipulations required are ab- solutely gentle and not exhausting. To relieve inflammatory complications of the brain in ty- phoid fever the hair ought to be cut very short, the head kept application of ice-water directly to the heads of small children may be washed frequently, or water poured over it while the body and throat are protected by an india-rubber cloth. The application of ice-water directly to the head in small children is not tolerated for a long time. It may give rise to collapse, and should be watched carefully. While the head is to be kept cool, the feet must be kept warm. Mustard foot-baths and hot applications to the feet, cold water or an ice-bag to the heart, an ice-bag around the neck, will be found very comfortable. When there is the slightest brain complication not depending on the infection itself or anaemia, no alcohol should be given, no opium, and no caffeine, though it may appear indicated by the condition of the heart. The head ought to be kept Eigh (low in anaemia), and it is sometimes necessary where the men- ingitic symptoms are quite clear to resort to local depletion. In these cases the leeches may be applied to the mastoid process or, better still, to the septum narium. Where the brain symp- toms belong to the infection alone, or to anaemia, opium, how- ever, is well tolerated, and relieves sleeplessness and the gen- eral irritability. Now and then codeine may take its place, or 212 THERAPEUTICS OF INFANCY AND CHILDHOOD. the hydrate of amylene, chloral hydrate, or sulphonal. Some- times the subcutaneous injection of morphine, one or two minims of Magendie's solution, will give instantaneous relief. Warm bathing will prove beneficial in such conditions of gen- eral excitability. In these cases the use of cold must be care- fully avoided. During convalescence sudden changes in feeding must be avoided. I repeat, it is dangerous, to give other than fluid diet before the tenth day after the fever has disappeared. After that time white meats, plain puddings, and jellies may be added. Eaw fruit must not be given under any circumstances. Patients should not be taken out of bed sooner than a fortnight after their fever has disappeared. Older children should not be allowed to read. No visitors ought to be admitted during that time any more than during the duration of the disease, for dur- ing that very time weakness of the cerebral functions makes its appearance or, when met with afterwards, is traceable to it. During that time the temperature and the movements should still be watched very carefully, for relapses may set in at any time. Such relapses are very frequently the result of improper food, which will irritate the intestinal ulcerations, the process of whose healing is thereby interrupted. The greatest care must be taken in those cases in which the spleen, when tume- fied during the progress of the disease, will not nearly assume its normal size about the middle of the third week. When it remains large, a relapse may be looked for. The large number of consecutive diseases which may result from typhoid fever are ample proofs that all such measures are by no means superfluous; multiple abscesses of the muscles, ostitis, epiphysitis, and arthritis are not very uncommon after typhoid fever. Noma is now and then seen, but it is only just to state that epiphysitis and arthritis are not so frequent after typhoid fever as, for instance, after scarlet fever, and noma not so frequent as after measles. But purpura may remain behind. Parotitis is not very uncommon. Thrombi in the INFECTIOUS DISEASES. 213 extremities are sometimes met with. Erysipelas, laryngeal perichondritis, and cutaneous gangrene are by no means rare. But it is certain that many of these occurrences can be avoided if greater care be taken during the progress of the disease. The kidneys suffer in typhoid fever as they do in most infectious fevers, and frequently at an early stage. The majority of such consecutive cases of nephritis are mild and run a favorable course. Bad cases will be considered below. Among possible complications — not only as the pretext of an uncertain diagnosis — we frequently hear of that with ma- laria. "Whether typho-malaria is a disease sui generis, as Hanson claims for China, may be uncertain. But there is no reason why plasmodia and bacilli should not be co-ordinate and co-operative. I have seen such cases. Having met with cases which appeared to permit the two diagnoses, and mainly such which during and after a clear course of typhoid fever devel- oped regular attacks of chills and fever, I have administered quinine for some time. Several times these attacks appeared to be quite grave, and were mostly obstinate. 5. Typhus. Relapsing Fever. WeiVs Disease. The hygienic and therapeutical measures to be taken in (petechial) exantliematic typhus are like those of typhoid fever. As there are no intestinal symptoms, feeding need not be ex- clusively fluid during recovery. Relapsing fever permits of solid food in the intermissions. The spleen, when very large and sensitive, requires ice-applica- tions. Complications with eye- or ear-diseases have their own indications. Of WeiVs disease (fever, large liver and spleen, icterus, nephritis, delirium, coma, erythema, labial herpes) even Ba- ginsky has seen but a single case. ("Lehrb.," oth ed., p. 214.) 6. Epidemic Cerelro-SpinaJ Meningitis. It is both endemic and contagious, and demands absolute isolation, also rest both for mind and body from the very begin- 214 THERAPEUTICS OF INFANCY AND CHILDHOOD. ning and for weeks or months after recovery. Though the prognosis of those cases which do not terminate fatally in the first twenty-four hours, and in some of which not even a differ- ential diagnosis can be made with certainty, be much better than in the different forms of cerebral meningitis, the long duration of the disease endangers the result. Noise and glaring light must be excluded, no muscular exertion permitted, the neck supported; in bad cases of hyperesthesia the bedclothing should not be permitted to touch the body. The urinary bladder re- quires watching. Leeches applied to the painful spine will do some good in the very early stages; an ice-bag, on which the neck must be made to rest comfortably, and another one to the occiput, and a purgative dose of calomel ought to usher in the remedial treatment. Unless contraindicated by great sensitive- ness, mercurial ointment externally and iodide of potassium internally are expected to do good. The latter is generally given in too small doses, and thus misses its effect; from three to five grammes (grs. 45-80) daily, and more, are easily toler- ated, and are required by a child of five years. Bromides will quiet excessive restlessness (doses of 1-4 grammes a day) ; there are, however, very few cases but will be greatly benefited by sufficient doses of opiates, or chloral, to insure comfort and sleep. Sinapisms should be applied for a few minutes at a time, and frequently repeated; in the later stages a vesicatory over the cervical part of the spine is indicated. I am not pleased with the effects of tincture of iodine or iodoform ointments. Salicylic acid and salicylates have been praised; but I am afraid that the cases in which their good effects were observed were those of mistaken diagnoses, for, indeed, rheumatism both of the muscles and the meninges has been taken for different forms — even the very gravest — of meningitis. The after-effects of the disease, particularly paralysis and contractures, are diffi- cult to handle; their treatment does not call for any special measures dictated by the original disease. Deafness originating in the labyrinth or in the acoustic nerve is liable to prove per- INFECTIOUS DISEASES. 215 manent, in spite of hydrotherapy, diaphoresis, and electro- therapy. Amblyopia from inflammation of the chiasma and the optic nerves gives a bad prognosis; keratitis and panophthal- mitis are serious. The actual cautery has been used extensively. In the acute stage of the disease it is useless or harmful; in the chronic it has been known to do good, and may be applied regularly. The modern progress of our acquaintance with the etiology of infectious diseases adds to our preventive, not yet to our curative, powers. H. Jaeger (Zeitsch. f. Hyg. u. Infect., xix. p. 351) asserts that sixty per cent, of all cases of cerebro-spinal meningitis are connected with or dependent on the pneumo- coccus (and diplococcus intracellularis ?). This explains the frequent complication with pneumonia. Thus, the nasal secre- tion in which the diplococcus is of frequent occurrence requires particular attention. Indeed, as early as 1888 the Prussian government ordered the disinfection of linen — mainly hand- kerchiefs — from this point of view. For the same reason the violent aspiration of the naso-pharyngeal secretion, for the pur- pose of expectoration, may prove unfortunate for the individual and, secondarily, for the community. Weichselbaum, Heubner, and Fiirbringer charge the meningococcus intracellularis with being the cause. This microbe may also penetrate into articu- lations and give rise to a sero-fibrinous exudation, which, like the cerebro-spinal, has a tendency to absorption and recovery, contrary to the termination of arthritis which depends on streptococci and staphylococci. 7. Glandular Fever. Under the name of "glandular fever" Pfeiffer (1887), A. Seibert (1894), I. P. West (1896), and Dawson Williams (1897) described a complex of symptoms which is claimed as a well characterized disease sui generis. Patients were from seven months to thirteen years old (Dr. Seibert's case fourteen). Parotids not affected. West's ninety-six cases occurred in forty- 216 THERAPEUTICS OF INFANCY AND CHILDHOOD. three families within three years, none during the summers. Many of the families lived at a distance from each other, but exposure and contagion could be proven in many. Incubation mostly seven days (Williams's five to seven to fifteen days, mostly seven). Williams also observed many cases in the same family. The disease begins with anorexia, malaise, sometimes vomiting, some slight diarrhoea, after some days dysphagia. There is (Seibert) no pseudo-membrane in the throat, no ton- sillitis; in a few cases opisthotonus, which is explained by the swelling of the lymph-nodes. Fever moderate, in some cases temperature (Seibert) normal in the morning, 104° F. in the evening. Some abdominal pain, diarrhoea in milder cases, con- stipation in more severe ones. ISTo sequela? and no second at- tacks in West's cases. The disease lasted up to six weeks, in West's cases sixteen days, in Williams's from four to twenty- seven, with an average of sixteen; one death in ninety-six cases (West), one in twenty-four (Seibert). The main symptoms were the swellings of lymph-nodes, rarely of one side, mostly of both, beginning, however, on the left side; the right side fol- lowed in a few days. The glandular swellings extend down- ward and forward from the angle of the jaw and can be felt distinctly and separated from each other (West). The number of these swellings varies from four described by West to many small hard nodes, distinctly palpable, mostly between the deep- seated muscles of the posterior half of the neck (Seibert). Pos- terior cervical, axillary, and inguinal lymph-nodes could be felt in seventy-five per cent., the mesenteric in thirty-seven cases. The liver was found enlarged in eighty-seven cases (by Williams in ninety per cent.), the spleen in fifty-three cases (by Williams in fifty per cent., by Seibert in none), the tracheo- bronchial glands in all of Williams's cases. There was no oedema, no suppuration, no permanent enlargement. In the discussion of the Pediatric Section of the New York Academy of Medicine, Koplik (who never saw a case in his many thou- sands of observations) suggested the possibility of an intestinal INFECTIOUS DISEASES. 217 infection because of the fact that the local symptoms started on the left side. The reports regarding the existence of an incu- bation and the occurrence of contagion cause me to connect the affection here, with infectious diseases of a special type, for the present. 8. Catarrhal Fever. This is not the "ephemeral fever" of a feverish infant or child the cause of which has not been diagnosticated, nor the result of overloaded stomach or of intestinal putrefaction, nor of cocci in the throat or nose, but of the reflex irritation de- pending on "cold," exposure to a cold temperature, or to a sudden change of temperature from hot to cold, particularly while the skin was perspiring. Sometimes a chill is noted in the beginning, or merely a high temperature, aching muscles, anorexia, headache, perspiration, and some catarrhal angina, — in other cases but little elevation of temperature and perspira- tion, but lassitude, sleepiness, and constipation. Labial herpes is apt to appear on the second or third day and a copious per- spiration is frequently noticed on the fourth or fifth day, after which improvement takes place. To speak of a gastric, hepatic, or cerebral variety, in order to denote the most prominent symptoms, is superfluous. The treatment consists in rest in bed, at a temperature of the room of from 65°to 75° F., plenty of water (preferably hot), or of hot lemonade for older children, a purgative (ol. ricini), tinct. aconiti in one-quarter- to one- half -drop doses every hour or every two hours, liquor ammonii acetatis from three to ten drops every two hours in hot water, and, if there be much headache and a high temperature, phen- acetin in one-half- to one-grain (0.03-0.06) doses from time to time. 9. Asiatic Cholera. It is almost always fatal in the infant, and little less so up to the fifth or sixth year. Its diagnosis is, during an epidemic, secured by the presence of the characteristic diarrhoea and vomiting, with cold extremities, cyanosis, algidity, and the ab- 218 THERAPEUTICS OF INFANCY AND CHILDHOOD. sence of pulse and of urine; lastly and positively, by the pres- ence of the comma bacillus in the faecal discharges. The dif- ferential diagnosis should be made from arsenic and tartar emetic poisoning, also from very acute nephritis. The latter may exhibit the same copious rushing "rice-water" discharges of serum with masses of epithelium. As the disease is identical with that in the adult, so the gen- eral features of the treatment are the same. Preventive im- munization has been practised, after many previous attempts made in vain, by Haffkin. If his favorable results obtained in the East Indies will be confirmed, and the Mecca pilgrimages closely watched, the world will be threatened with one less dan- ger. During the prevalence of an epidemic no child should be permitted to suffer either from diarrhoea or from vomiting. Whatever is to pass beyond the lips, mouth-wash or food or drink, should be boiled. Invalid or dyspeptic children should be sent away, and the schools closely watched for the slightest attack of loose bowels. A child suspected of cholera is to be kept in bed, with small hourly doses (five or ten milligrammes) of calomel, which ought to be continued until the fasces show the characteristic color. Creosote may be given in water, salol in doses of from five to fifty centigrammes every few hours. Hydrochloric acid diluted as a drink, after the administration of calomel has been stopped. The extremities should be kept warm, the abdomen, if hot and tender, covered with cold appli- cations, which are changed when becoming warm, and stimu- lants given freely (alcohol, caffeine, strychnine, camphor, tinct- ure of musk), subcutaneously if, or because, the stomach retains nothing. Warm bathing with friction while in the bath. No internal diaphoretics, and absolutely no pilocarpine subcutane- ously. For the heart is too feeble; even when the condition appears to improve, sudden relapses, and collapse, may turn up. The enteroclysis of Cantani (the irrigation to be carried up as far into the bowels as possible) is made with a solution of three or five parts of tannic acid in a thousand of warm, or hot, water. INFECTIOUS DISEASES. 219 The action of the heart may be re-established by subcutaneous salt-water infusions. For these Cantani's original prescription contained four parts of sodium chloride and three of sodium bicarbonate in one thousand of water. Opium is badly tolerated in all stages. High temperatures and delirium demand cold to the head; pneumonia, parotitis, nephritis, and other complica- tions furnish their own indications. 10. Dysentery. It is communicated from person to person, but by faecal discharges only, by the use of the same chamber, for instance. Indeed, all the bacillary diseases of the intestinal tract may enter through the anus. Privies and sewers are sources of dys- entery, as of typhoid fever. The catarrhal, the follicular, and the diphtheritic varieties may run their courses separately; in many instances, however, the first will only be the initial stage of the more serious forms. The treatment is not, for the present, influenced by the species of microbes causing or com- plicating the malady, bacterium diphtheria?, coli, or amoeba?. A patient with dysentery, to prevent communication, should be isolated. During the heat of the summer children should be protected against colds (the systematic use of cold water is, as always, the best prophylactic) and unripe fruit. The sufferings from dysentery are so intense, and the dan- gers from its acute (fever, convulsions, exhaustion) or chronic (scurvy, noma, nephritis, paralysis, diseases of joints) state so threatening, that active measures should be taken at once. A brisk purgative ought to precede every other treatment. Castor oil in sufficient quantities, or calomel — according to age — in doses of from one to eight grains (0.05-0.5), will have a favora- ble effect, the latter acting both as a laxative and a disinfectant. The food should be liquid, milk and strained farinaceous decoctions the exclusive diet for the first acute stage. It is on the general condition of the patient that the administration of other articles of food, such as jellies without sugar, beef- or 220 THERAPEUTICS OF INFANCY AND CHILDHOOD. mutton-broths with farinaceous decoctions, egg albumoses, or alcoholic and medicinal stimulants (either general or cardiac), will depend in the course of the disease. Great sensitiveness of the left hypogastric region and local heat will be alleviated by the application of ice. Very young infants, however, bear ice but a short time, whether applied to head or abdomen. I advise to watch the effect of the applica- tion of either the ice-bag or the ice-cold cloth. Now and then, even in adults, we meet with an idiosyncratic incompatibility with cold, which has to be respected. Indeed, quite often warm applications of either water or poultices prove more efficient in regard to the two indications, which consist in alleviating irri- tation and reducing temperature. The subnitrate and the subcarbonate of bismuth do not only cover and protect the mucous membrane, but have also a de- cided antifermentative effect. Thus bismuth is surely indi- cated in irritated conditions of the mucous membrane; it seldom fails when given in sufficient doses. There is no harm in sometimes giving it in such doses that part of the introduced material will pass through the entire length of the intestinal tract without undergoing decomposition. As its taste is not disagreeable, it may be given together with tannin (gallic acid is better) and opium; the daily dose ought not to be less than one drachm or a drachm and a half (4.0-6.0). At the same time the passages ought to be examined as to their reaction. Abun- dant acid, so frequently found in the slightest intestinal anom- alies, requires the additional administration of alkalies. Boiled milk should be mixed with equal parts of lime-water. In most cases carbonate of lime is preferable to either magnesium or the carbonate or bicarbonate of sodium, the salts of both of which are apt to increase diarrhoea. Sometimes, particularly when the stomach can be relied upon, the salicylate of sodium may be added to the internal treatment. Besides the favorable effect of the sodium in the intestinal tract, the salicylic acid may prove beneficial both by its antifebrile and disinfectant INFECTIOUS DISEASES. 221 action. Salol, about one or two grains (0.05-0.15), or resorcin, one-quarter or one grain (0.015-0.06), given every two hours, may take its place. The latter is better tolerated than the for- mer, but salol has a better chance to reach the lower part of the intestine. Opium and its alkaloids are invaluable in the treatment of intestinal ulcerations. The objections to their use are decidedly exaggerated. Such accidents as have been reported in isolated cases as resulting from the administration of opium is to be attributed to the fact that the dose was either absolutely or relatively too large, compared with the idiosyncrasy of the patient. Dysentery both requires and tolerates larger doses of opium than an average diarrhoea, no matter whether the latter be the result of catarrh or ulceration of the small intestine or the caecum, or the upper part of the colon. In this respect dysentery stands abreast almost with peritonitis. The main indications are to relieve pain, reduce peristalsis, and diminish the copious serous secretion; no other remedy fulfils all of them so well. For this purpose it ought to be given internally; for enemata containing opium may act favorably, but the more intense the tenesmus and the greater the hyperaemia or the more extensive the ulceration, the less reliance can be placed on their effect, and the amount of the opiate thus brought into real action cannot be estimated. Among all the opiates I prefer a tincture, or the wine, or opium in substance, or Dover's powder; rarely only have I injected morphine under the skin. The effect of the drug is easily watched and controlled, by com- mencing with moderate doses, not repeating them too often, and being guided by the effect obtained. If opium is to be dis- carded, opium with hyoscyamus, or with belladonna, or hyos- cyamus or belladonna alone, may take its place temporarily. Severe tenesmus may require the painting of the protruding part with Magendie's solution. Astringents may either be given in combination with opium or separately. They are expected to pass wholly or partly 222 THERAPEUTICS OF INFANCY AND CHILDHOOD. through the entire length of the intestinal canal, thus coming into contact with the inflamed and ulcerous mucous membrane. Among those eligible are tannin, gallic acid, and vegetables containing the same (ratanhia, catechu), besides subacetate of lead, nitrate of silver, and pernitrate of iron. The daily dose of gallic acid, when it is to be taken for a long time in succession, is from five to fifteen grains (0.3-1.0), sub- acetate of lead one to five grains (0.05-0.3), nitrate of silver one-fourth to one-half grain (0.015-0.03). The latter ought not to be given more than a week, or two, in succession, for fear of argyria, two cases of which occurred in my own practice, and of my own making, many years ago. All of these medicines are best taken, if possible, in the form of pills. They appear to be better tolerated, and are certainly more effective. Nitrate of silver in solution (distilled water) demands a glass of neutral color. The use of keratin, when it becomes handier and cheaper, will increase the efficiency of pills which are to affect the mid- dle and lower part of the bowels only. The keratin covering is meant to oppose the solving action of the gastric acid. The pills advertised as "intestinal" by a New York firm defy both the gastric and the intestinal secretions. Another antiseptic which I have frequently administered internally in every description of intestinal ulcerations, in both the acute and the chronic forms, is naphthalin. For its doses, and the methods of its administration, and some account of its effect on intestinal ulceration in general, I refer to the chapter on typhoid fever. We have to expect a great deal from such topical medication, and it appears that it will be one of the great aids in all infectious diseases whose principal localization is in the intestine, as, for instance, Asiatic cholera. Adults will take from fifteen to seventy-five grains (1.0-5.0) daily, in powders, capsules, or mucilage. Children bear, as a rule, according to their ages, from one-half of a grain to two or three grains (0.03-0.2), every two or three hours, in INFECTIOUS DISEASES. 223 some mucilaginous substance. Some do not bear it well, but when such is the case, the stomach will give warning at once. Its odor, it is true, is objectionable. The temperature will but rarely be so high as to require antipyretic medication. Frequent enemata will often reduce it effectively. Very young infants may demand an occasional dose of antipyrin or acetanilide (antifebrin) when the heat threatens either the nervous system or the normal structure of the tissues of the body. A warm bath will often do better than either. Consecutive paralysis requires a mild galvanic current in the beginning. The daily application both to the spinal cord and the extremities need not exceed ten minutes; the electrodes should be large, and the current reversed after five minutes. After a few weeks the interrupted current may be added the same length of time, but it should be applied to the paralyzed muscles only. Together with the latter, strychnine or (and) phosphorus may be used, in daily doses of one-thirtieth of a grain (0.002) in the case of a child of four or five years; the former is more effective when used subcutaneously. The local treatment of chronic dysenteric ulcerations re- quires the use of enemata. Their indications vary. They are to evacuate the bowels, or to reduce the irritability of the dis- eased intestine, or to accomplish a local cure. These indica- tions cannot be fulfilled separately; sometimes two, sometimes all three, may be met at the same time. The nature and quan- tity and the temperature of the liquid to be injected depend in part on the end aimed at, in part on the irritability of the individual intestine. Sometimes the bowel objects to the introduction of small amounts; sometimes, however, large quantities are tolerated very easily indeed. To introduce small amounts, the selection of the syringe is a' matter of indifference, provided the liquid enters the bowel gently and without pain. To inject large quantities, undue pressure and local irritation should be avoided. Therefore the fountain syringe alone will 224 THERAPEUTICS OF INFANCY AND CHILDHOOD. answer; it ought to hang but a trifle above the level of the anus, say from six to twenty inches. The temperature of the liquid is not always a matter of great importance. Some recommend the injections to be ice-cold, some, however, tepid; both are frequently recommended as panaceas. But the prac- titioner will soon ascertain that some bear and require the one, some the other, some, indeed, very hot ones. In my experience, for the large majority of patients suffer- ing either from acute or from chronic dysentery, tepid in- jections answer best. Not rarely is the intestine in such a condition of irritation that even small quantities of a very cold fluid are expelled at once. And again, there are cases in which enormous amounts of either cold or warm water are readily re- ceived. To accomplish the purpose of evacuating the bowel, plain water will often suffice, but three-fourths of one-per-cent. solutions of salt in water will usually prove more acceptable. Additions of bitartrate of potassium, or castor oil, have proved so uncomfortable in my cases that I have discarded them long ago. However, when the secretion of mucus on the rectal and intestinal mucous membranes was very large, one- or two-per- cent, solutions of bicarbonate of sodium answered very well indeed. For the purpose of clearing the intestines, either of fasces or the morbid products, a single enema is insufficient. It ought to be repeated several times daily. When much mucus is secreted and tenesmus intense, it may be applied after every evacuation. In many cases the substitution of flaxseed tea or mucilage of gum acacia will prove advantageous. I have had to continue them for weeks for both their evacuating and alle- viating effect. When, however, the latter alone is aimed at, — that is, when tenesmus is to be relieved, — small quantities will usually suffice. An ounce or two of thin mucilage, or starch- water, or flaxseed tea, with tincture of opium, or better, with extract of opium, prove very comforting. Glycerin in water has been recommended for the same purpose. The former alone, or but slightly diluted, irritates, nay, cauterizes. It will require INFECTIOUS DISEASES. 225 close judgment and individual experience to ascertain the de- gree of dilution, if it be used at all. When a local curative effect is aimed at, injections of small quantities are sometimes insufficient. As the local lesions are often extensive, the amount to be injected must be pretty large. Almost always astringents are required. Sulphate of zinc, or of aluminium, subacetate of lead, nitrate of silver, tannin, chlorate of potassium, ergotin, salicylic and carbolic acids, and creosote have been recommended. Of the more common astrin- gents I prefer alumina or tannin in one-per-cent. solutions. Creosote answered well in solutions of one-half of one per cent Salicylic acid resulted more frequently in pain than in benefit. Carbolic acid, in solutions of one-half of one per cent., has proved very beneficial, but I have learned long ago to be very careful in regard to its administration because of its detri- mental effects, particularly on the kidneys of very young patients. Injections of nitrate of silver may prove very useful in cases not quite acute. Before the solutions of a quarter of one per cent., or of one or two per cent, are injected, the intestine ought to be washed out with warm water without salt, or with, a two- or three-per-cent. boracic acid solution. After the injec- tion has been made it ought to be neutralized with a solution of chloride of sodium; it is still better to wash the anus and the portion of the rectum within easy reach with that solution before the medicinal injection is made. For even the mildest solutions, when acting on the sore sphincters, are liable to give rise to intense tenesmus when no such care has been taken. When the ulcerations are but few, or in the lower portion of the bowels only, small quantities suffice. But extensive lesions require large injections, the patient being on bis side, or in the knee-elbow position. For older children the nozzle of the fountain syringe should be lengthened by attaching to it an elastic catheter, which is introduced as high up as possible, after the same plan that nutrient enemata are to be given. In 15 226 THERAPEUTICS OF INFANCY AND CHILDHOOD. a number of cases, both mild and severe, where neither the usual astringents nor nitrate of silver appeared to answer, I have been very successful these twenty-five years, when resort- ing to injections of subnitrate of bismuth. The drug is mixed with six or ten times its amount of water; of this mixture from one to three ounces (30.0-100.0) are injected into the bowel, which has been washed out previously, twice or three times daily. The result is satisfactory, though a large portion of the injected mixture be soon expelled. Suppositories containing the above substances may prove beneficial. But in order not to irritate they must be so soft as to melt readily. They may always contain some opium. But its admixture is not always sufficient to relieve the irritability of the rectum. Indeed, to accomplish this end opium must at least begin to liquefy and to be absorbed, and absorption can- not be relied upon except where a part, at least, of the mucous surface is in a fair state of integrity. When no suppository is tolerated, and the administration of an opiate to the intes- tine is indicated, the painting with Magendie's solution, or the injection of a small quantity of olive oil with tincture of opium, may still be tried. The local application of cocaine relieves pain, but the drug is readily absorbed, and great caution should be used in its administration because of its poisonous effects. 11. Scarlatina. Preventive measures of the strictest nature are indicated in regard to no disease more than to scarlatina. Its mortality is very great, in some epidemics even excessive; and when the child survives, there may be a large number of sequelae which either terminate fatally, or in persistent injury to health, and in the curtailing of the enjoyment or usefulness of life. Among these are cardiac diseases, glandular affections, suppurative otitis, and nephritis. The first attack of the latter is not limited to the second or third week, when, it is true, it is mostly met with; for I have seen it to appear on the thirty-seventh INFECTIOUS DISEASES. 227 and on the fifty-second day of the disease. Baumler reports the case of a child with hemorrhagic nephritis which started as late as the forty-fourth day of scarlatina. There is another momentous indication for strict prevention. The facility of being attacked is by no means so great as, for instance, in measles. It is but rarely that any of the young inmates of a house escape contagion when measles has attacked one of them. The virus of scarlatina, however, is less catching. Infants of less than a year suffer but seldom, though very severely when taken. The vast majority of those affected, however, are less than five years old. After that period sus- ceptibility becomes less from year to year, so that, indeed, a child that has been protected against scarlatina during its first half-dozen years attains a certain degree of immunity for the future. There is no reason to believe in a primary origin of scarla- tina. The efficacy of the virus is so persistent, and it clings so long to clothing, bedding, and furniture, that it can be carried and transmitted to long distances by persons, towels, toys, letters, and even domestic animals and articles of food, principally milk. It is transferable through the whole duration of the disease, from the incubation to the disappearance of the very last trace of desquamation, and perhaps later; even before the appearance of the eruption. The incubation of scarlatina may last but a few hours, like that of diphtheria and erysipelas, or as long as nine days; in this it differs greatly from measles, variola, and varicella. The last symptoms may not disappear until long after the fortieth day, which, it is true, is the average termination. The fine desquamation of the second week may have terminated entirely, but the gross peeling, particularly of the hands and feet, extends frequently to the end of the seventh or eighth week. It carries contagion as well as the desquama- tion of the former weeks, or as the breath of the patient, or his expectoration in the earlier periods. So slow is sometimes the process of elimination that Spottiswood Cameron claims that 228 THERAPEUTICS OF INFANCY AND CHILDHOOD. the end of the disease is seldom reached before the eighth week, and not always in the thirteenth. AVhether the urine or the alvine dejections of the patient can spread the disease is not quite certain; but as long as there is an uncertainty they ought to be treated as dangerous elements, and disinfected and re- moved. Sore surfaces appear to admit the poison. Scarlatina will enter through the integuments denuded by eczema. I believe I have lost, many years ago, two patients because I operated upon them during the prevalence of an epidemic of scarlatina. A child of four years, on whom I resected the head of a femur, was taken with the eruption on the fourth day and died. Another one was stricken down thirty-six hours after the resec- tion of a tonsil. In both cases I had reason to believe that I opened an inroad to the invading toxin. Indeed, catarrhal or otherwise sore tonsils are very likely to furnish a means of in- vasion. Several times I observed scarlatina a few days after tracheotomy. Dispensaries and schools are the hot-beds of scarlatina. A single case waiting in the anteroom of a public charity until it is seen and diagnosticated may destroy a dozen innocents while craving the blessings of public beneficence. Schools ought to be closed during an epidemic as soon as a few cases have ap- peared. No child coming from a house with scarlatina must be admitted. Such as have been removed from the dangerous neighborhood and not exposed since may, after thorough disin- fection of the clothing worn during the time of exposure, be allowed to return after an interval of ten days. The daily school inspection of the New York Health Depart- ment, organized this year, after the profession had urged its necessity from time to time these twenty-five years, cannot fail to be very beneficent, and is among the best methods to improve public health employed by the efficient health department of the city. There cannot be a doubt as to its example being imitated in other places. The "inspectors are to carefully ex- INFECTIOUS DISEASES. 229 amine each pupil that has been set apart from the other pupils by the teachers of the school, and cause to be excluded from schools all those affected with, or showing symptoms of, any contagious disease; more especially the following: measles, diphtheria, scarlet fever, croup, whooping-cough, mumps, con- tagious eye-diseases, parasitic diseases of the head and body, or any illness which, in their judgment, shall require the pupil to be excluded from school." The inunction of the patient with pork, vaseline, and similar substances adds to the safety of the attendants by preventing the carrying into the air of the eliminated particles of epi- dermis. Soaping and bathing contribute to the same end, but are not perfectly reliable safeguards because the virus pene- trates the whole skin down to the rete Malpighii. The sick and their attendants must be strictly isolated; dur- ing the winter, when the warm air rises and carries contagion with it to the upper part of the house, in the highest story. Whoever enters the sick-room — friend, nurse, or physician — ought to wear special clothing while inside, or at least a linen or india-rubber cover. The physician must disinfect his hands after leaving the patient. In the room the air ought to be changed often. Draught can be avoided by means of screens. No dry linen or clothing must leave the room. It should be soaked in water, or better still, in a disinfectant fluid, before it is carried off, and boiled in soap and water immediately after arriving in the laundry. The same rules which hold good in the cases of infectious and contagious diseases in general, and those which refer to the disinfection of the room and furniture, and public vehicles which may have been used, must be obeyed to the letter. No room, in fair weather, will afford the same safety as a tent would, and in no disease, with the exception of variola and diphtheria, is the erection and maintenance of special hospitals more needed than in scarlatina. In connection with the question of prevention of contagious diseases, scarlatina and others, I cannot render better service 230 THERAPEUTICS OF INFANCY AND CHILDHOOD. than by giving the greatest possible publicity to the directions of the New York Health Department. They contain all that is known, and all that ought to be done, in city or country, to prevent scarlet fever, diphtheria, and measles, in the present state of society, and of our knowledge. "DIPHTHERIA, SCARLET FEVER, MEASLES. "These diseases are very contagious. Diphtheria is usually transmitted from the sick to the well by the moist or dry dis- charges from the nose and throat of the sick person. Scarlet fever and measles are transmitted by the discharges from the nose and throat, and also by the scales thrown off from the sur- face of the skin. These discharges and scales contain the minute germs that cause these diseases. The importance, there- fore, of their proper disinfection can be at once understood. "Directions to prevent other Cases of Diphtheria, Scarlet Fever, and Measles occurring in a Family where one case exists. "1. If possible, one attendant should take the entire care of the sick person, and no one else besides the physician should be allowed to enter the sick-room. The attendant should have no communication with the rest of the family. The members of the family should not receive or make visits during the illness. "2. The discharges from the nose and mouth must be re- ceived on handkerchiefs or cloths, which should be at once im- mersed in a carbolic solution (made by dissolving six ounces of pure carbolic acid in one gallon of hot water, which may be diluted with an equal quantity of water). All handkerchiefs, cloths, towels, napkins, bed-linen, personal clothing, night clothes, etc., that have come in contact in any way with the sick person, after use should be immediately immersed without re- moval from the room in the above solution. These should be soaked for two or three hours, and then boiled in water or soap- suds for one hour. INFECTIOUS DISEASES. 231 "3. In diphtheria and scarlet fever, great care should be taken in making applications to the throat or nose, that the dis- charges from them in the act of coughing are not thrown into the face or on the clothing of the person making the applica- tions, as in this way the disease is likely to be caught. "4. The hands of the attendant should always be thoroughly disinfected by washing in the carbolic solution, and then in soapsuds, after making applications to the throat or nose, and before eating. "5. Surfaces of any kind soiled by the discharges, should be immediately flooded with the carbolic solution. "6. Plates, cups, glasses, knives, forks, spoons, etc., used by the sick person for eating and drinking must be kept for his especial use, and under no circumstances removed from the room or mixed with similar utensils used by others, but must be washed in the room in the carbolic solution and then in hot soapsuds. After use the soapsuds should be thrown in the water-closet, and the vessel which contained it should be washed in the carbolic solution. "7. The room occupied by the sick person should be thor- oughly aired several times daily, and swept frequently, after scattering wet newspapers, saw-dust, or tea-leaves on the floor to prevent the dust from rising. After sweeping, the dust upon the wood-work and furniture should be removed with damp cloths. The sweepings should be burned, and the cloths soaked in the carbolic solution. In cold weather, the sick person should be protected from draughts of air by a sheet or blanket thrown over his head while the room is being aired. "8. "When the contagious nature of the disease is recognized within a short time after the beginning of the illness, after the approval of the Health Department Inspector, it is advised that all articles of furniture not necessary for immediate use in the care of the sick person, especially upholstered furniture, carpets and curtains, should be removed from the sick-room. "9. In scarlet fever and measles, when the patient is begin- 232 THERAPEUTICS OF INFANCY AND CHILDHOOD. ning to recover and the skin is peeling off, the body should be washed once daily in warm soapsuds, and afterwards anointed with oil or vaseline. This should be continued until all rough- ness of the skin has disappeared. "10. When the patient has recovered from any one of these diseases, the entire body should be bathed and the hair washed with hot soapsuds, and the patient should be dressed in clean clothes (which have not been in the room during the sickness) and removed from the room. Then the Health Department should be immediately notified, and disinfectors will be sent to disinfect the room, bedding, clothing, etc., and under no con- ditions should it be again entered or occupied until it has been thoroughly disinfected. Nothing used in the room during the sickness should be removed until this has been done. "11. The attendant and any one who has assisted in caring for the sick person, should also take a bath, wash the hair, and put on clean clothes, before mingling with the family or other people, after the recovery of the patient. The clothes worn in the sick-room should be left there, to be disinfected with the room and its contents by the Health Department. "Methods of Disinfection. "1. Hands and Person. — Standard Solution No. 1 should be diluted with an equal amount of water. Hands soiled in caring for persons suffering from contagious diseases, or soiled por- tions of the patient's person, should be immediately and thor- oughly washed in this solution, and then washed with soap and water. The nails should be kept perfectly clean and the hands should always be carefully disinfected before eating. "2. Soiled clothing, towels, napkins, bedding, etc., should be immediately immersed in Standard Solution No. 1, and soaked for twelve hours, being occasionally moved about in the fluid so as to bring the disinfectant in contact with all parts. They should then be wrung out and boiled in soapsuds for INFECTIOUS DISEASES. 233 one hour. Articles, such as beds, etc., that cannot be washed should be burned. "3. Food and Drink. — Food thoroughly cooked and drinks that have been boiled are free from disease germs. In presence of an epidemic of cholera or typhoid fever, milk and the water used for drinking, cooking, washing dishes, etc., should be boiled just before using, and all persons should avoid eating fruit, fresh vegetables, and ice. Ice may, however, be used when ordered for the sick by a physician. "4. Discharges of all kinds from patients suffering from contagious diseases should be received into earthern vessels con- taining Standard Solution No. 1 or 3. Special care should be observed to disinfect at once the vomited matter and the intes- tinal discharges from cholera patients, as these alone contain the dangerous germs. The volume of the disinfecting solution used should be at least four times as great as that of the dis- charge. After standing for at least one hour in the disinfecting solution, these discharges may be thrown into the water-closet. Bedding or clothing soiled by the discharges must be at once placed in Solution No. 1, and the hands of the attendants disin- fected, as described above. "5. Closets, Sinks, etc. — Each time the closet is used for in- fected material, at least one quart of Solution No. 1 should be poured into the emptied pan and allowed to remain there. All discharges should be disinfected before being thrown into the closet. Sinks should be flushed at least once daily with the same solution. "6. Dishes, spoons, etc., used by the patient should be kept for his exclusive use, should not be removed from the room, but should be washed there, first in Solution No. 1, and then boiled in strong soapsuds. These washing-fluids should afterwards be thrown into the water-closet. The remains of meals should be thrown into a vessel containing milk of lime. The contents of the vessel, after standing half an hour or more, should be thrown in the water-closet. 234 THERAPEUTICS OF INFANCY AND CHILDHOOD. "7. Soiled woodwork, floors, plain furniture, etc., should be thoroughly washed with Solution No. 2. Upholstered fur- niture, curtains, *or carpets which have been soiled by the discharges should be referred to the Health Department for disinfection or destruction. "It is important to remember that an abundance of fresh air, sunlight, and absolute cleanliness not only help protect the at- tendant from infection,, but also aid in the recovery of the sick. "Note. — The cost of the carbolic solution is much greater than that of the other solutions, but generally is to be much preferred. When the cost is an important element, the bi- chloride solution may be substituted for all purposes for which the carbolic is recommended, excepting for the disinfection of discharges, eating utensils, or articles made of metal, and of clothing, bedding, etc., which is very much soiled. Its poi- sonous character, except for external use, must be kept con- stantly in mind. "Disinfection and Disinfectants. "The contagious diseases are caused by minute living germs. The object of disinfection is to destroy these. In order that as few articles as possible shall be exposed to infection by the dis- ease germs, at the very beginning of the illness all unnecessary furniture (especially upholstered furniture and curtains), and other unnecessary articles, should be removed from the sick- room. "The following are the best-known disinfectants: "1. Heat. — Continued high temperatures destroy all forms of life. Boiling for at least one-half hour will destroy all dis- ease germs. "2. Carbolic Acid. — Standard Solution No. 1 is composed of six ounces of carbolic acid, dissolved in one gallon of hot water. This makes approximately a five-per-cent. solution of carbolic acid. The commercial colored impure carbolic acid will not answer for this purpose. Great care must be taken that the INFECTIOUS DISEASES. 235 pure acid does not come in contact with the skin. When practicable, the carbolic solution should be used as hot as pos- sible. "3. Corrosive Sublimate (bichloride of mercury). — Standard Solution No. 2 is composed of sixty grains pulverized corrosive sublimate and sixty grains of chloride of ammonia, dissolved in one gallon of water. This solution must be kept in glass, earthen, or wooden vessels (not in metal vessels). "The above solutions are very poisonous when taken by mouth, but are harmless when used externally. "4. Milk of Lime. — Standard Solution No. 3 is made by mix- ing one quart of dry freshly-slaked lime with five quarts of water. Lime is slaked by pouring a small quantity of water on a lump of quick-lime. The lime becomes hot, crumbles, and as the slaking is completed a white dry powder results. The powder is used to make Solution No. 3. Air-slaked lime has no value as a disinfectant. "The proprietary disinfectants, often widely advertised, and whose composition is kept secret, are relatively expensive and often unreliable and inefficient. It is important to remember that substances which destroy bad odors are not necessarily dis- infectants/' The medicinal treatment of mild cases may be expectant. Cooling drinks — ten or twelve drops of dilute hydrochloric acid in a goblet of water — will often suffice. The food must be liquid, or at most semisolid; in the first week milk and fari- nacea. Constipation in the first period is aptly relieved by a dose of calomel or a vegetable aperient. Diarrhoea, particularly in the later stages, requires bismuth, opium, perhaps astrin- gents, such as lead, and at all events antifermentatives, such as resorcin, salol, or naphthalin; the mild form of stomatitis and pharyngitis, half a grain or a grain of chlorate of potassium in a teaspoonful of water every hour or two hours. The throat complications of scarlatina should be attended to in time, both when caused by or attended with streptococci or Klebs-Loffler 236 THERAPEUTICS OF INFANCY AND CHILDHOOD. bacilli. The frequency of the latter varies according to locali- ties, seasons, and epidemics. Some observers claim them in fif- teen per cent, of all the cases of scarlatina. Eanke found pseudo-membranes in sixty-five per cent, of all the recent cases at the Munich Children's Hospital. In 53.7 per cent, of mild or severe (laryngeal) cases he met with the diphtheria bacillus, in 38.8 with streptococci. The former were also observed in most of those cases in which the pseudo-membranous complication arose in the later stages of the disease. That is why he recom- mends the use of the diphtheria antitoxin in doubtful cases also. This and the general subject of general and local treat- ment of pseudo-membranous affections will be discussed in the chapter on diphtheria. In most cases (there are exceptions to that rule) when they are first observed on the fourth or fifth day of scarlatina they are but seldom alarming; when on the first day, or previous to the scarlatinous eruption, they are quite ominous. In such instances they are often accompanied with rapid glandular swelling and serious symptoms of sepsis. Ap- plications of ice to the swollen neck will often keep the tume- faction within certain limits. When gangrenous degeneration of the glands cannot be prevented, and local suppuration occurs in the centre, deep incisions and the local use of carbolic acid are required in the same manner in which the same affection is dealt with in diphtheric diseases generally. In milder cases, two applications daily of one part of iodoform in eight or twelve of flexible collodion have a good effect. Even they are mostly not required, cool applications will suffice. Occasional retropharyngeal abscesses require incisions. High temperatures do not require very active treatment un- less they result in functional or organic changes of the heart or brain. As long as these two organs perform their duties normally the temperatures may be left alone. A very frequent and feeble pulse with a high temperature requires, besides a cardiac tonic, quinine, washing with cool water, or water and alcohol, cold applications to the heart, or a warm bath. A cold INFECTIOUS DISEASES. 237 bath is not borne well; in urgent cases a cold pack may do good. A feeble and arhythmic pulse requires the very strongest stimulants. Antifebrin and antipyrin are not to be recom- mended in these conditions. Delirium and somnolence, also convulsions, may be the results of high temperatures, and, par- ticularly when the whole body, feet included, is hot, require the same treatment. Antipyrin, however, I have never seen to reduce the temperature in congestive or inflammatory condi- tions of the brain. The latter may be the direct result of the in- fection, but also at a somewhat later period of rheumatism. In either case the treatment does not materially differ from what it would be under ordinary circumstances. The latter form requires salicylates, the application of ice to the head, counter- irritants to the feet (sinapisms) and intestines (calomel), and in some cases leeches to the septum narium or to the mastoid processes. The vital indication proceeding from the condition of the brain is here of the greatest importance. When the same symptoms set in with or without a high rectal temperature and cold extremities, a mottled skin, and a cya- notic hue, the large amount of the toxin which has invaded the system demands strong stimulants, — ammonia, musk, and camphor. They act better than alcohol. To their internal administration may be added camphor dissolved in almond oil, and sulphate of sparteine in water, subcutaneously, in free and frequent doses. These toxic symptoms while the temperature is but low bear opiates (morphine, one-fiftieth or one-twentieth of a grain, one to three milligrammes), in repeated doses, quite well. Universal heat requires tepid bathing, with cold affu- sions over, or applications to, the head; a cool surface, with cold extremities and frequent and filiform pulse, hot bathing and powerful friction, and hot enemata, with stimulants. Vomiting before and with the eruption is a frequent symp- tom. When moderate, it may be left alone; no food must be given for a number of hours, ice-water in teaspoon doses, or an ice pill, every five or fifteen minutes. When quite severe 238 THERAPEUTICS OF INFANCY AND CHILDHOOD. and exhausting, small doses of an opiate, once every hour or two, will be found useful. In a few obstinate cases the muriate of cocaine in doses of one-twentieth or one-fifteenth of a grain answered well; in others, arsenous acid, every two hours, a two- or three-hundredth part of a grain (one-third or one-fifth of a milligramme). One of the early complications is rheumatism. It makes its appearance often on the third or fifth day. In some cases it is muscular, and then mostly confined to the lower extremities; in others articular, but with less swelling than we are inclined to expect. Indeed, articular rheumatism in children exhibits the usual symptoms to a less characteristic degree than in adults, but they are so pronounced as not to be mistaken. This rheumatism ought to be treated at once, for endocarditis com- plicates it in infancy and childhood very much more readily than in advanced age. Most of the cases of scarlatinal endo- carditis carried into later life are due to rheumatism. The joints ought to be well covered with soft cotton, and salicylate of sodium given every two or three hours in doses of from four to ten grains (three to ten decigrammes). Endocarditis and pericarditis, without rheumatism, are but rare occurrences. Ulcerous endocarditis I have not seen except with serious general sepsis, caries of bones, thrombosis of a sinus, and other symptoms of a general pyaemia. Suppurative inflammations of joints are very rare. They are the cause, or part, of generalized pysemia. This can be prevented sometimes by early surgical treatment. There is an affection of the epiphyses, however, which is very common and differs from the above. It consists in extensive hyperemia, and possibly inflammation. Clinical observation yields quite a number of cases of infectious diseases, but mainly scarlatina, in which during convalescence, and long afterwards, the re- gions of the joints are swollen and painful. This epiphysitis is the cause of the rapid increase in the growth of children who have passed through scarlatina, but may also be the cause of INFECTIOUS DISEASES. 239 serious changes, from simple "growing pains" to suppurative separations of the epiphysis from the diaphysis. In every such case, during convalescence and afterwards, the joint ought to be well supported by soft splints, and emplastr. hydrarg., or iodoform collodion, absolute rest enjoined, and phosphorus given in- three daily doses of a two-hundredth of a grain (one- third of a milligramme), or more, several times daily. Complications with pneumonia and pleuritis are quite fre- quent; the latter is apt to be purulent; if so, its existence explains in many cases the continuance of the high tempera- ture. In every case, purulent or not, the indications are not those of an expectant plan of treatment. Both general and cardiac stimulants and tonics are required, and pyothorax re- quires an operation. Hemorrhages are not frequent, but ominous when they occur. Some appear like the symptoms of generalized purpura, more towards the end of the malady, some in the muscles in the third week or later with the result of starting a more or less universal myositis, others in the mucous membranes. Many are the result of embolic processes, and complicated with local gangrene. Spontaneous thromboses, however, of the ex- tremities, or the cheeks ("noma"), are not so frequent in scarla- tina as they are in measles. The presence of pemphigus during the eruption appears to indicate a high degree of vasomotor paralysis. It is an ominous complication and requires stimulants as above. Urticaria is more troublesome than dangerous. The inunction with pork, vaseline, glycerin, or lanolin — soothing and pleasing in most cases of scarlatina — may suffice to relieve it. Now and then mild alkaline lotions (bicarbonate of sodium in water, 1 : 100), or the washing with carbonated alkaline waters (from the siphon), or with a proper dilution of carbolic acid (1 : 200), will prove beneficial. When the burning and itching is quite an- noying, naphthol five parts, and vaseline one hundred or one hundred and fifty, may be tried to advantage. 240 THERAPEUTICS OF INFANCY AND CHILDHOOD. The rules for the general treatment of scarlatina must necessarily be very much like those applicable to all infectious diseases. Thus in regard to them, and particularly to the de- bility and failure of the heart, I refer to my remarks on the treatment of patients suffering from typhoid fever. In scar- latina, and eruptive fevers generally, there is, however, an ad- ditional indication resulting from the participation of the skin in the process. Indeed, more than in other diseases, the hy- giene of the surface is to be attended to. During the course of the disease, particularly during desquamation, a tepid bath, with soap, ought to be given from time to time, and the tem- perature of the room and bed kept equal. While the former is to be cool, the body must be well covered and kept warm. This is the more necessary, as nephritis may set in at any time during many weeks. This serious complication, it is true, may occur though the patient be kept in bed, in consequence of voluminous elimination of renal epithelia, and also, perhaps, of bacteric invasion, but exposure and sudden changes of tem- perature will always hold their place in etiology, in the minds of those who do not forget to notice the living clinical case besides the microscopical excrement. In this connection, while I reserve the subject of nephritis for some future occasion, I will only urge the advisability of beginning the treatment of scarlatinal nephritis with a moder- ate dose, one-half to one grain (0.03-0.06), of calomel, repeated from time to time, through the first two or three days. Its pur- gative effect, if too great, may be stopped by a small dose of opium given after every loose movement. There are a great many other complications, such as otitis media, purpura, noma, onychia, keratomalacia, etc. Each of them will be discussed in their proper places. Mere combina- tions with other diseases, such as whooping-cough, measles, varicella, vaccinia, variola, and typhoid fever, do not add to, or alter, the indications for treatment. At all events the belief in scarlet fever specifics should be discarded in the state of our INFECTIOUS DISEASES. 241 present knowledge. Neither sulphite of magnesium or of so- dium, nor benzoate of sodium, nor belladonna have fulfilled the promises of their sponsors. What some special antitoxin will do remains to be seen. Marmorek's streptococcus antitoxin is still in its experimental stage. If anywhere, an antitoxin is the only possible remedy which could hold out any hope in those cases which perish in a day, sometimes in the very first few hours of the illness, under the influence of an overwhelming intoxication, and are not relieved by hot bathing, or purging, or stimulation.* 12. Measles. The virus of measles appears to be more volatile than that of any of the other contagious diseases with the exception of influenza. Its communicability appears to be greatest during the prodromal stage, and the invasion takes place, in all proba- bility, through the bronchial mucous membrane. The incuba- tion may last thirteen days, the first four or five of which may be attended with some fever. During all this time, and during its whole course, the disease is contagious. Very few cases are seen during the first six months of life. After that it is common, and repeated invasions are frequent. In many seasons the mortality is very trifling; in some epi- demics it has reached thirty-three per cent, of all the cases. The first epidemic occurring in regions where measles had not been known previously was found to be very dangerous, and those which occur after long interruptions are likely to prove very severe. Thus the question whether the well should be separated from the sick will depend a great deal on the severity of the epidemic. * In their studies on the antitoxic and therapeutical effect of human blood after infectious diseases, O. Huber and F. Blumenthal (Berl. klin, Wocli., No. 31, 1897) come to some positive conclusion. They believe they have found specifically healing factors which, in their opinion, need only concentration to prove useful in scarlatina, measles, and also in pneumonia. 16 242 THERAPEUTICS OF INFANCY AND CHILDHOOD. The temperature of the room should be comfortable, a little warmer than in scarlatina, and the air moist. The light ought to be excluded to a certain extent, but not to absolute darkness. For a number of days the child should be kept in bed, unless very restless; in that case it may be taken out well covered. It is a good rule to keep the patient in bed a week after the disappearance of the fever, and in the house ten days or a fort- night longer. Eelapses are not uncommon, and those particu- larly who have a hereditary tendency to tuberculosis ought to be protected from exposure. Especial care must be taken dur- ing the cool or rainy season. Mild cases require mostly a hygienic treatment only; still, every case has its own indications. Where there is otitis, bron- chitis, pneumonia, or dysentery, it is self-understood that the patient must be kept in bed during the continuance of the complication. Warm and dry weather and a sandy soil will permit a patient to leave the house sooner than he would be permitted to do under other circumstances. Constipation may demand gentle treatment in the begin- ning. As a rule, an enema will suffice. Castor oil or the elixir of rhamnus purshiana may sometimes be required. No drastic should be used because of the tendency to diarrhoea or dysen- tery prevailing in many instances. For the same reason no glycerin should be injected into the rectum. A convulsion in the beginning of the disease does not always mean great harm. It takes the place of the chill in the adult, but is more dangerous because of the possibility of hemorrhages occurring while it lasts. Thus it ought to be cut short as soon as possible. Chloroform inhalations will relieve the spasm, chloral hydrate internally, or in an enema, the persistent irri- tability. Warm bathing may be resorted to when under these circumstances the eruption is slow in showing itself. The head is to be kept cool, the feet should be warmed. Epistaxis may be left alone while mild. Sometimes it re- lieves the congested mucous membrane of the nares. When severe it has to be stopped. INFECTIOUS DISEASES. 243 The organs of circulation do not suffer often in measles. Pericarditis and endocarditis are met with very rarely, but Baginsky reported a case of purulent pericarditis and myocar- ditis. In epidemics of unusual severity heart-failure is of fre- quent occurrence. It is to be treated according to the prin- ciples laid down in the articles on scarlatina and typhoid fever. A peculiar feature in very severe measles is the frequency of thromboses. Indeed, in no other infectious disease are they met with as often as in measles. The thrombi occur in the vulva, in the skin and subcutaneous tissue, about the face as cancrum oris (noma), on the distal parts of the extremities, particularly the legs. Disseminated purpura is not frequent, but gangrene of the skin is not at all uncommon. The odor of such gangrene, and of cancrum oris, is very offensive indeed, and requires strong disinfectants and deodorizers. Thymol in solution of one to one thousand, iodoform in powder or in vase- line ointment, will be found serviceable. The subject of noma will be discussed in another chapter. What has been called hemorrhagic measles is not always very malignant. In a great many cases it means nothing but the effusion of some haematin into the eruption. The complication of the eruption with a simple erythema, or with pemphigus is mostly an indifferent matter. The respiratory organs suffer mostly in measles. There is always catarrh of the nose, which may lead at an early period to tumefaction of the lymph-bodies around the neck. If such be the case the catarrh should not be left alone, but treated with gentle injections of a mild solution of salt water or boracic acid. The conjunctivitis connected with it requires tepid or cool application, or instillation several times a day of a few drops of a two-per-cent. cocaine solution. It should have close attention, for it is sometimes followed by destructive processes of the cornea. A moderate amount of bronchial catarrh may be left alone provided the cough is not very severe, for severe attacks of coughing, even without much congestion or inflam- 244 THERAPEUTICS OF INFANCY AND CHILDHOOD. mation, may produce bronchiectasis or emphysema. Particu- larly is this the case when there is complication with pertussis. Here morphine may be given in" sufficient doses. Bronchitis is rarely dangerous unless it be capillary. Broncho-pneumonia is always a serious complication and a very frequent one. In a number of cases its course is very rapid, accompanied with cyanosis and a very small pulse. Active treatment is required in these cases. The inhalation of oxygen will now and then bridge over urgent conditions. Warm bathing and cold affu- sion in a warm bath will be of good service, for it is necessary that the patients, particularly small children, should cry. Un- less they cry they will suffocate. Stimulant expectorants are in order, such as camphor, benzoic acid, or carbonate of am- monium. The muriate of ammonium is not sufficient. Cardiac stimulants are required at the same time, such as digitalis, sparteine, and musk. jN"o depressing expectorants should be given. Antimonials should be avoided at any rate. There is always some catarrh of the larynx and sometimes a pseudo-membranous laryngitis holding, or caused by, either cocci or Klebs-Loffler bacilli. In the latter case, the treatment is that of diphtheritic deposits. (See chapter on Diphtheria.) When the croupous symptoms are very urgent the air of the room ought to be filled with steam, and the patient encouraged to drink as much as possible, particularly of alkaline waters. The internal administration of the iodide of potassium in mod- erate doses will do good service. So will an opiate, particularly at bedtime. In connection with the catarrhal affection of the nose, otitis is seen now and then. According to Schwartze, three per cent, of all the cases of otitis can be traced back to measles. During all this time the kidneys ought to be watched. It is true that nephritis is by no means a frequent occurrence in measles, but it has been found often enough to justify the greatest attention. Cerebral complications have no special indications. Eules INFECTIOUS DISEASES. 245 for their treatment will form the subject of a future discussion. Meningitis as one of the localizations of tuberculosis, which often follows measles, is not infrequent. 13. Rotheln (Rubella). It has not yet conquered an indisputable place in pathology. There are still many who do not take it to be a separate disease. The eruption looks mostly like measles, sometimes like ery- thema, or urticaria, or scarlatina. According to some it begins on the face, others deny that and speak of a suffused blush only. Many cases have been described which were connected with catarrh of the respiratory organs and of the throat, with glandular swellings (submaxillary, mastoid, axillary, inguinal) and very moderate fever. These are the cases which have been described under the name of rubella morbillosa, and would be diagnosticated by many, myself included, not as rotheln, or rubella, but as a mild form of measles. If there be any such special disease, no special treatment is required, except that of complications (catarrh, coryza, conjunctivitis, bronchitis, men- ingitis, arthritis, albuminuria), most of which are rare. 14. Mumps. Its incubation lasts a fortnight, and sometimes three weeks. Thus prevention by isolation can seldom be accomplished. The infection must be presumed to take place through the Steno- nian duct. Thus a careful hygiene of the mouth should be con- sidered the best preventive. Often the patients do not feel very sick. Many do not take to their beds. In many cases covering the swelling with cotton is sufficient to protect it. Where there is a great deal of pain narcotic applications may be made, or ice applied. The latter certainly reduces the amount of swelling, although it may not shorten the course of the disease. I have often found the application of iodoform col- lodion (one to eight or ten), made twice a day over the whole surface, quite successful. When there is a tendency to suppu- 246 THERAPEUTICS OF INFANCY AND CHILDHOOD. ration, warm applications will favor it. Then a large incision must be made in time, and treated antiseptically. The diet must be that of all fevers, — fluid. A consecutive anaemia which is more frequent than the apparent mildness of the affection would seem to explain, requires generous feeding, iron, nux, and a change of climate. Complications with otitis, nephritis, or orchitis have their own indications. 15. Variola. Variolois. Vaccination ought to take place early, for genuine variola in the first year is quite frequent among those not vaccinated. There are also many cases of variola among those not vacci- nated between the eleventh and twelfth years. The small-pox reports of the German empire emphasize the fact that no case of variola (variolois) occurring in vaccinated children who had more than two cicatrices terminated fatally; nor was there a fatal case among those who were revaccinated. There was no fatal case where the vaccination marks were very distinct, be- tween the thirteenth and forty-fourth years. The fact that none died that exhibited more than two marks appears to prove that the single mark customary among us may not be sufficient. At all events, many of our children vaccinated in the first year of life will undergo a successful revacciu^tion when they are only from four to six years old. At that time revaccination ought to be tried, and if unsuccessful, should be repeated from year to year. Isolation is now recognized as an absolute necessity more in a case of variola than in any other disease. Thus little diffi- culty is caused by ill will or ignorance. Patients with variola ought to be kept cool, washed frequently with cold or tepid water; now and then an ether spray or an ice-bag over sore parts will be found quite agreeable. Fever is sometimes very high, and ought then to be modified by antipyretics. The delirium is sometimes so violent, and bordering on mania, that the inhalation of chloroform or the administration of chloral INFECTIOUS DISEASES. 247 hydrate is required. The influence of universal compulsory vaccination cannot be shown better than by the report of Ba- ginsky, who has not met, in children, a single case of genuine variola, and but few of variolois. The eyes ought to be covered with cold compresses, sore eyelids covered with vaseline or zinc ointment. Superficial sores on the skin, and those which yield an offensive odor, should be treated with thymol, salicylic acid, or iodoform. Scabs must be removed from the nostrils so as to facilitate respiration; abscesses should be opened in time and disinfected, and complications treated. One of the most severe complications is oedema of the larynx, and laryngitis, which may require, on short notice, tracheotomy or intubation. After the disappearance of the feverish stage the patient ought to be bathed once every day or every other day, and in- unctions of fat made all over the surface until desquamation is complete. 16. Varicella (Chichen-Pox). When varicella vesicles are in the mouth, they require washes with chlorate of potassium (1 : 30-50), when on the vulva, dermatol powder, or dermatol with cold cream (1 : 6-8). Con- stipation and gastric symptoms should be relieved. As the disease is very contagious, and not always mild, the child ought to be isolated, and on no account sent to school. Dissemination in schools and in dispensaries is an every-day experience. Bad cases must be kept in bed. Very few require medicinal treatment, except when there is local or disseminated gangrene, which I and many others have seen. A small number of in- stances of consecutive nephritis are now on record, as also in vaccinia; thus the urine ought to be examined in every case. 17. Vaccinia. Irregularities in the development of vaccinia cannot always be prevented. The appearance of the vaccination vesicles (and pustules) will be delayed sometimes without an apparent cause. Accidentally (transmission by scratching) they may come on 248 THERAPEUTICS OF INFANCY AND CHILDHOOD. distant parts. A universal eruption (from no such cause) has been reported by Colcott Fox (Lancet, 1893, i. p. 362) and one case by Baginsky ("Lehrb. d. Kind.," 5th ed., p. 178). Very high temperatures with nervous symptoms may require, in rare instances, an antipyretic treatment; they accompany mostly a high degree of local inflammation, which will be soothed by the application of cool water or of diluted aqua plumbi. Ulcerations result mostly from uncleanliness and from scratching. They may be prevented by great care and cleanliness in vaccination, which requires the same asepsis as any other operation. No plaster should be applied before the wound is perfectly dry. Moreover, they appear to be more frequent when humanized than when animal lymph is used. Iodoform, or dermatol, in powder or in ointments are indicated. Axillary lymphadenitis disappears, with very rare exceptions, with the local inflammation. Rhachitis, scrofula, and tuber- culosis, when they are observed after vaccination, are acci- dental. Syphilis has been transmitted when the serum taken from the arm contained blood of a syphilitic infant; that is another reason why animal lymph should be uniformly preferred. Erysipelas does not always originate from the margin of the local inflammation, but sometimes at some distance. Neither in regard to prevention nor to treatment can anything be said in addition to the remarks on erysipelas in general (p. 249). Diphtheria would arise from vaccination wounds, when we knew less about its communicability and its preventability, and were more careless than we are (?) at present. The local treatment of such accidents (or sins) will be discussed under Diphtheria. At the very height of the reactive inflammation, or in the week succeeding it, urticaria may appear, or small or large vesicular eruptions; which are liable to disappear with the desiccation and falling off of the scabs. They should be considered as nervous oufc breaks only, and not be considered in the same light as an eczema — local or universal — which dates from the time of vac- INFECTIOUS DISEASES. 249 cination. The latter should not be taken for its real, but for its proximate cause (the fever) and opportunity. 18. Erysipelas. It is so communicable that even a physician may carry it. Still, it is not probable that the healthy surface can be attacked by it. As in most cases of diphtheria, so in all cases of ery- sipelas, a sore surface forms the resting-place of the microbe (streptococcus). Erysipelas may make its appearance on an eczematous skin. On the head it sometimes escapes notice for some days. Excoriations of the anus and sexual organs, or slight injuries done by a pin or by the finger-nail, are sufficient to cause it. It often originates in the intertrigo of the infant, or in the neighborhood of a vaccination mark. In the latter case it seldom appears immediately after vaccination, very often not before the second week or later. Chronic nasal catarrh is a frequent cause. Some children will have erysipelas extending over both cheeks one or more times every year. Slight or large operation wounds are a frequent source; so is diphtheria with which erysipelas is occasionally complicated, and many cases are seen to take their start from a tracheotomy wound. In the newly-born it appears, as a rule, on or near the navel, and is generally connected with universal sepsis. Prevention of the disease will mainly depend on the removal, or relief, of the several causes which have been enumerated. Every case of erysipelas should be isolated, and diet and general treatment be regulated on general principles. The local treatment may be quite simple in some cases. The ery- sipelatous surface may simply be covered with soft cotton, or a powder of talcum, or of amylum, or one part of salicylic acid with perhaps ten parts of oxide of zinc and twenty-five of amylum. Applications of lead wash and opium, or of sulphate of zinc, have been in general use for a long time; also of solu- tions of sulphate of iron; now and then the application or in- unction of blue ointment. The latter I cannot advise because 250 THERAPEUTICS OF INFANCY AND CHILDHOOD. of the pain and irritation resulting. The inflamed surface has been covered with collodion. Infants and children will not bear it. Ferreire has used, in a case of erysipelas on the leg of a child of two years and a half, a mixture of one part of resorcin in seven thousand five hundred of traumaticin (0.008 : 60.0). Cold applications have been made, ice has been applied, and where the extent of the erysipelas is but limited, to great ad- vantage. Neither saturated solution of nitrate of silver nor the solid caustic have been of advantage. Hueter recommended many years ago the subcutaneous in- jection of a two-per-cent. solution of carbolic acid round the inflamed surface, and claimed to have confined every case within its original limits. In place of that, I advised the ap- plication, not on, but around, the erysipelatous area, of a mix- ture of one part of carbolic acid in eight, ten, or fifteen parts of oleic acid. I have treated many cases in that way, and most of them quite successfully. The application was rubbed into the surface around the diseased part at frequent intervals, or, when the erysipelas was confined to the extremity, a band or compress soaked in the mixture was applied just outside the diseased part, not infrequently with the result of stopping the process. Instead of the carbolic acid as administered by Hueter, Ducrey uses a solution of one part of corrosive sublimate in one thousand of water, and repeats the injections, which are to be made three centimetres apart, after twelve hours. A better plan, however, is, after all, to apply carbolic acid, one part dissolved in ten or fifteen of alcohol, directly to and beyond the surface, every hour or every few hours. It is readily absorbed, and may do good, but also harm by affecting the kid- neys. Thus in every case where it is to be applied the kidneys should be watched carefully, and particularly in young children. Washing with and applications of a solution of bichloride of hydrargyrum in water (1 : 2000) have been highly recom- mended; also an ointment of resorcin five parts and vaseline and adeps lanse hydrosus (lanolin) aa ten parts. I have seen a INFECTIOUS DISEASES. 251 few cases doing well with it, but I have been better pleased with a mixture of equal parts of ichthyol (sulpho-ichthyolate of am- monium) and vaseline. In place of this a solution of ichthyol (2-10) in equal parts of ether and glycerin (10-30) has been employed. The compound tincture of benzoin may be painted all over and beyond the diseased surface once every hour or two hours. Absolute alcohol (ninety-nine per cent.) applied frequently, has rendered me excellent service in limiting the area of infection. That is what is aimed at and accomplished by the hedging in of the morbid process, an operative procedure invented by Kraske and Riedel, and introduced to us by Willy Meyer. Eailfence-like scarifications are made under an anaes- thetic, down to the rete Malpighii, partly in the diseased and partly in the healthy surface, double so as to cross one another and allow no loophole. Then corrosive sublimate (1 : 500) is rubbed into and kept applied to the wounds, in most cases with almost instantaneous, at all events rapid, success. The modifi- cation of this procedure, which is practised in one of the large children's hospitals of Germany, by incising the erysipelas and squeezing with the intention of removing the cedematous in- filtration of the tissues, then scarifying deeply around it and rubbing in ichthyol, and repeating that "treatment" until scurfs are formed, appears to get dangerously near criminality. The internal administration of the tincture of chloride of iron has been considered a specific by many. That opinion is certainly based on an exaggeration of its merits. The prep- aration is, however, an antifermentative, and, while being a vascular stimulant, does not give rise to fever in infectious diseases as it would do in simple inflammatory fevers. Abscesses complicating erysipelas require large incisions and antiseptic treatment. Erysipelas of the neck is very often com- plicated with oedema of the larynx, and may require scarifica- tion, tracheotomy, or intubation. Meningitis which frequently accompanies erysipelas of the scalp, or of the naso-pharynx, has its own indications. It 252 THERAPEUTICS OF INFANCY AND CHILDHOOD. should not be forgotten, however, that many cerebral symptoms simulating meningitis and mostly attended with high tempera- tures, are merely those of the toxin infection, and an antiseptic treatment may do good. The recovery of a young man observed with such symptoms lately I attribute solely to the large quan- tities of brandy administered. In such cases a streptococcus antitoxin, such as Marmorek is trying to furnish, could be of incalculable benefit. 19. Diphtheria. The morphological structure of the pseudo-membranes in the throat, nares, larynx, and other places is identical. They have mostly been studied in the throat, where they are most frequently found. They consist of finely reticulated fibrin holding exudate cells, leucocytes, and some erythrocytes. When they are superficial, it is the epithelial protoplasm which is thus transformed; when they are deep-seated with a tendency to necrosis, ulceration, and, finally (in cases of recovery), cicatrization, it is the fibrillar basic substance of the connective tissue, mostly of the mucous membrane, some- times also of the submucous and deeper structures. This view, which underlies the discussions in my "Treatise on Diphtheria" (1880), has been again forcibly demonstrated, lately, by P. Baumgarten (Berl. hlin. Woch., Nos. 31 and 32, 1897). For some years, however, it was customary to differen- tiate between those pseudo-membranes which are caused by, or accompanied with, the Klebs-Loffler bacillus, and those which contain streptococci. That these microbes do not establish any disease by their mere presence, that, on the contrary, they are met with, to an indefinite degree, in the mouths of the healthy is well understood. To be considered pathological, or patho- genous, their presence in a pseudo-membrane in whatever stage of development is required. The Klebs-Loffler bacillus is found in its superficial layers only, and not throughout the whole thickness of the pseudo-membrane; the coccus pervades its whole substance, and is even found in greater numbers in INFECTIOUS DISEASES. 253 the deeper layers. To explain the absence of bacilli from these, it is assumed that they are destroyed by other microbes. Still, they are assumed — and that assumption has become an axiom, an article of faith — to evolve the toxin which gives rise to all the symptoms and dangers of certain forms of diphtheria. Pseudo-membranes with Klebs-Lomer bacilli are called by almost universal agreement, diphtheritic, those with cocci pseudo-diphtheritic; those cases which carry both bacilli and cocci are called mixed infections. It has been claimed that the second class is of little virulence, and attended with but little danger. This opinion leads to cruel mistakes in their manage- ment both by boards of health and such medical men as are influenced by them. For not only are many uncomplicated cases very grave and fatal, but the mixed infections are the very worst forms met with in practice. Moreover, the strepto- coccus cases are contagious. Still, it is important to mention at once, that the differentiation has its great practical weight. For it is only the first class, the bacillary diphtheria, and the third, which are favorably influenced by antitoxin. The streptococcus variety does not share that advantage. What I have to say of treatment, however, refers — always with the ex- ception of antitoxin — to all varieties. It will be for the atten- tive and experienced reader to apply it to the individual case, mild or serious, local or generalized, acute or chronic. Between these two latter varieties, however, the accurate differentiation is impossible, because diphtheria has no limited course. There are cases that last a week or less, there are those that take many months. Not a few of the latter (see my "Treatise") require, besides the general treatment, a very careful local diagnosis and treatment, as they are in part caused or prolonged by a local ulceration, tonsillar or peritonsillar abscess, or concrement, or other foreign body. Local diphtheritis, constitutional diphtheric infection, and diphtheric sepsis are different degrees of the same disease. The first may run a fairly mild course, or be the initial stage of the 254 THERAPEUTICS OF INFANCY AND CHILDHOOD. second and third. The treatment, accordingly, may be simple or complicated, successful or in vain. It should be preventive, local, increase the power of resistance to the toxin prepared by the bacilli and floating in the circulation and in the tissues, be directly antidotal, and be aimed against the results of the dis- ease, such as swelling of the lymph-nodes, laryngo-stenosis, nephritis, and paralysis. In many cases it may be only neces- sary to fulfil but one or two of these indications, in others a combination of measures and remedial agents may be de- manded. Diphtheria is one of the diseases in which it is easy to do too little, but also to kill the patient in the hurry and haste of fighting the disease. The treatment should be mainly preventive. In the light of the fact that the contagion of diphtheria need not be direct, but may be carried by persons who are not themselves taken, it will readily be seen how difficult it is to prevent, or to escape it. Herbert Peck reported (London Lancet, December 14, 1895) the case of house B, which was probably infected by the father of the family, who himself did not suffer from the disease. His son did not suffer, though there were germs in his throat, 'but he carried diphtheria to house C, whence it was taken to house D. This is only an instance of a large class. To what extent the bacilli and cocci in the mouths of healthy persons, where they are frequently found, may infect others, it is yet impossible to tell. That may depend on circumstances we have not yet much knowledge of. We know, for instance, that saliva is, to a certain extent, a disinfectant, but also that it is least so for the diphtheria bacillus (and the pneumococcus). It is also probable that a recent invasion is not so dangerous as older ones, which attain a higher degree of virulence when remaining some time in the crypts of the tonsils (E. Lexer, Arch. Tclin. Clair., 1897, vol. liv.). As a preventive measure* every individual case of diphtheria * See the New York Health Department's recommendations and rules on page 230. INFECTIOUS DISEASES. 255 demands isolation, during the winter on the upper floor of the house, the windows should be open as much as possible, furniture of any kind reduced to the least possible quan- tity, the room changed every few days, and the bedding fre- quently. To what extent the infecting substance may cling to sur- roundings is best shown by the cases of diphtheria springing up in premises which had not seen diphtheria for a long time, but had not been interfered with; and best, perhaps, by a series of observations of auto-infection. When a diphtheritic case has been in a room for some time, the room, bedding, curtains, and carpets are infected. The child is getting better, has a new attack, may again improve, and is again stricken down. Thus 1 have seen them die; but also improve immediately after hav- ing been removed from that room or that house. If barely pos- sible, a child with diphtheria ought to change its room and bed every few da} T s. The sick in crowded houses and quarters ought to be trans- ferred to a special hospital, which ought not to be too large. The Willard Parker Hospital, Xew York, with its sixty beds for scarlatina and diphtheria, is in that respect a praiseworthy example. The large amount of good it is doing would grow in geometrical progression if there were, as there ought to be in a large and ambitious metropolis, half a dozen institutions of the same class, not only in behalf of the poor, but of the well to do also, both townspeople and strangers. I have advocated, for dozens of years, the erection of a hospital for the accommoda- tion of infectious diseases breaking out among the thousands of strangers staying in Xew York City at all times. As long as there is no place to go to, the cases of scarlatina, diphtheria. etc., are hidden in, and are infecting, the boarding-houses and hotels, and the population at large. It is but two years now since a movement in favor of the establishment of such a hos- pital was begun. When diphtheria breaks out in a house, either private or 256 THERAPEUTICS OF INFANCY AND CHILDHOOD. tenement, with no facility of isolation and.no hospital in which to seek refuge, the well should be removed to a healthy place; in large cities, temporary homes ought to be provided for that purpose, to benefit the children of the poor. If the rich would but remember that their children will be affected through the many links between them and the poor (servants, messengers, schools, dresses brought home from the tailor or seamstress, or purchased in the stylish and expensive establish- ments which give out the work to tenement working-people and sweat-shops), their very egotism should compel them to do in their own interest what humanity does not appear to sug- gest to them. The sick should be reported to the health boards at once. The well children of a family with diphtheria must not go to school or church before a fortnight — the possible period of incubation, which some extend to twenty days — has elapsed since their last contact with the sick. Schools must even be closed now and then, when an epidemic makes its appearance; teachers should know how to examine a throat. In this respect the regular inspection of schools by medical men, as introduced in New York, will prove an infinite blessing to the community. The condition of the house is to be examined into and im- proved; attendants, servants, nurses and cooks, seamstresses and laundresses, teachers, shopkeepers, restaurant-keepers, bar- bers, hair-dressers, with their mild diphtheritic attacks and strong pecuniary interests, are frequent sources of infection. In times of common danger, public places, theatres, ball-rooms, dining-halls, public vehicles, hackney-coaches, and railroad-cars should be examined by the authorities. There must be no clashing permitted between the public good and the individual money-bag. Clothing, bedding, room, and house should be thoroughly disinfected; articles used in the sick-room burned or soaked in a disinfecting fluid in the room, not carried over the house in a dry state; the rooms thoroughly disinfected after a case terminated favorably or unfavorably; the corpse disinfected, the funeral private, nothing removed from the INFECTIOUS DISEASES. 257 house unless disinfected, no pieces of carpet thrown away to be picked up by beggars, no mattresses benevolently donated to the unsuspecting poor.* Prevention can accomplish a great deal for the individual. Diphtheria will, as a rule, not attack a healthy integument, be * To what extent contagion will prove dangerous the case reported to me by Dr. W. W. Ralston, of Horton, Kansas, may illustrate : . . . "The water used by the family is of the best quality, the drainage perfect, and the hygienic surroundings perfect, as far as I can make out. There has never been an undoubted case of diphtheria in the town, nor are there cases near here. The little fellow has not been away from home, nor have outsiders been at his home. "The case was at first tonsillitis, the result of exposure to cold. An abscess formed in one tonsil, and, after its rupture and discharge, the child had temporary relief. Up to this time there had been no par- ticular systemic disturbance other than the tonsillar trouble would account for, nor were the voice and breathing affected any different from what would be expected in this disease. A day or so before the abscess broke, his mother thought swabbing the throat with alum-water might give him relief, and she proceeded to do this, using a sponge- swab that she had used in swabbing the throat in a case of diphtheria in her family in Chicago two years ago. Two days after the use of this swab laryngeal stenosis began to show itself, together with a profound systemic disturbance characteristic of diphtheria, and death resulted in three or four days from septic absorption and obstruction to breathing. Before I saw him his mother had applied some liniment over the angle of jaw, which produced a blister. No change was ob- served on this blistered surface until about the time the laryngeal ste- nosis began to show itself, when a tough grayish membrane, closely adherent to the underlying surface and bleeding when detached, — which was done with difficulty, — showed itself. The urine showed by ordinary test about one-fourth albumin. I cannot account for the trouble in any other way than through the swab used. "The family moved from Chicago to Detroit, where they lived six months before coming here last February, carrying the swab with them on their travels. There can be no doubt but that the case in Chicago on which the swab was used was one of diphtheria. Diphtheria was epidemic in the part of the city in which they lived, and the diagnosis was made by an able physician. About one-third of those attacked in this epidemic died." . . . 17 258 THERAPEUTICS OF INFANCY AND CHILDHOOD. this cutis or mucous membrane. The best preventive is, there- fore, to keep the mucous membrane in a healthy condition, as I have tried to practise and teach these forty years. Catarrh of the mouth, pharynx, and nose must be treated in time. Many a chronic nasal catarrh, with big glands round the neck, requires sometimes but two or three daily salt-water irriga- tions (1-130, warm) of the nose, and, if the children be large enough to do so, gargling. The addition of one per cent, of alum will often be found useful. This treatment, however, must be continued for many months, and may require years. Still, there is no hardship in it, and no excuse for its omission. A. Caille's many eloquent appeals have done much to popularize it. The nasal spray of a solution of nitrate of silver, 1-500 or 1000, when there are erosions, will accelerate the cure. Its application must be repeated every other day for some time. Not infrequently has a treatment which was considered obso- lete when I was young been of great service to me. It consists in the internal administration of the tincture of pimpinella saxifraga. It is certainly an efficient remedy in subacute and chronic pharyngitis and laryngitis. I generally give it to adults, diluted with equal parts of glycerin and water, a tea- spoonful of the mixture every two or three hours, with the warning that no water must be taken soon after; children in proportion. Large tonsils should be resected and adenoid growths re- moved while there is no diphtheria. For during an epidemic every wound in the mouth is liable to become diphtheritic, and such operations ought to be postponed, if feasible. The scoop- ing out of the tonsils, for whatever cause, I have given up since I became better acquainted with the use, under cocaine, of the galvano-cautery. From one to four applications to each side (also to the post-nasal space) are usually sufficient for every case of enlarged tonsils or lacunar or deep-seated follicular amyg- dalitis ("tonsillitis"). It is advisable to cauterize but one side at a time, to avoid inconvenience in swallowing afterwards, and INFECTIOUS DISEASES. 259 to burn from the surface inward. Cauterization of the centre of the tonsils may result in swelling, pain, and suppuration, unless the cautery is carried entirely to the surface; that means to say, the scurf must be on, or extend to, the surface, not remain inside the tissue. Another precaution is to apply the burner cold, press it on, and then heat. A strong hook, bent in a con- venient angle, introduced into a follicular fistula, and torn through the superjacent tissue, will also cause cicatrization and a cure. Nasal catarrh and proliferation of the mucous and sub- mucous tissue may require the same treatment, but in my ex- perience the cases which demand it are less frequent than those in which the tonsils need correction. The presence of glandular swellings round the neck should not be tolerated. They, and the oral and mucous membranes, affect each other mutually. Most of them could be prevented, if every eczema of the head and face, every stomatitis and rhinitis resulting from uncleanliness, injury, or whatever cause, were relieved at once. Painstaking care of that kind would prevent many a case of diphtheria, glandular suppuration, de- formity, or pulmonary consumption. For its salutary effect on the mucous membrane of the mouth, chlorate of potassium, or sodium, which is still claimed by some to be a specific in diphtheria, or almost so, is counted by me among the preventive remedies. If it be anything more, it is an adjuvant only. It exhibits its best effects in the ca- tarrhal and ulcerous condition of the oral cavity. In diphtheria it preserves the mucous membrane in a healthy condition, or re- stores it to health. Thus it prevents the diphtheritic process from spreading. Diphtheria is seldom observed on healthy, or apparently healthy, tissues. The pseudo-membrane is mostly surrounded by a sore, hyperasmic, cedematous mucous membrane, to which it will then extend. Indeed, this hyperemia precedes the ap- pearance of the diphtheritic exudation in almost every case. 260 THERAPEUTICS OF INFANCY AND CHILDHOOD. The exceptions to this rule are formed by those cases in which the virus may take root in the interstices, pointed out by Stoehr, between the normal tonsillar epithelia. Indeed, many cases of throat-disease occurring during the prevalence of an epidemic of diphtheria are but those of pharyngitis, which, under favorable circumstances only, develop into diphtheria. These throat-diseases are so very frequent during the reign of an epidemic, that in my first paper on diphtheria (Amer. Med. Times, August 11 and 18, 1860) I based my reasoning on two hundred cases of genuine diphtheria, and one hundred and eighty-five of pharyngitis without a visible membrane. These cases of pharyngitis, and those of stomatitis and phar- yngitis which accompany the presence of membranes, are bene- fited by the local and general effect of chlorate of potassium. When the surrounding parts are healthy or return to health, the pseudo-membrane remains circumscribed. The generally benign character of purely tonsillar diphtheria, which is apt to run its full course in from four to six days, has in this manner contributed to secure to chlorate of potassium the undeserved reputation of being a remedy, the remedy, in diphtheria. The dose of the salt must not be larger than fifteen grains (one gramme) for an infant a year old, not over twenty or thirty (1.5-2) for a child from three to five years, in the twenty-four hours. An adult should not take more than one and a half drachms (six grammes) daily. These amounts must not be given in a few large doses, but in repeated doses and at short intervals. A solution of one part in sixty will allow a teaspoon- ful every hour or half a teaspoonful every half -hour in the case of a baby one or two years old. It is not too late yet to raise a warning voice against the use of larger doses. Simple truths in practical medicine do more than simply bear repetition: they require it. For though the cases of actual chlorate of potassium poisoning are no longer isolated, and ought to be generally known, fatal acci- dents are still occurring even in the practice of physicians. INFECTIOUS DISEASES. 261 When I experimented on myself, with half-ounce doses, forty- years ago, the results were 6ome gastric and intense renal irri- tation. The same were experienced by Fountain, of Daven- port, Iowa, whose death from an ounce (30.0) of the salt has been impressively described in Alfred Stille's "Materia Medica," from which I have quoted it in my "Treatise" on diphtheria. His death from chlorate of potassium induced me to prohibit large doses as early as 1860. In my contribution to Gerhardt's Handbuch der Kinderlcranklieiten, vol. ii., 18 7 7, I spoke of a series of cases known to me personally. In a paper read before the Medical Society of the State of New York in 1879 (Med. Record, March 15), I treated of the subject monographically, and alluded to the dangers attending the promiscuous use of the drug, which has descended into the ranks of domestic reme- dies; and finally, in my "Treatise" (Xew York, 1880), I col- lected all my cases and the few then recorded by others. Since that time the recorded cases have become quite numerous. The facts are undoubted, though the explanations may differ. The probability is that death occurs from methasmoglobinuria pro- duced by the presence of the poison in the blood, and consecu- tive nephritis, though Stockvis has tried, by a long series of experiments, to fortify my original assumption that the fatal issue was due to primary acute nephritis. There is, in every individual case, a certain danger, which, though it be common enough in other exhausting diseases, is of particular moment in diphtheria, where it is most fre- quent, even in apparently mild cases. It may be averted by meeting it early. It is heart-failure. "Where it has occurred, the indications for treatment become as clear as they are urgent but often futile. TThen it is simply feared, a preventive treat- ment will save many a case. Heart-failure is usually developed gradually. It is fore- shadowed by an increasing frequency and weakness of both heart-beats and pulse, by an occasional intermission, by un- equal frequency of the beats in a given period (say of ten 262 THERAPEUTICS OF INFANCY AND CHILDHOOD. seconds), or by the equalization of the interval between systole and diastole, and diastole and systole. This latter condition, which is normal in the embryo and fcetus, is always an ominous symptom; so is the too close proximity of the second sound (so as to become almost inaudible) to the first. Heart-failure is due, besides the influences common to every disease and every fever, to tissue changes in the myocardium, in the nerves, in the endocardium, and to the gradual forma- tion of blood-clots. These changes may be due to the ill- nutrition of the tissues resulting from every septic condition of the blood, or to specific alterations due to the diphtheritic pro- cess. Failure may either come on after having given warning, or it may be on you without any. Thus, every case of diph- theria ought to make us anxious and afraid. Indeed, there is no safety and no positive prognosis until the patient is quite recovered, and even advanced beyond the period in which paralysis may develop. Whatever enfeebles must be avoided; absolute rest must be enjoined. The patients must be in bed, without excitement of any kind; take their medicines — which ought to be as pala- table as possible — and their liquid food, and evacuate their bowels in a recumbent or semi-recumbent position; crying and worrying must be prevented; the room kept airy and rather dark, so as to encourage sleep if the patient be restless; and restless they are, unless they be under the influence of sepsis, and thereby subject to fatal drowsiness and sopor. In no dis- ease, except, perhaps, in pneumonia, have I seen more fatal results from exertion on the part of the sick, or from anything more fatiguing than a sudden change of posture. Unless abso- lute rest be enforced, neither physician nor nurse have dono their duty. The latter must avoid all the dangers attending the administration of medicines, injections, sprays, and washes. Preparations for the same must be made out of sight, every application should be made quickly and gently. On no account must a patient be taken out of bed for that purpose. I know of INFECTIOUS DISEASES. 263 children dying between the knees of nurses who called them- selves trained and had a diploma. Pharmaceutical preparations, such as digitalis, strophanthus, sparteine, caffeine, besides camphor, alcohol, and musk, should not be postponed until feebleness and collapse have set in. These are at least possible, even probable; and this is certain, that a cardiac stimulant will do no harm. It is advisable to use it at an early date, particularly in those cases in which, perhaps, antipyrin or antifebrin — the indications for which are certainly rare, as excessive temperatures are very exceptional only — is given. Besides, it is not enough that the patients should merely escape death; they ought to get up, cito, tuto, et ju~ cunde, with little loss and speedy recuperation; a few grains of digitalis or their equivalent — preferably a good fluid extract — • may or should be given, in a pleasant and digestible form, daily. When a speedy effect is required, one or two doses of two or four minims each are not too large, and must be fol- lowed up by smaller ones. When it is justly feared lest the effect of digitalis be too slow, I give, with or without it, strophanthus, in doses of from one to six drops of the tincture, or sulphate of sparteine. Of the latter an infant a year old will take one-tenth or one-fourth of a grain (six to fifteen milli- grammes) four times a day as a matter of precaution, and every hour or two hours in an emergency. Of the same importance are alcoholic stimulants. The ad- vice to wait for positive symptoms of heart-failure and collapse before employing the life-saving apparatus is bad. There are cases which get well without treatment, but we do not know beforehand which they will be. No alleged mild case is safe until it has recovered. When heart -failure has once set in — and often will it occur in apparently mild cases — our efforts are too often in vain. Thus alcoholic stimulants ought to be given early and often, and in large quantities, thoroughly di- luted. There is no such thing as danger from them or intoxica- tion in septic diseases. A few ounces daily may suffice; but I 264 THERAPEUTICS OF INFANCY AND CHILDHOOD. have often seen ten ounces (300.0) daily of brandy or whiskey save children who had been doing badly with three or four (90.0-120.0). Caffeine, or, in its stead, coffee, is an excellent cardiac tonic, except in those cases in which the brain is suffering from an active congestion. For subcutaneous injections the salicylate (or benzoate) of caffeine and sodium, which readily dissolves in two parts of water, is invaluable for emergencies, in occa- sional doses of from one to five grains (six to thirty centi- grammes) in from two to ten minims of water. From five to twenty grains (0.3-1.25) of camphor may be given daily, as camphor-water, or in a mucilaginous emulsion, which is easily taken. It does not so disturb the stomach as carbonate of am- monium is apt to do. For rapid effect it may be administered hypodermically, in four or five parts of sweet almond oil, which is milder and more convenient than ether. Strychnine may be added regularly from the beginning of danger, and mainly in cases with little increase of temperature. Its effect is more than momentarily stimulating. A child of three years will take a one-hundredth of a grain (^ milligramme) three times a day, and more in an urgent case, and then subcutaneously. But the very best internal stimulant in very urgent cases is Siberian musk. I prefer to give it from a bottle, in which it is simply shaken up with a thin mucilage. In urgent cases it ought to be given in sufficient doses and at short intervals. When ten or fifteen grains administered to a child one or two years old within three or four hours will not restore the heart's action to a more satisfactory standard, the prognosis is very bad. The local treatment of the pseudo-membranes of the fauces is a subject of great importance. To still look upon them as an excretion which needs no interference, is incorrect. If it were possible to remove or destroy them, it would be a great comfort; but they can be reached only in certain places, and just in those in which they do least harm. Pseudo-membranes on the ton- sils are the least dangerous, for their lymph communication INFECTIOUS DISEASES. 265 with the rest of the body is very scanty. Thus almost all forms of tonsillar diphtheria are among the most benign, at least as long as the process does not extend. Most cases of the kind run their mild course in from five to seven days, and it is just these which have given rise to the many proposals of tearing, scratching, cauterizing, swabbing, brushing, and burning. There are cases which do not show the harm done. But neither the galvano-cautery nor carbolic acid, nor tannin and glycerin, nor perchloride or subsulphate of iron can be applied with leisure and accuracy to the very membrane alone, except in the cases of very docile and very patient children. In almost every case the surrounding epithelium is getting scratched off or injured, and thus the diphtheritic deposit will spread. Besides, the membrane of the tonsil is altered surface tissue (it always is wherever the epithelium is pavement), and not deposited upon the mucous membranes, from which it might be easily detached, but embedded in the tissue. Whatever is done must be accomplished without violence of any kind. Nasal injec- tions or irrigations can be made so as to wash the posterior pharynx and the tonsils sufficiently, and thus render useless the special treatment directed exclusively to the throat. Be- sides, it is easier, meets with less objection, and gives rise to less exhaustion than the forcible opening of the mouth. This fact is of great importance, as I shall show in connection with the local treatment of the nasal cavity. Where it is possible to make local applications without difficulty, the membrane may be brushed with tincture of iodine several times daily, or a drop of rather concentrated carbolic acid. Of powders I know only one, the application of which is not contraindicated, — viz., calomel, perhaps also, iodol. Even this may irritate by its very form. Everything dry irritates and gives rise to cough or dis- comfort. Whatever has, besides, a bad taste or odor, such as sulphur, iodoform, or quinine, must be abhorred. Quidquid delirant medici pleduntur cegroti. Sugar has been recom- mended as a panacea, also table salt.(!) 266 THERAPEUTICS OF INFANCY AND CHILDHOOD. In bad cases of septic diphtheria applications of the tincture of the sesquichloride of iron have been highly recommended. The frequent doses of the tincture of chloride of iron intro- duced by me (see below) have the same, if no better, local effect. Loffler's solution of alcohol sixty, toluol thirty-six, and tincture of iron sesquichloride four parts is not preferable to many others. The injections into the tissue of the tonsils of carbolic acid or chlorine-water are objectionable in most cases, if it were only for the reason that they strike only the least danger- ous locality. The dioxide of hydrogen is a two-edged sword. It is cer- tainly a disinfectant, but in contact with mucous membranes it coagulates the soluble albumin of the tissue. More or less extensive discolorations and pseudo-membranous deposits were caused by it, which were quite often large enough to be mis- taken for diphtheritic. When they fell off there were sore sur- faces ready for another invasion of bacilli or cocci. Many such cases would get well only when the dioxide was stopped, and a simple local treatment with lime-water substituted. By some the injurious action was attributed to the presence in the drug of acid, while there have been those who claim the acidity to be the cause of its beneficial effect. For the purpose of dissolving membranes papayotin, or papain, has been employed. It is soluble in twenty parts of water, and may be injected, sprayed, or brushed on. I have used it in greater concentration, in two or four parts of water and glycerin, in the nose, throat, and, through the tracheotomy tube, in the trachea. One of the irrepressible drug manufac- turers and advertisers pushes the claims of a modification of the drug, which he calls papoid. For the same purpose trypsin is preferred by others. The mode of the application of papayotin is no indifferent matter. When applied in powder, it resulted in constant irritation of the throat, while the patient otherwise was convalescent. The pharyngeal hyperemia and slight exu- dation disappeared when mild alum washes were substituted. INFECTIOUS DISEASES. 267 Diphtheria of the nose is apt to terminate fatally unless ener- getic local treatment is commenced at once. This consists in persevering disinfection and cleansing of the mucous surface. The disinfecting procedure must not be omitted long, because general sepsis results from rapid absorption through the sur- face, which is supplied with lymph-ducts and small superficial blood-vessels to an unusual extent. Disinfectant or merely cleansing injections must be continued every hour, for one or more days. If they be well made, the consecutive adenitis, par- ticularly that about the angles of the lower jaw, is soon re- lieved, and the general condition improved. But there are cases in which it is not the lymph-bodies that are the main gates through which constitutional poisoning takes place, but the blood-vessels only. In the incipient stage of such cases the discharge from the nostrils is more or less sanguineous; in them the blood-vessels, thin and fragile, carry the poison in- ward with great rapidity. In a few cases injections are unsuccessful. They are those in which the whole nasal cavity is filled with membranous de- posits to such an extent as to require forcible removal. Some- times it is difficult to push a silver probe through them. This procedure may be repeated, the probe dipped in carbolic acid, or wrapped in absorbent cotton moistened with carbolic acid of fifty or ninety per cent. After a while injections or irriga- tions alone will suffice. But now and then the development of pseudo-membranes is very rapid, a few hours suffice to block the nostrils again, and the difficulty is the same. The liquids which are to be injected should be warm and fairly mild. Solutions of chloride of sodium (6 : 1000); satu- rated solutions of boric acid; one part of bichloride of mercury, thirty-five of chloride of sodium, and five thousand of water, more or less; or pure lime-water; or solutions of papayotin, or a solution of hyposulphite of sodium, will be found satisfactory. From the selection of these remedies it is at once apparent that the object in view is partly that of washing out and dissolving, 268 THERAPEUTICS OF INFANCY AND CHILDHOOD. and partly of disinfecting. I have not mentioned carbolic acid, which may be used in solutions of one per cent, or less. Its employment requires care, for much of the injected fluid is swallowed, and proves a danger to children of any age, but mostly to the young. Most of the syringes I find in my rounds are abominations. The nozzle must be large, blunt, and soft. After having rec- ommended for many years the common hard-rubber ear- syringe, the sharp end of which was cut off, I now use always a short stout glass syringe with soft-rubber mounting in front. When the children cannot, or must not, be raised, I employ the same solutions from a nasal cup, a spoon, or a plain David- son atomizer, the nozzle being lengthened by a short piece of rubber tubing. These applications can thus be made while the children are lying down, every hour or very much oftener, without any or much annoyance. The nozzle should be large enough to fit the nostril. Sprays will never be so effective as injections or irrigations. For a day or two these injections of fluids or sprays must be made hourly. It is not cruel to wake the children out of their septic drowsiness; for it is certain death not to do so. Injections of the nose are oftener ordered than judiciously made. Hundreds of times have I been assured that they had been made regularly, hourly, for days in succession. Still there was a steady increase of glandular swelling and sepsis. I never believe a nurse to have made them regularly unless I have seen her doing it. They will run up their syringe vertically and not horizontally; the fluid will return through the same nostril. On the successful injecting or spraying of the nares hangs every life in a case of nasal diphtheria. I have long learned to look upon a neglect to tell at every visit how to make an injection, as a dereliction of duty. This may appear a trifling way, but it is a safe one. The nurse must be made to tell you that at every injection the fluid returns through the other nostril, or through the mouth, or that it is swallowed. INFECTIOUS DISEASES. 269 The procedure is simple enough, and need not take more than half a minute for both nostrils. A towel is thrown over the child's chest up to the chin, and the child gently raised in bed by the person who is to make the injection. This person, sitting on the bed behind the patient, steadies the patient's head against her chest, while somebody else secures his hands. The syringe is introduced horizontally by the person sitting be- hind the patient, and gently emptied. No time must be lost in refilling and attending to the other side. There ought to be two syringes ready for use. When pain is complained of in the ears in spite of the utmost gentleness in injecting, — such cases will be found to be very exceptional, — more gentleness is re- quired, or the spray, or pouring in from a spoon, or minim- dropper even, or, better, from a nasal cup, has to take the place of the injection. Many sins are committed in doing this very simple thing. The unfortunate little one is made to see all the preparations, and is worried and excited, and the necessary gentleness in the proceedings is neglected in too many cases. For the purpose of softening and macerating pseudo-mem- branes steam has been utilized extensively. Its inhalation is useful in catarrh of the mucous membranes, and in many in- flammatory and diphtheritic affections. On mucous membranes it will increase the secretion and liquefy it, and thus aid in the throwing off of the pseudo-membranes. Its action is the more pronounced the greater the amount of muciparous follicles under or alongside a cylindrical or fimbriated epithelium. Thus it is that tracheo-bronchial diphtheria, so-called fibrinous bron- chitis, is greatly benefited by it. Children affected with it I have kept in small bath-rooms for days, turning on the hot water, and obliging the patient constantly to breathe the hot clouds. Several such cases I have seen recover with that treat- ment. Atomized cold water will never yield the same result. Nor have I seen the patented inhalers do much good. Still, where the surface epithelium is pavement rather than 270 THERAPEUTICS OF INFANCY AND CHILDHOOD. cylindrical, and but few muciparous follicles are present, and the pseudo-membrane is rather immerged in, and firmly co- herent with, the surface, — for instance, on the tonsils, — the steam treatment is less appropriate. On the contrary, moist heat is liable in such cases to favor the extension of the process by softening the hitherto healthy mucous membrane. Thus it takes all the tact of the practitioner to select the proper cases for the administration of steam, not to speak of the judgment which is required to determine to what extent the expulsion of air from the steam-moistened room or tent is permissible. Steam can be properly mixed with medicinal vapors. In the room of the patient water is kept boiling constantly over the fireplace, provided the steam is prevented from escaping di- rectly into the chimney, on a stove (the modern self-feeders are insufficient for that purpose and abominations for every reason); over an alcohol-lamp, if we cannot do better; not on gas, if possible, because of the large amount of oxygen which it consumes. Every hour a tablespoonful of oil of turpentine, and perhaps also a teaspoonful of carbolic acid, is poured on the water and evaporated. The air of the room is filled with steam and vapors, and thus the contact with the sore surfaces and the respiratory tract is obtained with absolute certainty. The secretion of the mucous membranes is sometimes quite abundant under the influence of steam, but still more, like that of the external integuments, increased by the introduction of water into the circulation. Therefore, drinking of large quan- tities of water, or water mixed with an alcoholic stimulant, must be encouraged. Over a thoroughly moistened mucous membrane the pseudo-membrane is more easily made to float and to macerate. To evolve large volumes of steam the slaking of lime has been resorted to. It is both an old and an effective procedure. Not only is the object in view accomplished by it, but it is the best means of bringing lime into contact with the morbid sur- face. In a room in which lime has been slaked, everything INFECTIOUS DISEASES. 271 is getting covered with it. Thus this method of profiting by the local effect of lime is decidedly preferable to the almost nugatory effect of lime-water sprayed into the throat. It was to fulfil the same indication of softening the pseudo- membrane, by increasing the secretion of the mucous mem- branes, that pilocarpine or jaborandi was highly recommended (Guttmann) as a panacea in all forms of diphtheria. There is no doubt that the secretion of the mucous membranes is vastly increased by its internal application, and by repeated subcu- taneous injections of the muriate or nitrate of the alkaloid, but the heart is enfeebled by its use. I have seen but few cases in which I could continue the treatment for a sufficient time. In many I had to stop it because after some days of persistent ad- ministration I feared for the safety of the patients. Therefore, as early as the meeting of the American Medical Association at Richmond, in 1880, I felt obliged to warn against its indis- criminate use in diphtheria. Thus it has shared the fate of all the hundreds of remedies and methods which have been de- clared to be infallible, and found wanting. Diphtheritic adenitis, the swelling of the cervical glands near the angles of the lower jaw, to which I have alluded as an ominous symptom, points to nasal and naso-pharyngeal (mostly mixed) infection. The main treatment consists in disinfection of the absorbing surfaces. Direct local treatment of the glands, if not entirely useless, is, at all events, of minor importance and efficiency. The ap- plication of an ice-bag of moderate size will render fair ser- vice. The use of one part of carbolic acid in ten of alcohol irritates both surface and patient more than it can do good. Inunctions may do some good by friction (massage) ; inunctions with some absorbable material in them may do a little better. The common iodide of potassium ointment is useless; iodide of potassium in three or five parts of glycerin is more readily absorbed; the same in equal parts of water, with a little animal fat, and six or eight times its quantity of lanolin, gives an 272 THERAPEUTICS OF INFANCY AND CHILDHOOD. ointment which is so rapidly absorbed that iodine is found in the urine within a few hours. Iodoform may be utilized in the same way. Injections of iodoform in ether, which I suggested years ago, are too painful. Mercurial inunctions, those of blue ointment, require too much time for any effect to take place. Oleates are too irritating locally; a lanolin ointment would prove more satisfactory in doing less harm. After all, however, the readiest method of reducing the swelling of the glands, and improving the prognosis accordingly, is that of cleansing and disinfecting the field of absorption. The rare cases of sup- puration in these glands require incision and disinfection. They are as ominous as they are rare, however. There is but little pus, as a rule, but one or many local deposits of disin- tegrated gland-cells and gangrenous connective tissue. The incisions must be extensive, the scoop and concentrated carbolic acid should be freely used. In these cases hemorrhages may occur, some of them very difficult to manage. I have seen some of them terminate fatally. In these carbolic acid must be avoided. Compression, actual cautery, and acupressure have rendered good service. Solutions of iron must be avoided, for the scurf formed is a shield, behind which deleterious absorp- tion is going on constantly in such wounds, as it does in the uterus. Antipyrin in water (1 : 5-2) is an excellent styptic. The internal treatment of an average case of pharyngeal diph- theria can be made to combine the indications of both internal and local administration. For forty years I have employed the tincture of the chloride of iron. It is an astringent and antiseptic. Its contact with the diseased surface is as impor- tant as is its general effect; therefore it must be given fre- quently, in hourly or half-hourly doses, even every twenty or fifteen minutes. An infant of a year may take three or four grammes (one drachm) a day, a child of three or five years eight or twelve grammes (two or three drachms). It is mixed with water to such an extent that the dose is half a teaspoonful or a teaspoonful; a drachm, or two drachms, with a small quantity INFECTIOUS DISEASES. 273 of chlorate of potassium (see above), in four ounces, allows half a teaspoonful every twenty minutes. No water must be drunk after the medicine. As a rule, it is well tolerated. There are some, however, who will not bear it well. Vomiting or diarrhoea is a contraindication to persevering in its use, for nothing must be allowed to occur which reduces strength and vigor. A good adjuvant is glycerin, a better one than syrups. From ten to fifteen per cent, of the mixture may consist of it. Now and then, but rarely, it is not well tolerated. When diar- rhoea sets in glycerin should be discontinued. Still, these cases are rare; indeed, the stomach bears glycerin very much better than the rectum. In connection with this remedy, I wish to make a remark of decidedly practical importance. I know quite well that re- covery does not always prove the efficacy of the remedy or remedies administered. But I have seen so many bad cases recover with chloride of iron, when treated after the method detailed above, that I cannot rescind former expressions of my belief in its value. Still, I have often been so situated that I had to give it up in peculiar cases. They were those in which the main symptoms were of so intense a sepsis, that the iron and other rational treatment were not powerful enough to pre- vent the rapid progress of the disease. Children with naso- pharyngeal diphtheria, large glandular swelling, feeble heart, and frequent pulse, thorough sepsis, and irritable stomach be- sides, those in which large doses only of stimulants, general and cardiac, may possibly promise any relief, are better off without the iron. When the circumstances are such as to leave the choice between iron and alcohol, it is best to omit the iron and rely on alcoholic stimulants mostly. The quantities re- quired are so large that the absorbent powers of the stomach are no longer sufficient for both. Nor is iron sufficient or safe in those cases which are pre- eminently laryngeal. To rely on iron in membranous croup means waste and danger. 18 274 THERAPEUTICS OF INFANCY AND CHILDHOOD. In this latter form of membranous croup, diphtheritic laryn- gitis, or laryngeal, also in general (pharyngeal and nasal), diph- theria, the most useful internal remedy is mercury. Empiri- cism has often praised calomel in small and large doses. My acquaintance with mercury in this connection is not at all new. Many years ago I published (Med. Record, May 24, 1884) a number of cases which got well under its use; at the same time that Dr. Thallon, of Brooklyn, published an article on the same subject. Since I have employed it (I prefer the bichloride), my conviction of the utter uselessness of internal medication in laryngeal diphtheria, so-called pseudo-membranous croup, is thoroughly shaken. Until about that time I felt certain of a mortality of ninety or ninety-five per cent, of all the cases "of laryngeal diphtheria not operated upon. These figures were not taken from small numbers, for I compared those of others with my own. The latter are not a few, either; for within thirty years (until about 1890) I have tracheotomized more than six hundred times, have assisted at as many more opera- tions, and have seen at least one thousand cases of laryngeal diphtheria which were not operated upon at all. During the years from 1883 to 1890 I have seen no less than two hundred cases, perhaps many more. Among them recoveries have not been rare at all, at all ages, from four months upward. The uni- form internal medication consisted in the administration of a dose of the bichloride every hour. The smallest daily dose ever given by me in the beginning was fifteen milligrammes, one-fourth of a grain, to a baby of four months; this was con- tinued a few days, and the dose then somewhat diminished. Half a grain (0.03) daily may be given to children of from three to five years, for four or eight days or longer. The doses vary from one-sixtieth to one-thirtieth (0.001-0.002). They require a dilution of one in six thousand or ten thousand of water or of whiskey and water. There is no stomatitis, gastric or intestinal irritation is very rare. It occurred in a few cases, but then it was found that the dilution had not been sufficient, one in two INFECTIOUS DISEASES. 275 thousand or three thousand only. If ever it exist, very small doses of opium will remedy it. The benefit to be derived from the remedy depends greatly upon the time of its administration. Tracheotomy or intuba- tion is required, as a rule, after days only, and can often be avoided if mercury be given in time. If the operation becomes necessary after all, the treatment must be continued diligently. Never have I seen so many cases of tracheotomy getting well, since 1863, as when the bichloride was being used constantly, since 1882. Nor am I alone with these favorable results. There are dozens of practitioners in New York City with whose methods and results I am well acquainted, some of whom are connected with me, in some capacity or other, who confirm the above statements. My experience with the bichloride is mainly gathered in cases of laryngeal and bronchial diphtheria, so-called pseudo- membranous croup and fibrinous bronchitis; it is there that it has been particularly effective. Still, but few of these were quite localized affections. Our cases of diphtheritic laryngitis are mostly descending, and complicated with either diphtheritic pharyngitis, rhinitis, or both. Not a few, mainly of the latter kind, exhibit constitutional symptoms of sepsis. Many such have also recovered. Another method of using mercury is that of sublimating calomel to be inhaled from time to time. It is particularly adapted to pseudo-membranous laryngitis. In any case of diphtheria there may occur conditions and complications which yield their own indications, and require the closest attention on the part of tne practitioner. I need not here refer again to the frequent attacks of exhaustion and heart-failure, which carry off a multitude of patients, unless they be met in time. What I said on previous pages on heart- failure and its prevention (or treatment) holds good in diph- theria, if anywhere. Therapeutical nihilism destroys as many lives as any number of direct mistakes in dosing. 276 THERAPEUTICS OF INFANCY AND CHILDHOOD. Nephritis, parenchymatous, interstitial and glomerular, and the varieties of pneumonia are frequent complications or con- sequences of diphtheria. The treatment of either of them re- quires no particular recognition in this place. Nor does oedema of the glottis yield indications differing from that occurring from other causes. Diphtheria of the skin and of the sexual organs requires disinfectant ointments. I have mostly relied on iodoform one part, in from eight to twelve of fat. Diphtheritic paralysis, though of various anatomical and histological origin, yields in all cases a certain number of iden- tical therapeutical indications. These are: the sustaining of the strength of the heart by digitalis and other cardiac tonics. A child of three years may take daily, for a month, three grains (0.2) or its equivalent; for instance, one grain (0.06) of the extract. This is an indication on which I cannot dwell too much. Many of the acute, and most of the chronic, diseases of all ages do very much better by adding to other medications a regular dose of a cardiac tonic. While it is a good practice to follow the golden rule to prescribe simply, and, if possible, a single remedy only, it is a better one to prescribe efficiently. Besides, there are some more indications: mild preparations of iron, provided the digestive organs are not interfered with; strychnine, or other preparations of nux, at all events. In ordi- nary cases a child of three years will take an eightieth of a grain three or four times a day (together 0.002). Local friction, massage of the throat, of the extremities, and trunk, dry or with hot water or oil, or water and alcohol; and the use of both the interrupted and continuous currents, according to the known rules and the locality of the suffering parts, find their ready indications. The paralysis of the respiratory muscles is quite dangerous; the apncea resulting from it may prove fatal in a short time. In such cases the electrical current used for very short periods, but very frequently, and hypodermic in- jections of sulphate of strychnine in more than text-book doses, and frequently repeated, will render good service. I remember INFECTIOUS DISEASES. 277 a case in which these, and the occasional use of an interrupted current, and occasional artificial respiration by Silvester's method, persevered in for the better part of three days, proved effective. In a few cases of diphtheritic paralysis the use of antitoxin appeared to score a success. Other forms of paralysis (hemiplegia, ataxia) demand a treatment like the above, modi- fied by their peculiar circumstances or symptoms. In regard to antitoxin, there are but few opposing voices left. Not quite so efficacious as thyreoid in myxcedema, it is more beneficial in its total usefulness because of the vast number of cases benefited by it. There is no practitioner but has at present the right — or rather the duty — to give it a place among his most reliable remedies. It is a pity that many of us, on account of distance, or other reasons for its inaccessibility, should be deprived of its services and compelled to rely exclu- sively on the treatment detailed above. There are in the worst forms of diphtheria so many urgent indications every one of which should be fulfilled, that the antidote of the circulating poison, if not on hand, will be sorely missed. For such a specific antidote it is, though it has not the power to cure every case of diphtheria any more than quinine cures every case of malaria or mercury of syphilis. Not counting isolated cases spread over the journals, the three hundred of Heubner's, five hundred of Baginsky's, thousand of Roux's, and the many hundreds of the hospitals of Paris and Vienna, besides those of our own country, yield a basis on which to establish calcula- tions. All observers agree on this point, that the sooner the antitoxin is injected the more certain is its effect. Some go so far as to assert that no case injected the first day need die. Dr. Henry Koplik, however, tells me that in cases complicated with pneumonia it acts badly. The doses to be administered are, according to Behring, as follows: according to the severity of a case, six hundred, one thousand, or fifteen hundred "antitoxin units" should be in- jected in a part of the body which contains loose subcutaneous 278 THERAPEUTICS OF INFANCY AND CHILDHOOD. tissue and is not exposed to pressure. This dose may be re- peated if the symptoms are not improved within a day. A "unit" is equivalent to one cubic centimetre of what is called "normal serum." Normal serum is the blood-serum of an im- munized animal, which has been made so efficacious that one- tenth of a cubic centimetre will antagonize ten times the mini- mum of diphtheria virus fatal to a guinea-pig weighing three hundred grammes (ten ounces). It appears to be a fact acknowledged by all that there is rarely, if ever, an immediate bad result of the injection, which ought to be made into the subcutaneous tissue, not into the muscles. The point of injection should then be covered with an antiseptic gauze, or with iodoform collodion. Not, infre- quently, however, there is redness, erythema, or urticaria around the point of injection. Besides, some of the after- effects are liable to be very severe. Urticaria, polymorphous eruptions, petechise and suggillations, excessive perspiration, swelling of glands, severe pain and swelling in feet and limbs and joints, pruritus recti, severe diarrhoea and vomiting, nose- bleeding, and great debility have lasted for weeks, yet termi- nated in recovery. Dr. Rauschenbusch observed on his four- year-old daughter, who took three times the dose while sick with diphtheria two years previously, pruritus, urticaria, vomit- ing, sopor, heart-failure, after two hundred units injected for the purpose of immunization (Berl. hlin. Woch., 1897, No. 32). A few sudden deaths have also been reported. No connection between them and the antitoxin has been established in any case, and venturesome generalizing speculations are not able to shed light on obscure subjects. Dr. James Ewing* studied the effect of antitoxin on the number and nature of leucocytes. While leucocytosis begins a few hours after the invasion of diphtheria, and increases, mainly as regards myelocytes (one nucleus, neutrophile granu- * New York Medical Journal, August 17, 1895. INFECTIOUS DISEASES. 279 lations, never found in the lymph-nodes), up to the climax of the disease and steadily declines during convalescence, — re- maining high only in most of the bad and fatal cases, — anti- toxin, according to Ewing, within thirty minutes after its in- jection, causes a reduction of the number of leucocytes. This reduction affects specially the uninuclear leucocytes, while the proportion of well-stained multinuclear cells is increased. In favorable cases, after the injection of antitoxin the leucocytosis never again reaches its original height. In severe and less favorable cases the injection is followed in a few hours by more hyperleucocytosis and fever. In very bad cases the immediate result may be either rapid increase or decrease of leucocytes, and death. The multinuclear leucocytes found in the blood of favorable cases after treatment with antitoxin show increased affinity for gentian violet. This change may be observed within twelve hours after the injection, and its non-occurrence is a very unfavorable prognostic sign. The existence of the after-effects mentioned above is not denied by any of the most enthusiastic admirers of antitoxin, but it is claimed that no serious or lasting results follow, and that if every life threatened by diphtheria were known to be protected by enduring the untoward effects of the remedy, we should willingly submit to them in every case. The balance of what we know of antitoxin is thus far favorable, and this addition to our therapeutical powers will forever be remem- bered as creditable to Emil Behring. The lack of recognition, which was some time ago withheld from him by many, was, most unfortunately, his own fault. The morbid vanity and some personal motives displayed in almost every one of his writings tallied so badly with the tendencies and spirit of a scientific benefactor as to render suspicious both his veracity and his motives. It is, therefore, a pleasure to notice greater circumspection and moderation in his later papers and dis- cussions. Still, it is a pity he is no clinician. If he were he would not have been tempted to assert that organotherapy has 280 THERAPEUTICS OF INFANCY AND CHILDHOOD. accomplished nothing, that cellular pathology has proved sterile, that remedies combat main symptoms only, that medi- cine hitherto had therapeutical principles only but no thera- peutical experiments, and that (his) experimental therapeutics is in conscious opposition to medication (German Congress of Int. Med., June, 1897). Altogether, the effects of antitoxin injections are eminently favorable. The fever of diphtheria is much lessened within or after a day, and the second fever-wave — so common between the third and the fifth day — is not often observed. The mem- brane is speedily disintegrated and disappears on the sixth day or sooner, while in cases not injected with antitoxin it lasts eight days or longer. Besides, there are but few cases on record in which the membrane returned after antitoxin, and not many in which it grew in size. In 181 cases of Heubner's there were but three relapses. Albuminuria and nephritis are common occurrences in diphtheria as early as the (second and) third day. Among those 181 cases of Heubner's, of those injected on the first day, five-sixths remained free; on the second, two- thirds; on the third, one-half; on the fourth, one-third. The results of Baginsky, Roux, and Widerhofer are similar. In 525 cases of Baginsky's treated with antitoxin there was al- buminuria in 40.95 per cent., clinical nephritis in 12.57 per cent., and post-mortem nephritis in 15.80 per cent. However, among 933 cases treated without antitoxin there was albu- minuria in 42 per cent., clinical nephritis in 25.78 per cent., and post-mortem nephritis in 16.31 per cent., — rather a favor- able showing for antitoxin. In his 525 cases, heart-failure was noticed as the cause of death in eight; it occurred in 5.69 per cent, of all the cases, while it took place in 10.9 per cent, of the 933 treated without serum, from 1891 to 1894. In Heubner's practice it occurred nine times, but was not fatal. It is claimed that whenever antitoxin is injected before laryngeal stenosis has developed, the larynx will remain free. It is certain that both tracheotomies and intubations have be- INFECTIOUS DISEASES. 281 come less in number. In Baginsky's hospital service there were, between the years 1890 and 1894, 1258 cases of diph- theria; 418 tracheotomies and 135 intubations were performed, with a total mortality in these 553 operations of 62 per cent. In the 418 tracheotomies the mortality was 64.4 per cent.; among these were 77 which were performed after intubation; these 77 had a mortality of 69 per cent.; 58 intubations with- out secondary tracheotomy had a mortality of 41.8 per cent. This condition of things changed with the period of antitoxin treatment. No case of laryngeal stenosis developed in those in whom the remedy had been injected before the larynx became affected. Thus, in 525 cases there were but 53 tracheotomies and 54 intubations, the former with 34 deaths, the latter with 2. It became necessary to perform tracheotomy after a pre- vious intubation in 12 cases; of these, 9 died. The speedier disintegration of the membranes and the (almost general) dis- continuance of their growth after the injection of antitoxin are the reasons why Baginsky prefers at the present time, in the injected cases, intubation to tracheotomy. Other observers arrive at similar results. Heubner had 33 operations in 181 cases, — viz., 23 tracheotomies with 52 per cent., 10 intubations with 80 per cent, recoveries. Paralysis is no less frequent in antitoxin cases than it was formerly. But we must not lose sight of the fact that it never was exclusively found in very bad cases, but quite often after mild ones. Perhaps it results more from a mild but protracted poisoning than from a sudden and severe one. It may be, also, that many cases which survive with antitoxin and develop paralysis would not have lived to become paralyzed under a less satisfactory treatment. The principal question, however, to be raised in reference to any medication in cases of serious disease is its life-saving power. In its issue of August 8, 1895, the Deutsche medi- cinische WocJienschrift published a preliminary result of its col- lective investigation of antitoxin treatment. The report refers 282 THERAPEUTICS OF INFANCY AND CHILDHOOD. to 10,312 cases of diphtheria treated in the city of Berlin and outside: total mortality, 11.8 per cent. Of that number, 4479 were treated without antitoxin and 5833 with it. Of all the patients, 1233 were below two years, with a mortality of 29 per cent.; 6740 from two to ten years, with a mortality of 11.4 per cent.; 2339 over ten years, with a mortality of 3.9 per cent. Of the 4479 treated without antitoxin (mortality 14.7 per cent.), 498 were below two years, with a mortality of 39.7 per cent.; 2710 from two to ten years, with a mortality of 15 per cent.; 1271 over ten years, with a mortality of 3.7 per cent. Of the 5833 treated with antitoxin, 735 were below two years, with a mortality of 21.8 per cent.; 4030 from two to ten years, with a mortality of 8.8 per cent.; 1068 over ten years, with a mortality of 4.1 per cent. On the first and second days antitoxin was injected in 401 cases of less than two years, with a mortality of 11.8 per cent.; 2256 cases of from two to ten years, with a mortality of 4 per cent.; 696 cases of over ten years, with a mortality of 1 per cent.; total, 3353 cases, with an average mortality of 4.2 per cent. On the third day and later antitoxin was injected in 334 cases of less than two years, with a mortality of 34.4 per cent.; 1774 cases of from two to ten years, with a mortality of 14.9 per cent.; 372 cases of over ten years, with a mortality of 9.9 per cent.; total, 2480 cases, with an average mortality of 16.9 per cent. Among the antitoxin cases there were 1018 of diphtheritic croup, of which 701 were treated without tracheotomy, with a mortality of 17.9 per cent.; 317 with tracheotomy, with a mortality of 33.1 per cent. These figures show, undoubtedly, that only the very urgent and most severe cases were subjected to the operation. Of all the cases of laryngeal stenosis, there were, below two years, without tracheotomy, 130, with a mor- tality of 29.3 per cent.; below two years, with tracheotomy, 49, with a mortality of 49 per cent.; from two to ten years, without INFECTIOUS DISEASES. 283 tracheotomy, 484, with a mortality of 15.9 per cent.; from two to ten years, with tracheotomy, 250, with a mortality of 30 per cent.; over ten years, without tracheotomy, 87, with a mortality of 12.7 per cent.; over ten years, with tracheotomy, 18, with a mortality of 38.8 per cent. Not the least interesting statements refer to the quantities of antitoxin employed. In 3497 cases, 600 antitoxin units, or less, were used in 497 cases under two years, with a mortality of 16.1 per cent.; 2370 cases from two to ten years, with a mortality of 5.3 per cent.; 630 cases over ten years, with a mor- tality of 1.8 per cent.; the average mortality being 6 per cent. In 2336 cases, up to 1000 antitoxin units were used, of which 238 cases were under two years, with a mortality of 33.6 per cent.; 1660 cases were from two to ten years, with a mor- tality of 13.8 per cent.; 438 cases were over ten years, with a mortality of 7.5 per cent.; the average mortality being 14.6 per cent. These figures show that the milder cases, in which 600 units were considered enough, did best; that those which from the beginning offered a worse prognosis were given more antitoxin and did not behave so well. That means, among other things, that mild cases do better under any treatment than severe ones, in proportion. It also proves the necessity of not relying, im- plicitly, on a single method of treatment exclusively. Among the most enthusiastic eulogizers of antitoxin there is none but admits failures. Many of these are attributed to an insufficient strength of the serum. Mere serum of an immune animal does not suffice. Others — and these are the most con- clusive — depend on the insufficient power of resistance on the part of the patient. Thus the antitoxin injection alone should not be relied on. Nutrition and alcoholic and other medicinal stimulation must be resorted to. In regard to other treatment the authorities differ. Some, like Escherich, Baginsky, and Roux, favor it, Escherich particularly after the membranes have fallen off. Heubner rejects it. At all events, there are 284 THERAPEUTICS OF INFANCY AND CHILDHOOD. but few left who maltreat both the throat and the child by the former cruel methods of local applications and cauterizations. It should not be overlooked that the antitoxin does not destroy bacilli, which continue the evolution of toxin persistently. I have advised, whenever I had an opportunity, the combina- tion of my mercurial treatment with the antitoxin, for the reports on the efficacy of mercurial treatment as recommended by me (p. 274) are becoming more and more favorable. Ben- ney's Australian results and reports are very conclusive.* Some New York friends, to whom I offered antitoxin, declined it, declaring themselves fully satisfied with the results they obtained from mercury and intubation. On the other hand, a towns-fellow of ours who handles antitoxin a good deal pro- nounces mercury and antitoxin to be incompatible, and believes that mercury will interfere with the effect of antitoxin. This assertion has not been proved, but shows the facility with which postulates may be substituted for experience during a period of enthusiasm. No greater eulogy, both on mercury and on antitoxin, can ever be pronounced than the figures detailed by Dillon Brown and referred to below. These results tally perfectly with the very exhaustive report of the hospitals of the London Metropolitan Asylums Board (London Lancet, June 5, 1897), which, for the year 1896, proves a great reduction in the mortality of cases brought under treat- ment on the first three days of illness, the lowering of the com- bined general mortality to a point below that of any former year, the still more remarkable reduction in the mortality of the laryngeal cases, the uniform improvement in the results of tracheotomy, and finally the beneficial effect produced on the clinical course of the disease (N. Y. Med. Rec, September 4). Additional statistics concerning the effect of antitoxin are too numerous to be reported here. The collective investigation of the American Pediatric Society of 1895, the results of the * Australian Medical Journal, January 20, 1895. INFECTIOUS DISEASES. 285 Boston City Hospital, and of endless other institutions, and those of painstaking practitioners all over the world, are unani- mous in regard to its efficiency, and to the lowered mortality following its use. The doses are, however, larger than those employed at first. So far as immunization through small doses of antitoxin is concerned, it appears to have been accomplished, in the opinion of many; but they all agree that it does not last long. Those who know that diphtheria, once induced, predisposes rather than protects will have no particular confidence in the effect of antitoxin as an immunizer; but if it saves the lives of many who are stricken, its sphere of usefulness will be indeed exten- sive. The collective investigation of the American Pediatric Society (Montreal session of May, 189G), which extends over many thousands of cases, is equally favorable. 20. Rheumatism. Acute articular rheumatism is a frequent disease both in in- fancy and childhood. Since I made this statement twenty-two years ago,* after ob- servations extending over more than twenty years, a few au- thors accepted and verified it. But the majority are still of the opinion, inherited from their predecessors, that infancy and childhood are immune or almost so. Thus it is only a dozen years ago that Edlefsen reported to the German Congress for Internal Medicine (Transactions, 1885, p. 323) but eleven cases of acute rheumatism under five years, none of which was younger than two. The assertion that the disease is rare under four or under two ) r ears is frequently met with. Nothing can be more erroneous. The frequency of valvular diseases, mainly of the left side of the heart, in children of * A. Jacobi, "Acute Rheumatism in Infancy and Childhood," 1875, in a series of American clinical lectures., edited by E. C. Seguin, M.D., vol. i. No. 2. 286 THERAPEUTICS OF INFANCY AND CHILDHOOD. from four or five years to adolescence ought to suggest the fre- quency of rheumatism; for only few of them are due to scarla- tina, almost all are secondary to rheumatism, than which there is no more frequent cause of cardiac disorder. They cannot be claimed as congenital, for the fact that very few of the foetal diseases of the heart are found on the left side, and but a small number survive the first (or perhaps second) year, remains un- disturbed. Nor is the number of rheumatic cases limited to those exhibiting cardiac symptoms; for though endocarditis is of more frequent occurrence — compared with the number of cases — in the rheumatism of children than it is observed in adults (in whom from ten to twenty per cent, contract a perma- nent organic lesion of the heart), still there must be, and are, many cases of acute rheumatism which run their full course without terminating in heart-disease. In order to ascertain this, the heart is to be watched in every doubtful case. Endo- carditis is sometimes the first symptom of acute rheumatism in children, and precedes every other even in apparently mild cases, and pericarditis and myocardial changes are not rare. When the slightest symptom of chorea minor shows itself, the heart should also be examined together with the joints, for there are those cases in which chorea is not the final develop- ment of rheumatism and rheumatic endocarditis, but the very beginning of the disease, and then referable to a rheumatic affection of the spinal membranes, or of the heart-muscle. All of these remarks I believe to be opportune, because of the frequency of cases in which the persistent notion that rheu- matism is a rare disease gives rise to an erroneous diagnosis — the ubiquitous "dentition," "worms," "malaria," and "colds" — and to false treatment. After all, a correct diagnosis is the foundation and sine qua non of sound therapeutics; thus I shall, in this neglected instance, add a few words on the subject of diagnosis, which is sometimes quite difficult. Fever is a common symptom in small children; every physi- cal disturbance raises their temperature. In acute rheumatism INFECTIOUS DISEASES. 287 it is often but slightly elevated; it sometimes rises at irregular times, being now and then highest about noon. The swelling of the joints is apt to be very trifling and is often overlooked, the pain (either spontaneous or on pressure) may be very much less than that resulting from fatigue, rhachitis, syphilitic bone- disease, colic, or otitis. Thus in every doubtful case of discom- fort or pain the joints and heart should be examined for rheu- matism. The diagnosis of acute articular rheumatism becomes quite difficult when but a single joint is affected, either tem- porarily or through the whole course of the attack, for a uni- lateral arthritis is very apt to be tuberculous or traumatic. Still, rheumatic monarthritis is observed principally in the hip- or knee-joint. Sometimes, after a week only or still later, the additional inflammation of other joints facilitates the rec- ognition of the exact condition. Isolated inflammatory rheu- matism fails also often to be recognized because of its being denominated "growing pain." The latter term dates from the medical nomenclature of past centuries, and ought to have been dropped long ago. What has been called by that name is of variable origin and nature. Sometimes it is fatigue only. It may be neurosis of a joint with or without an cedematous swell- ing. I have seen a number of such instances in children of both sexes, about the shoulder-, hip-, and knee-joint mostly. Another affection which has been classed under the head of "growing pain' 3 is rhachitical or other epiphysitis and the con- gestive swelling of the intermediate cartilage of the long bones. It is a frequent occurrence, without a perceptible cause besides the physiological hyperemia which is required for normal growth, and liable to become pathological; it is often noticed in the convalescence, or recovery, from infectious diseases, particu- larly scarlatina. Still, the large majority of attacks of "grow- ing pain" mean rheumatism; it is the failure to appreciate this fact that gives rise constantly to mistakes in diagnosis, and the neglect in the administration of both preventive and curative measures. 288 THERAPEUTICS OF INFANCY AND CHILDHOOD. Eheumatism of the cervical column is apt to be very painful and attended with high fever, stiffness of the neck, retracted head, delirium, and sometimes vomiting. Some of these symp- toms are those of cerebral meningitis, and errors in diagnosis are easily made. There is no uniform cause or character of rheumatism. Staphylococcus aureus and pyogenous streptococci, mainly streptococcus citreus and diplococcus, have been met with. Does that mean that one or all of them are the origin and foun- tain of rheumatism, and that perhaps the latter is the result of many different infections by pyogenous cocci, whose virulence is lessened? Besides, there are certainly cases of rheumatism which are not microbic; those connected with psoriasis seem to be neuropathic, those with erythema multiforme non- microbic, and the inflammations of joints occasionally caused by (Klebs-Lofner) diphtheria antitoxin are surely not so. The essential character of rheumatism becomes still more dubious when we consider those cases of joint inflammation whose connection with known infectious diseases can be proven. They are called rheumatoid, and exhibit either pain, or inflam- mation, or suppuration. They follow typhoid fever, dysentery, parotitis, gonorrhoea, pneumonia, diphtheria, influenza, cere- brospinal fever, scarlatina and other acute exanthems, hem- orrhagic diathesis, and catarrhal angina, also syphilis. The contents of the joint were found to differ in gonorrhoea, pneu- monia, diphtheria, and erysipelas; now and then the heart will be affected, mainly in scarlatina. In but few of them salicylic acid has the same effect which it displays in the majority (only) of genuine, independent, acute rheumatisms. In most of them antipyrin (with or without salicylates) acts better than sali- cylates alone. In syphilitic arthritis, however, it has no effect at all; iodides only are useful. Altogether, the treatment of acute articular rheumatism has been quite unsatisfactory down to a modern time. A few of the indications are furnished by the actual or alleged causes of the INFECTIOUS DISEASES. 289 disease. By some it has been believed to be endemic; it is sure that certain localities have been known to harbor a great many cases at the same time. In these, a change of residence, if practicable, ought to be resorted to, provided the individual case is but one of a great many in the same neighborhood. Contagion has now and then been presumed to cause the spreading of the malady; but the number of observations of the kind is but very limited indeed. The greatest possible care bestowed on those sick with infectious fevers will prove a powerful preventive of rheumatic fever. The blood has been found to be changed during the latter affection; the red cells and haemoglobin are diminished, the white cells and fibrin increased. According to many writers, both chemists and physicians, the alkaline condition of the blood is less pro- nounced. This change, or the actual prevalence of acid in the blood, has also been either proved, or assumed to exist, in cachectic conditions of many kinds, in fevers, uraemia, leucocythaemia, diseases of the liver, in poisoning with acids, lead, and mercury, in pyaemia, typhoid fever, gout, and diabetes. In them, as in acute rheumatism also, lactic acid has been found in an undue proportion. It is the same acid which has been found in over-exerted muscles; still, when introduced into the circulation, it never produced articular rheumatism. The diminution of the alkali of the blood would justify at once the administration, through the whole course of an acute rheuma- tism, of alkaline salts, and particularly potassium; the latter is greatly diminished according to Beneke, who, besides its rela- tive absence, looks upon the impairment of nerve-power and the accumulation of organic acids as the main factors in the pathogenesis of rheumatism. Sudden changes of temperature are certainly among the causes of acute rheumatism. Cold and moist weather, moist houses, exposure to wind and rain will bring it on. This effect may be immediate, and consists in the sudden suppression of the cutaneous circulation and elimination, or gives rise, by re- 19 290 THERAPEUTICS OF INFANCY AND CHILDHOOD. flex action, to vasomotor or trophic disturbances in the joints. Particularly is that so in those who have inherited a disposition. Such an inheritance is not at all infrequent. I have seen acute rheumatism in several children of a rheumatic father or mother. The treatment of such cases must be mainly preventive. The tendency to be influenced by sudden changes of the surround- ing temperature can be modified or removed by the systematic use of cold water. Children with disposition to rheumatism should have a daily cold wash, sponge, or bath. The former is the mildest mode of application. They may be rubbed down with a wet sheet, and afterwards with a warmed dry and coarse bathing towel. Those who have been strengthened by this procedure, or such as are stronger, may be sponged, or use a shower-bath for a few seconds, or a cold bath. These will be well tolerated and prove useful, when the surface, mainly of the extremities, becomes warm after a moderate dry friction. Such children as feel chilly after these applications, may begin their treatment with tepid water and alcohol (4-6 : 1). I ought to add here, that this treatment will accomplish its end best when throughout the rest of the day great care is used to protect the surface. A cold wash or bath, given to harden and strengthen, must be combined with warm clothing and bedding to protect. Nothing could be more injurious than the exposure of the sur- face to wind and rain. The bare knees and calves of the chil- dren of vain mothers are foolhardy provocations of the invasion of many of the serious diseases. Sea-bathing is a first-class roborant, except in the presence of heart-disease. The swollen and painful joints must be protected against the pressure of blankets or painful handling by raising the bed- clothes, keeping the limbs in a basket of proper size (waste- paper basket), and covering them thickly with cotton. Well- covered splints add greatly to the comfort of the patient. When pain and swelling are unusually severe, the application of an ice-bag or ice-cloth is advisable. Very young or anaemic chil- dren do not bear them long. Cold water will then take the place INFECTIOUS DISEASES. 291 of ice-water or ice. A wet bandage, or pack, round the afflicted joint is often borne well and relished. It ought to be changed every hour or half hour. Very anaemic and neurotic patients prefer hot and dry applications, mainly in those cases in which the pain is the principal symptom complained of. To relieve the latter I cannot advise the subcutaneous injections of car- bolic acid which have been recommended; in very severe cases I have been compelled to administer a few drops of a solution of morphine hypodermically. As a rule, however, oleate of morphine or a mild solution (from two to four per cent.) of muriate of cocaine on the skin, a chloroform liniment brushed on, chloroform poured into the cotton surrounding the joint and retained by oil silk, or a very mild galvanic current now and then, also the application of oil of winter-green, will give some relief. The swelling of the synovial membranes and ligaments in retarded convalescence or chronic cases taxes the patience of both the sick and the physician. Vesicatories kept on for half an hour, and frequently repeated; the wet bandage or pack snugly applied so as to compress gently; compression by band- ages, or collodion, gentle massage; the galvanic current daily applied, find their indications in many and various cases. Iodine will come in for its share of usefulness. Besides the internal administration of the iodides (potassium or sodium, or both combined, in doses of grs. 5-20 daily [0.3-1.25]), the external applications will be found beneficial. The officinal ointment will act through the gentle handling and kneading necessitated by its use. Solutions of the iodide of potassium in glycerin will act better, but are inferior to the lanolin oint- ment referred to in a former chapter. Superior to all, however, is the application, twice daily, of one part of iodoform in from eight to fifteen of collodion or flexible collodion. It is brushed over the swollen part copiously, and allowed to dry while the limb is kept absolutely at rest for ten minutes. Only such scales as get detached spontaneously may be removed; other- 292 THERAPEUTICS OF INFANCY AND CHILDHOOD. wise the next application is made on top of the preceding ones. Very old cases, with chronic effusion into the joint, require aspiration and washing out. These manipulations have become safe in the hands of every physician who learned the use of soap and of disinfectants on himself and his instruments since oper- ative surgery availed itself of the immense progress made in pharmacological laboratories. Endocarditis demands absolute rest, both of the organ and the body. Every exertion will prove injurious. Thus an occa- sional dose of opium or of a bromide, or of both combined, and the use of iodide of potassium in daily doses of from one-half to one gramme, have a good effect. The application of an ice- bag to the cardiac region, or, when that proves too heavy, an iced cloth, acts very favorably indeed. But not every murmur means endocarditis; it may be the result of muscular incom- petency or irregular contraction only, and quite temporary; it is sometimes observed in cases of but moderate severity, and mainly combined, or alternating with, or preceding chorea minor, which now and then makes its appearance in the very earliest period of acute rheumatism. Both chorea and endo- carditis can be mitigated or prevented by early attention. If every case of incipient rheumatism were sent to bed, if no "growing pain" were allowed to be on the play-ground, or at school, many a life-long ailment and early death would be avoided. The temperature is but rarely high, or rather there are a great many cases of articular rheumatism in infants and chil- dren in which the temperature is as little elevated as the rest of the symptoms urgent. But there are such as have rectal temperatures of from 104° to 107° and more. It is in these that delirium and other cerebral symptoms, and paralytic res- piration and collapse, may make their appearance, and that the most efficient antipyretics must be employed. Among them the cold pack, as described in a former chapter, and applied to the trunk and lower extremities as far down as the knees, is the INFECTIOUS DISEASES. 293 readiest and most effective remedy. It is particularly indicated in cases complicated with endocarditis; it is in these that anti- pyrin, acetanilide ("antifebrin"), and phenacetin will not always have a pleasant effect. All of them are inferior to the salicylate of sodium in regard to antirheumatic and antipyretic action. A child of three years may take from six to ten grains (0.4-0.6) every two or three hours, for one or more days. This is the less dangerous the more the symptoms of overdoses are understood. When they appear (mainly the brain symptoms, tinnitus, stupor, paralytic or interrupted, sighing, respiration) ample time is given for the discontinuation of the drug; a single large dose for the night, of from ten to twenty-five grains (0.6-1.5), succeeds better, sometimes, than the many smaller ones. As a rule, salicylate of sodium mitigates the symptoms of pain, swelling, and fever very soon. Many of the patients feel very much better after the lapse of a day; then the doses may be diminished or administered at longer intervals. Longer than from three to five days it ought not to be given; if no effect, or an insufficient one only, be obtained after that time, no further reliance need be bestowed on it. Then antipyrin, antifebrin, or phenacetin may accomplish what the salicylate failed in. In the same way salol, salicin, and cresotic and benzoic acids have been recommended. Lactophenin has been unsatisfactory. Salipyrin in three or four daily doses of from four to ten grains (0.25-0.6) acted more favorably. At the same time, particularly when there is a constant ten- dency on the part of the temperature to rise either permanently or periodically, sulphate (or another preparation) of quinine may be administered in one or two doses of from five to eight grains (0.3-0.5) each. The most opportune time is the period of remission which mostly takes place in the morning. Alka- line salts may be given alongside the other medication, alkaline mineral waters, such as Seltzer or Vichy or bicarbonate of sodium, from a scruple to a drachm (1.0-4.0) daily, or citrate of potassium, or the bitartrate; or one of the nitrates which have 294 THERAPEUTICS OF INFANCY AND CHILDHOOD. formerly been credited with almost a specific action. Vegetable acids have been warmly recommended, such as citric acid. They take the place of alkaline salts, inasmuch as they are elim- inated as carbonates. The iodides of potassium and sodium have been esteemed very highly, — justly so, indeed, — particu- larly as the tendency to chronicity renders desirable the per- sistent effect of a powerful absorbent. Of the other remedies, which have been given for their alleged specific effect (colchi- cum, colchicin, veratrum, aconite), I have seen but little effect in acute rheumatism of infancy and childhood. They, too, render better service in the cases which have become or are fast becoming chronic. During the attack of an acute, or subacute, articular rheu- matism the diet should be strictly milk, farinaceous food, light vegetables, and fruit. Meat and alcoholic beverages are posi- tively forbidden. Gonorrheal articular rheumatism is not excessively rare among infants and children, though direct sexual intercourse be not frequent at that age. It is not at all confined to one or a few joints, or to those of the lower extremities; it is subacute mostly; the effusion is liable to be excessive, and apt to be purulent. The latter condition, being dangerous partly to the joint, and partly through its tendency to infect the body, must be watched carefully; for it is often the beginning, or part, of a general pyaemia; in a few instances I have seen the eye de- stroyed by panophthalmitis in twenty-four hours, and the child died, after weeks of suffering, of the general infection. There are also cases of septic endocarditis. The cause is often what is easily taken for a common vaginal catarrh, but is gonorrhoea. The long time the latter may be concealed, unchanged in its contagiousness, within the vagina of the adult, and the facility of communicating it to the young by direct contact or mediate communication through towels, bedclothes, etc., yield a clue to certain otherwise unexplainable cases. In a small child's institution I saw a dozen cases at one time. The treatment of INFECTIOUS DISEASES. 295 the diseased vagina has its own indications. That of the joint affected with gonorrheal rheumatism must be more local than the average case. An aseptic puncture may be made for the purpose of ascertaining the contents of the synovial cavity. If there be pus, it must be removed and the cavity washed out, thoroughly disinfected, the limb rested on a splint and gently compressed; if serum in large quantity, puncture may become necessary when other treatment becomes unavailing. Other- wise gentle but steady compression by bandages, with or with- out mercurial plaster underneath, or by iodoform collodion, are indicated; at the same time the use of salicylate of sodium and iodide of potassium and (or) sodium must be continued a long time. During and after an attack of acute articular rheumatism there will be noticed, occasionally, small neoplasms on tendons and the insertions of muscles, on fasciae, and on periosteum, varying in size, numbers, and sensitiveness, which consist of young connective tissue with numerous cells, last from a few days to several months, and give rise to but little elevation of temperature. Sometimes they are the very last, or only remain- ing, symptoms of the disease; now and then a new endocarditis has been observed to make its appearance with them. This "nodulated rheumatism" "rheumatismus nodosus," is more fre- quent in children than in adults; the oldest patient in whom I have seen it was a boy of eighteen years. In his case the inser- tion of the occipital muscle was the principal seat of the nod- ules, dozens of which, from the size of a pea to that of a small hazel-nut, could early be distinguished. From syphilitic gum- mata, fibromata, gout, and cutaneous tubercles they can be dis- tinguished easily. Special therapeutics for this form there is none. But endocarditis is a frequent occurrence. Peliosis rlieumatica is the name of a peculiar form of more or less localized purpura. In some cases of rheumatism a large number of small subcutaneous and cutaneous hemorrhages appear mostly on the lower extremities, and mainly round the 296 THERAPEUTICS OF INFANCY AND CHILDHOOD. joints. Now and then they are painful, but frequently not sensitive at all. In this they do not differ from common pur- pura. In a number of cases of peliosis the heart was not found affected; and the inference has often been drawn that peliosis is no rheumatism at all. Indeed, purpuric hemorrhages are often noticed in other infectious diseases (typhoid, measles, whooping-cough, pneumonia, Bright's disease, syphilis, mer- curialism), and not infrequently round the malleoli and the joints in general (maybe in consequence of the impediment to circulation resulting from the smaller amount of subcutaneous fat and consequent tension of the integument in those regions), and in a number of instances the accompanying articular pains of such constitutional diseases are best explained by the pres- ence of hemorrhages inside. Still, peliosis will sometimes ap- pear quite early in acute rheumatism; these are the cases which were classified as a specific variety, and that is why peliosis was claimed to be a specific rheumatic affection. If so, it requires no special treatment; but the structural condition of the walls of the blood-vessels (and insufficient innervation and the presence of specific bacilli ?), which causes the hemorrhages, indicates the early administration of roborants and cardiac stimulants through the whole course of the disease, and great caution in the doses and quantities of salicylate of sodium, which has rather a disposition to increase the hemorrhagic tendency. There are a great many varieties, or rather degrees, of pelio- sis, similarly to what we know to take place in purpura. Ac- cording to whether the hemorrhage takes place near the surface or in the deeper layers of the tissue, both the color and the mas- siveness of the hemorrhage will differ. In some cases the result is an erythema, which has been called either papillosum or nodo- sum from the differences in the results of inspection and pal- pation. It is observed both in severe and mild cases of articu- lar rheumatism; it is somewhat raised above the level of the skin, sometimes deeply inserted and then circumscribed; and frequently found near the joints. In accordance with the indi- INFECTIOUS DISEASES. 297 cations furnished by rheumatismus nodosus and peliosis no special therapeutics is required for this form. Chronic articular rheumatism is but rare in childhood. Mon- corvo reports the case of a girl of two and a half years, whose rheumatism began with an acute attack, became chronic, and was finally cured by the galvanic current administered for a long time in succession. The youngest case of mine, also a girl, was five years old. She was puny and feeble, and her gen- eral nutrition defective. A number of the large and small joints, particularly of the hands, was affected, and the tumefac- tions of the ends of the bones were quite marked. There was neither an affection of the voluntary muscles nor of the heart, and no disease of any part of the nervous system, which Mitchell (1831) and Charcot (1868) found to be the cause of "arthropathia swellings. The treatment is about the same which is resorted to in the same disease when met in the adult. Salicylate of sodium should be given in those cases only which exhibit acute exacerbations. Colchicum, aconite, iodides will take its place, and will be required for a long period. Small doses of arsenous acid, from one-three-hundredth to one-five- hundredth of a grain (one-eighth to one-fifth of a milli- gramme) every two or three hours, will answer well. Prolonged warm baths, salt-water baths (cold or warm), and sulphur baths will improve many a case; so will galvanism and massage. Others will be benefited by dry heat of a high temperature, which increases tissue metamorphosis to a remarkable extent, mainly the amount of uric acid. As external treatment a di- luted tincture of iodine, iodoform ointment, iodoform collo- dion, or the iodide of potassium and lanolin ointment can ren- der good service. Narcotics are seldom required. Good results are obtained by the protracted use of alkaline waters. From what little I have seen of chronic rheumatism in children, and the many cases of the same disease in the adult, I recommend strongly the use of large quantities of water, to which is added from a scruple to half a drachm (1.0-2.0) of the bicarbonate 298 THERAPEUTICS. OF INFANCY AND CHILDHOOD. of potassium as a daily dose; also lithium carbonate in daily- doses of from four to ten grains (0.25-0.6). Our natural lithia waters contain too little lithia to have any effect except through the large amounts of water consumed. Muscular rheumatism can be diagnosticated occasionally in very young children; in those from six to twelve years it is not so very rare. Its nature and symptoms do not differ from those in the adult. The neck, back, and shoulders are most frequently affected. The best preventive is the habitual use of cold water. Diaphoretics are not very useful. Narcotic and stimulating liniments find their own indications. Oleate of morphine is of but little use; in a severe case I have injected a small dose of morphine with immediate and permanent effect. The interrupted current acts promptly in one or more sessions. Salicylate of sodium, antipyrin, antifibrin, and phenacetin have a speedy effect, in proper doses and frequently repeated. Semmola's experience in a severe case of neuro-muscular rheu- matism is worth remembering. The case was that of a woman of forty years, who suffered from stiffness and pain in a shoul- der and right arm, with good passive motility of the joint. After the pain had lasted several months, massage, electricity, quinine, and salicylic acid having proved inefficient, the patient was relieved in a few days by a few subcutaneous doses of one- twelfth of a grain of pilocarpine. It is in rare cases only that the rheumatic process in the mus- cle assumes the character of an inflammatory affection. Then there is, as in every myositis with a tendency to chronicity, a hyperplasia of the connective tissue between the fibrillar, the muscle becomes hard and somewhat shorter, its electrical irri- tability grows less or disappears, the skin even participates in the process. Such a case I once observed in a boy of twelve years. He never was entirely relieved, but greatly improved by massage, warm bathing, a mild continuous current, and the internal administration of hydrargyrum bichloride. The treat- ment was continued through more than a year. INFECTIOUS DISEASES. 299 21. Influenza. Epidemic bronchitis, influenza, can be prevented only by avoiding contagion, which is even more difficult than it is to escape measles. Its treatment depends a great deal on the variety; the catarrhal, gastric, and intestinal symptoms require early attention, for nervous exhaustion is imminent in every case, and many patients suffer more seriously from the sequelae than from the original attack. Antipyretics cannot always be avoided. Phenacetin, antipyrin, and salicylate of sodium, com- bined with a cardiac stimulant, may be thus employed, partic- ularly when muscular pain is one of the prominent complaints. Quinine also finds its ready indication. Opiates are often re- quired, either in small and frequent doses or in a single larger dose to secure sleep. Inhalations of steam, two per cent, of carbolic acid having been added to the water, have been highly recommended, but whatever adds to the bronchial irritation and produces cough should be avoided. Rest in bed is required long after apparent recovery, for collapse and nervous symp- toms of many kinds are liable to appear during convalescence, and there is no case, though apparently ever so mild, that may not turn out grave. Besides vomiting, diarrhoea, high tempera- ture, great lassitude, and all the symptoms of catarrh and in- flammation of the mucous membranes, complications with seri- ous forms of pneumonia and pleurisy, of diseases of the heart and the sensory organs, and of the nervous system (mental dis- orders included) are frequent. Among the ocular symptoms conjunctivitis is frequent, keratitis and iritis are met with, irido- choreitis and retinitis are not so frequent as acute glaucoma. Now and then atrophy of the optic nerve has been observed. Otitis media with mastoid abscess is not uncommon; hemor- rhagic myringitis requires incision. Meningitis and pyaemia are among the sequelae. Most frequent is utter exhaustion, which appears to be more than merely functional, and requires for weeks and months (years) the most careful and persistent roborant and stimulant measures. 300 THERAPEUTICS OF INFANCY AND CHILDHOOD. 22. Pertussis. The mortality from whooping-cough in New York City is as great as that from typhoid fever. Twenty-five per cent, of all the cases under a year terminate fatally; five per cent, of all those between the first and fifth year, and one per cent, of all those occurring after the fifth. Its direct mortality, however, is not the only danger, for not infrequently chronic laryngitis, pneumonia, emphysema, dilatation of bronchi, and the result of hemorrhages which occur during the attacks (convulsions, paralysis, either general or local, blindness), impair the health of the patient for many years or a lifetime. Thus the tendency of allowing whooping-cough to run its full course oh the plea that it is a self-limited disease, or that every child must have his whooping-cough, is certainly not justified. The prevention of whooping-cough, which is a specific and contagious disease, is certainly not easy, for the reason that contagion may take place very suddenly, and through the first and second stages of the disease, both of which extend over a large number of weeks. Contagion may take place, no matter whether the cause is to be looked for in the presence of micro- organisms or not, by means of the exhaled air, or mucus, or the masses brought up by vomiting. Prevention means protection against the effects of all these factors. As the disease is spread by contagion only, isolation is an absolute necessity, difficult though it be. In public institu- tions it is impossible. Thus no patient ought to be admitted to, or allowed to remain in, a public school or a hotel inhabited by children. Whooping-cough children must not even be per- mitted to congregate in large numbers, because the cases will become more severe by their mutually affecting each other. In one point only isolation is more effective in whooping-cough than in other contagious diseases, — namely, in this, that the disease does not appear to be carried by persons not thus af- fected. INFECTIOUS DISEASES. 301 The air must be kept pure, uniform, and moderately warm. No wind or draught, however, must be permitted. Utensils must be kept clean and be disinfected, and the masses brought up by vomiting disinfected, destroyed, or removed. The mucous membranes should be kept in, or restored to, a healthy condi- tion, particularly those of the mouth and respiratory organs. Thus no injudicious exposure must be allowed. The digestive organs have to be watched, the stomach must not be full at any time, the bowels kept regular, the food be digestible. As long as the microbic cause of the disease is not known, and therefore no causal indication can be fulfilled, the object of treatment limits itself to this: to relieve the severity and di- minish the number of the attacks, to procure quiet nights, to stop the vomiting, to shorten the course of the disease, and to prevent detrimental consequences. An important indication is that of treating a catarrhal or inflamed mucous membrane. It is quite possible that a sore mucous membrane only is capable of admitting the contagion of whooping-cough as it mostly does that of other infectious diseases, for instance diphtheria. Besides, by attending to the mucous membranes in time, the occurrence of serious complica- tions, such as pneumonia, may be prevented. Catarrh of the mouth and pharynx ought to be treated with doses of chlorate of potassium of from half a grain to a grain (0.03-0.06) in a teaspoonful of water every hour; and a large number of our ex- pectorants find their ready indications in such cases. All of those which have a depressing effect should be avoided,, particu- larly antimonials. Even ipecac should be given in small doses only. Alkaline waters have a beneficial effect. The muriate of ammonia in doses of from half a grain to two grains (0.03- 0.125) every hour or two hours will liquefy the viscid secretion of the bronchial mucous membrane. In a state of evaporation, as described in a former essay, it may be inhaled. The inhala- tion of other agents, which have been recommended as expec- torants, will at the same time act by its germicidal action, so the 302 THERAPEUTICS OF INFANCY AND CHILDHOOD. vapors of benzol, of carbolic acid, and cresolin; and the reputa- tion obtained by gas-works in the treatment of whooping-cough is thus finding its ready explanation. The effect attributed to astringents in the treatment of whooping-cough is best explained by their action on the mu- cous membranes. Particularly alum and tannin have been so employed. Emetics have been recommended for the purpose of relieving the surfaces of sticky mucus difficult to remove. Sulphate of copper or zinc, ipecac powdered, or turpeth min- eral are the proper substances to be selected for that purpose. Schliep has seen good effects of the use of the pneumatic chamber in whooping-cough. He kept the children with their mothers or attendants in compressed air. In a few cases a few sessions of two hours each were sufficient to relieve the patients considerably. In a number of cases from twelve to twenty ses- sions were required. In all of them he claims decided effects, not only in the reduction of the number and severity of the attacks, but also in the duration of the disease. The explana- tion of the good effect is looked for as well in the increased amount of oxygen inhaled as in the diminution of the hyper- aemia of the mucous membrane. I believe the plan is a good one, particularly if it could be combined with the inhalation of turpentine. Caille (Arch. Ped., August, 1892) says that ozone inhalations have a very distinct curative effect as regards the duration and severity of the disease. Cases exhibiting a severe degree of pharyngitis and laryngeal hyperemia, particularly in children who have suffered a long time from chronic inflammatory affections of those parts, will do well, as far as the local symptoms are concerned, under the use of the tincture of pimpinella saxifraga; a drachm (4.0) dis- tributed over the twenty-four hours will be the proper dose for a child of from two to three years. Local treatment has been resorted to by many. The pharynx has been treated locally with a solution of quinine (Hagen- i^m INFECTIOUS DISEASES. 303 bach), a two-per-cent. solution of resorcin (Moncorvo), a one- per-mille solution of bichloride of mercury, a one- or two-per- cent, solution of nitrate of silver, a five-per-cent. solution of hydrochlorate of cocaine, a four- or six-per-cent. solution of bromide of potassium. Applications have also been made di- rectly to the larynx of quinine mixed with bicarbonate of so- dium in different proportions, of mild solutions of salicylic acid, and of powdered sulphur. Inhalations have been resorted to, besides those enumerated above, of sulphurous acid, and ex- tolled as highly as any of those which have been mentioned. If they prove anything, they and the great number of the reme- dies recommended for the same purpose speak for the difficulty encountered in the treatment of whooping-cough, and for the confidence of the practitioner in the patience and submission of his wards. Michael treats whooping-cough as a neurosis, with the same means he employs against other neuroses attributable or attributed to nasal irritation. He claims that seventy-five per cent, of his cases of whooping-cough have done well when exposed to the influence of quinine, bromide of potassium, ben- zol, tannin, boracic acid, salicylic acid, iodoform, cocaine, bicar- bonate of sodium, or prepared chalk applied to the mucous membrane of the nares. The internal administration of chloral hydrate, or croton chloral hydrate, has been recommended by Lorey in 1879. The daily doses range from eight to fifteen grains (0.5-1.0). In all cases the attacks became less severe within a short time, but the disease itself was not shortened. Kennedy expresses him- self very enthusiastically in regard to the effect of the remedy, which is given by itself or combined with the bromide of potas- sium. To procure an occasional good night, a single dose of from six to twelve (0.4-0.75) grains has rendered me good ser- vice. Rest and sleep should be enforced. W. W. Johnston's (Arch. Ped. y April, 1895) advice to keep whooping-cough children in bed is good. In that way isolation, rest, and equable tempera- 304 THERAPEUTICS OF INFANCY AND CHILDHOOD. ture are secured, and the results of the feebleness and dilatation of the heart are avoided. The inhalation of chloroform, or, according to some, of ether, can be recommended in those cases in which convulsions have either occurred during severe attacks, or in which the interrup- tion of the circulation is such that cerebral hemorrhage or con- vulsions must be feared. In the case of a very young infant I have administered chloroform once every hour for every new attack during the course of a number of days in succession for that very purpose, with beneficial result. Quinine has been used both internally and externally by a number of authors of good repute. It was first recommended by Letzerich, who claimed to have found the cause of whoop- ing-cough in a coccus. That coccus has not been found to this very day to be the omnipresent cause of the disease, but still quinine has found favor for a number of reasons. Eossbach credits the drug with the power of relieving increased reflex irritability; Binz, however, attributes to it an antizymotic ac- tion. He gives as many decigrammes daily as the child has years, so that a child of five years takes eight grains of quinine a day. He expects to find an improvement after two or three days, inasmuch as the attacks are said to become by that time shorter and less severe. Where it cannot be given internally, he administers it in suppositories or in injections. "Where the sulphate or hydrochlorate are not tolerated, the neutral tannate of quinine is selected instead, with this proviso, however, that the latter salt is much weaker than the former, and has to be administered in doses from two to three times as large. It has the advantage of being tasteless. In our own country it is par- ticularly Forchheimer who advocates quinine. He reported ninety-seven cases as having been benefited by its administra- tion. Antipyrin has been recommended for whooping-cough, since 1886, by Demuth, Sonnenberger, Moncorvo, Guaita, Wendt, and many others, as almost a specific. Like all the other chemi- INFECTIOUS DISEASES. 305 cal relatives of chinolin, it destroys parasites outside the or- ganism. It has been claimed, or presumed, that it displays the same effect inside. Whether that is true remains to be seen. At all events, however, it is a powerful nervine. It is claimed that it can be given with the same beneficial result in the beginning of the disease and in its most severe stage, and that the latter will terminate favorably in from four to five weeks after the beginning of the treatment. The dose is from a grain and a half to two grains (0.1-0.125) three or four times a day for every year of the patient, with an occasional large dose for the night. Tussol, the amygdalate of antipyrin, is given in the same doses as antipyrin. As H. Eehn recommends it quite highly, it should be tried. It must not be given in milk, nor in close proximity to it. Of all the almost countless medicines advised against whoop- ing-cough I prize belladonna most highly. I have always re- turned to it after having discontinued it for the purpose of try- ing one after the other of the many remedies recommended during these thirty years. As early as 1861 I had occasion to express, in the American Medical Monthly, the following opinion: "Belladonna is the most powerful remedy in whooping- cough. I scarcely remember a single case in which its adminis- tration, for years past, proved unsuccessful in shortening the duration of the process. The result obtained by me has gen- erally been this: that a well-developed case of whooping-cough, after the diagnosis was made certain beyond a doubt, would last for only three or five weeks longer, instead of running through its full course of months and quarters of a year. The effect is mostly not a sudden one. Many cases in which bel- ladonna is given from the first commencement will become worse for a short while, then remain at their height for some days or a week, and gradually improve in both the character and frequency of the attacks. In others the effect is percepti- 20 306 THERAPEUTICS OF INFANCY AND CHILDHOOD. ble from the first days after their administration; the cases soon assuming a more favorable aspect. Such has been my uniform experience during the last five years, in each of which the children of this city have been suffering from a more or less severe epidemic. "My readers, many of whom have doubtless been in the habit of prescribing belladonna in whooping-cough with more or less marked success, need hardly be assured that I claim no priority. Belladonna has been recommended in this disease for many decades, and has just as long been objected to, as either useless or dangerous. I have touched upon the subject because of my conviction that both the former objection and the latter fear are groundless. "Belladonna is well known to produce readily symptoms of poisoning. An amount of two and a half or three grains taken by an adult in the course of a day, of either root or extract, has the effect of dilating the pupils, causing a feeling of dryness in the throat, scintillation and giddiness, and even erythema of the skin. This latter effect is, however, not frequently seen in adults, while the effects on the pupil and brain are very com- mon. It was therefore believed that, as nervous disorders are as common as they are dangerous in infantile age, these effects ought to counterindicate its use; it was stated that it would cause congestion, sopor, acute hydrocephalus, and idiocy; and the practical consequence simply was that the dose of the remedy, when given at all in a case where it appeared to be in- dicated, was entirely too small. Thus, doses of a sixtieth, a forty-eighth, a thirtieth of a grain of extract of belladonna, re- peated three or four times a day, were deemed sufficient and proper. These doses could not but prove unsatisfactory, and thus it happened that the remedy was misappreciated and given up. The doses, however, administered by me proved successful, because they were sufficient. "Infants of six or eight months of age affected with whoop- ing-cough require a sixth of a grain (0.01) of either the root or INFECTIOUS DISEASES. 307 the alcoholic extract three times a day; children of three or four years tolerate three doses, each of half a grain (0.03). These doses appear to be very large in proportion to those toler- ated by adults, but it is a fact which can easily be verified, that the effect of belladonna on the pupil and brain will hardly ever be perceptible in children from these or smaller doses. The succession of belladonna symptoms in children differs, moreover, altogether from that in adults; the erythematous and flushed appearance of the face and neck, sometimes even of the whole surface, is the first symptom in infantile age; whereas it is seldom observed in adults, or in cases of thorough poison- ing only. Some of the old authors advised the administration of belladonna to such an extent as to produce the first symptoms of poisoning; others, however, objected to this practice as dan- gerous. I, for my part, soon found that those children suffer- ing from whooping-cough who exhibited general erythema from an apparent overdose recovered soon, while others, in whom no such symptom was observed, remained sick for a long time; and continued experience has proved that the occurrence of this symptom is absolutely necessary for the full remedial effect. To obtain control of whooping-cough, the remedy must be given in a dose sufficient to produce erythema, or at least a flushed condition of the face, and, as it were, feverish appearance after every dose of belladonna. Thus the dose is to be gradually increased until this result is obtained. It is a remarkable fact that very young infants may take proportion- ately large doses: at all events, I do not remember a single case in which less than half a grain was taken in the course of a day. The prescriptions I have been in the habit of ordering are very simple ones. I either give the medicament as a pow- der, or have the extract dissolved and sweetened according to circumstances. "The administration of belladonna alone is indicated in such cases of whooping-cough as are not complicated with inflamma- tory affections of the respiratory organs. The latter take the 308 THERAPEUTICS OF INFANCY AND CHILDHOOD. lead in complicated cases as well in treatment as in the nature and gravity of the symptoms. This is so certain that, whenever a pneumonia coincides with or follows whooping-cough, the peculiar sound of the cough of the latter will disappear, and return only when the inflammation begins to give way. As this is, moreover, the most dangerous of the two, it requires at- tention before the other. As to bronchial and laryngeal ca- tarrh, the former especially is a very common symptom in whooping-cough. Where it is but slight it may be considered as unimportant; where, however, it gives rise to fever or dysp- noea, it constitutes a further indication to interfere." The preparations mentioned above need not be the only ones to be relied on. The tincture of belladonna is a convenient remedy, inasmuch as the dose can be readily and gradually in- creased. A baby of two years may take three daily doses, the first of which may be six drops. If the flush be perceptible within twenty or thirty minutes, that is the dose; if not, the number of drops must be increased to obtain the effect which is demanded after every dose. After a few days larger doses are required; there is no case but demands at least twice the amount of the original dose of belladonna within ten or twelve days, or before the disease disappears. Atropiae sulphas may take the place of belladonna. A child of two years will proba- bly begin with the five-hundredth part of a grain, to be given three times daily, and increased according to the rules stated before. Since that early time alluded to, Vogel speaks highly of the effect of belladonna, taking the dilatation of the pupils as a guide. As I have mentioned, this effect is rather late in appearing in children, and is not required; indeed, it may become quite uncomfortable. Meigs and Pepper combine belladonna and alum. Evans, in the Glasgow Medical Journal of 1880, recommends the administration of a large dose first, to be followed by smaller ones afterwards, and there are not a few authors who have seen immediate good effect following the INFECTIOUS DISEASES. 309 intended or accidental administration of a large, almost poi- sonous, dose. Indeed, the number of practitioners now relying on the effect of belladonna in whooping-cough is quite large, no matter whether they look for the beneficial action on the laryngeal and other branches of the pneumogastric nerve or on the medulla oblongata, or rely on its influence in modifying reflex action. Opium is spoken of favorably by a great many. I cannot recommend it for anything like regular administration, but it certainly has a good effect in procuring fair nights when given in a single dose. A grain of Dover's powder given to a child of two years, at bedtime, will at all events have the effect of procuring sleep. In a number of cases the combination of opium and belladonna acts quite well. The antagonistic effect claimed for these two drugs is not such as to interfere with the combination of their effects as sedatives. Netter (La Semaine Med., 1886, p. 321) recommends the oxymel scillae (No. 287 of the "National Formulary of Un- ofncinal Preparations," revised edition) for whooping-cough, and prescribes it in the following manner: After having taken food between three and four o'clock, the child is given a tea- spoonful every ten minutes; those under three years take four or five, those over three years six or seven, and adults seven or eight teaspoonfuls in the course of an hour. Food is again per- mitted at seven o'clock. In this way the administration of the drug is continued. It is claimed that both the number and the frequency of the attacks become less, but nothing is said of the duration of the disease. I. Widowitz (Wien. med. Woch., 1888, No. 17) has employed the same remedy in one hundred and forty-nine cases. Both the number and the severity of the attacks are stated to have become less after a single administration in fifty-nine; in twenty-four that result was accomplished after the second, and in nineteen after the third or fourth administration. In twelve per cent, there was no favorable result at all. The 310 THERAPEUTICS OF INFANCY AND CHILDHOOD. duration of the disease was not changed. M. T. Schnirer (Arch, f. Kinderh., 1889, p. 447) arrives at the same conclusions, and suggests therefore the combination of oxymel scillse with some antimycotic treatment. I should rather propose its combina- tion with belladonna. Bromoform in three or four daily doses of from two to six minims has been highly recommended by Stepp, and in New York by Dr. Louis Fischer. A case of poi- soning by doses of two drops in a mixture of alcohol, water, and sugar, every four hours, with the symptoms of excitement and coma, got well under the use of strychnia. VI. DISEASES OF THE NERVOUS SYSTEM. 1. General Indications. The great indication in the treatment of all diseases of the nervous system attended by symptoms of irritation is absolute protection against external disturbances. This is attained by equable climate, uniform temperature of the room, rest in bed, exclusion of light and noise, by comfortably warm clothing, warm bathing, warm applications and fomentations, and by the removal of anything and everything annoying and jarring. Therefore, children sick with nervous diseases must not be ex- cited by unnecessary constraint or coercion, their medicines ought to be given in a palatable form, and vesicatories and other distressing applications avoided, if possible. Sympto- matic treatment is perhaps more indicated than in the same class of ailments among adults. Pain and sleeplessness lead to speedy exhaustion. Nothing is more common and more dan- gerous than the prejudiced refusal to relieve pain by opiates and sleeplessness by properly selected hypnotics. It is particu- larly in those cases which are mostly, or entirely, of a reflex nature that a symptomatic treatment ought to accompany that of the causal indications. It is ludicrous as well as criminal to withhold chloroform when an eclamptic attack results from an intestinal irritation, or an antispasmodic when a cough is caused by stomach, ear, or nose. In conditions of depression, debility, and paralysis the treat- ment should be stimulant, exciting, and roborant. In such cases the electric current is frequently employed, and is, to a certain extent, useful. Massage has a beneficial effect not only 311 312 THERAPEUTICS OF INFANCY AND CHILDHOOD. on the periphery, but by its general action on innervation and circulation, by its effect on the muscles, and also by its direct influence in increasing the relative circulation of the red blood-cells (John K. Mitchell).* Strychnine stimulates (while curare depresses) the reflex and vasomotor centres. Ni- trate of silver appears to exert a favorable influence in spinal paralyses; muscarine, physostigmine, and nicotine in paralytic conditions of the unstriped muscular fibres. The interrupted electrical (faradic) current is an excitant — stimulant — of the nervous system, both locally and generally. For the latter effect general faradization has been practised, both through large electrodes and in the bath, to great advan- tage, according to many who have a right to claim a large experience. The generally stimulant effect does not, however, disprove the fact that, like the galvanic, the faradic bath is capable, particularly when the fine wire coil is used, of reducing undue sensitiveness. The action of the galvanic current is claimed to show itself in different ways. It is stimulant and excitant, and (directly, or when interrupted by reversing), mainly when the brush is employed, produces pain, contraction, and consecutive dilatation of blood-vessels. It is electro-tonic, * General massage (with dry hands) of the whole nude body, of extremities, neck, and trunk, lasting from fifteen to thirty minutes, is indicated in anaemia, chlorosis, tedious convalescence, chronic rheuma- tism, and neurasthenia. To reach the muscles some force should be used, but no violence, which is liable to cause capillary hemorrhages. Acute pain, local inflammations, and the presence of pus are contra- indications. The circulation of blood and lymph is best stimulated by massage of the whole length of the muscles. The lymph-ducts run along the intrafibrillar connective tissue. By compressing and empty- ing them and the blood-vessels from the peripherous ends in the direc- tion of the centre of circulation a new supply is furnished and the general nutrition improved. Locally it acts well in recent injuries, con- tusions, and distorsions, in subacute and chronic inflammations of joints, in neuroses, contractures, arthritis deformans, and arthritic mus- cular atrophy (Hoffa). DISEASES OF THE NERVOUS SYSTEM. 313 and thereby produces changes in the irritability of the tissues; it is chemical, and thereby decomposes fluids; and it is cata- phoric, and thereby transfers solutions through badly conduct- ing tissues. To the two poles different properties are attributed. It is the positive pole (anode) which is credited with a tranquil- lizing effect in inflammations and neuralgias (less in tic and hemicrania than in supraorbital, occipital, intercostal, lumbar, and sciatic neuralgias); the negative (cathode) is claimed to influence old inflammatory processes, cicatrices, and indura- tions. Still, there is no doubt in my mind as to the exaggerated character of the expectations once cherished in regard to the effects to be obtained by both electricity and galvanism. The difficulty of reaching a coveted spot through tissues of different conducting powers is always great; the accumulation of fat is a powerful obstacle to the transmission of the current, and its amount cannot be calculated. This is so true that even for pur- poses of diagnosis the subcutaneous fat of babies and of many women offers a serious impediment. Besides, different morbid conditions and different periods of life interfere with the esti- mation of the effect of the current. In what has been called the reaction of degeneration both the faradic and the galvanic irritability of the nerves are diminished and while the galvanic excitability of the muscles is preserved, the excitability by the faradic current is lowered. In the very young, — the baby under two months, — as general reflex irritability is quite low, comparatively strong electrical influences are required to obtain effects. At all events, therefore, the action of the different currents is, to some extent, not measurable, controllable, or certain. The time during which both the faradic and the gal- vanic current were considered far-reaching and omnipotent remedies has long gone by. Indeed, there are those, particu- larly among neurological specialists, who, while maintaining that the currents are great aids for diagnostic purposes, yet reject their claims as curative agents. But lately Meltzer — in a paper read before the Association of American Physicians — 314 THERAPEUTICS OF INFANCY AND CHILDHOOD. has proved the total absence of efficacy on the part of the elec- trical current when applied to the mucous membrane of the stomach and the intestines. It is to be hoped that the exer- tions of the American Electro-Therapeutic Society will clear up many doubts and obtain results commensurate with the en- thusiasm which gave rise to its foundation. Franklinism, once the only recognized electrical remedy, has rapidly regained a standing, much of which is due to Dr. W. J. Morton, of New York. But neither the common disruptive discharges which he uses in locomotor ataxia nor his "static induced currents," obtained by adding condensers to the static machine, will find many applications among children affected with diseases of the nervous system. The effect of the electrical and the galvanic current is per- haps best exhibited in cases of peripherous nervous affections. Paralysis of the facial nerve and of the brachial plexus, both not infrequent after difficult or clumsy deliveries, are among those in which the current is frequently used; its effect is mostly very slow, sometimes not very satisfactory. Particularly in cases of facial paralysis, where the reaction of degeneration has already been established, it leaves much to be desired. The paralysis of the brachial plexus *of the newly-born, as it depends on stretching, laceration, or hemorrhage, and is sometimes com- plicated with injuries to one or more of the joints of the upper extremity, — in the lower joints the affection is but rarely ob- served, — allows a doubtful prognosis only. It concerns mostly the fifth, sixth, and seventh lower cervical nerves, which form the posterior cords of the brachial plexus. In that case the deltoid, biceps, brachialis internus, coracobrachialis, infra- spinatus, and sometimes the exterior muscles of the hand are affected. When the inner cords are involved, the whole ex- tremity is paralyzed, and will be shortened and atrophic. Some of the cases, however, are distinctly the results of an intersti- tial inflammation and consecutive hyperplasia of the connective tissue of the nerve-fibres. In such, no matter whether on the DISEASES OF THE NERVOUS SYSTEM. 315 basis of syphilis or not, the interstitial hypertrophy should be fought with mercurials or iodides or both. The same must be said of polyneuritis, — such as follows infectious diseases, with its pain and increasing paralysis and degeneration, together with intact bladder and pupils, — in which rest, salicylate of sodium, and, later, strychnine yield better results than does the current. Nor is it more effective in hemicrania, no matter whether it be the result of congenital disposition, or compli- cated with hysteria and epilepsy, or dependent on anaemia, hypermetropia, dyspepsia, overwork, or confined air. In all these conditions the correction of the causes, a convex glass, country air, shortening of school hours, cold-water treatment, arsenic, iron, and aconitia, with an occasional dose of a bro- mide, will yield better results. To complete what I have to say on the subject of the reme- dial influence of electricity and galvanism, I may as well speak here of their employment in the peculiar changes of the muscles which are known under the heads of muscular atrophy, progressive juvenile muscular dystrophy, and pseudo-hyper- trophy. All of these names are applied to abnormal conditions whose coarse anatomical changes are better understood than their causes. As long as these are unknown we cannot help admitting that therapeutical experiments, such as those with thymus gland in pseudo-hypertrophy, be they ever so tentative, are justified. In a certain percentage (exactly as in Thomsen's congenital myotony) the alteration is in the beginning strictly local or confined to muscular tissue; in others there can hardly be a doubt as to the cerebral origin of the muscular anomaly. In all of them electricity and galvanism have been extensively used, together with massage, bathing, etc., but in no case have their effects been noteworthy. As in many other cases where the original cause (or change ?) is inflammatory, and ex- hibits itself in proliferation of cellular interstitial tissue (no matter what its final result is destined to be), mercury, mostly the bichloride, — administered patiently and watched carefully, 316 THERAPEUTICS OF INFANCY AND CHILDHOOD. — appears to have given me better results. At least, the prog- ress seemed to be slower and intermissions of the morbid pro- cess more distinct and prolonged. 2. Operations. Operations on the skull and brain are among the prides of modern operative surgery. Escapes from death on the table are more numerous than formerly, and recoveries from diseases formerly fatal, because permitted to die without an operation, are not unheard of. Craniotomy has been performed for in- juries, intra- and extra-dural hemorrhages, hydrocephalus, softening, tumors and cysts, Jacksonian epilepsy, athetosis, chronic contractures, certain mental diseases, otherwise in- curable headaches, old cicatrices, and abscesses. Infants and children come in for their share, mainly with abscesses, hemorrhages, hydrocephalus, Jacksonian epilepsy, and prema- ture ossification of the cranial bones and fontanelles, with epi- lepsy and idiocy among its results. So far as craniotomy and craniectomy are concerned in cases of microcephalics or idiocy, no other surgeon has met with the favorable results alleged to have been obtained by Lannelongue. Guided by thirty-three cases of American surgeons, — fourteen of which died soon, while nineteen only recovered from the operation, and very few showed any improvement, — I treated of the subject in my ad- dress before the Eleventh International Medical Congress at Rome, April, 1894,* and arrived at the following conclusions: that congenital idiocy is the result of many different forms of arrest of development (of blood-vessels, cortex, island of Reil, hemispheres), of inflammations (meninges, encephalon, with softening, or sclerosis), of thrombosis, and of hemorrhages; that it is a frequent result of microcephalus, which, as a rule, is not dependent on premature ossification of the bones and fontanelles, but in the large majority of cases on arrest of de- * "Non nocere," New York Medical Record, May 19, 1894. DISEASES OF THE NERVOUS SYSTEM. 317 velopment of some parts of the brain, mostly connected with long-continued patency of the fontanelles; that, therefore, oper- ations undertaken to widen the cranial cavity are of no use, for a brain which did not grow before the cranium closed will not grow afterwards, and absent or defective parts will not develop; that even cases with a clear history of premature ossification are not, or very doubtfully, benefited; that, finally, the operation undertaken for the purpose of enlarging the cranial cavity has the opposite effect, as is proved by the ex- perience of Van der Veer and Hun, also by a case reported and drawn by Bourneville, and, finally, by the skull, belonging to B. Sachs, of a child operated upon twice in the course of sixty-seven days by A. Gerster. It exhibits a mass of hard tissue proliferating into the cranial cavity along the whole wound made in the first operation. I trust, therefore, that the days of uncalled-for craniotomy and craniectomy are numbered. At the present time Bourneville {Prog. Med., 1897, p. 390) favors craniectomy for idiocy in cases of trauma, abscess, or tumor only. Starr collected, in 1889, a total of 270 brain tumors in chil- dren. Of these, 152 were tubercles, 37 gliomata, 34 sarcomata, 5 gliosarcomata, 30 echinococci, cysticerci, and cysts, 10 carcinomata, and 2 gummata. The carcinomata were mostly secondary, the gliomata and sarcomata primary. Forty of the two hundred and seventy were superficial, and in sixteen of the forty their localities could be distinctly diagnosticated. There- fore, trephining and operations on the substance of the brain for tumors will never be numerous. Their diagnosis is not always easily made, and that of the locality affected is l>eset, for the present, with still more difficulty. Gliomata are but rarely near the surface; solitary tubercles are sometimes found in the gray substance of the brain, but more frequently in the corpora striata or thalami optici. In many more instances an operation will be required because of tumors originating in the cranium or its periosteum and encroaching upon the brain; they are 318 THERAPEUTICS OF INFANCY AND CHILDHOOD. mostly sarcomata, fibro-sarcomata, or osteomata. One of the last mentioned I have removed. A cyst of the dura mater, re- sulting from hemorrhage, was successfully removed in the ser- vice of Dr. Henry Hun, at Albany, followed by marked im- provement of the child's idiocy and convulsibility. Starr is rather favorably inclined towards trepanation in a number of cerebral diseases; it is true that those which promise no success from medical treatment cannot lose by surgical in- terference. In such cases of hemorrhage as permit of a local- ized diagnosis, though that between an extra- or intra-dural situation may be impossible in many instances, he favors it. His advice of tentative interference with "microcephalus" I do not look upon favorably. Abscesses, unless they be the results of pulmonary gangrene, typhoid fever, or pyasmia, if their loca- tion can be determined upon, and be accessible, are to be oper- ated upon; the opening must be sufficiently large to permit of examination, and draining should be both extensive and pro- longed until granulation and complete recovery can take place. Tumors are not often the subjects of operation in children. It is true many are met with in infancy and childhood; accord- ing to Gowers two-thirds of all the cases of intracranial tumors occur in the first two decades of life. But those occurring in early life are mostly found in the cerebellum, the basal ganglia, capsula interna, corpora quadrigemina, pedunculi, pons, and medulla oblongata; very few such will ever be acces- sible to an operation. 3. Inflammatory and Exudative Processes. Arrest of Development. The simplest form of cerebral meningitis is that which results from insolation and mental emotions and exertions. Frights (especially protracted fears) and overstudy are frequent causes. So is trauma, which, however, is liable to produce the puru- lent form. In pneumonia, particularly of the upper lobes, it is not uncommon; less frequent in typhoid fever, more so in DISEASES OF THE NERVOUS SYSTEM. 319 the septic diseases of the newly-born, where, however, it is liable to form part of the general pyaemic condition. With the exception of the latter, where death is certain, an anti- phlogistic course of treatment is indicated here, if anywhere. The hair should be cropped short; the head must rest on a cool pillow and be placed high. Calomel at first in purgative, later in smaller doses. As the mercurial treatment is to be continued, a solution of potassic chlorate may be applied fre- quently to the gums and mouth. The heat of the head and the local inflammation must be fought by cautious cold applica- tions, according to the directions given formerly (p. 102), and by leeches applied to the nasal septum or to the mastoid pro- cesses, also by cupping to the neck and shoulders; coma by cold affusions to the head and hot bathing, with or without mustard, of the rest of the body. Great restlessness, sleeplessness, and general excitability demand warm bathing, bromides in gener- ous doses, from one to ten grammes (fifteen to one hundred and fifty grains) a day, chloral, and codeine. After the first invasion and the period of high fever have been successfully dealt with by calomel and a few large, afterwards moderate, doses of digitalis, the time for iodide of potassium (one to five grammes daily) has arrived, also for vesicatories to the neck and behind the ears. In regard to the latter, however, it is always well to be careful, for cantharides are the sworn enemies of the kidneys. The iodides must be continued a long time. Of the roborants to be given during convalescence, iron ought to be the last one selected. Lumbar puncture will be discussed shortly. It is not always easy to diagnosticate between a fully-devel- oped meningitis and a hyperemia resulting from similar causes, — viz., overexertion, emotion, insolation, and the continued effect of overheating and stimulating diet. The continuation of the treatment depends on the persistence of the symptoms. Quite frequently a warm or hot mustard bath, with temporary applications of ice to the head, repeated hot foot-baths, sin- 320 THERAPEUTICS OF INFANCY AND CHILDHOOD. apisms to the neck, an erect posture in bed, a calomel purga- tive (with or without local depletion), and occasional counter- irritation by derivant enemata (vinegar 1, water 5-6) will suf- fice. The passive hyperemia, however, complicated with and depending on general and local cerebral ancemia (occasionally- even thrombosis of small vessels) and that which is caused by the rapid inanition produced by the different forms of acute and exhausting intestinal discharges require an altogether dif- ferent treatment. In place of the antiphlogistic treatment, stimulation is indicated. Still, caffeine and alcohol are to be avoided during the worst stage; camphor, ammonium car- bonate, and musk will answer better. Food and medicines are to be regulated by the requirements of follicular or other enteritis, and water must be supplied in ample quantities. When, however, there is vomiting and when diarrhoea is per- sistent, neither the stomach nor the rectum will accept it. In these cases the only salvation may be in copious (pint or quart) subcutaneous infusions of warm and sterilized salt-water solu- tion (water 1000, table salt 6-7, with or without sodium car- bonate 10-12). Thromboses from other causes are treated on the same prin- ciples. Debility and paralysis require such stimulants and irri- tants as the brain will tolerate. Embolisms, with their secon- dary conditions of irritation and inflammation, should be treated according to the rules detailed above, and will require ice, purgatives, warm bathing, and iodides, with or without bromides. The resultant paralysis demands massage, elec- tricity, strychnine, and mineral baths such as St. Catherine or Kreuznach. Chronic remnants of an inflammatory disorder, no matter from what cause, may be benefited, even after a long time, by a protracted course of treatment with iodide of potas- sium, or with mercurials, or both together, or alternating. Ergot is useless in these cases of intracranial hyperemia; it does not have the favorable effect which often follows its use in similar changes in the spinal canal. DISEASES OF THE NEBYOUS SYSTEM. 321 Tubercular meningitis is not always fatal, though the diag- nosis permit of no doubt. The latter, however, is mostly made at a time when the prognosis is very ominous. Biedert had an opportunity to make an autopsy on a patient treated for tuber- cular meningitis, death resulting from another disease. He found old meningeal tubercles. Still, many of the recoveries reported — mainly for the purpose of proving the efficacy of specific treatments (tartar emetic and iodoform ointments, etc.) — are of doubtful character. I also have seen recoveries from what I diagnosticated as tubercular meningitis. One died after- wards of necrosis of the cranial bones, occasioned by my tartar emetic ointment. Another case, that recovered thirty years ago, is still alive in an insane asylum; he has never been normal, mentally, since I discharged him "cured." From what little I have said it is evident that a preventive treatment only may be expected to do good, if anything will. Infants and children of scrofulous or tuberculous families should be brought up with unusual care. Congestion of the brain, caused by feather pil- lows, exposure to the sun, hot rooms, coffee, tea, and alcohol, physical and mental overexertion, must be guarded against. Constipation must be overcome. Eczema and other eruptions of the surface should be slowly healed, but they must be healed. Their presence is a constant source of danger, both by reason of the opportunities afforded for a direct invasion of microbes, and of the irritation and swelling of lymph-bodies. These, when found, must be removed by internal treatment, massage, ointments (green soap, iodide-lanolin mixtures), or enucleation. Nasal catarrh should be immediately relieved; adenoid growths in the naso-pharynx, either regularly irrigated or when they are large, removed. Their persistence is a cause of "scrofulous glands" and, possibly, of secondary tuberculosis; also of direct invasion of germs through the patent orifices of the lymph- vessels at the base of the cranium and the extra-dural tissue. The best general preventive treatment of infants and children with a predisposition to tubercular meningitis, rendered proba- 21 322 THERAPEUTICS OF INFANCY AND CHILDHOOD. ble by hereditary taint and by suspicious symptoms, consists, in my opinion, in the regulation of the diet and hygiene: ani- mal food mostly, daily cool or cold bathing with vigorous fric- tion, open windows, exercise, cod-liver oil during the cool and cold months, arsenic in regular small doses, and pure guaiacol (or the carbonate of guaiacol) for many months in succession through a course of years, besides a'ttention to the nares and adenoid growths. When the disease is fully recognized, constipation must be overcome; the first drug to be used for that purpose should be, or contain, calomel. It may be repeated from time to time, provided the regular use of iodide of potassium does not con- traindicate it for chemical reasons. The latter ought to be given in large doses through (nearly) the whole duration of the illness. Tubercular meningitis both permits and demands large doses, — from one to three drachms (five to twelve grammes) daily. Mercury is indicated. Calomel and iodide of potassium being incompatible, the bichloride should be given, or mercurial ointments used instead. Cardiac stimulants may be employed to advantage from the beginning, the circulation being defective on account of the undue irritation of the pneu- mogastric nerve. Strophanthus (and strychnine in very small doses) will probably act better than digitalis. Caffeine and alcohol must be carefully avoided. Chloral will act well when headache is severe and a tendency to convulsions exhibits itself. To combat the latter the inhalation of chloroform cannot be avoided; nor morphine altogether, when the pain is exces- sive. Antipyretics are not indicated in the beginning, when the temperature is low; during the last few days, when it rises previous to death, they are useless. With tartar emetic oint- ments applied on the closely shaved head I have had ample ex- perience, and shall not employ them again. My experience with iodoform ointments (1 : 5-10) is but small, and my confi- dence in their efficacy less. Vesicatories may do harm by an- noying and irritating the patients; I expect more derivative DISEASES OF THE NERYOUS SYSTEM. 323 action from keeping the bowels open and the body sufficiently covered with clothing. Leeches are seldom useful, except when conjunctival injection and local heat of the head be- come apparent at an early date. Otherwise, symptomatic treat- ment is all that can be advised. Unusually severe vomiting in the beginning may require ice pills and mild doses of an opiate, or cocaine, perhaps tincture of iodine in one-quarter- to one- half-drop doses, or arsenous acid, one-three-hundredth to one- five-hundredth grain (J— J milligramme), from four to ten times a day. Ice applications are useless, for the temperature is low before the last stage sets in, the local hyperaemia mostly passive, and the tolerance of ice in small children easily exhausted. To what extent the operative treatment by trephining and draining will prove successful remains to be seen. There are but few cases of tubercular meningitis not complicated with general miliary tuberculosis; thus the prognosis of operative interference is not at all promising. Besides, the cranial can- not be compared with the peritoneal cavity, which is known to be favorably influenced by the performance of a laparotomy. Peritoneal tuberculosis is very apt to be isolated and uncom- plicated, its secreting surface of a different character, and drainage easier. Quincke, Fiirbringer, Caille, G. W. Jacoby, and many others since have tapped the spinal canal between the third and fourth lumbar vertebras. The operation of lum- bar puncture has resulted in facilitating a diagnosis in many instances, in temporarily relieving some symptoms, but never in a cure. In order to obtain any cerebro-spinal liquor from the cranial cavity, lumbar puncture should withdraw from ten to fifteen cubic centimetres. The total amount, however, should not exceed twenty or thirty at any one time. None may be ob- tained when the needle does not reach the spinal canal, or is obstructed by fibrin, or is caught between the nerve-fibres of the cauda equina, or when the connection between the ventri- cles and the cerebral and spinal subarachnoid spaces has been 324 THERAPEUTICS OF INFANCY AND CHILDHOOD. disturbed by exudative processes. The normal liquor, also that obtained in many pathological conditions, is clear, of 1007 specific gravity, and 0.2-0.5 per mille albumin. Sugar is rarely found in connection with tumors. In simple serous meningitis, in chronic hydrocephalus, in that connected with pneumonia and other infectious diseases, also with uncomplicated tumors, the liquor was clear, in cerebro-spinal meningitis it was turbid, somewhat purulent, and contained pneumococci and meningo- cocci, in many cases (by no means all) of abscess pus, and strep- tococci and staphylococci, in tubercular meningitis mostly bacilli (Jacoby eleven times in seventeen cases), in apoplexies and hemorrhagic pachymeningitis blood. Kiliani and Jacoby found blood when the diagnosis of spinal hemorrhage had been made. The puncture, which never should amount to an aspiration because of pain in back, head, and neck which are caused by it (Fiirbringer), though not always successful as a means of diag- nosis, gives less satisfaction from the view of therapeutics. It gave some relief in meningitis, headaches (inclusive of the head- ache of chlorosis), delirium, and hyperesthesia., but they would return. In a few cases of cerebral lead symptoms, and in those connected with chlorosis, it is said to have given relief. Len- hartz improved a case of cerebral oedema connected with trau- matic injury. Altogether it is to be hoped that we are standing in the vestibule of a new achievement. General paresis ("periencephalitis" and other changes) is no exception to the rule that the pathological changes occur- ring in the brains of adults are also found in children. It is rare, however. In a few cases there seemed to be a hereditary disposition as in other cerebral alterations leading to chronic intellectual disorders. The vast majority of cases are of syphi- litic origin, and a thorough antisyphilitic treatment ought to have a favorable result, now and then. The prognosis in, and the results of treatment of, chronic hydrocephalus depend on its nature. When it is congenital, DISEASES OF THE NERVOUS SYSTEM. 325 no matter whether internal or external, whether the result of a foetal inflammation or of an arrest of development, the morbid processes leading to it are so serious as to render the outcome of treatment — though it do not prove fatal — very problematic. Substantial changes of the original brain-substance cannot be remedied by the removal of fluid. Nor is it probable, or rather possible, that the cerebral atrophy produced by permanent intracerebral pressure can be overcome by attempts at relieving hydrocephalus. The chances are better when chronic hydro- cephalus is the result of a postnatal meningitis. But even in these cases, while the recoveries — I mean anatomical recoveries — from the secondary effusion are more numerous, the inflam- matory alterations both in meninges and brain are such as either to predispose to future meningitis, or to so alter both the physical and mental functions of the cranial contents as to render the result either very doubtful or far from desirable. Our prisons and lunatic and idiot asylums tell the tales. The chances of hydrocephalic patients are best when the disease is the result of chronic hyperemia, — for instance, in craniotabes. Such children with a slight amount of hydrocephalic effusion are always apt to get entirely well under proper antirhachitical treatment (fresh air, animal food, phosphorus, iron, etc.), and even large amounts of fluids are absorbable, with restitution of the brain and its functions, in a certain percentage of cases. After all, it is evident that iodides, mercurials, vesieatories, diaphoretics, diuretics, and purgatives are useless in congenital hydrocephalus. In the other forms the diagnostic and thera- peutical skill of the practitioner will make the required selec- tion, as far as indicated. Should the head grow rapidly, the prognosis is bad. In these cases even compression will do but little, inasmuch as compression of the increasing fluid, unless it can be removed, will also compress the brain. In less pro- gressive cases the application of rubber bandages or caps, also adhesive straps, may do some good. They should not be omitted in those cases which are punctured, provided the 326 THERAPEUTICS OF INFANCY AND CHILDHOOD. cranium is still compressible. Indeed, in almost all the cases on which it was performed the children were quite young and no ossification of the sutures had taken place. Therefore the case successfully operated upon by Helm, of Frankfort, Germany (with repeated punctures), — that of a girl of twelve years, presented (alive) before the German Congress for In- ternal Medicine of 1886,— may be considered very exceptional. Cases which require trephining before drainage can be estab- lished hold out no hope. Punctures of the hydrocephalic cranium were made in an- tiquity, but, like many other experiences of Hippocrates, were forgotten. It was not until this century that observations of recoveries were made after the intracranial fluids had found a spontaneous or traumatic outlet. Honing published a case (1828) of recovery after a complicated fracture of the frontal bones and a discharge extending over days; Greatgood (1828) one after an injury produced by a nail; Haase (1818) one of spontaneous perforation. Huguenin collected six cases of re- covery after a discharge through the nose (or ear) had been established. Punctures have been made in great numbers; many more, certainly, than have reached the eyes of the medi- cal public. It can, however, be easily understood that very probably not a single case of recovery has taken place but has been published. Indeed, the publications are mostly made very soon after the operation or operations were performed. Thus, when Beely collected twenty-seven cases of recovery after puncture (two of which were combined with tincture of iodine injections), he expressly stated that only eight of them had been under observation a year or more. Altogether, it may be more human than, unfortunately, scientific to pride oneself on one's results, particularly when these results speak of benefit to mankind. Thus, Conquest reports "ten cures" out of nineteen cases operated upon by himself. West, than whom there is no critic more learned, wise, and incorruptible, collected sixty-five cases with (alleged) "sixteen recoveries, ,, DISEASES OF THE NERVOUS SYSTEM. 327 which he, however, reduced to from three to perhaps five. Bat- tersby came to the conclusion that probably there was one re- covery in fourteen cases on which the operation was performed. But from my previous remarks, referring to the severity of the original lesion and to the results of the fluid present either outside or inside the brain, it is easily understood that I cannot look upon the result of the operation as anything so favorable as is claimed. Still, there are many cases in which it must not be omitted, together with general treatment. I have made a number of lumbar punctures for the same purpose, with the visible effects on the distended fontanelles and sutures, but without a cure. Among the remedies I value most highly here or wherever tissue-building is a main object, is phosphorus. It may be alternated or combined with iodides, digitalis, iron, or arsenic, according to circumstances. The puncture should be made over the large f ontanelle, about one centimetre or more (half an inch) from the median line; vertical when the lateral ventricle is to be reached, oblique when the hydrocephalus is external. It is best not to remove much fluid the first time; from twenty to twenty-five cubic centimetres (5-6 drachms) will suffice. As a rule, there is but little reaction, and the operation may be repeated within a few days or a week. During the operation and after it compression must be made to prevent hyperemia, hemorrhage, and rapid re-effusion. In cases of external hydrocephalus a mild injec- tion of iodine with iodide of potassium and water ("Lugol"), may be made to suppress secretion. It will take very numerous observations, however, during many future years to determine to what extent all these attempts at suppressing secretion and at facilitating meningeal adhesions and reproduction of brain are to be considered valuable in the interest of families or of mankind in general. When the percentage of albumin con- tained in the aspirated fluid increases after every operation, the prognosis is bad. A number of chronic degenerations of the brain, both gen- 328 THERAPEUTICS OF INFANCY AND CHILDHOOD. eral and local, are the result of inflammatory processes. If they be prenatal, the prognosis is very bad; if acquired after birth, the nearer the beginning of treatment to their starting the better the possible result. Such conditions are disseminated sclerosis, also the infantile spastic hemiplegia de- pending on encephalitis, and oulbar paralysis. The general indications for treatment are the same. In acute exacerbations, depletion, ice, and laxatives will be required; bulbar paralysis may often demand a local application of ice to the nape of the neck. The chronic condition, with fibrillary twitchings, elec- trical changes, and absence of reflexes, requires the different forms of electrical and galvanic treatment, iodides, mercurials, and warm bathing. In all such cases the indications are pro- nounced enough, but the results mostly negative. Meningocele and encephalocele (hernia of the brain) are but rarely amenable to a successful treatment. When they are small, the protruding contents may be retained by a properly fitting appliance of lead or leather or rubber, until the abnor- mal aperture has had time to close. This process may be accel- erated by the administration of phosphorus (ol. phosphoratum or elixir phosphori), of which the newly-born may take at the rate of one-third of a milligramme daily (one one-hundred-and- eightieth grain). When larger and irreducible, the tumefaction has been caught in a clamp and punctured, or removed alto- gether. In some cases the clamp was allowed to remain, in others it was removed; in the latter the wound was sutured. The complication with hydrocephalus impairs the prognosis. Similar treatment has been resorted to in a few cases of menin- gocele spuria, which results under an intact scalp from fis- sures of the cranium to which in infancy the dura mater is tightly adherent, induced by forceps operation, by fall or some other trauma, by caries, or by syphilis. There are complications of grave nature. When the brain is injured down to a lateral ventricle the gap may become per- manent and cause porencephalus. Ehachitis, and the interpo- DISEASES OF THE NERVOUS SYSTEM. 329 sition of brain substance between the fractured bone, prevents spontaneous recovery. Indeed, it appears that the fracture never heals spontaneously; practically, the fissure may close by the interposition of the thickened membranes and aponeurosis, together with diminution of the cerebro-spinal liquor. Such an apparent recovery may, however, not always be a blessing, for epilepsy and metastatic meningitis have been observed afterwards. Eecent cases may be treated by the elevation of depressed bone and bone suture. In incipient spontaneous im- provement, in fact in stationary cases also, the tumefaction should be protected by a pad. Iodine injections have been made into the cavity, which contains cerebro-spinal liquor only, with occasional success; and in a few cases of epilepsy, and of rhachitical hydrocephalus, the lateral ventricles were drained. 4. Psychical Diseases. Psychical diseases have been believed to be rare in infants and children. The statistics published by lunatic asylums and by specialists are meant to prove that. These statistics are cor- rect, but the conclusions drawn from them are not so. Every practitioner knows better. Dementia and mania are by no means rare at any period of infancy and childhood, melan- cholia often without delusions, and with suicidal tendency, and similar conditions of depression are not quite so frequent; they are more generally found before and about puberty. The pub- lic institutions do not contain such patients. A demented or even a maniacal child is managed and prevented from doing harm to itself or to others, at home and by the family, better than an adult, and it is there that numerous such patients can be observed. The same forms of mental disease occurring in the adult are also seen in the young. Besides those which have been mentioned, we meet with moral insanity (often character- ized merely as motor and psychical restlessness, or incorrigible conduct), monomania, epileptic and circular dementia, even "paresis" and delirium tremens. More frequent than either 330 THERAPEUTICS OF INFANCY AND CHILDHOOD. or all of them are idiocy and cretinism, the former of which is a not rare final termination of mental anomaly in the adult, while in the young it is among the first appearance of aberra- tion, though, indeed, but the result of ever so many different anatomical changes. Here also heredity is one of the factors. A peculiar form of family idiocy, generally fatal, and associated with early blindness, was described by B. Sachs. One such case, complicated with rhachitis and with atrophy of the optic nerve, was reported by H. Heiman, another by Koplik. Their varieties I have discussed above, also the possibilities of treating them medicinally or by surgical procedures (p. 316). Cretinism has some well-understood anatomical peculiarities or causes; promi- nent among them are the shortening of the cranial base by premature ossification of the occipito-sphenoidal synchondrosis and, it appears (principally), the absence or degeneration of the thyreoid gland. Thus, the cretinism of the foetus and infant and the myxcedema of the adult are among the results of the same anomaly. My object in enumerating most of the possible causes of men- tal disorders in the young is principally to show that preven- tive treatment should be considered more reliable than curative. Heredity plays an important role, so does inebriety and all other forms of psychical aberration or serious nervous disorders, — epilepsy, diabetes. To what extent matrimony between rela- tives contributes to mental disease in the offspring is by no means proven. I cannot, from theoretical reasoning and from practical experience, admit that two healthy persons, be they ever so nearly related, will for that reason have a diseased child. But to what extent the state of the future will interfere with the marriages of insane and epileptic people, as also with those of carcinomatous or tuberculous patients, provided our thera- peutics continues to be as unsatisfactory as hitherto, remains to be seen. It is but natural that the rapid favorable changes of the last few years in our therapeutics, both internal and ex- ternal, should increase our hopes in regard to great results. DISEASES OF THE NERVOUS SYSTEM. 331 Diseases of the foetus, mostly of inflammatory character, — meningitis, encephalitis, — predispose to mental disorders. During birth, a prolonged labor or undue pressure by pelvis or forceps invites hemorrhage with its results. Spontaneous hemorrhages are the more common and the more dangerous the younger the infant. Congestions and inflammation of the meninges or of the brain are frequent in the infant and child. Their causes are rhachitis of the cranium, insolation, hot stoves and bed-pillows, tumors, stimulants, such as coffee, tea, and alcohol, falls and blows, and diseases of the heart. Disorders of the ears are frequent, and affections of the nose not unheard of, causes of intracranial disease. Infectious diseases, such as typhoid, scarlatina, erysipelas, rheumatism, influenza, are known to be direct causes of mental disturbance in the young. The removal of intestinal worms has ended a psychical disorder. I have known overexertion at school to result in mental aber- ration, which terminated either in recovery or in death from exhaustion or meningitis. The period of puberty, with its sud- den changes, creates a predisposition, and excessive masturba- tion may cause derangement. Bad habits, bad training, and congenital migraine add oil to the fire. This cursory enumeration of causes gives plenty of food for thought. The conscientious family physician with a number of infants and children under his charge has a great responsi- bility. His cares ought to begin with conception. Many a case of infant meningitis (hydrocephalus) can be prevented by timely attention to the mother. Labor must not be permitted to last too long, asphyxia in the newly-born must be imme- diately attended to, and strict care should be taken of the diet and hygiene of the baby. Errors in this respect are not pun- ished immediately; and while some babies thrive, or appear to thrive, while mistakes are being constantly made, in others the foundations are being slowly laid for ill health and serious dis- ease, both physical and mental. That heart and ears ought to be attended to in time, and persistently, is self -understood; but 332 THERAPEUTICS OF INFANCY AND CHILDHOOD. procrastination — waiting for better times and "second denti- tion" and "puberty" — is too common an occurrence. Perhaps the greatest negligence on the part of medical men is exhibited in regard to mental overwork. Our schools have become hot- houses in which scoliosis, near-sightedness, anaemia, neuras- thenia, chlorosis, and cerebral exhaustion and disease are being bred in incredible numbers. If the children are sent to school at six or seven years of age, it should not be forgotten that their brains cannot endure constant work without getting ex- hausted and injured. Between the sixth and ninth year per- sistent exertion, the teaching unit, should not last more than twenty or twenty-five minutes of every hour, between the ninth and twelfth year thirty or thirty-five, after the twelfth year forty minutes. For the first class two or three, for the second three or four, for the third four or five hours is all that should be enforced. Short learning units permit earnest work and progress, long ones cause drudging labor and dangerous fatigue. The apparent offset to this mental overwork — gymnastic or "calisthenic" exercise in the same building, as part of the cur- riculum — adds to the general exhaustion. It is time that the medical profession looked into the increasing degeneration of the people resulting from this overstraining of the young brain, ninety per cent, of the growth of which is not attained until the seventh year, and the full growth not reached before the four- teenth or seventeenth. Physicians will do well to be no longer afraid of the charge of going into politics. If they do not wish to be "politicians," let them be something better, — statesmen. The general remarks made on the first pages of this chapter will suffice for both the general and causal treatment. Serious and unmanageable cases belong to an institution. Conditions of excitement, besides proper hygienic and dietetic treatment, require rest in bed, warm bathing (not hot), and plenty of sleep, which may safely be procured by opiates (extractum opii, codeia), or hyoscin, chloral, sulphonal, amylene hydrate. In the treatment of psychical disorders it is easy to do too DISEASES OF THE NERYOUS SYSTEM. 333 little or too much. As long as our lunatic asylums are (were ?) only more or less genteel prisons, and wherever the "superin- tendents" are more custodians than physicians, where records are kept slovenly, and no autopsies made, nothing whatever is (was ?) done to relieve the physical basis of intellectual dis- orders. Whenever that is sought for, and found with more or less certainty, the indications for treatment are self-evident. Overdoing, however, is as bad as underdoing. Hypnotism should not play a prominent part in the therapeutics of the nervous system. Its utility is doubtful, its dangers as great as those connected with all sorts of psychological experiments gen- erally. Autosuggestion is very active in neurasthenics and hysterical persons, also in the young, who, even when in average health, are imaginative, unreasoning, credulous, and impulsive. Mild forms of temporary mental aberration are the night- terrors (pavor nocturnus). They are mostly (not always) met with in delicate, pale, scrofulous, or rhachitical children, with neuropathic tendencies somewhere in the family. Like attacks of genuine dementia or mania, they are not remembered by the patients. But few of them are attended by fever; many result from or are connected with digestive disorders, nasal polypi, adenoid growths, or hypertrophic tonsils. They should be attended to. Heavy meals must be avoided, also emotions, frights, ghost-stories, exciting games; the attacks are often connected with reminiscences. The bowels should be kept re- laxed. A dose of quinia bromide or potassium bromide at bed- time and a room not absolutely dark are good preventives. 5. Spinal Inflammations, Genuine and Infectious, and Arrests of Development. The general rules for the treatment of diseases of the organs contained in the spinal canal are almost identical with those detailed in reference to the brain and meninges. With the ex- ception of rare cases of pseudoplasm, the changes occurring in 334 THERAPEUTICS OF INFANCY AND CHILDHOOD. the spinal cord and its meninges depend on anomalies of the circulation, or on some form of inflammatory process, either in an acute or a chronic state. To the latter class belong the final and persistent lesions of spinal pachymeningitis and leptomenin- gitis, transverse myelitis, poliomyelitis, lateral and amyotrophic lateral sclerosis, paramyoclonus, and tabes. Multiple dissem- inated sclerosis, with its, at first, slight tremor in voluntary movements, which may be the only symptom for years, and is followed by nystagmus, optic atrophy, scanning speech, and tendon- jerks, appears to me mostly localized in the spinal cord, in children. Before entering upon a course of treatment, it is of the greatest importance to study the etiology of an individual case; a disease of the bone, or tuberculosis, or syphilis must be known before it can be effectually treated. Nor is it super- fluous to omit the exact diagnosis of those ailments which are more and more supposed to be of an infectious nature and of bacteric origin, such as Landry's paralysis and poliomyelitis; for the time may come, even during our lives, when an exten- sive anti-infectious, antibacteric, antitoxic treatment or preven- tive immunization will be among the modern therapeutics of many apparently unmanageable diseases. In every case of acute disease of the spinal cord or its meninges absolute rest is required. But the patient, to avoid overheating and hypostasis, must not be kept on his back con- stantly, or most of the time, and not on feather-beds or pillows. Quilts covered with linen or cotton sheets, air-mattresses, or water-beds are often absolute necessities. When the acute disease can be localized, as mostly it can, cold water, ice-water, the ice-bag, with now and then an ether spray, or local deple- tion by cups or leeches, are indicated. Yesicatories or the tinc- ture of iodine ought to be avoided in this stage, because of their irritating and annoying effects. Purgatives are required on general principles, — calomel (and) or salines. Now and then a mustard bath, quite hot, will act well as a derivant. The in- dications for digitalis (or other heart regulators and invigora- DISEASES OF THE NEEVOUS SYSTEM. 335 tors) are frequent; direct antipyretics are seldom required. Quinine acts better here than in diseases of the brain, where it appears to give rise to occasional congestions. To influence the spinal circulation in acute and subacute diseases, ergot (useless in cerebral diseases) holds a high rank; the fluid extract may be given in doses amounting for the day to from one to eight or ten grammes in the beginning, later less, according to age. Its indication does not cease until the stage of chronicity, with anasmia, contraction, and incipient atrophy of the blood-vessels. Iodide of potassium is indicated early on account of its influ- ence on the circulation, and later for its absorbent effect. The difficulty in handling very old cases is due to the permanency of the local lesions which result from the solidification and cicatrization of the new cell proliferations. Nor are the dif- ficulties in this respect any less, with the exception of some syphilitic cases, in regard to mercury. The sooner and the more persistently these remedies are employed, either internally or externally, either simultaneously or alternatively, the better will be their gradual effect. The bugbear of saliva- tion is no longer feared, since it has become more widely known that the younger the patient the better will he bear mercury. Galvanism and the electro-magnetic current are used on general principles, as mentioned before. Neither should be employed at an early stage. The former requires large electrodes, well salted, to reach the cord; the direction of the current does not appear to make much, if any, difference. Sessions of from six to ten minutes, the current being inverted once or twice during that time, once or twice daily, are all that is demanded. The interrupted current is employed later to stimulate the muscular action, and should be used locally with small or more generally with large electrodes, or in the bath. Anaesthesia may require the application of the metal brush. Warm bathing is often at- tended by very good effects, due to its influence on circulation and the surface temperature. A bath may last minutes or hours; the latter mainly in secondary contractures, which may 336 THERAPEUTICS OF INFANCY AND CHILDHOOD. also require tenotomies. In these cases hot sand-baths have been used extensively in Europe, particularly where the fear of water has not yet begun to wane from the minds of the masses. Their usefulness consists mainly in the invariability of their temperature, which requires less attention and watching than a warm- water bath. In chronic cases ointments have been exten- sively used. Still, very few substances can be rubbed through the epidermis and cutis; indeed, hardly any except iodide of potassium (in glycerin, better still in lanolin) and mercury (ointment and oleate). Its application to the spinal column is of no advantage; it is better to select the usual places where the skin is thin and the lymphatics are near and numerous, — viz., the inner aspect of the extremities. Over the spine the actual cautery has also been found beneficial, together with the mineral springs containing salts and iodine (St. Catherine, Kreuznach, Oeynhausen, Nauheim). In many both of the acute and the chronic cases a sympto- matic treatment cannot be avoided. Pain must be lulled. Now and then the anode (positive pole) of a mild galvanic current will have some such effect; sometimes the local application of chloroform ointments or chloroform vapor in cotton, an ether spray, a menthol stick, or menthol in a ten-per-cent. alcoholic solution will do good. If not, hyoscine, chloral hydrate, croton chloral hydrate, opiates (internally or subcutaneously), or hot fomentations are required; for there is no greater enemy of the sick than pain, and no greater bliss and gain than rest. Other symptomatic treatment may be required for the motory and trophic paralyses resulting from a number of spinal- cord diseases, such as paralysis of the bladder, of the intes- tines, of the sphincters, and bed-sores. The latter are very ominous, and the ointments of bismuth, or tannin, or balsam of Peru, though they be indicated and locally useful, will not defer very long the final termination. Paralysis of the bladder is said to be benefited by local internal electrization; it is bene- fited by ice-cold injections; its secondary cystitis is certainly DISEASES OF THE NERVOUS SYSTEM. 337 improved by plain or medicated warm irrigation. Paralytic constipation requires physostigma and regular enemata. All of these forms of paralysis will be more benefited by the subcu- taneous than by the internal administration of the sulphate of strychnine. Suspension has been practised for several years in some of the chronic diseases of the spinal cord, mainly in tabes, which, fortunately, is rare among children. It may again become fashionable in another generation. Operative stretching of nerves is occasionally useful in contractures depending on cica- trization, as also in some neuralgias of adults. Acute poliomyelitis (spinal, essential, "dental" (!), infantile paralysis), as the initial stage may differ both in its onset and in its symptoms, may require different measures at first. Some cases exhibit a high fever, great excitement and prostration, even cerebral symptoms. The majority, however, come on sud- denly, without fever and without premonitory symptoms. The former class requires antipyretics and the necessary attention to cerebral and other urgent symptoms; much more can hardly be done, because in most cases of this class the diagnosis will probably not be made at first, with the exception of those in which it is assured by local pain and the observation of paraly- sis. These latter are the cases in which local applications of ice may prove beneficial. Every case, whether feverish or afebrile, requires absolute rest. The few which are suspected of originating in rheu- matism, or those which are complicated with peripheral neu- ritis, should be treated by salicylates, and locally by warm ap- plications or fomentations. All the rest will do better with cold applications — ice-water, ice-bag, cold water — continued for some time, but with interruptions. Depletion by means of leeches, or by cupping, is often indicated, particularly in such cases as exhibit local pain. I feel certain that a purgative in the beginning (calomel, salines) will do good; so will ergot; the equivalent of from one to three grammes or more may be 22 338 THERAPEUTICS OF INFANCY AND CHILDHOOD. given daily, either as extractum ergotae or as extractum ergotse fluidum. It may be accompanied by a few drops of the tinc- ture of belladonna. As early as possible — that is, as soon as the necessity of absolute rest will permit of inunctions being made — mercurial ointment (on the first day or days the oleate) may be used, and the internal administration of iodide of potassium commenced at once. Both may be continued — particularly the latter — for several weeks; the dose should be smaller than in cerebral meningitis, half a gramme to one gramme daily being sufficient. Tincture of iodine modified by the addition of alco- hol, or sinapisms frequently applied for a few minutes at a time, may be used with advantage. The rapid improvement during the first week after the onset of the disease, and the slow convalescence of the few months before the residual (mostly local) paralysis becomes imal, hav- ing been established, the indications for treatment will change. Congestion and dilatation of blood-vessels give way to anaemia and contraction, and in place of belladonna and ergot, strych- nine must be given; at first, perhaps, internally. It may be beneficial when so administered, but hypodermically it will act better. I cannot agree with Gowers, who claims that it is prob- ably "never either necessary or desirable to give it by hypo- dermic injection in this disease/'* Several times a day, for weeks in succession, the cold shower-bath applied one or two minutes to the back, followed by lively friction, will contribute to the stimulation of the spinal circulation. The rapid waste of the paralyzed muscles requires local stimulation. Frictions with oil, vaseline, alcohol and water, tepid water, or hot water must be used several times a day. Where the surface circulation is still fair, cold water may be preferable. Passive movement must take the place of active exercise when the latter is impossible. The faradic current will stimulate and may improve whatever there is left of contrac- tility. Should it become totally inactive, the reversed galvanic current may take its place for the purpose of exercising the DISEASES OF THE NERVOUS SYSTEM. 339 muscles. Otherwise the galvanic continuous current is emi- nently the nerve and blood-vessel stimulant, and must be used daily to keep up the circulation and thereby the nutrition of the degenerating tissues. It is best applied through large elec- trodes, and should be made to ascend and descend alternatively. Sessions of from six to ten minutes, one or two every day, are sufficient, but they must be continued a long time. I know that limbs which had remained unchanged in their atrophy and uselessness for years improved under patient galvanic handling, when persisted in for a long time. Mechanical appliances will prove useful. The arm must be so supported as to render the paralytic slipping out of the socket of the paralyzed humerus an impossibility. The rare cases of dorsal paralysis require a jacket or a properly fitting corset. The paralyzed (mostly extensor) muscles of the lower extremi- ties demand elastic bands, so as to counteract the contraction of the antagonistic flexors and thus to facilitate walking. Mean- while the remedial agents mentioned before must be continued. Strychnine will always do good, and phosphorus will act both as a nerve stimulant and as a tissue-builder. It may be given to a child a year old in doses of from half a milligramme (half a teaspoonful of the elixir of phosphorus of the United States Pharmacopoeia) to three-fourths of a milligramme daily. To expect an improvement of nutrition by ligating the paralyzed limb is a grave mistake. That procedure will tumefy, but not nourish, the constricted part. Consecutive club-foot requires the employment of proper orthopaedic apparatuses at as early a time as is judicious, to prevent an unnecessary degree of anaemia, atrophy, and loss of length. To avoid the necessity of such mechanical aids, an operation has been performed — arthrodesis — for the purpose of ankylosing the upper ankle-joint, in some cases also the talo- calcaneal joint. The after-treatment consists in the use of a plaster-of-Paris bandage, which should be carried three months by children under ten years, six weeks by adults. The 340 THERAPEUTICS OF INFANCY AND CHILDHOOD. highest degree of tendon contraction may require extirpation of the talus, but is usually overcome by tenotomies. After re- covery a snug shoe must be worn. Circumcision has been performed on children affected with poliomyelitis, without any justification either in theory or in practice. The varieties of hydrorrhachis (spina bifida) depend on the more or less extensive arrests of development and their second- ary changes. The treatment differs accordingly. In more ad- vanced years I have seen spina? bifida?, in the lumbar and in the cervical regions, whose connection with the spinal canal, origi- nally narrow, was totally obstructed, so that their removal caused no difficulty whatever. Cases accompanied by malfor- mations, contractures, or paralyses of the lower extremities do not respond favorably to treatment. Those rare ones which are complicated with superjacent tumors (mostly lipomata) or with hypertrichosis (very rare) must be carefully watched, for care- less operations on what was considered uncomplicated pseudo- plasms have proved fatal. Such as are of central origin, in which accordingly the posterior columns with the nerve-roots spread over the interior of the sac, give a grave prognosis. Spontaneous bursting of the sac must be guarded against, for much loss of cerebro-spinal liquor is apt to terminate fatally in a very short time. Puncture may be resorted to and re- peated, a fine needle being used. After each puncture pressure ought to be applied to prevent rapid filling up. A few cases — small ones of simple meningocele — have been known to get well in this way. Or, after the puncture, iodine may be in- jected. Morton's formula — iodine 1 part, potassic iodide 3 parts, and glycerin 48 parts — has been very felicitous in his hands and in mine. Favorable cases have been successfully treated by the clamp, suturing, and gentle compression, and bad cases by extirpation of the sac and utilization of the peri- osteum of the patient. Robson transplanted that of a rabbit in 1883. DISEASES OF THE NERVOUS SYSTEM. . 341 Nicolaier's discovery of the bacillus of tetanus in 1885, and its pure culture by Kitasato in 1889, together with the progress made in immunization and antitoxic treatment generally, add to our hopes of the curability of tetanus. Immunization against tetanus has been proved in mice, and recovery has taken place when serum was injected five hours after the introduction of the culture. But it is true that a hundred times the amount of serum was required in an animal infected only a quarter of an hour before, as compared with the amount required before infection was accomplished; it is also true that very few ab- solutely certain and indubitable successes have thus far been obtained, but there can be no reasonable doubt that most satis- factory results of antitoxic methods of treatment will be de- veloped shortly. The tetanus antitoxin prepared by the New York Health Department is recommended in rather large doses; three hundred cubic centimetres may have to be injected into a child of twelve years. "It is of vital importance that the anti- toxin be administered at the earliest possible moment, as the dose required to neutralize the tetanus toxin absorbed increases with great rapidity with each hour's delay," at the same time the disinfection of the locality of invasion by means of iodine should go on, "carbolic acid and bichloride of mercury are of little value for this purpose." Medicinal treatment should be kept up at the same time. The effect of heavy doses of the bromides, of chloral, of curare, and of opium is undoubted. Most of the cases of tetanus in the newly-born and in the adult that I have seen getting well did so under chloral, bromides, and occasional doses of opium. Carefully, but early, must the doses of chloral hydrate be increased. In some instances they were incredibly large. (See p. 116.) It seems certain that those cases of tetanus which are un- doubtedly of bacillary origin are least amenable to treatment. Such as are of rheumatic or traumatic origin, and even such as result from throat infections, are more easily influenced by remedies. 342 THERAPEUTICS OF INFANCY AND CHILDHOOD. 6. Neuroses of Central or Local Origin. The treatment of eclampsia depends on its etiology. Ke- peated attacks may be the results of identical causes, — for in- stance, feverishness, intestinal disturbances, and emotions, — but they suggest the existence of epilepsy. Indeed, a single eclamptic attack cannot be distinguished from an isolated epi- leptic seizure. According to the various causes to which eclamptic convulsions may be due, the best preventives are regulation of the diet, of the bowels, and the removal of worms; the withholding of alcohol, coffee, tea, and improper foods; the watching of every kind of fever, from a simple catarrh to an in- flammatory or infectious disease. In households where there are babies known to be subject to eclampsia the clinical ther- mometer is indispensable. Catarrhal fever, intermittent fever, pneumonia, otitis, meningitis, and acute eruptive diseases are often ushered in by a convulsion. Tight bandaging, renal cal- culus, and splinters in the skin are to be suspected when no other cause is readily found. A normal dentition never pro- duces a convulsion, and "difficult dentition" as a cause of a convulsion is among the affections which are as rare as they are too readily diagnosticated.* The frequency of the habit of lancing the gums, to which many practitioners are still addicted, proves the frequent absence of diagnoses and the readiness with which tribute is paid to the prejudices of past centuries and to those of the female population. Cranial and encephalic rhachitis, with or without laryngismus stridulus, is often attended by convulsions, and requires antirhachitical treatment. The habit of regularly administering bromides to infants who have convulsions is a bad one. As a regular medication they ought to be reserved for epilepsy. The attack demands the removal of the cause. Irrigation of the stomach, or an emetic; irrigation of the bowels with water, soap and water, * See my "Dentition and its Derangements," New York, 1862. DISEASES OF THE NERVOUS SYSTEM. 343 oil, turpentine, assafcetida; a purgative (calomel with or with- out an antifermentative, such as resorcin or salol, followed or not by castor oil); the proper use of a warm bath; a cold pack frequently repeated, with ice to the head and heat to the feet; the timely administration — in an urgent case antipyrin under the skin — of an antipyretic; chloral hydrate internally or by the rectum; inhalations of chloroform to shorten the at- tack, — all suggest themselves as most promising in certain cases. Chloroform ought not to be omitted, for any moment of a violent convulsion may occasion a cerebral hemorrhage with its dire results for life, or body, or mind. Sinapisms to the neck and to the extremities have often been recommended, but be- sides the possible after-effect of annoying and irritating the infant suffering from a vulnerable nervous system, they cannot be expected to have much, or sufficient derivative action. To quiet the irritability persisting after an attack, chloral hydrate with or without a bromide, or repeated small doses of codeine or extract of opium, or the camphorated tincture of opium may be administered. The causes of chorea minor — St. Vitus's dance — are either anatomical changes (some of them improvable, some incurable) or functional disturbances. Therefore the treatment should vary according to the etiology, but hardly a case will do well without attention to the functional treatment. Indeed, some forms of the latter are almost of a specific character. Preven- tion is indicated when the patient is of a neurotic constitution; the descendant of a neurotic family; when suffering from di- gestive or genito-urinary disorders (masturbation); when ac- customed to alcohol in more than medicinal doses, or when he has rheumatism or heart-disease. Capillary embolisms, cysts, tubercles, apoplexies, and exudative changes in the nerve- centres, particularly the brain, are not subject to preventive measures. The same holds good in any cerebral lesion located near the pyramidal tracts, — viz., in the cortex, the internal capsule, or in the basal ganglia. Demme observed a case 344 THERAPEUTICS OF INFANCY AND CHILDHOOD. depending on a fissure of the anus; it admitted of direct treatment; Soltmann a chorea of the left side after trau- matic depression of the right parietal bone; others report cases depending on shrinking cicatrices and on neuritis. I have observed a marked case of acute chorea which de- pended on spinal meningitis of the cervical portion. In this case ice, local depletion, purgatives, and ergot were the suc- cessful remedies. (Seguin's "Clinical Lectures," vol. i., 1872, second lecture.) In the American Journal of the Medical Sciences, April, 1886, and in the "Festschrift zum 70sten Ge- burtstag von Professor Henoch," Berlin, 1890, I published ob- servations of partly local, partly general chorea which depended on nasal reflexes due to catarrhal and inflammatory changes and to polypi. In all these cases the treatment and cure of dis- eases of the nose and naso-pharyngeal cavity are demanded pre- liminarily to the successful treatment of St. Vitus's dance. When heart-disease or a tendency to acute articular rheu- matism is the cause, preventives share largely in the success of the treatment. The hygiene must be strict and medicinal attention to the cardiac ailment close. The rheumatic child must be anxiously watched; pain, be it ever so slight, requires rest in bed for one or two days at least and tentative doses of salicylate of sodium. Helminthes must be expelled. Neurotic children should not be overworked, the school ses- sions must be short. Cool or cold washes, with friction, and systematic, but simple and brief, gymnastics in the open air, not in a close school-room, will strengthen them. The period of convalescence from any incidental disease must be passed in bed, which should be placed, if possible, near an open window. Anaemia must be carefully watched and treated. The patient should not be allowed intercourse with neurotic, or hysterical, or choreic, or epileptic, or even merely violent children; for some of the worst cases of chorea are those produced by fright. Headaches of a simply neuralgic or ocular origin must be at- tended to; the latter requires mostly glasses, sometimes the pro- DISEASES OF THE NERVOUS SYSTEM. 345 tracted use of strychnine, but no misdirected and unauthorized operations when there is no disturbance of muscular accommo- dation; in the former aconitine will often prove helpful. A patient sick with chorea minor must be kept quiet in body and mind. Bad cases will not get well, unless confined to bed in a quiet room, with no visitors or excitements, with but a single person present to entertain or read to them, with a warm, protracted bath daily, and with ample sleep. Very bad cases must be kept sleeping eighteen out of twenty-four hours by means of mild opiates or chloral hydrate with or without bromides. Sometimes large doses are necessary, but the effect must be obtained. I have met with cases in which an occasional inhalation of chloroform was also required. Meanwhile, the symptomatic measures adapted to the average case should also be attended to. The best symptomatic remedy is arsenic, in the form of liquor arsenitis potassii or arsenatis sodii. Three doses are to be given daily, much diluted, after meals. When the eyes or the intes- tines begin to give trouble, or when a serious cutaneous erup- tion makes its appearance, or should the urine show albumin and casts, it is time to intermit. The doses must be increased slowly but persistently, according to the rule detailed on page 131. The original dose can be doubled or quadrupled, indeed, can be increased almost indefinitely. The cause of failure on the part of arsenic is generally its insufficient dose. Of other remedies, nitrate of silver may be mentioned; it is of less service here than in some other ailments of the ner- vous system. Oxide of zinc or valerianate of zinc may be tried, if arsenic happen to be omitted. The galvanic current, warmly recommended by Benedict, has not satisfied me. Sulphur bathing, either natural or artificial, is adapted to cases conse- quent on rheumatism; it is indicated as after-treatment, as are also rational gymnastics and general roboration. Tetany has been observed in general disturbances of the gen- eral health, after gastro-intestinal disorders and during the 346 THERAPEUTICS OF INFANCY AND CHILDHOOD. presence of worms, in convalescence from acute and chronic (particularly infectious) diseases, after sudden exposures to changing temperatures, in chronic malaria, after injuries to the head, as the result of irritation, or as a consequence of the abuse of alcohol. The fact of the occurrence of tetany after total extirpation of the thyroid gland may lead in future to a correct diagnosis of many cases of tetany in children and to an accurate examination of the thyreoid gland. It is sometimes absent, or hypertrophied, or in an abnormal condition. The majority of cases are connected with rhachitis, mostly with its cranial (and encephalic) variety, and laryngismus stridulus. It is often found in cold springs, endemically, sometimes epidemically. The several causes enumerated above prove the occasional diffi- culty of a satisfactory etiological diagnosis, but suggest the pre- ventive and curative treatment. Pilocarpine has been mentioned as the successful remedy in a case which was probably caused by exposure. Gastro-intestinal disturbances (with or without autoinfection, accompanied by fever and by the occurrence of indican or aceton in the urine) demand proper medicinal and hygienic treatment. Tetany after infectious diseases and during convalescence generally requires rest in bed, good air, copious (perhaps forcible) alimentation, and roborants. A very mild galvanic current, prolonged warm (not hot) bathing, bromides, chloral at night, and small doses of codeine in older children will be required according to the severity of the cases; they will get well after weeks or months. A roborant and anti- rhachitical treatment with cod-liver oil, iron, strychnine in small doses, phosphorus, systematic exercise, and gentle hydro- therapeutic measures will restore the general health. The treatment with thyreoid gland has not proved a great success in the average case. Catalepsy is quite rare in children. I have seen but three well-marked cases, one of whom, a boy of thirteen, landed finally in a lunatic asylum. It is intimately related to hysteria and epilepsy, and often attended by psychical disorders. Both its DISEASES OF THE NERVOUS SYSTEM. 347 prognosis and its treatment are dependent on the causes, among which fright, masturbation, chlorosis, malaria, helmin- thiasis, epilepsy, and melancholia have been enumerated. Thus, depletion, diaphoretics, emetics, nervines, anthelmintics, and electricity have been recommended. In most cases medi- cines are less effective than is attention to general hygiene, both physical and mental. In this respect it shares the fate and prognosis of hysteria, of which it may be considered one of the manifestations, the existence of which among children has been more extensively observed and studied since its pres- ence, particularly in connection with masturbation, was dis- cussed by me in 1875 (Amer. Journ. Obsi. and Dis. W. and Children). Hirschel and Fleisch observed catalepsy after inter- mittent fever, and Glas noted the case of a boy of five years, who had an attack of catalepsy (instead of a chill), followed by perspiration. In these cases quinine and arsenic take the place of other treatment, with better success. Another, though rare, symptom of hysteria is chorea magna, which differs from chorea minor in the occasional appearance of paroxysms of co-ordinate spasms with psychopathic prodromi and (frequently) termination. Altogether, hysteria occurs with all the symptoms met with in adults. It is not confined to the female sex in children any more than it is in adults, and ex- hibits the same debility and irritability of the nervous system in general and of emotions, reflexes, imaginations, and will in particular. Hyperesthesia (more frequent than anaesthesia), localized paralysis (muscles of deglutition, first branch of facial nerve, ptosis), paraplegia, strabismus, spinal and other neu- ralgias, tachycardia and palpitations are among the symptoms. The lack of mental and emotional equilibrium is an early feature. It is found in psychopathic families as the result of mental strain, in badly ventilated schools, and depending on undue ambition, masturbation, diseases of the ovary, and emo- tions. Hysteria in a child means, unfortunately, in most cases, hysteria for life. Still, training and education are capable of 348 THERAPEUTICS OF INFANCY AND CHILDHOOD. accomplishing a great deal in strengthening will and character and independence of thought. Such children are better off among strangers than at home. School sessions ought to be regular but short; work in the open air, housework, gym- nastics, and hydrotherapy, with general roborants, are indicated and prove successful. Athetosis, that peculiar form of localized (ends of upper ex- tremities mostly) spasm, can hardly be improved when congeni- tal. Now and then it accompanies polioencephalitis or cerebral tumors. Improvement is claimed to have followed the use of arsenic, bromides, and galvanism. Most cases of epilepsy are observed in, or date from, infancy and childhood. In no disease is hereditary influence more marked; the state of the future will have to see to it that epileptic persons are not placed in a condition to raise progeny equally cursed. Epileptic mothers must not nurse their babies. The child known to be epileptic must be trained very carefully, both physically and mentally. Alcohol and other stimulants, physical and mental exertions, and sudden emotions must be avoided. The hygiene of the skin and of the bowels requires particular care; the use of cold water is imperative; con- stipation must not be permitted. Feeding with gruesome nursery stories, tight dressing, and early schooling, also horseback exercise and swimming, are forbidden. In the in- terest both of the patient and of his schoolmates a public school should not be attended. The child ought to be instructed and trained with a view of preparing him for his future calling, which must not overstrain body or mind, must not be seden- tary, nor should it confine him, if avoidable, to the limits and influences of city life and air. No case of epilepsy should remain without treatment. It is true that there are spontaneous recoveries; even hereditary cases may get better or well; remissions are frequent; inter- vening acute diseases and many operations have frequently a favorable effect. On the other hand, Gerhardt saw a relapse DISEASES OF THE NERVOUS SYSTEM. 349 after an intermission of twenty years. But the knowledge of these facts must not tempt us to procrastinate medicinal and hygienic interference, or to hold out a hope of recovery at the period of "second dentition/' of "puberty," or of "marriage." The best methods of treatment are always either specific or local. Symptomatic treatment may prove very successful with the aid of all-healing nature, but it is always a makeshift. The ideal indications for the cure of epilepsy ought to be — nay, must be — causal; its proximate seat is in the cerebral cortex, but its actual origin in anatomical lesions, mostly, of different localities. Thus, epilepsy may be cerebral, it may be the result of persistently abnormal circulation, or it may be of a reflex na- ture. A (brachial) Jacksonian epilepsy cured by the removal of a foreign body from the ear was reported by Monflier. Not a few cases have been traced to nasal irritation and relieved by nasal operations. All sorts of cerebral tumors, solid or cystic, the results of previous encephalitis and meningitis from inso- lation, otitis, or otherwise; arrests of cerebral development; premature ossification of one, some, or all of the cranial sutures and fontanelles; cerebral exhaustion from masturbation or pre- mature venery; diseases of the heart with secondary venous obstruction; congestion from other causes (in a case of Ger- hardt's, enlargement of the thyreoid); the influence of pro- longed use of alcohol or ergot; the sluggish brain circulation attending constipation and the general toxaemia of intestinal autoinfection; external irritations such as tumors, cicatrices, foreign bodies, and the reflex excitement produced by carious teeth, Schneiderian hypertrophy, and nasal and nasopharyn- geal growths; vesical and renal calculi; helminthes, from taenia to oxyuris; in older children delayed menstruation, are so many different causes of epilepsy. It is, therefore, only the most painstaking examination of all the organs and the whole surface of the body which gives a promise of finding the cause of the disease as well as the indications for rational causal treat- ment. 350 THERAPEUTICS OF INFANCY AND CHILDHOOD. Arrests of cerebral development are not amenable to treat- ment; the method of dealing with the chronic results of cere- bral and meningeal inflammations, also the possible value of operations on prematurely ossified skulls, have been previously discussed. Most of the operations on the cranium undertaken for the purpose of healing epilepsy have not been successful, and the most enthusiastic promoters of such operations have rescinded their favorable opinions. Thus, the American Neu- rological Association, in a discussion which was mainly carried on by Sachs, Mills, Putnam, and P. C. Knapp, expressed itself very reservedly on this topic. But there is no doubt as to an occasional success, nor can there be any as to the feasibility of removing tumors from the surface of the cortex, or of open- ing and removing cysts and the results of new or old haemato- mata. B. Sachs and A. Gerster (Am. Journ Med. Sc, October, 1896) came to the following conclusions: An operation is per- missible in traumatic epilepsjr when the case is not over one or two years old. When there is a depression of bone, the oper- ation is indicated at a later period, but should not be delayed. Trephining alone is sometimes sufficient. If the disease is of short duration, a part of the cortex may be excised. The com- plication with cerebral infantile paralysis, if the case be recent, is no contraindication to the operation. It must not be per- formed in epilepsy of long duration. Still, the human body, not being a machine manufactured wholesale on a uniform last, and medicine not being mathematics, the indications both for medical and surgical interference are neither geo- metrically exact nor are they gospel. For these reasons mistakes are always liable to occur. Jacksonian epilepsy will not always exhibit, at operations or at autopsies, the local lesions boldly diagnosticated. Aye, recoveries may not be ob- tained, though no error be committed; for, indeed, habitual convulsions may be so firmly established that even the removal of their original source is no longer an efficient cure. But the insufficiency of medicinal treatment may be such as to some- DISEASES OF THE NERVOUS SYSTEM. 351 times necessitate or permit surgical interference as a possible last resort. It is particularly in cases produced by reflex from cicatrices and nasal irritation that local treatment, excision, cauteriza- tion, and the removal of polypi and adenoid growths have their signal, though rare, triumphs. The eyes have been accused — "eye-strain" — of producing epilepsy, and hence have been sub- mitted to operations. My remarks on that subject, as con- nected with chorea, I can but repeat here. As regards local treatment, we have also to consider the effect on the genital organs when they are the cause of epilepsy. There is no doubt as to the occasional efficacy of digitalis, lupulin, or camphor in such cases. In others a chemical effect is aimed at; thus, in epilepsy from chronic lead-poisoning, sulphur baths and sul- phur and iodide of potassium internally have exhibited good results. If the approach of an attack be perceived, the patient ought to lie down on a low couch; the inhalation of amyl nitrite, if in time, has warded off many seizures; its effect must not go beyond the first deep flush. If an aura rises from an extremity, a stout ligature around the limb may also act as a preventive. "When the seizure cannot be prevented, it must not be inter- fered with; no hands must be forcibly opened, no convulsive jerking meddled with; but the patient must be protected against biting his tongue or otherwise hurting himself. Among the drugs recommended for epilepsy every narcotic and anti- spasmodic has had its day. Valerian, pgeonia, and artemisia were once highly thought of; so was belladonna, and later atropine, with its paralyzing influence on blood-vessels. Curare was praised for its effect on the muscles. Sulphate of copper has been recommended. Nitrate of silver, in doses of not more than one or two centigrammes daily (gr. J-J), best in pills, may be continued, with intermissions, for a long time, and is credited with cures. It ought not, however, to be administered more than a month in succession, lest the skin show its effect. 352 THERAPEUTICS OF INFANCY AND CHILDHOOD. Twice in my life have I thus succeeded in producing argyria. Zinc has proved serviceable: the oxide, the valerianate (25-50 centigrammes daily), and the sulphate. The latter I have made much use of, beginning with three centigrammes (gr. -J) three times daily for an adult (a child in proportion), in increasing doses. Four grammes (1 drachm) are dissolved in one pint, of water, the first dose being a teaspoonful for an adult, ten or twenty drops for a child, the second the same dose plus one drop, the third the same dose plus two drops, and so on until after twenty days the double dose, after forty days the treble dose is reached. It takes a long time for tolerance to become exhausted; should this happen, a small reduction of the dose is all that is required. To reduce the irritability of the cortex and the general con- vulsibility, and thus in the course of time to cure epilepsy, the main reliance is on the bromides. I have not been able to con- vince myself of the injuriousness of the potassium salt. A belief in its harmful action has been the cause of the substitu- tion of the sodium, or a mixture of the potassium, sodium, and ammonium salts. Whichever plan is followed, there are certain rules which are paramount. The remedy must be given for years; it must not be interrupted unless there have been no seizures for years, except for very good reasons (excessive acne, paresis, sopor, headache, and perhaps the intervention of acute diseases). The doses must be sufficient; a child of two years may take three or four grammes (grs. 45-60) daily. It is best to give a large dose at bedtime, perhaps half of the daily amount; in this way the cerebral symptoms of overdosing are most readily avoided. When they appear the dose may be re- duced, but, except in rare instances, the remedy should not be stopped altogether. Perhaps the strontium or lithium salt may take its place for a time, but I cannot say that either has im- pressed me with the superiority which has been claimed for them. The addition of moderate doses of digitalis has often appeared to me to reduce the drowsiness brought on by pro- DISEASES OF THE NERVOUS SYSTEM. 353 tracted large doses. Arsenic in small but regular doses will lessen the tendency to acne. I cannot say that bromides are badly tolerated in the even- ing; still, it is claimed that they have a disagreeable effect. In that case a sufficient dose of amylene hydrate to produce sleep should take their place. Weber, of Dahldorf, precedes his bromide treatment with a regular course of amylene hydrate; on the other hand, there are those who condemn its use alto- gether because of injurious effects which they claim to have observed (Jastrowitz, Jolly). Flechsig combines the bromide of sodium treatment with that of opium. His two or three daily doses of the latter, for adults, are from five to ten or twenty-five or thirty-five centi- grammes each (gr. f-6). Large doses cannot, however, be given except in well-supervised institutions. After six weeks it is suddenly discontinued and replaced by 7.5 grammes daily (2 drachms) of the bromide. After this treatment has been con- tinued two months the daily dose is reduced to two grammes. Only when fright or other emotions were the proximate causes, the two remedies were combined early. Flechsig claims no direct effect, but only a preparatory action of the opiate. In- deed, during the opium treatment there was no relief; but in combination with bromide of sodium, cases which had lasted decades were improved. Eadcliffe, however (according to Gowers, Lancet, 1880, p. 552), found opium effective in some cases. Gowers saw but rarely any good effects from bromides and opium combined, but believes in the usefulness of small subcutaneous doses of morphine when attacks reappear often and violently. The latest journal reports on the Flechsig treat- ment are very contradictory. From Dr. Charles A. Dana I learned the use of urethan in epilepsy. I have seen it to stop epileptic convulsions (fifty every day, severe and mild) within a few days never to return for more than half a year until the child died from causes not connected with her epilepsy. The doses amounted to from two 354 THEBAPEUTICS OF INFANCY AND CHILDHOOD. to three grammes (half a drachm to two scruples) a day, some- times refracted; sometimes a large dose was given at bedtime. Pasteur observed that in a patient under treatment for hy- drophobia the epileptic attacks ceased (as they do cease after operations of any kind, strong emotions, or acute diseases). For this reason Charcot suggested systematic injections of rabic virus for the purpose of relieving or curing epilepsy. Gibier has imitated the process and claims good results. Pierre Marie goes so far — a good deal too far — as to believe that "idio- pathic epilepsy," which he claims to be frequent, is of infec- tious origin in almost every case, is therefore preventable, and ought to be treated and cured with microbic toxin (Semaine Medicate, 1892, p. 283). The number of epileptics is so large, and the influence of the disease upon the intellectual, moral, and physical condition of the individual, as well as upon the state and mankind, so wide-spread, as to be alarming. The subject has finally roused the anxiety of philanthropists to a great extent. Country set- tlements of epileptics have been established in Europe, with beneficial results. As a result of combined efforts the following resolution was passed at a meeting of the American Neurologi- cal Association: "That it is the unanimous sense of the American Neuro- logical Association that the proper care of the epileptic class, so long delayed, be urged upon the public, upon State authori- ties, and especially upon all interested in the care of the sick and defective poor, whereby they may be retired from asylums and almshouses, and may receive the required care in such separate establishments as their deplorable situations demand.* One of the results of this resolution was an act of the Leg- islature of the State of New York, by which a tract of land in the interior of the State was set aside for the purpose of estab- lishing colonies for epileptics. The world is moving. Salaam spasm (spasmus nutans), a peculiar affection of the accessory nerve, must receive the treatment proper for its DISEASES OF THE NERVOUS SYSTEM. 355 causes, which are either central (rhachitical) or reflex (from intestinal disorders). Many of the patients are thoroughly anaemic. There are indications for bromide of potassium, the positive pole of the galvanic current upon the convulsive mus- cle (sterno-cleido-mastoid (or) and trapezius), also massage and antirhachitical treatment. Stammering is pre-eminently a disease of the nervous system, and is probably caused by a diseased condition or insufficient tone of the cerebral cortex, with lack of equilibrium, exhibited in some by choleric temperament, in others by cowardice, to- gether with disturbance of will-power and an absence of co- ordination of respiration and the muscles of the larynx and mouth. In some it is the result of nervous talkativeness, fid- getiness, and flightiness on the part of parents or attendants; in some of imitation not checked at the proper time. Strength- ening of mind and body is the main indication. Training, cold water, and exercise will fortify the character; bromides may for a time relieve irritability. Co-ordination of innervation and muscle may be achieved by loud and slow speaking and by reading, reciting, and singing. Self-confidence must be encour- aged in every way. Among strangers and in institutions estab- lished for the purpose such patients are mostly benefited, not infrequently in a short time. Local affections of the respira- tory tract must be attended to, adenoid vegetations of the naso-pharynx removed, and other anomalies of the nares, pro- vided they interfere with respiration, corrected. VII. DISEASES OF THE DIGESTIVE ORGANS. A. The Mouth. 1. Hare-Lip and Fissure of the Palate. The latter cannot be operated upon until the child is four or five years old. The former should undergo the operation, un- less there be a strong contraindication, on the first day of life, when the immediate necessity of feeding is not urgent. The difficulty of nursing is, in part, obviated by the successful closure of the cleft in the upper lip, and the sooner the de- formity is removed, the better are the chances for a correct position of the future teeth and for articulation. 2. Tumors in the Oral Cavity. An adenoma of the parotid was noticed in a nursling by Eros. Fibroma occurs in the periosteum, enchondroma and osteoma in the lower jaw, sarcoma (epulis) in the alveolar process, where it mostly originates in the periosteum. They should be removed soon. The first (of the very few cases on record) congenital sarcoma of the tongue I reported in 1869 (Journ. Oost. and Dis. of W. and Child.). It was removed by the galvano-cautery. Biedert ("Lehrb. d. Kind.," 11th ed., 1894, p. 168) reports the case of a girl of ten years with sarcoma, which commenced in a tonsil and extended over all the neighboring organs. When she seemed to be almost moribund she was taken with erysipelas and got well. The report was made eight years after her re- covery, which took place with considerable cicatrization. The case holds out great hopes for Coley's treatment of sarcoma by means of the serum prepared from the streptococcus of ery- sipelas andHhe bacillus prodigiosus. 356 DISEASES OF THE DIGESTIVE ORGANS. 357 3. Ranula. The sublingual glands are sometimes seen as gentle elevations, when the tongue is normally raised. Some acini of one or both glands, however, may undergo cystic degeneration and form cysts of any size up to that of a pigeon's egg. The same sort of cystic tumors are formed in the obstructed Rivinian duct and in the lymph-ducts between the genio-hyoid muscles, very rarely in the ductus lingualis or its ramifications. When they impede nursing, deglutition, or respiration, they should be removed. As the walls are very thin (mostly), enucleation is not practical; the simple incision is mostly useless because it will soon close up; the introduction of a silk-thread seton may favor suppura- tion and sepsis; the removal of a fairly large part of the visible wall, with subsequent application of the nitrate of silver stick (with immediate application of salt solution afterwards) gives the best results. Concretions in the efferent ducts of the sublingual and the submaxillary glands can mostly be expelled by gentle pressure. If not, a short incision will free them. 4. Milia. Epithelial Pearls. Along and near the raphe of the palate of the newly-born and nursling there are (sometimes numerous) hard, yellowish- white conglomerates of small size. Now and then they rise above the level of the surface. They are mostly (not cystic, not comedones) accumulations of epithelia in the small vacuoles of the mucous membrane. Mostly they disappear spontaneously; sometimes, under the influence of injury and microbes, they ulcerate. Pus is occasionally seen. I have observed perfora- tions of the palate. In that condition they are sensitive or painful, and interfere with nursing and nutrition, and are the starting-points of thrush, or of still more serious infectious dis- eases. A daily application of a solution of nitrate of silver (1 : 50-500), mild when only the surface is ulcerating, and fre- 358 THERAPEUTICS OF INFANCY AND CHILDHOOD. quent brushing (not rubbing) with a solution of potassic chlo- rate or of sodic biborate (1 : 30-40) will be all that is required. The perforation alluded to is very exceptional. Syphilitic and diphtheritic (rare) perforations furnish their own indica- tions both for local and general treatment. 5. Stomatitis. The catarrhal form, mostly with inflammation of the gums (gingivitis), results from uncleanliness (retention of food in the mouth), from constant sucking on fingers and nipples or is observed in connection with nasal catarrh, glossitis, pharyngitis, gastro-enteritis, peritonitis, or the exanthematic acute erup- tions. This mild form demands cleanliness, drinking of cool water (mainly after every feeding), cooler temperature of the food, unless it be breast-milk, and the washing either with chlorate of potassium or borax solutions. In those cases in which the mucous membranes and the tongue are dry, a solu- tion of nitrate of silver (1 : 500-1000) should be brushed on once a day. The follicular form, in which vesicles are found over the mucous membranes, tongue, and pharynx (not the gums), with a tendency to rupture, is very painful and often attended with high temperatures, and interferes with swallowing; it should be treated, besides locally, with chlorate of potassium, eight grains (0.5) in five ounces (150.0) of water and glycerin (10-15 : 1), a teaspoonful to be taken every half hour, and no water to be given immediately after so as to secure the local with the gen- eral effect. The ulcerous variety (stomacace) originates in the gums of the lower (more frequently than the upper) incisors and canines. The tissue undergoes a rapid parenchymatous dis- integration, looks white, is soft, breaks away, loosens the teeth, attacks the adjoining angle of the mouth and cheeks, which undergo the same destruction. There is copious salivation and offensive odor. As it is mainly observed after measles (most DISEASES OF THE DIGESTIVE ORGANS. 359 frequently) or pneumonia, and infectious diseases generally, feeding (which is often resisted), tonics, and stimulants are urgently indicated. Internally, chlorate of potassium as in the follicular form, in doses not larger, but more frequent. Most cases do not require anything besides, with the exception, perhaps, of the local application, a few times a day, of perman- ganate of potassium solutions (1 : 250-500). The aphthous variety, with yellowish or gray spherical and flat fibrinous deposits between epithelia and the tissue of the mucous membrane, sometimes complicated with small hemor- rhages, may become dangerous when grave, and may interfere with swallowing. When there is a tendency to superficial ulcer- ation, nitrate of silver in water (1 : 50) may be gently applied once daily. Other treatment was outlined above. 6. "Bednafs Aphthae." They are not aphthae, but flat and more or less extensive ulcerations, resulting from atrophy of and injury to the epi- thelium and mucous membrane of the alveolar processes and the palate of the very young (first month). In the newly-born desquamation takes place over all the integuments, both skin and mucous membranes. Thus, normally, the epithelium is thrown off. The oral mucous membrane is very thin, over the posterior alveolar process it is very tense, and mostly so about the insertion of the pterygo-mandibular ligament. There, while the mouth of the newly-born is kept opened, the mucous membrane becomes quite pale. Thus a slight stomatitis, a moderate ill nutrition, and careless and rough handling of the mouth of the baby, cause abrasions and ulcerations, which may be quite small, or extend over square inches. They are danger- ous to the same degree as they interfere with nursing or feed- ing, and facilitate the invasion of microbes which are numer- ous, but accidental. Still they may cause an infectious disease. Thrush is a frequent sequela. The above etiological remarks preach the sermon of prevention. Look after your nurses, their 360 THERAPEUTICS OF INFANCY AND CHILDHOOD. finger-nails, and the material they shove into the babies' mouths. Nitrate of silver (1 : 50-500) in one daily application, and gentle brushing with boracic acid (1 : 30-50), or with bi- borate of sodium, will mostly suffice. If a stronger disinfectant be required, permanganate of potassium (1 : 200-500) is pref- erable. Much crying on the part of the baby is injurious by the stretching of mucous membrane of the posterior lower alveolar processes. After each meal a few teaspoonfuls of water should be given to clear the mouth of food remnants. 7. Thrush. Membranous stomatitis is very frequent and popularly known as thrush (muguet). The postnatal desquamation of the epi- thelium, the open mouth which allows the constant passage of air and microbes, the narrow nares which add to that predis- position, uncleanliness, retention of food in the mouth, excess of sugar in the food, previous pneumonia or infectious disease, which add to the hyperemia of the oral cavity, facilitate the deposit of oidium (no healthy epithelium permits it), which, with streptococci and staphylococci, detritus, a little fibrin, and foreign remnants, form granulations and membranes mainly on surfaces covered with pavement epithelium (mouth, tonsils). Oidium is also found in the intertrigo of the nates, occasionally even in the cranial cavity; its gonidia are met with in the gas- tro-intestinal tract, where they cause gastritis and enteritis, atrophy, and possibly death. It is therefore necessary to treat thrush early. The membranes can almost always be scraped off easily. A solution of boric acid (three or four per cent.), of biborate of sodium (two or three per cent.), or of permanganate of potassium (one-half to one per cent.) should be applied five or six times daily. A daily application of nitrate of silver (1 : 500) is useful when the membranes have been removed. Internally, as gastro-intestinal complications are frequent, re- sorcin and bismuth may be administered (bism. subnitr. one gramme = grs. 15, resorcin twenty-five to forty centigrammes DISEASES OF THE DIGESTIVE ORGANS. 361 = grs. 4-6, water fifty grammes, glycerin ten, a teaspoonful every two hours). 8. Infectious Stomatitis. Hemorrhagic stomatitis is observed in scurvy, in diphtheria, and other infectious diseases; the diphtheritic form in diph- theria, the syphilitic, with its circumscribed whitish or grayish condylomata and other symptoms in nose, larynx, skin, or bones, in syphilis. The treatment of these local manifestations was discussed in other chapters. Mercurial stomatitis is rarely seen in infants and children, the less the younger they are. When it does occur, chlorate of potassium internally, and as a mouth-wash (1 : 30), is as good a curative as it is a preventive. 9. Noma. Phlegmonous gangrene of the cheek, sometimes originating in the gums, is commonly known as noma. It is of unknown cause (neuropathic, microbic, thrombotic ?), is mostly observed after measles, typhoid fever, scarlatina, or other infectious dis- eases, or after reckless mercurialization. The hard, black node grows fast, the fearfully fetid ulceration destroys soft parts, teeth, bones, and finally life, unless the process be stopped. The actual cautery (electro-, thermo-cautery) employed once or more is most effective, also fuming nitric or sulphuric acid; when it has stopped, the permanganate of potassium (1 : 100) may be applied, also tincture of iodine or formalin (1 : 15-30). The strongest stimulants in large doses, alcoholic beverages, musk, and strychnine should be given. As it is only seen after infectious diseases, etc., we should learn the lesson of not rely- ing too much on the lazy nihilism of thoughtless "expectant" methods. 10. Sublingual Adenitis. The inflammation of the sublingual gland (sometimes con- nected with parotitis) is mostly seen in the puerperal infections of the newly-born. It may heal, but requires early incision to relieve the pus, and frequent disinfection with permanganate 362 THERAPEUTICS OF INFANCY AND CHILDHOOD. of potassium (1 : 200-500). The abscess may become very large if the surrounding cellular tissue participates in the sup- puration. The incision should be large, and disinfection very careful. 11. Parotitis. The endemic and epidemic variety was treated of on page 245. If the Stenonian duct be obstructed by simple or mer- curial or ulcerous stomatitis, or by diphtheritic deposits, the gland will swell and get inflamed. Cold applications, gentle massage with green soap, or with an iodide of potassium lanolin ointment, will succeed, unless there be suppuration. In this case an incision is required. A metastatic form of parotitis, with numerous cocci in the pus, may be observed in variola, typhoid fever, scarlatina, and anaemia. Warm fomentations, large incision, and thorough disinfection are demanded. 12. Difficult Dentition. Dentition is a physiological process; before a tooth protrudes the gums above it are slowly absorbed so as to show a slight depression, with no hyperemia. Some time previously the gums are raised and more or less hyperaemic. The only per- ceptible symptom is the eagerness of the baby to bite. In- creased salivation has nothing to do with dentition, but with the increased function of the salivary glands, which itself, like the growth of the teeth, of the head, and of the brain, is the result of the physiological hyperemia of that part of the body. When the gums are abnormal, hard, tense, perhaps under the influence of a stomatitis, there may be a slight fever, hot head, sleeplessness which is improved by taking the baby up (head elevated), even some muscular twitching; for at that time ex- citability is great and inhibition insufficient. One or two deci- grammes of a bromide may be given (grs. 1 J-3) once or often, and the mouth should be washed with cool water. The period of dentition is also the time of many disorders and diseases, which are not easily diagnosticated and tempt the practitioner DISEASES OF THE DIGESTIVE ORGANS. 363 to suggest or accept the diagnosis of difficult teething. Lancing the gums, which, with calomel, was the every-day treatment of infants at the time of teething, has lost most of its charms. There are practitioners who prefer making a diagnosis of the real condition of the ailing baby, and that is the main treat- ment I recommend for "difficult dentition." 13. Dental Ulceration. Riga's Disease. When there are but two lower incisors, and they the only teeth present, the tongue is irritated by contact and friction; that is, as is readily understood, particularly frequent in whooping- cough. In this way the dental ulceration is caused. When the irritation lasts long, and results in a secondary inflammation with hyperplasia of the tissue, the tongue adjoining the frenulum is not only discolored, grayish, and slightly granu- lating, but exhibits a slight excrescence, with a somewhat ir- regular surface, and of marked density. That is what is called Riga's disease (by Fede and Concetti, who say it is very rare in Rome, but very common in some parts of Southern Italy). The name is an unnecessary addition to our nomencla- ture. According to the condition of the surface it may be moistened frequently with a solution of chlorate of potassium, or of borax, or of permanganate of potassium, or.be cauterized with the solid stick of nitrate of silver once every two days. The ulceration or tumor is almost certain to disappear when a few more teeth make their appearance in the lower jaw. B. The Tongue. 1. Congenital Anomalies. They are more or less amenable to surgical relief. The bifid tongue (arrest of development, consisting in the non-juncture of the two halves of the first branchial arch) may thus be im- proved. A sarcoma I removed with the galvano-cautery (see p. 356). Lipoma is mostly located on the tip of the tongue, is quite small, or reaches the size of a hen's egg; is sometimes 364 THERAPEUTICS OF INFANCY AND CHILDHOOD. pedunculated, and annoys nursing and nutrition. It should be extirpated, as also dermoids and cystic hygromata. The latter may also be injected with an irritant fluid (Lugol's solution, alcohol), lymphangioma may be punctured with the actual cau- tery in different places. The latter is one of the forms of macro- glossia; its other variety is muscular; it is mainly this latter which enlarges the tongue in every direction, makes it protrude, and excoriate, and dislodge the teeth. It has been reduced by the ecraseur and by ignipuncture. A wedge-shaped piece may be excised and the flaps joined. Hypertrophy of the tongue accompanying any of the varieties of cretinism requires the prolonged use of thyreoid. Adhesion of the tongue (ankylo- glosson), when in the rare form of extensive epithelial cohesion, is easily relieved by gentle traction, or separated by means of a blunt probe; when caused by the shortness and extensive inser- tion of the fraenum in the floor of the mouth, it requires an in- cision by scissors. It is better to make a superficial incision than to cause a hemorrhage which is stopped with difficulty. The affection does not interfere with nursing, so the little oper- ation is not urgent. 2. Glossitis. Superficial changes of the tongue (erythema, catarrh) partici- pate frequently in the same alterations of stomatitis, pharyn- gitis, infectious diseases, and digestive disorders. The latter do not influence the tongue, however, so much as they do in adults. These superficial alterations require no treatment. Very little, if any, is required in the peculiar changes of the epi- 'thelium, which is thrown off in the shape of smaller or larger islands and accumulated so as to form whitish and elevated edges round the bare spots ( (C pityriasis lingua"). It is only bad cases that require treatment. Lactic acid in solution has been recommended. I prefer nitrate of silver, once daily (1 : 500). The same solution I recommend on the smooth red tongue with or without fissures; it is mainly the latter which should be touched by the medicine. A mouth-wash of chlorate DISEASES OF THE DIGESTIVE ORGANS. 365 of potassium and the internal administration of the same is beneficial in all of these conditions, alone or in combination with the above; also in most ulcerations, those caused by carious teeth or in the attacks of epilepsy. The acute inflam- mation of the tongue (acute glossitis), however, should not wait for the slow effect of any treatment. Its rapid swelling and intense redness, with its tendency to suppuration, demands a deep and long incision, more than a mere scarification of the surface. C. The Thkoat. 1. Pharyngitis, including Amygdalitis ("Tonsillitis"). It is met with in many varieties, catarrhal, phlegmonous, erysipelatous, lacunar, follicular, and parenchymatous. All the diseases of the mouth may descend into the pharynx. The catarrhal inflammation of the pharynx is, however, apt to be more serious; fever, dysphagia, even convulsions are noticed, besides annoying or dangerous complications with nasal dis- eases. Exposure, dry (furnace) air, exertion (screaming) may bring it on. Nasal irrigations relieve the naso-pharynx and the pharynx of accumulations of mucus. Gargles are not so re- liable (see p. 83) as applications of ice-cloths, or of ice-bags, chlorate of potassium as advised above, with small doses of tincture of belladonna, also an astringent spray for older chil- dren. Tonsils, when swollen, are relieved by a scarification made at an early period. In that way chronicity may be avoided, with its liability to admit microbic infection and to cause the development of adenoid vegetations. The lacunae (crypts) of the tonsils, as they do not recede at all into their tissue, but are mere surface depressions, are the seat of a super- ficial process partly parasitic and partly irritative. The de- posits, sometimes large enough to form membranes, are made up of epithelium, detritus, and cocci, or, instead of the latter, leptothrix. This latter form was first described by B. Fraenkel in 1873. Loose deposits may be scraped off, and the sore sur- 366 THERAPEUTICS OF INFANCY AND CHILDHOOD. face (in docile children) touched with concentrated carbolic acid, or nitrate of silver either solid or in strong solution. Chlorate of potassium in frequent small doses internally. Follicular amygdalitis, the process being in the depths of the follicles, is liable to cause more general symptoms. High fever, pain, headache, even convulsions are very common. Epithelia, detritus, and a great variety of microbes form the tufts rising out of the follicles and the membranes in which a number of tufts coalesce. It will be discussed again together with diph- theria. Parenchymatous inflammation of the tonsils shares the char- acter and symptoms of phlegmonous pharyngitis in general, sometimes to an unusual degree. It results from or follows the (catarrhal or) follicular variety. Being caused by the latter it is originally localized, the abscess originating in a single fol- licle. That is why it is mostly on one side only, but may occur once or twice a year, until all the follicles are destroyed by sup- puration. An early incision should be made and followed by disinfectant gargles or medicines (chlorate of potassium). The abscesses of phlegmonous pharyngitis may be found any- where, without a trace, perhaps, of a microbic cause. Some are found in the submucous tissue, some hidden away behind a tonsil. They require an early incision. Erysipelas of the pharynx has no tendency to suppuration, but to considerable swelling, which may be so intense as to require tracheotomy. If intubation be possible, it should be preferred. Ice-applica- tions; ice-pills. Baginsky recommends a five-per-cent. ichthyol vaseline ointment. The chronic form of parenchymatous amygdalitis is some- times congenital (often hereditary), otherwise the result of re- peated acute processes. Scrofula predisposes. Mouth-breathing, vertigo, nocturnal (morning) cough, dyspnoea, incontinence of urine, night-terrors, ear-affections, mental hebetude, rheumatic affections, insufficient development of the chest, are symptoms or consequences. The chronically enlarged mass cannot be in- DISEASES OF THE DIGESTIVE ORGANS. 367 fluenced by medication, or astringent applications. It is use- less to tamper with caustics of any kind. Eesection is the only quick relief, to be followed, mainly during epidemics of diph- theria, by disinfectant washes or medicines. If the anterior arch of the soft palate is adhering to the tonsils, it must be loosened first to avoid hemorrhage. If this occur the readiest means to suppress it is digital compression inside. If the oper- ation be objected to, the galvano-cautery (after anaesthesia by cocaine) may take its place. Follicles which remain open, and permit a probe to enter a centimetre and more, are the causes of constant annoyances, new deposits, microbic invasions, etc. They ought to be burned out with the electro-cautery or ripped open with a rectangular hook suggested by Moritz Schmidt, and improved by Gleits- mann, who sharpens one of the edges. 2. Retro- and Latero-Pharyngeal Abscess. The lymph-nodes of the posterior wall of the pharynx drain the tonsils; the deep facial glands the orbit, jaw, and pharynx; the superior deep cervical glands the cranium, larynx, thyreoid, and pharynx. The intense growth and hyperemia of all the parts concerned during the first year of life, the frequency of stomatitis, pharyngitis, and rhinitis, and the activity of the lymph system at that period explain the frequency of retro- pharyngeal abscess in the second half of the first year. After the completion of the second year it is rare. Cases depending on genuine caseous tuberculosis of lymph-nodes are very rare, those resulting from caries of a vertebra not frequent. After all, Koplik (N. Y. Med. Journ., April 4, 1896) justly declines to accept the existence and name of idiopathic abscess; indeed, nothing should be called idiopathic, the cause of which is primarily located in another organ, or at a distance, though in the same class of tissue. The worst cases are those devel- oped through scarlatinous pharyngitis, or during erysipelas (rare) or measles; they have a tendency to become gangrenous 368 THERAPEUTICS OF INFANCY AND CHILDHOOD. and descend into the mediastinum, or to be, on the basis of uniform infection, complicated with pneumonia or suppurative pleurisy. The diagnosis is secured by dyspnceic, interrupted, snoring respiration, stiff neck (often held sideways), difficult deglutition, tinny voice, which will not be forgotten if heard once, frequently by the occurrence of a lateral swelling which can be seen outside, and by the presence of a posterior or lateral swelling, which can more often be felt than seen. The symp- toms are mostly urgent, sudden deaths not uncommon, and the abscess should be opened when felt, or even indistinctly felt to fluctuate. No anaesthesia. Hard swellings (in rare cases syphi- litic) should not be incised. The finger should never be used, or permitted, to burst an abscess though ever so soft; for the pharyngeal space being narrow (the larynx, as shown by Sym- ington, is higher by one vertebra in a child than in the adult), pus, which is quite copious mostly, may be forced into the larynx. The abscess may be opened in most cases by a hard silver probe, or director, which is run in quickly and made to tear a long opening, in others with a bistoury covered to nearly its point with adhesive plaster, or, better, with a covered knife which is withdrawn at once and the sheath of which is used to enlarge the opening. Immediately after the incision the head of the patient should be thrown forward, and gentle pressure employed laterally. There is rarely any hemorrhage; if there be, ice may be forced into the mouth; or ice-water injected into it forcibly, a single moment, will contract by reflex the small bleeding vessels. A sponge with a solution of antipyrin (ten to forty per cent.) will seldom be required. If the opening is large enough, a second incision will not often be necessary. In all cases where the lateral swelling is large and fluctu- ating or where the abscess is due to vertebral disease, or to scarlatinous or other sepsis, it is best to incise laterally be- hind the sterno-cleido-mastoid muscle, and to disinfect and drain. This method should not be followed except in the cases indicated, or when the mouth cannot be opened (contraction of DISEASES OF THE DIGESTIVE ORGANS. 369 the masseters), or when the presence of the abscess is diag- nosticated, but its location such as not to be reached by an in- cision from inside. The after-treatment is like that of phleg- monous pharyngitis generally. The diagnosis from a hematoma or from an angiomatous tumor, both of which are rare but will occur, should not be missed; for a mistaken diagnosis may cause death. Dangerous hemorrhages may take place from a branch of the pharyngeal artery when the anterior palate is injured in a resection of the tonsil, or from a branch of the external maxillary artery when a peritonsillar or latero-pharyngeal abscess is incised far away to the right or to the left. Septic abscesses may also lead to the spontaneous perforation of a large artery. Four hemor- rhages took place within six days, the last of which proved fatal, in a case of latero-pharyngeal abscess which resulted from what appeared to be a mild case of a streptococcus pharyngitis. The autopsy revealed a large opening in the right internal carotid which should have been ligated to save the child. 3. Adenoid Vegetations. They were first described by W. Meyer, of Copenhagen, in 1870, and their influence on articulation, hearing, and intel- lectual development and on countenance recorded. They are lymphoid swellings in great numbers, sometimes covering the whole pharyngeal roof, sometimes accumulated in one large mass (Luschka's "pharyngeal tonsil"), or in two masses with a recess between them. They cause or are dependent on or con- nected with catarrh of the nose and the pharynx, give rise to occasional bleeding, headache, cerebral congestion, cough, laryngitis, otitis, sometimes facial erysipelas, retard intellectual development, and produce the expression of stupidity common to all mouth-breathers. As the normal nose and naso-pharynx are full of microbes, the adenoid vegetations have been studied in reference to them. Streptococci, staphylococci, and pneu- mococci have been found on them, also leptothrix. Dieulafoy 24 370 THERAPEUTICS OF INFANCY AND CHILDHOOD. found tubercle bacilli in very many, and was disposed to claim the vegetations as tubercular, Gouce, however, not once in two hundred and thirteen cases, in thirty of which tuberculosis could be found in other organs. Dieulafoy's assumption is one of the many instances of the dangers, not of close investigation, but of previous conclusions based upon the mere presence of actual or alleged characteristic microbes. Contraction of the nose, pointed arching of the palate, and dental deviations with shortened and low inferior maxilla are not the results of ade- noid vegetations, but of original rhachitis or other (congenital) anomalies. Nasal irrigations of salt-water, boracic acid solu- tions, etc., while relieving the obstruction and catarrh of the naso-pharynx, are capable of reducing congestion and some- times render an operation superfluous. The latter, however, is preferable in almost every instance. As the vegetations spread often over a large surface, instruments like Gottstein's, which remove the prominences from a large area, are best. Del- stauche's modification of that instrument to which are added two sharp hooks bent downward, is a good one and applicable to larger tumors which can be caught. The small ones should be rubbed off with Gottstein's. The instrument should not be carried sideways in order not to injure the cartilaginous edge of the Eustachian tube. During or immediately after the oper- ation the head should hang down to avoid bleeding into the air-passages. Bleeding will stop spontaneously, or by a brief compression with the finger, or an application of a sponge dipped in ice-water. If there be more, the pressing on of a sponge dipped in a twenty- or forty-per-cent. solution of anti- pyrin in water is advisable. 4. Fistula Colli Congenita. It is caused by the incompleteness of the closure of the second branchial arch. It begins near the sterno-cleido-mus- cle and terminates in the pharynx. Here it is either open (com- plete fistula) or not (incomplete). If open inside, and closed in DISEASES OF THE DIGESTIVE ORGANS. 371 the middle, it forms a diverticle. Injections of iodine have been made to close it, and good results have been claimed. The total extirpation is by far preferable. D. The (Esophagus. Diseases of the mouth and pharynx descend into the oesopha- gus: catarrh, thrush, diphtheria. Injury by carbolic acid re- quires oil, also sulphate of sodium in solution; by acids: chalk, sodium bicarbonate, soap; by lye: fruit-juice, vinegar; by hot water: ice or ice-water, and cold applications. The sympto- matic treatment requires opiates. Stricture may be congenital (Demme). It follows injuries (mechanical or chemical) after months or sometimes years. Above the stricture a diverticle is apt to form, with the usual symptoms. Dilatation should be very gentle and gradual to avoid perforation; no metal instruments should be used. Gas- trostomy is performed to facilitate both nutrition and dilata- tion from below. Hjort claims to have opened a stricture in a boy of fourteen years by electrolysis in two sessions, the nega- tive pole of from ten to fifteen elements being introduced. Foreign bodies should be extracted, if possible, according to the methods taught for adults. If that be impossible, because of size or shape, they should be forced down into the stomach. If that fails, cesophagotomy is indicated. Of the one hundred and twenty cases of cesophagotomy collected by Fischer, four were under two years, eleven from two to ten, four from ten to fifteen years, altogether with a mortality of thirty-three per cent., due more to delay, and consequent sepsis, than to the operation. Gerster saved a boy of two years, in spite of deep ulceration caused by the foreign body, and a girl of nine years; Alexandroff, a boy of two years and nine months.* Periesophageal abscess may result from descending retro- or latero-pharyngeal abscess. Diseases of the vertebra? (the * F. KareTrski, Die ChiriTrg. Krankh. d. Kind., 1894, p. 367. 372 THERAPEUTICS OF INFANCY AND CHILDHOOD. oesophagus being in close contact with the cervical portion of the spine), of glands, pleura, and pericardium, also as foreign bodies will cause it. Glands may be found tumefied, the larynx dislodged, a soft swelling may be felt in the fauces. If it be within reach, an early incision should be made. E. The Stomach. 1. General Nosology. Dyspepsia. The indications for the therapeutics of the stomach, both dietetic and medicinal, are by no means simple and clear in every individual case. For it is difficult to make an exact diagnosis of the anatomical condition of the surface and the tissue of the organ, because of the frequent combination of various conditions. Indeed, the boundary-line between a sim- ple functional dyspepsia and a gastric catarrh is perhaps never made out clearly. The epithelium of the mucous membrane does not belong to it exclusively, but spreads in the contiguity of the tissue into the muciparous and the peptic glands. Thus the inflammatory condition of the surface becomes at once a "parenchymatous" affection, though it be possible that an uncomplicated catarrh and an uncomplicated inflammation have an occasional existence. This, however, will last but a short time, and unless a gastric catarrh, or a dyspepsia, or an intestinal irritation — for the intestine shares the peculiar ana- tomical condition of the epithelium of the stomach — be re- lieved at once, the merely functional or superficial disorder be- comes organic and deep-seated. These changes may refer either to the tissue or to the secretion. Inflammatory thickening, ero- sions, ulcerations, or (Moncorvo) dilatation of the stomach will be observed in a great many instances. The secretions become abnormal. The normal hydrochloric acid of the gastric juice is almost invariably diminished; now and then a case will be found, but in older children only, in which it will be increased in quantity; still, as a rule, it is wanting or but scantily sup- plied. Lactic acid, however, is produced in much larger quan- DISEASES OF THE DIGESTIVE ORGANS. 373 tities than the first stage of normal digestion requires, and with it acetic, butyric, and the rest of the fat acids. With this variety of changes the indications for treatment go hand-in- hand; others are suggested by the multitude of etiological factors. The direct paralyzing influence of heat, the imme- diate effect of irritant and bulky ingesta, and the poisonous action of bacteria introduced in food and rapidly multiply- ing render the intelligent and effective treatment of many of the cases which occur in the practice of every medical man a matter of great difficulty and responsibility. Nothing is more common, but less appropriate, than routine treatment directed against a variety of cases. The importance of diet in all questions connected with the pathology of the digestive organs justifies the repetition, in this place, of a few main points, the elaboration of which may be found in the first chapter of this book. The principal cause of the diseased conditions of the diges- tive organs of the young is to be sought for in improper food. Not even mother's milk will always agree with the baby; cow's milk cannot possibly take its place as a legitimate and satis- factory substitute. Much less reliance can be placed on manu- factured or home-made mixtures of unequal composition and doubtful quality. Children of more advanced years resemble adults in this, that they are endowed with more resistance to damaging influences. But the infant and young child are in constant danger of losing their pl^siological equilibrium by slight changes in feeding or by the deterioration of foods. The readiness with which milk, which is indispensable as a food, will decompose, acidulate, and become indigestible, renders the greatest attention a necessity in the interest of prevention. That attention must be first directed to the differences between cow's and woman's milk, which ought to be obviated as much as possible. The former contains more casein, usually less fat, less sugar and chloride of sodium. Besides, the casein of cow's and woman's milk differ both chemically and physiologically. 374 THERAPEUTICS OF INFANCY AND CHILDHOOD. That has always been so, and will be so, though a recent journal article declares the fact — or its assertion — a "bugbear." The former is less digestible, and its amount in the food given an in- fant must not be larger than one per cent., rather smaller. On the other hand, a large percentage (9-12) of fat is contained in every normal defecation of an infant fed on breast-milk, thus care should be taken not to exceed the quantity of fat contained in this normal food when artificial feeding is resorted to. In- deed, to what extent fat administered in excess, and indiscrim- inately, is apt to produce diarrhoea, is best illustrated by the "fat diarrhoea" which has been a frequent topic for discussion in medical journals. Water, salt, and sugar must be furnished the infant in sufficient quantities. Water is often wanting in infants' and children's food, and its absence is the cause of dyspepsia and of anatomical changes in the digestive organs. Its role in the organism is very manifold. Besides its influence on general metamorphosis, it is required to assist in pepsin digestion. In artificial digestion, albumin is liable to remain unchanged until large quantities of acidulated water have been supplied. The very presence of peptones even in the stomach requires water to facilitate their solution and absorption. The immediate relief felt by a draught of water taken during the prsecordial heaviness and discomfort experi- enced after a hearty meal is a matter of daily experience. In- fants and children — mainly the former — receive too little water. Whenever they are thirsty, both in winter and in sum- mer, they are given milk, — that is, food; and many a case of dyspepsia, with its results, could be obviated by adding plenty of waiter to the food. Excess of water, if under ordinary cir- cumstances there is such a thing, is attended with less incon- venience or danger, for it is readily absorbed and eliminated. Chloride of sodium ought to be added to most foods of infants and children. For instance, vegetable diet contains more potas- sium and less sodium than all the varieties of milk, and milk of herbivores more potassium than that of carnivores. Thus, cat's DISEASES OF THE DIGESTIVE ORGANS. 375 milk contains sodium 1 to potassium 0.76, woman's milk 1 : 1, 13-4.4, and sheep's and cow's milk 1 : 5.6. The amount of salt contained in woman's milk depends greatly on the presence of salt in her food. Thus many a defective milk can be reme- died by the mother or wet-nurse by adding salt to her food. Particularly is that necessary in dyspepsia and gastric catarrh in the baby, one of the main symptoms of which is the presence of large and hard curds in the masses brought up by vomiting or evacuated by the rectum. The addition of chloride of sodium to milk impedes or delays the solid curdling by rennet, — a physiological fact which explains the usefulness of salt in every kind of infant food. For in vegetables, and mainly in farinacea, the disproportion of potassium and sodium is still more evident than in milks. Souring of milk is prevented by boiling, mainly through the expulsion of a large quantity (three per cent.) of gases (car- bonic acid, nitrogen, and oxygen) contained in the milk when it leaves the udder, and by the destruction of parasitic growths. Thus I have always advised to boil the milk destined for the use of a baby as soon as obtained, fill it hot into bottles, containing from three to six ounces, up to the corks, close them tightly, and preserve them inverted in a cool place. Whenever a meal is to be prepared, the milk thus preserved should be heated again up to or near the boiling point, — preferably in a water- bath. That process should be repeated perhaps several times a day; while one bottle is being heated, the others may undergo the same procedure, for every boiling interrupts the beginning of lactic acid or other decomposition. The sterilization (or pasteurization) of milk in Soxhlet's apparatus, manufactured for that special purpose, and introduced in New York by A. Caille, is a still better procedure. Milk properly sterilized will keep one or more days, but for general use among those who cannot obtain or pay for the patented apparatus my method will suffice under ordinary circumstances and for peo- ple with the most ordinary intellect. 376 THERAPEUTICS OF INFANCY AND CHILDHOOD. A certain amount of starch is digested at the very earliest age, for saliva is secreted at that time. Its effect persists in the stomach as long as the percentage of hydrochloric acid in the gastric secretion does not surpass 0.06; within the first half -hour of the digestive process there is none at all but or- ganic (mainly lactic) acid only. Thus, though starch pass the oral cavity rather quickly, it will still undergo its change into dextrin in the stomach. In many abnormal conditions this digestive change lasts a still longer time; thus in fevers, severe gastric catarrh, and in dilatation of the stomach. These are the very conditions in which farinaceous foods are best toler- ated, for the reasons that the diastatic effect of the saliva is not disturbed, and that albuminoids could not be digested because of the absence in these conditions of hydrochloric acid (and pepsin). In all normal and many morbid conditions the pres- ence of certain quantities of amylaceous foods has some more functions. Besides being nutritious in its own way, starch serves to dilute cow's milk, to reduce the percentage of casein in the mixture, to prevent the latter from coagulating in large masses, and thus to render it more digestible. The reasons why I prefer in most instances either barley or oatmeal, or in others gum-arabic or gelatin, and reject condensed milk, etc., have been given above.* F. A. Hoffmann, in "Lectures on General Therapeutics," Leipsic, 2d ed., 1888, p. 223, says in connection with the rules on infant feeding, annually published by the New York Health Department, which he copies, "Unless woman's milk can be had there is a great danger in the probability that the sensitive intestinal tract be supplied with injurious material. For such is the very best cow's milk in the cases of very young infants, because the mixture of its constituents differs greatly from that * It is a source of gratification to the writer to learn that he has not been wrong in his practice and teaching. Beidert and Heubner also advocate the use of cereals. DISEASES OF THE DIGESTIVE ORGANS. 377 in woman's milk, and its casein is less digestible. Both physi- cians and manufacturers have tried to compound substitutes for woman's milk, but those only the composition of which is known should be noticed by scientific men and recommended. Another requisite is this, that such a food must be within the means and understanding of everybody, and that a certain supervision be possible. Jacobi's treatise in Gerhardt's 'Manual of Pediatrics' will be found satisfactory by all those who desire to inform themselves on all we know. From my own ex- perience, I confirm his recommendations to dilute milk with barley or oatmeal water. At present the hope has been ex- pressed that all this may be replaced by the sterilization of milk, but in practice there will be many impediments and ob- stacles. Sterilization can have but one result, — viz., to remove the danger arising from the decomposition of milk. But, after all, it is cow's milk and not woman's." From what I have said I draw the conclusion that as long as a baby is not nursed by a healthy woman, the opportunities for acquiring some kind of gastric disorder are very numerous indeed. Dyspepsia is therefore quite frequent. Its treatment consists in more or less abstinence, and in the regulation of the diet. As a rule, food should be more diluted than usually. As the gastric contents of infants who have been brought up on artificial foods is liable to be very acid, alkalies in small doses, and frequently administered, have a good effect. Bismuth may be added. "When there is vomiting, it must be determined whether it is gastric, and from what cause. Those who have been in practice know too well how often they have seen menin- gitis mistaken for a gastric disorder, and how common is the oc- currence of that symptom in the incipient stages of all kinds of inflammatory fevers. When all these and the local irritation of the stomach (brought on by foreign bodies, such as bulky foods, or by the presence of ascarides) and nephritis can be ex- cluded, only then the vomiting should be considered gastric only. Now and then abstinence only; or the drinking of warm 378 THERAPEUTICS OF INFANCY AND CHILDHOOD. water, or warm mustard water, to facilitate vomiting; or alka- lies (bicarbonate of sodium, magnesia, carbonate of calcium), or alkalies with bismuth; or resorcin to disinfect the contents; or dilute hydrochloric acid for disinfection and to correct the nature of the gastric acid; or the washing out of the stomach with warm water, or salt-water (6-10 : 1000), or with a bicar- bonate of sodium (1 : 100-200), or a resorcin (1 : 50-100) solu- tion; and, finally, after the stomach has been freed of its injuri- ous contents, small doses of opium, from one-half to one and a half milligrammes (one one-hundred-and-twentieth to one- fortieth grain), every hour or every two hours, or its equivalent in morphine or codeine, will prove satisfactory. Protracted and obstinate vomiting I have seen getting well with small doses of arsenous acid, from a thousandth to a four-hundredth part of a grain every hour or every two or three hours, according to the age of the patient or the individual indications of the case. Small doses of ice-water or, better still, small ice-pills repeated every five or ten minutes will answer in many instances. Ef- fervescent drinks, iced, such as small doses of Apollinaris, Seltzer, or Vichy, or champagne, may do well in certain cases, but will do so less frequently and less happily than in most adults under the same circumstances. 2. Acute Gastric Catarrh. When it is produced by injurious ingesta, these ought to be removed. If vomiting have not occurred spontaneously, or not sufficiently, it should be produced by the above-mentioned drinks, tickling the fauces, friction of the precordial region, ipecac, — the syrup is very often an unreliable preparation, — or other emetics. In cases of great urgency only the subcutaneous use of apomorphine may be resorted to. The mildest (and quite safe) way of emptying the stomach is by irrigation. Purgatives must not be given in the beginning; large enemata will act more favorably. They may consist of warm water, warm water with antispasmodics, such as assafcetida, or with stimulants, DISEASES OF THE DIGESTIVE ORGANS. 379 such as turpentine. After a day or two a purgative dose of calo- mel will answer. Fever, unless it be high, requires no special treatment; in urgent cases only antipyrin may be given, either by mouth or rectum or subcutaneously. Tendency to convul- sions requires cold to the head, or cold applications to the heart, which will reduce both the irritation of that organ and the tem- perature of the blood. A warm bath will often do good, but the customary bathing and jostling and tossing of a baby in convulsions do more harm than good. Thirst should be re- lieved by water, carbonic acid water, or water acidulated with hydrochloric acid (1 : 3000-5000). No solid food. Milk should be given in small quantities only, diluted with water, or lime-water, barley-water, or upon Kudisch's plan (dilute hydrochloric acid 1, water 250, milk 500). Vomiting is to be treated on the plan detailed above, predominance of acids by alkalies, constipation rather by cal- cined magnesia in small and frequent doses than by drastics. The aqueous tincture of rhubarb, in doses of from ten to thirty minims every few hours, will prove very satisfactory in many cases. 3. Gastritis. Severe forms of gastritis — the corrosive, diphtheritic, and suppurative varieties — require cold applications to the epigas- trium, and opium in the most available form; in the beginning, morphine subcutaneously. The corrosive form demands neu- tralization of the poison first: salt-water for nitrate of silver, di- luted acids (vinegar) for lye, alkali (chalk, magnesia, baking soda, soap) for acids, sulphate of sodium or oil for carbolic acid, egg, water, and milk for corrosive sublimate, etc. All of these require a total abstinence, which may be continued for more or less time. How long it ought to be endured depends on the condition of the patient and the good judgment of the medical adviser. Adults will bear it many days, and infants and chil- dren from twelve to thirty hours. If such an absolute rest be demanded longer than this period, nutritive injections into the 380 THERAPEUTICS OF INFANCY AND CHILDHOOD. rectum should take the place of feeding by the stomach. The rectum and the rest of the large intestine digest no albumin and emulsionize no fat, but they transform starch into dextrin, and cane-sugar into grape-sugar; moreover, they absorb pep- tones of every kind, egg, emulsionized fat, and starch. (See p. 57.) In all cases of rapid elimination of water by vomiting, or of utter exhaustion in gastro-intestinal catarrh with imminent thromboses in the small cerebral veins ("hy- drencephaloid"), the hourly or bihourly injection of salt-water (the usual strength) into the rectum in doses of an ounce or much more will fill the blood-vessels and restore circulation. 4. Chronic Gastric Catarrh. It is sometimes dependent on or interrupted by acute ca- tarrh; the attacks of the latter must therefore be promptly relieved. The several causes of chronic gastric catarrh have their own indications. Both in adults and children venous congestion resulting from pulmonary or cardiac diseases will give rise to it; thus in many cases digitalis in small doses, con- tinued a long time, will be the remedy or one of the measures of relief. Sedentary life must be avoided, school-hours and private lessons kept within reasonable limits, and regulated by the meals rather than that these should be controlled by the former. Masturbation must be watched: I have seen it to be the cause of gastric disturbances exactly as in adolescence. Diet and food want attention. Most children eat too much, and many too irregularly. Solid food is to be given but scantily; no sweets, no fat. Eating must be slow and mastica- tion careful. Toasted bread or stale wheat bread, milk diluted with cereals or according to the muriatic acid plan (Rudisch), or peptonized (but not to bitterness), — everything of moderate temperature or hot, — will answer. Slowness of digestion, with heavy sensation about the epigastrium, demands ad- ditional chloride of sodium, bicarbonate of sodium, efferves- cent alkaline drinks; fermentation indicates resorcin, or DISEASES OF THE DIGESTIVE ORGANS. 381 creosote in doses of from one-quarter to one-half of a drop. A few grains of salicylic acid diluted in large quantities of water (1 : 500-1000) may also be tried. Khubarb and magne- sia, rhubarb and bicarbonate of sodium, tinctura rhei aquosa, render excellent service. When there is a great deal of mucus, dilute hydrochloric acid with small doses of pepsin are indi- cated. When the tongue is thickly coated, with eructations, chloride of ammonium (half a gramme to one gramme daily) with tinctura rhei aquosa; the tendency to vomit and pain de- mands bismuth, in older children Carlsbad, Congress, or stronger (bitter) waters. These measures may be continued for a long period; bismuth may be given indefinitely in small doses; sulphate of zinc can be administered (doses from one- twenty-fifth to one-sixteenth of a grain = 2-4 milligrammes every few hours) a long time, nitrate of silver (doses of one- thirtieth or one-fifteenth of a grain = 2-4 milligrammes several times daily) for not more than a week in succession. Occasionally the irrigation of the stomach is resorted to with advantage, and may be repeated. 5. Dilatation of the Stomach. When it is met with in adults, it dates not infrequently from infancy or childhood. Its therapeutics is mostly controlled by its etiology, and its success in an individual case must depend on its causes, which may be numerous: over-feeding in general and with amylaceous material in particular; rhachitis with con- secutive muscular debility; voracity, imperfect digestion, and gas inflation; catarrhal inflammation with diminished absorp- tion; general muscular incompetency, as in anaemia and con- valescence; congenital imperfection or partial absence of mus- cular tissue in the wall of the stomach; hypertrophy and total or partial obstruction of the pylorus; or peritoneal adhesions of the stomach resulting in a triangular or quadrangular shape of the dilated organ. Many of these causes cannot be relieved; for instance, the congenital hypertrophy of the circular (in a case 382 THERAPEUTICS OF INFANCY AND CHILDHOOD. of Finkelstein's the longitudinal) muscular layers of the pylorus, which may even lead to a dilatation of the oesophagus. Death occurred in the known cases between the third week and the sixth month. In those which are amenable to treatment, this is prominently that of chronic catarrh. Though it be success- ful, it cannot positively effect the total diminution of the ex- cessive size (large curvature about the level of the umbilicus, and the lateral boundaries beyond the linea alba and the middle axillary line). Antifermentatives should be given, such as bismuth, nitrate of silver, calomel, or resorcin; all of these in small, but long- continued, doses. The quantity of food taken at once should be small; the meals should be numerous. Nothing should be given that is apt to ferment, like fat and great quantities of starch; a certain amount is digested; when too slowly, taka- diastase may be tried. Large_amounts of fluid should not be given. Milk in small quantities may be given often. Diarrhoea may require gallic acid and other astringents; it depends upon the condition of the stomach; indeed, most cases of consecutive diarrhoea will be best treated by attending to the stomach. Raw beef is among those articles of food which are most easily di- gested, and beef peptones in small quantities are very useful. Raw milk is not so easily digested as boiled. Peptonized milk and Rudisch's preparation should be tried. A bandage should be worn about the abdomen. The faradic and galvanic cur- rents can be used with advantage. According to Ewald, elec- tricity and massage accelerate the passage of chyme into the intestine. It seems to me, however, that it is questionable whether digestion was improved by them, for it may be that both of these applications resulted in premature opening of the pylorus, before the gastric digestion was finished. Einhorn's method of using the electric current in the interior of the stomach is hardly applicable to infants and children. Prepara- tions of nux vomica — the tincture — or strychnine in three daily doses of from one-one-hundred-and-twentieth to one-sixtieth DISEASES OF THE DIGESTIVE OEGANS. 383 (J-l milligramme) of a grain each will improve the muscular tone of the stomach. When the dilatation of the stomach de- pends on adhesions, operative procedures may be considered. 6. Nervous Dyspepsia. Its therapeutics must be simple; its effect is not very en- couraging. Food should be digestible and sufficiently copious. Purgatives should never be given; enemata must take their place, if required. Bitter tonics, country and sea air, cold bathing or sponge-baths, electricity, one large electrode being applied to the stomach and another to the spinal column, are indicated. In these cases, which are not quite rare among older children, particularly those with early and obstinate chorea and' other symptoms of anaemia and "neurasthenia," mild preparations of iron and of arsenic are among the very best remedies, and should be continued a long time. Training, arsenic, and hy- drotherapy will relieve many an obstinate case by improving general health and will-power. 7. Gastric Ulceration. With or without hemorrhage, it is not quite uncommon in children of from seven to thirteen years. Fatal hemorrhages have been observed, by me and others, even in infants. Hemor- rhage requires absolute rest in bed, ice-bag to the epigastrium, morphine under the skin in appropriate doses, ice-pills, ligature of the lower extremities to compress veins, for half an hour only; if tolerated, acetate of lead may be given. No matter whether the cause may be found in an embolic process, or a chronic catarrh of long standing, or a local injury (caustic or foreign bodies, stones, a safety-pin in a baby of eight months), the circulation in the parts is interrupted and the normal alka- linity of the tissues destroyed.. Thus these are constantly ex- posed to the injurious effects of the gastric acids, similarly to what occurs in the dead body when the effect of the acids on 384 THERAPEUTICS OF INFANCY AND CHILDHOOD. the non-secreting gastric surface results in softening and per- foration of the wall ("gastromalacia"). Thus the first indication is to keep the stomach and duodenum as alkaline as possible, at all events between meals. Now, the introduction of any food will give rise to the secretion of gas- tric juice, which is first lactic, afterwards hydrochloric acid; a certain amount of these is required for normal digestion. Whatever there is, however, in the stomach of unnecessary acid or acids, which are not required for the physiological pro- cess, particularly the acetic, the butyric, caprylic, or only an excess of lactic acid, must be neutralized. An occasional dose of an antacid is not sufficient for that purpose, but it must be given regularly, and for a long time. I generally give the doses at intervals of two hours. I also give a dose a few minutes be- fore each meal to neutralize every abnormal acid, no matter whether the patient is an adult or a child. Which antacid is to be selected, — the potassium, sodium, cal- cium, or magnesium salts? Of the latter, I prefer calcined magnesia to the carbonate, to obviate the expulsion of free carbonic acid into the stomach. I use it frequently, but rarely (for a child) in larger doses than from eight to ten or twelve grains (0.75) daily. A small part of this, say one grain (0.06), is taken every hour or two, before meals, mostly in water, which should not be too cold; hot water is even better. More than that quantity is seldom tolerated, because of diarrhoea caused by it; still, its purgative effect is very welcome in pa- tients suffering from constipation; these may take larger doses. When the above quantity does not suffice to neutralize the acids, or it is feared lest more magnesium may cause diarrhoea, it may be combined with the carbonate or the phosphate of lime. Sodium bicarbonate does not take the place of the cal- cium and magnesium so readily, inasmuch as it also appears to promote the secretion of gastric juice. Thus, in most cases, I use magnesium or calcium with or without bismuth, or such ad- juvants, if any, as may appear to be indicated for other reasons. DISEASES OF THE DIGESTIVE ORGANS. 385 The addition of small doses of an opiate is indicated (only) when the intense motory action of the stomach is to be quieted. This medicinal treatment must be continued for weeks or months; without it I do not see gastric or duodenal ulcers getting well. The Carlsbad waters, and salines in general, owe their effect partly to their neutralizing and partly to their purgative influ- ence. The effect of lime-water is illusory, if given for the pur- pose of neutralizing the acid, unless in sufficient quantities. Otherwise it is a failure because it contains only a single grain to nearly two nuidounces (50.0) of water. But when added to cow's milk in sufficient quantities (1 : 2-3) it certainly makes it more digestible. The very function of the diseased organ involves danger. Both the stomach and the duodenum should be kept as idle as possible, and their labor should be made easy. Indigestible food must not be given, and solid food must not be allowed. Most older children tolerate boiled milk, strained oatmeal, bar- ley gruel, stale wheat bread, and a few also raw beef. Some take nothing but boiled milk, or buttermilk, or koumiss. Many, particularly convalescents or adults, will tell you that they do not digest milk. That may be true, but then they gulped it down, and it formed in the stomach a large cheese-cake that was not afterwards dissolved and digested. They should boil their milk in the morning and heat it several times during the day almost to the boiling point, or should pasteurize it for the day. They should add a small quantity of table salt to it; also, in case the stomach is very acid, some bicarbonate of sodium, or calcium, or magnesium. They should not drink their milk, but pour it into a plate and sip it with a spoon. Thus prepared, they will digest it, particularly when it is not quite cold. In fact, many require their meals warm or hot. For the purpose of easier digestion, milk may be peptonized, according to Fairchild's directions; or it may be rendered 25 386 THERAPEUTICS OF INFANCY AND CHILDHOOD. more digestible by the process recommended by Dr. Rudisch, or mixed with farinaceous decoctions as recommended above. With an alkaline condition of the surface and an innocuous diet, the ulcers have an opportunity to heal. Their recovery may be aided by the administration of nitrate of silver. A child may take from one-thirtieth to one-twentieth of a grain (2-3 milligrammes) in a tablespoonful of distilled water four or five times a day; if possible, on a fairly empty stomach. Or a smaller quantity may be given in a pill with or without a small dose of opium, say one-sixtieth to one-fifteenth of a grain (1-4 milligrammes) in each pill. Sometimes I give but a single dose at bedtime, in addition to the alkaline treatment. Nitrate of silver must not be given beyond a reasonable time, to avoid argyria. The tincture of iodine, in doses of from one to three drops for the adult, of one-half to one drop to a child, well diluted with water, has often been recommended. Its action is prob- ably antifermentative here as in chronic gastric catarrh. When there is much pain and a great deal of acid or other secretion, opiates are indicated, mainly those which are very soluble. Chloral is tolerated badly. Bad cases require rest in bed, particularly those of anaemic girls (and women). The stomach has a better opportunity to get well when at rest than when at work. Thus it becomes necessary, some- times, to abstain from feeding by the mouth altogether. Rectal alimentation then comes in to great advantage. In conditions of such genuine starvation the lymphatics are very greedy and absorption from the rectum is very active. Ulcer of the stomach, both in the young and old, being fre- quently associated with intense anaemia, the result, in these as in many other cases, is mistaken for the cause. Then iron, the great presumed panacea for anaemia, is often introduced into the stomach which cannot digest it, and in its attempts to do so, pain, ulceration, and danger are increased, DISEASES OF THE DIGESTIVE ORGANS. 387 F. Intestinal Diseases. 1. Constipation. The catarrhal and inflammatory diseases of the mucous mem- brane of the intestinal tract have so many common anatomical and pathological features that, for practical reasons, and to avoid repetition, I prefer to discuss them under the heads of their principal symptoms. Indeed, the acute, subacute, and chronic catarrh (enteritis), cholera nostras, follicular enteritis, even membranous enteritis, are but varieties of the same process, differing only in individual acuteness, or extension, or in its localization in the epithelium, muciparous follicles, or lymph-bodies, or in innervation. The main symptoms observed in diseases of the intestinal tract are constipation (less frequent) and diarrhoea. The therapeutics of constipation depends on its etiology and its degree. In no case should the diagnosis be made without a thorough examination, which must be manual in many. The abdomen may be painless, but it is mostly inflated. Faeces come away in large lumps or in small and broken pieces. The liver and spleen may be displaced, the former turned in such a way as to protrude its edge and posterior surface. The abdom- inal veins may be enlarged, the appetite diminished; vomiting is sometimes met with, occasionally also intervening attacks of diarrhoea which are the result of the irritation produced by the hardened faecal masses contained in the colon. Actual constipation should not be mistaken for an apparent one, which is observed in infants that have a small movement every two or three days only. The baby is emaciated, atrophic, not always fretful. In it the scantiness of defecation is the result of lack of food, and the alleged costiveness is speedily remedied by the furnishing of a sufficient quantity of appro- priate nourishment. Among the foremost causes of constipation is mechanical obstruction, brought on by cystic and other tumors, imperfo- 388 THERAPEUTICS OF INFANCY AND CHILDHOOD. ration, hernia (pervious or incarcerated), intussusception and twisting of the intestine, or by a peculiar condition of the sigmoid flexure described by me in the Journal of Obstetrics of 1869. The cases of constipation depending on the undue length of the descending colon and on the multiplicity of flex- ures which compress each other and thus obstruct the passage are quite numerous in every physician's practice. These cases of constipation are apt to last up to the sixth or seventh year and require constant attention, but medicinal treatment should be avoided, unless it be required by intestinal autoinfection. The faeces may be so hardened and immovable as to necessitate their extraction from the rectum by means of the finger or a spoon. Now and then in this, also in other varieties of consti- pation, the hard masses are felt in the abdomen, and have been mistaken for tumors. On no account should purgatives be given as a regular thing, but an enema should be administered daily for many years in succession. At the above-mentioned age the relation of the several parts of the intestinal tract to one another becomes more normal, and the necessity for me- chanical interference ceases accordingly. An improper condition of food is a frequent cause of con- stipation. Excess of casein is relieved by diminishing its quan- tity, by replacing the milk of a cow by that of a wet-nurse, the white and heavy one of a wet-nurse by the thinner and more bluish one of another woman, or by reducing the amount of casein in artificial food to one per cent, or less. Besides, the milk thus reduced should be mixed with a glutinous (farina- ceous) substance; oatmeal, to remedy constipation, is preferable to barley or any of the rest. Large amounts of starch must be avoided. Milk and artificial food will often lose their consti- pating effect by the addition of cane-sugar. Babies at the breast are frequently cured of constipation by the administra- tion of one or two teaspoonfuls or a tablespoonful of water, or oatmeal-water, thoroughly sweetened, before each nursing. Many preparations kindly supplied by the ever-watchful and DISEASES OF THE DIGESTIVE ORGANS. 389 humanitarian trade contain large quantities of phosphates. They are apt to pass in part into the intestine undissolved and unabsorbed. So will large doses of bismuth. Thus constipa- tion may follow their use. The treatment of such a case is plainly indicated; likewise of those which are the direct result of the administration of astringents and opiates. The omission of such a medication is the first condition of a cure. Constipation is often dependent on the partial absence or the viscid condition of intestinal mucus. This is so in fevers, now and then in chronic enteritis (intestinal catarrh), mainly of the lower bowels; also when there is too large a secretion from the skin and (or) kidneys, and when too little water is introduced into the circulation. I have repeatedly emphasized the fact that most infants are given less water than they re- quire. In "membranous enteritis" the large amounts of mucus discharged through many weeks or months, and sometimes years, are less frequently found in children than in hysterical (men or) women. That mucus is no longer viscid, but appears in the shape of membranes, sometimes in casts, but consists of nothing but mucus, with more or less traces of fibrin. In this condition, also, there is constipation as regards faeces; the dis- charges may be quite frequent, however. Large injections of warm water with one or two per cent, of bicarbonate of sodium should be made daily, at least once daily. Xow and then a mild purgative (castor oil) is advisable. But the condition which is mostly found in neurotic children, or such as belong to a neu- rotic family, will not be relieved except through persistent at- tempt at improving the general condition by hydrotherapy and other general tonics. Incomplete peristalsis resulting in costiveness may depend on a morbid condition of either the muscle both of the in- testine and the abdominal wall, or its innervation. Early rhachitis shows its effect in producing muscular incompetency; babies with regular evacuations after birth will become costive in their second and third month, and remain so although they 390 THERAPEUTICS OF INFANCY AND CHILDHOOD. are alleged to "look the picture of health." Not rarely rhachitis will make headway in muscles, epiphyses, and diaph- yses, even in cranial bones; while the weight of the patient does not decrease, his skin feels soft and flabby, the limbs and trunk are rotund though bleached. Indeed, there are many in whom constipation is the very first symptom of rhachitis. In all of them it is self-evident that constipation cannot be relieved permanently except by a thoroughly successful anti- rhachitical treatment. Sedentary habits of school-children have the same effect in producing constipation. It is relieved by change of habit and plenty of physical exercise, and addi- tional fruit diet, but purgative medicines, given persistently, render these cases worse. The binding effects of chronic peri- tonitis, either general or local, must not be combated with purgatives; a snug bandage round the abdomen gives support and tone to the bowels, and an enema, given every day for months in succession, prevents accumulation and its conse- quences (dilatation, disorder of circulation, septic absorption). Universal emaciation and atrophy resulting in constipation has its own indications, and chronic cerebral disease (hydro- cephalus) may require such local and medical treatment as has been detailed above. In all forms of constipation in infants or children few medicaments ought to be used. As there is so often an excess of acid in the gastric and even intestinal contents, calcined magnesia finds its twofold indication. It may be given in many small doses or a single large one which need not exceed five or ten grains (0.3-0.6) a day. Doses of a grain or two grains may be continued for many days and repeated from three to six times daily. Ehubarb acts well when combined with it for the purpose of overcoming protracted costiveness. Eectal injections may be given from the common fountain syringe, the nozzle of which should be introduced beyond the two sphincters. In some cases it is desirable to introduce the in- strument to a greater distance; an elastic catheter attached to DISEASES OF THE DIGESTIVE ORGANS. 391 the nozzle may be used for that purpose, but the very condition of the sigmoid flexure, detailed above, renders the introduc- tion of the instrument beyond the very beginning of the sig- moid flexure a perfect illusion in many cases. It happens quite often that an elastic or flexible tube, when introduced to or be- yond the third sphincter, bends upon itself and reappears at the anus. To facilitate the entrance of the liquid into and beyond the sigmoid flexure the injection should be made gently and slowly while the pelvis of the infant is raised. To facilitate the downward movement of faecal masses and to stimulate peristalsis, friction and kneading (massage) may be resorted to. Kneading must be performed with the palm of the hand, gently and persistently; or gentle thumping with the closed hand and friction are best commenced in the right side and continued over the epigastrium and down the left side, in the course of the colon. Great caution and judgment must be used because of the frequency of local chronic peritonitis, which, when disturbed, causes subacute or acute exacerbations. Electricity has been used successfully when constipation was the result of insufficient peristalsis. E. Schillbach found that the several portions of the intestinal tract respond differently to the application of the faradic and galvanic currents.* The latter appears to have a stronger effect than the former. Local contractions result from the negative pole (cathode), peristaltic waves from the positive (anode). Thus for the relief of chronic constipation depending upon incompetency of muscular action the former ought to be applied to the interior of the rectum, the latter over the abdomen, along the colon. In the cases of persistent constipation depending upon an insufficient muscular action of the intestine now and then medi- cation may appear required. I have treated a number of oases of the kind with nux and (or) physostigma, adding some purga- tive extract. A little boy with a decidedly rhachitical history, three years old, took three times a day a sixteenth (4 milli- * See Meltzer, p. 313. 392 THERAPEUTICS OF INFANCY AND CHILDHOOD. grammes) of a grain of each. — extract of nux vomica, extract of physostigma, and compound extract of coloeynth — for many weeks in succession. But cases of the kind are, and should be, exceptional. As an occasional purgative, for the purpose of re- lieving the intestinal tract of indigestible and injurious masses, castor oil is probably the best and mildest; a few grains of calo- mel, or less, will act both as a purgative and an antifermenta- tive. The compound powder of liquorice will take the place of oil, when the latter is not tolerated, or is objected to; also the fluid extract of rhamnus frangula. Among the drastics, all of which are irritants, rhubarb and aloes are probably the mildest, and are tolerated a long time in succession. Of the salines, chloride of sodium is the simplest. Its main action is osmotic; besides, it occasions thirst and thereby induces the ingestion of a large amount of water. The continued use, however, of salines irritates the mucous mem- branes. The combination of the sulphate of sodium with that of magnesium and chloride of sodium has a mild and happy effect. A frequent accompaniment of constipation is colic. Its causes are, besides constipation, fermenting food, gastrointes- tinal catarrh, the presence of ascarides in large numbers, reflex spasm produced by cold feet and chilled skin, diminished tonicity of the muscular layers of parts of the intestine (in general anaemia and rhachitis during early infancy), and, finally, chronic peritonitis, which resulted in adhesions, or such local changes in the walls of the intestine as will produce local contractions or dilatations. Thus as the etiology of colic varies so much, the treatment must vary in order to be rational and effective and adapt itself to the cause. Its symptomatic treat- ment will often require either an enema or a purgative medi- cine, antispasmodics or narcotics (assafcetida, opium); they are apt to give speedy relief. Gentle friction of the abdomen, the application of dry heat (flannel, hot plate, hot sand-bag), and the administration of hot aromatic teas freshly prepared (fen- DISEASES OF THE DIGESTIVE ORGANS. 393 nel, anise, catnip, German chamomile), a few drops of essence of peppermint in a teaspoonful of hot water, or the injection into the rectum of large quantities of aromatic teas, at a tem- perature of 100° or more, will do good; great care should be taken lest atmospheric air enter the bowel. 2. Diarrhoea. Diarrhoea is always dependent on, or connected with, surface changes of the intestinal mucous membranes, from a simple catarrh to ulceration. Catarrh may be localized, but is gen- erally very extensive. It may descend from the stomach, ascend from the rectum and colon, or originate in any part of the small intestines. The treatment of diarrhoeal diseases depends in part on the locality, in part on the etiology of the individual affection. No "specific" treatment will ever do good, not even the modernized stomach-pump sticking conceitedly out of the coat-pocket of the delighted medical man who appears eager to emulate the midwife of our mothers with the rectal syringe under her arm as her emblem. The causes of diarrhoea are various. Food in improper quan- tity or quality, mostly unsuitable artificial food, is among the principal causes. But even mother's milk may cause it, as is proven by the fact that there are babies who, while falling sick at the breast of one woman, may recover at that of another. Mothers who are sick or convalescing, or subject to very strong emotions, those who nurse too often, who suffer from tubercu- losis or syphilis, who are pregnant, some when they are men- struating, and all anaemic persons, secrete an improper milk. The colostrum furnished immediately after childbirth is apt to give rise to diarrhoea. Milk containing too much fat is the principal cause of what has been described as "fat diarrhoea," by German authors mostly; that containing salts in super- abundance, mainly in anaemia of the mother, is liable to pro- duce the same effect. 394 THERAPEUTICS OF INFANCY AND CHILDHOOD. The amount of food introduced may be too large either ab- solutely or relatively; the latter when the secretion of gastric fluids is insufficient, thus facilitating gastric fermentation in place of digestion; or when the flow and activity of pancreatic juice, limited at a very early age, is still more interfered with by a diseased condition of any kind, and fever of any descrip- tion. The infant intestine is not controlled to the same extent as that of the adult by emotional influences; but local irritation is a frequent cause of diarrhoea, and the organ is very sensitive to the diminution or increase of atmospheric moisture and heat. It is quite probable that the overheating of the general surface affects the blood, the duodenum, and the general ner- vous system similarly to what is observed after serious burns. The mucous membrane with its lymph-vessels and follicles is easily irritated by such results and companions of fermentation as phenol, indol, skatol, and bacteria; by the alkaline salts formed through the frequent (normal and abnormal) prev- alence of acids in the upper part of the intestinal tract; by the direct influence of purgatives, occasionally by even the very smallest doses of arsenic and mercurials, though, indeed, the latter are tolerated very much better by the very young than by the adult; and by sudden exposures to a cold temperature. It is also liable to suffer long from the results of typhoid fever, dysentery, and occasionally from severe attacks of malaria. Disturbances of the circulation depending upon diseases of the liver, lungs, or heart, predispose to passive hyperemia of the intestine and to diarrhoea. Indeed, when it does occur in these diseases, it is an ominous symptom. In no case of intes- tinal disease ought the diagnosis to be considered complete or a prognosis ventured upon, unless the liver, and particularly heart and lungs, have been examined with great care. The variety of causes suggest a number of different treat- ments. Disorders of circulation should be regulated while the local disease is attended to; ulcerations of the intestines are to DISEASES OF THE DIGESTIVE ORGANS. 395 be treated on some such method as has been suggested in pre- vious remarks on dysentery; the skin, if there be fever, should be kept cool by bathing or sponging; the air-supply should be cool and plentiful. Most cases of intestinal catarrh (with or without gastric ca- tarrh) and diarrhoea depend on the administration of improper food and the derangement produced by it. That should be changed immediately. When the process of fermentation is still limited to, or going on in, the stomach, or the stomach still contains injurious masses, these ought to be brought up. In such a case the sound judgment of the practitioner has to decide whether emesis is still useful, or whether the stomach ought to be irrigated and washed out. Most cases of "gastro- enteritis v are pre-eminently enteritis; therefore the claim that the washing out of the stomach must not only take place in every case, but is the almost infallible remedy in the very worst class of cases, will have no other result but that of discrediting that useful procedure in the eyes of those who are inclined to believe implicitly in the value of "new" methods and the pre- tentious claims of short-sighted enthusiasts. If we were to believe some of the loud talk of the journals, and the reporter's columns in the secular press, gastro-intestinal catarrh would soon be "one of the lost arts." In fact, the injurious element is in most cases beyond the reach of the stomach-pump; indeed, the latter cannot remove anything but what is dissolved or suspended; the expulsion of large masses, curd particularly, through an elastic catheter is out of the question. The role played by bacteria in the stomach and intestines is probably great, the class of the schizomycetse is numerously represented alike in the healthy and the diseased intestine. Even within from four to eighteen hours after birth there are large numbers of bacteria, cocci, bacilli subfiles, and bacteria coli communia (Escherich) in the remnants of digested milk; the latter microbe in the large intestines. How many are intro- 396 THERAPEUTICS OF INFANCY AND CHILDHOOD. duced into the stomach immediately after birth, by the air swallowed by the newly-born, cannot be determined. Besides those enumerated above, there is the bacterium lactis aerogenes which is credited with the decomposition of milk-sugar into lactic acid, carbonic acid, and hydrogen, thus giving rise to most of the gases constantly present within the intestinal tract. The presence of immense quantities of micro-organisms need, however, prove nothing in regard to the etiology of dis- eases, for they are found in the healthy state as well, as also in those morbid conditions in which the cause of death cannot be attributed to the presence of parasites or the usual patho- logical changes. Thus in arsenical poisoning the intestines are swarming with saprophytes. To what extent bacteria, and which of them, are the actual causes of diarrhceal diseases is still debatable, in spite of Baginsky's and Booker's labors. During lactation, in the young child, the upper part of the small intestine holds bacterium lactis aerogenes, the ileum and colon bacterium coli commune. During the summer diarrhoeas both varieties increase in numbers, and swarm over the whole intestine; thus in neither of them is there anything specific or etiologically important. In protracted cases of catarrhal enteritis leading to ulceration, according to W. Booker, strepto- cocci are found in large numbers; in more than half the cases proteus vulgaris is found, mainly in the stomach and the colon; the putrid odor appears to depend on its presence. Both these microbes may emigrate to the abdominal viscera, the lungs, and the blood, thus, if they be causes of the original disease, estab- lishing a general, constitutional malady. To judge from the undoubted occurrence of diarrhceal diseases by contagion ascending through the anus (soiled diapers, fingers of nurses, contact in institutions), bacteria must be credited with being more than companions, — that is, direct causes and sources of the local and the general affections. The intestine may be emptied either by purgatives or ene- mata; the former act upon the whole length of the intestine, DISEASES OF THE DIGESTIVE ORGANS. 397 the latter upon its lower portion. Castor oil, so common in domestic practice, deserves all the credit given to it. It acts mildly and speedily. The addition of opium is not wise; the latter may be administered after the former has exhibited its effect; the action of the oil must not be inhibited by the seda- tive. In many cases a single dose of calomel (one-half grain to six) answers better, being both a purgative and antifermenta- tive. The surplus acids of the stomach — mostly lactic, acetic, and butyric — must be neutralized. Magnesium and sodium salts must not be selected for that purpose, for they add to the diar- rhoea. Calcium salts, the carbonate or phosphate, are prefera- ble because they have no such effect, but the additional advan- tage of forming with the fat acid an insoluble salt which acts as a protection to the sore surface. Doses of about one or two grains (0.05-0.1) may be given every hour or two. Besides being an antifermentative in general, bismuth (the subnitrate or carbonate) binds sulphide of hydrogen, and thus has a favor- able effect in frequent doses of from a quarter of a grain to two grains. They may be administered with or without the ad- dition of opium. If they be given in liquid form, no syrups should be added to correct the taste, but rather glycerin, which has the advantage of not turning sour. The subgallate is credited with still more constipating action. To combat the existing fermentation, antifermentatives may be given in regular intervals. Calomel, bismuth, alcohol, creo- sote, salicylate of sodium, salol, naphthalin, resorcin, bichloride of mercury, and others, have been eulogized. To take effect in the intestine it appears that those who are not readily soluble in the stomach ought to prove more useful. Still, I feel posi- tive that resorcin in doses of from a quarter to one-half of a grain (0.015-0.03) in solution, or as a constituent of a powder containing bismuth, chalk, or (and) opium, given every two hours, has rendered me the most valuable services in a great many cases. Of the two mercurials I prefer calomel by far, in THERAPEUTICS OF INFANCY AND CHILDHOOD. doses of from a twentieth to a quarter of a grain (3-15 milli- grammes) every few hours. The antifermentative effect of alco- hol in the dilution in which we are entitled to give it as a stimu- lant, though the sum total of a daily dose may be large now and then, is not great; salicylate of sodium is less effective than any of the rest, creosote acts more vigorously in the stomach than in the bowels, salol is readily taken; naphthalin is objec- tionable to many, because of its taste and odor. Opium, by its inhibitory effect on reflexes, diminishes hy- peresthesia, hyperperistalsis, and hypersecretion. The objec- tions to its use in the diarrhceal diseases are theoretical only. Doses of from one-tenth to one-third of a grain (6-20 milli- grammes) of Dover's powder every two hours, in all sorts of combinations, act very well indeed, and may well be considered indispensable, when the above indications are to be fulfilled. Its time has arrived when the odor of the evacuation begins to be normal; but it finds no contraindication in those cases of "follicular enteritis" of a chronic nature which exhibit their tendency to malodorous discharges for weeks in succession. In acute cases, and when the stomach participates in the process, astringents, such as lead, tannin, gallic acid, alum, etc., are badly borne. In chronic protracted cases they will find their indication. Nitrate of silver does better in many cases, one-fiftieth to one-thirtieth of a grain (1-2 milligrammes) in two drachms of distilled water (dark bottle) every two hours. In chronic cases only, coto, from half a minim to a minim of the fluid extract, will sometimes act favorably. Tannalbin, in daily doses of from four to fifteen grains (0.25-1.0) or more, as a powder or in mixtures, is among those modern medicines which are highly recommended by some observers, too highly by manufacturers. Of the stimulants, alcohol may be admixed to food. Bad brandy or whiskey contains fusel oil, which is a paralyzing agent. Whiskey is therefore preferable with us, because it can be obtained in greater purity for less money. It must not be DISEASES OF THE DIGESTIVE ORGANS. 399 administered unless diluted. Camphor is better borne than am- monium. It is easily taken when simply rubbed off with glyc- erin and suspended in mucilage (one-fourth to two grains every one or two hours). The strongest nerve-stimulant of all is Si- berian musk. Urgent cases of collapse require one or two grains (0.06-0.125) every fifteen or thirty minutes (best suspended in mucilage) until six or twelve grains have been taken. A very good stimulant in collapse is the injection into the bowels, through a long flexible tube (catheter No. 12, English) of hot water with not more than five per cent, of alcohol, and one or a few drops of tincture of opium. In threatening cases of heart-failure strong coffee, hot or iced according to circum- stances, by itself or in mixtures, may be used to advantage. Cold tea may be tried in small doses, particularly in the chronic cases of older children. In acute cases of intestinal (or gastro-intestinal) catarrh with high temperature, applications of water, of from 60° to 70° F., to the abdomen will render good service. The cloth must be wrung out thoroughly, covered with rubber cloth and flannel, and changed when warm. Anaemic children and those with much pain require warm or hot applications, which may be preceded by a warm bath. Frequent injections of water of 100° F. or more, with or without an antifermentative, such as thymol (1 : 1000 or 2000), answer well in most cases, not only in rectal catarrh. In great debility, or collapse, the water ought to be from 105° to 112° F., and contain some alco- hol and opium, or (and) a teaspoonful of the tincture of musk. The addition of gum-arabic to the injection, or the use of glutinous decoctions (flaxseed) instead of water has a satis- factory influence. Starch injections have the advantage of adding to the nutrition of the body by the facility with which the colon changes amylum into dextrin, which will be absorbed. Part of the injected water will always be absorbed, fill the blood-vessels, and may prevent intracranial and other throne boses. Indeed, in many bad cases in which the cerebral symp^ 400 THERAPEUTICS OF INFANCY AND CHILDHOOD. toms of the so-called hydrencephaloid condition have made their appearance, or are imminent, frequent injections into the rectum of a few ounces of warm fluid contribute considerably to the restoration of circulation. In hot weather doors and windows should be kept open, the coolest place selected in the house or neighborhood, day or night; for night air is preferable to no, or foul, air; and sea air or country air, particularly at some altitude, is superior to city air. When in hot weather the body feels hot, it should be washed with cold or cool water, or water and alcohol (5 : 1), frequently. Cold feet must be warmed by flannels, hot stones, hot sand- or water-bags, and gentle friction, and well covered. The food-supply must depend on the condition of the stomach and of the upper part of the intestine, and also on the rapidity of the peristaltic action of the latter. The complica- tion of gastritis with enteritis contraindicates the introduction of food altogether. Abstinence is better in cases of intense vomiting than the use of ice; the latter may quiet the stomach for awhile, feel pleasant, but it fills the stomach which ought to remain in absolute rest, and excites peristalsis. Babies with an irritated stomach tolerate abstinence better than ingesta. The ubiquitous beef -tea ought to be avoided; its concentration of salts is irritating. If in convalescence it be given at all, it should be mixed largely with barley-water or rice-water. In all cases of "summer" diarrhoea milk must be avoided. Bad cases forbid raw milk, boiled milk, milk in any and every shape, for days and longer. Its rapid fermentation contraindi- cates the smallest quantities, even in farinaceous mixtures. The absence of gastric juice (pepsin and hydrochloric acid) in the stomach of a feverish child or of one that is being drained of its fluids prevents the digestion of albuminoids. Even mother's milk is often not borne to any extent. When milk is again tried after a while, it ought to be done very carefully; cow's milk thoroughly boiled, or sterilized with six times its volume of barley-water at first, the percentage of milk to be increased DISEASES OF THE DIGESTIVE ORGANS. 401 slowly. I repeat: cow's milk, ever so often boiled or sterilized, is still cow's milk. Milk may be replaced by the white of egg, which should be thoroughly mixed with barley-water, and some salt added, and not more (cane-) sugar than is required to make the mixture palatable. During the course of a day and night the whites of from one to five eggs may be given according to the case and age. Severe vomiting and diarrhoea demand, as suggested, total abstinence for from two to eight hours or more. Afterwards, mucilaginous or farinaceous decoctions may be given in small doses at short intervals. A mixture which has rendered me very valuable services in the worst cases of vomit- ing and diarrhoea, after the period of absolute abstinence was terminated, is about as follows: Five ounces (150.0) of barley- water, the white of one egg, from one to two teaspoonfuls of brandy or whiskey, some salt and cane-sugar; a teaspoonful every five, ten, or twenty minutes according to circumstances. Mutton broth may be added to the above mixture, or it may be given by itself, with the white of egg and some little salt. 3. Tumefaction of the Mesenteric Lymph-Bodies. It is of frequent occurrence. Its results are very serious, though the non-absorption of chyle does not depend exclu- sively on the functional incompetency of the lymph-bodies. Simple inflammatory hyperplasia of the lymph-bodies can be more safely prevented than cured. Its original cause is mostly a diarrhoea of some form or another. The irritation of a mucous membrane always leads to that of the neighboring glands; the glands near a nasal catarrh, a stomatitis, a diphtheritic process, a pulmonary catarrh, produce secondary adenitis. Thus the mesenteric glands near an intestinal catarrh are soon congested, and begin to swell. Cell-proliferation accompanies the changed circulation; when its original cause — viz., the hyperemia of the mucous membrane — has ceased, absorption of the newly- deposited material will always take place in the same way that the swelled glands of the neck will disappear when a nasal ca- 26 402 THERAPEUTICS OF INFANCY AND CHILDHOOD. tarrh is treated with cleansing and disinfecting injections. As soon, however, as the newly-formed cells have been transformed into firm fibrous tissue, the possibility of absorption becomes less from day to day. Thus, the prevention of mesenteric glandular hyperplasia consists in the immediate removal of a diarrhoea. Be it ever so mild, it is always a morbid process. Be its name ever so innocent (for instance, "dental"), and the prejudice in favor of letting it alone ever so strong, it leads to anatomical changes which may become permanent in the mu- cous membrane and the glands. When a diarrhoea has been protracted, it may safely be assumed that the glands have undergone chronic changes. Then the cautious administration of an iodide, preferably sodium, is indicated, in daily doses of from five to fifteen grains (0.3-1.0), according to the age of the patient, the severity of the case, and the probable duration of the process. It should be continued for weeks, and then may be replaced by three daily doses of from five to twelve minims of the syrup of the iodide of iron. Morbid processes of any kind in neighboring organs may cause glandular swelling. Adenoma of the liver in a girl of twelve led to (not adenoma- tous, but simply hyperplastic) tumefaction of the periportal lymph-bodies and to a very rapid development of ascites {Trans. Assoc. Am. Phys., 1897). Primary tuberculization of the mesenteric glands is quite rare; so is primary tuberculosis of the intestine, in spite of the fact that meat (very rarely) and milk containing the bacillus are known to be the occasional cause of tuberculosis of the bowels. Both are, as a rule, the results, or complications, of general tu- berculosis, and in this way they, and tubercular peritonitis also, are not uncommon. Thus, the treatment of tubercular tume- faction of the mesenteric glands forms part of the measures undertaken for the relief of the symptoms of the general in- fection, and leaves but little to hope. Still, there are cases in which the tubercular nature of the swelling cannot be doubted, but still are liable to get well. There are now on record a DISEASES OF THE DIGESTIVE ORGANS. 403 number of cases of peritoneal tuberculosis in which laparotomy was performed, either through a mistaken diagnosis or pur- posely, with relief to the symptoms, and apparent recovery. Indeed, there can be no doubt that a number of cases of peri- toneal tuberculosis, in which the diagnosis was hardly dubious, improved considerably, either under no treatment at all, or under measures calculated to benefit the general tubercular condition. Thus, even such cases permit of a hesitation to pronounce a fatal prognosis. The conditions alluded to must not be mistaken for tume- faction of the mesenteric glands from other causes (for in- stance, primary lymphoma, the glandular enlargement of leuco- cythasmia or syphilis, or sarcoma which occurs primarily, or from carcinoma which is met with secondarily in young or older children). Lymphoma and sarcoma are positively im- proved by the protracted use of arsenic, in increasing doses, such as are discussed in a previous chapter. Syphilitic swell- ings require the persistent administration of active doses of both mercurials and iodides. 4. Appendicitis. It is a very frequent disease in childhood, and much more so than colitis or typhlitis not attended with an affection of the appendix. Absolute rest and very careful observation of the patient by a competent person are required. Even in the mildest cases the patient must use the bedpan and urinal, and must not be permitted under any circumstances to change his position without being aided. The disturbance of an incipient peritonitis by mechanical causes is a serious matter; recent adhesions are very liable to be torn and give rise to new attacks. No purgatives must be given except a dose of oil in those rare cases where no evacuation has taken place for some time, and the accumulation in the colon of large quantities of faeces is considered probable. In these cases, however, a large enema of soap and water given at once will mostly fulfil all the indica- 404 THERAPEUTICS OF INFANCY AND CHILDHOOD. tions. Thus, I am not at all prepared to advise, with a few modern authors, to commence the treatment of appendicitis (and peritonitis in general) with the sulphate of magnesium, or a large dose of calomel. The injection, however, first of a few ounces of olive oil, and afterwards of large quantities of soap and water, through a fountain syringe, is again indicated after a week or ten days. No stomach washing, no puncturing to establish a diagnosis. Opium must be given freely by the mouth, rectum, or subcutaneously, in full doses. In almost every case ice applications must be made for days to the right hypochondrium, and warm applications after many days when the fever subsides. The food must be liquid, and given in small quantities at a time. The patient must remain in a re- cumbent posture for weeks after apparent recovery, and be kept quiet even then, for an abscess may be encapsulated and perforation may occur. A positive diagnosis should be made early. Frequent pre- vious pain in the same locality, and intestinal disorders ac- companying them, or a similar attack which occurred months ago, a very sudden csecal pain with vomiting (or without) a few hours or days ago, and illness with fever, perhaps the pres- ence already of slight swelling since, leave but little doubt. When the diagnosis of appendicitis is established, to say with a modern author (Tyson), that the surgeon should be called in to decide on the time of operation, is rather rash. Of Biermer's one hundred and twelve hospital cases of all ages not operated upon, between the years 1874-89, ninety-eight left well and nine "relieved." Eelapses took place in seventeen, of whom two died. In five many recurrences took place. These figures are very favorable, too favorable in my experience, though the course is apt to be milder in children than in adults. Hawkins reports on two hundred and sixty-four cases with a mortality of fourteen per cent.; of those which terminated in abscess twenty-six per cent, died, of those with peritonitis seventy-five per cent. But even the complication with general peritonitis DISEASES OF THE DIGESTIVE ORGANS. 405 need not be despaired of. E. Abbe (Med. News, May 29, 1897) concludes from a large array of such cases, his own included, that "the earlier the operation the better the prognosis;" but "there still remains a chance for life if the period elapsing be not more than two and one-half days/' In many acute cases with violent symptoms a timely opera- tion alone will save the patient. To establish the indications for surgical interference in these cases is, however, rather diffi- cult. Pulse, temperature, and local pain (with or without pressure) and swelling require close watching. If the pulse goes up to 120-1-10 and stays there, if after five or six days there is no improvement in the general symptoms, in the fever and swelling (or only either of them), I consider the indication for operation very urgent. A general rule, however, cannot be made. The indications for the time in which the operation is to be performed are not easily found in many cases. Indeed, the opinions still vary with the very best authors and surgeons — a great many of whom, in all countries, have given the very closest attention and the very best thought to the subject — as to the best time in which the operation ought to be resorted to. Some recommend and practise the operation as soon as perfora- tion of the vermiform process has taken place, some favor pro- crastination until the beginning of the second week. Besides, there are those who object to any operation when universal peritonitis has set in, and those who perform laparotomy in the very same class of cases. In a number of instances the time of the operation depends on the condition of the patient; imme- diately after the perforation of the gut collapse is sometimes so great as to render the operation absolutely inadvisable. In these ice, opium, and stimulants are required to bridge over the imminent danger until the operation can be safely performed. I have seen such cases in which it was considered positively fatal at first, and proved successful a week afterwards. There is no class of cases in which the responsibility of the medical 406 THERAPEUTICS OF INFANCY AND CHILDHOOD. man is greater, and full knowledge and keen judgment are more urgently demanded. Not every case terminates in sup- puration. In some there is a great deal of inflammatory exu- dation. In them the protracted use of the iodide of potassium or sodium, lanolin ointments of the same, and occasional vesi- catories will render good service. I have known many who had repeated attacks extending over years, and finally got practically well, not having anything to complain of for long periods. Still, there remain the results of the inflammation, cicatriza- tion, shrinking, adhesions, and the constant danger of a relapse. If those cicatrices and the appendix were removed, how much safer that would be. The responsibility to advise an operation for the purpose of removing the appendix of those who have suffered from repeated attacks is great, that of not advising it is still greater. Of thirteen children of Broca's operated for that purpose after recovery from one of the attacks, — that is, elective treatment between attacks, — all got well. Of seventy- two operations during the attacks, however, thirty-five per cent, died; of five children whose appendix was removed during the operation for an acute attack, three died. The indication for the operation in acute cases, and the selec- tion of the time for its performance, are, perhaps, apt to be in- fluenced by the observation — in New York City — of two facts: first, no matter what its unknown cause or causes may be, ap- pendicitis is becoming more and more frequent; secondly, it is becoming more septic. In emergency cases, in the hands of the most skilled operators, many cases have died of sepsis soon after the operation, though it was not much delayed. That observation is liable to encourage early interference. After recovery, purgatives must not be given for a long time; but, as a matter of precaution, warm enemata should be admin- istered every day. 5. Paratyphlitis. That name refers to local inflammation, exudation, and sup- puration which have nothing to do with the vermiform process, DISEASES OF THE DIGESTIVE ORGANS. 407 but with the copious connective tissue between the bones of the pelvis and the colon, which at that place is not covered by peritoneum. Such abscesses are sometimes the result of trauma; not infre- quently of pelvic abscess; of inflammation of the psoas; of caries of the vertebrae; sometimes no cause can be found, even while or after it terminated in recovery. They will develop rapidly and some become very large. Sometimes pints or quarts of pus will either be discharged spontaneously or be removed by inci- sion. Still, suppuration will not always result from this in- flammatory process in the connective tissue, but organizing exudation and thickening only. When this happens, the treat- ment consists in the internal use of the iodides, and the appli- cations of ointments of iodoform or iodide and lanolin, or of iodoform collodion (1 : 8-10) several times daily; cold-water applications which are kept up until they become warmed; or sometimes warm poultices, particularly in the cases of very anaemic children. 6. Intussusception. Twenty-five per cent, of all the cases of invagination or in- tussusception of the bowels occur in the first half-year of life (two-thirds of them between the fourth and sixth month), and fifty-three before the end of the first year.* Thus, a knowledge both of the condition and the means to remedy it are essential to the family physician. The only successful treatment con- sists in the reposition of the intestine. When it has been ac- complished the relief to all the symptoms is immediate. The anxious expression, pallor, and collapse improve instantly, the little patient goes to sleep, and soon takes food. In the com- mencement of my practice, when an invagination extended down to the rectum I employed large sounds for the purpose of reducing the invaginated mass, but I have almost invariably * See my "Intestinal Diseases," p. 242. 408 THERAPEUTICS OF INFANCY AND CHILDHOOD. found the case to be worse afterwards, because the sound will crowd the parts upon each other. I also used to blow air into the intestine through a long tube by means of bellows; and in order to make the supply more regular I availed myself, thirty or forty years ago, of an apparatus for the production of car- bonic-acid gas. After that time, when the siphons with car- bonic acid and mineral waters were invented, I used them for the purpose of filling the intestine more or less slowly with both gas and water. All these measures have proved successful in occasional cases. What has rendered me better service, how- ever, is the following simple plan: The baby is turned on its belly, the hips are raised, the abdomen gently supported by a soft pillow. The mouth and nose, being the lowest part of the body, must be protected. The baby is then anaesthetized with chloroform, and warm water is poured into the rectum with but little pressure, not from a height of "fourteen feet." This is important, for the intestine is no iron pipe subject to the laws of hydrostatics only. The injection is frequently intermitted, while the anus is closed by the finger. At the same time the abdomen, in the direction from below upward, is gently kneaded and its contents moved about. In not a few cases have I seen immediate result from this treatment in the course of the last twenty or thirty years. When reduction has been completed, the baby must be kept absolutely quiet, take opium, now and then a rectal injection of chloral in solution, and wear an abdominal bandage just tight enough to steady the bowels. Eelapses are not at all un- common; probably it was a case of frequently relapsing intus- susception in which Knaggs operated after forty-four days (London Lancet, April 24, 1891). In adults, Kussmaul reports favorable results from washing out the stomach. When the simple measure which I propose is unsuccessful, after a number of trials, laparotomy should be performed. The successful cases of laparotomy are not very numerous, but sufficiently so to justify the operation as the DISEASES OF THE DIGESTIVE ORGANS. 409 only means that promises a favorable result in irreducible cases. The late Henry B. Sands was one of the first who saved a baby of six months by this operation; at present the number of re* ported (and not reported) cases, both successful and unsuccess- ful, is very great. The latter should not count to the same degree as the former. All those who are saved by the opera- tion would have died without it. Pitts (London Lancet, June 12, 189?) saved six out of seven consecutive operations. It is necessary to operate in time, and not delay too long; for at the best, laparotomy, in these cases, has its serious diffi- culties, and prolonged abdominal operations are not borne by infants. At an early period all the tissues involved are hyperaemic and soft, with a tendency towards gangrene. In a child of eight weeks, on whom I operated, it took me ten minutes to separate the parts from each other, although I had the invagi- nation, measuring six or seven inches, outside of the abdominal cavity. This delay was due to the softness of the tissues, the close impaction of the three layers, and the presence of a large amount of mesentery in the mass. Besides, the field of opera- tion is very small and the difficulty of returning the intestine into the abdominal cavity very great indeed. 7. Helminthes. The medicines available for dislodging intestinal worms are all strongly irritant. They must not be given unless the diag- nosis has been made positive. It is better that the diagnosis of a gastritis, enteritis, or meningitis, when present, should be made by the medical man than that the child should be pun- ished for his carelessness. Before taking anything to expel tcenia, a child ought to be in fair general condition. Moreover, its own taenia, the mediocanellata, is the most difficult to dis- lodge. The best time is when proglottides are seen in the move- ments. Moderate abstinence for days, at least for one day, and a purgative (castor oil), ought to precede the administration of 410 THERAPEUTICS OF INFANCY AND CHILDHOOD. drugs. The parasite must be expelled; for though the symp- toms may not be urgent, some day there will come either local or reflex disorders, possibly attended with danger. Spontaneous emigration will be noticed occasionally, but it is rare and should not be waited for. After the successful ter- mination of the cure the intestine should be allowed rest. The plainest diet, such as milk, strained farinacea, and peptones, is indicated for days. I have administered a great deal of kamala, sometimes ten to fifteen grammes (a quarter to one-half of an ounce), during one hour, early in the morning; the breakfast (milk) to be post- poned for two hours. The effect was not uniform, and often negative. It was improved by giving a dose of twenty-five cen- tigrammes to one-half gramme (four to eight grains) four or five times daily, for ten days or more, previous to the larger dose. A few hours after the larger dose castor oil ought to be given. Kousso, four to fifteen grammes within two hours, after the required preparation, to a child of from two to ten years. Ethereal extract of filix mas has proved most successful in my hands. A small child may take one gramme (fifteen grains) in an aromatic mixture, or in one or more capsules, within one early morning hour. Pour grammes are tolerated and required by a child of seven or eight years. The oleoresina aspidii of the Pharmacopoeia seems to act differently when purchased at dif- ferent places. As the whole procedure of expelling a taenia is no trifle, it is worth while to be very careful in the preparation selected. Pelletierin tannate is given in doses of one or three deci- grammes (grs. 1J-5). I have but little experience with it. It is obtained from cortex punicae granatum, which was (and is still) given as a decoction, but is too disagreeable and some- times dangerous a mess for a child or infant. For the removal of ascaris some general preliminary treat- ment like the above should precede medication; at least, the DISEASES OF THE DIGESTIVE ORGANS. 411 bowels ought to be moved gently. The powdered semina cynae (Santonicae), or flores cynaa, one gramme or more, mixed with a syrup, and followed by castor oil, will work well, but is very un- palatable. Santonin, which is obtained from it, works as well and more pleasantly; from one to six centigrammes (gr. J-J-l) several times a day, with a purgative such as magnesia, calomel, or jalap. The latter addition is desirable, inasmuch as now and then poisonous symptoms may appear. Older children will complain of "xanthopsia," yellow vision. Urine and conjunc- tiva? are yellow, sometimes. As oxyuris vermicularis is frequently found in the rectum, or its neighborhood, the internal administration of drugs will not relieve the local itching. Vaginal catarrh, resulting from the immigration of the worm, must be treated locally. The worm is removed by a small piece of blue ointment introduced into the rectum, or rectal injections of vinegar and water (1 : 3-4), of corrosive sublimate (1 : 1500-6000), or of decoc- tions of onions or garlic. It is difficult to dislodge, as it also inhabits the colon and even the small intestine. Anchylostoma duodenale has attracted a great deal of atten- tion of late, and may become of more practical importance to us when the blessing of immigration from the parts where the worm is indigenous will go on as hitherto. The male is from six to ten, the female from ten to eighteen, millimetres in length (^-J inch). The mouth is bell-shaped; there are two dental prominences above and four below. Par- ticularly the female is thus characteristically endowed, so that it sucks and bites at the same time. Eggs, smaller than those of ascaris, are found in the fasces of the patient. The parasite was found in large numbers among the Italian workmen of the St. Gothard tunnel, the tile laborers of the Ehenish provinces, and the Hungarian miners and their children. The cause of its presence is looked for in the muddy water they drink, which is filled with the ova, and the clay they work in, which contains the larvaa. The general symptoms are very severe and dan- 412 THERAPEUTICS OF INFANCY AND CHILDHOOD. gerous, — debility, pallor, utter exhaustion like that of per- nicious anaemia, and relative diminution of red blood-cells. This "Egyptian chlorosis" was explained by Griesinger by the presence of anchylostoma, as early as 1854. Besides, there is pain in the epigastrium, constipation, mucous and bloody dis- charges, sometimes real hemorrhages and dyspnoea. Anchylostoma duodenale requires santonin, thymol (adults took from two to ten grammes daily), and principally extract of filix mas. It would not enter the digestive organs if the water were boiled and filtered before drinking. 8. Umbilical Hernia* It is of very frequent occurrence, but seldom attended with danger. Incarceration takes place very rarely; still, Treves and others have reported successful operations for such acci- dents. As there is a predisposition to the development of this variety of hernia, so there is a tendency towards spontaneous recovery. The round umbilical aperture will normally change after a number of months, or even a year, into a narrow fissure, more fat will develop, the muscles will become stronger, and then the intestine will be retained within the abdominal cavity. To accomplish this still more certainly, it is desirable to retain the contents of the hernial sac inside the abdomen. For this purpose trusses are very unavailing. Strips of adhesive plaster will serve very much better, but in most cases they are objec- tionable because they irritate the sensitive skin of the baby. An adhesive plaster ("Dieterich's"), containing from ten to twenty per cent, of zinc, lately introduced, does not irritate and answers the purpose. Whatever application is made to the hernia directly must be larger than the aperture. It should not be too hard. Linen compresses, and those of woven lint, plates of cork covered with linen or lint, may be applied and held in position by means of a bandage. Knitted bandages will suit better than the ordinary bandage of linen, cotton, or flannel. DISEASES OF THE DIGESTIVE OEGA^S. 413 9. Inguinal Hernia. In the newly-born or the very young it is apt to disappear spontaneously; when, however, it depends on or is complicated with phimosis, circumcision should be performed to prevent the straining caused by it. When the short aud straight inguinal canal, in the course of a few years, becomes longer and more oblique and the amount of fat goes on increasing, the rupture may disappear; but all these predisposing factors never suc- ceeded in effecting a cure by themselves. This was accom- plished only when the hernia was retained inside the abdominal cavity completely and constantly, by means of a truss, which must be worn for years. It must not be removed except when the baby is sleeping quietly. Trusses are uncomfortable in the beginning, and give rise to cutaneous irritation, particularly under the influence of urine. So much the more is it necessary to keep the truss clean, and always to select one which fits ex- actly without exerting too much pressure. If these mechanical means did not effect a cure after a few years, the radical opera- tion (Bassini, Kocher, or a new procedure devised by Geo. E. Fowler, which consists in intraperitoneal displacement of the spermatic cord and obliteration of the internal ring and in- guinal canal (N. Y. Polyclinic, July 15, 1897), will save the patient much discomfort, and removes the danger of a possible strangulation. A similar operation is recommended by Xelaton and Ombreville (Lyon Med., August 1, 1897). Lannelongue's method of injecting chloride of zinc solutions into the tissue should be recommended as little as the same method applied to tuberculous joints, or to spondylitis. Hernia is easily reduced into the abdominal cavity, in most instances, by gentle pressure while the legs are raised, some- times best in a warm bath or under the influence of an anaes- thetic. But there are on record quite a number of cases in which incarceration and strangulation required operative inter- ference. The operation should not be delayed after reduction, 414 THERAPEUTICS OF INFANCY AND CHILDHOOD. tried under the influence of an anassthetic, proved impossible. The mortality after the operation does not seem to be larger in children or infants than in adults. An instance of a successful operation on a case of strangulated femoral hernia, which oc- curred in a girl of eleven years, has been reported by St. Ger- main, also by Dowd {Arch. Ped., May, 1897), and others. Eees succeeded in reducing an inguinal hernia by aspirating from the intestine a quantity of turbid liquid. An exceptional case of the kind, however, must not be recommended for general adoption. If strangulation is old, taxis should not be at- tempted at all. 10. Catarrh of the Rectum. It behaves very often like a merely local disease. Indeed, it may occur as the result of a local irritation of the anus (scratching, sitting on muddy stoops), of oxyuris, foreign bodies, or of hardened fasces. The immigration of bacteria through the anus was discussed above (p. 396). In all these cases the treatment has to be directed to the cause, which must be removed. Warm injections of water, flaxseed tea, starch decoc- tion (with a little opium in tenesmus) are ample. Real proc- titis, leading to ulceration (other than dysenteric) or fibrous hyperplasia, will not result frequently. But it may occur, the infiltration may become copious and lead to an invasion of the surrounding cellular tissue. This periproctitis gives rise to abscesses, and often to fistula, either external or internal, com- plete or incomplete. These, as well as the periproctitic ab- scesses, due to pyaemia, sepsis, or the severe form of typhoid fever, require early incision and large and careful antiseptic after-treatment. 11. Prolapse of the Anus and Rectum. It is the consequence of catarrhal and inflammatory irrita- tion and softening. It may follow chronic catarrh and dysen- tery. It is produced by debility of the sphincter, which is often congenital, or sometimes the result of neighboring diseases; DISEASES OF THE DIGESTIVE OBGANS. 415 also due to drastic purgatives, or to constipation with the inci- dental straining. Such straining, resulting in prolapsus, is also produced by the presence of polypus or worms in the rectum, by stone and catarrh of the bladder, and phimosis. A predisposi- tion arises from the peculiar shape of the rectum in the young. It is straighter, inasmuch as the sacrum is not so concave as it is in the adult. The temporary reduction of the prolapse is readily accom- plished, particularly in those many cases in which the sphincter is feeble, but the intestine will come down again. Atten- tion must be paid to defecation. The children should not be allowed to strain. Thus the chamber, if any be used, should be placed in such a position, and raised to such an extent, that the feet cannot touch the floor, or the child must not be per- mitted to sit up during defecation.* Many applications have been devised to retain the rectum inside. Adhesive plaster has been used «s best it could, and a number of instruments have been invented for the purpose of retaining the rectum in position, while leaving an opening for the passage of the fasces. They have been made of hard rubber, lead, and other materials. Some have used a tampon, and others a compress to hold the nates together; but a tampon will certainly dilate the paralyzed sphincter more than it was before. Curling confines his efforts to compressing the nates. * Hippocrates makes the following remark on this subject: "In chil- dren suffering from stone, and protracted genuine dysentery, the rectum is apt to protrude. It should be pressed in with a soft sponge, and touched with a snail. Then the patient should have his hands tied, and be suspended a short time, and thus the rectum will slip in. If it comes down again, a band should be placed around the loins; a bandage must be attached to this, and the rectum, after being moist- ened with a decoction of lotos, be replaced with a soft sponge. Also, the intestine must be washed with this decoction and the bandage carried up between the legs to the umbilicus. During defecation the baby must sit with extended legs upon the feet of the mother, its body leaning against her knees." 416 THERAPEUTICS OE INFANCY AND CHILDHOOD. The main attention should be paid to the treatment of con- stipation or diarrhoea, of the local catarrh, the rectal worms, the presence of polypi, and to the presence of stone in the bladder and phimosis, and all the causes of straining and pro- lapse which have been enumerated above. But there are direct indications. Astringents have been used locally in the form of injections; principally alum and tannin, in solutions of one or two per cent. Ice has been applied locally, and injections of from half an ounce to an ounce of ice- water may be used with advantage, three or four times a day. One enema must be given daily for the purpose of empty- ing the bowel and thus avoiding the possible straining. In most cases there is considerable swelling, sometimes real hypertrophy of the mucous membrane and of all the tissues. Swelling and hypertrophy must be reduced. A part of the hy- pertrophied tissues has been excised. Caustics have been used, for instance nitrate of silver. It should be carefully neu- tralized immediately after the application by chloride of sodium in solution. Concentrated nitric acid has been employed for the purpose of destroying some of the superfluous tissue. The best remedy, however, for this purpose is the actual cautery. It should be applied either in long welts or strips, or at half a dozen or a dozen points. It matters not whether the galvano- cautery, or Paquelin's thermo-cautery, or the common actual cautery is selected. For the purpose of strengthening the sphincter, I have used frequently, for dozens of years, an ointment consisting of ex- tract of nux vomica, one part, in ten or fifteen parts of fat, to be applied to the lower part of the rectum from three to five times a day, or every time the bowel protrudes. The internal administration of strychnine is of very little avail; but that of ergot is serviceable. The subcutaneous injection of strychnine (sulphate one-sixtieth to one-thirtieth grain dissolved in water, once daily) in the neighborhood of the sphincter will be bene- ficial, particularly when supported by the action of the inter- DISEASES OF THE DIGESTIVE ORGANS. 417 rupted electric current, which may be applied for a few minutes once or twice every day. Rational treatment is required for the constitutional causes of debility and emaciation (rhachitis, tuberculosis). 12. Fissure of the Anus. It is by no means rare in infants and children, particularly in the latter. It gives rise to symptoms similar to those en- countered in adults: severe pain during defecation, tenesmus, dysuria. Many cases of alleged flatulency and colic, and ex- cruciating screaming spells, are due to fissure. The more severe form follows a direct injury by foreign bodies, hard fasces, etc.; a mild form is due to slight erosions and ulcera- tions, the rhagades of congenital or acquired syphilis, or the sores made by erythema, eczema, or herpes, and by vulvo- vaginitis. The mildest form is that which is found on a very loose and dilatable anus. This yields readily to a mild treat- ment of the sore with a solution of nitrate of silver. Cases depending on syphilis require both a general and local treat- ment; vaginal catarrh must be stopped, and eczema healed. The treatment of the severe form has consisted in the relief of occasional diarrhoea, and that of the more frequent consti- pation by enemata and mild purgatives, in the application of astringents, such as lead, copper, zinc, or alum; or of caustics, such as nitrate of silver (Esmarch) or of nitric acid. This treatment is painful and tedious. Boyer advised incision through the whole of the sphincters. The open wound, how- ever, may bleed and give rise to ulceration, or sepsis. The proper treatment consists in dilatation of the sphincters. Jos- seline directs it to be gradual, thereby protracting uncertainty and pain. The best and speediest method, however, is forcible and instantaneous dilatation, without or with anaesthesia. The operation takes so little time that it is hardly required except in very puny or convulsive infants or children. The introduc- tion of two fingers of the same hand is rarely sufficient; three or four do better, or the thumbs of both hands. The easiest 27 418 THERAPEUTICS OF INFANCY AND CHILDHOOD. way is to use the two index-fingers for pulling; a sufficient dilatation is recognized by the distinct sensation that the mus- cular fibres have given way. The external wound is trifling and but superficial. In the rare cases of fissure and polypus combined the treat- ment has to be directed to both. 13. Polypus of the Rectum. They are tumors of the size of a pea up to that of a cherry or hazel-nut, or more. They are single or numerous, quite soft, or more frequently of greater consistency, composed mostly of cells or cellular tissue, quite vascular, and contain often a harder adenomatous nucleus and a Lieberkiihn gland embedded in them. They are either pedunculated or sessile, on a broad base. They are sometimes found between the two sphincters, mostly above and near the inner sphincter; not infrequently, however, all over the middle portion of the rectum, and some- times quite near the "third sphincter." Among the symptoms we occasionally meet with abnormal defecation (constipation, diarrhoea, or both in alternation), sometimes with enteralgia or tenesmus, and frequently a dis- charge of mucus or blood. Tenesmus is found about polypi when seated near the internal sphincter, or between the two sphincters. Blood is seldom mixed with mucus, mostly quite clear, from half a teaspoonful to a teaspoonful, sometimes more, so that the constant repetition of these small hemor- rhages is sufficient to result in anaemia, but also to establish the diagnosis. The tumor is often pushed into or through the anus during the evacuation of the bowels. The treatment consists in the removal of the tumor by means of the cold snare, the galvano-caustic snare, by pincers, or by the fingers, or by ligature. The latter is easy of applica- tion in all cases in which every movement of the bowels suc- ceeds in rolling out the growth like a foreign body. In these many excursions a polypus with a thin pedicle is often removed DISEASES OF THE DIGESTIVE ORGANS. 419 spontaneously. When that occurs there is hardly a show of blood. Indeed, there is seldom much bleeding after removal. It is true that some writers report the occurrence of hemor- rhages; but in infants and children, with whom varicosities ot the blood-vessels are exceedingly rare, I have never seen a hemorrhage of any account after breaking the pedicle with my finger in the rectum. The latter is very accessible indeed to an index-finger of moderate size. Sessile polypi do not give rise to urgent symptoms, and are not easy to find, sometimes. The astringent injections which are to remove them should be mild. Solutions of one per cent, of alum, injected several times daily, will be found sufficient, or a two-per-cent. ointment, or a suppository. G. The Livek. The diagnoses of alleged diseases of the liver are more nu- merous than its diseases. Primary affections are rare. Enlarge- ment is frequently assumed to exist when the size is normal. In the foetus and infant the liver is proportionately large, but ap- pears still more so because its lower part is not covered by the ribs (which in the young are placed more horizontally) as it is in the adult. Besides, the tympanitic intestines encroaching upon the liver from below and behind, and the rhachitical con- traction of the chest-wall, if present, render a much larger sur- face of the organ accessible to percussion and palpation. Thus, actual and primary enlargement is not a common occurrence. Secondary enlargement, however, may depend on constitutional — either chronic or acute — disorders, such as alcoholism, syphi- lis, leucocythasmia, chronic tuberculosis, suppuration of bones or glands, malaria, or typhoid fever. The therapeutics of these kinds of enlargement depend, therefore, on the character of the different causes. A case of multiple adenoma of the liver in a girl of twelve years was published by me in the Trans. Assoc. Am. Phys., 1897. Enlargement of the liver should not be diag- nosticated when the organ is merely dislodged downward 420 THERAPEUTICS OF INFANCY AND CHILDHOOD. (hepatoptosis). In very rare cases its position may be so changed that the diaphragmatic surface looks outward, to the right side. Another series of enlargements is that which results from changes in the circulation. Diaphragmatic pleurisy of the right side may constrict the vena cava inferior and thereby lead to hypertrophy of the liver, ascites, anasarca of the lower extremi- ties, and death. Pneumonia in its acute stage impedes the hepatic circulation, temporarily mostly; when it is chronic, the consecutive hyperemia may lead up to hypertrophy; the same effect may be produced by the persistence of pleural effusions on either side. Persistent obstruction of bile-ducts may have the same effect. More frequent yet is the secondary hepatic enlargement of heart-disease, not so much in the congenital form, in which the amount of blood is greatly reduced by the low state of general nutrition, as in acquired (mostly rheu- matic) endocarditis; also in chronic myocarditis. The number of such cases increases with every year of life; indeed, children of eight or ten years, with chronic valvular diseases and con- secutive enlargement of the liver, are subjects of frequent ob- servation. Myocardial alterations are not so frequent. Thus, indeed, the treatment of the hepatic disorders is rather that of the primary disease than of the secondary hepatic changes. Fatty infiltration of the liver is, in the very young, not often complicated with much increase in size. For, indeed, to a cer- tain extent it is normal. But, in ill nutrition, protracted diar- rhoea, chronic pulmonary tuberculosis, and after severe cases of diphtheria or scarlatina, an actual fatty degeneration is liable to occur, with enlargement of the organ. Sometimes it is found combined with interstitial inflammation (cirrhosis), par- ticularly in cases of syphilis, rhachitis, tuberculosis, or after measles or scarlet fever. All of these facts are here alluded to in order to show that the intellectual physician may accomplish a great deal by attending to an evil before it is developed. Nothing is easier and more luckless than to prescribe iodides, DISEASES OF THE DIGESTIVE ORGANS. 421 calomel, or purgatives for an established local disorder, and fold the hands at the sight of an impossibility; nothing more efficient and happy than to watch and treat in time rhachitis and measles and scarlatina and the whole army of primary ail- ments. Obsta principiis. Noiseless prevention counts more than the loud officiousness of the recipe fiend after the evil has been permitted to advance to maturity. Besides the cirrhotic induration of the liver, complicated with fatty infiltration, there are rare instances of genuine cases of cirrhosis, mostly connected with, or depending on, alcohol- ism, syphilis, rhachitis, acute exanthems (measles, scarlatina), and tuberculosis. The atrophic form is rare and mostly due to syphilis; the hypertrophic, with more or less jaundice and only a mild degree of splenic enlargement, is more frequent. Still, the records of the journals and transactions exhibit less than one hundred cases altogether. Gilbert and Fournier (Sem. Med., 1895, p. 248) publish six cases of from five to eleven years. There was jaundice in all, the spleens were large, in some cases larger than the liver, the last phalanges of fingers and toes were enlarged, the nails curved, the ends of femora, tibiae, and fibula? enlarged, many joints painful, there was syno- vial effusion in the knees. All the children were undersized and puny. Ascites is not so frequent in the young as it is in the adult; it is more often observed as the result of chronic peri- tonitis than of cirrhosis, and of portal obstruction of any kind. The energetic suppression of the alcoholic habit (more fre- quently found in children and adolescents than many presume) and the treatment of syphilis (not always hereditary) may result in recovery. Ascites gets well sometimes after a single paracen- tesis. Mercury and iodides are very effective, not only in syphi- litic cases. In every sort of cases, and in every age, I have succeeded in relieving cirrhosis, and sometimes permanently, by alternating, by the week or fortnight, the administration of iodides (potassium or sodium) and mercury (bichloride or the green iodide, and sometimes calomel). 422 THERAPEUTICS OF INFANCY AND CHILDHOOD. The therapeutics of congestion of the liver is that of its causes, the lungs and heart, phosphorus-poisoning, infectious fevers, or very high temperatures. While nothing is more preposterous than the abuse of antipyretics in the presence of moderate temperatures, nothing is indeed more reprehensible than to allow paralysis of blood-vessels and even disintegration of tissues to take place from excessive pyrexia. The same is true of hepatic inflammation and suppuration. In our country the former, when general, is mostly traumatic, the latter the result of pyaemia, umbilical phlebitis, dysentery, perityphlitis, and pleuritis, besides an occasional case produced by pylephle- bitis, or the immigration of an ascaris, or a contusion. Many a case of abscess need not have occurred if the dysenteric rec- tum had been disinfected by frequent enemata, a perityphlitic or pleural abscess been incised in time, and the umbilical phle- bitis prevented by keeping the cord aseptic. Multiple abscesses will always terminate fatally; a single abscess may get well by either aspiration or incision and drainage. Of the two I prefer the latter, though, indeed, I have seen a successful result from a single aspiration followed by antiseptic irrigation. Acute yellow atrophy has been observed in infants of from one month to fourteen years. Greves (Liver p. Med. Sur. Journ., July, 1884) collected seventeen cases; I have seen but two, with pain, vomiting, jaundice, nephritis, fever, and early brain symp- toms. They all die, mostly within a week. The treatment of jaundice depends on its causes. The dan- gerous form met with in the septic new-born might have been prevented, but cannot be cured. That which results from syphilitic stricture of the bile-ducts may recover, even after months, through a thorough mercurial treatment; complete obliteration of the bile-ducts leaves no hope, except in those cases which can be proved to be inflammatory. In them per- sistent alternation of mercury and iodides may relieve, or re- store health. With mercury alone, aided by but little iodide of potassium in the rectum, a child of ten years with large and DISEASES OF THE DIGESTIVE ORGANS. 423 hard liver (probably fatty, previously) got well of icterus which, lasted five months and was complicated with secondary ne- phritis. The mild form depending on the sudden postnatal change in the hepatic circulation corrects itself; that which follows a gastric and duodenal catarrh in the newly-born, the infant (rarely), or the child, will get well with proper diet and medicines, which have to be adapted both to individuality and age. As a rule, the amount of food ought to be diminished, but little meat (chicken) permitted, and milk and farinaceous foods preferred. Alkaline waters (Seltzer, Vichy, Waukesha, Poland), bicarbonate or phosphate of sodium, bismuth, hydrochloric acid, resorcin, calomel, will be found appropriate in a great many cases; in others, copious cool enemata or tinctura rhe'i aquosa. Jaundice attributed to the influence of foods, locali- ties, miasms, and atmospheric influences has been observed to occur epidemically. Such cases require, besides the treatment outlined above, rest in bed, warm bathing, and diaphoretics. H. Pletzer (7th Ann. Rep. Health Dep., Bremen) reports an extensive epidemic, not contagious, after revaccination. The glycerin lymph (humanized) which was employed, was all ob- tained through different agents, from Eastern Prussia. Jaun- dice from gall-stones, though it has been observed in the very young, even in the newly-born, is excessively rare. The rules both for dietetic and medicinal treatment of biliary calculi must be the same in all periods of life. Strictly nitrogenous food should be avoided or taken in small quantities only, and milk and fruit (oranges, grapes) and fresh vegetables permitted. Of all the medicinal agents known to me, the sulphate and the salicylate of sodium, administered for months in succession, have answered best as preventives, to guard against a repetition of the attacks. Baccelli's method of operation in echinococcus of the liver consists in aspirating thirty cubic centimetres (one ounce) of the liquid through a thin aseptic trocar and injecting twenty cubic centimetres of a one-per-mille solution of corrosive sub- 424 THERAPEUTICS OF INFANCY AND CHILDHOOD. limate. The puncture is then covered with gauze and adhesive plaster. In a few days the sac begins to be smaller, and finally contracts. I. von Bokay publishes three successful cases (Arch. f. Kindh, 1897, p. 310). H. The Spleen. Diseases of the spleen are rarely of a primary character; but most cases of pseudoplasm are congenital, and not amenable to any medicinal treatment, except sarcoma which cannot be cured, but favorably influenced by arsenic and by the toxin of the erysipelas coccus and the bacillus prodigiosus (Coley). It is not so rare as it is reputed to be. I am certain I see a case an- nually. The majority of changes occurring in the spleen are connected with, or dependent on, constitutional ailments, and result mostly in enlargement of the organ. Malaria, leucocy- thaemia and pseudo-leucocythsemia (Hodgkin's disease), and amyloid degeneration have their own indications. Ehachitis and syphilis are liable to produce induration depending on hyperplasia of the connective tissue. Tuberculosis of the spleen is a frequent complication, sometimes the first place of deposit in the very young, of general tubercular infection. The deposits are sometimes of microscopical size only. The differen- tiation between tubercular deposits (transparent in very acute cases only, otherwise slightly yellowish, sometimes caseous, of unequal size and irregular distribution) and the follicles of the spleen is not always easy. Heart-disease may lead to embolism and abscesses (the latter forming also a part of general pyasmia), typhoid fever to softening and enlargement. This condition expands the peritoneal covering and causes perisplenitis, though it be not quite distinctly accessible to diagnosis. For indeed the younger the infant the less is percussion — being hampered by the shortness of the chest and the frequent oc- currence of tympanites — able to reveal the exact size of the spleen. Unless it can be felt below the margin of the ribs, it should not be assumed to be enlarged. There are even cases in DISEASES OF THE DIGESTIVE ORGANS. 425 which it can be so felt, and still there is no enlargement, for in rare instances the spleen is found descended or floating. The therapeutics of the constitutional disorders above al- luded to has been discussed in previous papers. Quinine, ergot, and arsenic have been shown to be efficient in some and abso- lutely inert in others. The combination of quinine and ergot, with or without iodides, is probably among the most powerful remedies in chronic cases. Acute instances of swelling and inflammation require ice energetically applied, purgatives, and large doses of ergot; the presence of pus demands incision and drainage. To ascertain that condition exploring punctures, carefully executed, can be made with safety. To what extent extirpation of the organ can be rendered serviceable in chronic cases remains for the future to demonstrate. Many of them that are dependent upon disorder of circulation or nutrition are more amenable to a preventive than to a curative treatment. I. Peritonitis. Whether acute, subacute, or chronic, it is a frequent occur- rence at any age, and quite common in the young. The several forms will interchange and combine or alternate with each other; the chronic variety may remain dormant through an in- definite period, and suddenly break out with full force. All the forms of septic and infectious diseases give rise to it, from the sepsis of the newly-born to scarlatina, erysipelas, variola, dys- entery, and typhoid fever (much more frequently without than with perforation). Trauma and perforation from any source, straining and contusion, indigestion, diarrhoea, and constipa- tion (less frequently in the young than in the adult) will lead up to it. Inflammatory processes in the neighborhood, such as pleuritis, or simply local irritation, from incipient hernia or re- tained testicle, are among the frequent causes. Perhaps the most frequent origin is that from a previous attack which oc- curred at a period ever so distant. After all that has been said in these brief lines, it is easy to see to what extent preventive 426 THERAPEUTICS OF INFANCY AND CHILDHOOD. treatment may prove effective. The watching and mitigation of infectious disease with a typical course, the speedy disinfec- tion of the intestines in typhoid fever and dysentery, the pre- vention or cure of chronic constipation or diarrhoea, the proper attendance on appendicitis and pleuritis, the application of a truss and alleviation of the difficulties of a strangulated testicle, are just so many safeguards against attacks of peritonitis. When an acute attack of peritonitis, either local or general, has made its appearance, absolute rest is required by both the whole body and the affected organs. JSTo unnecessary exertion, no motion of the body, no sitting up to evacuate either bladder or bowels, no straining are permissible, no food other than liquid, — that is, milk and such f arinacea as contain least starch, — viz., ground barley or oatmeal, preferably the former. Meat requires more pepsin and hydrochloric acid than a stomach at a temperature of 104° or 106° is competent to furnish, and the system has no worse enemy than half-completed or not ab- sorbed peptones. Peristalsis must be stopped, for any dis- turbance of the consolidation of beginning adhesion is revenged by the tearing of newly-formed blood-vessels, the occurrence of hemorrhages, and the increase of danger. Opiates should be given by the mouth, rectum, or subcutaneously, or by com- bined methods, in doses sufficiently large not only to benumb pain or to procure an occasional sleep, but to obtain a condition of constant drowsiness, even sopor, and an effect on the pulse. When there is much vomiting, food ought to be withheld for half a day or a day. There are cases in which even ice pills fur- nish a new source of gastric irritation; still more frequent is the contraindication to carbonic acid gas, which, it is true, gives great relief in some cases either in an alkaline water or in champagne. In the later stages of the disease, when the neces- sity of feeding becomes urgent, vomiting may often be avoided by giving, either subcutaneously or on the tongue, undiluted, one or a few drops of Magendie's solution five minutes before the partaking of food. In the first days of acute peritonitis DISEASES OF THE DIGESTIVE OEGANS. 427 water is a greater necessity than food. When it cannot be in- troduced into the stomach, an ounce or two may be thrown into the rectum every hour or two hours without annoying it, and without inducing peristalsis of the intestinal tract. Ice-bags or, if they be too heavy, the ice-water coil, or iced cloths are applied to the abdomen to advantage; the former mainly when the inflammation is still local. When they are ob- jected to, water of the usual temperature may be employed first, and the latter reduced gradually. Cold must not be employed too long in very young or anaemic children; in these, indeed, warm applications are tolerated best. As long as an acute peri- tonitis is still local (pericystitis, perihepatitis), leeches may be expected to do good. No purgatives must be given; in chil- dren peritonitis caused by constipation is exceedingly rare, and the recommendations of magnesium sulphate, recommended by some gynaecologists in puerperal and other forms of peritonitis — though they may be considered justifiable in the adult — do not hold good for the infant or child. If it be desirable to re- lieve the intestinal tract to some extent, the incipient state of peritonitis may permit of a tepid enema gently administered, with or without the addition of a teaspoonful or half a table- spoonful of oil of turpentine added to half a pint or a pint of warm water. Rest to the intestinal tract is such an absolute in- dication that the locking up of the bowels for a week or ten days becomes a frequent necessity. The tympanites of peri- tonitis is not the result of constipation, but depends on the paralytic condition of the muscular layers of the gut, brought about mostly by oedematous effusion into its tissues. But when it becomes very annoying, or dangerous through pressure upon the diaphragm, some relief may sometimes be obtained by in- troducing one or more tubes of India-rubber into the rectum. External applications must not be made because of the danger attending renewed peristalsis. The question whether puncture of the intestine is advisable, with a view of allowing gas to escape, cannot be answered for every case. Experience has 428 THERAPEUTICS OF INFANCY AND CHILDHOOD. shown that such punctures accomplished this purpose, but also that over-extension of the intestinal wall destroyed its elasticity and prevented the puncture from closing immediately. I have seen liquid faeces in the abdominal cavity which had escaped through the fine apertures made by the needle of the aspirator. When the case turns out to be one of suppurative peritonitis, the accumulation of pus may be circumscribed (a local abscess) or the whole abdominal cavity is affected. In such cases there have occurred occasional perforations into and discharges through the intestine, ureters, bladder, or umbilicus, but it is not windfalls or godsends we have to calculate upon or look for. The choice is between an absolutely bad prognosis and the inci- sion of the abscess, or laparotomy with proper after-treatment. (See p. 405.) As to its performance, I refer to the recent books on surgery. If I have anything to suggest it is that the incis- sions should not be too small. The latter operation has also been recommended as a curative agent in tubercular peritonitis, and the number of reported successes is increasing. While we know that local tuberculosis is quite liable to heal sponta- neously, we are not justified in attributing the recovery of laparotomized tubercular peritonitis to that spontaneity alone, but should remember that a good empirical observation is of at least as great an objective value as a laboratory experiment made under different circumstances, or a microscopical draw- ing. When tubercular peritonitis is miliary, and complicated with general miliary tuberculosis, no operation should be made, for the disease will terminate fatally. Simple ascites does not contraindicate it, but will often get well without it. In caseous tubercular peritonitis, though complicated with chronic pul- monary disease, the result of the operation is quite favorable. The mere puncture with or without injections is not a proper substitute for laparotomy. Chronic peritonitis, whether the outcome of an acute attack or an independent affection, has its own indications. The ma- jority of cases are either traumatic or the results of previous DISEASES OF THE DIGESTIVE ORGANS. 429 diarrhoea, typhoid fever, or tuberculosis. Rest in bed, warm bathing, warm poultices, offer great relief. Baths containing iodine, such as St. Catherine's, Kreuznach, and the internal administration of iodide of potassium or sodium (of iron only when there has been no elevation of temperature for some time) will contribute to the absorption of part of the exudation, par- ticularly when the latter is very massive. An occasional vesi- catory will be found opportune. Iodoform may be used as an ointment, or be applied in collodion (1 : 8-12), twice daily, for a long time. Tincture of iodine is less efficient and more irri- tating. Ascites may require paracentesis, but I have seen many a case improved by iodides only, in connection with other diu- retics. Sparteine sulphate (scoparius) is one of the best, in daily doses of, altogether, one to four grains (0.06-0.25). It may be combined with the iodide. When the solid exudation is obstinate, the blue ointment may be used in addition to the iodide; it may be rubbed into the inner aspect of the thighs or forearms, particularly the former, twice daily; not, however, into the .abdominal wall. Nothing is easier than to transform a mild chronic form into an acute peritonitis by friction and similar traumatism, and nothing more certain than that the modern "massage" craze has multiplied the cases. On the other hand, there is no better means of alleviation and preven- tion than rest secured to the abdominal organs by the per- manent wearing by the patients, or those who ever suffered from peritonitis, of a bandage easy enough not to annoy, but sufficiently snug to hold in position the jumble of formerly dis- eased and still vulnerable intestinal convolutions. VIII. DISEASES OF THE GENITOURINARY ORGANS. 1. The Kidneys. The preventive treatment of the kidneys ought to begin with the first hours of the newly-born. After the second day, and frequently through a period of some two or three weeks, the urine, usually thin and limpid in the infant, is liable to elimi- nate a large amount of uric acid and urates. They are de- posited in the pyramids and papillae of the kidneys, also in the straight uriniferous tubes, even in the epithelia, as orange- colored crystals and an amorphous powder, and are sometimes so copious as to accumulate in the pelvis of the organ and. also in the bladder. Not infrequently these deposits are combined with some organic structure, which is dissolved by acetic acid, or with hsematoidin crystals resulting from small extravasations. Quite often are the cloths of the baby discolored by them. The pres- ence of this "uric acid infarction" is due to the sudden change in the circulation of the blood; it causes an unprecedented elimination of nitrogenous material which cannot be kept in solution and easily removed, because the newly-born is not sup- plied with a sufficient amount of water. Its speedy expulsion is of great importance, for it acts as a local irritant, and may give rise to a slight or a copious renal hemorrhage, to albuminuria (which is a frequent occurrence because of the defective con- struction of the epithelium of the glomeruli), and even to ne- phritis. Besides, its presence in both the kidneys and the blad- der is a ready cause of the formation of renal calculi; indeed, the vast majority of renal calculi and of the centres of vesical calculi consist of uric acid. The consideration of these facts 430 DISEASES OF THE GENITO- URINARY ORGAN'S. 431 conveys at once the conviction of the necessity of supplying the newly-born with ample quantities of water. Much suffering and illness can thus be prevented.* The malformations of the kidneys and their (mostly congeni- tal) malignant pseudoplasms furnish but few indications for treatment. Abnormal shape and unicity of the kidney (some- times amounting to horseshoe kidney), cystic degeneration of obstructed uriniferous tubes, carcinoma and sarcoma, are un- fortunately not uncommon. Of the latter I collected nearly four dozen in my paper on the subject presented to the Eighth International Congress, 1884. No treatment can be advised but that of removal at a time when the growth of the tumor is not yet too large. If no longer possible, the antitoxin (Coley) treatment may be tried. Fortunately, the diagnosis can be made with satisfactory certainty, and besides, as a rule, there is but one kidney affected. Metastatic deposits in the other kidney or in other organs take place, if at all, at a late period of the development of the pseudoplasm. Primary tuberculosis is more frequent in the kidneys than in any other part of tHe urinary tract. It is more frequently de- scending than ascending, and at first but one kidney is affected, begins in the cortex, affects the base of the pyramids, and may terminate in abscess. There is enuresis and local pain; blood, pus, connective and elastic fibres are found in the urine; but the diagnosis is difficult until bacilli are discovered. They are scarcely found except by centrifuging. Of fifty-four cases re- ported by S. M. Hamill (Internat. Med. Journ., January, 1896) seventeen were operated upon; four nephrotomies cured two, improved one. One died. Nephrectomy was performed on nine; five were cured, one improved, three died. Nephrotomy and subsequently nephrectomy were performed on four; one died. * See my paper on Nephritis in the Newly-Born, N. Y. Med. Journal, January 18, 1896. 432 THERAPEUTICS OF INFANCY AND CHILDHOOD. Echinococcus and hydronephrosis furnish the usual indica- tions. More than one-half of the latter are congenital, and therefore unfavorable. The secondary variety is caused by con- genital hypertrophy of the bladder, pseudoplasms in the blad- der or pelvis, calculi or abnormal valves obstructing a ureter, tuberculosis or shrinking, with partial obliteration, of the ure- ter, disease of the prostate gland and urethra and its neighbor- hood. Thus the prognosis of the causal treatment is very doubtful in most cases, and a direct surgical treatment — aspira- tion, drainage, and irritant injections — is demanded. A cystic tumor weighing three pounds was removed from a child of seven months by J. Campbell (Br. Med. Journ., May 15, 1897). It was located in front of the left kidney, contained three hun- dred grammes of a clear-yellow fluid and a solid mass in which a cartilage and a piece of bone were embedded. Most cases of floating kidneys in infants and children are congenital; in a few older children, of ten and twelve years, symptoms attributable to that anomaly originated in a fall or jump from a height. Fortunately, it is a rare occurrence; still I have met with at least a dozen in the course of more than forty years. I never could advise anything better than a snug and well-fitting abdominal bandage. I have not seen a case in which I felt justified in advising an operation (nephropexy). Among the symptoms connected with actual or apparent renal disease there are two of such importance as to render a special consideration advisable, — viz., hematuria and hemo- globinuria. The former is always the result of a rupture of blood-vessels which may be occasioned by many causes. Cal- culus in a kidney or the bladder, nephritis and cystitis, neo- plasms (mainly carcinoma, not often sarcoma), thrombosis of the renal vein, or an infectious disease, such as purpura and cerebro-spinal meningitis, are among the principal causes of hematuria. The angioneurotic form I have not seen in a child. The indications furnished in renal hemorrhage by the presence of infectious diseases and thrombosis are clear, but the efficacy DISEASES OF THE GENITO-URINAEY ORGANS. 433 of the means considered appropriate is very doubtful. Stone in the kidneys requires flushing the organ with alkali according to the method to be discussed below. The action of ergot, or of hydrastis, either as a fluid or a solid extract, may be tried. If the stomach be rebellious the remedy may be administered in the rectum, or subcutaneously. Heart stimulants are often in- dicated, but digitalis should not be selected, because of its local effect on the kidneys. Strophanthus or sulphate of sparteine are preferable. Astringents, such as are eliminated through the kidneys, lead, tannic and gallic acid, will render good service if given in more than the doses of the books. The application of ice over the bleeding kidney is superior to any other remedy, provided the patient be not too young; for very small infants do not bear the persistent use of ice. Haemoglobinuria, resulting from dissolution of blood-cells, is the occasional result of extensive burns. In the urine, be- sides haemoglobin, blood and casts may be found; in autopsies mostly blood in the capsule and in the canaliculi, besides detritus. Nephritis, in the acute, subacute, and chronic forms, is a very frequent disease in infancy and childhood. Even in the newly-born it is not infrequent (N. Y. Med. Journ., January 18, 1896). There it is either congestive (from feeble circulation, congenital heart-disease, asphyxia, or exposure to low tempera- tures), or obstructive (from the physiological rapid decomposi- tion of the blood in the newly-born; the formation of haema- toidin = bilirubin; from jaundice; from the production of methsemoglobin by chlorate of potassium, or by excessive heat ; or from the presence of blood in the uriniferous tubes), or irri- tative (by uric acid or by haBmatoidin infarctions, by the pres- ence of purpuric or other hemorrhages, or of microbes and toxins furnished by enteritis or by an infectious disease). As nephritis is not always primary, but quite often a secondary affection, it is liable to be overlooked until it is too late. When this excessive frequency will be generally recognized fatal re- 28 434 THERAPEUTICS OF INFANCY AND CHILDHOOD. suits will become less, and prevention will be appreciated at its full value. The enumeration of the causes of nephritis will always be incomplete, but the list of those conditions and dis- eases leading to it comprehends the principal ailments of in- fancy and childhood. First of all, there are the acute infec- tious diseases: scarlatina, diphtheria, measles, rubella, varicella, vaccinia even, malaria, typhoid and cerebro-spinal fevers, amyg- dalitis ("tonsillitis"), parotitis, and pyaemia. There are consti- tutional disorders, such as syphilis, purpura, and diabetes, also extensive eczema or impetigo, changes in the superficial cir- culation resulting from sudden exposure, sometimes also from the persistent influence of a low temperature. The latter is not so ominous as the former. A fall into the water, exposure to a rainstorm may cause an acute nephritis (interstitial or hemorrhagic) which may prove fatal in a few days. The slow influence of cold temperatures is better borne, almost as well as compulsory overwork of a kidney (for instance, after the other has been removed). Stasis and thrombosis, depending on pul- monary and cardiac diseases and diarrhoea, have the same result. Irritation of the kidneys by medicinal agents also leads up to nephritis; thus, for instance, chlorate of potassium, mineral acids, salicylic, carbolic, and pyrogallic acids, turpentine, naph- thol, styrax, petroleum, tar,* large doses of lead, phosphorus, arsenic, mercury, and manganese, — part of which are used for internal, part for external medication; finally, irritation of the organ by the uric acid infarctus of the newly-born, or by renal calculi, which are by no means rare in the very young, gives rise to inflammation. Most of these injurious substances exhibit * Balsam of Peru has also been charged with occasioning nephritis. Brautigam and Nowack, after having made daily examinations of the urines of twenty-two patients, though administering internally fifty- two and eight-tenths grammes in eleven days, and in another case eighty grammes in twenty-four days, found that it has no such detri- mental effect, provided it be free of ethereal oils. (Centralb. f. klin. Med., No. 7, 1890.) DISEASES OF THE GENITOURINARY ORGANS. 435 their detrimental effect the more the younger the infants; in them a single external application of a solution of carbolic acid has sufficed to produce nephritis. The large number of causes of nephritis, as enumerated above, if heeded, teaches at least two lessons: first, that the supine expectancy in the treatment of digestive and infectious diseases is very liable to become criminal; and, secondly, that the effect of every irritating remedy, both internal and external, must be carefully watched. When acute nephritis has been fully established, the first indication consists in the procuring of relief for the conges- tion of the kidneys. The child must be in bed, the skin warm; a warm bath will fill the cutaneous blood-vessels and relieve the internal circulation; dry cups and hot poultices applied to the renal region will have a similar effect. The mucous membrane of the intestinal tract should be made to share in the action of the skin; therefore, sulphate of magnesium should be adminis- tered in doses sufficient to produce three or four daily evacua- tions, or calomel in small doses frequently repeated. The arterial tension should be reduced by nitrites, particularly when there are cerebral symptoms; besides aconite in frequent one- quarter-drop doses, small doses of opium frequently given, or chloral hydrate, may be tried for the same purpose. Digitalis should be avoided in acute cases, but when exhaustion is threatening, strophanthus or sparteine sulphate may be admin- istered alongside the nitroglycerin. Iodide of potassium acts favorably in the same direction; the sulpho-ichthyolate of sodium has been recommended for the same purpose by Sen- ator, who gives to an adult pills containing from one deci- gramme (grs. 1^) to one gramme (grs. 15) daily. The greatest care must be bestowed on the diet of the patient. "Whatever is irritating must be avoided; for instance, alcohol, spice, or iron. The food should be exclusively liquid, and com- patible with the vulnerable condition of the kidneys. As the first products of the metamorphosis of albuminates are elimi- nated through these organs, and some of its products, such 436 THERAPEUTICS OF INFANCY AND CHILDHOOD. as phenol, kreatin, and extractive materials in general, may become positively poisonous, it follows that strongly nitrogen- ous foods — the opposite opinion of Oertel and Loewenmeyer and their followers notwithstanding — must be abhorred. No eggs should be taken, and, as a rule, no meat; now and then an exception may be made in favor of veal, spring lamb, chicken, fish, or oysters; but, as a rule, the diet in acute nephritis must be confined to milk and farinacea. Barley, wheat (stale bread), hominy, rice, and potatoes are permissible, also green vege- tables and fruit. The beverage consists of water or an alkaline mineral water. Lemonade is permissible unless it interfere with the digestion of milk. Neither in the acute, nor subacute, nor chronic form of nephritis must muscular exertion be al- lowed, for it is this that increases the metamorphosis of the albuminates. Moderate exercise, however, is not contraindi- cated in the chronic form; in the latter the elimination of albumin is not increased by exercise. The surrounding air is to be fairly warm when the patient is in bed, quite warm when he is about. The function of the skin must not be suppressed; a moderate amount of perspiration is beneficial. Thus it is that there is constant indication for warm bathing and a warm climate, for both diminish the labor of the kidneys (as also of the lungs). As moist air interferes with the action of the skin, a dry climate is preferable. Hot bathing must be avoided except in the occasional emergencies of uraemia. Subacute nephritis with its limpid and sometimes copious urine, changeable percentage of albumin, incidental oedema and gradual diminution of strength, occasional presence of arterial contraction, and of cerebral symptoms, is often over- looked. It is a frequent sequela of scarlatina and diphtheria. Hot-air and hot-water baths, and iron, which gets deposited in the epithelium of the uriniferous tubes (which is thereby subjected to premature elimination), should be avoided. Digi- talis is contraindicated during high arterial tension; indeed, DISEASES OF THE GENITOURINARY ORGANS. 437 there are but few cases which permit its administration. Small doses of opium benefit the circulation in most cases of uraemia complicated with high arterial pressure; so do the nitrites (nitroglycerin), chloral, and sparteine. Mercury in small doses (corrosive sublimate), one-fifteenth to one-tenth grain (0.004- 0.006), largely diluted (1 : 6000, or 10,000 at least) may be given daily, week after week, and may be combined in afebrile cases only, with small doses of iron. The air should be warm, a dry warm climate selected, a warm bath given every day, with gen- tle friction. Large quantities of water, both pure and alkaline, should be shunned, for the functional activity of the kidney must be diminished as far as compatible with a normal circula- tion. This rule is particularly stringent during the presence of local or general dropsy. Here the amount of liquid con- sumed ought not to be greater than the quantity of urine dis- charged. Mild diaphoretics and purgatives will also relieve the labor of the kidneys. When the amount of uric acid in the urine is persistently large (lithaemic disposition), salicylate of sodium may be administered daily, to the total (daily) amount of from ten to fifteen grains (0.6-1.0). Chronic nephritis is of frequent occurrence. The presence of occasional headaches, or of vomiting, or a slow convalescence from any ailment, is suspicious, and calls for the. examination of the urine. As albuminuria is not always present, and the amount of albumin very changeable, that examination must be repeated at short intervals and with the best methods; in- deed the use of the centrifuge reveals many a case .of alleged albuminuria, even of "transient" albuminuria, to be nephritis. That albuminuria should be differentiated from peptonuria (in leucocytosis, croupous pneumonia, empyema, ulcerative enter- itis, and purulent meningitis) is self -understood; also that the albumin of pyelitis or pyelonephritis should not be mistaken for that of nephritis. The absence of dropsy or oedema proves nothing at all, particularly in the very young infant, in whom chronic nephritis without dropsy is a frequent occurrence after 438 THERAPEUTICS OF INFANCY AND CHILDHOOD. pleurisy, pneumonia, erysipelas, or in syphilis. Indeed, the most dangerous cases are those in which no dropsical symptoms are apparent. Many a case of chronic nephritis could be pre--: vented by the discovery of the acute or subacute stage preced- ing it, and by heeding its many causes. I have seen a number of cases complicating or rather depending on purpura, in which evidently the presence of small hemorrhages in the renal tissue gave rise to the initial irritation. In these cases the constant use of phosphorus (one one-hundred-and-fiftieth grain twice or three times daily) administered during two or three months in succession added greatly to the final recovery. Now and then a case of chronic nephritis will recover. The majority of those I have seen getting well took corrosive subli- mate. The "poisonous" effect of the drug I have not seen in such cases; nor in any case where it was watched. Children of five years may safely have one-fiftieth or one-sixtieth of a grain (0.001) in a tablespoonful of water three or four times daily for many weeks in succession. When its intermission is deemed advisable, or together with the mercury, iodide of potassium may be given in doses of six or ten grains (0.4-0.6) daily. At the same time iron may be administered, the chloride (or one of the milder preparations), from ten to twenty drops of the tincture daily. A gentle stimulation of the kidneys by prepara- tions of juniper, or the bitartrate or the citrate of potassium, is advisable. Strong irritation of the kidneys must be avoided; digitalis is apt to do harm, except in complications with valvu- lar lesions of the heart. To increase diuresis through strength- ening the action of the heart, sparteine or caffeine render better services; the latter, however, should be carefully avoided when there are any cerebral symptoms whatsoever. Among the best diuretics, through fortifying the heart while diminishing ar- terial tension, is nitroglycerin, or other nitrites, the mildest of which is sweet spirits of nitre. To combat the latter condi- tion, small doses of opium are often useful. In cases of obstinate vomiting it is often the only reliable remedy. DISEASES OF THE GENITO- URINARY ORGANS. 439 Chronic nephritis is apt to call for immediate and strong measures during some of its worst sequelae. Uraemia (occa- sioned by the accumulation of urea in the blood, the presence of cerebral oedema, of arterial contraction and heightened blood-pressure, and by reflex irritation of the motory centres) results in vomiting, diarrhoea, coma, and convulsions. Strong purgatives may be required at once (calomel, five to ten grains; elaterium, one-twentieth grain, or croton oil, one-twentieth to one-tenth grain every hour, to be followed by sulphate of mag- nesium), or strong diaphoretics (hot-air bath, hot-water bath, hot-water pack, pilocarpine, subcutaneously, in doses of from a fifteenth to an eighth of a grain), and occasionally, when the symptoms of cerebral hyperemia predominate, a few leeches to the septum narium (the preferable place), or the mastoid processes, will save a case from imminent destruction. When, however, much water is eliminated from the body through all these procedures, a new supply must be introduced either by the stomach or by the rectum. Injections into the subcutane- ous tissue of large quantities of salt-water, which have been ad- vised for that purpose, I have not had an occasion to require or to recommend. Other sequelae or complications have each their own indications; oedema of the glottis cannot wait for the effect of the above medication, and demands either scarification or intubation. Hydropericardium and hydrothorax require paracentesis when the symptoms are urgent. The frequency of renal calculi has been alluded to before. Indeed, they are quite common, have been observed to occur in the foetus, and give rise to many attacks of screaming spells, with dysuria, local pain, retraction of the testicles, to the oc- casional presence of pus, blood, and gravel in the urine, and to vomiting and convulsions. Most of them consist of uric acid, very few of oxalates, of cystin (several cases in a family), or of the phosphate of ammonium 'and magnesium, and derive their positive indications for treatment from their chemical composition. Calcareous deposits (carbonates or phosphates), 440 THERAPEUTICS OF INFANCY AND CHILDHOOD. which are found in the newly-born at the lower end of the straight canaliculi, near the papillae, and also in epithelia, being whitish, have been mistaken for interstitial infiltrations. Cal- culi, however, are not only anorganic. The first uric acid in- farctions are covered with organic material, and the calculus is gradually formed of the mixture of both. Small hemorrhages contribute also to it. Indeed, hemorrhages may be both the re- sults and the causes of calculi. Meckel spoke of a stone-forming catarrh in the kidneys, as we now know that a catarrh of the gall-bladder occasions the formation of gall-stones. Particularly in those cases which occur in gouty families, the diet has to be limited to a moderate quantity of nitrogenous food. Meat may be permitted once a day, white rather more than black. Celery, parsley, asparagus, and all irritants should be avoided. The patients may be encouraged to drink much water, alkaline waters to be preferred. All of these contain more sodium than potassium; this latter having a greater affinity to uric acid, the bicarbonate of potassium, in daily quantities of from ten to twenty grains (0.6-1.5), may be given in Seltzer, Vichy, Bethesda, Poland, or Waukesha water, large amounts of which ought to be administered. The natural lithia waters contain less lithia than the occasion calls for; the carbonate of lithia taken during a day ought to amount to from three to eight grains (0.2-0.5). Thus the artificial lithia waters, if carefully prepared, are preferable to those furnished by nature. Piper- azin (and lysidin) may be given in three daily doses of from two to five grains (0.125-0.3) each. Urotropin is credited with the greatest solvent powers of all. In the test-tube it certainly has them. I gave it a long time, in alternating periods, to a child of two years. Without it, the uric acid appeared in the urine as a powder, with it in copious accumulations of needles. Urea, in a five- or ten-per-cent. solution, one-half to one tea- spoonful three times a day, deserves a trial. The presence of a stone in the kidney, besides giving rise to the symptoms enumerated above, may produce renal catarrh, DISEASES OF THE GENITOURINARY ORGANS. 441 and secondary catarrh in the ureter and the bladder. When it leads to pyelitis or pyelonephritis, the treatment directed against their cause should be continued. At the same time gallic acid in daily doses of from eight to twenty-five grains (0.5-1.5) should be given, and balsamics (cubeb, copaiba) may be tried if the stomach permits. Methylene blue (not pyok- tanin) I have tried largely and persistently. It reduced neither the quantity of pus nor the alkalinity of the urine. Saccharin deserves to be tried, from one to five grains daily. When the kidney is enlarged and pyaemia threatening, surgical inter- ference is called for. Nephrotomy or nephrectomy may save life. Pyelitis, when resulting from tuberculosis, indicates ne- phrectomy as soon as the diagnosis is beyond doubt. 2. Bladder. Of cystitis, infancy and childhood exhibit every possible form, from the catarrhal to the ulcerous or diphtheritic; the tuberculous form is very rare in children. It is more frequent than Ashby is willing to admit. Exposure to low temperatures, chilling of the parts by sitting on cold stones or wet grass, trauma, vulvo-vaginitis, the immigration of bacterium coli mainly during and after follicular enteritis, the administra- tion of cantharides or other irritants, the drinking of beer, severe indigestion, constitutional diseases, such as pneumonia, gastro-enteritis, meningitis, typhoid fever, variola, or diph- theria, and the presence of stone in the bladder, are just as many causes. Dysuria, retention or incontinence, vesical and rectal tenesmus, the presence of mucus, pus, and blood in the urine, fever, and secondary peritonitis or "typhoid" symptoms are among the possibilities. Trauma demands absolute rest in bed, and either cold or warm applications, besides opium, which may be administered internally or in suppositories; exposure ("cold"): warm bathing, diuretics and a narcotic; the cystitis of infectious fevers: rest in bed and tonics; that following the use of cantharides (administered internally or in vesica- 442 THERAPEUTICS OF INFANCY AND CHILDHOOD. tories): from two to ten grains of camphor (0.125-0.6) daily, internally; severe indigestion: the correction of the alimentary disturbances by abstinence, purgatives, and plenty of water; hyperacidity of the urine: the use of alkaline waters; hyper- alkalinity: that of hydrochloric acid; vesical calculus: its re- moval, preferably by the suprapubic operation. In most cases the patient ought to be kept in bed, apply warm poultices, drink plenty of carbonated alkaline water, abstain from cold beverages, live mostly on milk and farinaceous food, keep his body warm, particularly abdomen and feet, take a dose of calo- mel, and an opiate for occasional relief. But by far the best symptomatic remedy in the spasmodic pain of cystitis is hyos- cyamus; from two to four grains (0.125-0.25) of the extract may be taken daily for an indefinite period. The chronic cases require the internal use of boracic acid or chlorate of potassium (from 15-30 grains daily), turpentine, gallic or tannic acid, uva ursi, and salol or salicylates; the latter if there be no nephritis at the same time. In a number of instances the local treatment of the bladder is indispensable; the bladder may be washed out with sterilized warm water, or salt solution (6 : 1000), or a warm solution of boracic acid (two or three per cent.), or nitrate of silver (one-quarter or one-half of one per cent.), or lysol (one-quarter of one per cent.). This procedure requires sometimes, particularly in young children, anaesthesia by chloroform. Some of the symptoms met with in cystitis may occur with- out the presence of the latter. Painful spasm during mictu- rition, retention of the urine, or incontinence are very frequent under the influence of quite a number of different conditions; it is upon the causes that the treatment depends. The urine may contain, besides a superabundance of uric acid, salts or bile, or irritants of a nature which cannot always be determined accurately. Thus, urticaria of the surface, when resulting from ingesta, is quite often complicated with vesical spasm, so that it appears that the same cause acted simultaneously on the DISEASES OF THE GENITO UEINAEY ORGANS. 443 external and internal integuments. Dysuria may also depend upon a painful condition of the urethra, resulting from acidity of the urine or the transmission of a vulvo-vaginitis, or con- genital contraction of the urethral orifice or adhesion (mostly acquired) of the labia majora, which is easily corrected, or a balanitis resulting from the irritating effect of urine retained round the glans penis by phimosis. The indications for treat- ment in all of these cases are so plain that the enumeration of the etiological factors seems to be sufficient. There are also cases of "irritable bladder" as well in the young as in the adult, in which the result of the treatment gives sometimes the ex- planation of the cause. In a few cases the introduction of a catheter was sufficient to relieve the spasm of the neck, in others the administration of hyoscyamus proved satisfactory. Retention of urine by local atony and paralysis is rare in chil- dren, except as the result of hyperextension during school hours; still, it may occur in the course of spinal diseases. Now and then there are mechanical obstacles. In the newly-born the colliculus seminalis is often quite large and requires the intro- duction of a sound. Large stones in the bladder, or a smaller one near the neck, or one impacted in the urethra, or a string tied round the penis and buried in the swollen tissue, or the epithelial closure of the urethral orifice, or an oedematous pre- puce are more or less amenable to a diagnosis and speedy amelioration. The injection of warm or cold water into the bladder, warm bathing or hip-bath, the correction of the epi- thelial adhesion of the prepuce, and the use of the catheter or sound find their ready indications. Eetention during infectious- or cerebral diseases requires great attention. Unconsciousness is a frequent cause, and frequent percussion of the bladder ought to be resorted to when the brain becomes insensible to the expansion of the organ. Evidently the causes of retention are very numerous; one of the most puzzling cases was one in which the accumulation of urine was very great. The introduction of an elastic catheter, 444 THERAPEUTICS OF INFANCY AND CHILDHOOD. though it entered to its full length, availed nothing; a metal catheter entered with difficulty until it suddenly appeared to overcome an impediment and the urine was expelled with great force. The autopsy gave the explanation of the singular oc- currence. The whole bladder was lined with a thick diphthe- ritic membrane, which was easily detached but did not admit the elastic catheter. This was deflected along the wall of the bladder, while the silver catheter succeeded in perforating the pseudo-membrane of the diphtheritic cystitis. The great variety of the causes of incontinence of urine re- quires tact and discrimination in the election of remedies. General anasmia and muscular debility, rhachitis and tubercu- losis indicate a diet carefully selected for its nutritiousness and digestibility. Gentle massage of the whole body, sponging with alcohol and water (1:6) or with water, and efficient friction with thick towels, sea-bathing, and the use of medicinal robo- rants, such as iron or arsenous acid, will always prove beneficial. The elixir pepsini, bismuthi, et strychnine of the National Formulary is a good preparation in insufficient gastric diges- tion, with atony of the stomach; a child of three years may take a teaspoonful three times a day. Attention should be paid to the capacity of the bladder. In every case, particularly in the evening, the quantity of fluids allowed should be restricted. The sigmoid flexure and the rec- tum should be empty in the night, and the patient should be encouraged to evacuate both bladder and rectum before re- tiring. After a few hours' sleep the children ought to be taken up and roused sufficiently for both purposes. Muscular debility of the neck of the bladder (sphincter) re- quires general and local stimulation. The child should be en- couraged to hold the urine as long as barely possible. Strych- nine or other preparations of nux vomica prove effective to a certain extent by improving both the general innervation and the appetite; in desperate cases an occasionally subcutaneous injection into the perineum (one-fortieth to one-sixteenth DISEASES OF THE GENITOURINARY ORGANS. 445 grain) has rendered good service; an ointment of one part of extract of nux vomica in from ten to sixteen parts of fat, intro- duced into the rectum (size of a coffee or lima bean) several times daily, will also act well and may be continued for some time. The same indication is fulfilled by ergot, the fluid or the solid extract of which may be employed internally. The in- terrupted electrical current is perhaps the most powerful local stimulant; one of the electrodes is applied to the perineum, the other to the hypogastrium or the lumbar region. The advice to apply the negative pole to the interior of the urethra or blad- der and the positive somewhere externally is bad, because of the danger of urethritis and cystitis. It is particularly those cases in which the sphincter is liable to be overcome that the raising of the pelvis (by pillows, by raising the foot of the bed) has been recommended. The method is quite clever from a me- chanical point of view, but the patients are not patient enough to sleep that way. Whenever there is oxalic acid or sugar or an excess of urates and phosphates, or bacteria, in the urine, the source of the dis- turbance should be attended to. The digestive disorders form- ing the source of the anomalous condition require a correspond- ing change in the diet (diminution of nitrogenous food) or correction of the functional disorders of the stomach and liver by dilute hydrochloric, or nitro-hydrochloric acid, and an occa- sional purgative. Until that can be accomplished the prognosis is very uncertain. Vesical catarrh, nephritis, and the presence of a calculus in either the kidney or the bladder have their own indications. From the latter it is removed by the suprapubic operation. The hyperesthesia of the body of the bladder, com- plicated or not with catarrh, — it is often found without it, — requires belladonna or its alkaloid. Both belladonna and atro- pine are tolerated in much larger doses by children, in propor- tion to their size or age, than by adults. In many cases a single evening dose of extract of belladonna (gr. J-J-l = 0.015-0.06) or sulphate of atropine (one-one-hundredth to one-seventy- 446 THERAPEUTICS OF INFANCY AND CHILDHOOD. fifth) answers well, sometimes to an unexpected degree. Bro- mide of potassium (grs. 6-25 = 0.4-1.75), chloral hydrate (grs. 2-10 = 0.1-0.6), camphor (grs. 2-5 = 0.125-0.3), extract, humuli fluidum (tijj 4-10), or the elixir humuli of the National Formulary, in teaspoonful doses, given at bedtime, answer a similar purpose. Causes of reflex contraction located in the vagina, penis, or rectum require local correction. Vaginal catarrh is as obsti- nate because of its inaccessibility as it is frequent. Polypoid excrescences about the vagina or in the urethra (of the female) demand removal; if there be phimosis, circumcision is re- quired. But a great many cases which are presented for that purpose can easily be remedied by gentle dilatation of the pre- puce. Firm adhesion of the prepuce requires careful detaching. Intestinal worms must be expelled, and the fact remembered that oxyuris has its original seat in the upper part of the colon and the lower part of the ileum, so that rectal injections have but a temporary effect in most cases. Fissure of the rectum, mostly of small size and located posteriorly, requires forcible dilatation, — a procedure which demands little time and gener- ally no anaesthetic, but is very efficient. Irritability of the neck of the bladder and the prostatic part of the urethra has been treated by Henry Thompson with cau- terization by means of a two-per-cent. solution of nitrate of silver. A solution of one part in a thousand of distilled water will be found sufficient, or a solution of one or two parts of tannin or alum in a hundred. Still, it is a better plan to intro- duce either an elastic catheter or a metal sound into the blad- der, every few days, for two or four minutes. A few drops of a two- or three-per-cent. cocaine muriate solution instilled into and distributed in the urethra a few minutes before the in- sertion of the instrument will in many cases render general anaesthesia superfluous. The latter, however, cannot always be dispensed with. In the case of a girl of three years, with chronic catarrh of the DISEASES OF THE GENITOURINARY ORGANS. 447 bladder and incontinence, anaesthesia was required a dozen times, for two purposes, — first, to inject a solution of nitrate of silver (1 : 1000) into the bladder, and, secondly, to dilate forcibly, with increasing amounts of water, the organ, which had habituated itself not to hold more than a lew drachms of fluid at a time. This forced dilatation, under anaesthesia, I had to resort to in several cases with fair results. Masturbation, which is so frequently the cause of irritation of the prostatic portion and thereby of incontinence, has its own indications. Its cure is by no means easy. Infants can be watched and forcible prevention of self-abuse (more by the thighs than the hands) resorted to; but children of more ad- vanced years require an unusual amount of firmness and super- vision. Bodily punishment will avail but little in the treat- ment of incontinence from whatsoever cause, except in the diurnal form, when the boy refuses to give up his game, being either too much interested or too indolent. In a number of cases the removal of adenoid growths, or the resection of greatly hypertrophied tonsils have relieved incon- tinence. 3. Other Organs. Anomalies and Diseases. The development of the genital organs begins in the sixth week of embryonic life; that of the urorectal septum, by which the urethra of the penis is formed, about the middle of the third month. About the same time the anterior part of the urethra is developed by the invagination of the epidermoid integument of the glans penis. This invagination extends backward to the valvula Guerin in the fossa navicularis. Here, where the two parts of the urethra are to meet, the opportunity is furnished for the occurrence of many anomalies. That invagination may not take place at all. In that case there is no indication of an anterior urethra. There may be a superficial epithelial obstruction of the urethra after it has been formed, with retention of urine behind it; or a partial con- 448 THERAPEUTICS OF INFANCY AND CHILDHOOD. traction or narrowness of the external orifice, particularly in cases of genuine phimosis; or a genuine stricture in the pars cavernosa, of which instances have been reported by Guyon, Englisch, and Demme; or an extensive obstruction mostly complicated with rectal anomalies, and retention of urine, dila- tation of the ureters and renal pelves; or, finally (in a few reported cases), obstruction of the neck of the bladder, with the same disturbances unless the urachus be forcibly kept open. The emission of urine begins about the middle of foetal life. Sometimes the connection of the two parts of the urethra has not been established; in that case there is a dilatation behind the fossa navicularis with a constantly growing lake of urine. Its pressure may succeed in breaking through the obstacle with or without the formation of a valve, or it will burst the lower wall of the urethra behind the obstacle and form a mild form of hypospadias. If the urethra be perforated farther back, the hypospadias may be scrotal or perineal. That hypospadias may occur in this way, and not only by an arrest of development, is proven by the occurrence of cicatrices, and such contraction as depends on cicatrization only. Many of these anomalies are the subjects of surgical interfer- ence. Fortunately, all of them are but rare, as the careful reports gathered by Kauffmann in "Deutsche Chirurgie," and Bohn in "Gerhardt's Manual" will prove. Epithelial obstruc- tion of the external orifice can be remedied by puncturing and dilatation of the external orifice; one such case I have seen thirty years ago, and never since. Membranous obstruc- tion in the fossa navicularis has been pierced; even a case of foetal imperf oration of the whole glans penis has been perforated by Eauchfuss with apparent success. Congenital strictures have been treated with bougies. The narrow orifices of hypo- spadias should be dilated with bougies, or the knife, or both, and laminaria tents used to render the effect permanent. And hypospadias has been greatly benefited by operative procedures, DISEASES OF THE GENITOURINARY ORGANS. 449 with better success in modern times than the plastic operations of Dieffenbach could boast of. The prepuce begins to be evolved about the end of the third and in the beginning of the fourth month of embryonic life. Within a month afterwards it extends to the middle of the glans. Its covering epithelia are pavement. They form from six to eight superjacent layers, and extend as far as the urethra and sometimes into the fossa navicularis. They are also those which constitute the more or less numerous accumulations, principally about the corona glandis, which were formerly taken to be fat, the so-called epithelial pearls. They are met with as early as the fifth month of foetal life. They are some- times so large as to raise the adjoining part of the prepuce from the surface of the glans and to form small cavities around themselves, thus contributing to the spontaneous separation of the preputial adhesions. These adhesions are vastly more frequently soft agglutina- tions than solid unions. The causation is simple: as the pre- puce and glans are in close juxtaposition, the epithelia of both remain moist, and thus become coherent. It is only in those cases in which the prepuce does not snugly cover the glans — for instance in hypospadias and epispadias — that no, or but partial, cohesion takes place. There are cases, however, in which the union of the two surfaces becomes quite firm, partly in consequence of the occurrence of an inflammatory exudation, and partly because of the existence of an extraordinary amount of superficial papillae, which, according to Englisch, grasp and join each other. Thus the soft cohesion of the prepuce and glans penis is a physiological condition, and therefore met with in almost every male child. The degree, however, to which it is developed is liable to differ. The prepuce of the newly- born being long, it may cover the whole glans down to the orifice of the urethra, and then by its overlapping adhesion give rise to retention of urine, and in consequence of irritation by urine, and of the traction invariably connected with the 29 450 THERAPEUTICS OF INFANCY AND CHILDHOOD. slightest changes in the shape of the organ during micturition, to pain, redness, muco-purulent secretion, sometimes moderate extravasation, and erections which again produce a local irri- tation of the surface. It is the erections, when frequently repeated, and when occurring more normally in later years, combined with the effects of the cavities formed round the epi- thelial pearls, which usher in the gradual and final separation of the prepuce from the glans penis. That process takes place between about the ninth and thirteenth year of life. Thus, in the vast majority of cases, no interference is required. The more gradual the separation takes place the safer it proves. It is only artificial disjunction which may become a danger by secondary changes. The only reason for interference is in re- tention of urine and balanitis, both of which are often found together. The separation succeeds in most cases quite easily by holding the glans gently but firmly between the fingers and pushing or pulling the prepuce in the direction of the corona. Towards the end of the operation the pearls make their ap- pearance; the separation, however, must be completed without interfering with them, and the prepuce then carried forward again to avoid paraphimosis; for there will be some slight cedema by which the latter might be occasioned. Before that is done, the application of vaseline, or zinc or lead ointment, or a dust of boracic acid or subnitrate of bismuth, or of a mixture of one part of salicylic acid, fifteen of bismuth, and twenty of talcum, is advisable. Carbolic acid is contraindi- cated because of its tendency to facilitate bleeding, though that be ever so slight. In most cases it is best not to repeat the pro- cedure for some time, in order not to disturb the healing and hardening process. Every wound or tear may bring on cicatri- zation and secondary phimosis. In some cases the separation does not take place quite readily; in them a blunt probe intro- duced between the two layers will overcome the obstacle. Probe and fingers will succeed, if care and time be taken, not only to accomplish the end in view, but also to avoid tearing, DISEASES OF THE GENITOURINARY ORGANS. 451 bleeding, oedema, and inflammation. The occurrence of cica- trization is always a serious matter. I have succeeded without it in many more cases than I could take notes of; for the number of cases in which the medical man is consulted in reference to the advisability of circumcision — which is one of the modern onslaughts upon the genito-urinary organs — is very great. Twenty-nine out of thirty alleged cases of unconquerable phi- mosis are exactly of the kind in which a patient reduction and separation prevent both a surgical operation and a surgical fee. The solid cohesion which requires the use of the knife, and a careful and expert operation, is very rare; I have seen but few that were complete in a lifetime. I cannot imagine that a total synechia is curable without a plastic operation, or better still, the total removal of the prepuce after its separation; for new adhesion must follow the operative separation in the absence of mucous membrane. From what I have said it follows that we cannot recognize the existence of an actual phimosis in the young before the epithelial agglutination has been relieved. The actual cases may exhibit a long or a short prepuce, be partial or total, con- genital or acquired, atrophic or hypertrophic. The latter species is often dependent on changes in the internal lamina of the prepuce, which, when originally contracted and tight, is subject to inflammatory and exudative processes; the atrophic form is due more frequently to a defective development of the integu- ment, which thereby becomes attenuated. Both of these forms are liable to be congenital, and either is found as well among infants and children as in later life. The degree of the phi- mosis depends upon the development of those anomalies, and also upon the degree of the presence of the elastic layer de- scribed by Reiner and situated between the two laminae of the prepuce. Phimosis may be acquired by pathological changes of the tissue depending on accidental morbid processes. Dropsy may so swell the prepuce as to result in it. The frenulum, congeni- 452 THEBAPEUTICS OF INFANCY AND CHILDHOOD. tally short or otherwise, may suppurate and' cicatrize. Inflam- mation and ulceration from whatever cause, irritation and tears following inconsiderate or unsuccessful attempts at separating epithelial adhesions, and the cicatrization of circumcision wounds are apt to render the edges of the prepuce unduly rigid. The symptoms of phimosis may be both local and general. Irritation by contact with urine, and pouching of the prepuce by mechanical retention, is quite frequent. Smegma becomes rancid when the original epithelial adhesion has been sepa- rated. Eetention of urine, or incontinence, or both combined, are often met with. The former and the spastic dysuria pro- duced thereby result in straining, vesical symptoms resembling those met with in vesical calculus, prolapsus of the rectum with more or less constant tenesmus, the protrusion of hernia, the formation of struma, have been observed. Like balanitis, which is frequent, cystitis and hematuria will occur. The local irritation gives rise to erection, sexual excitement, and mastur- bation in the youngest of infants. Headaches are said to be frequent but mostly temporary, and permanent nervous symp- toms in great numbers have been attributed to phimosis. It has become quite customary, though less so to-day than ten years ago, to attribute severe nervous derangements to it. A London neurologist has gone so far as to make the statement that in twenty-five cases of epilepsy he found congenital phi- mosis eleven times. Probably it was the "phimosis" which is none, as can be proved by its ready reducibility. The so-called reflex paralysis from genito-urinary causes has played and is still playing an important (?) part in American pathology. Numerous cases of infantile poliomyelitis and cerebral pa- ralysis, spastic paraplegia and paralysis, chorea, epilepsy, con- tractures, and idiocy have been explained (?) by the presence of phimosis. The numerous cases alluded to above of alleged phimosis, in which the separation of the preputial adhesion and apparent phimosis was easily accomplished, were fre- quently such as had been condemned to be operated upon DISEASES OF THE GENITO-URINARY ORGANS. 453 for a serious spinal or cerebral disease. There was a time when, in a New York medical society, one of the sponsors of the theory of genito-urinary reflex paralysis related cases of contracture and convulsions. When reminded that his cases were convulsive and not paralytic, he retorted he was no physi- ological theorist, but he cured his patients. In another meet- ing, years afterwards, I stated that I had never seen a case that obliged me to assume a causal connection between paralysis or contraction on the one hand, and phimosis on the other, and was sustained by neurologists of rank, who also denied ever having seen a case which necessitated the assumption of a genito-urinary etiology. Still the bugbear is alive, many a prepuce is sacrificed, many a fee pocketed, many a diagnosis not made, and many a case either procrastinated or not cured. Many instances of moderate phimosis are best treated by the gentle method of gradual retraction, many are improved by the normal erection occasioned by micturition, and other causes. Thus it was that dozens of years ago an experienced pediatric surgeon, Guersant, could state that he seldom operated for phi- mosis before the fourth or fifth year. Forcible dilatation, if resulting in fissures of the edge, must be frequently repeated to avoid hard cicatrization and consecutive contraction. Many such cases, however, are served better by circumcision. Such cases as are not amenable to mechanical treatment require the knife. The incision of the inner lamina alone, which has been recommended, is very apt to be incomplete, though pain- ful, and to lead to swelling and imperfect results. The atrophic variety requires a dorsal incision by either knife, carried on a director, or a pair of scissors; the inner lamina is often not thoroughly divided, and requires the repetition of the incision; when the scissors cannot be carried over the whole length of the glans, it has become necessary to first cut down on the corona glandis, thus to enable the operator to carry the scissors over the entire length. The cut edges are mostly sub- jected to Kocher's continuous suture, and the whole surface 454 THERAPEUTICS OF INFANCY AND CHILDHOOD. treated antiseptically with bismuth (dermatol) and an aseptic dressing kept moist with a mild antiseptic, boric or boro-sali- cylic (Thiersch's) solution. Iodoform and carbolic acid should be avoided. The lower corners are mostly rounded off. This is particularly necessary in the cases of hypertrophic phimosis which are subjected to the same surgical treatment. Most of this class, however, demand complete circumcision, care being taken that more is removed of the dorsal prepuce than of the opposite side, that the inner lamina is separately divided after- wards and the epithelial adhesion carefully separated. The prepuce must be drawn forward sufficiently to protect the glans against being injured; more than once have I seen it mutilated. In one case the mutilated glans became infected with diph- theria. The wound must be sutured, and treated antisepti- cally. One of the saddest cases of my whole life, and one of persistent distress, was the death from erysipelas from that simple operation performed on a boy of three years. Infections of circumcision wounds by bacteric poisons are quite frequent; such of diphtheritic invasions I have published in my treatise of diphtheria (1880), and before that in the second volume of "Gerhardt's Manual" (1876); many more I have seen since; and syphilis and tuberculosis have been known to follow many instances of either surgical or, more frequently, ritual circum- cision. Diphtheria of the prepuce, or rather the genito-urinary organs in general, the female included, may occur as an origi- nally local affection — such as those alluded to — or a part of the general infectious diseases. The latter are mainly diph- theria, scarlatina, and measles. The last named is the very malady which appears to predispose the system to the most vehement forms of local invasions. The aphthous vulvitis of little girls, and noma, are mostly found after measles; and diphtheria, when found after the same eruption, is more apt to destroy life, with general symptoms, than under ordinary cir- cumstances. In many cases of localized diphtheria, however, DISEASES OF THE GENITO-UEINAEY OEGANS. 455 the constitutional symptoms are but few, provided that effec- tive local treatment is immediately resorted to. Absolute cleanliness of the parts, sponging and bathing, is first in order, after that, local disinfection. Applications of lime-water will suffice for mild cases; solutions of one or two parts of sulpho- carbolate of zinc in one hundred of water, or from one- to five- per-cent. solutions in water of acetico-tartrate of aluminium, will act well. These two may be used to advantage as a vaginal injection in the case of the smallest girls. The nozzle of a small hard-rubber or glass syringe should be lengthened by a thin india-rubber tube, from half an inch to an inch long, which passes the hymen easily and permits an irrigation of the otherwise inaccessible parts. In many cases solutions of the bichloride of mercury proved successful: for occasional appli- cations, of one in from three to five hundred of water; for fre- quent use, of one in from two to five thousand. In exceptional cases, however, it is not well borne and frets the surface. Iodo- form as a powder, or in from eight to fifteen parts of vaseline, has rendered very effective services. Boracic acid avails but little. Noma of the vulva and vagina requires more determined local treatment, besides assiduous roborant and stimulant ad- ministrations. Mineral acids in full strength, strong solutions of corrosive sublimate, have proved efficient in many cases in which the progress of the disease was not too rapid. I have had most successes with the actual cautery, Pyoktanin when used in cases of noma of the face, and in those of the vulva, was absolutely worthless. Paraphimosis results from manipulation. The separation of the epithelial congenital adhesion and the dilatation of a phi- mosis are liable to be followed by cedematous swelling. In both cases the prepuce should be replaced over the glans. If that be omitted, the prepuce — relatively long in the child — will swell, and may become gangrenous. Fortunately, the penis itself is not often drawn into that process. For the purpose of 456 THERAPEUTICS OF INFANCY AND CHILDHOOD. reduction, the glans penis, which is considerably swelled, is per- sistently compressed while the prepuce is drawn forward. A good deal of force is sometimes required, and not infrequently an anaBsthetic. Sometimes gradual compression by bandages (cotton or rubber) must precede the attempt at reduction; in some cases, however, a careful incision of the prepuce, the more careful when no director can be introduced between the glans and prepuce, is unavoidable to relieve the constriction. The treatment of the more common forms of balanitis and balano-posthitis, occasioned by the decomposition of smegma, or by masturbation, or gonorrhoea, or trauma, such as the constric- tion of the organ by a string, is not always quite simple. When there is much oedema it may become necessary to incise the pre- puce to get at the sore surface. In most cases, however, as- tringent or disinfectant solutions can be applied readily either directly or through a small syringe. Solutions of acetate of lead, sulphate of zinc, alum, tannin, the sulpho-carbolate of zinc, the acetico-tartrate of aluminium can be employed in dif- ferent strength, also permanganate of potassium (1 : 1000- 3000). Among the poor, when assiduous attention is out of the question, ointments or powders are preferable. Ointments are best made for this purpose with vaseline. Warm bathing and sponging with moist absorbent cotton will improve the chances of a rapid recovery. A similar local treatment is adapted to the vulvar and vaginal catarrh of both the adult and the infant or child. It is very common among the latter, and quite obstinate because of the comparative inaccessibility of the parts, no matter whether the catarrh is simple or specific. The causes of the former are very various. A predisposition may depend on that structural debility, with chronic inflammation, of most tissues, which we are in the habit of calling scrofulous. Local exposure to cold, sitting on house-stoops, the irritation brought on by masturba- tion, or by foreign bodies, mud, cotton, carpet-fuzz, glass, wood, all of which I have found in the narrowest vaginas; also oxyuris DISEASES OF THE GENITOURINARY ORGANS. 457 emigrating from the rectum, the use of soiled cloths and towels. and the gross neglect of the most urgent cleanliness, with the possibility of directly importing bacteria coli, are among the most frequent causes of vaginal catarrh. Specific vaginal ca- tarrh (gonorrhceal colpitis with its diplococcus) is by no means rare. The infection, though most often indirect, and conveyed by towels, bed-sheets, but also by immediate bodily contact (mostly in institutions which furnish those cases in large num- bers as a dispensation of providence), frequently gives rise, even in the smallest children, to glandular swellings, endometritis, parametritis, salpingitis, oophoritis, and peritonitis, also to ure- thritis, though the latter appears to be less common in chil- dren than in adults. That contagion should take place through the air, according to Bouchard, I have never been able to ob- serve. Besides the local treatment, in conformity with the details given above, absolute cleanliness of the body and cloth- ing, and frequent (general and hip) baths are required. Mas- turbation must be guarded against, and foreign bodies sought out and removed. Eectal oxyurides require injections with water, vinegar and water, or garlic decoctions, or cod-liver oil. They must be resumed after an intermission of weeks, because of the repeated immigration into the rectum from the upper parts of the intestine, where the nematoid has its habitat. In gonorrhceal cases the transmission of the virus to the eyes and to other persons must be guarded against. To reach the re- cesses of the vagina, partial or total removal of the hymen has been advised; but I have met with no such necessity. Besides the solutions enumerated above, nitrate of silver has been ad- vised. I have used it, in solutions of one in from five hundred to a thousand, in a number of cases of ulcerative catarrh. In some the restitution of the superficial losses of substance ap- peared to be more rapid. In stronger solutions and solid it has been employed in tubercular ulcerations, in reference to which I have no experience. In many cases of vaginal catarrh the surrounding parts are sore and suppurating, or 458 THERAPEUTICS OF INFANCY AND CHILDHOOD. eczematous. Lead or bismuth, ointments, or bismuth powder, with or without salicylic acid, will effect a cure in that com- plication. A frequent result of vaginal catarrh of long standing is a moderate degree of atresia of the vagina. It is usually of a superficial character only, and can be remedied by tearing the adhesion with both hands, or by piercing with a probe and by dilating the artificial opening. Astringent applications, or such of dermatol ointment (1 : 6-8), will prevent the renewal of the closure. Diphtheritic inflammation of the vulva and vagina I have known to result in pretty firm occlusion. In one case the reopening required some force, and the continued use of bou- gies and astringent applications to prevent a repetition of the union. The imperforate condition of the hymen, mostly con- genital, is often the same process of epithelial and inflammatory cohesion accomplished during foetal life. According to its early or later formation, and according to the presence or ab- sence of vaginal complications, it requires either the probe or the knife. Such a complication is mostly the result of either an arrest of development or of an inflammatory malformation. An early adhesive inflammation of the vagina will obstruct it in its entire length, or a transverse obstruction of the ducts of Miiller may produce an absence of the vagina below the ex- ternal os uteri. Vaginal hemorrhage, of a mild degree, has been observed in the newly-born, without any complication, least so with bleeding from other organs. It is mostly very slight. In mas- turbating infants and children, and in some of those who suffer from a severe vaginal catarrh, some blood may be noticed. It requires no special treatment; nor was there an indication or an opportunity to interfere in the very rare cases of genuine menstruation in the very young, which have been reported. In connection with vaginal catarrh I mentioned masturba- tion as one of the causes. Still, it is not only a cause in some cases; in many others it is its effect. Indeed, masturbation is DISEASES OF THE GENITO URINARY ORGANS. 459 so frequent that a few words on the subject may be deemed permissible at this place, in addition to my former discussion of the subject (Arch. Ped. y April, 1890, and Amer. Journ. Dis. Ch. and Women, 1875). That habit is very frequent in infants and children; more in girls of the earliest infancy, more in boys of advancing years, and there is a variety of causes leading to it. Such are local irritation (sometimes by nurses) of the geni- tals in the very youngest, excitation in those older, feather- beds, excess of animal food, and stimulating beverages, rancid smegma, eruptions on the penis, vaginal and vesical catarrh, renal calculi, preputial adhesion, phimosis, oxyuris, and con- stipation. Among remedies, I recommend the relief of the causes as enumerated, and partly alluded to on previous pages: cooling diet and cool coverings, attention to the kidneys, blad- der, and rectum, relief of external irritation caused by clothing, mainly by misfit trousers, immediate removal from the bed upon awakening, cold bathing and sponging, mechanical pre- vention, and timely punishment. Cryptorchis is the absence of the testicle from the scrotum. Normally it descends in the ninth month of utero-gestation, or during the first weeks of extrauterine life, but sometimes at a later period, or not at all. In the latter case, particularly when incarcerated in the canal, it is apt to undergo in later life ma- lignant degeneration. When in its descensus it gets under the femoral arch, resembling a crural hernia, or to the perineum, it is subject to inflammation, and requires the application of ice, and occasionally a local depletion, or a puncture for the relief of effusion; and sedatives for the removal of reflex convulsions. In most cases of incomplete descensus the testicle is found in the inguinal canal, and slightly movable; it may be complicated with hernia. No matter whether this complication is present or not, the treatment consists in the application and constant wearing of a truss so adjusted as to keep the testicle below and the intestine above. Its effect can be enhanced by frequent and gentle massage. This simple treatment, if started very 460 THERAPEUTICS OF INFANCY AND CHILDHOOD. early, I have found effective in so many cases that Ashby and Wright's advice — not to rely on it, but to operate and either fix the testicle below or remove it altogether — appears to me inappropriate in the very young. If, however, a result has not been accomplished in time, or if no attention was ever paid to the anomaly, it should be urgently advised to perform orchid- opexy between the tenth and fourteenth year (before puberty). If that be done the testicle will develop; if not, its atrophy is inevitable, or malignant degeneration may take place. Orchitis is occasionally found in children. The acute form is either traumatic, or alternates, even in the infant, with parotitis; or no cause is obvious. The treatment has to be con- ducted on general principles, and consists in the local use of ice, of purgatives, and, occasionally, of antipyretics and nar- cotics. Leeches resulted, in a few of my cases, in extensive swelling of the scrotum. Chronic orchitis is mostly combined with epididymitis, the result of trauma combined with a scrofu- lous disposition. It is apt to lead to induration, caseation, and tuberculization. If that occurs, the organ ought to be removed to avoid general tuberculosis. Primary tuberculosis appears to begin mostly in the epididy- mis, and requires removal, as well as dermoids, sarcomata, and carcinomata. Of the latter, I saw a case in a boy of four years. It was removed and no new local trouble arose; not even in the lymph-bodies of the neighborhood. But the disease reap- peared in the lungs. Both testicles and ovaries are more sub- ject to congenital tumors than perhaps any other organ, with the exception of the kidneys. Syphilis of the testes requires a strict antisyphilitic treat- ment. There is the indication for the internal administration of mercurials and iodides; in the first few weeks a daily hypodermic injection of a soluble mercurial salt will improve the chances of recovery. Hydrocele is a frequent occurrence. A few drops of serum are normally found in the tunica vaginalis propria. Larger DISEASES OF THE GENITOURINARY ORGANS. 461 accumulations of serum are met with in more than ten per cent, of all male infants, — mostly on the right side, seldom on both. In the majority of cases there is no longer a com- munication with the abdominal cavity. When it remains, a hernia may complicate the hydrocele, and the diagnosis may be more difficult because, in such a case, the fluid is apt to re- turn occasionally into the abdomen. Spontaneous absorption is not very rare, but suppuration uncommon. I have injected alcohol and diluted tincture of iodine, and setoned the scrotum with either silver wire or silk. All of these methods are bad to begin with. Simple punctures, one or more, made once or repeatedly with a sterilized needle or trocar, will allow the escape of the fluid, which frequently does not return after the first procedure. It is best to dislodge the integument a little, so as to have no direct escape of the serum. If there be a re- lapse, however, after a number of punctures, the injection of a small amount of tincture of iodine, or of Lugol's solution, or of two or three drops of carbolic acid, after the fluid has been withdrawn, will prove successful. Radical operations (Volk- mann, Bergmann) are rarely required. The cases in which the communication with the abdominal cavity is still patent require the application of a truss after the serum has been allowed to previously return to the abdomen, or a radical operation (Bas- sini). The pseudoplasms of the young female urogenital organs offer no special indications of their own. Tumors of the ovaries were mostly found, on operation, to be dermoid cysts, and very rarely carinomatous or tubercular. The latter and sar- coma, of which d'Arcy Power collected from literature twenty- five cases (St. Barthol. Hosp. Rep., xxxi.), are but rare occur- rences in the young vagina. Cysts have sometimes been found above the hymen, and soft polypi more frequently in the ure- thra. They are either easily recognized or mistaken for a sim- ple prolapse of the urethral mucous membrane. They give rise to vesical tenesmus and dysuria sometimes, and also to (mostly 462 THERAPEUTICS OF INFANCY AND CHILDHOOD. slight) hemorrhages. Evulsion, chromic acid, the scissors, and the actual cautery, now and then two of these means combined, have been used. Ligature never succeeded in my hands. It would always cut through at once, produce some bleeding, and necessitate some other method. IX. DISEASES OF THE RESPIRATORY ORGANS. 1. The Nares. Acute nasal catarrh (acute catarrhal rhinitis) is found either as a sporadic or an epidemic ailment; the latter is rarely de- pending on erysipelas, still less frequently on gonorrhoea, more frequently on influenza, measles, or whooping-cough. The mere presence of endless microbes of different varieties is of no account; as long as the surface is fairly intact, the nasal mucus is bactericidal to a great extent, and invasion does not mean infection. The sporadic form is sometimes local and uni- lateral; in that case it has a local cause, such as a traumatic lesion, or a foreign body; when bilateral and general, it is mostly the result of sudden thermometric or barometric changes, or exposure to dust, impure or dry furnace air, etc. In rare cases the irritation of trifacial branches of the maxillae will, when dentition is abnormal or unusually difficult, give rise to vasomotor and secretory changes of the nasal mucous membrane, which is supplied with ramifications of the same nerve. Acute nasal catarrh may be attended with high tem- peratures, considerable swelling, and obstruction (thus ren- dering respiration extremely difficult, particularly when the patient is newly born or quite young), and with secondary affections, such as swelling of the cervical lymph-bodies, acute pharyngitis, amygdalitis, conjunctivitis, otitis, headaches, and sleeplessness. The indications for treatment are various: the local hyperemia and swelling is to be reduced,, the secretion to be removed, the fever to be relieved, and secondary affec- tions either to be prevented or treated, among them all those 463 464 THERAPEUTICS OF INFANCY AND CHILDHOOD. occasioned by the unfiltered condition of the air admitted to the respiratory organs through the month. Hyperemia and swelling may prove dangerous to very yonng babies. In them the nasal cavities are narrow, and so easily obstructed by an acute catarrh that now and then a newly-born infant that has not yet learned how to breathe through the mouth in which the tongue is curled up, is in danger of suffo- cating. Some of the cases require constant attention; day and night the mouth must be kept open by gentle pressure on the chin to enable the little patient to breathe through the mouth until the nares become pervious. Particularly in cases where the mucous membrane is thickened from birth, or a nasal polypus is present, or a swelling of the pharyngeal or the palatine tonsils, and adenoid enlargement, the danger of suffocation is great. In a single case have I been compelled to apply the galvano- cautery to the left nasal cavity of a newly-born whose acute catarrh obstructed the narrow channel. Astringent solutions are indicated for a similar purpose, or ointments which may be applied by means of a camel's-hair brush. Still, I cannot ex- press much satisfaction at the effects obtained. Better is a two- per-cent. solution of hydrochlorate of cocaine, which may be applied with a brush, or by means of the atomizer, from time to time. Camphor inhalations have been praised. The secretion must be removed now and then by wiping out the nose and bringing on sneezing. The wiping out may be done with a probe covered with absorbent cotton, the latter to be introduced dry, or moistened with an alum or cocaine solution. The pas- sage may also be kept open by a physiological salt solution (1 : 150), or an astringent, or a disinfectant wash of alum, sul- phate of zinc, subnitrate of bismuth, or boracic acid. The latter is not always satisfactory. In most cases, it is true, it acts very mildly, but I have seen catarrhal secretions increased by it. These applications may be made in different ways. An atomizer, when the nozzle is covered with a short piece of india- rubber tubing, will do no harm; injections should be made DISEASES OF THE RESPIRATORY ORGANS. 465 very gently, else they are liable to injure the ear; irrigation by merely emptying a pipette or a small spoonful of a solution into the nostril will prove uniujurious, but not very efficient. Otherwise the rational general treatment of a catarrh may be resorted to: moderate temperature of the room (68°-74° F.), moist air when the secretion is thick and viscid, or scanty, an occasional warm bath, a dose of quinine about noon if there be a considerable rise of temperature in the afternoon, an occa- sional dose of phenacetin or antipyrin during the day or small doses of the tincture of aconite at intervals of two hours; prob- ably a single dose of opium as a sedative and diaphoretic, late in the evening. Chronic nasal catarrh derives its therapeutical indications from its many occasional causes; for instance, frequent returns of acute catarrh, dusty, cold, and moist air, the presence of a foreign body, or the deviation of the septum. This latter con- dition may be congenital, even hereditary, or due to a fracture of the septum, or to its dislocation from the ethmoid, or vomer, or superior maxilla. It results in obstruction, and behind it in accumulation of mucus which is disintegrated and irritates. Other causes of chronic nasal catarrh are enlarged tonsils, chronic pharyngeal catarrh, and adenoid vegetations, with their damaging influence on respiration, digestion, the sense of smell and taste, and intellectual development. Scrofula, tu- berculosis, and syphilis, with their effects on mucous mem- branes, bones, and cartilages, are frequent causes of chronic nasal catarrh. Less frequent are the effects of furunculosis, which is rarer than in the adult; of croupous inflammation; of diphtheria of the nose, which may be met with independently of pharyngeal diphtheria or may usher it in; or of eczema of the upper lip. Syphilis, tuberculosis, and scrofula have their own indica- tions. Thus, a chronic rhinitis occasioned by them demands mercury, arsenic, creosote, cod-liver oil, iron, phosphorus, ac- cording to general rules. Abscesses are to be opened, the small 30 466 THERAPEUTICS OF INFANCY AND CHILDHOOD. furuncles incised, necrotic bones removed. Foreign bodies must be extracted, adenoid vegetations removed, and hyper- trophied tonsils resected, or — in occasional cases — treated with the galvano-eautery. Many a case of chronic nasal catarrh will be relieved, or nearly cured, by these measures, or, on the other hand, there is many a case of chronic pharyngitis which gets well through the treatment of the nasal catarrh. Indeed, there are very many of these complications in which the de- termination of the primary seat of the affection is very difficult, or even impossible. If there be a considerable deviation of the septum, not to speak of the excessively rare cases of bony union, it must be corrected. In very young infants that correc- tion can be accomplished sometimes by manual pressure. The cleansing of the nasal cavities is of at least as much importance as in acute catarrh. They must be washed out from two to four times a day with some warm fluid. According to the case, this may be salt-water, or a solution of boracic acid (two to four per cent.), or alum (half per cent.), or acetico-tartrate of alu- minium (one per cent.). The same precautions should be used which were advised above. If larger quantities of the fluid be used the injection should be made very gently, and the child taught to keep his mouth comfortably open. Chlorate of potassium has been used in solutions of from one to three per cent.; resorcin, of two per cent.; creosote has been applied similarly; iodine or tannin, in combination with glycerin. Co- caine solutions have been employed with good results. Its im- mediate result is evident, but it is better than a merely tem- porary makeshift. What I have seen to do a great deal of good is nitrate of silver. A solution of 1 : 250-2000 may be sprayed into the nasal cavity once a day, or every other day. When a carious bone is underlying the chronic catarrh, an iodoform ointment (1 : 8 or 15 vaseline) may be applied several times a day, to advantage. Hypertrophy of the mucous membrane and submucous tissue, with ulcerations or granulations, add greatly to the difficulties of the case. Lactic acid in powder or in DISEASES OF THE RESPIRATORY ORGANS. 467 strong solutions has the reputation of destroying morbid tissues, mainly granulations, and of leaving the healthy tissue intact. Still, I cannot say that it has rendered me very appreciable service in cases I considered adapted to its alleged powers. The exuberant tissue will, however, be beneficially influenced by an application, every few days, of a solution of iodine (1:8 or 1 : 4), of iodol or aristol, of subnitrate of bismuth, of a strong solution (ninety per cent.) of carbolic acid every four or five days, of chromic acid once every week or ten days, and last and best, of the galvano-cautery under cocaine anaesthesia. For the purpose of compressing the swelled soft tissues and cor- recting a deviation bougies are also used, made with zinc, tan- nin, or carbolic acid. Chromic acid and the galvano-cautery are my preferences in the worst classes of cases. Even many cases of ozaena are doing well under their influence. Others require the frequent use of stronger solutions of nitrate of sil- ver as a spray, or hypermanganate of potassium solutions (1 : 1000-2000), or acetico-tartrate of aluminium in one- to three-per-cent. solutions, or iodol or aristol insufflations, or a combination of a few of these remedies. For the purpose of cleaning the nasal cavities docile children may learn how to employ the nasal douche for copious irrigation. The douche (fountain syringe) should not be raised more than a foot above the level of the nose, the fluid should be mild (salt water) and nearly of the temperature of the body, the head gently bent forward, the teeth parted, and respiration should not be inter- rupted by swallowing or coughing. If this happen, the tubing of the instrument should be momentarily compressed. The nozzle should be introduced horizontally into the narrower nostril. If sneezing comes on, it should take place while the mouth is kept open, and blowing the nose should be done with one nostril open. Polypi, either congenital or acquired through chronic ca- tarrh, though not frequent, will be met with in every medical practice. They are either soft and consist of mucous membrane, 468 THERAPEUTICS OF INFANCY AND CHILDHOOD. or harder and are composed of a dense connective tissue. Those with an admixture of sarcomatous tissue (not often round cells, more frequently spindle-shaped cells with copious stroma) are relatively rare. The cold or galvano-caustic snare is required by those which have a rather bulky pedicle. Evul- sion with a common polypus-forceps suffices for those which are distinctly pedunculated, and for such as consist in the main of mucous membrane. A firm tampon is seldom required by excessive hemorrhage after evulsion. In most cases the bleed- ing ceases spontaneously; or a tampon of moderate size covered with powdered alum or tannin is demanded; or the cauteriza- tion of the stump with chromic acid, either dry or in a concen- trated solution, by means of a camel's-hair brush or a probe covered with absorbent cotton. This application may be re- peated after a while to guard against a return. Foreign todies are often found in the nasal cavities of babies and children. Paper-balls, shoe-buttons, dry peas and beans, flies and bugs, cherry-stones, and beads are readily admitted. Their diagnosis is by no means always easy. Chronic catarrh, being their usual result, gives rise to the mistaken diagnosis of caries, syphilis, or tumor. The cases in which the presence of a foreign body causes delirium and convulsions, and may be taken for meningitis, are, fortunately, rare. In many, chloro- form anaesthesia is required to ascertain the nature of the dif- ficulty. The consecutive catarrh and ulceration require mild or disinfectant washes or injections. The ear-spoon, or Daviel's spoon will generally suffice to dislodge the foreign body. While the child is firmly held, the operator standing a little be- hind and on one side of the patient, introduces the instrument from above downward, the cavity looking forward. In this way the foreign body is easily scooped out. When the symptoms are urgent (convulsions, high fever), an ala nasi has been in- cised to facilitate the required extraction. Dr. G. Bieser recom- mends the following method (Ped., July 15, 1897): The child is placed in the ordinary position for intubation, the assistant DISEASES OF THE RESPIRATORY ORGANS. 469 holding his hand firmly over the child's mouth. One end of a piece of rubber tubing is snugly inserted into the nostril op- posite the one holding the foreign body, the other end is in- serted into the operator's mouth. The operator then blows suddenly and vigorously into the nostril and dislodges the foreign body. This method should not be employed, however, if it be too firmly impacted; for in that case forcible insuffla- tion might injure the middle ear. In every case the mouth should be tightly closed. Epistaxis depends on the rupture of one or more blood-ves- sels, either large or small, normal or abnormal. A normal blood-vessel may bleed in consequence of a traumatic injury, or of an erosion by chronic catarrh, ulceration, diphtheria, or syphilis. Bleeding from the nose may point to the presence of a polypus, or be the indication of obstruction in distant parts of the circulation in the abdomen, the lungs (chronic pneumonia, emphysema), the thyreoid body, or by cardiac dis- ease. The compression of the abdominal viscera by enforced confinement in the school-room, overheated and ill-ventilated at that, and consecutive constipation are a frequent cause of epistaxis. Blood-vessel walls become abnormally fragile in constitutional and infectious diseases, such as early chlorosis, tuberculosis, haemophilia, leucocythsemia, general amyloid de- generation; in purpura, scurvy, and typhoid fevers. Perhaps the most obstinate form of epistaxis, which is fortunately in- frequent, is that which depends on the congenital incompetency of the heart combined with smallness of the large arteries, and results in the most serious cases of chlorosis. All these dif- ferent causes of epistaxis suggest their own indications. The constitutional diseases resulting in local hemorrhage demand such management as has been indicated in other parts of this book. All of them may require local treatment. It is obvious that in every case of epistaxis the congestion of the nasal mu- cous membrane must be diminished if possible, and the forma- tion of a clot should be facilitated. By raising the arms over 470 THERAPEUTICS OF INFANCY AND CHILDHOOD. the head, and by forced inspiration, the chest is expanded and a large amount of blood accommodated in it; hot hand- and foot- baths have been resorted to for a similar purpose. Ice may be applied to neck and throat, pieces of ice introduced into the bleeding nostril. The local use of water (injection, washing) is not desirable, inasmuch as it is liable to prevent the coagula- tion of the blood on the bleeding surface. Solutions of alum or tannin will answer better. The use of a tampon is often required to stop the loss of blood. The introduction of a wick of absorbent cotton, or lint, by means of a pair of fine pincers, or, better, by loosely wrapping it round a smooth probe (whale- bone or other), or of the same covered with alum or tannin, or soaked in a solution of perchloride or subsulphate of iron ("haemostatic cotton"), combined with pressure from outside, or in an antipyrin solution (twenty to fifty per cent.), with or without tannin, will sometimes prove satisfactory. In but a few will it be found necessary to close the whole cavity from either side, by means of a tampon introduced through the mouth into the posterior nares, at the same time obstructing the nose anteriorly. Bellocq's tube should not be used for that purpose, as it tears or. cuts the tissue. An elastic catheter is easily carried through the nose and mouth, and the tampon attached to it. This procedure is not so annoying and irk- some as it appears to be, because it is in few cases only that nose-bleeding is bilateral. In rebellious cases of older children the local cause should be looked for, — viz., an ulceration ex- tending into blood-vessels. Ulcerations of the septum narium are not frequent in children, but they will occur. Chronic catarrh and ulceration of the nares must be treated according to the principles taught above, and the most frequent causes of epistaxis among children attended to according to their own indications. I cannot impress too much the neces- sity of attending to the intestinal congestions and disorders of school-children. Constipation of a lifetime is often the result of the cramped position on an improper chair or bench, and of DISEASES OF THE RESPIRATORY ORGANS. 471 the inability to evacuate the bowels at the proper time. Chil- dren suffering from constipation, particularly those who are affected with what I have described as congenital constipation, may require this daily injection and may be benefited in urgent cases by an occasional (vegetable) purgative. This is sometimes all that is required to relieve their epistaxis. That many are relieved only when taken from school and allowed the free use of their limbs in open air is self-evident. Another large class of nose-bleeders is that which originally suffered from chronic pneumonia or chronic heart-disease with general and persistent anaemia. Very many of these cases improve instantly under the sufficient use of digitalis and iron. 2. The Larynx. Acute laryngeal catarrh, acute laryngitis, is too common a disease to justify a discussion on these pages of its etiology or diagnosis. In regard to the latter, I refer to a single point only, — viz., that of the temperature, which is always elevated. An uncomplicated acute laryngeal catarrh is always attended with fever, while an uncomplicated laryngeal diphtheria ("pseudo- membranous croup") is not so accompanied. Dozens of years ago I brought out this fact, and a large experience has since convinced me of its reality. The other symptoms are unmis- takable, from the different degrees of dyspnoea to those of hoarseness or aphonia, and the barking cough, which is quite characteristic and easily differentiated from that of other dis- eases of the respiratory apparatus, or from the reflex cough of foreign bodies in the naso-pharynx or in the ear. The treat- ment requires the most perfect possible rest. Talking must be prohibited, crying avoided if feasible. For that reason, if for no other, opiates are indicated; partly to relieve the local irri- tation which produces cough, and partly to secure sleep for the purpose of equalizing circulation and resting the excited mus- cles. The temperature of the room ought to be equable, from 68° to 75° F., the air moist. The latter eases the large wind- 472 THERAPEUTICS OF INFANCY AND CHILDHOOD. pipes and procures rest, while dry and cold air increases the irri- tation. Whatever beverages are given should be warm. A general warm bath, warm applications (hot water, poultices, cold applications which are permitted to become warm), are both pleasant and beneficial. Plenty of water ought to be fur- nished, mild alkaline mineral water by preference. An infu- sion of ipecac with bicarbonate of sodium, in small and frequent doses, will aid in liquefying a viscid mucous secretion. The worst form of the acute catarrh of the larynx gives rise to attacks of dyspnoea ("croup"), which occurs quite frequently in the night after the children have been asleep for some hours. The drying up of the pharyngeal mucus is very apt to give rise to both cough and dyspnoea, and therefore it is a good plan to wake the patient from time to time sufficiently to make him drink. Average moisture of the air may not be enough. Water ought to be kept boiling constantly, so as to fill the air of the room (or a tent, which ought to be spacious) with steam. Spraying the throat with cold water is useless compared with the effect of warm vapors. That leeches, which I used some- times in bad cases of feverish and croupous catarrh, thirty years ago, ever resulted in any good I am not prepared to say. But a promptly administered emetic (ipecac, sulphate of zinc or copper, turpeth mineral, apomorphia) has often relieved the spasmodic dyspnoea accompanying these (mostly nocturnal) attacks of pseudo-croup. The effect of emetics, however, and their indispensability have often been exaggerated. Mostly, they are less required for the relief of the babies than for tran- quillizing the fears of the mother and allowing the family physician to stay in bed. Chronic laryngeal catarrh may develop out of a protracted acute catarrh, or the affection may be primarily mild, but result at an early time in the thickening of tissue. Even at the earli- est age this process may be observed. One such case I saw with Dr. Hopkins, of Brooklyn, in a newly-born baby, which got well after the protracted daily administration of a few grains of DISEASES OF THE RESPIRATORY ORGAN'S. 473 iodide of potassium, but after several months only. Constant warm applications, or cold ones which are permitted to become warm, will favor absorption. Those which are complicated with, or perhaps dependent upon, a chronic pharyngeal catarrh are often favorably influenced by the use of tincture of pini- pinella saxifraga, half a drachm or a drachm of which may be taken daily, in ten or twelve doses, in a solution of chlorate of potassium, in such a way that the dose of the latter be a cau- tious one, and the dilution (in water) of the tincture be not ex- cessive. This drug has long been "obsolete," but deserves to be reappointed to its former place in practice. The majority of such cases will do well when being treated with solutions of bicarbonate of sodium or iodide of potassium, also of chloride of ammonium in daily doses of from eight to thirty grains (0.5-2.0). Diphtheritic Laryngitis, Pseudo-Membranous Croup. — It is not necessary to discuss here pathological questions, or to re- assert the histological identity of diphtheria and "croup." When phanmgeal diphtheria has reached the larynx in its de- scent, or bronchial diphtheria resulted in its ascent in sudden laryngeal stenosis, the usual antidiphtheritic treatment avails but little. That neither general nor local depletion has any effect, except that of hopelessly reducing the patient's strength, has long been recognized; also, that vesicatories add a new diphtheritic membrane on the surface to those on the mucous membranes. Emetics are of no use unless a peculiar flapping sound betrays the presence of half-detached membrane in the air-passages. In such a case they are apt to save life. At all events, I have never been so fortunate as to observe the univer- sally beneficent effect attributed to their frequent administra- tion in an average case. Massage of the larynx has been recom- mended by Bela "Weiss. I cannot say that the few cases in which I advised the procedure were successful; it may be that the constant repetition of the advice to use mercurial or other ointments over the larynx is based on the observation of an 474 THERAPEUTICS OF INFANCY AND CHILDHOOD. occasional good effect of the friction ("massage") attending their employment. Locally, lactic acid, in more or less satu- rated solution, has been eulogized as a solvent of the mem- branes in the larynx, when often applied either by brush or spray. Most of the cases in which I have seen it used were not successful, but this untoward result is, unfortunately, not ex- ceptional. I have seen, or believe I have seen, papayotin (1) to dissolve membrane when applied in a mixture of glycerin and water (aa 2). Particularly would that occur in pharyngeal diphtheria slowly descending. Lime-water is still used as a spray and has its admirers. Lime slaked in a small room, or under a tent, is decidedly more effective, for during that pro- cess a large quantity of lime is carried up and is inhaled; at the same time the softening and solvent effect of the steam is obtained. The latter is not always as beneficent as it appears. In many the application, externally, of cold water to the neck, or ice-bags, is vastly preferable. But in most cases of anaemic and highly-nervous children the latter are not tolerated. Con- stant inhalations of turpentine, or carbolic acid, from a kettle containing boiling water have impressed me as beneficial in a large number of cases. Inhalations, in a small room, or under a tent, of calomel, which is sublimated in doses of eight or ten grains (0.5), every hour or in longer intervals, are certainly effective. The patient remains in bed as much as possible, and may continue such expectorants as he perhaps took for previous catarrhal symptoms; may also take diaphoretics and warm bev- erages; an occasional opiate for that indication and to procure some rest. The continuation of chlorate of potassium, when the invasion of the larynx is complete, is rather superfluous. Antipyretics are out of the question unless there is a very high temperature depending on a complication (general diph- theria, pulmonary inflammations). Pilocarpine injures by de- bilitating the patient; the cases which are really benefited by it are excessively rare. Mercurials have resulted in more actual DISEASES OF THE BESPIEATOEY OEGANS. 475 recoveries than any other internal treatment. The cyanide and iodide have been recommended. For nearly twenty years I have employed the bichloride in doses of a milligramme (one- sixtieth grain) or more once every hour. The smallest babies take one-fourth or one-third of a grain daily for days in suc- cession easily. Almost never will a stomatitis follow, and no gastric or intestinal irritation, provided the dilution be in the proportion of at least one in eight thousand. An "occasional slight diarrhoea may require the addition of a few drops of camphorated tincture of opium. I can repeat a former state- ment, that never have I seen cases of croup getting well in such numbers, either without or with tracheotomy or intubation, as with mercurial treatment. When this treatment proves unsuc- cessful, intubation or tracheotomy must be resorted to. A small, frequent, and intermittent pulse, aphonia, cyanosis, and marked retraction, with every inspiration, of the supraclavicu- lar fossae and the epigastrium, are the indications for the opera- tive procedure. I shall not here be tempted to defend the two operations; I shall not even be tempted to discuss the crimi- nality of allowing a child to suffocate without resorting to mechanical relief; or to compare the two operations with each other. I can only say that for years I have not seen a case in which intubation would not take the place of tracheotomy, and have therefore not performed the latter. Intubation has come to stay; it is not one of the many temporary devices which have been brought out to be instantly forgotten. In most cases it takes the place of tracheotomy; in none does it make it impossible when required in the opinion of the operator. The latter operation may be preferred or become necessary for the purpose of getting at the trachea and bronchi for the mechani- cal removal of membrane and other local treatment, rare though the cases be in which such procedures are attended with success. It is probable that the many secondary trache- otomies which are still performed in Europe when intubation is alleged to be insufficient, will not be considered requisite in the future. 476 THERAPEUTICS OF INFANCY AND CHILDHOOD. In the consideration of pseudo-membranous laryngitis it should not be overlooked that in the vast majority of cases the Klebs-Loffler bacillus is found; and that all of these are, there- fore, fit subjects for the use of the diphtheria antitoxin. Since its introduction both general and local (laryngeal) diphtheria have been greatly benefited* In its Washington meeting of May, 1897, the American Pediatric Society received, the "re- port of its committee on the collective investigation of the anti- toxin treatment of laryngeal diphtheria in private practice/' Its salient points are as follows: The number of cases reported during the eleven months ending April 1, 1897, was 1704, — mortality 21.12 per cent. The cases occurred in the practice of 422 physicians in the United States and Canada. Operations employed: Intubation in 637 cases, mortality 26 per cent.; tracheotomy in 20 cases, mortality 45 per cent.; intubation and tracheotomy in 11 cases, mortality 63.63 per cent. Num- ber of States represented 22, besides the District of Columbia and Canada. Non-operative cases 1036, mortality 17.18 per cent.; operated cases 668, mortality 27.24 per cent. Two facts may be recalled in connection with these statements: First, that before the use of antitoxin 90 per cent, of laryngeal diph- theria required operation, under the antitoxin, however, 39.21 per cent. Second, that the percentage figures have been re- versed, formerly 27 per cent, represented the recoveries, now, under antitoxin, the mortality. The committee expects still better results when antitoxin will be administered earlier and in larger doses, and recommends that all cases of laryngeal diphtheria, the patient being two years or over, should receive as follows: Two thousand units at the earliest possible moment, two thousand units after twelve or eighteen hours unless there be an improvement, and the same dose twenty-four hours after the second dose if there be still no improvement. Patients un- der two years should receive one thousand or fifteen hundred units. Dr. Dillon Brown's personal experience being unusually DISEASES OF THE RESPIRATORY ORGANS. 477 large and carefully recorded, I add without comment the fol- lowing figures reported by him. He divided his cases into three classes: Previous to November, 1890; from November, 1890, to September, 1894 (calomel sublimation period); from Sep- tember, 1894, to April 1, 1897 (antitoxin period). Of 442 cases of intubation without calomel sublimations and without anti- toxin, 27.3 per cent, recovered. Of 295 cases of intubation with calomel sublimations, 41.6 per cent.; of 69 cases of intubation with antitoxin 67.8 per cent, recovered. Without sublimations, 10.1 per cent.; with sublimations, 13.2 per cent.; with anti- toxin, 23.3 per cent, recovered. During the first year with antitoxin there were recoveries after operation in 38.4; during the second year, 62.9; during the third, 94.7 per cent. The apparently bad results during the first year were probably due to two causes: inferior antitoxic serums and insufficient doses. Neurotic affections of the larynx of infants (and children) are quite frequent, particularly spasm of the glottis, under the influence of the inferior laryngeal nerve, which controls both the contractors and the dilators of the glottis. The treatment is directed by its manifold causes. Indigestion, both chronic and acute, is a frequent cause and should be relieved; particu- larly in neuropathic families the diet and hygiene of the infant are of the utmost importance. Fresh air, cautious exposure to cool or cold water, and early addition of liquid animal food to mothers milk or to the artificial feeding are of importance. Ehachitis, being the most frequent cause of laryngismus stridu- lus (p. 143), requires early attention; digestive disorders must be corrected, and the general irritability relieved by bromides or camphor. Monobr ornate of camphor may be given for weeks in daily doses of from one to three grains (0.05-0.2). Emo- tional disturbances, which will affect neurotic children at an early age, should be avoided. A screaming spell and fright will act as proximate causes. The attacks (some beginning with apncea, mainly those of laryngismus stridulus) must be watched, the baby taken up so as to ease the larynx, the head 478 THERAPEUTICS OF INFANCY AND CHILDHOOD. raised, the tongue (if aspirated and doubled up) drawn forward, the throat tickled, water dashed into the face, and chloroform inhaled if the local spasm be followed by a general convulsion. The influence of the thymus gland was discussed on p. 161. Paralysis of the glottis is not so frequent; in the infant quite rare, and very rarely congenital. Diphtheria, hysteria, and cerebral diseases, also whooping-cough, which should be re- lieved as much as possible, may give rise to unilateral or bi- lateral paralysis, anaemia may create a predisposition, glandular swellings prove a proximate cause. Complete paralysis depend- ing on that of both posterior muscles, which contract the glot- tis, produces a very severe dyspnoea, which is relieved during expiration but cannot be tolerated long. Intubation or trache- otomy may be demanded for immediate aid. Otherwise, atten- tion to the predisposing causes, reduction or removal of glands, and mainly the systematic application of the interrupted cur- rent through the breadth of the larynx will offer relief and gradual, sometimes rapid, recovery. Neoplasms of the infant's or child's larynx are by no means rare. Many of them are congenital; mostly so the numerous papillomata. Fibromata and enchondromata are also met with, and epithelioma has been observed. Sometimes they develop their first symptoms after an incidental inflammatory affection. The rules for their removal are about the same as in the adult, only the latter are more amenable to operations through the mouth. Indeed, none but older children can be thus treated. A. Rosenberg collected two hundred and thirty-one cases of laryngeal papillomata in children {Arch. Laryngol., v.). Laryngotomy gave 37 per cent, recoveries. In 38.5 per cent, there occurred relapses. Mere tracheotomy was performed in 34 cases; 4 recovered spontaneously afterwards; endolaryngeal treatment after tracheotomy exhibited a permanent cure in 12, temporary improvement in 1, and relapses in 3 cases. Exclu- sive endolaryngeal treatment gave a complete cure in 50 per cent, of children under four years, 70 per cent, between four DISEASES OF THE RESPIRATORY ORGANS. 479 and eight, and 50 per cent, of eight years and older. According to these figures, endolaryngeal treatment is preferable unless there be a dangerous degree of dyspnoea which could be treated with intubation; tracheotomy with subsequent endolaryngeal treatment would be the next choice, and laryngotomy would be reserved for very serious and unusually urgent cases. Still, it appears that the latter will be preferred by all who do not claim great specialists skill and have no hospital at their disposal. Laryngotomy is performed with or without previous trache- otomy, according to surgical rules, exactly as for the extraction of foreign bodies. There is one danger more urgent in infants and children than in adults; that is hemorrhage, slight or copious. Blood flowing down into the narrow air-passages, even in small quantities, is liable to result in lobular pneumo- nias of a dangerous character. The operation should, there- fore, not be performed without a thermocauter or electrocauter ready for immediate use. Foreign todies in the larynx should be removed through the mouth if possible; if not, by laryn- gotomy. In order to facilitate the exit of a foreign body from the trachea or the bronchi tracheotomy is demanded, after which it is best not to introduce a tube, except temporarily. The trachea may then be sewed to the integuments, or may be kept open by hooks joined by an elastic band, according to A. Caille. Congenital stricture of either the larynx or the trachea (rare, fortunately) may be mistaken for laryngeal tumor. 3. The Bronchi. Bronchial catarrh, bronchitis, in all its localizations, from the windpipes of large size down to the capillaries, requires an equable temperature of about 70° F., moist air, and rest in bed, though there may be no fever except a slight one towards evening. Plenty of water, — no ice, — preferably alkaline mineral waters, should be given; older children may be prevailed upon to take gum-arabic water, flaxseed tea, or other glutinous decoc- 480 THERAPEUTICS OF INFANCY AND CHILDHOOD. tions which, relieve the accompanying pharyngeal irritation. Mitigated mustard-plasters (mustard 1, flour 4-8) or embroca- tions of turpentine are used to advantage. Underclothing must be changed when moist with perspiration. A cotton-batting wrapper round the chest (the sheet spread out and two arm- holes cut into it) acts favorably both by keeping up a uniform temperature and by gently irritating the surface. As a rule, it acts better than warm poultices, which are liable to moisten the clothing and bedding, and thus add discomfort and the dan- ger of a new attack. Where, however, the surface is dry, they may be applied, or, better still, in most cases, a sheet of one or two thicknesses well wrung out of cool water, wrapped round the chest and changed every hour or half-hour after it has got hot. Bicarbonate of sodium from ten to fifty grains (0.6-3.0) daily, according to age, and an equivalent of a grain of ipecac distributed over the day, or (and) from ten to twenty grains (0.6-1.5) of ammonium chloride with extract of licorice in repeated doses during a day when expectoration is viscid and requires liquefying, will answer in most cases. Apomorphia one one-hundred-and-twentieth grain (0.0005) every two or three hours will act as an expectorant, so will terpine hydrate in frequent doses of one-quarter to one-half grain (0.015-0.03), particularly in chronic catarrh. Complication with asthma and insufficient expectoration is benefited by iodide of potas- sium in daily doses of four or fifteen grains (0.25-1.0). Insuffi- cient expectoration with general debility demands the car- bonate of ammonium (gr. J-l == 0.015-0.06) every half -hour or at longer intervals, aq. camphor (one-half to one teaspoonful) often, or camphor (gr. J-l = 0.01-0.06) every half-hour to every two hours in diluted mucilage. The German preparation of liquor ammon. anisatus has been introduced into the Formu- lary of the American Pharmaceutical Association; from two to six drops may be taken every hour or two hours. Accumulation of mucus in the bronchial tubes, with inability to expectorate and danger of suffocation, may demand an emetic, and asphyxia DISEASES OF THE RESPIRATORY ORGANS. 481 cold affusion and raising the infant and carrying him about: frequent change of position is advisable in every severe case. When, in bad cases of capillary bronchitis, cyanosis is on the increase, and the voice has not been heard for some time, it is absolutely necessary to make the baby cry. Slapping with a wet handkerchief, swinging, or closing the nares for a few moments, and all the means recommended for the asphyxia of the newly-born, are demanded. The interrupted electric cur- rent may be used with the rules and restrictions recommended above (p. 93). Cough, when irritating and harassing, requires narcotics. Small doses of an opiate at regular intervals, or (and) a larger one at bedtime, or repeated doses of extr. hyoscyam. (grs. 1-1^ = 0.06-0.1 altogether through the day), and an opiate for the night, act very beneficially. The chronic form of bronchial catarrh demands similar medi- cation. Preventive measures are the habitual use of cool or cold water and the treatment of such constitutional disorders — for instance, rhachitis — as are known to create a predisposi- tion. Terpine hydrate, and of terebene ten or twenty drops daily, will act well. Chloride of ammonium may be evaporated on a hot stove or tin enough to penetrate the whole room (no tent required) and inhaled. Turpentine inhaled with steam or spread on sponges or towels is also useful. The pneumatic treatment (inhalation of compressed air) has been recom- mended again by Biedert; it finds its principal indications in atelectasis and peribronchitis. The frequent complication with pharjmgeal catarrh demands the local treatment of the fauces; a mild solution of nitrate of silver (1 : 500) may be used as a spray once every day or every two days. TYlien tuberculization is feared, the protracted use of cod-liver oil, guaiacol several times daily, in two- or four-drop doses (or creosote), together with a change of climate, preferably moderate altitudes, are indicated. Fibrinous bronchitis is by no means so rare as it was formerly reputed to be. Indeed, during epidemics of diphtheria it is not uncommon. Still, the pseudo-membranes found in the 31 482 THERAPEUTICS OF INFANCY AND CHILDHOOD. bronchi are not always of the same nature. While some are diphtheritic, others consist of dry and coagulated mucus re- sembling the membranes of "enteritis membranosa." In ac- cordance with this difference of the prevailing condition, a case may last days or months. Antipyretics are still less indicated than in the common forms of bronchitis. Mercurial treatment like that required in diphtheritic laryngitis of every variety (p. 476) is the most reliable internal remedy. Inhalations of steam, frequently repeated or kept up constantly in urgent cases, inhalations of turpentine with or without steam, of chloride of ammonium, often repeated, and fumigations through one or two days of from five to fifteen grains (0.3-1.0) of calomel (when dyspnoea is urgent, every hour or every few hours, under a tent) will act well. The internal use of iodide of potassium in daily doses of from ten to fifty (0.6-3.0) grains, and in cases of undoubted bacillary diphtheria (p. 253), anti- toxin are indicated and useful. Bronchial catarrh, croup, and some forms of pneumonia are proximate causes of a collapse of pulmonary tissue, atelectasis, the congenital and postnatal varieties of which have, been treated of before (p. 94). The predisposing causes are general atrophy with its muscular debility, and rhachitis through its narrowing the shape of the thorax. In this condition, replete as it is with imminent danger, the baby must be carried about, the posture in bed must be changed frequently, he must be made to cry, electricity should be used, and, besides an occa- sional emetic, stimulants such as alcohol, camphor, ammonium carbonate, and musk should be employed frequently and copi- ously. The nature and symptoms of asthma do not differ from those of the same affection in adults; nor does the treatment. Swell- ing of the mediastinal glands, and hypertrophy of the tonsils, flatulency which impedes the free movements of the diaphragm ("asthma dyspepticum"), peribronchitis, emphysema, which is by no means rare, and nasal reflexes are the main causes, and DISEASES OF THE RESPIRATORY ORGANS. 483 should be attended to. In the latter class of cases brushing the mucous membranes of the nose and pharynx with a cocaine solution of from two to ten per cent., or the use of cocaine spray, may, in appropriate cases, relieve an attack; the cauteri- zation (actual, or chromic acid) of the hypertrophied tissue and the removal of a polypus may occasionally be the only things required for an actual cure. Unfortunately, this class of cases is not so numerous as it was believed to be a number of years ago. Those depending on peribronchitis and emphysema are more frequent. In them the protracted use of three daily doses of from two to five grains (0.125-0.3) of potassium iodide, to- gether with a sufficient bedtime dose of chloral or of an opiate to meet the night attack, will have favorable results. Tincture of lobelia, two or three drachms (8-12 cubic centimetres), fluid extract of quebracho or of grindelia, one or two drachms (4-8 cubic centimetres) daily, will often have a beneficial effect in distressing dyspnoea. The inhalation of stramonium, of nitrate of potassium paper, or of pyridin vapors is often resorted to; unfortunately, with so little permanent result as to give any number of proprietary medicines and nostrums a large field of activity. The treatment of enlargement of mediastinal glands, of tonsils, and of flatulency was discussed in other chapters. The periodic night cough, described as a special variety in some of the books, is either a mild attack of asthma or is pharyngeal or tubercular; most pharyngeal coughs, however, are met with in the morning, after waking up. These noc- turnal attacks may be obviated by a drink of alkaline water at bedtime, to be repeated at every waking up, and by a dose of a bromide, or of chloral, or of an opiate at bedtime, and by atten- tion to indigestion and constipation. Quinine is useless. 4. The Lungs. Pneumonia. — There are three anatomical varieties of pneu- monia in infancy and childhood: the catarrhal or lobular, the fibrinous or lobar, and the interstitial. Nearly two-thirds of 484 THERAPEUTICS OF INFANCY AND CHILDHOOD. the cases belong to the first, one-third to the second, and a limited number to the third class. Not one of them, how- ever, is always found pure and uncomplicated. Indeed, com- plications of the lobular with the lobar, of either of them with the interstitial, and possibly of each of the three with pleu- risy, are quite numerous. The lobular form is almost always, the lobar quite frequently, preceded by bronchial catarrh, which has its well-understood sources in previous attacks, in exposure, sudden changes of temperature, local irritation by foreign bodies, rhachitical or tubercular mediastinal and bron- chial glands, diphtheria, measles, influenza, typhoid fever, whooping-cough, etc. Thus, the preventive treatment of pneu- monia has its positive and distinct indications. Nasal catarrh is never so slight as not, possibly, to endanger the lungs. Rha- chitis, glandular tuberculosis, measles, and whooping-cough must not be left alone to find their slow road to their legitimate termination for better or for worse. Every child, while well, should be armed against the results of exposure by regular in- vigorating ablutions and frictions with cold water, and when exposure has taken place and the consequent fever made its appearance, a warm bath, acetate of ammonia, camphorated tincture of opium, tincture of aconite, hot drinks, salicylate of sodium, or another one of the antipyretics and diaphoretics, with uniform temperature and rest in bed, may be the means of preventing pneumonia. The treatment of pneumonia is not yet influenced by modern views on etiology. The attempts at procuring immunity in animals by the blood-serum of pneumonic patients, thus es- tablishing a serumtherapy, may prove more successful, when more will be known. The large number of microbes which are found in pneumonia, pneumocoecus, diplococcus lanceolatus, streptococcus and staphylococcus, and others, do not yet justify the abrogation of pneumonia as an inflammatory process, and the claim that it is only a process of germ-culture in which the air-cells act as culture-tubes and the functional circulation as a DISEASES OF THE RESPIRATORY ORGANS. 485 culture medium, while the nutrient circulation maintains the integrity of structure without taking an essential part in the pneumonic process. Lungs of children who did not die of pneumonia, also those of recently killed domestic animals (Diirck in D. Arch. Min. Med., 1897, vol. lviii.), contained the diplococcus pneumoniae and the mixture of bacteria met with in pneumonia. Pure cultures of bacteria blown into healthy lungs gave Diirck no pneumonia, irritant dust did; so did cul- tures and dust mixed. Here, as almost everywhere in bacteric etiology, it is not the presence of ever so many ever so virulent microbes, but their fixation and their ability to generate toxins which deserve credit for morbid tissue changes. Acute lobular pneumonia is less a systemic disease than is the lobar form; its direct and immediate influence on the nervous and muscular, inclusive of the cardiac, systems is less marked; it is not so frequently complicated with pleurisy. Thus, there is less danger at first in lobular pneumonia; there is more at a later period, because its duration is liable to be so long as to make the prognosis uncertain. The danger may come from the heart, but it mainly lies in suffocation, which depends less on the extent of inflammatory exudation than on collateral congestion and oedema. Interstitial pneumonia runs the most protracted course. Fever is liable to be high and prolonged over weeks and months; recovery is but rarely complete, induration and re- traction of the pulmonary tissue, with bronchiectasis, being quite common. Thus, it becomes evident that no uniform course of treat- ment can be dictated either for all forms of pneumonia or for all cases. The former are several, the latter are individual. After all, the patient is to be treated, and not the Greek name of his disease. Still, there are certain rules which ought to be enforced in every case. Insist upon absolute rest of body and mind, exclude visitors, light, and noise. 486 THERAPEUTICS OF INFANCY AND CHILDHOOD. Keep the temperature of the room between 68° and 72° F. and the air moderately moist. Let the patient select his own position. Isolate a lobar case. Give liquid food, and plenty of water, or lemonade, or hy- drochloric acid and water. Believe the circulation from accessory incumbrances; a dose of calomel will facilitate the action of the diaphragm by empty- ing the bowels and relieving flatulency, and will diminish the tension of the arteries. The main dangers in acute pneumonia are: high tempera- ture, heart-failure, and suffocation, which may result from the condition either of the lungs, or of the right heart (the left not being at fault so often as it is in the adult), or of both; also complications like that with nephritis, which is either a coinci- dent or the result of toxic (pneumococcic ?) infection. Which degrees of temperature may be allowed to last, and which are to be interfered with? Is it 103°, 104°, 105° F.? It is well understood that persistent high temperature disinte- grates tissue, but this effect is not equally observed in all cases. Many a child bears 104° quite easily, while others succumb to 103°. Moreover, a temperature which is badly borne the first day or two appears to be an indifferent matter afterwards. Thus, an antipyretic treatment may be indicated at first and be no longer required later, particularly in those cases which exhibit a decided morning remission; for it is mainly a persistent height of temperature that is injurious, not its occasional, though regular, rise. That is why, for instance, relapsing fever, with its enormous temperatures but complete and long intermissions, has only a small mortality. The custom of depressing temperatures in all cases which ex- hibit a temperature of 103° F., or thereabouts, is bad; it is not the temperature that is injurious, but the absence or insuffi- ciency of resistance that the tissues offer to its action. To lower temperature we have er number of remedies. The latest DISEASES OF THE RESPIRATORY ORGANS. 487 additions to our antipyretic treasures are very well known and too universally employed. Phenacetin, antipyrin, and ace- tanilide have more frequently lowered temperatures than they have saved lives. Their doses, uses, and dangers are well un- derstood by all practitioners. Wherever they are found in- competent, their combination with quinine has proved more effective. The latter, by itself, is, however, no longer the sine qua non which it was formerly believed to be. In all cases with marked remission it acts well, but it is during the re- mission only that it should be given. Half a gramme to a gramme (grs. 8-15) may be thus employed. It may be used internally or hypodermically. Now and then injections into the rectum, or suppositories, are required or advisable when the stomach cannot be relied upon. The preparation to be used in the rectum must be one of those which are most soluble: the bisulphate, muriate, bromide, or carbamide. No acid should enter into the solution; large quantities of glycerin are objec- tionable. The rectal dose should be at least fifty per cent, larger than that employed internally. The internal administration is often hindered by the taste of the drug. Thirty parts of the compound known as elixir simplex cover the taste of one part of the sulphate, provided the mixture is made with each dose and not kept ready; thus, the drug should be prescribed in the form of a powder, to be mixed with the elixir when needed. Preparations of coffee, either infusion or syrup, hide the taste of quinine quite well; so does, to a certain extent, licorice extract; so does choco- late. The neutral tannate of quinine is tasteless, but the dose should be two and a half times larger than that of the sulphate. The muriate agrees best with an irritable stomach, the bromide with an impressible brain. The latter is slower in producing cinchonism. The best preparation for hypodermic injections is the carbamide of quinine, which dissolves easily in four or five parts of water, remains in solution, and yields no deposits of quinine in the subcutaneous tissue. I have employed it for ±88 THERAPEUTICS OF INFANCY AND CHILDHOOD. at least a dozen years, and observed serious local irritation in but one instance. The best antipyretic is cold. Its use has been praised and condemned, as everything deserves to be that is employed either properly or thoughtlessly. Most cases will do quite well with sponging, or with friction by means of wet and cold towels. The latter plan acts both as a refrigerant and a stimu- lant. Cold bathing was once eulogized immensely, then ab- horred and warm bathing substituted. The rationale of cold bathing is the cooling of the surface (that is, of fourteen square feet in the adult; more than proportionately that in the young) with its immense surface circulation. So long as this circulation continues active, new blood will come to the surface every moment, and the whole body is thereby cooled. TVhen it is no longer active, the heart weak, and the extremities cold, cold bathing is dangerous. The rule I have always followed is this: no cold bath for cold extremities: no more cold bathing when once, after it, the extremities remain cold or cool. In these cases after a cold bath the surface becomes colder than before, it is true; the interior, however, warmer than it was. I have reported the case of a little child, twenty years ago, who was the first to teach me that lesson. A few cold baths had reduced his temperature and his tendency to convulsions. Then another seemed to be indicated. It appeared to render the required service, but the baby became convulsed. The temper- ature in the rectum had risen from 104| o to 106° F. A hot bath, instantly given, restored the external circulation, and ten minutes afterwards the rectal temperature was below 102°. A great promoter of circulation, and thereby of radiation from the skin, is surface warmth, and particularly warm ex- tremities. "Warming-pans ought always to be applied to the feet and legs when cold is to be employed on the rest of the body. In place of cold bathing, I have mostly employed cold packing from the chest down to the thighs, the arms usually outside the pack. Xothing is easier than to wrap a baby up in DISEASES OF THE RESPIRATORY ORGANS. 489 a single wet towel, which is covered by a small blanket; in an urgent case it should be replaced by another one (spread out beforehand) every two or five minutes. From twenty to forty minutes' packing will reduce the temperature from 106° to 101° F., and below. In many instances the rapidly falling temperature demands artificial warming immediately after- wards. When the frequent changing of the pack is undesirable, the cloth may be allowed to remain, and is frequently cooled by rubbing a piece of ice over the whole surface. If water col- lect under the patient, it can easily be absorbed by towels or sponges. A temperature of 108° in a baby of four months, suffering from pneumonia, was reduced to 104° in twenty- five minutes; after that it sank rapidly to 94J°, and artificial warming of the surface was required. From what has been said it is evident that very feeble and anaemic babies do not tolerate cold, though their temperature be ever so high; in such cases a warm bath, or tepid packs either with water or alcohol and water, or a warm bath gradu- ally and gently cooled down while the little body is constantly being rubbed, should take the place of the cold pack; or cold applications to a part, perhaps the anterior aspect of the chest, are found to suffice. They both reduce temperature and relieve local pain. In many cases a light ice-bag over the heart acts both as a refrigerant and a stimulus to the organ at the same time. The acceptance of these views I urgently recommend to those to whom they are in part new. Before and after 1870, when I recommended {New York Medical Record) cold water in typhoid fever, scarlatina, variola, ophthalmia, diphtheritic conjuncti- vitis, diphtheria, lobar and other pneumonia, heart-disease, local inflammations, phlegmon, synovitis, and peritonitis, I had ample opportunities to test what I am here advocating. Those who want to inform themselves thoroughly on matters connected with this subject I refer to Dr. Simon Baruch's well- known book, and other writings. 490 THERAPEUTICS OF INFANCY AND CHILDHOOD. The heart furnishes urgent indications for treatment in many cases of pneumonia. When in a healthy condition, its innervation and force are not easily disturbed; still, every pul- monary disease taxes its powers. Lobar pneumonia requires cardiac stimulation at an earlier period than the lobular kind. There is none, however, but demands it at some time or other. That being the case, I earnestly advise not to wait, for heart- failure is more easily prevented than cured. Be our treatment ever so expectant, it must not be indolent and indifferent. In order to correct the faulty pulmonary circulation the heart should be stimulated at an early period. But how? Alcoholic beverages are employed for this purpose by many, for alcohol is certainly a cardiac stimulant; it is believed by many to lower arterial tension, — a function which is doubtful, at least in pure inflammatory disorders; moreover, it is believed to be an article of food. In the small quantities in which it is administered it certainly is not. Much of it is eliminated unaltered through the lungs, which are thus burdened with that additional labor while in a condition of congestion and incompetency. Besides, kidney complications, which are not rare in pneumonia, and brain affections, which are frequent, particularly in small children, contraindicate the use of alco- hol. I dare say that the pneumonia of a fairly developed in- fant or child contraindicates rather than demands the adminis- tration of alcohol at an early period of the disease. Later, when the conditions change, alcohol may be required in large doses, always, however, much diluted. A recent writer has indeed proclaimed that the doses of alcohol given by medical men in the diseases of children are in direct proportion to their ignorance, but epigrammatic pronunciamentos do not yet re- move alcoholics from among the stimulants. Digitalis stimulates and contracts the heart, but also the arteries, both the largest and the very smallest, and thereby increases the peripheral resistance. A few large doses may restore the equilibrium of the faltering circulation, and should DISEASES OF THE RESPIRATORY ORGANS. 491 then be stopped. I have not infrequently given the equivalent of from one to four grains of digitalis (0.06-0.25) in a single dose, which was repeated once or more times. This mode of administration insures all the coveted effect on the heart and pulse without any irregularity, and gives both a result in a few hours and the indication to cease, while the usual small doses exhibit their action after days only. ^Ye may afterwards con- tinue its use in small doses, either alone or in combination with strophanthus, sparteine, or caffeine, all of which have no such disagreeable effect on arterial tension as digitalis; or we may give them without digitalis. To give doses of tincture of strophanthus of less than a drop, or sparteine sulphate of less than one-quarter or one-eighth of a grain, every hour or two, is useless. Such effect as we require we have a right to demand speedily, and the doses should be large enough to enforce it. Whenever the peripheral circulation becomes insufficient, with small pulse, digitalis alone must not be continued; it should be combined with nitroglycerin or sodium nitrite, the former in hourly or bihourly doses of from one five-hundredth to one one-hundredth of a grain, the latter in doses of from one-tenth to one-quarter, or these remedies may be given alone until the pulse is revived. They are principally required when the feebleness of the heart is mainly perceptible in the right ventricle. There are cases of pneumonia in which the arterial pulse is good, but the external veins large, the nails blue, the skin cyanotic, with great dyspnoea and pulmonary oedema, to- gether with perspiration, increased cardiac dulness, enlarged liver, intestinal oversecretion, and albuminuria, — symptoms which point directly to incompetency of the right ventricle. In these cases the external circulation must be restored at once, and the nitrites will contribute to fulfilling that indication. So will diuretin in doses of from two to ten grains (0.125-0.6) administered from three to five times a day. Besides, local depletion by leeching will sometimes do good. In the adult we should open a vein; a child of advanced age may also be saved 492 THERAPEUTICS OF INFANCY AND CHILDHOOD. in this way. Once, and once only, when I was younger than I am to-day and more courageous or less cowardly, I opened the engorged jugular vein of a young child suffocating from pneu- monia. The tenement-house people for whom I did it thought it the proper thing and nothing else, while I was not quite so confident: the child got well. Cupping, both dry and some- times wet, large sinapisms, and mustard baths will serve a good purpose. Concerning the latter method, Dr. L. Weber pub- lished an elaborate article some fourteen years ago. "General mustard bathing I have now and then resorted to in severe inflammations of the lungs, as well as in those of the brain. I prepared a hot bath and threw mustard into it ad libitum in order to produce a very powerful derivation to the skin in a very few minutes, and I think it had most beneficial re- sults."* It is in these cases also that the inhalation of oxygen (better through the nose than the mouth) and artificial respi- ration will contribute a great deal towards saving time and life. The distressing cases of catarrhal pneumonia engrafted upon the extensive bronchial catarrh or capillary bronchitis of the very young will sometimes get well only after we shall have succeeded in making them cry, together with artificial respira- tion, inviting the respiratory muscles to reflex efforts by dash- ing cold water on them, using for brief moments the inter- rupted current, etc. Direct stimulation of the heart may require the use of strychnine in small and frequent doses (a baby of one year not often more than a thirtieth of a grain — two milligrammes during twenty-four hours), and carbonate of ammonium one- half of a grain or a grain (0.03-0.06) in anise-seed water or in milk every half, one, or two hours. In cases of urgent neces- sity the stimulants should be used subcutaneously, the sulphate of strychnine in repeated doses of one one-hundredth grain at * Jacobi, in New York Medical Record, August 15, 1870. DISEASES OF THE RESPIRATORY ORGANS. 493 least, the salicylate (or benzoate) of sodium and caffeine in doses of from one to five grains (equivalent to one-half of that amount in caffeine) every one or four hours; camphor will serve the same purpose. Its solutions in alcohol or ether are quite painful. I always employ it in four or five parts of sweet almond oil; of this I inject from six to twenty drops, according to indications; very slowly, because it passes through a fine needle with more difficulty than does a watery solution. In connection with these remarks we are enabled to judge of the claims of the routine treatment with strychnine, digi- taline, and aconitine which was imported a few years ago. It is easily perceived that it finds its indications like a ready-made coat which fits many, but not all, and would not be worn unless first tried on. But, a coat is not so easily believed to fit every- body as is a newly eulogized treatment. When, during hepatization and the period of incipient reso- lution, expectoration is insufficient, the remedy is inhalation of steam, with or without turpentine. The latter may be spread through the room by means of large sponges, or on towels which are soaked with it, or it may be evaporated on boiling water. The easiest way is to fill the whole room with the vapor. Inhalers are insufficient and annoying. Give camphor, aqua camphorse in teaspoonful doses or more, or one-quarter- to one- grain doses in diluted mucilage, or benzoic acid powders in the same doses, or ammonium carbonate. Ipecac may derange the stomach, senega is either an adjuvant or a placebo. Drinking of plenty of water, mainly alkaline waters, — Seltzer, Vichy, Poland, — also doses of bicarbonate of sodium or iodide of potas- sium, will increase and liquefy the bronchial secretion. Am- monium chloride is of but little use in hepatization; but evaporated in amounts of ten or twenty grains every few hours on a hot stove or over a flame, it fills the room with a white cloud which greatly stimulates the bronchi. Warm poultices will serve the same purpose. Their place is .during hepatiza- tion for the purpose of aiding absorption, not in the first stage 494 THERAPEUTICS OF INFANCY AND CHILDHOOD. of pneumonia. When nursing is insufficient, and there is dan- ger of wetting the clothing and bedding, it is best to substitute for them a cotton-wadding jacket, covered or not with oil silk or, better, flannel, which protects against exposure and keeps up a uniform temperature of the skin. Pleural pain is relieved by gently strapping the chest, when tolerated, — it mostly is, — by sinapisms, which must be kept on a few minutes only and repeated from time to time; warm poultices; a few doses of sodium salicylate or phenacetin; in urgent cases by a subcutaneous injection of morphine. Vesica- tories are injurious; they chafe, irritate, and annoy. Their only — rare — indication is in the long persistence of hepatization, with or without chronic pleurisy. Irritating, hacking cough demands small doses of opium. Much of this cough is pharyngeal, and is relieved by frequent drinking of small quantities of water. Sleeplessness and great general irritation demand a dose of opium for the night. A sleep of an hour or two affords great relief to the cough and to all the symptoms. As a general rule, however, the habit of giving opium in the first stage of pneumonia is a bad one. Rest should not be bought with death. The bad odor of complicating gangrene demands inhalations of turpentine, eucalyptol, or carbolic acid; the presence of ab- scesses in the lung demands surgical interference, unless there be a spontaneous rupture through a bronchus. Most abscesses are within reach of the knife and actual cautery, for generally there is a sufficient amount of pleural adhesion to render access devoid of much danger. Complication with malaria, which is rare, requires quinine; intermittent pneumonia, which is also uncommon, quinine and ergot; complication with nephritis contraindicates digitalis and alcohol, and suggests the substitution therefor of sparteine, camphor, and nitroglycerin; in atelectasis the stronger stimu- lants are required, and artificial respiration by the different methods; the patient should be made to cry; cerebral disease, DISEASES OF THE RESPIRATORY ORGANS. 495 while acute, indicates ice and purgatives, and bromides; when chronic, iodide of potassium. Hypostasis and hypostatic pneumonia, so common in infec- tious diseases and in conditions of great debility, require fre- quent changing of position from one side to the other and the early administration of stimulants in large doses, together with friction of the entire surface with cold or hot water, or with alcohol and water. The most powerful of all internal stimu- lants — Siberian musk — should be given frequently, — viz., every half to one or two hours, — in doses of from one-half to two grains, until from six to fifteen grains (0.4-1.0) have been taken in the course of half a day. Interstitial pneumonia is treated on the general principles laid down before. Later, iodide of potassium in sufficient doses, a mild tincture of iodine externally, and an occasional vesica- tory. When it has become chronic, digitalis may be given for months in small doses to keep up both a sufficient circulation through the indurated lung and a competent nutrition of the heart muscle, and iodide of potassium alternating with iodide of iron. Persistent and careful pulmonary gymnastics should be continued for years. Emphysema of the infant lungs, sometimes not easily diag- nosticated because of the size of the liver and of abdominal tympanites, and never unless percussion be performed very, very gently, is often overcome by the elasticity of the pul- monary tissue, and therefore its prognosis, no matter whether produced by forced inspiration (in pneumonia) or by forced ex- piration (severe attacks of coughing), or even that rare form which results from ill nutrition of the alveoli, is not so bad as it mostly is in adults. Its treatment is that of chronic catarrh, and by gymnastic exercise of the respiratory muscles and gen- eral roboration. Besides, forcible expiration ought to be prac- tised extensively; during expiration the chest wall ought to be well compressed. Snuff should be used half a dozen times daily, and copious sneezing procured. Expiration into the rarefied 496 THERAPEUTICS OF INFANCY AND CHILDHOOD. air of one of the many pneumatic apparatuses is also recom- mended. It may be tried on tractable children. Pulmonary cedema requires the causal treatment of its origin, which can be traced to cardiac, pulmonary, or renal disease. Urgent cases — for the disease may prove fatal in a short time — require dry cupping, now and then the emptying of the lungs by an emetic (apomorphine subcutaneously when vitality is low and the expelling muscles are unable to act), and stimulation of the excreting organs and of the heart. A powerful purga- tive — calomel, croton oil, or elaterium — is an active derivant. Digitalis in large doses (a few minims of the fluid extract at once) will stimulate the heart. The salicylate or benzoate of sodio-cafreine in subcutaneous injections, one to five grains (0.05-0.3), repeated five or six times at intervals of fifteen min- utes, acts beautifully. Acetate of lead stops oversecretion in a good many instances. Pilocarpine (one-twentieth to one-sixth grain) subcutaneously has relieved, and saved, many a case re- sulting from renal disease. Pulmonary hemorrhage is not frequent, for tuberculosis of the young lung produces induration and vascular obstruction rather than cavities; and though whooping-cough gives rise to hemorrhages, they are tracheal and bronchial rather than pulmonary. Cardiac diseases may lead to venous obstruction and thereby to hemorrhages. Digitalis, lead, alum, ergot, nar- cotics, mainly opiates in quieting doses, and ice temporarily to the chest, with a hot (mustard) bath of the lower half of the body, as well as absolute physical and mental rest, are indicated. Demelin collected twenty-two cases occurring in the newly- born (Rev. Obst. Internat., January 1, 1897). They were either speedily fatal, or gave rise to alleged melaena (blood swallowed). Infarction, with its sudden onset and vehement dyspncea (sometimes chill), is the result of embolism, in the newly-born, from the umbilical vein or the ductus arteriosus; later, from a marantic thrombosis of the sinus, the renal, femoral, or portal vein, or from caries of the petrous or some other bone; from DISEASES OF THE RESPIRATORY ORGANS. 497 valvular disease, from an infectious malady, or from an ex- tensive burn. The causal indications must be obeyed, if possi- ble. Ice applications to the affected part, opiates and digitalis, and stimulants when required, symptomatic treatment after- wards (antipyretics). Some of the cases are followed by gangrene. This condition, however, generally results from the presence of foreign bodies, from acute infectious diseases, — diphtheria, measles, noma, typhoid, — or from (mostly lobular) pneumonia. A few cases are also on record as having resulted from careless pneumatic treatment. Mineral acids largely diluted with water, as also quinine and lead, have been copiously used. Besides stimulants given to the required extent, I have relied mainly on inhala- tions of turpentine, either from a paper bag in which a sponge was kept soaked, or from a kettle with boiling water, or of terebene; internally, of terebene, from twenty to fifty drops daily, or creosote a few drops daily. Such pseudoplasms as have been or may be observed in the young lungs demand treatment on general principles. Carci- noma has been noticed a few times, also in the mediastinum. Sarcoma is more common, mostly in the pleura. The treatment should consist in increasing doses of arsenic, and in the injec- tion, according to Coley, of the toxin of the coccus erysipela- tos and bacillus prodigiosus. Ecliinococcus of the lungs and pleura (fluid without albumin and sodium chloride, and with scolices) demands free incision, resection of a rib, and drainage. Puncture and the injection of Lugol's iodine solution do not suffice. Actinomycosis has been reported by Soltmann; the case occurred in the posterior mediastinum of a boy of six years. Hernia of the lungs has been observed below the clavicle and on the back. The soft elastic tumor changes its size with res- piration. In such cases the lung is either normal or emphy- sematous. The cough disappears after the application of proper bandages. Deformities of the chest wall, with or without a defect in bones or muscles, particularly the funnel chest, in 32 498 THEBAPEUTICS OF INFANCY AND CHILDHOOD. which the lower part of the sternum is so drawn in as to almost touch the vertebral column, can never be removed, but the consecutive contraction of the intrathoracic space can be partially counterbalanced by systematic gymnastics and func- tional improvement of the lungs at an early age. 5. The Intrathoracic Lymph-Bodies. In close connection with the congestive and inflammatory diseases of the thoracic organs are many changes in the bron- chial and mediastinal lymph-bodies which can more easily be prevented than cured. A protracted catarrh of the bronchi results in glandular hyperemia and hyperplasia; a nasal ca- tarrh of the newly-born and the nursling descends rapidly with the same effect, or the consecutive glandular tumefactions of the submental and submaxillary regions implicate the adjoining tiers of lymph-bodies; rhachitis, scrofula, and tuberculosis are also causes of bronchial and mediastinal adenitis. Bacilli may reach the lymph-bodies though the mucous membrane of the bronchi though its epithelium be intact. Pressure on veins and nerves, also on the trachea; attacks of coughing without crow- ing inspiration; fremitus, feeble or increased; respiration, in- creased and bronchial, or feeble; dulness over the sternum down to the second rib, but not extending to the exterior mar- gin of the lungs; dulness posteriorly about the hilus of the lungs, more marked to the left than to the right (location of thoracic duct on the left), are among the principal symp- toms. Pressure on the trachea, or on one of the large bronchi, may be such as to cause an actual stenosis and suffocation. Fever, if present, depends on complications or on absorption from the glands while undergoing changes. Antirhachitical, antiscrofulous, and antitubercular treatment are the indica- tions. Mercurial ointment, iodide of potassium ointment, in- unction of green soap, iodide of potassium internally, iodide of iron, increasing doses of arsenic, ice externally if there be any local pain, and the treatment of sequela? or complications (ca- DISEASES OF THE RESPIEATOEY ORGANS. 499 tarrh, lobular pneumonia, dyspnoea, protracted fever) are de- manded, but will not always prove successful. 6. The Pleura. Pleurisy is of frequent occurrence during the first decade of life; empyema is, indeed, more common during infancy and childhood than in advanced age. The majority of cases of pleurisy which occur in the newly-born are of pyaemic origin, and depend mostly on umbilical phlebitis; still, cases with serous, and the usual forms of purulent, secretion are not un- common in the very young. Pleuritis may be the direct result of exposure ("cold"), of contusion, of broncho- and fibrinous pneumonia, or of pericarditis and peritonitis. It frequently accompanies pulmonary tuberculosis, diphtheria, acute rheu- matism, and eruptive fevers. Thus, there is but rarely a causal indication for treatment; prevention is best secured by giving the utmost care to the management of those diseases which cause its outbreak. Its symptoms are often deceptive, for even pain is not always present, though it is one of the most frequent occurrences. The pain is sometimes quite local; at other times, however, it extends over a large surface. Its locality does not always correspond with the seat of the pleuritis. The exten- sion of the peripherous ramifications of the intercostal nerves is so great that the children often complain bitterly of epigas- tric pain down fo the umbilicus on the affected side. The disease requires absolute rest and immobilization of the chest. Broad strips of the usual varieties of adhesive plaster, which irritate the surface and render local applications difficult, I have discarded long ago. A broad bandage or a moderate-sized towel fastened round the chest with safety-pins is more appro- priate and is well tolerated. An ice-bag applied to the diseased region will often render the best service; it must not come in contact with the bare skin. "Where no bandaging is required, a cloth well wrung out of cold water, of the size of half a square foot, more or less, or surrounding the whole chest, may be ap- 500 THERAPEUTICS OF INFANCY AND CHILDHOOD. plied every fifteen or thirty minutes. It should be covered with rubber cloth and flannel. In very bad cases the pain should be relieved by a subcutaneous injection of morphine; its internal administration is generally useless and sometimes hurtful. Local depletion by cups or leeches, I am glad to say, I have shunned these twenty-five years; dry cupping may re- lieve such children as are old enough and intelligent enough not to get excited and not to harm themselves by screaming and active resistance. Mustard plasters must not remain longer than a few minutes, and may be repeated every few hours. Warm fomentations will relieve anaemic and feeble children; if possible, they ought to be avoided in the beginning of the disease, when the indication to limit congestion and secretion is paramount. A dose of calomel sufficient to relieve the bowels (sometimes with an opiate) and the use of salicylate of sodium in doses adapted to the age of the patient are the remedies which will bring relief. The salicylic acid in the latter is not present in sufficient doses to lower blood-pressure to an uncom- fortable degree. Vesicatories are still less indicated in the first stage of pleurisy than later on; they irritate both the skin and the patient, cause sleepless nights, and add to the discomfort of the occasion, and discomfort and sleeplessness impair the prognosis. If there were a benefit to be derived from blister- ing, the condition of the pleura might be improved, perhaps, but the sick injured, probably. If the temperature be so high as to injure the patient, anti- pyretics should be given. Probably from three to ten grains of quinine administered before noon will lower the afternoon rise. If required, a dose of phenacetin, with or without a moderate dose of codeine, may be given at eight or ten o'clock at night. When the fever decreases, or when the heart begins to get weak previously, digitalis, strophanthus, sparteine, or caffeine, with or without ammonium carbonate or camphor, are indi- cated; no improvement, either through diaphoresis or through DISEASES OF THE RESPIRATORY ORGANS. 501 diuresis, need be expected so long as the heart remains weak. The choice between the caffeine preparations is a matter of indifference. The salicylic acid in the double salt (Na + Caffein) is not sufficient to lower the heart's action. At the same time an acetate, or a citrate, or an iodide may be given. Pilocarpine, which has been recommended, is a two-bladed sword, and requires a stronger constitution than almost any baby and most children can boast of; in pleurisy there is no vital indication that can be fulfilled by pilocarpine to such ad- vantage as may be derived from it in certain cases of acute pulmonary or intracranial oedema. Externally, at this period, tincture of iodine diluted with alcohol may do some little good, particularly in cases of "dry pleurisy." It is this form mainly which will be benefited by warm fomentations and the use of iodides. When the main indication is to absorb effusion, absti- nence from drinking, and the use, in fair doses, of table salt, which increases diuresis, will be found useful. Diuretin, in four daily doses of from two to five grains (0.125-0.3) or more, may stimulate the action of the kidneys to such an extent as to result in the absorption of the pleural effusion. The indications for operative interference with the pressure of pleural effusions, no matter of what description, are various. It is demanded when the difficulties of either respiration or cir- culation, or both, require immediate relief. The latter may suffer even without the participation to a great extent of the former. Indeed, Trousseau describes a case of fatal collapse due to nothing but disordered circulation. Among the symp- toms urging the operation are intense dyspnoea, cyanosis, dim- inution of renal secretion, anasarca and ascites, and a con- siderable dislocation of the heart or the liver. In many cases the intercostal interstices are no longer visible, either on in- spiration or expiration; they are even found bulging. Not in every case are the consecutive disorders proportionate to the amount of effusion; indeed, this may be small compared with its effects when the pleurisy is complicated or secondary to a 502 THERAPEUTICS OF INFANCY AND CHILDHOOD. disease of either heart or kidneys, or both. Still, the quantity of fluid contained in the pleural cavity is more frequently under- estimated than the reverse, no matter whether the healthy lung is pressed upward and is floating on the liquid in a compressed condition, or whether, congested or inflamed, it is swimming in the midst of the fluid or adheres in places to the chest wall. Thus it is impossible to exactly gauge the indications of the operation according to the amount of effusion. Potain's claim, that when the latter reaches the level of the clavicle the opera- tion should be performed, is justified by the fact that the con- secutive symptoms in most such cases are very urgent. In most cases we should not wait quite so long. In such per- sons as do not subjectively complain, indifference is mostly due to lack of cerebral perception, — in conditions of uncon- sciousness during meningitis, typhoid fever, or idiocy. When the dulness extends high up both anteriorly and posteriorly, and no absorption takes place within a few weeks, the opera- tion is required. The longer the compression of the lung has lasted the smaller will be the chances of its reinflation. It is true, however, that now and then it will re-expand after com- pression has lasted from two or three months. Another serious danger accompanying the pressure produced by the liquid is the inactivity of the blood- and lymph-vessels of the walls of the cavity; for in such a case total compression means absence of function (absorption). Thus, even a partial removal of the fluid, with partial relief to the vessels, is quite often the first stimulus to absorption and the commencement of recovery. In order to either make or confirm the diagnosis of exuda- tive pleurisy, an explorative puncture is often resorted to. For, in spite of a number of rational symptoms, the positive diag- nosis of a pleural effusion or exudation is sometimes impossible without its ocular confirmation. The puncture is made near the upper edge of a rib to avoid the course of the intercostal artery, while the hand of the diseased side is carried to the opposite shoulder to widen the intercostal spaces. The pain DISEASES OF THE RESPIRATORY ORGANS. 503 of the little operation is diminished by the quickness of its performance; besides, a slow introduction of the needle — par- ticularly when of larger size — may peel off the pleura from the chest wall. In many cases of copious exudation the place selected, within certain limits, is a matter of indifference. The puncture is mostly made where there is bulging, or a high degree of dulness, or more, or less complete absence of respira- tory murmur, frequently in the sixth intercostal space poste- riorly to the axillary line. When these spaces are narrow, or when the patient is restless, it is not always easy to penetrate them; these are the cases in which, now and then, the inter- costal artery has been wounded, or pain resulted from hitting periosteum and bone. When the point of the needle is not carried far enough, it may land in the chest wall or in the thickened pleura; when too far, it reaches the lung; when in a wrong direction, it may be fastened in the liver or in the spleen. In such cases the needle is liable to participate in the excursions produced by inspiration and expiration, and, when withdrawn, will carry blood instead of the contents of the pleural cavity. In rare cases it is possible, however, to exhibit the latter and still wound the lung. It has happened to me to extract pus from a pyothorax. On the very spot of the punc- ture the incision was made and a rib exsected; when the inci- sion through the pleura was made, there was bleeding from the lung. The wound was closed with iodoform gauze, a new punc- ture was made at a different locality, pus was found, the rib exsected, and again there was, on incision, pulmonary hemor- rhage, which also was stopped by compression with iodoform gauze. A third puncture and a third excision at last led di- rectly into the empyema. The failures were due to extensive pleural adhesions, and the deceptive results of the exploring punctures to the fact that the needle did not reach pus until it had perforated the adhering and twisted lung. While an absolute diagnosis cannot always be made without a puncture, the results of the latter are sometimes not conclusive. 504 THERAPEUTICS OF INFANCY AND CHILDHOOD. Though there be plenty of liquid (serum, pus, blood) in the cavity, it may not always follow the sucking piston. The point of the needle may first land in the lung after passing through liquid; this will enter the instrument only while the needle is being slowly withdrawn, provided again that it has not been closed by a blood-clot. Therefore, when the puncture is futile, the needle ought to be carefully examined as to its perviousness. Or the needle is too thin for the contents; pus is quite often present where serum was expected; or the needle is caught in thick fibrinous deposits. That may happen time and again, and lead to serious miscalculations and mistakes. Or the pleurisy may be localized, with the result of giving rise to an encysted empyema, instead of a general pyothorax. Such localized em- pyemata are more frequently met with posteriorly, and upward, than low down, where they are usually expected, from the fact that it is there that free pleural fluids are found. They are quite small sometimes, and not infrequently multiple, and therefore hard to find. Puncture after puncture must be made in such cases as yield all the rational symptoms of pysemia, and when no pus can be readily detected. When finally found, it is not always certain to come from a pleural abscess after all. It may be derived from a small pulmonary abscess, or from a pyo- pneumothorax. In the latter instance, however, and sometimes in the former also, there is often air (or gas) found mingled with the pus. There are other possibilities of mistake. The needle may have withdrawn serum only, and yet pus or blood may be present; for in patients who have been in a recumbent or semi- erect position, as usual with pleuritics, the solid constituents of blood and pus will be deposited near the diaphragm. Thus, a microscopic examination ought first to complete the diag- nosis of the nature of the pleural contents. When pus has been found, there is an urgent indication not to procrastinate the radical operation, for the puncture channel may become the cause of pus-infiltration, and possibly of pyaemia. Particularly DISEASES OF THE EESPIBATOEY OEGANS. 505 is this so when the pus is discolored and malodorous, as it is apt to be in cases of pyopneumothorax, or in those which are complicated with caries. The latter cases are apt to be at- tended with high temperatures (still, there are exceptions), the fever being either continuous or irregularly intermittent. Such fevers require an exploring puncture at an early date; it is mostly delayed too long. Indeed, every case of uncompli- cated pleurisy in which a high temperature is incessant for four or five days, mainly when complicated with much pain or local oedema, becomes suspicious. Even as early as the fourth day I have met with large amounts of pus, not only in infants and children, who are more apt to develop pleural suppurations, but also in adults. Moderately high temperatures, however, do not necessarily indicate the use of the needle, for through periods of weeks, temperatures of 100J° or 101° may persist without meaning anything but the systematic irritation caused by a perpetual process of absorption and elimination. Thus, after all, there is no positive certainty that can be conveyed to the unthinking; here it is, like everywhere in medicine, that experience comes handy, when guided by brains. Before the operation of puncturing is performed, the skin must be thoroughly washed (and disinfected); after the needle has been withdrawn, iodoform gauze or bismuth subnitrate (or some other disinfectant powder) is applied to the wound and covered with adhesive plaster or a bandage. If there be pain, ice is applied. At all events, the chest ought to be at rest; the patient, if possible, in bed; no exercise or work per- mitted for a day. As a remedial agent a simple puncture is of no account. When recovery follows an exploring puncture, it is spontaneous, and not induced by it; for spontaneous ab- sorption of the pleural fluids, both of transudations and exuda- tions, is quite frequent. That is mainly so when the liquid is serous only and not too excessive; in the latter case, absorption begins only when, by means of an aspiration, the pressure by which blood- and tymph-vessels are hampered has been in part 506 THEKAPEUTICS OF INFANCY AND CHILDHOOD. relieved. Nor is it infrequent for hemorrhagic exudations, or even extravasations, to be absorbed after the solid constituents have been deposited on the surfaces of the pleurae. Even the results of tubercular pleurisy may disappear, just as ascites caused by tubercular peritonitis is apt to get well, whether or not tubercle bacilli are found in the fluid. As a rule, in most of the cases of spontaneous recovery no microbes are present; if they be found, they are mostly the short-lived cocci of Fraenkel. No such favorable event, however, need be looked for when the long-lived streptococcus and staphylococcus are present; still worse is the influence of proteus vulgaris and mirabilis in the putrid empyema. Simple encysted empyema, however, may finally heal without any operative interference, through a process of gradual inspissation and absorption. Spontaneous perforation of pyothorax, either through the lungs or through the chest wall, may lead to recovery; but it is slow, and takes place at the expense of much time, suffering, tissue, and usually of future health and vigor. It should never be wished or waited for. Thoracocentesis ought to be performed soon after the ex- ploring puncture. In many cases, when a mere aspiration is made, the operation appears simple enough; but it ought to be considered serious in all cases, as in many it is. The patient must rest quietly and be well supported in the position recom- mended for a simple puncture, and so that respiration and cir- culation are not unduly interfered with. The needle is inserted with the precautions detailed in the remarks I made on puncture; if it be caught by a fibrin clot, the latter may be detected by a probe introduced through the needle, but a second insertion may be required, probably anteriorly and superiorly to the first one. Aspiration alone will not cure empyema, except occasionally in infants, whose ribs are flexi- ble and whose chests can be compressed more readily so as to approximate and adjust the walls of the abscess; even in them, however, the same operation must not be repeated DISEASES OF THE RESPIRATORY ORGANS. 507 after pus has again been formed, but a more extensive and radi- cal operation is to be undertaken. Aspiration is always contra- indicated in the empyema of adults, except in a vital indication for temporary relief, or when the fluid is hemorrhagic in char- acter, or in cases absolutely inoperable. During the operation the patient, if it be feasible, ought to be kept as much as possible on the diseased side, so as to avoid the dyspnoea due to the compression of the lung of the oppo- site side and the molestation of the heart. The fluid may be permitted to flow so long as the current remains equable during inspiration and expiration; the discharge must be stopped when the current begins to cease during inspiration. The relief given by the removal of a half -pint or a pint is sometimes con- siderable; but in young children, with their compressible chests and corresponding facility of accommodation to the ex- panding lung, it is safe and advisable to entirely empty the cavity. If the operation — because of the urgency of indica- tions — be performed while exudation is still progressing, and dyspnoea return, another thoracocentesis may become necessary within a short time. I had to operate twice within a day. If the contents be hemorrhagic (from tuberculosis, carcinoma, alcoholism, nephritis, a rare occurrence in childhood), as little as possible should be withdrawn. The operation requires time. It is advisable to interrupt the discharge from time to time; for the too rapid entrance of air into the bronchi causes violent attacks of coughing (er- roneously attributed to the needle irritating the pulmonary pleura), or the sudden rush into the expanding lung may give rise to large quantities of serous, strongly albuminous, bron- chial secretion, or to copious pulmonary oedema, or to hem- orrhages with slight surface lesions, or even to considerable rupture of pulmonary tissue. Fainting spells are also frequent during a rapid escape of serum, sometimes through psychical influences, sometimes from cerebral anaemia. In other cases (fortunately rare) thrombi formed in the compressed lung, or 508 THERAPEUTICS OF INFANCY AND CHILDHOOD. in the impeded heart, or in the torn surface of the bronchi may- be carried oft' into distant blood-vessels; thus, emboli are known to have been swept into the pulmonary artery or into the artery of a fossa Sylvii. After the operation the wound must be cared for as I sug- gested above, when speaking of the treatment of a mere punc- ture made for the purpose of a diagnosis. In addition, it is advisable to enforce absolute rest and to apply for some time an ice-bag to the part. This is particularly necessary when there is acute pain. Should this be severe, morphine may be used subcutaneously, but in uncommonly small doses, because its absorption is very rapid and its effect much more marked here than under ordinary circumstances. The simple operation of aspiration does not suffice in cases of exudative pleurisy in which the pleural contents hold, or consist of, pus, either laudable or putrid. As I mentioned before, pus may be found as early as the fourth day, and then it is often on both sides. When high fever attends such cases, far from contraindicating a radical operation, they require it for immediate relief. If such relief be not obtained after a reasonable time, it is either because of a complication such as pneumonia, pericarditis, or peritonitis, or of some pus con- cealed in a recess. The latter ought to be looked for and made to discharge; Nelson employed a metal sound for the purpose of breaking up adhesions and facilitating the escape of pus. The radical operation consists in the making of a large aperture, either by a simple incision between two ribs, if pos- sible, in the fifth or sixth intercostal space between the mam- millary and axillary lines, or by incision with the exsection of a piece of rib from one-third of an inch to an inch in length, large enough to admit two fair-sized drainage-tubes. The opening is insufficient so long as it gives no exit to the clots of fibrin, which sometimes are as large and perplexing as their presence is unsuspected. It is on their ready and speedy re- moval that the duration of convalescence or the favorable or DISEASES OF THE EESPIKATOEY ORGANS. 509 fatal termination depends. Therefore they should be removed at the time of the operation. There is no better means than to dislodge them from the surface of the lung and of the chest wall by the index-finger introduced into the cavity. During the following irrigation they are washed out or appear at the opening and may be caught in a forceps. There are those who, as the presence or absence of these large masses can- not be diagnosticated, insist upon exsection in every case of empyema, no matter whether of recent date or of long standing. At all events, whenever there has been a continued or a pya?mic fever, a great deal of pain, an intercostal oedema, or a complica- tion with infectious embolism, pyopneumothorax, tuberculosis, or superficial pulmonary or hepatic abscess, the exsection of a large piece of rib is indispensable. After the operation has been completed, the cavity may be thoroughly washed with quarts of warm saline (6 : 1000) or of Thiersch's solution. Stronger antiseptics should be avoided, or used only — largely diluted — when the fluid is decomposed. In the latter case irrigations are indispensable; they may be dispensed with alto- gether when pus is absolutely laudable and the patient in a low condition. The dressing should be soft, thick, and aseptic. The frequency of the removal of this dressing and the number of injections depend on the nature and quantity of the pleural secretion. In the majority of cases it is safe to wait until the dressing becomes moist. When the lungs expand readily, many days may elapse before the first dressing is removed and another one substituted. For the sake of thorough drainage the patient should, however, be placed horizontally (the incision being the most dependent part) with raised hips, at least three times a day and ordered to cough as hard as possible (Koenig). When, however, the pus is putrid, and in cases of complications such as are mentioned above, a daily change of dressing and daily irrigations, with occasional short interruptions, should take place. To expand the lungs and to promote the required adhe- sion between the pleura? the child should amuse himself with 510 THERAPEUTICS OF INFANCY AND CHILDHOOD. blowing soap-bubbles, trumpeting, or with W. T. James's enter- taining exercise. He is made to blow air into a bottle and dis- lodge the water (colored with f uchsine, methylene blue, or such like) into another one by means of a Simple system of rubber tubes. When fistulae remain behind, or the abscess cannot close because of the lung being kept from expanding by pleuritic thickening over it, larger pieces of one or more ribs must be removed to enable the chest wall to sink in and thereby facili- tate the approximation of the walls of the cavity. In these, as in many simpler cases, it is necessary to keep the opening patent for a long time; this is readily accomplished through the slowness of the growth of callus in that region. Hydrothorax (fluid with a low specific gravity, less than 1015, and from one to five per cent, of albumin) depends on or is complicated with malaria, nephritis, cardiac disease, anaemia, or cachexia. The cases resulting from scarlatina are among the most favorable. Besides the indications afforded by its cause, and good nutrition, hydrothorax demands diuretics, such as digitalis, sparteine sulphate, caffeine, diuretin, bitartrate of po- tassium. The less such patients drink the more readily will the fluid be absorbed. Plenty of sodium chloride in food and drink will increase renal action. If no reduction of the fluid take place, paracentesis is demanded. Pneumothorax is a complication or a result of the perfora- tion of a cavity, of pulmonary gangrene, of pleural infarction, or of perforating empyema, and in many cases of this kind pyopneumothorax will be observed. Foreign bodies are more apt to produce pneumothorax than whooping-cough, which is liable to tear the mediastinum rather than the pleura. Ice will relieve local inflammation and pain, so will opium, which, moreover, modifies the perturbed respiratory movements. Cases of pyopneumothorax which do not readily discharge their pus through the lungs demand a counter-opening of the chest wall, which should be made, not under a general but a local anaes- thetic. DISEASES OF THE ORGANS OF CIRCULATION. 1. The Heart. Both in acute and in chronic diseases of the heart the amount as well as the quality of food require some modification. In many cases the loss or diminution of appetite will regulate the former. As a rule, however, the amount taken ought to be much less than the same person would lake when in health. Not only ought the total quantity to be less, but also that con- sumed at each meal should be comparatively small. It is best, therefore, to divide the meals into halves and even thirds, so as to cause the patient to eat every two or three hours. Di- gestibility must be improved by slow eating. The diaphragm should not be annoyed by large quantities of food or by the evolution of gases. Therefore but few carbohydrates and but little fat are to be given, and the digestion of nitrogenous foods, such as meats (eggs) and milk, with or without cereals, ought to be aided by pepsin and dilute hydrochloric acid. The latter is an excellent adjuvant to the digestion of milk prepared according to J. Eudisch's formula (p. 23). Or it may be modi- fied or mixed according to the rules given by me in the first chapter of this book. At all events, milk is the main food to be given in cardiac ailments. Its digestion has a further ad- vantage in this, that it does not result in the physiological con- gestion of the stomach, liver, and spleen, which becomes irk- some after large and heavy meals by disturbing circulation and thereby adding to the labor of the heart, and that it does not contain the large mass of fat-forming elements present in the mixed food of healthy advanced childhood or adult age. Altogether, it is best to slightly underfeed the patient. 511 512 THERAPEUTICS OF INFANCY AND CHILDHOOD. Thereby the labor of the heart is facilitated, an object which must never be lost sight of. For the same reason fast drink- ing, even of water, must be avoided, for its sudden absorption fills the blood-vessels too suddenly for comfort. Its speedy elimination does not diminish the momentary overwork. This warning is of particular importance as regards iced liquids, which act both by their bulk and by reflex. This advice is by no means superfluous, either for medical men or for the sick. It was strongly urged by Williams fifty years ago. Stokes pro- hibited the use of large quantities of soups or milk. And it has been again introduced by Oertel with such impressive emphasis that thirsting has become almost fashionable and a craze among the fanatics. That stimulants, such as coffee, tea, and alcoholic beverages, must not form part of the regular diet in cardiac disease is self-understood. They may be required as medicinal agents, however, upon positive indications. In every form of cardiac disease absolute rest of both body and mind is among the very first indications. The latter is just as important — perhaps more so — here as in diseases of the nerves and nerve-centres. Fretting, worrying, crying are det- rimental, and must be avoided. Thus, it may become neces- sary to take a child out of bed, temporarily, to gratify and quiet him; or to change his position, for the recumbent po- sition of a hypertrophied heart may cause dragging of the phrenic nerve or of the sympathetic plexus; or to raise the trunk and head to relieve the intracranial hyperemia and the consecutive irritation of the pneumogastric nerve; or to give a mild opiate or a dose of bromide of potassium to insure quietude or sleep. The child must be permitted to select his own position; he knows best where he is most comfortable; but rest he must. The diseased heart is in its most favorable condition when working least; the number of heart-beats is reduced by ten or twenty-five in the recumbent position. Eest is not only a curative, but a preventive agent. Many a life- DISEASES OF THE ORGANS OF CIRCULATION. 513 long cardiac affection could be warded off if care were taken in time. We are beginning to become more and more aware of the frequency of affections of the heart muscle. Myocarditis in a chronic, subacute, and acute form is of very frequent oc- currence. In or after every case of typhoid fever, scarlatina, diphtheria, or small-pox we should be prepared to be overtaken by some cardiac disease, either interstitial myocarditis or paren- chymatous degeneration. Rest in bed or on the lounge (the former is better) will act as a preventive. It ought to be con- tinued for weeks in almost every case. Like the paralysis con- sequent upon infectious diseases, which develops after weeks, heart-disease may occur from the same cause, partly as a consequence of actual primary alterations, partly of nerve ex- haustion. So long as the pulse becomes more rapid on ex- ertion, or on getting out of bed, absolute rest is the best remedy and safeguard. In these cases it is not always possi- ble to distinguish between functional debility and actual dis- ease. Autopsies too frequently tell us of our mistakes. Trifling changes in size cannot be measured by percussion, feeble mur- murs cannot always be estimated according to their exact value. Functional murmurs are not so frequent in the child as in the adolescent or the adult. On the other hand, organic cardiac diseases have a better chance to be cured — really cured — in the young than later. So much the greater is the responsibility of the medical man in cases of preventable or remediable car- diac disorder. Even patients suffering from the very worst forms are apt to feel better within a very few (hours or) days after being confined to bed, with strict diet and loose and com- fortable clothing. These cases teach us the lesson of what can be accomplished through the same regime in milder or in- cipient forms, by reducing the labor of the heart and at the same time of the voluntary muscles, and by diminishing the overactivity as well of the general innervation as of the cardiac nerves, both exciting and inhibiting. It is difficult to decide to what extent exercise should take 33 514 THERAPEUTICS OF INFANCY AND CHILDHOOD. the place of rest in individual chronic cases. The hearts of patients are as little alike as are their noses and finger-tips, and their treatment ought to be as individual as the size and shape of their gloves. Neither fit everybody. Nor is the rule adopted to-day that which will accomplish the best end in a month or a year for the same patient. The heart is neither in health nor in disease a uniform body. Its innervation may change from minute to minute, its nutrition is dependent on sudden or gradual alterations. A heart muscle is influenced in its arterial supply, venous discharge, and lymph circulation not only by its own health or disease, but by the ever-changing conditions of the other organs. Thus, many of the rules given one day may not remain valid another. Still, after a fair time has elapsed since the occurrence of an acute myocarditis or en- docarditis, exercise should be recommended. The child may get up and have his quiet play sitting at the table, may begin to walk on the level floor, and may indulge in mild gymnastic exercise. More must not be permitted until the mucous mem- branes become a little more tinged, the arteries fuller, the heart quite regular. The systematic rules recommended by Stokes and by Oertel refer more to adults, with their incipient fatty degeneration and chronic myocarditis, than to children. In these, while they bear the imprint of cardiac changes, no iron- clad rules hold good. Gentle exercise and long rest should alternate. Gentle exercise may be replaced or complemented by mas- sage of the skin and the muscles, both of which are so essential for circulation and metamorphosis. The blood circulating in a resting muscle during one minute amounts to 17.5 per cent, of its weight; in a contracting muscle to five times as much. It is easily seen to what extent massage, hydrotherapeutic irri- tation of the whole surface, excitation of the muscles by the interrupted current must do good without an exertion of the heart muscle. The avoidance of the latter, while the muscles are gently exercised by "resistance movements," is the pecu- DISEASES OF THE ORGANS OF CIRCULATION. 515 liarity of the Schott treatment at Nauheim. It is indicated in a great many cases; in others it is Oertel's climbing exercises. In all, it is the judicious mind and common sense of the physi- cian in charge of the individual case. The skin requires judicious attention. Exposure to cold, with its consecutive contraction of the cutaneous blood-vessels, overloads the viscera, retards circulation, and increases the labor of the heart muscle. A cold general bath, therefore, is dangerous (as also in the atheromatous degeneration of the old) in acute carditis (where local application of cold acts quite favorably) or in extreme muscular weakness of the heart. On the other hand, a brief cold sponge-bath or wash, with thorough friction, is an intense stimulant and may be used to advantage for a weak heart, unless the extremities be cold and the mucous membranes cyanotic. In these latter conditions, hot washes and frictions, with or without alcohol, should take its place. In the average condition of the diseased heart general hot bathing must be avoided. It overstimulates and paralyzes, and proves an actual danger in both acute and chronic cases. Newspaper readers will remember the reports of people who go to the hot or "Turkish" bath with their heads erect and full of their own therapeutical wisdom, and leave it with their feet forward. A warm bath, the temperature of which ought to be over 90° or 92° F., is often relished. In fact, both the talking child and the silent will soon tell you the exact temperature best adapted to their wants. In these cases requirement and comfort are identical. The baths, particularly the first, must be limited to a few minutes; at all events, they should never be continued after the slightest weakness of the pulse is noted. The debilitating or fatiguing effect of the bath must be avoided. The mineral springs which have obtained a reputation in the treatment of chronic heart-disease, like the German Nauheim and Oeynhausen, owe their effect to the stimulating action of the salts and of the carbonic acid contained in them. 516 THERAPEUTICS OF INFANCY AND CHILDHOOD. Like hot water, hot air is contraindicated in heart-disease. The wilted forms of the little ones soon show the effects of summer heat. A temperature of from 65° to 70° F. and fairly- dry air are best for them. High altitudes do not agree with cardiac disease, particularly when no compensation has facili- tated the heart's action. Compensation is not complete until the hypertrophied left ventricle, having become so by mitral incompetency, transmits as much blood into the aorta as the pulmonary artery does into the lungs. Until that stage has been reached, the lungs are comparatively hypersemic and sub- ject to catarrh, oedema, or bleeding. In this condition, there- fore, the influence of the rarefied air of the high altitudes should be avoided; as a rule, I recommend an altitude of not more than from one thousand to fifteen hundred feet to chil- dren affected with chronic endocarditis. In the therapeutics of the heart it is most important not to mistake a functional disturbance of the heart's action for the immediate result of heart-disease. The contractions of the heart (the pulse), as to number and rhythm, are more fre- quently influenced by disorders of other organs or of the or- ganic economy in general. The pulse may become arhythmic from cardiac (mainly myocardial) disease, but also from men- ingitis, from neuroses (chorea, hysteria, epilepsy), from anae- mia in convalescence after grave diseases, in chlorosis, in uni- versal obesity, even in the apparently healthy; from the autoinfection caused by constipation or by jaundice; or from the effects of medicines. It is self-evident that all these different causes, and not their common symptom, should be relieved. The functions of the heart and blood-vessels are best con- sidered together, from a clinical point of view. Together they control the normal blood-pressure and circulation; when these are disturbed, it is mostly (not always) the same remedies or drugs that influence at the same time the heart and the arteries. Such disturbances are either an increase or a lowering of blood- DISEASES OF THE ORGANS OF CIRCULATION. 517 pressure, and alterations in the circulation which are character- ized by slowness or frequency of the pulse. In the diseases of the young it is mostly cardiac stimulation that is required with a view of contracting both heart and arteries. Its indication is furnished by primary feebleness of the heart muscle, or that which is caused by acute or chronic, inflammatory or infectious diseases; sometimes by congenital undersize; by impaired brain function after hemorrhages, in syncope, or in chronic cerebral anasmia; by insufficient diuresis; by pulmonary oedema; by reflexly lowered blood-pressure in shock, in colic, or after ex- tensive burns; by hemorrhages; or by toxic dilatation of blood- vessels caused by chloral hydrate, nitrites, pilocarpine, or mus- carine. Blood-pressure and circulation are improved by physical means, such as transfusion, salt-water infusion, lowering the head and raising the feet, ligature of the extremities, manual compression of the abdominal aorta, and hydrotherapy in dif- ferent forms. The centres of the medulla and of the spinal cord are influenced by strychnine and ergot, the vasomotor centres and the heart by caffeine, camphor, ammonium, and musk, the vasomotor centres and the peripherous vasomotor nerves by hy- drastis, the heart by alcohol, atropia, and sparteine, the heart and arteries by digitalis, strophanthus, adonis, convallaria, hellebore, and apocynum. Among the principal remedies employed for the purpose of reducing blood-pressure and dilating peripherous vessels are warm baths, or foot-baths with or without mustard, warm clothing, rest in bed, narcotics, such as morphine and chloral hydrate, acids and alkalies, and the nitrites. At the head of the list of heart and blood-vessel stimulants stands digitalis. It increases the action of the heart muscle and thereby increases cardiac pressure. It is indicated in all conditions of weakness of the heart muscle so long as the latter is not decomposed. This condition hardly ever occurs primarily in childhood, for uncomplicated fatty degeneration in which 518 THERAPEUTICS OF INFANCY AND CHILDHOOD. digitalis is contraindicated is almost unknown at an early age. Secondary parenchymatous degeneration is a frequent occur- rence in and after infectious diseases, such as typhoid fever, dysentery, rheumatism, scarlatina, diphtheria, and others. Digitalis is useless and sometimes worse than useless in nervous affections, such as the palpations of Graves's disease, of neu- rasthenia, or of fever. In all probability the effect of digitalis is mostly felt at first in the left ventricle, which is more muscu- lar, but in the right ventricle almost as soon. By acting on the left ventricle it regulates the general circulation and facilitates aspiration of the venous blood and the circulation in the lungs and in the right heart. During its administration the contrac- tions of the heart become more vigorous and less frequent, the arterial pulse slower and fuller, the urine increases in quantity, cyanosis and dyspnoea diminish, and dropsical symptoms disap- pear gradually. When large doses have been given for some time, accumulation of the effect takes place. The pulse be- comes quite slow and irregular, and vomiting sets in. If pos- sible, this effect should be avoided. For how long a time may digitalis be administered when given in moderate doses? This question has often been asked and as often answered. Unfortunately, the preparations sold in the markets are of different strengths and vary too often; so it is best to rely on preparations which are not liable to spoil on one's hands. With that proviso, I can say, from an experi- ence of several dozens of years, that I cannot agree with those who stop the administration of digitalis after a few days, to begin again after an intermission. Moderate doses may be given day after day for months without any ill effect and with great benefit. Nor is it necessary to alternate between cardiac stimulants so long as no uncomfortable effect of digitalis makes its appearance. In practice we are often disappointed. The preparations are as various as are the firms of wholesale, or sometimes retail, manufacturers or tradesmen. The United States Pharma- DISEASES OF THE ORGANS OF CIRCULATION. 519 copoea is, after all, the best stand-by of the practitioner, and its list of drugs and that of the National Formulary of the Pharmaceutical Association are sufficiently large to supply any taste. The infusion of digitalis, when reliable, may be given to a six-year-old child in doses of a teaspoonful two or four or five times a day, the fluid extract (I have often expressed my predilection for "Squibb's") two or three minims daily, the solid extract from one-half to one grain daily (0.03-0.06). They are not equivalent, the infusion being weaker by contain- ing the digitonin, which is highly soluble in water and acts rather as an antidote to digitalin and digitoxin. The tincture of digitalis, when reliable (not fixed up by mixing a poor "fluid extract" with alcohol), ought to be a competent equivalent of the fluid extract, if made of the English leaf. Indeed, chil- dren bear digitalis, and cardiac stimulants generally, better than adults, and in comparatively larger doses. Digitalin I have used a great deal. Unfortunately, the wares sold by that name are very unequal: they are resinoids, not alkaloids. In order to have — no matter whether resinoid or alkaloid — an article of probable uniformity, I prefer to prescribe Merck's. (Schmiedeberg's preparation may prove preferable.) A child of six years may take one-hundredth of a grain (1J milli- grammes) from three to ten times a day. I have often been obliged to give much larger doses to obtain its action; for, while in chronic cases we may safely spend some time on developing an effect, in urgent and acute cases one or more large doses should — nay, must — be given to accomplish the desired end immediately. In urgent cases a six-year-old child must take from one to five minims of the fluid extract at once. That dose may be repeated after a few hours, and perhaps again, until the effect is perceptible. Then it is time to slacken off or stop altogether. It is particularly in those cases in which the pulmonary circulation is obstructed, either by local inflam- matory processes or by cardiac incompetency, that this mode of proceeding is advisable. 520 THERAPEUTICS OF INFANCY AND CHILDHOOD. The effect of digitalis is not limited to the heart; the arteries are also affected by it. On this account digitalis is often con- traindicated in senile affections of the whole vascular system. As they (atheromatous conditions) are not found (except in a few stray cases of the literature) in infancy and childhood, this contraindication is rare in early age. There is a single excep- tion, however, to this rule, — viz., in abnormal congenital small- ness of the arteries, which is not so excessively rare as may be presumed, and is a frequent cause of lifelong migraine, neu- rasthenia, hysteria, and chlorosis. In these conditions, thus caused, digitalis is not well tolerated. In those cases in which the effect of digitalis appears to be retarded, or the practitioner has "reason to doubt the qualities of his drug," another one may be substituted for it or combined with it. I plead for occasional combinations of drugs. The "'simple prescription" flag of the "one drug only" fanatics waves over a childish affectation. They forget they are pre- scribing half a dozen different articles in their "one drug" digi- talis. Moreover, when the heart requires stimulation, we should remember that it is a composite organ; the muscle, the ganglia, the pneumogastric, sympathetic, and vasomotor nerves are suffering simultaneously. The tincture of strophanthus may be taken by the same child to the daily amount of from six to twenty-five minims; the fluid extract of convallaria majalis in the same or somewhat larger doses. Again I suggest that in most cases it is best to ascertain the moderate dose to be ad- ministered a long time in succession by giving a good dose from the very beginning and watching its effect. Of the sul- phate of sparteine (better than other preparations of scoparius) eight or ten doses are required daily, altogether amounting to from one-half to two and a half grains (0.03-0.15). Caffeine from two to ten grains, or the salicylate (or benzoate) of sodio- caffeine from four to fifteen grains a day, are fair doses, the effect of which will be pleasant in most cases. In a former chapter of this book (p. 77) I have alluded to the subcutaneous DISEASES OF THE ORGANS OF CIRCULATION. 521 use of the latter; it dissolves readily in twice its weight of water and is not a local irritant; it is therefore easily employed. The effect of these injections is often marked. More than a dozen years ago I published a case of cardiac pulmonary oedema, among others, in which recovery was the undoubted result of their use. There is, however, a positive contraindication to the use of caffeine (and coffee), — viz., cerebral hyperemia, either active or passive, or a tendency to convulsions. The same con- traindication holds good for sulphate of strychnine which has conquered a trusted place as a cardiac stimulant. If there be time, it may be given internally, daily, to the amount of one- sixtieth to one- twentieth of a grain (0.001-0.003) for many days or weeks in succession. Urgent cases require its subcu- taneous administration. Large doses, up to one-fourth to one- third grain (15-20 milligrammes), may be given to a child of ten years in emergencies of collapse and sepsis in a day, but such doses cannot be continued. The salicylate of sodio- theobromine has been introduced (as "diuretin") by G. See. It is a diuretic rather than a cardiac stimulant, and, unlike the former, it is often found wanting. Calomel in small doses is certainly a cardiac sedative, and, as it is surely a diuretic, it is entitled to the many praises bestowed on it rather by the older than by modern physicians. Salines owe their effect upon the heart mainly to their action on the digestive and the urinary organs, with the exception of the bromides and iodides, the former of which act as sedatives, and thus save labor and soothe irritation. The iodide of potassium has a more direct effect. It dilates arteries, diminishes arterial tension, and aids elimination through the bronchial mucous membranes and the kidneys. Obstructions of the pulmonary circulation depending on the heart are its happy indication. Sclerosis of the coronary arteries is not found in the young; therefore this is an indica- tion exclusively belonging to advanced age. A child of six years may readily take from five to twenty grains (0.3-1.25) a day, in three or four doses, in plenty of water, after meals. 522 THERAPEUTICS OF INFANCY AND CHILDHOOD. It need not often be interrupted because of the gastric symp- toms produced. The nitrites and their preparations play an im- portant part in lowering blood-pressure. They dilate blood- vessels by paralyzing the vasomotor centres (not the central nervous system) and the peripherous vessels. Large doses transform haemoglobin into methaemoglobin and thereby cause cyanosis, dyspnoea, and sometimes methaemoglobinuria. Nitrite of amyl may be inhaled in drop doses; nitroglycerin (trinitrite, glonoin) is given in doses of from one five-hundredth to one two-hundred-and-fiftieth grain (J-J milligramme) in solution. The spiritus glonoini of the United States Pharmacopoeia con- tains one one-hundredth grain in one drop. The effect of nitrite of sodium, one to four grains (0.06-0.25) a day, in solution or in powder, is milder but more permanent. Sweet spirits of nitre is of an unequal composition; its action on the kidneys is more pronounced than that on the circulation in general. There are occasional cases in which the secondary compen- sation required by mitral incompetency is not fully established, and serious disturbances of the circulation arise therefrom. The dangerous symptoms may be cyanosis and pulmonary (or) and cerebral oedema. There are stupor or convulsions, dysp- noea, cyanosis, dilated veins, cold extremities, and a small and intermitting pulse. It is in these cases that a few of the above- mentioned large doses of digitalis may do good; here it is that wavering and indecision become criminal. Whenever digitalis does not have any effect, a venesection may. Our ancestors were less pusillanimous. Maybe they overdid bleeding, but in an urgent case they did not fail to open a vein. I know that I have several times saved the lives of children (and adults) by opening a vein quickly. Chronic (and sometimes the final termination of acute) car- diac diseases may lead to heart-failure. In such cases stimu- lants are indicated. Alcohol must not be given by itself and in large doses in cerebral hyperaemia of any kind. A child of six years may take from three to twenty grains (0.2-1.25) of DISEASES OF THE ORGANS OF CIRCULATION. 523 camphor internally; subcutaneously, a solution of one part in five of sweet almond oil should be used, and from five to fifteen drops injected repeatedly. Ether may be given, in doses of from three to ten drops, in alcohol and water, and ammonium carbonate, in frequently repeated doses of from one-half to two grains (0.03-0.125), in anise-seed water or in milk. Siberian musk internally, strychnine subcutaneously, are required. The more urgent the case appears to be the greater is the indication for combining several of these remedies. Myocarditis. — Though myocarditis, both acute or chronic, is by no means so common in the child as in the adult, it is nevertheless not infrequent; it is, indeed, remarkable to ob- serve how often it is not diagnosticated, or how little its occur- rence is appreciated. The disease is met with either in con- nection with endocarditis, pericarditis, rheumatism, etc., or is spontaneous and uncomplicated. In its treatment muscle stimulants must not be given. Digi- talis is contraindicated. The recommendation of Heffen, to ad- minister ergot, I cannot approve of, for by its action on the muscular fibres it increases vascular pressure, and thereby secondarily the labor of the inflamed heart muscle. What- ever relieves this temporarily is welcome. Therefore, iodide of potassium combined with a bromide will act favorably. This is also the place for morphine, either in large doses at long intervals or in small doses more frequently administered, to- gether with ice to the chest. During attacks of collapse, or during weakness or prostration, ether, camphor, and alcohol should be given, either internally or in an urgent case subcu- taneously. A dose of calomel will relieve the bowels. Enemata for the same purpose daily, for regular evacuations are the best regulators of intra-abdominal circulation. In chronic cases iron may safely be given with the iodide; not in acute ones, which are injured by it through the increase of vascular irritation. Absolute rest, both physical and mental, is essen- tial. The extremities should be kept warm (stockings). Deri- 524 THERAPEUTICS OF INFANCY AND CHILDHOOD. vation by extensive mustard plasters and by hot foot-baths taken in a semi-recumbent position should be tried. A very small pulse demands nitrites. Endocarditis. — The treatment of this disease is more prom- ising in the child than in the adult, for entire recovery is more frequent in early life than later; but it is important that the diagnosis should be made early. In order not to be taken un- awares, we ought to remember that endocarditis may be present without, at least for some time, exhibiting a murmur; there are, indeed, cases which run their full course without a murmur. This is eminently so in ulcerous endocarditis. On the other hand, it is also necessary to remember that functional murmurs are not so common in the child as they are in the adult. Thus, every murmur — though there be no hypertrophy developed as yet — should be suspected of being dependent on organic dis- ease. This may also be surmised in most cases of acute chorea, which sometimes precedes and ushers in, instead of following, endocarditis; and in every case of articular rheumatism, the symptoms of which have been described in a former chapter of this book as sometimes so slight as to be easily overlooked (p. 286). Acute endocarditis is also common as a sequela of the chronic form, and as part of septico-pyasmia. It is not un- common as the result of acute and chronic nephritis, and of infectious diseases, such as scarlatina, measles, typhoid fever, variola, tuberculosis, and carcinosis, and is frequently com- plicated — mostly through the intercession of pericarditis — with pneumonia and pleurisy. Frequent and careful examina- tion, therefore, during the existence of such ailments, while it facilitates an exact and complete diagnosis, suggests the best method of prophylaxis. Most of the cases of endocarditis we meet with in children being due to acute rheumatism, every case of the latter, though ever so slight, must be watched, put to bed, and treated with salicylate of sodium. Almost every form of "growing pain" ought to be so treated, and in no case of infectious disease must the patient be permitted to leave DISEASES OF THE ORGANS OF CIRCULATION. 525 the bed before much of his previous strength has been re- stored. The special treatment of acute endocarditis requires absolute rest in bed, a dose of calomel sufficient to open the bowels, and regular discbarges through the course of the disease rather by means of enemata than of purgatives. Frequent but small meals, and articles of food as suggested before. If thirst be great, drinking should be permitted often rather than much at a time. No alcohol in the beginning. Depletion by leeches is rarely indicated, and then only when there is a serious com- plication with painful pleurisy. In rheumatic endocarditis depletion is not tolerated at all. For severe pain which depends on pleural complication the subcutaneous injection of a few drops of Magendie's solution of morphine is preferable. Dry or wet cupping will sometimes relieve in such cases; other deri- vants, such as sinapisms, will often suffice. Vesicatories I do not advise in an acute case, the patient having enough to suffer from nature's infliction. Ice applied in a bag, which must not be too heavy, or ice-water cloths well wrung out, are beneficial in most cases, rheumatic or other. The head and trunk must be raised so as to make the patient as comfortable as possible. Blue ointment has been recommended over the heart and other places. I cannot say that I have reason to advise it. Strong diuretics, such as act by increasing blood-pressure, must not be given; mild salines will answer best; a small dose of calomel may be given from time to time. According to the indications noted above, iodide of potassium, with or without an opiate, will answer best, in doses of from fifteen to twenty-five grains (1.0-1.75) daily, for a child of six years. An opiate at night secures rest; bromide of potassium may be given through the day. If the case be rheumatic, as it mostly is, salicylate of sodium, from fifteen to thirty grains (1.0-2.0) daily, will be tolerated and found serviceable. Phenacetin may take its place sometimes, in daily doses, all told, of from eight to twenty grains (0.5-1.5). It acts as a febrifuge, an antirheumatic, and 526 THERAPEUTICS OF INFANCY AND CHILDHOOD. a sedative at the same time, better than quinine, a dose of which may, however, answer well now and then, particularly during remission. No antipyrin, no acetanilide ("antifebrin" of the trade). Serious attacks of dyspnoea are best relieved by morphine, either internally or subcutaneously, or by lead and opium. Drastics will seldom be required and seldom answer the purpose. The nitrites may be tried, though they have not served me so well, or so often, as I formerly thought I had reason to expect; they act best when the pulse is dangerously small. When cachexia and debility are prominent symptoms, tonics and stimulants are indicated early. In septic cases the chloride of iron should be given at an earlier period than in those of a purely inflammatory or rheumatic character. Among the stimulants, I think highly of camphor and ammonium. Among the direct cardiac stimulants enumerated above, digi- talis ought to be given only after the acute changes in the muscular tissue of the heart have been repaired. (There is hardly a case of endocarditis unaccompanied by myocar- ditis.) It is here that the experience and tact of the practitioner have to decide an important point. In the further evolution of the case, digitalis with quinine, digitalis with belladonna, digitalis with strychnine, or with a bromide, or with an iodide, together with stimulation of the peripherous circulation by friction, either dry or with alcohol or hot or cold water, find their own indications. The hygienic treatment of chronic endocarditis has been disposed of in former remarks. The medicinal agents of most importance are digitalis and iron. Constipation and over- exertion must be avoided. In connection with the latter, the education and training of the child should be so guided as to prepare him for his future trade, business, or vocation. Endo- carditis terminating so often in valvular disorders with con- secutive hypertrophy, his future life ought not to be exposed, if avoidable, to great excitements or hard physical labor. A DISEASES OF THE ORGANS OF CIRCULATION. 527 child so affected must not take coffee, tea, or alcohol in any shape as an article of diet. He must not be trained to become a military man, a pugilist, or a medical practitioner. The management of valvular changes resulting from endo- carditis is more successful in childhood than in the adult. Compensation is brought about by consecutive hypertrophy; thus it is facilitated, about puberty, by the rapid growth of the heart at that period of life, and particularly by the in- crease in size of the aorta and also of the arteries in general, thereby easing the circulation. Besides, vascular disease, which is so common in the adult, is a rare exception in the child. Moderate exercise contributes its share in increasing the growth of muscular tissue of all kinds, and should be rec- ommended, according to Beneke,* as also in undersize of the heart. Pericarditis. — The pericardium is more accessible to the in- fluence of cold applications than the heart. They generally act well; but we must be prepared to meet with doubtful or no success in many cases, for pericarditis is but rarely a primary disease. Myocardial changes (fatty degeneration mostly in the adult), chronic interstitial myocarditis, or tubercle, or syphilitic gumma, or complications with purulent mediastinitis or pleu- ritis, are not uncommon. In pneumonia, pleurisy, rheumatism, * From birth to the seventh year the volume of the heart increases from twenty-three to one hundred cubic centimetres, by no means in proportion to the -weight of the body. Still, this increase is very much greater than that of the lumen of the arteries when compared with the length of the body. The pulmonary artery is wider than the aorta until puberty; afterwards they are equal or the aorta becomes larger. The subclavian arteries and the common carotids are very wide com- pared with the length of the body (thereby causing physiological and pathological congestions of the cranium and its contents). Between seven and fifteen years the volume of the heart is from one hundred and thirty to one hundred and forty cubic centimetres; at that time the large arteries increase in absolute width, in accordance with the rules given before. 528 THERAPEUTICS OF INFANCY AND CHILDHOOD. and scarlatina pericarditis is not unusual. The internal treat- ment of pericarditis is, therefore, in part directed by the com- plications. Digitalis is indicated mainly in cases which are rather complicated; strophanthus, convallaria, and iodide of potassium may take its place or be combined with it, according to the suggestions made before. Morphine is demanded in most cases, if only to give rest for the night. The fever may require phenacetin or (during a remission) quinine. After the fever has disappeared, or while it is waning, absorption of the effusion may be promoted by caffeine, sparteine, diuretin, iodides, and a vesicatory over the heart. Effusion into the pericardium is not often so copious as to produce suffocation, but I am afraid that puncture of the pericardium to relieve the fatal pressure is not made so often as it ought to be. Fortu- nately, errors in the diagnosis are not very easily made; still, they do occur, for I have been called to perform paracentesis where there was some pericarditis, more hypertrophy, and much pleurisy. The operation is not difficult, the liquid being so copious as to give the heart ample space to recede in a semi- recumbent position. The aspiration can be made in the mam- millary line, in the sixth intercostal space. In the same neighborhood, at the upper margin of the fifth or sixth rib, the incision can be made to remove pus, and irrigations may be made afterwards. Drainage has also been established in such cases. The heart has been punctured during the aspiration without evil result; but I am not prepared to say, even with Biedert, that "the puncturing of the heart is not connected with any danger." Hydropericardium, no matter from what cause, must be treated on the same principles as those which are valid for hydrothorax. Syphilis of the pericardium and of the heart, if diagnosti- cated, require their own specific treatment. Congenital anomalies of the heart claim attention from the moment of birth. The newly-born candidate for cyanosis is DISEASES OF THE ORGANS OF CIRCULATION. 529 liable to suffer from asphyxia, the rules for the treatment of which need no repetition here. When the troubles, being the result of embryonic arrests of development or of fcetal inflam- mations, prove incurable, almost the only thing to be done for the little sufferers is to protect them as much as possible. If they be so unfortunate as to grow up, exercise should be avoided, — indeed, is avoided. Alcohol is indicated in condi- tions of collapse only; no blood must ever be taken; laxatives should be sparely given if at all. The temperature in which the little waifs are to live ought to be equable, moderately warm, their wearing apparel warm and comfortable. Conges- tive disorders which would require the use of cold in otherwise healthy children must mostly do without it, as the patients seldom bear it. Mild vegetable acids are coveted by most. Only those who appear to develop hypertrophy of the heart should take digitalis or strophanthus. Small doses of an opiate will often relieve their discomfort and dyspnoea. The combina- tion of digitalis with iodides, administered for months in suc- cession, gave relief in a number of cases where the patients lived four years and more. There are anomalies of the infant heart which are congenital, or nearly so, and still not comparable in dignity to arrests of development. Eheumatism, scarlatina (rarely), or inflamma- tions of some intrathoracic viscus, when contracted in early life, may result in cardiac complications. They are on the left side of the heart (while fcetal endocarditis affects the right half pre-eminently). Hematoma at the free margin of the mitral valve is formed immediately, or soon after birth, below the endocardium. It is liable to disappear, and with it the systolic mitral murmur caused by it; but excrescences, hard noduli (Cruveilhier), cicatrization, and insufficiency of the mitral valve may persist. (Luschka, Yirch. Arch., xi.) The latter is easily diagnosticated and requires the usual treatment of acquired chronic endocarditis. Congenital undersize of the heart does not appear to be so 34 530 THERAPEUTICS OF INFANCY AND CHILDHOOD. frequent as that of the arteries. Indeed, in many cases of under- sized arteries it was found of normal size, or somewhat larger. In the latter case the heart was not always hypertrophic; on the contrary, in most instances there was some fatty degenera- tion of the flabby muscle. Like every small organ, the small heart, whenever found, may be built up by moderate and per- sistent gymnastic exercise, a small dose of strychnine given three times a day for weeks or months in succession, cold washing and friction and an altitude of one thousand to fifteen hundred feet. A certain amount of muscular hyper- trophy will probably result from it; it is quite welcome, for the labor of the heart requires either an organ of sufficient size or one of unusual strength. 2. Blood-Vessels. The structure of the blood-vessels may be very defective, the walls being thin, fragile, and pervious. In such cases hemor- rhage, small or copious, is a frequent symptom. The frequency of hemorrhages in the newly-born, leading, when in the cranial cavity, to asphyxia, convulsions, idiocy, or early death, is caused by the thinness of the vessel walls, whose tissue has not yet quite evolved from its embryonal condition. This, or a similar condition, may continue for life. This hypoplastic state, however, is not, of necessity, general: it may be local. The early nose-bleedings of some, though they have no heart- disease, and the congenital tendency to aneurism in places where the elastic tissue, either from arrest of local development, or by microbic destruction, is either scanty or absent (mostly at the origin of branches), prove the occasional occurrence of these circumscribed and local defects. A uniform thinness of the arteries, however, is most likely to be complicated with narrowness, which has been studied by Virchow, See, and others in its relation to incurable chlorosis, palpitation, and cardiac asthma. That thinness which predisposes to fatty degeneration of the intima and media, to sclerosis of the ad- DISEASES OF THE OKGANS OF CIRCULATION. 531 ventitia, to atheromatous endarteritis, and to the formation of aneurism at an early age has not been made the subject of active treatment, so far as I know, except by myself. The number of such cases is naturally small compared with the total number of a large practice or clinic; but I feel convinced that the administration of phosphorus, — not phosphates of any kind, — with its stimulant effect on the growth of connective tissue in general, has rendered me good service in habitual ten- dency to cutaneous, mucous, and internal hemorrhages. Ecemo- philia of moderate degrees appeared to improve under its use, and the children to be safer and better developed. The dose for a child of three years should be from one-fiftieth to one- thirtieth of a grain (0.001-0.002) daily; that means from two to three minims of the oleum phosphoratum, or from one to one and a half teaspoonfuls daily of the elixir phosphori (United States Pharmacopoeia of 1890). Thrombosis of veins in general, and of the sinuses of the dura mater in particular, is the result of retardation of the (general or) local circulation and of coagulation of blood by marasmus from whatever cause: rapid elimination of water (cholera in- fantum), debility of the heart, pressure on veins, or inflamma- tion in the neighborhood (for instance, caries of the petrous bone). In the same way thrombosis of the femoral vein may be caused by peritonitis or by a pelvic tumor. In the cranium the right transverse sinus is most frequently affected, but quite often also the inferior petrous, cavernous, and longitudinal sinuses. Such thromboses cause hyperemia, oedema, or extrav- asations; it is by their symptoms that the diagnosis is made. The treatment must be preventive in order to be successful. Early attention to the ear and mastoid process, treatment of diarrhoea before inspissation of the blood and heart-failure take place, timely stimulating and roborant treatment, and not pro re nata, — that is, when it is just a little too late, — are the best preventives. The subcutaneous injection of large quantities of warm sterilized water, with chloride of sodium (1000 : 7), 532 THEEAPEUTICS OF INFANCY AND CHILDHOOD. is capable of preventing the inspissation of the blood which results from acute and copious diarrhoea, and often proves life- saving. Congenital local dilatations of blood-vessels, capillaries, smallest veins, and smallest arteries, together with an increase of their number, and mostly with incompetent structure, are known by the names of ncevus, telangiectasia, angioma. Their color depends on the nature of the blood-vessels composing the anomaly, also on their distance from the surface, their size on the extension of the morbid process, and their size and con- sistency on the admixture of connective tissue. They are found in all sorts of tissues and organs, mostly on the surface of the body. In the subcutaneous tissue, when mixed with much connective tissue, they are liable, after having remained unchanged for many years, to undergo sarcomatous degenera- tion. Therefore, and because of their tendency to rapid growth in every direction, with increasing deformity and possible dan- ger from hemorrhage, the early removal of all those which do not exhibit from the beginning a tendency to fade and finally disappear is indicated. The methods followed to obtain that end are very numerous. Vaccination over a nsevus will gen- erally destroy it, but may do so but partially, and will leave a bad scar. The plasters of tartar emetic and of Vienna paste cannot be controlled to such an extent as to destroy the growth only. Injections of the perchloride or of the subsulphate of iron are known to have given rise to extensive thrombosis, gangrene, and death; injections of alcohol have been tried, but have not, I think, reached further than the ear of the medical public. Corrosive sublimate in collodion (1 : 8) is an excellent caustic where the naevus is not extensive, particularly on the head; it rarely requires more than a single application. Fuming nitric acid is perhaps the best of all local applications; the pain is but temporary, and the effect circumscribed and fairly thorough. But it ought to be used for superficial naevi. only, and even then requires repetition in a number of in- DISEASES OF THE ORGANS OF CIRCULATION. 533 stances. Excision is a good method if the operation can be performed in a short time and all the morbid parts can be safely removed without loss of too much blood. The ligation of angiomatous tumors is indicated where they can be entirely grasped either without or with the aid of needles run through their base; but time is required for them to fall off finally, and the wound demands careful and persistent antiseptic treat- ment until the danger from local infection has passed and a smooth scar has been perfected. Electrolysis has been praised very highly, particularly in the treatment of the extensive wine- marks. Still, personally, 1 never saw a satisfactory result in these cases. There remained always speckled, whitish scars of small size alternating with the original discoloration, a result which I should not claim as an improvement upon the original condition. The actual cautery is the most satisfactory of all our remedies; very few will at present use it in any other shape than that of the galvanic or the thermo-cautery. The heat should not be excessive; white heat destroys blood-vessels too rapidly to permit of simultaneous coagulation of the blood, and produces hemorrhages. Dull-red heat will accomplish a cure. A momentary application suffices for a superficial naevus; its action can always be controlled and strictly localized, and the formation of the scurf secures against surface infection. Nor are large angiomata inaccessible to it. When these are to be destroyed, it is best not to attempt too much at first. It is unnecessary to destroy everything; long after the direct effect has passed away, coagulation in the blood-vessels and slowly- progressing cicatrization result in the gradual lessening of the swelling. When the tumor ceases to diminish in size, the oper- ation is repeated, sometimes after many weeks or even months. The cautery is then introduced into the very spot where the previous application was made. In this way the cicatrix re- mains localized. As a general rule, a cicatrix following the application of the actual cautery is smooth and becomes more so and less perceptible from year to year. 534 THERAPEUTICS OF INFANCY AND CHILDHOOD. 3. The Lymph-Vessels. Lymphangioma is the dilatation of lymph-vessels, localized or multiple, with or without proliferations extending from the walls of the lymph-vessels. Careless operation with the knife may lead to lymphorrhoea; several I removed with the actual cautery. When in the skin, multiple, and connected with hy- pertrophy and oedema of the cutis, either localized (neck, shoul- der, dorsum, extremities) or diffuse, it is called elephantiasis. It may be removed when not so extensive as even to preclude, after removal, skin-grafting to replace the defect. Of chyluria (lymphorrhoea into the urinary organs), such as is frequent in tropical regions under the influence of filaria sanguinis, and was observed by Bouchut in a hysterical girl of fifteen (no cause known), I have seen one case in a child of eleven years. Kamienski has the case of chylous ascites in a baby of five weeks. Paracentesis appeared to be harmful, re- covery was spontaneous. ("Jahrb. f. Kind.," xli.) Cystic lymphangioma (hygroma, on the neck and in the axilla) is unilocular or multilocular, slightly movable, fluc- tuating, not compressible because there is no longer any open communication with the rest of the lymph-system. On the neck it may be mistaken for the hygroma resulting from a partially patent and endwise obstructed branchial arch. The total extirpation is the preferable operation if it can be done. Puncture and subsequent irritation by injection of alco- hol, or Lugol's solution, or diluted carbolic acid (3-5 per cent.), may require repetition in multilocular cases. That is why in- cision of the cavities and subsequent iodoform drainage should be preferred. XI. DISEASES OF THE SKIN. Burns. — Burns of the first degree require rarely more than cooling applications and rest, both general and local, water, lead wash of different strengths, oil, and cotton. Persistent cold applications are not tolerated. When large blisters have been formed, the epidermis should be removed and the sore sur- face irrigated with an antiseptic solution or an aseptic steril- ized saline solution (6 : 1000) and thoroughly dusted with sub- nitrate of bismuth or dermatol. An aseptic dressing then applied may remain eight or ten days; after that time the sores will generally be found cicatrized. Individual cases and op- portunities may command different methods. The time- honored application of equal parts of lime-water and oleum lini, to which a twentieth of a per cent, of thymol may be added, are still much favored. The burn should then be thickly covered with aseptic gauze. After this application is removed, a fine powder of bismuth nitrate should be spread over the wound and the whole covered with gauze again, or an ointment containing bismuth, or bismuth and boracic acid, or bismuth and zinc may be employed. To thoroughly guard against in- fection, the washing of the wound with a three-per-cent. solu- tion of carbolic acid, or of salicylic acid, or of boracic acid (not so painful as the other two) must precede the application of a gauze thoroughly covered with bismuth subnitrate finely pow- dered, or with a mixture of bismuth and starch, or the same with the addition of from one to two per cent, of salicylic acid. Such an application may remain undisturbed for weeks. Ex- 535 536 THERAPEUTICS OF INFANCY AND CHILDHOOD. tensive burns do well in the permanent warm bath. Should large defects result, transplantation may be practised after- wards; if contractures, extension must be employed in time and apparatuses used for a sufficient period. The younger the patients the more liable are they to suffer from burns, though apparently mild. Reflex symptoms of a nervous character are not quite so bad as the transformation of haemoglobin into methsemoglobin, or the toxic swelling of lymphatic glands, both, or either of which conditions are held responsible for the excessive dangerousness of extensive burns. Much reaction may set in after a day, with high fever and con- vulsions. Therefore the thermometer ought to be consulted soon after the accident and the symptoms prevented or treated. Diarrhoea is not uncommon, even after moderate burns, and requires opium and the regulation of diet; collapse demands stimulants, either internal or subcutaneous; and sleeplessness appropriate narcotics. Burns are more frequent than are the effects of cold, though there are patients who suffer every year. Common frost-bites are frequent, it is true, and annoying, but rarely of great im- portance. The rubbing of red, itching, and swollen parts with snow (or with petroleum) is quite effective in mild cases. The itching is often relieved by a mild tincture of iodine or by the application of a (from three to ten per cent.) solution of nitrate of silver or of chloride of calcium in water (1-2 : 100), also by camphor in lanolin (1 : 10). The popular remedies of tallow and whiskey or, better still, the application of carpenter's glue to frost-bites bring relief. This may also be obtained by sur- rounding the inflamed swelling by a protecting (corn) plaster. Vesicles on the toes and heels, filled with blood and resulting in ulcerations, require the latter treatment, together with sub- nitrate of bismuth, naphthalin, or cauterization with nitrate of silver until granulations spring up, or an ointment of balsam of Peru with or without zinc oxide, or bismuth, or applications of a three-per-cent. solution of acetate of aluminium. Gangrene DISEASES OF THE SKIN. 537 of the skin or of whole extremities is, fortunately, rare. When it occurs it demands rational surgical treatment. Erythema is met with at every age of infancy and childhood, and depends on a number of causes. The treatment is, there- 'fore, partly symptomatic, partly causal. In the newly-born, from the establishment of an unprecedented cutaneous circula- tion and the discontinuation of the intrauterine amniotic pressure, the skin becomes red, changes into yellow (alterations of haematin), is subject to extensive peeling, and, finally, ob- tains its normal pink color under ordinary circumstances. The erythema, however, is not always uniform; now and then it bears a resemblance to measles, and is attended by fever, but not by catarrh. As a rule, it demands no treatment, except preventive. The bath must not be hot, the temperature of the room not abnormally high, the bedding not hot and oppressive. Vaseline, cold cream, or lanolin is useful where the redness and the tendency to peeling are very marked. In the following months erythema is a common symptom when the babies are exposed to pressure or friction by clothing, to the heat of the summer, of stoves, bedding, or bathing, to irritation by urine, or to the septicemic after-effects of infec- tious fevers, such as measles, angina, diphtheria, typhoid, or influenza. In some of these cases desquamation is observed; it is the mbre readily a cause of mistaken diagnosis the longer it lasts and the greater its extent proves to be. Children of three or four years, when afflicted with diarrhoea and consecu- tive cachexia, are subject to a papular erythema which is mostly confined to the gluteal regions and the extremities. Finally, thin and feeble children exhibit frequently a general redness, sometimes mottled, which lasts as long as does the sluggish circulation depending on their general condition. The indications for treatment in all of these varieties are furnished by the causes. Irritation of the surface should be avoided; the patient must not be exposed to abnormal temper- atures, either of air or water, or to errors in diet; diarrhoea 538 THEBAPEUTICS OF INFANCY AND CHILDHOOD. and emaciation must be arrested, and vaseline and fats used according to necessities. In many cases a full supply of drink- ing-water, which is too frequently withheld from the very young, corrects the evil by stimulating cutaneous circulation and the tendency to perspiration, which is almost absent during the first month and very scanty in the second and third. Constipated and dyspeptic children are very apt to suffer from erythema as the result of intestinal autoinfection, some- times to such an extent that the diagnosis between it and scar- latina may become doubtful. The difficulty grows in those cases in which the intestinal erythema is attended by the corre- sponding intestinal fever, an occurrence not at all uncommon. Constipation may be congenital or acquired, and may lead to the same result. The diagnosis is not always easy for other reasons, — viz., the apparent normality of the stomach, the absence of diarrhoea, and the actual or alleged absence of flat- ulency. This erythema is not uncommon; it may last hours or many days, or may alternate with acute attacks of urticaria. The latter is, therefore, not always gastric or neurotic, either in its acute or chronic form, but may be toxic, and it thus shares the etiology of many cases of acne and some of senile pruritus. When occurring in the face exclusively, I have seen it mistaken for erysipelas. This variety of erythema is sometimes seen mostly on the hands and feet, is symmetrical, and now and then, like urti- caria, has vesicles or bullae (similar to herpes iris). When it ac- companies intestinal autoinfection, it is usually accompanied by indican and the ether-sulphuric acids in the urine, which is liable to be very scanty and of high specific gravity. Skatol and indol are found in the faeces. In most cases a purgative (pref- erably calomel) will bring speedy relief, but actual and lasting aid will only come from prolonged disinfection of the intestinal tract by naphthalin, salol, resorcin, oil of peppermint, small doses of calomel or bichloride of hydrargyrum, from large enemata containing a twentieth of one per cent, of thymol, or DISEASES OF THE SKIN. 539 from such as consist of aromatic infusions (mint, catnip, chamomile) exclusively, from occasional purgatives, and from the regulation of the diet, which must be such as not to cause fermentation and putrefaction. In the employment of the sulphites (of sodium and magnesium) I have been rather disap- pointed. The use of menthol is not to be recommended; it can be swallowed in capsules only, and to atone for its local irritation it has no eminent virtues. Erythema nodosum may be discussed in connection with this subject. It consists of large nodes, whose redness turns yellow in the course of the normal alterations of haematin; it is mostly seen on the legs, but also along a number of tendons from the occiput downward. It requires rest. When it is the result of rheumatism, salicylate of sodium is indicated; when it de- pends on malaria (Moncorvo), quinine. A six-per-cent. solution of nitrate of silver has been recommended for external applica- tion. I have used with benefit, I believe, inunctions of oleum gaultheriae, of iodide of potassium in glycerin (1 : 2-4), and of iodide of potassium and lanolin ointments. Erythema complicated with loss otf epidermis, either spon- taneously or through irritation by urine or faeces, or by friction of the adjoining surfaces of the nates, thighs, axillae, and the folds of the neck, together with secretion, and even crusts, is called intertrigo. It is mainly noticed in fat, flabby, and rhachitical babies, is painful and annoying, and may prove dangerous by becoming gangrenous or by inviting the invasion of erysipelas or of diphtheria. Therefore, its treatment and cure are imperative. The diapers must be soft, not pinned during sleep, and frequently changed; the babies must be kept scru- pulously clean and bathed at least once a day. A seven-per- mille solution of table-salt is more pleasant than water alone. Diarrhoea should be relieved by dieting, internal medication, and rectal injections. Astringent solutions (sulphate of zinc, acetate of aluminium, tannin) would be beneficial but for the difficulty of making regular applications; ointments containing 540 THERAPEUTICS OF INFANCY AND CHILDHOOD. zinc oxide, bismuth, tannin, or lead are preferable. Fine pow- ders of bismuth subnitrate, of talcum, of amylum, or mixtures of two of them, with or without the addition of one or two per cent, of salicylic acid, will act satisfactorily. The popular lyco- podium powder is not to be recommended. By reason of its gluing together it proves irritant, like all foreign bodies. Among the circumscribed inflammations of the skin met with in children, mostly of advanced age, are acne, lichen, and 'prurigo. Acne is dependent on an interrupted action of the sebaceous follicles. They begin their rapid development about the middle of intrauterine life, and are large and numerous at birth, particularly over the nose, ear, eyebrows, and around the mouth. When obstructed, they exhibit in the infant no black-heads like the comedones of the adolescent or adult, but are white. Normally, they secrete much tallow, which gives the foreheads of many babies their shining, glossy appearance. When this tallow accumulates and gets dry, and mixes with the scabs of the epidermis and foreign material, such as dust, etc., it forms seborrheica of any shade of color between whitish and black, which is more difficult to remove because of the conservative superstition of the mother than because of its own obstinacy. Its importance and its dangers are quite local; it interferes with the growth of hair and predisposes to local irri- tation of the scalp; it ought to be removed by oil, fat, soap, hot water, and brush, and the subjacent hyperemia relieved by an astringent ointment. When acne has formed (in older children) the comedones ought to be squeezed out. For this purpose an old-fashioned watch-key with broad edges will prove as serviceable as the mechanical devices of instrument-makers. Frequent hot wash- ing with green soap, or spirits of soap, followed by ice-cold washing, I have found very useful; besides, the skin should be washed four times a day with a solution of corrosive sub- limate in water, or in alcohol and water (1 : 20 : 2000 or 1 : 20 : 1000). DISEASES OF THE SKIN. 541 Washing with vinegar dissolves the epidermis cells and thus aids in disintegrating and loosening the obnoxious material. Various mixtures of emplastrum and unguentum plumbi may be employed. After a thorough cleansing with soap, equal parts of precipitated sulphur, glycerin, and alcohol (to be pre- served in a well-stoppered jar) are applied in the evening and washed off in the morning; or beta-naphthol 10 parts, pre- cipitated sulphur 50 parts, lanolin or vaseline 25 parts, and green soap 25 parts are applied, and removed by washing after fifteen or twenty minutes, after which the skin is covered with talcum or starch. Only in the very worst forms of acne (for- tunately, rare in children) must scarifications be resorted to. Lichen is mostly found in its mildest form: strophulus of pin-head size, slightly excavated on top, around a hair. It is not particularly resistant, but is liable to return. Lichen scrofulosorum, however, is apt to be obstinate. It is mostly met with in older children, is of a yellowish or red color, and forms a circle around a hair. It does not itch very much, but by reason of its duration and appearance is quite annoying. Locally, warm bathing and frequent ablutions with vinegar and water (1 : 3-6) will act well. Antipyrin in a nightly dose will relieve itching whenever troublesome, and by its sudorific effect will contribute to the disintegration of epidermic accumula- tions. The general treatment of scrofula is required on ac- count of its causal indication. Lichen acuminatus and planus consist of circular nodules congregated round a pigmented spot, the first in rows, the second flat. Both are rare in children. Prurigo is found, of pin-head size and pink color, on the extensor side of extremities and in the gluteal region and on the abdomen. In its neighborhood the lymph-bodies swell, and chronic pigmentations are frequent. The itching is terrible, intolerable, exhausting, and may prove fatal. Twice I saw it complicated with or depending on diabetes; in both cases it terminated only with the fatal cause. Inunctions of glycerin or fat and protracted warm bathing in water or alkaline water 542 THERAPEUTICS OF INFANCY AND CHILDHOOD. should be resorted to. The baths ought to be continued for hours, and may be allowed to last half a day. Vinegar will dissolve the epidermis. Pilocarpine will do well in subcu- taneous injections large enough to produce perspiration. As much and as long as permissible it may be combined with anti- pyrin; and if subcutaneous injections be found impossible, it ought to be administered internally. Tar, sulphur, and green soap have been found very useful, when continued for from four to six weeks in alternation with warm baths. Wilkinson's ointment contains all of them (flor. sulphuris, ol. rusci, aa 10 parts; sapon. virid., vaselin., aa 20 parts). Kaposi recommends naphthol ointment (5 : 100). The addition of five per cent, of menthol to every ointment used will prove helpful. But it should not be forgotten that the prognosis becomes more serious with every month or year of the duration of prurigo, and that general and preventive treatment demand urgent consideration. Most patients are stricken in their second year; thus a hereditary influence is to be suspected in many. Often the parents are tubercular. Both prurigo and lichen (also acne in the severe form — rosacea — of adults) will often be benefited by ichthyol (thiol has been recommended for the same purpose, locally) in from five- to twenty-per-cent. ointments. It may also be given in- ternally when there are hard and irritating infiltrations, in daily doses of from five to twelve grains (0.3-0.8). Other inter- nal medication is useless, except arsenic, an occasional purga- tive, and now and then a sedative (monobromate of camphor at bedtime in doses of from two to six grains = 0.125-0.4); strict avoidance of stimulants, and moderate use only of meat, are the main dietetic rules. Furunculosis in the very young does not often exhibit the same character as in adults. Both the sebaceous follicles and the perspiratory glands being rather patent, there are rarely such large and hard indurations. It is often complicated with acne, or follows eczema, and may complicate scabies. It is DISEASES OF THE SKIN. 543 frequently found in cachectic infants and children and after protracted diarrhoea, generally in the form of multiple and cold abscesses; sometimes in connection with tuberculosis. These abscesses are liable to lead to extensive suppurations of the connective tissue. The skin must be kept disinfected either by blue ointment or by corrosive sublimate in water (1 : 2000- 5000). Abscesses — no matter how many — must be incised and disinfected with sublimate solution, or iodoform, or treated with the sharp spoon, or filled with antiseptic gauze, according to circumstances and to sizes. Now and then these abscesses are found near the matrix of the nails, not multiple as in syphi- lis, but localized, and are liable to destroy the matrix unless incised and disinfected in time. Secondary lymphatic swell- ings round the neck will, when benign, disappear after a while. If not, they are probably tubercular, and if persistent, without a tendency to get smaller, ought to be enucleated. A preven- tive measure is the covering up of incipient furuncles with some indifferent plaster (saponis, belladonna?; no turpentine) to avoid the friction of the clothing. Arsenic in small doses, but persistently given, has a favorable effect. One of the most common forms of dermatitis in the young is eczema in its different forms, from the small vesicular and papular, with but slight desquamation or the formation of thin scabs, to the purulent variety, impetigo, with moderate crusts, and the rapidly growing and pointed ecthyma and rupia. For, indeed, all of them are but varieties of the same process. It may be microbic in isolated cases, but certainly is not a mi- crobic disease generally. It may be complicated, however, with a parasitic ailment such as scabies. A disposition is caused by the tendency to congestive, catarrhal, or inflammatory dis- order such as is understood by "scrofula," not by tuberculosis; also by rhachitis, chronic indigestion, and anaemia; also by incidental fevers, — for instance, that of vaccinia; indeed, it is not uncommon to date the first appearance of eczema back to the effect of vaccination. These occasional or constitutional 544 THERAPEUTICS OF INFANCY AND CHILDHOOD. partial causes of eczema must be considered as regards general and constitutional treatment. These are the cases apt to be benefited first by appropriate diet, then by the protracted use of arsenic, the hypophosphites, cod-liver oil, and iron. Still, it is important never to be tempted to begin such a treatment in an acute attack of eczema, which is more apt to be benefited by a few moderate doses of quinine and purgatives. Acute eczema is liable to run its course with a great deal of swelling and irritation, resembling in these respects ery- sipelas. It bears absolutely no water, and in the beginning no ointments. Powders of amylum, or of subnitrate of bismuth, or oxide of zinc, or aristol, pure or in different proportions, with or without the addition of one or three per cent, of sali- cylic acid, prove more efficient. After a while the same con- stituents may be used as ointments. Most of the cases presented for treatment are chronic, either in the moist, or crusty, or squamous form. Many of them are itching, and are apt to lead to persistent infiltration of the skin, even amounting to elephantiasis. In many of them the original local causes are still persistent and can and must be relieved or removed. All sorts of local irritation are found. Sebor- rhea, uncleanliness, secretions of the nose, ear, and eye which are permitted to remain and irritate the neighborhood, the oral secretion from whatever cause excoriating the cheeks and chin, the septic piercing of the ear, the presence of vermin on the skin, are all frequent causes of eczema, the predisposition to which is established on certain parts of the body where eczema is most common (head and face) through the large size of the carotids and the physiological congestion and rapid develop- ment of the head and all its organs. By mistaking this connec- tion, even the protrusion of the teeth has been charged with producing eczema. Indeed, everything causing sluggish circu- lation and congestion to the surface — the constipation, for in- stance, of fat babies, hot bathing, the influence of solar and stove heat — may have the same result. DISEASES OF THE SKIN. 545 The effect of protracted eczema on the head is liable to be grave by its interfering with the growth of the hair; by caus- ing and extending catarrh of the ear and nose, or blepharitis, conjunctivitis, or keratitis; by producing open sores and thus facilitating the invasion of erysipelas and possibly of tubercle germs; by irritating and tumefying the numerous lymph- bodies of the neighborhood with the complication of hyper- plasia or tuberculosis. Thus, the indications for treatment should be considered urgent in every case of eczema; the sooner it is suppressed the smaller is the number of complicating dan- gers which are direct outgrowths of what appears to be, in most cases, a merely local affection. The necessity for local as well as general hygienic and constitutional — mostly preventive — treatment is pre-eminent. The body of the infant must be kept clean, but the local eczema should not be touched by water more than is absolutely neces- sary; the reaction after the bath is liable to bring out a new eruption. If the eruption be on the head, the hair should be cropped close. The nails must be kept short so as to prevent scratching to a certain degree. Remove thin or thick scabs by warm water, soap and water, warm fomentations (not on the head), oil, fat, liquor potassii in oil or in cod-liver oil (1 : 8-12). Use the comb when the scabs are beginning to loosen. Below them the surface is hypera?mic or oozing; therefore the secre- tion must be dipped up and stopped as soon as possible. Solu- tions of astringents are neither so convenient nor so effective as ointments. The official zinc ointment will suffice in many cases. Vaseline by itself is irritating. Bismuth subnitrate 5 parts, with ungt. zinci and vaselin., aa 20 parts, is a good com- bination. Such applications may be made from two to five times a day. Hebra's ointment is thickly spread on linen and the surface covered with it; layers of it may be worn for days or weeks. There is no harm in the extensive use of lead; I never saw or heard of a case of direct cutaneous absorption which stood criticism, but I have seen lead-poisoning in a 35 546 THERAPEUTICS OF INFANCY AND CHILDHOOD. boy who scraped the lead ointment from his cheeks and ate it for many weeks in succession. The formulae now and then published in the journals are very numerous; every thoughtful practitioner will make or combine his own from bismuth, zinc, lead, or tannin. In addition to these, I mention for inveterate cases and the scaly form tar (tar, alcohol, and green soap in equal quantities, or ol. cadinum 1 part, ol. oliv. 1 part, lanolin. 10 parts) and hydrargyrum ammoniatum (either the official ointment or a modified formula, such as zinc oxide 1 part, hydrate of ammonia 1 part, ol. amygdal. dulc. 1 part, fat 10 parts), and, finally, nitrate of silver. It is mainly in the most obstinate chronic cases of eczema — the crustaceous or squa- mous variety — that a large surface will heal under the influ- ence of a solution of from three to ten to forty per cent, of nitrate of silver, thoroughly applied. Tar has but one grave inconvenience. On skins which ab- sorb rapidly it may prove dangerous to the kidneys. Nausea, vomiting, diarrhoea, headaches, vertigo, and a smoky or even black urine, occasionally with more than mere albuminuria, may be observed. The same, to a greater degree, must be said of carbolic acid, which may be added to ointments (2-3 : 100) to relieve itching. It requires watching. Where it cannot be used, cocaine (2-5 : 100)^ ointment of lead, zinc, or bismuth may take its place. Where the surface healing is slow, the pro- liferation of tissue can be accelerated by balsam of Peru (1 : 10) ointment. Bulkley recommends, even in acute eczema, alumnol, one to five per cent, in solution, ten to twenty per cent, in oint- ments. "Eczema sehorrhoicum" (Unna) is a parasitic (microbic) affec- tion. The ointment of zinc should be mixed with four or six per cent, of resorcin; or a solution of resorcin (five to ten per cent.) in alcohol and glycerin to be used twice a day. Pemphigus is more frequently observed in the newly-born and very young than in older children, mostly on the face and trunk, with a pale or hyperaemic basis, running its course, in- DISEASES OF THE SKIN. 547 elusive of the drying of scabs, in from six to twelve days. It is seldom chronic, and mostly so mild that no scabs remain, ex- cept when it is complicated with diphtheria or general cachexia. The serum (albuminous and mostly neutral or alkaline) con- tained in the bullae, which spring up at some distance from each other, becomes turbid after some days, but is seldom san- guineous. There is rarely any fever. New crops may start up. Strelitz and Almquist gave themselves pemphigus through cocci. Kiehl found in a single case a fungus resembling very much the trichophyton tonsurans. It is often found on the children in institutions, and will also spread to nurses or to members of the same family; it seems, therefore, to be con- tagious, and may get disseminated through careless midwives. Isolated cases are the result of hot bathing and bedding. Thus it seems that this disseminated pemphigus may be either the result of microbes (staphylococci, like those of impetigo) or of mere cutaneous irritation, particularly at the time when the surface is most vulnerable, that is, in the newly-born. In him dermatitis exfoliativa is the result of hot bathing, the hot sea- son, perhaps of sepsis. Dermatol, aristol, subnitrate of bis- muth, powdered, or in a five- or fifteen-per-cent. lanolin oint- ment, with soft covering, warmth to the feet, stimulants, and no bathing is the appropriate treatment. The treatment is suggested by the causes thus far enumerated. Beware of heat and of contagion. Cleanliness and disinfection are required as preventive and curative measures. Astringent ointments or bismuth powders are demanded locally, particularly where the epidermis has been torn off; general roborant treatment is required for puny and cachectic children, and antipyretics if (in exceptional cases) the temperature rise to an unbearable de- gree; for even delirium has been observed. In most cases pow- ders of bismuth, talcum, amylum, zinc oxide, etc., render good service. Pemphigus foliaceus, where no scabs form, but relapses take place contiguous to the first starting-point, is serious and apt 548 THERAPEUTICS OF INFANCY AND CHILDHOOD. to terminate fatally. Pemphigus exfoliativus, which, accord- ing to Bitter, begins at the mouth and extends all over the body, with an angry redness, gangrene, and phlegmons, and is fatal in one-half of the cases, requires careful and roborant nutrition, astringent ointments and baths, and stimulation. Neuropathic affections of the skin are apt to be congenital; while not always connected with cerebral defects resulting in paralysis or epilepsy, like the papillomata described by Neu- mann (fissured warts following the course of a nerve and cov- ering the whole side of a body), still, they are serious enough, and sometimes not influenced by treatment. The congenital disposition to the formation of vesicles is in later life often combined with other neuropathic symptoms. The pemphigus neuroticus chronicus described by me (Trans. Ass. Am. Phys., 1894) is of that nature. To this class also belongs urticaria pig- mentosa, which yields ever-returning crops, many of them with consecutive and persistent pigmentation. Even common warts are probably, in many instances, trophic disorders of a neurotic character; their sudden appearance in great numbers and their sometimes unexpected disappearance seem to prove it. While fuming nitric acid is a fair local application, the internal use of arsenic is often of much advantage. This is certainly the case in what has been noticed first by Hebra as "verrucae planse juveniles," and carefully described by Thin. These warts are met with in children and adolescents on the face and back of the hands and fingers; they are yellowish or reddish brown, of the size of a pea or less, flat with a central de- pression, and may have frequently been mistaken for lichen ruber planus. A neuropathic oedema has been described by Widowitz; it makes itself known, after exposure to cold, by extensive tume- faction with livid edges, and without any complication on the part of heart or kidneys. A neurotic cyanosis has been re- ported by Tordeus, and by him connected with dentition, viti- ligo in a boy of six years by Wladimiroff. DISEASES OF THE SKIN. 549 Symmetrical cutaneous hemorrhage connected with cerebral disorder has been reported by Epstein; erythromelalgia in a child, by Baginsky; symmetrical cutaneous gangrene (Raymond) of feet, nose, and ears, with hemoglobinuria, in a boy of three years, by Abercrombie; in children of seven, eleven, and thir- teen years, belonging to the same family, by Braman. Scleroderma has many of its (fortunately few) victims among children. It has been observed in the first year of life (Barth). I saw it in a girl of three, a girl of six, a boy of ten, and one of thirteen years. It begins with mostly symmetrical circum- scribed, mostly longitudinal, discolored hyperplasias, which (usually) after a long time lead to atrophy, shrinking, muscular immobility, and contractures. I never saw a case in a child or an adult that did not give me the impression of a neurotic (local, or more frequently central) origin. Mainly in the be- ginning mercurial treatment, in long-continued small doses, did some good. Salol (salicylic acid) has lately been recom- mended by A. Philippson, who reports two recoveries (adults) under doses of from two to three grammes (grs. 30-45) daily. L. Weber improved a case by giving thyreoid (Med. Monatssch., October, 1897). Scabies is apt to become chronic in children because it ia often mistaken for or complicated with the various forms of eczema and "prickly heat." Errors may readily take place because it is not pre-eminently the fingers which are affected, but also the face, the gluteal region, the abdomen, and the joints. These localities constitute a difference from prurigo, in which the extensor sides of the extremities are principally af- fected. The skin must be thoroughly cleansed with soap every morning, after balsam of Peru, or balsam of Peru 15 parts, alco- hol 10 parts, or balsam of Peru and vaseline, in equal parts, have been copiously applied the evening before. A few such applications will suffice, but they stain the linen. The un- guentum sulphuris of the Pharmacopoeia is too irritating to be applied to the skin of children, but may be mitigated by the ad- 550 THERAPEUTICS OF INFANCY AND CHILDHOOD. dition of fat, styrax liquidus, and olive oil, in equal parts; creolin (5-10 parts in 100 parts of olive oil) or naphthol with fat (5-15 : 100) will also render good service. The clothing must be thoroughly washed in hot soap and water, or disin- fected with sulphur. Both naphthol and styrax may irritate the kidneys, so that both are contraindicated in children with renal affections. In them, Williamson's ointment (ol. rusci, flor. sulph., aa 20 parts; sapon. virid., vaselin., aa 40 parts; cret. alb., 10 parts) is advisable. Impetigo contagiosa has thinner vesicles than pemphigus and no fever and no inflammatory basis. It is found on the un- covered parts of the body, face, hands, and feet; the vesicles are small or large and spread rapidly, and relapses take place. Serious results have not been noticed; still, a case of nephritis is reported as a sequela in a girl of twelve years. It is met with in schools and after wholesale vaccinations, through infection by vaccine lymph. Lassar found the staphylococcus aureus. As many as a thousand cases have been observed in a single epidemic. The treatment must be preventive, if opportunity be given; a school in which the disease is found ought to be closed temporarily and disinfected. The local (and general) treatment is that of a mild eczema. Favus is, through its achorion Schoenleini, eminently con- tagious from child to child and from animal (rabbit, cat, dog) to child, is communicated through beds, caps, and finger-nails, and is not confined to the head. A mild treatment may first be tried. Green soap and warm fomentations will succeed in re* moving the hard masses, and solutions of corrosive sublimate (1 : 100-300) and ointments of naphthol (5 per cent.) or pyro- gallic acid (10 per cent.) may prove beneficial. Or a ten- (or less) per-cent. ointment of chrysarobin may be tried (according to Wolff) daily for six weeks, alternating it with a corrosive sublimate ointment (1 : 100). After that time, if the treatment have been tolerated, the application should be made every other day, and later once a week. The unguentum hydrargyri am- DISEASES OF THE SKIN. 551 moniati will do the rest. I rarely saw a case improved without epilation, after a thorough removal of the yellow crusts by means of green soap and fomentations. Epilation can be done by pincers or by the old method of the pitch-cap, which is ap- plied after the hair has been cut to one-third or one-half inch in length. Biedert modifies the old plan by melting two hun- dred and fifty parts of white pitch and four of tallow. The mixture is then spread over a cloth from six to eight square inches in size, which is fastened on the hair stumps with a hot iron and allowed to remain an hour before it is pulled off. This procedure is repeated every six or eight days until the cra- nium is entirely bald and smooth. The pain can be over- come and the cruelty of the necessary process moderated by the use of an anaesthetic. Very obstinate deposits must be scraped out. Herpes tonsurans (from trichophyton tonsurans, a parasite very similar to achorion, common among domestic animals: circular vesicles, enlarging) requires a treatment similar to that of favus, including epilation. Before resorting to it, ointments of sulphur, ichthyol, salicylic acid, or chrysarobin may be tried. Corrosive sublimate (1 : 100) in solution and naphthol oint- ment are very efficacious. Molluscum contagiosum (light nodes from which lobulated whitish masses containing brilliant oval bodies, perhaps pro- tozoa, can be squeezed out, mostly on the uncovered, parts of the body) is very contagious and is met with epidemically. Communication from child to child or from baby to nurse must be guarded against, the morbid growths removed with the sharp spoon, and the wounds treated antiseptically (best with car- bolic acid); and, finally, if required, with balsam of Peru or ointments containing it. Lupus is in some of its forms (exfoliativus, tuberosus, ex- ulcerans, serpiginosus) not accessible to anything but external treatment. Still, the treatment of the patient who, as a rule, shows more symptoms of scrofula than of tuberculosis is not 552 THERAPEUTICS OF INFANCY AND CHILDHOOD. excluded. Zinc chloride has been mixed with two or three parts of starch and made into a paste with water. Its appli- cation is very painful and its effect slow. So are Lannelongue's repeated injections of a ten-per-cent. solution of zinc chloride in water; still more so Milton's indefinite and persistent use of carbolic acid and of a twelve-per-cent. solution of hyperman- ganate of potassium (joined to the internal administration of arsenic, iodide of potassium, and mercury). Another method consists in the repeated application of saturated solutions of lactic acid; still another is the use of the sharp spoon, and then for three or five days in succession that of a ten-per-cent. mixture of pyrogallic acid. Wherever the affected part is not too large, and in a convenient locality, excision ought to be made and the wound closed; should it be too large for that, transplantation may be performed afterwards. At all events, the destruction of the morbid part, wherever aimed at, is most easily accomplished by the actual thermo- or galvano-cautery. Tuberculin has failed here as in other cases of tubercular dis- ease. A paste composed of arsenous acid 1 part, hydrarg. sulph. rubr. 3 parts, vaseline 15 parts (or another menstruum), applied daily for several days in succession, has a deserved reputation for destroying the morbid masses. Lupus erythematosus has its localized inflammatory cell-infil- trations near the surface, particularly in its most' recent dis- seminations. That is why it may be most amenable to treat- ment. I. Schutz treated nine cases with two daily applications of a mixture of 4 parts of Fowler's solution in 20-30 of distilled water. When after four or six days the surface became irri- tated, a mild powder was substituted for a few days, and the treatment resumed after four or eight days. The cases got well in from ten to eleven weeks, without scars. Tuberculosis of the skin (both verrucosa and ulcerosa) may be treated with the actual cautery and with mercurial plaster; scrofuloderma (nodes in and under the skin of the face, neck, and extremities, with central softening and a cheesy pus), by DISEASES OF THE SKIN. 553 arsenic internally and the sharp spoon, and subsequently iodo- form and balsam of Peru. Psoriasis, when acute, is a very distressing disease because of its intense itching. It requires many and protracted baths and plenty of soap to remove the scales; unguentum hydrar- gyri ammoniati is used for the same purpose. Ichthyol oint- ment (five to ten per cent.) has rendered me good service in the only case I have seen in a child for years. Beta-naphthol has been highly praised in ointments containing from five to ten per cent. Neisser recommends chrysarobin or anthrarobin ointments (five to ten to twenty per cent.). They are positively dangerous in such doses, when used on children, because of the extensive erythema and conjunctivitis following them. On the head, therefore, he substitutes pyrogallic acid, but it dyes the hair black and is not so efficient. For chronic cases the prin- ciple of treatment is the same. The eruptions must be at- tended to locally; ichthyol ointments will also do some good. Chrysarobin ointments (one to two per cent.), or chrysarobin in traumaticin in the same proportion, should be applied once every day or every few days. Green soap, or liquor potassii, a daily bath in soap and water, will dissolve the scales and facili- tate the effect of the other applications. Internally, iodides will prove effective in syphilitic cases. Thyreoid in small doses (1-2 grains = 0.06-0.125 daily) has had some successes among many failures. The best internal remedy is arsenic in long- continued moderate doses. A number of congenital diseases of the skin and subcutaneous tissue are amenable to treatment; to them belong the neo- plasms. Lipoma is found in two varieties: first, the circum- scribed and capsulated; second, the diffuse. While the former is as easily removed as in the adult, the latter is sometimes in- operable, inasmuch as it extends over large areas, and resembles in some instances, or in some parts of the anomalous growths, a moderate or formidable surplus of normal fat only. I had to give up an operation for removal before it was completed. Hard 554 THERAPEUTICS OF INFANCY AND CHILDHOOD. fibroma (connective tissue, circumscribed tumors) should be ex- tirpated before it gives rise to facial leontiasis or elephantiasis (Trendelenburg). Soft fibroma (f. molluscum Virchow, mostly- multiple, with a tendency to immense growth, sometimes pen- dulous, connective tissue with areolar structure) should be removed quickly from the cutis in which it develops. Keloid is a hypertrophied cicatrix extending upward from the corium, with rapid growth. Extirpation is useless because of the new development of keloid. Daily painting with liquor potassii arsenitis and ointments of sulpho-ichthyolate of ammonium in lanolin and fat aa 5-8 parts may be tried. Eepeated semi- weekly subcutaneous injections of a ten-per-cent. solution in absolute alcohol of thiosinamine (doses for adults grs. f-1^ == 0.04-0.1) have been reoommended, as also for cicatricial con- tractures following lupus, etc. (Sinclair Tousey). Cysts and dermoid cysts are met with; many of them, though congenital, attract attention only after months or years. Atheromata (when small and superficial, embedded in skin only, — milia) are not infrequent about the head (eyebrows, etc.). They can be readily enucleated, and ought to be removed before they adhere to the skin and undergo suppuration. When they are sup- purating, and removal is very difficult or impossible, tartar emetic in water (1 : 30) may be injected, or hydrate of potas- sium introduced. Either of these will disintegrate the cyst wall to such an extent as to render their removal by pincers possible after a day or two. Congenital sarcoma has been described a few times, once by Neuhaus (Arch. f. Kinderh., vol. xxii., 1897), who collected a few other cases. They all commenced in the subcutaneous tissue. The only case beginning in the cutis itself was recorded by me for the Am. Pwd. Soc, 1897. It was on the upper part of the scrotum, with small metastases on the dorsum penis, and no swelling of lymph-bodies. It was excised, the metastatic deposits destroyed with the thermocauter, and the baby treated with arsenic. (Arch, of Ted., November, 1897.) DISEASES OF THE SKIN. 555 Congenital ichthyosis is the result of an exaggeration of the normally copious secretion of sebum during the second half of intrauterine life. Sebum not removed but thickened by epi- dermal cells and foreign material forms scales, which may be thrown off but are rapidly reproduced, and causes fissures and warts. This condition is not necessarily dangerous to life. A boy of fifteen was freed of his scales by a permanent warm bath of five days. Lanolin inunctions, with or without ichthyol (5-10 per cent.) will prove beneficial. Arsenic should be given internally. Thyreoid — with which, however, I have no experi- ence in this anomaly — might be tried. I should favor its use also in congenital idiopathic atrophy of the skin (head, face, hands, feet, nails, hair which is totally absent), which otherwise is not reached by treatment. The effect of thyreoid in myxoe- dema and its alopecia should encourage us. The worst forms of congenital ichthyosis, which terminate fatally in a few days, are not amenable to treatment. Partial, follicular ichthyosis, in which bony spina? grow out of hair- and tallow-follicles without affecting the general health, demands frequent bathing, green soap, plenty of fat inunctions, and a ten-per-cent. sulphur ointment. Congenital neoplasms on the neck are: hygromata (lymphan- giomata with albuminous contents and endothelia) ; serous and dermoid cysts, sometimes so dense as to render their diagno- sis from lymphatic tumors difficult when situated below and alongside the sterno-cleido-mastoid muscle; and sanguineous cysts, mostly diverticles of veins, or in a few cases rudimen- tary developments of the jugular vein. They require either enucleation or an extensive incision with aseptic tamponing. No3vus pigmentosus and verrucosus belong here. Their treat- ment is similar to that applicable to vascular nsevi and tumors (p. 373), the latter differing from the former by a greater prominence of the skin, which is produced by elongation of the papillae and by hyperplasia of connective tissue; also to the ncevus lipomatodes, which is a spherical or cylindrical fatty 556 THERAPEUTICS OF INFANCY AND CHILDHOOD. excrescence covered with normal skin, sometimes pedunculated, sometimes sessile and with a broad basis. A few of the latter class are liable to grow out of proportion; all the rest in con- formity with, or even less than, the rest of the body. In the majority of cases the time for an operative procedure is left to the medical attendant. Besides the methods of removal which have been detailed above, total extirpation is advisable in most cases. Indeed, it is the preferable method. Local anaesthesia can be easily accomplished by a mild solution of cocaine (grs. •J-2 : 100), or Schleich's solution, mentioned on page 78, in- jected into the skin. Excision is readily executed with but little loss of blood, and the sutured wound is covered with collodion. In a very few days, without a change of the collo- dion, recovery is apt to be complete. XII. DISEASES OF THE MUSCLES. Acute inflammation of the muscles — myositis — is located either in the external or internal perimysium, also in the con- tractile elements. Cellular infiltration, coagulation, fatty and hyaline degenerations, suppuration, nuclear proliferation, and the formation of new connective tissue are observed as its morphological changes, with either incurable retraction or curable contraction as their results. Traumatic myositis (see p. 99) requires absolute rest, the application of cold water or ice, after a while tincture of iodine once a day or every other day, iodide of potassium and lanolin ointment several times a day, or gentle massage without the ointment. Iodide of potas- sium internally is indicated when thickening remains behind. If, after a long time, the muscle, though without pain, does not become normal, the electrolytic effect of the galvanic and the stimulating action of the interrupted current, in short ses- sions, will improve the condition. Both traumatic and rheu- matic myositis have a tendency to relapses. The latter requires a treatment similar to that which has been detailed above, with this exception, that hot (dry) applications generally render better service, and the internal administration of salicylate of sodium is mostly indispensable. Inunctions of oil of winter- green are often useful, as are also diaphoretics. The infec- tious myositis of eruptive and septic fevers starts an effusion which is either serous or purulent, and requires accordingly, besides the active attention demanded by its origin, either ex- pectant or operative (and antiseptic) treatment. In those rare cases in which purpura is observed at the same time, the myo- 557 558 THERAPEUTICS OF INFANCY AND CHILDHOOD. sitis has probably a hemorrhagic origin. Syphilis produces either gummata or hyperplasia, and demands, in addition to internal specific treatment, either the inunction of an oleate of mercury or of the blue ointment, or subcutaneous injections of the bichloride. Tubercular deposits are caseous and purulent; they must be incised, scraped out and irrigated, and the cavity filled with iodoform gauze. Purulent myositis is hardly ever idio- pathic, and its cause or complications must be ascertained (syphilis, tuberculosis, sepsis). The chronic forms of myositis met with in children are, as a rule, outgrowths of the acute inflammation. The rare forms of traumatic ossifying and that of petrifying myositis are hardly ever seen in childhood, with the exception of the occasional appearance of the multiple progressive ossifying variety, — a col- lateral to the cartilaginous exostoses, — which exhibits inflam- mation and bone-formation in the cellular tissue of the fasciae, in the aponeuroses, and in the tendons of the back, the chest, the masseter, and the extremities. Sometimes it is complicated with a defect or with ankylosis of the phalanges of the thumb. It is a nutritive disorder, always of congenital origin. No avail- able treatment is known. Ischemic muscular paralysis is the result of anaemia (mostly local, as from the influence of cold). The pain, loss of elas- ticity, and resulting contracture require massage, gymnastic exercise, and electricity, and the subcutaneous daily use of strychnine. Trophoneurotic ill nutrition and paralysis comprise two varieties. One is the result of inflammation of a joint: from disuse the neighboring muscles become atrophic and more or less paralyzed. The other originates in a change of the spinal centres, as in poliomyelitis, with fatty degeneration and atrophy as inevitable consequences. In both varieties sys- tematic massage of the paralyzed muscle, executed with ana- tomical knowledge, will do good, in the first with mostly com- plete success. Electrical treatment and strychnine may be DISEASES OF THE MUSCLES. 559 combined with it. The atrophy is very rapid, with but slight changes of electrical irritability (no reaction of degeneration), and localized. If the knee be affected, it is the quadriceps that is suffering; if the hip-joint, the glutaei; if the shoulder, the deltoid, infraspinatus, and teres minor; if the elbow, the tri- ceps; if the wrist, the extensors of the forearm; if the fingers, the interossei. The "pseudo-paralysis" of rickety children is simply debility. Muscular atrophy, progressive juvenile muscular dystrophy, pseudo-hypertrophy, and congenital myotony have been men- tioned above (p. 315). The affection which has been described as grave pseudo- paralytic myasthenia, and which consists in a peculiar exhaus- tion of the muscles on slight exertion, to such an extent as to render voluntary contraction very difficult and to rapidly di- minish electrical excitability, appears to depend either on de- fective innervation or on chemical changes. In the single case I have seen, massage and strychnine rendered some service. Veratrine, physostigmine, and digitoxine are recommended. In neurasthenia the muscles are also unduly exhaustible, but from myasthenia it differs in this that the nerves are excitable. Torticollis (caput obstipum) means a contraction of the sterno-cleido-mastoid muscle, mostly its sternal end; the head is turned to the affected, the face to the opposite side, and the diseased side is not infrequently more or less atrophic. The treatment depends to a great extent on the cause of the con- traction. Spasmodic torticollis resulting from reflex of the sen- sitive nerves of the cervical plexus, requires the section of the latter. Malposition in the uterus is an occasional direct source, as also the hsematoma originating during birth, or later, which has been mentioned elsewhere (p. 98). Bilateral caput ob- stipum, with the result of forcing the head backward, has been observed in very young infants. In a case of Shaffer's the head was drawn forward. No blood was found in the muscles, but only firm connective tissue and atrophy of muscular fibres. 560 THERAPEUTICS OF INFANCY AND CHILDHOOD. This interstitial fibrous myositis depended, probably, on a num- ber of minute traumatic lesions during parturition. Tumors, such as sarcomata, have the same influence on the function of the muscle. This is impaired, in advanced childhood, by sud- den strains; for instance, by kite-flying, by loads carried on one shoulder, occasionally also by an abnormal position of the head enforced by paralysis of the ocular muscles, in order to avoid double vision (Landolt). Eheumatism of the muscle, isolated or more general, and of one or more vertebral articula- tions, and caries of the vertebrae have the same effect. Sali- cylate of sodium internally, oleum gaultherise, and ammoniacal or camphor inunctions will do good. The same may be said in regard to muscular rheumatism in general. Torticollis is also one of the symptoms of the acute rheumatism of the neck which, because of its serious symptoms (fever, vomiting, de- lirium, with no irregularity, however, of the pulse), has been mistaken for meningitis. Sometimes it depends on a neurosis (neuritis ?) of the accessory nerve. In that case the scalenus and trapezius muscles are also affected. Keflex torticollis has been mentioned in connection with intestinal worms and with carious teeth, and an intermittent form is known to exist (Forchheimer) and to depend on malaria. In these cases quinine and arsenic are indispensable. Worms must be removed, teeth corrected. A. J. Gillette says he cured a case by the removal of adenoid growths. In those cases in which heavy loads car- ried on one side cause contraction of the other, a systematic use of the diseased side will restore the equilibrium. Exag- gerated and forcible swinging of the arms will secure co-opera- tion and exercise of the muscles of the neck. Massage both of the muscles and of the articular processes of the cervical ver- tebrae from the third to the fifth is required. The galvanic current in mild doses relieves spasm. Gentle rubbing with lanolin (in inflammatory cases with iodide of potassium or mer- cury) is beneficial. Cold temperatures must be avoided. Other- wise unconquerable cases require tenotomy, to be performed DISEASES OF THE MUSCLES. 561 by open incision, which protects the jugular vein better than the old operation from inside outward. When tenotomy is not sufficient, Mikulicz practises the total extirpation of the sterno- cleido-mastoid muscle. Too violent attempts at reduction may prove dangerous. Brackett (11th Meeting Amer. Orth. Ass., 1897) met with alarming changes in pulse and respiration, which he attributed to adhesion and shortening of the pneumo- gastric nerve. XIII. DISEASES OF THE BONES AND JOINTS. 1. Congenital Anomalies. Of the congenital malformations of the extremities (bones and soft parts), many are not accessible to treatment. To this class belong arrests of development and spontaneous amputa- tions. Curvatures of the limbs (congenital, through fracture of the tibia) may require osteotomy or osteoclasy; but their domain is not very extensive, for in the large majority of acquired rhachitical curvatures of the legs recovery takes place spontaneously. Observations in the surgical clinic of Tubin- gen, extending over a number of years, prove that seventy-five per cent, of all such curvatures will straighten out in from two to four years. When the patients were first presented, plaster- of -Paris casts of the deformity were made, and another ex- amination took place after an average of four and one-half years. Improvement was noticed in 15.3 per cent, additional. In 9.7 per cent, only no spontaneous recovery or improvement took place. It is in these that operations are demanded. Super- numerary fingers and toes are either removed from their cu- taneous attachments or extirpated from their sockets. Con- genital enlargements of toes, consisting in hypertrophy both of bone and fat, are removed by amputation. Universal giant growth is always congenital, but not hereditary. The connec- tive tissue, muscles, bones, and blood-vessels, all of which evolve out of the mesoderm, are equally affected. The nervous sys- tem and the joints are normal, the skin sometimes thickened, the nails correspond with the phalanges. Whether it is related 562 DISEASES OF THE BONES AND JOINTS. 563 to akromegaly (which in its full development is observed in later years only, but may originate earlier) remains to be seen. For the present it is not amenable to treatment. Synechia of (webbed) fingers and toes must be separated; the operation be- ing difficult, it is best to delay it for some time, but not long enough to endanger the growth of the organ. Division of web with suture of the preserved skin on one finger and Thiersch's grafts on the other, or the latter on both fingers, is claimed to be the best treatment. Multiple infantile exostoses are congenital, sometimes heredi- tary, very rarely syphilitic, and then recognized by, or connected with, other symptoms of syphilis; they develop early, now and then only after puberty; grow near the periepiphyseal car- tilage, between epiphysis and diaphysis, sometimes from the very cartilage of the epiphysis; are now and then found on scapula, pelvis, and cranium; grow in rare instances even after the completion of the growth of the body; are now and then surrounded by a synovial membrane (exostosis bursata); re- main cartilaginous or become osseous, and then may interfere with the growth of the bones. They do not often disturb the functions of the long bones and joints, but the ulna has been known to become crippled by them, the skin may ulcerate over them, and the synovial capsule may be raised by one growing too near the joint. These complications require sometimes special treatment and attention. Exostoses, so long as they are but few and not cumbersome, are best left alone. However, in the next case of early age seen by me I shall give phosphorus (p. 141) systematically, for the purpose of enforcing speedy ossification, both local* and general. Extirpation is indicated when there are but few, and when these are large; under care- ful asepsis the operation is at present devoid of danger. Iodide of potassium has been administered extensively without ap- parent effect. When syphilis is suspected, mercury and iodides should be given a trial. 564 THERAPEUTICS OF INFANCY AND CHILDHOOD. 2. Congenital Luxations. Congenital luxation of th& hip-joint, with the exception of rare cases depending on injuries contracted during birth, is the result of scantiness of liquor amnii, by which, in the cramped position of the fcetus, the growing femur is pushed out of the socket, or, in other (rarer) cases, of an arrest of development of the acetabulum, which is sometimes hereditary and now and then complicated with other malformations. The head of the femur finds no accommodation, and the trochanter is found above its normal place. This is particularly so on the steep os ilium of the female. When the luxation is unilateral the gait is limping; when bilateral, waddling. Extension lengthens the extremity and conceals the deformity. Treatment is either mechanical or operative. Until a few years ago the mechanical treatment was the only one generally recommended. Volk- mann relied on permanent extension, particularly in unilateral cases. Hessing has good results with his apparatuses. Schede uses splints, with pelvic support, to extend and to abduct the extremity, for from two to four years in succession. He finds the indication for this treatment in bilateral cases up to the fourth year, in unilateral cases up to the eighth or ninth, for the rudiment of the acetabulum whose size can be improved upon frequently persists up to that period of life. Paci lost a girl of seven years by dysentery four months after re- duction and extension of her bilateral dislocation; he found at the autopsy two new joints which appeared to promise stability of the femoral head in the new position, if the child had lived. Within a short time the results of operations have become very favorable. At the Congress of German Surgeons of 1894, Lorenz — in that of 1895, Hoffa — presented very satisfactory statistics and patients. Neither of them cuts the muscles, but both reduce the dislocated limb by powerful extension. Hoffa's incision is longitudinal, like tha,t made for resection (Langen- beck); the capsule and soft parts are loosened from the trochan- DISEASES OF THE BONES AND JOINTS. 565 ter by subperiosteal operation, the acetabulum is enlarged and the head fitted into it. The superfluous capsular tissues are then extirpated, the wound is filled with iodoform gauze, and an extension apparatus applied. The extremity begins to grow, shortening becomes less, and head and acetabulum grad- ually increase in size. Hoffa's operations were performed be- tween the second and eighth years. He presented the statistics of one hundred and twelve operations performed on eighty-two patients without cutting muscles. The last forty-seven termi- nated without a death. Lorenz's incision runs anteriorly; he does not touch the insertion of the muscles. Lately, A. Lorenz* has published his objections to the pro- tracted employment of extension, which keeps the patient in a recumbent position, possibly for years, and interferes with the nutrition and function of the limb or limbs. Instead, he ex- tends forcibly, under anaesthesia, and reduces the head of the femur, the reposition being kept up by strong abduction. The head of the femur is then retained in the small acetabulum by apparatuses and the abduction is gradually diminished. After a while standing and walking are permitted. At first, while abduction is continued, these movements are clumsy and dif- ficult, but when the weight of the body and the constant friction have deepened the acetabulum, they become easier by degrees. The oldest child in whose case this procedure was successful, the luxation being bilateral, was six years and three months. In one case of unilateral luxation, standing and walking were interrupted three days only, in others sev- eral weeks. Even when the luxation was bilateral they were not long delayed. Two patients were able to stand in six weeks. To ascertain the actual result of a successful reduction, the X-rays have been employed before and after the treatment. As a result of more mature experience, public opinion among sur- * Centralblatt f. Chir., 1895, No. 33; Samml. klin. Vortr., 1896, Nos. 150, 151. 566 THERAPEUTICS OF INFANCY AND CHILDHOOD. geons is swinging back to mechanical treatment almost exclu- sively. Schede, Hoffa, Lorenz, Wolf, and Kiimmell (Assoc, of Germ. Pliys. and Nat., 1896) unanimously discredit any bloody operation in the treatment of even severe cases. It should be resorted to as a last resource, and promises no success, but is risky. Schede reported ninety-nine cases of infants and children up to fifteen years of age, ninety-eight of which recovered with manipulation only. Lorenz reported eighty-three cases treated by manipulation, and extension in abduction, successfully. (A. H. Tubby, London Lancet, May 1, 1897.) The advantages of mechanical treatment are its simplicity and the avoidance of the danger connected with every great operation, of scars, and of probable contractions in later life. Congenital luxation in the knee-joint is not so frequently ob- served as that in the hip-joint. Still, G. Muskat collected (Arch. Jclin. Chir., vol. liv.) seven genuine luxations, four contractures in flexion, and seventy-one incomplete luxations. Massage, cautious attempts at restoring motility, and — under the most urgent circumstances only — the opening of the joint are recom- mended. Congenital dislocation of the shoulder was observed in rare instances as the result of trauma during parturition. F. S. Eve (London Lancet, May 1, 1897) describes two cases. The head in one was below the spine of the scapula. In the other the joint was found "normal, the head elongated, obliquely back- ward." Eedundant cartilage was shaved off, and reduction performed. 3. The Bones. Fractures heal the more readily the younger the patient. Callus is speedily formed, and, the muscles being feeble, dis- location of the ends of the bones does not take place to any considerable extent. Elixir of phosphorus in increasing doses will hasten consolidation in the feeble and anaemic. The frac- ture of the humerus occasioned during birth requires a light splint with but little wadding. A piece of pasteboard and a DISEASES OF THE BOXES AND JOINTS. 567 few strips of adhesive plaster or a bandage, and the support of the limb by fastening it to the body, are sufficient. Clavicles heal readily when tied up in a triangular cloth, the arm being fastened to the body. Where moistening by urine, etc., is feared, the bandages should be painted with a solution of resina dammar in ether (1 : 10). Perichondritis and osteochondritis occur, of course, in earliest infancy only, mostly under the influence either of rhachitis or of syphilis, most frequently in the forearm and the leg, also on the ribs or clavicles, and terminate either in cutaneous in- filtration or disruption of epiphyses. Pain is rare, and the "pseudo-paralysis" of Parrot means but the functional dis- turbance due to infiltration of the tissues. Periostitis, ostitis, and osteomyelitis are due, in the first instance, to the disposition created by the activity of metamorphosis and by the physio- logical succulence of the bones, whose growth starts from the periosteum, from the marrow, and from the periepiphyseal car- tilage. The vulnerability of general scrofula and hereditary influences add to their liability to become diseased. Proximate causes of inflammation are trauma, colds, infectious diseases such as whooping-cough and measles, and the invasion of cocci and bacilli through umbilicus, mouth, tonsils, or any other sore surface, with the resulting septicopyemia. The ter- mination of periostitis is either in absorption, or thickening, or suppuration. In "albuminous periostitis" pus is substituted by serum and fat. In scrofulous and tuberculous children ostitis is mostly found in the short bones and in the epiphyses. The bones swell, become softened (porotic), in their interior sup- puration loosens the tissue and dilates the medullary spaces so as to inflate and expand the thin external layer (spina ventosa). Tubercular ostitis softens the bones into a yellowish caseous or fungous mass, and thereby forms cavities, which may heal by means of absorption of the liquid contents and calcification of the remnant, but mostly end in caries or necrosis, in sinuses, in persistent suppuration, and not rarely in amyloid degeneration. 568 THERAPEUTICS OF INFANCY AND CHILDHOOD. The degrees of the different forms vary considerably. For in- stance, necrosis may be superficial, with a favorable prognosis; or central, with the formation of a sequestrum the removal of which incites granulations and new formation of bone; or total, and thus removes whole bones, such as the calcaneous, the cuboid, entire phalanges, or the diaphysis of the long bones. The prognosis is best when the process is superficial. Ab- solute rest, elevation of the limb, cold applications, tincture of iodine, and deep incision in case of very severe pain which be- trays the presence of pus comprise the proper treatment of an acute periostitis. Chronic thickening will usually be reduced, perhaps even removed, by moderate pressure, iodide of potas- sium internally, and (or) an ointment of the same with lanolin. Syphilitic periostitis requires iodide of potassium in increasing doses, occasionally combined with mercury. Ostitis and osteo- myelitis (deep, agonizing pain, with but little swelling at first) require a treatment similar to that of periostitis. The bone should be kept at rest, well elevated and supported by splints, and ice applied. In mild and slow cases tincture of iodine, or the ignipuncture of Kocher, will yield favorable results. Syphilis demands its specific treatment no matter where met with. It should be remembered, that syphilitic dactylitis, in the shape of spina ventosa, cannot be diagnosticated, clinically, from the tuberculous form; also that syphilis and tuberculosis may be found in the same baby. In suoh cases a protracted antisyphilitic treatment is indispensable. Incision may strike an abscess, which is then drained. A sequestrum is removed, and will be replaced by bone as long as there is no dangerous general affection. Antiseptic irrigations are indicated in most of these cases, and antiseptic applications should be made con- stantly if gauzes are not used to fill a cavity or sinus. When caseous degeneration has taken place to a great extent, the question of mere scraping or of resection presents itself. Osteo- myelitis requires an early operation, sometimes within a few days after the appearance of the first symptoms. Esmarch's DISEASES OF THE BOXES AND JOINTS. 569 bandage, the chisel, and the sharp spoon are the main reliances of the surgeon; the seat of the disease must be reached and entirely uncovered; counter-openings and ample tamponing may be demanded. Spina ventosa should be treated in a similar manner; part of the remaining external osseous layer should be removed and the cavity filled with iodoform or other anti- septic gauze. Obstinate sinuses must be repeatedly scraped. They often heal under a carefully conducted Bier's treatment (p. 576), with parenchymatous injections into the surrounding tissue, not into the sinus itself, of an iodoform emulsion. In every case of this kind — in fact, in every case of subacute or chronic inflammation of the osseous tissue — phosphorus ought to be given. It may be continued in such doses as are recommended elsewhere (p. 141) for two or three months in succession. Tuberculosis of the body of a vertebra (more frequent than that of the arch or of a process) underlies spondylitis in almost every case. The intervertebral cartilages are but secondarily affected. In many cases a trauma is charged with being the proximate cause, in others the process develops spontaneously, with but few symptoms. Stiffness on moving, pain on moving and pressure, very little, if any, increase of temperature, inabil- ity to bend and rise without support on a knee or some near solid object, are quite often the persistent, but only, symptoms. When spondylitis is cervical, it is liable to produce headache, dyspnoea, and retropharyngeal abscess; when lumbar, pain in the thigh or symptoms resembling those of coxitis. Usually there is already pus either in the bone or at some distance from it. It finds its way along the fascia, rarely into the vertebral canal, and is met with in the lumbar and gluteal region, in the small pelvis, along the psoas and internal iliac muscles, and along the rectum. The latter occurrence is unfavorable be- cause of the slowness — if at all — of recovery. Lumbar and gluteal abscesses are more readily discovered than those of the psoas, and therefore more amenable to treatment. Incision, 570 THERAPEUTICS OF INFANCY AND CHILDHOOD. wiping out with aseptic gauze (better than irrigations) and in- jection of a five-per-cent. iodoform-glycerin emulsion, will lead to recovery, provided the suppurating and tubercular vertebra healed out. Even psoas abscesses close up in that way, after the destruction of the pyogenous membrane. As far as the spondylitis is concerned, there is unfortunately, rarely a re- covery without some deformity, but if treated in time and properly (corset with or without jury-mast), recovery may take place without it. Permanent gib bus should be avoided. Cases with much suppuration exhibit lasting and marked kyphosis (Pott's disease) or scoliosis, or kypho-scoliosis. As soon as the diagnosis can be made, the patient must remain on his mattress, with a moderate amount of extension. Ice will relieve local pain. When it is moderate, tincture of iodine will answer. Hueter recommended the subcutaneous injection of a two-per- cent, solution of carbolic acid. When there is no fever, the time for a plaster-of-Paris jacket, according to Sayre, has ar- rived. What the latter requires, however, is that the child should not be too young. To be useful, a certain length of the spine is necessary for its application. Thus, it is principally in the dorsal spondylitis of children of a certain age that it exhibits its best results. The jury-mast is added to support the head and thereby to reduce local pressure in cervical cases. Abscesses gravitating downward are better not touched before they reach the surface. Then, before their spontaneous per- foration, antiseptic irrigations and the use of iodoform emul- sions are indicated. Most cases of spondylitis are tubercular. Abscesses are fre- quent and difficult to diagnosticate. The disease is dangerous because of its origin, and its effect. Preventive treatment is always indicated, and mechanical treatment should be gentle. Calot's method of rapid reduction with or without removal of spinous processes (thirty times in thirty-seven cases) has natu- rally resulted in several deaths. The author's intrepidity and his disrespect both of human life and of public opinion is won- DISEASES OF THE BONES AND JOINTS. 571 derful to behold. His "method" would concern less the forum of medical than of criminal courts, but for the later modifica- tion of his original violent procedures. A number of cases described as chronic articular rheumatism are undoubtedly those of arthritis deformans. The differen- tial diagnosis is perhaps best made by remembering that the term "rheumatism" is still too vague to allow its use for diag- nostic purposes. The only condition which deserves it is acute (or subacute) articular rheumatism, rheumatic polyarthritis. It affects the synovial membranes. Gout (the affection has also been called "rheumatoid gout") requires uratic deposits. Ar- thritis deformans is an affection of the cartilage (influenced by anomalies in the bones ?), first, proliferation between the intercellular fibrilla3, then absorption, with, finally, hyperplastic eburnation around the absorbed cartilage and distortion of the limb (the hand in the ulnar direction mostly, with intact thumb and thoroughly enlarged phalangeal ends). A similar process takes place about the shoulder, elbow, knee, toes, and vertebrae. Marked cases such as I have seen myself have lately been pub- lished by A. G. Nichols (Montreal Med. Journ., 1896), H. Koplik (Arch. Ped., 1896), who collected eighteen, and Vargas (Bull. ofpc. de Barcelona, April, 1897. He counts "Jacobi among those who do not mention the disease," erroneously). Very suggestive are also the early changes which take place in the skin and the rest of the epidermoid tissues and in the mus- cles. The accompanying changes in the muscles, — a slowly pro- gressive atrophy with corresponding paralysis, without reaction of degeneration, and with only so much alteration of electrical and galvanic excitability as is explained by the atrophy of the muscular tissue, — trophic changes of the nails of fingers and toes (thickening, fragilit}^ and exfoliation), and those of the skin (vitiligo and chloasma and slight indications of sclero- derma, even ichthyosis in a few instances*) appear to prove * Curschmann in Schmidt's Jahrb., 1895, No. 8, p. 220. 572 THERAPEUTICS OE INFANCY AND CHILDHOOD. their great difference from rheumatism and their very intimate connection with the nervous system, which is known to influ- ence greatly both bones and joints (S. Weir Mitchell, Clin. Less, on New. Bis., 1897). Consequently the antirheumatic treatment, by salicylates, etc., is absolutely useless. The gal- vanic current, slowly increasing doses of arsenic administered a long time, and judicious massage have served me best. Ar- thritis deformans is not incurable. 4. The Joints. Inflammations of the joints are frequent, — more so in infancy than in childhood. Acute cases are rare, however, in children eight or ten years old, who have more control over their muscles and take better care of themselves. Younger children are more exposed to traumatic injuries; besides, not to speak of the phlebitis of the newly-born, there are in the earlier years dis- tinct predisposing causes of joint-disease in such infectious diseases as scarlatina and diphtheria. Syphilitic joint-diseases appear in infancy and childhood in different forms, as epiph- ysis with effusion into the joint without synovitis and with- out suppuration; as ostitis with effusion and with gummatous infiltration of synovial membranes and effusion; as primary gummatous synovitis (rarely); as symmetrical synovitis (mostly in the knees) in children of from eight to fifteen years, at the same period of life in which the interstitial keratitis of syphilis is commonly found. In all of these affections a thorough and protracted antisyphilitic treatment is required. In all joint- diseases the synovial membrane, the fibrous capsule, and the cartilage are affected either separately or collectively, and the contents of the diseased cavity are either serous, or purulent, or fungous. Most of the latter are tubercular, and were known to be so long before the tubercle bacillus was discovered. In- deed, as early as 1873, Koster recognized the tubercular nature of "tumor albus." The prognosis is fair when the secretion is serous. Fluctua- DISEASES OF THE BOXES AND JOINTS. 573 tion is easily recognized when the joint is superficial. It re- mains as "hydrarthros" in chronic cases. The treatment re- quires absolute rest, and in the acute stage the flexed position of the limb — which is either voluntarily chosen because it re- lieves tension, or is the result of a reflex contraction — must be respected. Other aids are: cold applications and mustard plasters; in less urgent cases, tincture of iodine, pure or diluted with alcohol, once or twice daily; in chronic cases, a vesicatory either to its full effect or applied for half an hour only, and repeated daily or several times a day; later, ointments of iodide of potassium and lanolin, or mercurial plaster, which may be made to cover the whole joint and may be changed once every few days; two daily applications of iodoform in collodion (1 : 8-20) over the whole joint; and compression, with a rub- ber bandage over a proper pasteboard, felt, or wood splint, the latter to protect the neighboring large blood-vessels. Iodide of potassium internally will render good service while the affec- tion is of a purely inflammatory character. Persistent contrac- ture must be overcome by massage, cautious passive movements as long as there is no pain, and forcible extension, either with- out or with anaesthesia. Massage improves the prognosis in subacute serous inflammation of the joints, also in contusions and distortions; after the massage the joint should be immo- bilized, slightly compressed, and raised. It acts well in chronic (rheumatic) inflammation, with thickening and proliferation of the capsule. Villous proliferations should be broken up by manipulation and changed into a detritus. Tubercular cases have a decided tendency towards either suppuration or fungous degeneration. About the knee the ab- scess is often outside the capsule and permits of an incision which does not reach the interior. Still, a small communica- tion with the latter is almost always present. Intracapsular abscesses, the opening of which was once so dangerous as to be considered semi-criminal, are no longer the bugbear of surgery. Repeated aspirations of the pus under aseptic precautions with 574 THERAPEUTICS OF INFANCY AND CHILDHOOD. subsequent injection of sterilized iodoform in oil or glycerin (1 : 5-10), or in liquefied vaseline, and intra-articular occasional operations, such as scooping, resection, etc., with, tamponing and draining, have reduced the dangers and are daily swelling the records of recoveries. General treatment to overcome the anaemic and cachectic condition, and particularly antitubercu- lar hygiene and medication, are demanded in most cases. Lately {Deutsche Zeitsch. f. Chirurgie, vol. xli., July 30, 1895, p. 378), E. Wieland published a contribution to the treatment of surgical tuberculosis in childhood with iodoform injections which, to my mind, contains everything now known on the subject and all that is sound and advisable. Iodoform treat- ment, however, is certainly not a panacea. Cases of tubercular coxitis, for instance, complicated with large abscesses and with perforation of the acetabulum, which offer great difficulties in the way of irrigation, of thorough cleaning out, of injections, and of compression, are liable as well to resist iodoform treat- ment as to yield unfavorable results after a radical operative interference. But in a large percentage of cases injections of iodoform emulsions, aided by orthopaedic measures (bandages, stays, plaster of Paris) or by mild operative procedures, and last, but by no means least, by constant attention to the general health (air, food, clothing, and bathing), and by medicinal sup- port with arsenic, creosote, or, preferably, guaiacol, yield good results. It is true, this treatment takes patience and time, is even apt to be expensive, and certainly exhibits no tangible proof of a great surgical achievement to the impressionable lay mind; but it is efficient, and has the advantage of not inter- fering with the growth and development of the limbs, which are mostly injured, and permanently so, by subjecting the epi- physeal cartilages to a radical operation. In a few cases the absorption of iodoform, when employed in solutions, has proved dangerous through a consequent toxic nephritis. For this rea- son, solutions in ether or oil are not to be recommended; for, after all, it is the local effect of iodoform which is aimed at, DISEASES OF THE BONES AND JOINTS. 575 and not a general one. Emulsions are preferable. Krause employs a suspension of ten per cent, of iodoform in water, with the addition of but little glycerin and gum-arabic. The places to be selected for injections, according to him, are, — for the wrist-joint, below the styloid process of the ulna; for the elbow, above the capitulum radii; for the shoulder, exteriorly to the coracoid process: for the hip, above the tro- chanter major; for the knee, below the patella; for the ankle- joint, below the malleolus, in an upward direction. The injection into the hip-joint is made, according to Kiister, who has followed that method these nearly ten years, at the interior margin of the sartorius muscle on a line drawn between the crossing of the femoral artery and the prominence of the tro- chanter major. That is where, in lean persons, the spherical head of the femur is liable to be felt, and where in coxitis visi- ble or palpable swellings are not uncommon. For at this point the capsule is thinnest, and here, also, is the location of the subiliac bursa which in ten per cent, of the cases communicates with the joint. As a trocar may hurt the cartilage, a hypo- dermic syringe is employed, the canula of which has a length of from five to seven centimetres and a thickness of one milli- meter. Kiister does not irrigate the joint, because in a large proportion of the cases there is either no fluid at all (paren- chymatous synovial tuberculosis), or when present it is either sero-fibrinous (hydrops tuberculosus) or purulent (cold abscess). Neither Bruns nor Kiister believe that an irrigation with a three-per-cent. solution of boracic acid, or another antiseptic, has any better effect than the uncombined injection of iodo- form. In the parenchymatous variety from five to ten cubic centimetres (1-2 J fluidrachms) of a mixture of twenty per cent, of iodoform and eighty of glycerin are employed; this operation is performed weekly (Bruns). In the serous or puru- lent variety, after the fluid is either aspirated or spontaneously discharged, from ten to thirty cubic centimetres, enough to moderately fill the cavity (2-| fluidrachms to 1 fluidounce), are 576 THERAPEUTICS OF INFANCY AND CHILDHOOD. injected. This procedure is repeated every two or four weeks (0. v. Biingner, Centralb. f. Chir., No. 51, 1892, pp. 1057-1064). Periarticular abscesses should be incised and scraped thor^ oughly before an injection is made. The same holds good for fungous degeneration of the capsule of a joint. Bones in a very diseased condition — the talus, for instance — should be removed entire. If pus cannot be removed thoroughly, counter-openings are required. At first, for the purpose of thorough cleansing and disinfection, irrigations may be made with a mild solution of bichloride of mercury (1 : 5000), to be followed for a few moments by a stronger one (1 : 1000-2000). The principle of conservatism must never be lost sight of. All surgeons are unanimous at present that conservative treatment is the more urgently demanded the younger the patient. Eadical opera- tions are indicated only when the case is one of extensive and protracted irremediable suppuration with progressive destruc- tion of tissue. Eesection, however, must not go beyond the cartilage between epiphysis and diaphysis. If tuberculosis be markedly developed, either locally or generally, it is better to amputate than to resect. Fistulas which do not contract or shorten should be treated with strips of gauze dipped in equal parts of balsam of Peru and alcohol, and when they are very dry and indolent, with (Villate's) injections composed of sulphate of copper 10 parts, sulphate of zinc 10 parts, and distilled water 120 parts. It is particularly the knee- and elbow- joints that require conservative treatment, both cautiously and patiently. Another method of conservative treatment of tubercular joints has been introduced by A. Bier (Arch. f. Iclin. Chir., 1894, p. 306). Encouraged by the fact that lungs in a condi- tion of passive hyperemia resulting from cardiac disease or from kyphosis have a rather pronounced immunity from tuber- culosis, he advises to produce a passive venous congestion of the tubercular joints by bandaging the limb tightly below the affected joint and compressing it above with an india-rubber band (Esmarch). To secure a moderate amount of hyperemia DISEASES OF THE BOXES AND JOINTS. 577 and cyanosis, and to avoid undue pressure and oedema, the bandaging should be gentle, and be interrupted once or twice a day. Such a degree of passive hyperemia is known to give rise to the new formation of connective tissue and to induration. This, it is suggested, affords a certain degree of protection against the proliferation and action of bacilli. This is also the effect aimed at by Landerer when he recommends cin- namylic acid, and by Lannelongue, who injects chloride of zinc for that purpose. That such was Koch's theory when he introduced tuberculin is well known. It is only very docile children that submit to the treatment readily. That is why days should be spent on playwise appli- cation of the method and on gaining the good will and the confidence of the patient. Bier continues his treatment at least three months. Massage, formerly used simultaneously, he has discarded. He found his method particularly practical when employed for tuberculosis about the ankle-, knee-, and elbow-joints, also for the testis, less so for the shoulder, not at all as yet for the hip-joint. He found, however, that if there was much suppuration, the limbs thus obstructed tended now and then to acute inflammation, lymphangitis, or erysipelas. Ulcerations increased in size, but finally healed; sometimes large granulations sprang up, but recovery took place eventu- ally. Tubercular sequestra were often absorbed, and sometimes firmly attached to and embedded in the surrounding osseous tissue. Even tubercular skin was benefited by frequent dry cupping, but not to such an extent as joints and bones by the above treatment. Glands were not accessible to the same method, except the cubital. Sarcoma, lupus, and syphilitic swellings were rather the worse for it; so was extensive sup- puration with streptococci and staphylococci. In acute rheu- matism the effects varied; in gonorrhceal joints, chronic articu- lar rheumatism, and arthritis deformans they were fair. If carried out with care and perseverance, Biers method yields sometimes astonishing results. (See Willy Meyer's report be- 37 578 THERAPEUTICS OF INFANCY AND CHILDHOOD. fore Orthop. Section of the N. Y. Acad. Med., Americ. Med. Surg. Bull, 1895). The treatment, however, is not always to be confined to this method alone. Abscesses are aspirated, if possible, in their upper part to avoid persistent discharge, and filled with a ten- per-cent. iodoform emulsion. Slight compression may follow, and the injection is repeated in about a week. If there be con- siderable purulent discharge, the iodoform treatment is con- tinued or Villate's solution (p. 576) employed. Under its use bone fistula? heal rapidly. If loose splinters be accessible, they are removed. Forcible extension by apparatuses under anaes- thesia, tenotomy, and plaster of Paris should be employed in the treatment when indicated; so should passive movement, massage, and warm baths, particularly where there is func- tional ankylosis. True ankylosis requires resection when the false position of the extremity becomes intolerable, for a con- siderable curvature of the lower extremity or the extension or hyperextension of the upper cannot be borne. That gener- ous diet and proper hygiene and antiscrofulous and antituber- cular medication must not be omitted in an ailment which either is the result or may be the beginning of a generalized infection is self-evident. The best results of the treatment of tubercular bones may be expected in the calcaneus; its ante- rior portion is mostly affected because its spongious part has a scanty circulation only and its medullary part is large and soft. For the same reason sequestra may be found, which are rare in the other bones of the tarsus. As it is least connected with other bones, its tuberculosis remains mostly local, but may affect the adjacent tendons (Finotti). So far as the antitubercular treatment with guaiacol is con- cerned, I can but repeat what I said on the subject formerly. No one treatment of all forms of tuberculosis ever satisfied me to the same degree as has that with guaiacol. In the different varieties of pulmonary tuberculosis, when the destructive pro- cess was not too acute, it has almost invariably improved both DISEASES OF THE BOXES AND JOINTS. 579 appetite and general condition, rendered expectoration less purulent, and increased the weight of the body as well as it im- proved the complexion. The more chronic the cases the more perceptible is the effect of guaiacol. Thus, in tuberculosis of the osseous system its action is very satisfactory. The dose for a small child is from a drop to two or more drops, to be re- peated three or four times a day, or the carbonate of guaiacol in three or four daily doses of from one to three or four grains each. Both of these preparations, particularly the latter, may be combined with other drugs, according to indications, — preferably with arsenic in generalized tuberculosis of the soft tissues, or with phosphorus in extensive inflammations of the bones of a chronic or subacute nature. Coxitis begins mostly in the head of the femur, and is rarely attended with very acute symptoms. As it is curable when recognized early, every case of dragging, of untimely fatigue, of favoring either limb, of vague pain, and of slight increase of body temperature in the afternoon requires careful and re- peated examination. Pain in the knee depending on irritation of the obturatorius and internal saphenous nerves is not in- creased by pressure. Limping and apparent lengthening of the limb with abduction and shortening with adduction are found not to be actual, but the result of voluntary change of position. These conditions are overcome by rest, the local applications mentioned above, and conscientious extension in bed. At a later period, when all the symptoms of acute irrita- tion have disappeared, extension by apparatuses and counter- extension may be employed for the purpose of permitting active exercise (Taylors and Phelps's extension splints). TThen, however, the swelling increases, an abscess is formed, and per- foration takes place, a spontaneous luxation will often be the result, with either elongation or shortening (luxation upward and backward with adduction and inward rotation of the ex- tremity). The os ilium may perforate, or what is left of the head of the femur may start for the sciatic foramen, or upward, 580 THERAPEUTICS OF INFANCY AND CHILDHOOD. and all of the head may be lost by suppuration. Even in these bad cases partial recovery takes place sometimes. A new joint may be formed or actual ankylosis result from the healing surfaces joining each other. The size of the incisions will de- pend on that of the abscesses, and the operations on the bones on their condition. Complete resections ought to be made in as few instances as possible; the periepiphyseal cartilages con- trolling the growth of the limb require careful protection. Tubercular coxitis is eminently a disease of early age. Nearly fifty per cent, of the cases occur during the first decade of life, nearly forty during the second. One-third of all the cases re- main free of suppuration; of these, seventy-seven per cent, get well; of the purulent form only forty-two. Altogether, about forty per cent, terminate fatally, death ensuing from tubercu- losis of the lungs or of the meninges, or from general miliary tuberculosis, amyloid degeneration, or exhaustion by suppura- tion or by sepsis. About fifty-five per cent, get well under con- servative treatment; still, the motility of the hip-joint is im- paired by contraction, so that either adduction (in two-thirds of the cases) or abduction, with actual or apparent shortening or lengthening of the extremity, results therefrom. Actual shortening depends either on retarded growth or (in the process of bone destruction) on displacement of the acetabulum, which is more frequent than spontaneous luxation; apparent shorten- ing results from the voluntary elevation of the hip, or by fixing the extremity in adduction parallel to its fellow. The general rules of constitutional and local treatment hold good for gonitis (inflammation of the knee-joint), which is liable to be tubercular in perhaps a larger percentage than any other joint. Deformity becomes very marked at an early date, the leg is very apt to be luxated backward, rotated outward and in genu valgum position, and both pseudo-ankylosis (ad- hesion of the ends of the bones by connective tissue) and true ankylosis (solid connection of the cartilages or of the bones) are frequent. DISEASES OF THE BONES AND JOINTS. 581 Inflammations of the ankle- and tarsal- joints are mostly tu- bercular. They take a slow course in most instances, and result but rarely in recovery unattended by deformity, unless there be timely, either conservative, or operative, or combined treat- ment, which may save many a foot and life. Unfortunately, constitutional tuberculosis is a frequent complication, and death, therefore, is not uncommon before even a local restitu- tion can take place. The elbow-joint exhibits the same ten- dency to deformity and ankylosis, but is rarely the source of a hectic condition and of death. Early fixation in a sling and the application of either water-glass or plaster-of-Paris bandages are indispensable, while the forearm and the humerus should be placed nearly rectangularly. The same position must be secured for the foot. In coxitis and gonitis the limb ought to be kept entirely or nearly straight. Genu valgum {knock-knee) is the exaggeration of a normal disposition produced by a slight depression of the external parts of the articular surface, mainly of the thigh. This disposition is increased by the rhachitical softening of the bone (in later life to an eminent degree by the pressure brought about by the occupation of bakers, waiters, saleswomen, etc.). The speedy cure of rhachitis is an essential preventive. A plaster- of-Paris support (which ought to be renewed every few weeks), made to dry while the extremity is gently flexed, procures a normal position while the bone is hardening under the in- fluence of phosphorus, etc. The elastic length-garters, which have to a great extent taken the place of the circular ones, ap- plied below or above the knee, must not be tense, for in that case they increase the external concavity. They ought to be worn on the inside of the thighs, or both inside and outside. In bad and chronic cases osteotomy is performed above the condyle of the femur (McEwen), also on the diaphysis of the tibia, and the bones are then allowed to heal in extension. Genu varum is almost always the result of a rhachitical out- ward curvature of (and below) the epiphysis of the tibia. It is 582 THERAPEUTICS OF INFANCY AND CHILDHOOD. but rarely that the femur participates in the deformity. If it be noticed in time, straightening can be effected before the parts harden. After this has taken place, osteotomy or osteo- clasy must be resorted to. Pes varus {club-foot) is often congenital. Defective supina- tion is normal in the foetus, and becomes exaggerated by the pressure of the uterus when amniotic liquor is scanty. In many cases there is at birth a deformity of the talus of such a character that its neck is long externally and the head turned inward; also of the calcaneus, whose anterior process is raised and articulations somewhat dislodged. According to H. von Meyer, the posterior tibial muscle is always primarily affected. The paralytic variety of club-foot results from immobility of the extremity, caused by complete paralysis or by some other sickness necessitating protracted rest in bed, or from paralysis of the extensor muscles of the lower extremities consequent on poliomyelitis. The deformity is rather an equino-varus than a mere varus. With proper timely precaution its develop- ment may be avoided. As the articulations begin to suffer at a very early period, and growth is very rapid, treatment should begin at once. In- deed, the foot which at birth is seventy-five millimetres in length, is one hundred and seven millimetres after a year, 122.3 millimetres after two years, and 136.4 millimetres after three years. There is an increase of forty-three per cent, in the course of the first year; this increase is the more rapid the younger the infant. After three months the foot has added one-seventh part to its original length, and another ninth in the second quarter. Therefore, recovery from a moderate de- gree of club-foot, when treatment begins at birth, will take three months; when after a year, twelve months. Manual correction must be resorted to many times during the day. At night the tender foot of the newly-born bears quite well a pasteboard splint, well lined, and strapped with a snug bandage. Later, or in procrastinated cases, a plaster-of- DISEASES OF THE BONES AND JOINTS. 583 Paris bandage, or one of water-glass, or of poroplastic felt modelled around the foot and lower two-thirds of the leg on its inner side will be required to preserve the normal position. As there is occasional anaesthesia of the surface, great care must be taken lest undue pressure be exercised. After the above treat- ment has had a satisfactory effect, Scarpa's, Stromeyer's, Sayre's, or any other shoe which permits of walking should be used. Tenotomy is required in a great many cases, — either of the tendo Achillis, or the anterior tibial, or the plantar aponeu- rosis, or several of them at the same time. The open operation of A. M. Phelps (preceded by Alfred C. Post) has gained many friends. He cuts all the layers of the soft parts at the sole of the foot successively, avoiding the ramifications of the plantar nerve, and occasionally incising the articulations of the talus and of the navicular and internal cuneiform bones. Healing takes place under the moist blood-clot. The paralytic muscles require persistent use of both the interrupted and the continu- ous currents. The function of the muscles can be improved, provided the patience both of the physician and of the patient is equal to the necessities of the case. Pes equinus is the result of paralysis, either local, or spinal, or cerebral, and is complicated with atrophy of the muscles of the calf and of the sole of the foot, the sole becoming con- cave and the toes pointing downward. Here also tenotomy of the tendo Achillis and of the plantar aponeurosis, together with the employment of electricity and galvanism, are indi- cated. An apparatus is required to lift the anterior part of the foot, and while the patient is lying down or sitting up, soon after the operation he may practise upon a band properly at- tached to temporarily restore the normal position. Children will easily learn to look upon the exercise as play. Pes calcaneus in a mild form is often congenital and some- times complicated with pes valgus. The desirable position is restored by a shoe supplied with a high heel and so constructed as to press the foot down. But lately operative surgery appears to have accomplished some of its greatest triumphs. 584 THERAPEUTICS OF INFANCY AND CHILDHOOD. Mcoladoni, to heal a talipes calcaneus with paralysis of the muscles of the calves, severed the peroneal muscles behind the malleolus and the tendo Achillis above the heel, and joined the central ends of the peroneal tendons to the stump of the tendo Achillis. Pocas, in a case of paralytic pes valgus, con- nected the tendons of the extensor hallucis longus and of the paralyzed anterior tibial. Ghillini, to supplant the action of the paralyzed anterior tibial muscle, cut the tendon of the peroneus longus near the cuboid bone, also that of the anterior tibial six centimetres above its insertion, and joined both by suture, with satisfactory result. Tendon grafting and muscle transplanta- tion for deformities following infantile paralysis has been prac- tised successfully. S. E. Milliken (N. Y. Med. Rec, November, 28, 1896) reports on fourteen operations performed on nine patients. They were transplantation of the sartorius into the sheath of the quadriceps, the joining of the extensor hallucis longus to the paralyzed tibialis anticus, of the gastrocnemius to the peroneus longus and trevis, of the extensor digitorum communis to the tibialis anticus and vice versa, of the extensor hallucis longus to the extensor digitorum communis, of the flexor hallucis longus to the tibialis anticus, and of a part of the deltoid to the tendon of the paralyzed triceps. Pes valgus (flat-foot) is not infrequently congenital, the talus being found downward and forward. In other cases the de- formity is rhachitical. Both to prevent and to cure it, anti- rhachitical treatment and temporary rest are demanded. There are also (rare) paralytic cases occasioned by paralysis of the supinator muscles of the foot. In these electrical treatment and the subcutaneous use of strychnine, together with massage of the calf and of the sole of the foot and stimulating embroca- tions and friction with cold or hot water, will render service. In all severe cases walking should not be permitted until a reason- able time has elapsed; the lower extremity should be raised, symptoms of vascular irritation relieved by applications of cold water, a normal position should be enforced by plaster-of-Paris bandaging, which must be continued through weeks and DISEASES OF THE BONES AND JOINTS. 585 months. When walking appears to be again permissible, the inner margin of the foot must be raised by thickening a part of the sole of the shoe, or by elevating it by springs which are elastic enough not to injure by pressure. I. Wolf insists upon not resting the patient at all, but makes him walk immediately after the application of plaster of Paris. From a practical point of view, the subdivision of scoliosis into three varieties is as follows: the first degree comprises those cases in which suspension of the body removes the de- formity altogether; the second, those in which this effect is but partially attained; the third, such as are not influenced by it. The prognosis in the first is favorable; in the second it is fair when the growth of the skeleton is not completed; in the third it is not good, but should not be considered absolutely bad. It greatly depends on whether the scoliosis results from a relative or an absolute insufficiency of muscles, or whether it is caused by a deformity of the vertebral bodies. The former may be either simply local in the muscles or depend on central paralysis, in poliomyelitis, in Friedreich's disease, and in some cases of progressive muscular atrophy. The latter may be con- genital, but is frequently the result of rhachitical softening later on. In such instances a thorough antirhachitical treat- ment, with proper food and hygiene and phosphorus, must not be postponed a single day. The habitual scoliosis of the first eight or ten years is of merely muscular origin, and mostly total and universal; the convexity generally to the left, and not often lumbar. This condition is found in babies who are persistently carried on the left arm; in school-children who rest the left arm on the table while the body is accommo- dating itself to the book and leans to the right; in girls who approach the bench sideways and pick up their skirts under the right gluteal region. The danger of becoming scoliotic is particularly great in those school-children whose sight is defec- tive. Those who stand a great deal and carry the right shoulder forward develop a right dorsal with a compensatory left lumbar scoliosis. The prevention of all varieties consists in the avoid- 586 THERAPEUTICS OF INFANCY AND CHILDHOOD. ance of their causes. A baby must not be persistently carried on one arm: a mother is more apt to obey this rule than a nurse. The muscles must be exercised at an early age, — simple domestic gymnastics, but not overexertion; and the habitual use of cool or cold washing once or twice a day, with good food and air and plenty of sleep on a hair mattress, are indispen- sable. The school lessons ought not to last more than twenty or forty-five minutes; there must not be too many of them; there should be ample light from the left side while the child is studying or writing; defective sight must be corrrected by glasses; the chairs or benches supplied with a support up to the lower dorsal region of the spine. During school sessions a light corset may also be worn, and at night an apparatus to restore the equality of the two sides. Massage of the defective side and of the muscles in general will add to the good effect, and the concave side of the chest may be exercised by the en- forcement of the habit of deep inspiration while the hand is firmly planted and pressed on the convexity. Dr. Teschner's successes are due to the systematic exercise and strengthening of all the muscles of the body. In more obstinate cases the foot corresponding with the lowered hip may be raised by thickening the sole of the shoe. Volkmann recommended the raising of the chair or bench under the dropping hip. Sayre's corset is either worn con- stantly or is made detachable. Eauchfuss's apparatus is so constructed as to leave the defective side but little or not at all supported while the patient is lying down. The kyphosis of feeble rhachitical children requires general antirhachitical treatment. The baby must not sit up until the muscles have become stronger; the bed should have a hair mattress; and the patient must take the air while being car- ried either on a hair mattress or in a wire cuirass, or in a tin or pasteboard or sole-leather mould sufficiently lined to be com- fortable. As the baby grows, walking must not be encouraged. He will rise when his bones are hard enough and his muscles sufficiently strong. XIV. DISEASES OF THE EAR. Malformations of the ear, both external and internal, are mostly the results of arrests of development, and are but rarely amenable to improvement by treatment. A faulty position of the auricle may be corrected after birth; when it protrudes unduly, bandages or adhesive plaster, worn for a number of weeks, will keep the organ in a more normal (adjacent) place. Obstruction of the auditory canal by either an epithelial or an organized membrane can be relieved; the former demands a metal probe to perforate it; the latter, a cruciform incision and removal of the flaps. Foreign hodies are common in all accessible cavities; these prove frequent receptacles of shoe-buttons, pearls, peas, beans, etc.; sometimes their removal is very difficult, particularly in the cases of vegetables, which swell and thereby totally obstruct the meatus. The use of probes during examination is some- times decisive in regard to diagnosis, sometimes very deceptive; the reflector is indispensable. The secretion of secondary catarrh must first be removed by syringing and wiping; pincers will remove a body which is not tightly incarcerated; a Daviel spoon, or the blunt end of a hair-pin bent upon itself, or a sharp spoon is often required for peas and beans. While the attempts at removal are going on, the ear ought to be fre- quently injected with warm water to expel shreds and blood and to facilitate inspection. Before the operation is begun, a cocaine solution may be instilled into the ear. A spray of ether may be demanded, and in urgent cases anaesthesia by 587 588 THERAPEUTICS OF INFANCY AND CHILDHOOD. chloroform; for the extraction of a foreign body being para- mount, even pieces of bone have to be removed sometimes to render its expulsion possible. Living bodies, such as insects, will die in water, oil, alcohol, or a two-per-cent. solution of carbolic acid. Dried secretion, or cerumen, is softened by filling the ear with oil or glycerin and syringing forcibly with soap and water. The after-treatment may demand all the requisites of the therapy of inflammation, — rest, cool and disinfectant applications, erect posture, and narcotics. Otitis externa (inflammation of the external auditory canal) is the result of irritation by foreign bodies or by clean or dirty finger-nails, brushes, and sponges, also of the frequent use of ear-spoons, or of exposure to a high wind or draught; or it may depend on eczema which extends inward from the neighboring surface. Gronoeocci and tubercle bacilli have been met with in the external ear, diphtheria not infrequently, and soiled bathing water is probably a more common cause of ear-disease than is generally supposed. Now and then external otitis com- plicates internal, particularly in infectious diseases such as measles and scarlet and typhoid fevers. The general disposi- tion to scrofula — that means to subacute or chronic inflamma- tion of the tissues with rapid disintegration of the surface epi- thelium and insufficient tendency to reparation — is a frequent factor in the production of external ear-disorder, and requires constitutional treatment. Preventive measures are indicated by the causes enumerated above. Foreign bodies must be looked for and, if present, extracted. The three forms of established external otitis are the ery- thematous, the catarrhal, and the phlegmonous (including the furuncular). The first exhibits a general redness, and produces scales rather than secretion. An occasional application of lead wash, or lead ointment, or zinc ointment, or bismuth subnitrate, finely powdered, will be all that is required in the average cases. Where the redness is marked and angry, with a good deal of DISEASES OF THE EAB. 589 itching, the ointment should contain five per cent, of cocaine; or a watery solution of cocaine hydrochlorate (two to six per cent.) may from time to time be brushed over the sore surface. The catarrhal form of external otitis is by no means a uni- form or always a mild affection. There may be pain, also secretion of a simply catarrhal or of a malodorous (fat acids) or cheesy nature. Erosions, ulcerations, and swelling of the neighboring lymph bodies are quite common. The integument is sometimes greatly swollen and now and then granulating; below and behind polypoid excrescences the bone may be af- fected; through the defective ossification (sometimes persist- ent) anteriorly and inferiorly, fistulae may form in the parotid region and even in the maxillary joint, and pus may find its way along the incisurae Santorini through the cartilaginous floor of the meatus. The drum membrane is frequently af- fected. Every form of myringitis is met with, from a slight hyperemia to thickening and turbidity of the membrane, even to perforation. Thus there is every reason for early and per- sistent treatment. In the interest of examination, the speculum must not be used at first, except in older and very docile chil- dren; it annoys, pains, and frightens, and is seldom as useful as in advanced age because of the horizontal position of the young drum membrane, only part of which, at best, can be seen. The secretion must be removed by syringing both frequently and forcibly (but the current must not be directed to the drum membrane) while the head is inclined so as to allow the instan- taneous egress of the fluid. The injection fluid may be warm water, soap and water, salt and water (6-7 : 1000), or mild astringent solutions of acetate of lead, sulphate of zinc, tannin, or alum (1 or 2 : 200); or the secretion may be removed by tufts of absorbent, or borated, or salicylated cotton, which are held tightly in a pair of pincers and not rubbed hard against the wall of the canal. A saturated solution of boracic acid (four per cent.) is both mild and disinfectant. Boracic acid finely powdered may be thrown in so as to fill the canal after it 590 THERAPEUTICS OF INFANCY AND CHILDHOOD. has been thoroughly dried. When the renewed secretion has liquefied the powder, after a few or many hours, they are both removed by cotton or by injections, the ear thoroughly dried, and boracic acid introduced again as before. Bichloride of mer- cury (1 : 5000) injections may be given several times a day, mainly when there are much hyperasmia and infiltration, in any of the varieties of external otitis; fomentations of the same solution should be made persistently. Two daily applications of carbolic acid in glycerin (1 : 10-20) have also been recom- mended; I believe they frequently irritate and fret the surface. Polypoid granulations have been removed by ligature. Chromic acid is liable to deliquesce so much, even when used carefully and in small quantities, as to endanger the drum membrane. The solid stick of nitrate of silver is safer, and requires for neu- tralization, after application, only a salt-water solution. A daily touching with liq. perchlorid. ferri or liq. subsulphat. ferri is very effective and quite safe. Biedert recommends the sozoiodolate of hydrargyrum. In external otitis leeches are sel- dom required, and then only when there is an excess of swell- ing. To relieve local pain and tension, cocaine solutions act better than do those of morphine. The oleate of morphia irritates the sore surface. Internally, a dose of morphine or some other opiate, or chloral, may become necessary. The pa- tient must be kept in a semi-recumbent or almost erect position, on a cool pillow, in every catarrhal or inflammatory condition of the ear. Cases of external otitis with copious secretion, complicated with or dependent on eczema, are greatly bene- fited by one or two daily applications of a small quantity (well rubbed in) of bichloride of mercury in lanolin (1 : 300-500). In obstinate cases of eczema a solution of nitrate of silver (1 : 10-50) may be brushed over the parts once every few days, or Lassar's paste may be used (oxide of zinc and amylum aa 25, salicylic acid 1, white vaseline 50), which need not be removed when a new application is made; or an ointment containing pure tannic acid and glycerin aa 4 parts, which are mixed thor- DISEASES OF THE EAR. 591 oughly, and to which are added fat 30 and carbolic acid 0.3 parts. The phlegmonous form of external otitis is mostly recog- nized with facility; the pain is intense, the swelling marked, more or less local, circumscribed, and red. Before an incision — which ought to be made in time — appears advisable, appli- cations of solutions of hydrargyrum bichloride (1 : 5000 water) are better than warm fomentations. As stated, incision must be made soon, and will relieve quickly. The furuncular form demands at once either an incision or carbolic acid treatment. Both should be preceded by local cocaine anaesthesia, for the pain may be intense. The incision must be as thorough as in a furuncle of any other region. It may often be substituted by a thorough application of concentrated carbolic acid. If ap- plied early, a single (or repeated) application will prove effec- tive. As its action is quite local, there is no danger. If the furuncle be pointed and the surface excessively painful, the acid ought to be introduced into the centre of the swelling by means of a slightly curved probe. Accompanying myringitis is apt to improve after its cause — the otitis externa — has been removed. A vesicatory or tinc- ture of iodine on and about the mastoid process is helpful. Direct injury of the drum membrane by cold water or salt- water during bathing can be averted by a wool tampon. Otitis media, both the catarrhal and the purulent variety, is a very frequent disease of infancy and childhood. Even in the middle ear of the newly-born accumulations are met with which either constitute or dispose to otitis. According to some, the masses frequently encountered consist of detritus developed out of the foetal epithelial covering; others accuse aspiration dur- ing and immediately after birth; some attribute the changes to oedema produced ex vacuo, the vacuum being due to the sud- den separation of the mucous membranes formerly immediately adjacent to each other. Infants have a large Eustachian tube, with a funnel-shaped pharyngeal aperture; thus infectious ma- 592 THERAPEUTICS OF INFANCY AND CHILDHOOD. terial of the common eruptive fevers, streptococci and staphy- lococci, the bacilli of a diphtheritic rhinitis, and even gonococci find an easy access. In lobular pneumonia otitis media is quite frequent; in scarlatina, also in measles and typhoid fever, it may be very severe. All the varieties of nasal, pharyngeal, and naso-pharyngeal catarrh, also adenoid vegetations and hyper- trophied tonsils, are known to be the principal causes of mid- dle-ear disease. Vehement spells of whooping-cough, forcible medicinal or other injections into the nares, and violent sneez- ing are apt to carry foreign material into the Eustachian tube and middle ear, particularly when the uvula is split in halves (bifida), and still more so when the hard palate is fissured; for in such a case the levatores palati have no support and the mus- cles of the tube are insufficient and atrophied. Preventive treatment has a wide scope. The number of cases of otitis media — according to Schwartze, twenty-two per cent, of all diseases of the organ of hearing are purulent forms of middle-ear disease — is as significant as its causes are manifold. Nasal, postnasal, and pharyngeal catarrhs must be attended to in their incipiency. Regular attention to the nose of infants would prevent much disease and many calamities. Indeed, de- fective hearing is more common than we suspect. Bezold found (1886) that of nineteen hundred and eighteen school-children, twenty-five per cent, had but one-third and eleven per cent, but one-fifth of normal hearing distance, and his statements have been amply confirmed. Most cases of perforation of the drum membrane, chronic suppuration, abscesses in the mastoid process, permanent paralyses of the facial nerve, and cerebral abscesses can be prevented by treating and curing the origin and fountain-head of the future distress. The hypertrophied mucous membrane of the nose must be reduced, adenoids re- moved, and enlarged tonsils resected in time. The interior of the nose ought to be washed — irrigated — at least once a day, according to known principles (p. 465). Gentle insufflation of the nares will clear the cavities of mucus. It may be done by a Politzer apparatus, or by blowing into a soft rubber tube in- DISEASES OF THE EAE. 593 troduced into one nostril, while the other is kept open. There is better reason, from the point of view of danger to health or life, for washing the inside than the outside. A child with an acute attack of middle-ear disease ought to be in bed, the head raised. The symptoms are not always urgent or easily recognized. In the very young the large size of the tube facilitates the exit of the internal secretion into the throat, so that the drum membrane is not annoyed and pain from internal pressure and irritation is insignificant in many instances. Careful examination, however, will leave a doubt as to the actual seat in few cases only. A mild antipyretic, a small dose of a narcotic, or a purgative will ameliorate the symptoms. In the very beginning the Eustachian tube ought to be treated by inflation (Politzer) very carefully, if at all; older children, who can be taught the use of Valsalva's method, must be warned against its excessive and vehement employ- ment. When the acute stage has passed, both are mostly in- dicated. The severe pain may be relieved by a cocaine solu- tion (2-10 : 100) instilled into the ear, also by one or more leeches to the mastoid process of the affected side, in most cases but one side being diseased. In mild ones tincture of iodine alone will suffice. When the drum membrane is red, a cloth moistened with a solution of hydrargyrum bichloride in water (1 : 5000) applied to the ear and frequently repeated, will, after getting warm, do equally as well as the most favored warm poultices. When secretion of mucus or pus is increasing inside, the posterior half of the drum membrane is pushed out first, afterwards the anterior; between the two, particularly in older children, the hammer can be distinguished. A spontaneous per- foration is apt to form in the anterior portion, but the presence of a white discoloration does not always indicate pus. When the protrusion of the membrane is very marked, an incision should be made, mostly posteriorly and inferiorly. The general opinion of experts, however, is no longer in favor of indiscrimi- nately early operation; still, when it is performed, the incision 38 594 THERAPEUTICS OF INFANCY AND CHILDHOOD. ought to be sufficiently large. Pus is then expelled by inflating through the nares (Politzer), and wiped out or carefully syr- inged out with a warm solution of table-salt or of boracic acid (3-4 : 100). The patient should rest on the diseased side. Boracic acid is then used as described in the rules laid down for its application in external otitis, or the canal is gently syringed with a mild solution of bichloride of hydrargyrum, or of an astringent, — sulphate of zinc, acetico-tartrate of aluminium (2 : 100-300). To what extent, during all this time, narcotics are to be used, or whether anaesthesia, local or general, ought to be employed, depends on the individual case and the judgment of the practitioner; also whether an antiscrofulous or antisyphi- litic treatment (the latter but rarely in children) be demanded. Chronic discharges require politzerization frequently, though cautiously, and the use of boracic acid and astringents; second- ary polypi, treatment similar to that detailed above. The secondary affections of the mastoid process demand leeches, ice, and tincture of iodine; where there is oedema, warm poultices and a deep incision. Abscesses of the mastoid process and of the brain require timely operation by an expert hand. The general rules laid down by Troltzsch are still valid. Cerebral affections due to ear-disease are, when originating in the external meatus and the temporal bone, in the transverse sinus and the cerebellum; when in the middle ear, in the cere- brum; when in the vestibulum and cochlea, in the medulla oblongata. In my opinion, one of the most important additions to modern surgery is our knowledge of the operative accessibility of all the spaces and nooks of the middle ear, as taught by Schwartze, and of the epitympanic part, by Zaufal, in all cases of chronic suppuration of the middle ear accompanied by sensi- tiveness or suppuration on the surface of the mastoid process, or by fistulae, with osseous stenosis of the meatus and facial paralysis; of middle-ear disease exhibiting cerebral symptoms, with or without persistent fever, though there be no external inflammation; also in cases of cholesteatoma of large size, with DISEASES OF THE EAE. 595 alarming cerebral symptoms during the operation, particularly while injections are being made, or in those in which sequestra or foreign bodies must be removed, mainly when they give rise to brain symptoms; and, lastly, in cases of profuse ichorous secretion, or of actinomycosis, or of tuberculosis of the middle ear. Deaf-mutism is rarely a primary affection of the organ of hearing, though arrests of development and the results of foetal inflammations are not uncommon. It is also found in many instances of cretinism. It would be better in a large percentage of cases to assign it a place in connection with diseases of the nervous system, for most of both the congenital and the ac- quired cases result from cerebral affections. It is not often hereditary. If more extensive statistics will prove its (doubtful) dependency on consanguineous marriages, a wiser social hy- giene can be made to act as a preventive. Alcoholism of the parents is a cause, and society and the state, with its organiza- tion of ignorance and disorder, are responsible for so much of deaf-mutism as is not directly pathological. About half of all the cases are acquired, some even after children commenced to talk, the majority of them through cerebral and cerebro-spinal inflammation. According to Biedert, fifty-five per cent, are of that class, twenty-eight per cent, depend on acute infectious diseases (typhoid, scarlatina, and diphtheria, also variola and measles), 3.3 per cent, on traumatic injuries, and 2.5 per cent, on ear affections. Thus many of the congenital cases and most of the acquired are preventable. The treatment must be di- rected to so much of pathological change in the brain, the acoustic nerve, or the ear as is still accessible to the influence of either remedial or operative interference. Chronic (mostly interstitial) inflammations of the brain should not be given up as incurable as long as mercury and iodides had no sufficient opportunity to show its absorbent powers during a protracted administration. External and internal otitis, naso-pharyngeal catarrh, hypertrophy of the tonsils, adenoid vegetations, should be attended to in time, though the case appear ever so slight. XV. DISEASES OF THE EYE. Malformations of the eye are of different variety and gravity. Some cannot be corrected, such as cyclopia, microphthalmia, and albinismus; some need no correction, like the common (vertical) form of coloboma of the iris, or the congenital atresia of the pupil. The latter consists in the persistency of a part of the pupillary membrane originating from the posterior as- pect of the lens, and, if still extant after birth, disappears slowly. Others require, and are corrected by, operations. Epi- canthus — an abnormal accumulation of cutis near the root of the nose — may be removed by an operative procedure, in the event of its not gradually disappearing spontaneously. Neoplasms of the eye and eyelids are not frequent in infancy and childhood. Congenital ncevi of every variety, however, are not uncommon. Very superficial ones on the eyelids should be kept under observation. When uniform and rather pale, they are liable to heal spontaneously. When a net-work of enlarged blood-vessels is found on the lids or conjunctiva, there is often a central point the compression of which by means of a silver probe empties all the neighboring branches. This centre ought to be destroyed by a single application of the thermo- or galvano-cautery, or by a trace of fuming nitric acid, or by running a silk ligature underneath and tying it. When they form small or large tumors, in most cases the actual cautery is easier and safer than the knife. The cautery must be used carefully and sparingly, — rather too little than too much, ac- cording to rules detailed above, — and always with a view of avoiding a consecutive ectropium. 596 DISEASES OF THE EYE. 597 Dermoid cysts are found on the lids, inside; also on the eye- ball; even in the orbit, from which their removal is rather dim- cult. They must be enucleated when the diagnosis is un- doubted. They have been mistakenly diagnosticated in cases of encephalocele of the interior angle of the eye. Lipoma is very rare, still more so than cysticercus celluloses. A few instances have been reported in which this cystic de- generation of the ovum of the taenia solium was found in chil- dren in the posterior chamber and under the skin of the lid. Chalazion (not always tubercular, as has been asserted) is a mucous cyst in the tarsal cartilage, with a tendency to indu- ration. The eyelid is turned over, the small tumor incised, its contents scraped out, and iodoform applied once. As the wound is covered by the lid, it heals favorably. Glioma of the retina (Beer's amaurotic cat-eye) develops rapidly. Its vascular, sometimes red and bleeding, surface dis- tinguishes it from suppuration of the vitreous body. It must be enucleated at once, as it is liable to grow rapidly in every direction. Syphilitic gummata have been observed in stray cases of re- tarded syphilis. They exhibit the symptoms of iritis, and require an ant i syphilitic treatment. Tubercles of the iris are, fortunately, rare. They give rise to an incurable chronic iritis and necessitate enucleation of the eyeball. Tubercles of the choroid are sometimes observed in the incipient, sometimes in an advanced stage of tubercular meningitis. They are not amenable to successful treatment. Foreign bodies hidden under the eyelids must be removed speedily, for conjunctivitis will immediately follow their pres- ence. They are often washed, out by the copious secretion of tears. The lower eyelid may be easily turned out and the cor- responding portion of the conjunctiva inspected. The upper requires turning up, which is more difficult because of the re- sistance of the child, but easier than in an adult, on account of the greater motility of the skin of the young eyelid. To 598 THERAPEUTICS OF INFANCY AND CHILDHOOD. facilitate inspection, the eye may be pressed gently backward into the orbit. The body, when seen, is removed by pincers, a fine sponge, a piece of gauze, or wiped off in the direction of the nose. In case of necessity, anaesthesia may be procured by a drop of a two-per-cent. solution of cocaine. This is indispensable when the foreign body is in the cornea and demands instru- mental removal. If it be iron, a strong magnet will remove it; when it is located externally, without, when in the deeper tissue, with, a previous operation. The danger connected with foreign bodies entering the eyeball, and the indication for immediate, or delayed, or no operation depends on the condition of the foreign body, which may be aseptic and not injurious, may irritate mechanically or chemically, or be infectious. As a general rule, the foreign body is readily recognized in the ante- rior chamber, the iris, or the lens, and should be removed im- mediately according to the rules laid down in ophthalmological works. Injuries of the eye by puncturing, cutting, blows, etc., re- quire absolute rest, the removal of foreign bodies, the applica- tion of ice, of atropine solution (eserine when the wound is peripheric), and gentle pressure. Bad cases of laceration and destruction are either irremediable or require special, perhaps operative, treatment. Burns should be treated on general principles. The effect of acids is best counteracted by copious irrigation of water, and cooling applications afterwards; of lime, by oil (not by water), and the careful removal of the foreign body, and ice applica- tions. The eyelids suffer from blepharitis mostly in scrofulous chil- dren, in whom dust, smoke, and infections of all kinds are apt to thoroughly influence the superficial tissues. It often ac- companies eczematous eruptions of the head and face, and is frequently carried by the fingers. Therefore, soap and water, a nail-brush, and cutting the nails short are good preventives; so is the successful treatment of the head and face. The bleph- DISEASES OF THE EYE. 599 aritis and conjunctivitis of measles require no special local treat- ment; the common forms do well with a zinc ointment, or one of the yellow oxide of mercury with vaseline (1 : 50-100). The secretion must not be permitted to get dry. Hard crusts are dissolved by a warm solution of carbonate of sodium (1 : 100- 200) or by frequent washing with soap and water. Grave cases demand epilation of the eyelashes, every one of which — so far as required — must be caught singly and drawn out slowly- enough to secure removal of the entire hair. Ointments and solutions of lead it is best to avoid, for complications with cor- neal erosions, grave or slight, are very frequent in affections of the eyelids and conjunctiva, and even the slightest ones may be indelibly stained by lead salts. Both the integuments and the connective tissue of the eye- lids being of loose structure and expansible, oedema is quite frequent. Insect bites are mostly diagnosticated by their cir- cumscribed and pointed appearance; cardiac and renal diseases require their own diagnoses and have their own indications; so has hydremia from whatever cause, besides the indications for the administration of iron, quinine, or arsenic. The conjunctiva is very liable to be affected by medicinal and poisonous agents. According to Silberman, aniline, potas- sic chlorate, and corrosive sublimate produce thrombosis; pun- gent gases, conjunctival hyperemia and conjunctivitis; anti- pyrin, urticaria of the eyelids; arsenite of copper, redness and corrosion; arsenide of hydrogen, a brownish-red or icteric dis- coloration; bromide of potassium, simple or phlyctenular con- junctivitis, without, however, influencing the blood-vessels of the interior; chrysarobin, a local inflammation; coniin, a burn- ing sensation; ergotin, hemorrhages; iodide of potassium, in- flammation; iodoform, when applied locally, an erysipelatous tumefaction; and salicylate of sodium, oedema and a bluish ex- anthem; in larger doses, tumefaction and vesicular eruption. Still, cases of conjunctival disease depending on these agents are comparatively rare. 600 THERAPEUTICS OF INFANCY AND CHILDHOOD. The majority of the diseases of the conjunctiva are of an inflammatory character. In a number of cases of conjunctivitis the conjunctiva of the bulbus does not participate extensively. Common forms of fevers, also whooping-cough and principally measles, are among the causes of acute conjunctivitis. Some- times there is but little redness; the lids are thickened and stiff with oedema. In other cases there is plenty of mucus, sometimes purulent, now and then with a tendency to coagu- lation, but not to such a degree as to render difficult the dif- ferential diagnosis from diphtheria of the eyelids. The mucous secretion must be wiped off with absorbent cotton or a moist cloth, boracic acid solution of three per cent, should be applied or instilled, and cold water employed at intervals of from one to ten minutes; chlorine-water, if obtainable fresh (a teaspoon- ful in a glass of water), should be used for applications; if the surface secretes much, corrosive sublimate (1 : 4000-5000). If the secretion be purulent, nitrate of silver, 1 part in 100 or 500 parts of distilled water (black bottle), must be applied once a day, best with a brush, and washed off with pure water. A high degree of congestion, with phlyctenular eruptions,— sometimes unilateral only, not infrequently combined with blepharitis, — demands persistent application of cold, best by keeping a number of small pieces of cloth on a lump of ice and applying them at short intervals until they begin to get warm. Atropise sulphas (1 : 200-500) should be instilled once or twice a day, and the lids kept at rest. To hold them immovable, if the patient be very young, a layer of absorbent cotton should be covered with, or slightly soaked in, collodion and applied after the eye has been wiped dry. Later an ointment of the yellow precipitate of mercury (1 : 50-100), or calomel finely powdered, may be employed once a day. Chronic conjunctivitis presents in many cases few symptoms only. The superficial hyperaemia does not always correspond with the burning sensation often complained of, and the mu- cous secretion is but trifling, and collects mostly in the inner DISEASES OF THE EYE. 601 angle of the eye. Overexertion of school-children, particularly of those who are hypermetropic or astigmatic, diseases of the nose of a catarrhal or ulcerous nature, indigestion and constipa- tion, anaemia, scrofulosis, or trichiasis are just so many causes and require the appropriate causal treatment, both medicinal and hygienic, change of air (country), and cool and cold bath- ing. These measures often suffice to relieve even secondary dis- orders of the lymph circulation, which is easily disturbed. Like the orbits which discharge their lymph-ducts into the deep facial lymph-bodies, the lids and conjunctivas are connected with the glands of the aural and submaxillary regions. The medicinal treatment is disinfectant and astringent; the remedies must be changed from time to time. Sulphate of zinc (1 : 250-500) with or without cocaine muriate (1-2 : 100), in more protracted cases ointments of sulphate of zinc or sulphate of copper (1 : 100-150), solutions of boracic acid (3 : 100) or of sodium carbonate (1 : 100-200), in suppurating cases a daily brushing with nitrate of silver (1 : 250-1000), combined with scrupulous cleanliness and avoidance of vascular stimulants, will meet all indications. The chemosis of scleral conjunctivitis does not require any additional applications; mild astringents and rest will suffice. Subbing, constipation, and coughing result in hemorrhagic dis- coloration (general blueness or extravasations) which requires rest and cool (or warm) fomentations. Diphtheritic conjunctivitis cannot readily be mistaken. The infiltration is hard and the pseudo-membrane not removable. There is no secretion; indeed, the eye is dry to such an extent that the pressure of the exudation alone ulcerates the cornea. Absolute caution in every case of — particularly nasal — diph- theria, and covering the healthy eye, when (as usual at first) but one eye is affected, with a cotton and collodion application, aided by more cotton and a bandage, are indispensable. Thor- ough and speedy mercurialization and antitoxin are indicated. Papayotin (1 : 5-10 of water and glycerin), not to be sub- 602 THERAPEUTICS OF INFANCY AND CHILDHOOD. stituted by "papoid," may be applied every hour. Nitrate of silver deserves no recommendation. Chlorine-water, carefully applied while the eyelid is kept away from the eyeball, when- ever that is possible, may render good service. Ice must be applied carefully and persistently. Most cases of gonorrhceal conjunctivitis are contracted during birth from the gonococcal discharge of the maternal vagina; others through handkerchiefs, towels, fingers, or bathing water. Its treatment has been discussed (p. 117). Trachoma, possibly of a microbic, surely of a specific char- acter, consists of granular deposits and proliferation of cells which crowd upon the normal tissue and render it atrophic. Its duration is long; its treatment must be persistent. The acute attack, or stage, requires daily brushing with nitrate of silver (1 : 100), and washing off with water when the first effect of the caustic becomes visible. The subacute cases de- mand a daily (or less frequent) application of the sulphate of copper stick. The granulations may also be scarified, scraped out, or squeezed out, — an old operation successfully re-estab- lished by modern surgery. Many cases do well with a daily application of one part of bichloride of mercury in one thou- sand parts of distilled water. The conjunctival duplicature, which is the pet seat of trachoma, has been excised to get rid of a large part of the diseased masses at once. For domestic treatment, an ointment of sulphate of copper and vaseline (1 : 100), with or without cocaine muriate, will prove beneficial. A similar treatment, somewhat modified and diluted, is ap- plicable to what is described as granular conjunctivitis, which probably is in no case anything but a mild form of trachoma. Follicular conjunctivitis is probably of the same nature in many cases; usually it is described as an inflammation of the (micro- scopically small) glands of the conjunctiva. The follicles are in rows near the margin of the eyelids. It is complicated with, or depends on, the presence of foreign bodies, of nasal disease, or of other varieties of conjunctivitis, and is not infrequently DISEASES OF THE EYE. 603 found in large numbers in families and in schools. The treat- ment is milder than that of the previous forms, — rest, washing, boracic acid solutions, astringents. Keratitis, beginning with a small vesicle, which is mostly not observed, and rapidly terminating in a superficial ulceration, is frequently met with in "scrofulous" children, who, besides, suf- fer from affections of the mucous membranes of the nose, lips, and ear, from eczema, glandular tumefactions, etc. Some pa- tients are rickety. To overcome the spasm of the conjunctiva, cocaine is often required to facilitate examination; for that purpose the dipping of the head into cold water, a popular remedy for photophobia, is probably not convenient. The con- stitutional disorder must be combated by cleanliness, fresh (country) air, bathing, plain and nutritious diet, quinine in small, iodide of iron in proper doses. Iodide of potassium in small doses (grs. 1-2), three times a day, given for a long time, is very successful in many cases. The room must be kept moderately dark and the eye protected by a shield. Good local applications are chlorine-water diluted in from twenty to one hundred parts of water, corrosive sublimate (1 : 5000), boracic acid (3 : 100), atropine solution of one-half per cent., or cocaine solution of two per cent, (the last two occasionally in combina- tion). When the ulceration is near the corneal margin, eserine is recommended in place of atropine; but it is advisable to re- member that it produces a congestion of the iris and may pre- dispose the latter to be drawn into the morbid process. Old cases will do well with occasional (one every day or two days) gentle applications of nitrate of silver (1 : 200-500) or (particu- larly when the conjunctiva is pale) of finely powdered calomel; this latter has always been highly recommended, and is useful, if persistently used through weeks and months, when turbidity of the cornea remains behind. Old cases with defective power of reparation will do well when the lids and eyeball are gently kneaded with an ointment of the yellow precipitate of mercury (1 : 50). In many instances some of these remedies will act 604 THERAPEUTICS OF INFANCY AND CHILDHOOD. better than others; alternation is often required. A simple ulceration, no matter what application is employed, will heal better, or best, by avoiding friction of the eyelids; they ought to be immobilized by cautious bandaging, which may be re- moved to make the demanded local applications. Under the bandage a cloth wet with a solution of corrosive sublimate (1 : 5000) or boracic acid (3 : 100) will prove quite acceptable and beneficial. Suppurating ulcerations lead to hypopyon and per- foration. They require, besides atropine, or eserine when near the margin, occasional applications of corrosive sublimate (1 : 2000) or nitrate of silver (1 : 100). Biedert recommends co- caine and scraping or burning of the abscess. According to him, the main obstacles in the way of speedy recovery are: com- plications with conjunctivitis, blepharitis, nasal affections, stenosis of the lachrymal duct and blennorrhea of the lach- rymal sac (but rarely its congenital obstruction), and blepharo- phimosis with photophobia and rhagades. Parenchymatous or diffuse keratitis is a peculiar variety. The turbidity and thickening of the two cornese (the process being bilateral) are extensive, not always uniform, often dis- seminated, and complicated with considerable vascular injec- tion on and around the corneae and with synechia of the iris. Very many cases of this variety — according to some, the vast majority, ninety-six per cent., according to Parinaud, thirty per cent., according to Siklossy — are the results of syphilis, either hereditary, or acquired, or retarded hereditary. They require persistent antisyphilitic treatment with iodide of po- tassium (and mercury). Scrofula, rhachitis, malaria, and ar- thritis are also charged with producing this form. It is certainly true that iodine and mercurial treatment are not always successful. Some cases are benefited by salicylate of sodium. Atropine is useful in all. In neuroparalytic keratitis both the conjunctiva and the cornea are deprived of sensibility, the lids do not move, the eye is kept open, the cornea is dry (xerosis) and may undergo DISEASES OF THE EYE. 605 softening (keratomalacia), with the result of either perforation or incurable turbidity and local thickening. It is met with in severe infectious fevers, particularly during the unconscious state of typhoid, and in the coma of encephalitis. These results are not often met with for a long time in succession, for most of the patients die of the original disease. They have also been noticed during and after frontal and conjunctival herpes zoster. In all these cases the eyeball must be moistened with salt and water (6-7 : 1000) and the lids closed by a band- age or by cotton with collodion. In most cases the latter will prove as effective as suturing of the two eyelids. Xerosis of the conjunctiva is also noticed, in very young infants, as the result of ill nutrition and consecutive marasmus. Most of the patients are from two to six months old. Proper and sufficient food will sometimes restore both the eye and the general health, but the mortality of these cases is very high. The same con- dition is found in children of from three to nine years (Thal- berg, Forster). Several such cases were complicated with hemeralopia. Keratoconus — the conical raising of the centre of the cornea — requires a cautious thermo- or galvano-cauterization; pan- nus, the centre of which is generally absolutely deprived of blood-vessels, demands stimulation. Daily insufflation of finely powdered calomel, continued for weeks or months, has met with some successes. Infection with erysipelas and gonorrhoea has been observed to restore circulation and absorption, and the latter has been utilized, consequently, to accomplish these ends. Acute iritis is rare in infancy and childhood; its complica- tion with glaucoma still more so. Of its two great causes, syphilis is almost exclusively of the hereditary variety, and rheumatism exhausts its main danger in starting endocarditis. Chronic iritis is not so often seen in early life, except in con- nection with diffuse keratitis. The treatment of iritis is essen- tially identical with that of the same affection in adults: hydrargyrum, iodides, and salicylates, according to the causal 606 THERAPEUTICS OF INFANCY AND CHILDHOOD. indication; instillations of atropise sulphas in distilled water (1 : 100-500) from two to ten times a day, or oftener if the danger of adhesion be imminent, with a two-per-cent. solution of muriate of cocaine if the pain be great; absolute rest in the acute variety; dry heat; a dark room; iridotomy, or rather iridectomy, in most cases to loosen synechias and restore a pupil. Subconjunctival injections of corrosive sublimate (1 : 1000, a few drops at a time) were used by Darier in 1892, and in Deutschmann's clinic. They are made near the margin of the cornea and downward, and are recommended principally for syphilitic affections of any part of the eye, except, perhaps, the optic nerve. Parenchymatous keratitis and iritis are also said to be amenable to the same treatment, though they be not syphilitic. Later reports are not quite so favorable. Suppurative cyclitis and a true abscess of the vitreous body are generally found together. Blindness is imminent, and enu- cleation to save the other eye becomes a necessity in almost every case, except in small children. In them the process has often exhausted itself, and may terminate in blindness and con- traction without secondary irritation. When the abscess is small, part of it may be absorbed, and a white cloud in the lower part of the vitreous body, and feeble vision, may be the only evident results. Uncomplicated inflammation of the choroid is rare in chil- dren. Idiopathic choroido-retinitis is observed in later years in both eyes after it has lasted a long time. It certainly com- mences at an early age, but takes decades before it ends in con- traction of the field of vision, degeneration of the retina and optic nerve, and turbidity of the vitreous body and the pos- terior capsule of the lens. In all cases, whether syphilitic or not, treatment with mercury and iodides is the only one either reliable or advisable. Congenital cataract demands an operation if vision be in- sufficient. If it be partial, atropine and iridectomy will suffice. Total cataract is rare in early years; more frequent is zonu- DISEASES OF THE EYK 607 lar cataract, which exhibits round its nucleus one or more turbid layers, followed by normal clear ones. As at the same time in a number of cases transverse phosphatic deposits are found in the teeth, zonular cataract has been attributed by many to rhachitis; others connect it with convulsive diseases. Some constitutional disorder has been charged with being the cause, but no treatment has been advised, nor is there any apparent indication, except to correct the accompanying myopia. Disease of the retina, the optic nerve, and the orbit show no particular symptoms in the young, nor do they require special treatment different from that employed in advanced age. In many cases of acute or chronic leptomeningitis with ample effusion, blindness depending on copious secretion in and around the tissue of the optic nerve is an early s}'mptom. Early diagnosis of this condition, and treatment with mercury, iodides, and derivants (diuretics, purgatives, diaphoretics), may succeed in reducing the cedema and preventing compres- sion and atrophy of the nerve. A number of such cases will get well. The tissues of the young eye being soft and elastic and ex- pansible from internal pressure, glaucoma is but rarely seen at an early age. Its place is taken by hydro phthalmos (buph- tlialmos), which requires the operative procedures employed for the glaucoma of advanced age, — either iridectomy or scle- rotomy. Strabismus is common in infants during the first few months of life. In them it is the result of an insufficient development of muscular power in general and of accommodation, and re- quires no treatment. That which makes its appearance during convalescence or in general hydremia terminates in recovery. Diphtheritic paralysis of the muscles of accommodation re- covers spontaneously, or through generous feeding and the administration of iron and strychnine. Muscular paralyses re- sulting from cerebral diseases depend on these for their treat- THERAPEUTICS OF INFANCY AND CHILDHOOD. ment, if any be possible. The ordinary form of ophthalmo- plegia, for instance, depends on nuclear degeneration. Still, there are a number of hereditary cases reported by Gourzein and considered by him as solely muscular. In them the ptosis was very marked; there was also nystagmus, and some am- blyopia. Persistent strabismus in children of five or six years requires the same methods of operative treatment as that of adults. NAMES. Abbe, 405. Abercrombie, 549. Ahlfeld, 96. Alexandroff, 371. Almquist, 547. American Pediatric Society, 284. Auerbaeh, 31. Baginsky, 277, 280, 283, 549. Bani, 90. Barth, 549. Baruch, 63, 489. Bassini, 413. Battersby, 327. Baumann, 158. Baumgarten, 252. Beely, 326. Behring, 77, 277. Benedict, 345. Beneke, 289, 527. Benney, 284. Bezold, 592. Biedert, 30, 34, 40, 175, 321, 590. Bienwald, 113. Bier, 576. Biermer, 404. Bieser, 468. Binz, 44, 304. Blumenthal, 241. Boas, 12, 59. Bonn, 448. Bokay, 424. Bouchut, 168, 534. Bourneville, 317. Brackett, 560. Braman, 549. Brenz, 119. Bretonneau, 40. Broca, 404. Brothers, 90. Broussais, 9. Brown, 284, 476. Bruns, 575. Budin, 110. Bull, 195. Biinger, 576. Caille, 32, 66, 81, 302, 323, 479. Calot, 570. Campbell, 432. Cantani, 167, 218. Caron, 166. Cattani, 116. Chapin, 96. Chossat, 9. Coates, 121. Coit, 35. Cohn, 24, 25. Coley, 78, 356, 424. Concetti, 363. Conquest, 326. Craig, 101. Crede, 96, 106. Cruveilhier, 529. Cunningham, 161. Curling, 415. Dana, 353. D'Arcy Power, 120. 121, 461. Darier, 606. 39 609 610 NAMES. Delstauche, 370- Demme, 448. Demuth, 304. Deutschmann, 606. Dew, 90. Dieulafoy, 369. D'Outrepont, 96. Dowd, 414. Doyen, 160. Ducrey, 250. Dujardin-Beaumetz, 59. Ebstein, 23. Edes, 161. Edlefsen, 285. Einhorn, 382. Elsaesser, 141. Englisch, 448. Epstein, 104, 549. Escherieh, 25, 116, 283, 395. Esmarch, 417, 576. Evans, 308. Ewald, 12, 382. Ewing, 278. Falkland, 42. Fede, 363. Ferreire, 250. Finkelstein, 382. Finotti, 578. Fischer, 309, 371. Flechsig, 353. Fleisch, 347. Fliigge, 26, 174. Forchheimer, 304. Forster, 605. Foster, 53. Fournier, 421. Fowler, 413. Fraenkel, 158, 365. Freeman, 32. Freudenreich, 178. Friedleben, 160. Fiirbringer, 323, 324. Gaertner, 39, 136. Gerster, 317, 350, 371. Ghillini, 584. Gibier, 354. Gilbert, 421. Gillette, 560. Glas, 347. Gleitsmann, 367. Gottstein, 370. Gourzein, 608. Gowers, 159, 338, 353. Gerhardt, 348, 349. Graves, 9. Greatgood, 326. Grenser, 89. Greves, 422. Griesinger, 412. Guaita, 304. Guerin, 447. Guersant, 453. Guillot, 103. Guyon, 448. Haase, 326. Haftkin, 77, 218. Hamill, 431. Hammarsten, 27. Hawkins, 404. Health Department of New York, 230. Hebra, 548. Heffen, 523. Heiman, 330. Hessing, 564. Heubner, 29, 35, 137, 143, 166, 195, 277, 280, 283. Hirscb, 347. Hirschfeld, 44. Hjort, 371. NAMES. 611 Honing, 326. Hoffa, 564, 565, 566. Hoffmann, 376. Hofmeier, 107. Holt, 33, 169, 197. Honigmann, 24. Hopkins, 472. Horsley, 158. Howard, 90. Huber, 241. Hueter, 250. Huguenin, 326. Hun, 162, 317, 318. llling, 107. Jacoby, 323, 324. Jastrowitz, 353. Jenkins, 97. Johnston, 303. Jolly, 353. Kamienski, 534. Kaposi, 542. Kassowitz, 141. Kauffmann, 448. Kiliani, 324. Kinnicutt, 162. Kitasato 341. Klebs, 183, 184. Klemperer, 43. Knaggs, 408. Knapp, 196, 350. Knochenstein, 24. Kobert, 130. Koch, 164, 173, 175, 183. Kocher, 119, 413, 453, 568. Koenig, 160. Koster, 572. Koplik, 28, 155, 216, 277, 367, 571. Kopp, 96. Korowin, 30. Kraske, 251. Kriiger, 11. Kulz, 166. Kummell, 159, 566. Kiister, 575. Kussmaul, 58, 408. Laborde, 92. Landau, 114. Landerer, 577. Landolt, 560. Langenbeck, 564. Lannelonguc, 316, 413, 577. Lanz, 143. Lassar, 101, 550. Lauth, 92. Lepine, 130. Leroux, 166. Letzerich, 304. Lexer, 254. Liebig, 44. Liebreich, 183. Loe wen m ever, 436. Lorey, 303. Luschka, 529. Macalister, 161. McEwen, 581. Mackenzie, 161. Malay, 11. Marie, 161, 354. Maragliano, 183. Marmorek, 78, 252. Marshall Hall, 90. Meckel, 108. Meigs, 34, 35, 308. Meltzer, 313. Menard, 103. Meyer, 251, 369, 577, 582. Michael, 303. Mikulicz, 161, 560. Milliken, 584. 612 NAMES. Mills, 350. Miquel, 178. Mitchell, 176, 572. Mitchell, J. K., 312. Moncorvo, 303, 304, 372, 539. Mouflier, 349. Moore, 96. Morton, 314, 340. Neisser, 553. Nelaton, 413. Nelson, 508. Netter, 309. Neuhaus, 554. Neumann. 24, 25, 107, 548. Nicoladoni, 584. Nicolaier, 341. Nichols, 571. Northrup, 33, 169. Oertel, 436, 514. Oliver, 70. Ombreville, 413. Oppenheimer, 159. Osier, 162. Owen, 161. Paci, 564. Pacini, 90. Palleske, 24. Parrot, 567. Pasteur, 354. Pavy, 17. Peck, 254. Pepper, 308. Pfeitfer, 215. Pernice, 92. Phelps, 579, 583. Philippson, 549. Pitts, 409. Pletzer, 423. Pocas, 584. Porak, 107. Post, 583. Putnam, 350. Quincke 323. Kabinowitsch , 175. Radclifle, 353. Ranke, 236. Rauchfuss, 586. Rauschenbusch, 278. Raymond, 549. Redman, 96. Redon, 166. Rehn, 305, 326. Reich, 89. Reinbach 159. Reiner, 451. Ribemont, 90. Riedel, 251. Riehl, 547. Rieth, 43 Ritter, 548. Rosenberg, 478. Rosenheim, 12. Rotch, 32, 36, 66, 96, 136. Roux, 77, 277, 280, 283. Rudisch, 42, 47, 382, 385, 511. Rummo, 130. Sachs, 317, 330, 350. St. Germain, 414. Salkowski, 28. Sands, 409. Sayre, 138, 570. Scanzoni, 103. Schaefer, 70. Schallern, 118. Schede, 566. Schifier, 30. Schild, 24. Schleich, 78. Schleif, 161. NAMES. 613 Schliep, 302. Schmidt, 367. Schott, 515. Schuchardt, 175. Schiiller, 90. Schultze, 90. Sehwartze, 592, 594. See, 530. Seibert, 32, 215, 216. Shaffer, 559. Siegfried, 28. Silbermann, 599. Silvester, 90. Sinclair Tousey, 554. Smellie, 89. Smith, A. H., 58. Solera, 11. Solis-Cohen, 161. Sonnenberger, 304. Soxhlet, 26, 34, 6(j. Springer, 38. Starr, 317, 318. Stepp, 309. Strelitz, 547. Sydenham, 9. Tarnier, 96. Taylor, 579. Teschner, 586. Thalberg, 605. Thallon, 274. Thin, 548. Tizzoni, 116. Tordeus, 548. Trendelenburg, 554. Treves, 412. Tubby, 566. Uffelmann, 12. Van der Veer, 317. Vargas, 571. Villate, 576. Virchow, 118, 163, 530. Volkmann, 564. Vogel, 144, 308. Voit, 44. Waldeyer, 118. Weber, 549. Wegeli, 166. Wegner, 141, 194. Weiss, 473. Wendt, 304. West, 215, 216, 326. Widerhofer, 193, 280. Widowitz, 309, 548. Wieland, 574. Willard Parker Hospital, 255. Williams, 215, 216. Winckel, 96, 111. Wittmaack, 28. Wladimiroff, 548. Woihler, 90. Wolf, 566. Wroblewski, 28. Zaufal, 594. Zweifel, 11, 30, 106. INDEX. Abscess of the vitreous body, 606. Abstinence in enteritis, 50. Acid, hydrochloric, 12; organic, 12. Acne, 540. Acute articular rheumatism, 288 ; blood in, 289. Addison's disease, 71, 161, 162. Adenitis in hereditary syphilis, 196 ; in diphtheria, 271 ; sublingual, 361. Adenoid vegetations, 369 ; in diph- theria, 258. Adenoma, 118; of the liver, 402. Adhesion of the prepuce, 449. Administration of medicines, 66. Adrenals, 70, 161. Akromegaly, 161, 162. Albinismus, 596. Albumose, 41 ; in rectal alimenta- tion, 58. Alcohol, 44 ; in sepsis, 44 ; in diph- theria, 263 ; in typhoid fever, 210. Alexin, 77. Alimentation, rectal, 57. Alkalies, 46, 48, 49 ; in gastric ulcer- ation, 384. Ammonium chloride, 79 ; no stimu- lant, 210. Amygdalitis, 365 ; follicular, 366. Amyl nitrite, 80. Amyotrophic sclerosis, 334. Anaemia, 122; primary, 122; causes of, 122 ; chronic, 123 ; food in, 125 ; hygiene in, 126 ; from gastric catarrh, 127; digitalis in, 127; strychnine in, 128 ; iron in, 128 ; cerebral, 320 ; splenic, 134. Anaesthesia, by infiltration, 78 ; not in mouth operations, 82. Anchylostoma duodenale, 411. Aneurism, 530. Angioma, 532. Ankle-joint, 581. Ankyloglosson, 364. Antipyrin as a styptic, 122. Antitoxin, 476 ; of diphtheria, 277 ; eruptions after, 278. Anus, prolapse of, 414 ; fissure of, 417. Aphthae, Bednar's, 359. Aphthous vulvitis, 454. Appendicitis, 403 ; operation in, 404. Applications, dry, to skin, 86. Arrest of development in nervous system, 318. Arsenic, 130 ; in various anaemias, 131 ; in intermittent fever, 198 ; in tuberculosis, 179. Arteritis, umbilical, 109 ; diagnosis of, from phlebitis, 110. Arthritis deformans, 571. Articular rheumatism, acute, 288 ; chronic, 297. Ascaris, 509. Ascites, 402. Asiatic cholera, 217. 615 616 INDEX. Asphyxia, 88; causes of, 88; pre- ventive treatment of, 88 ; treat- ment of, 90 ; electricity in, 92. Aspiration of meconium, 89. Asthma, 482 ; dyspeptic, 482. Asymmetry of cranium, 140. Atelectasis, 482 ; causes of, 95 ; treat- ment of, 95. Atheroma, 554. Athetosis, 348. Atresia of the pupil, 596 ; of the vagina, 458. Atrophy, acute yellow, 422 ; mus- cular, 315 ; of the skin, congeni- tal, 555. Autoinfection, 538. Bacilli, dissemination of, 170 ; in- halation of, 173. Bacteria in diarrhoea, 495. Balanitis, 456. Balano-posthitis, 456. Barley, 22. Barlow's disease, 165. Bath, cold, 65 ; warm, 65 ; hot, 65 ; the first, 100. Bathing, 63, 100. Bednar's aphthae, 359. Beef-broth, 41. Beef-scraped, 42. Beef-tea, 40, 41. Biliary ducts, congenital obliteration of the, 114. Bladder, 441 ; local treatment of, 443 ; spasm of, 442 ; irritable, 443 ; diphtheria of, 444 ; muscular debility of, 444, 446. Bleeding, cause of, 163. Blennorrhoea, 117 ; nitrate of silver in, 117. Blepharitis, 598. Blood, diseases of the, 122 ; in acute articular rheumatism, 289 ; of the infant, 125. Blood-pressure, 517; reduced, 517. Blood-vessels, 530 ; hypoplasia of, 530 ; thinness of, 530. Boiling milk, effects of, 23. Bones, 562 ; congenital malforma- tions of the, 462 ; curvatures, 562 ; rhachitical curvatures, 562 ; frac- tures, 566. Brachial plexus, paralysis of, 314. Brain, tumors, 317 ; symptoms in typhoid fever, 209. Bromides, 342. Bromoform, 309. Bronchi, 479. Bronchial catarrh, 479 ; chronic, 481. Bronchitis, 479 ; complication with asthma, 480; fibrinous, 481 ; in typhoid fever, 203. Bulbar paralysis, 328. Buphthalmos, 607. Burns, 535. Butter, 175. Calcium, 53. Calculi, renal, 439. Calomel in hereditary syphilis, 193. Cane-sugar, 16, 31. Cantharidal collodium, 85. Cantharidin, 183. Caput obstipum, 559. Carbolic acid, 234. Casein of different milks, 21. Caseous pneumonia, 170. Catalepsy, 346. Cataract, congenital, 606. Catarrh, acute gastric, 47 ; chronic gastric, 48 ; acute nasal, 463 ; chronic, 465, 470 ; chronic laryn- geal, 472; bronchial, 479 ; vulvar, 456 ; vaginal, 456. IXDEX. 6i; Catarrhal fever, 217. Caustics in naevus, 532. Cautery in naevus, 532. Cereals, 29 ; admixture to milk, 29, 30. Cerebral diseases, feeding in, 5G meningitis, 318; hyperemia, 319 anaemia, 320 , thrombosis, 320 embolism, 320. Chalazion, 597. Cheese, 175. Chemosis, 601. Chest, deformities of, 497. Chicken-pox, 247. Child, peculiarities of the, 10. Chlorate of potassium, 259. Chloride of iron in diphtheria, 272 ; in membranous croup, 273. Chloroform, 80, 81; in obesity, 82; in pneumonia, 82 ; in heart-dis- eases, 82. Chlorosis, 132 ; anatomical cause of, 132; haemoglobin in, 132; blood in, 132. Cholera, Asiatic, 217. Chorea magna, 347 ; minor, 343 ; in rheumatism, 292. Choroid, 606. Chronic articular rheumatism, 297. Chyluria, 534. Circular dementia, 329. Circulation, organs of, 511. Cirrhosis, congenital, 114. Climate in tuberculosis, 176. Clothing in tuberculosis, 178. Club-foot, 582 ; after poliomyelitis. 339. Coal-tar preparations, 64. Cocaine injections, 78. Cod-liver oil, 53 ; action of, 137. Cold water in typhoid fever, 204. Colic. 392. ' Collodium, cantharidal, 85. j Coloboma, 596. i Colon descendens, 121. Compensation in heart-disease, 522. Compressed air in pertussis, 302. Concretions in mouth, 357. Congenital constipation, 121 ; luxa- tions, 564; myotony, 315. Conjunctiva, 599 ; inflammation of, 599 ; scleral, 001 ; diphtheria of, 601 ; gonorrhoea of, 602 ; tra- choma of, 602 ; granulations of, 602 ; follicles of, 602. Constipation by starchy food, 52 ; lack of sugar, 52 ; causes of, 51 ; apparent, 51 ; by casein, 52 ; con- genital, 121 ; in rhachitis, 146 in typhoid fever, 297 ; actual, 387 apparent, 387 ; congenital, 388 medication in, 390, massage in, 391 ; electricity in, 391. Constitution, diseases of the, 122. Convalescence, 126. Convulsions. See Eclampsia. Cord, treatment of the, 106 ; liga- ture of the, 106 ; dry treatment of the, 108. Corrosive sublimate, 235. Cough, periodic night, 483. Couveuse. 96. Cow's milk not woman's milk, 29. Coxitis, 579. Craniotabes, 140. Craniotomy, 316. Creosote in tuberculosis, 182. Cretinism, 330; treatment of, 157. Croup, pseudo-membranous, 473 ; pseudo, 472 ; mercury in, 475 ; in- tubation in, 475; antitoxin in, 476. Cryptorchis, 459. Cyclitis, 606. Cyclopia, 577. 618 INDEX. Cystic lymphangioma, 534. Cystitis, 441. Deaf-mutism, 595. Degeneration, acute fatty, 111. Delirium tremens, 329. Dementia, 329 ; epileptic, 329 ; cir- cular, 329. Dental ulceration, 363. Dentition, difficult, 362. Depletion, 87 ; local and general, 87 ; Dermatitis exfoliativa, 547. Dermoid cysts of the skin, 554 ; of the neck, 555. Deviation of nasal septum, 466. Diabetes, 166 ; mellitus, 166 ; in- sipidus, 168. Diagnosis must precede treatment, 60. Diarrhoea, 393 ; causes of, 393 ; bac- teria in, 395 ; summer, 400 ; in typhoid fever, 206. Diet in typhoid fever, 212 ; relation to medication, 62. Digestive disorders in rhachitis, 136. Digestive organs, 356. Digitalis, 518/ in tuberculosis, 180; action of, 181 ; preparations of, 181. Diphtheria, 230, 252; bacillus in, 252 ; streptococcus in, 253 ; local, 253 ; prevention of, 254 ; contagion of, 254 ; self-infection in, 255 ; heart failure in, 264 ; stimulants in, 262 ; local treatment in, 264 ; nasal injec- tions in, 265 ; of the nose, 267 ; of eye-lid, 602 ; steam in, 269 ; slak- ing lime in, 270 ; adenitis in, 271 ; internal treatment of, 272 ; chlo- ride of iron in, 272 ; alcohol in, 273 ; mercury in, 274 ; nephritis in, 276 ; paralysis in, 276 ; an- titoxin in, 277; immunization against, 285. Diseases of the blood, 122. Disseminated sclerosis, 328. Doses of medicines, 68. Ductless glands, 155. Duodenum in gastric ulceration, 384. Dysentery, 219; varieties of, 219; food in, 219 ; opium in, 221 ; as- tringents in, 221 ; temperature in, 223 ; paralysis after, 223 ; ulcera- tions, 223 ; enemata in, 224; sup- positories in, 226. Dyspepsia, 45 ; 372 ; causes of, 45 ; treatment of, 46 ; alkalies in, 46, 373. Dystrophy, progressive, 315. Ear, diseases of the, 587 ; malforma- tions, 587 ; foreign bodies in, 587 ; eczema of, 588 ; inflammation of, 588 ; polypus in, 590. Eclampsia, 342. Ecthyma, 543. Eczema, 543 ; seborrhoicum, 546. Egg, 42 ; in rectal alimentation, 58. Elbow, 581. Electricity on skull, 84. Elephantiasis, 534. Embolism, cerebral, 320. Emetic in pseudo-croup, 472. Emphysema, 495. Encephalocele, 328. Enchondroma in mouth, 356. Endocarditis, 524 ; chronic, 526. Enema. 71. Enteritis, 50; treatment of, 50; membranous, 389. Epicanthus, 596. Epidemic cerebro-spinal meningitis, 213; sequelae of, 214; etiology of, 215. INDEX. 619 Epididymis, tuberculosis of, 4G0 ; pseudoplasms of the, 460. Epilepsy, 348. Epileptic dementia, 329. Epistaxis, 409. Epithelial pearls, 357. Ergot in brain-disease, 320 ; in inter- mittent fever, 199. Erysipelas, 249 ; operations for, 251. Erythema, 537 ; nodosum, 296, 539 ; papulosum, 296. Erythromelalgia, 549. Eucalyptus in intermittent fever, 199. Eustachian tube, 591. Excursions, 63. Exostosis, 563. Exomphalos, 119. Exophthalmic goitre, 158, 162. Expectant treatment, 61. Eye, diseases of the, 596 ; malforma- tions of the, 596 ; neoplasms, 596 ; cysticercus, 597; injuries of, 598; burns of, 598 ; afl'ected by medi- cines, 599. Eyelid, naevus of, 596 ; dermoid cysts, 597; lipoma, 597; foreign bodies under, 597. Facial nerve, paralysis of, 314. Factory work, 66. Fat diarrhoea, 19. Fat food, 136. Fat in normal fteces, 19 ; in foods, 20. Fat milk, 39. Favus, 550. Febrifuges in children, 68 ; in tuber- culosis, 184. Feeding, forcible, 59 ; through stom- ach-tube, 59 ; nasal, 59 ; in ty- phoid fever, 203. Ferratin, 130. Fever, catarrhal, 217; feeding in, 54 ; typhoid, 200. Fibroma in mouth, 356. Fingers, supernumerary, 562 ; webbed, 563. Fissure of the anus, 417 ; of the palate, 356. Fistula colli congenita, 370 ; in ano, 187. Flat-foot, 584. Fomentations, 86. Food in anaemia, 125 ; in tubercu- losis, 176 ; of cows, 24. Foods, artificial, 43. Foot, growth of, 582. Fractures, 566. Frost-bites, 536. Fungus, umbilical, 118. Funnel chest, 497. Furunculosis, 542. Gangrene, pulmonary, 497 ; sym- metrical cutaneous, 549 ; umbili- cal, 109. Gargles, 83. Gastric catarrh, 378; chronic, 380. Gastric neurosis, 383. Gastritis, 379. Gelatine, 22. Genital organs, embryology of the, 447. Genito-urinary organs, 430. Genu valgum, 581 ; varum, 581. Germs through the anus, 24 ; in breast-milk, 24. Giant growth, 562. Gingivitis, 358. Gland, pituitary, 161. Glands, ductless, 155. See Lymph- bodies. Glandular fever. 215. 620 INDEX. Glandular swellings in diphtheria, 259. Glans penis, 448. Glaucoma, 605, 607. Glioma of the retina, 597. Glossitis, 364. Glottis, spasm of the, 477 ; paralysis of the, 478. Goitre, 155, 161 ; exophthalmic, 158. Gonitis, 579. Gonorrhoeal rheumatism, 294. Granuloma, 118. Green-stick fractures, 139. Growing pains, 287. Guaiacol in tuberculosis, 182. Gum arabic, 22. Gymnastics, compulsory, 62 H asm atom a of the sterno-cleido-mas- toid muscle, 98. Hsematuria, 432. Haemogallol, 130. Haemoglobinuria, 432 ; epidemic, 111. Haemol, 130. Haemophilia, 163, 531. Haemoptysis, 177. Hare-lip, 356. Hay bacillus, 25. Heart, 511 ; acute and chronic dis- eases of the, 511; feeding, 511; rest, 512 ; exercise, 514 ; cold, 515 ; stimulants, 517 ; nitroglycerin, 522 ; failure, 522 ; syphilis, 528 ; congenital anomalies, 528 ; under size, 529. Heart-failure, 261 ; in typhoid fever, 209. Heart, hypoplasia of, 154 ; in rha- chitis, 144. Helminthes, 409. Hemicrania, 315. Hemiplegia, infantile spastic, 328. Hemorrhage, gastric, 383 ; in typhoid fever, 207 ; pulmonary, 188, 496 ; symmetrical cutaneous, 549 ; treat- ment of, 122; umbilical, 112; vaginal, 458. Hemorrhagic diathesis, 163. Hepatoptosis, 420. Hereditary influences, 134. Hereditary syphilis, 189; diet in, 190; nursing in, 190; preventive treatment of, 192 ; medicinal treat- ment of, 192. Hernia, 119; congenital umbilical, 119; acquired umbilical, 120 ; in- carceration of umbilical, 120; inguinal, 120, 413 ; umbilical, 412. Herpes tonsurans, 550, 551. High temperatures, treatment of, 203. Hip-joint, congenital luxation of the, 566. Hodgkin's disease, 133. Hydrargyrum in diphtheria, 274. Hydrarthros, 573. Hydrencephaloid, 15. Hydrocele, 460. Hydrocephalus, chronic, 324 ; punc- ture in, 327 ; injection into, 327. Hydronephrosis, 432. Hydropericardium, 528. Hydrophthalmos, 607. Hydrorrhachis, 340; with tumors, 340. Hydrotherapy, 63. Hydrothorax, 510. Hymen, imperforate, 458. Hyperaemia, cerebral, 319. Hypertrophy of pylorus, 381. Hypophysis, 161. Hypospadias, 448. INDEX. 621 Ice applications, 86 ; to the cranium, 86. Ichthyol in tuberculosis, 183. Ichthyosis, 555. Icterus of the newly-born, 113 ; hsematogene, 113; hepatogene, 113. Idiocy, 316, 330. Immunization, 77. Imperforate hymen, 458. Impetigo, 543 ; contagiosa, 550. Inanition, 10, 62. Incontinence of urine, 442, 444. Infantile spastic hemiplegia, 328. Infarction, pulmonary, 496; uric acid, 430. Infectious diseases, 169 ; cause of rheumatoid diseases, 288. Inflammation of nervous system, 318. Influenza, 299. Infusion of salt water, 15. Inhalation, 78 ; through mouth, 79 ; through nose, 79 ; through sprays, 79 ; by filling the room with gases, 79 ; of muriate of ammonium, 79 ; hot steam, 79; turpentine, 79; benzine, 80 ; chloroform, 80, 81 ; nitrate of amyl, 80 ; oxygen, 80 ; ether, 80, 81 ; ozone, 80. Injections, subcutaneous, 74. Inguinal hernia, 120. Insanity, moral, 329. Insufflation in asphyxia, 89 ; dan- gers of, 89. Intermittent fever, 197; types of, 197. Internal secretion, 70, 155. Intertrigo, 539. Intestinal autoinfection, 538; dis- eases, 387 ; mucus, 389 ; tubercu- losis, 187. Intestines, obstruction of, 61, Intubation 475. Intussusception, 407. Inunctions in hereditary syphilis, 193. Iodide of hydrargyrum in hereditary syphilis, 193. Iris, gumma in, 597 ; tubercle of, 597. Iritis, acute, 605 ; chronic, 605. Iron, preparations of, 129 ; subcu- taneous injections of, 130. Irritable bladder, 443. Jaundice, 422. Joints, 562, 572 ; inflammations of the, 572 ; tubercular, 573 ; ankle, 581 ; tarsal, 581 ; elbow, 581 ; in rheumatism, 190. Keloid, 554. Kephalhaematoma, 97 ; causes of, 97; internal, 97; treatment of, 97. Keratitis, 603 ; parenchymatous, 604 ; neuro-paralytic, 604. Keratoconus, 605. Keratomalacia, 599. Kidneys, 430 ; malformations of, 431 ; pseudoplasms of, 431 ; horse- shoe, 431 ; tuberculosis of, 431 ; echinococcus of, 432 ; hydrone- phrosis, 432 ; floating, 432 ; hemor- rhage from, 432 ; inflammation of, 433, 440. Knee-joint, congenital luxation of the, 566. Knock-knee, 581. Kreatin, 41. Kyphosis, 586. Lancing gums, 342. Landry's paralysis, 334. 622 INDEX. Laryngeal diphtheria, uncompli- cated, 471. Laryngismus stridulus, 143. Laryngitis, acute, 471 ; diphtheritic, 473. Larynx, 471 ; acute catarrh of the, 471 ; uncomplicated, 471 ; in tu- berculosis, 185; neurotic affections of the, 477 ; neoplasms, 478 ; papilloma, 478 ; fibroma, 478 ; enchondroma, 478 ; epithelioma, 478 ; foreign bodies in the, 479 ; stricture of the, 479. Lateral sclerosis, 334. Lateropharyngeal abscess, 367. Leontiasis, 554. Leucocythaemia, 133. Lichen, 540 ; scrofulosorum, 541 ; acuminatus, 541 ; planus, 541. Lime-water, 36, 49, 385. Lipanin, 20. Lipomatosis, 154. Liver, 419 ; enlargement of the, 419 ; adenoma of the, 419 ; descen- sus of, 420 ; fatty infiltration of, 420 ; cirrhosis of, 420, 421 ; con- gestion of, 422; inflammation of, 422 ; suppuration of, 422 ; acute atrophy of, 422 ; echinococcus of, 423 ; adenoma of the, 402. Locality of medication, 69. Lumbar puncture, 323. Lungs, 483 ; oedema of, 496 ; hemor- rhage of, 496 ; infarction of, 496 ; gangrene of, 497 ; p?eudoplasms of, 497 ; echinococcus of, 497 ; ac- tinomycosis of, 497 ; hernia of, 497. Lupus, 550, 551 ; erythematosus, 551. Luxation, congenital, 564; of the hip, 564 ; of knee, 566 ; of shoul- der, 566. Lymphangioma, cystic, 534. Lymphatism, 153 ; sudden death from, 154. Lymph-bodies, tumefaction of mes- enteric, 401 ; periportal, 402 ; tu- berculosis of, 402 ; lymphoma of, 403 ; sarcoma of, 403 ; syphilis of, 403 ; intrathoracic, 498 ; bron- chial, 498 ; mediastinal, 498 ; in rhachitis, 145 ; treatment of, 151. Lymph- vessels, 534. Macroglossia, 364. Mamma, 103 ; secretion of the, in the newly-born, 104; angioma in the, 105. Mania, 329. Massage, 312. Mastitis, 103. Mastoid process, 594. Masturbation, 447, 458. Measles, 230, 241; heart in, 243; hemorrhagic, 243 ; respiratory or- gans in, 243; larynx in, 244; kidneys in, 244. Meat of tubercular cows, 175. Meconium, aspiration of, 89. Medication, relation to dietetics, 62. Medicines, effects of, 67 ; absorba- bility of, 67 ; fixed doses of, 68 ; in brain-disease, 68 ; protracted ad- ministration of, 69 ; local adminis- tration of, 69; in the rectum, 67, 72 ; mode of administration of, 66, 67 ; nasal, 67. Melsena, 114; causes of, 115; from the nose, 115. Melancholia, 329. Melasma, 161. Membranous enteritis, 389. Meningitis, cerebral, 318 ; tubercular, 321 ; operations in, 323 ; cerebro- spinal, 213. INDEX. 623 Meningocele, 328; spuria, 328. Mercury in diphtheria, 274 ; subli- mation of, 275 ; in hereditary syph- ilis, 192 ; effects of, 68. Methylene blue in intermittent fever, 199. Microbes in rheumatism, 288. Microcephalus, 316. Microphthalmia, 597. Microphytes in the air, 177. Middle ear, 591. Milia, 357. Milk, boiled, 65; sterilized, 66; in rectal alimentation, 58 ; mixed with meat-soup, 40 ; modified, 33 ; bone development with, 38 ; of lime, 235; of tuberculous cows, 175 ; should be boiled, 23. Milk-sugar, 16. Molluscum contagiosum, 550, 551. Monomania, 329. Moral insanity, 329. Mouth, 356. Mucous membrane in diphtheria, 259. Mucus, intestinal, 389. Muguet, 360. Mumps, 245. Muscles, diseases of the, 557 ; in poliomyelitis, 338. Muscular atrophy, 315; paralysis, 558 ; ischsemic, 558 ; trophoneu- rotic, 558; rheumatism, 298, 560. Mustard-bath, 84. Myasthenia, grave pseudoparalytic, 559. Mj^elitis, transverse, 334. Myocarditis, 513, 523, 526. Myositis, 557 ; traumatic, 557 ; rheumatic, 557 ; infectious, 557 ; hemorrhagic, 548 ; syphilitic, 558 ; tubercular, 558 ; chronic, 558; ossifying, 558; petrifying. 558. Myotony, congenital, 315. Myringitis, 589, 591. Myxcederna, 71, 155, 156. Naevi on mamma, 105. Naevus, 532 ; pigmentosus, 555 ; lipomatodes, 555. Nares, 463 ; of the new-born, 464 ; polypus of the, 467 ; foreign bodies in the, 468 ; ulceration of the, 470. Nasal irrigation. 258, 265; polypus, 467 ; spray, 258. Neck, hygroma of, 555 ; dermoid cysts of, 555 ; sanguineous cysts of, 555 ; of the bladder, 446. Nephrectomy, 431. Nephritis, 433 ; acute, 435 ; sub- acute, 436 ; chronic, 437 ; after ether inhalations, 81 ; in diph- theria, 276. Nephrotomy, 431. Nervous diseases in hereditary syph- ilis, 196. Nervous dyspepsia, 383. Nervous system, 311 ; general indi- cations of treatment, 311 ; elec- tricity in, 312; massage in, 312; galvanism in, 313 ; Franklinism in, 314 ; operations on the, 316 ; inflammation of, 318. Neurasthenia, 383. Neuroses, 342. Neurosis, gastric, 383. Neurotic affections of the larynx, 477. Newly-born, epithelial elimination in the, 104 ; icterus of the, 113 ; treatment of the, 88, 101 ; sur- face of the, 102. 624 INDEX. Night-sweats, 189. Night-terrors, 333. Nitrate of silver in hlennorrhoea, 117. Nodulated rheumatism, 295. Noma, 361; of vulva, 455; of vagina, 455. Normal serum, 278. Nose, diphtheria of the, 267. Nuclein, 28. Nucleon, 28. Oatmeal, 22. Obesity, 162. Obstruction, mechanical, 387. (Edema, pulmonary, 496. (Esophagus, 371 ; stricture of, 371 ; foreign bodies in, 371. Oidium, 360. Ointments, 86 ; in nose, 83. Oleates, 86. Omphalitis, 109. Omphalo-mesenteric duct, 118. Operations in tuberculosis, 185. Optic nerve, 607. Oral cavity, 356 ; tumors in, 356. Oral secretion, 11. Orbit, 607. Orchitis, 460. Organotherapy, 70, 78, 162. Osteochondritis, 567. Osteoclasy, 139. Osteoma in mouth, 357. Osteomyelitis, 567. Osteotomy 139. Ostitis, 567 ; tubercular, 567. Otitis externa, 588; catarrhal, 589; phlegmonous, 590; media, 591. Ovaries, pseudoplasms of the, 461. Oxaluria, 445. Oxygen, 80 ; inhalations of, 130. Ozone, 80. Palate, fissure of, 356 ; syphilitic perforations of, 358 ; diphtheritic perforations of, 358. Pancreas, 11, 37. Papilloma of the skin, 548. Paralysis, diphtheritic, 276. Paramyoclonus, 334. Paraphimosis, 455. Paratyphlitis, 406. Paresis, 324, 329. Parotid, 11, 13 ; adenoma of, 356. Parotitis, 362. Pasteurization, 26. Pavor nocturnus, 333. Peliosis rheumatica, 163, 295. Pemphigus, 546; in hereditary syphi- lis, 194 ; contagious, 547 ; folia- ceus, 547 ; exfoliativus, 548 ; neu- roticus chronicus, 548. Peptone, 41 ; digestibility of, 42 ; disturbs digestion, 14. Peptonized beef preparations, 41. Pericarditis, 527 ; operations in, 528. Perichondritis, 567. Perimastitis, 103. Periodic night cough, 483. Pericesophageal abscess, 371. Periostitis, 567 ; albuminous, 567. Perisplenitis, 424. Peristalsis, incomplete, 51, 389. Peritonitis, 425; suppurative, 428; tubercular, 428 ; laparotomy in, 428 ; chronic, 428. Pernicious anaemia, 132 ; causes of, 132; bone-marrow in, 133; treat- ment of, 133. Pertussis, 300; prevention of, 300; catarrh in, 301 ; air in, 301 ; com- pressed air in, 302 ; local treat- ment in, 302; rest in, 303; inhala- tions in, 304 ; quinine in, 304 ; tussol in, 305 ; belladonna in, 305 ; INDEX. 625 opium in, 309 ; oxymel scillse in, 309 ; bromoform in, 310. Pes varus, 582 ; equinus, 583 ; cal- caneus, 583 ; valgus, 584. Pharyngitis, 365 ; catarrhal, 365 ; phlegmonous, 306 ; erysipelatous, 366. Pharynx in tuberculosis, 186. Pbimosis, 451 ; operation of, 453. Phlebitis, umbilical, 109; diagnosis of, from arteritis, 110. Phlegmonous gangrene, 361. Phosphaturia, 445. Phosphorus, 141. Phthisis, 170. Pigeon-breast, 138. Pituitary gland, 161. Pityriasis lingua?, 364. Placenta, removal of, 89. Play, 62. Pleura, 499. Pleurisy, 499 ; operation in, 501 ; compression of lung by, 502 ; ex- plorative puncture in, 502; local- ized, 504 ; uncomplicated, 505 ; thoracocentesis, 506 ; hemorrhagic. 507 ; purulent, 508. Pneumonia, 483 ; lobar, lobular, in- terstitial, 484 ; temperature in, 486 ; dangers of, 486 ; quinine in, 487; cold in, 488; warmth in, 488; alcohol in, 490; digitalis in, 490; stimulants in, 492 ; poultices in, 493 ; complications of, 494 ; hypostatic, 495 ; interstitial, 495 ; caseous. 170. Poliomyelitis, 334, 337; club-foot after, 339. Polyneuritis, 315. Postnatal asphyxia, 94. Potassium iodide in hereditary syphilis, 195. Prepuce, 449 ; adhesion of the, 449 : diphtheria of the, 454. Preventive treatment, 62. Progressive juvenile muscular dys- trophy, 315. Prolapse of anus and rectum, 414. Prurigo, 540, 541. Pseudohypertrophy, 161, 315. Pseudoleukemia, 133. Pseudo-membranes, 252. Pseudo-membranous croup, 473. Pseudoparalysis, 559. Pseudoplasms of the epididymis, 460 ; ovaries, 461. Psoriasis, 553. Psychical diseases, 329 ; causes of, 331. Pneumothorax. 510. Puerperal sepsis, 110. Pulmonary hemorrhages, 188, 496 ; oedema, 496. Puncture in hydrocephalus, 327 : lumbar, 323. Pupil, atresia of the, 596. Purpura in infectious diseases, 296. Pylorus, congenital hypertrophy of, 381. Pyopneumothorax, 510. Eanula. 357. Eectal alimentation, 57. Rectal injections of medicines, 71 ; constituents of, 73, 74 ; large, 73. Eectum, 71 ; catarrh of, 414, pro- lapse of, 414 ; polypus of, 418. Reflex contraction of the bladder. 446. Relapsing fever, 213. Renal calculi, 439. Renal diseases, feeding in, 57. Respiratory diseases, feeding in, 56 ; organs, 463 ; in rhachitis, 144. 40 626 INDEX. Retention of urine, 443. Retina, 597, 607 ; glioma of, 597. Retropharyngeal abscess, 367. Rhachitis, 52, 134 ; hygiene in, 235 ; sanitaria in, 135 ; air and food in, 135 ; bathing in, 136 ; cod-liver oil in, 137 ; thyreoid in, 137 ; malt in, 138 ; bones in, 138 ; osteoclasy in, 139 ; osteotomy in, 139 ; in- fractions, 139 ; scoliosis in, 140 ; craniotabes in, 140 ; brain in, 141 ; respiratory organs in, 144 ; laryn- gismus in, 143 ; constipation in, 146 ; due to digestive disorders, 136. Rheumatism, 285 ; endocarditis in, 286, 292; frequency of, 285; monarthritis in, 287 ; of the cer- vical column, 288 ; microbes in, 288 ; after infectious diseases, 288 ; prevention of, 290 ; joints in, 290 ; cold in, 290 ; vesicatories in, 291 ; chorea in, 292; temperature in, 292 ; remedies in, 293 ; gonor- rhoeal, 294 ; nodulated, 295 ; pelio- sis, 295 ; erythema in, 296 ; chronic articular, 297, 571 ; mus- cular, 298, 560 ; feeding in acute, 57. Riga's disease, 363. Rotheln, 245. Rubella, 245. Rupia, 543. St. Vitus's dance, 343. Salaam spasm, 354. Saliva, 11, 13, 37 ; when in the stomach, 12, 13. Sarcoma, 77 ; of the skin, 554. Scabies, 549. Scarlatina, 226 ; origin of, 227 ; con- tagion of, 227 ; invasion of, 228 ; school-inspection in, 228 ; inunc- tion in, 229 ; prevention in, 229 ; directions to prevent, 230; dis- charges in, 233 ; throat complica- tions, 235 ; diphtheria antitoxin in, 236; glands in, 236; febrifuges in, 237 ; rheumatism in, 237, 238 ; toxic symptoms in, 237, vomiting in, 237 ; joints in, 238 ; heart in, 238; complications of, 239, 240; hemorrhages in, 239 ; pemphigus in, 239 ; nephritis in, 240 ; strepto- coccus antitoxin in, 241. School hours, 332 ; inspection, 228 ; vacations, 62. Sclerema, 99. Scleroderma, 549. Sclerosis, disseminated, 328 ; amyo- trophic lateral, 334 ; multiple dis- seminated, 334. Scoliosis, 585. Scorbutic rhachitis, 143. Scrofuloderma, 552. Scrofulosis, 147 ; preventives of, 148; foods in, 149; medicines in, 149. Scurvy, 163 ; infantile, 165. Seborrhcea, 540. Secretion, internal, 70, 155. Semi-cretinism, 71, 156. Sepsis, puerperal, 111. Serumtherapy, 77. Shoulder, congenital luxation of the, 566. Sigmoid flexure, 121. Sinapism, 84. Skin, diseases of the, 535 ; in tuber- culosis, 178 ; neuropathic affec- tions of the, 548 ; papilloma of the, 548 ; oedema of the, 548 ; cya- nosis of the, 548 ; peculiarities of, 84 ; tuberculosis of the, 552 ; con- INDEX. 627 genital diseases of the, 553 ; neo- plasms of the, 553 ; lipoma, 553 ; fibroma, 554; cysts, 554; keloid, 554 ; atheroma, 554 ; sarcoma, 554 ; atrophy, 555. Sodium bicarbonate in milk, 37 ; chloride, 17; physiological effects, 17, 19. Solutions on skin, 86. Somatose, 43. Spasm of the glottis, 477. Spasmus nutans, 354. Spermin, 131. Spina bifida, 340 ; ventosa, 567. Spinal canal, 333. Spinal cord, arrest of development, 333. Spinal inflammation, 333 ; treatment of, 335. Spinal pachymeningitis, 334 ; lepto- meningitis, 334. Spleen, 424 ; embolism of, 424 ; ab- scess of, 424 ; in typhoid fever, 212. Splenic anaemia, 134. Spondylitis, 569 ; tubercular, 570. Sprays, 79. Stammering, 355. Starch changed into dextrin in the rectum, 58 ; transformation of, 11. Steam, 79 ; in diphtheria, 269. Sterilization, 25; not effective in killing bacteria, 25 ; separates cream, 27 ; at home, 26. Sterilized milk as exclusive food, 29. Sterno-cleido-mastoid muscle, hema- toma of, 98. Stimulants in typhoid fever, 209. Stomacace, 358. Stomach, 372 ; dilatation of, 381 ; the infantile, 46 ; ulceration of, 48, 383. Stomatitis, 358 ; follicular, 358 ; ul- cerous, 358 ; aphthous, 359 ; mem- branous, 360; infectious, 361. Strabismus, 607. Strophulus, 541. Styptics, 87. Subcutaneous injections, 74 ; localities of, 74 ; doses of, 75 ; of alkaloids, 75 ; quinine in, 76 ; pilocarpine in, 76 ; morphine in, 75 ; strychnine in, 76; caffeine in, 77; Fowler's solution in, 77. Sublimation of mercury, 275. Submaxillary glands, 11. Substitutes for breast-milk, 21. Sudden deaths, 154, 160, 161. Sugar, 16 ; in different milks, 16. Supernumerarj 7 fingers, 562. Suppositories, 74. Suprarenal melasma, 161. Surface of the newly-born, 102. Symmetrical cutaneous hemorrhage, 549 ; gangrene, 549. Synechia of fingers, 563. Syphilis, 189; of the newly-born, 114. Tabes, 334. Taenia, 409. Taka-diastase, 12. Tarsal-joints, 581. Teleangiectasia, 532. Temperature reduced by water, 63 ; influence of elevation of, 64 ; re- duction by drugs, 64 ; reduction of, in the newly-born, 102. Testicle, syphilis of the, 460. Tetanus, 115, 340 ; preventive of, 116; bacillary, 116; rheumatic, 116. Tetany, 345. Therapeutics, general, 60. 628 INDEX. Thiersch's solution, 109. Thomsen's disease, 315. Throat, 365. Thrombosis, 531 ; cerebral, 320. Thrush, 360. Thymus, 160. Thyreoid gland, 70, 155 ; carcinoma of, 155 ; tuberculosis of, 155 ; syphilis of, 155; atrophy of, 155; inflammation of, 155 ; uses of, 155, 160. Toes, congenital enlargements of the, 562. Tongue, 363 ; congenital anomalies of, 363 ; bifid, 363 ; sarcoma of, 363 ; lipoma of, 363 ; dermoids of, 364 ; hygroma of, 364 ; lymphan- gioma of, 364 ; adhesion of, 364 ; in tuberculosis, 186 ; sarcoma of, 356. Tonsil, 365 ; parenchymatous in- flammation of, 366 ; in diphtheria, 258. Tonsillitis, 365. Torticollis, 559. Trachoma, 602. Transverse myelitis, 334. Treatment, expectant, 61 ; pre- ventive, 62. Trismus, 115. Tubercular meningitis, 321 ; opera- tions in, 323. Tuberculin, 183. Tuberculocidin, 183. Tuberculosis, 169 ; dissemination of, 169 ; acute miliary, 170 ; preven- tion of, 171; causes of, 172; he- redity in, 173 ; direct transmission of, 173 ; food in, 176 ; climate in, 176; water in, 179; arsenic in, 179; digitalis in, 180; larynx in, 185; of the skin, 552. Tumor albus, 572. Turkish bath, 515. Turpentine, inhalations of, 185. Tussol, 305. Tympanites in typhoid fever, 205. Typhoid fever, 200; feeding in, 55 ; dangers of, 200 ; diagnosis of, 200; preventive treatment of, 201 ; abortion of, 201 ; antifer- mentatives in, 201 ; expectant treatment of, 202; feeding in, 203 ; complications with bronchitis in, 203 ; high temperatures in, 203 ; cold water in, 204; medicines in, 204 ; tympanites and meteorismus in, 205 ; diarrhoea in, 206 ; consti- pation in, 207; preparations in, 207 ; hemorrhages in, 207 ; heart- failure in, 208 ; brain symptoms in, 209; stimulants in, 209, 210; the brain in, 211; posture of head in, 211; opiates in, 211; convalescence from, 212 ; sequela? of, 212 ; muscles in, 212 ; bones in, 212 ; noma after, 212. Typho-malaria, 213. Typhus, 213. Ulceration, gastric, 383 ; alkalines in, 384; diet in, 385; anoemia in, 386 ; of stomach, 48 ; treatment of, 49. Umbilical fungus, 118 ; gangrene, 109 ; arteritis, 109 ; phlebitis, 109; hemorrhage, 112; before the separation of the cord, 112; after the separation of the cord, 112; hernia, 412. Urethra, epithelial obstruction of the, 448 ; membranous obstruction of the, 448 ; stricture of, 448. Uric acid infarction, 31, 430. INDEX. G29 Urine, retention of, 442, 443 ; incon- tinence of, 442. Urticaria pigmentosa, 548. Vaccinia, 247. Vagina, atresia of the, 458 ; noma of the, 455. Vaginal catarrh, 456 ; hemorrhage, 458. Varicella, 247. Variola, 226 ; vaccination and re- vaccination, 246. Vascular diseases, 527. Veal broth, 41. Veins, thrombosis of, 531. Verrucse planae juveniles, 548. Vertebrae, tuberculosis of, 569. Vesicatories. 84 ; contraindications to, 85. Vitiligo, 548. Vitreous body, abscess of, 606. Vomiting, 46. Vulva, noma of the, 455. Vulvar catarrh, 456. Vulvitis, aphthous, 454. Warts, 548. Water, cooling by, 64 ; stimulation by, 64 ; application of, 65 ; water- ice, 15; in food, 14; in pepsin digestion, 14; in tuberculosis, 179; in laryngitis and bronchitis, 15 ; in constipation, 15 ; should be boiled, 15; protects the kidneys, 431. Weil's disease, 213. 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